azathioprine
American Heritage Dictionary:
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az·a·thi·o·prine
Gale Encyclopedia of Cancer:
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Azathioprine
Key Terms: Analog, Antimetabolite, Bone marrow, Gout, Leukopenia, Lymphocytes, Macrocytic anemia, Myelosuppression, Pancytopenia, Purine.
Definition
Azathioprine is a nonspecific immunosuppressant antimetabolite that can be used as a chemotherapeutic agent to inhibit lymphocyte purine metabolism. In the United States, azathioprine is also known by the brand name Imuran.
Purpose
In 1968 the Food and Drug Administration approved azathioprine for use after organ transplantation to decrease the chance of the body rejecting the transplanted organ. Azathioprine, however, is also an experimental drug that can be used during treatment of such cancers as leukemia and lymphoma. In the body, azathioprine is converted to mercaptopurine (6-MP) and thus has the same effects as that chemotherapy drug. They both are purine analogs that interfere with the metabolism of purine-based nucleotides found in DNA.
The use of azathioprine results in killing cells such as T-lymphocytes. This effect is important in treating such cancers as lymphocytic leukemia. The idea is that if T-lymphocyte reproduction is inhibited by interfering with DNA synthesis, then the cancer cell reproduction will also be inhibited. Certain types of leukemia and lymphoma are treated with radiation and chemotherapy, which destroy dividing cells such as those in the bone marrow. As a result, the patient is no longer able to produce blood cells. To combat the loss of blood cells, a bone marrow transplant may be performed to provide the patient with healthy marrow. The body may react against the foreign bone marrow. Therefore, an additional benefit of azathioprine use as an immunosuppressant could be to produce fewer white blood cells, thus interfering with the body's natural immune response to foreign proteins, such as those found on the cell surfaces of bone marrow coming from a bone marrow donor.
Because azathioprine has anti-inflammatory action, it is also used to treat such disorders of the digestive tract as irritable bowel disease (IBD) as well as the vasculitides, which are a group of disorders characterized by inflammation of blood or lymphatic vessels.
Description
Azathioprine is a derivative of mercaptopurine, a purine analog antimetabolite, which interferes with the enzymatic pathways for biosynthesis of nucleic acids by substituting for normal metabolites. In this way, it can act as an immunosuppressant by interfering with the production of white blood cells such as lymphocytes.
Recommended Dosage
Azathioprine can be taken either orally (50 milligram scored tablets) or through an injection (100 milligram vials for intravenous use). Dosing is based on body weight and size of the patient. Initially, the oral dosage is approximately 3 to 5 milligrams per kilogram of body weight, while the injection dosage is approximately 1 milligram per kilogram of body weight. At time goes on, the physician may decrease the dosage. Patients can take this medicine in a single dose per day. The duration of treatment will continue until the fear of transplant rejection has passed.
Precautions
Since this medication is an immunosuppressant and results in a lower white blood cell count, there is a higher risk of developing infection. Therefore, patients using azathioprine should limit their contact with people that have existing infections, they should not have dental work done while on this medication, and they should not touch their eyes or inside of their nose unless they have just washed their hands. Patients should also take care not to cut themselves and should be careful when using a regular toothbrush and dental floss.
Although some early studies performed in animals stated that azathioprine should not be used during pregnancy, two groups of researchers in Italy and Canada respectively reported in 2004 that the drug has a very small potential for harm to the fetus. Moreover, although azathioprine can cross into breast milk, there is no evidence that the small amounts absorbed by a nursing infant are harmful.
Side Effects
The most common and less serious side effects include fatigue, weakness, loss of appetite (anorexia), nausea and vomiting, and upset stomach. Upset stomach can be alleviated if azathioprine is taken with food or milk.
Other side effects may occur that require the attention of a medical professional. These include:
- cough or hoarseness
- fever or chills
- lower back or side pain
- extreme fatigue
- black tarry stools
- blood in the urine
- red spots on the skin
- fast heartbeat
- shortness of breath
- liver problems
Since the immune system is depressed when azathioprine is used, the result can be pancytopenia, including leukopenia and thrombocytopenia as well as macrocytic anemia. The severity of these is dependent on the dose, and the dose may be lowered by the physician as needed.
