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van de Wint T, de Vries Schultink AHM, Meinders AJ, Harmsze A, Bruins P. Prolonged coma due to amitriptyline overdose and genetic polymorphism: a case report. J Med Case Rep 2022; 16:112. [PMID: 35296334 PMCID: PMC8925239 DOI: 10.1186/s13256-022-03294-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background Reduced consciousness has a wide variety of possible causes, not infrequently being toxic in nature. An intoxication might be obvious, but in this paper an unexpected case with a tricyclic antidepressant is presented. Case presentation A 76-year-old caucasian female was found unconscious. Primary diagnostic evaluation, including a negative drugs of abuse test, did not give direction to any clear cause. Yet an intraventricular conductive disorder with widening of the QRS complex and electroencephalogram abnormalities did suggest a possible drug effect. Heteroanamnestic information led to the suspicion of an amitriptyline intoxication, which was confirmed by further laboratory analysis. The patient remained comatose for several days. High concentrations of amitriptyline indicated a large overdose of amitriptyline and, in combination with a cytochrome P450 2D6 poor metabolizer status, could explain the long persistence of her comatose state. Conclusion We present a tricyclic antidepressant intoxication, where the patient is thought to have taken a large amount of amitriptyline at once, which, in combination with a cytochrome P450 2D6 poor metabolizer status, led to an unusual long persistence of her coma.
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Affiliation(s)
- Tijs van de Wint
- Department of Anesthesiology, Intensive Care and Pain Management, St. Antonius Hospital, Amsterdam, The Netherlands.
| | | | - Arend Jan Meinders
- Department of Internal Medicine and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ankie Harmsze
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Bruins
- Department of Anesthesiology, Intensive Care and Pain Management, St. Antonius Hospital, Amsterdam, The Netherlands
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2
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de Vries Schultink AHM, Sallevelt BTGM, Meinders AJ, van de Garde EMW, Roescher N. The need for gentamicin adjunctive to cefuroxime as empirical sepsis therapy: a local protocol evaluation. Clin Microbiol Infect 2021; 27:1354-1355. [PMID: 33845206 DOI: 10.1016/j.cmi.2021.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/17/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - Bastiaan T G M Sallevelt
- Department of Clinical Pharmacy, St Antonius Hospital, Utrecht/Nieuwegein, the Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arend Jan Meinders
- Department of Internal Medicine and Intensive Care Unit, St Antonius Hospital, Utrecht/Nieuwegein, the Netherlands
| | - Ewoudt M W van de Garde
- Department of Clinical Pharmacy, St Antonius Hospital, Utrecht/Nieuwegein, the Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.
| | - Nienke Roescher
- Department of Medical Microbiology and Immunology, St. Antonius Hospital, Utrecht/Nieuwegein, the Netherlands
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3
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de Vries Schultink AHM, Crombag MRBS, van Werkhoven E, Otten HM, Bergman AM, Schellens JHM, Huitema ADR, Beijnen JH. Neutropenia and docetaxel exposure in metastatic castration-resistant prostate cancer patients: A meta-analysis and evaluation of a clinical cohort. Cancer Med 2019; 8:1406-1415. [PMID: 30802002 PMCID: PMC6488109 DOI: 10.1002/cam4.2003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/09/2019] [Accepted: 01/13/2019] [Indexed: 12/17/2022] Open
Abstract
The incidence of neutropenia in metastatic castration‐resistant prostate cancer (mCRPC) patients treated with docetaxel has been reported to be lower compared to patients with other solid tumors treated with a similar dose. It is suggested that this is due to increased clearance of docetaxel in mCRPC patients, resulting in decreased exposure. The aims of this study were to (1) determine if exposure in mCRPC patients is lower vs patients with other solid tumors by conducting a meta‐analysis, (2) evaluate the incidence of neutropenia in patients with mCRPC vs other solid tumors in a clinical cohort, and (3) discuss potential clinical consequences. A meta‐analysis was conducted of studies which reported areas under the plasma concentration‐time curves (AUCs) of docetaxel and variability. In addition, grade 3/4 neutropenia was evaluated using logistic regression in a cohort of patients treated with docetaxel. The meta‐analysis included 36 cohorts from 26 trials (n = 1150 patients), and showed that patients with mCRPC had a significantly lower mean AUC vs patients with other solid tumors (fold change [95% confidence interval (CI)]: 1.8 [1.5‐2.2]), with corresponding AUCs of 1.82 and 3.30 mg∙h/L, respectively. Logistic regression, including 812 patient, demonstrated that patients with mCRPC had a 2.2‐fold lower odds of developing grade 3/4 neutropenia compared to patients with other solid tumors (odds ratio [95%CI]: 0.46 [0.31‐0.90]). These findings indicate that mCRPC patients have a lower risk of experiencing severe neutropenia, possibly attributable to lower systemic exposure to docetaxel.
