How SA’s medicine swot team delivers fast decisions on Covid treatments
When a pandemic strikes and the leader of the free world starts thinking out loud about injecting bleach, there’s an obvious question: who do you believe?
The answer, for South Africans, is a subcommittee of 14 scientists, with strings of letters after their names, who formed a swot team to assess new treatments.
With the same number of reports under its belt, the team — officially the national essential medicines list therapeutic guidelines subcommittee on Covid-19 — reflected on its first six months in an article on Tuesday in the SA Medical Journal. It has approved just one drug and advised against using 13.
Since the article was accepted on September 8, the subcommittee of the SA essential medicines list committee has completed four more reports or updates. All 18 are available on the health department website.
To illustrate the process it followed, the team describes how it decided not to recommend the antiviral remdesivir, but gave the thumbs-up to the steroid dexamethasone.
It said it aims to conduct rapid reviews and have draft reports ready within a week, pointing out that “full systematic reviews of high-quality randomised controlled trials” often take months or years.
But this is vital during a pandemic, said the team, which is chaired by Andy Parrish, from the internal medicine department at Walter Sisulu University in Mthatha.
“Rapid systematic reviews are a simplified but rigorous process to synthesise evidence within a short period of time,” it said.
The “evidence to decision” framework used by the subcommittee had three main components: a clearly formulated question, assessment of the evidence and a recommendation.
“The criteria applied ... are quality of evidence, balance between benefit and harm, feasibility, infrastructure/resource use, variability in stakeholders’ values and preferences, and health-care equity,” said the team.
“Acceptance and implementation of the guidelines depends on the level of trust and confidence clinicians have in the reliability and transparency of the process followed.”
The subcommittee looked at remdesivir because it had been effective against other coronaviruses. A search of research databases found two randomised controlled trials that compared it with usual care, both of which found the drug had no impact on mortality and one of which found remdesivir shortened recovery time by four days.
“The subcommittee considered a reduction in intensive care unit stay to be the most relevant clinical outcome, given SA’s limited ICU bed capacity,” said the team.
“However, there are as yet no data showing that remdesivir reduces ICU admission duration or prevents progression to invasive ventilation.”
Any potential benefits of using the drug would be modest, but it is expensive and supply is unreliable. “For these reasons, the subcommittee did not recommend the use of remdesivir on the state sector, except in the context of clinical trials.”
However, the team said its rapid review was being updated to reflect a new randomised controlled trial. The subcommittee said it relied on a wellconducted trial which found dexamethasone reduced mortality in patients who needed oxygen or ventilation.
Because the drug was cheap and widely available, it recommended its use in such patients, while acknowledging there was little evidence to show how safe and effective it would be in HIV-positive people and children.
In addition to remdesivir, the team advised against the use of the following drugs or therapeutics for Covid-19 patients: interferon, favipiravir, heparin, lopinavir-ritonavir, colchicine, chloroquine, hydroxychloroquine, convalescent plasma, BCG, azithromycin, tocilizumab and intravenous immunoglobulin.