Pharmacovigilance of herbal medicines: Concerns and future prospects

The metabarcoding of Grubs: Traditional herbal medicine of Scarabaeidae larvae

Grubs, called Qicao in China, have a long tradition as herbal medicine in East Asia. These larvae belong to the diverse family Scarabaeidae and are typically harvested from the wild during their immature stage based on morphological characteristics. However, rapid and accurate identification becomes challenging when relying solely on external morphological features, as the lack of clarity on biological sources raises safety concerns for clinical applications. The application of DNA metabarcoding provides a solution by enabling the determination of the biological source of a large sample. In the current study, we collected 19 batches of Grubs, consisting of 11,539 individuals, from the market and analyzed their biological composition through metabarcoding. We identified 49 Amplicon Sequence Variants (ASVs), 21 of which were Grubs. The 21 ASVs were classified into seven Molecular Operational Taxonomic Units (MOTUs) through species delimitation, which revealed that commercially available Grubs are predominantly sourced from Protaetia brevitarsis seulensis, while species of Rutelinae, Anomala, and Holotrichia were also abundant in some commercial batches. Among the identified ASVs, 28 belonged to non-Grub species and indicated adulteration from different animal families; high abundances of these ASVs were detected for Bombycidae, Tabanidae, and Viviparidae. Our findings underscore the complexity of Grubs' species composition and advocate for a deeper understanding of the wildlife sources contributing to herbal products. This research contributes valuable insights into the molecular identification of Grubs, paving the way for enhanced quality assurance in traditional medicine applications to provide safe and effective medicines for humanity.

Indigenous herbal medicine use and its associated factors among pregnant women attending antenatal care at public health facilities in Dire Dawa, Ethiopia: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate the prevalence of indigenous herbal medicine use and its associated factors among pregnant women attending antenatal care (ANC) at public health facilities in Dire Dawa, Ethiopia.

DESIGN

A facility-based cross-sectional study design.

SETTING

The study was conducted in seven public health facilities (one referral hospital, three urban and three rural health centres) in Dire Dawa, Ethiopia, from October to November 2022.

PARTICIPANTS

628 pregnant women of any gestational age who had been on ANC follow-up at selected public health facilities were included.

MAIN OUTCOME MEASURES

Prevalence of indigenous herbal medicine (users vs non-users) and associated factors.

RESULTS

The study revealed that 47.8% (95% CI 43.8% to 51.6%) of pregnant women used herbal medicines. Lack of formal education (adjusted OR, AOR 5.47, 95% CI 2.40 to 12.46), primary level (AOR 4.74, 95% CI 2.15 to 10.44), housewives (AOR 4.15, 95% CI 1.83 to 9.37), number of ANC visits (AOR 2.58, 95% CI 1.27 to 5.25), insufficient knowledge (AOR 4.58, 95% CI 3.02 to 6.77) and favourable perception (AOR 2.54, 95% CI 1.71 to 3.77) were factors significantly associated with herbal medicine use. The most commonly used herbs were garden cress (Lepidium sativum) (32%), bitter leaf (Vernonia amygdalina) (25.2%), moringa (Moringa oleifera) (24.5%). Common indications were related to gastrointestinal problems, blood pressure and sugar.

CONCLUSION

The prevalence of herbal medicine use is high (one in two pregnant women) and significantly associated with education level, occupation, ANC visits, knowledge and perceptions. The study's findings are helpful in advancing comprehension of herbal medicines using status, types and enforcing factors. It is essential that health facilities provide herbal counselling during ANC visits, and health regulatory bodies ought to raise awareness and implement interventions to lower the risks from over-the-counter herbal medicine use by pregnant women.

Comprehensive insights into herbal P-glycoprotein inhibitors and nanoformulations for improving anti-retroviral therapy efficacy

