Nghiên cứu độc tính, tác dụng của “hoàn chỉ thống” trong điều trị bệnh lý viêm khớp dạng thấp trên thực nghiệm và lâm sàng tt tiếng anh

INTRODUCTION Rheumatoid arthritis is a bone and joint disease found everywhere in the world, accounting for about 1% of the population In Vietnam, the rate of rheumatoid arthritis accounts for 0.5% of the population and 20% of arthritis diseases Rheumatoid arthritis is prolonged, alternates with acute attacks, causes disability, and greatly affects work performance and daily life The treatment of rheumatoid arthritis requires a combination of different methods: internal medicine, physical therapies, rehabilitation, and surgery Researching to find an effective and less-side-effects medicination for the treatment of rheumatoid arthritis has been being a target for researchers There is no name for rheumatoid arthritis disease in traditional medicine The symptoms of rheumatoid arthritis in traditional medicine belong to the category of pain due to stasis, such as, acute arthritis, crane knee arthritise, etc Traditional medical literature has mentioned the causes, mechanisms of pathogenesis, treatment methods for rheumatoid arthritis ‘Hoan chi thong’ remedy is a herbal product made of Tinospora sinensis, Gnetum montanum Mgf, Angelica dahurica, Achyranthes bidentata, Cinnamomum, and Sargentodoxa cuneata According to the traditional medicine theory ‘Hoan chi thong’ remedy has the effects dispelling wind evil, removing dampness, activating blood, activating and smoothing meridians, tonifying blood qi, nourishing liver and kidney, antiinflammatory, analgesic, the medicine is indicated to treat the osteoarthritis including rheumatoid arthritis However, there are no scientific studies evaluating the treatment effects of rheumatoid arthritis of the drug ‘Hoan chi thong’ Therefore, we carry out this research with the following objectives: Assessing the acute and semi-chronic toxicity of ‘Hoan chi thong’ in experiment 2.Evaluating the analgesic and anti-inflammatory effects of ‘Hoan chi thong’ in experiment Evaluating the therapeutic effects and undesirable effects of ‘Hoan chi thong’ on patients with rheumatoid arthritis stage and PRACTICAL MEANINGS AND NEW CONTRIBUTION OF THE THESIS The rapid development of economy, society, and disease patterns in Vietnam has changed markedly in recent years, from infectious diseases to non-communicable diseases Rheumatoid arthritis is a cause of complicated consequences for joints and disability, which affects work efficiency and daily life Modern medicine has shown a positive role and effectiveness in the treatment of rheumatoid arthritis, but it also causes some side effects of peptic ulcer, gastrointestinal bleeding, osteoporosis, etc Therefore, searching for effective and safe herbal medicines is always a need and is of interest to national and international scientists The scientific work of the thesis is experimentally and clinically organitinal and systematical The research and application of the medicine contribute to the clarification of traditional medicine theory and gradually modernize traditional medicine and is a scientific and practical work STRUCTURE OF THE THESIS The thesis consists of 123 pages, of which: Introduction: 02 pages; Overview: 37 pages; Research subjects and methods: 18 pages; Research results: 28 pages; Discussion: 35 pages; Conclusion: 02 pages Recommendations: 01 page The thesis has 120 references (48 in Vietnamese, 37 in English, and 35 in Chinese), 43 tables, 12 charts, 04 diagrams, 02 pictures, 12 photos and appendices Chapter OVERVIEW 1.1 Rheumatoid arthritis from the modern medical perspective Rheumatoid Arthritis:Rheumatoid Arthritis is an autoimmune pathology characterized by chronic inflammatory processes of joints, if it is not treated thoroughly or properly, joint disfigurement, deformation, and loss of motor movement would be consequences Rheumatoid arthritis develops complicatedly over many stages, in addition to presenting at joints, it might exist in the whole body at different degrees Rheumatoid arthritis can also cause damage to organs such as heart (pericarditis, endocarditis, myocarditis, arrhythmia, etc.), respiratory system (pleural effusion, fibrosis, etc), nerves (carpal tunnel syndrome), etc Cause: The cause of the disease is not clear, modern medicine has recently considered rheumatoid arthritis as an autoimmune disease with the participation of many factors A number of common viruses or bacteria affect the favorable atopic and genetic factors Rheumatoid arthritis has a family nature Pathogenesis: rheumatoid arthritis is an autoimmune disease, characterized by chronic inflammatory reactions that damage synovial membranes, cartilage and bone at inflamed joints Although the etiology of the disease is still unclear, new knowledge on immunology and molecular biology has contributed to further elucidation of the mechanism of rheumatoid arthritis Diagnosis standards: rheumatoid arthritis is diagnosed by a variety of criteria over time, such as the American college of Rheumatology: ACR, 1958, and the Roman standard (1961) By 1987, the American Association of Rheumatology