Syndrome Differentiation of Diabetes by the Traditional Chinese Medicine according to Evidence-Based Medicine and Expert Consensus Opinion

A study on the association between gut microbiota, inflammation, and type 2 diabetes

Type 2 diabetes mellitus (T2DM) was reported to be associated with impaired immune response and alterations in microbial composition and function. However, the underlying mechanism remains elusive. To investigate the association among retinoic acid-inducible gene-I-like receptors (RLRs) signaling pathway, intestinal bacterial microbiome, microbial tryptophan metabolites, inflammation, and a longer course of T2DM, 14 patients with T2DM and 7 healthy controls were enrolled. 16S rRNA amplicon sequencing and untargeted metabolomics were utilized to analyze the stool samples. RNA sequencing (RNA-seq) was carried out on the peripheral blood samples. Additionally, C57BL/6J specific pathogen-free (SPF) mice were used. It was found that the longer course of T2DM could lead to a decrease in the abundance of probiotics in the intestinal microbiome. In addition, the production of microbial tryptophan derivative skatole declined as a consequence of the reduced abundance of related intestinal microbes. Furthermore, low abundances of probiotics, such as Bacteroides and Faecalibacterium, could trigger the inflammatory response by activating the RLRs signaling pathway. The increased level of the member of TNF receptor-associated factors (TRAF) family, nuclear factor kappa-B (NF-κB) activator (TANK), in the animal colon activated nuclear factor kappa B subunit 2 (NFκB2), resulting in inflammatory damage. In summary, it was revealed that the low abundances of probiotics could activate the RLR signaling pathway, which could in turn activate its downstream signaling pathway, NF-κB, highlighting a relationship among gut microbes, inflammation, and a longer course of T2DM. KEY POINTS: Hyperglycemia may suppress tryptophanase activity. The low abundance of Bacteroides combined with the decrease of Dopa decarboxylase (DDC) activity may lead to the decrease of the production of tryptophan microbial derivative skatole, and the low abundance of Bacteroides or reduced skatole may further lead to the increase of blood glucose by downregulating the expression of glucagon-like peptide-1 (GLP1). A low abundance of anti-inflammatory bacteria may induce an inflammatory response by triggering the RLR signaling pathway and then activating its downstream NF-κB signaling pathway in prolonged T2DM.

Gegen Qinlian Decoction combined with Metformin for the treatment of patients with Type-2 Diabetes Mellitus: A retrospective observational study

Objectives

To investigate Gegen Qinlian Decoction (GQD) combined with metformin for treatment of patients with Type-2 Diabetes Mellitus (T2DM).

Methods

This retrospective observational study reviewed the clinical data of 89 patients diagnosed with T2DM in the Department of Acupuncture and Massage, Hainan Medical University from January 2021 to June 2022. Patients were non-randomized and divided into two groups based on the treatment received: observation group (n=41, GQD combined with metformin); control group (n=48, metformin only). Fasting blood glucose levels (FBG), traditional Chinese medicine (TCM) syndrome scores, clinical effect, blood glucose time in range and adverse reactions were compared between the two groups.

Results

There were no statistically significant differences in age, gender, BMI and duration of T2DM between the two groups (P>0.05). The FBG, 2h glucose, HbA1c levels and TCM syndrome scores of the two groups were significantly lower post-treatment (P<0.001) with a greater decrease in the observation group (P<0.001). The observation group was more clinically efficacious than the control group post-treatment (92.68% vs. 77.08%; P<0.05). Blood glucose time in range and the incidence of adverse reactions were lower in the observation group than the control group (P<0.001 and P<0.05).

Conclusions

GQD combined with metformin can significantly reduce FBG, 2h glucose and HbA1c levels, and improve TCM syndrome, with good clinical efficacy, shorter blood glucose time in range and less adverse reactions.

Application of machine learning in Chinese medicine differentiation of dampness-heat pattern in patients with type 2 diabetes mellitus

Background

China has become the country with the largest number of people with type 2 diabetes mellitus (T2DM), and Chinese medicine (CM) has unique advantages in preventing and treating T2DM, while accurate pattern differentiation is the guarantee for proper treatment.

Objective

The establishment of the CM pattern differentiation model of T2DM is helpful to the pattern diagnosis of the disease. At present, there are few studies on dampness-heat pattern differentiation models of T2DM. Therefore, we establish a machine learning model, hoping to provide an efficient tool for the pattern diagnosis of CM for T2DM in the future.

Methods

A total of 1021 effective samples of T2DM patients from ten CM hospitals or clinics were collected by a questionnaire including patients' demographic and dampness-heat-related symptoms and signs. All information and the diagnosis of the dampness-heat pattern of patients were completed by experienced CM physicians at each visit. We applied six machine learning algorithms (Artificial Neural Network [ANN], K-Nearest Neighbor [KNN], Naïve Bayes [NB], Support Vector Machine [SVM], Extreme Gradient Boosting [XGBoost] and Random Forest [RF]) and compared their performance. And then we also utilized Shapley additive explanation (SHAP) method to explain the best performance model.

Results

The XGBoost model had the highest AUC (0.951, 95% CI 0.925-0.978) among the six models, with the best sensitivity, accuracy, F1 score, negative predictive value, and excellent specificity, precision, and positive predictive value. The SHAP method based on XGBoost showed that slimy yellow tongue fur was the most important sign in dampness-heat pattern diagnosis. The slippery pulse or rapid-slippery pulse, sticky stool with ungratifying defecation also performed an important role in this diagnostic model. Furthermore, the red tongue acted as an important tongue sign for the dampness-heat pattern.

Conclusion

This study constructed a dampness-heat pattern differentiation model of T2DM based on machine learning. The XGBoost model is a tool with the potential to help CM practitioners make quick diagnosis decisions and contribute to the standardization and international application of CM patterns.

