Efficacy and safety of traditional Chinese medicine for Tourette's syndrome: A meta-analysis of randomized controlled trials

The effects of Shaoma Zhijing granules and its main components on Tourette syndrome

BACKGROUND

Tourette syndrome (TS) represents a neurodevelopmental disorder characterized by an uncertain etiology and influencing factors. Frequently, it co-occurs with conditions such as attention deficit hyperactivity disorder, obsessive-compulsive disorder, and sleep disturbances, which have garnered substantial attention from the research community in recent years. Clinical trials have demonstrated that Shaoma Zhijing Granules (SMZJG, 5-ling granule, also known as TSupport or T92 under U.S. development), a traditional Chinese medicine compound, is an effective treatment for TS.

PURPOSE

To conduct scientometric analysis on developing trends, research countries and institutions, current status, hot spots of TS and discuss the underlying mechanisms of SMZJG and its main components on TS. The aim is to provide valuable reference for ongoing clinical and basic research on TS and SMZJG.

STUDY DESIGN & METHODS

Using Tourette syndrome, SMZJG and its main components along with their synonyms as keywords, we conducted a comprehensive search across major scientific databases including the Web of Science Core Collection, PubMed and China National Knowledge Infrastructure (CNKI) databases. A total of 5952 references and 99 patents were obtained. Among these, 5039 articles and reviews, as well as 54 patents were analyzed by Citespace and VOSviewer software.

RESULTS

The available evidence indicates that the SMZJG's components likely exert their mechanisms in treating TS by regulating the dopaminergic pathway system, neurotransmitter imbalances, reducing neuroinflammation, promoting the repair of nerve damage and improving sleep disorders.

CONCLUSION

This comprehensive analysis lays the foundation for an extensive exploration of the feasibility and clinical applications of SMZJG in TS treatment.

Use of complementary and alternative medicine in children affected by oncologic, neurologic and liver diseases: a narrative review

Complementary and alternative medicine (CAM) consist of a broad group of restorative resources often linked to existing local cultures and established health care systems and are also increasingly used in children with some serious illnesses. In this narrative review, we examine the epidemiology of the use, efficacy, and safety of complementary and alternative medicine in pediatric oncology, neurology, and hepatology. We searched for relevant articles published in Pubmed evaluating CAM use and its efficacy in safety in children affected by oncologic, neurologic and liver diseases. CAM is used to improve the success of conventional therapies, but also to alleviate the pain, discomfort, and suffering resulting from the diseases and their treatment, which are often associated with a significant burden of adverse effects. CAM use must be evaluated in children with neurological, oncological and liver diseases.

Efficacy and Safety of Acupuncture Combined with Herbal Medicine for Children and Adolescents with Tourette Syndrome: A Systematic Review and Meta-Analysis

BACKGROUND

With the increasing prevalence of Tourette syndrome (TS), the search for alternative therapy for TS is a growing public concern. In recent years, a growing number of randomized controlled trials (RCTs) have revealed the value of acupuncture combined with herbal medicine for the treatment of TS; however, its holistic efficacy and safety remains unclear. This study aimed to evaluate the efficacy and safety of acupuncture combined with herbal medicine and to provide preliminary evidence for clinical practice.

METHODS

Eight databases were searched from their establishment to November 27, 2022, to collect RCTs of acupuncture combined with herbal medicine for TS treatment. Two researchers independently completed the study screening, data extraction, and risk of bias assessment by using NoteExpress, Excel, and Cochrane Risk of Bias Tool 2.0 (RoB 2.0). Stata 15.0 software was applied to conduct meta-analysis.

