1
|
Fiehn C, Leipe J, Weseloh C, Bergner R, Krüger K. Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search. Z Rheumatol 2024; 83:8-19. [PMID: 37831190 DOI: 10.1007/s00393-023-01417-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 10/14/2023]
Abstract
Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective product information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.
Collapse
Affiliation(s)
- C Fiehn
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany.
- Tätigkeitsschwerpunkt klinische Immunologie, Rheumatologie Baden-Baden, Beethovenstr. 2, 76530, Baden-Baden, Germany.
| | - J Leipe
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- V. Medizinische Klinik, Universitätsmedizin Mannheim, Mannheim, Germany
| | - C Weseloh
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
| | - R Bergner
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Medizinische Klinik A, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - K Krüger
- Kommission Pharmakotherapie, Deutsche Gesellschaft für Rheumatologie (DGRh), Berlin, Germany
- Rheumatologisches Praxiszentrum St. Bonifatius, Munich, Germany
| |
Collapse
|
2
|
Kim JW, Chung SW, Pyo JY, Chang SH, Kim MU, Park CH, Lee JS, Lee JS, Ha YJ, Kang EH, Lee YA, Park YB, Lee EY, Choe JY. Methotrexate, leflunomide and tacrolimus use and the progression of rheumatoid arthritis-associated interstitial lung disease. Rheumatology (Oxford) 2023; 62:2377-2385. [PMID: 36394143 DOI: 10.1093/rheumatology/keac651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/08/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE To examine the association between MTX, LEF and tacrolimus use and the progression of RA-associated interstitial lung disease (ILD). METHODS The Korean RA-ILD cohort prospectively enrolled patients with RA-associated ILD at multiple centres from 2015 to 2018 and followed up with them for 3 years. ILD progression was defined by any of the followings: a decrease of ≥10% in forced vital capacity, a decrease of ≥15% in the diffusing capacity of the lung for carbon monoxide, or death from respiratory failure. RESULTS Of 143 patients, 64 patients experienced ILD progression during a median follow-up period of 33 months. The use of MTX [adjusted hazard ratio (aHR), 1.06; 95% CI, 0.59, 1.89], LEF (aHR, 1.75; 95% CI, 0.88, 3.46) and tacrolimus (aHR, 0.94; 95% CI, 0.52, 1.72) did not increase the risk of ILD progression. However, the association between LEF use and the risk of ILD progression was significant in subgroups with poor lung function (aHR, 8.42; 95% CI, 2.61, 27.15). Older age, male sex, a shorter RA duration, higher RA disease activity and extensive disease at baseline were independently associated with ILD progression. CONCLUSION None of the three treatments increased the risk of RA-associated ILD progression, except for LEF, which increased the risk of ILD progression in patients with severe ILD. The appropriate use of conventional synthetic disease-modifying antirheumatic drugs considering RA disease activity and ILD severity would be important for the management of RA-associated ILD.
Collapse
Affiliation(s)
- Ji-Won Kim
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Sang Wan Chung
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Jung Yoon Pyo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hae Chang
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea
| | - Min Uk Kim
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Chan Ho Park
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea
| | - Ji Sung Lee
- Department of Medical Statistics, Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Jeong Seok Lee
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yeon-Ah Lee
- Division of Rheumatology, Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Yoon Choe
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| |
Collapse
|
3
|
[Assessment of interactions and dosage recommendations of synthetic DMARDs-Evidence-based and consensus-based recommendations based on a systematic literature search]. Z Rheumatol 2023; 82:151-162. [PMID: 36633662 DOI: 10.1007/s00393-022-01308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 01/13/2023]
Abstract
Conventional synthetic (cs) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARD) have potential interactions with a multitude of drugs. Furthermore, they sometimes have a lower therapeutic index, particularly in cases of limited organ functions. The aim of this work was to establish evidence-based recommendations on the therapeutic use of DMARDs in the context of drug interactions and dosage recommendations. A systematic literature search was carried out on the issue of drug interactions and dosages in cases of patients with limited kidney function and higher age and suffering from rheumatoid arthritis. A total of 2756 scientific publications were screened and 154 selected of which 68 were scrutinized in detail. Furthermore, the respective specialist subject information was also analyzed. A multitude of possible interactions of synthetic DMARDs with different drugs were detected, which were then assessed with respect to the clinical significance and consequences. A consensus process led to making recommendations with which the interactions were classified: A: dangerous combination, B: avoid combination (if possible, pausing DMARD treatment), C: possible combination requiring increased monitoring and potential adjustments in dosage and D: pharmacological interaction without relevance in DMARD standard doses. Apart from that dosage recommendations were established for each csDMARD and tsDMARD depending on kidney function and age. There are 3 primary recommendations and 11 core recommendations on interactions and dosages of csDMARDs and tsDMARDs meant as a practical help for therapeutic decision making and to improve safety in the treatment of rheumatoid arthritis.
