Paradoxical and bidirectional drug effects

Paradoxical Psoriasis and Worsening Spondylitis Due to Secukinumab in a Patient With Ankylosing Spondylitis: A Case Report and Literature Review

Axial spondyloarthritis (axSpA) is an autoimmune disease primarily affecting the axial skeleton, with associated extra-musculoskeletal manifestations. Treatment strategies targeting cytokines tumor necrosis factor-alpha (TNF-α) and interleukin 17 (IL-17) have proven effective. However, paradoxical reactions, including paradoxical psoriasis and arthritis, have been reported in axSpA patients receiving TNF-α inhibitors. IL-17 inhibitors have been used as an alternative treatment option, but paradoxical reactions have also been rarely observed. This case report presents a 45-year-old man with axSpA who responded to infliximab for six years before discontinuing it due to secondary failure. After the washout period of infliximab, he was started on secukinumab but developed paradoxical psoriasis and worsening of inflammatory back pain after receiving the second loading dose which necessitated replacing it with upadacitinib. Complete resolution of paradoxical psoriasis and significant improvement in his back pain after three months ensued. This case contributes to understanding the complex dynamics in treating axSpA and managing paradoxical reactions.

Paradoxical Reaction to Antitubercular Treatment in a Case of Tuberculous Meningitis

Tuberculous meningitis (TBM) is a challenging disease to treat, as Mycobacterium tuberculosis infects the meninges, which are the outer membranes of the brain and the spinal cord. The majority of patients diagnosed with TBM acquire various other central nervous system complications, and as a result, treating the disease becomes a challenging task. A paradoxical reaction to the treatment may occur in the course of managing TBM. This case study describes a 20-year-old Southeast Asian female who was diagnosed and treated for TBM and subsequently developed a resurgence of the disease due to a paradoxical reaction.

Pharmaceutical Methods for Enhancing the Dissolution of Poorly Water-Soluble Drugs

Low water solubility is the main hindrance in the growth of pharmaceutical industry. Approximately 90% of newer molecules under investigation for drugs and 40% of novel drugs have been reported to have low water solubility. The key and thought-provoking task for the formulation scientists is the development of novel techniques to overcome the solubility-related issues of these drugs. The main intention of present review is to depict the conventional and novel strategies to overcome the solubility-related problems of Biopharmaceutical Classification System Class-II drugs. More than 100 articles published in the last 5 years were reviewed to have a look at the strategies used for solubility enhancement. pH modification, salt forms, amorphous forms, surfactant solubilization, cosolvency, solid dispersions, inclusion complexation, polymeric micelles, crystals, size reduction, nanonization, proliposomes, liposomes, solid lipid nanoparticles, microemulsions, and self-emulsifying drug delivery systems are the various techniques to yield better bioavailability of poorly soluble drugs. The selection of solubility enhancement technique is based on the dosage form and physiochemical characteristics of drug molecules.

Evaluation of Anti-Alzheimer Activity of Synthetic Coumarins by Combination of in Vitro and in Silico Approaches

Series of synthetic coumarin derivatives (1-16) were tested against acetylcholinesterase (AChE) and butyrylcholinesterase (BChE), two enzymes linked to the pathology of Alzheimer's disease (AD). Compound 16 was the most active AChE inhibitor with IC₅₀ 32.23±2.91 μM, while the reference (galantamine) had IC₅₀ =1.85±0.12 μM. Compounds 9 (IC₅₀ 75.14±1.82 μM), 13 (IC₅₀ =16.14±0.43 μM), were determined to be stronger BChE inhibitors than the reference galantamine (IC₅₀ =93.53±2.23 μM). The IC₅₀ value of compound 16 for BChE inhibition (IC₅₀ =126.56±11.96 μM) was slightly higher than galantamine. The atomic interactions between the ligands and the key amino acids inside the binding cavities were simulated to determine their ligand-binding positions and free energies. The three inhibitory coumarins (9, 13, 16) were next tested for their effects on the genes associated with AD using human neuroblastoma (SH-SY5Y) cell lines. Our data indicate that they could be considered for further evaluation as new anti-Alzheimer drug candidates.

