Journal of Ethnopharmacology 164 (2015) 71–77
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Research Paper
The effectiveness and safety of a danshen-containing Chinese herbal medicine for diabetic retinopathy: A randomized, double-blind, placebo-controlled multicenter clinical trial Fengmei Lian a,1, Lie Wu a,1, Jiaxing Tian a,1, Ming Jin b, Shuiping Zhou c, Min Zhao c, Lijuan Wei d, Yanlin Zheng e, Yuliang Wang f, Mingchang Zhang g, Wei Qin h, Zhifeng Wu i, Chun-Su Yuan j,nn, Xiaolin Tong a,n a
Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China China–Japan Friendship Hospital, Beijing 100029, China Tasly Pharmaceutical Co., Tianjin 300410, China d The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun 130021, China e The Affiliated Hospital to Chengdu University of Chinese Medicine, Chengdu 610032, China f Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing 210005, China g The Affiliated Union Hospital to Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China h First Affiliated Hospital of Third Military Medical University, Chongqing 400038, China i Wuxi Number 2 People's Hospital, Wuxi 214002, China j Tang Center for Herbal Medicine Research, Pritzker School of Medicine, University of Chicago, IL 60037, USA b c
art ic l e i nf o
a b s t r a c t
Article history: Received 23 September 2014 Received in revised form 6 December 2014 Accepted 15 January 2015 Available online 7 February 2015
Ethnopharmacological relevance: Salvia miltiorrhiza (Danshen in Chinese) is a common traditional Chinese herbal medicine often used to treat many medical conditions. The Compound Danshen Dripping Pill (CDDP) is a danshen-containing Chinese herbal product for the treatment of cardiovascular diseases. However, to date, no controlled clinical studies have been conducted to evaluate the effects of CDDP on diabetic retinopathy (DR). Aim of the study: The present large-scale clinical trial was designed to assess the effectiveness and safety of CDDP in treating patients with non-proliferative diabetic retinopathy (NPDR). Materials and methods: 223 NPDR patients were enrolled in this controlled trial. Subjects received oral study medications three times daily for 24 weeks. The four groups were placebo, low-dose (270 mg), mid-dose (540 mg) and high dose (810 mg herbal medicine). Primary endpoints were changes in fluorescence fundus angiography (FFA) and fundoscopic examination parameters. Results and discussion: At 24 weeks, for the FFA, the percent of “Excellent” and “Effective” in the highdose and mid-dose CDDP groups was 74% and 77%, respectively, very significantly higher than 28% in the placebo group (Po 0.001). For fundoscopic examination, the percent of “Excellent” and “Effective” in the high-dose and mid-dose CDDP groups was 42% and 59%, respectively, very significantly higher than 11% in the placebo group (Po 0.001). No adverse events with clinical significance were observed. Conclusions: DR is a severe microvascular complication of diabetes and a major cause of adult blindness worldwide. Our clinical trial data demonstrated the therapeutic value and safety of a danshen-containing Chinese herbal medicine in patients with diabetic retinopathy. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Diabetic retinopathy Salvia miltiorrhiza Panax notoginseng Fluorescence fundus angiography (FFA) Fundoscopic examination Glycosylated hemoglobin (HbA1c)
1. Introduction
n
Corresponding author. Correspondence to: Tang Center for Herbal Medicine Research, The Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 4028, Chicago, IL 60637, USA. E-mail addresses: [email protected] (C.-S. Yuan), [email protected] (X. Tong). 1 Fengmei Lian, Lie Wu and Jiaxing Tian are the co-first authors in this work. nn
http://dx.doi.org/10.1016/j.jep.2015.01.048 0378-8741/& 2015 Elsevier Ireland Ltd. All rights reserved.
Diabetic retinopathy (DR), a severe microvascular complication of diabetes (Congdon et al., 2003), is a major cause of adult blindness worldwide. The prevalence of DR in China for individuals over 60 years of age is approximately 16%, and its incidence is 8.38/1000 person-years (Li and Wang, 2013). Treatment of DR includes medical management to control blood sugar, blood pressure and serum lipids, ocular management, and adjunctive pharmacologic therapies (Schwartz and Flynn, 2007; Simó and Hernández, 2009; ACCORD
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Study Group, ACCORD Eye Study Group, 2010). However, these approaches for DR management have limitations including invasive procedures and side effects of drug therapy (Schwartz and Flynn, 2007; Simó and Hernández, 2009; Feng et al., 2014). To date, there are no measures to effectively control the progression of DR. Thus, there is a strong motivation for exploring alternative strategies, including the use of Chinese herbal medicines, in DR therapeutics. Salvia miltiorrhiza (Danshen in Chinese) is a very commonly used traditional Chinese herbal medicine. Compound Danshen Dripping Pill (CDDP) is a Chinese herbal medicine product used for the treatment of cardiovascular diseases (Chu et al., 2011). It contains the extract from danshen (Salvia miltiorrhiza), notoginseng (Panax notoginseng; or Sanchi in Chinese), and borneol. These three traditional Chinese medicines have been used for over a thousand years to treat many medical conditions. The CDDP promotes blood circulation and alleviates pain (Chu et al., 2011). Based on the theory of traditional Chinese medicine (TCM), the pathogenesis of DR is due to blood stasis that damages collateral vessels in the eye (Duan et al., 2011). Published animal experiments using different animal models and clinical trials in DR patients have demonstrated that CDDP can improve the symptoms of DR (Zhou et al., 2002, 2006; Qi et al., 2007; Yang et al., 2013). In addition, CDDP has been studied in different body systems with a good safety record (H. Xu et al., 2014; Yang et al., 2014). However, to date, no controlled clinical trial has been conduced to evaluate the effects of CDDP on DR. In the present study, a randomized, double-blind, placebo-controlled, dose-ranging and multicenter clinical trial was conducted. We recruited glycemic-controlled DR patients with non-proliferative diabetic retinopathy (NPDR). These subjects were randomly assigned into four groups, and they received either placebo or three different doses of CDDP to explore the optimal therapeutic dose. The primary endpoints were changes in fluorescence fundus angiography (FFA) and fundoscopic examination parameters after 24 weeks of CDDP treatment. In addition, corrected visual acuity, intraocular pressure, glycosylated hemoglobin (HbA1c) and fasting plasma glucose (FPG) were obtained in these subjects. The safety profile of the CDDP in the study subjects was also collected.
2. Materials and methods 2.1. Study subjects The research protocol was approved by the local Medical Ethics Commission in China, and was implemented in accordance with the provisions of the Declaration of Helsinki.
The inclusion criteria were as follows: (1) Subjects were 30–70 years old. (2) Subjects were diagnosed with NPDR (American Association of Ophthalmology, 2006). (3) Subjects were on a stable oral hypoglycemic treatment for at least three months. (4) Subjects signed written informed consent. Exclusion criteria were as follows: (1) Subjects had HbA1c level 48%. (2) Subjects were treated with retinal photocoagulation or suitable for laser photocoagulation with proliferative diabetic retinopathy in one eye or both eyes. (3) Subjects were taking DR medications. (4) Subjects had other eye diseases, including glaucoma, with cataracts affecting fundoscopic examination. (5) Subjects had received cataract surgery within the previous 3 months. (6) Subjects had nondiabetic retinopathy, uveitis, retinal detachment, optic nerve diseases or highly myopic eyes. (7) Subjects had significant cardiovascular, liver, kidney, or hematopoietic systems diseases, mental illness, and other serious medical conditions. (8) Subjects had diabetic nephropathy with kidney failure. (9) Subjects were pregnant, planning to become pregnant, or lactating. (10) Subjects were allergic to Chinese herbal medicines. (11) Subjects had participated in any other clinical trials in the previous month. 2.2. Botanical materials The study's herbal drug, Compound Danshen Dripping Pill (CDDP) was obtained from the Tasly Pharmaceutical Group Co., Tianjin, China. The CDDP contains the extract from danshen (Salvia miltiorrhiza), notoginseng (Panax notoginseng) and borneol. 2.3. Study protocol After an initial screening visit, 223 glycemic-controlled patients with NPDR were recruited from 10 clinical research centers in China. All subjects received standard treatment without any diet intervention. A stratified, block randomization method was conducted by a biostatistician. Patients were assigned into four groups receiving placebo (n ¼56), low-dose CDDP (n ¼56), mid-dose CDDP (n ¼56) and high-dose CDDP (n ¼55) (Fig. 1). Subjects were orally administered study medications with plain water three times daily. Each CDDP pill contains 27 mg of herbal medicine. For each administration, subjects in the placebo group received 30 placebo pills, subjects in the low-dose CDDP group received 10 CDDP pills plus 20 placebo pills (270 mg herbal medicine), subjects in the mid-dose CDDP group received 20 CDDP pills plus 10 placebo pills (540 mg herbal medicine), and subjects in the high-dose CDDP group received 30 CDDP pills (810 mg herbal medicine). Placebo pills, which contained starch and caramel, had the same appearance as the CDDP pills, and were
Fig. 1. Flow diagram of study subjects randomization and the completion of the trial.
