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The antenatal use of ambroxol (bromhexine metabolite VIII) to prevent hyaline membrane disease: a controlled double-blind study.

A prospective double-blind clinical trial was carried out to determine whether ambroxol (bromhexine metabolite VIII) treatment (1000 mg/day for a period of 5 days) reduces the risk of hyaline membrane disease (HMD) in potentially premature infants. Amniocentesis was performed before the first and 24 h after the last application of ambroxol or placebo to assess the development of the total phospholipid phosphorus content, the L/S ratio, the P/S ratio, and the properties of the surface tension of the amniotic fluid after ambroxol or placebo. There were 246 infants born to 224 mothers. Of the 116 infants with less than or equal to 36 completed weeks' gestation, 56 were in the ambroxol and 60 in the placebo group. No differences between groups occurred in risk factors for HMD (diabetes, asphyxia, male sex, cesarean section). Statistically significant differences in favor of the infants in the ambroxol group were found in the HMD incidence: 23.2% in the ambroxol group compared with 41.7% in the placebo group (p less than 0.05). There was no reduction of the HMD incidence in the less than or equal to 32-week gestational age category in the ambroxol group compared with the placebo group inspite of the fact that all the examined parameters for determining lung maturity reflected a stimulatory effect of ambroxol compared with the results of the placebo group, particularly before the 33rd week of gestation. Prolonged rupture of the membranes played no protective role against HMD.

Ambroxol↗

Oxidant scavenger function of ambroxol in vitro: a comparison with N-acetylcysteine.

Highly reactive oxygen metabolites play an important role in inflammatory processes in the lung. Ambroxol (2-amino-3,5-dibromo-N-[trans-4- hydroxycyclohexyl]benzylamine) has been shown to reduce oxidant-mediated cell damage. However, the mechanism of this effect remains unclear. In order to evaluate oxidant scavenger function increasing concentrations of ambroxol (0-10(-3) mol/l) were compared with equimolar concentrations of N-acetylcysteine (NAC) and glutathione (GSH) in vitro to reduce OH. (hydroxyl radical), HOC1 (hypochlorous acid), O-2 (superoxide anion) and H2O2 (hydrogen peroxide). OH. was measured spectrophotometrically (deoxyribose assay); O-2 (xanthine/x-oxidase), H2O2 and HOC1 (HOC1/OC1-) were determined by chemiluminescence. Ambroxol, NAC and reduced GSH scavenged OH. significantly at 10(-3) mol/l, while HOC1 was inhibited at concentrations > or = 10(-4) mol/l completely (P < 0.01). NAC and GSH had no anti-O-2 function, while ambroxol (10(-4) mol/l) reduced O-2 by 14.3 +/- 6.7%. In contrast, GSH and NAC scavenged H2O2 at > 10(-6) mol/l (P < 0.01), while ambroxol had no anti-H2O2 effect. Our data demonstrate direct oxidant-reducing capabilities of ambroxol, which may be directly related to the aromatic moiety of the molecule. However, high concentrations (micromolar concentrations) are needed. Due to differences in direct oxidant scavenger function, a combination of ambroxol and NAC could be beneficial in antioxidant therapy.

Acetylcysteine↗

In vitro and in vivo antioxidant activity of ambroxol.

In addition to a mucolytic action, ambroxol has antioxidant and anti-inflammatory properties. The antioxidant effects of ambroxol were studied both in vitro and in vivo. In vitro methods, such as (1) inhibition of hyaluronic acid degradation induced by hydroxy radicals and (2) standard lipid peroxidation assay in rat liver mitochondria and gastric mucosa, induced by tert-butyl hydroperoxide, were used. The in vivo approach was based on the study of the protective effect of pretreatment with ambroxol in a rat model of gastric corpus and antral lesions, induced by indomethacin. The inhibition of the degradation of hyaluronic acid was measured as a change of its viscosity; ambroxol (1,000 microl/l) reduced the degradation by 93%. Lipid peroxidation with tert-butyl hydroperoxide as a source of radicals was followed by the formation of thiobarbituric acid reactive substances. Ambroxol (10 mmol/l) inhibited lipid peroxidation by 96% in the rat liver mitochondria, and by 74% in the gastric mucosa. In vivo, ambroxol was administered p.o. at a dose of 10, 30, and 50 mg/kg, at 5, 30, and 60 min prior to indomethacin administration. The highest inhibition of the number of corpus gastric lesions and lowering of the lesion index (38% and 62%, respectively) was shown after the administration of 50 mg/kg, 30 min before indomethacin administration. Antral lesions were inhibited to a lesser extent by the same dose of ambroxol, administered 30 min before indomethacin treatment. Inhibition of the number of antral lesions reached 27% and the total area of the gastric damage was even larger (the ulcer index reached -5%).

