Safety of Calcium Dobesilate in Chronic Venous Disease, Diabetic Retinopathy and Haemorrhoids

Study protocol for assessment of the efficacy of calcium dobesilate versus placebo on SARS-CoV-2 viral load in outpatients with COVID-19 (CADOVID study): a randomised, placebo-controlled, double-blind, monocentric phase II trial

INTRODUCTION

SARS-CoV-2 mainly infects respiratory endothelial cells, which is facilitated through its spike protein binding to heparan sulphate. Calcium dobesilate (CaD) is a well-established, widely available vasoactive and angioprotective drug interacting with heparan sulphate, with the potential to interfere with the uptake of SARS-CoV-2 by epithelial cells. The CADOVID trial aims to evaluate the efficacy and safety of CaD in reducing the SARS-CoV-2 viral load in non-hospitalised adult patients diagnosed with COVID-19, confirmed by a positive SARS-CoV-2 PCR, including its efficacy to reduce the impact of persistent COVID-19 symptoms.

METHODS AND ANALYSIS

This is a randomised, placebo-controlled, double-blind, monocentric phase II trial. Enrolment began in July 2022. A total of 74 adult patients will be randomly allocated to the CaD arm or the placebo group with a 1:1 ratio, respectively. Participants in the intervention arm will receive two capsules of CaD 500 mg two times per day and the placebo arm will receive two matching capsules of mannitol 312.5 mg two times per day, with a treatment period of 7 days for both arms, followed by a 77-day observational period without treatment administration. Participants will be asked to complete secured online questionnaires using their personal smartphone or other electronic device. These include a COVID-19 questionnaire (assessing symptoms, temperature measurement, reporting of concomitant medication and adverse events), a COVID-19 persistent symptoms' questionnaire and the Short Form 12-Item (SF-12) survey. SARS-CoV-2 PCR testing will be performed on nasopharyngeal swabs collected on days 1, 4, 8 and 21. The primary endpoint is the reduction from baseline of SARS-CoV-2 viral load determined by RT-PCR at day 4.

ETHICS AND DISSEMINATION

This trial has received approval by the Geneva Regional Research Ethics Committee (2022-00613) and Swissmedic (701339). Dissemination of results will be through presentations at scientific conferences and publication in scientific journals.

TRIAL REGISTRATION NUMBER

NCT05305508; Clinicaltrials.gov; Swiss National Clinical Portal Registry (SNCTP 000004938).

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

A nationwide study of compliance of venoactive drugs in chronic venous disease patients

Purpose

Venoactive drugs are widely used to improve the symptoms and signs of chronic venous disease. This study aimed to analyze the rate of adverse events after venoactive drug prescription and subsequent compliance and switching rates.

Methods

Using the National Health Insurance Service database, individuals with at least one chronic venous disease code between January 2009 and December 2019 were identified, and 30% (2,216,780 individuals) of these were sampled. Finally, 1,551,212 patients were included, and we analyzed adverse events, compliance, and switching rates with 8 venoactive drugs, including Vitis vinifera extract, naftazone, micronized purified flavonoid fraction, Vitis vinifera leaf extract, diosmin, diobsilate calcium, bilberry fruit dried extract, and sulodexide.

Results

The most commonly prescribed venoactive drug was Vitis vinifera extract (72.2%), followed by sulodexide (9.3%), and Vitis vinifera leaf dry extract (8.2%). Adverse event rates were significantly lower in the naftazone and diosmin groups (P = 0.001 and P = 0.002, respectively) and significantly higher in the Vitis vinifera leaf dry extract group (P = 0.009). Drug adherence to sulodexide was the highest throughout the study period, followed by billberry extract and dobesilate (all P < 0.001). For most drugs, the drug switching rate was low (<5.0%).

Conclusion

Vitis vinifera extract was the most commonly prescribed venoactive drug in Korea, and drug adherence to sulodexide was the highest among all venoactive drugs. The adverse event rates were significantly lower in the naftazone and diosmin groups.

Calcium dobesilate reduces SARS-CoV-2 entry into endothelial cells by inhibiting virus binding to heparan sulfate

Recent reports demonstrate that SARS-CoV-2 utilizes cell surface heparan sulfate as an attachment factor to facilitate the initial interaction with host cells. Heparan sulfate interacts with the receptor binding domain of SARS-CoV-2 spike glycoprotein, and blocking this interaction can decrease cell infection. We and others reported recently that the family of compounds of 2,5-dihydroxyphenylic acid interferes with the binding of the positively charged groove in growth factor molecules to negatively charged cell surface heparan sulfate. We hypothesized that Calcium Dobesilate (CaD)-calcium salt of 2,5-dihydroxyphenylic acid-may also interfere with the binding of SARS-CoV-2 spike protein to heparan sulfate. Using lentiviral SARS-CoV-2 spike protein pseudotyped particles we show that CaD could significantly reduce pseudovirus uptake into endothelial cells. On the contrary, CaD did not affect cell infection with VSVG-expressing lentivirus. CaD could also prevent retention of SARS-CoV-2 spike protein in ex vivo perfused mouse kidney. Using microfluidic culture of endothelial cells under flow, we show that CaD prevents spike protein interaction with heparan sulfate glycocalyx. Since CaD has no adverse side effects and is approved in humans for other medical indications, our findings can rapidly translate into clinical studies.

Pharmacological treatment for chronic venous disease: an umbrella review of systematic reviews

INTRODUCTION

Chronic venous disease is a persistent venous drainage alteration caused by valvular incompetence and/or outflow obstruction. Disease management includes a variety of treatments, whose evidence and clinical performance in the mid-long term are variable. The objective of this umbrella review was to summarise efficacy data for pharmacological treatments including venoactive drugs from previously published reviews that included a meta-analytic component.

