1. 1 Seminar sehari Uji Klinik Obat Herbal dalam Meningkatkan Kualitas Hidup Prof Dr dr M.T.Kamaluddin, MSc, SpFK Bagian Farmakologi Fakultas Kedokteran Unsri Palembang, 23 Februari 2013

2. 2 How to use herbal products ; efficaceous - safe

3. 3 Documented improvements Clinical Trials of some Herbal Products Several problems not applicable to synthetic drugs often influence the quality of herbal drugs : 1.Herbal drugs are usually mixtures of many constituents. 2.The active principle(s) is (are), in most cases unknown. 3.Selective analytical methods or reference compounds may not be available commercially. 4.Plant materials are chemically and naturally variable. 5.Chemo-varieties and chemo cultivars exist. 6.The source and quality of the raw material are variable.

4. 4 Chemical products First chemical products derived from herbal pattern Herbal products Long-time experience in phytotherapy Application of plants or parts of plants is historically the basis for any therapy Differences in medicinal products Chemical – Herbal

5. 5 Defined substance(s) as active ingredient(s) This active ingredient is chemically synthetizised and exactly characterized Whole plant extract as active ingredient These extracts are complex multisubstance mixtures Differences in medicinal products Chemical – Herbal Chemical productsHerbal products

6. Aug 2005PROSPAN ® 6 Differences in medicinal products Chemical – Herbal Defined doses of the active ingredient must have equivalent efficacy in every final product Pharmacokinetic studies are easy to perform due to monosubstance character Every substance of the extract may contribute to the efficacy (and tolerability) of the extract Pharmacokinetic studies are nearly impossible to perform due to multisubstance character Chemical productsHerbal products

7. Aug 2005PROSPAN ® 7 Differences in medicinal products Chemical – Herbal Products with the same active ingredient must guarantee the same efficacy –proven by studies respective to bioavailability or bioequivalence Products with an extract of the same plant from different manufacturers may differ in efficacy and tolerability Chemical productsHerbal products

8. Aug 2005PROSPAN ® 8 Differences in medicinal products Herbal – Herbal Herbal extracts of the same plant may be different in efficacy and tolerability !

9. Aug 2005PROSPAN ® 9 Differences in medicinal products Herbal – Herbal Herbal extracts are characterized by:  Kind of extract –Fluid extract –Spissum extract –Dried extract

10. Aug 2005PROSPAN ® 10 Differences in medicinal products Herbal – Herbal  Extractive agent –Influences the kind and amount of extracted substances (lipohilic or hydrophilic) Herbal extracts are characterized by:

11. Aug 2005PROSPAN ® 11 Differences in medicinal products Herbal – Herbal  Drug-Extract-Ratio (DER) –How many drug is used to get 1 g of extract? More or less concentrated! Herbal extracts are characterized by:

12. Aug 2005PROSPAN ® 12 Differences in medicinal products Herbal – Herbal  Composition of the extract itself –respective to quality and quantity of all contained substances Herbal extracts are characterized by:

13. drug facilitymanufact. process herbal extract extracting agent Dependency of the composition of a herbal extract from manufacturing and quality parameters specific extracting agent concentration amount flow rate filling quantity filling height / density static pressure batch size extraction pressure extraction temperature extraction time method of extraction homogeneity portion of powder cutting size content of water content of active substance

14. Aug 2005PROSPAN ® 14 Differences in medicinal products Herbal – Herbal Efficacy and safety of a herbal extract depends on its very special quality! Extracts from the same part of the same plant can show different clinical properties

15. Aug 2005PROSPAN ® 15 Differences in medicinal products Herbal – Herbal Results of clinical studies with an extract of manufacturer A are not automatically valid for the extract of manufacturer B The preparation of an extract and the production process for the medicinal product is based on a very special knowledge in each company!

16. Aug 2005PROSPAN ® 16 Clinical Trials Standardization and quality control of herbal crude drugs –WHO (1996a and b, 1992), is the process involved in the physicochemical evaluation of crude drug covering aspects: selection and handling of crude material, safety, efficacy and stability assessment of finished product, documentation of safety and risk based on experience, provision of product information to consumer and product promotion.

17. Aug 2005PROSPAN ® 17 Clinical Trials Attention in quality indices such as: 1.Macro and microscopic examination: For Identification of right variety and search of adulterants. 2.Foreign organic matter: This involves removal of matter other than source plant to get the drug in pure form. 3.Ash values: These are criteria to judge the identity and purity of crude drug – Total ash, sulphated ash, water soluble ash and acid insoluble ash etc. 4.Moisture content: Checking moisture content helps reduce errors in the estimation of the actual weight of drug material. Low moisture suggests better stability against degradation of product. 5.Extractive values: These are indicative weights of the extractable chemical constituents of crude drug under different solvents environment.

