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Impact of Colchicine and Low-dose Naltrexone on COVID-19 (COLTREXONE)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT04756128
Recruitment Status : Enrolling by invitation
First Posted : February 16, 2021
Last Update Posted : February 18, 2021
Sponsor:
Collaborator:
Park Nicollet Foundation
Information provided by (Responsible Party):
Daniel P. Delaney, PharmD, BCIDP, HealthPartners Institute

Brief Summary:
The purpose of this study is to explore the impact of two medications-colchicine and low-dose naltrexone (LDN)-relative to standard of care (SOC) on COVID-19 disease progression to severe/critical illness and/or intubation in patients hospitalized with moderate COVID-19. As researchers have learned, COVID-19's clinical course suggests that the hyperinflammatory response seen in severe/critical cases is involved in the pathogenesis of associated adverse sequelae such as acute respiratory distress syndrome (ARDS), thromboembolic disease, and acute cardiac injury. Given colchicine has demonstrated clinical utility in inflammatory syndromes within these systems (e.g. endothelial/vascular/myocardial), and LDN acts both to boost the immune system, and limit an excessive response; they may prove useful in minimizing the risk of disease progression and associated adverse sequelae.

Condition or disease Intervention/treatment Phase
Covid19 Drug: Colchicine 0.6 mg Drug: Naltrexone Phase 2

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 164 participants
Allocation: Randomized
Intervention Model: Factorial Assignment
Intervention Model Description: This will be a four arm, prospective, randomized, open label trial in patients hospitalized with moderate COVID-19. Randomization will be stratified by baseline severity score (2 or 3) to ensure balanced baseline severities between the four arms. Block randomization will be used to ensure equal group sizes. As the final sample size is unknown, study staff will use small blocks of eight for randomization. This is being done in an effort to ensure evenly distributed treatment arms.
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Impact of Colchicine and Low-dose Naltrexone on COVID-19 Disease Progression and Clinical Course in Hospitalized Patients
Actual Study Start Date : January 25, 2021
Estimated Primary Completion Date : December 31, 2021
Estimated Study Completion Date : December 31, 2021

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: Colchicine-Only Arm

Patients randomized to a colchicine-containing treatment arm will receive colchicine 0.6 mg twice daily for up to 28 days. On the day of enrollment, provided the first dose can be given prior to 16:00 that day, patients are eligible to receive two doses; the second dose will be scheduled for 22:00. Patients experiencing gastrointestinal side effects (nausea, vomiting, and diarrhea) on twice daily dosing may have the dose decreased to 0.6 mg daily. Dosing will continue twice daily unless there is a change that requires a dose adjustment or an exclusion criterion is met. Dosing deviations above the study protocol will be allowed if medically necessary for the treatment of an additional indication (e.g. colchicine for viral pericarditis).

Patients in this arm will also receive the investigating institution's current standard of care (described in detail in the "standard of care" arm) for patients with COVID-19.

Drug: Colchicine 0.6 mg

Colchicine is an oral anti-inflammatory agent that is relatively inexpensive, readily available, and has been used for generations. Approved for treatment and prophylaxis of gout flares and Mediterranean fever, it is also used in a variety of other inflammatory conditions (e.g. pericarditis and diffuse vascular inflammation such as Behcet syndrome). Colchicine binds to tubulin causing depolymerization, which interferes with neutrophil chemotaxis, adhesion, and mobilization to sites of inflammation, and contributes to reduction in superoxide production; through interference of the NLRP3 inflammasome protein complex, colchicine inhibits IL-1b, IL-6, and IL-18 production.

For this study, patients enrolled in a colchicine containing arm will receive 0.6mg of colchicine BID (unless renal function/gastrointestinal issues require adjustments described in the protocol)


Experimental: Colchicine and Naltrexone ("Combined") Arm

Patients randomized to a colchicine-containing treatment arm (including the "combined arm") will receive colchicine 0.6 mg twice daily for up to 28 days. On the day of enrollment, provided the first dose can be given prior to 16:00 that day, patients are eligible to receive two doses; the second dose will be scheduled for 22:00.

