Medicinal herbs and therapeutic drugs interactions

Comprehensive insights on treatment modalities with conventional and herbal drugs for the treatment of duodenal ulcers

Areas of the body accessible to gastric secretions, such as the stomach and duodenum, are most commonly damaged by circumscribed lesions of the upper gastrointestinal tract mucosa. Peptic ulcer disease is the term for this illness (PUD). About 80% of peptic ulcers are duodenal ulcers, with stomach ulcers accounting for the remaining 20%. Duodenal ulcers are linked to the two primary results about Helicobacter pylori infection and COX inhibitor users. Additional causes might include drinking, smoking, stress, and coffee consumption. The indications and symptoms of a duodenal ulcer depend on the patient's age and the lesion's location. For duodenal ulcers, proton pump inhibitors (PPIs) are the usual course of treatment. This comprehensive study included an in-depth literature search in the literature and methods section using electronic databases such as PubMed, ScienceDirect, and Google Scholar. The search method included publications published from the inception of the relevant database to the present. Inclusion criteria included studies investigating different treatment options for duodenal ulcer disease, including traditional pharmacotherapy and naturopathic treatments. Data mining includes information on treatment techniques, treatment outcomes, and possible synergies between conventional and herbal treatments. In addition, this review critically examines the available information on the effectiveness, safety, and possible side effects of different treatments. The inclusion of conventional and herbal treatments is intended to provide a comprehensive overview of the many treatment options available for duodenal ulcer disease. A more comprehensive and personalized treatment plan can be achieved by incorporating dietary changes, lifestyle modifications, and, if necessary, herbal therapies to complement other treatments normally.

Changing Trends Towards Herbal Supplements: An Insight into Safety and Herb-drug Interaction

Herbs have been used as sustenance and medicine for a very long time, often in conjunction with other prescribed medications. Even though they are thought to be natural and secure, many of these herbs can interact with other medications and cause potentially dangerous adverse effects or decrease the benefits of the medication. The complex and diverse pharmacological functions carried out by the active ingredients in herbs unavoidably alter the pharmacokinetics of chemical drugs when administered in vivo. Drug transporter expression has a direct impact on how medications are absorbed, distributed, metabolized, and excreted in living organisms. Changes in substrate pharmacokinetics can affect the effectiveness and toxicity of a drug when the active ingredients of a herb inhibit or stimulate the expression of transporters. By reviewing published clinical and preclinical studies, this review aims to raise awareness of herbdrug interactions and discuss their evidence-based mechanisms and clinical consequences. More clinical information on herb-drug interactions is required to make choices regarding patient safety as the incidence and severity of herb-drug interactions are rising due to an increase in the use of herbal preparations globally.This review seeks to increase understanding of herb-drug interactions and explore their evidence-based mechanisms and clinical implications by reviewing published clinical and preclinical studies. The incidence and severity of herb-drug interactions are on the rise due to an increase in the use of herbal preparations worldwide, necessitating the need for more clinical data on these interactions in order to make decisions regarding patient safety. Healthcare workers and patients will become more alert to potential interactions as their knowledge of pharmacokinetic herb-drug interactions grows. The study's objective is to raise readers' awareness of possible interactions between herbal supplements and prescription medications who regularly take them.

A qualitative study of pharmacists' perceptions and awareness of homoeopathic medicines in Durban, South Africa

BACKGROUND

 There is growing interest in the demand for and use of homoeopathic medicines by the public; however, little is known about the perspectives of pharmacists regarding the use of these medicines, particularly in the South African private health context.

METHODS

 A qualitative approach using an exploratory cross-sectional descriptive design was used. Data were collected from a purposive sample of 15 participants comprising pharmacy managers, pharmacists and pharmacy assistants from six different conveniently selected private pharmacy retail outlets. Data were collected using individual interviews utilising a semi-structured interview guide. An audiotape was used to record the data which were transcribed verbatim and analysed thematically, following Tech's steps of data analysis. Ethical approval to conduct the study was obtained from the Durban University of Technology's Institutional Research Ethics Committee.

RESULTS

 The findings of this study revealed four superordinate themes related to pharmacists' perceptions and self-reported awareness regarding homoeopathic medicines. These are (1) negative perceptions regarding homoeopathic medicines, (2) perceived benefits of homoeopathic medicines, (3) poor knowledge and awareness of homoeopathic medicines and (4) capacity development and curriculum aspects.

CONCLUSION

 The findings highlight the need for an educational intervention on homoeopathic medicines targeting pre-service and in-service pharmacy practitioners, to enable them to provide effective education regarding all types of medicines as the demand for homoeopathic medicines increases.Contribution: The study findings provide evidence to support advocacy for an educational intervention to improve awareness and knowledge of pharmacists to enable provision of effective health education for patients. More research, however, is required to inform the contents of this training intervention for pharmacists.

