1
|
Wei X, Zhao G, Jia Z, Zhao Z, Chen N, Sun Y, Kelso M, Rathore G, Wang D. Macromolecular Dexamethasone Prodrug Ameliorates Neuroinflammation and Prevents Bone Loss Associated with Traumatic Brain Injury. Mol Pharm 2022; 19:4000-4009. [PMID: 36042532 PMCID: PMC9643620 DOI: 10.1021/acs.molpharmaceut.2c00482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Traumatic brain injury (TBI) is one of the leading causes of death and disability among children and young adults in the United States. In this manuscript, we assessed the utility of an N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer-based dexamethasone (Dex) prodrug (P-Dex) in the treatment of TBI. Using a controlled cortical impact TBI mouse model, P-Dex was found to passively target and sustain at the traumatic/inflammatory brain tissue for over 14 days after systemic administration. The histological evidence supports P-Dex's therapeutic potential in ameliorating neuroinflammation and mitigating neurodegeneration. Behaviorally, the P-Dex-treated animals showed statistically significant improvement in balance recovery. A trend of neurological severity score improvement at the early time point post-TBI was also noted but did not achieve statistical significance. While probing the potential glucocorticoid side effects that may associate with P-Dex treatment, we discovered that the TBI mice develop osteopenia. Interestingly, the P-Dex-treated TBI mice demonstrated higher bone mineral density and better bone microarchitecture parameters when compared to free Dex and the saline control, revealing the osteoprotective effect of P-Dex in addition to its neuronal protection benefits post-TBI.
Collapse
Affiliation(s)
- Xin Wei
- Department of Pharmaceutical Sciences
| | - Gang Zhao
- Department of Pharmaceutical Sciences
| | | | | | | | | | | | - Geetanjali Rathore
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, 68198, USA
- Children’s Hospital & Medical Center, Omaha, NE, 68114, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences
| |
Collapse
|
2
|
Zhao Z, Jiang H, Xu X, Jia Z, Ren R, Foster KW, Wei X, Chen N, Goldring SR, Crow MK, Wang D. Polymeric dexamethasone prodrugs attenuate lupus nephritis in MRL/lpr mice with reduced glucocorticoid toxicity. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2022; 44:102579. [PMID: 35768036 PMCID: PMC9427713 DOI: 10.1016/j.nano.2022.102579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/10/2022] [Accepted: 06/14/2022] [Indexed: 06/15/2023]
Abstract
Due to their potent immunosuppressive and anti-inflammatory effects, glucocorticoids (GCs) are the most widely used medications in treating lupus nephritis (LN). Long-term use of GCs, however, is associated with numerous off-target adverse effects. To reduce GCs' adverse effects, we previously developed two polymeric dexamethasone prodrug nanomedicines: N-(2-hydroxypropyl) methacrylamide (HPMA) copolymer-based dexamethasone prodrug (P-Dex), and micelle-forming polyethylene glycol (PEG)-based dexamethasone prodrug (ZSJ-0228). Both P-Dex and ZSJ-0228 provided sustained amelioration of LN in lupus-prone NZB/W F1 mice with reduced GC-associated adverse effects. Here, we have extended our investigation to the MRL/lpr mouse model of LN. Compared to dose equivalent daily dexamethasone sodium phosphate (Dex) treatment, monthly P-Dex or ZSJ-0228 treatments were more effective in reducing proteinuria and extending the lifespan of MRL/lpr mice. Unlike the daily Dex treatment, ZSJ-0228 was not associated with measurable GC-associated adverse effects. In contrast, adrenal gland atrophy was observed in P-Dex treated mice.
