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Rehmanniae Radix in osteoporosis: A review of traditional Chinese medicinal uses, phytochemistry, pharmacokinetics and pharmacology
Author’s Accepted Manuscript Rehmanniae Radix in osteoporosis: A review of traditional Chinese medicinal uses, phytochemistry, pharmacokinetics and pharmacology Chenyue Liu, Rufeng Ma, Lili Wang, Ruyuan Zhu, Haixia Liu, Yubo Guo, Baosheng Zhao, Shangang Zhao, Jinfa Tang, Yu Li, Jianzhao Niu, Min Fu, Dongwei Zhang, Sihua Gao
PII: DOI: Reference:
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S0378-8741(16)30625-0 http://dx.doi.org/10.1016/j.jep.2017.01.021 JEP10668
To appear in: Journal of Ethnopharmacology Received date: 1 September 2016 Revised date: 14 January 2017 Accepted date: 14 January 2017 Cite this article as: Chenyue Liu, Rufeng Ma, Lili Wang, Ruyuan Zhu, Haixia Liu, Yubo Guo, Baosheng Zhao, Shangang Zhao, Jinfa Tang, Yu Li, Jianzhao Niu, Min Fu, Dongwei Zhang and Sihua Gao, Rehmanniae Radix in osteoporosis: A review of traditional Chinese medicinal uses, phytochemistry, pharmacokinetics and pharmacology, Journal of Ethnopharmacology, http://dx.doi.org/10.1016/j.jep.2017.01.021 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Rehmanniae Radix in osteoporosis: A review of traditional Chinese medicinal uses, phytochemistry, pharmacokinetics and pharmacology Chenyue Liu1, Rufeng Ma2, Lili Wang2, Ruyuan Zhu2, Haixia Liu2, Yubo Guo2, Baosheng Zhao3, Shangang Zhao4, Jinfa Tang5, Yu Li2, Jianzhao Niu2, Min Fu6, Dongwei Zhang7*, Sihua Gao7* 1
Chinese Material Medica School, Beijing University of Chinese Medicine, Beijing 100102, China;
2
Preclinical Medicine School, Beijing University of Chinese Medicine, Beijing 100029, China;
3
Beijing Research Institute of Chinese Medicine and Pharmacy, Beijing University of Chinese Medicine, Beijing 100029, China;
4
Touchstone Diabetes Center, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8549, USA;
5
The First Affiliated Hospital of He’nan TCM College, Zhengzhou 45000, China
6
The Research Institute of McGill University Health Center, Montreal, Quebec H4A 3J1, Canada;
7
Diabetes Research Center, Beijing University of Chinese Medicine, Beijing 100029, China
[email protected] [email protected] *
Co-correspondence to: Dr. Dongwei Zhang, MD & PhD, Diabetes Research Center, Beijing University of
Chinese Medicine, Beijing, 100029, PR China. Phone: (8610) 6428-6915. Fax: (8610) 6428-6929
*
Co-correspondence to: Dr. Sihua Gao, MD, Diabetes Research Center, Beijing University of Chinese Medicine,
Beijing, 100029, PR China. Phone: (8610) 6428-6929. Fax: (8610) 6428-6929
Abstract: Ethnopharmacological relevance: Emerging clinical usage and pharmacological effects have been achieved in using Rehmanniae Radix either singly or in combination with other herbs to treat skeletal diseases in traditional Chinese medicine (TCM) in the recent years. This study is
aimed to provide a comprehensive review about the historical TCM interpretation of the action of Rehmanniae Radix in osteoporosis, its usage in clinical trials and osteoporotic models, its main phytochemical constituents, and its pharmacokinetics. Materials and methods: Several databases included PubMed, China Knowledge Resource Integrated Database, China Science and Technology Journal Database, National Science and Technology Library and the Web of Science Database were consulted to locate the publications pertaining to Rehmanniae Radix. The initial inquiry was conducted for the presence of the following term combinations in the abstracts: Rehmanniae Radix, Dihuang, phytochemistry, pharmacokinetics, osteoporosis, bone, osteoclast and osteoblast. About 330 research papers and reviews were consulted. Results: In TCM, Rehmanniae Radix exerts the anti-osteoporotic effect via regulating the functions of kidney and liver as well as improving blood circulation. 107 clinical trials are identified that used Rehmanniae Radix in combination with other herbs to treat post-menopausal, senile and secondary osteoporosis. Most of the clinical trials are characterized by high efficacy and no obvious adverse effects. However, the efficacies of these clinical trials are limited because of small patient sample size, short treatment duration and poor clinical design. In addition, TCM herbs under the clinical study are not clear because of a lack of standardization and authentication. The pharmacokinetics data demonstrate that the ingredients of Rehmanniae Radix are
widely distributed after administration, and that catalpol and ajugol as well as acetoside are supposed to be the active constituents. More than 140 individual compounds have been currently isolated from this plant and reported to show pleiotropic effects on various diseases. Rehmanniae Radix displays bone protecting features
in
the
osteoporosis
models
via
the
delicate
balance
between
osteoclastogenesis and osteoblastogenesis through single herb extracts and its isolated compounds. Conclusions: The successful inclusion of Rehmanniae Radix in clinical trials and preclinical studies for the management of osteoporosis has attracted rising attentions for identifying potential anti-osteoporotic candidates from this plant and clinical existing TCM formulas, which will further speed up anti-osteoporosis drug discovery processes. Properly designed q~ and well controlled prospective studies are still needed to further demonstrate bone protective actions and safe use of this herb and its ingredients
Abbreviations ALP, alkaline phosphatase; BBB, blood–brain barrier; BMC, bone mineral content; BMD, bone mineral density; BW, body weight; CKD, chronic kidney disease; Col, collagen; CSF, cerebrospinal fluid ; CT, calcitonin; DREE, dried Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol; DREW, dried Rehmanniae Radix by aqueous extracted; E2, estradiol; FREE, fresh Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol; FREW, fresh Rehmanniae Radix by aqueous extracted; p.o., gavage; H/C, hydroxyproline /creatinine; IL, interleukin; i.m. ,
intramuscular administration ; Itg β1, integrin beta 1; i.v. , intravenous injection; NRS, numerical rating scale; OC, osteocalcin; OPG, osteoprotegerin; OPN, osteopontin; OVX, ovariectomized; PPRE, peroxisome proliferator response element; PTH, parathyroid hormone; RANKL, receptor activator of nuclear factor kappa-B ligand; Runx2, Runt-related transcription factor 2; TCM, traditional Chinese medicine; TRAP, tartrate-resistant acid phosphatase; UHP, urine hydroxyproline; VAS, visual analogue scale
Keywords: Rehmanniae Radix; Osteoporosis; Clinical trial; Phytochemistry; Pharmacokinetics; Pharmacology.
