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Methotrexate pneumonitis in a patient with Crohn’s disease, during the COVID pandemic: An unusual clinical case and review of the literature. GASTROENTEROLOGÍA Y HEPATOLOGÍA (ENGLISH EDITION) 2021. [PMCID: PMC8016549 DOI: 10.1016/j.gastre.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Methotrexate pneumonitis in a patient with Crohn's disease, during the COVID pandemic: An unusual clinical case and review of the literature. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:302-303. [PMID: 33051049 PMCID: PMC7494316 DOI: 10.1016/j.gastrohep.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/09/2020] [Indexed: 12/02/2022]
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Abstract
Introduction: The management of patients with ulcerative colitis (UC) has evolved over the past few decades. While aminosalicylates remain the mainstay of induction and maintenance therapy in patients with mild-to-moderate UC, the advent of biologic agents and novel oral small molecules has substantively changed the treatment landscape for patients with moderate-to-severe disease and confounded the role of traditional immunomodulators (IMMs) such as thiopurines and methotrexate in the UC management algorithm.Areas covered: We summarize the mechanism of action of thiopurines and methotrexate, identify clinical parameters for their use, and appraise the evidence supporting the efficacy and safety of IMMs in UC as both monotherapy and in combination with other therapies, emphasizing on prospective, controlled data.Expert opinion: With the advent of several classes of highly effective treatments for UC, emergence of data demonstrating no benefit of IMMs over placebo, and concerns about the relative safety profile of long-term IMM exposure, we propose that the role of thiopurines or methotrexate be restricted to patients with milder disease failing to maintain corticosteroid-free remission on aminosalicylates alone or in combination therapy with tumor necrosis factor antagonists in patients with moderate-to-severe UC.
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Affiliation(s)
- Tarun Chhibba
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Robarts Clinical Trials, Inc., London, Ontario, Canada
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Fragoulis GE, Conway R, Nikiphorou E. Methotrexate and interstitial lung disease: controversies and questions. A narrative review of the literature. Rheumatology (Oxford) 2019; 58:1900-1906. [DOI: 10.1093/rheumatology/kez337] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/10/2019] [Indexed: 01/16/2023] Open
Abstract
Abstract
MTX, which is the anchor-drug for the treatment of RA, has been associated with lung injury and in particular with MTX-related pneumonitis (M-pneu). Although the frequency of M-pneu has been reported to range between 0.3 and 11.6%, more recent studies and meta-analyses have challenged that, suggesting that it is less common than previously thought. M-pneu is considered a hypersensitivity reaction usually occuring early after MTX commencement, and to be dose-independent. Furthermore, it does not seem to be truly related to the development of interstitial lung disease observed in some patients as part of the natural history of RA (RA-ILD). On the other hand, there are data suggesting that clinicians should be cautious when commencing MTX in patients with pre-existing lung disease. However, treatment should not be delayed or limited in progressive RA that could lead to RA-ILD, and MTX remains one of the central players in the treat-to-target approach. In this review, we aimed to summarize the current evidence from observational studies and clinical trials on lung disease in MTX-treated RA patients. We focus the discussion on the lack of association between M-pneu and RA-ILD.
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Affiliation(s)
- George E Fragoulis
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Richard Conway
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Elena Nikiphorou
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
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Pudipeddi A, Kariyawasam V, Haifer C, Baraty B, Paramsothy S, Leong RWL. Safety of drugs used for the treatment of Crohn’s disease. Expert Opin Drug Saf 2019; 18:357-367. [PMID: 31026401 DOI: 10.1080/14740338.2019.1612874] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Medications in treating Crohn's disease (CD) have evolved over the last two decades, particularly with the use of biologic agents. There are, however, concerns about the safety and adverse events associated with these medications. The authors review the safety profile of immunosuppressive medications used in Crohn's disease in adult patients. AREAS COVERED The authors performed a literature search until October 2018 to examine safety data on thiopurines, methotrexate, anti-TNFα agents, vedolizumab and ustekinumab. The authors focused on 'trial' and 'real-world' data for the biologic agents. Safety in pregnancy and the elderly are also presented. EXPERT OPINION Available data in CD suggest that immunosuppressive medications are relatively safe, although there are concerns about an elevated risk of serious infections, skin cancer and lymphoma particularly with thiopurines and anti-TNFα agents. Data on vedolizumab and ustekinumab suggest these newer biologic agents are well tolerated; however, longer term data in CD are required to identify risks with extended use. Apart from methotrexate, there appear to be no adverse congenital outcomes with exposure of drugs during pregnancy.