Ambroxol↗

Ambroxol reduces LPS toxicity mediated by induction of alkaline phosphatases in rat lung.

Alkaline phosphatases (APs) have been suggested to detoxify lipopolysaccharide (LPS) by dephosphorylation. Ambroxol, a bronchial expectorant, is known to accelerate the secretion of pulmonary surfactant particles including AP molecules as a pharmacological action. In the present study, some beneficial effects of ambroxol on LPS toxicity in the rat lung were investigated. In an experiment using the rat lung organ culture, AP activities were enhanced in a time-dependent manner by incubation with 25 microM of ambroxol in both the tissue and the medium. Western blot analysis indicated that AP activity was elevated by the treatment with ambroxol, due to the induction of surfactant proteins (SPs) and AP molecules. In the in vivo experiment, the serum LPS content was markedly increased after LPS administration to rats by intratracheal instillation of 20 mg/kg. However, when the rats were pretreated with oral ambroxol (1.0 mg/kg) at 1 h before LPS challenge, the area under the concentration--time curve (AUC) of serum LPS was significantly decreased. These results suggest that ambroxol inhibits the translocation of LPS from the lung into the circulation as well as its detoxification effect via the elevation of AP activity. Bromhexine, another expectorant, is less effective than ambroxol as an LPS detoxificant. Maintenance of high AP activity level in the lung suggests APs to have physiological significant effects against the inflammatory events induced by LPS.

Administration, Oral↗

Cell-specific modulation of surfactant proteins by ambroxol treatment.

Ambroxol [trans-4-(2-amino-3,5-dibromobenzylamino)-cyclohexanole hydrochloride], a mucolytic agent, was postulated to provide surfactant stimulatory properties and was previously used to prevent surfactant deficiency. Currently, the underlying mechanisms are not exactly clear. Because surfactant homeostasis is regulated by surfactant-specific proteins (SP), we analyzed protein amount and mRNA expression in whole lung tissue, isolated type II pneumocytes and bronchoalveolar lavage of Sprague-Dawley rats treated with ambroxol i.p. (75 mg/kg body weight, twice a day [every 12 h]). The methods used included competitive polymerase chain reaction (RT-PCR), Northern blotting, Western immunoblotting, and immunohistochemistry. In isolated type II pneumocytes of ambroxol-treated animals, SP-C protein and mRNA content were increased, whereas SP-A, -B and -D protein, mRNA, and immunoreactivity remained unaffected. However, ambroxol treatment resulted in a significant increase of SP-B and in a decrease of SP-D in whole lung tissue with enhanced immunostaining for SP-B in Clara Cells. SP-A and SP-D were significantly decreased in BAL fluid of ambroxol-treated animals. The data suggest that surfactant protein expression is modulated in a cell-specific manner by ambroxol, as type II pneumocytes exhibited an increase in SP-C, whereas Clara cells exhibited an increase in the immunoreactivity for SP-B accounting for the increased SP-B content of whole lung tissue. The results indicate that ambroxol may exert its positive effects, observed in the treatment of diseases related to surfactant deficiency, via modulation of surfactant protein expression.

Ambroxol↗

Ambroxol inhibits peroxynitrite-induced damage of alpha1-antiproteinase and free radical production in activated phagocytic cells.

The present study examined the effect of ambroxol on toxic action of peroxynitrite and the respiratory burst in activated phagocytic cells. Ambroxol decreased the inactivation or destruction of alpha1-antiproteinase induced by peroxynitrite (ONOO-) or hypochlorous acid (HOCl), which was similar to penicillamine and glutathione and was greater than diclofenac sodium and naproxen sodium. Ambroxol significantly decreased ONOO--mediated tyrosine nitration and iron plus EDTA-mediated degradation of 2-deoxy-D-ribose. Ambroxol significantly attenuated the production of superoxide, hydrogen peroxide, HOCl, and nitric oxide in fMLP- or IL-1-activated phagocytic cells, while the inhibitory effects of antiinflammatory and thiol compounds were only observed in HOCl production. Ambroxol and antiinflammatory drugs did not show a cytotoxic effect on macrophages. The results suggest that ambroxol protects tissue components against oxidative damage by an action different from antiinflammatory drugs. Ambroxol may interfere with oxidative damage of alpha1-antiproteinase through a scavenging action on ONOO- and HOCl and inhibition of the respiratory burst of phagocytic cells.

