Rekha Priyadarshini

Background: Deprescribing fall risk-increasing drugs (FRIDs) is essential for reducing polypharmacy and falls in older adults, yet randomized controlled trials (RCTs) face unique implementation challenges. The DeFRID study is an ongoing multi-center RCT evaluating an Assess, Review, Minimize, Optimize, and Reassess-based deprescribing intervention versus usual care in adults aged ≥60 years prescribed FRIDs. The objectives of this review are threefold: (1) to describe practical challenges encountered during a multi-center deprescribing RCT in India; (2) to propose a conceptual framework for categorizing these barriers; and (3) to contextualize DeFRID’s experience within the broader deprescribing research landscape. Methods: We conducted a narrative review with systematic scoping elements, synthesizing global RCT evidence from PubMed, OpenAlex, and Google Scholar (inception-December 2025) with DeFRID process evaluation data. DeFRID barriers and facilitators were identified via mixed-methods (clinician KAP questionnaire and qualitative interviews), team meetings, retention logs, and Phase II RCT implementation data, thematically categorized, and then compared with global RCT challenges. Results: DeFRID implementation revealed four challenge categories: ethical-clinical difficulties establishing equipoise for FRID withdrawal; operational barriers to recruitment and retention; methodological complexities in fall outcome ascertainment; and context-specific constraints unique to the Indian low- and middle-income countries setting—limited deprescribing guidelines, polypharmacy normalization, fragmented care coordination, and hierarchical decision-making. Global RCTs revealed substantial implementation challenges: low clinician adherence, short follow-up periods, restrictive eligibility excluding frail or cognitively impaired older adults, and resource-intensive interventions limiting scalability. Conclusions: Deprescribing FRIDs in older adults is impeded by ethical, operational, methodological, and provider-patient challenges, necessitating multilevel strategies integrating training, shared decision-making, context-specific guidelines, and stakeholder engagement for scalable implementation. Clinical trial registration number: The DeFRID trial is registered with the Clinical Trials Registry of India (CTRI/2023/12/060516) [https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=ODg1NjM=&Enc=&userName=].

1. 1.1. Medications remain an important modality in the treatment of most diseases or disorders. But, about 25–80% of patients respond to a specific drug therapy and some of them cannot tolerate tr...

Aims: Deprescribing, the process of stopping unnecessary medications, is essential for optimizing pharmacotherapy in older adults but is hindered by systemic, knowledge and patient‐related barriers. This study explored physicians' perspectives on barriers and facilitators to deprescribing in older adults using the Theoretical Domains Framework (TDF), in an LMIC setting with limited evidence. Methods: A qualitative study was conducted using in‐depth interviews with physicians (n = 52) to explore barriers, facilitators and potential improvements in deprescribing practices. Thematic analysis was applied to identify key insights and patterns from the collected data. Results: This study identified several barriers to deprescribing, including limited healthcare access in rural areas and knowledge gaps in geriatric pharmacology among resident doctors. Patient‐specific challenges, such as advanced age and multiple comorbidities, further complicated the process. The chronic use of medications like proton pump inhibitors (PPIs) and benzodiazepines was also a prominent barrier. Systemic and logistical issues, such as inefficient workflows and poor interdisciplinary coordination, were noted as critical impediments. Key facilitators included patient acceptance, which was pivotal for adherence and outcomes, and the active participation of educated patients in shared decision‐making processes. A growing acceptance of deprescribing among doctors, especially in government healthcare, was observed, with effective communication key to overcoming patient resistance and building trust. Conclusion: Overcoming systemic barriers, enhancing patient education and implementing structured guidelines are key to improving deprescribing. Interdisciplinary collaboration and digital tools like electronic health records can further ensure safe medication discontinuation. Targeted interventions are essential to optimizing deprescribing and improving older adult's health outcomes.

