The Clinical Efficacy and Safety of the Sahastara Remedy versus Diclofenac in the Treatment of Osteoarthritis of the Knee: A Double-Blind, Randomized, and Controlled Trial

Hydroethanolic Leaf Extract of Cordia vignei Hutch and Dalziel Inhibits Carrageenan-Induced Foot Oedema in Chicks, Prostaglandin E2-Induced Paw Oedema in Mice, and Bradykinin-Induced Paw Oedema in Mice

Background

Cordia vignei Hutch and Dalziel (Fam. Boraginaceae) is a woody plant found in west tropical Africa. The aim of this research is to find out if the leaf extract of this plant prevents oedema in animal models.

Methods

(a) Inflammation was induced in the animals by injecting 100 µl of 2% lambda carrageenan into the subplantar tissue of the right footpads of 7-day-old chicks 1 h before or after oral administration of 30-300 mgkg-1 CVE. Oedema was measured for 5 h using the water displacement method. (b) Oedema was induced in ICR mice by subplantar injection of prostaglandin E2 (PGE2) (50 µl of 1 nM) 30 minutes before or after CVE administration. Oedema was measured for 3 h. (c) Oedema was induced in ICR mice by subplantar injection of bradykinin (BK) (10 nmol/paw) 30 min before or after administration of extract.

Results

We found that CVE significantly (P < 0.05) prevented inflammation that was induced by injecting carrageenan into the footpads of the chicks. Also, we observed that CVE prevented inflammation produced by injecting PGE2 into the subplantar tissue of mice. Finally, we also report that CVE prevented inflammation produced by injecting BK into the subplantar tissues of mice. All these effects were observed in both preventive and curative protocols.

Conclusion

We conclude that Cordia vignei leaf extract has potential anti-inflammatory activity.

A Meta-Analysis of the Impact of Nutritional Supplementation on Osteoarthritis Symptoms

Conflicting evidence exists concerning the effects of nutrient intake in osteoarthritis (OA). A systematic literature review and meta-analysis were performed using PubMed, EMBASE, and Cochrane Library up to November 2021 to assess the effects of nutrients on pain, stiffness, function, quality of life, and inflammation markers. We obtained 52 references including 50 on knee OA. Twelve studies compared 724 curcumin patients and 714 controls. Using the standardized mean difference, improvement was significant with regard to pain and function in the curcumin group compared to placebo, but not with active treatment (i.e., nonsteroidal anti-inflammatory drugs, chondroitin, or paracetamol). Three studies assessed the effects of ginger on OA symptoms in 166 patients compared to 164 placebo controls. Pain was the only clinical parameter that significantly decreased. Vitamin D supplementation caused a significant decrease in pain and function. Omega-3 and vitamin E caused no changes in OA parameters. Herbal formulations effects were significant only for stiffness compared to placebo, but not with active treatment. A significant decrease in inflammatory markers was found, especially with ginger. Thus, curcumin and ginger supplementation can have a favorable impact on knee OA symptoms. Other studies are needed to better assess the effects of omega-3 and vitamin D.

Osteoarthritis complications and the recent therapeutic approaches

The accelerated prevalence of osteoarthritis (OA) disease worldwide and the lack of convenient management led to the frequent search for unprecedented and specific treatment approaches. OA patients usually suffer from many annoying complications that negatively influence their quality of life, especially in the elderly. Articular erosions may lead eventually to the loss of joint function as a whole which occurs over time according to the risk factors presented in each case and the grade of the disease. Conventional therapies are advancing, showing most appropriate results but still greatly associated with many adverse effects and have restricted curative actions as well. Hence, novel management tools are usually required. In this review, we summarized the recent approaches in OA treatment and the role of natural products, dietary supplements and nanogold application in OA treatment to provide new research tracks for more therapeutic opportunities to those who are in care in this field.