Therapeutic Efficacies of Berberine against Neurological Disorders: An Update of Pharmacological Effects and Mechanisms

Neurological disorders are ranked as the leading cause of disability and the second leading cause of death worldwide, underscoring an urgent necessity to develop novel pharmacotherapies. Berberine (BBR) is a well-known phytochemical isolated from a number of medicinal herbs. BBR has attracted much interest for its broad range of pharmacological actions in treating and/or managing neurological disorders. The discoveries in basic and clinical studies of the effects of BBR on neurological disorders in the last decade have provided novel evidence to support the potential therapeutical efficacies of BBR in treating neurological diseases. In this review, we summarized the pharmacological properties and therapeutic applications of BBR against neurological disorders in the last decade. We also emphasized the major pathways modulated by BBR, which provides firm evidence for BBR as a promising drug candidate for neurological disorders.

What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications

Although psychiatric drug withdrawal syndromes have been recognized since the 1950s - recent studies confirm antidepressant withdrawal syndrome incidence upwards of 40% - medical information about how to safely go off the drugs has been lacking. To fill this gap, over the last 25 years, patients have developed a robust Internet-based subculture of peer support for tapering off psychiatric drugs and recovering from withdrawal syndrome. This account from the founder of such an online community covers lessons learned from thousands of patients regarding common experiences with medical providers, identification of adverse drug reactions, risk factors for withdrawal, tapering techniques, withdrawal symptoms, protracted withdrawal syndrome, and strategies to cope with symptoms, in the context of the existing scientific literature.

Estimating the frequency of hormesis and other non-monotonic responses in plants experiencing road traffic pollution in urban areas and experimental pollutant exposure

Various plant traits are widely utilised to assess environment health. However, non-monotonic responses in plants (hormesis and non-hormetic ones) can induce an incorrect assessment of contamination level because they have maximums and/or minimums. Hence, an increase in the pollution level will not always be accompanied by plant index deteriorations. The frequencies of non-monotonic responses, especially non-hormetic responses, have been insufficiently studied for plant traits. This study analysed the frequencies of non-monotonic changes in plants experiencing urban chemical pollution (B. pendula, T. cordata and T. officinale) and with different pollutant exposures (heavy metals, herbicide glyphosate, formaldehyde and sodium chloride) in experiments (T. aestivum and P. sativum). In the city, we evaluated the traits in plants with the same ontogenetic stages on plots near roads with various traffic and similar abiotic conditions. In urban areas, non-monotonic responses were found in both woody (B. pendula and T. cordata) and herbaceous (T. officinale) species for most traits. Their frequencies corresponded to the proportion of monotonic responses (B. pendula) or were even higher (T. cordata and T. officinale). In studied trees, non-monotonic responses were more common in biochemical traits compared with non-biochemical ones. With experimental pollutant exposure, non-monotonic responses were obtained for most traits of both dicotyledonous (P. sativum) and monocotyledonous (T. aestivum) plants, and their frequency was significantly higher than for monotonic ones. Non-hormetic responses significantly prevailed among non-monotonic changes of plant indexes in the city and experiments. Thus, it is necessary to consider both hormesis and non-hormetic responses to assess correctly environmental quality using plant indexes.

Change of Leaf Trait Asymmetry Type in Tilia cordata Mill. and Betula pendula Roth under Air Pollution

Leaf fluctuating asymmetry (FA) is widely used as an environmental stress index, including pollution. Besides FA, leaf bilateral traits can have directional asymmetry (DA) and antisymmetry (AS), which are considered hereditary. Leaf FA transitioning to DA/AS or mixed asymmetry, under air pollution, has been insufficiently investigated. This study analysed leaf asymmetry types in Tilia cordata Mill. and Betula pendula Roth under traffic air pollution over several years. In addition, the relations of such transitions to pollution, and their effect on FA-integrated index, were studied. The asymmetry types of all studied leaf traits varied with air pollution increase, as well as in control trees in different years. T. cordata most often had FA transition to DA/mixed asymmetry, while B. pendula rarely had a mixed asymmetry and FA transitions to DA/AS were observed with the same frequency. Air pollution impacted FA transitions to other asymmetry types. In most cases their frequency changed non-monotonically that corresponded to hormesis and paradoxical effects. However, FA integrated index in studied trees did not depend on change of leaf asymmetry type. Thus, DA and AS in studied plants were not exclusively hereditary. Hence, the changes of leaf asymmetry type should be considered when using leaf FA in environment assessment.