Overcoming the Challenges of Phytochemicals in Triple Negative Breast Cancer Therapy: The Path Forward

Triple negative breast cancer (TNBC) is a very aggressive subtype of breast cancer that lacks estrogen, progesterone, and HER2 receptor expression. TNBC is thought to be produced by Wnt, Notch, TGF-beta, and VEGF pathway activation, which leads to cell invasion and metastasis. To address this, the use of phytochemicals as a therapeutic option for TNBC has been researched. Plants contain natural compounds known as phytochemicals. Curcumin, resveratrol, and EGCG are phytochemicals that have been found to inhibit the pathways that cause TNBC, but their limited bioavailability and lack of clinical evidence for their use as single therapies pose challenges to the use of these phytochemical therapies. More research is required to better understand the role of phytochemicals in TNBC therapy, or to advance the development of more effective delivery mechanisms for these phytochemicals to the site where they are required. This review will discuss the promise shown by phytochemicals as a treatment option for TNBC.

Pharmacy practitioners' practice, awareness and knowledge about herbal products and their potential interactions with cardiovascular drugs

Background: Herbal medicine use is widespread among patients, as community pharmacies may provide such products. Therefore, pharmacy practitioners should be aware of potential herbal products' adverse effects and herb-drug interactions, particularly with medications for comorbid diseases, such as cardiovascular drugs, in which pharmacy practitioners need to have good knowledge to provide patients with relevant advice to get optimal and safe therapeutic outcomes. Accordingly, the study is designed to assess the knowledge and awareness of pharmacy practitioners regarding herbal product dispensing and cardiovascular drug interaction in Jordan and view their role in patients' counselling to set up safe and effective drug use. Methods: A cross-sectional study was conducted in Jordan using an online formatted questionnaire distributed to pharmacy practitioners working in community pharmacies. Descriptive and analytical statistics were performed for the responses using the Statistical Package for the Social Sciences (SPSS) software, version 26. Results: Out of 508 participants, 41.7% had medium knowledge of herbal products pertaining mainly to university education (68.1%); 55.1% of participants dispensed herbal products without prescriptions for obesity and weight reduction (72.8%) and gastrointestinal problems (70.9%); this is because respondents agreed that herbal remedies are safe (28.5%) and effective (38.4%). Whilst the knowledge level of respondents about herbal medicine interaction with cardiovascular medication was medium, with a mean of 1.94, as this interaction may result in potentially serious consequences, 40.7% of respondents strongly agreed to gain more knowledge about the side effects of herbal products and medicine interactions through educational courses. Conclusions: The pharmacy practitioners had medium knowledge of herbal products; however, more attention should be paid to herb-drug interactions in the pharmacy educational curriculum. Additionally, pharmacy practitioners need to refresh their knowledge by attending periodic educational courses and by using reliable resources for information about herbal products in order to provide effective and competent pharmaceutical care.

Anti-tumour activity and toxicological studies of combination treatment of Orthosiphon stamineus and gemcitabine on pancreatic xenograft model

BACKGROUND

Pancreatic cancer is the most aggressive cancer type. Gemcitabine is the first line chemo-drug used for pancreatic cancer but exerts a broad spectrum of organ toxicities and adverse effects in patients.

AIM

To evaluate the anti-tumour activity and toxicological effects of Orthosiphon stamineus extract formulation (ID: C5EOSEW5050ESA trademarked as Nuva-staticTM), and gemcitabine combination on pancreatic xenograft model.

METHODS

Mice were randomly divided into six groups of 6 mice each (n = 6) and given different treatments for 28 d. The study design consisted of a 2 x 3 factorial treatment structure, with gemcitabine (yes/no) by oral (at 1200 and 400 mg/kg per day). Human pancreatic cancer cells were injected subcutaneously into the flanks of athymic nude mice. C5EOSEW5050ESA (200 or 400 mg/kg per day) was administered orally, while gemcitabine (10 mg/kg per 3 d) was given intraperitoneally either alone or in combination treatment. Histopathological analyses of vital organs, tumour tissues, and incidence of lethality were analysed. Analyses of tumour necrosis and proliferation were determined by haematoxylin-eosin staining and immunohistochemistry for Ki-67, respectively.

RESULTS

No signs of toxicity or damage to vital organs were observed in all treatment groups compared to the untreated group. C5EOSEW5050ESA at 200 mg/kg and gemcitabine combination had no additive antitumor effects compared to a single treatment. Remarkably, a comparably greater response in a reduction in tumour growth, Ki-67 protein expression, and necrosis was demonstrated by 400 mg/kg of C5EOSEW5050ESA and gemcitabine combination than that of the individual agents.

CONCLUSION

These results highlighted the synergistic activity of C5EOSEW5050ESA with gemcitabine to reduce pancreatic tumour growth in mice compared to a single treatment. Thus, this study provides valuable insights into using C5EOSEW5050ESA as a complementary treatment with gemcitabine for pancreatic cancer.

