Tocilizumab induced immunosuppression in a case of adult-onset still’s disease: are these newer biologics double edged sword?

Adult-onset still’s disease (AOSD) is a rare multisystemic inflammatory disorder of unknown etiology characterised by high spiking fever, evanescent skin rash, arthralgias, arthritis, neutrophilic leucocytosis. Initial treatment strategy includes use of hands-on drugs like non-steroidal anti-inflammatory drugs, low dose corticosteroids, conventional DMARDs. But as the disease progresses to severe form, targeted and biologic DMARDs could be the option for management. Interleukin-6 being one among the many cytokines involved in the pathogenesis of AOSD, has made itself a target for the treatment of refractory cases. Tocilizumab, a recombinant humanized anti IL-6 monoclonal antibody, is one such biologic drug available in the market that has proven its therapeutic efficacy in several clinical trials. We are presenting a case of 37-year-old female patient, known case of AOSD for 4 years. Patient was initially maintained on low dose corticosteroid and conventional DMARD like hydroxychloroquine and methotrexate. Flare ups of the disease warranted the use of tocilizumab and tofacitinib in this patient. After clinical as well as pathological improvement with tocilizumab 2 years before, signs of immunosuppression were observed when tocilizumab was reintroduced for the treatment. Patient suffered from acute pyelonephritis, septicemia, shock, oropharyngeal candidiasis and bronchitis which could be owned to immunosuppressive action of tocilizumab. One can reduce the chances of infection and other adverse effects by careful periodic monitoring of various laboratory parameters like total W.B.C., total platelet count and liver enzymes. Cautious selection of the patient is needed for the treatment with newer biologic agents

A case report on angioedema induced by levofloxacin: an unexpected occurrence

Angioedema is an abrupt swelling of the skin, mucous membrane, or both. It can be either food or drug induced. Drug induced Angioedema (allergic or non-allergic) is known with ACE inhibitors, NSAIDs, Beta-lactams. Levofloxacin is a well-tolerated, broad-spectrum fluoroquinolone commonly prescribed for urinary or respiratory tract infections. Common side effects with levofloxacin involve gastrointestinal tract. However, reports on Levofloxacin induced Angioedema are scarce. Hence, we report two cases of Levofloxacin induced Angioedema. In both the cases, patients developed swelling of face following ingestion of Tab. Levofloxacin 500 mg orally BD on previous day. Drug was prescribed for urinary or respiratory infection. After a provisional diagnosis of Levofloxacin induced Angioedema by the dermatologist, both the patients were asked to withdraw the drug immediately. The reaction was treated with Inj. Avil (Pheniramine maleate) 1 cc i.v. stat and Inj. Dexona (Dexamethasone) 2 cc i.v. stat in one patient whereas oral corticosteroid (Tab. Prednisolone 10mg orally OD with tapering dose) was used in second patient. Oral antihistaminics were also prescribed as per the necessity. Both patients recovered within 4-7 days. Both ADRs were uploaded via Vigiflow under Pharmacovigilance Programme of India (PvPI) with likely relationship between suspected drug and ADR. Incidence of Drug induced cutaneous ADRs (CADRs) in India is 2.85%. Instances of hypersensitivity or anaphylactic reactions with fluoroquinolones are much lesser and milder than with NSAIDs or Beta-lactams. These reactions are associated with quinolone-specific Ig E. Existence of cross reactivity with quinolones is also high. This property is due to a similar ring (4-oxo-1, 4-dihydroquinoline ring) possessed by all fluoroquinolones. This allergic angioedema confined to the skin can be treated with antihistaminics or glucocorticoids

Drug utilization pattern and analysis of quality of life in Indian patients of Parkinson’s disease

Background: Parkinson's disease (PD) is a highly debilitating disease characterized by tremors, bradykinesia and rigidity. It leads to lowered self-esteem and psychological consequences which affect quality of life. The aim of this study is to study the drug utilization pattern and assess the quality of life in patients of Parkinson’s Disease.Methods: 40 patients of PD at least 1 month duration and 20 age-based controls were analyzed for quality of life using Parkinson’s Disease Questionnaire-39 (PDQ-39). Drug prescriptions were analyzed.Results: Mean number of anti-Parkinson drugs prescribed is 2.65±1.21. Of 106 anti-Parkinson drugs prescribed, 45% were levodopa and carbidopa combinations, followed by dopamine agonists (18%), anticholinergic drugs (15%), amantadine (12%), MAO inhibitors (5%) and COMT inhibitors (5%). There were significant problems in speech, performance of daily chores and daytime somnolence (p<0.0001). Depression, isolation, cognitive decline and memory loss were noteworthy in the patients as compared to controls (p<0.05). 25% patients felt embarrassed due to their disease; 59% felt affected by others’ opinion, 60% felt difficulty in communicating with others (p<0.05). Almost 2/3rd patients needed help in personal care as compared to the control group (p<0.0001).Conclusions: Quality of life of parkinsonian patients is severely affected in spite of them receiving a large number of drugs. This may be both due to disease progression as well as medication. Levodopa-carbidopa combination is the most prescribed medication. Use of levodopa and carbidopa combination must be evaluated properly. Newer guidelines and interventions are the need of the hour which may provide a better outcome on the quality of life of parkinsonian patients