The necessity of providing evidence for the therapeutic eff - PowerPoint Presentation

Slide1

The necessity of providing evidence for the therapeutic effectivity of herbal preparations A success journey for STW 5 in gastro-intestinal disorders.

Mohamed T. Khayyal

Faculty of Pharmacy, Cairo UniversitySlide2

Herbal Remedies used by the

Ancient Egyptians

Acacia

(acacia

nilotica

) :

vermifuge

, eases

diarrhoea

and internal bleeding, also used to treat skin diseases.

Aloe

vera

: worms, relieves headaches, soothes chest pains, burns, ulcers and for skin disease and allergies.

Basil

(

ocimum

basilicum

)

: excellent for heart.

Balsam Apple (

malus

sylvestris

) :

laxative, skin allergies, headaches, gums and teeth, for asthma, liver stimulant, digestion.

Bayberry

(

Myrica

cerifera

)

:

stops

diarrhoea

, ulcers,

haemorrhoids

.

Liquorice

(

Glycyrrhiza

glabra

):

laxative

, expels phlegm, liver, pancreas and

chest

respiratory problems.

Fenugreek (

Trigonella

foenumgraecum

): respiratory disorders, cleanses the stomach, calms the liver, soothes pancreas, reduces swelling.

Caraway

(

Carum

carvi

): flatulence

, digestive, breath freshener. Slide3
Slide4

Herbal CombinationsEarly in the history of use of medicinal agents, it was realized that the presence of one herb may alter the effect of the other when they are co-administered.The combined effect, either complementary or antagonistic, would be manifested in the clinical

outcome.

* Herb-Herb Combination for Therapeutic Enhancement and Advancement: Theory, Practice and Future Perspectives

Chun-Tao Che, Zhi Jun Wang, Moses Sing Sum Chow and Christopher Wai Kei Lam

Molecules

2013,

18

, 5125-5141Slide5

Need for evidence based medicineMany herbal medicines have been developed empirically and their therapeutic usefulness proven clinically.Developing models for human disease conditions helps to establish evidence of mechanisms of action and therapeutic usefulness.Evidence increases credibility for both patients and physicians.

Synergism between academia and industry mandatorySlide6

Shown clinically/experimentally to be a multi-target preparation for gastrointestinal disorders, such as:Ulcers (anti-inflammatory & ↓

hyperacidity)

1

Functional

dyspepsia

2

Irritable bowel

syndrome

3

DSS induced colitis4(1) Khayyal MT et al. (2006), Phytomedicine. 2006;13 Suppl 5:56-66. (2) Schmulson MJ (2008) Nature clinical practice gastroenterology & hepatology, 5, 136-137.(3) Madisch A et al. (2004) Aliment Pharmacol Ther, 19: 271-279. (4) Wadie,W. et al. (2012) Int J Colorectal Dis. 2012 Nov;27(11):1445-53.

STW5 (Iberogast

®

) Slide7

STW 5 (Iberogast®, Steigerwald, Germany)Slide8

Anti-ulcerogenic activityin Pyloric – ligated ratsSlide9

Anti-ulcerogenic effect of STW5 & componentsSlide10

Effect of STW5 & components on gastric aciditySlide11

Effect of STW5 & components on gastric mucinSlide12

Effect of STW5 & components on PGE2 in gastric juice Slide13

Effect of STW5 & components on LTD4 in gastric juiceSlide14

ConclusionsIndividual components exert effects in their own right on various parameters relevant to gastric ulcers.Combined effect as STW 5 gives evidence to its beneficial activitySlide15

Novel mechanisms underlying the effectiveness of STW 5 in functional dyspepsia.Slide16

IntroductionFunctional dyspepsia often correlated with subjection to stress at some stage in life.

Clinical evidence suggests that stress in early life followed by stress in adulthood could lead to functional dyspepsia (FD)

1,2,

involving derangement in gastric function.

Present study assesses the value of a novel developed stress model for determining mechanisms involved in the effectiveness of STW 5 in FD.