Collapse
|
4
|
Wang Z, Wu J, Li D, Tang X, Zhao Y, Cai X, Chen X, Chen X, Huang Q, Huang R. Traditional Chinese medicine Biqi capsule compared with leflunomide in combination with methotrexate in patients with rheumatoid arthritis: a randomized controlled trial. Chin Med 2020; 15:36. [PMID: 32336980 PMCID: PMC7178961 DOI: 10.1186/s13020-020-00319-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/16/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Biqi capsule is a traditional Chinese medicine widely used as a complementary and alternative treatment for rheumatoid arthritis (RA). The objective is to understand the efficacy, safety and mechanism of Biqi combined with methotrexate (MTX) in RA. METHODS We present a randomized, controlled pilot trial on Biqi combined with MTX against patients with active RA. Seventy patients were randomized 1:1 to receive Biqi + MTX or Leflunomide (LEF) + MTX for 24 weeks, and were assessed at baseline, 4, 12 and 24 weeks. Serum and urine samples were collected for metabolomics. RESULTS Overall, 81.2% patients in Biqi group achieved ACR20 at 24 weeks. No statistically significant differences were observed in primary or secondary outcomes between the two groups. A better safety profile was observed for Biqi with significantly fewer adverse effects reported (11.4%) compared to LEF group (40%, P < 0.05). Comparison between treatment responders and non-responders indicated a unique urine metabolic profile of enriched fatty acids and decreased acylcarnitines associated with Biqi responders, indicating a restored energy homeostasis in response to Biqi. The gene targets of these metabolites were significantly enriched in interleukin-4 and interleukin-13 pathways, implying that Biqi could ameliorate Th2-derived inflammatory response. Multivariate network analysis indicated that patient morning stiffness and SJC were key factors associated with metabolomics in Biqi-treated patients, whereas CRP was the main factor in LEF group. Therefore, Biqi and LEF likely work by influencing different patient clinical parameters. CONCLUSIONS Our study suggests that Biqi capsule can be a promising alternative option in combination with MTX for RA treatment, and demonstrates the capability of using metabolomics to interrogate mechanism of action for traditional Chinese medicine.Trial registration This trial is registered with ChiCTR, No. ChiCTR-IPR-16009029. Registered August 15, 2016. http://www.chictr.org.cn/showprojen.aspx?proj=15034.
