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Giuliano L, Durante V, Battaglia G, Gasparini S, Zambrelli E, Ermio C, La Neve A, Mostacci B. Sex Differences in Adverse Effects of Antiseizure Medications in Adults with Epilepsy: A Systematic Review. CNS Drugs 2024; 38:409-423. [PMID: 38691320 DOI: 10.1007/s40263-024-01088-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Sex differences in epilepsy have been described in prevalence, seizure propensity and response to treatment. Therefore, taking into account sex-based differences in epilepsy is important for both diagnostic purposes and therapeutic considerations. However, little is known about sex differences in adverse effects of antiseizure medications (ASMs). OBJECTIVES We performed a systematic review searching for sex differences in adverse effects of ASMs in adult persons with epilepsy (PWE) as part of a wider project aimed to assess sex-based differences in efficacy and adverse effects of ASMs in PWE. METHODS We conducted a comprehensive literature search in the PubMed database. The search was conducted with no restriction on publication date, and all results up to April 2020 were included. We included articles written in English, Italian, Spanish, or French that evaluated adverse effects of one or more ASMs in PWE, with specific mention of the two sexes. When appropriate, Newcastle-Ottawa or Jadad scales were used to assess study quality. RESULTS Of 5164 identified studies, only 167 considered sex in the analysis and were therefore included. Significant sex-related differences were found in 58 of those studies. We found a consistently higher frequency of cutaneous adverse effects in females; higher risk of developing general adverse effects on different ASMs in females; stronger risk of adverse effects on bone metabolism in females, mainly on treatment with enzyme-inducing ASMs; a concordant higher risk of visual field loss was noted in males on vigabatrin; an overall worse lipid profile in males; as well as higher leptin levels and higher body mass index in females treated with various ASMs. CONCLUSIONS Our analysis has identified some important sex differences in the adverse effects of ASMs. Clinicians should be aware of these differences when informing patients about the risks associated with ASM treatment in PWE.
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Affiliation(s)
- Loretta Giuliano
- Department of Medical, Surgical Sciences and Advanced Technologies G.F. Ingrassia, Section of Neurosciences, University of Catania, Catania, Italy.
| | - Vania Durante
- Neurology Unit, "A. Perrino" Hospital, Brindisi, Italy
| | - Giulia Battaglia
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
- Regional Epilepsy Center, "Great Metropolitan Hospital", Reggio Calabria, Italy
| | - Elena Zambrelli
- Epilepsy Center, Sleep Medicine Center, Childhood and Adolescence Neuropsychiatry Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Caterina Ermio
- Department of Neuroscience, "S. Giovanni Paolo II" Hospital, Lamezia Terme, Catanzaro, Italy
| | - Angela La Neve
- Department DiBrain, University of Bari "Aldo Moro", Bari, Italy
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy
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Miners JO, Polasek TM, Hulin JA, Rowland A, Meech R. Drug-drug interactions that alter the exposure of glucuronidated drugs: Scope, UDP-glucuronosyltransferase (UGT) enzyme selectivity, mechanisms (inhibition and induction), and clinical significance. Pharmacol Ther 2023:108459. [PMID: 37263383 DOI: 10.1016/j.pharmthera.2023.108459] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Drug-drug interactions (DDIs) arising from the perturbation of drug metabolising enzyme activities represent both a clinical problem and a potential economic loss for the pharmaceutical industry. DDIs involving glucuronidated drugs have historically attracted little attention and there is a perception that interactions are of minor clinical relevance. This review critically examines the scope and aetiology of DDIs that result in altered exposure of glucuronidated drugs. Interaction mechanisms, namely inhibition and induction of UDP-glucuronosyltransferase (UGT) enzymes and the potential interplay with drug transporters, are reviewed in detail, as is the clinical significance of known DDIs. Altered victim drug exposure arising from modulation of UGT enzyme activities is relatively common and, notably, the incidence and importance of UGT induction as a DDI mechanism is greater than generally believed. Numerous DDIs are clinically relevant, resulting in either loss of efficacy or an increased risk of adverse effects, necessitating dose individualisation. Several generalisations relating to the likelihood of DDIs can be drawn from the known substrate and inhibitor selectivities of UGT enzymes, highlighting the importance of comprehensive reaction phenotyping studies at an early stage of drug development. Further, rigorous assessment of the DDI liability of new chemical entities that undergo glucuronidation to a significant extent has been recommended recently by regulatory guidance. Although evidence-based approaches exist for the in vitro characterisation of UGT enzyme inhibition and induction, the availability of drugs considered appropriate for use as 'probe' substrates in clinical DDI studies is limited and this should be research priority.