Patients in the "combined" arm will also receive naltrexone. Patients randomized to an LDN-containing treatment arm (including the "combined arm") will receive naltrexone 4.5 mg once daily. The first dose can be given at any time during the day of enrollment/randomization, and will be timed at 08:00 daily thereafter (with AM colchicine dose, if in combined colchicine/LDN arm) for up to 28 days (unless new contraindication or exclusion criteria met).

Patients in this arm will also receive the investigating institution's current standard of care (described in detail in the "standard of care" arm) for patients with COVID-19.

Drug: Colchicine 0.6 mg

Colchicine is an oral anti-inflammatory agent that is relatively inexpensive, readily available, and has been used for generations. Approved for treatment and prophylaxis of gout flares and Mediterranean fever, it is also used in a variety of other inflammatory conditions (e.g. pericarditis and diffuse vascular inflammation such as Behcet syndrome). Colchicine binds to tubulin causing depolymerization, which interferes with neutrophil chemotaxis, adhesion, and mobilization to sites of inflammation, and contributes to reduction in superoxide production; through interference of the NLRP3 inflammasome protein complex, colchicine inhibits IL-1b, IL-6, and IL-18 production.

For this study, patients enrolled in a colchicine containing arm will receive 0.6mg of colchicine BID (unless renal function/gastrointestinal issues require adjustments described in the protocol)


Drug: Naltrexone

Most well known as an opioid antagonist, or a treatment for alcohol dependence, naltrexone also possesses immunomodulatory effects. Seen exclusively at low doses, this attribute is being employed in the pain community as a novel anti-inflammatory agent that has been shown to reduce symptom severity in fibromyalgia, Crohn's disease, multiple sclerosis, and complex regional pain syndrome.

For this study, patients enrolled in a naltrexone-containing arm will take their daily dose of the medication (4.5mg) by oral suspension.


Experimental: Naltrexone-Only Arm

Patients randomized to an LDN-containing treatment arm (including the "combined arm") will receive naltrexone 4.5 mg once daily. The first dose can be given at any time during the day of enrollment/randomization, and will be timed at 08:00 daily thereafter (with AM colchicine dose, if in combined colchicine/LDN arm) for up to 28 days (unless new contraindication or exclusion criteria met).

Patients in this arm will also receive the investigating institution's current standard of care (described in detail in the "standard of care" arm) for patients with COVID-19.

Drug: Naltrexone

Most well known as an opioid antagonist, or a treatment for alcohol dependence, naltrexone also possesses immunomodulatory effects. Seen exclusively at low doses, this attribute is being employed in the pain community as a novel anti-inflammatory agent that has been shown to reduce symptom severity in fibromyalgia, Crohn's disease, multiple sclerosis, and complex regional pain syndrome.

For this study, patients enrolled in a naltrexone-containing arm will take their daily dose of the medication (4.5mg) by oral suspension.


No Intervention: Standard of Care Arm
Patients in this arm will receive the investigating institution's current standard of care for patients with COVID-19. For example, all patients requiring supplemental oxygen (assuming no contraindications) would be candidates for both remdesivir 200 mg x 1 IV dose followed the next day by 100 mg q24h IV x up to 4 doses, as well as dexamethasone 6 mg q24h x 10 up to 10 doses.



Primary Outcome Measures :
  1. Progression of COVID-19 from "moderate" classification to "severe/critical" [ Time Frame: Assessed from time of hospitalization until (1) 14 days after enrollment, while still hospitalized (or until discharge, which may be less than 14 days) ]
    Moderate illness is defined as patients requiring hospitalization due to laboratory confirmed COVID-19, and a clinical score of 2 or 3 on a modified version of the World Health Organization's R&D Blueprint Ordinal Clinical Scale. A score of 4 or 5 will be defined as severe/critical illness. An increase of 2 or more points over the baseline scale will constitute progression to the primary endpoint. The study will determine if the odds of progression from moderate to severe/critical illness is different among the four treatment arms.


