Life threatening acute kidney injury in a patient of rheumatoid arthritis, is it drug or disease related?

Even low-dose MTX therapy for treatment of rheumatic diseases is claimed to cause impairment in renal function. We report an insidious and progressive deterioration of renal function of patient with RA on low-dose MTX in a 41-year-old woman. We suggest that patients on low-dose MTX therapy should be periodically monitored for creatinine levels

Prevalence and pattern of self-medication in elderly individuals

Background: Self-medication that is taking medicines without prescription by the doctor is highly prevalence in the community. Elderly population is more likely to self-medicate due to multiple morbidities. This study was undertaken to evaluate the prevalence and pattern of use of self-medication among elderly individuals.Methods: Study was carried out at tertiary care hospital. The questionnaire which was used in our earlier studies regarding self-medication was utilized. After obtaining consent, the elderly individuals (≥60 years) reporting for health check-up were requested to fill up the questionnaire themselves or were asked to respond to questions verbally in the case of illiterate. Questionnaire mainly contained demographic and clinical data and self-medication details - frequency, symptoms/disease for self-medication, drugs, reasons for self-medication, sources of information, awareness regarding the risk of self-medication.Results: Out of 200 elderly included in the study, 177(88.5%) reported self-medication in 6-month recall period. About 60% were male and mean age - 69.64±6.21 (60-85) years. About 21% reported frequent self-medication. Abdominal pain (16%) and headache (14%) were the most common symptoms, and diabetes (7%) was the most common disease for self-medication. Allopathic medicines (55%) mainly paracetamol (13.5%) were most frequently used followed by home remedies (23%) and ayurvedic (17%). Previous experience with the drug (50%) followed by advertisements (23.2%) were common source of information. Most common reasons for self-medication were convenience (69.5%) and cost (56%). None of respondents were aware of risks of self-medicationConclusion: Self-medication is highly prevalent in elderly people who are unaware of risks involved

Comparison of analgesic, anti-inflammatory and anti-pyretic efficacy of diclofenac, paracetamol and their combination in experimental animals

Background: Various combinations of analgesics antipyretic drugs are available in the market for treatment of various musculoskeletal disorders and pain relief. Diclofenac and paracetamol combination is most commonly used combination and its rationality is questionable. The objective of this study was to compare the analgesic, anti-inflammatory and anti-pyretic activities of diclofenac, paracetamol and their combination.Methods: Experimental animals were divided into 4 different groups – control, diclofenac, paracetamol and their combination. Analgesic activity was compared by using tail-clip method in rats and writhing test in mice, anti-inflammatory activity was compared by carrageenan paw edema method using plethysmometer and anti-pyretic action was compared using TAB vaccine induced pyrexia and measuring the rectal temperature. Different doses of diclofenac (1mg/kg and 2mg/kg) and paracetamol (10mg/kg and 20mg/kg) used and same doses were used in combination group.Results: Diclofenac sodium (1mg/kg) showed significantly higher analgesic activity using tail-clip and writhing method compared to paracetamol (10mg/kg) (p<0.0001) and the combination group (p<0.05). Diclofenac sodium (2mg/kg) showed significantly higher analgesic activity using tail-clip and writhing method compared to paracetamol (20mg/kg) (p<0.0001) and the combination group (p<0.1). Diclofenac has no significant difference in anti-inflammatory activity using carrageenan induced paw edema when compared to the combination group (p<0.1) for both doses. But diclofenac when compared to paracetamol for anti-inflammatory effect, it was highly significant (p<0.0001 and p<0.0004) for both doses at 1st and 3rd hour. Paracetamol 20mg/kg was superior antipyretic (p<0.05,0.01 and 0.01 ) when compared to the combination group at 1hr, 2hr and 3hr duration after injecting TAB vaccine.Conclusion: Diclofenac and paracetamol combination was either equal or inferior in all three activities studied as compared to the individual drugs

Survey of use of over the counter drug and other than over the counter drugs among medical students, nursing and technician staff of a tertiary care teaching hospital

