Utilization and prescription patterns of traditional Chinese medicine for patients with hepatitis C in Taiwan: a population-based study

Ethnopharmacology of five flowers herbal tea, a popular traditional beverage in Hong Kong and South China

BACKGROUND

It has been a long-standing tradition of using herbal tea for preventive and therapeutic healthcare in Hong Kong and South China and Five Flowers Tea is one of the most popular herbal teas. Based on the principle of traditional Chinese medicine, the pharmacological functions are to clear heat and dispel dampness in the body. Heat and dampness are thought to contribute to a range of health problems, especially during the hot and humid season in South China and Hong Kong. The most prevalent herbs in the formula contain bioactive compounds including flavonoids, alkaloids and terpenoids, which have a wide range of pharmacological properties including anti-inflammation, antivirus, antidiarrhoea, antibacteria, and antioxidation. However, with the composition varies widely, the ethnopharmacological benefits described may not be delivered uniformly. This study is to provide a comprehensive analysis on the composition of the Five Flowers Tea sold in Hong Kong and investigate the rationale behind the selection of herbs used in the formula. This study also provides information on the variation and quality of the Five Flowers Tea in the market.

METHODS

Thirty-three Five Flowers Tea samples were collected from various locations in Hong Kong. The size, texture, colour and organoleptic properties were documented. Macroscopic and molecular authentication methods were employed to identify the individual components.

RESULTS

Macroscopic identification revealed there were 23 herbs belonging to 18 plant families. The most prevalent herb was Bombax ceiba L., followed by Chrysanthemum morifolium. Ten adulterants and the existence of insect Lasioderma serricorne were confirmed by DNA barcoding techniques.

CONCLUSION

This study employed a comprehensive approach to authenticate the herbs in Five Flowers Tea samples collected from various locations in Hong Kong. Macroscopic and molecular methods were used to identify the herbs and adulterants. The findings revealed the varied composition in Five Flowers Tea and the occurrence of adulterants in some samples. This shows that quality assurance of Five Flowers Tea is essential for the effective use of this popular folk medicine.

Traditional Chinese medicine may be associated with a reduced risk of recurrent exacerbation in patients with rheumatoid arthritis: A matched cohort study based on 1383 individuals

Ethnopharmacological relevance

This study determines whether traditional Chinese medicine (TCM) treatment is associated with the risk of recurrent exacerbation in patients with rheumatoid arthritis (RA).

Materials and methods

In this retrospective study, we selected 1383 patients who were diagnosed with RA between 2013 and 2021 from the medical record information management system of the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine. Then, patients were classified into TCM users and non-TCM users. Gender, age, recurrent exacerbation, TCM, death, surgery, organ lesions, Chinese patent medicine, external medicine, and non-steroidal anti-inflammatory drugs were adjusted one TCM user-to-one non-TCM user with propensity score matching to reduce selection bias and confusion using propensity score matching (PSM). A Cox regression model was used to compare the hazard ratio of the risk of recurrent exacerbation and the Kaplan Meier curve of recurrent exacerbation proportion between the two groups.

Results

Most of the tested clinical indicators in this study improved in patients, which was correlated with the use of TCM, with a statistical significance. TCM was preferred in female and younger (<58 years old) patients with RA. Of note, recurrent exacerbation was observed in more than 850 (61.461%) RA patients. The results of the Cox proportional hazard model showed TCM as a protective factor for the recurrent exacerbation of RA patients (HR = 50%, 95% CI = 0.65-0.92, P < 0.01). Kaplan Meier curves demonstrated that the survival rate of TCM users was higher than that of non-TCM users (log-rank P < 0.01).

Conclusion

Conclusively, the use of TCM may be related to a lower risk of recurrent exacerbation in RA patients. These findings provide evidence for the recommendation of TCM treatment for RA patients.

Utilization and Impact of Complementary and Alternative Medicines in Symptomatic Autoimmune Hepatitis Patients

BACKGROUND

Complementary and alternative medicine (CAM) use has become increasingly common. It is also prevalent in patients with chronic liver disease, but the scope, depth, and safety of use is not well known.

AIMS

This study aimed to evaluate the prevalence and patterns of CAM use in autoimmune hepatitis (AIH) patients.

METHODS

Electronic invitation to complete a 22 item CAM-specific questionnaire was posted weekly to well-established AIH Facebook communities (combined membership of 4700 individuals) during a 6-week study period. Age ≥ 18 years and AIH diagnosis made by a treating physician were the eligibility criteria.