Ambroxol↗

Effect of early ambroxol treatment on lung functions in mechanically ventilated preterm newborns who subsequently developed a bronchopulmonary dysplasia (BPD).

In a randomized trial in 102 preterm newborns with respiratory distress syndrome (RDS) it has been shown that early Ambroxol treatment (30 mg kg(-1) over the first 5 days) significantly reduces the incidence of RDS-associated complications [bronchopulmonary dysplasia (BPD), intraventricular haemorrhage, post-natal acquired pneumonia]. The aim of the present analysis was to investigate the effect of Ambroxol treatment on lung function in newborns who developed BPD. Respiratory function testing (RFT) was performed immediately after extubation and at day 28. Tidal volume (VT) and respiratory frequency (f) were measured during tidal breathing using the deadspace free flow-through technique. The lung mechanic parameter VT/maxPes was determined by measuring the maximal oesophageal pressure changes, maxPes, with a catheter tip pressure transducer. In the placebo group 36/50 infants were extubated within the first 28 days of life and 13/36 (36%) developed BPD. In the Ambroxol group 44/52 were extubated and 9/44 (20%) developed BPD. After extubation, RFT showed (i) no statistically significant difference in the ventilatory parameters of either treatment group, (ii) improved (P<0.05) lung mechanics (VT/maxPes) in Ambroxol group compared to controls (94+/-27 ml kPa(-1) vs. 8.1+/-2.6 ml kPa(-1)) and (iii) no statistically significant difference in lung function between infants with and without BPD. At day 28 we found (i) no effect of early Ambroxol treatment on lung functions, (ii) significantly (P < 0.05) higher f (58.5+/-11.7 min(-1) vs. 49.7+/-10.1 min(-1)) and significantly (P<0.01) lower V(T) (9.6+/-1.9 ml vs. 12.3+/-2.7 ml) and V(T)/maxPes (8.9+/-2.6 ml kPa(-1)] vs. 12.0+/-2.9 ml kPa(-1)) in infants with BPD compared to infants without and (iii) these differences are not influenced by early Ambroxol treatment. If the process of BPD development is induced, early Ambroxol treatment has no influence on impaired lung function at day 28.

Ambroxol↗

[Effect of ambroxol on surfactant secretion and synthesis in isolated type II alveolar cells].

The effect of ambroxol is attributed in part to an effect on surfactant synthesis and secretion. Evidence supporting this hypothesis is largely indirect; a direct effect of ambroxol on surfactant synthesis and secretion remains to be demonstrated. In this study a direct effect of ambroxol was evaluated using isolated alveolar type II cells. Secretion of labelled phosphatidylcholine was measured following the addition of increasing concentrations (10(-8) M to 10(-4) M) of ambroxol to the culture medium for increasing time intervals. There was no significant increase in surfactant secretion with increased ambroxol concentration or prolonged exposure time. Uptake of 3H-choline and synthesis into 3H-phosphatidylcholine was analyzed as an indicator of surfactant synthesis. Again, increasing concentrations of ambroxol (10(-7) M to 10(-5) M) were followed for 1, 2, 4, 8 and 24 h. There was no significant effect on synthesis at any time point. Concentrations higher than those mentioned here resulted in LDH release from cultured cells. Ambroxol which also has anti-oxidative and anti-inflammatory effects does not exhibit direct stimulatory effects on surfactant synthesis and secretion in isolated (rat) alveolar type II cells as has been demonstrated e.g. for beta 2-adrenergic stimulation. A specific pharmacologic way to stimulate the surfactant system remains to be developed.

Ambroxol↗

The inhibitory effect of ambroxol on respiratory burst, degranulation and cytosolic Ca2+ change in degraded immunoglobulin G-activated neutrophils.

