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Clinical safety evaluation of a tea containing Cissampelos sympodialis in healthy volunteers

ABSTRACT

Cissampelos sympodialis Eichler, Menispermaceae, is widely used by Indian tribes and folk medicine to treat various inflammatory disorders, including asthma. Clinical toxicological trials were made with the tea of C. sympodialis, a medicinal plant. The study took place at Lauro Wanderley Hospital/UFPB-PB, where seventeen healthy volunteers were chosen, among those six men and eleven women who orally ingested, during four weeks uninterruptedly, 150 ml of the tea, once a day. Before the first ingestion and after the last one, the participants were subjected to clinical and laboratorial tests for their overall conditions in order to analyze the toxicity of the plant. The results demonstrated that the volunteers neither experience clinical nor laboratorial alterations, as well as no significant adverse effects, apart from little change detected in their hematological tests. Nevertheless, none demonstrated any pathological conditions, just alterations of the normal human being physiology. Therefore, it is concluded that these data complement that obtained during pre-clinical studies and confirm a low toxicity of this plant.

Keywords:
Clinical; Cissampelos sympodialis ; Menispermaceae; Tea

Introduction

The herbal infusion is a drink made from leaves, flowers, seeds, fruit, stalks and some plant species roots (Zhao et al., 2013Zhao, J., Deng, J.W., Chen, Y.W., Li, S.P., 2013. Advanced phytochemical analysis of herbal tea in China. J. Chromatogr. A 1313, 2-23.; Anvisa, 2010Anvisa, 2010. Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Resolução RDC nº 10,de 9 de março de 2010. Dispõe sobre a notificação de drogas vegetais junto à Agência Nacional de Vigilância Sanitáriae dá outras providências. Diário Oficial da União, Brasília, DF.). The preparation consists of pouring boiling water over the herbal drug (Anvisa, 2010Anvisa, 2010. Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Resolução RDC nº 10,de 9 de março de 2010. Dispõe sobre a notificação de drogas vegetais junto à Agência Nacional de Vigilância Sanitáriae dá outras providências. Diário Oficial da União, Brasília, DF.).

Herbal products are easily available and widely commercialized (Zhao et al., 2013Zhao, J., Deng, J.W., Chen, Y.W., Li, S.P., 2013. Advanced phytochemical analysis of herbal tea in China. J. Chromatogr. A 1313, 2-23.; Owens et al., 2014Owens, C., Baergen, R., Puckett, D., 2014. Online sources of herbal product information. Am. J. Med. 127, 109-115.), therefore being a way of complementing traditional medicine all over the world (Owens et al., 2014Owens, C., Baergen, R., Puckett, D., 2014. Online sources of herbal product information. Am. J. Med. 127, 109-115.). However, those are not completely free of possible toxicity or other adverse effects (De Smet, 2004De Smet, P.A., 2004. Health risks of herbal remedies: an update. Clin. Pharmacol. Ther. 76, 1-17.).