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Affiliation(s)
- Aviv Pudipeddi
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Viraj Kariyawasam
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Craig Haifer
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Brandon Baraty
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Rupert WL Leong
- Department of Gastroenterology and Liver Services, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Faculty of Medicine, UNSW, Sydney, Australia
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Methotrexate Pneumonitis in Crohn's Disease: A Rare Case Report and Review of Literature. Arch Bronconeumol 2018; 54:535-536. [PMID: 29503065 DOI: 10.1016/j.arbres.2018.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/23/2022]
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Cohn HM, Dave M, Loftus EV. Understanding the Cautions and Contraindications of Immunomodulator and Biologic Therapies for Use in Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:1301-1315. [PMID: 28708806 PMCID: PMC5731468 DOI: 10.1097/mib.0000000000001199] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ulcerative colitis and Crohn's disease are chronic inflammatory bowel diseases for which there are no cures. These diseases are immunopathogenic, and medical treatment is centered on the temperance of a dysregulated immune response to allow mucosal healing and prevent the sequelae of fistulation and stenosis. Accordingly, the armamentarium of medications, which has expanded immensely in recent history, is not without significant infectious and neoplastic risks. Many of these untoward effects can be mitigated by screening and avoidance of contraindicated medications. This review seeks to highlight the cautions for use of immunomodulators, anticytokine, and α4-integrin antagonists. The potential adverse events are further complicated by substantial heterogeneity in disease phenotype in the inflammatory bowel disease population. Large patient registries and databases provide considerable experience and knowledge to calculate the incidence of safety outcomes. To identify rarer outcomes after prolonged therapy, more prospective studies and continued adverse event reporting will aid safe application and minimize potential harms.
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Affiliation(s)
- H. Matthew Cohn
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Maneesh Dave
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
- Division of Gastroenterology and Liver Disease, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | - Edward V. Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota Review Article for Inflammatory Bowel Disease Journal
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Gomollón F, Rubio S, Charro M, García-López S, Muñoz F, Gisbert JP, Domènech E. [Reccomendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of methotrexate in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 38:24-30. [PMID: 25454602 DOI: 10.1016/j.gastrohep.2014.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 10/09/2014] [Indexed: 12/17/2022]
Abstract
Methotrexate is an immunosuppressant that may be useful in several clinical scenarios in inflammatory bowel disease. In this article, we review the available evidence in Crohn's disease and ulcerative colitis and establish general recommendations for its use in clinical practice. Although the available data are limited, it is very likely that methotrexate is underused because its effectiveness is underestimated and its toxicity is overestimated. Both in induction therapy and in maintenance of remission, methotrexate is useful in Crohn's disease. When prescribed in combination with biologic agents, immunogenicity is less frequent and consequently long-term response could potentially be improved. There are few published studies, but several data suggest that methotrexate could also be useful in ulcerative colitis. Although myelotoxicity and liver toxicity are well known risks, methotrexate is a drug that is well tolerated in many patients, even in the long term.
