A study to evaluate the hepatoprotective effect of N- acetylcysteine on anti tuberculosis drug induced hepatotoxicity and quality of life

BACKGROUND

Drug induced liver injury (DILI) is a serious adverse effect caused by first-line anti-TB (ATT) drugs, limiting the TB-treatment. The tissue inflammation induced by free radical burst and poor dietary intake in TB induces oxidative stress, which was proposed as one of the mechanisms responsible for ATT induced DILI. N-acetylcysteine (NAC) exerts a hepato-protective effect by enhancing the cellular antioxidant defense mechanism. There are few studies evaluating the effect of NAC on ATT induced DILI in Indian-population.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled, parallel-group study. Thirty-eight newly diagnosed TB patients on first-line ATT with normal liver function test (LFT) were recruited and randomized to receive either NAC 600 mg tablet or placebo twice daily for 4 weeks and followed-up for next 4 weeks. LFT [AST, ALT, ALP and Total bilirubin] was assessed at baseline, 2, 4 and 8 weeks. Oxidative-stress biomarkers [Malondialdehyde (MDA), Nitric Oxide (NO), Glutathione (GSH)] and quality of life (QOL) by SF-36 questionnaire were assessed at baseline, 4 and 8 weeks. Adverse Drug Reactions (ADRs) were monitored at every visit. Compliance was assessed by pill-count method.

RESULTS

Baseline characteristics were homogenous among both the groups. In the NAC group, there was significant reduction in ALT (p < 0.01), ALP (p < 0.01), total bilirubin (p < 0.001) at 4 weeks compared to baseline. AST, MDA and NO showed a reduction of 19%, 21.6% and 5.5% respectively from baseline and GSH at showed an increase of 2.6% from baseline at 4 weeks in the NAC group, however these were not statistically significant. These effects in LFT and oxidative biomarkers persisted even at the end of 8 weeks. Significant improvement from baseline in QOL was observed in both the groups (p < 0.05). Between group analysis showed, significant reduction in ALT (p < 0.05) and AST (p < 0.05) in NAC group at 4 weeks, whereas bilirubin, MDA, NO and GSH showed improvement at 4 weeks compared to placebo in NAC group, however it was not statistically significant. This improvement in the LFT and oxidative biomarkers continued even at the end of 8 weeks. Itching and rashes were the most common ADRs, with similar incidence in both the groups. Compliance to treatment was good in both the groups.

CONCLUSION

Significant improvement in liver function parameters is suggestive of hepatoprotective effect of NAC. This observed effect at 4 weeks was found to be persistent at 8 weeks, which signifies prolonged hepato-protective effect of NAC. Long duration studies with large sample size are required for further confirmation of hepato-protective action of NAC.

Effect of Teneligliptin versus Glimepiride on Tumour Necrosis Factor Alpha and High Sensitivity C-Reactive Protein in Type 2 Diabetes Mellitus Patients Treated with Metformin: A Randomised Double-blind Parallel Group Study