The infusion of Cissampelos sympodialis Eichler, Menispermaceae, species is widely used by Indian tribes and folk medicine to treat various inflammatory disorders, including asthma (Bezerra-Santos et al., 2004Bezerra-Santos, C.R., Balestieri, F.M., Rossi-Bergmann, B., Peçanha, L.M.T., Piuvezam, M.R., 2004. Cissampelos sympodialis Eichl. (Menispermaceae): oral treatment decreases Ige levels and induces a Th1-skewed cytokine production in ovalbumin-sensitized mice. J. Ethnopharmacol. 95, 191-197.; Costa et al., 2008Costa, H.F., Bezerra-Santos, C.R., Barbosa- Filho, J.M., Martins, M.A., Piuvezam, M.R., 2008. Warifteine, a bisbenzylisoquinoline alkaloid, decreases immediate allergic and thermal hyperalgesic reactions in sensitized animals. Int. Immunopharmacol. 8, 519-525.; Rocha et al., 2010Rocha, J.D., Decoté-Ricardo, D., Redner, P., Lopes, U.G., Barbosa-Filho, J.M., Piuvezam, M.R., Arruda, L.B., Peçanha, L.M.T., 2010. Inhibitory effect of the alkaloid warifteine purified from Cissampelos sympodialis on B lymphocyte function in vitro and in vivo. Planta Med. 76, 325-330.; Marinho et al., 2012Marinho, A.F., Barbosa-Filho, J.M., Oliveira, E.J., 2012. A validated method for the simultaneous quantitation of bioactive alkaloid markers in the leaf ethanolicextract of Cissampelos sympodialis Eichl: a phenological variation study. Phytochem. Anal. 23, 426-432.; Cavalcanti et al., 2013Cavalcanti, A.C., Melo, I.C.A.R., Medeiros, A.F.D., Neves, M.V.M., Pereira, A.N., Oliveira, E.J., 2013. Studies with Cissampelos sympodialis: the search towards the scientific validation of a traditional Brazilian medicine used for the treatment of asthma. Rev. Bras. Farmacogn. 23, 527-541.; Vieira et al., 2013Vieira, G.C., De Lima, J.F., De Figuereido, R.C., Mascarenhas, S.R., Bezerra-Santos, C.R., Piuvezam, M.R., 2013. Inhaled Cissampelos sympodialis down-regulates airway allergic reaction by reducing lung CD3+T cells. Phytother. Res. 27, 916-925.). Asthma is a medical condition which presents as main physiopathological characteristic bronchial inflammation, accompanied by lower airway hyper responsiveness and variable airflow limitation. This inflammation is associated with severe leukocyte recruitment and their activation at the site of lesion (Bezerra-Santos et al., 2012Bezerra-Santos, C.R., Vieira-de-Abreu, A., Vieira, G.C., Ribeiro-Filho, J., Barbosa-Filho, J.M., Pires, A.L., Martins, M.A., Souza, H.S., Bandeira-Melo, C., Bozza, P.T., Piuvezam, M.R., 2012. Effectiveness of Cissampelos sympodialis and its isolated alkaloid warifteine in air way hyperreactivity and lung remodeling in a mouse model of asthma. Int. Immunopharmacol. 13, 148-155.; Cavalcanti et al., 2013Cavalcanti, A.C., Melo, I.C.A.R., Medeiros, A.F.D., Neves, M.V.M., Pereira, A.N., Oliveira, E.J., 2013. Studies with Cissampelos sympodialis: the search towards the scientific validation of a traditional Brazilian medicine used for the treatment of asthma. Rev. Bras. Farmacogn. 23, 527-541.; Ribeiro-Filho et al., 2013Ribeiro-Filho, J., Calheiros, A.S., Vieira-de-Abreu, A., Carvalho, K.I., Silva- Mendes, D., Melo, C.B., Martins, M.A., Silva- Dias, C., Piuvezam, M.R., Bozza, P.T., 2013. Toxicol. Appl. Pharmacol. 273, 19-26.).

The species is endemic in the Northeast and Southeast of Brazil, frequently occurring in open areas, as shrubs in sandy soil (Barbosa-Filho et al., 1997Barbosa-Filho, J.M., Agra, M.F., Thomas, G., 1997. Botanical, chemical and pharmacological investigation on C. sympodialisfrom Paraíba (Brazil). Cienc. Cult. 49, 386-394.). The plant is popularly known as "milona", "jarrinha", "orelha-de-onça" and "abuteira" (Agra et al., 2007aAgra, M.F., Freitas, P.F., Barbosa-Filho, J.M., 2007a. Synopsis of the plants known as medicinal and poisonous in Northeast of Brazil. Rev. Bras. Farmacogn. 17, 114-140.,bAgra, M.F., Nurit-Silva, K., Baracho, G.S., Basilio, I.J.L.D., 2007b. Estudo famacobotânico de folhas de Nicotiana glauca(Solanaceae). Lat. Am. J. Pharm. 26, 499-506.).

