There is no name for rheumatoid arthritis disease in traditional medicine.The symptoms of rheumatoid arthritis in traditional medicine belong tothe category of pain due to stasis, such a
Trang 1Rheumatoid arthritis is a bone and joint disease found everywhere in theworld, accounting for about 1% of the population In Vietnam, the rate ofrheumatoid arthritis accounts for 0.5% of the population and 20% ofarthritis diseases Rheumatoid arthritis is prolonged, alternates with acuteattacks, causes disability, and greatly affects work performance and dailylife
The treatment of rheumatoid arthritis requires a combination of differentmethods: internal medicine, physical therapies, rehabilitation, andsurgery Researching to find an effective and less-side-effectsmedicination for the treatment of rheumatoid arthritis has been being atarget for researchers
There is no name for rheumatoid arthritis disease in traditional medicine.The symptoms of rheumatoid arthritis in traditional medicine belong tothe category of pain due to stasis, such as, acute arthritis, crane kneearthritise, 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 windevil, removing dampness, activating blood, activating and smoothingmeridians, tonifying blood qi, nourishing liver and kidney, anti-inflammatory, analgesic, the medicine is indicated to treat theosteoarthritis including rheumatoid arthritis However, there are noscientific studies evaluating the treatment effects of rheumatoid arthritis
of the drug ‘Hoan chi thong’ Therefore, we carry out this research withthe following objectives:
1 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.
3 Evaluating the therapeutic effects and undesirable effects of
‘Hoan chi thong’ on patients with rheumatoid arthritis stage 1 and 2.
PRACTICAL MEANINGS AND NEW CONTRIBUTION OF THE THESIS
The rapid development of economy, society, and disease patterns inVietnam has changed markedly in recent years, from infectious diseases
Trang 2to non-communicable diseases Rheumatoid arthritis is a cause ofcomplicated consequences for joints and disability, which affects workefficiency and daily life Modern medicine has shown a positive role andeffectiveness in the treatment of rheumatoid arthritis, but it also causessome side effects of peptic ulcer, gastrointestinal bleeding, osteoporosis,etc Therefore, searching for effective and safe herbal medicines isalways a need and is of interest to national and international scientists.The scientific work of the thesis is experimentally and clinicallyorganitinal and systematical.
The research and application of the medicine contribute to theclarification of traditional medicine theory and gradually modernizetraditional 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; Researchresults: 28 pages; Discussion: 35 pages; Conclusion: 02 pages
Recommendations: 01 page
The thesis has 120 references (48 in Vietnamese, 37 in English, and 35 inChinese), 43 tables, 12 charts, 04 diagrams, 02 pictures, 12 photos andappendices
Chapter 1 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 nottreated thoroughly or properly, joint disfigurement, deformation, and loss
of motor movement would be consequences
Rheumatoid arthritis develops complicatedly over many stages, inaddition to presenting at joints, it might exist in the whole body atdifferent degrees Rheumatoid arthritis can also cause damage to organssuch as heart (pericarditis, endocarditis, myocarditis, arrhythmia, etc.),respiratory system (pleural effusion, fibrosis, etc), nerves (carpal tunnelsyndrome), etc
Cause: The cause of the disease is not clear, modern medicine has
recently considered rheumatoid arthritis as an autoimmune disease withthe participation of many factors A number of common viruses orbacteria affect the favorable atopic and genetic factors Rheumatoidarthritis has a family nature
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Trang 3Pathogenesis: rheumatoid arthritis is an autoimmune disease,
characterized by chronic inflammatory reactions that damage synovialmembranes, cartilage and bone at inflamed joints Although the etiology
of the disease is still unclear, new knowledge on immunology andmolecular biology has contributed to further elucidation of themechanism 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 AmericanAssociation of Rheumatology had agreed to improve the diagnosticcriteria for ACR (1987), including 7 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 basicmanifestations 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 determinesbones, the diease is closely related to these organs Prolonged diseasewill 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 thepresence of yin qi deficiency, or damages of kidney and liveraccompanied by phlegm stagnation, which causes asthenia accompaniedwith plenitude, of which the manifestation is plenitude stheniasyndrome