Introduction: Inflammatory markers like Tumour Necrosis Factor-α (TNF-α), C-Reactive Protein (CRP), and Interleukin-6 (IL-6) play intermediary role in insulin resistance, pathogenesis of Type 2 Diabetes Mellitus (T2DM) and its complications. Hence, antidiabetic drugs having anti-inflammatory effects may play an important role in management of T2DM and prevention of its complications. Aim: To study the effect of glimepiride versus teneligliptin on TNF-α, high sensitivity C-reactive Protein (hsCRP) and Diabetic Peripheral Neuropathy (DPN) in T2DM patients on metformin. Materials and Methods: The randomised, double-blind, parallel group study was conducted in Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India, from April 2018 to October 2019. Total 44 participants were screened and 40 participants of either gender, age range of 35-65 years, Body Mass Index (BMI) ≥25-≤35 kg/m2 and Fasting Blood Sugar ≥126 to ≤200 mg/dL, and glycosylated-haemoglobin (HbA1c) 7.0 to ≤10.0% were included into the study. The T2DM patients (N=40) on metformin (1500- 2500 mg/day) were randomised to receive glimepiride (2 mg/day) and teneligliptin (20 mg/day) in group A and group B for 12 weeks, respectively. TNF-α, hsCRP and Vibration-Perception Threshold (VPT) at baseline, 4 weeks and 12 weeks were evaluated for all participants. FBS, HbA1c, Adverse Drug Reactions (ADRs) were also recorded. Unpaired t-test and repeated-measures Analysis of Variance (ANOVA) for normally-distributed variables using Shapiro-Wilk’s test was done. Mann-Whitney and Friedman’s test for non normally distributed variables; for between-group and within-group analysis, respectively were done. Results: Forty T2DM patients (17 males and 23 females) with mean age of 49.45±6.8 and 50.3±7.9 years, were studied. The mean TNF-α level reduced significantly, in group B (159.25±58.58 to 83.15±26.18 pg/mL; p-value<0.001) from baseline to 12 weeks. Similar significant reduction was seen in the group A (175.2±66.13 to 116.15±63.32 pg/mL; p-value<0.05). There was significant reduction observed in mean VPT-scores (25±6 to 18.0±5.22 V; p-value<0.001) and (26±12.11 to 25±12 V; p-value<0.05) in group B and group A, at 12 weeks, respectively. However, both study groups showed non significant decrease in mean hsCRP levels at 12 weeks. There was a non significant reduction in all study parameters at four weeks. Mean percentage reduction of 34% and 44% in TNF-α, 13% and 11% in hsCRP and 7% and 27% in VPT-scores was observed in group A and group B, respectively at 12 weeks. Improvement in FBS and HbA1c levels (p-value<0.001) was observed in both study groups. Both treatments were tolerated well and no serious adverse drug reactions were observed. Conclusion: Teneligliptin by reducing TNF-α level, demonstrated modest anti-inflammatory activity along with metformin, by 12 weeks. It also improved VPT-scores. Glimepiride showed lesser degree of anti-inflammatory activity compared to teneligliptin. Both study drugs did not affect hsCRP levels.

Impact of Drug Information Services on Promotion of Rational Use of Antimicrobial Agents: A Descriptive Retrospective Study

Introduction: Drug Information Services (DIS) is dedicated to provide information about drugs and pharmacotherapy, on request from health care professionals, organisations or patients. World Health Organisation (WHO) recommends DIS to promote rational use of medicines. Aim: The study was done to understand the impact of DIS on promotion of rational use of antimicrobial agents, at a tertiary care hospital. Materials and Methods: In this retrospective descriptive study, 126 cases with infection related medication issues requiring opinion related to appropriate antimicrobial therapy from January 2014-June 2018 were included and studied in September 2018. Data related to culture/susceptibility results, treatment offered, reason for referral and suggestions given by the DIS captured in the case details form were analysed. The number of antimicrobials prescribed per case before and after DIS opinion was compared using paired t-test. Results: Of the 126 cases (mean age: 35±18.2 years), 82 were culture positive, of which 43 samples reported Multi-Drug Resistant (MDR) organisms. Of 126 case referrals, 53 (42.1%) were regarding opinion on appropriate antimicrobial therapy, 18 (14.3%) for suspected ADRs and rechallenge opinion, 27 (21.5%) for dosage adjustment of antimicrobials and 12(9.5%) for suspected drug-drug interactions. Based on DIS recommendations, mean number of antimicrobials prescribed per patient reduced from 3.4±1.85 to 1.62±1.38 (p<0.0001) when tested by paired t-test. Sixteen culture-negative cases were referred for opinion on appropriate antimicrobial therapy. Conclusion: DIS is a very useful resource, which provides unbiased, factual drug information to clinicians and patients and must be established in all healthcare facilities. DIS strengthen rational use of antimicrobials.

