A systematic review of the quality of homeopathic pathogenetic trials published from 1945 to 1995

A unified framework for bias assessment in clinical research

Methodological flaws, limitations, and inadequate practices in research are well known and pose threats to the internal validity of any research study. However, there are ways of safeguarding research conduct to reduce the chance of research producing distorted results. Numerous tools now exist to assess the incorporation of such safeguards into primary research studies (also known as quality and/or risk-of-bias assessment). These tools typically include a variety of items that are then checked against those implemented in the study. Despite a lot of research in this area, no comprehensive generic classification of safeguards across study designs exist, although attempts have been made to clarify aspects of this. We review the developments in this area as well as use preliminary data from 100 methodological studies to illustrate our proposed approach. We conclude by proposing a new framework for identifying research studies at risk of being biased and the information in this article will promote a unification of the diverse approaches to facilitating bias assessment in clinical research.

Against all odds-the persistent popularity of homeopathy

The use of homeopathy is remarkably popular. Popularity, however, is not an arbiter in a scientific discourse. In fact, the assumptions underlying homeopathy violate fundamental laws of nature. Homeopathy does not have any explanatory power and fails other criteria established for a scientific approach. Two large-scale efforts have recently documented that in spite of a plethora of clinical trials there is no evidence that homeopathic remedies have any therapeutic effect, which goes beyond that of a placebo. Relaxed regulations and lack of scientific literacy and of health education allow for continuous thriving of homeopathy. While the tide may be changing on the regulatory side, health education of the general public is presumably more important to support informed decision making by patients. Otherwise, the responsible patient, who is posited to decide on the medical choices, remains a convenient legal fiction.

Homeopathic treatments modify inflammation but not behavioral response to influenza antigen challenge in BALB/c mice

BACKGROUND

Influenza affects thousands of people worldwide every year, motivating the development of new therapies. In this work, the effects of two homeopathic preparations (influenza biotherapies and thymulin) were chosen following two different rationales: isotherapy and endo-isotherapy models. The homeopathic effects were evaluated individually considering the inflammatory and behavioral responses against influenza virus antigen were studied in BALB/c mice.

METHODS

Male adult mice were treated orally and blindly for 21 days with highly diluted influenza virus or with thymulin, and were divided in two sets of experiments. The first series of experiments aimed to describe their behavior, using an open field (OF) device. In the second series, mice were challenged subcutaneously with influenza hemagglutinin antigen (7 μg/200 μl) at day 21. At day 42, behavior and inflammation response were evaluated.

RESULTS

No behavioral changes were seen in OF tests at any time point after treatments. Flow cytometry and morphometry revealed significant changes in T and B cell balance after influenza antigen challenge, varying according to treatment.

CONCLUSION

The results show that both homeopathic treatments induced subtle changes in acquired immune anti-viral response regulation. A deeper understanding of the mechanism could elucidate their possible use in influenza epidemiological situations.

Scientific proving of ultra high dilutions on humans

BACKGROUND

Homeopathic drug provings or pathogenetic trials (HPTs) are the pillar of homeopathy. This review summarizes the authors' findings and interpretations derived from a series of homeopathic drug proving between 1994 and 2015. It gives an overview over a series of attempts to use modern scientific experimental methodology to answer the question, whether such HPTs produce symptoms in healthy volunteers that can be distinguished from placebo symptoms.

METHODS

Various experimental models were used: repeated crossover trials with categorical data collection, and a single-case, randomised study. Final models use diligent qualitative data-collection in experienced volunteers. In those, raters decide whether symptoms are typical for a remedy delivered or not. The design is triple-blind and placebo-controlled.

RESULT

While previous attempts were inconclusive, this new model allowed to separate placebo symptoms from verum symptoms repeatedly in a series of two definitive studies following promising pilot studies. Results were statistically significant. Also, some signs of the purported non-local signature of homeopathic effects were visible, and the consequences for future methodology is discussed.

