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Repaglinide (Monograph)

Drug class: Meglitinides
- Glinides
ATC class: A10BX02
VA class: HS502
Chemical name: (S)-2-Ethoxy-4-[2-[[methyl-1-[2-(1-piperidinyl)-phenyl]butyl]amino]-2-oxoethyl]-benzoic acid
CAS number: 135062-02-1

Medically reviewed by Drugs.com on Jun 11, 2024. Written by ASHP.

Introduction

Antidiabetic agent; meglitinide (glinide) derivative.2 6 8 11 12 14 56 57 59 60 61 63 65

Uses for Repaglinide

Type 2 Diabetes Mellitus

Used as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus.1 5 61 65

Also has been used in combination with metformin and/or other antidiabetic agents for the management of type 2 diabetes mellitus.5 13 59 61 102

Glinides (e.g., nateglinide, repaglinide) generally not preferred as second-line therapy by some experts after failure of metformin monotherapy because of their lower effectiveness and comparatively limited clinical data; however, may be appropriate choices in selected patients.698

Current guidelines for the treatment of type 2 diabetes mellitus generally recommend metformin as first-line therapy in addition to lifestyle modifications in patients with recent-onset type 2 diabetes mellitus or mild hyperglycemia because of its well-established safety and efficacy (e.g., beneficial effects on glycosylated hemoglobin [hemoglobin A1c; HbA1c], weight, and cardiovascular mortality).698 704 705

In patients with metformin contraindications or intolerance (e.g., risk of lactic acidosis, GI intolerance), some experts suggest that initial therapy with a drug from another class of antidiabetic agents (e.g., a glucagon-like peptide-1 [GLP-1] receptor agonist, sodium-glucose cotransporter 2 [SGLT2] inhibitor, dipeptidyl peptidase-4 [DPP-4] inhibitor, sulfonylurea, thiazolidinedione, basal insulin) based on patient factors.698 704

May need to initiate therapy with 2 agents (e.g., metformin plus another drug) in patients with high initial HbA1c (>7.5% or ≥1.5% above target).698 704 In such patients with metformin intolerance, some experts suggest initiation of therapy with 2 drugs with complementary mechanisms of action from other antidiabetic drug classes.698

Consider early initiation of combination therapy for the treatment of type 2 diabetes mellitus to extend the time to treatment failure and more rapidly attain glycemic goals.704

For patients with inadequate glycemic control on metformin monotherapy, consider patient comorbidities (e.g., atherosclerotic cardiovascular disease [ASCVD], established kidney disease, heart failure), hypoglycemia risk, impact on weight, cost, risk of adverse effects, and patient preferences when selecting additional antidiabetic agents for combination therapy.698 699 704 705 706

Consider early introduction of insulin for severe hyperglycemia (e.g., blood glucose ≥300 mg/dL or HbA1c >9–10%), especially if accompanied by catabolic manifestations (e.g., weight loss, hypertriglyceridemia, ketosis) or symptoms of hyperglycemia.698 704

Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.1 5 61 71

Repaglinide Dosage and Administration

General

Administration

Oral Administration

Generally, instruct patients to take within 30 minutes before meals.1 59 61 71 Administration with food may affect extent of absorption.14 59 (See Food under Pharmacokinetics.)

Pre-meal doses may enhance glycemic control compared with twice-daily dosing at breakfast and dinner using the same total daily dosage.11 71

If a meal is skipped or added, skip or add a dose, respectively, for that meal.1 5 14 59 61 62 68 71

Dosage

Adults

Type 2 Diabetes Mellitus
Oral

Initially, 0.5 mg (the minimum effective dosage) preprandially 2–4 times daily (depending on meal patterns) in patients not previously treated with oral antidiabetic agents or in those who have relatively good glycemic control (i.e., glycosylated hemoglobin <8%).1 5 14 40 56 61 62 71

Patients with glycosylated hemoglobin ≥8% despite treatment with other oral antidiabetic agents: Initially, 1 or 2 mg with or preceding each meal.1 5 14 61 62 71

Approximately 90% of maximal glucose-lowering effect is achieved with dosage of 1 mg 3 times daily.56 57 66

May double dosage at no less than weekly intervals until desired fasting blood glucose concentration (e.g., 80–140 mg/dL with infrequent hypoglycemic episodes) is achieved or maximum daily dosage of 16 mg (e.g., 4 mg four times daily depending on meal patterns) is attained.1 3 5 14 27 31 36 56 59 61 62 71

Safety and efficacy of higher dosages (8–20 mg 3–4 times daily before meals) not established.14 71

Prescribing Limits

Adults

Type 2 Diabetes Mellitus
Oral

Maximum daily dosage of 16 mg (e.g., 4 mg four times daily depending on meal patterns) recommended by manufacturer;1 3 5 14 27 31 36 56 59 61 62 71 higher dosages have been used.14 71 (See Type 2 Diabetes Mellitus under Dosage and Administration.)

