Double-blind, placebo-controlled, 1:1 randomized Phase III clinical trial of Immunoxel honey lozenges as an adjunct immunotherapy in 269 patients with pulmonary tuberculosis

AIM

Safer and shorter antituberculosis treatment (ATT) regimens represent the unmet medical need.

PATIENTS & METHODS

The patients were randomly assigned into two arms: the first (n = 137) received once-daily sublingual honey lozenge formulated with botanical immunomodulator Immunoxel and the second (n = 132) received placebo lozenges along with conventional ATT. Immunoxel and placebo arms were demographically similar: 102 versus 106 had drug-susceptible TB; 28 versus 20 multidrug-resistant TB (MDR-TB); 7 versus 7 extensively drug-resistant TB (XDR-TB); and 22 versus 20 TB-HIV. The primary end point was sputum smear conversion.

RESULTS

After 1 month 87 out 132 (65.9%) of Immunoxel recipients became sputum smear negative, whereas 32 out of 127 (25.2%) in placebo group had converted (p < 0.0001). Sputum clearance produced by Immunoxel was equally effective across all forms of TB. In the immunotherapy arm the average weight gain was 2 kg, but placebo recipients gained only 0.6 kg. Immunoxel reduced TB-associated inflammation as evidenced by defervescence and normalization of elevated leukocyte counts and erythrocyte sedimentation rate. No adverse effects were seen at any time. The liver function tests indicate that ATT-caused hepatotoxicity was counteracted by Immunoxel. These results are in agreement with prior 20 trials of Immunoxel conducted over the past 17 years.

CONCLUSION

Immunoxel is affordable, safe, effective, fast-acting, commercially available immunotherapeutic intervention to supplement conventional TB chemotherapy. Clinicaltrials.gov ID: NCT01061593.

Clinical validation of sublingual formulations of Immunoxel (Dzherelo) as an adjuvant immunotherapy in treatment of TB patients

Immunoxel (Dzherelo) is a water-alcohol extract of medicinal plants used in Ukraine as an adjunct immunotherapy to TB and HIV therapy. Four types of solid sublingual formulations of Immunoxel were made: sugar dragées, sugar-coated pills, gelatin pastilles and dried-honey lozenges. They were administered once-daily along with TB drugs. After 1 month, 84.1% of TB patients became sputum-negative with rates in individual groups of 89.5, 70, 76.9 and 100%, respectively. The conversion rate was independent of bodyweight, age, gender, differences in chemotherapy regimens or whether subjects had newly diagnosed TB, re-treated TB, multidrug-resistant TB or TB with HIV coinfection. Patients experienced earlier clinical improvement, faster defervescence, weight gain, a higher hemoglobin content and reduced inflammation as evidenced by lower leukocyte counts and erythrocyte sedimentation rate. By contrast, in the placebo group, only 19% of patients had converted. These findings imply that mucosal delivery of solid Immunoxel is equivalent to the original liquid formula given per os twice-daily for 2-4 months.

Enhancement of efficacy of tuberculosis drugs with Immunoxel (Dzherelo™) in HIV-infected patients with active pulmonary tuberculosis

