Commentary: Discussing the antidepressant potential of silymarin

The therapeutic potential of diet, dietary supplements, herbal remedies, and nutraceuticals for treatment of depression and anxiety is being increasingly explored. In this commentary, we discuss the recent findings on the antidepressant potential of silymarin (SILY) in mice and present an alternative approach. We highlight the extensive research on another phytochemical, curcumin, for the treatment of depression and anxiety. Finally, we suggest a future application, which investigates the potential synergistic effects of combined treatment with SILY and curcumin for depression.

In silico insight into Amurensinine - an N-Methyl-D-Aspartate receptor antagonist

BACKGROUND

Some isopavines can exhibit important biological activity in the treatment of neurological disorders since it is considered an antagonist of the specific N-methyl-D-Aspartate (NMDA) receptor. Amurensinine is an isopavine which still has few studies. In view of the potential of isopavines as NMDA receptor antagonists, theoretical studies using bioinformatics were carried out in order to investigate whether Amurensinine binds to the NMDA receptor and to analyze the receptor/Ligand complex. This data can contribute to understanding of the onset of neurological diseases and contribute to the planning of drugs for the treatment of neurological diseases involving the NMDA receptor.

AIM

To investigate the interaction of the antagonist Amurensinine on the GluN1A/ GluN2B isoform of the NMDA receptor using bioinformatics.

METHODS

The three-dimen-sional structure of the GluN1A/GluN2B NMDA receptor was selected from the Protein Data Bank (PDB) - PDB: 4PE5, and the three-dimen-sional structure of Amurensinine (ligand) was designed and optimized using ACD/SchemsketchTM software. Prediction of the protonation state of Amur-ensinine at physiological pH was performed using MarvinSketch software (ChemAxon). Protonated and non-protonated Amurensin were prepared using AutoDock Tools 4 software and simulations were performed using Autodock Vina v.1.2.0. The receptor/Ligand complexes were analyzed using PyMol (Schrödinger, Inc) and BIOVIA Discovery Studio (Dassault Systemes) software. To evaluate the NMDA receptor/Amurensinine complex and validate the molecular docking, simulations using NMDA receptor and Ifenprodil antagonist were performed under the same conditions. Ifenprodil was also designed, optimized and protonated, under the same conditions as Amurensinine.

RESULTS

Molecular docking simulations showed that both non-protonated and protonated Amurensinine bind to the amino terminal domain (ATD) domain of the GluN1A/GluN2B NMDA receptor with significant affinity energy, -7.9 Kcal/mol and -8.1 Kcal/mol, respectively. The NMDA receptor/non-protonated Amurensinine complex was stabilized by 15 bonds, while the NMDA receptor/protonated Amurensinine complex was stabilized by less than half, 6 bonds. Despite the difference in the number of bonds, the variation in bond length and the average bond length values are similar in both complexes. The complex formed by the NMDA receptor and Ifenprodil showed an affinity energy of -8.2 Kcal/mol, a value very close to that obtained for the NMDA receptor/Amurensinine complex. Molecular docking between Ifenprodil and the GluN1A /GluN2B NMDA receptor demonstrated that this antagonist interacts with the ATD of the receptor, which validates the simulations performed with Amurensinine.

CONCLUSION

Amurensinine binds to the NMDA receptor on ATD, similar to Ifenprodil, and the affinity energy is closer. These data suggest that Amurensinine could behave as a receptor inhibitor, indicating that this compound may have a potential biological application, which should be evaluated by in vitro and preclinical assays.

Recurrent ciprofloxacin induced hypoglycemia in a non-diabetic patient: A case report

BACKGROUND

Fluoroquinolones are a class of broad-spectrum antimicrobials used for various bacterial infections. Frequent use of fluoroquinolones has been questioned due to severe associated adverse effects, including dysglycemia (hypoglycemia or hyperglycemia) due to an alternation in glucose metabolism. Recent clinical trials showed the association of poor clinical outcomes with hypoglycemia in critically ill patients without diabetes. Many predisposing factors worsen fluoroquinolone-induced hypoglycemia, including diabetes, concomitant medication use like sulfonylureas or insulin, renal disease, and the elderly.

CASE SUMMARY

We report a case of recurrent hypoglycemia after ciprofloxacin initiation for a 71-year-old, non-diabetic, critically ill patient despite the presence of total parenteral nutrition and nasogastric tube feeding. The adverse drug reaction probability (Naranjo) scale was completed with a probable adverse drug reaction. The hypoglycemia resolved entirely after ciprofloxacin discontinuation.

CONCLUSION

Although ciprofloxacin-induced hypoglycemia is rare, special consideration is needed for the elderly due to their higher susceptibility to adverse side effects.

Pharmacokinetics/Pharmacodynamics study of Fixtral SB as compared to supra bioavailable itraconazole and conventional itraconazole

BACKGROUND

Itraconazole is a broad-spectrum triazole antifungal inhibiting fungal growth by inhibiting ergosterol synthesis and exhibits a nonlinear pharmacokinetic profile. Erratic absorption pattern with wide fluctuations in blood levels causes inconsistent and unpredictable clinical behaviour of this drug despite its low minimum inhibitory concentration (MIC) as compared to other antifungal agents.

AIM

To compare the oral bioavailability and bioequivalence of Fixtral SB (supra bioavailable itraconazole) with reference product R2 (supra bioavailable 2 × 50 mg itraconazole).

METHODS

The study population consisted of 54 healthy volunteers, aged between 18-45 years and randomized to receive a single oral dose of either test [T; Fixtral SB (supra bioavailable itraconazole) 100 mg] or reference product (R1; Sporanox 100 mg × 2 capsules and R2; Lozanoc capsules 50 mg × 2 capsules). Blood samples were taken pre-dose and post-dose up to 96 h. The study evaluated bioequivalence by comparing the oral bioavailability of the test product with reference product R2. The pharmacodynamic characteristics of the drug were evaluated by comparing the test product with reference product R1. Pharmacokinetics (PK)-PD comparative analysis [area under the concentration-time curve (AUC)/ minimum inhibitory concentration (MIC) > 25] was performed for conventional itraconazole 100 mg and supra bioavailable itraconazole 50 mg. Adverse events (AEs) assessments were performed in each study period and post-study evaluation.

RESULTS

Statistical analysis of primary PK variables revealed bioequivalence, with confidence intervals being completely inside the acceptance criteria of 80%-125%. The peak concentration levels of itraconazole were achieved at 10 h (T) and 8.5 h (R2), respectively. Pharmacodynamic parameter assessment showed that AUC/MIC for R1 are comparable to Fixtral SB 100mg for MIC levels up to 16mcg/mL (P > 0.05 and observed P = 0.3196). Six AEs were observed that were mild to moderate in severity and resolved. No severe AE was reported.

CONCLUSION

Test product itraconazole Capsule 100 mg is bioequivalent with the reference product (R2) at 100 mg dose (2 capsules of Lozanoc^® 50 mg) under fed conditions. Pharmacodynamics activity in terms of AUC/MIC is comparable between the test product at 100 mg dose and marketed itraconazole 200 mg. Fixtral SB is expected to have therapeutically similar efficacy at half the equivalent dose. Tested formulations were found to be safe and well tolerated.

