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Liu C, Zhang J, Ye Z, Luo J, Peng B, Wang Z. Research on the role and mechanism of the PI3K/Akt/mTOR signalling pathway in osteoporosis. Front Endocrinol (Lausanne) 2025; 16:1541714. [PMID: 40421249 PMCID: PMC12104071 DOI: 10.3389/fendo.2025.1541714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Accepted: 04/17/2025] [Indexed: 05/28/2025] Open
Abstract
Osteoporosis is a systemic metabolic bone disease characterised mainly by reduced bone mass, bone microstructure degradation, and loss of bone mechanical properties. As the world population ages, more than 200 million people worldwide suffer from the pain caused by osteoporosis every year, which severely affects their quality of life. Moreover, the prevalence of osteoporosis continues to increase. The pathogenesis of osteoporosis is highly complex and is closely related to apoptosis, autophagy, oxidative stress, the inflammatory response, and ferroptosis. The PI3K/Akt/mTOR signalling pathway is one of the most crucial intracellular signal transduction pathways. This pathway is not only involved in bone metabolism and bone remodelling but also closely related to the proliferation and differentiation of osteoblasts, osteoclasts, and bone marrow mesenchymal stem cells. Abnormal activation or inhibition of the PI3K/Akt/mTOR signalling pathway can disrupt the balance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption, ultimately leading to the development of osteoporosis. This review summarises the molecular mechanisms by which the PI3K/Akt/mTOR signalling pathway mediates five pathological mechanisms, namely, apoptosis, autophagy, oxidative stress, the inflammatory response, and ferroptosis, in the regulation of osteoporosis, aiming to provide a theoretical basis for the development of novel and effective therapeutic drugs and intervention measures for osteoporosis prevention and treatment.
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Affiliation(s)
- Chuanlong Liu
- Hunan Hospital of Integrated Traditional Chinese and Western Medicine, Changsha, Hunan, China
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Jianqiang Zhang
- Liuyang Traditional Chinese Medicine Hospital, Liuyang, Hunan, China
| | - Ziyu Ye
- Hunan Hospital of Integrated Traditional Chinese and Western Medicine, Changsha, Hunan, China
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Ji Luo
- Hunan Hospital of Integrated Traditional Chinese and Western Medicine, Changsha, Hunan, China
| | - Bing Peng
- Hunan Hospital of Integrated Traditional Chinese and Western Medicine, Changsha, Hunan, China
| | - Zhexiang Wang
- Hunan Hospital of Integrated Traditional Chinese and Western Medicine, Changsha, Hunan, China
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Wu C, Tong Y, Huang J, Wang S, Kobori H, Zhang Z, Suzuki K. Atrophic C2C12 Myotubes Activate Inflammatory Response of Macrophages In Vitro. Cells 2025; 14:317. [PMID: 40072046 PMCID: PMC11899532 DOI: 10.3390/cells14050317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2025] [Revised: 02/15/2025] [Accepted: 02/18/2025] [Indexed: 03/15/2025] Open
Abstract
BACKGROUND Skeletal muscle wasting is commonly observed in aging, immobility, and chronic diseases. In pathological conditions, the impairment of skeletal muscle and immune system often occurs simultaneously. Recent studies have highlighted the initiative role of skeletal muscle in interactions with immune cells. However, the impact of skeletal muscle wasting on macrophage inflammatory responses remains poorly understood. METHODS To investigate the effect of atrophic myotubes on the inflammatory response of macrophages, we established two in vitro models to induce myotube atrophy: one induced by D-galactose and the other by starvation. Conditioned medium (CM) from normal and atrophic myotubes were collected and administered to bone marrow-derived macrophages (BMDMs) from mice. Subsequently, lipopolysaccharide (LPS) stimulation was applied, and the expression of inflammatory cytokines was measured via RT-qPCR. RESULTS Both D-galactose and starvation treatments reduced myotube diameter and upregulated muscle atrophy-related gene expression. CM from both atrophic myotubes models augmented the gene expression of pro-inflammatory factors in BMDMs following LPS stimulation, including Il6, Il1b, and Nfkb1. Notably, CM from starvation-induced atrophic myotubes also enhanced Il12b, Tnf, and Nos2 expression in BMDMs after stimulation, a response not observed in D-galactose-induced atrophic myotubes. CONCLUSIONS These findings suggest that CM from atrophic myotubes enhanced the expression of LPS-induced pro-inflammatory mediators in macrophages.
