Adverse drug reactions of Highly Active Antiretroviral Therapy (HAART) in HIV infected patients at the General Hospital, Douala, Cameroon: a cross sectional study

BACKGROUND

The use of highly active antiretroviral therapy (HAART) as the main option for management of people living with Human Immune deficiency virus (HIV) is associated with decrease morbidity and mortality. This is due to its effectiveness in inhibiting viral replication. However this effectiveness is not without adverse drug effects which in many settings are not monitored.

METHODS

A cross sectional clinical chart review of adult Cameroonian patients on HAART between 2003 and 2009 at the Douala General Hospital was done in search of reported HAART-associated Adverse Drug effects (ADRs). The prevalence of ADR defined as the proportion of the study population with ADR was determined and stratified by age, sex, weight and HAART regimen.

RESULTS

Sixty-six (19.5%) of the 339 patients on HAART reported ADRs. Among those who reported ADRs, 29.6% were on D4T-3TC-EFV, 29.3% on D4T-3TC-NVP, 16% on AZT-3TC-EFV and 10.8% on AZT-3TC-NVP. Peripheral Neuropathy was the most common ADR and represented 21.2% of all ADRs. Patients on D4T containing regimens were more likely to develop ADR (OR = 3.5, 95% CI 1.5 - 9.8, p<0.01) and 56.1% of all ADRs were associated to D4T. Hospital admissions were for patients with severe anaemia, no fatal cases of ADRs were recorded.

CONCLUSION

HAART-associated ADRs are common and therefore should be actively looked for by caregivers so as to ameliorate the quality of life of HIV patients on treatment.

Ceftriaxone-induced acute reversible encephalopathy in a patient with enteric fever

Ceftriaxone is a commonly used, third-generation cephalosporin. Encephalopathy is a rare side effect of third- and fourth-generation cephalosporins. Renal failure and previous disease of the central nervous system predispose to this neurotoxicity. We describe a case of acute transient encephalopathy in a patient treated with ceftriaxone for enteric fever infection. Early detection of this complication is relevant given that stopping the drug usually reverts the neurological syndrome.

ABCC2 Haplotype is Associated With Antituberculosis Drug-Induced Maculopapular Eruption

Genetic variants in ATP-binding cassette (ABC) transporter genes are associated with increased susceptibility to adverse drug reactions. We hypothesized that genetic variant ABC transporters (ABCB1 and ABCC2) may be candidate markers for predicting maculopapular eruption (MPE) induced by antituberculosis therapy. We compared the genotype distributions of single nucleotide polymorphisms and haplotypes in the ABCB1 and ABCC2 genes between 62 antituberculosis drug (ATD)-induced MPE cases and 159 ATD-tolerant controls using multivariate logistic regression analysis. There was no significant association between genetic polymorphisms in ABCB1 and ATD-induced MPE (P>0.05). Among seven selected SNPs of ABCC2, IVS3-49C>T in intron and I1324I were associated with ATD-induced MPE (P=0.029 and 0.036, respectively). In an analysis of the ABCC2 haplotypes (ht; -1549G>A_-24C>T_IVS3-49C>T_V417I), ht1[G-C-C-G] was significantly associated with ATD-induced MPE (P=0.032, OR=0.35, 95% CI: 0.16-0.95). No significant association between the other haplotypes and ATD-induced MPE was observed. An ABCC2 haplotype is associated with the presence of ATD-induced MPE in patients with tuberculosis and may be a genetic risk factor for the development of MPE induced by ATD.

Medication error - Inadvertent high dose intradermal cloxacillin induced skin necrosis

Medication error is one of the important causes of preventable adverse drug reactions. It can occur in the form of administration of a wrong drug, in the wrong dose, to the wrong patient, in an unsuitable dosage form, for the wrong duration or by using an inappropriate route of administration. Intradermal skin testing for cloxacillin hypersensitivity is done at low doses to check for drug allergy. In this report, three patients were given 50 times higher dose of cloxacillin than recommended for skin testing, resulting in pain and necrosis at the site of injection. The error occurred due to wrong dilution of the drug as done by a nursing intern. Some reasons for this could be overtime working, under trained staff, unsupervised nursing interns, complicated and unclear protocols, interpersonal communication gap between health care professionals and also poor availability of ideal resources. Pharmacovigilance centers must alert health care professionals about the significance of reporting medication errors through bulletins and journals.