The worldwide HIV cases were 39.0 million (33.1-45.7 million) in 2022. Due to genetic variations, HIV-1 is more easily transmitted than HIV-2 and favours CD4 + T cells and macrophages, producing AIDS. Conventional HIV drug therapy has many drawbacks, including adherence issues leading to resistance, side effects that lower life quality, drug interactions, high costs limiting global access, inability to eliminate viral reservoirs, chronicity requiring lifelong treatment, emerging toxicities, and a focus on managing infections. Conventional dosage forms have bioavailability issues due to intestinal P-glycoprotein (P-gp) efflux, which can reduce anti-retroviral drug efficacy and lead to resistance. Use of phyto-constituents with P-gp regulating actions has great benefits for semi-synthetic modification to create formulations with greater bioavailability and reduced toxicity, which improves drug effectiveness. Lipid-based nanocarriers, solid lipid nanoparticles, nanostructured lipid carriers, polymer-based nanocarriers, and inorganic nanoparticles may inhibit P-gp efflux. Employing potent P-gp inhibitors within nanocarriers as a Trojan horse approach can enhance the intracellular accumulation of anti-retroviral drugs (ARDs), which are substrates for efflux transporters. This technique increases oral bioavailability and offers lower-dose options, boosting HIV patient compliance and lowering costs. Molecular docking of the inhibitor with P-gp may anticipate optimum binding and function, allowing drug efflux to be minimised.

Mechanisms of hepatocellular toxicity associated with the components of St. John's Wort extract hypericin and hyperforin in HepG2 and HepaRG cells

St. John's Wort preparations are used for the treatment of mild to moderate depression. They are usually well tolerated but can cause adverse reactions including liver toxicity in rare cases. To date, the mechanism(s) underlying the hepatotoxicity of St. John's Wort extracts are poorly investigated. We studied the hepatocellular toxicity of hypericin and hyperforin as the two main ingredients of St. John's Wort extracts in HepG2 and HepaRG cells and compared the effects to citalopram (a synthetic serotonin uptake inhibitor) with a special focus on mitochondrial toxicity and oxidative stress. In HepG2 cells, hypericin was membrane-toxic at 100 µM and depleted ATP at 20 µM. In HepaRG cells, ATP depletion started at 5 µM. In comparison, hyperforin and citalopram were not toxic up to 100 µM. In HepG2 cells, hypericin decreased maximal respiration starting at 2 µM and mitochondrial ATP formation starting at 10 µM but did not affect glycolytic ATP production. Hypericin inhibited the activity of complex I, II and IV of the electron transfer system and caused mitochondrial superoxide accumulation in cells. The protein expression of mitochondrial superoxide dismutase 2 (SOD2) and thioredoxin 2 (TRX2) and total and reduced glutathione decreased in cells exposed to hypericin. Finally, hypericin diminished the mitochondrial DNA copy number and caused cell necrosis but not apoptosis. In conclusion, hypericin, but not hyperforin or citalopram, is a mitochondrial toxicant at low micromolar concentrations. This mechanism may contribute to the hepatotoxicity occasionally observed in susceptible patients treated with St. John's Wort preparations.

Identifying in-market application of Pelargonium root extract EPs 7630 for the treatment of COVID-19: analysis of pharmacovigilance data

Introduction: Phytopharmaceutical products are successfully used for acute respiratory infections and may therefore be promising candidates for adjuvant symptomatic treatment of COVID-19. In vitro and clinical studies suggest that the proprietary Pelargonium sidoides DC. root extract EPs 7630 has antiviral and immunomodulatory properties, and effects on SARS-CoV-2 propagation have been shown in vitro. Medicinal products containing the extract have been approved for the symptomatic treatment of acute viral respiratory tract infections. Methods: We present a retrospective review of case reports submitted spontaneously to the pharmacovigilance database of the manufacturer of EPs 7630 and containing information on the off-label use of the extract for the treatment and prophylaxis of COVID-19 and of post-COVID-19 syndrome. Eligible case reports were identified by automated database searches. Results: Forty-four case reports filed between December 2019 and February 2023 were eligible for analysis. More than ¾ described the use of EPs 7630 for treatment of COVID-19 while the remaining reports referred to the treatment of post-COVID-19 syndrome or to COVID-19 prophylaxis. 15/22 cases which reported on treatment duration indicated an intake of EPs 7630 for up to 7 days. Five case reports indicated the use of EPs 7630 as COVID-19 monotherapy while 14 indicated a combination treatment with other drugs. All 28 cases that reported on treatment outcome characterized the patients as improved. Thirty case reports (68%) did not indicate any complications. The most frequent suspected adverse reactions were gastrointestinal complaints and hypersensitivity reactions, both of which may occur as known adverse effects of EPs 7630. No unexpected adverse reactions were observed. Conclusion: Reported cases confirm that there was a certain off-label use of EPs 7630 for COVID-19 in the market. Even though no formal conclusions about the efficacy of EPs 7630 in COVID-19 can be drawn, a beneficial effect would be explainable by the pharmacological profile of the extract. Further assessment of the effects of EPs 7630 in COVID-19-related indications therefore appears to be both justified and promising, particularly as the available case reports did not give rise to any safety concerns also in this patient group.

