In vitro modulatory effects of Terminalia arjuna, arjunic acid, arjunetin and arjungenin on CYP3A4, CYP2D6 and CYP2C9 enzyme activity in human liver microsomes

Ethnobotanical survey and scientific validation of liver-healing plants in northeastern Morocco

Introduction

Liver diseases represent a significant global health challenge, with primary causes including excessive alcohol consumption, infections, chemotherapy, and autoimmune disorders. Medicinal plants, due to their natural bioactive compounds, hold promise for developing effective treatments and preventive measures against liver ailments. This study aimed to document the use of herbal remedies in northeastern Morocco for liver diseases and correlate these uses with scientific evidence through a bibliometric analysis.

Methods

An ethnobotanical survey was conducted in remote communities of northeastern Morocco from October 2020 to January 2022. A total of 189 informants were interviewed using semi-structured questionnaires to gather information on local medicinal plants used for liver ailments. The data were analyzed using four ethnobotanical quantitative indices: use value (UV), familial use value (FUV), informant consensus factor (ICF), and fidelity level (FL). Additionally, a bibliometric analysis was performed to evaluate the scientific support for the ethnopharmacological uses documented.

Results

The survey identified 45 plant species from 26 different families used in the treatment of liver diseases. The most frequently utilized species were Cuminum cyminum L. (UV = 0.1065), Allium sativum L. (UV = 0.1015), Salvia officinalis L. (UV = 0.0761), Asparagus officinalis L. (UV = 0.0558), and Ziziphus lotus (L.) Lam. (UV = 0.0457). The Apiaceae family showed the highest familial use value (FUV = 0.1066), followed by Alliaceae (FUV = 0.1015). Liver congestion had the highest informant consensus factor (ICF = 0.83), followed by hepatic colic (ICF = 0.80). Bibliometric analysis revealed that 61% of the plants identified had documented pharmacological effects related to liver health.

Discussion

The study demonstrates that traditional knowledge in northeastern Morocco encompasses a rich diversity of medicinal plants used to treat liver diseases. The high ICF values indicate a strong consensus among informants on the efficacy of these remedies. The correlation between ethnopharmacological use and scientific validation for a significant portion of these plants suggests their potential as reliable therapeutic agents for liver conditions. However, further scientific investigations are necessary to confirm their efficacy and safety in clinical settings. This research contributes valuable information for future studies on the therapeutic potential of these plants.

Conclusion

This ethnobotanical survey provides a comprehensive database of medicinal plants used in northeastern Morocco for liver diseases. The findings highlight the potential of these plants in developing novel treatments for hepatic conditions, although further research is essential to substantiate their therapeutic claims.

Novel extraction technique: quantification of major phytoconstituents of arjuna in infused edible oil

A rapid, precise, accurate, and cost-effective liquid chromatography-mass spectrometer method was developed by using a novel extraction technique for the simultaneous quantification of major oleane derivatives: arjunetin, arjungenin, arjunolic acid, and arjunic acid of Terminalia arjuna in infused edible oil. An innovative idea was implemented to extract the active phytoconstituents from the oil matrix based on the freezing point of oils and extraction solvent. The developed method was validated for all four active compounds in the linear working range of 0.47-1.72 µg/mL, 0.845-2.93 µg/mL, 1.73-5.95 µg/mL and 0.62-2.22  µg/mL with good correlations value (r2) more than 0.99 for arjunetin, arjungenin, arjunolic acid, and arjunetin, respectively. Furthermore, the HPTLC method was also developed for the quick identification of all four active markers along with other phytoconstituents infused in oil.