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Affiliation(s)
| | - Marie-Rose B S Crombag
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute & MC Slotervaart, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hans-Martin Otten
- Department of Medical Oncology, MC Slotervaart, Amsterdam, The Netherlands
| | - Andre M Bergman
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan H M Schellens
- Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacology, Division of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute & MC Slotervaart, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute & MC Slotervaart, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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de Vries Schultink AHM, Huitema ADR, Beijnen JH. Therapeutic Drug Monitoring of endoxifen as an alternative for CYP2D6 genotyping in individualizing tamoxifen therapy. Breast 2018; 42:38-40. [PMID: 30153552 DOI: 10.1016/j.breast.2018.08.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/02/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022] Open
Abstract
Different strategies have been proposed to individualize tamoxifen treatment in order to improve recurrence-free survival in estrogen receptor (ER)-positive breast cancer. To date, the debate remains on which strategy should be used. The objective of this viewpoint is to highlight Therapeutic Drug Monitoring of endoxifen, the active tamoxifen metabolite, as the preferred methodology compared to CYP2D6 genotyping for individualizing tamoxifen therapy for ER-positive breast cancer patients treated in the adjuvant setting.
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Affiliation(s)
- Aurelia H M de Vries Schultink
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute and MC Slotervaart, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute and MC Slotervaart, Louwesweg 6, 1066 EC Amsterdam, The Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute and MC Slotervaart, Louwesweg 6, 1066 EC Amsterdam, The Netherlands; Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, P.O. Box 80082, 3508 TB Utrecht, The Netherlands
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de Vries Schultink AHM, Doornbos RP, Bakker ABH, Bol K, Throsby M, Geuijen C, Maussang D, Schellens JHM, Beijnen JH, Huitema ADR. Translational PK-PD modeling analysis of MCLA-128, a HER2/HER3 bispecific monoclonal antibody, to predict clinical efficacious exposure and dose. Invest New Drugs 2018; 36:1006-1015. [PMID: 29728897 PMCID: PMC6244972 DOI: 10.1007/s10637-018-0593-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/19/2018] [Indexed: 01/15/2023]
Abstract
Introduction MCLA-128 is a bispecific monoclonal antibody targeting the HER2 and HER3 receptors. Pharmacokinetics (PK) and pharmacodynamics (PD) of MCLA-128 have been evaluated in preclinical studies in cynomolgus monkeys and mice. The aim of this study was to characterize the PK and PD of MCLA-128 and to predict a safe starting dose and efficacious clinical dose for the First-In-Human study. Methods A PK-PD model was developed based on PK data from cynomolgus monkeys and tumor growth data from a mouse JIMT-1 xenograft model. Allometric scaling was used to scale PK parameters between species. Simulations were performed to predict the safe and efficacious clinical dose, based on AUCs, receptor occupancies and PK-PD model simulations. Results MCLA-128 PK in cynomolgus monkeys was described by a two-compartment model with parallel linear and nonlinear clearance. The xenograft tumor growth model consisted of a tumor compartment with a zero-order growth rate and a first-order dying rate, both affected by MCLA-128. Human doses of 10 to 480 mg q3wk were predicted to show a safety margin of >10-fold compared to the cynomolgus monkey AUC at the no-observed-adverse-effect-level (NOAEL). Doses of ≥360 mg resulted in predicted receptor occupancies above 99% (Cmax and Cave). These doses showed anti-tumor efficacy in the PK-PD model. Conclusions This analysis predicts that a flat dose of 10 to 480 mg q3wk is suitable as starting dose for a First-in-Human study with MCLA-128. Flat doses ≥360 mg q3wk are expected to be efficacious in human, based on receptor occupancies and PK-PD model simulations.
