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Ulcerative colitis (UC) is a chronic inflammatory bowel disease that primarily occurs in the colon or rectum. The incidence of UC is generally higher in Caucasian populations, with the incidence rate among this group being as high as 70 per 100,000 individuals (
Many herbal medicines have showed significant efficacy compared with 5-aminosalicylic acid therapy (5-ASA) (
Clinical evidence and potential mechanism of Kushen for the treatment of (ulcerative colitis) UC with (damp-heat accumulation syndrome) DHAS.
A systematic literature search was performed to identify randomized controlled trials (RCTs) that involved the use of Kushen-based TCM formulations alone or in combination with 5-ASA for the treatment of UC with DHAS. No exclusion criteria were defined for the publication language of the articles. Computer searches were performed in PubMed, EMBASE, Chinese Biomedical Literature (CBM) database, China National Knowledge Infrastructure (CNKI) database, Chongqing VIP Information (CQVIP) database, and Wanfang Database for the retrieval of relevant articles published from January 2000 up to July 2020. The search keywords we used included “UC” AND (“
Studies were required to fulfill the following inclusion criteria to be part of the meta-analysis: 1) studies with a prospective randomized controlled trial design; 2) studies that included UC patients whose clinical presentations, colonoscopy results, and mucosal biopsy results follow the diagnostic criteria stated in the Third European Evidence-based Consensus on Diagnosis and Management of UC (
In the selected studies, the treatment regimen for the control group consisted of conventional 5-ASA for fever and pain relief. Interventions for the treatment group consisted of Kushen-based formulations in any form, including oral and rectal administration.
Two researchers (Dr. Ding and Dr. Chen) independently retrieved articles from the databases under the inclusion and exclusion criteria described above and extracted the following data from each article: authors’ names, date of publication, intervention method, the composition of TCM formulation, routes of administration, remission rate, and adverse drug reactions. Disagreements in the included studies were resolved by cross-checking and discussion between the two researchers, seeking the opinion of a third researcher (Prof. Tong), or contacting the authors as necessary.
The risk of bias of the included RCTs in the aspects of randomization, allocation, and loss to follow-up were assessed following the Cochrane Handbook for Systematic Reviews of Interventions (
The primary outcome indicator of the included studies was clinical remission after treatment, which was defined as a total Mayo score of ≤2, with no sub-score ≥1 and a rectal bleeding sub-score of 0. Alternatively, the reported clinical remission rates were assessed based on the diagnostic criteria. The secondary outcome was the clinical response, Chinese medical syndrome scores, Mayo (endoscopy) scores, and incidence of adverse events. Clinical response was evaluated in terms of basic or complete disappearance of clinical symptoms. Adverse events during the intervention period included infections that required treatment, hospitalization or surgery, or death.
The meta-analysis was performed with RevMan 5.3.5 (The Cochrane Collaboration) using the risk ratio (RR) and mean differences (MD). If heterogeneity (I2 > 50%) existed between different treatment groups in the included studies, the random-effects model was adopted for the calculation of overall mean differences and the corresponding 95% confidence intervals. Otherwise, calculations were performed using the fixed-effects model. Differences were considered statistically significant when
All components in Kushen were retrieved from the TCM Systems Pharmacology (TCMSP) database (
The Component-Target (C-T) network of Kushen against UC/DHAS was established by using the Cytoscape v.3.7.0 software (
All the candidate components and genes were further assessed via pathway enrichment analysis (Kyoto Encyclopedia of Genes and Genomes, KEGG). The system R3.5.0 was utilized to detect the potential pathways of candidate genes of UC-related and DHAS-related targets. The top 20 terms of both highly enriched pathways were imported into Cytoscape for visualization of the Component-Target-Pathway (C-T-P) network of Kushen against UC/UC with DHAS. The “Network Analyzer” function of Cytoscape was also employed for exploration of the key targets, components, and pathways with the greatest degrees.
