All patients should be allowed access to promising treatments under compassionate use provisions. There is a completely misguided and highly unethical belief that new treatments should only be given in the context of randomised controlled trial, no matter how promising the treatment is (the pre-test probability) and no matter whether the patient is otherwise going to die.

RCTs and evidence-based medicine are not suited to a fast-paced, hugely combinatorial, often lethal pandemic, such as the case with CoViD-19.

The insistence within the establishment on the RCT model is reminiscent of the lethal futility of early World War 1 generals sending men 'over the top' in mass futile attacks. That is what the establishment had been doing for centuries, but it wasn't suited to modern warfare. It took people such as General Monash to change the paradigm to a much more adaptive one.

It has reached absurd stages where an editorial viewpoint in JAMA was advocating that unless a disease is '100% lethal' only those enrolled in an RCT should have access to new treatments, no matter how promising the treatment is. That would mean the author would literally advocate for an RCT of parachutes!

Almost all the advancement we have had in treating CoViD has come through clinical innovation through an evolutionary, learning system. The RCT has provided us almost nothing, except that which was so apparent, that those particular treatments were being used anyway.

Regeneron developed two very specific immunotherapies, antibodies, and these target the so-called spike protein of the virus - the part of the virus that it uses to attach to human cells. Once it is inside the human cells it starts to multiply. The idea is that these antibodies can block these spike proteins from attaching to the cells and thereby prevent the virus getting into cells in the first place.

We don’t know how effective this drug will be. The drug has been tested in about 275 people and the average age in that clinical trial is 44, so that is quite different to Mr Trump. Those investigators were able to show a lower viral load and also time to recovery, but in any individual, it would be very hard to predict what is going to happen.

Mr Trump is in a very high-risk category, because of his age, his weight, being a man – men are more likely to develop severe complications with COVID-19. It may be that the trial group don’t match these criteria. It will be a bit of an unknown how he will respond to this therapy.

We know from all the studies that have been done around the world and how people are affected by this virus that in people of older age, in people who have underlying heart disease or co-morbidities like diabetes, or they are overweight, or male, they’re much more likely to experience severe complications with the coronavirus.

We haven’t done clinical trials on things like zinc and vitamin D and how that impacts people’s response to the coronavirus. So really, Mr Trump is in a very experimental situation.

Mr Trump apparently received three medications to treat COVID-19. Dexamethasone is a type of steroid that is widely available and relatively cheap. The RECOVERY trial in the UK showed that it reduced the death rate from COVID-19 in those who were on a ventilator or were receiving supplemental oxygen. Apparently, the President received supplemental oxygen for a brief period, although the duration of this and his oxygen levels haven't been given. 

Remdesivir is an antiviral agent that has been found to have activity against coronaviruses, including against SARS-CoV-2. A new guideline issued by the American College of Physicians 'points toward a net benefit' in people with moderate or severe COVID-19; however, a randomized controlled trial didn't show a clear reduction in deaths from remdesivir.

The final therapy - monoclonal antibodies - attacks the virus just like our own immune system. The company (Regeneron) released some early data on 275 participants showing that in non-hospitalised patients who haven't as yet naturally developed antibodies to COVID-19, this therapy might reduce the amount of virus and help their symptoms. But as the trial is ongoing, we should be cautious about drawing conclusions. Also, while dexamethasone is cheap, remdesivir and the monclonal antibody therapy together are likely to cost many thousands of dollars.

It has been reported that the President Trump has received therapy that includes dexamethasone, remdesivir and Regeneron’s antibody cocktail. Dexamethasone and Remdesivir are two therapies for COVID-19 for which there is an evidence base, however the evidence to date supports their use more for patients with more severe disease than has been reported in the case of President Trump thus far.

Dexamethasone is a very commonly used steroid or strong anti-inflammatory medication, however no benefit has been demonstrated in those who are not critically ill, and so in patients with mild infection the risks likely outweigh the benefits. Remdesivir is an antiviral medication that has been shown to have an effect against SARS-CoV-2, and has subsequently been approved for use in many countries including the USA, although not all trials have demonstrated significant benefits. Given he was hospitalised, treatment with remdesivir would be considered reasonable.

The Regeneron antibody cocktail containing two monoclonal antibodies designed to block the virus has shown promising early data that suggests it can reduce the viral load and time to alleviate symptoms, however it is still considered investigational hence use should remain in the context of clinical trials.

The difficulty in combining therapies and using experimental intervention outside of a properly conducted clinical trial is that whatever the outcome it will be challenging to know which, if any of these interventions, actually contributed favourably or otherwise. I wish him a speedy recovery, however, as with all patients, would favour seeing treatment in accordance with the best available evidence at the time.

This group of experts from the American College of Physicians has done a good professional job of summarising the currently available evidence on a complex problem. Their assessment is that on the balance of evidence Remdesivir has some limited effects that are potentially of clinical value. Most of the outcomes are defined as of low certainty but include the possibility of slightly reduced mortality, fewer serious side effects compared to standard care, although that was not defined. There was a modest increase in recovery and clinical improvement and possibly a reduction in time to recovery. More data are available on 5 days of treatment than 10 days. But the data are insufficient for it to be clear whether one is better or worse than the other.