Antibiotic residues in milk and milk products: A momentous challenge for the pharmaceutical industry and medicine

Dairy products are nutritious food items that contain various essential nutrients, however, it has been proven that residual antibiotics have contaminated such products. These residues can cause several side effects on human health. They increase antimicrobial resistance against several threatening microorganisms, as well as significant growth in allergenic reactions. Various methods, including heat treatments, have been applied to alleviate and reduce the effect of antibiotic residue level in milk and milk products. Changes in drug levels were not significantly remarkable, obliging researchers to find new approaches to prevent or reduce their risk and limit their complications on human health.

Antidepressant-like potential of silymarin and silymarin-sertraline combination in mice: Highlighting effects on behaviour, oxidative stress, and neuroinflammation

BACKGROUND

Currently, there is increasing advocacy for the use of diet, dietary supplements, and herbal remedies in depression management.

AIM

To determine the antidepressant effects of standardized silymarin (SILY) extract either as a sole agent or as an adjunct in depression therapy.

METHODS

Adult mice were assigned into three main groups based on the neurobehavioural models; and each main group had ten treatment groups of 10 mice each. Treatment groups were: Vehicle control group, oral sertraline (SERT) group, two groups fed SILY)-supplemented diet (SILY at 140 and 280 mg/kg of feed, respectively), dexamethasone (DEX; i.p.) group, DEX/SERT group, two groups of DEX/SILY (SILY at 140 and 280 mg/kg of feed, respectively), and another two groups of (SERT/DEX/SILY) (SILY at 140 and 280 mg/kg of feed, respectively, plus i.p. DEX plus SERT). Duration of the study was 7 wk, and treatments were administered daily.

RESULTS

SILY (alone) increased body weight, open field locomotor activity, rearing, and grooming; it also enhanced spatial working memory while decreasing anxiety-related behaviours and behavioural despair. SILY also improved antioxidant status while decreasing lipid peroxidation, acetylcholinesterase activity, and inflammatory markers. Neuronal integrity of the cerebral cortex and hippocampus was preserved. Overall, when administered alone or with SERT, SILY counteracted DEX-induced behavioural and biochemical changes while preserving neuromorphological integrity.

CONCLUSION

In conclusion, SILY is beneficial in mitigating DEX-induced central nervous system and other related changes in mice.

Controversial usages of kratom (Mitragyna speciosa): For good or for evil

Kratom (Mitragyna speciosa) is a plant that grows well in tropical climates such as in Southeast Asia. Traditionally, people discovered it possessed a stimulating effect that relieved tiredness. Furthermore, it contains analgesic and medicinal properties for the treatment of pain, diarrhea, muscle discomfort, and blood pressure and to enhance stamina. Nevertheless, long term or regular consumption of kratom leads to addiction. This is because the main alkaloid of kratom, mitragynine, binds to opioid receptors and exerts a euphoric effect similar to that of morphine, which may lead to death. Due to this reason, kratom has been listed as a regulated substance in many countries including the United States, Thailand, Malaysia, Bhutan, Finland, Lithuania, Denmark, Poland, Sweden, Australia, and Myanmar. Usages of kratom carry two pharmacological effects depending on dosage. Low-dose kratom exerts a stimulating effect that refreshes the user. High-dose kratom exerts sedative effects that can lead to addiction similar to that of morphine. Despite the euphoric effect of kratom, the beneficial values of kratom to human health is indisputable. Therefore, a complete banning of kratom may cause a loss to pharmaceutical industry. Rather, a controlled or selective usage of kratom will be a better choice.

Botanical, chemical, and pharmacological characteristics of Lomatogonium rotatum: A review

Lomatogonium rotatum (L. rotatum) Fries ex Nym, a dry whole grass belonging to the family Gentianaceae, is widely used to treat liver diseases in Mongolian medicine. In Mongolian medicine, L. rotatum Fries ex Nym, also known as Digeda, is a rare medicinal herb with low yield and widespread clinical use. Currently, it is included in over 25 traditional Mongolian medicine prescriptions that help reduce heat, dispel xieri, enhance stomach function, and heal wounds. Recent studies have shown that L. rotatum Fries ex Nym contains a variety of metabolites, including flavonoids, xanthone compounds, terpenoids, organic acids, steroids, and alkaloids. In addition, its anti-hepatitis B, anti-inflammatory, anti-acute liver injury, and anti-obesity effects have been proven by pharmacological studies. In this review, we summarize the ecological resources, traditional pharmacodynamics, chemical constituents, and pharmacological actions of L. rotatum Fries ex Nym, with an aim to provide a theoretical basis for future applied research and new product development.

Mammalian target of rapamycin-novel insight for management of inflammatory bowel diseases

Inflammatory bowel diseases (IBDs), with blurred etiology, show a rising trend and are of global concern. Of various factors involved in IBD pathogenesis and development, inflammation has been shown to play a major role. Recognition of the molecular and cellular pathways that induce IBD is an emerging subject to develop targeted therapies. Mammalian target of rapamycin (mTOR) is one the most common receptors of many inflammatory pathways, including that of IBD. To this end, we intend to overview the mTOR inhibitors for their possible efficacy in present and future approaches to treatment of IBD.

Treatment of SARS-CoV-2 (COVID-19): A safety perspective

The goal of this review is to report a balanced perspective of current evidence for efficacy of treatments for coronavirus disease 2019 (COVID-19) against the historical safety of these treatments as of May 2021. We preselected therapies of interest for COVID-19 based on national guidelines and modified over time. We searched PubMed and Medline for these specific COVID-19 treatments and data related to their efficacy. We also searched for prior randomized controlled trials of each therapy to assess adverse effects, and we obtained the Food and Drug Administration Approval label for this information. Several drugs have been approved for the treatment of COVID-19, and many more are under study. This includes dexamethasone, remdesivir, hydroxychloroquine/chloroquine, lopinvir/ritonavir, interferon or interleukin inhibitors, convalescent plasma and several vitamins and minerals. The strongest evidence for benefit is mortality benefit with dexamethasone in patients with COVID-19 and hypoxemia, although there is a signal of harm if this is started too early. There are several other promising therapies, like interleukin inhibitors and ivermectin. Hydroxychloroquine/chloroquine, lopinvir/ritonavir, and convalescent plasma do not have enough evidence of benefit to outweigh the known risks of these drugs.

Advances in the treatment of nonalcoholic steatohepatitis

Nonalcoholic steatohepatitis is a subtype of metabolic dysfunction-associated liver disease which has emerged as one of the most common causes of cirrhosis and liver transplantation in the United States and many western countries. The two leading risk factors associated with nonalcoholic steatohepatitis are obesity and insulin resistance with patients often demonstrating features of the metabolic syndrome. Histological improvement including arrest or improvement in fibrosis can occur in patients who are able to modify these risk factors when diagnosed early in the course of their disease. In addition to the development of cirrhosis and its life-threatening complications including hepatocellular carcinoma, variceal bleeding, ascites and hepatic encephalopathy, nonalcoholic steatohepatitis is also associated with coronary artery, carotid artery and peripheral vascular disease with coronary artery disease identified as the most common cause of death. Although multiple clinical trials evaluating a variety of medications targeted at different aspects in the pathogenesis and progression of nonalcoholic steatohepatitis have been completed and are still in progress, there is currently no approved treatment for this disease except for risk factor modification. This article will review the most recent and salient medical advances in the treatment of nonalcoholic steatohepatitis.