Collapse
Affiliation(s)
- Zhifeng Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA
| | - Haochen Jiang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA
| | - Xiaoke Xu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA
| | - Zhenshan Jia
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA
| | - Rongguo Ren
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA
| | - Kirk W Foster
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, NE 68198-5900, USA
| | - Xin Wei
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA
| | - Ningrong Chen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA
| | | | - Mary K Crow
- Hospital for Special Surgery, New York, NY 10021, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6125, USA.
| |
Collapse
|
3
|
Zhao G, Ren R, Wei X, Jia Z, Chen N, Sun Y, Zhao Z, Lele SM, Zhong HA, Goldring MB, Goldring SR, Wang D. Thermoresponsive polymeric dexamethasone prodrug for arthritis pain. J Control Release 2021; 339:484-497. [PMID: 34653564 PMCID: PMC8599655 DOI: 10.1016/j.jconrel.2021.10.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 12/13/2022]
Abstract
Intra-articular (IA) glucocorticoids (GC) are commonly used for clinical management of both osteoarthritis and rheumatoid arthritis, but their efficacy is limited by the relatively short duration of action and associated side effects. To provide sustained efficacy and to improve the safety of GCs, we previously developed a N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer-based dexamethasone (Dex) prodrug. Serendipitously, we discovered that, by increasing the Dex content of the prodrug to unusually high levels, the aqueous solution of the polymeric prodrug becomes thermoresponsive, transitioning from a free-flowing liquid at 4 °C to a hydrogel at 30 °C or greater. Upon IA injection, the prodrug solution forms a hydrogel (ProGel-Dex) that is retained in the joint for more than 1 month, where it undergoes gradual dissolution, releasing the water-soluble polymeric prodrug. The released prodrug is swiftly internalized and intracellularly processed by phagocytic synoviocytes to release free Dex, resulting in sustained amelioration of joint inflammation and pain in rodent models of inflammatory arthritis and osteoarthritis. The low molecular weight (6.8 kDa) of the ProGel-Dex ensures rapid renal clearance once it escapes the joint, limiting systemic GC exposure and risk of potential off-target side effects. The present study illustrates the translational potential of ProGel-Dex as a potent opioid-sparing, locally delivered adjuvant analgesic for sustained clinical management of arthritis pain and inflammation. Importantly, the observed thermoresponsive properties of the prodrug establishes ProGel as a platform technology for the local delivery of a broad spectrum of therapeutic agents to treat a diverse array of pathological conditions.
Collapse
Affiliation(s)
- Gang Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA; Ensign Pharmaceutical, Inc., Omaha, NE 68106, USA
| | - Rongguo Ren
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Xin Wei
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Zhenshan Jia
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Ningrong Chen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Yuanyuan Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Zhifeng Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Subodh M Lele
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, NE 68198-5900, USA
| | - Haizhen A Zhong
- Department of Chemistry, University of Nebraska at Omaha, Omaha, NE 68182, USA
| | | | - Steven R Goldring
- Ensign Pharmaceutical, Inc., Omaha, NE 68106, USA; Hospital for Special Surgery, New York, NY 10021, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198, USA; Ensign Pharmaceutical, Inc., Omaha, NE 68106, USA; Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE 68198, USA.
| |
Collapse
|
4
|
Zhao Z, Jia Z, Foster KW, Wei X, Qiao F, Jiang H, Jin Y, Li G, Chen N, Zhao G, Thiele GM, Medlin JL, O'Dell JR, Wang D. Dexamethasone prodrug nanomedicine (ZSJ-0228) treatment significantly reduces lupus nephritis in mice without measurable side effects - A 5-month study. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2020; 31:102302. [PMID: 32980548 DOI: 10.1016/j.nano.2020.102302] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022]
Abstract
Lupus nephritis (LN) is a major cause of morbidity and mortality among systemic lupus erythematosus patients. Glucocorticoids (GCs) are uniformly used in clinical LN management. Their notorious toxicities, however, have hampered the long-term clinical application. To circumvent GC side effects while maintaining their potent therapeutic efficacy, we have developed a macromolecular prodrug nanomedicine based on dexamethasone (ZSJ-0228). The focus of this study was to investigate its long-term efficacy and, most importantly, safety in the lupus-prone NZB/W F1 mouse. Monthly ZSJ-0228 treatment for five months significantly reduced the incidence of nephritis in NZB/W F1 mice with an improved survival rate. In contrast to treatment with dose equivalent daily free dexamethasone, long-term monthly ZSJ-0228 did not result in any measurable GC-associated side effects. With its outstanding efficacy and exceptional safety, it is anticipated that ZSJ-0228 may be a novel therapy for long-term clinical management of LN.