Azathioprine has been used in children and has not been shown to induce side effects different from those found in adults. However, as with many medications there have not been any specific tests done with the elderly. It is not expected to cause any different side effects from those encountered in younger adults.
Interactions
There are medications and other medical conditions that can interact with azathioprine. A medication called allopurinol is used to treat gout and can increase the effects and toxicity of azathioprine because it interferes with the removal of azathioprine from the body.
Both kidney disease and liver disease can increase the effects and toxicity of azathioprine. Both diseases interfere with the removal of azathioprine from the body. If the patient has either of these diseases, the physician may make adjustments in the dosage given.
Resources
Books
Beers, Mark H., MD, and Robert Berkow, MD, editors. "Transplantation." Section 12, Chapter 149 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
Wilson, Billie Ann, Margaret T. Shannon, and Carolyn L. Stang. Nurse's Drug Guide 2003. Upper Saddle River, NJ: Prentice Hall, 2003.
Periodicals
Danesi, R., and M. Del Tacca. "Teratogenesis and Immunosuppressive Treatment." Transplantation Proceedings 36 (April 2004): 705–707.
Moskovitz, D. N., C. Bodian, M. L. Chapman, et al. "The Effect on the Fetus of Medications Used to Treat Pregnant Inflammatory Bowel-Disease Patients." American Journal of Gastroenterology 99 (April 2004): 656–661.
Russell, J. P., and R. H. Weenig. "Primary Cutaneous Small Vessel Vasculitis." Current Treatment Options in Cardiovascular Medicine 6 (April 2004): 139–149.
Su, C., and G. R. Lichtenstein. "Treatment of Inflammatory Bowel Disease with Azathioprine and 6-Mercaptopurine." Gastroenterology Clinics of North America 33 (June 2004): 209–234.
Younger, D. S. "Vasculitis of the Nervous System." Current Opinion in Neurology 17 (June 2004): 317–336.
Organizations
American Society of Health-System Pharmacists (ASHP). 7272 Wisconsin Avenue, Bethesda, MD 20814. (301) 657-3000.
United States Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857-0001. (888) INFO-FDA.
—Sally C. McFarlane-Parrott; Rebecca J. Frey, PhD
Drug Info:
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Azathioprine
Brand names: Azasan®, Imuran®
Chemical formula:
- Drug Forms:
- Azathioprine Oral tablet (below)
- Azathioprine Sodium Solution for injection
Azathioprine Oral tablet
What is this medicine?
AZATHIOPRINE (ay za THYE oh preen) suppresses the immune system. It is used to prevent organ rejection after a transplant. It is also used to treat rheumatoid arthritis.
This medicine may be used for other purposes; ask your health care provider or pharmacist if you have questions.
What should I tell my health care provider before I take this medicine?
They need to know if you have any of these conditions:
•infection
•kidney disease
•liver disease
•an unusual or allergic reaction to azathioprine, other medicines, lactose, foods, dyes, or preservatives
•pregnant or trying to get pregnant
•breast feeding
How should I use this medicine?
Take this medicine by mouth with a full glass of water. Follow the directions on the prescription label. Take your medicine at regular intervals. Do not take your medicine more often than directed. Continue to take your medicine even if you feel better. Do not stop taking except on your doctor's advice.
Talk to your pediatrician regarding the use of this medicine in children. Special care may be needed.
Overdosage: If you think you have taken too much of this medicine contact a poison control center or emergency room at once.
NOTE: This medicine is only for you. Do not share this medicine with others.
What may interact with this medicine?
Do not take this medicine with any of the following medications:
•mercaptopurine
This medicine may also interact with the following medications:
•allopurinol
•aminosalicylates like sulfasalazine, mesalamine, balsalazide, and olsalazine
•leflunomide
•medicines called ACE inhibitors like benazepril, captopril, enalapril, fosinopril, quinapril, lisinopril, ramipril, and trandolapril
•mycophenolate
•sulfamethoxazole; trimethoprim
•vaccines
•warfarin
This list may not describe all possible interactions. Give your health care provider a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.
What should I watch for while using this medicine?
Visit your doctor or health care professional for regular checks on your progress. You will need frequent blood checks during the first few months you are receiving the medicine.