Bacterial biofilms in human gastrointestinal tract: An intricate balance between health and inflammatory bowel diseases

Inflammatory bowel disease (IBD) has been a worldwide health problem. It is characterized by severe intestinal inflammation due to immune responses against the gut microbes in genetically susceptible individuals. The understanding of gut microbiota for its composition and complex interaction in normal and diseased conditions has been assisted by the use of molecular, metagenomics and meta transcriptomics studies. The alteration of intestinal microbiota is the key determinant in the degree of inflammation caused and the prolonged course of disease. The relationship between luminal gut bacteria and innate immunity is also of prime significance. Such developments have further led to the search of specific (including bacteria and fungi) as a causative agent of IBD. Although detailed research has been done for the role of gut microbiota in IBD, molecular mechanisms and related gene expression are still not well understood in this disease, which hampers the generation of effective therapeutic agents for IBD. This paper assessed various factors contributing to IBD, genetic dysbiosis and pathogenic influence in the gut microbiota, interactions such as microbiome-host immune system interaction and microbe-microbe interactions involved in IBD, currently available IBD therapies, followed by a detailed review on bacterial infections that might be involved in IBD, globally and specifically in India.

Tobacco smoking and its drug interactions with comedications involving CYP and UGT enzymes and nicotine

Tobacco smoking is a global public health threat causing several illnesses including cardiovascular disease (Myocardial infarction), cerebrovascular disease (Stroke), peripheral vascular disease (Claudication), chronic obstructive pulmonary disease, asthma, reduced female infertility, sexual dysfunction in men, different types of cancer and many other diseases. It has been estimated in 2015 that approximately 1.3 billion people smoke, around the globe. Use of medications among smokers is more common, nowadays. This review is aimed to identify the medications affected by smoking, involving Cytochrome P450 (CYP) and uridine diphosphate-glucuronosyltransferases (UGTs) enzymes and Nicotine. Polycyclic aromatic hydrocarbons (PAHs) of tobacco smoke have been associated with the induction of CYP enzymes such as CYP1A1, CYP1A2 and possibly CYP2E1 and UGT enzymes. The drugs metabolized by CYP1A1, CYP1A2, CYP2E1 and UGT enzymes might be affected by tobacco smoking and the smokers taking medications metabolized by those enzymes, may need higher doses due to decreased plasma concentrations through enhanced induction by PAHs of tobacco smoke. The prescribers and the pharmacists are required to be aware of medications affected by tobacco smoking to prevent the toxicity-associated complications during smoking cessation.

Pharmacology and clinical applications of flupirtine: Current and future options

Flupirtine is the first representative in a class of triaminopyridines that exhibits pharmacological properties leading to the suppression of over-excitability of neuronal and non-neuronal cells. Consequently, this drug has been used as a centrally acting analgesic in patients with a range of acute and persistent pain conditions without the adverse effects characteristic of opioids and non-steroidal anti-inflammatory drug and is well tolerated. The pharmacological profile exhibited involves actions on several cellular targets, including Kv7 channels, G-protein-regulated inwardly rectifying K channels and γ-aminobutyric acid type A receptors, but also there is evidence of additional as yet unidentified mechanisms of action involved in the effects of flupirtine. Flupirtine has exhibited effects in a range of cells and tissues related to the locations of these targets. In additional to analgesia, flupirtine has demonstrated pharmacological properties consistent with use as an anticonvulsant, a neuroprotectant, skeletal and smooth muscle relaxant, in treatment of auditory and visual disorders, and treatment of memory and cognitive impairment. Flupirtine is providing important information and clues regarding novel mechanistic approaches to the treatment of a range of clinical conditions involving hyper-excitability of cells. Identification of molecules exhibiting specificity for the pharmacological targets (e.g., Kv7 isoforms) involved in the actions of flupirtine will provide further insight into clinical applications. Whether the broad-spectrum pharmacology of flupirtine or target-specific actions is preferential to gain benefit, especially in complex clinical conditions, requires further investigation. This review will consider recent advancement in understanding of the pharmacological profile and related clinical applications of flupirtine.

Kv7 channels a potential therapeutic target in fibromyalgia: A hypothesis

Fibromyalgia is characterized by the primary symptoms of persistent diffuse pain, fatigue, sleep disturbance and cognitive dysfunction. Persistent pain conditions, such as fibromyalgia, are often refractory to current available therapies. An involvement of K⁺ channels in the pathophysiology of fibromyalgia is emerging and supported by drug treatments for this condition exhibiting action at these molecular processes. K⁺ channels constitute potential novel target candidates for pain therapy offering peripheral and/or central actions. The Kv7 channel activators, flupirtine and retigabine, have exhibited pharmacological profiles compatible to the requirements needed for use as a therapeutic approach to fibromyalgia. Clinical trials to address the multidimensional challenges of fibromyalgia with flupirtine and retigabine will provide important insight to the role of K⁺ channels in this condition.

Tenofovir induced severe thrombocytopenia

Tenofovir disoproxil fumarate is used in the management of hepatitis B and human immunodeficiency virus infection. We present a 50 years old lady, post liver transplant, who was switched over from entecavir to tenofovir, for management of hepatitis B reactivation. She developed bleeding diathesis and severe thrombocytopenia was detected on investigations. Bone marrow examination showed normocellular marrow with megakaryocytes. Tenofovir was stopped and she was started on intravenous immunoglobulin, followed by steroids. There was improvement in platlet counts. The case highlights a rare side effect of tenofovir therapy.

Emerging pharmacological strategies for the treatment of fibromyalgia

Fibromyalgia (FM) has been described as a chronic clinical condition related to multisensory hypersensitivity presenting with a complex of symptoms dominated by chronic widespread pain associated with the existence of a range of co-morbidities, such as fatigue, sleep disturbance, cognitive impairment, anxiety and depression. Current treatments include drugs that target serotonin and noradrenaline levels within the central nervous system, e.g., tricyclic antidepressants, serotonin noradrenaline reuptake inhibitors, and voltage-gated calcium channel subunit ligands, e.g., gabapentin and pregabalin. Investigation of a range of novel targets, such as melatoninergic, cannabinoid, dopamine, NMDA, angiotensin, orexin and opioid receptors, and ion channels, in addition revisiting bioamine modulation and subunits has provided efficacy outcomes that improve the health status of patients with FM. Nevertheless, modest and limited efficacy is often observed reflecting the heterogeneity of FM with existence of subpopulations of patients, the contribution of peripheral and central components to the pathophysiology, and the extensive range of accompanying co-morbidities. The complexity and multidimensional nature of FM is emphasized by the diversity of pharmacological targets gaining interest. Clues to underlying mechanisms which offer themselves as novel and potential targets for new medications are being provided by advances in the understanding of the pathophysiology of FM.

Innovate combination of sevoflurane dilution in dimethyl sulfoxide: A stability study by gas chromatography and nuclear magnetic resonance

AIM

To investigate physicochemical stability of sevoflurane in dimethyl sulfoxide using gas chromatography with a flame ionization detector and nuclear magnetic resonance (NMR).

METHODS

Undiluted sevoflurane, plus dilutions 1:2, 1:5, 1:10, 1:25, and 1:50 in dimethyl sulfoxide were prepared in a vertical laminar flow cabinet class II type B and stored at different temperatures (23 °C, 6 °C, and -10 °C) for 45 d. Sterile 1 mL polypropylene amber syringes to minimize light degradation, caps and needles were used. The presence of sevoflurane and its degradation products in the samples was determined by gas chromatography with flame ionization detector (260 °C, 40 min), and by ¹H, ¹⁹F, and proton-decoupled ¹⁹F nuclear magnetic resonance.

