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Cogen JD, Nichols DP, Goss CH, Somayaji R. Drugs, Drugs, Drugs: Current Treatment Paradigms in Cystic Fibrosis Airway Infections. J Pediatric Infect Dis Soc 2022; 11:S32-S39. [PMID: 36069901 DOI: 10.1093/jpids/piac061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/23/2022] [Indexed: 12/15/2022]
Abstract
Airway infections have remained a prominent feature in persons living with cystic fibrosis (CF) despite the dramatic improvements in survival in the past decades. Antimicrobials are a cornerstone of infection management for both acute and chronic maintenance indications. Historic clinical trials of antimicrobials in CF have led to the adoption of consensus guidelines for their use in clinical care. More recently, however, there are efforts to re-think the optimal use of antimicrobials for care with the advent of novel and highly effective CF transmembrane conductance regulator modulator therapies. Encouragingly, however, drug development has remained active concurrently in this space. Our review focuses on the evidence for and perspectives regarding antimicrobial use in both acute and maintenance settings in persons with CF. The therapeutic innovations in CF and how this may affect antimicrobial approaches are also discussed.
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Affiliation(s)
- Jonathan D Cogen
- Department of Pediatrics, University of Washington , Seattle, Washington, USA
| | - David P Nichols
- Department of Pediatrics, University of Washington , Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington , USA
| | - Christopher H Goss
- Department of Pediatrics, University of Washington , Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington , USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Hypoxia-sensitive adjuvant loaded liposomes enhance the antimicrobial activity of azithromycin via phospholipase-triggered releasing for Pseudomonas aeruginosa biofilms eradication. Int J Pharm 2022; 623:121910. [PMID: 35710071 DOI: 10.1016/j.ijpharm.2022.121910] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022]
Abstract
Robust biofilms and the complex airway environment with thick sputum, local hypoxia and persistent inflammation induce the intractability of chronic pulmonary infections caused by Pseudomonas aeruginosa (P. aeruginosa). Herein, we proposed a type of antibiotic-adjuvant liposomes (NANO@PS-LPs), co-incorporating azithromycin (AZI), adjuvant (2-nitroimidazole derivative, 6-NIH) and biofilm dispersant (nitric oxide donor, DETA NONOate). NANO@PS-LPs possessing negatively-charged surface and good hydrophilicity could easily penetrate through the sputum layer, then disassembled triggered by overexpressed phospholipase A2 (PLA2) in the microenvironment around biofilms. Nitric oxide produced by DETA NONOate promoted P. aeruginosa biofilms dispersal. 6-NIH was reduced to 2-aminomidazole derivative (6-AIH) under a hypoxic condition, and hence acted as an AZI adjuvant to enhance the antibacterial activity of AZI. It was found that NANO@PS-LPs could significantly eliminate mature P. aeruginosa biofilms, effectively kill dispersed bacteria, inhibit the metabolism of survivors and prevent P. aeruginosa adherence to airway epithelial cells, accordingly restrain recurrent infections. Additionally, NANO@PS-LPs performed a remarkable advantage in killing AZI-resistant P. aeruginosa and removing their biofilms. In summary, NANO@PS-LPs present a potential nano-strategy to treat stubborn pseudomonal pulmonary infections and overcome correlative drug resistance.
