Herb-drug interactions: a literature review

Herbs are often administered in combination with therapeutic drugs, raising the potential of herb-drug interactions. An extensive review of the literature identified reported herb-drug interactions with clinical significance, many of which are from case reports and limited clinical observations.
Cases have been published reporting enhanced anticoagulation and bleeding when patients on long-term warfarin therapy also took Salvia miltiorrhiza (danshen). Allium sativum (garlic) decreased the area under the plasma concentration-time curve (AUC) and maximum plasma concentration of saquinavir, but not ritonavir and paracetamol (acetaminophen), in volunteers. A. sativum increased the clotting time and international normalised ratio of warfarin and caused hypoglycaemia when taken with chlorpropamide. Ginkgo biloba (ginkgo) caused bleeding when combined with warfarin or aspirin (acetylsalicylic acid), raised blood pressure when combined with a thiazide diuretic and even caused coma when combined with trazodone in patients. Panax ginseng (ginseng) reduced the blood concentrations of alcohol (ethanol) and warfarin, and induced mania when used concomitantly with phenelzine, but ginseng increased the efficacy of influenza vaccination. Scutellaria baicalensis (huangqin) ameliorated irinotecan-induced gastrointestinal toxicity in cancer patients.
Piper methysticum (kava) increased the 'off' periods in patients with parkinsonism taking levodopa and induced a semicomatose state when given concomitantly with alprazolam. Kava enhanced the hypnotic effect of alcohol in mice, but this was not observed in humans. Silybum marianum (milk thistle) decreased the trough concentrations of indinavir in humans. Piperine from black (Piper nigrum Linn) and long (P. longum Linn) peppers increased the AUC of phenytoin, propranolol and theophylline in healthy volunteers and plasma concentrations of rifamipicin (rifampin) in patients with pulmonary tuberculosis. Eleutheroccus senticosus (Siberian ginseng) increased the serum concentration of digoxin, but did not alter the pharmacokinetics of dextromethorphan and alprazolam in humans. Hypericum perforatum (hypericum; St John's wort) decreased the blood concentrations of ciclosporin (cyclosporin), midazolam, tacrolimus, amitriptyline, digoxin, indinavir, warfarin, phenprocoumon and theophylline, but did not alter the pharmacokinetics of carbamazepine, pravastatin, mycophenolate mofetil and dextromethorphan. Cases have been reported where decreased ciclosporin concentrations led to organ rejection. Hypericum also caused breakthrough bleeding and unplanned pregnancies when used concomitantly with oral contraceptives. It also caused serotonin syndrome when used in combination with selective serotonin reuptake inhibitors (e.g. sertraline and paroxetine).
In conclusion, interactions between herbal medicines and prescribed drugs can occur and may lead to serious clinical consequences. There are other theoretical interactions indicated by preclinical data. Both pharmacokinetic and/or pharmacodynamic mechanisms have been considered to play a role in these interactions, although the underlying mechanisms for the altered drug effects and/or concentrations by concomitant herbal medicines are yet to be determined. The clinical importance of herb-drug interactions depends on many factors associated with the particular herb, drug and patient. Herbs should be appropriately labeled to alert consumers to potential interactions when concomitantly used with drugs, and to recommend a consultation with their general practitioners and other medical carers.

An improved purification procedure for cyclosporine synthetase

We have developed expedient and reliable methods to isolate cyclosporin synthetase for in vitro biosynthesis of cyclosporins. We have examined enzyme purification strategies suited to large-scale processing and present a chromatographic sequence that serves as a pilot model for industrial scale preparation of cyclosporin synthetase from cyclosporin producing fungi. A chromatographic sequence consisting of ammonium sulfate precipitation → gel filtration → hydrophobic interaction chromatography → anion exchange chromatography, yielded an electrophoretically homogeneous cyclosporin synthetase preparation (Coomassie G-250 brilliant blue staining). Furthermore, a native polyacrylamide gel electrophoresis system was developed for the isolation of active cyclosporin synthetase enzyme from crude extracts of cyclosporin producing fungi. The environmental factors affecting enzyme stability and the continuity of the in vitro cyclosporin biosynthetic reaction-temperature, pH, and substrate depletion were assessed and manageable conditions have been defined for sustainable cyclosporin biosynthesis with enzyme isolates. Cyclosporin synthetase exhibited an optimal temperature range of 24–29 °C and a pH optimum of 7.6. The native enzyme displayed a pI of 5.7, as determined by isoelectric focusing. The industrial implementation of an in vitro biosynthetic approach could potentially prove useful for the production of important therapeutic cyclosporins which occur as only minor fermentation by-products.

