Role of Co-Processed Superdisintegrants in Enhancing the Dissolution Rate of Nifedipine in Sublingual Tablets

 

Ashok Thulluru*, C. Madhavi, K. Nandini, S. Sirisha, D. Spandana

Dept. of Pharmaceutics, Sree Vidyanikethan College of Pharmacy, A. Rangampet,

Tirupati-517 102,  Chittoor (Dist.), A.P., India.

*Corresponding Author E-mail: ashokthulluru@gmail.com

 

ABSTRACT:

The objective of the study was to formulate and optimize sublingual tablets (SLT) of Nifedipine for the treatment of angina and hypertension. The dissolution rate of Nifedipine was improved by co-processed superdisintegrants prepared by solvent evaporation technique. FTIR studies confirmed the absence of drug-excipients interactions. Cross carmellose sodium (CCS), sodium starch glycolate (SSG) and crospovidone (CPV) and their 1:1 ratio co-processed combinations were used as superdisintegrants. Six formulations (F1-F6) of SLTs were prepared by direct compression method using various concentrations of individual and co-processed superdisintegrant(s). The directly compressible blends have good flow characteristics. The formulated tablets were evaluated for hardness, thickness, weight variation, friability, wetting time; in-vitro dispersion time, water absorption ratio, drug content, disintegration time and the results were within USP limits. Formulation F6 (with co-processed SSG: CPV) showed shorter wetting time 22.21 sec and disintegration time of 1 min 45 sec, hence it was selected as the optimized formulation. The drug release from the SLTs follows first order release kinetics. Optimized formulation (F6) passes the test for stability as per ICH guidelines in final pack. Hence co-processed superdisintegrants are superior to individual ones.

 

KEYWORDS: Nifedipine, sublingual, co-processed superdisintegrant(s), angina and hyper tension.

 

 


INTRODUCTION:

The oral route is the most preferred route of administration of dosage forms, due to its potential advantages like ease of administration, convenient dosing, self-medication, no pain and patient compliance. Hence tablets and capsules are the most popular dosage forms1, but the important drawback of these dosage forms is dysplasia2 which can be solved by developing a novel drug delivery  system (NDDS), fast dissolving sublingual tablet (SLT).

 

The sublingual route usually produces a faster onset of action than orally ingested tablets and the portion absorbed through the sublingual blood vessels bypasses the hepatic first‐ pass metabolic processes. A fast dissolving tablet system can be defined as a dosage form for oral administration, which, when placed in the mouth, rapidly dispersed or dissolved and can be swallowed in the form of liquid. For these formulations, the small volume of saliva is usually enough to result in disintegration in the oral cavity. The drug can then be absorbed partially or entirely into the systemic circulation from blood vessels in the sublingual mucosa, or it can be swallowed as a solution to be absorbed from the gastrointestinal tract3‐5. Nifedipine (NFD) is used for treating high blood pressure, certain types of angina, and coronary heart failure. It is a dihydro pyridine calcium antagonist (calcium ion antagonist or slow channel blocker) that inhibits the trans‐ membrane influx of calcium ions into vascular smooth muscle and cardiac muscle6. It is a crystalline powder with a molecular weight of 567.1 g/Mol. It is slightly soluble in water. Its absolute bioavailability has been estimated to be between 64% and 80% only, due to its extensive hepatic metabolism, when taken as a conventional tablet, hence it is a suitable candidate for to formulate as SLTs. The purpose of this investigation was to formulate NFD SLTs by direct compression technique. The present study was aimed to study the effect of co-processed superdisintegrants prepared by solvent evaporation technique on enhancing the dissolution of NFD from its SLTs.

 

MATERIALS AND METHODS:

Materials:

Nifedipine was obtained from Hetero Drugs Pvt. Ltd., Hyderabad, India as a gift sample, powder vanilla flavor was a gift sample from Firmenich, Chennai, sodium starch glycolate (Primogel®), croscarmellose sodium (Ac-Di-Sol®), Crospovidone (Crospovidone M®), microcrystalline cellulose (Avicel PH102), mannitol (Pearlitol® 200 SD), aspartame and sodium stearyl fumarate. All the excipients used in the study were of pharmaceutical grade.

