Herbal medicine in the treatment of liver diseases

Exploring the hepatoprotective properties of citronellol: In vitro and in silico studies on ethanol-induced damage in HepG2 cells

Citronellol (CT) is a monoterpene alcohol present in the essential oil of plants of the genus Cymbopogon and exhibits diverse pharmacological activities. The aim of the current study was to investigate the hepatoprotective potential of CT against ethanol-induced toxicity in HepG2 cell lines. Silymarin (SIL) was used as a standard drug. MTT, crystal violet assay, DAPI, and PI staining were carried out to assess the effect of ethanol and CT on cell viability. RT-PCR determined the molecular mechanisms of hepatoprotective action of CT. CT ameliorated cell viability and restricted ethanol-induced cell death. DAPI and PI staining showed distinct differences in cell number and morphology. Less cell viability was observed in the diseased group obviously from strong PI staining when compared to the CT- and SIL-treated group. Moreover, CT showed downregulation of interleukin (IL-6), transforming growth factor-beta 1 (TGF-β1), collagen type 1 A 1 (COL1A1), matrix metalloproteinase-1 (MMP-1), tissue inhibitor of metalloproteinase-1 (TIMP-1) and glutathione peroxidase-7 (GPX-7) levels. Molecular docking studies supported the biochemical findings. It is concluded that the cytoprotective activity of CT against ethanol-induced toxicity might be explained by its anti-inflammatory, immunomodulatory, and collagen-regulating effects.

Evaluation of the Hepatoprotective Properties of Traditional Formulations Based on Cochlospermum tinctorium Used in Benin

Hepatic diseases represent a public health problem. Among the approaches to their management is the use of traditional treatments based on the use of medicinal plants. In Benin, several recipes based on Cochlospermum tinctorium are used in the treatment of hepatitis without a real scientific basis. This study aimed to evaluate the hepatoprotective effects and acute oral toxicity of 10 of these recipes. The variables studied were the variety of C. tinctorium (wild form vs. cultivated form), the species associated with C. tinctorium (Combretum micranthum vs. Chromolaena odorata), and the proportion of C. tinctorium in the recipe (1; 4/5; 1/2). The hepatoprotective effect of these extracts at doses of 100, 200, and 400 mg/kg/bw was evaluated in Wistar rats subjected to hepatotoxicity induction through the administration of 5 g/kg of paracetamol. Acute oral toxicity was assessed following the OECD 423 protocol. The results revealed an absence of acute oral toxicity for the 10 recipes. The hepatoprotective tests conducted indicated that the hepatoprotective effect of C. tinctorium is dose dependent. The wild variety of C. tinctorium had a better hepatoprotective effect than the cultivated one. The association with C. micranthum enhances the hepatoprotective effect of C. tinctorium, unlike that with C. odorata. This study emphasizes that the combination of C. tinctorium with C. micranthum in the treatment of hepatitis is scientifically justified and it exhibits a dose-dependent hepatoprotective effect.

Profiling of two Lampranthus species using LC-ESI/MS with evidence of their hepatoprotective activity

Lampranthus glaucus and Lampranthus glaucoides are only reported to have significant cytotoxic activity against certain cancer cell lines with phytochemical investigation of their petroleum ether and the ethyl acetate extracts. Further investigation was suggested concerning their hepatoprotective activity and relating it to the metabolic profile of their defatted methanol extracts using LC-ESI/MS analysis. Hepatoprotective activity was evaluated through assessment of three liver parameters as well as liver histopathological examination in thioacetamide-induced hepatotoxicity model. Sixty-eight and 26 phytochemicals were tentatively identified in L. glaucoides and L. glaucus, respectively, with phenolic compounds as the major class. Both plants showed significant inhibition of serum GPT and GOT levels, inhibition of tissue IL-1β and TNF-α levels and inhibition of tissue NF-κβ and caspase-3 gene expression proving hepatoprotective action. Liver treated with L. glaucoides showed lesion scoring range between negative to mild, whereas L. glaucus showed a range between mild to moderate.

Medicinal herbs and their metabolites with biological potential to protect and combat liver toxicity and its disorders: A review

The liver is an essential organ that helps the body with immunity, metabolism, and detoxification, among other functions. Worldwide, liver illnesses are a leading cause of mortality and disability. There are few effective treatment choices, but they frequently have unfavorable side effects. Investigating the potential of medicinal plants and their bioactive phytoconstituents in the prevention and treatment of liver disorders has gained more attention in recent years. An assessment of the hepatoprotective potential of medicinal plants and their bioactive secondary metabolites is the goal of this thorough review paper. To determine their hepatoprotective activity, these plants were tested against liver toxicity artificially induced in rats, mice and rabbits by chemical agents such as carbon tetrachloride (CCl4), paracetamol (PCM), thioacetamide (TAA), N-nitrosodiethylamine, d-galactosamine/lipopolysaccharide, antitubercular medicines (rifampin, isoniazid) and alcohol. To find pertinent research publications published between 1989 and 2022, a comprehensive search of electronic bibliographic databases (including Web of Science, SpringerLink, ScienceDirect, Google Scholar, PubMed, Scopus, and others) was carried out. The investigation comprised 203 plant species from 81 families in total. A thorough discussion was mentioned regarding the hepatoprotective qualities of plants belonging to several families, such as Fabaceae, Asteraceae, Lamiaceae, and Euphorbiaceae. The plant groups Asteraceae and Fabaceae were the most frequently shown to have hepatoprotective properties. The phytochemical constituents namely flavonoids, phenolic compounds, and alkaloids exhibited the highest frequency of hepatoprotective action. Also, some possible mechanism of action of some active constituents from medicinal plants was discussed in brief which were found in some studies. In summary, the information on medicinal plants and their potentially hepatoprotective bioactive phytoconstituents has been consolidated in this review which emphasizes the importance of further research to explore the efficacy and safety of these natural remedies for various liver ailments.

Medicinal herbs consumption in relation to cardiometabolic indices and coronary artery stenosis in participants undergoing coronary angiography: A cross-sectional study

Few studies have investigated the association between herbal medicine consumption and coronary artery disease severity. This cross-sectional study aimed to investigate the association between the frequency of medicinal herbs consumption and coronary artery stenosis (CAS), lipid profile, fasting blood sugar (FBS), and blood pressure level in participants undergoing coronary angiography. This study was conducted on 662 participants aged 35-75 years. Serum cardiometabolic markers were measured using standard kits. The extent and severity of CAS were evaluated using the Gensini score (GS) and syntax score (SS). Higher consumption of Thymus vulgaris and Sumac was associated with decreased odds of artery-clogging according to the GS. A higher intake of Thymus vulgaris and Mentha was associated with lower levels of serum cholesterol and triglyceride. Monthly intake of Thymus vulgaris, and weekly/daily intake of Mentha, Nigella Sativa, and Cuminum Cyminum were associated with lower low-density lipoprotein. Weekly/daily intake of Turmeric and Thymus vulgaris were associated with lower high-density lipoprotein levels and monthly intake of Mentha was related to lower serum FBS levels. Higher consumption of Mentha, Mentha pulegium L, Lavandula angustifolia, and Nigella Sativa was associated with lower levels of systolic blood pressure. According to the results of the present study, herbs consumption might be related to a reduction in CAS risk factors.

Optimizing the Extraction of Polyphenols from the Bark of Terminalia arjuna and an In-silico Investigation on its Activity in Colorectal Cancer

BACKGROUND

The interconnection between different fields of research has gained interest due to its cutting-edge perspectives in solving scientific problems. Terminalia arjuna is indigenously used in India for curing several diseases, and its pharmacological activities are being revisited in recent drug-repurposing research.

OBJECTIVES

Efficient ultrasound-assisted extraction of phytochemicals from the bark of Terminalia arjuna is highlighted in this study. Following the optimization of the extraction process, the crude hydroethanolic extract is subjected to phytochemical profiling and an in-silico investigation of its anti-cancer properties.

MATERIALS AND METHODS

A three-level four-factor Box-Behnken design is exploited to optimize four operational parameters, namely extraction time, ultrasonic power, ethanol concentration (as the extracting solvent) and solute (in g): solvent (in mL) ratio. At the optimum parametric condition, the crude extract is obtained, and its GC-MS analysis is carried out. An analysis of network pharmacology (by constructing and visualizing biological networks using Cytoscape) combined with molecular docking reveals the potential antineoplastic targets of the crude extract.

RESULTS

The ANOVA table exhibits the significance, adequacy and reliability of the proposed second-order polynomial model with the R² value of 0.917 and adjusted R² of 0.865. Experimental results portray the significant antioxidant potential of the prepared extract in its crude form. The GC-MS analysis of the crude extract predicts the extracted phytochemicals, while the constructed biological networks highlight its multi-targeted activity in colorectal cancer.

CONCLUSION

The study identifies three phytochemicals viz. luteolin, β-sitosterol and arjunic acid as potent anti-cancer agents and can be extended with in-vitro and in-vivo experiments to validate the in-silico results, thus establishing lead phytochemicals in multi-targeted colorectal cancer therapies.

Medicinal Plant-derived Phytochemicals in Detoxification

The average worldwide human life expectancy is 70 years, with a significantly higher value in Western societies. Many modern diseases are not associated with premature mortality but with a decreased quality of life in aged patients and an excessive accumulation of various toxic compounds in the human body during life. Today, scientists are especially interested in finding compounds that can help increase a healthy lifespan by detoxifying the body. Phytotherapy with specific approaches is used in alternative medicine to remove toxins from the body. Worldwide, research is conducted to identify medicinal plant-derived molecules that, with few or no side effects, may protect the liver and other organs. This review provides updated information about the detoxification process, the traditional and modern use of the most effective medicinal plants, their active metabolites as detoxifying agents, and the mechanisms and pathways involved in the detoxification process. Among medicinal plants with substantial detoxifying properties, a major part belongs to the Asteraceae family (Silybum marianum, Cynara scolymus, Arctium lappa, Helichrysum species, Inula helenium, and Taraxacum officinale). The most widely used hepatoprotective phytocomponent is silymarin, a standardized extract from the Silybum marianum seeds containing a mixture of flavonolignans. Many polysaccharides, polyphenols, and terpenoids have a detoxifying effect. Overall, scientific data on medicinal plants used in phytotherapeutic practice worldwide provides an understanding and awareness of their efficacy in detoxification.