Superoxide and H2O2 production by neutrophils stimulated by 0.5 mg/ml degraded immunoglobulin G (IgG) and 1 microM N-formyl-methionyl-leucyl-phenylalanine (fMLP) was inhibited by ambroxol in a dose-dependent fashion, and at the concentration of 100 microM, 43.3% to 64.3% of inhibitions were detected. The inhibitory effect of ambroxol on H2O2 production by neutrophils was greater than that on superoxide production. The production of nitrite by lipopolysaccharide-activated murine peritoneal macrophages was significantly attenuated by ambroxol in a dose-dependent fashion and NG-monomethyl-L-arginine (NMMA). Ambroxol decreased the release of myeloperoxidase and lysozyme evoked by 0.5 mg/ml degraded immunoglobulin G and 1 microM fMLP in a dose-dependent fashion, and at the concentration of 100 microM, 37.1% to 64.2% of inhibitions were observed. The stimulatory effect of phorbol 12-myristate 13-acetate (PMA) (0.1 microg/ml) on superoxide production and myeloperoxidase, which is inhibited by 100 nM staurosporine, was not affected by 100 microM ambroxol. Degraded immunoglobulin G (0.5 mg/ml) caused an immediate elevation of [Ca2+]i in fura-2 load neutrophils in 1.23 mM Ca2+-containing medium. Preincubation of neutrophils with 10 microM to 100 microM ambroxol, 5 mM EGTA and 100 microM verapamil depressed the elevation of [Ca2+]i elicited by 0.5 mg/ml degraded immunoglobulin G. In conclusion, the inhibitory action of ambroxol on stimulated neutrophil responses, including respiratory burst and lysosomal enzyme release, appears to be attributed to its depressant action on the activation process, including the change in intracellular Ca2+ level. in which the role of protein kinase C is uncertain.

Ambroxol↗

Ambroxol improves the broncho-spasmolytic activity of clenbuterol in the guinea-pig.

The effects of ambroxol on the spasmolytic action of clenbuterol were investigated on acetylcholine-induced bronchospasm in guinea-pigs. Ambroxol (50 mg kg-1 day-1) or vehicle was administered orally for 14 days. Approximately 45 min after the final dose on day 14, the animals were anaesthetized and the spasmolytic effects of clenbuterol (3, 6 or 12 micrograms kg-1 injected intravenously) were determined by use of acetylcholine (40 micrograms kg-1, i.v.)-induced bronchoconstriction. For both vehicle- and ambroxol-treated animals, a positive linear relationship was observed between the log-dose of clenbuterol and the percent inhibition of bronchospasm. The calculated ED25 of clenbuterol (i.e., the dose producing 25% inhibition of the acetylcholine-induced bronchospasm) was 3.98 micrograms kg-1 (3.29 to 4.82 micrograms kg-1, 95% confidence interval) in the presence of ambroxol and 5.81 micrograms kg-1 (4.98 to 6.79 micrograms kg-1) in the absence of ambroxol. The linear regressions with or without ambroxol differed from each other (P < 0.001) but ran parallel (covariance analysis), enabling us to calculate a relative potency, the value of which was 1.46 (1.16 to 1.84). These results demonstrate that the spasmolytic activity of clenbuterol is significantly improved in animals pretreated with ambroxol.

Ambroxol↗

Depressant effect of ambroxol on stimulated functional responses and cell death in rat alveolar macrophages exposed to silica in vitro.

The present study examined the effect of ambroxol on free radical production, granule enzyme release, and cell death in silica-activated rat alveolar macrophages. The action of ambroxol was assayed by measuring changes in the activities of protein kinase C (PKC) and tyrosine kinase (PTK) and in the intracellular calcium level. Ambroxol attenuated the production of superoxide, hydrogen peroxide, and nitric oxide and the release of acid phosphatase and lysozyme in macrophages activated by silica. Staurosporine, genistein, EGTA, and trifluoperazine inhibited the silica-induced free radical production and granule enzyme release. Silica induced the increase in PKC and PTK activities and the elevation of intracellular calcium level in macrophages, which was decreased by ambroxol. Silica induced a cell death and increased the caspase-3 activity in macrophages in a concentration-dependent manner. Ambroxol decreased the silica-induced cell viability loss in macrophages. The results show that ambroxol decreases the stimulated responses and cell death in rat alveolar macrophages exposed to silica, which may be accomplished by inhibition of activation processes, protein kinases, and calcium transport. The inhibitory effect of ambroxol on silica-induced cell death appears to provide the protective effect on pulmonary tissues against the toxic action of silica.

