Drug use in acute otitis media: a prospective study at a tertiary care teaching hospital

Background: Drug use study identifies the problems that arise from prescription and highlights the current approaches to the rational use of drugs. The objective of the study was to assess drug use pattern in patients diagnosed of acute otitis media in tertiary care teaching hospital.Methods: This prospective observational study was carried in the Otorhinolaryngology department of a tertiary care teaching hospital over a period of twelve months. The data collected for patients with acute otitis media included the patient's demographic details and the drugs prescribed. Data were analysed for drug use pattern and cost per prescription and assessment of rationality of prescription.Results: Total 153 patients were analysed, 100 (65.35%) belonged to male patients and 53 (34.65%) belonged to female patients. Children less than 2years age were the most diagnosed with AOM 47.71%, the major diagnostic symptoms were earache (58.16%) and fever (54.90%) and signs were congestion (52.94%) and discharge (43.13%). In a total 153 prescriptions (469 drugs), 33.68% were antimicrobials, followed by mineral supplements (23.67%). Average number of drugs per prescription was found to be 3.0. Most common antibiotic prescribed was amoxicillin (with or without clavulanate) in 142 (92.81%) patients. Paracetamol alone or in fixed dose combination with antihistaminics were prescribed in 131 patients. Average cost per prescription was 87.74(±35.67) Indian rupees. Seventeen (11.11%) prescriptions were rational in all the aspects based on standard guidelines.Conclusions: The present study showed that paracetamol and amoxicillin with or without clavulanate were mostly commonly prescribed in children with AOM. Irrational prescribing was seen in maximum number of cases.

Interaction of two memory enhancing herbal drugs Memory Plus and Mentat with diazepam and phenytoin sodium in mice.

Background: The non-medical self-administration of memory enhancing drugs is a common practice. Present study was designed to evaluate interactions of two such herbal drugs Memory Plus (MP) and Mentat, with other central nervous system (CNS) active drugs. Methods: Two activities - pentobarbitone sleeping time (PST) and maximal electroshock seizures (MES) were performed using adult albino mice weighing 25-30 g to observe the interactions of the herbal drugs with diazepam and phenytoin sodium, respectively. For each activity, animals were divided into seven groups of six mice each. Group I was a control group receiving 0.2 ml of 1% Tween 80 i.p/0.2 ml saline p.o, Group II, III and IV acute treatment groups; received single dose of herbal (2 mg/kg i.p MP or 200 mg/kg p.o Mentat) CNS-active drugs alone in subeffective doses group II - diazepam 5 mg/kg i.p, Group III PS 15 mg/kg i.p and Group IV - MP/Mentat+diazepam or PS, respectively. Groups V, VI, and VII were subchronic treatment groups, received drugs once daily for 8 days same as acute treatment groups. Sleeping time was measured as the interval between the loss and recovery of righting refl ex and anticonvulsant activity by giving supra maximal shock via ear electrodes using a techno electro convulsiometer. Results: Both MP and Mentat showed potentiation of effect of diazepam and PS in subchronic treatment groups by signifi cantly prolonging PST (p<0.05) and by showing signifi cant percentage protection in MES method (p<0.05) compared to control group. Conclusion: Subchronic administration of MP and Mentat shows significant interaction with diazepam and PS. Further human studies are warranted to confi rm these fi ndings.

Morbidity and drug utilization pattern among admitted pregnant anemic women and to find out rationality of drug by using Indian guidelines.

Background: Pregnancy represents a special physiological state during which the use of drug is of growing concern due to risk of teratogenicity. Anemia is common threat to mother. Therefore, our aim was to study the drug utilization, teratogenic risk among patients of anemia in pregnancy and check rationality of prescriptions. Methods: An observational, prospective study was carried out in 150 indoor patients in the tertiary care hospital. Protocol was approved by the Institutional Review Board. The data were collected in a pre-designed proforma. Data were analyzed using SPSS version 20.0 Software. Results: Among 150 patients, 23, 111, and 16 were of <20, 20-30 and more than 30 years of age respectively. Among anemic patients Pregnancy induced hypertension (18.7%), antepartum hemorrhage (12.7%) were common. About 71% women have complaint of weakness, followed by headache. Iron (93.3%) and calcium (86.0%) were the most common drugs prescribed. Iron sucrose and packed cell volume given in severe anemia. Drug risk category, Category A (90.21%) was most frequently prescribed, which is followed by Category B (8.0%) and Category C (1.8%). Percentage of drugs prescribed by generic name and from essential drug list was 70.3 and 89.2. Overall prescribing habit was rational according to Indian guideline. Conclusion: Iron, calcium, and folic acid were most commonly prescribed drugs in anemic patients. No teratogenic risk was found out during drug use. Drug and dose of the drug was rational and appropriate. There is lesser number of drugs prescribed by generic name and hospital supply.

