Retrospective Observational Study to Evaluate Causality, Preventability and Severity of Adverse Drug Reaction Associated with Anticancer Drugs in a Tertiary Care Hospital in Northern India.

BACKGROUND: Chemotherapy has high efficacy, but it is associated with several adverse drug reactions (ADRs). OBJECTIVES: A retrospective observational study to explore the prevalence, causality, and preventability of ADRs of anticancer agents was conducted. METHODS: The study was carried out at Punjab Institute of Medical Sciences Jalandhar, Punjab after obtaining IEC approval. The data was collected from cancer patients undergoing treatment at the hospital. The causality assessment of the collected data was done by using WHO causality assessment criteria. The preventability and severity of the reported ADRs were also assessed. RESULTS: From 50 medical records, a total of 47 ADRs were recorded among 25 patients, out of which 16 were females and the rest were males. The cancer cases observed were breast carcinoma, leukaemia, lung, colon, and ovarian cancer. The highest number of ADRs were observed with alkylating agents, followed by taxanes, antimetabolites, kinase inhibitors, and monoclonal antibodies. The most affected organ systems were the gastrointestinal system, blood, and lymphatic system. According to the causality assessment, the majority of the ADRs were of the "possible" category. Preventability analysis showed that 85.11% of ADRs were unavoidable reactions, while 14.89% of ADRs were possibly avoidable. Severity analysis of ADRs showed that 87.23% of ADRs were mild and 12.77% were of moderate severity. The majority of the ADRs were unavoidable and mild to moderate in severity. CONCLUSION: Since the majority of the ADRs were of the unavoidable category, it indicates that the treatment regimens are acceptable as per the current clinical management of cancer patients.

Cefixime-associated acute generalized exanthematous pustulosis: Rare cases in India.

BACKGROUND: Cefixime is a widely used third-generation cephalosporin schedule H1 drug, which is prescribed for the treatment of otitis media, respiratory tract infections, and uncomplicated urinary tract infections and is effective against infections caused by Enterobacteriaceae and Haemophilus influenzae species in India. The National Coordination Centre (NCC)-Pharmacovigilance Programme of India (PvPI), Indian Pharmacopoeia Commission (IPC), has received rare individual case safety reports (ICSRs) for acute generalized exanthematous pustulosis (AGEP) associated with the use of cefixime. MATERIALS AND METHODS: IPC, NCC-PvPI also acts as a national collaborating center for pharmacovigilance activities under the aegis of Ministry of Health and Family Welfare, Government of India; moreover, it is a member country in global pharmacovigilance system, World Health Organization-Uppsala Monitoring Centre, Sweden. There are more than 250 government/corporate medical colleges and hospitals acting as regional adverse drug reaction monitoring centers, actively functioning under PvPI. Furthermore, various stakeholders including consumers and pharmaceutical industries also play a significant contribution. NCC-PvPI receives spontaneous ICSRs from various stakeholders. RESULTS: NCC-PvPI, IPC has received a total of four spontaneous ICSRs for cefixime-induced AGEP. After clinical evaluation of reported ICSRs, a strong causal relationship was established between AGEP and cefixime and was supported by published literature and histopathological examination of skin. Based on the statistics with positive information component (IC025 Value: 0.17) and proportionality relative risk (PRR:3.4), PvPI considered cefixime-associated AGEP may be a potential signal. CONCLUSION: Hence, initially, AEGP is considered by PvPI as drug safety alert in July 2016. Therefore, to enhance the safety of population in rational usage of medication, as a result, there is a need for physicians and health-care professionals to sensitize about serious adverse reaction while prescribing the cefixime as signal in India.

Augmentation of hepatoprotective potential of Aegle marmelos in combination with piperine in carbon tetrachloride model in wistar rats.

The current study investigated hepatoprotective and antioxidant effects of Aegle marmelos leaves extract. The major constituent present in the extract i.e. rutin was quantified by using HPLC. Further, the study explored hepatoprotective effect of A. marmelos (70% ethanol extract) in combination with piperine. The normal control and carbon tetrachloride (CCl4) administered rats were divided into 7 groups. Hepatic damage biomarkers were determined in serum samples and oxidative stress biomarkers (malondialdehyde, reduced glutathione, glutathione reductase, glutathione peroxidase, glutathione-S-transferase, superoxide dismutase and catalase), pro-inflammatory and anti-inflammatory cytokines were determined in liver homogenates. CCl4 caused marked liver damage as evident by significant increased activities of serum alkaline phosphatase, bilirubin, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, Interleukin 10 and Tumor necrosis factor-α levels compared to normal control. The oxidative stress parameters also significantly modulated in CCl4 group as compared to normal control. Treatment with A. marmelos reduced the severity of toxicity in a dose dependent fashion and the results of A. marmelos extract 50 mg/kg group were comparable to silymarin group. The low dose of A. marmelos extract (25 mg/kg) per se did not significantly reversed the hepatotoxicity but low dose of A. marmelos in combination with piperine showed significant reversal of hepatotoxicity. In conclusion, A. marmelos exerts potential hepatoprotective activity through its antioxidant and anti-inflammatory properties which was enhanced by co-treatment with piperine.

