old medicine new use

There is a good article cited by Gruntdoc. This is about the use of Minocycline in CVA.

It is surprising so many unrelated drugs are found to have so many other uses. Some have turned out to be quiet useful. Many just a hype. The example for previous one is Chloroquine in arthritis including the recent Chikungunya epidemic. i hope this minocycline is not just one of the later. Usually what happens is after some positive effect is found, many possible explanations (which are educated guesses) are given. Obviously only a large randomized, placebo controlled study with a large sample will be the answer.

This tPA business is also of questionable use, at least in Indian settings. The patient is supposed to report to a stroke unit and tPA can be given, if we can rule-out a hemorrhage. All these within three hours (For anterior circulation strokes – the commonest). Most of the time when a patient comes after a stroke he has already crossed the gloden window period. So tPA is useless. Secondly, most of the strokes occur in the early mornings. How do we know how long the stroke process has gone? A patient wakes-up and finds out he has weakness. May be it happened just five minutes before he woke-up or maybe just after he went to sleep, 6-7 hours before. Thirdly when a CT is normal, it can mean he is having an early stroke (Conventional CT can take -12 hours for obvious changes to occur) or he is having a Transient Ischemic Attack. So what happens – you lyse a patient with TIA and take credit for natural recovery and collect the fees in between? i just feel it is not suited to India where money, resources (Trained doctors & CT) are not that freely available.

For the non-medicos visiting my site, jargon buster for the above post.

Minocycline is an antibiotic of tetracycline group.

CVA – Cerebra-vascular accident – commonly called stroke – is due to blockage of arteries most of the time by a blood clot and some times by a bleed due to a rupture of a blood vessel. Thrombolysis is the process by which the clots are removed (Thrombus- blood clot, lysis- break-down). So obviously if accidentally a patient with bleed into brain is given a thrombo-lytic drug (like tPA – Tissue Plasminogen Activator), the bleed will worsen and can sometimes be fatal.

Usually a CT scan is done as the initial investigation to evaluate whether a stroke is due to clot or bleed. It will pick-up a bleed as soon as it occurs and a clot after a few hours (Up to 12hours).

TIA – is due to a small clot in the artery, which dissolves itself and so the patient recovers completely. It is a warning of instability in that area and these patients need to go on prophylactic drugs to prevent a full blown stroke in the near future.

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6 Responses

  1. Minocycline for CVA? Isn’t it nephrotoxic? (Exam over, and pharma went out the window :( Can’t even find my Tripathi.) Certainly hope it works.

  2. Is it not what we would have thought the first time for chloroquine in arthritis. Chloroquine for arthritis?!

  3. Stdoc, I think you are the very person to comment on a study I read about several years ago.

    Dr. S. D. Chakrabarti and company first noted that strokes occurred disproportionately in the morning, and in the toilet. In an analysis of 100 stroke patients in Calcutta, over one-third of them suffered the attack while squatting in the bathroom, mostly while defecating. The doctors from Calcutta next measured blood pressure in healthy and hypertensive persons in both the squatting and lying down positions. While healthy subjects exhibited an 8 point rise in systolic blood pressure as they hunkered on the floor, the hypertensive folks averaged a 15 point rise in this particular posture. Dr. Chakrabarti advises ” refrain from squatting at any time, especially in the toilets.”

    In another study about stroke and body posture, Dr. Natan M. Bornstein and his colleagues in Tel Aviv also analyzed the events preceding a stroke. In their study of 150 patients, they found that a sudden change in body position, such as a startle response (say someone suddenly opens the bathroom door as you squat at your duties) increased the risk of stroke sevenfold. They theorize that a sudden change in posture may trigger a flood of adrenalin, causing a narrowing of blood vessels and an increased risk of clots.

    Early morning hours, accompanied by a rise in blood pressure, are notoriously bad for strokes, squatting or not.

  4. That was an good information by Denver Doc. I just wrote a post about a possible stroke in the bathroom. I wrote it days ago, just haven’t posted it yet. I didn’t know about the link with the bathroom and stroke. I was familiar with early morning, but not the other.

  5. i cannot tell why it happens in the bathroom and the information about increased blood pressure response to squatting in hypertensives is also new to me. My guess would be, hypertensive patients may have exaggerated blood pressure response to a variety of stimuli and that leads to an un-stable plaque rupturing.
    But there are a number of reasons given for the increased ischemic strokes in the morning.
    Like:
    1. Rapid physiologic increase in blood pressure, particularly after awakening in early morning, may lead to over-response of auto-regulation and may provoke a fragmentation of a carotid plaque, if present.
    2. Increase in platelet aggregatability and activation
    3. Increase in hematocrit and blood viscosity
    4. Increase in catecholamine and sympathetic tone
    5. Decrease in fibrinolytic activity
    6. Decrease in endogenous tissue plasminogen activator activity
    7. Circadian fluctuations in central dopamine activity
    I will say, if the patient’s fate is that he has to get a stroke, all these uncommon possibilities click into place and give him a stroke.

    There is yet another association of bathroom with death. You would have noticed patients who are quiet sick – like after a massive myocardial infarction, bleed…feel sick and fell like passing motion and fall down dead on the way to the toilet itself. This is assumed to be increased vagal tone at this time, leading to a feeling of sensation of passing urine and motion.

  6. Wow, great information. It reminds me of this post I was working on. I haven’t put it up yet…there is another element to it I’m not to sure about posting about, even though I have the gentleman’s permission. Weird how these cardiovascular things show themselves.

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