If you get a cold or other infection while receiving this medicine, call your doctor or health care professional. Do not treat yourself. The medicine may increase your risk of getting an infection.
Women should inform their doctor if they wish to become pregnant or think they might be pregnant. There is a potential for serious side effects to an unborn child. Talk to your health care professional or pharmacist for more information.
Men may have a reduced sperm count while they are taking this medicine. Talk to your health care professional for more information.
This medicine may increase your risk of getting certain kinds of cancer. Talk to your doctor about healthy lifestyle choices, important screenings, and your risk.
What side effects may I notice from receiving this medicine?
Side effects that you should report to your doctor or health care professional as soon as possible:
•allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
•fever, chills, or any other sign of infection
•severe stomach pain
•unusual bleeding, bruising
•unusually weak or tired
•vomiting
•yellowing of the eyes or skin
Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):
•hair loss
•nausea
This list may not describe all possible side effects. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
Where should I keep my medicine?
Keep out of the reach of children.
Store at room temperature between 15 and 25 degrees C (59 and 77 degrees F). Protect from light. Throw away any unused medicine after the expiration date.
Last updated: 4/22/2004 10:49:00 AM
Important Disclaimer: The drug information provided here is for educational purposes only. It is intended to supplement, not substitute for, the diagnosis, treatment and advice of a medical professional. This drug information does not cover all possible uses, precautions, side effects and interactions. It should not be construed to indicate that this or any drug is safe for you. Consult your medical professional for guidance before using any prescription or over the counter drugs.
Oxford A-Z of Medicinal Drugs:
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azathioprine
An immunosuppressant that is a powerful cytotoxic drug. It is used to prevent the rejection of transplants (and to minimize the use of corticosteroids for this purpose) and also to treat a number of autoimmune conditions, usually when corticosteroids have been inadequate, including myasthenia gravis and rheumatoid arthritis. Azathioprine is available as tablets on prescription only.
Side effects:
include nausea and vomiting, loss of appetite, malaise, dizziness, fever, muscular aches and pains, rashes, and hair loss. Azathioprine can suppress production of white blood cells and platelets in the bone marrow, leading to increased susceptibility to infections and unusual bruising or bleeding.
Precautions:
azathioprine should only be taken under specialist supervision, and blood counts should be monitored during the treatment period. Any evidence of infection or unusual bruising or bleeding should be reported to a doctor immediately.
Interactions with other drugs:
Allopurinol increases the toxic effects of azathioprine, whose dosage will therefore need to be reduced.
Co-trimoxazole increases the risk of blood disorders.
Warfarin: its anticoagulant effect may be reduced by azathioprine.
Proprietary preparations:
Immunoprin; Imuran.
| azapropazone, azacitidine, attapulgite | |
| azelaic acid, azelastine hydrochloride, azithromycin |
Oxford Dictionary of Biochemistry:
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azathioprine
6(1-methyl-4-nitro-5-imidazolyl) mercaptopurine: 6-[(1-methyl-4-nitroimidazol-5-yl)thio]purine; a derivative of mercaptopurine, into which it is converted in vivo. It is useful as an immunosuppressive and antimitotic agent. One proprietary name: Imuran.
| azaserine, aza+, axoplasm | |
| azelaic acid, azeotrope, azide |
Saunders Veterinary Dictionary:
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azathioprine
A mercaptopurine derivative used as a cytotoxic and immunosuppressive agent in the treatment of leukemia and autoimmune diseases and in transplantation therapy.
Mosby's Dental Dictionary:
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azathioprine
n
trade name: Imuran; drug class: immunosuppressant; action: inhibits purine synthesis in cells, thereby preventing RNA and DNA synthesis; uses: renal transplants to prevent graft rejection, refractory rheumatoid arthritis, bone marrow transplants, glomerulone-phritis.