EVIDENCE ACQUISITION

Systematic database searches were conducted via Ovid SP on 13 August 2019, covering MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. Reviews that included a meta-analytic component of four or more clinical trials or observational studies reporting on the efficacy of systemic or topical pharmacological treatments for adults with chronic venous disease published since 2010 were eligible for inclusion.

EVIDENCE SYNTHESIS

Eleven publications were included in this umbrella review. Change in ankle circumference was the most commonly reported outcome. Overall, several systemic treatments had significant effects compared with placebo on multiple efficacy outcomes, including measures of oedema and pain. Out of them, Micronized Purified Flavonoid Fraction had the most comprehensive evidence of effectiveness on main symptoms and signs and on improving quality of life throughout chronic venous disease stages.

CONCLUSIONS

Systemic pharmacotherapies represent a valuable therapeutic option in CVD management. As a result of this umbrella review, several gaps were identified with respect to research topics that warrant further investigation, particularly in the category of topical medications.

Calcium dobesilate alleviates renal dysfunction and inflammation by targeting nuclear factor kappa B (NF-κB) signaling in sepsis-associated acute kidney injury

Acute kidney injury (AKI) is a serious complication of sepsis that increases mortality and the risk of progression to chronic kidney disease. Oxidative stress and apoptosis are reported to exert critical function in the pathogenesis of sepsis-associated AKI. Calcium dobesilate (CaD) was reported to play a protective role in renal diseases. Therefore, we explored the antioxidant effect and potential mechanism of CaD in lipopolysaccharide (LPS)-induced AKI in mice. We evaluated renal function (blood urea nitrogen (BUN) and serum creatinine (SCr)), histopathology, oxidative stress (superoxide dismutase (SOD) and malondialdehyde (MDA)), inflammation cytokines, and apoptosis in kidneys of mice. The effect of CaD on NF-κB signaling was evaluated by Western blot. Our findings showed that CaD alleviated renal dysfunction and kidney injury, and also reversed upregulated MDA concentration and reduced SOD enzyme activity in AKI mice. Moreover, LPS-induced inflammatory response was attenuated by CaD. CaD treatment also reduced the apoptosis evoked by LPS. Additionally, CaD downregulated phosphorylation of nuclear factor kappa B (NF-κB) signaling components in LPS mice. Conclusively, CaD alleviates renal dysfunction and inflammation by targeting NF-κB signaling in sepsis-associated AKI.

Intravitreal Ranibizumab Alone or in Combination with Calcium Dobesilate for the Treatment of Diabetic Macular Edema in Nonproliferative Diabetic Retinopathy Patients: 12-Month Outcomes of a Retrospective Study

OBJECTIVE

This study investigates the efficacy of CaD combined with intravitreal ranibizumab for the treatment of diabetic macular edema (DME) in patients with nonproliferative DR.

METHODS

This retrospective, observational, case-control study enrolled consecutive patients newly diagnosed with DME. The patients were treated with 3-monthly loading dose injections of intravitreal ranibizumab (IVR) followed by pro re nata injections (3 + PRN), with or without daily oral CaD. The patients were treated and followed up for 12 months. We reviewed their medical records to determine the optical coherence tomography (OCT) findings, number of injections, best-corrected visual acuity (BCVA), and central macular thickness (CMT) at 3, 6, and 12 months after the first injection.

RESULTS

We reviewed 102 eyes of 102 patients; 54 patients received IVR combined with oral CaD (IVR + CaD group) and 48 received only IVR (IVR group). In both groups, BCVA was higher, and CMT was lower, at 3, 6, and 12 months after the injection compared to those at the baseline (p < 0.05 for all), while there were no significant differences in BCVA improvement or CMT reduction between the two groups (p > 0.05). The mean number of IVR injections was significantly lower in the IVR + CaD group than the IVR group (5.4 ± 1.1 vs. 6.7 ± 1.6 injections, p < 0.05) during 1 year of treatment. No adverse events were noted in either group.

CONCLUSIONS

Compared to IVR alone, the addition of oral CaD to IVR in DME patients was safe and effective for improving visual function and restoring the retinal anatomy and was associated with the need for fewer injections.

Corneal lymphangiogenesis as a potential target in dry eye disease - a systematic review

Dry eye disease (DED) is a common ocular surface condition causing symptoms of significant discomfort, visual disturbance, and pain. With recent advancements, DED has become recognized as a chronic self-perpetuating inflammatory condition triggered by various internal and environmental factors. DED has been shown to arise from the activation of both the innate and adaptive immune systems, leading to corneal epithelium and lacrimal gland dysfunction. While the cornea is normally avascular and thus imbued with angiogenic and lymphangiogenic privilege, various DED models have revealed activated corneal antigen-presenting cells in regional lymph nodes, suggesting the formation of new corneal lymphatic vessels in DED. The recent availability of reliable lymphatic cell surface markers such as LYVE-1 has made it possible to study lymphangiogenesis. Accordingly, numerous studies have been published within the last decade discussing the role of lymphangiogenesis in DED pathology. We systematically review the literature to identify and evaluate studies presenting data on corneal lymphangiogenesis in DED. There is considerable evidence supporting corneal lymphangiogenesis as a central mediator of DED pathogenesis. These findings suggest that anti-lymphangiogenic therapeutic strategies may be a viable option for the treatment of DED, a conclusion supported by the limited number of reported clinical trials examining anti-lymphangiogenic modalities in DED.

Protective Effect of Calcium Dobesilate on Induced AKI in Severely Burned Mice

BACKGROUND

Early acute kidney injury (AKI) predicts a high mortality rate in severely burned patients. However, the pathophysiology of early AKI induced by severe burn has not been well-defined. This study was designed to examine the protective effects of calcium dobesilate (CaD) against severe burn-induced early AKI in mice and explore the mechanism.