Background: To find out pattern and extent of use of OTC and other than OTC drugs among medical students, nursing and technician staff.Methods: Study began after taking permission and approval from Institutional Review Board (IRB). Medical student, nursing and technician staff of tertiary care teaching hospital was enrolled after written informed consent. Pre validated questionnaire regarding use of such use was administered to each participant.Results: A total of 200 participants responded to questionnaire, M:F ratio was 1:1.7. Majority of the participants had taken OTC drugs for cough/cold (72.6%) followed by headache/ body ache (71.1%). Paracetamol (81%) followed by Diclofenac (42.5%), ibuprofen (37.8%) were the most common drugs taken. About 85% participants had taken antimicrobial considering it as an OTC product. Most commonly used antimicrobials were metronidazole (19.4%) followed by levofloxacin (17.9%).Most common reason for self medication was the perception that the disease wasn’t serious (44.8%), favourable prior advertisement (34.3%). About 52% requested for drug by mentioning name of drug. Most (50.7%) felt that OTC drug improved their illness. 45.9% stopped when symptoms disappeared. Majority of the participants (57.2%) believed use of OTC drug is a good practice. Most of the participants (56.7%) believed they can treat symptoms with OTC drugs.64.7% participants believed use of OTC drug is beneficial for them. Most of the participants lack the knowledge for dose (73.6%) and frequency (68.2%) of drug. A substantial number of participants (58.61%) were taking drugs outside OTC list.Conclusions: Awareness and dangers of misuse of OTC medications among all the participants was less. Therefore it is suggested that proper education should be imparted regarding illness where self-administration of OTC drugs to be employed

Polymicrobial therapy induced nephrotoxicity: more is not always better

Polymicrobial induced nephrotoxicity (PIN) occurs more commonly in critically ill patients. Exposure to drugs often results in toxicity in kidney which represents a major control system maintaining homeostasis of body and thus is especially susceptible to xenobiotics. We present here an adverse drug reaction which is additive nephrotoxicity with combined antimicrobial use in critically ill patient. Blood urea and serum creatinine levels were raised much above the baseline after a fortnight of therapy. The suspected drugs were withdrawn leading to a gradual improvement and normalization of blood urea and serum creatinine levels This suggested a causal relationship which was possibly due to the administration of nephrotoxic antimicrobials. The present case highlights that critically ill patients on prolonged Polymicrobial therapy should be closely monitored, and dose increments should be made cautiously

Immunosuppressants in Behcet’s disease: a boon or a bane?

Adalimumab is a disease-modifying antirheumatic drug and monoclonal antibody that works by antagonising tumour necrosis factor-alpha prescribed in many rheumatological conditions like Rheumatic arthritis, Ankylosing spondylitis and Behcet’s disease. Serious side effects with this drug include heart and liver failure, nervous and blood disorders, allergic and immune system reactions and opportunistic infections. A 27-year-old female patient, known case of Behcet’s disease presented to the hospital with complaints of fever, cough and breathlessness following administration of Adalimumab, six doses over three months. Chest X-ray and BAL-CBNAAT was suggestive of Tuberculosis. AKT was started and Adalimumab was suspended until patient recover

A case series on drug induced hyponatremia: uncommon adverse effect of commonly used drugs

Older patients suffering from depression and psychosis have markedly increased since last decade. So, has the use of antidepressants and antipsychotics. The prevalence of hyponatremia due to these drugs is common in general as well as psychiatric practice. It may also lead to life threatening morbidity and mortality. Loss of renal function, polypharmacy, dementia and other conditions of advanced age can either exacerbate the severity of hyponatremia or mask its onset. In this case series, total four cases were reported of hyponatremia and drugs causing it were escitalopram, quetiapine, tianeptine and oxcarbazepine. Due to polypharmacy, a chance of hyponatremia was more in these patients. Patients received infusion of hypertonic saline with salt added diet to treat hyponatremia. Symptoms of hyponatremia were improved after the treatment. In all four cases, WHO and Naranjo’s causality assessment revealed ‘possible’ causal relationship with the prescribed drug. Prescribers should be aware of such adverse effect due to these drugs

