Systematic review of clinical data with BNO-101 (Sinupret) in the treatment of sinusitis

[Comparative evaluation of the effectiveness of the drug Sinupret in preoperative preparation and the postoperative period of observation (treatment) during planned rhino-surgical interventions]

INTRODUCTION

Pathology of the nose and paranasal sinuses currently occupy one of the leading places in the general structure of diseases of the ENT organs. The proportion of patients in this group who are treated in highly specialized departments of the hospital and who undergo surgical interventions in the nasal cavity is more than 65%.

OBJECTIVE

To equalize the efficacy and safetyof the preparation Sinupret in combination with standard therapy in patients in the preoperative and postoperative periods with planned surgical interventions in violation of the architectonics of the nasal cavity.

MATERIAL AND METHODS

On the clinical basis of the Department of Otorhinolaryngology of the Ural State Medical University of Yekaterinburg, the comparative efficacy and safety of the use of Sinupret in planned surgical interventions in the nasal cavity in patients in preoperative preparation and postoperative management were evaluated.

RESULTS

After performing planned surgical interventions in the nasal cavity (septoplasty and submucosal vasotomy with partial resection of the posterior extremities of the lower nasal turbinates), in the observed who in combination with standard conservative therapy received a plant-based remedy, the average score of the total amount of the SNOT-22 test was 20.4, and in patients who, after a similar operation, received only standard conservative treatment, the average score of the total test amount was 20.4, and in patients who after a similar operation received only standard conservative treatment, the average score of the total test amount of the test SNOT-22 corresponded to 28.1, given that the average score of the total amount of the SNOT-22 test before these interventions and the course of therapy was 56.8. The recovery period of nasal breathing was also shortened and the clinical picture improved in patients receiving complex treatment.

CONCLUSION

The use of herbal remedies in combination with standard therapy can reduce the time spent in the hospital after planned surgical interventions in the nasal cavity, accelerate the healing and restoration of the nasal mucosa after surgery, and also qualitatively facilitate postoperative care.

Herbal medicinal product Sinupret extract (BNO 1016) is safe and effective in the treatment of acute viral rhinosinusitis

Aim. The pooled efficacy data of two similar randomized placebo-controlled clinical trials were analyzed. Safety was evaluated on the basis of the individual trials. Materials and methods. The efficacy analysis was based on 589 patients. Treatment was performed orally with either 3160 mg BNO 1016 (n=294) or 31 tablet placebo (n=295) for 15 days. In both trials patients underwent five visits to the investigational sites. Symptoms were evaluated according to the EPOS 2012 guideline. Ultrasonography was used to confirm the diagnosis at onset of treatment and the remission of symptoms at the last visit. Efficacy was evaluated by the investigator as the mean major symptom score (MSS) at the end of treatment (visit 5, day 14). Patients reported symptoms and social/emotional consequences of rhinosinusitis using a quality of life questionnaire (SNOT-20 GAV). Results. MSS improved during the treatment period by a mean of 10.021.61 score points to 2.472.55 for BNO 1016 and of 9.871.52 to 3.633.63 for placebo. Differences between treatment groups at end of therapy (1.163.14 score points; p0.0001) and patient-assessed quality of life (p=0.0015) were statistically significant in favor of BNO 1016. Conclusion. Daily intake of 480 mg of BNO 1016 for 15 days is an effective treatment in acute viral rhinosinusitis.

Plant-Based Support of Respiratory Health during Viral Outbreaks

Respiratory viruses are linked to major epidemic events that have plagued humans through recorded history and possibly much earlier, ranging from common colds, influenza, and coronavirus infections to measles. However, difficulty in developing effective pharmaceutical solutions to treat infected individuals has hindered efforts to manage and minimize respiratory viral outbreaks and the associated mortality. Here we highlight a series of botanical interventions with different and often overlapping putative mechanisms of action to support the respiratory system, for which the bioactive pharmacophore was suggested and the initial structure-activity relationships have been explored (Bupleurum spp., Glycyrrhiza spp., Andrographis spp.), have been proposed with uncertainty (Echinacea spp., Zingiber spp., Verbascum spp., Marrubium spp.), or remained to be elucidated (Sambucus spp., Urtica spp.). Investigating these metabolites and their botanical sources holds potential to uncover new mediators of the respiratory health outcomes as well as molecular targets for future break-through therapeutic interventions targeting respiratory viral outbreaks.

