Snake bite treatment - Rectogesic ointment

[LandSailor]

After seeing this link mentioned in a few places on the use of angina ointment for the treatment of snake bite, I contacted the researcher to get more info.

The ointment that was tested is called Rectogesic. Its normally used for the treatment of anal fissures (no giggling in the back).
It costs about $35 and is sold over the counter at pharmacists (no prescription required).
It has a 3 year shelf life and is recommended to store at temperatures below below 25 C so I guess more appropriate southern parts of Australia.
Who knows though, maybe at 30 C it only lasts for 1 year and thats still possibly a worthwhile investment. The active ingredient is nitroglycerine (gun powder) which is probably reasonably stable.

He said to apply it around and especially just above (but not on) the bite. And remember that you should use this approach with a pressure bandage and it is still important to stay immobile and be carried out (if possible).

What Rectogesic does apparently is delay the entry of toxins from snakebites into the bloodstream boosting survival times by about 50%.

The research paper can be seen here (behind a paywall).

.

[corvus]

Interesting post does that mean my Perscription Only Nitrolingual Pumpspray 14.7ml in solution Glyceryl Trintrate would work ??
corvus
P.S. Nitroglycerin is an oily liquid not a powder Gun Powder is a mixture of Potassium Nitrate, Sulphur and Charcoal

[Nuts]

Interesting post does that mean my Perscription Only Nitrolingual Pumpspray 14.7ml in solution Glyceryl Trintrate would work ??
corvus

Well, you'd first have to find someone willing to hold the cheeks if its a spray (edit, sorry, perhaps yours is not a 'rectogesic' treatment..?)

Sounds like a breakthrough. Interesting L/Sailor.

[corvus]

Nuts as it is a spray no need for any tactile treatment
corvus

[Nuts]

I think I'd have trouble relaxing.. knowing it was coming.. : )

[corvus]

You are concentrating far to much on the ASSpect .

[madmacca]

At 54 minutes transit time, I'm not going to leave my pressure bandage at home anytime soon.

But used in combination with the existing pressure bandage treatment, this could be great.

And the plus is, as an existing OTC medicine, it shouldn't take all that long for it to get approval for a new application (unlike brand new drugs which have an approval pipeline of 10-15 years).

If it's stored for 355 out of 365 days of the year at your home, then I'm sure a few days bushwalking even in warmer climates isn't going to be a problem. More problematic might be 1st aid kits that bump around in the back of cars, where temps can go above 50C parked in the sun.

[wander]

I wonder what prompted some boffin to think of using such a treatment for such an alternative use?

Are boffins the true original artists?

[photohiker]

And the plus is, as an existing OTC medicine, it shouldn't take all that long for it to get approval for a new application (unlike brand new drugs which have an approval pipeline of 10-15 years).

Not likely, unfortunately. The product will have registration for the claim/s on it's label. Any other use is considered 'off label' and inserts unknown risk into the equation for the Australian distributor, who is restricted from broadcasting such off label claims by the registration authorities. Getting registration for a new unrelated use for an existing product may involve clinical trials and reams of paperwork. Big bucks that are likely not justified by the relatively small sales. Such is the trials and tribulations of medical product registration.

I agree it's worth getting and carrying in the backpack.

[LandSailor]

Big bucks that are likely not justified by the relatively small sales.

Spot on Photohiker..thats pretty much what I was told by the researcher. He said they'd approached the manufacturer about this new use but they weren't keen as they didnt think it would be profitable. No doubt precisely for the reasons you mention.
I guess from their perspective, the best outcome is for word to get out and they sell to this new market as is, with no additional investment needed. And I guess thats happening now

Im waiting on the day that someone invents the holy grail...a fast-acting, self-injectable, multi-valent antivenom that stores at room temperature. So all snake bites become just an annoyance...a bit of a hangover for the day then you continue on with your walk Of course its a bit more complicated than that I know.

On a side note, I was also told that even with the recommended Setopress bandages it is still important for people to be taught the bandaging procedure by an expert, as without this the probability of getting it right is ~15% and even when trained it only seems to work in ~ 50% of cases (not sure why).

