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1.
RSC Adv ; 14(27): 19197-19205, 2024 Jun 12.
Article in English | MEDLINE | ID: mdl-38882479

ABSTRACT

Entresto™ (LCZ696) has been approved globally for heart failure management. However, its lifelong use alongside over-the-counter (OTC) drugs like ibuprofen (IBU) and fexofenadine (FEX) necessitates an in-depth investigation of potential pharmacokinetic interactions, as they share the same metabolic and elimination pathways. This study aimed to develop a bioanalytical HPLC method with a fluorescence detector (FLD) to quantify LCZ696 analytes (valsartan, VAL; sacubitril, SAC; and sacubitril active metabolite, LBQ657) in rat plasma. Additionally, an in vivo study was performed to investigate the pharmacokinetic interactions of LCZ696 with IBU and FEX. Utilizing HPLC with a gradient-mode mobile phase of acetonitrile and 0.025 M phosphate buffer (pH 3), the study demonstrated a significant increase in the bioavailability of LCZ696 analytes (VAL and LBQ657) when co-administered with IBU (C max 0.23 ± 0.07 and 0.53 ± 0.21 µg mL-1, respectively) compared to the control (0.17 ± 0.03 and 0.33 ± 0.14 µg mL-1). A more significant increase in C max was noticed with FEX (0.38 ± 0.01 and 0.77 ± 0.18 µg mL-1, respectively). Moreover, a decrease in the clearance (Cl/F) of VAL and LBQ657 was observed (18.05 ± 1.94 and 12.42 ± 2.97 L h-1 kg, respectively) with a more pronounced effect in the case of FEX (30.87 ± 4.29 and 33.14 ± 9.57 L h-1 kg, respectively) compared to the control (49.99 ± 7.31 and 51.19 ± 9.12 L h-1 kg, respectively). In conclusion, our study underscores the importance of cautious administration and appropriate dose spacing of IBU and FEX in patients treated with LCZ696 to prevent elevated serum concentrations and potential toxicity. The novelty of this work lies in its dual contribution: developing a highly sensitive HPLC-FLD method and comprehensively elucidating significant pharmacokinetic interactions between LCZ696 and common OTC drugs.

2.
Int J Pharm X ; 5: 100170, 2023 Dec.
Article in English | MEDLINE | ID: mdl-36844895

ABSTRACT

Caffeine (CAF) is a challenging natural bioactive compound with proven antiaging efficacy. However, being hydrophilic hampers its permeation through the skin. Our aim is to develop a novel CAF-loaded nano-cosmeceutical tool counteracting skin photoaging via improving CAF skin permeation using a bioactive nanocarrier. Caffeinated hyalurosomes are novel biocompatible antiaging nanoplatforms designed by immobilization of phospholipid vesicles with a hyaluronan polymer. Physicochemical properties of the selected hyalurosomes formulation showed nano-sized vesicles (210.10 ± 1.87 nm), with high zeta potential (-31.30 ± 1.19 mv), and high encapsulation efficiency (84.60 ± 1.05%). In vitro release results showed outstanding sustained release profile from caffeinated hyalurosomes compared to the CAF-loaded in conventional gel over 24 h. The in-vivo study revealed a photoprotective effect of caffeinated hyalurosomes, reflected from the intact and wrinkling-free skin. Results of biochemical analyses of oxidative stress, pro-inflammatory mediators, and anti-wrinkling markers further confirmed the efficacy of the prepared hyalurosomes compared to the CAF conventional gel. Finally, histopathological examination demonstrated normal histological structures of epidermal layers with minimal inflammatory cell infiltrates in the caffeinated hyalurosomes group compared to the positive control group. Conclusively, caffeinated hyalurosomes successfully achieved enhanced CAF loading and penetration into the skin besides the hydration effect of hyaluronan. Consequently, the developed delivery system presents a promising skin protection nano-platforms via the double effects of both hyaluronan and CAF, hence it guards against skin photodamage.