Identification of Alkaloids from Terminalia chebula as Potent SARS- CoV-2 Main Protease Inhibitors: An In Silico Perspective

Natural compounds in medicinal plants are best remedies for different diseases and are important to develop new drugs. This work was dedicated to understand the role of different natural compounds of Terminalia Chebula, a well-known herbal plant, in the treating of Covid 19. In this article, we have investigated interactions of such natural compounds from Terminalia Chebula with the main protease (Mpro) of the SARS-CoV-2, which is a key component for cleavage of viral polyprotein, and an important target for the development of drugs towards COVID-19. We have performed molecular docking study on 22 different molecules of Terminalia Chebula and proposed that 7 of the natural compounds (triterpenoids and sterols) interacts with a comparable or stronger interactions than the inhibitor N3. Molecular dynamics simulations (100 ns) revealed that 7 Mpro-Terminalia Chebula complexes are stable, conformationally less fluctuated, slightly less compact, and marginally expanded than ligand-free conformation of Mpro. The intermolecular H-bonding and detailed MM/PBSA and MM-GBSA analysis showed Daucosterol interaction to be the most strong, whereas comparable interactions were observed for Arjunetin, Maslinic acid, and Bellericoside. Our study suggested that these natural compounds can act as potent Mpro inhibitors for SARS-CoV-2, and may evolve as promising anti-COVID-19 drugs in the near future.

Inhibitory and inductive effects of 4- or 5-methyl-2-mercaptobenzimidazole, thyrotoxic and hepatotoxic rubber antioxidants, on several forms of cytochrome P450 in primary cultured rat and human hepatocytes

Effects of 4-methyl-2-mercaptobenzimidazole (4-MeMBI) and 5-methyl-2- mercaptobenzimidazole (5-MeMBI) on cytochrome P450 (CYP) activity were examined in primary cultured rat hepatocytes. Hepatocytes from male Wistar rats were cultured in the presence of 4-MeMBI or 5-MeMBI (0-400 μM), and the activity of CYPs 3A2/4 (48 and 96 h) and 1A1/2 (48 h) was determined by measuring the activity of testosterone 6β-hydroxylation and 7-ethoxyresorufin O-deethylation, respectively. As a result, 4-MeMBI and 5-MeMBI (≥12.5 μM) inhibited CYP3A2 activity. On the other hand, 4-MeMBI (≥25 μM) and 5-MeMBI (≥100 μM) induced CYP1A1/2 activity, being consistent with the previous in vivo results. In a comparative metabolism study using primary cultured human hepatocytes from two Caucasian donors, 4-MeMBI and 5-MeMBI induced the activity of CYPs 3A4 and 1A1/2 with individual variability. It was concluded from these results that 4-MeMBI, 5-MeMBI and MBI caused inhibition of CYP3A2 activity in primary cultured rat hepatocytes, suggesting their potential for metabolic drug-drug interactions. Primary cultured rat and human hepatocytes were considered to be useful for the evaluation of effects of the benzimidazole compounds on their inducibility and inhibitory activities of cytochrome P450 forms.

Medicinal Plants and Phytochemicals for the Treatment of Pulmonary Hypertension

Background

Pulmonary hypertension (PH) is a progressive disease that is associated with pulmonary arteries remodeling, right ventricle hypertrophy, right ventricular failure and finally death. The present study aims to review the medicinal plants and phytochemicals used for PH treatment in the period of 1994 – 2019.

Methods

PubMed, Cochrane and Scopus were searched based on pulmonary hypertension, plant and phytochemical keywords from August 23, 2019. All articles that matched the study based on title and abstract were collected, non-English, repetitive and review studies were excluded.

Results

Finally 41 studies remained from a total of 1290. The results show that many chemical treatments considered to this disease are ineffective in the long period because they have a controlling role, not a therapeutic one. On the other hand, plants and phytochemicals could be more effective due to their action on many mechanisms that cause the progression of PH.

Conclusion

Studies have shown that herbs and phytochemicals used to treat PH do their effects from six mechanisms. These mechanisms include antiproliferative, antioxidant, antivascular remodeling, anti-inflammatory, vasodilatory and apoptosis inducing actions. According to the present study, many of these medicinal plants and phytochemicals can have effects that are more therapeutic than chemical drugs if used appropriately.

