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Deitelzweig S, Bergrath E, di Fusco M, Kang A, Savone M, Cappelleri JC, Russ C, Betts M, Cichewicz A, Schaible K, Tarpey J, Fahrbach K. Real-world evidence comparing oral anticoagulants in non-valvular atrial fibrillation: a systematic review and network meta-analysis. Future Cardiol 2022; 18:393-405. [PMID: 35360925 DOI: 10.2217/fca-2021-0120] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare real-world effectiveness/safety of non-vitamin K antagonist oral anticoagulants and vitamin K antagonists among patients with non-valvular atrial fibrillation. Materials & methods: A systematic review of electronic databases yielded 7661 citations published from January 2013 to January 2020. Fifty-five studies were included in Bayesian network meta-analyses of hazard ratios. Results & conclusion: In comparison with vitamin K antagonists, apixaban, dabigatran and rivaroxaban were associated with a reduced risk of stroke or systemic embolism, ischemic stroke, intracranial hemorrhage and all-cause mortality. Apixaban, dabigatran and edoxaban, but not rivaroxaban, were associated with a reduced risk of major bleeding. This study confirmed the effectiveness and safety of non-vitamin K antagonist oral anticoagulants for the treatment of non-valvular atrial fibrillation in real-world settings, consistent with clinical trial evidence.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Health System, Department of Hospital Medicine, New Orleans, LA 70121, USA
| | - Evelien Bergrath
- Regeneron Pharmaceuticals, Inc., Health Economics and Outcomes Research, Tarrytown, NY 10591, USA
| | - Manuela di Fusco
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Amiee Kang
- Bristol Myers Squibb Company, Health Economics and Outcomes Research, Lawrenceville, NJ 08648, USA
| | - Mirko Savone
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Joseph C Cappelleri
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Cristina Russ
- Pfizer, Inc., Health Economics and Outcomes Research, New York, NY 10017, USA
| | - Marissa Betts
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Allie Cichewicz
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Kassandra Schaible
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Jialu Tarpey
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
| | - Kyle Fahrbach
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA 02451, USA
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Jin J, Zhuo X, Xiao M, Jiang Z, Chen L, Devi Shamloll Y. Increased bleeding events with the addition of apixaban to the dual anti-platelet regimen for the treatment of patients with acute coronary syndrome: A meta-analysis. Medicine (Baltimore) 2021; 100:e25185. [PMID: 33761699 PMCID: PMC9282097 DOI: 10.1097/md.0000000000025185] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/24/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Dual anti-platelet therapy (DAPT) with aspirin and clopidogrel has been the mainstay of treatment for patients with acute coronary syndrome (ACS). However, the recurrence of thrombotic events, potential aspirin and clopidogrel hypo-responsiveness, and other limitations of DAPT have led to the development of newer oral anti-thrombotic drugs. Apixaban, a new non-vitamin K antagonist, has been approved for use. In this meta-analysis, we aimed to compare the bleeding outcomes observed with the addition of apixaban to DAPT for the treatment of patients with ACS. METHODS Online databases including EMBASE, Cochrane Central, http://www.ClinicalTrials.gov, MEDLINE and Web of Science were searched for English based publications comparing the use of apixaban added to DAPT for the treatment of patients with ACS. Different categories of bleeding events and cardiovascular outcomes were assessed. The analysis was carried out by the RevMan software version 5.4. Odds ratios (OR) with 95% confidence intervals (CI) were used to represent the data following analysis. RESULTS This research analysis consisted of 4 trials with a total number of 9010 participants. Thrombolysis in myocardial infarction (TIMI) defined major bleeding (OR: 2.45, 95% CI: 1.45-4.12; P = .0008), TIMI defined minor bleeding (OR: 3.12, 95% CI: 1.71-5.70; P = .0002), International society of thrombosis and hemostasis (ISTH) major bleeding (OR: 2.49, 95% CI: 1.80-3.45; P = .00001) and Global Use of Strategies to Open Occluded Arteries (GUSTO) defined severe bleeding (OR: 3.00, 95% CI: 1.56-5.78; P = .01) were significantly increased with the addition of apixaban to DAPT versus DAPT alone in these patients with ACS. However fatal bleeding (OR: 10.96, 95% CI: 0.61-198.3; P = .11) was not significantly different. CONCLUSIONS Addition of the novel oral anticoagulant apixaban to the DAPT regimen significantly increased bleeding and therefore did not show any beneficial effect in these patients with ACS. However, due to the extremely limited data, we apparently have to rely on future larger studies to confirm this hypothesis.
