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   2022| November-December  | Volume 54 | Issue 6  
    Online since January 31, 2023

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Use of drugs not listed in the National List of Essential Medicines: Findings from a prescription analysis by the Indian Council of Medical Research-Rational Use of Medicines Centres Network in tertiary care hospitals across India
Ratinder Jhaj, Aditya Banerjee, Nilima Arun Kshirsagar, Balakrishnan Sadasivam, Sujith J Chandy, Heber Rew Bright, Preetha Kaur Chugh, CD Tripathi, Dinesh Kumar Badyal, Madhulika Peter Samuel, Bikash Medhi, Ajay Prakash, Rupa Joshi, Sandhya Kamat, Raakhi Tripathi, Urwashi Indrakumar Parmar, Harihar Dikshit, Hitesh Mishra, Sukalyan Saha Roy, Niyati Trivedi, Janki Chauhan, Suparna Chatterjee, Manjari Bhattacharya, Chetna K Desai, Shamil Sheth, Pooja Gupta, Atanu Roy, Ramasamy Raveendran, Jayanthi Mathaiyan, G Jeevitha, Sandeep Kaushal, Kanchan Gupta, Samriti Jain, Rajni Kaul
November-December 2022, 54(6):407-416
BACKGROUND: The concept of listing essential medicines can lead to improved supply and access, more rational prescribing, and lower costs of drugs. However, these benefits hinge on the prescription of drugs from an Essential Medicines List (EML). Several studies have highlighted the problem of underutilization of EMLs by prescribers. Therefore, as part of prescription research by the Indian Council of Medical Research-Rational Use of Medicines Centres Network, we evaluated the extent of prescription of drugs not listed in the National List of Essential Medicines (NLEM). MATERIALS AND METHODS: Prescriptions of outpatients from participating centers were included after obtaining verbal/written informed consent as approved by the Ethics Committee, and evaluated for prescription of drugs from the NLEM 2015. RESULTS: Analysis of 4838 prescriptions from 13 tertiary health-care institutes revealed that 2677 (55.33%) prescriptions had at least one non-NLEM drug prescribed. In all, 5215 (31.12%) of the total 16,758 drugs prescribed were not in NLEM. Of these, 2722 (16.24%) were single drugs and 2493 (14.88%) were fixed-dose combinations (FDCs). These comprised 700 different drug products – 346 single drugs and 354 FDCs. The average number of non-NLEM drugs prescribed per prescription was 1.08, while the average number of all drugs prescribed was 3.35 per prescription. It was also found that some of the non-NLEM drugs prescribed had the potential to result in increased cost (for example, levocetirizine), increased adverse effects (dextromethorphan), and less effectiveness (losartan) when compared to their NLEM counterparts. Nonavailability of an essential drug (oral hydroxocobalamin) was another important finding of our study. CONCLUSION: This study highlights the extent and pattern of drugs prescribed from outside the NLEM at the tertiary health-care level and the need for training and enhanced awareness among prescribers for greater utilization of the NLEM.
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Lasmiditan abortive therapy for episodic migraine in Phase II/III randomized clinical trials: A meta-analysis
Marya Ahsan, Ayaz Khurram Mallick
November-December 2022, 54(6):397-406
OBJECTIVE: Although migraine is common, there are very few treatment options. Recently, lasmiditan, a specific 5-HT1F agonist, has gained approval as abortive therapy for migraine. This meta-analysis and trial sequential analysis (TSA) was performed to analyze efficacy and tolerability of lasmiditan therapy for episodic migraine. MATERIALS AND METHODS: Phase II and Phase III double-blinded placebo-controlled randomized controlled trials (RCTs) evaluating lasmiditan for episodic migraine were searched for from electronic databases. The risk of bias was estimated, data were extracted, and relative risk (RR) were calculated for efficacy and safety outcomes with a fixed/random effect model. Forest plots and funnel plots were created. TSA graph was plotted. Therapeutic gain with lasmiditan was calculated. RESULTS: Six high-quality RCTs were included with 7122 patients. Compared to placebo, lasmiditan demonstrated a significant proportion of migraineurs reporting freedom from headache, most bothersome symptom, headache response, no disability, global impression “very much/much better” 2 h posttreatment and sustained pain freedom at 24 and 48 h with 50, 100, 200, and 400 mg doses (RR range = 1.26–2.50). 39.3% of patients in the lasmiditan group (RR = 2.43) reported one or more treatment-emergent adverse event (TEAE). Dizziness, somnolence, paresthesia, fatigue, nausea, vertigo, hypoesthesia, asthenia, muscular weakness, lethargy, and malaise had a high incidence (RR range = 3.16–12.77). Most TEAEs were mild to moderate. No vasoconstriction-related TEAE was reported. CONCLUSION: Lasmiditan demonstrated efficacy as abortive therapy for episodic migraine with central nervous system-related side effects.
