Prescription-based cost analysis of medicines for cardiovascular risk factors at Indian Council of Medical Research-Rational Use of Medicine Centre Hospitals of India

OBJECTIVES

India has taken several initiatives to provide health care to its population while keeping the related expenditure minimum. Since cardiovascular diseases are the most prevalent chronic conditions, in the present study, we aimed to analyze the difference in prices of medicines prescribed for three cardiovascular risk factors, based on (a) listed and not listed in the National List of Essential Medicines (NLEM) and (b) generic and branded drugs.

MATERIALS AND METHODS

Outpatient prescriptions for diabetes mellitus, hypertension, and dyslipidemia were retrospectively analyzed from 12 tertiary centers. The prices of medicines prescribed were compared based on presence or absence in NLEM India-2015 and prescribing by generic versus brand name. The price was standardized and presented as average price per medicine per year for a given medicine. The results are presented in Indian rupee (INR) and as median (range).

RESULTS

Of the 4,736 prescriptions collected, 843 contained oral antidiabetic, antihypertensive, and/or hypolipidemic medicines. The price per medicine per year for NLEM oral antidiabetics was INR 2849 (2593-3104) and for non-NLEM was INR 5343 (2964-14364). It was INR 806 (243-2132) for generic and INR 3809 (1968-14364) for branded antidiabetics. Antihypertensives and hypolipidemics followed the trend. The price of branded non-NLEM medicines was 5-22 times higher compared to generic NLEM which, for a population of 1.37 billion, would translate to a potential saving of 346.8 billion INR for statins. The variability was significant for sulfonylureas, angiotensin receptor blockers, beta-blockers, diuretics, and statins (P < 0.0001).

CONCLUSION

The study highlights an urgent need for intervention to actualize the maximum benefit of government policies and minimize the out-of-pocket expenditure on medicines.

Usage Pattern of Fixed-dose Combinations at ICMR Network of Rational Use of Medicine Centres across India: Recommendations for Policymakers and Prescribers

AIM

Irrational use of medicines is a global problem. In India, one contributing factor is the availability of a large number of fixed-dose combinations (FDCs). To improve rational use and to strengthen policies, it is important to assess the usage patterns and rationality of FDCs.

METHODS

This study was conducted as part of a 1-year prospective cross-sectional analysis of prescriptions in the outpatient clinics of broad specialities from 13 tertiary care hospitals across India. Five most commonly prescribed FDCs in each center were analyzed. In addition, all the prescribed FDCs were classified as per the Kokate Committee classification and it was noted whether any of the FDCs were irrational or banned as per the reference lists released by regulatory authorities.

RESULTS

A total of 4,838 prescriptions were analyzed. Of these, 2,093 (43.3%) prescriptions had at least one FDC. These 2,093 prescriptions had 366 different FDCs. Of the 366 FDCs, 241 were rational; 10 were irrational; 14 required further data generation; and the remaining 96 FDCs could not be categorized into any of the above. Vitamins and minerals/supplements, antibacterial for systemic use, and drugs for gastroesophageal reflux disease (GERD) and peptic ulcer were the most used FDCs.

CONCLUSION

Based on the finding that some prescriptions contained irrational FDCs, it is recommended that a rigorous, regular, and uniform method of evaluation be implemented to approve/ban FDCs and that prescribers be periodically notified about the status of the bans.

Use of drugs not listed in the National List of Essential Medicines: Findings from a prescription analysis by the Indian Council of Medical Research-Rational Use of Medicines Centres Network in tertiary care hospitals across India

BACKGROUND

The concept of listing essential medicines can lead to improved supply and access, more rational prescribing, and lower costs of drugs. However, these benefits hinge on the prescription of drugs from an Essential Medicines List (EML). Several studies have highlighted the problem of underutilization of EMLs by prescribers. Therefore, as part of prescription research by the Indian Council of Medical Research-Rational Use of Medicines Centres Network, we evaluated the extent of prescription of drugs not listed in the National List of Essential Medicines (NLEM).

