Medications compromising Covid Infections

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April 2, 2020 | 61 Comments

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  1. Absolutely brilliant post. Thank you Joan-Ramon Laporte for this highly informative and empowering Report. Let’s hope as many GPs and clinicians as possible see this and take it seriously. Maybe in the long term, once the current pandemic subsides, prescribing of all these medicines may be lessened in any case once the possible dangers of their side effects are more fully understood by those being offered them routinely by prescribers.

  2. Is this important document being circulated though ‘official’ channels ? Are there mechanism for doing this? eg Health authorities ,’care homes’ , nursing organisation etc

    • Suzanne

      No its not at the moment being circulated and if you can see anyway to help get it circulated this would be great. Chances are it would have to go through endless committees to be approved before circulating and someone on at least one committee will figure now is not the time to suggest any medicines could be causing problems

      David

    • Thank you for your comments.
      I have circulated the document to the French and Italian agencies, and to several responsible people at the Spanish agency. I have also repeatedly sent the document to various persons responsible for medicines policies within the health system here in Catalonia, and to the working group on iatrogenia at the local medical association. Basically no replies, except from family physicians and those attending nursing homes, who share and comment in their social networks. I have appeared twice in the public TV to explain parts of the document. I have shared the report in the NoGracias website. I have also written to NICE asking to consider medicines pausing as a measure of risk minimisation, and I put a twit with the US CDC asking for the same (they both do not consider medication among avoidable risk factors, except ACEIs, ARBs and ibuprofen).

      I know that is is being circulated in other regions in Spain, Italy, and France, but I have no idea of the extent of this circulation

  3. Is there any way of finding out what medicines were prescribed to the numerous patients who have died? Could the fact that so many over 65s are on many prescribed meds. be a reason for this virus apparently attacking the elderly?
    The message above definitely needs to be made public, whether affecting mainly the elderly or all ages, as every possible avenue of explanation should surely be known to all.
    Have just picked up meds. from pharmacy today – shouldn’t they be aware of this and be ready to point out the possible added dangers of the drugs they’re handing over at this time?

  4. I suspect the amount of ‘medications’ most over 65’s are taking is reaching, or has reached obscene levels.
    For a couple of years I worker as a carer, both in Nursing homes, Residential Care Homes and in the community.
    Care Homes are run in the main in the UK by private owners, they are extremely busy places, usually understaffed.
    There is a Manager, sometimes a Nurse and an assortment of minimum wage staff. With Care in the Community there is usually only minimum wage staff, who have an extremely fast turnover. My sister and brother have both worked in the care industry too.
    On a daily basis in the above environments many residents are prompted to swallow in excess of 10 different pills. Often the diets of these people are poor, so goodness knows how the pills interact.
    My own Mother, prior to her heart attack in 2014, was on nothing except Insulin.
    Now her daily chemical cocktail includes, Z-drugs, diazepam, mirtazapine and dosulepin. She is fairly fit physically, less so mentally.
    How often do the prescribers ever go into a ‘Care Home’ except to write a death certificate? How often do they go to a vulnerable individual stuck at home, dutifully swallowing their meds, as the ‘carer, ticks them off on the MARS chart. How did we ever get to this point ?
    How are we going to get out of it?
    Deprescribing, if not done carefully would cause chaos, Most Drs do not know how to get people off prescribed medications who are young and relatively healthy, let alone help those who already self isolate and who are vulnerable.
    There has to be a revolution, Drs have got to really think through WHY they are prescribing all these pills…..Do the patients truly benefit both in the short term or long term or are Drs just being pharma’s pimps ……..

    • Anna

      Good point. At some point when we come out the far side questions will be asked as to why so many were on so much with so little gain – how did this happen

      D

    • I totally agree. I am 80 and take nothing except a bit of Thyroxin.. I so healthy and eat well . I have watch the over medication with horror. people really believe something is being done for them rather than being done to them . We are totally int he grip of profit makers. The cartels are holy men cmpared with the pharmas.

  5. I made a couple of comments on “kidnapped” after witnessing the death of my mother, who, aged 95, was given Gabapentin, Fentanyl patches and doses of Morphine. She was completely taken advantage of, and I witnessed it. ‘Death from Pneumonia’.

    We’re not going to weigh her any more, they said, as her bones protruded through her flesh.
    Giving her a little hug, her shoulder blades were like daggers.

    There was no adjustment to what they were giving her.
    They didn’t have the sense to realise that she only became bed bound when they first administered the drugs. Look at the drugs –

    There will be thousands upon thousands of Coronavirus deaths from people whose health was already compromised with drugs.

    Loosely bearing on ‘Compromising’, with a particularly ‘sage’ remark from Nelson Mandela –

    The Right not to be Kidnapped

    https://rxisk.org/the-right-not-to-be-kidnapped/

  6. David are you not able to send the paper direct to the Chief Medical Officer or Public Health? I know this is a damn stupid question really but ………. Like you I get regularly derided by people when I talk to them about such things as this and they won’t believe what is put in front of their noses until it actually affects them and even then it is an uphill struggle. How about every person who gets the RxISK newsletter sending this paper to their GPs?

    • Everybody sending it to their family doctors would be a great start. This is aimed though at the whole world, not just the UK and the UK’s Chief Medical Officer. My experience of the Dept of Health is they will never countenance the possibility that any medicine anyone is on could be causing them any problems – so other routes look a better bet to me

      David

      • Since I had recent involvement with high-level Health Board officials, I’ve sent them details of this important article.
        Tried local doctors but contact there impossible at present – so letter in their ‘repeat prescriptions’ box will happen when I next go out.
        Have sent a tweet to MIND Wales – in English and Welsh. Also contacted Welsh language radio programme – they’ve retweeted the message.
        Person collecting info on opioids etc for a different Welsh language programme (who contacted me through Twitter a few weeks ago) has also now been given details of this message.
        Quite proud of myself – amazing what you have time for when at home every day!

      • I think everyone should make an effort to interpellate health authorities and health officers, at least to be sure in the future that they had received signals and they did nothing.

        Right now, the responsibility lies more in people responsible for health care than in the regulatory agencies, although in my opinion these should be more proactive in the regulation of research. For example, I looked at the clinical trials on covid developed in Spain in ClinicalTrials.gov. All but two say in the protocol that they would not share the data with other researchers. This is a shame, a system shame.

  7. I’m so glad you wrote this. Just the other day I was concerned when I read somewhere patients with Coronavirus in hospital were being given morphine and midazalam while in an induced coma. I was shocked because as you say these drugs alone suppress breathing so it makes sense it’s the worst drugs to give someone with pneumonia let alone someone in an induced coma.

    I once had midazalam given to me for a routine persidure, that night I suffered terrible sleep apnea and woke several times gasping for air. I would never want to take that again although I was on mirtazapine as well at the time so maybe the two drugs together made this worse. I stayed awake for the rest of the night too afraid to sleep untill I knew the drug had worn off.

    Morphine suppresses breathing too this is what they give palliative patients in hospices. It’s quite known that most people know it was probably the morphine that ended the patient’s life rather than the cancer so it’s very strange to give morphine to someone with pneumonia that really does shock me.

  8. I have noticed that when an NSAID is specified, it is normally ibuprofen. Does the caution regarding NSAIDS vs favoring acetaminophen/paracetemol also include naproxen sodium?

    • W

      Broadly speaking all NSAIDs are similar. There may be small variations between them. Some people though are NSAID rather than paracetamol responders – me for instance – so I personally would still reach for an NSAID but with care

      D

    • Agree with David.
      I would like to add that very often 0.5 g of acetaminophen/paracetamol is enough for decreasing fever, and patients do not need to take 1 g every 6 hours (no more than 4 g a day should be taken).

