Phytochemical Screening & Biological Investigations of Ficus Racemosa
Abdul Kader Mohiuddin1*, Sayra Akter Lia2
1Secretary and Treasurer, Nasirullah Memorial Trust, Tejgaon, Dhaka 1215, Bangladesh
2B. Pharm (World University of Bangladesh), North South University, Bangladesh
Received Date: 25/07/2020; Published Date: 06/08/2020
*Corresponding author: Abdul Kader Mohiuddin, Secretary and Treasurer, Nasirullah Memorial Trust, Tejgaon, Dhaka 1215, Bangladesh
Orcid Id: https://orcid.org/0000-0003-1596-9757
Web of Science Researcher ID: T-5428-2019
Cite this article: Abdul Kader Mohiuddin*, Sayra Akter Lia, Phytochemical Screening & Biological Investigations of Ficus Racemosa. Op Acc J Bio Sci & Res 4(1)-2020.
Ficus racemosa is a traditional medicinal plant found in Southeast Asia, India, Australia and. It is commonly known as 'gular.' Owing to the presence of β-sitosterol it decreases the blood glucose concentration. Many active constituents isolated from different parts of this plant exhibit useful pharmacological activity. The objective of this dissertation is to identify the biological activity of the roots of an indigenous medicinal plant, viz., Ficus racemosa (Family: Moraceae) and to evaluate the possible phytochemical and pharmacological profiles of the crude extracts. Some chemical and biological researches on this plant have been conducted out so far, focusing mainly on the plant's bark and root. That's why the objective of this framework is to assess the different possibilities of developing new therapeutic targets from this plant's fruit that could be crucial for the treatment of many diseases.
Keywords: Ficus racemosa; Phytochemical Screening; Thrombolytic Activity; Antimicrobial activity; Medicinal Plants of Bangladesh
Rationale and Objective of the Work
Phytochemistry is a branch of Pharmacognosy, with chemical and biological characters, which study the obtaining of medicaments by natural or semi synthesis methods? The subject “Phytochemstry” deals with the chemical structures of secondary metabolites, their metabolism, and their distribution and biological functions  (Figure 1).
Figure 1: Ficus racemosa Tree.
Written records of plant use as therapeutic agents date back millennia. The ancient records are from Mesopotamia, and date back to around 2600 BC. These records are not just a case of one or two plant-based 'drugs' finding their way into common use, as the documents indicate that plants contained many drugs in use (up to 1,000 in the particular instance of Mesopotamia) . Around 119 pure chemical substances extracted from the higher plants are used worldwide in medicine. In most medicinal herbs, fresh or dried parts, whole, chopped, powdered or an advanced form of herb, usually produced by a solvent such as water, ethanol or organic solvent, play an important role and are the backbone of traditional medicines .
Goals of using plants as sources of therapeutic agents are:
To isolate bioactive compounds for direct use as drugs e.g. digoxin, digitoxin, morphine, reserpine, taxol, vincristine, and vinblastine.
a. To generate bioactive compounds of novel or known structures as semi-synthesized lead compounds to produce protectable entities with higher activity and/or lower toxic effects e.g. metformin, nabilone, oxycodone, taxotere, teniposide, verapamil and miodarone based on galegin, A9-tetrahydrocannabinol, morphine, taxol, podophyllotoxin, khellin.
b. To use agents as pharmacologic tools e.g. lysergic acid diethylamide, mescaline .
There are several familiar approaches for lead searching from the plants and the isolated bioactive compounds are utilized in three basic ways: Unmodified medicinal plant products where ethnomedical uses suggested clinical efficacy e.g. digitoxin (a), digoxin (b), morphine (c) (Figure 2).