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Affiliation(s)
- Fernando Gomollón
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, IIS Aragón, España Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD).
| | - Saioa Rubio
- Servicio de Aparato Digestivo, Hospital de Navarra, PamplonaEspaña
| | - Mara Charro
- Servicio de Aparato Digestivo, Hospital Royo Villanova, Zaragoza España
| | - Santiago García-López
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Fernando Muñoz
- Servicio de Aparato Digestivo, Hospital de León, León España
| | - Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid España, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
| | - Eugeni Domènech
- Servicio de Aparato Digestivo, Hospital Germans Trías i Pujol, Badalona España, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
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Barbisan F, Motta JDR, Trott A, Azzolin V, Dornelles EB, Marcon M, Algarve TD, Duarte MMMF, Mostardeiro CP, Unfer TC, Schott KL, da Cruz IBM. Methotrexate-related response on human peripheral blood mononuclear cells may be modulated by the Ala16Val-SOD2 gene polymorphism. PLoS One 2014; 9:e107299. [PMID: 25330300 PMCID: PMC4203676 DOI: 10.1371/journal.pone.0107299] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 08/01/2014] [Indexed: 01/24/2023] Open
Abstract
Methotrexate (MTX) is a folic acid antagonist used in high doses as an anti-cancer treatment and in low doses for the treatment of some autoimmune diseases. MTX use has been linked to oxidative imbalance, which may cause multi-organ toxicities that can be attenuated by antioxidant supplementation. Despite the oxidative effect of MTX, the influence of antioxidant gene polymorphisms on MTX toxicity is not well studied. Therefore, we analyzed here whether a genetic imbalance of the manganese-dependent superoxide dismutase (SOD2) gene could have some impact on the MTX cytotoxic response. An in vitro study using human peripheral blood mononuclear cells (PBMCs) obtained from carriers with different Ala16Val-SOD2 genotypes (AA, VV and AV) was carried out, and the effect on cell viability and proliferation was analyzed, as well as the effect on oxidative, inflammatory and apoptotic markers. AA-PBMCs that present higher SOD2 efficiencies were more resistance to high MTX doses (10 and 100 µM) than were the VV and AV genotypes. Both lipoperoxidation and ROS levels increased significantly in PBMCs exposed to MTX independent of Ala16Val-SOD2 genotypes, whereas increased protein carbonylation was observed only in PBMCs from V allele carriers. The AA-PBMCs exposed to MTX showed decreasing SOD2 activity, but a concomitant up regulation of the SOD2 gene was observed. A significant increase in glutathione peroxidase (GPX) levels was observed in all PBMCs exposed to MTX. However, this effect was more intense in AA-PBMCs. Caspase-8 and -3 levels were increased in cells exposed to MTX, but the modulation of these genes, as well as that of the Bax and Bcl-2 genes involved in the apoptosis pathway, presented a modulation that was dependent on the SOD2 genotype. MTX at a concentration of 10 µM also increased inflammatory cytokines (IL-1β, IL-6, TNFα and Igγ) and decreased the level of IL-10 anti-inflammatory cytokine, independent of SOD2 genetic background. The results suggest that potential pharmacogenetic effect on the cytotoxic response to MTX due differential redox status of cells carriers different SOD2 genotypes.
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Affiliation(s)
- Fernanda Barbisan
- Pharmacology Graduate Program, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | | | - Alexis Trott
- Laboratory of Molecular Biology, University of Western Santa Catarina, UNOESC, Chapecó, SC, Brazil
| | - Verônica Azzolin
- Pharmacology Graduate Program, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | | | - Matheus Marcon
- Biogenomic Laboratory, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Thaís Doeler Algarve
- Biochemical Toxicology Graduate Program, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | | | | | - Taís Cristina Unfer
- Biogenomic Laboratory, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Karen Lilian Schott
- Biochemical Toxicology Graduate Program, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Ivana Beatrice Mânica da Cruz
- Biogenomic Laboratory, Federal University of Santa Maria, Santa Maria, RS, Brazil
- Pharmacology Graduate Program, Federal University of Santa Maria, Santa Maria, RS, Brazil
- Biochemical Toxicology Graduate Program, Federal University of Santa Maria, Santa Maria, RS, Brazil
- * E-mail:
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Antunes O, Filippi J, Hébuterne X, Peyrin-Biroulet L. Treatment algorithms in Crohn's - up, down or something else? Best Pract Res Clin Gastroenterol 2014; 28:473-83. [PMID: 24913386 DOI: 10.1016/j.bpg.2014.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Crohn's disease is a chronic, progressive and disabling condition. New therapeutic goals have emerged in Crohn's disease such as the need to look beyond symptoms by achieving mucosal healing that is known to be associated with better outcomes. Anti-TNF (Tumour Necrosis Factor) therapy is the most potent drug class to induce and maintain mucosal healing in Crohn's disease. Recent evidence indicates that the efficacy profile of thiopurines has been overestimated while the increased risk of malignancies (lymphoma, non-melanoma skin cancers, myeloid disorders) has been underestimated. Methotrexate is well-tolerated, but its potential for disease modification is unknown. Achieving mucosal healing in patients with early Crohn's disease might be the best way to change disease course and patients' life. In 2014, anti-TNF treatment should be the first-line therapy in patients with Crohn's disease who suffer from severe and/or complicated disease and in those with poor prognostic factors. In the remaining patients, a rapid step-up approach based on a tight monitoring is recommended.
