Chinese traditional medicine (GuiZhi-ShaoYao-ZhiMu decoction) as an add-on medication to methotrexate for rheumatoid arthritis: a meta-analysis of randomized clinical trials

Guizhi Shaoyao Zhimu Decoction ameliorates gouty arthritis in rats via altering gut microbiota and improving metabolic profile

BACKGROUND

The incidence of gouty arthritis (GA) has gradually increased, and modern drug therapies have obvious side effects. Guizhi Shaoyao Zhimu Decoction (GSZD), a classic prescription in Traditional Chinese Medicine for treating various osteoarthritis, has shown significant advantages in curing GA.

PURPOSE

To verify the therapeutic effect of GSZD on GA and investigate its potential pharmacological mechanism via integrated analysis of the gut microbiota and serum metabolites for the first time.

METHODS

The chemical composition of GSZD was determined using UPLC-MS. The GA rat model was established by the induction of a high-purine diet combined with local injection. We examined the effects and mechanisms of GSZD after 21 d using enzyme-linked immunosorbent assays, 16S rRNA, and non-targeted metabolomics. Finally, correlation analysis and validation experiment were performed to explore the association among the gut microbiota, serum metabolites, and GA-related clinical indices.

RESULTS

In total, 19 compounds were identified as GSZD. High-purine feedstuff with local injection-induced arthroceles were significantly attenuated after GSZD treatment. GSZD improved bone erosion and reduced the serum levels of inflammatory factors (lipopolysaccharide, tumor cell necrosis factor-α, and interleukin) and key indicators of GA (uric acid). 16S rRNA analysis indicated that GSZD-treated GA rats exhibited differences in the composition of the gut microbiota. The abundance of flora involved in uric acid transport, including Lactobacillus, Ruminococcaceae, and Turicibacter, was elevated to various degrees, whereas the abundance of bacteria involved in inflammatory responses, such as Blautia, was markedly reduced after treatment. Moreover, serum metabolite profiles revealed 27 different metabolites associated with the amelioration of GA, which primarily included fatty acids, glycerophospholipids, purine metabolism, amino acids, and bile acids, as well as primary metabolic pathways, such as glycerophospholipid metabolism and alanine. Finally, correlation analysis of the heat maps and validation experiment demonstrated a close relationship among inflammatory cytokines, gut microbial phylotypes, and metabolic parameters.

CONCLUSION

This study demonstrated that GSZD could modulate the gut microbiota and serum metabolic homeostasis to treat GA. In addition, the application of gut microbiota and serum metabolomics correlation analyses sheds light on the mechanism of Traditional Chinese Medicine compounds in the treatment of bone diseases.

Rheumatoid Arthritis Has Won the Battle but Not the War: How Many Joints Will We Save Tomorrow?

Rheumatoid arthritis refers to joint diseases of unclear etiology whose final stages can lead to unbearable pain and complete immobility of the affected joints. As one of the most widely known diseases of the joints, it serves as a study target for a large number of research groups and pharmaceutical companies. Modern treatment with anti-inflammatory drugs, including janus kinase (JAK) inhibitors, monoclonal antibodies, and botanicals (polyphenols, glycosides, alkaloids, etc.) has achieved some success and hope for improving the course of the disease. However, existing drugs against RA have a number of side effects which push researchers to elaborate on more selective and effective drug candidates. The avant-garde of research, which aims to develop treatment of rheumatoid arthritis using antisense oligonucleotides along with nonsteroidal drugs and corticosteroids against inflammation, increases the chances of success and expands the arsenal of drugs. The primary goal in the treatment of this disease is to find therapies that allow patients with rheumatoid arthritis to move their joints without pain. The main purpose of this review is to show the victories and challenges for the treatment of rheumatoid arthritis and the tortuous but promising path of research that aims to help patients experience the joy of freely moving joints without pain.

Guizhi Shaoyao Zhimu granules attenuate bone destruction in mice with collagen-induced arthritis by promoting mitophagy of osteoclast precursors to inhibit osteoclastogenesis

BACKGROUND

Guizhi Shaoyao Zhimu decoction, a traditional Chinese medicine formula used empirically for the treatment of rheumatoid arthritis (RA), has been shown to alleviate bone destruction in rats with collagen-induced arthritis (CIA).

PURPOSE

The aim of this study is to characterize the effects of Guizhi Shaoyao Zhimu granules (GSZGs) on bone destruction in RA and the underlying mechanism.

STUDY DESIGN

A CIA arthritis model using DBA/1 mice. The animals were divided into a normal group; CIA model group; low, medium, and high-dose GSZG groups (3, 6, and 9 g/kg/day); and a methotrexate group (1.14 mg/kg/w). In vitro, a cytokine induced osteoclastogenesis model was established.