Causality assessment of adverse events following immunization: the problem of multifactorial pathology

The analysis of Adverse Events Following Immunization (AEFI) is important in a balanced epidemiological evaluation of vaccines and in the issues related to national vaccine injury compensation programs. If manufacturing defects or vaccine storage and delivering errors are excluded, the majority of adverse reactions to vaccines occur as excessive or biased inflammatory and immune responses. These unwanted phenomena, occasionally severe, are associated with many different endogenous and exogenous factors, which often interact in complex ways. The confirmation or denial of the causal link between an AEFI and vaccination is determined pursuant to WHO guidelines, which propose a four-step analysis and algorithmic diagramming. The evaluation process from the onset considers all possible "other causes" that can explain the AEFI and thus exclude the role of the vaccine. Subsequently, even if there was biological plausibility and temporal compatibility for a causal association between the vaccine and the AEFI, the guidelines ask to look for any possible evidence that the vaccine could not have caused that event. Such an algorithmic method presents some concerns that are discussed here, in the light of the multifactorial nature of the inflammatory and immune pathologies induced by vaccines, including emerging knowledge of genetic susceptibility to adverse effects. It is proposed that the causality assessment could exclude a consistent association of the adverse event with the vaccine only when the presumed "other cause" is independent of an interaction with the vaccine. Furthermore, the scientific literature should be viewed not as an exclusion criterion but as a comprehensive analysis of all the evidence for or against the role of the vaccine in causing an adverse reaction. These issues are discussed in relation to the laws that, in some countries, regulate the mandatory vaccinations and the compensation for those who have suffered serious adverse effects.

Causality assessment of adverse events following immunization: the problem of multifactorial pathology

The analysis of Adverse Events Following Immunization (AEFI) is important in a balanced epidemiological evaluation of vaccines and in the issues related to vaccine injury compensation programs. The majority of adverse reactions to vaccines occur as excessive or biased inflammatory and immune responses. These unwanted phenomena, occasionally severe, are associated with many different endogenous and exogenous factors, which often interact in complex ways. The confirmation or denial of the causal link between an AEFI and vaccination is determined pursuant to WHO guidelines, which propose a four-step analysis and algorithmic diagramming. The evaluation process from the onset considers all possible "other causes" that might explain the AEFI and thus exclude the role of the vaccine. Subsequently, even if there was biological plausibility and temporal compatibility for a causal association between the vaccine and the AEFI, the guidelines ask to look for any possible evidence that the vaccine could not have caused that event. Such an algorithmic method presents several concerns that are discussed here, in the light of the multifactorial nature of the inflammatory and immune pathologies induced by vaccines, including emerging knowledge of genetic susceptibility to adverse effects. It is proposed that the causality assessment could exclude a consistent association of the adverse event with the vaccine only when the presumed "other cause" is independent of an interaction with the vaccine. Furthermore, the scientific literature should be viewed not as an exclusion criterion but as a comprehensive analysis of all the evidence for or against the role of the vaccine in causing an adverse reaction. Given these inadequacies in the evaluation of multifactorial diseases, the WHO guidelines need to be reevaluated and revised. These issues are discussed in relation to the laws that, in some countries, regulate the mandatory vaccinations and the compensation for those who have suffered serious adverse effects.

