A survey of traditional Chinese medicine use among rheumatoid arthritis patients: a claims data–based cohort study

Illumination on Chemical Compounds from Qufeng Zhitong Capsule and Its Potential Pharmacological Mechanism against Rheumatoid Arthritis Based on UHPLC/Q-Orbitrap-MS Combined with Network Pharmacology Analysis

Qufeng Zhitong capsule (QZC), a Chinese patent medicine officially approved in China for the treatment of rheumatoid arthritis (RA) and other diseases, possesses the primary effects of dispelling wind, relieving pain, and promoting blood circulation, whose clinical applications have been confined owing to the incomplete elucidation of its chemical compositions and the underlying molecular mechanism for the treatment of RA. In this study, 61 compounds including 16 phenylpropanoids, 15 organic acids, 13 alkaloids, seven flavonoids, six iridoids, one saccharide, two aldehydes, and one saponin in QZC were simultaneously identified and traced to their herbal origins by ultra-high performance liquid chromatography tandem Q-Exactive Orbitrap high-resolution mass spectrometry (UHPLC/Q-Orbitrap-MS), where 31 of them were unambiguously identified by reference compounds, and the other 30 were tentatively characterized. Besides, all these compounds were proven to have potential pharmacological activity in the treatment of RA based on network pharmacology analysis. In conclusion, this study first investigated the chemical composition and potential pharmacological effects of the main chemical compounds in QZC, which will contribute to the revelation of bioactive compounds in QZC and provide evidence for clinical application.

China rheumatoid arthritis registry of patients with Chinese medicine (CERTAIN): Rationale, design, and baseline characteristics of the first 11,764 enrollees

BACKGROUND

Chinese medicine (CM) has become a popular interventional treatment for rheumatoid arthritis (RA). However, limited knowledge about general characteristics and long-term clinical outcomes hampers the development of CM for RA.

PURPOSE

The main objectives of the China Rheumatoid Arthritis Registry of Patients with Chinese Medicine (CERTAIN) were to describe the population of RA patients receiving CM treatment in multiple centers in China using different variables and compare these findings with internationally reported data.

STUDY DESIGN

The CERTAIN is a prospective, multicenter, observational disease registry.

METHODS

Adult RA patients who fulfilled the 2010 American College of Rheumatology/ European League Against Rheumatism classification criteria for RA and received CM treatment were recruited into the CERTAIN by rheumatologists from 145 hospitals across 30 provinces in China. Data on demographics, disease characteristics, comorbidities, treatments, and adverse events, with a 2-year follow-up, were collected and documented using a predefined protocol.

RESULTS

In the 2 years since the study began in September 2019, 11,764 patients have been enrolled (enrolment is ongoing), and 13.10% of participants have completed the 6-month follow-up. We present the baseline characteristics of the first 11,764 enrollees.

CONCLUSIONS

The CERTAIN is the first nationwide registry to document comprehensive data on CM treatment in patients with RA. The development of the CERTAIN resource is a significant step forward for Chinese RA patients, herbal medicine users, and research communities and will deepen our understanding of CM for RA.

REGISTRATION

The study was registered at ClinicalTrials.gov (NCT05219214).

Quantitative Analysis of Multicomponents in Qufeng Zhitong Capsule and Application of Network Pharmacology to Explore the Anti-Inflammatory Activity of Focused Compounds

Qufeng Zhitong capsule (QZC) is a well-known Chinese patent medicine that has been widely applied for the clinical treatment of rheumatoid arthritis and other inflammatory diseases. To date, its material basis is still unclear, which has greatly limited its clinical application. In this study, by taking advantage of ultra-high-performance liquid chromatography tandem Q-Exactive Orbitrap high-resolution mass spectrometry, 16 chemical components such as gallic acid, protocatechuic acid, and neochlorogenic acid in QZC were characterized and unambiguously identified based on comparison with the corresponding reference standards. In addition, the correlation between the focused components and their corresponding raw herbs from QZC prescription was investigated. For the first time, the relationship between the components mentioned above and their anti-inflammatory activity was explored via network pharmacology analysis, and a visualized network of "medicinal materials-QZC-compounds-targets-pathways" was established. Based on the brief prediction results of network pharmacological analysis, ultra-performance liquid chromatography coupled with photodiode array detector method was validated in terms of linearity, limit of detection, limit of quantification, precision, repeatability, stability, and recovery test and was successfully employed to determine 16 compounds in 28 batches of QZCs, which confirmed the feasibility and reliability of the established method for the quantitative analysis of 16 compounds in QZC. Considering the content and bioactivity of the tested components, four compounds were recommended as candidate indicators for quality evaluation ultimately. The potential value of this study could not only support a quality evaluation of QZC but also provide a theoretical basis for further in-depth research of QZC in clinical research.