F. Lian et al. / Journal of Ethnopharmacology 164 (2015) 71–77
obtained from the same manufacture. All study medications were provided by Tasly Pharmaceutical Group Co., China. The treatment for each group lasted consecutive 24 weeks. 2.4. Evaluation of effectiveness
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pre-treatment, 12 weeks and 24 weeks. Adverse events were assessed using vital signs, clinical signs and symptoms, laboratory examinations, and results were recorded at each visit. 2.6. Statistical analysis
Primary endpoints of this study were changes in fluorescence fundus angiography (FFA) and fundoscopic examination parameters after 24 weeks of the CDDP treatment. The following clinical evaluations were conduced at pre-treatment, 12 weeks, and 24 weeks: (1) FFA, (2) fundoscopic examination, (3) HbA1c, and (4) FPG. At pre-treatment and 24 weeks, a retinopathy severity evaluation was conduced. At pre-treatment and every 4 weeks during the study period, visual acuity and intraocular pressure examinations were conduced. Results were recorded after each visit. The FFA data was based on the retinal circulation time, retinal capillary non-perfusion, and vascular leakage. “Excellent” denoted one of total retinal circulation time, retinal capillary non-perfusion area and vascular leakage improved over 20%, while the others did not deteriorate. “Effective” denoted one of the total retinal circulation time, retinal capillary non-perfusion area and vascular leakage improved between 10% and 20%, while the others did not deteriorate. “Worsened” denoted one of the total retinal circulation time, retinal capillary non-perfusion area and vascular leakage deteriorated over 10%. “Stable” denoted cases other than “Excellent”, “Effective” and “Worsened”. The fundoscopic examination data was based on the degree of retinal microangiopathy and macular edema. “Excellent” denoted both retinal microangiopathy and macular edema alleviated. “Effective” denoted retinal microangiopathy alleviated, while macular edema did not deteriorate. “Worsened” denoted either retinal microangiopathy or macular edema deteriorated or neovascularization was found. “Stable” denoted cases other than “Excellent”, “Effective” and “Worsened”. 2.5. Safety monitoring and adverse event observation Routine blood, urine and stool tests, electrocardiogram, liver function, creatine kinase, and renal function were measured at
Data were presented as the mean7S.D. Statistical software SAS8.0 was used for the data analysis. The primary analysis was conducted in the intention-to-treat (ITT) population using a full analysis set (FAS). For the data presentation in different groups, groups were compared using a variance test or the Kruskal–Wallis (K–W) test. Also, the ranked data was evaluated using the K–W test. For the adverse events analysis, a chi square test or fisher exact test was used. Po0.05 was considered statistically significant.
3. Results From the 10 clinical research centers, 223 subjects who met the inclusion criteria and exclusion criteria were enrolled in the study. The mean age of the subjects was 59.3 years old, and among them 41.7% were male subjects. The average duration of NPDR in these patients was 29.7 months. There were no significant differences in the baseline variables of the four groups. The subjects’ baseline characteristics are shown in Table 1 using the Kruskal–Wallis test. Among them, 182 subjects completed the study (Fig. 1). 3.1. FFA examination Compared to the placebo, subjects who received middle-dose and high-dose CDDP had significant improvements in FFA results at 12 and 24 weeks (Fig. 2). At 24 weeks, the number of “Excellent” subjects on FFA in the placebo, low-dose, mid-dose and high-dose groups was 4, 6, 21 and 20, respectively. The number of “Effective” subjects in these four groups was 9, 9, 12 and 12, respectively. The number of “Worsened” subjects in these four groups was 15, 13, 1 and 4, respectively. As shown in Fig. 2B, the percent of “Excellent” and “Effective” in the high-dose, mid-dose and low-dose CDDP
Table 1 Characteristics of study subjects at baseline. Placebo (n¼ 56)
Low-dose (n¼ 56)
Mid-dose (n¼ 56)
High-dose (n¼55)
P value
Age (years) Gender (M/F) Height (m) Weight (kg) Heart rate (beat/min) Respiration rate (/min) Systolic pressure (mmHg) Diastolic pressure (mmHg) Duration of diabetes (month) Duration of DR (month) Corrected visual acuity Intraocular pressure (mmHg) Total retinal circulation time (s) Retinal capillary non-perfusion (PD) Vascular leakage (PD)
58.9 7 7.6 27/29 1.6 7 0.1 64.07 10.0 72.7 79.4 18.5 71.4 127.0 7 12.4 77.7 7 8.6 119.0 761.7 27.17 27.9 4.8 7 0.2 15.4 7 2.4 8.5 7 4.1 0.2 7 0.6 0.2 7 0.7
59.9 7 6.0 18/38 1.6 70.1 62.7 7 11.4 73.9 7 10.7 18.6 7 1.3 127.4 7 13.7 77.9 7 9.0 129.3 7 65.0 31.7 736.1 4.8 7 0.2 15.4 7 2.5 8.1 7 2.5 0.2 7 0.5 0.7 7 1.7
58.9 7 8.1 25/31 1.7 70.1 66.5 711.2 74.3 7 8.9 18.8 7 1.4 128.5 7 11.2 79.9 7 7.3 117.5 7 67.4 24.07 25.1 4.9 7 0.2 15.4 7 2.6 9.36 7 3.6 0.3 7 0.9 0.17 0.3
59.5 7 8.7 23/32 1.6 7 0.1 65.9 7 12.4 74.8 710.9 18.8 72.0 129.17 11.3 78.3 7 8.6 131.4 7 71.3 36.0 7 38.1 4.8 7 0.2 15.3 7 2.5 8.9 7 3.2 0.6 7 2.8 0.5 7 1.8
0.86 0.35 0.30 0.19 0.85 0.71 0.65 0.75 0.65 0.51 0.50 0.96 0.33 0.47 0.20
Fundus changes Capillary hemangioma Hard exudates Cotton spot Bleeding Microvascular abnormal (%) Venous beading (%) Macular edema (%) Neovascularization (%)
9.0 7 7.9 0.5 7 0.8 0.1 70.6 0.9 7 2.1 2(3.6) 0(0.0) 4(7.4) 1(1.8)
9.0 7 6.6 0.7 7 1.6 0.1 7 0.5 1.3 72.7 6(10.7) 1(1.8) 7(12.5) 0(0.0)
12.5 7 9.6 1.4 72.3 0.17 0.5 1.17 3.4 4(7.1) 3(5.4) 5(9.1) 2(3.6)
13.4 7 10.2 1.17 2.4 0.1 70.83 1.4 7 2.3 3(5.6) 0(0.0) 7(13.8) 0(0.0)
0.17 0.06 0.75 0.17 0.54 0.20 0.70 0.52
Values are expressed as mean7 S.D.
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groups was 74.42%, 76.75%, and 37.50%, respectively, very significantly higher than 28.27% in the placebo group (Po0.001). At 24 weeks, compared to the placebo group, the effects of CDDP on FFA were very significantly better in the middle-dose and high-dose group (P o0.001). There was no significant difference in the low-dose group and placebo (P¼ 0.444). The improvement of the middle-dose group and high-dose group was significantly greater than that of the low-dose group (both Po 0.01). There was no statistically significant difference in the improvement of the middle-dose group and high-dose group (P¼ 0.557).
Table 2 shows the FFA examination data. The retinal circulation time of the low-dose, mid-dose and high-dose CDDP groups were shorter than that of the placebo group at 24 weeks. Compared to the placebo group, the time was shortened very significantly in the middose (Po0.001) and high-dose groups (Po0.001), but there was no statistically significant difference in the circulation time of the low-dose and placebo groups (P¼ 0.569). However, there were no statistically significant differences in the values of the capillary non-perfusion area and vascular leakage among the CDDP treatment and placebo groups. The Kruskal–Wallis test was for the above analysis.