  9. Well done David (and your colleagues) for putting this together and getting it out there. So valuable! Stay safe and well. Very best wishes from Perth, down-under.

  10. David

    As regards spreading the word about this drug information, if you put it on your own Facebook page we can all share it from there to our contacts who will doubtless share it then to theirs, and so on and on, till it reaches the thousands of individuals who are the people who really need to know about this. The Health Authorities, as you say, are never going to run with this. The GPs are always worth a try but tend not to seem to want to comment. Whenever I raise these kind of issues they say “ah yes, but this is unproven” or “the jury’s still out on this one” …..whatever that’s supposed to mean. It’s the people taking these meds who REALLY need to raise it strongly with their GPs, having discovered how vulnerable these drugs can be making them to pneumonia and Covid-19. Then they are empowered to ask the GP how they can be offering them these meds without warning them about the risk. I remember reading the PIL when I was given omeprazole and the first thing that screamed out at me written there in ‘rare side effects’ was ‘pneumonia’. Thankfully I had an allergic response to them so only took them for 3 days. My GP advised me to stop them.

    And Anna’s point about Care Homes makes one shudder in horror. Not that we didn’t always suspect this, but how tragic, to think of these elderly folk who survived the Second World War and all the privations afterwards, many worked hard all their working lives, saved for a home and raised a family, and then get dosed up like this, ruining their chances of good quality of mental life up till its end. Like Anna says, one can raise this issue with one’s peers till you are blue in the face but no one admits it, they just say we are SO lucky to have these drugs which keep us living longer, whereas our grandparents’ expectation of years lived was so much shorter. But who would really want to live, drugged up to the eyeballs, on up to 10 meds a day, and have no power to refuse or protest? Living hell.

  11. Abel Novoa
    @AbelNovoa 8h

    Muy importante desprescribir en tiempos de crisis

    Medicamentos que aumentan el riesgo de neumonía

    http://nogracias.org/2020/04/04/medicamentos-que-aumentan-el-riesgo-de-neumonia-por-joan-ramon-laporte-y-david-healy/… Por @joanrlaporte y @DrDavidHealy

    Juan Gérvas Retweeted

    Nogracias
    @nogracias_eu

    Medicamentos que aumentan el riesgo de neumonía

    http://nogracias.org/2020/04/04/medicamentos-que-aumentan-el-riesgo-de-neumonia-por-joan-ramon-laporte-y-david-healy/… Por @joanrlaporte y @DrDavidHealy

    Nogracias
    @nogracias_eu 7h

    Medicamentos que aumentan el riesgo de neumonía

    http://nogracias.org/2020/04/04/medicamentos-que-aumentan-el-riesgo-de-neumonia-por-joan-ramon-laporte-y-david-healy/… Por @joanrlaporte y @DrDavidHealy

    Amar Jesani
    @amarjesani

    Researcher and Teacher, Bioethics, Public Health. Editor, Indian Journal of Medical Ethic

    First do no harm … In our enthusiasm to find drugs to cure of Covid19, let us not forget drugs that could increase problems in its infection … Medications compromising Covid Infections https://rxisk.org/medications-compromising-covid-infections/… via @RxISK

  12. ‘Health and Social care’ To all Scumbags and humbugs when all this is over you might just might be called to justice.

    UK care home bosses threaten to quit over return of coronavirus patients

    @byameliahill The Guardian
    Thu 2 Apr 2020 20.32 BSTLast modified on Thu 2 Apr 2020 22.40 BST
    Care home managers have threatened to resign over new government guidelines that state they have to accept residents who have coronavirus.

    The guidance also says hospitals will not routinely test residents entering care homes, meaning managers will not know if returning residents are infectious but asymptomatic.

    “Some [returning] patients may have Covid-19, whether symptomatic or asymptomatic,” the guidance says. “All of these patients can be safely cared for in a care home if this guidance is followed.”

    The guidance also states that if a home has more than one symptomatic resident, health protection teams may arrange swabbing for up to five residents to confirm the existence of an outbreak. “Testing all cases is not required as this would not change the subsequent management of an outbreak,” the guidance says.
    The advice comes after hospitals, Public Health England and local councils were accused of putting care homes under intense pressure to readmit residents who have tested positive for Covid-19 and to accept residents who have not been tested at all.

    This is an examp[le social care for older vulnerable people – and another of many by now-

    Statement: Llynfi Surgery
    01.4.20

    Older People’s Commissioner for Wales, Heléna Herklots CBE, said:

    “The letter sent to vulnerable patients, many of whom will be older people, by the Llynfi Surgery in Bridgend has caused significant worry and upset, and I’m shocked that it was even written, let alone sent out.
    “Many of those who will have received the letter will no doubt have been left feeling worthless, that their lives do not matter and will have felt significant pressure to sign a DNACPR form. This is shameful and unacceptable.

    “Whilst difficult and painful decisions will need to be made in the weeks ahead, these must be taken on a case-by-case basis, through honest discussions between patients, doctors and their families that consider risks and benefits, as well as people’s own wishes.

    “At this difficult time, it is crucial that we continue to protect people’s fundamental human rights. It would be completely unacceptable to abandon these rights in favour of taking blanket, discriminatory decisions.

    “I welcome the fact that the surgery and the health board has apologised to the patients affected, and I hope this awful situation will lead to stronger leadership and guidance, from health boards and the Welsh Government, to ensure that people’s rights are upheld and communication with vulnerable patients is handled in a far more sensitive way as we navigate the difficult path ahead.”

    Have sent copy of the document to her and all other England Wales Irish Child and Older People Commissioners. (Doesn’t Scotland have commissioners?)Also the Guardian who expresses outrage but will probs do nothing , Big Issue, HIV Nat Org, and am sending individual copies to older peoples’ ‘care’ homes and childrens’ ‘homes’ Where no doubt they will refer to their ‘higher ups’ who will tell them to ignore it – but it’s worth a try.

    In Spain there is an ‘investigation’ going on re older people left to die in ‘care homes’ and their bodies just left there.
    Nobody seems to be blowing the whistle on what’s happening in psychiatric institutions or childrens’ units – yet.
    Meanwhile the idiot Matt Hancock has the nerve to give ‘stern messages’ to us about staying in – while people are dying for lack of ‘care’ Fuck off Matt.

  13. I am 62 years old and have for 20+ years have been on Paroxetine. I have managed to get my daily dose down to 10 mg. If I try to go any lower I have buzzing in my head and dreadful nightmares. I see that this drug is on alist of ones that can increase the risk of pneumonia in infections of SARS CoV2. I am now very worried. Please help.

    • Margaret

      Several doctors have said in response to this post that there is little that can be done in many cases of people on these drugs. Trying to panic-stop now may be a bad move. If you are only on this and otherwise relatively healthy, I wouldn’t try stopping. The big issue is when all this is over is we all need to ask the docs who put us on all these drugs – what were you thinking about and how did you get it so badly wrong

      David

  14. This marvellous post is now on David Healy’s Facebook page. PLEASE like and SHARE it publicly all those who can, maybe writing a short endorsement to draw people’s attention to the enormous importance of reading it and circulating it.

