KOL Views Results: French physician says hospital weathered first COVID-19 wave leaning on hydroxychloroquine but wary of next wave

FirstWord hosted an expert call this week with Benjamin Davido – an infectious disease specialist and medical director for the COVID-19 crisis at Raymond Poincaré University Hospital (on the outskirts of Paris) – to get a better sense of how the response to and management of COVID-19 in France have evolved over the past couple months.

Summary points from expert feedback:

  • Hydroxychloroquine plus azithromycin has been the treatment of choice for severe COVID-19 patients
  • Local resources were stretched thin two weeks ago but cases now receding
  • Holding out hope that prophylactic use of hydroxychloroquine might work, which would be very useful given safety profile and ease of administration
  • KOL has some concerns about how long-lasting the immunity from a vaccine will prove to be

FirstWord: How are patients with COVID-19 infection currently being treated?

“We decide how to treat every patient admitted depending on their clinical status, whether they require oxygen or not, and the percentage of lung lesion – it must be over 10%. [For these severe patients] we use hydroxychloroquine plus azithromycin.”

FirstWord: What drugs are available either under emergency authorisation or in clinical trials?

“We can only prescribe hydroxychloroquine in our hospital though other drugs are available, such as [HIV drug] lopinavir.”

“Remdesivir is available in clinical trials and under certain circumstances. We also use monoclonal antibody (mAb) therapy and immunoglobulin in trials.”

FirstWord: Are any medicines typically being prescribed (off-label)?

“Hydroxychloroquine is prescribed off-label. We also use compassionate steroids when a patient cannot be resuscitated.”

FirstWord: How has the treatment protocol changed since patients first began turning up with COVID-19?

“Before March 16 we could not prescribe any drug, especially chloroquine, which was considered off-label and dangerous. We were therefore out of stock in hospitals [because] the government removed all the current stock.”

“Since mid-March we changed totally in my hospital from lopinavir to hydroxychloroquine plus azithromycin as it is an oral regimen and seems to reduce contagiosity and local inflammation.”

“Since early April we got interested in steroids for the secondary phase of the infections after 10 days when a patient cannot be in the intensive care unit (either elderly or contraindicated due to comorbidities) – with some success.

FirstWord: How close to capacity is your healthcare system?

“We are on the edge. [At the peak] we had 2,670 patients in this Paris suburb compared to a capacity of 2,700 beds.”

“Things are now going better since we reached the famous peak of the epidemic on April 8. We are now trying to find a rehabilitation flux for the patients, which is hard, and we hope there won’t be a second wave after the end of the lockdown on May 11.”

FirstWord: What are the most important lessons that have been learned about how to manage COVID-19?

“COVID-19 showed us that primary care is very useful to manage this flux of patients, and that we need to work hand-in-hand with different countries to flatten the curve worldwide. Otherwise there will be a continuous wave. Also it showed in France how quickly and efficiently the hospital can change our daily practice to handle a true Hollywood sci-fi movie, but on the other hand we lacked masks and essential stuff like tests. How can it be like this when we have a European CDC? I don’t get it.”

FirstWord: What are your go-to sources for new information on treatment strategies and how frequently are they being used to update practice patterns?

“Pubmed for medical publications is the best tool we use daily. Every day things are changing fast.”

FirstWord: What is your level of optimism about the therapeutic prospects for (hydroxy)chloroquine?

“I hope it will work, especially because we won’t get a vaccine for a year or more. So the best track is to find quickly a drug more than a vaccine. A recent Brazilian study suggested it has efficacy in an early strategy in outpatients.”

FirstWord: What is your level of optimism about the prospects for Gilead Sciences’ remdesivir?

“Remdesivir could be very interesting, however, it may be prescribed too late in severe forms of the disease because – as an antivral drug – it should be given early (within five days of infection).”

“There is an alert about a potential risk of acute kidney failure that should be monitored.”

FirstWord: What is your level of optimism about the prospects for other antiviral drugs (eg, Avigan)?

“No idea.”

FirstWord: What is your level of optimism about the prospects for convalescent sera?

“It is possibly a good idea. However, we do have concerns about the real effect of antibodies. It is especially hard to find donors with high levels of antibodies. I also have concerns about the reproducibility of such strategy at a national scale.”

FirstWord: What is your level of optimism about the prospects for

“Possibly, but it will depend on the convalescent sera. Once again when we look at the physiopathology of the disease, especially this cytokine storm, it should be demonstrated that a mAb can avoid such stage. Time will tell.”

FirstWord: What is your level of optimism about the prospects for any other medicines/strategies (not mentioned here) that seem particularly promising?

“I guess the best strategy could be a preventive therapy. As far I know chloroquine has not been tried as such and is a good candidate for many reasons. First it is already use as such, based on experience in malaria, and it works at the early stage of the infection.”

FirstWord: What is your level of optimism about the prospects for conventional vaccines?

“Vaccines are for the moment at the first stage of development. My concerns are about the immunity because if it does not last long enough then I don’t know how a vaccine will work – maybe with multiple injections at different time points.”

FirstWord: What is your level of optimism about the prospects for DNA/RNA vaccines?

“No opinion.”

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