Impact of the Drug Prices Control Order (2013) on the Utilization of Anticancer Medicines in India: An Interrupted Time-Series Analysis.

Objectives The National Pharmaceutical Pricing Authority introduced a series of Drug Prices Control Orders since 1970 to regulate the prices of essential medicines in India. This study evaluated the impact of the Drug Prices Control Order of 2013 on the utilization of anticancer medicines in the Indian private sector. Methods We used monthly sales audit data for a period of 2012-15, provided by Intercontinental Medical Statistics (IMS) Health. Through interrupted time series design and segmented regression models, we estimated the change in utilization of anticancer medicines following the drug pricing policy implementation. Results Of 1556 anticancer drug packs, 22.3% (n= 347) were price-controlled. The policy led to an immediate monthly reduction of 27.3% (95% CI -38.6%, -13.9%; p=0.001) and a long-term monthly reduction of 0.7% (95% CI -1.6%, 0.3%; p=0.16) in price-controlled formulation's utilization. In the final study month, the price-controlled formulation's utilization was 5.03 thousand standard units lower than what would have been expected without the policy. Melphalan showed the highest immediate reduction, and alpha-interferon showed the highest long-term reduction in utilization. Conclusion Drug prices control order 2013 caused an immediate and long-term decline in the utilization of anticancer medicines in the Indian private sector. However, study data was limited to a specific part of the Indian anticancer drug market, which must be considered when interpreting findings

Antibiotic prescriptions for oral diseases in India: evidence from national prescription data

Introduction: The key objective of this research was to describe the prescription rate of various antibiotics for dental problems in India and to study the relevance of the prescriptions by analysing antibiotic types associated with different dental diagnoses, using a large-scale nationally representative dataset. Methods: We used a 12-month period (May 2015 to April 2016) medical audit dataset from IQVIA (formerly IMS Health). We coded the dental diagnosis provided in the medical audit data to the International Statistical Classification of Diseases and Related Health Problems (ICD-11) and the prescribed antibiotics for the diagnosis to the Anatomic Therapeutic Chemical (ATC) -2020 classification of the World Health Organization. The primary outcome measure was the medicine prescription rate per 1,000 persons per year (PRPY1000). Results: Our main findings were—403 prescriptions per 1,000 persons per year in the year 2015 -2016 for all dental ailments. Across all ATC level 1 classification, ‘Diseases of hard tissues’ made up the majority of the prescriptions. ‘Beta-lactam’, ‘Penicillin,’ and ‘Cephalosporins’ were the most commonly prescribed antibiotics for dental diagnoses followed by ‘Macrolides’ and ‘Quinolones’. ‘Dental caries’, ‘Discoloration of tooth’, and ‘Toothache’ were the most common reasons for ‘Beta-Lactams’ and ‘Penicillin’ prescriptions. Conclusion: To conclude our study reports first ever country (India) level estimates of antibiotic prescription by antibiotic classes, age groups, and ICD-11 classification for dental ailments

Quantifying antibiotic use in typhoid fever in India: a cross-sectional analysis of private sector medical audit data, 2013-2015

OBJECTIVES: To estimate the antibiotic prescription rates for typhoid in India. DESIGN: Cross-sectional study. SETTING: Private sector primary care clinicians in India. PARTICIPANTS: The data came from prescriptions of a panel of 4600 private sector primary care clinicians selected through a multistage stratified random sampling accounting for the region, specialty type and patient turnover. The data had 671 million prescriptions for antibiotics extracted from the IQVIA database for the years 2013, 2014 and 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Mean annual antibiotic prescription rates; sex-specific and age-specific prescription rates; distribution of antibiotic class. RESULTS: There were 8.98 million antibiotic prescriptions per year for typhoid, accounting for 714 prescriptions per 100 000 population. Children 10-19 years of age represented 18.6% of the total burden in the country in absolute numbers, 20-29 year age group had the highest age-specific rate, and males had a higher average rate (844/100 000) compared with females (627/100 000). Ten different antibiotics accounted for 72.4% of all prescriptions. Cefixime-ofloxacin combination was the preferred drug of choice for typhoid across all regions except the south. Combination antibiotics are the preferred choice of prescribers for adult patients, while cephalosporins are the preferred choice for children and young age. Quinolones were prescribed as monotherapy in 23.0% of cases. CONCLUSIONS: Nationally representative private sector antibiotic prescription data during 2013-2015 indicate a higher disease burden of typhoid in India than previously estimated. The total prescription rate shows a declining trend. Young adult patients account for close to one-third of the cases and children less than 10 years account for more than a million cases annually.SFK is supported by The Rockefeller Foundation–Boston University 3-D Commission as a Research Fellow (2019 HTH 024)

Systemic antibiotic sales and WHO recommendations, India.