METHODS

The shaved backs of mice were immersed in 100°C water for 10 s to make severe burn (40% of the total body surface area). CD-57 male mice were randomly divided into sham, burn, burn + vehicle, and burn + CaD groups. Renal function, reactive oxygen species generation, tubular necrosis, and phosphorylation of mitogen-activated protein kinase, protein kinase B (Akt), and nuclear factor (NF)-κB were measured at 24 and 48 h after the burn. Renal histology, ELISA, qRT-PCR, and Western blotting were performed on the renal tissue of mice to examine the effects and mechanisms at 24 and 48 h after the burn.

RESULTS

Tubular damage, cast formation, and elevations of serum creatinine, BUN, and renal tissue kidney injury molecule 1 levels were all observed in the burned mice, and these were all alleviated in the mice with CaD treatment. In addition, the levels of oxidation-reduction potential and malondialdehyde were decreased, while the activities of the endogenous antioxidative enzymes were increased in the kidney tissues from the mice after CaD treatment. Furthermore, the activities of Akt, p38, extracellular sign-regulated kinase, Jun N-terminal kinase, and NF-κB signaling were increased in the kidney of burned mice and normalized after CaD treatment.

CONCLUSION

This study has established, for the first time, the protective effect of CaD against early AKI in severely burned mice. CaD may exert its protective effect through alleviating oxidative stress, apoptosis, and inflammation, as well as modulating some signaling pathways in the kidney.

Novel recyclable acidic hydrophobic deep eutectic solvents for highly efficient extraction of calcium dobesilate in water and urine samples

Deep eutectic solvents (DESs) have been considered to be one of the most promising green alternatives of conventional volatile solvents for liquid-liquid separation. However, acidic hydrophobic DESs have been less studied although they are of great importance for the extraction of compounds which are unstable in alkaline conditions. In this study, a novel family of acidic hydrophobic deep eutectic solvents was designed and prepared from methyl trioctyl ammonium chloride and a series of haloacetic acids. For the first time, the obtained DESs were used for extraction and determination of calcium dobesilate, which is an extensively used medicine for treating vascular diseases, but it can be easily oxidized under alkaline and neutral conditions. The factors influencing extraction process including pH, temperature, extract time, inorganic salts and organic coexistence were systematically investigated. It is found that these DESs exhibited outstanding extraction performance towards calcium dobesilate. The extraction equilibrium time was only 3 min in a wide range of pH (1.2-9.2) at room temperature and the extraction capacity was up to 504 mg/g. The detection limit of calcium dobesilate extracting from water samples was 0.05 μg/L and the limit of quantification was 0.5 μg/L. A variety of inorganic salts with the concentration up to 1.0 mol/L and common coexisting organic compounds, such as glucose and starch, with the concentration more than 1000 times higher than the target analyte had no obvious impact on the extraction efficiency. The relative recovery for real samples ranged from 93.2% to 108.6%. Furthermore, the DESs could be recycled and regenerated through back extraction. After fifteen cycles, the extraction efficiency was still up to 99%. Finally, the extraction and back extraction mechanism was discussed in detail.

Calcium dobesilate mediates renal interstitial fibrosis and delay renal peritubular capillary loss through Sirt1/p53 signaling pathway

Calcium dobesilate (Cad), a protective agent, protects against microvascular damage, and diseases such as diabetic retinopathy and diabetic nephropathy. However, these vascular protective effects have not been demonstrated in chronic kidney disease (CKD). In this study, we aimed to determine the ability of Cad to protect against renal interstitial fibrosis induced by unilateral ureteral obstruction (UUO) and identify the underlying therapeutic mechanisms of Cad during hypoxia/serum deprivation (H/SD) in human umbilical vein endothelial cells (HUVECs). A total of 36 male mice were randomly assigned into 3 groups (12 mice in each group): the Sham-operated group (Sham), the saline solution-treated UUO mice group (UUO), and the Cad administration (intragastrically) group (Cad). The mice in Cad group were administered Cad (100 mg/kg) daily by oral gavage and slaughtered on the 7th and 14th days post-surgery. Six mice from each group were sacrificed by sodium pentobarbital injection on the 7th and 14th day after surgery. Tissue hypoxia, cell apoptosis and fibrotic lesions were detected by Immunostaining and Western blot. Peritubular capillaries (PTCs) injury was measured by a novel technique of fluorescent microangiography (FMA). Endothelial cell-to-mesenchymal transition (EndMT) were identified by immunofluorescence and Western blot. HUVECs proliferation was measured via Cell Counting Kit‑8 assays and Edu staining. Sirt1 and its downstream gene in Cad regulation of endothelial were detected. Hematoxylin-eosin (HE), Masson-trichrome stains and Histological findings showed that Cad administration markedly reduced hypoxia and renal interstitial fibrosis at each time point in UUO. Meanwhile, Cad protect against EndMT process of PTCs by increasing CD31 expression and decreasing α-smooth muscle actin and fibronectin expression. in vitro studies showed that there was a proliferative response of the HUVECs incubated with Cad (10 μM) in H/SD. Sirt1 was suppressed after small interfering RNA (siRNA) was transfected in HUVECs. Mechanistically, Cad enhanced Sirt1 signaling, which was accompanied by increased levels of p53 acetylation (ac-p53). Meanwhile, protein expression of Bcl-2, and VE-cadherin were downregulated, Bax, and α-SMA were upregulated. In summary, the therapeutic effect of Cad in obstructive nephropathy were likely through suppressing EndMT progression and promoting anti-apoptotic effects after via activating the Sirt1/p53 signaling pathway.