1

Kim HI et al. J Korean Med Sci 2013;28:431-7;

2

Monnikes H et al. Dig Dis 2001;19:201-11Slide17

Assessment of stress in animal models: Plasma CRFNeonatal maternal stress (NMS)Weanling

Wistar

rats

exposed

to

(NMS) by removing pups from mother cage for 3 h/day from postnatal day 2 till 21 then weaned

.

Restraint

stress (RS)

Adult Wistar rats subjected (RS) by confining them restrained in tightly fitting ventilated Perspex cylinders 90 min/day for 1 week.Plasma CRF measured 24h after last subjection to stress Slide18

Stress induces ↑ plasma CRF, normalization by STW 5Slide19

Sequential model: NMS/RSWeanling rats exposed to NMS

then weaned. Once adult, subjected to

RS for 1

week.

STW

5 (

Iberogast

®

Steigerwald

, Darmstadt, Germany) was administered orally at 2 dose levels (2 and 5 ml/Kg) for 1 week before and during exposure to RS.Experimentation started 24 h after last restraining session.Slide20

Parameters studiedGastric emptying using a phenol red meal*

.

Corticosterone and ghrelin in plasma

S

tomach

fundus strips

tested ex-vivo for sensitivity

towards carbachol, KCl, serotonin and adrenaline.

Duodenal homogenates

examined using qPCR for expression of some signalling and tight junction proteins, including CSE, RelA, Nrf-2, ZO-1, occludin. * Scarpignato C, et al. Arch Int Pharmacodyn Ther1980; 246: 286-94Slide21

Gastric emptying inhibited by model but normalized by STW5Slide22

Plasma corticosterone ↑model tended to be normalized

by STW5Slide23

Plasma ghrelin raised by model hardly

affected by STW5Slide24

Stress induced ↓ fundus sensitivity to carbachol/amelioration by STW5Slide25

Stress induced ↓ fundus sensitivity to KCl amelioration by STW5Slide26

Stress induced ↓ fundus sensitivity to serotonin / improvement by STW5Slide27

Stress induced ↓ fundus sensitivity to adrenaline improvement by STW5Slide28

Stress ↓duodenal ZO1, RelA, Nrf2 & ↑Occludin, CSE expression/ partial improvement by STW5Slide29

Summary & ConclusionsStress model led to marked delay in gastric emptying, raised plasma level of active ghrelin and corticosterone, but reduced expression of Nrf-2 and ZO-1 and

raised

occludin

in duodenal homogenates: changes normalized by STW5

.

Stress

markedly reduced gastric fundus sensitivity of parasympathetic, sympathetic and serotonergic

receptors.

Since

deranged gastric functions (emptying, fundus sensitivity) are among symptoms of FD, present findings help to elucidate mechanisms underlying therapeutic usefulness of STW 5 in that condition.Sequential stress offers a new model for studying agents with potential usefulness in FD Slide30

Novel Therapeutic Potential for STW 5: Prophylactic Measure against Intestinal Mucositis induced by RadiationSlide31

BackgroundExposure to radiotherapy often leads to mucositis of intestinal epithelium, possibly as a result of release of ROS and induction of apoptosis. This severely limits continuation of treatment.Treatment of mucositis usually carried out with agents with anti-inflammatory properties. So far, no standard medication has proved effective in preventing mucositis.

STW 5 was studied for its potential usefulness.Slide32

Induction & Assessment of MucositisMale Wistar rats exposed to whole body gamma radiation levels of 4, 6 and 8 Gy from Cs 137 source.

Animals sacrificed 3 days after exposure, segments of intestine examined histologically.

Intestinal homogenates and serum examined for parameters of apoptosis, inflammation and oxidative stress.Slide33

Rats were divided into the following groups

Non-irradiated control

Acute Irradiated

4

Gy

6

Gy

8

Gy

STW 5 + 8

Gy

STW 5

(2, 5 or 10

ml/kg)

orally for 5 days before and 2 days after radiation exposure. Rats sacrificed one day later.

Experimental DesignSlide34

At SacrificeSegments of small intestine examined histologically.