Chemical compounds studied: Catalpol, CID 91520; rehmannioside A, CID 78407230; rehmannioside B, CID 101654196; rehmannioside C, CID 101654197; rehmaionoside A, CID 10023290; rehmaionoside B, CID 10430488; rehmaionoside C, CID 11740990; rehmaglutin A, CID 5320903; rehmaglutin B, CID 14413769; rehmaglutin D, CID 5320906; rehmaglutin C, CID 21637649; ajugol, CID 6325127; rehmannioside D, CID 92044472; and geniposide, CID 107848; gentisic acid, CID 3469; versulin, CID 5280443; oleanolic acid, CID 10494.
1. Introduction Osteoporosis is a progressive and silent bone disease characterized by reduction of bone mass and density, and microstructural deterioration of bone tissues leading to enhanced skeletal fragility and a consequent increased risk of hip and vertebral fractures (Wang et al., 2016). According to the report from international osteoporosis foundation, an osteoporotic fracture is statistically to occur globally every 3 seconds.
Current marketed drugs include bisphosphonates (Maraka and Kennel, 2015), the receptor activator of nuclear factor kappa-B ligand (RANKL)-antibody (Diedhiou et al., 2015; Yasuda, 2013), parathyroid hormone (Li et al., 2016), estrogen replacement therapy (Gambacciani and Levancini, 2014), calcitonin (CT) (Shohrati et al., 2015), and selective estrogen receptor modulators (Andersson et al., 2015), etc. Some of novel potential drug candidates are currently in development, such as cathepsin K inhibitors, c-Src kinase inhibitors, chloride channel inhibitors, sclerostin antibody (MacNabb et al., 2016), Dickkopf-1 antibody (Montagnani, 2014), Wnt (Ohlsson, 2013) and Sema agonists (Tang et al., 2015). However, most of these drugs have been evidenced to exhibit certain side effects on patients with osteoporosis (Che et al., 2016; Guo et al., 2015; Ju et al., 2014; Leung and Siu, 2013; Liu et al., 2014a; Mukwaya et al., 2014). Meanwhile, nature products have recently appealing to researcher’s interests in the management of osteoporosis with its relatively inexpensive, low risk of adverse events and multi-targeting effects. Rehmanniae Radix, a sweet medicinal and edible herb known as Dihuang in Chinese, is derived from the root of perennial plant Rehmannia glutinosa (Gaertn.) DC. (Fig. 1A), and has been clinically used for more than 3000 years. Rehmannia glutinosa (Gaertn.) DC. mainly grows in the provinces of He’nan, Shanxi, Shandong and Hebei in China. Rehmanniae Radix (Fig. 1B) is usually harvested in every autumn and then can be used in various preparations (fresh, steamed or processed with wine) to treat patients. And it was first recorded as a “top-tier” herb (The ancient term
“top-tier” was given to herbs without observable toxicity) in the Shennong's Classic Materia Medica (Shennong Bencao Jing) written during the period from 100 BC to 200 AD. Further, Rehmanniae Radix was also described in classical traditional Chinese medicine (TCM) works such as in the Essentials of Materia Medica (Bencao Beiyao, Ming dynasty, 1368-1644 AD) and The Grand Compendium of Materia Medica (Bencao Gangmu, Ming dynasty, 1578 AD). In the text books of academic TCM, Rehmanniae Radix preparata (Fig. 1C) is characterized as a common hematologic drug with the following functions: nourishing Yin, supplementing bloods, boosting essence, and filling the marrow. And also fresh Rehmanniae Radix (Fig. 1D) has the ability of clearing heat to cool blood, nourishing Yin and promoting the production of body fluids. So far, Rehmanniae Radix has been broadly studied in more than 148,000 publications sourced from the Chinese National Knowledge Infrastructure
(www.cnki.net),
(http://www.nstl.gov.cn/),
China
National Science
Science and
and
Technology
Technology
Journal
Library Database
(http://en.cqvip.com/cstj.html) and approximate 270 from web of science database. This herb has been officially recorded in the Chinese Pharmacopoeia since 1953. Modern phytochemical research reveals that Rehmanniae Radix contains more than 140 individual compounds, such as monoterpenoids, phenethyl alcohol glycosides, and triterpenes. Pharmacological studies reveal that Rehmanniae Radix exhibits a protective role in the management of diabetes, senile osteoporosis, hematological and gynecological diseases.