Collapse
Affiliation(s)
- Zhang Wang
- Institute of Ecological Sciences, School of Life Sciences, South China Normal University, Guangzhou, China
| | - Jiaqi Wu
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Dongyun Li
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xuan Tang
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Yue Zhao
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangdong Provincial Key Laboratory of Clinical Research on Traditional Chinese Medicine Syndrome, and State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiao Cai
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xianghong Chen
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xiumin Chen
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Qingchun Huang
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Runyue Huang
- Section Rheumatology Research, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangdong Provincial Key Laboratory of Clinical Research on Traditional Chinese Medicine Syndrome, and State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| |
Collapse
|
5
|
Wang W, Zhou H, Liu L. The role of Chinese herbal medicine in the management of adverse drug reactions of leflunomide in treating rheumatoid arthritis. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2020; 68:153136. [PMID: 32062477 DOI: 10.1016/j.phymed.2019.153136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/30/2019] [Accepted: 11/17/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The high discontinuation rate in RA patients who use LEF might be attributed to their intolerance rather than irresponsibility. The concomitant administration of Leflunomide (LEF) with Chinese herbal medicine (CHM) provides a potential solution to preventing the adverse drug reactions (ADRs) induced by LEF during the treatment of rheumatoid arthritis (RA). PURPOSE To investigate whether co-administration of LEF with CHM could bring in both increased therapeutic outcomes and reduced ADRs due to the framework of treatment at the level of entire body. STUDY DESIGN The mechanism of LEF in RA treatment and the ADRs it induced was introduced based on recent papers. Reported clinical examples of CHM concurrent use with LEF was revealed to provide more evidence. The management of the ADRs caused by LEF was suggested by current researches on the concomitant therapy of CHM with LEF. RESULTS The active ingredients, compounds and medicinal herbs all demonstrated properties in relieving toxicities and reducing ADRs when used with LEF and reported in several clinical cases. The wide application of concurrent use of CHM with LEF is however hindered by the complex pathogenesis of RA which requires further scientific grounds for diagnosis and treatment. CONCLUSION This review introduced that the adoption of CHM is emerging as a novel strategy for the management of ADRs caused by LEF.
Collapse
Affiliation(s)
- Wanying Wang
- Faculty of Chinese Medicine/State Key Laboratory of Quality Research in Chinese Medicine/Institute of Rheumatic Diseases, Macau University of Science and Technology, Avenida Wailong, Taipa, Macau, PR China
| | - Hua Zhou
- Faculty of Chinese Medicine/State Key Laboratory of Quality Research in Chinese Medicine/Institute of Rheumatic Diseases, Macau University of Science and Technology, Avenida Wailong, Taipa, Macau, PR China; Joint Laboratory for Translational Cancer Research of Chinese Medicine of the Ministry of Education of the People's Republic of China, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, PR China
| | - Liang Liu
- Faculty of Chinese Medicine/State Key Laboratory of Quality Research in Chinese Medicine/Institute of Rheumatic Diseases, Macau University of Science and Technology, Avenida Wailong, Taipa, Macau, PR China.
| |
Collapse
|
6
|
Klotz L, Havla J, Schwab N, Hohlfeld R, Barnett M, Reddel S, Wiendl H. Risks and risk management in modern multiple sclerosis immunotherapeutic treatment. Ther Adv Neurol Disord 2019; 12:1756286419836571. [PMID: 30967901 PMCID: PMC6444778 DOI: 10.1177/1756286419836571] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
In recent years, there has been a paradigm shift in the treatment of multiple
sclerosis (MS) owing to the approval of a number of new drugs with very distinct
mechanisms of action. All approved disease-modifying drugs primarily work
directly on the immune system. However, the identification of an ‘optimal
choice’ for individual patients with regard to treatment efficacy, treatment
adherence and side-effect profile has become increasingly complex including
conceptual as well as practical considerations. Similarly, there are
peculiarities and specific requirements with regard to treatment monitoring,
especially in relation to immunosuppression, the development of secondary
immune-related complications, as well as the existence of drug-specific on- and
off-target effects. Both classical immunosuppression and selective immune
interventions generate a spectrum of potential therapy-related complications.
This article provides a comprehensive overview of available immunotherapeutics
for MS and their risks, detailing individual mechanisms of action and
side-effect profiles. Furthermore, practical recommendations for patients
treated with modern MS immunotherapeutics are provided.