Phenytoin induced chorea in a pediatric patient: An interaction between phenytoin, phenobarbital and clobazam

A 3-year-old female patient developed chorea possibly due to an interaction between phenytoin, phenobarbital and clobazam used for generalized tonic clonic seizures. Phenytoin withdrawal resulted in recovery within 24 hours. Post reaction computerized tomography (CT)-scan of brain was normal. Combined use of anti-seizure drugs and interactions between them may be responsible for the reaction. Therapeutic drug monitoring is important while prescribing two or more anti-seizure drugs.

A clinical trial of Pippali (Piper longum Linn.) with special reference to Abheshaja

The classification of Dravya has been undertaken in many ways, but according to the medicinal value, they are mainly divided into two - Bheshaja and Abheshaja. No study has been documented on Abheshaja to date as per the scholar's knowledge. Therefore, the present study was carried out to understand the concept of Abheshaja by a practical study. The drug Pippali (Piper Longum Linn.) has been contraindicated to be used for a longer duration. A clinical study was carried out on patients with Kaphaja Kasa, to evolve and assess if the drug acts as Abheshaja or not, and if yes, then under what circumstances. The patients of Kaphaja Kasa had been selected by the random sampling method. They were randomly divided into two groups - Group A and Group B. In Group A, test drug Pippali Churna was administered. Group B was a standard control group and Vasa Churna was given to this group. The dose of both the drugs was 4 g B.I.D. The result was assessed after three weeks of drug administration with the help of a specially prepared proforma. All the important hematological, biochemical, urine, and stool investigations were carried out. There was no adverse drug reaction (ADR) observed after the administration of Pippali in this particular study.

Steroid-induced central serous retinopathy

A-24 year-old male was prescribed prednisolone (60 mg/day) for left sided facial palsy. After three days of therapy, the patient complained of black spots in his vision in right eye. Fluorescein angiography of right eye showed evidence of central serous retinopathy (CSR). Prednisolone dose was withdrawn gradually and the patient improved within a week. There were no other systemic or ophthalmic diseases reported by the patient, which could have caused this condition. An improvement after dechallenge confirmed steroid-induced CSR. Recurrent CSR is known to cause permanent loss of vision. Hence, awareness regarding this adverse drug reaction (ADR) with steroids and its reporting can minimize this complication and help in better patient management.

A study of adverse drug reactions in pediatric patients

Aim:

To study the adverse drug reaction (ADR) pattern in a pediatric population in a tertiary care hospital.

Materials and Methods:

An observational study was done in the department of pediatrics in a tertiary care hospital. The ADRs occurring in the inpatient wards and outpatient department of pediatrics were actively monitored. The collected reports were analyzed for ADR pattern, drug groups, demographic profile, causality, severity, and preventability of the ADR.

Results:

A total of 30 ADRs were documented during the mid period of 2009 among pediatric patients. Most of the ADRs (60%) occurred below the age of 1 year. Antibiotics comprised the major group of drugs causing ADRs (67%). Rashes and urticaria were the most common type of ADR (37%) followed by fever, anaphylactic shock, vomiting, chills, and rigors. A single case of death had been reported in the study period. There were more occurrences of ADRs with multiple drugs compared to single drug therapy. About 80% of the ADRs were of probable causality and 87% were of probable preventability. There were no mild reactions, with 77% of reactions being moderate and 23% of reactions being severe in the severity scale.

Conclusions:

ADRs occur more among infants and antibiotics were more commonly implicated. Most of the reactions were of moderate severity. This indicates the need for a rigid ADR monitoring among pediatric patients to ensure safety of drug therapy.

