Traditional Chinese medicine, Xin-yi-san, reduces nasal symptoms of patients with perennial allergic rhinitis by its diverse immunomodulatory effects

Xin-yi-san contains potent human CYP1A2 inhibitors and its combined use with theophylline in treatment increases adverse risks in patients

BACKGROUND

The Xin-yi-san herbal decoction (XYS) is commonly used to treat patients with allergic rhinitis in Taiwan. Theophylline is primarily oxidized with high affinity by human cytochrome P450 (CYP)1A2, and has a narrow therapeutic index.

PURPOSE

This study aimed to investigate the inhibition of human CYP1A2-catalyzed theophylline oxidation (THO) by XYS and its adverse effects in patients.

METHODS

Human CYPs were studied in recombinant enzyme systems. The influence of concurrent XYS usage in theophylline-treated patients was retrospectively analyzed.

RESULTS

Among the major human hepatic and respiratory CYPs, XYS inhibitors preferentially inhibited CYP1A2 activity, which determined the elimination and side effects of theophylline. Among the herbal components of XYS decoction, Angelicae Dahuricae Radix contained potent THO inhibitors. Furanocoumarin imperatorin was abundant in XYS and Angelicae Dahuricae Radix decoctions, and non-competitively inhibited THO activity with Ki values of 77‒84 nM, higher than those (20‒52 nM) of fluvoxamine, which clinically interacted with theophylline. Compared with imperatorin, the intestinal bacterial metabolite xanthotoxol caused weaker THO inhibition. Consistent with the potency of the inhibitory effects, the docking analysis generated Gold fitness values in the order-fluvoxamine > imperatorin > xanthotoxol. During 2017‒2018, 2.6 % of 201,093 theophylline users consumed XYS. After inverse probability weighting, XYS users had a higher occurrence of undesired effects than non-XYS users; in particular, there was an approximately two-fold higher occurrence of headaches (odds ratio (OR), 2.14; 95 % confidence interval (CI), 1.99‒2.30; p < 0.001) and tachycardia (OR, 1.83; 95 % CI, 1.21‒2.77; p < 0.05). The incidence of irregular heartbeats increased (OR, 1.36; 95 % CI, 1.07‒1.72; p < 0.05) only in the theophylline users who took a high cumulative dose (≥ 24 g) of XYS. However, the mortality in theophylline users concurrently taking XYS was lower than that in non-XYS users (OR, 0.24; 95 % CI, 0.14‒0.40; p < 0.001).

CONCLUSION

XYS contains human CYP1A2 inhibitors, and undesirable effects were observed in patients receiving both theophylline and XYS. Further human studies are essential to reduce mortality and to adjust the dosage of theophylline in XYS users.

Identification of the perpetrator imperatorin in Xin-yi-san-theophylline interaction: observed and predicted herb-drug interaction in rats

OBJECTIVES

Theophylline is a bronchodilator with a narrow therapeutic index and primarily metabolised by cytochrome P450 (CYP) 1A2. Xin-yi-san (XYS) is a herbal formula frequently used to ameliorate nasal inflammation. This study aimed to investigate the effects of XYS and its ingredient, imperatorin, on theophylline pharmacokinetics in rats.

METHODS

The kinetics of XYS- and imperatorin-mediated inhibition of theophylline oxidation were determined. Pharmacokinetics of theophylline were analysed. Comparisons were made with the CYP1A2 inhibitor, fluvoxamine.

KEY FINDINGS

XYS extract and its ingredient, imperatorin, non-competitively inhibited theophylline oxidation. Fluvoxamine (50 and 100 mg/kg) and XYS (0.5 and 0.9 g/kg) significantly prolonged the time to reach the maximum plasma concentration (tmax) of theophylline by 3-10 fold. In a dose-dependent manner, XYS and imperatorin (0.1-10 mg/kg) treatments significantly decreased theophylline clearance by 27-33% and 19-56%, respectively. XYS (0.9 g/kg) and imperatorin (10 mg/kg) significantly prolonged theophylline elimination half-life by 29% and 142%, respectively. Compared with the increase (51-112%) in the area under curve (AUC) of theophylline by fluvoxamine, the increase (27-57%) by XYS was moderate.

CONCLUSIONS

XYS decreased theophylline clearance primarily through imperatorin-suppressed theophylline oxidation. Further human studies are essential for the dose adjustment in the co-medication regimen.

Identification of Potential Targets and Mechanisms of Sinomenine in Allergic Rhinitis Treatment Based on Network Pharmacology and Molecular Docking

This study aimed to investigate the potential targets and molecular mechanism of sinomenine in treating allergic rhinitis (AR) using network pharmacology and molecular docking. Relevant targets of sinomenine and AR were obtained from public databases, and differentially expressed genes (DEGs) for AR were identified in the Gene Expression Omnibus database. Using VennDiagram, we identified 22 potential targets of sinomenine against AR by crossing disease targets, drug targets, and DEGs. Functional analysis revealed that sinomenine may act via its anti-inflammatory and immunosuppressive effects, and its action pathways may include the MAPK, HIF-1, and JAK-STAT pathways. Furthermore, hub targets were identified using EPC, MCC, and MNC algorithms, and six hub targets (STAT3, EGFR, NFKB1, HIF1A, PTGS2, and JAK1) were selected by integrating the top 10 hub genes and 22 potential targets. Molecular docking analysis indicated that STAT3, EGFR, PTGS2, and JAK1 may be key targets of sinomenine against AR. Overall, our results suggest that sinomenine has potential therapeutic effects against AR, and its mechanism of action may involve the regulation of key targets and pathways related to inflammation and immunity.

