Renu Agarwal, Siti Amrah Sulaiman, Mafauzy Mohamed*

Department of Pharmacology, *Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus 16150 Kubang Kerian, Kelantan, Malaysia
Correspondence : Dato’ Prof. Mafauzy Mohamed, MBBS (Adel), MMedSci (Sheffield), MRCP (U.K.), FRCP (Edinburgh). Department Medicine, School of Medical Sciences, Universiti Sains Malaysia, health Campus, 16150 Kubang Kerian, Kelantan, Malaysia Phone 09-7651700, e-mail: mafauzy@kb.usm.my

Code Number: mj05004

Adverse effects and tolerance to dry powder of aerial part of Andrographis paniculata (Burm.f.) Nees were studied in 20 patients with type 2 diabetes mellitus for a period of 12 weeks. Patients were given powdered A. paniculata starting with 600 mg daily, gradually increasing to a maximum of 1.8 gm daily. Parameters monitored included body weight, blood pressure, liver function tests, renal function tests, cardiac enzymes, haemogram, serum electrolytes, fasting blood glucose, HbA1c, blood cholesterol, serum triglycerides and blood hormone levels (triiodotyronine, thyroxine, thyrotropin, insulin, fasting cortisol). None of the above mentioned parameters showed significant change during the study period except for a fall in HbA1c by 5.46%(p<0.01) and fasting S. insulin by 20.93%(p<0.003). In conclusion, A. paniculata powder did not induced significant adverse events based on parameters observed in our study but significantly lowered HbA1c and fasting serum insulin in patients with type 2 diabetes.

Key words : Andrographis paniculata, diabetes mellitus type 2

For validation of HPLC method Waters^TM 610 fluid unit coupled with Waters‘ 600 controller , Waters‘ 486 tunable UV absorbance detector(230 nm). Lichrosorb reverse phase (RP-18) analytical column(250×4.6 mm, ID) and 50ul loop was used. The column consisted of particles of the size 5 um, 3390A integrator from Hewlett Packard. The mobile phase was prepared using 30% acetonitril and 70% distilled water. A flow rate of 1.1 ml/min was maintained throughout and injection volume was 50ul each time. By comparing retention times our HPLC assay was found to be free from possible interference from other diterpene compounds present in the dry leaves of Andrographis paniculata. A calibration graph was constructed in the concentration range of 1ug/ml to 60ug/ml using 5 concentrations (n=2 each). The linearity of calibration graph was demonstrated by good determination coefficient (r²=0.9983) obtained for regression line The precision of the method was evaluated by determining the interday RSD% (5.4911.58) intraday RSD% (3.24-14.93) of the measured peak areas for different concentrations. The LOQ defined in the present experiment as lowest andrographolide concentration in the calibration curve that can be measured routinely with acceptable precision (RSD<20%) and accuracy (80-120%) was 1ug/ml. Recovery data was determined at three concentration levels as recommended by center for Drug Evaluation and Research (96.20% to 103%). Andrographolide contents of the herb were found to be 5.45% as determined by first extracting the dry powder with methanol and then using above mentioned validated high pressure liquid chromatography method.

Selection of subjects

Twenty patients, already diagnosed with diabetes mellitus type 2 and undergoing treatment in diabetes clinic, Hospital Universiti Sains Malaysia (USM) were recruited for this study. These included 6 males and 14 females. For subjects to be included into the trial, they were required to fulfill inclusion and exclusion criteria. Subjects of both sexes between the age of 35 and 70 years, body mass index between 25 and 40 kg/m² , glycosylated haemoglobin (HbA1c) between 7% and 10% and fasting plasma glucose (FPG) between 7mmol and 15mmol were included in the trial if they fulfilled all the exclusion criteria. Exclusion criteria were, impaired hepatic function (ALT or ALP >2x ULN), impaired renal function (S. creatinine>150 µmol/l), history of cardiac problem (IHD, cardiac failure), uncontrolled blood pressure (SBP>160mmηg DBP >100mmηg), history of treatment with insulin, proteinuria (2+ and above) and pregnant/breast feeding mothers). All subjects were required to give written informed consent.

At first screening visit, subjects were evaluated for eligibility criteria. After physical examination, blood was collected to determine eligibility for the study. On 2^nd visit (2 weeks after 1^st visit) all subjects came after overnight fasting and blood results were reviewed for eligibility. For eligible subjects, general physical examination was done, blood was collected for baseline investigations, which included FBG, HbA1c, complete haemogram, LFT, RFT, electrolytes, CK, LDH, cholesterol, triglycerides, insulin, T4, TSH and cortisol.