Background: Falls in older patients can lead to serious health complications and increased health care costs. Fall risk–increasing drugs (FRIDs) are a group of drugs that may induce falls or increase the tendency to fall (ie, fall risk). Deprescribing is the process of withdrawal from an inappropriate medication, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes. Objective: This study aims to assess the effectiveness of a deprescribing intervention based on the Assess, Review, Minimize, Optimize, and Reassess (ARMOR) tool in reducing the risk of falls in older patients and evaluate the cost-effectiveness of deprescribing FRIDs. Methods: This is an open-label, parallel-group randomized controlled academic trial. Individuals aged 60-80 years who are currently taking 5 or more prescribed drugs, including at least 1 FRID, will be recruited. Demographic data, medical conditions, medication lists, orthostatic hypotension, and fall history details will be collected. Fall concern will be assessed using the Fall Efficacy Scale, and fall risk will be assessed by the Timed Up and Go test and Tinetti Performance-Oriented Mobility Assessment tool. In this study, all treating physicians will be randomized using a stratified randomization method based on seniority. Randomized physicians will do deprescribing with the ARMOR tool for patients on FRIDs. Participants will maintain diaries, and monthly phone follow-ups will be undertaken to monitor falls and adverse events. Physical assessments will be performed to evaluate fall risk every 3 months for a year. The rationality of prescription drugs will be evaluated using the World Health Organization’s core indicators. Results: The study received a grant from the Indian Council of Medical Research–Safe and Rational Use of Medicine in October 2023. The study is scheduled to commence in April 2024 and conclude by 2026. Efficacy will be measured by fall frequency and changes in fall risk scores. Cost-effectiveness analysis will also include the incremental cost-effectiveness ratio calculation. Adverse events related to deprescription will be recorded. Conclusions: This trial will provide essential insights into the efficacy of the ARMOR tool in reducing falls among the geriatric population who are taking FRIDs. Additionally, it will provide valuable information on the cost-effectiveness of deprescribing practices, offering significant implications for improving the well-being of older patients and optimizing health care resource allocation. The findings from this study will be pertinent for health care professionals, policy makers, and researchers focused on geriatric care and fall prevention strategies. Trial Registration: Clinical Trials Registry – India CTRI/2023/12/060516; https://ctri.nic.in/Clinicaltrials/pubview2.php International Registered Report Identifier (IRRID): PRR1-10.2196/55638

BACKGROUND Falls in older patients can lead to serious health complications and increased health care costs. Fall risk–increasing drugs (FRIDs) are a group of drugs that may induce falls or increase the tendency to fall (ie, fall risk). Deprescribing is the process of withdrawal from an inappropriate medication, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes. OBJECTIVE This study aims to assess the effectiveness of a deprescribing intervention based on the Assess, Review, Minimize, Optimize, and Reassess (ARMOR) tool in reducing the risk of falls in older patients and evaluate the cost-effectiveness of deprescribing FRIDs. METHODS This is an open-label, parallel-group randomized controlled academic trial. Individuals aged 60-80 years who are currently taking 5 or more prescribed drugs, including at least 1 FRID, will be recruited. Demographic data, medical conditions, medication lists, orthostatic hypotension, and fall history details will be collected. Fall concern will be assessed using the Fall Efficacy Scale, and fall risk will be assessed by the Timed Up and Go test and Tinetti Performance-Oriented Mobility Assessment tool. In this study, all treating physicians will be randomized using a stratified randomization method based on seniority. Randomized physicians will do deprescribing with the ARMOR tool for patients on FRIDs. Participants will maintain diaries, and monthly phone follow-ups will be undertaken to monitor falls and adverse events. Physical assessments will be performed to evaluate fall risk every 3 months for a year. The rationality of prescription drugs will be evaluated using the World Health Organization’s core indicators. RESULTS The study received a grant from the Indian Council of Medical Research–Safe and Rational Use of Medicine in October 2023. The study is scheduled to commence in April 2024 and conclude by 2026. Efficacy will be measured by fall frequency and changes in fall risk scores. Cost-effectiveness analysis will also include the incremental cost-effectiveness ratio calculation. Adverse events related to deprescription will be recorded. CONCLUSIONS This trial will provide essential insights into the efficacy of the ARMOR tool in reducing falls among the geriatric population who are taking FRIDs. Additionally, it will provide valuable information on the cost-effectiveness of deprescribing practices, offering significant implications for improving the well-being of older patients and optimizing health care resource allocation. The findings from this study will be pertinent for health care professionals, policy makers, and researchers focused on geriatric care and fall prevention strategies. CLINICALTRIAL Clinical Trials Registry – India CTRI/2023/12/060516; https://ctri.nic.in/Clinicaltrials/pubview2.php INTERNATIONAL REGISTERED REPORT PRR1-10.2196/55638

Objective: To evaluate the level of understanding (knowledge), beliefs (attitude), and behavior (practice) of staff nurses toward medication errors (MEs). Methods: Self-administered questionnaires were distributed to nursing professionals who had at least 1 year of work experience. Each questionnaire contained 19 items assessing “knowledge,” “attitude,” and “practice” attributes toward MEs. Results: Responses from 47 nursing respondents were included for the final analysis. The mean knowledge score was 3.8 ± 1.1 (out of 6); 66% and 79% of the respondents had awareness of medication reporting systems and interventions in preventing MEs, respectively. Lack of adequate knowledge in recognizing MEs ( P = 0.003), or presuming MEs are not as important enough to be reported ( P = 0.002), was considered as the major reason for under-reporting of MEs. Nurses with higher knowledge score were against administration of medication through a different route than that prescribed by the physician ( P = 0.023), and tried to rectify an ME ( P = 0.020) and stayed with the patient until an oral medication had been swallowed ( P = 0.037). Conclusions: The nursing professionals were aware of the ME reporting system and methods to prevent the occurrence of MEs. They also exhibited a positive attitude and followed optimal practices in controlling MEs.

