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'''Pemoline''', sold under the brand name '''Cylert''' among others, is a [[stimulant]] medication which has been used in the treatment of [[attention-deficit hyperactivity disorder]] (ADHD) and [[narcolepsy]].<ref name="Cylert-Label" /> It has been discontinued in most countries to due to rare but serious problems with [[liver toxicity]].<ref name="pmid28366595" /> The medication is taken [[oral administration|by mouth]].<ref name="Cylert-Label" />
'''Pemoline''', sold under the brand name '''Cylert''' among others, is a [[stimulant]] medication which has been used in the treatment of [[attention-deficit hyperactivity disorder]] (ADHD) and [[narcolepsy]].<ref name="Cylert-Label" /> It has been discontinued in most countries to due to rare but serious problems with [[liver toxicity]].<ref name="pmid18830438">{{cite journal | vauthors = Billiard M | title = Narcolepsy: current treatment options and future approaches | journal = Neuropsychiatr Dis Treat | volume = 4 | issue = 3 | pages = 557–66 | date = June 2008 | pmid = 18830438 | pmc = 2526380 | doi = | url = }}</ref><ref name="pmid28366595">{{cite journal | vauthors = Shader RI | title = Risk Evaluation and Mitigation Strategies (REMS), Pemoline, and What Is a Signal? | journal = Clin Ther | volume = 39 | issue = 4 | pages = 665–669 | date = April 2017 | pmid = 28366595 | doi = 10.1016/j.clinthera.2017.03.008 | url = }}</ref> The medication is taken [[oral administration|by mouth]].<ref name="Cylert-Label" />


[[Side effect]]s of pemoline include [[insomnia]], [[decreased appetite]], [[abdominal pain]], [[irritability]], and [[headache]]s.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" /> Rarely, the medication can cause serious [[hepatotoxicity|liver damage]], and this can result in [[liver transplantation]] or death.<ref name="pmid11865963">{{cite journal | vauthors = Nakamura H, Blumer JL, Reed MD | title = Pemoline ingestion in children: a report of five cases and review of the literature | journal = J Clin Pharmacol | volume = 42 | issue = 3 | pages = 275–82 | date = March 2002 | pmid = 11865963 | doi = 10.1177/00912700222011292 | url = }}</ref><ref name="pmid11392339">{{cite journal | vauthors = Safer DJ, Zito JM, Gardner JE | title = Pemoline hepatotoxicity and postmarketing surveillance | journal = J Am Acad Child Adolesc Psychiatry | volume = 40 | issue = 6 | pages = 622–9 | date = June 2001 | pmid = 11392339 | doi = 10.1097/00004583-200106000-00006 | url = }}</ref> Pemoline is a [[psychostimulant]] and acts as a [[binding selectivity|selective]] [[dopamine reuptake inhibitor]] and [[dopamine releasing agent|releasing agent]].<ref name="PatrickMarkowitz1997" /><ref name="pmid9185233" /><ref name="Cylert-Label" /> Hence, it functions as an indirect [[agonist]] of [[dopamine receptor]]s.<ref name="pmid9708845" /> Pemoline has little effect on [[norepinephrine]] and hence has minimal or no [[cardiovascular]] or [[sympathomimetic]] effects, in contrast to many other stimulants.<ref name="PatrickMarkowitz1997" /><ref name="pmid9185233" /><ref name="Cylert-Label" />
[[Side effect]]s of pemoline include [[insomnia]], [[decreased appetite]], [[abdominal pain]], [[irritability]], and [[headache]]s.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" /> Rarely, the medication can cause serious [[hepatotoxicity|liver damage]], and this can result in [[liver transplantation]] or death.<ref name="pmid11865963">{{cite journal | vauthors = Nakamura H, Blumer JL, Reed MD | title = Pemoline ingestion in children: a report of five cases and review of the literature | journal = J Clin Pharmacol | volume = 42 | issue = 3 | pages = 275–82 | date = March 2002 | pmid = 11865963 | doi = 10.1177/00912700222011292 | url = }}</ref><ref name="pmid11392339">{{cite journal | vauthors = Safer DJ, Zito JM, Gardner JE | title = Pemoline hepatotoxicity and postmarketing surveillance | journal = J Am Acad Child Adolesc Psychiatry | volume = 40 | issue = 6 | pages = 622–9 | date = June 2001 | pmid = 11392339 | doi = 10.1097/00004583-200106000-00006 | url = }}</ref> Pemoline is a [[psychostimulant]] and acts as a [[binding selectivity|selective]] [[dopamine reuptake inhibitor]] and [[dopamine releasing agent|releasing agent]].<ref name="PatrickMarkowitz1997" /><ref name="pmid9185233" /><ref name="Cylert-Label" /> Hence, it functions as an indirect [[agonist]] of [[dopamine receptor]]s.<ref name="pmid9708845" /> Pemoline has little effect on [[norepinephrine]] and hence has minimal or no [[cardiovascular]] or [[sympathomimetic]] effects, in contrast to many other stimulants.<ref name="PatrickMarkowitz1997" /><ref name="pmid9185233" /><ref name="Cylert-Label" />
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==Medical uses==
==Medical uses==
Pemoline was formerly used in the treatment of [[attention-deficit hyperactivity disorder|ADHD]] and [[narcolepsy]].<ref name="Cylert-Label" /><ref name="PatrickMarkowitz1997" />{{Additional citation needed|date=April 2022}} It has also been used in the treatment of [[excessive daytime sleepiness]].<ref name="pmid9185233">{{cite journal | vauthors = Nishino S, Mignot E | title = Pharmacological aspects of human and canine narcolepsy | journal = Prog Neurobiol | volume = 52 | issue = 1 | pages = 27–78 | date = May 1997 | pmid = 9185233 | doi = 10.1016/s0301-0082(96)00070-6 | s2cid = 31839355 | url = }}</ref> The medication was typically used at doses of 18.75 to 112.5{{nbsp}}mg once per day in the treatment of ADHD, with the effective dose for most people being in the range of 56.25 to 75{{nbsp}}mg.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" /> The [[onset of action]] of pemoline is gradual and therapeutic benefits may not occur until the third or fourth weeks of use.<ref name="Cylert-Label" /><ref name="PatrickMarkowitz1997" /> This may be due to a cautious low initial starting dose of 37.5{{nbsp}}mg and gradual titration in dose upwards over several weeks.<ref name="PatrickMarkowitz1997" />
Pemoline has been used in the treatment of [[attention-deficit hyperactivity disorder|ADHD]] and [[narcolepsy]].<ref name="Cylert-Label" /><ref name="PatrickMarkowitz1997" /><ref name="pmid28366595" /> It has also been used in the treatment of [[excessive daytime sleepiness]].<ref name="pmid9185233">{{cite journal | vauthors = Nishino S, Mignot E | title = Pharmacological aspects of human and canine narcolepsy | journal = Prog Neurobiol | volume = 52 | issue = 1 | pages = 27–78 | date = May 1997 | pmid = 9185233 | doi = 10.1016/s0301-0082(96)00070-6 | s2cid = 31839355 | url = }}</ref> The medication was typically used at doses of 18.75 to 112.5{{nbsp}}mg once per day in the treatment of ADHD, with the effective dose for most people being in the range of 56.25 to 75{{nbsp}}mg.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" /> The [[onset of action]] of pemoline is gradual and therapeutic benefits may not occur until the third or fourth weeks of use.<ref name="Cylert-Label" /><ref name="PatrickMarkowitz1997" /> This may be due to a cautious low initial starting dose of 37.5{{nbsp}}mg and gradual titration in dose upwards over several weeks.<ref name="PatrickMarkowitz1997" />