Here, we review the clinical usages of Rehmanniae Radix in the treatment of osteoporosis, and the current knowledge of its phytochemistry, pharmacokinetics and bone protecting activities. Firstly, we summarize the interpretation of the action of Rehmanniae Radix in TCM, which is useful to understand the rationale of clinical trials using this herb in various combinations with other herbs to treat osteoporosis in China. 2. The bone-protective activity of Rehmanniae Radix in the theory of traditional Chinese medicine In TCM, Rehmanniae Radix is recognized as a herb with a sweet and bitter flavor (here the word flavor not only reflects the taste of the herb but also corresponds to a pathophysiological response and organ target based on ancient observations) as well as cold property (the property reflects the combined effects of the Chinese medicine felt by a patient and the outcome of the treatment) (Gao et al., 2013). However, Rehmanniae Radix preparata was considered as an herb with sweet flavor and slightly warm property after processed with yellow rice wine. According to the theory of channel tropism that describes a selective action of an herbal medicine manifested on one or several specific meridians (Liu et al., 2013), Rehmanniae Radix components can be distributed to the heart, liver and kidney, However, Rehmanniae Radix preparata only can be distributed to the liver and kidney. The readers should be alerted that organ designations in TCM are not identical with their appropriate anatomical counter parts but rather represent functional entities (Guo et al., 2014). In TCM, sweet
flavor of herb materials is traditionally associated with tonic, relaxing and harmonious effects. And bitter flavor is associated with eliminating dampness, and improving the functions of the stomach and intestine. The property of cold is able to dispel the “heat”, such as irritability, fever and inflammatory conditions in the body. And the property of warm can nourish kidney and Yin. Therefore, Rehmanniae Radix has been traditionally used to treat blood ejection and spontaneous external bleeding, menstrual disorders, blood stasis induced heartache, relative weakness in the loins and knees, diabetes, rheumatism, nocturnal emission, and premature graying hair. And Rehmanniae Radix preparata has been used to treat lumbar debility, blood deficiency and sallow complexion, metrorrhagia and metrostaxis, kidney and liver Yin deficiency, palpitations, abnormal menstruation (Tan et al., 2012). Meanwhile, in TCM, osteoporosis is described as “bone atrophy”, “bone rheumatism” or “bone loss”. The main pathogenesis of osteoporosis is attributed to deficiencies in kidney, spleen and liver, which is linked to “a ‘stagnation’ or ‘lack of flow’ of water and blood” (Guo et al., 2015). According to the TCM theory, Rehmanniae Radix may have the effect on improving the functions of the liver and kidney as well as correcting blood deficiency (Gao et al., 2013). Thus, Rehmanniae Radix can be used to treat patients with osteoporosis.
3. Rehmanniae Radix in TCM clinical trials of osteoporosis
Rehmanniae Radix has been widely used in combination with other TCM herbs to treat patients with osteoporosis. We identified 107 clinical studies of primary and secondary osteoporosis that Rehmanniae Radix was used in co-prescription with other TCM herbs such as Epimedii Brevicornus Herba, Astragali Radix, Cornus officinalis, Angelicae Sinensis Radix and Drynariae Rhizoma (Table 1 and 2). Some of clinical trials have also appeared in Dr. Liu et al’s review (Liu et al., 2014a) . The identified 107 clinical trials comprised a total of 6224 patients. The majority of 107 trials targeted the treatment of primary osteoporosis (80 trials); out of which 35 studies explicated the post-menopausal osteoporosis, 9 studies addressed the senile osteoporosis. 9 trials addressed secondary osteoporosis patients. The minority of these studies targeting diabetes-induced osteoporosis patients. Only 4 trials caused by glucocorticoid. 18 trials did not specify the disease type. The overall efficacy (with markedly and moderately improved conditions) of trials treating primary osteoporosis patients was between 65% and 100%, and that for secondary osteoporosis patients was between 73.3% and 100% (Table1). Therefore, the accumulating evidence suggests that Rehmanniae Radix may be effective for preventing the development of primary and secondary osteoporosis. However, of 107 clinical trials, 2 were randomized placebo double-blind controlled trials, 3 were randomized controlled double-blind trials, 2 were randomized single-blind and 85 were open trials. The remaining 15 trials carried on statistical analysis of the results of the self-comparison before and after treatment. Few clinical
trials meet the standards of randomized, double blind, placebo-control and multi-centered. Among all the available data on clinical osteoporosis trials containing Rehmanniae Radix, we found that all of these studies are characterized by a small patient sample size (mostly less than 100) and short treatment duration of 4 weeks to 18 months. There are difficulties in comparing overall validation of the studies because clinical trials differ in the time frame, observed biomarkers, participants’ ethnicity, and administration of the prescriptions (Liu et al., 2014a). Most of the trials were reported to observe the improvement in increasing bone mineral density, while few of the clinical trials addressed fracture rates, which is a reliable marker to make a statement on a truly clinically therapeutic effect (Guo et al., 2014). Therefore, the literatures present weaker evidence for marginal benefits of the prescriptions. Furthermore, no trials reported possible herb–herb interactions of the prescription. As there is a rising concern about the potential toxicity of TCM herbs, the future studies on the safety of the prescriptions and single herbs are badly warranted. In addition, well-designed clinical trials with strong evidence to interpret the endpoints are also urgently required. The TCM ingredients in the osteoporosis studies range from 4 to 24 individual elements. The relative weight contributions of Rehmanniae Radix in these therapeutic mixtures are ranged from 3.9% to 37.5%, and listed in Table 1. Therefore, further studies focusing on the correlation between therapeutic effects and relative
Rehmanniae Radix content are not easy due to the large variability of the herbal compositions (number of herbs used and their individual dosages). Meanwhile, non-standardized preparations of the prescriptions studied are also main grave area of concern. It should be noted that the recommended dosage of Rehmanniae Radix in Chinese Pharmacopeia (2015 version) is 10-15 g for Rehmanniae Radix, or 12-30 g for fresh Rehmanniae Radix and 9-15 g for Rehmanniae Radix preparata (2015). However, these identified prescriptions may offer a library in searching synergistic formulations and potential herbs for the management of osteoporosis. In addition, cautions should be excised as some medicinal effects of plants may be dependent upon the season, time of harvest, degree of ripening, method of preparation, etc. Furthermore, future TCM clinical studies are also required to determine the real contributions of Rehmanniae Radix in the management of patients with osteoporosis through standardizing the preparations of TCM prescriptions and employing serum pharmacological and pharmacokinetic methods (Huang et al., 2016b) as well as systems pharmacology approaches (Li et al., 2014), which will also provide strong scientific evidence for evaluation of the effects of Rehmanniae Radix on osteoporosis.