Effects of BNO 1016 on ciliary transport velocity and cell culture surface liquid height of sinonasal epithelial cultures

Background

BNO 1016 is an ethanolic extract of a mixture of five herbs that has been sold in different formulations for decades in the European market and more recently, in the United States market as an over-the-counter treatment for rhinosinusitis. Previous studies indicated activation of chloride secretion and increase in ciliary beat frequency by BNO 1016 but the functional consequences on mucociliary transport velocity and airway surface liquid homeostasis are unknown. This study intends to examine the effects of BNO 1016 on these properties in vitro.

Results

Human sinonasal epithelial cells were grown at an air-liquid interface, with addition of BNO 1016 basolaterally in each experiment. Polystyrene fluorescent microspheres were added to the apical surface of the culture, and distance traveled across the surface of the culture over a fixed time period was measured using live imaging. BNO 1016 concentrations of 50 μg/ml and 500 μg/ml were tested. Basolateral application of compound resulted in a non-dose-dependent increase in culture surface liquid height compared to controls at 30 min, and this effect persisted through the one-hour duration of the experiment (p < 0.01). Basolateral application of BNO 1016 also resulted in a non-dose-dependent increase in microsphere transport velocity at 45 and 60 min following compound application (p < 0.01).

Conclusions

Basolateral application of BNO 1016 at a concentration mimicking post-ingestion serum levels appears to elicit increases in cell culture surface liquid height and mucociliary clearance, as assessed by microsphere transport velocity. These properties can potentially be leveraged for therapeutic efficacy in diseases affecting mucus production and mucociliary transport.

Evidence-based management of acute rhinosinusitis with herbal products

Background

The overuse of antibiotics for unjustified indications such as the management of acute uncomplicated rhinosinusitis has contributed to the emergence of antibiotic-resistant strains of bacteria and prompted the need for alternative treatments. This review assesses the quality of evidence for the management of acute rhinosinusitis with herbal products, with the goal of positioning them among other treatments and identifying future research directions. The MEDLINE database was searched for randomized controlled trials with Sinupret®, Pelargonium sidoides extract, Cyclamen europaeum (CE), cineole, and GeloMyrtol®. Searches with N-acetylcysteine and mometasone furoate nasal spray (MFNS) were performed to compare the strength of evidence of herbal products to these conventional products, which are indicated for acute rhinosinusitis.

Main body

Evidence was strongest for Sinupret, followed by Pelargonium sidoides extract. Their use in acute rhinosinusitis is supported by randomized placebo-controlled trials demonstrating both clinical efficacy and safety. Comparative data with conventional treatments such as topical glucocorticosteroids were found only for Sinupret and suggested comparable efficacy in a small study.

For other herbal products, the overall level of evidence was low. The search retrieved two small-scale placebo-controlled randomized studies with CE nasal spray. The two trials were not powered to draw conclusions about the safety and efficacy of CE nasal spray and reported a lack of efficacy with CE on symptom reduction. Only one randomized placebo-controlled trial was identified for GeloMyrtol and cineole. These suggested an improvement in acute rhinosinusitis symptoms with both products, but the results warrant replication in larger trials.

Studies directly comparing herbal products are scarce; one randomized trial has compared cineole with Sinupret, but the results need confirmation in further studies.

Studies with N-acetylcysteine are limited to small-scale clinical trials, while MFNS is supported by a strength of evidence comparable to Sinupret in this indication.

Conclusion

State-of-the-art studies demonstrating the efficacy and safety of herbal products for the management of acute rhinosinusitis are available. Given that the evidence for Sinupret is the strongest and comparable to that of a widely available topical corticosteroid, MFNS, Sinupret may be considered for the management of acute uncomplicated rhinosinusitis.