Phytochemical Properties of Croton gratissimus Burch (Lavender Croton) Herbal Tea and Its Protective Effect against Iron-Induced Oxidative Hepatic Injury

Oxidative stress plays a vital role in the pathogenesis and progression of various liver diseases. Traditional medicinal herbs have been used worldwide for the treatment of chronic liver diseases due to their high phytochemical constituents. The present study investigated the phytochemical properties of Croton gratissimus (lavender croton) leaf herbal tea and its hepatoprotective effect on oxidative injury in Chang liver cells, using an in vitro and in silico approach. C. gratissimus herbal infusion was screened for total phenolic and total flavonoid contents as well as in vitro antioxidant capacity using ferric reducing antioxidant power (FRAP) and 2,2-diphenyl-1-picryl-hydrazyl (DPPH) methods. Oxidative hepatic injury was induced by incubating 0.007 M FeSO4 with Chang liver cells which has been initially incubated with or without different concentrations (15-240 μg/mL) of C. gratissimus infusion or the standard antioxidants (Gallic acid and ascorbic acid). C. gratissimus displayed significantly high scavenging activity and ferric reducing capacity following DPPH and FRAP assays, respectively. It had no cytotoxic effect on Chang liver cells. C. gratissimus also significantly elevated the level of hepatic reduced glutathione (GSH), superoxide dismutase (SOD), and catalase activities as well as suppressed the malondialdehyde (MDA) level in oxidative hepatic injury. Liquid Chromatography-Mass Spectrometry (LC-MS) analysis of the herbal tea revealed the presence of 8-prenylnaringenin, flavonol 3-O-D-galactoside, caffeine, spirasine I, hypericin, pheophorbide-a, and 4-methylumbelliferone glucuronide. In silico oral toxicity prediction of the identified phytochemicals revealed no potential hepatotoxicity. Molecular docking revealed potent molecular interactions of the phytochemicals with SOD and catalase. The results suggest the hepatoprotective and antioxidative potentials of C. gratissimus herbal tea against oxidative hepatic injury.

Lippia javanica (Burm. F.) Herbal Tea: Modulation of Hepatoprotective Effects in Chang Liver Cells via Mitigation of Redox Imbalance and Modulation of Perturbed Metabolic Activities

Introduction: Hepatic oxidative injury is one of the pathological mechanisms that significantly contributes to the development of several liver diseases. In the present study, the hepatoprotective effect of Lippia javanica herbal tea was investigated in Fe2+- mediated hepatic oxidative injury. Methods: Using an in vitro experimental approach, hepatic oxidative injury was induced by co-incubating 7 mM FeSO4 with Chang liver cells that have been pre-incubated with or without different concentrations (15-240 μg/mL) of L. javanica infusion. Gallic acid and ascorbic acid served as the standard antioxidants. Results: The infusion displayed a reducing antioxidant activity in ferric-reducing antioxidant power (FRAP) assay and a potent scavenging activity on 2,2-diphenyl-2- picrylhydrazyl (DPPH) radical. Pretreatment with L. javanica infusion significantly elevated the levels of reduced glutathione and non-protein thiol, and the activities of superoxide dismutase (SOD) and catalase, with concomitant decrease in hepatic malondialdehyde levels, acetylcholinesterase, glucose-6-phosphatase, fructose-1,6-bisphosphatase, glycogen phosphorylase and lipase activities. The infusion showed the presence of phytoconstituents such as phenolic compounds, tannins, phenolic glycosides and terpenoids when subjected to liquid chromatography-mass spectrometry analysis. Molecular docking revealed a strong binding affinity of dihydroroseoside and obacunone with both SOD and catalase compared to other phytoconstituents. Conclusion: These results portray a potent antioxidant and hepatoprotective effect of L. javanica, which may support the local usage of the herbal tea as a prospective therapeutic agent for oxidative stress-related liver diseases.

Promising hepatoprotective agents from the natural sources: a study of scientific evidence

Background

Natural bioactive components derived from plant secondary metabolites have been pronounced as valuable alternatives for anticipating and subsiding hepatotoxic effects and its chronic complications based on experimental verification. The focus of this review is to elucidate the commonly used modern medicine for the treatment of liver disease and how major phytoconstituents have been tested for hepatoprotective activity, mechanism of action of some promising agents from natural sources, and clinical trial data for treating in patients with different liver diseases by the aid of natural phytoconstituents.

Main text

The review shows fifteen major isolated phytoconstituents, their biological sources, chemical structures, utilized plant parts, type of extracts used, hepatoprotective assay method, and their possible mechanism of action on the hepatoprotection. Nine promising hepatoprotective leads from natural sources with their chemistry and hepatoprotective mechanism are mentioned briefly. The review further includes the recent clinical trial studies of some hepatoprotective leads and their clinical outcome with different liver disease patients. Scientific studies revealed that antioxidant properties are the central mechanism for the phytoconstituents to subside different disease pathways by upsurging antioxidant defense system of cells, scavenging free radicals, down surging lipid peroxidation, improving anti-inflammatory potential, and further protecting the hepatic cell injury. In this review, we summarize recent development of natural product-based hepatoprotective leads and their curative potential for various sort of liver diseases. Furthermore, the usefulness of hit and lead molecules from natural sources for significant clinical benefit to discover new drug molecule and downsizing the problems of medication and chemical-induced hepatotoxic effects is extrapolated.

Conclusion

Further research are encouraged to elucidate the pharmacological principle of these natural-based chemical agents which will stimulate future pharmaceutical development of therapeutically beneficial hepatoprotective regimens.

Plant-Derived Products with Therapeutic Potential against Gastrointestinal Bacteria

The rising burden of antimicrobial resistance and increasing infectious disease outbreaks, including the recent COVID-19 pandemic, has led to a growing demand for the development of natural products as a valuable source of leading medicinal compounds. There is a wide variety of active constituents found in plants, making them an excellent source of antimicrobial agents with therapeutic potential as alternatives or potentiators of antibiotics. The structural diversity of phytochemicals enables them to act through a variety of mechanisms, targeting multiple biochemical pathways, in contrast to traditional antimicrobials. Moreover, the bioactivity of the herbal extracts can be explained by various metabolites working in synergism, where hundreds to thousands of metabolites make up the extract. Although a vast amount of literature is available regarding the use of these herbal extracts against bacterial and viral infections, critical assessments of their quality are lacking. This review aims to explore the efficacy and antimicrobial effects of herbal extracts against clinically relevant gastrointestinal infections including pathogenic Escherichia coli, toxigenic Clostridioides difficile, Campylobacter and Salmonella species. The review will discuss research gaps and propose future approaches to the translational development of plant-derived products for drug discovery purposes for the treatment and prevention of gastrointestinal infectious diseases.

Natural Compounds as Integrative Therapy for Liver Protection against Inflammatory and Carcinogenic Mechanisms: From Induction to Molecular Biology Advancement

The liver is exposed to several harmful substances that bear the potential to cause excessive liver damage ranging from hepatitis and non-alcoholic fatty liver disease to extreme cases of liver cirrhosis and hepatocellular carcinoma. Liver ailments have been effectively treated from very old times with Chinese medicinal herbal formulations and later also applied by controlled trials in Japan. However, these traditional practices have been hardly well characterized in the past till in the last decades when more qualified studies have been carried out. Modern advances have given rise to specific molecular targets which are specifically good candidates for affecting the intricate mechanisms that play a role at the molecular level. These therapeutic regimens that mainly affect the progression of the disease by inhibiting the gene expression levels or by blocking essential molecular pathways or releasing cytokines may prove to play a vital role in minimizing the tissue damage. This review, therefore, tries to throw light upon the variation in the therapies for the treatment of benign and malignant liver disease from ancient times to the current date. Nonetheless, clinical research exploring the effectiveness of herbal medicines in the treatment of benign chronic liver diseases as well as prevention and treatment of HCC is still warranted.

Validation of Unani concept of Abadāl-i-Adwiya (drug substitution) by physicochemical standardization and hepatoprotective activity of Aristolochia rotunda Linn. and its substitute Curcuma Zedoaria Rosc. in albino Wistar rats

OBJECTIVES

To validate the concept of abadāl-i-adwiya (drug substitution) by evaluation of physicochemical standardization and hepatoprotective activity of Aristolochia rotunda & its substitute, Curcuma Zedoaria in albino Wistar rats.

METHODS

Physicochemical standardization by estimation of moisture content, ash values and extractive values were carried out using standard methods. Hepatotoxicity was induced in albino Wistar rats using CCl₄ 1 mL/kg s. c. on alternate day for 14 days. Group I was served as Plain control and Group II as Negative control. Group III was administered silymarin 50 mg/kg p. o. while Group IV received HAE of A. rotunda 89.64 mg/kg p. o., and Group V was administered HAE of C. Zedoaria 45.73 mg/kg p. o. At the end of the study, serum bilirubin, AST (SGOT), ALT (SGPT) and ALP were estimated. The histopathology of liver was also carried out.

RESULTS

The physicochemical parameters of both test drugs viz. moisture content, total ash, acid insoluble ash and water soluble ash were found within normal limit. The total serum bilirubin, direct bilirubin, AST (SGOT), ALT (SGPT) levels were significantly decreased in Test groups A and B when compared to the Negative and Standard controls. The microscopic examination of liver collected from animals of Group IV and Group V revealed significant recovery from hepatic toxicity compared to the Negative control.

