UJI KLINIK DAN EVIDENCE-BASED

HERBAL MEDICINES

oleh :
Prof.Dr.dr.M.T.Kamaluddin, MSc.,SpFK
Ketua Bagian Farmakologi
Fakultas Kedokteran Unsri

Kuliah Pilihan
Fakultas Kedokteran
Universitas Muhammadiah Palembang
Palembang, 11 Desember 2015
Objektif

1. Isolasi zat aktif herbal/Obat Tradisional

Indonesia (OTI)

2. Uji zat aktif secara preklinik & klinik

3. Pantau khasiat – efek samping -

farmakovigilan
WHO
Traditional medicine refers to health
practices, approaches, knowledge and
beliefs incorporating plant, animal and
mineral based medicines, spiritual
therapies, manual techniques and
exercises, applied singularly or in
combination to treat, diagnose and
prevent illnesses or maintain well-being.

3
Chinese Herb Leaves
Kunci Penggunaan Produk Obat
Herbal ;
Berkhasiat - Aman

Awareness Acceptability
• Increasing use • Market
• > 80 % world pop • Quality
•Collection, handling,
processing, production
• Price
Herbal products

Abuse Adulteration
• Hazards • Social problems

5
 Efek dan
Kelas Contoh Senyawa Contoh Sumber
kegunaan
SENYAWA
MENGANDUNG
NITROGEN Arah
Mempengaruhi Farmakognosi
Nikotin, kokain, neurotransmisi dan
Alkaloid Tembakau, coklat
teobromin menghambat kerja
enzim

TERPENOID
Metabolit Sekunder
Mempengaruhi Tumbuhan
sebagai obat modern
Tumbuhan mint dan
neurotransmisi,
Monoterpena Mentol, linalool banyak tumbuhan
menghambat transpor
lainnya
ion, anestetik

Menghambat fosforilasi,
1.Alkaloid – Rauvolvia
Diterpena Gossypol Kapas
toksik serpentina
Stimulasi otot jantung, 2.Atropine – Hyoscymus niger
3.Caffeine – Coffea arabica
Triterpena, glikosida Digitalis (Foxglove
Digitogenin memengaruhi transpor
kardiak (jantung) digitalis sp.)
4.Cocaine – Erythorxylon
ion

Mempengaruhi kerja coca

Sterol spinasterol Bayam
hormon hewan 5.Nikotin – Nicotiana tabacum
6.Quinine – Cinchona
FENOLIK
officinalis
7.Scopolamine – N. niger
Menyebabkan kerusakan
oksidatif, timbulnya 8.Vinblastine – Catharanthus
Asam fenolat Kafeat, klorogenat Semua tanaman
warna coklat pada buah roseus
dan wine.
Mariska, 2013
Mengikat protein,
gallotanin, tanin
Tannins oak, kacang-kacangan enzim, menghambat
terkondensasi
digesti, antioksidan.

Lignin Lignin Semua tanaman darat Struktur, serat

6
Jack Schultz, Wiki 2014
Uji Klinik

Normal flora

2009
Body defences against infections

2009
 Introduction
Toxicology is arguably the oldest scientific discipline, as the
earliest humans had to recognize which plants were safe to
eat.

Most exposure of humans to chemicals is via naturally occurring

compounds consumed from food plants.
Humans are exposed to chemicals both inadvertently and
deliberately.
Biologically Based Practices

 Foods as healing agents

 Functional foods
 Nutraceuticals
 Herbal Medicine paradigm

Advantages
• Used over centuries.
Considered safe.
Disadvantages
• Poorly defined:contain many molecules.
• General impression that they
are good for degenerative
• Detailed composition known
diseases.
approximately.

• Active molecules notalways known.

• Seldom proven through invitro, invivo

and clinical trials.

• Mechanisms involved generally not

known. Interactions among molecules
may have adverse effects.
11
 Differences in medicinal products
Chemical – Herbal
Chemical products Herbal products

 First chemical  Long-time

products derived experience in
from herbal pattern phytotherapy
 Application of
plants or parts of
plants is historically
the basis for any
therapy
 Differences in medicinal products
Chemical – Herbal
Chemical products Herbal products

 Defined  Whole plant extract

substance(s) as as active ingredient
active ingredient(s)
 These extracts are
 This active complex
ingredient is multisubstance
chemically mixtures
synthetizised and
exactly
characterized
 Differences in medicinal products
Chemical – Herbal
Chemical products Herbal products

 Defined doses of  Every substance of

the active the extract may
ingredient must contribute to the
have equivalent efficacy (and
efficacy in every tolerability) of the
final product extract
 Pharmacokinetic
 Pharmacokinetic studies are nearly
studies are easy to impossible to
perform due to perform due to
monosubstance multisubstance
character character
Differences in medicinal products
Chemical – Herbal
Chemical products Herbal products

