Rational Drugs 33 & 34

7/30/2019 Rational Drugs 33 & 34

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An Update on Rational Drug Use Issue No. 33 & 34July - December 2008

REVIEW TOPIC

What is a drug food interaction?

Adrug food interaction happens when the food or liquidaffects the ingredients in a medicine that is taken so thatthe medicine cannot work the way it should. Drug-

food interactions can happen with both prescription andover-the-counter medicines. Drug interaction can alsohappen with herbal supplements which are consumed fornutritional purposes. When a drug is mixed with food oranother herb, each can alter the way the body metabolises theother. Some drugs interfere with the bodys ability to absorbnutrients; some herbs and foods can lessen or increase theimpact/absorption of a drug.

Not all medicines are affected by food, but many medicinescan be affected by what is eaten and when. Taking somemedicines at the same time as other food may interfere withthe way the stomach and the intestines absorb the medicine.This is why some medicines should be taken on an emptystomach. There are some medicines which are tolerated wellwhen taken with food. The doctor or the pharmacist should beasked whether it is fne to take the medicine with a snack or a

meal or whether it should be taken on an empty stomach.

clinical relevance of drug food interactionClinically a drug food interaction can lead to therapeutic fail-ure, increased toxicity, pharmacokinetic interactions alteringthe bioavailability and pharmacodynamic interactions.

Food may decrease drug absorption mainly because of foodbinding to a drug. There are also medicines that irritate theGI tract, eg aspirin.

Medications to be taken on an EMPTY STOMACH:- Foodgenerally decreases and delays absorption of certain drugs.

Medications to be taken WITH FOOD:- There are medicinesthat cause stomach upset where food will help to buffer, likecorticosteroids, some antibiotics, a few antiviral drugs usedin HIV/AIDS treatment, some NSAIDs and antifungals.

DRUG FOOD INTERACTION

Specic drug based food Interactions:

The drug-food interaction of some of the drugs is given

in the table below.Drugs Effects and Precautions

Antibiotics, Anti-infectivesCiprooxacin Avoid calcium-containing foods, minerals containing

iron and antacids as they decrease drug concentration

Metronidazole No alcohol, including medicines containing al-cohol while taking the medicine and for 3 days

after stopping

Anticonvulsants

Phenytoin,

Phenobarbital

Increase the risk of anaemia and nerve problemsdue to deciency of folate and other B vitamins

Antidepressants

Fluoxetine Reduces appetite and can lead to excessiveweight loss

Lithium A low-salt diet increases the risk of lithiumtoxicity; excessive salt increases the clearanceof lithium

Monoamine oxidaseinhibitors (MAO

Inhibitors), used inthe treatment of de-pression and anxietydisorder

Foods high in tyramine (processed cheeses,processed meats, legumes, wine, and beer,

among others) may lead to fatal increase inblood pressure. More examples of this categoryare, cured meats such as sausage and salami,protein extracts from meat, yeast, or yeast vi-tamin supplements, dried sh, shrimp paste,some preparations of ginseng, banana peels,resins, fermented soya products & sauce

Antihypertensives, Heart Medications (Cardiovascular)

ACE inhibitors Concurrent ethanol administration will in-crease hypotensive effect

Erythromycin Dont take with fruit juice or wine, whichdecrease the drugs effectiveness

Dairy products reduce the drugs effectiveness.Lowers Vitamin C absorption. Do not take withmilk or other dairy products; avoid calcium-containing foods, minerals containing iron andantacids as they decrease drug concentration

Roxithromycin Take at least 15 minutes before or after a meal

Sulfa drugs Increase the risk of Megaloblastic anaemia

Tetracycline

Drugs Effects and Precautions

Captopril

Alpha blockers

Beta blockers

Digitalis

Take 1 hour before meals for maximumabsorption

Take with liquid or food to avoid excessivedrop in blood pressure

Take before meals

Calcium and potassium salts can howeverincrease toxicity


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2 Issue 33 & 34

Unless a doctor advises otherwise, dont takepotassium sparing diuretics with potassiumsupplements or salt substitutes, which cancause potassium overload

It is poorly absorbed without food; so thepatient is advised to take this with an eveningmeal

Dietary consistency is important in maintaininga sustained, stable response during warfarintherapy. Patients should be particularly awareof foods high in vitamin K like green leafyvegetables (broccoli, spinach), cauliflower,legumes, mayonnaise and soybean oils, andshould maintain a consistent amount of thesefoods in their diet. Food items like caffein-ated beverages (cola, coffee, tea, hot chocolate,chocolate milk) should be avoided or limited,since they also can affect warfarin therapy.

Potassium sparingdiuretics

Statin like Lovastatin

Warfarin

Diuretics Increase the risk of potassium deciency. Tri-amterene and spironolactone are potassium-sparingand patients should avoid potassium-rich food.