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Affiliation(s)
- Cong Wu
- Graduate School of Sport Sciences, Waseda University, Tokorozawa 359-1192, Japan; (C.W.); (Y.T.); (J.H.); (S.W.); (H.K.); (Z.Z.)
| | - Yishan Tong
- Graduate School of Sport Sciences, Waseda University, Tokorozawa 359-1192, Japan; (C.W.); (Y.T.); (J.H.); (S.W.); (H.K.); (Z.Z.)
| | - Jiapeng Huang
- Graduate School of Sport Sciences, Waseda University, Tokorozawa 359-1192, Japan; (C.W.); (Y.T.); (J.H.); (S.W.); (H.K.); (Z.Z.)
| | - Shuo Wang
- Graduate School of Sport Sciences, Waseda University, Tokorozawa 359-1192, Japan; (C.W.); (Y.T.); (J.H.); (S.W.); (H.K.); (Z.Z.)
| | - Haruki Kobori
- Graduate School of Sport Sciences, Waseda University, Tokorozawa 359-1192, Japan; (C.W.); (Y.T.); (J.H.); (S.W.); (H.K.); (Z.Z.)
| | - Ziwei Zhang
- Graduate School of Sport Sciences, Waseda University, Tokorozawa 359-1192, Japan; (C.W.); (Y.T.); (J.H.); (S.W.); (H.K.); (Z.Z.)
| | - Katsuhiko Suzuki
- Faculty of Sport Sciences, Waseda University, Tokorozawa 359-1192, Japan
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Jia J, Wang L, Zhou Y, Zhang P, Chen X. Muscle-derived extracellular vesicles mediate crosstalk between skeletal muscle and other organs. Front Physiol 2025; 15:1501957. [PMID: 39844898 PMCID: PMC11750798 DOI: 10.3389/fphys.2024.1501957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Accepted: 12/18/2024] [Indexed: 01/24/2025] Open
Abstract
Skeletal muscle (SKM) has crucial roles in locomotor activity and posture within the body and also functions have been recognized as an actively secretory organ. Numerous bioactive molecules are secreted by SKM and transported by extracellular vesicles (EVs), a novel class of mediators of communication between cells and organs that contain various types of cargo molecules including lipids, proteins and nucleic acids. SKM-derived EVs (SKM-EVs) are intercellular communicators with significant roles in the crosstalk between SKM and other organs. In this review, we briefly describe the biological characteristics, composition, and uptake mechanisms of EVs, particularly exosomes, comprehensively summarize the regulatory effects of SKM-EVs on the function of, which include myogenesis, muscle repair and regeneration, as well as metabolic regulation. Furthermore, we explore the impact of SKM- EVs on various organs including bone, the cardiovascular system, adipose tissue, and nervous system. As emerging evidence suggests that SKM-EVs are involved in the development and regulation of type 2 diabetes (T2D), systemic inflammation, and other chronic diseases, we also highlight the potential of SKM-EVs as therapeutic targets and diagnostic biomarkers, emphasizing the need for further research to elucidate the complex mechanisms underlying intercellular communication in physiological and pathological contexts.