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Translational research: Bridging the gap between preclinical and clinical research
Vidya Mahalmani, Shweta Sinha, Ajay Prakash, Bikash Medhi
November-December 2022, 54(6):393-396
  1,942 124 -
Pharmacological treatment of bipolar disorder in pregnancy: An update on safety considerations
Swarndeep Singh, Raman Deep
November-December 2022, 54(6):443-451
Pregnancy in women with bipolar disorder (BD) can be considered a high-risk pregnancy in view of several clinical and pharmacotherapeutic considerations. Pharmacological treatment during pregnancy requires a careful weighing of psychotropic drug exposure against the risk of BD relapse. An untreated bipolar illness can negatively affect the health of mother as well as unborn child in the event of a relapse. Availability of well balanced, latest information on safety of prophylactic drugs for BD is crucial for making informed decisions. The review provides an evidence-based update (2015–2021) on the drug safety considerations involved in providing care for women with BD who are either pregnant or planning to conceive in near future. Literature review based on systematic reviews, meta-analyses, and data available from studies based on large-scale cohorts and birth registries has been synthesized and presented along with clinically relevant recommendations.
  1,152 124 -
Pharmacovigilance study of amphotericin B for mucormycosis in post-COVID and non-COVID patients at a tertiary care hospital in Eastern India
Suparna Chatterjee, Manjari Bhattacharjee, Avijit Hazra, Pradip Mukhopadhyay, Biman Kanti Ray, Sayan Chatterjee, Souvik Dubey
November-December 2022, 54(6):417-422
BACKGROUND: Mucormycosis is a rare but serious fungal infection which has dramatically increased in post-COVID patients. There is a paucity of safety data on amphotericin B (amphoB) used for mucormycosis treatment. OBJECTIVES: The objective of this prospective, observational, active safety surveillance study was to evaluate the safety profile of amphoB in a cohort of hospitalized patients who were on the drug for suspected mucormycosis. MATERIALS AND METHODS: All suspected adverse drug reactions (ADRs) in hospitalized mucormycosis patients who had received amphoB were analyzed. The nature, severity, outcome of the ADRs were recorded and analyzed. RESULTS: Of the 77 patients enrolled, 70% had documented history of prior COVID-19 infection. 96% had comorbidities, the most common being diabetes. Majority received conventional amphotericin B deoxycholate formulation. 97% experienced at least one suspected ADR and the median ADR/patient was 3. Out of 214 ADRs, 91 were serious but there were no ADR-related deaths. The most common ADRs were hypokalemia (31.78%), infusion-related reactions (22.43%), and anemia (17.29%). Thirty-three patients had serum potassium <2.5 mEq/L, while 11 had serum magnesium <1.25 mg/dL. Doubling of pretreatment creatinine level was noted in 15 patients. Seventy percent ADRs were of “possible” category as per the World Health Organization Uppsala Monitoring Centre categorization. CONCLUSION: AmphoB deoxycholate use in mucormycosis patients was associated with a high incidence of electrolyte abnormalities and infusion-related reactions. All ADRs subsided with medical management and none were fatal. The safety data generated from this study may be useful in resource-limited settings where the far more expensive liposomal formulation is not being used.
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Evaluation of mechanism(s) of action underlying the antioxidant and antiulcer activity of Sesamum indicum leaves extract in experimental rats
Shivam , Phool Chandra, Neetu Sachan
November-December 2022, 54(6):423-430
OBJECTIVE: The current study aimed to estimate phytochemical screening, in vitro antioxidant activity, and gastroprotective activity of Sesamum indicum Linn ethanolic extract. MATERIALS AND METHODS: The current study was held out by ulceration induced by pylorus ligation and indomethacin-induced ulcer screening models in Wister albino rats. The screening of antiulcer activity of ethanolic extract of S. indicum leaves (EESIL) at the different amounts (100, 200, and 400 mg/kg; per orally for 7 days) was compared with omeprazole as a usual antiulcer drug. Additional parameters such as gastric content, pH, total acidity, pepsin activity ulcer score, free acidity, ulcer index (UI), % inhibition of ulcers, mean mucin, pepsin content, and total protein content were observed. RESULTS: In the pylorus ligation model, the pepsin activity free acidity, pepsin content, UI, total acidity, ulcer score, total protein content, and percentage ulcer inhibition were considerably decreased (P < 0.05 and P < 0.01), and mean mucin and gastric content pH extensively elevated (P < 0.05 and P < 0.01) in EESIL tested groups in the comparison of the control group. Doses (100, 200, and 400 mg/kg p.o.) of EESIL showed dose-reliant gastro protective outcomes, a considerable (P < 0.05 and P < 0.01) decrease in gastric parameters as UI and ulcer score and induction in gastric pH and percentage inhibition of ulcer compared with the control group. CONCLUSION: Antioxidant, anti-Ulcer, EESIL, and EESIL show antioxidant activity at different concentration. The fallout of the study indicated that the EESIL had improved antiulcer potential due to the decrease in offensive factors and increase in defensive factors.