RESULTS

The gas chromatography analysis showed sevoflurane and dimethyl sulfoxide (DMSO) retention times were 2.7 and 13.0 min, respectively. Pure DMSO injection into the column resulted in two additional peaks at 2.1 and 2.8 min. The same sevoflurane peak at 2.7 min was observed in all the dilutions at -10 °C, 4 °C and 25 °C. The NMR spectra showed signals consistent with the sevoflurane structure in all the dilutions at -10 °C, 4 °C and 25 °C. In the ¹H spectrum, two signals corresponding to the sevoflurane molecule were observed at 5.12 and 4.16 parts per million (ppm). In the ¹⁹F-NMR spectrum, two signals were observed at chemical shift -76.77 ppm and chemical shift -157.13 ppm. In the ¹⁹F{¹H}-NMR CPD, two signals were observed at chemical shift -76.77 ppm and chemical shift -157.13 ppm. The first one showed a doublet (J^F-F = 3.1 Hz) which integrated by six fluorine nuclei from the hexafluoro-isopropyl group. The second signal was integrated by a fluorine atom and showed a septuplet (J^F-F = 3.1 Hz).

CONCLUSION

This study shows that different concentrations of sevoflurane in dimethyl sulfoxide retain their chemical composition after exposure to different temperatures for a period of 45 d.

Long-term potentiation in autonomic ganglia: Potential role in cardiovascular disorders

Ganglionic long-term potentiation (gLTP) is an activity-dependent, enduring enhancement of ganglionic transmission. This phenomenon may be induced in autonomic ganglia of an organism under certain conditions where repetitive impulses surge from the central nervous system (CNS) to the periphery. Chronic stress, repetitive epileptic seizure or chronic use of CNS stimulants could induce gLTP, which would result in a long lasting heightening of sympathetic tone to the cardiovascular system causing hypertension and disturbed cardiac rhythm that may lead to sudden cardiac death. These conditions are briefly reviewed in this article.

Novel strategies for the treatment of diabetic macular edema

Macular edema such as diabetic macular edema (DME) and diabetic retinopathy are devastating back-of-the-eye retinal diseases leading to loss of vision. This area is receiving considerable medical attention. Posterior ocular diseases are challenging to treat due to complex ocular physiology and barrier properties. Major ocular barriers are static (corneal epithelium, corneal stroma, and blood-aqueous barrier) and dynamic barriers (blood-retinal barrier, conjunctival blood flow, lymph flow, and tear drainage). Moreover, metabolic barriers impede posterior ocular drug delivery and treatment. To overcome such barriers and treat back-of-the-eye diseases, several strategies have been recently developed which include vitreal drainage, laser photocoagulation and treatment with biologics and/or small molecule drugs. In this article, we have provided an overview of several emerging novel strategies including nanotechnology based drug delivery approach for posterior ocular drug delivery and treatment with an emphasis on DME.

Adalimumab and pharmacokinetics: Impact on the clinical prescription for inflammatory bowel disease

Anti-tumor necrosis factor (TNF) drugs are widely prescribed for inflammatory disease. A loss of response to adalimumab is frequent and the pharmacokinetics of anti-TNF therapy have important implications for patient management. Individual factors such as albumin, body weight, and disease severity based on the C-reactive protein level influence drug metabolism. Adalimumab trough levels are associated with clinical remission. On the other hand, the detection of antibodies is associated with clinical relapse. Immunosuppressive therapy could reduce antibody formation although the clinical impact is not proven. New algorithms are available to provide personalized treatment and adapt the dosage. More data are needed on dose de-escalation.

Non-selective beta-blockers in cirrhosis: Current concepts and controversies

Non-selective beta-blockers (NSBBs) have been at the forefront in the management of portal hypertension in liver cirrhosis for the last three decades, a trusty component in the armamentarium of the Hepatologist. The role of beta-blockers has been cemented for years in cardiac disease including angina, hypertension and in heart failure, however NSBBs with their non-selective effects on β1 and β2 receptors have led to them fondly being termed “the hepatologist’s aspirin”. NSBBs’ role in reduction of portal pressure in the setting of primary and secondary prophylaxis for variceal haemorrhage has been well established. NSBBs include propranolol, nadolol and carvedilol - with the latter having been shown to be effective in patients who often fail to demonstrate a haemodynamic response to propranolol. Recent observational studies however have served for the Hepatology community to question the beneficial role of NSBBs in portal hypertension, especially in advanced cases with refractory ascites. The deleterious effect in patients with refractory ascites in a few studies led to a U-turn in clinical practice, with some in the Hepatology community withdrawing their usage in patients with advanced cirrhosis. This also led to the “window hypothesis” suggesting there may be only be a finite time frame when NSBBs have a beneficial effect in portal hypertension. The window hypothesis proposed the window for the benefits of NSBBs is closed in early portal hypertension, opening as portal hypertension progresses with it closing in advanced liver disease. The window was proposed to close in conditions such as refractory ascites or spontaneous bacterial peritonitis when patients may not necessarily mount a compensatory haemodynamic response when on NSBBs. Some centres however have continued the practice of NSBBs in advanced cirrhosis with published data challenging the scepticisms of other groups who stop NSBBs. Thus the debate, like the window hypothesis has opened, with more questions to be answered about NSBB’s mechanism of action not only in reducing portal hypertension but also their effects on systemic haemodynamics and on the pro-inflammatory pathways often activated in cirrhosis especially in advanced disease. This article serves to review the role of NSBBs in the management of portal hypertension/cirrhosis and concentrate on current concepts and controversies in this field.

Allosteric modulation of cholinergic system: Potential approach to treating cognitive deficits of schizophrenia

Schizophrenia is a psychiatric disorder affecting approximately 1% of the population worldwide and is characterised by the presence of positive and negative symptoms and cognitive deficits. Whilst current therapeutics ameliorate positive symptoms, they are largely ineffective in improving negative symptoms and cognitive deficits. The cholinergic neurotransmitter system heavily influences cognitive function and there is evidence that implicates disruption of the central cholinergic system in schizophrenia. Historically, targeting the cholinergic system has been impeded by poor selectivity leading to intolerable side effects warranting the need to develop more targeted therapeutic compounds. In this review we will summarise evidence supporting the roles of the cholinergic system, particularly the muscarinic M₁ receptor, in the pathophysiology of schizophrenia and discuss the potential of a promising new class of candidate compounds, allosteric ligands, for addressing the difficulties involved in targeting this system. The body of evidence presented here highlights the dysfunction of the cholinergic system in schizophrenia and that targeting this system by taking advantage of allosteric ligands is having clinically meaningful effect on cognitive deficits.

Role of mitogen- and stress-activated kinases in inflammatory arthritis

Lysophosphatidic acid (LPA) is a pleiotropic lipid mediator that promotes motility, survival, and the synthesis of chemokines/cytokines in human fibroblast-like synoviocytes (FLS) from patients with rheumatoid arthritis. LPA activates several proteins within the mitogen activated protein (MAP) kinase signaling network, including extracellular signal-regulated kinases (ERK) 1/2 and p38 MAP kinase (MAPK). Upon docking to mitogen- and stress-activated kinases (MSKs), ERK1/2 and p38 MAPK phosphorylate serine and threonine residues within its C-terminal domain and cause autophosphorylation of MSKs. Activated MSKs can then directly phosphorylate cAMP response element-binding protein (CREB) at Ser133 in FLS. Phosphorylation of CREB by MSKs is essential for the production of pro-inflammatory and anti-inflammatory cytokines. However, other downstream effectors of MSK1/2 such as nuclear factor-kappa B, histone H3, and high mobility group nucleosome binding domain 1 may also regulate gene expression in immune cells involved in disease pathogenesis. MSKs are master regulators of cell function that integrate signals induced by growth factors, pro-inflammatory cytokines, and cellular stresses, as well as those induced by LPA.