===Available forms===
===Available forms===
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==Side effects==
==Side effects==
[[Side effect]]s of pemoline include [[insomnia]], [[decreased appetite]], [[abdominal pain]], [[irritability]], and [[headache]]s.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" /> It has minimal [[cardiovascular]] or [[sympathomimetic]] side effects.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" />
[[Side effect]]s of pemoline include [[insomnia]], [[decreased appetite]], [[abdominal pain]], [[irritability]], and [[headache]]s.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" /> It has minimal [[cardiovascular]] or [[sympathomimetic]] side effects.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label" /> Pemoline is described as a lower-efficacy/milder stimulant than classical stimulants like [[amphetamine-type stimulant|amphetamine]]s and [[methylphenidate]] and is said to have fewer side effects than them.<ref name="NishinoKotorii2016">{{cite book | title = Narcolepsy | last1 = Nishino | first1 = Seiji | last2 = Kotorii | first2 = Nozomu | chapter = Overview of Management of Narcolepsy | date = 2016 | pages = 285–305 | publisher = Springer International Publishing | doi = 10.1007/978-3-319-23739-8_21 | url = }}</ref>


===Liver toxicity===
===Liver toxicity===
In some patients pemoline is suspected of causing [[hepatotoxicity]],<ref name="PatrickMarkowitz1997" /><ref name="pmid9602211">{{cite journal |vauthors=Marotta PJ, Roberts EA |title=Pemoline hepatotoxicity in children |journal=J. Pediatr. |volume=132 |issue=5 |pages=894–7 |date=May 1998 |pmid=9602211 |doi=10.1016/S0022-3476(98)70329-4 }}</ref> so the FDA recommended that regular liver tests should be performed on those treated with it.<ref name="pmid12108802">{{cite journal |vauthors=Willy ME, Manda B, Shatin D, Drinkard CR, Graham DJ |title=A study of compliance with FDA recommendations for pemoline (Cylert) |journal=J Am Acad Child Adolesc Psychiatry |volume=41 |issue=7 |pages=785–90 |date=July 2002 |pmid=12108802 |doi=10.1097/00004583-200207000-00009 |url=https://zenodo.org/record/1234804 |access-date=2020-09-10 |archive-date=2021-05-31 |archive-url=https://web.archive.org/web/20210531152527/https://zenodo.org/record/1234804 |url-status=live }}</ref> Since receiving FDA approval in 1975, it has been linked with 21 cases of [[liver failure]], of which 13 resulted in liver replacement or death. Approximately 1–2% of patients taking the drug show elevated levels of liver [[transaminase]] enzymes, a marker for liver toxicity, though serious cases are rare. Over 200,000 children with ADHD were prescribed pemoline in the United States and Canada alone during the 25 years it was available, plus a smaller number of adults prescribed it for indications such as [[chronic fatigue syndrome]] and [[apathy]] in the elderly (and not including prescriptions in the rest of the world), so the number of liver failure cases was statistically not that large. However the reactions proved idiosyncratic and unpredictable, with patients sometimes taking the drug with no issue for months or even years, before suddenly developing severe liver toxicity. There was no clear exposure-toxicity relationship, and no characteristic liver [[pathology]] findings. Some patients showed as little as one week between first appearance of [[jaundice]] and complete liver failure, and some of the patients that developed liver failure had not showed elevated liver transaminase levels when tested previously.<ref name="pmid18217792">{{cite journal |vauthors=Etwel FA, Rieder MJ, Bend JR, Koren G |title=A surveillance method for the early identification of idiosyncratic adverse drug reactions |journal=Drug Saf |volume=31 |issue=2 |pages=169–80 |year=2008 |pmid=18217792 |doi= 10.2165/00002018-200831020-00006|s2cid=19964105 }}</ref>
In some patients pemoline is suspected of causing [[hepatotoxicity]],<ref name="PatrickMarkowitz1997" /><ref name="pmid9602211">{{cite journal |vauthors=Marotta PJ, Roberts EA |title=Pemoline hepatotoxicity in children |journal=J. Pediatr. |volume=132 |issue=5 |pages=894–7 |date=May 1998 |pmid=9602211 |doi=10.1016/S0022-3476(98)70329-4 }}</ref> so the FDA recommended that regular liver tests should be performed on those treated with it.<ref name="pmid12108802">{{cite journal |vauthors=Willy ME, Manda B, Shatin D, Drinkard CR, Graham DJ |title=A study of compliance with FDA recommendations for pemoline (Cylert) |journal=J Am Acad Child Adolesc Psychiatry |volume=41 |issue=7 |pages=785–90 |date=July 2002 |pmid=12108802 |doi=10.1097/00004583-200207000-00009 |url=https://zenodo.org/record/1234804 |access-date=2020-09-10 |archive-date=2021-05-31 |archive-url=https://web.archive.org/web/20210531152527/https://zenodo.org/record/1234804 |url-status=live }}</ref> Since receiving FDA approval in 1975, it has been linked with 21 cases of [[liver failure]], of which 13 resulted in liver replacement or death. Approximately 1–2% of patients taking the drug show elevated levels of liver [[transaminase]] enzymes, a marker for liver toxicity, though serious cases are rare. Over 200,000 children with ADHD were prescribed pemoline in the United States and Canada alone during the approximate 25 years that it was available, plus a smaller number of adults prescribed it for indications such as [[chronic fatigue syndrome]] and [[apathy]] in the elderly (and not including prescriptions in the rest of the world), so the number of liver failure cases was statistically not that large. However the reactions proved idiosyncratic and unpredictable, with patients sometimes taking the drug with no issue for months or even years, before suddenly developing severe liver toxicity. There was no clear exposure-toxicity relationship, and no characteristic liver [[pathology]] findings. Some patients showed as little as one week between first appearance of [[jaundice]] and complete liver failure, and some of the patients that developed liver failure had not showed elevated liver transaminase levels when tested previously.<ref name="pmid18217792">{{cite journal |vauthors=Etwel FA, Rieder MJ, Bend JR, Koren G |title=A surveillance method for the early identification of idiosyncratic adverse drug reactions |journal=Drug Saf |volume=31 |issue=2 |pages=169–80 |year=2008 |pmid=18217792 |doi= 10.2165/00002018-200831020-00006|s2cid=19964105 }}</ref> On the other hand, there are no cases of liver failure associated with pemoline in Japan, although it is used at lower doses and is only prescribed for the niche indication of narcolepsy in this country.<ref name="pmid28366595" />