Drug safety alerts of pharmacovigilance programme of India: A scope for targeted spontaneous reporting in India.

BACKGROUND: The National Coordination Centre-Pharmacovigilance Programme of India (NCC-PvPI), Indian Pharmacopoeia Commission works under the aegis of Ministry of Health and Family Welfare, Government of India. It promotes patient safety in India and also supports postmarketing surveillance programs. Currently, almost hundred thousand case reports are submitted to NCC-PvPI each year through its 250 ADR Monitoring Centers (AMCs) located across India, and India is the one of the top ten contributor countries under WHO-Uppsala Monitoring Centre since 2012 and start issuing drug safety alerts from March 2016. AIM: This study aims to highlight the drug safety alerts issued by NCC-PvPI from March 2016 to June 2017 and urgent need for further monitoring by adopting targeted spontaneous reporting (TSR) methodology at AMCs and its impact on the NCC's drug safety database, i.e., VigiFlow in India. METHODOLOGY: A retrospective analysis was done for the reported unlisted ADRs by various AMCs to PvPI through VigiFlow, i.e., individual case safety report (ICSR) management system at NCC, where these unlisted drug-ADR combinations considered and issued as drug safety alerts for further reporting these to NCC, if any detected at healthcare settings during routine clinical practice by healthcare professionals. RESULTS: From July 2011 to June 2017, NCC-PvPI was collated 250,787 ICSRs and contributed to WHO international drug safety database, i.e., VigiBase, from these ICSRs; NCC-PvPI was issued 56 drug safety alerts from March 2016 to June 2017. CONCLUSION: In India, spontaneous reporting of ADRs existed since 1998 under passive surveillance method, but there is an urgent need to initiate TSR, which is a complementary method to spontaneous reporting on these drug safety alerts for further regulatory action by Central Drugs Standard Control Organization.

Hepatoprotective effect of Aegle marmelos augmented with piperine co-administration in paracetamol model

ABSTRACT The current study explored hepatoprotective effect of Aegle marmelos (L.) Corrêa, Rutaceae, leaves extract. Potentiation of A. marmelos hepatoprotective effect with piperine co-administration was also explored. Wistar rats were randomly divided into seven groups: (i) normal control, (ii) paracetamol group, (iii) silymarin group, (iv) extract-25 group (25 mg/kg body), (v) extract-50 group: (50 mg/kg), (vi) extract-100 group (100 mg/kg) and (vii) extract-25 + piperine group. Hepatotoxicity was induced by administering paracetamol orally in a dose of 400 mg/kg for seven days. The drugs were administered 30 min prior to paracetamol administration and continued for seven days. Animals were 'sacrificed' at the end of treatment and serum was collected for evaluating alkaline phosphatase, bilirubin, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase IL-10 and TNF-α levels. Liver homogenates were used for determination of oxidative stress (malondialdehyde, reduced glutathione, superoxide dismutase, catalase, glutathione reductase, GSH-S-transferase, glutathione peroxidase and glucose-6-phosphate dehydrogenase). Serum biochemical markers were significantly higher in paracetamol group as compared to normal control group. Significant increase in oxidative stress parameters and inflammatory mediators was also observed. Treatment with A. marmelos curtailed the toxic effects of paracetamol in a dose dependent fashion. 100 mg/kg dose of A. marmelos was found to be most hepatoprotective. The results of extract-100 group were comparable to silymarin group. Low dose of A. marmelos i.e., 25 mg/kg was combined with piperine to evaluate potentiation of hepatoprotective effects of A. marmelos. Piperine co-administration potentiated the hepatoprotective effects, because the combination group results were comparable to high dose A. marmelos group. A. marmelos exerts hepatoprotective activity through its antioxidant and anti-inflammatory properties which was enhanced by piperine.

The novel role of ß-aescin in attenuating CCl4-induced hepatotoxicity in rats.