Products with the Products with an

same active extract of the same
ingredient must plant from different
guarantee the same manufacturers may
efficacy differ in efficacy
 proven by studies and tolerability
respective to
bioavailability or
bioequivalence
Differences in medicinal products
Herbal – Herbal

Herbal extracts of the same plant

may be different in
efficacy and tolerability !
Differences in medicinal products
Herbal – Herbal

Herbal extracts are characterized

by:

 Kind of extract

 Fluid extract
 Spissum extract
 Dried extract
Differences in medicinal products
Herbal – Herbal

Herbal extracts are characterized by:

 Extractive agent

 Influences the kind and amount of

extracted substances (lipohilic or
hydrophilic)
 Metabolite cage

28/10/2010 Ngatidjan, UJIPRAKLINIK 19

 PROSES EKSTRAKSI (SOXHLETASI)

N-Heksana
500 ml
Biji Nigella s.
Timbang 250 gr dihaluskan

Alat Soxhlet
*Ulangi Ekstraksi
kembali
jalur hijau
dengan Labu
Soxhlet
MetanolEtilasetat
Ampas

Hasil Ekstraksi

N M
E

Evaporasi
dengan Evaporasi dengan Proses Soxhletasi
Penangas air Rotavapor (3 x 6 jam/pelarut)
 UJI AKTIVITAS ANTIBAKTERI
Peremajaan Bakteri Pembuatan media
(inokulasi) NA & NB (K.pneumoniae)
Blood Agar (S.pneumoniae)
Dikerjakan dalam alat Laminar
Air Flow (LAF) dalam kondisi
steril
Nutrient
Isolat Agar
bakteri

Penimbangan
NA

Inokulasi 0,1 ml bakteri + 10-12 ml NA/

bakteri ke aquades
dari suspensi Blood Agar
media NB/HIA
(2-3 jarum ose) Didihkan
Ratakan dengan pengadukan 8 dengan
Inkubasi (metode difusi agar) hotplate
2x 24 jam

Penentuan Tuang ke
Penanaman cakram tabung reaksi
KHM
Pengukuran diameter @ 10-12 ml
zona hambat sekitar Inkubasi
Uji
cakram
Sterilisasi
Kesetaraan 24-48 jam suhu 370
(autoklaf)
Assessing the Risks and
Benefits of CAM Treatments

Figure 17.3
Penelitian Ilmiah

Perbandingan kompleksitas penelitian

Least Complexity Most

Internal Exploratory study Small-scale Large-scale study

study

Small-scale
Exploratory contract Large-scale
External research contract research contract research

Large-scale
government
sponsored
Master’s thesis Doctoral research
Student Term paper
dissertaion
 Hierarchy of Study Types??

Descriptive Analytic
•Case report
•Case series
•Survey Observational Experimental
•Cross sectional •Randomized
•Case-control controlled trials
•Cohort studies

Strength of evidence for causality between a risk factor and outcome

STUDI EKSPERIMENTAL
Bentuk uji klinik:
1. Paralel : Pada kasus yang cukup; tidak
selalu matching
2. Cross-over (silang): Pada kasus yang jarang;
matching
3. Add on : Penambahan satu jenis obat
terhadap suatu protab pengobatan
Contoh : Pemberian levofloksasin pada penderita
TB kategori 2
BENTUK UJI KLINIK

Paralel

Washout
Sampel
periode
Uji Keamanan - Uji
Toksisitas

analisis
hidup
Periksa
Wistar organ
Periksa
mati
organ

27
Bentuk uji klinik
 Cross-over

Sampel Washout Washout

periode periode
Pharmacodynamics
Pharmacokinetics

29
Research Guidelines for Evaluating the Safety and Efficacy of
Herbal Medicines (WHO/WPRO; 1993)

Foreword
1. Introduction
1. Background
2. Goal
3. Objectives
4. Definition of Terms

2. General considerations in Herbal Medicine Research

1. Legal considerations
2. Ethical considerations
1. Research on humans subjects
2. Research on animals
3. Respect for the environment
30
 3. Traditional knowledge on Herbal Medicine
4. Regulatory requirements
5. Purposes of research
6. Selection of research projects
7. Research approaches
8. Assuring access to relevant databases
9. Education

3. Research Studies
1. Literature background
2. Protocol preparation
3. Quality specifications of plant materials and preparations
4. Non-clinical studies
1. Pharmacodynamics investigations
2. General pharmacological investigations
3. Toxicological investigations
4. Methods

