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Medicines: When less is more – The Big Story News

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My stomach feels as though it is on fire every time I eat solid food,” says Supriya Mallik, a 39-year-old acoustical engineer from Kolkata. In the two months since she tested negative for Covid, Mallik has lost 15 kgs due to persistent gastrointestinal (GI) problems. Mallik’s case was mild—around two days of fever and a slightly dry throat. Fear, she says, drove her to self-medicate with the antibiotic doxycycline, sold popularly in India as Doxy 100. Her father had been prescribed the drug for his mild illness and Mallik used his prescription to buy her own strip. The medicine left her physically weak and aggravated her previous history of gastroesophageal reflux disease. “Gastric issues run in the family. My doctor says that Doxy 100 was not needed in my case and that taking it depleted the good bacteria in my gut. Since then, I have faced severe digestive issues.” Mallick is currently seeking treatment from Apollo Hospital in Kolkata.

The increase in antibiotic consumption during the pandemic has many medical experts concerned. “Fear of a secondary bacterial infection or the lack of a specific treatment for Covid has led to over-prescription of antibiotics. Antimicrobial resistance is a silent pandemic on its own in India and Covid is adding to it,” says Kamini Walia, a microbiologist with the Indian Council of Medical Research.

Indians purchased medicines worth Rs 15,662 crore in April, 51.5 per cent more than they did last year. According to the latest report by market research firm AIOCD-AWACS, which tracks sales of medicines at chemists across India, there has been 134 per cent growth in the sale of anti-infectives, of which antibiotics form a major part. The two most common antibiotics being taken for Covid were azithromycin and doxycycline and the spiralling demand for these could be seen in the huge spike in orders for the active pharmaceutical ingredients that make up the drugs—for azithromycin, it increased by Rs 3,500 per kg as compared to its price in February 2021 (before the onset of the second wave); for doxycycline, it doubled to Rs 6,000 per kilo. “Many chemists had trouble finding popular brands of both drugs during the peak of the second wave. People were even panic buying antibiotics in case they couldn’t get them later,” says T.V. Narayana, director of the Indian Pharmaceutical Association.

The initial case for antibiotics

The real worry lies not in the use of antibiotics, but in their misuse. Covid is a virus and antibiotics are designed to act on bacteria, an entirely different pathogen. However, at the start of the pandemic, some limited evidence had suggested that azithromycin and doxycycline could have immunomodulatory effects that would help prevent the virus from escalating into a moderate or severe disease. “During the first wave, Covid was a challenge for everyone, including doctors,” says Dr Sudha Menon, director, internal medicine at Fortis Hospital, Bannerghatta, Bengaluru. “Initially, we were trying to revamp old molecules to see if they would have any effect. We were getting anecdotal evidence on some antibiotics from around India and the world. These are old drugs with some kind of immunomodulant activities, so their initial use was mostly out of a lack of choice.”

As the pandemic progressed, many doctors began to limit the use of these medicines to just the cases where there was a possibility of a secondary bacterial infection. “We began to see that there was no scientific evidence to support the use of antibiotics to treat Covid. If someone had UTI or bacterial pneumonia during Covid, only then was an antibiotic used. Plus, in Covid, you usually only get a bacterial infection if you have low immunity or have been put on steroids which lower your immunity,” says Dr Rommel Tickoo, the director of internal medicine at Max Healthcare.

Indeed, by the end of 2020, studies began to be published that conclusively stated antibiotics did not help in the treatment of Covid. According to a September 2020 study in The Lancet journal, randomised trials found that azithromycin was not an effective treatment for patients admitted to hospitals for Covid, either alone or in combination with hydroxychloroquine. The guidelines for treatment issued by the World Health Organization (WHO) and those followed by the US, the UK and, closer home, Bangladesh and Pakistan, never included any antibiotics. In India, azithromycin was recommended in the March 2020 guidelines issued by the ministry of health and family welfare (MoHFW), but was dropped by July 2020. However, fear and anxiety prompted people to continue taking the medicine. Some doctors have even had patients insist that an antibiotic be included in their Covid treatment plan. “I was giving antibiotics to my Covid patients till July last year, but stopped after that. In the second wave, I had patients who threatened me because my prescription for their family or friends was different from last year. They are so frightened that they won’t listen to reason,” says Dr Amol Chavan, a Pune-based general physician.

The continued use of antibiotics led the MoHFW, in its latest guidelines issued on July 7, 2021, to explicitly state that “no medication” was required for mild Covid cases. “There has been irrational overtreatment in Covid already. These new guidelines are evidence-based, focusing on what is known to work and at what stage of the disease,” says Dr Gagandeep Kang, noted microbiologist and virologist.