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Nichols DP, Singh PK, Baines A, Caverly LJ, Chmiel JF, GIbson RL, Lascano J, Morgan SJ, Retsch-Bogart G, Saiman L, Sadeghi H, Billings JL, Heltshe SL, Kirby S, Kong A, Nick JA, Mayer-Hamblett N. Testing the effects of combining azithromycin with inhaled tobramycin for P. aeruginosa in cystic fibrosis: a randomised, controlled clinical trial. Thorax 2022; 77:581-588. [PMID: 34706982 PMCID: PMC9043040 DOI: 10.1136/thoraxjnl-2021-217782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/30/2021] [Indexed: 11/03/2022]
Abstract
RATIONALE Inhaled tobramycin and oral azithromycin are common chronic therapies in people with cystic fibrosis and Pseudomonas aeruginosa airway infection. Some studies have shown that azithromycin can reduce the ability of tobramycin to kill P. aeruginosa. This trial was done to test the effects of combining azithromycin with inhaled tobramycin on clinical and microbiological outcomes in people already using inhaled tobramycin. We theorised that those randomised to placebo (no azithromycin) would have greater improvement in forced expiratory volume in one second (FEV1) and greater reduction in P. aeruginosa sputum in response to tobramycin. METHODS A 6-week prospective, randomised, placebo-controlled, double-blind trial testing oral azithromycin versus placebo combined with clinically prescribed inhaled tobramycin in individuals with cystic fibrosis and P. aeruginosa airway infection. RESULTS Over a 6-week period, including 4 weeks of inhaled tobramycin, the relative change in FEV1 did not statistically significantly differ between groups (azithromycin (n=56) minus placebo (n=52) difference: 3.44%; 95% CI: -0.48 to 7.35; p=0.085). Differences in secondary clinical outcomes, including patient-reported symptom scores, weight and need for additional antibiotics, did not significantly differ. Among the 29 azithromycin and 35 placebo participants providing paired sputum samples, the 6-week change in P. aeruginosa density differed in favour of the placebo group (difference: 0.75 log10 CFU/mL; 95% CI: 0.03 to 1.47; p=0.043). CONCLUSIONS Despite having greater reduction in P. aeruginosa density in participants able to provide sputum samples, participants randomised to placebo with inhaled tobramycin did not experience significantly greater improvements in lung function or other clinical outcomes compared with those randomised to azithromycin with tobramycin.
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Affiliation(s)
- David P Nichols
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Pradeep K Singh
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - Arthur Baines
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F Chmiel
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ronald L GIbson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jorge Lascano
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Sarah J Morgan
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - George Retsch-Bogart
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Hossein Sadeghi
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Joanne L Billings
- Department of Medicine, Pulmonary, Allergy and Critical Care Division, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Shannon Kirby
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Ada Kong
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jerry A Nick
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
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Chin M, Brennan AL, Bell SC. Emerging non-pulmonary complications for adults with cystic fibrosis. Chest 2021; 161:1211-1224. [PMID: 34774529 DOI: 10.1016/j.chest.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/27/2021] [Accepted: 11/04/2021] [Indexed: 11/30/2022] Open
Abstract
Improved treatments of cystic fibrosis (CF) related lung disease have resulted in increased longevity, but also increasing prevalence and severity of extrapulmonary manifestations of CF, treatment related complications, age-related conditions and psychosocial effects of longstanding chronic disease. Likewise, the recognition of mild CF phenotypes has changed the landscape of CF disease. This review outlines our current understanding of the common extrapulmonary complications of CF, as well as the changing landscape and future directions of the extrapulmonary complications experienced by patients with CF.
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Affiliation(s)
- Melanie Chin
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Amanda L Brennan
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Scott C Bell
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia.
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Effect of Concomitant Azithromycin and Tobramycin Use on Cystic Fibrosis Pulmonary Exacerbation Treatment. Ann Am Thorac Soc 2021; 18:266-272. [PMID: 32810412 DOI: 10.1513/annalsats.202002-176oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Pulmonary exacerbations (PExs) are associated with significant morbidity in people with cystic fibrosis (CF). Severe PExs are treated with intravenous antibiotics, including tobramycin. CF care guidelines recommend continuing chronic maintenance medications during PEx treatment. Azithromycin (AZM) is one of the most widely prescribed chronic medications for CF in the United States. Recent evidence has identified a potential antagonistic relationship between AZM and tobramycin.Objectives: To determine whether, among PEx treated with intravenous tobramycin, concomitant AZM use is associated with worse clinical outcomes.Methods: Retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System (CFFPR-PHIS)-linked dataset. People with CF age 6-21 years were included if they were hospitalized between 2006 and 2016 for a PEx. Inverse probability of treatment weighing was used to minimize the effects of confounders, including indication bias. Associations of concomitant treatment with AZM and lung function outcomes were determined using linear mixed-effect models and generalized estimating equations. Cox proportional hazard regression models were used to evaluate associations with time to next PEx.Results: Among the 10,660 people with CF included in the CFFPR-PHIS-linked dataset, 2,294 children and adolescents with 5,022 PExs that had intravenous tobramycin use were identified. A little less than half (n = 2,247; 45%) of all PExs were treated concomitantly with AZM and intravenous tobramycin. AZM use both at the most recent outpatient clinic encounter and during PEx treatment in combination with intravenous tobramycin was associated with a significantly lower absolute improvement in percentage-predicted forced expiratory volume in 1 second (ppFEV1) (-0.93%; 95% confidence interval [CI], -1.78 to -0.07; P = 0.033), a lesser odds of returning to 90% or more of baseline ppFEV1 (odds ratio, 0.79; 95% CI, 0.68-0.93; P = 0.003), and a shorter time to next PEx requiring intravenous antibiotics (hazard ratio, 1.22; 95% CI, 1.14-1.31; P < 0.001) compared with intravenous tobramycin use without concomitant AZM.Conclusions: Concomitant AZM and intravenous tobramycin use for in-hospital PEx treatment was associated with poorer clinical outcomes than treatment with intravenous tobramycin without AZM. These results support the hypothesis that an antagonistic relationship between these two medications might exist.
