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Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 1
PsoriasisPsoriasisPsoriasisPsoriasis
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
Psoriasis is a common chronic skin disease that affects about 2% of the
population psora = "itch"
The most common type of psoriasis is the chronic plaque psoriasis, affects about 90% of the psoriatic patient
population
Psoriasis is a common chronic skin disease that affects about 2% of the
population psora = "itch"
The most common type of psoriasis is the chronic plaque psoriasis, affects about 90% of the psoriatic patient
population
What is Psoriasis?What is Psoriasis?What is Psoriasis?What is Psoriasis?
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
Characterized by well defined, scaly red skin
patches on the body (arms, legs and trunk) and scalp Usually distributed
symmetrically May involve the nails that can
eventually progress to the joints (arthritis)
Characterized by well defined, scaly red skin
patches on the body (arms, legs and trunk) and scalp Usually distributed
symmetrically May involve the nails that can
eventually progress to the joints (arthritis)
PsoriasisPsoriasisPsoriasisPsoriasis
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 4
PsoriasisPsoriasisPsoriasisPsoriasis
• Auto-immune disease• T-cell mediated inflammatory disease
– Epidermal hyperproliferation – Altered maturation of skin– Inflammation– Vascular changes
• Auto-immune disease• T-cell mediated inflammatory disease
– Epidermal hyperproliferation – Altered maturation of skin– Inflammation– Vascular changes
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
T-lymphocyte which normally help protect the body against infection
become active, migrate to the dermis and trigger the release
of cytokines (tumor necrosis factor-alpha TNFα) which cause
inflammation and the rapid production of skin cells
T-lymphocyte which normally help protect the body against infection
become active, migrate to the dermis and trigger the release
of cytokines (tumor necrosis factor-alpha TNFα) which cause
inflammation and the rapid production of skin cells
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
• Have genetic component • Nongenetic Factors:
- Mechanical, ultraviolet, chemical injury- Infections: Strep, viral, HIV- Prescription Drugs, stress, endocrine, hormonal, obesity, alcohol, smoking
Drugs that are most strongly related to psoriasis are lithium, β-blockers, NSAIDs and antimalarials
• Have genetic component • Nongenetic Factors:
- Mechanical, ultraviolet, chemical injury- Infections: Strep, viral, HIV- Prescription Drugs, stress, endocrine, hormonal, obesity, alcohol, smoking
Drugs that are most strongly related to psoriasis are lithium, β-blockers, NSAIDs and antimalarials
PsoriasisPsoriasisPsoriasisPsoriasis
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 7
PrevalencePrevalencePrevalencePrevalence
• Equal frequency in males and females• May occur at any age • Life-long disease
–Remitting and relapsing unpredictably–Spontaneous remissions of up to 5
years have been reported in approximately 5% of patients
• Equal frequency in males and females• May occur at any age • Life-long disease
–Remitting and relapsing unpredictably–Spontaneous remissions of up to 5
years have been reported in approximately 5% of patients
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 8
Symptoms of Chronic Plaque Symptoms of Chronic Plaque PsoriasisPsoriasis
Symptoms of Chronic Plaque Symptoms of Chronic Plaque PsoriasisPsoriasis
• Itching• Pain• Excessive heat loss• Patient complaints
– Unsightliness of the lesions– Feelings of being socially outcast– Excessive scale
• Itching• Pain• Excessive heat loss• Patient complaints
– Unsightliness of the lesions– Feelings of being socially outcast– Excessive scale
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 9