To analyse sales of fixed-dose combination and single antibiotics in India in relation to World Health Organization (WHO) recommendations and national regulatory efforts to control antibiotic sales. We extracted data on sales volumes of systemic antibiotics in India from a market research company sales database. We compared the market share of antibiotic sales in 2020 by WHO AWaRe (Access, Watch and Reserve) category and for those under additional national regulatory controls. We also analysed sales of fixed-dose combinations that were: formally approved for marketing or had a no-objection certificate; on the national essential medicines list; and on the WHO list of not-recommended antibiotics. There were 78 single and 112 fixed-dose combination antibiotics marketed in India, accounting for 7.6 and 4.5 billion standard units of total sales, respectively. Access, Watch and Reserve antibiotics comprised 5.8, 5.6 and 0.1 billion standard units of total market sales, respectively. All additionally controlled antibiotics were Watch and Reserve antibiotics (23.6%; 2.9 billion standard units of total sales). Fixed-dose combinations on the WHO not-recommended list were marketed in 229 formulations, with 114 formulations (49.8%) having no record of formal approval or no-objection certificate. While there were no not-recommended fixed-dose combinations on the national list of essential medicines, 13 of the top-20 selling antibiotic fixed-dose combinations were WHO not-recommended. The sale of Watch group drugs, and antibiotics banned or not approved, needs active investigation and enforcement in India. The evidence base underpinning formal approvals and no-objection certificates for not-recommended fixed-dose combinations should be audited. Analyser les ventes d'antibiotiques en association fixe et à dose unique en Inde, à la lumière des recommandations de l'Organisation mondiale de la Santé (OMS) et des efforts de réglementation à l'échelle nationale visant à contrôler la vente d'antibiotiques. Nous avons prélevé des données relatives aux volumes de vente d'antibiotiques systémiques en Inde dans la base de données commerciales d'une société d'études de marché. Nous avons ensuite comparé la part de marché qu'occupe, en 2020, la vente d'antibiotiques appartenant à chaque catégorie AWaRe (Access, Watch and Reserve) établie par l'OMS, mais aussi de ceux ciblés par des mesures nationales de contrôle supplémentaires. Enfin, nous avons examiné les ventes d'associations fixes: dont la commercialisation a été officiellement approuvée ou qui ont fait l'objet d'un certificat de non-objection; figurant sur la liste nationale de médicaments essentiels; et reprises dans la liste des antibiotiques non recommandés par l'OMS. Nous avons comptabilisé 78 antibiotiques à dose unique et 112 antibiotiques en association fixe sur le marché indien, représentant respectivement 7,6 et 4,5 milliards d'unités standard sur l'ensemble des ventes. Les antibiotiques des catégories Access (dont l'accessibilité est essentielle), Watch (à utiliser sélectivement) et Reserve (de réserve, non recommandés) équivalaient à 5,8 milliards, 5,6 milliards et 0,1 milliard d'unités standard sur le total des transactions. Tous les antibiotiques soumis à des contrôles supplémentaires faisaient partie des catégories Watch et Reserve (23,6%; 2,9 milliards d'unités standard sur l'ensemble des ventes). Des associations fixes déconseillées par l'OMS étaient commercialisées dans 229 formulations, dont 114 (49,8%) ne possédaient ni attestation d'approbation officielle, ni certificat de non-objection. Bien qu'aucune association fixe déconseillée ne soit mentionnée sur la liste nationale de médicaments essentiels, 13 des 20 antibiotiques en association fixe les plus vendus n'étaient pas recommandés par l'OMS. Il est nécessaire de mener une enquête approfondie en Inde sur la vente de médicaments appartenant à la catégorie Watch et d'antibiotiques interdits ou non approuvés, et de prendre des mesures concrètes. Les preuves sur lesquelles reposent les autorisations officielles et les certificats de non-objection pour les associations fixes non recommandées doivent être vérifiées. Analizar las ventas de los antibióticos combinados en dosis fijas y en dosis únicas en la India en relación con las recomendaciones de la Organización Mundial de la Salud (OMS) y los esfuerzos nacionales de regulación para controlar las ventas de los antibióticos. Se extrajeron datos sobre los volúmenes de ventas de antibióticos sistémicos en la India de una base de datos de ventas de empresas de investigación de mercado. Se comparó la cuota de mercado de las ventas de antibióticos en 2020 por categoría AWaRe (Access, Watch and Reserve) de la OMS y para los que estaban sometidos a controles regulatorios nacionales adicionales. También se analizaron las ventas de combinaciones en dosis fijas que estaban: formalmente aprobadas para su comercialización o tenían un certificado de no objeción; en la lista nacional de medicamentos esenciales; y en la lista de antibióticos no recomendados de la OMS. En la India se comercializaron 78 antibióticos en dosis única y 112 antibióticos combinados en dosis fijas, que representaron 7,6 y 4,5 mil millones de unidades estándar de ventas totales, respectivamente. Los antibióticos de acceso, vigilancia y reserva supusieron 5,8, 5,6 y 0,1 mil millones de unidades estándar de las ventas totales del mercado, respectivamente. Todos los antibióticos controlados adicionalmente fueron antibióticos de vigilancia y reserva (23,6 %; 2,9 mil millones de unidades estándar de las ventas totales). Las combinaciones en dosis fijas incluidas en la lista no recomendada de la OMS se comercializaron en 229 formulaciones, de las que 114 (49,8 %) no tenían registro de aprobación formal ni certificado de no objeción. Mientras que no había combinaciones en dosis fijas no recomendadas en la lista nacional de medicamentos esenciales, 13 de las 20 combinaciones en dosis fijas de antibióticos más vendidas no estaban recomendadas por la OMS. Se debe investigar y controlar activamente la venta de medicamentos del grupo Watch y de antibióticos prohibidos o no aprobados en la India. Asimismo, se debe auditar la base de pruebas que sustenta las aprobaciones formales y los certificados de no objeción para las combinaciones en dosis fijas no recomendadas.