CONCLUSIONS

The study experimentation has revealed that C. Zedoaria may be used as a substitute for A. rotunda in the treatment of liver diseases. However, the outcome has to be further corroborated with phytochemical evaluation and clinical trials of both the drugs. Furthermore, the concept of drug substitute in Unani system of medicine is also validated in the light of above study.

Antioxidant and Hepatoprotective Effect of a Nutritional Supplement with Silymarin Phytosome, Choline Chloride, l-Cystine, Artichoke, and Vitamin E in Dogs

Phytotherapy has been promoted for the treatment of liver diseases in dogs. The interest in identifying the antioxidant/hepatoprotective potential of various plants is increasing. Every 10 days for 30 days, forty dogs were subjected to blood sampling and hepatic ultrasound assessment. Clinically healthy dogs (group A) and dogs with liver enzyme and ultrasound hepatic aspects and sizes outside the physiological range (group B) were divided into two subgroups. Every day for 30 days, one subgroup received Epacare pet + pasta^® and the other received a placebo. Differences due to groups were observed in dROM, SHp, AST and LDH serum concentrations. The administration of Epacarepet + pasta^® for 30 days had an influence on the serum concentration of dROMs, SHp, AST, ALT, ALP, LDH, and urea. The application of paired Student's t-test showed a decrease in the longitudinal and transverse liver axis size. In conclusion, feed supplementation with Epacare pet + pasta^® had a beneficial effect on the antioxidant status and liver enzymes in animals with liver enzymatic alterations and in healthy dogs.

Herbal therapies in gastrointestinal and hepatic disorders: An evidence-based clinical review

The gastrointestinal tract (GIT) and the liver constitute the major organs of the human body. Indeed, the very survival of the human body depends on their proper functioning. Because the GIT is a huge and complex organ system, the maintenance of proper GIT and liver health is an arduous task. GIT disturbances such as diarrhea, stomach ache, flatulence, constipation, nausea, and vomiting are very common, and they contribute to a significant burden on the healthcare system. Pharmacies are full of over-the-counter pharmacological drugs to alleviate its common conditions. However, these drugs do not always prove to be fully effective and patients have to keep on living with these ailments without a proper and long-term solution. The aim of this review article is to present a practical reference guide to the role of herbal medicines in dealing with gastrointestinal and hepatic disorders, which is supported by systematic reviews and evidence-based trials. People have depended on herbal medications for centuries for the treatment of various ailments of the GIT, liver, and other organ system problems. Recently, this trend of incorporating herbal medication for the treatment of various diseases in both developing and developed countries have surged. Many people continue to use herbal medications, even though substantial data about their efficacy, uses, and toxicological effects do not exist. In addition, while herbal medicines have enormous benefits in both the prevention and the treatment of medical ailments, they can also have toxicological effects. It is, therefore, of the utmost importance that appropriate time, energy, and resources are spent on the development of ethnopharmacology. In addition, herbal products should be classified in a pattern similar to pharmacological medications, including their uses, side effects, mechanism of action, efficacy, and so on.

Therapeutic effects of mesenchymal stem cells-conditioned medium derived from suspension cultivation or silymarin on liver failure mice

BACKGROUND

Common treatments of liver disease failed to meet all the needs in this important medical field. It results in an urgent need for proper some new adjuvant therapies. Mesenchymal stem cells (MSCs) and their derivatives are promising tools in this regard. We aimed to compare the Silymarin, as traditional treatment with mesenchymal stem cell conditioned medium (MSC-CM), as a novel strategy, both with therapeutic potentialities in term of liver failure (LF) treatment.

METHODS AND RESULTS

Mice models with liver failure were induced with CCl₄ and were treated in the groups as follows: normal mice receiving DMEM-LG medium as control, LF-mice receiving DMEM-LG medium as sham, LF-mice receiving Silymarin as LF-SM, and LF-mice receiving MSC sphere CM as LF-MSC-CM. Biochemical, histopathological, molecular and protein level parameters were evaluated using blood and liver samples. Liver enzymes, MicroRNA-122 values as well as necrotic score were significantly lower in the LF-SM and LF-MSC-CM groups compared to sham. LF-SM showed significantly higher level of total antioxidant capacity and malondialdehyde than that of LF-MSC-CM groups. Sph-MSC-CM not only induced more down-regulated expression of fibrinogen-like protein 1 and receptor interacting protein kinases1 but also led to higher expression level of keratinocyte growth factor. LF-MSC-CM showed less mortality rate compared to other groups.

CONCLUSIONS

Hepato-protective potentialities of Sph-MSC-CM are comparable to those of Silymarin. More inhibition of necroptosis/ necrosis and inflammation might result in rapid liver repair in case of MSC-CM administration.

Brassica oleracea L. var. botrytis Leaf Extract Alleviates Gentamicin-Induced Hepatorenal Injury in Rats—Possible Modulation of IL-1β and NF-κB Activity Assisted with Computational Approach

Background: Recently, crop byproducts are considered a hot topic and can be converted into beneficial products. Cauliflower is well-known for its protective effects against oxidative stress-induced damage. The current study aimed to investigate the chemical profile and the ameliorative effects of cauliflower leaf extract (CL) on gentamicin-induced renal and hepatic injuries in rats. Methods: Cauliflower leaf was extracted with methanol to give the total methanol extract (TME) followed by the determination of total phenolic contents (TPC). Rats were divided into five groups; Group I was assigned as the control group, while the other groups were injected with gentamicin for ten days. Group II was given distilled water. Rats in groups III and IV were treated with oral CL (200 mg/kg and 400 mg/kg, respectively). Group V received L-cysteine (as a positive control). The functions of the kidneys and liver; oxidative stress and morphological and apoptotic changes of renal and hepatic tissues were assessed. Results: The TME was subjected to chromatographic techniques to yield ferulic acid, vanillic acid, p-coumaric acid and quercetin. TPC was 72.31 mg GAE/g of dried extract. CL treatment dose-dependently ameliorated gentamicin-induced impaired kidney and liver functions and improved the histopathological appearance of both organs. It also reduced gentamicin-induced oxidative stress. CL demonstrated downregulation of mRNA and protein expressions of IL-1β and NF-κB compared to nontreated rats. In silico interaction of the isolated compounds with amino acid residues of IL-1β and NF-κB might explain the current findings. Conclusion: Taken together, this study raises the waste-to-wealth potential of cauliflower to mitigate gentamicin-induced hepatorenal injury and convert the waste agromaterials into valuable products.

Identification of phytochemicals from Eclipta alba and assess their potentiality against Hepatitis C virus envelope glycoprotein: virtual screening, docking, and molecular dynamics simulation study

Hepatitis C virus has a major role in spreading chronic liver disease and hepatocellular carcinoma. Factors such as high costs, pharmacological side effects, and the development of drug resistance strains require the development of new and potentially effective antiviral to treat the various stages of Hepatitis C. Bioactive chemicals have been extracted from medicinal plants and are utilized by humans for the goal of maintaining a healthy lifestyle. The goal of this work is to recognize phytochemicals from Eclipta alba and assess their potentiality activity against the hepatitis C virus envelope glycoprotein using in silico approaches. Phytochemicals from Eclipta alba were virtually screened by Auto dock raccoon and 12 compounds were selected for molecular docking to probe the active binding site. The top two compounds based on the binding score like ecliptalbine and oleanolic acid with HCV E2 glycoprotein exhibit binding energy -8.88 and -8.02 kcal/mol, respectively. The chemicals' usefulness was reinforced by positive pharmacokinetic data. The phytocompounds were identified as potent HCV inhibitors based on the drug likeness and ADMET properties. Both ecliptalbine and oleanolic acid underwent molecular dynamics simulations to determine features such as RMSD, RMSF, SASA, hydrogen-bond number, and MM-PBSA-based binding free energy. From the molecular docking and molecular dynamics simulation study revealed that oleanolic acid obtained from Eclipta alba can be used as inhibitors against Hepatitis C. The identified inhibitor from our study will be study in vitro and in vivo studies to check their efficacy against Hepatitis C.Communicated by Ramaswamy H. Sarma.

Hepatoprotective effect of Physalis divaricata in paracetamol induced hepatotoxicity: In vitro, in silico and in vivo analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Physalis divaricata D. Don. is an erect weed of family Solanaceae. The root extract of this plant is used by the indigenous communities of Sub-Himalayan region of Uttarakhand, India for the treatment of liver disorders.

AIM OF THE STUDY

To evaluate hepatoprotective potential of P. divaricata in paracetamol (PCM) induced hepatotoxicity in rats.

MATERIALS AND METHODS

The dried roots of P. divaricata were subjected to extraction using different solvents. The chloroform extract, methanol extract and bioactive aqueous fraction of methanol extract were evaluated for hepatoprotective effect. After initial in vitro screening, all extracts were screened for hepatoprotective potential in PCM (3 g/kg p.o) induced hepatotoxicity. Following PCM administration, extracts were administered orally for 7 days in increasing dose concentrations. All the animals were euthanized on eighth day, serum and liver tissues were collected and subjected to various biochemical and histopathological analysis. Aqueous fraction of methanol extract was further analyzed using LC- MS analysis.

RESULTS

Methanol extract and its bioactive aqueous fraction exhibited significant and better in vitro antioxidant and antiproliferative activity as compared to chloroform extract. PCM treatment caused hepatotoxicity as assessed by altered levels of various hepatic biomarkers (increase in the levels of ALT, AST, ALP, albumin, triglycerides, cholesterol, TBARS, and AOPPs as well as decrease in GSH and TrxR levels) along with histopathological changes (portal to portal bridging, necrosis, and inflammation). Methanolic extract (200, 400 and 800 mg/kg) and its aqueous fraction treatment (25, 50 and 100 mg/kg) significantly restored elevated hepatic biomarkers, oxidative stress, and protected normal hepato-architecture. LC-MS analysis of aqueous fraction showed presence of rutin and kaempferol. In silico analysis further showed the capability of rutin to make complex with TNF-α and block its interaction with the target site.