Acid Phosphatase↗

Antenatal ambroxol effects on surfactant pool size and postnatal lung function in preterm ventilated rabbits.

Following maternal treatments with 50 mg/kg/day ambroxol for 2 or 3 days before delivery at 28 days gestation, preterm rabbits were ventilated to evaluate lung function. Subsequently, surfactant saturated phosphatidylcholine (SatPC) pool sizes were measured. One half of the ambroxol treated and control rabbits were given surfactant at delivery. Although surfactant improved lung function comparably for control and ambroxol treated rabbits, ambroxol treatments did not change ventilatory pressure requirements, compliances, or the recovery of intravascular labeled albumin in the lungs. Ambroxol treatments tended to increase lung volumes as evaluated by pressure-volume curves. The ambroxol treatments significantly increased lung tissue SatPC by 22%, but there were no changes in alveolar SatPC pool values. These results do not indicate a large effect of ambroxol on lung function in preterm rabbits.

Ambroxol↗

Ambroxol suppresses influenza-virus proliferation in the mouse airway by increasing antiviral factor levels.

The protective effect of ambroxol, a mucolytic agent which has antioxidant properties and stimulates the release of pulmonary surfactant, against influenza-virus proliferation in the airway was investigated in mice. Ambroxol or the vehicle was administered intraperitoneally twice a day for 5-7 days to mice shortly after intranasal infection with a lethal dose of influenza A/Aichi/68 (H3N2) virus, and the survival rate, virus titre and levels of factors regulating virus proliferation in the airway fluid were analysed. Ambroxol significantly suppressed virus multiplication and improved the survival rate of mice. The effect of ambroxol reached a peak at 10 mg x kg(-1) x day(-1), higher doses being less effective. Ambroxol stimulated the release of suppressors of influenza-virus multiplication, such as pulmonary surfactant, mucus protease inhibitor, immunoglobulin (Ig)-A and IgG, although it stimulated the release of a trypsin-type protease that potentiates virus proliferation. In addition, ambroxol transiently suppressed release of the cytokines, tumour necrosis factor-alpha, interferon-gamma and interleukin-12, into airway fluid. Although ambroxol had several negative effects on the host defence system, overall it strikingly increased the concentrations of suppressors of influenza-virus multiplication in the airway.

Ambroxol↗

Protective effect of ambroxol against heat- and hydrogen peroxide-induced damage to lung lipids in mice.

We wanted to determine whether ambroxol, a drug which stimulates the release of surfactant by type II pneumocytes, can protect lung lipids from peroxidative damage in mice. Animals were injected intraperitoneally with ambroxol, 0.169 mmol.kg-1, or 1 ml buffer once a day for three consecutive days. Lipid peroxidation was then induced in lung homogenates either by means of heat, 50 degrees C, or H2O2, 10 mmol.l-1. The lung homogenates from ambroxol-treated animals revealed decreased lipid peroxidation in response to both stimuli. The heat- and H2O2-induced generation of conjugated dienes (a first lipid peroxidation product) in ambroxol-treated lung homogenates was 3.7 and 3.1 fold lower than in the lungs from buffer-injected mice. Ambroxol, as an inhibitor of heat- and H2O2-induced lipid peroxidation, was equipotent to and stronger than the two antioxidants, N-acetylcysteine and methionine, respectively. Ambroxol was not able to protect heart and liver lipids. These results suggest that ambroxol can sufficiently enhance the antioxidant defence in lung tissue and can act as a lung lipid antioxidant.

Acetylcysteine↗

[Effects of ambroxol HCl on the guinea pig tracheal mucous secretion and the rat pulmonary surfactant secretion].

The effects of orally administered ambroxol HCl (ambroxol) on guinea pig tracheal mucous secretion and rat pulmonary surfactant secretion were investigated histologically and biochemically. Ambroxol significantly increased the number of active goblet cells in guinea pig tracheal epithelium and total mucopolysaccharide level. Moreover, ambroxol significantly increased the neutral mucopolysaccharide level and PAS-positive substance in the guinea pig tracheal submucosal glands. Ambroxol did not show a significant effect on the content of the total phosphatidylcholine in rat lung lavage fluid, while ambroxol significantly increased the ratio of disaturated phosphatidylcholine to total phosphatidylcholine. From these results, it is suggested that ambroxol increases both the tracheal mucous secretion, especially the neutral mucopolysaccharide, and pulmonary surfactant secretion and these effects reflect part of the expectorant mechanism of the drug.