Quinolone-based first, second and third-line therapies for Helicobacter pylori

Helicobacter pylori (H. pylori) is a very common bacterium that infects about 50% of the world population in urban areas and over 90% of people living in rural and developing countries. Fluoroquinolones, a class of antimicrobials, have been extensively used in eradication regimens for H. pylori. Levofloxacin is the most commonly used, and in second-line regimens, is one of the most effective options. However, an increasing resistance rate of H. pylori to fluoroquinolones is being observed, that will likely affect their effectiveness in the near future. Other novel fluoroquinolone molecules, such as moxifloxacin, sitafloxacin, gatifloxacin and gemifloxacin, have been proposed and showed encouraging results in vitro, although data on their clinical use are still limited. Further studies in large sample trials are needed to confirm their safety and efficacy profile in clinical practice.

Therapeutic targets and delivery challenges for Alzheimer’s disease

Dementia, including Alzheimer’s disease, the 21^st Century epidemic, is one of the most significant social and health crises which has currently afflicted nearly 44 million patients worldwide and about new 7.7 million cases are reported every year. This portrays the unmet need towards better understanding of Alzheimer’s disease pathomechanisms and related research towards more effective treatment strategies. The review thus comprehensively addresses Alzheimer’s disease pathophysiology with an insight of underlying multicascade pathway and elaborates possible therapeutic targets- particularly anti-amyloid approaches, anti-tau approaches, acetylcholinesterase inhibitors, glutamatergic system modifiers, immunotherapy, anti-inflammatory targets, antioxidants, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors and insulin. In spite of extensive research leading to identification of newer targets and potent drugs, complete cure of Alzheimer’s disease appears to be an unreached holy grail. This can be attributed to their ineffective delivery across blood brain barrier and ultimately to the brain. With this understanding, researchers are now focusing on development of drug delivery systems to be delivered via suitable route that can circumvent blood brain barrier effectively with enhanced patient compliance. In this context, we have summarized current drug delivery strategies by oral, transdermal, intravenous, intranasal and other miscellaneous routes and have accentuated the future standpoint towards promising therapy ultimately leading to Alzheimer’s disease cure.

Progress in pancreatic cancer therapeutics: The potential to exploit molecular targets

Pancreatic ductal adenocarcinoma is an aggressive and devastating disease associated with poor survival outcomes. Even though significant advances have been made towards understanding the intricate pathology of this cancer, several important aspects remain unknown. Recently, key genetic mutations within the tumour have been identified, but the exact role they play in tumourigenesis has yet to be determined. For many years, the micro-tumour environment and stroma was thought to aid proliferation but there is now emerging research that suggests the contrary. Several novel targeted agents in pre-clinical and early clinical studies have been promising but it remains to be seen whether they will have a significant impact on patient outcomes. In this review we discuss the unique nature of pancreatic cancer biology, current treatment options and summarise the latest results from pre-clinical and clinical research. We also discuss the future strategies that are needed to improve outcomes for this disease.

Protective effect of fu-qi granule on carbon tetrachloride-induced liver fibrosis in rats

AIM: To investigate the efficacy of fu-qi granule (FQG) on carbon tetrachloride (CCl₄) induced liver fibrosis in rats and the underlying mechanisms.

METHODS: Sixty rats were randomly divided into six groups: normal control group, CCl₄ induced liver fibrosis group, AnluoHuaxianWan group and three treatment groups of FQG. Treatment of rats with intraperitoneal injection of carbon tetrachloride solution at 0.3 mL per 100 g body weigh twice a week for 8 wk. The normal control group the rats were given the media (olive oil) at the same time. In the first 2 wk, rats were raised with feedstuff (80% corn meal, 20% lard, 0.5% cholesterol). Serum samples were collected for alanine transaminase, aspartate aminotransferase, alkaline phosphatase, albumin, total protein assay and typical histopathological changes was observed in Hematoxylin-eosin staining sections. Smooth muscle alpha actin (α-SMA) was analyzed with immunohistochemistry. Mammalian target of rapamycin (mTOR) and hypoxia-inducible factor-1 (HIF-1α) expressions were detected by Western blotting. Tissue inhibitor of matrix metalloproteinases-1 (TIMP-1) and matrix metalloproteinases-9 (MMP-9) were measured with semi-quantitative reverse transcriptase-polymerase chain reaction.

RESULTS: FQG significantly reduced the serum levels of alanine transaminase, aspartate aminotransferase, alkaline phosphatase and increased the serum contents of albumin, total protein in rats with liver fibrosis. Moreover, FQG promoted extracellular matrix degradation by increasing MMP-9 and inhibiting TIMP-1 and α-SMA. mTOR and HIF-1α expression in liver significantly decreased in the rats treated with FQG.

CONCLUSION: The results indicated that FQG significantly reverse fibrosis induced by CCl₄, which should be developed as a new and promising preparation for the prevention of liver fibrosis.

Challenges and opportunities in the treatment of ulcerative colitis

Ulcerative colitis (UC) is an inflammatory destructive disease of the large intestine occurred usually in the rectum and lower part of the colon as well as the entire colon. Drug therapy is not the only choice for UC treatment and medical management should be as a comprehensive whole. Many synthetic drugs are available for the treatment of UC like 5-aminosalicylic acid, oral or systemic corticosteroids, immunomodulator, etc. but these drugs are associated with many serious side effects after long term use or have certain disadvantage or not suitable for the use in some patients. In short synthetic drugs have many disadvantages and for this reason effective and safe alternative drug treatment for the UC is the challenge. Herbal drugs are found to be very promising results of the treatment of UC and enzymatic level. Researchers explored many herbal drugs for the treatment and even many more may found effective in the treatment of UC. At this point we feel herbal medicine is the better alternative for the treatment of UC.

Appropriate prescribing in the elderly: Current perspectives

Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selection in older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drug-drug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.

Lipoprotein based drug delivery: Potential for pediatric cancer applications

While survival rates for patients with childhood cancers have substantially improved, the quality of life of the survivors is often adversely impacted by the residual effects of chemo and radiation therapy. Because of the existing metabolic and physiological disparities between pediatric and adult patients, the treatment of pediatric cancer patients poses special challenges to oncologists. While numerous clinical trials being conducted, to improve treatment outcomes for pediatric cancer patients, new approaches are required to increase the efficacy and to minimize the drug related toxic side effects. Nanotechnology is a potentially effective tool to overcome barriers to effective cancer therapeutics including poor bioavailability and non-specific targeting. Among the nano-delivery approaches, lipoprotein based formulations have shown particularly strong promise to improve cancer therapeutics. The present article describes the challenges faced in the treatment of pediatric cancers and reviews the potential of lipoprotein-based therapeutics for these malignancies.

Therapeutic options and vaccine development in the treatment of leishmaniasis

Early treatment of leishmaniasis is critical to achieve cure, prevent psychological and social distress, and prevent transmission of disease. Untreated Leishmaniasis-cutaneous leishmaniasis, mucocutaneous leishmaniasis and visceral leishmaniasis - results in disfiguring scars and high rates of morbidity and mortality in highly endemic regions of the world. However, cure rates with available therapeutics are limited due to cost, therapeutic toxicity and the growing rate of resistance. New therapeutic targets for medications and vaccine development are under investigation to provide improved healing and efficacy for the treatment of Leishmania spp.