(a) Digoxin (source: Chemistry World)
(b) Digitoxin (source: sciencedirect.com)
(c) Morphin (source: ChemSpider)
Figure 2: Lead compound search & utilization from plants.
a. Unmodified natural products of which the therapeutic efficacy was only remotely suggested by folk medicine use e.g. vincristine.
b. Modified natural or synthetic substances based on a natural product used in traditional medicine e.g. aspirin .
c. Terrestrial plants, especially higher plants, have a long history of use in the treatment of human diseases . Fossil records date human use of plants as medicines at least to the Middle Paleolithic age some 60,000 years ago . Several well-known species, including licorice (Glycyrrhiza glabra) myrrh (Commiphoraspecies), and poppy capsule latex (Papaver somnjferum), were referred to by the first known written record on clay tablets from Mesopotamia in 2600 BC, and these plants are still in use today for the treatment of various diseases as ingredients of official drugs or herbal preparations used in systems of traditional medicine. Furthermore, morphine, codeine, noscapine (narcotine), and papaverine isolated from P. somnferum were developed as single chemical drugs and are still clinically used. Hemisuccinate carbenoxolone sodium, a semi-synthetic derivative of glycyrrhetic acid found in licorice, is prescribed for the treatment of gastric and duodenal ulcers in various countries .
A careful selection of plants is conditioned by success in the research of natural products, based on various criteria such as chemotaxonomic data, ethnomedical information, field observations or even discrete collection . Historical encounters with plants as therapeutic instruments helped to introduce particular chemical entities into modem medicine. Plants, especially those with ethno- pharmacological have been the primary sources of medicines for early drug discovery. In fact, a recent sis by Fabrican and Farnsworth showed that the uses of 80% of 122 plant-derived drugs were related to their original ethno pharmacological purposes. Current drug development from terrestrial plants has relied mainly on bioactivity-guided isolation methods which have led, for example, to the discovery of essential anticancer agents, Taxus brevifolia paclitaxel and Camptotheca acuminate camptothecin . The goals of using plants as sources of therapeutic agents are a) to isolate bioactive compounds for direct use as drugs, e.g. digoxin, digitoxin, morphine, reserpine, taxol, vinbiastine, vincristine; b) to produce bioactive compounds of novel or known structures as lead compounds for semisynthesis to produce patentable entities of higher activity and/or lower toxicity, e.g., metformin, nabilone, oxycodon (and other narcotic analgesics), taxotere, teniposide, verapamil, and miodarone, which are based, respectively, on galegine, 9- tetrahydrocannabinol, morphine, taxol, podophyllotoxin, and khellin; c) to use agents as pharmacologic tools, e.g., lysergic acid diethlamide (LSD), mescaline, yohimbine; and d) to use the whole plant or part of it as a herbal remedy, e.g., cranberry, echinacea, feverfew, garlic, etc .The number of higher plant species (angiosperms and gymnosperms) on this planet is estimated at 250,000.with a lower level at 215,000 .and an upper level as high as 500,000.Of these, only about 6% have been screened for biologic activity, and a reported 5% have been evaluated phytochemically .
It was estimated that in 1991 in the United States, for every 10,000 pure compounds most likely those based on synthesis) that arebiologically evaluated (primarily in vitro), 20 would be tested in animal models, and 10 of these would be clinically evaluated, and only one would reach U.S. Food and Drug administration approval for marketing. The time required for this process was estimated at 10 years at a cost of $231 million (U.S.) . The major drawback of this strategy is the frequent isolation of known metabolites. Therefore, hyphenated techniques (LC-UV, LC-MS, and LC-NMR have been developed; in order to detect is early as possible potential original structures. These compounds can then be tested in various bioassays . More recently combinatorial chemistry and high throughput robotic screening techniques have been employed as viable strategies for drug discovery programs . Chemical diversity of secondary plant metabolites that results from plant evolution is superior to at found in synthetic combinatorial chemical libraries . Medicinal plants have played an essential role in the development of human culture, for example religions and different ceremonies. (E.g. Dutura has long been associated with the worship of Shiva, the Indian God). Plants are directly used as medicines by a majority of cultures around the world, for example Chinese medicine and Indian medicine. Many food crops have medicinal effects, for example garlic. Medicinal plants are resources of new drugs. Studying medicinal plants helps to understand the plant toxicity and protect human and animals from natural poisons. Cultivation and preservation of medicinal plants protect biological diversity, for example metabolic engineering of plants . The medicinal plants are used in the pharmaceutical, cosmetic, agricultural, and food industries. With the onset of scientific research into herbals, it becomes increasingly clear that medicinal herbs have potential in today's synthetic era, as numbers of medicines become resistant. According to one estimate only 20% of the plant flora has been studied and 60% of synthetic medicines owe their origin to plants. Ancient knowledge coupled with scientific principles can come to the forefront and provide us with powerful remedies to eradicate the diseases. In real sense, coupling of ancient knowledge and scientific principle is essential-
