STEROIDS IN THE TREATMENT OF CHRONIC DISEASES

Authors

  • SHARMA P Department of Pharmaceutical Chemistry, MM College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Ambala, Haryana, India.
  • IMAM S Department of Pharmaceutical Chemistry, MM College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Ambala, Haryana, India.
  • MEHTA DK Department of Pharmaceutical Chemistry, MM College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Ambala, Haryana, India.

DOI:

https://doi.org/10.22159/ajpcr.2019.v12i7.33543

Keywords:

Corticosteroids,, Disease,, Rational,, Side effects,, Steroids

Abstract

Since their identification, which was almost 80 years ago, steroids have played a prominent role in the treatment of many disease states such as chronic obstructive pulmonary disease, asthma, rheumatoid arthritis, and inflammatory bowel disease. Many of the clinical roles of steroids are related to their potent anti-inflammatory and immune-modulating properties. Numerous skin diseases are successfully treated with systemic steroids. Corticosteroids, though they are lifesaving drugs, produce adverse reactions which may be mild or life threatening. Steroids have diverse effects on various systems of the body. Therefore, educational interventions among physician, patients, as well as students should be carried out to further enhance rational drug use. The purpose of this review was to identify the most commonly prescribed steroids and their side effects, basic pharmacology, complications, as well as the assessment of patient knowledge about the use of steroids in tertiary care teaching hospitals.

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References

Meikle AW, Tyler FH. Potency and duration of action of glucocorticoids. Effects of hydrocortisone, prednisone and dexamethasone on human pituitary-adrenal function. Am J Med 1977;63:200-7.

Kendall EC, Reichstein T, Hench SP. The development of cortisone as a therapeutic agent. Indian Med J 1951;45:239-41.

Woods JA, Wheeler JS, Finch CK, Pinner NA. Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2014;9:421-30.

Buckley WE, Yesalis CE 3rd, Friedl KE, Anderson WA, Streit AL, Wright JE. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA 1988;260:3441-5.

Basaria S, Wahlstrom JT, Dobs AS. Clinical review 138: Anabolic-androgenic steroid therapy in the treatment of chronic diseases. J Clin Endocrinol Metab 2001;86:5108-17.

Wade N. Anabolic steroids: Doctors denounce them, but athletes aren’t listening. Science 1972;176:1399-403.

Jacobsen RP, Pincus G. The chemistry of adrenal steroids. Symposium on the adrenal gland. Am J Med 1951;10:531-3.

Saag KG, Furst DE, Barnes PJ. Major Side Effects of Inhaled Glucocorticoids. In: Basow DS, editor. UpToDate. Waltham, MA: UpToDate; 2011. p. 31.

Joseph J. What is Corticosteroid Phobia? Contact Magazine News; 2013. p. 102-15.

Schweiger TA, Zdanowicz M. Systemic corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. Am J Health Syst Pharm 2010;67:1061-9.

Brunton LL, Chabner BA, Knollmann BC. Androgens. Goodman & Gilman’s the Pharmacological Basis of Therapeutics. 12th ed., Ch. 41. New York: McGraw Hill Education; 2007. p. 1804-10.

Godkar PB, Godkar DP. Hormones. Textbook of Medical Laboratory Technology. 3rd ed., Ch. 1. Mumbai: Bhalani Publishing House; 2014. p. 570-1.

Altschule MD, Tillotson KJ. The use of testosterone in the treatment of depressions. N Engl J Med 1948;239:1036-8.

Frati P, Busardò FP, Cipolloni L, Dominicis ED, Fineschi V. Anabolic androgenic steroid (AAS) related deaths: Autoptic, histopathological and toxicological findings. Curr Neuropharmacol 2015;13:146-59.

Lusetti M, Licata M, Silingardi E, Bonsignore A, Palmiere C. Appearance/Image- and performance-enhancing drug users: A forensic approach. Am J Forensic Med Pathol 2018;39:325-9.