Table 1 The prescriptions containing Rehmanniae Radix used by physicians for management of osteoporosis*. Prescription name;
#
of
components
Percentage
Type
of
of
osteoporosis;
Rehmanniae
of
Radix
Treatment
(preparata)
duration
Treatment aim and biomarker measurements
Results (# of patients)
Ref.
Markedly improved (6)
(Zeng, 2005)
#
Patients;
in prescription; Study design Liuwei Dihuang
Not Known;
Post-menopausal
Significant
Pill
Randomized
osteoporosis
deficiency; Increase in bone mineral content
Moderately improved (58)
a
single-blind
70
(BMC); Bone mineral density (BMD) in radius
Ineffective (6)
6
trial
6 months
effect:
Disappearance
of
kidney
2
and ulna increased by ı 0.05 g/cm . Effective:
Kidney
deficiency
Overall efficacy: 91.4%. significantly
No control.
alleviated; BMD in radius and ulna increased by ˘ 0.05 g/cm2. Ineffective:
No
significant
improvement
in
symptoms of kidney deficiency, BMC and BMD. Liuwei Dihuang
Not known;
Post-menopausal
Significant
Capsule
Open trial
osteoporosis
6
b
effect:
BMD
increased;
Clinical
Markedly improved (8)
(Li,
symptoms disappeared.
Moderately improved (48)
2011)
70
Effective: Clinical symptoms alleviated; BMD
Ineffective (14)
6 months
remained the same.
Overall efficacy: 80.0%.
Ineffective: BMD and clinical symptoms remained the same. Qidan Dihuang
Not known;
Post-menopausal
Significant effect: No pain in waist, back and
Markedly improved (16)
(Zhang
Granule
Randomized
osteoporosis
chest; Work and life as usual.
Moderately improved (31)
et
single-blind
58
Effective:
Ineffective (11)
2008)
trial
3 months
significantly alleviated; Work and life as usual.
5
c
Pain
in
waist,
back
and
chest
al.,
Overall efficacy: 81.0%.
Ineffective: Prominent pain, difficult to work and life. 9.3%;
Post-menopausal
Significant effect: BMD increased; Clinical
Markedly improved (16)
(Jiao and
Open trial
osteoporosis
symptoms disappeared; Work and life as usual;
Moderately improved (11)
Yang,
Decoction
30
Effective: Clinical symptoms alleviated; BMD
Ineffective (3)
2009)
14d
3 months
remained the same; Work and life as usual.
Overall efficacy: 90.0%.
Ineffective: BMD and clinical symptoms remained
No control.
Bushen
Yipi
Zhuanggu
the same; Difficult to work and life. Zhibai Dihuang
*
Not known;
Post-menopausal
Significant effect: Pain disappeared; BMD in
Markedly improved (39)
(Bai
et
The medicinal plant names of TCM herbs used in the above-mentioned prescriptions (Table 1) are not available reliably in the papers we consulted, and therefore this information cannot be provided.
Pill 9
Open trial
e
osteoporosis
radius and ulna increased by ı 0.05 g/cm2;
Moderately improved (26)
al.,
70
Effective: Pain significantly alleviated; BMD in
Ineffective (5)
2014)
6 months
Bushen
Yigu
Gao 5
2
radius and ulna increased by ˘ 0.05 g/cm .
Overall efficacy: 92.9%.
Ineffective: Prominent pain; BMD remained the
Control treatment: Caltrate D and
same.
Gugua Extractive Injection.
Not known;
Post-menopausal
Effective: BMD and bone metabolism biochemical
Effective (27)
(Wang et
Open trial
osteoporosis
criterion tend toward bone formation; Treatment
Ineffective (3)
al.,
30
score of kidney-weakness improved between
Overall efficacy: 90.0%.
1998)
3 months
2/3̚1/2.
f
Ineffective:
BMD
and
bone
metabolism
biochemical markers tend toward bone resorption; Treatment score of kidney-weakness improved by İ 1/3. Bushen
11.4%;
Post-menopausal
Significant effect: No pain; BMD significantly
Markedly improved (21)
(Zhang
Zhuanggu
Open trial
osteoporosis
increased.
Moderately improved (12)
et
Decoction
41
Effective: Pain significantly alleviated; BMD
Ineffective (8)
2013)
12g
180 Days
increased or remained the same.
Overall efficacy: 80.5%
al.,
Ineffective: No changes in pain and signs. Jiarong Pill 12
h
Not known;
Post-menopausal
Significant effect: No pain; Clinical score
Markedly improved (10)
(Chen
Open trial
osteoporosis
decreased by ı 2/3; BMD increased by ı
Moderately improved (8)
and
2
20
0.06 g/cm .