18. Aug 2005PROSPAN ® 18 Clinical Trials 6. Crude fibre: This helps to determine the woody material component, and it is a criterion for judging purity. 7. Qualitative chemical evaluation: This covers identification and characterization of crude drug with respect to phytochemical constituent. It employs different analytical technique to detect and isolate the active constituents. Phytochemical screening techniques involve botanical identification, extraction with suitable solvents, purification, and characterization of the active constituents of pharmaceutical importance.

19. Aug 2005PROSPAN ® 19 Clinical Trials 8. Chromatographic examination: Include identification of crude drug based on the use of major chemical constituents as markers. 9. Quantitative chemical evaluation: To estimate the amount of the major classes of constituents. 10. Toxicological studies: This helps to determine the pesticide residues, potentially toxic elements, safety studies in animals like LD50 and Microbial assay to establish the absence or presence of potentially harmful microorganisms.

20. Clinical Trials Naturally occurring anxiolytic substances from aromatic plants of genus citrus Pimenta, Flávia Cristina Fernandes 1*, Correia, Nadja de Azevedo 2, Albuquerque, Katy Lísias Gondin Dias 2, De Sousa, Damião Peregrino 3, Da Rosa, Marine Raquel Diniz 4, Pimenta, Martina Bragante Fernandes 5, Diniz, Margareth de Fátima Formiga Melo 6 and De Almeida, Reinaldo Nóbrega 2 1Departamento de Medicina Interna, Centro de Ciências Médicas, Universidade Federal da Paraíba, Brazil. 2Departamento de Fisiologia e Patologia, Centro de Ciências da Saúde, Universidade Federal da Paraíba, Brazil. 3Departamento de Fisiologia, Universidade Federal de Sergipe, São Cristóvão-SE, Brazil. 4Departamento de Fonoaudiologia, Centro de Ciências da Saúde, Universidade Federal da Paraíba, Brazil. 5Faculdade de Medicina Nova Esperança – PB, Brazil. 6Departamento de Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal da Paraíba, Brazil. Accepted 8 September, 2011 Currently, anxiety is one of the most common mental disorders affecting humanity and its prevalence is increasing. Anxiolytic substances occupy a prominent post in the ranking of the most utilized drugs by man. However, the anxiolytic drugs have an unfavorable risk/benefit ratio, especially benzodiazepines. Several medicinal plants have been used in traditional folk medicine for their anxiolytic or sedative properties. It is well reported in the literature that aromatic substances have the power to influence emotional states in humans. Several plants rich in essential oil have been used in the treatment of anxiety. In addition, a great number of essential oils are currently in use as aromatherapy agents to relieve stress and depression. These oils are considered a holistic complementary therapy utilized for increased comfort and reduce stress. For this reason, we performed a literature review used papers indexed in Elsevier Science Direct and PubMed a source of research. The dates were collected of reviewed studies from 2000 to 2011 using essential oils of genus citrus with anxiolytic effects in preclinical models and clinical studies. Ethnopharmacological data has confirmed the popular use of plant species of the genus Citrus with sedatives, hypnotics, tranquilizers and anti-epileptics activities to treat disorders of the central nervous system. Given these assumptions, this paper aims to describe the principal evidence in the literature about the use of essential oils of genus citrus with anxiolytic effects in preclinical models and clinical studies. Key words: Genus citrus, anxiolytic effects, preclinical models, clinical studies of anxiety. Journal of Medicinal Plants Research Vol. 6(3), pp. 342-347, 23 January, 2012

21. Clinical Trials Herbs/essential oilEffectSpeciesReference Linalool Anxiolytic, increased social interaction and decreased aggressive behavior MiceLinck et al. (2010) Citrus bergamia oilAnxiolyticRat Carvalho-Freiras and Costa (2002), Pultrini et al. (2006), Saiyudthong and Marsden (2010 ) Cittrus aurantium oilAnxiolytic, sedative and anticonvulsiveRat Leite et al. (2008) Mice Blanco et al. (2009) Cymbopogon citrates- Citrus grass oil Anxiolytic, sedative and AnticonvulsiveMiceFaturi et al. (2010) Citrus sinensis oilAnxiolyticRatKomiya et al. (2006) Citrus lemon oilAnti-stress, SedativeMice Fukumoto et al. (2008) Citrus latifolia and C. reticulata oil Anti-stress and anxiolyticMiceGargano et al. (2008) Table 1. Preclinical studies of essentials oils from genus Citrus and their effects on the central nervous system. Journal of Medicinal Plants Research Vol. 6(3), pp. 342-347, 23 January, 2012

