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A case of hypersensitivity to soluble and isophane insulins but not to insulin glargine Mahesh N. Belhekar, Sarayu Pai, Parimal Tayade1, Pradip Dalwadi1, Renuka Munshi, Prema Varthakavi1
ABSTRACT
Departments of Clinical Pharmacology and 1Endocrinology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
Insulin is an important agent for the treatment of diabetes mellitus (DM). Allergic reactions to insulin therapy, although rare, have been evident since animal insulin became available for the treatment of DM in 1922. Hypersensitivity to insulin has considerably been reduced with the introduction of human insulin produced by recombinant deoxyribonucleic acid technology. Here, we present a case of Type 2 DM who demonstrated immediate (Type 1) hypersensitivity reaction on the sites of subcutaneous injection of soluble and isophane insulin but insulin glargine was tolerated well and provided good glycemic control.
Received: 05-06-2014 Revised: 18-01-2015 Accepted: 11-02-2015 Correspondence to: Dr. Renuka Munshi, E-mail: [email protected]
KEY WORDS: Allergic reaction, diabetes mellitus, hypersensitivity, insulin
Introduction Insulin has been used for the treatment of diabetes mellitus (DM) since 1920. Earlier bovine and porcine insulin were available for human use. Allergic reactions to these types of insulin were frequent due to the differences in the amino acid sequences with human insulin.[1] At present, the prevalence of allergic reactions to insulin appears to be approximately 2% and less than one-third of these events have been considered related to the insulin itself. These reactions occur mainly due to the other substances present in the insulin preparation like additives and preservatives, including zinc, protamine and solvents such as meta-cresol, glycerol, phenol, sodium phosphate, etc.[2,3] The clinical presentation of insulin allergic reactions may differ from minor local symptoms to a severe generalized allergic reaction. These reactions can be Type I or immunoglobulin E (IgE) mediated, Type III or arthus and Type IV or delayed-type hypersensitivity reactions. Type I reactions are the most common and can, rarely, cause anaphylaxis.[2,3] We present here a case where a patient, who developed an immediate hypersensitivity reaction to short and Access this article online Website: www.ijp-online.com DOI: 10.4103/0253-7613.153438
Quick Response Code:
intermediate-acting insulin, but not to the long-acting form. Similar cases have been reported previously in Japanese and American[4,5] patients but this is probably the first case to be reported in Indian patients. Case Report A 41-year-old patient diagnosed with Type 2 DM in 2012, was admitted in the general surgery ward for complaints of pain in right lower limb since 1-week. She had a history of claudicating pain in the same limb associated with tingling and numbness since last 2 months. The patient had undergone left below knee amputation in 2007 due to acute arterial thrombosis. At that time, she was found to be allergic to pentoxyfylline and amoxicillin. In 2012, she was advised tablet metformin for the control of hyperglycemia, which she took for 1-year and thereafter had stopped. Other concomitant medications prescribed were; tablet atorvastatin 10 mg daily, tablet enalapril 2.5 mg daily, tablet glimepiride 4 mg daily, tablet aspirin 150 mg daily, tablet cilostazol 50 mg daily and tablet multivitamin B complex (single tablet twice daily). She did not give any family history of diabetes, allergic or autoimmune diseases. The color Doppler of her right lower limb was suggestive of severe aorto-arteritis/right femoral vein thrombosis. On investigation, the patient was found to have high fasting (304 mg/dL; normal 80–110 mg/dL) and postprandial (410 mg/dL; normal up to 140 mg/dL) blood glucose. She was therefore advised to take subcutaneous injections of short-acting insulin (Actrapid [soluble insulin, Novo Nordisk, strength: 40 IU/mL]) the dose being 10 U each in the Indian Journal of Pharmacology | April 2015 | Vol 47 | Issue 2 227
Belhekar, et al.: Hypersensitivity to soluble and isophane insulin
morning, afternoon and before dinner and intermediate-acting insulin (Wosulin N [Isophane Insulin, Wockhardt, strength: 40 IU/mL]) the dose being 12 U in the morning and 8 U at bedtime. The patient developed immediate hypersensitivity reaction to both these insulin preparations. The reaction started as erythema, rashes and itching all over the body immediately after insulin injections. She developed itching all over the body followed by erythema (redness). The next dose of insulin was administered under the supervision of the medical physician in order to ensure the correct method of administration however she developed reaction again. She was then given a different brand of soluble insulin but there was a recurrence of the reaction. Thus there is evidence of positive dechallenge and