METHODS

After 28 days of treatment, the paw volume was measured, bone destruction was examined by micro-CT, and the generation of osteoclasts in bone tissue was evaluated via tartrate-resistant acid phosphatase (TRAP) staining. Furthermore, the inhibitory effect and underlying mechanism of action of GSZG on RANKL-induced osteoclastogenesis were investigated in vitro.

RESULTS

The in vivo analyses demonstrated that the paw volume and degree of bone erosion of mice in the medium- and high-dose GSZG groups were significantly decreased compared to the CIA model group. In addition, GSZG treatment suppressed the excessive generation of osteoclasts in the bone tissue of CIA mice. In vitro, GSZG inhibited RANKL-induced osteoclastogenesis and osteoclast-mediated bone resorption. Specifically, it only inhibited the generation of osteoclast precursors (OCPs); it had no significant effect on the fusion of OCPs or maturation of osteoclasts. Finally, we showed that the inhibitory effect of GSZG on osteoclastogenesis was related to the promotion of PTEN-induced kinase protein 1 (PINK1)/Parkin pathway-mediated mitophagy of osteoclast precursors, which was verified using a PINK1 knockdown small interfering RNA in OCPs.

CONCLUSION

These findings indicate that GSZG is a candidate for the treatment of bone destruction in RA and provide a more detailed elucidation of the mechanism of GSZG anti-RA bone erosion, i.e., inhibition of the ROS/NF-κB axis through the PINK1/Parkin-mediated mitochondrial autophagic pathway to inhibit osteoclast precursor production, compared to the published literature.

Integrative medicine using East Asian herbal medicine for inflammatory pain in patients with rheumatoid arthritis: A protocol for systematic review and meta-analysis integrated with multiple data mining for core candidate discovery

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory autoimmune disease characterized by a wide range of clinical symptoms affecting various bodily functions, including skeletal, vascular, metabolic, and cognitive functions. This review aimed to evaluate the efficacy and safety of integrative medicine (East Asian herbal medicine combined with conventional medicine) used for the treatment of inflammatory pain in rheumatoid arthritis and to identify key candidate drugs based on the data.

METHODS

A comprehensive literature search will be conducted in 4 core databases (PubMed, Excerpta Medica database, Cochrane Library, and Cumulative Index to Nursing & Allied Health Literature) 4 Korean databases (Oriental Medicine Advanced Searching Integrated System, Korean Studies Information Service System, Research Information Service System, and Korea Citation Index), 2 Chinese databases (Chinese National Knowledge Infrastructure Database and Wanfang data), and 1 Japanese database (Citation Information by National Institute of Informatics) for randomized controlled trials from December 13, 2022. Statistical analysis will be performed using R version 4.1.2 and R Studio program. The American College of Rheumatology 20/50/70 score and rate of adverse events will be the primary outcomes. All outcomes will be analyzed using a random-effects model to produce more statistically conservative results. Sensitivity, meta-regression, and subgroup analyses will be used to identify the sources of any heterogeneity in the study. The revised tool for assessing the risk of bias in randomized trials, version 2.0, will be used to evaluate methodological quality. The overall quality of evidence will be assessed according to the Grading of Recommendations Assessment, Development, and Evaluation Pro Framework.

ETHICS AND DISSEMINATION

There are no ethical issues, as no primary data will be collected directly from the participants. The results of this review will be reported in a peer-reviewed scientific journal.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023412385.

Efficacy and safety of traditional Chinese medicine for the treatment of epilepsy: A updated meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and safety of Traditional Chinese Medicine (TCM) in the treatment of epilepsy.

METHODS

A comprehensive search of the database in both Chinese and English was performed. Data from the selected studies were extracted and analyzed independently by two authors.

RESULTS

30 randomized controlled trials (RCTs) were included in the meta-analysis with a total of 2471 patients. Among them, 4 trials (n = 235) focused on TCM monotherapy, while the other 26 trials (n = 2236) assessed the benefit of TCM as an add-on therapy to antiseizure medications (ASMs). For the efficacy, the meta-analysis found (1) The effective rate in TCM monotherapy group was higher than that in control group (OR = 4.92, 95 % CI: 2.29-10.57, Z = 4.08, P 0.0001); (2) The add-on of TCM also increased the effective rate (OR = 3.37, 95 % CI: 2.65-4.30, Z = 9.85, P 0.00001) and seizure freedom rate (OR = 1.93, 95 % CI: 1.53-2.44, Z = 5.58, P 0.00001). In terms of safety, the add-on of TCM reduced the rate of total adverse events (OR = 0.46, 95 % CI: 0.31-0.67, Z = 3.96, P 0.0001) as well as adverse events of the gastrointestinal and nervous system. 26 different TCM prescriptions were used in these included RCTs. Among them, the 5 most frequently used herbs were Acorus tatarinowii (19 out of 26), Glycyrrhiza uralensis (13 out of 26), Gastrodia elata (12 out of 26), Pinellia ternata (11 out of 26) and Poria cocos (11 out of 26).