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Paxlovid: A promising drug for the challenging treatment of SARS-COV-2 in the pandemic era
Niraj Niraj, Sonia Shinde Mahajan, Ajay Prakash, Phulen Sarma, Bikash Medhi
November-December 2022, 54(6):452-458
Coronavirus infection is a pandemic threat and the most dangerous disease of the 21st century. Despite the rigorous exertion of world-class researchers, there is no perfect cure for it. It has been seen in presently available studies that Paxlovid prevents the progression of diseases and reduces severity in patients tremendously who are at high risk of hospitalization and death. It is a safe oral antiviral drug and has the potential to treat infections from multiple corona variants including omicron which affects humans. Paxlovid is comparatively less expensive than other available effective medicines. Consequently, it reduces hospitalization and death and helps to plummet the economic burden on patients and the health-care system globally. This medicine is still under investigation, and numerous clinical trials are still underway. Its potential side effects are minor and well tolerated by research study participants. Studies show its benefits outweigh the risk, and it is an effective and good alternative for the treatment of coronavirus disease.
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Baboon syndrome with lactulose: An apparently inert drug causing a systemic reaction
Diksha Agrawal, Pooja Arora
November-December 2022, 54(6):464-465
  739 86 -
An idiosyncratic reaction of unilateral common peroneal nerve palsy associated with below desired therapeutic range of tacrolimus level in a patient postheart transplantation
Ayush Srivastava, P Ansuman Abhisek, Shweta Supriya Pradhan
November-December 2022, 54(6):459-461
Tacrolimus (TAC) is a very effective medication in routine use after solid organ transplantation. The potential, but infrequently reported neurological adverse effect of TAC is peripheral neuropathy (PN). This has rarely been reported in heart transplant patients. To the best of our knowledge, the data regarding mononeuropathy of common peroneal nerve presented with foot drop due to low whole blood trough TAC level are very limited in the early days postheart transplantation. An idiosyncratic reaction might be suspected in the early postoperative period, when the whole blood trough levels of TAC fall below or within the desired therapeutic range associated with any adverse events after ruling out other causes. We report a 21-year-old patient, who underwent heart transplantation after a suitable donor was identified, and presented with a new-onset right side foot drop on the 10th postoperative day. According to the WHO-Uppsala Monitoring Center causality assessment scale, the likely culprit agent is TAC. Rapid and progressive improvement of foot drop occurred after stopping it and changed over to cyclosporine.
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Virtual screening and molecular dynamics simulation study of approved drugs as a binder to the linoleic acid binding site on spike protein of SARS-CoV-2 and double mutant (E484Q and L452R)
Manisha Prajapat, Phulen Sarma, Nishant Shekhar, Arushi Chauhan, Gurjeet Kaur, Anusuya Bhattacharyya, Pramod Avti, Gajendra Choudhary, Seema Bansal, Saurabh Sharma, Hardeep Kaur, Subodh Kumar, Harvinder Mann, Anupam Raja, Ashutosh Singh, Rahul Singh, Amit Raj Sharma, Ajay Prakash, Bikash Medhi
November-December 2022, 54(6):431-442
INTRODUCTION: Binding of linoleic acid (LA) to the spike trimer stabilizes it in closed conformation hindering its binding to angiotensin-converting enzyme-2, thus decreasing infectivity. In the current study, we tend to repurpose Food and Drug Administration-approved drugs as binder to the LA binding pocket in wild and double mutant spike protein. MATERIALS AND METHODS: Approved drugs from DrugBank database (n = 2456) were prepared using Ligprep module of Schrodinger. Crystal structure of LA bound to spike trimer was retrieved (PDB: 6ZB4) and prepared using protein preparation wizard and grid was generated. A virtual screening was performed. With the help of molecular dynamics (MD) studies interaction profile of screened drugs were further evaluated. The selected hits were further evaluated for binding to the double mutant form of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). RESULTS AND DISCUSSION: Following virtual screening, a total of 26 molecules were shortlisted, which were further evaluated using 1ns MD simulation study. Four ligands showing better root mean square deviation (RMSD), RMSD to LA with interaction profile similar to LA were further evaluated using 100 ns MD simulation studies. A total of 2 hits were identified, which performed better than LA (selexipag and pralatrexate). Both these ligands were also found to bind to LA binding site of the double mutant form (E484Q and L452R); however, the binding affinity of pralatrexate was found to be better. CONCLUSION: We have identified 2 ligands (selexipag and pralatrexate) as possible stable binders to the LA binding site in spike trimer (wild and mutant form). Among them, pralatrexate has shown in vitro activity against SARS-CoV-2, validating our study results.
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Intradermal versus intramuscular COVID-19 vaccination aiming at protection for delta variant: cost utility analysis
Rujittika Mungmunpuntipantip, Viroj Wiwanitkit
November-December 2022, 54(6):462-463
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