Recommendations for reporting randomized controlled trials of herbal interventions: explanation and elaboration

Clinical effects of Hibiscus sabdariffa Linn. on obesity treatment: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Obesity is associated with many chronic non-communicable diseases, including hypertension, diabetes, cardiovascular and cerebrovascular diseases, cancer, gallbladder disease, bone and joint disorders, skin diseases, fatty liver disease, etc. (Wharton et al., 2020)1 The recent report revealed that overweight and obesity were prevalent in 60 % of the adult population. Several studies have been published to determine the effect of Hibiscus sabdariffa Linn. on obesity treatment, but the findings are still inconclusive. The purpose of this study was to determine the efficacy and safety of H. sabdariffa Linn in the treatment of obesity.

METHODS

We searched PubMed, EMBASE, and CENTRAL from inception to February 2024. Randomized controlled trials (RCTs) were included if they explored the effect of H. sabdariffa on one of the following outcomes: body weight, body mass index (BMI), waist circumference, and waist-to-hip ratio. A random-effects model was used to meta-analyze the data. I2 was used to quantify statistical heterogeneity among the included RCTs. PROSPERO registered protocol: CRD42023408880.

RESULTS

A total of six RCTs with 339 participants were included. Four trials used H. sabdariffa extract in capsules as the intervention of interest compared to placebo, while the other two trials used H. sabdariffa tea compared to black or green tea. Our meta-analyses showed that the mean difference in weight reduction between H. sabdariffa and control was - 0.27 kg (95 % confidence interval (CI); - 1.98 to 1.42, I2 = 0.0 %). The mean differences for BMI and waist circumference reduction were - 0.06 kg/m2 (95 % CI; - 0.58 to 0.47, I2 = 0.0 %) and - 0.20 centimeters (95 % CI; - 2.06 to 1.66, I2 = 0.00 %). No safety concerns were reported in the included studies.

CONCLUSION

Our study did not show a clinical benefit of H. sabdariffa extract in obesity treatment. However, further high-quality RCTs with a longer treatment duration and a standard dose are still warranted.

Reporting characteristics and quality of randomized controlled trial protocols in traditional Chinese medicine: a cross-sectional study

Objectives

The impact of the Standard Protocol Items: Recommendations for Interventional Trials of Traditional Chinese Medicine (SPIRIT-TCM) Extension 2018 statement on the reporting quality of randomized controlled trial (RCT) protocols in traditional Chinese medicine (TCM) is not clear. This review aimed to assess the reporting characteristics and quality of RCT protocols involving interventions such as Chinese herbal medicine formulas (CHMF), acupuncture, and moxibustion published in the last 3 years.

Methods

We conducted an extensive search among multiple databases, including All EBM Reviews, Allied and Complementary Medicine (AMED), Embase, Ovid MEDLINE(R), PubMed, Web of Science, Google Scholar, and ClinicalTrials.gov for publications in English from 1 January 2020 to 10 August 2023. Two reviewers independently assessed the eligibility of the publications, extracted predetermined information, and evaluated the reporting based on the SPIRIT-TCM Extension 2018 checklist.

Results

Of the 420 eligible protocols (comprising 163 studies on CHMF, 239 on acupuncture, and 18 on moxibustion), the average reporting compliance rate was only 35.4%. Approximately half of the assessed items fell into the category of poorly reported, demonstrating a compliance rate below 65%. Notably, reporting compliance in acupuncture and moxibustion interventional studies exhibited higher scores than compliance in CHMF studies.

Conclusion

Continued, concerted, and coordinated efforts are required by journals, editors, reviewers, and investigators to improve the application and promotion of the SPIRIT-TCM Extension 2018 reporting guideline.

Medicinal plants for allergic rhinitis: A systematic review and meta-analysis

Herbal medicine is popularly used among patients who suffer from allergic rhinitis. This systematic review and meta-analysis was conducted to evaluate the efficacy and safety of single medicinal plants in the management of allergic rhinitis. We searched MEDLINE, CENTRAL, and Web of Science for randomised controlled trials which evaluated the use of single medicinal plant for allergic rhinitis among adults and children. Twenty-nine randomised controlled trials (n = 1879) were eligible while 27 (n = 1769) contributed data for meta-analyses. Most studies (studies = 20) compared medicinal plants against placebo and Petasites hybridus was most frequently investigated (studies = 5). Very-low-to-low-certainty evidence suggests that compared to placebo, single medicinal plants may improve overall total nasal symptoms (SMD -0.31, 95% CI -0.59 to -0.02; participants = 249; studies = 5; I2 = 21%) especially nasal congestion and sneezing; and rhinoconjunctivitis quality of life (RQLQ) scores (MD -0.46, 95% CI -0.84 to -0.07; participants = 148; studies = 3; I2 = 0%). Moderate-certainty evidence show no clear differences between single medicinal plants and antihistamine in overall symptoms (Total nasal symptoms: SMD -0.14, 95% CI -0.46 to 0.18; participants = 149; studies = 2; I2 = 0%). As adjunctive therapy, moderate-certainty evidence shows that medicinal plants improved SNOT-22 scores when given as intranasal treatment (MD -7.47, 95% CI -10.75 to -4.18; participants = 124; studies = 2; I2 = 21%). Risk of bias domains were low or not clearly reported in most studies while heterogeneity was substantial in most pooled outcomes. Route of administration and age were identified to be plausible source of heterogeneity for certain outcomes. Medicinal plants appear to be well tolerated up to 8 weeks of use. Clear beneficial evidence of medicinal plants for allergic rhinitis is still lacking. There is a need for improved reporting of herbal trials to allow for critical assessment of the effects of each individual medicinal plant preparation in well-designed future clinical studies.

Drug and Natural Health Product Data Collection and Curation in the Canadian Longitudinal Study on Aging

This study aimed to develop an efficient data collection and curation process for all drugs and natural health products (NHPs) used by participants to the Canadian Longitudinal Study on Aging (CLSA). The three-step sequential process consisted of (a) mapping drug inputs collected through the CLSA to the Health Canada Drug Product Database (DPD), (b) algorithm recoding of unmapped drug and NHP inputs, and (c) manual recoding of unmapped drug and NHP inputs. Among the 30,097 CLSA comprehensive cohort participants, 26,000 (86.4%) were using a drug or an NHP with a mean of 5.3 (SD 3.8) inputs per participant user for a total of 137,366 inputs. Of those inputs, 70,177 (51.1%) were mapped to the Health Canada DPD, 20,729 (15.1%) were recoded by algorithms, and 44,108 (32.1%) were manually recoded. The Direct algorithm correctly classified 99.4 per cent of drug inputs and 99.5 per cent of NHP inputs. We developed an efficient three-step process for drug and NHP data collection and curation for use in a longitudinal cohort.

Efficacy of Kan Jang® in Patients with Mild COVID-19: A Randomized, Quadruple-Blind, Placebo-Controlled Trial

Background and aim. This study aimed to assess the efficacy of the treatment of Kan Jang®, a fixed combination of Andrographis paniculata (Burm. F.) Wall. ex. Nees and Eleutherococcus senticosus (Rupr. & Maxim.) Maxim extracts in patients with mild symptoms of COVID-19. Methods. One hundred and forty patients received six capsules of Kan Jang® (n = 68, daily dose of andrographolides-90 mg) or placebo (n = 72) and supportive treatment (paracetamol) for 14 consecutive days in a randomized, quadruple-blinded, placebo-controlled, two-parallel-group design. The efficacy outcomes were the rate of cases turning to severe, the detection rate of coronavirus SARS-CoV-2 over the time of treatment, the duration, and the severity of symptoms (sore throat, runny nose, cough, headache, fatigue, loss of smell, taste, pain in muscles) in the acute phase of the disease. Other efficacy measures included improving cognitive and physical performance, quality of life, and the levels of inflammatory blood markers-interleukin 6 (IL-6), C-reactive protein, and D-dimer. Results. Kan Jang® significantly (p < 0.05) reduced the rate of cases turning to severe (5.36%) compared to the placebo (17.86%) and decreased the detection rate of SARS-CoV-2 virus over the time of the treatment. The statistical difference in the rates of patients with clinical deterioration in the Kan Jang treatment and placebo control groups was significant (p = 0.0176) both in the 112 patients in the included-per-protocol (IPP) analysis and in the 140 patients in the intended-to-treat (ITT) analysis (p = 0.0236); the absolute risk reduction in cases thanks to the Kan Jang treatment was 12.5%, and the number we needed to treat with Kan Jang was 8. The patient's recovery time (number of sick days at the home/clinic) was shorter in the Kan Jang group compared with the placebo group. The rate of attenuation of inflammatory symptoms in the Kan Jang® group was significantly higher, decreasing the severity of cough, sore throat/pain, runny nose, and muscle soreness compared with the placebo group. Kan Jang® significantly decreased the Wisconsin Upper Respiratory Symptoms scores compared to the placebo in the sample size of 140 patients. However, the relief of fatigue and headache and the decrease in IL-6 in the blood were observed only in a subset of 86 patients infected during the second three waves of the pandemic. Kan Jang® significantly increased physical activity and workout; however, it did not affect cognitive functions (attention and memory), quality of life score, inflammatory marker D-dimer, and C-reactive protein compared with the placebo group. Conclusions. Overall, the results of this study suggest that Kan Jang® is effective in treating mild and moderate COVID-19 irrespective of the SARS-CoV-2 variant of infection.

