Don't worry 'bout the 'Bute

"Corned beef, with chips or with salad

It's corned beef, even Buckingham Palace eats

Corned beef, so why don't you try corned beef hash"

-Jerry, Phoenix Nights

So today's news (well, what news has managed to slip through the ridiculously large amount of attention Margaret Thatcher's death has been receiving) brings us the revelation that Asda's Smart Price corned beef contains phenylbutazone. I had sort of thought that the FSA's statement after the initial horsemeat scandal might have gone some way to assuage peoples' fear, but it would appear that the media are pretty hysterically reporting about it, and a small sampling of the general public (i.e. my mum) would suggest that people are still worried about it. 

"The levels of bute that have previously been found in horse carcasses mean that a person would have to eat 500 - 600 one hundred per cent horsemeat burgers a day to get close to consuming a human's daily dose."- FSA

Let's have a think about phenylbutazone then. It's a member of a group of drugs called the non-steroidal anti-inflammatory drugs (NSAIDs), the same group as ibuprofen and aspirin. This is reassuring- its not some horrifically toxic chemotherapy agent, or poison, or anything like that. It's a painkiller, related to one of the most commonly used OTC painkillers. That's already looking reassuring. It used to be used in humans as a painkiller, but it was discontinued as it was superseded by other NSAIDs which have a better safety profile.

Whoah there, I hear you say in a panicked fashion. It was withdrawn for safety reasons? What safety reasons? ARE WE ALL GOING TO DIE BECAUSE OF CORNED BEEF? Well, in short: no. Yes, phenylbutazone can be associated with some nasty side effects, as can pretty much every drug going, but these are incredibly unlikely with small (I'll come onto how small later), acute doses from the occasional corned beef hash. Aplastic anemia, for example, is associated with long-term therapeutic use of the drug- usually after about a year. Likewise with leukemia, which has an even less clear association with phenylbutazone. I sincerely doubt that there will be many people who eat Asda Smart Price corned beef in large quantities every day for a year, and if there are, I suspect their heart may be more likely to give out than them suffering from any drug toxicity.

Deadly killer? Definite artery clogger, if nothing else.

Let's say though that you had eaten some. This doesn't necessarily mean that you will have ingested all of the drug. Drug companies invest quite a bit of money in their drug delivery systems: tablets, capsules, injections etc. There's a reason why corned beef isn't used commonly as a drug delivery system: there's no data on stability of drugs within it or its dissolution properties. For all we know, phenylbutazone may well be broken down if its stored in such a substance for any appreciable length of time. stability. When you take a tablet, you don't absorb all of the drug within it immediately. Some of it wont even get through your GI tract or into your blood stream. Some of it will tag onto blood proteins, whilst some might be converted into inactive metabolites by the liver. Only the free drug portion that remains will actually exert any effect. And in this case, the drug has had to go through all this process already in the horse before it even gets into you.


All of this is by-the-by when you get down to looking at amounts.  If you eat 1kg of horsemeat containing the highest possible levels of phenylbutazone, the dose you would get in the worst case scenario is 0.0019 milligrams. Back in the days when it was used therapeutically, the dose given was 100mg every 4 hours.

The corned beef in question has been found to contain 1% horse DNA. Lets say that's all horsemeat. And lets say this horsemeat had the highest possible levels of phenylbutazone in it.

If you ate an entire 340g tin, you'd  a)be fairly greedy or hungry and b) eating 3.4g horsemeat:

3.4g horsemeat= 0.0000019 milligrams phenylbutazone

Now, by my reckoning, that works out as having to eat 100,000,000 tins of Asda Smart Price Corned Beef to get the equivalent of two therapeutic doses (and its only half of the recommended loading dose). Even by Adam Richman's standards, that is a hell of a lot of corned beef. And remember, you'd have to eat that for approximately a year before you got any of the nasty side effects.

So really, don't worry about the 'bute. The amount of salt in there is more likely to cause toxicity first.

I'll leave you with this video: It's been running through my head all day so I feel like I should make you all suffer too :)

Hxxx

Vicks, feet, and a whole load of nonsense.

And so it was that I ventured onto Facebook last night, for the first time in a while. And what I discovered there was an intriguing post about putting Vicks Vaporub on your feet to cure a cough.