AGREE II for TCM: Tailored to evaluate methodological quality of TCM clinical practice guidelines

Background: The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument has been widely used in the methodological quality assessment of clinical practice guidelines (CPG). Chinese medicine CPGs have unique characteristics which distinguish them from those of Western medicine, e.g. syndrome differentiation, on which treatments are based. As such, certain domains and items in AGREE II are unsuitable for assessing TCM CPGs. Therefore, it is necessary to adjust and supplement the description and rating section of some items of the AGREE Ⅱinstrument. Purpose: To adjust and expand AGREE II according to characteristics of TCM clinical practice guidelines. Methods: A research working group was established, consisting of a core working group and an expert consensus group, before a systematic literature search performed to screen for TCM guidelines. Two researchers evaluated the quality of the included guidelines using AGREE Ⅱ and later proposed adjustments to some items of AGREE Ⅱ and supplementary comments, which were applicable to TCM CPGs, and drafted an initial version of AGREE Ⅱ for TCM. Suggestions from literature on development and evaluation of TCM CPGs were solicited and integrated into the revised version, which 16 experts were then invited to advise on. When the experts reached a consensus, their comments to the draft were adopted by the core group into the final version. Results: After evaluating the included TCM guidelines, the two researchers offered adjustments and supplementary comments for AGREE Ⅱ Items 1, 7, 10, 11, 12, 15, and 18, and drafted an initial version of AGREE Ⅱ for TCM. Combining suggestions from the literature on development and quality evaluation of TCM clinical guidelines, the core working group modified AGREE Ⅱ items 2, 4, 5, 8, 9, 13, 20, and 21, then proposed the revised version of AGREE Ⅱ for TCM, on which was advised by a group of experts, before consensus on improvements was reached. The results of the first round of expert surveys showed strong agreement, and experts' opinions were adopted into the final version of AGREE Ⅱ for TCM. Conclusion: Based on the characteristics of the TCM CPGs, we adjustment and expansion were made to create AGREE II for TCM. This version is suitable for the assessment of methodological quality of TCM CPGs, capable of providing content support for the standardization of procedures and methods of formulating TCM CPGs.

Combined analysis of whole-exome sequencing and RNA sequencing in type 2 diabetes mellitus patients with thirst and fatigue

BACKGROUND

The principal objective of this study was to gain a better understanding of the mechanisms of type 2 diabetes mellitus (T2DM) patients with fatigue (D-T2DM) through exome and transcriptome sequencing.

METHODS

After whole-exome sequencing on peripheral blood of 6 D-T2DM patients, the consensus mutations were screen out and analyzed by a series of bioinformatics analyses. Then, we combined whole-exome sequencing and transcriptome sequencing results to find the important genes that changed at both the DNA and RNA levels.

RESULTS

The results showed that a total of 265,393 mutation sites were found in D-T2DM patients compared with normal individuals, 235 of which were consensus mutations shared with D-T2DM patients. These genes significantly enriched in HIF-1 signaling pathway and sphingolipid signaling pathway. At the RNA level, a total of 375 genes were identified to be differentially expressed. After the DNA-RNA joint analysis, eight genes were screened that changed at both DNA and RNA levels. Among these genes, FUS and LMNA were related to carbohydrate metabolism, energy metabolism, and mitochondrial function. Subsequently, we predicted the herbs, including Qin Pi and Hei Zhi Ma, that might play a therapeutic role in D-T2DM through the SymMap database.

CONCLUSION

These findings have significant implications for understanding the mechanisms of D-T2DM and provide potential targets for D-T2DM diagnosis and treatment.

Exploring the pathogenesis of type 2 diabetes mellitus intestinal damp-heat syndrome and the therapeutic effect of Gegen Qinlian Decoction from the perspective of exosomal miRNA

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetes is a common, complex, chronic metabolic disease. A randomized, double-blind, placebo-parallel controlled clinical study has shown that Gegen Qinlian Decoction (GQD) can reduce glycosylated hemoglobin in type 2 diabetes mellitus (T2DM) intestinal damp-heat syndrome patients in a dose-dependent manner.

AIM

To explore the pathogenesis of T2DM intestinal damp-heat syndrome and the therapeutic effect of GQD from the perspective of exosomal microRNA (miRNA).

METHODS

Eligible patients were selected and treated with GQD for 3 months to evaluate their clinical efficacy. Effective cases were matched with healthy volunteers, and saliva samples were collected. Exosomal miRNA was extracted from saliva and analyzed by chip sequencing. Subsequently, the function of the differential gene and the signal transduction pathway were analyzed using bioinformatics technology. Finally, three target miRNAs were randomly selected from the T2DM group/healthy group, and two target miRNAs in the T2DM before treatment/after treatment group were randomly selected for qPCR verification. Finally, we conducted a correlation analysis of the miRNAs and clinical indicators. The registration number for this research is ChiCTR-IOR-15006626.

RESULTS

(1) The expression of exosomal miRNA chips showed that there were 14 differentially expressed miRNAs in the T2DM group/healthy group, and 26 differentially expressed miRNAs in the T2DM before treatment/after treatment group. (2) Enrichment results showed that in the T2DM group/healthy group, it was primarily related to cell development, body metabolism, TGF-β, and ErbB signaling pathways. In the T2DM before treatment/after treatment group, it was mainly related to cellular metabolic regulation processes, and insulin, Wnt, and AMPK signaling pathways. (3) The qPCR verification showed that the expressions of hsa-miR-9-5p, hsa-miR-150-5p, and hsa-miR-216b-5p in the T2DM group was higher (P<0.05). Following GQD treatment, hsa-miR-342-3p and hsa-miR-221-3p were significantly downregulated (P<0.05). (4) hsa-miR-9-5p was positively correlated with BMI (P<0.05), and hsa-miR-150-5p was positively correlated with total cholesterol and triglycerides (P<0.05). The GQD efficacy-related gene hsa-miR-342-3p was positively correlated with the patient's initial blood glucose level (P<0.05), and hsa-miR-221-3p was positively correlated with total cholesterol and triglycerides (P<0.05).