Eupatoriopicrin Inhibits Pro-inflammatory Functions of Neutrophils via Suppression of IL-8 and TNF-alpha Production and p38 and ERK 1/2 MAP Kinases

During chronic inflammation, neutrophils acting locally as effector cells not only activate antibacterial defense but also promote the inflammatory response. Interleukin 8 (IL-8), the main cytokine produced by activated neutrophils, positively correlates with the severity of respiratory tract diseases. By screening European plants traditionally used for treating respiratory tract diseases, we found that extracts of aerial parts of Eupatorium cannabinum inhibit IL-8 release from neutrophils. Using bioassay-guided fractionation, we identified five sesquiterpene lactones, eupatoriopicrin (1), 5'-deoxyeupatoriopicrin (2), hiyodorilactone A (3), 3-hydroxy-5'- O-acetyleupatoriopicrin = hiyodorilactone D (4), and hiyodorilactone B (5), that efficiently (IC₅₀ < 1 μM) inhibited IL-8 and TNF-α release in lipopolysaccharide (LPS)-stimulated human neutrophils. Moreover, all these sesquiterpene lactones suppressed the adhesion of human neutrophils to an endothelial monolayer by downregulating the expression of the β2 integrin CD11b/CD18 on the neutrophil surface. Furthermore, eupatoriopicrin efficiently suppressed LPS-induced phosphorylation of p38 MAPK and ERK and attenuated neutrophil infiltration in the thioglycolate-induced peritonitis model in mice. Altogether, these results demonstrate the potential of the sesquiterpene lactone eupatoriopicrin as a lead substance for targeting inflammation.

A Review of the Antiviral Properties of Black Elder (Sambucus nigra L.) Products

Black elder (Sambucus nigra L.) has a long ethnobotanical history across many disparate cultures as a treatment for viral infection and is currently one of the most-used medicinal plants worldwide. Until recently, however, substantial scientific research concerning its antiviral properties has been lacking. Here, we evaluate the state of current scientific research concerning the use of elderberry extract and related products as antivirals, particularly in the treatment of influenza, as well as their safety and health impacts as dietary supplements. While the extent of black elder's antiviral effects are not well known, antiviral and antimicrobial properties have been demonstrated in these extracts, and the safety of black elder is reflected by the United States Food and Drug Administration approval as generally recognized as safe. A deficit of studies comparing these S. nigra products and standard antiviral medications makes informed and detailed recommendations for use of S. nigra extracts in medical applications currently impractical. Copyright © 2017 John Wiley & Sons, Ltd.

[Clinical efficacy of a herbal drug combination in acute viral rhinosinusitis]

BACKGROUND

Acute rhinosinusitis is a frequent inflammatory disease of the mucosa of the nose and paranasal sinuses, usually associated with substantial morbidity having considerable socioeconomic impact. A new herbal drug based on a dry extract of a combination of 5 medicinal drugs (Sinupret® extract Dragees) was tested in a confirmatory trial in patients with acute viral rhinosinusitis.

METHODS

386 patients with symptomatic acute viral rhinosinusitis have been treated with the herbal drug combination (daily dosage 3 × 160 mg) or placebo in a double-blind, randomised, placebo-controlled clinical trial for 15 days. Primary efficacy endpoint was the investigator assessed symptom score at the end of therapy (Major Symptom Score, MSSINV).

RESULTS

Treatment with verum lead to a statistically significant, clinically relevant improvement of the symptom score (2.07 ± 0.18 [SEM] vs. 3.47 ± 0.28 score points, p = 0.0001; PP: N = 300) compared to placebo at visit 5. The Number Needed to Treat (NNT) was 7 (PP). Adverse events occurred in 9.8% of the patients treated with verum and 14.1% of the patients treated with placebo. No serious adverse event was observed. The investigators assessed the tolerability of the herbal drug combination predominantly as good and very good (96.4% verum, 95.3% placebo).

CONCLUSION

The results prove the efficacy and tolerability of the herbal drug in the indication acute viral rhinosinusitis. Especially due to the favorable benefit-risk ratio the drug represents a suitable treatment alternative.

Herbal drug BNO 1016 is safe and effective in the treatment of acute viral rhinosinusitis

CONCLUSION

Daily intake of 480 mg of BNO 1016 for 15 days is an effective treatment in acute viral rhinosinusitis.