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Azithromycin and Tobramycin Therapy in Cystic Fibrosis Pulmonary Exacerbations: Less Is More? Ann Am Thorac Soc 2021; 18:213-215. [PMID: 33522874 PMCID: PMC7869784 DOI: 10.1513/annalsats.202009-1227ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Pharmacokinetic and Pharmacodynamic Optimization of Antibiotic Therapy in Cystic Fibrosis Patients: Current Evidences, Gaps in Knowledge and Future Directions. Clin Pharmacokinet 2021; 60:409-445. [PMID: 33486720 DOI: 10.1007/s40262-020-00981-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Antibiotic therapy is one of the main treatments for cystic fibrosis (CF). It aims to eradicate bacteria during early infection, calms down the inflammatory process, and leads to symptom resolution of pulmonary exacerbations. CF can modify both the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of antibiotics, therefore specific PK/PD endpoints should be determined in the context of CF. Currently available data suggest that optimal PK/PD targets cannot be attained in sputum with intravenous aminoglycosides. Continuous infusion appears preferable for β-lactam antibiotics, but optimal concentrations in sputum are unlikely to be reached, with some possible exceptions such as meropenem and ceftolozane. Usual doses are likely suboptimal for fluoroquinolones and linezolid, whereas daily doses of 45-60 mg/kg and 200 mg could be convenient for vancomycin and doxycycline, respectively. Weekly azithromycin doses of 22-30 mg/kg could also be appropriate for its anti-inflammatory effect. The difficulty with achieving optimal concentrations supports the use of combined treatments and the inhaled administration route, as very high local concentrations, concomitantly with low systemic exposure, can be obtained with the inhaled route for aminoglycosides, colistin, and fluoroquinolones, thus minimizing the risk of toxicity.
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Nichols DP, Odem-Davis K, Cogen JD, Goss CH, Ren CL, Skalland M, Somayaji R, Heltshe SL. Pulmonary Outcomes Associated with Long-Term Azithromycin Therapy in Cystic Fibrosis. Am J Respir Crit Care Med 2020; 201:430-437. [PMID: 31661302 PMCID: PMC7049934 DOI: 10.1164/rccm.201906-1206oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rationale: Chronic azithromycin is commonly used in cystic fibrosis based on short controlled clinical trials showing reductions in pulmonary exacerbations and improved FEV1. Long-term effects are unknown. Objectives: Examine pulmonary outcomes among chronic azithromycin users compared with matched controls over years of use and consider combined azithromycin use in cohorts using chronic inhaled tobramycin or aztreonam. Methods: This retrospective cohort study used the U.S. cystic fibrosis Foundation Patient Registry. Incident chronic azithromycin users were compared with matched controls by FEV1% predicted rate of decline and rates of intravenous antibiotic use to treat pulmonary exacerbations. Propensity score methods were utilized to address confounding by indication. Predefined sensitivity analyses based on lung function, Pseudomonas aeruginosa (PA) status, and follow-up time intervals were conducted. Measurements and Main Results: Across 3 years, FEV1% predicted per-year decline was nearly 40% less in those with PA using azithromycin compared with matched controls (slopes, −1.53 versus −2.41% predicted per yr; difference: 0.88; 95% confidence interval [CI], 0.30–1.47). This rate of decline did not differ based on azithromycin use in those without PA. Among all cohorts, use of intravenous antibiotics was no different between azithromycin users and controls. Users of inhaled tobramycin and azithromycin had FEV1% predicted per-year decline of −0.16 versus nonusers (95% CI, −0.44 to 0.13), whereas users of inhaled aztreonam lysine and azithromycin experienced a mean 0.49% predicted per year slower decline than matched controls (95% CI, −0.11 to 1.10). Conclusions: Results from this study provide additional rationale for chronic azithromycin use in PA-positive patients to reduce lung function decline.