3.
Pharmaceutics ; 14(5)2022 May 06.
Article in English | MEDLINE | ID: mdl-35631589

ABSTRACT

Preparation and evaluation of a non-invasive intranasal luteolin delivery for the management of cognitive dysfunction in Alzheimer's disease (AD) using novel chitosan decorated nanoparticles. Development of luteolin-loaded chitosomes was followed by full in vitro characterization. In vivo efficacy was evaluated using a sporadic Alzheimer's disease (SAD) animal model via intracerebroventricular injection of 3 mg/kg streptozotocin (ICV-STZ). Treatment groups of luteolin suspension and chitosomes (50 mg/kg) were then intranasally administered after 5 h of ICV-STZ followed by everyday administration for 21 consecutive days. Behavioral, histological, immunohistochemical, and biochemical studies were conducted. Chitosomes yielded promising quality attributes in terms of particle size (PS) (412.8 ± 3.28 nm), polydispersity index (PDI) (0.378 ± 0.07), Zeta potential (ZP) (37.4 ± 2.13 mv), and percentage entrapment efficiency (EE%) (86.6 ± 2.05%). Behavioral findings showed obvious improvement in the acquisition of short-term and long-term spatial memory. Furthermore, histological evaluation revealed an increased neuronal survival rate with a reduction in the number of amyloid plaques. Biochemical results showed improved antioxidant effects and reduced pro-inflammatory mediators' levels. In addition, a suppression by half was observed in the levels of both Aß aggregation and hyperphosphorylated-tau protein in comparison to the model control group which in turn confirmed the capability of luteolin-loaded chitosomes (LUT-CHS) in attenuating the pathological changes of AD. The prepared nanoparticles are considered a promising safe, effective, and non-invasive nanodelivery system that improves cognitive function in SAD albino mice as opposed to luteolin suspension.

4.
Pharmaceutics ; 14(3)2022 Mar 05.
Article in English | MEDLINE | ID: mdl-35335952

ABSTRACT

Impaired memory and cognitive function are the main features of Alzheimer's disease (AD). Unfortunately, currently available treatments cannot cure or delay AD progression. Moreover, the blood-brain barrier hampers effective delivery of treatment to the brain. Therefore, we aimed to evaluate the impact of intranasally delivered luteolin on AD using bile-salt-based nano-vesicles (bilosomes). Different bilosomes were prepared using 23-factorial design. The variables were defined by the concentration of surfactant, the molar ratio of cholesterol:phospholipid, and the concentration of bile salt. Results demonstrated optimized luteolin-loaded bilosomes with particle size (153.2 ± 0.98 nm), zeta potential (-42.8 ± 0.24 mV), entrapment efficiency% (70.4 ± 0.77%), and % drug released after 8 h (80.0 ± 1.10%). In vivo experiments were conducted on an AD mouse model via intracerebroventricular injection of 3 mg/kg streptozotocin. We conducted behavioral, biochemical marker, histological, and immune histochemistry assays after administering a luteolin suspension or luteolin bilosomes (50 mg/kg) intranasally for 21 consecutive days. Luteolin bilosomes improved short-term and long-term spatial memory. They also exhibited antioxidant properties and reduced levels of proinflammatory mediators. They also suppressed both amyloid ß aggregation and hyperphosphorylated Tau protein levels in the hippocampus. In conclusion, luteolin bilosomes are an effective, safe, and non-invasive approach with superior cognitive function capabilities compared to luteolin suspension.

5.
Int J Pharm ; 615: 121523, 2022 Mar 05.
Article in English | MEDLINE | ID: mdl-35104596

ABSTRACT

Vitiligo is a depigmentation disorder that affects 0.5-2% of the world population. It has a severe impact on a patient's quality of life and even causes suicidal attempts. Up to date, no curative therapy is available which have created a substantial demand for novel vitiligo treatments. Berberine (BRB) is an isoquinoline alkaloid with promising pharmacological effects. However, it suffers from poor membrane permeability hindering its topical application. The current work is the first to design and assess topical BRB-loaded hyalurosomes for targeted vitiligo treatment. BRB-hyalurosomes are hyaluronan-immobilized phospholipid nanovesicles that showed promising invitro physicochemical properties. Novel ex vivo studies were performed using full-thickness human skin to mimic its dermal application. Furthermore, in-vivo studies were conducted using a vitiligo-induced mouse model followed by biochemical, histological and immunohistochemical investigations. In addition, gene expression of skin inflammatory markers was assessed using quantitative reverse-transcription PCR. Biological studies showed significant improvement of the biochemical markers in BRB-hyalurosomes group compared to the vitiligo-model group and BRB conventional gel. It is worthy to mention that placebo hyalurosomes demonstrated significant enhancement in the biological activity confirming its intrinsic activity. Conclusively, BRB-hyalurosomes is considered a novel nanodermatological tool that paving the way for its clinical application for vitiligo treatment.