31
5. Clinical trials using Herbal Medicine
1. Clinical trial protocol development
2. Phases of a clinical trial
3. Ethics review board
4. Responsibilities of investigators
5. Responsibilities of sponsor
6. Data management
7. Statistical analysis
8. Reporting
6. Evaluation of Herbal Medicine research
7. Technology transfer and education
1. Herbal medical research
2. The health care professions
3. The public

32
4. Using the guide lines
1. Guidelines for quality spesification of plant materials and
preparations
1. Information for fresh, dried and processed plant materials
2. Information for medicinal preparation of plant materials
2. Guidelines for pharmacodynamic and general pharmacological
studies of Herbal Medicine
1. Animals
2. Administration
3. Guidelines for toxicity investigation of Herbal Medicine
1. Acute toxicity test
2. Long-term toxicity test
3. Local toxicity test
4. Special toxicity test

33
 All parts of plants
Mix active substances

Extractions
Certain active substance Certain active substance

Fractination & Isolation

Pure active substance Pure active substance

34
 NON-CLINICAL TESTING OF
HERBAL DRUG PREPARATIONS
WITH LONG-TERM MARKETING
EXPERIENCE
Guidance to facilitate mutual recognition
and use of bibliographic data
September 1998
Effects that are difficult, even impossible to detect
clinically
- Toxicity to Reproduction
- Genotoxicity
- Carcinogenicity
Expert-Report points out the necessity or not of
new studies
 NON-CLINICAL TESTING OF
HERBAL DRUG PREPARATIONS
WITH LONG-TERM MARKETING
EXPERIENCE

Tests not required, if sufficient experience in

humans is available:
 single dose toxicity,
 repeated dose toxicity,
 immunotoxicity
 local tolerance testing
 pharmacological tests including safety
pharmacology,
 pharmacokinetic studies.
Main constituents of Hedera helix L.

Triterpensaponins

COO R

 -L-rhamnose)1 2  -L-arabinose)1 O H
HOCH2

 -hederin: R=H
hederacoside C:
hederacoside C: R
R ==
1(1(β-D-glucose)6 – 1(β-D-glucose)4
-D-glucose)6 1(  -D-glucose)4 – 1(α-L-rhamn
1(  -L-rhamnose)

-hederin: R=H
 Mode of action of Ivy

indirect increase of
ß2-adrenergic
effects
key role

Ca2+ channel

lamellar
cAMP
bodies
ß2-adrenergic
surfactant receptor [Ca2+i]
PKA cAMP

lung cell unstriated muscle

cell
Regulation of β2-adrenergic receptor density

Accumulation of
RL - complexes Ligand
in „coated pits“ (L)
RL-complex β2-
in „lipid adrenergic
rafts“ receptor (R)

Endocytosi Recycling
s

early
endosome

Degradatio
n
Degradatio
n
 How to increase ß2-adrenergic effects on living cells?

accumulation of
receptor-ligand- ligand
complexes (L)
(coated pit) RL-
complex in ß2-
lipid rafts adrenergic
clathri receptor
n
(R)
endocytosi α-hederin recycling
s

early
endosome

degradati
on
degradatio
n
Fluorescence
Correlation
Spectroscopy
FCS: Free ligand

Detection volume
Ligand

-
SO3H SO3 Ligand
O +
HN NH
HC CH3
Diffusion time
3
of free
ligand 45 µs
H3C CH3 H3C CH3

HO

C
HO NH O Cell membrane

OH Alexa-NA
(ß2-adrenergic
agonist)
FCS: Ligand-Receptor-Complex

Detection volume

Receptor-ligand
complex

Diffusion time of
ligand-receptor-complex
3.3 ms

Cell membrane
FCS: Accumulated Ligand-Receptor-Complex

Detection volume

Accumulated
receptor-ligand
complex

Diffusion time of
accumulated ligand-receptor-complex
95 ms

Cell membrane
 Receptor-ligand-complex

cell + Alexa-NA cell + a-hederine + Alexa-NA

49,6%
32,8%
21,9%
11,8%

38,6%
45,3%

Free ligand Accumulated complex

Inhibition of internalization of 2-adrenergic
receptors
in pulmonary epithelial cells (A549)
by -hederin.

control, 10µM terbutaline 20 pretreatment with

untreated min 1µM -hederin for 24
h, then 10 µM
terbutaline 20 min
 Prospan: mode of action

-hederin influences regulatory processes of ß2-adrenergic

receptors:

-hederin inhibits redistribution as well as internalisation of

even redistributed ß2-adrenergic receptors after ligand binding.
 Ivy: Mode of action – consequences I

An increased ß2-adrenergic receptor density and an

increased
signal transduction lead to an increased production of cAMP:

 increased exocytosis of surfactant in pulmonary epithelial

cells (alveolar type II cells) (secretolytic effect, decrease
in mucus viscosity, decrease in coughing intensity and
frequency).

