key: cord-0921612-vjw7d5ju
authors: Brown, Joshua D.; Vouri, Scott M.; Manini, Todd M.
title: Survey reported medication changes among older adults during the SARS-CoV-2 (COVID-19) pandemic
date: 2020-11-12
journal: Res Social Adm Pharm
DOI: 10.1016/j.sapharm.2020.11.005
sha: 9ba69268dfe15915b73c77e218539ee0455398df
doc_id: 921612
cord_uid: vjw7d5ju

BACKGROUND: Speculation on benefits and harms of prescription, over-the-counter and complementary medications has been widespread during the SARS-CoV-2 (or COVID-19) pandemic. This community-based survey assessed self-reported changes in medications including those stopped, started, or if access had been impacted. METHODS: A survey was collected via Research Electronic Data Capture (REDCap). The survey was advertised in the community through social media, email lists, websites, and post-cards. Survey responses were collected between 5/21/2020 and 6/24/2020. Included variables were those related to demographic characteristics such as age, sex, race, marital status, education, employment, income, and community type. Questions related to medication changes included: “Have you started any medication due to COVID-19”, “Have you stopped any medication due to COVID-19” and “Have you had issues getting your prescription medications.” Respondents aged 50 years or older were included. RESULTS: There were N=1,397 responses of which 1,169 were older adults ≥50 years-old. Of these, 1,141 responded to the medication changes survey questions and 28 had missing responses and were excluded from the survey sample for this analysis. Among these, 31 (2.7%) reported a medication change included 5 (0.4%) reported stopping a medication, 18 (1.6%) reported starting a medication, and 8 (0.7%) reported trouble obtaining medications. Medications started included mostly vitamins or other supplements including zinc (n=9), vitamin C (6), and other supplements (3). Among prescription medications, antidepressants and anti-anxiety medications (4) were reported as well as aspirin (1), losartan (1), and low dose naltrexone (1). One respondent reported unidentified homeopathy. There were no significant differences between those with medication changes and those with none. CONCLUSIONS: In this community-based survey sample of over one thousand older adults, only a small percentage (2.7%; n=31) reported any changes to medications during the pandemic. As essential workers during this crisis, pharmacists have played a critical role in providing medication information and continued access.

naltrexone (1). One respondent reported unidentified homeopathy. There were no significant 22 differences between those with medication changes and those with none. 23

Conclusions: In this community-based survey sample of over one thousand older adults, only a 24 small percentage (2.7%; n=31) reported any changes to medications during the pandemic. As 25 essential workers during this crisis, pharmacists have played a critical role in providing 26 medication information and continued access. remained an underlying theme during the SARS-CoV-2 (or COVID-19) pandemic. 1,2 Many 32 conventional prescription and over-the-counter medications, dietary supplements, and 33 vitamins have been discussed as preventative or curative options for COVID-19. Conversely, 34 many medications have also been implicated as contributing to the risk of infection and disease 35 severity. Hypotheses on how these effects occur relate to potential viral targets, 36 pharmacological properties, and other associations found in observational studies have led to 37 intense attention for certain medications. These medications include, among others, ibuprofen, 38 renin-aldosterone system antagonists, hydroxychloroquine, azithromycin, and zinc. These 39 benefits and harms, whether true or not, have been widely discussed, debated, and politicized 40 across lay and social media. At the same time, there has been a persistent concern over 41 continuity of medication supplies in pharmacies and interruptions in access to medical care. 3 42 43 Media headlines of peer-reviewed or pre-print scientific studies has led to increasing public 44 awareness of several of these unfounded claims and hypotheses about how medications may 45 impact risk of COVID-19. There has been growing concern among the medical community 46 related to changes in patient medication taking behaviors including inherent risks of stopping or 47 starting medications. These concerns could be considered particularly high among older adults 48 who greatly depend on medications and who are at much higher risk of infection and poor 49 outcomes related to medication mismanagement and COVID-19. Understanding these 50 dynamics can be informative in practice settings to influence how patient concerns are 51 addressed. In order to understand the scope of changes in medication use during the 52 pandemic, a community-based online survey was developed and distributed. The survey aimed 53 to understand the prevalence of changes in medication use and to associate the changes with 54 demographic, social, and clinical characteristics among survey respondents ≥50 UFHealth. Additionally, a marketing list was purchased with addresses of adults 60+ years of 71 age to increase responses from older adults. Direct mail post-cards (70,000) that advertised the 72 online survey were sent the second week of May 2020. The first response was on 5/21/2020 and the last response was on 6/24/2020. The University of Florida Institutional Review Board 74 approved the study as exempt. 75 76 This report specifically focuses on medication changes. Questions related to medication 77 changes included: "Have you started any medication due to COVID-19", "Have you stopped any 78 medication due to COVID-19" and "Have you had issues getting your prescription medications." 79

These three questions were coded as binary responses and combined into an overall stratified 80 group for those who had changes in their medications and those that did not. Free text answers 81 were collected after the "started/stopped" questions and these responses were described. 82

Individual medications names were not collected for the "issues getting" medications as the 83 aim was to identify any issues, not specific medications. 84 85 Included variables were those related to demographic characteristics such as age, sex, race, 86 marital status, education, employment, income, and community type. Health related questions 87 included self-rated health and presence of selected comorbid conditions associated with 88 COVID-19. Specific COVID-19 related questions included if the respondent had tested positive 89 for the novel coronavirus or if they knew someone who had tested positive. Additional 90 questions also asked about consumption of media coverage and use of social media during the 91 pandemic. Each characteristic was stratified by medication change groups described above and 92 chi-squared or Fisher's exact tests evaluated the distributions of these variables between these 93 two groups. All analyses were conducted in SAS Enterprise Guide v7.1. 94