CONCLUSION

This study suggested that TCM may be a relatively efficacious and safe clinical strategy for the treatment of epilepsy. Several limitations still exist, such as the risk of bias in the included studies, the diversified composition of TCM prescriptions, and the relatively low quality of study design.

Efficacy and safety of bisphosphonates on childhood osteoporosis secondary to chronic illness or its treatment: a meta-analysis

Background:

Bisphosphonates are a type of medication that prevents the loss of bone density. Secondary childhood osteoporosis reduces bone strength and results in an increased risk of fragility fracture. This meta-analysis aims to explore the efficacy and safety of bisphosphonates on secondary childhood osteoporosis.

Methods:

We performed a systematic search of PubMed, Cochrane library, and Web of Science databases up to 31 July 2022 to screen for random clinical trials (RCTs) on bisphosphonate treatment for childhood secondary osteoporosis. Data from selected studies, mainly changes in lumbar spine (LS) bone mineral density (BMD), changes in LS BMD Z-scores, fracture events, and adverse events (AEs), were extracted and analyzed.

Results:

Nine RCTs (n = 429 in total) were included in our meta-analysis. The meta-analysis indicated that bisphosphonates improved the changes in LS BMD [mean difference (MD) = 0.04, 95% confidence intervals (CIs) = 0.01–0.07, p < 0.01] and LS BMD Z-scores [MD = 0.52, 95% CI = 0.23–0.81, p < 0.01]. Use of bisphosphonates did not increase the risk of AEs [odds ratio (OR) = 1.61, 95% CI = 0.87–2.99, p = 0.13]. Subgroup analysis showed that routes of administration, but not causes of secondary osteoporosis, might influence the efficacy of bisphosphonates. IV bisphosphonates close to significantly improved the incidence of fracture (OR = 0.34, 95% CI: 0.11–1.08, p = 0.07).

Conclusions:

The use of bisphosphonates improves LS BMD without increasing AE rates, which supports the clinical use of bisphosphonates in secondary childhood osteoporosis. Further large RCTs are still warranted, especially for their long-term effects on fracture rates.

Clinical evidence construction of East Asian herbal medicine for inflammatory pain in rheumatoid arthritis based on integrative data mining approach

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease that leads to a significant social burden. East Asian herbal medicine (EAHM) has long been used to treat RA. Therefore, a systematic study of how EAHM treatments can be developed into new drugs using specific materials is needed.

METHODS

Eleven databases containing literature in English, Korean, Chinese, and Japanese were searched for randomized controlled trials comparing EAHM with conventional medicine (CM). A meta-analysis was performed on the variable data to assess their effects on inflammatory pain. Subsequently, we searched for core materials and combinations of core material-based data mining methods.

RESULTS

A total of 186 trials involving 19,716 patients with RA met the inclusion criteria. According to the meta-analysis, EAHM had a significantly superior effect on continuous pain intensity, tender joint count, and response rate. Patients treated with EAHM had a significantly reduced incidence of adverse events compared with those treated with CM. Based on additional analysis of the EAHM formula data included in this meta-analysis, 21 core materials and five core herbal combinations were identified.

CONCLUSION

EAHM remedies for RA have the adequate potential for use as candidate materials for treating inflammatory pain in RA. The candidate core herbs evaluated in this study act on multiple pathways and are expected to provide pain relief, sustained inflammation suppression, immune regulation, and prevention of joint destruction. It seems worthwhile to conduct follow-up research on drug development using the core materials derived from this review.

An intersectional analysis of LncRNAs and mRNAs reveals the potential therapeutic targets of Bi Zhong Xiao Decoction in collagen-induced arthritis rats

Background

Bi Zhong Xiao decoction (BZXD), a traditional Chinese herbal formula, has been used clinically for many years to treat rheumatoid arthritis (RA). Both clinical and experimental studies have revealed that BZXD is effective in treating RA, but the mechanism remains unclear. In this study, we aimed to explore the mechanism of efficacy of BZXD through transcriptomic analysis of lncRNA and mRNA.