Fig. 2. Distribution of “Excellent”, “Effective”, “Stable” and “Worsened” after fluorescence fundus angiography (FFA) in subjects who received placebo, low-dose, mid-dose and high-dose of CDDP administrations. (A) FFA results at 12 weeks. (B) FFA results at 24 weeks. At 24 weeks, the percent of “Excellent” and “Effective” in the high-dose and middose CDDP groups is very significantly higher than that in the placebo group (Po0.001). For the definition of “Excellent”, “Effective”, “Stable” and “Worsened”, see “Evaluation of effectiveness” in Section 2.
Fig. 3. Distribution of “Excellent”, “Effective”, “Stable” and “Worsened” after fundoscopic examination in subjects who received placebo, low-dose, mid-dose and high-dose of CDDP administrations. (A) fundoscopic results at 12 weeks. (B) fundoscopic results at 24 weeks. At 24 weeks, the percent of “Excellent” and “Effective” in the high-dose and middose CDDP groups is very significantly higher than that in the placebo group (Po0.001). For the definition of “Excellent”, “Effective”, “Stable” and “Worsened”, see “Evaluation of effectiveness” in Section 2.
Table 2 Fundoscopic fluorescein angiography (FFA) examination data. Placebo
Low-dose
Mid-dose
High-dose
P value
Total retinal circulation time (s) Changes at 12 weeks Changes at 24 weeks
0.62(3.02) 0.22(2.27)
0.29(1.81) 0.10(2.08)
1.60(2.23) 1.71(2.37)
1.32(2.15) 1.39(1.97)
o 0.001 o 0.001
Capillary non-perfusion area (PD) Changes at 12 weeks Changes at 24 weeks
0.02(0.14) 0.04(0.19)
0.13(0.61) 0.13(0.55)
0.00(0.02) 0.02(0.14)
0.03(0.15) 0.03(0.19)
0.158 0.071
Vascular leakage (PD) Changes at 12 weeks Changes at 24 weeks
0.05(0.20) 0.05(0.20)
0.10(0.55) 0.12(0.63)
0.01(0.05) 0.01(0.05)
0.01(0.07) 0.00(0.00)
Values are presented in the changes from the baseline, expressed mean 7S.D.
o 0.05 o 0.05
F. Lian et al. / Journal of Ethnopharmacology 164 (2015) 71–77
3.2. Fundoscopic examination Compared to those who received the placebo, subjects who received middle-dose and high-dose CDDP had significant improvements in fundoscopic results at 12 and 24 weeks (Fig. 3). At 24 weeks, a number of subjects treated with mid-dose and high-dose CDDP had significantly improved fundoscopic examination parameters. The number of “Excellent” subjects on fundoscopic examination in the placebo, low-dose, mid-dose and high-dose groups was 1, 1, 14 and 8, respectively. The number of “Effective” subjects in these four groups was 5, 6, 15 and 13, respectively. The number of “Worsened” subjects in these four groups was 23, 13, 2 and 4, respectively. As shown in Fig. 3B, the percent of “Excellent” and “Effective” in the high-dose, mid-dose and low-dose CDDP groups was 42.00%, 59.18%, and 13.46%, respectively, very significantly higher than 10.91% in the placebo group (Po0.001). At 24 weeks, compared to the placebo group, the effects of CDDP on the fundoscopic examination parameters were very significantly better in the middle-dose (Po 0.001) and high-dose groups (P o0.001). There was no statistically significant difference in the low-dose and placebo groups (P¼ 0.140). The improvements of the middle-dose group and high-dose group were significantly greater than that of the low-dose group (both P o0.01). There was no statistically significant difference in the improvement of the middle-dose group and high-dose group (P¼ 0.311). Fundoscopic examination data are presented in Table 3. At 24 weeks, subjects in the CDDP treatment groups had significantly fewer capillary hemangioma than those in the placebo group (Po0.001). Also, subjects in the CDDP treatment groups had significantly fewer hard exudates at 24 weeks. The middle-dose and high-dose groups had fewer hard exudates than the placebo group (both Po0.01). There was no statistically significant difference in the amount of hard exudates in the low-dose group and placebo group (P¼0.741). In addition, subjects in the CDDP treatment groups had less retinal hemorrhaging at 24 weeks. Subjects in the mid-dose and high-dose groups had significantly less retinal hemorrhaging than the placebo
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group (both Po0.001). However, there were no statistically significant differences in the values cotton spots, microvascular abnormalities, retinal vein beading, neovascularization and macular edema among the CDDP treatment and placebo groups. In addition, no statistically significant differences in retinopathy severity classification were observed among the three CDDP treatment groups and the placebo group (P¼ 0.671). Further, no significant differences in corrected visual acuity and intraocular pressure were observed among the three CDDP treatment groups and the placebo group (P ¼0.767 and P ¼0.760, respectively). The Kruskal–Wallis test was for the above analysis. 3.3. Effects on HbA1c and FPG HbA1c and FPG levels were evaluated at 12 and 24 weeks using the Kruskal–Wallis test. There were no statistically significant differences among the placebo and CDDP treatment groups (at 24 weeks, P ¼0.768 for HbA1c and P ¼0.411 for FPG). 3.4. Adverse events No adverse events with clinical significance were observed in any groups during the study using the chi square test. The number of reported minor adverse effects in the placebo, high-dose, middose and low-dose CDDP groups were 2, 3, 1 and 4, respectively. There was no statistically significant difference in the frequency of adverse effects among the groups (P ¼0.622) using.
4. Discussion Diabetes is a significant metabolic disorder that endangers public health. DR is one of the most common complications of diabetes. With DR, the growth of friable and poor-quality new blood vessels in the retina as well as macular edema can eventually lead to severe vision loss or blindness. The retinal damage makes it the most common
Table 3 Fundoscopic examination data. Placebo
Low-dose
Mid-dose
High-dose
P value
Capillary hemangioma Changes at 12 weeks Changes at 24 weeks
2.09(6.27) 3.40(11.33)
0.89(4.64) 1.55(4.79)
4.25(6.41) 4.89(6.94)
4.41(5.78) 5.61(6.79)
o0.001 o0.001
Hard exudates Changes at 12 weeks Changes at 24 weeks
0.04(0.45) 0.08(0.48)
0.02(0.53) 0.04(0.97)
0.33(0.78) 0.31(0.91)
0.13(1.30) 0.08(1.25)
o0.01 o0.01
Retinal hemorrhage Changes at 12 weeks Changes at 24 weeks
0.12(0.52) 0.22(1.03)
0.15(0.83) 0.12(1.08)
0.49(0.96) 0.56(0.99)
0.30(0.97) 0.24(1.18)
o0.001 o0.001
Cotton spot Changes at 12 weeks Changes at 24 weeks
0.02(0.14) 0.02(0.14)
0.02(0.41) 0.07(0.51)
0.08(0.33) 0.06(0.30)
0.10(0.46) 0.12(0.59)
0.093 0.265
Microvascular abnormalities Changes at 12 weeks Changes at 24 weeks
3(5.36) 3(5.36)
7(12.50) 7(12.50)
4(7.14) 3(5.36)
2(3.64) 3(5.45)
0.375 0.393
Retinal venous beading Changes at 12 weeks Changes at 24 weeks
0(0.00) 0(0.00)
1(1.79) 1(1.79)
3(5.36) 3(5.36)
0(0.00) 0(0.00)
0.197 0.197
Neovascularization Changes at 12 weeks Changes at 24 weeks
1(1.79) 2(3.57)
2(3.57) 2(3.57)
2(3.57) 2(3.57)
0(0.00) 0(0.00)
0.759 0.609
Macular edema Changes at 12 weeks Changes at 24 weeks
5(8.93) 5(8.93)
7(12.50) 8(14.29)
5(9.09) 6(10.91)
7(13.73) 7(13.73)
0.810 0.804
Values are presented in the changes from the baseline, expressed as mean 7 S.D.