Calcium dobesilate (Doxium®) in bone marrow edema syndrome and suspected osteonecrosis of the hip joint - A case series

Osteonecrosis of the femoral head is a disease that leads to gradual degeneration of the hip joint causing immobility and a devastating impairment of quality of life. Early stage disease is characterised by a bone marrow edema of the proximal femur, a sight it shares with bone marrow edema syndrome. Although total hip arthroplasty offers quick symptom relief and functionally appealing results the treatment remains challenging, with its particularly young patients and considering limited non-invasive treatment options. We treated 6 patients with bone marrow edema in MRI and suspected osteonecrosis of the hip joint with calcium dobesilate, a vasoactive agent used in the treatment of diabetic retinopathy. We could demonstrate rapid symptom relief and concomitant disease remission on control MRI in early stage disease without any adverse events. Patients at advanced stages benefited in terms of pain reduction, but the treatment failed to halt disease progression. To the best of our knowledge, this is the first report of the therapeutic administration of calcium dobesilate in patients with bone marrow edema syndrome or osteonecrosis of the hip joint.

Effects of calcium dobesilate (CaD) interference on serum creatinine measurements: a national External Quality Assessment (EQA)-based educational survey of drug-laboratory test interactions

Objectives

Drug-laboratory test interactions (DLTIs) are one of the major sources of laboratory errors. Calcium dobesilate (CaD) interference on serum creatinine testing is a widespread problem that has long been ignored in China. A national EQA-based survey was launched to investigate the current status of CaD interference on creatinine routine methods used in China and enhance the education of CaD interference in clinical laboratories.

Methods

A descriptive survey was developed to characterize the status quo of Chinese laboratory professionals' cognition to CaD interference. Four of survey samples which were spiked with/without interference additive were shipped to 175 participant laboratories. The target reference values from a reference measurement procedure were compared against the results from participating laboratories to evaluate the CaD interference on serum creatinine measurements using enzymatic method or Jaffé method.

Results

The lack of knowledge of DLTIs and the barriers to collect information from pharmacological and laboratory data systems had become the main problems on implementing DLTIs education in China. A significant negative influence of CaD on enzymatic method was observed regardless of measurement platforms. Jaffé method was generally free from interaction with CaD but showed poor precision and accuracy at low creatinine concentrations.

Conclusions

More efforts should be made to enhance the education of DLTIs in clinical laboratories in China.

Calcium Dobesilate and Micro-vascular diseases

Micro-vascular diseases and its associated complications continue to be a significant health problem worldwide. Vascular lesions from microvascular involvement lead to impaired blood flow and contribute to damage and dysfunction of one or more target organs, that is, the heart, kidneys, eyes, and nervous system. Calcium Dobesilate Drug (CAD) is an established vasoactive and angioprotective drug that has shown a unique, multitarget mode of action in several experimental studies and in different animal models of diabetic microvascular complications. CAD has been widely used as an antioxidant and a vascular protective agent. At present, the application of Calcium Dobesilate is mainly related to Micro-vascular damage-related diseases, such as diabetic retinopathy (DR) and diabetic nephropathy (DN), and it is found to significantly improve the related symptoms. Its beneficial effects make it an attractive therapeutic compound especially in the early stages of these diseases. Scholars at home and abroad have studied the effectiveness, safety, and mechanisms of the related diseases, furthermore, the subjects involved patients and animal models, they have found some new clinical effects of this medicine. This paper makes a brief summary of a research progress of clinical application about Vascular injury related diseases and other aspects.

Selected Physicochemical Properties of Lyophilized Hydrogel with Liposomal Fraction of Calcium Dobesilate

Lyophilization is the process of drying and improving the stability of various pharmaceutical preparations. In this work we evaluated the properties of 11 hydrophilic gels calcium dobesilate with liposomes based on soybean lecithin, subjected to the freeze-drying procedure. Liposomes were produced by using method thin lipid film. Lyophilization was carried out under conditions of temperature equal (-30 °C) and pressure 0.37 mbar. We evaluated the preparations with dynamic light scattering (DLS) method, optical microscopy and Fourier-transform infrared spectroscopy (FTIR). In this work we presented the average results for the particle diameter in the sample and PDI (polydispersity index) value for the samples that produced the results. When testing using the DLS method on a Malvern Zetaseizer, results for 7 samples were not obtained. Two of next four samples were characterized by an increased size of the liposome particle resulting from a lower concentration of ethanol compared to the rest of them. Three samples under the microscope did not show any differences. It was possible only to see single crystals probably of undissolved calcium dobesilate. Some clusters were observed in the 4 samples, and when they appeared they were very small. The aggregates and irregular liposomes present in the rest of the samples may have been formed due to the destabilizing activity of ethanol towards lipid membranes. In the FTIR spectrum for MC, the peak was observed at the wavenumber of ca. 2900 cm-1 and of about 1050 cm-1. In case of pure calcium dobesilate we observed low pick at the wavenumber of about 3400 cm-1. The spectrum has a low peak at the wavenumber of 1450 cm-1 and intense peaks ranging from approx. 1000 cm-1 to approx. 1200 cm-1. Decay of the lecithin peak in formulations with liposomes at 1725 cm-1 wavelength may indicate the occurrence of the hydrolysis reaction in the system. Probably there was a hydrolysis of the ester bond connecting the rest of the phosphoric acid and the choline with the glycerol residue.

The Effect of Calcium Dobesilate on Liver Damage in Experimental Obstructive Jaundice

Purpose/Aim of the study: Inflammation and oxidative stress are two significant factors affecting the degree of liver damage in obstructive jaundice. The aim of this study was to evaluate the effect of calcium dobesilate (CaDob), an effective antioxidant and anti-inflammatory drug, on damage to liver caused by experimental obstructive jaundice.

MATERIALS AND METHODS

30 rats in total were randomly placed into three groups, each group consisting of 10 rats. The sham group (Group 1) only received solely laparotomy. In the control group (Group 2), ligation was applied to the biliary tract and no treatment was implemented. In the CaDob group (Group 3), following ligation of the biliary tract, 100 mg/kg/day CaDob was implemented via an orogastric tube for a 10-day period. Liver tissue and blood samples were taken for histopathological and biochemical examination.