    Obviously many folk in Margaret’s situation would be ill advised to suddenly panic and stop their medications, but the day of reckoning for the loose prescribing of these drugs must be coming. Even for only the short number of years that I’VE been following RxISK blog, the message has mainly been to raise awareness of ADRs, and no doubt DH has been working on this for decades. A lot of us have felt frustrated in the extreme that we were fighting a losing battle in raising true awareness. Almost all medical doors have been shut in our faces. Many GPs have looked away in embarrassment or growled impatiently when we’ve had the temerity to raise these issues time after time. We’ve risked being removed from their Lists. Now this pandemic, much as no one could ever have wanted it, has suddenly brought with it the potential to wake people up at last to the double edged sword of many medications. This post of DH and Joan-Ramon Laporte M.D. gives us comprehensive evidence at a time of enormous relevance to all.
    Thank you!

    A mantra…..Dear Doctor, “what were you thinking about and how did you get it so wrong?” Absolutely!

    • I actually feel that the time to hit the general public with this important message will actually be once we are out of lockdown. It is obvious that we will, at that point, still be moving forwards with extreme care. The message will probably be that “the elderly and vulnerable still need to be extra vigilant” or similar, AT THAT POINT we should aim to make sure that as many people as possible understand that the term “vulnerable” could well apply to them too.
      A question that I have already been asked is whether or not the ‘pneumonia once-in-a-lifetime vaccine’ in any way protects during this pandemic?

  15. Meanwhile. Philip Morris, Japan Tobacco International, and British American Tobacco are worried about the harm this virus may cruelly inflict upon the ‘financial’ health of their Russia subsidiaries as Putin declares tobacco a non-essential item in the Covid-19 crisis. Critics warn that this will lead to rioting on the streets.
    https://www.rt.com/russia/484885-coronavirus-cigarettes-shortage-russia/

    Now. If one had to come up with an example of a decision based on good and proven medical science that no-one deputes. I reckon this would be amongst the top runners and have almost unanimous public support. Lets the riots begin.

    • Pogo they’re missing a trick? surely someone in BAT should be inventing a snazzy mask with a gap for for smokers to put the cigs in their mouths BAT used to fund research at the Institute of psychiatry on the grounds of the greater good……
      British American Tobacco warns of coronavirus sales fall as lockdowns around the world hit smokers
      JIM ARMITAGE
      1 day ago
      The Evening Standard
      BATS said sales were down today
      Lucky Strike cigarettes giant British American Tobacco today warned sales and profits would be lower than expected due to stricter-than-expected lockdowns in South Africa, Mexico and Argentina.
      The London-based tobacco giant, which sells Pall Mall, Rothmans and other higher-end brands overseas, pointed to South Africa in particular, where sales of tobacco were stopped altogether in March as part of strict measures to stop the virus from spreading through the country where 37% of men smoke.
      Alongside the previously announced hit from the lack of people buying boxes of cigarettes as they pass through airport, revenues for this year will now be only 1-3% up on a year ago instead of the lower end of 3-5% as previously forecast by the company.
      Shares fell 3% as investors responded to the gloomier picture for the group, which has now pushed back its target for revenues of £5 billion from new generation products such as vapes by a year to 2025.
      Profits would also come in at “mid-single digit” percentage growth instead of “high single figure” indicated before.
      However, the company insisted it would still be paying down its debts, albeit at a slower rate than previously hoped due to the covid impact on revenues.
      It also noted that there were few signs of smokers “trading down” to cheaper brands from other suppliers.
      Although debts are not coming down as fast as predicted, BAT will still be paying out dividends at the same ratio to profits as before – 65% – as it cited continued strong growth in its share of the cigarette market despite the industry being down around 7%.
      Chief executive Jack Bowles said: “We have made a good start to the year, with strong volume and value share growth in combustibles underpinning the sustainability of the business.”
      In the US, where BAT is a leading player, it said sales were proving more resilient than expected across the industry, with sales volumes declining only around 4% this year.
      World Health Organisation figures suggest more than 8 million people a year are killed by smoking, with more than 7 million from direct tobacco use and a further 1.2 million from passive smoking.
      BAT, like other Big Tobacco companies, has shifted towards vaping products.
      Despite being hit by safety concerns around vaping in the US, BAT said its Vuse brand was growing its share of the market there in value terms, likewise in the UK and Canada, France and Germany.

      Its Vype brand also increased its share of the UK market, but grew more in France and Germany.

      Its tobacco-free nicotine pouch Velo, which users put under their lip, is growing across the US although the marketing push has been held back by covid. Tobacco pouches known as snus – whose sale is banned in the UK because of fears they cause mouth cancer, are growing strongly in Scandinavia.

      Rae Maile, analyst at Panmure Gordon said BAT remained a high quality company and praised its resilience. He said: “The sector is cheap. While they may not outperform the market in the short term [with BAT’s dividends], if you hold the shares you will make money. Hold it for 10 to 15 years and you could very well make a lot of money.”

  16. Covid-19: what treatments are being investigated?
    BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1252 (Published 26 March 2020)
    Cite this as: BMJ 2020;368:m1252
    Read our latest coverage of the coronavirus outbreak

    All rapid responses
    Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. (‘Users is broadly used to include readers who may or may not be academics)

    Medications that may compromise Covid infections

    Dear Editor
    The torrent of literature about Covid to date covers treatments and tests and issues as tricky as DNR orders but there is nothing on the treatments the people who end up seriously ill and dying seem almost always to have been taking – except for a brief mention of ARBs and ACEs.

    We have discussed medicines that might increase the risk of pneumonia where consideration could be given to pausing treatment and monitoring
    https://rxisk.org/medications-compromising-covid-infections/

    It would be great to get input from readers on how best to distribute these messages effectively in local settings and how best to handle the dilemmas that might arise.

    David Healy
    Competing interests: No competing interests
    03 April 2020
    David Healy
    Professor of Psychiatry
    McMaster University
    Hamilton, ON
    @drdavidhealy

    Coronavirus infection and its disease COVID

    Rapid responses disappear quickly from sight as new articles and responses are published. It is possible to keep David’s request for help visible by making a response to the article – and mentioning his r.r. in yours if you wish.

