Impact of COVID‐19 on clinical practice

Abstract

These are strange times. As I write this, we are yet to reach the peak of the first wave of the coronavirus outbreak in the UK. For academics like me, it has been reasonably easy to adjust to home working, sitting in the damp and cold office in our cellar, getting to grips with a multitude of different video-conferencing tools. Teaching is being redesigned to suit online delivery after the Easter break, but most non-COVID-19 related clinical research has paused. Away from work, I'm getting my daily exercise with the family – a weird affair, as we cheerfully cross the road to avoid passing too close to a person walking the other way. Finding eggs and flour in the supermarket is impossible, but at least there is toilet roll now. Of course, the impact on clinical practice is something I am certain I will never witness again in my lifetime. My poor hospital colleagues are experiencing the terrifying brunt of the pandemic, and routine practice has ceased. In contrast, my own clinical work as a GP has dwindled and comprises primarily phone calls, as people avoid their GP surgery at all costs. We've been trying to persuade patients for years that antibiotics won't fix viral infections, but people are all too aware that there is currently nothing their GP can prescribe that will treat SARS-CoV-2. But there are nonetheless some really important issues that have arisen from the perspective of medicines use in primary care. There are shortages of inhalers as patients stockpile just in case they get sick, and pharmacies are requesting that repeat prescriptions are not reissued too early, again to maintain supplies. I suspect the standards of drug monitoring and medication review have dropped considerably, and one must ask whether prescribing in the absence of standard face-to-face clinical assessment could be leading to harm. People are asking about the safety of ibuprofen – the evidence suggests that it may prolong other respiratory illnesses, although whether that translates to COVID-19 is as yet unknown. So paracetamol is a preferred option, despite the considerable lack on many shop shelves. Questions have also been asked about the safety of ACE inhibitor use, the third most commonly prescribed drug class in primary care. Because SARS-CoV-2 enters its target cells using angiotensin-converting enzyme 2 (ACE2), and expression of this enzyme is increased in patients taking ACE inhibitors and angiotensin II-receptor blockers, concerns have been raised that these drugs may increase severe infection rates, although theoretical benefits in terms of reducing serious lung complications have also been suggested. Again, the jury is out, but the MHRA advice is to continue these for now until further information is available. Repurposing of certain drugs, such as hydroxychloroquine and HIV antivirals, are being explored in clinical trials; some of these have been added to a growing list of products for which parallel exports have been banned to ensure the UK retains sufficient supplies (disturbingly, this list also includes various anaesthetic agents for those people requiring ventilation). I am certain that the impact of the pandemic on prescribing (and indeed life more generally) will be felt for years to come. Whether it makes us more appreciative of the huge benefits pharmaceuticals bring to us, or improves how effectively we use medicines, remains to be seen. For now, we must get though the coming difficult months, and simply acknowledge the wonderful work that all those amazing prescribers and other people working in the health service are doing. Thank you all and stay safe.