OBJECTIVES

The pooled efficacy data of two similar randomized placebo-controlled clinical trials were analyzed. Safety was evaluated on the basis of the individual trials.

METHODS

The efficacy analysis was based on 589 patients. Treatment was performed orally with either 3 × 160 mg BNO 1016 (n = 294) or 3 × placebo (n = 295) for 15 days. In both trials patients underwent five visits to the investigational sites. Symptoms were evaluated according to the EPOS 2012 guideline. Ultrasonography was used to confirm the diagnosis at onset of treatment and the remission of symptoms at the last visit. Efficacy was evaluated by the investigator as the mean major symptom score (MSS) at the end of treatment (visit 5, day 14). Patients reported symptoms and social/emotional consequences of rhinosinusitis using a quality of life questionnaire (SNOT-20 GAV).

RESULTS

MSS improved during the treatment period by a mean of 10.02 ± 1.61 score points to 2.47 ± 2.55 for BNO 1016 and of 9.87 ± 1.52 to 3.63 ± 3.63 for placebo. Differences between treatment groups at end of therapy (1.16 ± 3.14 score points; p < 0.0001) and patient-assessed quality of life (p = 0.0015) were statistically significant in favor of BNO 1016.

Sinupret activates CFTR and TMEM16A-dependent transepithelial chloride transport and improves indicators of mucociliary clearance

Introduction

We have previously demonstrated that Sinupret, an established treatment prescribed widely in Europe for respiratory ailments including rhinosinusitis, promotes transepithelial chloride (Cl⁻) secretion in vitro and in vivo. The present study was designed to evaluate other indicators of mucociliary clearance (MCC) including ciliary beat frequency (CBF) and airway surface liquid (ASL) depth, but also investigate the mechanisms that underlie activity of this bioflavonoid.

Methods

Primary murine nasal septal epithelial (MNSE) [wild type (WT) and transgenic CFTR^−/−], human sinonasal epithelial (HSNE), WT CFTR-expressing CFBE and TMEM16A-expressing HEK cultures were utilized for the present experiments. CBF and ASL depth measurements were performed. Mechanisms underlying transepithelial Cl⁻ transport were determined using pharmacologic manipulation in Ussing chambers, Fura-2 intracellular calcium [Ca²⁺]_i imaging, cAMP signaling, regulatory domain (R-D) phosphorylation of CFTR, and excised inside out and whole cell patch clamp analysis.

Results

Sinupret-mediated Cl⁻ secretion [ΔI_SC(µA/cm²)] was pronounced in WT MNSE (20.7+/−0.9 vs. 5.6+/−0.9(control), p<0.05), CFTR^−/− MNSE (10.1+/−1.0 vs. 0.9+/−0.3(control), p<0.05) and HSNE (20.7+/−0.3 vs. 6.4+/−0.9(control), p<0.05). The formulation activated Ca²⁺ signaling and TMEM16A channels, but also increased CFTR channel open probability (Po) without stimulating PKA-dependent pathways responsible for phosphorylation of the CFTR R-domain and resultant Cl⁻ secretion. Sinupret also enhanced CBF and ASL depth.

Conclusion

Sinupret stimulates CBF, promotes transepithelial Cl⁻ secretion, and increases ASL depth in a manner likely to enhance MCC. Our findings suggest that direct stimulation of CFTR, together with activation of Ca²⁺-dependent TMEM16A secretion account for the majority of anion transport attributable to Sinupret. These studies provide further rationale for using robust Cl⁻ secretagogue based therapies as an emerging treatment modality for common respiratory diseases of MCC including acute and chronic bronchitis and CRS.

A prospective, controlled study of SNS01 (ectoine nasal spray) compared to BNO-101 (phytotherapeutic dragées) in patients with acute rhinosinusitis

OBJECTIVES

In this observational study, data on the efficacy, effects on quality of life and tolerability of the topical formulation SNS01 (Ectoin Rhinitis nasal spray) were compared to those of BNO-101 (Sinupret forte dragées) in patients with acute rhinosinusitis in the ear, nose, and throat (ENT) clinical setting.