RESULTS

The CaDob group had significantly lower test values for serum liver functions when compared to the control group. Statistically lower levels of tissue malondialdehyde (MDA) and fluorescent oxidation products (FOP) were detected in the CaDob group, and the CaDob group had significantly higher levels of sulfydryl (SH) than the control group. Histopathological scores in the CaDob group were found out to be statistically less than the scores the control group received (p < 0.05).

CONCLUSIONS

CaDob treatment repaired the histpatological changes induced by bile duct ligation. The hepatoprotective effects of CaDob can be associated with its antioxidant properties of the drug.

Calcium Dobesilate Prevents Diabetic Kidney Disease by Decreasing Bim and Inhibiting Apoptosis of Renal Proximal Tubular Epithelial Cells

Apoptosis of renal proximal tubular epithelial cells (PTECs) plays a vital role in the pathogenesis and progression of diabetic kidney disease (DKD). Calcium dobesilate is a vascular protective compound used for treatment of diabetic retinopathy and chronic venous insufficiency. The aim of this study was to determine whether calcium dobesilate can protect PTECs from glucose-induced apoptosis and the potential mechanism of this effect. It is indicated that high glucose promoted abnormal apoptosis of HK2 cells, which was inhibited by treatment of calcium dobesilate, while Bim expression decreased in response to calcium dobesilate in high-glucose-treated HK2 cells. These findings confirmed the therapeutic effects of calcium dobesilate on DKD and emphasized the importance of it as a potentially crucial drug in treatment of DKD.

Executive Summary - The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016

This paper outlines the recommendations from the Association of Colon & Rectal Surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids-2016. It includes diagnosis and management of haemorrhoids including dietary, non-surgical, and surgical techniques. These guidelines are intended for the use of general practitioners, general surgeons, colorectal surgeons, and gastrointestinal surgeons in India.

[Modern approach to early diagnosis and pathogenetic treatment of diabetic retinopathy]

AIM

To improve the approach to pathogenetic treatment of diabetic retinopathy (DR) through early diagnosis and a new method for predicting disease progression.

MATERIAL AND METHODS

The study enrolled 330 type 2 diabetes patients with DR (660 eyes), of whom women constituted 64.6%, men - 35.4%. The mean patient age was 62.3±2.3 years. Three groups were formed: the controls - 30 healthy volunteers (60 eyes) and 30 type 2 diabetes patients without ocular involvement (DR 0, 60 eyes); group 1 - 30 type 2 diabetes patients with DR I but no diabetic macular edema (DR I without DME, 60 eyes) that were treated with calcium dobesilate; group 2 - 240 type 2 diabetes patients, who had diabetic retinopathy of different stages (DR I, II, or III with DME, 480 eyes) and received laser retinal photocoagulation (LRP). The groups were all alike in terms of sex and age distribution. All patients underwent ophthalmic examination, including best corrected visual acuity (BCVA) and critical flicker fusion frequency (CFFF) testing, tonometry, biomicroscopy, MAIA fundus microperimetry, optical coherence tomography (OCT), and fluorescein angiography (FAG) of the retina. Traditionally we also determined blood sugar and glycated hemoglobin levels as well as vascular endothelial growth factor (VEGF-A) and monocyte chemoattractant protein (MCP-1) in tear fluid by ELISA.

RESULTS

In group 1, which was under conservative therapy with calcium dobesilate, there was an increase in BCVA by the average of 0.95±0.02 and CFFF by 42.5±0.2 Hz (p<0,05). The mean central retinal thickness decreased reliably down to 265.1±12.1 µm (p<0.05). Light sensitivity of the macula improved and scored 24.13±12.3 dB (p<0.05). In group 2, the mean central retinal thickness appeared to be 383.1±221 µm, which was reliably higher than that in healthy individuals (p<0.05) and in type 2 diabetes patients without diabetic retinopathy (DR 0) (p<0.05). Tear assessment 12 months after the treatment revealed a significant decrease in VEGF-A and MCP-1 concentrations - down to 655.1±86.1 pg/ml and 1133 pg/ml, respectively (p<0.05).

CONCLUSION

Conservative treatment with calcium dobesilate has proved effective in patients with DR I without DME as it ensures improvement and stabilization of the state of the retina (clinical and morphological) in one month already (judging from FAG and OCT findings). Laser treatment is rational in DR I, DR II, and DR III patients, whose condition is complicated with DME. Improvement and stabilization take, however, longer to be achieved - up to 1 year (according to FAG and OCT). Tear fluid assessment for particular participants in disease pathogenesis, such as VEGF-A and MCP-1, is a unique method for disease control and patient follow-up with account to different treatments. A new method for predicting the progression of diabetic retinopathy and diabetic macular edema has been suggested (RF patent for invention №2520826).

A randomized, double-blind, placebo-controlled, clinical study on the efficacy and safety of calcium dobesilate in the treatment of chronic venous insufficiency

OBJECTIVE

To show the superiority of 500 mg calcium dobesilate vs. placebo in reduction of edema of the lower limbs in patients with chronic venous insufficiency, Clinical, Etiological, Anatomical and Pathophysiological classes C3/C4.

METHODS

A total of 351 patients were randomized (n = 174 calcium dobesilate, n = 177 placebo). Active treatment was 500 mg calcium dobesilate, three times daily for 12 weeks, with a 12-week follow-up.

RESULTS

At the end of treatment, the relative volume change in the most pathological leg was -0.6 ± 4.8% with calcium dobesilate compared to -0.3 ± 3.3% with placebo (p = 0.09). At the end of follow-up, this was -1.01 ± 5.4% for calcium dobesilate vs. -0.08 ± 3.5% for placebo (p = 0.002).

CONCLUSIONS

Calcium dobesilate treatment resulted in no significant volume change in the most pathological leg between baseline and end of treatment. However, the calcium dobesilate group showed a significantly greater volume decrease in the most pathological leg at the end of follow-up. Calcium dobesilate was well-tolerated, with a safety profile consistent with previously published data.

Diacetyloxyl derivatization of the fibroblast growth factor inhibitor dobesilate enhances its anti-inflammatory, anti-angiogenic and anti-tumoral activities

BACKGROUND

Dobesilate (2,5-dihydroxyphenyl sulfonate, DHPS) was recently identified as the most potent member of a family of fibroblast growth factor (FGF) inhibitors headed by gentisic acid, one of the main catabolites of aspirin. Although FGFs were first described as inducers of angiogenesis, they were soon recognized as broad spectrum mitogens. Furthermore, in the last decade these proteins have been shown to participate directly in the onset of inflammation, and their potential angiogenic activity often contributes to the inflammatory process in vivo. The aim of this work was to evaluate the anti-inflammatory, anti-angiogenic and anti-tumoral activities of the derivative of DHPS obtained by acetoxylation of its two hydroxyl groups (2,5-diacetoxyphenyl sulfonate; DAPS).

METHODS

Anti-inflammatory, anti-angiogenic and anti-tumoral activities of DHPS and DAPS were compared using in vivo assays of dermatitis, angiogenesis and tumorigenesis. The effects of both compounds on myeloperoxidase (MPO) and cyclooxygenase (COX) activities, cytokine production and FGF-induced fibroblast proliferation were also determined.

RESULTS

Topical DAPS is more effective than DHPS in preventing inflammatory signs (increased vascular permeability, edema, leukocyte infiltration, MPO activation) caused by contact dermatitis induction in rat ears. DAPS, but not DHPS, effectively inhibits COX-1 and COX-2 activities. DAPS also reduces the increase in serum cytokine concentration induced by lipopolysaccharide in rats. Furthermore, DAPS displays higher in vivo efficacy than DHPS in inhibiting FGF-induced angiogenesis and heterotopic glioma progression, with demonstrated oral efficacy to combat both processes.

CONCLUSIONS

By inhibiting both FGF-signaling and COX-mediated prostaglandin synthesis, DAPS efficiently breaks the vicious circle created by the reciprocal induction of FGF and prostaglandins, which probably sustains undesirable inflammation in many circumstances. Our findings define the enhancement of anti-inflammatory, anti-angiogenic and anti-tumoral activities by diacetyloxyl derivatization of the FGF inhibitor, dobesilate.

Non-traditional systemic treatments for diabetic retinopathy: an evidence-based review

The rapid escalation in the global prevalence diabetes, with more than 30% being afflicted with diabetic retinopathy (DR), means it is likely that associated vision-threatening conditions will also rise substantially. This means that new therapeutic approaches need to be found that go beyond the current standards of diabetic care, and which are effective in the early stages of the disease. In recent decades several new pharmacological agents have been investigated for their effectiveness in preventing the appearance and progression of DR or in reversing DR; some with limited success while others appear promising. This up-to-date critical review of non-traditional systemic treatments for DR is based on the published evidence in MEDLINE spanning 1980-December 2014. It discusses a number of therapeutic options, paying particular attention to the mechanisms of action and the clinical evidence for the use of renin-angiotensin system blockade, fenofibrate and calcium dobesilate monohydrate in DR.

Improvement in the signs and symptoms of dry eye disease with dobesilate eye drops

BACKGROUND

Dry eye is a multifactor disease of the tear film and ocular surface that substantially affects quality of life.

CASE PRESENTATION

Dobesilate administered as eye drops was well tolerated and effective in treating both the objective signs and subjective symptoms of dry eye disease in this 2-week study.

CONCLUSION

To the best of our knowledge, this is the first clinical report of using dobesilate in eye drops. Dobesilate may provide a novel approach to treating drying diseases of the eye.

Effect of adding oral calcium dobesilate to laser photocoagulation on the macular thickness in patients with diabetic macular edema: a randomized clinical trial

PURPOSE

To evaluate the effect of oral calcium dobesilate (Doxium) on macular thickness in clinically significant macular edema (CSME).

METHODS

Overall, 71 eyes of 40 patients with non-proliferative diabetic retinopathy and clinically significant macular edema were included. All patients were received laser treatment for macular edema. Coherence optical tomography was used to determine the retinal thickness. Patients were randomized into two groups: group A received three Doxium capsule daily and group B received three placebo capsule daily for six months.

RESULTS

The mean macular thickness before and after treatment in the group A was 340 and 257 micrometers respectively (24.5% reduced), and in the group B was 336 micrometers and 263 micrometers respectively (21.5% reduced). Macular thickness significantly decreased after treatment in both groups and the reduction in group A is higher but the difference of reduction between the two groups was not statistically significant (P>0.05).

CONCLUSION

In respect to the effect of adding oral Doxium to Laser Photocoagulation on the macular thickness in patients with diabetic macular edema, this study showed no statistically significant difference between Doxium and placebo.

Linking the beneficial effects of current therapeutic approaches in diabetes to the vascular endothelin system

The rising epidemic of diabetes worldwide is of significant concern. Although the ultimate objective is to prevent the development and find a cure for the disease, prevention and treatment of diabetic complications is very important. Vascular complications in diabetes, or diabetic vasculopathy, include macro- and microvascular dysfunction and represent the principal cause of morbidity and mortality in diabetic patients. Endothelial dysfunction plays a pivotal role in the development and progression of diabetic vasculopathy. Endothelin-1 (ET-1), an endothelial cell-derived peptide, is a potent vasoconstrictor with mitogenic, pro-oxidative and pro-inflammatory properties that are particularly relevant to the pathophysiology of diabetic vasculopathy. Overproduction of ET-1 is reported in patients and animal models of diabetes and the functional effects of ET-1 and its receptors are also greatly altered in diabetic conditions. The current therapeutic approaches in diabetes include glucose lowering, sensitization to insulin, reduction of fatty acids and vasculoprotective therapies. However, whether and how these therapeutic approaches affect the ET-1 system remain poorly understood. Accordingly, in the present review, we will focus on experimental and clinical evidence that indicates a role for ET-1 in diabetic vasculopathy and on the effects of current therapeutic approaches in diabetes on the vascular ET-1 system.