 

Methods:

The Standard calibration curve of NFD in pH 6.8 phosphate buffer solution (PBS):

Preparation of pH 6.8 PBS:

Place 50 mL of 0.2M potassium hydrogen phosphate in a 200 mL volumetric flask, add the 22.4 mL of 0.2 M sodium hydroxide and the add water to the volume.

 

Preparation of stock solution-I (1000 μg /mL):

Was prepared by dissolving 50 mg of NFD in 10 mL of methanol in a 50 mL volumetric flask and the volume was made up to mark with pH 6.8 PBS.

 

Preparation of working dilutions:

Aliquots of (0.25, 0.5, 0.75, 1.0, 1.25 and 1.5 mL) of Stock-I was transferred into a series of 10 mL volumetric flasks and the volume was made up to mark with pH 6.8 PBS to obtain concentrations of (25, 50, 75, 100, 125 and 150 μg/mL respectively). The obtained dilutions were analyzed at the λmax 235 nm using a UV-Visible spectrophotometer (UV-1700, Shimadzu, Mumbai, India) and their absorbance were noted. The Standard calibration curve was plotted by taking the concentration of drug solution (μg/mL) on X-axis and absorbance on Y-axis7.

 

Drug-excipient compatibility (FT-IR) studies:

Were performed on NFD and (1:1 ratio) physical mixtures of NFD with normal and co-processed superdisintegrants by an IR spectrophotometer (Shimadzu, FTIR 8700), in the region between 400 and 4000 cm-1 by the direct sampling method8.

 

Preparation of NFD SLT:

All the formulations were prepared by direct compression method, by keeping the amount of NFD constant at 10 mg. The composition of other excipients is varied as mentioned in formulation table (Table 1). In these formulations CPV, CCS and SSG are used as superdisintegrants, mannitol as a directly compressible diluent, aspartame is an artificial sweetener, powder vanilla flavor as a flavoring agent, sodium stearyl fumarate as a water soluble lubricant. NFD and all the other excipients excluding sodium stearyl fumarate were co-sifted through Sieve No. # 40 (ASTM), blended uniformly in a poly bag for 10 min and lubricated with Sieve No. # 60 (ASTM) passed sodium stearyl fumarate by mixing in a same poly bag for an additional 2-3 min. Tablets were compressed on a tablet compression machine (10 station, Yogesh Pharma Machinery Pvt. Ltd., India) fitted with 8mm standard round punches with an Avg. wt. of 150 mg and 3-4 kg/cm2 of hardness8.

 


 

Table 1. Formulation table of NFD SLTs

Ingredient(s)

Qty/ tablet (mg)

F1

F2

F3

F4

F5

F6

CCS

SSG

CPV

CCS: SSG

CCS: CPV

SSG: CPV

Nifedipine

10

10

10

10

10

10

Croscarmellose sodium

15

-

-

7.5

7.5

-

Sodium starch glycolate

-

15

-

7.5

-

7.5

Cross povidone

-

-

15

-

7.5

7.5

Aspartame

3

3

3

3

3

3

Powder vanilla flavor

1.5

1.5

1.5

1.5

1.5

1.5

Mannitol

72

72

72

72

72

72

Micro crystalline cellulose

47

47

47

47

47

47

Sodium stearyl fumarate

1.5

1.5

1.5

1.5

1.5

1.5

Total

150 mg

150 mg

150 mg

150 mg

150 mg

150 mg

 

 

Pre-compression studies:

The directly compressible NFD SLT blends were evaluated for their flow and compression properties9.

 

Angle of Repose (θ):

Was determined by funneling method, the blend was poured through the walls of a funnel, which was fixed at a position such that its lower tip was at a height of exactly 2 cm above hard surface. The blend was poured till the time when the upper tip of the pile surface touched the lower tip of the funnel. The θ is calculated by the equation.

 

θ = tan –1 h/ r                                                   Eq. No. (1)

 

Where,

θ = angle of repose,

h = height of the heap and

r = radius of base of heap circle.

 

Bulk density (BD): A quantity of 2 gm of SLT blend from each formulation, previously lightly shaken to break any agglomerates formed, was introduced into a 10 mL measuring cylinder and the volume is noted as bulk volume. The BD was calculated by the equation.

