Ulcerative proctitis: a review of pharmacotherapy and management

Exploring the Impact of Cyanidin-3-Glucoside on Inflammatory Bowel Diseases: Investigating New Mechanisms for Emerging Interventions

Cyanidin-3-O-glucoside (C3G), the most widely distributed anthocyanin (ACN) in edible fruits, has been proposed for several bioactivities, including anti-inflammatory, neuro-protective, antimicrobial, anti-viral, anti-thrombotic and epigenetic actions. However, habitual intake of ACNs and C3G may vary widely among populations, regions, and seasons, among individuals with different education and financial status. The main point of C3G absorption occurs in the small and large bowel. Therefore, it has been supposed that the treating properties of C3G might affect inflammatory bowel diseases (IBD), such as ulcerative colitis (UC) and Crohn's disease (CD). IBDs develop through complex inflammatory pathways and sometimes may be resistant to conventional treatment strategies. C3G presents antioxidative, anti-inflammatory, cytoprotective, and antimicrobial effects useful for IBD management. In particular, different studies have demonstrated that C3G inhibits NF-κB pathway activation. In addition, C3G activates the Nrf2 pathway. On the other hand, it modulates the expression of antioxidant enzymes and cytoprotective proteins, such as NAD(P)H, superoxide dismutase, heme-oxygenase (HO-1), thioredoxin, quinone reductase-oxide 1 (NQO1), catalase, glutathione S-transferase and glutathione peroxidase. Interferon I and II pathways are downregulated by C3G inhibiting interferon-mediating inflammatory cascades. Moreover, C3G reduces reactive species and pro-inflammatory cytokines, such as C reactive protein, interferon-γ, tumor necrosis factor-α, interleukin (IL)-5, IL-9, IL-10, IL-12p70, and IL-17A in UC and CD patients. Finally, C3G modulates gut microbiota by inducing an increase in beneficial gut bacteria and increasing microbial abundances, thus mitigating dysbiosis. Thus, C3G presents activities that may have potential therapeutic and protective actions against IBD. Still, in the future, clinical trials should be designed to investigate the bioavailability of C3G in IBD patients and the proper therapeutic doses through different sources, aiming to the standardization of the exact clinical outcome and efficacy of C3G.

Bifidobacterium BLa80 mitigates colitis by altering gut microbiota and alleviating inflammation

This study was conducted to explore the therapeutic effect of the probiotic Bifidobacterium animalis subsp. lactis BLa80 on inflammatory bowel disease. A model of ulcerative colitis (UC) was induced in C57BL/6 mice by administering of 2.5% dextran sulphate sodium (DSS) for 8 days. After developing UC, some mice were treated via intragastric administration of BLa80 at a dose of 10⁹ colony-forming units to assess the preventive effects of BLa80 on DSS-induced UC. Compared with non-treated UC model mice, BLa80-treated mice had reduced colon shortening and improvements in colonic tissue structure. Treatment with BLa80 also decreased the serum concentrations of the proinflammatory cytokines tumor necrosis factor-alpha (TNF-α), interleukin (IL) 6 and IL-17 in mice. 16S rRNA gene sequencing revealed that BLa80 increased gut microbial diversity in mice and modulated UC-associated imbalances in the gut microbiota. BLa80 selectively promoted the growth of beneficial bacteria, including Romboutsia and Adlercreutzia, the abundances of which were negatively correlated with concentration of cellular inflammatory factors. In summary, the study results demonstrated that pretreatment with B. lactis BLa80 reduced intestinal inflammation and altered the gut microbiota, implying that BLa80 is a promising probiotic strain with potential therapeutic function in UC.

