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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 11 | Issue 2
Page Nos. 35-85

Online since Wednesday, October 21, 2020

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REVIEW ARTICLE  

Linagliptin: Cardiovascular and renal safety beyond doubt at a steep price p. 35
Shubham Atal, Zeenat Fatima, Sadasivam Balakrishnan, Rajnish Joshi
DOI:10.4103/jpp.JPP_10_20  
Dipeptidyl peptidase-IV inhibitors or “gliptins” are commonly used oral anti-diabetic drugs for Type 2 diabetes mellitus, preferred as add-on therapy after metformin. Various cardiovascular outcome trials (CVOTs) have established their cardiovascular safety. Approved later than other gliptins, linagliptin has unique pharmacokinetic profile. A literature review was performed by searching science databases, in addition to the Medline database via PubMed, for relevant articles. The search included meta-analyses, systematic reviews, review articles, and randomized and nonrandomized trials. Related publications in the English language were reviewed, and the most relevant papers were summarized. This review explores the potential of clinical use of this drug in light of the two recently reported CVOTs, and cost of therapy. Results of CAROLINA and CARMELINA, published in 2019 and 2018, respectively, provide robust proof of long-term CV and renal safety of linagliptin. Both trials are first of their kinds for including diabetes population with renal compromise and use of an active comparator, respectively. Physicians can confidently choose in subsets of adults with diabetes who have compromised renal or cardiac functions or who are at high risk without any dose adjustments. However, the price of the drug is very high, costlier than other oral drugs. Cost remains the biggest hurdle and is likely to remain so with the drug being patent protected for a considerable time in future. Thus, despite the promise of CV and renal safety, linagliptin is likely to remain out of reach for majority of the Indian population with diabetes.
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RESEARCH PAPERS Top

