Recombinant protein subunit COVID-19 vaccine-induced Guillain-Barré Syndrome in an adolescent: A case report.

Guillain-Barré Syndrome (GBS), an autoimmune neurological disease of peripheral nerves, has been causally associated with COVID-19 vaccination in adults. However, no such report has been published so far in children. We describe a 13-year-old female child who presented to the emergency department with complaints of bilateral upper limb, lower limb and truncal weakness over 3 days following first dose of recombinant protein subunit COVID-19 vaccine (Corbevax). Clinical examination and nerve conduction studies showed pure motor axonal polyneuropathy with absent compound muscle action potential (CMAP) in all sampled nerves of upper and lower limbs which was consistent with the diagnosis of GBS after ruling out possible alternative aetiologies. A temporal association between first dose of protein subunit COVID-19 vaccine administered a day prior and symptom onset was noted. The causality assessment using the World Health Organization (WHO) tool for adverse event following immunization (AEFI) assessment indicated vaccine product-related reaction categorized as A1. The patient's clinical condition improved after seven sessions of plasmapheresis. The purpose of this report is to create awareness among health care professionals about COVID-19 vaccine-induced GBS in children as early diagnosis and management can be critical in avoiding complications and improving patient outcomes.

A multicentre point prevalence survey (PPS) of antimicrobial use amongst admitted patients in tertiary care centres in India.

OBJECTIVES: Data from point prevalence surveys (PPSs) in India are scarce. Conducting PPSs is especially challenging in the absence of electronic medical records, a lack of dedicated resources and a high patient load in resource-poor settings. This multicentre survey was conducted to provide background data for planning and strengthening antimicrobial stewardship programmes across the country. METHODS: This inpatient PPS was conducted over 2 weeks in May 2019 simultaneously across five study centres in India. Data about patient characteristics, indications for antimicrobials use and details of each antimicrobial prescribed including supportive investigation reports were collected in predesigned forms. RESULTS: A total of 3473 admitted patients in wards and ICUs were covered across five study centres. Of these, 1747 (50.3%) patients were on antimicrobials, with 46.9% patients being on two or more antimicrobials. Out of the total antimicrobials prescribed, 40.2% of the antimicrobials were prescribed for community-acquired infection requiring hospitalization followed by surgical prophylaxis (32.6%). Third-generation cephalosporins and drugs from the 'Watch' category were prescribed most commonly. Only 22.8% of the antimicrobials were based on microbiology reports. CONCLUSIONS: The survey demonstrated a high use of antimicrobials in admitted patients with a considerable proportion of drugs from the 'Watch' category. The targets for interventions that emerged from the survey were: improving surgical prophylaxis, decreasing double anaerobic cover, initiating culture of sending cultures and de-escalation with targeted therapy.

Deciphering the COVID-19 cytokine storm: Systematic review and meta-analysis.

INTRODUCTION: The coronavirus pandemic has affected more than 20 million people so far. Elevated cytokines and suppressed immune responses have been hypothesized to set off a cytokine storm, contributing to ARDS, multiple-organ failure and, in the most severe cases, death. We aimed to quantify the differences in the circulating levels of major inflammatory and immunological markers between severe and nonsevere COVID-19 patients. METHODS: Relevant studies were identified from PubMed, EMBASE, Web of Science, SCOPUS and preprint servers. Risk of bias was assessed for each study, using appropriate checklists. All studies were described qualitatively and a subset was included in the meta-analysis, using forest plots. RESULTS: Based on 23 studies, mean cytokine levels were significantly higher (IL-6: MD, 19.55 pg/mL; CI, 14.80, 24.30; IL-8: MD, 19.18 pg/mL; CI, 2.94, 35.43; IL-10: MD, 3.66 pg/mL; CI, 2.41, 4.92; IL-2R: MD, 521.36 U/mL; CI, 87.15, 955.57; and TNF-alpha: MD, 1.11 pg/mL; CI, 0.07, 2.15) and T-lymphocyte levels were significantly lower (CD4+ T cells: MD, -165.28 cells/µL; CI, -207.58, -122.97; CD8+ T cells: MD, -106.51 cells/µL; CI, -128.59, -84.43) among severe cases as compared to nonsevere ones. There was heterogeneity across studies due to small sample sizes and nonuniformity in outcome assessment and varied definitions of disease severity. The overall quality of studies was sub-optimal. CONCLUSION: Severe COVID-19 is characterized by significantly increased levels of pro-inflammatory cytokines and reduced T lymphocytes. Well-designed and adequately powered prospective studies are needed to amplify the current evidence and provide definitive answers to dilemmas regarding timing and type of anti-COVID-19 therapy particularly in severe patients.