COVID-19 Crisis, Herbal Medicines, and Natural Products - Concerns and Suggestions

: Since the outbreak of the COVID-19 pandemic in the last days of 2019 in China, medical experts and organizations worldwide have proposed guidelines for its prevention and treatment. However, despite the availability of state-of-the-art technologies, modern medicine specialists have so far not been successful in controlling it. This has led traditional medicine experts to propagate their knowledge to prevent and cure COVID-19, creating an open debate. According to scientific literature, traditional medicine experts claim beneficial effects of herbal medicines against viral infections and their effectiveness in controlling the symptoms of respiratory disorders. Modern medicine specialists express their concerns about the quality, safety, and efficacy of herbal medicines, in addition to the risk of herb-drug interactions and the lack of randomized clinical studies. Herbal medicines have been popular since prehistoric times, and during the COVID-19 pandemic, they are increasingly used worldwide. The lack of definite cure and the high cost of available modern medicines have also promoted the use of herbal medicines. An evidence-based approach using herbal medicines with proven antiviral activities or containing compounds providing symptomatic relief in COVID-19 can be considered for clinical studies. The interaction of herbal medicines with modern drugs should also be considered in patients taking them. Traditional and modern medicine aim to provide effective and safe treatment and prevent COVID-19 infection. Considering the ground realities of the COVID-19 crisis and keeping in view the worldwide use of herbal medicines, in our opinion, the pros and cons of their use should be carefully weighed, and practical solutions should be considered.

Evaluation of Benzaldehyde as an Antibiotic Modulator and Its Toxic Effect against Drosophila melanogaster

Products of natural origin remain important in the discovery of new bioactive molecules and are less damaging to the environment. Benzaldehyde is a product of the metabolism of plants, and similarly to oxygenated terpenes, it can have antibacterial activity against Staphylococcus aureus and toxic action against Drosophila melanogaster; we aimed to verify these activities. The broth microdilution tests determined the minimum inhibitory concentration (MIC) of benzaldehyde alone and in association with antibiotics and ethidium bromide (EtBr). Toxicity against Drosophila melanogaster was determined by fumigation tests that measured lethality and damage to the locomotor system. The results indicated that there was an association of norfloxacin and ciprofloxacin with benzaldehyde, from 64 μg/mL to 32 μg/mL of ciprofloxacin in the strain K6028 and from 256 μg/mL to 128 μg/mL of norfloxacin in the strain 1199B; however, the associations were not able to interfere with the functioning of the tested efflux pumps. In addition, benzaldehyde had a toxic effect on flies. Thus, the results proved the ability of benzaldehyde to modulate quinolone antibiotics and its toxic effects on fruit flies, thus enabling further studies in this area.

Herbal Supplement Use and Herb-drug Interactions among Patients with Kidney Disease

Objective:

The prevalence of herb–drug interactions and herb's adverse effects may be serious in susceptible population such as patients with chronic kidney disease (CKD). In this study, we planned to determine the usage prevalence of herbal products and herb–drug interactions in CKD patients.

Methods:

A cross-sectional prospective study was conducted on CKD and posttransplant patients with a history of using herbal supplements in Isfahan, Iran. The patients were subjected to a validated checklist, containing demographic and clinical information. The knowledge of herbal use, side effects, and herb–drug interactions was assessed based on patients' responses. Data were reported as prevalence (percent) of the occurrence.

Findings:

The prevalence of herbal supplement usage among CKD patients was 18.6% in this study. The study included 400 patients (261 males and 139 females). The majority of the study population were in the age range of 50–70 years (61.5%). Hypertension (34.36%) was the most common cause of kidney failure, while diabetes mellitus (21.80%) took the second place. The most frequently used unformulated medicinal herb was Echium (Echium amoenum) (15.27%), and the most commonly used formulated herbal products were anticough and mucolytic based on Thymus vulgaris (24.27%). Eighteen patients (4.5%) used herbal mix with unknown entity and sources. In this study, ginseng has the most possible interactions with prescription drugs (18 interactions), while this interaction (with clopidogrel, warfarin, and heparin) was severe in six cases.

Conclusion:

The present study provided the information on possible herb–drug interactions in CKD patients on herbal usage. Since the issue of using herbal products may be arbitrarily in the majority of the patients, and considering the importance of adverse reactions or major interactions, health-care providers should play an active role to identify these cases and inform the patients regarding herbal product safety, adverse effects, and possible interactions.

Interactions of clinical relevance associated with concurrent administration of prescription drug and food or medicinal plants: a systematic review protocol

BACKGROUND

An inadequate combination of prescription drugs with food or medicinal plants could cause adverse effects in patients or produce negative therapeutic results. Therefore, this generic systematic review protocol aims to identify and synthesize the literature on clinical characteristics and safety issues of these types of pharmacological interactions occurring in children, adolescents, adults, pregnant/lactating women, and older adults.

