Is COVID-19 ushering in an era of renewed pragmatism in medicine? 10 Jun 2020
As healthcare systems have battled the coronavirus epidemic, treatment in areas such as oncology has unfortunately faced significant disruption. One of the issues that healthcare providers face is the need to reduce vulnerable patients’ risks of viral exposure. With an increased risk of infection in hospitals, there is a knock-on effect on hospital-based cancer treatment provision. In response to this disruption, the National Institute for Clinical Excellence (NICE) recently issued a guidance ‘Interim treatment change options during the COVID-19 pandemic’ (1). Endorsed by NHS England, the Guidance provides alternative treatment options for patients suffering from various cancer types. The recommendations are based on the expert clinical opinion of members of the Chemotherapy Clinical Reference Group as well as specialised services cancer pharmacists. The alternative options address various critical needs. First of all, the Guidance makes a general recommendation to prescribe a prophylactic to prevent neutropenic fever and reduce the risk of hospital admissions. There are also options for treatments that have a lower immunosuppressive effect and so reduce the risk of patients contracting and suffering severe complications from COVID-19. Importantly, there are home-based treatment alternatives in place of hospital-based options.
The issuing of this Guidance is an interesting and necessary development to ensure that at-risk patients continue to receive adequate treatment during difficult circumstances. The document brings together the best available clinical opinion of medics and pharmacists and provides a more formal cohesion to conventional off-label usage. Fundamentally it was a pragmatic decision, to act quickly and use the body of clinical evidence and opinion already available to make treatment decisions.
This particular NICE Guidance represents a ‘reconfiguring’, rather than a ‘repurposing’ of treatments. However, repurposing of medicines has also been an essential part of the pandemic response- again driven by pragmatism. With an unknown virus, there were no approved treatments available. Clinicians in the field had to make swift and sensible decisions in light of what was known, using safe medicines likely to have an effect. Since then, of course, multiple trials have emerged using existing drugs repurposed for treatment of COVID-19. While none of these drugs has as yet emerged as a “magic bullet” for COVID-19, over time, we should be able to expect improvements in our ability to treat the disease. The concept of repurposing, in general, is a useful and pragmatic tool that helps to address many of the problems we face in clinical development; lengthy trial cycles, patient enrollment challenges, rare diseases and an ongoing productivity crisis. Advances in artificial intelligence will enable us to better harness the potential of repurposing existing medicines.
Randomised controlled trials remain the gold standard for delivering treatments to patients. However, beyond the pandemic, how could we further embrace this pragmatism in other healthcare situations? Pragmatism has always been a crucial part of medicine, and now more than ever, we need to apply old-fashioned common sense in tandem with innovation to help drive advances in healthcare.