Multielement Determination in Medicinal Plants and Herbal Medicines Containing Cynara scolymus L., Harpagophytum procumbens D.C., and Maytenus ilifolia (Mart.) ex Reiss from Brazil Using ICP OES

Worldwide, medicinal plants and herbal medicines are widely consumed. The aim of this study was to determine macro- (Ca, K, Mg, Na, and P) and microelements (Al, As, Ba, Cd, Co, Cr, Cu, Fe, Mn, Mo, Ni, Pb, Sb, Se, Si, Sn, Sr, V, and Zn) in medicinal plants and herbal medicines: "globe artichoke" - Cynara scolymus L., "devil's claw" - Harpagophytum procumbens D.C., and "espinheira santa" - Maytenus ilifolia (Mart) ex Reiss. Concentrations of 24 (essential and toxic potentially) elements in samples from Brazil were determined using a sequential optical emission spectrometer with inductively coupled plasma optical emission spectrometry (ICP OES) after acid digestion, assisted by microwave radiation. Principal component analysis (PCA) and hierarchical cluster analysis (HCA) were used to carry out an exploratory analysis of samples. The elements were quantified (in μg/g): Al (20.24-1261.64), Ba (18.90-63.18), Ca (2877.6-19,957.40), Cr (0.28-1.38), Cu (4.16-21.99), Fe (8.54-627.49), K (1786.12-32,297.19), Mg (505.82-6174.52), Mn (0.40-205.64), Na (1717.23-18,596.45), Ni (< LoQ-0.99), P (35.12-2899.91), Se (1.52-3.71), Sn (1.53-12.43), Sr (52.33-84.31), V (< LoQ-0.24), and Zn (2.60-30.56). As, Cd, Co, Mo, Pb, and Sb, in all the investigated samples, were found to be below the limit of detection (LoD) and quantification (LoQ) values of ICP OES. These medicinal plants and herbal medicines can be sources of Ca, K, Mg, Na, P, Cu, Fe, Mn, Se, and Zn. All samples showed considerable levels of Al. PCA and HCA showed that the samples separated into two large groups.

Analysis of Effectiveness of a Supplement Combining Harpagophytum procumbens, Zingiber officinale and Bixa orellana in Healthy Recreational Runners with Self-Reported Knee Pain: A Pilot, Randomized, Triple-Blind, Placebo-Controlled Trial

Recreational running (RR) is becoming a popular way to increase physical activity for improving health, together with a higher incidence of knee injuries. The aim was to analyze the effect of a four-week supplementation with a mixture of Harpagophytum procumbens, Zingiber officinale and Bixa orellana on males, middle-aged, RR with an undiagnosed knee discomfort. A randomized triple-blind placebo-control trial was conducted among male RR aged 40-60 years suffering from self-declared knee discomfort after training. Participants were assigned to supplementation (2 g/day in 6 doses; n  =  13; intervention group (IG)) or matched placebo (n  =  15; control group (CG)) for 4 weeks. At pre- and post-intervention, assessment of routine blood biomarkers, body composition, running biomechanics and body temperature was performed using standardized procedures. Machine learning (ML) techniques were used to classify whether subjects belonged to IG or CG. ML model was able to correctly classify individuals as IG or CG with a median accuracy of 0.857. Leg fat mass decreased significantly (p = 0.037) and a deeper reduction in knee thermograms was observed in IG (p < 0.05). Safety evaluation revealed no significant differences in the rest of parameters studied. Subjects belonging to IG or CG are clearly differentiated, pointing into an effect of the supplement of ameliorating inflammation.

Antiarthritic Effects of a Root Extract from Harpagophytum procumbens DC: Novel Insights into the Molecular Mechanisms and Possible Bioactive Phytochemicals

Harpagophytum procumbens (Burch.) DC. ex Meisn. is a traditional remedy for osteoarticular diseases, including osteoarthritis (OA), although the bioactive constituents and mechanisms involved are yet to be clarified. In the present study, an aqueous H. procumbens root extract (HPE; containing 1.2% harpagoside) was characterized for its effects on synoviocytes from OA patients and phytochemical composition in polyphenols, and volatile compounds were detected. HPE powder was dissolved in different solvents, including deionized water (HPE_H2O), DMSO (HPE_DMSO), 100% v/v ethanol (HPE_EtOH100), and 50% v/v ethanol (HPE_EtOH50). The highest polyphenol levels were found in HPE_DMSO and HPE_EtOH50, whereas different volatile compounds, mainly β-caryophyllene and eugenol, were detected in all the extracts except for HPE_H2O. HPE_H2O and HPE_DMSO were able to enhance CB2 receptor expression and to downregulate PI-PLC β2 in synovial membranes; moreover, all the extracts inhibited FAAH activity. The present results highlight for the first time a multitarget modulation of the endocannabinoid system by HPE, likely ascribable to its hydrosoluble compounds, along with the presence of volatile compounds in H. procumbens root. Although hydrosoluble compounds seem to be mainly responsible for endocannabinoid modulation by HPE, a possible contribution of volatile compounds can be suggested, strengthening the hypothesis that the entire phytocomplex can contribute to the H. procumbens healing properties.

