DRUGS & SUPPLEMENTS
Active ingredient: Methylene Blue
Methylene Blue uses
WARNING: SEROTONIN SYNDROME WITH CONCOMITANT USE OF SEROTONERGIC DRUGS
Methylene Blue may cause serious or fatal serotonergic syndrome when used in combination with serotonergic drugs. Avoid concomitant use of Methylene Blue with selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors ( 5.1, 7.1).
1 INDICATIONS AND USAGE
Methylene Blue is indicated for the treatment of pediatric and adult patients with acquired methemoglobinemia.
This indication is approved under accelerated approval. Continued approval for this indication may be contingent upon verification of clinical benefit in subsequent trials.
Methylene Blue (methylene blue) is an oxidation-reduction agent indicated for the treatment of pediatric and adult patients with acquired methemoglobinemia. This indication is approved under accelerated approval. Continued approval for this indication may be contingent upon verification of clinical benefit in subsequent trials. ( 1, 14)
2 DOSAGE AND ADMINISTRATION
2.1 Dosage and Administration
2.2 Preparation and Storage
Each mL of Methylene Blue contains 5 mg Methylene Blue
Each 10 mL ampule of Methylene Blue contains 50 mg Methylene Blue.
Methylene Blue is hypotonic and may be diluted before use in a solution of 50 mL 5% Dextrose in Water (D5W) in order to avoid local pain, particularly in the pediatric population. Use the diluted solution immediately after preparation.
Do not mix with sodium chloride 9 mg/mL (0.9%) solution for injection, because it has been demonstrated that chloride reduces the solubility of Methylene Blue.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
Keep the ampule in the original package to protect from light.
3 DOSAGE FORMS AND STRENGTHS
Injection: 50 mg/10 mL (5 mg/mL) clear dark blue solution in single-dose ampules
50 mg/10 mL (5 mg/mL) single-dose ampule. ( 3)
Methylene Blue is contraindicated in the following conditions:
Methylene Blue is contraindicated in the following conditions ( 4):
5 WARNINGS AND PRECAUTIONS
5.1 Serotonin Syndrome with Concomitant Use of Serotonergic Drugs
The development of serotonin syndrome has been reported with use of Methylene Blue class products. Most reports have been associated with concomitant use of serotonergic drugs (e.g., selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors). Some of the reported cases were fatal. Symptoms associated with serotonin syndrome may include the following combination of signs and symptoms: mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, and hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, and incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Avoid concomitant use of Methylene Blue with serotonergic drugs.
Patients treated with Methylene Blue should be monitored for the emergence of serotonin syndrome. If symptoms of serotonin syndrome occur, discontinue use of Methylene Blue, and initiate supportive treatment. Inform patients of the increased risk of serotonin syndrome and advise them to not to take serotonergic drugs within 72 hours after the last dose of Methylene Blue .
Anaphylactic reactions to Methylene Blue class products have been reported. Patients treated with Methylene Blue should be monitored for anaphylaxis. If anaphylaxis or other severe hypersensitivity reactions should occur, discontinue use of Methylene Blue and initiate supportive treatment. Methylene Blue is contraindicated in patients who have experienced anaphylaxis or other severe hypersensitivity reactions to a Methylene Blue class product in the past.
5.3 Lack of Effectiveness
Methemoglobinemia may not resolve or may rebound after response to treatment with Methylene Blue in patients with methemoglobinemia due to aryl amines such as aniline or sulfa drugs such as dapsone. Monitor response to therapy with Methylene Blue through resolution of methemoglobinemia. If methemoglobinemia does not respond to 2 doses of Methylene Blue or if methemoglobinemia rebounds after a response, consider additional treatment options .
Patients with glucose-6-phosphate dehydrogenase deficiency may not reduce Methylene Blue to its active form in vivo. Methylene Blue may not be effective in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency.
5.4 Hemolytic Anemia
Hemolysis can occur during treatment of methemoglobinemia with Methylene Blue. Laboratory testing may show Heinz bodies, elevated indirect bilirubin and low haptoglobin, but the Coombs test is negative. The onset of anemia may be delayed 1 or more days after treatment with Methylene Blue. The anemia may require red blood cell transfusions. . Use the lowest effective number of doses of Methylene Blue to treat methemoglobinemia. Discontinue Methylene Blue and consider alternative treatments of methemoglobinemia if severe hemolysis occurs.
Treatment of patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency with Methylene Blue may result in severe hemolysis and severe anemia. Methylene Blue is contraindicated for use in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency .
5.5 Interference with In Vivo Monitoring Devices
The presence of Methylene Blue in the blood may result in an underestimation of the oxygen saturation reading by pulse oximetry. If a measure of oxygen saturation is required during or shortly after infusion of Methylene Blue, it is advisable to obtain an arterial blood sample for testing by an alternative method.
A fall in the Bispectral Index (BIS) has been reported following administration of Methylene Blue class products. If Methylene Blue is administered during surgery, alternative methods for assessing the depth of anesthesia should be employed.
5.6 Effects on Ability to Drive and Operate Machinery
Treatment with Methylene Blue may cause confusion, dizziness and disturbances in vision . Advise patients to refrain from driving or engaging in hazardous occupations or activities such as operating heavy or potentially dangerous machinery until such adverse reactions to Methylene Blue have resolved.
5.7 Interference with Laboratory Tests
Methylene Blue is a blue dye which passes freely into the urine and may interfere with the interpretation of any urine test which relies on a blue indicator, such as the dipstick test for leucocyte esterase.
6 ADVERSE REACTIONS
The following adverse reactions are discussed in greater detail in other sections of the labeling:
The most commonly reported adverse reactions (≥10%) are pain in extremity, chromaturia, dysgeusia, feeling hot, dizziness, hyperhidrosis, nausea, skin, discoloration and headache. ( 6.1)
To report SUSPECTED ADVERSE REACTIONS, contact American Regent at 1-800-734-9236 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The safety of Methylene Blue was determined in 82 healthy adults of median age of 36 years (range, 19-55 years); 54% were male, and 68% were white. Each individual in the safety population received a single dose of Methylene Blue 2 mg/kg intravenously. There was one serious adverse reaction reported (syncope due to sinus pauses of 3-14 seconds). The most common (≥2%) moderate or severe adverse reactions were pain in the extremity (56%), headache (7%), feeling hot (6%), syncope (4%), back pain (2%), hyperhidrosis (2%) and nausea (2%). Table 1 lists the adverse reactions of any severity that occurred in at least 2% of individuals who received Methylene Blue.
Other adverse reactions reported to occur following administration of Methylene Blue class products include the following:
Blood and lymphatic system disorders: hemolytic anemia, hemolysis, hyperbilirubinemia, methemoglobinemia
Cardiac disorders: palpitations, tachycardia
Eye disorders: eye pruritus, ocular hyperemia, vision blurred
Gastrointestinal disorders: abdominal pain lower, dry mouth, flatulence, glossodynia, tongue eruption
General disorders and administration site conditions: death, infusion site extravasation, infusion site induration, infusion site pruritus, infusion site swelling, infusion site urticaria, peripheral swelling, thirst
Investigations: elevated liver enzymes
Musculoskeletal and connective tissue disorders: myalgia
Renal and urinary disorders: dysuria
Respiratory, thoracic and mediastinal disorders: nasal congestion, oropharyngeal pain, rhinorrhea, sneezing
Skin and subcutaneous tissue disorders: necrotic ulcer, papule, phototoxicity
Vascular disorders: hypertension
7 DRUG INTERACTIONS
7.1 Serotonergic Drugs
Avoid concomitant use of Methylene Blue with medicinal products that enhance serotonergic transmission including SSRIs, MAO inhibitors, bupropion, buspirone, clomipramine, mirtazapine and venlafaxine; because of the potential for serious CNS reactions, including potentially fatal serotonin syndrome. Although the mechanism is not clearly, understood, literature reports suggest inhibition of MAO by Methylene Blue may be involved. In addition, in vitro studies cannot rule out the potential involvement of CYP 2D6 inhibition by Methylene Blue. If the intravenous use of Methylene Blue cannot be avoided in patients treated with serotonergic medicinal products, choose the lowest possible dose and observe closely the patient for CNS effects for up to 4 hours after administration .
7.2 Agents Metabolized by Cytochrome P450 Enzymes
Methylene Blue inhibits a range of CYP isozymes in vitro, including 1A2, 2B6, 2C8, 2C9, 2C19, 2D6 and 3A4/5. This interaction could be more pronounced with narrow therapeutic index drugs that are metabolized by one of these enzymes (e.g, digoxin, warfarin, phenytoin, alfentanil, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus and tacrolimus). However, the clinical relevance of these in vitro interactions is unknown.
8 USE IN SPECIFIC POPULATIONS
Methylene Blue may cause fetal harm when administered to a pregnant woman. Intra-amniotic injection of pregnant women with a Methylene Blue class product during the second trimester was associated with neonatal intestinal atresia and fetal death. Methylene Blue produced adverse developmental outcomes in rats and rabbits when administered orally during organogenesis at doses at least 32 and 16 times, respectively, the clinical dose of 1 mg/kg . Advise pregnant women of the potential risk to a fetus.