Methods

The combination method of ultra-high performance liquid chromatography-mass spectrometry/mass spectrometry was used to assess the quality of BZXD. The efficacy of BZXD in treating collagen-induced arthritis (CIA) was evaluated by clinical assessment, weight changes, hematoxylin–eosin and safranin o-fast green staining, and Micro-CT. Arraystar rat lncRNA-mRNA chip technology was used to determine the lncRNA and mRNA expression profiles of the Control, CIA and BZXD groups, and to screen gene expression profiles related to the curative effect of BZXD. A lncRNA-mRNA co-expression network was constructed for the therapeutic efficacy genes. Through GO function and KEGG pathway enrichment analysis, the biological functions and signaling pathways of therapeutic efficacy genes were determined. Based on fold change and functional annotation, key differentially expressed lncRNAs and mRNAs were selected for reverse transcription-quantitative polymerase chain reaction (RT-qPCR) validation. The functions of lncRNAs targeting mRNAs were verified in vitro.

Results

We demonstrated that BZXD could effectively reverse bone erosion. After BZXD treatment, up to 33 lncRNAs and 107 mRNAs differentially expressed genes were reversely regulated by BZXD. These differentially expressed lncRNAs are mainly involved in the biological process of the immune response and are closely related to the ECM-receptor interaction, MAPK signaling pathway, Focal adhesion, Ras signaling pathway, Antigen processing and presentation, and Chemokine signaling pathway. We identified four lncRNAs (uc.361−, ENSRNOT00000092834, ENSRNOT00000089244, ENSRNOT00000084631) and three mRNAs (Acvr2a, Cbx2, Morc4) as potential therapeutic targets for BZXD and their microarray data consistent with the RT-qPCR. In vitro experiments confirmed that silencing the lncRNAs ENSRNOT00000092834 and ENSRNOT00000084631 reversed the expression of target mRNAs.

Conclusions

This study elucidates the possible mechanism of BZXD reversing bone erosion in CIA rats from the perspective of lncRNA and mRNA. To provide a basis and direction for further exploration of the mechanism of BZXD in treating RA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13020-022-00670-z.

Quantitative proteomic analysis of Bi Zhong Xiao decoction against collagen-induced arthritis rats in the early and late stages

Background

Rheumatoid arthritis (RA) is a chronic, progressive, systemic autoimmune inflammatory disease. Bi Zhong Xiao decoction (BZXD) performs multiple functions for rheumatoid arthritis (RA) treatment for decades. In this study, we aimed to study the protein alterations of BZXD in the early and late stages of RA.

Methods

Sprague–Dawley rats were randomly divided into the Control, collagen-induced arthritis (CIA) and BZXD groups. Clinical assessment, paw thickness, weight changes and serum inflammatory cytokine levels were used to evaluate anti-inflammatory effects. Histopathological tests were performed to assess the improvement of inflammation and synovial hyperplasia. Moreover, we analyzed the proteins profiling of synovial tissue samples with different time intervals after BZXD treatment by Isobaric Tag for Relative Absolute (ITRAQ) quantitative proteomics technology. To further explore the interrelationships among differentially expressed proteins (DEPs), we used DAVID Bioinformatics Resources v6.8 and STRING 11.0 for bioinformatics analysis. Besides, the western blot and immunohistochemistry were exerted to verify related proteins.

Results

In our study, BZXD ameliorated joint inflammation, and suppressed the pathological changes in arthrosis of CIA rats. The proteomic analysis demonstrated that CIA rats were mainly involved in two significant pathways (the focal adhesion and the ECM-receptor interaction) in the early stage. BZXD down-regulated the expression of proteins involved in these pathways, such as CAV1, CHAD, COL3A1, COL5A2, COL6A1, and COL6A5. Additionally, BZXD exerts anti-inflammatory effects in the late stage mainly by increasing the expression of FASN and affecting fatty acid metabolism.

Conclusion

BZXD exerts therapeutic effects on RA through multi-pathways in the early and late stages. This work may provide proteomic clues for treating RA by BZXD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03663-5.

Oral administration of East Asian herbal medicine for rheumatoid arthritis: A protocol for systematic review and meta-analysis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, inflammatory, and painful joint disease. The aim of this review is to systematically evaluate the efficacy and safety of oral administration East Asian herbal medicine monotherapy for inflammatory pain of RA, and to explore core herb material information based on collected data.