  17. Unfortunately Swansea Uni is shut down so it is impossible to contact Prof Jordan and colleagues to ask if they can help,but might it be possible to adapt their project to help with issues raised here re the Covid crisis? – Publications in Open Access Journals –
    a study examining the effects of the West Wales Adverse
    Drug Reaction Profile. Nursing Standard. 31, 14, 42-53.
    1 July 2016. doi: 10.7748/ns.2016.e10447
    Correspondence
    s.e.jordan@swansea.ac.uk
    Abstract
    Aim The physical health of people with mental health conditions is often suboptimal, and in many
    cases this may be related to their prescription medicines. One issue is that patients are monitored
    inconsistently for adverse drug reactions (ADRs). The aim of this study was to explore whether the
    nurse-led West Wales Adverse Drug Reaction (WWADR) Profile for Mental Health Medicines could
    improve recognition and management of ADRs in a crisis resolution home treatment service.
    Method The WWADR Profile was implemented in addition to usual care, in a one-group ‘before
    and after’ comparison study (n=20). The study took place from October to November 2013.
    Results The WWADR Profile identified previously unreported physical healthproblems for
    all participants in the study, including two potentially life-threatening conditions: cardiac
    arrhythmia, chest pain plus breathlessness, and valproate-induced pancreatitis. In total, four
    participants’ medicines were discontinued, three were referred to a consultant psychiatrist, three
    were referred to GPs, one was referred to an electrocardiogram technician and one was referred
    to a dentist. Previously overlooked health promotion issues were also recognised.
    Conclusion The WWADR Profile identified several physical health problems that had been
    overlooked previously. Therefore, it might be beneficial to use the WWADR Profile in routine
    mental health practice.evidence & practice / research
    MEDICINES OPTIMISATION
    Nurse-led medicines monitoring: a
    study examining the effects of the West
    Wales Adverse Drug Reaction Profile
    Jones R, Moyle C, Jordan S (2016) Nurse-led medicines monitoring: a study examining the effects of the West Wales Adverse
    Drug Reaction Profile. Nursing Standard. 31, 14, 42-53.
    Date of submission: 10 February 2016; date of acceptance: 1 July 2016. doi: 10.7748/ns.2016.e10447
    s.e.jordan@swansea.ac.uk
    Abstract
    Aim The physical health of people with mental health conditions is often suboptimal, and in many
    cases this may be related to their prescription medicines. One issue is that patients are monitored
    inconsistently for adverse drug reactions (ADRs). The aim of this study was to explore whether the
    nurse-led West Wales Adverse Drug Reaction (WWADR) Profile for Mental Health Medicines could
    improve recognition and management of ADRs in a crisis resolution home treatment service.
    Method The WWADR Profile was implemented in addition to usual care, in a one-group ‘before
    and after’ comparison study (n=20). The study took place from October to November 2013.
    Results The WWADR Profile identified previously unreported physical healthproblems for
    all participants in the study, including two potentially life-threatening conditions: cardiac
    arrhythmia, chest pain plus breathlessness, and valproate-induced pancreatitis. In total, four
    participants’ medicines were discontinued, three were referred to a consultant psychiatrist, three
    were referred to GPs, one was referred to an electrocardiogram technician and one was referred
    to a dentist. Previously overlooked health promotion issues were also recognised.
    Conclusion The WWADR Profile identified several physical health problems that had been
    overlooked previously. Therefore, it might be beneficial to use the WWADR Profile in routine
    mental health practice.
    West Wales Adverse Drug Reaction Profile
    BMJ Open
    Download PDFPDF
    Pharmacology and therapeutics
    Protocol
    Nurse-led medicines’ monitoring in care homes study protocol: a process evaluation of the impact and sustainability of the adverse drug reaction (ADRe) profile for mental health medicines
    Sue Jordan1, Timothy Banner2, Marie Gabe-Walters1, Jane M Mikhail1, Jeff Round3, Sherrill Snelgrove1, Mel Storey1, Douglas Wilson1, David Hughes1 the Medicines Management Group
    Author affiliations
    Abstract
    Introduction Improved medicines’ management could lead to real and sustainable improvements to the care of older adults. The overuse of mental health medicines has featured in many reports, and insufficient patient monitoring has been identified as an important cause of medicine-related harms. Nurse-led monitoring using the structured adverse drug reaction (ADRe) profile identifies and addresses the adverse effects of mental health medicines. Our study investigates clinical impact and what is needed to sustain utilisation in routine practice in care homes.

    RESEARCH ARTICLE in PLOS ONE
    Nurse-Led Medicines’ Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial
    Susan Jordan,Marie Ellenor Gabe-Walters ,Alan Watkins,Ioan Humphreys,Louise Newson,Sherrill Snelgrove,Michael S DennisArticle
    Abstract
    Background
    People with dementia are susceptible to adverse drug reactions (ADRs). However, they are not always closely monitored for potential problems relating to their medicines: structured nurse-led ADR Profiles have the potential to address this care gap. We aimed to assess the number and nature of clinical problems identified and addressed and changes in prescribing following introduction of nurse-led medicines’ monitoring.
    Design
    Pragmatic cohort stepped-wedge cluster Randomised Controlled Trial (RCT) of structured nurse-led medicines’ monitoring versus usual care.
    Setting
    Five UK private sector care homes
    Participants
    41 service users, taking at least one antipsychotic, antidepressant or anti-epileptic medicine.
    Intervention
    Nurses completed the West Wales ADR (WWADR) Profile for Mental Health Medicines with each participant according to trial step.
    Outcomes
    Problems addressed and changes in medicines prescribed.
    Data Collection and Analysis
    Information was collected from participants’ notes before randomisation and after each of five monthly trial steps. The impact of the Profile on problems found, actions taken and reduction in mental health medicines was explored in multivariate analyses, accounting for data collection step and site.

    Results
    Five of 10 sites and 43 of 49 service users approached participated. Profile administration increased the number of problems addressed from a mean of 6.02 [SD 2.92] to 9.86 [4.48], effect size 3.84, 95% CI 2.57–4.11, P <0.001. For example, pain was more likely to be treated (adjusted Odds Ratio [aOR] 3.84, 1.78–8.30), and more patients attended dentists and opticians (aOR 52.76 [11.80–235.90] and 5.12 [1.45–18.03] respectively). Profile use was associated with reduction in mental health medicines (aOR 4.45, 1.15–17.22).

    Conclusion
    The WWADR Profile for Mental Health Medicines can improve the quality and safety of care, and warrants further investigation as a strategy to mitigate the known adverse effects of prescribed medicines.

    Trial Registration
    ISRCTN 48133332

    Figures
    Published: October 13, 2015https://doi.org/10.1371/journal.pone.0140203
    HELPING TO MONITOR MEDICINES
    In Welsh, ‘adre’ means 'homeward', to a place of safety where you can enjoy your health and wellbeing, and this sums up the ethos behind ADRe, the Adverse Drug Reaction profile.

    Adverse drug reactions (known as ADRs) can occur both in the home, and within the healthcare setting, when combinations of medications produce unexpected side effects. Unfortunately this means that in the most serious cases fatalities can occur. However ADRe has helped all service users by addressing life-threatening problems, reducing pain or improving quality of life.

    With preventable ADRs responsible for 5-8% unplanned hospital admissions in the UK, and costing the NHS up to £2.5bn pa, it is crucial that healthcare organisations take advantage of tools which can help improve how medicines are managed. ADRe has been developed with the aid of nursing professionals to help nursing staff take a structured approach to the monitoring of medicines, identifying any ADRs service users may be experiencing, and then making changes to improve a patients' health and wellbeing.

    REGISTER
    If you would like to request a copy of ADRe, or stay informed about new developments then please register here. (Unable to contact them at present)

    • Susan Jordon hasn’t found herself able to respond to a letter asking whether she might enable her project to be used to investigate the Covid crisis, Not altogether surprising admittedly. But she was also contacted by somebody else though reading the Rxisk blog and was keen to get involved with his PhD project. Now or never, is not the time to be precious about owning projects which could be used or adapted to help .S Jordan could still claim kudos for her and her colleagues but the idea of collaboration is not a mind set established in institutions sadly.

  18. “What were you thinking about and how did you get it so wrong.” Question we can all raise, now or later, suggested by Dr David Healy, with regard to the use of so many medications with pneumonia-type side effects, particularly in the elderly, which could make them less able to fight off Covid-19.

    There was a brilliant article by a Daily Telegraph Reporter in Saturday’s paper, April 4th 2020, entitled ‘Four-year-olds can be just as over confident as bankers’. It relates to research done on children and their over confidence using a card game designed for the purpose when 70% of those studied indicated being sure they are right, even though being shown time and time again that they are not.

    “Over-confidence, a trait identified in those who have a much higher belief in their own abilities than evidence suggests, is said to be common amongst high achievers.

    But it is also shown amongst children of a very young age, suggesting it is a “cognitive bias” that develops from infancy rather than in later life, said researchers from University of Sussex Business School……this kind of over-confidence is usually displayed by business leaders, PHYSICIANS and bankers”. (my capitals) “ said study author Dr Dominik Piehlmaier.
    Speaking to the ‘Scientific Reports Journal’ he said
    “Much of our knowledge and judgement on decision making is based on adult participants but there is no reason to believe that humans only develop such an omnipresent cognitive illusion once we reach adulthood.”