Usefulness of drug provocation tests in children with a history of adverse drug reaction

Purpose

There are very few reports of adverse drug reactions (ADR) and almost no study of drug provocation test (DPT) in Korean children. We aimed to assess the role of DPT in children with unpredictable ADRs, and compare the causative drugs and clinical characteristics between detailed history of ADRs and result of DPTs.

Methods

We included 16 children who were experienced ADRs referred to pediatric allergy clinic at Ajou University Hospital (January 2006 to December 2009). With various suspected drugs, 71 DPTs were done in 16 patients using our own protocol, and skin tests to antibiotics were combined in ADRs to antibiotics in medical history.

Results

There were 17 (23.9%) positive DPTs results out of 71 individual DPTs, and 11 patients (68.8%) from 16 patients were positive to at least one drug. Drugs causing positive reactions were acetaminophen in 5 (31%), Non-steroidal anti-inflammatory drugs in 4 (25%), penicillin in 3 (19%), cephalosporin in 2 (13%), and cotrimoxazole, macrolide and lactose in 1 each.

Conclusion

DPT seems a safe and useful procedure to confirm causative drug and identify safely administering alternative drugs in children with ADR.

A pharmacovigilance study on patients of bronchial asthma in a teaching hospital

Objective:

The present study was conducted to monitor adverse drug reactions in patients of bronchial asthma in outpatient department and inpatient department of a university teaching hospital in South Delhi.

Materials and Methods:

About 200 patients irrespective of age and sex with established asthma were interviewed during the time period of January 2006 to April 2006 using structured questionnaire. Naranjo’s adverse drug reaction probability scale was used to assess the adverse drug reactions.

Results:

A total of 15 adverse drug reactions were reported in 13 out of 200 asthmatic patients. Among the 13 patients reported with adverse drug reactions, 5 (38.5%) were male and 8 (61.5%) patients were female. Maximum percentage of ADRs (2 in 15 prescriptions, 13.3%) observed with montelukast, followed by beclomethasone (1 in 12 prescriptions, 8.3%), salbutamol (6 in 109 prescriptions, 5.5%), and ipratropium (3 in 63 prescriptions, 4.8%).

Conclusions:

Montelukast was found to be associated with greater percentage of adverse drug reactions as compared to other antiasthamatics. The above findings are constrained by a small sample size and need to be corroborated by conducting long-term studies using a larger sample size.

Nevirapine induced Stevens-Johnson syndrome in an HIV infected patient

Nevirapine, a non-nucleoside reverse transcriptase inhibitor (NNRTI), is widely prescribed as a part of the combination therapy of human immunodeficiency virus (HIV) infection because of its efficacy and good tolerability. Here, we report a case of Stevens-Johnson syndrome (SJS) secondary to nevirapine. The patient had a diffuse, exfoliating exanthema with generalized bullous eruptions that involved the face, trunk and both extremities with elevated hepatic alanine aminotransferase and aspartate aminotransferase enzyme activities. The condition improved with stoppage of nevirapine-based highly active antiretroviral therapy (HAART) regimen, so we attributed this adverse event to nevirapine. A strict vigilance of adverse drug reaction is required in HAART.

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.

Atorvastatin-induced pancreatitis

Drugs account for 1–2% of all cases of pancreatitis. A 58-year-old man was prescribed atorvastatin 10 mg for 6 months for hyperlipidemia. He developed acute abdominal pain and vomiting with epigastric tenderness. Serum lipase and CT scan of the patient suggested the presence of acute pancreatitis. The patient was hospitalized; atorvastatin was stopped and treated symptomatically. He recovered completely within 10 days of drug withdrawal. The causality of the adverse drug reaction according to Naranjo and WHO-UMC Scale was probable. The exact mechanism of pancreatitis due to atorvastatin is not known. It may be a class effect of HMG CoA reductase inhibitors as it had been reported with other statins too. The definite causal relationship is difficult to establish, as rechallenge with the suspected drug was not done due to ethical consideration.

