Bird flu clinicians -- the handful of doctors that have actually treated human cases of bird flu -- met in Turkey last month, and upon comparing notes made new recommendations. Among them, don't use steroids:
Doctors caring for H5N1 patients should not treat them with corticosteroids, the World Health Organization said Thursday, noting the drugs don't help and sometimes harm patients trying to battle the often severe infection.Corticosteroids should only be used on patients with persistent septic shock, a condition in which blood pressure drops to dangerous levels because of an infection in the bloodstream, the WHO advised in updated treatment guidelines, published on the agency's website. (Helen Branswell, Canadian Press)
Here are some other recommendations (details will be published in a scientific journal):
- Experiences with early oseltamivir treatment suggest its usefulness in reducing H5N1-associated mortality. In addition, evidence of prolonged H5N1 virus replication indicates that treatment is warranted even with late presentation.
- As previously discussed, modified regimens of oseltamivir treatment, including two-fold higher dosage, longer duration and possibly combination therapy with amantadine (in countries where the H5N1 virus is susceptible to amantadine) may be considered on a case by case basis, especially in patients with pneumonia or progressive disease. Ideally this should be done in the context of prospective data collection.
- Antibiotic prophylaxis should not be used. When pneumonia is present, antibiotic treatment is appropriate initially for community-acquired pneumonia according to published evidence-based guidelines. When available, the results of microbiologic studies should be used to guide antibiotic usage in patients with A(H5N1) infection. /li>
- Therapy for H5N1-associated ARDS should be based upon published evidence-based guidelines for sepsis-associated ARDS, specifically including lung protective mechanical ventilation with low tidal volume. (WHO)
These are updates and modifications of earlier WHO clinical guidelines. The salient features are the caution against corticosteroid use, except to treat refractory sepsis with adrenal insufficiency, recommendations against prophylactic antibiotics and the recommendation to double the dose of oseltamivir (Tamiflu).
This is the second meeting of treating docs and clinical care specialists, the first having been held in Hanoi in 2005. It seems to have borne some fruit, and its value was recognized:
Participants agreed that standardizing care and promptly sharing clinical and treatment information are critically important to understanding the disease in humans and to improving clinical management. (WHO)
That's great. But it would be nice if some concrete steps were taken to standardize collection of clinical data and make more timely arrangements for harvesting it. Maybe we'll hear this is underway.
I hope so.
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"First of all, when people say, well, this is, you know, the 21st century -- we'll have antibiotics. Today antibiotics are a just in time delivery product in many hospitals. We've seen an increase number of hospitals in this country get deliveries three times a day now for pharmaceutical and central supply products. We'll run out overnight." Dr. Michael Osterholm
Is the Bird Flu Threat still real and are we prepared?
Council on Foreign Relations
No mention of Relenza. Cute!
No mention of black elderberry extract.
No mention of any alternative therapy, such as serum injection which apparently saved the life of the Chinese woman last mention I saw being that she's alive and in hospital.
Dinosaurs talking about known therapeutic options. Hope they had a nice get together. Everything they said has been covered ad nauseum in the flu tracking newsgroups.
Disappointing?
Isn't amantadine the generic name for Relenza? Because that was mentioned.
And you can't expect clinicians to get their treatment recommendations from flu tracking newsgroups. I'd be alarmed if they did. Clinicians have to talk to each other, or at least read each others' detailed treatment/outcome reports, and that's what this was about.
caia: Amandatine is Symmetrel (and I suppose other names). Relenza is zanamivir. It must be inhaled. I am not sure if it has ever been used with a vent. Critical care physicians have some of the toughest management jobs in medicine. They are not dinosaurs. They literally deal with life and death, minute by minute. The "omission" of elderberry extract in this context is not surprising. It would have been surprising if it had been included. Clinical management by computer keyboard isn't the same as the job these folks have. But I guess that is lost on some people.
Let's see if this peer-reviewed journal article is going to freely avaliable on an open access journal or restricted.
Then we will discuss their findings or lack thereof.
The only conclusion that can be reached at this point, is that generally their treatments not been very successful.
It seems that chronic sequelae have not been reported as yet...that shouldn't be too hard to track.
Of course, as it stands now, there will be no pharmaceuticals or anything else to treat any patients...
...personally, I hope Gaudia Ray's elderberry extract works...because that is what we are going to be reduced to.
But don't take my word for it...take Dr. Osterholm's word...he must have failed Dr. Sandman's high impact-low probability spin class.