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cause of blindness among non-elderly adults. Since Western medicine has limitations in controlling diabetes and its complications, alternative strategies, including the use of Chinese herbal medicines, have been sought (Duan et al., 2011; Gao et al., 2013; Feng et al., 2014; Wang et al., 2014). DR is caused by microangiopathy and capillary closure (Brownlee, 2005), which results in the breakdown of the blood-retinal barrier with retinal hemorrhage, exudate and edema formation, and macular edema. Capillary closure gives rise to cotton spots, arteriovenous shunting and neovascularization (Shah and Chen, 2011). NPDR has been treated by controlling blood glucose levels and blood pressure using prescription medications (Singh et al., 2008; Simó and Hernández, 2009). The Chinese herbal medicine product, CDDP, consists of three herbal medicines, Salvia miltiorrhiza, Panax notoginseng and borneol. The former two are very commonly used herbs for cardiovascular conditions (Park et al., 2014; Y. Xu et al., 2014). Data from animal experiments showed that CDDP increased retinal blood flow, reduced the pulsatility index, resistance index and plasma viscosity, and improved blood perfusion (Zhou et al., 2002). CDDP also played a role in scavenging oxygen free radicals, preventing lipid peroxidation, and reducing the proliferation of endothelial cells (Li et al., 2002; Zhao, 2011). Data from previous clinical studies suggested that CDDP reduced the symptoms of DR. However, most of these studies were not well-controlled trials. In this study, we evaluated the use of CDDP in 223 NPDR patients from 10 clinical research centers with 24 consecutive weeks of treatment and very encouraging data were obtained. The percent of “Excellent” and “Effective” subjects evaluated by FFA was 28%, 38%, 77% and 74% in the placebo, low-dose, mid-dose and high-dose groups, respectively. The percent of “Excellent” and “Effective” subjects evaluated by fundus examination was 11%, 13%, 59% and 42% in the placebo, low-dose, mid-dose and high-dose groups, respectively. High-dose and mid-dose CDDP groups significantly improved multiple parameters, including capillary hemangioma, hard exudates and hemorrhage. Since our study patients were in the early stage DR, there were no significant differences among all study groups in the visual acuity, intra-ocular tension or amount of macular edema. Significant improvement was observed by FFA in the high-dose and mid-dose CDDP treatment groups at 12 weeks (63% and 73%, respectively) and at 24 weeks (74% and 77%, respectively). Also, significant improvement was observed by fundoscopic examination in the high-dose and mid-dose CDDP groups at 12 weeks (42% and 50%, respectively) and at 24 weeks (42% and 59%, respectively). Our results suggested the potential curative effect of CDDP in patients with NPDR and preventive effect of CDDP against the progression of the disease. Among the reported large-scale clinical studies related to NPDR, aspirin reduced the number of microaneurysms present in the macular field and slowed the progression in patients with early DR in conjunction with dipyridamole (The DAMAD Study Group, 1989; Early Treatment Diabetic Retinopathy Study Research Group, 1991; Chew et al., 1995). CDDP possessed similar activities in improving blood circulation, and our data in NPDR subjects from this controlled trial supported the beneficial effects of this herbal drug. It is important to explore the dose-effect relationship in traditional Chinese medicine, including in the herbal medicine used for the treatment of diabetes (Tong et al., 2010, 2011). In this dose-ranging study, we used three CDDP doses to evaluate its effectiveness in DR. Our data showed significant effects of CDDP on NPDR in a dose-related manner. The effects of the high-dose and mid-dose treatment groups were significantly better than those of the low-dose group. Interestingly, there were no differences in the benefits between the high-dose and mid-dose groups, suggesting the clinical therapeutic dose for the NPDR should be somewhere between the high-dose and mid-dose. In addition, consistent with
the previous safety profile of CDDP, there were no serious adverse events reported in this trial. There were some limitations in this study. The clinical observation time in our study was relatively short for a chronic disease like DR. Although we showed that the mid-dose of CDDP is as effective as the high-dose, it is unknown whether CDDP has this dose-related effect in an extended treatment time period. A future large-scale controlled trial with extended observation time, much longer than 24 weeks, is needed to further support the clinical effectiveness of CDDP. In addition, vascular endothelial growth factor (VEGF) is an important mediator of angiogenesis in the eye (Nguyen et al., 2006). Thus, future study is needed to evaluate the effects of CDDP on VEGF expression. In summary, using FFA and fundoscopic examinations, we observed significant effectiveness CDDP on NPDR in this randomized, double-blind, placebo-controlled, dose-ranging multicenter trial. Our data suggest that this Chinese herbal medicine product has a role in treating NPDR and in delaying the progression of NPDR to the proliferative diabetic retinopathy.
Acknowledgments The efforts of many institutions and scholars made the execution of this project possible. We sincerely thank all the individuals and their affiliated institutions that contributed to this project. We also would like to thank the Tasly Pharmaceutical Group Co., Tianjin, China for providing the Compound Danshen Dripping Pill (CDDP) and placebo pills. This work was supported in part by the National Basic Research Program of China (973 Program, No. 2010CB530600). References ACCORD Study Group, ACCORD Eye Study Group, 2010. Effects of medical therapies on retinopathy progression in type 2 diabetes. New England Journal of Medicine 363, 233–244. American Association of Ophthalmology, 2006. Preferred Practice Pattern. People's Medical Publishing House, Beijing, pp. 184–187. Brownlee, M., 2005. The pathobiology of diabetic complications: a unifying mechanism. Diabetes 54, 1615–1625. Chew, E.Y., Klein, M.L., Murphy, R.P., Remaley, N.A., Ferris, F.L., 1995. Effects of aspirin on vitreous/preretinal hemorrhage in patients with diabetes mellitus. Archives of Ophthalmology 113, 52–55. Chu, Y., Zhang, L., Wang, X.Y., Guo, J.H., Guo, Z.X., Ma, X.H., 2011. The effect of compound dripping pills, a Chinese herb medicine, on the pharmacokinetics and pharmacodynamics of warfarin in rats. Journal of Ethnopharmacology 137, 1457–1461. Congdon, N.G., Friedman, D.S., Lietman, T., 2003. Important causes of visual impairment in the world today. Journal of American Medical Association 290, 2057–2060. Duan, J.G., Jin, M., Jie, C.H., Ye, H.J., 2011. Standard of TCM diagnosis and treatment of diabetic retinal lesions. World Journal of Integrated Traditional and Western Medicine 6, 632–637. Early Treatment Diabetic Retinopathy Study Research Group, 1991. Effects of aspirin treatment on diabetic retinopathy. Ophthalmology 98, 757–765. Feng, L., Liu, W.K., Deng, L., Tian, J.X., Tong, X.L., 2014. Clinical efficacy of aconitumcontaining traditional Chinese medicine for diabetic peripheral neuropathic pain. American Journal of Chinese Medicine 42, 109–117. Gao, Y., Zhou, H., Zhao, H., Feng, X., Feng, J., Li, Y., Zhang, H., Lu, H., Qian, Q., Yu, X., Zhang, N., Yu, J., Ni, Q., Pan, M., 2013. Clinical research of traditional Chinese medical intervention on impaired glucose tolerance. American Journal of Chinese Medicine 41, 21–32. Li, J., Lin, J., Li, Z., Huang, X.M., Cao, Y.X., 2002. Research of compound danshen dripping pills in the changes in hemorheology in experimental hyperlipidemia rats. Journal of Traditional Chinese Medicine 20, 496–497. Li, X., Wang, Z., 2013. Prevalence and incidence of retinopathy in elderly diabetic patients receiving early diagnosis and treatment. Experimental and Therapeutic Medicine 5, 1393–1396. Nguyen, Q.D., Tatlipinar, S., Shah, S.M., Haller, J.A., Quinlan, E., Sung, J., Zimmer-Galler, I., Do, D.V., Campochiaro, P.A., 2006. Vascular endothelial growth factor is a critical stimulus for diabetic macular edema. American Journal of Ophthalmology 142, 961–969. Park, C.H., Kim, D.H., Park, M.H., Kim, M.K., Kim, N.D., Kim, C.M., Tanaka, T., Yokozawa, T., Chung, H.Y., Moon, H.R., 2014. Chinese prescription Kangenkaryu and Salviae miltiorrhizae radix improve age-related oxidative stress and inflammatory response through the PI3K/Akt or MAPK pathways. American Journal of Chinese Medicine 42, 987–1005.