In-silico therapeutic investigations of arjunic acid and arjungenin as an FXR agonist and validation in 3T3-L1 adipocytes

The present study was to illustrate the agonistic property of arjungenin and arjunic acid towards farnesoid X receptor protein (FXR).The pharmacokinetic properties like molecular interactions, absorption, distribution, metabolism, elimination and toxicity (ADMET) of the ligands were checked through in-silico studies. Protein-ligand docking was carried out using autodock software. Molecular docking analysis confirmed strong binding energy and interaction of arjungenin and arjunic acid with the target protein and the ADMET profiles identified for both compounds were promising.Further in vitro studies were performed in 3T3-L1 adipocyte to verify the agonistic property of arjungenin and arjunic acid. Oil red O staining was done to check differentiation induction. Adiponectin, leptin, triglycerides and total cholesterol levels were quantified. The mRNA expression of FXR, Cyp7a1, PPAR-γ and SREBP-1c were quantified using fluorescent real-time PCR. Cytotoxicity assay was confirmed that up to 150 μM concentration there is no significant cell death on treatment with arjunic acid and arjungenin. Treatment with arjungenin and arjunic acid confirms increased differentiation of the cells with significant (P < 0.05) increase in adiponectin (118.07% and 132.92%) and leptin (133.52% and 149.74%) protein levels compared to the negative control group. After treatment with arjungenin and arjunic acid in 3T3-L1 preadipocytes the mRNA expression of FXR, PPAR-γ and SREBP-1c were significantly (P < 0.01) increased and cyp7a1 was significantly (P < 0.01) decreased when compared with the negative control group. Overall, our results suggest that arjungenin and arjunic acid acts as an FXR agonist and may be useful for rational therapeutic strategies as a novel drug to treat cholesterol mediated metabolic syndrome and insulin resistance.

Improvements in morphology and membrane stability obtained from TPP-TAB, a cryopreservation medium treated infertile smoker sperm cells - An in vitro study

•

As a first time upto 6 months the sperm cells were stored with new medium from green formulation.

•

TPP-TAB of E4 medium reduces ROS damage.

Background

Plants are the major sources of antioxidants, which maintains oxidant: antioxidant state or is to protect from excessive reactive oxygen species in case of cryo medium selection though maintain sperm stability.

Bottleneck

Cryo preservation of infertile smokers is challengeable with the available medium due to over production of ROS hitches, were cause loss of sperm physiology. Hence, a novel medium is needed to store/protect sperm cells of infertile smokers where they attending/ongoing IVF or oncogenic surgical treatment.

Aim

The aim of this study, is to check the stability of sperm cells by TPP-T.arjuna bark (TAB) (E4) cryo medium preserved infertile smoker’s against ROS/cryo injury- as a continuous study.

Materials and methods

42 infertile smoker’s subjects with 28 control subjects were selected. Surface morphology (acrosome) of sperm by scanning electronic microscope, sperm membrane proteins by colorimetric method, sperm head and tail defects by CASA method and finally sperm cell stability is checking its zeta electric potential charges, were all done with E4 cryo medium treated frozen/thawed selected study subjects.

Results

Sperm morphology and zeta potential shows there is no damage along the stability of cells maintained during E4 medium cryopreservation in infertile subjects.

Summary

This is the first study is too established for infertile smokers sperm stability was checked for six months with E4 cryo medium.

Traditional tonifying polyherbal infusion, Jatu-Phala-Tiga, exerts antioxidant activities and extends lifespan of Caenorhabditis elegans

Background

The imbalance between the generation of free radicals and natural cellular antioxidant defenses, known as oxidative stress, can cause oxidation of biomolecules and further contribute to aging-associated diseases. The purpose of this study was to evaluate the antioxidant capacities of Thai traditional tonifying preparation, Jatu-Phala-Tiga (JPT) and its herbal ingredients consisting of Phyllanthus emblica, Terminalia arjuna, Terminalia chebula, and Terminalia bellirica and further assess its effect on longevity.

Method

Antioxidant activities of various extracts obtained from JPT and its herbal components were carried out using well-established methods including metal chelating, free radical scavenging, and ferric reducing antioxidant power assays. Qualitative analysis of the chemical composition from JPT water extract was done by high-performance liquid chromatography tandem with electrospray ionisation mass spectrometry. The effect of JPT water extract on the lifespan of Caenorhabditis elegans were additionally described.

