Q: TEN years ago, my grandson, 20, had to have his spleen removed after falling from a roof. He was told to take daily penicillin for the rest of his life and has done so without fail. I was recently told this was unnecessary and that this medication was not helping his condition.
James Marr, Alveston, Glos.
A: The spleen plays a vital role in the immune system — making white blood cells that fight infection as well as filtering the blood. So if you don’t have a spleen, you’re at lifelong risk of contracting dangerous infections.
This is true whether the spleen was removed following an accident, as in your grandson’s case, or whether there’s a problem with spleen function as a result of a disease such as sickle cell anaemia.
There are two options for these patients: first, is a daily antibiotic, such as penicillin; and second, the patient can be given an emergency supply of antibiotics to be immediately begun if there are signs of an infection, such as a fever. In the latter case, the patient must also seek prompt medical help. Taking a daily antibiotic long-term has several risks and disadvantages.
These include developing allergies such as to the penicillin, which may be severe, and potential alterations to the natural balance of the gut microbiome (the collection of microbes that we now know plays a vital role in immunity as well as digestion).
The spleen plays a vital role in the immune system — making white blood cells that fight infection as well as filtering the blood.
There is also the risk of contracting drug-resistant bacteria — and the fact that people may forget to take the antibiotic medication regularly (though this is not the case for your grandson).
If a patient has been equipped with an emergency supply of antibiotics (typically amoxicillin-clavulanate, although there are others), it is vital that they remember to keep this with them at all times — at home, at work or when travelling — so that the medication can be taken and medical help sought the instant they become ill, no matter how mild the symptoms may initially seem.
No time should be wasted because infections in patients with no spleen or poor spleen function can develop rapidly and even become fatal within hours.
My view is that the course of treatment your grandson is receiving certainly has merit, but there is this alternative ‘emergency supply’ option, and that may suit him better. He could discuss this with his GP.
Q: Some years ago, I was prescribed the painkiller diclofenac while awaiting hip replacement surgery and it enabled me to carry on working. Now my other hip is causing a lot of pain. But when I suggested diclofenac, my GP was adamant it is no longer used and has been banned. Is this correct?
Jean Guilford, Oxon.
A: Diclofenac is the most widely prescribed non-steroidal anti-inflammatory drug (NSAID) in the world and is well established as a painkiller.
But it is associated with an increased risk of heart attacks and strokes, especially among those who use it long term or people who have existing heart disease. It’s also not meant to be used by people who have kidney ailments such as chronic renal failure (due to high blood pressure) or diabetes, as the drug can cause a potentially serious drop in blood flow through the kidneys — possibly as a result of the NSAID causing arteries supplying the kidneys to constrict.
Diclofenac is the most widely prescribed non-steroidal anti-inflammatory drug (NSAID) in the world
As such, like all drugs in the same class, it must be given at the lowest possible dose which helps that patient achieve pain relief.
But the drug is not banned from use and I suspect there has been a breakdown in communication with your GP on this point.
Instead, it may be the case that you have risk factors that mean diclofenac is no longer suitable for you. Your GP can confirm if this is the case.
In my view… Some good news about the NHS
When I first began my training in general practice, the experienced GP who mentored me continually stressed the importance of my signature — having a recognisable and repeatable signature that pharmacists and others would confirm and recognise.
Not only is a GP’s signature in regular use for writing prescriptions, it is also uniquely important in issuing and signing death certificates, something that only a qualified doctor is allowed to do.
But this system is about to change with the introduction this April of a new role: medical examiner.
This person, also a qualified doctor, will now review all medical certificates — and records — issued by the last GP to examine the deceased.
This means that bereaved relatives will have the chance to raise concerns about the standard of care their loved one received, with a doctor not involved in their care.
If there are any doubts about this, the medical examiner can refer the case to the coroner.
Given the fragmented and highly variable state of front-line care in the UK, this reassurance is a most welcome development — something good to say about the NHS, for a change.