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Affiliation(s)
- John O Miners
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Thomas M Polasek
- Certara, Princeton, NJ, USA; Centre for Medicines Use and Safety, Monash University, Melbourne, Australia
| | - Julie-Ann Hulin
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Andrew Rowland
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Robyn Meech
- Discipline of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Zanussi JT, Zhao J, Dorn CA, Liu G, Feng Q, Wei W, Mosley JD, Stein CM, Kawai VK. Identifying Potential Therapeutic Applications and Diagnostic Harms of Increased Bilirubin Concentrations: A Clinical and Genetic Approach. Clin Pharmacol Ther 2022; 111:435-443. [PMID: 34625956 PMCID: PMC8748314 DOI: 10.1002/cpt.2441] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/16/2021] [Indexed: 02/03/2023]
Abstract
Bilirubin has antioxidant and anti-inflammatory properties in vitro and in animal studies and protects against inflammatory, cardiovascular, and other diseases in observational studies; therefore, bilirubin has potential as a therapeutic agent. However, observational studies could be confounded by many factors. We used a genetic (n = 61,281) and clinical (n = 234,670) approach to define the association between bilirubin and 19 conditions with a putative protective signal in observational studies. We also tested if individuals with genetically higher bilirubin levels underwent more diagnostic tests. We used a common variant in UGT1A1 (rs6742078) associated with an 26% increase in bilirubin levels in the genetic studies. Carriers of the variant had higher bilirubin levels (P = 2.2 × 10-16 ) but there was no significant association with any of the 19 conditions. In a phenome-wide association study (pheWAS) to seek undiscovered genetic associations, the only significant finding was increased risk of "jaundice-not of newborn." Carriers of the variant allele were more likely to undergo an abdominal ultrasound (odds ratio = 1.04, [1.00-1.08], P = 0.03). In contrast, clinically measured bilirubin levels were significantly associated with 15 of the 19 conditions (P < 0.003) and with 431 clinical diagnoses in the pheWAS (P < 1 × 10-5 adjusted for sex, age, and follow-up). With additional adjustment for smoking and body mass index, 7 of 19 conditions and 260 pheWAS diagnoses remained significantly associated with bilirubin levels. In conclusion, bilirubin does not protect against inflammatory or other diseases using a genetic approach; the many putative beneficial associations reported clinically are likely due to confounding.
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Affiliation(s)
- Jacy T. Zanussi
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Juan Zhao
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Chad A. Dorn
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ge Liu
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - QiPing Feng
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - WeiQi Wei
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jonathan D. Mosley
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - C. Michael Stein
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vivian K. Kawai
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Fisch U, Baumann SM, Semmlack S, Marsch S, Rüegg S, Sutter R. Accuracy of Calculated Free Valproate Levels in Adult Patients With Status Epilepticus. Neurology 2020; 96:e102-e110. [PMID: 33055270 DOI: 10.1212/wnl.0000000000011000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/20/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the accuracy of an equation in adult patients with status epilepticus that calculates the free concentration of serum valproic acid (fVPA) from the total concentration of serum valproic acid (tVPA) and serum albumin. METHODS All adult patients with status epilepticus who were treated at a Swiss academic medical center between 2005 and 2018 with concurrent measurements of tVPA, fVPA, and serum albumin were included. fVPA was categorized as subtherapeutic, therapeutic (5-10 mg/L), or supratherapeutic. Agreement was defined as the proportion of measured and calculated fVPA falling within the same category. RESULTS Of 676 patients with status epilepticus, 104 had 506 measurements, with a median of 3 (interquartile range [IQR] 1.5-6.5) per patient. The median tVPA was 43.5 mg/L (27.4-63.6), with measured fVPA 9.1 mg/L (4.5-14.7) and calculated fVPA 10.1 mg/L (7.0-13.0), respectively. The median deviation of calculated from measured fVPA was -0.8 mg/L (-3.2 to 2.5) with 336 measurements >1 mg/L. While the association between measured and calculated fVPA was linear (regression coefficient 1.1, 95% confidence interval 0.9-1.2, p < 0.0001), the agreement on effective drug levels did not match in 39.8% of measurements regardless of serum albumin levels, with calculated fVPA overestimating measured fVPA in 30.4%. tVPA and serum albumin independently influenced the accuracy of the calculated fVPA in the multivariable model. CONCLUSIONS Calculated fVPA is inaccurate when using the proposed equation in adult patients with status epilepticus, calling for drug monitoring based on measured fVPA in this context.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland.