In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies are 2-4% and 15-20%, respectively.
Fetal/neonatal adverse reactions
Intra-amniotic injection of a Methylene Blue class product hours to days prior to birth can result hyperbilirubinemia, hemolytic anemia, skin staining, methemoglobinemia, respiratory distress and photosensitivity in the newborn. Following administration of Methylene Blue to a pregnant woman at term, observe the newborn for these adverse reactions and institute supportive care.
Methylene Blue was administered orally to pregnant rats at doses of 50 to 350 mg/kg/day, during the period of organogenesis. Maternal and embryofetal toxicities were observed at all doses of Methylene Blue, and were most evident at the 200 and 350 mg/kg/day doses. Maternal toxicity consisted of increased spleen weight. Embryo-fetal toxicities included reduced fetal weight, post-implantation loss, edema, and malformations including enlarged lateral ventricles. The dose of 200 mg/kg (1200 mg/m 2) in rats is approximately 32 times a clinical dose of 1 mg/kg based on body surface area.
Methylene Blue was administered orally to pregnant rabbits at doses of 50, 100, or 150 mg/kg/day, during the period of organogenesis. Maternal death was observed at the Methylene Blue dose of 100 mg/kg. Embryofetal toxicities included spontaneous abortion at all dose levels and a malformation (umbilical hernia) at the 100 and 150 mg/kg/day doses. The dose of 50 mg/kg (600 mg/m 2) in rabbits is approximately 16 times a clinical dose of 1 mg/kg based on body surface area.
There is no information regarding the presence of Methylene Blue in human milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions, including genotoxicity discontinue breast-feeding during and for up to 8 days after treatment with Methylene Blue .
8.4 Pediatric Use
The safety and effectiveness of Methylene Blue have been established in pediatric patients. Use of Methylene Blue is supported by two retrospective case series that included 2 pediatric patients treated with Methylene Blue and 12 treated with another Methylene Blue class product. The case series included pediatric patients in the following age groups: 3 neonates (less than 1 month), 4 infants (1 month up to less than 2 years), 4 children (2 years up to less than 12 years), and 3 adolescents (12 years to less than 17 years). The efficacy outcomes were consistent across pediatric and adult patients in both case series .
8.5 Geriatric Use
The retrospective case series included 3 patients age 65 years and over treated with Methylene Blue and 5 treated with another Methylene Blue class product. The efficacy outcomes were consistent across adult and elderly patients in both case series . This drug is known to be substantially excreted by the kidney, so the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, treatment of methemoglobinemia in these patients should use the lowest number of doses needed to achieve a response .
8.6 Renal Impairment
Approximately 40% of Methylene Blue is excreted by the kidneys. Patients with any renal impairment should be monitored for toxicities and potential drug interactions for an extended period of time following treatment with Methylene Blue.
8.7 Hepatic Impairment
Methylene Blue is extensively metabolized in the liver. Monitor patients with any hepatic impairment for toxicities and potential drug interactions for an extended period of time following treatment with Methylene Blue.
Hypotension, wheezing and reduced oxygenation have been reported in patients who received Methylene Blue class products in single doses of 3 mg/kg or more.
Administration of large intravenous doses (cumulative dose ≥ 7 mg/kg ) of a Methylene Blue class product caused nausea, vomiting, precordial pain, dyspnea, tachypnea, chest tightness, tachycardia, apprehension, tremor, mydriasis, blue staining of the urine, the skin and mucous membranes, abdominal pain, dizziness, paresthesia, headache, confusion, mild methemoglobinemia (up to 7%) and electrocardiogram changes (T-wave flattening or inversion) These effects lasted 2-12 hours following administration.
A severe overdosage (single dose of 20 mg/kg or more) of a Methylene Blue class product caused severe intravascular hemolysis, hyperbilirubinemia and death.
In case of overdose of Methylene Blue, maintain the patient under observation until signs and symptoms have resolved, monitor for cardiopulmonary, hematologic and neurologic toxicities, and institute supportive measures as necessary.
Methylene Blue is an oxidation-reduction agent. Methylene Blue (methylene blue) is a sterile solution intended for intravenous administration. Each Methylene Blue, 10 mL ampule contains 50 mg Proveblue ® Methylene Blue and water for injection q.s. Each mL of solution contains 5 mg Methylene Blue and water for injection q.s.
