Dr. Deepak Kumar Bandari, PharmD : Short Profile

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Dr. Deepak Kumar Bandari, PharmD, (PhD) (Europe)

Research Scientist, ICMR-NICPR, Noida.

Current Position: National

1) Project Research Scientist - Indian Council of Medical Research (ICMR) - National Institute of Cancer Prevention and Research (NICPR), Noida and Delhi. 

Project: AccEEND TB, India.

2) Board of Studies Member - Master’s in Clinical Research and Experimental Medicine, School of Allied and Health Sciences, Malla Reddy University, Hyderabad.

3) Book reviewer - BSP Publications, Pharma Med Press and Kakatiya Publications.

Current Position: International
PhD Researcher and Early Stage Researcher participant
Project: FIP 7 programme of EuroAgeism H2020 project, involving 13 European and Non-European countries.

Early-Stage Researcher (ESR) Participant, Euro Ageism H2020, Faculty of Pharmacy in Hradec Králové, Charles University, Europe.

Thesis: Polypharmacy and comparison of differences in potentially inappropriate prescribing in India, Ethiopia, and European countries.
Projects and Grants handled: 

• Project: FIP 7 programme of EuroAgeism H2020 project, involving 13 European and Non-European countries.

Grant: European Commission, FIP7 program Euro Ageism H2020-764632-MSCA-ITN supported by the scientific group “Ageing and Changes in the Therapeutic Values of Drugs in the Aged”, Charles University, Progress Programme Q42, SVV program 260 417.
Total Finance - 232 422,48 EU (Detailed budget - not disclosed)
EU Consortium: Israel, Czech Republic (CZ), UK, Poland, Netherlands, Sweden, Finland, Belgium.
Participating countries: Czech Republic, Serbia, Croatia, Bulgaria, Estonia, Turkey, Spain, Ireland, Belgium, India, Ethiopia.
Collaborating Institutions: Alliance Health and Social Care Alliance Scotland (AL), EMDA – The Alzheimer’s Association Israel (AAI), European Centre for Social Welfare Policy and Research (Euro Centre), National University of Ireland Galway (NUIG), United Nations Economic Commission for Europe (UNECE) and World Health Organization (WHO).

• Project No. START/MED/093

Thesis: Rational geriatric pharmacotherapy, medication errors and clinical pharmacy services in long-term care.
Total Finance - 2,299,968 CZK (Personal cost-1,353,600; Mentor remuneration-40,000; Travel costs-361,000; Training costs- 120,000; Costs of non-investment equipment, materials etc. - 80,000; Overhead costs - 345,368)
Grant: Charles University, Research Unit “Ageing, Polypharmacy and Changes in the Therapeutic Value of Drugs in the AgeD”, United Nations Economic Commission for Europe and World Health Organization, University of Zagreb, Croatia, University of Belgrade.

Previous Positions: National

1)Project Technical Support - III (Field Investigator) - Indian Council of Medical Research (ICMR) - National Institute of Nutrition (NIN), Hyderabad, India. 

Project: Strengthening the Monitoring of Tuberculosis Elimination in India - District Level Sentenial Survey (DLSS), India.

2) Associate Consultant (Epidemiology and Outcomes Research) - Bridge Medical Consulting Pvt. Ltd, New Delhi. 

3) Team Leader - Indian Council of Medical Research (ICMR) – National Institute of Nutrition (NIN), Hyderabad, India.

Project: National Sero-surveillance to monitor the trend of SARS-CoV-2 infection transmission in India.

4) Investigator (Field) - Indian Council of Medical Research (ICMR) – National Institute for Research in Tuberculosis (NIRT), Chennai, India.

Project: National survey for the state-wise prevalence of microbiologically confirmed pulmonary tuberculosis in India.

5) Assistant Professor and Clinical Preceptor: Vaagdevi Institute of Pharmaceutical Sciences, Warangal, India. 

No. of Research Publications: 18
Cumulative Impact Factor: 153
Number of Citations: 3000+

h-index: 14; i-10 index: 15 

Awarded grants: Total 7 (International: 6, National: 1)
Achievements: Total 9 (International: 5, National: 4)
My Interviews in Magazines and Newsletters: 3 (International: 2, National: 1)

Scientific presentations: (International: 11, National: 8)
Book reviews: 9 (International: 2, National: 7)
Guest Lectures: Total 3 (International: 1, National: 2)
Editorial member and reviewer: 8
Certification courses: Total 10 (2 - Stanford University, 8 - National and International Organizations)
Countries affiliated: USA, Italy, Poland, Slovak Republic, The Czech Republic, Germany, Hong Kong and 10 other European countries.