CONCLUSION

The exosomal miRNA expression profile and signaling pathways related to T2DM intestinal damp-heat syndrome and the efficacy of GQD were established, which provides an alternative strategy for precision traditional Chinese medicine treatment.

Gegen Qinlian Decoction ameliorates type 2 diabetes osteoporosis via IGFBP3/MAPK/NFATc1 signaling pathway based on cytokine antibody array

BACKGROUND

Osteoporosis affects more than half the patients with type 2 diabetes mellitus (T2DM). Up to data, there is no effective clinical practice in managing type 2 diabetes osteoporosis (T2DOP) because of its complex pathogenesis. Gegen Qinlian Decoction (GQD) has been used for the long-term management of T2DM. However, the underlying mechanism of GQD in the treatment of T2DOP remains unknown.

PURPOSE

To reveal the role of GQD in T2DOP and its potential therapeutic targets in the management of T2DOP.

STUDY DESIGN

The effect of GQD on T2DOP was observed in db/db mice in four groups: model group, GQD low-dose group (GQD-L), GQD high-dose group (GQD-H), and metformin (positive control) group. C57BL/6J mice were used as the negative control group.

METHODS

Quantitative phytochemical analysis of GQD was performed using high-performance liquid chromatography (HPLC). Micro-CT and hematoxylin-eosin (H&E) staining were used to evaluate bone histomorphometry. To screen for candidate targets of GQD, a cytokine antibody array was used, followed by bioinformatics analysis. Quantitative real-time PCR (qRT-PCR) and western blotting (WB) were used to determine expression levels.

RESULTS

The major active components of GQD were confirmed by HPLC. Micro-CT and H&E staining showed that bone mass was significantly increased in the GQD-H group compared with the model group. Antibody arrays revealed that the expression of insulin-like growth factor binding protein 3 (IGFBP3) was elevated in the GQD-H group. The MAPK pathway was identified using bioinformatics analysis. Additionally, the levels of osteoclastogenesis-related genes, including cathepsin K (Ctsk), acid phosphatase 5 (Acp5), matrix metallopeptidase 9 (Mmp9), and ATPase H+ transporting V0 subunit D2 (Atp6v0d2) were significantly decreased in the GQD-H group. Compared with the model group, high-dosage GQD inhibited phosphorylation of extracellular signal-regulated kinases (ERKs) and P38 mitogen-activated protein kinase (MAPK) and the expression of c-Fos and nuclear factor of activated T cells 1 (NFATc1).

CONCLUSION

GQD plays a protective role in T2DOP by upregulating IGFBP3 expression and downregulating the IGFBP3/MAPK/NFATc1 signaling pathway. IGFBP3 in serum may also be a novel biomarker in the treatment of T2DOP. Our current findings not only expand the application of GQD, but also provide a theoretical basis and guidance for T2DOP.

Treatment of type 2 diabetes mellitus using the traditional Chinese medicine Jinlida as an add-on medication: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Numerous randomized controlled trials (RCTs) conducted in China have shown that jinlida granules are a promising traditional Chinese medicine (TCM) for the treatment of persons with type 2 diabetes mellitus (T2DM). Controversial results have been reported in different RCTs. The aim of our study was to evaluate the adjuvant hypoglycemic effect of jinlida granules on persons with T2DM and to explore the source of heterogeneity between these RCTs.

MATERIALS AND METHODS

Medical article databases were individually searched by two authors for RCTs that provided data regarding the effect of jinlida granules in the treatment of T2DM before 1 June 2022. The methodological quality of the included RCTs was comprehensively assessed by two authors. Data from RCTs with low risk of bias were pooled using Stata SE 12.0 (random-effects model). Evidence derived from the meta-analysis will be assessed according to the GRADE system.

RESULTS

Twenty-two RCTs were eventually included in the systematic review and three RCTs with low risk of bias were analyzed in the meta-analysis. Compared with the control groups, significant changes were found in lowering glycosylated hemoglobin a1c (mean difference -0.283 with 95% CI -0.561, -0.004; P=0.046), and were not found in lowering 2-hour postprandial glucose (mean difference -0.314 with 95% CI -1.599, 0.972; P=0.632) and fasting blood glucose (mean difference -0.152 with 95% CI -0.778, -0.474; P=0.634) in the jinlida groups. The GRADE-assessed evidence quality for the outcomes was moderate.

CONCLUSION

The adjuvant hypoglycemic effect of jinlida granules on adult Chinese persons with T2DM was statistically found in lowering HbA1c and was not statistically found in lowering FPG and 2h-PG. Evidence grading should be considered moderate, and the results should be interpreted cautiously. Whether the efficacy of HbA1c-lowering related to clinical significance remains to be investigated in future RCTs. Differences in HbA1c, FPG and 2h-PG at baseline and high risk of bias were important source of heterogeneity between these RCTs. In order to objectively evaluate the efficacy of jinlida granules on T2DM, it is urgently needed that high-quality RCTs evaluating the hypoglycemic effect of jinlida granules in the treatment of qi-yin deficiency pattern T2DM.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42018085135.

