Adverse drug reactions in a complementary medicine hospital: a prospective, intensified surveillance study

UHPLC-MS metabolomic profile and in silico pharmacokinetic approach of Kalanchoe daigremontiana Raym.-Hamet & H. Perrier aqueous extracts

Throughout humanity's development, the medicinal use of plants has evolved as an observational and empirical matter; Yorubá culture uses Kalanchoe sp. as universal antidotes. They are believed to be "ewé òdúndún" or plants of goodness and are traditionally and religiously used in preparations to treat diseases and physiological disorders. Our main goals were to determine the comparative phytochemical composition panel of two Kalanchoe daigremontiana Raym.-Hamet & H. Perrier aqueous extracts through UHPLC-MS metabolomic approaches and highlight the drug-likeness properties of the most abundant compounds in the complex mixture prepared according to its traditional uses. K. daigremontiana leaf aqueous extracts were prepared by cold water maceration (Kd1) or decoction (Kd2). The metabolomics analysis of the extracts was performed through UHPLC-ESI-MS/MS acquisition in positive and negative modes. An in-house database was built with molecules found in plants from the Crassulaceae family and was applied to the annotation step. Our analysis identified 132 compounds, showcasing variations between negative (ESI(-)) and positive (ESI(+)) ionization modes. Notably, flavonoids such as quercetin and kaempferol glycosides, known for their potent antioxidant properties, were abundant in both extracts. Additionally, bufadienolides, associated with diverse biological activities, were present. Both extracts presented similar phytochemical compositions in terms of the number of compounds. Differential analysis revealed significantly higher intensities for specific molecules in both Kd1 and Kd2 extracts. Considering the relative abundance, Kd1 showed a significant amount of Fatty Acids and Steroids concerning Kd2. Additionally, the 15 most abundant compounds were analyzed using in silico pharmacokinetic and toxicity algorithms (SwissADME, pkCSM, and LAZAR) to predict their drug-likeness profile. The fifteen most abundant molecules (Corchorifatty acid F; 9,12,13-TriHOME; Acetylsagittatin A; Apiin; Kaempferol; L-Malic acid; 19-Oxodesacetylcinobufagin; Lucyoside Q; (12 S,13 S)-Epoxylinolenic acid; Isocitric acid; 4''-O-Acetylafzelin; Hellebrigenin; Senedigitalene; Blumenol C and Sativoside R2) had their ADMET in silico profiles predicted using computational tools. Importantly, our in silico assessments pinpointed six promising compounds with favorable absorption, pharmacokinetics, and drug-likeness properties, suggesting their potential as bioactive agents. This finding underscores the significance of these traditional aqueous extracts in folk medicine. In conclusion, our study not only supports the traditional use of Kalanchoe spp. but also sheds light on the safety and pharmacological potential of these extracts. By exploring different extraction methods and employing metabolomics, we have gained valuable insights into the bioactivity and safety of plant extracts, which can guide future research in this field.

An In Vitro Anticancer, Antioxidant, and Phytochemical Study on Water Extract of Kalanchoe daigremontiana Raym.-Hamet and H. Perrier

Kalanchoe species are succulents with anti-inflammatory, antioxidant, and analgesic properties, as well as cytotoxic activity. One of the most popular species cultivated in Europe is Kalanchoe daigremontiana Raym.-Hamet and H. Perrier. In our study, we analyzed the phytochemical composition of K. daigremontiana water extract using UHPLC-QTOF-MS and estimated the cytotoxic activity of the extract on human ovarian cancer SKOV-3 cells by MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay, flow cytometry, luminometric, and fluorescent microscopy techniques. The expression levels of 92 genes associated with cell death were estimated via real-time PCR. The antioxidant activity was assessed via flow cytometry on human keratinocyte HaCaT cell line. The DPPH (2,2-diphenyl-1-picrylhydrazyl) radical and FRAP (ferric-reducing antioxidant power) assays were also applied. We identified twenty bufadienolide compounds in the water extract and quantified eleven. Bersaldegenin-1,3,5-orthoacetate and bryophyllin A were present in the highest amounts (757.4 ± 18.7 and 573.5 ± 27.2 ng/mg dry weight, respectively). The extract showed significant antiproliferative and cytotoxic activity, induced depolarization of the mitochondrial membrane, and significantly arrested cell cycle in the S and G2/M phases of SKOV-3 cells. Caspases-3, 7, 8, and 9 were not activated during the treatment, which indicated non-apoptotic cell death triggered by the extract. Additionally, the extract increased the level of oxidative stress in the cancer cell line. In keratinocytes treated with menadione, the extract moderately reduced the level of oxidative stress. This antioxidant activity was confirmed by the DPPH and FRAP assays, where the obtained IC₅₀ values were 1750 ± 140 and 1271.82 ± 53.25 μg/mL, respectively. The real-time PCR analysis revealed that the extract may induce cell death via TNF receptor (tumor necrosis factor receptor) superfamily members 6 and 10.