Psoriasis: TreatmentPsoriasis: Treatment Psoriasis: TreatmentPsoriasis: Treatment
• Lubrication• Removal of scales• Slow down lesion proliferation• Pruritus management• Prevent complications• Lessen patient stress• Season and climate
• Lubrication• Removal of scales• Slow down lesion proliferation• Pruritus management• Prevent complications• Lessen patient stress• Season and climate
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 10
Treatment of PsoriasisTreatment of PsoriasisTreatment of PsoriasisTreatment of Psoriasis
• Topical and systemic• Wide range of therapies for the
treatment of moderate to severe psoriasis
• None induce a permanent remission• Many have side effects that can place
limits on their use
• Topical and systemic• Wide range of therapies for the
treatment of moderate to severe psoriasis
• None induce a permanent remission• Many have side effects that can place
limits on their use
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
Topical TreatmentTopical TreatmentTopical TreatmentTopical Treatment
11
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 12
Topical TherapiesTopical TherapiesTopical TherapiesTopical Therapies
– Topical corticosteroids– Topical vitamin D3 analogues– Topical retinoids– Topical emollients– Topical salicylic acid ointment– Photo chemotherapy– Tar– Excimer laser
– Topical corticosteroids– Topical vitamin D3 analogues– Topical retinoids– Topical emollients– Topical salicylic acid ointment– Photo chemotherapy– Tar– Excimer laser
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 13
CorticosteroidsCorticosteroidsCorticosteroidsCorticosteroids The most widely prescribedmedications for plaque psoriasis
MOA • Reduce inflammation, itching and scaling• Anti-inflammatory effect
– Decrease in vascular permeability, decreasing dermal edema and leukocyte penetration into skin
• Antiproliferative effect• Immunosuppressive effect
The most widely prescribedmedications for plaque psoriasis
MOA • Reduce inflammation, itching and scaling• Anti-inflammatory effect
– Decrease in vascular permeability, decreasing dermal edema and leukocyte penetration into skin
• Antiproliferative effect• Immunosuppressive effect
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
CorticosteroidsCorticosteroids CorticosteroidsCorticosteroids
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 15
• Topical corticosteroids are available in
numerous vehicles including powders, sprays, lotions, gels foams, creams, emollient creams, ointments
• Ointments: helps hydrate; good for dry, hyperkeratotic, scaly lesions
• Cream: for use on all areas, useful for infected lesions
• Solutions: for scalp psoriasis, often contain alcohols which can be painful with open lesions
• Topical corticosteroids are available in numerous vehicles including powders, sprays, lotions, gels foams, creams, emollient creams, ointments
• Ointments: helps hydrate; good for dry, hyperkeratotic, scaly lesions
• Cream: for use on all areas, useful for infected lesions
• Solutions: for scalp psoriasis, often contain alcohols which can be painful with open lesions
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 16
Side effects Side effects Side effects Side effects – Systemic absorption Suppression of the
hypothalamic-pituitary-adrenal axis– Skin atrophy, burning sensation– Poor wound healing– Pyogenic infections Tachyphylaxis ( medications that are highly
effective initially, lose efficacy with prolonged use).
To avoid tachyphylaxis and the other side effects of topical corticosteroids, They are applied twice daily for 2 weeks, after which they are applied on weekends
– Systemic absorption Suppression of the hypothalamic-pituitary-adrenal axis
– Skin atrophy, burning sensation– Poor wound healing– Pyogenic infections Tachyphylaxis ( medications that are highly
effective initially, lose efficacy with prolonged use).