A Patient with Tracheal Leiomyoma and Meningioma: A Case Report.

Most of the tumors that form in the trachea and bronchi in adults are malignant but a few are benign. Common benign tumors of the trachea are squamous cell papilloma, fibroma, hemangioma and leiomyoma. Leiomyoma of trachea constitute only 1% of the common benign tumors of the trachea and hence few cases are reported in the literature. Meningiomas are a diverse set of tumors arising from the meninges, majority of these tumors are usually benign and only 8% are either atypical or malignant, which could recur after treatment or removal. Presence of both this uncommon tumors in a single patient is quite rare. We present a case of a woman with both the tumors.

Study of potential drug-drug interactions between benzodiazepines and four commonly used antiepileptic drugs in mice.

Background: Benzodiazepines (BZD) is one of the commonly used drug groups for certain neurological diseases. As sometimes, the anti-epileptic drugs (AEDs) may be used concomitantly with BZD there is a potential for drug-drug interactions. Study aimed to study potential drug-drug interactions between four commonly used AEDs (phenytoin, carbamazepine (CBZ), phenobarbitone, sodium valproate) and BZD (diazepam, clonazepam) in mice using maximal electroshock seizure (MES) method and pentylenetetrazole (PTZ) method. Methods: Adult male albino mice were divided into four different groups of six animals each and anti-epileptic activity was assessed using MES method and PTZ method. Group I acted as a control, Group II received any one of the four AEDs (phenytoin, CBZ, phenobarbitone or sodium valproate) in sub-effective doses, Group III received diazepam or clonazepam alone, Group IV received a combination of diazepam or clonazepam with any one of the AEDs. Results: In MES method, the groups receiving combination of diazepam with phenytoin and CBZ showed significant protection compared to the control group (p<0.01 and p<0.02), respectively. However, diazepam in combination with sodium valproate and phenobarbitone did not show any significant protection compared to the control group and individual antiepileptic group. All the four antiepileptic showed significant protection against MES seizure in combination with clonazepam when compared to control group. In PTZ method, combination of sodium valproate with clonazepam showed significant protection compared to control group (p<0.02). However, this was not observed with diazepam-valproate combination. Conclusion: Clonazepam potentiates the action of all the four anti-epileptics while diazepam potentiates only phenytoin and CBZ against MES seizures. Clonazepam but not diazepam potentiates the action of sodium valproate against PTZ seizures.

Prescribing quality in patients with chronic diseases at primary and secondary health care facilities using prescription quality index tool.

Background: Prescribing quality is a matter of major concern worldwide. This study was carried out to determine the quality of prescribing in chronic diseases at primary health care (PHC) and secondary health care (SHC) settings using the new prescription quality index (PQI) tool. Methods: A cross-sectional observational study was carried out at four PHC and two SHC facilities in Anand district of India. Patients attending these facilities for at least 3 months were included. Complete medical history and prescriptions received were noted. Total and criteria wise PQI scores were derived for each prescription. Prescriptions were categorized as poor (score of ≤31), medium (score 32-33), and high quality (score 34-43) based on PQI total score. The internal consistency of PQI was measured using item total correlation and Cronbach’s α so as to validate it in our settings. Data were analyzed using Statistical Package for Social Science 20. Results: A total of 134 prescriptions were collected and evaluated for quality of prescribing. Mean age of patients was 60.6 ± 13.5 years. Mean PQI score was 23.60 ± 9.3 with 71.6% prescriptions being of poor quality. Quality of prescribing did not differ at PHC and SHC (P>0.05). Of 22 criteria, PQI score was strongly correlated with drug indication, drug effectiveness, evidence-based prescribing, unnecessary duplication, duration of therapy, and cost (P<0.01). PQI total score was negatively correlated to the number of drugs per prescription. Cronbach’s α for the entire 22 criteria were 0.90. Conclusion: PQI was found to be a reliable tool for assessment of prescribing quality in chronic diseases.

Prescription and cost-analysis of antiemetic medication use in pediatric wards: a prospective observational study .

