* Drugs for dyslipidemia treatment according to modern medicine: Based on the mechanism of action, drugs for dyslipidemia treatment aredivided into 2 main groups as follows:... - The gro
Trang 1Cardiovascular disease has been a major health concern in the world,with the leading cause of mortality and disability According to estimates by theWorld Health Organization, there are about 17 million people died fromcardiovascular disease every year, mainly caused by atherosclerosis
Dyslipidemia pattern is one of the most important risk factors but avariable risk factor for the formation and development of atherosclerosis.Modern medicine has many drugs used to treat dyslipidemia, but some of themalso have undesirable effects such as muscle pain, muscle cramps, impairedliver function, etc
HVT remedy is made up of three commonly used medicinal herbs:
Folium Nelumbinis nuciferae, Cleistocalyx operculatus Roxb and Pericarpium Citri reticulatae perenne, are prepared into liquid form which act on improving
healthy qi, resolving phlegm-dampness and fortifying the spleen Currently,there are no studies evaluating the effects of treatment of HVT on dyslipidemiapattern To demonstrate the effects and toxicity of HVT, as a scientific basistowards the ability to widely use this product in clinical practice, we conductthe research on the topic “A study on the toxicity and effectiveness of HVTliquid drug on dyslipidemia pattern” with the following goals:
1 To study the acute toxicity and semi-chronic toxicity of liquid HVT
2 To study the effect of dyslipidemia adjustment of liquid HVT inexperimental animals
3 To evaluate the therapeutic effects and unwanted effects of liquid HVT
in patients with dyslipidemia caused by internal phlegm-dampness
PRACTICAL SIGNIFICANCE AND NEW CONTRIBUTIONS
OF THE STUDY Practical significance
Although the treatment of dyslipidemia with modern medicine iseffective, it also causes some unwanted effects Therefore, the search forremedies derived from herbs, with few tastes, effective and safe is always anecessity as well as a research direction that is of interest to domestic andinternational scientists
Scientific significance
The dissertation has been systematically studied in both experimentaland clinical practice The drug is produced in liquid form with ingredients ofthree traditional medicine drugs which are originated from Vietnamesetraditional medicinal drugs, easy to find and convenient for use in treatingdyslipidemedia The study has provided scientific evidence on the effect of
Trang 2dyslipidemedia adjustment as well as unwanted effects (if any) on experimentaland clinical issues.
The applied research of a remedy in treatment has made a contribution
to the clarification of the theory of traditional medicine At the same time,gradually modernizing traditional medicine is also a scientific and practicalsignificance
ORGANIZATION OF THE STUDY
The dissertation consists of 128 pages, of which: Rationale (2 pages), Literaturereview (32 pages), Subjects and research methods (18 pages), Research results(43 pages), Discussions (30 pages), Conclusions (2 pages), Recommendations(1 page) There are 145 references used in the study, of which there are 53documents in Vietnamese, 92 documents in English and 2 documents inChinese The dissertation has been presented and illustrated through 61 tables, 9charts, 18 pictures, 5 diagrams and appendices
Chapter 1 LITERATURE REVIEW 1.1 Dyslipidemia from modern medicine point of view.
1.1.1 Definition of dyslipidemia
Dyslipidemia is a condition of the increase of either total cholesterol (TC) ortriglyceride (TG) or both, or the decrease of high-density lipoprotein cholesterol(HDL-C), or the increase of low-density lipoprotein cholesterol (LDL-C) whichincreases the process of atherosclerosis
1.1.2 Causes of dyslipidemia
The cause of dyslipidemia can be primary (due to genetic diseases) orsecondary (due to eating habits, lifestyles or some pathologies) Secondary causesmay contribute to dyslipidemia due to the causes of the primary which becomemore severe
1.1.3 Treatment of dyslipidemia
* Treatment principles:
- Lifestyle changes (proper diet, exercise regime) are the basic and coreproblem in treatment The time to evaluate the effectiveness of lifestyle changes isusually 2-3 months
- Medications when needed
- Treatment goals based on tests and assessments of patient risks, in whichLDL-C is recommended as the first treatment target TC is the target for treatment
if there are no other tests, while non-HDL-C or ApoB is the second target
* Drugs for dyslipidemia treatment according to modern medicine:
Based on the mechanism of action, drugs for dyslipidemia treatment aredivided into 2 main groups as follows:
Trang 3- The group that reduces lipid synthesis: Statins, fibric acid (Fibrat), andnicotinic acid (Niacin)
- The group that reduces absorption and increases lipid elimination: bile acidsequestrants (Resin), cholesterol absorption inhibitor (Ezetimib)
- In addition, some other drugs are used to treat dyslipidemia, such asPCSK9 inhibitors, MTP inhibitors, CETP inhibitors, and so on