To avoid tachyphylaxis and the other side effects of topical corticosteroids, They are applied twice daily for 2 weeks, after which they are applied on weekends
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 17
Topical Vitamin DTopical Vitamin D33 Analogues AnaloguesTopical Vitamin DTopical Vitamin D33 Analogues Analogues
• The second most commonly used group of medications consists of the vitamin D analogues
• Calcipotriol is available as cream, ointment, and scalp lotion
• MOA: inhibition of cell proliferation and induction of cell differentiation in psoriatic skin
• The second most commonly used group of medications consists of the vitamin D analogues
• Calcipotriol is available as cream, ointment, and scalp lotion
• MOA: inhibition of cell proliferation and induction of cell differentiation in psoriatic skin
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 18
Topical Vitamin DTopical Vitamin D33 Analogues AnaloguesTopical Vitamin DTopical Vitamin D33 Analogues Analogues
• Side Effects; Burning, pruritus, skin irritation, tingling of the skin
• Phototherapy may inactivate vitamin D analogues and thus these topical
agents should be applied after phototherapy, not before
• Side Effects; Burning, pruritus, skin irritation, tingling of the skin
• Phototherapy may inactivate vitamin D analogues and thus these topical
agents should be applied after phototherapy, not before
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 19
Topical RetinoidsTopical RetinoidsTopical RetinoidsTopical Retinoids
• Vitamin A derivatives
• MOA:1.Normalization of abnormal
keratinocyte differentiation2.Reduction in keratinocyte
proliferation3.Reduction in inflammation
• Vitamin A derivatives
• MOA:1.Normalization of abnormal
keratinocyte differentiation2.Reduction in keratinocyte
proliferation3.Reduction in inflammation
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 20
Topical RetinoidsTopical RetinoidsTopical RetinoidsTopical Retinoids
• Tazarotene; Gel and cream• a third-generation retinoid approved for
the treatment of psoriasis
• Side Effects; itching, burning, skin irritation
• Contraindicated in women who are or may become pregnant
• Tazarotene; Gel and cream• a third-generation retinoid approved for
the treatment of psoriasis
• Side Effects; itching, burning, skin irritation
• Contraindicated in women who are or may become pregnant
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 21
PhototherapyPhototherapyPhototherapyPhototherapy
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 22
Photo-chemotherapyPhoto-chemotherapyPhoto-chemotherapyPhoto-chemotherapy
– Psoralen +Ultraviolet A (PUVA)– Consists of oral or topical treatment with psoralen
followed by UVA (2 to 3 times per week for several months)
• Theories of MOA:1.Psoralen intercalates into DNA, inhibiting DNA
replication and thus, inhibiting epidermal cell hyperproliferation
2.Free radical formation damages cell membrane, cytoplasmic contents and nucleus of epidermal cells…inhibiting growth of cells
3. Increased apoptosis of activated T-cells
– Psoralen +Ultraviolet A (PUVA)– Consists of oral or topical treatment with psoralen
followed by UVA (2 to 3 times per week for several months)
• Theories of MOA:1.Psoralen intercalates into DNA, inhibiting DNA
replication and thus, inhibiting epidermal cell hyperproliferation
2.Free radical formation damages cell membrane, cytoplasmic contents and nucleus of epidermal cells…inhibiting growth of cells
3. Increased apoptosis of activated T-cells
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 23
Side effects with PsoralenSide effects with PsoralenSide effects with PsoralenSide effects with Psoralen
– Pruritus– Skin ageing– Increased risk for skin cancer
with long-term exposure to the drug
– Pruritus– Skin ageing– Increased risk for skin cancer
with long-term exposure to the drug
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 24
Coal Tar Coal Tar الفحم Coal Tar Coal Tar قطران الفحم قطران
Old topical medication MOA: Decreases epidermal cell mitosis and scale
development (anti-scaling properties)Reduces sebum productionAnti-inflammatory effects5% coal tar concentration most effective
(1%-6%)Used together with salicylic acid
(keratolytic) for psoriasis of the scalp Tar baths and shampoos are helpful
Old topical medication MOA: Decreases epidermal cell mitosis and scale
development (anti-scaling properties)Reduces sebum productionAnti-inflammatory effects5% coal tar concentration most effective
(1%-6%)Used together with salicylic acid
(keratolytic) for psoriasis of the scalp Tar baths and shampoos are helpful