1. To identify alternative and complementary medicine.
2. To reduce the toxicity of drug therapy especially toxicity reduction of synthetic and semi synthetic drugs.
3. To find the lead compound diversification to treat various diseases .
History of Traditional Herbal Medicine in Bangladesh
Traditional Medicine is the medicine or treatment based on traditional uses of plants, animals or their products, other natural substances (including some inorganic chemicals), religious verses, cultural practices, and physical manipulations including torture. As this system of medicine has been in use almost unchanged generation after generation throughout the ages for the treatment of various physical and psychological diseases, it is called traditional. Most of the times, the type, preparation, and uses of traditional medicines are largely influenced by folklore customs and the cultural habits, social practices, religious beliefs and, in many cases, superstitions of the people who prescribe or use them . The earliest mention of traditional medicine is found in “Rigveda”, the oldest repository of knowledge in this subcontinent. Later “Ayurveda”, developed from the Vedic concept of life, became the important source of all systems of medical sciences. In course of time it became a part of culture and heritage of the people of the Indian subcontinent Traditional medicine involves the use of both material and non-material components. The material components invariably comprise parts or organs of plants and their products. They also consist of animal organs, minerals and other natural substances.
The non-material components, which constitute important items of religious and spiritual medicines, include torture, charms, magic, incantations, religious verses, amulets and rituals like sacrifices, appeasement of evil spirits, etc. . Treatments in traditional medicine involve internal and external use of medicinal products, physical manipulation of different parts of the body, performing rituals, psychological treatment, and also minor surgery. Ayurvedic medicinal preparations consist mainly of powdered plant materials, semi-solid preparations, decoctions, elixirs, and distillate. Many of these also contain inorganic chemical substances, minerals, and products for animals. Ayurvedic medicine also uses alcoholic extracts and alcoholic solutions of the ingredients, tinctures and elixirs . The major constituents of Unani medicine are whole plants or their powders or pastes or products and their extracts, infusions, decoctions and distillates. In the preparation of these medicines, minerals, inorganic chemicals, and animal products are also frequently used. The Indian subcontinent's medical knowledge is termed Ayurveda for hundreds of years. Plant alkaloids are the primary active ingredients of Ayurvedic drugs. Toda’ the pharmacologically active ingredients of many Ayurvedic medicines are being identified and their usefulness in drug therapy being determined. As only a certain percentage of plants are used in traditional medicines, it is roughly estimated that of the discovered 17,000 species, nearly 3,000 species are used in medicinal field . Some crude drugs used as medicine in Bangladesh are reported in following (Table 1).
Below it is presented the medication table recommended by the multidisciplinary team of doctors (diabetologist, nephrologists, cardiologist, family doctor) [12-17] and followed by the patient (Figures 1-3). Here are just some examples of constraints identified for the rehabilitation protocol, due to medication, the evolution of electrolytes values, of the blood pressure, edema etc.:
A. Treatment of SLE with administration of combine diuretic treatment: high-ceiling diuretics (furosemidum), Vasopressin antagonists (tolvaptan) , Diuretic thiazide and potassium sparing (amiloride hydrochloride and hydrochlorothiazide), thiazide diuretics (hydrochlorothiazidum) and combination immunosuppressant (cyclophosphamid, mycophenolate mofetil), cyclosporine and corticosteroids (prednisolone)
a. Specific exercises that do not involve risks factors for strokes, bruises, bleeding;
b. Exercises that do not present risk factors for people with high blood pressure;
c. Exercises that take into account the electrolyte imbalance (already existing due to the disease). We present below a picture of the evolution of values for electrolytes, recorded for the patient (Figure 4).In nutrients cycling within the soil microorganisms play a vital role and and all the beneficial microbes are located around the root zones of the plant. Microorganisms are the indicator of soil health as well as soil productivity. The presence of organic matter within the soil is itself nothing until or unless
Figure 4: Evolution in blood levels of sodium, chlorine, calcium and potassium from September 2017 unitl August 2018
As a general rule:
i. low blood values of electrolytes can lead to: cardiac arrhythmia, confusion, changes in blood pressure, various reactions in the nervous or bone system.