الغرض تحليل مبيعات تركيبة الجرعة الثابتة، والمضادات الحيوية المفردة في الهند فيما يتعلق بتوصيات منظمة الصحة العالمية (WHO)، والجهود التنظيمية الوطنية للتحكم في مبيعات المضادات الحيوية. الطريقة قمنا باستخراج بيانات عن أحجام مبيعات المضادات الحيوية الجهازية في الهند من قاعدة بيانات مبيعات شركة أبحاث السوق. قمنا بمقارنة الحصة السوقية لمبيعات المضادات الحيوية في عام 2020 حسب فئة AWaRe (الوصول والمراقبة والاحتياطي) التابعة لمنظمة الصحة العالمية (WHO)، وتلك التي تخضع للضوابط التنظيمية الوطنية الإضافية. كما قمنا أيضًا بتحليل مبيعات تركيبات الجرعة الثابتة التي تم: الموافقة عليها رسميًا للتسويق، أو لديها شهادة عدم ممانعة؛ على قائمة الأدوية الأساسية الوطنية؛ وعلى قائمة منظمة الصحة العالمية (WHO) للمضادات الحيوية غير الموصى بها. النتائج تم تسويق مضادات حيوية منها 112 تركيبة ذات جرعة ثابتة، و78 مضادًا حيويًا ذات تركيبة منفردة في الهند، وهو ما يمثل 7.6 و4.5 مليار وحدة قياسية من إجمالي المبيعات على الترتيب. تضم المضادات الحيوية Access وWatch وReserve 5.8 و5.6 و0.1 مليار وحدة قياسية من إجمالي مبيعات السوق على الترتيب. جميع المضادات الحيوية الإضافية الخاضعة للرقابة كانت Watch وReserve (%23.6؛ 2.9 مليار وحدة قياسية من إجمالي المبيعات). تركيبات الجرعة الثابتة الواردة في القائمة غير الموصى بها لدى منظمة الصحة العالمية (WHO) تم تسويقها في 229 مستحضرًا، مع 114 مستحضرًا (49.8%) ليس لها سجل بالموافقة الرسمية أو شهادة عدم ممانعة. على الرغم من عدم وجود تركيبات جرعة ثابتة غير موصى بها في القائمة الوطنية للأدوية الأساسية، فإن 13 من الـ 20 تركيبة جرعة ثابتة من المضادات الحيوية الأكثر مبيعًا لم تكن موصى بها من جانب منظمة الصحة العالمية (WHO). الاستنتاج إن بيع أدوية مجموعة Watch، والمضادات الحيوية المحظورة أو التي لم تحصل على الموافقة، يحتاج إلى تحقيق وإنفاذ فعال في الهند. يجب مراجعة قاعدة الأدلة التي تقوم عليها الموافقات الرسمية، وشهادات عدم الممانعة لتركيبات الجرعة الثابتة غير الموصى بها. 根据世卫组织 (WHO) 推荐的药物目录和控制抗生素销售的国家监管措施,分析印度固定剂量组合抗生素和单一抗生素的销量。. 我们从一家市场调研公司的销售数据库中提取了印度全身性抗生素的销量数据。我们比较了 2020 年按 WHO AWaRe 【可广泛使用 (Access)、谨慎使用 (Watch) 和保留使用 (Reserve)】分级目录和其他国家监管规定分类的抗生素的销售量市场份额。我们还分析了固定剂量组合抗生素(正式批准上市或者具有无异议证明;全国基本药物目录;世卫组织不推荐的抗生素目录)的销量。. 印度有 78 种单一抗生素和 112 种固定剂量组合抗生素上市, 总销量分别为 76 和 45 亿标准单位。可广泛使用 (Access)、谨慎使用 (Watch) 和保留使用 (Reserve) 抗生素的市场总销量分别为 58、56 和 1 亿标准单位。所有额外受监管抗生素均为谨慎使用 (Watch) 和保留使用 (Reserve) 抗生素(占 23.6%,总销售额为 29 亿标准单位)。有 229 种非世卫组织推荐药物目录中的固定剂量组合抗生素上市,其中 114 种(49.8%)没有正式批准或无异议证明。虽然没有国家基本药物清单中不推荐的固定剂量组合抗生素,但在 20 种最畅销的固定剂量组合抗生素中,有 13 种是世卫组织不推荐使用的。. 在印度还需对谨慎使用 (Watch) 类别的药物以及禁用或未批准的抗生素的销量进行积极调查并采取措施。应对不推荐使用的固定剂量组合抗生素取得的正式批准和无异议证明进行审查。. Проанализировать продажи комбинированных препаратов с фиксированными дозами и отдельных антибиотиков в Индии в соответствии с рекомендациями Всемирной организации здравоохранения (ВОЗ) и мерами национального регулирования по контролю за продажами антибиотиков. Авторы извлекли данные об объемах продаж системных антибиотиков в Индии из базы данных по продажам исследовательской компании. Они сравнили рыночную долю продаж антибиотиков в 2020 г. по категориям AWaRe (Access (Доступ), Watch (Наблюдение), Reserve (Резерв)) ВОЗ, а также антибиотиков, на которые распространяются дополнительные национальные регулирующие меры контроля. Авторы также проанализировали продажи комбинированных препаратов с фиксированными дозами, которые были официально одобрены для продажи или имели сертификат об отсутствии возражений, находились в национальном перечне основных лекарственных средств и в списке ВОЗ не рекомендованных для использования антибиотиков. В Индии на рынке представлены 78 отдельных и 112 комбинированных препаратов с фиксированными дозами антибиотиков, что составило 7,6 и 4,5 млрд условных единиц от общего объема продаж соответственно. Антибиотики групп Access, Watch и Reserve составили 5,8; 5,6 и 0,1 млрд условных единиц от общего объема продаж на рынке соответственно. Все дополнительно контролируемые антибиотики относились к антибиотикам групп Watch и Reserve (23,6%; 2,9 млрд условных единиц от общего объема продаж). Комбинированные препараты с фиксированными дозами, включенные в список ВОЗ не рекомендованных для использования антибиотиков, продавались в виде 229 лекарственных форм, при этом 114 форм (49,8%) не имели официального одобрения или сертификата об отсутствии возражений. Хотя в национальном перечне основных лекарственных средств не было нерекомендованных комбинированных препаратов с фиксированными дозами, 13 из 20 наиболее продаваемых комбинированных антибиотиков с фиксированными дозами не были рекомендованы ВОЗ. Продажа антибиотиков группы Watch, а также продажа запрещенных или не имеющих одобрения антибиотиков требует активного расследования и правоприменения в Индии. Необходимо проверить доказательную базу, лежащую в основе официальных одобрений и сертификатов об отсутствии возражений для нерекомендованных комбинированных препаратов с фиксированными дозами