[LandSailor]

Interesting post does that mean my Perscription Only Nitrolingual Pumpspray 14.7ml in solution Glyceryl Trintrate would work ??
corvus
P.S. Nitroglycerin is an oily liquid not a powder Gun Powder is a mixture of Potassium Nitrate, Sulphur and Charcoal

Actually I think we are both right, although to be fair you are probably more correct. I was quoting someone else with that comment.
Although nitroglycerine is not the original definition of gunpowder it is now commonly used (combined with other stuff like nitrocellulose) in more modern gunpowders (according to wikipedia anyway).

[photohiker]

Im waiting on the day that someone invents the holy grail...a fast-acting, self-injectable, multi-valent antivenom that stores at room temperature.

I'd buy that

The challenge is with the volume of the antivenom required currently (polyvalent is a large volume, 120ml if I remember) and the risk of anaphalaxis. Recommended administration is in ICU situation. Antivenene is harvested from horses dosed with venom, so it contains foreign proteins...

Perhaps a snakebite vaccine. If snakes are immune to ticks, then why can't we be immune to snakes? but I'm sure the toxicologists would shoot that idea down too

[slparker]

Woah.... Steady on people... Before you dive fo the anginine let's wait for more clinical trials. Be aware that one of the toxins in Australian snake venom is an anticoagulant. Anticoagulants and peripheral vasodilators used together may have unintended side effects....
I agree that the initial tests look very promosing but More trials will work out whether this is any more efficacious than just using the PIM bandaging method. I imagine that the next step would be to do more animal studies to see whether this effect when using real snake venom decreases morbidity, decreases side effects (including the clotting and neurotoxicity effects) and increases survivability in animals whose physiology more closely resembles humans.
Until that time all this research suggests is that nitrates increase survivability and venom transit time if you are a mouse.
To suggest that you should abandon a method with proven effect (PIM) to one with no demonstrated effect and no recommendation from toxicologists is premature.
Time will tell if this is a useful and recommended treatment, until then its snake oil.

[photohiker]

To suggest that you should abandon a method with proven effect (PIM) to one with no demonstrated effect and no recommendation from toxicologists is premature.

Steady on slparker, I haven't seen anyone suggesting they are leaving their pressure bandages at home. As far as I am concerned, this is an additional treatment. Under a pressure bandage when it can be applied.

Note that there is little to no effective first aid treatment for abdominal snake bites. In which case, this may well be the only thing you can do other than sit tight and wait for medical help to arrive. If I'm ever in that situation, I'll gladly rub a little snake oil on my wound while I wait for the venom to take effect.

Until that time all this research suggests is that nitrates increase survivability and venom transit time if you are a mouse.

Well, Rat actually, and humans by inference but not yet tested:

To test their theory, the researchers injected a venom-like substance into one foot of 15 volunteers, and measured the time it took for the toxin substitute to reach lymph nodes in the groin.

The experiment was later repeated, except this time the drug-laced ointment was spread around the puncture within one minute of the injection.

The transit time dropped from an average of 13 minutes to 54 minutes, four times slower.

Those were humans.

Further experiments using real toxins in rats yielded roughly the same results.

There's the Rats!

Finally, the researchers compared the survival time in rats injected with venom that were treated with the ointment against those that were not, and found the nitric oxide rats kept breathing 50 per cent longer.

So best case is 50% longer delay out of the ointment PLUS whatever we get out of the PIM. Worst case is some so far unreported clotting or maybe haematoma problems and no improvement over PIM.

I'll put some in my pack. Also comes in a 15g tube btw.

[LandSailor]

To suggest that you should abandon a method with proven effect (PIM) to one with no demonstrated effect and no recommendation from toxicologists is premature.

Point taken slparker. I should have been more clear on that. Ive updated my original post to clarify. This new technique has been tested on humans and proven to be of benefit, at least for the venoms they tested with.
It's also recommended that it be used in conjunction with (and not replace) conventional pressure bandage and immobilisation.