In March 2005 [[Abbott Laboratories]] and generic manufacturers withdrew pemoline from the American market due to concerns about the liver toxicity risk.<ref>{{cite journal | title = Pemoline - Withdrawn due to liver toxicity risk | journal = WHO Pharmaceuticals Newsletter | year = 2005 | issue = 5 | url = http://apps.who.int/medicinedocs/en/d/Js8120e/1.3.html#Js8120e.1.3 | access-date = 2012-09-26 | archive-date = 2013-12-03 | archive-url = https://web.archive.org/web/20131203011634/http://apps.who.int/medicinedocs/en/d/Js8120e/1.3.html#Js8120e.1.3 | url-status = dead }}</ref> Pemoline (as Betanamin) continues to be available in Japan, where no liver failure cases have been reported associated with its use, however it is only prescribed for the niche indication of [[narcolepsy]], and at a lower dose than previously used in the United States.<ref name="pmid28366595">{{cite journal | vauthors = Shader RI | title = Risk Evaluation and Mitigation Strategies (REMS), Pemoline, and What Is a Signal? | journal = Clin Ther | volume = 39 | issue = 4 | pages = 665–669 | date = April 2017 | pmid = 28366595 | doi = 10.1016/j.clinthera.2017.03.008 | url = }}</ref>


==Overdose==
==Overdose==
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The [[pharmacodynamics]] of pemoline are poorly understood and its precise [[mechanism of action]] hasn't been definitively determined.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label">{{cite web|title=Cylert (Pemoline)|url=http://www.accessdata.fda.gov/drugsatfda_docs/label/2003/016832s022_017703s018lbl.pdf|publisher=FDA|access-date=15 February 2014|date=December 2002|archive-date=4 March 2016|archive-url=https://web.archive.org/web/20160304002256/http://www.accessdata.fda.gov/drugsatfda_docs/label/2003/016832s022_017703s018lbl.pdf|url-status=live}}</ref> However, pemoline has similar activity and effects to those of other [[psychostimulant]]s, and in animals the medication appears to act as a [[dopamine reuptake inhibitor]] and [[dopamine releasing agent|releasing agent]].<ref name="PatrickMarkowitz1997" /> By increasing dopamine levels in the brain, it functions as an indirect [[agonist]] of [[dopamine receptor]]s.<ref name="pmid9708845">{{cite journal | vauthors = Solanto MV | title = Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration | journal = Behav Brain Res | volume = 94 | issue = 1 | pages = 127–52 | date = July 1998 | pmid = 9708845 | doi = 10.1016/s0166-4328(97)00175-7 | url = }}</ref> In contrast to most other stimulants, pemoline appears to produce no significant [[central nervous system|central]] or [[periphery (body)|peripheral]] [[noradrenergic]] effects.<ref name="PatrickMarkowitz1997" /> As a result, it has minimal or no [[cardiovascular]] or [[sympathomimetic]] effects.<ref name="PatrickMarkowitz1997" /> Pemoline is described as a [[binding selectivity|selective]] dopamine reuptake inhibitor that only weakly stimulates dopamine release.<ref name="pmid9185233" />
The [[pharmacodynamics]] of pemoline are poorly understood and its precise [[mechanism of action]] hasn't been definitively determined.<ref name="PatrickMarkowitz1997" /><ref name="Cylert-Label">{{cite web|title=Cylert (Pemoline)|url=http://www.accessdata.fda.gov/drugsatfda_docs/label/2003/016832s022_017703s018lbl.pdf|publisher=FDA|access-date=15 February 2014|date=December 2002|archive-date=4 March 2016|archive-url=https://web.archive.org/web/20160304002256/http://www.accessdata.fda.gov/drugsatfda_docs/label/2003/016832s022_017703s018lbl.pdf|url-status=live}}</ref> However, pemoline has similar activity and effects to those of other [[psychostimulant]]s, and in animals the medication appears to act as a [[dopamine reuptake inhibitor]] and [[dopamine releasing agent|releasing agent]].<ref name="PatrickMarkowitz1997" /> By increasing dopamine levels in the brain, it functions as an indirect [[agonist]] of [[dopamine receptor]]s.<ref name="pmid9708845">{{cite journal | vauthors = Solanto MV | title = Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration | journal = Behav Brain Res | volume = 94 | issue = 1 | pages = 127–52 | date = July 1998 | pmid = 9708845 | doi = 10.1016/s0166-4328(97)00175-7 | url = }}</ref> In contrast to most other stimulants, pemoline appears to produce no significant [[central nervous system|central]] or [[periphery (body)|peripheral]] [[noradrenergic]] effects.<ref name="PatrickMarkowitz1997" /> As a result, it has minimal or no [[cardiovascular]] or [[sympathomimetic]] effects.<ref name="PatrickMarkowitz1997" /> Pemoline is described as a [[binding selectivity|selective]] dopamine reuptake inhibitor that only weakly stimulates dopamine release.<ref name="pmid9185233" />