Thanks, Revere. And I agree, these people have extremely difficult jobs, and I for one am glad they're pooling their knowledge.
If the doctors who treated a woman in China with a serum injection weren't part of this meeting, and haven't submitted the procedure and results, then it can't very well be part of a recommendation, for or against.
As for elderberry, even some of its most fervent amateur proponents recommend it only as a prophylactic, since it appears to stimulate some of the same cytokines involved in cytokine storm. So for all we know they know all about elderberry, but aren't using it on purpose.
Tom you are the king of doom! I look forward to the entertainment value of your posts LOL.
I sgree with the steroids recommendation (generally). My own paper on the subject, which describes the issue in detail will be published in the Journal of Medical Microbiology in the next few months.
"Corticosteroid therapy has failed so far to show effectiveness," the WHO warned in a statement. "Prolonged or high dose corticosteroids can result in serious adverse events." Frederick Hayden of WHO's global influenza program
If you take normal subjects with no disease pathology at all, and give them prolonged or high dose steroids, they will suffer from "serious adverse events".
JT. Thanks. I think!
My message is clear.
At the moment, limited funds are being spent on two solutions: vaccines and antivirals.
There will be no vaccines until after most of the damage is done...which renders them ineffectual.
As far as the antivirals go, there has been historically significant (18%) resistant in treating the far less virulent seasonal influenza's...and there has been a number of examples of resistant H5N1 already demonstrated in a very small number of clinical cases (approx. 250)...
...when you start hearing about dosages being doubled or then tripled or then added in combinations to other antivirals...that is a very clear indication that they don't work.
I believe that in a pandemic, a certain percentage of patients will die no matter what heroic treatment protocols are used (approx. 5%)...
...treatments must be aimed at the next 10-20% of cases that are completely curable without lifelong life-limiting sequelae such as permenant lung damage from primary viral pneumonia or secondary bacterial pneumonia.
My experience has shown that in animal models moderate to low dose prednisolone for short periods or time 4-7 days, will offset toxic effects of simiar viruses or secondary bacterial sepsis...and this antishock drug is very cheap, pennies a pill, and is avaliable in an oral form that could be given at home.
I believe that an investment of twenty dollars per person would provide a package that could be given out from seconded fast food windows in the event of a pandemic. The package would contain oral broadspectrum antibiotics, oral electrolyte powders that would be mixed with water at home, prednisolone (antishock-antisepsis pills) and antifever medications like acetominophen...FOR THESE TREATMENTS TO WORK, THEY MUST ALL BE GIVEN IN THE VERY EARLY STAGES OF THE INFECTION AS PROPHYLACTICS-PREVENTATIVES.
...also, there would be instructions for sources of advice from healthcare personnel on line or on the phone.
I believe that we can beat a pandemic but if we continue to concentrate on their two 'magic pills' that have clearly demonstrated very limited overall effects on a pandemic...we are screwed.
The advantages of N95 masks must stop being downplayed...
...and I would like to see the health authorities mentioned in the articles explore the use of DMSO-Dimethylsulfoxide as a potential assist in the cytokine storm...as they have no other workable solution at the moment.
If they are going to tell us that standard antishock-antisepsis drugs have failed, they first must give us an understandable physiological reason why they won't work and secondly they must come up with an alternative treatment that makes some sense physiologically...
...so far that hasn't happened.
If these statements makes me 'The King of Doom'...sobeit.
Help.... I am attending a town meeting at Columbia Medical Center on the ethics of vent use in a pandemic.
Can you tell me what is the success rate using vents to treat H5N1 patients?
Hang on JT----I am the resident king of doom and gloom. Not really though. Tom like me has followed this down to its logical conclusion based on the 70% current CFR. He understands that even today in the national stockpile (though I think he is Canuck) that we have maybe a three-five week supply in highly discriminate of medical supplies. But that five week supply is based upon normal use and we would blow thru that in about a week to ten days. Not much help there.
Sheyit, I would snort elephant doo if I thought that it would work any better than elderberry extract. If I or someone that I know gets it, I will assess the hospital situation to ascertain if there are beds, doctors or supplies. Any break in that little triangle and they will just stay with me and I'll do the best I can with what I have at the time. If they are going to go, it aint going to be alone.
Revere, has anyone thought of high doses of vitamin C as a prophylactic in the blood. Can you even drip it in there without damage? Kind of tough for a virus to reproduce in that environment and I know that one of the first cases of Ebola survived because as a doctor he attributed it to the fact that he took one of those day and ate fruits and veggies at least three times a day... Might just be pure snake oil but thats what I read. He jabbed an infected needle into his finger from a highly infected patient.
