A case of carbamazepine-induced vitamin B12 deficiency and neuropathy

Drug induced Neuropathy is seen commonly in patients undergoing treatment with drugs like phenytoin, dapsone, isoniazid etc. Carbamazepine is a drug used in the treatment in the treatment of focal seizure, generalized tonic - clonic seizure and trigeminal neuralgia. It is presented a case of carbamazepine induced vitamin B12 deficiency and neuropathy. A 21 year old male presented to our hospital with complaints of history of slipping of footwear while walking, numbness, impairment of balance and unsteadiness of gait in both lower limbs. Detailed history revealed the patient was on treatment with carbamazepine for tonic - clonic seizure for three months. He is non- smoker, non -alcoholic, not on treatment with other drugs and there is no family history of diabetes mellitus/ sensory neuropathy. On examination power was normal on both lower limbs, vibration sensation was decreased in both lower limbs, sensation was reduced, joint position was affected in bilateral toe and ankle reflex was absent. Vitamin B12 level was found to be 83pg/ml. The patient was discontinued from carbamazepine and started on vitamin B12 therapy and the symptoms subsides slowly. Causality assessment done by WHO- UMC probability method and Naranjo Adverse Drug Reactions Probability Scale showed “Probable” association

Unveiling supply chain efficiency: exploring ABC-VED analysis studies on drug inventory management in India

About one-third of annual hospital budget is spent on buying materials and supplies including medicines. In any health facility, be it small health center or a big teaching institution, drugs forms an essential and indispensable element. Non-availability of drugs particularly in the developing countries is due to lack of proper material management. A poor management in a public pharmaceutical supply can result in wastage or blockade of financial resources, irrational utilization of drugs, shortage or overage of essential drugs, increased holding cost, and reduction in flexibility and decline in quality of health care services. Adaptation of a scientific approach of inventory management in healthcare manages all the issues regarding stocking of pharmaceutical items, ensuring safety, stability, efficacy, availability and maintenance of quality of drugs to provide better healthcare services. This review will focus on inventory management and its importance with special emphasis on always better control-vital, essential, desirable (ABC-VED) analysis technique on essential medicine concept and report of various research studies conducted on ABC-VED analysis in different parts of country

WHO AWaRe strategy and antimicrobial stewardship to combat antimicrobial resistance: An Indian perspective

Antimicrobial resistance is a serious problem to solve especially in developing countries like India. Antibiotic use in India increased several times since 2005. Many studies in India have reported inappropriate and overuse of antibiotics which could be one of the possible reasons for increased antibiotic resistance in the country. This is an important and urgent issue that mandates strict regulations regarding the rational use of antibiotics. World Health Organization (WHO) has done a major revision to the essential medicines list which classifies antibiotics into three categories (access, watch, and reserve) to ensure the availability and correct use of antibiotics. Several countries started antimicrobial stewardship programs to promote appropriate use of antibiotics, reduce antibiotic resistance as well a financial burden. Indian government started a national action plan on antibiotic resistance in 2017 to promote the rational use of antibiotics but it is still in its formative stage as all stewardship components are yet to be implemented. This review emphasizes the importance and the need for implementing WHO’s AWaRe strategy and antimicrobial stewardship to promote rational antibiotic use in the country

Influence of SLC22A1 gene polymorphisms on gastrointestinal adverse effects with metformin therapy in South Indian type 2 diabetes mellitus patients

Background: Metformin, a first-line agent in Type 2 diabetes mellitus, causes gastrointestinal adverse effects in 20-30% of patients, leading to discontinuation in 5-10% of them. Organic cation transporter 1 (OCT1) encoded by SLC22A1, transports metformin from the enterocytes into the bloodstream. Reduced function OCT1 variants could lead to increased luminal concentration of metformin leading to gastrointestinal adverse effects. Two single nucleotide polymorphisms in the SLC22A1 gene were studied in this cross-sectional study with cases and controls. Objective was to determine the association between genetic polymorphisms rs628031 (1222A>G) and rs622342 (1386C>A) in SLC22A1 gene and gastrointestinal adverse effects to metformin therapy in South Indian type 2 diabetes mellitus patients. Methods: The study was conducted in JIPMER, Puducherry, India in T2DM patients (n=300) of South Indian origin, who were categorized into case (N=100) and control (N=200) groups, based on their gastrointestinal tolerance to metformin. DNA was extracted from the patients using whole blood by phenol-chloroform method and genotyping was done using real-time PCR. Results: Minor allele frequency of rs628031 (A allele) and rs622342 (C allele) were 33.8% and 26.5% respectively. Genotype frequencies did not differ significantly between the case and control groups (rs628031, p=0.45, rs622342, p=0.28). Female gender (AOR 3.77; 95% CI 2.07, 6.85; p<0.001) and proton pump inhibitor usage (AOR 7.66; 95% CI 3.01, 19.47; p<0.001) had higher association with metformin intolerance. Conclusions: No significant association was found between the genotypes of single nucleotide polymorphisms (rs628031 and rs622342) in the SLC22A1 gene and gastrointestinal adverse effects to metformin therapy in South Indian type 2 diabetes mellitus patients