Ineffective (2)
Huang,
6 months
Effective: Pain in back and waist significantly
Overall efficacy: 90.0%.
2001)
alleviated; 1/3 İ clinical score < 2/3; BMD
Control treatment: Caltrate D.
2
increased by < 0.06 g/cm . Ineffective: No changes in pain and BMD; Clinical score decreased by 1/3. Bushen
Jianpi
Jingu Decoction 12
11.5%;
Post-menopausal
Significant effect: No pain; No soreness and
Markedly improved (24)
(Mao,
Open trial
osteoporosis
weakness of waist and knees; BMD increased by
Moderately improved (10)
2011)
39
ı 2%.
Ineffective (5)
12 weeks
Effective: Pain and soreness and weakness of
Overall efficacy: 87.17%.
i
waist and knees significantly alleviated; BMD increased by < 2%. Ineffective: No changes in the above items. Shugan Huoxue Decoction j
14
Zishen
6.8%;
Post-menopausal
Clinical curative effect assessment: 0 score: no
Markedly improved (16)
(Han
Open trial
osteoporosis
pain; 1 score: occasionally pain; 2 scores: pain
Moderately improved (8)
al.,
25
repeatedly and alternatively, work as usual; 3
Ineffective (1)
2007)
6 months
scores: pain continuously, difficult to life and
Overall efficacy: 96.0%.
work.
Control treatment: Caltrate D and
Significant
effect:
Clinical
curative
effect
assessment reduced by 2 scores. Effective: Clinical curative effect assessment
Alendronate Sodium.
et
reduced by 1 score. Ineffective: Clinical curative effect assessment reduced by 0 score. Jiawei
Shujin
Not known;
Post-menopausal
Significant effect: No pain; BMD increased by ˚ 2
Markedly improved (13)
(Wang et
osteoporosis
0.06 g/cm .
Moderately improved (16)
al.,
Decoction
75
Effective: Pain significantly alleviated; BMD
Ineffective (1)
2015a)
10k
6 months
increased by ˘0.06 g/cm2.
Overall efficacy: 96.67%.
Ineffective: Prominent pain; BMD remained the
No control.
Zhuanggu
Open trial
same. Gengnian Anyi
Not known;
Post-menopausal
Significant effect: No pain, score increased by ı
Markedly improved (12)
(Fan
Pill
Open trial
osteoporosis
2/3.
Moderately improved (8)
al.,
22
Effective: Pain significantly alleviated; 1/3 İ
Ineffective (2)
2004)
6 months
pain score decreased by ˘ 2/3.
Overall efficacy: 90.91%.
Ineffective: Prominent pain; BMD remained the
Control treatment: Calcitrate D
4
l
et
same; Pain score decreased by ˘1/3. Jiangu
Not known;
Post-menopausal
Serum alkaline phosphatase (ALP), Ca, estradiol (E2),
Serum ALP significantly decreased,
(Ke
Formulation
Open trial
osteoporosis
BMD.
E2 significantly increased, Serum
al.,
6
m
2+
32
Ca and BMD increased.
2005)
et
3 months Jiawei
Zuogui
Pill 11
9.8%;
Post-menopausal
Cured: Main symptoms disappeared.
Cured (33)
(Huang
Open trial
osteoporosis
Significant effect: Main symptoms significantly
Markedly improved (8)
et
53
improved.
Moderately improved (7)
2013a)
6 months
Effective: Main symptoms slightly improved.
Ineffective (5)
Ineffective: No changes in main symptoms.
Overall efficacy: 90.57%
n
al.,
Control treatment: D-cal Shujin
Not known;
Post-menopausal
E2, CT, Tartrate resistant acid phosphatase (TRAP),
Markedly improved (25)
(Sun
Zhuanggu
Open trial
osteoporosis
osteocalcin (OC).
Moderately improved (13)
al.,
40
Significant effect: Disappearance of pain; BMD
Ineffective (2)
2015)
Decoction 10
o
6 months
2
increased by ı 0.06 g/cm .
Overall efficacy: 95.0%
Effective: Pain significantly alleviated; BMD
No control.
2
Hugu Granule 10
p
increased by < 0.06 g/cm .
TRAP decreased. OC, CT and E2
Ineffective: No changes in symptom and BMD.
increased.
et
Not known;
Primary
BMD in lumbar (2~4), neck, Ward’s and
Total effective rates:
(Hong et
RCT
osteoporosis
trochanter; Serum ALP; Urine hydroxyproline
BMD in lumbar: 59.8%,
al.,
placebo
338
/creatinine (H/C).
BMD in neck: 54.6%,
2008)
double-blind
6 months
BMD in Ward’s: 56.4%, BMD in trochanter: 50.7%. ALP maintained the same level, H/C significantly decreased.
Zhuanggu
7.8%;
Post-menopausal
Significant effect: Pain demoted from 3 or 2 to 0.
Markedly improved (91)
(Dong et
Qiangjin
Open trial
osteoporosis
Effective: Pain demoted from 3 or 2 to 1.
Moderately improved (20)
al., 2011)
Decoction 9
q
120
Ineffective: Pain remained the same or above level
Ineffective (9)
6 months
2.
Overall efficacy: 92.5% Control treatment: Vitamin D and Calcium.
Significant effect: Improvement of pain in back
Markedly improved (12)
(Yu
osteoporosis
and waist; Average score decreased by ı 2
Moderately improved (26)
al.,
40
scores; BMD increased byı 0.06 g/cm2.
Ineffective (2)
2013)
6 months
Effective: Improvement of pain in back and waist,
Overall efficacy: 95.0%.
