Sunday Roundup number 2
Rwanda makes a lot of progress in containing the Marburg virus and we see semaglutide in action against arthritis.
A variety of interesting news stories came out this week. However, building on from last week, it was the Marburg virus and lifestyle disorders which really caught my eye.
Progress on combating the Marburg Virus
The Marburg Virus has been the cause of much concern around the world, with multiple actors working to develop vaccines. However, recent news from Rwanda has been very encouraging. The country has recorded 15 Marburg virus related deaths (out of 66 confirmed cases) with a case fatality rate of 22.7%, which is quite remarkable. Past outbreaks have seen case fatality rates of between 24% - 88%. The past two weeks have seen four new cases, with the trend being that of an outbreak tapering off.
However, it is important to note that this does not mean that the threat is over. The country's health minister has stressed upon remaining on alert and looking out for new cases as and when they come. The country's public health system is in much better shape than its neighbours, allowing Rwanda to hopefully add to the pool of knowledge on combating the virus.
Indeed, the country has built upon its existing strengths to inoculate more than 1,600 people against the virus. The healthcare response has focussed on contacts of known positives and people at high risk. Another 500 contacts of known positive patients are being followed up with to ensure that they receive proper treatment should they show signs of the virus. The country has used a strategy of rapid detection, rapid testing, quick isolation, treatment of positive cases and vaccination, which has proven remarkably effective in slowing further spread.
Rwanda has also demarcated the cave thought to be the most likely origin of the virus and fenced it off to humans. DNA sequencing has revealed that the virus has probably jumped from bats to humans exactly once, with the very first identified patient having a history of being exposed to fruit bats in that particular cave. Rwanda has gone further and marked out a number of caves where human-bat interaction may lead to other such zoonotic events.
Semaglutide for arthritis
A new trial, funded by Novo Nordisk, tries to identify the benefits of semaglutide (sold as either Ozempic or Wegovy depending on whether you take it for weigth loss or diabetes) for people suffering from knee osteoarthritis.
Osteoarthritis is a disorder characterised by the breakdown of cartilage in one's joints over time. It is the most common form of arthritis and tends to affect weight bearing joints like the knees, hips, and the spine. The standard way to treat it is to treat the symptoms. This usually involves lifestyle modifications such as weight loss and increased exercise as well as pain relief medications (opioids in some extreme cases) and at times assistive devices.
However, given the primary observable effect of semaglutide is weight loss, it was thought to have potential to help with alleviating the symptoms of osteoarthritis as well. A double blind randomised placebo-controlled trial was held across 61 sites in 11 countries. Around 400 participants were enrolled in a 2:1 ratio and given either semaglutide or a placebo. All participants were also given counselling and instructions on regular methods of weight loss.
The results were incredibly encouraging for the intervention group. While both groups were able to reduce weight, the target group was able to achieve a much higher reduction in weight as compared to the control group. The target group also reported lesser pain, achieving reductions which were at par with opioids, demonstrating the anti-inflammatory properties of semaglutide. In fact, the results were so effective that many in the target group effectively got treated out of the study.
While these results are incredibly encouraging, it is important to exercise caution when interpreting them. The trial explicitly focussed on those with an extremely high BMI. The mean BMI for study participants was 40.3, which is well into the spectrum of obesity. In addition, it is known that participants tend to regain weight very quickly after being taken off semaglutide, which is a very costly drug to be taken regularly. It remains to be seen whether these benefits transfer to those with lower BMIs and whether the treatment reduces in price enough to become an easy prescription for doctors dealing with these cases.
Involving pregnant individuals in trials relating to rheumatic and musculoskeletal disease
Clinical trials tend to be cautious about recruiting pregnant individuals due to fears about affecting the foetus. This is the ethical thing to do: it would be strange for someone to argue against this in principle. However, the incidence and prevalence of rheumatic and musculoskeletal disorders in younger people (often of childbearing age) is rising. Unfortunately, the mechanics and ethics of clinical trials often work at cross-purposes with efficient diagnosis of these issues during and around pregnancy.
Most studies dealing with rheumatic disorders have historically targeted older populations: these disorders tend to be more common in that age group. Despite the need to test and understand the effect of these drugs during pregnancy, clinical trials in pregnancy are rare, therapeutics are often not validated for pregnant individuals, and pregnant individuals are routinely excluded from premarketing clinical trials. Most data on the effects of new drugs as well as the efficacy of new therapeutics on pregnant individuals come from post-marketing observational trials. Observational studies assessing the bidirectional relationship between rheumatic and musculoskeletal diseases and pregnancy, as well as interventional studies of treatments during pregnancy, are scarce.
The historical bias of medicine against women is well-known. However, new ways to conduct trials for this population which are acceptable to everyone involved, from those conducting the trials to those participating in them. Unless the systems around ethics for clinical trials do not resolve this dilemma and start working towards actively trying to create a set of standards which ensure both mother and foetal needs are prioritised, this will remain a major gap within the healthare system.