CONCLUSION

Aqueous fraction showed maximum hepatoprotective potential as conceived through in vitro and in vivo studies. Presence of rutin may explain hepatoprotective potential of P. divaricata.

Assessment of membrane stability, central nervous system depressant, and gut motility effects of Lablab purpureus seeds

Introduction: Lablab purpureus, under the family of Fabaceae, is a plant with various pharmacological activities. The present study was aimed to investigate the phytoconstituents, membrane stabilizing activity, central nervous system (CNS) depressant potential, and gastrointestinal (GI) motility of the methanol extract of L. purpureus seeds (MELPS).Methods: The methanol plant extract was screened for different phytochemical groups. Mice were classified into four groups for in vivo activities. Group-I was designated as negative control and received distilled water (10 mL/kg body weight); group-II served as positive control and received diazepam (1 mg/kg body weight). Group-III and group-IV both were experimental groups and received plant extract at 200 and 400 mg/kg body weight, respectively.Results: Alkaloids, carbohydrates, saponins, glycosides, tannins, phenols, flavonoids, and proteins were found after phytochemical analysis. On hypotonic solution-induced hemolysis of erythrocyte membrane, MELPS9 (9 mg/mL) resulted in the highest percentage of inhibition (60.51 ± 0.889), and on heat-induced hemolysis, MELPS9 (9 mg/mL) resulted in the highest percentage of inhibition (33.97 ± 0.21). In the case of the CNS depressant potential experiment, mice that received a sample at a dose of 400 mg/kg body weight showed the highest result (54.40 ± 4.51) compared with the positive control (14.2 ± 3.70) (P < 0.001). Similarly, 400 mg/kg dose sample exhibited the highest percentage of inhibition (60.51 ± 0.889) of hemolysis and GI motility (22.26%).Conclusion: It can be concluded that the MELPS has potential membrane stability, CNS depressant, and antimotility effects.

Hepatoprotective Potential of Malaysian Medicinal Plants: A Review on Phytochemicals, Oxidative Stress, and Antioxidant Mechanisms

Hepatotoxicity is a major global public health concern. Despite advances in modern medicine, the demerits of chemically prepared drugs outweigh their merits. In addition, the treatment of liver diseases based on modern medical principles has been found to produce several undesired side effects. Therefore, the exploration of medicinal plants has gained worldwide attention for treating various diseases, including liver diseases, owing to their potential efficacy and cost effectiveness. Several plants, including Andrographis paniculata, Bauhinia purpurea, Commelina nudiflora, Dillenia suffruticosa, Elaeis guineensis, Lygodium microphyllum, and Nephrolepis biserrata, have been reported with hepatoprotection. Moreover, these plants have been shown to play a vital role in ameliorating cellular damage because they contain several phytochemicals, including alkaloids, saponins, flavonoids, tannins, terpenoids, steroids, polyphenols, and diterpenoid lactones. The following antioxidant, anti-inflammatory, immunomodulatory, and hepatoprotective compounds have been found in these plants: andrographolide, rosmarinic acid, phenol, eugenol, 9,12-octadecadienoic, n-hexadecanoic acid, dihydroxy dimethoxy flavone, sitosterol, demethoxycurcumin, quercetin, linoleic acid, stigmasterol, kojic acid, indole-2-one, α-terpinol, linalool, kaempferol, catechin, ellagic acid, and oleanolic acid. This paper aimed to provide an in-depth review of in vivo studies on Malaysian medicinal plants possessing hepatoprotective properties, phytochemical ingredients, and antioxidant mechanisms, with an emphasis on the species proven particularly useful for treating hepatic disorders.

Combined Treatment with Herbal Medicine and Drug Ameliorates Inflammation and Metabolic Abnormalities in the Liver of an Amyotrophic Lateral Sclerosis Mouse Model

To date, no effective drugs exist for amyotrophic lateral sclerosis (ALS), although riluzole (RZ) and edaravone have been approved for treatment. We previously reported that Bojungikgi-tang (BJIGT) improved motor activity through anti-inflammatory effects in the muscle and spinal cord of hSOD1^G93A mice. Therefore, whether combined treatment with BJIGT and RZ synergistically affects liver function in hSOD1^G93A mice was investigated. Two-month-old male hSOD1^G93A mice were treated with BJIGT (1 mg/g) and RZ (8 μg/g) administered orally for 5 weeks. Drug metabolism and liver function tests of serum and liver homogenates were conducted. mRNA expression levels of cytochrome P450 (CYP) isozymes, inflammatory cytokines, metabolic factors, and mitochondrial oxidative phosphorylation (OXPHOS) subunits were examined using qPCR and Western blotting. Combined administration of BJIGT and RZ did not alter mRNA expression levels of drug-metabolism-related isozymes (CYP1A2 and CYP3A4) but significantly decreased the activity of liver-function-related enzymes (AST, ALT, ALP, and LDH). Increased expression of inflammatory cytokines (IL-1β, TNF-α, and IL-6) and of intracellular stress-related proteins (Bax, AMPKα, JNK, and p38) was reduced by the combined treatment in hSOD1^G93A mice compared to that in control mice. Combined administration reduced the mRNA expression of metabolism-related factors and the expression of OXPHOS subunits. Elevated ATP levels and mitochondrial-fusion-associated protein were decreased after co-administration. Co-administration of BJIGT and RZ did not cause liver damage or toxicity but rather restored liver function in hSOD1^G93A mice. This suggests that this combination can be considered a candidate therapeutic agent for ALS.

Antioxidant properties of red raspberry extract alleviate hepatic fibrosis via inducing apoptosis and transdifferentiation of activated hepatic stellate cells

Hepatic fibrosis is a wound-healing process caused by prolonged liver damage and often occurs due to hepatic stellate cell activation in response to reactive oxygen species (ROS). Red raspberry has been found to attenuate oxidative stress, mainly because it is rich in bioactive components. In the current study, we investigated the inhibitory effects and associated molecular mechanisms of red raspberry extract (RBE) upon activated hepatic stellate cell (aHSC) in cellular and rat models. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were increased in the dimethylnitrosamine (DMN)-applied samples, whereas treatment of RBE significantly suppressed the activities of these enzymes. In addition, a histopathological analysis demonstrated that RBE could substantially diminish the hepatic collagen content and alpha-smooth muscle actin (α-SMA) expression induced by DMN. Administration of 250 μg/mL RBE could also arrest the growth and enhance the apoptosis of activated HSC-T6 cells, which was accompanied with elevated levels of activated caspases and poly (ADP-ribose) polymerase (PARP) cleavage. Particularly, RBE application remarkably abolished oxidative damage within the cells and reduced the carbonylation of proteins, which was attributed to the upregulation of catalase, nuclear factor erythroid 2-related factor 2 (Nrf2), and heme oxygenase-1 (HO-1). Moreover, the knockdown of Nrf2 together with the RBE treatment synergistically abrogated the expression of α-SMA and promoted the level of peroxisome proliferator-activated receptor gamma (PPAR-γ), suggesting that RBE could mitigate the transdifferentiation of HSC in a Nrf2-independent manner. These findings implied that the application of RBE could effectively remove oxidative stress and relieve the activation of HSC via modulating the caspase/PARP, Nrf2/HO-1 and PPAR-γ pathways, which may allow the development of novel therapeutic strategies against chemical-caused liver fibrogenesis.

Antioxidant and anti-apoptotic prophylactic effect of silymarin against lead-induced hepatorenal toxicity in rats

This study assessed prophylactic potentials of silymarin against lead-induced hepatorenal toxicity in rats with the respect to its antioxidant and anti-apoptotic activities. Forty male albino rats were distributed into four groups. Control group is provided with distilled water. Lead acetate group was given lead acetate (100 mg/kg bwt) orally for 10 weeks. The third and fourth groups administered silymarin at doses of 50 or 100 mg/kg bwt, respectively, 1 h before administration of lead acetate for 10 weeks. Lead acetate altered liver structure and function that represented by significant elevation of the activities of serum aspartate and alanine aminotransferases and serum levels of urea and creatinine. Hepatic and renal tissues' malondialdehyde concentrations were increased, while reduced glutathione content and superoxide dismutase and catalase activities were reduced in the lead acetate group. Also, lead acetate increased caspase-3 mRNA expression and inhibited alpha-fetoprotein mRNA expression in hepatic tissues, as well as it altered liver and kidney tissues' architectures. In contrast, silymarin ameliorated in a dose dependent mannar the toxic effects of lead acetate on the liver and kidneys through modulation of lead acetate which altered liver and kidney function and structures via reducing lipid oxidation and pathological changes of hepatic and renal tissue structure, improving antioxidant defense system of liver and kidneys, and decreasing pro-apoptotic gene expression in hepatic tissue. This study indicated that silymarin ameliorated lead acetate-induced hepatorenal toxicity via its antioxidant and cytoprotective potentials.