ii. high blood levels of electrolytes is instead characterized by muscle weakness and spasm, paresthesia, fatigue, emotional inballance, irregular heartbeat and change in blood pressure.
iii. Next we review normal values for an adult and problematic factors to be considered for rehabilitation protocol:
iv. Calcium, with normal values between 8.6-10 mg/dl, helps to contract and relax the muscles, influences the signal transmissions through nerves, plays an important role in blood coagulation, cell division and in the formation and maintenance of bone and tooth health. In this case the values ranged between 7,5-8,8 mg/dl, rarely fits in comfortable levels.
v.Chloride, normaly between 9,8 - 10,6 mmol/dl, helps maintain optimal levels of fluid in the body. With few exceptions, the levels were lower than normal or of a lower power range, in line with the evolution of the edema.
vi. Potassium regulates blood pressure and heart contraction and supports the muscular system functions; accelerates diuresis and intervenes in the elimination of sodium. In this case, the oscillations of potasium values compared to those specified as reference values for adults under 60 (3.5 - 5.4 mmol/l) were common in both directions (below minimum / over maximum), but with the general tendency to exceed the ceiling of normal values.
vii. Magnesium, necessary for the proper functioning of the muscular system, supports normal heart, bones and nerves performances and contributes to the development of resistance. It also reduces anxiety, supports digestion and maintains the balance of proteins and fluids in the body (normaly between 1,5-2,5 mg/dl . Given the correlated action of magnesium and calcium in the body, these values were monitored too, as they tended to decrease during critical periods crossed by the patient.
viii. Sodium (136 - 145 mmol/l) helps the body to balance its fluid levels and plays an important role in the normal functioning of nerves and muscle.
The changes in the normal level of potassium, magnesium, sodium, calcium, etc. have led to the manifestation of muscle spasms and weakness. As shown by the results of the blood tests, level oscillations of potassium, magnesium, sodium and calcium appear, which led to the patient's above mentioned manifestations. Also, the increase or decrease marked by potassium, magnesium or sodium led to heart rhythm disorders. Hypercalcemia was accentuated by dehydration, the kidneys being stimulated to remove as much water as possible (the patient having an additional accumulation of water in the body of almost 25 liters). There have been periods when hyperkalemia or hypokalemia have occurred. Hyperkalemia is more risky due to the more severe effects on the body than hypokalemia. The cause of it were kidney failure and the use of drugs that led to changes in the amount of potassium, eliminated from the body through the kidneys. Increased potassium levels were accompanied by abnormal heart rate. The low sodium level (in the present case being cumulated with the characteristics of SLE disease), produces drowsiness, confusion, muscle weakness and spasms. The specific manifestations of the hypopotassemia are the states of fatigue, confusion, muscular weakness and cramps etc. Very low potassium values can cause paralysis and arrhythmia.
Treatment for elevated blood pressure:
a. Possible adverse manifestations existed due to the administration of nebivololum, a selective beta-blocker (with selective action in the cardiovascular system), associated with the patients’ background of bronchial childhood asthma, including wheezing and swollen hands and feet.
This medicine has no effect on blood sugar, but may mask the warning signs for hypoglycaemia (eg, palpitations, increased heart rate).
b Amlodipine, a product of the calcium antagonists, also led to the swelling of the ankles up to the replacement with perindopril arginine (perindoprilum), an inhibitor of angiotensin converting enzyme.
