Field based research in the era of the pandemic in resource limited settings: challenges and lessons for the future.

The coronavirus pandemic that began in December 2019, has had an unprecedented impact on the global economy, health systems and infrastructure, in addition to being responsible for significant mortality and morbidity worldwide. The "new normal" has brought along, unforeseen challenges for the scientific community, owing to obstructions in conducting field-based research in lieu of minimizing exposure through in-person contact. This has had greater ramifications for the LMICs, adding to the already existing concerns. As a response to COVID-19 related movement restrictions, public health researchers across countries had to switch to remote data collections methods. However, impediments like lack of awareness and skepticism among participants, dependence on paper-based prescriptions, dearth of digitized patient records, gaps in connectivity, reliance on smart phones, concerns with participant privacy at home and greater loss to follow-up act as hurdles to carrying out a research study virtually, especially in resource-limited settings. Promoting health literacy through science communication, ensuring digitization of health records in hospitals, and employing measures to encourage research participation among the general public are some steps to tackle barriers to remote research in the long term. COVID-19 may not be a health emergency anymore, but we are not immune to future pandemics. A more holistic approach to research by turning obstacles into opportunities will not just ensure a more comprehensive public health response in the coming time, but also bolster the existing infrastructure for a stronger healthcare system for countries.

Intravenous BCAA Infusion Does Not Lead to a Sustained Recovery From Overt HE in ACLF - An Open Label Randomized Clinical Trial.

Background: Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE at 24 h, day 3, and day 7. The primary outcome was an improvement in encephalopathy by ≥ 1 grade at 72 h. Patients and methods: European association for study of liver (EASL) defined ACLF patients with overt HE were assessed and randomized into the experimental arm (IV-BCAA - 500 mL/day for 3 days + Lactulose; n = 39) and the comparator arm (Lactulose alone; n = 37). Six patients developed COVID-19 after randomization and were excluded (4-experimental arm and 2-comparator arm). Results: Of 222 screened patients, 70 (35 in each arm) were included in the analysis. Baseline characteristics, including HE grade (2.9 ± 0.7 vs 2.8 ± 0.7; P = 0.86) and (chronic liver failure) CLIF-C ACLF score (54.2 ± 5.6 vs 54.8 ± 5.7; P = 0.65), were similar. Overall survival was 40% at 28 days (48.5% vs 31.4%; P = 0.14). Improvement in hepatic encephalopathy scoring algorithm (HESA) by ≥ 1 grade at 24 h occurred in 14 patients (40%) in the BCAA arm and 6 patients (17.1%) in the control group (P = 0.03) which translated to a shorter intensive care unit (ICU) stay. The median change in HESA at 24 h was greater in the BCAA arm than the control arm (P = 0.006), which was not sustained at days 3 or 7. Ammonia levels did not correlate with the grade of HE (Spearman's correlation coefficient (ρ) = - 0.0843; P = 0.29). Conclusion: Intravenous BCAA does not lead to a sustained improvement in HE grade in ACLF. Trial registration no: NCT04238416 (clinicaltrials.gov).

Effect of nutritional-deficiency anemia on peripapillary retinal nerve fiber layer: A North Indian study.

PURPOSE: The purpose of this study was to evaluate the effect of nutritional-deficiency anemia (NDA) on peripapillary retinal nerve fiber layer thickness (PPRNFLT) using spectral-domain optical coherence tomography and to determine any correlation arising thereof. This was a single-center, cross-sectional, observational study. MATERIALS AND METHODS: A total 115 eyes of 115 NDA patients (50 of each with iron-deficiency anemia [IDA] and Vitamin B12-deficiency anemia [BDA], and 15 with folic acid-deficiency anemia [FDA]) aged 18-65 years were compared with a total 100 eyes of 50 age- and sex-matched healthy controls. All subjects underwent comprehensive clinical, ophthalmic, and hematological evaluation, followed by PPRNFLT assessment for the mean total, superior, inferior, nasal, and temporal quadrants. RESULTS: PPRNFLT for the mean total and all four quadrants in IDA patients, for the mean total, inferior, nasal, and temporal quadrants in BDA patients, and for the mean total, inferior, and nasal quadrants, in FDA patients, was significantly lower as compared to the controls (P < 0.05). The mean total PPRNFLT of all NDA patients correlated significantly (P < 0.05) with their relevant hematological parameters with Pearson's coefficient (r) value of 0.613, 0.610, 0.336, 0.295, 0.337, 0.374, and - 0.509, respectively, for serum haemoglobin (Hb), iron, ferritin, mean corpuscular volume (MCV), mean cell hemoglobin, mean corpuscular hemoglobin concentration, and total iron binding capacity in IDA; 0.310, 0.435, and - 0.386, respectively, for serum Hb%, Vitamin B12, and MCV in BDA; and 0.557, 0.358, and - 0.294 for Hb%, folate, and MCV, respectively, in FDA cases. Mean total retinal nerve fiber layer thinning of all NDA patients showed progression with the increasing severity grades of anemia, except in very severe BDA where an inverse relationship was documented. CONCLUSION: Our study revealed that PPRNFLT is significantly thinner in all NDA patients (total and all four quadrants in IDA; total, inferior, nasal, and temporal in BDA; and total, inferior, and nasal in FDA) correlating well with their relevant hematological parameters. Early detection of this may be crucial in preventing potential blinding sequelae and differentiating glaucomatous and other neuro-ophthalmic disorders.

