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   2016| April-June  | Volume 7 | Issue 2  
    Online since June 28, 2016

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L-asparaginase in the treatment of patients with acute lymphoblastic leukemia
Rachel A Egler, Sanjay P Ahuja, Yousif Matloub
April-June 2016, 7(2):62-71
DOI:10.4103/0976-500X.184769  PMID:27440950
Acute lymphoblastic leukemia (ALL) is a hematologic malignancy that predominantly occurs in children between 2 and 10 years of age. L-asparaginase is an integral component of treatment for patients with ALL and since its introduction into pediatric treatment protocols in the 1960s, survival rates in children have progressively risen to nearly 90%. Outcomes for adolescent and young adult (AYA) patients, aged 15-39 years and diagnosed with ALL, have historically been less favorable. However, recent reports suggest substantially increased survival in AYA patients treated on pediatric-inspired protocols that include a greater cumulative dose of asparaginase. All  currently available asparaginases share the same mechanism of action - the deamination and depletion of serum asparagine levels - yet each displays a markedly different pharmacokinetic profile. Pegylated asparaginase derived from the bacterium Escherichia coli is used as first-line therapy; however, up to 30% of patients develop a treatment-limiting hypersensitivity reaction. Patients who experience a hypersensitivity reaction to an E. coli-derived asparaginase can continue treatment with Erwinia chrysanthemi asparaginase. Erwinia asparaginase is immunologically distinct from E. coli-derived asparaginases and exhibits no cross-reactivity. Studies have shown that with adequate dosing, therapeutic levels of Erwinia asparaginase activity can be achieved, and patients switched to Erwinia asparaginase due to hypersensitivity can obtain outcomes similar to patients who do not experience a hypersensitivity reaction. Therapeutic drug monitoring may be required to ensure that therapeutic levels of asparaginase activity are maintained.
  8,664 2,108 22
Warfarin and phenytoin drug interaction with possible purple glove syndrome
Carolyn S Hunter, Stephanie V Phan
April-June 2016, 7(2):96-98
DOI:10.4103/0976-500X.184774  PMID:27440955
Though the impact of phenytoin on warfarin has been reported to potentiate the anticoagulant effect or interact in a biphasic manner, the effect of phenytoin on warfarin appears to be unpredictable and dependent upon multiple factors. Additionally, purple glove syndrome has rarely been reported secondary to therapeutic doses of oral phenytoin. We report on the case of a patient who experienced international normalized ratio (INR) fluctuations upon initiation of warfarin and phenytoin concurrently and who subsequently required discontinuation of therapeutic-dose phenytoin secondary to possible purple glove syndrome.
  5,955 564 1
Expedited drug review process: Fast, but flawed
Krishnan Vengadaraga Chary
April-June 2016, 7(2):57-61
DOI:10.4103/0976-500X.184768  PMID:27440949
  3,075 736 3
Factors influencing adherence to anti-craving medications and drinking outcomes in patients with alcohol dependence: A hospital-based study
K Lohit, Chanda Kulkarni, RB Galgali
April-June 2016, 7(2):72-79
DOI:10.4103/0976-500X.184770  PMID:27440951
Objective: To examine the factors influencing the pattern and extent of anti-craving medication adherence and drinking outcomes in alcohol-dependent patients. Materials and Methods: Demographic data from 102 inpatients were collected at discharge from hospital. The pattern of anti-craving medication, extent of adherence, and drinking outcome was collected at 1 st , 3 rd , 8 th , and 12 th week follow-up. Patients' self-reported adherence, medication diary, and simplified medication adherence questionnaire were used and data were analyzed using SPSS. Results: Majority (99%) were male patients with a mean age of 41.17 ± 9.86 years and 70% belonged to middle socioeconomic status. There was a decrease in the number of patients coming for follow-up over time from 99.01% to 77.45% on day 90. Acamprosate was used in 74% and naltrexone and disulfiram in 7% of patients each. A significant reduction in adherence to acamprosate and naltrexone (P < 0.001) was associated with simultaneous decrease in days to alcohol abstinence and increase in relapse rate compared to adherent group (P < 0.001). Main barriers to adherence included younger age (odds ratio = 1.05 95% [1.01-1.09]; P < 0.01), self-decision, emotional factors, and adverse effects. Conclusions: The study demonstrated the need for safer therapeutic options along with suitable intervention at "grass root level" for sustenance of adherence to anti-craving medication among young adults to prevent relapse and achieve near-complete abstinence from alcohol dependence.