A total of 1,108 articles were returned by the preliminary search. The title, abstract, and introduction of each article were read to exclude reviews, case reports, animal experiments, duplicate articles, and other articles that did not fulfill the inclusion and exclusion criteria. After the full text of the 22 articles that were preliminarily included had been read, eight published RCTs were ultimately included in the meta-analysis (
Flow diagram of the literature screening and study selection.
Characteristics of included studies.
Study | Sample size | Intervention measures | Administration | Duration (Western medicine/TCM) | No. of adverse events (treatment group/control group) | No. of withdrawals (treatment group/control group) | ||
---|---|---|---|---|---|---|---|---|
Treatment group | Control group | Treatment group | Control group | |||||
|
60 | 60 | Compound Kushen Enteric Capsule | 5-ASA | Oral | Mild, moderate, severe UC/Damp-heat accumulation syndrome | 0/6 | — |
|
45 | 40 | Kushen |
5-ASA | Enema | Mild, moderate UC/Damp-heat accumulation syndrome | 3/10 | — |
|
48 | 48 | Retention Enema with TongGuan Solution | 5-ASA | Enema | Chronic UC/ Damp-heat accumulation syndrome | 0 | — |
|
30 | 30 | Kushen |
5-ASA | Enema | Mild, moderate, recurrent UC/ Damp-heat accumulation syndrome | 0/1 | — |
|
240 | 80 | Fufangkushen Colon-coated Capsule | 5-ASA | Oral | Mild, moderate, severe UC/Damp-heat accumulation syndrome | 38/10 | 35/18 |
|
120 | 40 | Composite Sophora Colon-Soluble Capsules | 5-ASA | Oral | Mild, moderate, severe UC/Damp-heat accumulation syndrome | 2/2 | 20/4 |
|
30 | 28 | Baiji Kusen Decoction+5-ASA | 5-ASA | Enema | Mild, moderate, severe UC/Damp-heat accumulation syndrome | 0 | — |
|
42 | 42 | Composite Sophora Colon-Soluble Capsules | 5-ASA | Oral | Mild, moderate, severe UC/Damp-heat accumulation syndrome | 2/2 | 1/1 |
5-ASA, 5-aminosalicylic acid therapy.
A total of 983 subjects were included in the selected RCTs. There were no differences in the baseline data of the treatment and control groups. The treatment regimens for the control and treatment groups were conventional Western drugs (5-ASA) and Kushen-based TCM formulations, respectively. Among all included trials, Kushen-based TCM formulations were prescribed with direct action on the local target tissues of the colon by oral administration of colon enteric-coated capsules (4 trials) or enema administration (4 trials). The general data of the included studies and the components and types of the TCM formulations used are detailed in
Data regarding Kushen-containing TCM formulations.
Study | TCM formulations | Components |
---|---|---|
|
Compound Kushen Enteric capsule | Kushen (radix sophorae flavescentis), Diyu (the root of |
|
Kushen |
Kushen, raw Diyu, Xianhecao (aboveground parts of |
|
Retention enema with TongGuan solution | Kushen, Huangbai (Phellodendron bark), Baiji, alum, Xueyutan (carbonized hair), Chuanxinlian (aerial parts of |
|
Kushen |
Kushen, Huangbai, Diyu, Baiji, powdered Sanqi, Xileisan (a compound TCM herbal preparation) |
|
Fufangkushen Colon-coated capsule | Kushen, diyu, qingdai, baiji, raw gancao |
|
Composite Sophora Colon-soluble capsules | Kushen, Diyu, Qingdai, Baiji, raw Gancao |
|
Baiji Kusen decoction + S | Kushen, baiji, baizhu (rhizome of |
Zhike (immature bitter orange peel), Yingsuke (opium poppy husk), Paojiang (roasted ginger) | ||
|
Composite Sophora Colon-soluble capsules | Kushen, Diyu, Qingdai, Baiji, raw Gancao |
Risk of bias summary.
The comparisons of clinical remission rates between the treatment and control groups were reported in all the included studies (
Forest plot for the meta-analysis of clinical remission rates.