Methodological Characteristics of Clinical Trials: Impact of Mandatory Trial Registration.

PURPOSE: Numerous studies across multiple specialties have evaluated the impact of trial registration on quality of study reports and found significant improvements over several domains. However, the impact of mandatory trial registration on the quality of clinical trial protocols remains hitherto unexplored. METHODS: We carried out a retrospective cohort study of clinical trial applications submitted to drug regulatory authority of India for initial review with the objective of comparing methodological characteristics of their protocols. Since trial registration was made mandatory in the country in June 2009, we selected two study periods as between January 2007 to May 2009 (Period I) and July 2009 to December 2011 (Period II). Seventy-five protocols were randomly selected using a computer-generated list for each study period, making a total of 150 protocols. Data on twelve key methodological characteristics were collected including clearly defined primary outcomes, randomization, blinding, use of control group, statistical methods, handling of withdrawals amongst others. RESULTS: More than 3/4th of the trial applications in the two study periods were for new chemical entities and nearly 90% were pharmaceutical industry sponsored studies. Comparing the period before and after implementation of mandatory trial registration, description of clearly defined trial outcomes improved from nearly 42% to 80% (p<0.001), sample size justifications increased from 38% to 70% (p<0.001) and use of allocation concealment improved from 24% to 49% (p=0.001). Marked improvement was also noted for blinding, description of statistical methods and handling of withdrawals and dropouts. Remaining characteristics did not change significantly between the two study periods. The mean cumulative scores for the study protocols improved significantly from 7± 0.296 in the first period to 8.93± 0.346 (p<0.001) in the second period. CONCLUSIONS: Our study found a significant improvement in the methodological quality characteristics of the protocols particularly in elements related to minimization of bias and statistical methods, which could be attributed to mandatory trial registration. Overall, the significant improvement was limited to global clinical trials, and room for improvement was noted for two quality characteristics - proportion of randomized studies and trials adequately describing the generation of allocation sequence.

Satisfaction With Statin Treatment Among Adult Coronary Artery Disease Patients: An Experience From a Resource-Constrained Setting.

BACKGROUND: Statins are the most widely prescribed hypolipidaemic drugs for coronary artery disease (CAD) patients, but have been found to cause muscle and nerve related adverse effects which can affect patient satisfaction with treatment. Literature on treatment satisfaction among statin users, especially from resource-limited settings is inadequate. The aim of this cross-sectional study was to assess the level of satisfaction with treatment among statin users and evaluate the relationship between adverse effects experienced by patients and their satisfaction with the medication. METHODS: This study included 300 adult CAD patients visiting the cardiology department of a tertiary care hospital in the northern region of India, who were prescribed statins for their diagnoses. An interviewer administered, validated and standardised Treatment Satisfaction Questionnaire for Medication (version 1.4) was used for data collection. RESULTS: Around three quarters of the population reported being overall satisfied with their medication. Mean scores were calculated for Effectiveness, Convenience, Side-Effects and Global Satisfaction. The patients reported high scores (above 60%) for all domains. Those experiencing any adverse effect were found to be more likely to report lower effectiveness. Additionally, medication effectiveness showed a positive correlation with overall treatment satisfaction. CONCLUSIONS: The study shows that treatment satisfaction is critical to gauge patient experiences with the treatment which can impact medication adherence and compliance. It's a crucial measure especially among CAD and other chronic disease patients since greater satisfaction can improve clinical outcomes. More research is warranted to better understand the relationship between medication effectiveness and treatment satisfaction.

Decoding the Roadmap for Capacity Building of Pharmacology Academicians in Catering to Drug Information Center Services in a Developing Country.