Average score decreased by between 1~1.9 scores;
No control.
Zhuanggu
Not known;
Primary
Capsule
Open trial
11r
et
2
BMD increased by < 0.06 g/cm . Ineffective: No change in pain and BMD; Average score decreased by less than 1 score. Bushen
5.3%;
Primary
Significant effect: No pain; Clinical symptoms
Markedly improved (18)
(Han,
Zhuanggu
Open trial
osteoporosis
improved, and BMD significantly increased.
Moderately improved (6)
2013)
Decoction
28
Effective: Pain in limbs significantly alleviated;
Ineffective (4)
14s
6 months
BMD increased.
Overall efficacy: 85.7%.
Ineffective: No changes in pain and BMD; Bone
No control.
fracture occurred easily. Rengong Jianbu
Not known;
Primary
Significant effect: No pain; Clinical signs score
Markedly improved (35)
(Zhang
Huqian Pill
RCT
osteoporosis
decreased by ı 70%; BMD increased by ˚
Moderately improved (71)
et
double-blind
120
2%.
Ineffective (14)
2005)
3 months
Effective: Pain significantly alleviated; Clinical
Overall efficacy: 88.34%.
signs score decreased by between 30% and 70%;
No control.
24
t
al.,
BMD increased by between 1 % and 2%. Ineffective: No change in symptoms; Clinical signs score decreased by ˘30%; BMD increased by ˘1%. Yishen
18.2%;
Primary
Significant
Zhuanggu
Open trial
osteoporosis
significantly increased.
96
Effective:
6 months
significant increase in BMD.
Overall efficacy: 98.96%.
Ineffective: Pain and BMD remained the same.
No control.
Mixture 7
u
effect:
Pain
Pain
disappeared;
significantly
BMD
alleviated;
No
Markedly improved (52)
(Wang et
Moderately improved (43)
al.,
Ineffective (1)
2003)
Guben
Not known;
Primary
Cured: No symptoms; Clinical score decreased by
Cured (3)
(Dai and
Zhuanggu
Open trial
osteoporosis
ı 95 %.
Markedly improved (12)
Li, 2015)
60
Significant effect: Main symptoms significantly
Moderately improved (11)
6 months
improved; 70% İ clinical score decrease ˘
Ineffective (1)
95%;
Overall efficacy: 96.29%.
Capsule 7
v
Effective: Main symptoms improved; 30%
İ
score decrease ˘70%; Ineffective: No change in symptoms; score decrease ˘ 30%.
No control.
Xianling
Migu
Granule 9
Not known;
Primary
Cured: No symptoms; Score decrease ı 95%.
Cured:(2)
(Dai
Open trial
osteoporosis
Significant effect: Main symptoms significantly
Markedly improved (5)
and Li,
60
improved; 70% İ clinical score decrease ˘
Moderately improved (14)
2015)
6 months
95%.
Ineffective (4)
Effective: Main symptoms improved; 30% İ
Overall efficacy: 84.0%.
clinical score decrease ˘ 70%.
No control.
w
Ineffective: No change in symptoms; Clinical score decrease ˘ 30%. Jiawei
Bushen
Zhuangjin 13
9.8%;
Primary
Significant effect: No pain in waist and back;
Markedly improved (26)
(Lv
Open trial
osteoporosis
Significant increase in BMD; Disappearance of
Moderately improved (25)
al.,
56
Yin deficiency.
Ineffective (5)
2003)
3 months
Effective: Pain in waist and back significantly
Overall efficacy: 91.07%.
alleviated; No significant increase in BMD; No
No control.
x
et
significant improvement in symptoms of Yin deficiency. Ineffective: Prominent pain; BMD and symptoms of Yin deficiency remained the same. Gusongling
7.9%;
Primary
Significant effect: Disappearance of clinical
Markedly improved (23)
(Wang,
Decoction
Open trial
osteoporosis
symptoms; BMD increased by ı 20%.
Moderately improved (20)
2015)
50
Effective: Symptoms significantly alleviated;
Ineffective (7)
BMD increased by ı 20%.
Overall efficacy: 86.0%.
Ineffective: No changes in symptom and BMD.
No control.
15
y
3
months
Shisiwei
10.8%;
Primary
Significant effect: No pain in waist, back and
Markedly improved (19)
(Zhang
Jianzhong
Open trial
osteoporosis
chest; Work and life as usual.
Moderately improved (13)
et
Decoction
34
Effective:
Ineffective (2)
2002)
14z
2 months
significantly alleviated; Work and life as usual.
Overall efficacy: 94.11%.
Ineffective: Pain still existed˗Difficult to work and
No control.
Pain
in
waist,
back
and
chest
al.,
life. Bushen Tongluo
Not known;
Primary
Significant effect: Disappearance of pain; BMD
Markedly improved (13)
(Shi
Formulation
Open trial
osteoporosis
significantly increased;
Moderately improved (5)
al.,
32
Effective: Pain significantly alleviated; No change
Ineffective (4)
2007)
6 months
in BMD;
Overall efficacy: 87.5%.
Ineffective: No changes in symptom and BMD.
Control treatment: Osteoform.
6
aa
Duhuo
Jisheng
Decoction 17
6.0%;
Primary
Very good: Clinical symptoms improved by >
Very good: (20)
(Song et
Open trial
osteoporosis
75%.
Good: (10)
al.,
41
Good: Clinical symptoms improved by between
Average: (6)
2013)
3 months
50% and 74%.
Bad: (5)
ab
Average:
Clinical
symptoms
improved
between 25% and 49%.
by
Overall efficacy: 87.8%. Control treatment: Caltrate D.