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Qi, Z.X., Tan, X.H., Li, Q.G., Wang, X.L., 2007. The clinical research of compound danshen dripping pills in the treatment of diabetic retinopathy. Journal of Chinese Medicinal Materials 30, 375–377. Schwartz, S.G., Flynn, H.W., 2007. Pharmacotherapies for diabetic retinopathy: present and future. Experimental Diabetes Research 2007, 52487. Shah, C.P., Chen, C., 2011. Review of therapeutic advances in diabetic retinopathy. Therapeutic Advances in Endocrinology and Metabolism 2, 39–53. Simó, R., Hernández, C., 2009. Advances in the medical treatment of diabetic retinopathy. Diabetes Care 32, 1556–1562. Singh, R., Ramasamy, K., Abraham, C., Gupta, V., Gupta, A., 2008. Diabetic retinopathy: an update. Indian Journal of Ophthalmology 56, 178–188. The DAMAD Study Group, 1989. Effect of aspirin alone and aspirin plus dipyridamole in early diabetic retinopathy. A multicenter randomized controlled clinical trial. Diabetes 38, 491–498. Tong, X.L., Wang, Y.S., Fu, Y.L., Xu, G.L., Lian, F.M., Rao, Y., Yu, R.Y., Song, J., Liu, F., Zhao, L.H., Jiao, Y.Z., 2010. Discussion on relationship between dose and effect. Journal of Traditional Chinese Medicine 51, 965–967. Tong, X.L., Zhao, L.H., Lian, F.M., Zhou, Q., Xia, L., Zhang, J.C., Chen, X.Y., Ji, H.Y., 2011. Clinical observations on the dose–effect relationship of Gegen qin lian decoction on 54 out-patients with type 2 diabetes. Journal of Traditional Chinese Medicine 31, 56–59. Wang, C.Y., Bai, X.Y., Wang, C.H., 2014. Traditional Chinese medicine: a treasured natural resource of anticancer drug research and development. American Journal of Chinese Medicine 42, 543–559. Xu, H., Wang, D., Peng, C., Huang, X., Ou, M., Wang, N., Wang, P., Zhou, L., Ye, X., 2014. Rabbit sera containing compound danshen dripping pill attenuate
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leukocytes adhesion to TNF-alpha-activated human umbilical vein endothelial cells by suppressing endothelial ICAM-1 and VCAM-1 expression through NFkappaB signaling pathway. Journal of Cardiovascular Pharmacology 6, 323–332. Xu, Y., Lin, L., Tang, L., Zheng, M., Ma, Y., Huang, L., Men, W., Wang, W., 2014. Notoginsenoside R1 attenuates hypoxia and hypercapnia-induced vasoconstriction in isolated rat pulmonary arterial rings by reducing the expression of ERK. American Journal of Chinese Medicine 42, 799–816. Yang, P.J., Li, S.M., Lv, Y.P., Huang, Z.Y., Huang, H., 2013. Effect of compound danshen dripping pills on vascular endothelial function in early diabetic retinopathy patients. Chinese Journal of Experimental Traditional Medical Formulae 19, 340–343. Yang, R., Chang, L., Guo, B.Y., Wang, Y.W., Wang, Y.L., Jin, X., Liu, S.Y., Li, Y.J., 2014. Compound danshen dripping pill pretreatment to prevent contrast-induced nephropathy in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Evidence Based Complementary and Alternative Medicine 2014, 256268. Zhao, Q.P., 2011. Study on the establishment and compound danshen dripping pills of blood stasis in rat model of acute blood stasis. Journal of Ningxia Medical University 33, 849–852. Zhou, S.P., Guo, Z.X., Tong, X.L., Pan, L., Zhao, J.B., 2002. Effect of compound danshen dripping pills on rats with diabetic retinopathy. World Journal of Integrated Traditional and Western Medicine 22, 174–178. Zhou, S.P., Tong, X.L., Pan, L., Gao, W.Y., 2006. Apoptosis effects of Luotong on retinal capillary in different course of diabetic rats. China Journal of Traditional Chinese Medicine and Pharmacy 21, 273–275.
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Journal of Ethnopharmacology journal homepage: www.elsevier.com/locate/jep
Research Paper
The effectiveness and safety of a danshen-containing Chinese herbal medicine for diabetic retinopathy: A randomized, double-blind, placebo-controlled multicenter clinical trial Fengmei Lian a,1, Lie Wu a,1, Jiaxing Tian a,1, Ming Jin b, Shuiping Zhou c, Min Zhao c, Lijuan Wei d, Yanlin Zheng e, Yuliang Wang f, Mingchang Zhang g, Wei Qin h, Zhifeng Wu i, Chun-Su Yuan j,nn, Xiaolin Tong a,n a
Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China China–Japan Friendship Hospital, Beijing 100029, China Tasly Pharmaceutical Co., Tianjin 300410, China d The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun 130021, China e The Affiliated Hospital to Chengdu University of Chinese Medicine, Chengdu 610032, China f Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing 210005, China g The Affiliated Union Hospital to Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China h First Affiliated Hospital of Third Military Medical University, Chongqing 400038, China i Wuxi Number 2 People's Hospital, Wuxi 214002, China j Tang Center for Herbal Medicine Research, Pritzker School of Medicine, University of Chicago, IL 60037, USA b c
art ic l e i nf o
a b s t r a c t
Article history: Received 23 September 2014 Received in revised form 6 December 2014 Accepted 15 January 2015 Available online 7 February 2015
Ethnopharmacological relevance: Salvia miltiorrhiza (Danshen in Chinese) is a common traditional Chinese herbal medicine often used to treat many medical conditions. The Compound Danshen Dripping Pill (CDDP) is a danshen-containing Chinese herbal product for the treatment of cardiovascular diseases. However, to date, no controlled clinical studies have been conducted to evaluate the effects of CDDP on diabetic retinopathy (DR). Aim of the study: The present large-scale clinical trial was designed to assess the effectiveness and safety of CDDP in treating patients with non-proliferative diabetic retinopathy (NPDR). Materials and methods: 223 NPDR patients were enrolled in this controlled trial. Subjects received oral study medications three times daily for 24 weeks. The four groups were placebo, low-dose (270 mg), mid-dose (540 mg) and high dose (810 mg herbal medicine). Primary endpoints were changes in fluorescence fundus angiography (FFA) and fundoscopic examination parameters. Results and discussion: At 24 weeks, for the FFA, the percent of “Excellent” and “Effective” in the highdose and mid-dose CDDP groups was 74% and 77%, respectively, very significantly higher than 28% in the placebo group (Po 0.001). For fundoscopic examination, the percent of “Excellent” and “Effective” in the high-dose and mid-dose CDDP groups was 42% and 59%, respectively, very significantly higher than 11% in the placebo group (Po 0.001). No adverse events with clinical significance were observed. Conclusions: DR is a severe microvascular complication of diabetes and a major cause of adult blindness worldwide. Our clinical trial data demonstrated the therapeutic value and safety of a danshen-containing Chinese herbal medicine in patients with diabetic retinopathy. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Diabetic retinopathy Salvia miltiorrhiza Panax notoginseng Fluorescence fundus angiography (FFA) Fundoscopic examination Glycosylated hemoglobin (HbA1c)
1. Introduction
n
Corresponding author. Correspondence to: Tang Center for Herbal Medicine Research, The Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 4028, Chicago, IL 60637, USA. E-mail addresses: [email protected] (C.-S. Yuan), [email protected] (X. Tong). 1 Fengmei Lian, Lie Wu and Jiaxing Tian are the co-first authors in this work. nn
http://dx.doi.org/10.1016/j.jep.2015.01.048 0378-8741/& 2015 Elsevier Ireland Ltd. All rights reserved.