 

BD = wt. of blend/ Bulk volume.                     Eq.No. (2)

 

Tapped density (TD): After the determination of BD, the measuring cylinder was fitted to a tapped density apparatus. The tapped volume was measured by tapping the powder for 500 times. Later the tapping was done for another 750 times and the tapped volume was noted (the difference between these two volumes should be less than 2%). If it is more than 2%, tapping is continued for another 1250 times and the constant tapped volume was noted. The TD was calculated by the equation.

 

TD = Wt. of blend / Tapped volume               Eq. No. (3)

 

Carr’s Index (CI): The percentage of CI is calculated by the equation.

 

CI = (TD-BD) ×100/TD.                                 Eq. No. (4)

 

Hausner’s Ratio (HR):

Is a number that correlates to the flow ability of a powder. It is calculated by the equation.

 

HR =TD/BD.                                                   Eq. No. (5)

 

Post compression studies9:

Avg. wt. of tablets:

An electronic balance (Mettler Toledo, 3- MS-S / MS-L, Japan) was used to accurately weigh the individual wt. of twenty tablets (n=20) which were randomly selected from each formulation and checked for the acceptability of wt. variation.

 

Friability test:

The friability of the 20 tablets from each batch (n=1) was tested by a friabilator (SINGLA, TAR 120, Germany) at a speed of 25rpm for 4min. The tablets were then dedusted, reweighed, and percentage weight loss was calculated by the equation,

 

   (Initial Wt.- Wt. after friability)

% Friability = --------------------------------------× 100 /

                                      Initial Wt.                         Eq. No (6)

 

Hardness test:

To evaluate the diametrical crushing strength, 3 tablets from each formulation were tested using a hardness tester (Monsanto type hardness tester, MHT-20, Campbell Electronics, India).

 

Thickness:

Thickness of 3 tablets from each formulation was determined using a Vernier caliper (Mitutoyo Corporation, Japan).

 

In vitro disintegration time & fineness of dispersion:

It is specified in the European Pharmacopeia (EP 6.0), the disintegration time determination procedure for fast disintegrating tablets is same as that of conventional uncoated tablets and the tablets should be dispersed within less than 3 min. The obtained tablet’s dispersion was passed through a sieve screen with a nominal mesh aperture of 710 mm to confirm the fineness of dispersion10.

 

Wetting time and Swelling Index:

A piece of tissue paper folded twice was placed in petri dish having an internal diameter of 5.5 cm, containing 6 mL of water. A tablet was placed on the paper and the time required for complete wetting was measured as wetting time (WT), using a stopwatch. The wetted tablet was then reweighed and swelling index (SI) was determined using the following equation11.

 

SI = [(Wa – Wb) / Wb] × 100   .                          Eq. No (7)

 

Where,

Wb and Wa were the weights of the tablet before and after swelling.

 

Assay:

To evaluate the drug assay, 3 tablets (n=3) from each formulation were powdered in mortar and pestle. Blend equivalent to 1 mg of NFD was accurately weighed and transferred into a 100 mL volumetric flask containing 10 mL of methanol, and the volume was made up to 100 mL with pH 6.8 phosphate buffer and ultra-sonicated for 2 min to extract the NFD from the tablet blend and filtered through 0.45 µm poly tetra flour ethylene (PTFE) filter disc. The filtrate was suitably diluted if necessary and its absorbance was measured by UV- Visible spectrophotometer at 235 nm8.

 

In vitro dissolution studies:

Were performed on 10 mg of pure drug (NFD) and 6 tablets from each batch (n=6) using the dissolution apparatus (Lab India Disso2000, Lab India Analytical Instruments Pvt. Ltd., India) with USP-II / Paddle. Each dissolution flask contains 900 mL of pH 6.8 Phosphate buffer; the speed of the paddle was maintained at 50 rpm; the temperature was kept stable at37 0C± 0.5 0C. At required time intervals, 5 mL of dissolution media was withdrawn with a pipette containing 0.45 µ (PTFE) filter disc, suitably diluted if necessary and its absorbance was measured by UV-Visible spectrophotometer at 235 nm. Furthermore, 5 mL of fresh pH 6.8 phosphate buffer was replaced to the dissolution flask to keep the volume of dissolution medium constant8.

 

In vitro dissolution kinetics:

The in vitro drug release data was fitted into zero-order plots/ dissolution profiles (%CDDVs time) and first order plots (Log % CDUDVs time) as per the following equations11.