The standards of reporting trials in pets (PetSORT): Explanation and elaboration

Well-designed randomized controlled trials (RCTs) provide the best evidence of the primary research designs for evaluating the effectiveness of interventions. However, if RCTs are incompletely reported, the methodological rigor with which they were conducted cannot be reliably evaluated and it may not be possible to replicate the intervention. Missing information also may limit the reader's ability to evaluate the external validity of a trial. Reporting guidelines are available for clinical trials in human healthcare (CONSORT), livestock populations (REFLECT), and preclinical experimental research involving animals (ARRIVE 2.0). The PetSORT guidelines complement these existing guidelines, providing recommendations for reporting controlled trials in pet dogs and cats. The rationale and scientific background are explained for each of the 25 items in the PetSORT reporting recommendations checklist, with examples from well-reported trials.

Co-administration of AYUSH 64 as an adjunct to standard of care in mild and moderate COVID-19: A randomized, controlled, multicentric clinical trial

OBJECTIVE

Evaluate the efficacy of AYUSH 64, a standard polyherbal Ayurvedic drug in COVID-19.

METHODS

During the first pandemic wave, 140 consenting and eligible hospitalized adult participants with mild-moderate symptomatic disease (specific standard RT-PCR assay positive) were selected as per a convenience sample, and randomized (1:1 ratio) to an open-label (assessor blind) two-arm multicentric drug trial; standard of care (SOC as per Indian guidelines) versus AYUSH 64 combined with SOC (AYUSH plus). Participants were assessed daily and discharged once clinical recovery (CR, primary efficacy) was achieved which was based on a predetermined set of criteria (resolution of symptoms, normal peripheral oximetry, and negative specific RT-PCR assay). Each participant was followed using an indigenous software program(mobile phone) and completed a 12-week study period. The dose of AYUSH 64 was 2 tablets oral, 500 mg each, bid for 12 weeks (AYUSH plus only). Significant P was <0.05 (two-sided). On randomization, the groups were found well matched.

RESULTS

The mean interval time from randomization to CR was significantly superior in the AYUSH plus group [mean 6.45 days versus 8.26 days, 95% Confidence Interval of the difference -3.02 to -0.59 (P = 0.003, Student's 't test] as per-protocol analysis (134 participants); significant (P = 0.002) on an intention to treat analysis. 70% of the participants in AYUSH plus recovered during the first week (P = 0.046, Chi-square) and showed a significantly better change in physical health, fatigue, and quality of life measures. 48 adverse events, mostly mild and gut related, were reported by each group. There were 20 patient withdrawals (8 in AYUSH plus) but none due to an AE. There were no deaths. Daily assessment (hospitalization) and supervised drug intake ensured robust efficacy data. The open-label design was a concern (study outcome).

CONCLUSIONS

AYUSH 64 in combination with SOC hastened recovery, reduced hospitalization, and improved health in COVID-19. It was considered safe and well-tolerated. Further clinical validation (Phase III) is required.

TRIAL REGISTRATION

CTRI/2020/06/025557.

Role of Herbal Medication in Tobacco Cessation Treatment: A Systematic Review and Meta-analysis

BACKGROUND

Literature reports randomized trials have examined herbal drugs and other smoking cessation therapies such as aromatherapy acupuncture but no comprehensive overview of the overall results has been provided. The present systematic review and meta-analysis aimed to describe the overall effectiveness and safety of herbal medicines.

METHODS

This study was conducted from December 2020 to April 2021 by searching seven databases. Herbal drugs have been shown to help people quit smoking in randomized controlled studies. Two teams of researchers independently extracted the data.

FINDINGS

A total of 12 trials with 762 smokers were included in this study. The heterogeneity I2 was 43.6% with P=0.03 (Cochrane Q test) and χ2=15.77. The overall odds ratio (OR) at 95% confidence interval (CI) was 0.91 (0.68- 1.20) which shows a protective factor of herbal preparations and very low heterogeneity. The herbal treatments such as Vernonia cinerea, St. John's Wort, and lavender essential oil were significantly related to a higher continuous abstinence rate (CAR) compared to the controls with risk ratio (RR): 2.13 (0.57-4.61) at week 8; RR: 2.72 (0.77-5.3) at week 12; and RR: 2.77 (0.37-1.13) at week 24. A 7-day point abstinence rate (PAR) at week 8 was RR: 1.24 (0.81-6.34) with 95% CI; RR: 2.09 (0.93-8.29) at week 12, and RR: 2.11 (0.3-3.08) at week 24. Black pepper and lime were better in craving reduction than the placebo group. This study found no significant difference between the treatment and control groups in adverse effects, despite some minor side effects with herbal drugs.

CONCLUSION

The results of this study showed herbal treatments have the potential to help smokers quit the habit. Further well-designed trials comparing standardized herbal medicines with conventional therapy and placebo are recommended to reinforce this data.

Cognitive and biological effects of citrus phytochemicals in subjective cognitive decline: a 36-week, randomized, placebo-controlled trial

Background

Auraptene (AUR) and naringenin (NAR) are citrus-derived phytochemicals that influence several biological mechanisms associated with cognitive decline, including neuronal damage, oxidative stress and inflammation. Clinical evidence of the efficacy of a nutraceutical with the potential to enhance cognitive function in cohorts at risk of cognitive decline would be of great value from a preventive perspective. The primary aim of this study is to determine the cognitive effects of a 36-week treatment with citrus peel extract standardized in levels of AUR and NAR in older adults experiencing subjective cognitive decline (SCD). The secondary aim is to determine the effects of these phytochemicals on blood-based biomarkers indicative of neuronal damage, oxidative stress, and inflammation.

Methods

Eighty older persons with SCD will be recruited and randomly assigned to receive the active treatment (400 mg of citrus peel extract containing 0.1 mg of AUR and 3 mg of NAR) or the placebo at a 1:1 ratio for 36 weeks. The primary endpoint is a change in the Repeatable Battery for the Assessment of Neuropsychological Status score from baseline to weeks 18 and 36. Other cognitive outcomes will include changes in verbal and nonverbal memory, attention, executive and visuospatial functions. Blood samples will be collected from a consecutive subsample of 60 participants. The secondary endpoint is a change in interleukin-8 levels over the 36-week period. Other biological outcomes include changes in markers of neuronal damage, oxidative stress, and pro- and anti-inflammatory cytokines.

Conclusion

This study will evaluate whether an intervention with citrus peel extract standardized in levels of AUR and NAR has cognitive and biological effects in older adults with SCD, facilitating the establishment of nutrition intervention in people at risk of cognitive decline.

Trial registration

The trial is registered with the United States National Library of Medicine at the National Institutes of Health Registry of Clinical Trials under the code NCT04744922 on February 9^th, 2021 (https://www.clinicaltrials.gov/ct2/show/NCT04744922).

Chinese Herbal Medicine for Mild Cognitive Impairment: A Systematic Review of Randomized Controlled Trials

Objectives

This study aims to explore the benefits and harms of Chinese Herbal Medicine (CHM) for mild cognitive impairment (MCI).

Methods

Electronic searching was conducted in two English and four Chinese databases till 2021 December. Randomized clinical trials on CHM compared to no intervention, placebo or other therapies for MCI were included.

Results

Forty-nine RCTs (48 finished trials and 1 protocol) were identified. The overall methodological quality of included trials was relatively low. This review found that compared to no intervention or placebo, CHM can significantly decrease the number of patients who progressed to dementia (RR 0.36, 95% CI 0.22-0.58) and increase the cognitive function assessed by MMSE (MD 1.96, 95% CI 1.41-2.50) and MoCA (MD 2.44, 95% CI 1.57-3.31). The subgroup analysis of different CHM showed that Ginko leaf tablets can significantly improve the cognitive function compared to no intervention or placebo when assessed by MMSE (MD 2.03, 95% CI 1.18-2.88) and MoCA (MD 3.11, 95% CI 1.90-4.33). Compared to western medicine, CHM can significantly increase the score of MMSE (MD 0.88 95% CI 0.46-1.30) and MoCA (MD 0.87, 95% CI 0.33-1.41), but there was no significant difference on the score of ADL (SMD -0.61, 95% CI -1.49 to 0.27). None of the RCTs reported on the quality of life. Of 22 RCTs that reported adverse events, there was no statistical difference between the CHM and the control group.

Conclusions

CHM, Ginko leaf extracts in particular, could help to prevent progression into dementia and to improve cognitive function and ability of daily living activities. More qualified RCTs were needed to confirm the conclusion due to the low quality of current trials.

Systematic Review Registration

Unique Identifier: CRD42020157148.

A Randomized Controlled Trial of Thai Medicinal Plant-4 Cream versus Diclofenac Gel in the Management of Symptomatic Osteoarthritis of the Knee

Background

Osteoarthritis of the knee is a common degenerative musculoskeletal condition. Thai Medicinal Plant-4 (TMP-4) cream is made up of Garcinia mangostana peel, Sesamum indicum seeds, Glycine max (L.) Merr. seeds, and Centella asiatica leaves, all of which have anti-inflammatory and analgesic properties. The present study aimed at determining the efficacy and safety of TMP-4 cream versus diclofenac gel in the treatment of symptomatic osteoarthritis of the knee.

Methods

A randomized-controlled trial was conducted to assess knee pain on a scale of 100 mm Visual Analog Scale (VAS) and other key metrics, including VAS knee stiffness, a modified 10-step stair climb test, a timed up and go test, the Knee Injury and Osteoarthritis Outcome Score, and safety outcomes, following administration of either TMP-4 cream or diclofenac gel for 4 weeks.

