The Randomized Embedded Multifactorial Adaptive Platform Trial in Community-Acquired Pneumonia (REMAP-CAP): Enshrining a Global Pandemic Research Response to COVID-19 and Beyond

The Randomized Embedded Multifactorial Adaptive Platform Trial in Community-Acquired Pneumonia (REMAP-CAP) is an international clinical trial conceived in Canada a decade ago. It was designed to provide a mechanism to rapidly identify the most effective treatments for severely ill patients during an emerging pandemic. With the COVID-19 pandemic, the trial expanded to 361 hospitals around the world. REMAP-CAP is a platform trial that can study many different treatments at the same time; its design enables new options to be studied as the trial proceeds. We have evaluated 55 different potential treatments, and improved the care of COVID-19 patients by identifying those that are effective (corticosteroids, IL-6 receptor antagonists, heparin in some patients, and antiplatelet agents such as aspirin), ineffective (convalescent plasma, heparin in severely ill patients, interleukin-1 receptor antagonist), and harmful (hydroxychloroquine, angiotensin receptor blockers). To date we have studied 10,000 patients with COVID-19; the trial is ongoing. Our overall goal is to establish REMAP-CAP as a core element of the Canadian response to COVID-19 and future pandemics. This application seeks support to recruit a further 540 Canadian patients, and to expand the network both within Canada and internationally, providing mentorship to new sites and new investigators in resource-limited settings. We will study new therapies that target inflammation, and collaborate with other programs in the Canadian Critical Care Trials Group to study the best supportive care of critically ill COVID-19 patients in the areas of fluid management, and sedation. Finally, we will work with patient and family partners and international colleagues to improve the informed consent process for the trial, and to better understand the ethical dimensions of pandemic research. COVID-19 has brought pain and disruption, but it has also shown what we can accomplish when we collaborate globally.