METHODS

A comprehensive literature search will be conducted in 11 electronic databases including PubMed, Cochrane Library, Cumulative Index to Nursing & Allied Health Literature, Excerpta Medica database, Korean Studies Information Service System, Research Information Service System Oriental Medicine Advanced Searching Integrated System, Korea Citation Index, Chinese National Knowledge Infrastructure Database, Wanfang data, citation information by NII for randomized controlled trials from their inception until October 13, 2021. Statistical analysis will be performed in the software R version 4.1.1. and R studio program using the default settings of the "meta" and "metafor" package. When heterogeneity in studies is detected, the cause will be identified through subgroup analysis. Methodological quality will be assessed independently using the revised tool for risk of bias in randomized trials (Rob 2.0).

RESULTS

This study will provide more comprehensive and specific evidence of East Asian herbal medicine monotherapy for RA pain management.

CONCLUSIONS

Based on the results of this review, it is expected that the efficacy and safety of East Asian herbal medicine for inflammatory pain of RA may be confirmed. In addition, it will be possible to derivation of a core herb material information related to this research topic through additional data mining.

ETHICS AND DISSEMINATION

There are no ethical issues as there are no primary data collected by directly recruiting subjects. The results of this review will be reported in a peer-reviewed scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42021273643.

Guizhi-Shaoyao-Zhimu decoction attenuates monosodium urate crystal-induced inflammation through inactivation of NF-κB and NLRP3 inflammasome

ETHNOPHARMACOLOGICAL RELEVANCE

Guizhi-Shaoyao-Zhimu decoction (GSZD), a classical traditional Chinese medicine (TCM) prescription, is used empirically to treat various types of arthritis in TCM clinical practice. However, the underlying mechanisms of GSZD on gouty inflammation are not totally elucidated.

AIM OF STUDY

The purpose of this study is to investigate the effects of GSZD on peritoneal recruitment of neutrophils, production of proinflammatory mediators, activations of nuclear factor (NF)-κB and nucleotide oligomerization domain-like receptor protein-3 (NLRP3) inflammasome in mice with monosodium urate crystal (MSU)-induced peritonitis (MIP).

MATERIALS AND METHODS

Mice were intragastrically administered with GSZD for 7 days. After the last administration, mice were intraperitoneally injected with MSU. Peritoneal exudates of mice were harvested, and total peritoneal cells were calculated. Levels of interleukin (IL)-1β, IL-6 and monocyte chemotactic protein (MCP)-1 in peritoneal exudates were tested by enzyme-linked immunosorbent assay. Expressions of IL-1β, NLRP3, cysteinyl aspartate specific proteinase (caspase)-1, apoptosis-associated speck-like protein containing the caspase activation and recruitment domain (ASC), phosphorylated (p)-p65, inhibitor of NF-κB (IκB)α, p-IκB kinase (IKK)β, nuclear p65, p-mitogen-activated protein kinases (MAPKs) in peritoneal cells were analyzed by Western blot. Binding activity of NF-κB to DNA was measured by a Trans AM™ kit for p65. Interaction between ASC and pro-caspase-1 was assessed by co-immunoprecipitation assay.

RESULTS

Total peritoneal cells, levels of IL-1β, IL-6 and MCP-1 were significantly reduced by GSZD treatment in peritoneal exudates of MIP mice. As for the activation of NF-κB, GSZD treatment significantly reduced the levels of p-p65, p-IKKβ, nuclear p65 and p-MAPKs, enhanced the level of IκBα and abated the binding ability of NF-κB to DNA in peritoneal cells of MIP mice. As for the activation of NLRP3 inflammasome, GSZD treatment significantly reduced the levels of IL-1β, NLRP3 and caspase-1, and alleviated the interaction between ASC and pro-caspase-1 in peritoneal cells of MIP mice. Nevertheless, GSZD didn't remarkably change the level of ASC.

CONCLUSIONS

These results suggest that GSZD attenuates the MSU-induced inflammation through inhibiting the activations of NF-κB and NLRP3 inflammasome.

Natural Plant Extracts and Compounds for Rheumatoid Arthritis Therapy

Natural plant extracts and compounds (NPECs), which originate from herbs or plants, have been used in the clinical treatment of rheumatoid arthritis (RA) for many years. Over the years, many scientists have carried out a series of studies on the treatment of RA by NPEC. They found a high quantity of active NPECs with broad application prospects. In view of various complex functions of these NPECs, exploring their potential as medicines for RA treatment will be beneficial for RA patients. Thus, to help advance the development of high-quality NPECs for RA, we herein aimed to review the research progress of NPECs in the treatment of RA in recent years. Our findings showed that, from the pharmacological perspective, natural plant extracts or mixed herbal compounds effectively regulate the immune system to alleviate RA by inhibiting pro-inflammatory cytokines. Further, individualized medication can be applied according to each patient's physical condition. However, the pathogenesis of RA and its immune mechanism has not been fully understood and requires further studies.