Where traditional Chinese medicine meets Western medicine in the prevention of rheumatoid arthritis

Network pharmacology combined with affinity ultrafiltration to elucidate the potential compounds of Shaoyao Gancao Fuzi Decoction for the treatment of rheumatoid arthritis

ETHNOPHARMACOLOGICAL RELEVANCE

Shaoyao Gancao Fuzi Decoction (SGFD), has been employed for thousands of years in the treatment of rheumatoid arthritis (RA) with remarkable clinical efficacy. However, the material basis underlying the effectiveness of SGFD still remains unclear.

AIM OF THE REVIEW

This study aims to elucidate the material basis of SGFD through the application of network pharmacology and biological affinity ultrafiltration.

RESULTS

UPLC-Q-TOF-MS/MS was employed to characterize the components in SGFD, the identified 145 chemical components were mainly categorized into alkaloids, flavonoids, triterpenoids, and monoterpenoids according to the structures. Network pharmacology method was utilized to identify potential targets and signaling pathways of SGFD in the RA treatment, and the anti-inflammatory and anti-RA effects of SGFD were validated through in vivo and in vitro experiments. Moreover, as the significant node in the pharmacology network, TNF-α, a classical therapeutic target in RA, was subsequent employed to screen the interacting compounds in SGFD via affinity ultrafiltration screening method, 6 active molecules (i.e.,glycyrrhizic acid, paeoniflorin, formononetin, isoliquiritigenin, benzoyl mesaconitine, and glycyrrhetinic acid) were exhibited significant interactions. Finally, the significant anti-inflammatory and anti-TNF-α effects of these compounds were validated at the cellular level.

CONCLUSIONS

In conclusion, this study comprehensively elucidates the pharmacodynamic material basis of SGFD, offering a practical reference model for the systematic investigation of traditional Chinese medicine formulas.

Molecular mechanism of quercetin in treating RA-ILD based on network pharmacology, molecular docking, and experimental validation

Rheumatoid arthritis (RA) is an autoimmune disease that is associated with systemic complications. Interstitial lung disease (ILD) is the most common pulmonary complication and second leading cause of death in patients with RA. In this study, we used network pharmacology and experimental validation to identify the targets and pathways of quercetin (Que) in the treatment of RA-associated ILD (RA-ILD). A total of 32 potential targets of Que for RA-ILD treatment were screened from six databases, and 10 core targets were screened using protein-protein interaction network analysis. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis, and molecular docking were employed to explore the potential mechanisms of Que in RA-ILD treatment. The results suggested the IL-17 signaling pathway as an important pathway through which Que alleviates RA-ILD. Subsequently, LPS (1 µg/ml) was used to establish an inflammation model on RAW 264.7 cells, and different concentrations of Que (25, 50, and 100 µM) were used for intervention. Que significantly reduced the expression levels of IL-17, TNF-α, IL-6, and IL-1β in RAW 264.7 cells. Our findings suggest that Que alleviates RA-ILD by regulating the IL-17 signaling pathway and reducing inflammation.

Growing attention on the toxicity of Chinese herbal medicine: a bibliometric analysis from 2013 to 2022

Introduction: Despite the clinical value of Chinese herbal medicine (CHM), restricted comprehension of its toxicity limits the secure and efficacious application. Previous studies primarily focused on exploring specific toxicities within CHM, without providing an overview of CHM's toxicity. The absence of a quantitative assessment of focal points renders the future research trajectory ambiguous. Therefore, this study aimed to reveal research trends and areas of concern for the past decade. Methods: A cross-sectional study was conducted on publications related to CHM and toxicity over the past decade from Web of Science Core Collection database. The characteristics of the publication included publication year, journal, institution, funding, keywords, and citation counts were recorded. Co-occurrence analysis and trend topic analysis based on bibliometric analysis were conducted on keywords and citations. Results: A total of 3,225 publications were analyzed. Number of annal publications increased over the years, with the highest number observed in 2022 (n = 475). The Journal of Ethnopharmacology published the most publications (n = 425). The most frequently used toxicity classifications in keywords were hepatotoxicity (n = 119) or drug-induced liver injury (n = 48), and nephrotoxicity (n = 40). Co-occurrence analysis revealed relatively loose connections between CHM and toxicity, and their derivatives. Keywords emerging from trend topic analysis for the past 3 years (2019-2022) included ferroptosis, NLRP3 inflammasome, machine learning, network pharmacology, traditional uses, and pharmacology. Conclusion: Concerns about the toxicity of CHM have increased in the past decade. However, there remains insufficient studies that directly explore the intersection of CHM and toxicity. Hepatotoxicity and nephrotoxicity, as the most concerned toxicity classifications associated with CHM, warrant more in-depth investigations. Apoptosis was the most concerned toxicological mechanism. As a recent increase in attention, exploring the mechanisms of ferroptosis in nephrotoxicity and NLRP3 inflammasome in hepatotoxicity could provide valuable insights. Machine learning and network pharmacology are potential methods for future studies.

Polygonum perfoliatum L. ethanol extract ameliorates 2,4-dinitrochlorobenzene-induced atopic dermatitis-like skin inflammation

ETHNOPHARMACOLOGICAL RELEVANCE

Polygonum perfoliatum L. (PP) is classified as a heat-clearing and detoxifying agent in traditional Chinese medicine, and is believed to possess therapeutic properties for treating eczema, furuncles, and venomous snake bites. Previous studies have demonstrated that PP extract exhibits multiple bioactivities, including antibacterial, anti-inflammatory, antitumor, antioxidation, and antiviral properties. However, no existing studies have evaluated the effects of PP on animal models of atopic dermatitis (AD)-like skin symptoms, which are closely associated with traditional ethnic usage.

AIM OF THE STUDY

In present study, therefore, we aimed to explore the potential anti-atopic effect of Polygonum perfoliatum L. ethanol extract (PPE) in 2,4-Dinitrochlorobenzene (DNCB)-induced dermatitis-like skin lesions.

MATERIALS AND METHODS

For reaching this aim, DNCB-induced mice with AD-like skin inflammation were subjected to topical administration of PPE gels for a period of 21 days, and subsequently, the biological impacts of PPE were evaluated.

RESULTS

PPE gels effectively mitigated AD-like skin symptoms induced by DNCB in mice, as demonstrated by a marked reduction in epidermal thickness and dermatitis severity. Moreover, PPE significantly decreased the production of various cytokines, including TNF-α, IL-6, IL-1β, IL-4, IL-5, IL-13 and IgE, in addition to suppressed the production of key inflammation-related enzymes (iNOS and COX-2) and decreased the phosphorylation of p38 mitogen-activated protein kinase (MAPK) and nuclear factor (NF)-κB in AD-like skin samples. Furthermore, PPE treatment inhibited the abnormally elevated CD4+/CD8+ ratio in DNCB-induced AD mice. The results of the skin irritation test revealed that PPE exhibited no adverse toxicity in mice at dose of 10 mg/day.

CONCLUSIONS

PPE exhibits potential as a safe therapeutic agent for atopic dermatitis by efficiently mitigating DNCB-induced atopic symptoms and diminishing inflammation, and does not carry the risk of over-immunosuppression or treatment-associated adverse effects.

Research progress of targeted therapy regulating Th17/Treg balance in bone immune diseases

Rheumatoid arthritis (RA) and postmenopausal osteoporosis (PMOP) are common bone-immune diseases. The imbalance between helper (Th17) and regulatory T cells (Tregs) produced during differentiation of CD4+ T cells plays a key regulatory role in bone remodelling disorders in RA and PMOP. However, the specific regulatory mechanism of this imbalance in bone remodelling in RA and PMOP has not been clarified. Identifying the regulatory mechanism underlying the Th17/Treg imbalance in RA and PMOP during bone remodelling represents a key factor in the research and development of new drugs for bone immune diseases. In this review, the potential roles of Th17, Treg, and Th17/Treg imbalance in regulating bone remodelling in RA and PMOP have been summarised, and the potential mechanisms by which probiotics, traditional Chinese medicine compounds, and monomers maintain bone remodelling by regulating the Th17/Treg balance are expounded. The maintenance of Th17/Treg balance could be considered as an therapeutic alternative for the treatment of RA and PMOP. This study also summarizes the advantages and disadvantages of conventional treatments and the quality of life and rehabilitation of patients with RA and PMOP. The findings presented her will provide a better understanding of the close relationship between bone immunity and bone remodelling in chronic bone diseases and new ideas for future research, prevention, and treatment of bone immune diseases.

Study on the mechanism of action of Wu Mei Pill in inhibiting rheumatoid arthritis through TLR4-NF-κB pathway

BACKGROUND

Wu Mei Pills (WMP) is a traditional Chinese medication that exhibits considerable anti-inflammatory effects. While WMP has been documented for its efficacy in treating RA, its mechanism of action on the condition remains unestablished.

METHODS

The chemical composition of WMP was analyzed through UPLC-MS. Next, the enzyme-linked immunosorbent assay, cell scratch, Transwell, and Western blotting techniques were used to investigate its intrinsic mechanism. Lastly, the effect of WMP in inhibiting RA was explored by applying it to CIA rats.

RESULT

UPLC-MS analysis detected 181 compounds in WMP. RA-FLS migration and invasion mechanisms were significantly hindered by serum containing WMP (2%, 8%). Moreover, WMP (0.5 g/kg, 2 g/kg) restricted arthritis and immune organ indices in CIA rats with type II collagen-induced rheumatoid arthritis by blocking TLR4-NF-κB inflammatory pathway activation.

CONCLUSIONS

WMP is valuable in mitigating the course of RA through inhibiting the classical TLR4-NF-κB inflammatory pathway and reducing the secretion of inflammatory factors in the serum of RA-FLS and CIA rats. Moreover, it regulates the dynamic balance of MMP-2/TIMP-2, MMP-9/TIMP-1, modulates the mechanism of RA-FLS invasion, and safeguards articular cartilage tissues in RA.

Water extracts of Tibetan medicine Wuweiganlu attenuates experimental arthritis via inducing macrophage polarization towards the M2 type

ETHNOPHARMACOLOGICAL RELEVANCE

Wuweiganlu (WGL) is a well-known formulation described in the "Four Medical Scriptures of Tibetan medicine", which is mainly used for the treatment of Rheumatoid Arthritis (RA) and other chronic ailments prescribed by Tibetan medicine. Nonetheless, the active constituents present in the water extracts of Wuweiganlu (WGLWE) specifically targeting arthritis treatment are largely unknown.

AIM OF THE STUDY

The aim of this study is to explore the effects and underlying mechanisms of the active components in WGLWE on RA.

MATERIALS AND METHODS

We utilized ultra-performance liquid chromatography coupled with Q-TOF mass spectrometry (UPLC-Q-TOF-MS) to identify the main chemical compositions of WGLWE. The polarization effect of WGLWE on bone marrow-derived macrophages (BMDM) was determined. A rat model of collagen-induced arthritis (CIA) was established by injecting an emulsion of bovine type II collagen mixed with an equal volume of incomplete Freund's adjuvant into the tail, paw and back of rats. A WGLWE-based ointment was topically applied to the legs and paws of the rats for 30 days. The rats' ankles were photographed to measure the degree of swelling. Micro-CT was used to image the knee joint and paw of rats, and the bone mineral density (BMD) and bone volume fraction (BV/TV) of knee joint in rats were analyzed. High-frequency ultrasound imaging of the rat knee joint was performed to observe knee joint effusion. Further, the serum levels of tumor necrosis factor (TNF-α), interleukin-6 (IL-6), IL-10, and arginine (Arg-1) in CIA rats were detected by enzyme-linked immunosorbent assay (ELISA). Immunohistochemistry (IHC) and immunofluorescence (IF) co-staining were employed to detect the expression levels of inflammatory factors in synovium.

RESULTS

A total of 28 main components were identified in WGLWE, and these compounds can directly bind to the inflammatory pathway proteins such as JAK2, NFκB and STAT3. In vitro experiments demonstrated that WGLWE promoted the transformation of M1 macrophages into M2 macrophages and suppressed the release of proinflammatory cytokines TNF-α and IL-6. In vivo studies showed that WGLWE effectively reduced ankle swelling, alleviated knee joint effusion, and improved BV/TV while also reducing synovial inflammation levels. Furthermore, WGLWE compounds induced the transition of M1-type macrophages to M2-type macrophages in synovial tissue, resulting in decreased secretion of inflammatory factors TNF-α, WGLWE improved the synovial inflammatory state.

CONCLUSION

Our results indicated that WGLWE alleviated joint inflammation in CIA rats and the underlying mechanism may be related to inducing the transformation of bone marrow-derived M1 macrophages to M2 macrophages, leading to an increase in the secretion of anti-inflammatory factors and a decrease in pro-inflammatory factors. Therefore, WGLWE may be used as a potential herbal preparation for the treatment of RA.

Leonurine alleviates rheumatoid arthritis by regulating the Hippo signaling pathway

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune disease that can cause joint inflammation and damage. Leonurine (LE) is an alkaloid found in Leonurus heterophyllus. It has anti-inflammatory effects.

HYPOTHESIS/PURPOSE

The molecular mechanisms by which LE acts in RA are unclear and further investigation is required.

METHODS

Mice with collagen-induced arthritis (CIA), and RA-fibroblast-like synoviocytes (FLSs) isolated from them were used as in vivo and in vitro models of RA, respectively. The therapeutic effects of LE on CIA-induced joint injury were investigated by micro-computed tomography, and staining with hematoxylin and eosin and Safranin-O/Fast Green. Cell Counting Kit-8, a Transwell® chamber, enzyme-linked immunosorbent assays, RT-qPCR, and western blotting were used to investigate the effects of LE on RA-FLS viability, migratory capacity, inflammation, microRNA-21 (miR-21) levels, the Hippo signaling pathway, and the effects and intrinsic mechanisms of related proteins. Dual luciferase was used to investigate the binding of miR-21 to YOD1 deubiquitinase (YOD1) and yes-associated protein (YAP). Immunofluorescence was used to investigate the localization of YAP within the nucleus and cytoplasm.

RESULTS

Treatment with LE significantly inhibited joint swelling, bone damage, synovial inflammation, and proteoglycan loss in the CIA mice. It also reduced the proliferation, cell colonization, migration/invasion, and inflammation levels of RA-FLSs, and promoted miR-21 expression in vitro. The effects of LE on RA-FLSs were enhanced by an miR-21 mimic and reversed by an miR-21 inhibitor. The dual luciferase investigation confirmed that both YOD1 and YAP are direct targets of miR-21. Treatment with LE activated the Hippo signaling pathway, and promoted the downregulation and dephosphorylation of MST1 and LATS1 in RA, while inhibiting the activation of YOD1 and YAP. Regulation of the therapeutic effects of LE by miR-21 was counteracted by YOD1 overexpression, which caused the phosphorylation of YAP and prevented its nuclear ectopic position, thereby reducing LE effect on pro-proliferation-inhibiting apoptosis target genes.

CONCLUSION

LE regulates the Hippo signaling pathway through the miR-21/YOD1/YAP axis to reduce joint inflammation and bone destruction in CIA mice, thereby inhibiting the growth and inflammation of RA-FLSs. LE has potential for the treatment of RA.

Comparison of different extraction methods of active ingredients of Chinese medicine and natural products

Like other traditional medicine in the world, Chinese traditional medicine (CTM) has a long history, which is a treasure of the combination of medicine and Chinese classical culture even more than 5000 years. For thousands of years, CTM has made great contributions to the reproduction and health of the Chinese people. It was an efficient therapeutic tool under the guidance of Chinese traditional medical theory, its source is generally natural products, but there are also a small number of it are natural products after some processing methods. In fact, the definition of Chinese medicine (CM) includes both traditional and new CM developed by modern technology. It is well known that the chemical composition of most CM and natural products is very complex, for example, a single herb may contain hundreds of different chemicals, including active ingredients, side effects, and even toxic ingredients. Therefore, the extraction process is particularly crucial for the quality and clinical efficacy of CM and natural products. In this work, a new classification method was proposed to divide the extraction technologies of CM and natural products into 21 kinds in recent years and analyze their status, advantages, and disadvantages. Then put forward a new technical route based on ultra-high-pressure extraction technology for rapid extraction else while removing harmful impurities and making higher utilization of CM and natural products. It is a useful exploration for the extraction industry of medicinal materials and natural products in the world.

Applications and recent advances in transdermal drug delivery systems for the treatment of rheumatoid arthritis

Rheumatoid arthritis is a chronic, systemic autoimmune disease predominantly based on joint lesions with an extremely high disability and deformity rate. Several drugs have been used for the treatment of rheumatoid arthritis, but their use is limited by suboptimal bioavailability, serious adverse effects, and nonnegligible first-pass effects. In contrast, transdermal drug delivery systems (TDDSs) can avoid these drawbacks and improve patient compliance, making them a promising option for the treatment of rheumatoid arthritis (RA). Of course, TDDSs also face unique challenges, as the physiological barrier of the skin makes drug delivery somewhat limited. To overcome this barrier and maximize drug delivery efficiency, TDDSs have evolved in terms of the principle of transdermal facilitation and transdermal facilitation technology, and different generations of TDDSs have been derived, which have significantly improved transdermal efficiency and even achieved individualized controlled drug delivery. In this review, we summarize the different generations of transdermal drug delivery systems, the corresponding transdermal strategies, and their applications in the treatment of RA.

Advances in the implications of the gut microbiota on the treatment efficacy of disease-modifying anti-rheumatic drugs in rheumatoid arthritis

Alterations in the composition or function of the gut microbiota are associated with the etiology of human diseases. Drug-microbiota interactions can affect drug bioavailability, effectiveness, and toxicity through various routes. For instance, the direct effect of microbial enzymes on drugs can either boost or diminish their efficacy. Thus, considering its wide range of metabolic capabilities, the gut microbiota is a promising target for pharmacological modulation. Furthermore, drugs can alter the microbiota and the mechanisms by which they interact with their host. Individual variances in microbial profiles can also contribute to the different host responses to various drugs. However, the influence of interactions between the gut microbiota and drugs on treatment efficacy remains poorly elucidated. In this review, we will discuss the impact of microbiota dysbiosis in the pathogenesis of rheumatoid arthritis (RA), and we will attempt to elucidate the crosstalk between the gut microbiota and disease-modifying anti-rheumatic drugs (DMARDs), with an emphasis on how drug-microbiota interactions affect the treatment efficacy in RA. We speculate that improved knowledge of these critical interactions will facilitate the development of novel therapeutic options that use microbial markers for predicting or optimizing treatment outcomes.

Guizhi Shaoyao Zhimu granules attenuate bone destruction in mice with collagen-induced arthritis by promoting mitophagy of osteoclast precursors to inhibit osteoclastogenesis

BACKGROUND

Guizhi Shaoyao Zhimu decoction, a traditional Chinese medicine formula used empirically for the treatment of rheumatoid arthritis (RA), has been shown to alleviate bone destruction in rats with collagen-induced arthritis (CIA).

PURPOSE

The aim of this study is to characterize the effects of Guizhi Shaoyao Zhimu granules (GSZGs) on bone destruction in RA and the underlying mechanism.

STUDY DESIGN

A CIA arthritis model using DBA/1 mice. The animals were divided into a normal group; CIA model group; low, medium, and high-dose GSZG groups (3, 6, and 9 g/kg/day); and a methotrexate group (1.14 mg/kg/w). In vitro, a cytokine induced osteoclastogenesis model was established.

METHODS

After 28 days of treatment, the paw volume was measured, bone destruction was examined by micro-CT, and the generation of osteoclasts in bone tissue was evaluated via tartrate-resistant acid phosphatase (TRAP) staining. Furthermore, the inhibitory effect and underlying mechanism of action of GSZG on RANKL-induced osteoclastogenesis were investigated in vitro.

RESULTS

The in vivo analyses demonstrated that the paw volume and degree of bone erosion of mice in the medium- and high-dose GSZG groups were significantly decreased compared to the CIA model group. In addition, GSZG treatment suppressed the excessive generation of osteoclasts in the bone tissue of CIA mice. In vitro, GSZG inhibited RANKL-induced osteoclastogenesis and osteoclast-mediated bone resorption. Specifically, it only inhibited the generation of osteoclast precursors (OCPs); it had no significant effect on the fusion of OCPs or maturation of osteoclasts. Finally, we showed that the inhibitory effect of GSZG on osteoclastogenesis was related to the promotion of PTEN-induced kinase protein 1 (PINK1)/Parkin pathway-mediated mitophagy of osteoclast precursors, which was verified using a PINK1 knockdown small interfering RNA in OCPs.

CONCLUSION

These findings indicate that GSZG is a candidate for the treatment of bone destruction in RA and provide a more detailed elucidation of the mechanism of GSZG anti-RA bone erosion, i.e., inhibition of the ROS/NF-κB axis through the PINK1/Parkin-mediated mitochondrial autophagic pathway to inhibit osteoclast precursor production, compared to the published literature.

Integrative medicine using East Asian herbal medicine for inflammatory pain in patients with rheumatoid arthritis: A protocol for systematic review and meta-analysis integrated with multiple data mining for core candidate discovery

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory autoimmune disease characterized by a wide range of clinical symptoms affecting various bodily functions, including skeletal, vascular, metabolic, and cognitive functions. This review aimed to evaluate the efficacy and safety of integrative medicine (East Asian herbal medicine combined with conventional medicine) used for the treatment of inflammatory pain in rheumatoid arthritis and to identify key candidate drugs based on the data.

METHODS

A comprehensive literature search will be conducted in 4 core databases (PubMed, Excerpta Medica database, Cochrane Library, and Cumulative Index to Nursing & Allied Health Literature) 4 Korean databases (Oriental Medicine Advanced Searching Integrated System, Korean Studies Information Service System, Research Information Service System, and Korea Citation Index), 2 Chinese databases (Chinese National Knowledge Infrastructure Database and Wanfang data), and 1 Japanese database (Citation Information by National Institute of Informatics) for randomized controlled trials from December 13, 2022. Statistical analysis will be performed using R version 4.1.2 and R Studio program. The American College of Rheumatology 20/50/70 score and rate of adverse events will be the primary outcomes. All outcomes will be analyzed using a random-effects model to produce more statistically conservative results. Sensitivity, meta-regression, and subgroup analyses will be used to identify the sources of any heterogeneity in the study. The revised tool for assessing the risk of bias in randomized trials, version 2.0, will be used to evaluate methodological quality. The overall quality of evidence will be assessed according to the Grading of Recommendations Assessment, Development, and Evaluation Pro Framework.

ETHICS AND DISSEMINATION

There are no ethical issues, as no primary data will be collected directly from the participants. The results of this review will be reported in a peer-reviewed scientific journal.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023412385.

Single-cell RNA transcriptomic and plasma Lipidomic reveal the potential mechanisms of a Methotrexate-based therapy against Rheumatoid Arthritis

OBJECTIVE

To assess whether a Methotrexate-based therapy could achieve more clinical benefit, we arranged a Simon 2-Stage Phase 1 Trial. Single-cell RNA sequencing and lipidomic profiling were performed to reveal the potential mechanisms.

METHODS

Patients were enrolled in an open-label, Simon 2-stage, single-center, single-arm trial at Guangdong Provincial Hospital of Chinese Medicine. Main inclusion criteria were defined as follows: Aged 18 to 70, low to medium disease activity, fulfilled the RA classification criteria of EULAR/ACR 2010. Patients received the oral medication of MTX 10-15 mg weekly and natural product granules twice a day. Primary outcome was the American College of Rheumatology (ACR) 20% preliminary definition of improvement. Single-cell RNA sequencing(scRNA-seq) on peripheral blood mononuclear cells (PBMCs) was used to show the aberrant metabolism before and after the trial. Plasma lipidomic profiling quantified the lipid changes caused by this MTX-based therapy. Finally, post-hoc analysis on responders and non-responders were used for further analysis.

RESULTS

Between October 2020 and June 2022, 46 patients received treatment, while 42 finished follow-ups. 27 of 46 (58.70%) patients achieved ACR20, and significant changes were observed in several secondary outcomes. Comparative scRNA-seq analysis before and after the treatment revealed that lipidomic metabolism was broadly downregulated. Plasma lipidomic profiling reveals that 40 lipids were observed significantly changed. Post-hoc analysis showed the lipid changes were separately linked to clinical parameters in responders and non-responders.

CONCLUSION

The study reveals that the combination therapy of HQT+MTX is effective and has a certain correlation with lipid metabolism, but more rigorous study design is still needed to confirm this speculation.

Effectiveness of Yishen Tongbi decoction versus methotrexate in patients with active rheumatoid arthritis: A double-blind, randomized, controlled, non-inferiority trial

BACKGROUND

Yishen Tongbi decoction (YSTB) which is an herbal formula, has been used for the treatment of rheumatoid arthritis (RA) for more than ten years with a better curative effect. Methotrexate (MTX) is an effective anchoring agent used to treat rheumatoid arthritis. There were, however, no head-to-head comparative randomized controlled trials comparing traditional Chinese medicine (TCM) to MTX, Therefore, we performed this double-blind, double-model, randomized controlled trial of the efficacy and safety of YSTB and MTX in the treatment of active RA for 24 weeks.

METHODS

Patients who met the enrollment criteria were randomly selected (1:1) to receive either YSTB therapy (YSTB 150 ml once daily + MTX placebo 7.5-15 mg once weekly) or MTX therapy (MTX 7.5-15 mg once weekly + YSTB placebo 150 ml once daily) in treatment cycles lasting 24 weeks. The percentage of patients who achieve a clinical disease activity index (CDAI) response at week 24 is the primary efficacy outcome. A 10% risk differential non-inferiority margin was previously defined. The Chinese Clinical Trials Registry has recorded this trial (ChiCTR-1,900,024,902, registered on August 3rd 2019, http://www.chictr.org.cn/index.aspx).

RESULTS

Out of 118 patients whose eligibility was determined from September 2019 to May 2022, 100 patients (n = 50 for each group) were enrolled in the research overall. The 24-week trial was completed by 82% (40/49) of the YSTB group's patients and 86% (42/49) of the MTX group's patients. In the intention-to-treat analysis, 67.4% (33/49) of patients in the YSTB group met the main outcome of CDAI response criteria at week 24, compared to 57.1% (28/49) in the MTX group. The risk difference was 0.102 (95% CI -0.089 to 0.293), which demonstrated the non-inferiority of YSTB to MTX. After further testing for superiority, the ratio of CDAI responses achieved by the YSTB and MTX groups was not statistically significant (p = 0.298). At the same time, in week 24, secondary outcomes such as the ACR 20/50/70 response, the European Alliance of Associations for Rheumatology good or moderate response, remission rate, simplified disease activity index response, and low disease activity rate all showed similar statistically significant patterns. There was statistically significant attainment of ACR20 (p = 0.008) and EULAR good or moderate response (p = 0.009) in two groups at week 4. The intention-to-treat analysis results and the per-protocol analysis results were in agreement. The incidence of drug-related adverse events was not statistically different between the two groups (p = 0.487).

CONCLUSIONS

Previous studies have used TCM as an adjunct to conventional therapy, and few of them have directly compared it with MTX. In order to lessen disease activity in RA patients, this trial demonstrated that YSTB compound monotherapy was non-inferior to MTX monotherapy and had superior efficacy following short-term treatment. This study provided evidence-based medicine in the treatment of RA with compound prescriptions of TCM and contributed to promoting phytomedicine use in RA patients.