Roles of Suaeda vermiculata Aqueous-Ethanolic Extract, Its Subsequent Fractions, and the Isolated Compounds in Hepatoprotection against Paracetamol-Induced Toxicity as Compared to Silymarin

Suaeda vermiculata, a halophyte consumed by livestock, is also used by Bedouins to manage liver disorders. The aqueous-ethanolic extract of S. vermiculata, its subsequent fractions, and pure compounds, i.e., pheophytin-A (1), isorhamnetin-3-O-rutinoside (2), and quercetin (3), were evaluated for their hepatoprotective efficacy. The male mice were daily fed with either silymarin, plant aq.-ethanolic extract, fractions, pure isolated compounds, or carboxyl methylcellulose (CMC) for 7 days (n = 6/group, p.o.). On the day 7th of the administrations, all, except the intact animal groups, were induced with hepatotoxicity using paracetamol (PCM, 300 mg/kg). The anesthetized animals were euthanized after 24 h; blood and liver tissues were collected and analysed. The serum aspartate transaminase (AST) and alanine transaminase (ALT) levels decreased significantly for all the S. vermiculata aq.-ethanolic extract, fraction, and compound-treated groups when equated with the PCM group (p < 0.0001). The antioxidant, superoxide dismutase (SOD), increased significantly (p < 0.05) for the silymarin-, n-hexane-, and quercetin-fed groups. Similarly, the catalase (CAT) enzyme level significantly increased for all the groups, except for the compound 2-treated group as compared to the CMC group. Also, the glutathione reductase (GR) levels were significantly increased for the n-butanol treated group than for the PCM group. The oxidative stress biomarkers, lipid peroxide (LP) and nitric oxide (NO), the inflammatory markers, IL-6 and TNF-α, and the kidney's functional biomarker parameters remained unchanged and did not differ significantly for the treated groups in comparison to the PCM-induced toxicity bearing animals. All the treated groups demonstrated significant decreases in cholesterol levels as compared to the PCM group, indicating hepatoprotective and antioxidant effects. The quercetin-treated group demonstrated significant improvement in triglyceride level. The S. vermiculata aq.-ethanolic extract, fractions, and the isolated compounds demonstrated their hepatoprotective and antioxidant effects, confirming the claimed traditional use of the herb as a liver protectant.

Non-pharmacologic approach to pediatric constipation

Functional constipation (FC) is a pervasive problem in pediatrics. Although pharmaceuticals are commonly used for FC, parents and patients show reluctance or find dissatisfaction with available medications at times. Further, patients often have interest in utilizing nutraceutical supplements and botanicals that are available over the counter. This literature review aims to summarize research studies performed on non-pharmacologic approaches to constipation and to evaluate the safety and efficacy of these modalities. Overall data on non-pharmacologic treatments for childhood constipation were sparse, and though some studies were available for adult populations, pediatrics studies were generally limited, lacking or flawed. Certain supplements, such as prebiotics, probiotics and fiber, are safe and are without significant side effects. Though fiber supplements such as glucomannan, green banana mass, cocao husk and various fiber blends have emerging evidence in children, evidence for psyllium, cellulose and flaxseed only have supportive studies in adults. Other than senna, studies of botanicals indicate significant safety concerns (in particular with Aloe vera with aloin and Cascara sagrada) and insufficient evidence. For patients with a significant behavioral or anxiety component to their FC and exhibit dyssynergia, mind-body interventions (e.g. diaphragmatic breathing, biofeedback, cognitive behavioral therapy, and behavioral modifications) are certainly safe and effective. Finally, movement and manipulative interventions such as abdominal massage, reflexology, acupuncture and transcutaneous nerve stimulation show promise in the field of pediatric constipation, and data is accumulating for efficacy. These modalities require further study to determine mechanisms of action and which populations may benefit the most from these therapies.

Salvianolic acid B protects against acute and chronic liver injury by inhibiting Smad2C/L phosphorylation

Salvianolic acid B (Sal B) has strong antioxidant and anti-fibrosis effects, which are related to the transforming growth factor β/Smad signaling pathway. However, how Sal B affects this antioxidant pathway and the phosphorylation (p-) of Smad2 at both the COOH-terminal (pSmad2C) and linker region (pSmad2L) are unknown. The aims of the present study were to investigate the underlying mechanisms of Sal B on acute and chronic liver injury induced by CCl₄ and H₂O₂, and its effects on p-Smad2C/L. In in vivo experiments, acute and chronic liver injury models were induced by CCl₄, and the oxidative damage cell model was established in vitro with H₂O₂. Liver histopathology was assessed using hematoxylin and eosin and Van Gieson's staining. Moreover, serum biochemical indicators were analyzed using specific assay kits. Furthermore, the present study evaluated the oxidant/antioxidant status in acute and chronic liver injury models by oxidative stress parameters such as malondialdehyde, glutathione and superoxide dismutase. In addition, western blot analysis was performed to analyze the protein expression levels of pSmad2C, pSmad2L, nuclear factor erythroid-2-related factor 2 (Nrf2) and heme oxygenase-1 (HO-1). It was found that Sal B improved liver histology, decreased the levels of aminotransferase and attenuated oxidative stress in acute and chronic liver injury models. Additionally, the protein expression levels of pSmad2C and pSmad2L were decreased, but Nrf2 and HO-1 expression levels were increased both in vivo and in vitro. Collectively, the present results suggested that Sal B may protect against acute and chronic liver injury via inhibition of Smad2C/L phosphorylation, and the Nrf2/HO-1 signaling pathway may play an important role in this process.

Toxic Prediction of Pyrrolizidine Alkaloids and Structure-Dependent Induction of Apoptosis in HepaRG Cells

Pyrrolizidine alkaloids (PAs) are common phytotoxins and could cause liver genotoxicity/carcinogenicity following metabolic activation. However, the toxicity of different structures remains unclear due to the wide variety of PAs. In this study, the absorption, distribution, metabolism, excretion, and toxicity (ADMET) of 40 PAs were analyzed, and their toxicity was predicted by Komputer Assisted Technology (TOPKAT) using Discovery Studio software. The in silico results showed that all PAs except retronecine had good intestinal absorption, and all PAs were predicted to have different toxicity ranges. To verify the predictive results, 4 PAs were selected to investigate cell injury and possible mechanisms of the differentiation in HepaRG cells, including retronecine type of twelve-membered cyclic diester (retrorsine), eleven-membered cyclic diester (monocrotaline), noncyclic diester (retronecine), and platynecine type (platyphylline). After 24 h exposure, retronecine-type PAs exhibited concentration-dependent cytotoxicity. The high-content screening assay showed that cell oxidative stress, mitochondrial damage, endoplasmic reticulum stress, and the concentration of calcium ions increased, and neutral lipid metabolism was changed notably in HepaRG cells. Induced apoptosis by PAs was indicated by cell cycle arrest in the G2/M phase, disrupting the mitochondrial membrane potential. Overall, our study revealed structure-dependent cytotoxicity and apoptosis after PA exposure, suggesting that the prediction results of in silico have certain reference values for compound toxicity. A 1,2-membered cyclic diester seems to be a more potent apoptosis inducer than other PAs.

Studies on Ethanol Extracts of Olax subscorpioidea Against Carbon Tetrachloride-Induced Hepatotoxicity in Rats

<b>Background and Objective:</b> Liver disease orchestrated by noxious chemicals are serious health problems the world over. Traditionally, there are claims that ethanol extracts of leaves and stem barks of <i>Olax subscorpioidea</i> are used in the treatment of hepatic disorders. Thus, it investigated the impacts of ethanol extract of leaves and stem bark of <i>Olax subscorpioidea</i> against carbon tetrachloride (CCl₄)-induced liver damage in rats. <b>Materials and Methods:</b> Liver toxicity was induced by intraperitoneal injection of 2.5 mg kg¹ b.wt., of CCl₄ in experimental rats. Rats were treated with 200, 400 and 800 mg kg¹ dose ethanol leaves and stem bark of <i>Olax subscorpioidea</i>, respectively after induction of liver damage. <b>Results:</b> Obtained results showed a significant rise in the serum levels of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), Alkaline Phosphatase (ALP), Malondialdehyde (MDA) and bilirubin as well as decreased Albumin (ALB), Superoxide Dismutase (SOD), Catalase (CAT), reduced Glutathione (GSH) in CCl₄-challenged rats. Treatment with the extracts attenuated serum levels of AST, ALT, ALP, MDA and bilirubin in addition to increased activities of SOD, CAT and the levels of ALB and GSH when compared to the CCl₄ group. Histopathological studies demonstrated that the extracts ameliorated liver necrosis and inflammation due to CCl₄ insult. <b>Conclusion:</b> These results concluded that ethanol extract of leaves and stem bark of <i>Olax subscorpioidea </i>may reduce hepatic oxidative injury caused by CCl₄ by its antioxidant potentials.

Astragaloside IV Induces Apoptosis, G1-Phase Arrest and Inhibits Anti-apoptotic Signaling in Hepatocellular Carcinoma

BACKGROUND/AIM

Hepatocellular carcinoma (HCC) is a primary malignancy of the liver and the third leading cause of cancer death worldwide. Although multiple chemotherapies options are available for HCC, chemo-induced toxicity is inevitable during clinical treatment. Therefore, identifying possible adjuvant agents with both liver-protective and antitumor effects is critical. Herbal medicines have chemopreventive and anti-HCC effect, such as Juzen taiho-to and Sho-saiko-to. Astragaloside IV is a compound extracted from the Chinese medical herb Astragalus membranaceus (Fisch.) Bge. with liver protection potential. However, whether astragaloside IV may also possess tumor-inhibitory capability and its underlying mechanism is remaining unknown.

MATERIALS AND METHODS

Viability analysis, cell-cycle analysis, apoptosis analysis, western blotting analysis and invasion trans-well assay were performed to identify tumor-inhibitory potential of astragaloside IV on HCC cells (SK-Hep1 and Hep3B cells).

RESULTS

We found that astragaloside IV may induce cytotoxicity and extrinsic/intrinsic apoptosis effect, but also trigger G₁ arrest in HCC cells. The expression of anti-apoptotic proteins of HCC were all reduced by astragaloside IV. Additionally, astragaloside IV also suppressed HCC cell invasion ability.

CONCLUSION

Astragaloside IV effectively suppressed HCC cell proliferation, invasion and anti-apoptosis in vitro.