CONCLUSION

Provided some cautionary notes are taken into account, HPTs can be used to separate out true specific symptoms from placebo symptoms. By the same token this is a road to experimental proof that homeopathic remedies are not just placebos. However, this needs to be taken forward by independent groups.

Homeopathic medicines for prevention of influenza and acute respiratory tract infections in children: blind, randomized, placebo-controlled clinical trial

BACKGROUND

Influenza and its complications are common at all ages, especially in children. Vaccines and anti-influenza drugs aim to prevent it. Preventative approaches with favorable risk profiles should be considered for flu, particularly since the evidence of the efficacy of anti-viral drugs is debated.

METHODS

This pragmatic clinical trial was conducted in the Brazilian Public Health System in Petrópolis (BPHSP) with children aged from 1 to 5 years old. The medications used were mainly selected based on in vitro experiments (InfluBio), and in successful qualitative clinical experiences (Homeopathic Complex). Following informed parental consent, subjects were randomly distributed, in a blind manner, to three experimental groups: Homeopathic Complex, Placebo, and InfluBio. BPHSP health agents collected flu and acute respiratory infection symptomatic episodes monthly following the established protocol. The number of these episodes was registered in one year (2009-2010).

RESULTS

Out of the 600 children recruited, 445 (74.17%) completed the study (149: Homeopathic complex; 151: Placebo; 145: InfluBio). The number of flu and acute respiratory infection symptomatic episodes detected in this clinical trial was low; however, it was different between homeopathic groups and placebo (p < 0.001). In the first year post-intervention, 46/151 (30.5%) of children in the placebo group developed 3 or more flu and acute respiratory infection episodes, while there was no episode in the group of 149 children who used Homeopathic Complex, and only 1 episode in the group of 145 (1%) children who received InfluBio.

CONCLUSION

These results suggested that the use of homeopathic medicines minimized the number of flu and acute respiratory infection symptomatic episodes in children, signalizing that the homeopathic prophylactic potential should be investigated in further studies.

A minimum protocol for randomised homeopathic drug proving as basis for further research

BACKGROUND

In order to further improve the methodology and quality of data collection in homeopathic drug provings (HDP), there is a need for a minimum standardised HDP protocol. The objective of the present study was to test the feasibility of this type of protocol.

MATERIALS AND METHODS

The study protocol embraced a multi-centre, randomised, double-blind, placebo-controlled trial with 2 parallel groups. It was approved by an ethics review committee. During the pre-approval phase, discordances between the regulatory and homeopathic requirements for the protocol were checked and solutions found. The study medication was Potentilla anserina. 6 participants received verum and 4 placebo. The resulting symptom list will be published elsewhere. The procedure was accepted by all participants.

RESULTS

Three important issues were addressed: the requirement to keep all participants blinded; the adverse events reporting to regulatory authorities; and the necessity of a placebo control group. Other issues that need further investigations were identified, e.g. sample size, observation period and dosage regimen.

CONCLUSIONS

A minimum protocol of a HDP is feasible. All important design elements of HDP could be solved in discussions with the respective regulatory authorities, and participating homeopaths accepted the procedure.

Effect of orally administered potentized capsaicin and dihydrocapsaicin in humans: a homeopathic pathogenetic trial

BACKGROUND

A homeopathic pathogenetic trial is a procedure to examine the disease-producing effect of any substance on humans. Capsaicin and dihydrocapsaicin are known as pain-producing agents. According to the homeopathic law of similars, any substance having the capacity to produce certain symptoms should also be able to treat them in return, when administered in small (potentized) dose.

METHODS

In a doubleblind, randomized placebo-controlled homeopathic pathogenetic trial with 22 volunteers, 15 received a combination of capsaicin and dihydrocapsaicin as a single remedy in 30c potency, while 7 received placebo. The volunteers' symptoms during 5 weeks were carefully noted as per protocol. The participants signed an informed consent, the study was approved by the ethics committee, and laboratory investigations were documented and safety measures adopted.