An improved method for the purification of rat liver-type fatty acid binding protein from Escherichia coli

We have developed expedient and reliable methods to isolate cyclosporin synthetase for in vitro biosynthesis of cyclosporins. We have examined enzyme purification strategies suited to large-scale processing and present a chromatographic sequence that serves as a pilot model for industrial scale preparation of cyclosporin synthetase from cyclosporin producing fungi. A chromatographic sequence consisting of ammonium sulfate precipitation → gel filtration → hydrophobic interaction chromatography → anion exchange chromatography, yielded an electrophoretically homogeneous cyclosporin synthetase preparation (Coomassie G-250 brilliant blue staining). Furthermore, a native polyacrylamide gel electrophoresis system was developed for the isolation of active cyclosporin synthetase enzyme from crude extracts of cyclosporin producing fungi. The environmental factors affecting enzyme stability and the continuity of the in vitro cyclosporin biosynthetic reaction-temperature, pH, and substrate depletion were assessed and manageable conditions have been defined for sustainable cyclosporin biosynthesis with enzyme isolates. Cyclosporin synthetase exhibited an optimal temperature range of 24–29 °C and a pH optimum of 7.6. The native enzyme displayed a pI of 5.7, as determined by isoelectric focusing. The industrial implementation of an in vitro biosynthetic approach could potentially prove useful for the production of important therapeutic cyclosporins which occur as only minor fermentation by-products.

Phospholipase activity in human mesenteric ischaemia and infarction

Currently, diagnostic tests for mesenteric ischaemia and infarction are inadequate due to poor sensitivity and specificity. In addition, many potential markers appear too late to be clinically useful. At present, definitive diagnosis can only be made at the time of surgery, which is not ideal as surgery is often to be avoided in critically ill and elderly patients. A clinically useful, minimally invasive test is likely to decrease the currently very high mortality rate and allow monitoring of 'at risk' patients during their hospital stay. A two-dimensional electrophoresis based proteomic approach was undertaken to assess plasma protein differences between patients with surgically confirmed bowel infarction and control Intensive Care patients. The major protein differences were found to be members or variants of acute phase proteins. Serum amyloid A showed the largest difference between the two patient groups, and this protein was investigated in greater depth. An analysis was performed to compare the diagnostic ability of several commonly used indicators of critical illness and bowel infarction with serum amyloid A and phospholipase A2. Although none of the variables were ideal for clinical use, plasma phospholipase A2 activity showed the best discriminatory power, as determined by Receiver Operating Characteristic curves. From a review of the literature, phospholipase AI (PLA2) appeared to be increased in the bowel as a result of ischaemia and infarction. In one patient, matched tissues were obtained, and PLA2 activity was found to be significantly higher in infarcted bowel tissue compared to ischaemic bowel tissue. PLA2 activity was significantly greater in bowel lumen than tissue, suggesting that the protein was being released, and may enter the circulation. PLA2 activity was increased in the plasma of bowel infarction patients compared with control patients, though the difference was not significant. The phospholipase activity exhibited a number of similarities to typical phospholipase A2 proteins, but also showed a number of inconsistent characteristics. For this reason, we wished to identify the protein responsible for the increased phospholipase activity in infarcted human bowel. The PLA2 activity in human bowel could not be abolished by immunoprecipitation of the PLA2 isoforms IIA (well described in bowel) and V (a closely related isoform). To investigate these proteins, a native urea protein gel devised for snake venom phospholipase A2 was modified for use with mammalian phospholipase AI. The modified gel was used to show that the protein with phospholipase activity from infarcted gut was different from normal gut PLA2 and type IIA PLA2. A number of extensions were devised for these native gels and were found to be useful both in this investigation and for venom investigations. Protein purification was undertaken to identify the protein responsible for the increased phospholipase activity in infarcted bowel. Protein was purified from infarcted human bowel using a number of techniques that exploited unusual characteristics of the protein. The purification techniques each retained the native activity of the protein and the purification could therefore be monitored with a phospholipid hydrolysis assay at each stage. The protein identified by mass spectrometry was an excellent match for cyclophilin B, an inflammatory protein that had previously been identified in rat bowel at the mRNA level (Hasel et al, 1991, Kainer & Doris, 2000). As the purification progress had been monitored throughout with a phospholipid hydrolysis assay, cyclophilin B was an unexpected identification, as it is not known to have phospholipase activity. Cyclophilin B was removed from the highly purified samples via immunoprecipitation and this process abolished all phospholipase activity. The addition of cyclosporin A, (the pharmaceutical ligand of cyclophilin B), did not effect the phospholipase activity. Cyclophilin B protein was found in normal and infarcted human bowel using Western blotting. Cyclophilin B protein also appeared to be present in the bowel lumen and plasma of several patients with bowel infarction, but not in control patients. Immunohistochemistry confirmed the ubiquitous nature of cyclophilin B that had been reported by other groups. This project has investigated the use of two dimensional gel electrophoresis based proteomics to identify proteins present in the plasma of patients with confirmed bowel infarction and control intensive care patients. The major protein classes observed were members of the acute phase proteins, which highlights the need for pre-fractionation of plasma to identify lower abundance, disease associated proteins. A series of potential plasma markers were compared using Receiver Operating Characteristic Curves. Although no ideal marker was clear from this analysis, phospholipase activity appeared to warrant further investigation. Phospholipase activity was investigated in human infarcted bowel. Protein purification identified cyclophilin B as a bowel protein that showed unusual phospholipid hydrolysing activity. Cyclophilin B is a ubiquitous protein in intestinal cell types in both normal and infarcted tissue. There appears to be release of cyclophilin B into bowel lumen and plasma under conditions of mesenteric ischaemia and infarction.