Herbal medicine for low-back pain

BACKGROUND

Low-back pain (LBP) is a common condition and imposes a substantial economic burden upon people living in industrialized societies. A large proportion of people with chronic LBP use complementary and alternative medicine (CAM), visit CAM practitioners, or both. Several herbal medicines have been purported for use in treating people with LBP. This is an update of a Cochrane Review first published in 2006.

OBJECTIVES

To determine the effectiveness of herbal medicine for non-specific LBP.

SEARCH METHODS

We searched the following electronic databases up to September 2014: MEDLINE, EMBASE, CENTRAL, CINAHL, Clinical Trials.gov, World Health Organization International Clinical Trials Registry Portal and PubMed; checked reference lists in review articles, guidelines and retrieved trials; and personally contacted individuals with expertise in this area.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) examining adults (over 18 years of age) suffering from acute, sub-acute, or chronic non-specific LBP. The interventions were herbal medicines which we defined as plants used for medicinal purposes in any form. Primary outcome measures were pain and function.

DATA COLLECTION AND ANALYSIS

A library scientist with the Cochrane Back Review Group conducted the database searches. One review author contacted content experts and acquired relevant citations. We downloaded full references and abstracts of the identified studies and retrieved a hard copy of each study for final inclusion decisions. Two review authors assessed risk of bias, GRADE criteria (GRADE 2004), and CONSORT compliance and a random subset were compared to assessments by a third individual. Two review authors assessed clinical relevance and resolved any disagreements by consensus.

MAIN RESULTS

We included 14 RCTs (2050 participants) in this review. One trial on Solidago chilensis M. (Brazilian arnica) (20 participants) found very low quality evidence of reduction in perception of pain and improved flexibility with application of Brazilian arnica-containing gel twice daily as compared to placebo gel. Capsicum frutescens cream or plaster probably produces more favourable results than placebo in people with chronic LBP (three trials, 755 participants, moderate quality evidence). Based on current evidence, it is not clear whether topical capsicum cream is more beneficial for treating people with acute LBP compared to placebo (one trial, 40 participants, low quality evidence). Another trial found equivalence of C. frutescens cream to a homeopathic ointment (one trial, 161 participants, very low quality evidence). Daily doses of Harpagophytum procumbens (devil's claw), standardized to 50 mg or 100 mg harpagoside, may be better than placebo for short-term improvements in pain and may reduce use of rescue medication (two trials, 315 participants, low quality evidence). Another H. procumbens trial demonstrated relative equivalence to 12.5 mg per day of rofecoxib (Vioxx®) but was of very low quality (one trial, 88 participants, very low quality). Daily doses of Salix alba (white willow bark), standardized to 120 mg or 240 mg salicin, are probably better than placebo for short-term improvements in pain and rescue medication (two trials, 261 participants, moderate quality evidence). An additional trial demonstrated relative equivalence to 12.5 mg per day of rofecoxib (one trial, 228 participants) but was graded as very low quality evidence. S. alba minimally affected platelet thrombosis versus a cardioprotective dose of acetylsalicylate (one trial, 51 participants). One trial (120 participants) examining Symphytum officinale L. (comfrey root extract) found low quality evidence that a Kytta-Salbe comfrey extract ointment is better than placebo ointment for short-term improvements in pain as assessed by VAS. Aromatic lavender essential oil applied by acupressure may reduce subjective pain intensity and improve lateral spine flexion and walking time compared to untreated participants (one trial, 61 participants,very low quality evidence). No significant adverse events were noted within the included trials.

AUTHORS' CONCLUSIONS

C. frutescens (Cayenne) reduces pain more than placebo. Although H. procumbens, S. alba, S. officinale L., S. chilensis, and lavender essential oil also seem to reduce pain more than placebo, evidence for these substances was of moderate quality at best. Additional well-designed large trials are needed to test these herbal medicines against standard treatments. In general, the completeness of reporting in these trials was poor. Trialists should refer to the CONSORT statement extension for reporting trials of herbal medicine interventions.

The use of glucosamine, devil's claw (Harpagophytum procumbens), and acupuncture as complementary and alternative treatments for osteoarthritis

Osteoarthritis is one of the most common chronic inflammatory conditions seen in the general population. Current pharmacological treatments focus on reduction of pain and increased mobility to improve overall quality of life. However, the relief afforded by current standard care is often insufficient and can be associated with significant side effects. Many patients, therefore, seek the option of non-standard therapies, such as nutritional and herbal supplements, acupuncture, and exercise regimens. Glucosamine, Harpagophytum procumbens, and acupuncture are among the most commonly used complementary and alternative medicine approaches utilized by patients suffering from osteoarthritis. Their clinical relevance, safety, and potential mechanisms of action are discussed in this review.

Impact of herbal medicines on physical impairment

The usefulness of recording physical impairment during intervention studies in chronic low back patients has been questioned. A re-analysis of all of our studies investigating aqueous extracts of Harpagophytum procumbens and a proprietary ethanolic Salix extract for chronic non-specific low back pain revealed that the "physical impairment" component of the Arhus low back pain index changed very little during treatment despite appreciable changes in the other two components, "pain" and "disability", over time. For comparison, we also extracted data from the literature on the topical use of capsaicin, which showed the same thing. There may be little to lose from omitting the time-consuming assessments of "physical impairment" in studies of the (primarily analgesic) effectiveness of herbal preparations.