Regulatory enforcement of the marketing of fixed-dose combinations in India: a case study of systemic antibiotics

Background: In India, states have licensed the manufacture of large numbers of fixed-dose combination (FDC) drugs without the required prior approval of the central regulator. This paper describes two major regulatory initiatives to address the problem, which began in 2007 and 2013, and examines whether they have been sufficient to remove centrally unapproved systemic antibiotic FDCs from the market. Methods: Information was extracted from documents published by the central regulator and the ministry of health, including the National List of Essential Medicines (NLEM), and court judgments, and analysed alongside sales volume data for 2008–2020 using PharmaTrac market dataset. Results: The regulatory initiatives permitted 68 formulations to be given de facto approvals (‘No Objection Certificates’) outside the statutory regime, banned 46 FDCs and restricted one FDC. Market data show that FDCs as a proportion of total antibiotic sales increased from 32.9 in 2008 to 37.3% in 2020. The total number of antibiotic FDC formulations on the market fell from 574 (2008) to 395 (2020). Formulations with a record of prior central approval increased from 86 (2008) to 94 (2020) and their share of the antibiotic FDC sales increased from 32.0 to 55.3%. In 2020, an additional 23 formulations had been permitted de facto approval, accounting for 10.6% of the antibiotic FDC sales. Even in 2020, most marketed formulations (70.4%, 278/395) were unapproved or banned, and comprised a 15.9% share of the antibiotic FDC sales. The share of NLEM-listed antibiotic FDC sales increased from 21.2 (2008) to 26.7% (2020). Conclusion: The initiatives had limited impact. Regulatory enforcement has been slow and weak, with many unapproved, and even banned, FDCs remaining on the market