The consequences of self-medication

Taking too much medicine or the wrong medicine has been noted to have an immediate negative impact on GI health. According to a study on the post-Covid effects on GI health published in The Lancet in March 2021, 44 per cent of the 117 Covid patients it studied, continued to experience GI symptoms up to 90 days after testing negative. One of the possible reasons cited for this was the impact of the various medicines consumed during treatment. “We don’t know the exact cause—it could be the virus impacting the GI lining or the overuse of medicines. But we do know that antibiotics in particular have had a history of upsetting the GI equilibrium,” says Dr Vikas Singla, director of gastroenterology at the Max Super Speciality Hospital in Saket, Delhi. “In our large intestine, where our food is digested, we have a lot of good bacteria that help us break down food for digestion. Fibre or complex carbohydrates cannot be digested by the human digestive system, it is bacteria that digest them and we derive energy.” In healthy individuals, adds Dr Singla, the good bacteria outnumber the bad bacteria. When patients take antibiotics, the medicine often selectively kill sthe good bacteria. “When this happens, the carbohydrates in our food don’t get digested, leading to water retention and diarrhoea. Antibiotics like amoxicillin are among the most common causes of diarrhoea,” he adds.

There is also concern that overuse or incorrect use of antibiotics will lead to bacteria becoming resistant to some types of medicine. According to the ‘WHO Antimicrobial Resistance: Global Report on Surveillance in 2014’, from all studies conducted in India with 30 isolates or more, the resistance rates of E-coli to the most popularly-used antibiotics was 82 per cent. An ICMR study on secondary infections, which analysed data from 17,534 Covid patients admitted to one of 10 chosen hospitals from June 1 to August 30, 2020, found that in Covid, co-infections were caused by multidrug-resistant organisms in about half the cases.

“We will be in a real mess even post-Covid,” says Dr Menon. “When you need to use an antibiotic to treat a bacterial infection next time, it won’t work as the bacteria would already be resistant to the drug. And this drug-resistant bacteria can be transmitted to others as well. We have already reached a point where even tonsillitis requires hospitalisation, which never happened before. Because of random misused antibiotics, we find patients with a very resistant tonsil infection.”

Illustrations by Siddhant Jumde

In search of immunity

It isn’t just antibiotics that have seen an irrational overuse over the past months. Indians have also been massively overdosing on nutritional supplements since the pandemic began. In October 2020, the country’s pharmaceutical market recorded a startling change. For the first time, a multivitamin brand sold more of its pills than medicine for lifestyle ailments such as diabetes and heart disease. Zincovit, a 30-year-old brand by Apex Labs in Chennai, recorded sales of Rs 50 crore that month—more than that of Human Mixtard or insulin, which clocked Rs 47 crore. This multivitamin and multimineral supplement was a paltry No. 53 on the list of top medicines sold in the organised pharma retail market in January 2020. Post-pandemic, it was number one. But there has been no proof that either Zinc or Vitamin C can help fight Covid. In fact, a small study published this year in medical journal JAMA Network Open of 214 people suggested that high doses of Zinc and Vitamin C consumption did not significantly improve symptoms.

Dr Mulund Rasika Parab, a nutritionist with Fortis Hospital, Mumbai, says: “You can’t just pop a pill or eat a lot of one food group and get immunity. Zinc became a wonder nutrient during the pandemic, but your body needs only a little bit of it alongside several other vitamins. Overdosing on vitamins, particularly if you are already on other medication, has many side-effects,” says Dr Parab. For Delhi-based Kalpana Jain (name changed on request), a 41-year-old heart patient, taking a Zinc supplement alongside others which also had Zinc in it, caused her to lose consciousness one morning. The overconsumption of Zinc had reacted adversely with the blood thinners in her heart medication. “Everybody said take Zinc for Covid. So I took it. I didn’t think there would be side-effects,” says Jain.

What to do in mild cases

The latest MoHFW guidelines suggest treatment based purely on symptoms. For those with no symptoms, only isolation and rest are advised. “You don’t need to do repeated blood tests or CT scans if you have no symptoms or just some fever. You can do a six-minute walk on the eighth or the 12th day to keep a check on the active phase of the infection,” says Dr Menon. “The return of fever or worsening of cough after testing negative might be signs of a bacterial infection. That’s when you check in with your doctor.”

There is some scope of corticosteroids preventing the disease from escalating. “No medicine does not mean you don’t treat symptoms or use clinically proven solutions. For example, if you have fever and cough, then inhaling budesonide early in the disease reduces the virus’s progression. Beyond this, there is nothing else for mild cases—moderate to severe have to be admitted to hospitals,” says Dr Tickoo.

Antibiotics are wonderful drugs and have a history of saving lives. They just need to be used correctly.

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