Hormesis and paradoxical effects of pea (Pisum sativum L.) parameters upon exposure to formaldehyde in a wide range of doses

Formaldehyde is a widespread pollutant of soil near roads including agricultural lands. Non-monotonic changes (hormesis and paradoxical effects) in chlorophyll (Ch) and carotenoid (Car) contents, the lipid peroxidation (LP) rate in plant leaves and growth parameters (GP) of plants can be caused by various pollutants. Hormesis is a biphasic dose-response phenomenon, characterised by low-dose stimulation and high-dose inhibition. The remaining types of non-monotonic responses are classified as paradoxical effects. While most authors who have studied formaldehyde and plants considered gaseous exposure to shoots, the effect of this pollutant in soil solution has been poorly examined. Thus, we studied the non-monotonic changes in Ch and Car contents, LP rate and GP in pea (Pisum sativum L.) upon exposure to formaldehyde in solution, at a wide range of sublethal concentrations from 0.063 × 10-2 to 0.16 g L-1. With formaldehyde exposure, LP and Ch contents had paradoxical effects (triphasic and multiphase changes, accordingly), while Car level did not change and GP exhibited a hormetic response. The date showed that pea parameters display diverse types of non-monotonic responses upon exposure to the same formaldehyde concentrations. High pollutant concentrations (0.08-0.16 g L-1) increased LP and significantly decreased GP (to 2.3-2.5 times compared to the control), while the Ch content was increased. Lower concentrations (<0.08 g L-1) caused a moderate deviation in all parameters from the control (not more than 62%) for hormesis and paradoxical effects.

The law of mass action and the pharmacological concentration-effect curve: resolving the paradox of apparently non-dose-related adverse drug reactions

BACKGROUND

Adverse drug reactions are sometimes described as being 'non-dose-related' because no relationship has been found between increasing doses and either the intensity of the response or the proportion of individuals in whom the response occurs; furthermore, hypersensitivity reactions are often regarded as being non-dose-related, even if different doses have not been studied. However, the law of mass action implies that all pharmacological effects are concentration related and should increase in intensity with increasing dose. We set out to explain this paradox.

METHODS

We searched for published adverse drug reactions that have been described as non-dose-related and analysed them.

RESULTS

We identified four categories of explanations that resolve the paradox: (i) the reaction is not real; it may have occurred by chance or there may be methodological problems, such as bias or confounding factors; (ii) the dose-response curve for the adverse effect reaches a maximum at doses lower than were studied (i.e. a hypersusceptibility reaction); this underpins the use of test doses to predict the possibility of an adverse reaction at therapeutic doses; (iii) susceptibility to the adverse reaction differs widely among individuals; and (iv) imprecision or inaccuracy in the measurement of either dose or effect obscures dose responsiveness. This last explanation encompasses: (a) reactions related to cumulative dose; (b) dissociation between dose and concentration through saturable pharmacokinetics; and (c) variability in the measurement of the effect.

CONCLUSIONS AND IMPLICATIONS

If an adverse drug reaction appears to be non-dose-related, the reasons should be sought, having these mechanisms in mind.

Causal assessment of pharmaceutical treatments: why standards of evidence should not be the same for benefits and harms?

It is increasingly acknowledged both among epidemiologists and regulators that the assessment of pharmaceutical harm requires specific methodological approaches that cannot simply duplicate those developed for testing efficacy. However, this intuition lacks sound epistemic bases and delivers ad hoc advice. This paper explains why the same methods of scientific inference do not fare equally well for efficacy and safety assessment by tracing them back to their epistemic foundations. To illustrate this, Cartwright's distinction into clinching and vouching methods is adopted and a series of reasons is provided for preferring the latter to the former: (1) the need to take into account all available knowledge and integrate it with incoming data; (2) the awareness that a latent unknown risk may always change the safety profile of a given drug (precautionary principle); (3) cumulative learning over time; (4) requirement of probabilistic causal assessment to allow decision under uncertainty; (5) impartiality; and (6) limited and local information provided by randomised controlled trials. Subsequently, the clinchers/vouchers distinction is applied to a case study concerning the debated causal association between paracetamol and asthma. This study illustrates the tension between implicit epistemologies adopted in evaluating evidence and causality; furthermore, it also shows that discounting causal evidence may be a result of unacknowledged low priors or lack of valid alternative options. We conclude with a presentation of the changing landscape in pharmacology and the trend towards an increased use of Bayesian tools for assessment of harms.