Immunoxel (Dzherelo™) is an oral, herbal immunomodulator used in Ukraine for adjunct therapy of infectious and autoimmune diseases. Antiretroviral drug-naive, tuberculosis (TB)/HIV coinfected patients with active pulmonary TB were divided into two arms, A (n = 20) and B (n = 20), to receive first-line anti-TB therapy (ATT) or ATT + Dzherelo, respectively. As a result, three (16%) versus 12 (67%; p = 0.003) patients had Mycobacterium tuberculosis culture conversion, with time to negative culture of 6 and 4 months in arms A and B, respectively. In the ATT-alone arm, the healing of pulmonary cavitations was observed in 25% of patients at weeks 24–28, while 60% of individuals in arm B healed at 16–18 weeks (p = 0.025). The TB lesions, on chest x-ray, had cleared in 46 and 84%, with time-to-clearance of 24–28 and 16–18 weeks in arms A and B, respectively. In the ATT-alone arm, the bodyweight at baseline was 64 ± 6.3 kg, with 13 cachexic patients who had an average weight deficit of -5.2 ± 1.7 kg. At the end of 6 months of follow-up, they have lost an additional 0.6 kg (-5.8 ± 2.4). The study entry-level weight in arm B was 52 ± 5.7 kg, with 12 individuals who had a body mass deficit of -8.5 ± 2.7 kg. The immunotherapeutic intervention increased bodyweight by an average of 5.8 ± 2.6 kg above baseline (p < 0.0001). The inclusion of Dzherelo into the ATT regimen decreased the incidence of new opportunistic infections (OI) with three episodes of OI versus 12 in arm A (p = 0.003). These findings indicate that Dzherelo contributes positively to the clinical efficacy of TB drugs.

Effect of Immunomodulating Adjuvant Dzherelo (Immunoxel) in HIV Infected Patients Receiving Standard Antiretroviral Therapy

Open-label, matched-case, comparative trial was conducted in 40 HIV-infected patients to evaluate the adjunct effect of Dzherelo (Immunoxel) on immune and viral parameters. Arm A (n=20) received anti-retroviral therapy (ART) consisting of zidovudine, lamivudine, and efavirenz and arm B (n=20) received ART with Dzherelo. After 2 months total T-lymphocytes increased in ART recipients from 664 to 819 cells/μl (P=0.06), whereas in Dzherelo recipients they rose from 595 to 785(P=0.03). The CD4 T-cells expanded by 57.3% (218 to 343; P=0.002) in the ART arm and by 93.5% (184 to 356; P=0.004) in the Dzherelo arm. The accrual in absolute and relative number of CD8+ lymphocytes in ART and in the Dzherelo recipients was 43.2% (2.7%) and 50.4% (-0.5%) respectively. The CD4/CD8 ratio in Dzherelo recipients increased from 1.495 to 1.940 (P=0.03) but insignificant in the control: 1.418 to 1.613 (P=0.14). Activated CD3+ HLADR+ T-cells increased from 209 to 264 (P=0.02) and from 161 to 348 (P=0.0007) in ART and Dzherelo recipients respectively. No changes in CD20+ B-lymphocytes were seen in the control, but in Dzherelo patients they declined from 509 to 333 (P=0.00008). The proportion of CD3- CD16+CD56+ NK cells was not affected by ART but addition of Dzherelo raised NK cells from 11.2% to 17.1% (P=0.0001). About three-quarters (14/19) of patients on ART displayed decrease in viral load (1718 to 1419 copies/ml; P=0.008), while 95% of patients on Dzherelo had a decrease (1793 to 1368; P=0.001). Dzherelo has a favorable effect on the immune status and viral burden when given as an immunomodulating adjunct to ART.

Changes in CD4+ T-cells and HIV RNA resulting from combination of anti-TB therapy with Dzherelo in TB/HIV dually infected patients

The open-label, phase II clinical trial of antituberculosis therapy (ATT) with or without oral immunomodulator Dzherelo (Immunoxel) was conducted in TB/HIV coinfected, antiretroviral therapy naïve patients to evaluate the effect on CD4 T-lymphocyte counts and viral load. The arm A (n = 20) received isoniazid (H); rimfapicin (R); pyrazinamide (Z); streptomycin (S); and ethambutol (E), and arm B (n = 20) received 50 drops of Dzherelo twice per day in addition to HRZSE. After 2 months in 90% of Dzherelo patients the population of absolute CD4 T-cells expanded by an average of 71.2% (from 174 to 283 cells/microl; P = 0.00003), but declined in ATT-alone patients (182 to 174; P = 0.34). The ratio between CD4/CD8 cells deteriorated in 80% of individuals in arm A (1.213 > 0.943; P = 0.002), but improved in the same proportion of patients in arm B (1.244 > 1.536; P = 0.007). The number of total CD3+ lymphocytes rose from 728 to 921 cells in arm B (P = 0.025) whereas it fell from 650 to 585 cells in arm A (P = 0.25). The viral load, as measured by plasma RNA-PCR, decreased in 70% of Dzherelo recipients (2.174 > 1.558 copies/ml; P = 0.002), but increased in 70% of HRZSE only receivers (1.907 > 2.076 copies/ml; P = 0.03). Dzherelo has a favorable effect on the immune status and viral burden in TB/HIV patients when given as an immunomodulating adjunct to ATT.