 

Zero order equation: Qt = Q0 + K0t              Eq. No. (8)

 

First order equation: Log Qt = Log Q0 – K1t/2.303.

                                                                         Eq. No. (9)

 

Where Qt is the amount of the drug dissolved in time t, Q0 is the initial amount of drug in the solution; K0 & K1 refers to the rate constants of zero & first order respectively.

 

Dissolution Efficiency at 30 min (DE30) by Trapezoid Rule12; and time for 50 % drug release (t50) were calculated from dissolution profiles.

Equations for calculating DE30:

 

[AUC]= Ʃ[(c1+c2) (t2-t1)].                          Eq. No (10)

 

DE30 =                                          Eq. No. (11)

 

Where,

[]  = Area under curve between time points t1 to t2

 

Total area under 30 min = 30 x 100 = 3000 cm2

 

Accelerated stability studies of the optimized NFD SLTs (F6): Were carried according to an international conference on harmonization (ICH) guidelines. 20 tablets were packed in each 10 CC HDPE bottle and sealed thermally and were placed in a humidity chamber (NSW-175, Narang Scientific work, India) maintained at 45 °C ± 2 °C and 75 % ± 5 % RH. Up to 3 months, at the end of every month the respective samples were withdrawn and evaluated for post compression studies13.

 

RESULTS AND DISCUSSION:

The standard calibration curve of NFD in pH 6.8 phosphate buffer:

Based on the measurement of absorbance at ʎ max of 235 nm in pH 6.8 phosphate buffer in the conc. range of 0-150 µg/mL, a straight line with an equation, y = 0.003 x - 0.004 and a regression coefficient (r2) of 0.999 was obtained, which indicates it follows the Beers-Lambert law in the mentioned concentration range.

 

Drug-excipient compatibility (FT-IR) studies:

The FT-IR spectrum of NFD is characterized by sharp characteristic peaks at 3300.20 cm–1: (N-H) free, trans-isomer, 3158.50 cm–1: Ar-H/ -CH band, 1651.08 cm–1: C=O stretching vibration, and 1616.08 cm–1: Ring vibration. All the above characteristic peaks appear in the (1:1 ratio) physical mixtures of NFD with superdisintegrants at same wave numbers indicating no modification or interaction in the drug with the combination of superdisintegrants used in the study14 (Fig .1).

 

 

Fig.1. FTIR Spectra of A. NFD, B. CCS+CPV+NFD, C. CPV+SSG+NFD & D. SSG+CCS+NFD

 

Pre-compression studies: The directly compressible blends of NFD SLTs, reveals that the AR was found between 22˚.51’ ± 2.01 to 26˚.28’± 0.73, HR between 1.30 to 1.40 and CI between 21.82 to 28.92 %. The micromertic studies indicate good flow and compression characteristics of all the blends. In these formulations sugar based excipient, directly compressible mannitol is used as diluent, which imparts good flow and compressibility to the blends. It also exhibits good aqueous solubility along with sweetness and negative heat of solution. Hence, it imparts a pleasant mouth feel15. Pre-compression studies of all the formulations carried out in triplicate (n=3); the consolidated results (mean ± SD) were tabulated in (Table 2).

 

Table 2. Results of pre-compression studies on NFD SLTs

F.

Code

Angle of repose (°)

BD

(gm/cm3)

TD

(gm/cm3)

CI*

(%)

HR*

(  )

F1

26.27±0.62

0.32±0.02

0.46±0.05

27.92

1.38

F2

23.64±2.15

0.46±0.01

0.62±0.02

22.81

1.32

F3

25.19±2.27

0.44±0.01

0.58±0.09

23.80

1.40

F4

26.37±2.31

0.40±0.01

0.54±0.02

26.41

1.36

F5

26.28±0.73

0.33±0.04

0.47±0.06

28.92

1.39

F6

22.51±2.01

0.45±0.02

0.53±0.03

21.82

1.30

*All the tests expect for CI & HR were performed in triplicate (n=3) and the values are expressed as (mean ± SD). CI & HR were calculated from the mean values of BD & TD.