MATERIALS AND METHODS

Prescriptions of outpatients from participating centers were included after obtaining verbal/written informed consent as approved by the Ethics Committee, and evaluated for prescription of drugs from the NLEM 2015.

RESULTS

Analysis of 4838 prescriptions from 13 tertiary health-care institutes revealed that 2677 (55.33%) prescriptions had at least one non-NLEM drug prescribed. In all, 5215 (31.12%) of the total 16,758 drugs prescribed were not in NLEM. Of these, 2722 (16.24%) were single drugs and 2493 (14.88%) were fixed-dose combinations (FDCs). These comprised 700 different drug products - 346 single drugs and 354 FDCs. The average number of non-NLEM drugs prescribed per prescription was 1.08, while the average number of all drugs prescribed was 3.35 per prescription. It was also found that some of the non-NLEM drugs prescribed had the potential to result in increased cost (for example, levocetirizine), increased adverse effects (dextromethorphan), and less effectiveness (losartan) when compared to their NLEM counterparts. Nonavailability of an essential drug (oral hydroxocobalamin) was another important finding of our study.

CONCLUSION

This study highlights the extent and pattern of drugs prescribed from outside the NLEM at the tertiary health-care level and the need for training and enhanced awareness among prescribers for greater utilization of the NLEM.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Spaced education and student learning: Results from a medical school

BACKGROUND

It is critical for medical students to retain and apply their knowledge of basic sciences to become competent prescribing physicians. Poor long-term retention is a pervasive concern. We investigated the impact of 'spaced education' teaching modules to improve knowledge retention in medical students on a topic of public health: vitamin D and its role in health and disease. It is critical for medical students to retain and apply their knowledge of basic sciences to become competent prescribing physicians METHODS: In a self-matched design, 148 medical students were randomised and evaluated on vitamin D-related topics to assess reinforced and non-reinforced knowledge in a multiple-choice question format. Initial learning and long-term retention were assessed with an estimation of Cohen's effect size at 24 and 72 weeks, respectively.

RESULTS

The administration of spaced educational material significantly improved composite formative test scores at 24 weeks (p < 0.001, effect size = 1.33). Although the scores dipped, there was a retention of knowledge at 72 weeks (effect size = 0.48).

DISCUSSION

Spaced reinforcement and testing statistically improved knowledge retention among our medical students. Gaps in the present teaching could be bridged by motivating the students to extend their learning time by appropriate spacing intervals and to understand the relevance of course content in different scenarios as a physician. Further research could be instrumental in optimising interventions to enhance learning opportunities for medical students.

Protective effect of pioglitazone on cardiomyocyte apoptosis in low-dose streptozotocin & high-fat diet-induced type-2 diabetes in rats

BACKGROUND & OBJECTIVES

Cardiomyocyte apoptosis is one of the pathologic phenomena associated with diabetes and related conditions including obesity, insulin resistance and hyperlipidaemia. In the present study, the protective effects of pioglitazone on cardiomyocyte apoptosis was evaluated in experimental diabetes induced by low dose of streptozoticin (STZ) combined with high fat diet (HFD) in rats.

METHODS

Male Wistar rats (150-200 g) were injected with low-dose STZ (45 mg/kg, i.v., single dose) and orally fed with a HFD (20 g/day/rat) for a period of 28 days and simultaneously treated with pioglitazone (20 mg/kg/p.o.) for a period of 21 days (from 8 th day to 28 th day). On 29 th day blood was collected, serum separated and used for biochemical parameters. Heart tissue was used for cardiomyocyte apoptosis measurement and also for histopathological examination.

RESULTS

Pioglitazone treatment resulted in a decrease in cardiomyocyte apoptosis as revealed by a decrease in cardiac caspase-3, lactate dehydrogenase (LDH) levels and DNA fragmentation, and an increase in Na+K+ATPase levels in diabetic rats. Cardiac histology of diabetic control rats showed dense focal fatty infiltration in the myocardial cells whereas normal architecture with regular morphology and well preserved cytoplasm was observed with pioglitazone treatment. Pioglitazone treatment significantly reduced the heart rate, mean arterial blood pressure, body mass index (BMI) and levels of serum glucose, leptin, insulin, HOMA-IR, total cholesterol (TC) and triglycerides (TGs), apoliproprotein-B glycosylated haemoglobin (HbA1c) levels and atherogenic index, and increased the levels of serum high density lipoprotein cholesterol (HDL-C) and cardiac antioxidant enzymes.