rechallenge, hence the causality can be certain as per WHO-UMC causality assessment scale. On local examination, we found erythematous rashes all over the body, especially on thigh, abdomen and forearm. The symptoms subsided after administration of injection pheniramine and topical application of calamine and liquid paraffin lotion. To maintain glycemic control, 2 days after admission, the patient was given long-acting, insulin glargine (single dose 30 U at night) (Basalog [insulin glargine, Biocon, strength: 100 IU/ mL]) and she did not develop any hypersensitivity reaction. She tolerated the long-acting form well even when the dose was increased to 10 U in the morning and 30 U at night. She was also advised to take tablet voglibose 0.9 mg daily and achieved adequate glycemic control. The long-acting, insulin glargine was well tolerated and was also effective in achieving glycemic control. Serum IgE was found 368 IU/ml (reference value in adults: up to 200 IU/ml). However, her insulin antibody test was found negative (observed value 2.34 U/ml; biological reference interval: 18 U/ml positive). Solid phase antinuclear antibodies (ANA) estimation was carried out and was found to be negative. The hypersensitivity to soluble insulin and isophane insulin developed immediately after the administration of the injection. Thus there is a temporal relationship between administration of the short acting insulin and hypersensitivity. The patient tolerated insulin glargine even when given daily for glycemic control. In this case temporality between administration of short acting and intermediate acting insulin and development of hypersensitivity reaction was evident and after stopping these two insulin preparations hypersensitivity reaction disappeared. Intradermal test with increasing doses of antigen (insulin) however was not attempted as the patient had vascular complications and had history of hypersensitivity to other drugs, amoxicillin and pentoxyfylline. Discussion Though true insulin allergy is rare, allergic reaction to various components of the insulin preparations is more common.[3] Various additives such as meta-cresol, zinc or protamine, included in commercial insulin preparations, may be the responsible allergens and this possibility was not excluded in the present case.[6] The insulin allergy may be explained by presence of plenty of antigen presenting Langerhans cells in 228 Indian Journal of Pharmacology | April 2015 | Vol 47 | Issue 2
the epidermis which may augment presentation of antigenic components of the human insulin such as meta-cresol and phenol, which acting as haptens can mediate a localized immune response.[7] Insulin glargine is favored due to its long half-life and low risk of hypoglycemic events. Insulin glargine is a clear solution having pH of 4. The long-acting form of insulin releases monomers slowly and hence does not elicit an immune response. It was ensured that the subcutaneous dose of insulin was injected appropriately to rule out any reaction due to incorrect dosing.[8] In addition, the epitopes of human insulin A-chain and animal insulin (AlaB30) has been modified in insulin glargine. The tolerance of insulin glargine appeared to suppress the allergy to human regular insulin.[9] The present case showed that, among several insulin preparations, short-acting and inter mediate-acting insulin caused the hypersensitivity reactions, while long-acting insulin did not. Similar patients have been described in the literature.[4] Moreover, a review of the summary of product characteristics of various insulins used for this patient revealed similar additives in the three different forms. Hence, we hypothesize that the hypersensitivity is due to the human insulin per se rather than the additives. There are very few reports documenting hypersensitivity to pentoxyfylline and is mostly IgE mediated Type 1 reaction.[10] As this patient was a known case of hypersensitivity to penicillin and pentoxyfylline, there must be circulating IgE antibodies to these drugs, which may have cross-reacted with soluble and Isophane insulin, but not with insulin glargine. On investigation for IgE antibodies, we found an increase in IgE antibodies in this patient. However, the test for antibodies to insulin was negative reinforcing the fact that the patient was hypersensitive to the drug product (formulation) and not drug substance per se Insulin glargine injection by virtue of its crystalline nature may have affected antigen presentation to the antibodies present on the surface of mast cells which elicit a Type 1 hypersensitivity reaction. Similar cases of hypersensitivity have been dealt with by using Insulin aspart and lispro.[5] These findings corroborate the allergenic potential of short-acting and long-acting insulin analogs of earlier studies.[11] Limitations We could not test whether this patient was intra dermal test positive to human insulin or to any of the additives. References 1. 2. 3. 4. 5. 6.