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Affiliation(s)
- Jing Jin
- Department of Cardiology, The Fourth Hospital of Changsha, Changsha, Hunan
| | - Xiaojun Zhuo
- Department of Cardiology, Hospital of Northwestern Polytechnical University, Xi an, Shanxi
| | - Mou Xiao
- Department of Cardiology, The Fourth Hospital of Changsha, Changsha, Hunan
| | - Zhiming Jiang
- Department of Cardiology, The Fourth Hospital of Changsha, Changsha, Hunan
| | - Linlin Chen
- Department of Cardiology, The Fourth Hospital of Changsha, Changsha, Hunan
| | - Yashvina Devi Shamloll
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
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3
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Wei L, Su E, Liu W, Xing W, Liu X, Zhang Y, Wang S, Cheng Q, Qi D, Gao C. Antithrombotic therapy in coronary artery disease patients with atrial fibrillation. BMC Cardiovasc Disord 2020; 20:323. [PMID: 32631244 PMCID: PMC7339421 DOI: 10.1186/s12872-020-01609-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background Coronary artery disease (CAD) and atrial fibrillation (AF) frequently coexist in clinical practice, making it challenging for the treating physician to choose anticoagulation and antiplatelet therapies. The aim of this study was to investigate antithrombotic strategies and assess related adverse outcomes in stable coronary artery disease (SCAD) and acute coronary syndrome (ACS) patients with AF when the CHA2DS2-VASc score was ≥2. Methods We performed a retrospective study and collected data from a computer-based patient record management system in Zhengzhou University People’s Hospital in China. In total, 2978 patients with a hospital discharge diagnosis of CAD and concomitant AF who met the inclusion criteria were enrolled from January 1, 2012 to December 31, 2016, and data from 2050 patients were finally analysed. The χ2 test was used to compare the incidences of clinical endpoints between the SCAD+AF group and the ACS + AF group. Multivariable Cox regression analysis was performed to identify independent predictive factors of adverse outcomes in both groups. Results Oral anticoagulant (OAC) monotherapy was the most common antithrombotic therapy in SCAD+AF patients (49.55%), while double antiplatelet therapy (DAPT) was the most common treatment in ACS + AF patients (54.19%) at discharge. OAC monotherapy significantly increased and the use of single antiplatelet therapy (SAPT) decreased during follow-up (34 ± 13 months) when compared to their use at discharge in the SCAD+AF group (all p < 0.001). In the ACS + AF group, the proportion of patients using DAPT decreased notably, while the proportions of patients using SAPT and dual therapy (DT) combining OAC with SAPT increased significantly during follow-up (all p < 0.001) compared to the proportions at discharge. According to multivariable Cox regression analysis, age, hypertension and prior stroke were independent risk factors for ischaemic stroke in the SCAD+AF group and ACS + AF group (all p < 0.05). OAC was an independent protective factor for ischaemic stroke in both groups (all p < 0.05). Previous bleeding independently increased the risk of haemorrhage in both groups (all p < 0.01). Conclusions In this study, the proportion of anticoagulant-antiplatelet combined therapy was low in ACS + AF patients with high stroke risk. In clinical practice, the awareness of anticoagulation needs to be strengthened regarding patients with CAD and AF.
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Affiliation(s)
- Lili Wei
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Health Management, Henan Provincial People's Hospital, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Enyong Su
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China.,Department of Cardiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Weili Liu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Wenlu Xing
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Xinyun Liu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - You Zhang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Shan Wang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Qianqian Cheng
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Datun Qi
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Chuanyu Gao
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China. .,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China.