Validation of an HPLC method for quantification of anti-inflammatory markers in an ethanolic extract of Sahastara and its anti-inflammatory activity in vitro

Background and purpose:

Sahastara (SHT) is a traditional Thai medicine for the treatment of musculoskeletal and joint pain. It consists of 21 plant components. A previous study demonstrated the anti-inflammatory activity of SHT on inhibition of nitric oxide production and prostaglandin E₂ (PGE₂) production, however, inhibitory effects on tumor necrosis factor-alpha (TNF-α) has not been reported. In this study, we evaluated the anti-inflammatory activity of SHT on inhibitory effects on TNF-α and PGE₂ production and presented an analytical method for validation of SHT.

Experimental approach:

Anti-inflammatory activity was evaluated by inhibitory activity on TNF-α and PGE₂ production in RAW264.7 cells. The validated procedure was conducted according to ICH guidelines. The validated parameters were specificity/selectivity, linearity, range, the limit of detection (LOD), and limit of quantitation (LOQ).

Findings/Results:

Ethanolic extract of SHT exerted inhibitory activity on PGE₂ production in RAW264.7 cells with IC₅₀ 16.97 ± 1.16 μg/mL. Myristica frangrans seed extract showed the highest inhibitory activity on PGE₂ production. Piper retrofractum extract showed the highest inhibitory activity on TNF-α production. For the HPLC method, all validated parameters complied with standard requirements. Each analyzed peak showed good selectivity with a baseline resolution greater than 1.51. The linearity of all compounds was > 0.999. The % recovery of all compounds was within 98.0-102.0%. The precision of all compounds was less than 2.0% CV.

Conclusion and implications:

Ethanolic extracts of SHT possess anti-inflammatory activity by inhibition of TNF-α and PGE₂ production in vitro. This study provides support for the traditional use of SHT. The validated results showed good specificity/selectivity, linearity, precision, and accuracy with appropriate LOD and LOQ. This study is the first report on the validation of the HPLC method of SHT for use as quality control of the SHT extract.

Can Medical Cannabis Therapies be Cost-Effective in the Non-Surgical Management of Chronic Knee Pain?

Introduction:

Chronic knee pain is a common musculoskeletal condition, which usually leads to decreased quality of life and a substantial financial burden. Various non-surgical treatments have been developed to relieve pain, restore function and delay surgical intervention. Research on the benefits of medical cannabis (MC) is emerging supporting its use for chronic pain conditions. The purpose of this study was to evaluate the cost-effectiveness of MC compared to current non-surgical therapies for chronic knee pain conditions.

Methods:

We conducted a cost-utility analysis from a Canadian, single payer perspective and compared various MC therapies (oils, soft gels and dried flowers at different daily doses) to bracing, glucosamine, pharmaceutical-grade chondroitin oral non-steroidal anti-inflammatory drugs (NSAIDs), and opioids. We estimated the quality-adjusted life years (QALYs) gained with each treatment over 1 year and calculated incremental cost-utility ratios (ICURs) using both the mean and median estimates for costs and utilities gained across the range of reported values. The final ICURs were compared to willingness-to-pay (WTP) thresholds of $66 714, $133 428 and $200 141 Canadian dollars (CAD) per QALY gained.

Results:

Regardless of the estimates used (mean or median), both MC oils and soft gels at both the minimal and maximal recommended daily doses were cost-effective compared to all current knee pain therapies at the lowest WTP threshold. Dried flowers were only cost-effective up to a certain dosage (0.75 and 1 g/day based on mean and median estimates, respectively), but all dosages were cost-effective when the WTP was increased to $133 428/QALY gained.

Conclusion:

Our study showed that MC may be a cost-effective strategy in the management of chronic knee pain; however, the evidence on the medical use of cannabis is limited and predominantly low-quality. Additional trials on MC are definitely needed, specifically in patients with chronic knee pain.