Should avoid black licorice (which containsglycyrrhizin). Together, they can produceirregular heart rhythms and cardiac arrest;

licorice and diuretics will produce dan-gerously low potassium levels leading tomuscle pain and even paralysis.

Oatmeal in large amounts and other high-fiber cereals should not be eaten whentaking digoxin. The ber can interfere withthe absorption of the drug.

Sudden stopping of cereals could causedigoxin levels to increase to toxic levels.

Digoxin

Should be administered as a suspension bymixing with water, juice etc.

Administer 30 minutes before meals

Drugs Effects and Precautions Drugs Effects and Precautions

Asthma Drugs/ Bronchodilators

Avoid caffeine along with bronchodilators as caffeine also stimulatesCNS

Lethal dose of Caffeine is 10 gm (100 cups of coffee) and with-drawal symptoms are observed in people who routinely have morethan 600 mg/day (6 cups)

Pseudoephedrine Avoid caffeine, which increase feelings ofanxiety and nervousness

Cholesterol Lowering Drugs

Cholestyramine

Gembrozil

Contains xanthines, which are also found intea, coffee, chocolate, and other sources ofcaffeine. Consuming large amounts of thesesubstances while taking theophylline increasesthe risk of drug toxicity. Charbroiled / high

carbohydrate foods and high protein diet re-duce absorption. High-fat meals may increasetheophylline in body. Caffeine increases therisk of drug toxicity. Should be preferablygiven with meals to avoid gastric irritation

Theophylline

Lansoprazole,Omeprazole

Take 30 minutes before eating

Interfere with the absorption of many miner-als; for maximum benet, take medication1 hour after eating

Heartburn and Ulcer Medications

Antacids

Antifungal medicines

Laxatives

Mineral Oils Overuse can cause a deciency of vitaminsA, D, E, and K

Always take with food to lower the risk ofgastrointestinal irritation; avoid taking withalcohol, which increases the risk of bleeding.

Painkillers

Aspirin and strongernon-steroidal anti-in-ammatory drugs

Codeine

Never take with alcohol. Caffeine increasesanxiety and reduces drugs effectiveness

Sleeping Pills, Tranquilizers

Antigout

Benzodiazepines

Take after meal and with plenty of uid

Glyburide Take with breakfast

Antidiabetic

Allopurinol

Iron Preparation

Best absorbed when taken with water onan empty stomach. If GI upset occurs takebetween meals or with food. If taken withfood, avoid bran, eggs, ber supplements, tea,

coffee, dairy products, calcium supplementsand dairy products

Iron preparations

Large amounts of broccoli, spinach, and othergreen leafy vegetables high in vitamin K,which promotes the formation of blood clots,can counteract the effects of heparin, warfarinand other drugs given to prevent clotting

Vitamins

Vitamin K

Griseofulvin Should be given with fatty meal to increaseabsorption

Antiosteoporosis

Give on empty stomach along with plainwater only

Risedronate

Hormone Preparations

Take with food to decrease nausea. Grape

fruit juice can increase effect

Take with food to avoid gastric irritation

Take on empty stomach with water

Oral contraceptives

Steroids

Thyroid drugs

Increase ber and water intake to avoidconstipation


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Issue 33 & 34 3

Drug-food interaction needs to be studied for different healthconditions in different situations. A few specic cases aregiven below as examples.

1) Cancer Treatment:

Lapatinib is an oral dual tyrosine kinase inhibitor. It isindicated in combination with capecitabine for the treat-ment of patients with advanced or metastatic breast cancerwhose tumors overexpress HER2 and who have received

prior therapy, including an anthracycline, a taxane, andtrastuzumab. Simply by changing the timing taking thismedication with a meal instead of on an empty stomach wecould potentially use 40% or even less of the drug, Dr Ratainsaid. In this case, the drug-food interaction has provided animproved treatment option with low drug content therebyeven reducing the cost. (Source: Cut Cancer Drug Costs ByExploring Food Interactions, Allison Gandey, J Clin Oncol.2007. Published online 16 July 2007, http://www.medscape.com/viewarticle/560026)

2) Food and Beverages Affect Drug Bioavailability:

Adding a glass of grapefruit juice to a meal may be a com-mon activity in some societies. According to Dr Ratain,

We expect that a 250-mg lapatinib pill accompanied byfood and washed down with a glass of grapefruit juicemay yield plasma concentrations comparable to 5 pills onan empty stomach. Dr Cohen says, If we understood therelationship between, say, grapefruit juice and commondrugs, such as the statins, which are taken daily by millionsof people to prevent heart disease, we could save a fortunein drug costs. These statements are not surprising giventhat food often increases a drugs bioavailability. Drs Ratainand Cohen say, The rapidly escalating price of medica-tions has provided incentives to explore pharmacologicalapproaches to lower the costs of drugs. (Source: www.medscape.com)

3) HIV/AIDS Drug-food interaction:HIV therapy (particularly combination therapy of ARVdrugs) drug interactions with food occur when either thepharmacokinetics or the pharmacodynamics of one drugare altered by the administration of food or a concomitantdrug. Alcohol can reduce effectiveness of HARRT by reduc-ing adherence.