METHODS/DESIGN

This generic protocol follows the stated guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement. A literature search will be performed in PubMed, Scopus, and Virtual Health Library (VHL) electronic databases from 1960 till present for studies reporting clinical characteristics and safety issues associated with pharmacological interactions occurring between prescription drugs and food or medicinal plants in participants from birth-age to ≥ 65-year-old, including pregnant/lactating women. Lateral searching will be carried out in PubMed via related citation. Two reviewers will carry out an independent evaluation of eligible studies as well as the corresponding data extraction of the selected ones. Subsequently, the methodological quality evaluation of the selected articles will be completed using the corresponding Joanna Briggs Institute Checklists. Moreover, the quality of evidence will be graded according to the criteria of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group. Quantitative research in humans comprising clinical trials and clinical, comparative and, observational studies will be included. The main outcomes of this protocol involve reported potential food-drug and herb-drug interactions, associated safety issues, and adverse reactions along with the generic name of the prescribed drug and the scientific name of the food and medicinal plants involved in these types of pharmacological interactions. Finally, findings extracted from the selected studies will be summarized in a narrative synthesis.

DISCUSSION

This generic systematic review protocol seeks to synthesize and critically evaluate current knowledge besides to identify any comprehension gaps in the concurrent administration of prescription drugs with food and herbs. By achieving a better understanding of this topic, this information will allow healthcare professionals to develop useful strategies to recognize, manage, and prevent these types of pharmacological interactions at different age stages, including pregnant/lactating women.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018117308.

Reviewing the mechanisms of natural product-drug interactions involving efflux transporters and metabolic enzymes

The World Health Organization (WHO) and other worldwide health agencies have recently taken initiatives to encourage the use of traditional medicine and/or complementary/alternative medicine in order to promote well-being and public health. In this way, one of the WHO's concerns is the safe use of these therapies. Phytotherapy is a strategy consisting of the use of medicinal plants (MP) and/or herbal medicinal products (HMP) for medicinal purposes. The use of phytotherapy concomitantly with drugs may cause interactions compromising the expected pharmacological action or generating toxic effects. These interactions are complex processes that may occur with multiple medications targeting different metabolic pathways, and involving different compounds present in MP and HMP. Thus, the aim of this review was to summarize the main MP- and HMP-drug interactions that involve specific transporters (P-glycoprotein and BCRP) and CYP450 enzymes (CYP3A4 and CYP2D6), which play relevant roles in the mechanisms of interactions. Firstly, multiple databases were used to search studies describing in vitro or in vivo MP and HMP-drug interactions and, after that, a systematic note-taking and appraisal of the literature was conducted. It was observed that several MP and HMP, metabolic pathways and transcription factors are involved in the transporters and enzymes expression or in the modulation of their activity having the potential to provide such interactions. Thus, the knowledge of MP- and HMP-drug interaction mechanisms could contribute to prevent harmful interactions and can ensure the safe use of these products to help the establishment of the therapeutic planning in order to certify the best treatment strategy to be used.

A High Throughput HPLC-MS/MS Method for Antihypertensive Drugs Determination in Plasma and Its Application on Pharmacokinetic Interaction Study with Shuxuetong Injection in Rats

A high-throughput HPLC-MS/MS method was developed and validated for the determination of four antihypertensive drugs including metoprolol tartrate, hydrochlorothiazide, nifedipine, and valsartan in rat plasma. The Sprague-Dawley rats were randomly divided into three groups: A Group: gastric-administration of metoprolol tartrate, hydrochlorothiazide, nifedipine, or valsartan; B Group: a single intravenous injection of SXT, then dosing as the A group; C Group: daily injection of SXT through the tail vein for 8 consecutive days and dosing as the A group on the eighth day. For metoprolol tartrate and valsartan, blood samples were collected before administration and at time points 0.03, 0.08, 0.17, 0.25, 0.5, 1, 2, 4, 6, 8, 10, 12, and 24 h from the fossa orbitalis vein. For hydrochlorothiazide and nifedipine, the time points were 0, 0.08, 0.17, 0.25, 0.5, 0.75, 1, 2, 4, 6, 8, 10, 12, and 24 h. The plasma samples containing different individual antihypertensive drug were mixed and prepared by protein precipitation with methanol. The chromatographic separation was performed on an Agilent Eclipse Plus C18 column (2.1 mm×100 mm, 3.5 μm) using gradient elution with mobile phase consisting of acetonitrile and water (containing 0.1% formic acid). The flow rate was 0.3 mL/min. The detection was accomplished on a tandem mass spectrometer with an electrospray ionization (ESI) source by multiple reaction monitoring (MRM) in both positive and negative modes. The method was successfully applied to a pharmacokinetic interaction study of Shuxuetong injection on the antihypertensive drugs. The results suggested that SXT could increase the total amount of metoprolol tartrate and nifedipine in plasma and showed little influence on the pharmacokinetic behaviors of hydrochlorothiazide and valsartan.

Improving rating scales: Applying Rasch analysis to student pharmacists' attitudes towards herbal medications

BACKGROUND

This study analyzed the psychometric properties of a cross-sectional survey of student pharmacists' attitudes regarding herbal medications using a polytomous Rasch model. Seven items assessed students' attitudes towards herbal medications using a 6-point agreement scale (0 to 5). Student responses were reviewed to identify outliers and aberrant response patterns, assess scale fit, and perform item analysis. Scale performance was assessed to determine if response categories were independent and equally represented. Items were reviewed for model fit and construct validity with significant item gaps identified using a z-test.