1.2 Dyslipidemia from traditional medicine point of view.
1.2.1 Causes
In terms of traditional medicine, dyslipidemia is caused by the followingsyndromes: irregular congentinal factors, uncontrolled diet leading to spleen-stomach disharmony; internal injury leading to liver-gallbladder damage; thedebilitation of the elderly leading to the debilitation of source qi liver When thefunction of the viscera and bowels is disordered, it causes phlegm-dampnesspattern
1.2.2 Disease mechanism
The process of disease development consists of three stages:
- The dysfunction of spleen and kidney affects the metabolism of water andfood substances causing endogenous dampness turbidity pattern
- The function of damaged viscera and bowels causes endogenous dampness turbidity and pattern of depressed dampness transforming into heat.The symptom in this stage is phlegm turbidity depressing fire
phlegm The development of the disease causes binding of phlegm stasis, qidamage, yin damage, and yin-yang disharmony which can lead to a more seriouscondition and damage of the visceral organs, resulting in complications
1.2.3 Clinical classification in terms of traditional medicine
- Pattern of internal phlegm-dampness: Body obesity, headache, chest pain,
abdominal distention, nausea or vomiting, dry mouth without being thirsty, thinlimbs, heavy limbs, pale swollen tongue, white greasy coating tongue, slipperypulse
- Pattern of Phlegm-heat and fu-organ excess syndrome: Strong well-being,
heavy head, irritability, red face, red eyes, bitter mouth, tight chest,uncomfortable, indigestion, constipation, pink red tongue, yellow greasy coatingtongue, slippery pulse
- Pattern of Spreen-kidney yang deficiency: puffy face, pain in back and knees,
fear of cold, mental fatigue, indigestion, sloppy stool, night urination, paletongue, edge of tongue with teeth, thick white fur tongue, slow sunken pulse
- Pattern of liver-kidney yin deficiency: Pain in back and knees, irritable people,
head pain, dizziness, fatigue, tinnitus, nightly sweats, dry and thirsty mouth, redtongue, thin fur tongue, ripid fine pulse
Trang 4- Pattern of phlegm stagnation and blood statis: Fatty body, heavy and
numbness limbs, tight chest, headache, dizziness, purple fur & spotted tongue,thick fur tongue, strink-like and slippery pulse or rough pulse
- Pattern of liver depression and spleen deficiency: Tight pain in the edge of
ribs, unstable pain, headache, dizziness, irritability, poor appetite, mental fatigue,sloppy stool, menstrual disorders, pale tongue, thin fur tongue, strink-like pulse
1.3 Overview of therapeutic remedy research.
According to folk experiences and documents on traditional medicines, thereare many medicinal herbs, remedies for treatment of phlegm-dampness pattern,which are proved to be clinically effective in adjusting dyslipidemia Mostremedies have too many herbs or they derive from abroad, making it difficult forpatients to take drugs for the prolonged treatment HVT remedy is based on thetheory of traditional medicine and some studies of modern medicine on theeffectiveness of each herb HVT remedy is made up of Vietnamese medicinalherbs, so they are easy to find, easy to use and have been commonly used bypeople:
+ Folium Nelumbinis nuciferae which acts on upbearing the clear, dissipating
stasis, moving water, removing phlegm-dampness There have been manydomestic and foreign studies published results that Folium Nelumbinis nuciferaehas the effects of lowering blood pressure, lowering blood sugar, preventingobesity, adjusting dyslipidemia, so it has the effect of preventing atherosclerosis
+ Cleistocalyx operculatus Roxb is a drink that has been used for many