INTERPRETATION & CONCLUSIONS

The present study results suggest that pioglitazone possesses cardiac anti-apoptotic potential in diabetic rat model and can be further explored for its use for treatment of diabetic cardiomyopathy.

Vitamin D supplements in the Indian Market

It is now known that vitamin D deficiency is a worldwide health problem. In our country, as food fortification is lacking, supplementation with pharmaceutical preparations is the only means of treatment of vitamin D deficiency. We aimed to study the composition and availability of various vitamin D preparations in the Indian market, data about which was collected from annual drug compendium. The preparations were assessed for total number, different formulations, constituents and amount of each constituent present in the formulation. Vitamin D3 is available in the form of cholecalciferol, alfacalcidiol and calcitriol as single ingredient products and in combination with calcium and other micronutrients. Most of the supplements contain calcitriol (46.5%) or alfacalcidiol (43%) as tablets (51.1%) and capsules (35.2%). Cholecalciferol, the preferred form for prophylaxis and treatment of vitamin D deficient states, constitutes only 10% of the available market preparations. High market sales of calcium supplements containing calcitriol indicate increasing intake of calcitriol rather than cholecalciferol; which could predispose to toxicity. There is a need for marketing and rational prescribing of the appropriate vitamin D supplement in ostensibly healthy Indian population. Implementation of population-based education and intervention programmes with enforcement of strict regulations could generate awareness and curb unsupervised intake of vitamin D containing dietary supplements. This health challenge mandates effective nutritional policies, fortification and supplementation programmes and partnership between government, healthcare and industry to safeguard the health of Indian population at large.

Commiphora mukul attenuates peripheral neuropathic pain induced by chronic constriction injury of sciatic nerve in rats

OBJECTIVE

The management of neuropathic pain remains unsatisfactory till date, despite immense advances in the therapeutic strategies. Commiphora mukul (CM), also known as Commiphora wightii, is well known in the traditional Indian system of medicine, and has been used to treat ailments such as obesity, bone fractures, arthritis, inflammation, cardiovascular diseases, and lipid disorders. The present study was performed to investigate the effect of CM on peripheral neuropathic pain in rats.

METHODS

Neuropathic pain was induced by the chronic constriction injury of the sciatic nerve. Following this, CM was orally administered for 2 weeks in doses of 50, 100, and 200 mg/kg, and pain assessment was performed by employing the behavioral tests for thermal hyperalgesia (hot-plate and tail-flick tests) and cold allodynia (acetone test).

RESULTS

Following the induction of neuropathic pain, significant development of thermal hyperalgesia and cold allodynia was observed. The administration of CM (50 mg/kg) did not have any effect on the hot-plate and tail-flick tests, but significant anti-allodynic effect was observed in the acetone test. Furthermore, administration of CM (100 mg/kg) caused significant decrease in pain as observed on the tail-flick and acetone tests, but not in the hot-plate test. CM in a dose of 200 mg/kg significantly modulated neuropathic pain as observed from the increased hot-plate and tail-flick latencies, and decreased paw withdrawal duration (in acetone test).

DISCUSSION

Therefore, the present study suggests that CM may be used in future as a treatment option for neuropathic pain.

Clinical review of sitagliptin: a DPP-4 inhibitor

Type 2 Diabetes Mellitus is most common form of diabetes. Oral agents are the main stay of pharmacological treatment for type 2 diabetes mellitus. Dipeptidyl peptidase-4 (DPP-4) inhibitors represent a new therapeutic approach for type 2 diabetes. Sitagliptin is highly selective DPP-4 inhibitor that has been approved for type 2 diabetes therapy. It acts by increasing the levels of incretins by inhibiting their degradation by DPP-4. Sitagliptin has been shown to be effective, well tolerated and safe in the treatment of type 2 diabetes in monotherapy or in combination with metformin or thiozolidinediones with minimal side effects.