Results

Among the extracts, JPT water extract exerted remarkable antioxidant activities as compared to the extracts from other solvents and individual constituting plant extract. JPT water extract was found to possess the highest metal chelating activity, with an IC₅₀ value of 1.75 ± 0.05 mg/mL. Moreover, it exhibited remarkable scavenging activities towards DPPH, ABTS, and superoxide anion radicals, with IC₅₀ values of 0.31 ± 0.02, 0.308 ± 0.004, and 0.055 ± 0.002 mg/mL, respectively. The ORAC and FRAP values of JPT water extract were 40.338 ± 2.273 μM of Trolox/μg of extract and 23.07 ± 1.84 mM FeSO₄/mg sample, respectively. Several well-known antioxidant-related compounds including amaronols, quinic acid, gallic acid, fertaric acid, kurigalin, amlaic acid, isoterchebin, chebulagic acid, ginkgolide C, chebulinic acid, ellagic acid, and rutin were found in this extract. Treatment with JPT water extract at 1 and 5 mg/mL increased C. elegans lifespan under normal growth condition (7.26 ± 0.65 vs. 10.4 0± 0.75 (p < 0.01) and 10.00 ± 0.73 (p < 0.01) days, respectively).

Conclusions

The results indicated that JPT and its herbal ingredients exhibited strong antioxidant activities, in particular the water extract of the polyherbal tonic. These findings rationalize further investigation in JPT infusion as a promising agent for anti-aging and oxidative stress prevention.

Terminalia arjuna extract and arjunic acid mitigate cobalt chloride-induced hypoxia stress-mediated apoptosis in H9c2 cells

Arjunic acid (AA) is one of the major active component of Terminalia arjuna known for its health benefits. In the present study, we evaluated cardioprotective potential of Terminalia arjuna extract (TAE) and AA against cobalt chloride (CoCl₂)-induced hypoxia damage and apoptosis in rat cardiomyocytes. TAE (50 μg/ml) and AA (8 μg/ml) significantly (p < 0.001) protected H9c2 cells as evidenced by cell viability assays against CoCl₂ (1.2 mM)-induced cytotoxicity. TAE and AA pretreatments protected the cells from oxidative damage by decreasing the generation of free radicals (ROS, hydroperoxide, and nitrite levels). TAE and AA pretreatments retained mitochondrial membrane potential by alleviating the rate of lipid peroxidation induced by CoCl₂ treatment. TAE and AA pretreatments elevated antioxidant status including phase II antioxidant enzymes (superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase) and total glutathione levels against CoCl₂-induced oxidative stress. Further immunoblotting studies confirmed anti-apoptotic effects of TAE and AA by alleviating the phosphorylation of JNK and c-jun and also by regulating protein expression levels of Bcl2, Bax, caspase 3, heat shock protein-70, and inducible nitric oxide synthase. Overall, our results suggest that both the extract and the active component exhibit antioxidant and anti-apoptotic defense against CoCl₂-induced hypoxic injury.

Bioactivity guided fractionation of methanolic extract of Terminalia arjuna for its CYP3A and CYP2D inhibition in rat liver microsomes

Terminalia arjuna (T. arjuna) is an Indian medicinal plant belonging to the family Combretaceae and possesses numerous therapeutic activities including its immense cardioprotective activity. In the present work, a methanolic bark extract of T. arjuna was evaluated for CYP3A and CYP2D inhibition potential in rat liver microsomes (RLM). Further, the methanolic bark extract was fractionated successively using increasing polarity solvents starting with petroleum ether, chloroform, ethyl acetate and n-butanol. The fractions so obtained were also evaluated for their CYP3A and CYP2D inhibition potential. Probe substrates testosterone and dextromethorphan were used for CYP3A and CYP2D respectively. The IC₅₀ values for the methanolic extract and the fractions were found to be less than 50 μg/ml in RLM for both CYP3A and CYP2D isoenzymes. The most potent n-butanol fraction was further fractionated with column chromatography to isolate the highest active constituent responsible for the activity. Fraction 4 of the n-butanol extract was the most potent fraction with IC₅₀ values of 5.64 ± 0.735 μg/ml and 16.63 ± 0.879 μg/ml for CYP3A and CYP2D in RLM, respectively. Therefore, in vitro data indicated that the Terminalia arjuna extract contains constituents that can potentially inhibit the CYP3A and CYP2D isoenzymes which may in turn lead to pharmacokinetic drug-herb interaction.