Recombinant protein subunit COVID-19 vaccine-induced Guillain-Barré Syndrome in an adolescent: A case report.

Guillain-Barré Syndrome (GBS), an autoimmune neurological disease of peripheral nerves, has been causally associated with COVID-19 vaccination in adults. However, no such report has been published so far in children. We describe a 13-year-old female child who presented to the emergency department with complaints of bilateral upper limb, lower limb and truncal weakness over 3 days following first dose of recombinant protein subunit COVID-19 vaccine (Corbevax). Clinical examination and nerve conduction studies showed pure motor axonal polyneuropathy with absent compound muscle action potential (CMAP) in all sampled nerves of upper and lower limbs which was consistent with the diagnosis of GBS after ruling out possible alternative aetiologies. A temporal association between first dose of protein subunit COVID-19 vaccine administered a day prior and symptom onset was noted. The causality assessment using the World Health Organization (WHO) tool for adverse event following immunization (AEFI) assessment indicated vaccine product-related reaction categorized as A1. The patient's clinical condition improved after seven sessions of plasmapheresis. The purpose of this report is to create awareness among health care professionals about COVID-19 vaccine-induced GBS in children as early diagnosis and management can be critical in avoiding complications and improving patient outcomes.

Dipeptidyl peptidase 4 (DPP-4) inhibitors and the risk of lung cancer: current evidence and future directions.

INTRODUCTION: Recent evidence has linked long-term use of angiotensin converting enzyme (ACE) inhibitors with the risk of developing lung cancer by increasing levels of substance P (SP) and bradykinin in lung tissue. DPP-4 inhibitors, by virtue of their mechanism of action, may increase the level of SP and pose a similar risk of incident lung cancer. Concomitant use of DPP-4 inhibitors and ACE inhibitors may further exaggerate this plausible risk. AREA COVERED: Here we discuss both direct and indirect evidence involving mechanisms by which DPP-4 inhibitors may increase the risk of lung cancer in treated patients. We highlight that increased levels of SP with DPP-4 inhibitor monotherapy and raised levels of both SP and bradykinin with add-on ACE inhibitor therapy may further enhance this risk. EXPERT OPINION: DPP-4 inhibitors are prescribed in type-2 diabetes mellitus patients with or without cardiovascular disease. When used together, ACE inhibitors and DPP-4 inhibitors may act synergistically and further amplify the lung cancer risk. Consequently, physicians should consider this plausible association while prescribing them concomitantly especially in high-risk individuals. Well-planned research studies are required to assess the association of DPP-4 inhibitors with lung cancer and other adverse effects linked to increased levels of SP and bradykinin.

Population Pharmacokinetics of Hydroxychloroquine Sulfate in Healthcare Workers, Given for Prophylaxis Against Coronavirus Disease 2019 (COVID-19) in India.

