Double-blind, placebo-controlled, randomized phase II study of TJ-14 (Hangeshashinto) for infusional fluorinated-pyrimidine-based colorectal cancer chemotherapy-induced oral mucositis

Hangeshashinto Inhibits Porphyromonas gingivalis Pathogen-Associated Molecular Patterns-Mediated IL-6 and IL-8 Production through Toll-Like Receptors in CAL27 Cells

While previous reports have established the anti-inflammatory effects of hangeshashinto, the intracellular signal transduction pathways involved have yet to be elucidated. We aim to employ an experimental system using oral cancer cells to assess the impact of hangeshashinto on intracellular signal transduction pathways in response to stimulation by Porphyromonas gingivalis pathogen-associated molecular patterns (PAMP). Hangeshashinto demonstrated the ability to inhibit the production of interleukin (IL)-6 and IL-8 induced by P. gingivalis PAMP. Furthermore, hangeshashinto suppressed the activation of the IL-6 promoter stimulated by PAMP. Hangeshashinto, like Toll-like receptor (TLR) signaling inhibitors (resatorvid and C29) and an immunosuppressant (dexamethasone), exhibited the ability to suppress TLR-mediated activation of the transcription factor nuclear factor-κB (NF-κB) in response to PAMP stimulation. This study suggests that the anti-inflammatory effects of hangeshashinto may be attributed to the inhibition of TLR signal transduction pathways including NF-κB activation, thereby suppressing NF-κB-dependent gene expression.

Prospective feasibility study of indigo naturalis ointment for chemotherapy-induced oral mucositis

OBJECTIVES

Indigo naturalis, a herbal medicine effective against ulcerative colitis, exhibits anti-inflammatory effects and induces interleukin-22-mediated antimicrobial peptide production. Anti-inflammatory activity and the prevention of secondary infection are essential for the management of chemotherapy-induced oral mucositis (CIOM); therefore, we developed an indigo naturalis ointment to be administered topically for CIOM and evaluated its feasibility.

METHODS

We performed a single-centre, open-label, prospective feasibility study from March 2017 to December 2018. The key eligibility criteria for the subjects were as follows: (1) receiving chemotherapy for a malignant tumour; (2) grade 1 or 2 CIOM and (3) receiving continuous oral care. The treatment protocol comprised topical indigo naturalis ointment application three times a day for 7 days. The primary endpoint assessed was feasibility. The secondary endpoints assessed were the changes in oral findings, oral cavity pain and safety.

RESULTS

Nineteen patients with CIOM were enrolled. The average feasibility (the proportion of prescribed applications that were carried out) observed in this study was 94.7%±8.9% (95% CI 90.5% to 99.0%), which was higher than the expected feasibility. The revised oral assessment guide scores of the mucous membrane domain and total scores were significantly improved. All patients reported a reduction in oral cavity pain, with a median pain resolution duration of 6 days. No serious adverse events were observed.

CONCLUSIONS

The indigo naturalis ointment was feasible, and showed the potential for efficacy and safety. Larger randomised controlled trials are needed to further assess the efficacy and safety of indigo naturalis compared with a placebo.

TRIAL REGISTRATION NUMBER

UMIN000024271.

Hangeshashinto for prevention of oral mucositis in patients undergoing hematopoietic stem cell transplantation: a randomized phase II study

PURPOSE

Oral mucositis (OM) is a side effect associated with cancer treatment. Hangeshashinto (HST), a Kampo medicine, was originally prescribed to treat diarrhea, gastritis, and stomatitis. Several reports have described the effects of HST for OM induced by chemotherapy in patients with gastric or colorectal cancer. In this study, the effects of HST for prevention of OM were investigated in patients undergoing hematopoietic stem cell transplantation (HSCT).

METHODS

Thirty patients scheduled to receive allogeneic grafts were enrolled from July 2020 to December 2021. They were randomly assigned to two groups and instructed to wash their mouth using HST dissolved in saline solution or using only saline solution three times a day. The observation period was from the initiation date of the conditioning regimen to the date of engraftment, and the end point was the incidence of OM.

RESULTS

Eighteen patients developed OM, the most severe of which was Grade (G)3. There was no significant difference in the incidence of OM between the HST group and the control group. However, a negative correlation tended to be observed between the duration using HST use and the duration of OM (G2-3: P = 0.027, G3: P = 0.047).

CONCLUSIONS

The present study demonstrated that HST use did not clearly inhibit onset of OM but showed a tendency to inhibit OM exacerbation. However, further studies are necessary to fully understand the effects of HST on OM in patients undergoing HSCT.

TRIAL REGISTRATION

This study was registered in the Japan Registry of Clinical Trials on 7 May 2020 (jRCTs071200012).

Bibliometric analysis of Kampo medicine hotspots and trends for the decade: 2013-2022

BACKGROUND

Kampo medicine is a traditional medicine that originated in ancient China and has since developed as a uniquely Japanese medicine. Although Kampo medicine is one of Japan's most important therapeutic modalities and numerous papers have been published recently, information on current hotspots and trends in Kampo research is lacking. This bibliometric analysis of Kampo medicine surveyed the latest research hotspots and trends.

METHODS

Articles on Kampo medicine were retrieved from the Web of Science Core Collection. We used medical subject headings related to Kampo medicine and searched for publications from 2013 to 2022. The retrieved articles were analyzed for countries, authors, journals, references, and keywords related to Kampo medicine using CiteSpace, VOSviewer, and SCImago Graphica.

RESULTS

A total of 1170 articles were included. The number of Kampo medicine-related publications and citations has recently increased, mainly from Japan. Author Keiko Ogawa-Ochiai published the most papers (40 papers), while Yoshio Kase had the highest frequency at 663 citations. Among the co-cited authors, Toru Kono was the most cited and had the highest total link strength. The journal with the most submissions was Evidence-based Complementary and Alternative Medicine. A comprehensive keyword and literature analysis revealed the following research hotspots: "Yokukansan and behavioral and psychological symptoms of dementia," "Ninjinyoeito and geriatric care," "Daikenchuto and postoperative gastrointestinal cancer," and "Rikkunshito and functional dyspepsia." We also identified a new research frontier by identifying an association between hochuekkito and COVID-19.

CONCLUSIONS

Our findings reveal trends in Kampo medicine research, with specific hotspots and the authors and publications with the largest research impact. Collecting a large volume of literature data, analyzing the impact of studies, and identifying research hotspots, as in this study, will provide researchers with future directions for Kampo research.

The role of pharmacists in multimodal cancer cachexia care

Cancer cachexia is a complex syndrome, and multidisciplinary management has the potential to improve patient outcomes and efficiency of care. Multidisciplinary management consists primarily of exercise, nutrition, and pharmacotherapy. The pharmacist's role in cancer cachexia is to contribute to appropriate pharmacotherapy practices. For example, anamorelin is an oral drug with ghrelin-like effects that may improve the pathogenesis of cancer cachexia by stimulating appetite and increasing food intake and body weight. Many patients with cancer cachexia are under treatment with anticancer agents, and pharmacists need to determine whether symptoms such as anorexia and nausea are due to cancer cachexia or anticancer agents. Based on that determination, they are then expected to suggest supportive care to the physician. Provision of multidisciplinary care for cancer cachexia requires communication with not only physicians but also with nurses, dietitians, and other professionals so that nutritional therapy can be provided at the time cachexia is detected. However, the role of pharmacists in the management of cancer cachexia is not well established, and there is no evidence that pharmacist interventions are of benefit to patients. In this article, to contribute to the treatment of cancer cachexia by multidisciplinary care, we describe the role of pharmacists in cancer cachexia as currently practiced at our hospital. We also consider future challenges to this type of multidisciplinary care. Evidence concerning multidisciplinary treatment of cancer cachexia is scarce, including therapeutic agents, and there is a current lack of collaboration among medical professionals and education in cancer cachexia. Solving these problems will require efforts in the practice and evaluation of treatment for cancer cachexia.