Anti-obesity effect of Gymnema sylvestre extract on high fat diet-induced obesity in Wistar rats

Gymnema sylvestre R. BR. (Asclepiadaceae) has been used frequently in traditional Indian folk medicine for the treatment of diabetes. Study was performed in high fat diet (HFD)-induced obesity in murine model. Obesity was induced by oral feeding of HFD for 28 days. The anti obesity effect of water soluble fraction of Gymnema sylvestre extract (120 mg/kg, p.o. for 21 days) in HFD fed rats was evaluated by the measurement of body weight gain, food intake, hemodynamic changes (systolic, diastolic, mean blood pressure and heart rate), serum lipid profiles (triglycerides, total cholesterol, LDL-cholesterol, HDL-cholesterol), leptin, insulin, glucose, apolipoproteins A1 and B, lactate dehydrogenase (LDH) and antioxidant enzymes such as reduced glutathione (GSH), glutathione peroxidase (GPx), glutathione reductase (GR), glutathione-S transferase (GST), superoxide dismutase (SOD) and catalase (CAT) levels in liver tissues. Organs and visceral fat pad weight were measured. Histopathological studies were also carried out. Water soluble fraction of G. sylvestre ethanolic extract and rimonabant significantly reduced serum lipids, leptin, insulin, glucose, apolipoprotein B and LDH levels while it significantly increased the HDL-cholesterol, apolipoprotein A1 and antioxidant enzymes levels in liver tissue as compared to the HFD fed rats. Histopathological studies of tissues showed no pathological changes. The results of this study show that water soluble fraction of G. sylvestre extract possess antiobesity effect.

The effect of aqueous extract of Embelia ribes Burm on serum homocysteine, lipids and oxidative enzymes in methionine induced hyperhomocysteinemia

Objective:

The present study was designed to evaluate the effect of the aqueous extract of Embelia ribes Burm fruits on methionine-induced hyperhomocysteinemia, hyperlipidemia and oxidative stress in albino rats.

Materials and Methods:

Adult male Wistar albino rats were fed with the aqueous extract of Embelia ribes (100 and 200 mg/kg, p.o.) for 30 days. Hyperhomocysteinemia was induced by methionine treatment (1 g/kg, p.o.) for 30 days and folic acid (100 mg/kg, p.o.) was used as a standard drug. The animals were evaluated for various biochemical parameters in serum and brain homogenates, followed by histopathological studies at the end of the study.

Results:

Administration of methionine (1 g/kg, p.o.) for 30 days to vehicle control rats produced significant increase (P < 0.01) in homocysteine, lactate dehydrogenase (LDH), total cholesterol, triglycerides, low density lipoprotein (LDL-C), very low density lipoprotein (VLDL-C) levels in serum and lipid peroxides (LPO) levels in brain homogenates, with reduction in high density lipoprotein (HDL-C) levels in serum, and glutathione (GSH) content in brain homogenates, as compared to vehicle control rats. Administration of the aqueous extract of Embelia ribes (100 and 200 mg/kg, p.o.) for 30 days, to hyperhomocysteinemic rats, significantly (P < 0.01) decreased the levels of homocysteine, LDH, total cholesterol, triglycerides, LDL-C and VLDL-C and increased the HDL-C levels in serum. In addition, a significant (P < 0.01) decrease in LPO levels with increase in GSH content was observed in hyperhomocysteinemic rats treated with the aqueous extract of Embelia ribes. The results were comparable to those obtained with folic acid, a standard antihyperhomocysteinemic drug.

Conclusion:

The present results provide clear evidence that the aqueous extract of Embelia ribes treatment enhances the antioxidant defense against methionine-induced hyperhomocysteinemia, hyperlipidemia and oxidative stress in brain.