Reenvisioning Traditional to Regenerative Therapeutic Advances in Managing Nonalcoholic Fatty Liver Disease in Diabetes Mellitus

Reports indicate the increasing prevalence of liver disorders in diabetes mellitus (DM) patients. Clinically, it has also been revealed that the existence of nonalcoholic fatty liver disease (NAFLD) enhances the incidence of type 2 diabetes mellitus (T2DM), while T2DM exacerbates NAFLD to extremely severe forms of steatohepatitis, cirrhosis, and hepatocellular carcinoma. This implies the coexistence and bidirectional nature of NAFLD and T2DM, which function synergistically to drive adverse consequences in clinical practice. For treatment of such comorbid state, though the existing practices such as lifestyle management, traditional Chinese medicines (TCM), and pharmaceuticals have offered somewhat relief, the debate continues about the optimal therapeutic impacts. Recent developments in the field of tissue engineering have led to a renewed interest in novel biomaterial alternatives such as stem cells. This might be attributable to their differentiation potential towards hepatic and pancreatic lineage. These cellular therapies could be further complemented by platelet-derived biomaterials, TCM formulations, or any specific drug. Based on these abovementioned approaches, we aimed to comprehensively analyze various preclinical and clinical studies from traditional to regenerative therapeutic approaches in managing concomitant NAFLD and T2DM.

Herbalism for Modern Obstetrics

More pregnant and nursing mothers are using herbal remedies than health care providers realize. Lack of familiarity with herbalism in addition to the sparsity of high-quality research for many complementary and alternative medicines are barriers for the western practitioner to engage a patient about herbal therapies. This review provides historical information and available evidence for Traditional Chinese and Western herbal medicines commonly sought by pregnant and nursing mothers. We will review herbs commonly used for: nausea and vomiting, constipation, gestational diabetes, threatened miscarriage, immune system support, parturition preparation, postpartum depression, postpartum bleeding and pain, wound healing, and lactation support.

SYmptom-Based STratification of DiabEtes Mellitus by Renal Function Decline (SYSTEM): A Retrospective Cohort Study and Modeling Assessment

Background: Previous UK Biobank studies showed that symptoms and physical measurements had excellent prediction on long-term clinical outcomes in general population. Symptoms and signs could intuitively and non-invasively predict and monitor disease progression, especially for telemedicine, but related research is limited in diabetes and renal medicine. Methods: This retrospective cohort study aimed to evaluate the predictive power of a symptom-based stratification framework and individual symptoms for diabetes. Three hundred two adult diabetic patients were consecutively sampled from outpatient clinics in Hong Kong for prospective symptom assessment. Demographics and longitudinal measures of biochemical parameters were retrospectively extracted from linked medical records. The association between estimated glomerular filtration rate (GFR) (independent variable) and biochemistry, epidemiological factors, and individual symptoms was assessed by mixed regression analyses. A symptom-based stratification framework of diabetes using symptom clusters was formulated by Delphi consensus method. Akaike information criterion (AIC) and Bayesian information criterion (BIC) were compared between statistical models with different combinations of biochemical, epidemiological, and symptom variables. Results: In the 4.2-year follow-up period, baseline presentation of edema (-1.8 ml/min/1.73m2, 95%CI: -2.5 to -1.2, p < 0.001), epigastric bloating (-0.8 ml/min/1.73m2, 95%CI: -1.4 to -0.2, p = 0.014) and alternating dry and loose stool (-1.1 ml/min/1.73m2, 95%CI: -1.9 to -0.4, p = 0.004) were independently associated with faster annual GFR decline. Eleven symptom clusters were identified from literature, stratifying diabetes predominantly by gastrointestinal phenotypes. Using symptom clusters synchronized by Delphi consensus as the independent variable in statistical models reduced complexity and improved explanatory power when compared to using individual symptoms. Symptom-biologic-epidemiologic combined model had the lowest AIC (4,478 vs. 5,824 vs. 4,966 vs. 7,926) and BIC (4,597 vs. 5,870 vs. 5,065 vs. 8,026) compared to the symptom, symptom-epidemiologic and biologic-epidemiologic models, respectively. Patients co-presenting with a constellation of fatigue, malaise, dry mouth, and dry throat were independently associated with faster annual GFR decline (-1.1 ml/min/1.73m2, 95%CI: -1.9 to -0.2, p = 0.011). Conclusions: Add-on symptom-based diagnosis improves the predictive power on renal function decline among diabetic patients based on key biochemical and epidemiological factors. Dynamic change of symptoms should be considered in clinical practice and research design.

Effective Dose of Rhizoma Coptidis Extract Granules for Type 2 Diabetes Treatment: A Hospital-Based Retrospective Cohort Study

Rhizoma Coptidis is a popular phytomedicine for the treatment of type 2 diabetes in Asia, but its effective dose for diabetes treatment remains confused because of diverse origins. This study aimed to investigate the dose-response effects of Rhizoma Coptidis extract granules (RCEG), produced with standardized quality control, on hypoglycemic effects in patients with type 2 diabetes. We conducted a retrospective analysis of Chang Gung Research Database from January 01, 2008 to November 30, 2017. Outpatients visiting traditional Chinese medicine clinics and receiving RCEG for type 2 diabetes treatment were included. Plasma glucose, lipid, and other parameters were analyzed from 93 patients with a total of 737 visits within 60 weeks. Scatter plots with the LOESS analysis were used to explore the association between RCEG dose and hypoglycemic effect. The minimal effective dose was chosen to divide the study population into the high-dose and low-dose RCEG groups. Non-parametric tests were used for between-group and within-group comparisons. The multivariate nonlinear mixed-effects model was applied to access the effect of treatment length and groups simultaneously on the change of HbA1c and fasting plasma glucose. The “arule” package in R was used to present the network diagram of RCEG and other co-prescriptions. We first discovered a significant relationship between RCEG dose and HbA1c reduction when the dose reached 0.08 g/kg/day or higher. We thus defined 0.08 g/kg/day of RCEG as the minimum effective dose, and a threshold to separate patients into the high-dose (≥0.08 g/kg/d) and low-dose (<0.08 g/kg/d) RCEG groups. In the high-dose RCEG group, a significant decrease in total cholesterol and a trend toward triglyceride reduction were also noted. Patients more effectively responded to RCEG treatment if they had a higher initial HbA1c level, higher heart rates, better liver function tests, and better tolerance to the higher dose and treatment duration of RCEG. In addition, digestive/tonic/dampness draining formulas and blood regulation recipes were two of the most frequent co-prescriptions with RCEG. This study concluded that RCEG at a dose exceeding 0.08 g/kg/d had beneficial effects on glycemic and lipid control, without showing nephro- or hepatotoxicity, in patients with type 2 diabetes.