* 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 beaccompanied by swelling; Limited joint muscle movements; The onset
of the disease is most frequently accompanied by diseases of superficies
Trang 4such as fear of wind, fever, pale tongue; Whitish tongue moss; Floatingmoderate 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 ismore severe at night than day, the pain increases when it’s cold, and hotcompresses may help with pain; At swollen joints , there are stiff andlimited 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 do not want to drinkwater; Feeling irritated and uncomfortable, yellowish urine, limited jointmovements; 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; Jointmovements 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 benigntumors under the skin; Dark face and dry skin; Dry mouth but unlike todrink; Purplish tongue with blood stasis spots, thin whitish and yellowishmoss; Sluggish fine taut deep pulse
- Blood qi deficiency type: swollen joints, aches, muscle atrophy,
stiffness, deformed joints, limited joint movements; The disease isaccompanied with dizziness, poor appetite, dry skin, or bleeing; Thereare benign tumors under the skin; The tongue is pale or redish or withcracks, thin whitish moss with little or no moss; Fine deep pulse or weakfine pulse
- Liver-kidney deficiencyn type: swollen joints, aches, stiffness, muscle
atrophy, deformed joints, limited joint movements; Accompanied withback and knee pain, afraid of cold, cold limbs, sleeplessness; Bone heatsydrome and hectic fever; Dry mouth but drink little or dislike to drinkwater Reddish or pale tongue, thin tongue moss, Weak taut deep pulse orrapid taut pulse
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Trang 5osteoarthritis 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 isindicated to treat the osteoarthritis including rheumatoid arthritis.
Chapter 2 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 tosoft medicated balls, and weighs 8.5g/ ball The medication meets thestandardsof the institute
Research materials: Aspirin, prednisolone, carrageenin solution,
formaldehyde, amiant fiber, etc
- Rriteria to selecting patients: the patients diagnosed with rheumatoid
arthritis according to the standards of the American Association ofRheumatology and the European Anti-Rheumatology Federation 2010ACR / EULAR 2010 If the patient has at least 4/7 criteria and clinicalsymptoms that persist for more than 6 weeks, they are diagnosed withrheumatoid arthritis Selected patients who meet the criteria for diagnosisaccording to modern medicine as above and in accordance with theevidence diagnosis of traditional medicine The patients were examinedaccording to 4 methods of examination: inspection, listening andsmelling, questioning, and palpation the symptoms were devided intotwo main categories: wind cold wetness type and wind wetness heattype
- Criteria to excluding patients: Patients with liver, kidney, and
infectious diseases, diseases of the hematopoietic system, diabetes andthose who suffer from mental neurological diseases, sensory disorders,cancer, etc
2.2.3 Location, study time
Trang 6The experimental and clinical research was conducted at the MilitaryTraditional 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 byoral route, with 6 groups of 10 heads each, receiving reagents inincreasing doses from 12.2g/kg to 61g/kg (maximum tolerable dose formice) the general condition of the rats and the number of dead mice ineach group were monitored in 72 hours (mice that died within the first 24hours 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 theMinistry of Health of Vietnam and the guidance of OECD and WHO.'Hoan chi thong' was taken orally by white rats 30 experimental micewere divided into 3 groups of 10 heads each; the control group drankdistilled water at a dose of 2 ml/kg/day; the research group 1 took 'Hoanchi thong' 4.8g/kg (equivalent to the human dose), the research group 2took the 'Ha mo mau' nuggets 14.4g/kg/day (equivalent to 3 times thehuman dose)
Monitoring criteria: The general condition and body weight of white
rats The evaluation of hematopoietic function, assessment of liver andkidney function, liver histopathology, kidney rats' kidney