22. 22 Citrus Bergamia (Bergamot) Italy Citrus Lemon Italy - Asia

23. Clinical Trials Experimental designEffectReference 35 patients were exposed to odor orange and the state anxiety was measured through questionnaires. Reduced levels of state- anxiety in female. Lehrner et al. (2000) 50 patients were exposed to odor orange and the state anxiety was measured through questionnaires Lower levels of state anxiety, more positive mood and a higher level of calmness Lehrner et al. (2005) 81 patients were exposed to odor orange and the state anxiety was assessed through questionnaires. No effects on the anticipatory anxiety Toet et al. (2010) Journal of Medicinal Plants Research Vol. 6(3), pp. 342-347, 23 January, 2012 Table 2. Clinical studies of the essential oils of orange ( Citrus sinensis ).

24. Clinical Trials Autoimmune diseases and immunomodulant plant M. M. Akram 1, M. Saim Jamil 1, Zahid Mehmood 2, Khan Usmanghani 1, Iqbal Azhar 4, Muhammad Akram 5, H. M. Asif 3 and Umar Iqbal 1 1Shifa ul Mulk Memorial Hospital, Hamdard University, Karachi, Pakistan. 2Department of Chemistry and Biochemistry, University of Agriculture, Faisalabad, Pakistan. 3Department of Pharmacy, The Islamia University of Bahawalpur, Pakistan. 4Department of Pharmacognosy, University of Karachi, Pakistan. 5Department of Pharmacy, University of Sargodha, Pakistan. Accepted 4 November, 2011 The immune system in general responds appropriately to the presence of foreign antigens. Body immune system protects the body against invading organisms. In an autoimmune disease, immune system attacks healthy cells in body by mistake. Autoimmune diseases can affect many parts of the body. Various plants are used to strengthen the immunity due to their immunomodulatory activities. In this article, autoimmune diseases, description of autoimmune diseases, and plants used as immunomodulant agent has given. Key words: Autoimmune diseases, immunomodulatory activity, medicinal plants, research study. Journal of Medicinal Plants Research Vol. 6(7), pp. 1100-1105, 23 February, 2012

25. Clinical Trials DiseaseAntibody against Juvenile insulin-dependent diabetesPancreatic islet cells Pernicious anemiaGastric parietal cells Addison's diseaseAdrenal cells Idiopathic hypoparathyroidismParathyroid cells Autoimmune hemolytic anemiaErythrocytes Idiopathic thrombocytopenic purpuraPlatelets Idiopathic neutropeniaNeutrophils VitiligoMelanocytes Chronic active hepatitisNuclei of hepatocytes Goodpasture's syndromeBasement membranes Rheumatoid arthritisGamma globulin, virus-related antigens Sjogren's syndromeNuclei and centromeres Systemic lupus erythematosusNuclei, DNA, RNA, erythrocytes, etc Myasthenia gravisAcetylcholine receptors Grave’s diseaseThyroid-stimulating hormone receptor ThyroiditisThyroid Insulin-resistant diabetesInsulin receptor AsthmaBeta-2 adrenergic receptors Table 3. Autoimmune classification. Journal of Medicinal Plants Research Vol. 6(7), pp. 1100-1105, 23 February, 2012

26. Clinical Trials Plant/titleActivity Ginseng In one study, it has been evaluated that ginseng polysaccharide decreases the expression of TNF-α and interferon-gamma (IFN-γ), and regulate the function of lymphocytes in enteric mucosal immune system in collagen-induced arthritis (CIA) rats. This study indicates that ginseng polysaccharide could be used in the treatment of autoimmune disease (Hongyan et al., 2011) O. basilicum It has been studied that aqueous extract of O. basilicum is a powerful natural immunomodulatory spice influencing various types of immune-responses and have potential health effects (Tsai1 et al., 2011). T. cordifolia It has been studied that T. cordifolia has immunomodulatory properties, and is used for the treatment of jaundice, skin diseases, diabetes and anemia (Chopra et al., 1982). In one study, it has been evaluated that T. cordifolia improves the phagocytic and bactericidal activities in patients suffering from polymorphism in surgical jaundice (Thatte et al., 1989). In one study, effect of feeding T. cordifolia has been observed in broiler birds which were immunosuppressed with cyclophosphamide, and found a significant rise in antibody titer against ND virus with augmentation of inflammatory reaction to skin contact sensitivity test (Kolte et al., 2007). Rege et al. (1989) and Bishavi et al. (2002) have proved the hepatoprotective effect of T. cordifolia. W. somniferaAkram et al. (2010) studied the immunomodulant effect of W. somnifera Ocimum sanctumModulates humoral immune response (Kujur, 2001; Krishnamohan et al., 1997; Kumar, 2003) A. racemosusStimulates both humoral and cell mediated immune responses (Kuttan et al., 1992). Table 4. Research study Journal of Medicinal Plants Research Vol. 6(7), pp. 1100-1105, 23 February, 2012