Effectiveness and safety of Devil's Claw tablets in patients with general rheumatic disorders

Arthritis and other rheumatic conditions (AORC) are the leading cause of disability, are associated with poor quality of life and incur considerable direct and indirect costs. It is considered that the instance of AORC will continue to increase. To assess the effectiveness, safety and tolerability of Harpagophytum (Bioforce) in the treatment of AORC, a single group open study of 8 weeks duration (259 patients) was performed in the United Kingdom. Effectiveness was assessed by numeric rating scales, the Western Ontario and McMasters Universities Osteoarthritis (WOMAC) Index and the Algofunctional Hand Osteoarthritis Index. Tolerance was measured by a numeric rating scale and safety by self-reporting, blood analysis and liver function tests. Quality of life was measured by SF-12 questionnaire. There were statistically significant (p < 0.0001) improvements in patient assessment of global pain, stiffness and function. There were also statistically significant reductions in mean pain scores for hand, wrist, elbow, shoulder, hip, knee and back pain. Quality of life measurements (SF-12) were significantly increased from baseline and 60% patients either reduced or stopped concomitant pain medication. Harpagophytum is an effective and well-tolerated serious treatment option for mild to moderate degenerative rheumatic disorders providing improved quality of life measure.

Dietary supplements for osteoarthritis

A large number of dietary supplements are promoted to patients with osteoarthritis and as many as one third of those patients have used a supplement to treat their condition. Glucosamine-containing supplements are among the most commonly used products for osteoarthritis. Although the evidence is not entirely consistent, most research suggests that glucosamine sulfate can improve symptoms of pain related to osteoarthritis, as well as slow disease progression in patients with osteoarthritis of the knee. Chondroitin sulfate also appears to reduce osteoarthritis symptoms and is often combined with glucosamine, but there is no reliable evidence that the combination is more effective than either agent alone. S-adenosylmethionine may reduce pain but high costs and product quality issues limit its use. Several other supplements are promoted for treating osteoarthritis, such as methylsulfonylmethane, Harpagophytum procumbens (devil's claw), Curcuma longa (turmeric), and Zingiber officinale (ginger), but there is insufficient reliable evidence regarding long-term safety or effectiveness.

Devil's Claw (Harpagophytum procumbens) as a treatment for osteoarthritis: a review of efficacy and safety

BACKGROUND

Osteoarthritis (OA) is a highly prevalent musculoskeletal disorder. Conventional treatment (i.e., the use of nonsteroidal anti-inflammatory drugs-NSAIDs) is associated with well-documented adverse effects. Devil's Claw (Harpagophytum procumbens) a traditional South African herbal remedy used for rheumatic conditions, may be a safer treatment option. To date, 14 clinical trials have assessed its efficacy/ effectiveness in OA.

AIM

To address the two main questions of importance to clinicians: (1) Does Devil's Claw work for the treatment of OA, and (2) Is it safe?

METHODS

A review of the literature on Devil's Claw and OA from 1966 to 2006 was performed using multiple search databases, monographs, and citation tracking. Relevant trials in all languages were identified and included. Both internal validity (i.e., adequacy of the dosage and period of treatment for this condition, reporting of randomization, rates of dropout, blinding, and statistical analysis) and external validity (i.e., inclusion/ exclusion criteria, baseline characteristics of the study populations, trial setting, and the appropriateness of the outcome measures of the trials) were assessed.

RESULTS

Fourteen studies were identified: eight observational studies; 2 comparator trials (1 open, the other randomized to assess clinical effectiveness); and 4 double-blinded, placebo-controlled, randomized controlled trials to assess efficacy. Many of the published trials lacked certain important methodological quality criteria. However, the data from the higher quality studies suggest that Devil's Claw appeared effective in the reduction of the main clinical symptom of pain. The assessment of safety is limited by the small populations generally evaluated in the clinical studies. From the current data, Devil's Claw appears to be associated with minor risk (relative to NSAIDs), but further long-term assessment is required.

CONCLUSIONS

The methodological quality of the existing clinical trials is generally poor, and although they provide some support, there are a considerable number of methodologic caveats that make further clinical investigations warranted. The clinical evidence to date cannot provide a definitive answer to the two questions posed: (1) Does it work? And (2) is it safe? A definitive high-quality trial that addresses the necessary methodologic improvements noted is needed to answer these important clinical questions.

A review of the biological and potential therapeutic actions ofHarpagophytum procumbens

Harpagophytum procumbens (Hp), commonly known as Devil's Claw is a perennial plant which thrives in arid conditions. For centuries, it has been used as a traditional treatment for a variety of illnesses, including fevers, skin complaints, arthritis and diseases of the digestive tract as well as an appetite stimulant. Since its introduction to Europe in the early twentieth century, it has become a popular antiinflammatory and analgesic preparation amongst herbalists for supportive or adjuvant treatment of degenerative joint diseases, tendonitis, headache, backache and menstrual pain. The validity of Hp as an effective antiinflammatory and analgesic preparation, particularly in the relief of arthritic symptoms, has been investigated in numerous animal, clinical and in vitro studies. Although some contradictory evidence exists, the majority of animal studies appear to indicate Hp as an effective antiinflammatory and analgesic preparation in the treatment of acute and subacute inflammation. Clinical trials support Hp as a beneficial treatment for the alleviation of pain and improvement of mobility in a variety of musculoskeletal conditions. Analysis of the in vitro and ex vivo studies that currently exist, indicate that Hp has significant effects on numerous proinflammatory markers. However, the exact mechanism(s) by which Hp may reduce inflammation remain to be elucidated.