Curcumin improves the behavior and memory in mice by modulating the core circadian genes and their associated micro-RNAs p. 44
Dhondup Namgyal, Kumari Chandan, Sher Ali, Rachna Mehta, Maryam Sarwat
DOI:10.4103/jpp.JPP_86_20  
Objective: To investigate the neuroprotective effects of curcumin in albino mice focusing on memory and behavior. Materials and Methods: Four groups of 7 mice each, different concentrations of curcumin were administered for 3 weeks in 3 groups and the remaining group was kept as control. The effect of curcumin on behavior and memory was studied using various tests. The expression of core circadian rhythm genes and micro RNAs were also studied. Results: Our results revealed that curcumin improves the mice's behavior by regulating oxidative stress, hippocampal neurogenesis, and modulation of core circadian genes and their associated micro-RNA. Conclusion: This study shows that curcumin has a potential neuroprotective effect.
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Potentially inappropriate medications in indian geriatric patients visiting out-patient departments of tertiary care teaching hospital p. 53
Maulik M Patel, Andrew S Mark, Varsha J Patel
DOI:10.4103/jpp.JPP_16_20  
Aim: To investigate the prevalence of potentially inappropriate medications (PIMs) identified by the American Geriatrics Society Beers 2019 criteria in geriatric patients in India. Materials and Methods: This cross-sectional study was conducted between October 2018 and October 2019 in the tertiary care teaching hospital of the Gujarat state, India. Patients of either sex attending outpatient departments of age 65 years and above were included. Data including age, gender, department, relevant laboratory investigations, prescribed drugs, dosages, and duration was recorded in the Case Record Form. PIMs identified as per 2019 Beers criteria and analyzed. The association between age, gender, polypharmacy and encounter of PIMs was analyzed. Results: A total of 306 patients were analyzed. Mean age of patients was 69.43 (standard deviation = 5.47) years and 185 (60.46%) were male. At least one PIM was prescribed in 46% (140) patients. Two or more PIMs were prescribed in 18.6% of patients. The most frequent PIMs independent of diagnosis and condition (Criteria 1) were first-generation antihistaminics 25.7%, skeletal muscle relaxants 21% and sulfonylureas (glimepiride) 17.4%. The most common drugs to be used with caution (Criterion 3) included tramadol 50.75%, diuretics 25.4%, and antipsychotics 13.5%. Patients who were on polypharmacy were at significantly high (P < 0.001) risk of PIM use with an adjusted odds ratio 4.864 (95% confidence interval: 2.95–8.03). Conclusion: Our study showed a high prevalence of PIMs use in Indian geriatric patients. There was an association between inappropriate medication use and polypharmacy.
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Assessment of adverse drug reactions in patients on cardiovascular drugs: A prospective study p. 59
C Sneha, HV Anuradha, Ashok Karthik
DOI:10.4103/jpp.JPP_106_19  
Objectiv: To quantify ADRs in patients on cardiovascular drugs and to assess their severity. Materials and Methods: Based on inclusion and exclusion criteria, 265 inpatients on cardiovascular drugs from a tertiary care center were included in this prospective study. All patients were assessed for occurrence of ADR and followed up till the recovery of the ADR. Causality assessment of ADR was done, severity of ADR was graded, and preventability of ADR was assessed. Results: In the present study, descriptive statistics were used to analyze the data. Out of 265 patients screened, 137 (51.69%) had 245 ADRs. About 175 (71%) ADRs were due to antihypertensives, 175 (71%). On causality assessment of these ADRs, 230 (94%) were found to be possible and 15 (6%) probable. Two hundred and nine (85%) ADRs were mild, 34 (14%) were moderate, and 2 (1%) were severe. The most common ADR encountered in the study was giddiness due to various classes of antihypertensives in 26% about patients. Conclusions: Among the cardiovascular system drugs, antihypertensives were the most common group of drugs to cause giddiness as ADR. Majority of the ADRs had a score of “possible” because of concomitant medications.
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Factors driving self-medication with antimicrobials in Karaikal, Puducherry, India p. 64
Devashree Moktan, Syed Ilyas Shehnaz
DOI:10.4103/jpp.JPP_21_20  
Aims: To determine factors driving individuals to self medicate with antimicrobials and to ascertain the prevalence and practice of consumption of nonprescribed antimicrobials in Karaikal district of union territory of Puducherry, India. Materials and Methods: A structured, validated questionnaire was used to collect data from 504 patients and their relatives visiting the General Hospital, Karaikal. A picture containing a collage of various commonly purchased antimicrobials were shown to the participants to help them recall their SMA in the past 6 months. Data analysis was performed using SPSS version 25. Bivariate and multivariate logistic regressions revealed factors affecting SMA. Results: One-third of the participants (33.9%) reported SMA in past 6 months with prevalence significantly affected by male gender (adjusted odds ratio [OR] = 1.83; 95% confidence interval [CI]: 1.2–2.79), a preference for SMA during minor illnesses (adjusted OR = 3.05; 95% CI: 1.77–5.25) and a history of SMA among family members (adjusted OR = 3.43; 95% CI: 2.16–5.43). The most commonly self-prescribed drug was amoxicillin (55.2%) and the antimicrobials were mostly obtained from pharmacies (91.8%). Self-prescribed antimicrobials were commonly used to treat cold, cough, and fever. Our participants had self-medicated with antimicrobials because they found it easier to do so (32.2%) and as it saved them time (35.7%) and money (32.2%). Conclusions: The prevalence of SMA was found to be high in Karaikal. This misuse of antimicrobials can be lowered by approaching societal-cultural practices through community education, the supply-demand chain through stricter regulations of pharmacies, and enforcing health policies for rational use of antimicrobials.
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CASE REPORTS Top