Efficacy and Safety of Sahastara Remedy Extract Capsule in Primary Knee Osteoarthritis: A Randomized Double-Blinded Active-Controlled Trial

Sahastara (SHT) remedy is a Thai traditional medicine described in the Thai National List of Essential Medicine (NLEM) for the relief of muscle pain. The purpose of this study was to investigate the efficacy and safety of SHT remedy extract capsule for treating primary OA. A phase 2, double-blind, randomized, and controlled trial study was used to determine the clinical efficacy and safety of SHT in comparison with diclofenac for the treatment of knee OA. The outcome of reduce pain was measured from VAS, 100 meter time walk, and the WOMAC score of day 14 and day 28 which should reduce significantly when compared with day 0 and should be equal with or better than diclofenac. Blood pressure and blood chemistry values at day 14 and day 28 did not change when compared with day 0. The results found that SHT remedy ethanolic extract capsule can reduce all OA knee scores at day 14 and day 28 significantly when compared with day 0 and also no significant difference with diclofenac (P > 0.05). The SHT also showed safety values on blood pressure and blood chemistry. The SHT was observed that it had no serious side effect. The results of this study are the first report of using the SHT ethanolic extract capsule in the treatment of primary osteoarthritis of the knee. It can be recommended as an anti-inflammatory herbal drug for reducing pain in knee osteoarthritis patients.

Pharmacokinetics of piperine after oral administration of Sahastara remedy capsules in healthy volunteers

Background and purpose:

To investigate the pharmacokinetics of piperine after single oral doses of capsules containing Sahastara (SHT) remedy dried ethanolic extracts in healthy Thai volunteers.

Experimental approach:

Twenty-four healthy volunteers were divided into two dosage groups. They received a single oral dose of SHT remedy extract capsules of 100 or 200 mg. Blood was collected at time intervals of 0, 0.5, 1, 2, 4, 6, 8, 12, 24, and 48 h. Acute clinical safety was monitored by complete physical examination and laboratory tests during the study period. Piperine concentration in blood and urine was determined by liquid chromatography tandem-mass spectrometry.

Findings/Results:

No serious adverse events were detected, only one volunteer had abdominal pain that was self-limiting. The pharmacokinetics of piperine following SHT remedy extract capsule administration demonstrated a mean peak concentration (C_max) of piperine of 3.77 μg/mL and 6.59 μg/mL after dosing with 100 and 200 mg, respectively. Interestingly, a secondary maximum concentration of piperine was observed in this study, which might be related to enterohepatic recirculation. Negligible amounts of unchanged piperine were detected in urine.

Conclusion and implication:

The systemic exposure of piperine after SHT remedy ethanolic extract demonstrated dose proportionality after single oral dosing of 100-200 mg. Piperine was detectable in plasma for at least 48 h with evidence of enterohepatic recirculation. Metabolism and excretion profiles of piperine after administration of SHT remedy extract capsule need to be further explored for phytopharmaceutical product development.

Application of film-forming solution as a transdermal delivery system of piperine-rich herbal mixture extract for anti-inflammation

Piperine-rich herbal mixture (PHM) used in this study is a traditional Thai medicine that contains 21 oriental herbs. It is called "Sahastara remedy" and is officially included in the Thai National List of Essential Medicine since A.D. 2011. PHM has been used orally to relieve muscle and bone pains. It contains Piper nigrum fruits as a major constituent and also Piper retrofractum fruits, PHM thus has anti-inflammatory activities that mostly come from the bioactivities of piperine consisting of these pepper fruits. Unfortunately, PHM usually causes gastrointestinal side effects. Consequently, a topical product containing an alcoholic extract of PHM (PHM-E), i.e., film-forming solution (FFS) was developed to overcome this drawback. The aims of this study were to investigate the anti-inflammatory activity of PHM-E, to evaluate physicochemical properties and the anti-inflammatory activity of FFS containing PHM-E (PHM-E FFS). Anti-inflammatory activities of PHM-E were investigated in the RAW 264.7 cells. Physicochemical properties, in vitro toxicities and anti-inflammatory activities of PHM-E FFS including its dry film (PHM-E film) were determined. PHM-E showed anti-inflammatory activities with dose dependent manners via inhibition of nitric oxide and prostaglandin E₂ production by the RAW 264.7 cells and promotion of the cell phenotype polarization from M1 to M2. PHM-E FFS had low viscosity and exhibited the Newtonian behavior. It provided elastic PHM-E film with low tensile strength. The release profile of piperine from PHM-E film followed a zero-kinetic model. PHM-E FFS demonstrated compatibility with the skin cells, minimal ocular irritant when accidentally splashing into the eye and moderate-to-high potency for inhibition of inflammatory symptoms in the rats. PHM-E FFS thus had potential for use in the further clinical study to investigate its efficacy and safety in patients.