lamellar
bodies
ß2-adrenergic
surfactant receptor

PKA cAMP
 Ivy: Mode of action – consequences II

An increased ß2-adrenergic receptor density and an

increased
signal transduction lead to an increased production of cAMP:

 decrease in intracellular [Ca2+i] with subseeding bronchial

muscle relaxation (formation of less active myosin kinase
via phosphorylation by phosphokinase A).
Ca2+ channel

cAMP
ß2-adrenergic
receptor
[Ca2+i]
 Ivy - Resorption
In vitro (CaCo-2-
cells)

Transport
Transport of
of Hederacosid C Transport ofα-Hederin
Transport of alpha-
Hederacosid C hederin
cumulated concentration [µg/ml]

kumulierte Konzentration
0,45 0,6
0,4 0,5
0,35
0,3 0,4

[µg/ml]
0,25
0,2 0,3
0,15
0,1 0,2
0,05 0,1
0
0
0 50 100
0 20 40 60 80 100
time [min]
Time (min) time (min)
Time [min]
 Ivy - Resorption
In vivo – first results

alpha-hederin

• discovered in blood of treated animals

and humans
• the amount of hederacosid C given in an
extract seems to support the
concentration of alpha-hederin in blood
(prodrug??)

Actually: Ongoing works on the sensitivity of

analytical methods for further clarification
 Ivy- mode of action
-hederin

increased β2 –adrenergic stimulation

lung epithelium bronchial muscle

surfactant- Ca++
production (intracellular)

secretolytic
broncholytic
reduction of dilatation of bronchial
mucus viscosity musculature
Expectorant
Ivy: Effect on ß2-receptors in general

In theory -hederin supports indirectly the stimulaton of all ß2-

receptors

but
given by the smooth and indirect effect, a result will only be seen in
those organs with a pathological condition

(e.g. ivy will have no bronchiolytic effect in case of

„normal“ bronchial muscles)
Medicine or Food?
 In traditional herbalism plants are used for
both
 Substantial healing can occur by nourishing the
body or systems of the body
 Many herbs occupy both roles
 The nourishing herbs are far less likely to have
unwanted side effects
 Weeds in Michigan are often higher in available
nutrients than conventional foods
 PerMenkes 760/Menkes/Per/IX/1992
daftar obat tradisional yang harus
dikembangkan menjadi fitofarmaka

1. Antelmintik 10. Anti TBC

2. Anti Histamin 11. Anti Hepatitis Kronik
3. Anti Ansietas (Anti 12. Antitusif /
Cemas) ekspektoransia
13. Anti Herpes Genitalis
4. Anti Inflamasi
14. Disentri
5. Anti Asma 15. Anti Hiperlipidemia
6. Anti Kangker 16. Dispepsia (Gastritis)
7. Anti Diabetes 17. Anti Hipertensi
(Hipoglikemik) 18. Diuretik
8. Anti Malaria 19. Anti Hipertiroidisma
9. Anti Diare
 METODOLOGI SAINTIFIKASI JAMU

• Riskesda
s
• Ristoja
• Mapping
dokter
herbal

Uji klinik
Di Dokter
SJ dan
Poli CAM 57
 The House of Evidence

Reality
(objectivity) Relevance

Research methods (Goals)

Systematic review Health services

Regulator Public
(meta-analysis) research health

Randomized Mixed Epidemiology

controlled trials methods research Clinicians
Clinical
research
(attribution) (association)

Laboratory Qualitative Patients

Basic
science (mechanism) research
(meanings)
Values
58
 Conventional pharmaceutical Suggested models for CAM
development research

Screening of chemical substances Biological mechanism

Component efficacy
Biological mechanisms

Comparative effectiveness

Phase I CT
Safety status
Phase II CT

Context, paradigms, philosophical

understanding, and utilization
Phase III CT

Clinical Practice
Clinical Practice (Traditional Healer / CAM
practioners

59
Tradi
tiona
l
Heal
ers
(Co
mmu
nity)

Healt
h
pro-
fessi
onals

La
bo
ra
to
ry

60
ALTERNATIF PENEMUAN BUKTI ILMIAH PENGOBATAN TRADISIONAL

Jamu

61
Clinical Trials

Standardization and quality control of herbal crude

drugs –WHO (1996a and b, 1992), is the process
involved in the physicochemical evaluation of crude
drug covering aspects:
• selection and handling of crude material,
• safety, efficacy and stability assessment of finished
product,
• documentation of safety and risk based on
experience, provision of product information to
consumer and product promotion.
62
 Clinical Trial
Regulated under Schedule Y of Drugs and
Cosmetic Act 1940

Human clinical trials are conducted

 To demonstrate the efficacy and safety of

a new drug
 To explore new indication,
 New route of administration
 New combination of old drugs.