27. 27 Asparagus racemosus (Satavar, Shatavari, or Shatamull) Panax quinquefolius foliage and fruit Withania somnifera Tinospora cordifolia

28. Clinical Trials Main constituents of Hedera helix L. Triterpensaponins hederacoside C: R = 1(β-D-glucose)6 – 1(β-D-glucose)4 – 1(α-L-rhamnose)

29. 29 Hedera rhombea, Aizu, Fukushima pref., Japan Osimum basilicum, lemon Basil

30. Aug 2005PROSPAN ® 30 PROSPAN ® Dried extract of Ivy leaves (DER 5-7.5 : 1) Efficacy and safety for this extract has been proved in various clinical studies secretolyticbroncholyticcough relieving

31. Aug 2005PROSPAN ® 31 PROSPAN ® Objective (Lung function) - vital capacity (VC), - forced vital capacity (FVC), - forced expiratory volume/sec. (FEV 1 ), - intrathoracic gas volume (ITGV), - residual volume (RV), - airway resistance (RAW, obstruction marker) - peak expiratory flow (PEF) Subjective - coughing frequency - coughing intensity - painful coughing - sputum production - expectoration - dyspnoea - general well-being Documented improvements

32. endocytosis How to increase ß 2 -adrenergic effects on living cells? degradation recycling ligand (L) accumulation of receptor-ligand- complexes (coated pit) clathrin early endosome ß 2 -adrenergic receptor (R) RL-complex in lipid rafts α-hederin

33. 10µM terbutaline 20 min control, untreated pretreatment with 1µM  -hederin for 24 h, then 10 µM terbutaline 20 min Inhibition of internalization of  2 -adrenergic receptors in pulmonary epithelial cells (A549) by  -hederin.

34. Aug 2005PROSPAN ® 34  -hederin influences regulatory processes of ß 2 -adrenergic receptors:  -hederin inhibits redistribution as well as internalisation of even redistributed ß 2 - adrenergic receptors after ligand binding. Prospan: mode of action

35. Aug 2005PROSPAN ® 35 An increased ß 2 -adrenergic receptor density and an increased signal transduction lead to an increased production of cAMP:  increased exocytosis of surfactant in pulmonary epithelial cells (alveolar type II cells) (secretolytic effect, decrease in mucus viscosity, decrease in coughing intensity and frequency). Ivy: Mode of action – consequences I lamellar bodies cAMP surfactant PKA ß 2 -adrenergic receptor

36. Aug 2005PROSPAN ® 36 An increased ß 2 -adrenergic receptor density and an increased signal transduction lead to an increased production of cAMP:  decrease in intracellular [Ca 2+ i ] with subseeding bronchial muscle relaxation (formation of less active myosin kinase via phosphorylation by phosphokinase A). cAMP SR [Ca 2+ i  ] Ca 2+ channel ß 2 -adrenergic receptor Ivy: Mode of action – consequences II

37. Aug 2005PROSPAN ® 37 Ivy - Resorption In vitro (CaCo-2-cells) Transport of Hederacosid C Transport of alpha-hederin Time (min)

38. Aug 2005PROSPAN ® 38 Ivy - Resorption In vivo – first results alpha-hederin discovered in blood of treated animals and humans the amount of hederacosid C given in an extract seems to support the concentration of alpha- hederin in blood (prodrug??) Actually: Ongoing works on the sensitivity of analytical methods for further clarification

39. Aug 2005PROSPAN ® 39 Ivy- mode of action  -hederin reduction of mucus viscosity dilatation of bronchial musculature increased β 2 –adrenergic stimulation lung epitheliumbronchial muscle surfactant- production Ca ++ (intracellular) secretolytic broncholytic Expectorant

40. Aug 2005PROSPAN ® 40 Ivy: Effect on ß 2 -receptors in general In theory  -hederin supports indirectly the stimulaton of all ß 2 -receptors but given by the smooth and indirect effect, a result will only be seen in those organs with a pathological condition (e.g. ivy will have no bronchiolytic effect in case of „normal“ bronchial muscles)

41. Clinical Trials Conclusion Plants contain of some chemical substances that synergistically delivered their effects to biological systems It would no obviously affect the living cells and could be observed as clinical effects

42. 42 Thank you

43. 43 Thank you