IMPACT

A total of 324 students completed the survey. The initial 6-point scale was analyzed. Student responses with outfit mean-square (MNSQ) values >5 were removed, yet the scale did not have appropriate functionality. The categories were merged to form a 4-point scale with no improvement. Therefore, two different 3-point scale options were analyzed: response categories of 0, 1 to 3, and 4 to 5; and response categories of 0, 1 to 4, and 5. With ten students removed, both 3-point scales met the requirements for functionality and all items exhibited good fit with MNSQ values between 0.6 and 1.4, person-separation value of 1.29, and person-reliability value of 0.62.

RECOMMENDATIONS

Both 3-point scales met the requirements for Rasch analysis. The most optimal scale was the 0, 1 to 4, and 5 option.

DISCUSSION

This study provides findings from the survey validity assessment alongside the survey results, which is useful for readers to have confidence in the quality of the study findings.

Safety effect of fractions from methanolic leaf extract of Ocimum gratissimum on reproduction in male wistar rats

This study evaluates the reproductive toxicity of ethyl acetate and butanolic fractions from crude methanolic leaf extract of Ocimum gratissimum in male Wistar rats. Acute toxicity was assessed to determine the safety dose, Sub-chronic reproductive toxicity studies were carried out by administering daily 25, 100 and 400 mg/kg body weight doses of the fractions to respective group of animals and 1 ml of normal saline daily for the control group for 28 days. Blood, epididymis and testes were harvested for reproductive hormones, sperm parameters, and histopathologic analysis respectively. There was significant (P < 0.05) increase in serum levels of testosterone, body-weight gain, sperm count. There was also apparent increase in mean-testicular weight and preservation of testicular histology with increase spermatogenesis in both the ethyl acetate and butanolic fraction treated groups compared with control. Serum levels of luteinising hormone was however significantly (P < 0.05) decrease across the groups compared to control. These effects were more pronounced in the butanolic fraction group compared to the ethyl acetate treated group. Sperm motility was also significantly (P < 0.05) higher in the ethyl acetate treated group compared to control. Findings from this studies demonstrate that these fractions were non-toxic at the tested doses with regards to male reproduction but, rather, exhibited fertility enhancing effects which was better with the butanolic fraction. Our findings also shows that the ethyl acetate fraction may be safer than the butanolic fraction.

Influence Factors of the Pharmacokinetics of Herbal Resourced Compounds in Clinical Practice

Herbal medicines have been used to prevent and cure diseases in eastern countries for thousands of years. In recent decades, these phytotherapies are becoming more and more popular in the West. As being nature-derived is the essential attribute of herbal medicines, people believe that taking them for diseases treatment is safe enough and has no side-effects. However, the efficacy of herbal resourced compounds (HRC) depends on the multiple constituents absorbed in the body and their pharmacokinetics. Thus, many factors will influence the clinical practice of HRC, i.e., their absorption, distribution, metabolism, and excretion (ADME). Among these factors, herb-drug interaction has been widely discussed, as these compounds may share the same drug-metabolizing enzymes and drug transporters. Meanwhile there are many other potential factors that can also change the ADME of HRC, including herb pretreatment, herb-herb interactions, pathological status, gender, age of patient, and chemical and physical modification of certain ingredients. With the aim of ensuring the efficacy of HRC and minimizing their clinical risks, this review provides and discusses the influence factors and artificial improvement of the pharmacokinetics of HRC.

Peptic Ulcer Disease: A Brief Review of Conventional Therapy and Herbal Treatment Options

Peptic ulcer is a chronic disease affecting up to 10% of the world's population. The formation of peptic ulcers depends on the presence of gastric juice pH and the decrease in mucosal defenses. Non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori (H. pylori) infection are the two major factors disrupting the mucosal resistance to injury. Conventional treatments of peptic ulcers, such as proton pump inhibitors (PPIs) and histamine-2 (H2) receptor antagonists, have demonstrated adverse effects, relapses, and various drug interactions. On the other hand, medicinal plants and their chemical compounds are useful in the prevention and treatment of numerous diseases. Hence, this review presents common medicinal plants that may be used for the treatment or prevention of peptic ulcers.

Toxicological studies of Orthosiphon stamineus (Misai Kucing) standardized ethanol extract in combination with gemcitabine in athymic nude mice model

Pancreatic cancer has the highest mortality rate among cancers due to its aggressive biology and lack of effective treatment. Gemcitabine, the first line anticancer drug has reduced efficacy due to acquired resistance. The current study evaluates the toxicological effects of Orthosiphon stamineus (O.s) and its marker compound (rosmarinic acid) in combination with gemcitabine. O.s (200 or 400 mg/kg/day) and rosmarinic acid (32 mg/kg/day) were administered orally and gemcitabine (10 mg/kg/3 days) intraperitoneally either alone or in combination treatment for fourteen days. Parameters including blood serum biochemistry, hematology, myeloid-erythroid ratio, incident of lethality, and histopathological analysis of liver, kidney, and spleen tissues were studied. Neither, individual drugs/extract nor chemo-herbal combinations at tested doses induced any toxicity and damage to organs in nude mice when compared to control group. Toxicological data obtained from this study will help to select the best doses of chemo-herbal combination for future pancreatic xenograft tumor studies.