Jones IA, Togashi R, Hatch GF, Weber AE, Vangsness CT. Anabolic steroids and tendons: A review of their mechanical, structural and biologic effects. J Orthop Res 2018;26:250-7.

Armstrong JM, Avant RA, Charchenko CM, Westerman ME, Ziegelmann MJ, Miest TS, et al. Impact of anabolic androgenic steroids on sexual function. Transl Androl Urol 2018;7:483-9.

Melo Junior AF, Dalpiaz PLM, Sousa GJ, Oliveira PWC, Birocale AM, Andrade TU, et al. Nandrolone alter left ventricular contractility and promotes remodelling involving calcium-handling proteins and renin-angiotensin system in male SHR. Life Sci 2018;208:239-45.

Zhou S, Glowacki J. Dehydroepiandrosterone and bone. Vitam Horm 2018;108:251-71.

Miller WL, Auchus RJ. The molecular biology, biochemistry, and physiology of human steroidogenesis and its disorders. Endocr Rev 2011;32:81-151.

Kumar R, Thompson EB. Gene regulation by the glucocorticoid receptor: Structure: Function relationship. J Steroid Biochem Mol Biol 2005;94:383-94.

Gomez-Sanchez EP. Brain mineralocorticoid receptors: Orchestrators of hypertension and end-organ disease. Curr Opin Nephrol Hypertens 2004;13:191-6.

Sakai RR, Nicolaïdis S, Epstein AN. Salt appetite is suppressed by interference with angiotensin II and aldosterone. Am J Physiol 1986;251:R762-8.

Vaz M, Raj T, Anura K. Adenocortical hormones. Guyton and Hall Textbook of Medical Physiology. 2nd ed., Ch. 78. Philadelphia, PA: Saunders, Elsevier; 2016. p. 561-72.

Barrett KE, Barman SM, Boitano S, Brooks HL. Hormonal control of calcium and phosphate metabolism and the physiology of bone. In: Ganong WF, editor. Review of Medical Physiology. 24th ed., Ch. 21. New York: McGraw-Hill Medical; 2012. p. 377-80.

Tripathi KD. Essentials of Medical Pharmacology. 6th ed., Ch. 32. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2008. p. 660-5.

Bruton L, Lazo J, Parker K. Goodman & Gilman’s the Pharmacological Basis of Therapeutics. 11th ed., Ch. 58. New York: McGraw Hill Education; 2006. p. 1573-86.

Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson L, et al., editors. Harrison’s Principles of Internal Medicine by Kasper. 17th ed., Ch. 58. New York: McGrawHill; 2008. p. 1000-6.

Trevor AJ, Katzung BG, Kruidering-Hall M. Corticosteroids and antagonists. Pharmacology Examination and Board Review. 11th ed., Ch. 39. New York: McGraw-Hill Education; 2015. p. 322-5.

Barnes PJ. Mechanisms and resistance in glucocorticoid control of inflammation. J Steroid Biochem Mol Biol 2010;120:76-85.

Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM. Global burden of COPD: Systematic review and meta-analysis. Eur Respir J 2006;28:523-32.

Whalen K. Estrogens and androgens. In: Harvey RA, Champe PC, editors. Lippincott’s Illustrated Reviews-Pharmacology. 4th ed., Ch. 25. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. p. 308.

Tuder RM, Petrache I. Pathogenesis of chronic obstructive pulmonary disease. J Clin Invest 2012;122:2749-55.

Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.

Diaz-Guzman E, Mannino DM. Epidemiology and prevalence of chronic obstructive pulmonary disease. Clin Chest Med 2014;35:7-16.

Cheyne L, Irvin-Sellers MJ, White J. Tiotropium versus ipratropium bromide for chronic obstructive pulmonary disease. Cochrane Database Syst Rev2015;9:238-45.