International collaborative research: Early Stage Researcher participant in the FIP 7 programme of EuroAgeism H2020 project under Marie-Curie Innovative Network and EU COST Action IS1402 network aimed at describing main prescribing problems in rational geriatric pharmacotherapy in 13 European and Non- European countries (including India and Ethiopia). 

Collaborating Institutions: Alliance: Health and Social Care Alliance Scotland (AL), EMDA – The Alzheimer’s Association Israel (AAI), European Centre for Social Welfare Policy and Research (EuroCentre), National University of Ireland Galway (NUIG), United Nations Economic Commission for Europe (UNECE) and World Health Organization (WHO).

Remarkable Achievements:

1. Award and Position: Early Stage Researcher (ESR) participant in the network of FIP7 EuroAgeism H2020 – ITN project, European Commission.
2. Reviewer: Acknowledged in Davidson’s Principles and Practice of Medicine textbook, 23rd Edition, 2018; Elsevier publishers ISBN: 9780702070280.
3. Personal interview: “I expect the 8-star Pharmacist Concept of World Health Organization will come true in India in the Future” published in an International Magazine “Lekarnicke Listy”, March 2018, Bratislava, Slovak Republic.
4. Best reviewer award: Textbook of Hutchison’s Clinical Methods 23rd International Edition by Michael Glynn &William Drake. Saunders Publishers, UK ISBN: 978-0-7020-4091
5. ERASMUS+ Student Mobility: Internship in various European countries.

A few other Achievements:

1. Award and Interview: Winner of “Ideathon” First Nobel Prize Series in India, Department of Biotechnology, India. Interview entitled “Pharmacist Nobel Prize Series: Science Impacts Lives – The Pride of India”, Indian Pharmaceutical Association – Community Pharmacy Division (IPA - CPD) e-Times 6 (2), March – April 2017.

2. Story of Success (2017): Published by Elsevier, as a part of the budding Medicos National contest.

3. Elsevier Student Ambassador (ESA) and Mentor’ for South Asia from July 2014 to June 2016.

4. Felicitation and award: Special Faculty Achievement Award at Viswambhara Educational Society Silver Jubilee Celebrations, March 2018, Warangal, India.

5. Award: Pharmacy Practice contribution award on World Pharmacist’s Day, 25th September 2017 for the successful delivery of an invited lecture on the Prescriptive role of Clinical Pharmacist in Ambulatory Care at Deccan School of Pharmacy, Hyderabad, India.

Acknowledgement: 

• I thank Prof. Daniela Fialova, PharmD, PhD, BCCP; Chair of the Horizon 2020 EuroAgeism FIP7 program; Head of the University Centre of Clinical Pharmacy, Faculty of Pharmacy, Charles University; Department of Social and Clinical Pharmacy, Faculty of Pharmacy, Charles University, Department of Geriatrics and Gerontology,1st Faculty of Medicine, Charles University, Czech Republic.
• Dr Akshaya Srikanth Bhagavathula, PharmD, PhD; Associate Professor of Epidemiology, Department of Public Health, North Dakota State University, United States of America. 
• Prof. Yamsani Madhusudan Rao, M.Pharm, PhD; Director, Vaagdevi group of Pharmacy Colleges, Warangal, India for their valuable guidance and support throughout my career.

 

Which Drug Interactions Matters a lot in Older Adults?

Conventional wisdom has it that the elderly are at greater risk for adverse drug interactions, and the published evidence supports this view. Older patients take more medications and experience physiologic changes that may affect drug disposition, making them potentially more susceptible to the adverse outcomes from drug interactions. 

Over the past decade or so, we have also accumulated some useful data on which specific drug interactions increase the risk of serious reactions in older patients. In a recent paper, Hines and Murphy from the University of Arizona reviewed population-based studies over the past 10 years, and discussed those that detected serious adverse outcomes due to particular drug interactions. The Table lists the interactions found to result in either increased risk of hospitalization or death. It is important to remember that the interactions in the Table are the ones that were chosen for study, and other related interactions involving these drugs are also likely to increase the risk of serious adverse outcomes. For example, angiotensin receptor blockers may also increase the risk of hyperkalemia when combined with potassium-sparing diuretics or co-trimoxazole; combining calcium-channel blockers with cytochrome P450 (CYP) 3A4 inhibitors other than macrolides may increase the risk of hypotension or shock; digoxin toxicity may occur with concurrent use of many P-glycoprotein inhibitors other than macrolides; and phenytoin toxicity can be produced by CYP2C9 inhibitors other than co-trimoxazole.