Background: Very few medical institutions are currently providing drug information center (DIC) services in low-resource countries. Objective: To assess whether academician pharmacologists of India are prepared to deliver countrywide services with regard to DICs. Methods: A cross-sectional knowledge attitude and practice study was planned in the form of an online survey. A hyperlink to the questionnaire was sent to academician pharmacologists via email, Facebook, and WhatsApp. Determinants associated with pharmacologists' capacity and willingness in uplifting the DIC services were determined using logistic regression. Results: One hundred and thirteen academician pharmacologists responded. Participants who were working in limited functional DIC had 0.30 (95% confidence interval [CI] = 0.09-0.98) times association with answering that referring to promotional drug literature is an inappropriate practice for DIC services to that of nonfunctional DIC participants. However, the same had 5.28 (95% CI = 1.74-16.00) times association with referring to literature for establishing and running the services more as compared with participants with nonfunctional DIC. Participants from fully functional DICs in their departments had 6.31 (95% CI = 1.92-20.70) times association with identifying that adverse event reporting is not the function of DIC as compared with participants from a non-functional DIC. Participants with more academic experience had 6.7 (95% CI = 1.36 to 32.93) times association with an identification of challenges as compared with that of less experience participants. Conclusion: Academician pharmacologists need to be trained in critical appraisal of published literature and guided on how to establish and maintain the services for hospital clinicians. Senior pharmacology academicians' advice will be crucial in strengthening the roadmap for capacity building.

Statin related adverse effects and patient education: a study from resource limited settings.

BACKGROUND: Statins are the most widely prescribed class of drugs for coronary artery disease (CAD) patients and yet literature on the prevalence of statin related adverse effects (AEs) and gaps in patient education is quite limited especially in resource-limited settings of developing world. OBJECTIVES: The present study was conducted to determine the prevalence of myopathy (muscle ailments) and other statin associated adverse effects among CAD patients on statin therapy. The study also aimed to assess patient perceptions, attitudes and awareness concerning the use of statins. METHODS: It was a cross-sectional study conducted among 300 adult CAD patients visiting the out-patient department of a tertiary care hospital in North India, who were receiving statins for their diagnosis. An interviewer administered questionnaire was used to collect data on statin use among patients and adverse effects experienced. RESULTS: Myopathy or muscle related ailments like muscle pain, cramps and muscle weakness were the most prevalent (32, 34 and 47%, respectively), followed by numbness, tingling and burning in the extremities (31%). Joint pain and cognitive impairments were seen in nearly 20% of the patients. The level of awareness among participants regarding the use of statins was sub-optimal. Lack of knowledge and under-reporting of adverse effects were major concerns. CONCLUSION: The study shows that a considerable proportion of statin users experience adverse effects and knowledge and awareness amongst patients is inadequate. Awareness programmes and counselling for patients, sensitisation of healthcare professionals and better screening systems for monitoring AEs can help improve the scenario.

Impact of regulatory spin of pioglitazone on prescription of antidiabetic drugs among physicians in India: A multicentre questionnaire-based observational study.

Background & objectives: Pioglitazone was suspended for manufacture and sale by the Indian drug regulator in June 2013 due to its association with urinary bladder carcinoma, which was revoked within a short period (July 2013). The present questionnaire-based nationwide study was conducted to assess its impact on prescribing behaviour of physicians in India. Methods: Between December 2013 and March 2014, a validated questionnaire was administered to physicians practicing diabetes across 25 centres in India. Seven hundred and forty questionnaires fulfilling the minimum quality criteria were included in the final analysis. Results: Four hundred and sixteen (56.2%) physicians prescribed pioglitazone. Of these, 281 used it in less than the recommended dose of 15 mg/day. Most physicians (94.3%) were aware of recent regulatory events. However, only 333 (44.8%) changed their prescribing pattern. Seventeen of the 416 (4.1%) physicians who prescribed pioglitazone admitted having come across at least one type 2 diabetes mellitus patient (T2DM) who had urinary bladder carcinoma, and of these 13 said that it was in patients who took pioglitazone for a duration of more than two years. Only 7.8 per cent of physicians (n=58) categorically advocated banning pioglitazone, and the rest opined for its continuation or generating more evidence before decision could be taken regarding its use in T2DM. Interpretation & conclusions: Majority of the physicians though were aware of the regulatory changes with regard to pioglitazone, but their prescribing patterns were not changed for this drug. However, it was being used at lower than the recommended dose. There is a need for generating more evidence through improved pharmacovigilance activities and large-scale population-based prospective studies regarding the safety issues of pioglitazone, so as to make effectual risk-benefit analysis for its continual use in T2DM.

Comparison of body composition in persons with epilepsy on conventional & new antiepileptic drugs.