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Affiliation(s)
- Aurelia H M de Vries Schultink
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute and MC Slotervaart, Louwesweg 6, 1066, EC, Amsterdam, the Netherlands.
| | | | | | - Kees Bol
- Merus N.V, Yalelaan 62, 3584, CM, Utrecht, the Netherlands
| | - Mark Throsby
- Merus N.V, Yalelaan 62, 3584, CM, Utrecht, the Netherlands
| | - Cecile Geuijen
- Merus N.V, Yalelaan 62, 3584, CM, Utrecht, the Netherlands
| | - David Maussang
- Merus N.V, Yalelaan 62, 3584, CM, Utrecht, the Netherlands
| | - Jan H M Schellens
- Department of Clinical Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute, P.O Box 90203, 1006, BE, Amsterdam, the Netherlands.,Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, P.O. Box 80082, 3508, TB, Utrecht, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute and MC Slotervaart, Louwesweg 6, 1066, EC, Amsterdam, the Netherlands. .,Science Faculty, Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, P.O. Box 80082, 3508, TB, Utrecht, the Netherlands.
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek - The Netherlands Cancer Institute and MC Slotervaart, Louwesweg 6, 1066, EC, Amsterdam, the Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, the Netherlands
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6
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Bastida C, Ruiz-Esquide V, Pascal M, de Vries Schultink AHM, Yagüe J, Sanmartí R, Huitema ADR, Soy D. Fixed dosing of intravenous tocilizumab in rheumatoid arthritis. Results from a population pharmacokinetic analysis. Br J Clin Pharmacol 2018; 84:716-725. [PMID: 29314183 DOI: 10.1111/bcp.13500] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/17/2017] [Accepted: 12/23/2017] [Indexed: 02/06/2023] Open
Abstract
AIMS Intravenous tocilizumab is currently dosed on body weight, although a weak correlation between body weight and clearance has been described. The aim of the study was to assess the current dosing strategy and provide a scientific rational for dosing using a modelling and simulation approach. METHODS Serum concentrations and covariates were obtained from intravenous tocilizumab treated subjects at a dose of 4, 6 or 8 mg every 28 days. A population pharmacokinetic analysis was performed using nonlinear mixed effects modelling. The final model was used to simulate tocilizumab exposure to assess a dosing strategy based on body weight or fixed dosing, using as target a cumulative area under the curve at 24 weeks of treatment above 100 × 103 μg h ml-1 . RESULTS A one-compartment disposition model with parallel linear and nonlinear elimination best described the concentration-time data. The typical population mean values for clearance, apparent volume of distribution, maximum elimination rate and Michaelis-Menten constant were 0.0104 l h-1 , 4.83 l, 0.239 mg h-1 and 4.22 μg ml-1 , respectively. Interindividual variability was included for clearance (17.0%) and volume of distribution (30.8%). Significant covariates for clearance were patient body weight and C-reactive protein serum levels. An estimated exponent for body weight of 0.360 confirms the weak relationship with tocilizumab clearance. Simulations demonstrate that patients with lower weights are at risk of underdosing if the weight-based dosing approach is used. However, fixed-dosing provides a more consistent drug exposure regardless of weight category. CONCLUSIONS Our study provides evidence to support fixed dosing of intravenous tocilizumab in rheumatoid arthritis patients since it reduces variability in tocilizumab exposure among weight categories compared to the current weight-based dosing approach.