Wikipedia on Answers.com:
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Azathioprine
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| Systematic (IUPAC) name | |
| 6-[(1-methyl-4-nitro-1H-imidazol-5-yl)sulfanyl]-7H-purine | |
| Clinical data | |
| Pregnancy cat. | D |
| Legal status | ℞ Prescription only |
| Routes | oral |
| Pharmacokinetic data | |
| Bioavailability | Well absorbed |
| Metabolism | By xanthine oxidase |
| Half-life | 3 hours |
| Excretion | Renal, minimally |
| Identifiers | |
| CAS number | 446-86-6  |
| ATC code | L04AX01 |
| PubChem | CID 2265 |
| DrugBank | DB00993 |
| ChemSpider | 2178 |
| UNII | MRK240IY2L |
| KEGG | D00238 |
| ChEBI | CHEBI:2948 |
| ChEMBL | CHEMBL1542 |
| Chemical data | |
| Formula | C9H7N7O2S |
| Mol. mass | 277.263 g/mol |
| SMILES | eMolecules & PubChem |
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Azathioprine (/ˌæzəˈθaɪɵpriːn/) is a purine analogue immunosuppressive drug. It is used to prevent rejection following organ transplantation, and to treat a vast array of autoimmune diseases, including rheumatoid arthritis, pemphigus, inflammatory bowel disease (such as Crohn's disease and ulcerative colitis), multiple sclerosis, autoimmune hepatitis, atopic dermatitis, myasthenia gravis, neuromyelitis optica or Devic's disease, restrictive lung disease, and others.
Azathioprine is produced by a number of generic manufacturers and as brand names (Azasan by Salix in the U.S., Imuran by GlaxoSmithKline in Canada,the U.S., Australia, Ireland and Great Britain, Azamun in Finland and Imurel in Scandinavia and France).
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History
Azathioprine was first introduced into clinical practice by Sir Roy Calne, the British pioneer in transplantation. Following the work done by Sir Peter Medawar and Gertrude Elion in discovering the immunological basis of rejection of transplanted tissues and organs, Calne introduced 6-mercaptopurine as an experimental immunosuppressant for kidney and cardiac transplants. When azathioprine was discovered, he then introduced it as a less-toxic replacement for 6-mercaptopurine. For many years, dual therapy with azathioprine and steroids was the standard antirejection regimen, until cyclosporine was introduced into clinical practice (also by Calne) in 1978.
Mechanism of action
Azathioprine is a pro-drug; following oral ingestion, it is metabolized into the active 6-mercaptopurine, itself a purine synthesis inhibitor. 6-Mercaptopurine impedes DNA synthesis and thus inhibits the proliferation of cells, especially the fast-growing lymphocytes. T-cells and B-cells are particularly affected by the inhibition of purine synthesis. Azathioprine is an effective drug used alone in certain autoimmune diseases, or in combination with other immunosuppressants in organ transplantation. Azathioprine blocks the downstream effects of CD28 costimulation. 6-MP (the active metabolite) interacts directly with GTP-binding protein Rac1, thus blocking upregulation of BCL-xl mRNA and protein. In vivo data indicate inflammatory bowel disease patients treated with azathioprine have more apoptotic mononuclear cells than untreated controls, indicating this mechanism may be responsible for the in vivo response to the drug in this disease.[1]
Immediate or short-term side effects
Side effects are uncommon, but include nausea, fatigue, hair loss, and rash. Because azathioprine suppresses the bone marrow, patients will be more susceptible to infection. Acute pancreatitis can also occur, especially in patients with Crohn's disease.[2] Caution should be exercised when it is used in conjunction with purine analogues such as allopurinol. The enzyme thiopurine S-methyltransferase (TPMT) deactivates 6-mercaptopurine. Genetic polymorphisms of TPMT can lead to excessive drug toxicity, thus assay of serum TPMT may be useful to avoid this complication.[3]
Cyclosporine has now replaced some of the azathioprine use due to fewer side effects, especially in heart-related transplantations.[4][5][6] Moreover, despite being 15 times more expensive,[7] mycophenolate mofetil is also increasingly being used in place of azathioprine in organ transplantation, as it is associated with less bone marrow suppression, fewer opportunistic infections, and a lower incidence of acute rejection.[8]
Long-term side effects
It is listed as a human carcinogen in the 11th Report on Carcinogens of the U.S. Department of Health and Human Services, although they note the International Agency for Research on Cancer considered some of the animal studies to be inconclusive because of limitations in the study design and inadequate reporting.[9] In the 12th and current report, it is asserted that azathioprine is "known to be a human carcinogen based on sufficient evidence of carcinogenicity from studies in humans."[10] Furthermore,as is detailed below, additional postmarketing experience has meant the U.S. Food and Drug Administration has required warnings to be placed on packaging with respect to increased risks of certain cancers.