Clinical trials form the basis for therapeutic

decisions by all physicians, therefore, it is
essential that they be able to evaluate the
results and conclusions of such trials
critically.
63
New Drug Development
Clinical Evaluation-Good Clinical Practices
Phase I
(Safety / tolerance) Pharmacokinetic-Healthy
volunteers/exceptions

Phase II
(Efficacy and dose range studies conducted on
patients)

Phase III
(Clinical trials on large number of patients)

Phase IV
(Post marketing surveillance)
64
Data needs for CT
• Safety – Toxciology
• Efficacy in preclinical trials
• Pharmacokinetics
• Pharmacodynamics
SHORT COURSE:
CLINICAL TRIALS OVERVIEW

 OVERIEW OF TRIALS METHODOLOGY

 BASIC ISSUES: CLINICAL TRIALS DESIGN
 RECRUITMENT AND ADHERENCE
 SUBGROUP ANALYSES
 EQUIVALENCE AND NON-INFERIORITY
TRIALS, AND SURROGATE OUTCOMES
FACTORIAL DESIGN

Indications
 Interaction - small chance
 Interaction - important
 Interaction - must estimate
Contraindications
 Design too complex -
adherence
 Power of simple comparison
greater
 Interaction - large change
Types of Clinical Research
1. Case Reports
Anecdotal  Problem

2. Observational
a. Case Control/Retrospective (lung cancer)
b. Cross Sectional (WESDR) Beaver Dam
c. Prospective (Framington) WESDR-II
 Risk Factor Associations

3. Drug Development
(Phase 0, Phase I, & Phase II)
 Dose and activity

4. Experimental (Clinical Trial) Phase III

 “Effect” 542-03-#69
Phases of Clinical Trials (Cancer)
[1]
Phase 0 - Preclinical
•Preclinical animal studies
•Looking for dose-response

Phase I
•Seeking maximum tolerated dose (MTD)
•Patients usually failed other alternatives

Phase II
•Estimate of drug activity
•Decide if drug warrants further testing (Phase
III)
•Estimate of serious toxicities
542-03-#70
Phases of Clinical Trials (Cancer)
[2]
Phase III
• Provide effectiveness of drug or
therapy
• Various designs
– No control
– Historical control
– Concurrent
– Randomized
• Testing for treatment effect

Phase IV
• Long term post Phase III follow-up
• Concern for safety 542-03-#71
542-03-#72
Design
 The choice of design depends on the
goal of the trial
 Choice also depends on the
population, knowledge of the
intervention
 Proper design is critical, analysis
cannot rescue improper design

542-03-#73
Dose-response curves
used in simulations (1)

542-03-#74
Dose-response curves
used in simulations (2)

542-03-#75
Table 4: Known plants having hypoglycemic activities

No Common name Botanical name Parts used Therapeutic action

and family

1 Asiatic ginseng Panax ginseng Roots Lowers blood glucose by

(Araliaceae) decreasing the rate of
carbohydrate absorption,
increasing glucose
transport and modulation
of insulin secretion

2 Ashvagandha, winter Withania somnifera Roots Decrease in blood glucose

cherry (Solanaceae) Level

3 Asiatic sweet- leaf Symplocos Paniculata Leaves Stems Inhibits protein tyrosine
(Symplocaceae) phosphatase 1B (PTP1B) 1
and 2

4 Banana Musa sapientum Fruits/Flower Decreases blood glucose

Kuntz(Musaceae) and glycosylated
haemoglobin level

5 Banyan tree Ficus bengalensis Bark Inhibits insulinase activity

(Moraceae) from liver and kid- ney,
stimulates insulin
76 secretion
Pravin K. Bhoyar et al., Int. J. Res. Pharm. Sci., 2(1), 2011, 30-37
N Common Botanical Parts Therapeutic
o name name and used action
family

6 Barbados Aloe barbadensis Leaves Stimulates synthesis

Mill. (Liliaceae) and/or release of insulin
from -cells

7 Betel, Betel vine Piper betle Leaf Antihyperglycemic,

(Piperaceae) glucose metabolism

8 Bilwa, bael fruit Aegle marmelos Leaf extract Decreases blood urea &
(Rutaceae) cholesterol

9 Bitter-kola, false Garcinia kola Seed Hypoglycaemic and

kola (Clusiaceae) Hypolipidemic

10 Black tea Camellia sinensis Leaves Decreases blood glucose

L.(Theaceae) level

11 Common fig Ficus carica L. Leaves Decreases

(Moraceae) hyperglycaemia and
level
Pravin K. Bhoyar et al., Int. ofPharm.
J. Res. total Sci.,
cholesterol
2(1), 2011, 30-37