The comparisons of clinical response rates between the treatment and control groups were reported in all the included studies (
Forest plot for the meta-analysis of Clinical response rates.
Chinese medical syndrome scores were provided in three studies (
Forest plot for the meta-analysis of Chinese medical syndrome scores.
Mayo (endoscopy) scores were provided in two studies (
Forest plot for the meta-analysis of Mayo (endoscopy) scores.
The occurrence or non-occurrence of adverse events after treatment was reported in all studies. Non-occurrence of adverse drug reactions was reported in two studies (
Forest plot for the meta-analysis of adverse drug reaction rates.
A total of 22 candidate bioactive components from Kushen were obtained from the TCMSP database (
Chemical properties of the components of Kushen with OB ≥ 30% and a DL index ≥0.18.
Parameter | Min | Max | Mean | Std. Deviation |
---|---|---|---|---|
OB | 32.04 | 97.27 | 53.8624 | 13.66713 |
DL | 0.18 | 0.76 | 0.3582 | 0.17403 |
MW | 244.37 | 580.59 | 311.2391 | 91.10597 |
AlogP | −0.87 | 8.62 | 1.9693 | 1.65912 |
Hdon | 0 | 7 | 1.89 | 1.910 |
Hacc | 3 | 14 | 5.07 | 2.742 |
OB, Oral bioavailability; DL, Drug-likeness; MW, Molecular weight; AlogP, Partition coefficient between octanol and water; Hdon, hydrogen-bond donors; Hacc, hydrogen-bond acceptors.
Overlapping targets of Kushen against (ulcerative colitis) UC and (damp-heat accumulation syndrome) DHAS related genes.
The C-T network contained 91 nodes (22 components, 63 gene targets, and six disease labels) and 292 edges, indicating the component-target interactions of Kushen against UC/UC with DHAS TCM symptoms (
PPI networks of (ulcerative colitis) UC and UC with (damp-heat accumulation syndrome) DHAS related targets.
Top five components of Kushen in degrees from Network Analyzer.
Molecular ID | Molecule name | OB (%) | DL | Degree |
---|---|---|---|---|
MOL000098 |
|
46.43 | 0.28 | 69 |
MOL000006 |
|
36.16 | 0.25 | 31 |
MOL005944 |
|
63.77 | 0.25 | 13 |
MOL000392 |
|
69.67 | 0.21 | 12 |
MOL000456 |
|
78.2 | 0.73 | 10 |
The topological parameters of UC with DHAS targets of Kushen from the String database (Top 10 in degrees).
Name | Description | Degree | Average shortest path length | Betweenness centrality | Closeness centrality |
---|---|---|---|---|---|
IL6 | Interleukin-6 | 6 | 1.25 | 0.39285714 | 0.8 |
MYC | Myc proto-oncogene protein | 5 | 1.375 | 0.19642857 | 0.72727273 |
CCND1 | G1/S-specific cyclin-D1 | 5 | 1.375 | 0.19642857 | 0.72727273 |
ICAM1 | Intercellular adhesion molecule 1 | 5 | 1.375 | 0.14285714 | 0.72727273 |
SELE | E-selectin | 3 | 1.875 | 0 | 0.53333333 |
VCAM1 | Vascular cell adhesion protein 1 | 3 | 1.875 | 0 | 0.53333333 |
BCL2 | Apoptosis regulator Bcl-2 | 2 | 2.125 | 0 | 0.47058824 |
CHEK2 | Serine/threonine-protein kinase Chk2 | 2 | 2.125 | 0 | 0.47058824 |
NR3C2 | Mineralocorticoid receptor | 1 | 2.125 | 0 | 0.47058824 |
The topological parameters of UC targets of Kushen from the String database (Top 10 in degrees).
