Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

BCG as a game-changer to prevent the infection and severity of COVID-19 pandemic?

The impact of COVID-19 is changing with country wise and depend on universal immunization policies. COVID-19 badly affects countries that did not have universal immunization policies or having them only for the selective population of countries (highly prominent population) like Italy, USA, UK, Netherland, etc. Universal immunization of BCG can provide great protection against the COVID-19 infection because the BCG vaccine gives broad protection against respiratory infections. BCG vaccine induces expressions of the gene that are involved in the antiviral innate immune response against viral infections with long-term maintenance of BCG vaccine-induced cellular immunity. COVID-19 cases are reported very much less in the countries with universal BCG vaccination policies such as India, Afghanistan, Nepal, Bhutan, Bangladesh, Israel, Japan, etc. as compared to without BCG implemented countries such as the USA, Italy, Spain, Canada, UK, etc. BCG vaccine provides protection for 50–60 years of immunization, so the elderly population needs to be revaccinated with BCG. Several countries started clinical trials of the BCG vaccine for health care workers and elderly people. BCG can be uses as a prophylactic treatment until the availability of the COVID-19 vaccine.

Therapeutic Potential of Cytosolic PLA2 Isoform–Specific Inhibitor Arachidonyl Trifluromethyl Ketone in Cigarette Smoke Condensate–Induced Pathological Conditions in Alveolar Type I and II Epithelial Cells

Background: Cigarette smoking is responsible for various lung pathologies including chronic lung inflammation, emphysema, chronic obstructive pulmonary disease (COPD), cancer, and annually causes almost 10 million deaths globally. During smoke exposure, most affected cells are the alveolar epithelial cells where as a repair mechanism, activation of cytosolic phospholipase A2 enzymes takes place. High free radicals and cPLA2 activity due to continuous exposure of smoke exposure leads to elevated levels of secondary metabolites and various pathophysiologic conditions such as chronic inflammation, oxidative stress and cancer. To reduce the burden of chronic inflammation as well as oxidative stress, and higher levels of secondary metabolites whose role is well defined in progression of cancer, we checked the therapeutic potential of cPLA2 inhibitor arachidonyl trifluromethyl ketone (ATK) by pharmacologically targeting the most expressible cPLA2 during continuous exposure of cigarette smoke. Aim: To check the therapeutic potential of cytosolic PLA2 isoform specific inhibitor arachidonyl trifluromethyl ketone in cigarette smoke condensate–induced pathologic conditions in alveolar type I and II epithelial cells. Methods: Effect of cPLA2 inhibitor on CSC-induced cPLA2 activity were checked using colorimetric assay, cell viability using MTT assay, FDA uptake assay using fluorescence microscopy, ROS levels and apoptosis markers through flow cytometry, and ERK levels using ELISA, in both type of alveolar epithelial cells. Results: ATK significantly mimicked CSC-induced cPLA2 activity, free radicals, primary apoptosis, ratio of apoptotic/apoptotic proteins and levels of ERK whereas protected cells from loss of cell viability and membrane integrity. Conclusion: Current observations revealed cPLA2s as a potential therapeutic target and their inhibitor ATK as a potential therapeutic agent in Cigarette smoke induced pathological conditions in alveolar type I and II epithelial cells.

Prospective Observational Study of Adverse Drug Reactions of Anticancer Drugs Used in Cancer Treatment in a Tertiary Care Hospital