Results

A total of 199 patients with moderate knee pain intensity were randomly assigned to either TMP-4 cream or diclofenac gel (allocation ratio 1 : 1). The mean changes of VAS knee pain in the TMP-4 cream and diclofenac gel groups were −31.68 ± 14.18 mm and −31.09 ± 12.41 mm, respectively, (mean difference = −0.58, 95% confidence interval = −4.37–3.20, P=0.761). The upper limit of 95% confidence interval for the comparison between TMP-4 cream and diclofenac gel was within the predefined margin of 7 mm for noninferiority. The safety was comparable between the two interventions.

Conclusions

TMP-4 cream was noninferior to diclofenac gel in relieving osteoarthritic knee pain and may be considered as an alternative therapeutic option in the treatment of symptomatic osteoarthritis of the knee.

Methodological Aspects in Randomized Clinical Trials of Nutritional Interventions

Nutrition is an essential component when promoting human health. Without a doubt, improving the quality of one’s diet can improve one’s quality of life as a whole and help postpone the onset or control of many chronic diseases. The volume of publications in this field has increased in recent years, in line with increased awareness of the importance of nutrition in health; however, the quality of the evidence on which most nutritional guidelines are based remains low, due to errors in conducting nutritional interventions or because the information is primarily derived from observational studies. To enhance the evidence supporting clinical guidelines in nutrition, the quality of randomized clinical trials (RCT) based on nutritional interventions must be improved; nevertheless, due to their heterogeneous nature and a lack of specific guidelines for designing, performing, documenting, and reporting on this type of intervention, conducting a nutritional intervention is a real challenge. Following a review of the literature on the methodological and ethical standards, as well as four extensions of the CONSORT (Consolidated Standards of Reporting Trials) guidelines that should be considered when implementing a nutritional intervention, seven essential aspects were identified. The current narrative review includes definitions, examples, diagrams, and algorithms regarding aspects of the appropriate study design, the intervention of the control group, the randomization and blinding processes, the study population selection, as well as a description of the type of intervention and the personnel involved in carrying out the study in order to make the implementation of a nutritional intervention easier.

Future Directions for the Discovery of Natural Product-Derived Immunomodulating Drugs

Drug discovery from natural sources is going through a renaissance, having spent many decades in the shadow of synthetic molecule drug discovery, despite the fact that natural product-derived compounds occupy a much greater chemical space than those created through synthetic chemistry methods. With this new era comes new possibilities, not least the novel targets that have emerged in recent times and the development of state-of-the-art technologies that can be applied to drug discovery from natural sources. Although progress has been made with some immunomodulating drugs, there remains a pressing need for new agents that can be used to treat the wide variety of conditions that arise from disruption, or over-activation, of the immune system; natural products may therefore be key in filling this gap. Recognising that, at present, there is no authoritative article that details the current state-of-the-art of the immunomodulatory activity of natural products, this in-depth review has arisen from a joint effort between the International Union of Basic and Clinical Pharmacology (IUPHAR) Natural Products and Immunopharmacology, with contributions from a Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation number of world-leading researchers in the field of natural product drug discovery, to provide a "position statement" on what natural products has to offer in the search for new immunomodulatory argents. To this end, we provide a historical look at previous discoveries of naturally occurring immunomodulators, present a picture of the current status of the field and provide insight into the future opportunities and challenges for the discovery of new drugs to treat immune-related diseases.

The Importance of Reference Materials and Method Validation for Advancing Research on the Health Effects of Dietary Supplements and Other Natural Products

Insufficient assessment of the identity and chemical composition of complex natural products, including botanicals, herbal remedies, and dietary supplements, hinders reproducible research and limits understanding mechanism(s) of action and health outcomes, which in turn impede improvements in clinical practice and advances in public health. This review describes available analytical resources and good methodological practices that support natural product characterization and strengthen the knowledge gained for designing and interpreting safety and efficacy investigations. The practice of validating analytical methods demonstrates that measurements of constituents of interest are reproducible and appropriate for the sample (e.g., plant material, phytochemical extract, and biological specimen). In particular, the utilization of matrix-based reference materials enables researchers to assess the accuracy, precision, and sensitivity of analytical measurements of natural product constituents, including dietary ingredients and their metabolites. Select case studies are presented where the careful application of these resources and practices has enhanced experimental rigor and benefited research on dietary supplement health effects.

Prioritized research recommendations and potential solutions: addressing gaps surrounding dietary supplement ingredients for boosting brain health and optimizing cognitive performance

In the market of dietary supplements, a low level of certainty exists in the state of the science, coupled with not always knowing what is in the product. Together these issues make weighing benefits/risks difficult and hinder the ability to guide evidence-based practice decisions. The authors sought to identify priorities and develop potential solutions to address research gaps so that information disseminated, can ultimately, be relied upon, when trying to make appropriate and safe decisions. Using a modified-Delphi process, 8 panelists reviewed evidence, provided from systematic review, on dietary supplement ingredients for brain health, and prioritized gaps identified and offered potential solutions. Research gaps specific to dietary supplements research included the need for quality testing of products, the question of bioavailability and absorption of ingredients, and optimal composition and standardization of supplements under investigation. Other gaps related to populations studied; a general sense of bias towards focusing research on diseased rather than maintaining or optimizing performance in healthy populations. Additionally, the lack of uniform cognitive performance measures and metrics used across research is a gap, as well as whether the metrics are accurate representations of or even generalizable to "real-life" participants wishing to optimize their performance. Methodological quality and ethical concerns in the conduct and reporting of science encompass all issues. If resources map to potential solutions outlined in this paper, then these proposed next steps offered will help facilitate meaningful research, move evidence into practice recommendations, and ultimately develop better decision-making tools for consumers to trust and rely upon for making safe supplement decisions.

A randomized, open-label, multicentre, comparative study of therapeutic efficacy, safety, and tolerability of BNO 1030 extract, containing marshmallow root, chamomile flowers, horsetail herb, walnut leaves, yarrow herb, oak bark, dandelion herb, in the treatment of mild forms of COVID-19

Background

COVID19 is a high burden for medicine and society as still no specific therapy exists. Most patients depend on symptomatic treatment, comparable to the symptomatic treatment in common respiratory infection e.g., Acetaminophen or Ibuprofen. Many cases of COVID19 show mild forms without need of hospitalization. In this randomized, open-label, multicentre, comparative trial we analysed the efficacy, safety, and tolerability of the herbal medicinal product BNO 1030 in mild cases of COVID-19 to offer an additional symptomatic relive.

Methods

The study was designed as an open label randomized, prospective, multicentred clinical trial. Out of 133 screened outpatients aged 18 to 70 with mild COVID-19 symptoms 120 patients were randomised (1:1) in 2 parallel groups. The main group received BNO 1030 in addition to symptomatic therapy (acetaminophen or ibuprofen). The control group got a symptomatic therapy only. The patients with laboratory proven COVID 19 were included for the final analyses: 47 – in the main group and 46 – in the control one. The evaluation criteria were dynamics of the symptoms: hyperthermia, myalgia, nasal congestion, nasal discharge, coughing, anosmia, rhinolalia, sore throat, duration of the use of antipyretics (clinically significant fever). These symptoms were assessed during the physician’s visit on a 4-point scale (0 — absent, 1 — insignificant, 2 — moderate, 3 — strong/pronounced) and self- assessed via ten-point visual analogue scale (VAS) daily in a patient’s diary. The primary endpoint was the decrease of the average score compared to the baseline defined as “therapeutic benefit” from the usage of BNO 1030.

Results

In the comparison of both groups over the treatment time, the main group (n = 47) showed a greater decrease in the severity of symptoms of fever, myalgia, nasal congestion, coughing, anosmia and rhinolalia, assessed by the doctor on a 4-point scale on V2 (4th day) and V3 (14th day) compared to those on V1, as well as a reduction of the antipyretics intake duration (p < 0.05). Significant differences of the main group were obtained, too, based on the results of symptoms self-assessment by the patient. The “therapeutic benefit from the use of BNO 1030 was 3 days. There is an increase in the number of recovered patients from 73.9–96.6 % according to the average symptom score, and a decrease in the number of hospitalized patients from 8.6–4.4 % in the main group., as compared to the data of the control group (p < 0.05). All patients tolerated the herbal medicine well, with no adverse drug reactions being reported.

Conclusions

BNO 1030 (Imupret®) offers a safe and effective treatment benefit in patients with mild forms of diagnosed COVID-19 aged 18–70 in addition to symptomatic treatment with acetaminophen or NSAIDs. COVID 19 positive patients treated with Imupret showed an earlier relive of symptoms when being treated with BNO 1030.

Trial registration

This trial was registered in ClinicalTrial.gov: NCT04797936.

Effects of Bryophyllum pinnatum Administration on Wistar Rat Pregnancy: Biochemical and Histological Aspects

INTRODUCTION

Bryophyllum pinnatum is widely used in folk medicine. It has neuropharmacological, anti-inflammatory, immunomodulatory, antidiabetic, hepatoprotective, and nephroprotective effects, among others. It also acts on uterine contractility. It is prescribed by practitioners of anthroposophic medicine for preterm labor, insomnia, and emotional disorders, and has other potential uses in obstetrics. As all drugs currently used in preterm labor have side effects, new tocolytic agents remain an area of active research.

OBJECTIVE

To evaluate the effect of B. pinnatum mother tincture (MT) on albino rats and their offspring throughout pregnancy from a biochemical and histological standpoint.