Johnston AK, Mannino DM. Epidemiology of COPD exacerbations. In: Wedzicha JA, Martinez FJ, editors. Exacerbations of Chronic Obstructive Pulmonary Disease. Vol. 6. London: Informa Healthcare; 2008. p. 15-26.

Seemungal TA, Donaldson GC, Paul EA, Bestall JC, Jeffries DJ, Wedzicha JA, et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157:1418-22.

Vestbo J, Vogelmeier C, Small M, Higgins V. Understanding the GOLD 2011 strategy as applied to a real-world COPD population. Respir Med 2014;108:729-36.

Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002;57:847-52.

Suissa S, Barnes PJ. Inhaled corticosteroids in COPD: The case against. Eur Respir J 2009;34:13-6.

Sarithamol S, Divya V, Sunitha VR, Suchitra S, Pushpa VL, Manoj KB. Genetic involvement of interleukin 4 for asthma and identification of potential phytochemical scaffold through molecular docking studies. Int J Curr Pharm Res 2018;10:45-57.

Holgate ST, Polosa R. Treatment strategies for allergy and asthma. Nat Rev Immunol 2008;8:218-30.

Ahmetaj LN. The Global Asthma Report 2014. Auckland, New Zealand: Global Asthma Network; 2014. p. 102-12.

Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, et al. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015;32:S3-42.

Clark TJ. Effect of beclomethasone dipropionate delivered by aerosol in patients with asthma. Lancet 1972;1:1361-4.

Barnes PJ. How corticosteroids control inflammation: Quintiles prize lecture 2005. Br J Pharmacol 2006;148:245-54.

Alamanos Y, Drosos AA. Epidemiology of adult rheumatoid arthritis. Autoimmun Rev 2005;4:130-6.

Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, et al. 2010 rheumatoid arthritis classification criteria: An American College of Rheumatology/European League against rheumatism collaborative initiative. Ann Rheum Dis 2010;69:1580-8.

Baan H, Haagsma CJ, van de Laar MA. Corticosteroid injections reduce size of rheumatoid nodules. Clin Rheumatol 2006;25:21-3.

Aviña-Zubieta JA, Abrahamowicz M, De Vera MA, Choi HK, Sayre EC, Rahman MM, et al. Immediate and past cumulative effects of oral glucocorticoids on the risk of acute myocardial infarction in rheumatoid arthritis: A population-based study. Rheumatology (Oxford) 2013;52:68-75.

Caplan L, Russell AS, Wolfe F. Steroids for rheumatoid arthritis: The honeymoon revisited (once again). J Rheumatol 2005;32:1863-5.

Chandrappa M, Biswas S. Glucocorticoids in management of adult rheumatoid arthritis-current prescribing practices and perceptions of physicians in India: GLUMAR Survey. J Ancient Dis Prev Remedies 2017;7:220.

Krasselt M, Baerwald C. The current relevance and use of prednisone in rheumatoid arthritis. Expert Rev Clin Immunol 2014;10:557-71.

Sharma GN, Dave R, Sanadya J, Sharma P, Sharma KK. Various types and management of breast cancer: An overview. J Adv Pharm Technol Res 2010;1:109-26.

Saddick SY. The impact of nandrolone decanoate administration on ovarian and uterine tissues in rat: Luteinizing hormone profile, histopathological and morphometric assessment. Saudi J Biol Sci 2018;25:507-12.

Balentine JR. Improved survival in metastatic breast cancer. Int J Breast Cancer 2017;31:105-15.

Suissa S, Dell’Aniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: Severe exacerbations and mortality. Thorax 2012;67:957-63.

Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010;303:2359-67.

O’Driscoll R. Home nebulized therapy – is it effective? Respir Med 1991;85:1-3.

Newhouse M, Dolovich M. Aerosol therapy: Nebulizer vs. metered dose inhaler. Chest 1987;91:799-800.

Kelly HW. Levalbuterol for asthma: A better treatment? Curr Allergy Asthma Rep 2007;7:310-4.