Safety of Anthroposophic Medicinal Products: An Analysis of Adverse Drug Reactions from German Pharmacovigilance Databases

BACKGROUND

Anthroposophic medicinal products (AMPs) are widely used in Europe and world-wide.

OBJECTIVE

To determine the frequency of reported adverse drug reactions (ADRs) from all AMPs on the market, in absolute numbers and relative to the maximum daily administration doses (MDADs).

PATIENTS AND METHODS

Retrolective safety analysis of AMP-related ADRs in pharmacovigilance databases of four AMP Marketing Authorisation Holders in Germany. For each ADR, information about the patient, outcome, causality and AMP was retrieved. Primary outcome was the frequency of reported ADRs relative to MDADs sold.

RESULTS

In the period 2010-2017, a total of 5506 ADRs were reported that had occurred in 2765 different patients, comprising 370 different AMPs. A total of 104 ADRs (1.9%) were classified as serious. The frequency of ADRs for all AMPs was 1.50 per million MDADs. For serious ADRs the frequency was 0.03 per million MDADs. ADRs were more frequently reported with parenteral AMP administration (injections) than with oral or local administration (18.85 vs. 0.59 vs. 1.61 ADRs per million MDADs, respectively; p < 0.0001). The large majority of users (91.9%) had recovered or were recovering from the ADRs and there were no reports with a fatal outcome. Most frequently reported ADR symptom was injection site inflammation for parenteral AMPs (4.66 ADRs per million MDADs), nausea for oral AMPs (0.03 ADRs per million MDADs), and eye irritation for locally administered AMPs (0.23 ADRs per million MDADs).

CONCLUSIONS

In this retrolective safety analysis of pharmacovigilance data, the frequency of ADRs to AMPs was 1.50 per million MDADs. Notably, the ADR frequency in this study based on spontaneous reporting is not directly comparable to frequencies in prospective clinical studies nor to frequencies based on other measures of patient exposure than MDADs.

From Ethnomedicine to Plant Biotechnology and Machine Learning: The Valorization of the Medicinal Plant Bryophyllum sp

The subgenus Bryophyllum includes about 25 plant species native to Madagascar, and is widely used in traditional medicine worldwide. Different formulations from Bryophyllum have been employed for the treatment of several ailments, including infections, gynecological disorders, and chronic diseases, such as diabetes, neurological and neoplastic diseases. Two major families of secondary metabolites have been reported as responsible for these bioactivities: phenolic compounds and bufadienolides. These compounds are found in limited amounts in plants because they are biosynthesized in response to different biotic and abiotic stresses. Therefore, novel approaches should be undertaken with the aim of achieving the phytochemical valorization of Bryophyllum sp., allowing a sustainable production that prevents from a massive exploitation of wild plant resources. This review focuses on the study of phytoconstituents reported on Bryophyllum sp.; the application of plant tissue culture methodology as a reliable tool for the valorization of bioactive compounds; and the application of machine learning technology to model and optimize the full phytochemical potential of Bryophyllum sp. As a result, Bryophyllum species can be considered as a promising source of plant bioactive compounds, with enormous antioxidant and anticancer potential, which could be used for their large-scale biotechnological exploitation in cosmetic, food, and pharmaceutical industries.