METHODS

Longitudinal, prospective, randomized controlled bioassay. This is the second stage of a trial that investigated 60 animals distributed across six equal groups: controls C1 and C2, which received 1 and 25 times the vehicle dose (30% ethanol), B1 and B2 (1- and 25-fold doses of B. pinnatum MT), and B3 and B4 (which received 50- and 100-fold doses of B. pinnatum concentrate). At this stage, blood chemistry parameters (glucose, alanine aminotransferase [ALT], aspartate aminotransferase [AST], creatinine, and blood urea nitrogen) were measured in dams, as well as histological aspects of dam liver, kidney, placenta, and uterine tissue and fetal liver, kidney, heart, and brain.

RESULTS

No differences were found between group B1 (therapeutic dose) and its control C1 in relation to glucose, AST, ALT, and creatinine. Group B2 exhibited lower glucose levels than groups C1, B3, and B4. There was no difference in AST across groups. Groups B3 and B4 exhibited higher ALT levels than groups C1 and B1. Groups B1-B4 exhibited higher urea nitrogen levels than group C1. Creatinine levels were higher in groups B2 and B3 than group C1. On morphological evaluation, fatty infiltration of the liver was observed in the alcoholic vehicle control groups (C1 and C2).

CONCLUSIONS

Daily administration of B. pinnatum at therapeutic doses (group B1) to pregnant albino rats appears to be safe, with reduced glucose at dose B2, elevated ALT at doses B3 and B4, and increased urea at doses B1 to B4 and creatinine at B2 and B3, but never exceeding the normal reference range. It was not associated with histological changes in specimens of the maternal or fetal structures of interest.

Characterisation of mesenchymal stromal cells in clinical trial reports: analysis of published descriptors

BACKGROUND

Mesenchymal stem or stromal cells are the most widely used cell therapy to date. They are heterogeneous, with variations in growth potential, differentiation capacity and protein expression profile depending on tissue source and production process. Nomenclature and defining characteristics have been debated for almost 20 years, yet the generic term 'MSC' is used to cover a wide range of cellular phenotypes. Against a documented lack of definition of cellular populations used in clinical trials, our study evaluated the extent of characterisation of the cellular population or study drug.

METHODS

A literature search of clinical trials involving mesenchymal stem/stromal cells was refined to 84 papers upon application of pre-defined inclusion/exclusion criteria. Data were extracted covering background trial information including location, phase, indication, tissue source and details of clinical cell population characterisation (expression of surface markers, viability, differentiation assays and potency/functionality assays). Descriptive statistics were applied, and tests of association between groups were explored using Fisher's exact test for count data with simulated p value.

RESULTS

Twenty-eight studies (33.3%) include no characterisation data. Forty-five (53.6%) reported average values per marker for all cell lots used in the trial, and 11 (13.1%) studies included individual values per cell lot. Viability was reported in 57% of studies. Differentiation was discussed: osteogenesis (29% of papers), adipogenesis (27%), and chondrogenesis (20%) and other functional assays arose in 7 papers (8%). The extent of characterisation was not related to the clinical phase of development. Assessment of functionality was very limited and did not always relate to the likely mechanism of action.

CONCLUSIONS

The extent of characterisation was poor and variable. Our findings concur with those in other fields including bone marrow aspirate and platelet-rich plasma therapy. We discuss the potential implications of these findings for the use of mesenchymal stem or stromal cells in regenerative medicine, and the importance of characterisation for transparency and comparability of literature.

Carica papaya L. Leaf: A Systematic Scoping Review on Biological Safety and Herb-Drug Interactions

INTRODUCTION

The Carica papaya L. leaf is gaining interest as a potential therapeutic agent for alleviating dengue- and non-dengue-associated thrombocytopaenia. In that regard, safety considerations are as important as efficacy potential. The safety evaluation of botanical products for human use is complicated by variable formulations, complex phytochemical composition, and extrinsic toxicants. This review aimed to systematically collate related safety clinical and preclinical data, as well as reports on herb-drug interactions of C. papaya leaf consumption.

METHODS

A systematic search using predetermined keywords on electronic databases (MEDLINE, Cochrane Library Central, LILACS, and Web of Science) and grey literature was conducted. Relevant clinical and preclinical studies were identified, screened, and analysed to present an overall safety profile of C. papaya leaf consumption.

RESULTS

A total of 41 articles were included (23 clinical, 5 ongoing trials, and 13 preclinical) for descriptive analysis on study characteristics, adverse reactions, toxicity findings, and herb-drug interactions, from which 13 randomised controlled and quasiexperimental trials were further assessed for risk of bias and reporting quality. Overall, C. papaya leaf consumption (in the form of juice and standardised aqueous extract) was well tolerated by adult humans for short durations (

CONCLUSION

C. papaya leaf consumption in adults is generally safe for short-term use though cautioned in pregnancy and people with liver impairment. It has potential herb-drug interactions with oral hypoglycaemic agents, p-glycoprotein substrates, and antibiotics with cation chelating properties.

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Affiliation(s)

X. Y. Lim Herbal Medicine Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Setia Alam 40170, Shah Alam, Malaysia
J. S. W. Chan Herbal Medicine Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Setia Alam 40170, Shah Alam, Malaysia
N. Japri Herbal Medicine Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Setia Alam 40170, Shah Alam, Malaysia
J. C. Lee Herbal Medicine Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Setia Alam 40170, Shah Alam, Malaysia
T. Y. C. Tan Herbal Medicine Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Setia Alam 40170, Shah Alam, Malaysia

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Carvacrol improves pulmonary function tests, oxidant/antioxidant parameters and cytokine levels in asthmatic patients: A randomized, double-blind, clinical trial

BACKGROUND

Carvacrol effects on inflammatory mediators, lung pathology and tracheal responsiveness were indicated in animal models of pulmonary diseases.

PURPOSE

To evaluate carvacrol effects on respiratory symptoms, pulmonary function tests (PFT), oxidative stress markers and cytokine levels in asthmatic patients.

STUDY DESIGN

This study was a randomized, placebo-controlled double-blind, clinical trial.

METHODS

Thirty-three moderate asthmatic patients were divided to the two groups of: placebo group (n = 16) and carvacrol group (1.2 mg/kg/day, n = 17). Prepared capsules were taken for two months along, 3 times/day along with routine medications. Respiratory symptoms, PFT, and oxidative stress markers were evaluated before the treatment (step 0), and one (step I) and two months (step II) after the beginning of the treatment. However, cytokine levels in serum and supernatant of peripheral blood mononuclear cells (PBMC), and their gene expression were evaluated in step 0 and II.

RESULTS

In carvacrol-treated group, respiratory symptoms significantly decreased after one- and two-month treatment with carvacrol compared to pre-treatment values (p < 0.05 to p < 0.001). Compared to step 0, PFT values were significantly increased in step I and II, in treated group with carvacrol (p < 0.05 to p < 0.001). Most oxidative stress markers were improved following carvacrol treatment (p < 0.05 to p < 0.001). Treatment with carvacrol for two-month also significantly improved cytokine levels in serum and supernatant of PBMC, compared to step 0 (p < 0.05 to p < 0.001). However, no significant changes were observed in the above-noted parameters in the placebo group.

CONCLUSION

Due to anti-inflammatory and antioxidant effect, carvacrol could be suggested as a therapeutic agent for asthma.

The Template for Intervention Description and Replication as a Measure of Intervention Reporting Quality: Rasch Analysis

Objective

To determine whether the 12 items of the Template for Intervention Description and Replication (TIDieR) can be combined into a single summary score reflecting intervention reporting completeness and quality.

Design

Systematic review and reanalysis of published data. After a systematic search of the published literature, 16 review articles were retrieved with 489 sets of 12 TIDieR ratings of experimental intervention, comparator, or the 2 combined as reported in primary studies. These 489 sets were recoded into a common format and analyzed using Rasch analysis for binary items.

Setting

Not applicable.

Participants

Not applicable.

Interventions

Not applicable.

Main Outcome Measures

Psychometric qualities of a Rasch Analysis-based TIDieR summary score.

Results

The data fit the Rasch model. Infit and outfit values were generally acceptable (range, 0.70-1.45). TIDieR was reasonably unidimensional in its structure. However, the person (here: study) separation ratio was 1.25 with a corresponding reliability of 0.61. In addition, the confidence interval around each estimate of reporting completeness was wide (model standard error of 0.78).

Conclusion

Several Rasch indicators suggested that TIDieR is not a strong instrument for assessing the quality of a researcher's reporting on an intervention. It is recommended that it be used with caution. Improvements in TIDieR itself may make it more helpful as a reporting tool.

The Use of Essential Oils and Their Isolated Compounds for the Treatment of Oral Candidiasis: A Literature Review

In this literature review, we present the main scientific findings on the antifungal activity of essential oils (EOs) applicable for a new drug formulation to treat oral candidiasis. Seven literature databases were systematically searched for eligible in vitro and clinical trials. Selected articles were screened for biological activity, botanical species, phytochemical composition, study design, and methodological quality. A total of 26 articles were included in the review, of which 21 were in vitro studies and 5 clinical trials. The most promising EOs were obtained from Allium tubeorosum, Cinnamomum cassia, Cinnamomum zeylanicum, and Coriandrum sativum L. Among the phytochemicals, citral and thymol were the most active. Clinical trials indicated that the EOs from Pelargonium graveolens and Zataria multiflora are potentially effective to treat oral candidiasis. Further nonclinical and clinical studies with these EO are warranted to determine their potential use and safety for the treatment of oral candidiasis.