Adverse drug reactions associated with the use of anticancer drugs are a worldwide problem and cannot be ignored. Adverse drug reactions can range from nausea, vomiting or any other mild reaction to severe myelosuppression. The study was planned to observe the suspected adverse drug reactions of cancer chemotherapy in patients aged >18 years having cancer attending Postgraduate Institute of Medical Education and Research, Chandigarh. During the study period, 101 patients of breast cancer and 73 patients of lung cancer were screened for occurrence of adverse drug reactions during their treatment with chemotherapy. About 87.36% patients experienced adverse drug reactions, 90.09% and 83.56% of breast and lung cancer patients experienced at least one adverse drug reaction respectively. In breast cancer patients, 41.58% patients were prescribed fluorouracil+doxorubicin+cyclophosphamide while paclitaxel was prescribed to 22.77% patients. Alopecia (54.94%), nail discolouration (43.96%), dysgeusia (38.46%), anorexia (30.77%), nausea (29.67%), and neuropathy (29.67%) were found to be very common in breast cancer patients treated with single/combined regimen. In lung cancer group of patients, cisplatin with docetaxel, cisplatin with pemetrexed and cisplatin with irinotecan were prescribed to 30.14, 24.65 and 17.81% patients, respectively. Dysgeusia (40.98%), diarrhoea (39.34%), anorexia (32.77%) and constipation (31.15%) and alopecia (31.15%) were commonly observed adverse drug reactions having lung cancer patients. Causality assessments using World Health Organization causality assessment scale showed that observed adverse drug reactions were of probable (64.67%) and possible (35.33%) categories. Alopecia, dysgeusia, anorexia, constipation diarrhoea, nausea, nail discoloration were more prevalent amongst the cancer patients undergoing chemotherapy.

Comparison of tolterodine with standard treatment in pediatric patients with non-neurogenic dysfunctional voiding/over active bladder: a systematic review

To examine the efficacy, safety and tolerability of tolterodine in children with overactive bladder in comparison with standard treatment i.e. oxybutynin as demonstrated in randomized clinical trials and other studies. A systematic search was done to screen the studies evaluating the effect of tolterodine in children with non-neurogenic overactive bladder. Results of studies were pooled and compared. Efficacy was determined from micturition diaries and dysfunctional voiding symptoms score. Safety and tolerability were assessed from the reported treatment emergent adverse events. A total of six randomized clinical trials and 11 other studies of tolterodine in children with urinary incontinence were included in the present systematic review. The dose of tolterodine used in different settings ranged from '0.5 to 8 mg/day' instead of '0.5 to 8 mg/kg per day' and the duration of studies ranged from 2 weeks to 12 months. Both extended and immediate release preparations of tolterodine were shown to have comparable efficacy and tolterodine proved to have comparable efficacy with better tolerability than oxybutynin in these studies. It can be concluded that tolterodine is efficacious in treatment of urinary incontinence in children. Moreover, its efficacy is comparable to oxybutynin, the most commonly prescribed anticholinergic in this condition, while having better tolerability. Hence, it can be considered as first line therapy for the treatmentof urinary incontinence in children.

Effect of esomeprazole on pharmacokinetics of phenytoin in rabbits

Esomeprazole is commonly prescribed proton pump inhibitor for gastritis and peptic ulcer disease. Most of the time in clinical practice, phenytoin and esomeprazole are prescribed for patients of generalized seizures with concomitant peptic ulcer. Hence there are chances of drug-drug interaction because of modulations of isoenzymes CYP2C9 and CYP2C19, are involved in metabolism of phenytoin and esomeprazole. But it is important to maintain the therapeutic level of phenytoin in plasma for effective seizures control. So, the aim of the study was to determine the effect of esomeprazole on the pharmacokinetics of phenytoin in rabbits. In a parallel design study, phenytoin, 30 mg/kg/day per oral was given daily for 14 days. On day 15, blood samples were taken at various time intervals between 0-24 hours. In esomeprazole-phenytoin group, phenytoin was administered for seven days as mentioned earlier and from day 8th onward, esomeprazole 2.8 mg/kg along with phenytoin 30 mg/kg/day was administered till 14th days and blood samples were drawn as above on 15th day. Plasma phenytoin levels were assayed by HPLC and pharmacokinetic parameters were calculated. In esomeprazole-phenytoin group, there was a significant increase of t1/2el than phenytoin alone group and significant increase in AUC0-24 was also observed in the esomeprazole and phenytoin treated group. These results suggest that esomeprazole alters the pharmacokinetics of phenytoin. Confirmation of these results in further clinical studies will warrant changes in phenytoin dose or frequency when esomeprazole is co-administered.

Evaluation of eperisone hydrochloride in the treatment of acute musculoskeletal spasm associated with low back pain: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Eperisone hydrochloride is a centrally acting muscle relaxant inhibiting the pain reflex pathway, having a vasodilator effect.