Lamkin N, Lieberman P, Hashimoto K, Morohashi M, Sullivan P. Clinical conference: Allergic reactions to insulin. J Allergy Clin Immunol 1976;58:213-23. Ghazavi MK, Johnston GA. Insulin allergy. Clin Dermatol 2011;29:300-5. Heinzerling L, Raile K, Rochlitz H, Zuberbier T, Worm M. Insulin allergy: Clinical manifestations and management strategies. Allergy 2008;63:148-55. Adachi A, Fukunaga A, Horikawa T. A case of human insulin allergy induced by short-acting and intermediate-acting insulin but not by long-acting insulin. Int J Dermatol 2004;43:597-9. Kara C, Kutlu AO, Evliyaoglu O, Bilgili H, Yildirim N. Successful treatment of insulin allergy in a 1-year-old infant with neonatal diabetes by lispro and glargine insulin. Diabetes Care 2005;28:983-4. Pföhler C, Müller CS, Hasselmann DO, Tilgen W. Successful desensitization with human insulin in a patient with an insulin allergy and hypersensitivity to protamine: A case report. J Med Case Rep 2008;2:283.
Belhekar, et al.: Hypersensitivity to soluble and isophane insulin
7.
Cumberbatch M, Dearman RJ, Griffiths CE, Kimber I. Epidermal Langerhans cell migration and sensitisation to chemical allergens. APMIS 2003;111:797-804. 8. Gonzalo MA, De Argila D, Revenga F, García JM, Díaz J, Morales F. Cutaneous allergy to human (recombinant DNA) insulin. Allergy 1998;53:106-7. 9. Tian J, Lehmann PV, Kaufman DL. Determinant spreading of T helper cell 2 (Th2) responses to pancreatic islet autoantigens. J Exp Med 1997;186:2039-43. 10. Gonzalez-Mahave I, Del Pozo MD, Blasco A, Lobera T, Venturini M. Urticaria due to pentoxyfylline. Allergy 2005;60:705.
11. Caruso C, Alonzi C, Gaeta F, Viola M, Romano A. Same-patient allergy to ampicillin and human insulin. Allergy 2009;64:1105-7. Cite this article as: Belhekar MN, Pai S, Tayade P, Dalwadi P, Munshi R, Varthakavi P. A case of hypersensitivity to soluble and isophane insulins but not to insulin glargine. Indian J Pharmacol 2015;47:227-9. Source of Support: Nil. Conflict of Interest: No.
FORM IV Statement of ownership and other particulars about the publication, Indian Journal of Pharmacology as per Rule 8 1. Place of publication
:
M/S Medknow Publications and Media Pvt. Ltd, B9, Kanara Business Center, Off Link Road, Ghatkopar (East), Mumbai – 400075, India
2. Periodicity of its publication
:
Bimonthly (January, March, May, July, September and November)
3. Printer’s Name Nationality (a) Whether a citizen of India? (b) If a foreigner, the country of origin Address
: :
Mr. Hemant Rameshchandra Manjrekar Indian Yes NA B9, Kanara Business Center, Off Link Road, Ghatkopar (East), Mumbai – 400075, India
4. Publisher’s Name Nationality (a) Whether a citizen of India? (b) If a foreigner, the country of origin Address
: :
5. Editor’s Name Nationality (a) Whether a citizen of India? (b) If a foreigner, the country of origin
: :
Dr. Chetna Desai Indian Yes NA
:
Chief Editor, Indian Journal of Pharmacology, Department of Pharmacology, B. J. Medical College, Ahmedabad – 380016, India E-mail: [email protected] Indian Pharmacological Society
Address
6. Names and addresses of individuals who own the newspaper and partners or shareholders holding More than one per cent of the total capital.
