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'Only 4 drugs reduce COVID-19 mortality. Everything else is stupidity'

June 09, 2021 11:08 IST

'Unfortunately, during this pandemic, everybody started saying that well, these are desperate times and desperate times need desperate solutions.'
'Purely out of fear, anxiety, panic, this knowledge that people started acquiring from WhatsApp University and social media, it pushed science completely to the backseat.'

IMAGE: Healthcare workers interact with a COVID-19 patient at a temporary Covid hospital at the Tau Devi Lal stadium in Gurugram, June 8, 2021. Photograph: Yogendra Kumar/ANI Photo
 

Dismay.

Depressing dismay.

That's what the legion of more principled Indian doctors, attempting bravely to treat COVID-19 by the correct internationally accepted protocol have felt, for many, many months now, about the guidelines issued by the Indian Council of Medical Research, New Delhi, for the treatment of COVID-19.

These ICMR guidelines had drugs like ivermectin, remdesivir, hydroxychloroquine, doxycycline, favivirapir listed on them, long after the medications had lost their place in the sun.

As well as plasma therapy.

None of these drugs have been found to be particularly or conclusively effective in the treatment of this terrible, overly-ambitious virus.

The verdict was out on remdesivir for a very long time and now it's in and remdesivir is discovered to be not specifically or noticeably curative.

Nor, it has been realised, is plasma therapy useful.

Instead, the procurement of the drugs, for patients, has led to long, crowded lines and a run on medical shops, a situation certainly not desirable in a pandemic.

Further, much energy, frail hopes and valuable resources -- especially financial, of patients' families -- have been sadly wasted in tracking down these drugs and plasma. And the relative dies anyway, their brave efforts, not withstanding.

Fortunately, as of a few days ago, to the palpable relief of doctors everywhere in the country -- check Twitter -- the ICMR has revised its guidelines for COVID-19 treatment, offering a much more sensible protocol.

But it will probably still take months for these unrequired drugs, along with steroids, to finally go off the list of medications on lengthy prescriptions being handed out to even young people with very mild home infections of COVID-19.

The outspoken, forthright Dr Shriprakash Kalantri, right from the start, has been anti polypharmacy and heavily overloaded prescriptions that have no logic them. He has been sagely using social media to try and effectively influence the line of thinking on COVID-19 treatment.

He proudly tells you that he treated the 15 various members of his extended family, who got sick with mild COVID-19, with just paracetamol.

Dr Kalantri, a teacher and specialist in internal medicine and epidemiology, with over 40 years of experience, is the director professor of medicine at Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, and medical superintendent of the Kasturba Hospital, Wardha.

He earned his specialisation in medicine from the Government Medical College, Nagpur, and a master's in public health in epidemiology from the School of Public Health, University of California, Berkeley.

Dr Kalantri, who is also is deeply involved in research and is a pioneer in clinical care, has crusaded against drug industry sponsorship of medical conferences and at MGIMS, through his efforts, a regime of low-cost drugs is in practice.

In the first of a multi-part conversation with Rediff.com's Vaihayasi Pande Daniel, Dr Kalantri explains the consequences of the excessive prescription of antibiotics and strong drugs for COVID-19 and the kind of havoc it can cause for the country medically in the long run.

IMAGE: A health worker interacts with a patient undergoing COVID-19 treatment at the Netaji Subhas Chandra Bose Medical College and Hospital, in Jabalpur. Photograph: PTI Photo

COVID-19 cases have risen dramatically all over India during this second wave. The bulk of the cases would be home cases. Yet azithromycin and various antibiotics have been prescribed for even mild cases at home for a viral disease.
What could be the fallout of such an excessive use of antibiotics be?
Can this cause a massive situation of resistance to other bacterial diseases and microbes later on? And how can that present itself?

We need to understand that COVID-19 is a viral disease.

All through my academic and professional life, I have never seen a virus illness treated by about a dozen drugs!

I have also never seen a virus illness being treated by antibiotics.

Antibiotics kill bacteria. Not viruses.