The role of Piper chaba Hunt. and its pure compound, piperine, on TRPV1 activation and adjuvant effect

Background

Piper chaba Hunt. is used as an ingredient in Thai traditional preparation for arthritis. Its isolated compound is piperine which shows anti-inflammatory activity. Piperine produces a burning sensation because it activates TRPV1 receptor. The TRPV1 activation involved with the analgesic and adjuvant effect. P. chaba Hunt. has not been reported about TRPV1 activation and adjuvant effect. The aim of this study was to investigate the effect of P. chaba extract and piperine on TRPV1 receptor, which is considered as a target for analgesic and their adjuvant effects to support the development of an analgesic drug from herbal medicine.

Methods

The effect of P. chaba extract and piperine on HEK cells expressing TRPV1 channel was examined by calcium imaging assay. Adjuvant effects of P. chaba extract and piperine were investigated by a fluorescein isothiocyanate (FITC)-induced contact hypersensitivity (CHS) model in mice.

Results

P. chaba extract induced calcium influx with EC₅₀ value of 0.67 μg/ml. Piperine induced calcium influx with EC₅₀ value of 0.31 μg/ml or 1.08 μM. For mouse CHS model, we found that 1% piperine, 5% piperine, 1% P. chaba extract and 5% P. chaba extract significantly enhanced sensitization to FITC as revealed by ear swelling responses.

Conclusion

P. chaba extract and piperine activated TRPV1 channel and enhanced contact sensitization to FITC.

Potential in vitro anti-allergic, anti-inflammatory and cytotoxic activities of ethanolic extract of Baliospermum montanum root, its major components and a validated HPLC method

Background

The root of Baliospermum montanum has been used as an ingredient of traditional Thai medicines for the treatments of several diseases including itching eczema, muscle and joint inflammation, and cancer. Few studies have been done on phytochemical components of this root. In this study, we isolated major compounds of the crude ethanolic extract of B. montanum root and developed and validated a high performance liquid chromatographic (HPLC) method for the determination of its major components. We then investigated anti-allergic, anti-inflammatory and cytotoxic activities of the extract.

Methods

The aims of this study were to investigate in vitro activities including inhibitory effect of β-hexosaminidase released from RBL-2H3 cells, inhibition of nitric oxide (NO) production from RAW 264.7 cells and cytotoxic activity against cancerous liver cell lines (HepG2 and KKU M156) by using sulforhodamine B (SRB) assay. Isolation of major components was conducted by using column chromatographic method. Isolated major compounds were analyzed by using high performance liquid chromatography (HPLC).

Results

The crude extract exhibited the highest cytotoxic activity, with IC₅₀ less than 1 μg/mL, while its anti-allergy and anti-inflammation were also potent with IC₅₀ less than 6 μg/mL. Three propiophenones isolated from B. montanum root exhibited moderate cytotoxic activities (IC₅₀ > 20 μg/mL). Two of the propiophenones found were major components that can be detected by HPLC. The developed and validated HPLC method showed good accuracy, precision, and linearity.

Conclusion

The results of this study suggested that ethanolic extract of of B.montanum root can be a potential source of anti-allergy, anti-inflammation, and anti-cancer compounds. The isolated compounds can serve as markers when B. montanum is used in herbal remedies but not as overall responsive markers. The HPLC method developed may be useful for quality control in the production of the extract and for further formulation developments. However, investigation of several associated biological activities is necessary before the development can proceed further. Minor active compounds should be isolated and a more sensitive analytical method should be developed to detail the key responsive components of the ethanolic extract of B. montanum root.