Name | Description | Degree | Average shortest path length | Betweenness centrality | Closeness centrality |
---|---|---|---|---|---|
VEGFA | Vascular endothelial growth factor A | 45 | 1.26229508 | 0.10527857 | 0.79220779 |
CASP3 | Caspase-3 | 44 | 1.27868852 | 0.07339591 | 0.78205128 |
IL6 | Interleukin-6 | 43 | 1.29508197 | 0.10311185 | 0.7721519 |
EGFR | Epidermal growth factor receptor | 41 | 1.32786885 | 0.04501933 | 0.75308642 |
ESR1 | Estrogen receptor | 40 | 1.3442623 | 0.05122988 | 0.74390244 |
MYC | Myc proto-oncogene protein | 40 | 1.3442623 | 0.04340003 | 0.74390244 |
CCND1 | G1/S-specific cyclin-D1 | 38 | 1.37704918 | 0.02824009 | 0.72619048 |
ERBB2 | Receptor tyrosine-protein kinase erbB-2 | 32 | 1.47540984 | 0.02728821 | 0.67777778 |
FOS | Proto-oncogene c-Fos | 31 | 1.49180328 | 0.03609432 | 0.67032967 |
MDM2 | E3 ubiquitin-protein ligase Mdm2 | 29 | 1.54098361 | 0.01135205 | 0.64893617 |
KEGG pathway enrichment analyses were performed using R3.5.0. Among the 103 enriched KEGG pathways of UC-related targets that met the requirements of Adjust
Detailed information of Kushen-related KEGG pathways against UC targets (Top 10 in Gene Ratio).
ID | Term | Gene Ratio | Count | Related targets | Adjust |
---|---|---|---|---|---|
hsa05205 | Proteoglycans in cancer | 16/63 | 16 | CASP3, CAV1, CCND1, CD44, EGFR, ERBB2, ERBB3, ESR1, HIF1A, HPSE, IGF2, MDM2, MYC, PLAU, RAF1, VEGFA | 1.47E−10 |
hsa04151 | PI3K-Akt signaling pathway | 16/63 | 16 | BCL2, CASP9, CCND1, EGFR, ERBB2, ERBB3, GSK3B, IGF2, IL6, MCL1, MDM2, MYC, NOS3, RAF1, RELA, VEGFA | 7.51E−08 |
hsa05167 | Kaposi sarcoma-associated herpesvirus infection | 15/63 | 15 | CASP3, CASP8, CASP9, CCND1, FOS, GSK3B, HIF1A, ICAM1, IL6, MYC, NFKBIA, RAF1, RB1, RELA, VEGFA | 3.65E−10 |
hsa05163 | Human cytomegalovirus infection | 15/63 | 15 | CASP3, CASP8, CASP9, CCND1, EGFR, GSK3B, IL6, MDM2, MYC, NFKBIA, PTGER3, RAF1, RB1, RELA, VEGFA | 3.40E−09 |
hsa05215 | Prostate cancer | 13/63 | 13 | BCL2, CASP9, CCND1, EGFR, ERBB2, GSK3B, GSTP1, MDM2, NFKBIA, PLAU, RAF1, RB1, RELA | 4.80E−11 |
hsa05418 | Fluid shear stress and atherosclerosis | 13/63 | 13 | BCL2, CAV1, FOS, GSTM1, GSTP1, ICAM1, NFE2L2, NOS3, NQO1, RELA, SELE, VCAM1, VEGFA | 1.32E−09 |
hsa05161 | Hepatitis B | 13/63 | 13 | BCL2, BIRC5, CASP3, CASP8, CASP9, FOS, IL6, MYC, NFKBIA, PCNA, RAF1, RB1, RELA | 5.27E−09 |
hsa05169 | Epstein-Barr virus infection | 13/63 | 13 | BCL2, CASP3, CASP8, CASP9, CCND1, CD44, ICAM1, IL6, MDM2, MYC, NFKBIA, RB1, RELA | 4.61E−08 |
hsa05206 | MicroRNAs in cancer | 13/63 | 13 | BCL2, CASP3, CCND1, CD44, EGFR, ERBB2, ERBB3, MCL1, MDM2, MYC, PLAU, RAF1, VEGFA | 3.19E−06 |
hsa04210 | Apoptosis | 12/63 | 12 | BCL2, BIRC5, CASP3, CASP8, CASP9, CTSD, FOS, MCL1, NFKBIA, PARP1, RAF1, RELA | 8.34E−09 |
Components-targets-pathways network of Kushen. The top 20 enriched KEGG pathways of (ulcerative colitis) UC and UC with (damp-heat accumulation syndrome) DHAS were integrally submitted to Cytoscape for Kushen C-T-P network constructions with nine common pathways of UC and DHAS, 11 unique UC-related pathways, and 11 unique DHAS-related pathways. The yellow, pink, and blue vees represent pathways of unique UC-related pathways, common pathways, and unique DHAS-related pathways, respectively. The red, blue, yellow, and green ellipses represent the disease UC, the TCM symptoms of DHAS, components of Kushen, and targets of Kushen, respectively.