However these possible modest to minor gains have to be set against the possibility of adverse reactions. The most severe of these is an allergic reaction which itself could be life threatening, although treatable if the patient is in a clinal setting, as is likely in the case of COVD-19 infection.

Remdesivir is known to interact adversely with hydroxychroquine (and a more than 200 other drugs). If President Trump was still taking hydroxychroquine or other drug treatment he would have to have been weaned off that before starting remdesivir treatment.

The use of dexamethasone is on a sounder footing. This partly because this anti-inflammatory steroid has been used in other infectious and inflammatory conditions. There is some clinical trial evidence that in Covid-19 dexamethasone ameliorates some of the potential life- threatening effects of Covid-19 on lung function.

The antibody treatment given to President Trump is an unknown quantity and impossible to assess as I am not aware of any published evidence on what the treatment contains or results from administration to patients. As with any antibody treatment it will carry the risk of an allergic reaction.

Overall this plethora of treatment smacks of a sense of desperation.

President Trump has recently received the antiviral drug remdesivir as part of a combination of therapies designed to reduce the possible adverse outcomes of his SARS-CoV-2 infection. The combination of treatments employed here would normally be used on patients with moderate to severe disease. In the President's case, the time from initial diagnosis to the time showing showing serious symptoms, e.g. sudden drops in blood oxygenation and need to administer supplementary oxygen is exceptionally short. The normal progression towards severity usually takes 8-10 days rather than 1 or 2 for Trump. Assuming the testing time-scales reported are correct, It is possible that the medical team were alarmed by the sudden decline and thus have used an aggressive combination of therapies (including an unlicensed experimental antibody cocktail still under clinical trials).

The least controversial component of the President's treatment is the remdesivir itself, although it is still experimental for COVID-19. In several clinical trials remdesivir has been shown to assist the recovery of some patients who require oxygenation, but the overall effects are not dramatic, it statistically improves the severity. Remdesivir appears to be well tolerated and does not give severe side effects in most patients, although it might impair liver function in some. This is a potential worry for extended therapy, given that the virus can also cause liver damage in some patients. The purpose of clinical trials is to estimate the probabilities of such interactions but that is still unknown for remdesivir but the president's medical team has not reported any abnormal liver function tests.

Dexamethazone has also been used in the President's combination therapy, again this would be normally only given to patients with quite serious disease as it can cause significant side effects. One side effect of this is 'euphoria', which might partly explain the President's strong feeling that he is recovering rapidly. If the COVID-19 trajectory shown by the President is 'typical' we will not know if he is really recovering for several days yet.

Last month the U.S. Food and Drug Administration broadened the scope of the existing emergency use authorization (EUA) for Veklury (remdesivir) to all hospitalised adult and paediatric patients with suspected or laboratory-confirmed COVID-19, irrespective of their severity of disease. The expanded scope of the EUA was supported by analysis of additional data from two randomised, controlled clinical trials that included patients with mild or moderate disease. 

Both trials showed benefits in treating hospitalised patients with COVID-19 of mild to moderate severity, though neither was sufficiently large to show a statistically significant reduction in mortality due to COVID-19. Much larger clinical trials will be required to demonstrate this. However, together with steroids, patients hospitalised with COVID-19 infections now have more treatment options available to them. Mr Trump may have benefited from the availability of these treatments during his recent hospitalisation.

On the assumption that the Therapeutic Goods Administration has, or will, expand allowed use of Veklury to hospitalised patients with mild to moderate COVID-19 and sufficient stocks of the drug are available in Australia, hospitalised patients here should also benefit from the expanded availability of Veklury.

President Trump’s failure to delegate authority during his illness is a danger to the world: no-one with low oxygen levels or hospitalised with COVID-19 should hold the power to launch nuclear weapons.

Mr Trump can decide alone to launch nuclear weapons, without consulting anyone. 

Mr Trump’s male sex, age (74) and obesity put him at high risk of severe illness with COVID-19. Mr Trump is reported to have had high fever, reduced oxygen levels and abnormal lung imaging. He has been treated with an experimental monoclonal antibody cocktail, oxygen, the antiviral remdesivir, and dexamethasone, recommended for patients with severe and critical illness. 

Low oxygen is a potent cause of impaired mental functioning. COVID-19 can affect mental functioning both acutely and longer term. Medications can cause side effects, especially in combination in older persons. Steroids like dexamethasone can cause anxiety, mood swings, psychotic episodes and paranoid states. 

Yesterday his physician advised that Mr Trump was not 'out of the woods yet'. Patients with COVID-19 can deteriorate rapidly and develop blood clots up to 10 days after illness onset.

No human being is infallible or invulnerable. No human being should have the power to unleash worldwide indiscriminate radioactive incineration. If Mr Trump has not voluntarily delegated authority during his illness, the cabinet or Congress should delegate it for him, and then act to remove sole presidential authority to launch nuclear weapons for any president.