High-fat diet enhances the bioavailability of ARVs likeTenofovir, but reduces absorption of drugs like Indinavirand Zidovudine. Didanosine is a nucleoside reverse tran-scriptase inhibitor with food interaction and so is Efavirenz,a non-nucleoside reverse transcriptase inhibitor. Accordingto Angela D M Kashuba, there is no data to show whetherfood effects occur with the Protease Inhibitorcombinationsof Nelnavir/Ritonavir or Amprenavir/Ritonavir (AngelaD M Kashuba, Medscape HIV/AIDS, February 2001). Con-sumption of the ARV Didanosine with alcohol can causeinammation of the pancreas, and alcohol with Isoniazidmay increase the risk of inammation of the liver.

References:

1) Family Doctor.org; http://familydoctor.org2) Risky Cocktails, Risky Business Drug Interactions between Recreational Drugs

and HAART: Patricia Martin, Pharm D3) Food-Drug Interactions, Dr William Diehl-Jones, Faculty of Nursing and

Department of Zoology4) http://nepenthes.lycaeum.org/Misc/maoi.foods.html5) http://www.foodmedinteractions.com

6) http://www.globalrph.com/drugfoodrxn.htm Global RPh.Com7) Herbal Medicine, Holistic online.com; http://www.holisticonline.com/8) J Clin Oncol. 2007, Published online July 16, 2007, www.medscape.com, 5600269) HIV Pharmacology and Drug Interactions, 10 February 2001; Medscape Today,

www.medscape.com10) Preventing Food and Drug Interactions by The University of Georgia Cooperative

Extension Service

specific food based drug interactions

Grapefruit: The juice modies the bodys way of metabo-lising the medication, affecting the livers ability to workthe drug through a persons system. Active ingredients ingrapefruit juice are CYP inhibitors, which when metabolisedslowly are at risk for toxicity and adverse drug effects, andwhen metabolised fast have unpredictable response. A largenumber of medicines including HIV/AIDS drugs interact

with grapefruit juice. Grapefruit juice interacts with calciumchannel blockers, cholesterol control medications, somepsychiatric medications, estrogen, oral contraceptives andmany allergy medications.

Orange juice: It shouldnt be consumed with antacidscontaining aluminum. The juice increases the absorption ofaluminum. Orange juice and milk should be avoided whentaking antibiotics. The juices acidity decreases the effective-ness of antibiotics, as does milk.

Milk:Does not mix with laxatives containing bisacodyl. Thelaxative effect is more in the morning.

Leafy green vegetables: High in vitamin K; should notbe taken in great quantities while taking warfarin. Thesevegetables could totally negate the effects of the drug andcause blood clotting.

Caffeinated beverages: Taken together with asthma drugscan cause excessive excitability. Those taking cimetidine,quinolone antibiotics and oral contraceptives should beaware that these medicines along with their cup of coffeemay cause a sudden high.

Grilled meat: It can lead to problems for those on asthmamedications containing theophyllines. The chemical com-pounds formed when meat is grilled somehow prevent thistype of medication from working effectively, increasing thepossibility of an unmanageable asthma attack.

Diet high in fat: Regularly consuming this while takinganti-inammatory and arthritis medications can cause kid-ney damage and can leave the patient feeling drowsy andsedated.

Alcoholic beverages: These have a tendency to increase thedepressive effects of medications such as benzodiazepines,antihistamines, antidepressants, antipsychotics, muscle re-laxants, narcotics, or any drug with sedative actions. Alcoholinteracts with almost every medication, especially antide-pressants and other drugs that affect the brain and nervoussystem. Antioxidants and beta-carotenes intensify alcoholseffect on the liver. Alcohol can lower blood pressure withbeta blockers and nitrate containing drugs. It can cause liver

damage with statin drugs.Dietary ber: Pectin and other soluble bers slow downthe absorption of acetaminophen (paracetamol), a popularpainkiller. Bran and other insoluble bers have a similareffect on digoxin, a major heart medication.

Herbs and Foods Taken with Drugs: There is a notion that,being natural, all herbs and foods are safe. This is not true.Very often, herbs and foods may interact with medicationsthat sometimes result in serious side reactions. It is alwaysa good practice to tell the doctor and/or health practition-ers about such food/herb habits so that they can advise onpossible complications, if any. The patient should also keepan eye out for unusual symptoms. High-risk patients suchas the elderly, patients taking three or more medicationsfor chronic conditions, patients suffering from diabetes, hy-pertension, depression, high cholesterol or congestive heartfailure should be especially on the lookout for reactions.