    Does this indicate that maybe an inability to listen, an arrogance in prescribing un necessary meds willy nilly, self confidently and at the same time refusing to take anecdotal patient evidence into account, starts in the early years of life? An inbuilt over-confident self belief which was there from the very start? I’ve often wondered about this. If so, maybe we need to look to what we rate most highly in primary schools. Can allowing a child to bask in its own brilliance lead to this problem later? Parental pride in “ my little Freddy wants to be a doctor” could perhaps fuel this attitude…
    If you want to read the rest, maybe Annie could be very kind and help with finding the link.

  19. sent few more a document – only sadly expected useless standard letter from CQC so far –
    Age concern, Tavi-portman NHS Hosp, Will hall survivor-researcher Maastricht uni, Nat survivor user network, Womens Aid, NHS mental health director Claire Murdock (sounded more surreal when they were called Tzars) ,the bma, the GPs cttee, college of psychs and psychologists – if they use the fob off tecnique of requesting a form to be filled I don’t bother but try to find a name on the site or google and ask doc to be forwarded – sometimes works if they have a press/media dept.
    few snippets
    https://www.thepharmaletter.com/article/agencies-mull-use-of-covid-19-clinical-data-in-regulatory-approach? (sounds fishy?)
    mc_cid=df83930fb9&mc_eid=https://www.thepharmaletter.com/article/psychiatric-conditions-set-to-rise-due-to-covid-19?mc_cid=df83930fb9&mc_eid=1360aeb99c
    And profits to rise by 27m

  20. Juan Gérvas
    @JuanGrvas

    “Medicines compromising #Covid19 ” Frank Barat interviews David Healy. Video 16 min English subtitles. ¿Did we put people at risk of dying from Covid19? YES The media ignore the hazards of medical treatments. Drugs are more dangerous than viruses.

    Replying to
    @RxISK @joanrlaporte
    and 4 others

    The link https://youtube.com/watch?v=s3DH5g8fYoE… Excellent interview. “Did we put people at risk of dying from Covid19?” YES In some way, “drugs are more dangerous than viruses and germs” The media ignore (prefer to) “the hazards of medical treatments”

    Covid-19 Chronicles with Dr. David Healy

    https://roarmag.org/2020/04/08/covid-19-chronicles-with-dr-david-healy/

    • This is an absolutely brilliant interview, ‘drugs are more dangerous than viruses and gsrms’. This should be widely circulated.

      A case in point: it takes courage and determination for the patient, with limited medical knowledge, to battle against being given drugs in an arbitrary way, when they fear that (a) they may not really need them and (b) once on them, they may not be able to get off.

      Suffering long term from, and awaiting surgery for bad varicose leg veins and chronic varicose eczema, I suddenly experienced an unusual dull pain in the calf for some days and my wife was concerned lest it was a DVT so we went to A&E to get it checked as it was a Saturday and my GP surgery was closed. This was several weeks ago before the Covid19 really became prevalent. I’d had the repair of a hernia a month prior, and experienced numbness in that leg for some days later. Now I had some swellingand a strange pain. It seemed wise to check it when it persisted over several days.

      1. The Registrar (whose interest is Cardiology) read an ECG taken at the time and noted two ectopic beats every ten or so normal beats. In examination she didn’t think there was a DVT.

      ( I should add that I am 80, don’t smoke, drink, eat healthily, am very physically active and pride myself on never having taken any medication. My GP insisted I took a short course of Doxycycline two years ago when it looked like I’d had a tic bite. The Doxycycline gave me gout in my toes but the GP denied it could be the drug. It abated when the drug course finished. The tic bite test came back negative). I only mention this to show I am not anti drug, I would take one if it was vital.

      2. The Registrar suggested I had an injection of Heparin at the weekend as the scanning of my leg for DVT could not be done till Monday and she had to cover herself (Guidelines- NICE) in case it WAS a DVT, overnight till next day. She explained the risks of the blood thinning Heparin. I decided against it and took a letter from her to my GP next day, accepting the risk myself of the DVT killing me overnight. Scanned next day, there WAS no DVT.

      3. The Registrar also gave me betablockers to take home and implored me to take them ‘as they would save my life.’

      4. I did not take them but showed them, and her letter, to my GP next day. She said it was good I hadn’t had the Heparin injection as it could have caused a stroke, bleed in the brain etc and said she would only ever give anticoagulants in pill form as they were easier to dose control.
      Phew, I had done the right thing.

      5. GP also said hold fire on the betablockers, let’s do another ECG in surgery and then re-consider. May be a good idea, but may not.
      Phew, I had done the right thing.

      6. Had an ECG in surgery. (Bit nervous being there as Covid19 now taking hold everywhere). ECG shows possibly two left bundle branch blocks and the same ectopic beat ratio as before. Another GP (younger and with very poor English) says OMG if you’d taken the betablockers they could have killed you, forcing the blood too strongly through the heart.
      Phew, I had done the right thing,

      7. Same young GP (with very tricky English to follow) looks up on computer and says take these tablets at once, they are an anticoagulant. Amilodipine. Once on those, he says, you must stay in them for life but anyway I will also write an urgent referral to the local cardiologist.

      8. Checked this drug out on RxISK. They are not an anticoagulant. They are to regulate heart beats and reduce blood pressure.
      Decided therefore to wait before taking them, to see cardiologist.

      9. Cardiology Dept (‘choose and book’) say I’m not an urgent case so will have to wait several months to be seen. This despite remarks on my heart scan tests taken later and emailed to me at my request saying ‘high risk’.

      10. Now waiting to see cardiologist or at least have consultation over phone if all test results can be sent to him. I have tried to help myself in any way I can. No caffeine, no alcohol, now only limited exercise, wondering if I can actually still get away with no drugs.

      My point in all this is to show how, had I taken unquestioningly every one of these treatments offered immediately it was offered, and by whoever it was offered on those various days that month, II could have now found myself in more trouble than perhaps (or perhaps not) I am.
      This shows exactly how, in Dr Healy’s interview, the patient needs to be discerning and not take everything for gospel. But it also shows we have to negotiate a minefield. It’s difficult to stick out against taking a drug when it would be so easy to put blind faith in the doctor and swallow whatever you are told to swallow. And regret it later. What if I’d taken the Amlodipine and the cardiologist had then said, oh dear, what a pity, I wouldn’t have given you that but we can’t take you off it now. Who carries the can for that?

      I just pray that somehow this Covid19 does open some honest dialogue at last about the damage drugs can do. I am very pleased to have seen the interview between Frank Barat and Dr Healy. It will help me in my negotiations with the cardiologist eventually. It will help so many others too. Thank you.

  21. Re: Medications-Compromising-Covid-Infections-.pdf
    4:16 PM (2 hours ago)
    Hi Susanne,
    We can’t really share any kind of advice like this that doesn’t come from NHS England/ PHE BUT I have raised this with them and will await a response from them hopefully sooner rather than later!
    Best wishes,
    Zoe
    We won’t hold our breath obviously but thanks v much to Zoe at NSUN ,will see what they say anyway

    • BCUHB (our local health board) have replied, following my email to them regarding the Rxisk/Covid-19 message, that they have now informed the Health Emergency Control Centre of this “important message”. What will happen to the ‘message ‘ now is anyone’s guess I suppose!

    • Vorre MM. Lange P. April 2019. (Danish)

      ‘This case report describes a patient, who presented with extrapyramidal side effects to the treatment with metoclopramide, which is used as an antiemetic, for gastroparesis and reflux. However, beyond its desired effect, serious neurological adverse reactions can be seen, which is why the European Medicines Agency and the Danish Medicines Agency have changed the recommendations for its use. If the extrapyramidal side effects include the respiratory muscles, the patient’s ability to breathe can be affected. If a patient receiving metoclopramide or anti-psychotic drugs shows signs of tachypnoea or acute respiratory distress, the possibility of respiratory dyskinesia should always be considered’.