:
:
:
Mr. Hemant Rameshchandra Manjrekar Indian Yes NA B9, Kanara Business Center, Off Link Road, Ghatkopar (East), Mumbai – 400075, India
I, Mr. Hemant Rameshchandra Manjrekar, hereby declare that the particulars given above are true to the best of my knowledge and belief. Date: 10th March 2015
[Publisher's Signature]
Indian Journal of Pharmacology | April 2015 | Vol 47 | Issue 2 229
Copyright of Indian Journal of Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A case of hypersensitivity to soluble and isophane insulins but not to insulin glargine Mahesh N. Belhekar, Sarayu Pai, Parimal Tayade1, Pradip Dalwadi1, Renuka Munshi, Prema Varthakavi1
ABSTRACT
Departments of Clinical Pharmacology and 1Endocrinology, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India
Insulin is an important agent for the treatment of diabetes mellitus (DM). Allergic reactions to insulin therapy, although rare, have been evident since animal insulin became available for the treatment of DM in 1922. Hypersensitivity to insulin has considerably been reduced with the introduction of human insulin produced by recombinant deoxyribonucleic acid technology. Here, we present a case of Type 2 DM who demonstrated immediate (Type 1) hypersensitivity reaction on the sites of subcutaneous injection of soluble and isophane insulin but insulin glargine was tolerated well and provided good glycemic control.
Received: 05-06-2014 Revised: 18-01-2015 Accepted: 11-02-2015 Correspondence to: Dr. Renuka Munshi, E-mail: [email protected]
KEY WORDS: Allergic reaction, diabetes mellitus, hypersensitivity, insulin
Introduction Insulin has been used for the treatment of diabetes mellitus (DM) since 1920. Earlier bovine and porcine insulin were available for human use. Allergic reactions to these types of insulin were frequent due to the differences in the amino acid sequences with human insulin.[1] At present, the prevalence of allergic reactions to insulin appears to be approximately 2% and less than one-third of these events have been considered related to the insulin itself. These reactions occur mainly due to the other substances present in the insulin preparation like additives and preservatives, including zinc, protamine and solvents such as meta-cresol, glycerol, phenol, sodium phosphate, etc.[2,3] The clinical presentation of insulin allergic reactions may differ from minor local symptoms to a severe generalized allergic reaction. These reactions can be Type I or immunoglobulin E (IgE) mediated, Type III or arthus and Type IV or delayed-type hypersensitivity reactions. Type I reactions are the most common and can, rarely, cause anaphylaxis.[2,3] We present here a case where a patient, who developed an immediate hypersensitivity reaction to short and Access this article online Website: www.ijp-online.com DOI: 10.4103/0253-7613.153438
Quick Response Code:
intermediate-acting insulin, but not to the long-acting form. Similar cases have been reported previously in Japanese and American[4,5] patients but this is probably the first case to be reported in Indian patients. Case Report A 41-year-old patient diagnosed with Type 2 DM in 2012, was admitted in the general surgery ward for complaints of pain in right lower limb since 1-week. She had a history of claudicating pain in the same limb associated with tingling and numbness since last 2 months. The patient had undergone left below knee amputation in 2007 due to acute arterial thrombosis. At that time, she was found to be allergic to pentoxyfylline and amoxicillin. In 2012, she was advised tablet metformin for the control of hyperglycemia, which she took for 1-year and thereafter had stopped. Other concomitant medications prescribed were; tablet atorvastatin 10 mg daily, tablet enalapril 2.5 mg daily, tablet glimepiride 4 mg daily, tablet aspirin 150 mg daily, tablet cilostazol 50 mg daily and tablet multivitamin B complex (single tablet twice daily). She did not give any family history of diabetes, allergic or autoimmune diseases. The color Doppler of her right lower limb was suggestive of severe aorto-arteritis/right femoral vein thrombosis. On investigation, the patient was found to have high fasting (304 mg/dL; normal 80–110 mg/dL) and postprandial (410 mg/dL; normal up to 140 mg/dL) blood glucose. She was therefore advised to take subcutaneous injections of short-acting insulin (Actrapid [soluble insulin, Novo Nordisk, strength: 40 IU/mL]) the dose being 10 U each in the Indian Journal of Pharmacology | April 2015 | Vol 47 | Issue 2 227
Belhekar, et al.: Hypersensitivity to soluble and isophane insulin