The role of adrenal corticosteroids in the anti-inflammatory effect of the whole extract of Harpagophytum procumbens in rats

This study was carried out to evaluate whether the anti-inflammatory response in rats to the whole extract of Harpagophytum procumbens is a consequence of adrenal corticosteroid release. Carrageenan-induced inflammatory responses in the hindpaws were evaluated in control, sham-operated and adrenalectomized rats. The extract was administered orally (by gavage) or intraperitoneally, 30min prior to injury stimulus. Blood samples were then collected, and the number of circulating leukocytes was estimated. Pretreatment with the whole extract of H. procumbens reduced the intensity of inflammatory response in normal, sham-operated and adrenalectomized animals. When administered orally, the extract was ineffective. The reduced number of circulating leukocytes observed following intraperitoneal injection of the extract characterized adrenal hyperactivity. The inhibitory effect of the whole extract of H. procumbens on acute inflammatory response in the rat, when administered intraperitoneally, does not depend on the release of adrenal corticosteroids.

Herbal medicine for low back pain

BACKGROUND

Low-back pain is a common condition and a substantial economic burden in industrialized societies. A large proportion of patients with chronic low-back pain use complementary and alternative medicine (CAM), visit CAM practitioners, or both. Several herbal medicines have been purported for use in low-back pain.

OBJECTIVES

To determine the effectiveness of herbal medicine for non-specific low-back pain.

SEARCH STRATEGY

We searched the following electronic databases: Cochrane Complementary Medicine Field Trials Register (Issue 3, 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005); checked reference lists in review articles, guidelines and retrieved trials; and personally contacted individuals with expertise in this very specialized area.

SELECTION CRITERIA

We included randomized controlled trials, examining adults (over 18 years of age) suffering from acute, sub-acute or chronic non-specific low-back pain. The interventions were herbal medicines, defined as plants that are used for medicinal purposes in any form. Primary outcome measures were pain and function.

DATA COLLECTION AND ANALYSIS

Two authors (JJG & MVT) conducted the database searches. One author contacted content experts and acquired relevant citations. Full references and abstracts of the identified studies were downloaded. A hard copy was retrieved for final inclusion decisions. Methodological quality and clinical relevance were assessed separately by two individuals. Disagreements were resolved by consensus.

MAIN RESULTS

Ten trials were included in this review. Two high quality trials examining the effects of Harpagophytum Procumbens (Devil's Claw) found strong evidence that daily doses standardized to 50 mg or 100 mg harpagoside were better than placebo for short-term improvements in pain and rescue medication. Another high quality trial demonstrated relative equivalence to 12.5 mg per day of rofecoxib (Vioxx). Two trials examining the effects of Salix Alba (White Willow Bark) found moderate evidence that daily doses standardized to 120 mg or 240 mg salicin were better than placebo for short-term improvements in pain and rescue medication. An additional trial demonstrated relative equivalence to 12.5 mg per day of rofecoxib. Three low quality trials on Capsicum Frutescens (Cayenne), examining various topical preparations, found moderate evidence that Capsicum Frutescens produced more favourable results than placebo and one trial found equivalence to a homeopathic ointment.

AUTHORS' CONCLUSIONS

Harpagophytum Procumbens, Salix Alba and Capsicum Frutescens seem to reduce pain more than placebo. Additional trials testing these herbal medicines against standard treatments are needed. The quality of reporting in these trials was generally poor. Trialists should refer to the CONSORT statement extension for reporting trials of herbal medicine interventions.

Devil's Claw (Harpagophytum procumbens DC): an evidence-based systematic review by the Natural Standard Research Collaboration

An evidence-based systematic review including written and statistical analysis of scientific literature, expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interaction, adverse effects, toxicology, and dosing.

A 1-year follow-up after a pilot study with Doloteffin for low back pain

OBJECTIVE

To complete a year's follow-up on patients from a 6-week double-blind pilot comparison between 44 Doloteffin patients and 44 rofecoxib patients being treated for acute exacerbations of chronic low back pain.

METHODS

38 "ex-Doloteffin" (ex-D) and 35 "ex-rofecoxib" (ex-R) received Doloteffin containing 60 mg harpagoside per day for up to 54 weeks. Pain, additional analgesics, mobility, general health and adverse events were assessed from diary records and at 6-week visits.