Healthcare workers (HCWs) and frontline workers were recommended hydroxychloroquine (HCQ) 400 mg twice a day on day 1, followed by 400 mg once weekly for the next 7 weeks, as prophylaxis against COVID-19. There was limited information on the population pharmacokinetics (popPK) of HCQ in an Indian setting when administered for prophylaxis against COVID-19, and hence this study was proposed. It was a multicentric prospective study conducted at 3 sites in India wherein HCWs who were already on HCQ prophylaxis, who were about to start prophylaxis or who had stopped the prophylaxis for any reason were enrolled. Each participant gave 2 to 6 blood samples at different time points and whole-blood HCQ concentrations were assayed using liquid chromatography with tandem mass spectrometry (LC MS/MS). popPK analysis was performed using PUMAS 1.1.0. A total of N = 338 blood samples from N = 121 participants were included in the popPK analysis. A 2-compartment structural model with linear elimination was able to explain the observed data. Body weight was found to be a significant covariate influencing drug clearance. The final model was assessed using goodness-of-fit plots, a visual predictive check and a bootstrap, all of which confirmed that the model was appropriate. Simulations based on the current regimen showed that trough values were below the half-maximal effective concentration (EC50) of 0.7 µmol against COVID-19. A new weight-based dosage regimen was proposed to maintain the trough concentration above the EC50 threshold.

Knowledge, attitude, and practice survey on antimicrobial use and resistance among Indian clinicians: A multicentric, cross-sectional study.

Purpose: This multicentric questionnaire-based study was undertaken to address the lack of systematic background data on the knowledge, attitudes, and practices among Indian physicians related to antimicrobial use and resistance. Materials and Methods: A validated structured study questionnaire was used for capturing respondent particulars, antimicrobial prescribing habits, knowledge of antimicrobial resistance (AMR), ways of choosing and learning about antibiotics, agreement or disagreement with certain perceptions regarding antibiotics, selection of antibiotics in specific settings, and suggestions regarding rationalizing antimicrobial use in the practice setting. Summary statistical analysis of the pooled data was done. Results: Five hundred and six respondents with a mean (standard deviation) age of 31.4 (8.71) years participated in the study. Three hundred and twenty-seven were medical and 179 surgical discipline clinicians. Overall, the theoretical knowledge about antimicrobials was satisfactory, but areas of concern were noted in the attitude and practice domains. A substantial proportion of participants failed to identify the correct choice of antibiotics in the case-based scenarios. 38.33% reported not attending a single continuing medical education on antimicrobials during the past year. Statistically significant differences were not observed in the KAP quotient scores between medical and surgical discipline respondents. Conclusions: Despite satisfactory background knowledge regarding the rational use of antimicrobials and AMR patterns, there are discrepancies in the physicians' prescribing attitude and thus strengthen the case for instituting specific interventions to improve antimicrobial prescribing.

A multicentre point prevalence survey (PPS) of antimicrobial use amongst admitted patients in tertiary care centres in India.

OBJECTIVES: Data from point prevalence surveys (PPSs) in India are scarce. Conducting PPSs is especially challenging in the absence of electronic medical records, a lack of dedicated resources and a high patient load in resource-poor settings. This multicentre survey was conducted to provide background data for planning and strengthening antimicrobial stewardship programmes across the country. METHODS: This inpatient PPS was conducted over 2 weeks in May 2019 simultaneously across five study centres in India. Data about patient characteristics, indications for antimicrobials use and details of each antimicrobial prescribed including supportive investigation reports were collected in predesigned forms. RESULTS: A total of 3473 admitted patients in wards and ICUs were covered across five study centres. Of these, 1747 (50.3%) patients were on antimicrobials, with 46.9% patients being on two or more antimicrobials. Out of the total antimicrobials prescribed, 40.2% of the antimicrobials were prescribed for community-acquired infection requiring hospitalization followed by surgical prophylaxis (32.6%). Third-generation cephalosporins and drugs from the 'Watch' category were prescribed most commonly. Only 22.8% of the antimicrobials were based on microbiology reports. CONCLUSIONS: The survey demonstrated a high use of antimicrobials in admitted patients with a considerable proportion of drugs from the 'Watch' category. The targets for interventions that emerged from the survey were: improving surgical prophylaxis, decreasing double anaerobic cover, initiating culture of sending cultures and de-escalation with targeted therapy.

System for administering and monitoring hydroxychloroquine prophylaxis for COVID-19 in accordance with a national advisory: preliminary experience of a tertiary care institute in India.