Diabetic retinopathy (DR), a severe microvascular complication of diabetes (Congdon et al., 2003), is a major cause of adult blindness worldwide. The prevalence of DR in China for individuals over 60 years of age is approximately 16%, and its incidence is 8.38/1000 person-years (Li and Wang, 2013). Treatment of DR includes medical management to control blood sugar, blood pressure and serum lipids, ocular management, and adjunctive pharmacologic therapies (Schwartz and Flynn, 2007; Simó and Hernández, 2009; ACCORD
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Study Group, ACCORD Eye Study Group, 2010). However, these approaches for DR management have limitations including invasive procedures and side effects of drug therapy (Schwartz and Flynn, 2007; Simó and Hernández, 2009; Feng et al., 2014). To date, there are no measures to effectively control the progression of DR. Thus, there is a strong motivation for exploring alternative strategies, including the use of Chinese herbal medicines, in DR therapeutics. Salvia miltiorrhiza (Danshen in Chinese) is a very commonly used traditional Chinese herbal medicine. Compound Danshen Dripping Pill (CDDP) is a Chinese herbal medicine product used for the treatment of cardiovascular diseases (Chu et al., 2011). It contains the extract from danshen (Salvia miltiorrhiza), notoginseng (Panax notoginseng; or Sanchi in Chinese), and borneol. These three traditional Chinese medicines have been used for over a thousand years to treat many medical conditions. The CDDP promotes blood circulation and alleviates pain (Chu et al., 2011). Based on the theory of traditional Chinese medicine (TCM), the pathogenesis of DR is due to blood stasis that damages collateral vessels in the eye (Duan et al., 2011). Published animal experiments using different animal models and clinical trials in DR patients have demonstrated that CDDP can improve the symptoms of DR (Zhou et al., 2002, 2006; Qi et al., 2007; Yang et al., 2013). In addition, CDDP has been studied in different body systems with a good safety record (H. Xu et al., 2014; Yang et al., 2014). However, to date, no controlled clinical trial has been conduced to evaluate the effects of CDDP on DR. In the present study, a randomized, double-blind, placebo-controlled, dose-ranging and multicenter clinical trial was conducted. We recruited glycemic-controlled DR patients with non-proliferative diabetic retinopathy (NPDR). These subjects were randomly assigned into four groups, and they received either placebo or three different doses of CDDP to explore the optimal therapeutic dose. The primary endpoints were changes in fluorescence fundus angiography (FFA) and fundoscopic examination parameters after 24 weeks of CDDP treatment. In addition, corrected visual acuity, intraocular pressure, glycosylated hemoglobin (HbA1c) and fasting plasma glucose (FPG) were obtained in these subjects. The safety profile of the CDDP in the study subjects was also collected.
2. Materials and methods 2.1. Study subjects The research protocol was approved by the local Medical Ethics Commission in China, and was implemented in accordance with the provisions of the Declaration of Helsinki.
The inclusion criteria were as follows: (1) Subjects were 30–70 years old. (2) Subjects were diagnosed with NPDR (American Association of Ophthalmology, 2006). (3) Subjects were on a stable oral hypoglycemic treatment for at least three months. (4) Subjects signed written informed consent. Exclusion criteria were as follows: (1) Subjects had HbA1c level 48%. (2) Subjects were treated with retinal photocoagulation or suitable for laser photocoagulation with proliferative diabetic retinopathy in one eye or both eyes. (3) Subjects were taking DR medications. (4) Subjects had other eye diseases, including glaucoma, with cataracts affecting fundoscopic examination. (5) Subjects had received cataract surgery within the previous 3 months. (6) Subjects had nondiabetic retinopathy, uveitis, retinal detachment, optic nerve diseases or highly myopic eyes. (7) Subjects had significant cardiovascular, liver, kidney, or hematopoietic systems diseases, mental illness, and other serious medical conditions. (8) Subjects had diabetic nephropathy with kidney failure. (9) Subjects were pregnant, planning to become pregnant, or lactating. (10) Subjects were allergic to Chinese herbal medicines. (11) Subjects had participated in any other clinical trials in the previous month. 2.2. Botanical materials The study's herbal drug, Compound Danshen Dripping Pill (CDDP) was obtained from the Tasly Pharmaceutical Group Co., Tianjin, China. The CDDP contains the extract from danshen (Salvia miltiorrhiza), notoginseng (Panax notoginseng) and borneol. 2.3. Study protocol After an initial screening visit, 223 glycemic-controlled patients with NPDR were recruited from 10 clinical research centers in China. All subjects received standard treatment without any diet intervention. A stratified, block randomization method was conducted by a biostatistician. Patients were assigned into four groups receiving placebo (n ¼56), low-dose CDDP (n ¼56), mid-dose CDDP (n ¼56) and high-dose CDDP (n ¼55) (Fig. 1). Subjects were orally administered study medications with plain water three times daily. Each CDDP pill contains 27 mg of herbal medicine. For each administration, subjects in the placebo group received 30 placebo pills, subjects in the low-dose CDDP group received 10 CDDP pills plus 20 placebo pills (270 mg herbal medicine), subjects in the mid-dose CDDP group received 20 CDDP pills plus 10 placebo pills (540 mg herbal medicine), and subjects in the high-dose CDDP group received 30 CDDP pills (810 mg herbal medicine). Placebo pills, which contained starch and caramel, had the same appearance as the CDDP pills, and were
Fig. 1. Flow diagram of study subjects randomization and the completion of the trial.
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obtained from the same manufacture. All study medications were provided by Tasly Pharmaceutical Group Co., China. The treatment for each group lasted consecutive 24 weeks. 2.4. Evaluation of effectiveness
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pre-treatment, 12 weeks and 24 weeks. Adverse events were assessed using vital signs, clinical signs and symptoms, laboratory examinations, and results were recorded at each visit. 2.6. Statistical analysis
Primary endpoints of this study were changes in fluorescence fundus angiography (FFA) and fundoscopic examination parameters after 24 weeks of the CDDP treatment. The following clinical evaluations were conduced at pre-treatment, 12 weeks, and 24 weeks: (1) FFA, (2) fundoscopic examination, (3) HbA1c, and (4) FPG. At pre-treatment and 24 weeks, a retinopathy severity evaluation was conduced. At pre-treatment and every 4 weeks during the study period, visual acuity and intraocular pressure examinations were conduced. Results were recorded after each visit. The FFA data was based on the retinal circulation time, retinal capillary non-perfusion, and vascular leakage. “Excellent” denoted one of total retinal circulation time, retinal capillary non-perfusion area and vascular leakage improved over 20%, while the others did not deteriorate. “Effective” denoted one of the total retinal circulation time, retinal capillary non-perfusion area and vascular leakage improved between 10% and 20%, while the others did not deteriorate. “Worsened” denoted one of the total retinal circulation time, retinal capillary non-perfusion area and vascular leakage deteriorated over 10%. “Stable” denoted cases other than “Excellent”, “Effective” and “Worsened”. The fundoscopic examination data was based on the degree of retinal microangiopathy and macular edema. “Excellent” denoted both retinal microangiopathy and macular edema alleviated. “Effective” denoted retinal microangiopathy alleviated, while macular edema did not deteriorate. “Worsened” denoted either retinal microangiopathy or macular edema deteriorated or neovascularization was found. “Stable” denoted cases other than “Excellent”, “Effective” and “Worsened”. 2.5. Safety monitoring and adverse event observation Routine blood, urine and stool tests, electrocardiogram, liver function, creatine kinase, and renal function were measured at
Data were presented as the mean7S.D. Statistical software SAS8.0 was used for the data analysis. The primary analysis was conducted in the intention-to-treat (ITT) population using a full analysis set (FAS). For the data presentation in different groups, groups were compared using a variance test or the Kruskal–Wallis (K–W) test. Also, the ranked data was evaluated using the K–W test. For the adverse events analysis, a chi square test or fisher exact test was used. Po0.05 was considered statistically significant.