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 25
Coal TarCoal TarCoal TarCoal Tar
• Use only on lesions that are well separated, not too big
• Problems with coal tar:–Smell–Sting ; irritation –Stain skin and fabrics–Sensitize , contact dermatitis,
• Use only on lesions that are well separated, not too big
• Problems with coal tar:–Smell–Sting ; irritation –Stain skin and fabrics–Sensitize , contact dermatitis,
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 26
Emollients and MoisturizersEmollients and MoisturizersEmollients and MoisturizersEmollients and Moisturizers
Soothe, smooth and hydrate the skin
for dry and scaly skin In case of scalp psoriasis, the scales may be thick and adherent Emollients are useful with other
more specific treatment White soft paraffin ointment
Soothe, smooth and hydrate the skin
for dry and scaly skin In case of scalp psoriasis, the scales may be thick and adherent Emollients are useful with other
more specific treatment White soft paraffin ointment
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 27
Topical salicylic acidTopical salicylic acidTopical salicylic acidTopical salicylic acid
In particular, emollients containing keratolytic agents such as salicylic
acid helps remove scales and reduce hyperkeratosis
• Ointments containing 2%-10% salicylic acid are used with topical medications to Enhance absorption of other drugs
In particular, emollients containing keratolytic agents such as salicylic
acid helps remove scales and reduce hyperkeratosis
• Ointments containing 2%-10% salicylic acid are used with topical medications to Enhance absorption of other drugs
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
Systemic TreatmentSystemic TreatmentSystemic TreatmentSystemic Treatment
28
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 29
• For severe, resistant , complicated forms of psoriasis
– Oral retinoids; acitretin– Psoralin and UVA– Immunosuppressant therapy– Patients undergoing systemic treatment are
required to have regular blood and liver function tests because of the toxicity of the medication
– Pregnancy must be avoided for the majority of these treatments
• For severe, resistant , complicated forms of psoriasis
– Oral retinoids; acitretin– Psoralin and UVA– Immunosuppressant therapy– Patients undergoing systemic treatment are
required to have regular blood and liver function tests because of the toxicity of the medication
– Pregnancy must be avoided for the majority of these treatments
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 30
AcitretinAcitretinAcitretinAcitretin
• Oral retinoid approved for the treatment of severe psoriasis in
adults resistant to other form of therapies
• Significant improvement can be achieved within 8 weeks of therapy
• Side effects; dryness of skin , mm; conjunctiva, pruritus
• Oral retinoid approved for the treatment of severe psoriasis in
adults resistant to other form of therapies
• Significant improvement can be achieved within 8 weeks of therapy
• Side effects; dryness of skin , mm; conjunctiva, pruritus
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 31
Acitretin - ContraindicationsAcitretin - ContraindicationsAcitretin - ContraindicationsAcitretin - Contraindications
• Patients with severely impaired liver or kidney function
• Hyperlipidemia• Contraindicated in pregnant females
or those who intend to become pregnant.
• Patients with severely impaired liver or kidney function
• Hyperlipidemia• Contraindicated in pregnant females
or those who intend to become pregnant.
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 32
Oral PUVAOral PUVAOral PUVAOral PUVA
• Psoralen = “P” in PUVA = a photosensitizer
• Given 2 hours before UVA irradiation• Symptomatic control of severe,
disabling psoriasis, not responsive to other therapy
• Long-term: premature aging, cataracts, skin cancer
• Psoralen = “P” in PUVA = a photosensitizer
• Given 2 hours before UVA irradiation• Symptomatic control of severe,
disabling psoriasis, not responsive to other therapy
• Long-term: premature aging, cataracts, skin cancer
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
Drugs affectingDrugs affecting the immune response the immune response
Drugs affectingDrugs affecting the immune response the immune response
• Systemic drugs acting on the immune system are generally used by specialists in a hospital setting
• Examples: Methotrexate Cyclosporin Tacrolimus Mycophenolate mofetil
• Systemic drugs acting on the immune system are generally used by specialists in a hospital setting