Perspectives of international multi-center clinical trials on traditional Chinese herbal medicine

With the introduction of various subjects, such as clinical epidemiology and evidence-based medicine, the qualities and levels of Traditional Chinese Herbal Medicine (TCHM) in China improved substantially, and the processes of internationalization of Traditional Chinese Medicine (TCM) are further accelerated. Since, a variety of drug products in China have been approved for marketing in other countries, and approximately 10 products have submitted the IND application to FDA of United States, of which various Chinese herbal preparations such as compound Danshen dripping pills, Xingling granules, and HMPL-004 have been approved to be investigated in phase III clinical trials. In general, multi-center studies of TCHM are increasing with years, but most of the studies are performed in some certain country, and the actual international multi-center clinical trials are very rare. Number of SCI literatures on multi-center clinical trials of TCHM that published in the recent decade also showed increasing tendency with years, despite the evident reduction in the past 2 years due to the influence of COVID-19 pandemic. Of the multi-center clinical trials of TCHM that performed by mainland China and other oversees regions, except for Taiwan, China, nearly 70% were focused on classic Chinese medicinal formulae and Chinese patent medicine, while the other 30% were on dietary supplements and plant extracts. Facing the future, the "human experience" has attracted close attentions from researchers throughout the world. Effectively utilizing the historic "human experience" is an important method to vitalize potential of original scientific and technological resources of TCHM. Performing multi-center clinical trials with high qualities is still an essential method for TCHM in accessing the mainstream medicine market. In addition, it is also required to further improve the evaluation techniques and methods that not only meet the international standards but also meet the characteristics of TCHM. Furthermore, we should also focus on the TCHM specific clinical values and scientific reports.

Interactions between natural products and cancer treatments: underlying mechanisms and clinical importance

Natural products, also referred to as dietary supplements, complementary and alternative medicines, and health or food supplements are widely used by people living with cancer. These products are predominantly self-selected and taken concurrently with cancer treatments with the intention of improving quality of life, immune function and reducing cancer symptoms and treatment side effects. Concerns have been raised that concurrent use may lead to interactions resulting in adverse effects and unintended treatment outcomes. This review provides an overview of the mechanisms by which these interactions can occur and the current evidence about specific clinically important natural product-drug interactions. Clinical studies investigating pharmacokinetic interactions provide evidence that negative treatment outcomes may occur when Hypericum perforatum, Grapefruit, Schisandra sphenanthera, Curcuma longa or Hydrastis canadensis are taken concurrently with common cancer treatments. Conversely, pharmacodynamic interactions between Hangeshashinto (TJ-14) and some cancer treatments have been shown to reduce the side effects of diarrhoea and oral mucositis. In summary, research in this area is limited and requires further investigation.

Preparation and pharmaceutical properties of Hangeshashinto oral ointment and its safety and efficacy in Syrian hamsters with 5-fluorouracil-induced oral mucositis

Chemotherapy-induced oral mucositis (COM) is a common adverse effect of cancer chemotherapy. Several clinical studies reported that repetitive use of mouthwashes containing 2.5-6.25% Hangeshashinto (HST), a Kampo formula, relieves COM, but the effect is insufficient. To solve this problem, we produced an oral ointment of 12% HST extract (considered quantitatively equivalent to 20% commercially available HST), which will increase the local concentrations of its active ingredients and prolong the contact time with COM. In this study, we evaluated the pharmaceutical properties (spreadability and stability) of HST oral ointment. In addition, its safety (oral mucosal irritation) and therapeutic effects on 5-fluorouracil-induced oral mucositis were evaluated in male Syrian hamsters. The HST ointment showed good spreadability and stability for more than 8 weeks at 4 °C. In the oral mucosal irritation test, topical application of HST ointment (0.2 g) three times per day for 14 days had no adverse effect on the oral mucosa of hamsters. In hamsters treated with 5-fluorouracil (60 mg/kg) twice, COM was induced by a submucosal injection of 5% acetic acid into the cheek pouch. When HST ointment (50 µg) was topically applied to the mucositis area once per day for 12 days, the area and macroscopic score of mucositis were significantly decreased, and the depth of the wound tended to be reduced compared with the lactose ointment-treated control animals. These findings suggest that HST oral ointment shows good properties in spreadability, stability, and safety, and elicits a therapeutic effect in an animal model of COM.

Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline

PURPOSE

The aim of this joint guideline is to provide evidence-based recommendations to practicing physicians and other health care providers on integrative approaches to managing pain in patients with cancer.

METHODS

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included pain intensity, symptom relief, and adverse events. Expert panel members used this evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 227 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Among adult patients, acupuncture should be recommended for aromatase inhibitor-related joint pain. Acupuncture or reflexology or acupressure may be recommended for general cancer pain or musculoskeletal pain. Hypnosis may be recommended to patients who experience procedural pain. Massage may be recommended to patients experiencing pain during palliative or hospice care. These recommendations are based on an intermediate level of evidence, benefit outweighing risk, and with moderate strength of recommendation. The quality of evidence for other mind-body interventions or natural products for pain is either low or inconclusive. There is insufficient or inconclusive evidence to make recommendations for pediatric patients. More research is needed to better characterize the role of integrative medicine interventions in the care of patients with cancer.Additional information is available at https://integrativeonc.org/practice-guidelines/guidelines and www.asco.org/survivorship-guidelines.

The Japanese Herbal Medicine Hangeshashinto Induces Oral Keratinocyte Migration by Mediating the Expression of CXCL12 Through the Activation of Extracellular Signal-Regulated Kinase

Several clinical studies have reported that Japanese herbal medicine Hangeshashinto (HST) has beneficial effects on chemotherapy-induced oral ulcerative mucositis (OUM). Our previous research demonstrated that HST improves chemotherapy-induced OUM through human oral keratinocyte (HOK) migration, which was suppressed by mitogen-activated protein kinase (MAPK) and C-X-C chemokine receptor 4 (CXCR4) inhibitors. However, the association between these molecules and HOK migration was unclear. Here, we examined the effects of HST on the expression of CXCR4/CXCR7 and C-X-C motif chemokine ligands 11 and 12 (CXCL11/CXCL12) in HOKs. Our results indicated that HST upregulated CXCL12, but not CXCR4, CXCR7, nor CXCL11 in HOKs. HST-induced expression of CXCL12 was significantly suppressed by an inhibitor of extracellular signal-regulated kinase (ERK), but not of p38 and c-Jun N-terminal kinase (JNK). In addition, HST induced phosphorylation of ERK in HOKs. These findings suggest that HST enhances HOK migration by upregulating CXCL12 via ERK.

Development of Kampo（traditional Japanese medicine）e-learning program: evaluation of the flipped classroom for medical students

In May 2019, the World Health Assembly, in an unprecedented move, endorsed the inclusion of traditional medicine in the International Classification of Diseases, 11th Revision. In Japan, traditional medicine (known as Kampo) is regulated by the government and prescribed by over 90% of physicians along with modern medicine under the national health insurance system. Although Kampo education must be included in Japan's core medical curricula, there are significant challenges to implementation. In the educational context, the flipped classroom teaching method has received considerable attention in recent years. This study developed a Kampo e-learning program and verified the effectiveness of a flipped classroom using Kampo e-learning. The Kampo e-learning Committee determined three courses and assigned an administrator for each. The administrators appointed lecturers who developed Kampo e-learning lessons. Physicians, pharmacists, medical students, and pharmacy students were asked to participate in the e-learning program, and their comments and suggestions were collected after program completion. The flipped classroom was evaluated by implementing Kampo e-learning in the Kampo session with fourth-year students at Keio University School of Medicine in Japan. Seven courses were created, including four based on volunteer suggestions. The 'Systematic Kampo Curricula' featured 88 lessons developed by 54 Kampo specialists. Out of 118 fourth-year medical students who participated in the flipped classroom, 113 registered for the Kampo e-learning program, 100 attended the session, and 88 answered the post-session questionnaire. Among the students who answered the questionnaire, 86.4% were satisfied with the flipped classroom, 79.5% replied that the program made them understand Kampo and 80.7% stated that it should be adopted. The flipped classroom using Kampo e-learning program was shown to be attractive in one medical school. Further expanded study is necessary in the near future to reveal the usefulness of the flipped classroom of Kampo learning.

Roles of Kampo Medicine in Modern Cancer Therapy: Towards Completion of Standard Treatment

Kampo Medicine is a traditional Japanese medicine that is well-integrated in modern medicine. Anti-cancer agents are highly developed, and evidence of standard treatment has accumulated. Kampo Medicine is needed to support patients with cancer who lose vital energy and feel cold. Cancer chemotherapy is associated with various adverse reactions, such as anorexia, general malaise/fatigue, and peripheral neuropathy, which are refractory to modern therapy. Recently, evidence of Kampo Medicines for these symptoms has been reported as randomized controlled trials (RCTs). The Japan Society for Oriental Medicine celebrated the first 20 years of the activities of evidence-based medicine (EBM) committee in June 2021. Among the activities of the EBM committee, Evidence Reports of Kampo Treatment contains RCTs and meta-analyses, including RCTs on cancer supportive care. There is accumulating evidence for the following Kampo formula for each symptom: Hangeshashinto for mucositis, rikkunshito for anorexia, goshajinkigan and ninjin'yoeito for peripheral neuropathy, hochuekkito for general malaise/fatigue, and shakuyakukanzoto for myalgia/arthralgia. However, there is insufficient evidence, and further clinical trials are needed. Supportive care with Kampo Medicine will lead to a more complete standard treatment for cancer.