BACKGROUND: Hydroxychloroquine (HCQ) was one of the earliest drugs to be recommended for tackling the COVID-19 threat leading to its widespread usage. We provide preliminary findings of the system, established in a tertiary care academic center for the administration of HCQ prophylaxis to healthcare workers (HCW) based on Indian Council of Medical Research (ICMR) advisory. METHODS: A dedicated clinical pharmacology and internal medicine team screened for contraindications, administered informed consent, maintained compliance and monitored for adverse events. RESULTS: Among the 194 HCWs screened for ruling out contraindications for prophylaxis, 9 were excluded and 185 were initiated on HCQ. A total of 55 adverse events were seen in 38 (20.5%) HCWs out of which 70.9%, 29.1% were mild and moderate & none were severe. Before the completion of therapy, a total of 23 participants discontinued. Change in QTc interval on day 2 was 5 (IQR: -3.75, 11) ms and the end of week 1 was 15 ms (IQR: 2, 18). Out of the 5 HCW who turned positive for COVID-19, 2 were on HCQ. CONCLUSION: HCQ prophylaxis was found to be safe and well tolerated in HCW when administered after appropriate screening and with monitoring for adverse events.

Assessment of Appropriateness of Antimicrobial Therapy in Resource-Constrained Settings: Development and Piloting of a Novel Tool-AmRAT.

Inappropriate antimicrobial prescribing is considered to be the leading cause of high burden of antimicrobial resistance (AMR) in resource-constrained lower- and middle-income countries. Under its global action plan, the World Health Organization has envisaged tackling the AMR threat through promotion of rational antibiotic use among prescribers. Given the lack of consensus definitions and other associated challenges, we sought to devise and validate an Antimicrobial Rationality Assessment Tool-AmRAT-for standardizing the assessment of appropriateness of antimicrobial prescribing. A consensus algorithm was developed by a multidisciplinary team consisting of intensivists, internal medicine practitioners, clinical pharmacologists, and infectious disease experts. The tool was piloted by 10 raters belonging to three groups of antimicrobial stewardship (AMS) personnel: Master of Pharmacology (M.Sc.) (n = 3, group A), Doctor of Medicine (MD) residents (n = 3, group B), and DM residents in clinical pharmacology (n = 4, group C) using retrospective patient data from 30 audit and feedback forms collected as part of an existing AMS program. Percentage agreement and the kappa (κ) coefficients were used to measure inter-rater agreements amongst themselves and with expert opinion. Sensitivity and specificity estimates were analyzed comparing their assessments against the gold standard. For the overall assessment of rationality, the mean percent agreement with experts was 76.7% for group A, 68.9% for group B, and 77.5% for group C. The kappa values indicated moderate agreement for all raters in group A (κ 0.47-0.57), and fair to moderate in group B (κ 0.22-0.46) as well as group C (κ 0.37-0.60). Sensitivity and specificity for the same were 80% and 68.6%, respectively. Though evaluated by raters with diverse educational background and variable AMS experience in this pilot study, our tool demonstrated high percent agreement and good sensitivity and specificity, assuring confidence in its utility for assessing appropriateness of antimicrobial prescriptions in resource-constrained healthcare environments.

Concomitant use of dexamethasone and tetracyclines: a potential therapeutic option for the management of severe COVID-19 infection?

Introduction: The global coronavirus disease-2019 (COVID-19) pandemic has posed a critical challenge to the research community as well as to the healthcare systems. Severe COVID-19 patients are at a higher risk of developing serious complications and mortality. There is a dire need for safe and effective pharmacotherapy for addressing unmet needs of these patients. Concomitant use of dexamethasone and tetracyclines, by virtue of their immunomodulatory and other relevant pharmacological properties, offers a potential strategy for synergy aimed at improving clinical outcomes.Areas covered: Here we review the potential benefits of combining dexamethasone and tetracyclines (minocycline or doxycycline) for the management of severe COVID-19 patients. We have critically examined the evidence obtained from in silico, experimental, and clinical research. We have also discussed the plausible mechanisms, advantages, and drawbacks of this proposed combination therapy for managing severe COVID-19.Expert opinion: The concomitant use of dexamethasone and one of the tetracyclines among severe COVID-19 patients offers several advantages in terms of additive immunomodulatory effects, cost-effectiveness, wide-availability, and well-known pharmacological properties including adverse-effect profile and contraindications. There is an urgent need to facilitate pilot studies followed by well-designed and adequately-powered multicentric clinical trials to generate conclusive evidence related to utility of this approach.