Background: Use of anti-emetic drugs in pediatric population is often warranted, but choice of drug remains questionable within pediatricians. Objective of current study is: to study prescribing pattern and to calculate cost of antiemetic drug therapy in pediatric wards. Methods: A prospective, observational study was conducted in pediatric wards of a tertiary care hospital of over 14 month’s duration. Institutional ethics committee approval was obtained and written informed consent of parents/guardians was taken. Data of any pediatric patient receiving anti-emetic agent were included in the study. Results: A total of 218 prescriptions were collected. Mean age of patients was 4.39±3.16 (range 4 months to 12 years). Gastroenteritis was the most frequently diagnosed disease in 137(63%) patients. Domperidone was prescribed in 52.4% and ondansetron in 47.6% children. Oral liquid dosage formulation was prescribed in 109 (48.4%) followed by solid dosage form 47 (20.9%). Mean cost of domperidone therapy was 25.34±6.55 INR and for ondansetron it was 36.62±17.94 INR. Conclusions: Gastroenteritis was most frequent indication for use of anti-emetics. Domperidone pharmacotherapy was cheaper and most frequently prescribed than ondansetron.

To study cost effectiveness of topical permethrin versus oral ivermectin in patients of uncomplicated scabies.

Background: The objective of this study was to compare the cost and effectiveness of topical permethrin and oral ivermectin in the treatment of uncomplicated scabies. Methods: This was an open label randomized comparative study conducted in 210 patients, randomly allocated to two groups. First group received permethrin 5% cream as single application, second group received tablet ivermectin 200mcg/kg as single dose. All the patients received antihistaminic for pruritus. The patients were followed up at intervals of one, two, three and four weeks. If there were no signs of cure, the same intervention was repeated at each follow up. The cost effectiveness was calculated on the basis of total expenditure incurred on therapy. Results: At the end of first week cure rate was 74.8% in permethrin group, 30% in oral ivermectin group. At the end of second week cure rate was 99% in permethrin group, 60% in oral ivermectin group. At the end of third week 100% cure rate was observed in permethrin while 99% in oral ivermectin group. The total cost of treatment shows that cost of tab. ivermectin was less compared to permethrin 5% but the cost to relieve itching and cost of transport was higher than permethrin 5%. Conclusions: Topical permethrin is more cost effective than oral ivermectin in treatment of uncomplicated scabies.

Pattern of antidiabetic drugs use in type-2 diabetic patients in a medicine outpatient clinic of a tertiary care teaching hospital.

Background: Diabetes mellitus (DM) is an important public health problem in developing countries. Drug utilisation study of antidiabetic agents is of paramount importance to promote rational drug use in diabetics and make available valuable information for the healthcare team. The aim of study was to investigate the drug utilization pattern in type-2 diabetic patients. Methods: A prospective, cross-sectional study was carried out in medicine outpatient clinic of tertiary care hospital, Ahmedabad for eight weeks. Patients with type-2 diabetes and on drug therapy for at least one month were included. Patients’ socio-demographic and clinical data were noted in a pre-designed proforma. Data was analysed by using SPSS version 20 and Excel 2007. Results: Total 114 patients were enrolled with mean (± standard deviation) age and duration of diabetes of 56.8 ± 10.5 and 8.3 ± 9.4 years respectively. Male: Female ratio was 0.72:1. Mean fasting and postprandial blood glucose levels were 147.5 ± 73.1 and 215.6 ± 97.3 mg/dl respectively. Most common symptom was weakness/fatigue (77.2%). Hypertension (70.2%) was most common co-morbid illness. Mean number of drugs prescribed were 7.8 ± 2.5. Total numbers of patients receiving more than five drugs were 89.5%. Most commonly used drug group was biguanides (87.7%) followed by sulphonylureas (68.4%). Conclusion: Metformin (biguanide) was the most utilized (87.7%) antidiabetic drug for type-2 diabetes. This study revealed that the pattern of antidiabetic prescription was rational and largely compliant with NICE (National Institute for Health and Clinical Excellence) guidelines.

Study of drug utilization, morbidity pattern and cost of hypolipidemic agents in a tertiary care hospital.

Background: Data on the extent of use and costs of lipid-lowering agents are not widely available. Our aim was to study the drug utilization and morbidity pattern, cost of different hypolipidemic drugs along with the risk assessment for coronary heart disease. Methods: After approval of protocol by the Institutional Review Board, an observational, prospective study was carried out in 300 patients using NCEP and ATP III Guidelines-2002 for evaluation of presence or absence of risk factors for coronary heart diseases. Data were analysed using SPSS software version 16.0and WHO Core Drug Prescribing Indicators. Results: Patient’s morbidity pattern revealed that 62%, 49.3%, 28% suffered from ischemic heart disease, hypertension and type 2 diabetes mellitus respectively. On risk assessment, 48%, 13.3% patients had borderline and high level of total cholesterol respectively; 42%, 22.7% had borderline and high triglyceride levels respectively; 71.1% men and 62% women had low HDL cholesterol levels while 17.3%, 6% and 2.7% patients had borderline high, high and very high level of LDL cholesterol levels respectively. Frequency of prescriptions was atorvastatin (82%), rosuvastatin (9.3%) and simvastatin (4.7%) among the most frequently prescribed statins drug group. The mean number of drugs per prescription was 7.34. Drugs prescribed by generic name and from essential drugs list was 24.96% and 71.81% respectively. Mean cost of hypolipidemic agents/prescription/day was 10.74 (±1.96) Indian Rupees with rosuvastatin being the costliest. Conclusion: Rational use of hypolipidemic agents with an increasing trend of statins prescriptions will significantly reduce the morbidity and mortality from coronary heart diseases.

