The infectiologists have the floor: An opinionated take on NEJM highlights for March 2020

A first Covid-19 interventional study – unfortunately negative

The first of what promises to be a series of many interventional studies for acute Covid-19 disease to appear in the Journal. Lopinavir is an HIV drug that had shown in-vitro activity against SARS, another corona virus, and ritonavir is a drug that boosts lopinavir concentration by reducing its rate of metabolization – so it was worth trying the combo in sick patients with Covid-19.  The study was clearly conducted in quasi-battlefield conditions in one of Wuhan’s main hospital from mid-January to mid-February 2020. Many corners were cut for speed and efficiency, but it’s still a highly valuable trial showing that if the lopinavir-ritonavir combo has an effect in Covid-19, it’s not a large one. Unfortunately, we will have to look elsewhere for relief.  A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19 (free access)


The natural course of Covid-19 in the ICU in the US

A brief report on the first 24 Covid-19 patients admitted to an ICU in the Seattle area. Fatality rate was 50% and probably will be higher given that 3 patients were still on a ventilator at the time of submission, more than 14 days out. For reference, a typical fatality rate in a (medical) ICU is around 25%.  Covid-19 in Critically Ill Patients in the Seattle Region — Case Series (free access)


Depo HIV drugs

Injectable long acting drugs in replacement to the equivalent oral drugs have a place in treatment given two conditions: (1) the therapy is chronic and (2) interruption of therapy can have serious long-term consequences. Obvious cases are contraceptives, and antipsychotics, but HIV therapy can fall in the same category. In two 1-year studies comparing monthly injections of depo HIV drugs vs. equivalent orals, there was essentially no difference in outcomes and greater satisfaction in the injection group. My guess is that the lead patient profile for this type of therapy are those who get monthly depo shots of contraceptives and/or antipsychotics. Long-Acting Cabotegravir and Rilpivirine for Maintenance of HIV-1 Suppression; Long-Acting Cabotegravir and Rilpivirine after Oral Induction for HIV-1 Infection; Monthly Injectable Antiretroviral Therapy — Version 1.0 of a New Treatment Approach


And on a positive note, an outstanding Hepatitis C eradication campaign in Egypt

As a result of a large scale program to treat endemic schistosomiasis with unsafe intravenous injections decades ago, Egypt ended up with a high prevalence of Hepatitis C.  From October 2018 to April 2019, a herculean screening effort was conducted including 50 million Egyptians; approximately 2.2 million were found to be seropositive, and 1.1 million were HCV RNA positive (out of 1.5 million that could be tested). About 1 million were treated and >98% had a sustained virological response.  Estimated fully loaded cost per cure was $130 (made possible by use of generic versions of sofosbuvir and daclatasvir) – now that is a heck of a medical ROI. Screening and Treatment Program to Eliminate Hepatitis C in Egypt


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer an opinionated perspective on selected highlights that might be of interest to our clients and others.

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