Valproic acid-induced normal pressure hydrocephalus in a tertiary care hospital p. 72
Samriddhi Kamath, Veena Venugopal, Kanav Khera, KN Shivashankar, B Athira
DOI:10.4103/jpp.JPP_111_19  
Behavioral and psychological symptoms of dementia (BPSD) are a common psychological disorder in the geriatric population with dementia. The causes and risk factors are multiple, and they include biological, psychological, and environmental variables. The combination of these symptoms, rather than any specific factor, explains the occurrence of BPSD in an individual patient. Treatment is targeted to a specific symptom; anticonvulsants such as valproic acid (VPA), carbamazepine, and anti-psychotics have been used to treat agitation in elderly patients. Atypical antipsychotics are used to treat psychosis, and Selective Serotonin Reuptake inhibitors are used to treat depression and anxiety. VPA is dosed using the weight-based dosing approach, which is usually found to be very safe and effective in elderly patients. However, in certain cases, it has also been known to produce reversible neurological symptoms such as dementia, altered sensorium, psychological disturbances, and normal pressure hydrocephalus (NPH) on its prolonged use. The present case report is unique as we identified that an elderly patient with a history hypertension, type 2 Diabetes and asthma, and BPSD was diagnosed with NPH after a short-term treatment with Divalproex sodium-125 mg which is once daily which was added on to his on-going therapy to better control his symptoms.
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Ticagrelor-Induced complete heart block: A rare entity p. 75
Wagle Varun Anand, Isha khadke, R Padmakumar, M Sudhakar Rao, Bharti Chogtu
DOI:10.4103/jpp.JPP_121_19  
Ticagrelor, a purinergic P2Y12 receptor blocker, is a potent platelet antagonist and an important component in the treatment for acute coronary syndromes identified to have a potential risk to cause bradyarrhythmias. Here, we report the case of a diabetic patient of unstable angina with left bundle branch block who was prescribed ticagrelor post angioplasty. Electrocardiogram (ECG) revealed a complete heart block after about 1 week. Ticagrelor was stopped and replaced by clopidogrel. The patient became asymptomatic and ECG showed baseline rhythm after 1 week of stoppage of ticagrelor.
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Intra-arterial nimodipine combined with intra-arterial milrinone for the treatment of cerebral vasospasm following subarachnoid hemorrhage p. 78
Jina Raj, Vysakh Visweswaran, Remya Reghu, NR Sreehari
DOI:10.4103/jpp.JPP_65_20  
Cerebral vasospasm is a potentially devastating complication of subarachnoid hemorrhage (SAH) associated with substantial morbidity and mortality. Although various studies have separately examined the use of intra-arterial nimodipine and intra-arterial milrinone for the treatment of delayed cerebral vasospasm in SAH, information regarding the use of the modality combining the two treatments is scarce. This is the case of a 44 year old female patient who developed cerebral vasospasm due to the rupture of a left internal carotid artery at the level of anterior choroidal saccular aneurysm. Patients were treated with intra-arterial nimodipine 5 mg, followed by a total milrinone dose of 18 mg into the vasospastic territories preoperatively to facilitate catheter access for coiling with controlled infusion. The angiographic spasm recovered well and aneurysm coiling was done. The patient was stable throughout the hospital course and was discharged in stable condition. Intra-arterial nimodipine along with milrinone was found to be effective in this case with severe cerebral vasospasm preoperatively which is rarely reported in the literature.
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Hypersensitivity to aerosol spray dressing p. 81
Isha Khadke, Navin Patil, Nishanth Ampar, Shalini Adiga, Shyamasunder N Bhat
DOI:10.4103/jpp.JPP_41_20  
We report case of a 12-year-old girl who had undergone surgical correction for Lenke's Type 1A right-sided adolescent idiopathic scoliosis in the spine unit of our hospital. Postoperatively, secondary suturing was required due to wound dehiscence. After the secondary suturing, an aerosol spray dressing in the form of polyvinyl polymer 2.52% w/w + benzocaine 0.36% w/w + cetrimide 0.50% w/w + propellant solvent 100% w/w was applied topically on the day of discharge. On the same day at home, the patient developed a hypersensitivity reaction in the form of erythema, rash, and blebs at the site of application along the suture line and adjacent areas. It was diagnosed as a hypersensitivity reaction to the aerosol dressing spray. The patient was started on tablet prednisolone 10 mg TID tapered over a period of 9 days with topical fusidic acid and Betnesol® ointment. She recovered in about 10-12 days and had uneventful further followups in the clinic.
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RESEARCH LETTER Top

Assessment of adverse drug reactions, severity, preventability status, and its determinants among inpatients in tertiary care hospitals in South India p. 83
Nitin Joseph, SM Rakshitha, Diksha Shankar Partunor, Naisargi Bhaveshkumar Bhayani, SD Tejas, S Mallik Mujawar
DOI:10.4103/jpp.JPP_74_20  
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