Dependence of Guaiacol Peroxidase Activity and Lipid Peroxidation Rate in Drooping Birch (Betula pendula Roth) and Tillet (Tilia cordata Mill) Leaf on Motor Traffic Pollution Intensity

Hormesis and paradoxical effects are frequently found for different plant parameters. These phenomena were also observed for lipid peroxidation (LP) rate at environmental pollution. However, the role of antioxidant enzymes, particularly guaiacol peroxidases (GPX), in a nonmonotonic variation in the LP rate remains insufficiently explored. Therefore, dependence of GPX activity and LP rate in Betula pendula and Tilia cordata leaf on motor traffic pollution intensity was studied. Regression analysis revealed dependences of LP rate and GPX activity on traffic intensity. In B pendula, GPX activity enhanced significantly (up to 2.8 times relatively control) under increased traffic that induced biphasic paradoxical effect for LP rate. In the first phase, LP level increased in comparison with the control, and in the second phase, it was normalized by enhanced GPX activity. In T cordata, dependences of GPX activity and LP rate on traffic pollution were paradoxical effects. However, there was no connection between change of GPX activity and LP rate under middle- and high-level pollution: LP level reduced relatively the control or normalized even if GPX activity was lower than the control. This indicates that in T cordata, other regulatory mechanisms instead of GPX were activated which could control LP rate under middle- and high-level pollution.

Hormesis and Paradoxical Effects of Drooping Birch (Betula pendula Roth) Parameters Under Motor Traffic Pollution

Various plant indexes are used or recommended for bioindication. However, the nonmonotonic dose-response dependences (hormesis and paradoxical effects) of these indexes are insufficiently explored upon exposure to pollution. We studied the dependences of these Betula pendula indexes on the intensity of motor traffic pollution. Regression analysis did not reveal any dependence of chlorophyll and carotenoid content on traffic intensity (in 2008 and 2010-2013). Lipid peroxidation rate had different versions of paradoxical effects in 2008 and 2010 to 2012 and increased in comparison with control under an increase in pollution level in 2013. In 2010 to 2012, all dose-response dependences for total protein and thiol group content were biphasic and multiphasic paradoxical effects. In 2013, an increase in traffic intensity induced a linear reduction in protein content and an increase in thiol group level in comparison with the control. In most cases, the studied phenological indexes and seed production decreased monotonically in comparison with the control following an increase in traffic intensity. Only in 2010 and 2013, share of fallen leaves had hormesis and paradoxical effect accordingly. Fluctuating asymmetry had a paradoxical effect and hormesis in 2008 and 2012, accordingly, and increased in comparison with the control under an increase in the level of pollution in 2010 to 2011.

Dependence of Dandelion (Taraxacum officinale Wigg.) Seed Reproduction Indices on Intensity of Motor Traffic Pollution

Dandelion (Taraxacum officinale Wigg.) seed reproduction indices such as the total number of seeds, the number of normally developed seeds and underdeveloped seeds per anthodium, and seed weight are suggested to assess the level of environmental pollution (bioindication). However, the non-monotonic dose-response dependences (hormesis and paradoxical effects) of these indices are insufficiently explored upon exposure to pollution. We studied the dependence of some T. officinale seed reproduction indices on intensity of motor traffic pollution in wide range of values over 2 years of observation. In 2010, the increase in traffic intensity induced a monotonic increase in the total seed number and the number of normally developed seeds. Besides, motor traffic pollution decreased the number of undeveloped seeds and seed weight in comparison with the control. In 2011, for all studied T. officinale indices except seed weight, complicated non-monotonic dependences on traffic intensity were found that could be attributed to paradoxical effects. It is hypothesised that the significant differences in the studied dependencies in 2010-2011 were caused by changes in weather conditions because traffic intensity did not differ significantly between the two observation years.

Reducing the noise in signal detection of adverse drug reactions by standardizing the background: a pilot study on analyses of proportional reporting ratios-by-therapeutic area

PURPOSE

Disproportionality screening analysis is acknowledged as a tool for performing signal detection in databases of adverse drug reactions (ADRs), e.g., in the European Union (EU) Drug Authority setting. The purpose of this study was to explore the possibility of decreasing false-positive signals of disproportionate reporting (SDR) by calculating the proportional reporting ratio (PRR)-by-therapeutic area (TA), while still maintaining the ability to detect relevant SDRs.