While drugs like [[dextroamphetamine]] and [[methylphenidate]] are classified as [[Controlled Substances Act#Schedule II controlled substances|Schedule II]] and have considerable misuse potential, pemoline is listed as [[Controlled Substances Act#Schedule IV controlled substances|Schedule IV]] (non-narcotic).<ref name="Cylert-Label" /> In studies conducted on primates, pemoline fails to demonstrate a potential for self-administration.<ref name="Cylert-Label" /> It is thought to have little potential for abuse and dependence.<ref name="PatrickMarkowitz1997" /> Nonetheless, misuse may theoretically occur owing to its similarity to other psychostimulants.<ref name="Cylert-Label" />
While drugs like [[dextroamphetamine]] and [[methylphenidate]] are classified as [[Controlled Substances Act#Schedule II controlled substances|schedule II]] and have considerable misuse potential, pemoline is listed as [[Controlled Substances Act#Schedule IV controlled substances|schedule IV]] (non-narcotic).<ref name="Cylert-Label" /> In studies conducted on primates, pemoline fails to demonstrate a potential for self-administration.<ref name="Cylert-Label" /> It is thought to have little potential for abuse and dependence.<ref name="PatrickMarkowitz1997" /> Nonetheless, misuse may theoretically occur owing to its similarity to other psychostimulants.<ref name="Cylert-Label" />


===Pharmacokinetics===
===Pharmacokinetics===
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Pemoline was first synthesized in 1913<ref name="Elks2014" /><ref name="ChemischeBerichte1913">Chemische Berichte, 1913, vol.46, p. 2083</ref> but its activity was not discovered until the 1930s.<ref name="ActaAcademiaeAboensis1939">Acta Academiae Aboensis, Series B: Mathematica et Physica, 1939, vol. 11, #14 p. 3,7</ref> Pemoline was approved for the treatment of ADHD in the United States in 1975.<ref name="PatrickMarkowitz1997" /><ref name="pmid28366595" />
Pemoline was first synthesized in 1913<ref name="Elks2014" /><ref name="ChemischeBerichte1913">Chemische Berichte, 1913, vol.46, p. 2083</ref> but its activity was not discovered until the 1930s.<ref name="ActaAcademiaeAboensis1939">Acta Academiae Aboensis, Series B: Mathematica et Physica, 1939, vol. 11, #14 p. 3,7</ref> Pemoline was approved for the treatment of ADHD in the United States in 1975.<ref name="PatrickMarkowitz1997" /><ref name="pmid28366595" />