Secondary Outcome Measures :
  1. Total duration of hospitalization [ Time Frame: Assessed from time of hospitalization until discharge, calculated after patient completes hospital stay - approximately 7 days on average ]

    Study team will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Total amount of time (in hours) patient spent in hospital from admission to discharge


  2. Total duration of hospitalization (from first dose of study drug to discharge) [ Time Frame: Assessed from time of study drug administration to discharge, calculated after patient completes hospital stay; 7 days after admission on average) ]

    Study team will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Total amount of time (in hours) patient spent in hospital from first dose of any study medication (or when first dose would be given for standard of care arm) to hospital discharge (or when ready for discharge but remains hospitalized for non-medical reasons [e.g. transitional care unit placement delays])


  3. Composite in-hospital mortality [ Time Frame: Assessed/evaluated following patient's hospital stay; 7 days after admission on average) ]
    Count of patients in each study arm who expire during their hospital admission for COVID-19

  4. Total duration of ICU Admission [ Time Frame: Assessed/evaluated following patient's hospital stay; 7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Among patients admitted to the ICU; total amount of time spent receiving this level of care, in hours


  5. Total duration of intubation [ Time Frame: Assessed/evaluated following patient's hospital stay; 7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Among patients intubated, total amount of time spent intubated, in hours


  6. Total duration of time spent on HFNC or NIPPV from first dose of study drug to discharge [ Time Frame: Assessed/evaluated after patient's hospital stay after enrollment; 7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Total amount of time (in hours) patients spent on High Flow Nasal Cannula (HFNC) or Non-Invasive Positive Pressure Ventilation (NIPPV) from first dose of study drug (or anticipate first dose, if in standard of care arm) to discharge.

    *will exclude time spent on NIPPV for obstructive sleep apnea/night time use in patients who use these devices (CPAP, BiPAP) and baseline


  7. Total duration of time above baseline oxygen requirements from first dose of study drug to discharge [ Time Frame: Assessed/evaluated following patient's hospital stay; 7 days after admission on average ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Total amount of time (in hours) patients spent above their baseline oxygen requirements from first dose of study drug (or anticipated study drug, if in standard of care arm) to discharge.


  8. In hospital days with a fever >/= 38 degrees Celsius (00:00 to 23:59:59) from first dose of study drug to discharge (or anticipated first dose if in standard of care arm) [ Time Frame: Assessed/evaluated following patient's hospital stay after enrollment; 7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Count (frequency) of in-hospital days with a fever >/= 38 degrees Celsius (00:00 to 23:59:59) from first dose of study drug (or anticipated first dose if in standard of care arm) to discharge


  9. Incidence of adverse events associated with the study drug [ Time Frame: Assessed/evaluated daily during patient's hospital stay from randomization to discharge from hospital (on average, 7 days), but up to 60 days. ]
    Will document the type and count of AEs that are known to be related to each study drug (will document the specific diagnosis and report the frequency of with which they occur among all participants in the study.

  10. Incidence of significant adverse outcomes associated with/attributable to COVID-19 [ Time Frame: Assessed/evaluated daily during patient's hospital from randomization to discharge from hospital (on average, 7 days), but up to 60 days, ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Frequency with which the following known sequelae of COVID-19 occur:

    1. Acute Respiratory Distress Syndrome (ARDS)
    2. Thromboembolic disease
    3. Myocardial injury
    4. Acute Kidney Injury
    5. Myocardial Injury
    6. Encephalopathic delirium

  11. Cumulative dose of corticosteroids received in ED/Hospital [ Time Frame: Assessed/evaluated Following patient's hospital stay; 7 days after admission on average ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Cumulative dose of corticosteroids received in ED/Hospital (excluding those used prior to admission for an alternative indication) converted to a single equivalent unit. Study team will document steroid type and total amount given prior to conversion to equivalency unit.


  12. Cumulative dose of remdesivir received in ED/Hospital [ Time Frame: Assessed/evaluated following patient's hospital stay; 7 days after admission on average ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Cumulative dose of remdesivir received during hospital stay (i.e. total number of doses received)


  13. Discharge Anticoagulation Needs [ Time Frame: Assessed/evaluated following patient's hospital stay; 7 days after admission on average). ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on this metric:

    Need for discharge anticoagulation (i.e., whether or not patient was prescribed direct oral anticoagulant specifically for prophylaxis of increased venous thromboembolism risk due to COVID-19 following hospitalization).