had agreed to improve the diagnostic criteria for ACR (1987), including factors that are still widely applied in the world 1.2 Rheumatoid arthritis according to traditional medicine * Reasons Traditional medicine believes that the main causes of the disease is due to qi deficiency and evil qi Yang qi deficiency, weakend protective qi, and opening pores lead to wind, cold, wetness evils invading muscles, meridians, and joints), which causes diseases * Pathogenesis mechanism - Onset of the disease: due to external evils, either wind cold wetness evils or wind wetness heat evils, initially, the disease is acute The basic manifestations are muscle aches and pains, numbness in the limbs, limited joint activities and the whole body feeling heavy, etc - Positions: mainly in muscles, meridians, and joints Since liver determines tendon, spleens determine muscles, and kidney determines bones, the diease is closely related to these organs Prolonged disease will affect heart and kidneys, or even all the five organs - The nature of the disease: the onset or progression of the diease is mainly caused by wind, cold, wetness, heat or blood stastic, dyslipidemia ,mostly of plenitude sthenia syndrome In the late stage, there is often the presence of yin qi deficiency, or damages of kidney and liver accompanied by phlegm stagnation, which causes asthenia accompanied with plenitude, of which the manifestation is plenitude sthenia syndrome * Types of diseases according to traditional medicine - Wind wetness type: aches and pains in musles and joints, dull pains, unpleasant feeling of heaviness, painful points are not fixed; May be accompanied by swelling; Limited joint muscle movements; The onset of the disease is most frequently accompanied by diseases of superficies such as fear of wind, fever, pale tongue; Whitish tongue moss; Floating moderate pulse or solf moderate pulse - Cold wetness type: limbs, body, muscles, and joints feel cold and painful; Feelings of heavy, irritated, and uncomfortable; The disease is more severe at night than day, the pain increases when it’s cold, and hot compresses may help with pain; At swollen joints , there are stiff and limited joint movements; non reddish color and non burning skin Whitish tongue moss; Tense taut pulse or tense moderate pulse - Wetness heat type: joints are swollen, burning, reddish, and painful; Feeling heavy, accompanied by fever, thirst but not want to drink water; Feeling irritated and uncomfortable, yellowish urine, limited joint movements; There are benign tumors under the skin; Redish tongue, yellowish tongue moss; Rapid soft pulse or rapid taut pulse - Phlegm stasis type: patients with prolonged illness feel severe pain like needle pricking, joints become swollen, bruised, and deformed; Joint movements are limited; There are benign tumors under the skin;Tongue is purplish with rashes, white viscous moss; Rapid fine taunt deep pulse - Blood stasis type: Muscle aches and pains like needle pricking; Pain points are often fixed; Irritated pain persists; swelling, rashes or benign tumors under the skin; Dark face and dry skin; Dry mouth but unlike to drink; Purplish tongue with blood stasis spots, thin whitish and yellowish moss; Sluggish fine taut deep pulse - Blood qi deficiency type: swollen joints, aches, muscle atrophy, stiffness, deformed joints, limited joint movements; The disease is accompanied with dizziness, poor appetite, dry skin, or bleeing; There are benign tumors under the skin; The tongue is pale or redish or with cracks, thin whitish moss with little or no moss; Fine deep pulse or weak fine pulse - Liver-kidney deficiencyn type: swollen joints, aches, stiffness, muscle atrophy, deformed joints, limited joint movements; Accompanied with back and knee pain, afraid of cold, cold limbs, sleeplessness; Bone heat sydrome and hectic fever; Dry mouth but drink little or dislike to drink water Reddish or pale tongue, thin tongue moss, Weak taut deep pulse or rapid taut pulse * Research remedies ‘Hoan chi thong' is produced by the Military Traditional Medicine Institute under a science and technology project of the Ministry of Defense It includes Tinospora sinensis, Gnetum montanum, Angelica dahurica, Achyranthes bidentata, Cinnamomum, and Sargentodoxa cuneata They are common ingredients used in the treatment of osteoarthritis diseases such as: osteoarthritis, rheumatoid arthritis, gout, etc The remedy has the effects dispelling wind evil, removing dampness, activating blood, activating and smoothing meridians, tonifying blood qi, and nourishing liver and kidney, anti-inflammatory, analgesic, and it is indicated to treat the osteoarthritis including rheumatoid arthritis Chapter SUBJECTS AND METHODS OF THE STUDY 2.1 Research material Research medication: 'Hoan chi thong' is produced by the Faculty of Pharmacy, the Military Traditional Medicine Institute, is formulated to soft medicated balls, and weighs 8.5g/ ball The medication meets the standardsof the institute Research materials: Aspirin, prednisolone, carrageenin solution, formaldehyde, amiant fiber, etc 2.2 Research subjects 2.2.1 Research on animals - Swiss white mice, both