A comparative study of microbial community and functions of type 2 diabetes mellitus patients with obesity and healthy people

The gut microbiota is crucial in the pathogenesis of type 2 diabetes mellitus (T2DM). However, the metabolism of T2DM patients is not well-understood. We aimed to identify the differences on composition and function of gut microbiota between T2DM patients with obesity and healthy people. In this study, 6 T2DM patients with obesity and 6 healthy volunteers were recruited, and metagenomic approach and bioinformatics analysis methods were used to understand the composition of the gut microbiota and the metabolic network. We found a decrease in the abundance of Firmicutes, Oribacterium, and Paenibacillus; this may be attributed to a possible mechanism and biological basis of T2DM; moreover, we identified three critical bacterial taxa, Bacteroides plebeius, Phascolarctobacterium sp. CAG207, and the order Acidaminococcales that can potentially be used for T2DM treatment. We also revealed the composition of the microbiota through functional annotation based on multiple databases and found that carbohydrate metabolism contributed greatly to the pathogenesis of T2DM. This study helps in elucidating the different metabolic roles of microbes in T2DM patients with obesity.

Use of Traditional Chinese Medicine May Delay the Need for Insulin Treatment in Patients with Type 2 Diabetes: A Population-Based Cohort Study

Objectives: Traditional Chinese medicine (TCM) has been shown to reduce insulin resistance and improve beta cell function in previous studies. The aim of this study was to assess whether the use of TCM can delay the need for insulin therapy in patients with type 2 diabetes. Design: Data on patients with type 2 diabetes who received medical treatment for the first time between 2000 and 2003 were obtained from National Health Insurance Research Database (NHIRD) in Taiwan. Among these patients, those with a cumulative use of TCM of more than 28 days were defined as TCM users, and the others as non-users. Kaplan-Meier analysis was used to evaluate the cumulative risk of initiating insulin therapy. Cox proportional hazards models with and without competing risk events were used to evaluate the association between the use of TCM and insulin therapy. Settings/Location: Data were obtained from National Health Insurance Research Database (NHIRD) in Taiwan. Subjects: Patients with type 2 diabetes who received medical treatment for the first time between 2000 and 2003. Interventions: Among these patients, those with a cumulative use of TCM of more than 28 days were defined as TCM users, and the others as non-users. Outcome measures: After 1:1 propensity score matching, both groups were tracked until the initiation of insulin therapy, death, or the end of 2013. Results: We identified 6524 TCM users and 6524 non-users. The TCM users had a significantly lower risk of insulin initiation in a dose-dependent manner (log-rank test p < 0.001). This effect was consistent across subgroups with different severities of diabetes, and remained significant in competing risk analysis (for TCM users with 28 to 83 days cumulative use, HR 0.78 [0.70-0.87], p < 0.0001; for TCM users with ≥ 84 days cumulative use, HR 0.47 [0.42-0.53], p < 0.0001). Conclusions: The use of TCM in addition to standard diabetes treatment may delay the need for insulin treatment in patients who received medical treatment for type 2 diabetes for the first time. This benefit was strongly dose-dependent and applicable in patients with different severities of diabetes.

Analysis of the Efficacy of Cinnamon for Patients with Diabetes Mellitus Type II Based on Traditional Persian Medicine Syndrome Differentiation: A Randomized Controlled Trial

Background: Conflicting results have been obtained from the studies on the hypoglycemic effect of cinnamon in patients with diabetes mellitus type II (T2DM). Objectives: This research aimed at assessing the effect of applying the syndrome differentiation model based on traditional Persian medicine (TPM) to identify the patients who benefit more from cinnamon supplementation. Methods: This study was a randomized, triple-blind, placebo-controlled trial based on a parallel design. One hundred and forty eligible patients referring to the Diabetes Clinic of Yazd University of Medical Sciences, who were diagnosed with T2DM, were randomly divided into the cinnamon and placebo groups. Then, 500-mg capsules of cinnamon bark powder or placebo were administered to them twice a day for three months. All the participants completed a standard questionnaire for syndrome diagnosis in traditional Persian medicine (TPM). Fasting plasma glucose (FPG), glycated hemoglobin (HbA1C), fasting insulin (FI), and insulin resistance (IR), calorie intake, and physical activity were measured before and after the interventions. The glycemic outcomes were analyzed according to the TPM syndrome. Results: There was no statistically significant difference between the patients’ demographic and clinical features in the two groups. Glycemic indices were improved in patients receiving cinnamon supplementation compared to placebo group (-13.1 ± 1.7, -1.7 ± 1.9, P < 0.001 for change in FPG and -0.27 ± 0.039 vs. 0.001 ± 0.019, P < 0.001 for change in HbA1C respectively). All the outcomes were more improved in the patients with wet syndrome compared to dry ones, which was compatible with Persian syndrome differentiation (P < 0.05). Conclusions: Diabetic patients with wet syndrome based on TPM benefit more form cinnamon supplementation.