Tom I speak of the total body of your work and not just the posts in this thread.
Your posts are fantastically gloomy and the entertainment value is absolutely priceless. I've been reading your apocalyptic musings for two years now and for the most part your posts just keep getting better and better. I especially like your rants against revere. Very good stuff.
Thanks and please keep them coming. ;0)
Goju-So far the arsenal for treating BF hasnt been found. Vents, Tamiflu, Relenza, etc; nothing has worked including the Kool-Aid vaccine that was made. I for one will hold off on the final analysis of that one because as Revere said, no one has ever been given it for BF, nor has it been tested on BF patients. It produces an antibody response and that happened in only 1/2 of the people. It also apparently has to be on board before you get sick and its a 2 dose and 28 days apart. Just about nil by the way on vents. I saw something last year (late) on MMWR.....Anyone see it besides me?
JT. Thanks I think.
This kind of abrupt correction in the animal kingdom occurs all the time.
I would rather not see what I have observed, do the same to humans...when we have proven, straight forward, boring but highly effective technology to blunt the effects.
MRK. LOL!!
Actually, there is a great body of evidence that Vit D is the prophylactic vitamin supplementation to take that may have a real positive effect on the outcomes.
Tom DVM: Although you and revere argue I for one appreciate reading the dialogue. Hidden between the jabs lies valuable information. Everyone just needs to be a little kinder and not hide behind their computer screen blasting one another.
As for the Vit D, I took some over the winter. Must have overdone it as the muscles on the left side of the body started to ache. I've stopped since then and the side effects have improved.
Vit C sounds interesting and should we find ourselves in a situation where we can get nothing else it's now on my list of must haves. There is a Vit C that mixes with water, pretty good and has a decent shelf life. Would be to grainy to shoot up though.
Hm, I can see it now- Gloom&Doom Co-Housing Enclave;
upstream from the GreenBurialGround Parkway.
M. Randolph Kruger on the tactical end of the clu-de-sac, and Tom DVM at the other, the Pakistani family and I can take the houses across from each other in the middle, have Prof Eccles get our power and communications in... invite Dr.Nabarro by for a block party, before all heck breaks loose.
Wikipedia doesn't even say who all makes prednisolone.
Something else the US imports, I'd guess?
Revere, there was nothing new announced by those who gathered to recognize what has been reported and recorded in the newsgroups. Your own comments and postings on statins (long ago...hence my stash of them) plus your additional curative and prophylactic discussions are also to me more meaningful than the dinosaur meeting and pronouncements.
The problem is this. This is a high consequence outcome disease. It's also has, as you and I have explored, an indeterminate arrival. Due to two facts: one, nothing really works but for early and larger dosage administration of antivirals, and two, indeterminancy, we who are interested in surviving the encounter, believe we have no option but to seek knowledge at the leading edge.
When the lay public, that's me, knows as much and more than the gathering doctors, they're dinosaurs. And I know because of the contributions of the dozens of people tracking and reporting data and discussion via the publicly available newsgroups.
The doc's as a group will be late to this catastrophy. A responsible summary, monthy, in fluwiki, or in any of the 3 main pandemia newsgroups, would be more valuable than the late pronouncements of what I continue to view as the academic international party goers. Where next? How about the Canary Isles for a bit more R&R? As I said, I'm stickin' with the newsgroups, this blog, and Niman's for the smart facts on what's truly happening.
Actually I meant Ventilators
They will be discussing the ethics of who gets the ventilators.
With that cleared, anyone know what the success rate use of the ventilator is with H5N1?
I assumed that when the patient got bad enough for one, they were post tamiflu treatment and heading into death.
CRF-I think that prednisolone is really just prednisone. Try it under that name. A PDR probably has who makes it.
I am with both Revere and Tom and elephant doo on this one. If it comes I think we are going to have to try everything. With the mass of patients they will come up with things to try and the sick will become IMO guinea pigs but not because the docs want to, only because it will blow thru Tamiflu and Relenza pretty quick or it wont be available.
GoJu-They wont be discussing the ethics of ventilators. In all likelyhood and the mean time between failures of someone who has BF and if the power is on, they will get to cycle the use of a machine give or take in a four month event something like 20 times. Thats assuming that someone is around to hook them up to it.
Prednisolone is the active metabolite of prednisone. They are not the same.