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Zuckerman S, Barlavie Y, Niv Y, Arad D, Lev S. Accessing unproven interventions in the COVID-19 pandemic: discussion on the ethics of 'compassionate therapies' in times of catastrophic pandemics. JOURNAL OF MEDICAL ETHICS 2022; 48:1000-1005. [PMID: 34645620 PMCID: PMC8520601 DOI: 10.1136/medethics-2020-106783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/26/2021] [Indexed: 06/13/2023]
Abstract
Since the onset of the SARS-CoV-2 pandemic, an array of off-label interventions has been used to treat patients, either provided as compassionate care or tested in clinical trials. There is a challenge in determining the justification for conducting randomised controlled trials over providing compassionate use in an emergency setting. A rapid and more accurate evaluation tool is needed to assess the effect of these treatments. Given the similarity to the Ebola Virus Disease (EVD) pandemic in Africa in 2014, we suggest using a tool designed by the WHO committee in the aftermath of the EVD pandemic: Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI). Considering the uncertainty around SARS-CoV-2, we propose using an improved MEURI including the Plan-Do-Study-Act tool. This combined tool may facilitate dynamic monitoring, analysing, re-evaluating and re-authorising emergency use of unproven treatments and repeat it in cycles. It will enable adjustment and application of outcomes to clinical practice according to changing circumstances and increase the production of valuable data to promote the best standard of care and high-quality research-even during a pandemic.
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Affiliation(s)
- Shlomit Zuckerman
- Department of Disaster Medicine & Center for Bioethics and Law, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron Barlavie
- Division of Intensive Care, Rambam Health Care Campus, Haifa, Israel
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Yaron Niv
- Quality and Safety Program, Ministry of Health, Jerusalem, Israel
- Department of Internal Medicine, Ariel University, Ariel, Israel
| | - Dana Arad
- Division of Patient Safety, Ministry of Health, Jerusalem, Israel
- Department of Health System Managment, Bar Ilan University, Ramat Gan, Israel
| | - Shaul Lev
- Unit of General Intensive Care, Hasharon Hospital, Petah Tikva, Israel
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Old drugs for a new indication: a review of chloroquine and analogue in COVID-19 treatment. Porto Biomed J 2021; 6:e132. [PMID: 34136717 PMCID: PMC8202634 DOI: 10.1097/j.pbj.0000000000000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/12/2021] [Accepted: 01/25/2021] [Indexed: 12/27/2022] Open
Abstract
As an innovative therapeutic strategy, drug repurposing affords old, approved, and already established drugs a chance at new indications. In the wake of the COVID-19 pandemic and the accompanied urgency for a lasting treatment, drug repurposing has come in handy to stem the debilitating effects of the disease. Among other therapeutic options currently in clinical trials, chloroquine (CQ) and the hydroxylated analogue, hydroxychloroquine (HCQ) have been frontline therapeutic options in most formal and informal clinical settings with varying degrees of efficacy against this life-threatening disease. Their status in randomized clinical trials is related to the biochemical and pharmacological profiles as validated by in vitro, in vivo and case studies. With the aim to bear a balance for their use in the long run, this review not only synopsizes findings from recent studies on the degrees of efficacy and roles of CQ/HCQ as potential anti-COVID-19 agents but also highlights our perspectives for their consideration in rational drug repositioning and use.
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COVID-19, Chloroquine Repurposing, and Cardiac Safety Concern: Chirality Might Help. Molecules 2020; 25:molecules25081834. [PMID: 32316270 PMCID: PMC7221598 DOI: 10.3390/molecules25081834] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
The desperate need to find drugs for COVID-19 has indicated repurposing strategies as our quickest way to obtain efficacious medicines. One of the options under investigation is the old antimalarial drug, chloroquine, and its analog, hydroxychloroquine. Developed as synthetic succedanea of cinchona alkaloids, these chiral antimalarials are currently in use as the racemate. Besides the ethical concern related to accelerated large-scale clinical trials of drugs with unproven efficacy, the known potential detrimental cardiac effects of these drugs should also be considered. In principle, the safety profile might be ameliorated by using chloroquine/hydroxychloroquine single enantiomers in place of the racemate.