Treatment of water retention, edema with diuretics
a. Prolonged treatment with high-ceiling diuretics (furosemide), increased persistence of elevated creatinine and triglyceride levels, orthostatic hypotension, and decreased blood levels of sodium and chlorine, and persistent electrolyte imbalances presented above. The significant part of the rehabilitation protocol started in the third period of treatment, when the patient was medically stable and started the home treatment (treated as an outpatient).
Figure 5: The firs and intermediate pahses of rehabilitation strategy followed in the management of the patients.
The rehabilitation strategy was build according to the patient's evolution, with a carefully tracking of the body’s functionality at each step, following the food and drug indications, taking into account the degree of muscle and joint rehabilitation, including the equilibrium function that has been greatly affected (Figure 5). The patient had a positive evolution alternating stagnant and good rehabilitation moments, being affected at times by environmental changes (atmospheric pressure, temperature and climate change) and the different body response to the medical treatment applied [18-20]. The evolution of the disease is ongoing in present with a hemorrhagic retinopathy on both eyes, with tractional retinal detachment, as a result of the combined LES and diabetes reply of the glycolic index variation. The treatment applied was with laser therapy, surgical intervention of the retinal detachment and postoperative with a drug combination of Netilmicinum + Dexamethasonum.
The functional state of the patient in October 2017 was that of functional disability to service and personal care, unable to have orthostatic position, the seated posture and the displacement. The clinical admission file showed: „generalized edema, Neohioid Follicular Lymphoma, fluid overload, 10kg weight gain, positional inspiratory dyspnea, general mediocre status, bilateral Pleurisy, small Pleuro-Pericarditis, type 2 Diabetes Mellitus, Anemia, Vulgare Lichen, Acute Nephritis Syndrome, Thrombocytopenia, EKG RS 100/min; BP = 170/9 0mmHg, HR= 108 beats/minute, Weight= 84 kg.”. We present a few images of the leg edema during that period (Figure 6).
Figure 6: Representative images of the foot edema and neuropathy skin lesions from 20.10.2017.
2The functional state of the patient in April 2018 was that of functional and personal care integrity, the ability to perform standing posture and walking with a moderate balance and state of equilibrium. The clinical admission file showed: “Type 2 Diabetes in treatment with OAD (Oral Anti-Diabetic) drugs, Cutaneous Ichthyosis under treatment, previously diagnosed bilateral Pleurisy, grade 1 Steatosis, Secondary Parenchyma Hypertension; Chronic Nephritis Syndrome, Diabetic Nephropathy. EKG RS 70/min; BP = 130/70 mmHg, HR = 72 beats/min, Weight= 93 kg”. We present a few images of the leg edema during that period (Figure 7).
Figure 7: Representative images of the foot edema and neuropathy skin lesions from 20.04.2018.
The functional state of the patient in June 2018 was that of functional and personal care integrity, the ability to perform standing posture and walking with a moderate balance and state of equilibrium. The clinical admission file showed: “Type 2 Diabetes in treatment with OAD, Cutaneous Ichthyosis under treatment; Chronic Nephritis Syndrome, Diabetic Nephropathy. EKG RS 70/min; BP = 120/60 mmHg, HR = 62 b/min, Weight= 83 kg”. We present a few images of the leg edema during that period (Figure 8).
Figure 8: Representative images of the foot edema and neuropathy skin lesions from 20.06.2018
4The functional state of the patient in January 2019 was that of functional and personal care integrity, the ability to perform standing posture and walking with a moderate balance and state of equilibrium. The clinical admission file showed: “Type 2 Diabetes in treatment with OAD, Cutaneous Ichthyosis under treatment; Chronic Nephritis Syndrome, Diabetic Nephropathy. EKG RS 70/min; BP = 140/70 mmHg, HR = 65b/min, Weight= 79 kg”. We present a few images of the foot edema during that period (Figure 9).