Liver injury from herbal and dietary supplements

Herbal and dietary supplements (HDS) are used increasingly both in the United States and worldwide, and HDS-induced liver injury in the United States has increased proportionally. Current challenges in the diagnosis and management of HDS-induced liver injury were the focus of a 2-day research symposium sponsored by the American Association for the Study of Liver Disease and the National Institutes of Health. HDS-induced liver injury now accounts for 20% of cases of hepatotoxicity in the United States based on research data. The major implicated agents include anabolic steroids, green tea extract, and multi-ingredient nutritional supplements. Anabolic steroids marketed as bodybuilding supplements typically induce a prolonged cholestatic but ultimately self-limiting liver injury that has a distinctive serum biochemical as well as histological phenotype. Green tea extract and many other products, in contrast, tend to cause an acute hepatitis-like injury. Currently, however, the majority of cases of HDS-associated liver injury are due to multi-ingredient nutritional supplements, and the component responsible for the toxicity is usually unknown or can only be suspected. HDS-induced liver injury presents many clinical and research challenges in diagnosis, identification of the responsible constituents, treatment, and prevention. Also important are improvements in regulatory oversight of nonprescription products to guarantee their constituents and ensure purity and safety. The confident identification of injurious ingredients within HDS will require strategic alignments among clinicians, chemists, and toxicologists. The ultimate goal should be to prohibit or more closely regulate potentially injurious ingredients and thus promote public safety. (Hepatology 2017;65:363-373).

Mucuna pruriens in Parkinson Disease: A Kinetic-Dynamic Comparison With Levodopa Standard Formulations

OBJECTIVES

We compared levodopa (LD) kinetic-dynamic profile of a dose of LD/aromatic amino acid decarboxylase peripheral inhibitors versus a nominally equivalent dose of a commercial Mucuna pruriens (Mucuna) seeds extract in 2 patients with Parkinson disease chronically taking LD standard combined with self-prescribed Mucuna.

METHODS

Patients were challenged with a fasting morning dose of 100 mg LD/25 mg carbidopa (patient 1) or benserazide (patient 2) versus 100 mg LD from Mucuna capsules in 2 different sessions, after a 12-hour standard LD formulations' washout. They underwent kinetic-dynamic LD monitoring based on LD dose intake and simultaneous serial assessments of plasma drug concentrations and motor test performances. Quantitative analysis of LD in Mucuna capsules was also performed.

RESULTS

Levodopa bioavailability was markedly lower after Mucuna administration compared with LD standard formulations: in patient 1, peak plasma LD concentration (Cmax) decreased from 2.0 to 1.0 mg/L and the area under the plasma concentration time curve from 137 to 33.6 mg/L per minute; in patient 2, Cmax was 0.7 mg/L after LD/benserazide and nearly undetectable after Mucuna. In patient 1, impaired LD bioavailability from Mucuna resulted in reduced duration and overall extent of drug response compared with LD/carbidopa. In patient 2, no significant subacute LD motor response was observed in either condition. Quantitative analysis of Mucuna formulation confirmed the 100 mg LD content for the utilized capsules.

CONCLUSIONS

Our results show an impaired LD bioavailability from Mucuna preparation, as expected by the lacking aromatic amino acid decarboxylase inhibitors coadministration, which might explain the suggested lower dyskinetic potential of Mucuna compared with standard LD formulations.

Exploring the interaction between Salvia miltiorrhiza and human serum albumin: Insights from herb-drug interaction reports, computational analysis and experimental studies

Human serum albumin (HSA) binding is one of important pharmacokinetic properties of drug, which is closely related to in vivo distribution and may ultimately influence its clinical efficacy. Compared to conventional drug, limited information on this transportation process is available for medicinal herbs, which significantly hampers our understanding on their pharmacological effects, particularly when herbs and drug are co-administrated as polytherapy to the ailment. Several lines of evidence suggest the existence of Salvia miltiorrhiza-Warfarin interaction. Since Warfarin is highly HSA bound in the plasma with selectivity to site I, it is critical to evaluate the possibility of HSA-related herb-drug interaction. Herein an integrated approach was employed to analyze the binding of chemicals identified in S. miltiorrhiza to HSA. Molecular docking simulations revealed filtering criteria for HSA site I compounds that include docking score and key molecular determinants for binding. For eight representative ingredients from the herb, their affinity and specificity to HSA site I was measured and confirmed fluorometrically, which helps to improve the knowledge of interaction mechanisms between this herb and HSA. Our results indicated that several compounds in S. miltiorrhiza were capable of decreasing the binding constant of Warfarin to HSA site I significantly, which may increase free drug concentration in vivo, contributing to the herb-drug interaction observed clinically. Furthermore, the significance of HSA mediated herb-drug interactions was further implied by manual mining on the published literatures on S. miltiorrhiza.