RESULTS

53 patients remained in the follow-up at 24 weeks and 43 at 54 weeks. There was never any convincing difference between ex-D and ex-R patients in the number of patients remaining in follow-up, diary pain scores, additional analgesics, Arhus Index and health assessment questionnaire scores (HAQ). Individual fluctuations notwithstanding, the follow-up showed a slight overall improvement on the improvements in Arhus and HAQ scores achieved in the pilot study (MANOVA p = 0.016). Of the 21761 patient-days, the respective percentages with no, mild, moderate, severe and excruciating pain were 28%, 39%, 22%, 8.5% and 1.5%, respectively. Few patients requested additional treatments for their pain. Three patients suffered from minor adverse drug reactions.

CONCLUSION

Long-term treatment with Doloteffin was well tolerated. Ex-R and ex-D patients behaved similarly during the follow-up.

Analgesic, antiinflammatory and antidiabetic properties ofHarpagophytum procumbens DC (Pedaliaceae) secondary root aqueous extract

South Africa is blessed with a rich floral biodiversity of medicinally useful plants. One such plant is Harpagophytum procumbens DC (Family: Pedaliaceae). H. procumbens is widely used in South African traditional medicine for the treatment, management and/or control of a variety of human ailments. In the present study, the analgesic effect of H. procumbens secondary root aqueous extract was evaluated in mice, using the 'hot-plate' and 'acetic acid' test methods; while the antiinflammatory and antidiabetic effects of the plant's secondary root extract were investigated in rats. Fresh egg albumin-induced pedal oedema and streptozotocin (STZ)-induced diabetes mellitus were used as experimental test models of inflammation and diabetes Diclofenac (DIC, 100 mg/kg i.p.) was used as a reference analgesic and antiinflammatory agent for comparison. Chlorpropamide (250 mg/kg p.o.) was used as a reference hypoglycaemic agent for comparison. H. procumbens root aqueous extract (HPE, 50-800 mg/kg i.p.) produced significant (p < 0.05-0.001) analgesic effects against thermally and chemically induced nociceptive pain stimuli in mice. H. procumbens root extract (HPE, 50-800 mg/kg i.p.) also produced dose-related, significant reductions (p < 0.05-0.001) of the fresh egg albumin-induced acute inflammation of the rat hind paw oedema. Furthermore, the plant extract (HPE, 50-800 mg/kg i.p.) produced dose-dependent, significant reductions (p < 0.05-0.001) in the blood glucose concentrations of both fasted normal and fasted diabetic rats. The results of this experimental animal study indicate that H. procumbens root aqueous extract possesses analgesic, antiinflammatory and hypoglycaemic properties, and lend pharmacological support to the suggested folklore uses of Harpagophytum procumbens root in the management and/or control of painful, arthritic and other inflammatory conditions, as well as for adult-onset, type-2 diabetes mellitus in some communities of South Africa.

Harpgophytum procumbens for osteoarthritis and low back pain: a systematic review

BACKGROUND

The objective of this review is to determine the effectiveness of Harpagophytum procumbens preparations in the treatment of various forms of musculoskeletal pain.

METHODS

Several databases and other sources were searched to identify randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials testing Harpagophytum preparations in adults suffering from pain due to osteoarthritis or low back pain.

RESULTS

Given the clinical heterogeneity and insufficient data for statistical pooling, trials were described in a narrative way, taking into consideration methodological quality scores. Twelve trials were included with six investigating osteoarthritis (two were identical trials), four low back pain, and three mixed-pain conditions.

CONCLUSIONS

There is limited evidence for an ethanolic Harpagophytum extract containing less than <30 mg harpagoside per day in the treatment of knee and hip osteoarthritis. There is moderate evidence of effectiveness for (1) the use of a Harpagophytum powder at 60 mg harpagoside in the treatment of osteoarthritis of the spine, hip and knee; (2) the use of an aqueous Harpagophytum extract at a daily dose of 100 mg harpagoside in the treatment of acute exacerbations of chronic non-specific low back pain; and (3) the use of an aqueous extract of Harpagophytum procumbens at 60 mg harpagoside being non-inferior to 12.5 mg rofecoxib per day for chronic non-specific low-back pain (NSLBP) in the short term. Strong evidence exists for the use of an aqueous Harpagophytum extract at a daily dose equivalent of 50 mg harpagoside in the treatment of acute exacerbations of chronic NSLBP.

Harpagophytum procumbens suppresses lipopolysaccharide-stimulated expressions of cyclooxygenase-2 and inducible nitric oxide synthase in fibroblast cell line L929

Harpagophytum procumbens (Pedaliaceae) has been used for the treatment of pain and arthritis. The effect of Harpagophytum procumbens against lipopolysaccharide-induced inflammation was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, reverse transcription-polymerase chain reaction, prostaglandin E(2) (PGE(2)) immunoassay, and nitric oxide detection on mouse fibroblast cell line L929. The aqueous extract of Harpagophytum procumbens was shown to suppress PGE(2) synthesis and nitric oxide production by inhibiting lipopolysaccharide-stimulated enhancement of the cyclooxygenase-2 and inducible nitric oxide synthase (iNOS) mRNAs expressions in L929 cells. These results suggest that Harpagophytum procumbens exerts anti-inflammatory and analgesic effects probably by suppressing cyclooxygenase-2 and iNOS expressions.