Impact of ophthalmic webinars on the resident's learning experience during COVID-19 pandemic: An insight into its present and future prospects.

PURPOSE: To analyze the impact of ophthalmic webinars on the resident's learning experience during the COVID-19 pandemic (CP). METHODS: This cross-sectional nationwide study was carried out for 1 month during CP and included a total of 382 ophthalmic residents. A questionnaire was sent through various social media platforms. RESULTS: Residents expressed a decline in their clinical exposure (74%; 220), thesis work (58%; 218), and acquisition of the knowledge and skills (42.5%; 161) during CP. Benefits of webinars as perceived by the residents included gain in additional knowledge (77%; 286), feedback on queries (56%; 209), access to multiple speakers (50%; 191), and topics (30%; 110). Nearly 75% (291) of residents endorsed webinars as good to the very good academic tool, and 54% (202) preferred to continue attending webinars in the post-CP phase. However, connectivity/download/data issues (54%; 200) followed by loss of personal touch (53%; 188), lengthy or irrelevant topic (37%; 134), and poor transmission quality (33%; 121) were major deterrents against the webinar. CONCLUSION: The current study generated overall mixed responses from the ophthalmic postgraduate residents in favor of webinars. In the present format, webinars bear enormous potentials to supplement the traditional learning tools by providing uninterrupted learning experiences. However, they are still limited by their pedagogical and technical issues.

A multicentric knowledge-attitude-practice survey in the community about antimicrobial use and resistance in India.

BACKGROUND: To address the reasons for inappropriate use of antimicrobials, it is important to understand the knowledge, attitude and practices (KAP) of all pertinent stakeholders. This multicentric survey is aimed at understanding the KAP quotients of the community regarding antimicrobial use and antimicrobial resistance (AMR), as such information is lacking in India. METHODS: A cross-sectional survey was conducted by face-to-face interviews across five centers in India using a validated, field-tested questionnaire incorporating KAP domain questions. Scores were appropriately assigned to the questions. RESULTS: The mean (SD) age of the respondents was 35.2 (12.61) y and 62% had a graduate or higher level of education. The median (IQR) KAP scores were 10 (8-12), 5 (3-5) and 2 (2-3) out of a maximum of 18, 5 and 6, respectively. Higher educational and socioeconomic levels were associated with better attitude scores, but knowledge levels were comparable. Correlations between KAP scores were poor. CONCLUSIONS: This study reveals that laypeople have appropriate knowledge and attitude regarding antibiotic use and AMR to some degree but there are important lacunae and practices are often wanting. These issues need to be addressed in sustained public awareness and motivation campaigns to improve the rational use of antibiotics in India.

Hydroxychloroquine for the treatment and prophylaxis of COVID-19: The journey so far and the road ahead.

As mortality and morbidity from novel coronavirus disease (COVID-19) continue to mount worldwide, the scientific community as well as public health systems are under immense pressure to contain the pandemic as well as to develop effective medical countermeasures. Meanwhile, desperation has driven prescribers, researchers as well as administrators to recommend and try therapies supported by little or no reliable evidence. Recently, hydroxychloroquine-sulfate (HCQS) has got significant media and political attention for the treatment as well as prophylaxis of COVID-19 despite the lack of convincing and unequivocal data supporting its efficacy and safety in these patients. This has unfortunately, yet foreseeably led to several controversies and confusion among the medical fraternity, the patient community as well as the general public. Based on the available studies, many with high risk of bias, relatively small sample sizes, and abbreviated follow-ups, HCQS is unlikely to be of dramatic benefit in COVID-19 patients and yet has the potential to cause harm, particularly when used in combination with azithromycin or other medications in high risk individuals with comorbidities. Although definitive data from larger well-controlled randomized trials will be forthcoming in the future, and we may be able to identify specific patient subpopulations likely to benefit from hydroxychloroquine, till that time it will be prudent to prescribe it within investigational trial settings with close safety monitoring. Here we review the current evidence and developments related to the use of HCQS in COVID-19 patients and highlight the importance of risk-benefit assessment and rational use of HCQS during this devastating pandemic.

Assessment of the Impact of Clinical Pharmacology Consultations Provided to Hospital Clinicians From the Drug Information Center-An Outcome Research in a Developing Country.