Clinical Efficacy of Sanfeng Tongqiao Diwan in the Treatment of Allergic Rhinitis: A Randomized Controlled Trial

Objective. To explore the clinical effect of Sanfeng Tongqiao Diwan in the treatment of allergic rhinitis. Methods. Allergic rhinitis patients included in this study were randomly divided into control group and study group for 7 days of treatment. The control group was treated with Tongqiao Biyan Pian, while the study group was treated with Sanfeng Tongqiao Diwan. Results. After 7 days of treatment, the total effective rate of Sanfeng Tongqiao Diwan was 75.76%, which was higher than that of Tongqiao Biyan Pian (65.62%). The scores of visual analogue scale (VAS), symptom relief, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Epworth sleepiness scale (ESS) in both groups were significantly improved before and after treatment ( $P<0.05$ ), and the improvement was most significant 24 hours after treatment. The adverse reactions in both groups were low. Conclusion. Sanfeng Tongqiao Diwan can significantly alleviate the symptoms and improve the quality of life of patients with allergic rhinitis, with less adverse reactions.

The genus Asarum: A review on phytochemistry, ethnopharmacology, toxicology and pharmacokinetics

ETHNOPHARMACOLOGICAL RELEVANCE

In essentially every quadrant of the globe, many species of genus Asarum are used as a common herbal medicine and appear in many formulas or Kampo. Crude drug from several medicinal plants of genus Asarum (MA) known as Asari Radix et Rhizoma (ARR) has been proven to have the functions of dispelling cold, relieving pain, and reducing phlegm according to Traditional Chinese Medicine (TCM) theory for thousands of years.

AIM OF THE STUDY

This article reviews the ethnopharmacology, phytochemistry, pharmacology, toxicology and metabolic kinetics related research of genus Asarum to evaluate its ethnopharmacology use and future opportunities for research.

MATERIALS AND METHODS

Information on relevant studies of the genus Asarum was gathered via the Internet using Baidu Scholar, Web of Science, Elsevier, ResearchGate, ACS, Pudmed and Chinese National Knowledge Infrastructure (CNKI). Additionally, information was also obtained from some local books, PhD, MS's dissertations and Pharmacopeias.

RESULTS

The genus Asarum has played an important role in herbal treatment. At present, more than 277 compounds have been isolated or identified from genus Asarum. Among them, volatile oil and lignans are the major active constituents and important chemotaxonomic markers. Modern pharmacological studies indicated that genus Asarum and its active compounds possess a wide range of pharmacological effects, especially analgesic, anti-inflammatory, neuroprotective, cardiovascular protection, antitussive, immunosuppressive, anti-tumor, and microbicidal activities.

CONCLUSIONS

Based on this review, therapeutic potential of genus Asarum has been demonstrated with the pharmacological effects on inflammation, CNS, respiratory regulation, cardiovascular diseases, cancer and microbial infection. The available literature showed that the major activities of the genus Asarum can be attributed to the active lignans and essential oils. Further in-depth studies on the aspects of the genus for mechanism of actions, metabolism, pharmacokinetics, toxicology, drug interactions, and clinical trials are still limited, thereby intensive research and assessments should be performed.

Herbal Medicines for Allergic Rhinitis: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

To assess the effects of herbal medicine (HM) therapy in various durations and analyze the effects of HM separately by mechanism of action in the treatment of allergic rhinitis (AR).

RECENT FINDINGS

Thirty-two studies were included (2,697 patients, mean age 34.6 years). For the ≤ 4 weeks of treatment duration, HM brought greater benefits over placebo in reduction of total nasal symptoms score (standardized mean difference (SMD) -0.68; 95% confidence interval (CI) -0.98, -0.38; p <0.01) and improvement in Rhinoconjunctivitis Quality of Life Questionnaire score (SMD -0.53; 95% CI -0.81, -0.25; p <0.01). For the 4-12 weeks duration, total nasal symptoms score (SMD -0.22; 95%CI -0.4, -0.05; p =0.01) and Rhinoconjunctivitis Quality of Life Questionnaire score (SMD -0.48; 95% CI -0.89, -0.06; p =0.03) favored the HM. However, HM therapy for longer than 12 weeks was related to tachyphylaxis and showed no benefit over placebo in any outcomes. There was no difference between the HM and standard treatment on symptoms improvement. Anti-allergic effect, anti-inflammatory effect, anti-leukotriene effect, and anti-histaminic effect of HM were revealed. HM was safe and their adverse effects were comparable placebo. HM therapy is safe and provides better results than placebo in improving nasal symptoms and disease-specific quality of life in patients with AR. Its beneficial effects are demonstrated only in less than 12 weeks of treatment.

TRIAL REGISTRATION

PROSPERO ID: CRD42020168367.

Identifying the Chinese Herbal Medicine Network and Core Formula for Allergic Rhinitis on a Real-World Database

MATERIALS AND METHODS

Patients with a primary diagnosis of AR (ICD-9-CM code: 477.9) in 2010 were included, and the National Health Insurance Research Database in Taiwan was used as the data source. Association rule mining and social network analysis were used to establish and explore the CHM network. Possible molecular pathways of the CHM network were summarized and compared with commonly used western medicine (WM) by conducting overrepresentation analysis in the Reactome pathway database. The potential proteins acted by CHMs were obtained from the CHM ingredient-protein databases, including STITCH, TCMSP, TCMID, and TCM@Taiwan.