A Narrative Review about Nutritional Management and Prevention of Oral Mucositis in Haematology and Oncology Cancer Patients Undergoing Antineoplastic Treatments

Cancer is a prevalent disease worldwide, and treatments such as radiotherapy and chemotherapy sometimes lead to adverse events. Oral mucositis is one of the most disabling adverse events, and clinical guidelines do not take into account nutritional interventions. The primary endpoint was to gather the evidence about the efficacy of nutritional interventions in the prevention and/or treatment of antineoplastic-induced oral mucositis in oncological patients. A bibliographic review was carried out in the PubMed data base by combining MeSH terms with Boolean operators. Articles were selected based on inclusion and exclusion criteria; 50 final articles were found. Although further evidence is needed, glutamine, honey, and vitamins appear to be good therapeutic options. The rest of the compounds presented controversial or insufficient results, making it difficult to draw conclusions over their utilization as prevention or treatment options. Little evidence is reported about oral mucositis nutritional interventions in spite of them being attainable and affordable compounds. Scarce evidence is shown in paediatric patients compared with adults. Developing higher quality studies and combinations with the compounds researched is necessary for creating a stronger body of evidence.

Multiple stage IV colorectal cancers in a patient who received multidisciplinary treatment, including chemotherapy and Japanese Kampo medicine: A case report

FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan) plus bevacizumab is the preferred first-line treatment for right-sided metastatic colorectal cancer with RAS mutation. However, severe adverse events are common in Japanese patients. We report the successful management of multiple stage IV colorectal cancers in a patient who received multidisciplinary treatment, including chemotherapy and Japanese Kampo medicine. A 68-year-old man presented with epigastralgia and appetite loss and was diagnosed with multiple stage IV colorectal cancers. Colonoscopy identified type II tumors in the ascending colon, sigmoid colon, and upper rectum. Histopathological examination of a biopsy specimen revealed well- to moderately differentiated tubular adenocarcinoma. Enhanced computed tomography of the thorax and abdomen showed multiple pulmonary nodules and para-aortic lymph node swelling. Laparoscopic loop-ileostomy was performed to avoid bowel obstruction due to severe stenosis of ascending colon cancer. Intraoperative observation revealed two white nodules suggestive of metastasis in the lateral area of the liver. Therefore, we diagnosed multiple stage IV colorectal cancers with multiple metastases (lung, liver, and distant lymph nodes). His postoperative course was uneventful, and chemotherapy was started. Since the cancer cells harbored a RAS mutation, he received FOLFOXIRI plus bevacizumab. Japanese Kampo medicine consisting of Hangeshashinto and Juzen-taiho-to, to prevent diarrhea and fatigue, was administered daily. After 12 courses of chemotherapy, though circumferential stenosis still existed in the ascending colon, the tumors in the sigmoid colon and upper rectum were unclear. Enhanced computed tomography showed shrinkage of the pulmonary nodules and para-aortic lymph node; therefore, laparoscopic-assisted ileocecal resection was performed. The postoperative histopathological examination revealed moderately differentiated adenocarcinoma. The patient recovered uneventfully, and Kampo medicine consisting of Ninjin'yoeito was administered for postoperative weakness. Administration of adjuvant chemotherapy in this patient led to a near complete response that has been maintained without recurrence for 2 years and 8 months without reduced quality of life.

Hangeshashinto for preventing oral mucositis in patients receiving cancer treatment: protocol for a systematic review and meta-analysis

INTRODUCTION

Hangeshashinto has been employed for oral mucositis prevention in patients receiving cancer treatment, but the evidence has not been sufficiently robust to guide clinical decision-making. This study will therefore be undertaken to assess the effectiveness of Hangeshashinto for preventing oral mucositis in patients with cancer who are receiving treatment.

METHODS AND ANALYSIS

The databases will include PubMed, Embase, the Cochrane Library, Chinese databases and Japanese databases. The literature will be searched from the databases' inception until May 2021. Other sources, such as potential grey literature, reference lists from included studies and relevant systematic reviews and conference papers, will also be searched. The primary outcome is the incidence of mucositis of any severity, and the secondary outcomes are interruptions to cancer treatment, oral pain and nutritional status. The risk of bias of eligible studies will be assessed using the Cochrane Collaboration's 'risk of bias' tool. Both the Q test and I² statistic will be performed to assess statistical heterogeneity. If I² >50%, sensitivity and subgroup analysis will be conducted. The quality of evidence will be rated according to the Grading of Recommendations, Assessment, Development and Evaluation approach. Egger's test will be used to assess reporting bias.

ETHICS AND DISSEMINATION

This systematic review will evaluate only published data; therefore, ethical approval is not required.

PROSPERO REGISTRATION NUMBER

CRD42020216145.

Efficacy of Herbal Medicines Intervention for Colorectal Cancer Patients With Chemotherapy-Induced Gastrointestinal Toxicity - a Systematic Review and Meta-Analysis

Purpose: Chemotherapy-induced gastrointestinal (CIGI) toxicity affects the quality of life of patients with colorectal cancer (CRC) and the clinical application of treatment drugs. This review aims to evaluate the efficacy of traditional herbal medicines (HMs) in alleviating symptoms of CIGI toxicity (including nausea and vomiting, anorexia, diarrhea, constipation, oral mucositis, abdominal pain, and abdominal distension), and to explore further individual herb or herbal combinations in alleviating the CIGI toxicity.

Methods: Nine electronic databases were screened from 2010 to 2020. Twenty-two randomized controlled trials with a total of 1,995 patients evaluating the complementary efficacy of HMs with chemotherapy compared with chemotherapy-alone were included. Further, sensitivity analyses of orally administered multi-ingredient HM interventions were explored based on the composition of HM interventions.

Results: The meta-analysis showed that HM treatment combined with chemotherapy significantly alleviated the overall CIGI toxicity (RR = 0.78 [0.72, 0.84], p < 0.001, I² = 44%), nausea and vomiting (RR = 0.74 [0.66, 0.82], p < 0.001, I² = 35%), diarrhea (P = 0.02, RR = 0.64, 95% CI = 0.44–0.93, I² = 50%), oral mucositis (RR = 0.65 [0.48, 0.88], P = 0.005, I² = 24%), and abdominal distension (RR = 0.36 [0.18, 0.73], P = 0.004, I² = 0%). However, no statistically significant effects of HMs were shown in studies with a double-blind design for CIGI toxicity. Based on the ingredients of the HMs, further sensitivity analyses identified five herbs [Glycyrrhiza uralensis Fisch., Atractylodes macrocephala Koidz., Astragalus membranaceus (Fisch.) Bge., Codonopsis pilosula (Franch.) Nannf., and the pericarp of Citrus reticulata Blanco.] that were associated with significant reductions in CIGI toxicity.

Conclusion: A statistically significant effect of HMs combined with chemotherapy on alleviating the overall CIGI toxicity, nausea and vomiting, diarrhea, oral mucositis, or abdominal distension is only shown in studies without a double-blind design. Further well-designed, double-blinded, large-scaled randomized controlled trials (RCTs) are warranted to comprehensively evaluate the treatment efficacy. Further clinical research that includes the five herbs with chemotherapy for patients, the safety of the combinations of these herbs, and the potential synergistic effects of these combinations of herbs should be conducted.

Clinical applicability of natural products for prevention and treatment of oral mucositis: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis was carried out to verify evidence regarding the efficacy and safety of the clinical applicability of natural products in the prevention and treatment of oral mucositis induced by chemotherapy and/or radiotherapy.

METHODOLOGY

An electronic research according to the PICOS strategy, using the terms "natural products" and "oral mucositis," was carried out at Pubmed, Cochrane, Embase, and "gray literature." The stages of eligibility, data extraction, and quality assessment of the studies were carried out independently and in duplicate.

RESULTS

The number of studies identified as eligible was 151, including 47 randomized controlled trials, reporting a total of 3075 participants undergoing some therapy with natural products on oral mucositis. The included clinical trials covered a variety of 31 types of natural products. Considering the risk of bias of the clinical trials, 24 studies (51.1%) were considered to have a low overall risk of bias, nine (19.1%) were at moderate risk, and 14 clinical trials (29.8%) were at high risk of bias. Honey was the most assessed natural agent. Fourteen studies (3.4%) reported that natural agents reduced pain.