Enhanced permeability and retention effect based nanomedicine, a solution for cancer

Tumor-targeting is becoming more and more important for cancer chemotherapy. Though many molecular-target drugs have been developed in the past two decades which shed some light on targeted tumor therapy, clinical results of those molecular-target drugs are not so encouraging especially for solid tumors, problems mostly relating to the heterogeneity and mutations of target molecules in human solid tumors. More general tumor-targeting strategy is thus anticipated. In this regard, the enhanced permeability and retention (EPR) effect which is a unique phenomenon of solid tumors based on the anatomical and pathophysiological nature of tumor blood vessels, is receiving more and more attentions. This EPR effect now served as a standard for tumor-targeted macromolecular anticancer therapy, namely nanomedicine. Many nanoplatforms have been developed as targeted drug delivery systems, including liposome, polymeric micelles, polymer conjugate, nanoparticles. Ample macromolecular drugs are now approved for clinical use or in clinical stage development, all of which by taking advantage of EPR effect, show superior in vivo pharmacokinetics and remarkable tumor selectivity, resulting in improved antitumor effects with less adverse effects. We thus believe EPR-based nanomedicine will be a solution for cancer in the future, whereas further consideration of factors involved in EPR effect and strategies to augment/improve EPR effect are warranted.

Levomilnacipran and vortioxetine: Review of new pharmacotherapies for major depressive disorder

Major depressive disorder (MDD) is a common psychiatric disorder with an estimated lifetime prevalence rate in the range of 13% to 16% in the United States population. Patients with MDD often have symptoms such as depressed mood, loss of interest or pleasure in usual activities, changes in eating or sleeping patterns, fatigue, difficulty concentrating and thoughts of suicide. Although many pharmacotherapy treatment options are available for MDD, antidepressants can often cause adverse effects that could affect adherence to the medication. Additionally, it is estimated that MDD is unremitting in 15% of patients and 35% can have recurrent episodes. Given the high rate of recurrence and the adverse effects associated with existing medications, new treatment options for depression are needed. Both levomilnacipran and vortioxetine are new antidepressants that were approved by the food and drug administration in 2013 for the treatment of MDD in adults. Levomilnacipran is a serotonin norepinephrine reuptake inhibitor that was effective in several short term studies and sustained efficacy and tolerability was demonstrated in a 48-wk extension study. Vortioxetine is a multi-modal antidepressant and it is thought to work via inhibition of the serotonin (5-HT) transporter, 5-HT_3A, 5-HT₇ and 5-HT_1D antagonist, a 5-HT_1B partial agonist, and a 5-HT_1A agonist. Vortioxetine was effective in the treatment of MDD in both short-term trials as well as in the prevention of relapse in a 24-36 wk trial. Sustained efficacy and tolerability was demonstrated in several long-term open-label trials. Further studies comparing levomilnacipran and vortioxetine to other currently available antidepressants are needed to establish its place in therapy.

Role of opioid receptor heterodimerization in pain modulation and tolerance development

Protein to protein interactions leading to homo/heteromerization of receptor is well documented in literature. These interactions leading to dimeric/oligomers formation of receptors are known to modulate their function, particularly in case of G-protein coupled receptors. The opioid receptor heteromers having changed pharmacological properties than the constituent protomers provides preferences for novel drug targets that could lead to potential analgesic activity devoid of tolerance and physical dependence. Heterodimerization of opioid receptors appears to generate novel binding properties with improved specificity and lack of side effects. Further the molecules which can interact simultaneously to both the protomers of the heteromer, or to both the binding sites (orthosteric and allosteric) of a receptor protein could be potential therapeutic molecules. This review highlights the recent advancements in exploring the plausible role of heteromerization of opioid receptors in induction of tolerance free antinociception.

Importance of microenvironment in preclinical models of breast and prostate cancer

The majority of cancer drugs entering clinical trials fail to reach the market due to poor efficacy. Preclinical efficacy has been traditionally tested using subcutaneous xenograft models that are cheap, fast and easy to perform. However, these models lack the correct tumor microenvironment, leading to poor clinical predictivity. Selecting compounds for clinical trials based on efficacy results obtained from subcutaneous xenograft models may therefore be one important reason for the high failure rates. In this review we concentrate in describing the role and importance of the tumor microenvironment in progression of breast and prostate cancer, and describe some breast and prostate cancer cell lines that are widely used in preclinical studies. We go through different preclinical efficacy models that incorporate the tissue microenvironment and should therefore be clinically more predictive than subcutaneous xenografts. These include three-dimensional cell culture models, orthotopic and metastasis models, humanized and transgenic mouse models, and patient-derived xenografts. Different endpoint measurements and applicable imaging techniques are also discussed. We conclude that models that incorporate the tissue microenvironment should be increasingly used in preclinical efficacy studies to reduce the current high attrition rates of cancer drugs in clinical trials.

Improving cancer therapy by targeting cancer stem cells: Directions, challenges, and clinical results

Cancer stem cells (CSC) are a rare cell population within a tumor characterized by the ability to form tumors following injection into an immunocompromised host. While the role of CSC has been clearly established in animal models, evidence of their clinical relevance has been harder to demonstrate. A number of markers, or combination thereof, have been used to detect and measure, although non-specifically, CSC in almost all human tumors. Several pathways have been identified as crucial for, but not necessarily unique to, CSC survival and proliferation, and novel agents have been designed to target such pathways. A number of such agents have entered early phase development. Further, drugs that have long been marketed for non-oncological indications have been redirected to oncology as they appear to affect one or more of such pathways. This article aims to review the available evidence on the clinical relevance of CSC from a drug development standpoint and the results of early phase clinical trials of agents interfering with the above pathways. It also discusses limitations of current clinical trial design and endpoints to demonstrate anti-CSC activity as well as possible strategies to overcome these limitations.

Hepatocellular carcinoma and multidrug resistance: Past, present and new challenges for therapy improvement

Hepatocellular carcinoma (HCC) is the most frequent form of liver cancer and the third most common cause of cancer-related death in the world. The main risk factor worldwide for this type of malignancy is chronic hepatitis caused by hepatitis B virus and hepatitis C virus infections. Advances in early detection and treatment have improved life expectancy of patients with HCC. However, this disorder remains as a disease with poor prognosis. In fact, epidemiological studies have revealed that there is an 8-mo median survival rate in patients, approximately 20% of whom survive one year while only 5% remain alive after three years. Additionally, HCC is particularly difficult to treat because of its high recurrence rate, and its resistance to conventional chemotherapy is due, among other mechanisms, to several members of the ATP-Binding Cassette protein family involved in drug transport being overexpressed. Fortunately, there is evidence that these patients may benefit from alternative molecular-targeted therapies. This manuscript intends to provide further insight into the etiology and molecular mechanisms related to HCC development and the latest therapeutic approaches to treat this malignancy. The development of effective delivery systems of antitumor drugs able to target the liver parenchyma is also assessed. Finally, the prospects in the development of more efficient drug therapies to overcome multidrug resistance are also examined.