Adverse drug reaction profile of nanoparticle versus conventional formulation of paclitaxel: An observational study

Objectives:

Conventional polyethoxylated castor oil (PCO)-based paclitaxel is associated with major adverse drug reactions (ADRs). Nanoxel, a nanoparticle-based formulation, may improve its tolerability by removing the need for PCO vehicle, and also permit its use in a higher dose. We conducted intensive monitoring of the ADR profile of Nanoxel in comparison with conventional paclitaxel in a public tertiary care set-up.

Materials and Methods:

ADR data were collected from 10 patients receiving Nanoxel and 10 age-matched controls receiving conventional paclitaxel in this longitudinal observational study, conducted in a medical oncology ward over 18 months. Severity was graded as per US National Cancer Institute Common Terminology Criteria for Adverse Events.

Results:

The groups had comparable demography at baseline. The median disease duration and per cycle median dose of paclitaxel were greater in the Nanoxel arm. Total 119 ADRs were noted with Nanoxel and 123 with conventional paclitaxel. Of these, 25 (21.0%, 95% CI 13.69–28.33%) in the Nanoxel and 20 (16.2%, 95% CI 9.74–22.78%) in paclitaxel group were of grade 3/4 severity. Common events included myalgia, nausea, anemia, paresthesia, alopecia, diarrhea, and vomiting with Nanoxel, and paresthesia, anemia, myalgia, anorexia, alopecia, vomiting, diarrhea, stomatitis, and nausea with paclitaxel. Of the less common events (<5%), grade 2 or 3 arthralgia was seen exclusively with Nanoxel while motor neuropathy with muscular weakness was more frequent and severe with conventional paclitaxel. Hypersensitivity reactions were not encountered in either arm, although no antiallergy premedication was employed for Nanoxel.

Conclusions:

Despite its ADR profile being statistically comparable to conventional paclitaxel, this observational study suggests that Nanoxel tolerability could be better, considering that a significantly higher dose was employed. This hypothesis needs confirmation through an interventional study.

Pharmacovigilance: Boon for the safety and efficacy of Ayuvedic formulations

Pharmacovigilance is a corrective process originating in pharmaco-epidemiology. The 1997 Erice Declaration, presented at the World Health Organisation, became the basis on which the concept was implemented internationally for conventional systems of medicine. The increasing international acceptance of Ayurveda, led regulators to implement a similar program for Ayurveda, particularly as some medical professionals, scientists and members of the public reported adverse reactions after taking Ayurvedic formulations. The World Health Organisation therefore persuaded the Department of AYUSH, Ministry of Health and Family Welfare, Government of India, to implement a pharmacovigilance program for Ayurveda, as a means to ensuring the safety and efficacy of Ayurvedic medicines. After a year of due diligence, the pharmacovigilance program was launched nationally on 29 September 2008. Since that time, Ayurveda, Siddha and Unani medicines have been monitored according to the provisions of a protocol prepared by the National Pharmacovigilance Resource Centre, IPGTRA, Jamnagar, and approved by Department of AYUSH. The program was reviewed, first, on 21st January 2009 by the National Pharmaco-vigilance Consultative Committee for ASU drugs (NPCC-ASU), and again, on 15 Feburary, 2010, when an evaluation meeting effectively rubber stamped the program. Among the outcomes of these meetings were several suggestions of measures to improve the program’s efficiency. Recent developments include the constitution of pharmacovigilance centers at all Ayurveda Teaching institutes and research centers.

Analysis of Adverse Drug Reactions of Atypical Antipsychotic Drugs in Psychiatry OPD

BACKGROUND

Novel atypical antipsychotics are superior to conventional antipsychotics as they significantly reduce both positive and negative symptoms of schizophrenia and have lower risk of extrapyramidal symptoms (EPS). However, these drugs have separate set of adverse drug reactions (ADRs). Therefore, this study was carried out to assess these ADRs, which can have impact on long-term compliance and achieving successful treatment.