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Affiliation(s)
- Jiajie Jia
- National Key Laboratory of Human Factors Engineering, China Astronaut Research and Training Center, Beijing, China
- Department of Exercise Physiology, Beijing Sport University, Beijing, China
| | - Lu Wang
- National Key Laboratory of Human Factors Engineering, China Astronaut Research and Training Center, Beijing, China
- Department of Exercise Physiology, Beijing Sport University, Beijing, China
| | - Yue Zhou
- Department of Exercise Physiology, Beijing Sport University, Beijing, China
| | - Peng Zhang
- National Key Laboratory of Space Medicine, China Astronaut Research and Training Center, Beijing, China
| | - Xiaoping Chen
- National Key Laboratory of Human Factors Engineering, China Astronaut Research and Training Center, Beijing, China
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Sbarigia C, Rome S, Dini L, Tacconi S. New perspectives of the role of skeletal muscle derived extracellular vesicles in the pathogenesis of amyotrophic lateral sclerosis: the 'dying back' hypothesis. JOURNAL OF EXTRACELLULAR BIOLOGY 2024; 3:e70019. [PMID: 39534483 PMCID: PMC11555536 DOI: 10.1002/jex2.70019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 10/04/2024] [Accepted: 10/19/2024] [Indexed: 11/16/2024]
Abstract
Amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord, and is characterized by muscle weakness, paralysis and ultimately, respiratory failure. The exact causes of ALS are not understood, though it is believed to combine genetic and environmental factors. Until now, it was admitted that motor neurons (MN) in the brain and spinal cord degenerate, leading to muscle weakness and paralysis. However, as ALS symptoms typically begin with muscle weakness or stiffness, a new hypothesis has recently emerged to explain the development of the pathology, that is, the 'dying back hypothesis', suggesting that this degeneration starts at the connections between MN and muscles, resulting in the loss of muscle function. Over time, this damage extends along the length of the MN, ultimately affecting their cell bodies in the spinal cord and brain. While the dying back hypothesis provides a potential framework for understanding the progression of ALS, the exact mechanisms underlying the disease remain complex and not fully understood. In this review, we are positioning the role of extracellular vesicles as new actors in ALS development.
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Affiliation(s)
- Carolina Sbarigia
- Department of Biology and Biotechnology “C. Darwin”University of Rome SapienzaRomeItaly
| | - Sophie Rome
- CarMeN Laboratory, INSERM 1060‐INRAE 1397, Department of Human Nutrition, Lyon Sud HospitalUniversity of LyonLyonFrance
| | - Luciana Dini
- Department of Biology and Biotechnology “C. Darwin”University of Rome SapienzaRomeItaly
- Research Center for Nanotechnology for Engineering (CNIS)Sapienza University of RomeRomeItaly
| | - Stefano Tacconi
- Department of Biology and Biotechnology “C. Darwin”University of Rome SapienzaRomeItaly
- CarMeN Laboratory, INSERM 1060‐INRAE 1397, Department of Human Nutrition, Lyon Sud HospitalUniversity of LyonLyonFrance
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Ma X, Yamaguchi A, Maeshige N, Tanida K, Uemura M, Lu F, Kondo H, Fujino H. Facilitatory effect of low-pulse repetition frequency ultrasound on release of extracellular vesicles from cultured myotubes. J Med Ultrason (2001) 2024; 51:397-405. [PMID: 38575766 PMCID: PMC11272820 DOI: 10.1007/s10396-024-01429-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/11/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Extracellular vesicles (EVs) serve as carriers of intracellular factors with therapeutic effects, including tissue regeneration and attenuation of inflammatory responses. The majority of EVs in vivo are derived from skeletal muscle, which is reported to have anti-inflammatory effects. While high-intensity pulsed ultrasound (US) irradiation has been shown to promote EV secretion from myotubes, the impact of pulse repetition frequency, a US parameter affecting pulse length, on EV release remains unclear. This study aimed to investigate the impact of pulse repetition frequency of US on the release of EVs from myotubes. METHODS C2C12 myoblasts were used in this study. After differentiation into C2C12 myotubes, US was performed for 5 min at an intensity of 3.0 W/cm2, duty cycle of 20%, acoustic frequency of 1 MHz, and different pulse repetition frequencies (100 Hz, 10 Hz, or 1 Hz). After 12 h, EVs and cells were collected for subsequent analyses. RESULTS US did not cause a reduction in cell viability across all US groups compared to the control. The concentration of EVs was significantly higher in all US groups compared to the control group. In particular, the highest increase was observed in the 1-Hz group on EV concentration as well as intracellular Ca2+ level. CONCLUSION This study investigated the effect of three different pulse repetition frequencies of US on the release of EVs from cultured myotubes. It is concluded that a low-pulse repetition frequency of 1 Hz is the most effective for enhancing EV release from cultured myotubes with pulsed ultrasound.