• Examples: Methotrexate Cyclosporin Tacrolimus Mycophenolate mofetil
33
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 34
MethotrexateMethotrexateMethotrexateMethotrexate• For moderate-severe psoriasis non-responsive to
topical treatment• MOA:
– binds to DHFR which leads to reduction of tetrahydrofolate, which inhibits pyrimidine synthesis , thus inhibiting DNA replication esp rapidly dividing cells as in skin
– Induces apoptosis of activated T cells
• For moderate-severe psoriasis non-responsive to topical treatment
• MOA: – binds to DHFR which leads to reduction of
tetrahydrofolate, which inhibits pyrimidine synthesis , thus inhibiting DNA replication esp rapidly dividing cells as in skin
– Induces apoptosis of activated T cells
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004 35
Methotrexate: PrecautionsMethotrexate: PrecautionsMethotrexate: PrecautionsMethotrexate: Precautions
• Contraindicated: – Pregnancy, lactating mothers – Renal & liver problems– Preexisting severe anemia,
leukopenia, thrombocytopenia– Alcoholics– Active infectious disease– Side effects : BM depression, N, V,
stomatitis and development of megaloblastic anemia (Folate supplementation)
• Contraindicated: – Pregnancy, lactating mothers – Renal & liver problems– Preexisting severe anemia,
leukopenia, thrombocytopenia– Alcoholics– Active infectious disease– Side effects : BM depression, N, V,
stomatitis and development of megaloblastic anemia (Folate supplementation)
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
MethotrexateMethotrexateMethotrexateMethotrexate
• Folic acid antagonist that competitively inhibits dihydrofolate reductase
• effective treatment for psoriasis and psoriatic arthritis • Weekly single oral dose• Side effects :bone marrow depression,
nausea, stomatitis and development of megaloblastic anemia (Folate supplementation)
.
• Folic acid antagonist that competitively inhibits dihydrofolate reductase
• effective treatment for psoriasis and psoriatic arthritis • Weekly single oral dose• Side effects :bone marrow depression,
nausea, stomatitis and development of megaloblastic anemia (Folate supplementation)
.
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
CyclosporinCyclosporinCyclosporinCyclosporin
• Cyclosporin is a potent immuno-suppressant• Calcineurin Inhibitor and ultimately results in
inhibition of T-cell activation• Hypertension and renal dysfunction are the
major adverse effects
• Cyclosporin is a potent immuno-suppressant• Calcineurin Inhibitor and ultimately results in
inhibition of T-cell activation• Hypertension and renal dysfunction are the
major adverse effects
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
TacrolimusTacrolimusTacrolimusTacrolimus
• It is a potent macrolide immuno-suppressant traditionally used to prevent kidney, liver, and heart allograft rejection
• Calcineurin inhibitors, it works mainly by inhibiting early activation of T-lymphocytes
• Topical tacrolimus compared with topical glucocorticoids does not cause skin atrophy and therefore can be used safely in locations such as the face
• It is a potent macrolide immuno-suppressant traditionally used to prevent kidney, liver, and heart allograft rejection
• Calcineurin inhibitors, it works mainly by inhibiting early activation of T-lymphocytes
• Topical tacrolimus compared with topical glucocorticoids does not cause skin atrophy and therefore can be used safely in locations such as the face
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
Mycophenolate mofetil Mycophenolate mofetil Mycophenolate mofetil Mycophenolate mofetil
• It is an anti-proliferative immuno-suppressant approved for prophylaxis of organ rejection in patients with renal, cardiac, and hepatic transplants
• It inhibits the enzyme inosine mono-phosphatase dehydrogenase thereby depleting guanosine nucleotides essential for DNA and RNA synthesis
•
• It is an anti-proliferative immuno-suppressant approved for prophylaxis of organ rejection in patients with renal, cardiac, and hepatic transplants
• It inhibits the enzyme inosine mono-phosphatase dehydrogenase thereby depleting guanosine nucleotides essential for DNA and RNA synthesis
•
Dermatologic and Ophthalmic Drugs Advisory Committee Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004July 12, 2004
Monoclonal antibodiesMonoclonal antibodiesMonoclonal antibodiesMonoclonal antibodies
• Several monoclonal antibodies (MAbs)
(infliximab) work against TNF-alphaimmunomodulators
• Several monoclonal antibodies (MAbs)
(infliximab) work against TNF-alphaimmunomodulators
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