The risks involved seem to be related both to the duration and to the dosage used. People who have previously been treated with an alkylating agent may have an excessive risk of cancers if treated with azathioprine. Epidemiological studies have provided "sufficient" evidence of azathioprine carcinogenicity in humans,[11] although the methodology of past studies and the possible underlying mechanisms are questioned.[12] The various diseases requiring transplantation, and thus azathioprine, may in themselves increase the risks of non-Hodgkin's lymphoma, squamous cell carcinomas of the skin, hepatobiliary carcinomas, and mesenchymal tumours to which azathioprine may add additional risks. Those receiving azathioprine for rheumatoid arthritis may have a lesser risk than those undergoing transplantation.[13]
Cases of hepatosplenic T-cell lymphoma - a rare type of T-cell lymphoma - have been reported in patients treated with azathioprine. The majority occurred in patients with inflammatory bowel disease. Adolescents and young adult males were the major cohort of cases. They presented with a very aggressive disease course and, with one exception, died of the lymphoma. The FDA has required changes to the labeling to inform users and clinicians of the issue.[14]
While azathioprine had not been thought to cause fetal malformation (teratogenesis), and the risk to the offspring of treated women is small, [15] a more recent product monograph produced by Glaxo Smith Kline and dated June 2005 does note that Imuran can cause fetal harm when given to a pregnant woman. Their document also states the drug should not be given during pregnancy or in patients of reproductive potential without careful weighing of benefit versus the risks, and should be avoided whenever possible in pregnant women. It goes on to state, when used in pregnancy, the patient should be apprised of the potential hazard to the fetus. While stating no adequate and well-controlled studies have taken place in humans, when given to animals in doses equivalent to human dosages, teratogenesis was observed. Transplant patients already on this drug should not discontinue or becoming pregnant. This contrasts to the later-developed drugs tacrolimus and mycophenolate, which are contraindicated by the manufacturers during pregnancy.[15] As for all cytotoxic drugs, the manufacturer advises not to breastfeed whilst taking azathioprine. The Lactation Risk Category (LAC) reported by Thomas Hale in "Medications and Mothers' Milk" lists azathioprine as "L3", termed "moderately safe".
Under FDA rules, this drug, like many others, excludes eligibility for blood donation.[16]
References
- ^ Maltzman, J. S.; Koretzky, G. A. (2003). "Azathioprine: Old drug, new actions". Journal of Clinical Investigation 111 (8): 1122–1124. doi:10.1172/JCI18384. PMC 152947. PMID 12697731. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=152947.
- ^ Weersma, R. K., Peters, F. T. M., Oostenbrug, L. E., van den Berg, A. P., van Haastert, M., Ploeg, R. J., Posthumus, M. D., Homan van der Heide, J. J., Jansen, P. L. M. and van Dullemen, H. M. (October 2004). "Increased incidence of azathioprine-induced pancreatitis in Crohn's disease compared with other diseases". Alimentary Pharmacology & Therapeutics 20 (8): 843–850. doi:10.1111/j.1365-2036.2004.02197.x. PMID 15479355.
- ^ Konstantopoulou M, Belgi A, Griffiths KD, Seale JR, Macfarlane AW (February 2005). "Azathioprine-induced pancytopenia in a patient with pompholyx and deficiency of erythrocyte thiopurine methyltransferase". BMJ 330 (7487): 350–1. doi:10.1136/bmj.330.7487.350. PMC 548735. PMID 15705694. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=548735.
- ^ Bakker, R. C.; Hollander, A. A. M. J.; Mallat, M. J. K.; Bruijn, J. A.; Paul, L. C.; De Fijter, J. W. (2003). "Conversion from cyclosporine to azathioprine at three months reduces the incidence of chronic allograft nephropathy". Kidney International 64 (3): 1027–1034. doi:10.1046/j.1523-1755.2003.00175.x. PMID 12911553.
- ^ Henry, M. L.; Sommer, B. G.; Ferguson, R. M. (1985). "Beneficial effects of cyclosporine compared with azathioprine in cadaveric renal transplantation". The American Journal of Surgery 150 (5): 533. doi:10.1016/0002-9610(85)90431-3.