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Affiliation(s)
- Xiaoqi Ma
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, 10-2 Tomogaoka 7-chome, Suma-ku, Kobe, Hyogo, 654-0142, Japan
| | - Atomu Yamaguchi
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, 10-2 Tomogaoka 7-chome, Suma-ku, Kobe, Hyogo, 654-0142, Japan
| | - Noriaki Maeshige
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, 10-2 Tomogaoka 7-chome, Suma-ku, Kobe, Hyogo, 654-0142, Japan.
| | - Kento Tanida
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, 10-2 Tomogaoka 7-chome, Suma-ku, Kobe, Hyogo, 654-0142, Japan
| | - Mikiko Uemura
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, 10-2 Tomogaoka 7-chome, Suma-ku, Kobe, Hyogo, 654-0142, Japan
| | - Fuwen Lu
- Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), Tongji University School of Medicine, 2209 Guangxing Rd., Songjiang District, Shanghai, 201619, China
| | - Hiroyo Kondo
- Faculty of Health and Nutrition, Shubun University, 72 Momo Higashiyashiki, Yamato-cho, Ichinomiya, Aichi, 491-0932, Japan
| | - Hidemi Fujino
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, 10-2 Tomogaoka 7-chome, Suma-ku, Kobe, Hyogo, 654-0142, Japan
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Wang Y, Ding S. Extracellular vesicles in cancer cachexia: deciphering pathogenic roles and exploring therapeutic horizons. J Transl Med 2024; 22:506. [PMID: 38802952 PMCID: PMC11129506 DOI: 10.1186/s12967-024-05266-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Cancer cachexia (CC) is a debilitating syndrome that affects 50-80% of cancer patients, varying in incidence by cancer type and significantly diminishing their quality of life. This multifactorial syndrome is characterized by muscle and fat loss, systemic inflammation, and metabolic imbalance. Extracellular vesicles (EVs), including exosomes and microvesicles, play a crucial role in the progression of CC. These vesicles, produced by cancer cells and others within the tumor environment, facilitate intercellular communication by transferring proteins, lipids, and nucleic acids. A comprehensive review of the literature from databases such as PubMed, Scopus, and Web of Science reveals insights into the formation, release, and uptake of EVs in CC, underscoring their potential as diagnostic and prognostic biomarkers. The review also explores therapeutic strategies targeting EVs, which include modifying their release and content, utilizing them for drug delivery, genetically altering their contents, and inhibiting key cachexia pathways. Understanding the role of EVs in CC opens new avenues for diagnostic and therapeutic approaches, potentially mitigating the syndrome's impact on patient survival and quality of life.
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Affiliation(s)
- Yifeng Wang
- Department of Thoracic Surgery, Affiliated Hospital 2 of Nantong University, Nantong First People's Hospital, Nantong, 226001, P.R. China
- School of Medicine, Nantong University, Nantong, 226001, P.R. China
| | - Shengguang Ding
- Department of Thoracic Surgery, Affiliated Hospital 2 of Nantong University, Nantong First People's Hospital, Nantong, 226001, P.R. China.
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Zhang J, Gao Y, Yan J. Roles of Myokines and Muscle-Derived Extracellular Vesicles in Musculoskeletal Deterioration under Disuse Conditions. Metabolites 2024; 14:88. [PMID: 38392980 PMCID: PMC10891558 DOI: 10.3390/metabo14020088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 02/25/2024] Open
Abstract
Prolonged inactivity and disuse conditions, such as those experienced during spaceflight and prolonged bedrest, are frequently accompanied by detrimental effects on the motor system, including skeletal muscle atrophy and bone loss, which greatly increase the risk of osteoporosis and fractures. Moreover, the decrease in glucose and lipid utilization in skeletal muscles, a consequence of muscle atrophy, also contributes to the development of metabolic syndrome. Clarifying the mechanisms involved in disuse-induced musculoskeletal deterioration is important, providing therapeutic targets and a scientific foundation for the treatment of musculoskeletal disorders under disuse conditions. Skeletal muscle, as a powerful endocrine organ, participates in the regulation of physiological and biochemical functions of local or distal tissues and organs, including itself, in endocrine, autocrine, or paracrine manners. As a motor organ adjacent to muscle, bone tissue exhibits a relative lag in degenerative changes compared to skeletal muscle under disuse conditions. Based on this phenomenon, roles and mechanisms involved in the communication between skeletal muscle and bone, especially from muscle to bone, under disuse conditions have attracted widespread attention. In this review, we summarize the roles and regulatory mechanisms of muscle-derived myokines and extracellular vesicles (EVs) in the occurrence of muscle atrophy and bone loss under disuse conditions, as well as discuss future perspectives based on existing research.