CONTEXT: ß-Aescin has anti-inflammatory, anti-oxidant and antiedematous properties. OBJECTIVE: The present study investigated the hepatoprotective effect and underlying mechanisms of ß-aescin in CCl4-induced liver damage. MATERIALS AND METHODS: Thirty-five Wistar rats were divided into six groups: normal control, CCl4 control, silymarin (50 mg/kg, p.o) and ß-aescin (0.9, 1.8 and 3.6 mg/kg, i.p.) treatment for 14 d. CCl4 (1 mL/kg, i.p. for 3 d) was administered to produce hepatic damage. Ponderal changes and liver marker enzymes were estimated. Hepatic oxidative and nitrosative stress was estimated by levels of thiobarbituric acid reactive substances (TBARS), glutathione (GSH) and nitrite/nitrate. Serum TGF-ß1 and TNF-α were estimated by ELISA technique. Hepatic collagen and histopathological studies were carried out. RESULTS: ß-Aescin (3.6 mg/kg) markedly decreased CCl4-induced increased levels of ALT, AST, ALP (71.77 versus 206.7, 71.39 versus 171.82, 121.20 versus 259 IU/L, respectively), total bilirubin (0.41 versus 1.35 mg/dL), TBARS (2.0 versus 8.83 nmol MDA/mg protein), nitrite/nitrate (352.50 versus 745.15 µg/mL) and increased CCl4-induced decreased GSH levels (0.095 versus 0.048 µmol/mg protein). ß-Aescin (3.6 mg/kg) induced focal regenerative changes in liver and markedly decreased TBARS (2.0 versus 8.83 nmol MDA/mg protein), nitrite/nitrate (352.50 versus 745.15 µg/mL), TGF-ß1 (92.28 versus 152.1 pg/mL), collagen content (110.75 versus 301.74 µmol/100 mg tissue) and TNF-α (92.82 versus 170.56 pg/mL) when compared with CCl4 control. DISCUSSION AND CONCLUSION: The findings suggest that ß-aescin has a protective effect on CCl4-induced liver injury, exhibited via its anti-inflammatory, antioxidative, antinitrosative and antifibrotic properties inducing repair regeneration of liver. Hence, it can be used as a promising hepatoprotective agent.

Calendula officinalis ameliorates l-arginine-induced acute necrotizing pancreatitis in rats.

CONTEXT: Calendula officinalis L. (Asteraceae) has been traditionally used in treating inflammation of internal organs, gastrointestinal tract ulcers and wound healing. OBJECTIVE: The present study investigates the effect of ethanol extract (95%) of Calendula officinalis flowers in l-arginine induced acute necrotizing pancreatitis in rats. MATERIALS AND METHODS: Rats were divided into four groups: normal control, l-arginine control, Calendula officinalis extract (COE) treated and melatonin treated (positive control), which were further divided into subgroups (24 h, day 3 and 14) according to time points. Two injections of l-arginine 2 g/kg i.p. at 1 h intervals were administered in l-arginine control, COE and melatonin-treated groups to produce acute necrotizing pancreatitis. Biochemical parameters [serum amylase, lipase, pancreatic amylase, nucleic acid content, total proteins, transforming growth factor-ß1 (TGF-ß1), collagen content, lipid peroxidation, reduced glutathione and nitrite/nitrate] and histopathological studies were carried out. RESULTS: COE treatment (400 mg/kg p.o.) was found to be beneficial. This was evidenced by significantly lowered histopathological scores (2 at day 14). Nucleic acid content (DNA 21.1 and RNA 5.44 mg/g pancreas), total proteins (0.66 mg/mL pancreas) and pancreatic amylase (1031.3 100 SU/g pancreas) were significantly improved. Marked reduction in pancreatic oxidative and nitrosative stress; collagen (122 µmoles/100 mg pancreas) and TGF-ß1 (118.56 pg/mL) levels were noted. Results obtained were comparable to those of positive control. DISCUSSION AND CONCLUSION: The beneficial effect of COE may be attributed to its antioxidant, antinitrosative and antifibrotic actions. Hence, the study concludes that COE promotes spontaneous repair and regeneration of the pancreas.

Protective effect of Mimosa pudica L. in an L-arginine model of acute necrotising pancreatitis in rats.