Subject(s)
Berberine , Vitiligo , Animals , Gene Expression , Mice , Quality of Life , Skin , Vitiligo/drug therapy
6.
Colloids Surf B Biointerfaces ; 211: 112299, 2022 Mar.
Article in English | MEDLINE | ID: mdl-34953364

ABSTRACT

The present study improved the effectiveness of a poorly water-soluble drug, luteolin (LUT), by encapsulating it in lecithin-bile salt-integrated system called bilosomes (BLs). Such a delivery system offers the benefits of mimicking the skin's biological structure and being a prominent tool to circumvent skin delivery obstacles. The prepared BLs underwent complete in vitro assessment. The developed BLs showed enhanced characteristics compared to free luteolin suspension (P < 0.05). Optimized BLs attained good entrapment efficiency (78.60% ± 0.88%), small particle size (226.1 ± 2.45 nm), and sustained drug-release pattern. The study also showed that both blank and LUT-loaded BLs preparations were safe to the skin with a primary irritancy index of < 2 based on the Draize test. In vivo tests were conducted to study the effect of the bile salt-based nanovesicles compared with the free LUT suspension. The photoprotective effect was evaluated according to the visual examination and biochemical analyses of antioxidant, anti-inflammatory, and anti-wrinkling markers after ultraviolet B irradiation. Results of biochemical markers and histopathological examination demonstrated that the LUT-BLs effect was superior than the LUT suspension (P < 0.05). Consequently, the current study proves that novel LUT-loaded BLs is a promising nanoplatform that overcome LUT delivery obstacles and, hence, alleviate UV-induced skin damage.


Subject(s)
Lecithins , Luteolin , Animals , Bile Acids and Salts , Luteolin/pharmacology , Rats , Rats, Wistar , Skin
7.
AAPS PharmSciTech ; 22(7): 246, 2021 Oct 06.
Article in English | MEDLINE | ID: mdl-34617166

ABSTRACT

Andrographolide (AG) is an antitumor phytochemical that acts against non-Hodgkin's lymphoma. However, AG shows low oral bioavailability due to extensive first-pass metabolism and P-glycoprotein efflux. Novel biocompatible lipoprotein-simulating nanosystems, emulsomes (EMLs), have gained significant attention due to their composition of natural components, in addition to being lymphotropic. Loading AG on EMLs is believed to mitigate the disadvantage of AG and enhance its lymphatic transport. This study developed a chylomicron-simulating system (EMLs) as a novel tool to overcome the AG oral delivery obstacles. Optimized EML-AG had a promising vesicular size of 281.62 ± 1.73 nm, a zeta potential of - 22.73 ± 0.06 mV, and a high entrapment efficiency of 96.55% ± 0.25%, which favors lymphatic targeting. In vivo pharmacokinetic studies of EML-AG showed significant enhancement (> sixfold increase) in the rate and extent of AG absorption compared with free AG. However, intraperitoneal injection of a cycloheximide inhibitor caused a significant decrease in AG absorption (~ 52%), confirming the lymphatic targeting potential of EMLs. Therefore, EMLs can be a promising novel nanoplatform for circumventing AG oral delivery obstacles and provide targeted delivery to the lymphatic system at a lower dose with fewer side effects.


Subject(s)
Diterpenes , Administration, Oral , Biological Availability , Phytochemicals
8.
Nanomedicine (Lond) ; 16(22): 1983-1998, 2021 09.
Article in English | MEDLINE | ID: mdl-34420422

ABSTRACT

Aim: The aim of this study was to elaborate on 'bioemulsomes,' novel biocompatible lipoprotein analogs for effective lymphatic transport of baicalin (BCL). Methods: BCL bioemulsomes were developed and optimized and in vitro physicochemical characterization performed. The bioavailability of BCL bioemulsomes compared with free BCL was investigated using in vivo pharmacokinetics studies. Finally, BCL lymphatic transport was assessed via cycloheximide blockade assay. Results: Optimized BCL-loaded nanoemulsomes showed promising in vitro characteristics that favor lymphatic targeting. In vivo pharmacokinetics showed a significant improvement in bioavailability over free BCL. A significant decrease in BCL emulsome absorption (33%) was exhibited after chemical blockage of the lymphatic pathway, confirming the lymphatic transport potential. Conclusion: Bioemulsomes could be a promising tool for bypassing BCL oral delivery hurdles as well as lymphatic transport, paving the way for potential treatment of lymphoma.