Cases of serious liver toxicity and associated death related to pemoline in children and adolescents were reported to the [[United States]] [[Food and Drug Administration]]'s [[MedWatch]] between 1977 to 1996.<ref name="pmid11392339" /> Serious liver toxicity with pemoline was first described in the medical literature in 1984 and 1989 [[letter to the editor|letters to the editor]].<ref name="pmid11392339" /> Clinicians were little-aware of liver toxicity with pemoline until the 1990s.<ref name="pmid11392339" /> Warnings for liver toxicity for pemoline were added to the [[United States]] [[Food and Drug Administration]] (FDA) label for the medication in December 1996 and a [[black box warning]] was added in June 1999 along with requirements for written consent and frequent monitoring of [[liver enzyme]]s.<ref name="pmid18793403">{{cite journal | vauthors = Zito JM, Derivan AT, Kratochvil CJ, Safer DJ, Fegert JM, Greenhill LL | title = Off-label psychopharmacologic prescribing for children: history supports close clinical monitoring | journal = Child Adolesc Psychiatry Ment Health | volume = 2 | issue = 1 | pages = 24 | date = September 2008 | pmid = 18793403 | pmc = 2566553 | doi = 10.1186/1753-2000-2-24 | url = }}</ref><ref name="pmid18217792" /><ref name="pmid11392339">{{cite journal | vauthors = Safer DJ, Zito JM, Gardner JE | title = Pemoline hepatotoxicity and postmarketing surveillance | journal = J Am Acad Child Adolesc Psychiatry | volume = 40 | issue = 6 | pages = 622–9 | date = June 2001 | pmid = 11392339 | doi = 10.1097/00004583-200106000-00006 | url = }}</ref> These warnings followed a 1995 publication on liver toxicity with pemoline.<ref name="pmid11392339" /><ref name="pmid7781270">{{cite journal | vauthors = Berkovitch M, Pope E, Phillips J, Koren G | title = Pemoline-associated fulminant liver failure: testing the evidence for causation | journal = Clin Pharmacol Ther | volume = 57 | issue = 6 | pages = 696–8 | date = June 1995 | pmid = 7781270 | doi = 10.1016/0009-9236(95)90233-3 | url = }}</ref> However, findings suggested that clinicians poorly followed the FDA's directives on use of pemoline.<ref name="pmid18793403" /> In any case, sales of pemoline in the United States increased until 1997 and declined between 1996 and 1999.<ref name="pmid11392339" /> Pemoline was [[withdrawn drug|withdrawn]] due to liver toxicity in the [[United Kingdom]] in September 1997, in [[Canada]] in September 1999, and in the United States in 2005.<ref name="pmid18793403" /><ref name="pmid16981848">{{cite journal | vauthors = Shah RR | title = Can pharmacogenetics help rescue drugs withdrawn from the market? | journal = Pharmacogenomics | volume = 7 | issue = 6 | pages = 889–908 | date = September 2006 | pmid = 16981848 | doi = 10.2217/14622416.7.6.889 | url = }}</ref><ref name="pmid18217792" /><ref name="pmid11392339" /> Abbott Laboratories voluntarily withdraw pemoline from the United States market in May 2005 and the FDA withdrew approval of generic pemoline in November 2005.<ref name="pmid18793403" /><ref name="pmid18217792" />
Cases of serious liver toxicity and associated death related to pemoline in children and adolescents were reported to the [[United States]] [[Food and Drug Administration]]'s [[MedWatch]] between 1977 to 1996.<ref name="pmid11392339" /> Serious liver toxicity with pemoline was first described in the medical literature in 1984 and 1989 [[letter to the editor|letters to the editor]].<ref name="pmid11392339" /> Clinicians were little-aware of liver toxicity with pemoline until the 1990s.<ref name="pmid11392339" /> Warnings for liver toxicity for pemoline were added to the [[United States]] [[Food and Drug Administration]] (FDA) label for the medication in December 1996 and a [[black box warning]] was added in June 1999 along with requirements for written consent and frequent monitoring of [[liver enzyme]]s.<ref name="pmid18793403">{{cite journal | vauthors = Zito JM, Derivan AT, Kratochvil CJ, Safer DJ, Fegert JM, Greenhill LL | title = Off-label psychopharmacologic prescribing for children: history supports close clinical monitoring | journal = Child Adolesc Psychiatry Ment Health | volume = 2 | issue = 1 | pages = 24 | date = September 2008 | pmid = 18793403 | pmc = 2566553 | doi = 10.1186/1753-2000-2-24 | url = }}</ref><ref name="pmid18217792" /><ref name="pmid11392339">{{cite journal | vauthors = Safer DJ, Zito JM, Gardner JE | title = Pemoline hepatotoxicity and postmarketing surveillance | journal = J Am Acad Child Adolesc Psychiatry | volume = 40 | issue = 6 | pages = 622–9 | date = June 2001 | pmid = 11392339 | doi = 10.1097/00004583-200106000-00006 | url = }}</ref> These warnings followed a 1995 publication on liver toxicity with pemoline.<ref name="pmid11392339" /><ref name="pmid7781270">{{cite journal | vauthors = Berkovitch M, Pope E, Phillips J, Koren G | title = Pemoline-associated fulminant liver failure: testing the evidence for causation | journal = Clin Pharmacol Ther | volume = 57 | issue = 6 | pages = 696–8 | date = June 1995 | pmid = 7781270 | doi = 10.1016/0009-9236(95)90233-3 | url = }}</ref> However, findings suggested that clinicians poorly followed the FDA's directives on use of pemoline.<ref name="pmid18793403" /> In any case, sales of pemoline in the United States increased until 1997 and declined between 1996 and 1999.<ref name="pmid11392339" /> Pemoline was [[withdrawn drug|withdrawn]] due to liver toxicity in the [[United Kingdom]] in September 1997, in [[Canada]] in September 1999, and in the United States in 2005.<ref name="pmid18793403" /><ref name="pmid16981848">{{cite journal | vauthors = Shah RR | title = Can pharmacogenetics help rescue drugs withdrawn from the market? | journal = Pharmacogenomics | volume = 7 | issue = 6 | pages = 889–908 | date = September 2006 | pmid = 16981848 | doi = 10.2217/14622416.7.6.889 | url = }}</ref><ref name="pmid18217792" /><ref name="pmid11392339" /> Abbott Laboratories voluntarily withdraw pemoline from the United States market in May 2005 and the FDA withdrew approval of generic pemoline in November 2005.<ref name="pmid18793403" /><ref name="pmid18217792" /> Pemoline remains available in Japan for treatment of narcolepsy as of 2017.<ref name="pmid28366595" />


==Society and culture==
==Society and culture==
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===Availability===
===Availability===
Pemoline has been marketed in the [[United States]], [[Canada]], the [[United Kingdom]], [[Belgium]], [[Luxembourg]], [[Spain]], [[Germany]], [[Switzerland]], and [[Argentina]].<ref name="SwissPharmaceuticalSociety2000">{{cite book | editor = Swiss Pharmaceutical Society | author = Swiss Pharmaceutical Society | date = 2000 | title = Index Nominum 2000: International Drug Directory | publisher = Taylor & Francis | pages = 799– | isbn = 978-3-88763-075-1 | url = https://books.google.com/books?id=5GpcTQD_L2oC&pg=PA799}}</ref>
Pemoline has been marketed in the [[United States]], [[Canada]], the [[United Kingdom]], [[Belgium]], [[Luxembourg]], [[Spain]], [[Germany]], [[Switzerland]], and [[Argentina]].<ref name="SwissPharmaceuticalSociety2000">{{cite book | editor = Swiss Pharmaceutical Society | author = Swiss Pharmaceutical Society | date = 2000 | title = Index Nominum 2000: International Drug Directory | publisher = Taylor & Francis | pages = 799– | isbn = 978-3-88763-075-1 | url = https://books.google.com/books?id=5GpcTQD_L2oC&pg=PA799}}</ref> It remains available in [[Japan]] for the treatment of narcolepsy as of 2017.<ref name="pmid28366595" /> However, it is rarely used in Japan as narcolepsy is a niche indication and as clinicians are wary of the liver toxicity it has been associated with.<ref name="pmid28366595" /><ref name="Takeda2009">{{cite journal | last1 = Takeda | first1 = Toshinobu | title = Psychopharmacology for attention-deficit/hyperactivity disorder in Japan | journal = Current Attention Disorders Reports | date = March 2009 | volume = 1 | issue = 1 | pages = 21–28 | issn = 1943-4561 | eissn = 1943-457X | doi = 10.1007/s12618-009-0004-5 | pmid = | url = }}</ref>