  3,112 609 1
A new mathematical approach to methadone conversion
Steven J Baumrucker, Manar Jbara, Richard Marc Rogers
April-June 2016, 7(2):93-95
DOI:10.4103/0976-500X.184773  PMID:27440954
  3,172 499 -
Effect of losartan and atenolol on insulin sensitivity in nondiabetic hypertensive patients
Sandesh Madhukar Bharati, Nishith Singh
April-June 2016, 7(2):80-86
DOI:10.4103/0976-500X.184771  PMID:27440952
Objective: To study the effects of losartan and atenolol on glucometabolic parameters in nondiabetic hypertensive patients. Materials and Methods: In a prospective, open-label, parallel group study, nondiabetic patients with mild to moderate hypertension were randomized to either losartan (titrated from 50 to 100 mg/day, n = 20) or atenolol (titrated from 25 mg to 100 mg/day, n = 20) for period of 24 weeks. At baseline, 12 and 24 weeks fasting plasma glucose (FPG), fasting plasma insulin (FPI), homeostasis model assessment for insulin resistance (HOMA-IR) apart from lipid parameters, mean systolic, and diastolic blood pressures levels were determined. Results: At the end of study, losartan significantly (P < 0.05) reduced FPG, FPI, and HOMA-IR compared to atenolol and baseline. While atenolol increased the HOMA-IR levels significantly compared to the baseline. Conclusions: Losartan improved the insulin sensitivity while atenolol worsened it. Losartan is better than atenolol for its effects on the glucose-insulin metabolism.
  2,785 709 1
Is the peripheral arterial disease in low risk type 2 diabetic patients influenced by body mass index, lipidemic control, and statins?
Jayesh Dalpatbhai Solanki, Amit H Makwana, Hemant B Mehta, Pradnya A Gokhale, Chinmay J Shah
April-June 2016, 7(2):87-92
DOI:10.4103/0976-500X.184772  PMID:27440953
Objective: To correlate BMI, lipidemic control, and statin therapy with PAD measured by ABI in low risk type 2 diabetics. Materials and Methods: A sample of 101 nonsmoking, asymptomatic type 2 diabetics (50 males, 51 females) with known glycemic (fasting blood sugar, postprandial blood sugar, glycosylated hemoglobin) and lipidemic (total cholesterol, lipoproteins, and triglycerides [TGAs]) control was taken. Vascular Doppler was used to derive ABI and PAD was defined as ABI <0.9. ABI values were compared amongst groups and P < 0.05 was considered statistically significant. Results: We found fairly good lipid but poor glycemic control and prevalence of PAD 30%. There was insignificantly low ABI profile in patient having BMI ≥25, hyperlipidemia and absent statin therapy with odds ratio being highest for TGAs ≥150 (3.23) followed by BMI ≥25 (2.61), high-density lipoprotein ≤50 (1.61), low-density lipoprotein ≥100 (1.20), and disuse of statin (1.14) with significance only for BMI. Conclusion: We observed small, insignificant PAD risk by dyslipidemia or non-use of statins in low-risk ambulatory T2DM patients, not so by BMI. This suggests importance of good glycemic control, maintenance of optimum weight, and lifestyle modifications as primary prevention rather than opting for costly and inefficient secondary prevention.
  2,783 436 1
Fixed drug eruption due to levocetirizine
Ratinder Jhaj, Dinesh Prasad Asati, Deepa Chaudhary
April-June 2016, 7(2):109-111
DOI:10.4103/0976-500X.184778  PMID:27440959
A fixed drug eruption (FDE) is a cutaneous adverse drug reaction due to Type IV or delayed cell-mediated hypersensitivity. Antihistamines, which antagonize the action of histamine during an allergic reaction by blocking the H 1 histamine receptors, are used routinely for the treatment of various allergic disorders such as urticaria, eczemas, and also in itchy lesions of skin like scabies.Levocetirizine, an active (R)-enantiomer of cetirizine, is a newer or second generation antihistamine, with more specific actions and fewer side effects, including cutaneous reactions. FDE due to levocetirizine as well as with cetirizine are rare. We report a case of levocetirizine induced FDE in a 49-year-old male patient with scabies. The patient had a history of cetirizine induced FDE in the past.