Lim SS, Conn DL. The use of low-dose prednisone in the management of rheumatoid arthritis. Bull Rheum Dis 2001;50:1-4.

Cooper C, Coupland C, Mitchell M. Rheumatoid arthritis, corticosteroid therapy and hip fracture. Ann Rheum Dis 1995;54:49-52.

Caldwell JR, Furst DE. The efficacy and safety of low-dose corticosteroids for rheumatoid arthritis. Semin Arthritis Rheum 1991;21:11.

Elks J. The Dictionary of Drugs: Chemical Data: Chemical Data, Structures and Bibliographies. Vol. 43. New York: Springer; 2014. p. 660-70.

William L. Anabolics. Mol Nutr Llc 2011;29:460-7.

Liu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol 2013;9:30.

Eustice C. Corticosteroids for inflammation. Verywell Health 2018;36:112-8.

Min KH, Rhee CK, Jung JY, Suh MW. Characteristics of adverse effects when using high dose short term steroid regimen. Korean J Audiol 2012;16:65-70.

Waljee AK, Rogers MA, Lin P, Singal AG, Stein JD, Marks RM, et al. Short term use of oral corticosteroids and related harms among adults in the United States: Population based cohort study. BMJ 2017;357:j1415.

Curtiss PH Jr., Clark WS, Herndon CH. Vertebral fractures resulting from prolonged cortisone and corticotropin therapy. J Am Med Assoc 1954;156:467-9.

Adler RA, Rosen CJ. Glucocorticoids and osteoporosis. Endocrinol Metab Clin North Am 1994;23:641-54.

Canalis E. Clinical review 83: Mechanisms of glucocorticoid action in bone: Implications to glucocorticoid-induced osteoporosis. J Clin Endocrinol Metab 1996;81:3441-7.

Lukert BP, Raisz LG. Glucocorticoid-induced osteoporosis: Pathogenesis and management. Ann Intern Med 1990;112:352-64.

Manolagas SC, Weinstein RS. New developments in the pathogenesis and treatment of steroid-induced osteoporosis. J Bone Miner Res 1999;14:1061-6.

Joshisree KP, Rajesh G, Siddarama R. Corticosteroid induced ecchymosis. Int J Pharm Pharm Sci 2018;10:211-3.

Reid IR, Heap SW. Determinants of vertebral mineral density in patients receiving long-term glucocorticoid therapy. Arch Intern Med 1990;150:2545-8.

Pocock NA, Eisman JA, Dunstan CR, Evans RA, Thomas DH, Huq NL, et al. Recovery from steroid-induced osteoporosis. Ann Intern Med 1987;107:319-23.

van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Oral corticosteroids and fracture risk: Relationship to daily and cumulative doses. Rheumatology (Oxford) 2000;39:1383-9.

Buckley LM, Leib ES, Cartularo KS, Vacek PM, Cooper SM. Effects of low dose corticosteroids on the bone mineral density of patients with rheumatoid arthritis. J Rheumatol 1995;22:1055-9.

Vermaat H, Kirtschig G. Prevention and treatment of glucocorticoid-induced osteoporosis in daily dermatologic practice. Int J Dermatol 2008;47:737-42.

Zelissen PM, Croughs RJ, van Rijk PP, Raymakers JA. Effect of glucocorticoid replacement therapy on bone mineral density in patients with Addison disease. Ann Intern Med 1994;120:207-10.

van Raalte DH, Ouwens DM, Diamant M. Novel insights into glucocorticoid-mediated diabetogenic effects: Towards expansion of therapeutic options? Eur J Clin Invest 2009;39:81-93.

Ruzzin J, Wagman AS, Jensen J. Glucocorticoid-induced insulin resistance in skeletal muscles: Defects in insulin signalling and the effects of a selective glycogen synthase kinase-3 inhibitor. Diabetologia 2005;48:2119-30.