Intestinal

homogenates and serum

samples

used to

assess

relevant parameters

for:

a) mucosal damage and apoptosis b) inflammation c) oxidative stress. Slide35

Histological ResultsSlide36

STW 5 inhibits radiation induced histological changes dose-dependently

normal

8

Gy

: shortened

villi, activated mucous glands, apoptotic bodies.

STW 5 (2 ml/kg):Short villi, activation of

muc

. glands, inflam. cell infiltration

STW 5 (5ml/kg):

Epith

.

denudation

, few

inflam.cell

infilt

.

activation

of

muc

. glands.

STW 5 (10 ml/kg):

very few

histological

changesSlide37

Semi-quantitative histological assessment of intestinal damageA total score for each proximal jejunal specimen was derived from the sum of scores for 9 histological criteria.

1) number of apoptotic bodies

2) villus fusion and stunting (atrophy)

3) epithelial denudation and erosion

4 ) activation of glandular epithelium

5) reduction in goblet cell number

6) activation of nuclei of enterocytes

7) inflammatory cell infiltration 8) oedema 9) haemorrhage in lamina propria Each histological variable was scored from 0 (normal) to 3 (maximal damage) for each rat intestine. Slide38

Acute irradiation induced intestinal mucosal damageSlide39

STW 5 dose dependently suppresses radiation-induced mucosal damageSlide40

Concluding RemarksAcute exposure to radiation dose levels of 4, 6, and 8 Gy produced graded extents of intestinal mucositis as judged by light and

elecron

microscopy with evidence of apoptotic cells with the highest exposure level.

STW 5 in a dose of 10 ml/kg was most effective in reducing the severity of degenerative changes observed after acute irradiation. Slide41

Markers for Mucosal Damage LDH in serumDiamine oxidase

in serum

TNF

α

in intestinal homogenatesSlide42

Radiation induces release of LDH in serum

Significantly different at P

≤

0.05 from control group (*)Slide43

STW 5 protects against rise in LDH in SerumSlide44

Significantly different at P≤0.05 from control group (*) or from irradiated group (#)

STW 5 suppresses radiation induced rise in serum diamine oxidase (DAO)Slide45

Significantly different at P≤0.05 from control group (*) or from irradiated group (#)

STW 5 suppresses radiation induced rise in intestinal TNF-

αSlide46

Apoptotic markers- Cytosolic calcium

content

-

Mitochondrial

cytochrome c

(pro-apoptotic protein)

- Mitochondrial B-cell lymphoma-2 (Bcl-2) (anti-apoptotic protein)- Mitochondrial respiratory chain complex I activity. Slide47

Radiation induces release of cytosolic Calcium in Intestinal Tissue

Significantly different at P

≤

0.05 from control group (*)Slide48

STW 5 prevents radiation induced rise of cytosolic CalciumSlide49

STW 5 supresses radiation induced depletion in mitochondrial cytochrome c

Significantly different at P

≤

0.05 from control group (*) or from irradiated group (#)Slide50

Significantly different at P≤0.05 from control group (*) or from irradiated group (#)

STW 5 supresses radiation induced depletion in mitochondrial Bcl-2Slide51

Significantly different at P≤0.05 from control group (*) or from irradiated group (#)

STW 5 supresses radiation induced depletion in mitochondrial complex ISlide52

Oxidative stress biomarkersReduced glutathione (GSH) content in intestinal homogenate

Malondialdehyde

(MDA)

content in intestinal homogenateSlide53

Significantly different at P≤0.05 from control group (*) or from irradiated group (#)

STW 5 suppresses radiation induced depletion in intestinal GSHSlide54

Significantly different at P≤0.05 from control group (*) or from irradiated group (#)

STW 5 suppresses radiation induced rise in intestinal MDASlide55

Summary & Conclusions STW 5 protected to a large extent in a dose dependent manner against histological changes induced by gamma radiation and counteracted to different extents the derangement in all the relevant parameters measured suggesting that it may be useful as an adjuvant during radiotherapy to reduce the tendency to develop radiation enteritis.Slide56