β-Sitosterol attenuates liver injury in a rat model of chronic alcohol intake

Liver disease associated with long-term drinking is one of the leading causes of death. There is an urgent need for more effective drugs to reduce alcoholic liver damage. Yin Chen Hao, a traditional Chinese herbal medicine, is widely used for liver diseases. Here, we aimed to explore the protective effect of β-sitosterol (the active ingredient of Artemisia spp.) on alcoholic liver injuries. We treated the rats with alcohol and different dosages of β-sitosterol to detect the expression levels of liver function indicators in serum. The functions of β-sitosterol were evaluated based on variations in histology, liver function indicators and DNA oxidative damages. The underlying mechanism was investigated by measuring lipid peroxidation, the antioxidant, the expression of cytochrome P450 2E1 and the expression of apoptosis related genes. The results showed that β-sitosterol could improve liver histology and suppress biochemical indicators caused by alcohol in serum. In addition, β-sitosterol alleviates alcohol-induced oxidative stress, such as restoring erythrocyte membrane fluidity, reducing glutathione depletion, restoring antioxidant enzyme activity and reducing malondialdehyde overproduction. Furthermore, β-sitosterol downregulated the expression of apoptosis-related genes through the PI3K/Akt pathway. In conclusion, β-sitosterol has a protective effect on chronic alcoholism and has broad clinical application prospects in the treatment of alcohol-induced liver damage.

Anti-cancer properties of specific Chinese herbal medicines for hepatocellular carcinoma treatment

AIMS

This essay explores the anti-cancer activity of specific Chinese herbal medicines to clarify how effective Chinese herbal medicine is used for handling hepatocellular carcinoma.

METHODS

Literature form publica domain were studied and an analysis of anti-cancer activity of specific Chinese herbal medicines is presented in this review.

RESULTS

Hepatocellular carcinoma is one of the most dangerous malignant tumors in the world. The operative diagnosis of liver cancer remains a significant challenge. Although surgery tissue resection is encouraging, a high risk of recurrence and metastasis, illustrating disease-related mortality is desperately required to enhance postoperative preventive and therapeutic clinical procedures. The almost only effective clinical intervention seems to be developing advanced targeted therapies such as sorafenib for hepatocellular carcinoma patients, but there is little research in this field. Because their preventative/therapeutic properties strengthen Chinese herbal medicinal compounds, they are deemed relevant to the treatment of hepatocellular carcinoma. Conclusion: Chinese herbal medicine derivates provide multifaceted, orientated and orchestrated therapy, making it an ideal candidate for inhibiting hepatocellular tumor production and metastasis.

Traditional Uses, Chemical Constituents, Biological Properties, Clinical Settings, and Toxicities of Abelmoschus manihot L.: A Comprehensive Review

Abelmoschus manihot, an annual herbal flowering plant, is widely distributed throughout eastern Europe and in temperate and subtropical regions of Asia. Its flowers have been traditionally used for the treatment of chronic kidney disease in China. Currently, more than 128 phytochemical ingredients have been obtained and identified from the flowers, seeds, stems, and leaves of A. manihot. The primary components are flavonoids, amino acids, nucleosides, polysaccharides, organic acids, steroids, and volatile oils. A. manihot and its bioactive constituents possess a plethora of biological properties, including antidiabetic nephropathy, antioxidant, antiadipogenic, anti-inflammatory, analgesic, anticonvulsant, antidepressant, antiviral, antitumor, cardioprotective, antiplatelet, neuroprotective, immunomodulatory, and hepatoprotective activities, and have effects on cerebral infarction, bone loss, etc. However, insufficient utilization and excessive waste have already led to a rapid reduction of resources, meaning that a study on the sustainable use of A. manihot is urgent and necessary. Moreover, the major biologically active constituents and the mechanisms of action of the flowers have yet to be elucidated. The present paper provides an early and comprehensive review of the traditional uses, chemical constituents, pharmacological activities, and pharmaceutical, quality control, toxicological, and clinical settings to emphasize the benefits of this plant and lays a solid foundation for further development of A. manihot.

Protective effect of picroside I against hepatic fibrosis in mice via sphingolipid metabolism, bile acid biosynthesis, and PPAR signaling pathway

Picroside I, a hepatoprotectant isolated from Picrorhiza kurroa Royle ex Benth and P. scrophulariiflora Pennell, can reduce liver injury in humans and animals. However, its anti-fibrosis effect remains elusive. This work aimed to explore the mechanism underlying the hepatoprotective effect of picroside I against hepatic fibrosis. Male mice (12 mice per group) were randomly divided into six groups: the control group; the model group, which received thioacetamide (TAA); the positive group, which received TAA + S-(5'-adenosyl)-l-methionine (SAMe, 10 mg/kg); the low-dose group, which received TAA + picroside I (25 mg/kg); the middle-dose group, which received TAA + picroside I (50 mg/kg); and the high-dose group, which received TAA + picroside I (75 mg/kg). Serum biochemical indicators were detected, and histological evaluation was performed. Metabolomics and proteomic analyses were conducted via liquid-chromatography coupled with tandem mass spectrometry (LC-MS/MS). Data showed that picroside I could decrease the serum levels of alanine transaminase (ALT), aspartate transaminase (AST), collagen type IV (CIV), N-terminal peptide of type III procollagen (PIIINP), laminin (LN), and hyaluronic acid (HA) and reduced fibrosis area. Picroside I altered metabolomic profiles, including energy, lipid, and glutathione (GSH) metabolism, in ice with fibrosis. Additionally, 25 differentially expressed proteins in the picroside I high-dose-treated group were reversed relative to in the model group. These proteins were involved in the sphingolipid signaling pathway, primary bile acid biosynthesis, and peroxisome proliferator-activated receptor (PPAR) signaling pathway. Moreover, this study revealed how picroside I could protect against TAA-induced liver fibrosis in mice. Results indicated that picroside I can serve as a candidate drug for hepatic fibrosis.

Composite ammonium glycyrrhizin has hepatoprotective effects in chicken hepatocytes with lipopolysaccharide/enrofloxacin-induced injury

Composite ammonium glycyrrhizin (CAG) has anti-inflammatory activity. Lipopolysaccharide (LPS) and enrofloxacin (ENR) induce liver damage; however, the mechanism underlying LPS/ENR-induced hepatic injury remains to be elucidated. In the present study, the mechanism of LPS/ENR-induced liver injury was investigated in vitro and the protective effects of CAG were also evaluated. Primary chicken hepatocytes were isolated and a model of LPS/ENR-induced hepatocyte injury was established. mRNA and protein expression levels were evaluated by reverse transcription-quantitative polymerase chain reaction and western blot, respectively. LPS/ENR exposure significantly increased supernatant aspartate aminotransferase (AST) and alanine aminotransferase (ALT). In the LPS/ENR-treated group, glutathione (GSH) and the antioxidant enzymes, superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) activities were significantly increased. Flow cytometry results revealed that the apoptotic rate significantly increased in the LPS/ENR-treated group compared with the control, while treatment with CAG given 24 h prior to LPS/ENR caused a significant decrease in the apoptotic rate compared with the model group. Furthermore, CAG treatment reversed LPS/ENR-associated alterations in the mRNA and protein expression of Caspase-3, apoptosis regulator Bcl-2 (Bcl-2) and Bcl-2 associated X-protein. The mitochondrial membrane potential significantly decreased and the mitochondrial microstructure was notably altered following exposure to LPS/ENR compared with the control. In conclusion, these results suggested that LPS/ENR-treated hepatocytes were damaged via apoptotic signaling pathways and CAG prevented LPS/ENR-induced hepatocyte injury.

Glycyrrhizic Acid Modulates Apoptosis through Extrinsic/Intrinsic Pathways and Inhibits Protein Kinase B- and Extracellular Signal-Regulated Kinase-Mediated Metastatic Potential in Hepatocellular Carcinoma In Vitro and In Vivo

A previous study presented that glycyrrhizic acid as the hepatoprotective agent inhibits total parenteral nutrition-associated acute liver injury in rats. However, the anticancer effect and mechanism of glycyrrhizic acid in human hepatocellular carcinoma (HCC) is ambiguous. The purpose of the present study was to investigate the effect of glycyrrhizic acid on apoptosis dysregulation and metastatic potential in HCC in vitro and in vivo. Both SK-Hep1 and Hep3B cells were treated with different concentrations of glycyrrhizic acid for 24 or 48h. SK-Hep1/luc2 tumor-bearing mice were treated with vehicle or glycyrrhizic acid (50mg/kg/day by intraperitoneal injection) for 7 days. Tumor cells growth, apoptotic, and metastatic signaling transduction were evaluated by using MTT assay, digital caliper, bioluminescence imaging (BLI), flow cytometry, western blotting assay, and immunohistochemistry (IHC) staining. The results demonstrated glycyrrhizic acid significantly inhibits tumor cell growth, cell invasion, and expression of AKT (Ser473), extracellular-signal-regulated kinase (ERK), epidermal growth factor receptor (EGFR) phosphorylation, anti-apoptotic and metastatic proteins in HCC in vitro and in vivo. Glycyrrhizic acid also significantly triggered apoptosis and extrinsic/intrinsic apoptotic signaling transduction. In addition, PD98059 (ERK inhibitor) and LY294002 (AKT inhibitor) obviously reduced cell invasion and expression of metastasis-associated proteins. Taken together, these results indicated that glycyrrhizic acid induces apoptosis through extrinsic/intrinsic apoptotic signaling pathways and diminishes EGFR/AKT/ERK-modulated metastatic potential in HCC in vitro and in vivo.

Improved hepatoprotective activity of Beta vulgaris L. leaf extract loaded self-nanoemulsifying drug delivery system (SNEDDS): in vitro and in vivo evaluation

OBJECTIVE

Beta vulgaris L. (beetroot) is a vegetable plant rich in phytochemical compounds such as phenolic acids, carotenoids and flavonoids. The objective of the current study is the development and optimization of self-nanoemulsifying drug delivery systems (SNEDDSs) to enhance the hepatoprotective activity of beet leaf (BL) extract.