Bad: Clinical symptoms improved by ˘ 25%. Bushen Huoxue
et
10.8%;
Senile
Numerical rating scale (NRS)ˈBMDˈE2
BMD
and
E2
significantly
(Jiang,
Formulation 18
Open trial
ac
osteoporosis
increased, NRS decreased.
2015)
60 3 months
Jingui
Shenqi
Pill 10
Not known;
Primary
Visual analogue scale (VAS) score.
Markedly improved (23)
(Li
Open trial
osteoporosis
Significant effect: VAS < 2, Sleep and turning
Moderately improved (10)
Chen,
45
were not affected; No pain when walk and sitting.
Ineffective (11)
2014)
6 months
Effective: VAS < 5; Sleep improved and pain
Overall efficacy: 75.6%
relieved.
Control treatment: Alendronate
Ineffective: VAS ı 6; Pain remained the same.
sodium, Calcitriol capsule, and
ad
and
Caltrate D. Jingui
Shenqi
Pill 8
Not known;
Primary
Open trial
ae
Pain scale, serum ALP, P, Ca, BMD.
Pain scale decreased obviously,
(Wang et
osteoporosis
BMD increased, serum ALP, P,
al., 2011)
30
Ca
6 months
statistically before and after the
were
not
significant
treatment, Control
treatment:
Calcium
gluconate. Kanggusong
Not known;
Primary
Serum ALP, Ca, parathyroid hormone (PTH), E2,
Markedly improved (10)
(Wu
Granule
Open trial
osteoporosis
urine hydroxyproline (UHP), BMD. CT.
Moderately improved (15)
al.,
30
Curative effect evaluation: BMD.
Ineffective (5)
2001)
3 months
Significant effect: BMD increased by > 2%.
Overall efficacy: 83.3%
Effective: BMD increased by > 1%.
No control.
Ineffective: BMD increased by < 1%.
Serum Ca, CT and E2 significantly
4
af
et
increased, UHP and PTH decreased.
Kanggusong
Not known;
Primary
acupuncture
Open trial
points patch 4
ag
Markedly improved (11)
(Wu
osteoporosis
Moderately improved (14)
al.,
30
Ineffective (5)
2001)
3 months
Overall efficacy: 83.3%
Same as above.
et
No control. Serum Ca, CT and E2 significantly increased, UHP and PTH decreased.
Qiangjin
4.2%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (12)
(Chen et
Zhuanggu Pill
Open trial
osteoporosis
significantly increased.
Moderately improved (22)
al.,
38
Effective: Pain significantly alleviated; BMD
Ineffective (4)
2015)
6 months
increased.
Overall efficacy: 89.47%
Ineffective: No changes in symptom and BMD.
No control.
16
ah
Yishen Decoction 14
ai
Jiangu
11.1%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (15)
(Huang,
Open trial
osteoporosis
significantly increased.
Moderately improved (26)
2006)
46
Effective: Pain significantly alleviated; BMD
Ineffective (5)
3 months
increased.
Overall efficacy: 89.13%
Ineffective: No changes in symptom and BMD.
No control.
Zhibai Dihuang
Not known;
Primary
Cured: Disappearance of symptoms and signs of
Cured (40)
(Sun,
Pill
Open trial
osteoporosis
TCM; Score decreased by more than 95%; BMD
Markedly improved (42)
2015)
113
significantly increased.
Moderately improved (18)
6 months
Significant effect: Symptoms and signs of TCM
Ineffective (13)
significantly alleviated; Score decreased by ı
Overall efficacy:88.5%
75%; BMD increased.
Control treatment: Caltrate D.
8
aj
Effective: Symptoms and sign of TCM improved; Clinical score decreased byı 30%. Ineffective: No changes in symptoms and BMD; Score decreased by < 30%. Zhuanggu
9.0%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (24)
(Zhang
Decoction
Open trial
osteoporosis
significantly increased.
Moderately improved (14)
and Wu,
45
Effective: Pain significantly alleviated; BMD
Ineffective (7)
2008)
3 months
increased.
Overall efficacy:84.4%
13
ak
Ineffective: No changes in symptom and BMD. Zuogui
Pill
combined
with
Taohong
Siwu
9.6%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (45)
(Chang,
Open trial
osteoporosis
significantly increased.
Moderately improved (34)
2012)
85
Effective: Pain significantly alleviated; BMD
Ineffective (6)
6 months
increased.
Overall efficacy: 92.9%.
Decoction 20
al
Ineffective: No changes in symptom and BMD.
Dihuang
Not Known;
Primary
Cured: Disappearance of pain in limbs; Walk as
Cured (18)
(He and
Gutongkang
Open trial
osteoporosis
usual; Numbness of the limbs disappeared; No
Markedly improved (4)
Zhang,
40
dizziness.
Overall efficacy: 95%.
2014)
2 months
Significant effect: Pain in limbs; Numbness of the
Control treatment: Caltrate D and
limbs and dizziness significantly alleviated;
Rocaltrol.
Capsule 12
am
Difficulty walking occasionally appeared. Effective: Pain in limbs; Numbness of the limbs and dizzy alleviated; Difficulty walking often appears. Ineffective: No changes in main symptoms. Significant effect: No pain.
Markedly improved (85)
(Deng et
osteoporosis
Effective: Pain significantly relieved.
Moderately improved (11)
al.,
101
Ineffective: Pain remained the same.
Ineffective (5)
2006)
Bushen
Not Known;
Male
Zhuanggu
Open trial
Granule 13
an
primary
4 weeks
Overall efficacy: 95.0%. No control.
Gusong’an
Not Known;
Kidney-yang
Significant effect: Clinical score decreased by ı
Markedly improved (7)
(He,
Capsule
Open trial
deficiency
2/3.