BACKGROUND: Drug Information Center (DIC) with on-call evidence-based medicine service can revolutionize health-care practice and also can play a major role in health-care delivery in both developed and developing countries. OBJECTIVE: To assess the feedback received from hospital clinicians for the newly initiated DIC services in a tertiary care hospital of North India. METHODS: This is a retrospective cohort study conducted between January 1, 2016, to December 31, 2018. The clinicians approached DIC for specific pharmacotherapeutic questions for managing an index patient. After providing consultation, DIC followed up with them for the action taken and feedback on the consultation. The results of the data analyzed using Fisher Exact test and descriptive statistics. RESULTS: Of 264 encounters, more than 98% of clinicians found the service satisfactory. There was a statistically significant association between the timely answer provided to treating physicians and their level of satisfaction with the service (P < .05). There was no significant association between academic experiences and the satisfaction or dissatisfaction among the clinical fraternity colleagues. The interpretation ability of on-call pharmacology postgraduate students was a significantly associated factor with clinician's satisfaction level (P < .05). More than 96% of clinicians followed the pharmacotherapy advice recommended by DIC in their patient management. CONCLUSION: Thorough evaluation of published research needs to be taught to budding pharmacologists, pharmacists in their curriculum for an effective DIC service. DIC service has the potential to minimize the barrier of evidence-based medicine practice in developing as well as developed countries.

Deciphering the COVID-19 cytokine storm: Systematic review and meta-analysis.

INTRODUCTION: The coronavirus pandemic has affected more than 20 million people so far. Elevated cytokines and suppressed immune responses have been hypothesized to set off a cytokine storm, contributing to ARDS, multiple-organ failure and, in the most severe cases, death. We aimed to quantify the differences in the circulating levels of major inflammatory and immunological markers between severe and nonsevere COVID-19 patients. METHODS: Relevant studies were identified from PubMed, EMBASE, Web of Science, SCOPUS and preprint servers. Risk of bias was assessed for each study, using appropriate checklists. All studies were described qualitatively and a subset was included in the meta-analysis, using forest plots. RESULTS: Based on 23 studies, mean cytokine levels were significantly higher (IL-6: MD, 19.55 pg/mL; CI, 14.80, 24.30; IL-8: MD, 19.18 pg/mL; CI, 2.94, 35.43; IL-10: MD, 3.66 pg/mL; CI, 2.41, 4.92; IL-2R: MD, 521.36 U/mL; CI, 87.15, 955.57; and TNF-alpha: MD, 1.11 pg/mL; CI, 0.07, 2.15) and T-lymphocyte levels were significantly lower (CD4+ T cells: MD, -165.28 cells/µL; CI, -207.58, -122.97; CD8+ T cells: MD, -106.51 cells/µL; CI, -128.59, -84.43) among severe cases as compared to nonsevere ones. There was heterogeneity across studies due to small sample sizes and nonuniformity in outcome assessment and varied definitions of disease severity. The overall quality of studies was sub-optimal. CONCLUSION: Severe COVID-19 is characterized by significantly increased levels of pro-inflammatory cytokines and reduced T lymphocytes. Well-designed and adequately powered prospective studies are needed to amplify the current evidence and provide definitive answers to dilemmas regarding timing and type of anti-COVID-19 therapy particularly in severe patients.

Minocycline for the management of multiple sclerosis: repositioning potential, opportunities, and challenges.

INTRODUCTION: Multiple sclerosis (MS) is a chronic demyelinating inflammatory disorder with variable clinical and pathologic characteristics reflecting multiple underlying pathophysiologic mechanisms. Repositioning of existing drugs for the new indications offers several advantages including significant reduction in the cost and time of drug development and exemption from early phase clinical trials. Minocycline has been reported to exhibit immunomodulation in several pre-clinical and clinical studies through suppression of migratory inflammatory cells, modulation of peripheral immune response, and inhibition of microglial activation within the CNS. AREAS COVERED: Here, the authors review the repositioning potential of minocycline for the treatment of MS along with appraisal of the evidence obtained from preclinical and clinical research. The authors also discuss the advantages and potential safety concerns related to the use of minocycline for the management of MS. EXPERT OPINION: Minocycline offers several distinct advantages in terms of well-known safety profile, lower cost of therapy, widespread availability, and being available as an oral formulation. The authors call upon the public and private funders to facilitate well designed and adequately powered randomized clinical trials that can provide conclusive evidence regarding the safety and efficacy of minocycline in patients with MS.