CONCLUSION

The results of the meta-analysis support a positive effect of honey and Aloe vera in reducing mucositis in patients receiving cancer therapy.

CLINICAL RELEVANCE

The results found add relevant information to the scientific community regarding the prevention and treatment of mucositis. Graphical abstract.

Weak acids induce PGE2 production in human oesophageal cells: novel mechanisms underlying GERD symptoms

The role of weak acids with pH values in the range of 4–7 has been implicated in the symptoms of gastroesophageal reflux disease (GERD). Prostaglandin E₂ (PGE₂) is associated with heartburn symptom in GERD patients; however, the precise productive mechanisms remain unclear. In this study, we revealed that exposure to weak acids increases PGE₂ production with a peak at pH 4–5, slightly in human normal oesophageal cells (Het-1A), and robustly in oesophageal squamous carcinoma cells (KYSE-270). Release of PGE₂ from the oesophageal mucosa was augmented by weak acid treatment in rat. Chenodeoxycholic acid (CDCA), a bile acid, upregulated cyclooxygenase-2 (COX-2) expression in Het-1A and KYSE-270 and induced PGE₂ production in KYSE-270 cells. Weak acid-induced PGE₂ production was significantly inhibited by cytosolic phospholipase A2 (cPLA2), ERK, and transient receptor potential cation channel subfamily V member 4 (TRPV4), a pH-sensing ion channel, inhibitors. Hangeshashinto, a potent inhibitor of COX-2, strongly decreased weak acid- and CDCA-induced PGE₂ levels in KYSE-270. These results indicated that weak acids induce PGE₂ production via TRPV4/ERK/cPLA2 in oesophageal epithelial cells, suggesting a role in GERD symptoms like heartburn. Interventions targeting pH values up to 5 may be necessary for the treatment of GERD.

How to transfer traditional knowledge about medicinal herbs? or TCM plants: a black box for modern oncologists

OBJECTIVE

How could we transfer knowledge about healing plants from other cultures? We analyzed the results of literature search in two exemplary fields-oral mucositis and polyneuropathy.

MATERIALS AND METHODS

In both systematic searches of existing literature, we found 57 studies investigating 68 plants from different traditional cultures (16 Western Medicine, 14 Persian Medicine, 9 Japanese, 10 Chinese, and 8 other sources). We analyzed studies regarding their ingredient plants and reproducibility in relation to the system of origin.

RESULTS

Western and Persian Medicine trials investigate single plants, whereas Japanese and Chinese trials focus on mixtures and decoctions. European folk medicine knows of only 50% of plants used in both Asian cultures. The used ingredients and dosages were reproducible in all analyzed trials except TCM studies.

CONCLUSIONS

Herbal knowledge has been transferred from all folk medicines worldwide. However, Western oncologists should be aware that Traditional Chinese Medicine herbs are still a black box of knowledge for us until today.

Plant Extracts as Possible Agents for Sequela of Cancer Therapies and Cachexia

Cancer is a leading cause of the death worldwide. Since the National Cancer Act in 1971, various cancer treatments were developed including chemotherapy, surgery, radiation therapy and so forth. However, sequela of such cancer therapies and cachexia are problem to the patients. The primary mechanism of cancer sequela and cachexia is closely related to reactive oxygen species (ROS) and inflammation. As antioxidant properties of numerous plant extracts have been widely reported, plant-derived drugs may have efficacy on managing the sequela and cachexia. In this study, recent seventy-four studies regarding plant extracts showing ability to manage the sequela and cachexia were reviewed. Some plant-derived antioxidants inhibited cancer proliferation and inflammation after surgery and others prevented chemotherapy-induced normal cell apoptosis. Also, there are plant extracts that suppressed radiation-induced oxidative stress and cell damage by elevation of glutathione (GSH), superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and regulation of B-cell lymphoma 2 (BcL-2) and Bcl-2-associated X protein (Bax). Cachexia was also alleviated by inhibition of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6) and monocyte chemoattractant protein-1 (MCP-1) by plant extracts. This review focuses on the potential of plant extracts as great therapeutic agents by controlling oxidative stress and inflammation.

The effect of Hangeshashinto on Oral Mucositis Caused by Induction Chemotherapy in Patients with Head and Neck Cancer

Background

Oral mucositis (OM) is a side effect of chemotherapy in head and neck cancer. Severe OM often has a large impact on quality of life. Therefore, the treatment of OM during chemotherapy is very important. It was recently reported that Hangeshashinto (TJ-14), a Japanese traditional medicine (Kampo), is effective for OM caused by fluorinated pyrimidine-based agents used in colon cancer. We investigated the efficacy of TJ-14 for OM.

Methods

We enrolled patients with head and neck cancer who were treated with induction chemotherapy between September 2014 and March 2016. In this double-blind trial, patients were randomly assigned to the TJ-14 group or placebo group. Patients were instructed to dissolve 2.5 g of TJ-14 or placebo in 100 ml of drinking water, rinse their mouths with the solution for 30 s and then spit it out. They were not allowed to eat anything for 30 minutes before or after using the mouthwash.

Results

The incidence of ≥ grade 2 OM was 37.5% (three patients) in the TJ-14 group and 50.0% (four patients) in the placebo group, with no significant difference between the two groups. The mean day of onset was 9.7 in the TJ-14 group and 6.7 in the placebo group. The mean duration of ≥ grade 2 OM was 1.3 days in the TJ-14 group and 3.7 days in the placebo group. Thus TJ-14 significantly reduced the duration of ≥ grade 2 OM.

Conclusion

Treatment of OM with TJ-14 was associated with a statistically significant reduction in the duration of ≥ grade 2 OM compared to placebo. Gargling with TJ-14 is a safe and effective method of administering the drug to patients with head and neck cancer.

The clinical effect of Kampo medicine in multimodal treatment for Gastrointestinal Cancer in Japan

Kampo medicine or Japanese/Chinese traditional herbal medicine has long been used for the treatment of various diseases, mainly in Asian countries. In recent years, Asian investigators have attempted to clarify the mechanism and clinical efficacy of Kampo medicine. This review summarizes the background, current status, and future perspectives of Kampo medicine in the multimodal treatment of gastrointestinal cancer. Regarding the clinical effect of Kampo medicine on postoperative dysfunction after gastrointestinal surgery, several investigators have reported that Daikenchuto (TJ-100) had clinical efficacy after abdominal digestive surgery. The administration of TJ-100 during the immediate postoperative period after esophageal cancer surgery, gastric cancer surgery, and liver cancer surgery appeared to promote early recovery of the postoperative bowel function. Regarding Kampo medicine for chemotherapy-induced adverse effects in gastrointestinal cancer, promising results have been obtained for Hangeshashinto (TJ-14) and Goshajinkigan (TJ-107). The addition of TJ-14 might be associated with an improvement in the duration of chemotherapy-induced oral mucositis, and the addition of TJ-107 might be associated with an improvement in oxaliplatin-induced peripheral neurotoxicity. However, while several clinical trials have shown the positive results of Kampo medication for gastrointestinal cancer treatment, the clinical effects of such medicines have been limited. Further trials to investigate the clinical benefits of Kampo medicine are needed.

Systematic review of natural and miscellaneous agents, for the management of oral mucositis in cancer patients and clinical practice guidelines - part 2: honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents

OBJECTIVE

To update the clinical practice guidelines for the management of oral mucositis (OM) that were developed by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). This part focuses on honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents.

METHODS

A systematic review was conducted by the Mucositis Study Group of MASCC/ISOO. The body of evidence for each intervention, in each clinical setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, one of the following guidelines were determined: Recommendation, Suggestion, No Guideline Possible.

RESULTS

A total of 78 papers were identified within the scope of this section, of which 49 were included in this review and merged with nine publications that were reported in the previous guidelines update. A new Suggestion was made for honey (combined topical and systemic delivery) for the prevention of OM in head and neck cancer patients receiving radiotherapy with or without chemotherapy. A new Suggestion clarified that chewing gum is not effective for the prevention of OM in pediatric patients with hematological or solid cancer treated with chemotherapy. No guideline was possible for other interventions.

CONCLUSIONS

Numerous natural products and herbal remedies were studied for the management of OM. Of the agents reviewed in this systematic review, a guideline in favor was made for honey (combined topical and systemic), while a guideline against was made for chewing gum. Additional research is warranted to clarify the potential of other interventions.