An open-label, multicentre, randomized comparative study of efficacy, safety and tolerability of the 5 plant - extract BNO 1012 in the Delayed Antibiotic Prescription Method in children, aged 6 to 11 years with acute viral and post-viral rhinosinusitis

Acute rhinosinusitis (ARS) can be characterized as bacterial (ABRS) and require antibiotic therapy only in 0.5-5% of cases. In most cases, the disease is in a viral and post-viral form, which requires pathogenetic and symptomatic treatment. The study objective was to determine the efficacy of BNO 1012 extract in the technology of delayed antibiotic prescribing in children with acute rhinosinusitis.

METHODS

292 children aged 6 to 11 years with ARS were randomized in the multicenter, comparative study. They received an extract of five medicinal plants in addition to standard symptomatic therapy or standard therapy only. EVALUATION CRITERIA: reduction of the sinusitis severity according to a 4-point medical assessment scale (nasal congestion, severity of anterior and posterior rhinorrhea) at each visit, dynamics of self-scoring of rhinorrhea and headache (according to a 10-point visual analogue scale), "therapeutic benefit" in days, frequency of antibiotic prescriptions due to the use of an extract of five plants.

RESULTS

The use of the 5-plant extract BNO 1012 in addition to the standard symptomatic treatment of acute rhinosinusitis provides a clinically significant, adequate reduction in the severity of rhinorrhea, nasal congestion and post-nasal drip, assessed by a physician at V2 (p < 0.005). Significant differences are noted in the patient's self-scoring of rhinorrhea on the second or third day in viral RS, and from the fourth to the eighth day in post-viral RS. Symptoms of similar intensity in control group were observed at V3. Thus, in the first week of treatment, the treatment group compared to the control one showed a "therapeutic benefit" of three days. The use of BNO 1012 in patients with acute rhinosinusitis can 1.81-fold reduce the prescription of antibacterial drugs.

CONCLUSION

The combination of five medicinal plants is effective for the treatment of acute rhinosinusitis in children aged 6 to 11 years. Its use provides a significant "therapeutic benefit" when administered in addition to standard symptomatic therapy, reducing the need for antibiotic use.

A clinical study on safety and efficacy of Naesohwajung-tang on functional dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a chronic gastrointestinal disorder diagnosed with dyspeptic symptoms, such as recurrent or persistent postprandial fullness, epigastric pain, burning, and early satiety without any evidence of structural abnormality. In traditional Korean medicine, herbal remedies are one of the preferred treatments for gastrointestinal symptoms. Among them, Naesohwajung-tang (NHT) has been frequently prescribed to improve dyspeptic symptoms for a long time. However, the safety and efficacy of NHT still remain unclear. Therefore, this study aims to evaluate the safety and efficacy of NHT in patients with FD using a randomized controlled trial.

METHODS

This is a protocol for a multi-center, randomized, double-blind, placebo-controlled trial. Total 116 participants aged between 19 and 75 years diagnosed with FD according to the Rome IV diagnosis criteria will be recruited at two Korean medicine hospitals. Eligible participants will be randomly assigned to either a NHT group or a placebo group in a 1:1 ratio. Each participant will be instructed to take NHT or placebo granules three times a day for 4 weeks. The primary outcome is the change in the total dyspepsia symptom score to confirm the efficacy of NHT. The secondary outcomes include overall total effect, single dyspepsia symptom scale, food retention questionnaire, Damum questionnaire, FD-related quality of life, electrogastrography, and safety assessments. Adverse events will be evaluated at every visit. The primary endpoint will be measured at week 4, and then re-evaluated at week 8 through a follow-up phone visit.

DISCUSSION

This trial will evaluate the safety and efficacy of NHT as a treatment of FD. The results of this trial will not only verify whether NHT improves FD symptoms and gastric myoelectrical activity, but also clarify those correlations.

TRIAL REGISTRATION NUMBER

CRIS KCT0003405.

Pilot and feasibility trials in traditional Chinese medicine: a literature review of current practice

Background

The guidelines for pilot and feasibility studies were published in 2016. Little is known about the guideline adherence of TCM (traditional Chinese medicine) pilot trials or whether the guidelines can significantly enhance the quality of implementation and reporting of TCM pilot trials. We aimed to investigate the guideline adherence, assess the impact of guidelines on TCM pilot trials, and discuss potential challenges specific to TCM pilot trials, by conducting a literature review.

Methods

We systematically searched MEDLINE, EMBASE, and CNKI to retrieve TCM pilot trials. We randomly chose 50 pilot trials from the eligible studies for analyses. The CONSORT extension to pilot and feasibility studies was used as a framework to assess the methodology and reporting quality of the studies.

Results

The included studies had a guideline adherence level ranging from 4 to 96%, where the lowest adherence was found in the item 6c (prespecified criteria used to judge progression to future definitive trial). The guidance published in 2016 seemed to exert minimal effect on guideline adherence in TCM pilot trials. The unidentified issues related to TCM pilot trials from the guidelines included blinding, lack of standard formula of interventions, difficulty in comparison for effect assessment of interventions, and difficulty in bias control.

Conclusions

The current practice in TCM pilot trials required substantial improvement in the literature. Further endeavors are needed for training and dissemination of guideline adherence, and development of more detailed methodology in the field of TCM pilot trials.

Efficacy and safety of Ojeok-san plus Saengmaek-san for gastroesophageal reflux-induced chronic cough: protocol for a pilot, randomized, double-blind, placebo-controlled trial

BACKGROUND

Gastroesophageal reflux disease (GERD) is a major cause of chronic cough. GERD-induced chronic cough is difficult to diagnose because some patients do not complain of any gastrointestinal (GI) reflux symptoms. Although chronic cough due to GERD is highly prevalent, no effective treatment is currently available, especially for GERD-related cough without GI symptoms. Because the herbal medicines Ojeok-san and Saengmaek-san can effectively treat GERD and cough, we aim to evaluate the efficacy and safety of a combination of these components for relieving chronic cough due to GERD.

METHODS/DESIGN

This is a study protocol of a randomized, double-blind, placebo-controlled, single-center pilot trial. After a 1-week run-in period, a total of 30 patients with GERD-induced chronic cough will be randomly allocated to an intervention group (n = 15) or a placebo group (n = 15). Participants will receive 5.76 g of Ojeok-san plus Saengmaek-san or a placebo three times per day for 6 weeks. The primary outcome measures, which are the frequency and severity of cough, will be recorded using a cough diary. The secondary outcome measures will include a cough visual analogue scale, the Leicester Cough Questionnaire (Korean version), the Gastrointestinal Symptom Rating Scale, the Hull Airway Reflux (hypersensitivity) Questionnaire, the Pattern Identification for Chronic Cough Questionnaire, the Pattern Identification for Gastroesophageal Reflux Disease, and safety testing. Adverse events will also be reported.

DISCUSSION

This will be the first clinical trial to explore the use of herbal medicines for GERD-related chronic cough, including patients without GI reflux symptoms. This study will provide useful evidence regarding the efficacy and safety of Ojeok-san plus Saengmaek-san treatment. In addition, this trial will offer a scientific basis for the combination of herbal medicines. This study will also provide important data for conducting a larger-scale clinical trial on GERD-induced chronic cough.

TRIAL REGISTRATION

This trial has been registered with Clinical Research Information Service (CRIS) of South Korea (http://cris.nih.go.kr; registration number KCT0003115). Registered August 28, 2018.

Improving natural product research translation: From source to clinical trial

While great interest in health effects of natural product (NP) including dietary supplements and foods persists, promising preclinical NP research is not consistently translating into actionable clinical trial (CT) outcomes. Generally considered the gold standard for assessing safety and efficacy, CTs, especially phase III CTs, are costly and require rigorous planning to optimize the value of the information obtained. More effective bridging from NP research to CT was the goal of a September, 2018 transdisciplinary workshop. Participants emphasized that replicability and likelihood of successful translation depend on rigor in experimental design, interpretation, and reporting across the continuum of NP research. Discussions spanned good practices for NP characterization and quality control; use and interpretation of models (computational through in vivo) with strong clinical predictive validity; controls for experimental artefacts, especially for in vitro interrogation of bioactivity and mechanisms of action; rigorous assessment and interpretation of prior research; transparency in all reporting; and prioritization of research questions. Natural product clinical trials prioritized based on rigorous, convergent supporting data and current public health needs are most likely to be informative and ultimately affect public health. Thoughtful, coordinated implementation of these practices should enhance the knowledge gained from future NP research.

Nigella sativa L. for prevention of acute radiation dermatitis in breast cancer: A randomized, double-blind, placebo-controlled, clinical trial

OBJECTIVE

The present study aimed to evaluate the effectiveness of Nigella sativa L. (N. sativa) extract on preventing the incidence of acute radiation dermatitis (ARD) in breast cancer patients.

METHODS

Sixty-two breast cancer patients undergoing radiotherapy (RT) were randomly assigned to receiveN. sativa 5% gel or placebo. Patients were instructed to apply the medications twice daily during RT period. The severity of ARD, the incidence of moist desquamation, worst experienced pain, and skin-related quality of life (SRQOL) scores were assessed weekly during RT.

RESULTS

Patients who were treated with the N. sativa gel developed ARD significantly less frequently compared to those who used the placebo (p < 0.05 for all weeks except week 2, p = 0.36). The incidence time of grade 2 and 3 of Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer (RTOG/EORTC) toxicity was prolonged significantly with N. sativa gel as compared to placebo (35 vs. 29 days, p = 0.00 and 42 vs. 40 days, p = 0.01, respectively). Furthermore, the occurrence of moist desquamation was delayed in the N. sativa gel group compared with the placebo group (37 vs. 33 days, p = 0.01). The mean score of the worst pain that patients experienced in the placebo group was significantly higher than that of the N. sativa gel group at week 3 (2.5 ± 0.5 vs. 1.2 ± 0.3, p < 0.05). Nonetheless, the application of N. sativa gel had no significant effect on the SRQOL of patients at any week.