METHODS

Total flavonoids content was estimated in the BL extract and its solubility was evaluated in various vehicles to select proper component combinations. Pseudo-ternary phase diagrams were constructed employing olive, linseed, castor and sesame oils (oil phase), Tween^® 20 (Tw20) and Tween^® 80 (Tw80) (surfactants (SAs)) as well as dimethyl sulfoxide (DMSO) and propylene glycol (PG) (co-surfactants (Co-SAs)). Optimization of formulations from the phase diagrams took place through testing their thermodynamic stability, dispersibility and robustness to dilution.

RESULTS

Four optimized BL-SNEDDS formulations, comprising linseed oil or olive oil, Tw80 and DMSO at two SA/Co-SA ratios (2:1 or 3:1) were chosen. They exhibited high cloud point and percentage transmittance values with spherical morphology of mean droplet sizes ranging from 14.67 to 16.06 nm and monodisperse distribution with negatively charged zeta potential < -9.51 mV. The in vitro release profiles of the optimized formulations in pH 1.2 and 6.8 were nearly similar, with a non-Fickian release mechanism. In vivo evaluation of BL-SNEDDSs hepatoprotective activity in a thioacetamide-induced hepatotoxicity rat model depicted promoted liver functions, inflammatory markers and histopathological findings, most prominently in the group treated by F7.

CONCLUSION

The results indicate that SNEDDS, as a nanocarrier system, has potential to improve the hepatoprotective activity of the BL extract.

Preclinical Evidence of Curcuma longa and Its Noncurcuminoid Constituents against Hepatobiliary Diseases: A Review

Hepatobiliary disease currently serves as an important public health issue due to the fact that it is one of the major causes of death among economically active individuals and can easily progress to chronic diseases. Despite the development of vaccines and numerous drugs, a definite treatment remains lacking owing to different stages of the disease itself, its intricate pathogenesis, an effect uncertainty for long-term use, resistance, and side effects. Curcuma longa (C. longa), which belongs to the family Zingiberaceae and the genus Curcuma, has long been used not only as spice for curry or dye but also as a constituent of herbal formula for the treatment of different diseases due to its bioactive activities. Recently, many studies on the experimental results of C. longa have been published relative to hepatobiliary diseases such as fatty liver, hepatitis, cirrhosis, and tumors. Therefore, in this review, we aimed to summarize the pharmacological effects and underlying molecular mechanisms of C. longa and its four compounds, β-elemene, germacrone, ar-turmerone, and bisacurone, against hepatobiliary diseases. C. longa exhibited antioxidant, hepatoprotective, antisteatotic, anti-inflammatory, antifibrotic, antitumor, and cholagogic effects by regulating apoptosis, CYP2E1, Nrf, lipid metabolism-related factors, TGF-β, NF-κB, CYP7A1, and so on. In particular, β-elemene could be an attractive compound owing to its remarkable hepatoprotective, anti-inflammatory, antifibrotic, and antitumor activities. Altogether, the present review provides a preclinical basis for the efficacy of C. longa as an effective therapeutic agent for the prevention and treatment of hepatobiliary diseases, despite the need for further studies to establish the extraction conditions and separation of active constituents with high bioavailability, and warrants further evaluation in clinical trials.

Structure-Based Reactivity Profiles of Reactive Metabolites with Glutathione

Therapeutic agents can be transformed into reactive metabolites under the action of various metabolic enzymes in vivo and then covalently combine with biological macromolecules (such as protein or DNA), resulting in increasing toxicity. The screening of reactive metabolites in drug discovery and development stages and monitoring of biotransformation in post-market drugs has become an important research field. Generally, reactive metabolites are electrophilic and can be captured by small nucleophiles. Glutathione (GSH) is a small peptide composed of three amino acids (i.e., glutamic acid, cysteine, and glycine). It has a thiol group which can react with electrophilic groups of reactive metabolic intermediates (such as benzoquinone, N-acetyl-p-benzoquinoneimine, and Michael acceptor) to form a stable binding conjugate. This paper aims to provide a review on structure-based reactivity profiles of reactive metabolites with GSH. Furthermore, this review also reveals the relationship between drugs' molecular structures and reactive metabolic toxicity from the perspective of metabolism, giving a reference for drug design and development.

Herbal medicine use among patients with viral and non-viral Hepatitis in Uganda: prevalence, patterns and related factors

Background

There is some evidence that patients with liver diseases commonly use complementary and alternative therapies to address general and liver-disease specific health concerns. The purpose of this study was to assess and describe prevalence, patterns and related factors of herbal medicine use among adults diagnosed with viral and non-viral hepatitis in Kampala, Uganda.

Methods

A cross-sectional study was conducted on 310 adult patients attending the gastrointestinal clinic in Mulago hospital referral hospital in Kampala. Data on prevalence, types and reasons for herbal medicine use was collected using standardized questionnaires and focus group discussions. Modified Poisson regression analyses were used to examine factors related to use.

Results

Usage of various herbal remedies within 12 months prior to April 2018 was reported by 46.1% (143/310) of patients with 27.3% (39/143) of these reporting having used conventional and herbal therapies concurrently. Herbal remedies were used to treat various health conditions including hepatitis. Patients with hepatitis C virus infection (PRR = 1.16, p = 0.02) compared to those with hepatitis B virus infection, and those who believed that it was safe to use herbal and conventional therapies concurrently (PRR = 1.23, p = 0.008) had higher prevalence odds of herbal medicine use. Conversely, patients who had been newly diagnosed with hepatitis (PRR = 0.69, p = 0.03) compared to those who had been diagnosed more than one-year prior, had lower prevalence odds of herbal medicine use. Various types of local herbs were reported as most commonly used however most patients did not know the ingredients of commercially prepared herbal therapies.

Conclusion

A high prevalence of herbal medicine use was found among newly-diagnosed patients and patients with hepatitis C more likely to use herbal remedies after adjusting for other factors. Usage was influenced by the belief that herbal medicine is safe and effective. Health workers need to consistently elicit information about herbal remedy use. Research is needed on benefits, adverse effects and outcomes in patients who use herbal remedies to treat primary liver diseases in order to facilitate evidence of efficacy and product safety.

Simultaneous characterization and quantification of flavonoids in Morus australis root as potential hepatoprotective nutraceutical

Morus australis distributed widely in China has high value in food and agriculture. Twelve phenolic compounds were isolated and identified as major constituents of M. australis root from Shaanxi province, China, while the protective effect of M. australis root on liver injury has never been determined in detail. In this study, the hepatoprotective ability of M. australis root was investigated in vivo and in vitro. The ethanol-water extract prepared from M. australis root showed protection on alcohol-induced liver damage in mice by decreasing the levels of serum alanine aminotransferase, aspartate transaminase, triacylglycerol and malondialdehyde, and by increasing glutathione contents. Furthermore, among 12 major constituents of M. australis root, 10 flavonoids (especially 1) showed protection against carbon tetrachloride (CCl₄ )-intoxicated HepG2 cell lines by decreased lactic dehydrogenase levels. In addition a validated HPLC-DAD method was established for the quantitative analysis of 10 flavonoids in the bioactive extract. PRACTICAL APPLICATIONS: Our results showed that M. australis root extract significantly alleviated the liver damage in mice. Ten flavonoids from the root of this plant exhibited protection on CCl₄ -intoxicated HepG2 cell lines. This study suggests that Morus australis root has hepatoprotective potential as a promising supplement for the prevention and treatment of liver diseases.

Network Pharmacology-Based Approaches of Rheum undulatum Linne and Glycyrriza uralensis Fischer Imply their Regulation of Liver Failure with Hepatic Encephalopathy in Mice

Rheum undulatum and Glycyrrhiza uralensis have been used as supplementary ingredients in various herbal medicines. They have been reported to have anti-inflammatory and antioxidant effects and, therefore, have potential in the treatment and prevention of various liver diseases. Considering that hepatic encephalopathy (HE) is often associated with chronic liver failure, we investigated whether an R. undulatum and G. uralensis extract mixture (RG) could reduce HE. We applied systems-based pharmacological tools to identify the active ingredients in RG and the pharmacological targets of RG by examining mechanism-of-action profiles. A CCl₄-induced HE mouse model was used to investigate the therapeutic mechanisms of RG on HE. We successfully identified seven bioactive ingredients in RG with 40 potential targets. Based on an integrated target–disease network, RG was predicted to be effective in treating neurological diseases. In animal models, RG consistently relieved HE symptoms by protecting blood–brain barrier permeability via downregulation of matrix metalloproteinase-9 (MMP-9) and upregulation of claudin-5. In addition, RG inhibited mRNA expression levels of both interleukin (IL)-1β and transforming growth factor (TGF)-β1. Based on our results, RG is expected to function various biochemical processes involving neuroinflammation, suggesting that RG may be considered a therapeutic agent for treating not only chronic liver disease but also HE.

Apoptosis induction and ERK/NF-κB inactivation are associated with magnolol-inhibited tumor progression in hepatocellular carcinoma in vivo

Although hepatitis B and/or hepatitis C virus were recognized as major risk factor for the development of hepatocellular carcinoma (HCC), certain occupational, environmental, and lifestyle factors also play key roles in HCC tumorigenesis. Moreover, in molecular signaling route, extracellular signal-regulated kinase (ERK)/nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signaling was found to be overexpressed and linked to poor prognosis in HCC. Thus, to identify possible nature compound that can suppress ERK/NF-κB may be benefit to HCC patient. Magnolol, a natural compound derived from herbal plant Magnolia officinalis, has been recognized as a liver protection and antitumor reagent. However, whether magnolol-inhibited HCC progression correlates with disruption of ERK/NF-κB signaling is remained unclear. In this studies, we performed SK-Hep1/luc2 HCC bearing animal model to investigate the anticancer efficacy and mechanism of magnolol on tumor progression. Tumor size and tumor growth rate were dramatically suppressed after treatment of magnolol. In addition, expression of phospho-ERK (p-ERK), NF-κB p65 (Ser536), and tumor progression-associated proteins, such as matrix metallopeptidase 9 (MMP-9), vascular endothelial growth factor (VEGF), X-linked inhibitor of apoptosis protein (XIAP), and CyclinD1 were all significantly decreased by magnolol. Most important, major extrinsic and intrinsic apoptosis signaling factors, including active caspase-8 and caspase-9 were both enhanced by magnolol. This study indicated that apoptosis induction through extrinsic/intrinsic pathways and blockage of ERK/NF-κB activation were associated with magnolol-inhibited tumor progression in HCC in vivo.