3. Results From the 10 clinical research centers, 223 subjects who met the inclusion criteria and exclusion criteria were enrolled in the study. The mean age of the subjects was 59.3 years old, and among them 41.7% were male subjects. The average duration of NPDR in these patients was 29.7 months. There were no significant differences in the baseline variables of the four groups. The subjects’ baseline characteristics are shown in Table 1 using the Kruskal–Wallis test. Among them, 182 subjects completed the study (Fig. 1). 3.1. FFA examination Compared to the placebo, subjects who received middle-dose and high-dose CDDP had significant improvements in FFA results at 12 and 24 weeks (Fig. 2). At 24 weeks, the number of “Excellent” subjects on FFA in the placebo, low-dose, mid-dose and high-dose groups was 4, 6, 21 and 20, respectively. The number of “Effective” subjects in these four groups was 9, 9, 12 and 12, respectively. The number of “Worsened” subjects in these four groups was 15, 13, 1 and 4, respectively. As shown in Fig. 2B, the percent of “Excellent” and “Effective” in the high-dose, mid-dose and low-dose CDDP
Table 1 Characteristics of study subjects at baseline. Placebo (n¼ 56)
Low-dose (n¼ 56)
Mid-dose (n¼ 56)
High-dose (n¼55)
P value
Age (years) Gender (M/F) Height (m) Weight (kg) Heart rate (beat/min) Respiration rate (/min) Systolic pressure (mmHg) Diastolic pressure (mmHg) Duration of diabetes (month) Duration of DR (month) Corrected visual acuity Intraocular pressure (mmHg) Total retinal circulation time (s) Retinal capillary non-perfusion (PD) Vascular leakage (PD)
58.9 7 7.6 27/29 1.6 7 0.1 64.07 10.0 72.7 79.4 18.5 71.4 127.0 7 12.4 77.7 7 8.6 119.0 761.7 27.17 27.9 4.8 7 0.2 15.4 7 2.4 8.5 7 4.1 0.2 7 0.6 0.2 7 0.7
59.9 7 6.0 18/38 1.6 70.1 62.7 7 11.4 73.9 7 10.7 18.6 7 1.3 127.4 7 13.7 77.9 7 9.0 129.3 7 65.0 31.7 736.1 4.8 7 0.2 15.4 7 2.5 8.1 7 2.5 0.2 7 0.5 0.7 7 1.7
58.9 7 8.1 25/31 1.7 70.1 66.5 711.2 74.3 7 8.9 18.8 7 1.4 128.5 7 11.2 79.9 7 7.3 117.5 7 67.4 24.07 25.1 4.9 7 0.2 15.4 7 2.6 9.36 7 3.6 0.3 7 0.9 0.17 0.3
59.5 7 8.7 23/32 1.6 7 0.1 65.9 7 12.4 74.8 710.9 18.8 72.0 129.17 11.3 78.3 7 8.6 131.4 7 71.3 36.0 7 38.1 4.8 7 0.2 15.3 7 2.5 8.9 7 3.2 0.6 7 2.8 0.5 7 1.8
0.86 0.35 0.30 0.19 0.85 0.71 0.65 0.75 0.65 0.51 0.50 0.96 0.33 0.47 0.20
Fundus changes Capillary hemangioma Hard exudates Cotton spot Bleeding Microvascular abnormal (%) Venous beading (%) Macular edema (%) Neovascularization (%)
9.0 7 7.9 0.5 7 0.8 0.1 70.6 0.9 7 2.1 2(3.6) 0(0.0) 4(7.4) 1(1.8)
9.0 7 6.6 0.7 7 1.6 0.1 7 0.5 1.3 72.7 6(10.7) 1(1.8) 7(12.5) 0(0.0)
12.5 7 9.6 1.4 72.3 0.17 0.5 1.17 3.4 4(7.1) 3(5.4) 5(9.1) 2(3.6)
13.4 7 10.2 1.17 2.4 0.1 70.83 1.4 7 2.3 3(5.6) 0(0.0) 7(13.8) 0(0.0)
0.17 0.06 0.75 0.17 0.54 0.20 0.70 0.52
Values are expressed as mean7 S.D.
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groups was 74.42%, 76.75%, and 37.50%, respectively, very significantly higher than 28.27% in the placebo group (Po0.001). At 24 weeks, compared to the placebo group, the effects of CDDP on FFA were very significantly better in the middle-dose and high-dose group (P o0.001). There was no significant difference in the low-dose group and placebo (P¼ 0.444). The improvement of the middle-dose group and high-dose group was significantly greater than that of the low-dose group (both Po 0.01). There was no statistically significant difference in the improvement of the middle-dose group and high-dose group (P¼ 0.557).
Table 2 shows the FFA examination data. The retinal circulation time of the low-dose, mid-dose and high-dose CDDP groups were shorter than that of the placebo group at 24 weeks. Compared to the placebo group, the time was shortened very significantly in the middose (Po0.001) and high-dose groups (Po0.001), but there was no statistically significant difference in the circulation time of the low-dose and placebo groups (P¼ 0.569). However, there were no statistically significant differences in the values of the capillary non-perfusion area and vascular leakage among the CDDP treatment and placebo groups. The Kruskal–Wallis test was for the above analysis.
Fig. 2. Distribution of “Excellent”, “Effective”, “Stable” and “Worsened” after fluorescence fundus angiography (FFA) in subjects who received placebo, low-dose, mid-dose and high-dose of CDDP administrations. (A) FFA results at 12 weeks. (B) FFA results at 24 weeks. At 24 weeks, the percent of “Excellent” and “Effective” in the high-dose and middose CDDP groups is very significantly higher than that in the placebo group (Po0.001). For the definition of “Excellent”, “Effective”, “Stable” and “Worsened”, see “Evaluation of effectiveness” in Section 2.
Fig. 3. Distribution of “Excellent”, “Effective”, “Stable” and “Worsened” after fundoscopic examination in subjects who received placebo, low-dose, mid-dose and high-dose of CDDP administrations. (A) fundoscopic results at 12 weeks. (B) fundoscopic results at 24 weeks. At 24 weeks, the percent of “Excellent” and “Effective” in the high-dose and middose CDDP groups is very significantly higher than that in the placebo group (Po0.001). For the definition of “Excellent”, “Effective”, “Stable” and “Worsened”, see “Evaluation of effectiveness” in Section 2.
Table 2 Fundoscopic fluorescein angiography (FFA) examination data. Placebo
Low-dose
Mid-dose
High-dose
P value
Total retinal circulation time (s) Changes at 12 weeks Changes at 24 weeks
0.62(3.02) 0.22(2.27)
0.29(1.81) 0.10(2.08)
1.60(2.23) 1.71(2.37)
1.32(2.15) 1.39(1.97)
o 0.001 o 0.001
Capillary non-perfusion area (PD) Changes at 12 weeks Changes at 24 weeks
0.02(0.14) 0.04(0.19)
0.13(0.61) 0.13(0.55)
0.00(0.02) 0.02(0.14)
0.03(0.15) 0.03(0.19)
0.158 0.071
Vascular leakage (PD) Changes at 12 weeks Changes at 24 weeks
0.05(0.20) 0.05(0.20)
0.10(0.55) 0.12(0.63)
0.01(0.05) 0.01(0.05)
0.01(0.07) 0.00(0.00)
Values are presented in the changes from the baseline, expressed mean 7S.D.
o 0.05 o 0.05
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3.2. Fundoscopic examination Compared to those who received the placebo, subjects who received middle-dose and high-dose CDDP had significant improvements in fundoscopic results at 12 and 24 weeks (Fig. 3). At 24 weeks, a number of subjects treated with mid-dose and high-dose CDDP had significantly improved fundoscopic examination parameters. The number of “Excellent” subjects on fundoscopic examination in the placebo, low-dose, mid-dose and high-dose groups was 1, 1, 14 and 8, respectively. The number of “Effective” subjects in these four groups was 5, 6, 15 and 13, respectively. The number of “Worsened” subjects in these four groups was 23, 13, 2 and 4, respectively. As shown in Fig. 3B, the percent of “Excellent” and “Effective” in the high-dose, mid-dose and low-dose CDDP groups was 42.00%, 59.18%, and 13.46%, respectively, very significantly higher than 10.91% in the placebo group (Po0.001). At 24 weeks, compared to the placebo group, the effects of CDDP on the fundoscopic examination parameters were very significantly better in the middle-dose (Po 0.001) and high-dose groups (P o0.001). There was no statistically significant difference in the low-dose and placebo groups (P¼ 0.140). The improvements of the middle-dose group and high-dose group were significantly greater than that of the low-dose group (both P o0.01). There was no statistically significant difference in the improvement of the middle-dose group and high-dose group (P¼ 0.311). Fundoscopic examination data are presented in Table 3. At 24 weeks, subjects in the CDDP treatment groups had significantly fewer capillary hemangioma than those in the placebo group (Po0.001). Also, subjects in the CDDP treatment groups had significantly fewer hard exudates at 24 weeks. The middle-dose and high-dose groups had fewer hard exudates than the placebo group (both Po0.01). There was no statistically significant difference in the amount of hard exudates in the low-dose group and placebo group (P¼0.741). In addition, subjects in the CDDP treatment groups had less retinal hemorrhaging at 24 weeks. Subjects in the mid-dose and high-dose groups had significantly less retinal hemorrhaging than the placebo
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group (both Po0.001). However, there were no statistically significant differences in the values cotton spots, microvascular abnormalities, retinal vein beading, neovascularization and macular edema among the CDDP treatment and placebo groups. In addition, no statistically significant differences in retinopathy severity classification were observed among the three CDDP treatment groups and the placebo group (P¼ 0.671). Further, no significant differences in corrected visual acuity and intraocular pressure were observed among the three CDDP treatment groups and the placebo group (P ¼0.767 and P ¼0.760, respectively). The Kruskal–Wallis test was for the above analysis. 3.3. Effects on HbA1c and FPG HbA1c and FPG levels were evaluated at 12 and 24 weeks using the Kruskal–Wallis test. There were no statistically significant differences among the placebo and CDDP treatment groups (at 24 weeks, P ¼0.768 for HbA1c and P ¼0.411 for FPG). 3.4. Adverse events No adverse events with clinical significance were observed in any groups during the study using the chi square test. The number of reported minor adverse effects in the placebo, high-dose, middose and low-dose CDDP groups were 2, 3, 1 and 4, respectively. There was no statistically significant difference in the frequency of adverse effects among the groups (P ¼0.622) using.