RESULTS

There were 89,148 AR subjects found in 2010, and a total of 33,507 patients ever used CHM. On an average, 5.6 types of CHMs were utilized per prescription. Xin-Yi-Qing-Fei-Tang was used most frequently (25.5% of 222,279 prescriptions), while Xiao-Qing-Long-Tang with Xin-Yi-San was the most commonly prescribed CHM-CHM combination. Up to six distinctive clusters could be found among the CHM network, and core CHMs could be found for AR, such as Xiao-Qing-Long-Tang and Xin-Yi-Qing-Fei-Tang. A total of 140 molecular pathways were covered by the CHM network (2,432 ingredients from 31 kinds of CHMs), while 39 WMs covered 55 pathways. Among pathways responding to the immune system, WM mainly acted on cytokine signaling-related pathways, while CHM mostly acted on neutrophil/macrophage-related innate pathways and dendritic cell-related adaptive immunity pathways.

CONCLUSION

Our study demonstrated and analyzed the CHM network for AR. Core CHM for AR and possible molecular pathways were presented as well, and this information is crucial for researchers to select candidates for CHM-related studies.

Traditional Chinese Medicine (TCM) and Allergic Diseases

PURPOSE OF REVIEW

This paper purports to review recent relevant publications on the efficacy of traditional Chinese medicine in treating allergic diseases, to illustrate the pertinent mechanisms of action of TCM, and to explore the possible role of TCM in the management of allergic diseases in the foreseeable future. As TCM embodies multiple treatment modalities, only the most popular two, namely CHM (Chinese herbal medicine) and acupuncture, were discussed. Publications, especially reviews involving randomized controlled trials (RCTs) on the use of TCM on allergic diseases, published up to June 2019 were reviewed and analyzed. Papers reporting the mechanisms of action of TCM in allergic diseases were also included. Other publications in Chinese were also discussed.

RECENT FINDINGS

A startling escalation in the incidence of allergic diseases in the last several decades has posed tremendous social and financial burdens on the community. Failing to locate a cure for these chronic diseases, patients have resorted to using alternative medications of which traditional Chinese medicine (TCM) is a popular one. Thus CHM has been extensively employed for treating allergic diseases. Some investigations have been conducted to ascertain the therapeutic efficacy of CHM for allergic diseases. Although CHM has been widely deployed for treating allergic diseases, it appears from the published data that there is a dearth of conclusive evidence to establish the effectiveness of CHM for allergic diseases. It is recommended that more large- scale RCTs with prolonged durations be carried out to corroborate the efficacy of CHM for allergic diseases. On the other hand, there is ample evidence indicating that acupuncture is useful when administered alone in allergic rhinitis and asthma or when applied as an adjunct to conventional western therapy. Evidence of its utility in atopic eczema and urticaria is not definitive. It is recommended that acupuncture be integrated into the therapy of allergic rhinitis and asthma, and that CHM be used as an adjunct in the treatment of allergic diseases on an individual basis.

Long-term use of Chinese herbal medicine therapy reduced the risk of asthma hospitalization in school-age children: A nationwide population-based cohort study in Taiwan

BACKGROUND

Clinical trials have indicated some traditional Chinese medicine formulas reduce airway hyperresponsiveness and relieve asthma symptoms. This study investigated Chinese herbal Medicine (CHM) for childhood asthma and clarified the relationship between CHM use and consequent asthma hospitalization by a population-based cohort study.

METHODS

We used the data of one million individuals randomly selected from Registry of Beneficiaries of the National Health Insurance Research Database. Patients aged less than 18 years and diagnosed as asthma were followed from 2000 to 2012 and divided into the CHM group and the non-CHM group. Cox proportional hazard regression model was conducted to estimate the adjusted hazard ratio (aHR) of the two groups, and the Kaplan-Meier survival curve was used to determine the association between CHM cumulative days and consequent asthma hospitalization.

RESULTS

Of the total of 33,865 patients, 14,783 (43.6%) were included in the CHM group, and 19,082 (56.4%) were included in the non-CHM group. After adjustment for gender, age, comorbidities, and total numbers of asthma medication, CHM users had a lower risk of asthma hospitalization than non-CHM users (aHR: 0.90, 95% confidence interval [CI]: 0.83-0.95). Children older than 6 years who used CHM therapy for more than 180 days exhibited a reduction of 29% for the risk of consequent asthma hospitalization (aHR: 0.71, 95% CI: 0.51-0.98).

CONCLUSION

Children aged 6-18 years who used more than 6 months CHM therapy reduced the risk of consequent asthma hospitalization. Long-term CHM therapy has benefit in school-age children with asthma.

Synopsis

Akute entzündliche Reaktionen bzw. der akute Infekt mit Restitutio ad integrum laufen in einer perfekt modulierten Kaskade ab, bei dem eine akute inflammatorische Einleitungsphase von einer antiinflammatorischen Phase und einer Entzündungsauflösungsphase abgelöst werden.