BACKGROUND & OBJECTIVES: Certain antiepileptic drugs (AEDs) such as valproic acid (VPA) are known to affect body weight, and lipid profile. However, evidences regarding effects of AEDs on the body composition are deficient. This cross-sectional study compared the body composition and lipid profile among patients with epilepsy on newer and conventional AEDs. METHODS: The patients with epilepsy (n=109) on treatment with conventional and newer AEDs (levetiracetam, lamotrigine and clobazam) for > 6 months were enrolled. Of these, 70 were on monotherapy: levetiracetam (n=12), VPA (n=16), carbamazepine (n=20) and phenytoin (n=22) and the remaining on polytherapy. Their body composition [body fat mass, lean dry mass (LDM), total body water (TBW), intracellular water (ICW), extracellular water (ECW) and basal metabolic rate (BMR) was estimated and biochemical parameters were assessed. RESULTS: Levetiracetam group had no significant difference with VPA, carbamazepine, phenytoin and control groups, except low LDM (17.8±2.4) than VPA groups (20.2±2.7, p<0.05). In comparison with control, AEDs monotherapy groups had no significant difference, except higher LDM and ECW in VPA group. Among groups based on conventional and newer AEDs, there was no significant difference in body composition parameters except for higher LDM (as % of BW) in conventional AEDs only treated group than control (p<0.01). INTERPRETATION & CONCLUSIONS: The alterations observed in body composition with valproic acid in contrast to other AEDs like levetiracetam, carbamazepine and phenytoin could affect treatment response in epilepsy especially in subjects with already altered body composition status like obese and thin frail patients, which needs to be established by prospective studies (CTRI/2013/05/003701).

Effect of lamotrigine, levetiracetam & topiramate on neurobehavioural parameters & oxidative stress in comparison with valproate in rats.

BACKGROUND & OBJECTIVES: Though newer antiepileptic drugs are considered safer than conventional antiepileptics, the effects of lamotrigine, levetiracetam and topiramate on neurobehavioural functions are yet to be established. This study evaluated neurobehavioural parameters and oxidative stress markers in brain tissue of rats treated with lamotrigine, levetiracetam and topiramate compared to sodium valproate . METHODS: Five groups of male Wistar rats were treated respectively with normal saline (control), sodium valproate (370 mg/kg), lamotrigine (50 mg/kg), levetiracetam (310 mg/kg) and topiramate (100 mg/kg) for 45 days. Neurobehavioural parameters were assessed using elevated plus maze (EPM), actophotometer, rotarod, passive avoidance and Morris water maze (MWM) at baseline and at the end of treatment. Oxidative stress parameters [malondialdehyde (MDA), reduced glutathione (GSH) and superoxide dismutase (SOD)] were estimated in rat brain at the end of treatment. RESULTS: Valproate and lamotrigine showed no significant effect on learning and memory in passive avoidance and MWM tests. However, levetiracetam and topiramate reduced retention memory significantly as compared to control (P<0.01) and lamotrigine (P<0.05) groups. Performances on EPM, rotarod and actophotometer were not significantly different between the groups. In comparison to control group, MDA was higher in the levetiracetam and topiramate (360.9 and 345.9 nmol/g of homogenized brain tissue, respectively) groups. GSH and SOD activity were significantly reduced by valproate and levetiracetam treatment. Lamotrigine did not induce significant oxidative stress. INTERPRETATION & CONCLUSIONS: Long-term and therapeutic dose treatment with levetiracetam and topiramate significantly impaired learning and memory, which was not seen with valproate and lamotrigine in rats. Levetiracetam, topiramate and valproate augmented oxidative stress, whereas lamotrigine has little effect on it. These antiepileptic drugs are used in clinical practice, hence pharmaco- vigilance studies are required to evaluate their safety profile.

Obinutuzumab for chronic lymphocytic leukemia: promise of the first treatment approved with breakthrough therapy designation.

Obinutuzumab (also known as GA101, afutuzumab, Gazyva) is a humanized, glycoengineered type II monoclonal antibody targeted against CD20. The US Food and Drug Administration has approved obinutuzumab for use with chlorambucil in patients with previously untreated chronic lymphocytic leukemia. The drug is the first treatment to receive approval under the agency's breakthrough therapy designation, a program intended to facilitate and expedite the review and development of therapies for serious and life-threatening conditions. In preclinical studies, obinutuzumab has showed superior efficacy, as compared with rituximab, by inducing direct cell death and increased antibody-dependent cellular cytotoxicity activity with less complement-dependent cytotoxicity. Regulatory approval of obinutuzumab is based on a phase III (CLL11) study that demonstrated improved outcomes with a combination of obinutuzumab with chlorambucil in previously untreated patients with chronic lymphocytic leukemia and comorbidities. Obinutuzumab plus chlorambucil induced deeper and longer remissions than rituximab plus chlorambucil combination as evidenced by prolongation of progression-free survival and higher complete response and molecular response rates. Marketing applications for obinutuzumab have also been submitted to other regulatory authorities including the European Medicines Agency.