Subject(s)
Flavonoids , Administration, Oral , Animals , Biological Availability , Rats , Rats, Sprague-Dawley
9.
J Control Release ; 311-312: 125-137, 2019 10.
Article in English | MEDLINE | ID: mdl-31476342

ABSTRACT

Ovarian carcinoma (OC) is one of the leading causes of death among gynecologic malignancies all over the world. It is characterized by high mortality rate because of the lack of early diagnosis. The first-line chemotherapeutic regimen for late stage epithelial ovarian cancer is paclitaxel in combination to carboplatin. However, in most of cases, relapse occurs within six months despite the initial success of this chemotherapeutic combination. A lot of challenges have been encountered with the conventional delivery of paclitaxel in addition to the occurrence of severe off-target toxicity. One major problem is poor paclitaxel solubility which was improved by addition of Cremophor EL that unfortunately resulted in hypersensitivity side effects. Another obstacle is the multi drug resistance which is the main cause of OC recurrence. Accordingly, incorporation of paclitaxel, solely or in combination to other drugs, in nanocarrier systems has grabbed attention of many researchers to circumvent all these hurdles. The current review is the first article that provides a comprehensive overview on multi-faceted implementations of paclitaxel loaded nanoplatforms to solve delivery obstacles of paclitaxel in management of ovarian carcinoma. Moreover, challenges in physicochemical properties, biological activity and targeted delivery of PTX were depicted with corresponding solutions using nanotechnology. Different categories of nanocarriers employed were collected included lipid, protein, polymeric, solid nanoemulsion and hybrid systems. Future perspectives including imperative research considerations in ovarian cancer therapy were proposed as well.


Subject(s)
Antineoplastic Agents, Phytogenic/administration & dosage , Drug Delivery Systems , Nanoparticles/administration & dosage , Ovarian Neoplasms/therapy , Paclitaxel/administration & dosage , Animals , Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Female , Gene Silencing , Humans , Nanotechnology
10.
Pharm Res ; 35(1): 18, 2018 01 05.
Article in English | MEDLINE | ID: mdl-29305670

ABSTRACT

PURPOSE: To develop novel bioactive-chylomicrons to solve oral delivery obstacles of Berberine chloride and target the lymphatic system. METHODS: Berberine-loaded bioactive-chylomicrons were prepared and underwent full in vitro characterization. Intestinal permeability was appraised via both non-everted gut sac model and Caco-2 cell model. Furthermore, Bioactive-chylomicrons' cellular uptake and distribution were examined by laser scanning confocal microscopy. Finally, a novel chylomicron flow-blockage assay on tissue and cellular levels were elaborated to assess the lymphatic targeting ability. RESULTS: Berberine-loaded chylomicrons showed spherical vesicles of size (175.6 nm), PDI (0.229), zeta potential (-16 .6 mV) and entrapment efficiency (95.5%). Ex-vivo intestinal permeability studies demonstrated 10.5 fold enhancement in permeability of Berberine-loaded chylomicrons over free Berberine. Moreover, Caco-2 studies revealed significant improvement in chylomicrons' permeability and cellular uptake. Furthermore, confocal microscopy analyses revealed 2 fold increase in berberine-loaded chylomicrons' intracellular fluorescence. Lymphatic targeting models were successfully elaborated using cycloheximide protein synthesis inhibitor. Such models demonstrated 47 and 27.5% reduction in ex-vivo and Caco-2 permeability respectively. Finally, a good rank order correlation was established between different permeability assessment techniques. CONCLUSION: The findings shed the light on the underlying mechanisms of Berberine bioavailability improvement. Consequently, berberine-loaded chylomicrons could be considered as promising bioactive-nanocarriers for Berberine lymphatic targeting and bioavailability improvement.