Several studies were conducted with this plant, which have proved its therapeutic potential (Cavalcanti et al., 2013Cavalcanti, A.C., Melo, I.C.A.R., Medeiros, A.F.D., Neves, M.V.M., Pereira, A.N., Oliveira, E.J., 2013. Studies with Cissampelos sympodialis: the search towards the scientific validation of a traditional Brazilian medicine used for the treatment of asthma. Rev. Bras. Farmacogn. 23, 527-541.). Studies revealed anti-inflammatory activity and the potential for modulating the microbicide activity of macrophages by increasing the IL-10 production along with inhibition of NO synthesis. Furthermore, the findings proved the efficacy of C. sympodialis upon the regulation of B cell function and the immunoglobulin secretion in allergic diseases, as well as autoimmune disease synthesis (Cavalcanti et al., 2013Cavalcanti, A.C., Melo, I.C.A.R., Medeiros, A.F.D., Neves, M.V.M., Pereira, A.N., Oliveira, E.J., 2013. Studies with Cissampelos sympodialis: the search towards the scientific validation of a traditional Brazilian medicine used for the treatment of asthma. Rev. Bras. Farmacogn. 23, 527-541.; Vieira et al., 2013Vieira, G.C., De Lima, J.F., De Figuereido, R.C., Mascarenhas, S.R., Bezerra-Santos, C.R., Piuvezam, M.R., 2013. Inhaled Cissampelos sympodialis down-regulates airway allergic reaction by reducing lung CD3+T cells. Phytother. Res. 27, 916-925.; Piuvezam et al., 2012Piuvezam, M.R., Bezerra-Santos, C.R., Bozza, P.T., Melo, C.B., Vieira, G.C., Costa, H.F., 2012. Cissampelos sympodialis (Menispermaceae): a novel phytotherapic weapon against allergic diseases? In: Pereira, C. (Ed.), Allergic Diseases – Highlights in the Clinic, Mechanisms and Treatment. InTech, ISBN 978-953-51-0227-4, http://dx.doi.org/10.5772/25739, Available from: http://www.intechopen.com/books/allergic-diseases-highlights-in-the-clinic-mechanisms-and-treatment/cissampelos-sympolialis-menispermaceae-a-novel-phytotherapic-weapon-against-allergic-diseases-
http://dx.doi.org/10.5772/25739...
).

Vieira et al. (2013)Vieira, G.C., De Lima, J.F., De Figuereido, R.C., Mascarenhas, S.R., Bezerra-Santos, C.R., Piuvezam, M.R., 2013. Inhaled Cissampelos sympodialis down-regulates airway allergic reaction by reducing lung CD3+T cells. Phytother. Res. 27, 916-925. demonstrated that the inhalation of C. sympodialis in animals with allergic inflammation of the airways is as effective as the oral treatment with dexamethasone for controlling the inflammatory response in the lungs and the production of IgE. Ultimately, the results suggest that the leaves of C. sympodialismay be material for a herbal medicine.

In pre-clinical toxicological assays with the AFL (alcoholic fraction of leaves) of C. sympodialis done in rats (male and female), it was investigated the sub-acute (four weeks) and chronicle (thirteen weeks) toxicity of the popular administration (9 mg/kg/orally). These studies suggested lack of toxicity in these animals. Doses administrated 5–225 times higher than the ones ingested by men evidenced, in mice, inflammatory processes and an increase of hepatic enzymes, besides the hyperplasia of Kupffer cells, reversible thirty days after the administration of the extract was suspended (Diniz, 2000Diniz, M.F.F.M., 2000. Ensaios toxicológicos pré-clínicos com as folhas de Cissampelos sympodialis Eichl (Menispermaceae). Tese de doutorado, Programa de Pós-graduação em Produtos Naturais e Sintéticos Bioativos. Universidade Federal da Paraíba, João Pessoa.).

Data published in pre-clinical studies with C. sympodialis leaves enable clinical assays which may initially establish the safety and subsequently the effectiveness of C. sympodialis in humans. Thus, this study intended to ascertain the safety of this medicine in potential. Based on clinical phase 1 parameters in conjunction with the ones in the pre-clinical studies which have already been published, there is craving for registering with Anvisa (CNS, 1997CNS, 1997. Ministério da Saúde, Conselho Nacional de Saúde. Resolução nº 251, de 7 de agosto de 1997. Contempla a norma complementar para a área temática especial de novos fármacos, vacinas e testes diagnósticos. Diário Oficial da União, Brasília, DF.; Anvisa, 2010Anvisa, 2010. Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Resolução RDC nº 10,de 9 de março de 2010. Dispõe sobre a notificação de drogas vegetais junto à Agência Nacional de Vigilância Sanitáriae dá outras providências. Diário Oficial da União, Brasília, DF.).