RESULTS

A preparation of orally administered ultra-high diluted capsaicin and dihydrocapsaicin unveiled qualitatively and quantitatively distinct symptoms, comparable with effects of the crude substance. Compared to placebo, the homeopathic preparation produced significant symptoms in healthy human volunteers. These findings can subsequently be used therapeutically.

CONCLUSION

The administration of potentized capsaicin and dihydrocapsaicin combination produced symptoms of pain (and others) in healthy volunteers. This preparation can be applied therapeutically following a basic homeopathic principle. Further research to confirm the assumptions is warranted.

Homeopathic drug proving of Okoubaka aubrevillei: a randomised placebo-controlled trial

BACKGROUND

Homeopathic drug proving is a basic concept in homeopathy. This study aimed to record symptoms produced by a homeopathic drug compared with placebo.

METHODS

This multicentre, randomised, double-blind, placebo-controlled phase 1 trial consisted of a 7-day run-in period, a 5-day intervention period and a 16-day post-intervention observation period. Subjects, investigators and statisticians were blinded for intervention groups and identity of the homeopathic drug. Subjects in the intervention group received Okoubaka aubrevillei (potency C12) and subjects in the placebo group received the optically identical sucrose globules. Dosage in both groups was five globules taken five times per day over a maximum period of 5 days. Subjects documented the symptoms they experienced in a semistructured online diary. The primary outcome parameter was the number of characteristic proving symptoms compared with placebo after a period of 3 weeks. Characteristic symptoms were categorised using content analysis. Secondary outcome parameters were the qualitative differences in profiles of characteristic and proving symptoms and the total number of all proving symptoms. The number of symptoms was quantitatively analysed on an intention-to-treat basis using analyses of covariance with the subject's expectation and baseline values as covariates.

RESULTS

Thirty-one subjects were included (19 Okoubaka and 12 placebo). Data for 29 participants could be analysed. No significant differences in number of characteristic symptoms in both groups were observed between Okoubaka (mean±standard deviation 5.4±6.0) and placebo (4.9±5.6). The odds ratio for observation of a characteristic symptom was 1.11 (95% confidence interval 0.4 to 3.05, P=0.843). Females and subjects expecting a higher number of symptoms at baseline or feeling more sensitive to homeopathic drugs experienced more characteristic symptoms regardless of allocation. The qualitative analysis showed an inter-coder reliability of 0.69 (95% confidence interval 0.62 to 0.76). The qualitative comparison of symptom profiles was inconclusive.

CONCLUSIONS

Combined results of qualitative and quantitative methods did not result in a significant difference of characteristic proving symptoms between O. aubrevillei C12 and placebo. The qualitative comparison of the symptom profiles leaves some open questions. The nocebo effect might be a plausible explanation for most of the phenomena observed in this trial.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01061229.

Homeopathic drug discovery: theory update and methodological aspect

BACKGROUND

Homeopathy treats patient on the basis of totality of symptoms and is based on the principle of 'like cures like'. It uses ultra-low doses of highly diluted natural substances as remedies that originate from plants, minerals or animals.

OBJECTIVE

The objectives of this review are to discuss concepts, controversies and research related to understanding homeopathy in the light of modern science.

METHODS

Attempts have been made to focus on current views of homeopathy and to delineate its most plausible mechanism(s) of action.

RESULTS

Although some areas of concern remain, research carried out so far both in vitro and in vivo validates the effects of highly diluted homeopathic medicines in a wide variety of organisms.

CONCLUSION

The precise mechanism(s) and pathway(s) of action of highly diluted homeopathic drugs are still unknown.

Nonlinear dynamical systems effects of homeopathic remedies on multiscale entropy and correlation dimension of slow wave sleep EEG in young adults with histories of coffee-induced insomnia

BACKGROUND

Investigators of homeopathy have proposed that nonlinear dynamical systems (NDS) and complex systems science offer conceptual and analytic tools for evaluating homeopathic remedy effects. Previous animal studies demonstrate that homeopathic medicines alter delta electroencephalographic (EEG) slow wave sleep. The present study extended findings of remedy-related sleep stage alterations in human subjects by testing the feasibility of using two different NDS analytic approaches to assess remedy effects on human slow wave sleep EEG.