Efficacy of turmeric (curcumin) in pain and postoperative fatigue after laparoscopic cholecystectomy: a double-blind, randomized placebo-controlled study

OBJECTIVE

Better patient-reported outcomes (PROs) of laparoscopic cholecystectomy (LC) are premised upon PROs such as postoperative pain and fatigue. These PROs are indices of convalescence and return to normal activity. Curcumin (turmeric) is used in India for traumatic pain and fatigue for its anti-inflammatory/antioxidant and tissue modulation/healing properties. We studied the effect of curcumin on pain and postoperative fatigue in patients of LC.

METHODS AND PROCEDURES

From July to September 2009, 50 consecutive day-care LC candidates were enrolled for a prospective, double-blind randomized placebo-controlled study. A uniform general anesthesia and analgesia protocol was followed. Curcumin/placebo and rescue analgesic were prescribed at discharge. Patients were told to maintain pain/fatigue/adverse event diaries based upon 100-point visual analog pain scale (VAS) and 10-point interval rating fatigue scale (IRS). Patients were followed up at third day (D3), first week (W1), second week (W2), and third week (W3). The blind labels were opened at the end of study.

RESULTS

Demographic characteristics, comorbidity, and gallbladder pathology profiles were comparable in the study (n = 25) and control groups (n = 25). There was no adverse surgical outcome, adverse PRO or withdrawal. Pain and fatigue scores at D3 were similar in the two groups. At W1 and W2, the study group showed significantly lower (p value 0.000) mean pain scores, i.e., 15 ± 5.204 versus 30 ± 13 in controls. Fatigue scores at W1, W2, and W3 were significantly lower (p value 0.000) in the study group, i.e., 2.16 ± 1.748, 1, and 0, respectively, versus 5.16 ± 1.375, 4.20 ± 1.633, and 1 in controls. All patients were pain free at W3. Analgesic tablet usage was significantly lower (p value 0.000) in the study group, i.e., 6.96 ± 1.837 versus 39.32 ± 16.509 in controls.

CONCLUSIONS

Turmeric (curcumin) improves postoperative pain- and fatigue-related PROs following LC.

Evaluation of antioxidant and neuroprotective effect of ethanolic extract of Embelia ribes Burm in focal cerebral ischemia/reperfusion-induced oxidative stress in rats

Antioxidants have been the focus of studies for developing neuroprotective agents to be used in the therapy for stroke, which is an acute and progressive neurodegenerative disorder and is the second leading cause of death throughout the world. In fact, many herbal antioxidants have been developed in in vitro and in vivo experiments and some of these have been tested in clinical studies of stroke. Embelia ribes have been reported to have antioxidant and antidiabetic effects. In addition to these effects, this study was designed to investigate the neuroprotective effect of ethanolic extract of E. ribes Burm fruits on middle cerebral artery occlusion (MCAO)-induced focal cerebral ischemia in rats. Male Wistar albino rats were fed ethanolic E. ribes extract (100 and 200 mg/kg body weight; p.o.) for 30 days. After 30 days of feeding, all animals were anaesthetized with chloral hydrate (400 mg/kg, i.p.). The right middle cerebral artery was occluded with a 4-0 suture for 2 h. The suture was removed after 2 h to allow reperfusion injury. Ischemia followed by reperfusion in ischemic group rats significantly (P < 0.001) reduced the grip strength activity and non-enzymatic (reduced glutathione, GSH) and enzymatic [glutathione peroxidase (GPx), glutathione reductase (GR) and glutathione-S-transferase (GST)] antioxidant levels in hippocampus and frontal cortex compared to sham-operated rats. Further, serum lactate dehydrogenase (LDH) and thiobarbituric acid reactive substance (TBARS) levels in hippocampus and frontal cortex were significantly increased in ischemic group compared to sham-operated rats. Furthermore, ethanolic E. ribes extracts pretreatment significantly (P < 0.001) increased the grip strength activity, and GSH, GPx, GR and GST levels in hippocampus and frontal cortex with significant decrease in LDH levels in serum and TBARS levels in hippocampus and frontal cortex compared to MCAO + vehicle group rats. The data from this study suggest that chronic treatment with ethanolic E. ribes extract enhances the antioxidant defense against MCAO- induced focal cerebral ischemia in rats and exhibits neuroprotective activity.