Effect of saroglitazar in South Indian patients with diabetic dyslipidemia uncontrolled on a moderate-intensity statin and the association of PPAR α and γ gene polymorphisms with its response

Background: Diabetic dyslipidemia is associated with atherosclerosis risk factors and cardiovascular disease. Saroglitazar is a dual PPAR α and γ agonist approved initially for diabetic dyslipidemia and later for managing non-alcoholic steatohepatitis and hyperglycemia in T2DM. This study was conducted to estimate the association of studied PPAR α and γ gene polymorphisms among patients with diabetic dyslipidemia at baseline and with triglyceride response to saroglitazar administration. Methods: A total of 54 diabetic dyslipidemia patients who are not controlled i.e., triglycerides (TG)>200 mg/dl with moderate intensity of atorvastatin (≥10 mg) were recruited to the study. All the patients were given saroglitazar 4 mg once daily for 12 weeks. PPARα single nucleotide polymorphisms (SNPs) rs1800206, rs4253778, rs135542 and those of PPARγ gene rs3856806, rs10865710, rs1805192 were genotyped by real-time PCR. Results: 54 patients (67% female) with a mean age of 48.01±6.73 years were given saroglitazar 4 mg once daily for 12 weeks. There was a significant decrease in TG (36.9%) from baseline of 292.33±83.81mg/dl (mean±SD) to 184.46±95.90 mg/dl (<0.001) and in HbA1c (0.66%) from baseline of 8.5% to 7.8% (<0.001). PPAR α and PPAR γ gene variants did not show any association with TG lowering response. Conclusions: Saroglitazar 4mg once daily effectively decreases the TG, non-HDL-C levels, and HbA1c with no major adverse events, and TG lowering response is not associated with the studied polymorphisms.

Identifying the Most Effective Essential Medicines Policies for Quality use of Medicines: A Replicability Study Using Three World Health Organisation Data-sets

Suboptimal (irrational, incorrect, inappropriate) use of medicines is widespread, wasteful, and causes poor patient outcomes including anti-microbial drug resistance [1–9]. Interventions to improve quality use of medicines (QUM) in low/middle-income countries have mostly been small-scale, of limited duration, with small to modest effects [10–11]. Evidence from studies that we conducted in public healthcare sectors in developing and transitional countries suggests that implementation of WHO essential medicines (EM) policies is associated with better quality use (rational use) of medicines (QUM), including more appropriate use of anti-microbial agents [12–14]. The original WHO global data-set [12] covered the period 2003–2007 and there was uncertainty about how well EM policies were executed (based on country self-reports), with simultaneous deployment of multiple policies making it difficult to estimate individual impacts. We accessed a second source of data collected during 2-week visits to countries in South-East Asia during 2010–15, where policy implementation was observed independently [14]. The analyses of these data confirmed several of the findings of the earlier studies [12–13], including a correlation between the total numbers of EM policies implemented and composite measures of QUM. However, it remains unclear which policies are associated with the largest beneficial effects on medicines use. The aims of the present work were to analyse an updated global WHO data-set (2007– 2011), which included some policies not previously evaluated, and to test the consistency of our earlier findings of an increased impact with larger numbers of implemented EM policies. In addition, we wished to assess replicability of findings by correlating the rankings of policies that were common to the three studies to determine whether certain policies were consistently associated with the largest effects

WHO AWaRe strategy and antimicrobial stewardship to combat antimicrobial resistance: An Indian perspective

Antimicrobial resistance is a serious problem to solve especially in developing countries like India. Antibiotic use in India increased several times since 2005. Many studies in India have reported inappropriate and overuse of antibiotics which could be one of the possible reasons for increased antibiotic resistance in country. This is an important and urgent issue that mandate strict regulations regarding rational use of antibiotics. World Health Organization (WHO) has done major revision in essential medicines list which classify antibiotics in three categories (access, watch and reserve) to ensure the availability and correct use of antibiotics. Several countries started antimicrobial stewardship programme to promote appropriate use of antibiotics, reduce antibiotic resistance as well as financial burden. Indian government implemented national action plan on antibiotic resistance in 2017 with the aim of prompting rational use of antibiotics but it is still in its formative stage as all stewardship components are yet to be implemented. This review emphasizes on the importance and the need for implementing WHO’s AWaRe classification and antimicrobial stewardship to promote rational antibiotic use in country.</jats:p