Pregnant Woman Caucasian

This week is breastfeeding awareness week in the U.K. In recognition of this, we’ll be posting a series of short articles on breastfeeding advice alongside our usual content.

The first one relates to updated information bulletin produced by U.K. Medicines Information Pharmacists on the 21st of May, 2020. You may download a copy of this bulletin here. Please take note of the disclaimer at the top of the bulletin.

In summary, here is what we currently know about breastfeeding and ibuprofen:

  • Ibuprofen is one of the painkillers of choice whilst breastfeeding
  • Only very small amounts of ibuprofen pass into the breast milk, and these amounts are far below the doses that would normally be given to infants directly
  • The properties of ibuprofen are such that there is no risk of it building up in the infant’s system.
  • There have been no side-effects reported in infants exposed to ibuprofen through breast milk
  • Ibuprofen is widely available to purchase as an over-the counter medicine and is also found in some cold and flu remedies.
  • This also applies to ibuprofen formulated as the lysine salt.
  • This applies to infants born full term and healthy. If an infant is unwell, or premature, or the mother is taking multiple medicines, then an individual risk assessment will need to be made.
  • If a breastfeeding mother is infected with coronavirus (COVID-19) it is still advisable for her to breastfeed her infant since the benefits of breastfeeding outweigh any risk of transmission of the infection. For the latest guidance, see Public Health England.

The latest NHS advice regarding the use of ibuprofen to manage the symptoms of coronavirus (COVID-19) is available here.

Tablets

One of the outcomes of the emergence of Covid-19 is that it has shown how the slow, methodical manner in which scientists prefer to gather evidence, upon which to base advice, can prove unsatisfactory in a world in which rapid answers are required both in the political and social spheres. Nowhere is this more vividly illustrated than in the plethora of opinions about supposed causes, cures and preventatives for the infection. In this post we look at the main allegations in relation to the four drugs above and compare them with the findings and views of the main body of scientific understanding. This is of course not a substitute for any medical intervention that a qualified professional might prescribe individually for you. It is also not intended as a commentary on the choices or actions of any individual in relation to any of the drugs.

Let’s start with ibuprofen. This is a drug that is widely used as an anti inflammatory pain-killer that also helps reduce high temperatures.
The allegation: Back in March 2020, growing circulation of rumours online and in social media, alleging that ibuprofen could make symptoms of Covid-19 worse, led to cautionary advice being given that, wherever possible, people should use paracetamol in preference to ibuprofen; even though there was no evidence that ibuprofen could cause worse outcomes for those infected with the coronavirus.
The confirmed findings: On the 14th of April, 2020, the Commission of Human Medicines (CHM) Expert Working Group on coronavirus (COVID-19) release an update that it had reached the conclusion that there was insufficient evidence to establish a link between use of ibuprofen, or other non-steroidal anti-inflammatory drugs (NSAIDs), and susceptibility to contracting COVID-19 or the worsening of its symptoms. In other words, ibuprofen, aspirin, naproxen and similar medicines are considered safe to use if you get infected with Covid-19.

Hydroxychloroquine: The British National Formulary indicates that this is licensed for use in active rheumatoid arthritis, systemic and discoid lupus erythematosus and skin conditions caused or aggravated by sunlight (all under expert advice). In children, it is not licensed for the last use. It is recognised as having similar properties for the prophylaxis of malaria as Chloroquine in those already using it for other licensed conditions, but is not itself used for this primary purpose in the U.K. (See Chloroquine below). The drug has recently been in clinical trials for effectiveness against Covid-19.
The allegation: This drug was widely alleged to be effective in treating Covid-19, Including receiving an endorsement on the 19th of March, from a very high office, as a potential “game-changer.
The confirmed findings: Results from randomised controlled trials across a number of countries have so far found the drug to be ineffective against Covid-19. These are the kind of studies that do the most to try to eliminate participant and observer bias and are therefore regarded as “gold standard” at the experimental stage of drug use. Although other studies continue, particularly in the U.K., results so far have not been encouraging and concerns have been raised about increased risks of side effects for participants. The drug is therefore not recommended for use in the treatment of Covid-19 at this stage.

Chloroquine: This is used in rheumatoid arthritis and lupus erythematosus like Hydroxychloroquine (see above); but, in addition, is used for prophylaxis against and treatment of certain types of malaria (see BNF online).
The allegations: Chloroquine received the same endorsement as Hydroxychloroquine, from the same sources, as a prophylaxis and treatment against Covid-19.
The confirmed findings: Like Hydroxychloroquine, scientific studies so far have failed to find any benefit from the use of chloroquine in coronavirus patients. There are confirmed reports of death involving an Arizona man who took the drug for this purpose. At this stage therefore, it is not recommended for either prophylaxis or treatment of Covid-19.

Azithromycin: This is an antibiotic used for a wide range of bacterial infections. At the minute it has no known use in viral infections. Covid-19 is caused by a coronavirus.
The allegation: Azithromycin has been promoted as a potential cure for Covid-19, either alone or in combination with Hydroxychloroquine. This was partly fuelled by news released in late March, by Pfizer, from a very small trial involving the two drugs.
The confirmed findings: The methodology of the Pfizer study has been questioned. Not only does the Centre for Evidence-based medicine confirm the absence of evidence for benefits from the use of the drug for Covid-19 patients, it highlights the potential for side effects. In addition, ongoing findings from other studies continue to highlight the absence of evidence for the effectiveness of the drug.

Conclusion
Decisions around the use of any medication by individuals are dependent on several factors, among the most significant of which are education and trust. The information above relates to the education element, which is a mainly cerebral function. Trust, on the other hand, will be influenced by emotions and biases. It is likely that, because of the public nature of the discourse around some of these drugs, and the affiliations associated with the debates, readers will find themselves agreeing or disagreeing with the conclusions based on the opinions of public figures with whom they align. If you are concerned about this, it is recommended that you discuss it at length with a trained medical practitioner and reach a conclusion based on an objective evaluation of facts as they unfold.

Multiracial Meal

On the 29th of April, NHS England released guidance to all health professional bodies and NHS employers highlighting the need to undertake specific risk assessments for BAME (Black, Asian and Minority Ethnic) employees in light of growing evidence that they were likely to be more adversely affected by Covid-19, with potentially higher mortality rates. The NHS Employers’ Federation, the Royal College of Nursing, the Royal College of Psychiatrists, General Practitioners, and Pharmaceutical Publications have drawn attention to the NHS England guidance, as has the media. In addition to this, NHS England wrote an open letter to BAME health personnel on the 1st of May, assuring them of the steps that it was taking to enhance their protection in light of the identified risks.

This video discusses the background to this. Visit our website for a fuller discussion

Over the course of the first two weeks of May, I have published a number of videos on my Podcast and social media platforms on the topic of displacement values. While the videos have no audio commentary, they are still useful if you want to get to grips with the concept; which, I have found, tends to confuse a lot of pharmacy graduates. Nurses, doctors and pharmacy technicians should also find them useful.

I’m working on a full lecture that incorporates both these videos and additional material for those who want a more comprehensive treatment of the subject. Let me know what you would like to see in the lecture and look out for it in the next few weeks.

In the meantime, I’ve put together the videos from the past two weeks in one convenient location below. Enjoy

Enjoy!
Displacement Values No 1
Displacement Values No 2
Displacement Values No 3
Displacement Values No 4
Displacement Values No 5
Displacement Values No 6
Displacement Values No 7
Displacement Values No 8