Titanium dioxide particles from the diet: involvement in the genesis of inflammatory bowel diseases and colorectal cancer

The gastrointestinal tract is a complex interface between the external environment and the immune system. Its ability to control uptake across the mucosa and to protect the body from damage of harmful substances from the lumen is defined as the intestinal barrier function (IBF). The IBF involves four elements: the intestinal microbiota, the mucus layer, the epithelium and the immune system. Its dysfunction is linked with human diseases including inflammatory, metabolic, infectious, autoimmune and neurologic disorders. Most of these diseases are complex and involve genetic, psychological and environmental factors. Over the past 10 years, many genetic polymorphisms predisposing to inflammatory bowel disease (IBD) have been identified. Yet, it is now clear that they are insufficient to explain the onset of these chronic diseases. Although it has been evidenced that some environmental factors such as cigarette smoking or carbohydrate intake are associated with IBD, other environmental factors also present potential health risks such as ingestion of food additives introduced in the human diet, including those composed of mineral particles, by altering the four elements of the intestinal barrier function. The aim of this review is to provide a critical opinion on the potential of TiO₂ particles, especially when used as a food additive, to alter the four elements of the intestinal barrier function, and consequently to evaluate if this additive would likely play a role in the development and/or exacerbation of IBD.

Jiaolong capsule protects SD rats against 2,4,6-trinitrobenzene sulfonic acid induced colitis

ETHNOPHARMACOLOGICAL RELEVANCE

Jiaolong capsule (JLC) was approved for the therapy of gastrointestinal diseases by the State Food and Drug Administration (SFDA) of China. It has a satisfactory curative effect in the treatment of patients with inflammatory bowel disease, however, the mechanism remains to be elucidated.

AIM OF THE STUDY

In current study, the effects and possible mechanisms of JLC on 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis were investigated.

MATERIALS AND METHODS

Sulfasalazine and JLC were administrated orally and initialized 6 h after TNBS enema, once a day for seven consecutive days. The effect of JLC on intestinal microbial populations and LPS/TLR-4/NF-κB pathway was observed and assessed. Thirty female SD rats were distributed into six groups randomly and equally, namely, control, TNBS, TNBS + sulfasalazine (625 mg/kg), and TNBS + three different doses of JLC (25, 50, and 100 mg/kg) groups.

RESULTS

The effect of JLC on restoring normal structures of colorectum and repairing colonic damage were superior to that of sulfasalazine. JLC showed a positive effect in re-balancing intestinal bacteria population of colitis, and suppressed the activation of LPS/TLR-4/NF-κB pathway.

CONCLUSION

The results suggest that JLC demonstrated a beneficial effect on treating colitis in a rat model. The possible mechanisms may be through the regulatory effect of intestinal commensal bacteria and down-regulation of LPS/TLR-4/NF-κB pathway.

Comparison of the efficiency of different enemas on patients with distal ulcerative colitis

Objectives

Rectal application of steroids and 5‐aminosalicylic acid (5‐ASA) is associated with few side effects and has a high therapeutic efficacy in left‐sided colitis. Previous studies have shown that rectal administration of both steroids and 5‐ASA is superior to one single alone. However, some reports are still controversial. Therefore, it is necessary to investigate the treatment choice and efficacy of these different enemas in distal ulcerative colitis (UC) patients.

Materials and Methods

Questionnaire survey and a retrospective study were carried out in Chinese hospitals to investigate the efficacy of 5‐ASA or hydrocortisone/dexamethasone or their combination enema in patients with distal active UC. Dextran sodium sulphate (DSS)‐induced colitis model in mice was also utilized to evaluate the effects in vivo.

Results

The results from questionnaire survey showed that majority of physicians would prefer oral 5‐ASA with topical 5‐ASA therapy for distal UC patients. However, 43.01% of physicians would like to choose oral 5‐ASA and topical hydrocortisone/dexamethasone with or without 5‐ASA enema. A retrospective study demonstrated that 5‐ASA enema or 5‐ASA combined with hydrocortisone/dexamethasone enema therapy was superior to hydrocortisone/dexamethasone enema to decrease C‐reactive protein, erythrocyte sedimentation rate (ESR), Mayo score and induce clinical remission and clinical response. No superiority of combination therapy was further proved in DSS‐induced colitis in mice.

Conclusions

Although 43.01% of physicians would like to choose hydrocortisone/dexamethasone with or without 5‐ASA enema for the treatment of distal UC, the combination was not superior to 5‐ASA enema. Hydrocortisone/dexamethasone enema with 5‐ASA enema is not recommended for distal active UC patients.