Mesenchymal stem cells combined with traditional Chinese medicine (qi-fang-bi-min-tang) alleviates rodent allergic rhinitis

Mesenchymal stem cells (MSCs) have been proved to exert anti-inflammatory effects and regulate immune reactions. Traditional Chinese medicine (TCM), qi-fang-bi-min-tang, is effective for some patients with allergic diseases. However, it remains unclear whether MSCs combined with TCM could benefit the treatment of allergic rhinitis (AR). In this study, we reported an additional effect of TCM (qi-fang-bi-min-tang) on the therapy of AR under MSCs treatment. Intriguingly, we observed that TCM-treated MSCs significantly inhibited the symptoms of AR and reduced the pathological changes of nasal mucosa in ovalbumin (OVA)-induced rats. The expression levels of interferon γ (IFN-γ), interleukin-17 (IL-17), and IL-4 were significantly decreased in the plasma of AR rats after injection of TCM-treated MSCs. TCM-treated MSCs reduced the levels of histamine secreted by mast cells and immunoglobulin E (IgE) secreted by plasma cells. In addition, we found that MSCs combined with TCM had a better therapeutic effect than TCM alone on AR in an OVA-induced mouse model. After OVA induction, MSCs combined with TCM significantly reduced the ratio of T helper type 1 (Th1), Th2, and Th17, but increased the proportion of Treg in the spleen of mice. Consistently, the expression levels of IFN-γ, IL-4, and IL-17 were significantly decreased, but transforming growth factor-β1 was significantly increased in the plasma of AR mice after treated with TCM and MSCs. Our results from both rats and mice indicated that the effects of TCM combined with MSCs on the AR might be through regulating the secretion of Th1, Th2, and Th17 cytokines. This study suggested that TCM (qi-fang-bi-min-tang)-treated MSCs could be used in the clinical therapy of AR.

A multicenter study on the efficacy and safety of So-Cheong-Ryong-Tang for perennial allergic rhinitis

BACKGROUND

So-Cheong-Ryong-Tang (SCRT), also known as Xiao-Qing-Long-Tang or Sho-seiryo-to, is a mixed herbal formula that is used to treat allergic rhinitis, bronchitis, allergic asthma, and common cold in traditional Korean medicine.

OBJECTIVE

To assess the efficacy and safety of the SCRT for the treatment of allergic rhinitis.

METHODS

We conducted a double-blind, randomized, placebo-controlled, parallel-group, multicenter study of Korean adults with perennial allergic rhinitis. The trial consisted of a 4-week oral administration of SCRT or placebo, with two visits at 2-week intervals, and an 8-week follow-up period, with two visits at 4-week intervals. The primary outcome was a change in the total nasal symptoms score. The secondary outcomes included changes in the Rhinoconjunctivitis Quality of Life Questionnaire score, total serum immunoglobulin E (IgE), cytokines levels, and nasal endoscopy index.

RESULTS

SCRT improved nasal symptoms and quality of life in patients with PAR after 4 weeks medication, and these effects did not last 8 weeks after the end of medication. The level of serum IgE, eosinophil counts, and cytokines did not alter after medication. Nasal endoscopy index did not show significant difference. No serious AEs and safety assessment changes were observed in this trial.

CONCLUSION

SCRT is an effective and safe medication for patients with chronic, perennial, and moderate to severe AR. A clinical study with a >4-week period of medication use, and more participants for immune material test is needed to investigate the long-term efficacy of SCRT in relieving the symptoms of nasal obstruction and identifying the underlying mechanisms of action and indications for traditional Korean medicine.

Trends and prescription patterns of traditional Chinese medicine use among subjects with allergic diseases: A nationwide population-based study

Background

The alarmingly rising prevalence of allergic diseases has led to substantial healthcare and economic burdens worldwide. The integrated use of traditional Chinese medicines (TCM) and Western medicines has been common in treating subjects with allergic diseases in clinical practice in Taiwan. However, limited studies have been conducted to evaluate long-term trends and prescription patterns of TCM use among subjects with allergic diseases. Thus, we conducted a nationwide population-based study to characterize TCM use among subjects with allergic diseases.

Methods

A total of 241,858 subjects with diagnosed atopic dermatitis, asthma or allergic rhinitis in the period of 2003–2012 were identified from the National Health Insurance Research Database (NHIRD) in Taiwan and included in this study. We assessed trends and prescribed patterns related to TCM (both single herbs and herbal formulas) among the study subjects over the 10-year study period.

Results

The overall proportions of TCM use were 30.5%, 29.0% and 45.7% in subjects with atopic dermatitis, asthma and allergic rhinitis, respectively. We found increasing trends of TCM use among subjects having atopic dermatitis and asthma, with annual increase of 0.91% and 0.38%, respectively, over the 10-year study period while the proportion remained steadily high (from 46.6% in 2003 to 46.3% in 2012) among subjects having allergic rhinitis. Moreover, the number of hospitalization due to allergic diseases in TCM users was significantly smaller than that in non TCM users for all three allergic diseases.

Conclusion

A notable proportion (30%–50%) of subjects with allergic diseases in Taiwan has used TCM, with the highest proportion of TCM use found in subjects with allergic rhinitis, whereas increasing trends of TCM use are found among subjects with atopic dermatitis and asthma, respectively. Our results suggest that TCM use may help reduce the severe episodes of allergic diseases necessitating hospitalizations.

Geraniol suppresses proinflammatory mediators in phorbol 12-myristate 13-acetate with A23187-induced HMC-1 cells

Background

Geraniol is a monoterpene alcohol that has anti-fungal, anti-cancer and anti-nociceptive properties, but its anti-allergic rhinitis (AR) property is unclear.