      Other authors report that respiratory dyskinesia may precede tardive dyskinesia in those taking antipsychotics.

      I have experienced denial by psychiatry that “second generation antipsychotics” cause tardive dyskinesia.

      It is to be hoped that Respiratory Dyskinesia is not subject to similar denial.

      The potential importance in Covid 19 disease in general, and for the elderly in care homes, given neurotoxic drugs for “behaviour management”, is surely self evident?

  22. And more goodies for the older population – they will surely be targeting younger people than normally considered ‘old’ as the ‘aging population’ is decreasing not growing.

    Global Neurodegenerative Drugs Market to 2022 – Growth Driven by an Aging Population, the Approval of Novel Immunomodulators and Neuromodulators, and $4995

    Neurodegenerative disorders are a cluster of conditions that affect the central nervous system. They include both hereditary and sporadic conditions that are characterized by slow, irreversible, progressive dysfunction of the nervous system with the increasing degeneration of neurons, which causes symptoms such as motor impairment, memory loss and declining cognitive ability. Neurodegenerative disorders cannot currently be cured, and treatment is aimed at managing the disease indication in order to reduce the severity of symptoms and slow progression.
    The report focuses on five key indications within neurodegenerative disorders: Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis and multiple sclerosis. With no curative therapies available, symptomatic medications prescribed off-label are an important part of the treatment paradigm, especially in amyotrophic lateral sclerosis and multiple sclerosis. This indicates the need for extensive R&D within this area.

    Immunomodulators are the most effective and most common therapies used in neurodegenerative disorders. This class of compounds has been the most commercially successful in the past decade, particularly in the multiple sclerosis market, with many clinical trials underway for amyotrophic lateral sclerosis. The market for neurodegenerative disorders is largely accounted for by premium products, with generic products holding only a relatively small share. However, some generic products have been able to secure sizable market shares after the patent expiries of leading drugs. Glatopa (a generic version of Copaxone) recently entered the market and is expected to reach sales of $233m within the forecast period.

    Although there is a high degree of failure and uncertainty within the R&D of neurodegenerative disorder drugs, the number of drugs in the pipeline is very high, at 1,494. The majority of pipeline products are novel active pharmaceutical ingredients, with only a small proportion of products being either generics or repositioned from other indications. This shows progression in terms of the variety of molecules being developed as therapeutic agents within the neurodegenerative disorders pipeline. The market is expected to grow over the forecast period, which is attributed to the approval of new drugs, as well as the increasing aging population.

  23. Brown, Jamie

    Hi Susanne
    Thank you for your email – we don’t advise our members on medical advice: that has to come from NHS England or Public Health England
    Jamie

    Unison is the Union which is responsible for Care Workers/ Even more of their members have died in the last few days together with high numbers of people in ‘care homes’
    It seems when people die it is recorded as death from Covid19. There needs to bve an investigation of what part the prescription drugs played in their deaths after this is over. Let’s hope they won’t already be binning the records

  24. The Frank Barat interviews are great. He is a film maker .amongst other things – wonder if he would consider making a film when the time is right ?

    Frank_Barat
    Frank Barat is a French activist, author and film producer. He was the coordinator of the Russell Tribunal on Palestine from 2008 until 2014. He is the co-founder of BARC Productions, a film production company, created in Brussels in February 2019.

  25. Juan Gérvas Retweeted

    @samizdathealth
    @DrDavidHealy

    @RxISK Your medicines might be more dangerous than any germs Part 2 – interview with Joan-Ramon Laporte https://youtu.be/Fy381m47-QY

    @fiddaman@pauljohnscot@AbelNovoa@JuanGrvas@joanrlaporte
    @jojoryan56

    https://www.youtube.com/watch?v=Fy381m47-QY&feature=youtu.be

    Dr. Joan-Ramon Laporte “The pharmaceutical industry competes for patients.”

    /Doctor Joan-Ramon Laporte is one of the most eminent clinical pharmacologist in the world. He talks to Frank Barat are the type of medicine people should take, the “magic drug” hydroxychloroquine, the role of pharmaceutical companies in the midst of a crisis, and the fact that “the sacred cows of clinical research are still there”.

  26. This is an interesting read and raises some useful discussion points. Nonetheless, I have a number of concerns regarding this article.
    1. The authors fail to suggest a link between being on certain medications and the underlying pathology requiring their prescription. For example, it is well known than people with mental health problems have far higher rate of mortality from many illnesses than people without and this is multi-factorial: often low income with inadequate housing, drug and alcohol misuse, poor self-care and the direct immunosuppressive effect of some mental illness on the immune system. Being on medications such as olanzapine etc may have an effect but it’s very hard to separate from the underlying problem.
    3. The authors appear to be concerned regarding polypharmacy. As such, the article comes across as somewhat biased. I’m inclined to agree that we seem to have far to many people on too many medications, but to link that to increased risk of problems with COVID is entirely speculative.
    4. Being on more medications is a marker of being more sick and having more underlying health problems.
    5. We have no robust data yet about the impact of medications on COVID (see above, speculative only).
    6. COVID is not pneumonia. It is a viral issue and we’re understanding increasingly that the problems in the lungs appear to be related to micro-thrombi (clots) caused by a huge immune cascade that predisposes to clot; patients to not have pneumonia, and they do not have classical ARDS (adult respiratory distress syndrome, where the blood vessels become ‘leaky’ leading to fluid accumulation in the interstitial lung tissue), so to link predisposition to pneumonia to risk from COVID is flawed in itself.
    I suspect that the situation regarding these medications will become clearer in the coming months, but for now I am concerned that such articles will foster unfounded panic in members of the public – my mother, a worried non-medic, for example, was the one who sent this to me for my views. Patients abruptly stopping routine medications has the potential to cause more problems than the supposed risk of COVID. Whilst I agree to a large extent with your views on polypharmacy, this needs to be rigorously assessed in this context.

    • Freya

      1. The increased mortality in mental health stems from the drugs people get put on for their conditions which lead to suicides in young people and diabetes, metabolic syndromes, toxic malignant syndromes and compromised immunity – I believe in using these treatments when appropriate but not for older folk in residential homes.
      2. If you think polypharmacy is a problem – then increasing the risk from Covid pretty well naturally follows. The poisons that are drugs are in general more harmful than germs.
      3. Being on more meds is not a marker for being more sick – its a marker for medicating more risk factors – that is giving more meds to people who are by definition healthy. The use of medicines for diseases ordinarily involves a limited timespan – as in treating infections with an antibiotic.
      4. We know that those who are dying are in the age group and settings where it is almost certain they are on more meds than they should be.
      5 I have family members on the healthcare frontline for this infection – I may have more family members proportionately than almost anyone else – and so i am well aware of shifting views in this area and recent thoughts about thrombo-emboli. To my mind the reports from physicians treating individual patients according to their physiology and getting better results than people treating according to protocol – for pneumonia or thrombo-emboli or whatever are convincing. Part of treating the individual is going to involved managing a physiology that may be badly compromised by concomitant meds or withdrawal from the same meds.

      David Healy

    • Surely it is better to be totally open with people and to point out that problems COULD arise for anyone on certain medications. Noone is saying to suddenly come off these medications – rather to bear in mind that extra care may be a good idea. Once lives are lost it’s too late to then feel that maybe more should have been shared with the public. Openness leads to trust which is so necessary in this present situation.

    • Thank you for your comments Dr. Lodge.