Special Populations

Renal Impairment

Mild to moderate renal dysfunction: No adjustment in initial dosage necessary.1 May administer usual initial dosage but use caution with subsequent dosage increases.1 5 59 61 71 104

Severe renal impairment (e.g., Clcr 20–40 mL/minute): Initiate dosage of 0.5 mg daily and titrate carefully.1

Use not established in patients with Clcr <20 mL/minute or those with renal failure requiring hemodialysis.1

Hepatic Impairment

Use with caution.1 5 59 71 Manufacturer recommends same initial dosage used in patients with normal hepatic function, but should make subsequent dosage adjustments at longer than usual intervals (e.g., 3 months) to allow full assessment of response.1 5 59 61 71 105 Some clinicians suggest lower initial dosage in patients with hepatic impairment.64

Patients Receiving Interacting Drugs

Concomitant administration of repaglinide and strong CYP2C8 or CYP3A4 inhibitors or inducers may require dosage adjustments1 (see Drugs or Foods Affecting Hepatic Microsomal Enzymes under Interactions); concomitant repaglinide and gemfibrozil contraindicated.1 (See Specific Drugs and Foods under Interactions.)

Avoid concomitant repaglinide and clopidogrel; if unable to avoid concomitant use, limit initial repaglinide dosage to 0.5 mg preprandially and do not exceed total daily dosage of 4 mg.1 (See Specific Drugs and Foods under Interactions.)

With concomitant cyclosporine, do not exceed total daily repaglinide dosage of 6 mg.1 (See Specific Drugs and Foods under Interactions.)

Detailed Repaglinide dosage information

Cautions for Repaglinide

Contraindications

Warnings/Precautions

Hypoglycemia

Potential for hypoglycemia.1 5 14 80 81 99 100 101 102 104 105 Debilitated, malnourished, or geriatric patients and those with hepatic or severe renal impairment or adrenal or pituitary insufficiency may be particularly susceptible.1 5 61 Strenuous exercise, alcohol ingestion, insufficient caloric intake, or use in combination with other antidiabetic agents may increase risk.1 5 61 71

Hypoglycemia may be difficult to recognize in geriatric patients or in those receiving β-adrenergic blocking agents.1 5 Increased risk of serious hypoglycemia in patients with hepatic failure, who may have reduced clearance of repaglinide and diminished gluconeogenic capacity.1 5 61 64

Appropriate patient selection, patient education, and careful attention to dosage are important to avoid hypoglycemic episodes.1

Combination Therapy with Isophane (NPH) Insulin

Myocardial ischemia was observed in a few patients receiving repaglinide in combination with NPH insulin in clinical trials, and the manufacturer states that repaglinide is not indicated for use in combination with NPH insulin.1

Macrovascular Outcomes

The manufacturer states that there have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with repaglinide.1

Specific Populations

Pregnancy

Limited data suggest no apparent drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes with repaglinide use during pregnancy.1 Abnormal maternal blood glucose concentrations during pregnancy may be associated with a higher incidence of congenital abnormalities.1 31 48 71

Most experts recommend use of insulin during pregnancy.14 56 64 71 109

Lactation

Distributed into milk in rats; not known whether distributed into human milk.1

Discontinue nursing or the drug.1 14 71

Pediatric Use

Safety and efficacy of repaglinide in children <18 years of age not established.40 71 However, the American Diabetes Association (ADA) states that most pediatric diabetologists use oral antidiabetic agents in children with type 2 diabetes mellitus because of greater patient compliance and convenience for the patient’s family.109