AIMS

To evaluate the efficacy and tolerability of eperisone in patients with acute musculoskeletal spasm associated with low back pain.

SETTINGS AND DESIGN

Prospective, randomized, double-blind, placebo-controlled, multicentric trial conducted at five tertiary care orthopedic centers across India.

MATERIALS AND METHODS

It was planned to enroll 240 patients of either sex between 18-60 years with acute musculoskeletal spasm (AMSP) with low back pain (LBP) due to spondylosis deformans, prolapsed disc or muscle sprain. Patients with other associated unrelated spasm conditions were excluded. Assessments were done for finger-to-floor distance (FFD), lumbar pain, Lasegue's sign, tenderness of vertebral muscles, need for rescue medication and response to therapy for efficacy and tolerability.

STATISTICAL ANALYSIS

Parametric data were analyzed by 't' test and ANOVA, and non-parametric data were analyzed using Mann-Whitney 'U' test and Kruskall-Wallis test. Proportions were compared using Fischer's (Chi-square) test.

RESULTS

Two hundred and forty patients were randomized to receive eperisone 150 mg/day in three divided doses (n=120) or placebo (n=120) for 14 days, of which 15 patients did not complete and 225 patients completed the study (eperisone, 112 and placebo, 113). Significantly greater improvement in FFD (P<0.001) from baseline on Day 14 was seen with eperisone (150.66 to 41.75) compared to placebo (138.51 to 101.60). Improvements in other parameters were greater with the eperisone group. For 89 (79.46%) patients the therapy was rated as good-excellent with eperisone compared to 43 (38.05%) patients with placebo. Nausea, abdominal pain, headache and dizziness were the common adverse events with both therapies. Rescue drug was needed by 40 (35.71%) eperisone patients and 83 (73.45%) placebo patients.

CONCLUSIONS

Eperisone hydrochloride was effective and well tolerated for the treatment of patients with AMSP with LBP.

Effect of combination of thalidomide and sulfasalazine in experimentally induced inflammatory bowel disease in rats

Thalidomide provided significant protection against tri nitro benzene sulfonic acid induced colitis. Combination therapy also reduced colonic inflammation and all the biochemical parameters (myeloperoxidase assay, malondialdehyde assay and tumor necrosis factor-alpha, estimation) were significant as compared to control as well as thalidomide alone treated group. Combination therapy showed additive effect of thalidomide which restored lipid peroxidation as well as reduced myeloperoxidase and TNF-a towards the normal levels. Morphological and histological scores were significantly reduced in combination groups. In experimental model of colitis, oral administration of thalidomide (150 mg/kg) alone as well as its combination with sulfasalazine (360 mg/kg) significantly reduced the colonic inflammation. The results indicate the additive effect of thalidomide with sulfasalazine in rat colitis model which requires further confirmation in human studies.

Bacteria in cancer therapy: a novel experimental strategy

Resistance to conventional anticancer therapies in patients with advanced solid tumors has prompted the need of alternative cancer therapies. Moreover, the success of novel cancer therapies depends on their selectivity for cancer cells with limited toxicity to normal tissues. Several decades after Coley's work a variety of natural and genetically modified non-pathogenic bacterial species are being explored as potential antitumor agents, either to provide direct tumoricidal effects or to deliver tumoricidal molecules. Live, attenuated or genetically modified non-pathogenic bacterial species are capable of multiplying selectively in tumors and inhibiting their growth. Due to their selectivity for tumor tissues, these bacteria and their spores also serve as ideal vectors for delivering therapeutic proteins to tumors. Bacterial toxins too have emerged as promising cancer treatment strategy. The most potential and promising strategy is bacteria based gene-directed enzyme prodrug therapy. Although it has shown successful results in vivo yet further investigation about the targeting mechanisms of the bacteria are required to make it a complete therapeutic approach in cancer treatment.

Impact of the impact factor in biomedical research: its use and misuse

The impact factor was created in the biomedical research field in order to measure a journal's value by calculating the average number of citations per article over a period of time. It was initially developed to help libraries decide which highly-cited journals to subscribe to. However, at present, it is being misused to judge the quality of a researcher or medical scientist as well as the quality of the work done. It contains serious sources of errors and flaws, resulting in strong biases against culture- and language-bound medical subspecialties. The present article is aimed to highlight the impact of the impact factor in the biomedical research, as well as its use and misuse.