Methods

In this study, the anti-inflammatory role and its possible mechanisms of geraniol in human mast cell line (HMC-1) cells stimulated by inflammatory trigger phorbol 12-myristate 13-acetate plus A23187 (PMACI), as well as in ovalbumin (OVA)-induced AR mice models were investigated.

Results

PMACI results in a significant increase in the production of proinflammatory cytokines, such as TNF-α, IL-1β, MCP-1, IL-6 and as well as histamine. Geraniol was found to inhibit both TNF-α, IL-1β and IL-6 protein and mRNA expressions at concentrations of 40, 80, 160 μM. In OVA-induced AR models, geraniol treatment was able to suppress AR biomarkers (OVA-specific IgE and IL-1β as well as histamine) and nasal rub scores. Interestingly, p38, a member of the mitogen-activated protein kinase (MAPK) signaling family, was found to be increasingly hypophosphorylated as geraniol dose was increased. Similar decreases in the nuclear level of p65, a member of the nuclear factor kappa B (NF-κB) signaling pathway, were also observed.

Conclusion

Our data highlights that the anti-inflammatory properties of geraniol on AR-related markers in activated HCM-1 cells and OVA-induced AR models may be mediated through the regulation of the MAPK/NF-κB signaling pathway.

Qingfeijianpi therapy for persistent allergic rhinitis: A randomized, positive-controlled clinical trial

This study aims to investigate the effectiveness and safety of Qingfeijianpi therapy for persistent allergic rhinitis (AR).A total of 101 patients with persistent AR were included into the study. These patients were randomly divided into 2 groups: treatment group, in which patients were given Qingfeijianpi decoction (1 dose/day for 4 weeks); control group, in which patients were given an oral dose of loratadine (tablet, 10 mg/time, once per day for 4 weeks). A total of 96 patients completed the 16-week course of treatment. The nasal symptom and traditional Chinese medicine syndrome were scored to evaluate symptom improvement, and the Rhinoconjunctivitis Quality of Life Questionnaire was used to assess the quality of life of patients. Furthermore, the 4-week clinical treatment effect and 16-week follow up were evaluated.After the 4-week treatment, the mean difference in symptom score in the treatment group was similar to that in the control group. However, during the follow-up, the decrease in symptom score was better with the Qingfeijianpi therapy than with loratadine.Compared to loratadine, the Qingfeijianpi decoction exhibited a significant benefit in symptom improvement of persistent AR.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Chinese Herbal Medicine to Treat Allergic Rhinitis: Evidence From a Meta-Analysis

Purpose

Chinese herbal medicine (CHM) has been widely used in China to treat allergic rhinitis (AR). However, several studies have produced conflicting data with regard to the efficacy of the medicine. Our aim was to perform a meta-analysis of randomized clinical trials (RCTs) to evaluate the relative efficacy of CHM.

Methods

We systematically searched the PubMed, Medline, and Springer electronic databases up to March 2017 for RCTs comparing the efficacy of CHM versus placebo for the treatment of patients with AR. Total nasal symptoms and quality of life were assessed through pooling mean difference (MD) with its 95% confidence interval (CI). Moreover, sensitivity and subgroup analyses according to control design and quality of life assessment were performed to evaluate the source of heterogeneity.

Results

Eleven RCTs were enrolled in the meta-analysis. Assessment of overall heterogeneity indicated significant heterogeneity among the individual studies (I²=100%, P<0.00001), and thus ransomed effects model was used to pool data. CHM was found to significantly enhance quality of life compared with placebo (MD=-0.88, (95% CI: -1.55, -0.21); P=0.01). The symptom of itchy nose, sneezing or total nasal symptoms scores were not significantly improved after CHM treatment, although the improvement in itchy nose just failed to reach significance (MD=0.09, (95% CI: 0.00, 0.18); P=0.06).

Conclusions

This study suggests that CHM appears to improve the quality of life of AR patients. However, these findings, as well as the findings for the effect of CHM on sneezing, total nasal symptoms, and the symptom of itchy nose, need to be substantiated in larger cohorts of AR patients by further well-designed studies.

Efficacy and safety of So-Cheong-Ryong-Tang in treatment of perennial allergic rhinitis: study protocol for a double-blind, randomised, parallel-group, multicentre trial

INTRODUCTION

So-Cheong-Ryong-Tang (SCRT) is a herbal medicine widely used in traditional medicine for treating allergic rhinitis (AR). In animal studies, SCRT has suppressed the progression of AR. The main purpose of this study is to assess the efficacy and safety of the SCRT for the treatment of perennial allergic rhinitis (PAR) and discover the underlying mechanisms resulting in anti-inflammatory effects in humans.

METHODS AND ANALYSIS

We will conduct a double-blind, randomised, placebo-controlled, parallel-group, multicentre trial of Korean adults with PAR. For the study, 156 subjects with PAR will be recruited. The trial will consist of a 4-week oral administration of SCRT or placebo with two visits at 2-week intervals and an 8-week follow-up period with two visits at 4-week intervals. The primary outcome is a change in the total nasal symptoms score. The secondary outcomes include changes in the Rhinoconjunctivitis Quality of Life Questionnaire score, total serum IgE and cytokines levels.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board at each research centre (name of each centres and approval numbers): Kyung Hee University Hospital at Gangdong (KHNMC-OH-IRB 2015-04-009), Kyung Hee University Medical Centre (KOMCIRB-160321-HRBR-011), Pusan National University Hospital (2016-004), Dongguk University Medical Centre (2016-03) and Semyung University hospital (2016-01). This result will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03009136; Pre-results.