METHODS

Subjects (N=54) were young adult male and female college students with a history of coffee-related insomnia who participated in a larger 4-week study of the polysomnographic effects of homeopathic medicines on home-based all-night sleep recordings. Subjects took one bedtime dose of a homeopathic remedy (Coffea cruda or Nux vomica 30c). We computed multiscale entropy (MSE) and the correlation dimension (Mekler-D2) for stages 3 and 4 slow wave sleep EEG sampled in artifact-free 2-min segments during the first two rapid-eye-movement (REM) cycles for remedy and post-remedy nights, controlling for placebo and post-placebo night effects.

RESULTS

MSE results indicate significant, remedy-specific directional effects, especially later in the night (REM cycle 2) (CC: remedy night increases and post-remedy night decreases in MSE at multiple sites for both stages 3 and 4 in both REM cycles; NV: remedy night decreases and post-remedy night increases, mainly in stage 3 REM cycle 2 MSE). D2 analyses yielded more sporadic and inconsistent findings.

CONCLUSIONS

Homeopathic medicines Coffea cruda and Nux vomica in 30c potencies alter short-term nonlinear dynamic parameters of slow wave sleep EEG in healthy young adults. MSE may provide a more sensitive NDS analytic method than D2 for evaluating homeopathic remedy effects on human sleep EEG patterns.

Short-term effects of repeated olfactory administration of homeopathic sulphur or pulsatilla on electroencephalographic alpha power in healthy young adults

INTRODUCTION

Homeopathic pathogenetic trials usually rely on symptom self report measures. Adding objective biomarkers could enhance detection of subtle initial remedy effects. The present feasibility study examined electroencephalographic (EEG) effects of repeated olfactory administration of two polycrest remedies.

METHODS

College student volunteers (ages 18-30, both sexes) from an introductory psychology course were screened for good health and relatively elevated Sulphur or Pulsatilla symptom scores on the Homeopathic Constitutional Type Questionnaire (CTQ). Subjects underwent a series of 3 once-weekly double-blind sessions during which they repeatedly sniffed the remedy matched to their CTQ type and solvent controls. Each remedy was given in a 6c, 12c, and 30c potency, one potency per week, in randomly assigned order. Solvent controls included both plain distilled water and a water-ethanol (95%) solution. All sniff test solutions were further diluted just prior to laboratory sessions (0.5 ml test solution in 150 ml distilled water). Within a session, remedies and control solvents were administered via 2-s sniffs (8 sniffs of each of 4 different succussion levels for the potency in randomized order). Primary outcome variable was relative EEG power (alpha 1 8-10 Hz; alpha 2 10-12 Hz) averaged over 19 electrode sites, including all succussions for a given potency.

RESULTS

Mixed-effect models revealed significant main effects for remedy type (Sulphur >Pulsatilla) in both alpha bands, controlling for gender, baseline resting EEG alpha, and solvent control responses. Additional analyses showed significant nonlinear interactions between dilution and time (weekly session) in alpha 2 for both remedies and alpha 1 for Sulphur.

CONCLUSION

EEG alpha offers an objective biomarker of remedy effects for future studies and potential method for distinguishing time-dependent effects of specific remedies and remedy potencies from one another.

Protocol for a phase 1 homeopathic drug proving trial

Background

This study protocol adapts the traditional homeopathic drug proving methodology to a modern clinical trial design.