Effects of Topical Hangeshashinto (TJ-14) on Chemotherapy-Induced Oral Mucositis

Purpose

Hangeshashinto (TJ-14), a Kampo medicine comprising seven types of herbs, has been used in Japan to alleviate the side effects associated with anticancer drug treatments. However, the pharmacological effects of this medicine currently remain unclear. The present study aimed to demonstrate the efficacy of TJ-14 against anticancer drug-induced stomatitis, the pain associated with which may have a negative impact on mastication and swallowing.

Methods

Mucositis was induced in Sprague-Dawley rats by cancer chemotherapy. Changes in body weight, stomatitis grades, histopathological scores, and oral bacterial counts were examined among TJ-14-treated, saline-treated, and Control (no treatment) rats. In vitro studies, including cell proliferation and wound healing assays, using epidermal keratinocyte and fibroblast cell lines were conducted.

Results

The local application of TJ-14 exerted strong antibacterial effects and attenuated oral chemotherapy-induced stomatitis in rats. TJ-14 also increased the viability and invasion of epidermal keratinocytes and fibroblasts.

Conclusion

The present results demonstrated the potential of TJ-14 to attenuate chemotherapy-induced stomatitis.

How to bridge the gap? European medical plants used for treating oral mucositis: on the search for evidence

PURPOSE

Oral mucositis is a common, painful side effect of cancer treatment-be it locoregional (e.g. irradiation) or systemic (e. g. chemotherapy). Phytotherapy is often used by patients to alleviate symptoms. However, knowledge on which medical plants are recommended by literature about Traditional European Medicine (TEM), their effect(s) on symptoms and their efficacy is severely lacking. Therefore, we developed a novel approach to assess traditional knowledge of herbals used in TEM and searched the online databases for studies reporting effects of these plants.

METHODS

At first, online research did not yield a satisfying number of studies (MESH terms: "mucositis" OR "stomatitis" AND "herbal" OR "herbal medicine"). Trials were labelled by the country conducting the study. In parallel, we compiled a list of 78 plants recommended for treating oral mucositis by screening 14 books on TEM. Then, a "hit list" of the plants most often mentioned was composed and used further for a second online investigation using the Latin plant designations as MESH term. Studies of both online searches were pooled for analysis.

RESULTS

There is a gap between traditional knowledge and trials investigating medical plants used by TEM. Overall, herbal remedies alleviate oral mucositis and especially, gingivitis well. There is good evidence for using Matricaria recutita L., Salvia officinalis L., Calendula officinalis L. and Thymus spp. L. for treating oral mucositis.

CONCLUSION

Clinical trials investigating medical plants known in TEM are rare. However, following our research strategy, we could extrapolate four plants with good evidence for alleviating symptoms of oral mucositis and gingivitis.

The Japanese herbal medicine Hangeshashinto enhances oral keratinocyte migration to facilitate healing of chemotherapy-induced oral ulcerative mucositis

Chemotherapy often induces oral ulcerative mucositis (OUM) in patients with cancer, characterized by severe painful inflammation. Mouth-washing with the Japanese herbal medicine hangeshashinto (HST) ameliorates chemotherapy-induced OUM in patients with colorectal cancer. Previously, we demonstrated that HST decreased interleukin 1β-induced prostaglandin E2 production in human oral keratinocytes (HOKs) and OUM-induced mechanical or spontaneous pain in rats. However, HST effects on tissue repair functions in HOKs remain unclear. Here, we examined the effects of HST on scratch-induced wound healing in vitro and in vivo. In vitro, HST enhanced wound healing mainly through scratch-induced HOK migration. Screening of the seven constituent medicinal herbs and their major components revealed that Scutellaria root, processed ginger, and Glycyrrhiza components mainly induced the scratch-induced HOK migration. Pharmacokinetic analyses indicated that the active ingredient concentrations in rat plasma following oral HST administration were below the effective doses for HOK migration, suggesting direct effects of HST in OUM. Mitogen-activated protein kinase and C-X-C chemokine receptor 4 inhibitors significantly suppressed HST-induced HOK migration. Moreover, HST enhanced tissue repair in our OUM rat model. Thus, HST likely enhanced OUM tissue repair through oral keratinocyte migration upon MAPK and CXCR4 activation and may be useful in patients with cancer-associated OUM.

Efficacy and safety of hangeshashinto for treatment of GERD refractory to proton pump inhibitors : Usual dose proton pump inhibitors plus hangeshashinto versus double-dose proton pump inhibitors: randomized, multicenter open label exploratory study

BACKGROUND

Proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) leads to a clinical decline in the quality of life (QOL). Therefore, new treatment options are needed. We performed a multicenter, randomized, parallel-group exploratory trial to determine the efficacy of hangeshashinto (HST) in patients with PPI-refractory GERD.

METHODS

We enrolled 78 patients with PPI-refractory GERD for standard PPI regimens for at least 4 weeks and randomly assigned patients to receive either a combination of usual dose of rabeprazole (10 mg/day) + HST (7.5 g/day; HST group) or a double dose of rabeprazole (20 mg/day; double-dose PPI group). The primary end points were the extent of improvement in FSSG (Frequency Scale for the Symptoms of GERD) score and the change over time in FSSG score.

RESULTS

There was no significant difference in terms of the improvement degree of the FSSG score between the two groups. Although the total FSSG score and reflux syndrome score decreased significantly for both groups over time (p < 0.001), the acid-related dyspepsia (ARD) score decreased significantly in the HST group from 1 week after drug administration (p < 0.05), indicating an improvement in the condition earlier than in the double-dose PPI group. Moreover, in examinations concerning BMI and age, the HST group had a significantly higher improvement degree of ARD score in patients with BMI < 22 (p < 0.05) and aged < 65 years (p < 0.05) than the double-dose PPI group.

CONCLUSIONS

HST may be beneficial for patients with PPI-refractory GERD, particularly in non-obese and non-elderly patients with dyspepsia symptoms.

Kampo (Traditional Japanese Herbal) Formulae for Treatment of Stomatitis and Oral Mucositis

Stomatitis is occasionally multiple, recurrent, and refractory. Currently, mucositis induced by chemotherapy and radiation therapy in patients with cancer has become a significant clinical problem. Effective treatments have not been established and the treatment of numerous cases remains a challenge for physicians. Traditional Japanese herbal medicines termed Kampo formulae (i.e., Hangeshashinto, Orengedokuto, Inchinkoto, Orento, Byakkokaninjinto, Juzentaihoto, Hochuekkito, and Shosaikoto) are used for treating various types of stomatitis and mucositis. Its use has been based on the Kampo medical theories—empirical rules established over thousands of years. However, recently, clinical and basic research studies investigating these formulae have been conducted to obtain scientific evidence. Clinical studies investigating efficacies of Shosaikoto and Orento for the treatment of cryptogenic stomatitis and acute aphthous stomatitis and those investigating the effects of Hangeshashinto, Orengedokuto, and Juzentaihoto on chemotherapy- or radiotherapy-induced mucositis have been conducted. The Kampo formulae comprise several crude drugs, whose mechanisms of action are gradually being clarified. Most of these drugs that are used for the treatment of stomatitis possess anti-inflammatory, analgesic, and antioxidative properties. In this review, we introduce the clinical applications and summarize the available evidence on the Kampo formulae for the treatment of stomatitis and oral mucositis.

Chinese Herbal Medicines Facilitate the Control of Chemotherapy-Induced Side Effects in Colorectal Cancer: Progress and Perspective

Side effects, including nausea, vomiting, mucositis, peripheral neuropathy, and diarrhea, have been frequently reported in colorectal cancer (CRC) patients undergoing chemotherapy. Chinese Herbal Medicines (CHMs) display distinct clinical outcomes, as a result, they have been increasingly used as an adjuvant therapy to manage chemotherapy-induced side effects. In this review, we aim to intensively explore the molecular mechanisms of CHMs, underline the significance of CHMs in mitigating the side effects induced by chemotherapy, and examine the necessary studies required to understand the role of CHMs in alleviating chemotherapy-induced side effects. Specifically, ginger, Astragali Radix, and Liujunzi Decoction have been verified to ameliorate nausea and vomiting. Banxia Xiexin Decoction and Huangqin Decoction have been confirmed to be beneficial to mucositis and delayed-onset of diarrhea. Moreover, Niuche Shenqi Wan, Guilong Tongluo Decoction, Huangqi Guizhi Wuwu Decoction, and tumeric have been found to display potential therapeutic effects for preventing the genesis and development of peripheral neurotoxicity. These findings have further emphasized the pivotal role of CHMs in improving the outcomes of chemotherapy-induced side effects in CRC. Nonetheless, more molecular evidence is required to comprehensively understand and more appropriately apply CHMs in routine clinical practice for CRC.

