Adapting for the future: what can we learn from REMAP-CAP and COVID-19 pandemic trials?

In this issue of Thorax , the REMAP-CAP investigators publish the final results from the COVID-19 Immune Modulation Therapy Domain for COVID-19 of Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP).1 REMAP-CAP is an international, adaptive, platform trial focused on hospitalised patients with pneumonia. At the outset of the COVID-19 pandemic in early 2020, REMAP-CAP added a COVID-19 appendix to the existing master protocol to include investigational studies focused on hospitalised patients with COVID-19. The Immune Modulation Therapy Domain for COVID-19 evaluated two interleukin 6 (IL-6) receptor antagonists (tocilizumab and sarilumab), the IL-1 receptor antagonist anakinra and interferon β1a (IFN-β1a) against control (usual care) in an open-label design. The preliminary results from this Domain were previously published in the midst of the COVID-19 pandemic in April 2021.2 It included 353 patients in the tocilizumab arm, 48 in the sarilumab arm and 402 assigned to control. The report demonstrated that the IL-6 receptor antagonists improved both organ support-free days and mortality with posterior probabilities of over 99% compared with control. These results, along with those published by the RECOVERY group, established tocilizumab as a key therapeutic for severe COVID-19, and its use was …