Evaluation of the effects of a standardized aqueous extract of Phyllanthus emblica fruits on endothelial dysfunction, oxidative stress, systemic inflammation and lipid profile in subjects with metabolic syndrome: a randomised, double blind, placebo controlled clinical study

BACKGROUND

Endothelial dysfunction (ED) has been observed in individuals with metabolic syndrome (MetS) and contributes to the initiation and progression of atherosclerosis. The primary management of MetS involves lifestyle modifications and treatment of its individual components with drugs all of which have side effects. Thus, it would be of advantageous if natural products would be used as adjuncts or substitutes for conventional drugs. The aim of the present study was to evaluate the effect of standardized aqueous extract of fruits of Phyllanthus emblica (P. emblica) 250 mg and 500 mg twice daily on ED, oxidative stress, systemic inflammation and lipid profile in subjects with MetS.

METHODS

In this randomised, double-blind, placebo-controlled clinical study endothelial function was measured by calculating reflection index (RI) using digital plethysmograph. Oxidative stress biomarkers used were nitric oxide (NO), glutathione (GSH) and malondialdehyde (MDA). Systemic inflammation was measured by determining high sensitivity C-reactive protein (hsCRP) and dyslipidemia by lipid profile. ANOVA, paired and unpaired t-test were used. P-value < 0.05 was considered statistically significant.

RESULTS

Out of 65 screened subjects all 59 enrolled completed the study. P. emblica aqueous extract (PEE), 250 mg and 500 mg twice daily dosing, showed significant reduction in mean RI, measure of endothelial function, at 8 and 12 weeks (p <  0.001) compared to baseline and placebo. Significant mean % change was seen in oxidative stress biomarkers, NO (+ 41.89%, + 50.7%), GSH (+ 24.31%, + 53.22%) and MDA (- 21.02%, - 31.44%), and systemic inflammation biomarker, hsCRP (- 39.68%, - 53.77%) (p <  0.001) at 12 weeks with 250 mg and 500 mg twice daily dosage respectively. Significant mean % change was also seen at 12 weeks with TC (- 7.71%, - 11.11%), HDL-C (+ 7.33% + 22.16%, p <  0.05), LDL-C (- 11.39%, - 21.8%) and TG (- 9.81%, - 19.22%) respectively with 250 mg and 500 mg twice daily (p <  0.001). PEE 500 mg twice daily was significantly more efficacious than the 250 mg twice daily and placebo. No participant discontinued the study because of adverse events.

CONCLUSIONS

P.emblica aqueous extract significantly improved endothelial function, oxidative stress, systemic inflammation and lipid profile at both dosages tested, but especially at 500 mg twice daily. Thus, this product may be used as an adjunct to conventional therapy (lifestyle modification and pharmacological intervention) in the management of metabolic syndrome.

TRIAL REGISTRATION

This study was registered with Clinical Trials Registry - India (CTRI) with the registration number of CTRI/2017/09/009606 . The study was registered retrospectively on 4th September 2017.

A randomized, double blind placebo controlled study of efficacy and tolerability of Withaina somnifera extracts in knee joint pain

Background

Root extracts of Withania somnifera (Ashwagandha) are known to possess analgesic, anti-inflammatory and chondroprotective effects. An aqueous extract of roots plus leaves of this plant has shown to yield higher percentages of withanolide glycosides and, accordingly, may possess better analgesic, anti-inflammatory and chondroprotective effects than root alone extracts.

Objectives

To evaluate efficacy and tolerability of a standardized aqueous extract of roots plus leaves of W. somnifera in patients with knee joint pain and discomfort.

Material and methods

Sixty patients with knee joint pain and discomfort were randomized in a double-blind manner to W. somnifera 250 mg, W. somnifera 125 mg and placebo, all given twice daily. Assessment was done by Modified WOMAC, Knee Swelling Index (KSI), Visual Analogue Scale (VAS) at baseline and at the end of 4, 8, 12 weeks. Tolerability was assessed by incidence of adverse effects in treatment groups. Student's ‘t’ test and ANOVA were used to compare mean change from baseline within and between the study groups. A p < 0.05 was considered significant.