Collapse
Affiliation(s)
- Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Building A1, Albert Schweitzer Campus 1, 48149 Münster, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, University Hospital; Data Integration for Future Medicine consortium (DIFUTURE), Ludwig-Maximilians University, Munich, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians University, Munich, Germany Munich Cluster for Systems Neurology, Ludwig-Maximilians University, Munich, Germany
| | | | - Stephen Reddel
- Brain and Mind Centre, University of Sydney, NSW, Australia
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Building A1, Albert Schweitzer Campus 1, 48149 Münster, Germany
| |
Collapse
|
7
|
Hodkinson B, Magomero KR, Tikly M. Combination leflunomide and methotrexate in refractory rheumatoid arthritis: a biologic sparing approach. Ther Adv Musculoskelet Dis 2016; 8:172-179. [PMID: 27721903 PMCID: PMC5037498 DOI: 10.1177/1759720x16664324] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In resource-constrained settings where biologic agents are not widely available, there are limited therapeutic options for patients with rheumatoid arthritis (RA) refractory to other synthetic disease modifying antirheumatic (DMARD) therapies. The aim of this study is to evaluate the effectiveness and safety of leflunomide (LEF) with methotrexate (MTX) in refractory RA. METHODS A retrospective record review of adult RA patients treated with LEF/MTX. Demographic details, adverse reactions, and the 3-variable 28 joint disease activity score (DAS28-3) were recorded at initiation of LEF/MTX therapy, and after 4 and 12 months of treatment. RESULTS Of 194 patients, most were middle-aged seropositive Black African females, with established disease [mean (standard deviation, SD) disease duration 9.4 (8.2) years] and time on previous DMARDs of 7.0 (5.5) years. Before adding LEF, the mean (SD) dose of MTX was 21.7 (3.5) mg/week, and 87.6% of patients used low dose oral corticosteroids. A good or moderate EULAR response was achieved by 44% and 42% of patients, and the retention rate was 71%. Major infections were seen in 6 patients: comprising 2 deaths, 3 cases of leucopaenia and septicaemia and 1 case of tuberculosis. Hepatotoxicity (n = 3), intolerable gastrointestinal symptoms (n = 3), and hypertension (n = 17) were the most common problems. Predictors of remission or low disease activity at 12 months was a baseline DAS28-3 ⩽ 5.5 [odds ratio (OR) = 2.7; 95% confidence interval (CI) 1.1-5.6; p = 0.01]. CONCLUSIONS LEF/MTX was effective in the majority of patients in this cohort of mainly Black African women who failed other combination synthetic DMARDs, particularly in those with moderate disease activity at the time of addition of LEF. Infections and hypertension were important complications. In a setting where biologic DMARDs are not readily accessible, the combination of LEF/MTX is a cost-effective approach.
Collapse
Affiliation(s)
- Bridget Hodkinson
- Division of Rheumatology, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences and University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Kingsley Ross Magomero
- Division of Rheumatology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed Tikly
- Division of Rheumatology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
8
|
Fragoso YD, Brooks JBB. Leflunomide and teriflunomide: altering the metabolism of pyrimidines for the treatment of autoimmune diseases. Expert Rev Clin Pharmacol 2015; 8:315-20. [PMID: 25712857 DOI: 10.1586/17512433.2015.1019343] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Leflunomide modulates T-cell responses and induces a shift from the Th1 to Th2 subpopulation. This process results in a beneficial effect in diseases in which there is good evidence that T cells play a major role in both initiation and perpetuation of the inflammatory condition. Leflunomide has been successfully used for treating rheumatoid arthritis and psoriatic arthritis for many years. The active metabolite of leflunomide is teriflunomide, which has been approved for treating multiple sclerosis. Teriflunomide, just like the mother drug, inhibits dihydro-orotate dehydrogenase and synthesis of pyrimidine. The present review presents and discusses the safety profiles of leflunomide and teriflunomide, two drugs that are indeed the same, considering that much can be learned from the reported side effects of both.
Collapse
Affiliation(s)
- Yara Dadalti Fragoso
- Department of Neurology, Medical School, Universidade Metropolitana de Santos, Rua da Constituicao 374, CEP 11015-470, Santos SP, Brazil
| | | |
Collapse
|