Multi-Component Herbal Products in the Prevention and Treatment of Chemotherapy-Associated Toxicity and Side Effects: A Review on Experimental and Clinical Evidences

Chemotherapy is nowadays the main treatment of human cancers. Chemotherapeutic agents target rapidly dividing cancer cells to suppress tumor progression, however, their non-specific cytotoxicity often leads to significant side effects that might be intolerable to cancer patients. Multi-component herbal products have been used for thousands of years for the treatment of multiple human diseases. This study aims to systematically summarize and evaluate the experimental and clinical evidences of the efficacy of multi-component herbal products in improving chemotherapy-induced side effect. Literature was retrieved from PubMed database and evaluated based on the side effects described. Multi-component herbal products were found to be effective in ameliorating the neurotoxicity, gastrointestinal toxicity, hematological toxicity, cardiotoxicity, hepatotoxicity and nephrotoxicity. Both experimental and clinical evidences were found, indicating the potential of applying multicomponent herbal products in the clinical treatment of chemotherapy-induced side effects. However, the lack of mechanistic and pharmacokinetic studies, inconsistency in product quality, as well as insufficient clinical evidence suggested that more investigations are urgently necessary. In all, our review shed light on the potential of using multi-component herbal products in the clinical management of chemotherapy-induced toxicity and side effects. We also discussed the potential threats of natural products for cancer treatment and compared the advantages of using herbs to conventional chemical drugs.

Clinical effects of high frequency hyperthermia-assisted irinotecan chemotherapy on patients with middle and advanced colorectal cancer and its safety assessment

Clinical effects of high frequency hyperthermia-assisted irinotecan chemotherapy on patients with middle and advanced colorectal cancer and its safety assessment were investigated. A retrospective analysis was performed on the medical records of 103 patients with middle and advanced colorectal cancer treated in Cancer Center of Guangzhou Medical University from May 2011 to June 2015, including 48 patients receiving irinotecan plus conventional treatment (irinotecan group) and 55 patients receiving high frequency hyperthermia-assisted irinotecan plus conventional treatment (combination group). The treatment effects, severity and incidence of adverse reactions, quality of life and 3-year survival rates of patients were analyzed and compared between the two groups. After 4 courses of treatment, there were statistically significant differences in the proportions of patients with partial remission and objective remission, with those in combination group higher than those in irinotecan group (both P<0.05). After 4 courses of treatment, no patient died. After 4 courses of treatment, those that increased in different degrees (all P<0.05), compared with those in combination group were significantly higher than those in irinotecan group (all P<0.05). The 1-, 2- and 3-year survival rates of patients in irinotecan group were 31.25% (15 cases), 22.92% (11 cases) and 12.50% (6 cases), respectively. Those in combination group were 58.18% (32 cases), 29.09% (16 cases) and 16.36% (9 cases), respectively. The results of K-M survival curve analysis showed that there was no statistically significant difference in survival rate between the two groups of patients (P=0.050). High frequency hyperthermia-assisted chemotherapy for patients with middle and advanced colorectal cancer can effectively improve its treatment effects and patients' quality of life, with better treatment safety, worthy of clinical promotion.

Natural agents in the management of oral mucositis in cancer patients-systematic review

INTRODUCTION

Oral mucositis is most severe complication of cancer therapy characterized by ulcerative lesions of oral mucosa causing negative impact on patient's quality of life. Wide variety of therapeutic agents are available to reduce the lesions of mucositis. Currently, natural herbal remedies have become popular in treating this condition due to fewer side effects than synthetic drugs.

AIM

The aim of this systematic review is to compile evidence based studies to evaluate the effectiveness of natural agents in the management of oral mucositis induced by chemotherapy or radiotherapy in cancer patients.

MATERIALS AND METHOD

Computerized literature searches were performed to identify all published articles in the subject. The following databases were used: PUBMED [MEDLINE], SCOPUS, COCHRANE DATABASE, EMBASE and SCIENCE DIRECT using specific keywords. The search was for limited articles published in English which were read in full by two authors.

RESULTS

Twenty six randomized controlled trials satisfied our inclusion criteria. Most studies showed statistically significant result demonstrating the efficacy of natural agents with minimal side effects except manuka honey which was not tolerated by few patients.

CONCLUSION

Natural agents proved to be promising in healing cancer induced oral mucositis but future demands further randomized controlled clinical trials on these agents which should also be focused on drug interactions of the natural remedies.

Prevention of the Chemotherapy-Induced Oral Mucositis in Esophageal Cancer by Use of Hangeshashinto (TJ-14)

Objective:

Oral mucositis and diarrhea are adverse effects (AEs) of chemotherapy and chemoradiotherapy (CR/CRT) that commonly occur in patients of esophageal cancer (EC). We investigated whether Hangeshashinto (TJ-14)—a Japanese traditional medicine—could control oral mucositis, pain, incidence of esophagitis, and diarrhea in patients who underwent CT/CRT for EC.

Methods:

We enrolled 39 patients (36 men, 3 women) who underwent docetaxel- or cisplatin-based CT/CRT for EC between July 2012 and June 2014, of whom 19 used TJ-14 dissolved in water as an oral rinse 3 times a day over the first 2 courses of their treatment, and 20 (the control group) received no particular prophylaxis against mucositis. Their AEs, including mucositis, were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.

Results:

Although incidences of oral mucositis, appetite loss, nausea, constipation, and vomiting did not significantly differ between the TJ-14 group and controls, diarrhea incidence was significantly lower in the TJ-14 group by the second treatment course (P = 0.0261 by per protocol set analyses).

Conclusions:

TJ-14 significantly decreases diarrhea caused by CT/CRT in patients treated for EC, although TJ-14 cannot prevent of causing oral mucositis.

Use of a Caco-2 permeability assay to evaluate the effects of several Kampo medicines on the drug transporter P-glycoprotein

In modern medical care in which Kampo and Western drugs are often combined, it is extremely important to clarify drug–drug interaction (DDI) to ensure safety and efficacy. However, there is little evidence of DDI in Kampo medicines. Therefore, as part of our studies to clarify the DDI risk for Kampo medicines, we evaluated the effects of five Kampo medicines [yokukansan (YKS), rikkunshito (RKT), shakuyakukanzoto (SKT), hangeshashinto (HST), and goshajinkigan (GJG)] that are widely used in Japan, on drug transporter P-glycoprotein (P-gp) using a Caco-2 permeability assay. These Kampo medicines inhibited the P-gp transport of digoxin through a Caco-2 cell monolayer. The IC₅₀ values were 1.94–10.80 mg/ml. Of the five Kampo medicines, YKS showed the strongest inhibition (IC₅₀ = 1.94 mg/ml), which was attributed to Uncariae Uncis Cum Ramulus. Unfortunately, we could not find the active ingredients responsible for its action. Finally, the I_gut/IC₅₀ values for the five Kampo medicines were calculated, and the DDI risk was objectively evaluated according to the criteria in the DDI guidance issued by the Japanese Ministry of Health, Labor, and Welfare and the US Food and Drug Administration. The I_gut/IC₅₀ values for the five Kampo medicines were ≤3.4. As these values were <10, they were evaluated as having a weak P-gp inhibitory effect that does not require further verification in humans, suggesting that the DDI risk due to P-gp inhibition for these Kampo medicines is low. The results should provide useful clinical information on the safety and efficacy of the combined use of Kampo and Western medicines.

The clinical impact of Hangeshashinto (TJ-14) in the treatment of chemotherapy-induced oral mucositis in gastric cancer and colorectal cancer: Analyses of pooled data from two phase II randomized clinical trials (HANGESHA-G and HANGESHA-C)

Background: The current pooled analysis evaluated the efficacy of Hangeshashinto (TJ-14) in the prevention and/or treatment of chemotherapy-induced oral mucositis (COM) in gastric cancer and colorectal cancer using two prospective, multi-institutional, randomized, double-blind, placebo-controlled phase II trials.

Patients and Methods: HANGESHA-G and HANGESHA-C randomly assigned patients with gastric cancer or colorectal cancer who developed moderate to severe COM (grade ≥1) during any cycle of chemotherapy to receive either TJ-14 or a placebo as a double-blind trial. The patients received a placebo or TJ-14 for four to six weeks, according to the chemotherapy regimen, from the start of their next course of chemotherapy. The primary endpoint was the incidence of grade ≥2 COM in the protocol treatment course, and the secondary endpoints were the time to disappearance of COM and the incidence of adverse events.