Wirksamkeit pflanzlicher Schmerzmittel am Beispiel des Teufelskrallenwurzelextrakts

Preparations from devil's claw differ in their content of active ingredients as assessed by the quantity of harpagoside present. The harpagoside content in the daily dose of Doloteffin (extraction solvent water) is double that of preparations extracted with 60% ethanol. Only preparations with proven effectiveness for painful lower back or arthrotic pain are an attractive alternative to synthetic analgesics, and are of substantial benefit in the treatment of chronic pain. From an evidence based view, extract with at least 50 mg harpagoside in the daily dose should be recommended for the treatment of pain. Treatment with devil's claw extract is associated with a lower risk of adverse events than treatment with synthetic analgesics, and may contribute in the majority of patients to the relief of pain.

Evaluation of acute and chronic treatments with Harpagophytum procumbens on Freund's adjuvant-induced arthritis in rats

The extract of Harpagophytum procumbens, widely utilized in Europe and, more recently, in other countries, is traditionally indicated to treat inflammatory processes. Harpagophytum procumbens acts by way of interleukins and leukocyte migration to the painful and inflamed joint area. Chemically, its secondary tuberous roots contains iridoid glycosides, harpagogide, procumbide, and harpagoside, as the active principle. The purpose of the present study was evaluate the therapeutic potential as anti-inflammatory and analgesic agent in rat model of Freund's adjuvant-induced arthritis both in the acute and chronic phases. The animals were injected with Freund's adjuvant in sub-plantar tissue of the right posterior paw and randomly assigned in acute (25, 50, or 100 mg/kg) or chronic (100 mg/kg) treatments with Harpagophytum procumbens solution test or vehicle. Then, submitted to behavioral test and assessment of body weight and right paw's measurements. The results show that Harpagophytum procumbens extract increased the animals 'latency of paws' withdrawal, indicating a protective effect against the pain induced by the thermal stimulus, both in acute and chronic treatments. In addition to reduction in the right paw edema in the experimental groups when compared to control group. Thus, the data showed anti-inflammatory and peripheral analgesic properties of Harpagophytum procumbens extract with all doses tested, thus confirming its indication for inflammatory processes.

Effectiveness of Harpagophytum extracts and clinical efficacy

Various preparations from Harpagophytum procumbens are used for the treatment of pain in the joints and lower back. Studies published in peer reviewed journals were examined for their clinical evidence. The studies offering preparations with 50-60 mg harpagoside in the daily dosage are of better quality and provide more reliable evidence on efficacy than a proprietary ethanol extract with half the amount of harpagoside per day. However, confirmatory studies are required for all extracts before they can gain a place in treatment guidelines.

Treatment of patients with arthrosis of hip or knee with an aqueous extract of devil's claw (Harpagophytum procumbens DC.)

Preparations made from the secondary tubers of Devil's claw (Harpagophytum procumbens) are successfully used in patients with rheumatic diseases (arthrosis and low back pain). In order to add data on the efficacy and long-term safety of an aqueous extract (Doloteffin; 2400 mg extract daily, corresponding to 50 mg harpagoside), which has been tested successfully in patients with low back pain, an uncontrolled multicentre drug surveillance study for about 12 weeks was conducted in 75 patients with arthrosis of the hip or knee. To standardize the assessment of treatment effects, the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index (10 point scale) as well as the 10 cm VAS pain scale were used. The results of the study revealed a strong reduction of pain and the symptoms of osteoarthritis. There was a relevant improvement of each WOMAC subscale as well as of the total WOMAC index: 23.8% for the pain subscale, 22.2% for the stiffness subscale and 23.1% for the physical function subscale. The WOMAC total score was reduced by 22.9%. VAS pain scores were decreased by 25.8% for actual pain, 25.2% for average pain, 22.6% for worst pain and 24.5% for the total pain score. The physicians reported a continuous improvement in typical clinical findings such as 45.5% for pain on palpation, 35% for limitation of mobility and 25.4% for joint crepitus. Only two cases of possible adverse drug reactions were reported (dyspeptic complaints and a sensation of fullness). Although this was an open clinical study, the results suggest that this Devil's claw extract has a clinically beneficial effect in the treatment of arthrosis of the hip or knee.

New and known iridoid- and phenylethanoid glycosides from Harpagophytum procumbens and their in vitro inhibition of human leukocyte elastase

Ten compounds, harpagoside (1), 8- p-coumaroylharpagide (2), 8-feruloylharpagide (3), 8-cinnamoylmyoporoside (4), pagoside (5), acteoside (6), isoacteoside (7), 6'- O-acetylacteoside (8), cinnamic acid (9) and caffeic acid (10) were isolated from the storage roots of Harpagophytum procumbens, Pedaliaceae. Compounds 1, 2, 6, 7 and 9 are known for H. procumbens; 3 and 10 were isolated the first time from H. procumbens; compounds 4, 5 and 8 are new natural products. Their structures were elucidated using spectroscopic data (NMR, with NOE, COSY and HMBC experiments, UV, [alpha]). The inhibitory activity of aqueous extracts of the roots of H. procumbens and H. zeyheri as well as the main compounds isolated from H. procumbens was tested on human neutrophile elastase. Although inhibition was comparatively weak a dose-dependence was observed. An IC (50) of 542 microg/mL was determined for the aqueous extract of H. procumbens, but 1012 microg/mL for that of H. zeyheri. 6'- O-Acetylacteoside (8), that is not present in H. zeyheri, inhibited the enzyme with an IC (50) of 47 microg/mL (70 microM), compound 7 with 179 microg/mL (286 microM), 2 with 179 microg/mL (331 microM), 5 with 154 microg/mL (260 microM) and 10, which was also used as reference compound, with an IC (50) of 86 microg/mL (475 microM). The IC (50) values of acteoside, harpagoside, cinnamic acid and stachyose were higher than 300 microg/mL and thus not further determined.