 

 

 

 

 
Post-compression studies:

Of all the NFD SLT, reveals that the Avg. wt. of tablets of was found to be 296±1.10 to 301±0.98 mg. The Avg. thickness of tablets was found to be 5.3±0.02 to 5.7±0.03 mm. The Avg. hardness of the tablets ranges between 3.5±1.22 to 4.2±1.70 Kg/cm2, indicating satisfactory mechanical strength. The % wt. loss in the friability test ranges from 0.06 to 0.12 %, which was NMT 1 % w/w as per   pharmacopeia limits indicating a good mechanical resistance of tablets. Assay of all the prepared batches is within 97.6±0.85 to 99.6±0.86% of the labeled content, indicating the content uniformity of all the formulations. The DT of F6 (10% w/w SSG: CPV; 1:1) achieved the fastest (52.12±1.11sec) of all, as it produces the highest tablet breaking force at a given compression force. The wetting time of all the formulations was obtained in the range of 22.21 ±1.11 to 78.21±1.06 sec. Wetting is related to the inner structure of the tablets, hydrophilicity of the components and swelling mechanism of superdisintegrant. The swelling index is also related to the hydrophilicity of the matrix. The SLTs with CPV were fully hydrated and soft throughout because CPV quickly wicks water into the tablet by imparting porosity16. Water wicking is the ability to draw water into the tablet matrix. Both the extent and the rate of water uptake are critically important. Exposure to water can cause ingredients to swell and exert pressure against surrounding tablet ingredients, causing existing bonds between particles to break17. Water wicking and swelling are the two most important mechanisms of disintegrant action for CCS18. SSG is a commonly used super disintegrant employed to promote rapid disintegration by swelling mechanism19. The water insoluble superdisintegrants show better disintegration property than the slightly water-soluble ones, since they do not tend to swell. Superdisintegrants that tend to swell show slight retardation of the disintegration property due to formation of viscous barrier20. Hence, among the used superdisintegrants CPV is superior21.The order of normal and co-processed superdisintegrants efficiency was observed as SSG: CPV>CCS: CPV> CCS: SSG>CPV > SSG > CCS, indicates co-processed superdisintegrants are superior to normal ones22. The formulation F6 (10% w/w of SSG: CPV; 1:1) which shows min wetting time of 22.21 ±1.11 sec and disintegration time of 52.12±1.11 sec and highest SI of 262±1.52 %. Post compression studies of all the formulations, except for Avg. wt. (n=20) and friability test (n=1); carried out in triplicate (n=3); the consolidated results as, (mean ± SD) were tabulated in (Table 3). Pictures while measuring the DT of optimized NFD SLT F6 was shown in (Fig.2).


 

Table 3. Results of post-compression studies on NFD SLTs

F.

Code

Avg Wt.*

(mg)

Hardness (Kg/cm2)

Thickness (mm)

Friability* (%)

SI

(%)

WT

(Sec)

DT

(Sec)

Assay

(%)

F1

296±1.10

4.2±1.70

5.3±0.02

0.06

65±1.12

78.21±1.06

99.12±2.13

98.8±0.92

F2

297±0.92

3.5±1.22

5.4±0.03

0.07

92±1.25

72.15±1.21

93.52±2.31

99.6±0.86

F3

298±1.11

4.2±1.71

5.6±0.03

0.12

103±0.99

65.22±0.66

85.11±2.12

97.6±0.85

F4

301±0.98

4.1±1.22

5.5±0.04

0.08

163±1.48

58.12±1.52

71.22±5.12

97.9±0.88

F5

299±1.26

3.5±1.21

5.7±0.03

0.06

231±1.21

55.21±1.22

64.24±2.14

98.6±0.95

F6

299±1.11

4.1±1.74

5.6±0.02

0.07

262±1.52

22.21 ±1.11

52.12±1.11

98.9 ±0.95

* Except for Avg. wt. (n=20); friability test (n=1) all other were performed in triplicate (n=3) and the values are expressed as (mean ± SD).

 


 

Fig.2. Pictures while measuring the DT of optimized NFD SLT; F6 A) Initial stage, B) at 20 sec and C) at 52.12 sec

 

 

In vitro dissolution studies:

The order of normal and co-processed superdisintegrants in enhancing the dissolution rate of NFD from its SLTs is SSG: CPV>CCS: CPV>CCS: SSG>CPV > SSG > CCS. The dissolution profiles were represented graphically in (Fig.3).

