The insidious threat of jamu and unregulated traditional medicines in the COVID-19 era

Case Report: Hypercalcemia as a manifestation of acute adrenal crisis precipitated by fluconazole use, and a review of the literature

Acute adrenal crisis classically presents with vomiting, altered sensorium, and hypotension. We describe a unique case manifesting with severe hypercalcemia. Addisonian crisis was unusually precipitated by fluconazole use. We reviewed other reported cases and discuss the possible mechanisms of hypercalcemia in adrenal insufficiency. This 67-year-old man presented with fever, cough, and vomiting for 1 week and with anorexia and confusion for 3 weeks. He was hypotensive and clinically dehydrated. Investigations revealed left-sided lung consolidation, acute renal failure, and severe non-parathyroid hormone (PTH)-mediated hypercalcemia (calcium, 3.55mol/L; PTH, 0.81pmol/L). Initial impression was pneumonia complicated by septic shock and hypercalcemia secondary to possible malignancy. He received mechanical ventilation; treatment with intravenous fluids, inotropes, and hydrocortisone for septic shock; and continuous renal replacement therapy with low-calcium dialysate. Although hypercalcemia resolved and he was weaned off inotropes, dialysis, and hydrocortisone, his confusion persisted. When hypercalcemia recurred on day 19 of admission, early morning cortisol was <8 nmol/L, with low ACTH level (3.2 ng/L). Other pituitary hormones were normal. Hypercalcemia resolved 3 days after reinstating stress doses of hydrocortisone, and his mentation normalized. On further questioning, he recently received fluconazole for a forearm abscess. He previously consumed traditional medications but stopped several years ago, which may have contained glucocorticoids. He was discharged on oral hydrocortisone. Cortisol levels improved gradually, and glucocorticoid replacement was ceased after 8 years, without any recurrence of hypercalcemia or Addisonian crisis. Both hypercalcemia and adrenal insufficiency may present with similar non-specific symptoms. It is important to consider adrenal insufficiency in hypercalcemia of unclear etiology.

Risk characterisation of constituents present in jamu to promote its safe use

Safety in use of jamu consumption, as part of traditional medicine from Indonesia, is dependent on the complete and adequate assessment of potential hazards and risks of the botanicals and botanical constituents included. This includes especially hazards and risks related to the presence in jamu of active pharmaceutical ingredients (APIs) as well as of constituents that are genotoxic and carcinogenic. The present review presents an overview of the current state-of-the art on these hazards and risks based on case reports on adulteration, and the actual detection of genotoxic and carcinogenic ingredients of concern in jamu. Based on the overview thus obtained, it appears that drug-adulteration presents important hazards responsible for potential adverse effects, due to overdosing. The potential hazards of exposure to APIs mainly relate to the presence of constituents that may cause liver damage, renal impairment, kidney failure, steroid dependence or genotoxicity and carcinogenicity. For these APIs, a risk characterisation was performed based on comparison of health-based guidance values (HBGVs) and exposure, while for the genotoxic carcinogens the margin of exposure (MOE) approach was used. Results of this risk characterisation should be used by risk managers to impose specification for constituents of health concern to protect consumers. It is concluded that to manage the risks identified and further improve the safety in use of jamu, a collaboration between farmers, manufacturer/producers, academia, government, health professionals, and consumers is indicated.

Potential of algal metabolites for the development of broad-spectrum antiviral therapeutics: Possible implications in COVID-19 therapy

Covid-19 pandemic severely affected human health worldwide. Till October 19, 2020, total confirmed patients of COVID-19 are 39,944,882, whereas 1,111,998 people died across the globe. Till to date, we do not have any specific medicine and/or vaccine to treat COVID-19; however, research is still going on at war footing. So far vaccine development is concerned, here it is noteworthy that till now three major variants (named A, B, and C) of severe acute respiratory syndrome-coronavirus2 (SARS-CoV-2) have been recognized. Increased mutational rate and formation of new viral variants may increase the attrition rate of vaccines and/or candidate chemotherapies. Herbal remedies are chemical cocktails, thus open another avenue for effective antiviral therapeutics development. In fact, India is a large country, which is densely populated, but the overall severity of COVID-19 per million populations is lesser than any other country of the world. One of the major reasons for the aforesaid difference is the use of herbal remedies by the Government of India as a preventive measure for COVID-19. Therefore, the present review focuses on the epidemiology and molecular pathogenesis of COVID-19 and explores algal metabolites for their antiviral properties.

Efficacy and Safety of New and Emerging Drugs for COVID-19: Favipiravir and Dexamethasone

Purpose of Review

The widespread respiratory disease of virus known as severe acute respiratory syndrome-coronavirus 2019 (SAR-CoV-2) had infected more than 200 countries and caused pandemic and havoc in the world.

Recent Findings

The genome of the virus was sequenced rapidly to study its mechanism, epidemiology, drugs, and vaccines. Many drugs and vaccines are being studied by researchers to treat and prevent the SARS-CoV-2. Favipiravir and dexamethasone are repurposed drugs which showed therapeutic potential and pharmaceutical efficacy against SARS-CoV-2.

Summary

The review describes the path of favipiravir and dexamethasone from chemistry to mechanisms of action to combat SARS-CoV-2. In addition, the potential side effects are also summarized to study their potential to control corona virus 2019.

Charlson comorbidity index and a composite of poor outcomes in COVID-19 patients: A systematic review and meta-analysis

BACKGROUND AND AIMS

The ongoing COVID-19 pandemic is disproportionately affecting patients with comorbidities. Therefore, thorough comorbidities assessment can help establish risk stratification of patients with COVID-19, upon hospital admission. Charlson Comorbidity Index (CCI) is a validated, simple, and readily applicable method of estimating the risk of death from comorbid disease and has been widely used as a predictor of long-term prognosis and survival.

METHODS

We performed a systematic review and meta-analysis of CCI score and a composite of poor outcomes through several databases.

RESULTS

Compared to a CCI score of 0, a CCI score of 1-2 and CCI score of ≥3 was prognostically associated with mortality and associated with a composite of poor outcomes. Per point increase of CCI score also increased mortality risk by 16%. Moreover, a higher mean CCI score also significantly associated with mortality and disease severity.

CONCLUSION

CCI score should be utilized for risk stratifications of hospitalized COVID-19 patients.