      We refer to unnecessary use of medicines, and particularly in the elderly. A number of studies have shown that the medicines quoted in the report are in their majority prescribed to people who do not need them, for long periods of time, without any clinical follow up. 20,000 of 64,000 residents in nursing homes in Catalonia receive at least one antipsychotic, 11% receive two, more han 5% receive three. Many of these people can also receive tramadol or fentanyl for months and months. Many receive omeprazol or an analogue just as a gastric protector, for an unidentifiable indication. And a hypnotic. And an antidepressant… We provide links in the article where this has been shown (unfortunately in catalan, similar to spanish). But this is not a local problem in Catalonia, it happens in the US and all “developed” economies.

      We do not refer to patients taking these medicines for real medical problems, we are not saying that all these treatments should be abandoned.

      Yes, we are concerned about polymedication. What we know about drug interactions is based on the data of studies on two different medicines, rarely three. Taking more than three different medicines is a risk in itself.

      We refer to the risk of pneumonia, and we are aware that there is no data regarding the risks with SARS-Co2. However, the majority of deaths by pneumonia which occur each year, particularly in winter, among the elderly, are caused by other coronavirus, which in turn cause a disease pattern which is certainly different from the cytokines storm we are seeing in patients with severe covid, or the pattern of hypoxia without hypoxemia which seems typical in patients with moderate covid (and who in their majority are not admitted to hospital).

      We agree we have no robust data yet on the impact of medications on covid severity. This is why we make a call to establish international cooperative platforms for research, not only on possible effective and safe treatments, but also on the favorable or unfavorable effects of chronic “baseline” treatments.

      More than 80% of patients under gabapentin or pregabalin have been prescribed the drug because of back pain, where the efficacy compared to placebo is zero, and neurological adverse effects are common. What is the danger of trying to stop this kind of chronic intoxication? The majority of patients in nursing homes who are on antipsychotics do not have a mental disease, a psychotic episode or whatsoever which is usually quoted as an excuse to prescribe, it seems to me that it is rather the drug which seriously affects cognitive function, and surely increases the risk of pneumonia, which is a real problem in many patients with covid, not only those admitted to hospital or even to the ICU.

      • Thank you to the authors for this review.
        I kind of agree with Dr.Lodge that this article, although valuable for scientific questioning, might send the wrong message to patients. My other question is why is this review not published in a peer reviewed journal?
        With regard to antidepressants, this article fails to cite a large study that found no association between antidepressants (including tricyclics, SSRIs and SRNIs) and risk of pneumonia.
        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2042508/
        Also, it fails to cite another study that found no association between amitriptyline and other tricyclic antidepressants and pneumonia. https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.13932

        I think that stopping antidepressants for many patents might be counterproductive and cause more harm than benefit, specially if based in not well proven data.
        I have not reviewed the other drug classes information in detail but think the antidepressant data might be incomplete and excessively alarming.

        • Joan

          Thanks for the comments. I think the key thing is this – if patients were just on one med, this would be fine but they 50% of elderly patients are on 5 or more and it is likely the percentage in residential homes where the death rate is 80 times the rest of the population is likely to be much greater. We could probably find articles that would seemingly reduce the risks for any one drug or drug group but there is nothing that supports the idea there is minimal risk from having people on as many drug as they’re on.

          Why not a peer-reviewed journal – they’re scared. A cut-down version is being reviewed at the moment.

          Re studies – the anticholinergic article you cite shows an increased risk. Personally I do not think anticholinergicity is a problem per se – its other actions of most of these drugs that cause the problem.

          The antidepressant and pneumonia study depends on adjustments. On the face of it the results look worrying and this was undertaken in the days before it was not uncommon for people to be on 3 antidepressants along with some mood-stabilizers and stimulants at the same time. Saying this is not good practice is no help – it is current practice.

          There was an amusing story from the 1980s when a German pharamacovigilance group wanted mianser (mirtazapine) removed from the market for rarely depleting white cells. The company acknowledged the white cell risk but pointed out that it was safe in overdose to which the bureaucratic response is that this is immaterial – suicide is not legal. We do have to deal with the real world.

          David

          • Thank you for your quick response and for the debate.

            I agree with the polypharmacy part, but many patients do not respond to one drug and need to stay on combination of drugs to recover functionality and quality of life.

            I agree overall you raise a good point and think we need to think in further studying whether or not the factors you suggest are really putting more patients at risk of severe pneumonia in the current pandemic, but caution is also needed because many patients or doctors can panic, stop medications and decompensate,which has happened historically after the FDA issued warnings on antidepressants before.

          • Joan

            If they don’t respond to a drug you should stop. Adding something else in means you may end up treating problems the first drug is causing rather than simply non-response. The number of patients who should be on more than one psychotropic is pretty small.

            D

  27. My friend had alzheimers disease for several years., Until she had a stroke we could share looking after her at home using strategies to alleviate her confusion. In hospital she became very distressed and began calling loudly for her sister who had passed away years before. She was given an anti-psychotic to ‘quieten her’ without any information beforehand or consent from her the family. As was common. Anti psychotics are not a treatment for strokes.She was frail but mostly happy at home – after being in hospital she could not walk, the anti psychotic was partly the cause as well as the stroke, she was dribbling , another effect of the anti-psychotic and could hardly sit up after being medicated., a definite effect of the anti psychotic ,I worked as an advocate for some years and know the effects of over medication. I would advice anybody with a loved one, or anybody they care for in any way to constantly make the health-workers aware of your presence and to monitor all medications they are being given. I would like to see an advocate in every elderly persons care home and hospital unit.. We all rallied around to get her discharged and she carried on for several years with occasional upsets but mainly with her old trusting happy self partly recovered with careful attendance to her needs – and with no anti psychotics ever allowed again. I will for sure continue to alert as many people as I can and have no worries that this could be labelled irresponsible or lacking in knowledge. Rather to withhold information would be unforgivable.

  28. I don’t know if amitryptiline is still used but one of the reasons people refused to take it or cut it or binned it years ago was it was one of the many drugs which increased weight. It was/is also used to relieve pain.I read on twitter I think,that ‘obesity’ is a feature of Covid19
    People in care homes might be being prescribed it for both depression and pain.

  29. Over medication and perhaps over sanitation – leading to methemoglobinemia?
    Was watching a webinar between Dr Meryl Nass and Dr James Lyons-Welier last week and she mentioned how ICU practices had changed since her day. The thought occurred to me that if a patents history is no longer taken on arrival then could ‘some’ people with low oxygen saturation’s (SpO2) be borderline glucose-6-phosphate dehydrogenase deficient and have been pushed over the edge into methemoglobinemia, by taking cough and sore throat OTC remedies that contain benzocaine, methyl hydroxybenzoate and other drugs that require the G6PD enzyme to detoxify? Labels say don’t take for more than three days. If so there are treatments for this such as N-acetylcysteine and IV vitamin C, methylene blue (in the lab, we called it Prussian Blue and whilst it seems to gone out of fashion we had sodium thiosulfate — both for cyanide poisoning) but I don’t hear it being mentioned.

    Many of the BAME population have genetically determined lower levels of G6PD and they currently suffering higher fatality rates.
    Statistically, I would think this must be occurring more frequently than before due to the high numbers of people taking OTC remedies and medical staff may be missing the connection, thinking the low Sp02 is due to the virus and so just following the CDC protocol. Must add that Dr Rohin Francis (aka Medlife Crisis on Youtube) assured his audience that in the UK ‘we’ do things properly and on a case to case basis in the UIC’s but on that I’m not going to comment as I don’t know.