Effect of oral immunomodulator Dzherelo in TB/HIV co-infected patients receiving anti-tuberculosis therapy under DOTS

Open-label, phase II clinical trial was conducted in 40 HIV/TB dually infected patients to evaluate the effect of oral immunomodulator Dzherelo on immune and viral parameters. The anti-retroviral therapy naïve patients were randomized into two equal groups to be given anti-tuberculosis therapy (ATT) under DOTS. The arm A, which served as a control, received Isoniazid (H); Rimfapicin (R); Pyrazinamide (Z); Streptomycin (S); and Ethambutol (E), and arm B received 50 drops of Dzherelo twice per day in addition to the daily dose of HRZSE. After 2months the total CD3+ lymphocytes increased from 728 to 921cells/microl (P=0.025) in Dzherelo recipients, whereas in the control group they decreased from 651 to 585 cells (P=0.25). The population of CD4 T-cells expanded in Dzherelo arm (174 to 283; P=0.00003) but declined in ATT group (182 to 174; P=0.34). The CD8 cells fluctuated slightly upward in both groups: 159>180 (P=0.17) and 159>183 (P=0.13). The ratio between CD4/CD8 cells deteriorated in arm A (1.213>0.943; P=0.002) but improved in arm B (1.244>1.536; P=0.007). The percent of CD3+HLA-DR+ activated lymphocytes had fallen in ATT group (22.6>20.5; P=0.004), but rose in Dzherelo recipients (21.5>30.5; P=0.0001). The changes in CD20+ B lymphocytes were insignificant in both arms (28.4%>28.6%; P=0.4) and (27.2%>26.7%; P=0.38). No difference was seen in the amount of CD3-CD16+CD56+ natural killer (NK) cells in arm A (21.3%>22.6%; P=0.1), while in Dzherelo recipients they declined significantly (19.9%>14.5%; P=0.0026). The viral load, measured by plasma RNA-PCR, decreased in Dzherelo group (2174>1558; P=0.002), but increased in ATT group (1907>2076 copies/ml; P=0.03). Dzherelo has a favorable effect on the immune status and viral burden in HIV/TB patients when given as the immunomodulating adjunct to ATT.

[Phytoconcentrates "dzherelo" and "lizorm" in therapy of autoimmune thyroiditis]

Treatment of patients with autoimmune thyroiditis with phytoconcentrates dzherelo and lizorm has been shown to improve the patients general well-being, alleviate gross manifestations of the condition, impede the development of the autoimmune process. The above therapy is well-tolerated, has no hepato-/nephrotoxic effect, causes no functional/structural disturbances, and does not affect the sizes of the thyroid gland. The phytoconcentrates dzherelo and lizorm can be recommended as treatment of autoimmune thyroiditis (euthyroid state, mild hypothyroisis, in those settings where activity of the autoimmune process is not very high.

[Phytopreparation Diabetin in treatment of patients with insulin-independent diabetes mellitus]

The phytopreparation "Diabetin" has a sugar-reducing, anorexigenic effects, facilitates loss of flesh lowering the body mass, causes the manifestations of diabetic angio- and neuropathies to delay. It is recommended as treatment of a mild form of diabetes as monotherapy or in moderately severe course of the trouble it can be used in combination with other peroral sugar-lowering drug preparations.