Diabetes mellitus and its management with medicinal plants: A perspective based on Iranian research

ETHNOPHARMACOLOGICAL RELEVANCE

Complementary and alternative medicine has been increasingly used to treat chronic illnesses, such as diabetes mellitus. However, various limitations in terms of their application and efficacies exist. Furthermore, there is still much to be done to discover the right herbal medicine for diabetes.

AIM OF THE STUDY

This paper aims to evaluate previous herbal studies on the management of diabetes mellitus, to address their strengths and weaknesses and propose a general framework for future studies.

APPROACH AND METHODS

Data sources such as PubMed, ScienceDirect, Scopus, SpringerLink, and Wiley were searched, limited to Iran, using 36 search terms such as herbal, traditional, medicine, and phytopharmacy in combination with diabetes and related complications. Reviewed articles were evaluated regarding the use of botanical nomenclature and included information on (1) identity of plants and plant parts used, (2) the processing procedure, and (3) the extraction process. The main outcomes were extracted and then surveyed in terms of the efficacies of herbs in the management of diabetes mellitus. Then a comparative study was performed between Iranian and non-Iranian studies with respect to herbs best studied in Iran.

RESULTS

Of the 82 herbs studied in Iran, only six herbs were endemic and 19 were studied in detail. Although most of the reviewed herbs were found to decrease the level of blood glucose (BG) and/or glycated hemoglobin (HbA1C) in both Iranian and non-Iranian studies, information on their pharmacological mechanisms is scarce. However, the level of HbA1C was measured in a limited number of clinical trials or animal studies. Available information on both short- and long-term use of studied herbs on diabetes related complications and functions of involved organs as well as comorbid depression and/or simultaneous changes in lifestyle is also insufficient. Furthermore, little or no information on their phytochemical, toxicological, and herb-drug interaction properties is available. It is worth noting that the efficacy of the reviewed herbs has been studied scarcely in both humans and animals regarding both Iranian and non-Iranian studies. A significant number of reviewed articles failed to cite the scientific name of herbs and include information on the processing procedure and the extraction process.

CONCLUSIONS

Treatment of diabetes mellitus as a multifactorial disease using herbal medicines requires a comprehensive approach. In order to discover the right herbal medicine for the management of diabetes many other important factors than the levels of BG, HbA1C and insulin should be considered. According to our criteria, all the reviewed herbs suffered from inadequate investigation in human, animal and in vitro models in this respect, whereas they are worth investigating further. However, more research on endemic plants and the traditional history of herbal medicine is warranted. In our opinion, the pharmacological, toxicological, and phytochemical information should be obtained before clinical trials. Furthermore, information such as botanical scientific nomenclature, side effects, and toxicity will improve the quality and validity of publications in herbal research. In particular, designing a database covering all valid information about herbs and/or diseases will decrease unnecessary costs and increase the efficiency of research.

Impact of physiological, pathological and environmental factors on the expression and activity of human cytochrome P450 2D6 and implications in precision medicine

With only 1.3-4.3% in total hepatic CYP content, human CYP2D6 can metabolize more than 160 drugs. It is a highly polymorphic enzyme and subject to marked inhibition by a number of drugs, causing a large interindividual variability in drug clearance and drug response and drug-drug interactions. The expression and activity of CYP2D6 are regulated by a number of physiological, pathological and environmental factors at transcriptional, post-transcriptional, translational and epigenetic levels. DNA hypermethylation and histone modifications can repress the expression of CYP2D6. Hepatocyte nuclear factor-4α binds to a directly repeated element in the promoter of CYP2D6 and thus regulates the expression of CYP2D6. Small heterodimer partner represses hepatocyte nuclear factor-4α-mediated transactivation of CYP2D6. GW4064, a farnesoid X receptor agonist, decreases hepatic CYP2D6 expression and activity while increasing small heterodimer partner expression and its recruitment to the CYP2D6 promoter. The genotypes are key determinants of interindividual variability in CYP2D6 expression and activity. Recent genome-wide association studies have identified a large number of genes that can regulate CYP2D6. Pregnancy induces CYP2D6 via unknown mechanisms. Renal or liver diseases, smoking and alcohol use have minor to moderate effects only on CYP2D6 activity. Unlike CYP1 and 3 and other CYP2 members, CYP2D6 is resistant to typical inducers such as rifampin, phenobarbital and dexamethasone. Post-translational modifications such as phosphorylation of CYP2D6 Ser135 have been observed, but the functional impact is unknown. Further functional and validation studies are needed to clarify the role of nuclear receptors, epigenetic factors and other factors in the regulation of CYP2D6.

Evaluation of potential drug- herb interactions among a group of Palestinian patients with chronic diseases

Background

The aim of this study was to find the prevalence of potential drug-herb interactions in patients with chronic diseases and identify factors associated with these interactions if present.

Method

The study was a questionnaire based cross-sectional study. It was conducted at a number of governmental primary healthcare centers which include outpatient clinics for chronic diseases between July and November 2013. Patients come to these clinics monthly or bimonthly to receive their medications for their chronic diseases free. The patients in this study were seen at these clinics and their medications were reported from the most recent prescription in their files.