Electronic supplementary material

The online version of this article (10.1186/s12906-019-2449-0) contains supplementary material, which is available to authorized users.

Hepatotoxicity of Nonsteroidal Anti-Inflammatory Drugs: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most widely used medication in several countries, including Thailand. NSAIDs have been associated with hepatic side effects; however, the frequency of these side effects is uncertain.

AIM OF THE REVIEW

To systematically review published literature on randomized, controlled trials that assessed the risk of clinically significant hepatotoxicity associated with NSAIDs.

METHODS

Searches of bibliographic databases EMBASE, PubMed, and the Cochrane Library were conducted up to July 30, 2016, to identify randomized controlled trials of ibuprofen, naproxen, diclofenac, piroxicam, meloxicam, mefenamic acid, indomethacin, celecoxib, and etoricoxib in adults with any disease that provide information on hepatotoxicity outcomes.

RESULTS

Among the 698 studies, 18 studies met the selection criteria. However, only 8 studies regarding three NSAIDs (celecoxib, etoricoxib, and diclofenac) demonstrated clinically significant hepatotoxic evidence based on hepatotoxicity justification criteria. Of all the hepatotoxicity events found from the above-mentioned three NSAIDs, diclofenac had the highest proportion, which ranged from 0.015 to 4.3 (×10^-2), followed by celecoxib, which ranged from 0.13 to 0.38 (×10^-2), and etoricoxib, which ranged from 0.005 to 0.930 (×10^-2).

CONCLUSION

Diclofenac had higher rates of hepatotoxic evidence compared to other NSAIDs. Hepatotoxic evidence is mostly demonstrated as aminotransferase elevation, while liver-related hospitalization or discontinuation was very low.

IL-1β-induced modulation of gene expression profile in human dermal fibroblasts: the effects of Thai herbal Sahatsatara formula, piperine and gallic acid possessing antioxidant properties

Background

Pain is the main symptom of most musculoskeletal disorders and can be caused by inflammation in association with oxidative stress. Thai herbal Sahatsatara formula (STF), a polyherbal formula, has been traditionally used for relieving muscle pain and limb numbness. This study aimed to investigate biologically active compounds of STF and its pharmacological effects related to antioxidant and anti-inflammatory activities.

Methods

The identification of possibly active compounds of STF was performed by high performance liquid chromatography (HPLC). Moreover, this study also assessed the free radical scavenging activities of STF and its components using DPPH radical scavenging assay and their inhibitory effects on IL-1β-induced intracellular reactive oxygen species (ROS) formation in primary human dermal fibroblasts (NHDFs) using DCFDA-flow cytometry analysis. Modulation of human gene expression by STF and its active compounds was investigated by microarray analyzed through Gene Ontology (GO) classification and pathway enrichment analysis.

Results

HPLC analysis has revealed the presence of gallic acid (GA) and piperine (PP) as the major compounds in STF extracts. Our finding discovered that STF and its active compounds (GA and PP) yielded free radical scavenging activities and abilities to inhibit IL-1β-induced cellular ROS formation in NHDFs. Furthermore, microarray analysis demonstrated that a total of 84 genes (54 upregulated and 30 downregulated) were significantly affected by IL-1β involved in inflammatory cytokines, chemokines, transcription factors, cell adhesion molecules and other immunomodulators participating in NF-κB signaling. The significantly upregulated genes in IL-1β-treated in NHDFs participate in interleukin and cholecystokinin (CCRK) signaling pathways. The GO analysis of the target genes showed that all test compounds including indomethacin, STF and its active compounds, can downregulate the genes involved in NF-кB signaling pathway in IL-1β-treated NHDFs compared to the cells treated with IL-1β alone.

Conclusions

STF and its active compounds possessing antioxidant actions can modulate the effects of IL-1β-mediated alteration of gene expression profiles associated with inflammatory signaling in NHDFs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-016-1515-0) contains supplementary material, which is available to authorized users.