Clinical evidence also suggests that a number of other oral antidiabetic agents are metabolized by CYP2C9 and CYP3A4, and hypoglycemia may occur when inhibitors of these isozymes are given concurrently; CYP2D6 inhibitors other than paroxetine may inhibit the efficacy of tamoxifen in breast cancer; CYP1A2 inhibitors other than ciprofloxacin can cause theophylline toxicity; and any CYP2C9 inhibitor would be expected to increase the anticoagulant response to warfarin. Moreover, the elderly may take many other drugs that have substantial risk of drug interactions, especially psychotherapeutic drugs, but also drugs such as colchicine, statins, drugs for Parkinson’s disease, cholinesterase inhibitors for Alzheimer’s disease, and nonsteroidal anti-inflammatory drugs. The vast majority of publications on drug–drug interactions are either case reports or pharmacokinetic studies in healthy subjects. Such data provide evidence that a drug interaction exists, but seldom give us information on how often adverse consequences occur or how severe they are likely to be. The value of the population-based studies discussed above is that they help us determine which drug interactions actually can result in severe adverse consequences, and give us some idea of the incidence of the adverse outcomes. 

References:

1. Drs. Horn and Hansten are both professors of pharmacy at the University of Washington School of Pharmacy. 
2. For an electronic version of this article, including references if any, visit www.hanstenandhorn.com.

Drug Interactions : An addition to Beer's Criteria

In 1991, the first “Beers Criteria” were published to alert clinicians to drugs that are potentially inappropriate for use in older adults. Updates to the list have appeared periodically, and the most recent (November 2015) includes drug– drug interactions (DDIs) for the first time. The expert panel included primarily pharmacists, physicians, and nurses, and they used a modified Delphi method to compile the criteria. 

Criteria for the Inclusion of DDIs:

The panel members made it clear that the DDI list is not intended to be comprehensive, and that individuals should not assume that these are the only DDIs worth considering in older adults. The panel selected DDIs it felt were particularly problematic in the elderly, regarding the potential for adverse outcomes. The panel did not include anti-infective agents or address drug therapy in individuals receiving palliative and hospice care. 

Drug Interactions that Were Included:

The DDIs the panel added to the Beers Criteria fell into several categories, but the most prevalent was an increased risk of falls due to combined use of 2 or more central nervous system (CNS) drugs (eg, antidepressants, antipsychotics, benzodiazepines, hypnotics, opioid analgesics). 

Unfortunately, despite the fact that these additive pharmacodynamic effects are well known and predictable, they are still too often overlooked in the elderly. Also included in the list were the following: 

• Lithium toxicity from concurrent angiotensin-converting enzyme (ACE) inhibitors or loop diuretics 

• Hyperkalemia from ACE inhibitors with amiloride or triamterene • Cognitive decline from multiple anticholinergics 

• Peptic ulcers and gastrointestinal (GI) bleeding from nonsteroidal anti-inflammatory drugs (NSAIDs) plus systemic corticosteroids 

• Urinary incontinence in older women from peripheral alpha-1 blockers plus loop diuretics 

• Theophylline toxicity due to cimetidine 

• Increased bleeding risk from warfarin when combined with amiodarone or NSAIDs 

Evaluation:

The expert panel appears to have achieved its goal of preparing a list of DDIs that can be particularly dangerous in the elderly. It would not be difficult for pharmacists to commit these to memory given that there are only 13 DDIs on the list. When alerted to these DDIs by a computerized screening system, pharmacists could pay particular attention to the alert for elderly patients. In general, the DDIs on the list should be avoided in older adults when possible; therefore, action by a pharmacist may well be warranted. It is important to keep in mind that this list is not comprehensive. The risk of GI bleeding due to NSAIDs can be increased by drugs other than corticosteroids (eg, spironolactone). The risk of lithium toxicity can be increased by drugs other than ACE inhibitors or loop diuretics (eg, angiotensin receptor blockers, NSAIDs). Many drugs other than cimetidine inhibit CYP1A2 and can cause theophylline toxicity. In addition, dozens of drugs other than amiodarone and NSAIDs can increase the risk of bleeding in patients on warfarin, usually through inhibition of CYP2C9 or by inhibitory effects on platelet function. Moreover, many other important DDIs were not included, as the expert panel pointed out. Leaving out antiinfective agents was probably prudent, but many anti-infectives have properties that result in clinically important DDIs. It is important to note that the new Beers Criteria DDIs are not intended to be applied to patients in palliative and hospice care. These patients, for example, may well need therapy with various combinations of CNS-active drugs that can be problematic in other older adults. For most of the 13 DDIs on the list, the expert panel recommended that they should be avoided if possible, but for one of the interactions (theophylline plus cimetidine), the panel simply said “Avoid.” This is appropriate because other histamine2 -receptor antagonists have little effect on theophylline and there is no reason to use cimetidine. 