Method

Multi-centre, randomised, double-blind, placebo-controlled phase 1 trial with 30 healthy volunteers. The study consists of a seven day run-in period, a five day intervention period and a 16 day post-intervention observation period. Subjects, investigators and the statisticians are blinded from the allocation to the study arm and from the identity of the homeopathic drug. The intervention is a highly diluted homeopathic drug (potency C12 = 10²⁴), Dose: 5 globules taken 5 times per day over a maximum period of 5 days. The placebo consists of an optically identical carrier substance (sucrose globules). Subjects document the symptoms they experience in a semi-structured online diary. The primary outcome parameter is the number of specific symptoms that characterise the intervention compared to the placebo after a period of three weeks. Secondary outcome parameters are qualitative differences in profiles of characteristic and proving symptoms and the total number of all proving symptoms. The number of symptoms will be quantitatively analysed on an intention-to-treat basis using ANCOVA with the subject's expectation and baseline values as covariates. Content analysis according to Mayring is adapted to suit the homeopathic qualitative analysis procedure.

Discussion

Homeopathic drug proving trials using the terminology of clinical trials according GCP and fulfilling current requirements for research under the current drug regulations is feasible. However, within the current regulations, homeopathic drug proving trials are classified as phase 1 trials, although their aim is not to explore the safety and pharmacological dynamics of the drug, but rather to find clinical indications according to the theory of homeopathy. To avoid bias, it is necessary that neither the subjects nor the investigators know the identity of the drug. This requires a modification to the informed consent process and blinded study materials. Because it is impossible to distinguish between adverse events and proving symptoms, both must be documented together.

Trial registration

ClinicalTrials.gov identifier: NCT01061229.

Brief homeopathic pathogenetic experimentation: a unique educational tool in Brazil

In homeopathy, many difficulties are encountered in understanding theoretical presuppositions because they represent different paradigms from those of hegemonic science. In our medical school, we developed a brief homeopathic pathogenetic experimentation course to be added as curricular content and a didactic method in homeopathic disciplines to add practical experience to the theoretical approach of homeopathic presuppositions. In accordance with the premises laid out by Hahnemann, the father of homeopathy, brief pathogenetic experimentation was offered on a voluntary basis for students who were free of chronic diseases and who had not regularly used medication in the last 3 months. The clinical test, either crossed or sequential (randomized and blind), was used as a study model. Single weekly doses of a homeopathic medicine of 30 cH or placebo were taken by participants during 4 weeks after which crossover of the experimented substances took place for another 4 weeks. Polycrest medicines were used so that symptoms developed by the participants could be compared to those described in Homeopathic Materia Medica. Thirty-three of the 50 students who studied homeopathy as an elective discipline over the last 4 years at the School of Medicine of the University of São Paulo (FMUSP) participated. Participants described symptoms according to specific methodology including many comments with peculiar characteristics and notable idiosyncrasies. All these students endorsed the course because it contributed to their understanding of how dynamized substances produced symptoms in healthy participants as well as the cure of symptoms according to the casual similitude principle. Brief homeopathic pathogenetic experimentation proved to be an effective method to observe the idiosyncratic manifestations of human individuality based on qualitative methodology, thus building a basis of understanding of homeopathy.

Homeopathic pathogenetic trials produce more specific than non-specific symptoms: results from two double-blind placebo controlled trials

We conducted two parallel, blinded homeopathic pathogenetic trials conducted at two different sites to determine whether symptoms reported by healthy volunteers were significantly different for homeopathic remedies than for placebos. Study 1 used a two-armed design, testing ozone against placebo. Study 2 used a three-armed design, testing ozone and iridium against placebo. We found significantly more remedy-specific symptoms in provers taking ozone or iridium than in provers taking placebo in the three-armed trial and in both trials pooled for ozone and placebo. We, therefore, conclude that homeopathic remedies produce more symptoms typical for a remedy than non-typical symptoms. The results furthermore suggest a somewhat non-classical pattern because symptoms of one remedy appear to be mimicked in the other trial arm. This might be indicative of entanglement in homeopathic systems.

Should NICE evaluate complementary and alternative medicines?

Demand for complementary and alternative medicine is high despite limited evidence. Linda Franck and colleagues believe that a thorough review by NICE would benefit the NHS and patients, but David Colquhoun argues that it cannot afford to re-examine evidence that has shown little benefit