Transcriptome Sequencing Analysis of Peripheral Blood of Type 2 Diabetes Mellitus Patients With Thirst and Fatigue

Purpose: The purpose of this study is to explore the differences in transcriptome expression profiles between healthy subjects and type 2 diabetes mellitus patients with thirst and fatigue (D-T2DM) and, in addition, to investigate the possible role of noncoding ribonucleic acids (RNAs) in the pathogenesis of D-T2DM. Methods: We constructed the expression profiles of RNAs by RNA sequencing in the peripheral blood of D-T2DM patients and healthy subjects and analyzed differentially expressed RNAs. Results: Compared with healthy subjects, a total of 469 mRNAs, 776 long non-coding RNAs (lncRNAs), and 21 circular RNAs (circRNAs) were differentially expressed in D-T2DM patients. Furthermore, several genes associated with insulin resistance, inflammation, and mitochondrial dysfunction were identified within the differentially expressed mRNAs. Differentially expressed lncRNAs were primarily involved in biological processes associated with immune responses. In addition, differentially expressed circRNAs may target miRNAs associated with glucose metabolism and mitochondrial function. Conclusions: Our results may bring a new perspective on differential RNA expression involved in the pathogenesis of D-T2DM and promote the development of novel treatments for this disease.

Differing Spontaneous Brain Activity in Healthy Adults with Two Different Body Constitutions: A Resting-State Functional Magnetic Resonance Imaging Study

Traditional Chinese medicine (TCM) practitioners assess body constitution (BC) as a treatment basis for maintaining body homeostasis. We investigated patterns in spontaneous brain activity in different BC groups using resting-state functional magnetic resonance imaging (rsfMRI) and determined the relationship between these patterns and quality of life (QOL). Thirty-two healthy individuals divided into two groups (body constitution questionnaire (BCQ)-gentleness [BCQ-G] and BCQ-deficiency [BCQ-D]) based on the body constitution questionnaire (BCQ) underwent rsfMRI to analyze regional homogeneity (ReHo) and the amplitude of low-frequency fluctuation (ALFF). The World Health Organization Quality of Life Instruments (brief edition) scale was used to evaluate the QOL. The BCQ-G group (n = 18) had significantly greater ReHo values in the right postcentral gyrus and lower ALFF values in the brainstem than the BCQ-D group (n = 14). In the BCQ-D group, decreased ReHo of the postcentral gyrus correlated with better physiological functioning; increased ALFF in the brainstem correlated with poor QOL. BCQ-subgroup analysis revealed a nonsignificant correlation between ReHo and Yang deficiency/phlegm and stasis (Phl & STA). Nonetheless, the BCQ-D group showed a positive correlation between ALFF and Phl & STA in the parahippocampus. This study identified differences between BCQ-G and BCQ-D types of healthy adults based on the rsfMRI analysis. The different BCQ types with varied brain endophenotypes may elucidate individualized TCM treatment strategies.

Evaluating Traditional Chinese Medicine and Herbal Products for the Treatment of Gestational Diabetes Mellitus

Gestational diabetes mellitus is the most common metabolic disorder during pregnancy with health consequences for both lives during and after pregnancy. Studies found that many pregnant women turn to complementary and alternative medicine for health maintenance or symptom relief, such as herbal medicine and acupuncture from traditional Chinese medicine. With the growing popularity of traditional Chinese medicine, we conducted a systemic search in PubMed, Web of Science, and Embase databases on research studies that investigated traditional Chinese medicine during pregnancy. The resultant hits were further searched in relation to all diabetes mellitus. In total, we found three major herbal medicine/herbal products that were associated with glycemic control in gestational diabetes, including Zuo Gui Wan, red raspberry leaves, and Orthosiphon stamineus. We further reviewed them and their relatives in relation to type 2 diabetes mellitus and found more evidence of metabolic benefits. None of the herbal medicine and products examined reported toxicity in the experimental models. Overall, treatments of gestational diabetes by western or alternative interventions are grossly understudied. It is critical to have a standardized protocol when evaluating efficacy of herbal medicine and produce quality results for women and their health-care providers to make informed treatment decisions.

Tangduqing Granules Attenuate Insulin Resistance and Abnormal Lipid Metabolism through the Coordinated Regulation of PPARγ and DGAT2 in Type 2 Diabetic Rats

Insulin resistance (IR) is a vital hallmark of type 2 diabetes mellitus, which is characterized by an impaired ability of insulin to promote glucose uptake and utilization. Lipid deposition is closely associated with impaired insulin sensitivity. PPARγ plays an important role in glucose homeostasis, adipocyte differentiation, and insulin sensitivity. Likewise, DGAT2 also exerts a crucial role in integrating carbohydrate and lipid metabolism in the liver. The present study is aimed at evaluating a Chinese medicinal formula, Tangduqing granules (TDQ), with multifaceted actions against lipid and glucose metabolism disorder and IR of type 2 diabetes. An animal model of type 2 diabetes was developed by high-fat diet feeding plus low-dose streptozotocin injection. After oral administration of TDQ for 5 weeks, the effects on glucose and lipid metabolism and the underlying mechanism were evaluated by biochemical, histological, RT-PCR, and western blotting methods. The results showed that TDQ decreased fasting blood glucose, ameliorated glucose tolerance, and improved IR. Besides, TDQ regulated hyperlipidemia symptoms, decreased serum lipid levels and liver TG, and reduced hepatic steatosis in a type 2 diabetic rat model. Furthermore, TDQ reversed diabetes-induced decrease in the mRNA and protein expression of PPARγ and elevation in the mRNA and protein levels of DGAT2 in the liver. In addition, we showed that interference of TDQ ameliorated palmitate-induced glucose and lipid metabolic abnormalities in HepG2 cells. TDQ are, therefore, a potential Chinese medicinal formula that relieves IR and lipid metabolism disorder might be through promotion of PPARγ and decrease of DGAT2 expression.