METHODS

In the EudraVigilance (EV) Database, output from PRR calculated with a restricted TA comparator background was compared in detail to output from conventional authority-setting PRR calculations for four drugs: bicalutamide, abiraterone, metformin, and vildagliptin, within the TAs of prostate gland disease and type 2 diabetes mellitus.

RESULTS

ADR reports per investigated drug ranged from 2,400 to 50,000. The PRR-TA's ability to detect true-positive SDRs (as acknowledged in approved labeling) was increased compared to the conventional PRR, and performed 8-31 % better than a recently proposed stricter EU-SDR definition. The PRR-TA removed false SDRs confounded by disease or disease spill-over by up to 63 %, while retaining/increasing the number of unclassified SDRs relevant for manual validation, and thereby improving the ratio between confounded SDRs (i.e., noise) and unclassified SDRs for all investigated drugs (possible signals).

CONCLUSIONS

The performance of the PRR was improved by background restriction with the PRR-TA method; the number of false-positive SDRs decreased, and the ability to detect true-positive SDRs increased, improving the signal-to-noise ratio. Further development and validation of the method is needed within other TAs and databases, and for disproportionality analysis methods.

Distinguishing hazards and harms, adverse drug effects and adverse drug reactions : implications for drug development, clinical trials, pharmacovigilance, biomarkers, and monitoring

The terms 'adverse drug effects' and 'adverse drug reactions' are commonly used interchangeably, but they have different implications. Adverse drug reactions arise when a compound (e.g. a drug or metabolite, a contaminant or adulterant) is distributed in the same place as a body tissue (e.g. a receptor, enzyme, or ion channel), and the encounter results in an adverse effect (a physiological or pathological change), which results in a clinically appreciable adverse reaction. Both the adverse effect and the adverse reaction have manifestations by which they can be recognized: adverse effects are usually detected by laboratory tests (e.g. biochemical, haematological, immunological, radiological, pathological) or by clinical investigations (e.g. endoscopy, cardiac catheterization), and adverse reactions by their clinical manifestations (symptoms and/or signs). This distinction suggests five scenarios: (i) adverse reactions can result directly from adverse effects; (ii) adverse effects may not lead to appreciable adverse reactions; (iii) adverse reactions can occur without preceding adverse effects; (iv) adverse effects and reactions may be dissociated; and (v) adverse effects and reactions can together constitute syndromes. Defining an adverse drug reaction as "an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product" suggests a definition of an adverse drug effect: "a potentially harmful effect resulting from an intervention related to the use of a medicinal product, which constitutes a hazard and may or may not be associated with a clinically appreciable adverse reaction and/or an abnormal laboratory test or clinical investigation, as a marker of an adverse reaction."

Hormesis and paradoxical effects of wheat seedling (triticum aestivum L.) parameters upon exposure to different pollutants in a wide range of doses

Chlorophyll and carotenoid content (ChCar), lipid peroxidation (LP) and growth parameters (GP) in plants are often used for environmental pollution estimation. However, the nonmonotonic dose-response dependences (hormesis and paradoxical effects) of these indices are insufficiently explored following exposure to different pollutants. In this experiment, we studied nonmonotonic changes in ChCar, LP, GP in wheat seedlings (Triticum aestivum L.) upon exposure to lead, cadmium, copper, manganese, formaldehyde, the herbicide glyphosate, and sodium chloride in a wide range from sublethal concentration to 10(2)-10(5) times lower concentrations. 85.7% of dose-response dependences were nonmonotonic (of these, 5.5% were hormesis and paradoxical effects comprised 94.5%). Multiphasic dependences were the most widespread type of paradoxical effect. Hormesis was a part of some multiphasic responses (i.e. paradoxical effects), which indicates a relationship between these phenomena. Sublethal pollutant concentrations significantly increased LP (to 2.0-2.4 times, except for manganese and glyphosate) and decreased GP (to 2.1-36.6 times, except for glyphosate), while ChCar was reduced insignificantly, normalized or even increased. Lower pollutant concentrations caused a moderate deviation in all parameters from the control (not more than 62%) for hormesis and paradoxical effects. The seedling parameters could have different types of nonmonotonic responses upon exposure to the same pollutant.