TLR9 and MyD88 are crucial for the maturation and activation of dendritic cells by paromomycin–miltefosine combination therapy in visceral leishmaniasis

BACKGROUND AND PURPOSE

The combination of paromomycin–miltefosine is a successful anti-leishmanial therapy in visceral leishmaniasis (VL). This encouraged us to study its effect on Toll-like receptor (TLR)-mediated immunomodulation of dendritic cells (DC), as DC maturation and activation is crucial for anti-leishmanial activity.

EXPERIMENTAL APPROACH

In silico protein–ligand interaction and biophysical characterization of TLR9–drug interaction was performed. Interaction assays of HEK293 cells with different concentrations of miltefosine and/or paromomycin were performed, and NF-κB promoter activity measured. The role of TLR9 and MyD88 in paromomycin/miltefosine-induced maturation and activation of DCs was evaluated through RNA interference techniques. The effect of drugs on DCs was measured in terms of counter-regulatory production of IL-12 over IL-10, and characterized by chromatin immunoprecipitation assay at the molecular level.

KEY RESULTS

Computational and biophysical studies revealed that paromomycin/miltefosine interact with TLR9. Both drugs, as a monotherapy/combination, induced TLR9-dependent NF-κB promoter activity through MyD88. Moreover, the drug combination induced TLR9/MyD88-dependent functional maturation of DCs, evident as an up-regulation of co-stimulatory markers, enhanced antigen presentation by increasing MHC II expression, and increased stimulation of naive T-cells to produce IFN-γ. Both drugs, by modifying histone H3 at the promoter level, increased the release of IL-12, but down-regulated IL-10 in a TLR9-dependent manner.

CONCLUSIONS AND IMPLICATIONS

These results provide the first evidence that the combination of paromomycin–miltefosine critically modifies the maturation, activation and development of host DCs through a mechanism dependent on TLR9 and MyD88. This has implications for evaluating the success of other combination anti-leishmanial therapies that act by targeting host DCs.     

An update on pharmacotherapy for leishmaniasis

Introduction: Leishmaniasis broadly manifests as visceral leishmaniasis (VL), cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis. The treatment of leishmaniasis is challenging and the armamentarium of drugs is small, duration of treatment is long, and most drugs are toxic.

Areas covered: A literature search on treatment of leishmaniasis was done on PubMed. Single dose of liposomal amphotericin B (L-AmB) and multidrug therapy (L-AmB + miltefosine, L-AmB + paromomycin (PM), or miltefosine + PM) are the treatment of choice for VL in the Indian subcontinent. A 17-day combination therapy of pentavalent antimonials (Sb^v) and PM remains the treatment of choice for East African VL. L-AmB at a total dose of 18 – 21 mg/kg is the recommended regimen for VL in the Mediterranean region and South America. Treatment of CL should be decided by the severity of clinical lesions, etiological species and its potential to develop into mucosal leishmaniasis.

Expert opinion: There is an urgent need to implement a single-dose L-AmB or combination therapy in the Indian subcontinent. Shorter and more acceptable regimens are needed for the treatment of post – kala-azar dermal leishmaniasis. Combination therapy with newer drugs needs to be tested in Africa. Due to the toxicity of systemic therapy, a trend toward local treatment for New World CL is preferred in patients without risk of mucosal disease.     

A prospective study of adverse drug reactions to artemisinin-based combination therapy in a tertiary care hospital in India

Objectives:

Antimalarial drugs are commonly prescribed for the treatment of malaria and suspected cases of malaria in India. The recent trend is to prescribe ACT and the incidence of adverse reactions to this therapy is notwell-documented in Indian population. Therefore, this study was designed to assess ADR pattern of antimalarial drugs particularly ACT in India.

Materials and Methods:

Over a period of 1 year, 500 patients who were administered antimalarial drugs were enrolled in the study. The World Health Organization causality assessment scale was used for classifying the ADR.

Results:

In this study out of 500 patients, 251 complained of ADRs. The sex-wise difference in reporting of ADRs was statistically not significant (P=0.0943). The most common ADRs reported were nausea, anorexia and vomiting. ADRs were most commonly reported when chloroquine was coprescribed.