 

 

Fig. 3. In vitro dissolution profiles of NFD SLTs

 

In vitro dissolution kinetics: Reveals formulation F6 (10% w/w of SSG: CPV; 1:1) had the highest DE30 (24.33 %); K1 (0.018min-1) with r2 (0.959) and lowest t30 (15 min). Hence, it is considered as an optimized NFD SLT. First order dissolution rate constant (K1) and regression coefficient (r2) of first order profiles were calculated from first order plots. The consolidated in vitro dissolution kinetic parameters of NFD SLT were tabulated in (Table 4).

 

 

 

 

Table 4. Results of in vitro dissolution kinetic studies on NFD SLTs

F.

Code

Dissolution plots

First order plots

t30 (min)

DE30 (%)

K1 (min-1)

r2

NFD

ˉˉ

0.49

ˉˉ

ˉˉ

F1

60

5.19

0.005

0.956

F2

60

9.13

0.005

0.996

F3

45

13.07

0.007

0.982

F4

45

18.70

0.012

0.974

F5

30

21.51

0.014

0.967

F6

15

24.33

0.018

0.959

 

Accelerated stability studies of the optimized NFD SLTs (F6):

There were no significant differences in post compression studies of initial and accelerated stability samples of optimized NFD SLTs; F6 (10% w/w of SSG:CPV; 1:1) up to 3 months in a 20 cc HDPE pack, hence it passes the test for stability as per ICH guidelines. The consolidated results of post compression studies on accelerated stability samples of optimized NFD SLT F6; except Avg. wt. (n=20) and friability test (n=1), the other was carried out in triplicate (n = 3) and the results as (mean ± SD) were tabulated in (Table 5). In vitro dissolution profiles of initial and accelerated stability samples of optimized NFD SLTs (F6) were represented graphically in (Fig.4).  Comparative FTIR spectra of NFD, optimized NFD SLT F6-Initial sample and 45°C/ 75% RH-3M sample is shown in (Fig. 5).


 

Table 5. Results of post-compression studies on accelerated stability samples of optimized NFD SLTs (F6)

Parameter

Initial

45°C / 75% 4RH

1M

2M

3M

Avg. wt. (mg)

299±1.11

298±1.12

298±1.09

297±1.10

Hardness (kg/cm2)

6.5±1.74

6.5±1.5

6.5±1.44

6.4±1.74

Thickness (mm)

5.6±0.02

5.5±0.09

5.5±0.04

5.4±0.02

*Friability (%)

0.070

0.068

0.064

0.060

Assay (%)

98.9 ±0.95

98.6 ±0.92

97.7 ±0.95

96.9 ±0.91

DT (Sec)

105.12±1.11

105.11±1.12

105.08±1.03

104.07±1.04

WT (Sec)

22.21 ±1.11

22.19 ±1.10

22.12 ±1.01

21.09±1.05

SI (%)

53±1.52

52.8±1.98

52.5±1.09

52±1.10

 


 

Fig.4. In vitro dissolution profiles of accelerated stability samples of optimized NFD SLTs (F6)

 

Fig.5. Comparative FTIR spectra of A. NFD, B. Optimized NFD SLT F6-Initial sample & D. Optimized NFD SLT F6-45°C/ 75% RH-3M sample

CONCLUSION:

In the view of the above findings, there is drug-excipient compatibility between NFD, normal and co-processed super-disintegrants used in the study. All the formulations passed the pre- & post- compression evaluation parameters as per USP. The order of normal and co-processed superdisintegrants efficiency was observed as SSG: CPV>CCS: CPV> CCS: SSG >CPV > SSG >CCS. The combination of superdisintegrants SSG and CPV is superior among others. The optimized NFD SLTs; F6 (10% w/w of SSG: CPV; 1:1) passes the test for stability as per ICH guidelines. Hence co-processed super-disintegrants are more beneficial in the dissolution rate enhancement of poorly soluble drugs like NFD, than conventional ones.

 

ACKNOWLEDGEMENTS:

The authors are thankful to Padmasree Dr. M. Mohan Babu, Chairman, Sree Vidyanikethan Educational Institutions, Tirupati; A.P.; INDIA for providing us the required facilities and being a constant support to carry out this academic research.

 

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

 

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Received on 21.08.2019         Accepted on 18.09.2019

© Asian Pharma Press All Right Reserved

Asian J. Pharm. Res. 2019; 9(4):253-259.

DOI: 10.5958/2231-5691.2019.00041.8