Antibiotic prescriptions for oral diseases in India: evidence from national prescription data

IntroductionThe key objective of this research was to describe the prescription rate of various antibiotics for dental problems in India and to study the relevance of the prescriptions by analysing antibiotic types associated with different dental diagnoses, using a large-scale nationally representative dataset.MethodsWe used a 12-month period (May 2015 to April 2016) medical audit dataset from IQVIA (formerly IMS Health). We coded the dental diagnosis provided in the medical audit data to the International Statistical Classification of Diseases and Related Health Problems (ICD-11) and the prescribed antibiotics for the diagnosis to the Anatomic Therapeutic Chemical (ATC) -2020 classification of the World Health Organization. The primary outcome measure was the medicine prescription rate per 1,000 persons per year (PRPY1000).ResultsOur main findings were-403 prescriptions per 1,000 persons per year in the year 2015 -2016 for all dental ailments. Across all ATC level 1 classification, 'Diseases of hard tissues' made up the majority of the prescriptions. 'Beta-lactam', 'Penicillin,' and 'Cephalosporins' were the most commonly prescribed antibiotics for dental diagnoses followed by 'Macrolides' and 'Quinolones'. 'Dental caries', 'Discoloration of tooth', and 'Toothache' were the most common reasons for 'Beta-Lactams' and 'Penicillin' prescriptions.ConclusionTo conclude our study reports first ever country (India) level estimates of antibiotic prescription by antibiotic classes, age groups, and ICD-11 classification for dental ailments

Bridging minds and machines : the recent advances of brain-computer interfaces in neurological and neurosurgical applications

Brain-Computer Interfaces (BCIs), a remarkable technological advancement in neurology and neurosurgery, mark a significant leap since the inception of electroencephalography (EEG) in 1924. These interfaces effectively convert central nervous system signals into commands for external devices, offering revolutionary benefits to patients with severe communication and motor impairments due to a myriad of neurological conditions like stroke, spinal cord injuries, and neurodegenerative disorders. BCIs enable these individuals to communicate and interact with their environment, using their brain signals to operate interfaces for communication and environmental control. This technology is especially crucial for those completely locked in, providing a communication lifeline where other methods fall short. The advantages of BCIs are profound, offering autonomy and an improved quality of life for patients with severe disabilities. They allow for direct interaction with various devices and prostheses, bypassing damaged or non-functional neural pathways. However, challenges persist, including the complexity of accurately interpreting brain signals, the need for individual calibration, and ensuring reliable, long-term use. Additionally, ethical considerations arise regarding autonomy, consent, and the potential for dependence on technology. Despite these challenges, BCIs represent a transformative development in neurotechnology, promising enhanced patient outcomes and a deeper understanding of brain-machine interfaces.Peer reviewe