CONCLUSION

N. sativa extract significantly decreases the severity of ARD and delays the onset of moist desquamation in breast cancer patients.

Consolidated Standards of Reporting Trials (CONSORT) extensions covered most types of randomized controlled trials, but the potential workload for authors was high

OBJECTIVES

Our aim was to determine the coverage of randomized controlled trials (RCTs) by the Consolidated Standards of Reporting Trial (CONSORT) Statement and its extensions and to evaluate the potential workload for authors to adhere to the guidelines.

STUDY DESIGN AND SETTING

We identified CONSORT extensions from the CONSORT Web site. We randomly selected a sample of 1,000 RCTs indexed in PubMed in 2016 and recorded whether they were covered by CONSORT extensions for specific study designs or interventions. We evaluated the potential workload for authors by counting the number of documents and pages they have to consult to have a full understanding of the guidelines.

RESULTS

We identified 14 extensions. Only one extension was updated concurrently with the main CONSORT in 2010, three were updated after 2-7 years, and three are still based on CONSORT 2001. Overall, 81% of RCTs are covered by relevant CONSORT guidelines; missing extensions for specific study designs were under development at the time of the search (Nov 2018). However, 6 of 10 extensions covered <2% of the trials. A median [Q1-Q3] of 4 [4-5] documents and 67 [57-78] pages should be consulted.

CONCLUSION

Most RCTs indexed in PubMed are covered by the CONSORT Statement and extensions, but the potential workload for authors could be high.

Pharmacokinetics of mitragynine, a major analgesic alkaloid in kratom (Mitragyna speciosa): A systematic review

BACKGROUND AND OBJECTIVE

Kratom (Mitragyna speciosa) is a tropical tree found in southern Thailand and northern states of the Malay Peninsula. Kratom is commercially available and used as an alternative to treat opioid withdrawal. Mitragynine is the major indole alkaloid found in kratom leaves. This review aimed to summarize available pharmacokinetic information about mitragynine.

METHODS

PubMed, Scopus, and Web of Science were systematically searched from their inceptions to June 2018. All types of pharmacokinetic studies of mitragynine were included for further systematic review.

RESULTS

Seventeen articles were reviewed. Mitragynine is a lipophilic weak base passively transported across the intestinal wall and blood brain barrier. 85-95% is bound to plasma protein and extensively metabolized by phase I and particularly phase II enzymes. Actions on CYP enzymes are unlikely to impact drug metabolism at concentrations likely to exist in kratom-consuming humans. In rats and humans, mitragynine is rapidly absorbed after orally administration (T_max˜1.5 h, C_max˜0.3-1.8 μM). V_d was 37-90 L/kg; t_1/2 was 3-9 hr; mostly excreted as metabolites in urine. Bioavailability was estimated as 21%. It also rapidly penetrated and redistributed in brain. A quality assessment tool tailored for pharmacokinetic studies was also created which rated some studies of lower value.

CONCLUSION

Rudimentary pharmacokinetics of mitragynine was described in this systematic review. However, the discovered studies provided scant information on the role of metabolism and redistribution into tissues nor the rate of excretion.

Medicinal plants as therapeutic options for topical treatment in canine dermatology? A systematic review

Background

Medicinal plants have been used traditionally since centuries for wound care and treatment of skin diseases both in human and animals. Skin diseases are one of the most common reasons for owners to take their dog to the veterinarian. The demands for treatment and prophylaxis of these diseases are broad. A wide range of bacteria including antibiotic-resistant bacteria can be involved, making the treatment challenging and bear an anthropo-zoonotic potential. The aim of this review is to systematically evaluate based on recent scientific literature, the potential of four medicinal plants to enrich the therapeutic options in pyoderma, canine atopic dermatitis, otitis externa, wounds and dermatophytosis in dogs.

Results

Based on four books and a survey among veterinarians specialized in phytotherapy, four medicinal plants were chosen as the subject of this systematic review: Calendula officinalis L. (Marigold), Hypericum perforatum L. agg. (St. John’s Wort), Matricaria chamomilla L. (syn. Matricaria recutita L., Chamomile) and Salvia officinalis L. (Sage). According to the PRISMA statement through literature research on two online databases a total of 8295 publications was screened and narrowed down to a final 138 publications for which full-text documents were analyzed for its content resulting in a total of 145 references (21 clinical, 24 in vivo and 100 in vitro references).

Conclusions

All four plants were proven to have antibacterial and antifungal effects of a rather broad spectrum including antibiotic-resistant bacteria. This makes them an interesting new option for the treatment of pyoderma, otitis externa, infected wounds and dermatophytosis. Marigold, St. John’s Wort and Chamomile showed wound-healing properties and are thus promising candidates in line to fill the therapeutic gap in canine wound-healing agents. St. John’s Wort and Chamomile also showed anti-inflammatory and other beneficial effects on healthy skin. Due to the wide range of beneficial effects of these medicinal plants, they should be taken into account for the treatment of dermatologic diseases in dogs at least in future clinical research.

Electronic supplementary material

The online version of this article (10.1186/s12917-019-1854-4) contains supplementary material, which is available to authorized users.

The Safety of Mother's Milk® Tea: Results of a Randomized Double-Blind, Controlled Study in Fully Breastfeeding Mothers and Their Infants

BACKGROUND

Various natural products are reported to improve maternal milk supply yet are not necessarily safe for infants. Researchers have not systematically studied galactagogue teas for safety.

RESEARCH AIM

This study evaluates the safety of a galactagogue tea in breastfeeding women and their infants, assessing short- and long-term adverse effects.

METHODS

Healthy, exclusively/fully breastfeeding women ( N = 60) with no milk insufficiency were randomized into (1) an all-natural tea containing fruits of bitter fennel, anise, and coriander; fenugreek seed; and other herbs (Mother's Milk^® herbal tea; test) group or (2) a lemon verbena leaf (placebo) group. Maternal diaries captured self-reported maternal and infant adverse effects, tea consumed, and perceived infant satisfaction. Maternal quality of life and psychological state were assessed at baseline and 2 and 4 weeks. Poststudy calls assessed adverse effects through the infants' age of 12 months.

RESULTS

No adverse effects attributable to the interventions were reported at any time point. No differences were found between test and placebo groups in sociodemographic characteristics, maternal or infant adverse symptoms, quality of life, breastfeeding self-efficacy, maternal psychological measures, infant growth, and infant satisfaction (all p >.05).

CONCLUSIONS

This double-blind, randomized controlled trial (RCT) of an herbal galactagogue versus placebo among healthy, exclusively/fully breastfeeding mothers and infants found no adverse events associated with the test tea across the 30-day study or the first year of their infant's life. This composite tea appears to present no safety risk for mothers or their young babies.

A randomized, open-label, multicenter, comparative study of therapeutic efficacy, safety and tolerability of BNO 1030 extract, containing marshmallow root, chamomile flowers, horsetail herb, walnut leaves, yarrow herb, oak bark, dandelion herb in the treatment of acute non-bacterial tonsillitis in children aged 6 to 18 years

Seventy to 95% of acute tonsillitis episodes are caused by viral infection, therefore why antibiotic therapy is not indicated in majority of cases. In such cases, acetaminophen or ibuprofen are used to alleviate the symptoms. The objective of this study was assessment of efficacy of phytoneering extract BNO 1030 (Imupret®) in patients with acute non-bacterial tonsillitis.

METHODS

This randomized, open-label, multicenter, comparative study randomised 238 outpatients aged 6-18 years to receive either BNO 1030 (Imupret®) as a supplement to standard symptomatic therapy, or standard therapy. Assessment criteria were as follows: sore throat dynamics at rest and at swallowing, throat irritation associated with cough, general condition, day of withdrawal of antipyretics, the share of treatment responders, as well as assessment of "therapeutic benefit" from the use of BNO 1030.

RESULTS

Decreased intensity of acute tonsillitis symptoms to 1 point and lower, assessed using 4-point scale starting from the day 5 of treatment (p < 0.005), alleviation of local symptoms and general condition starting from day 2 of the disease (р < 0.001), withdrawal of antipyretics starting from day 4 of treatment (p < 0.005), increase of the number of treatment responders to 81.6% (p < 0.005) versus the control were reported. "Therapeutic benefit" was 4.2 days. All patients tolerated phytotherapy well, and no adverse reactions were seen.

CONCLUSION

BNO 1030 (Imupret®) is a safe and effective product for treatment of acute non-bacterial tonsillitis in children aged 6-18 years, assuring therapeutic benefit when prescribed additionally to the standard symptomatic therapy.

Diagnoses associated with dietary supplement use in a national dataset

OBJECTIVES

The purpose of this study was to determine if participant diagnosis, as determined by a health care provider, is associated with dietary supplement (DS) use.

DESIGN/SETTING

Surveys from 1255 study participants aged 34-84, part of the Midlife in the US Study (MIDUS 2 Survey) Biomarker Project, were reviewed. Participant data included pharmaceutical use (prescription and over-the-counter medications (OTC)), clinical symptoms and diagnosis, and laboratory results. Associations were calculated between the above participant characteristics and DS use.

MAIN OUTCOME MEASURES

Frequency of DS use for physician-reported diagnoses.