[slparker]

Thanks Landsailor, that is a clarification that was indeed necessary. But actually ( according to the link) this hasn't been tested on humans with snake venom.The test on humans would require clinical trial. Just because transit time from lymphatic system to bloodstream is slowed in the experiment ( and in rodents with actual venom) does not mean that morbidity or lethality would be affected in real envenomations. It is inference only.
The real test would be to administer the treatment in a series of actual envenomations in humans and compare the coag results over time with a number of subjects ( and also compare other envenomation symptoms).Or even do a blinded study if one could get ethics approval. At the moment this treatment works well if you are a rodent.

[LandSailor]

Thanks Landsailor, that is a clarification that was indeed necessary. But actually ( according to the link) this hasn't been tested on humans with snake venom.The test on humans would require clinical trial. Just because transit time from lymphatic system to bloodstream is slowed in the experiment ( and in rodents with actual venom) does not mean that morbidity or lethality would be affected in real envenomations. It is inference only.

Ok but the research in question came from university department specialising in biomedical sciences/pharmacy so I am assuming they have considered some of these issues (who knows what the "mock venom" actually was).
Either way, if more research is required, hopefully will happen soon.

[claudicles]

I hve to admit I am stunned recogesic has this effect. It is a vasodilator! I had no idea it slowed lymphatic drainage. I guess that isn't something that is usually desirable in a drug so doesn't have much of a market.

[andrewbish]

I will get some to use in conjunction with a bandage. Went looking for Rectogesic in a local chemist but only found powder and wipes - no cream.
(FYI for some reason I felt compelled to tell the pretty young female that served me that I don't have a problem with anal fissures )

If someone finds it please share (the location of the store).

[photohiker]

Andrew, just order it from your local Chemist. They are all served by a pretty good wholesale distribution system, most items not in stock can be had in a day.

[wildwalks]

Woah.... Steady on people... Before you dive fo the anginine let's wait for more clinical trials. Be aware that one of the toxins in Australian snake venom is an anticoagulant. Anticoagulants and peripheral vasodilators used together may have unintended side effects..........
Time will tell if this is a useful and recommended treatment, until then its snake oil.

I agree with slparker on this one.

A very interesting study, but not one that will change my first aid approach. There is a lot we don't know about interaction this drug may have with the venom or a possible vaccine. What are the risks using the drug in remote areas for the first time?? What effect does the PIB have on the drug?? What is the quailty of this study?, has it been peer reviewed?? Was the trial double blinded?? what results where excluded from the findings?? what side effects where found??

This is an interesting study, that sounds like it merrits further research.
The benfit stated was comparing the use of the drug to no other treatment. The trial we really need to know if this is effective is to see it compaired to current best practise first aid management.

Why did the drug company say "no", to re-labbeling there product?? I suspect they understand that this study is not enough on its own to prescribe this approach as a better and safer method. A cream that doubles you survival time if bitten by a snake - that would sell like hot cakes to our parranoid society. Marketing would be easy and sales would be very high. But they know there is to much unknown, and the risk too high.

About 2 people a year die from snake bites in Australia. I have not read every report of these, but it seems to me the deaths occure when people do not use the basic first aid.
The most effective method know to reduce transport in the lymphatic system is to stay still, and have someone else apply a pressure bandage. then call for help (PLB if know other reasonable means).

If you are thinking putting this drug in your first aid kit, please, at the very least talk to your doctor and see what she has to say.

Matt

[photohiker]

Why did the drug company say "no", to re-labbeling there product?? I suspect they understand that this study is not enough on its own to prescribe this approach as a better and safer method. A cream that doubles you survival time if bitten by a snake - that would sell like hot cakes to our parranoid society. Marketing would be easy and sales would be very high. But they know there is to much unknown, and the risk too high.

Oh, but it's just not so simple as re-labelling their product...