A very quick google search suggests this is a long-standing bit of nonsense that's been doing the rounds with pretty much exactly the same wording for years. I thought it might be worth revisiting. so, here it is in its entirety, with my skeptical, critical thinking thoughts inserted in blue. I guess its a bit of an example about how to think about claims that appear at first glance to be too good to be true:

"Some of us have used Vicks Vaporub for years for everything from chapped lips to sore toes and many body parts in between. <Wait, What? Who uses Vicks Vaporub for chapped lips? I've never heard of anyone do this, ever. Firstly, it would sting lots, and secondly it could potentially be highly toxic, given its essential oil content, and aspiration risk when swallowed due to petroleum. I wouldn't put the stuff anywhere near my mouth.> But I’ve never heard of this. And don’t laugh, it works 100% of the time <100% of the time? Nothing in medicine works 100% of the time, so alarm bells are ringing loudly, unless this is the single most important medical discovery that's ever happenee, ever.>, although the scientists who discovered it aren’t sure why. <what scientists?>

To stop night time coughing in a child (or adult as we found out personally), put Vicks Vaporub generously on the bottom of the feet at bedtime, then cover with socks. <Feet seem to be a favourite of the quackery world, what with detox patches, reflexology and all that sort of thing. Alarm bells are a lot louder already. Why would Vicks be particularly effective on your feet? Is this as compared to any other parts of your body, or compared to nothing at all? Wouldn't it sting, and could it have potential to cause sensitisation in the area? Where is the prior plausibility here?>  Even persistent, heavy, deep coughing will stop in about 5 minutes and stay stopped for many, many hours of relief. <A coughing fit usually does stop after a few minutes of its own accord regardless of treatment. If it doesn't, and you're coughing constantly for more than 5 minutes, you probably need to be checked out by a doctor.> Works 100% of the time and is more effective in children than even very strong prescription cough medicines. <There are very few prescription cough medicines, on account of the fact that most preparations for cough don't really work anyway.Again, this 100% of the time claim is quite extraordinary and would require major clinical evidence to back it up.> In addition it is extremely soothing and comforting and they will sleep soundly. <Is the stinging, cold sensation you get with menthol really soothing?>

Just happened to tune in A.M. Radio and picked up this guy talking about why cough medicines in kids often do more harm than good, due to the chemical makeup of these strong drugs so, I listened. <What guy? What radio station? What are you on about? The only medicines now available for coughs in children OTC in the UK are glycerol and simple linctus paed- basically, sugary water. No "strong drugs here".> It was a surprise finding and found to be more effective than prescribed medicines for children at bedtime, in addition to have a soothing and calming effect on sick children who then went on to sleep soundly. <Where is this finding published? What sort of a study was it and how was it designed? How many participants were there? Was there a control group, or a comparator group and if so, what was the comparator? As it happens, none of these questions really matter given the studies themselves don't actually exist>

My wife tried it on herself when she had a very deep constant and persistent cough a few weeks ago and it worked 100%! <anecdote. It worked 100%, but in one person? This doesn't even make sense.> She said that it felt like a warm blanket had enveloped her, coughing stopped in a few minutes and believe me, this was a deep, (incredibly annoying!) every few seconds uncontrollable cough, and she slept cough-free for hours every night that she used it. <I'd imagine it would actually just feel like you had some oily gunk on your feet that would sting a little bit and feel cold. Who is this wife, and why should we believe this anecdote from an anonymous person? There's no way to remove regression to the mean as an explanation to this, but by now I'm suspecting this wife with a cough is mainly mythical>

If you have grandchildren, pass this on. <so presumably you don't need to bother if you're simply a parent, only if you're a grandparent?> If you end up sick, try it yourself and you will be absolutely amazed at how it works! <Actually, I suspect I'll just feel a bit silly. And will have minty-smelling feet>"


So of course I have done a search for the evidence and claims included in the post and have found a grand total of Nothing At All. I will say this though: If I was the manufacturer of Vicks, and someone had done some studies which found my product to be 100% effective, I would sing it loudly from every rooftop I could find. I would be the manufacturer of The Number One Most Effective Medical Product In The World Ever, and I would make sure that I made my millions on the back of that fact, as well as collecting my Nobel prize for Medicine and probably world peace as well. What I probably wouldn't do is ignore the claims, and continue on selling my product and advising that its used in a way which has a less than 100% chance of it working.