In vitro antiplasmodial activity of abietane and totarane diterpenes isolated from Harpagophytum procumbens (devil's claw)

The development of drug resistance and resurgence of malaria has highlighted the need for new chemically diverse antimalarial drugs. This study investigates Harpagophytum procumbens DC. as a source of antiplasmodial hit compounds. The roots of wild harvested plants as well as the aerial sections, seeds and roots of cultivated H. procumbens were evaluated for in vitro antiplasmodial activity. Bioassay-guided fractionation of the petroleum ether root extract yielded two diterpenes, (+)-8,11,13-totaratriene-12,13-diol (1) and (+)-8,11,13-abietatrien-12-ol (2). Compounds 1 and 2 displayed significant (IC50 < 1 microg/mL) in vitro antiplasmodial activity against a chloroquine-resistant (K1) and -sensitive (D10) strain of Plasmodium falciparum, and low cytotoxicity (SI > 65) against two mammalian cell lines (CHO and HepG2). It was found that 1 and 2 did not modify the erythrocyte shape, which in conjunction with the cytotoxicity results, indicates selective antiplasmodial activity.

The quality of clinical trials with Harpagophytum procumbens

OBJECTIVE

To examine systematically the quality of the clinical trials investigating the effectiveness of Harpagophytum products.

METHODS

Literature searches and enquiries to experts identified 20 studies of treatment with various Harpagophytum products (powder, aqueous and ethanolic extracts) for exacerbations of chronic musculoskeletal pain. Eight were open uncontrolled observational studies, one comparing progress under treatment for pain in back, knee and hip pain. Two were open comparisons with conventional treatment, only one of which was randomised. Ten were double-blinded, randomised controlled comparisons, 8 with placebo and 2 with NSAID comparator treatments. Indices of the internal and external validities were examined by reference to a checklist to see how well the studies answered the questions: do Harpagophytum products work and do they work as well as more conventional comparator treatments?

RESULTS

The uncontrolled trials, though providing useful preliminary estimates of the possible effect of treating various conditions, could not separate the effects of the Harpagophytum product from whatever placebo effect might have been exerted in the circumstances of the study. The 2 open comparisons were open to performance, detection and/or selection bias. Of the 8 randomised double blinded controlled comparisons with placebo, 6 were marred by lack of transparency, one could not provide definitive evidence from its pre-selected principal outcome measure, and one provided good quality evidence of a dose dependent superiority of effect over placebo, though this was with a product that is not generally available for clinical practice. One of the randomised controlled comparisons with comparator (Doloteffin versus rofecoxib) was intended only as a pilot and studied too few patients for definitive conclusions whereas the other did provide good evidence that the powder, Harpadol is not importantly less effective than the weak NSAID diacerhein.

CONCLUSIONS

Evidence of effectiveness of Harpagophytum products is not transferrable from product to product. The results of some studies suggest some effectiveness for some products, but for none of the clinically available products is the quality of evidence totally satisfactory. It is better so far with products that contain at least 50 mg of harpagoside in the daily dosage than with products (which happen to be of ethanolic extraction) that contain less.

A randomized double-blind pilot study comparing Doloteffin and Vioxx in the treatment of low back pain

OBJECTIVE

This randomized, double-dummy, double-blind pilot study of acutely exacerbated low back pain was aimed to inform a definitive comparison between Doloteffin, a proprietary extract of Harpagophytum, and rofecoxib, a selective inhibitor of cyclo-oxygenase-2 (COX-2).

METHODS

Forty-four patients (phyto-anti-inflammatory drug-PAID-group) received a daily dose of Doloteffin containing, inter alia, 60 mg of harpagoside for 6 weeks and 44 (non-steroidal anti-inflammatory drug-NSAID-group) received 12.5 mg/day of rofecoxib. All were allowed rescue medication of up to 400 mg/day of tramadol. Several outcome measures were examined at various intervals to obtain estimates of effect size and variability that might be used to decide the most suitable principal outcome measure and corresponding numbers required for a definitive study.

RESULTS

Forty-three PAID and 36 NSAID patients completed the study. Ten PAID and 5 NSAID patients reported no pain without rescue medication for at least 5 days of the 6th week of treatment. Eighteen PAID and 12 NSAID patients had more than a 50% reduction in the week's average of their pain scores between the 1st and 6th weeks. The mean percentage decrease from baseline in the pain component of the Arhus Index was 23 (S.D. 52) in PAID and 26 (S.D. 43) in NSAID. The corresponding measures for the overall Arhus Index were 11 (31) and 16 (24) and, for the Health Assessment Questionnaire, 7 (8) and 6 (7). Tramadol was used by 21 PAID patients and 13 NSAID patients. Fourteen patients in each group experienced 39 adverse effects, of which 28 (13 in PAID) were judged to some degree attributable to the study medications.