Results: The pooled population included 181 patients. The incidence of grade ≥2 COM in the TJ-14 group was 55.7% (49 patients), while that in the placebo group was 53.8% (50 patients); there was no significant difference between the two groups (p=0.796). The median time to remission of grade ≥2 COM to grade <1 was 8 days in the TJ-14 group and 15 days in the placebo group (p= 0.072). The hazard ratio was 1.54 [1.02 to 2.31] in favor of TJ-14. Treatment with TJ-14 was associated with marginally significant reduction in the duration of severe grade ≥2 COM in comparison to patients receiving placebo indicating the effect of TJ-14 in reducing the severity of COM.

Conclusion: The present-pooled analysis showed that TJ-14 had a treatment effect in gastric cancer and colorectal cancer patients with COM in comparison to a placebo. Further phase III studies with a larger sample size are needed to clarify the protective effects of TJ-14 against COM.

Preventive effect of oral hangeshashinto (TJ-14) on the development of reflux-induced esophageal cancer

BACKGROUND

Prostaglandin E2 is one of the potential products that promotes development of tumors and also is a strong inducer of M2 phenotype macrophages, which contribute to tumor development in the immunosuppressed microenvironment. Hangeshashinto (TJ-14), a Japanese traditional medicine (Kampo medicine), has been reported to be effective in preventing chemotherapy-induced oral mucositis through the reduction of prostaglandin E2. We previously developed a surgical rat reflux model of esophageal cancer and used this well-established animal model to investigate the action of TJ-14 in preventing esophageal cancer. We also assessed the effect of TJ-14 on the downregulation of prostaglandin E2 production, utilizing esophageal squamous cell carcinoma cell line exposed to bile acid.

METHODS

An end-to-side esophagojejunostomy was performed for the reflux model. A daily oral diet was subsequently administered, consisting of either diet-incorporated TJ-14 or standard diet as a control group. The rats were killed at 40 weeks after surgery. The incidence of esophageal cancer, Barrett's metaplasia, and proliferative hyperplasia were assessed histologically. CD163, a M2 phenotype macrophage marker, was assessed with immunohistochemistry. Prostaglandin E2 enzyme immunoassay and lactate dehydrogenase assay were performed on chenodeoxycholic acid or gastroesophageal reflux contents exposed to esophageal squamous cell carcinoma cell line.

RESULTS

Sixty-seven percent of the controls (n = 12) developed esophageal cancer, but animals that received TJ-14 (n = 10) had a cancer incidence of 10% (P=.007). Barrett's metaplasia was found in 83% of the rats in the control group and 50% of the rats in the TJ-14 indicating a protective tendency of TJ-14 (P=.095). All of the rats developed proliferative hyperplasia. The number of M2 phenotype macrophage were significantly decreased in the TJ-14 group compared to the control group in both Barrett's metaplasia and esophageal cancer lesions. TJ-14 inhibited chenodeoxycholic acid or gastroesophageal reflux content-induced prostaglandin E2 production in esophageal squamous cell carcinoma cell.

CONCLUSION

TJ-14 reduced the incidence of reflux-induced esophageal cancer and the infiltration of M2 macrophages in a surgical rat model or suppressed prostaglandin E2 production in esophageal squamous cell carcinoma cell. Further investigation is required regarding the potential clinical use of TJ-14 as an esophageal cancer chemopreventive agent.

The Use of Oral Herbal Medicine (Hange-Shashin-To) in Patients with Pouchitis: A Pilot Study

OBJECTIVES

Hange-Shashin-To (HST), which is a combination of seven herbs, has previously been used in the treatment of inflammatory or ulcerative gut disease. The aim of this study was to evaluate the safety and efficacy of HST for the treatment of chronic pouchitis.

METHODS

Nineteen patients with chronic pouchitis, defined as either frequent episodes (≥ three episodes per six months) of pouchitis or persistent symptoms that required continuous antibiotic therapies, were selected and treated with ciprofloxacin (CPFX) 600 mg/day for 2 weeks (week 0~2) and HST 3,750 mg/day for 32 weeks (week 0~32). The Pouchitis Disease Activity Index (PDAI) score was measured at week 0 and 6 for short-term evaluation. For long-term evaluation, total CPFX dose in the 26-week period prior to study entry (from 30 weeks before study entry to 5 weeks before study entry) was compared with the total CPFX dose during the 26-week study period (week 7~32). Although no concomitant administration of CPFX was permitted from week 2-6, patients whose condition deteriorated were prescribed CPFX from week 7 to week 32.

RESULTS

Fourteen patients completed this 32-week study. The PDAI scores of eight patients decreased below seven. The mean total PDAI scores decreased significantly from 11 ± 2.5 to 6.5 ± 2.5 (P < 0.001). The mean value of total CPFX dose decreased significantly from 491.6 ± 182.4 mg/kg to 392.5 ± 184.0 mg/kg (P < 0.05). No severe adverse events were noted.

CONCLUSIONS

Our data suggest that HST has a positive effect on chronic pouchitis with no adverse effects.

Effects of Banxia Xiexin Decoction () on Cisplatin-Induced Apoptosis of Human A549 Lung Cancer Cells

OBJECTIVE

To examinie the synergistic effects of Banxia Xiexin Decoction (, Known as Banhasasim-tang in Korean) extract (BXDE) on cisplatin-induced cytotoxicity in the A549 human lung cancer cell lines.

METHODS

A549 cells were treated with varying concentrations (50-200 μg/mL) of cisplatin and BXDE alone or in combination for 96 h. We used 1-(4,5-dimethylthiazol-2-yl)-3,5-diphenylformazan assay and flow cytometry to analyze cell viability and apoptosis, respectively.

RESULTS

The exposure of cells to cisplatin and BXDE alone or in combination decreased cell viability dose- and time-dependently (P<0.05), which was found to be mediated by the apoptotic pathway as confirmed by the increase in the annexin V⁺/propidium iodide- stained cell population and a ladder pattern of discontinuous DNA fragments. Furthermore, the apoptosis was inhibited by the pan-caspase inhibitor, benzyloxycarbonyl-Val-Ala-Asp (OMe) fluoromethylketone (z-VAD-FMK).

CONCLUSIONS

BXDE significantly potentiated apoptotic effects of cisplatin in A549 cells. Moreover, apoptosis induced by BXDE might be the pivotal mechanism mediating its chemopreventative action against cancer.

Antitumor Activity of the Chinese Medicine JC-001 Is Mediated by Immunomodulation in a Murine Model of Hepatocellular Carcinoma

JC-001 is a Chinese medicine that has been used to treat liver disease; however, its significance in cancer treatment has not been characterized. In this study, we used an immunocompetent tumor model to characterize the antitumor activity of JC-001. A total of 48 Hepa 1-6 tumor-bearing C57BL/6 mice were randomly grouped into 4 groups and treated with H2O or JC-001 via oral administration. After hepatoma cell lines, including HepG2, Hep3B, SK-Hep-1, and Hepa 1-6, underwent 96 hours of JC-001 treatment, a low cytotoxic effect was observed. In contrast, no direct cytotoxic effect of JC-001 on a normal human liver cell line, THLE-3, was observed under the same incubation conditions. Using a murine tumor model, we found that tumor growth could be inhibited by JC-001 in C57BL/6 mice but not in immunodeficient mice. Histopathological analysis of tumors from C57BL/6 mice revealed immune cell infiltration in tumors from the JC-001-treated group, as observed by hematoxylin and eosin staining; in addition, Ki67, hypoxia-inducible factor-1-α, and high mobility group box 1 expression levels were suppressed in the tumors. Both the coculture assay and murine spleen mRNA quantitative PCR analyses demonstrated that JC-001 could suppress Th17 immunity. Our data suggest that JC-001 is a Chinese medicine with low cytotoxicity that can significantly suppress tumor growth by immune regulation. This herbal remedy has great potential for future clinical application in hepatoma therapy.