DESIGN AND METHODS

Patients with the diagnosis of acute rhinosinusitis were included in this non-interventional study with a treatment duration of 14-16 days. They received either a herbal phytotherapeutic dragée (control) or an ectoine-based nasal spray (investigational product), each to be taken according to the instructions for use (IFU) and summary of product characteristics (SPC). At each visit, the physician performed a nasal endoscopy, recorded the Sinusitis Symptom Score and checked for adverse events. During the entire treatment period, patients recorded the Sinusitis Symptom Score in patient diaries. In addition, patients receiving the nasal spray filled out a questionnaire to assess the tolerability of the treatment. To investigate effects on quality of life patients were asked to fill out the German version of a sinusitis-specific HRQL (health related quality of life) questionnaire.

CLINICAL TRIAL REGISTRATION

NCT01684540.

RESULTS

Patient diary entries, the assessment of the Sinusitis Symptom Score and the HRQL questionnaire demonstrated that the ectoine nasal spray was as effective as the phytotherapeutic dragées in treating acute rhinosinusitis. After two weeks of treatment, the assessments of both the patients' diaries and physicians' record forms indicated statistically significant improvement (p ≤ 0.001) in the symptom scores of the two groups (57.8% improvement for ectoine and 49.3% improvement for the phytotherapeutic dragées compared to baseline). Also, overall scores of 80 in the sensory questionnaire confirmed the good tolerability of the nasal spray. Correspondingly, HRQL improved significantly over the course of the treatment in both groups.

CONCLUSION

SNS01 and BNO-101 demonstrated comparable effects in the treatment of acute rhinosinusitis.

LIMITATIONS

Following German regulations, this trial was set up as an observational 'non-interventional' study, which does not allow for a placebo group or randomization of patients. Although the grade of evidence delivered by the study data is thus reduced from Ib to IIa, it does, however, reflect a realistic view of the most common clinical practice.

New horizons: Current and potential future self-treatments for acute upper respiratory tract conditions

Acute upper respiratory tract conditions (URTCs), including the common cold, allergic rhinitis (AR), and acute sinusitis, are among the most common afflictions worldwide, affecting millions of individuals annually in the United States alone. A common theme among these conditions is that they share similar symptomatology and are often inadequately treated. These conditions typically cause mild, albeit bothersome, symptoms for a typical duration of 7 to 10 days in the case of the common cold, ≥ 2 weeks for AR exacerbations, and > 4 weeks for acute sinusitis. The common cold and AR elicit localized (upper airway) and systemic inflammatory cascades responsible for symptoms such as cough, nasal congestion, rhinorrhea, watery eyes, sneezing, headache, and general malaise. Acute sinusitis typically occurs because of a secondary bacterial or fungal infection of mucus-clogged nasal and sinus cavities and has symptoms similar to those previously listed, with the addition of increased facial and ear pressure/pain. Acute URTC symptoms are frequently managed with over-the-counter (OTC) products. Currently available OTC options can have limited efficacy in treating the broad array of symptoms associated with acute URTCs, and some have unwanted side effects. There is an unmet need for OTC therapies that have broad clinical activity, can reduce the severity and duration of illness when taken at the first sign of symptoms, and/or provide prophylaxis. This review article examines the available evidence supporting emerging and potentially new OTC pharmacologic, nutraceutical, and nonpharmacologic therapies on the horizon for the treatment of acute URTCs. This review is not intended to be a comprehensive evaluation of all potential URTC therapies, and the approvability of many of the agents discussed for OTC use in the United States may be subject to debate.

Phytotherapeutic and naturopathic adjuvant therapies in otorhinolaryngology

Phytotherapeutic pharmaceuticals and herbal medicinal products with its roots in classical phytotherapeutic medicine have a well-established role in otolaryngological therapy, especially for diseases of the upper airways and acute and chronic infections. A thorough selection and application could mean huge benefit for the patient, in particular in cases with contraindications, chemo- and antibiotic resistance or patient request. Besides, it might spare other medications. Phytotherapeutic pharmaceuticals must fulfil the same criteria of quality, effectiveness and harmlessness of evidence-based medicine like chemical pharmaceuticals, although they are often prescribed due to its well established or traditional based use. This review focuses on phytotherapeutic therapies well established within the European Community for otolaryngologic disease patterns by referring to clinical studies or meta-analysis.