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Affiliation(s)
- Ophélie Antunes
- Department of Hepato-Gastroenterology and Clinical Nutrition, Nice Teaching Hospital (CHU), 06200 Nice, France.
| | - Jérôme Filippi
- Department of Hepato-Gastroenterology and Clinical Nutrition, Nice Teaching Hospital (CHU), 06200 Nice, France.
| | - Xavier Hébuterne
- Department of Hepato-Gastroenterology and Clinical Nutrition, Nice Teaching Hospital (CHU), 06200 Nice, France.
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Université de Lorraine, Vandoeuvre-lès-Nancy, France.
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Strianese D, Iuliano A, Ferrara M, Comune C, Baronissi I, Napolitano P, D'Alessandro A, Grassi P, Bonavolontà G, Bonavolontà P, Sinisi A, Tranfa F. Methotrexate for the treatment of thyroid eye disease. J Ophthalmol 2014; 2014:128903. [PMID: 24678411 PMCID: PMC3941785 DOI: 10.1155/2014/128903] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/30/2013] [Accepted: 11/02/2013] [Indexed: 02/08/2023] Open
Abstract
Background/Aim. To evaluate the efficacy of methotrexate for the treatment of thyroid eye disease (TED). Methods. 36 consecutive patients with active TED, previously treated with corticosteroids but stopped due to the occurrence of side effects, were commenced on methotrexate therapy. Two different weekly doses were administered depending on the weight of the patient (7.5 mg or 10 mg). Clinical activity score (7-CAS), visual acuity (VA), ocular motility, exophthalmos, and eyelid position were retrospectively evaluated at 3, 6, and 12 months and compared with baseline data. Results. There was a statistically significant improvement in 7-CAS at 3, 6, and 12 months after treatment (P < 0.0001). There was no significant change in visual acuity. Ocular motility disturbances improved at 6 and 12 months (P < 0.001). There was no significant change in exophthalmos (mean 24 mm, SD 3 mm) or eyelid position (marginal reflex distance mean 6 mm, SD 1.5 mm) during the follow-up period. No side effects were registered. Conclusions. Methotrexate therapy is effective in reducing CAS and ocular motility disturbances. No significant improvement in proptosis or eyelid retraction should be expected from this treatment. Eventually, it might be considered a suitable alternative treatment in TED for patients who cannot tolerate steroids.
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Affiliation(s)
- Diego Strianese
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Adriana Iuliano
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Mariantonia Ferrara
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Chiara Comune
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Immacolata Baronissi
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Pasquale Napolitano
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Alessia D'Alessandro
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Piergiacomo Grassi
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Giulio Bonavolontà
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Paola Bonavolontà
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
| | - Antonio Sinisi
- Department of Endocrinology, Second University of Naples, Italy
| | - Fausto Tranfa
- Department of Neuroscience, Odontostomatological and Reproductive Sciences, University “Federico II” of Naples, Via Pansini No. 5, 80131 Naples, Italy
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