Subject(s)
Berberine/administration & dosage , Berberine/chemistry , Chylomicrons/chemistry , Lymphatic System/drug effects , Administration, Oral , Animals , Berberine/therapeutic use , Biological Availability , Biological Transport , Caco-2 Cells , Cell Survival , Chemistry, Pharmaceutical/methods , Chromatography, High Pressure Liquid/methods , Drug Carriers/chemistry , Drug Liberation , Humans , Intestinal Absorption/physiology , Male , Optical Imaging/methods , Particle Size , Permeability , Rats, Sprague-Dawley , Surface Properties
11.
Int J Pharm ; 535(1-2): 316-324, 2018 Jan 15.
Article in English | MEDLINE | ID: mdl-29138046

ABSTRACT

Berberine chloride (BER) is an antineoplastic phytomedicine that combat non-Hodgkin lymphoma. BER suffers from low oral bioavailability due to p-glycoprotein efflux and first-pass metabolism. Lymphatic drug targeting recently gained a profound attention due to circumventing hepatic first-pass metabolism and targeting lymph diseases. Therefore, novel BER-loaded cremochylomicrons were elaborated to mitigate BER drawbacks and enhance its lymphatic targeting and bioavailability. Optimized cremochylomicron was prepared with 2.5%w/v Cremophor El and 12.5% w/w berberine content. Promising in vitro characteristics (particle size = 175.6 nm and entrapment efficiency = 95.5%) were obtained. Lyophilized system showed high colloidal stability over 6 months. In addition in vivo pharmacokinetics study demonstrated significant enhancement (>2fold) in the rate and extent of absorption in cremochylomicron over free BER. Moreover, cremochylomicrons demonstrated in significant increase in mean residence time and volume of distribution with decreased intestinal drug clearance as a result of efflux inhibition. In another avenue, a significant reduction in BER absorption (43%) in presence of cycloheximide inhibitor was obtained confirming the lymphatic targeting ability of cremochylomicrons. In conclusion, berberine-loaded cremochylomicron could be considered as a promising nanoplatform for targeting lymphatic system and improving BER oral bioavailability with lower dose and side effects.


Subject(s)
Antineoplastic Agents, Phytogenic/administration & dosage , Berberine/administration & dosage , Lipoproteins/administration & dosage , Administration, Oral , Animals , Antineoplastic Agents, Phytogenic/blood , Antineoplastic Agents, Phytogenic/chemistry , Antineoplastic Agents, Phytogenic/pharmacokinetics , Berberine/blood , Berberine/chemistry , Berberine/pharmacokinetics , Biological Availability , Lipoproteins/chemistry , Lipoproteins/pharmacokinetics , Male , Rats, Sprague-Dawley , Surface-Active Agents/administration & dosage , Surface-Active Agents/chemistry , Surface-Active Agents/pharmacokinetics
12.
Nanomedicine (Lond) ; 13(2): 209-232, 2018 Jan.
Article in English | MEDLINE | ID: mdl-29199881

ABSTRACT

AIM: A novel luteolin (LUT) loaded dual bionanocarrier 'phytochylomicron' was elaborated to allow LUT injectable delivery and liver cancer targeting. METHODS: LUT-phospholipid complex was prepared and loaded into chylomicron nanocarrier. Then phytochylomicron underwent physicochemical characterization, cell culture and pharmacodynamics studies on a new liver-tumor model. RESULTS: Phytochylomicron showed sustained release pattern with minimum drug leakage until reaching the liver. Cell culture studies showed high growth inhibition of Hep G2 cells with 2.6-fold enhancement in cellular uptake. Pharmacodynamics demonstrated enhanced tumor growth inhibition (sixfold) with a significant tumor size reduction. Finally, cell culture results demonstrated an excellent correlation with pharmacodynamics confirming the obtained findings. CONCLUSION: A novel phytochylomicron nanosystem was successfully elaborated with promising characteristics that promoted injectable LUT delivery and liver cancer targeting. [Formula: see text].