MATERIALS AND METHODS

A prospective study of analysis of ADR of atypical antipsychotic drugs was carried out in the psychiatry outpatient department. Patients of psychotic disorder (any age, either sex), who were prescribed atypical antipsychotic drugs, were included. Those who were prescribed conventional antipsychotics or combinations of antipsychotics were excluded from the study. Apart from spontaneously reported ADRs, a questionnaire related to the likely ADR was used and patients' responses were recorded in the case record form.

RESULTS

Totally 93 ADRs were recorded from 84 prescriptions. Majority of the ADRs (82 out of 93) were seen with risperidone and olanzepine, as they were the commonly prescribed drugs. Weight gain, dizziness, sleep disturbance and appetite disturbance accounted for nearly 78% of the total events. With risperidone (at 4-6 mg/day) and olanzepine (at 10-15 mg/day), gastrointestinal and sleep disturbance were observed in the initial (within 7 days to 2-3 months after treatment) course of treatment, while EPS, fatigue, seizure, increased frequency of micturition and dizziness were observed after long-term (3-9 months) use.

CONCLUSION

The present study adds to the existing information on the prevalence of adverse effects of atypical antipsychotic drugs. Role of active surveillance in post-marketing phase is also emphasized.

Vesiculobullous eruption of the right arm after intravenous clarithromycin

Clarithromycin is a macrolide antibiotic. In clinical trials, adverse drug reactions of clarithromycin are usually mild and transient. Only 1% of the adverse reactions are severe. Herein, we present a case with vesiculobullous skin reaction and vein thrombosis caused by administration of intravenous clarithromycin.

A population-based case-crossover study of polyethylene glycol use and acute renal failure risk in the elderly

AIM: To evaluate the possibility of an association between polyethylene glycol (PEG) and acute renal failure (ARF) in elderly patients using a health insurance claims database.

METHODS: We conducted a population-based case-crossover study using information obtained from Korean Health Insurance Review and Assessment Service (HIRA) claims from January 1, 2005 to December 31, 2005 (Seoul, Korea). The study population consisted of elderly patients who received PEG prior to experiencing their first ARF-related hospitalization from April 1, 2005 to December 31, 2005. For each patient, one case and two control periods were matched. PEG use in a 2- or 4-wk window period prior to hospitalization for ARF was compared with PEG use in two earlier 2- or 4-wk control window periods. Conditional logistic regression analysis was used to estimate odds ratios (ORs) and 95% CI, adjusting for concomitant uses of diuretics, angiotensin converting enzyme inhibitors, non-steroidal anti-inflammatory drugs, antibiotics, anti-cancer drugs, and contrast media.

RESULTS: Within the HIRA database which contained 1 093 262 elderly patients, 1156 hospitalized ARF cases were identified. Among these cases, PEG was prescribed to 17 (1.5%) patients before hospitalization. The adjusted ORs when applying the 2- and 4-wk window periods were 0.4 (95% CI: 0.03-5.24) and 2.1 (95% CI: 0.16-27.78), respectively.

CONCLUSION: No increased risk of ARF was found in elderly PEG users. However, based on the limited number of study subjects, further analysis should be performed to confirm these results.

Adverse drug reactions of nonsteroidal anti-inflammatory drugs in orthopedic patients

OBJECTIVES

To identify the ADRs due to NSAIDs and to know how to monitor the drug's effect.

MATERIALS AND METHODS

A descriptive study was undertaken in the Orthopedic Outpatients Department of a tertiary care teaching hospital. Hundred patients were enrolled in this study to observe the risk of adverse drug reactions (ADRs) due to NSAIDs. All the ADRs were further analyzed in relation to age and sex, type of drug and its pattern. Probability scale was used for the causality assessment of the ADRs.

RESULTS

26% of the 100 patients developed ADR due to NSAIDs. There was not much of a difference in the number of the ADRs in relation to the gender. Diclofenac was the highest prescribed drug (65 patients), followed by paracetamol (12), nimesulide (10), ibuprofen (6), piroxicam (5) and Etoricoxib (2). Diclofenac accounted for the maximum number (73%) of ADRs, followed by nimesulide (16%), paracetamol (7%), and Etoricoxib (4%).