But unfortunately, during the pandemic, evidence-based medicine and science were thrown to the backseat. The entire country was seized with anecdotal medicine, personal experiences, and many of the practices were defensive, borne out of pure fear.

Two major problems have resulted.

First, when your patients have just turned positive for COVID-19 and they're barely symptomatic, it is not uncommon to see at least two to three antibiotics being prescribed to them.

The most common antibiotics are doxycycline and azithromycin.

Almost every prescription in this country today carries either doxycycline or azithromycin on it.

Some patients also get a third antibiotic like amoxycillin.

Or a fourth antibiotic is added like ciproflox.

The problem is, when a virus illness is in its very early (stages), and your patients are barely symptomatic and all that they have is a fever, when you treat them with two, three or four antibiotics, then you are building a massive antibiotic resistance all over the country.

Two, antibiotics don't work here, because it is a viral illness. Antibiotics don't kill a virus.

Three, you're making those prescriptions pretty costly.

Four, you're adding a dozen drugs and you have no idea how these drugs will interact with each other.

You are definitely subjecting your patients to the significant adverse events, of which you are not aware and the patients are not aware. And when those patients come with some complications, or adverse events, everybody has forgotten that this patient was on two, three or four antibiotics, and whether that antibiotics combination, with other drugs, could have contributed to the adverse events.

The other problem, that I see, is that when this patient's disease gets more advanced, they become a hypoxic (short of oxygen in the tissues) and they need hospital admission or an ICU admission, more often than not, almost all major hospitals in the country start them on extremely potent reserve antibiotics, like meropenem, imipenem and piperacillin-tazobactam.

These are reserve antibiotics which need to be used in very special circumstances. They cannot be used to prevent an infection because antibiotics are used to treat not prevent an infection.

On Day 7 or 8, when this patient is admitted to a ward or ICU, they are started on these quote unquote prophylactic antibiotics and when they really need antibiotics, we have no antibiotics to lay our hands on.

This I am seeing now even in my rural, teaching hospital in Sevagram, where I work and practice medicine and in almost all hospitals: The number of resistant bugs has started growing.

When we take cultures from patients -- blood samples, sputum samples, stool samples, urine samples, we find the growth of organisms which are resistant to all antibiotics. So, the most potent antibiotics, the most expensive antibiotics, antibiotics, that we have probably never used in the past -- bugs have acquired a resistance to those antibiotics.

This is an extremely frightening situation because once a bug has acquired resistance to all antibiotics, even if you try your best, you give a patient the best care, you put them on a mechanical ventilator, you take care of their blood pressure, you try to treat their pneumonias, but the antibiotics are completely ineffective now.

We get a lot of these patients, who develop more and more complications in the hospitals, because the bugs are proliferating, the bacteria are having a field day. Ultimately, we lose patients.

So, it's a double whammy for a patient. In the first week, the patient was attacked by a virus. In the second week, when they get admitted to the hospital, they are attacked by a bacteria and bacteria that are no longer responsive to antibiotics.

So even though they might have escaped a virus, now they are caught in the bacterial spiral. They spend a couple of days or of weeks, sometimes in the ICU, and then they die a very painful, very tragic death.

And probably many of these cases are iatrogenic, that is caused by doctors and healthcare, because of a very injudicious and irrational use of antibiotics, which is happening almost all over the country.

So, whether it is the public sector or the private sector, small nursing homes, or large tertiary care hospitals, irrational use of antibiotics is extremely rampant.

All over at this same time?

At the same time. It is not only absolutely unscientific but it has always led to antibiotic resistance, and the patient goes through more and more progression of the disease and ultimately, we lose the patient.

IMAGE: A crowd waits to buy Remdesivir outside the Jawaharlal Nehru Stadium in Chennai, May 15, 2021. Photograph: Anantha Krishnan/ANI Photo

In the context of over prescribing, a young person of 25, who I know, who had a mild case of COVID-19, and is at home, was prescribed a string of medicines including steroids, favivirapir and the very strong drug thalomide.
Patients do not seem to have the ability to question a prescription. It's very hard to persuade patients, even people you know, that you do not need to take all these medicines.
My question is, how do you convince people that they should not? That they should question what they're being given? Even very sensible people are spending thousands filling unnecessary, huge prescriptions?