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4
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Comparative Effectiveness and Safety of Direct Oral Anticoagulants: Overview of Systematic Reviews. Drug Saf 2019; 42:1409-1422. [DOI: 10.1007/s40264-019-00866-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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5
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Comparative Effectiveness and Safety of Direct Oral Anticoagulants in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis of Observational Studies. Drug Saf 2019; 42:1135-1148. [DOI: 10.1007/s40264-019-00842-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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6
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Li G, Lip GYH, Holbrook A, Chang Y, Larsen TB, Sun X, Tang J, Mbuagbaw L, Witt DM, Crowther M, Thabane L, Levine MAH. Direct comparative effectiveness and safety between non-vitamin K antagonist oral anticoagulants for stroke prevention in nonvalvular atrial fibrillation: a systematic review and meta-analysis of observational studies. Eur J Epidemiol 2018; 34:173-190. [PMID: 29948370 DOI: 10.1007/s10654-018-0415-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 05/25/2018] [Indexed: 02/05/2023]
Abstract
The non-vitamin K antagonist oral anticoagulants (NOACs) have been increasingly prescribed in clinical practice for stroke prevention in patients with nonvalvular atrial fibrillation (AF). Direct comparisons between NOACs in trials are lacking, leaving an important clinical decision-making gap. We aimed to perform a systematic review and meta-analysis to summarize the evidence of observational studies for direct comparative effectiveness and safety amongst NOACs in patients with AF. Conference proceedings and electronic databases including MEDLINE, CINAHL, EMBASE and PUBMED were systematically searched. We included observational studies directly comparing individual NOACs in patients with nonvalvular AF who were aged ≥ 18 years for stroke prevention. Primary outcome included effectiveness outcome (stroke or systemic embolism) and safety outcome (major bleeding). Data were extracted in duplicated by two reviewers independently. A random-effects meta-analysis was conducted to synthesize the data from included observational studies. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to rate the overall quality of evidence for each outcome. Fifteen studies were included for qualitative synthesis, twelve studies for meta-analyses. It was found that rivaroxaban and dabigatran were similar with regard to risk of stroke or systemic embolism (Hazard ratio [HR] = 1.00, 95% CI 0.91-1.10; evidence quality: low), but rivaroxaban was associated with higher risk of major bleeding (HR = 1.39, 95% CI 1.28-1.50; evidence quality: moderate). Compared with apixaban, a significantly higher risk of major bleeding was observed with rivaroxaban (HR = 1.71, 95% CI 1.51-1.94; evidence quality: low). Apixaban was associated with lower risk of major bleeding, in comparison with dabigatran (HR = 0.80, 95% CI 0.68-0.95; evidence quality: low). No differences in risk of stroke or systemic embolism was observed between rivaroxaban versus apixaban, and apixaban versus dabigatran. In this study, apixaban was found to have the most favorable safety profile amongst the three NOACs. No significant difference was observed in risk of stroke or systemic embolism between the NOACs. Such findings may provide some decision-making support for physicians regarding their choices amongst NOACs in patients with AF.Registration PROSPERO (identifier: CRD42016052908).
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Affiliation(s)
- Guowei Li
- Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong Province, China. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada. .,St. Joseph's Healthcare Hamilton, Hamilton, Canada.