Bufadienolides of Kalanchoe species: an overview of chemical structure, biological activity and prospects for pharmacological use

Toad venom is regarded as the main source of bufadienolides; however, synthesis of these substances takes also place in a variety of other animal and plant organisms, including ethnomedicinal plants of the Kalanchoe genus. Chemically, bufadienolides are a group of polyhydroxy C-24 steroids and their glycosides, containing a six-membered lactone (α-pyrone) ring at the C-17β position. From the pharmacological point of view, bufadienolides might be a promising group of steroid hormones with cardioactive properties and anticancer activity. Most of the literature concerns bufadienolides of animal origin; however, the medicinal use of these compounds remains limited by their narrow therapeutic index and the risk of development of cardiotoxic effects. On the other hand, plants such as Kalanchoe are also a source of bufadienolides. Kalanchoe pinnata (life plant, air plant, cathedral bells), Kalanchoe daigremontiana (mother of thousands) and other Kalanchoe species are valuable herbs in traditional medicine of Asia and Africa. The present review focuses on the available data on chemical structures of 31 compounds, biological properties and prospects for therapeutic use of bufadienolides from Kalanchoe species. Furthermore, it presents some new investigational trends in research on curative uses of these substances.

Antioxidant efficacy of Kalanchoe daigremontiana bufadienolide-rich fraction in blood plasma in vitro

CONTEXT

The main source of bufadienolides is toad venom; however, plants such as members of Kalanchoe Adans. (Crassulaceae) genus may also synthesize these bioactive substances.

OBJECTIVE

This is the first study on antioxidant effects and cytotoxicity of bufadienolide-rich fraction isolated from Kalanchoe daigremontiana Raym.-Hamet & H. Perrier.

MATERIALS AND METHODS

The methanolic fraction was extracted from the plant roots and contained 0.48 mg bufadienolides/mg of dry mass (11α,19-dihydroksytelocinobufagin, bersaldegenin-1-acetate, bersaldegenin-1,3,5-orthoacetate, 19-(acetyloxy)-3β,5β,11α,14-tetrahydroxyl-12-oxo-bufa-20,22-dienolide and 19-(acetyloxy)-1β,3β,5β,14-tetrahydroxyl-bufa-20,22-dienolide, mainly). The cytotoxicity of K. daigremontiana fraction was evaluated in an in vitro experimental model of blood platelets. The viability of blood platelets was determined on the basis of a release of lactate dehydrogenase.

RESULTS

The fraction scavenged DPPH^• radicals, with EC₅₀ of 21.80 μg/mL. Studies on an experimental model of blood plasma under peroxynitrite-induced oxidative stress revealed that the plant preparation had moderate antioxidant properties. Levels of 3-nitrotyrosine and thiol groups indicated that the protective effect of K. daigremontiana was significant mainly for its concentration of 50 μg/mL. No effect was found in prevention of oxidation of low-molecular plasma thiols (glutathione, cysteine and cysteinylglycine). Simultaneously, measurements of lipid hydroperoxides and thiobarbituric acid-reactive substances (TBARS) indicated that the examined fraction might be effective antioxidant at broader concentration range, that is 1-5 and 25-50 μg/mL for hydroperoxides and TBARS generation, respectively. No cytotoxicity was observed at the concentration range of 1-50 μg/mL.

CONCLUSIONS

Based on the obtained results, we suggest that antioxidant activity may additionally contribute to beneficial properties of K. daigremontiana-derived extracts.