  14. Continuous lab results - B-Type Natriuretic Peptide [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment and at (2) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    B-Type Natriuretic Peptide (pg/mL)


  15. Continuous lab results - C-Reactive Protein [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment, (2) once in the 3-day time period between study days 5-7, and (3) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    C-Reactive Protein (pg/dL)


  16. Continuous lab results - D-Dimer [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment and at (2) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    D-Dimer (pg/dL)


  17. Continuous lab results - Ferritin [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment and at (2) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Ferritin (ng/mL)


  18. Continuous lab results - Procalcitonin [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment and at (2) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Procalcitonin (ng/mL)


  19. Continuous lab results - Serum Creatinine [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment and (2) every 48 hours after enrollment until discharge from hospital (7 days on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Serum Creatinine (mg/dL)


  20. Continuous lab results - Troponin [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment and at (2) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Troponin (ng/mL)


  21. Continuous lab results - Hepatic Function Panel (ALT/AST/Alkaline Phosphotase) [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment, (2) one time on study day 6, and (3) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    AST Aspartate aminotransferase (U/L) ALT alanine aminotransferase (U/L) alkaline phosphotase (U/L)


  22. Continuous lab results - Hepatic Function Panel (Bilirubin) [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment, (2) one time on study day 6, and (3) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Bilirubin (total) - mg/dL Bilirubin (indirect) - mg/dL


  23. Continuous lab results - Hepatic Function Panel (Protein/Albumin) [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment, (2) one time on study day 6, and (3) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Protein - g/dL Albumin- g/dL

    Will document results of each individual test obtained throughout patient's stay. Will document if ordered standard-of-care or for research. For patients with a 7 day hospital stay, 2-3 hepatic function panel labs will be collected.


  24. Continuous lab results - Complete Blood Count with Differential Part 1 [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment, (2) once in the 3-day time period between study days 5-7, and (3) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Red Blood Cell Count White Blood Cell Count Platelets Neutrophil Absolute Lymphocyte Absolute Monocyte Absolute Eosinophil absolute Basophil absolute

    (all reported as 10^9 cells per L)


  25. Continuous lab results - Complete Blood Count with Differential Part 2 [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment, (2) once in the 3-day time period between study days 5-7, and (3) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Hemocrit (HCT) % Immature granulocytes (%)


  26. Continuous lab results - Complete Blood Count with Differential Part 3 [ Time Frame: Documented during patient's hospital stay at (1) baseline/enrollment, (2) once in the 3-day time period between study days 5-7, and (3) completion of study/hospital discharge (7 days after admission on average) ]

    Will investigate the effects of colchicine and LDN, alone or in combination, relative to standard care on the following continuous lab values:

    Hemoglobin (g/dL)




Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Male and (non-pregnant, non-breastfeeding) females aged 18 years or older
  2. Requiring admission to Methodist or Regions Hospital due to laboratory-confirmed COVID-19
  3. Meets criteria of only up to moderate COVID-19 disease as defined by a clinical score of 2 or 3 at the time of enrollment, and one or more of the following:

    1. Dyspnea limiting usual activities on baseline O2 needs
    2. Respiratory rate >/= 30/min on O2 or room air
    3. Blood oxygen saturations <94% on room air (or on baseline O2 needs if on supplemental oxygen prior to presentation at the hospital for a condition unrelated to COVID-19).
    4. Requiring supplemental 02 above baseline needs (i.e. prior to presentation at hospital)
  4. Ability to provide written informed consent, or has identifiable LAR that is able to do so on the patient's behalf as defined by study protocol, prior to performing study procedures.