Complementary and Alternative Treatment for Allergic Conditions

This article explains the proposed pathophysiology, evidence of efficacy, and adverse effects of several complementary and alternative medicine modalities, for the treatment of allergic conditions, such as traditional Chinese medicine formula, herbal treatments, acupuncture, and homeopathy.

Immunosuppressive effect of sinomenine in an allergic rhinitis mouse model

Allergic rhinitis (AR) is a chronic allergic airway disease that has become a significant global public health issue. Sinomenine (SN), a natural phytochemical found in Sinomenium acutum, showed anti-inflammatory and immunosuppressive effect in previous studies. In order to explore the role of SN in the treatment of AR, mice were sensitized and challenged by ovalbumin (OVA) to establish an AR mouse model. SN was administered to AR mice orally, and compared with dexamethasone treatment as a positive control. Nasal symptoms and histopathological changes were used to evaluate the effect of SN treatment in the AR mice model. In addition, the levels of anti-OVA specific IgE and various cytokines in the serum were measured by enzyme-linked immunosorbent assay, while the levels of transforming growth factor-β (TGF-β) in the mucosa were also detected by western blot analysis and reverse transcription-quantitative polymerase chain reaction. AR mice that received SN treatment had reduced symptom scores and milder eosinophil infiltration. The serum levels of anti-OVA specific IgE and interleukin-4 significantly decreased following SN treatment. Furthermore, TGF-β expression levels in the serum and nasal mucosa tissue in AR mice increased when compared with those in AR mice without treatment. In conclusion, SN treatment alleviated the symptoms of AR in mice and had an immunosuppressive effect on AR, which may result from the upregulation of TGF-β.

Effect of curcumin on nasal symptoms and airflow in patients with perennial allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common disorder that can significantly affect patient quality of life. Previous studies have found that curcumin had anti-inflammatory and antioxidant effects and clinical benefits in cancer and asthma.

OBJECTIVE

To determine the efficacy of curcumin in the treatment of AR and to explore the molecular mechanisms involved.

METHODS

In a randomized, double-blind study, 241 patients with AR received either placebo or oral curcumin for 2 months. The therapeutic effects of curcumin were evaluated by nasal symptoms and nasal airflow resistance. In addition, the production of interferon γ, interleukin (IL) 4, IL-10, and tumor necrosis factor α from mononuclear cells and IL-8, soluble intercellular adhesion molecule, polyethylene glycol 2, and leukotriene C₄ from polymorphonuclear neutrophils were compared before and after curcumin treatment.

RESULTS

Curcumin alleviated nasal symptoms (sneezing and rhinorrhea) and nasal congestion through reduction of nasal airflow resistance. Curcumin was found to exert diverse immunomodulatory effects, including suppression of IL-4, IL-8, and tumor necrosis factor α and increased production of IL-10 and soluble intercellular adhesion molecule. However, curcumin did not affect the release of prostaglandin E₂ and leukotriene C₄ from polymorphonuclear neutrophils.

CONCLUSION

This pilot study provides the first evidence of the capability of curcumin of improving nasal airflow and modulating immune response in patients with AR.

Hyeonggaeyeongyo-Tang for Treatment of Allergic and Nonallergic Rhinitis: A Prospective, Nonrandomized, Pre-Post Study

Hyeonggaeyeongyo-tang (HYT) is an ancient formula of oriental medicine traditionally used to treat rhinitis; however, clinical evidence has not yet been established. The aim of this study was to investigate the short-term and long-term efficacy and safety of HYT for chronic rhinitis. Adult subjects with chronic rhinitis symptoms were recruited. The subjects received HYT for 4 weeks and had follow-up period of 8 weeks. Any medicines used to treat nasal symptoms were not permitted during the study. The skin prick test was performed to distinguish the subjects with allergic rhinitis from those with nonallergic rhinitis. After treatment, the total nasal symptoms score and the Rhinoconjunctivitis Quality of Life Questionnaire score significantly improved in the whole subject group, in the allergic rhinitis group, and in the nonallergic rhinitis group, with no adverse events. This improvement lasted during a follow-up period of 8 weeks. Total IgE and eosinophil levels showed no significant difference after treatment in the allergic rhinitis group. HYT improved nasal symptoms and quality of life in patients with allergic rhinitis and nonallergic rhinitis. This is the first clinical study to evaluate the use of HYT to treat patients with rhinitis. This trial has been registered with the ClinicalTrials.gov Identifier NCT02477293.

Integrative medical approaches to allergic rhinitis

PURPOSE OF REVIEW

Complementary and integrative medicine (CIM), formerly known as alternative medicine, is now part of the mainstream management for patients with a host of medical issues. This current opinion focuses on the use of CIM, more specifically, the use of nutritional and herbal therapies and homeopathic medications for patients with allergic symptoms.

RECENT FINDINGS

The literature review revealed that naturally occurring substances when compared with placebo more often than not resulted in significant improvement of the allergic rhinitis symptoms.

SUMMARY

Despite encouraging results, additional studies with greater rigor are needed.