  2,655 476 2
A case of figurate urticaria by etanercept
Maurizio Sessa, Maria Giuseppa Sullo, Annamaria Mascolo, Daniela Cimmaruta, Francesca Romano, Rosa Valentina Puca, Annalisa Capuano, Francesco Rossi, Ada Lo Schiavo
April-June 2016, 7(2):106-108
DOI:10.4103/0976-500X.184777  PMID:27440958
Etanercept is a competitive inhibitor of tumor necrosis factor-alpha (TNF-α) a polypeptide hormone, involved in the development of the immune system, in host defense and immune surveillance. Even if the etanercept mechanism of action is not completely understood, it is supposed that it negatively modulates biological responses mediated by molecules (cytokines, adhesion molecules, or proteinases) induced or regulated by TNF. For this reason, it is widely used in the treatment of immunologicals diseases, such as rheumatoid and psoriatic arthritis, polyarticular juvenile idiopathic active, ankylosing spondylitis, and plaque psoriasis. Etanercept has a good tolerability profile. Adverse events related to skin are rare, arising usually in about 5% of patients treated with anti-TNF α. In this scenario, we describe a case of figurate urticaria arose after the re-administration of etanercept in a patient affected by psoriasis and hepatitis B. A 65-year-old man, affected by psoriasis, was hospitalized in September 2014 to the Regional Center for the treatment of psoriasis and Biological Drugs of Second University of Naples for progressive extension of psoriatic skin lesions. The laboratory analysis detected positivity for hepatitis B virus (HBV) antigens. For this reason, it was administered to him lamivudine 100 mg/die about 30 days before to start etanercept treatment. The etanercept therapy has resulted in a progressive improving of skin manifestations, and the patient decided individually to stop the therapy. Afterwards, for worsening of the psoriatic lesions, he was again hospitalized and treated with the same therapeutic schedule (lamivudine followed by etanercept). Ten days after the start of therapy, the patient showed the onset of urticarial rash. Due to this, the treatment with lamivudine and etanercept was suspended and the patient's clinical conditions improved. It is probably that immunological disorders due to etanercept therapy and HBV infection could explain the onset of figurate urticaria in our patient. In this contest, the post-marketing surveillance confirms its important role in the monitoring of drugs tolerability and effectiveness.
  2,403 400 6
Acute hepatic injury with amphotericin B deoxycholate in an immunocompetent patient
Jamie L Wagner, Allison M Bell
April-June 2016, 7(2):112-114
DOI:10.4103/0976-500X.184779  PMID:27440960
Amphotericin B deoxycholate (AmBd) is rarely used due to its adverse effect profile, which includes nephrotoxicity, infusion-related reactions, and hepatotoxicity. The incidence of hepatotoxicity related to AmBd is 18-23%, but the reports of this adverse effect are mainly in immunocompromised patients receiving chemotherapy. We report a case of AmBd-related acute hepatic injury in an immunocompetent male with multiple medical problems. The patient initially had acute hepatic injury likely caused by poor nutritional status and a diagnosis of failure to thrive, but was recovering. He was also diagnosed with bilateral renal fungal mycetomas and received systemic treatment initially with micafungin and then fluconazole after urine cultures returned with the growth of Candida glabrata. Therapy was expanded to systemic AmBd when the fungal balls persisted. The patient subsequently developed hepatic re-injury with 1 dose of AmBd, and the therapy was discontinued. Caution should be exerted when utilizing AmBd in treating patients with previous hepatic injury.
  2,193 327 1
An unusual case of glipizide-induced proximal myopathy
Saibal Das, Anand Ramasamy, Soumyadip De, Somnath Mondal
April-June 2016, 7(2):99-101
DOI:10.4103/0976-500X.184775  PMID:27440956
This case report outlines a very rare case of glipizide-induced severe proximal myopathy in a 61-year-old diabetic man. After taking 10 mg glipizide for 5 months, diabetes was well controlled but the patient presented with progressive proximal muscle weakness in all the four limbs. Clinical examination and relevant investigations suggested it to be a case of proximal myopathy and might be drug induced. De-challenge was done and was treated resulting in reversal of the diseased state. After 3 more months, controlled re-challenge was done and there was recurrence of proximal muscle weakness. There were no evidences of any other possible metabolic, infective, organic or other pathologic causes giving rise to that condition and Naranjo adverse drug reaction probability scale suggested that it was "probable" that glipizide was responsible for the development of myopathy in this patient.
  2,082 312 1
QT interval prolongation and torsade de pointes: Synergistic effect of flecainide and H 1 receptor antagonists
Carlos Acosta-Materán, Eloy Díaz-Oliva, Diego Fernández-Rodríguez, Julio Hernández-Afonso
April-June 2016, 7(2):102-105
DOI:10.4103/0976-500X.184776  PMID:27440957
A high percentage of patients having atrial fibrillation (AF) presents with paroxysmal AF. Flecainide, the prototypic class Ic anti-arrhythmic drug is the most effective drug to maintain sinus rhythm in this subgroup of patients, though the drug has potential pro-arrhythmic effects. Furthermore, the H 1 receptor antagonists are the most commonly prescribed drugs for the symptomatic treatment of pruritus. Despite having low number of adverse effects, the H 1 receptor antagonists have cardiotoxic effects. Flecainide and H 1 receptor antagonists present arrhythmic complications including QT interval prolongation and torsade de pointes (TdP). The case presented here is a 65-year-old female who was diagnosed of atrial fibrillation and presented with rashes in lower extremities. The patient was treated using flecainide and H 1 receptor antagonists (loratadine and hydroxyzine) that prolonged QT interval and induced TdP. The concomitant administration of flecainide and H 1 receptor antagonists seems to have a synergistic effect in QT interval prolongation and subsequent TdP. The concurrent administration of H 1 receptor antagonists to patients receiving class Ic anti-arrhythmic drugs should be avoided in order to reduce arrhythmic risk in this population.
  1,045 122 2