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Buckley M, O’neil C. The Practice of Pharmaceutics and the Obligation to Expand Access to Investigational Drugs. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 45:193-211. [DOI: 10.1093/jmp/jhz038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Do pharmaceutical companies have a moral obligation to expand access to investigational drugs to patients outside the clinical trial? One reason for thinking they do not is that expanded access programs might negatively affect the clinical trial process. This potential impact creates dilemmas for practitioners who nevertheless acknowledge some moral reason for expanding access. Bioethicists have explained these reasons in terms of beneficence, compassion, or a principle of rescue, but their arguments have been limited to questions of moral permissibility, leaving for future research the question of whether expanded access is morally obligatory. We take up this further question and argue that pharmaceutical companies have a moral obligation to expand access. Our defense is not based on beneficence, compassion, or rescue, but instead on a reciprocal moral expectation resulting from existing social commitments that help ensure a robust pharmaceutical practice within the broader healthcare system. Our aim is to give this obligation, along with several others, a coherent and plausible structure within the wider clinical trial process so that one might better explain the sources of the dilemmas and their possible resolutions.
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Affiliation(s)
- Michael Buckley
- Lehman College, City University of New York, Bronx, New York, USA
| | - Collin O’neil
- Lehman College, City University of New York, Bronx, New York, USA
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Bhadelia N, Sauer L, Cieslak TJ, Davey RT, McLellan S, Uyeki TM, Kortepeter MG. Evaluating Promising Investigational Medical Countermeasures: Recommendations in the Absence of Guidelines. Health Secur 2019; 17:46-53. [PMID: 30724616 DOI: 10.1089/hs.2018.0092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Emerging and re-emerging infectious diseases pose growing global public health threats. However, research on and development of medical countermeasures (MCMs) for such pathogens is limited by the sporadic and unpredictable nature of outbreaks, lack of financial incentive for pharmaceutical companies to develop interventions for many of the diseases, lack of clinical research capacity in areas where these diseases are endemic, and the ethical dilemmas related to conducting scientific research in humanitarian emergencies. Hence, clinicians providing care for patients with emerging diseases are often faced with making clinical decisions about the safety and effectiveness of experimental MCMs, based on limited or no human safety, preclinical, or even earlier product research or historical data, for compassionate use. Such decisions can have immense impact on current and subsequent patients, the public health response, and success of future clinical trials. We highlight these dilemmas and underscore the need to proactively set up procedures that allow early and ethical deployment of MCMs as part of clinical trials. When clinical trials remain difficult to deploy, we present several suggestions of how compassionate use of off-label and unlicensed MCMs can be made more informed and ethical. We highlight several collaborations seeking to address these gaps in data and procedures to inform future clinical and public health decision making.