Material and methods

Plant material

The leaves of Cissampelos sympodialis Eichler, Menispermaceae, were collected during the months of March and September of 2012 in the garden of medicinal plants at the Laboratory of Pharmaceutical Technology Prof. Delby Fernandes de Medeiros, Campus I at Federal University of Paraíba, where the plant has been cultivated. The identification and morphological description of the plant were made by Dra. Maria de Fátima Agra. A sample is located in the Lauro Pires Xavier herbarium, at UFPB, by the voucher specimen number Agra 1456 (JPB).

The acquisition of C. sympodialis sachets

The leaves of C. sympodialis were dehydrated in a greenhouse with air flowing at 38 °C for 72 h and ground in a Harley type grinder, having the average yields calculated. After the pounding, the dried leaves were submitted to a phytochemical/quality control triage, and then sent to the Aplaf Ltda, São Paulo-SP, being this company responsible for producing and ratifying the quality control of the C. sympodialis sachets. Each unit, produced with filter paper for specific use, contained 1 g of the powder.

Phytochemical

A phytochemical trial of C. sympodialis leaves infusion was conducted according to Matos (1997)Matos, F.J.A., 1997. Introdução a Fitoquímica Experimental. Edições UFC, Fortaleza.. During the trial, the presence of alkaloids, steroids, tannins, flavonoids and saponin were detected.

The classes of chemical substances present on the leaves of C. sympodialis were characterized before the sachets production, thus being considered an indispensable stage for their standardization.

Search of warifteine and methylwarifteine alkaloids in teas sachets of C. sympodialis

The teas were prepared under the same conditions of clinical studies (one sachet containing 1 g of the powder C. sympodialis was subjected to infusion for 15 min).

HPLC equipment and conditions

All solvents used were HPLC level. Deionized Milli Q water (Millipore, Bedford, MA) was used to prepare the mobile phase and diluents solutions. All chromatographic runs were carried out using a Sykam HPLC System, consisting of a S7131 pump. A S3240 photodiode-array detector (DAD) was used for detection. Full spectra were recorded in the range 200–400 nm. Equipment control, data acquisition and integration were performed with Clarity software. Chromatographic separations were achieved using methodologies based on Aragão (2002)Aragão, C.F.S., 2002. Desenvolvimento de metodologias analíticas para padronização de extratos de Cissampelos sympodialisEichl(Milona). Tese de doutorado, Programa de Pós-graduação em Produtos Naturais e Sintéticos Bioativos. Universidade Federal da Paraíba, João Pessoa, 210p. and Marinho (2011)Marinho, A.F., 2011. Caracterização dos marcadores, desenvolvimento e avaliação de método analítico aplicado ao estudo de sazonalidade e identificação de novos alcaloides de Cissampelos sympodialis. Tese de doutorado, Programa de Pós-graduação em Produtos Naturais e Sintéticos Bioativos. Universidade Federal da Paraíba, João Pessoa.. The mobile phase consisted of a mixture of methanol/CH3CO2H 0.1% (35:65, v/v). Flow-rate was set to 0.3 ml/min and the injection volume was 20 µl. All experiments were carried out at room temperature. The DAD detected the presence or not of alkaloids peaks in sachets of C. sympodialis. It was obtained spectrum UV of alkaloid templates of C. sympodialis (warifteine and methylwarifteine) within the same conditions proposed by the method and saved on a data base supported by the Clarity software. The substances were analyzed through HPLC/UV-DAD and by comparing the time retention in the extract peaks with the ones collected with authentic reference standards.

Research field

This research took place in Lauro Wanderley University Hospital at Federal University of Paraíba, where further trials were done in the clinical analysis laboratory, in the cardiology room as well as in the ambulatory at CRAS (Reference Server Care Center). Protocol clinic was conducted/defined according to the Brazilian resolutions n° 251/97 and 466/12 from the CNS, the international standards from the World Health Organization 2011 and good clinical practice (GCP) (CNS, 1997CNS, 1997. Ministério da Saúde, Conselho Nacional de Saúde. Resolução nº 251, de 7 de agosto de 1997. Contempla a norma complementar para a área temática especial de novos fármacos, vacinas e testes diagnósticos. Diário Oficial da União, Brasília, DF.; CNS, 2012CNS, 2012. Ministério da Saúde, Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Aprova as normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União, Brasília, DF.).