Comparative efficacy between ketamine, memantine, riluzole and d-cycloserine in patients diagnosed with drug resistant depression: a meta-analysis

Background: Glutamate modulators are having immense potential and are newer entities for treating drug resistant depression. The objectives were to generate statistical evidence on basis of existing data of ketamine, memantine, riluzole and d-cycloserine in resistant depression.Methods: A total of 14 RCTs following PRISMA guidelines and matching inclusion and exclusion criteria were collected of ketamine (5), memantine (3), riluzole (2) and d-cycloserine (4) vs placebo in drug resistant depression. Only RCTs with primary diagnosis of drug resistant depression (Previously on two standard antidepressant therapy) were included. Studies with treatment response rate, 50% reduction in total score of the depression rating scale-Montgomery-Åsberg Depression Rating Scale or the Hamilton Depression Rating Scale or Beck Depression Inventory was chosen as clinical outcome measure. RevMan 5.3 software was used for the analysis.Results: In ketamine group using random effect model SMD was 2.122 (95% CI 0.659-3.584). P-value was statistically significant (random effect p <0.005 and in fixed effect <0.001). In memantine group, using random effect model -0.963 was SMD and (95% CI -1.958-0.0324). P-value was <0.001, significant in fixed effect. In riluzole group, SMD was -0.564 with (95% CI -3.927-2.799) in random effect. P-value was 0.741. In d-cycloserine group SMD was 0.316 with (95% CI -1.252-1.885) in random effect. P-value was 0.690.Conclusions: Ketamine showed best efficacy followed by memantine. Riluzole and DCS as such have no efficacy although its acts by same glutamate pathway. More molecular based research is required in use of glutamate modulators in resistant depression

Cutaneous manifestations of anti retroviral therapy used for post-exposure prophylaxis

Health care workers are at increased risk of needle stick injuries. Blood borne diseases that could be transmitted by such an injury include HIV, Hepatitis B, HCV and many others. Post exposure prophylaxis should be immediately started within 72 hours and should be continued for 28 days. Currently two Nucleoside Reverse Transcriptase Inhibitors (NRTIs) are given along with one NNRTI (Non- Nucleoside reverse Transcriptase Inhibitor) including Efavirenz or Nevirapine. Multiple adverse effects have been reported with all the Anti- Retroviral Therapies including various cutaneous manifestations. A 22-year-old intern doctor studying in tertiary hospital of Ahmedabad had a needle stick injury with a needle contaminated with blood of HIV positive patient. Post Exposure prophylaxis was started within 72 hours consisting of fixed dose regimen of Tenofovir disprodoxil sulphate, Efavirenz and lamivudine. He was started with the drug within 2 hours and was prescribed one drug per day for next 27 days. On 22nd day he started having rash on his body which started on palms and soles. On 23rd day he saw severe facial edema along with edema on lips and rash spreading to other parts of the body. He was diagnosed with Hypersensitivity reaction and angioedema due to ART drug therapy. He was instructed to stop ART medications and was given antihistaminic for the symptoms. Patient's angioedema was relieved in 2-3 days and rash disappeared after 4-5 days. As he had already finished 23 days of therapy he was instructed to discontinue the drugs. No recurrence of rash or angioedema was noted. This case points out the severity of side effects in the normal healthy people taking ART as Post Exposure Prophylaxis. Apart from cutaneous manifestations, angioedema is a very grievous condition which doctors should always have lower threshold for diagnosis. Early diagnosis can prevent further complications. ART drugs have many complications and these patients should have intensive regular monitoring while on treatment. Also, proper education is required for needle cut injuries in health care workers

Warfarin induced hematuria

Warfarin is an oral vitamin K antagonist prescribed to those patients for the treatment and prevention of thromboembolism. The major challenges to be faced during the therapy were a greater risk for both major as well as minor bleeding, which makes the regular monitoring of INR (international normalized ratio) mandatory. Herein, we reported a case of Warfarin induced hematuria which is serious and we concluded this causality as possible category according WHO-UMC causality category