Subjects were then instructed to take 2 capsules of AP (600 mg) daily with breakfast as an add on treatment to their ongoing medication. Subsequently subjects were asked to attend Clinical Trial Unit at 2 weekly intervals after overnight fasting for a total of 7 visits. During visits 3, 4, 5 and 6 general physical examination was repeated and blood was collected for FBG, ALT, ALP, and creatinine, Urine was also taken for testing of protein and sugar. Those subjects who had FBG above 7 mmol/l, the dose of AP was increased by 1 capsule (300 mg) each time. Maximum doses achieved were 3 capsules (900 mg each) twice a day for 2 weeks. On visit 7 all investigations were repeated as in visit 2. During all visits after starting this herbal treatment subjects were inquired about adverse events experienced since last visit and state of compliance to the medication.

During all visits subjects were asked about occurrence of any adverse event since last visit. During the entire period of trial one patient complained of gastric irritation and nausea after swallowing the capsule. She was prescribed antacid gel and was able to continue with the trial without further experiencing similar symptoms.

Physical examination conducted during all 7 visits showed no significant changes in mean values of body weight (BMI), systolic blood pressure, diastolic blood pressure and pulse rate (Figure 2 and 3a, and 3b). Mean fasting blood glucose was 10.19 (S.E.± 0.53) mmol/L at screening visit and 9.71 (S.E.± 0.76) mmol/L at visit 7 (Figure 2), thus showing no significant change during treatment. However mean HbA1c fell from 8.61 (S.E. ± 0.25)% at screening visit to 8.13 (S.E. ± 0.29)% at visit 7, a fall by 5.46% (p<0.01). Liver function tests showed no changes as seen in Figure 2. In the same way renal functions were well preserved and comparing results of blood urea, creatinine and uric acid (Figure 5) showed no significant change. Cardiac functions were monitored by measuring CK and LDH enzyme levels from visit 2 to 7. Comparison of these enzyme levels in Figure 6 showed no significant rise or fall. Serum electrolyte values measured from visit 2 to 7 were well within normal limits (serum sodium 139.5 ± 0.97 mmol/L to 139.85 ± 0.54 mmol/L, serum potassium 4.15 ± 0.21 to 4.34 ± 0.09 mmol/L, serum calcium 2.23 ± 0.08 mmol/L to 2.39 ± 0.03 mmol/L, serum phosphorus 1.77 ± 0.64 mmol/L to 1.23 ± 0.03 mmol/L). Mean hemoglobin, total WBC, platelet counts and ESR also showed no changes (Figure 7). Blood lipid levels (cholesterol 5.7 ± 0.26 mmol/L to 5.85 ± 0.26 mmol/L and triglycerides 1.59 ± 0.12 mmol/L to 1.56 ± 0.15 mmol/L) showed no significant change from visits 2 to 7 and similar results were observed for thyroid hormone ( FT4 14.03 ± 0.61 nmol/L to 13.6 ± 0.44 nmol/L, TSH 0.98 ± 0.08 mU/L to 1.06 ± 0.10 mU/L) and fasting cortisol levels (319.63 ± 30.42 nmol/L to 342.16 ± 35.46 nmol/L). Fasting insulin levels however showed a significant fall from 11.18 (S.E.± 1.46) IU/L at visit 2 to 8.84 (S.E.± 1.05) IU/L at visit 7, a reduction by 20.93% (p<0.003) (Table 1). Average patient compliance as determined by capsule counting was 90.93%.

Many researchers have studied the effects of Andrographis paniculata in animals and in human. In various animal experiments it has been found to have hepatoprotective (9, 10), antioxidant, antidiabetic (2), antihypertensive (11) and anti HIV (12) effects. In human clinical trial it was found to be effective against common cold (3, 4) and pharyngotonsillitis (13). Various animal experiments have also been done to study toxicity to Andrographis paniculata (5, 6). These experiments have shown Andrographis to be a safe herb. The results of our study showed no changes in physical and biochemical parameters of toxicity with doses as high as 900mg twice a day for 2 weeks.

These results support the results of previously conducted studies. However as reported by Zhang et al. (2) the increase in body weight and fall in fasting blood glucose of diabetic rats after treatment with ethanolic extract of AP was not observed in our clinical trial. The fall in HbA1c and fasting insulin level in diabetic patients in our study suggests its efficacy as an antidiabetic agent. These results suggest that the mechanism of action of Andrographis is by increasing peripheral utilization of glucose, probably by potentiating insulin action and not by a direct insulin releasing action on islet cells in pancreas. However other possible extrapancreatic effects on glucose metabolism (enzymatic and non enzymatic) in liver or carbohydrate absorption in GIT remain unclear.

In conclusion, dry powder of aerial part of Andrographis paniculata caused no significant adverse effects in parameters observed in patients with type 2 diabetes mellitus. Physical and biochemical parameters of toxicity were not affected during treatment with Andrographis paniculata for a period of 12 weeks and at the same time it showed antidiabetic property. Andrographis paniculata therefore was found to be a safe herb, which needs to be further evaluated for its long term safety and efficacy as antidiabetic agent.

We would like to thank Suhaila binti Che Dir, Roslina binti Mat Zain, Mr. Othman Ismail and Mr. Manaf Jusoh for their dedicated research assistance at Clinical Trial Unit and the Malaysian Ministry of Science and Technology for financial support under IRPA. (Intensified Research in Priority Area) research grant.

1. Ahmed and Asmawi, M.Z. Some pharmacological effects of aqueous extract of Andrographis paniculata Nee. In: Proceedings of the International Conference on the use of traditional medicine and other natural products in Health-Care, 8-11 June 1993, Penang, Malaysia. School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang.
2. Zhang, X.F., Tan, B.K. Antihyperglycaemic and antioxidant properties of Andrographis paniculata in normal and diabetic rats. Journal of Clinical Experimental Pharmacology and Physiology 2000; 27(5-6): 358-363.
3. Cáceres, D.D., Hancke, J.L., Burgos,R.A., Sandberg, F., Wikman.G.K. Use of visual analogue scale measurements (VAS) to assess the effectiveness of standardizing Andrographis paniculata extract SHA- 10 in reducing the symptoms of common cold. A randomized double blind-placebo study. Phytomedicine 1999; 6(4): 217- 223.
4. Cáceres D.D., J.L. Hancke, R.A. Burgos, G.K. Wikman. Prevention of common colds with Andrographis paniculata dried extract. A Pilot double blind trial. Phytomedicine 1997; 4(2): 101-104.
5. Chantasutra, V., S. Limpapanichkul. Acute antiinflammatory activity of Andrographis paniculata Nees in rats. The Eight Conference, Faculty of Pharmacy,Chulalongkorn University 1989.
6. CCZSDJ : Cooperative clinic of Zuoqiao, Sanca Douchang Jiangki. Treating burns using pumpkin pulp plus Andrographis paniculata powder. Journal of Barefoot Doctor 1975; 4: 11
7. Akbarsha, M.A., Manivannan, B., Hamid, K.S., Vijayan, B. Antifertility effect Of Andrographis paniculata (Nees) in male albino rat. Indian Journal of Experimental Biology 1990; 28(5): 421-426.
8. Burgos, R.A., Caballero, E.E., Sanchez, N.S., Schroeder, R.A., Wilkman, G.K., Hancke, J.L. Testicular toxicity assessment of Andrographis paniculata dried extract in rats. Journal of Ethnopharmacology 1997; 58(3): 219-224.
9. Trivedi,N.P., Rawal,U.M. Hepatoprotective and antioxidant property of Andrographis paniculata (Nees) in BHC induced liver damage in mice. Indian Journal of Experimental Biology 2001; 39(1): 41-46.
10. Rana, A.C., Avadhoot, Y. Hepatoprotective effects of Andrographis paniculata against carbon tetrachlorideinduced liver damage. Arch Pharmacology 1991; 14(1): 93-95.
11. Zhang, C.Y.and Tan, B.K. Hypotensive activity of aqueous extract of Andrographis paniculata in rats. Journal of Clinical Experimental Pharmacology and Physiology 1996; 23(8): 675-678.
12. Calabrese, C., Berman,S.H., Babish,J.G., Ma, X., Shinto, L., Dorr, M., Wells, K., Wenner, C.A., Standish, L.J. A phase I trial of andrographolide in HIV positive patients and normal volunteers. Phytotherapy Res 2000; 14(5): 333-338.
13. Thamilikitkul,V., Dechatiwongse, T., and Theerapong, S. Effect of Andrographis paniculata Nees for Pharyngotonsillitis in Adults. Journal of Medical Association of Thailand 1991; 74: 433-442.

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