Evaluation of the toxicity of the hydroethanolic extract of the stem bark of Virola elongata (Benth.) Warb. in in vitro and in vivo models

ETHNOPHARMACOLOGICAL RELEVANCE

Virola elongata (Benth.) Warb. (Myrsticaceae), referred to as "mucuíba" in Mato Grosso, is a native tree species that can be found in the Amazon Rainforest regions of South America and the Tropical Forests of Central America. The macerated extracts from the stem bark of this tree have been traditionally used to address various health issues, including gastric ulcers, infections, inflammations, and other ailments. In scientific literature, V. elongata has demonstrated pharmacological properties such as antiulcer, gastroprotective, antiproliferative, antimitotic, and psychoactive effects. Nevertheless, it is important to note that the safety profile of V. elongata has not been thoroughly established.

AIM OF THE STUDY

To evaluate the toxicity of the hydroethanolic extract of the stem bark of Virola elongata (HEVe) in experimental models in vivo and in vitro.

MATERIALS AND METHODS

HEVe was obtained by macerating the stem bark powder in 70% hydroethanolic solution (1:10 w/v). The cytotoxicity of HEVe (3.125-200 μg/mL) was evaluated by Alamar blue assay in Chinese hamster ovary epithelial cells (CHO-k1) and human gastric adenocarcinoma (AGS). Genotoxicity assessment of HEVe (10, 30, or 100 μg/mL) was performed in CHO-k1 cells by the micronucleus test. The acute toxicity of HEVe was assessed by single-dose oral administration (2000 mg/kg) in mice of both sexes. The subacute toxicity of HEVe was assessed by oral administration of 300, 600, and 1200 mg/kg of the extract over 30 days in rats. Clinical observations of toxicological parameters were noted and pooled every 6 days. After the treatment period, blood was collected for hematological and biochemical analyses, and some organs were removed for macroscopic and histopathological analyses.

RESULTS

HEVe did not show cytotoxicity in CHO-K1 and AGS cells (IC50 > 200 μg/mL) and did not cause DNA damage in CHO-k1 cells. Oral administration of HEVe in a single dose of 2000 mg/kg did not result in the death of the mice, with a reduction in body weight variation (33.03%, p < 0.05) and an increase in the relative weight of the stomach (12 0.82%, p < 0.05) in male mice, and increased relative weight of the spleen (25.00%, p < 0.01) in female mice. In the assessment of subacute toxicity, HEVe did not result in the death of the animals over the 30 days. A reduction (p < 0.05) in water consumption of 36.65% and 34.12% was observed in the groups treated with 300 and 600 mg/kg, respectively, of HEVe on D6., and the urine excretion of animals treated with 600 mg/kg of HEVe showed an increase (p < 0.05) throughout the experiment, with a maximum value of 46.72% on D12. The blood counts showed that the dose of 300 mg/kg reduced (p < 0.05) the absolute number of lymphocytes, while the doses of 300, 600, or 1200 mg/kg of HEVe reduced the red blood cell count in whole blood by 24.84% (p < 0.01), 16.72% (p < 0.05), and 22.14% (p < 0.01), and the absolute number of monocytes (p < 0.05) in 59.77%, 65.51%, and 79.81%, respectively. As for the biochemical parameters, the glucose level found increased by 22.41% (p < 0.05) only at the highest dose, while creatinine was reduced by 44.71% (p < 0.05) at the dose of 300 mg/kg of HEVe. In animals treated with the three doses tested, plasma levels of AST and alkaline phosphatase showed a reduction (p < 0.05) with the vehicle group. However, the hematological and biochemical changes observed are within the physiological limits for this animal species. No macroscopic and histopathological changes were observed in the organs of the animals treated with the three doses of HEVe within 30 days.

CONCLUSION

The results showed that HEVe did not show cytotoxicity or genotoxicity in vitro. HEVe proved to be safe in rodents in both acute and subacute toxicity tests. In rats, the no-observed-adverse-effect level (NOAEL) dose was greater than 1200 mg/kg p. o. in rats.

Why Pharmacovigilance of Non-steroidal Anti-inflammatory Drugs is Important in India?