Conclusions:

This study indicates that ACT was commonlyused in the treatment of malaria. Results of the analysis suggest that all the ADRs were of moderate intensity and no serious ADR was observed. This baseline information will be useful to implement the ACT in India.KEY WORDS: Adverse drug reaction, antimalarial drugs, artemisinin, artemisinin-based combination therapy     

The effect of intracerebroventricular injection of histamine in visceral nociception induced by acetic acid in rats

Objective:

This study was designed to investigate the role of brain histamine and H1 and H2 receptors in mediating the central perception of visceral pain in rats.

Materials and Methods:

In conscious rats implanted with a lateral brain ventricle cannula, the effect of intracerebroventricular (i.c.v.) injection of histamine (2.5, 10, and 40 μg), and chlorpheniramine and ranitidine at the same doses of 5, 20, and 80 μg were investigated on visceral pain. Visceral nociception induced by intraperitoneal (i.p.) injection of acetic acid (1 mL, 1%), and the number of complete abdominal wall muscle contractions accompanied with stretching of hind limbs (writhes) were counted for 1 h.

Results:

Histamine at doses of 10 and 40 μg and chlorpheniramine and ranitidine at the same doses of 20 and 80 μg, significantly decreased the numbers of writhes (P < 0.05). Pretreatment with chlorpheniramine and ranitidine at the same dose of 80 μg, significantly prevented histamine (40 μg)-induced antinociception (P < 0.05).

Conclusion:

The results of this study suggest that brain histamine may be involved in modulation of visceral antinociception through both central H₁and H₂receptors.     

A comparative effect of atorvastatin with other statins in patients of hyperlipidemia

Objective:

The objective of the study was to evaluate the safety and efficacy of atorvastatin compared with simvastatin and pravastatin in patients of hyperlipidemia.

Materials and Methods:

This was a randomized, parallel group, open-label study conducted at KG hospital, Coimbatore, Tamilnadu, India. Twenty hyperlipidemia patients each taking atorvastatin 20 mg, pravastatin 20 mg and simvastatin 20 mg tablets were selected for the study after clinical and baseline investigations. The patients were reviewed after 3^rd and 5^th month of statin therapy for lipid profile. The liver enzyme levels (SGOT, SGPT, ALP), albumin, bilirubin, protein and biochemical infraction parameters (Creatine Kinase, Creatine Kinase - Myocardial Band) after 5^th month of treatment with statins were also reviewed.

Results:

The results showed that atorvastatin significantly reduced the lipid levels (LDL-C, TC, TG, VLDL) when compared to simvastatin and pravastatin after 3^rd and 5^th month of treatment. Atorvastatin increased the HDL-C levels significantly when compared to simvastatin and pravastatin after 5 months of treatment. Atorvastatin also significantly reduced the CK levels when compared to pravastatin but no increase in liver enzyme levels was observed.

Conclusion:

The study showed that atorvastatin is more effective when compared to simvastatin and pravastatin in patients with hyperlipidemia.KEY WORDS: Creatine kinase, creatine kinase - myocardial band, pravastatin, simvastatin     

Assessment of quality of life in epilepsy patients receiving anti-epileptic drugs in a tertiary care teaching hospital

Objectives:

Health-related quality of life (QOL) is an important outcome in epilepsy treatment. Very few studies have been carried out on the quality of life in epilepsy (QOLIE-31) in India. The present study aimed to determine the level of health-related QOLIE-31 in patients of epilepsy.

Materials and Methods:

This was a cross-sectional, questionnaire-based study conducted in a tertiary care teaching hospital. Respondents were adults aged at least 18-year-old with a diagnosis of epilepsy. QOLIE-31 was used for collecting data on health-related QOL. The unpaired t-test or one-way analysis of variance was used to compare means of QOL scores between groups.

Results:

Totally, 60 patients of epilepsy were included in the study. The mean (standard deviation) total score of QOLIE-31 was 64.61. A score of cognitive and medication effect were significantly better in carbamazepine group as compared to valproate group.

Conclusions:

Patients on monotherapy had a better QOL as compared to patients receiving polytherapy.KEY WORDS: Antiepiletic drugs, carbamazepine, phenytoin, QOL, seizure, valproate     

Efficacy and safety of anti-tuberculosis drugs in HIV-positive patients: A prospective study

Objectives:

To assess the efficacy and safety of anti-tuberculosis drugs in HIV-positive patients at a tertiary care teaching hospital.

