A scientist’s opinion : Interview with Dr Juan Pablo Horcajada about covid-19 treatment

Interview with Juan Pablo Horcajada, MD. is Head of the Department of Infectious Diseases and General Coordinator of the COVID-19 Service at the Hospital del Mar, Barcelona.

Remdesivir is the first drug approved by the EMA to be used as part of the treatment of COVID-19 patients. How’s the use of this antiviral in your hospital?

Juan Pablo HorcajadaJuan Pablo Horcajada: We certainly use remdesivir for the treatment of some of the patients with COVID-19. At the beginning we used the drug in severe patients, but then research was published indicating that it didn’t benefit those cases treated in intensive care units or in need of respiratory support. Now we only administer the drug to patients who need oxygen.

Do you use other antivirals as treatments?

Juan Pablo Horcajada: It is currently the only antiviral we use. In the past, we used others such as lopinavir, which later proved to be ineffective and was withdrawn from the guidelines. There are no other antivirals from clinical trials that can be used.

What else do you use

Juan Pablo Horcajada: Currently we have three types of drugs to treat COVID-19 patients: first, the antiviral remdesivir I just described. Second, the corticosteroid dexamethasone, a broad-spectrum anti-inflammatory drug. COVID-19 presents a great inflammatory phenomenon. Not only does it affect the cells, but the body responds to that aggression with a strong immune response. In some patients, this inflammatory response is excessive, and is what puts the patient in a very serious condition. New analyses show that dexamethasone reduces the risk of death by a third in severe and critical cases (those in need of a mechanical ventilator), compared to a placebo. And third, interleukins inhibitors (type 6) that can repair the damage to the lungs caused by the cytokine storm produced by the body’s immune response. Contrary to corticosteroids, it works in very specific sites of this cascade. That’s it, this is all we’ve got. For preventing thrombosis (that is more frequent in COVID-19 patients) we also use low-dose anticoagulants.

But can this number be increased given the high number of possible treatments and vaccines under study?

Juan Pablo Horcajada: It can be, and we certainly hope so, but so far there is no solution that tackles the core of the problem: the virus. What we are doing now is seeing how the human body fights against the virus infection, and our role is only to try to regulate the inflammatory processes with the anti-inflammatory treatments we have. This is all we can do now. I know this is discouraging, but the only way we have to test things and make sure these new drugs are safe takes a lot longer than we thought. There are now many different molecules on the way to being tested in humans, but clinical trials are something very complex and resource-intensive, so not every hospital is capable of performing them. We must choose those molecules with the best chance of targeting the virus and, even better, also fighting the inflammatory process. But we need more time to do it properly.

What do you think about the interim results from the Solidarity trial that appears to show that remdesivir has no effect on the mortality of COVID-19 patients?

Juan Pablo Horcajada: What we already know from the ACTT-1 trial is that remdesivir shows a reduced duration of the disease without manifesting a reduction in mortality either. It is a positive clinical effect, and it gives the medical community enough reason to continue using it while new and more successful molecules come up. If remdesivir had no beneficial effect, then it would have to be discontinued.

Compared to the first wave of infections, what differences do you see from those days, in the type of patients you treat and receive?

Juan Pablo Horcajada: Patients we admit now are younger than those in March, April and May, when we were at the peak of the wave. There we saw more elderly people and we had higher mortality. Now we see younger patients and the mortality rate is much lower. Also, the number of patients we receive is not increasing exponentially as happened before. This is because, I believe, we’re no longer controlling the epidemic in hospitals but in the streets, thanks to public health control measures and the primary care services that are now preventing many patients from reaching hospital. In March, hospitals were the only place where COVID-19 patients were treated.

What do you think it will be the situation in the coming months with the arrival of the cold temperatures?

Juan Pablo Horcajada: This is a key moment for the understanding of the crisis, to see how the virus spreads, and how the number of cases and deaths behave with the beginning of the school year and the arrival of the autumn. We’re not sure what will happen, and certainly we hope nothing comes close to what we had in the spring. Back then, we had over 900 patients being treated at the same time in different locations of the hospital centre. Our initial capacity was 1 092 beds, but during the crisis we managed to increase that capacity by 590 more beds. Now we only have around 50 – 55 patients admitted for COVID-19, but developments in coming weeks will tell us a lot of what to expect.

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