Adverse Drug Reactions and Expected Effects to Therapy with Subcutaneous Mistletoe Extracts (Viscum album L.) in Cancer Patients

Background. In Europe, mistletoe extracts are widely used as a complementary cancer therapy. We assessed the safety of subcutaneous mistletoe as a conjunctive therapy in cancer patients within an anthroposophic medicine setting in Germany. Methods. A multicentre, observational study was performed within the Network Oncology. Suspected mistletoe adverse drug reactions (ADRs) were described by frequency, causality, severity, and seriousness. Potential risk factors, dose relationships and drug-drug interactions were investigated. Results. Of 1923 cancer patients treated with subcutaneous mistletoe extracts, 283 patients (14.7%) reported 427 expected effects (local reactions <5 cm and increased body temperature <38°C). ADRs were documented in 162 (8.4%) patients who reported a total of 264 events. ADRs were mild (50.8%), moderate (45.1%), or severe (4.2%). All were nonserious. Logistic regression analysis revealed that expected effects were more common in females, while immunoreactivity decreased with increasing age and tumour stage. No risk factors were identified for ADRs. ADR frequency increased as mistletoe dose increased, while fewer ADRs occurred during mistletoe therapy received concurrent with conventional therapies. Conclusion. The results of this study indicate that mistletoe therapy is safe. ADRs were mostly mild to moderate in intensity and appear to be dose-related and explained by the immune-stimulating, pharmacological activity of mistletoe.

Acute adverse events from over-the-counter Chinese herbal medicines: a population-based survey of Hong Kong Chinese

Background

Although over-the-counter traditional Chinese herbal medicine (COTC) is commonly used to treat everyday illness in many parts of the world, no population-based study has been done to examine the prevalence and factors associated with COTC-related adverse events.

Methods

A cross-sectional telephone survey was conducted among Hong Kong Chinese adults in 2011 (n = 1100) with informed verbal consent. Stepwise logistic regression of demographic, attitudinal and behavioral variables was used to determine factors associated with past-year adverse events.

Results

Of study respondents, 71.7% (789/1100) reported past-year COTC use and 2.3% (25/1100) reported at least one COTC-related adverse event in the past year. Of the 27 adverse events cases reported among COTC users, the most common were allergic reactions (n = 11) dizziness (n = 5), and gastro-intestinal problems (n = 4). Pills/capsules were the dosage form that caused the highest proportion of adverse events (n = 10), followed by plasters (n = 7), creams/ointments (n = 5), and ingestible powders (n = 2).

Although COTC users reporting adverse events were more likely to report greater practices to avoid adverse events (OR = 6.47; 95% CI: 1.38-30.3); they were also more likely to possess lower education levels (OR = 9.64, 95% CI: 2.20-42.3) and to have received COTC information from non-reliable, mass-media information sources such as magazines (OR = 3.32; 95% CI: 1.01-8.50) or television (OR = 2.93; 95% CI: 1.03-10.7). Package labels were also felt to be unclear by 42.9% of COTC users. A large proportion of COTC users demonstrated low levels of COTC-related knowledge, while the main impediment to greater information-seeking was the belief that reliable COTC information is not obtainable from Western health professionals.

Conclusions

Despite global movements toward more stringent complementary medicine regulation, the limited accessibility of reliable information and widespread misperceptions among consumers present major challenges for the safe use of complementary medicine.

Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social

Virtudes atribuídas às terapias complementares, como abordagem holística e centrada nos pacientes e estímulo à autocura, vêm sendo valorizadas e podem, em tese, atenuar a excessiva medicalização social hoje vigente. Dentre elas, a acupuntura destaca-se pela institucionalização e aceitação progressiva. O objetivo foi analisar a experiência de pacientes com acupuntura no Sistema Único de Saúde e como ela se insere no seu cuidado, à luz da medicalização social, esta pensada nos seus aspectos constitutivos das representações e modelos explicativos dos usuários. Foram entrevistados trinta pacientes selecionados das atenções primária e secundária de Florianópolis, Santa Catarina, Brasil. Observou-se relevantes resultados terapêuticos nas queixas principais, no sono, na disposição, no estado emocional e diminuição do uso de fármacos. Os modelos explicativos dos usuários e seu autocuidado foram pouco ou nada modificados pelo tratamento com acupuntura. Notou-se, todavia, um cuidado ampliado e menos iatrogênico, principalmente na atenção primária à saúde, em que houve pouca oferta de outras práticas da medicina chinesa associadas.