Role of different cytokines and seizure susceptibility: a new dimension towards epilepsy research

Epilepsy is a common health problem. Although variety of factors influence the incidence and prevalence of seizures, cytokines are considered to play an important role in seizures. Cytokines are also known to be involved in other neurodegenerative disorders. Proinflammatory cytokines like IL-1, IL-6, TNF-alpha and growth factor vascular endothelial growth factor (VEGF) as well as anti-inflammatory cytokine IL-10 and related molecules have been described in CNS and plasma of experimental models of seizures and clinical cases of epilepsy. There are reports suggesting more predispositions to seizures during inflammatory conditions like colitis, pneumonia and rheumatoid arthritis. These inflammatory cytokines and growth factors are also known to have dual roles in affecting seizure susceptibility. It remains to be seen if cytokine modulators can be therapeutically exploited for patients with inflammatory disorder and suffering from epilepsy.

Experimentally induced various inflammatory models and seizure: understanding the role of cytokine in rat

BACKGROUND

The mechanism of epileptogenesis is not well established. There is higher incidence of seizures among patients with chronic inflammatory disease. Cytokines are rapidly induced in the brain after a variety of stimuli including inflammation. Aim of this study was to produce various inflammatory models and seizure to understand the role of TNFalpha in above mentioned models.

MATERIALS AND METHODS

A total of 54 male rats were included in the study. Animals were divided into 3 groups of colitis, arthritis, and cotton wool granuloma. Each group had 3 subgroups of control, model and treatment. At the end of 3 days in colitis, 17 days in arthritis and 7 days in cotton wool granuloma groups a subconvulsive dose of PTZ (40 mg/kg i.p) was injected to note seizure onset and seizure score. Brain samples were subjected to DNA fragmentation testing. Presence of inflammation was confirmed by morphology and histology. Plasma and brain TNFalpha levels were measured.

RESULTS

The models of colitis, arthritis and CWG were effectively produced as evidenced by morphology and histology scores (p<0.001). Seizure onset was reduced and grade was increased (p<0.001). Thalidomide reduced the morphological, histological (p<0.002), DNA fragmentation and seizure grade (p<0.001) while increased seizure onset (p<0.001) in the arthritis group. TNFalpha levels in both plasma and brain were reduced following thalidomide treatment (p<0.002) in arthritis group. There were no significant findings in colitis or cotton wool granuloma groups.

CONCLUSION

Inflammation was associated with decreased threshold to PTZ induced seizure. Thalidomide is effective in reducing the extent of arthritis as well as reducing the seizure scoring and increasing seizure onset in the adjuvant arthritis group. Thalidomide was also effective in reducing TNFalpha levels thus contributing to its antiepileptic activity.

Seasonal variation in plasma levels of lithium in the Indian population: is there a need to modify the dose?

INTRODUCTION

Lithium still remains an important choice in the therapy of manic-depressive psychosis (MDP), and though there are reports of seasonal variation in lithium levels from a few countries, such studies have not been conducted in India. Variability in the lithium level can lead to lack of efficacy or toxicity, making seasonal variation clinically relevant.

METHODS

A retrospective case sheet audit was performed for 101 MDP patients for recording plasma lithium level, oral lithium dose, age and gender for one year. The overall average oral lithium dose and level were recorded; the monthly average to which it most closely matched was noted as the control month, and values of other months were compared with this control month by Friedman's test followed by Dunn's test.

RESULTS

The mean age of patients was 38.22 (standard deviation 12.07) years, and 72 out of 101 patients were male. The mean lithium dose in November (938.61 +/- 243.40 mg/day), which was the closest to the overall mean dose (938.24 +/- 241.78 mg/day) was taken as the control month, which when compared with other monthly values, did not show any significant difference. The June (0.54 +/- 0.23 meq/L), July (0.55 +/- 0.24 meq/L) and August (0.55 +/- 0.24 meq/L) mean plasma lithium values were significantly high when compared to the October value (0.45 +/- 0.22 meq/L) as control. High-low variability between the plasma lithium values of different months was found to be 25 percent.