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Affiliation(s)
- Nahid Bhadelia
- Nahid Bhadelia, MD, MA, is Medical Director, Special Pathogens Unit, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA
| | - Lauren Sauer
- Lauren Sauer, MS, is Assistant Professor, Director of Research, Johns Hopkins Biocontainment Unit, Department of Emergency Medicine, Johns Hopkins Medicine, Baltimore, MD
| | - Theodore J Cieslak
- Theodore J. Cieslak, MD, MPH, is Associate Professor, Department of Epidemiology, University of Nebraska College of Public Health, Omaha, NE
| | - Richard T Davey
- Richard T. Davey, MD, is Deputy Clinical Director, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Susan McLellan
- Susan McLellan, MD, MPH, is Medical Director, Biocontainment Treatment Unit, Division of Infectious Diseases, University of Texas Medical Branch at Galveston, TX
| | - Timothy M Uyeki
- Timothy M. Uyeki, MD, MPH, MPP, is Chief Medical Officer, Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mark G Kortepeter
- Mark G. Kortepeter, MD, MPH, is Professor, Department of Epidemiology, University of Nebraska College of Public Health, Omaha, NE
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Borysowski J, Saxena A, Bateman-House A, Papaluca M, Różyńska J, Wnukiewicz-Kozłowska A, Górski A. Expanded access: growing importance to public health. J Epidemiol Community Health 2018; 72:557-558. [PMID: 29627785 DOI: 10.1136/jech-2017-210409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/07/2018] [Accepted: 03/22/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Jan Borysowski
- Department of Clinical Immunology, Medical University of Warsaw, Warsaw, Poland.,Centre for Research Ethics, Institute of Law Studies, Polish Academy of Sciences, Warsaw, Poland
| | - Abha Saxena
- Coordinator, Global Health Ethics, Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Alison Bateman-House
- Division of Medical Ethics, NYU Langone Health, NYULH Working Group on Compassionate Use and Pre-Approval Access, New York City, New York, USA
| | | | - Joanna Różyńska
- Department of Ethics, Institute of Philosophy, University of Warsaw, Warsaw, Poland
| | - Agata Wnukiewicz-Kozłowska
- Public International and European Law, Faculty of Law, Administration and Economy, Wrocław University, Wrocław, Poland
| | - Andrzej Górski
- Department of Clinical Immunology, Medical University of Warsaw, Warsaw, Poland.,Laboratory of Bacteriophages, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Warsaw, Poland
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Calain P. The Ebola clinical trials: a precedent for research ethics in disasters. JOURNAL OF MEDICAL ETHICS 2018; 44:3-8. [PMID: 27573153 PMCID: PMC5749307 DOI: 10.1136/medethics-2016-103474] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/15/2016] [Accepted: 08/07/2016] [Indexed: 05/07/2023]
Abstract
The West African Ebola epidemic has set in motion a collective endeavour to conduct accelerated clinical trials, testing unproven but potentially lifesaving interventions in the course of a major public health crisis. This unprecedented effort was supported by the recommendations of an ad hoc ethics panel convened in August 2014 by the WHO. By considering why and on what conditions the exceptional circumstances of the Ebola epidemic justified the use of unproven interventions, the panel's recommendations have challenged conventional thinking about therapeutic development and clinical research ethics. At the same time, unanswered ethical questions have emerged, in particular: (i) the specification of exceptional circumstances, (ii) the specification of unproven interventions, (iii) the goals of interventional research in terms of individual versus collective interests, (iv) the place of adaptive trial designs and (v) the exact meaning of compassionate use with unapproved interventions. Examination of these questions, in parallel with empirical data from research sites, will help build pragmatic foundations for disaster research ethics. Furthermore, the Ebola clinical trials signal an evolution in the current paradigms of therapeutic research, beyond the case of epidemic emergencies.
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Royo-Bordonada MÁ, García López FJ. Ethical considerations surrounding the response to Ebola: the Spanish experience. BMC Med Ethics 2016; 17:49. [PMID: 27538685 PMCID: PMC4991003 DOI: 10.1186/s12910-016-0135-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/10/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The recent Ebola virus disease (EVD) outbreak, with 28,646 reported cases and 11,323 deaths, was declared a public health emergency of international interest by the World Health Organisation. In Spain, a single reported case triggered a public health crisis of a markedly media-centred nature. The approach to the first EVD epidemic has given rise to various ethical considerations around the world. We address the most relevant ethical considerations emanating from the management of EVD in Spain. MAIN BODY Firstly, for reasons of global justice and humanitarian assistance, rich countries have the duty to support poorer countries in building up their core public-health capacities. Secondly, quarantine for high-risk contacts might have been a disproportionate and not properly justified measure, which could have contributed to stigmatising contacts and spreading panic. Thirdly, when the first secondary case was reported in Spain, it is doubtful whether informed consent requirements were strictly complied with when disclosing information concerning the alleged accident potentially causing the contagion. Moreover, this information was used by the Regional Health Minister to blame the patient, evading his responsibility to ensure safe medical procedures for health workers. Finally, the patient received convalescent plasma for compassionate use from a colleague of the first missionary repatriated, who also participated in a research study in Spain, despite having previously been denied the chance of being transferred to Spain to receive treatment. This fact highlights the asymmetry in the relationship between rich and poor countries. SHORT CONCLUSION The management of this crisis highlighted the technical capacity of the health system and its professionals to respond effectively to public health emergencies caused by emerging diseases. This said, the failures in the protection of the EVD patient's privacy remind us that this aspect has to be borne in mind from the outset in crisis situations. Certain coercive measures, such as quarantine, should only be applied where there is some evidence that the benefit-risk balance could be favourable. Lastly, it is essential that research and interventions targeted at combating the fragility of the health systems in poor countries respond to reasons of global justice.