Collapse
Affiliation(s)
- Zhifeng Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Zhenshan Jia
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Kirk W Foster
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Xin Wei
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Fangfang Qiao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Haochen Jiang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Yan Jin
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Guojuan Li
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Ningrong Chen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Gang Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
| | - Geoffrey M Thiele
- Division of Rheumatology and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE; Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jennifer L Medlin
- Division of Rheumatology and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - James R O'Dell
- Division of Rheumatology and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE; Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE.
| |
Collapse
|
5
|
Kopeček J, Yang J. Polymer nanomedicines. Adv Drug Deliv Rev 2020; 156:40-64. [PMID: 32735811 PMCID: PMC7736172 DOI: 10.1016/j.addr.2020.07.020] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022]
Abstract
Polymer nanomedicines (macromolecular therapeutics, polymer-drug conjugates, drug-free macromolecular therapeutics) are a group of biologically active compounds that are characterized by their large molecular weight. This review focuses on bioconjugates of water-soluble macromolecules with low molecular weight drugs and selected proteins. After analyzing the design principles, different structures of polymer carriers are discussed followed by the examination of the efficacy of the conjugates in animal models and challenges for their translation into the clinic. Two innovative directions in macromolecular therapeutics that depend on receptor crosslinking are highlighted: a) Combination chemotherapy of backbone degradable polymer-drug conjugates with immune checkpoint blockade by multivalent polymer peptide antagonists; and b) Drug-free macromolecular therapeutics, a new paradigm in drug delivery.
Collapse
Affiliation(s)
- Jindřich Kopeček
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112, USA; Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA.
| | - Jiyuan Yang
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112, USA
| |
Collapse
|
6
|
Wei X, Zhao G, Wang X, Gautam N, Jia Z, Zhao Z, Kong D, Zhang F, Kumar S, Sun Y, Chen N, Wang X, Yang L, Ren R, Thiele GM, Bronich TK, O'Dell JR, Alnouti Y, Wang D. Head-to-head comparative pharmacokinetic and biodistribution (PK/BD) study of two dexamethasone prodrug nanomedicines on lupus-prone NZB/WF1 mice. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2020; 29:102266. [PMID: 32679269 DOI: 10.1016/j.nano.2020.102266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 01/27/2023]
Abstract
HPMA copolymer-based dexamethasone prodrug (P-Dex) and PEG-based dexamethasone prodrug (PEG-Dex, ZSJ-0228) were previously found to passively target the inflamed kidney and provide potent and sustained resolution of nephritis in NZB/WF1 lupus-prone mice. While both prodrug nanomedicines effectively ameliorate lupus nephritis, they have demonstrated distinctively different safety profiles. To explore the underlining mechanisms of these differences, we conducted a head-to-head comparative PK/BD study of P-Dex and PEG-Dex on NZB/WF1 mice. Overall, the systemic organ/tissue exposures to P-Dex and Dex released from P-Dex were found to be significantly higher than those of PEG-Dex. The high prodrug concentrations were sustained in kidney for only 24 h, which cannot explain their lasting therapeutic efficacy (>1 month). P-Dex showed sustained presence in liver, spleen and adrenal gland, while the presence of PEG-Dex in these organs was transient. This difference in PK/BD profiles may explain PEG-Dex' superior safety than P-Dex.