Targeting oxidative stress mechanisms to treat Alzheimer's and Parkinson's disease: A critical review

Neurodegenerative disorders such as Alzheimer's disease (AD) and Parkinson's disease (PD) are becoming more frequent as the age increases. Contemporary therapies provide symptom resolution instead of targeting underlying pathological pathways. Consequently, there is considerable heterogeneity in response to treatment. Research has elucidated multiple potential of pathophysiological mechanisms contributing to neurodegenerative conditions, among which oxidative stress pathways appear to be suitable drug targets. The oxidative stress pathway has given rise to numerous novel pharmacological therapies that may provide a new avenue for neurodegenerative diseases. For example, SKQ (plastoquinone), MitoVitE, vitamin E, SOD mimic, MitoTEMPO (SOD mimetic), and bioactive molecules like curcumin and vitamin C have indeed been examined. To better understand how oxidative stress contributes to neurodegenerative diseases (such as Alzheimer's and Parkinson's), we analyzed the medicinal qualities of medicines that target markers in the cellular oxidative pathways. The specific pathway by which mitochondrial dysfunction causes neurodegeneration will require more investigation. An animal study should be carried out on medications that tackle cellular redox mechanisms but are not currently licensed for use in the management of neurodegenerative conditions

Outpatient antibiotic prescription rate and pattern in the private sector in India: Evidence from medical audit data.

The key objective of this research was to generate new evidence on outpatient antibiotic prescription rate and patterns in the private sector in India. We used 12-month period (May 2013 to April 2014) medical audit dataset from IQVIA (formerly IMS Health). We coded the diagnosis provided in the medical audit data to International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the prescribed antibiotics for the diagnosis to Anatomic Therapeutic Chemical (ATC) classification of World Health Organization (ATC index-2016). We calculated and reported antibiotic prescription rate per 1,000 persons per year, by age groups, antibiotic class and disease conditions. Our main findings are-approximately 519 million antibiotic prescriptions were dispensed in the private sector, which translates into 412 prescriptions per 1,000 persons per year. Majority of the antibiotic prescriptions were dispensed for acute upper respiratory infections (J06) (20.4%); unspecified acute lower respiratory infection (J22) (12.8%); disorders of urinary system (N39) (6.0%); cough (R05) (4.7%); and acute nasopharyngitis (J00) (4.6%) and highest antibiotic prescription rates were observed in the age group 0-4 years. To conclude our study reports first ever country level estimates of antibiotic prescription by antibiotic classes, age groups, and ICD-10 mapped disease conditions

Encephalopathy associated with autoimmune thyroid disease: A grave situation

Background: Encephalopathy associated with autoimmune thyroid disease (EAATD) is an uncommon disorder affecting the central nervous system and associated with autoimmune thyroid disorders. It has myriad manifestations. Although most commonly seen with Hashimoto's thyroiditis, it has also been reported with Graves' disease. As it has no pathognomonic features (apart from response to steroids), it is a diagnosis of exclusion, and can be very challenging for the clinician. Clinical Description: An 11-year-old girl presented with a fever and altered sensorium for a few hours. In-depth history was unable to identify any significant history apart from recent weight loss. Salient examination findings were severe thinness, tachycardia, an enlarged thyroid gland, and altered sensorium, but the absence of neurological deficit, meningeal involvement, and increased intracranial tension. The clinical phenotype was acute encephalitis syndrome. Investigations ruled out biomarkers of infection, metabolic acidosis, hypoglycemia, dyselectrolytemia, uremia, hepatic dysfunction, and diabetic ketoacidosis. Neuroimaging was normal. Cerebrospinal fluid abnormalities were lymphocytosis, high protein, and normal glucose. A thyroid function test identified hyperthyroidism. Doppler ultrasonography revealed a diffusely enlarged and hypervascular thyroid gland. Thyrotropin-receptor antibodies were elevated (>10 IU/L). The final diagnosis was EAATD secondary to Graves' disease. Management and Outcome: Intravenous methylprednisolone (30 mg/kg/day), antithyroid drugs, and beta-blockers were started, on which she showed rapid and marked improvement. Conclusions: A detailed history, diligent clinical examination, and rational systemic approach needs to be undertaken to establish a diagnosis of EAATD