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Clinical pharmacology at the frontline

Published: 17 Jun 2020
Category:
By Reecha Sofat

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Our working, social and personal lives have been hugely disrupted over the past few months. For those, like me, who are involved in direct care of patients either with COVID-19 or dealing with consequences of routine services being turned upside down this has been a testing time. It has also been a time when complex decisions about clinical therapeutics have been at the forefront – a time when the expertise of clinical pharmacologists has been indispensable.

The initial strategy was to identify and test a number of existing drugs in clinical trials to see if they were useful in for the treatment of COVID-19. Given we know something about the safety profile of these drugs, so it takes less time to get them to patients. Such drugs include remdesivir (the anti-viral originally developed for ebola), hydroxychloroquine (an anti-malarial), tocilizumab (an immunomodulator) and dexamethasone (a steroid).

However, without trial evidence it is unknown which if any of these drugs could be useful. Moreover, when faced with very sick patients, medical staff always feel like they should be able to offer more. However, without high quality evidence from clinical trials this  is a difficult decision to make, as it us unknown if the drug will be of benefit or cause harm.

As a speciality, clinical pharmacology plays a key role in how medicines are used based on the best evidence through Drugs and Therapeutics committees (DTC) and/ or Area Prescribing committees (APC). At the early stage of the pandemic as the Chair of the Joint Formulary Committee for North Central London (the APC for NCL), I received calls from member trusts asking if we had a position on the use of some of these off-label drugs. In parallel we had already engaged with infectious disease doctors and pharmacists who were having these conversations about anti-virals; rheumatologists who were interested in understanding how to treat the inflammation associated with COVID-19 and intensive care doctors involved in treating the sickest of these patients.  Bringing these three strands together (anti-virals, immunomodulators and formulary processes), the COVID-19 Therapeutics Advice and Support Group (CTAG) was born.

The group’s central aim is to support the evidence-based use of medicines for COVID-19. At the start of the pandemic it was a matter of ensuring that a general message of standard of care is best rather that ‘off label’ use of medicines (for an indication other than the one they were licenced for). This was in line with advice from the Chief Medical Officer (CMO). CTAG has evolved into a channel through which emerging evidence about the safety and effectiveness of potential treatments for COVID-19 can be made available to front line clinicians in all hospitals - the group has developed interim guidance for antivirals and immunomodulators. The aim is to promote recruitment to trials rather than off-label use. Where evidence is emerging (e.g. remdesevir and now dexamethasone) CTAG provides updates to guide use at a local level, again in keeping with CMO advice but bridging until formal NICE guidance and commissioning statements are in place.  

CTAG is now an official advisory group of the Royal College of Physicians, with endorsements from BPS, BIA, UKPCA. It allows experts in multiple specialities including but not limited to Clinical Pharmacologists and Pharmacists to collaborate on the appraisal, formulary work and implementation of access to medicines for COVID-19, and to reach medical staff around the country.

I am proud to be a clinical pharmacologist. COVID-19 has demonstrated the value of Clinical Pharmacology as a speciality spanning academia, health care and industry.  Clinical pharmacologists have been involved in drug development, evaluation and safe use of medicines in patients, helping ensure that the use of medicines is supported by the best evidence, which is especially needed during this challenging time.
 
 

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