The evolving drug development landscape: from blockbusters to niche busters in the orphan drug space.

Strategy, Management and Health Policy Large pharmaceutical companies have traditionally focused on the development of blockbuster drugs that target disease states with large patient populations. However, with large-scale patent expirations and competition from generics and biosimilars, anemic pipelines, escalating clinical trial costs, and global health-care reform, the blockbuster model has become less viable. Orphan drug initiatives and the incentives accompanied by these have fostered renewed research efforts in the area of rare diseases and have led to the approval of more than 400 orphan products. Despite targeting much smaller patient populations, the revenue-generating potential of orphan drugs has been shown to be huge, with a greater return on investment than non-orphan drugs. The success of these "niche buster" therapeutics has led to a renewed interest from "Big Pharma" in the rare disease landscape. This article reviews the key drivers for orphan drug research and development, their profitability, and issues surrounding the emergence of large pharmaceutical firms into the orphan drug space.

Field based research in the era of the pandemic in resource limited settings: challenges and lessons for the future.

The coronavirus pandemic that began in December 2019, has had an unprecedented impact on the global economy, health systems and infrastructure, in addition to being responsible for significant mortality and morbidity worldwide. The "new normal" has brought along, unforeseen challenges for the scientific community, owing to obstructions in conducting field-based research in lieu of minimizing exposure through in-person contact. This has had greater ramifications for the LMICs, adding to the already existing concerns. As a response to COVID-19 related movement restrictions, public health researchers across countries had to switch to remote data collections methods. However, impediments like lack of awareness and skepticism among participants, dependence on paper-based prescriptions, dearth of digitized patient records, gaps in connectivity, reliance on smart phones, concerns with participant privacy at home and greater loss to follow-up act as hurdles to carrying out a research study virtually, especially in resource-limited settings. Promoting health literacy through science communication, ensuring digitization of health records in hospitals, and employing measures to encourage research participation among the general public are some steps to tackle barriers to remote research in the long term. COVID-19 may not be a health emergency anymore, but we are not immune to future pandemics. A more holistic approach to research by turning obstacles into opportunities will not just ensure a more comprehensive public health response in the coming time, but also bolster the existing infrastructure for a stronger healthcare system for countries.

Modified subretinal dye extrusion technique (MORE-DETECH): subretinal diluted trypan blue for detecting occult retinal breaks in retinal detachment after endotamponade removal.

To investigate the effectiveness of a new technique for the identification of occult retinal breaks in retinal redetachment after removal of silicone oil endotamponade. The technique involves injection of subretinal dye and extrusion through the unidentified breaks. A prospective interventional case series. Main outcome measures were rate of break detection, rate of retinal attachment at 3 months after removal of endotamponade, and improvement in visual acuity after surgery. A total of 21 patients fulfilled the study criterion. The occult rhegma could be identified successfully in all except two cases (90.4 % success). In most cases the rhegma was identified at the posterior edge of the laser retinopexy scar. Complete retinal attachment could be seen in all cases at 12 weeks after removal of silicone oil. The mean visual acuity improved from logMAR 1.4, preoperatively to logMAR 0.81 (p = 0.001) postoperatively. Subretinal dye injection was useful in detecting occult retinal breaks in patients with retinal redetachment and was helpful in preventing surgical failure.

Dipeptidyl peptidase 4 (DPP-4) inhibitors and the risk of lung cancer: current evidence and future directions.

INTRODUCTION: Recent evidence has linked long-term use of angiotensin converting enzyme (ACE) inhibitors with the risk of developing lung cancer by increasing levels of substance P (SP) and bradykinin in lung tissue. DPP-4 inhibitors, by virtue of their mechanism of action, may increase the level of SP and pose a similar risk of incident lung cancer. Concomitant use of DPP-4 inhibitors and ACE inhibitors may further exaggerate this plausible risk. AREA COVERED: Here we discuss both direct and indirect evidence involving mechanisms by which DPP-4 inhibitors may increase the risk of lung cancer in treated patients. We highlight that increased levels of SP with DPP-4 inhibitor monotherapy and raised levels of both SP and bradykinin with add-on ACE inhibitor therapy may further enhance this risk. EXPERT OPINION: DPP-4 inhibitors are prescribed in type-2 diabetes mellitus patients with or without cardiovascular disease. When used together, ACE inhibitors and DPP-4 inhibitors may act synergistically and further amplify the lung cancer risk. Consequently, physicians should consider this plausible association while prescribing them concomitantly especially in high-risk individuals. Well-planned research studies are required to assess the association of DPP-4 inhibitors with lung cancer and other adverse effects linked to increased levels of SP and bradykinin.