UPLC-Q/TOF-MS-Based Serum Metabolomics Reveals Hypoglycemic Effects of Rehmannia glutinosa, Coptis chinensis and Their Combination on High-Fat-Diet-Induced Diabetes in KK-Ay Mice

Diabetes is a worldwide severe health issue which causes various complications. This study aimed to evaluate the hypoglycemic effects of Rehmannia glutinosa (RG), Coptis chinensis (CC) alone and their combination on high-fat-diet-induced diabetes in mice via biochemical assays and UPLC-Q/TOF-MS-based serum metabolomic analysis. Diabetic KK-Ay mice were induced by high-fat diet and treated for eight weeks, separately with RG, CC and their combination and the positive control drug metformin. Administration of RG and CC alone, and their combination could decrease the fasting blood glucose level, ameliorate the tolerance of glucose, and recover the levels of total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) in sera of diabetic mice. Orthogonal partial least squares discriminant analysis (OPLS-DA) on serum metabolomes revealed that 79 ESI⁺ and 76 ESI⁻ metabolites were changed by diabetes mellitus (DM) compared to the normal control. Heatmaps on these diabetes-related metabolites showed that CC and RG/CC were clustered closer with the normal control, indicating that they had the better antidiabetic effects at the metabolite level. Fifteen of the differential metabolites in DM serum were annotated and their related metabolic pathways were lipid metabolism. These data suggested that RG and CC alone and in combination treatment had the antidiabetic activity in lowering glycemia and improving lipid metabolism. UPLC-Q/TOF-MS-based metabolomics shed light on the differential metabolite effects of RG and CC in DM treatment. However, it should be noted that some differential metabolites were possibly generated or not detected due to our groupwise run order, which possibly contributed to or covered the group difference in our experiment. They need to be further discriminated in the future work.

Tangshen formula improves inflammation in renal tissue of diabetic nephropathy through SIRT1/NF-κB pathway

The present study investigated the mechanism underlying the anti-inflammatory effects of Tangshen formula (TS) in Sprague Dawley (SD) rats with diabetic nephropathy (DN). A rat model of DN was established by intraperitoneal injection of 1% (40 mg/kg) streptozotocin and administration of a high fat and glucose diet. Subsequently, SD rats were randomly divided into six groups (n=8): A DN group, a valsartan group, a high-dose TS group, a middle-dose TS group, a low-dose TS group and a control group with normal SD rats. Once rats received their allocated treatment for 12 weeks, body weight and kidney weight were recorded, and fasting blood glucose, ratio of urinary protein, β₂-MG and creatinine clearance rate were determined. Furthermore, hemodynamic indices, including plasma viscosity and whole blood reduction viscosity were detected. Immunohistochemistry was used to detect the infiltration of macrophages in the kidneys of rats. Reverse transcription-quantitative polymerase chain reaction and western blotting were performed to investigate the activation; mRNA and protein expression levels of monocyte chemoattractant protein-1 (MCP-1), macrophage migration inhibitory factor (MIF), nuclear factor-κB (NF-κB) and sirtuin-1 (SIRT1) in each group. In comparison with the DN group, each biochemical indicator of rats in the high-dose TS group was significantly decreased (P<0.05). Blood viscosity in each treatment group was significantly decreased when compared with the DN group (P<0.01). Hematoxylin and eosin staining indicated that the infiltration of macrophages was significantly decreased in the high-dose TS group when compared with the DN group (P<0.01). mRNA and protein expression levels of MCP-1 and MIF in the high-dose TS group were significantly decreased when compared with the DN group (P<0.05). In the treatment groups, SITR1 mRNA expression levels were significantly increased, whereas the mRNA expression levels of NF-κB were significantly decreased (P<0.01). Western blotting results indicated a significant decrease in the protein expression levels of acetylated NF-κB in the treatment groups when compared with the DN group (P<0.01) and the propensity of protein expression of the other inflammatory factors were consistent with the mRNA findings. The results of the high-dose TS group were similar to those of the valsartan group. The present study indicates that TS was able to activate SITR1, which lead to NF-κB deacetylation, thus reducing the release of inflammatory factors and decreasing the severity of diabetic nephropathy.

Stroke in Traditional Korean Medicine: A Nine-Year Multicentre Community-Based Study in South Korea

In Korea, patients with stroke are commonly treated using traditional Korean medicine (TKM). The aim of this study was to provide information on the clinical characteristics of the pattern identification (PI) of stroke used in TKM. Stroke patients admitted to 15 TKM university hospitals from April 2005 through December 2013 were evaluated. The measured variables included the following factors as they related to the PI: (a) stroke etiology; (b) distribution of symptoms/signs; (c) physical characteristics and lifestyle parameters; (d) medical history; and (e) stroke-related laboratory results. Among 4912 stroke patients, 3466 patients received the same PI by two experts with the following distribution: Qi-Deficiency pattern (n = 810), Fire-Heat (FH) pattern (n = 1031), Dampness-Phlegm (DP) pattern (n = 1127), and Yin-Deficiency pattern (n = 498). Approximately 89.9% of subjects enrolled in this study had cerebral infarction. Some of specific symptoms were related to each type of PI, and obese phenotypes and blood lipids were significantly related to DP and FH. These results showed the characteristics of each type of PI and should lead to the standardization of diagnosis for stroke in TKM.

Traditional Chinese medicines in the management of cardiovascular diseases: a comprehensive systematic review

AIMS

The aim was to perform a systematic review of the efficacy of traditional Chinese medicines (TCM) in cardiovascular disease.

METHODS

Electronic databases were searched up to 11 November 2015 for all randomized-controlled trials evaluating the effect of TCM in hypertension, ischaemic stroke, heart failure, coronary heart disease and type 2 diabetes mellitus. Pooled odds ratios (ORs) were calculated using a fixed-effects model.

RESULTS

Four hypertension studies were eligible for statistical analysis and included 133 patients receiving TCM and 130 control patients. There were significant reductions in systolic blood pressure in patients receiving TCM, comparable to results achieved with pharmaceutical medicines. An OR of 3.781 (95% confidence interval 2.392, 5.977; P = 0.000) was observed for the anti-hypertensive effect of TCM. Significant heterogeneity was present (P = 0.011), with a tendency towards publication bias that did not reach significance (P = 0.05275). Outcome measures for other cardiovascular diseases were inconsistent.