Materials and Methods:

As a part of an ongoing study of opportunistic infections (OIs) in HIV-positive patients, drug treatment in patients suffering from tuberculosis was assessed to determine its efficacy and safety. Based on prevalence data for last three years, a purposive sampling of study population was carried out in this observational, prospective, single centre study. Tuberculosis (TB) was the most common OI observed. The selected patients were followed up for a period of one year to evaluate the clinical course and outcome of OIs, and the efficacy and safety of drugs used was checked.

Results:

Tuberculosis was observed in 89 out of 134 enrolled patients. These included 79 adults and 10 children. Males (66.2%) were commonly affected. Extra pulmonary TB (73%) was the most common manifestation with abdominal TB observed in 55 (61.7%) patients. All patients were treated in accordance with the Revised National Tuberculosis Control Programme (RNTCP) guidelines as recommended by National AIDS Control Organization (NACO), India. Outcome of TB was assessable in 70 patients. Majority (82.8%) of the patients were cured, while 12 patients (17.1%) died during the course of treatment. A total of 149 ADRs were observed in 67 (75.2%) patients. Majority of ADRs (n = 147) were non-serious and did not warrant a change in therapy. Discoloration of urine was the most common ADR observed.

Conclusion:

TB is the most common opportunistic infection in HIV-positive patients with abdominal TB being the most common manifestation. RNTCP and NACO guidelines are adhered to in these patients. Anti-tuberculosis drugs are well tolerated and effective in majority of the patients.KEY WORDS: Adverse drug reactions, anti-tuberculosis drugs, efficacy, HIV, safety, tuberculosis     

Nicotine quantity and packaging disclosure in smoked and smokeless tobacco products in India

Objectives:

A variety of smoked and smokeless tobacco products with varying nicotine content are accessible in India. Nicotine quantity in tobacco products has direct bearing on tobacco dependence. Our objective was to estimate nicotine content in various types of smoked and smokeless products. Disclosure for essential health warning was also checked.

Materials and Methods:

Liquid-liquid extraction was used for nicotine extraction and high-performance thin layer chromatography technique was applied for quantification of nicotine in seventy-one smoked and smokeless tobacco products.

Results:

Significant variation in nicotine content was observed across products. In smoked tobacco, nicotine content varied from 1.01 to 13.0 mg/rod, while in smokeless tobacco products it ranged from 0.8 mg/g to 50.0 mg/g. Moisture content varied from 9% to 21%.

Conclusion:

This work lists a range of smoked and smokeless tobacco products available in this region. We report a wide variability in nicotine quantity across smoked and smokeless tobacco products. Such variation in nicotine content may have important implications for tobacco cessation interventions and policiesKEY WORDS: High-performance thin layer chromatography, nicotine, packaging disclosures, tobacco, tobacco products     

Evaluation of antidepressant activity of tramadol in mice

Objective:

To evaluate antidepressant like effect of tramadol in mice.

Materials and Methods:

Tramadol was administered at three different doses (10,20 and 40 mg/kg, i.p) once daily for 7 days to Swiss albino mice of either sex. The immobility period of control and drug treated mice were recorded in tail suspension test (TST).The antidepressant effect of tramadol was compared to that of fluoxetine (20 mg/kg, i.p), administered for seven days.

Results:

Tramadol produced significant antidepressant effect at all the doses, as indicated by reduction in immobility times as compared to control. The efficacy of tramadol at doses of 20 and 40 mg/kg was comparable with that of fluoxetine. Tramadol at 10 mg/kg dose showed significantly less antidepressant activity compared to fluoxetine.

Conclusion:

The results of the present study indicate antidepressant like activity of tramadol.     

Diclofenac-induced biochemical and histopathological changes in white leghorn birds (Gallus domesticus)

Objective:

Objective: To evaluate diclofenac-induced biochemical and histopathological changes in White Leghorn birds.