Geriatric Use

Safety and efficacy appear to be similar in geriatric and younger patients except for the expected age-related increase in cardiovascular morbidity observed with repaglinide and other comparative oral antidiabetic agents.1 5 14 1 5 14 101 (See Absorption: Special Populations under Pharmacokinetics.) No increase in frequency and severity of hypoglycemia in geriatric versus younger patients receiving repaglinide.1 14 101

Individualize antidiabetic therapy when implementing strict glycemic control considering advanced age, comorbid conditions, preexisting clinically relevant microvascular and macrovascular complications or other vascular risk factors, degree of hyperglycemia, and life expectancy.31 58

Hepatic Impairment

Use with caution.1 5 59 71

Renal Impairment

Use with caution.1 5 61

Common Adverse Effects

Hypoglycemia,1 5 14 80 81 99 100 101 102 104 105 upper respiratory tract infection,1 headache,1 64 71 80 81 arthralgia,1 sinusitis,1 nausea,1 diarrhea,1 back pain.1

Drug Interactions

Metabolized by CYP3A4 and CYP2C8 to inactive metabolites.1

Appears to be a substrate for organic anion-transporting protein (OATP) 1B1.1 200

Drugs or Foods Affecting Hepatic Microsomal Enzymes

Inhibitors of CYP3A4 or CYP2C8: Potential pharmacokinetic interaction (increased repaglinide AUC and peak plasma concentrations).1 Close monitoring of blood glucose concentrations suggested.40 59 71 (See Specific Drugs and Foods under Interactions.)

Inducers of CYP3A4 or CYP2C8: Potential pharmacokinetic interaction (decreased repaglinide AUC and peak plasma concentrations).1 14 59 62 64 71 Close monitoring of blood glucose concentrations suggested.40 59 71 (See Specific Drugs and Foods under Interactions.)

Drugs Affecting Transport Systems

OATP 1B1 inhibitors: Potential pharmacokinetic interaction (increased repaglinide concentrations).1

Protein-bound Drugs

Potential pharmacokinetic interaction with other protein-bound drugs (increased free repaglinide concentrations due to displacement from plasma protein binding sites by other drugs).1 5 14 61 64 71 104 Conversely, repaglinide could displace other protein-bound drugs from binding sites.1 14 71

Observe patient for evidence of hypoglycemia or loss of glycemic control when other protein-bound drugs are initiated or withdrawn, respectively, in patients receiving repaglinide.1 5 14 71

Specific Drugs and Foods

Drug or Food

Interaction

Comments

ACE inhibitors

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

β-Adrenergic blocking agents

Potential for displacement of repaglinide and/or β-adrenergic blocking agents from plasma proteins14 71

May blunt signs and symptoms of hypoglycemia1

Observe for evidence of hypoglycemia or loss of glycemic control when β-adrenergic blocker is added to therapy or withdrawn5 14 71

May require increased frequency of blood glucose monitoring1

Angiotensin II receptor antagonists

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Antidiabetic agents

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Antifungal agents, azole (e.g., itraconazole, ketoconazole)

May increase the risk of hypoglycemia1

Itraconazole: Increases of 1.4- and 1.5-fold in repaglinide AUC and peak plasma concentration, respectively, due to CYP3A4 inhibition by itraconazole1

Ketoconazole: Increases of 15 and 16% in repaglinide AUC and peak plasma concentration, respectively, due to CYP3A4 inhibition by ketoconazole1

Itraconazole and gemfibrozil: Increases of 19- and 2.8-fold in repaglinide AUC and peak plasma concentration, respectively1 (see Fibrates [e.g., gemfibrozil] entry in this table)

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Antipsychotics, atypical (e.g., clozapine, olanzapine)

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Antiretroviral agents (HIV protease inhibitors)

Potential inhibition of repaglinide metabolism200 201

May decrease the blood glucose-lowering effect of repaglinide1

May require repaglinide dosage adjustment and increased frequency of blood glucose monitoring1 200 201

Barbiturates

Potential for increased repaglinide metabolism due to CYP3A4 and/or CYP2C8 induction1 14 59 62 64 71

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Calcium-channel blocking agents

May decrease the blood glucose-lowering effect of repaglinide1

May cause hyperglycemia and exacerbate glycemic control in patients with diabetes mellitus1 14 61 71

Observe for evidence of altered glycemic control when a calcium-channel blocker is added to therapy or discontinued1 5 14 71