Perez A, Jansen-Chaparro S, Saigi I, Bernal-Lopez MR, Miñambres I, Gomez-Huelgas R. Glucocorticoid-induced hyperglycemia. J Diabetes 2014;6:9-20.

Pichardo-Lowden AR, Fan CY, Gabbay RA. Management of hyperglycemia in the non-intensive care patient: Featuring subcutaneous insulin protocols. Endocr Pract 2011;17:249-60.

Trence DL. Management of patients on chronic glucocorticoid therapy: An endocrine perspective. Prim Care 2003;30:593-605.

Brown ES, Chandler PA. Mood and cognitive changes during systemic corticosteroid therapy. Prim Care Companion J Clin Psychiatry 2001;3:17-21.

Wung PK, Anderson T, Fontaine KR, Hoffman GS, Specks U, Merkel PA, et al. Effects of glucocorticoids on weight change during the treatment of Wegener’s granulomatosis. Arthritis Rheum 2008;59:746-53.

Stenson WF, Cort D, Rodgers J, Burakoff R, DeSchryver-Kecskemeti K, Gramlich TL, et al. Dietary supplementation with fish oil in ulcerative colitis. Ann Intern Med 1992;116:609-14.

Hjelmesaeth J, Hartmann A, Kofstad J, Stenstrøm J, Leivestad T, Egeland T, et al. Glucose intolerance after renal transplantation depends upon prednisolone dose and recipient age. Transplantation 1997;64:979-83.

Gorard DA, Hunt JB, Payne-James JJ, Palmer KR, Rees RG, Clark ML, et al. Initial response and subsequent course of Crohn’s disease treated with elemental diet or prednisolone. Gut 1993;34:1198-202.

McKenzie R, O’Fallon A, Dale J, Demitrack M, Sharma G, Deloria M, et al. Low-dose hydrocortisone for treatment of chronic fatigue syndrome: A randomized controlled trial. JAMA 1998;280:1061-6.

Chrousos GA, Kattah JC, Beck RW, Cleary PA. Side effects of glucocorticoid treatment. Experience of the optic neuritis treatment trial. JAMA 1993;269:2110-2.

Cheskin LJ, Bartlett SJ, Zayas R, Twilley CH, Allison DB, Contoreggi C. Prescription medications: A modifiable contributor to obesity. South Med J 1999;92:898-904.

Messer J, Reitman D, Sacks HS, Smith H Jr., Chalmers TC. Association of adrenocorticosteroid therapy and peptic-ulcer disease. N Engl J Med 1983;309:21-4.

Piper JM, Ray WA, Daugherty JR, Griffin MR. Corticosteroid use and peptic ulcer disease: Role of nonsteroidal anti-inflammatory drugs. Ann Intern Med 1991;114:735-40.

Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis. Ann Intern Med 1991;115:787-96.

Herrala J, Puolijoki H, Liippo K, Raitio M, Impivaara O, Tala E, et al. Clodronate is effective in preventing corticosteroid-induced bone loss among asthmatic patients. Bone 1998;22:577-82.

Kikuchi Y, Imakiire T, Yamada M, Saigusa T, Hyodo T, Kushiyama T, et al. Effect of risedronate on high-dose corticosteroid-induced bone loss in patients with glomerular disease. Nephrol Dial Transplant 2007;22:1593-600.

Moghadam-Kia S, Werth VP. Prevention and treatment of systemic glucocorticoid side effects. Int J Dermatol 2010;49:239-48.

Miller ML. Glucocorticoid-induced myopathy. UpToDate 2013;11:34-6.

Horne R. Compliance, adherence, and concordance: Implications for asthma treatment. Chest 2006;130:65S-72S.

Boulet LP. Perception of the role and potential side effects of inhaled corticosteroids among asthmatic patients. Chest 1998;113:587-92.