Volunteers

The clinical study was open and not randomized, performed with individuals participating voluntarily. The sample consisted of eighteen volunteers, six men and eleven women (one quitclaim) between 23 and 60 years old, were chosen after complete clinical and laboratorial trials which aimed to ascertain proper health conditions in order to participate in this research.

Experimental protocol

The volunteers had a 150 ml dose of the herbal product orally, once a day, using the sachets with leaves of C. sympodialis for four weeks. Thus, this study was conducted from May 2012 to June 2013. After receiving the sachets, the participants were weekly monitored (0-1-2-3-4 weeks), starting from day 0.

Before the first ingestion of the product and a day after the last one, the participants (men and women) were subjected to a clinical and laboratorial evaluation for their overall conditions. They did the following tests: glucose, creatinine phosphokinase (CPK), triacylglyceride, total cholesterol and fractions, lactate dehydrogenase (LDH), amylase, sodium, potassium, aspartate transaminase, alanine transaminase, total bilirubin and fractions, gamma GT, alkaline phosphatase, total protein and fractions, creatinine, uric acid, urea, complete blood count, platelet count and urinalysis I. A twelve-lead electrocardiogram was also done.

Throughout the course of the study, the volunteers were instructed to report to the researchers any signs or symptoms that might present adverse reaction and were also given a questionnaire to fill in, if at all.

Exclusion criteria

Individuals who had any clinical or laboratorial alterations – hepatic, renal or cardiac dysfunction; pregnancy; use of alcohol and/or any medicines – during the initial clinical tests were excluded from this study.

Ethical aspects

The research project, with the protocol and consent forms, was submitted and approved by the Committee of Ethics in Research with humans at Lauro Wanderley University Hospital – UFPB on 25/05/2010 – protocol no. 284/10.

All volunteers were informed about the nature and objectives of the study and those who agreed to participate gave their formal written consent after signing the Statement of Informed Consent.

Statistical analysis

The evaluation of the volunteers' hematological and biochemical parameters, which aimed to diagnose whether the participants met the standards for an individual considered healthy, was performed by comparing the results obtained throughout the treatment and the ones acquired during the initial trial for each volunteer (basal time). The figures were expressed by mean ± standard error of mean (SEM) of the seventeen participants, separating them by gender, according to the type of test and evaluation period. It was used the Student's "t" test for paired samples *p < 0.05 and One-way ANOVA/Tukey. *p < 0,05. All data were analyzed using the statistical program Graph Pad Prism ® version 6.02.

Results and discussion

The search for warifteine and methylwarifiteine in teas prepared with C. sympodialis sachets were performed through analysis by High Performance Liquid Chromatography coupled to UV detector with photodiode array (HPLC/DAD). The HPLC chromatogram, Fig. 1, in C. sympodialis tea showed five unknown peaks defined as: A, B, C, D, E and the absence of warifteine and methylwarifteine in measurable concentrations. This fact can be explained because previous studies used ethanolic extraction. This study used hot water extraction.

Fig. 1
The chromatogram and UV spectra of the separation of tea of Cissampelos sympodialis. Five unknown peaks are eluting: A, B, C, D and E.

This study investigated the clinical toxicity in seventeen humans, in search of the safety of this medicine in potential. The clinical phase I concerns the first moment when the medicine is tested in a group of healthy volunteers. This phase seeks to establish the safety, pharmacokinetic profile and tolerability in a preliminary format of the substance in humans (CNS, 1997CNS, 1997. Ministério da Saúde, Conselho Nacional de Saúde. Resolução nº 251, de 7 de agosto de 1997. Contempla a norma complementar para a área temática especial de novos fármacos, vacinas e testes diagnósticos. Diário Oficial da União, Brasília, DF.; Mesia et al., 2011Mesia, K., Cimanga, K., Tona, L., Manpunza, M.M., Ntamabyaliro, N., Muanda, T., Muyembe, T., Totté, J., Met, T., Pieters, L., Vlientinck, A., 2011. Assessment of the short-term safety and tolerability of a quantified 80% ethanol extract from the stem bark of Naucleapobeguinii(PR 259 CT1) in healthy volunteers: a clinical phase I study. Planta Med. 77, 111-116.).