sexes, healthy, weigh 25 ± 2g, provided by the National Institute of Hygiene and Epidemiology - White rats of the Wistar strain, both sexes, healthy, weigh 150 - 180g, provided by the Military Medical Academy 2.2.2 Clinical research - Rriteria to selecting patients: the patients diagnosed with rheumatoid arthritis according to the standards of the American Association of Rheumatology and the European Anti-Rheumatology Federation 2010 ACR / EULAR 2010 If the patient has at least 4/7 criteria and clinical symptoms that persist for more than weeks, they are diagnosed with rheumatoid arthritis Selected patients who meet the criteria for diagnosis according to modern medicine as above and in accordance with the evidence diagnosis of traditional medicine The patients were examined according to methods of examination: inspection, listening and smelling, questioning, and palpation the symptoms were devided into two main categories: wind cold wetness type and wind wetness heat type - Criteria to excluding patients: Patients with liver, kidney, and infectious diseases, diseases of the hematopoietic system, diabetes and those who suffer from mental neurological diseases, sensory disorders, cancer, etc 2.2.3 Location, study time The experimental and clinical research was conducted at the Military Traditional Medicine Institute, from February 2015 to November 2017 2.3 Research Methods 2.3.1 Acute and semi-chronic toxicity study Acute toxicity: The acute toxicity is determined in accordance with the guidelines of the Ministry of Health and OECD on the white mice by oral route, with groups of 10 heads each, receiving reagents in increasing doses from 12.2g/kg to 61g/kg (maximum tolerable dose for mice) the general condition of the rats and the number of dead mice in each group were monitored in 72 hours (mice that died within the first 24 hours were operated for the macro image observation) ) The calculation of LD50 was done by Litchfield-Wilcoxon method The study on the chronic toxicity was under the regulations of the Ministry of Health of Vietnam and the guidance of OECD and WHO 'Hoan chi thong' was taken orally by white rats 30 experimental mice were divided into groups of 10 heads each; the control group drank distilled water at a dose of ml/kg/day; the research group took 'Hoan chi thong' 4.8g/kg (equivalent to the human dose), the research group took the 'Ha mo mau' nuggets 14.4g/kg/day (equivalent to times the human dose) Monitoring criteria: The general condition and body weight of white rats The evaluation of hematopoietic function, assessment of liver and kidney function, liver histopathology, kidney rats' kidney Evaluation time: before the treatmemt, after weeks, and weeks of the treatment 2.3.2 Experimental research on the analgesic and anti-inflammatory effects - Studying the etopic analgesic effect by Koster method - Studying the central analgesic effect using hot plate - Studying the acute anti-inflammatory effects on edema-induced by carrageenin model - Studying the acute anti-inflammatory effect on the peritonitis-induced model - Studying the acute anti-inflammatory effect on the vascularpermeability-inhibition model: Assessing the acute anti-inflammatory effect on Anderson K.W.-vascular-permeability-suppression model - Studying the chronic anti-inflammatory effects on Ducrot R., Julon L et al granulomatous model (1965) 2.3.3 Studying the effect of ‘Hoan chi thong’ clinically Research design: clinical trial, cross-sectional description with intervention, vertical monitoring Compare results before and after the treatment The treatment: 60 patients with rheumatoid arthritis took balls of 'Hoan chi thong' daily, in the morning and in the afternoon; hour after eating, the duration of treatment is 30 consecutive days Patients with chronic cardiovascular disease, blood pressure are allowed to use specialized drugs prescribed by a doctor Patients with severe pain who are recommended to use painkillers should receive Celebrex 200mg Clinical and subclinical research criteria * Diagnosis of rheumatoid arthritis: under the EULAR/ACR 2010 standards * Monitoringthe criteria according to traditional medicine: Classifying the patients according to the clinical form of wind cold wetness type and wind wetness heat type After the clinical classification, comparing the responses of patients in these two groups to the assessment criteria of rheumatoid arthritis in modern medicine * Subclinical monitoring criteria: - Hand pressure is measured by a Japanese hand dynamometer When being measured, the patient's arms were spreaded horizontally, three times each hand and the highest results were taken The unit of calculation is kg Blood test: red blood cell count, white blood cell count, white blood cell count, platelet count, hemoglobin, sedimentation rate Biochemistry: glusose, total protein, AST, ALT, GGT, total bilirubin, urea, creatinine, uric acid - Testing for rheumatoid factor (RF), quantification of CRP - 10-parameter urine tests by automated machine; Heart X-ray, joint Xray, abdominal ultrasound, ECG * Assessing unwanted effects: Monitoring clinical undesired effects such as