Collapse
Affiliation(s)
- Xin Wei
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Gang Zhao
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Xiaobei Wang
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nagsen Gautam
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Zhenshan Jia
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Zhifeng Zhao
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dexuan Kong
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Fan Zhang
- Department of Pharmacy Practice and Science, College of Pharmacy, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sushil Kumar
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Yuanyuan Sun
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ningrong Chen
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Xiaoyan Wang
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Libin Yang
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Rongguo Ren
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Geoffrey M Thiele
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Tatiana K Bronich
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - James R O'Dell
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Yazen Alnouti
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| |
Collapse
|
7
|
Structural optimization of HPMA copolymer-based dexamethasone prodrug for improved treatment of inflammatory arthritis. J Control Release 2020; 324:560-573. [PMID: 32445658 DOI: 10.1016/j.jconrel.2020.05.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 12/12/2022]
Abstract
Despite their notorious adverse effects, glucocorticoids (GC, potent anti-inflammatory drugs) are used extensively in clinical management of rheumatoid arthritis (RA) and other chronic inflammatory diseases. To achieve a sustained therapeutic efficacy and reduced toxicities, macromolecular GC prodrugs have been developed with promising outcomes for the treatment of RA. Fine-tuning the activation kinetics of these prodrugs may further improve their therapeutic efficacy and minimize the off-target adverse effects. To assess the feasibility of this strategy, five different dexamethasone (Dex, a potent GC)-containing monomers with distinctively different linker chemistries were designed, synthesized, and copolymerized with N-(2-hydroxypropyl) methacrylamide (HPMA) to obtain 5 macromolecular Dex prodrugs. Their Dex releasing rates were analyzed in vitro and shown to display a wide spectrum of activation kinetics. Their therapeutic efficacy and preliminary toxicology profiles were assessed and compared in vivo in an adjuvant-induced arthritis (AA) rat model in order to identify the ideal prodrug design for the most effective and safe treatment of inflammatory arthritis. The in vivo data demonstrated that the C3 hydrazone linker-containing prodrug design was the most effective in preserving joint structural integrity. The results from this study suggest that the design and screening of different activation mechanisms may help to identify macromolecular prodrugs with the most potent therapeutic efficacy and safety for the management of inflammatory arthritis.
Collapse
|
8
|
Weber L, Wang X, Ren R, Wei X, Zhao G, Yang J, Yuan H, Pang H, Wang H, Wang D. The Development of a Macromolecular Analgesic for Arthritic Pain. Mol Pharm 2019; 16:1234-1244. [PMID: 30702897 PMCID: PMC6413733 DOI: 10.1021/acs.molpharmaceut.8b01197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The addictive potential of clinically used opioids as a result of their direct action on the dopaminergic reward system in the brain has limited their application. In an attempt to reduce negative side effects as well as to improve the overall effectiveness of these analgesics, we have designed, synthesized, and evaluated an N-(2-hydroxypropyl)methacrylamide (HPMA)-based macromolecular prodrug of hydromorphone (HMP), a commonly used opioid. To this end, P-HMP was synthesized via RAFT polymerization and a subsequent polymer analogous reaction. Its interaction with inflammatory cells in arthritic joints was evaluated in vitro using a RAW 264.7 cell culture, and subsequent confocal microscopy analysis confirmed that P-HMP could be internalized by the cells via endocytosis. In vivo imaging studies indicated that the prodrug can passively target the arthritic joint after systemic administration in a rodent model of monoarticular adjuvant-induced arthritis (MAA). The inflammatory pain-alleviating properties of the prodrug were assessed in MAA rats using the incapacitance test and were observed to be similar to dose-equivalent HMP. Analgesia through mechanisms at the spinal cord level was further measured using the tail flick test, and it was determined that the prodrug significantly reduced spinal cord analgesia versus free HMP, further validating the peripheral restriction of the macromolecular prodrug. Immunohistochemical analysis of cellular uptake of the P-HMP within the MAA knee joint proved the internalization of the prodrug by phagocytic synoviocytes, colocalized with HMP's target receptor as well as with pain-modulating ion channels. Therefore, it can be concluded that the novel inflammation-targeting polymeric prodrug of HMP (P-HMP) has the potential to be developed as an effective and safe analgesic agent for musculoskeletal pain.