CONCLUSION

Though no significant intergroup differences were demonstrable, large numbers will be needed to show equivalence.

Comparison of outcome measures during treatment with the proprietary Harpagophytum extract doloteffin in patients with pain in the lower back, knee or hip

Besides checking estimates of effectiveness and safety of using the proprietary Harpagophytum extract Doloteffin, this postmarketing surveillance compared various disease-specific* and generic** measures of effect. We enrolled 250 patients suffering from nonspecific low back pain (Back group: n = 104) or osteoarthritic pain in the knee (Knee group: n = 85) or hip (Hip group: n = 61). They took an 8-week course of Doloteffin at a dose providing 60 mg harpagoside per day. The measures of effect on pain and disability included the percentage changes from baseline of established instruments (Arhus low back pain index*, WOMAC index*, German version of the HAQ**) and unvalidated measures (total pain index*, three score index*, the patient's global assessment** of the effectiveness of treatment). Patients also received a diary for the daily recording of their pain and any additional treatments for it. The three groups differed in age, weight and characteristics of initial pain. 227 patients completed the study. Multivariate analysis confirmed that several dimensions of effect were recorded by the several outcome measures but, in all groups, both the generic and disease-specific outcome measures improved by week 4 and further by 8. In multivariable analysis, the improvement tended to be more when the initial pain and disability score was more: older patients tended to improve less than younger, the hip group tended to improve convincingly more than the back group, whereas the improvement in the knee group was less readily differentiated from that in the back group. The subgroup of Back patients who required NSAIDs during the 8 weeks used significantly more per patient than patients in the other two groups, but that requirement also declined more with time. About 10% of the patients suffered from minor adverse events that could possibly have been attributable to Doloteffin. Between 50% and 70% of the patients benefitted from Doloteffin with few adverse effects. Thus, Doloteffin is well worth considering for osteoarthritic knee and hip pain and nonspecific low back pain.

Efficacy and tolerance of Harpagophytum extract LI 174 in patients with chronic non-radicular back pain

The aim of this open, multicentre study was to evaluate the clinical effectiveness and tolerance of the Devil's Claw extract LI 174 in patients suffering from non-radicular back pain over a period of at least 6 months. A total of 130 patients were treated twice a day with tablets containing 480 mg LI 174. The treatment lasted for 8 weeks. The effectiveness was judged according to the Multidimensional Pain Scale (MPS), Arhus back pain index and to parameters evaluating the mobility of the lumbar spine (finger-floor distance, Schober's sign). Data from 117 patients were evaluated for efficacy. The results showed a significant improvement of pain symptoms and mobility of the affected sections of the patient's spine in the course of treatment. No serious side effects were observed. In view of the excellent compliance and tolerability the investigated extract appears to be an effective plant alternative for the treatment of chronic back pain. However, further studies will be needed to clarify the therapeutic value of this plant remedy.

[Effects of Harpagophytum procumbens LI 174 (devil's claw) on sensory, motor und vascular muscle reagibility in the treatment of unspecific back pain]

PROBLEM

This randomised, double-blind, placebo controlled study was intended to investigate the effects of Harpagophytum procumbens (Devil's Claw) on sensory, motor and vascular mechanisms of muscle pain. In addition to clinical efficacy and tolerability, possible action mechanisms were analysed by means of experimental algesimetric methods.

METHODOLOGY

The study was performed on patients with slight to moderate muscular tension or slight muscular pain of the back, shoulder and neck. On a double-blind randomised basis the verum group received 2x1 film tablets per day, i. e. 2x480 mg/day, of Harpagophytum extract LI 174 (Rivoltan(R)) at 8.00 a.m. and 8.00 p.m. over a certain period. The duration of the therapy was 4 weeks. Data recording at 14-day intervals was made using a visual analogue scale, pressure algometer test, recording of antinociceptive muscular reflexes, muscle stiffness test, EMG surface activity, muscular ischaemia test, clinical global score and subjective patient and physician ratings.

RESULTS

A total of 31 patients in the verum group and 32 in the placebo group were treated. After four weeks of treatment there was found to be a clear clinical efficacy of the verum on the clinical global score and in the patient and physician ratings. Highly significant effects were found in the visual analogue scale, the pressure algometer test, the muscle stiffness test and the muscular ischaemia test. No difference from placebo was found in the recording of antinociceptive muscular reflexes or in the EMG surface activity. Tolerability was good; no serious adverse effects occurred.

CONCLUSIONS

A highly significant clinical efficacy was achieved with a monotherapy of Harpagophytum dry extract LI 174 after four weeks' treatment at a dosage of 2x480 mg/day in cases of slight to moderate muscular pain. With regard to the action mechanisms investigated, it may be concluded that treatment with Harpagophytum extract LI 174 may be expected to have a significant influence on sensory and vascular muscular response and bring about a reduction in muscle stiffness. No central nervous effects were discovered.