Ambroxol↗

[Effect of ambroxol on lipid peroxidation in homogenates of the human placenta].

Free radically induced lipid peroxidation has been suggested as a possible pathogenic factor in pregnancy complications. The placenta is a potential source of lipid peroxides, due to its high lipid concentration. Cells and tissues are protected against toxic lipid peroxides by antioxidants. Ambroxol was found to be equipotent to well-known antioxidants in protecting lipids from peroxidative attack in lungs. To date there is no information on ambroxol capacity to act as a lipid antioxidant in the human placenta. Therefore, the aim of our study was to investigate the effect of ambroxol on lipid peroxidation in homogenates of the human placenta by malondialdehyde measurements. Fourteen homogenates of placentas obtained from healthy women were incubated for 24 hours (pH = 7.4, temp. 37 degrees C) without (group II) and with (group III) ambroxol hydrochloride solutions (Boehringer Ingelheim--Germany) at concentration of 2200 ng/mL. Non-incubated homogenates were treated as a control group (group I). It was found that lipid peroxidation and malondialdehyde formation is significantly higher in group II homogenates than in the control group (p < 0.05). Incubation with ambroxol (group III) caused a non-significant increase of malondialdehyde concentration in comparison with the control group and a non-significant but distinct decrease when compared with group II (incubation without ambroxol). This investigation shows that ambroxol decreases malondialdehyde formation in homogenates of the human placenta and can be regarded as lipid antioxidant.

Adult↗

Effect of ambroxol on ion transport -- a model study.

BACKGROUND: Effect on ambroxol on reflexive physiological reactions of isolated frog skin was studied with electrophysiological methods designed to assess ion currents occurring in epithelial tissues or organs. The experiments permitted to analyze an effect of ambroxol on regulatory mechanisms, which in turn influence the constant electrical potential defined as PD and reversible changes of this potential during mechanical stimulation (marked as dPD). A contribution of sodium- and chloride ions transport to the value of transepithelial electrical potential of frog skin (before and after ambroxol administration) has been demonstrated using amiloride - a blocker of sodium ion transport and bumetanide - a blocker of chloride ion transport. MATERIAL/METHODS: The experimental material comprised 34 fragments of hybrid frog (Rana esculenta L.), representing 14 specimens. The experiments involved measuring the transepithelial electrical potential (PD in mV) on an isolated frog skin placed in an Ussing apparatus. RESULTS: It has been demonstrated that ambroxol influences the processes of ion transport (dPD) which in turn depend on mechanical stimulation. The reaction of hyperpolarization decreased immediately after administration of ambroxol to the stimulating fluid, when transepithelial transport of sodium ion was maintained in the preparations studied. Consequently, no effect of ambroxol on the frog skin incubated with amiloride was recorded. CONCLUSIONS: It has been demonstrated, based on the experiments carried out in the present study, that ambroxol can modify processes of ion transport related to activation of sensory receptors. In particular, it can influence the stimulated transepithelial sodium ion transport in frog skin.

Ambroxol↗

Failure of ambroxol to influence the allergen induced bronchial constriction in sensitized guinea pigs.

The action of ambroxol was tested in an in vivo guinea pig asthma model. Ambroxol, a compound with antiallergic properties effects the mediator releasing cells in vitro and surfactant secretion from alveolar type II cells. This paper deals with the action of ambroxol in an in vivo asthma model in guinea pigs. Ovalbumin sensitized guinea pigs were artificially ventilated by negative chest wall pressure, using a tank respirator. Breathing parameters were measured pneumotachographically. The experimental animals were treated with 50 mg/kg ambroxol i.p. for 5 days; control animals received saline only. The results indicate that pretreatment with ambroxol had no significant effect on the allergic bronchial constriction, while in vitro ambroxol effects on mediator releasing cells and surfactant production point to antiallergic properties. An explanation of the failure of allergenic preventing effects of ambroxol in vivo may be its insufficient concentration in the tissue.

Allergens↗