Madhan Ramesh

Clinical Pharmacy in a South Indian Teaching Hospital

OBJECTIVE: To describe how clinical pharmacy is helping to improve medication use at a South Indian teaching hospital by addressing medication use problems, which are commonly encountered in India. SUMMARY: Clinical pharmacy is practiced in many countries and makes a significant contribution to improved drug therapy and patient care. India is a country with significant problems with medication use, but until recently Indian pharmacists have not been educated for a patient-care role. Postgraduate pharmacy practice programs have been established at 2 pharmacy colleges in South India as a result of a joint Indo-Australian program of cooperation. At a teaching hospital associated with the colleges, clinical pharmacy services such as drug information, medication counseling, drug therapy review, adverse drug reaction reporting, and the preparation of antibiotic guidelines are assisting clinicians to improve drug therapy and patient care. Seven hundred twenty-seven requests for drug information were received from July 1997 to February 2001, and 543 suspected adverse drug reactions were evaluated from November 1997 to February 2001. The most common drug classes causing adverse drug reactions were antibiotics, nonsteroidal antiinflammatory drugs, and antitubercular agents. Physician opinion and service utilization have also been surveyed: 82% of respondents had sought drug information from the Clinical Pharmacy Department and 71% of respondents had sought advice on individual patient management. The success of this program is raising awareness of clinical pharmacy among pharmacy educators elsewhere in India and has led to the introduction of clinical pharmacy services at other Indian hospitals.

Assessment of Drug-Related Problems and Clinical Pharmacists' Interventions in an Indian Teaching Hospital

Aim: To identify drug‐related problems (DRPs) at a major Indian teaching hospital, to assess the acceptance of recommendations made by clinical pharmacists and evaluate the level of involvement of pharmacists in drug therapy decisions.

An adverse drug interaction of haloperidol with levodopa

Drug interactions are known to play a significant role in the incidence of adverse drug reactions (ADRs) both in the community and in hospitals. Both the newer atypical antipsychotics and their more traditional counterparts are subject to drug — drug interactions amongst themselves, with other psychotropics, and with the agents used in the treatment of various physical ailments. The most common interactions encountered in clinical practice are pharmacodynamic in nature. It is well established that antipsychotic drugs reduce the efficacy of levodopa in parkinsons disease by blockade of dopamine receptors in the corpus striatum. The case reported here illustrates a common pharmacodynamic drug interaction of haloperidol with levodopa in a 60-year-old female patient.

Gender differences in the occurrences and pattern of adverse drug reactions in psychiatric patients: A prospective observational study

Background: The female gender appears to suffer from more adverse drug reactions (ADRs) than the male gender. There are lacunae in epidemiologic studies analyzing gender-based differences in the ADR risks of patient with mental illness. Aim: The aim of this study was to establish a drug risk stratification adjusted to age, number of prescriptions, and drug classes with respect to gender differences. Setting: Prospective study was conducted in mental Health Department of a Tertiary Care Hospital over a period of 2 years. Materials and Methods: Patients of either sex or age prescribed with at least one psychotropic agent were included and monitored for ADRs. Results: A total of 775 ADRs were identified from 426 patients giving an overall incidence rate of 35.5%. Incidence of ADRs in male and females were 33.6% and 45.9%, respectively (adjusted odds ratio [OR], 1.6, 95% confidence interval [CI]: 1.26-2.05, P < 0.001). Female gender was found to be a significant risk factor in age Group 1 (adjusted OR, 1.55, 95% CI: 1.19-2.02, P = 0.001) and Group 2 (adjusted OR, 2.90, 95% CI: 1.01-8.28, P = 0.047). Furthermore, female patients receiving more drugs are at high risk of developing ADRs than the male [OR, 1.72, 95% CI: 1.14-2.72, P = 0.011 for Group 1 and OR, 1.83, 95% CI: 1.12-2.97, P = 0.015 for Group 2]. Conclusion: The incidence rate of ADRs is much higher (45.9) in females than the males with mental illness. To heighten drug safety for females, the complex interaction between pharmacokinetics, pharmacodynamics, and pharmacogenetics needs further research.

Frequency and Nature of Medication‐Related Problems in Elderly Indian Inpatients

Geriatrics is an emerging clinical specialty in India. Although studies on medication use in the elderly have been conducted in India, data on medication‐related problems (MRP) in the hospitalised elderly population are limited.