Materials and Methods:

Six-week-old birds were equally divided into three groups of six birds each. Group I served as control and received vehicle orally. The birds of Group II and III were orally administered with a single low (2 mg/kg) and high dose (20 mg/kg) of diclofenac sodium, respectively, and were observed for 7 days. The acute toxicity was assessed by observing the clinical signs and symptoms, mortality, alterations in blood biochemistry, and necropsy findings.

Results:

The birds of Group II showed only mild symptoms of diarrhea. In Group III, 50% of birds died in between 24 and 36 h post-treatment showing the symptoms of segregatory behavior, lethargy, terminal anorexia, and severe bloody diarrhea. The birds of Group II and the surviving birds of Group III showed a significantly (P<0.05) increased plasma uric acid, creatinine and plasma glutamic pyruvic transaminase (PGPT), and decreased total protein and albumin at 12 and 24 h post-treatment which returned to the normal levels at 36 h post-treatment. The dead birds of the high-dose group also showed similar pattern of biochemical changes at 12 and 24 h post-treatment and revealed extensive visceral gout with characteristic histopathological lesions in liver, kidney, heart, spleen, and intestine on post-mortem.

Conclusion:

The results indicate that diclofenac sodium has hepatotoxic, nephrotoxic, and visceral gout inducing potentials in White Leghorn birds, especially at higher dose.     

Assessment of adherence to cardiovascular medicines in rural population: An observational study in patients attending a tertiary care hospital

Introduction:

Nonadherence to cardiovascular medicines is a major concern. It increases the morbidity and mortality of cardiovascular patients. The work was conducted to evaluate the adherence to cardiovascular medicines in patients of rural India.

Methods:

The study was conducted in the Department of Medicine involving rural patients with essential hypertension (HTN), congestive cardiac failure (CCF), and ischemic heart disease (IHD) over 12 months period. Patients were prescribed with cardiovascular medicines at the initial visit and adherence to medicines was assessed in the subsequent visit. Four items Morisky''s Medication Adherence Scale (MMAS-4) was used for assessing medication adherence. Patients were considered adherent to medication if they answered negatively to all four questions.

Results:

Overall adherence to medication was 20.83%, 28.37% and 32% in HTN, CCF, and IHD patients, respectively. Nonadherence was highest in patients of HTN. Among the four reasons of nonadherence assessed by MMAS-4, carelessness was the most common and forgetfulness was the least common cause of nonadherence in all the three groups of patients.

Conclusion:

Patients of rural India adhere poorly to cardiovascular medicines. Nonadherence should be considered as a public health problem. Strategies for detecting the level of adherence of cardiovascular medicines, its barriers, and subsequent interventions should be developed by policy-makers to reduce morbidity and mortality due to cardiovascular disorders.KEY WORDS: Cardiovascular medicines, congestive cardiac failure, essential hypertension, ischemic heart disease     

Loratadine versus levocetirizine in chronic idiopathic urticaria: A comparative study of efficacy and safety

Background:

Treatment of chronic idiopathic urticaria (CIU) is challenging because of its unpredictable course and negative influence on the quality of life. New treatments are being developed, but antihistaminics remain the cornerstone of the therapeutic approach. Newer generation antihistaminics such as loratadine and levocetirizine have already proved to be safe and efficacious for CIU.

Objective:

To choose the better drug between loratadine and levocetirizine for CIU, by comparing their efficacy and safety.

Methods:

A randomized, open, outdoor-based clinical study was conducted on 60 patients of CIU, to compare the two drugs. After initial clinical assessment and baseline investigations, loratadine was prescribed to 30 patients and levocetirizine to another 30 patients for four weeks. At follow-up, the patients were re-evaluated and then compared using different statistical tools.

Result:

The comparative study showed that the changes in differential eosinophil count (P = 0.006) and absolute eosinophil count (P = 0.003) in the levocetirizine group was statistically significant. The results of the Total Symptom Score showed better symptomatic improvement of CIU with levocetirizine as compared to loratadine. The overall incidence of adverse drug reactions was also found to be less in the levocetirizine group.

Conclusion:

An analysis of the results of all the parameters of safety and efficacy proves the superiority of levocetirizine over loratadine for CIU.     