Collapse
Affiliation(s)
- Laura Weber
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Xiaobei Wang
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Rungguo Ren
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Xin Wei
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Gang Zhao
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Junxiao Yang
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Hongjiang Yuan
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Huiling Pang
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Hanjun Wang
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| |
Collapse
|
9
|
Jia Z, Wang X, Wei X, Zhao G, Foster KW, Qiu F, Gao Y, Yuan F, Yu F, Thiele GM, Bronich TK, O’Dell JR, Wang D. Micelle-Forming Dexamethasone Prodrug Attenuates Nephritis in Lupus-Prone Mice without Apparent Glucocorticoid Side Effects. ACS NANO 2018; 12:7663-7681. [PMID: 29965725 PMCID: PMC6117746 DOI: 10.1021/acsnano.8b01249] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/02/2018] [Indexed: 05/27/2023]
Abstract
Nephritis is one of the major complications of systemic lupus erythematosus. While glucocorticoids (GCs) are frequently used as the first-line treatment for lupus nephritis (LN), long-term GC usage is often complicated by severe adverse effects. To address this challenge, we have developed a polyethylene glycol-based macromolecular prodrug (ZSJ-0228) of dexamethasone, which self-assembles into micelles in aqueous media. When compared to the dose equivalent daily dexamethasone 21-phosphate disodium (Dex) treatment, monthly intravenous administration of ZSJ-0228 for two months significantly improved the survival of lupus-prone NZB/W F1 mice and was much more effective in normalizing proteinuria, with clear histological evidence of nephritis resolution. Different from the dose equivalent daily Dex treatment, monthly ZSJ-0228 administration has no impact on the serum anti-double-stranded DNA (anti-dsDNA) antibody level but can significantly reduce renal immune complex deposition. No significant systemic toxicities of GCs ( e. g., total IgG reduction, adrenal gland atrophy, and osteopenia) were found to be associated with ZSJ-0228 treatment. In vivo imaging and flow cytometry studies revealed that the fluorescent-labeled ZSJ-0228 primarily distributed to the inflamed kidney after systemic administration, with renal myeloid cells and proximal tubular epithelial cells mainly responsible for its kidney retention. Collectively, these data suggest that the ZSJ-0228's potent local anti-inflammatory/immunosuppressive effects and improved safety may be attributed to its nephrotropicity and cellular sequestration at the inflamed kidney tissues. Pending further optimization, it may be developed into an effective and safe therapy for improved clinical management of LN.
Collapse
Affiliation(s)
- Zhenshan Jia
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Xiaobei Wang
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Xin Wei
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Gang Zhao
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Kirk W. Foster
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Fang Qiu
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Yangyang Gao
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Fang Yuan
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Fang Yu
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Geoffrey M. Thiele
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Tatiana K. Bronich
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - James R. O’Dell
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| | - Dong Wang
- Department
of Pharmaceutical Sciences, College of Pharmacy, Department of Pathology
and Microbiology, College of Medicine, Department of Biostatistics, College
of Public Health, and Division of Rheumatology, Department of Internal
Medicine, College of Medicine, University
of Nebraska Medical Center, Omaha, Nebraska 68198-6125, United States
| |
Collapse
|
10
|
Wei X, Wu J, Zhao G, Galdamez J, Lele SM, Wang X, Liu Y, Soni DM, Purdue PE, Mikuls TR, Goldring SR, Wang D. Development of a Janus Kinase Inhibitor Prodrug for the Treatment of Rheumatoid Arthritis. Mol Pharm 2018; 15:3456-3467. [PMID: 29966420 DOI: 10.1021/acs.molpharmaceut.8b00433] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