Methylene Blue is 3,7-bis(dimethylamino)phenothiazin-5-ium, chloride. The molecular formula of Methylene Blue is C 16H 18ClN 3S and its molecular weight is 319.86 g/mol. Its structural formula is:
Methylene Blue is a clear dark blue solution with a pH value between 3.0 and 4.5. The osmolality is between 10 and 15 mOsm/kg.
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Methylene Blue is a water soluble thiazine dye that promotes a non-enyzmatic redox conversion of metHb to hemoglobin. In situ, Methylene Blue is first converted to leucomethylene blue via NADPH reductase. It is the LMB molecule which then reduces the ferric iron of metHb to the ferrous state of normal hemoglobin.
Low concentrations of Methylene Blue speeds up the in vivo conversion of methemoglobin to hemoglobin. Methylene Blue has been observed to stain tissues selectively. The exposure-response or –safety relationship for methylene is unknown.
The results of a thorough QT study demonstrated Methylene Blue at an intravenous dose of 2 mg/kg as a 5-minute intravenous infusion had no effect on the QT, PR or QRS intervals.
The mean (CV%) Cmax and AUC of Methylene Blue 2,917 ng/mL (39%) and 13977 ng.hr/mL (21%) following a 2 mg/kg dose administered as a 5-minute intravenous infusion.
The mean± standard deviation steady state volume of distribution of a 2 mg/kg dose of Methylene Blue was 255 L ± 58. The mean plasma protein binding of Methylene Blue is approximately 94% in vitro. Methylene Blue exhibits concentration-dependent partitioning into blood cells in vitro. The blood-to-plasma ratio was 5.1±2.8 at 5 minutes from the start of a 2 mg/kg dose administered as a 5-minute intravenous infusion and reached a plateau of 0.6 at 4 hours in a clinical study. Methylene Blue is a substrate for the P-glycoprotein (P-gp, ABCB1) transporter, but not for BCRP or OCT2 in vitro.
Methylene Blue has a half-life of approximately 24 hours.
Methylene Blue is metabolized by CYPs 1A2, 2C19 and 2D6 in vitro; however, the predominant in vitro pathway appears to be UGT-mediated conjugation by multiple UGT enzymes, including UGT1A4 and UGT1A9.
Azure B, which is a minor impurity in Methylene Blue, is also formed in humans as a metabolite of Methylene Blue, with an overall drug/metabolite AUC ratio of greater than 6:1. Azure B has 8-fold lower potency than Methylene Blue.
Approximately 40% of Methylene Blue is excreted in to the urine unchanged.
Drug Interaction Studies
The clinical relevance of in vitro inhibition or induction of the metabolizing enzymes and transporter systems described below is unknown, but it cannot be excluded that the systemic exposure of medicinal products being substrates for these enzymes or transporter systems may be affected with concomitant administration with Methylene Blue Injection.
Methylene Blue inhibits CYP isozymes 1A2, 2B6, 2C8, 2C9, 2C19, 2D6 and 3A4/5 in vitro. Possible time-dependent inhibition of CYP2C9, CYP2D6 and CYP3A4/5 (testosterone as substrate) was also observed in vitro. Methylene Blue induces CYP1A2, but does not induce CYP2B6 or CYP3A4 in vitro.
Methylene Blue inhibits UGT1A9 and UGT1A4 in in vitro, but did not significantly inhibit UGTs 1A1, 1A3, 1A6, 2B7 or 2B15.
Methylene Blue is both a substrate for and an inhibitor of P-gp, but is not a substrate for BCRP or OCT2 in vitro. Methylene Blue is not a significant inhibitor of BCRP, OAT1, OAT3, OAT1B1 or OAT1B3 in vitro. Methylene Blue inhibits OCT2, MATE1 and MATE2-K in vitro. The OCT2/MATE pathway for renal transport is reported to play a significant role in the elimination of several substances, including metformin, cimetidine, acyclovir and creatinine
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
In a two-year carcinogenicity study, rats were administered oral doses of Methylene Blue at 5, 25, or 50 mg/kg. Methylene Blue caused pancreatic islet adenomas or carcinomas (combined) in male rats. In a two-year year carcinogenicity study, mice were administered oral doses of Methylene Blue at 2.5, 12.5, or 25 mg/kg. There were no drug-related neoplastic findings in mice.
Methylene Blue was genotoxic in gene mutation assays in bacteria (Ames test), and in an in vitro sister chromatid exchange test and an in vitro chromosomal aberration test in Chinese hamster ovary (CHO) cells. Methylene Blue was negative for micronucleus induction in bone marrow or peripheral blood collected from mice treated with Methylene Blue.