Pien Tze Huang ameliorates DSS‑induced colonic inflammation in a mouse colitis model through inhibition of the IL‑6/STAT3 pathway

Interleukin‑6 (IL‑6)/signal transducer and activator of transcription 3 (STAT3) pathway plays essential roles in the development of inflammatory diseases including ulcerative colitis (UC). Therefore, suppression of IL‑6/STAT3 signaling provides a promising therapeutic strategy in UC. Pien Tze Huang (PZH), a well‑known traditional Chinese formula, has been used in China and Southeast Asia for centuries as a folk remedy for various inflammatory diseases. However, the molecular mechanisms of its anti‑inflammatory effects remain to be elucidated. In the present study, we generated a mouse colitis model by using dextran sulfate sodium (DSS) and evaluated the therapeutic efficacy of PZH against UC by observing the clinical manifestations. We found that PZH obviously alleviated DSS‑induced colitis symptoms, including body weight loss, rectal bleeding and stool consistency. In addition, administration of PZH profoundly prevented DSS‑induced colon shortening, and ameliorated colonic histopathological changes such as mucosal ulceration, infiltration of inflammatory cells, crypt distortion and hyperplastic epithelium. Moreover, PZH markedly inhibited the serum level of the inflammatory biomarker serum amylase A (SAA) in UC mice. Furthermore, PZH treatment significantly inhibited DSS‑induced expression of IL‑6 in colon tissues. Finally, the increased phosphorylation level of STAT3, induced either by DSS in experimental mice or by IL‑6 in the differentiated human colorectal carcinoma cells, was significantly suppressed by PZH. These results suggest that the inhibition of IL‑6/STAT3 signaling is a potential mechanism by which PZH is used in the treatment of UC.

Chymase inhibitor TY-51469 in therapy of inflammatory bowel disease

AIM: To investigate the effect of chymase inhibitor TY-51469 in the therapy of inflammatory bowel disease and the underlying mechanism.

METHODS: Seventy-five healthy Sprague-Dawley rats were randomly assigned to one of the three groups (control group, model group and TY-51469 experiment group) and each group had twenty-five rats. The rats of the model group and experiment group were subjected to treatment with 3.5% dextran sulfate sodium (DSS) 10 mg/kg to induce colitis. The control group and model group were subjected to intraperitoneal injection of saline, while the experiment group was subjected to intraperitoneal injection of 10 mg/kg TY-51469 each day. Five rats of each group were sacrificed on 0, 7, 14, 21 and 28 d, respectively. The degree of inflammation was assessed by histopathological scoring; flow cytometry was performed to detect the proportion of CD4⁺CD25⁺ Tregs in peripheral blood; colon tissues of rats were collected to measure mRNA and protein expression by PCR, Western blot and immunohistochemistry; serum levels of interleukin (IL)-10, transforming growth factor (TGF)-β1 and IL-17A were detected by ELISA.

RESULTS: The rats in the experiment group and model group had significantly more severe colitis than the ones in the control group (P < 0.05) before treatment on day 0; no significant difference was observed between the experiment group and model group (P > 0.05). After treatment with TY-51469, the rats in the experiment group had significantly less severe colitis compared with the model group on 7, 14, 21 and 28 d (P < 0.05). The proportion of CD4⁺CD25⁺ Tregs was lower in the model group and experiment group than in the control group; the experiment group had a significantly higher proportion of CD4⁺CD25⁺ Tregs than that in the model group (P < 0.05). The model group and experiment group demonstrated lower expression of Foxp3 than the control group; the experiment group had higher Foxp3 expression than the model group (P < 0.05). Cytokines IL-10, TGF-β1 and IL-17A were lower in the model group and experiment group than in the control group; the experiment group had higher expression than the model group (P < 0.05).

CONCLUSION: After treatment with chymase inhibitor TY-51469, the experiment group demonstrated more significantly reduced intestinal inflammation and higher expression of immune tolerance related cytokines (IL-10, TGF-β1, IL-17A) and Foxp3 which is specifically expressed in Tregs compared with the model group. Therefore, chymase inhibitor TY-51469 might ameliorate the progression of DSS-induced colitis possibly by increasing the expression of Tregs and cytokines.