Reperfusion-induced myocardial dysfunction is prevented by endogenous annexin-A1 and its N-terminal-derived peptide Ac-ANX-A12-26

BACKGROUND AND PURPOSE : Annexin-A1 (ANX-A1) is an endogenous, glucocorticoid-regulated anti-inflammatory protein. The N-terminal-derived peptide Ac-ANX-A12–26 preserves cardiomyocyte viability, but the impact of ANX-A1-peptides on cardiac contractility is unknown. We now test the hypothesis that ANX-A1 preserves post-ischaemic recovery of left ventricular (LV) function.

EXPERIMENTAL APPROACH : Ac-ANX-A12–26 was administered on reperfusion, to adult rat cardiomyocytes as well as hearts isolated from rats, wild-type mice and mice deficient in endogenous ANX-A1 (ANX-A1–/–). Myocardial viability and recovery of LV function were determined.

KEY RESULTS: Ischaemia–reperfusion markedly impaired both cardiomyocyte viability and recovery of LV function by 60%. Treatment with exogenous Ac-ANX-A12–26 at the onset of reperfusion prevented cardiomyocyte injury and significantly improved recovery of LV function, in both intact rat and wild-type mouse hearts. Ac-ANX-A12–26 cardioprotection was abolished by either formyl peptide receptor (FPR)-nonselective or FPR1-selective antagonists, Boc2 and cyclosporin H, but was relatively insensitive to the FPR2-selective antagonist QuinC7. ANX-A1-induced cardioprotection was associated with increased phosphorylation of the cell survival kinase Akt. ANX-A1−/− exaggerated impairment of post-ischaemic recovery of LV function, in addition to selective LV FPR1 down-regulation.

CONCLUSIONS AND IMPLICATIONS : These data represent the first evidence that ANX-A1 affects myocardial function. Our findings suggest ANX-A1 is an endogenous regulator of post-ischaemic recovery of LV function. Furthermore, the ANX-A1-derived peptide Ac-ANX-A12–26 on reperfusion rescues LV function, probably via activation of FPR1. ANX-A1-based therapies may thus represent a novel clinical approach for the prevention and treatment of myocardial reperfusion injury.

Caracterização funcional de dois cDNAs homólogos à ciclofilina e à proteína reprimida por auxina (ARP) identificados em bibliotecas subtrativas a para floração em tomateiro