Isopsoralen ameliorates rheumatoid arthritis by targeting MIF

BACKGROUND

Isopsoralen (IPRN), one of the active ingredients of Psoralea corylifolia Linn, has anti-inflammatory properties. We attempted to investigate the inhibitory effects of IPRN on rheumatoid arthritis (RA) and characterize its potential mechanism.

METHODS

RA fibroblast-like synoviocytes (FLSs) and mice with collagen-induced arthritis (CIA) were used as in vitro and in vivo models to analyze the antiarthritic effect of IPRN. Histological analysis of the inflamed joints from mice with CIA was performed using microcomputed tomography (micro-CT) and hematoxylin-eosin (HE) staining. RNA sequencing (RNA-Seq), network pharmacology analysis, molecular docking, drug affinity responsive target stability (DARTS) assay, and cellular thermal shift assay (CETSA) were performed to evaluate the targets of IPRN.

RESULTS

IPRN ameliorated the inflammatory phenotype of RA FLSs by inhibiting their cytokine production, migration, invasion, and proangiogenic ability. IPRN also significantly reduced the severity of CIA in mice by decreasing paw thickness, arthritis score, bone damage, and serum inflammatory cytokine levels. A mechanistic study demonstrated that macrophage migration inhibitory factor (MIF), a key protein in the inflammatory process, was the specific target by which IPRN exerted its anti-inflammatory effects in RA FLSs.

CONCLUSION

Our study demonstrates the antiarthritic effect of IPRN, which suggests the therapeutic potential of IPRN in RA.

Traditional Chinese Medicine Qingre Huoxue Treatment vs. the Combination of Methotrexate and Hydroxychloroquine for Active Rheumatoid Arthritis: A Multicenter, Double-Blind, Randomized Controlled Trial

Traditional Chinese medicine (TCM) has been used successfully to treat rheumatoid arthritis (RA). Qingre Huoxue treatment (Qingre Huoxue decoction (QRHXD)/Qingre Huoxue external preparation (QRHXEP)) is a therapeutic scheme of TCM for RA. To date, there have been few studies comparing the efficacy and safety of QRHXD and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) for the treatment of active RA. This was investigated in a multicenter, double-blind, randomized controlled trial involving 468 Chinese patients with active RA [disease activity score (DAS)-28 > 3.2] treated with QRHXD/QRHXEP (TCM group), methotrexate plus hydroxychloroquine [Western medicine (WM) group], or both [integrative medicine (IM) group]. Patients were followed up for 24 weeks. The primary outcome measure was the change in DAS-28 from baseline to 24 weeks. The secondary outcome measures were treatment response rate according to American College of Rheumatology 20, 50, and 70% improvement criteria (ACR-20/50/70) and the rate of treatment-related adverse events (TRAEs). The trial was registered at ClinicalTrials.gov (NCT02551575). DAS-28 decreased in all three groups after treatment (p < 0.0001); the score was lowest in the TCM group (p < 0.05), while no difference was observed between the WM and IM groups (p > 0.05). At week 24, ACR-20 response was 73.04% with TCM, 80.17% with WM, and 73.95% with IM (based on the full analysis set [FAS], p > 0.05); ACR-50 responses were 40.87, 47.93, and 51.26%, respectively, (FAS, p > 0.05); and ACR-70 responses were 20.87, 22.31, and 25.21%, respectively, (FAS, p > 0.05). Thus, treatment efficacy was similar across groups based on ACR criteria. On the other hand, the rate of TRAEs was significantly lower in the TCM group compared to the other groups (p < 0.05). Thus, QRHXD/QRHXEP was effective in alleviating the symptoms of active RA—albeit to a lesser degree than csDMARDs—with fewer side effects. Importantly, combination with QRHXD enhanced the efficacy of csDMARDs. These results provide evidence that QRHXD can be used as an adjunct to csDMARDs for the management of RA, especially in patients who experience TRAEs with standard drugs.

Clinical Trial Registration: ClinicalTrials.gov, identifier NCTNCT025515.

The Relationship of Acupuncture Use to the Endometriosis Risk in Females With Rheumatoid Arthritis: Real-World Evidence From Population-Based Health Claims

Objectives: Women affected by rheumatoid arthritis (RA) have a higher risk of endometriosis, an estrogen-dependent, chronic inflammatory disease. Though acupuncture has long been a safe and effective therapy for treating inflammatory conditions, it is unclear whether it could prevent the onset of endometriosis. This study aims to determine the effect of acupuncture on the subsequent risk of endometriosis in female RA patients.

Methods: Between 1998 and 2010, female subjects with RA were recruited from a nationwide database (5,736 patients; age ≥20 years). Enrolled patients included 2,407 acupuncture users and 2,407 nonusers randomly selected using propensity scores. The occurrence of endometriosis was recorded through the end of 2012. Cox proportional hazards regression was used to estimate the adjusted hazard ratio (HR) associated with acupuncture use.

