CDC Warns of Increased Ivermectin Overdoses

The US Centers for Disease Control and Prevention (CDC) is warning of an increase in cases of ivermectin overdose due to people self-prescribing the drug in an effort to prevent or treat COVID-19 (1). Ivermectin is used to treat river blindness and intestinal roundworm infection in humans and to de-worm pets and livestock. 

A study published earlier this year showed that ivermectin killed SARS-CoV-2 in cells in vitro. The authors proposed that the medication be investigated as a cheap and easily available treatment for COVID-19. However, subsequent studies have failed to find any benefit in humans (3).

In a new communication to its Health Alert Network, the CDC says cases of overdose and misuse are rising (1). More than 88,000 prescriptions were written for the drug ivermectin in the week ending August 13, an increase of 2400% over the weekly average prior to the COVID-19 pandemic (Figure 1).

Figure 1. Ivermectin prescriptions by week (from CDC, reference 1).

Unfortunately, the signs of overdose are nonspecific but can include gastrointestinal symptoms (nausea, vomiting, and diarrhea), hypotension and altered mental status (change in consciousness, confusion, hallucinations, seizures, coma).

The CDC is asking doctors to alert their patients to the risks of ivermectin, particularly ivermectin products intended for veterinary use. Physicians might suspect ivermectin in a patient with unexplained symptoms and are encouraged to contact their local poison control for assistance.

References

1. CDC. Rapid Increase in Ivermectin Prescriptions and Reports of Severe Illness Associated with Use of Products Containing Ivermectin to Prevent or Treat COVID-19. August 26, 2021. Available at: https://emergency.cdc.gov/han/2021/han00449.asp (accessed 8/27/21).
2. Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020 Jun;178:104787. [CrossRef] [PubMed]
3. Popp M, Stegemann M, Metzendorf MI, Gould S, Kranke P, Meybohm P, Skoetz N, Weibel S. Ivermectin for preventing and treating COVID-19. Cochrane Database Syst Rev. 2021 Jul 28;7:CD015017. [CrossRef] [PubMed]

Cite as: Robbins RA. CDC Warns of Increased Ivermectin Overdoses. Southwest J Pulm Crit Care. 2021;23(2):62-3. doi: https://doi.org/10.13175/swjpcc038-21 PDF 

Poisoning by Hand Sanitizers

The CDC has recommended hand sanitizers as part of their strategy to prevent spread of the COVID-19 pandemic. However, some sanitizers contain high amounts of methanol and some people are drinking the sanitizers to get an alcohol high. Others have believed a rumor, circulated online, that drinking the highly potent and toxic alcohol can disinfect the body, protecting them from COVID-19 infection (1).

Banner Poison and Drug Information Center at Banner University Medical Center in Phoenix alerted the state health department, who brought in the CDC and FDA to investigate. In the CDC's Morbidity and Mortality Weekly Report from Aug. 14, the first 15 cases seen in Arizona and New Mexico were reported (2).

The FDA first alerted consumers about toxic hand sanitizers in mid-June, when the agency warned against the use of hand sanitizer products with methanol made by Eskbiochem. By Aug. 12, that list had grown to 160 brands. Prominent amongst these has been sanitizers manufactured by Global SAPI de CV from Mexico and sold under the name Blumen (3)

Besides methanol, the FDA warns, some hand sanitizers contain insufficient levels of ethyl alcohol or isopropyl alcohol, the acceptable active ingredients for hand sanitizers. In some cases, the companies with methanol in their products have voluntarily recalled them, following the FDA's recommendation. For others, the FDA has issued an import alert to stop the product from entering the country. While some hand sanitizers are marked "FDA approved," the FDA says that is a fraudulent claim, as there are none approved by the FDA.

Methanol, also called wood alcohol, can be toxic when ingested or very rarely when absorbed through the skin. Early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), but persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. If left untreated methanol poisoning can be fatal (5). Survivors of methanol poisoning might have permanent visual impairment, including complete vision loss; data suggest that vision loss results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve (3).

The 15 adult patients with reported methanol poisoning including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Persons should never ingest alcohol-based hand sanitizer, avoid use of specific imported products found to contain methanol, and continue to monitor FDA guidance (3). Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.

Richard A. Robbins MD

Editor, SWJPCC

References

1. Kathleen Doheny K. Toxic Methanol in Hand Sanitizers: Poisonings Continue. Medscape. August 17, 2020. Available at: https://www.medscape.com/viewarticle/935835?nlid=136939_5761&src=wnl_dne_200818_mscpedit&uac=9273DT&impID=2512049&faf=1#vp_1 (accessed 8/18/20).
2. Yip L, Bixler D, Brooks DE, et al. Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol - Arizona and New Mexico, May-June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1070-1073. Published 2020 Aug 14. [CrossRef] [PubMed]
3. FDA. FDA updates on hand sanitizers consumers should not use. Current as of 8/18/20. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-hand-sanitizers-consumers-should-not-use (accessed 8/18/20).

Cite as: Robbins RA. Poisoning by hand sanitizers. Southwest J Pulm Crit Care. 2020;21(2):54-5. doi: https://doi.org/10.13175/swjpcc047-20 PDF

Healthcare Layoffs During the COVID-19 Pandemic

Despite overcrowding of the ICUs with patients infected with coronavirus (COVID-19, SARS-CoV-2), hospitals have halted or downsized other operations. Phoenix-based Banner Health, which is Arizona's largest private employer, will impose "short-term" furloughs and pay cuts for some employees (1). Other major hospitals and hospital systems including the Mayo Clinic Arizona, Dignity Health, Tucson Medical Center and Carondelet have announced similar cost-cutting reductions. Banner Health, which has approximately 43,000 employees in Arizona, is starting the furloughs this week. The nonprofit company anticipates that the measures will affect 5% to 7% of its workforce, or up to 3,000 Arizona employees. The company says the furloughs are temporary and employees will be eligible for unemployment benefits, including an extra $600 per week provided by Arizona via the federal CARES Act. All senior leaders, including senior vice presidents, presidents, vice presidents and CEOs, will take up to a 20% reduction in pay beginning in May, Banner said. The company will pause hiring for most non-clinical, non-revenue-generating positions across the organization. This includes newly created jobs as well as vacant roles in the corporate office and facilities. The company will continue to post and recruit for positions that are essential to meet the needs of COVID-19.

An analysis by the Arizona Hospital and Healthcare Association shows Arizona hospitals are reporting revenue losses of 30% to 40% because of the cancellation of elective procedures and a reduction in emergency department visits. Hospitals had an operating margin, the difference between revenues and expenses, that averaged 2.7% in 2016 (2). The hospital association has asked Arizona’s governor, Doug Ducey, to relax his executive orders on halting elective surgeries and on expanding hospital bed capacity, citing recent modeling projections that indicate Arizona will not be as hard-hit by the disease as previously was predicted.

It is unclear how other healthcare organizations other than hospitals are managing during the COVID-19 pandemic. Our small pulmonary practice has been shut down since mid-March although we are doing some telemedicine. Yet compared to the large healthcare systems, we have managed to retain all our employees at a full-time basis as of today. Our group did apply for a small business loan to the Federal government which was denied.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Innes S. Banner Health, Arizona's largest health system, to implement pay cuts and furloughs. Arizona Republic. April 20, 2020. Available at: https://www.azcentral.com/story/money/business/health/2020/04/20/banner-health-implement-pay-cuts-and-furloughs-arizona-coronavirus-covid-19/5165992002/ (accessed 4/21/20).
2. Moody's Investors Service. Moody's: preliminary FY 2016 US NFP hospital medians edge lower on revenue, expense pressure. Moody's. 16 May 2017. https://www.moodys.com/research/Moodys-Preliminary-FY-2016-US-NFP-hospital-medians-edge-lower--PR_366813 Accessed 4/21/20.

Cite as: Robbins RA. Healthcare layoffs during the COVID-19 pandemic. Southwest J Pulm Crit Care. 2020;20(4):135-6. doi: https://doi.org/10.13175/swjpcc029-20 PDF 

Practice Fusion Admits to Opioid Kickback Scheme

Practice Fusion, a San Francisco-based health information technology developer, will pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) software (1). The Department of Justice announced on January 27th that the company admitted it solicited and received kickbacks from a major opioid company in exchange for utilizing its software to influence physicians prescribing opioid pain medications. The pharmaceutical company is widely speculated to be Purdue Pharma which faces U.S. Justice Department probes and sprawling litigation over allegations it played a central role in the deadly opioid crisis (2).

The DOJ said Practice Fusion extracted kickbacks from pharmaceutical companies in exchange for implementing a clinical decision support (CDS) system in its electronic health records (EHR) software designed to increase prescriptions for their drug products. In exchange for “sponsorship” payments from pharmaceutical companies, Practice Fusion allowed the companies to craft CDS alerts to increase sales of the companies’ products, resulting in alerts that did not always reflect accepted medical standards. In their criminal probe of opioid makers, federal prosecutors have indicted pharmaceutical company executives, physicians and pharmacists. This is the first criminal action against an EHR vendor and no indictments of any Practice Fusion executives were made.

Founded in 2005, Practice Fusion offers an EHR tailored for smaller, independent physician practices. It supports practices that comprise 112,000 health care workers who see 5 million patient visits per month. Practice Fusion had expected to go public at a valuation of about $1.5 billion, but was instead acquired in 2018 by Chicago-based Allscripts for $100 million in cash.

Our practice at Arizona Chest and Sleep Medicine uses Practice Fusion in its outpatient clinics. None of us were aware of receiving any alerts advising prescribing opioids.

References

1. Johnson T. S.F.-based Practice Fusion Inc. admits to opioid kickback scheme. San Francisco Business Times. January 28, 2020. Available at: https://www.bizjournals.com/sanfrancisco/news/2020/01/28/s-f-based-practice-fusion-inc-admits-to-opioid.html (accessed 2/3/20).
2. Spector M, Hals T. OxyContin maker Purdue is 'Pharma Co X' in U.S. opioid kickback probe – sources. Reuters. January 28, 2020. Available at: https://www.reuters.com/article/us-purdue-pharma-investigation-opioids-e/exclusive-oxycontin-maker-purdue-is-pharma-co-x-in-us-opioid-kickback-probe-sources-idUSKBN1ZR2RY (accessed 2/3/20).

Cite as: Robbins RA. Practice Fusion admits to opioid kickback scheme. Southwest J Pulm Crit Care. 2020;20(2):63. doi: https://doi.org/10.13175/swjpcc010-20 PDF

Arizona Medical Schools Offer Free Tuition for Primary Care Commitment

The University of Arizona (UA) Colleges of Medicine in Tucson and Phoenix will offer free tuition starting in the spring semester for qualifying medical students agreeing to practice primary care (1). To be considered for free tuition, applicants must be an Arizona resident and current full-time medical student. A minimum commitment of 2 years practicing in an underserved Arizona community must be started within 6 years of graduation from medical school and completed within 10 years of graduation.

The money will come from part of the $8 million annual funding approved by the Arizona Legislature in May. According to the press release, nearly 100 students or about 10% of the student body could get free tuition at the two medical schools. Currently, tuition is $31,652/year in Tucson and $33,402 in Phoenix.

Arizona currently meets only 40% of its primary care physician (PCP) need, according to the Health Resources and Services Administration. Arizona ranks 42nd among states for total active PCPs at 77.9 per 100,000 (the US average is 91.7) according to the university's physician workforce report published in October.

In addition to enlarging the primary care workforce, the waived tuition is meant to reduce financial barriers to even applying to medical school with the looming promise of student debt. Nearly half of medical school graduates owe more than $200,000 in medical school loans, according to the latest Medscape Residents Salary and Debt Report.

UA joins a growing list of medical schools offering free tuition including New York University, the University of Houston, Kaiser Permanente, and Weill Cornell. None of the others require practicing primary care as a requirement for receiving the free tuition.

Reference

1. Marcia Frellick M. U of Arizona offers free med school tuition for primary care. Medscape. December 6, 2019. Available at: https://www.medscape.com/viewarticle/922275?nlid=132930_5461&src=wnl_dne_191209_mscpedit&uac=9273DT&impID=2196790&faf=1 (accessed 12/9/19).

Cite as: Robbins RA. Arizona medical schools offer free tuition for primary care commitment. Southwest J Pulm Crit Care. 2019;19(6):163. doi: https://doi.org/10.13175/swjpcc071-19 PDF