===Legal status===
===Legal status===
Under the [[Convention on Psychotropic Substances]], it is a Schedule IV drug.<ref name="INCB">[http://www.incb.org/pdf/e/list/green.pdf Annual Estimates Of Requirements Of Narcotic Drugs, Manufacture Of Synthetic Drugs, Opium Production And Cultivation Of The<!-- Bot generated title -->] {{webarchive |url=https://web.archive.org/web/20051205125434/http://www.incb.org/pdf/e/list/green.pdf |date=December 5, 2005 }}</ref> Pemoline is Schedule IV Non-Narcotic (Stimulant) controlled substance with a DEA ACSCN of 1530 and is not subject to annual manufacturing quotas.<ref name="CRC2014" />
Under the [[Convention on Psychotropic Substances]], it is a [[Controlled Substances Act#Schedule IV|schedule IV]] [[controlled substancce]].<ref name="INCB">[http://www.incb.org/pdf/e/list/green.pdf Annual Estimates Of Requirements Of Narcotic Drugs, Manufacture Of Synthetic Drugs, Opium Production And Cultivation Of The<!-- Bot generated title -->] {{webarchive |url=https://web.archive.org/web/20051205125434/http://www.incb.org/pdf/e/list/green.pdf |date=December 5, 2005 }}</ref> Pemoline is Schedule IV Non-Narcotic (Stimulant) controlled substance with a DEA ACSCN of 1530 and is not subject to annual manufacturing quotas.<ref name="CRC2014" />


==Research==
==Research==

Revision as of 02:43, 9 May 2022

Pemoline
Clinical data
Trade namesCylert, others
Other namesPheniminooxazolidinone; Phenylisohydantoin; Phenylpseudohydantoin; Phenilone; 2-Imino-5-phenyl-4-oxazolidinone; 2-Amino-5-phenyl-1,3-oxazol-4(5H)-one
AHFS/Drugs.comMicromedex Detailed Consumer Information
Routes of
administration		Oral[1][2]
ATC code
Legal status
Legal status
Pharmacokinetic data
Protein binding≤50%[2][1]
MetabolismLiver[2]
MetabolitesVarious[2]
Elimination half-life7–12 hours[1][2]
ExcretionMainly urine[2]
Identifiers
  • (RS)-2-amino-5-phenyl-1,3-oxazol-4(5H)-one
CAS Number
PubChem CID
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.016.763 Edit this at Wikidata
Chemical and physical data
FormulaC9H8N2O2
Molar mass176.175 g·mol−1
3D model (JSmol)
ChiralityRacemic mixture
  • O=C2\N=C(/OC2c1ccccc1)N
  • InChI=1S/C9H8N2O2/c10-9-11-8(12)7(13-9)6-4-2-1-3-5-6/h1-5,7H,(H2,10,11,12) checkY
  • Key:NRNCYVBFPDDJNE-UHFFFAOYSA-N checkY
 ☒NcheckY (what is this?)  (verify)

Pemoline, sold under the brand name Cylert among others, is a stimulant medication which has been used in the treatment of attention-deficit hyperactivity disorder (ADHD) and narcolepsy.[2] It has been discontinued in most countries to due to rare but serious problems with liver toxicity.[3][4] The medication is taken by mouth.[2]

Side effects of pemoline include insomnia, decreased appetite, abdominal pain, irritability, and headaches.[1][2] Rarely, the medication can cause serious liver damage, and this can result in liver transplantation or death.[5][6] Pemoline is a psychostimulant and acts as a selective dopamine reuptake inhibitor and releasing agent.[1][7][2] Hence, it functions as an indirect agonist of dopamine receptors.[8] Pemoline has little effect on norepinephrine and hence has minimal or no cardiovascular or sympathomimetic effects, in contrast to many other stimulants.[1][7][2]

Pemoline was synthesized in 1913 but was not discovered to be a stimulant until the 1930s and was not used in the treatment of ADHD until 1975.[9][10][1] It was withdrawn due to liver toxicity in many countries between 1997 and 2005, including the United States.[11][6][12] However, it remains available in Japan for the treatment of narcolepsy at lower doses than used for ADHD.[4] Pemoline is a schedule IV controlled substance in the United States due to its relation to other stimulants and a potential for misuse.[13][14] It seems to have less misuse potential than other stimulants.[1]

Medical uses

Pemoline has been used in the treatment of ADHD and narcolepsy.[2][1][4] It has also been used in the treatment of excessive daytime sleepiness.[7] The medication was typically used at doses of 18.75 to 112.5 mg once per day in the treatment of ADHD, with the effective dose for most people being in the range of 56.25 to 75 mg.[1][2] The onset of action of pemoline is gradual and therapeutic benefits may not occur until the third or fourth weeks of use.[2][1] This may be due to a cautious low initial starting dose of 37.5 mg and gradual titration in dose upwards over several weeks.[1]

Available forms

Pemoline was available in the form of 18.75, 37.5, and 75 mg oral immediate-release tablets (Cylert) as well as 37.5 mg oral immediate-release chewable tablets.[1][2] It was provided mainly in the form of the free base but also as the magnesium salt.[15]

Side effects

Side effects of pemoline include insomnia, decreased appetite, abdominal pain, irritability, and headaches.[1][2] It has minimal cardiovascular or sympathomimetic side effects.[1][2] Pemoline is described as a lower-efficacy/milder stimulant than classical stimulants like amphetamines and methylphenidate and is said to have fewer side effects than them.[16]

Liver toxicity

In some patients pemoline is suspected of causing hepatotoxicity,[1][17] so the FDA recommended that regular liver tests should be performed on those treated with it.[18] Since receiving FDA approval in 1975, it has been linked with 21 cases of liver failure, of which 13 resulted in liver replacement or death. Approximately 1–2% of patients taking the drug show elevated levels of liver transaminase enzymes, a marker for liver toxicity, though serious cases are rare. Over 200,000 children with ADHD were prescribed pemoline in the United States and Canada alone during the approximate 25 years that it was available, plus a smaller number of adults prescribed it for indications such as chronic fatigue syndrome and apathy in the elderly (and not including prescriptions in the rest of the world), so the number of liver failure cases was statistically not that large. However the reactions proved idiosyncratic and unpredictable, with patients sometimes taking the drug with no issue for months or even years, before suddenly developing severe liver toxicity. There was no clear exposure-toxicity relationship, and no characteristic liver pathology findings. Some patients showed as little as one week between first appearance of jaundice and complete liver failure, and some of the patients that developed liver failure had not showed elevated liver transaminase levels when tested previously.[12] On the other hand, there are no cases of liver failure associated with pemoline in Japan, although it is used at lower doses and is only prescribed for the niche indication of narcolepsy in this country.[4]

Overdose

Overdose of pemoline may present with choreoathetosis symptoms.[19]

Interactions

Other stimulants and monoamine oxidase inhibitors are contraindicated with pemoline.

