The ICMR must assess evidence and be very specific with recommendations on treatment
The Indian Council of Medical Research (ICMR) has finally dropped its espousal of convalescent plasma therapy (CPT) as treatment for moderate COVID-19 in its latest guidelines. In its guidelines of April 22, CPT was already on its last legs, with the advisory recommending that it is advisable only in early moderate disease, or within seven days of symptoms. These updates flow from periodic reviews of medicines and treatment protocol by a task force of doctors and experts of the ICMR. Practising doctors are not legally bound to follow these recommendations to the T but are expected to circumscribe their treatments within the guidelines. Last year, the ICMR, in one of the definitive clinical trials in the world, demonstrated that CPT neither saved lives nor improved patient outcomes but was equivocal about it in public. This gave leeway to some States, particularly the Delhi government, which openly disavowed the ICMR’s findings, encouraging several doctors to put the onus on hapless caregivers to source such plasma from those who had recovered from the illness. The clamour for plasma had birthed its own kind of ecosystem. There were apps designed to connect donors to recipients, an inevitable black market, and, if the plasma did not seem to be working, the tendency was to blame the quality of plasma rather than recognise the futility of the treatment.
Last week, it took a letter by a clutch of concerned public health professionals to India’s Principal Scientific Adviser as well as results from a trial, published in The Lancet, spanning around 11,000 patients — that again found no benefit — to demote CPT. Further evidence is emerging that CPT may be contributing to the evolution of coronavirus mutations that, together, may have been the final nail in the coffin. However, this is not the end of the road for treatments with limited scientific basis finding a mention in the ICMR guidelines. Hydroxychloroquine and the anti-parasitic drug, ivermectin, continue to find a place for the treatment of mild disease despite a specific mention of “low certainty of evidence”. There is an argument that doctors, battling a disease that has so far defied a predictable treatment regime, cannot always observe the necessary clinical equipoise. Unlike doctors on the frontline, a collective of experts such as the ICMR taskforce, has the comfort and the distance to dispassionately assess evidence and be very specific with its recommendations. Publicising these at regular intervals serves to educate the public about the evolving nature of treatment and be better prepared as future patients and caregivers. This will work better towards easing the pressure on doctors as well as in improving trust in systems that are designed to offer the best possible expertise.