RESULTS

A total of 1,400 participants in 18 RCTs were included. Compared with the Western medicine, acupuncture combined with herbal medicine had better curative effect in the field of effective rate (risk ratio [RR] = 1.18, 95% CI: [1.12, 1.23], p < 0.05, I2 = 0%), Yale Global Tic Severity Scale (YGTSS) total score (mean difference [MD] = -3.91, 95% CI: [-5.49, -2.33], p < 0.05, I2 = 96.4%), TCM syndrome total score (MD = -2.42, 95% CI: [-3.71, -1.13], p < 0.05, I2 = 87.1%), and serum IgE negative rate (RR = 3.41, 95% CI: [1.69, 6.87], p < 0.05, I2 = 0%). Furthermore, acupuncture combined with herbal medicine reduced the adverse reaction rate (RR = 0.20, 95% CI: [0.14, 0.30], p < 0.05, I2 = 0%) and the recurrence rate (RR = 0.27, 95% CI: [0.13, 0.52], p < 0.05, I2 = 0%).

CONCLUSION

This study demonstrated the efficacy and safety of acupuncture combined with herbal medicine, which is probably a better alternative therapy for TS. However, the small number, low quality, and potential bias of the included studies caused the limitations of our results. More high-quality RCTs are required to provide supplementary evidence in the future.

Hintergrund

Mit der steigenden Prävalenz des Tourette-Syndroms (TS) ist die Suche nach alternativen Therapien für TS zunehmend zu einer Angelegenheit von öffentlichem Interesse geworden. In den vergangenen Jahren zeigte eine immer größer werdende Zahl randomisierter, kontrollierter Studien den Nutzen der Akupunktur in Kombination mit Heilkräutern; ihre ganzheitliche Wirksamkeit und Sicherheit ist jedoch weiterhin nicht klar. Mit dieser Studie sollten die Wirksamkeit und Sicherheit von Akupunktur in Kombination mit Heilkräutern beurteilt und erste Belege für die klinische Praxis gewonnen werden.

Methoden

Acht (8) Datenbanken wurden ab ihrer Einrichtung bis zum 27. November 2022 nach randomisierten kontrollierten Studien (RCTs) über Akupunktur in Kombination mit Heilkräutern zur Behandlung von TS durchsucht. Das Screening der Studien, die Datenextraktion und die Bewertung des Verzerrungsrisikos wurden von zwei unabhängigen Forschern mit Hilfe von NoteExpress, Excel und dem Cochrane Risk of Bias Tool 2.0 (RoB 2.0) durchgeführt. Die Metaanalyse erfolgte mit der Software Stata 15.0.

Ergebnisse

Insgesamt wurden 1400 Teilnehmer in 18 RCTs eingeschlossen. Im Vergleich zur westlichen Medizin (WM) hatte Akupunktur in Kombination mit Heilkräutern eine bessere kurative Wirkung in Bezug auf die Wirksamkeitsrate (RR = 1,18, 95%-KI [1,12, 1,23], p < 0,05, I2 = 0%), den Gesamtscore der Yale Global Tic Severity Scale (YGTSS) (MD = -3,91, 95%-KI [-5,49, -2,33], p < 0,05, I2 = 96,4%), den TCM-Syndrom-Gesamtscore (MD = -2,42, 95%-KI [-3,71, -1,13], p < 0,05, I2 = 87,1%) und die Serum-IgE-Negativrate (RR = 3,41, 95%-KI [1,69, 6,87], p <0,05, I2 = 0 %). Darüber hinaus verringerte Akupunktur in Kombination mit Heilkräutern die Nebenwirkungsrate (RR = 0,20, 95%-KI [0,14, 0,30], p < 0,05, I2 = 0%) sowie die Rezidivrate (RR = 0,27, 95%-KI [0,13, 0,52], p < 0,05, I2 = 0%).

Schlussfolgerung

Diese Studie belegt die Wirksamkeit und Sicherheit der Akupunktur in Kombination mit Heilkräutern, die wahrscheinlich eine bessere alternative Therapie für TS darstellt. Unsere Ergebnisse werden allerdings durch die geringe Zahl, die niedrige Qualität und die potenzielle Verzerrung der eingeschlossenen Studien eingeschränkt. Zukünftig sind weitere hochwertige RCTs erforderlich, die zusätzliche Belege liefern.