Tests were carried out for urinalysis I, hematological and biochemical parameters of patients, which showed that there was just a significant change in statistics in four hematological parameters, in which it was observed a decline in leucocytes and neutrophils in men, an increase in eosinophils in women and in lymphocytes in men. Although these changes were statistically significant, they do not represent a pathological condition, and perhaps are just an alteration of normal human physiology (Tables 14).

Table 1
Patients' biochemical parameters, either sex, from the Clinical Trial with infusion of the leaves of Cissampelos sympodialis. Values are expressed in mean ± SEM.
Table 2
Patients' biochemical parameters, either sex, from the Clinical Trial with infusion of the leaves of Cissampelos sympodialis.
Table 3
Patients' hematological parameters, either sex, from the Clinical Trial with infusion of the leaves of Cissampelos sympodialis.
Table 4
Patients' hematological parameters, either sex, from the Clinical Trial with infusion of the leaves of Cissampelos sympodialis.

The leucocytes and lymphocytes are cells responsible for protecting the organism against infections. Lymphocytosis is caused by neoplasia, viral infections such as rubella, mononucleosis, and mumps; bacterial infections, protozoans, among others (Hoffbrand and Moss, 2013Hoffbrand, A.V., Moss, J.E., 2013. Fundamentos em hematologia. Artmed, Porto Alegre.; Musso et al., 2014Musso, A., Catellani, S., Canevali, P., Tavella, S., Vene, R., Boero, S., Pierri, I., Gobbi, M., Kunkl, A., Ravetti, J.L., Zocchi, M.R., Poggi, A., 2014. Amino bisphosphonates prevent the inhibitory effects exerted by lymph node stromal cell sonanti-tumor Vδ 2T lymphocytes in non-Hodgkin lymphomas. Haematologica 99, 131-139.). The neutrophils are mainly responsible for the phagocytes is of cells and extraneous material. Neutropenia is mainly caused by dysplasia, infections, inflammation, intravascular destruction (immune), drugs and chemicals, among others (Musso et al., 2014Musso, A., Catellani, S., Canevali, P., Tavella, S., Vene, R., Boero, S., Pierri, I., Gobbi, M., Kunkl, A., Ravetti, J.L., Zocchi, M.R., Poggi, A., 2014. Amino bisphosphonates prevent the inhibitory effects exerted by lymph node stromal cell sonanti-tumor Vδ 2T lymphocytes in non-Hodgkin lymphomas. Haematologica 99, 131-139.; Spaan et al., 2013Spaan, A.N., Surewaard, B.G., Nijland, R., Strijp, J.A., 2013. Neutrophils versus Staphylococcus aureus: a biological tug of war. Annu. Rev. Microbiol 67, 629-650.). On the other hand, the eosinophilia is related to allergic responses, parasitic diseases, acute infection, certain skin diseases, drug sensitivity, among others (Chen et al., 2013Chen, L., Zhong, N., Lai, K., 2013. Re-challenge with ovalbumin failed to induce bronchial asthma in mice with eosinophilic bronchitis. PLOS ONE 8, e75195.; Dasgupta et al., 2013Dasgupta, A., Neighbour, H., Nair, P., 2013. Targeted therapy of bronchitis in obstructive air way diseases. Pharmacol. Ther. 140, 213-222.; Musso et al., 2014Musso, A., Catellani, S., Canevali, P., Tavella, S., Vene, R., Boero, S., Pierri, I., Gobbi, M., Kunkl, A., Ravetti, J.L., Zocchi, M.R., Poggi, A., 2014. Amino bisphosphonates prevent the inhibitory effects exerted by lymph node stromal cell sonanti-tumor Vδ 2T lymphocytes in non-Hodgkin lymphomas. Haematologica 99, 131-139.). These pathologies were not detected in the volunteers who participated in the study.