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Affiliation(s)
- Miguel Ángel Royo-Bordonada
- National School of Public Health, Institute of Health Carlos III, 8 Sinesio Delgado Street, Madrid, 28029 Spain
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Gleicher N, Kushnir VA, Barad DH. Why Prospectively Randomized Clinical Trials Have Been Rare in Reproductive Medicine and Will Remain So? Reprod Sci 2015; 23:6-10. [PMID: 26282699 DOI: 10.1177/1933719115597768] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There is almost unanimity that modern medicine should be "evidence based." In this context, lack of prospectively randomized clinical trials (RCTs) is widely lamented in reproductive medicine. Some leading voices, indeed, increasingly suggest that only RCT-based clinical conclusions should be integrated into clinical practice, since lower levels of evidence are inadequate. We have argued that reproductive medicine requires special considerations because, like clinical oncology, fertility treatments (especially in older women) are time dependent. Unlike clinical oncology, reproductive medicine, however, does not receive substantial financial research support from government or industry and, at least in the United States, has, therefore, to be primarily funded via patient revenues. Given a 50% chance of receiving placebo, infertility patients are, understandably, reluctant to fund their own RCTs. We here selectively review this subject, contrasting opposing opinions recently published in the literature by a prominent reproductive scientist and one of the world's leading experts on evidence-based medicine. Placing these recent publications into the evolving context of infertility practice, as also addressed in this journal in recent publications, we conclude that objective reasons explain why relatively few RCTs are performed in reproductive medicine and predict that this will not change in the foreseeable future. Reproductive medicine, therefore, has to find ways to develop satisfactory clinical evidence in other ways, satisfying patients' rights to easy access to potentially beneficial medical treatments with low costs and low risks. The RCTs should be reserved for relatively high risk and/or high cost treatments.
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Affiliation(s)
- Norbert Gleicher
- The Center for Human Reproduction, New York, NY, USA The Foundation for Reproductive Medicine, New York, NY, USA Stem Cell and Molecular Embryology Laboratory, The Rockefeller University, New York, NY, USA
| | - Vitaly A Kushnir
- The Center for Human Reproduction, New York, NY, USA Department of Obstetrics and Gynecology, Wake Forest University, Winston Salem, NC, USA
| | - David H Barad
- The Center for Human Reproduction, New York, NY, USA The Foundation for Reproductive Medicine, New York, NY, USA Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, NY, USA
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Keirns CC. Everyday ethics and Ebola: planning for the unlikely. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:68-70. [PMID: 25856610 DOI: 10.1080/15265161.2015.1010020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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White BD, Gelinas LC, Shelton WN. In particular circumstances attempting unproven interventions is permissible and even obligatory. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:53-55. [PMID: 25856604 DOI: 10.1080/15265161.2015.1009566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Allen NG, Blumenthal-Barby JS, McCullough LB. Placing and evaluating unproven interventions within a clinical ethical taxonomy of treatments for Ebola virus disease. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:50-53. [PMID: 25856603 DOI: 10.1080/15265161.2015.1009567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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