Results

A total of 400 patients agreed to be interviewed, 209 (52.3 %) were females. The most commonly used medications were metformin, insulin, and enalapril. Among the patients, 237 (59.3 %) were using 395 medicinal herbs. The most commonly used herbs were sage, anise and peppermint. In 51 out of the 237 cases (21.5 %) at least one potential drug-herb interaction was found. Male patients were more likely to have potential drug-herb interactions. Patients with potential drug herb interactions were older, having a higher mean number of chronic diseases and medications (P-value < 0.05). Only 133 out of 237 (56.1 %) users told their prescribers or pharmacists before using medicinal herbs.

Conclusion

Use of medicinal herbs is a common practice among Palestinian patients attending primary healthcare centers. A substantial proportion failed to disclose to their doctors or pharmacists about herbal products they used, therefore, the physicians and pharmacists are recommended to ask patients about the use of medicinal herbs to avoid any possible negative outcomes. Better counseling and communication between patients and healthcare providers is recommended.

Plants Consumption and Liver Health

The liver is a very important organ with a lot of functions for the host to survive. Dietary components are essential for and can be beneficial or detrimental to the healthy or diseased liver. Plants food is an essential part of the human diet and comprises various compounds which are closely related to liver health. Selected food plants can provide nutritional and medicinal support for liver disease. At the present, the knowledge of the effects of plants on the liver is still incomplete. The most urgent task at the present time is to find the best dietary and medicinal plants for liver health in an endless list of candidates. This review article updates the knowledge about the effects of plants consumption on the health of the liver, putting particular emphasis on the potential beneficial and harmful impact of dietary and medicinal plants on liver function.

Oral contraceptives and antibiotics. A cross-sectional study about patients' knowledge in general practice

Background

The evidence regarding oral contraceptives and its effectiveness with concomitant ingestion of antibiotics is conflicting. Until evidence becomes clearer, patients should be aware of this possible interaction. The aim of this study was to assess the knowledge and the source of information about this interaction in GP patients in Austria.

Methods

Within the framework of the APRES study, 20 Austrian GPs were purposefully selected from among a GP research network and were asked to recruit 200 patients each. The patient cohort was asked to complete a questionnaire. Subsequent analysis included descriptive statistics, statistical tests and logistic regression models.

Findings

Overall, 3280 questionnaires could be used for analysis. Of these, 29.7 % (n = 974) of patients acknowledged an awareness of the interaction of antibiotics with OCPs. Women under the age of 46 years acknowledged this interaction in 52.3 % of cases. Positive associations for the belief in an existing interaction in women were identified with age (OR 2.2) and having read the package inserts (OR 1.6). Further, belief was recognized in males based on age (OR 2.5) and tertiary education (OR 2.0). The main source of information regarding antibiotics was the GP (55.9 %).

Conclusions

Less than one-third of all participants and half of the women in the reproductive age acknowledged an interaction between antibiotics and OCPs. Since the GP is the main source of information, this finding depicts a large potential for knowledge transfer within the primary health care setting. A multifaceted strategy is needed at both the population and the GP level to improve awareness and to address these educational gaps.

Thyroid storm caused by a chinese herb contaminated with thyroid hormones

Patient: Male, 70

Final Diagnosis: Thyroid storm

Symptoms: Atrial fibrillation • confusion • hyperthermia • tachycardia

Medication: —

Clinical Procedure: Intubation • cardioversion

Specialty: Critical Care Medicine

Evaluation of drug interaction potential of Labisia pumila (Kacip Fatimah) and its constituents

Labisia pumila (Kacip Fatimah) is a popular herb in Malaysia that has been traditionally used in a number of women's health applications such as to improve libido, relieve postmenopausal symptoms, and to facilitate or hasten delivery in childbirth. In addition, the constituents of this plant have been reported to possess anticancer, antioxidant, and anti-inflammatory properties. Clinical studies have indicated that cytochrome P450s (CYPs), P-glycoprotein (P-gp), and Pregnane X receptor (PXR) are the three main modulators of drug-drug interactions which alter the absorption, distribution, and metabolism of drugs. Given the widespread use of Kacip Fatimah in dietary supplements, the current study focuses on determining the potential of its constituents to affect the activities of CYPs, P-gp, or PXR using in vitro assays which may provide useful information toward the risk of herb-drug interaction with concomitantly used drugs. Six compounds isolated from the roots of L. pumila (2 saponins and 4 alkyl phenols) were tested, in addition to the methanolic extract. The extract of L. pumila showed a significant time dependent inhibition (TDI) of CYP3A4, reversible inhibition of CYP2C9 and 2C19 and a weak inhibition of 1A2 and 2D6 as well as an inhibition of P-gp and rifampicin-induced PXR activation. The alkyl phenols inhibited CYP3A4 (TDI), CYP2C9, and 2C19 (reversible) while saponins inhibited P-gp and PXR. In conclusion, L. pumila and its constituents showed significant modulation of all three regulatory proteins (CYPs, P-gp, and PXR) suggesting a potential to alter the pharmacokinetic and pharmacodynamic properties of conventional drugs if used concomitantly.