Flowering is a fundamental process in the life cycle for plant. This process is marked by vegetative to reproductive apical meristem conversion, due to interactions between several factors, both internal and external to plant. Therefore, eight subtractive libraries were constructed using apical meristem induced or not induced for two contrasting species: Solanum lycopersicum cv. Micro-Tom and Solanum pimpinellifolium. Several cDNAs were identified and among these, were selected two cDNAs: one homologous cDNA to cyclophilin (LeCYP1) and the other to Auxin repressed protein (ARP). It has observed that LeCYP1 and ARP genes are important in the developmental process to plants. In silico analysis, were used several databases with the exclusion criterion E-value <1.0x10-15. As a result, conservation was observed for proteins analyzed by means of multiple alignments and the presence of functional domains. Then, overexpression cassettes were constructed for the ARP cDNA in sense and antisense orientations. For this step, it was used the CaMV35S promoter. The cDNA orientation (sense or antisense) in relation to the promoter was determined by restriction enzymes and sequencing. Then, this cassette was transferred to binary vector pZP211 and these cassettes were transferred into Agrobacterium tumefaciens LBA4404. S. lycopersicum cv. Micro-Tom (MT) and MT-Rg1 plants were transformed. In addition, seedlings were subjected to hormone treatments using a synthetic auxin (- naphthalene acetic acid) and cyclosporin A (cyclophilin inhibitor) treatments and it was found that the hormone treatment there were changes in development of lateral roots pattern, probably related to decreases in auxin signaling caused by reduction of LeCYP1 in MT-dgt plants while cyclosporin A treatments, there was a slight delay in flowering in cv. MT plants. Furthermore, assay with real-time PCR (RT-qPCR) were done for expression level analysis from LeCYP1 and ARP in order to functionally characterize these sequences in tomato plants.

Experimental pancreas transplantation: the consequences of the portocaval shunt on the blood glucose, plasma insulin, and glucagon

A proposição foi realizada, no período pós-operatório imediato, em 40 ratos Wistar, distribuídos por sorteio em doi grupos: grupo NC, vinte ratos correspondentes ao grupo controle, não diabético, submetidos a operação simulada e o grupo PT, 20 ratos correspondentes ao grupo diabético que recebeu transplante de pâncreas heterotópico de ratos Wistar normais. Durante sete dias, antes do transplante, e 1, 3, 6, 12, 24, 48, 72, 96 horas após, determinava-se a glicose sanguínea, a insulina plasnática e o glucagon. Estes parâmetros eram obtidos também do grupo NC. Diabetes mellitus experimental era induzida pela administração intravenosa de aloxana. O grupo PT era imunosuprimido com ciclosporina A. O grupo NC apresentou níveis normais de glicose sanguínea, de insulina plásmica e de glucagon, durante todo o experimento. Foi encontrada nítida hiperinsulinemia no sangue venoso periférico do grupo PT. A insulina plasmática era significantemente maior no grupo PT comparada ao grupo NC começando 72 horas após o transplante. O glucagon plasmático, elevado no período pré-transplante, não se alterou após o transplante. Apesar de hiperinsulinemia e hiperglucagonemia, os níveis de glicose sanguínea eram elevados 6 horas após o transplante e mantiveram-se normais após este período. Considerando-se os níveis de glicose sanguínea 12 horas pós-transplante, não houve diferença estatisticamente significante entre os grupos PT e NC, até o sacrifício.

Exposição de fibroblastos da cápsula de Tenon de pterígios à ciclosporina 0,05%

OBJETIVO: Avaliar o comportamento dos fibroblastos da cápsula de Tenon de pterígios e normais em cultura, quando expostos a ciclosporina 0,05%. MÉTODOS: Estudo prospectivo, controlado, do qual participaram 20 portadores de pterígio primário. Foram colhidas amostras da cápsula de Tenon normal e proveniente do pterígio, ambas do mesmo indivíduo, colocadas para crescimento em cultura e expostas a ciclosporina 0,05%. As avaliações foram feitas aos 3, 6, 12 e 17 dias após a exposição. RESULTADOS: Das amostras colhidas, 7 foram utilizadas para exposição a ciclosporina - 6 provenientes de pterígios e 1 da Tenon normal. Houve redução significativa na proliferação celular das culturas de fibroblastos expostos a ciclosporina (p<0,05). CONCLUSÃO: A ciclosporina 0,05% é capaz de inibir a proliferação de fibroblastos provenientes da cápsula de Tenon de pterígio e também da Tenon normal. Novos estudos devem ser providenciados para definir o papel da ciclosporina no tratamento do pterígio.