Pelargonium sidoides extract for acute respiratory tract infections

BACKGROUND

Pelargonium sidoides (P. sidoides), also known as Umckaloabo, is a herbal remedy thought to be effective in the treatment of acute respiratory infections (ARIs).

OBJECTIVES

To assess the efficacy and safety of P. sidoides for the treatment of ARIs in children and adults.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 4) which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to November 2007); EMBASE (1974 to December 2007); and other electronic databases.

SELECTION CRITERIA

Randomized controlled trials (RCTs) examining the efficacy of P. sidoides preparations in ARIs compared to placebo, no treatment or any other treatment. Complete resolution of all symptoms was defined as a primary outcome.

DATA COLLECTION AND ANALYSIS

Three review authors (AT, JG, WK) independently extracted and quality scored the data. Separate analyses were performed by age group and disease entity. Heterogeneity was examined using the I-square (I(2)) statistic. Pooled relative risks (RR) were calculated using a fixed-effect model if heterogeneity was absent (I(2) < 5%; P > 0.1), or a random-effects model in the presence of heterogeneity. If heterogeneity was substantial (I(2) > 50%; P < 0.10), a pooled effect was not calculated.

MAIN RESULTS

Three trials (746 patients) of efficacy in acute bronchitis in adults showed substantial heterogeneity for all relevant outcomes. and three trials (819 children) were similarly inconsistent for acute bronchitis in children. Type of preparation was a potential cause of heterogeneity (not effective in tablet form). One unpublished study in patients with sinusitis (n = 103 adults) showed significant treatment effects (complete resolution at day 21; RR 0.43, 95% CI 0.30, 0.62). One study in the common cold demonstrating efficacy after 10 days, but not five days. Four trials were excluded because of excessive risk of bias. There were no valid data for the treatment of other acute respiratory tract infections. Adverse events were more common with P. sidoides, but none were serious.

AUTHORS' CONCLUSIONS

P. sidoides may be effective in alleviating symptoms of acute rhinosinusitis and the common cold in adults, but doubt exists. It may be effective in relieving symptoms in acute bronchitis in adults and children, and sinusitis in adults. Reliable data on treatment for other ARIs were not identified.

[Prescribing practices in the treatment of upper respiratory tract infections in anthroposophic medicine]

BACKGROUND

Upper respiratory tract infections (URTI) are among the leading reasons for doctor consultations. This study investigates the prescribing practices of medical doctors specialized in anthroposophic medicine in the treatment of URTI with a special focus on the prescription of antibiotics, complications, recurrence rates and costs.

MATERIALS AND METHODS

Starting in May 2004 all prescriptions within a 1-year period by 35 primary care practitioners in Germany were analysed. Data were extracted from practice software with special interfaces with additional linking of medications and diagnoses by practitioners.

RESULTS

21,818 prescriptions for 12,081 patients (73.7%children) with 19,050 cases of URTI were analysed. The most common diagnosis was common cold (63.3%), followed by acute tonsillitis (12.9%). 63.0% were treated purely with complementary medicine. Antibiotics were given in 6.3% of cases (minimum: common cold 1.9%, maximum: tonsillitis 24.3%). Predictive factors for antibiotic prescribing were the diagnoses tonsillitis (odds ratio [OR]: 6.7; 95% confidence interval [CI]:4.5-9.9) and sinusitis (OR: 1.9; 95% CI: 1.1-3.1), concomitant disease (OR: 1.2; 95% CI: 1.0-1.4), complications (OR: 7.2; 95% CI:5.5-9.4) and the specialty paediatrics (OR: 2.1; 95% CI: 1.7-2.6). In cases that were initially treated with only complementary medicine, antibiotics were eventually prescribed in 0.7%. Overall complication rates were 2.9% and follow-up visits occurred in 6.3%. Patients had an average of 2.4 URTI/year (adults 1.7,children 2.7). Treatment costs did not differ between complementary care and antibiotics.

CONCLUSION

Prescription practices in the treatment of URTI by anthroposophic practitioners were documented through the processing of routine medical data with minimal additional data. The therapy was found to be in accordance with the guidelines, however, the prescription rate for antibiotics was well below the German average.