RESULTS

The prevalence of ever CAM use among participants was 56.4%, and nearly 42% used CAM after AIH diagnosis. Among those reporting CAM use after diagnosis, 53.7% (51/95) indicated CAM was used to mitigate AIH-related phenomenon, most often targeting liver inflammation/fibrosis (67.7%), fatigue (51%), joint pain (47.1%), and sleep issues (45.1%). Most frequent physical CAM strategies were exercise (49.5%) and yoga (34%), whereas most frequent consumable CAM included healthier eating (45.3%), cannabidiol preparations (45.3%), and probiotics (44.3%). Seventy-five percent reported that CAM improved AIH symptoms and no severe adverse events were reported.

CONCLUSIONS

CAM use in AIH patients is prevalent, yet providers have historically failed to document their patient's CAM strategies. Beyond inherent drug-induced liver injury risk, drug-drug interactions remain a concern and could alter baseline immunosuppression levels in AIH. Despite a majority found CAM approaches that improved targeted symptoms, all were unable to alter the course of chronically prescribed medications by physicians.

Chinese herbal medicine might be associated with a lower rate of joint replacement in patients with osteoarthritis: A 12-year population-based matched cohort analysis

ETHNOPHARMACOLOGICAL RELEVANCE

To determine whether adjuvant Chinese herbal medicine (CHM) treatment is associated with the risk of joint replacement in osteoarthritis (OA) patients.

MATERIALS AND METHODS

This retrospective study used a population-based national health insurance (NHI) database from 2000 to 2012 in Taiwan. A total of 125,023 newly diagnosed OA patients were selected from one million beneficiaries of longitudinal health insurance database. Based on applying ten selected frequently used CHM formulas for OA, patients were divided into CHM user and non-CHM user. One-CHM to four-non-CHM user were propensity score matched with age, gender, monthly income, urbanization, comorbidities, Nonsteroidal anti-inflammatory drugs (NSAIDs) and index year were adjusted to reduce selection bias and confounding. Cox regression model was used for comparing the hazard ratios (HR) for the risk of joint replacement and Kaplan-Meier curve for the proportion of joint replacement.

RESULTS

OA patients who were female, younger (20-60 years), higher income and lived in urbanization location were found to preferred using CHM. Younger CHM users had a lower adjusted HR (0.63) of the risk of joint replacement (95% confidence interval (CI) = 0.42-0.94). Compared to non-CHM user, HR among CHM users (≥225 days annually) is 0.48 (95% CI = 0.31-0.76). The proportion of joint replacement in younger non-CHM user began to rise notably with time (log-rank test, p = 0.026). However, this benefit by CHM did not apply to older (over 60 years) OA patients.

CONCLUSION

This study suggested that adjuvant CHM might be associated with a lower rate of joint replacement in OA patients. CHM therapy might be considered in OA patients to reduce the need of joint replacement.

The Pharmacological Effects and Pharmacokinetics of Active Compounds of Artemisia capillaris

Artemisia capillaris Thunb. (A.capillaris, Yin-Chen in Chinese) is a traditional medicinal herb with a wide spectrum of pharmacological properties ranging from effects against liver dysfunction to treatments of severe cirrhosis and cancer. We used relevant keywords to search electronic databases, including PubMed, Medline, and Google Scholar, for scientific contributions related to this medicinal herb and the pharmacokinetics of its components. The pharmaceutical effects of A.capillaris contribute to the treatment not only of viral hepatitis, cirrhosis, and hepatocellular hepatoma, but also metabolic syndrome, psoriasis, and enterovirus in the clinic. The bioactive compounds, including scoparone, capillarisin, scopoletin, and chlorogenic acid, exhibit antioxidant, anti-inflammatory, antisteatotic, antiviral, and antitumor properties, reflecting the pharmacological effects of A.capillaris. The pharmacokinetics of the main bioactive compounds in A. capillaris can achieve a maximum concentration within 1 hour, but only chlorogenic acid has a relatively long half-life. Regarding the use of the A. capillaris herb by health professionals to treat various diseases, the dosing schedule of this herb should be carefully considered to maximize therapeutic outcomes while lessening possible side effects.

Preclinical study of simultaneous pharmacokinetic and pharmacodynamic herb-drug interactions between Yin-Chen-Hao-Tang and spironolactone

BACKGROUND

The prevalence and therapeutic effects of the use of herbal remedies for chronic liver diseases make the combined administration of herbal products with conventional treatment unable to be ignored. This study investigated the pharmacokinetic and pharmacodynamic herb-drug interactions between the herbal formula Yin-Chen-Hao-Tang (YCHT) and spironolactone.