UC is a disease featuring immunological disorders in the intestinal tract caused by chronic intestinal inflammation, characterized by recurring episodes of inflammation and a relatively long disease course. It is currently believed that a key factor in the onset and development of UC is immune dysfunction in the intestinal mucosa, which was widely recognized as being associated with multiple cellular immune responses and dysbiosis (
Based on the TCM theory, UC consists of several types of TCM syndromes, most of which (34.8%) are for the DHAS, and Kushen (Radix
Kushen is a kind of Chinese herbal medicine commonly used to treat UC with DHAS that exerts extensive influence in anti-inflammatory, immunosuppression, and antibacterial functions (
In the present meta-analysis, a total of eight studies were included, among which three were multi-center clinical studies. Kushen-based TCM formulations were delivered site-specifically to the disease focus of UC directly in all included trials (four studies utilized oral colon enteric-coated capsules, four studies utilized enema administration). Results of the analysis showed that Kushen-based TCM formulations used alone or in combination with 5-ASA for the treatment of UC with DHAS led to a significantly higher clinical remission rate and lower incidence of adverse events in the treatment groups than in the control groups.
However, among the eight studies analyzed in this work, it should be noted that only three had clearly stated the enforcement of blinding, allocation concealment, and the reasons for subject withdrawal. Other articles were of lower quality as blinding and subject withdrawal had not been reported. Moreover, the result of clinical remission rates showed relatively high heterogeneity (
Based on the evidence of this meta-analysis, a network pharmacology approach was employed to illuminate the exact mechanism underlying the effects of Kushen on UC with DHAS with multiple components and targets. Based on the data retrieved from the SymMap and GeneCards database,
To the best of our knowledge, this was the first attempt to track targets of UC with DHAS for further analysis of its interaction with herbal bioactive components. This analysis was based on a recently presented database, SymMap, which integrates TCM with modern medicine both at the molecular and phenotypic levels (
However, besides quality of evidence, several other limitations are included in the present study. First, some possibilities may exist that the supplementary herbal medicines (prescribed for secondary syndromes treatment or toxicity reduction with small dosage) in the Kushen-based TCM formulations may exert positive effects. Second, pharmacology analysis was mainly employed to show a synergistic action of herbal chemical components acquired through existing databases rather than experimental verification, which needs further validation in future research.
In conclusion, Kushen-based TCM formulations provide good efficacy and possess great potential in the treatment of UC. A major pathway (PI3K-Akt signaling pathway) of Kushen against DASH-UC was predicted from the results of network pharmacology analysis. This study presented an effective Chinese herbal medicine, Kushen, for UC with DHAS treatment, with a new prospect integrating meta-analysis and network pharmacology investigation for exploring the actual efficacies and mechanisms between diseases and TCM syndromes in more detail.
The original contributions presented in the study are included in the article/
Conceptualization: ZT. Data analysis: MC and YD. Writing – original draft: MC. Writing – review and editing: MC and YD.
This study was supported by the National Natural Science Foundation of China (No. 81673965). The funding agency was not involved in any aspect of the study design, data collection, data analysis, or manuscript writing.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The Supplementary Material for this article can be found online at:
DHAS, damp-heat accumulation syndrome; TCM, traditional Chinese medicine; UC, ulcerative colitis.