Exclusion Criteria:

  1. Patients meeting criteria for severe/critical COVID-19 as defined by study protocol or requiring O2 supplementation ≥6L nasal cannula at screening
  2. Patients currently in shock as defined by hemodynamic instability requiring vasopressors
  3. Patients with a current hospitalization for COVID-19 that is >/=7 days at the time of screening.
  4. Clinical estimation of attending physician that the patient will require mechanical respiratory support within 48 hours of enrollment
  5. Clinical estimation of attending physician that patient will be discharged within 48 hours of enrollment
  6. Patients in which EITHER symptom onset OR a positive COVID-19 laboratory test occurred >10 days prior to enrollment.
  7. Patients with concomitant influenza A or B at time of hospitalization if tested as part of ED/hospital admission.
  8. Female patients who are pregnant or breastfeeding at time of hospital admission
  9. Diagnosis of Chronic Kidney Disease stage ≥4 as documented in the patient's problem list (not based on CrCI calculations alone)
  10. CrCl < 30 mL/min or requiring renal replacement therapy (e.g. intermittent hemodialysis, continuous renal replacement therapy, peritoneal dialysis) at screening
  11. History of cirrhosis or advanced liver disease, or active hepatic viral infection
  12. Transplant of kidney, lung, heart, or liver in the past 2 years
  13. Uncontrolled severe gastrointestinal disorders, Crohn's disease, ulcerative colitis, chronic diarrhea, diarrhea predominant irritable bowel syndrome, active stomach or intestinal ulcer, or one that was treated within the last 6 months
  14. Patients currently receiving agents that are p-glycoprotein AND strong CYP3A4 inhibitors with CrCl < 60 mL/min, or any combination of drug interactions that is not amenable to dosage adjustment (refer to list of medications with potential Colchicine and Naltrexone interactions).
  15. Patients actively undergoing chemotherapy for an active malignancy, or history of a hematologic malignancies
  16. Chronic or current use of colchicine or any mu-opioid antagonist.
  17. Chronic, scheduled opioid therapy (i.e. not intermittent as needed use), or, prior to enrollment, an acute condition requiring continued pain control that is unattainable without ongoing opioid therapy.
  18. Pre-existing condition that is being treated with tocilizumab, anakinra, sarilumab, other interleukin-antagonists, TNF-inhibitors, or JAK inhibitors.
  19. Participation in any other clinical trial of an experimental treatment for COVID-19, note: a. While convalescent plasma is no longer recommended within HP, it can be given if deemed appropriate by the medical team once ≥ 24 hours has elapsed since enrollment; b. Patients previously enrolled in the C3PO study can enroll in this study, as any convalescent plasma received would have been outpatient; c.Remdesivir is allowed per standard protocol; d. Dexamethasone is allowed per standard protocol
  20. Patients actively enrolled in hospice or that are DNI or on palliative care
  21. History of hypersensitivity reaction to colchicine or its inactive ingredients
  22. History of hypersensitivity reaction to naltrexone or its inactive ingredients
  23. Incarcerated or a ward of the state
  24. Any patient considered an unsuitable candidate, for any reason, by study investigators.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT04756128


Locations
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United States, Minnesota
Park Nicollet Methodist Hospital
Saint Louis Park, Minnesota, United States, 55426
Regions Hospital
Saint Paul, Minnesota, United States, 55101
Sponsors and Collaborators
HealthPartners Institute
Park Nicollet Foundation
Investigators
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Principal Investigator: Dan Delaney, PharmD Park Nicollet Methodist Hospital
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Responsible Party: Daniel P. Delaney, PharmD, BCIDP, Principal Investigator, HealthPartners Institute
ClinicalTrials.gov Identifier: NCT04756128    
Other Study ID Numbers: X2103400
First Posted: February 16, 2021    Key Record Dates
Last Update Posted: February 18, 2021
Last Verified: February 2021
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No
Plan Description: There is no plan to share IPD with investigators not currently involved in the study.

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: Yes
Additional relevant MeSH terms:
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Colchicine
Naltrexone
Alcohol Deterrents
Narcotic Antagonists
Physiological Effects of Drugs
Sensory System Agents
Peripheral Nervous System Agents
Gout Suppressants
Antirheumatic Agents
Tubulin Modulators
Antimitotic Agents
Mitosis Modulators
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents