Functional dyspepsia--a multicausal disease and its therapy

Pharmacological disadvantages in the spasmolytic effects by using the mixture known as "three toronjiles" in folk medicine

ETHNOPHARMACOLOGY RELEVANCE

In Mexico, Agastache mexicana subsp. mexicana (PT) and subsp. xolocotziana (WT), and Dracocephalum moldavica (BT), are used together as the "three toronjiles" to treat gastrointestinal spasms.

AIM OF STUDY

To evaluate if the spasmolytic activity of these three medicinal species is better in combination or in an individual manner.

MATERIALS AND METHODS

Spasmolytic effect of PT, WT and BT alone or combinate were evaluated in rings of the guinea-pig ileum contracted with potassium chloride (KCl), electrical field stimulation (EFS), or acetylcholine (ACh). Chemical analysis by thin layer and ultra-high pressure liquid chromatography of the aqueous extracts of each species were done for their comparison, and their acute toxicity were determined in mice.

RESULTS

PT and WT diminished in a dose-dependent manner the contractions induced by KCl, EFS, and ACh. Whereas BT did not altered contractions in any experimental protocol. A combination of the PT (EC50) and WT (EC50) diminished the contractions induced by KCl or EFS. Interestingly, the addition of BT extract (10 μg/ml) to the combination (PT EC30 + WT EC30) blocked the inhibitory effect produced on the contracted tissue in the presence of KCl, EFS, or ACh. Moreover, addition of BT extract (100 μg/ml) to the same combination blocked the inhibitory effect on the pre-contracted tissue only in the presence of EFS. None of the aqueous extracts produced toxicity in its individual administration in mice. Chemical analysis demonstrated similarities between PT and WT, but differences with BT.

CONCLUSIONS

The results of this study confirmed that either combined or by themselves aqueous extracts of PT and WT produced a spasmolytic action on guinea pig ileum, suggesting that this combination of medicinal plants could relieve gastrointestinal diseases in human, but when BT aqueous extract is added to those obtained with PT and WT, the spasmolytic activity diminished or even was blocked. Our results give evidence that mixture of several plants might produce disadvantages in the medicinal properties of their individual activity.

Synergy quantifications to identify individual contributions of combination partners to the overall activity - The example of STW 5

BACKGROUND

The rationale of combinations of plant extracts is often questioned. The common argument for combinations is a higher efficacy of the combination partners by multitargeting and the elimination of adverse events.

AIM

STW5, a well-known fixed herbal multicomponent preparation, is recommended in the German treatment guidelines for functional gastrointestinal diseases. The study assessed effects of STW5, its single plant components and combinations thereof on different targets to identify synergistic, additive or antagonistic effects of the combination partners.

STUDY DESIGN/METHODS

STW5, its nine components and triple combinations thereof were investigated in two in vitro models - human esophageal epithelial cells (Het1A) and intestinal smooth muscle cells (HISMC) - in comparison to Omeprazole (OM) for the release of interleukin 8 (IL-8) as surrogate for inflammation and of Ca²⁺ as surrogate for motion, under non-inflammatory and inflammatory (Capsaicin 80 µM (CAP)) conditions. The combination index (CI) of triple combinations was calculated to assess synergistic, antagonistic and additive effects.

RESULTS

In Het-1A cells, STW5 showed, under non-inflammatory as well as inflammatory conditions, releases of IL-8 (49.3 ± 4.2 pg/ml, 33.7 ± 2 pg/ml) comparable to the untreated control (46.3 ± 4.8 pg/ml). CAP increased IL-8 releases to 85.8 ± 14 pg/ml (p < 0.005). Among the single plant extracts the Iberis amara extract (IBE) induced high IL-8 releases under non-inflammatory (441 ± 177 pg/ml) and inflammatory (625± 121 pg/ml) conditions. The Silybum marianum (L.) extract (SM) reduced releases up to 20.1 ± 8 pg/ml (inflammation). The CI-values of triple combinations with IBE ranged from high synergy (CI<0.03) to antagonism (CI:480). Within the triple combinations SM was the most effective combination partner to reduce IL-8. The combination of Angelica archangelica (L.)/Carum carvi (L.) was also effective. In HISMCs, STW5 induced concentration dependent higher Ca²⁺-releases. Only Melissa officinalis (L.) (MO) induced high Ca²⁺- releases in HISMCs.

CONCLUSION

In Het-1A, STW5 inhibited Il-8 releases, although one of its components (IBE) stimulated IL-8 strongly. The combination partners in STW5 assured an overall marked anti-inflammatory action. In the triple combinations SM was identified as most important combination partner for the IL-8 reduction. CI-measurements can support the identification of active combination partners in a multicomponent preparation and can give directions towards the search for multitarget effects.

Validity and Reliability of the Persian Version of Leeds Dyspepsia Questionnaire

BACKGROUND

It is essential in clinical care services to measure the symptoms of functional dyspepsia both in the primary examination and treatment outcomes. No valid assessment tool is already available for functional dyspepsia in Iran. The present study aimed at evaluating the reliability, validity, and responsiveness of the Leeds dyspepsia questionnaire (LDQ).

MATERIALS AND METHODS

The LDQ was completed by 67 subjects with no dyspepsia symptoms and 93 subjects with certain functional dyspepsia diagnosed via endoscopy by a gastroenterologist and other clinical assessments. After definite diagnosis of functional dyspepsia, the participants were assessed by the LDQ. The psychometric characteristics of the questionnaire were then documented to investigate its reliability, validity, and responsiveness.

RESULTS

The internal consistency of the LDQ ranged from 0.80 to 0.89 and its test-retest reproducibility was 0.96. The LDQ was significantly correlated with all domains of dyspepsia symptom severity index (DSSI) and also with some of the domains of gastrointestinal symptom rating scale (GSRS). The LDQ had a sensitivity of 90.3% with a great specificity and a very good predictive validity. Moreover, a significant responsiveness to changes was observed (P<0.05).

CONCLUSION

The LDQ is a valid, reliable, reproducible, and self-rated instrument responsive to change, which can be used to measure the frequency and severity of functional dyspepsia symptoms in clinical trials.

Phytotherapy in Functional Gastrointestinal Disorders

BACKGROUND

Phytotherapy is an important therapeutic option in functional gastrointestinal diseases (FGID). It has a large tradition, with different approaches in different regions of the world, some of which have made their way into modern evidence-based medicine (EBM).

SUMMARY

Taking into account the number of herbs in use, and also the cumulated scientific evidence on them, FGID are possibly the most important indication in phytotherapy. This does not only apply for European phytotherapy, but also for other regions, such as Asia. Within European phytotherapy, herbs active in FGID are usually classified according to their main active constituents and their activities. Typically, the herbs used in FGID are grouped into amara, aromatica, amara aromatica combining both properties, herbs stimulating gastric secretion, herbs containing spasmolytic and carminative essential oils or spasmolytic alkaloids, mucilaginosa soothing the mucosa, and flavonoid containing drugs with anti-inflammatory properties. In phytotherapy, different plants are frequently combined to maximize effectiveness and specificity of action. Very potent combination products can be developed when the mechanisms of action of the combination partners are complementary. This approach can be demonstrated by the example of STW 5. For this herbal combination product, therapeutic efficacy in FGID has been clinically proven according to the highest standards of EBM. This example also underlines that modern rational phytotherapy is definitely part of modern EBM. Key Messages: FGID is one of the most important indications in phytotherapy and rationally combined herbal preparations are established evidence-based therapeutic options.

Mechanism of Action of STW 5 in Functional Dyspepsia and IBS: The Origin of Multi-Target

BACKGROUND

STW 5 is a complex herbal combination preparation composed of 9 different herbal extracts. As an herbal medicinal product, this preparation is indicated for treating functional dyspepsia (FD) and irritable bowel syndrome (IBS). Its efficacy and practical applicability was demonstrated in several clinical studies.

SUMMARY

Each herbal constituent of STW 5 has distinct effects on the gastrointestinal tract, and each shows activity through different mechanisms of action: among others, the single extracts have effects on nerves, smooth muscles, epithelial, and inflammatory cells. For example, they have relaxing or tonicizing effects on gastrointestinal muscles, and they counteract inflammation through different physiological systems, contributing to the clinical efficacy through modulation of multiple therapeutic targets. Key Messages: STW 5 is a role model for the concept of multi-targeting in therapy. Especially in complex syndromes such as FD and IBS, simultaneous multi-targeting of different functional causes seems to be a more promising approach than the classical paradigm of one disease - one receptor - one effect.

Relationship between spicy food intake and chronic uninvestigated dyspepsia in Iranian adults

OBJECTIVE

To assess the association between spicy food consumption and chronic uninvestigated dyspepsia (CUD) in a large sample of Iranian adults.

METHODS

In this cross-sectional study we assessed the consumption of spicy foods in 4763 Iranian adults living in Isfahan Province using a dietary habit questionnaire. A modified validated version of the Rome III questionnaire was used to assess CUD-related symptoms. CUD was defined as having one or more of the following characteristics: distressing postprandial fullness, early satiation and/or epigastric pain or epigastric burning at least often during the past three months. Information on meal regularity, meal frequency, intra-meal intake of fluid as well as other potential confounders was also collected.

RESULTS

CUD was prevalent in 15% of the participants. The frequent consumption of spicy foods (≥ 10 times/week) was associated with greater odds of having CUD [odds ratio (OR) 1.64, 95% confidence interval (CI) 1.09-2.49, P < 0.05). This relationship was significant even after adjusted for diet-related practices (OR 1.68, 95% CI 1.01-2.79, P < 0.05). There was a significantly positive association between spicy food consumption and postprandial fullness (OR 1.76, 95% CI 1.29-2.40, P < 0.05) and epigastric pain (OR 1.78, 95% CI 1.30-2.44, P < 0.05). However, no significant relationship was observed between the frequent consumption of spicy foods and early satiation.

CONCLUSIONS

High consumption of spicy foods is associated with greater odds of CUD, frequent postprandial fullness and epigastric pain. Further studies, particularly of a prospective nature, are needed to confirm our findings.

The Pharmacological Effects of Benachio-F(®) on Rat Gastrointestinal Functions

Functional dyspepsia (FD) is a prevalent idiopathic upper gastrointestinal (GI) disorder characterized by diverse symptomatology including epigastric pain or discomfort, postprandial fullness, and early satiety. Although its pathophysiological mechanisms have not yet been fully established, the available studies suggest that the etiology of FD is invariably multifactorial. Benachio-F(®) (BF) is a proprietary liquid formulation of 7 herbal extracts that has been proposed to address this multifactorial etiology using multi-drug phytotherapy. The pharmacological effects of BF, in comparison with those of two other herbal products (Whalmyungsu(®); WM and Iberogast(®); IB) were evaluated in rats. In a laparotomy-induced rat model of delayed GI transit, BF significantly accelerated the delayed gastric emptying caused by morphine, apomorphine, and cisplatin, and also significantly increased mean gastric transit, as compared to the control animals. BF markedly increased gastric accommodation in rats and produced higher gastric volume values than did the control treatment. The effects of BF were generally comparable or superior to those of WM and IB in these models. Furthermore, BF significantly stimulated biliary flow, as compared to the control treatment. These results indicated that BF might have great potential as an effective phytotherapeutic agent capable of reducing GI symptoms and increasing quality of life in FD patients.

Sasang constitution affects the prevalence of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD), which is a very common disorder worldwide, is known to be caused by multiple factors including environmental and genetic factors. Sasang constitutional medicine (SCM) is a component of traditional Korean medicine that emphasizes inherited characteristics of the physical and psychological patterns of a patient. This study investigated whether the prevalence of FD differs depending on Sasang classification.

METHODS

A total 517 subjects (190 males and 327 females) were recruited, and interviewed for the presence of FD using a Rome III-based questionnaire. The Sasang constitution of all subjects were diagnosed using a Sasang constitutional analytical tool (SCAT). A Chi-square test was performed to compare prevalence of DF among different Sasang constitutional types.

RESULTS

Of the 517 subjects, 115 (22.2 %) met the diagnostic criteria for FD, and the prevalence was significantly higher in females (26.9 %) than males (14.2 %, p < 0.01). The Sasang-constitution-based prevalence among all subjects was 27.5 % for Taeumin, 23.1 % for Soumin, and 16.4 % for Soyangin (p = 0.055). When compared by sex, the prevalence of FD among Sasang types showed significantly different patterns between males and females (p < 0.05); in females with FD, Taeumin predominated (32.5 % compared with 29.5 % and 18.8 % for Soumin and Soyangin, respectively; p < 0.05), whereas males with FD displayed a higher prevalence of Soumin (17.3 % compared with 9.1 % and 11.3 % for Taeumin and Soyangin, respectively; p > 0.05).

CONCLUSIONS

This study identified significant differences in FD prevalence depending on Sasang constitution and sex. Our findings provide data to guide future research on the prevention and management of FD.

Isolation and evaluation of the myorelaxant effect of bergapten on isolated rat jejunum

CONTEXT

Plants of the genus Heracleum L. (Apiaceae) have a long history of being used in traditional medicines for the treatment of alimentary tract disorders, and these biological effects have been ascribed to the presence of furanocoumarins (including bergapten).

OBJECTIVES

This study aimed to develop an efficient, preparative, counter-current chromatographic separation of bergapten in order to characterize its spasmolytic activity in isolated rat jejunum strips.

MATERIALS AND METHODS

Successful separation of the dichloromethane extract of the fruits of Heracleum leskovii Grossh. was achieved by high-performance countercurrent chromatography (HPCCC) using a two-phase solvent system composed of n-heptane/EtOAc/MeOH/H2O (6:5:6:5, v/v/v/v). The pharmacological assessment of bergapten (0.0001-50 μM) on jejunum smooth muscle strips isolated from rats was conducted under isotonic conditions, following up to three hours of incubation.

RESULTS

The separation method was scaled up six-fold from analytical to semi-preparative conditions, affording bergapten of >99% purity in less than 30 min. This permitted bergapten to be available in quantity for spasmolytic tests on isolated jejunum strips from rats. Bergapten caused myorelaxation of the intestine preparations in the concentration range of 0.0001-1 μM. At higher doses, bergapten caused either relaxation or contraction of the smooth muscle.

DISCUSSION AND CONCLUSION

Bergapten was successfully isolated by rapid HPCCC and its spasmolytic activity was confirmed, thereby providing a preliminary evidence base for the traditional medicine application. The data suggest that bergapten causes no irreversible changes to intestinal tissue.

Multicomponent phytotherapeutic approach gaining momentum: Is the "one drug to fit all" model breaking down?

Natural product based drugs constitute a substantial proportion of the pharmaceutical market particularly in the therapeutic areas of infectious diseases and oncology. The primary focus of any drug development program so far has been to design selective ligands (drugs) that act on single selective disease targets to obtain highly efficacious and safe drugs with minimal side effects. Although this approach has been successful for many diseases, yet there is a significant decline in the number of new drug candidates being introduced into clinical practice over the past few decades. This serious innovation deficit that the pharmaceutical industries are facing is due primarily to the post-marketing failures of blockbuster drugs. Many analysts believe that the current capital-intensive model-"the one drug to fit all" approach will be unsustainable in future and that a new "less investment, more drugs" model is necessary for further scientific growth. It is now well established that many diseases are multi-factorial in nature and that cellular pathways operate more like webs than highways. There are often multiple ways or alternate routes that may be switched on in response to the inhibition of a specific target. This gives rise to the resistant cells or resistant organisms under the specific pressure of a targeted agent, resulting in drug resistance and clinical failure of the drug. Drugs designed to act against individual molecular targets cannot usually combat multifactorial diseases like cancer, or diseases that affect multiple tissues or cell types such as diabetes and immunoinflammatory diseases. Combination drugs that affect multiple targets simultaneously are better at controlling complex disease systems and are less prone to drug resistance. This multicomponent therapy forms the basis of phytotherapy or phytomedicine where the holistic therapeutic effect arises as a result of complex positive (synergistic) or negative (antagonistic) interactions between different components of a cocktail. In this approach, multicomponent therapy is considered to be advantageous for multifactorial diseases, instead of a "magic bullet" the metaphor of a "herbal shotgun" might better explain the state of affairs. The different interactions between various components might involve the protection of an active substance from decomposition by enzymes, modification of transport across membranes of cells or organelles, evasion of multidrug resistance mechanisms among others.

Effects of DA-9701, a novel prokinetic agent, on phosphorylated extracellular signal-regulated kinase expression in the dorsal root ganglion and spinal cord induced by colorectal distension in rats

BACKGROUND/AIMS

DA-9701, a standardized extract of Pharbitis Semen and Corydalis Tuber, is a new prokinetic agent that exhibits an analgesic effect on the abdomen. We investigated whether DA-9701 affects visceral pain induced by colorectal distension (CRD) in rats.

METHODS

A total of 21 rats were divided into three groups: group A (no CRD+no drug), group B (CRD+no drug), and group C (CRD+DA-9701). Expression of pain-related factors, substance P (SP), c-fos, and phosphorylated extracellular signal-regulated kinase (p-ERK) in the dorsal root ganglion (DRG) and spinal cord was determined by immunohistochemical staining and Western blotting.

RESULTS

The proportions of neurons in the DRG and spinal cord expressing SP, c-fos, and p-ERK were higher in group B than in group A. In the group C, the proportion of neurons in the DRG and spinal cord expressing p-ERK was lower than that in group B. Western blot results for p-ERK in the spinal cord indicated a higher level of expression in group B than in group A and a lower level of expression in group C than in group B.

CONCLUSIONS

DA-9701 may decrease visceral pain via the downregulation of p-ERK in the DRG and spinal cord.

Distributions of Sasang constitutions and six syndromes in patients with functional dyspepsia and healthy subjects

OBJECTIVE

To investigated the characteristics of patients with functional dyspepsia (FD) in terms of Sasang constitutional medicine.

METHODS

A total of 116 patients with FD were recruited based on diagnosis by gastroscopy and symptomatic measurements. The distributions of Sasang constitutions and six syndromes in terms of TKM theory in the patients was compared with those from 1423 healthy subjects.

RESULTS

The distribution of Sasang constitutions for the patients with FD significantly differed from that for healthy subjects, especially among women; 36.7% vs 45.6% for Taeumin, 28.9% vs 33.9% for Soumin, and 34.4% vs 20.4% for Soyangin. Our results assumed a high prevalence of Soyangin women (around 1.7 folds), and Soumin (45.2%), in particular, had a high prevalence of "deficiency and coldness of spleen and stomach" compared with Taeumin (14.9%) and Soyangin types (15.7%).

CONCLUSION

This study identified a trend for the frequency of FD and the Sasang constitutions. The findings may provide new ideas for the study of prevention and management of FD,

Modified chaihu shugan powder for functional dyspepsia: meta-analysis for randomized controlled trial

Context. Modified Chaihu Shugan powder (MCSP) is a popular traditional Chinese herbal formula for functional dyspepsia, which is revised from Chaihu Shugan San and recorded in a medical classic works of China. However, its role and effect in treating functional dyspepsia have not been well established. Objective. To assess the effect and safety of modified Chaihu Shugan powder for functional dyspepsia. Methods. We searched the published and unpublished studies up to August 2012. Only RCTs of modified Chaihu Shugan powder with or without prokinetic drugs versus prokinetic drugs in the patients diagnosed with functional dyspepsia were included. Results. Twenty-two clinical trials involving 1998 participants were included. There were evidences that modified Chaihu Shugan powder (RR = 1.20, 95%, CI 1.14 to 1.27) and modified Chaihu Shugan powder plus prokinetic drugs (RR = 1.18, 95%, CI 1.11 to 1.25) were significantly better treatment options than prokinetic drugs alone in improving symptoms. No serious adverse events were described in the included trials. Conclusions. This meta-analysis showed that modified Chaihu Shugan powder alone or in combination with prokinetic drugs might be more effective than prokinetic drugs alone. However, with poor methodological quality, all the included trials were at high risk of bias. Further large-scale high-quality trials are required for assessment.

The comparative study of the effectiveness of cimetidine, ranitidine, famotidine, and omeprazole in treatment of children with dyspepsia

Background. Functional dyspepsia is a common chronic disorder with non specific upper abdominal pain or discomfort. Different approaches with anti-secretory, spasmolytic, prokinetic and anti-inflammatory effects and most preferably reduction of visceral hypersensitivity seem logical. In this study, we compared the effectiveness of the four most drugs used for treatment of dyspepsia in children. Methods. 169 patients between 2 to 16 years old that 47.3% was male and 52.7% was female were enrolled in this clinical trial study by the diagnosis of functional dyspepsia. Then for each patient one of the drugs; Omeprazole, Famotidine, Ranitidine or Cimetidine was administered, for a period of 4 weeks. Patients were followed after 2 and 6 weeks from the beginning of the treatment. Results. The distribution of drugs between these patients were including; 21.9% with Cimetidine, 21.3% with Famotidine, 30.8% with Omeperazole and 26% with Ranitidine that the proportion of patients with all symptoms relief were: 21.6% for Cimetidine, 44.4% for Famotidine, 53.8% for Omeprazole and 43.2% for Cimetidine (P = .024). In followups within 2 and 6 weeks after beginning medical therapy, no side effects due to drugs were seen. Conclusion. If a cure is defined as all symptoms relief after a period of 4 weeks treatment, our findings showed that Omeperazole are superior to Ranitidine, Famotidine, and Cimetidine for management of functional dyspepsia.

Ghrelin and functional dyspepsia

The majority of patients with dyspepsia have no identifiable cause of their disease, leading to a diagnosis of functional dyspepsia (FD). While a number of different factors affect gut activity, components of the nervous and endocrine systems are essential for normal gut function. Communication between the brain and gut occurs via direct neural connections or endocrine signaling events. Ghrelin, a peptide produced by the stomach, affects gastric motility/emptying and secretion, suggesting it may play a pathophysiological role in FD. It is also possible that the functional abnormalities in FD may affect ghrelin production in the stomach. Plasma ghrelin levels are reported to be altered in FD, correlating with FD symptom score. Furthermore, some patients with FD suffer from anorexia with body-weight loss. As ghrelin increases gastric emptying and promotes feeding, ghrelin therapy may be a new approach to the treatment of FD.

Davilla elliptica and Davilla nitida: gastroprotective, anti-inflammatory immunomodulatory and anti-Helicobacter pylori action

ETHNOPHARMACOLOGICAL RELEVANCE

Davilla elliptica and Davilla nitida are species commonly found in the Brazilian Cerrado biome.

AIM OF THE STUDY

Based on ethnopharmacological and phytochemical analyses, methanolic extracts from leaves of Davilla elliptica (EDE) and Davilla nitida (EDN) were evaluated for their anti-ulcer, anti-inflammatory, immunological and anti-Helicobacter pylori activities.

MATERIALS AND METHODS

The gastroprotective action of both extracts was evaluated in rodent experimental models (HCl/ethanol, ethanol or NSAID). We also evaluated anti-inflammatory (carrageenin-induced rat hind paw edema), immunomodulatory (murine peritoneal macrophages) and antibacterial action of both extracts against a standard strain of Helicobacter pylori.

RESULTS

EDE and EDN (500 mg/kg) were able to protect gastric mucosa against HCl/ethanol solution (EDE 63%; EDN 59%), absolute ethanol (EDE 95%; EDN 88%), and also against injurious effect of NSAID (EDE 77%; EDN 67%). When EDE and EDN were challenged with sulfhydryl depleter compound, the gastroprotective action of both extracts was completely abolished. EDE had gastroprotective effect related to increase of glutathione bioavailability and stimulated higher levels of NO, H2O2 and TNF-alpha production. Otherwise EDN showed better anti-Helicobacter pylori action than EDE. Neither extracts presented anti-inflammatory activity by oral route.

CONCLUSION

The phytochemical investigation showed that both extracts possess phenolic acid derivatives, acylglycoflavonoids and condensed tannins with evident quantitative variations that probably influenced the pharmacological differences between extracts.

Clinical effects of STW 5 (Iberogast) are not based on acceleration of gastric emptying in patients with functional dyspepsia and gastroparesis

STW 5, a herbal extract, is effective for the treatment of symptoms in patients with functional dyspepsia (FD). However, its mode of action is still unclear and a modulation of gastric motility is hypothesized. This multicentre, placebo-controlled double-blind study addressed the question of whether STW 5 accelerates gastric emptying in patients with FD and gastroparesis. One-hundred and three patients diagnosed with FD were randomly assigned to a treatment with either STW 5 or a liquid placebo for 28 days. The primary end point of the study was a change of a validated gastrointestinal symptom (GIS) score under treatment. Additionally, patients underwent a (13)C octanoic acid breath test for the assessment of the gastric half-emptying time (t(1/2)). Patients with prolonged t(1/2) were diagnosed with gastroparesis and requested to repeat the test at the end of treatment. A change of t(1/2) was defined a secondary study end point. t(1/2) was prolonged in 48.6% of patients in the STW 5 group and in 43.8% of the placebo group. During treatment, t(1/2) increased non-significantly in patients treated with STW 5 (+23 +/- 109 min; P = 0.51) and slightly accelerated among patients in the placebo arm (-26 +/- 51 min; P = 0.77) (P = 0.49). The improvement of the GIS (P = 0.08) and the proportion of patients with a treatment response (P = 0.03) were more pronounced in the STW 5 group. Our findings suggest that the clinical effects of STW 5 in patients with FD and gastroparesis are not directly mediated by an acceleration of gastric emptying. A clear-cut correlation with symptom improvement is still lacking.

Hormones of the gut-brain axis as targets for the treatment of upper gastrointestinal disorders

The concept of the gut forming the centre of an integrated gut-brain-energy axis - modulating appetite, metabolism and digestion - opens up new paradigms for drugs that can tackle multiple symptoms in complex upper gastrointestinal disorders. These include eating disorders, nausea and vomiting, gastroesophageal reflux disease, gastroparesis, dyspepsia and irritable bowel syndrome. The hormones that modulate gastric motility represent targets for gastric prokinetic drugs, and peptides that modify eating behaviours may be targeted to develop drugs that reduce nausea, a currently poorly treated condition. The gut-brain axis may therefore provide a range of therapeutic opportunities that deliver a more holistic treatment of upper gastrointestinal disorders.

STW 5/Iberogast: Multi-Target-Wirkung bei funktioneller Dyspepsie und Reizdarmsyndrom

Functional gastro-intestinal diseases such as functional dyspepsia and irritable bowel syndrome are a therapeutic challenge, as they are not only characterized by a multitude of symptoms, some of them with severe consequences for affected patients, but are also caused by a multitude of factors. The clinical efficacy of the therapeutics STW 5/Iberogast in these diseases has been proven in a number of randomized prospective clinical studies. Several preclinical studies suggest that its efficacy could be due to its complex composition of nine standardized herbal extracts, which act differently on multiple sites. This principle, which is quite popular in clinical medicine, was introduced as a multi-target therapy for functional bowel disorders. Components of STW 5/Iberogast reduce gastro-intestinal hypersensitivity and act spasmolytic on spastic, tonicising on atonic gastro-intestinal muscle. In addition a stimulating effect on reduced mucus-secretion, an inhibitory effect on enhanced gastric acid secretion and an anti-inflammatory effect have been shown. These effects could explain the clinical efficacy of STW5/Iberogast in a large range of symptoms.

The active components and the pharmacological multi-target principle of STW 5 (Iberogast)

The therapeutic equivalence of the multi-herbal drug combination STW 5 (Iberogast) with two synthetic standard drugs can be explained by an additive or overadditive pharmacological synergism. A review of the different chemical constituents contained in this fixed combination of nine herbal drug extracts and their dominant mechanisms of action shows that they correlate very well with the clinically relevant overall pharmacological profile of the multi-herbal drug combination. This comprises modulatory effects on gastro-intestinal motility, anti-inflammatory action, inhibitory effects on gastric acid production and anti-oxidative and radical-inhibiting properties. As a multi-drug preparation with a multitude of therapeutic targets relevant in functional gastrointestinal diseases, its pharmacological profile of action in accordance with the multi-target principle.

Radical scavenging and anti-inflammatory properties of STW 5 (Iberogast) and its components

A combination of ethanolic extracts from nine medicinal plants is successfully used in STW 5 (Iberogast((R))) for treatment of gastrointestinal disorders. To elucidate possible modes of action, the focus of this study is on antioxidant properties of the phytomedicine STW 5. In fact, functional gastrointestinal diseases, such as non-ulcer dyspepsia (NUD) and irritable bowel syndrome, are often initiated by or correlated to inflammatory processes, where oxidants such as reactive oxygen species (ROS) play a crucial role. Prominent in vivo sources of ROS generation are represented by the enzymes xanthine oxidase (XOD) or myeloperoxidase (MPO). Applying these enzymes in models in vitro, we show that STW 5 and its components possess strong antioxidant activities. Depending on the model investigated, even pro-oxidant activities of single components of STW 5 could be observed. Interestingly, these effects were absent in STW 5, indicating cooperation between the components. Moreover, if one of the component extracts of STW 5 is omitted, the antioxidant activity is reduced. Thus we conclude that all the single extracts combined in STW 5 are of importance for the therapeutic effect, working in concert. The component of STW 5 performing best in vitro differed with the model investigated, respectively, with ROS and ROS generators. In the XOD system, the extracts of lemon balm leaf and peppermint leaf showed the best antioxidant result, whereas concerning MPO driven chlorination reactions, bitter candy tuft extract was the most efficient antioxidant. Best protection against peroxynitrite induced oxidation of methionine like sulfur-compounds exhibited the STW 5 components lemon balm leaf, Matricaria flower and peppermint leaf.

Binding of STW 5 (Iberogast) and its components to intestinal 5-HT, muscarinic M3, and opioid receptors

Clinical studies with the fixed herbal combination product STW 5 (Iberogast) have indicated an efficacy comparable to metoclopramide (5-HT(3) antagonist) and cisapride (5-HT(4) agonist) in functional gastro-intestinal diseases like functional dyspepsia (FD) and irritable bowel syndrome (IBS). Since serotonin (5-HT(3) and 5-HT(4)) and muscarinic M(3) receptors are known to play a central role in the etiology of FD and IBS, the extracts contained in STW 5 and several of their phytochemical components were studied in vitro for binding affinities to these receptors of the intestine. STW 5 inhibited the binding of (3)H-GR113808 and (3)H-4-DAMP to 5-HT(4) and M(3) receptors, respectively, about 10 times more potently than the binding of (3)H-GR65630 to 5-HT(3) receptors. IC(50) values for STW 5 did correspond to extract dilutions of 1:1000 (M(3) binding) and 1:2000 (5-HT(4) binding). In addition, STW 5 also potently inhibited the binding to opioid receptors with an IC(50) value of 1:2000. Of the nine herbal extracts contained in STW 5, the fresh plant extract of bitter candy tuft (Iberis amara) selectively inhibited binding to M(3) receptors, while ethanolic extracts of celandine herb and chamomile flower were selective to 5-HT(4), and liquorice root to 5-HT(3) receptors. Binding affinities to human recombinant 5-HT(3), 5-HT(4) and M(3) receptors were qualitatively similar to those of the corresponding intestinal receptors. The benzylisoquinoline alkaloid berberine had significant inhibitory action on 5-HT(4) and M(3) binding, showing IC(50) values of 40 ng/ml (100 nM) and 200 ng/ml (500 nM), respectively, but is present in the extract of celandine herb only in traces, so that also for the celandine extract a cooperative effect of several phytochemical constituents can be assumed. These in vitro data indicate that 5-HT(4) (to a lesser degree 5-HT(3)), muscarinic M(3), and opioid receptors represent target sites for the treatment of FD and IBS with STW 5 (Iberogast).