There were N=1,397 responses of which 1,169 were older adults ≥50 years-old. Nearly 50% 97 (576) of respondents were from the Alachua County, FL and surrounding areas and 33% (380) reported starting a medication, and 8 (0.7%) reported trouble obtaining medications (Table 1) . 106

These respondents were mutually exclusive. Among medications reported to be stopped, four 107 respondents implicated ibuprofen and one fluticasone nasal spray. Medications started 108 included mostly vitamins or other supplements including zinc (n=9), vitamin C (6), and other 109 supplements (3). Among prescription medications, antidepressants and anti-anxiety 110 medications (4) were reported as well as aspirin (1), losartan (1), and low dose naltrexone (1). 111

One respondent reported unidentified homeopathy. 112

Those with changes to their medications were overall similar to those without any changes and 114 no variables were significantly different between these groups ( Table 2 ). The mean age was 73 115 in both groups with most White (93-94%) and 77-78% of the sample reported "good, very good, 116 or excellent" overall health. The sample was characteristic of the local community including a 117 majority of respondents having post-graduate education, high income, and residing in a small 118 city or suburb. There were no clear associations between those with medication changes and 119 comorbid conditions, media consumption, or social media use (Table 2) . Increased vitamin and supplement use were not a surprising finding as these "natural 133 remedies" or nutraceuticals have been promoted for many decades to prevent or treat 134 illnesses. 4-6 Zinc in particular has been a focus as a sole regimen as well as a combination with 135 hydroxychloroquine and azithromycin. 7 Zinc is postulated by many to have its own anti-viral 136 properties but has also been implicated as a modulator of viral entry by interrupting the link 137 between viral spike proteins and the angiotensin-converting enzyme 2 (ACE2) on host cells. 8 138

Curcumin and other nutraceutical preparations are also experiencing increased attention based 139 on Ayurveda and Traditional Chinese Medicine concepts. 7 140 141 Changes in prescription medications and over-the-counter were anticipated but less frequently 142

reported. The emotional impact of the pandemic -ranging from causes such as loss of 143 employment or income, social isolation, feelings of uncertainty, and so on -has led to 144 increased stress, depression, and anxiety. 9,10 Respondents reported new use of antidepressants 145 and antianxiety medications as well as one reporting increased dosages of an antidepressant. 146

The impact of natural disasters and traumatic events has been documented but the impact of 147 such a global social and economic disaster is unprecedented and will likely be explored in future 148 research. 11-13 149 150

The viral relationship with ACE2 also led to hypothesis for medications such as ACE inhibitors 151 and angiotensin-receptor blockers (ARBs) to be implicated in hypotheses related to increased 152 risk as well as potential treatments. 14 Developing evidence indicates that these agents likely 153 have no relationship with viral risk or as therapeutic agents. Nonetheless, many have published 154 guidance to maintain treatment continuity or to take caution when halting treatment with 155 these agents due to widespread concern regarding these common treatments. [15] [16] [17] Ibuprofen 156 also gained attention after French authorities warned against its use based on anecdotal 157 reports and a mechanistic link between ibuprofen and ACE2 upregulation. 18 Similarly, this 158 hypothesis has not been confirmed and evidence has since emerged suggesting non-steroidal 159 (and steroidal) anti-inflammatory agents may improve symptoms by decreasing inflammation. 19 160 Thus, despite widespread coverage, few respondents reported changes in these medications 161 indicating little penetration of media coverage into respondents medication taking behaviors. In addition, the few access issues reported by respondents indicate a robust response by the 176 medical community to ensure access to medications. Pharmacists and pharmacy technicians 177 are essential workers during this pandemic and there have been few reports of interrupted 178 service. 23-25 There has likely been some shifts in these services during the pandemic including 179 increased focus on drive-thru services as well as delivery, mail order, and virtual pharmaceutical 180 care. 23, 24, 26, 27 Decreased patient mobility due to desire to remain socially isolated, decreases in 181 use of medical services, or decreased public transportation could also drive these medication 182 interruptions. 28 External forces such as reduced medication imports still threaten the 183 medication supply as well. 29 Pharmacists should be prepared to offer patients and physicians 184 guidance on availability of alternative regimens and substitutes and to provide services virtually 185 or in other non-traditional paradigms. (9); Vitamin C (6); antidepressants or antianxiety medications (4); losartan (1); other vitamins (3); aspirin (1); homeopathic medicines (1); other supplements (3); low dose naltrexone (1*). Had trouble obtaining medications and stopped some or all 8 (0.7%) N/A Total (N=1141) 31 (2.7%) Note: Missing data and excluded from survey sample, n=28. There was no overlap in individuals reporting medication changes. Medications started: Other supplements included elderberry, curcumin, and "Noxylane 4." Other vitamins included vitamins D3, B complex, and vitamin A. *One participant reported "LDN." Text search by the authors in reference to COVID-19 found reports on use of "low dose naltrexone." J o u r n a l P r e -p r o o f 

COVID-19): A Review

The Mental Health of Older Persons After Human-273

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Ecological Disasters and Mental Health: Causes

Are patients with hypertension and diabetes mellitus at 278 increased risk for COVID-19 infection? The Lancet Respiratory Medicine

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Antihypertensive drugs and risk of COVID-19?

Drive-thru pharmacy services: A way forward to 310

Missing data by variable: Age (0); sex (39); race (28)

Abbreviations: SD=standard deviation; SARS-CoV-2=Severe acute respiratory syndrome coronavirus 2 Note: All data is self-reported by survey participants. Distribution between groups was evaluated for all variables using chi-squared or Fisher's exact tests and no significant values were found