Subject(s)
Antineoplastic Agents/administration & dosage , Chylomicrons/chemistry , Drug Carriers/chemistry , Liver Neoplasms/drug therapy , Luteolin/administration & dosage , Animals , Apoptosis , Carcinoma, Ehrlich Tumor/drug therapy , Cell Line, Tumor , Cell Survival , Drug Liberation , Humans , Liver/metabolism , Male , Mice , Nanoparticles/chemistry , Particle Size , Phospholipids/chemistry , Surface Properties , Tissue Distribution
13.
J Control Release ; 194: 92-102, 2014 Nov 28.
Article in English | MEDLINE | ID: mdl-25194779

ABSTRACT

Nanomedicines are enjoying a widespread popularity realizing their intriguing potential to solve drug delivery obstacles. Assessment of major quality attributes of nanocarriers is a crucial process for approving their therapeutic outcomes. Disparate assessment methods that recently encompassed cell line technique were employed . Routinely, a cell line model was viewed as an excellent platform for gene and vaccine deliveries. However, its application in pharmaceutical assessment of nanocarriers was not so far overviewed. This review provides a meticulous look at cell culture implementations in evaluation of major quality attributes of nanocarriers, including oral permeability, cytotoxicity and efficiency of tumor targeting. Among others, cell culture technique strikes the right balance between predictability and throughput. It could circumvent drawbacks of in-vivo and in-vitro techniques while gathering privileges of both. Imperative pharmaceutical considerations demanded for proper application of this technique were emphasized. Furthermore, challenges encountered in assessment of versatile nanocarriers were highlighted with proposed solutions. Finally, future research perspectives in this theme issue were suggested.


Subject(s)
Cells, Cultured/drug effects , Drug Carriers/chemistry , Nanoparticles , Pharmacology, Clinical/methods , Animals , Cell Survival/drug effects , Drug Carriers/adverse effects , Humans , Nanomedicine/methods
14.
Int J Nanomedicine ; 7: 3787-802, 2012.
Article in English | MEDLINE | ID: mdl-22888234

ABSTRACT

Raloxifene hydrochloride (RLX) is a selective estrogen-receptor modulator for treatment of osteoporosis and prevention of breast and endometrial cancer. By virtue of extensive presystemic clearance, RLX bioavailability is only 2%. The current study aimed to tailor and characterize RLX-loaded self-nanoemulsifying drug-delivery systems (SNEDDS) using bioactive excipients affecting drug metabolism. The potential of oral nanocarriers to enhance RLX delivery to endocrine target organs was assessed in fasted and fed female Wistar rats using high-performance liquid chromatography. RLX was loaded in the dissolved and dispersed status in the alkalinized (A-SNEDDS) and nonalkalinized (NA-SNEDDS) systems, respectively. Optimization and assessment relied on solubility studies, emulsification efficiency, phase diagrams, dilution robustness, cloud point, particle size, zeta potential (ZP), polydispersity index (PDI), and transmission electron microscopy. In vitro release was assessed using dialysis bag versus dissolution cup methods. NA-SNEDDS were developed with suitable globule size (38.49 ± 4.30 nm), ZP (31.70 ± 3.58 mV), PDI (0.31 ± 0.02), and cloud point (85°C). A-SNEDDS exhibited good globule size (35 ± 2.80 nm), adequate PDI (0.28 ± 0.06), and lower ZP magnitude (-21.20 ± 3.46 mV). Transmission electron microscopy revealed spherical globules and contended data of size analysis. Release studies demonstrated a nonsignificant enhancement of RLX release from NA-SNEDDS compared to drug suspension with the lowest release shown by A-SNEDDS. A conflicting result was elucidated from in vivo trial. A significant enhancement in RLX uptake by endocrine organs was observed after nanocarrier administration compared to RLX suspension. In vivo studies reflected a poor in vitro/in vivo correlation, recommended nanocarrier administration before meals, and did not reveal any advantage for drug loading in the solubilized form (A-SNEDDS). To conclude, NA-SNEDDS possessed superior in vitro characteristics to A-SNEDDS, with equal in vivo potential. NA-SNEDDS elaborated in this work could successfully double RLX delivery to endocrine target organs, with promising consequences of lower dose and side effects of the drug.


Subject(s)
Drug Carriers/chemistry , Nanoparticles/chemistry , Raloxifene Hydrochloride/chemistry , Animals , Drug Stability , Emulsions/chemistry , Excipients/chemistry , Female , Glycerol/analogs & derivatives , Glycerol/chemistry , Hydrogen-Ion Concentration , Microscopy, Electron, Transmission , Particle Size , Photomicrography , Raloxifene Hydrochloride/pharmacokinetics , Rats , Rats, Wistar , Solubility , Vaginal Smears
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