Antimicrobial resistance in clinically important biofilms

A biofilm contains a consortium of cohesive bacterial cells forming a complex structure that is a sedentary, but dynamic, community. Biofilms adhere on biotic and abiotic surfaces, including the surfaces of practically all medical devices. Biofilms are reported to be responsible for approximately 60% of nosocomial infections due to implanted medical devices, such as intravenous catheters, and they also cause other foreign-body infections and chronic infections. The presence of biofilm on a medical device may result in the infection of surrounding tissues and failure of the device, necessitating the removal and replacement of the device. Bacteria from biofilms formed on medical devices may be released and disperse, with the potential for the formation of new biofilms in other locations and the development of a systemic infection. Regardless of their location, bacteria in biofilms are tolerant of the activities of the immune system, antimicrobial agents, and antiseptics. Concentrations of antimicrobial agents sufficient to eradicate planktonic cells have no effect on the same microorganism in a biofilm. Depending on the microbial consortium or component of the biofilm that is involved, various combinations of factors have been suggested to explain the recalcitrant nature of biofilms toward killing by antibiotics. In this mini-review, some of the factors contributing to antimicrobial resistance in biofilms are discussed.

Carbapenemases: A worldwide threat to antimicrobial therapy

Carbapenems are potent β-lactams with activity against extended-spectrum cephalosporinases and β-lactamases. These antibiotics, derived from thienamycn, a carbapenem produced by the environmental bacterium Streptomyces cattleya, were initially used as last-resort treatments for severe Gram-negative bacterial infections presenting resistance to most β-lactams but have become an empirical option in countries with high prevalence of Extended Spectrum β-lactamase-producing bacterial infections. Imipenem, the first commercially available carbapenem, was approved for clinical use in 1985. Since then, a wide variety of carbapenem-resistant bacteria has appeared, primarily Enterobacteriaceae such as Escherichia coli or Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa and Acinetobacter baumannii, presenting different resistance mechanisms. The most relevant mechanism is the production of carbapenem-hydrolyzing β-lactamases, also known as carbapenemases. These enzymes also inactivate all known β-lactams, and some of these enzymes can be acquired through horizontal gene transfer. Moreover, plasmids, transposons and integrons harboring these genes typically carry other resistance determinants, rendering the recipient bacteria resistant to almost all currently used antimicrobials, as is the case for K. pneumoniae carbapenemase - or New Delhi metallo-β-lactamases-type enzymes. The recent advent of these enzymes in the health landscape presents a serious challenge. First, the emergence of carbapenemases limits the currently available treatment options; second, these enzymes pose a risk to patients, as some studies have demonstrated high mortality associated with carbapenemase-producing bacterial infections; and third, these circumstances require an extra cost to sanitary systems, which are particularly cumbersome in developing countries. Therefore, emphasis should be placed on the early detection of these enzymes, the prevention of the spread of carbapenemase-producing bacteria and the development of new drugs resistant to carbapenemase hydrolysis.

Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome

Prostatitis comprises of a group of syndromes that affect almost 50% of men at least once in their lifetime and makeup the majority of visits to the Urology Clinics. After much debate, it has been divided into four distinct categories by National Institutes of Health namely (1) acute bacterial prostatitis; (2) chronic bacterial prostatitis; (3) chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) which is further divided into inflammatory and non-inflammatory CP/CPPS; and (4) asymptomatic inflammatory prostatitis. CP/CPPS has been a cause of great concern for both patients and physicians because of the lack of presence of thorough information about the etiological factors along with the difficult-to-treat nature of the syndrome. For the presented manuscript an extensive search on PubMed was conducted for CP/CPPS aimed to present an updated review on the evaluation and treatment options available for patients with CP/CPPS. Several diagnostic criteria’s have been established to diagnose CP/CPPS, with prostatic/pelvic pain for at least 3 mo being the major classifying symptom along with the presence of lower urinary tract symptoms and/or ejaculatory pain. Diagnostic tests can help differentiate CP/CPPS from other syndromes that come under the heading of prostatitis by ruling out active urinary tract infection and/or prostatic infection with uropathogen by performing urine cultures, Meares-Stamey Four Glass Test, Pre- and Post-Massage Two Glass Test. Asymptomatic inflammatory prostatitis is confirmed through prostate biopsy done for elevated serum prostate-specific antigen levels or abnormal digital rectal examination. Researchers have been unable to link a single etiological factor to the pathogenesis of CP/CPPS, instead a cluster of potential etiologies including atypical bacterial or nanobacterial infection, autoimmunity, neurological dysfunction and pelvic floor muscle dysfunction are most commonly implicated. Initially monotherapy with anti-biotics and alpha adrenergic-blockers can be tried, but its success has only been observed in treatment naïve population. Other pharmacotherapies including phytotherapy, neuromodulatory drugs and anti-inflammatories achieved limited success in trials. Complementary and interventional therapies including acupuncture, myofascial trigger point release and pelvic floor biofeedback have been employed. This review points towards the fact that treatment should be tailored individually for patients based on their symptoms. Patients can be stratified phenotypically based on the UPOINT system constituting of Urinary, Psychosocial, Organ-specific, Infectious, Neurologic/Systemic and symptoms of muscular Tenderness and the treatment algorithm should be proposed accordingly. Treatment of CP/CPPS should be aimed towards treating local as well as central factors causing the symptoms. Surgical intervention can cause significant morbidity and should only be reserved for treatment-refractory patients that have previously failed to respond to multiple drug therapies.

Chemoprevention of gastrointestinal cancers by natural honey

Gastrointestinal cancers are the most common human cancers in both men and women worldwide. Several epidemiological and experimental studies suggest a relationship between gastrointestinal cancers risk and dietary factors. Natural honey has been widely used in traditional medicine for many centuries to treat a wide range of ailments and complaints. Honey contains various components that exhibit wide activities including antibacterial, anti-inflammatory, antioxidant and anticancer properties. The anticancer effects of honey are mediated via diverse mechanisms, including inhibition of proliferation, induction of apoptosis, suppression of free radicals and modulation of inflammatory signalling pathways. The present review assesses the chemopreventive effects of natural honey and its components in the modulation of gastrointestinal cancers and its modes of action in the prevention of the development of gastrointestinal tumors. Honey can be an approach as a cancer-preventive strategy which merits further experimental and clinical research in the near future.

Drug therapy for Parkinson’s disease: An update

Parkinson’s disease (PD) is the most common neurodegenerative movement disorder, affecting about 1% of the population above the age of 65. PD is characterized by a selective degeneration of the dopaminergic neurons of the substantia nigra pars compacta. This results in a marked loss of striatal dopamine and the development of the characteristic features of the disease, i.e., bradykinesia, rest tremor, rigidity, gait abnormalities and postural instability. Other types of neurons/neurotransmitters are also involved in PD, including cholinergic, serotonergic, glutamatergic, adenosine, and GABAergic neurotransmission which might have relevance to the motor, non-motor, neuropsychiatric and cognitive disturbances that occur in the course of the disease. The treatment of PD relies on replacement therapy with levodopa (L-dopa), the precursor of dopamine, in combination with a peripheral decarboxylase inhibitor (carbidopa or benserazide). The effect of L-dopa, however, declines over time together with the development of motor complications especially dyskinesia in a significant proportion of patients within 5 years of therapy. Other drugs include dopamine-receptor-agonists, catechol-O-methyltransferase inhibitors, monoamine oxidase type B (MAO-B) inhibitors, anticholinergics and adjuvant therapy with the antiviral drug and the N-methyl-D-aspartate glutamate receptor antagonist amantadine. Although, these medications can result in substantial improvements in parkinsonian symptoms, especially during the early stages of the disease, they are often not successful in advanced disease. Moreover, dopaminergic cell death continues over time, emphasizing the need for neuroprotective or neuroregenerative therapies. In recent years, research has focused on non-dopaminergic approach such as the use of A_2A receptor antagonists: istradefylline and preladenant or the calcium channel antagonist isradipine. Safinamide is a selective and reversible inhibitor of MAO-B, a glutamate receptor inhibitor as well as sodium and calcium channel blocker. Minocycline and pioglitazone are other agents which have been shown to prevent dopaminergic nigral cell loss in animal models of PD. There is also an evidence to suggest a benefit from iron chelation therapy with deferiprone and from the use of antioxidants or mitochondrial function enhancers such as creatine, alpha-lipoic acid, l-carnitine, and coenzyme Q10.