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4 Issue 33 & 34

COMMON SKIN CONDITIONS

There are a number of skin related conditions thatpeople are concerned with, mainly because of cosmeticimplications. Some of the most common skin condi-

tions are presented in this article.

dandruff and seborrheic dermatitis

Dandruff and seborrheic dermatitis are conditions thatshare a common manifestation the patients scalp orskin producing scales. Generally there is common etiologytoo. Many nonprescription products are also used to treatboth conditions.

etiologyAbnormal Cell Turnover: Epidermal cells formed in thestratum germinativum, the innermost layer, graduallybegin to migrate upward to the next layers, eventuallyreaching the uppermost layer, the stratum corneum, afterlosing their nuclei and gaining keratin. Such keratinizedcells act to protect the living tissues beneath them. Thetimeframe required for stratum germinativum cells to losetheir nuclei and become keratinised is 25-30 days. For themost part, normal cell-shedding is not noticed and causesno symptoms. In dandruff, cell turnover is commonly 13-15 days and for seborrheic dermatitis it is only 9-10 days.According to the FDA OTC Review Panel in 1982, the causeof dandruff is known to involve an increase in the rate ofepidermal turnover.

Fungal Etiology: Research on the possible causative roleof fungi on dandruff and seborrheic dermatitis resulted inisolating an organism Pityrosporum ovale that inhabits skinfollicles. In 1982, FDA OTC Review Panel Report foundthat though there was support for the use of antimicrobi-als in controlling dandruff, there is no denite correlationbetween the presence ofP. ovale and the development ofdandruff. But in 1984, a researcher, after reviewing lit-

erature, came to the conclusion that P. ovale fullled all ofKochs postulates for dandruff and seborrheic dermatitis;the efcacy of ketoconazole in those conditions was sup-ported by the medical opinion.

Dandruff: Dandruff is a condition of less severity thanseborrheic dermatitis. Even if it is not treated, the patientwill not experience any further symptom/s, althoughsome patients may complain of minor itching. Its effectsare only cosmetic. It does not cause or result from inam-mation, and it is not allergic in origin. Scaling of dandruffis large clumps of dry, white or gray scales that are easilyvisible. Dandruff is uncommon in children aged 2-10, butthe incidence begins to rise from puberty onwards and riseseven more rapidly thereafter, until they reach their earlytwenties when it begins to fall. It is not very common inmiddle-aged patients and the elderly.

Seborrheic Dermatitis: Seborrheic dermatitis is a moresevere condition than dandruff. The age of onset is usuallypuberty, and it is common to have pruritus (severe itching)associated with the condition. The sites most often affectedby seborrheic dermatitis are those where sebum production isheaviest, due to a greater concentration of sebaceous glands,like scalp, eyebrows, eyelashes, external ear canal, behindthe ears, in nasal folds, the midchest, armpits, between theshoulder blades, and the pubic area and groin. P. ovale isdependent on fatty acids from its surroundings for synthesis.While metabolising these fats, it may cause skin damage byproducing irritant metabolites.

Treatment Options: For self-treatment of dandruff and se-borrheic dermatitis there are different ingredients that aresafe and effective. For these two conditions, salicylic acid,selenium sulphide, zinc pyrithione and coal tar are effective.Sulphur and ketoconzole are effective in treating dandruffonly, and hydrocortisone is effective for seborrheic dermatitistreatment only. These products can be used for all ages above2 years except ketoconazole, which should be used for thoseaged over 12 years.

Salicylic Acid 1.8%-3%: Salicylic acid is available in the formof shampoo and foam and it increases hydration of skin. Thescales of dandruff and seborrheic dermatitis are removed bythe keratolytic action.

Selenium Sulphide 1%: Selenium sulphide is highly activein inhibiting the growth ofP. ovale. For dandruff, 0.6% micro-nised form of selenium sulphide is safe and effective.

Zinc Pyrithione: For dandruff, zinc pyrithione 0.3%-2%, andfor seborrheic dermatitis 0.95%-2% concentration in shampoois safe and effective.

Hydrocortisone 0.25%-1%: Hydrocortisone cream is safe andeffective for treatment of seborrheic dermatitis, and shouldnot be used to treat dandruff, as seborrheic dermatitis has aninammatory component, while dandruff does not.

Coal Tar 0.5%-5%: Various forms of coal tar (e.g., coal tardistillate, coal tar extract, coal tar solution) are effective forboth conditions, though it is not the best choice. Besides un-pleasant odour, it can stain the skin and hair. It also can causefolliculitis, irritant dermatitis, and allergic dermatitis. It maycause photosensitivity reactions, and patients should avoidsun exposure up to 24 hours of using it. It is also potentiallycarcinogenic. The patient should consult a physician beforeuse if the condition covers a large part of the body.

Sulphur 2%-5%: For dandruff, 2%-5% concentration sulphurin shampoo form can be used alone or in combination withsalicylic acid.

Ketoconazole 1%: Antifungal activity of ketoconazole 1%in shampoo can control the aking, scaling, and itching ofdandruff. If the scalp is broken or inamed, this should notbe used.