The immune-modulatory effects of a mixed herbal formula on dendritic cells and CD4+ T lymphocytes in the treatment of dust mite allergy asthma and perennial allergic rhinitis

OBJECTIVE

Asthma and allergic rhinitis are chronic inflammatory diseases of the conducting nasal airway. Traditional Chinese medicine has long been used for supplemental therapy of allergic diseases, especially asthma and allergic rhinitis. We previously reported the effects of a mixed herbal formula in patients with allergic rhinitis. However, the immune-modulatory mechanism underlying the effects of herbal medicine for the treatment of allergic diseases remains unclear.

METHODS

We investigated the physiologic changes in dendritic cell (DC) and CD4(+) T cell activity in patients with asthma and allergic rhinitis who were treated with a mixed herbal formula composed of Xin-yi-san + Xiao-qing-long-tang + Xiang-sha-liu- jun-zi-tang. Specifically, we set up in vitro autologous or heterologous co-culture experiments between DCs and CD4(+) T cells, and used flow cytometry and ELISA to analyze the expression of surface molecules on DCs and the release of cytokines by CD4(+) T cells.

RESULTS

Expression of HLA-DR on DCs was suppressed following treatment with the mixed herbal formula. Surface expression of CD40, CD54 and CD86 on DCs was also attenuated after treatment. In autologous co-cultures, CD4(+) T cells increased their IL-10 production while decreasing TNF-α production. In heterologous co-cultures, IL-10 secretion by T cells was enhanced, while IL-12, IL-4, IL-5 and TNF-α secretion were reduced.

CONCLUSION

Our mixed herbal formula attenuated the allergic reaction by modifying the physiologic function of the DC-CD4(+) T cell interaction. Further investigations are necessary to understand the mechanism of immune modification mediated by the mixed herbal formula.

Complementary and alternative therapy (CAM) in the treatment of allergic rhinitis

CAM is any therapeutic intervention that exists outside traditional allopathic medicine. The utilization in the US population is increasing up to 4 out of 10 patients in some surveys. Given this increasing prevalence, it is essential that clinicians have the resources to advise their patients in the utilizations, benefits, and potential harms of these alternative therapies. Recent literature was reviewed in regard to traditional Chinese medicine [TCM], acupuncture, homeopathy, and herbal therapy in the treatment of allergic rhinitis limited to randomized controlled trials. Several complementary treatment studies demonstrated statistically significant benefits to patients' quality of life and symptom scoring without providing duration of effect. Alternative therapy studies have revealed mixed results in regard to efficacy. Although the adverse effect profile is low, additional studies will be required to further promote integration into the standard of care for the routine treatment of allergic rhinitis.

The effects of two Chinese herbal medicinal formulae vs. placebo controls for treatment of allergic rhinitis: a randomised controlled trial

Background

Allergic rhinitis is a chronic illness, affecting 10 to 40% of the worldwide population. Chinese herbal medicines, the treatment of allergic rhinitis, adopted thousands of years in ancient China, has recently raised much attention among researchers globally. This study evaluates the effects of two Chinese herbal formulae [Cure-allergic-rhinitis Syrup (CS) and Yu-ping-feng San (YS)] in treating undergraduate nursing students with allergic rhinitis over a 3-month follow-up, when compared to a placebo control group.

Methods

A double-blind, randomised controlled trial with repeated-measures, three-parallel-groups design was conducted in a random sample of 249 participants recruited from one university in Hong Kong. After baseline measurements, participants were randomly assigned to CS, YS, or placebo groups (n = 83 per group). The main outcomes, including symptom severity, quality of life, and body constitution, were measured with self-administered questionnaires at baseline and immediately, 1 and 3 months after the 4-week interventions.

Results

240 participants completed the trial, with 9 (3.6%) drop-outs. The results of Generalised Estimating Equations test followed by pairwise contrasts tests indicated that the participants who received CS showed significantly greater reduction of symptoms (mean difference of CS vs. placebo = 26.13–34.55, P <0.0005) and improvements in quality of life (mean difference of CS vs. placebo = 12.81–16.76, P <0.001), and body constitution in ‘Qi-deficiency’, ‘Yang-deficiency’, and ‘Inherited Special’ (mean difference of CS vs. placebo = 7.05–8.12, 7.56–8.92, and 4.48–8.10, P = 0.01– < 0.0005, 0.001–0.004, and 0.01– < 0.0005, accordingly, at three post-tests). The participants who received YS also indicated significant greater improvements in symptom severity, quality of life, and a few patterns of body constitution when compared to the placebo group. However, its effects were lesser in strength (i.e., smaller effect sizes), varieties of symptoms, and body constitution and sustainability over the 3 months.

Conclusions

The herbal formula CS was found effective to reduce symptoms and enhance quality of life in young adults (nursing students) with allergic rhinitis in ‘Yang- and/or Qi-deficiency’ body constitution. Further controlled trials of its effects in Chinese and/or Asians with allergic rhinitis in terms of socio-demographic, ethnic and illness characteristics and a longer-term follow-up are recommended.

Trial registration

The trial has registered at ClinicalTrials.gov with an ID: NCT02027194 (3 January 2014).

Characteristics and prescription patterns of traditional Chinese medicine in atopic dermatitis patients: ten-year experiences at a medical center in Taiwan

OBJECTIVES

Complementary and alternative therapies in treating atopic dermatitis are not uncommon. However, substantial evidence and consensus on treating atopic dermatitis is lacking. The aim of this study is to investigate the characteristics and utilization of traditional Chinese medicine in patients with atopic dermatitis.