Monitoring of incidence, severity, and causality of adverse drug reactions in hospitalized patients with cardiovascular disease

Background:

Patients admitted to cardiology department are mostly on polypharmacy. So drug-drug interactions and adverse effects of drugs are quite common. Yet, there is a paucity of data regarding adverse drug reaction (ADR) monitoring in cardiology department in India. The present study is an effort to fill up these lacunae.

Materials and Methods:

A prospective, observational study registering 966 indoor cardiology patients according to predetermined inclusion and exclusion criteria was conducted for one year. ADR profile was noted by spontaneous reporting and intensive monitoring. Naranjo ADR probability scale was used to establish the causality.

Results:

A total of 208 ADRs were reported from 188 patients (19.5%). Of these 188 patients, 62 patients (33%) were hospitalized primarily due to the development of ADRs, while 126 (67%) patients developed ADRs during hospital stay. Nitrates were the most common offender drug group (17.8%).

Conclusion:

Development of ADR in one of every five cardiac patient points toward a grave situation, but a higher incidence of Type A reactions in cardiology department means that these can be avoided.     

Protective effect of rutin on cognitive impairment caused by phenytoin

Objective:

To study the effect of the co-administration of phenytoin (PHT) and rutin in comparison with PHT and piracetam (PIM) on seizure control, cognitive, and motor functions in mice.

Materials and Methods:

Increasing current electroshock seizure (ICES) test was used to evaluate the effect of the co-administration of PHT and PIM on convulsions. Cognitive functions in mice were assessed by a spontaneous alternation in behavior on a plus maze while motor functions were screened using rolling roller apparatus and by counting the number of arms entries on a plus maze. Brain acetyl-cholinesterase (AChE) activity was also estimated.

Statistical Analysis:

The expression of data was done as mean ± standard error of the mean. The normally distributed data were subjected to one-way ANOVA followed by Dunnett''s test. P < 0.05 was considered significant.

Results:

The study showed that rutin when co-administered with PHT, significantly reversed PHT-induced reduction in spontaneous alternation without altering the efficacy of PHT against ICES, in both acute and chronic studies. Further, it also reversed PHT-induced increase in AChE activity.

Conclusion:

Rutin alleviated the PHT-induced cognitive impairment without compromising its antiepileptic efficacy.KEY WORDS: Acetyl-cholinesterase, cognitive functions, diphenylhydantoin, rutin     

Impact of visceral leishmaniasis and curative chemotherapy on cytochrome P450 activity in Brazilian patients

Aims

The aim of the present study was to investigate the impact of human visceral leishmaniasis (VL) and curative chemotherapy on the activity of cytochrome P450 (CYP) 3A, CYP2C9 and CYP2C19 in patients from an endemic region in Brazil.

Methods

Adult patients with parasitologically confirmed VL were given a CYP phenotyping cocktail, comprising midazolam, omeprazole and losartan, immediately before (Study phase 1), 2–3 days (phase 2) and 3–6 months (phase 3) after curative VL chemotherapy. CYP activity was assessed by the apparent clearance of midazolam (CYP3A), omeprazole/5-hydroxyomeprazol ratio in plasma (CYP2C19) and losartan/E3174 ratio in urine (CYP2C9).

Results

Mean values (95% confidence interval) in phases 1, 2 and 3 were, respectively: log apparent midazolam clearance, 1.21 (1.10–1.31), 1.45 (1.32–1.57) and 1.35 (1.26–1.44) ml min^–1 kg^–1; omeprazole/5-hydroxyomeprazole ratio, 0.78 (0.61–0.94), 0.45 (0.27–0.63) and 0.37 (0.20-0.55); losartan/E3174 ratio, 0.66 (0.39–0.92), 0.35 (0.20–0.50) and 0.35 (0.16–0.53). Analysis of variance revealed significant differences in CYP3A (P = 0.018) and CYP2C19 (P = 0.008), but not CYP2C9 (P = 0.11) phenotypic activity, across the three study phases.

Conclusion

The phenotypic activities of CYP3A4 and CYP2C19 were significantly reduced during acute VL compared with post-chemotherapy. We propose that increased plasma concentrations of proinflammatory cytokines during active disease account for the suppression of CYP activity. The failure to detect significant changes in CYP2C9 activity in the overall cohort may reflect differential effects of the inflammatory process on the expression of CYP isoforms, although the possibility of insufficient statistical power cannot be dismissed.     