Cochrane MG, Bala MV, Downs KE, Mauskopf J, Ben-Joseph RH. Inhaled corticosteroids for asthma therapy: Patient compliance, devices, and inhalation technique. Chest 2000;117:542-50.

Laforest L, Van Ganse E, Devouassoux G, Bousquet J, Chretin S, Bauguil G, et al. Influence of patients’ characteristics and disease management on asthma control. J Allergy Clin Immunol 2006;117:1404-10.

Armour C, Bosnic-Anticevich S, Brillant M, Burton D, Emmerton L, Krass I, et al. Pharmacy asthma care program (PACP) improves outcomes for patients in the community. Thorax 2007;62:496-502.

Barbanel D, Eldridge S, Griffiths C. Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial. Thorax 2003;58:851-4.

Mangiapane S, Schulz M, Mühlig S, Ihle P, Schubert I, Waldmann HC. Community pharmacy-based pharmaceutical care for asthma patients. Ann Pharmacother 2005;39:1817-22.

Saini B, Krass I, Armour C. Development, implementation, and evaluation of a community pharmacy-based asthma care model. Ann Pharmacother 2004;38:1954-60.

Schulz M, Verheyen F, Mühlig S, Müller JM, Mühlbauer K, Knop-Schneickert E, et al. Pharmaceutical care services for asthma patients: A controlled intervention study. J Clin Pharmacol 2001;41:668-76.

Weinberger M, Murray MD, Marrero DG, Brewer N, Lykens M, Harris LE, et al. Effectiveness of pharmacist care for patients with reactive airways disease: A randomized controlled trial. JAMA 2002;288:1594-602.

Wright D, Twigg M, Barton G, Thornley T, Kerr C. An evaluation of a multi-site community pharmacy-based chronic obstructive pulmonary disease support service. Int J Pharm Pract 2015;23:36-43.

Wei L, Yang X, Li J, Liu L, Luo H, Zheng Z, et al. Effect of pharmaceutical care on medication adherence and hospital admission in patients with chronic obstructive pulmonary disease (COPD): A randomized controlled study. J Thorac Dis 2014;6:656-62.

van Boven JF, Tommelein E, Boussery K, Mehuys E, Vegter S, Brusselle GG, et al. Improving inhaler adherence in patients with chronic obstructive pulmonary disease: A cost-effectiveness analysis. Respir Res 2014;15:66.

Ottenbros S, Teichert M, de Groot R, Griens F, Sodihardjo F, Wensing M, et al. Pharmacist-led intervention study to improve drug therapy in asthma and COPD patients. Int J Clin Pharm 2014;36:336-44.

Kumar S, Goyal A, Gupta YK. Abuse of topical corticosteroids in India: Concerns and the way forward. J Pharmacol Pharmacother 2016;7:1-5.

Al Hawsawi K, Alaauldeen S, Albarnawi N, Mashrai H, Alosaimi R, Alsufyani H, et al. Prevalence of misuse of topical corticosteroids among populations in Western region of Saudi Arabia. Int J Adv Res 2017;5:297-307.

Saraswat A, Lahiri K, Chatterjee M, Barua S, Coondoo A, Mittal A, et al. Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology outpatients. Indian J Dermatol Venereol Leprol 2011;77:160-6.

Nagesh TS, Akhilesh A. Topical steroid awareness and abuse: A Prospective study among dermatology outpatients. Indian J Dermatol 2016;61:618-21.

Ashique KT, Chandrasekhar D. Role of clinical pharmacist in cosmeto-vigilance of misuse and abuse of topical corticosteroids. Indian J Dermatol 2017;62:213.

Published

07-07-2019

How to Cite

SHARMA P, IMAM S, and MEHTA DK. “STEROIDS IN THE TREATMENT OF CHRONIC DISEASES”. Asian Journal of Pharmaceutical and Clinical Research, vol. 12, no. 7, July 2019, pp. 91-97, doi:10.22159/ajpcr.2019.v12i7.33543.

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Review Article(s)