Direct harms from following this advice could include dermatitis and skin reactions. Indirect harms? Well, you've slathered some slippery, oily unguent onto the bottom of your feet. When you take your socks off, you may be slip-sliding all over the place.

The moral of the story is:Very rarely should you believe anything posted on Facebook. Unless its me, posting a link to my blog, of course.

Hxxx

UPDATE: I get a LOT of hits on this blog because of this post. If you've stumbled across it, i would love to know whether it has had any impact on what you thought about whether putting Vicks on your Feet would work, so please do leave a comment or drop me an e-mail.

Red wine as painkiller... In babies?!

A couple of years ago, I was working a locum shift in a supermarket pharmacy. It was quite late at night, and a man came up to the counter to ask me if I did circumcisions. I assumed I had heard incorrectly, but no. "I thought you would be able to do circumcisions, since you can do healthcare services and you have a private room" he said, pointing at the extremely small and flimsy consulting "room" and the end of the counter. I couldn't help but notice the small boy cowering behind him as I politely explained that no, circumcision certainly wasn't a pharmacy service.

At the time, I remember being amazed that it would occur to someone to take their child to a supermarket for what is a surgical procedure. Whilst it may be considered minor surgery, I'm sure to the young boy himself it didn't seem all that minor, and I'm pretty sure he wouldn't be wanting a pharmacist to do it in the middle of a supermarket with only some thin plastic walls between him and the vegetable aisle.

Anyway, I shall leave aside the ethics of circumcision for now, and consider a tweet I saw this morning by Andy Lewis. One particular Doctor, on his website, is advising pain relief options for babies who are about to be circumcised. He advises loading the child up on red wine as a preferred option. Now hold on here, this is a GMC registered Dr advising on giving babies alcohol. Whilst he doesn't give any information about how much wine to give, i'm assuming it would have to be enough to get the child at least slightly intoxicated to have any painkilling effect. A quick google search suggests the 8th day after birth is a usual time for the circumcision to take place.

"1. To give the baby sweet, red wine prior to the procedure. (Kiddush wine is ideal). This is very effective in calming the baby. Ideally it is given about 15 minutes before the circumcision and I will give it on arrival if you wish. You will need to provide the wine."

At this point, let us consult TOXbase.org, the database of the National Poisons Information Service (NPIS). They advise that any children under the age of 10 who are symptomatic due to an alcohol ingestion (i.e. intoxicated) are taken into hospital for medical assessment.

Why is it dangerous to advise wine as a painkiller in a child of this age? Well, alcohol in children can be very nasty. It can cause hypoglycaemia, particularly in children, and a seemingly well child can sometimes suddenly and quickly go downhill fast- that's why NPIS recommend that they are observed in hospital.

Such advice, coming from a trusted Doctor, is very concerning indeed. It appears from the website that he expects the baby to be "prepared" prior to his arrival, so he is expecting the parents to administer and provide the wine (whilst he says he can give it "if they wish", to me this implies that its more usual for the parents to give it). He also recommends Emla cream, which he says the parents can buy from a pharmacy. This is an off-label use that he is openly promoting.

I have emailled the GMC to ask what their stance on such advice is:

"To whom it may concern,

I have happened upon the following website, which promotes the work of a GMC registered doctor, Dr Howard Cohen GMC number 3057256, and wish to clarify with yourselves whether I would be able to make a complaint against the advice he gives on his website:
www.mohel-circumcision.co.uk

I am particularly concerned about the advice regarding pain relief that Dr Cohen is giving. He recommends giving babies "sweet red wine prior to the procedure". It is my understanding that children should not be given alcohol, particularly on the advice of a healthcare professional. I regularly use Toxbase in my daily work and note that children who have ingested notable amounts of alcohol should be observed in hospital due to the risk of hypoglycaemia and other issues. A Dr recommending that a child is given presumably enough wine to be intoxicated as pain relief is highly dangerous advice.

He also advises purchasing Emla cream from a pharmacy for use prior to circumcision. It is my understanding that, although Emla cream is licensed in children, its use on the skin of male genital organs is only licensed in adults. Dr Cohen is therefore promoting off-label use of a drug on his website, without giving sufficient dosing advice or guidance.

I look forward to hearing from yourselves if this would be grounds for a complaint, or if promoting such advice is reasonable from your point of view.

Kind regards,"

Let's hope I get a decisive reply back. 

Hxxx

Update: As of 25th Feb I still haven't heard back from the GMC.