RESULTS

Overall prevalence of DS use was 32.4%. Participants taking DS were more often female (p = .048), white (p < 0.001), and older (mean age 57 years, p < 0.001). Participants taking DS reported taking more OTC (p < .001) and prescription medications (p = .024), and had an increased number of chronic conditions (p = .004). Participants reporting physician-diagnosed diabetes were significantly less likely to be taking DS (p = .0066), while participants with eye disease (p = .001), high cholesterol (p = 0.041), cancer (p = 0.042), and arthritis (p = 0.044) were more likely to be taking DS than those without those conditions. No difference in DS use was found between patients with and without other identified medical conditions. After adjusting for age, race/ethnicity, and gender, only diabetes remained a significant predictor of decreased DS use (OR 0.588, CI 0.388-0.873, p = .01).

CONCLUSIONS

Some physician-reported participant diagnoses were associated, positively or negatively, with DS use.

Herbal medicine (Hyeolbuchukeo-tang or Xuefu Zhuyu decoction) for treating primary dysmenorrhea: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Primary dysmenorrhea is a condition characterized by painful menstrual cramps that usually occurs in the absence of any identifiable pathological condition among menstruating women, with the prevalence estimates varying between 45% and 95%. Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered as a standard treatment for primary dysmenorrhea; however, the failure rate of NSAIDs is often 20% to 25% and these drugs commonly cause adverse effects. In this review, we investigated the current evidence related to the effectiveness of Xuefu Zhuyu decoction (XZD) or Hyeolbuchukeo-tang, a traditional herbal formula, as a treatment for primary dysmenorrhea.

METHODS

Literature search was conducted about randomized controlled trials (RCTs) for XZD on primary dysmenorrhea. PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure Database, Oriental Medicine Advanced Searching Integrated System, and other Chinese, Korean, Japanese databases were searched up to December 20, 2017. Two independent reviewers extracted and assessed the data. The main outcome domains were visual analogue scale (VAS) score and response rate.

RESULTS

Among 475 publications, 8 RCTs involving 1048 patients were finally included. Methodological quality of included RCTs was relatively low. In 4 add-on design studies, XZD plus western medication (WM) group showed better response rate as compared to the WM sole therapy (relative risk 1.18, 95% confidence interval [1.11, 1.25], P < .01). VAS score after the 3rd month of treatment in the XZD plus WM group was also lower than that in the WM group (mean difference -0.45, 95% confidence interval [-0.79, -0.12], P < .01). In 4 XZD versus WM design studies, XZD sole therapy showed better response rate than did WM sole therapy (relative risk 1.26, 95% confidence interval [1.06, 1.49], P < .01).

CONCLUSION

The existing trials showed a favorable effect of XZD for the management of primary dysmenorrhea. However, the efficacy of XZD on primary dysmenorrhea is not conclusive owing to the small number of studies and the high risk of bias. Large-scale, long-term RCTs with rigorous methodological input are needed to clarify the role of XZD for the management of primary dysmenorrhea.

TRIAL REGISTRATION NUMBER

CRD42016050447 in PROSPERO 2016.

Interaction of herbal products with prescribed medications: A systematic review and meta-analysis

Although several studies on pharmacokinetic and/or pharmacodynamic herb-drug interactions (HDI) have been conducted in healthy volunteers, there is large uncertainty on the validity of these studies. A qualitative review and a meta-analysis were performed to establish the clinical evidence of these interaction studies. Out of 4026 screened abstracts, 32 studies were included into the qualitative analysis. The meta-analysis was performed on eleven additional studies. St. John's wort (SJW) significantly decreased the AUC (p < 0.0001) and clearance (p = 0.007) of midazolam. Further subgroup analysis identified age to affect C_max of midazolam (p < 0.01) in the presence of SJW. Echinacea purpurea (EP) significantly increased the clearance of midazolam (p = 0.01). Evidence of publication bias (p > 0.001) was shown on the effect of the herbal products o half-life of midazolam. Green tea (GT) showed significant 85% decrease in plasma concentration of nadolol. The study findings suggest that GT, SJW and EP perpetuate significant interactions with prescribed medications via CYP3A4 or OATP1A2. Our studies show that meta-analyses are important in the area of natural products to provide necessary information on their use in overall medication plans in order to avoid unintended interactions.

Traditional Chinese herbal medicine for vascular dementia

BACKGROUND

Traditional Chinese herbal medicine (TCHM) is widely used for treating vascular dementia (VaD) in China. Recent studies of a number of TCHMs have demonstrated in vitro biological activity and therapeutic effects in animals, but the published clinical evidence has not been systematically appraised.

OBJECTIVES

To evaluate the efficacy and safety of TCHMs listed in either the Chinese Pharmacopoeia (CP) or the Chinese National Essential Drug List (NEDL) that are used to treat VaD. A secondary aim was to identify promising TCHMs for further clinical research.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialised Register (on 14 March 2018) and also several Chinese biomedical databases: the Chinese Biological Medicine Database (January 1979 to May 2015), Wanfang database (January 1998 to May 2015), Chongqing VIP Information Co. Ltd or Weipu (January 1998 to May 2015) and the Chinese National Knowledge Infrastructure (January 1979 to May 2015).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of TCHMs compared to placebo, to Western medicine (WM) or to routine therapy for VaD risk factors. Eligible participants were men and women aged 18 years and above, diagnosed with VaD by any of the following four criteria: (1) Diagnostic and Statistical Manual of Mental Disorders (DSM) versions III, III-R, IV, IV-TR; (2) National Institute of Neurological Disorders and Stroke (NINDS-AIREN); (3) International Classification of Diseases 9 or 10; (4) the Hachinski or the Modified Hachinski Ischaemic Score. We required the use of an imaging technique to differentiate VaD from other dementias. We excluded (1) trials with participants diagnosed with mixed dementia or those that did not use an imaging technique to ascertain VaD; (2) trials of NEDL-listed Gingko biloba or Huperzine A as experimental interventions, to avoid duplication of existing Cochrane Reviews; (3) trials using acupuncture alone as the experimental intervention; (4) trials using another CP- or NEDL-listed TCHM (except for Huperzine A and Gingko which are popular in Western practice) as the control intervention; and (5) trials using purely non-pharmacological interventions as the control intervention unless explicitly described as 'routine therapy for VaD risk factors'.

DATA COLLECTION AND ANALYSIS

We assessed the risks of bias using the Cochrane 'Risk of bias' tool and adapted the Outcome Reporting Bias in Trials (ORBIT) classification system for outcome reporting bias. We assessed TCHM effects on five clinically important outcomes: cognition, global performance, safety, activities of daily living and behaviour and summarised the effects using mean differences for continuous outcomes and risk ratios or risk differences for binary outcomes. We stratified the studies into those that estimated the TCHM versus 'no treatment' effect and those that estimated the TCHM versus the WM effect, with further stratification by the specific TCHM tested or by one of the four modes of action. We pooled using a random-effects model. Due to substantial clinical and design heterogeneity, we did not estimate an 'overall TCHM effect'.

MAIN RESULTS

We only found studies (47 studies, 3581 participants) for 18 of the 29 eligible TCHMs as defined by our inclusion criteria. All were superiority trials conducted in China between 1997 and 2013, with most employing a two-arm parallel design with sample sizes ranging from 26 to 240 and a median treatment duration of 12 weeks (range: 2 to 24 weeks).We found that reporting and trial methodology were generally poor; in particular, there was a lack of information on randomisation, an absence of blinding of participants and outcome assessors and incomplete reporting of adverse events (AEs). None of the 30 trials published from 2007 onwards adopted the CONSORT recommendations for reporting RCTs of herbal interventions.We found seven TCHMs which each had potentially large benefits in studies estimating the TCHM versus 'no treatment' effect and in studies estimating the TCHM versus the WM effect. Two TCHMs (NaoXinTong and TongXinLuo) were common to both groups. Three of these TCHMs - Nao XinTong, NaoMaiTai and TongXinLuo - had the strongest evidence to justify further research. Two TCHMs (NaoMaiTai and TongXinLuo) had a 5% or more increased risk of AEs compared to the 'no Treatment' control, but the quality of this evidence was poor.

AUTHORS' CONCLUSIONS

We found moderate- to very low-quality evidence of benefit and harm of TCHMs for VaD. Methodological inadequacies need to be addressed by better conducted and reported trials. We identified NaoMaiTai, NaoXinTong and TongXinLuo as warranting special research priority.

Cannabis for the treatment of ulcerative colitis

BACKGROUND

Cannabis and cannabinoids are often promoted as treatment for many illnesses and are widely used among patients with ulcerative colitis (UC). Few studies have evaluated the use of these agents in UC. Further, cannabis has potential for adverse events and the long-term consequences of cannabis and cannabinoid use in UC are unknown.

OBJECTIVES

To assess the efficacy and safety of cannabis and cannabinoids for the treatment of patients with UC.

SEARCH METHODS

We searched MEDLINE, Embase, WHO ICTRP, AMED, PsychINFO, the Cochrane IBD Group Specialized Register, CENTRAL, ClinicalTrials.Gov and the European Clinical Trials Register from inception to 2 January 2018. Conference abstracts and references were searched to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any form or dose of cannabis or its cannabinoid derivatives (natural or synthetic) to placebo or an active therapy for adults (> 18 years) with UC were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results, extracted data and assessed bias using the Cochrane risk of bias tool. The primary outcomes were clinical remission and relapse (as defined by the primary studies). Secondary outcomes included clinical response, endoscopic remission, endoscopic response, histological response, quality of life, C-reactive protein (CRP) and fecal calprotectin measurements, symptom improvement, adverse events, serious adverse events, withdrawal due to adverse events, psychotropic adverse events, and cannabis dependence and withdrawal effects. We calculated the risk ratio (RR) and corresponding 95% confidence interval for dichotomous outcomes. For continuous outcomes, we calculated the mean difference (MD) and corresponding 95% CI. Data were pooled for analysis when the interventions, patient groups and outcomes were sufficiently similar (determined by consensus). Data were analyzed on an intention-to-treat basis. GRADE was used to evaluate the overall certainty of evidence.