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Affiliation(s)
- Carla Bastida
- Pharmacy Department, Division of Medicines, Hospital Clinic Barcelona, Universitat de Barcelona, Spain.,Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Virginia Ruiz-Esquide
- Arthritis Unit, Rheumatology Department, Hospital Clinic Barcelona, Universitat de Barcelona, Spain
| | - Mariona Pascal
- Immunology Department, CDB, Hospital Clinic Barcelona, Universitat de Barcelona, Spain.,IDIBAPS, Barcelona, Spain
| | - Aurelia H M de Vries Schultink
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jordi Yagüe
- Immunology Department, CDB, Hospital Clinic Barcelona, Universitat de Barcelona, Spain.,IDIBAPS, Barcelona, Spain
| | - Raimon Sanmartí
- Arthritis Unit, Rheumatology Department, Hospital Clinic Barcelona, Universitat de Barcelona, Spain
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dolors Soy
- Pharmacy Department, Division of Medicines, Hospital Clinic Barcelona, Universitat de Barcelona, Spain.,IDIBAPS, Barcelona, Spain
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7
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de Vries Schultink AHM, Zwart W, Linn SC, Beijnen JH, Huitema ADR. Effects of Pharmacogenetics on the Pharmacokinetics and Pharmacodynamics of Tamoxifen. Clin Pharmacokinet 2016; 54:797-810. [PMID: 25940823 PMCID: PMC4513218 DOI: 10.1007/s40262-015-0273-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The antiestrogenic drug tamoxifen is widely used in the treatment of estrogen receptor-α-positive breast cancer and substantially decreases recurrence and mortality rates. However, high interindividual variability in response is observed, calling for a personalized approach to tamoxifen treatment. Tamoxifen is bioactivated by cytochrome P450 (CYP) enzymes such as CYP2B6, CYP2C9, CYP2C19, CYP2D6 and CYP3A4/5, resulting in the formation of active metabolites, including 4-hydroxy-tamoxifen and endoxifen. Therefore, polymorphisms in the genes encoding these enzymes are proposed to influence tamoxifen and active tamoxifen metabolites in the serum and consequently affect patient response rates. To tailor tamoxifen treatment, multiple studies have been performed to clarify the influence of polymorphisms on its pharmacokinetics and pharmacodynamics. Nevertheless, personalized treatment of tamoxifen based on genotyping has not yet met consensus. This article critically reviews the published data on the effect of various genetic polymorphisms on the pharmacokinetics and pharmacodynamics of tamoxifen, and reviews the clinical implications of its findings. For each CYP enzyme, the influence of polymorphisms on pharmacokinetic and pharmacodynamic outcome measures is described throughout this review. No clear effects on pharmacokinetics and pharmacodynamics were seen for various polymorphisms in the CYP encoding genes CYP2B6, CYP2C9, CYP2C19 and CYP3A4/5. For CYP2D6, there was a clear gene-exposure effect that was able to partially explain the interindividual variability in plasma concentrations of the pharmacologically most active metabolite endoxifen; however, a clear exposure-response effect remained controversial. These controversial findings and the partial contribution of genotype in explaining interindividual variability in plasma concentrations of, in particular, endoxifen, imply that tailored tamoxifen treatment may not be fully realized through pharmacogenetics of metabolizing enzymes alone.
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Affiliation(s)
- Aurelia H M de Vries Schultink
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek-The Netherlands Cancer Institute, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
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Abdulla A, van Leeuwen RWF, de Vries Schultink AHM, Koch BCP. Stability of colistimethate sodium in a disposable elastomeric infusion device. Int J Pharm 2015; 486:367-9. [PMID: 25863116 DOI: 10.1016/j.ijpharm.2015.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/02/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022]
Abstract
Infections of the respiratory tract with Pseudomonas aeruginosa in cystic fibrosis patients are frequently treated with colistimethate sodium (CMS). For the intravenous administration of CMS a disposable elastomeric pump is a convenient option. To date, there are no data available on the chemical stability of CMS solutions stored in elastomeric pumps. We evaluated the chemical stability of 0.8 mg/mL solutions of CMS by measuring the degradation over a period of 7 days. Test samples were prepared by diluting CMS with saline solution (0.9%). The preparations were transferred to 100-mL elastomeric pumps and stored at 4 °C. The chemical stability was measured by a high-performance liquid chromatography method with UV detection. There was no degradation of CMS (<0.5% of CMS present as colistin) for at least 3 day at 4 °C, and after 7 days all test samples remained chemically stable (<5% of CMS present as colistin). Since colistin formed in pharmacy-compounded CMS solutions prior to administration may cause toxicity, we advise that the solution should be used before the hydrolysis of CMS occurs. Therefore, we recommend that the 0.8 mg/mL solution of CMS can be stored for up to 3 days at 4 °C in an elastomeric pump.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Roelof W F van Leeuwen
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
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