Unfortunately, in this pandemic, India's highest scientific body failed. The Indian Council of Medical Research, gave protocols and its protocols, for several months, still had hydroxychloroquine and still continues to have ivermectin (the protocol was revised a few days after this interview). Convalescent plasma was there in the protocol for quite some time and was just recently deleted now.

So, what happens is that once the medical profession feels that this is coming from the highest scientific body in the country and ICMR itself is recommending hydroxychloroquine or ivermectin or plasma or earlier favivirapir, then it gets almost an official approval, scientific approval that it needs to run.

Unfortunately, during this pandemic, everybody started saying that well, these are desperate times and desperate times need desperate solutions. Purely out of fear, anxiety, panic, this knowledge that people started acquiring from WhatsApp University and social media, it pushed science completely to the backseat.

IMAGE: Dr Shriprakash Kalantri. Photograph: Kind courtesy spkalantri/Twitter.com

Let me give my own example of my family. I must have treated 15 of my family members, who got infected with the COVID-19 virus in my immediate family. But almost everybody got nothing beyond a couple of tablets of paracetamol. That's it! Period!

They all got one drug, paracetamol to take care of their fevers and aches and pains. And they all got better.

So, when today I see about a dozen drugs making its way into the doctor's prescription -- two antibiotics and hydroxychloroquine, ivermectin, favivirapir, vitamin A, vitamin C, vitamin D, zinc ---I must have missed some more (laughs), I feel very sorry that the medical profession has failed.

And this was a time when the medical profession should have spoken and said: This is a viral illness. Eighty per cent of the patients are going to get better on their own. There is no drug which can probably prevent a progression from mild case to moderate case. So about 80 per cent of the population can be treated only at home, by only a paracetamol tablet, isolation and monitoring oximeter readings.

Should oxygen levels drop, take them to the hospital and they can get dexamethasone. If they deteriorate, in spite of dexamethasone, then there is a small case for a drug called tocilizumab, period.

Oxygen, steroids and tocilizumab and the fourth is a blood thinner for those who are 50 plus and who have diabetes, heart attack, stroke etc.

There are only four drugs, which have reduced the mortality in COVID-19. Rest everything else is absolutely plain stupidity.

IMAGE: A 'Women Special' vaccination drive at the Avanti Bai Mahila Chikitsalaya in Lucknow, June 7, 2021. Photograph: Naeem Ansari/ANI Photo

The vaccine makers, who are making the COVID-19 vaccines say -- apart from tiny percentage for whom this viral illness may still be fatal -- that if you get COVID-19 after vaccination, you will only have mild illness.
But we are hearing that people are yet dying of COVID-19, in spite of vaccination.
The vaccine is not protecting them because they are not getting mild illness. And the reason they are not getting mild illness is because of complications that occur in a hospital environment, because systems are overwhelmed. So, it looks like the vaccine has failed. But it is actually the system which has failed?

Yes, you are right, in a way.

Because once you get two vaccines, we have got a lot of evidence after getting two vaccines and a certain period then you have enough antibodies in the blood.

It won't prevent an infection. The virus might still enter the body, but it reduces the severity of the disease. So, you might end up with only a mild illness. It will not progress to a severe illness.

But then sometimes, somebody now gets COVID-19 and gets admitted to the hospital. Unfortunately, gets admitted to an ICU and then unfortunately develops some complications. Probably this entire failed healthcare system, the hospital's prevention programmes not being in place, the irrational use of antibiotics there and sanitation practices not being very actively practiced and handwashing not in place etc. They might all contribute to a person's death.

Otherwise, if you look purely at the vaccine, the vaccine confers you a significant benefit from getting severe COVID-19. You might still end up with a mild COVID-19. That is okay. But it confers you a huge protection against severe COVID-19.

Feature Presentation: Ashish Narsale/Rediff.com

VAIHAYASI PANDE DANIEL