- ^ Modry, D. L.; Oyer, P. E.; Jamieson, S. W.; Stinson, E. B.; Baldwin, J. C.; Reitz, B. A.; Dawkins, K. D.; McGregor, C. G. et al (1985). "Cyclosporine in heart and heart-lung transplantation". Canadian journal of surgery. Journal canadien de chirurgie 28 (3): 274–280, 282. PMID 3922606.
- ^ Remuzzi, G.; Lesti, M.; Gotti, E.; Ganeva, M.; Dimitrov, B.; Ene-Iordache, B.; Gherardi, G.; Donati, D. et al (August 2004). "Mycophenolate mofetil versus azathioprine for prevention of acute rejection in renal transplantation (MYSS): a randomised trial". The Lancet 364 (9433): 503–12. doi:10.1016/S0140-6736(04)16808-6. PMID 15302193.
- ^ Woodroffe R, Yao G, Meads C, Bayliss S, Ready A, Raftery J, Taylor R (2005). "Clinical and cost-effectiveness of newer immunosuppressive regimens in renal transplantation: a systematic review and modelling study". Health Technol Assess 9 (21): 1–194. PMID 15899149.
- ^ Sittig's Handbook of Toxic and Hazardous Chemicals and Carcinogens
- ^ The 12th Report on Carcinogens of the US Department of Health and Human Services. http://ntp.niehs.nih.gov/?objectid=03C9AF75-E1BF-FF40-DBA9EC0928DF8B15
- ^ International Agency for Research on Cancer (IARC) (1987). "Azathioprine - 5. Summary of Data Reported and Evaluation". Summaries & Evaluations. World Health Organization. pp. VOL.: 26 (1981) (p. 47). http://www.inchem.org/documents/iarc/vol26/azathioprine.html.
- ^ Gombar V, Enslein K, Blake B, Einstein K (1993). "Carcinogenicity of azathioprine: an S-AR investigation". Mutat Res 302 (1): 7–12. doi:10.1016/0165-7992(93)90083-8. PMID 7683109.
- ^ International Agency for Research on Cancer (IARC) (1987). "Azathioprine - Evidence for carcinogenicity to humans (sufficient)". Summaries & Evaluations. World Health Organization. pp. Supplement 7: (1987) (p. 119). http://www.inchem.org/documents/iarc/suppl7/azathioprine.html.
- ^ FDA Warning with respect to cancer/lymphoma risks with azathioprine http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm258794.htm
- ^ a b British National Formulary 45 March 2003
- ^ Carol Eustice (October 23, 2005). "Blood Donation - Are rheumatoid arthritis patients able to donate blood?". About.com. http://arthritis.about.com/od/arthqa/f/blooddonation.htm. Retrieved 29 November 2011.
External links
- Imuran (GlaxoSmithKline Patient Information Leaflet)
- Azasan (manufacturer's website)
- Medline Plus advice on Imuran ( A service of the National Institutes of Health)
- GSK Product Monograph for Imuran (for Canadian patients only)
- U.S. National Library of Medicine: Drug Information Portal - Azathioprine
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American Heritage Dictionary
The American Heritage® Dictionary of the English Language, Fourth Edition Copyright © 2007, 2000 by Houghton Mifflin Company. Updated in 2009. Published by Houghton Mifflin Company. All rights reserved.
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Gale Encyclopedia of Cancer
Gale Encyclopedia of Cancer. Copyright © 2006 by The Gale Group, Inc. All rights reserved.
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Oxford A-Z of Medicinal Drugs
Market University Press. © 2000, 2003, 2010 An A-Z of Medicinal Drugs. All rights reserved.
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Oxford Dictionary of Biochemistry
Oxford University Press. Oxford Dictionary of Biochemistry and Molecular Biology © 1997, 2000, 2006 All rights reserved.
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Saunders Veterinary Dictionary
Saunders Comprehensive Veterinary Dictionary 3rd Edition. Copyright © 2007 by D.C. Blood, V.P. Studdert and C.C. Gay, Elsevier. All rights reserved.
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Mosby's Dental Dictionary
Mosby's Dental Dictionary. Copyright © 2004 by Elsevier, Inc. All rights reserved.
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