The paracetamol paradox

I'll often bang on about how "natural" does not necessarily mean safe, and you'll often hear me muttering about how new drugs can be a cause for concern because of lack of safety data. Today, however, I want to talk about some problems with one of our oldest, most reliable friends in the drug world: paracetamol (acetaminophen to our US friends).

Paracetamol appears to have first been used clinically as far back as 1887. It's very widely used in the UK and is very easily accessbile: packs of 16 tablets are classed as GSL medicines, meaning they can be sold pretty much anywhere. Its accepted as a social norm: adults take paracetamol for headaches, and they give their children Calpol (a branded liquid paracetamol) at the first sign of illness.

And herein lies my first point: its almost so widely available that I think people are starting to forget that it works. I've come across patients and friends who instantly dismiss paracetamol for their pain because "its not strong enough" or "it won't work, this headache's too bad". I'm starting to think that its dismissed offhand without trying it because its so well accepted its almost forgotten in the general public's mind that it is still a medicine, and one that works well. People are too quick to dismiss plain old paracetamol in favour of a shiny new combination product which costs more but works less well, or they're taken in by the promise of a "stronger" painkiller like co-codamol (with little evidence of benefit over paracetamol alone, but a whole lot more problems). Paracetamol has hardly any significant side effects, and it does actually work well for mild to moderate (and even some types of severe) pain, but many people won't even give it a chance. I'm interested to know what you guys think of this and whether or not you would agree that this is the case- do let me know by leaving a comment or tweeting me @SparkleWildfire. Do you think this yourself, or have friends that do? If you're a pharmacist or another healthcare professional, have you noticed a similar attitude? Or is it just me?

More scary, though,  is my second point: Because people seem to be sort-of-forgetting its a medicine, they are forgetting that it can be dangerous. Horrifically so, in actual fact. Whilst it has few side effects with normal, recommended use, it's horribly toxic in overdose.

Overdose? Lets have a think about that word. It immediately brings to mind suicide attempts, right? So that wouldn't apply to most people, right? Very much wrong. In the last few weeks and months (it being the cold season and all), I've noticed a few of my friends on social media rather jokingly saying things like how they've taken a few extra doses of paracetamol, or they're taking lots of Lemsips because they like the taste, or they're combining a branded cold and flu product with paracetamol tablets, and I've felt the need to intervene and ask them to be careful about the amounts that they are taking. Would they consider themselves to be taking "overdoses"? I fear not. I also don't think they're taking me seriously, to be honest, and I think they think "what's a few extra doses going to do, it's just paracetamol after all". What they don't realise is that this sort of therapeutic excess or staggered overdose scenario can be just as-if not more-serious than a classsic, acute self-harm attempt-type of overdose. And the sort of toxicity that happens is not pleasant, and ultimately, in the worst case scenario could mean a slow, painful death, or a liver transplant. The antidote to paracetamol poisoning (although its not always able to be used, particularly in these sorts of cases) isn't a walk in the park either. It's a lengthy course of an IV drug (in the UK, anyway) which could mean at least a few days hospital stay.

Unfortunately, its easy to accidentally take too much paracetamol. There's so many branded products that require a fair amount of package-reading before you work out that they contain paracetamol.  I think its also easy for people to feel blase about the way they're using it, because if its available everywhere and its "just paracetamol" its safe to take more than is directed. Maybe people think taking extra paracetamol "proves" that their pain is more severe than other people's pain, who knows. I think many of us would agree that we've heard anecdotal reports of parents putting Calpol in babies' bottles, or leaving the bottle with a child to self-administer overnight, or giving their child Calpol "to make them sleep" (it would have no direct effects to promote sleep).It's just so pervasive that it's almost become like vitamins or a foodstuff in some peoples' mind, or so it would seem.

Just because a drug is as old as the hills, and its safe in everyday use, and it works, doesn't mean that its innocuous and we can throw caution to the wind when we're using it and have as much as we like, whenever we like.

Why am I on about this? Well, part of my day job involves advising on management of poisoning cases, and as a result I see a lot of these types of cases. And it can be really sad and frustrating and sometimes scary to hear of how commonly this sort of thing happens, and the variety of reasons for it.

So my point is: if you're taking paracetamol, please take no more than 4 grams per 24 hour period, and please check for other sources of paracetamol in cold remedies or other branded products first.

H xxx