Effects of STW 5 and STW 5-II in dextran sodium sulfate-induced colitisSlide57

How does STW 5-II differ from STW 5

Iberis amara

15%

tonicising

anti-inflammatory

Liquorice

10%

spasmolytic

anti-inflammatory

Lemon balm

15%

spasmolytic

anti-inflammatory

Chamomille

30

%

spasmolytic

anti-inflammatory

Caraway

20

%

spasmolytic

bacteriostatic

Peppermint

10%

spasmolytic,

anti-emeticSlide58

Inflammatory Bowel Disease (IBD)1. Crohn‘s Disease: STW 5 found effective in TNBS induced colitis. Abdel-Aziz H, Wadie W, Abdallah DM, Vinson B, Kelber O, Weiser D, Khayyal

MT.

Z.Gastroenterol

. 2008, 46, 362

2. Ulcerative Colitis: STW 5 found effective in DSS induced colitis.

Wadie

W, Abdel-Aziz H, Zaki HF, Kelber O, Weiser D, Khayyal MT (2012) Int.J.Colorectal Dis. 27, 1445 – 1453Slide59

Experimental DesignMale Wistar

rats (n=7-9) administered 5%

Dextran Sodium

Sufate

(DSS)

in drinking water. Lesions in the colon develop within 7 days

.

Drugs

given orally for 1 week before starting adding DSS in the drinking water and continued for a further week. Rats sacrificed. Colon length and weight recorded. The colon was cut longitudinally into 2 segments. One was examined histologically, and the other homogenized

and tested for various relevant parameters.Slide60

STW5 improved abnormal body weight changes. Slide61

STW 5 II prevents body weight lossSlide62

STW5

prevents DSS induced colon shortening.Slide63

STW 5 II tends to prevent colon shorteningSlide64

STW5

protects

against increase in colon weight

(

oedema

formation).Slide65

STW 5 II protects against rise in colon mass indexSlide66

STW5 guards against rise in myeloperoxidase activity induced by DSS (measure of neutrophilic infiltration).Slide67

STW 5 II prevents rise in MPOSlide68

STW 5 prevents

DSS induced

decrease in glutathione

levels.Slide69

STW 5 II prevents DSS induced fall in GSH levelsSlide70

STW5 largely

prevents DSS induced fall

in glutathione

peroxidaseSlide71

STW 5 II protects against DSS induced fall in GPxSlide72

STW5 completely

prevents DSS induced reduction of

SOD

levels

.Slide73

STW 5 II prevents DSS induced fall in colonic SOD levelsSlide74

STW5 completely

protects against DSS induced

rise in

TNF-

α

.Slide75

Histological ExaminationDSS induced following changes:marked necrosis of the

epithelium

intra-luminal

accumulation of mucous

exudates

sub-mucosal oedema

massive

inflammatory cell infiltration in the lamina

propria

and sub-mucosa. The infiltrated inflammatory cells included polymorphonuclear leucocytes, lymphocytes and plasma cells.Treatment with either STW 5 or STW 5 II largely prevented the above changesSlide76

Histology Scores after treatment with STW 5 or STW 5 IISlide77

Conclusions IDSS induced marked colitis, as evidenced by changes in both histological and biochemical parameters. Earlier studies showed that treatment with either STW 5 or sulfasalazine was effective in preventing such changes

(Abdel-Aziz H et al. Gastroenterology 2011; 14: S-

608

).

STW 5 II was developed to contain only 6 of the original components of STW 5 but with modified concentrations.

Present findings show that STW 5 II in a dose of 2 ml/kg was as effective as STW 5 in protecting against DSS-induced changes in both histological and biochemical parameters.

.

Slide78

Conclusions IIThe results point to the good anti-oxidant and anti-inflammatory properties of STW 5 II, imaging those of STW 5.

This

lends support to its potential therapeutic usefulness in inflammatory conditions of the GIT,

such as

ulcerative colitis.Slide79

Final concluding remarksExperimental models help to establish credibility for therapeutic usefulness of herbal combinations for both patients and physicians.The models may help to develop novel therapeutic applications for established preparations.

Close interaction between academia and industry is imperative for better development of herbal medications.Slide80

Thank you for your kind attention

STW 5-II

STW5