| | - Sira M Baumann
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
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Factors to influence the accuracy of albumin adjusted free valproic acid concentration. J Formos Med Assoc 2020; 120:1114-1120. [PMID: 32978045 DOI: 10.1016/j.jfma.2020.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is recommended during treatment with valproic acid (VPA), as is the measurement of free VPA concentration (MfVPA). However, MfVPA is unavailable in many institutions. Based on the highly protein-bound characteristics of VPA, an albumin-adjusted formula has been proposed to predict free VPA concentration (PfVPA). Nevertheless, the factors affecting the accuracy of this formula remain unknown, as does the concordance between MfVPA and PfVPA. METHODS Adult patients receiving VPA and undergoing TDM were enrolled. Free and total serum concentration (TVPA) were categorized as subtherapeutic, therapeutic, or supratherapeutic based on the reference range of 5-15 and 50-100 μg/mL, respectively. Concordance was defined as MfVPA and PfVPA, or MfVPA and TVPA, falling within the same category. Multivariate logistic regression with generalized estimating equation was adopted to identify factors affecting concordance, and the receiver operating characteristic curve was applied to determine the cutoff values of predictors. RESULTS A total of 98 data points from 51 participants were included for analysis. The concordance of MfVPA and PfVPA, and MfVPA and TVPA, was 72% and 44%, respectively. Blood urea nitrogen (BUN) (0.97 [0.95-0.99], P = 0.01) and TVPA (0.97 [0.95-0.99], P = 0.02) had a significant influence on the concordance of MfVPA and PfVPA. The cutoff values of TVPA and BUN for the accuracy of the albumin-adjusted formula were 56.4 μg/mL and 51.05 mg/dL, respectively. CONCLUSION If MfVPA is not available, the albumin-adjusted formula should be applied before VPA dosage adjustment when TVPA is < 56.4 μg/mL and BUN is < 51.05 mg/dL.
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Hypoglycemic, antilipidemic and antioxidant effects of valproic acid in alloxan-induced diabetic rats. Eur J Pharmacol 2015; 762:174-83. [DOI: 10.1016/j.ejphar.2015.05.044] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/16/2015] [Accepted: 05/20/2015] [Indexed: 01/04/2023]
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Substantial effect of efavirenz monotherapy on bilirubin levels in healthy volunteers. Curr Ther Res Clin Exp 2014; 76:64-9. [PMID: 25352936 PMCID: PMC4209507 DOI: 10.1016/j.curtheres.2014.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2014] [Indexed: 01/11/2023] Open
Abstract
Background Efavirenz exhibits multiple interactions with drug-metabolizing enzymes and transporters, and for this reason efavirenz-based HIV therapy is associated with altered pharmacokinetics of coadministered drugs. Probably by the same mechanism, efavirenz-based HIV therapy affects the disposition of endogenous compounds, but this effect is difficult to directly link with efavirenz because it is used in combination with other drugs. Objectives To explore the effect of efavirenz monotherapy on biochemical laboratory values in a clinical trial of healthy volunteers. Methods Men and women (aged 18–49 years) with body mass index ≤32 who were assessed to be healthy based on medical history, physical examination, and standard laboratory screening received a single (600 mg) and multiple doses (600 mg/d for 17 days) of efavirenz orally. This trial was designed to determine the pharmacokinetics and drug interactions of efavirenz. As part of this study, analysis of serum chemistries that were measured at study entry (screening) and 1 week after completion of the multiple dose study (exit) is reported. Results Data from 60 subjects who fully completed and 13 subjects who partially completed the study are presented. Total bilirubin was substantially reduced at exit (by ~30%, with large intersubject variability) compared with screening values (P < 0.0001). The percent changes were in part explained by the intersubject differences in baseline total bilirubin because there was a significant correlation between baseline (screening) values and percent change at exit (r = 0.50; P < 0.0001). Hemoglobin and absolute neutropenia were also substantially decreased at exit compared with screening, but this may be due to intensive blood sampling rather than direct effect of efavirenz on these parameters. No significant correlation was found between percent change in hemoglobin versus percent change in bilirubin, indicating the effect of efavirenz on bilirubin is independent of its effects on hemoglobin. Conclusions Efavirenz monotherapy significantly lowers plasma total bilirubin concentration in healthy volunteers independent of its effect on hemoglobin, probably through its effects on bilirubin metabolism and transport (uptake and efflux). These findings help explain reversal by efavirenz of hyperbilirubinemia induction observed by some protease inhibitor antiretroviral drugs (eg, atazanavir). Besides its well-documented role on drug interactions, efavirenz may alter the disposition of endogenous compounds relevant in physiologic homeostasis through its interaction with drug metabolizing enzymes and/or drug transporters. ClinicalTrials.gov identifier: NCT00668395.