BACKGROUND

Non-steroidal Anti-Inflammatory Drugs (NSAIDs) are among the drugs that are most regularly administered to manage inflammation and pain. Over-the-Counter (OTC) NSAIDs are widely accessible, particularly in developing countries like India. This casual approach to using NSAIDs may operate as a magnet for NSAID-related adverse drug reactions (ADRs) among patients.

OBJECTIVES

As patients in India are less informed about the appropriate use of NSAIDs and consumption patttern, adverse drug reactions, and the importance of reporting ADRs, the current study's objective is to promote patient safety by using pharmacovigilance as a tool to educate patients.

METHODS

A targeted literature methodology was utilized to gather the data pertaining to NSAIDs, their ADRs and their pharmacovigilance. Different scientific databases, such as Science Direct, PubMed, Wiley Online Library, Springer, and Google Scholar, along with authentic textbooks, were explored as reference literature.

RESULTS

In general, NSAIDs consumption pattern depends upon the different age groups. Around 1.6 billion tablets of NSAIDs are consumed in India for ailments, such as headaches, arthritis, menstrual cramps, osteoarthritis, back pain, rheumatoid arthritis, gout, osteoporosis, tendinitis, cancer pain and chronic pain. Common ADRs of NSAIDs include nausea, vomiting, headache, gastritis, abdominal pain, and diarrhoea. Also, they can cause renal damage and cardiovascular problems if not consumed in a dose-dependent manner. However, Diclofenac and Ibuprofen have both been linked to depression and dementia. There have been reports of aplastic anaemia, agranulocytosis linked to phenylbutazone, Stevens-Johnson, and Lyell's syndrome linked to isoxicam and piroxicam, as well as the vulnerability of new-borns to Reye's syndrome after aspirin use. Lack of awareness, time constraints and unpredictability, poor training in ADRs identification, etc., are some of the reasons for the under-reporting of ADR of NSAIDs in India.

CONCLUSION

In order to rationally prescribe NSAIDs, it is essential to be aware of probable ADR's and establish prescription guidelines. Prescribers' behaviour can be changed toward excellent prescribing practices by conducting routine prescription assessments dealing with NSAIDs and providing feedback. In the near future, it will be critical to strengthen ADR data management and expand the reach of pharmacovigilance programs, ADR monitoring centers, and healthcare professionals' especially pharmacists' training in rural locations.

Natural Compounds of Salvia L. Genus and Molecular Mechanism of Their Biological Activity

The study of medicinal plants is important, as they are the natural reserve of potent biologically active compounds. With wide use in traditional medicine and the inclusion of several species (as parts and as a whole plant) in pharmacopeia, species from the genus Salvia L. are known for the broad spectrum of their biological activities. Studies suggest that these plants possess antioxidant, anti-inflammatory, antinociceptive, anticancer, antimicrobial, antidiabetic, antiangiogenic, hepatoprotective, cognitive and memory-enhancing effects. Phenolic acids, terpenoids and flavonoids are important phytochemicals, which are primarily responsible for the medicinal activity of Salvia L. This review collects and summarizes currently available data on the pharmacological properties of sage, outlining its principal physiologically active components, and it explores the molecular mechanism of their biological activity. Particular attention was given to the species commonly found in Kazakhstan, especially to Salvia trautvetteri Regel, which is native to this country.

Phytochemical and Nutraceutical Screening of Ethanol and Ethyl Acetate Phases of Romanian Galium verum Herba (Rubiaceae)

Galium species are used worldwide for their antioxidant, antibacterial, antifungal, and antiparasitic properties. Although this plant has demonstrated its antitumor properties on various types of cancer, its biological activity on cutaneous melanoma has not been established so far. Therefore, the present study was designed to investigate the phytochemical profile of two extracts of G. verum L. herba (ethanolic and ethyl acetate) as well as the biological profile (antioxidant, antimicrobial, and antitumor effects) on human skin cancer. The extracts showed similar FT-IR phenolic profiles (high chlorogenic acid, isoquercitrin, quercitrin, and rutin), with high antioxidant capacity (EC50 of ethyl acetate phase (0.074 ± 0.01 mg/mL) > ethanol phase (0.136 ± 0.03 mg/mL)). Both extracts showed antimicrobial activity, especially against Gram-positive Streptococcus pyogenes and Staphylococcus aureus bacilli strains, the ethyl acetate phase being more active. Regarding the in vitro antitumor test, the results revealed a dose-dependent cytotoxic effect against A375 melanoma cell lines, more pronounced in the case of the ethyl acetate phase. In addition, the ethyl acetate phase stimulated the proliferation of human keratinocytes (HaCaT), while this effect was not evident in the case of the ethanolic phase at 24 h post-stimulation. Consequently, G. verum l. could be considered a promising phytocompound for the antitumor approach of cutaneous melanoma.