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Carbamazepine

Potential for increased repaglinide metabolism due to CYP3A4 and/or CYP2C8 induction1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Chloramphenicol

Potential for displacement of repaglinide and/or chloramphenicol from plasma proteins14 71

Observe for evidence of hypoglycemia or loss of glycemic control when chloramphenicol is added to therapy or discontinued5 14 71

Cimetidine

No appreciable effect on repaglinide pharmacokinetics1 14 49 64 71 106

Clarithromycin

Increased AUC and peak plasma concentration of repaglinide due to CYP3A4 inhibition1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Clonidine

May blunt signs and symptoms of hypoglycemia1

May require increased frequency of blood glucose monitoring1

Clopidogrel

Increases repaglinide exposures by 3.9- to 5.1-fold1

Avoid concomitant use; if concomitant use unavoidable, do not exceed initial repaglinide dosage of 0.5 mg before each meal and total daily dosage of 4 mg1

May require increased frequency of blood glucose monitoring1

Corticosteroids

May decrease the blood glucose-lowering effect of repaglinide1 and exacerbate glycemic control in patients with diabetes mellitus14 61 71

Observe closely for evidence of altered glycemic control when corticosteroid is added to therapy or discontinued5 14 71

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Cyclosporine

Increased repaglinide AUC and peak plasma concentration by 2.5- and 1.8-fold, respectively1

Do not exceed maximum daily repaglinide dosage of 6 mg; increased frequency of blood glucose monitoring may be required1

Danazol

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Deferasirox

Increased repaglinide AUC and peak plasma concentration by 2.3-fold and 62%, respectively1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Digoxin

No clinically relevant effect on digoxin pharmacokinetics1 71

Disopyramide

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Diuretics (e.g., thiazides)

May cause hyperglycemia and exacerbate glycemic control in patients with diabetes mellitus14 61 71

May decrease the blood glucose-lowering effect of repaglinide1

Observe closely for evidence of altered glycemic control when thiazides or other diuretics are added to therapy or discontinued5 14 71

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Erythromycin

Potential inhibition of repaglinide metabolism due to CYP3A4 inhibition1 14 59 62 64 71

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Estrogens

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Fibrates (e.g., gemfibrozil)

May increase the risk of hypoglycemia1

Gemfibrozil: Increased repaglinide AUC and peak plasma concentration by 8.1-fold and 2.4-fold, respectively1

Fenofibrate: Concomitant use did not substantially affect repaglinide AUC or peak plasma concentration1 200

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring when fibrates coadministered

Gemfibrozil: Concomitant therapy contraindicated1

Fluoxetine

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Furosemide

In vitro evidence that furosemide decreases the protein binding of repaglinide and increases free circulating repaglinide concentrations64

Interaction not thought to be clinically important64

Glucagon

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Grapefruit juice

Potential inhibition of repaglinide metabolism; may increase the risk of hypoglycemia71 202

Limited data suggest interaction unlikely to be clinically important200

HMG-CoA reductase inhibitors (e.g., simvastatin)

Potential for displacement of repaglinide and/or certain statins from plasma proteins14 71

Also, increased peak plasma repaglinide concentrations with concomitant simvastatin1

Observe closely for evidence of hypoglycemia or loss of glycemic control when certain statins added to therapy or discontinued5 14 71

Isoniazid

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

MAO inhibitors

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Montelukast

Montelukast known to inhibit CYP2C8 in vitro;1 710 however, no substantial effect on repaglinide pharmacokinetics noted in healthy individuals710

Manufacturer states that decreased repaglinide dosage and increased frequency of blood glucose monitoring may be required1

Niacin

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Nifedipine

No clinically relevant effect on nifedipine pharmacokinetics1 71

Close observation for hypoglycemia or loss or glycemic control suggested when nifedipine is added to therapy or discontinued71

NSAIAs (e.g., salicylates)

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Oral contraceptives (e.g., ethinyl estradiol/levonorgestrel/

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Pentoxifylline

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Phenothiazines

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Phenytoin

May cause hyperglycemia and exacerbate glycemic control in patients with diabetes mellitus14 61 71

Observe closely for evidence of altered glycemic control when phenytoin added to therapy or discontinued5 14 71

Pramlintide

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Probenecid

Potential for displacement of repaglinide and/or probenecid from plasma proteins14 71