Assessment of impact of pharmacophilia and pharmacophobia on medication adherence in patients with psychiatric disorders: A cross-sectional study

Aims: To investigate the impact of pharmacophilia and pharmacophobia on medication adherence among patients with psychiatric disorders. Materials and Methods: A cross-sectional, observational study was conducted in the Department of Psychiatry over a period of 2 months. Patients above 18 years of age with a psychiatric diagnosis as per the International Classification of Diseases 10 and receiving at least one psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) for >1 month were enrolled in the study. Patients who were critically ill, on magico-religious treatment (beliefs prevalent in a particular culture concerning various supernatural influences operating in the environment), diagnosis of dementia, or mental retardation and patients from whom reliable history of illness cannot be obtained were excluded from the study. Drug attitude inventory scale was used to classify patients into pharmacophilic and pharmacophobic groups. Medication adherence rating scale was used to identify the extent of medication adherence. Results: Among 176 patients included, 110 were found to be pharmacophilic and 54 were pharmacophobic. The number of hospitalizations (P < 0.03) and adverse drug reactions (P < 0.001) were found to be higher in pharmacophobic group as compared to pharmacophilic group. Antipsychotics were found to be most commonly prescribed medications among pharmacophobic group (P < 0.001). In this study, patients who had pharmacophilia were found to be have higher adherence score (mean score: 6.98) than patients with pharmacophobia (mean score: 2.9), with P< 0.001. Conclusions: This study concluded that pharmacophobia toward psychopharmacological agents can significantly reduce the medication adherence among patients with psychiatric disorders.

Economic impact and severity of adverse drug reactions in patients with mental illness: A prospective observational study

INTRODUCTION: Psychotropic medications are the mainstay in the management of psychiatric disorders but they are not devoid of side effects. The occurrence of adverse drug reactions (ADRs) in Indian psychiatry populace varies from 5.9% to 45%. The cost associated with the management of ADRs in general settings ranges from Rs. 412.76 to 1080/- per ADR. MATERIALS AND METHODS: A prospective observational study was conducted for a period of 1 year. The ADRs were assessed for causality by the World Health Organization probability scale and severity by modified Hartwig and Siegel scale. The direct costs in the management of ADRs were calculated. RESULTS: A total of 494 ADRs were reported and evaluated from 300 patients. Of the total reported ADRs, 3.44% (n = 17) lead to hospital admissions and 2.83% (n = 14) prolonged the hospital stay. The gastrointestinal system 25.10% (n = 125) and central and peripheral nervous system 20.64% (n = 102) were the most common system organ class affected by ADRs. The drug classes mainly implicated with ADRs were antipsychotics 53.03% (n = 262) and antidepressants 23.88% (n = 118). Majority (24.29%) of the reactions that lead to cost impact was moderate in severity. Total cost incurred for the management of 131 reported ADRs was Rs. 57,891.33/- with an average cost of Rs. 117.18/- per ADR. CONCLUSION: In 131 cost impact ADRs, 114 patients had a cost impact of Rs. 57,891.33/- A directly proportionate relationship was observed between the severity and cost incurred for the management of ADRs. Hence, it is necessary to identify and prevent these reactions as they cause burden to the patients.

Sulfasalazine Induced Toxic Epidermal Necrolysis in a Rheumatoid Arthritis Patient-A Case Report

Toxic epidermal necrolysis also known as Lyells syndrome is a rare but potentially life threatening severe cutaneous adverse reaction with widespread epidermal detachment and mucosal erosions. Drug exposure and a resulting hypersensitivity reaction is the cause of the very large majority of cases of Steven Johnson Syndrome. This is a case of 34-year-old female patient, presented to hospital with a presentation of rash, throat pain, fever and eye pain with redness. The patient medical history shows that she is a known case of rheumatoid arthritis and treated with sulfasalazine 500 mg, paracetamol 650 mg and aceclofenac 100 mg which she took for 16 days and injection methylprednisolone IM for 20 days. She has no improvement of joint pain and developed few fluid filled lesions in oral cavity, which ruptured spontaneously. She gives history of a pain and burning sensation while swallowing and her first biopsy report showed erythema multiforme on hospital admission and was finally diagnosed as Toxic Epidermal Necrolysis. Patient was treated with capsule cyclosporine and injection dexamethasone. The patient showed good response to treatment and lesions, erosions decreased within span of 20 days. Toxic epidermal necrolysis is a severe cutaneous adverse drug reactions associated with high mortality. Patients prescribed with sulfanamides like sulfasalazine, educating them regarding the appropriate use of medications are of utmost importance.

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.