Mimosa pudica is used in traditional medicine for treating various disorders such as inflammatory conditions, diarrhoea, insomnia, alopecia, urogenital infections and wounds. The present study investigated the effect of M. pudica extract (MPE) on L-arginine-induced acute necrotising pancreatitis in rats. The ethanolic extract of M. pudica leaves was studied for the presence of quercetin and gallic acid using high-performance liquid chromatography. Four groups were employed-normal control rats, L-arginine control rats (two intraperitoneal [i.p.] injections of 2 g/kg at an interval of 1 h), MPE-treated rats (400 mg/kg orally) and melatonin-treated rats (positive control 10 mg/kg i.p.), which were further divided into subgroups according to time points (24 h, 3 days and 14 days). Serum amylase, lipase, tumour necrosis factor-α (TNF-α), pancreatic amylase, nucleic acid content, protein, transforming growth factor-ß1 (TGF-ß1), thiobarbituric reactive substances, glutathione, nitrite/nitrate, collagen content and histopathological examination were carried out. MPE significantly improved acute necrotising pancreatitis by modulating diagnostic markers of pancreatitis such as serum lipase and pancreatic amylase, inflammation (TNF-α), and oxidative and nitrosative stress. Moreover, MPE administration induced regenerative changes in the pancreas evidenced by increased levels of pancreatic proteins, nucleic acid content and histopathology report. In addition, MPE improved TGF-ß1 and collagen levels thereby preventing fibrosis. The current investigation indicates the novel role of MPE in reducing the severity of acute necrotising pancreatitis by plausible mechanisms such as anti-inflammatory and anti-fibrotic activity and by promoting repair and regeneration of the pancreas.

Hepatoprotective effect of trans-Chalcone on experimentally induced hepatic injury in rats: inhibition of hepatic inflammation and fibrosis.

The current study investigated the hepatoprotective effect of trans-Chalcone in carbon tetrachloride (CCl4) and paracetamol (PCM) induced liver damage in rats. Administration of CCl4 and PCM (1 mL/kg, i.p., 3 days, and 2 g/kg, p.o., single dose, respectively) produced hepatic injury. Ponderal changes (percent change in body mass and relative liver mass) and biochemical parameters (serum ALT, AST, ALP, bilirubin) were estimated. The markers of oxidative and nitrosative stress (TBARS, reduced GSH, nitrite and nitrate), hepatic fibrosis (TGF-ß1, collagen content), hepatic inflammation (TNF-α), and histopathological study were evaluated. trans-Chalcone (5, 10, and 20 mg/kg, i.p.) was found to be beneficial as demonstrated by significant reversal of liver histology by perceptible reduction of inflammatory cell infiltration with regenerative changes in hepatocytes. Improvement in percent change in body mass and significant reduction in relative liver mass were observed. Marked reduction in serum levels of ALT, AST, ALP, and bilirubin were noted. Decreases in TBARS and nitrites and nitrates and increases in reduced GSH levels were noted. Hepatic fibrosis and inflammation were significantly decreased. The findings indicate a novel hepatoprotective role for trans-Chalcone by improving hepatic injury by possible actions such as anti-oxidant, anti-nitrosative, anti-fibrotic, and anti-inflammatory. Hence, it can be used as promising hepatoprotective agent.

Optimization and development of Nisoldipine nano-bioenhancers by novel orthogonal array (L27 array).

Our key objective was an attempt to apply a novel statistical method intended for designing, optimizing and developing Nisoldipine nano-bioenhancers using Taguchi (3 × 3=L27) design. This quality improvement orthogonal design array (L27) was used as a mathematical tool to find and study the response prediction of independent as well as significant variables (A=poly-concentration; B=bio-enhancer and C=ratio of organic medium). The array orthogonal (3 × 3=L27) at each level/spaces has been studied with respect to responses changeable (dependent factors); entrapment enhancement (X; evaluated using particle size; Y). All through experimentally performed runs, the results showed independent variables effect individually or simultaneously on changeable (dependent) variables. It also predicted significant variable via its "better to best" optimized spaces (independent level) and would be considered as novel statistically advanced oral drug delivery vehicle for anti-hypertensive agents.

Rosiglitazone promotes pancreatic regeneration in experimental model of acute pancreatitis.

Acute pancreatitis is an inflammatory disease of the pancreas caused by release of activated digestive enzymes in the pancreas. A number of therapeutic options have been explored for acute pancreatitis, but none has been unambiguously proven to be effective. Rosiglitazone has been shown to be efficacious in acute pancreatitis; thus, the present study was planned to evaluate the effect of rosiglitazone on pancreatic regeneration. Pancreatitis was induced by l-arginine in rats which were divided into three groups: cholecystokinin (CCK-8), rosiglitazone and vehicle. Rats were sacrificed at four time points after induction of pancreatitis i.e. 24h, day 3, day 14 and day 28 for determination of biochemical parameters and histological examination. Rate of DNA synthesis, immunohistochemistry and RT-PCR were performed at day 3 and day 7. Drug administration was started 2h after last L-arginine injection and continued till the day of sacrifice. The lower levels of enzyme in rosiglitazone-treated group compared to vehicle group proved the efficacy of rosiglitazone treatment in reducing severity of acute pancreatitis. The nucleic acid content and rate of DNA synthesis were significantly higher in rosiglitazone group indicating promotion of pancreatic regeneration. The histopathological score were lower in rosiglitazone group. Rosiglitazone treatment promoted pancreatic regeneration after acute injury. Currently, only symptomatic treatment is available, regeneration of pancreatic tissue can be a future strategy in the management of acute pancreatitis. Further studies are required to support the findings of the present study.