Dietary anthocyanins as a complementary medicinal approach for management of inflammatory bowel disease

Inflammatory bowel disease (IBD) is thought to result from a chronic or relapsing activation of the immune system in the GI tract. A growing body of evidence confirms the health benefits of dietary anthocyanins as plant-derived natural agents. The aim of this review is to provide an overview of several natural products rich in anthocyanins used worldwide for the treatment of IBD. Anthocyanins possess both protective and therapeutic functions in the management of IBD by alleviating oxidative stress processes, cytoprotective functions, downregulation of inflammatory cytokines and suppressing cellular signaling pathways of inflammatory processes. In conclusion, the consumption of anthocyanin-rich natural formulations must be promoted on the basis of their possible function in the prevention and treatment of gastrointestinal inflammatory disorders.

A randomized clinical trial of mesalazine suppository: the usefulness and problems of central review of evaluations of colonic mucosal findings

BACKGROUND

The methods of evaluating endoscopic mucosal findings and the definition of mucosal healing in inflammatory bowel disease have not been standardized.

AIM

To examine a third-party central review of colonic mucosal evaluations.

METHODS

A double-blind, placebo-controlled, parallel-group trial was performed for 4weeks, which involved continuous administration of a 1-g mesalazine suppository to 129 patients with mild to moderate ulcerative colitis and active rectal inflammatory findings. Mucosal findings were evaluated by using a 4-grade score (0, 1, 2, 3). Reviews by attending physicians were considered the primary evaluations. Concurrently, a central review committee of 7 gastroenterologists served as the third party.

RESULTS

The endoscopic remission induction rate from the attending physicians' evaluations was 82.8% in the mesalazine suppository group and 31.1% in the placebo suppository group, whereas the respective rates from the central review committee were 90.6% and 59.0%. However, there was a difference of 27.9 percentage points between the remission induction rates of the placebo group found by the two groups of raters. Differences in the evaluations of mucosal finding scores were also found among the third-party reviewers.

CONCLUSIONS

The evaluations of the attending physicians were consistent with those of the central review committee in showing the effectiveness of mesalazine suppository through the index of mucosal healing. However, differences were observed among the raters in their evaluations of mucosal finding scores. Therefore, standardizing evaluation criteria and improving review methods for mucosal findings would enable the more effective use of third-party central reviews in clinical drug trials.

Total glucosides of peony attenuates 2,4,6-trinitrobenzene sulfonic acid/ethanol-induced colitis in rats through adjustment of TH1/TH2 cytokines polarization

The present study is to investigate effects of total glucosides of peony (TGP) on 2,4,6-trinitrobenzene sulfonic acid (TNBS)/ethanol-induced colitis in rats and to explore potential clinical use of TGP for treatment of inflammatory bowel disease. Sixty Sprague-Dawley rats were randomly grouped into normal controls, model controls, sulfasalazine (SASP) controls (100 mg/kg/day), and low, medium, and high-dose TGP groups (25, 50, and 100 mg/kg/day, respectively). 24 h following colonic instillation of TNBS, TGP, and SASP were given by gastric gavage three times a day for 7 days. Disease activity index (DAI), colon macroscopic damage index (CMDI), histopathological score (HPS), and myeloperoxidase (MPO) activity were evaluated. Levels of serum TNF-α, IL-1β, and IL-10 were measured by ELISA, and expression of TNF-α, IL-1β, and IL-10 mRNA and protein in colonic tissues was detected by RT-PCR and western blot, respectively. Compared with rats in the model controls, TGP (50 or 100 mg/kg/day)-treated rats with TNBS/ethanol-induced colitis showed significant improvements of DAI, CMDI, HPS, and MPO activity. Moreover, administration of TGP (50 or 100 mg/kg/day) decreased the up-regulated levels of serum TNF-α and IL-1β, and expression of TNF-α and IL-1β mRNA and protein in colonic tissues, and increased the serum IL-10 and colonic IL-10 mRNA and protein level. And there was no significant difference compared with administration of SASP (P > 0.05). TGP attenuates TNBS/ethanol-induced colitis in rats and its efficacy is similar to SASP, the potential mechanism might be related to the adjustment of Th1/Th2 cytokines polarization by decreasing pro-inflammatory cytokine TNF-α and IL-1β, and increasing anti-inflammatory cytokine IL-10.