Pharmacology

Pharmacodynamics

The pharmacodynamics of pemoline are poorly understood and its precise mechanism of action hasn't been definitively determined.[1][2] However, pemoline has similar activity and effects to those of other psychostimulants, and in animals the medication appears to act as a dopamine reuptake inhibitor and releasing agent.[1] By increasing dopamine levels in the brain, it functions as an indirect agonist of dopamine receptors.[8] In contrast to most other stimulants, pemoline appears to produce no significant central or peripheral noradrenergic effects.[1] As a result, it has minimal or no cardiovascular or sympathomimetic effects.[1] Pemoline is described as a selective dopamine reuptake inhibitor that only weakly stimulates dopamine release.[7]

While drugs like dextroamphetamine and methylphenidate are classified as schedule II and have considerable misuse potential, pemoline is listed as schedule IV (non-narcotic).[2] In studies conducted on primates, pemoline fails to demonstrate a potential for self-administration.[2] It is thought to have little potential for abuse and dependence.[1] Nonetheless, misuse may theoretically occur owing to its similarity to other psychostimulants.[2]

Pharmacokinetics

Studies of the pharmacokinetics of pemoline in humans are very limited.[1] The time to peak levels of pemoline is 2 to 4 hours.[2][1] Peak levels have been reported to be in the range of 2 to 4.5 μg/mL.[1] Steady-state levels of pemoline are reached in 2 to 3 days.[2]

Pemoline is variously reported to have no significant plasma protein binding or to have 50% plasma protein binding.[1][2]

Pemoline is metabolized in the liver.[2] Its metabolites include pemoline conjugate, pemoline dione, mandelic acid, and unidentified polar metabolites.[2]

Pemoline is excreted mainly by the kidneys with around 50% excreted in unchanged form and only minor amounts present as metabolites.[2] The elimination half-life of pemoline is 7 to 12 hours.[1][2] The half-life is 7 hours in children but may increase to 11 to 12 hours with age.[1] The relatively long half-life of pemoline allows for once-daily administration.[1]

No differences in the pharmacokinetics of pemoline were found with conventional tablets, chewable tablets swallowed, or chewable tablets chewed.[1]

Chemistry

Pemoline is a member of the 4-oxazolidinone class and is structurally related to other members of the class including aminorex, 4-methylaminorex, clominorex, cyclazodone, fenozolone, fluminorex, and thozalinone.

The salts of pemoline in use are pemoline magnesium (free base conversion ratio .751), pemoline iron (.578), pemoline copper (.644), pemoline nickel (.578), pemoline rubidium, pemoline calcium, pemoline chromium, and chelates of the above which are identical in weight to the salt mentioned. Pemoline free base and pemoline cobalt, strontium, silver, barium, lithium, sodium, potassium, zinc, manganese, and caesium are research chemicals which can be produced in situ for experiments.[14][20][21] Others such as lanthanide pemoline salts such as pemoline cerium can be prepared; pemoline beryllium would presumably be toxic.

Synthesis

Pemoline is synthesized by the condensation of racemic ethyl mandelate with guanidine.

Pemoline synthesis: U.S. patent 2,892,753 DE 462077 

History

Pemoline was first synthesized in 1913[22][9] but its activity was not discovered until the 1930s.[10] Pemoline was approved for the treatment of ADHD in the United States in 1975.[1][4]

Cases of serious liver toxicity and associated death related to pemoline in children and adolescents were reported to the United States Food and Drug Administration's MedWatch between 1977 to 1996.[6] Serious liver toxicity with pemoline was first described in the medical literature in 1984 and 1989 letters to the editor.[6] Clinicians were little-aware of liver toxicity with pemoline until the 1990s.[6] Warnings for liver toxicity for pemoline were added to the United States Food and Drug Administration (FDA) label for the medication in December 1996 and a black box warning was added in June 1999 along with requirements for written consent and frequent monitoring of liver enzymes.[11][12][6] These warnings followed a 1995 publication on liver toxicity with pemoline.[6][23] However, findings suggested that clinicians poorly followed the FDA's directives on use of pemoline.[11] In any case, sales of pemoline in the United States increased until 1997 and declined between 1996 and 1999.[6] Pemoline was withdrawn due to liver toxicity in the United Kingdom in September 1997, in Canada in September 1999, and in the United States in 2005.[11][24][12][6] Abbott Laboratories voluntarily withdraw pemoline from the United States market in May 2005 and the FDA withdrew approval of generic pemoline in November 2005.[11][12] Pemoline remains available in Japan for treatment of narcolepsy as of 2017.[4]

Society and culture

Names

Pemoline is the generic name of the drug and its INNTooltip International Nonproprietary Name, USANTooltip United States Adopted Name, and BANTooltip British Approved Name.[22][15]

Pemoline was formerly marketed under the brand names Cylert, Betanamin, Ceractiv, Hyperilex, Kethamed, Ronyl, Stimul, Tamilan, Tradon, Tropocer, and Volital.[15][25][22]

Availability

Pemoline has been marketed in the United States, Canada, the United Kingdom, Belgium, Luxembourg, Spain, Germany, Switzerland, and Argentina.[15] It remains available in Japan for the treatment of narcolepsy as of 2017.[4] However, it is rarely used in Japan as narcolepsy is a niche indication and as clinicians are wary of the liver toxicity it has been associated with.[4][26]

Legal status

Under the Convention on Psychotropic Substances, it is a schedule IV controlled substancce.[13] Pemoline is Schedule IV Non-Narcotic (Stimulant) controlled substance with a DEA ACSCN of 1530 and is not subject to annual manufacturing quotas.[14]

Research

Fatigue

Pemoline has been studied in and reported to be effective in the treatment of fatigue due to multiple sclerosis and HIV-related disease.[27]