Beneficial effects of Emblica officinalis in L-arginine-induced acute pancreatitis in rats.

Acute necrotizing pancreatitis is characterized by focal macroscopic or diffuse necrosis, hemorrhage, and vascular thrombosis of the pancreas. Current treatment options are limited to supportive and symptomatic interventions. A large amount of experimental work is ongoing to identify novel therapeutic agents for acute pancreatitis. The present study was carried out to explore the beneficial effects of Emblica officinalis, a medicinal plant of India, on acute pancreatitis. Ascorbic acid is one of the major chemical components of E. officinalis, so a vitamin C group was included for comparison. Acute pancreatitis was induced by L-arginine. Rats were divided into the following groups: control (saline), arginine + saline, arginine + E. officinalis, and arginine + vitamin C. Animals in each group were sacrificed at 24 hours and 3, 14, and 28 days after pancreatitis induction for determination of biochemical parameters and histological examination. For rate of DNA synthesis and immunohistochemical studies, animals were sacrificed on Day 3 and Day 7. Drug administration was started 2 hours after the last arginine injection and continued until the day of sacrifice. E. officinalis treatment was found to be beneficial for treating acute pancreatitis. Serum levels of lipase and interleukin-10 were significantly lower than in the arginine group. Nucleic acid content, rate of DNA synthesis, pancreatic proteins, and pancreatic amylase content were significantly improved. Histopathological examination showed significantly lower total scores in the Emblica group. Vitamin C was found to be less efficacious than E. officinalis for all outcome parameters. Thus E. officinalis treatment was found to be beneficial in acute necrotizing pancreatitis.

Melatonin treatment is beneficial in pancreatic repair process after experimental acute pancreatitis.

Current treatment options for acute pancreatitis are supportive and symptomatic. Due to lack of agents targeting the underlying pathophysiology a large amount of experimental work is going on to identify novel therapeutic agents. The present study was carried out to explore if melatonin can modulate the spontaneous regeneration process of the pancreas after experimentally induced acute pancreatitis. Rats were given two i.p. injections of l-arginine in a dose of 200mg/100g at an interval of 1h for induction of pancreatitis. After this rats were randomly divided into three groups i.e. saline, CCK-8 and melatonin. Drug treatment was started 2h after the last l-arginine injection and continued till the day of sacrifice. An additional only saline treated control group was included for comparison. Animals in each group were sacrificed at 24h, days 3, 14 and 28 after pancreatitis induction for determination of biochemical parameters (serum amylase, lipase and IL-10 and pancreatic amylase, total proteins and nucleic acid content) and histological examination. For rate of DNA synthesis and immunohistochemical studies animals were sacrificed at day 3 and day 7. Melatonin treatment was found to be beneficial in acute pancreatitis. Severity of acute pancreatitis was significantly reduced in melatonin group. Nucleic acid content, rate of DNA synthesis, pancreatic proteins and pancreatic amylase content were significantly improved. Histopathological examination showed significantly lower total scores in melatonin group. Results of melatonin group were comparable to that of positive control, CCK-8 group. Thus melatonin treatment was found to promote the spontaneous regeneration process of pancreatic tissue.

Effect of nimesulide co-administration on pharmacokinetics of lithium.

In a crossover study, lithium was given orally at a dose of 56 mg/kg, prepared as suspension (0.5%) in carboxymethyl cellulose (CMC) and blood samples (1 ml) collected after 0-24 hr after drug administration. After a washout period of two weeks, nimesulide (10 mg/kg) was administered alongwith lithium (56 mg/kg) and blood samples were drawn at the same time intervals (0-24 hr) after drug administration. Plasma was separated and assayed for lithium by M 654 Na+/K+/Li+ analyzer and various pharmacokinetic parameters were calculated. C(max), K(el), t(1/2el) and AUC(0-alpha) of lithium were significantly increased when nimesulide was administered along with lithium as compared to control group.