In vitro Inhibitory Effect of Gymnema sylvestre Extracts and Total Gymnemic Acids Fraction on Select Cytochrome P450 Activities in Rat Liver Microsomes

BACKGROUND AND OBJECTIVES

Gymnema sylvestre R. Br. is a well-known Indian medicinal herb. Gymnemic acids are pentacyclic triterpenes saponins and active phytoconstituents of Gymnema sylvestre. The study aimed at evaluation of the in vitro rat liver cytochrome P450 (CYP) inhibition potential of extracts and total gymnemic acid (TA)-enriched fractions from G. sylvestre.

METHODS

Standardization of G. sylvestre [ethanolic (EL), hydroethanolic (HE), total acid of ethanolic (TAE), total acid of hydroethanolic (TAHE) and total acid of aqueous (TAAQ) extract] was done with respect to deacyl gymnemic acid (DAGA), using reverse phase-high performance liquid chromatography (RP-HPLC). Total triterpenoid content was determined by vanillin perchloric acid assay.

RESULTS

Total triterpene content was found to be the highest in TAAQ (59.86 ± 0.005% w/w) and TAE (49.77 ± 0.009% w/w). TAAQ showed IC₅₀ ≤ 50 µg/ml for all selected CYP activities. Testosterone 6β-hydroxylation was strongly inhibited by TAE (IC₅₀: 15.48 ± 2.13 µg/ml) and was moderately by TAAQ and EL with IC₅₀ ≥ 50 µg/ml. Flurbiprofen 4'-hydroxylation was subject to strong, weak and moderate inhibition by TAAQ (IC₅₀: 34.67 ± 1.38 µg/ml), TAE (IC₅₀: ≥ 50 µg/ml) and EL (IC₅₀: > 50 µg/ml), respectively. Dextromethorphan O-demethylation was inhibited by TAHE and TAAQ.

CONCLUSIONS

In vitro inhibition studies suggested that TA strongly inhibits activity of selected CYP. This inhibition may possibly be due to triterpenoids and gymnemic acids that have been reported to be present in it. Data also suggest a potential for possible in vivo herb-drug interactions involving G. sylvestre and other medications that are metabolized by the same CYP.

Evaluation of herb-drug interaction of a polyherbal Ayurvedic formulation through high throughput cytochrome P450 enzyme inhibition assay

ETHNOPHARMACOLOGICAL RELEVANCE

Arishtas are Ayurvedic formulation made with decoction of herbs. Arjunarishta formulation is being used in Ayurveda for cardio-protective activity. Ashwagandharishta formulation possesses antioxidant, anti-atherosclerotic and anti-stress properties. Ridayarishta, a novel empirical formulation was prepared using combination of selected ingredients from these two formulations to support healthy heart functions and to reduce stress.

AIM OF THE STUDY

Aim of the Study was to investigate herb-drug interaction (HDI) of Ridayarishta formulation through human hepatic cytochrome P450 (CYP450) enzyme inhibition assay.

MATERIALS AND METHODS

Ridayarishta formulation was phyto-chemically standardized against arjunolic acid, arjunetin, berberine, piperine, resveratrol and withaferin-A using high performance thin layer chromatography (HPTLC) analysis. The formulation was standardized with respect to ethanol by gas chromatographic (GC) analysis. HDI was evaluated with Ridayarishta formulation and amlodipine besilate, atenolol, atorvastatin, metformin, glipizide glimepiride cocktail using high throughput CYP450 enzyme inhibition assay; against CYP1A2, 2C19, 2D6 and 3A4 isozymes.