METHODS

A selective high-performance liquid chromatography (HPLC) method was developed and validated for the detection of spironolactone and its metabolite canrenone in rat urine. The interaction study was conducted by collecting urine samples after oral administration of spironolactone alone or in combination with YCHT for 5 days. Urine pharmacokinetic parameters and urinary sodium, potassium, volume, and weight were analyzed.

RESULTS

The results revealed significant increases in the cumulative amount and the area under the rate curve (AURC) of the metabolite canrenone after pretreatment with the high dose of YCHT. The urine weight and volume were significantly reduced dose-dependently as a result of pretreatment with YCHT. The urinary sodium-to-potassium ratio, which indicates diuretic effects, was also reduced in the high-dose YCHT condition.

CONCLUSIONS

Herb-drug pharmacokinetic and pharmacodynamic interactions between YCHT and spironolactone were observed in the study. The herb-drug interaction that appeared with a single dose of spironolactone should be considered when patients are being treated with a continuous administration of this drug.

Decreased overall mortality rate with Chinese herbal medicine usage in patients with decompensated liver cirrhosis in Taiwan

Background

Liver cirrhosis is one of the main causes of the morbidity and mortality in liver diseases. Chinese herbal medicine (CHM) has long been used for the clinical treatment of liver diseases. This study was designed to explore the usage frequency and prescription patterns of CHM for patients with decompensated liver cirrhosis and to evaluate the long-term effects of CHM on overall mortality.

Methods

Two thousand four hundred sixty-seven patients with decompensated liver cirrhosis (ICD-9-CM code: 571.2, 571.5, and 571.6) diagnosed between 2000 and 2009 in Taiwan were identified from the registry for catastrophic illness patients. Of these, 149 CHM users and 298 CHM non-users were matched for age, gender, and Charlson comorbidity index score. The chi-squared test, paired Student’s t-test, Cox proportional hazard model, and Kaplan–Meier method were applied for various comparisons between these groups of patients.

Results

CHM-treated patients showed a lower overall mortality risk compared with non-treated patients (Multivariable: p < 0.0001; HR: 0.54, 95% CI: 0.42–0.69). The cumulative incidence of overall mortality was lower in the CHM-treated group (stratified log-rank test, p = 0.0002). The strongest CHM co-prescription pattern- Yin-Chen-Hao-Tang (YCHT) → Long-Dan-Xie-Gan-Tang (LDXGT) had the highest support, followed by Zhi-Zi (ZZ) → Yin-Chen-Wu-Ling-San (YCWLS) and Bai-Hua-She-She-Cao (BHSSC) → Da-Huang (DaH).

Conclusion

CHM, as adjunct therapy, might decrease the risk of overall mortality in patients with decompensated liver cirrhosis. CHM co-prescription patterns and network analysis showed that comprehensive herbal medicines have a protective role against liver fibrosis. Further studies are required to enhance the knowledge of safety and efficacy of CHM in patients with decompensated liver cirrhosis.

Chinese Herbal Medicine Ameliorated the Development of Chronic Kidney Disease in Patients with Chronic Hepatitis C: A Retrospective Population-Based Cohort Study

Chronic kidney disease (CKD) is a serious complication affecting patients with chronic hepatitis. The effectiveness of CHM for the prevention of CKD in hepatitis patients remains unclear. Therefore, we conducted a retrospective cohort study to investigate the effectiveness of CHM in preventing the development of CKD in hepatitis patients. From a subdataset of the Taiwan National Health Insurance Research Database (NHIRD), we included 19,409 patients newly diagnosed with hepatitis B and hepatitis C between the years 2000 and 2010. After exclusion criteria and 1 : 1 propensity score matching process, we compared demographic factors, comorbidities, and correlated drugs between the CHM and non-CHM cohorts. Statistical analysis was applied to evaluate the differences in characteristic distributions and to compare the cumulative incidence of CKD between the CHM and non-CHM cohorts. This study showed that the patients suffering from hepatitis C with CHM treatment more than 90 days as an adjuvant therapy combined with western medical treatment modalities exhibited a decreased risk of developing CKD (hazard ratio (HR) = 0.40, 95% confidence interval (CI) = 0.21–0.76, p value <0.01). The Kaplan–Meier curve revealed a lower cumulative incidence rate of CKD (p value = 0.004) for the CHM cohort. For further reference, we herein offer the ten most frequently prescribed single herbs and herbal formulas; as such, Salviae miltiorrhizae and Jia-Wei-Xiao-Yao-San were the most commonly prescribed single herb and formula, respectively. This nationwide retrospective cohort study provides evidence that CHM is an effective adjuvant treatment to decrease the risk of developing CKD in hepatitis C patients.