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Issue 33 & 34 5

Topical Minoxidil and Scalp Flaking: Use of topicalminoxidil in the presence of alcohol for long periods maycause drying of scalp, resulting in aking. The patient maydiscontinue the topical minoxidil for a brief period, and usea moisturising shampoo and moisturising conditioner afterconsulting a dermatologist.

Urticaria:

In urticaria, recurrent wheals occur which are usually

pruritic, pink-to-red swelling plaques with pale centersmostly. The wheal sizes vary from a few millimeters toseveral centimeters in diameter, and can form plaques. Theitch is relieved more by rubbing than by scratching. Urticariacan be diagnosed on the basis of the clinical presentation.Although acute urticaria often has an identiable trigger(foods, drugs, virus), chronic urticaria tends to remainidiopathic (a primary disease without apparent cause).

treatment

Treatment includes general measures to prevent or avoidtriggers and pharmacotherapy. Management of treatment canbe classied into rst-, second-, and third-line therapies.

f- t:First-line therapy includes patient education and generalnon-drug measures followed by a trial of histamine H

1re-

ceptor antihistamines if symptoms persist. General measuresinclude avoiding aggravating factors such as overheating,stress, alcohol, acetylsalicylic acid, NSAIDs, and ACE inhibi-tors. Cooling antipruritic lotions such as menthol 1% or 2%in aqueous cream or calamine lotion is useful. It is importantto keep patients well informed about the disease, specicallyabout the lack of a cure.

Histamine H1

Receptor Antihistamines: Antihistamineshave the capacity to inhibit histamine release and prevent

the actions of mast cell and basophil-derived histamine onits target organs. H

1receptor inhibition also reduces allergen-

induced eosinophil accumulation. The second-generationH

1receptor antihistamines like cetirizine and levocetirizine,

have anti-inammatory effects.

The response to treatment with antihistamines:

alleviates pruritus and decreasing the number of hives,though all patients will not respond.

only less than half the patients treated with antihistaminesexperience complete clearing of their symptoms.

they only reduce the severity of pruritus and decrease thenumber and duration of wheals in some patients.

most effective if taken daily, rather than on a needbasis.

more than one antihistamine should be tried since efcacyis patient specic.

First-generation H1

receptor antihistamines includehydroxyzine, diphenhydramine, cyproheptadine, andchlorpheniramine (chlorphenamine). These are not usedas much as monotherapy because of their sedating andanticholinergic side effects. But, they are good as adjunctivetherapy for patients whose sleep is disturbed by symptoms ofurticaria. The second-generation H

1receptor antihistamines

are like cetirizine, levocetirizine, loratadine, desloratadine,fexofenadine, ebastine, and mizolastine. Advantage of

second-generation antihistamines is the lack of CNS andanticholinergic adverse effects.

H2

Receptor Antagonists: About 15% of histaminereceptors in the skin are of the H

2type, for whom H

2

receptor antihistamines are useful in addition to H1receptor

antihistamines in some patients with chronic urticaria. But,H

2receptor antagonists should not be used alone since

they have only minimal effects on pruritus. Examples ofH

2receptor antagonists are cimetidine, ranitidine, and

famotidine. Overall, data supporting the efficacy of H2

receptor antagonists are limited.

s- t:Second-line therapies include both pharmacologic and non-pharmacologic measures like,

phototherapy with UV light or photochemotherapy (pso-ralen plus ultraviolet PUVA therapy)

relaxation therapiesgroups of drugs like antidepressants, corticosteroids, cal-

cium channel antagonists, levothyroxine sodium supple-ments, leukotriene receptor antagonists, and others.

t- t:Patients with urticaria who do not respond to rst- andsecond-line treatments are administered with third-linetherapy including use of immunomodulatory agents likecyclosporine, tacrolimus, methotrexate, cyclophosphamide,

mycophenolate mofetil, and intravenous immunoglobulins(IVIG). Other third-line therapies include plasmapheresis,colchicine, dapsone, salbutamol, tranexamic acid, terbutaline,sulfasalazine, warfarin and hydroxychloroquine.

allergies:

Besides cosmetics, there are a variety of items like food, pet,pollen, household dust, certain clothing materials, some met-als and some drugs which cause allergic conditions on theskin. Though doctors prescribe medicines like anti-histamineointment to alleviate reaction, the most effective condition isto identify and avoid the offending allergic condition.

Reference:

1) W. Steven Pray, PhD, RPh, Professor of Nonprescription Products and Devices,School of Pharmacy, Southwestern Oklahoma State University, Weatherford,OK; U.S. Pharmacist 26(4) 2001.