Inhibition of the interleukin-23/interleukin-17 pathway by anti-interleukin-23p19 monoclonal antibody attenuates 2,4,6-trinitrobenzene sulfonic acid-induced Crohn's disease in rats

The interleukin (IL)-23/IL-17 pathway is considered to be important in the pathogenesis of Crohn's disease (CD). The present study aimed to evaluate the effects of targeting the IL‑23/IL‑17 pathway using the anti-IL-23p19 monoclonal antibody (mAb) on 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced CD rats. A total of 60 Sprague-Dawley rats were randomly divided into a control group, model group and an anti-IL-23p19 mAb treatment group (administered intramuscularly every week at a dose of 1 ml/mg). Disease activity index (DAI), colon macroscopic damage index (CMDI) and tissue damage index (TDI) were then evaluated. The mRNA expression of IL-23p19, p40 (IL-23/12), retinoic acid-related orphan receptor-γt (ROR‑γt) and IL‑17 in colonic tissues were detected by reverse transcription‑polymerase chain reaction and levels of serum IL-23p19, p40, ROR-γt and IL-17 were measured using an enzyme‑linked immunosorbent assay. Anti‑IL‑23p19 mAb was found to effectively attenuate colonic inflammation demonstrated by reduced DAI, CMDI and TDI scores, improvement in pathological evaluation and downregulation of expression levels of IL‑23p19, p40 (IL-23/12), ROR-γt and the downstream proinflammatory cytokine, IL-17. Anti-IL-23p19 mAb attenuated TNBS-induced CD in model rats. The possible underlying mechanisms may be associated with inhibition of the IL-23/IL-17 pathway by inhibiting the expression of IL‑23p19 and downregulating the downstream proinflammatory cytokine IL‑17. Targeting the IL-23/IL-17 pathway may be a relevant and realistic therapeutic approach for the development of additive and alternative treatments to the biologics currently available in the treatment of CD.

Topical therapy is underused in patients with ulcerative colitis

The availability of new topical preparations for the treatment of left sided ulcerative colitis offers a therapy optimization for many patients. Rectal application of steroids and 5-aminosalicylic acid (5-ASA) is associated with fewer side effects and has a higher therapeutic efficacy in left-sided colitis as compared to a systemic therapy. Therefore, we were interested in the use of topical therapy in patients with ulcerative colitis. The key question was whether topical treatment is more frequently used than oral therapy in patients with proctitis and left sided colitis. Data of 800 patients of the Swiss IBD cohort study were analyzed. Sixteen percent of patients of the cohort had proctitis, 21% proctosigmoiditis and 41% pancolitis. Topical therapy with 5-ASA or corticosteroids was given in 26% of patients with proctitis, a combined systemic and topical treatment was given in 13%, whereas systemic treatment with 5-ASA without topical treatment was given in 29%. Proportion of topical drug use decreased with respect to disease extension from 39% for proctitis to 13.1% for pancolitis (P=0.001). Patients with severe colitis received a significantly higher dose of topical 5-ASA than patients in remission. Side effects of topical or systemic 5-ASA or budesonide treatment were less frequently seen compared to other medications. Topical treatment was frequently stopped over time. The quality of life was the same in patients with limited disease compared to patients with pancolitis. Topical treatment in proctitis patients was underused in Switzerland. Since topical treatment is safe and effective it should be used to a larger extend.

Natural products as a source of anti-inflammatory agents associated with inflammatory bowel disease

Accumulating epidemiological and clinical study indicates that inflammation is a significant risk factor to develop various human diseases such as inflammatory bowel disease (IBD), chronic asthma, rheumatoid arthritis, multiple sclerosis, and psoriasis. Suppressing inflammation is therefore important to control or prevent various diseases. Among them, IBD is one of the major problems affecting people worldwide. IBD affects at least one in a thousand persons in many Western countries. Various natural products have been shown to safely suppress pro-inflammatory pathway and control IBD. In vivo and/or in vitro studies indicate that anti-IBD effects of natural products occur by inhibition of the expression of pro-inflammatory cytokines (for example, tumor necrosis factor-α (TNF-α), intercellular adhesion molecule expression and pro-inflammatory mediators (such as inducible nitric oxide synthase (iNOS) and cyclooxygenase 2 (COX2), master transcription factors (such as nuclear factor-κB (NF-κB)), reactive oxygen species (ROS) and by improving the antioxidant activity. In this review, we summarize recent research focused on IBD and the effects that natural products have on IBD factors.