generations in Vietnam as well as in many countries around the world It has theeffect of fortifying the spleen and removing the excess There have been a lot ofstudies on Cleistocalyx operculatus Roxb which have found that it is not only ahealthy drink, but also significantly effective in many activities: anti-microbial,anti-dyslipidemia, lowering atherosclerosis, lowering blood sugar, inhibiting thedevelopment of cancer cells, improving congestion, soothing gallbladder,releasing pain and anti-allergy
+ Pericarpium Citri reticulatae perenne is effective in fortifying spleen,
regulating qi, and drying dampness to resolve phlegm Pericarpium Citrireticulatae perenne is widely used as medicine and food in Vietnam and manycountries in the world This herb has been presented in more than 10% ofChinese pharmacopoeia formulations There have been many studies proving theeffect of Pericarpium Citri reticulatae perenne in treating dyslipidemia, reducingobesity and preventing atherosclerosis
The effects of HVT remedy are fortifying spleen, regulating qi, dryingdampness and resolving phlegm
Trang 5Chapter 2 SUBJECTS AND METHODS OF RESEARCH 2.1 Research materials
2.1.1 Experimental drug: HVT remedy is produced in liquid form with a ratio of
1:1 (g/ml), bottled with volume of 240ml (Folium Nelumbinis nuciferae 90g,Cleistocalyx operculatus Roxb 90g, Pericarpium Citri reticulatae perenne 60g) byDepartment of Pharmacology, Military Institute of Traditional Medicine, meetingthe basic standards
2.1.2 Control drug (Statin group): Experimental study: Atorvastatin 10mg
(Lipistad-Stada Vietnam) Clinical study: Atorvastatin 10mg (Lipitor-PfizerPharmaceutic Germany)
2.2 Subjects of research
2.2.1 Research subjects on experimental study
- White Swiss mice, healthy, weighing 200 ± 20g, provided by NationalInstitute of Hygiene and Epidemiology
- White Wistar rats, healthy, weighing 150 – 180g, provided by MilitaryMedical University
2.2.2 Research subjects on clinical study
- Criteria for selecting patients
* In terms of modern medicine: the patients over 40 years old, regardless of
occupation and gender The patients are diagnosed with dyslipidemia when theyhave at least one of the following four abnormal indicators:
TC > 5.2 mmol/l, TG > 2.3 mmol/l; LDL-C > 3.4 mmol/l; HDL-C < 0.9 mmol/l
* In terms of traditional medicine: the patients have manifestations of
phlegm-dampness such as obesity, pale swollen tongue, white greasy coating tongue,dizziness, severe head pain, numbness of limbs, fatigue, palpitations, insomnia,slippery pulse or string-like pulse
- Exclusion criteria: the patients with chronic diseases, liver failure, renal failure,
secondary dyslipidemia syndrome or being taking drugs that affect blood lipidindex; the patients with hypersensitivity to the drug ingredients; the patients with ahistory of myocardial infarction, brain stroke, pregnancy or breastfeeding; thepatients do not abide by the treatment rules
2.3 Research methods
2.3.1 Experimental research methods
- Acute toxicity study: According to the method of Litchfield - Wilcoxon,
the guidelines of the Vietnam Ministry of Health, WHO and OECD, Swiss whitemice are divided into groups with 10 mice per group Mice in each group weretaken HVT at the dose from the highest dose (non-lethal dose) to the lowest dose(lethal dose) Mice were completely starved for 12 hours before taking HVT (butdrunk freely) The mice were monitored the death rate in the first 72 hours as well
as their general condition for 7 days after taking the drug (including eating
Trang 6activity, mental activity, walking, climbing, excretion, and so on) Died micewere operated to evaluate the injuries of organs and then calculated LD50.
- Semi-chronic toxicity study: According to guidelines of the Vietnam
Ministry of Health, WHO and OECD, Wistar white rats were divided into 3groups with 10 rats per group Rats in control group were drunk distilled water1ml/100g/day while rats in experimental group 1 were taken low dose HVT of11.2 g medicinal/kg (dose equivalent to the dose used on humans), and rats inexperimental group l2 were taken high-dose HVT of 33.6g medicinal/kg (3 timeshigher than experimental group 1) Rats were drunk solvents and experimentaldrugs for 8 weeks, once a day in the morning After 8 weeks, the rats stoppedtaking the drugs and were monitored for 2 weeks to evaluate the ability ofrehalilitation (if there was toxicity) or the causing ability of the slow toxicity of thedrug Monitoring indicators before and during the study include generalcondition, body weight, assessment of hematopoietic function, assessment ofliver and kidney function and histopathology of liver and kidney of white rats
- Studying the effect of HVT liquid on dyslipidemia adjustment in the model of exogenous hyperlipidemia
Rats were divided into 5 groups Each group had 10 rats with the samemale/female ratio All these groups were given medicine for 4 weeks as follows:Group 1 (biological control group) was drunk distilled water 1ml/100g rat Group
2 (model group) was drunk cholesterol oil mixture 1ml/100g, then drunk distilledwater 1ml/100g after 2 hours Group 3 (atorvastatin group) was taken 1 ml/100gcholesterol oil mixture, then taken atorvastatin 10 mg/kg after 2 hours Group 4(the 1st dosage of HVT) was taken cholesterol oil mixture 1 ml/100g, then takenHVT dose 11.2g/kg after 2 hours Group 5 (the 2nd dosage of HVT) was takencholesterol oil mixture 1 ml/100g, then taken HVT dose 33.6g / kg after 2 hours.The rats in all groups were weighed before and after one, two and fourweeks of the experiment Then, they were taken blood at their tails to doquantative tests of blood lipid indices: TC, TG, HDL-C The non-HDL-cholesterol index is calculated by the formula: non-HDL-C = TC - (HDL-C)
- Model of endogenous hyperlipidemia:
The model of endogenous hyperlipidemia was adjusted by Poloxamer
407 (P-407) according to Millar et al The 50 white mice were divided into 5groups: Group 1 (white control group), Group 2 (model group), Group 3(atorvastatin group), Group 4 (HVT dose of 19.2g/kg), and Group 5 (HVT dose
of 96g/kg) The mice were taken HVT, atorvastatin or distilled water within 7days constantly before taking intraperitoneal injection P-407 After taking P-407injection, the mice were completely starved and drunk freely Within 24 hoursafter receiving P-407, the mice were taken blood at the carotid arteries to do
Trang 7quantative tests of TC, TG, HDL-C, non- HDL- C The index of choleserol was calculated based on formula Non-HDL-C = (TC) – (HDL-C).
non-HDL-2.3.2 Clinical research methods
- Prospective study conducted randomized, opened clinical trial with controlgroup, result comparison between pre-treatment and post-treatment The 120patients compliance with diet and exercise were devided into 2 groups as follows:+ Group 1: The experimental group consisted of 60 patients who used HVTliquid with 80gam/day, 2 times per day, 30 minutes after lunch and dinner
+ Group 2: The control group consisted of 60 patients who used atorvastatin10mg, 1 tablet per day, 1 hour after dinner
The patients were examined, taken case history, performed hematologictests and taken biochemical blood tests before treatment (D0) and after 30 days oftreatment (D30) The patients were taken venous blood in the morning (withouteating anything at least 12 hours before the previous meal) Blood biochemicaltests were done afterward (TC, TG, LDL-C, HDL-C)
Evaluation of treatment results in terms of modern medicine:
+ We evaluated the change of each lipid index at the times of D0 andD30, and compared the results of each group and between 2 groups as well.+ The effectiveness of HVT in the patients with dyslipidemia wasevaluated by criteria as follows:
• Excellent: All blood lipid components returned to normal limits, or one
of them achieved the following changes: TC decreased by ≥ 20%, TG decreased
by ≥ 40%, HDL- C increased by ≥ 0.26mmol/l, TC-HDL-C/HDL-C C/HDL-C) decreased by ≥ 20%
(nonHDL• Good: when achieving one of the following criteria: TC reduced by 10%
-20%, TG decreased by 20% - 40%, HDL-C increased by 0.104mmol/l - 0.26mmol/l, TC-HDL-C/HDL-C (non-HDL-C/HDL-C) decreased by 10% - 20%
• Ineffective: Blood lipid components did not achieve the above changes
Evaluation of treatment results in terms of traditional medicine