Evaluation time: before the treatmemt, after 2 weeks, and 4 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 bycarrageenin model
- Studying the acute anti-inflammatory effect on the peritonitis-inducedmodel
- Studying the acute anti-inflammatory effect on the permeability-inhibition model: Assessing the acute anti-inflammatoryeffect 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
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Trang 7Research design: clinical trial, cross-sectional description with
intervention, vertical monitoring Compare results before and after thetreatment
The treatment: 60 patients with rheumatoid arthritis took 4 balls of 'Hoan
chi thong' daily, 2 in the morning and 2 in the afternoon; 1 hour aftereating, 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 painwho are recommended to use painkillers should receive Celebrex 200mg
Clinical and subclinical research criteria
* Diagnosis of rheumatoid arthritis: under the EULAR/ACR 2010standards
* Monitoringthe criteria according to traditional medicine: Classifyingthe patients according to the clinical form of wind cold wetness type andwind wetness heat type After the clinical classification, comparing theresponses of patients in these two groups to the assessment criteria ofrheumatoid arthritis in modern medicine
* Subclinical monitoring criteria:
- Hand pressure is measured by a Japanese hand dynamometer Whenbeing measured, the patient's arms were spreaded horizontally, threetimes each hand and the highest results were taken The unit ofcalculation 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 ray, joint ray, abdominal ultrasound, ECG
X-* 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 thebiomedical 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, thepatients understood and voluntarily participated in the research, all thepatients’ personal information kept confidentially, only aggregatedresults are published
Chapter 3 RESULTS
Trang 83.1 Acute and semi-chronic toxicity study results
The 50% lethal dose (LD50) of ‘Hoan chi thong’ at a dose of 61g/kgwas not determined (the highest dose likely to be given to rats underlaboratory 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 3 groups were normal and agile, had silkyhair, good appetie, and firm feces
After 2 weeks and 4 weeks of reagents, the weight of mice in all 3groups (01 control and 2 research groups) was higher than that of thebefore-test (p <0.05) There was no difference in the degree of theincrease in the mice weight between control group and research groups
at the same time of testing (p> 0.05)
- Effects on the hematological indicators: There were no differences in
the number of erythrocytes, hemoglobin content, white blood cells, andplatelets, hematocrit concentration, and the percentage of neutrophils andlymphocytes between the control group and the research groups andbetween 2 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 thecontrol group and the research groups and between 2 research groups atthe 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 thecontrol group and the research groups and between 2 research groups atthe 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 andbetween 2 reaserach groups at the same testing times Smooth kidneysurface, evenly shinny, reddish-brown color can be seen and there were
no bleeding and elastic when being pressed
- Liver microscopic morphology (HEx400):
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Trang 9Control group Research group 1 Research group 2
The HEx400 image showed that Remak was formed in central vein ofthe liver cells The image of broken or dissolved liver cells were notseen The images of hemorrhage or necrosis in the lobes of the uteruswere not seen Conclusion: Normal liver images The liver microscopicmorphology images in the 2 study groups were not different from thecontrol group
- The microscopic morphology images of kidney (HEx400):
Control group Research group 1 Research group 2
The HEx400 kidney microscopic morphology images of the controlgroup showed glomerular, Bowman cavity, capillary coil, and tubule.The nucleus of the glomerular cells and tubular became dark Glomerularand tubular lesions were not seen Conclusion: Normal kidney images.The Micrograph of kidney in the 2 study groups were not different fromthat 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
5 minutes after the injection, the pain of mice in the Aspirin group dose100mg/kg and ‘Hoan chi thong' dose 6.8g/kg group decreasedsignificantly compared to the other two groups (p <0 , 05) After 10, 15and 20 minutes, the number of pain in the white mice that took‘Hoan chithong' dose 6.8g/kg/day decreased significantly compared to controlgroup and taking‘Hoan chi thong' dose 13.6g/kg (p<0.05) After 25 and