Effects of Chinese herbal medicine therapy on survival and hepatic outcomes in patients with hepatitis C virus infection in Taiwan

BACKGROUND

Chinese herbal medicine (CHM) is a complementary natural medicine that is used widely for the treatment of hepatic diseases. The aim of this study was to investigate the effects of the long-term use of CHM for the treatment of liver diseases, as prescribed by TCM doctors, on overall mortality and hepatic outcomes in patients with HCV.

PATIENTS AND METHODS

We identified 98788 patients with HCV. Of these, 829 and 829 patients who were users and non-users of CHM, respectively, were matched for age, gender, CCI, and comorbidities prior to CHM treatment. The chi-squared test, Cox proportional hazard model, Kaplan--Meier method, and log-rank test were used for comparisons.

RESULTS

CHM users had a lower risk of overall mortality than non-users after adjustment for comorbidities by using a multivariate Cox proportional hazard model (p-value < 0.001; HR: 0.12, 95% CI: 0.06-0.26). In addition,the CHM users had a lower risk of liver cirrhosis than non-users after adjustment for comorbidities (p-value = 0.028; HR: 0.29, 95% CI: 0.09-0.88). The 12-year cumulative incidences of overall mortality and liver cirrhosis were lower in the CHM group (p-value < 0.05 for both, log rank test). The CHM co-prescription for Dan-Shen, Bie-Jia, Jia-Wei-Xiao-Yao-San => E-Shu was found to occur most often associated for the specific treatment of HCV infection.

CONCLUSION

CHM as adjunctive therapy may reduce the overall mortality and the risk of liver cirrhosis in patients with HCV. The comprehensive list of the herbal medicines that may be used for the treatment of patients with HCV may be useful in future scientific investigations or for future therapeutic interventions to prevent negative hepatic outcomes in patients with HCV.

Chinese herbal medicine therapy and the risk of mortality for chronic hepatitis B patients with concurrent liver cirrhosis: a nationwide population-based cohort study

Chronic hepatitis B (CHB) is increasingly recognized as a public health problem in Taiwan. After affected patients are diagnosed with contaminant liver cirrhosis (LC), adverse clinical outcomes, especially death, are common. This study aimed to investigate the effect of Chinese herbal medicine (CHM), an essential branch of Traditional Chinese medicine (TCM), on the mortality risk among CHB patients with contaminant LC. This longitudinal cohort study used the Taiwanese National Health Insurance Research Database to identify 1522 patients 20–70 years of age with newly diagnosed CHB with LC during 1998–2007. Among them, 508 (33.37%) had received CHM products after the onset of CHB (CHM users), and the remaining 1014 patients (66.63%) were designated as a control group (non-CHM users). All enrollees were followed until the end of 2012 to determine deaths during the study period. We applied the Cox proportional hazards regression model to compute the hazard ratio for the association of CHM use and the subsequent risk of death. During the follow-up period, 156 CHM users and 493 non-CHM users died. After controlling for potential confounders, CHM users were found to have a significantly reduced risk of death compared with non-CHM users by 56%, and the effect was predominantly observed among those treated with CHM for > 180 days. CHM therapy lowered the risk of death among CHB patients with contaminant LC, which supported CHM might provide further treatment options for those with chronic liver diseases.

Danshen improves survival of patients with colon cancer and dihydroisotanshinone I inhibit the proliferation of colon cancer cells via apoptosis and skp2 signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Danshen (Salvia miltiorrhiza Bunge) is widely used in traditional Chinese medicine. However, it's definite clinical effect and mechanism on colon carcinoma is unclear.

AIM OF THE STUDY

To test the hypothesis that the protective effect of danshen on colon cancer and discover the bioactive compounds through in vitro study.

MATERIALS AND METHODS

We conducted a nationwide cohort study by using population-based data from the Taiwan National Health Insurance Research Database (NHIRD). The study cohort comprised patients diagnosed with malignant neoplasm of colon (ICD-9-CM codes:153) in catastrophic illness database between January 1, 2000, and December 31, 2010. We used the Kaplan-Meier method to estimate colon [corrected] cancer cumulative incidences. Next, human colon cancer cells (HCT 116 cells and HT29 cells) were used to investigate the effect of dihydroisotanshinone I (DT) on the proliferation and apoptosis of human colon cancer cells and the underlying mechanism through XTT assay and flow cytometry. The in vivo effect of DT treatment was investigated through a xenograft nude mouse model.