morning, afternoon and before dinner and intermediate-acting insulin (Wosulin N [Isophane Insulin, Wockhardt, strength: 40 IU/mL]) the dose being 12 U in the morning and 8 U at bedtime. The patient developed immediate hypersensitivity reaction to both these insulin preparations. The reaction started as erythema, rashes and itching all over the body immediately after insulin injections. She developed itching all over the body followed by erythema (redness). The next dose of insulin was administered under the supervision of the medical physician in order to ensure the correct method of administration however she developed reaction again. She was then given a different brand of soluble insulin but there was a recurrence of the reaction. Thus there is evidence of positive dechallenge and rechallenge, hence the causality can be certain as per WHO-UMC causality assessment scale. On local examination, we found erythematous rashes all over the body, especially on thigh, abdomen and forearm. The symptoms subsided after administration of injection pheniramine and topical application of calamine and liquid paraffin lotion. To maintain glycemic control, 2 days after admission, the patient was given long-acting, insulin glargine (single dose 30 U at night) (Basalog [insulin glargine, Biocon, strength: 100 IU/ mL]) and she did not develop any hypersensitivity reaction. She tolerated the long-acting form well even when the dose was increased to 10 U in the morning and 30 U at night. She was also advised to take tablet voglibose 0.9 mg daily and achieved adequate glycemic control. The long-acting, insulin glargine was well tolerated and was also effective in achieving glycemic control. Serum IgE was found 368 IU/ml (reference value in adults: up to 200 IU/ml). However, her insulin antibody test was found negative (observed value 2.34 U/ml; biological reference interval: 18 U/ml positive). Solid phase antinuclear antibodies (ANA) estimation was carried out and was found to be negative. The hypersensitivity to soluble insulin and isophane insulin developed immediately after the administration of the injection. Thus there is a temporal relationship between administration of the short acting insulin and hypersensitivity. The patient tolerated insulin glargine even when given daily for glycemic control. In this case temporality between administration of short acting and intermediate acting insulin and development of hypersensitivity reaction was evident and after stopping these two insulin preparations hypersensitivity reaction disappeared. Intradermal test with increasing doses of antigen (insulin) however was not attempted as the patient had vascular complications and had history of hypersensitivity to other drugs, amoxicillin and pentoxyfylline. Discussion Though true insulin allergy is rare, allergic reaction to various components of the insulin preparations is more common.[3] Various additives such as meta-cresol, zinc or protamine, included in commercial insulin preparations, may be the responsible allergens and this possibility was not excluded in the present case.[6] The insulin allergy may be explained by presence of plenty of antigen presenting Langerhans cells in 228 Indian Journal of Pharmacology | April 2015 | Vol 47 | Issue 2
the epidermis which may augment presentation of antigenic components of the human insulin such as meta-cresol and phenol, which acting as haptens can mediate a localized immune response.[7] Insulin glargine is favored due to its long half-life and low risk of hypoglycemic events. Insulin glargine is a clear solution having pH of 4. The long-acting form of insulin releases monomers slowly and hence does not elicit an immune response. It was ensured that the subcutaneous dose of insulin was injected appropriately to rule out any reaction due to incorrect dosing.[8] In addition, the epitopes of human insulin A-chain and animal insulin (AlaB30) has been modified in insulin glargine. The tolerance of insulin glargine appeared to suppress the allergy to human regular insulin.[9] The present case showed that, among several insulin preparations, short-acting and inter mediate-acting insulin caused the hypersensitivity reactions, while long-acting insulin did not. Similar patients have been described in the literature.[4] Moreover, a review of the summary of product characteristics of various insulins used for this patient revealed similar additives in the three different forms. Hence, we hypothesize that the hypersensitivity is due to the human insulin per se rather than the additives. There are very few reports documenting hypersensitivity to pentoxyfylline and is mostly IgE mediated Type 1 reaction.[10] As this patient was a known case of hypersensitivity to penicillin and pentoxyfylline, there must be circulating IgE antibodies to these drugs, which may have cross-reacted with soluble and Isophane insulin, but not with insulin glargine. On investigation for IgE antibodies, we found an increase in IgE antibodies in this patient. However, the test for antibodies to insulin was negative reinforcing the fact that the patient was hypersensitive to the drug product (formulation) and not drug substance per se Insulin glargine injection by virtue of its crystalline nature may have affected antigen presentation to the antibodies present on the surface of mast cells which elicit a Type 1 hypersensitivity reaction. Similar cases of hypersensitivity have been dealt with by using Insulin aspart and lispro.[5] These findings corroborate the allergenic potential of short-acting and long-acting insulin analogs of earlier studies.[11] Limitations We could not test whether this patient was intra dermal test positive to human insulin or to any of the additives. References 1. 2. 3. 4. 5. 6.