2) http://www.medscape.com/

3) Urticaria - A Review; Tasneem Poonawalla, Brent Kelly; American Journal ofClinical Dermatology; Published: 05/08/2009

US FDA Insists Boxed Warning for all Botulinumtoxin productsWith reports of serious adverse events, the US Food and DrugAdministration (FDA) announced safety label changes, includinga boxed warning, and a risk evaluation and mitigation strategy(REMS), for all botulinum toxin products. The US FDA, has askedthe companies to submit the revised safety label changes, includingthe boxed warning and the Medication Guide, to the FDA within 30days, or to provide a reason why they do not believe such changesare necessary. The effects of the botulinum toxin may spread fromthe area of injection to other areas of the body, causing symptomssimilar to those of botulism, including unexpected loss of strength ormuscle weakness, hoarseness or trouble talking, trouble saying wordsclearly, loss of bladder control, trouble breathing, trouble swallowing,double vision, blurred vision and drooping eyelids. Dosage strength

(potency) expressed in Units is different among the botulinum toxinproducts. Clinical doses expressed in units are not interchangeablefrom one product to another.

Source: http://www.fda.gov/cder/drug/

Warning


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6 Issue 33 & 34

Though a number of combination formulations are approved by the Drugs Controller General (India), in practice,it is the rationality of use that matters for the prescriber. In the previous issue we had published the new drugsapproved upto 29August 2006. The following is the list of new drugs approved by the Drugs Controller General (India)from 30August 2006 to May 2007.

NEW DRUGS

Adjunct diet in primary hypercholesterolaemia

NSAID

For schizophrenia

For cervical ripening, prevention of post partumhaemorrhage & rst trimester of abortion withmifepristone

Anti HIV

For IBS

Antibiotic

For acute Musculoskeletal pain

For diarrhea

For naturopathic pain & partial seizuresNSAID

Chemotherapy induced nausea & vomiting

Edema associated with congestive heart failure& hypertension

Seasonal allergic rhinitis & chronic idiopathicurticaria

For pulmonary osterial hypertension

For Type II Diabetes

To treat hypercholesterolemia

Corticosteroid responsive dermatomes

For insomnia

For anal ssure

For moderate to severe pain

For emergency contraceptive

For gastric ulcer, duodenal ulcer, Z. E Syn-drome, GERD

For lower respiratory tract infection in adults

For testosterone deciency (i) primary hypogo-nadism (ii) Hypogonadotropine hypogonadism

For Type II Diabetes; particularly for overweightpatients

For steroid responsive inammatory ocularcondition

Antihypertensive

Antidiabetic

For short term treatment of pain due to postoperative and post traumatic cases

Angina pectoris in adults

ACE Inhibitor

Essential hypertension

Multiple sclerosisMuscle relaxant

For hypertension

Allergic nasal inammation hives, itching withskin diseases

Atorvastatin 5mg + Fenobrate 160mg (additional strength)

Aceclofenac Inj. 50mg/ml (additional strength)

Amisulpride 400mg tablet (additional strength)

Misoprostol tablet 25mcg/100mcg/200mcg(additional strength/indication)

Atazanavir 150mg + Ritonavir 50mg capsules

Mebeverine Hcl 135mg + Chlordiazepoxide 5mg tablet

Ampicillin 250mg + Dicloxacillin 250mg tablet

Etoricoxib 10mg + Methyl Salicylate 100mg + Mentol 50mg +Linseedoil 30mg per gm of GelRacecadotril dispersible tablet 10mg/30mg (new dosage form)

Gabapentin ER 450/600/900mg tablet

Aceclofenac dispersible tablet 100mg (new dosage form)

R-Ondansetron (As Hcl. Dihydrate) 1mg/ml injection

Torsemide 10mg + Amiloride 5mg tablets

Fexofenadine suspension (30mg/5ml)

Sildenal Citrate 20mg tablet

Pioglitazone 15mg/30mg + Metformin ER 1000mg tablet(additional strength)

Fluvastatin Tablet (As calcium) 10mg/20mg/40mg(additional strength)

Halobetazol Propionate Cream 0.05%

Eszopiclone tablet 1mg/2mg/3mg

Diltiazem Hcl. 2% gel

Nalbuphine injection 10mg/20mg per ml

Levonorgestrel 1.5mg tablets

Pantaprazole sodium 20mg/40mg Tablet (with sodium bicarbonate,as buffer)

Levooxacin 250mg/500mg + Ambroxol SR 75mg tablet

Testosterone cypionate 100mg/200mg + Cotton seed oil 736/566mgper ml injection

Rosiglitazone 1mg + Metformin Hcl 500mg tablet(additional strength)

Loteprednol Etabonate 5mg + Tobramycine 3mg per mlophthalmic solution

Amlodipine (As besylate) 5mg + Metoprolol (As succinate) ER 25mg(additional strength)

Glibenclamide 5mg + Metformin SR 850mg tablet(additional strength)

Aceclofenac injection (150mg/3ml)

Metoprolol (As succinate) 50mg/25mg ER + Amlodipine5mg/2.5mg tablet (For additional indication)

Ramipril 10mg + HCTZ 12.5mg tablet (additional strength)