Functional Aesthetic Treatment of Patient With Phenytoin-Induced Gingival Overgrowth

Gingival overgrowth (GO) may be related to the frequent use of certain medications, such as cyclosporin, phenytoin (PHT), and nifedipine, and is therefore denominated drug-induced GO. This article reports a case of a patient who with chronic periodontitis made use of PHT and presented generalized GO. A 30-year-old man with GO was referred to the clinic of the Universidade Estadual Paulista, Brazil. The complaint was poor aesthetics because of the GO. The patient had a medical history of a controlled epileptic state, and PHT was administered as an anticonvulsant medication. The clinical examination showed generalized edematous gingival tissues and presence of bacterial plaque and calculus on the surfaces of the teeth. The diagnosis was GO associated with PHT because no other risk factors were identified. Treatment consisted of meticulous oral hygiene instruction, scaling, root surface instrumentation, prophylaxis, and daily chlorhexidine mouth rinses. After this stage, periodontal surgery was performed, and histopathologic evaluation was made. The patient has been under control for 3 years after the periodontal surgery, and up to the present time, there has been no recurrence. It can be concluded that PHT associated with the presence of irritants favored gingival growth and that the association of nonsurgical and surgical periodontal therapies was effective in the treatment of GO. Besides, motivating the patient to maintain oral hygiene is a prerequisite for the maintenance of periodontal health.

Mitochondrial alterations and apoptosis in smooth muscle from aged rats

We studied changes in mitochondrial morphology and function in the smooth muscle of rat colon. Under confocal microscopy, tissues loaded with potentiometric dye displayed rapid and spontaneous depolarization. Cyclosporin A (CsA), inhibitor of the permeability transition pore (PTP), caused an increase in mitochondrial membrane potential (DeltaPsi(m)) in tissues from adult young animals. In aged rats these changes were not observed. This suggests that physiological activation of PTP in aged rats is reduced. Electron microscopy showed alterations of the mitochondrial ultrastructure in tissues from aged rats involving a decreased definition of the cristae and fragmentation of the mitochondrial membranes. We also detected an increase in apoptotic cells in the smooth muscle from aged animals. Our results show that the aging process changes PTP activity, the ability to maintain DeltaPsi(m) and mitochondrial morphology. It is suggested that these can be associated with mitochondrial damage and cell death. (C) 2004 Elsevier B.V. All rights reserved.

Functional Characterization of an Aspergillus fumigatus Calcium Transporter (PmcA) that Is Essential for Fungal Infection

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

EFFECTS OF CYCLOSPORINE-A IMMUNOSUPPRESSION ON PANCREATICODUODENAL TRANSPLANTATION IN ALLOXAN-DIABETIC RATS

1. Forty-five outbred Wistar rats were randomly assigned to three experimental groups: GI, 10 non-diabetic control rats; GII, 10 alloxan-diabetic control rats; GIII, 25 alloxan-diabetic tats which received pancreaticoduodenal transplantation (PDT) from normal Wistar donor rats and were immunosuppressed with cyclosporin A (Cy-A), 10 mg kg body weight-1 day-1, administered intraperitoneally for 30 days.2. In parallel, 15 alloxan-diabetic inbred Wistar rats received isogeneic PDT from normal Wistar donor rats.3. Cy-A prevented graft rejection in the 15 surviving animals in group III. These observations were confirmed by clinical and biochemical parameters (body weight, urine output, water and food intake, blood and urinary glucose and plasma insulin) and by histology and immunohistochemistry of the pancreas.4. However, Cy-A was associated with 60% of the infectious complications in transplanted rats leading to 40% mortality. Pulmonary infections were the main cause of death. There were no side effects of immunosuppression on the pancreas. Infections were not significant in inbred rats submitted to PDT.

METABOLIC EFFECT OF PANCREATICODUODENAL TRANSPLANTATION IN DIABETIC RATS

Outbred Wistar rats were randomly assigned to three experimental groups: GI, 10 nondiabetic control rats; GII, 10 alloxan-diabetic control rats; GIII, 25 alloxan-diabetic rats that received pancreaticoduodenal transplantation (PDT) from normal donor Wistar rats and were immunosuppressed with cyclosporin A. For 7 prior and 4, 7, 14, 21, and 30 days posttransplantation (during which the animals were housed in metabolic cages for periods of 24 hours) body weight, water and food intake, urine output, blood and urinary glucose, plasma insulin, and glucagon were recorded. These parameters were also concurrently recorded for diabetic and nondiabetic control rats. Animals were sacrificed after 30 days and histological and immunohistochemical studies of the pancreas were performed. Pancreatic transplants consistently and significantly improved the metabolic abnormalities of the diabetic rat (P < 0.01) by restoring body weight gain, and by immediate relief of hyperglycemia, glucosuria, polyuria, polydipsia, and also the low levels of plasma insulin. The plasma glucagon, elevated in diabetic control rats, did not change after transplant.