Effect of nutritional-deficiency anemia on peripapillary retinal nerve fiber layer: A North Indian study.

PURPOSE: The purpose of this study was to evaluate the effect of nutritional-deficiency anemia (NDA) on peripapillary retinal nerve fiber layer thickness (PPRNFLT) using spectral-domain optical coherence tomography and to determine any correlation arising thereof. This was a single-center, cross-sectional, observational study. MATERIALS AND METHODS: A total 115 eyes of 115 NDA patients (50 of each with iron-deficiency anemia [IDA] and Vitamin B12-deficiency anemia [BDA], and 15 with folic acid-deficiency anemia [FDA]) aged 18-65 years were compared with a total 100 eyes of 50 age- and sex-matched healthy controls. All subjects underwent comprehensive clinical, ophthalmic, and hematological evaluation, followed by PPRNFLT assessment for the mean total, superior, inferior, nasal, and temporal quadrants. RESULTS: PPRNFLT for the mean total and all four quadrants in IDA patients, for the mean total, inferior, nasal, and temporal quadrants in BDA patients, and for the mean total, inferior, and nasal quadrants, in FDA patients, was significantly lower as compared to the controls (P < 0.05). The mean total PPRNFLT of all NDA patients correlated significantly (P < 0.05) with their relevant hematological parameters with Pearson's coefficient (r) value of 0.613, 0.610, 0.336, 0.295, 0.337, 0.374, and - 0.509, respectively, for serum haemoglobin (Hb), iron, ferritin, mean corpuscular volume (MCV), mean cell hemoglobin, mean corpuscular hemoglobin concentration, and total iron binding capacity in IDA; 0.310, 0.435, and - 0.386, respectively, for serum Hb%, Vitamin B12, and MCV in BDA; and 0.557, 0.358, and - 0.294 for Hb%, folate, and MCV, respectively, in FDA cases. Mean total retinal nerve fiber layer thinning of all NDA patients showed progression with the increasing severity grades of anemia, except in very severe BDA where an inverse relationship was documented. CONCLUSION: Our study revealed that PPRNFLT is significantly thinner in all NDA patients (total and all four quadrants in IDA; total, inferior, nasal, and temporal in BDA; and total, inferior, and nasal in FDA) correlating well with their relevant hematological parameters. Early detection of this may be crucial in preventing potential blinding sequelae and differentiating glaucomatous and other neuro-ophthalmic disorders.

Intravenous BCAA Infusion Does Not Lead to a Sustained Recovery From Overt HE in ACLF - An Open Label Randomized Clinical Trial.

Background: Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE at 24 h, day 3, and day 7. The primary outcome was an improvement in encephalopathy by ≥ 1 grade at 72 h. Patients and methods: European association for study of liver (EASL) defined ACLF patients with overt HE were assessed and randomized into the experimental arm (IV-BCAA - 500 mL/day for 3 days + Lactulose; n = 39) and the comparator arm (Lactulose alone; n = 37). Six patients developed COVID-19 after randomization and were excluded (4-experimental arm and 2-comparator arm). Results: Of 222 screened patients, 70 (35 in each arm) were included in the analysis. Baseline characteristics, including HE grade (2.9 ± 0.7 vs 2.8 ± 0.7; P = 0.86) and (chronic liver failure) CLIF-C ACLF score (54.2 ± 5.6 vs 54.8 ± 5.7; P = 0.65), were similar. Overall survival was 40% at 28 days (48.5% vs 31.4%; P = 0.14). Improvement in hepatic encephalopathy scoring algorithm (HESA) by ≥ 1 grade at 24 h occurred in 14 patients (40%) in the BCAA arm and 6 patients (17.1%) in the control group (P = 0.03) which translated to a shorter intensive care unit (ICU) stay. The median change in HESA at 24 h was greater in the BCAA arm than the control arm (P = 0.006), which was not sustained at days 3 or 7. Ammonia levels did not correlate with the grade of HE (Spearman's correlation coefficient (ρ) = - 0.0843; P = 0.29). Conclusion: Intravenous BCAA does not lead to a sustained improvement in HE grade in ACLF. Trial registration no: NCT04238416 (clinicaltrials.gov).