Results: During the follow-up period, 35 acupuncture users and 94 non-users developed endometriosis, with incidence rates of 2.36 and 4.91 per 1,000 person-years, respectively. Acupuncture use was associated with a 55% lower endometriosis risk (adjusted HR, 0.45; 95% confidence interval, 0.31–0.65). Those who received high intensity acupuncture (≥15 packages) had the greatest benefit.

Conclusions: Findings suggest that adding acupuncture to conventional therapy may decrease the subsequent endometriosis risk in female RA patients. Prospective randomized trials are recommended to further clarify whether the association revealed in this study supports a causal link.

Chinese Herbal Formula Huayu-Qiangshen-Tongbi Decoction Compared With Leflunomide in Combination With Methotrexate in Patients With Active Rheumatoid Arthritis: An Open-Label, Randomized, Controlled, Pilot Study

Background: Traditional Chinese Medicine is complementary and an alternative to modern medicine. The combination therapies of herbal products with disease-modifying anti-rheumatic drugs are gradually and widely adopted in the management of rheumatoid arthritis (RA) in China. Purpose: To evaluate the efficacy and safety of Huayu-Qiangshen-Tongbi (HQT) decoction, a Chinese medicine formula, combined with methotrexate (MTX) in the treatment of patients with active RA, in comparison with the combination therapy of MTX with leflunomide (LEF). Methods: This pilot study was a monocenter, open-label, randomized controlled trial with two parallel arms. Ninety patients with active RA were randomly allocated to receive either HQT at a dose of 250 ml twice daily or LEF at a dose of 20 mg once daily, and all participants received MTX at a dose of 10-15 mg once weekly. The primary efficacy endpoint was the proportion of patients who achieved a 20% improvement in the American College of Rheumatology criteria (ACR20) after a 24-week treatment. Results: 84.4% (76/90) patients completed the 24-week observation. In the intention-to-treat analysis, the percentage values of patients achieving the ACR20 response criteria were 72.1% (31/43) in MTX + HQT group and 74.4% (32/43) in MTX + LEF group (p = 0.808). No significant difference was observed in other parameters, including ACR50, ACR70, clinical disease activity index good responses, European League Against Rheumatism good response, remission rate, and low disease activity rate. The results of the per-protocol analysis showed consistency with those of the intention-to-treat analysis. The mean change from baseline at week 24 for the van der Heijde modified total sharp score had no significant difference between two groups (3.59 ± 4.75 and 1.34 ± 8.67 in the MTX + HQT group and MTX + LEF group, respectively, p = 0.613). The frequency of adverse events was similar in both groups (11 cases in the MTX + HQT and 17 cases in the MTX + LEF, p > 0.05). Conclusions: In patients with active RA, treatment with the combination of HQT and MTX was associated with improvement in signs, symptoms, and physical function. With a beneficial clinical response and acceptable tolerability, HQT or other Chinese medicine formula may be a good therapeutic option in combination with MTX for RA treatment. Trial registration: Chinese Clinical Trails Registry, ChiCTR-INR-16009031, Registered on 15th August 2016, http://www.chictr.org.cn/enindex.aspx.

Innovated formulation of TCM pangolin scales to develop a nova therapy of rheumatoid arthritis

Pangolin scale (PS) is a traditional Chinese medicine (TCM) for treating rheumatic arthritis (RA), and diverse medicinal formulations and therapeutic properties of PS have proved great potential to supplement conventional treatments in integrative medicine-based strategies. However, few studies have investigated how different PS formulations can impact the management of RA. Herein, we developed an innovative formulation of PS processed with vinegar (PSP) and evaluated it by comparing with the traditional decoction of PS (PSD) and non-steroidal anti-inflammatory drug (NASID) (i.e., meloxicam) in a RA Sprague Dawley rat model, which is induced with a complete Freund's adjuvant (CFA). The anti-inflammatory activities were evaluated by paw edema measurement, arthritic score, histopathological examination, pro-inflammatory cytokines (IL-1β and TNF-α) production and the whole blood viscosity. PSP treatments (249.0 mg/kg.bw) from day 14-42 alleviated paw edema (P < 0.001), arthritic index (score 0-1.5) and the inflammatory cell infiltration in the ankle joint, which may be attributed to inhibiting the production of TNF-α (P < 0.01) and IL-1β (P < 0.05) in the serum. Although PSP is with fewer efficacies than meloxicam, it outperformed traditional formulation PSD (830 mg/kg.bw) in all above mentioned metrics. Furthermore, PSP exhibited a unique effect on reducing whole blood viscosity (P < 0.05) unobserved in meloxicam intervention. The present study demonstrates that PSP showed more efficient anti-inflammatory activity than PSD in CFA-induced RA rats, possibly due to the presence of higher levels of active ingredients. Thus, PSP may be a promising therapy for anti-inflammation in RA and can be integrated with conventional treatments, particularly for long-term RA management in an integrative treatment strategy.