4. Discussion Diabetes is a significant metabolic disorder that endangers public health. DR is one of the most common complications of diabetes. With DR, the growth of friable and poor-quality new blood vessels in the retina as well as macular edema can eventually lead to severe vision loss or blindness. The retinal damage makes it the most common
Table 3 Fundoscopic examination data. Placebo
Low-dose
Mid-dose
High-dose
P value
Capillary hemangioma Changes at 12 weeks Changes at 24 weeks
2.09(6.27) 3.40(11.33)
0.89(4.64) 1.55(4.79)
4.25(6.41) 4.89(6.94)
4.41(5.78) 5.61(6.79)
o0.001 o0.001
Hard exudates Changes at 12 weeks Changes at 24 weeks
0.04(0.45) 0.08(0.48)
0.02(0.53) 0.04(0.97)
0.33(0.78) 0.31(0.91)
0.13(1.30) 0.08(1.25)
o0.01 o0.01
Retinal hemorrhage Changes at 12 weeks Changes at 24 weeks
0.12(0.52) 0.22(1.03)
0.15(0.83) 0.12(1.08)
0.49(0.96) 0.56(0.99)
0.30(0.97) 0.24(1.18)
o0.001 o0.001
Cotton spot Changes at 12 weeks Changes at 24 weeks
0.02(0.14) 0.02(0.14)
0.02(0.41) 0.07(0.51)
0.08(0.33) 0.06(0.30)
0.10(0.46) 0.12(0.59)
0.093 0.265
Microvascular abnormalities Changes at 12 weeks Changes at 24 weeks
3(5.36) 3(5.36)
7(12.50) 7(12.50)
4(7.14) 3(5.36)
2(3.64) 3(5.45)
0.375 0.393
Retinal venous beading Changes at 12 weeks Changes at 24 weeks
0(0.00) 0(0.00)
1(1.79) 1(1.79)
3(5.36) 3(5.36)
0(0.00) 0(0.00)
0.197 0.197
Neovascularization Changes at 12 weeks Changes at 24 weeks
1(1.79) 2(3.57)
2(3.57) 2(3.57)
2(3.57) 2(3.57)
0(0.00) 0(0.00)
0.759 0.609
Macular edema Changes at 12 weeks Changes at 24 weeks
5(8.93) 5(8.93)
7(12.50) 8(14.29)
5(9.09) 6(10.91)
7(13.73) 7(13.73)
0.810 0.804
Values are presented in the changes from the baseline, expressed as mean 7 S.D.
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cause of blindness among non-elderly adults. Since Western medicine has limitations in controlling diabetes and its complications, alternative strategies, including the use of Chinese herbal medicines, have been sought (Duan et al., 2011; Gao et al., 2013; Feng et al., 2014; Wang et al., 2014). DR is caused by microangiopathy and capillary closure (Brownlee, 2005), which results in the breakdown of the blood-retinal barrier with retinal hemorrhage, exudate and edema formation, and macular edema. Capillary closure gives rise to cotton spots, arteriovenous shunting and neovascularization (Shah and Chen, 2011). NPDR has been treated by controlling blood glucose levels and blood pressure using prescription medications (Singh et al., 2008; Simó and Hernández, 2009). The Chinese herbal medicine product, CDDP, consists of three herbal medicines, Salvia miltiorrhiza, Panax notoginseng and borneol. The former two are very commonly used herbs for cardiovascular conditions (Park et al., 2014; Y. Xu et al., 2014). Data from animal experiments showed that CDDP increased retinal blood flow, reduced the pulsatility index, resistance index and plasma viscosity, and improved blood perfusion (Zhou et al., 2002). CDDP also played a role in scavenging oxygen free radicals, preventing lipid peroxidation, and reducing the proliferation of endothelial cells (Li et al., 2002; Zhao, 2011). Data from previous clinical studies suggested that CDDP reduced the symptoms of DR. However, most of these studies were not well-controlled trials. In this study, we evaluated the use of CDDP in 223 NPDR patients from 10 clinical research centers with 24 consecutive weeks of treatment and very encouraging data were obtained. The percent of “Excellent” and “Effective” subjects evaluated by FFA was 28%, 38%, 77% and 74% in the placebo, low-dose, mid-dose and high-dose groups, respectively. The percent of “Excellent” and “Effective” subjects evaluated by fundus examination was 11%, 13%, 59% and 42% in the placebo, low-dose, mid-dose and high-dose groups, respectively. High-dose and mid-dose CDDP groups significantly improved multiple parameters, including capillary hemangioma, hard exudates and hemorrhage. Since our study patients were in the early stage DR, there were no significant differences among all study groups in the visual acuity, intra-ocular tension or amount of macular edema. Significant improvement was observed by FFA in the high-dose and mid-dose CDDP treatment groups at 12 weeks (63% and 73%, respectively) and at 24 weeks (74% and 77%, respectively). Also, significant improvement was observed by fundoscopic examination in the high-dose and mid-dose CDDP groups at 12 weeks (42% and 50%, respectively) and at 24 weeks (42% and 59%, respectively). Our results suggested the potential curative effect of CDDP in patients with NPDR and preventive effect of CDDP against the progression of the disease. Among the reported large-scale clinical studies related to NPDR, aspirin reduced the number of microaneurysms present in the macular field and slowed the progression in patients with early DR in conjunction with dipyridamole (The DAMAD Study Group, 1989; Early Treatment Diabetic Retinopathy Study Research Group, 1991; Chew et al., 1995). CDDP possessed similar activities in improving blood circulation, and our data in NPDR subjects from this controlled trial supported the beneficial effects of this herbal drug. It is important to explore the dose-effect relationship in traditional Chinese medicine, including in the herbal medicine used for the treatment of diabetes (Tong et al., 2010, 2011). In this dose-ranging study, we used three CDDP doses to evaluate its effectiveness in DR. Our data showed significant effects of CDDP on NPDR in a dose-related manner. The effects of the high-dose and mid-dose treatment groups were significantly better than those of the low-dose group. Interestingly, there were no differences in the benefits between the high-dose and mid-dose groups, suggesting the clinical therapeutic dose for the NPDR should be somewhere between the high-dose and mid-dose. In addition, consistent with
the previous safety profile of CDDP, there were no serious adverse events reported in this trial. There were some limitations in this study. The clinical observation time in our study was relatively short for a chronic disease like DR. Although we showed that the mid-dose of CDDP is as effective as the high-dose, it is unknown whether CDDP has this dose-related effect in an extended treatment time period. A future large-scale controlled trial with extended observation time, much longer than 24 weeks, is needed to further support the clinical effectiveness of CDDP. In addition, vascular endothelial growth factor (VEGF) is an important mediator of angiogenesis in the eye (Nguyen et al., 2006). Thus, future study is needed to evaluate the effects of CDDP on VEGF expression. In summary, using FFA and fundoscopic examinations, we observed significant effectiveness CDDP on NPDR in this randomized, double-blind, placebo-controlled, dose-ranging multicenter trial. Our data suggest that this Chinese herbal medicine product has a role in treating NPDR and in delaying the progression of NPDR to the proliferative diabetic retinopathy.
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