Can calcium dobesilate be used safely for peripheral microvasculopathies that require neoangiogenesis?

Background

Calcium dobesilate (CaD) is a member of the synthetic veno-active drug family. Only a small number of reports are available that describe the micro-angiogenic effects of CaD in the current literature.

Material/Methods

The antiangiogenic potential of CaD was compared with bevacizumab (Bb), which is a potent angiogenesis inhibitor, in a chick chorioallantoic membrane model. Four different concentrations (10⁻⁷, 10⁻⁶, 10⁻⁵, and 10⁻⁴ M) of drug pellet were prepared for each drug. Changes in vessel formation were scored and compared for each drug according to the previous literature.

Result

The antiangiogenic behavior of CaD was lower than Bb, despite the significant dose-dependent manner of escalation. The anti-angiogenic scores of CaD were determined as 0.20, 0.47, 0.66, 1.0 in 10⁻⁷, 10⁻⁶, 10⁻⁵, and 10⁻⁴ M concentrations, respectively (average score >0.5 was significant).

Conclusions

According to the data obtained, this agent should be used carefully for cases in which angiogenesis plays an important role in healing.

Pharmacological treatment of hemorrhoids: a narrative review

INTRODUCTION

Hemorrhoid disease is the cause of most proctologic complaints and hundreds of medical and surgical therapies have been proposed to relieve symptoms. However, the role and the correct indication of medical treatments are still controversial. Further, the utility of conservative measures are rarely scientifically supported by adequate trials.

AREAS COVERED

This narrative review is based on the search and analysis of full papers in English language selected from PubMed in the past 30 years using the following MeSH Editing: hemorrhoids, conservative treatment, medical treatment and hemorrhoids, pregnancy and hemorrhoids, thrombosed hemorrhoids, randomized trials and hemorrhoids, postoperative pain and hemorrhoids.

EXPERT OPINION

Early stages (I/II degrees) of this disease could be effectively managed conservatively with several approaches as lifestyle changes, fiber supplement, topical ointments and phlebotonic drugs. The more advanced hemorrhoid stages (III/IV degrees) need some type of surgery, but medical therapy is still useful to minimize anal symptoms as a bridge-to-surgery treatment. Further, post-hemorrhoidectomy pain, hemorrhoidal crisis even in pregnancy could benefit from the adjunct of local and systemic medical treatment. This expert opinion, based also on long-lasting clinical practice, also supports the use of medical treatment in symptoms relief in patients with hemorrhoid disease.

Therapeutic effects of calcium dobesilate on diabetic nephropathy mediated through reduction of expression of PAI-1

The aim of this study was to investigate whether calcium dobesilate (calcium dihydroxy-2,5-benzenesulfonate) may be used to treat diabetic nephropathy. A total of 121 patients with type 2 diabetic nephropathy received calcium dobesilate (500 mg, 3 times a day) for 3 months. The levels of glycated hemoglobin, fasting serum C peptide, triglyceride, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, alanine aminotransferase, γ-glutamyl transferase, urea nitrogen, creatinine, hematocrit, plasma viscosity, whole blood reduced viscosity, high, medium and low shear rate whole blood viscosity, fibrinogen, plasminogen activator inhibitor-1 (PAI-1) and endothelin were determined. The urinary albumin excretion rate (UAER) was also determined once a month during the study. The UAER and medium and low shear rate whole blood viscosity were significantly lower in the treated patients. The rate of microalbuminuria normalization was 90%. During the treatment, the UAERs decreased. The results revealed that calcium dobesilate has therapeutic effects on type 2 diabetes patients with microalbuminuria. In addition, the benefit was positively correlated with the calcium dobesilate treatment time. The therapeutic effect may be due to decreases in the levels of PAI-1.

Treatment of Stargardt disease with dobesilate

Stargardt disease is a common inherited macular degeneration characterised by a significant loss in the central vision during the first or second decade of the life. Bilateral atrophic changes in the central retina are associated with degeneration of photoreceptors and underlying retinal pigment epithelium, and yellow flecks are extending from the macula. We present a patient with Stargardt disease treated with an intravitreal injection of dobesilate, showing an improvement of visual acuity 4 weeks after treatment.

Intravitreal dobesilate in the treatment of choroidal neovascularisation associated with age-related macular degeneration: report of two cases

This case report presents the effectiveness of intravitreal administration of dobesilate, a synthetic fibroblast growth factor inhibitor, in two patients showing neovascular age-related macular degeneration of the classic, and of the occult choroidal neovascularisation types, respectively. Our study demonstrates that the treatment induces the regression of both forms of this pathology, as assessed by spectral optical coherence tomography. Improvement of the lesions was accompanied of visual acuity improvement.

Short-term efficacy of intravitreal dobesilate in central serous chorioretinopathy

PURPOSE

To report the anatomic and functional outcome of intravitreal dobesilate to treat recurrent central serous chorioretinopathy (CSC).

METHODS

This is an interventional case report in which dobesilate was intravitreally injected in a case of recurrent CSC. Main measures included fundoscopy, Snellen visual acuity (VA) testing, fluorescein angiography and optical coherence tomography (OCT).

RESULTS

We present anatomical and functional evidences, obtained as early as eleven days after the treatment, of the efficacy of intravitreal dobesilate, in the treatment of chronic CSC condition. The effect after intravitreal dobesilate injection for CSC might be related to the normalization of retinal architecture.

CONCLUSIONS

Intravitreal dobesilate may be an effective treatment option for recurrent CSC.

Treatment of dry age-related macular degeneration with dobesilate

The authors present anatomical and functional evidences of dry age-macular degeneration improvement, after intravitreal treatment with dobesilate. Main outcomes measures were normalisation of retinal structure and function, assessed by optical coherence tomography, fundus-monitored microperimetry, electrophysiology and visual acuity. The effect might be related to the normalisation of the outer retinal architecture.