Reduction in oxidative stress levels in the colonic mucosa without fecal stream after the application of enemas containing aqueous Ilex paraguariensis extract

PURPOSE: To evaluate the antioxidant effects of enemas containing aqueous extract of Ilex paraguariensis, comparing segments with and without fecal stream and correlating the segments with the duration of intervention. METHODS: Twenty-six Wistar rats were subjected to a diversion of the fecal stream in the left colon by a proximal colostomy and distal mucosal fistula. The rats were distributed randomly into two experimental groups of 13 animals each based on the time of sacrifice after surgical procedure (two or four weeks). Each group was then divided into two experimental subgroups that received either second daily enemas containing 0.9% saline solution or aqueous extract of Ilex paraguariensis at 0.2g/100g. Colitis was diagnosed by histopathological analysis and the detection of oxidative tissue damage by measuring the levels of malondialdehyde. The Mann-Whitney test was used to compare the tissue levels of malondialdehyde between colon segments with and without fecal stream in each experimental group, and the Kruskal-Wallis test was used to verify the variance between the levels of oxidative stress according the duration of the irrigation; both tests determined significance at 5% (p<0.05). RESULTS: The levels of malondialdehyde in the animals subjected to intervention in the colon with saline with and without fecal stream after two and four weeks of irrigation were 0.05±0.006 and 0.06±0.006, and 0.05± 0.03 and 0.08 ±0.02, respectively. The malondialdehyde levels in the animals irrigated with Ilex paraguariensis with and without fecal stream after two and four weeks of irrigation were 0.010±0.002 and 0.02±0.004, and 0.03±0.007 and 0.04±0.01, respectively. After two and four weeks of intervention, the levels of malondialdehyde were lower in the animals irrigated with Ilex paraguariensis regardless of the time of irrigation (p=0.0001 and p=0.002, respectively). CONCLUSION: The daily rectal application of enemas containing aqueous extract of Ilex paraguariensis decreases oxidative tissue damage in the colon without fecal stream regardless of the time of irrigation.

Inflammatory bowel disease

This review focuses on the prominent etiological and pathogenetic aspects of inflammatory bowel disease (IBD), with particular attention being paid to the mucosal immune response to commensal micro-organisms in health and disease. Pathogenetic implications for target therapy will also be discussed. The clinical presentation, diagnostic aspects, and currently recommended therapeutic options for the two main types of IBD are also taken into consideration, including manifestations of these conditions in the oral cavity.

5-aminosalicylic acid (5-ASA) can reduce levels of oxidative DNA damage in cells of colonic mucosa with and without fecal stream

BACKGROUND

No studies have evaluated the effectiveness of 5-ASA against oxidative DNA damage in experimental models of diversion colitis.

AIM

To evaluate the effects of 5-ASA against oxidative DNA damage in an experimental model of diversion colitis.

METHODS

Twenty-six Wistar rats were divided into two groups corresponding to sacrifice at 2 or 4 weeks after fecal diversion of the left colon by means of proximal colostomy and distal mucosa fistula. Each group was divided into two subgroups according to intervention in excluded colon performed with 0.9% saline solution or 5-ASA. Level of oxidative DNA damage was determined by comet assay in cells obtained from segments with and without fecal stream before and after H2O2 challenge. For statistical analysis, was used one-way analysis of variance (ANOVA), adopting a 5% significance level (P<0.05).

RESULTS

Levels of DNA damage were always higher in colon segments without fecal stream, regardless of the intervention solution employed. DNA damage in colon segments with and without fecal stream in animals irrigated with 5-ASA was lower when compared with those treated with saline solution, regardless of time of irrigation. These levels remained lower after intervention with 5-ASA, even after H2O2 challenge.

CONCLUSIONS

Enema with 5-ASA reduces oxidative DNA damage in epithelial cells of colon segments without fecal stream, even after H2O2 challenge, confirming the effects of 5-ASA against DNA damage by oxygen free radicals.

A multicenter, randomized study to evaluate the efficacy and safety of mesalamine suppositories 1 g at bedtime and 500 mg Twice daily in patients with active mild-to-moderate ulcerative proctitis

BACKGROUND

Ulcerative proctitis (UP) is a prevalent condition associated with increased morbidity and mortality. Topical mesalamine (5-aminosalicylic acid [5-ASA]) inhibits inflammatory processes in UP.