Toxicity Derived from Interaction between Natural Compounds and Cancer Therapeutic Drugs Metabolized by CYP3A4: Lessons Learned from Two Clinical Case Reports

The use of natural compounds and, in general, the use of Complementary and Alternative Medicine (CAM), is growing steadily worldwide, both due to commercial pressure and the increasing use of self-medication and the desire to manage one's own personal health and well-being. Patients facing a cancer diagnosis are also strongly pressured to use these compounds, which are often added to standard therapeutic regimens, that should instead be based solely on diagnostic and therapeutic care pathways (DTCP) or evidence-based medicine (EBM). This study presents two clinical cases of cancer patients who presented to the pharmaceutical consultation service (PCD-Pharmacy Clinical Desk) established at the CRO Institute in Aviano, Italy. Both patients were using natural products along with prescribed chemotherapy. In the first case, a 55-year-old woman diagnosed with bilateral breast cancer with bone metastases, who was using natural compounds based on diosmin, escin (or aescin) and resveratrol in combination with ribociclib anticancer therapy, a severe ADR (neutropenia) was identified as a consequence of the drug-natural product interaction. In the second case, following a detailed medication review by the PCD, we avoided taking a therapeutic treatment (with natural compounds) that in itself could potentially render chemotherapy ineffective in a 57-year-old woman with multiple infiltrating ductal carcinoma of the left breast; the patient was planning to take a natural product containing St. John's Wort tincture and lemon balm tincture, in combination with paclitaxel and trastuzumab. In addition, we describe the corrective actions taken, thus outlining the main objectives of the activity of the PCD's pharmacy counseling service: first, to identify, report, and manage adverse drug reactions (ADRs), and second, to identify therapeutic combinations that present potential risks of toxicity or ineffectiveness of the drug therapy itself.

Natural products as a source of new anticancer chemotypes

INTRODUCTION

Exploring the chemical diversity and molecular mechanisms of natural products continues to be an important research area for identifying novel promising therapeutic approaches for fighting cancer. This is a complex disease and poses important challenges, which require not only targeted interventions to improve chemotherapy efficacy and tolerability, but also adjuvant strategies to counteract chemoresistance development and relapses.

AREAS COVERED

After a brief description of the recent literature on the anticancer potential of natural compounds, we searched for patents following the PRISMA guidelines, filtering the results published from 2019 onwards. In addition, some relevant publications from the overall scientific literature were also discussed.

EXPERT OPINION

This review comprehensively covers and analyzes the most recent advances on the anticancer mechanism of licensed natural compounds and their chemical optimization. Patentability of natural compounds was discussed according to the recent legislation in the U.S.A. and Europe.

Spice and Herb Frauds: Types, Incidence, and Detection: The State of the Art

There is a necessity to protect the quality and authenticity of herbs and spices because of the increase in the fraud and adulteration incidence during the last 30 years. There are several aspects that make herbs and spices quite vulnerable to fraud and adulteration, including their positive and desirable sensorial and health-related properties, the form in which they are sold, which is mostly powdered, and their economic relevance around the world, even in developing countries. For these reasons, sensitive, rapid, and reliable techniques are needed to verify the authenticity of these agri-food products and implement effective adulteration prevention measures. This review highlights why spices and herbs are highly valued ingredients, their economic importance, and the official quality schemes to protect their quality and authenticity. In addition to this, the type of frauds that can take place with spices and herbs have been disclosed, and the fraud incidence and an overview of scientific articles related to fraud and adulteration based on the Rapid Alert System Feed and Food (RASFF) and the Web of Science databases, respectively, during the last 30 years, is carried out here. Next, the methods used to detect adulterants in spices and herbs are reviewed, with DNA-based techniques and mainly spectroscopy and image analysis methods being the most recommended. Finally, the available adulteration prevention measurements for spices and herbs are presented, and future perspectives are also discussed.