30 minutes, the number of pain in the white mice taking‘Hoan chi thong'dose 6.8g/kg/day decreased significantly compared to the other groups (p
<0.05)
* Central analgesic effect of ‘Hoan chi thong' by hot plate method
Table 3.1 Effects of ‘Hoan chi thong' on reaction time to temperature of
white mice (seconds; SD)
Groups Before (a) Reaction time After (b) p a-b
Group 1 (control) 12.23 ± 1.51 11.91 ± 1.71* >0.05Group 2 (Codein 10 mg/kg) 12.05 ± 1.84 20.29 ± 2.42 <0.05
Trang 10Group 3 (HCT 6.8g/kg/day) 11.30 ± 1.33 11.82 ± 1.60 >0.05Group 4 (HCT 13.6g/kg/day) 11.91 ± 1.53 12.16 ± 1.71* >0.05
Comments: the reaction time to temperature of rats in both doses of
‘Hoan chi thong' after taking the medicination was not different fromthat of the control group (p> 0.05) After taking the medicination, thereaction time of mice in the codeine phosphate group was significantlylonger than the ‘Hoan chi thong' and the distilled water group (p <0.05)
3.2.2 Results of anti-inflammatory effect on trials
* The acute anti-inflammatory effect on the foot-edema-caused-by carrageenin model
Comments: the ability to inhibit the food edema reaction compared to
the control group 2 hours after the injection in the aspirin group wasbetter than the 2 ‘Hoan chi thong’ groups 4 hours, 6 hours, and 24 hoursafter the injection, the ability of mice to inhibit the foot edema of theAspirin group ‘Hoan chi thong’ 4.8g/kg body weight was equivalent (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 exudate (ml) Proteincontent (mg/dl) White blood cells (K/ul)
Group 1: distilled water
Group 2: aspirin 150
Group 3: HCT 4.8 g/kg 2.06 0.51* 3.16 0.37* 7.01 0.98*Group 4: HCT 9.6 g/kg 3.69 0.42*▲■ 5.04 0.35*▲■ 10.89 2.80▲■
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Trang 11Comments:The ‘Hoan chi thong’ dose of 4.8 g/kg body weight reduced
inflammatory exudate, reduced protein content in the exudate andreduced the number of white blood cells in inflammatory exudatecompared to the control group (p <0.05), equivalent to the aspirin dose150mg/kg body weight (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 1: distilled water0.2ml/10g body weight 0.272 0,
Group 2: Aspirin 200mg/kg body weight 0.125 0.088*Group 3: ‘Hoan chi thong’ 6.8 g/kg 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 bloodsignificantly better than that of the control group, the difference wasstatistically significant with p <0.05 The effect of inhibiting the amount
of pigments exiting the lumen of the ‘Hoan chi thong’ was lower than that
of mice taking aspirin in the same test conditions with p <0.05
* The anti-chronic inflammatory effect of the ‘Hoan chi thong’ in the granulomas caused model
Table 3.4 The effect of ‘Hoan chi thong’ on granulomatous weight
Groups Granulomatous weight (mg)
Group 1: distilled water0.2ml/10g (1) 30.96 5.88
Group 2: Prednisolon 5 mg/kg (2) 19.70 4.70*
Group 3: ‘Hoan chi thong’ 6.8 g/kg (3) 18.21 3.98*
Group 4: ‘Hoan chi thong’ 13.6 g/kg (4) 25.95 4.73▲■
Comments: After 7 days of continuous use of the medicination, the
granulomatous weight in the ‘Hoan chi thong’6.8g/kg body weightsignificantly decreased compared to that of the control group (p <0.05)and equivalent to the reduction of the prednisolone group (p> 0.05)
3.3 Clinical research results
Trang 12Comments: The average age of rheumatoid arthritis patients is 58.60 ±
11.95 years old The proportion of female patients (81.7%) was higherthan the male patients (18.3%) The mean age of the male group was notdifferent from the female group (p> 0.05)
Table 3.6 Occupation and duration of disease
Comments: The average duration of the disease was 7.95 ± 6.09 (years),
the majority of patients had the duration of disease from 11-25 years(66.7%) The target group was unskilled workers with high proportion(66.7%)
Table 3.7 Characteristics of the disease according to traditional
medicine
Traditional medicine disease
type
Number of patients Percentage %
Comments: most patients with rheumatoid arthritis belong to the wind
wetness heat type (73.3%); 26.7% of the patients belongs to wind coldwetness type
3.3.2 Research results on the analgesic effect of 'Hoan chi thong' on clinic
Table 3.8 Time of stiffness before and after the treatment
Time of joint stiffness (minute) 46.83 ± 20.66 17.17 ± 8.04 <0.001
Changes the time of joint stiffness 30.00 ± 15.12 (5-70)
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