RESULTS

In our study, the in vivo protective effect of danshen in the different stage of colon cancer patients was validated through data from the National Health Insurance Research Database in Taiwan. In vitro, we found that dihydroisotanshinone I (DT), a bioactive compound present in danshen, can inhibit the proliferation of colon carcinoma cells, HCT 116 cells and HT-29 cells. Moreover, DT induced apoptosis of colorectal cancer cells. DT also repressed the protein expression of Skp2 (S-Phase Kinase Associated Protein 2) and the mRNA levels of its related gene, Snail1 (Zinc finger protein SNAI1) and RhoA (Ras homolog gene family, member A). In addition, DT also blocked the colon cancer cells recruitment ability of macrophage by decreasing CCL2 secretion in macrophages. DT treatment also significantly inhibited the final tumor volume in a xenograft nude mouse model.

CONCLUSION

Danshen has protective effects in colon cancer patients, which could be attributed to DT through blocking the proliferation of colon cancer cells through apoptosis.

Saikosaponins induced hepatotoxicity in mice via lipid metabolism dysregulation and oxidative stress: a proteomic study

BACKGROUND

Radix Bupleuri (RB) has been popularly used for treating many liver diseases such as chronic hepatic inflammation and viral Hepatitis in China. Increasing clinical and experimental evidence indicates the potential hepatotoxicity of RB or prescriptions containing RB. Recently, Saikosaponins (SS) have been identified as major bioactive compounds isolated from RB, which may be also responsible for RB-induced liver injury.

METHODS

Serum AST, ALT and LDH levels were determined to evaluate SS-induced liver injury in mice. Serum and liver total triglyceride and cholesterol were used to indicate lipid metabolism homeostasis. Liver ROS, GSH, MDA and iNOS were used to examine the oxidative stress level after SS administration. Western blot was used to detect CYP2E1 expression. A 8-Plex iTRAQ Labeling Coupled with 2D LC - MS/MS technique was applied to analyze the protein expression profiles in livers of mice administered with different doses of SS for different time periods. Gene ontology analysis, cluster and enrichment analysis were employed to elucidate potential mechanism involved. HepG2 cells were used to identify our findings in vitro.

RESULTS

SS dose- and time-dependently induced liver injury in mice, indicated by increased serum AST, ALT and LDH levels. According to proteomic analysis, 487 differentially expressed proteins were identified in mice administrated with different dose of SS for different time periods. Altered proteins were enriched in pathways such as lipid metabolism, protein metabolism, macro molecular transportation, cytoskeleton structure and response to stress. SS enhanced CYP2E1 expression in a time and dose dependent manner, and induced oxidative stress both in vivo and in vitro.

CONCLUSION

Our results identified hepatotoxicity and established dose-time course-liver toxicity relationship in mice model of SS administration and suggested potential mechanisms, including impaired lipid and protein metabolism and oxidative stress. The current study provides experimental evidence for clinical safe use of RB, and also new insights into understanding the mechanism by which SS and RB induced liver injury.

Clinical efficacy of Rong-Yang-Jyh-Gan-Tang on patients with chronic hepatitis C: A double-blinded randomized placebo-controlled crossover study

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medicine (TCM) has been widely used by the Chinese population for treatment of chronic hepatitis. However, the efficacy of TCM for patients with chronic hepatitis has not been confirmed, mostly due to the lack of available scientific parameters such as serum viral load to evaluate treatment response.

AIM OF THE STUDY

We evaluated the efficacy of Rong-Yang-Jyh-Gan-Tang (RYJGT, composed of Long-Dan-Xie-Gan-Tang, Jia-Wei-Xia-Yao-San, Dan-Shen, and Hou-Po) on patients with chronic hepatitis C.

MATERIALS AND METHODS

Thirty-six patients with chronic hepatitis C who had no response to or had contraindications to interferon-ribavirin therapy were randomly allocated to receive RYJGT 15g/day or placebo for 12 weeks. After a 2-week washout period, patients were crossed over to receive placebo or RYJGT for another 12 weeks. Evaluation parameters included liver biochemistries, serum HCVRNA, side effects of RYJGT/placebo, and TCM symptoms.

RESULTS

Of the patients who had 12-week RYJGT treatment, 51.7% had decreased serum HCVRNA levels, whereas only 25.8% patients had decreased levels in the placebo group (p=0.036). TCM patterns of "Damp-Heat" and "Liver Qi Depression" had significantly improved after RYJGT treatment in comparison with the placebo. Logistic analyses showed that RYJGT treatment, and pre-treatment values of TCM symptoms of "Damp-Heat" and "Liver Qi Depression", were statistically significant factors in predicting the decrease in serum HCVRNA.

CONCLUSION

Chronic hepatitis C patients who received a 12-week RYJGT treatment had significantly higher HCVRNA decrease ratio, and improved TCM symptoms of "Damp-Heat" and "Liver Qi Depression", than those who received the placebo. Our results require further larger scale clinical trials.