References

  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad Patrick, Kennerly S.; Markowitz, John S. (November 1997). "Pharmacology of methylphenidate, amphetamine enantiomers and pemoline in attention-deficit hyperactivity disorder". Human Psychopharmacology: Clinical and Experimental. 12 (6): 527–546. doi:10.1002/(SICI)1099-1077(199711/12)12:6<527::AID-HUP932>3.0.CO;2-U. eISSN 1099-1077. ISSN 0885-6222.
  2. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab "Cylert (Pemoline)" (PDF). FDA. December 2002. Archived (PDF) from the original on 4 March 2016. Retrieved 15 February 2014.
  3. ^ Billiard M (June 2008). "Narcolepsy: current treatment options and future approaches". Neuropsychiatr Dis Treat. 4 (3): 557–66. PMC 2526380. PMID 18830438.
  4. ^ a b c d e f g h Shader RI (April 2017). "Risk Evaluation and Mitigation Strategies (REMS), Pemoline, and What Is a Signal?". Clin Ther. 39 (4): 665–669. doi:10.1016/j.clinthera.2017.03.008. PMID 28366595.
  5. ^ Nakamura H, Blumer JL, Reed MD (March 2002). "Pemoline ingestion in children: a report of five cases and review of the literature". J Clin Pharmacol. 42 (3): 275–82. doi:10.1177/00912700222011292. PMID 11865963.
  6. ^ a b c d e f g h i Safer DJ, Zito JM, Gardner JE (June 2001). "Pemoline hepatotoxicity and postmarketing surveillance". J Am Acad Child Adolesc Psychiatry. 40 (6): 622–9. doi:10.1097/00004583-200106000-00006. PMID 11392339.
  7. ^ a b c d Nishino S, Mignot E (May 1997). "Pharmacological aspects of human and canine narcolepsy". Prog Neurobiol. 52 (1): 27–78. doi:10.1016/s0301-0082(96)00070-6. PMID 9185233. S2CID 31839355.
  8. ^ a b Solanto MV (July 1998). "Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration". Behav Brain Res. 94 (1): 127–52. doi:10.1016/s0166-4328(97)00175-7. PMID 9708845.
  9. ^ a b Chemische Berichte, 1913, vol.46, p. 2083
  10. ^ a b Acta Academiae Aboensis, Series B: Mathematica et Physica, 1939, vol. 11, #14 p. 3,7
  11. ^ a b c d e Zito JM, Derivan AT, Kratochvil CJ, Safer DJ, Fegert JM, Greenhill LL (September 2008). "Off-label psychopharmacologic prescribing for children: history supports close clinical monitoring". Child Adolesc Psychiatry Ment Health. 2 (1): 24. doi:10.1186/1753-2000-2-24. PMC 2566553. PMID 18793403.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  12. ^ a b c d e Etwel FA, Rieder MJ, Bend JR, Koren G (2008). "A surveillance method for the early identification of idiosyncratic adverse drug reactions". Drug Saf. 31 (2): 169–80. doi:10.2165/00002018-200831020-00006. PMID 18217792. S2CID 19964105.
  13. ^ a b Annual Estimates Of Requirements Of Narcotic Drugs, Manufacture Of Synthetic Drugs, Opium Production And Cultivation Of The Archived December 5, 2005, at the Wayback Machine
  14. ^ a b c DEA office of Diversion Control site: Federal Register publications of CSA schedules, 2014 Q1
  15. ^ a b c d Swiss Pharmaceutical Society (2000). Swiss Pharmaceutical Society (ed.). Index Nominum 2000: International Drug Directory. Taylor & Francis. pp. 799–. ISBN 978-3-88763-075-1.
  16. ^ Nishino, Seiji; Kotorii, Nozomu (2016). "Overview of Management of Narcolepsy". Narcolepsy. Springer International Publishing. pp. 285–305. doi:10.1007/978-3-319-23739-8_21.
  17. ^ Marotta PJ, Roberts EA (May 1998). "Pemoline hepatotoxicity in children". J. Pediatr. 132 (5): 894–7. doi:10.1016/S0022-3476(98)70329-4. PMID 9602211.
  18. ^ Willy ME, Manda B, Shatin D, Drinkard CR, Graham DJ (July 2002). "A study of compliance with FDA recommendations for pemoline (Cylert)". J Am Acad Child Adolesc Psychiatry. 41 (7): 785–90. doi:10.1097/00004583-200207000-00009. PMID 12108802. Archived from the original on 2021-05-31. Retrieved 2020-09-10.
  19. ^ Stork CM, Cantor R (1997). "Pemoline induced acute choreoathetosis: case report and review of the literature". J. Toxicol. Clin. Toxicol. 35 (1): 105–8. doi:10.3109/15563659709001175. PMID 9022662.
  20. ^ The A-Z Encyclopaedia of Alcohol and Drug Abuse
  21. ^ CRC Handbook of Chemistry & Physics
  22. ^ a b c J. Elks, ed. (14 November 2014). The Dictionary of Drugs: Chemical Data: Chemical Data, Structures and Bibliographies. Springer. pp. 70–. ISBN 978-1-4757-2085-3. OCLC 1058412474.
  23. ^ Berkovitch M, Pope E, Phillips J, Koren G (June 1995). "Pemoline-associated fulminant liver failure: testing the evidence for causation". Clin Pharmacol Ther. 57 (6): 696–8. doi:10.1016/0009-9236(95)90233-3. PMID 7781270.
  24. ^ Shah RR (September 2006). "Can pharmacogenetics help rescue drugs withdrawn from the market?". Pharmacogenomics. 7 (6): 889–908. doi:10.2217/14622416.7.6.889. PMID 16981848.
  25. ^ Ashutosh Kar (2005). Medicinal Chemistry. New Age International. pp. 201–. ISBN 9788122415650. OCLC 818800751.
  26. ^ Takeda, Toshinobu (March 2009). "Psychopharmacology for attention-deficit/hyperactivity disorder in Japan". Current Attention Disorders Reports. 1 (1): 21–28. doi:10.1007/s12618-009-0004-5. eISSN 1943-457X. ISSN 1943-4561.
  27. ^ Kaminski, Marek; Sjøgren, Per (2007-02-22). "The use of psychostimulants in palliative and supportive treatment of cancer patients". Advances in Palliative Medicine (in Polish). 6 (1): 23–32. ISSN 1898-3863. Retrieved 2022-05-09.
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