Comparative epidemiology of hospital-acquired adverse drug reactions in adults and children and their impact on cost and hospital stay--a systematic review

PURPOSE

To study and analyze the comparative impact of hospital-acquired adverse drug reactions (ADRs) in adult and pediatric patients in terms of the economic implications, (length of) hospital stay, and salient features in relation to the incidence rate, severity, morbidity, mortality, and preventability of the ADRs.

METHODS

A systematic search to identify and retrieve relevant articles/studies in the PubMed, Medline, Scopus, MEDPAR, and Cochrane databases and by the Google search engine was performed for the study period 2000 to April 2013. In total, 51 studies were identified on patients hospitalized for ADRs, and these were included in the study. The incidence rate of ADRs, their severity, mortality, morbidity, preventability, cost, and association with extended hospital stay due to ADRs were extracted and scrutinized.

RESULTS

Hospital-acquired ADRs are more widely studied in adults than in children, and the incidence rate is higher in the former. However, a wide variation in the incidence rate worldwide is observed in both groups. Irrespective of the ages of patients, ADRs are among the most frequent causes of morbidity and mortality. Interestingly, preventable ADRs are more frequently observed in patients at the younger and older ends of the age spectrum. Hospital-acquired ADRs place an immense economic burden on healthcare systems, with the overall cost for a hospitalized patient with an ADR reported to be $2,401 per patient, which is equivalent to a 19.86 % additional increase in the total cost of care and an increase in average length of hospital stay of 8.25 %.

CONCLUSION

Based on the findings of this review, we suggest that excellent assertive measures of pharmacovigilance with the aim to diminish the incidence rate of hospital-acquired ADRs and support the development of interventions are needed to promote vital facets of drug safety with an overall objective to avert potential ADRs.

The effects of integrative in-patient treatment on patients' quality of life: a meta-analysis

Background. In the last decades, several hospitals have adopted this concept of integrative medicine for the treatment of chronic and acute states of illnesses in in-patient treatment. The aim of this paper was to summarize the current evidence for a possible effectiveness of integrative on-patient treatment in patients' quality of life by means of a meta-analysis. Material and Methods. The databases MEDLINE, EMBASE, AMED, PsycInfo, PsycLit CCMED, and CAMbase were screened to find articles. We also screened publisher databases to find relevant information. Articles were included if patients were treated in a hospital. To guarantee comparability SF-36 was the predefined outcome measure for patients' quality of life. Data of pre/posteffects on the mental and physical scores of the SF-36 were extracted and effect sizes were calculated and entered into a random effect meta-analysis. Results. Eight articles published between 2003 and 2010 were included in the final meta-analysis. Random effect meta-analysis of the eight studies revealed an overall effect size of 0.37 (95% CI: [0.28; 0.45]) in the physical score and 0.38 (95% CI: [0.30; 0.45]) in the mental score of the SF-36. I² statistics indicate a high heterogeneity in the effects in both the physical and mental scores of the SF-36 (I² = 91.8%, P < 0.001, resp.; I² = 86.7%, P < 0.001). Discussion. This meta-analysis might help to rediscover the importance of integrative in-patient treatment for patients, physicians, and stakeholders.

Práticas integrativas e complementares: oferta e produção de atendimentos no SUS e em municípios selecionados

A Medicina Tradicional/Complementar e Alternativa tem crescido no mundo e sua importância vem sendo ressaltada em diversos estudos. No Brasil, a Política Nacional de Práticas Integrativas e Complementares incentiva sua inserção e fortalecimento na atenção primária. Buscou-se identificar a oferta dos serviços e de práticas integrativas e complementares no SUS e a produção de atendimentos entre os anos 2000 e 2011, analisando as informações disponíveis nos bancos de dados nacionais vis-à-vis os dados da atenção primária nos municípios de Campinas (São Paulo), Florianópolis (Santa Catarina) e Recife (Pernambuco). A análise permitiu identificar um descompasso entre o que se registra nos sistemas de informação e o que se pratica nos municípios. Esse descompasso deve-se, em grande parte, à indefinição do escopo do que se compreende como práticas integrativas e complementares na Política Nacional, o que significa uma grande limitação para sua mensuração e avaliação, já que os sistemas de informação atuais não permitem o registro adequado dessas práticas.