MAIN RESULTS

Two RCTs (92 participants) met the inclusion criteria. One study (N = 60) compared 10 weeks of cannabidiol capsules with up to 4.7% D9-tetrahydrocannabinol (THC) with placebo capsules in participants with mild to moderate UC. The starting dose of cannabidiol was 50 mg twice daily increasing to 250 mg twice daily if tolerated. Another study (N = 32) compared 8 weeks of therapy with two cannabis cigarettes per day containing 0.5 g of cannabis, corresponding to 23 mg THC/day to placebo cigarettes in participants with UC who did not respond to conventional medical treatment. No studies were identified that assessed cannabis therapy in quiescent UC. The first study was rated as low risk of bias and the second study (published as an abstract) was rated as high risk of bias for blinding of participants and personnel. The studies were not pooled due to differences in the interventional drug.The effect of cannabidiol capsules (100 mg to 500 mg daily) compared to placebo on clinical remission and response is uncertain. Clinical remission at 10 weeks was achieved by 24% (7/29) of the cannabidiol group compared to 26% (8/31) in the placebo group (RR 0.94, 95% CI 0.39 to 2.25; low certainty evidence). Clinical response at 10 weeks was achieved in 31% (9/29) of cannabidiol participants compared to 22% (7/31) of placebo patients (RR 1.37, 95% CI 0.59 to 3.21; low certainty evidence). Serum CRP levels were similar in both groups after 10 weeks of therapy. The mean CRP in the cannabidiol group was 9.428 mg/L compared to 7.638 mg/L in the placebo group (MD 1.79, 95% CI -5.67 to 9.25; moderate certainty evidence). There may be a clinically meaningful improvement in quality of life at 10 weeks, measured with the IBDQ scale (MD 17.4, 95% CI -3.45 to 38.25; moderate certainty evidence). Adverse events were more frequent in cannabidiol participants compared to placebo. One hundred per cent (29/29) of cannabidiol participants had an adverse event, compared to 77% (24/31) of placebo participants (RR 1.28, 95% CI 1.05 to1.56; moderate certainty evidence). However, these adverse events were considered to be mild or moderate in severity. Common adverse events included dizziness, disturbance in attention, headache, nausea and fatigue. None (0/29) of the cannabidiol participants had a serious adverse event compared to 13% (4/31) of placebo participants (RR 0.12, 95% CI 0.01 to 2.11; low certainty evidence). Serious adverse events in the placebo group included worsening of UC and one complicated pregnancy. These serious adverse events were thought to be unrelated to the study drug. More participants in the cannabidiol group withdrew due to an adverse event than placebo participants. Thirty-four per cent (10/29) of cannabidiol participants withdrew due to an adverse event compared to 16% (5/31) of placebo participants (RR 2.14, 95% CI 0.83 to 5.51; low certainty evidence). Withdrawls in the cannabidiol group were mostly due to dizziness. Withdrawals in the placebo group were due to worsening UC.The effect of cannabis cigarettes (23 mg THC/day) compared to placebo on mean disease activity, CRP levels and mean fecal calprotectin levels is uncertain. After 8 weeks, the mean disease activity index score in cannabis participants was 4 compared with 8 in placebo participants (MD -4.00, 95% CI -5.98 to -2.02). After 8 weeks, the mean change in CRP levels was similar in both groups (MD -0.30, 95% CI -1.35 to 0.75; low certainty evidence). The mean fecal calprotectin level in cannabis participants was 115 mg/dl compared to 229 mg/dl in placebo participants (MD -114.00, 95% CI -246.01 to 18.01). No serious adverse events were observed. This study did not report on clinical remission, clinical response, quality of life, adverse events or withdrawal due to adverse events.

AUTHORS' CONCLUSIONS

The effects of cannabis and cannabidiol on UC are uncertain, thus no firm conclusions regarding the efficacy and safety of cannabis or cannabidiol in adults with active UC can be drawn.There is no evidence for cannabis or cannabinoid use for maintenance of remission in UC. Further studies with a larger number of patients are required to assess the effects of cannabis in UC patients with active and quiescent disease. Different doses of cannabis and routes of administration should be investigated. Lastly, follow-up is needed to assess the long term safety outcomes of frequent cannabis use.

Effects of Shuganjianpihuatanxingqi decoction on mild subclinical hypothyroidism: A SPIRIT compliant randomized controlled trial study protocol

INTRODUCTION

Mild subclinical hypothyroidism (SCH) can cause depression, fatigue, cognitive dysfunction, or other hypothyroid symptoms, and even progress to hypothyroidism. The treatment of mild SCH is controversial. Shuganjianpihuatanxingqi decoction (SD) is a frequently prescribed Chinese herbal medicine in patients with mild SCH. However, scientific evidence is needed to confirm the therapeutic effect of SD.

METHODS AND ANALYSIS

This study is a randomized, double-blind, and controlled clinical trial. A total of 228 participants with the diagnosis of mild SCH will be randomly assigned to the SD or placebo group in a ratio of 1:1. Participants will receive treatment for 12 weeks and undergo 12-month follow-up. The primary outcome measure is the thyroid-stimulating hormone level, and secondary outcomes will be the differences in the results of Thyroid-related Quality of Life Questionnaire, blood lipids, and Traditional Chinese Medicine Symptom Score Scale between baseline and at 12 weeks after intervention.

ETHICS AND DISSEMINATION

The study has been approved by Guang'anmen Hospital of China Academy of Chinese Medical Sciences (no.2018-005-ky-01). The trial results will be published via peer-reviewed journals and the Clinical Research Information Service.

TRIAL REGISTRATION NUMBER

ChiCTR1800015781 (approval date: 20 April 2018).

Cinnamon and Cassia Nomenclature Confusion: A Challenge to the Applicability of Clinical Data

Several Cinnamomum species' barks are generally labeled as cinnamon, although only Cinnamomum verum carries the common name of true cinnamon. Cassia, a common name for a related species, is rarely used on labels; instead, various cassia types may also be labeled "cinnamon." Confusion of true cinnamon and cassia spices in foods generally does not present a risk to health, except possibly at the highest intake levels. However, clinical studies with Cinnamomum investigational products have been published that inadequately describe or lack botanical identification information. The results of such studies are confounded by an inability to determine which species was responsible for the observed effects. Due to differences in the quality and composition of various Cinnamomum species, safety and efficacy data are not generalizable or transferable. Pharmacopeial monographs for characterizing the identity, composition, purity, quality, and strength of Cinnamomum investigational products should be applied to remove the ambiguity of cinnamon.

Integration of botanicals in contemporary medicine: road blocks, checkpoints and go-ahead signals

The use of botanicals for maintaining good health and preventing diseases is undisputed. The claimed health benefits of natural health products and herbal medicines are based on traditional claims, positive results obtained in preclinical studies and early phase clinical trials that are not backed by safety and efficacy evidences approved by regulatory agencies. Although, the popularity of botanicals is growing, health care practitioners of modern medicine seldom recommend their use because of ill equipped database of their safety and potency. This review discusses problems that preclude botanicals from integrating into the mainstream contemporary therapeutics and cues that provide impetus for their realisation.

Oral administration of herbal medicines for radiation pneumonitis in lung cancer patients: A systematic review and meta-analysis

BACKGROUND

Radiation pneumonitis is a common and serious complication of radiotherapy. Many published randomized controlled studies (RCTs) reveal a growing trend of using herbal medicines as adjuvant therapy to prevent radiation pneumonitis; however, their efficacy and safety remain unexplored.

OBJECTIVE

The aim of this systematic review is to evaluate the efficacy and safety of herbal medicines as adjunctive therapy for the prevention of radiation pneumonitis in patients with lung cancer who undergo radiotherapy.

METHODS

We searched the following 11 databases: three English medical databases [MEDLINE (PubMed), EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL)], five Korean medical databases (Korean Studies Information, Research information Service System, KoreaMed, DBPIA, National Digital Science Library), and three Chinese medical databases [the China National Knowledge Database (CNKI), Journal Integration Platform (VIP), and WanFang Database]. The primary outcome was the incidence of radiation pneumonitis. The risk of bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Twenty-two RCTs involving 1819 participants were included. The methodological quality was poor for most of the studies. Meta-analysis showed that herbal medicines combined with radiotherapy significantly reduced the incidence of radiation pneumonitis (n = 1819; RR 0.53, 95% CI 0.45-0.63, I2 = 8%) and the incidence of severe radiation pneumonitis (n = 903; RR 0.22, 95% CI 0.11-0.41, I2 = 0%). Combined therapy also improved the Karnofsky performance score (n = 420; WMD 4.62, 95% CI 1.05-8.18, I2 = 82%).

CONCLUSION

There is some encouraging evidence that oral administration of herbal medicines combined with radiotherapy may benefit patients with lung cancer by preventing or minimizing radiation pneumonitis. However, due to the poor methodological quality of the identified studies, definitive conclusion could not be drawn. To confirm the merits of this approach, further rigorously designed large scale trials are warranted.