Results

At the end of 12 weeks, compared to baseline and placebo, significant reductions were observed in mean mWOMAC and KSI in W. somnifera 250 mg (p < 0.001), W. somnifera 125 mg (p < 0.05) groups. VAS scores for pain, stiffness and disability were significantly reduced in W. somnifera 250 mg (p < 0.001), W. somnifera 125 mg (p < 0.01) groups. W. somnifera 250 mg group showed earliest efficacy (at 4 weeks). All treatments were well tolerated.

Conclusions

Both the doses of an aqueous extract of W. somnifera produced significant reduction in outcome variables, with the 250 mg group showing significantly better response. In addition, the therapeutic response appears to be dose-dependent and free of any significant GI disturbances.

•

Aqueous extract of Withania somnifera roots plus leaves demonstrated dose – dependent therapeutic response.

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Onset of therapeutic activity is seen as early as 4 weeks with the W. somnifera 250 mg group.

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Aqueous extract of W. somnifera roots plus leaves has good safety profile and is well tolerated.

A randomized, double-blind, placebo-, and positive-controlled clinical pilot study to evaluate the efficacy and tolerability of standardized aqueous extracts of Terminalia chebula and Terminalia bellerica in subjects with hyperuricemia

Objectives

To evaluate the efficacy and tolerability of standardized aqueous extracts of Terminalia chebula and Terminalia bellerica versus febuxostat and placebo on reduction in serum uric acid levels in subjects with hyperuricemia.

Materials and methods

A total of 110 eligible subjects with hyperuricemia were enrolled and randomized to either of the five treatment groups – T. chebula 500 mg twice a day (BID), T. bellerica 250 mg BID, T. bellerica 500 mg BID, placebo BID, and febuxostat 40 mg once daily plus an identical placebo – for a duration of 24 weeks. Serum uric acid levels were measured at baseline and at the end of 4, 8, 12, 16, 20, and 24 weeks. Statistical analysis was done using GraphPad Prism Software 4.

Results and interpretation

All active treatment groups showed a reduction in serum uric acid levels compared to baseline and placebo. Significant reduction in mean serum uric acid levels started as early as 4 weeks following treatment, compared to baseline, with T. bellerica (500 and 250 mg), febuxostat (P<0.001), and T. chebula 500 mg (P<0.01); an increase in serum uric acid levels was seen with placebo (P<0.05). The serum uric acid levels became steady after 16 weeks of treatment and remained the same until the end of 24 weeks. The reduction of serum uric acid levels in the T. bellerica 500 mg group was nearly twice that of the T. chebula 500 mg group as well as T. bellerica 250 mg group at all time points. T. bellerica 500 mg reduced serum uric acid levels from 8.07±0.87 to 5.78±0.25 compared to febuxostat, which reduced serum uric acid levels from 8.53±0.97 to 4.28±0.67 (P<0.001) at the end of 24 weeks. The efficacy of T. bellerica appeared to be dose dependent. All the formulations were well tolerated.

Conclusion

T. bellerica has the potential for treating hyperuricemia as it was devoid of any serious adverse effects in the present study. Further studies are needed to confirm this potential.

Effects of Phyllanthus emblica extract on endothelial dysfunction and biomarkers of oxidative stress in patients with type 2 diabetes mellitus: a randomized, double-blind, controlled study

BACKGROUND

It has been reported that hyperglycemia can induce endothelial dysfunction via increased oxidative stress and that it plays a central role in the development of atherosclerosis and coronary heart disease. Phyllanthus emblica (Emblica officinalis, amla) is known for its antioxidant and antihyperlipidemic activity. The present study compared the effects of an aqueous extract of P. emblica (highly standardized by high-performance liquid chromatography to contain low molecular weight hydrolyzable tannins, ie, emblicanin A, emblicanin B, pedunculagin, and punigluconin) versus those of atorvastatin and placebo on endothelial dysfunction and biomarkers of oxidative stress in patients with type 2 diabetes.