Fertility studies with Methylene Blue have not been conducted. In vitro, Methylene Blue reduced motility of human sperm in a concentration dependent manner.
14 CLINICAL STUDIES
14.1 Treatment of Acquired Methemoglobinemia
The efficacy of Methylene Blue was assessed on the basis of a methemoglobin decrease of at least 50% within 1 hour after intravenous administration of 1 – 2 mg/kg Methylene Blue (or a bioequivalent formulation) in 6 patients identified by retrospective chart review or literature search. The 6 patients included 3 males and 3 females of median age 54 years (range, 6 days to 69 years). The median methemoglobin level at baseline was 37% (range, 11% to 47%). All 6 (100%) patients had a decrease in methemoglobin by at least 50% within 1 hour after treatment.
An additional 41cases of treatment of methemoglobinemia with a Methylene Blue class product were identified in the published literature. These cases included 24 males and 17 females of median age 33 years (range, 9 days to 80 years). The median methemoglobin level at baseline was 40% (range, 10% to 98%). Of these 41 patients, 37 (90%) had a methemoglobin decrease of at least 50% within 1 hour after intravenous administration of the Methylene Blue class product.
In a combined analysis of all 47 patients treated intravenously with Methylene Blue (or a bioequivalent formulation) or with another Methylene Blue class product, there was no difference in response rate by dose. The methemoglobin decreased by at least 50% within 1 hour of infusion for 15/17 (88%) of patients treated with 1 mg/kg, 12/13 (92%) treated with 2 mg/kg and 16/17 (94%) treated with a different dose or for those whose dose was not reported.
16 HOW SUPPLIED/STORAGE AND HANDLING
Methylene Blue is supplied in 10 mL single-dose ampules. Each 10 mL ampule contains 50 mg of Methylene Blue as a clear dark blue solution. A box contains five ampules placed in a tray.
Box of 5 ampules: NDC 0517-0374-05
Store at 20°C to 25°C (68°F to 77°F).
Any unused product or waste material should be disposed of in accordance with local practice.
Do not refrigerate or freeze.
Keep the ampule in the original package to protect from light.
17 PATIENT COUNSELING INFORMATION
Advise patients of the possibility of serotonin syndrome, especially with concomitant use of serotonergic agents such as medications to treat depression and migraines. Advise patients to seek immediate medical attention if the following symptoms occur after treatment with Methylene Blue : changes in mental status, autonomic instability, or neuromuscular symptoms with or without gastrointestinal symptoms .
Advise pregnant women of the potential risk to the fetus with the use of Methylene Blue during pregnancy .
Advise patients to discontinue breast-feeding for up to 8 days after treatment with Methylene Blue .
Driving and Using Machines
Advise patients to avoid driving and use of machines during treatment with Methylene Blue. Driving can be affected as a result of a confusional state, dizziness and possible eye disturbances .
Advise patients to take protective measures against exposure to light, because phototoxicity may occur after administration of Methylene Blue .
Skin and Body Fluid Blue Discoloration
Advise patients that Methylene Blue may cause a blue discoloration of the skin and body fluids .
22 rue Marc Donadille
13013 Marseille, France
52 rue Marcel et Jacques Gaucher
94120 Fontenay sous Bois, FRANCE
Questions? : 1-800-734-9236
[controlled part number code]
Principal Display Panel - 5 mg Ampule Label
NDC 0517-0374-01 28039135 Rev 4/16
(methylene blue) Injection, 0.5%
50 mg/10 mL (5 mg/mL)
Intravenous use only
Single dose ampule - RX only
Discard unused portion
AMERICAN REGENT, INC
Shirley, NY 19967
Principal Display Panel - 5 mg Carton Label
NDC 0517-0374-05 5 ampules
(methylene blue) Injection, 0.5%
50 mg/10 mL (5 mg/mL)
Intravenous use only - For slow intravenous injection.
10 mL - Single dose ampule -
Discard unused portion
Shirley, NY 11967
Patented: US 8,765,942; US 9,227,945
Methylene Blue available forms, composition, doses:
Indications and Usages:
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Frequently asked QuestionsCan i drive or operate heavy machine after consuming Methylene Blue?
Depending on the reaction of the Methylene Blue after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Methylene Blue not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.Is Methylene Blue addictive or habit forming?
Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.
Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.
Reviewsdrugs.com conducted a study on Methylene Blue, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Methylene Blue consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.
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The information was verified by Dr. Arunabha Ray, MD Pharmacology