Current status of TNF blocking therapy in heart failure

Recent experimental studies have shown that tumor necrosis factor alpha (TNF-alpha) has deleterious cardiovascular effects. Tumor necrosis factor alpha antagonists bind to TNF-a and functionally inactivate this cytokine and thereby reverse some of these effects. Various clinical studies of TNF-alpha antagonists have reported conflicting results. The present review analyses all reported clinical trials of TNF-alpha antagonists in congestive heart failure (CHF). The effect of these agents on clinical composite score, CHF hospitalizations, and mortality were compared. Early clinical studies of blocking TNF in patients with heart failure demonstrated promising results. However, recent large-scale, placebo-controlled trials have failed to show any improvement in the clinical status of heart failure. There have in fact, been some reports of worsening of heart failure with these agents. It may be concluded that TNF-alpha antagonists could adversely affect the clinical condition of patients with moderate to severe heart failure.

Adverse drug reaction monitoring: knowledge, attitude and practices of medical students and prescribers

BACKGROUND

Adverse drug reactions (ADRs) contribute to excessive health care costs through increased patient morbidity and mortality. Thus, there is an urgent need to create awareness among physicians towards ADR monitoring. The present study was designed to assess the knowledge, attitude and practices of fifth semester undergraduate students and prescribers (interns, junior residents and senior residents) towards the recording and reporting of ADRs.

METHODS

The fifth semester MB,BS undergraduate students (n=107) and prescribers (n=l 17) working in different disciplines of Lady Hardinge Medical College and associated hospitals were given a questionnaire to answer. The responses of the undergraduate students were compared with those of prescribers.

RESULTS

Knowledge about definition, classification, objectives and methods of ADR monitoring was found to be comparable in both groups. Spontaneous and intensive methods of ADR monitoring were known to the majority of participants of both groups. Attitude and practices of the prescribers were significantly (p<0.01 ) better with regard to the status of ADR monitoring in the institute. A significantly higher (p<0.001) proportion of prescribers (82%) as compared to the undergraduate students (64.5%), felt that ADRs should be reported both when it causes inconvenience to the patient as well as death. ADRs were encountered by both undergraduates (46%) and prescribers (66%) during their clinical project exercises and patient care, respectively. Commonly encountered ADRs were allergic reactions, symptoms of upper gastrointestinal irritation, extrapyramidal symptoms and hepatitis. The common offending groups of drugs causing these ADRs were non-steroidal anti-inflammatory drugs, antidopaminergics and chemotherapeutic agents. A majority of ADRs were suspected and subsided on their own by either stopping the drug or reducing its dose.

CONCLUSIONS

The knowledge, attitude and practices of both undergraduates and prescribers were comparable but need further improvement. This suggests the need for suitable changes in the undergraduate teaching curriculum. Further, the prescribers also need periodic reinforcement regardingADR monitoring.

Study of drug utilization pattern in dental OPD at tertiary care teaching hospital

Irrational prescribing is a global phenomenon. The objective of the study was to find out the prescribing practices of dental prescribers in a tertiary care teaching hospital with special emphasis on the utilization of antimicrobial agents. A prospective study was conducted in the month of March 2000. A total of 491 prescriptions were collected randomly. Prescribing pattern was analyzed using WHO basic drug indicators. The average number of drugs for prescription was 2.4. 78.8% of all prescriptions contained antimicrobial agents. It was most commonly prescribed (40.37%) group of drugs followed by anti-inflammatory and analgesics (33.8%). Fixed dose combination of ampicillin and cloxacillin was most commonly prescribed antimicrobial agents. Prophylactic use of AMA (78%) was more than therapeutic purpose (21.9%). Prophylactic use of antimicrobial agents was irrational in all the cases as duration for the use of antimicrobial agents was 5.1 +/- 0.5 days. Fixed dose combinations (45%), drugs by brand name (98.5%) were frequently used. Drug prescribed from Essential Drug List was maximum when one drug was prescribed. Results indicate that there is a scope for improving prescribing habits and minimizing the use of antimicrobial agents. This could be facilitated by periodic education to the prescribers.