Madhavi Eerike, M.D., Vijaya Prasanna Parimi, M.D., D.M., Anand Pyati, M.D., Ph.D., Raja Sundaramurthy, M.D., Varadharajan Sakthivadivel, M.D., Aswini Bramarambika Pidugu, Pharm.D., Bhavana Surapareddy, M.D., Naga Tejaswini Ramineni, M.D., Rekha Priyadarshini, M.D., Parag Parshuram Patil, M.D.. J Rheum Dis 2024;31:15-24. https://doi.org/10.4078/jrd.2023.0054

Background Molnupiravir is an oral antiviral drug that received Emergency Use Authorization in three countries for the treatment of mild COVID-19. The aim of this systematic review was to find out the safety and efficacy of Molnupiravir in SARS-COV-2 infections. Methods The electronic databases such as PubMed, MedRxiv, BioRxiv, FDA, ClinicalTrials.Gov, ctri.nic.in and Google Scholar were searched for articles from January 2021 to March 2022 using the keywords such as “Molnupiravir”, “COVID-19”, “Oral antiviral pill”, “MK-4482”, “EIDD-280”, “Efficacy” and “Safety”. Details of published, unpublished with interim reports and ongoing studies of Molnupiravir in COVID-19 were retrieved, and a systematic review was performed. Results A total of 6 articles and 18 ongoing trials data were collected. Out of these, data from 4 published and 2 unpublished with interim reports were extracted. After review of these studies, it was observed that the daily dose of 1600 mg Molnupiravir for 5 days was safe and tolerable with nausea, diarrhea and headache as the common adverse effects. The results also showed significant decrease in time to viral clearance with 800 mg twice daily in mild patients and reduction in the risk of hospitalization or death by 50% in non-hospitalized COVID-19 patients. Conclusion Evidence from clinical studies showed that Molnupiravir caused significant reduction in the risk of hospitalization or death in high-risk mild COVID-19 patients. Molnupiravir was also found to be well tolerated and safe without any major adverse events on short-term use. For confirmative use of this drug in mild-to-moderate COVID-19 disease, further studies are required in vaccinated COVID-19 patients and against emerging variants.

Monoclonal antibodies (mAbs) as alternatives or more often as complementary to the conventional antimicrobials have been developed for the management of infectious conditions for the past two decades. These pharmacotherapeutic strategies are inevitable as the burden of antimicrobial resistance is far-reaching in recent times. MAbs are part of the targeted pharmacotherapy armamentarium with a high degree of specificity - hence, exert comparatively superior efficacy and tolerability than the conventional polyclonal antisera. So far, only five mAbs have been approved for the management of infectious states, since the marketing authorization (1998) given to palivizumab (Synagis®) for the prophylaxis of lower respiratory tract disease caused by a respiratory syncytial virus in pediatric patients. Ibalizumab-uiyk (Trogarzo™) used for the management of multidrug-resistant HIV-1 infection not yielding to at least 10 antiretroviral drugs, was approved recently. Among the three antibacterial mAbs, raxibacumab (ABthrax®/ Anthrin®) and obiltoxaximab (Anthim®) are indicated for the treatment and prophylaxis of inhalation anthrax due to Bacillus anthracis; bezlotoxumab (Zinplava®) is used to reduce the recurrence of Clostridium difficile infection. There are also around 30 and 15 mAbs in different phases of development for viral and bacterial conditions. As alternatives to the traditional antivirals and antibacterials, the antimicrobial mAbs are the need of the hour. These mAbs are more relevant to the management of conditions like emerging viral outbreaks wherein there is a lack of prophylactic vaccines. The current cutting-edge engineering technologies revolutionizing the production of mAbs include phagedisplayed antibody libraries, cloning from single-memory B cells or single-antibody-secreting plasma B cells, proteomics-directed cloning of mAbs from serum clubbed with high-throughput sequencing techniques. Yet, the cost of manufacture continues to be the main limiting factor. In this review, the different therapeutic monoclonal antibodies directed against the microbial pathogens are discussed.