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.

Prevalence, pattern and perceptions of self-medication in medical students.

Background: The use of self-medication is highly prevalent in the community more so amongst the medical students. Self-medication can be defined as the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms. Aims and Objectives: To study the prevalence and pattern of use of self-medication among medical students from first year to internship. Methods: This cross sectional study was carried out among under graduate medical students including interns of Smt. NHL Municipal Medical College, Ahmedabad during the period of March 2010 to May 2010. Results: Out of 747 students and interns enrolled, 685 responded (91.7%). Out of 685 respondents 564 (82.3%) reported self-medication within one year of recall period. Most common conditions/symptoms for self-medication in students were fever (72.7%), headache (69.1%), upper respiratory tract infections (64.1%) followed by others like body-ache, abdominal pain, diarrhoea etc. Over the counter drugs (84.2%) was the most common category of drugs used by all the students except first year students who used prescription only drugs more frequently (48.5%). Herbal and Ayurvedic drugs were also used as self-medication (17.8%); most frequently by the first year students (22.7%). Conclusion: The pattern of self-medication practice changes with time and advancement of knowledge.

Newer approaches in the treatment of asthma.

Asthma is a worldwide public health problem. The most effective anti-asthmatic drugs - inhaled β2-agonists and glucocorticoids controls asthma in about 90-95% of patients. However, severe glucocorticoid-dependent and resistant asthma presents a great clinical burden. Therefore, reducing glucocorticoids - related adverse effects using novel steroid-sparing agents is needed. Furthermore, the mechanisms involved in the persistence of inflammation are poorly understood and the reasons why some patients have severe life threatening asthma and others have very mild disease are still unknown. Although glucocorticoids effectively control the inflammatory process in asthma, they have little effect on the lower airway remodeling processes that appear to play a role in the pathophysiology of asthma. Several new drugs developed to target specific components of the inflammatory process in asthma [e.g. anti-IgE antibodies (omalizumab), cytokines and/or chemokines antagonists, immunomodulators, antagonists of adhesion molecules)], have not yet been proven to be particularly effective. Hence, considering the central role of T lymphocytes in the pathogenesis of asthma, drugs targeting disease-inducing Th2 cells are promising future therapeutic strategies. Some of these new anti-asthmatic treatment approaches may in the future not only control symptoms and modify the natural course of asthma, but also potentially prevent or cure the disease. Hence, the development of novel drugs may allow resolution of these changes.

Comparative efficacy and safety of topical permethrin, topical ivermectin, and oral ivermectin in patients of uncomplicated scabies.

Background: Ivermectin has opened a new era in the management of scabies as orally effective drug. However, topical route has been little explored for ivermectin. Aims: To compare the efficacy and safety of topical permethrin, oral ivermectin, and topical ivermectin in the treatment of uncomplicated scabies. Methods: This was an open-label, randomized, comparative, parallel clinical trial conducted in 315 patients, randomly allocated to 3 groups. First group received permethrin 5% cream as single application, second group received tablet ivermectin 200 mcg/kg as single dose, and third group received ivermectin 1% lotion as single application. All the patients received anti-histaminic for pruritus. The patients were followed up at intervals of 1, 2, 3, and 4 weeks. If there were no signs of cure, the same intervention was repeated at each follow up. Primary efficacy variable was clinical cure of lesions. Statistical analysis was done by chi square test and one way ANOVA test using SPSS version 12. Results: At the end of first week, cure rate was 74.8% in permethrin group, 30% in oral ivermectin group, and 69.3% in topical ivermectin group (P < 0.05). At the end of second week, cure rate was 99% in permethrin group, 63% in oral ivermectin group, and 100% in topical ivermectin group (P < 0.05). At the end of third week, 100% cure rate was observed in permethrin and topical ivermectin group while 99% in oral ivermectin group (P = 0.367). No serious adverse events were observed. Conclusions: Permethrin and topical ivermectin were equally effective against scabies while oral ivermectin was significantly less effective up to 2 weeks. Topical ivermectin can be used as an alternative to permethrin.