Summary:

The American Geriatrics Society 2015 Updated Beers Criteria included DDIs for the first time. The panel listed 13 DDIs that may be particularly dangerous in older adults. It would be prudent for pharmacists to pay particular attention to these DDIs in all patients, but especially in the elderly. 

References: 

1. Drs. Horn and Hansten are both professors of pharmacy at the University of Washington School of Pharmacy. 
2. For an electronic version of this article, including references, visit hanstenandhorn.com.

Drug–Disease Interactions : Lot to Know

This column usually deals with interactions that occur when one drug directly affects the pharmacokinetics or pharmacodynamics of a second drug. It is possible, however, for a precipitant drug to indirectly affect the object drug. A common example would be drug-induced renal or hepatic dysfunction that reduces the elimination of another drug. It is also possible for effective drug therapy to enhance the elimination of an object drug by treating a disease that inhibits drug elimination.

Effect of Disease on Drug Metabolism:

The activity of several cytochrome P450 enzymes (eg, CYP1A2, CYP3A4, CYP2C19, CYP2C9) can be inhibited by disease states that are characterized by infection or inflammation. These disease states increase cytokine concentrations in response to infection, trauma, ischemia, immune-activated T cells, and toxins. Cytokines associated with this CYP inhibitor effect include interleukin-6 (IL-6), IL-1, tumor necrosis factor, and interferon. During active disease periods, the metabolism of drugs may be reduced by the elevated cytokine concentrations; however, it is unknown if these cytokines reduce CYP activity in the liver or the intestinal enterocytes, or both. 

Treatment of the disease may reduce cytokine production and the suppressant effect on CYP enzymes. Schmitt et al reported on the simvastatin plasma concentrations in 12 patients with rheumatoid arthritis (RA) before and after treatment with tocilizumab (Actemra). Patients were administered a single 40-mg dose of simvastatin before and at 7 and 35 days after a single dose of tocilizumab 10 mg/kg. Following treatment with the IL-6 antagonist, the mean simvastatin peak plasma concentration and area under the concentration time curve (AUC) were reduced by close to 60% compared with baseline values. The reduction in simvastatin AUC following tocilizumab administration correlates to approximately a doubling of its oral clearance. At 35 days after the tocilizumab dose, simvastatin plasma concentrations were still 40% less than levels prior to the tocilizumab dosing. The inhibition of CYP3A4 activity by cytokines is likely responsible for the increased simvastatin concentration observed prior to tocilizumab treatment. There was no observable change in the half-life of simvastatin after treatment, suggesting that the change in simvastatin AUC may have been due to increased first-pass effect rather than a change in systemic clearance. It appears that cytokine inhibition of metabolism is rapidly reversed by agents that reduce the inflammatory response (Table). 

A decrease in omeprazole plasma concentration was noted following tocilizumab administration to patients with RA.5 The decrease was about 40% in extensive metabolizers of CYP2C19, but less than 20% in poor metabolizers. These data suggest that the activity of both CYP2C19 and CYP3A4 is reduced in patients with RA and this inhibition is reversed by IL-6 inhibition. Clinical Perspective The magnitude of the change in a drug’s elimination following the administration of a cytokine inhibitor will likely be limited to the degree of cytokine-induced inhibition of the CYP enzymes. Based on the limited data available, cytokine induced inhibition may approach a 50% reduction in drug clearance. In disease states with chronic inflammation, drug dosages may be adjusted downward to avoid adverse events. Treating the inflammation with a cytokine inhibitor will result in an increase in drug clearance and reduction in drug concentration. For drugs with a narrow therapeutic range (eg: warfarin, theophylline, cyclosporine) or in cases in which low plasma concentrations pose a risk of therapeutic failure (eg, antivirals, immunosuppressants, antineoplastics), the increase in clearance may result in an altered patient response. Drug dosage may require an increase when cytokine inhibitors are administered. Patients treated with tocilizumab or other cytokine inhibitors should be monitored for altered response to long-term medications that undergo CYP metabolism. 

References: 

1. Drs. Horn and Hansten are both professors of pharmacy at the University of Washington School of Pharmacy.
2. For an electronic version of this article, including references, visit hanstenandhorn.com.

Drugs acting on Cardiovascular System : Classification at tips

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Deepak Kumar Bandari,

Pharm.D Intern,

Vaagdevi College of Pharmacy - India

Elsevier Student Ambassador - South Asia

Drug Information at a Glance : Images by Dr. Alyaa Fadhil

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The Images above are created by Dr. Alyaa Fadhil - Clinical Pharmacist. We do not deserve any rights to copy them rather we would like to thank her for her way of presentation and information. These images were found in social sites and we found them liable for sharing. 

