COMMENTARY

Has the Pandemic 'Infected' Our Approach to Medicine?

Vinay Prasad, MD, MPH

Disclosures

May 20, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

All doctors are familiar with the idea of superinfections: an infection occurring on top of another, earlier infection. For example, a patient suffering from a viral pneumonia may also develop a bacterial one.

COVID-19 is a contagious, infectious disease spreading from person to person, destroying some cities and regions, and, for the time being and for unclear reasons, sparing others. And on top of this there is also a superinfection.

It is not biological, however; the superinfection I'm talking about is spreading in the hearts and minds of physicians and academics. The superinfection has led us to forget longstanding principles of evidence-based medicine, abandon logic and clear-headedness, and lower the bar for adopting unproven standards of care.

Here are four ways in which I believe COVID-19 has attacked our thinking in medicine.

Anticoagulation

Patients admitted to the hospital are at risk for venous thromboembolism. Patients sick enough to go to the ICU are at greater risk. Patients ill with sepsis, acute respiratory distress syndrome (ARDS), or respiratory failure are at highest risk. This risk can be reduced by administering prophylactic doses of anticoagulation, typically heparin products, and all major guidelines unequivocally recommend this practice for critically ill patients. These are long-held truths in medicine.

Recent studies suggest that COVID-19 has at least as high, and potentially much higher, thrombotic risks compared with patients with similar illness severity due to non–COVID-19 causes. There are several preliminary results that support this case. In the face of this emerging evidence, a hypothesis has emerged: Will COVID-19 patients benefit from more aggressive anticoagulation, even in the absence of an objectively documented venous or arterial thrombotic event?

I have never witnessed a doctor giving five, six, or 10 drugs to treat a virus without any proof that it will help.

It is not just one question but several linked ones. Should all hospitalized patients with COVID-19 be given therapeutic doses of unfractionated or low-molecular-weight heparin? Should some patients continue prophylactic dose anticoagulation even after discharge, and could we use direct oral anticoagulants? Should we use a D-dimer to risk-stratify patients and then alter antithrombotic therapies?

There is only one logical response to these questions: We need randomized studies testing the standard of care against these and other alternatives.

Should we change our protocols in the absence of this kind of scientifically rigorous data? The answer is simple: No.

While escalating anticoagulant doses seems intuitive as well as tempting due to its simplicity, more anticoagulation does not guarantee better outcomes. It is possible that more aggressive anticoagulation will increase the risk of bleeding but do little or nothing to lower the rate of thrombosis. The net effect of these strategies may even be harmful.

If bioplausibility was truly enough to change practice, dozens of ongoing clinical trials—like testing anticoagulants in cancer patients—could be closed, as we already know the answer. But the truth is that we do not.

And yet, many institutions are jumping the gun and changing long-standing protocols outside of a clinical trial. They are not testing their ideas; they are implementing them. This is bad science and bad medicine.

It will be impossible to tell if these measures are helping or hurting. History may prove me wrong, but only through a randomized controlled trial.

Throwing Everything but the Kitchen Sink at a Viral Illness

For decades, doctors have cared for patients with life-threatening viral illnesses. Many of these patients had grave prognoses, and a fraction were destined to die of these diseases. We had no proven, effective therapies for many viruses. COVID-19 is similar to these viruses of yesteryear. Among sick and hospitalized patients, most get better. Among ventilated patients, mortality rates are significant, but thankfully not 100%.

For a sick patient with any other viral illness without a proven treatment, I have never witnessed doctors giving five, six, or 10 drugs to treat the virus without any proof that it will help. I have never seen a severely ill patient with influenza, pneumonia, viral hepatitis, or HIV receiving vitamin C, zinc, hydroxychloroquine, and tocilizumab—all without any evidence.

With COVID-19, however, the primary rule of medicine—first do no harm—appears to have been discarded. It is common to see physicians using not one but many unproven drugs simultaneously. The situation is baffling: If the patient recovers, we will never know if one, all, or some combination of these drugs helped, hurt, or didn't matter at all. If the patient dies, all of these same questions remain unanswered.

The only rational way to give unproven drugs for a viral illness from which many recover, but some die, is in a randomized trial, but this essential lesson appears to have been completely forgotten as we face COVID-19.

Is It Really ARDS?

There has been much discussion in the physician community about whether COVID-19 lung injury or damage truly represents ARDS. ARDS is a broad category definition that has always been known to contain diverse, heterogeneous phenotypes. Not all patients with ARDS have the same compliance and not all patients respond equally to positive end-expiratory pressure therapy. These are not new observations; however, due to the fact that COVID has exposed many providers to more ARDS patients simultaneously, the full breadth of the disease may be newly apparent. And yet, there is no evidence that patients with COVID-19–related ARDS on a ventilator should be managed with different strategies. Low tidal volume remains the mainstay of therapy, and deviating from this needs to be proven rather than haphazardly attempted.

Harsh Tactics Against Those Who Disagree

Under normal circumstances, academics could disagree about the results of a new trial or study, with their debate being more or less civil. In the COVID era, this cultural and intellectual standard has been abandoned. Recently, Angela Rasmussen, PhD, a Columbia University virologist, reported that her Twitter post debating the evidence for universal cloth masks resulted in an email being sent to her supervisor asking for a "Twitter retraction."

https://twitter.com/angie_rasmussen/status/1254957405432975360?s=20

Having spent considerable time reviewing the evidence for and against a mandate for universal wearing of cloth masks, I can safely say that there is a legitimate debate there. There are points on both sides, and there is no clear and obvious winner. Graham Martin and colleagues have done a nice job making the case for uncertainty. Academics should be allowed to debate both positions freely. When a fellow academic emails your boss, however, I believe that a line has been crossed and the effect is chilling. There are other examples as well.

Living in Fear

Why are we so eager to change our anticoagulation policies, throw everything but the kitchen sink at COVID-19, discard established ARDS protocol, and bully our colleagues over differences of opinion?

I believe that the root cause is fear. COVID-19 is a new and merciless virus. Our lives have been entirely transformed by it and our newsfeeds are filled with nothing but it. Our clinics and practices are either flooded with COVID-19 management questions or are empty in anticipation.

When the entire world is facing an unprecedented threat, it is natural to believe that our response must also be unprecedented. Under normal circumstances, we would not so easily change anticoagulation protocols. We would not throw multiple unproven drugs at a virus, and we would not try to silence our colleagues. Yet these things are happening.

COVID-19 may someday lead to two sets of lessons for physicians: We struggled to protect the globe from a pandemic, and we struggled to protect ourselves, our principles, and our medical evidence from fear.

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