Management of afatinib-induced stomatitis

Severe stomatitis may lead to the need to interrupt or discontinue cancer therapy and, thus, may affect control of the primary disease. Stomatitis may also increase the risk of local and systemic infection and significantly affects the quality of life and the cost of care. The present study was conducted to evaluate the efficacy of two traditional herbal medicines in controlling treatment-induced stomatitis in a small cohort of lung cancer patients treated with afatinib. All patients who were treated with afatinib for epidermal growth factor receptor (EGFR) mutated nonsmallcell lung cancer (NSCLC) between January, 2015 and March, 2016, were included in this study. During the study period, a total of 14 NSCLC patients were treated with afatinib, an EGFR-tyrosine kinase inhibitor (TKI). Two patients already had stomatitis at the time of initiation of afatinib therapy; among the remaining 12 NSCLC patients, 2 (16.7%) developed stomatitis. All the lesions in the 4 patients who developed stomatitis were completely alleviated after 2 weeks of therapy with Aznol mouthwash, a chamomile extract with anti-inflammatory effects, and Hangeshashinto, a traditional herbal (Kampo) medicine. Afatinib therapy was re-initiated, but none of the patients developed stomatitis thereafter. To the best of our knowledge, this is the first report evaluating oral care and management of stomatitis. This type of care and treatment may reduce the incidence of complications associated with EGFR-TKI therapy.

[6]-gingerol and [6]-shogaol, active ingredients of the traditional Japanese medicine hangeshashinto, relief oral ulcerative mucositis-induced pain via action on Na+ channels

The traditional Japanese herbal medicine hangeshashinto (HST) has beneficial effects for the treatment of oral ulcerative mucositis (OUM) in cancer patients. However, the ingredient-based mechanism that underlies its pain-relieving activity remains unknown. In the present study, to clarify the analgesic mechanism of HST on OUM-induced pain, we investigated putative HST ingredients showing antagonistic effects on Na⁺ channels in vitro and in vivo. A screen of 21 major ingredients using automated patch-clamp recordings in channel-expressing cells showed that [6]-gingerol and [6]-shogaol, two components of a Processed Ginger extract, considerably inhibited voltage-activated Na⁺ currents. These two ingredients inhibited the stimulant-induced release of substance P and action potential generation in cultured rat sensory neurons. A submucosal injection of a mixture of [6]-gingerol and [6]-shogaol increased the mechanical withdrawal threshold in healthy rats. In a rat OUM model, OUM-induced mechanical pain was alleviated 30min after the swab application of HST despite the absence of anti-bacterial and anti-inflammatory actions in the OUM area. A swab application of a mixture of [6]-gingerol and [6]-shogaol induced sufficient analgesia of OUM-induced mechanical or spontaneous pain when co-applied with a Ginseng extract containing abundant saponin. The Ginseng extract demonstrated an acceleration of substance permeability into the oral ulcer tissue without an analgesic effect. These findings suggest that Na⁺ channel blockage by gingerol/shogaol plays an essential role in HST-associated analgesia of OUM-induced pain. This pharmacological mechanism provides scientific evidence supporting the use of this herbal medicine in patients suffering from OUM-induced pain.

Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments

Gastrointestinal (GI) side-effects of chemotherapy are a debilitating and often overlooked clinical hurdle in cancer management. Chemotherapy-induced constipation (CIC) and Diarrhea (CID) present a constant challenge in the efficient and tolerable treatment of cancer and are amongst the primary contributors to dose reductions, delays and cessation of treatment. Although prevalence of CIC is hard to estimate, it is believed to affect approximately 16% of cancer patients, whilst incidence of CID has been estimated to be as high as 80%. Despite this, the underlying mechanisms of both CID and CIC remain unclear, but are believed to result from a combination of intersecting mechanisms including inflammation, secretory dysfunctions, GI dysmotility and alterations in GI innervation. Current treatments for CIC and CID aim to reduce the severity of symptoms rather than combating the pathophysiological mechanisms of dysfunction, and often result in worsening of already chronic GI symptoms or trigger the onset of a plethora of other side-effects including respiratory depression, uneven heartbeat, seizures, and neurotoxicity. Emerging treatments including those targeting the enteric nervous system present promising avenues to alleviate CID and CIC. Identification of potential targets for novel therapies to alleviate chemotherapy-induced toxicity is essential to improve clinical outcomes and quality of life amongst cancer sufferers.

The traditional Japanese medicine hangeshashinto alleviates oral ulcer-induced pain in a rat model

OBJECTIVE

Recent studies have demonstrated that mouthwash made with the traditional Japanese medicine hangeshashinto exhibits anti-inflammatory action and alleviates oral mucositis scores, including pain complaints, in patients undergoing chemoradiotherapy. However, no study has demonstrated the mechanism underlying how hangeshashinto provides pain relief in oral ulcers.

DESIGN

The analgesic effects on pain-related behaviors following the topical application of hangeshashinto were evaluated in an oral ulcer rat model treated with acetic acid using recently developed methods. Indomethacin, the representative anti-inflammatory agent, was intraperitoneally administered. The tissue permeability of the oral mucosa was histologically evaluated after applying the fluorescent substance FluoroGold.

RESULTS

The topical application of hangeshashinto in ulcerative oral mucosa suppressed mechanical pain hypersensitivity over 60 min, without any effects on healthy mucosa. The same drug application also inhibited oral ulcer-induced spontaneous pain. Indomethacin administration failed to block the mechanical pain hypersensitivity, though it did largely block spontaneous pain. Topical anesthesia with lidocaine showed hyposensitivity to mechanical stimulation in healthy mucosa. In the ulcer regions in which the oral epithelial barrier was destroyed, deep parenchyma was stained with FluoroGold, in contrast to healthy oral mucosa, in which staining was limiting to the superficial site.

CONCLUSIONS

Hangeshashinto leads to long-lasting analgesic effects, specifically in the ulcer region by destroying the epithelial barrier. Hangeshashinto alleviates oral ulcer-induced pain in inflammation-dependent and/or independent manner.

Comprehensive Assessment of Host Responses to 5-Fluorouracil-Induced Oral Mucositis through Transcriptomic Analysis

Background

Chemotherapy plays an important role in current cancer therapy; however, several problems remain unsolved on the issue of host-therapeutics interaction. The purpose of this study was to investigate the host responses after 5-flurouracil (5-FU) administration and to find the target genes and their relationship with other cytokines in the 5-FU-induced oral mucositis (OM) mouse model through transcriptomic analysis.

Materials and Methods

Thirty-six 6 to 8 week-old male BALB/c mice were randomly divided into the control group and 5-FU-treated group. In the 5-FU group, mice received 5-FU (100 mg/kg, intraperitoneally) on day 1, day 8, day 15, day 22, and day 29, respectively. We evaluated the oral mucosal change under macroanalysis and histological examination at indicated periods, and then applied transcriptomic analysis of gene expression profile and Immunohistochemical stain to identify the target molecules related to 5-FU-induced OM.

Results

The most prominent histological change in this model was observed in the fifth week. The gene expression of Bone gamma-carboxyglutamate protein, related sequence 1 (Bglap-rs1) (–12.69-fold) and Chitinase 3-like 4 (Chi3l4) (–6.35-fold) were significantly down-regulated in this phase. The quantitative real-time PCR results also revealed the expression levels were 0.62-fold in Bglap-rs1 and 0.13-fold in Chi3l4 compared with the control group. Immunohistochemical stain showed significant expression of cluster of differentiation 11b (p<0.01), interleukin-1β (p<0.001) and tumor necrosis factor-α (p<0.05), and down-regulation of Bglap-rs1 (p<0.01) compared with the control group. By Kyoto Encyclopedia of Genes and Genomes pathway analysis, there were twenty-three pathways significantly participated in this study (p<0.05).

Conclusions

Through comprehensively transcriptomic analysis and IHC stain, we discovered several valuable pathways, verified the main pro-inflammatory cytokines, and revealed two significantly down-regulated genes in the 5-FU-induced OM model. These findings highlighted the way of seeking effective therapeutic agents for chemotherapy-induced OM in future.

Herbal medicines for the treatment of cancer chemotherapy-induced side effects

Accumulating evidence suggests that Japanese herbal medicines, called Kampo, have beneficial effects on cancer chemotherapy-induced side effects. Rikkunshito ameliorates cisplatin-induced anorexia through an antagonistic effect on the 5-HT receptors and by increasing the serum ghrelin levels. Hangeshashinto improves irinotecan-induced diarrhea and chemotherapy-induced mucositis by inhibiting the activity of β-glucuronidase as well as the synthesis of prostaglandin E2. Goshajinkigan prevents oxaliplatin-induced neurotoxicity, possibly through suppressing functional alterations of the transient receptor potential channels. In this review, we will summarize the currently available literature regarding the clinical efficacy and potential mechanisms of Kampo medicines in the treatment of cancer chemotherapy-induced side effects.