Integrated network pharmacology and experimental verification to explore the molecular mechanism of Jingxin Zhidong formula for treating Tic disorder

ETHNOPHARMACOLOGICAL RELEVANCE

As a traditional Chinese medicine formula, Jingxin Zhidong Formula (JXZDF) based on ancient amber powder has been prescribed to alleviate tic disorders (TD) according to our clinical practice for many years. However, the underlying molecular mechanisms remain largely unknown.

AIM OF STUDY

To explore the potential mechanism of JXZDF in the treatment of TD by using network pharmacology and experimental validation.

MATERIALS AND METHODS

The chemical components of JXZDF were detected and the potential pathway enrichment analyses were conducted based on network pharmacology. Finally, we performed cell viability assays and Western blotting on LPS-induced BV-2 cells, and subsequently performed behavioral tests and Western blotting in SD rats model for TD to explore the mechanism of JXZDF on TD.

RESULTS

By LC-ESI-MS/MS system and searching the databases, we identified 5 key compounds and 29 hub targets of JXZDF on TD. KEGG enrichment analysis showed that PI3K/AKT signaling pathway may be the key pathway for JXZDF on TD. The vitro experimental results proved that JXZDF can inhibit the phosphorylation of PI3K and AKT proteins on LPS-induced BV-2 cells. The animal experimental results indicated that JXZDF can effectively alleviate the stereotypic behavior and hyperactivity of the TD rats, and downregulated PI3K/AKT pathway to inhibit microglia activation in the hippocampus tissue.

CONCLUSION

This study indicated that JXZDF can change microglial activation and expression of proinflammatory mediators through the inactivation of PI3K/AKT signaling pathway, which may be one of the mechanisms of JXZDF in treating TD.

Toxicological safety evaluation of Qin-Zhi-Zhu-Dan formula in rats during the treatment and recovery periods

Background: Qinzhi Zhudan Formula (QZZD), optimized from Angong Niuhuang Wan, consists of Radix Scutellariae, Fructus Gardeniae and Pulvis Fellis Suis. We had investigated the neuroprotective effects of QZZD and its active components, and demonstrated that it could treat cerebral ischemia and dementia through multiple pathways and mechanisms. Nevertheless, toxicological data on this formula still remains limited. In the study, we sought to examine the toxicological effects of QZZD during the treatment and recovery periods.

Methods: We investigated potential toxicities of QZZD in Sprague-Dawley (SD) rats via 28-day gavage administration. SD rats were randomly divided into control group and treatment groups of A (0.5 g/kg/d QZZD), B (1.5 g/kg/d QZZD), and C (5.0 g/kg/d QZZD). The 56-day course includes treatment period (administration with water or QZZD once a day for 28 consecutive days) and recovery period (28 days). The rats received daily monitoring of general signs of toxicity and mortality, as well as weekly determination of body weight and food consumption. Moreover, the complete blood cell count, biochemistry, coagulation, and urine indicators, organ weights, and histopathological report were analyzed respectively at the end of the treatment and recovery periods.

Results: There was no death related to the active pharmaceutical ingredients of QZZD during the treatment period. The maximum no observed adverse effect level (NOAEL) was 0.5 g/kg/d, which is approximately 16.7 times of the equivalent dose of clinical dose in rats. In group TB (1.5 g/kg/d QZZD) and TC (5.0 g/kg/d QZZD), there were adverse effects of blue coloring of tail skin, weight loss, a significant increase of total bilirubin (TBIL), blackening of liver and kidney in gross examination, hyperplasia of bile duct and karyomegaly of hepatocytes in histopathological examination. Besides, in females rats, the food consumption was reduced, while in male rats, there was decrease in triglycerides (TG) and slight increase in white blood cell (WBC) count and neutrophils. In group TC (5.0 g/kg/d QZZD), the indicators of red blood cell (RBC) count, hemoglobin (HGB) and hematocrit (HCT) were decreased slightly, while the platelet count (PLT) was increased. However, these changes were not considered to be toxicologically significant because they resolved during the recovery period.