77
N Common Botanical Parts Therapeutic
o name name and used action
family

12 Custard apple, Annona squamosa Fruit pulp Decreased urine sugar,

sugar apple (Annonaceae) urine protein and gly-
co-haemoglobin

13 Desert Indian Plantago ovata Husks extrac Inhibits intestinal

wheat,Ispghul (Plantaginaceae) glucose absorption, en-
hancement of mobility

14 Prickly chaff flower Achyranthes aspera Whole plant Provides necessary

(Amaranthaceae) elements like Ca, Zn,
Mg, Mn, and Cu to the -
cells

Pravin K. Bhoyar et al., Int. J. Res. Pharm. Sci., 2(1), 2011, 30-37

78
 Table 5: Active antidiabetic principles
isolated from certain plants

Plant Part Used Active Principles

Acontium carmichaeii Root Aconitan A, B, C and D
Anemarans Rhizomes Anemarans A, B, C and D
Atractylodes japonica Rhizomes Glycans A, B, C and D
Coptis chinensis Aerial part Bernerine
Capsicum annum Fruit Capsaicin
Dioscorea japonica Rhizome Glycans A, B, C, D, E, F
Galega officinalis Seed Galegin
Gandoderma lucidium Fruit Glycans A, B
Lathyrus japonica Seed Lathyrines
Oriza sativum Root Glycans A, B, C, D
Tinospora cardifolia Plant 1,2 Substituted
Pyrolidines
Pravin K. Bhoyar et al., Int. J. Res. Pharm. Sci., 2(1), 2011, 30-37

79
Clear proposed mechanism of actions

Hongxiang Hui et al, Chin Med. 2009; 4:

11
80
 Hongxiang Hui et al, Chin Med. 2009; 4:
81 11
 Hongxiang Hui et al, Chin Med. 2009; 4:
11
82
 Hongxiang Hui et al, Chin Med. 2009; 4:
11
83
 Hongxiang Hui et al, Chin Med. 2009; 4:
11
84
HEPAR-P capsule:
Approved for clinical trial
 HEPAR-P Capsule contains standardized
Phyllanthus niruri extract.
 1st local product approved by Medical
Research & Ethics Committee, Ministry of
Health Malaysia.
 For clinical testing to evaluate antiviral
activities in patients with chronic
hepatitis B.
Two phases of development process:
Pre-clinical and clinical studies

1. Pre-clinical studies (Animal studies)

 Evaluate the pharmacological
activities.
 Evaluate the toxicity.

2. Clinical studies (Human studies)

 Evaluate the efficacy.
 Evaluate the toxicity.
Flow chart of development of
HEPAR-P Capsule

Medical plant

Extract

Bioassays Fractions Toxicology

Chemical
characterization
Flow chart of development of
HEPAR-P Capsule

Chemical standardization
Qualitative & quantitative analytical methods

Standardized extract – EPN 797 Pure compound

Drug Delivery Technology New chemical entity

Manufacturing technology for

Finished product

Stability studies
Flow chart of development of
HEPAR-P Capsule

Quality control protocol

• Chemical standardization
• Biological standardization

Complete monograph (of herbal product)

Approved herbal supplement

Animal toxicology studies (on the finished product)

-- Rodents & Non-rodents
-- According to FDA / WHO / Malaysian guidelines
Flow chart of development of
HEPAR-P Capsule
• LD 50
• Acute toxicology studies
• Sub-acute toxicology studies
• Chronic toxicology studies

Completion of pre-clinical studies

Submission to National Committee for Research and

Development In Herbal Medicine (NRDHM)

Approval to conduct clinical trial at appointed hospitals

Report of clinical trial by clinical investigators

Recommendation by NRDHM

Application to DCA for registration with therapeutic

claim
Specification of a botanical drug

i. Chemical standardization
 Identification of chemical constituents
 Measurement of marker compounds

ii. Biological standardization

 In vitro anti-HBsAg activity (ELISA method)
 In vivo liver protective activity in rats

iii. Stability of the finished product

 Accelerated stability study
 Real time stability study
Chemical structure:
Corilagin & Phyllanthus flavonoids
Corilagin – Polyphenol Phyllanthus flavonoids
(Anti-viral & liver protective) (Liver protective)

Chemical structure of rutin,

Chemical structure of corilagin. one of the Phyllanthus total
flavonoids.
TLC fingerprint
TLC identification of Phyllanthin and fingerprints of HEPAR-P capsule

Niranthin
Hypophyllanthin
Phyllanthin
 TLC fingerprints (Cont’d)
TLC identification of corilagin in TLC identification of rutin in
HEPAR-P capsule HEPAR-P capsule