Lamkin N, Lieberman P, Hashimoto K, Morohashi M, Sullivan P. Clinical conference: Allergic reactions to insulin. J Allergy Clin Immunol 1976;58:213-23. Ghazavi MK, Johnston GA. Insulin allergy. Clin Dermatol 2011;29:300-5. Heinzerling L, Raile K, Rochlitz H, Zuberbier T, Worm M. Insulin allergy: Clinical manifestations and management strategies. Allergy 2008;63:148-55. Adachi A, Fukunaga A, Horikawa T. A case of human insulin allergy induced by short-acting and intermediate-acting insulin but not by long-acting insulin. Int J Dermatol 2004;43:597-9. Kara C, Kutlu AO, Evliyaoglu O, Bilgili H, Yildirim N. Successful treatment of insulin allergy in a 1-year-old infant with neonatal diabetes by lispro and glargine insulin. Diabetes Care 2005;28:983-4. Pföhler C, Müller CS, Hasselmann DO, Tilgen W. Successful desensitization with human insulin in a patient with an insulin allergy and hypersensitivity to protamine: A case report. J Med Case Rep 2008;2:283.
Belhekar, et al.: Hypersensitivity to soluble and isophane insulin
7.
Cumberbatch M, Dearman RJ, Griffiths CE, Kimber I. Epidermal Langerhans cell migration and sensitisation to chemical allergens. APMIS 2003;111:797-804. 8. Gonzalo MA, De Argila D, Revenga F, García JM, Díaz J, Morales F. Cutaneous allergy to human (recombinant DNA) insulin. Allergy 1998;53:106-7. 9. Tian J, Lehmann PV, Kaufman DL. Determinant spreading of T helper cell 2 (Th2) responses to pancreatic islet autoantigens. J Exp Med 1997;186:2039-43. 10. Gonzalez-Mahave I, Del Pozo MD, Blasco A, Lobera T, Venturini M. Urticaria due to pentoxyfylline. Allergy 2005;60:705.
11. Caruso C, Alonzi C, Gaeta F, Viola M, Romano A. Same-patient allergy to ampicillin and human insulin. Allergy 2009;64:1105-7. Cite this article as: Belhekar MN, Pai S, Tayade P, Dalwadi P, Munshi R, Varthakavi P. A case of hypersensitivity to soluble and isophane insulins but not to insulin glargine. Indian J Pharmacol 2015;47:227-9. Source of Support: Nil. Conflict of Interest: No.
FORM IV Statement of ownership and other particulars about the publication, Indian Journal of Pharmacology as per Rule 8 1. Place of publication
:
M/S Medknow Publications and Media Pvt. Ltd, B9, Kanara Business Center, Off Link Road, Ghatkopar (East), Mumbai – 400075, India
2. Periodicity of its publication
:
Bimonthly (January, March, May, July, September and November)
3. Printer’s Name Nationality (a) Whether a citizen of India? (b) If a foreigner, the country of origin Address
: :
Mr. Hemant Rameshchandra Manjrekar Indian Yes NA B9, Kanara Business Center, Off Link Road, Ghatkopar (East), Mumbai – 400075, India
4. Publisher’s Name Nationality (a) Whether a citizen of India? (b) If a foreigner, the country of origin Address
: :
5. Editor’s Name Nationality (a) Whether a citizen of India? (b) If a foreigner, the country of origin
: :
Dr. Chetna Desai Indian Yes NA
:
Chief Editor, Indian Journal of Pharmacology, Department of Pharmacology, B. J. Medical College, Ahmedabad – 380016, India E-mail: [email protected] Indian Pharmacological Society
Address
6. Names and addresses of individuals who own the newspaper and partners or shareholders holding More than one per cent of the total capital.
:
:
:
Mr. Hemant Rameshchandra Manjrekar Indian Yes NA B9, Kanara Business Center, Off Link Road, Ghatkopar (East), Mumbai – 400075, India
I, Mr. Hemant Rameshchandra Manjrekar, hereby declare that the particulars given above are true to the best of my knowledge and belief. Date: 10th March 2015
[Publisher's Signature]
Indian Journal of Pharmacology | April 2015 | Vol 47 | Issue 2 229
Copyright of Indian Journal of Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