The efficient biogeneration of Ag and NiO nanoparticles from VPLE and a study of the anti-diabetic properties of the extract

Vitex pseudo-negundo leaf extract (VPLE) is used to mediate the green biosynthesis of Ag and NiO nanoparticles in aqueous solutions under mild conditions. The synthesized nanoparticles, with a narrow size range and good distribution, are characterized by means of powder X-ray diffraction (PXRD), Fourier-transform infrared (FT-IR), scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), and transmission electron microscopy (TEM) techniques. SEM and TEM micrographs proved formation of mostly spherical or ellipsoidal nanoparticles with little agglomeration, and the average particle size was less than 20–35 nm for both types of nanoparticle. Then, the protective role of VPLE toward the liver is assessed in streptozotocin-induced diabetic rats. For this purpose, diabetes is induced in rats through the intraperitoneal injection of streptozotocin, and VPLE is administered via oral gavage for 6 weeks. This study suggests that VPLE can ameliorate biochemical and structural changes in the livers of diabetic rats, showing that VPLE can improve the condition of rats with diabetic hepatopathy via a decrease in oxidative stress and an enhancement in the activity of antioxidant enzymes in the liver.

Vitex pseudo-negundo leaf extract (VPLE) is a mediator for the green biosynthesis of Ag and NiO nanoparticles, and its protective effects are assessed in the livers of streptozotocin-induced diabetic rats.

Protein Kinase B Inactivation Is Associated with Magnolol-Enhanced Therapeutic Efficacy of Sorafenib in Hepatocellular Carcinoma In Vitro and In Vivo

Although sorafenib, an oral multikinase inhibitor, was approved as a treatment drug of advance hepatocellular carcinoma (HCC), treatment efficacy still requires improvement. Searching for the adjuvant reagent for enhancing sorafenib efficacy remains as a critical issue. Sorafenib has been proved to suppress extracellular signal-regulated kinases (ERK) in HCC; however, protein kinase B (AKT) was not affected by it. Targeting AKT in combination with sorafenib could be an important breakthrough point of HCC treatment. Many herbal compounds and composite formulas have been shown to enhance anti-HCC activity of sorafenib. Magnolol is a bioactive compound extracted from the bark of the Magnolia officinalis and has been shown to induce apoptosis and inhibit cell invasion in HCC in vitro. However, whether magnolol sensitizes HCC to sorafenib is ambiguous. In this study, we indicated that magnolol significantly enhanced sorafenib-diminished tumor cell growth, expression of anti-apoptotic proteins, and migration/invasion ability compared to sorafenib alone. Magnolol significantly boosted sorafenib-induced extrinsic/intrinsic dependent apoptosis pathways in HCC. Notably sorafenib could not reduce protein level of AKT (Ser473), but expression of AKT (Ser473) was significantly decreased by magnolol or magnolol combined with sorafenib. LY294002 as specific AKT inhibitor was used to confirm that AKT inactivation may promote anticancer effect of sorafenib. Taken together, AKT inhibition is associated with magnolol-enhanced the therapeutic effect of sorafenib in HCC. We suggested magnolol as the potential adjuvant which may enhance therapeutic benefits of sorafenib in patients with HCC.

Recovery from hepatitis A after Korean medicine-based treatment : a case report

BACKGROUND

Many studies reported that Korean medicine (KM) is effective for treating liver disease, including hepatitis A. However, KM, specifically with herbal medicine (Chungganplus, CGP) has not been reported yet. We aimed to report a patient with hepatitis A who was treated with KM including CGP, acupuncture, and moxibustion for 12 days.

METHODS

A 39-year-old man with hepatitis A who was hospitalized for 12 days after being admitted to our hospital with abdominal pain, diarrhea and vomiting. We prescribed CGP three times a day, with acupuncture performed twice daily and moxibustion at conception vessel (CV)-12 once a day. Follow-up blood tests have been done 4 times during the admission in order to access the effect of the treatment.

RESULTS

In 12 days the symptoms had disappeared and the blood test results improved steadily. His AST level have declined from 1,189 IU/L to 44 IU/L, ALT from 2,423 IU/L to 127 IU/L, r-GTP from 1,347 IU/L to 339 IU/L, ALP from 384 IU/L to 205 IU/L, and total bilirubin from 3.6 mg/dL to 0.89 mg/dL.

CONLCUSIONS

This case suggests that KM-based treatment using CGP may be effective for hepatitis A with no adverse effect. Further research and clinical trial on CGP would be needed to make the basis more valid.

Xiao Chai Hu Tang, a herbal medicine, for chronic hepatitis B

BACKGROUND

Chronic hepatitis B is associated with high morbidity and mortality. Chronic hepatitis B requires long-term management aiming at reduction of the risks of hepatocellular inflammatory necrosis, liver fibrosis, decompensated liver cirrhosis, liver failure, and liver cancer, and improving health-related quality of life. The Chinese herbal medicine formula Xiao Chai Hu Tang has been used to decrease discomfort and replication of the virus in people with chronic hepatitis B. However, the benefits and harms of Xiao Chai Hu Tang formula have never been established with rigorous review methodology.

OBJECTIVES

To assess the benefits and harms of Xiao Chai Hu Tang formula versus placebo or no intervention in people with chronic hepatitis B.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and seven other databases to 1 March 2019. We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp), ClinicalTrials.gov (www.clinicaltrials.gov/), and the Chinese Clinical Trial Registry for ongoing or unpublished trials to 1 March 2019.

SELECTION CRITERIA

We included randomised clinical trials, irrespective of publication status, language, and blinding, comparing Xiao Chai Hu Tang formula versus no intervention or placebo in people with chronic hepatitis B. We included participants of any sex and age, diagnosed with chronic hepatitis B according to guidelines or as defined by the trialists. We allowed co-interventions when the co-interventions were administered equally to all the intervention groups.

DATA COLLECTION AND ANALYSIS

Review authors independently retrieved data from reports and after correspondence with investigators. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. Our secondary outcomes were hepatitis B-related mortality, hepatitis B-related morbidity, and adverse events considered 'not to be serious'. We presented the meta-analysed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the risks of bias using risk of bias domains with predefined definitions. We used GRADE methodology to evaluate our certainty in the evidence.

MAIN RESULTS

We included 10 randomised clinical trials with 934 participants, but only five trials with 490 participants provided data for analysis. All the trials compared Xiao Chai Hu Tang formula with no intervention. All trials appeared to have been conducted and published only in China. The included trials assessed heterogeneous forms of Xiao Chai Hu Tang formula, administered for three to eight months. One trial included participants with hepatitis B and comorbid tuberculosis, and one trial included participants with hepatitis B and liver cirrhosis. The remaining trials included participants with hepatitis B only. All the trials were at high risk of bias, and the certainty of evidence for all outcomes that provided data for analyses was very low. We downgraded the evidence by one or two levels because of outcome risk of bias, inconsistency or heterogeneity of results (opposite direction of effect), indirectness of evidence (use of surrogate outcomes instead of clinically relevant outcomes), imprecision of results (the CIs were wide), and publication bias (small sample size of the trials). Additionally, 47 trials lacked the necessary methodological information needed to ensure the inclusion of these trials in our review. None of the included trials aimed to assess clinically relevant outcomes such as all-cause mortality, serious adverse events, health-related quality of life, hepatitis B-related mortality, or hepatitis B-related morbidity. The effects of Xiao Chai Hu Tang formula on the proportion of participants with adverse events considered 'not to be serious' is uncertain (RR 0.43, 95% CI 0.02 to 11.98; I2 = 69%; very low-certainty evidence). Only three trials with 222 participants reported the proportion of people with detectable hepatitis B virus DNA (HBV-DNA), but the evidence that Xiao Chai Hu Tang formula reduces the presence of HBV-DNA in the blood (a surrogate outcome) is uncertain (RR 0.62, 95% CI 0.45 to 0.85; I2 = 0%; very low-certainty evidence). Only two trials with 160 participants reported the proportion of people with detectable hepatitis B virus e-antigen (HBeAg; a surrogate outcome) (RR 0.72, 95% CI 0.50 to 1.02; I2 = 38%; very low-certainty evidence) and the evidence is uncertain. The evidence is also uncertain for separately reported adverse events considered 'not to be serious'.

FUNDING

two of the 10 included trials received academic funding from government or hospital. None of the remaining eight trials reported information on funding.

AUTHORS' CONCLUSIONS

The clinical effects of Xiao Chai Hu Tang formula for chronic hepatitis B remain unclear. The included trials were small and of low methodological quality. Despite the wide use of Xiao Chai Hu Tang formula, we lack data on all-cause mortality, serious adverse events, health-related quality of life, hepatitis B-related mortality, and hepatitis B-related morbidity. The evidence in this systematic review comes from data obtained from a maximum three trials. We graded the certainty of evidence as very low for adverse events considered not to be serious and the surrogate outcomes HBeAg and HBV-DNA. We found a large number of trials which lacked clear description of their design and conduct, and hence, these trials are not included in the present review. As all identified trials were conducted in China, there might be a concern about the applicability of this review outside China. Large-sized, high-quality randomised sham-controlled trials with homogeneous groups of participants and transparent funding are lacking.