A double-blind, randomized, multicentric, placebo-controlled clinical trial of antarth, a phytomedicine, in the treatment of osteoarthritis

Objective:

To test Antarth, a polyherbal phytomedicine, for its efficacy and safety in patients with osteoarthritis (OA) and compared with placebo.

Material and Methods:

A total of 90 male or female adult patients who were diagnosed clinically and radiologically with OA were recruited in the study. Antarth or placebo was given 2 capsules b.i.d. for 3 months and the patients were assessed every month for its efficacy. Diclofenac sodium was allowed to be taken as rescue medication.

Results:

After 3 months of treatment, the reduction in severity of pain on Visual Analog Scale (VAS) was more in Antarth group compared to placebo but the difference between the two groups was not significant. However, pain during functioning of disabled joints while walking distance, squatting, sitting cross-legged and climbing steps were significantly reduced in Antarth group compared to placebo (P < 0.05). Reduction in consumption of rescue medication, diclofenac sodium, was more in Antarth than in placebo group.

Conclusions:

In Patients’ Global Assessment, patients treated with Antarth were more satisfied than the ones treated with placebo. Observations were similar in Physicians’ Global Assessment too. There were no adverse events in both the groups.     

Evaluation of efficacy of combination of methotrexate and hydroxychloroquine with leflunomide in active rheumatoid arthritis

Background:

Several new drugs for rheumatoid arthritis are available including leflunomide. Comparative studies of treatment with leflunomide (against methotrexate) report a better quality of life.

Aim:

This study was designed to evaluate the efficacy of combination of methotrexate and hydroxychloroquine with leflunomide, a new disease modifying antirheumatoid drug. Analysis was of intent to treat group.

Materials and Methods:

This was an open labeled, randomized, comparative clinical trial in the department of rheumatology and immunology, at a tertiary care center in Bangalore. Patients who have diagnosed with rheumatoid arthritis as per American College of Rheumatology aged between 18 and 60 years were recruited and randomized to receive leflunomide (10 mg/day p.o.) or a combination of methotrexate and hydroxychloroquine (7.5 mg/week p.o. and 200 mg/day p.o., respectively) along with folate supplementation for 12 weeks. The European League Against Rheumatism criteria of improvement according to disease activity score 28 was considered as the primary efficacy variable. Baseline and end of study values were evaluated. The duration of the study period was 1 year. Analysis of variance (ANOVA) and Wilcoxon Signed rank test were used for statistical analysis.

Results:

After 12 weeks, improvement noted in patients treated with leflunomide was similar to those treated with a combination of methotrexate and hydroxychloroquine. There was no statistical significance in improvement in disease activity between the two groups (P = 0.377).

Conclusion:

Combination of methotrexate and hydroxychloroquine is equivalent to leflunomide in terms of efficacy in reducing disease activity in the initial treatment of severe rheumatoid arthritis.     

A comparative study of dalteparin and unfractionated heparin in patients with unstable angina pectoris

Objective:

To compare the efficacy and safety profile of dalteparin, a low-molecular-weight heparin with a standard unfractionated heparin in patients with unstable angina pectoris.

Materials and Methods:

This was a 6-month, prospective, parallel, randomized and open-labeled study. Patients of angina pectoris were randomized to receive either unfractionated heparin or dalteparin for 5 days. They were followed for 21 days during three visits on 1^st, 5^th and 21^st days. A series of resting electrocardiogram were undertaken in all patients on each visit.

Results:

The frequency of the combined clinical outcome of death, myocardial infarction and recurrence of angina was similar during 21 days of follow-up with either dalteparin or intravenous unfractionated heparin. In patients who received dalteparin 2.43% patients developed minor bleeding in the form of epistaxis and 2.5% patients who received unfractionated heparin developed minor bleeding in the form of macroscopic hematuria.

Conclusion:

Dalteparin is as effective and safe as unfractionated heparin in the treatment of unstable angina. Dalteparin does not require routine laboratory monitoring as with unfractionated heparin.KEY WORDS: Anticoagulant, bleeding, low-molecular-weight heparin, unstable angina