METHODS

We evaluated effects of mesalamine 1-g suppository administered QHS compared with 500-mg suppository administered BID on UP activity (e.g., disease extension/mucosal appearance), remission, onset of response, safety and compliance in 97 patients with UP. A 6-week, randomized, multicenter, parallel-group, noninferiority study was conducted (and published) with Disease Activity Index (DAI) at week 6 as the primary efficacy variable and individual components of DAI at week 6 (i.e., stool frequency, rectal bleeding, mucosal appearance, global assessment) as secondary variables. Unreported outcomes were remission (DAI < 3 at weeks 3 and 6), disease extension, and complete response to treatment (DAI = 0; post-hoc, exploratory analysis).

RESULTS

DAI values after 6 weeks were significantly reduced (±SD) from 6.6 ± 1.5 to 1.6 ± 2.3 (500-mg BID); and from 6.1 ± 1.5 to 1.3 ± 2.2 (1-g QHS). Mucosal appearance significantly improved from baseline after 3 and 6 weeks of treatment from 1.8 ± 0.5 to 0.8 ± 0.7 and 0.5 ± 0.7 (500-mg BID; P ≤ 0.0062) and from 1.7 ± 0.5 to 0.9 ± 0.5 and 0.4 ± 0.6 (1-g QHS; P ≤ 0.0001), respectively. Remission was comparable (78.3-86.1%); onset of response generally occurred within 3 weeks, and disease extension was reduced (>70%) after 6 weeks in both groups. Mesalamine was well tolerated. Compliance was >96%.

CONCLUSIONS

Mesalamine 500-mg BID and 1-g QHS suppositories are safe and effective for patients with UP. Most patients reported significant improvement within 3 weeks and UP remission and reduced disease extension after 6 weeks of treatment. Validity of QHS administration was confirmed.

Evidence for the complementary and synergistic effects of the three-alkaloid combination regimen containing berberine, hypaconitine and skimmianine on the ulcerative colitis rats induced by trinitrobenzene-sulfonic acid

Ulcerative colitis involves complicated etiology and presents diverse symptoms including intestine inflammation, bowel pain and diarrhea. Anti-inflammatory drugs are the mainstay in patient care, accompanied with antidiarrhea and analgesic agents used as symptomatic treatment. A classic traditional Chinese medicine formula, Fructus Mume pill (FMP), showed remarkable therapeutic efficacy in treating ulcerative colitis. However, since it contains many herbs and countless chemicals, the underlying mechanism is not clear. In this study, we selected three alkaloids from FMP, namely, berberine, hypaconitine and skimmianine to study the individual drug effect and compare these results with the BHS combination on: 1) The recovery of ulcerative colitis rats induced by trinitrobenzene-sulfonic acid. 2) Mice with xylene-induced acute exudative edema and acetic acid-induced writhing. 3) Gastrointestinal transit inhibition, and 4) the response of HT29 cells after treatment with lipopolysaccharide. We found that the compound hypaconitine showed a potent analgesic effect, while skimmianine acted as an antidiarrhea agent and the component berberine was the key agent exerting anti-inflammatory effect. However, since berberine killed the commensal bacteria and induced lipopolysaccharide release, it could at the same time aggravate colon inflammation. The three-alkaloid combination BHS produced complementary and synergistic effects in colon inflammation recovery, relieving acetic acid-induced bowel pain and xylene-induced acute exudative edema. BHS also decreased lipopolysaccharide production and enhanced the therapeutic efficacy. It is hoped that this study will lay the foundation to further dissect and understand the FMP formula to improve the treatment with simplified and well defined drug combinations for this dreadful disease.

The possible mechanisms of Fructus Mume pill in the treatment of colitis induced by 2,4,6-trinitrobenzene sulfonic acid in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Fructus Mume pill (FMP) has been used as a folk remedy for gastrointestinal diseases in China over thousands of years. FMP was approved for the treatment of gastrointestinal diseases in 2001 by the State Food and Drug Administration (SFDA) of China. Although FMP had significant efficacy for treatment of the patients with inflammatory bowel disease (IBD) in the clinic, the mechanism of action is still unclear.