While highly efficacious in treating rheumatoid arthritis (RA), the approved Janus kinase (JAK) inhibitor, Tofacitinib (Tofa, CP-690 550), has dose-dependent toxicities that limit its clinical application. In this study, we have examined whether a prodrug design that targets arthritic joints would enhance Tofa's therapeutic efficacy, which may provide an opportunity for future development of safer Tofa dosing regimens. A prodrug of Tofa (P-Tofa) was synthesized by conjugating the drug to the N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer via an acid cleavable carbamate linker. The therapeutic efficacy of a single dose of P-Tofa was compared to the dose-equivalent daily oral administration of Tofa in an adjuvant-induced arthritis (AA) rat model. Saline treated AA rats and age-matched healthy rats were used as controls. Observational analyses support the superior and sustained efficacy of a single dose P-Tofa treatment compared to the dose-equivalent daily Tofa administration in ameliorating joint inflammation. Micro-CT and histological analyses demonstrated that the P-Tofa treatment provided a structural preservation of the joints better than that of the dose-equivalent Tofa. Optical imaging, immunohistochemistry, and fluorescence-activated cell sorting analyses attribute P-Tofa's superior therapeutic efficacy to its passive targeting to arthritic joints and inflammatory cell-mediated sequestration. In vitro cell culture studies reveal that the P-Tofa treatment produced sustained the inhibition of JAK/STAT6 signaling in IL-4-treated murine bone marrow macrophages, consistent with a gradual subcellular release of Tofa. Collectively, a HPMA-based nanoscale prodrug of P-Tofa has the potential to enhance the therapeutic efficacy and widen the therapeutic window of Tofa therapy in RA.
Collapse
Affiliation(s)
- Xin Wei
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| | - Jianbo Wu
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| | - Gang Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| | - Josselyn Galdamez
- Hospital for Special Surgery , New York , New York 10021 , United States
| | - Subodh M Lele
- Department of Pathology and Microbiology, College of Medicine , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| | - Xiaoyan Wang
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| | - Yanzhi Liu
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| | - Dhruvkumar M Soni
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| | - P Edward Purdue
- Hospital for Special Surgery , New York , New York 10021 , United States
| | - Ted R Mikuls
- Division of Rheumatology, Department of Internal Medicine, College of Medicine , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States.,Veterans Affairs Nebraska-Western Iowa Health Care System , Omaha , Nebraska 68105 , United States
| | - Steven R Goldring
- Hospital for Special Surgery , New York , New York 10021 , United States
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Nebraska Medical Center , Omaha , Nebraska 68198 , United States
| |
Collapse
|
11
|
Xiao C, Zhou Q, Li X, Li H, Zhong Y, Meng T, Zhu M, Sun H, Liu S, Tang R, Pu J, Xu Y, Xiao P. Losartan and Dexamethasone may inhibit chemotaxis to reduce the infiltration of Th22 cells in IgA nephropathy. Int Immunopharmacol 2017; 42:203-208. [PMID: 27930971 DOI: 10.1016/j.intimp.2016.11.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 11/19/2016] [Accepted: 11/21/2016] [Indexed: 11/30/2022]
Abstract
Angiotensin II is considered a major profibrotic factor that is involved in tissue remodeling processes, as the inhibition of Angiotensin II can halt renal inflammatory processes. Dexamethasone, an important anti-inflammatory and immunosuppressive agent, has been widely used to treat renal disease for decades. In this study, we explored the frequency of Th22 cells in a mouse model of IgA nephropathy and compared the possible effects of Losartan and Dexamethasone on Th22 cells. The experiments were performed using 6-week-old BALB/c female mice in an established IgA nephropathy model. The mice were randomly separated into 4 groups, which were administered Losartan (30mg/kg/d) or Dexamethasone (10mg/kg/d) and subjected to IgA nephropathy or the normal control treatment for 1month. The frequency of Th22 cells was measured via flow cytometry, and the relative pathological changes in renal morphology were measured with different pathological staining methods. Immunohistochemistry was performed to verify the expression of CCR10 and CCL27, which is specialized receptor on Th22 cells and its corresponding chemokine, respectively. The concentrations of CCL27 and IL-22 in renal tissue homogenates and sera were detected using ELISAs. Losartan and Dexamethasone differentially decreased the frequency of Th22 cells after 1month, and mesangial cell proliferation was also improved. Moreover, the expression of CCR10, CCL27 and IL-22 was reduced by treatment with either drug. However, significant differences between Losartan and Dexamethasone were not observed. Based on these findings, Losartan and Dexamethasone may suppress inflammatory responses by inhibiting the chemotaxis of Th22 cells in IgA nephropathy.