Within this context, the low toxicity of C. sympodialis was verified, since it was not revealed any significant statistical changes in the volunteers' biochemical tests, despite the fact that studies demonstrate hepatic alterations in humans throughout continuous use of medicinal plants (Paulo et al., 2009Paulo, P.T.C., Diniz, M.F.F.M., Medeiros, I.A., Morais, L.C.S.L., Andrade, F.B., Santos, H.B., 2009. Ensaios clínicos toxicológicos, fase I, de um fitoterápico composto (Schinus terebinthifolius Raddi, Plectranthus amboinicus Lour e Eucalyptu sglobulus Labill). Rev. Bras. Farmacogn. 19, 68-76.; Bunchorntavakul and Reddy, 2013Bunchorntavakul, C., Reddy, K.R., 2013. Review article: herbal and dietary supplement hepatotoxicity. Aliment. Pharmacol. Ther. 37, 3-17.). Furthermore, when comparing the results from the pre-clinical trials to the clinical ones, we realized that there may be some statistical variation, yet only in overdose (Diniz, 2000Diniz, M.F.F.M., 2000. Ensaios toxicológicos pré-clínicos com as folhas de Cissampelos sympodialis Eichl (Menispermaceae). Tese de doutorado, Programa de Pós-graduação em Produtos Naturais e Sintéticos Bioativos. Universidade Federal da Paraíba, João Pessoa.).

Along the clinical tests, anamnesis, temperature measurement, blood pressure investigation, respiratory and cardiac frequency, body mass index and application of questionnaires related to possible side and adverse effects were conducted by the physician responsible for the research, who evaluated and diagnosed that the individuals involved in the study were in normal standards (Figs. 2 and 3). The electrocardiograms showed eleven normal ones before and after ingestion of the product; two conduction disorders of the right bundle branch before and after; one short PR before and after; one bradycardic before and after; one normal before and one altered ventricular repolarization after; one bradycardic before and 1altered ventricular repolarization after. Nevertheless, all electrocardiographic tests were as expected based on normal limits.

Fig. 2
Weekly evaluation of women according to the following parameters: temperature, respiratory and cardiac frequency, systolic and diastolic blood pressure and body mass index. Values are expressed in mean ± SEM. One-way ANOVA/Tukey. *p < 0.05.
Fig. 3
Weekly evaluation of men according to the following parameters: temperature, respiratory and cardiac frequency, systolic and diastolic blood pressure and body mass index. Values are expressed in mean ± SEM. One-way ANOVA/Tukey. *p < 0.05.

The electrocardiogram (ECG) is a simple and low cost test which provides data about the myocardium status, perhaps useful in cardiovascular epidemiology, therefore supporting the diagnosis of the myocardial infarction, ischemia and cardiac hypertrophy, and yet detecting the risk of future cardiac events (Cardoso et al., 2002Cardoso, E., Martins, I.S., Fornari, L., Monachini, M.C., Mansur, A.P., Caramelli, B., 2002. Alterações eletrocardiográficas e sua relação com os fatores de risco para doença isquêmica do coração em população da área metropolitana de São Paulo. Rev. Assoc. Med. Bras. 48, 231-236.; Ribeiro et al., 2012Ribeiro, S.M., Morceli, J., Gonçalves, R.S., Franco, R.J., Habermann, F., Meira, D.A., Matsubara, B.B., 2012. Accuracy of chest radiography plus electrocardiogram in diagnosis of hypertrophy in hypertension. Arq. Bras. Cardiol. 99, 825-833.).

However, the normal range of the electrocardiogram is controversial, hence it demands a thorough analysis of variations considered expected in the ECG of healthy people, and, only after, some reflection on the meaning of the electrocardiograms which are undoubtedly abnormal (Moffa and Sanches, 2001Moffa, P.J., Sanches, P.C.R., 2001. Eletrocardiograma: normal e patológico. Roca, (Sério InCor) São Paulo.; Hampton, 2011Hampton, J., 2011. ECG na prática. Elsevier, Brasil.).