Figure 9: Representative images of the foot edema and neuropathy skin lesions from 3.01.2019.
The functional state the of patient in October 2019 was that of total integrity of functionality and personal care, ability of standing posture, walking, climbing stairs, with a moderate balance and state of equilibrium. The clinical admission file showed: “Type 2 Diabetes in treatment with OAD, Vascular Ocular Disorder, and Diabetic Nephropathy. EKG RS 70/min; BP = 140/70mm Hg, HR = 64 b/min, Weight= 82 kg”. We present a few images of the foot during that period (Figure 10).
Figure 10: Representative images of the foot from 12.09.2019.
The recommended strategy for addressing rehabilitation of motor function in such a complex case, requires monitoring of at least these five levels of observation:
A. Always be aware of the disease progression (even more in the context of risk of relapse) and medication administration, constantly consult physician recommendations, the results of medical tests, imagistic investigations and so on. In this case, multiple impairment of the organ systems has led to chronic or acute manifestations of imbalances in the body [21,22]. Permanently check the treatment schedule, especially in the case of a long-term treatment plan disease with the adjustment of the substances and doses used (side effects of drugs can often have an impact on the patient's condition).
B. Permanent assessment of the patients’ evolution, in points where difficulties were found: posture, coordination and motricity.
C. The importance of food is proven to be not only a supportive treatment by itself, but an estimate progression in the patients’ survival, because many of the associated diseases, both in the kidneys and other organs, make it difficult to choose the correct and balanced diet and medication.
D. An important path leading to complete rehabilitation in this case, as in many others, was the combination of sustained social - psychological - spiritual support through faith and managed with attention focused on the patient. The psychological support received from the medical staff and family, largely based on the patients’ trust in them, was even more necessary as the treatment with corticosteroids can cause changes in behavior (periods of extreme energy and activity, combined with periods of insomnia and irritability). We identified at least three main engines of the patients’ desire to recover - the confidence in the attending physician and successful completion of the treatment, the desire to return to a normal life and sacred therapy.
E. The prolonged treatment with furosemide, increased persistence of elevated creatinine and triglyceride levels, orthostatic hypotension, decreased sodium and chlorine blood levels and persistent electrolyte imbalances and also possible adverse manifestations due to the administration of nebivololum, a selective beta-blocker (with selective action in the cardiovascular system), against the background of bronchial asthma in the patient's childhood: wheezing, swollen hands and feet.
F. The cause that led to changes in the amount of potassium, eliminated from the body through the kidneys was kidney failure and the use of drugs. Increased potassium levels were accompanied by abnormal heart rate .
G. The changes in the normal level of potassium, magnesium, sodium, calcium, etc. have led to the manifestation of muscle spasms and weakness [24,25].
H. Once the prednisolone administration was completed, the patient regained bone and muscle mass and the functionality approached normal parameters.
I. The polypathology, as well as the delicate situation of the patient, have greatly raised the stakes of the entire medical staff in choosing the most suitable treatment management, which is still on progress daily.
J. We mention that all authors have quoted equally.
1. Ciccacci C (2017) A polymorphism upstream MIR1279 gene is associated with pericarditis development in Systemic Lupus Erythematosus and contributes to definition of a genetic risk profile for this complication. Lupus 26(8): 841-848.
2. Ivan C, Popescu L (2019) Adapted training sessions - a plus for beginner athletes- Discobolul - Physical Education, Sport and Kinetotherapy Journal Year 57(3): 31-35.
3. Petri MA , Van Vollenhoven RF , Buyon J (2013) Baseline predictors of systemic lupus erythematosus flares: data from the combined placebo groups in the phase III belimumab trials. Arthritis Rheum 65: 2143-53.
4. Yeganeh MZ, Sadeghi S (2013) Risk factors of glucocorticoid-induced diabetes mellitus in systemic lupus erythematosus. Galen Medical Journal 2: 39-43.