+ The effectiveness of HVT was evaluated through the methods ofinspection, inquiry and palpation
+ The effectiveness of HVT in the patients with dyslipidemia wasevaluated by criteria as follows:
• Excellent: There were significant improvements in clinical symptomswith the total decreased score ≥ 70%
• Good: There were small changes in clinical symptoms with the totaldecreased score ≥ 30%
• Ineffective: The total decreased score of clinical symptoms was less than30%
Evaluation of unwanted effects of HVT
Trang 8Clinical evaluation: Some symptoms such as abdominal pain, nausea,
rash, diarrhea, muscle pain, etc were evaluated
Sub-clinical evaluation: The results of hematological test and blood
biochemical tests before and after treatment were used as good indicators toassess
Data analysis: The data was collected and analyzed by the method and
Biomedical statistical algorithm of STATA 14.0
Research Ethics: The study was approved by the Medical Council of
Traditional Medicine Hospital, Ministry of Public Security The patients, whovoluntarily participated in the study, were performed tests and given treatmentwithout paying any fee All information was kept confidential and only generalresults were allowed to publish
Chapter 3 RESEARCH RESULTS 3.1 Acute toxicity and sub-chronic toxicity of HVT liquid drug
3.1.1 Acute toxicity
White mice were taken HVT by increasing doses from the lowest to thehighest dose with 600.0g medicinal/kg/24 hours (up to 31.25 times higher thanthe equivalent dose on the human) but there were no abnormal signs within 7day follow-up and no mice died within 72 hours after taking the sample drug.Therefore, the acute toxicity of LD50 of HVT has not been determined by oraladministration
3.1.2 Sub-chronic toxicity
* General condition: During the experiment, the rats in all 3 groups were
operating normally with bright eyes, smooth hair, good eating, dry feces There were
no particular manifestations in these three groups of rats during the study period
* Changes in body weight of rats: At 4-8 weeks after taking the sample
drugs and 2 weeks after stopping the drugs, the weight of rats in all 3 groups weredocumented to be increased compared to the weight before the study There was
no difference in the level of weight gain of the rats between the control group andthe experimental group (p> 0.05)
* The effect of HVT on the mice’s blood lipid index
Table 3.1 The effect of HVT on the number of rat’s red blood cells
p3-2
The controlgroup (n=10) (1) The group 1(n=10) (2) The group 2(n=10) (3)Before taking
drugs 8,49 ± 0,56 8,27 ± 0,34 8,32 ± 0,55 >0,05
Trang 9Table 3.3 The effect of HVT on the number of rat’s white blood cells
3-1, p3-2
The controlgroup (n=10) (1) The group 1(n=10) (2) The group 2(n=10) (3)Before taking
Trang 10Times The number of thrombocytes (G/l) p2-1, p3-1,
p3-2
The control group(n=10) (1) The group 1(n=10) (2) The group 2(n=10) (3)Before taking
* Evaluation of liver function
Table 3.5 The effect of HVT on the activity of AST (GOT) in rat blood
p3-2
The controlgroup (n=10) (1) The group 1(n=10) (2) The group 2(n=10) (3)Before taking
Table 3.6 The effect of HVT on the activity of ALT (GPT) in rat blood
p3-2
The controlgroup (n=10) (1) The group 1(n=10) (2) The group 2(n=10) (3)Before taking 57,30 ± 5,33 61,70 ± 4,76 61,60 ± 7,26 >0,05
Trang 11* Evaluation of kidney function
Table 3.7 The effect of HVT on the concentration of creatinine in rat blood
p3-2
The controlgroup (n=10) (1) The group 1(n=10) (2) The group 2(n=10) (3)Before taking drugs 1,06 ± 0,05 1,06 ± 0,05 1,07 ± 0,05 >0,05
4 weeks after taking
3.2 The pharmacological effect of HVT in experiment study
Table 3.8 The lipid index at the time after 4 weeks of experiment in exogenous model (n=10)
Trang 12Group 4: The 1st
dose of HVT
(11,2 g/kg)
2,92 0,09*** 0,87 0,03 1,49 0,05** 0,11***1,43
Group 5 : The
2nd dose of HVT
(33,6 g/kg)
2,96 0,11*** 0,89 0,03 1,55 0,04** 0,11***1,41
Notes: The differences in comparison to the model group: *: p < 0,05; **: p<0,01;
***: p < 0,001.
There was a significant decrease in the concentration of TC and
non-HDL-C in in both doses of 11.2 g/kg and 33.6 g/kg, in comparison to the model group (p
<0.001) The effect of 2 doses of HVT was similar and equivalent to atorvastatin 10
mg / kg (p> 0.05) There was no statistically significant difference in theconcentration of blood lipid index between the atorvastatin group and two HVTdoses at the time after 4 weeks of experiment (p> 0.05)
Table 3.9 Blood lipid index after the experiment in
(↓ 34,2%)
8,16 ± 2,65
2,13 ±0,94**
(↓ 49,3%) Group 4:
(↓ 51,7%)