Conclusion: Overall, QZZD exhibited a good safety profile. The maximum no observed adverse effect level was 0.5 g/kg/d, and no target organs toxicity were identified. The present findings might confirm the safety of QZZD in clinical practices.

Current and emerging pharmacotherapeutic strategies for Tourette syndrome

INTRODUCTION

Tourette syndrome (TS) is a chronic tic disorder characterized by both motor and vocal tics. The vast majority of patients present with co-morbid behavioral problems, especially tic-related obsessive-compulsive behaviors and attention-deficit and hyperactivity disorder. Evidence-based guidelines on the pharmacotherapy of TS have become available in recent years.

AREAS COVERED

The main purpose of this paper is to provide an overview of the current and emerging pharmacotherapeutic strategies for TS. A comprehensive search for the literature on the pharmacotherapy of tics was conducted using multiple databases (MEDLINE, Scopus, Web of Science, and Google Scholar), without date limits.

EXPERT OPINION

In consideration of the heterogeneity of the TS phenotypes, pharmacotherapy should be tailored to the individual patient. The choice of the pharmacological agent should take into account both the efficacy-to-tolerability ratio and the presence of co-morbid conditions. Evidence-based pharmacotherapy should aim at improving health-related quality life within a dynamic framework that typically requires active monitoring of the clinical presentation and reevaluation of the treatment intervention over time.

Tourette Syndrome Treatment Updates: a Review and Discussion of the Current and Upcoming Literature

Purpose of Review

This study aims to examine the treatments currently available for Tourette syndrome (TS) and to discuss evolving therapies, spanning behavioral, pharmacologic, complementary and alternative medicine, and neuromodulation approaches.

Recent Findings

Behavioral therapies have undergone several modifications to improve accessibility, including transitioning to a virtual format which is particularly important in the current pandemic. There are several recent or ongoing pharmacologic studies that have shown promise including the selective D1 receptor antagonist ecopipam and various cannabinoid compounds. Adaptive DBS may enable the physiologic markers of tics to determine stimulation parameters and improve tic outcomes related to neuromodulation.

Summary

In recent years, there has been a wealth of research across multiple treatment domains in the TS field. This review highlights exciting and new potential options for the future treatment of patients with TS.

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment

In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients' self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient's needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician's preferences, experience, and local regulatory requirements.

Toxicological safety evaluation of Qiguiyin formula in rats at the treatment phase and recovery phase

ETHNOPHARMACOLOGICAL RELEVANCE

Qiguiyin, a hospital preparation of traditional Chinese medicinal formula, is a combination of Astragalus hamosus L., Angelica sinensis (Oliv.) Diels, Lonicera sempervirens L., Artemisia annua L., and Polygonum cuspidatum Siebold & Zucc. at a ratio of 12:3:3:2:2. It has been used to treat severe pneumonia caused by drug-resistant bacteria in clinical practice, while studies on its toxicological safety are rare in the literature.

AIM OF THE STUDY

In the present study, we aimed to develop a new application of Qiguiyin according to the general research routine of traditional Chinese medicine (TCM), and the toxicological effects of the Qiguiyin formula at the treatment phase and recovery phase were also evaluated.

MATERIALS AND METHODS

The rats were administered with the Qiguiyin formula at 10, 30, and 50 times of the corresponding dosage in humans for 13 consecutive weeks. During 13 weeks of the treatment phase and 4 weeks of the recovery phase, the general signs of toxicity and mortality were monitored daily, and the body weight and food consumption were determined every week. Moreover, the hematology, biochemistry, urine, organ weights, and histopathology were analyzed, and the reproductive system was examined at the end of the treatment phase or recovery phase, respectively.

RESULTS

The toxicological results showed no deaths and no changes in general behavior. Moreover, there was no clinically significant effect of the Qiguiyin formula on body weight or food consumption in rats. Although the Qiguiyin formula resulted in some changes in hematological, biochemical, and urinary indexes, these alterations were not related to the treatment because they remained within normal ranges throughout the 17 weeks. Besides, the main organs were not affected basically. All the above-mentioned results showed no gender difference. Furthermore, a clinical dosage of 50 times of the Qiguiyin formula did not affect the reproductive system of female rats, while it could lead to atrophied seminiferous tubules in two out of 10 male rats. However, such abnormality could not be found at the end of the recovery phase.