Amlodipine (As besylate) 5mg/5mg/10mg + Valsartan80mg/160mg/160mg tablet

Glatiramer Acetate injection 20mg/mlBaclofen ER (GRS) capsule 45mg/60mg (additional strength)

Amlodipine (As besylate) 5mg/10mg + Perindopril 4mg tablet

Olopatadine Hcl. tablet 2.5mg/5mg

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Issue 33 & 34 7

Metoprolol (As succinate) ER 25mg/50mg + Ramipril 2.5mg/5mg

Rabeprazole Sodium 20mg/10mg with sodium bicarbonate, as buffer

Ciclesonide 160mcg/320mcg + Formoterol Fumarate 12mcg (Drypowder inhaler (additional strength)

Moxonidine tablet 0.2mg/0.3mg/0.4mg

Ceftriaxone (As sodium) 125mg/250mg + Sulbactam (As sodium)62.5mg/125mg for injection (additional strength)

Quetiapine (As fumarate) SR 400mg tablet (additional strength)

Cabergoline 1mg tablet (additional strength)

Levooxacin Oral Solution, each 240ml bottle contains Levo-oxacin 125mg/5ml

Clindamycin 1% + Isotretinoin 0.05% gel

Estradiol topical emulsion 2.5mg/gm

Levosalbutamol MDI 50mcg/actuation & Dry Powder inhaler100mcg/capsule (new dosage form)

Polonosetron (As Hcl.) for injection 0.25mg/5ml

Cixime 200mg + Erdosteine 300mg capsules

Aminophylline CR 225/350mgEtoricoxib 10mg + Methyl salicylate 20mg per gm. of cream

Eberconazole cream 1%

ISMN 60mg Sr + Atenolol 50mg/100mg

Levonorgestrel 0.03mg tablet

Bortezomib 2mg/vial (additional pack size)

Comb kit of two capsule of Azaranari 150mg each + 1 tablet ofRitonavir 100mg

Mecobalamine 500mcg + Alpha Lipoic acid 100mg soft gelatincapsule

Propofol 10mg + Lignocain 1mg per ml injection

Ezetimibe 10mg + Fenobrate 160mg tabletMethylprednisolone Acrponate topical solution 0.1%

Citicoline 750mg tablet (additional strength), syrup 500mg/5ml(new dosage form, not for children)

Ertapenem for injection 1gm/vial

Letrozole 2.5mg tablet (for additional indication)

Quetiapine SR tablets 50mg (additional strength)

Metoprolol (As succinate) 25mg + Amlodipine (As besylate) 5mg(additional strength)

Sunitinib Maleate Capsules 12.5mg/25mg/50mg

Comb pack of 1 bottle of Ciprooxacin injection 200mg/100ml &1 bottle of Ornidazole injection 500mg/100ml

Aprepitant 40mg capsules (additional strength)

Olopatadime Ophthalmic solution 0.2% (additional strength)

Combi pack of 1 tablet of Residronate sodium 35mg + 6 tablets ofcalcium carbonate equivalent to 500mg calcium each

Levocetirizine 2Hcl. Dispersible tablet 2.5mg

Amlodipine (As besylate) 10mg + Perindopril 8mg tablets (ad-ditional strength)

Etodolac ER tablets 400mg/500mg

Levosulpiride tablet 25mg

Rimonabant tablet 20mg

Lactitol monohydrate Syrup 66.67/100ml

S(-) Metoprolol (As succinate) 25mg + S(-) Amlodipine (As be-sylate 2.5/5mg

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Essential hypertension

For Duodenal ulcer, G.U, Z.E.S. & GERD

Bronchospasm relaxant

For hypertension

Antibiotic

Sedative

For Hyperprolactinemia

Antibiotic (For adult use only)

For acne

Vasomotor symptoms associated with menopause

Bronchospasm relaxant (not recommended for children)

Chemotherapy induced nausea & vomiting

Acute exacerbation of chronic bronchitis

Asthma, COPD, BronchitisAcute Musculoskeletal pain

Dermatophyte infection of skin such as T-corporis,

T-Pedis

For angina pectoris

For control of fertility

Chemotherapeutic drug

For HIV infection

For diabetic neuropathy

For induction of anesthesia

For combined hypertipidemiaAtopic dermatitis (eczema) inammatory and allergicskin reaction

Antiparkinson

Antibiotic

For induction of ovulation in anovulatory infertility

For schizophrenia

Antihypertensive

For G.I. Stromal tumor, advanced renal cell carcinoma

Antibiotic

Prevention of post-operative nausea & vomiting(additional indication)

For allergic conjunctivitis

For osteoporosis in postmenopausal women

For allergic rhinitis & chronic urticaria

Antihypertensive

For osteoarthritis & rheumatoid arthritis

For G.I. problem like fanatical dyspepsia, nausea,vomiting and diabetic gastroperisis