Calcium dobesilate and oxerutin: effectiveness of combination therapy

Objectives

Chronic venous insufficiency (CVI) is an important cause of discomfort and inability to work. Hydroxyethylrutosides (Venoruton®; 0-[beta-hydroxyethyl]-rutosides) has been used for decades for the treatment of CVI. Studies have reported symptomatic relief and a decreased capillary filtration after the administration of the oral preparations. Calcium dobesilate is a synthetic venoactive drug acting on several levels. It inhibits capillary permeability; it has antioxidant properties; and it inhibits the synthesis of prostaglandins and thromboxanes, reducing platelet and erythrocyte aggregation, as well as blood viscosity. The aim of this study is to determine whether the combination of both drugs is more effective in decreasing patients' complaints.

Methods

One hundred and fifty patients with primary venous insufficiency were randomized into three groups: Group A receiving calcium dobesilate only, Group B receiving oxerutin only and Group C receiving both calcium dobesilate and oxerutin. Patients were evaluated with a questionnaire before and four weeks after treatment regarding following parameters: itching, fatigue, heaviness, numbness, cramp, swelling and sensitiveness. Patients rated their symptoms from 0 to 4 (0: absent; 1: mild; 2: moderate; 3: severe; 4: very severe).

Results

Complaints, which were scored by patients before and after treatment, decreased. Among the single-drug groups, itching score decreased more in Group B, whereas scores of fatigue, heaviness, numbness, cramp and swelling decreased more in Group A. But the difference was not significant, statistically. But all complaints decreased significantly in Group C. Difference of scores after treatment revealed no statistical significance in Group A and B, but scores of Group C produced a significant difference when compared with Group A and B.

Conclusion

Results demonstrate that a combination of calcium dobesilate and oxerutin shows a better improvement of complaints. These observations have to be confirmed in larger series with objective tests. Changes of quality of life after a combination therapy might also be of interest.

Effect of calcium dobesilate on occurrence of diabetic macular oedema (CALDIRET study): randomised, double-blind, placebo-controlled, multicentre trial

BACKGROUND

Medical treatment for diabetic retinopathy could have an important role in prevention of complications such as visual loss. We aimed to assess the effect of calcium dobesilate on occurrence of diabetic macular oedema.

METHODS

We undertook a randomised, double-blind, placebo-controlled, multicentre study in 40 centres in 11 countries. We enrolled outpatients with adult-onset type 2 diabetes and mild-to-moderate non-proliferative diabetic retinopathy, and randomly allocated them via sealed envelopes either calcium dobesilate (1500 mg per day) or placebo. The primary endpoint was development of clinically significant macular oedema (CSME) within a follow-up period of 5 years. Patients who dropped out of the study early were censored. Analysis was by intention to treat.

FINDINGS

We enrolled 635 patients. 324 were randomly allocated calcium dobesilate and 311 were assigned placebo. In the calcium dobesilate group, 86 patients developed CSME compared with 69 in the placebo group. Accounting for censored cases, estimated cumulative 5-year CSME probability was 35% and 28%, respectively (hazard ratio 1.32, 95% CI 0.96-1.81; p=0.0844). Adverse events did not differ between treatment groups (78 [24%] on calcium dobesilate and 90 [29%] with placebo). No relevant drug-related complications were noted. Nine patients (3%) died in the calcium dobesilate group and eight (3%) deaths were recorded on placebo.

INTERPRETATION

Calcium dobesilate did not reduce the risk of development of CSME.

Randomized, double blind, placebo-controlled clinical trial to evaluate the lymphagogue effect and clinical efficacy of calcium dobesilate in chronic venous disease

The aims of the present study were to investigate the effect of calcium dobesilate on lymph flow and lymphovenous edema in patients with chronic venous disease. It was a randomized, placebo-controlled, double-blind clinical trial. Patients received 1 capsule of 500 mg calcium dobesilate every 8 hours (1.5 g/day) or placebo by 49 days. By the end of the treatment period, only the patients treated with calcium dobesilate had normalization of lymphogammagraphy (capture index and speed of lymph flow; 80 and 78%, respectively). Only patients treated with calcium dobesilate had statistically significant reduction in the perimeter of leg, calf, and ankle. Twenty-two out of 25 (88%) calcium dobesilate-treated patients presented clinical improvement versus 5 out of 24 (20.8%) in the placebo group. One patient on calcium dobesilate developed rash and one patient on placebo complained of vomiting. In the present study, calcium dobesilate normalized lymph physiology and improved symptoms in patients with chronic venous disease.

Calcium Dobesilate in the Treatment of Diabetic Retinopathy

The incidence of diabetic retinopathy is still increasing in developed countries. Tight glycemic control and laser therapy reduce vision loss and blindness, but do not reverse existing ocular damage and only slow the progression of the disease. New pharmacologic agents that are currently under development and are specifically directed against clearly defined biochemical targets (i.e. aldose reductase inhibitors and protein kinase C-beta inhibitors) have failed to demonstrate significant efficacy in the treatment of diabetic retinopathy in clinical trials. In contrast, calcium dobesilate (2,5-dihydroxybenzenesulfonate), which was discovered more than 40 years ago and is registered for the treatment of diabetic retinopathy in more than 20 countries remains, to our knowledge, the only angioprotective agent that reduces the progression of this disease. An overall review of published studies involving calcium dobesilate (CLS 2210) depicts a rather 'non-specific' compound acting moderately, but significantly, on the various and complex disorders that contribute to diabetic retinopathy. Recent studies have shown that calcium dobesilate is a potent antioxidant, particularly against the highly damaging hydroxyl radical. In addition, it improves diabetic endothelial dysfunction, reduces apoptosis, and slows vascular cell proliferation.