Corilagin
Rutin
Chemical standardization:
HEPAR-P Capsule

Content of one HEPAR-P Capsule

250 mg of Phyllanthus niruri extract

EPN 797 standardized to contain:

i. Corilagin 10 mg
ii. Total flavonoids 45 mg
HPLC analysis of corilagin
Chromatogram of Phyllanthus niruri extract EPN
797
Biological standardization
 Chemical standardization is inadequate.
 Botanical drug contains a complex
mixture of chemical compounds.
 Chemical standardization does not give a
complete picture of a herbal product.
 We have combined biological assays
with chemical fingerprints to provide
assurance of efficacy and consistency.
HEPAR-P Capsule:
Quality control
 Chemical standardization
 Ensures batch-to-batch consistency in
chemical composition.

 Biological standardization
 Ensures batch-to-batch reproducible
biological activities.
Biological standardization

 Liver protective – In vivo (animal

study)
 Anti-viral – In vitro (ELISA test)
 Result of liver protective
study
Effect of Phyllanthus on CCL4 induced Effect of Phyllanthus on CCL4 induced
Liver injury in rats. Liver injury in rats.

AST (U/L)
200 200
ALT (U/L)

150 150

100 100

50 50

0 0
Control CCL4 control Treatment with Control CCL4 control Treatment with
Phyllanthus Phyllanthus
Result of Inactivation of
HBsAg study
In vitro inhibitory activity against
Hepatitis B surface antigen (HBsAg) by HEPAR-P™
HEPAR-P Capsule:
Monograph
Quality specification (as compared to USP , IHP , CP)
 Definition of product
 Chemical identification
 Chemical assays for characteristic marker compounds
 Assays for biological activity (or biological assay)
 Heavy metals
 Microbial limits
 Specification of HEPAR-P
Capsule

Specification

Appearance Identity Impurities Potency Contaminan Quality

description ts

Color Heavy metals

Product related
Smell Microbial
Pesticide
residues
Process related
Safety of HEPAR-P Capsule:
Animal toxicology studies

Toxicology evaluation on the finished product:

i. Acute studies (14 days, rodents and non-
rodents)
ii. Sub-acute studies (90 days , rodents and non-
rodents)
iii. Chronic study – Rodents (180 days)
iv. Chronic study – Non-rodents (270 days)
Pre-clinical studies for HEPAR-
P Capsule (Animal studies)
 Identification – The active fraction.
 Characterization – The marker compound(s).
 Establishment – Chemical standardization methods.
(Optional – Biological standardization methods)
 Animal toxicology studies.
 Stability studies.
 Formulation development.
 To establish a complete monograph of the product.
 Medical Research & Ethnics Committee – approval to
conduct clinical trial.
Completion of pre-clinical studies:
Approval for clinical trial

-- Approval by National Committee For

Research And Development In Herbal

Medicine (NRDHM).

-- Clinical trial at Selayang General

Hospital on Jan / Feb., 2005.

Clinical studies (Human studies)

 Clinical evaluation of safety and efficacy in human

subjects by appointed clinical investigators.
 Report of the clinical evaluation by the investigators.
 Recommendation by National Committee for
Research and Development in Herbal Medicine.
 Submission to DCA for registration of product as botanical
drugs with approved therapeutic claim.
 Summary for report
publication
Descriptive Information

Brief Title ICMJE Evaluation of Echinacea for the Common Cold

Official Evaluation of Echinacea in a Human Rhinovirus Challenge

Title ICMJE

Brief Summary The purpose of this study is to determine whether three Echinacea preparations with
different chemical compositions are effective for prevention or treatment of the common
cold.
Detailed Echinacea is a widely used herbal remedy for the common cold. Previous clinical trials
Description designed to assess the efficacy of Echinacea for prevention or treatment of the common
cold have produced inconsistent results. A variety of different Echinacea products have been
used in these clinical trials. Recent studies indicate that different Echinacea preparations
have dramatically different phytochemical profiles. The available clinical trial data provide no
information about the potential role of the different constituents of Echinacea in common
cold prevention or treatment. Our hypothesis is that the variation in reported clinical
effectiveness may be due to differences in the phytochemical profile of the Echinacea
preparations used. This study will address the following specific aims: 1) Evaluate the
effectiveness of chemically defined extracts of E. angustifolia root which contain alkamides,
echinacoside or polysaccharidelglycoprotein for common cold prevention or treatment; 2)
Assess the correlation between specific Echinacea metabolites in serum and nasal secretions
and efficacy for prevention and treatment of colds; and 3) Determine the effect of different
Echinacea preparations on the host response to rhinovirus infection.
 Summary for report
publication