METHODS

Eligible patients were randomized to receive either P. emblica 250 mg twice daily, P. emblica 500 mg twice daily, atorvastatin 10 mg in the evening and matching placebo in the morning, or placebo twice daily for 12 weeks. The primary efficacy parameter was the change in endothelial function identified on salbutamol challenge at baseline and after 12 weeks of treatment. Secondary efficacy parameters were changes in biomarkers of oxidative stress (malondialdehyde, nitric oxide, and glutathione), high sensitivity C-reactive protein levels, the lipid profile, and glycosylated hemoglobin (HbA1c) levels. Laboratory safety parameters were measured at baseline and after 12 weeks of treatment.

RESULTS

Eighty patients completed the study. Treatment with P. emblica 250 mg, P. emblica 500 mg, or atorvastatin 10 mg produced significant reductions in the reflection index (-2.25%±1.37% to -9.13%±2.56% versus -2.11%±0.98% to -10.04%±0.92% versus -2.68%±1.13% to -11.03%±3.93%, respectively), suggesting improvement in endothelial function after 12 weeks of treatment compared with baseline. There was a significant improvement in biomarkers of oxidative stress and systemic inflammation compared with baseline and placebo. Further, the treatments significantly improved the lipid profile and HbA1c levels compared with baseline and placebo. All treatments were well tolerated.

CONCLUSION

Both atorvastatin and P. emblica significantly improved endothelial function and reduced biomarkers of oxidative stress and systemic inflammation in patients with type 2 diabetes mellitus, without any significant changes in laboratory safety parameters.

Localization of Cytochrome b-559 in the Chloroplast Thylakoid Membranes in Spinach

Cytochrome b-559 was purified from spinach leaves and antibodies were made against it in rabbit. Using affinity-purified, monospecific antibodies, we have found that cytochrome b-559, which is closely associated with the primary photochemical activity of photosystem II, is localized exclusively in the grana thylakoids.

Characterization of three abnormal factor IX variants (Bm Lake Elsinore, Long Beach, and Los Angeles) of hemophilia-B. Evidence for defects affecting the latent catalytic site

Abnormal factor IX variant proteins were isolated from the plasmas of three unrelated severe hemophilia-B families that had been previously shown to contain functionally impaired molecules immunologically similar to normal factor IX. The families studied were: (1) a patient with markedly prolonged ox brain prothrombin time, designated factor IX Bm Lake Elsinore (IXBmLE); (b) three patients (brothers) with moderately prolonged ox brain prothrombin time, designated factor IX Long Beach (IXLB); and (c) a patient with normal ox brain prothrombin time designated factor IX Los Angeles (IXLA). Each variant molecule comigrates with normal factor IX (IXN) both in the sodium dodecyl sulfate and in the nondenaturing alkaline gel electrophoresis. All three variant proteins are indistinguishable from IXN in their amino acid compositions, isoelectric points, carbohydrate distributions and number of gamma-carboxyglutamic acid residues. Each variant protein undergoes a similar pattern of cleavage by factor XIa/Ca2+ and by factor VIIa/Ca2+/tissue factor, and is activated at a rate similar to that observed for IXN. All of the three variant proteins also react with an anti-IXN monoclonal antibody that interferes with the binding of activated IXN(IXaN) to thrombin-treated factor VIIIC. However, in contrast to IXaN, the cleaved IXBmLE has negligible activity (approximately 0.2%), and cleaved forms of IXLA and IXLB have significantly reduced activity (approximately 5-6%) in binding to antithrombin-III/heparin, and in activating factor VII (plus Ca2+ and phospholipid) or factor X (plus Ca2+ and phospholipid) +/- factor VIII. These data, taken together, strongly indicate that the defect in these three variant proteins resides near or within the latent catalytic site. This results in virtually a complete loss of catalytic activity of the cleaved IXBmLE molecule and approximately 95% loss of catalytic activity of the cleaved IXLA and IXLB molecules.