Pharmacophore approaches in protein kinase inhibitors design

Protein kinases constitute a superfamily of therapeutic targets for a number of human and animal diseases that include more than 500 members accordingly to sequencing data of the human genome. The well characterized nature of protein kinases makes them excellent targets for drug development. Pharmacophore approaches have become one of the major tools in the area of drug discovery. Application of pharmacophore modeling approaches allows reducing of expensive overall cost associated with drug development project. Pharmacophore models are important functional groups of atoms in the proper spatial position for interaction with target protein. Various ligand-based and structure-based methods have been developed for pharmacophore model generation. Despite the successes in pharmacophore models generation these approaches have not reached their full capacity in application for drug discovery. In the following review, we summarize the published data on pharmacophore models for inhibitors of tyrosine protein kinases (EGFR, HER2, VEGFR, JAK2, JAK3, Syk, ZAP-70, Tie2) and inhibitors of serine/threonine kinases (Clk, Dyrk, Chk1, IKK2, CDK1, CDK2, PLK, JNK3, GSK3, mTOR, p38 MAPK, PKB). Here, we have described the achievements of pharmacophore modeling for protein kinase inhibitors, which provide key points for further application of generated pharmacophore hypotheses in virtual screening, de novo design and lead optimization.

Pharmacological role of efflux transporters: Clinical implications for medication use during breastfeeding

The World Health Organisation recommends exclusive breastfeeding for the first six months of an infant’s life and in combination with solid food thereafter. This recommendation was introduced based on research showing numerous health benefits of breastfeeding for both the mother and the infant. However, there is always concern regarding the transfer of medications from mother to their breastfed baby via milk. Pharmacokinetic properties of a drug are usually used to predict its transferability into breast milk. Although most drugs are compatible with breastfeeding, cases of toxic drug exposure have been reported. This is thought to be due to active transport mechanisms whereby efflux transporter proteins expressed in the epithelial cells of the mammary gland actively secrete drugs into milk. An example of such efflux transporters including the breast cancer resistance protein which is strongly induced during lactation and this could result in contamination of milk with the substrates of this transporter which may place the suckling infant at risk of toxicity. Furthermore, there is little known about the substrate specificity of most efflux transporters as we have highlighted in this review. There also exists some degree of contradiction between in vivo and in vitro studies which makes it difficult to conclusively predict outcomes and drug-drug interactions.

Association of serum bilirubin and non-alcoholic fatty liver disease: A feasible therapeutic avenue?

AIM: To the look at the current strength of evidence and the potential application of anti-oxidants in this setting.

METHODS: Two electronic databases (PubMed and Web of Knowledge) were searched to January 2013 to find studies addressing serum bilirubin levels in non-alcoholic fatty liver disease (NAFLD). The search used key word combinations in relation to NAFLD and serum bilirubin specific to human adults only. After screening selected studies were reviewed in depth by two independent reviewers. Data synthesis with further meta-analysis was planned but not possible due to the heterogeneity of the outcome measures in these studies.

RESULTS: Out of 416 studies screened only seven studies were considered suitable for inclusion. All seven studies consistently reported an inverse association of bilirubin with NAFLD despite the heterogeneous sample of studies. Only two studies were prospective. No negative studies were found.

CONCLUSION: Most studies suggest a correlation between high bilirubin levels of any type are inversely correlated with NAFLD. But to date most of these studies have been poorly designed to allow meaningful conclusions, except one cohort study. There is a need for a large prospective cohort study in multiple populations to test this hypothesis fully before mechanistic associations can be established and therapeutic options of the apparent anti-oxidant effect of bilirubin be explored in NAFLD. Furthermore these studies should include analysis of UGT1A1 gene to expound upon underlying cause of unconjugated hyperbilirubinaemia.

Use of eltrombopag in thrombocytopenia of liver disease

Second generation thrombopoietin agonists including eltrombopag and romiplostim act on the thrombopoietin receptor to increase the megakaryocyte production. These agents were needed as use of first generation recombinant products was associated with formation of autoantibodies. Eltrombopag is an oral thrombopoietin agonist found effective in raising platelet counts in patients with immune thrombocytopenia. The drug has now been found to be useful in raising platelet counts in thrombocytopenia related to liver disease including cirrhosis and chronic viral hepatitis. Although the drug may help enable adequate interferon therapy in patients with HCV infection and help carry out invasive procedures in patients with cirrhosis, concerns have been raised of possible thrombotic complications including portal vein thrombosis. Randomized trials have shown that use of eltrombopag concomitant with pegylated interferon and ribavirin increased the chances of sustained virologic response while decreasing the dose reductions of interferon. The data on use of romiplostim in these clinical indications is also emerging. However, in the future, availability of interferon free regimens is likely to decrease the use of eltrombopag for enabling antiviral therapy. The review discusses the role of eltrombopag in management of liver disease related thrombocytopenia in wake of recent data as also the dosage, precautions and adverse effects associated with its use.

Telomerase activity: An attractive target for cancer therapeutics

Telomeres are non-coding tandem repeats of 1000-2000 TTAGGG nucleotide DNA sequences on the 3’ termini of human chromosomes where they serve as protective “caps” from degradation and loss of genes. The “cap” at the end of chromosome required to protect its integrity is a 150-200 nucleotide-long single stranded G-rich 3’ overhang that forms two higher order structures, a T-loop with Sheltering complex, or a G-quadruplex complex. Telomerase is a human ribonucleoprotein reverse transcriptase that continually added single stranded TTAGGG DNA sequences onto the single strand 3’ of telomere in the 5’ to 3’ direction. Telomerase activity is detected in male germ line cells, proliferative cells of renewal tissues, some adult pluripotent stem cells, embryonic cells, but in most somatic cells is not detected. Re-expression or up-regulation of telomerase in tumours cells is considered as a critical step in cell tumorigenesis and telomerase is widely considered as a tumour marker and a target for anticancer drugs. Different approaches have been used in anticancer therapeutics targeting telomerase. Telomerase inhibitors can block directly Human TElomerase Reverse Transcriptase (hTERT) or Human TElomerase RNA telomerase subunits activity, or G-quadruplex and Sheltering complex components, shortening telomeres and inhibiting cell proliferation. Telomerase can become an immune target and GV1001, Vx-001, I540 are the most widespread vaccines used with encouraging results. Another method is to use hTERT promoter to drive suicide gene expression or to control a lytic virus replication. Recently telomerase activity was used to activate pro-drugs such as Acycloguanosyl 5’-thymidyltriphosphate, a synthetic ACV-derived molecule when it is activated by telomerase it does not require any virus or host active immune response to induce suicide gene therapy. Advantage of all these therapies is that target only neoplastic cells without any effects in normal cells, avoiding toxicity and adverse effects of the current chemotherapy. However, as not all the approaches are equally efficient, further studies will be necessary.