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Affiliation(s)
- Dave P Nichols
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington.,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, and
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, and
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine and Department of Pediatrics, University of Washington, Seattle, Washington
| | - Clement L Ren
- Division of Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, Indiana; and
| | - Michelle Skalland
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
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Bush A. Azithromycin is the answer in paediatric respiratory medicine, but what was the question? Paediatr Respir Rev 2020; 34:67-74. [PMID: 31629643 DOI: 10.1016/j.prrv.2019.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023]
Abstract
The first clinical indication of non-antibiotic benefits of macrolides was in the Far East, in adults with diffuse panbronchiolitis. This condition is characterised by chronic airway infection, often with Pseudomonas aeruginosa, airway inflammation, bronchiectasis and a high mortality. Low dose erythromycin, and subsequently other macrolides, led in many cases to complete remission of the condition, and abrogated the neutrophilic airway inflammation characteristic of the disease. This dramatic finding sparked a flurry of interest in the many hundreds of macrolides in nature, especially their anti-inflammatory and immunomodulatory effects. The biggest subsequent trials of azithromycin were in cystic fibrosis, which has obvious similarities to diffuse panbronchiolitis. There were unquestionable improvements in lung function and pulmonary exacerbations, but compared to diffuse panbronchiolitis, the results were disappointing. Case reports, case series and some randomised controlled trials followed in other conditions. Three trials of azithromycin in preschool wheeze gave contradictory results; a trial in pauci-inflammatory adult asthma, and a trial in non-cystic fibrosis bronchiectasis both showed a significant reduction in exacerbations, but none matched the dramatic results in diffuse panbronchiolitis. There is clearly a huge risk of antibacterial resistance if macrolides are used widely and uncritically in the community. In summary, Azithromycin is not the answer to anything in paediatric respiratory medicine; the paediatric respiratory community needs to refocus on the dramatic benefits of macrolides in diffuse panbronchiolitis, use modern - omics technologies to determine the endotypes of inflammatory diseases and discover in nature or synthesise designer macrolides to replicate the diffuse panbronchiolitis results. We must now find out how to do better!
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Affiliation(s)
- Andrew Bush
- Professor of Paediatrics and Paediatric Respirology, Imperial College Consultant Paediatric Chest Physician, Royal Brompton & Harefield NHS Foundation Trust, National Heart and Lung Institute, UK; Paediatric Chest Physician, Royal Brompton Harefield NHS Foundation Trust, UK.
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Abstract
PURPOSE OF REVIEW Due to continuous development of new drugs and better treatment strategies, survival of patients with cystic fibrosis has changed dramatically. Recently, targeted therapy of cystic fibrosis transmembrane conductance regulator (CFTR) modulators have become available. Despite these promising developments, treatment of this complex multiorgan disease constitutes a high and variable amount of other drugs. Complications of pharmacotherapeutic treatment are, therefore, expected to become more prevalent. This gives cause to review drug-related side effects in this new era in cystic fibrosis treatment. RECENT FINDINGS We will discuss cystic fibrosis-related pharmacotherapies with a focus on indication of treatment, side effects and their complications, drug--drug interactions, and options to monitor and prevent drug-induced toxicity. Many recent publications about pharmacotherapy in cystic fibrosis, focus on antifungal therapy and CFTR modulators. We will give an overview of the most important studies. SUMMARY With increased life expectancy which is, in part, because of better treatment options, the burden of pharmacotherapy in cystic fibrosis patients will increase. This has a high impact on quality of life as pharmacotherapy is time consuming and may cause side effects. Therefore, it is very important to be aware of possible pharmacotherapy-related side effects and their complications, drug--drug interactions, and options to monitor and prevent drug-induced toxicity.
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