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Torben B Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Cardiovascular Research Centre, Aalborg University Hospital, Aalborg, Denmark
| | - Xin Sun
- Chinese Evidence-based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Tang
- School of Public Health, Guangzhou Medical University, Guangzhou, China
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, USA
| | - Mark Crowther
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mitchell A H Levine
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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7
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Yuan J. Efficacy and safety of adding rivaroxaban to the anti-platelet regimen in patients with coronary artery disease: a systematic review and meta-analysis of randomized controlled trials. BMC Pharmacol Toxicol 2018; 19:19. [PMID: 29720261 PMCID: PMC5932859 DOI: 10.1186/s40360-018-0209-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/23/2018] [Indexed: 01/27/2023] Open
Abstract
Background Rivaroxaban, a direct factor Xa inhibitor, has seldom been used in patients with coronary artery disease. In this analysis, we aimed to systematically compare the efficacy and safety of rivaroxaban in addition to the anti-platelet regimen in patients with coronary artery disease. Methods Online databases (MEDLINE, EMBASE, Cochrane database, www.ClinicalTrials.gov and Google scholar were searched for randomized controlled trials which were exclusively based on patients with coronary artery disease; and which compared efficacy (cardiovascular outcomes) and safety (bleeding outcomes) outcomes with the addition of rivaroxaban to the other anti-platelet agents. Analysis was carried out by the RevMan 5.3 software whereby odds ratios (OR) and 95% confidence intervals (CI) were generated following data input. Results Four trials with a total number of 40,148 patients were included (23,231 participants were treated with rivaroxaban whereas 16,919 participants were treated with placebo) in this analysis. Patients’ enrollment period varied from years 2006 to 2016. The current results showed addition of rivaroxaban to significantly lower composite endpoints (OR: 0.81, 95% CI: 0.74–0.88; P = 0.00001). In addition, all-cause death, cardiac death, myocardial infarction, and stent thrombosis were also significantly reduced (OR: 0.82, 95% CI: 0.72–0.92; P = 0.0009), (OR: 0.80, 95% CI: 0.69–0.92; P = 0.002), (OR: 0.87, 95% CI: 0.77–0.98; P = 0.03) and (OR: 0.73, 95% CI: 0.55–0.97; P = 0.03) respectively. However, stroke was not significantly different. However, TIMI defined minor and major bleeding were significantly higher with rivaroxaban (OR: 2.27, 95% CI: 1.47–3.49; P = 0.0002) and (OR: 3.44, 95% CI: 1.13–10.52; P = 0.03) respectively. In addition, intracranial hemorrhage and bleeding which was defined according to the International Society on Thrombosis and Hemostasis criteria were also significantly higher with rivaroxaban (OR: 1.63, 95% CI: 1.04–2.56; P = 0.03) and (OR: 1.80, 95% CI: 1.45–2.22; P = 0.00001) respectively. Nevertheless, fatal bleeding was not significantly different. Conclusions Addition of rivaroxaban to the anti-platelet regimen was effective in patients with coronary artery disease, but the safety outcomes were doubtful. Further future trials will be able to completely solve this issue.
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Affiliation(s)
- Jun Yuan
- Department of Cardiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, Guangxi, China.
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Zhang X, Hu M, Wei G, Jia M, Gong T, Liu J. An injectable in situ lipid phase transition system for sustained delivery of dabigatran etexilate with low burst release. RSC Adv 2017. [DOI: 10.1039/c7ra10375a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The first report of dabigatran exilate sustained release injection that exhibited great potential in controlling initial burst release.
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Affiliation(s)
- Xuanmiao Zhang
- Department of Biochemistry and Molecular Biology
- West China School of Basic and Forensic Medicine
- Sichuan University
- Chengdu 610041
- China
| | - Mei Hu
- Key Laboratory of Drug Targeting and Drug Delivery Systems
- Ministry of Education
- West China School of Pharmacy
- Sichuan University
- Chengdu 610041
| | - Guangfei Wei
- Key Laboratory of Drug Targeting and Drug Delivery Systems
- Ministry of Education
- West China School of Pharmacy
- Sichuan University
- Chengdu 610041
| | - Mengdi Jia
- Key Laboratory of Drug Targeting and Drug Delivery Systems
- Ministry of Education
- West China School of Pharmacy
- Sichuan University
- Chengdu 610041
| | - Tao Gong
- Key Laboratory of Drug Targeting and Drug Delivery Systems
- Ministry of Education
- West China School of Pharmacy
- Sichuan University
- Chengdu 610041
| | - Ji Liu
- Department of Biochemistry and Molecular Biology
- West China School of Basic and Forensic Medicine
- Sichuan University
- Chengdu 610041
- China
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