headache, dizziness, nausea, loose stools, rashes, abdominal pain, joint pain increase * Data processing: The data collected in the study was processed by the biomedical statistical method using SPSS 22.0 software * Ethics in the research: the research is conducted under the Scientific and Ethical Council of the Military Institute of Traditional Medicine, the patients understood and voluntarily participated in the research, all the patients’ personal information kept confidentially, only aggregated results are published Chapter RESULTS 3.1 Acute and semi-chronic toxicity study results The 50% lethal dose (LD50) of ‘Hoan chi thong’ at a dose of 61g/kg was not determined (the highest dose likely to be given to rats under laboratory conditions) * The results of the semi-chronic toxicity evaluation - The effects of ‘Hoan chi thong’ on the general conditions and weight change of white rats after taking the medicine: during the experiment, the experimental mice in all groups were normal and agile, had silky hair, good appetie, and firm feces After weeks and weeks of reagents, the weight of mice in all groups (01 control and research groups) was higher than that of the before-test (p 0.05) - Effects on the hematological indicators: There were no differences in the number of erythrocytes, hemoglobin content, white blood cells, and platelets, hematocrit concentration, and the percentage of neutrophils and lymphocytes between the control group and the research groups and between research groups at the same testing times (p> 0.05) - Effects on the liver function: There are no differences in the acctivity of AST, ALT, total bilirubin enzymes in white rats blood between the control group and the research groups and between research groups at the same testing times (p> 0.05) - Effects on the kidney function:There are no differences in the urea concentration and serum creatinine concentration of rats between the control group and the research groups and between research groups at the same testing times (p> 0.05) * The changes in the histopathology - Macro image: There are no differences in the macroscopic morphology of kidney between the control group and the research groups and between reaserach groups at the same testing times Smooth kidney surface, evenly shinny, reddish-brown color can be seen and there were no bleeding and elastic when being pressed - Liver microscopic morphology (HEx400): Control group Research group Research group The HEx400 image showed that Remak was formed in central vein of the liver cells The image of broken or dissolved liver cells were not seen The images of hemorrhage or necrosis in the lobes of the uterus were not seen Conclusion: Normal liver images The liver microscopic morphology images in the study groups were not different from the control group - The microscopic morphology images of kidney (HEx400): Control group Research group Research group The HEx400 kidney microscopic morphology images of the control group showed glomerular, Bowman cavity, capillary coil, and tubule The nucleus of the glomerular cells and tubular became dark Glomerular and tubular lesions were not seen Conclusion: Normal kidney images The Micrograph of kidney in the study groups were not different from that of the control group 3.2 Results of the pharmacological effects evaluation 3.2.1 Results of empirical analgesic effect evaluation * Peripheral analgesic effect by the acetic acid pain induced method minutes after the injection, the pain of mice in the Aspirin group dose 100mg/kg and ‘Hoan chi thong' dose 6.8g/kg group decreased significantly compared to the other two groups (p 0.05) After taking the medicination, the reaction time of mice in the codeine phosphate group was significantly longer than the ‘Hoan chi thong' and the distilled water group (p 0.05) ) * Acute anti-inflammatory effect on the peritonitis caused by carrageenin + formaldehyde solution model Table 3.2 The effect of ‘Hoan chi thong’ on the inflammatory exudate test criteria Groups Inflammatory Proteincontent exudate (ml) (mg/dl) Group 1: distilled water 4.90  0.70 ml/100g Group 2: aspirin 150 2.05  0.69* mg/kg Group 3: HCT 4.8 g/kg 2.06  0.51* Group 4: HCT 9.6 g/kg 3.69  0.42*▲■ 10 White blood cells (K/ul) 5.53  0.51 13.82  3.36 2.90  0.42* 6.76  0.76* 3.16  0.37* 5.04  0.35*▲■ 7.01  0.98* 10.89  2.80▲■ Comments:The ‘Hoan chi thong’ dose of 4.8 g/kg body weight reduced inflammatory exudate, reduced protein content in the exudate and reduced the number of white blood cells in inflammatory exudate compared to the control group (p 0.05) * The anti-acute inflammatory effect on the vascular permeability inhibited model Table 3.3 Effect of ‘Hoan chi thong’ on the concentration of abdominal fluid Group Pigment concentration Group 1: distilled water0.2ml/10g body weight Group 2: Aspirin 200mg/kg body weight Group 3: ‘Hoan chi thong’ 6.8 g/kg 0.272  0, 0.125  0.088* 0.180  0.048*▲ Comments: ‘Hoan chi thong’dose of 6.8g / kg body weight had the effect of inhibiting the amount of pigment released from the lumen of the blood significantly better than that of the control group, the difference was statistically significant with p