February 13, 2021

REBEL Cast Ep95: Colchicine in COVID (COLCORONA)? Don’t Believe the Hype.

Background: Science by press release. Not the way any of us would choose to operate but, the COVID pandemic has made this a reality. It’s vital that we understand that while pharmaceutical companies have a responsibility to release this information, we as clinicians should not be practicing medicine based on press releases. Of course, these press releases don’t only originate from pharma. On January 22nd, 2021, the Montreal Heart Institute released a statement about the results from the COLCORONA study investigating the use of colchicine in COVID-19. The press release painted a very positive picture but, does the pre-peer reviewed publication stand up?

REBEL Cast Ep95: Colchicine in COVID (COLCORONA)? Don’t Believe the Hype.

Paper: Tardif JC et al. Efficacy of Colchicine in Non-Hospitalized Patients with COVID-19. MedRxiv 2021[Link is HERE] ClinicalTrials.gov

Clinical Question: Does colchicine reduce the risk of hospitalization or death in outpatients with COVID-19 who are at high-risk for decompensation?

Population: Patients ≥ 40 years of age with a diagnosis of COVID-19 who could be enrolled within 24 hours of diagnosis, were not currently hospitalized and not under immediate consideration for hospitalization. All patients had to have at least one of the following high-risk criteria:

  • Age > 70
  • Obesity (BMI > 30 kg/m2)
  • Diabetes
  • Uncontrolled hypertension (SBP > 150 mm Hg)
  • Known respiratory disease
  • Known heart failure
  • Known coronary artery disease
  • Fever > 38.4 C within the last 48 hours
  • Dyspnea at the time of presentation
  • Bicytopenia
  • Pancytopenia
  • Combination of high neutrophil and low lymphocyte count

Intervention: Colchicine 0.5 mg Q12 X 3 days followed by 0.5 mg Q24 X 27 days

Control: Placebo

Outcome (Primary): Composite endpoint of death or hospitalization due to COVID-19 within 30 days following randomization (intention to treat analysis)

Outcomes (Secondary): Components of the composite primary endpoint (death or hospitalization within 30 days), mechanical ventilation within 30 days of randomization

Design: Randomized, double-blind, placebo-controlled, investigator-initiated trial. Interim analyses pre-specified at 25, 50 and 75% enrollment

Exclusion:

  • Pregnant women
  • Women not practicing adequate contraception
  • Inflammatory bowel disease
  • Chronic diarrhea
  • Pre-existing malabsorption
  • Pre-existing neuromuscular disease
  • GFR < 30 ml/min
  • Severe liver disease
  • Current treatment with colchicine
  • Current chemotherapy
  • History of colchicine sensitivity

Results:

Primary Results:

  • Enrollment from March 2020 to December 2020
  • 4488 patients underwent randomization
    • Primary endpoint status known for 97.9% of patients
  • 4159 patients found to be SARS-CoV2 PCR positive
  • Patients enrolled a mean of 5.3 days after symptom onset

Critical Results:

Adverse Events:

  • Diarrhea:
    • Colchicine: 300/2195 (13.7%)
    • Placebo: 161/2217 (7.3%)
    • P<0.0001

Strengths:

  • Randomized, double-blind, placebo-controlled trial
  • Multicenter, multinational study increasing external validity
  • Baseline characteristics that were reported are well-balanced
  • Evaluated patients in the outpatient setting, early in disease with a medication that is orally administered and inexpensive

Limitations:

  • Primary endpoint was composite of outcomes that are not equivalent (death and hospitalization are not the same)
  • Enrollment was non-consecutive which may introduce bias
  • Study powered to find a 25% relative risk reduction which may have been overly ambitious
  • Study stopped at 75% enrollment
  • Follow up was only 30 days

Discussion:

  • Regardless of press release and spin of data, this was a negative study. It is only after manipulation of the data that the authors were able to show a small benefit in preventing hospitalization.
  • Secondary analysis removed patients who were PCR negative
    • The authors state that this was a prespecified analysis but, there is no indication of this on clinicaltrials.gov
    • PCR results are not 100% sensitive. Exclusion of patients who were PCR negative may have resulted in exclusion from secondary analysis of patients who actually did have COVID
    • Statistical significance was driven by hospitalization rate (subjective) not mortality (objective)
    • Regardless, this is a post-hoc analysis and should not be used to change management
  • Colchicine has considerable toxicity including multisystem organ dysfunction

Author Conclusion: “Among non-hospitalized patients with COVID-19, colchicine reduces the composite rate of death or hospitalization. “

Our Conclusions: The authors have taken substantial liberties in their interpretation. Based on the sound methodology set up for this study, there is no significant clinical benefit for colchicine in the treatment of COVID19.

Bottom Line: Colchicine should not be given to patients with COVID19 outside of the setting of a clinical study

ADDENDUM 03/05/2021 – RECOVERY Trial Press Release 

References:

  1. Tardif JC et al. Efficacy of Colchicine in Non-Hospitalized Patients with COVID-19. MedRxiv 2021[Link is HERE] ClinicalTrials.gov

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Cast Ep95: Colchicine in COVID (COLCORONA)? Don’t Believe the Hype.", REBEL EM blog, February 13, 2021. Available at: https://rebelem.com/rebel-cast-ep95-colchicine-in-covid-colcorona-dont-believe-the-hype/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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