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Deepak Kumar Bandari,

Pharm.D Intern,

Vaagdevi College of Pharmacy - India

Elsevier Student Ambassador - South Asia

Oral Contraceptive failure due to Antibiotics : A Bogus Interaction

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Over past 3 decades, published literature described hundreds of women on oral contraceptives have become pregnant after a course of oral antibiotic therapy. Accordingly, many pharmacists warned their patients who were on oral contraceptives to take additional precautions to avoid pregnancy when using antibiotics concomitantly. Yet, there exists many misconceptions about this purported interaction. First of which is that adequate data are available to prove or disprove the existence of the interaction.

A Bogus Interaction? 
This interaction has not been disproved, despite frequent proclamations that it is a “myth.” Some people have erroneously concluded that—because there are substantial flaws in the data supporting the existence of the interaction—the interaction has been shown not to exist. In making this claim, however, they have failed to understand the saying

“Absence of proof is not Proof of absence.”

Inadequacies in the Positive Studies and Reports:

The reports of oral contraceptive failure during antibiotic therapy are numerous, but they are with amusing results. Specific details of the cases are rarely reported, and it is not possible to determine whether the unintended pregnancy resulted from the antibiotic or simply represents the “background” failure rate normally seen with oral contraceptives. Although some of the pregnancies occurred in women who had been taking oral contraceptives correctly and successfully for years, there is still no certainty that the antibiotic caused the contraceptive failure in any given case.

Inadequacies in the Negative Studies and Reports:

There are also serious flaws in the studies that failed to find an increase in oral contraceptive failure rate with concurrent antibiotics. All of the studies had 1 or more of the following flaws: retrospective design, dependence on patients’ memory of events, long-term antibiotic use, or combining data for antibiotics that might reduce estrogen levels (amoxicillin) with those for antibiotics that may increase estrogen levels (erythromycin, clarithromycin). 

Some of the antibiotics (clarithromycin, ciprofloxacin, metronidazole) would not be expected to reduce estrogen levels. Moreover, if only a small fraction of women (< 5%) develop this interaction, a statistically significant change in estrogen pharmacokinetics would not be expected. Women taking an antibiotic for an acute infection might be less likely to have sexual intercourse because they are not feeling well, either due to the infection or because of side effects of the antibiotic (nausea, vomiting, diarrhea). This could result in an underestimation of the ability of antibiotics to reduce the efficacy of oral contraceptives. Another flaw in most negative studies is the failure to consider how many of the patients received information on how to avoid the interaction.

Proposed Mechanism of the Interaction:

The mechanism, if any, is not clear. Theoretically, antibiotics such as penicillin and tetracycline can reduce bacteria in the intestine that are involved in the enterohepatic circulation of estrogens, leading to a reduction in estrogen serum concentrations. Other mechanisms include enzyme induction following rifampin, griseofulvin, nafcillin, and dicloxicillin, or malabsorption of contraceptive hormones due to antibiotic-induced diarrhea and vomiting.

Pharmacists’ Role:

Women on oral contraceptives still should be warned about the possibility of contraceptive failure if they receive a prescription for an oral antibiotic. To comply with oral contraceptive product information, the patient should be advised to add alternative non-hormonal contraception during the time and for 7 days after the antibiotic is taken. No one knows, however, whether 7 days is enough. The pharmacist should recommend backup contraception for 2 weeks after discontinuation of the antibiotic or through the end of the current cycle—whichever is longer. Advising the patient to report any menstrual irregularities may be efficient, but there is no evidence that their absence ensures adequate contraception.

Conclusion:

In any given patient, antibiotics are unlikely to impair the efficacy of oral contraceptives. The data emphatically, however, do not establish that any antibiotic can be used in any woman on any oral contraceptive without increasing the risk of unintended pregnancy. Thus, only 2 possibilities are left:

1. Antibiotics cause contraceptive failure in a very small percentage of patients.
2. Antibiotics have no effect on oral contraceptive efficacy.

With the available data, it is simply not possible to choose which of these 2 possibilities is correct, so pharmacists must continue to warn patients accordingly.

References: 

1. Drug Interactions by Hasten and Horn : Current topics in Drug Interactions.
2. Lexicomp - clinical information solutions and drug interaction checker.

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Regards,

Deepak Kumar Bandari,

Pharm.D Intern,

Vaagdevi College of Pharmacy - India

Elsevier Student Ambassador - South Asia