Sinus rhythm is the only one sustained as normal. In youth, the space RR is reduced, in other words, the cardiac frequency is increased during inspiration and it is named respiratory sinus arrhythmia. When the sinus arrhythmia is intense, it may simulate an atrial one (Moffa and Sanches, 2001Moffa, P.J., Sanches, P.C.R., 2001. Eletrocardiograma: normal e patológico. Roca, (Sério InCor) São Paulo.; Hampton, 2011Hampton, J., 2011. ECG na prática. Elsevier, Brasil.).

There is no single definition for a normal cardiac frequency, and the terms bradycardia and tachycardia ought to be used cautiously. There is no point at which a high cardiac frequency in sinus rhythm should be called sinus tachycardia and no upper limit for sinus bradycardia. However, unexpected high or low rates should be investigated. The possible causes for a sinus rhythm of low cardiac frequency are: good physical condition, hypothyroidism, hypothermia, acute myocardial infarction, vasovagal attacks and use of beta-blockers. The most common causes described as sinus rhythm of high cardiac frequency is: pain, fear, obesity, acute myocardial infarction, pulmonary embolism, anemia, thyrotoxicosis, use of beta-adrenergic drugs (Moffa and Sanches, 2001Moffa, P.J., Sanches, P.C.R., 2001. Eletrocardiograma: normal e patológico. Roca, (Sério InCor) São Paulo.; Hampton, 2011Hampton, J., 2011. ECG na prática. Elsevier, Brasil.). These pathologies were not detected in the volunteers who participated in the study.

Studies showed that small changes in the ECG may be regarded as "predictive" for clinical signs of a coronary heart disease, which is related to cardiovascular mortality (Moffa and Sanches, 2001Moffa, P.J., Sanches, P.C.R., 2001. Eletrocardiograma: normal e patológico. Roca, (Sério InCor) São Paulo.; Hampton, 2011Hampton, J., 2011. ECG na prática. Elsevier, Brasil.). Some authors suggest that an abnormality in the ST-T segment is an independent indicator of morbidity and mortality from coronary atherosclerosis (Moffa and Sanches, 2001Moffa, P.J., Sanches, P.C.R., 2001. Eletrocardiograma: normal e patológico. Roca, (Sério InCor) São Paulo.; Baranowski et al., 2012Baranowski, R., Małek, L., Prokopowicz, D., Spiewak, M., Miśko, J., 2012. Electrocardiographic diagnosis of the left ventricular hypertrophy in patients with left bundle branch block: is it necessary to verify old criteria? Cardiol. J. 19, 591-596.).

For this reason, the ECG has been widely used to identify individuals at risk for isquemic heart diseases, still during asymptomatic stage. This population, once subjected to preventive and quite aggressive strategies, may be benefited.

Throughout the clinical research, some side and adverse effects were observed, such as: decreased muscle aches; skin hydration; increased intestinal motility; decreased tingling sensation. Moreover, dizziness, insomnia, fluid retention, somnolence, reduction in candida and decreased appetite were also reported as side and adverse effects (Table 5).

Table 5
Side effects and adverse reactions described throughout the clinical study.

These adverse reactions may be classified Type A, referred to as toxic or side effects, which can be explained by the action mechanism of drugs, being a common and expected reaction and of low mortality rate (Edwards and Aronson, 2000Edwards, I.R., Aronson, J.K., 2000. Adverse drug reactions: definitions, diagnosis, and management. Lancet 356, 1255-1259.; Sobrafo, 2011Sobrafo, 2011. Guia para Notificação de Reações Adversas em Oncologia. In: Sociedade Brasileira de Farmacêuticos em Oncologia. Conectfarma Publicações Científicas, São Paulo.).

The data collected from this study demonstrated that the administration of C. sympodialis leaves infusion in humans, ingested during thirty days, was well tolerated, indicating neither clinical nor laboratorial alterations, nor any significant adverse reactions. These results complement those obtained in the pre-clinical toxicological studies, suggesting low toxicity, in the dosage and route of administration tested. With this data, there is craving for registering this medicine in potential with Anvisa and proceed with the phase II studies.

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Publication Dates

  • Publication in this collection
    Oct 2015

History

  • Received
    12 Jan 2015
  • Accepted
    19 June 2015
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