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Demircioğlu S, Soylu A, Dirik E. Carbamazepine and valproic acid: effects on the serum lipids and liver functions in children. Pediatr Neurol 2000; 23:142-6. [PMID: 11020639 DOI: 10.1016/s0887-8994(00)00175-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We aimed to determine the effects of carbamazepine, which induces liver microsomal enzymes, and valproic acid on the serum lipids and liver function test results in epileptic children. Thirty-eight epileptic children (18 males, 20 females, mean age 8.6 +/- 3.9 years) were evaluated for serum lipids and liver function test results at the onset and the second and sixth months of antiepileptic therapy. The results of the children receiving carbamazepine (n = 31) and valproic acid (n = 7) were compared. In addition, the values obtained at different periods of treatment were compared within each group. The differences in the serum lipid levels and liver function test results of the children in the carbamazepine group and the valproic acid group were not statistically significant throughout the study. However, the total cholesterol, low-density lipoprotein, total cholesterol/high-density lipoprotein, and gamma glutamyl transferase levels were significantly increased in the carbamazepine group during treatment (P < 0.05) but not in the valproic acid group. Carbamazepine treatment alters the serum lipid profile of the children in such a way that it facilitates the development of atherosclerosis. Valproic acid does not alter the levels of the serum lipids.
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Affiliation(s)
- S Demircioğlu
- Department of Pediatrics, Dokuz Eylül University; Medical Faculty, Izmir, Turkey
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Yu HY, Shen YZ. Effect of valproate on the pharmacokinetics of free and total plasma bilirubin in experimental hyperbilirubinemia in guinea pigs. J Pharm Sci 1998; 87:21-4. [PMID: 9452963 DOI: 10.1021/js970236+] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The effects of valproate (VPA) on free and total bilirubin concentrations in plasma were studied in guinea pigs. Steady-state hyperbilirubinemia (around 2.5-3.0 mg/100 mL) was induced by constant intravenous (i.v.) infusion of bilirubin followed by an i.v. bolus dose of sodium valproate (VPA-Na) of 50 (n = 4) or 200 (n = 5) mg/kg. Steady-state plasma total bilirubin concentration was lowered by 40% and 55% and the unbound fraction (fu) increased by 1.9- and 4.9-fold at the respective doses of 50 mg/kg and 200 mg/kg VPA-Na. Free bilirubin was not significantly changed by 50 mg/kg VPA-Na, but did show a significant transient elevation with the 200 mg/kg dose. In another experiment, guinea pigs (n = 3) were given a constant i.v. infusion of VPA-Na to maintain a steady-state plasma concentration (58 micrograms/mL), followed by an i.v. bolus dose of bilirubin (2 mg/kg). A control study (n = 3) was performed simultaneously using normal saline instead of VPA. Free bilirubin was detectable only following induction of hyperbilirubinemia in either group. A higher volume of distribution and lower elimination rate constant of bilirubin were observed in the VPA-treated than in the control animals. The displacement effect of VPA on bilirubin-plasma binding in vitro was studied by adding serial concentrations of VPA-Na to bilirubin-plasma solution. VPA displaced bilirubin from the high-affinity plasma protein binding site, with a binding constant (KD) of 5.7 x 10(-2)/microM. Similar displacement of bilirubin plasma protein binding was observed in vivo. These results suggest that VPA reduces plasma protein binding and slows the elimination rate of bilirubin. The principal mechanism for decreased plasma concentrations of total bilirubin by administration of VPA is caused by decreased plasma binding, as opposed to metabolic induction.
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Affiliation(s)
- H Y Yu
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, ROC.
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