RESULTS

Contents of arjunolic acid, arjunetin, berberine, piperine, resveratrol and withaferin-A in Ridayarishta formulation were found to be 1.76±0.12, 1.51±0.09, 1.85±0.05, 3.2±0.12, 1.21±0.08, and 2.16±0.09ppm, respectively. Quantity of ethanol in Ridayarishta was found to be 7.95±0.023% (V/V). Ridayarishta showed significantly higher (P<0.001) IC₅₀ value against CYP1A2 (IC₅₀-13.80±1.96µg/mL), 2C19 (IC₅₀-14.343±2.28µg/mL), 2D6 (IC₅₀-0.897±0.28µg/mL) and 3A4 (IC₅₀-32.057±2.51µg/mL) compared to positive controls such as furafylline, tranylcypromine, quinidine and ketoconazole respectively. Cocktail of herbal formulation and cardio protective, antihypertensive, anti-diabetic drugs showed significantly (P<0.001and P<0.01) less or negligible HDI.

CONCLUSION

Ridayarishta formulation alone and cocktail with amlodipine besilate, atenolol, atorvastatin, metformin, glipizide, glimepiride had negligible or insignificant effect on CYP450 inhibition. It may be concluded that consumption of Ridayarishta along with selective cardio protective, antihypertensive and anti-diabetic conventional medicine is safe with negligible or without any significant CYP450 (CYP1A2, 2C19, 2D6 and 3A4) inhibition mediated HDI.

Beneficial effects of aqueous extract of stem bark of Terminalia arjuna (Roxb.), An ayurvedic drug in experimental pulmonary hypertension

ETHNOPHARMACOLOGICAL RELEVANCE

The stem bark of Terminalia arjuna (Roxb.) is widely used in Ayurveda in various cardiovascular diseases. Many animal and clinical studies have validated its anti-ischemic, antihypertensive, antihypertrophic and antioxidant effects. Pulmonary hypertension (PH) is a fatal disease which causes right ventricular hypertrophy and right heart failure. Pulmonary vascular smooth muscle hypertrophy and increased oxidative stress are major pathological features of PH. As available limited therapeutic options fail to reduce the mortality associated with PH, alternative areas of therapy are worth exploring for potential drugs, which might be beneficial in PH.

AIM OF THE STUDY

The effect of a standardised aqueous extract of the stem bark of Terminalia arjuna (Roxb.) in preventing monocrotaline (MCT)-induced PH in rat was investigated.

MATERIALS AND METHODS

The study was approved by Institutional Animal Ethics Committe. Male Wistar rats (150-200g) were randomly distributed into five groups; Control, MCT (50mg/kg subcutaneously once), sildenafil (175µg/kg/day three days after MCT for 25 days), and Arjuna extract (TA125 and TA250 mg/kg/day orally after MCT for 25 days). PH was confirmed by right ventricular weight to left ventricular plus septum weight (Fulton index), right ventricular systolic pressure (RVSP), echocardiography, percentage medial wall thickness of pulmonary arteries (%MWT). Oxidative stress in lung was assessed by super oxide dismutase (SOD), catalase, reduced glutathione (GSH) and thiobarbituric acid reactive substance (TBARS). The protein expressions of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX-1) in lung and gene expression of Bcl2 and Bax in heart were analyzed by Western blot and RT PCR respectively.

RESULTS

MCT caused right ventricular hypertrophy (0.58±0.05 vs 0.31±0.05; P<0.001 vs. control) and increase in RVSP (33.5±1.5 vs 22.3±4.7mm of Hg; P<0.001). Both sildenafil and Arjuna prevented hypertrophy and RVSP. Pulmonary artery acceleration time to ejection time ratio in echocardiography was decreased in PH rats (0.49±0.05 vs 0.32±0.06; P<0.001) which was prevented by sildenafil (0.44±0.06; P<0.01) and TA250 (0.45±0.06; P<0.01). % MWT of pulmonary arteries was increased in PH and was prevented by TA250. Increase in TBARS (132.7±18.4 vs 18.8±1.6nmol/mg protein; P<0.001) and decrease in SOD (58.4±14.1 vs 117.4±26.9U/mg protein; P<0.001) and catalase (0.30±0.05 vs 0.75±0.31U/mg protein; P<0.001) were observed in lung tissue of PH rats, which were prevented by sildenafil and both the doses of Arjuna extract. Protein expression of NOX1 was significantly increased in lung and gene expression of Bcl2/Bax ratio was significantly decreased in right ventricle in MCT-induced PH, both were significantly prevented by Arjuna and sildenafil.