CONCLUSION

Pharmacovigilance improves recognition of ADRs by the medical students. It allows the treating physician to identify the ADR associated with drugs, in particular, with the ones considered relatively safe and with those commonly prescribed by the medical and non-health professionals.

Status of disulfiram in present day alcoholic deaddiction therapy

AIM

Assessment of safety and efficacy profile of disulfiram (DSM) in the alcoholic de-addiction regimen.

OBJECTIVES

a. Assessment of Adverse Drug Reaction (ADR) profile; b. Evaluation of effectiveness of various deaddiction regimen; c. Defaulters and dropouts

PATIENTS AND METHODS

Fifty-one patients in a de-addiction center were investigated on 0(th) , 30(th) and 60(th) day along with psychiatric evaluation, ADR surveillance was made. Statistical analysis was done thereafter.

RESULTS

125 mg DSM given OD for 2 months. 76.5% patients had taken full course of treatment, 45% didn't complain of any ADR. Of ADR reported 27.4% had drowsiness, 21.4% tiredness, 7.8% skin manifestation.

CONCLUSION

DSM is the main drug among naltrexone, acamprosate, nalmefene and other drugs used in alcoholic de-addiction. Relative and effectiveness is lost by the degree of dropouts and hence relapses. Low-dose DSM had decreased adverse effects with 76.5% patients taking the full course of treatment. DSM alters liver functions as there were significant changes in the lab parameters of SGPT(P=0.007), SGOT(P=0.001), GGT(P=<0.001) between first and third samples. Occurrence of ADR is not the cause of default; patients find it confusing to differentiate between the symptoms of alcohol withdrawal and those due to ADR of DSM.

Adverse drug reactions in inpatients of internal medicine wards at a tertiary care hospital: A prospective cohort study

OBJECTIVE

To find out incidence of adverse drug reactions (ADR) in patients of internal medicine wards and study various aspects of ADR, e.g., causality, mortality, drugs commonly causing ADR in internal medicine wards of Guru Gobind Singh Hospital, Jamnagar, a tertiary care hospital.

MATERIALS AND METHODS

This was prospective, observational study carried out at Department of Medicine, Shri Meghji Pethraj Shah Medical College attached with Guru Gobind Singh Hospital, a tertiary care teaching hospital, Jamnagar, Gujarat over a period of 6 months. For statistical analysis, ADR were analyzed by using Chi-square test.

RESULTS

Out of total 860 patients admitted, 830 were analyzed as they met the inclusion criteria. A total of 45 (5.42%) patients developed 47 ADR. Among them, 27 (3.25 %) (95% CI, 2.03, 4.47%) patients due to ADR required hospital admission in medicine ward (ADR Ad), 18 (2.17%) (95% CI, 1.17%-3.17%) patients developed ADR while already hospitalized in medicine ward (ADR In). Most of the fatal and life-threatening reactions occurred due to chemotherapeutic agents. Majority of patients discontinued suspected drug and recovered from ADR.

CONCLUSION

Fatal and life-threatening adverse reactions reported in the present as well as other studies underline the importance of such studies and need for creating awareness among health professionals about looking for and reporting such reactions.

Mesalamine induced symptom exacerbation of ulcerative colitis: Case report and brief discussion

This paper describes a rare case in which the oral administration of mesalamine resulted in the exacerbation of ulcerative colitis (UC) in a patient who was previously responsive to mesalamine and whose colitis had been in remission for eight years. Mesalamine and other 5-aminosalicylic acid compounds are the mainstay of treatment for UC; however up to 8% of patients are unable to take the medications due to intolerance or hypersensitivity reactions. Common drug reactions are fever, nausea, diarrhea and abdominal pain; however, exacerbation of UC has rarely been reported. This study highlights the importance of ruling out mesalamine as the causative agent in cases of UC exacerbations.

