Treating COVID-19 one year in: what have we learned?

When COVID-19 hit a little over a year ago, we really had no idea what we were facing. Hospitals were filling up. Doctors were faced with patients in critical condition, with no really good understanding of the disease or how to fight it.

"I think it was a time that is probably what many of us who deal with infectious diseases (...) have been fearing for a long time, which is a whole slew of cases of people infected with the disease where there's no effective treatment," said Dr. Andrew Morris, an infectious disease specialist at the University Health Network and Sinai Health in Toronto, and professor in the University of Toronto's Faculty of Medicine. 

The virus has now killed two million people around the world, including 22,000 Canadians, and countless others have cycled through hospitals and critical care. 

But thanks to trial-and-error efforts by front-line physicians, and careful and ongoing experimentation and analysis by scientists, we've learned important lessons about different treatments for COVID-19. We now have an improving picture of what works, what doesn't and what the best standard of care should be. 

When you really don't have a clear answer, for some of us, the approach is: do the things that we believe or know to help patients and are unlikely to harm patients.- Dr. Andrew Morris, UNH, Sinai Health and University of Toronto

Dr. Morris has been one of the contributors to the ongoing effort to provide the best scientific guidance for medical professionals. He's the co-chair of the Drugs and Biologics Clinical Practice Guidelines Working Group of the Scientific Advisory Table in Ontario. 

He said that by the time the pandemic hit Canada, doctors tried to to learn from the experience in China, Italy, and New York City who had dealt with major outbreaks. There was also very early scientific advice coming from the World Health Organization. 

"When you really don't have a clear answer, for some of us, the approach is: do the things that we believe or know to help patients and are unlikely to harm patients," he told Quirks & Quarks host Bob McDonald. 

That led doctors to prescribe existing antivirals that could potentially attack the virus itself, as well as treatments known to target COVID-19's destructive inflammatory response.

The other approach, Dr. Morris said — especially with extremely sick patients, was to "throw the kitchen sink at them." 

What hasn't worked

The kitchen sink included antibiotics, in the event that some kind of bacterial infection might be complicating the viral infection, which we've now learned is unlikely.

The data so far about antiviral drugs have so far been mixed to disappointing. 

The HIV antiviral drug combination — lopinavir-ritonavir — turned out to not be effective, but Dr. Morris thinks the jury is still out on remdesivir that was first developed to treat Ebola. 

Another medication medical professionals first suspected might work, turned out to be a cautionary tale. It was the anti-parasitic malaria drug, hydroxychloroquine, a treatment that was politicized early in the epidemic.

"I think we should learn from the hydroxychloroquine story, which is even a drug that we think is relatively safe — when it's consumed in very, very large amounts, cause[s] unnecessary harm," said Dr. Morris.

"Hydroxychloroquine probably caused more than a few deaths because of its use."

'2021 version of hydroxychloroquine'

The latest drug that's getting public and media attention is ivermectin, another anti-parasitic medication. 

"It certainly has more YouTube hype than evidence supporting it. It's what I would say is the 2021 version of hydroxychloroquine," added Dr. Morris.

A group of U.S. physicians who call themselves the Front Line COVID-19 Critical Care Alliance (FLCCC) have been strong proponents of ivermectin after a study last spring showed — in petri dishes in the lab — that it had high activity against SARS-CoV-2.

That was followed by what Dr. Morris describes as a large collection of very small randomized trials that seemed to show an impressive response to treatment

"The problem is, when you look really carefully at these studies, they're very small studies. The quality of the studies in general are quite poor, and there's very few endpoints that give us a signal whether or not they're beneficial."

Dr. Morris worries that support for this unproven drug, which he says seems to be based more on scientific hunches than robust scientific data, could lead to more anti-scientific sentiment to may distract us from the real science.

"I think that's one of the things that has been so difficult with COVID-19, in general, is that there's been a tremendous amount of scientific mis- and disinformation with people who seemingly to the untrained eye, seem to have quite a lot of credibility."

What has worked and what we're learning

There is good news, however. Some treatments are showing benefits. 

Dr. Morris said corticosteroids that have been used since the early days of the pandemic, like dexamethasone, have proved to be quite helpful. These drugs help reduce the body's inflammatory response that can be harmful when the immune system overreacts to infection.

"We can comfortably say that, with corticosteroids alone, we probably are saving an extra life for every seven to 9 patients admitted to the intensive care unit," he wrote in an email.

There was great hope for blood plasma from recovered patients, or "convalescent plasma," which contains antibodies to the virus. While it has shown what Morris calls "pretty disappointing" results when used late in the course of the disease, he thinks there could still be a benefit for patients treated early on in an infection.

There's also a lot of hope around engineered monoclonal antibodies — essentially synthetic versions of the antibodies the immune system produces to fight the virus. Morris said he remains uncertain about whether or not they will prove useful.

In the end, he thinks there is unlikely to be a single treatment that will be a game changing magic bullet.

"I think what we're going to see over the next year or so is a whole suite of treatments that will probably be used in combination and we'll have a much better understanding of when to use them."

He expects we'll also get better at mixing and matching medications, according to a patient's disease state.

"I think that's going to give us tremendous strides in patient outcomes while we hopefully see the benefits of vaccines."

Produced and written by Sonya Buyting