CONCLUSIONS

Aqueous extract of Terminalia arjuna prevented MCT-induced pulmonary hypertension which may be attributed to its antioxidant as well as its effects on pulmonary arteriolar wall thickening.

Medicinal properties of Terminalia arjuna (Roxb.) Wight & Arn.: A review

Medicinal plants have been a main source of therapeutic agents from ancient time to cure diseases. Terminalia arjuna (Roxb.) Wight & Arn. (T. arjuna) is one of the most accepted and beneficial medicinal plants in indigenous system of medicine for the treatment of various critical diseases. This comprehensive review provides various aspects of its ethnomedical, phytochemical, pharmacognostical, pharmacological and clinical significance to different diseases particularly in cardiovascular conditions. This plant has a good safety outline when used in combination with other conventional drugs. This review highlights various medicinal properties of T. arjuna through different studies such as antioxidant, hypotensive, anti-atherogenic, anti-inflammatory, anti-carcinogenic, anti-mutagenic and gastro-productive effect.

Clinical efficacy of water extract of stem bark of Terminalia arjuna (Roxb. ex DC.) Wight & Arn. in patients of chronic heart failure: a double-blind, randomized controlled trial

BACKGROUND

The stem bark of Terminalia arjuna (Roxb. ex DC.) Wight and Arn. (Arjuna) is used in Indian system of medicine (Ayurveda) for treatment of various cardiac diseases, including heart failure. However, well designed clinical trials exploring its efficacy and safety in chronic heart failure (CHF) are lacking.

PURPOSE

To ascertain the add-on efficacy and safety of a standardized water extract of stem bark of Arjuna (Arjuna extract) in CHF patients on standard pharmacotherapy.

STUDY DESIGN

Double-blind, parallel, randomized, placebo-controlled add-on clinical trial.

METHODS

After approval of institutional ethics committee, 100 patients of CHF of New York Heart Association (NYHA) functional class II on standard pharmacotherapy having an echocardiographic left ventricular ejection fraction (LVEF) ≤ 40% were consecutively recruited with informed consent and randomized 1:1 to Arjuna extract 750 mg or matching placebo twice daily. The primary outcome measure was change in LVEF at 12 weeks. Secondary outcome measures included changes in (i) NYHA functional class, (ii) distance covered in 6 min walk test (6MWT), (iii) quality of life (QoL), as determined by the Kansas City Cardiomyopathy Questionnaire (KCCQ), (iv) plasma brain natriuretic peptide, (v) plasma cytokines (interleukin-6, high sensitivity C-reactive protein and tumour necrosis factor-α) and (vi) oxidative stress markers [serum thiobarbituric acid reactive substances (TBARS), red blood cell (RBC) superoxide dismutase (SOD), RBC catalase and RBC glutathione (GSH)] at 6 and 12 weeks. Safety assessment was done by adverse event monitoring and laboratory investigations. Results were expressed as mean ± SD or median (interquartile range) and analysed with intention-to- treat principle using appropriate two-sided statistical tests. A p-value < 0.05 was considered significant.

RESULTS

Arjuna extract was well-tolerated, but did not change LVEF (24.3 ± 7.1 versus 25.5 ± 7.7%; p = 0.4) or secondary outcome measures except preservation of RBC catalase activity [1275(104, 10350) versus 1243.5(104, 10350) U/g haemoglobin; p = 0.01] compared to placebo. Significantly greater percentage increases occurred in distance covered in 6 MWT, RBC-SOD, RBC catalase, RBC GSH and in symptom severity and stability domains of KCCQ in patients on Arjuna extract versus those on placebo, on a post-hoc analysis, between subgroups of patients who improved in these outcomes.

CONCLUSION

Arjuna extract did not improve LVEF in CHF patients over 12 weeks, although there was improvement in functional capacity, antioxidant reserves and symptom-related QoL domains in some patients.