AIM OF THE STUDY

In the present study, the effects and possible mechanism of FMP on colitis induced by 2,4,6-trinitrobenzene sulfonic acid (TNBS) were investigated.

MATERIALS AND METHODS

Fifty-four SD rats were divided into six groups. Nine rats for each group from three independent experiments were investigated for the effects of FMP.

RESULTS

FMP protected against diarrhea, colon weight increase, colonic accretion, ulceration and myeloperoxidase (MPO) activity elevation. The effects of FMP on recovery of colonic damage and restoration of the normal structures of colorectums were superior to dexamethasone (DEX). FMP promoted the restoration of abnormal cytokine secretion after TNBS treatment. FMP was effective in restoring the balance of intestinal bacteria population from the imbalance of G(+)/G(-) in rats with colitis.

CONCLUSIONS

The results indicated that FMP is effective in treatment of colitis in an experimental rat model. The possible mechanisms may be through down-regulation of Th1-polarized immune response and opsonic effect of intestinal commensal bacteria in this model system.

Immunomodulation of Rheum tanguticum polysaccharide (RTP) on the immunosuppressive effects of dexamethasone (DEX) on the treatment of colitis in rats induced by 2,4,6-trinitrobenzene sulfonic acid

Dexamethasone (DEX) is still the main choice for colitis, although the immunosuppressive side effects are still the troublesome problems to overcome. In our previous study, Rheum tanguticum polysaccharide (RTP), extracted from traditional Chinese medicine rhubarb, targeted mannose receptor, showed immunoregulatory effect on the balance of Th1 and Th2 polarization in colitis rats. For the present study, we hypothesized that RTP could regulate the immunosuppressive effects of DEX. Taking advantage of the colon delivery ability of the polysaccharide, we prepared the double emulsion of RTP microsphere containing DEX to investigate the potential immunoregulatory effects of RTP on DEX immunosuppression in TNBS-induced colitis in rats. As expected, DEX-RTP microsphere showed not only significant immunomodulatory effects, but also strong anti-inflammation. The microsphere balanced enteric bacteria disorder, decreased TLR4 activation and promoted the balance of Th1 and Th2 polarization, inhibited NF-kappaB activity. Especially, DEX-RTP showed significant colon injury reparation. DEX alone exhibited a strong anti-inflammatory effect by suppressing MPO activity, down-regulate NF-kappaB activity and Th1 cytokines production. However, DEX showed severe immunosuppressive effects. It aggravated the intestinal commensal bacteria disorder, induced thymus atrophy and the further imbalance of Th1/Th1 cytokine polarization. RTP showed significant immunoregulatory effects. A significant protection on the intestinal bacterial balance, TLR4 and NF-kappaB activation decreased, and Th1/Th2 cytokine production balance were showed in RTP. In conclusion, DEX-RTP microsphere delivered DEX directly to the colon avoiding the absorption at the upper intestinal tract and showed synergistic effects on colitis both from the strong anti-inflammatory effects of DEX and from the immunoregulation of RTP.

Therapeutic strategies for the management of ulcerative colitis

Induction and maintenance of remission, mucosal healing, the avoidance of surgical intervention, and decreasing the likelihood of cancer developing are the primary therapeutic goals in ulcerative colitis (UC). For the traditional therapies, 5-aminosalicylic acid (including mesalamine), corticosteroids, and thiopurines (azathioprine and mercaptopurine), there are major changes evolving in terms of formulation, patterns of use, and appreciation of long-term benefits and toxicities. The calcineurin inhibitors cyclosporin and tacrolimus, and infliximab, have recently defined, well-established roles. Preliminary supportive evidence is emerging in relation to novel antiinflammatory molecules such as curcumin, manipulation of the bacterial flora, enhancement of the mucosal barrier, and direct epithelial restoration. For patients in whom the disease is resistant to standard simple therapies, strategies are required to integrate these developing and new therapies into clinical practice. This review aims to highlight the evidence supporting new patterns of use of existing therapies and new therapies, and to devise therapeutic pathways that incorporate these new treatments. We propose how treatment might be optimized to improve the outcome in patients with mild-to-moderately active UC, chronic active UC, resistant proctitis, and fulminant UC.