CONCLUSIONS

Overall, the Qiguiyin formula could be used safely. The administration at doses of less than 1000 g/day for 13 weeks showed no distinct toxicity or side effects.

The clinical intervention choice for pediatric tic disorder patients from a tertiary children's hospital in China: a large-scale retrospective study based on electronic medical records

Pharmacological intervention played an important role in the management of tic disorder. Large-scale prescription data for pediatric tic disorder patients in the real-world setting were scarce. The demographic and prescription data of tic disorder were extracted from the electronic medical records database of Beijing Children's Hospital from 2018 to 2020. The intervention choice for outpatient pediatric tic disorder patients was analyzed. A total of 20 417 patients were included, 28.1% (n = 5028) of them did not receive any pharmacological treatment. Over 70% were prescribed with anti-tic medication. For children less than 6 years of age, clonidine adhesive patches (CAPs) and traditional Chinese medicine (TCM) were the common choice. With the age growing, the use of antipsychotics was on the rise; 22% (n = 3389) were prescribed for at least two anti-tic medication, and the most common medication combination group was tiapride and TCM (33.7%), followed by CAP and TCM (22.1%). The clinical intervention choice for tic disorder is highly individualized. The pharmacological choice was influenced by severity, duration of symptom, age, the acceptance of parents and other factors.

Traditional Chinese Medicine Strategy for Patients with Tourette Syndrome Based on Clinical Efficacy and Safety: A Meta-Analysis of 47 Randomized Controlled Trials

OBJECTIVE

Although increasing evidence reveals the efficacy of traditional Chinese medicine (TCM) and its safety on Tourette Syndrome (TS) patients, whether TCM is indeed improving TS remains unclear. The purpose of the current study is to perform a meta-analysis to evaluate the efficacy and safety of TCM on treating TS patients.

METHOD

An elaborate search strategy was conducted based on several databases including Medline, Embase, Cochrane, Web of Science, CINAHL, CBM, VIP, CNKI, and Wanfang Data in order to identify the relevant randomized controlled trials (RCTs) from their inception to as late as May 1st, 2020. General information and data needing analysis were extracted simultaneously for the necessity of various analyses such as descriptive analysis and metaquantitative analysis.

RESULTS

Forty-seven trials with 5437 TS patients in total were eventually included according to our criteria. All trials were conducted in China, and the publication years ranged from 2004 to 2017. In terms of clinical efficacy, clinical symptoms of patients with TCM were more likely to be improved compared with the control group (odds ratio, OR = -1.29, 95% confidence interval, CI: -2.54 to -0.06, I 2 = 0.00%). As to the outcome of recurrence rate, the pooled results revealed that the TCM group was more inclined to stabilize the recurrence (OR = 0.44, 95% CI: 0.24 to 0.78, I 2 = 0.00%). Similar results were observed in adverse reaction (OR = 0.32, 95% CI: 0.24 to 0.43, I 2 = 32.90%).

CONCLUSION

The results of our study recommend applying TCM to treat TS patients for better efficacy and safety. Results need to be interpreted cautiously due to certain limitations in our study.