Collapse
Affiliation(s)
- Chenggen Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Qiaoling Zhou
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Xiaozhao Li
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Hui Li
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Yong Zhong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Mengyuan Zhu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Hong Sun
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Shuang Liu
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Rong Tang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Jiaxi Pu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Yan Xu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Ping Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China.
| |
Collapse
|
12
|
Yoachim SD, Nuxoll JS, Bynoté KK, Gould KA. Estrogen receptor alpha signaling promotes Sle1-induced loss of tolerance and immune cell activation and is responsible for sex bias in B6.Sle1 congenic mice. Clin Immunol 2015; 158:153-66. [PMID: 25862391 DOI: 10.1016/j.clim.2015.03.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 03/19/2015] [Accepted: 03/30/2015] [Indexed: 12/18/2022]
Abstract
Sex bias in lupus incidence is thought to be due, in part, to the ability of estrogens to promote loss of tolerance. Previously, we showed that estrogens promote lupus via estrogen receptor α (ERα). C57BL/6 (B6) mice carrying the Sle1 lupus susceptibility locus (B6.Sle1) display loss of tolerance and develop anti-nuclear antibodies and immune cell hyperactivation. The incidence of loss of tolerance in B6.Sle1 females is greater than in males. Here, we show that a deficiency of either estrogens or ERα attenuates loss of tolerance and autoantibody development in B6.Sle1 females. Furthermore, we demonstrate that immune cell activation in B6.Sle1 mice shows sex bias and that ERα deficiency diminishes this phenotype in B6.Sle1 females. Thus, estrogens, acting via ERα, control sex bias in the Sle1 phenotype. Furthermore, we show that ERα may impact the Sle1 phenotype by modulating the expression of Pbx1, one of genes that underlies the Sle1 locus.
Collapse
Affiliation(s)
- Shayla D Yoachim
- Department of Genetics, Cell Biology & Anatomy, University of Nebraska Medical Center, 985805 Nebraska Medical Center, Omaha, NE 68198-5805, USA
| | - Jenny S Nuxoll
- Department of Genetics, Cell Biology & Anatomy, University of Nebraska Medical Center, 985805 Nebraska Medical Center, Omaha, NE 68198-5805, USA
| | - Kimberly K Bynoté
- Department of Genetics, Cell Biology & Anatomy, University of Nebraska Medical Center, 985805 Nebraska Medical Center, Omaha, NE 68198-5805, USA
| | - Karen A Gould
- Department of Genetics, Cell Biology & Anatomy, University of Nebraska Medical Center, 985805 Nebraska Medical Center, Omaha, NE 68198-5805, USA.