CONCLUSIONS

Certain TCM compounds appear to have significant anti-hypertensive effects, and although some are associated in some studies with improved outcomes in coronary heart disease, heart failure and type 2 diabetes mellitus, the data are inconsistent and will require large-scale randomized-controlled trials to allow full evaluation of any potential therapeutic benefit in these areas.

Global Mapping of Traditional Chinese Medicine into Bioactivity Space and Pathways Annotation Improves Mechanistic Understanding and Discovers Relationships between Therapeutic Action (Sub)classes

Traditional Chinese medicine (TCM) still needs more scientific rationale to be proven for it to be accepted further in the West. We are now in the position to propose computational hypotheses for the mode-of-actions (MOAs) of 45 TCM therapeutic action (sub)classes from in silico target prediction algorithms, whose target was later annotated with Kyoto Encyclopedia of Genes and Genomes pathway, and to discover the relationship between them by generating a hierarchical clustering. The results of 10,749 TCM compounds showed 183 enriched targets and 99 enriched pathways from Estimation Score ≤ 0 and ≥ 5% of compounds/targets in a (sub)class. The MOA of a (sub)class was established from supporting literature. Overall, the most frequent top three enriched targets/pathways were immune-related targets such as tyrosine-protein phosphatase nonreceptor type 2 (PTPN2) and digestive system such as mineral absorption. We found two major protein families, G-protein coupled receptor (GPCR), and protein kinase family contributed to the diversity of the bioactivity space, while digestive system was consistently annotated pathway motif, which agreed with the important treatment principle of TCM, “the foundation of acquired constitution” that includes spleen and stomach. In short, the TCM (sub)classes, in many cases share similar targets/pathways despite having different indications.

Effect of Rhizoma coptidis (Huang Lian) on Treating Diabetes Mellitus

The rapidly increasing diabetes mellitus (DM) is becoming a major public health issue globally; considerable progress has been made in the field of western hypoglycemic drug and insulin, but some shortages still exist. As one of the most important parts in complementary and alternative therapies, traditional Chinese medicine (TCM) performs a good clinical practice and is showing a bright future in the treatment of DM. TCM therapy has certain advantages of less toxicity and/or side effects, and Chinese herbal medicine which usually contains various active ingredients could provide multiple therapeutic effects. Huang Lian (Rhizoma coptidis, RC) is a herb frequently used in many traditional formulas for properties of “clearing damp-heat, quenching fire, and counteracting poison” in Asia for centuries. In this review, we summarize the application of RC in the treatment of DM from two aspects of contents. Firstly, theoretical principles are explained, including the properties and related records about RC in ancient references and modern pharmacological researches and pharmacokinetics on RC and its active components. Secondly, the clinical application of RC is mainly reviewed, such as applicable stage and syndrome, the reasonable dose range, the preparation formulations, and the toxicity and/or side effects and solutions to its adverse actions. This review provides scientific evidence about the effective components, pharmacological researches, and toxicity of RC, as well as introducing traditional Chinese medical theory and clinical experience, in order to guide clinician to use RC more suitably and reasonably in the clinical practice.

Application of berberine on treating type 2 diabetes mellitus

Traditional Chinese medicine (TCM) performs a good clinical practice and is showing a bright future in the treatment of diabetes mellitus (DM). TCM treatment has certain advantages of less toxicity and/or side effects, and herbs could provide multiple therapeutic effects. Berberine (BBR) is a classical natural medicine. In this review, we summarize the application of BBR in the treatment of DM from two aspects. First, modern pharmacological effects of BBR on glucose metabolism are summarized, such as improving insulin resistance, promoting insulin secretion, inhibiting gluconeogenesis in liver, stimulating glycolysis in peripheral tissue cells, modulating gut microbiota, reducing intestinal absorption of glucose, and regulating lipid metabolism. BBR is used to treat diabetic nephropathy (DPN), diabetic neuropathy (DN), and diabetic cardiomyopathy due to its antioxidant and anti-inflammatory activities. Second, the clinical application of BBR is reviewed, such as listing some clinical trials on the effectiveness and safety of BBR, explaining applicable stage and syndrome, the reasonable dose and dose formulation, and the toxicity and/or side effects. This review provides scientific evidence about BBR, as well as introducing some traditional Chinese medical theory and clinical experience, in order to guide clinician to use BBR more suitably and reasonably.

Diabetes Mellitus, Cognitive Impairment, and Traditional Chinese Medicine

Diabetes mellitus (DM) is a metabolic disorder affecting a large number of people worldwide. Numerous studies have demonstrated that DM can cause damage to multiple systems, leading to complications such as heart disease, cancer, and cerebrovascular disorders. Numerous epidemiological studies have shown that DM is closely associated with dementia and cognition dysfunction, with recent research focusing on the role of DM-mediated cerebrovascular damage in dementia. Despite the therapeutic benefits of antidiabetic agents for the treatment of DM-mediated cognitive dysfunction, most of these pharmaceutical agents are associated with various undesirable side-effects and their long-term benefits are therefore in doubt. Early evidence exists to support the use of traditional Chinese medicine (TCM) interventions, which tend to have minimal toxicity and side-effects. More importantly, these TCM interventions appear to offer significant effects in reducing DM-related complications beyond blood glucose control. However, more research is needed to further validate these claims and to explore their relevant mechanisms of action. The aims of this paper are (1) to provide an updated overview on the association between DM and cognitive dysfunction and (2) to review the scientific evidence underpinning the use of TCM interventions for the treatment and prevention of DM-induced cognitive dysfunction and dementia.