Spasmolytic and tonic effect of Iberogast (STW 5) in intestinal smooth muscle

STW 5 (Iberogast) is a fixed combination of nine medicinal plant extracts effective in the treatment of functional dyspepsia and irritable bowel syndrome. The effects of STW 5, a combination of Iberis amara fresh plant extract, and other eight plant extracts as well as single extract components including extracts from Menthae piperitae folium, Matricariae flos and Liquiritiae radix, were assayed in guinea pig ileum with or without stimulation with acetylcholine or histamine, in order to find a possible effect on the contractility of intestinal smooth muscle. STW 5 decreased acetylcholine- and histamine-induced contraction of guinea pig ileum. This was also true for extracts of Menthae piperitae folium, Matricariae flos and L. radix. Extract from I. amara, however, showed no spasmolytic action; in contrary, it increased the basal resting tone and contraction of atonic ileal segments. This was also true when STW 5 was employed. A spasmolytic action of STW 5 could also be observed in duodenum, jejunum and colon. These data are the first to show not only the spasmolytic effects of STW 5 and its component extracts in intestinal muscle but also the tonicising effects of STW 5 through its component Iberis amara extract in relaxed intestinal muscle. Thus, pharmacological evidence suggests a dual-action principle and may explain, at least in part, the clinically observed therapeutic efficacy of STW 5 (Iberogast) in both hypotonic and spastic dysmotility symptoms of functional dyspepsia and irritable bowel syndrome.

Intestinal spasmolytic effects of STW 5 (Iberogast) and its components

Functional gastro-intestinal diseases as the irritable bowel syndrome are very common in the population and are characterized by a broad spectrum of symptoms which mostly are related to spastic or paralytic intestinal function without defined histopathological changes of the tissue. Due to the multifactorial pathogenesis a multifactorial therapy with multi-target action seems to be reasonable. STW 5 (Iberogast), its constituent herbal extracts and some isolated compounds were used in an in vitro model provided by intestinal samples from guinea pig in order to test their activity on histamine-induced contractions and spontaneous motility, respectively. For comparison the known spasmolyticum papaverine was used. The results show that the lytic effect of the phytotherapeuticum on histamine-induced contraction represents additively the actions of the different components and corresponds to approx. 10 microM of papaverine. Spontaneous peristaltic motion was differently modulated by the various constituent extracts. The experiments with silibinin, glycyrrhicine, chelidonine, and protopine showed that the effects of the extracts were not comparable to those of the respective chemical constituents.

Phytotherapy for functional dyspepsia: a review of the clinical evidence for the herbal preparation STW 5

Functional gastrointestinal disorders such as functional (or non-ulcer) dyspepsia are characterized by a broad spectrum of symptoms referred to the upper abdomen without a detectable cause utilizing routine diagnostic measures. It is now believed that disordered gut function (including abnormalities like disturbances of motility such as postprandial fundic relaxation, gastric emptying and disturbed visceral sensory function) play a key role for the manifestation of these disorders. The underlying pathophysiology is not yet fully understood. However, the available data suggest that a number of factors may contribute to the manifestation of symptoms. These factors include environmental factors such as acute infections as trigger event, psychological stressors that may precede acute exacerbations and a genetic predisposition. Considering the large number of mechanisms, a treatment targeting a single mechanism is unlikely to be effective in all patients. Indeed, chemically defined treatments usually gain a 10-15% superiority over placebo. In recent years placebo-controlled studies have demonstrated superiority of a commercial multicomponent herbal preparation, STW 5, with the trade name Iberogast, for the treatment of patients with functional dyspepsia and irritable bowel syndrome. This phytopharmacon is a combination of nine plant extracts each with a number of different active constituents. Pharmacological studies have shown different effects of the single plant extracts on the (molecular) mechanisms which are discussed as underlying the manifestation of symptoms. Various well-controlled clinical trials have independently confirmed clinical efficacy and safety. The clinically efficacy of this multicomponent herbal preparation questions the current trend of highly targeted drug molecules that usually target one single receptor population while it has not been shown that a single receptor group plays a pivotal role for the control of symptoms. Herbal medicines are obtained from various plants and contain complex extracts with a large number of different active substances. While there are only limited head-to-head comparisons with conventional chemically defined medications, the combination of extracts with various gastrointestinal active ingredients appears to be advantageous for a heterogeneous condition such as functional dyspepsia.