| |
Collapse
|
13
|
Shirai T, Hilhorst M, Harrison DG, Goronzy JJ, Weyand CM. Macrophages in vascular inflammation--From atherosclerosis to vasculitis. Autoimmunity 2015; 48:139-51. [PMID: 25811915 DOI: 10.3109/08916934.2015.1027815] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The spectrum of vascular inflammatory disease ranges from atherosclerosis and hypertension, widespread conditions affecting large proportions of the population, to the vasculitides, rare syndromes leading to fast and irreversible organ failure. Atherosclerosis progresses over decades, inevitably proceeding through multiple phases of disease and causes its major complications when the vessel wall lesion ruptures, giving rise to lumen-occlusive atherothrombosis. Vasculitides of medium and large arteries progress rapidly, causing tissue ischemia through lumen-occlusive intimal hyperplasia. In both disease entities, macrophages play a decisive role in pathogenesis, but function in the context of other immune cells that direct their differentiation and their functional commitments. In atherosclerosis, macrophages are involved in the removal of lipids and tissue debris and make a critical contribution to tissue damage and wall remodeling. In several of the vasculitides, macrophages contribute to granuloma formation, a microstructural platform optimizing macrophage-T-cell interactions, antigen containment and inflammatory amplification. By virtue of their versatility and plasticity, macrophages are able to promote a series of pathogenic functions, ranging from the release of cytokines and enzymes, the production of reactive oxygen species, presentation of antigen and secretion of tissue remodeling factors. However, as short-lived cells that lack memory, macrophages are also amendable to reprogramming, making them promising targets for anti-inflammatory interventions.
Collapse
Affiliation(s)
- Tsuyoshi Shirai
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA and
| | | | | | | | | |
Collapse
|
14
|
Ding Y, Yang H, Xiang W, He X, Liao W, Yi Z. CD200R1 agonist attenuates LPS-induced inflammatory response in human renal proximal tubular epithelial cells by regulating TLR4-MyD88-TAK1-mediated NF-κB and MAPK pathway. Biochem Biophys Res Commun 2015; 460:287-94. [PMID: 25791482 DOI: 10.1016/j.bbrc.2015.03.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/06/2015] [Indexed: 01/13/2023]
Abstract
Previous studies have revealed the anti-inflammatory effect of CD200Fc, an agonist of CD200R1 in autoimmune disease. However, little is known about its anti-inflammatory effects in kidney diseases. The aim of this study is to assess the function of CD200Fc in regulating lipopolysaccharide (LPS)-induced inflammatory response in human renal proximal tubular epithelial cells (hRPTECs) and the possible mechanisms. LPS reduced the CD200R1 expression in hRPTECs, and this effect was attenuated by CD200Fc in a dose-dependent manner. In addition, CD200Fc inhibited LPS-induced expressions of TLR4 and its adapter molecule (MyD88 and phosphorylation of TAK1), and abolished its interactions with MyD88 or TAK1 in hRPTECs cells. CD200Fc also attenuated LPS-induced phosphorylation of IκB, NF-κB-P65 translocation to nucleus, and increased phosphorylation of ERK1/2, p38 and JNK in hRPTECs. Moreover, CD200Fc suppressed the LPS-induced release of pro-inflammatory mediators in hRPTECs, including IL-1β, IL-6, IL-8, MCP-1, VCAM-1, ICAM-1, TNF-α, INF-α and INF-γ. Our results suggested that CD200Fc could inhibit the TLR4-mediated inflammatory response in LPS-induced hRPTECs, thus might be beneficial for the treatment of renal disease, such as lupus nephritis.
Collapse
Affiliation(s)
- Yan Ding
- Department of Dermatology, Maternal and Child Health Care Hospital of Hainan Province, Haikou 570206, China; Department of Cardiology, Hainan General Hospital, Haikou 570102, China
| | - Huilan Yang
- Department of Dermatology, General Hospital of Guangzhou Military Command of PLA, Southern Medical University, Guangzhou 510010, China.
| | - Wei Xiang
- Department of Dermatology, Maternal and Child Health Care Hospital of Hainan Province, Haikou 570206, China.
| | - Xiaojie He
- Department of Nephropathy, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha 410000, China
| | - Wang Liao
- Department of Cardiology, Hainan General Hospital, Haikou 570102, China
| | - Zhuwen Yi
- Department of Nephropathy, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha 410000, China
| |
Collapse
|
15
|
Kahlenberg JM, Kaplan MJ. Reply. Arthritis Rheumatol 2014; 66:2311-2. [DOI: 10.1002/art.38677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Mariana J. Kaplan
- National Institute of Arthritis and Musculoskeletal and Skin Disorders, NIH; Bethesda MD
| |
Collapse
|