Comparative bioavailability of two formulations of azithromycin

AIM

To compare the bioequivalence of two brands of azithromycin capsules in healthy male volunteers for regulatory purpose.

METHOD

A single oral dose of 500 mg of either test (Panacea Biotec Ltd.) or reference (Pfizer India Ltd.) preparation of azithromycin was administered to 12 volunteers in double blind randomised cross over fashion. Serum levels of azithromycin were analysed using microbiological assay. The pharmacokinetic parameters studied were Cmax, Tmax, AUC, t1/2, Ke, CL and MRT. In vitro dissolution tests were conducted for both the preparations and compared with in vivo absorption.

RESULTS

The mean peak serum azithromycin concentration of 0.516 +/- 0.008 microgram/ml was observed at 2.33 +/- 0.22 h with test brand and was similar to that of reference brand with Cmax of 0.494 +/- 0.011 microgram/ml at 2.71 +/- 0.26 h. The statistical difference between all the other paharmacokinetic parameters were insignificant.

CONCLUSION

Both the brands of azithromycin can be considered to be bioequivalent on the basis of results obtained.

Drug utilisation patterns in the Third World

Drugs are not available to the majority of the population in developing countries. Aggravating factors include weak healthcare structure, inadequate financial resources, nonavailability of pharmaceuticals, lack of drug legislation and policy, ineffective drug utilisation and the prevalence of self-medication. Although most of the population lives in rural areas, available funds are mostly utilised for urban areas. The use of drugs by injection is common in developing countries. In addition, many patients self-medicate because most drugs are available without a prescription from a doctor. There is therefore a great need for prescriber education in rational drug use, and for public education in the use of commonly used drugs. National health and drug policies should be formulated which incorporate the essential drug concept, and drug legislation needs to be revamped and implemented effectively. These measures may be helpful in providing better healthcare to the majority of the population in developing countries.

A study on the vasopressin induced delay in the gastrointestinal transit in mice: possible mechanism of action

The effect of arginine vasopressin (AVP) on the gastrointestinal (GI) transit and its possible mechanism were studied using charcoal meal test in mice. A dose related inhibitory effect was recorded. The effect appears to be independent of the time allowed between AVP administration and testing. The studies on the mechanism reveal that AVP acts without involving V1 and V2 vasopressin receptors. An almost complete reversal of the effect by physostigmine and potentiation by atropine indicate that AVP might act through an inhibition of the release of acetylcholine. However, the neural nicotinic receptors mechanisms do not seem to contribute since hexamethonium failed to modify the AVP action. Further, a partial antagonism by naloxone or prazosin pretreatment indicates that opioid and alpha 1 adrenergic systems also contribute to this action of AVP. However, the effect appears to be independent of alpha 2 and beta adrenergic systems since yohimbine and propranolol failed to modify the same.

Effect of alcohols and their potentiating responses on acetylcholine induced contractures on frog rectus abdominis

Ethanol, propanol and butanol cause contraction and potentiate the responses of acetylcholine (Ach) on frog's rectus muscle. These actions are minimum with ethanol and maximum with butanol. Various drugs acting at different levels of neuromuscular transmission inhibited the responses of alcohol itself and also its potentiating responses of Ach. The results show that these effects are partly due to enhanced release of Ach at neuromuscular junction and partly due to release of sarcoplasmic calcium suggesting that more than one mechanism may be responsible for these actions.

Mechanism of haloperidol-induced miosis

Haloperidol administration (iv) has been shown to produce miosis in dogs. In the present study on rabbits, haloperidol administration (iv) produced dose-related miosis but when administered intracerebroventricularly, it failed to produce any change in pupillary size. Higher degree of miosis was observed when haloperidol was administered directly into the anterior chamber of eye. Haloperidol pretreatment failed to significantly modify the mydriasis produced by phenylephrine or atropine. These observations suggest that the miosis produced by haloperidol is a peripheral effect, and also that the miosis is not mediated through the blockade of alpha adrenoceptors of radial muscles or stimulation of cholinoceptors of circular muscles of iris.