CONCLUSION

The present study showed a significant high variability of lithium levels in different months of the year, therefore frequent plasma level monitoring and oral lithium dose adjustment to prevent situations of toxicity and lack of efficacy in MDP.

Effect of Manuka honey and sulfasalazine in combination to promote antioxidant defense system in experimentally induced ulcerative colitis model in rats

Manuka honey (MH, 5g/kg) provided protection against trinitro-benzo-sulphonic acid induced colonic damage. Combination therapy (MH+sulfasalazine) also reduced colonic inflammation and all the biochemical parameters were significant compared to control and MH alone treated group. Combination therapy showed additive effect of the MH which restored lipid peroxidation and improvement of antioxidant parameters. Morphological and histological scores were significantly reduced in combination groups. In inflammatory model of colitis, oral administration of MH (5g/kg) and combination with sulfasalazine (360 mg/kg) with MH (5g/kg) significantly reduced the colonic inflammation. The results indicate the additive effect of Manuka honey with sulfasalazine in colitis.

Effect of propofol in altering pentylenetetrazol induced seizure threshold in rats

The present study was undertaken to evaluate the role of propofol in altering pentylenetetrazol induced seizure threshold in rats. Total 42 Wistar rats were used to evaluate different parameters (onset of action, duration of seizure, seizure severity score and number of seizure) following propofol injection. The present results showed that there was significant reduction in the time required for onset of seizure in propofol treated groups following PTZ treatment. If treated with propofol alone (2 and 5 mg/kg), there was no significant difference as compared to controls. In seizure severity score assessment, there was no significant difference with various doses of propofol alone treated groups, but the difference was observed in propofol (2 and 5 mg/kg) treated groups following PTZ treatment. Duration of seizure also significantly increased in propofol (5 mg/kg) treated group, but at 2 mg/kg of propofol treatment, no significant difference was observed. The present results showed that propofol ameliorate seizure threshold and caused prolongation of duration of seizure. However, further study and trials are needed to confirm the present results.

Genetic basis of HIV-1 resistance and susceptibility: an approach to understand correlation between human genes and HIV-1 infection

HIV infection is the serious medical and public health issue of present generation. By 2005, it has already infected a cumulative total of more than sixty million people worldwide and the number of HIV positive cases are rising day by day. India is currently estimated to have about 5.1 million infected persons with HIV-1 or AIDS (second only to South Africa) and this number could increase to 24 million in the next ten years. This pandemic situation of the AIDS stimulated a plethora of longitudinal cohort studies which are designed to document medical heterogeneity as well as to mitigate the factors that regulate the HIV-1 infection, disease progression and the immune defenses. In recent years these genetic studies have led to the discovery of various MHC and non MHC encoded genes, which directly or indirectly influence the susceptibility and resistance to HIV infection and AIDS. These genes and their mutated forms and their products which play a major role in determining the susceptibility or resistance to HIV-1 infection and AIDS. These genes have been categorized into MHC or non MHC encoded genes. The MHC encoded genes which determine HIV resistance or susceptibility are HLA-B57, HLA-B58, HLA-B27, HLA-Bw4 and HLA-A11 in Southeast Asians. On the other hand, non MHC encoded genes are CCR5, CCR2, RANTES, CXCL12, CXCR6, CCL3L1, Interleukin-10 (IL-10), and interferon gamma. The site specific mutations in these genes determine the susceptibility or resistance to HIV-1 infection and AIDS. In future the study of host genes in relation to HIV-1 infection may provide the researchers to develop newer chemotherapeutic approaches to prevent or cure HIV-1 infection effectively.

Honey--a remedy rediscovered and its therapeutic utility

Honey is a common household product with many medicinal uses described in traditional medicine. Modern system of medicine is also finding the honey efficacious in various medical and surgical conditions. Antimicrobial, antioxidant and wound healing properties of honey are being evaluated with successful outcome. Prevention and treatment of various infections due to a wide variety of organisms and promoting surgical wound healing are some of the areas where honey is making its mark.