Observe closely for evidence of hypoglycemia or loss of glycemic control when probenecid added to therapy or discontinued5 14 71

Progestogens (e.g., in oral contraceptives)

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Rifampin

Decrease in rifampin AUC and peak blood concentration due to CYP3A4 and/or CYP2C8 induction1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Somatostatin analogs (e.g., octreotide)

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Somatropin

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Sulfonamide antibiotics

May increase the risk of hypoglycemia1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Sympathomimetics (e.g., albuterol, epinephrine, terbutaline)

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Theophylline

No clinically relevant effect on theophylline pharmacokinetics1 71

Thyroid preparations

May decrease the blood glucose-lowering effect of repaglinide1

May require increased repaglinide dosage and increased frequency of blood glucose monitoring1

Tolbutamide

In vitro evidence that tolbutamide decreases the protein binding of repaglinide64

Interaction not thought to be clinically important64

Trimethoprim

Increased repaglinide AUC and peak plasma concentration due to CYP2C8 inhibition1

May require decreased repaglinide dosage and increased frequency of blood glucose monitoring1

Warfarin

Pharmacokinetic interaction not observed,1 but in vitro evidence suggests that warfarin decreases the protein binding of repaglinide64

In vitro interaction not thought to be clinically relevant 64
Repaglinide drug interactions (more detail)

Repaglinide Pharmacokinetics

Absorption

Bioavailability

Approximately 56% (absolute).1 5 14 61 71

Peak plasma drug concentrations attained within approximately 1 hour.1 10 14 56 59 60 61 62 64 65 68 71 100 107

Onset

Peak serum insulin concentrations achieved in approximately 1.5 hours.113 Maximum glycemic effect within 3–3.5 hours.2 61 79 Most of the hypoglycemic effect occurs within 1–3 weeks.1 5 11 14 61 65 71 80 113

Duration

Plasma insulin concentrations remain elevated for 4 hours after each meal in patients with type 2 diabetes mellitus;10 return toward premeal concentrations between meals and at bedtime.1 2 5 11 14 61 64 71

Food

Food may delay and reduce the extent of GI absorption.1 5 14 59 61 71 Administration with a high-fat meal slightly reduces peak plasma concentration and AUC but not time to peak concentration;60 61 64 reduction not clinically important.14 59

Special Populations

Greater systemic exposure (as determined by peak plasma concentrations and AUCs) to repaglinide in patients with hepatic impairment.1 5 14 61 71 105

Increases in plasma concentrations and AUC of repaglinide in patients with severe renal impairment (Clcr 20–40 mL/minute).1 5 59 60 61 64 71 104 Such alterations not found in patients with mild to moderate renal impairment.1 5 71 104

No pharmacokinetic differences (peak plasma concentration, AUC) observed in geriatric individuals (≥65 years of age) compared with healthy younger individuals.1 5 14 101

Distribution

Extent

Distributes into erythrocytes.107

Distributes into milk in rats; not known whether distributed into human milk.1 14

Plasma Protein Binding

>98%.1 5 14 61 64 71 104

Elimination

Metabolism

Rapidly metabolized by CYP3A4 and CYP2C8 to inactive metabolites.1 5 14 59 62 64 65 67 71 80 81 99 100 101 104 105 107

Elimination Route

Extensively metabolized in liver and excreted into bile and feces (90%) as metabolites.1 3 5 14 40 56 59 60 61 64 68 71 73 80 99 104 106 107

Small amount excreted in urine (8%) principally as metabolites.1 5 14 56 59 60 61 64 65 68 80 99 104 106 107

Does not appear to be removed by hemodialysis.1 104

Half-life

About 1 hour.1 3 5 14 59 61 62 64 65 68 101 107

Special Populations

In patients with hepatic impairment, elimination of unbound repaglinide reduced compared with that in healthy individuals.14 71 105

Stability

Storage

Oral

Tablets

Well-closed containers at ≤25°C; protect from moisture.1 Stable for at least 12 months in the original container at 25°C and 60% relative humidity.71

Actions

Advice to Patients

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Repaglinide

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets

0.5 mg*

Repaglinide Tablets

1 mg*

Repaglinide Tablets

2 mg*

Repaglinide Tablets

AHFS DI Essentials™. © Copyright 2024, Selected Revisions June 21, 2021. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

References

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