DESIGN

We retrospectively collected patients with atopic dermatitis at the Chang Gung Memorial Hospital in Taiwan between 2002 and 2011. Patients' demographic data, duration and frequency of treatment, serum total immunoglobulin E levels, and traditional Chinese medicine treatment principles and prescription were analyzed.

RESULTS

There were 4145 patients (8.8%) received traditional Chinese medicine therapy between 2002 and 2011. Among them, 2841 (68.54%) chose TCM only and 1304 (31.46%) chose to combine TCM and WM therapies. Those who chose combination therapy were younger, and needed more times of visit and longer duration of treatment. The most frequent comorbid conditions accompany atopic dermatitis were allergic rhinitis (46.06%) and asthma (21.46%). Among the 87,573 prescriptions written for Chinese medicine, the most frequently prescribed herbal formula and single herb were Xiao-Feng-San (Eliminate Wind Powder) (16.98%) and Bai-Xian-Pi (Cortex Dictamni) (12.68%), respectively. The most commonly used therapeutic principles of herbal formulas and single herbs were releasing exterior (20.23%) and clearing heat (41.93%), respectively.

CONCLUSION

Our hospital-based study characterized the utilization patterns of traditional Chinese medicine in atopic dermatitis patients. This information could be used as references for clinical application and provide valuable information for future clinical trials.

The exploration of disease pattern, zheng, for differentiation of allergic rhinitis in traditional chinese medicine practice

Pattern, or "zheng," differentiation is the essential guide to treatment with traditional Chinese medicine (TCM). However, the considerable variability between TCM patterns complicates evaluations of TCM treatment effectiveness. The aim of this study was to explore and characterize the relationship between patterns and the core patterns of allergic rhinitis. We summarized 23 clinical trials of allergic rhinitis with mention of pattern differentiation; association rule mining was used to analyze TCM patterns of allergic rhinitis. A total of 205 allergic rhinitis patients seen at Chang Gung Memorial Hospital from March to June 2005 were included for comparison. Among the 23 clinical trials evaluated, lung qi deficiency and spleen qi deficiencies were the core patterns of allergic rhinitis, accounting for 29.50% and 28.98% of all patterns, respectively. A higher prevalence of lung or spleen qi deficiency (93.7%) was found in Taiwan. Additionally, patients with lung or spleen qi deficiency were younger (27.99 ± 12.94 versus 58.54 ± 12.96 years) and the severity of nasal stuffiness was higher than among patients with kidney qi deficiency (1.35 ± 0.89 versus 0.62 ± 0.65; P < 0.05). Lung and spleen qi deficiencies are the core patterns of allergic rhinitis and determining the severity of nasal stuffiness is helpful in differentiating the TCM patterns.

Characteristics of pediatric traditional Chinese medicine users in Taiwan: a nationwide cohort study

BACKGROUND AND OBJECTIVES

Traditional chinese medicine (TCM) is one of the most commonly used complementary and alternative medicines. However, there is a paucity of epidemiologic reports on features of pediatric TCM users. As TCM services are fully reimbursed by National Health Insurance in Taiwan, this study used a nationwide cohort database to investigate demographics, diseases patterns, and parents' characteristics of pediatric TCM users.

METHODS

Children aged <12 years were extracted from the National Health Insurance Research Database for analysis. These pediatric TCM users' demographics, medical conditions, and reasons for medical services were compared with users of Western medicine by Poisson regression. Children who did not use any medical services were excluded.

RESULTS

Of 107,337 children who were enrolled and followed up in 2005, 19,669 children (18.3%) used TCM. Compared with Western medicine-only users, school-age children (aged 6-12 years), preschool age children (3-5 years), and toddlers (1-2 years) were more likely to use TCM than infants (<1 year; rate ratio = 4.47, 3.66 and 2.59, respectively; P < .001 for all). Parental factors were associated with more TCM use, including female gender, age >35 years, past experience with TCM, and higher income levels. Allergic reactions and respiratory tract, gastrointestinal tract, and musculoskeletal problems were also associated with higher TCM use.

CONCLUSIONS

The use of TCM was correlated with both patient and parental factors, among which children's age and parental TCM use were the most prominent. Additional studies on the efficacy of TCM are warranted.

Meta-analysis of clinical trials on traditional Chinese herbal medicine for treatment of persistent allergic rhinitis

BACKGROUND

Chinese herbal medicine (CHM) has been used for the prevention and treatment of persistent allergic rhinitis (PAR), but results are still equivocal. This study was to assess the clinical effectiveness of CHM in patients with PAR.

MATERIALS AND METHODS

Databases searched included articles published in the Cochrane library, MEDLINE, EMBASE, China National Knowledge Infrastructure, and Wanfang database from 1999 to 2011. The studies included were randomized controlled trials (RCTs) comparing CHM to placebo if they included patients with PAR. The main outcomes were the changes in the standardized mean difference (SMD) of nasal symptom scores and total serum IgE level. Methodological quality was assessed by the modified Jadad's scale.

RESULTS

Seven RCTs with 533 patients were identified and analyzed. In the meta-analysis, CHM reduced the total nasal symptom scores compared to placebo (SMD, -1.82; 95% confidence interval [CI], -3.03 to -0.62; P = 0.003). The effect estimate was in favor of the CHM intervention (SMD, -1.09; 95% CI, -2.74 to 0.55) in reducing the total serum IgE level, although this was not significant (P = 0.19).

CONCLUSIONS

CHM interventions appear to have beneficial effects in patients with PAR. However, the published efficacy studies are too small to draw firm conclusion.