5. Houssiau FA , Vasconcelos C , D'cruz D (2010) The 10-year follow-up data of the Euro-Lupus nephritis trial comparing low-dose and high-dose intravenous cyclophosphamide. Ann Rheum Dis 69: 61-64.
6. Koutsonikoli A, Trachana M, Heidich AB (2015) Dissecting the damage in northern Greek patients with childhood-onset systemic lupus erythematosus: a retrospective cohort study. Rheumatol Int 35: 1225-1232.
7. Schroeder M, Russo S, Costa C, Hori J, Tiscornia I, et al. (2017) Pro-inflammatory Ca++-activated K+ channels are inhibited by hydroxychloroquine. Sci Rep 7(1): 1892.
8. Cortes S, Chambers S, Jerónimo A, Isenberg D (2008) Diabetes mellitus complicating systemic lupus erythematosus-analysis of the UCL lupus cohort and review of the literature. Lupus 17: 977-980.
9. Wahono CS, Rusmini H, Soelistyoningsih D, Hakim R, Handono K, et al. (2014) Effects of 1,25(OH)2D3 in immune response regulation of systemic lupus erithematosus (SLE) patient with hypovitamin DInt J Clin Exp Med 7(1): 22-31.
10. Stoicescu I (1999) Practice Dermato-Venerology Guide, Sitech Publishing House, Craiova, pp. 147-150.
11. Ulivieri C, Baldari CT (2014) Statins: from cholesterol-lowering drugs to novel immunomodulators for the treatment of Th17-mediated autoimmune diseases- Pharmacol Res 88: 41-52.
12. Bucur G, Opris DA (2002) Dermatoveneric Encyclopedia Diseases. (National Medical edn), Bucharest, Romania, pp. 468-471
13. Calabrese L, Resztak K (1998) Thalidomide revisited: pharmacology and clinical applications. Exp Opin Invest Drugs 7: 2043-2060.
14. Hanjani NM, Nousari CH (2002) Mycophenolate Mofetil for the Treatment of Cutaneous Lupus Erythematosus With Smoldering Systemic Involvement Arch Dermatol 138: 1616-1618.
15. Housman TS, Jorizzo JL Colab SI (2003) Low-Dose Thalidomide Therapy for Refractory Cutaneous Lesions of Lupus Erythematosus Arch Dermatol 139: 50-54.
16. Tien KJ (2013) Epidemiology and Mortality of New-Onset Diabetes after Dialysis. Diabetes care 36: 3027-3032.
17. Van Vollenhoven RF, Mosca M , Bertsias G (2014) Treat-to-target in systemic lupus erythematosus: recommendations from an international Task Force. Ann Rheum Dis 73: 958-967.
18. Van Vollenhoven RF, Mosca M , Bertsias G (2014) Treat-to-target in systemic lupus erythematosus: recommendations from an international Task Force. Ann Rheum Dis 73: 958-967.
19. Popescu V (2005) Clinica de Pediatrie și Neurologie pediatrică, Spitalul Clinic de copii „Dr. Victor Gomoiu“, București - Criteriile revizuite pentru diagnosticul LES (după Tass și colab, 1982); JURNALUL MEDICINEI ROMÂNEªTI 3(4): 59.
20. Ugarte-GIL MF, Wojdyla D, Pons-Estel GJ (2017) Remission and low disease activity status (LDAS) protect lupus patients from damage occurrence: data from a multiethnic, multinational Latin American lupus cohort (GLADEL). Ann Rheum Dis 76: 2071-2074.
21. Knop J, Bonsmann, G, Happle R si colab (1983) Thalidomide in the treatment of sixty cases of chronic discoid lupus erythematosus. Br J Dermatol 108: 461-466.
22. Tseng S, Pak G (1996) Rediscovering thalidomide: a review of its mechanism of action, side effects, and potential uses. J Am Acad Dermatol 35: 969-979.
23. Powell RJ (1999) Thalidomide: current uses. Bio Drugs 11(6): 409-416.
24. Werth V (2001) Current Treatment of Cutaneous Lupus Erythematosus. Dermatology Online Journal 7(1): 2.