    Below MetHb levels of around 50% patients can still be lucid and coherent as reported. Yet, I have found no mention of this possibility being actively included as part of a differential diagnosis. That is not to say it isn’t — just that I haven’t seen it reported anywhere — at all.

    Other triggers for that are biological plausible are many but seldom cause problems in normal use but these are not normal times.
    Benzalkonium chloride, benzethonium chloride, and sodium nitrite is used in some hand sanitizers. The latter is also added to cured meat products (to prevent botulinum) which is being consumed more as frozen fresh meat is getting rarer in some areas). In quantity, this combo has caused methemoglobinemia. It can also lead to ARDS as reported in a case of barbicidal overdose involving benzalkonium chloride [1]. ARDS which as we know, is also getting reported as a complication of Covid-19.
    Have already witnessed one couple not wanting to wait till they get home from the supermarket, sanitize an apple each. How many other people are naïvely ingesting too much via novel routes not explicitly advised against on the container ? And that’s if they read the warnings at all.

    I may have missed many more normally ‘safe-ish’ chemicals listed here. [ 2]

    Also, I think that when methemoglobinemia is induced in people with hitherto normal liver function it doesn’t respond to the treatments mentioned above, due to the damage being done to a different detoxification pathway.

    Then there are very popular Youtube channels showing people how to mix up their own sanitizers (and very inexpensively too) without any warning that in concentrated form they are going to be more toxic. The body can quickly metabolize most, but the skin is not completely impervious and will let some through into the blood stream. Don’t know if these other chemicals can induce methemoglobinemia but its hard to imagine that they’re doing the liver any good.

    Statistically, I would think that this is the cause of some admissions to ICU’s but whether it is significant enough to alert the public (whom already suffer ‘information overload’) is another matter. Not having kept up with my subscriptions to BMJ I can’t ask there but I would dearly like to know if the NHS 111 and ICU’s are checking for this possible causality?

  30. thebmj 24 june 2020
    Poly-pharmacy and deprescribing: A root cause analysis should be a prerequisite
    Re: Inappropriate medication use and polypharmacy in older people Doron Garfinkel, Aaron Bilek. 369:doi 10.1136/bmj.m2023
    The claim “Evidence is accumulating that the most powerful strategy to combat inappropriate drug use and polypharmacy is poly-deprescribing” deserves comment.(1)

    Firstly, how to deprescribe? Among 15 tools for deprescribing in the eldest only four have been tested in clinical conditions, all with very low-quality design.(2) Further, time to review prescriptions and to reassure the patient are most critical issues. Further, calls for “poly-deprescribing” may be biting off more than you can chew when the list of a hundred “drugs to avoid” published yearly by the independent drug bulletin “Prescrire International” is so rarely used.(3) These are drugs which are largely prescribed and still on the market despite having adverse effects that outweigh their benefits or having been superseded by others with a better harm-benefit balance.

    Secondly, the editorial acknowledged, although only once, “inappropriate prescribing”.(1) This is one of the root causes and deserves scrutiny as actions must target the cause. Even more because healthcare professionals find it harder to stop a treatment (withdraw) than to refrain from starting the treatment (withhold) though withholding and withdrawing are regarded as equivalent in medical guidelines and ethics literature.(4)

    Thirdly, the patient must not be by-passed. We must confess that shared decision making when prescribing is not adequate. How many patients know: a) what their medication is for and for what, treating symptoms or preventing a complication? b) when the medication is working or not working? c) side effects they should watch out for? However, shared decision making is also about informing professionals. Why don’t medical journals systematically provide the “number need to treat” as a benefit in publications?

    Last, the issue is a global one: the pharmaceuticalisation of life, the translation of human conditions and unmet social needs into opportunities for pharmaceutical interventions. Pilling is sometimes curing, although too rarely, but it is never about caring.

    Prescrire IN ENGLISH –

    Prescrire: independence and transparency, in the name of better patient care
    The independent French medical journal Prescrire is produced by healthcare professionals who strive to protect medical information and continuing education from the contradictory influences at play in the medico-pharmaceutical arena.

    La Revue Prescrire was created by and for healthcare professionals, in order to provide them with trustworthy sources of information and continuing education, first and foremost in the interest of patients. Had most healthcare professionals and regulators been reading Prescrire regularly, a large part of the Mediator° disaster might well have been avoided altogether.

    Association Mieux Prescrire, a non-profit organisation under the French law of 1901, publishes all of Prescrire’s products. The Association’s accounts have been made public every year since 1992, and the latest financial information is available > HERE.

    Prescrire’s editorial staff, composed of over 100 members, most of them doctors and pharmacists, as well as Prescrire’s managers all sign the “Non merci… ” charter every year, along with an annual declaration of absence of conflicts of interest, ruling out any ties to health products companies.

    Prescrire’s editorial methods are outlined > HERE. The names of the dozens of individuals who have contributed to the articles published in each issue are published in issue’s masthead, as described > HERE. For each review published, the literature search strategy is defined, often with dozens of references selected for inclusion. This transparency, highly unusual in publishing, and especially in the medical press, demonstrates the Prescrire team’s commitment to the reliability and credibility of its content.

    ©Prescrire 1 June 2020

  31. Clozapine treatment and risk of COVID19
    When I first glanced at this pre-publication back in June, didn’t think it worth posting as it didn’t really add anything we didn’t know or could guess at, together with too many confounding factors to make paper of any real use. It just seemed to be a survey done as a means of a ‘thankyou’ to a couple of charities, who agreed to pay towards the cost of infrastructure.[1]
    Then yesterday, when I was going through some half finished correspondence from 2004 which I had with a doctor who had some administrative roles within a local NHS Trust — it triggered a memory.

    In this pre-publication paper they proffer advice on how to reduce SARS CoV-2 transmissions. My advice to aid the reduction of clinical symptomatic infections would be to tell all of the UK Trusts works-engineers to re-set the air exchange ratio on the ventilation systems (which mixes fresh air into the recirculated warm air) from minimum to something inline with the industrial norm.

    My 2004 correspondence was initiated because both staff and patients knew that their dry throats, ‘frequent colds’ and other complaints were caused by the poor ventilation of the buildings. The only sensible answer to my enquires back then, and more importantly, as to why nothing was ever done about it, was what I gleaned from my ‘unofficial chats’ with people responsible for building maintenance. The gist was: It had become common practice to reduce the ratio of fresh air —to be mixed with the recirculated air— to the minimum, so as to reduce heating costs. And with the government making further funding cuts, the Trust accountants just weren’t going to budge. To be fair. The Trust Board Members and middle management were faced with many tough decisions and rather than resign their posts, they made them. As I could borrow a CO2 meter for use as an objective guide (although it was quite obvious without it), (and being the sort of person I am, made sure it was properly calibrated and accompanied by a witness), we went walk-abouts. The exceptions, where the air was very OK was the Trust’s administration block, incorporating the library and lecture rooms, etc. So was the local Primary Care Trust building (and whilst we were passing, the Town Hall). A case of ‘I’m alright jack’ perhaps? Time didn’t permit a check of other healthcare properties.
    This situation is likely true for all NHS Trust property and for care homes, both here and abroad. There are many google reference regarding healthcare facilities, showing bad air quality (and filthy surfaces) is an ongoing concern. Can’t imagine Glaxo’s lab animals suffering the same conditions— can you?
    [1] James H. MacCabe et al; June 20, 2020. Clozapine treatment and risk of COVID19. King’s College London. London.

  32. I posted a comment today saying it started 14yrs ago my mistake it started 20yrs ago made to feel unwell it a long time and pychiatry still cant get it right. I was also diagnosed with osteocarosis of the jaw rare like the rare side effects i experiance like me im rare an indevidual not a stat for data.

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