For obese patients BMI 30kg/m2 or overweight pa-tients BMI 27kg/m2 with associated risk factors such

as type-I diabetes or dyslipidemia

For constipation

For essential hypertension

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8 Issue 33 & 34

Published by

The General Secretary, CMAI

All correspondence to:

Policy Advocacy Group

Christian Medical Association of India Plot

No 2, A-3 Local Shopping Centre

Janakpuri, New Delhi 110 058

Phone:2559 9991/2/3 or 2552 1502

E-mail: [email protected],

[email protected]

website: www.cmai.org

CMAI Bangalore Ofce

HVS Court, 3rd Floor, 21 Cunningham

Road, Bangalore 560 052

Tel: (080) 2220 5464, 2220 5837

E-mail: [email protected]

Editorial Committee

Dr Alice Kuruvilla

Dr Sujith Chandy

Dr Santanu K Tripathi

Sr Jessie Saldanha

Dr Vijay Aruldas

Ms Jaya Philips

Dr Abhijeet Sangma

Editor

Dr R Sweety Prem Kumar

Design & Production

Ms Lata Anthony

Printed at: Impulsive Creations

Amlexanox Oral Paste 5%

Lenalidomide capsule 5mg/10mg/15mg/25mg

Cefotaxim (As sodium) 0.5mg/1gm + Sulbactam (As so-dium) 250mg/500mg injection (for additional indication)

Lornoxicam tablet 4mg/ 8mg

Atenolol 25mg/50mg + Indapamide SR 1.5mg

Livetiracetam conc. for infusion 100mg/ml (new dosageform)

Eplerstat tablet 50mg

Citicoline tablet 200mg (additional strength)

Varenicline (As tartrate) 0.5mg/1mg tablets

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For apthous ulcers in people with normal immune system

For transfusion dependent anaemia due to myalodysplasticsyndrome associated with deletion 5q cytogenic abnormality

For surgical prophylaxis (additional indication)

For Osteoarthritis rheumatoid arthritis

For essential hypertensionAs adjunctive therapy in partial onset seizures in adults withepilepsy when oral administration is temporarily not feasible

For abnormality of vibration sense and abnormal change inheart rate associated with diabetic peripheral neuropathy

Antiparkinson

As an aid to smoking cessation treatment in adults

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Readers are requested to

suggest topics for future issues

ALERT A Ivitati

NPPA on Marketing Evion 400 as Dietary Supplement

National Pharmaceutical Pricing Authority (NPPA) is to take action against MerckIndia Ltd for classifying its leading Vitamin E brand, Evion 400 tablets, into a

dietary supplement, so that it is out of price control. The company has obtained theproduct license with change in the composition from drug authorities of Daman.NPPA has xed the ceiling price of a strip of 10 caps of Evion 400 tablets as Rs 14.82

inclusive of all taxes. But the company after changing the product from a drug to adietary supplement has xed the MRP at Rs 60 for a strip of 10 caps, after recentlychanged its formulations with the addition of vitamin E 400 IU, wheat gram oil 100mg

and Omega3 fatty acid 30mg.

Source: Chronicle Pharmabiz

Nutri-system advanced diet

T

he nutri-system diet plan was introduced in 1972. After undergoing several

changes, the present nutri-system advanced plan was launched in 2008. This planfollows a glycemic advantage approach promoting good carbs, low fat, healthyprotein, and high-bre prepackaged ready-to-eat meals. Nutri-system advanced meals

also contain soluble bre and Omega-3 fatty acids. Exercise is recommended whilefollowing this diet plan. Though it is expected to have certain tangible health benets,it is not an established tool for weight management. The idea of good carbs and

bad carbs is debatable. Some healthy low glycemic index foods include whole pulsesand legumes, vegetables, fruits and low-fat dairy products to help control sugar levelsand appetite.

Look for the nutrition facts on the food label on prepackaged foods for calories,

serving size, total fat, saturated fat (associated with raising blood cholesterol), trans fats(increases risk of heart disease by raising LDL or bad cholesterol level and decreasesHDL or good cholesterol level), total cholesterol, sodium, total carbohydrate, dietary

bre, vitamins andminerals.Source: Chronicle Pharmabiz

ChristianMedicalAssociation ofIndia

A health education publication from the

Policy Advocacy Group of CMAI.

Rational Drugs has been a well-appreciated publication. In order to reach more people,

we will be sending it only by email from now on. However, if you would prefer to receive

a printed version, please send a donation of Rs 100/- by DD to CMAI, Delhi, towards

cost of publication and postage.

To receive Rational Drugs by email, please send a request by email with the following

information - name, address & pin code, phone number, email id, membership number

(if CMAI member.) If the label in which you received this issue has the Reader ID,

please send that to us. This may be sent to [email protected] do write and let us know your preference by 30 September 2009. If we do not

hear from you, we will assume that you have changed your address, and discontinue

mailing to you.

RATIonAL DRugs goEs ELEcTRonIc

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Documents

Rational Drugs 33 & 34