Not likely, unfortunately. The product will have registration for the claim/s on it's label. Any other use is considered 'off label' and inserts unknown risk into the equation for the Australian distributor, who is restricted from broadcasting such off label claims by the registration authorities. Getting registration for a new unrelated use for an existing product may involve clinical trials and reams of paperwork. Big bucks that are likely not justified by the relatively small sales. Such is the trials and tribulations of medical product registration.

I know it's easy to jump the gun. Of course it is too early for the company to even think of applying for registration for a new claim for an existing product, if you have had any involvement with medical registration in Australia you would know this, and you would also know that there has to be a positive cash benefit at the end: extra profits have to more than compensate for the trials, costs and risks of the new registration. Not many people die from anal fissures, but they do die from snake bite - for instance, what will that new label claim do to the costs of product indemnity insurance? (this is another minefield for medical products) I honestly doubt registration will be applied for even if the trials are done and are positive. We might be paranoid, but once you have a tube in your first aid kit, that's it. This is not a product you are going to buy every week while you recover from a difficult and painful condition.

My take is that I would be happy to take the side effect risks described unless trials show those risks to be more life threatening than a snake bite. That's a personal decision and I respect you for making your own decision as your own situation is different to mine. As a regular solo hiker in brown snake territory I see a lot of snakes and already take at least one pressure bandage with me during warmer months, and I have practised application of the bandage and I understand the need for immobilisation.

Tell me this, What first aid can I perform if I get struck on the abdomen?, we cannot pressure bandage there, so we cannot do anything to restrict lymphatic flow by any current method other than lying down and waiting for help. Given that some places I walk are quite remote and I could be many hours from rescue, why wouldn't I drop a tube of this in my FAK?

[stuey69]

Given that some places I walk are quite remote and I could be many hours from rescue, why wouldn't I drop a tube of this in my FAK?

I'm in a similar situation, so a valid point.

[corvus]

With all due respect how many abdominal snake bites have been recorded in recent years ?? I would guess that normal clothing would reduce any envenomation also as I have mentioned preveviously more die from Jack Jumper bite than from Snakes
corvus

[photohiker]

I wouldn't know how many have been recorded, but that is not the point. I have inadvertently approached snakes on rock ledges that are above knee height. Summer clothing will do little to stop envenomation, but better than no clothing I guess. Not looking for a snake bite, but if one happens I aim to be prepared as best I can.

A little perspective is required here. This is a personal decision to carry a 15 gram tube of ointment that is an over the counter medicine. If you can stick it in your bum (which is what the label says it is for), I think it will be just fine spread on unbroken skin around a snake bite.

[Swaddo]

With noting that venom form Australian slaps travels in the lymphatic system and not the blood stream. I'd be wanting to see some clinical trial data too

Tapatalk made me do it

[Swaddo]

that should read "elapids". Bah humbug

Tapatalk made me do it

[Nuts]

(Corvus) I agree, can't help thinking of the lady bitten on the *&%$#! though
Tbh I don't even personally carry a specific snake bandage, different for mainlanders however- their snakes attack

[LandSailor]

Ive attached the relevant research paper to my original first post (its removed! see below). If I understand it correctly (and Im certainly no expert) Rectogesic is almost as effective as bandages in inhibiting movement through the lymphatic system.

The testing methodology they used, measuring transit times through the lymphatic system, is the same method originally used for testing pressure bandages.
The likelihood of tests being peformed on humans using real snake venom seems pretty slim to me for both commercial and ethical reasons.
So I would suggest that people perhaps talk it over with their GP and get what information they can from other sources and then weigh up the risks.

Some important caveats - if people do use Rectogesic it should be applied as quickly as possible to get the maximum benefit.
Whether using this ointment or not, it is always important to stay immobilised as any movement will speed up the delivery of venom to the body.

UPDATE: Just realised the research paper is copyright (doh!) so maybe I shouldnt be posting on public forum. The paper can be sourced here behind a paywall.

[corvus]

I think this may be interesting information on Tasmanian Snakes including the last recorded death and the one Nuts referred to where the young lady was bitten whilst toileting and was too embarrassed to tell anyone
http://www.wildlifetasmania.com/images/Snakes.pdf
corvus