Drug reaction with herbal supplement: a possible case of drug induced lupus erythematosus

A 24-year-old lady presented with four days history of fever, non-pruritic rash, ankle pain and swelling. She had consumed herbal supplement five days before the onset of symptoms. Examinations revealed erythematous maculo-papular lesions of varying sizes on sun exposed areas. Patient was suspected to have Drug Induced Lupus Erythematosus (DILE) and subsequently symptoms subsided rapidly on withholding the herbal medication.

Valproic acid-induced abnormal behavior

A 12-year-old female was admitted to hospital with complaints of abnormal behavior. She was on valproic acid 200mg twice daily and clobazam 5mg at night for the past 13 weeks for her complex partial seizures with secondary generalized seizures. On day 60 of the treatment with valproic acid she developed behavioral disturbances and initiated treatment with tablet chlorpromazine, olanzapine and risperidone. During the present hospitalization, as there was no improvement in abnormal behavior, antipsychotics were discontinued and she was on observation for five days. On day 6, valproic acid was replaced with carbamazepine. Patient started recovering gradually from the abnormal behavior three days after the withdrawal of valproic acid and completely recovered after three months. Causality of valproic acid-induced abnormal behavior was 'possible'. Behavioral disturbances associated with valproic acid are rare and is reversible upon discontinuation of the drug. There is a need for vigilance on abnormal behavioral effects in patients receiving valproic acid.

A Survey of Knowledge, Attitude and Practice of Nurses towards Pharamacovigilance in Taleqani Hospital

Detection of probable harmful consequences arised from the usage of pharmaceutical products requires decisive, continuous and close monitoring by medical staff whom should have knowledge of adverse drug reactions and they should also have to report any suspected instances, when any kind of adverse drug reactions have been observed. This study has been carried out on the knowledge, attitude and practice of nurses towards pharmacovigilance in the Taleqani medical, teaching and treatment center in Tehran, before and after an ADR educational program. This study was commenced in March 2005 and ended in October 2005, using a questionnaire through two steps. In every step, 150 questionnaires were distributed in various wards of the Taleqani Hospital. Collected data were entered into the Excel software and then data analyzed using the SPSS statistical software. Familiarity of nurses with the ADR center and it's duties is the first step in training how to report ADR, and could help to enhance thire awareness. The use of lecture training for increasing the awareness of nurses was found to be very effective. Regression multivariable analyses showed that the knowledge of nurses, regarding previous familiarity with the ADR center is better than the others (r = 0.38, P = 0.01), and the attitude of female nurses is better than males (r = 0.27, P = 0.01). According to the statistical results, the knowledge of nurses before the seminar was significantly less than the knowledge after the seminar (P= 0.0001), but there was no significant effect on the attitude (P= 0.05). Regarding the submission place of ADR reports, only 3.4% of nurses pointed out to the ADR center. Before and after training, a limited duration of time was reported to be the most restricted factor for clinical recognition of adverse drugs. Based on the results of this study, it is necessary to offer continuous ADR educational program until we reach the point that voluntary reporting of adverse drug reactions becomes conventional and habitual among the nursing staff.

Clinical features of adverse reactions associated with telbivudine

AIM: To analyze the clinical features and risk factors of adverse reactions associated with telbivudine.

METHODS: Clinical data were collected from cases that presented with serious adverse reactions to telbivudine. We analyzed general information and medicine status, clinical features, results of examination, and misdiagnosis.

RESULTS: Out of 105 patients who were treated with telbivudine for hepatitis B in an outpatient department from January, 2007 to January, 2008, five presented with serious adverse drug reactions. Most of these five patients had used other nucleoside analogues in the past. Four were treated with a combination of telbivudine and interferon or another nucleoside analogue, while the other received an increased dose of telbivudine. The main adverse reactions were myalgia and general weakness. This was accompanied by cardiac arrhythmia in one patient, and nervous symptoms in three. Serum creatine kinase was elevated. The rate of misdiagnosis was high.

CONCLUSION: The adverse reactions were related to telbivudine, but the biological mechanism of the reactions is not yet clear. Combination therapy with interferon or another nucleoside analogue and a high dose may increase the risk of adverse reactions.