Study Interventional
Type ICMJE
Study Phase Phase 2

Study Allocation: Randomized

Design ICMJE Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double-Blind
Primary Purpose: Prevention
Condition ICMJE Common Cold

Intervention I Drug: Echinacea

CMJE

Study Arm (s) Not Provided

Publications * Turner RB, Bauer R, Woelkart K, Hulsey TC, Gangemi JD. An

evaluation of Echinacea angustifolia in experimental rhinovirus
infections. N Engl J Med. 2005 Jul 28;353(4):341-8.
Pharmaceuticals 2012, 5, 853-874; doi:10.3390/ph5080853
Pharmaceuticals ISSN 1424-8247 www.mdpi.com/journal/pharmaceuticals

Review Phytomedicine in
Otorhinolaryngology and
Pulmonology: Clinical Trials with
Herbal Remedies
Koosha Ghazi-Moghadam 1,2, Hasan Mete Inançlı 3, Nazanin Bazazy 1, Peter K. Plinkert 1,
Thomas Efferth 4 and Serkan Sertel 1,2,4,*

1 Department of Otorhinolaryngology, Head & Neck Surgery, University of Heidelberg, Im Neuenheimer Feld 400,
69120 Heidelberg, Germany
2 Molecular Mechanisms of Head and Neck T—A102, Division Signal Transduction and Growth Control, German Cancer
Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
3 Department of Otorhinolaryngology, Near East University Hospital, 922022 Lefkosa, Turkish Republic of Northern
Cyprus
4 Department of Pharmaceutical Biology, Institute of Pharmacy and Biochemistry, University of Mainz, Staudingerweg
5, 55099 Mainz, Germany
Clinical Trials
Table 1. Preclinical studies of essentials oils from genus
Citrus and their effects on the central nervous system.

Herbs/essential oil Effect Species Reference

Linalool Anxiolytic, increased social interaction Mice Linck et al. (2010)
and decreased aggressive behavior
Citrus bergamia oil Anxiolytic Rat Carvalho-Freiras and
Costa (2002), Pultrini et
al. (2006), Saiyudthong
and Marsden (2010 )
Cittrus aurantium oil Anxiolytic, sedative and anticonvulsive Rat Leite et al. (2008) Mice
Blanco et al. (2009)
Cymbopogon citrates- Anxiolytic, sedative and Anticonvulsive Mice Faturi et al. (2010)
Citrus grass oil
Citrus sinensis oil Anxiolytic Rat Komiya et al. (2006)
Citrus lemon oil Anti-stress, Sedative Mice Fukumoto et al. (2008)
Citrus latifolia and C. Anti-stress and anxiolytic Mice Gargano et al. (2008)
reticulata oil

Journal115
of Medicinal Plants Research Vol. 6(3), pp. 342-347, 23 January, 2012
Clinical Trials
Table 2. Clinical studies of the essential oils of
orange
( Citrus sinensis ).
Experimental design Effect Reference
35 patients were exposed to odor Reduced levels of state- Lehrner et al.
orange and the state anxiety was anxiety in female. (2000)
measured through questionnaires.
50 patients were exposed to odor Lower levels of state Lehrner et al.
orange and the state anxiety was anxiety, more positive (2005)
measured through questionnaires mood and a higher level of
calmness
81 patients were exposed to odor No effects on the Toet et al. (2010)
orange and the state anxiety was anticipatory anxiety
assessed through questionnaires.
Journal of Medicinal Plants Research Vol. 6(3), pp. 342-347, 23 January, 2012

116
 Drugs Sources
• “B” Biological; usually a large
(>45 residues) peptide or
protein either isolated from New Chemical Entities (Total 1010 NCE’s )
an organism/cell line or by Source of Compound 01/1981-06/2006
produced by biotechnological
means in a surrogate host.
• “N” Natural product. V
B
S*/NM 12%
• “ND” Derived from a natural S* 11% 4% N
product and is usually a 5% 4%
semisynthetic modification.
• “S” Totally synthetic drug, S/NM
often found by random 11% ND
screening/ modification of an 23%

existing agent.
• “S*” Made by total synthesis, S
but the pharmacophore 30%
is/was from a natural
product.
• “V” Vaccine.
• Subcategory. “NM” Natural J. Nat. Prod. 2007, 70, 461-477
product mimic
Conclusion
1. The development of botanical drugs is likely to be a major
area of plant biotechnology expansion in the 21st century.

2. The future of botanical drugs will depend on consumer and

regulatory acceptance.

3. The important challenge is to provide science-based

evidence to consumers and regulatory authority on:
i. Efficacy (By clinical evaluation in human),
ii. Quality (Establish monograph of the standardized
extract), and
iii. Safety (By toxicological evaluations in animals and in
human).
119
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