Efficacy and Safety of Traditional Chinese Herbal Medicine for Antipsychotic-Related Constipation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Constipation is a common but often ignored side effect of antipsychotic treatment, although it is associated with adverse outcomes. The results of the efficacy and safety of traditional Chinese herbal medicine (TCM) in treating constipation are mixed across studies. This is a systematic review and meta-analysis of randomized controlled trials (RCTs) of the efficacy and safety of TCM compared to Western medicine (WM) in treating antipsychotic-related constipation. Methods: Major international electronic (PubMed, EMBASE, Cochrane Library, and Web of Science) and Chinese (Wanfang, WeiPu VIP, SinoMed, and CNKI) databases were searched from their inception to November 29, 2020. Meta-analysis was performed using the random-effects model. Results: Thirty RCTs with 52 arms covering 2,570 patients in the TCM group and 2,511 patients in the WM group were included. Compared with WM, TCM alone was superior regarding the moderate response rate [risk ratio (RR) = 1.165; 95% confidence interval (CI): 1.096-1.238; P < 0.001], marked response rate (RR = 1.437; 95% CI: 1.267-1.692; P < 0.001), and remission rate (RR = 1.376; 95% CI: 1.180-1.606; P < 0.001) for constipation, while it was significantly associated with lower risk of rash (RR = 0.081; 95% CI: 0.019-0.342; P = 0.001). For the moderate response rate, meta-regression analyses revealed that publication year (β = -0.007, P = 0.0007) and Jadad score (β = 0.067, P < 0.001) significantly moderated the results. For the remission rate, subgroup and meta-regression analyses revealed that the geographical region (P = 0.003), inpatient status (P = 0.035), and trial duration (β = 0.009, P = 0.013) significantly moderated the results. Conclusions: The efficacy of TCM for antipsychotic-related constipation appeared to be greater compared to WM, while certain side effects of TCM, such as rash, were less frequent.

A double-blind, randomized, sham-controlled study of cranial electrotherapy stimulation as an add-on treatment for tic disorders in children and adolescents

AIM

The aim of this study was to determine the efficacy and safety of cranial electrotherapy stimulation (CES) as an add-on treatment for TD.

METHODS

A randomized, double-blind, sham-controlled trial was conducted at an outpatient, single-center academic setting. A total of 62 patients aged 6-17 years with TD and lack of clinical response to 4 weeks' pharmacotherapy were enrolled. Patients were divided randomly into 2 groups and given 4 weeks' treatment, including 30 min sessions of active CES (500 μA-2 mA) or sham CES (lower than 100 μA) per day for 40 d on weekdays. Change in Yale Global Tic Severity Scale (YGTSS), Clinical Global Impression-severity of illness-severity (CGI-S) and Hamilton Anxiety Scale-14 items (HAMA-14) were performed at baseline, week 2, week 4. Adverse events (AEs) were also evaluated.

RESULTS

53 patients (34 males and 9 females) completed the trial, including 29 in the active CES group and 24 in the sham CES group. Both groups showed clinical improvement in tic severities compared to baseline respectively at week 4. Participants receiving active CES showed a reduction of 31.66 % in YGTSS score, compared with 23.96 % in participants in sham CES group, resulting in no significant difference between the two groups (t = 1.54, p = 0.13).

CONCLUSION

Four-week's treatment of CES for children and adolescents with TD is effective and safe, but the improvement for tic severity may be related to placebo effect.

Current Status, Diagnosis, and Treatment Recommendation for Tic Disorders in China

Tic disorders (TD) are a group neuropsychiatric disorders with childhood onset characterized by tics, i.e. repetitive, sudden, and involuntary movements or vocalizations; and Tourette syndrome (TS) is the most severe form of TD. Their clinical manifestations are diverse; and are often associated with various psychopathological and/or behavioral comorbidities, including attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, depression, and sleep disorders. Individual severity and response to treatment are highly variable, and there are some refractory cases, which are less responsive to conventional TD treatment. TD/TS are also common in the Chinese pediatric population. To help improve the understanding of TD for pediatricians and other health professionals, and to improve its diagnosis and treatment in China, the Chinese Child Neurology Society (CCNS) has developed an Expert Consensus on Diagnosis and Treatment of TD in China, which is based on our clinical experience and the availability therapeutic avenues. It is focused on clinical diagnosis and evaluation of TD and its comorbidities, psychological and educational intervention, nonpharmacological therapy, pharmacological treatment, including traditional Chinese medicine and acupuncture, as well as prognosis in children with TD in China. A summary of the current status of TD and up-to-date diagnosis and treatment recommendations for TD in China is presented here.