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Affiliation(s)
- Jie Zhang
- Institute of Special Medicine, Shanxi Medical University, Jinzhong 030619, China;
| | - Yunfang Gao
- Shaanxi Key Laboratory for Animal Conservation, College of Life Sciences, Northwest University, Xi’an 710069, China
| | - Jiangwei Yan
- Institute of Special Medicine, Shanxi Medical University, Jinzhong 030619, China;
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Yamaguchi A, Maeshige N, Noguchi H, Yan J, Ma X, Uemura M, Su D, Kondo H, Sarosiek K, Fujino H. Pulsed ultrasound promotes secretion of anti-inflammatory extracellular vesicles from skeletal myotubes via elevation of intracellular calcium level. eLife 2023; 12:RP89512. [PMID: 38054662 PMCID: PMC10699803 DOI: 10.7554/elife.89512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
The regulation of inflammatory responses is an important intervention in biological function and macrophages play an essential role during inflammation. Skeletal muscle is the largest organ in the human body and releases various factors which mediate anti-inflammatory/immune modulatory effects. Recently, the roles of extracellular vesicles (EVs) from a large variety of cells are reported. In particular, EVs released from skeletal muscle are attracting attention due to their therapeutic effects on dysfunctional organs and tissues. Also, ultrasound (US) promotes release of EVs from skeletal muscle. In this study, we investigated the output parameters and mechanisms of US-induced EV release enhancement and the potential of US-treated skeletal muscle-derived EVs in the regulation of inflammatory responses in macrophages. High-intensity US (3.0 W/cm2) irradiation increased EV secretion from C2C12 murine muscle cells via elevating intracellular Ca2+ level without negative effects. Moreover, US-induced EVs suppressed expression levels of pro-inflammatory factors in macrophages. miRNA sequencing analysis revealed that miR-206-3p and miR-378a-3p were especially abundant in skeletal myotube-derived EVs. In this study we demonstrated that high-intensity US promotes the release of anti-inflammatory EVs from skeletal myotubes and exert anti-inflammatory effects on macrophages.
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Affiliation(s)
- Atomu Yamaguchi
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Noriaki Maeshige
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Hikari Noguchi
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Jiawei Yan
- School of Life Sciences and Technology, ShanghaiTech University, Shanghai, China
| | - Xiaoqi Ma
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Mikiko Uemura
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Dongming Su
- Department of Pathology, Nanjing Medical University, Nanjing, China
| | - Hiroyo Kondo
- Department of Health and Nutrition , Shubun University, Ichinomiya, Japan
| | - Kristopher Sarosiek
- John B. Little Center for Radiation Sciences, Harvard University T.H. Chan School of Public Health, Boston, United States
| | - Hidemi Fujino
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
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Zhu M, Song Y, Xu Y, Xu H. Manipulating Microbiota in Inflammatory Bowel Disease Treatment: Clinical and Natural Product Interventions Explored. Int J Mol Sci 2023; 24:11004. [PMID: 37446182 DOI: 10.3390/ijms241311004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/16/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a complex multifactorial chronic inflammatory disease, that includes Crohn's disease (CD) and ulcerative colitis (UC), having progressively increasing global incidence. Disturbed intestinal flora has been highlighted as an important feature of IBD and offers promising strategies for IBD remedies. A brief overview of the variations occurring in intestinal flora during IBD is presented, and the role of the gut microbiota in intestinal barrier maintenance, immune and metabolic regulation, and the absorption and supply of nutrients is reviewed. More importantly, we review drug research on gut microbiota in the past ten years, including research on clinical and natural drugs, as well as adjuvant therapies, such as Fecal Microbiota Transplantation and probiotic supplements. We also summarize the interventions and mechanisms of these drugs on gut microbiota.
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Affiliation(s)
- Mengjie Zhu
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yijie Song
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yu Xu
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Hongxi Xu
- Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
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