Moderately improved (14)
2001)
primary
Effective: 2/3 < Clinical score decrease ı 1/3.
Ineffective (7)
osteoporosis
Ineffective: Clinical score decreased by ˘ 1/3.
Out of touch (4)
11
ao
32 6 months
Overall efficacy: 65.0%.
Liuwei Dihuang
4.7%;
Senile
Significant effect: Disappearance of pain in back,
Markedly improved (11)
(Zhou,
Decoction
Open trial
osteoporosis
lumbar vertebra and limb; BMD significantly
Moderately improved (29)
2011)
46
increased.
Ineffective (6)
3-5 months
Effective:
15
ap
Clinical
symptoms
significantly
alleviated; BMD increased.
Overall efficacy: 86.96%. No control.
Ineffective: No change in symptoms after 3 courses of treatment. Shuanggu
10.8%;
osteoporotic
Monthly take X-ray after fracture fixation to
Excellent (25)
(Zhou et
Decoction
Open trial
fracture
check the registration situation, and fracture
Good (10)
al.,
48
healing situation.
Average (8)
2006)
10
aq
Bad (5)
Not known
Control
treatment:
Salcatonin
injection Overall efficacy: 89.6%. Bushen
Jiangu
Decoction
16.8%;
Osteoporotic
Cured: Fracture healed; Vertebral compression
Markedly improved (32)
(Liu
Open trial
vertebral
cured; No pains in chest and back; Paraplegia
Moderately improved (12)
al.,
compression
disappeared; Body function fully recovered.
Ineffective (2)
2014b)
fractures
Effective: Fracture healed; Vertebral compression
Overall efficacy: 95.7%
46
improved; Pain alleviated in chest and back;
Control treatment: D-cal and
6 months
Paraplegia disappeared; Body function
vitamin D.
13 ar
et
significantly improved.
Ineffective: No change in the above items. Jiawei
Zhibai
Dihuang Pill 9
7.4%;
Osteoporosis
Significant effect: No pain in waist and back;
Markedly improved (38)
(Xu,
Open trial
58
Significant increase in BMD; Disappearance of
Moderately improved (20)
2011)
3 months
Yin deficiency.
Ineffective (0)
Effective: Pain in waist and back significantly
Overall efficacy: 100%.
alleviated; No significant increase in BMD; No
No control.
as
significant improvement in symptoms of Yin deficiency. Ineffective: Pain, BMD and symptoms of Yin deficiency remained the same. Zishen Gukang
Not known;
Osteoporosis
Cured: Pain disappeared; BMD significantly
Cured (24)
(Quan,
Pill
Open trial
54
increased.
Markedly improved (18)
2012)
6 months
Significant effect: Pain significantly alleviated;
Moderately improved (10)
BMD increased.
Ineffective (2)
Effective: Pain significantly alleviated; No change
Overall efficacy: 96.3%.
6
at
in BMD. Ineffective: No changes in symptom and BMD. Zuogui Pill 12
au
9.4%;
Osteoporosis
Significant effect: Pain disappeared; BMD
Markedly improved (45)
(Zhang
Open trial
75
increased significantly.
Moderately improved (27)
et
6 months
Effective: Pain significantly alleviated; BMD
Ineffective (3)
2015a)
al.,
increased.
Overall efficacy: 96%.
Ineffective: No changes in symptom and BMD.
Control
treatment:
Calcium
carbonate D3, Calcitriol capsule, Allen phosphoric acid sodium and pulsed magnetic therapeutic apparatus. For other prescriptions that contained Rehmanniae Radix, such as Jiangu San, Gushukang Granule, Ziyin Bushen Zhuanggu Decoction, Qihuodan
(Guo
Jiangu prescription, Kanggusong Capsule, Shiwei Gukang Oral Liquid, Bushen Jianpi Huoxue Decoction, Kanggusong Capsule, Kanggusong
al.,
Decoction, Kanggusong Decoction plus Caltrate D, Gushukang Capsule, Bushen formulation, Kanggusong Urinary bladder meridian sticking
2014)
et
patch, Kanggusong kidney meridian sticking patch, Bushen Qianggu Huoxue Decoction, Shangke Yishen Zhuanggu pill, Bupi Yishen Huoxue Formulation, Tanggukang Decoction, Bushen Jiangu Capsule, Bushen Zhuanggu Pill, Xianling Gubao Capsule, Gukang prescription, please refers to Yubo Guo et al’s review. Bushen Qiangshen Wan, Gubi Decoction combined with western medicine, Yanghe Decoction, Bushen Qiangdu Formulation, Zhuanggu
(Wang et
Decoction, Gukang Pill, Er’xian Decoction, Jiawei Er’xian Granule, Guwei Decoction, Guwei formula, Shuanggu Decoction, Shigu Yin, Jinlong
al.,
Pill, Jiawei Liuwei Dihuang Decoction, Liuwei Dihuang Decoction and Sijunzi Decoction, Gushen Yijing Decoction, Bushen Huoxue
2016)
Formulation, Yishen Zhuanggu Formulation, Yigu Yin, Xiangu Decoction, Bushen Yijing Formula, Zishen Gukang Decoction, Gukang Tablet, Bushen Jiangu Formulation, Bushen Jiangu Formulation, Bushen Jianpi Decoction, Bushen Qianggu Formulation, Kangguzhi Shusong Pill, Jianpi Yanggu Decoction, Tangmaikang Granule, Wenyang Bushen Decoction, Yangxue Gushen Decoction, Yishen Guben Decoction, Bugu Decoction, Hugu Capsule, Gugu Granule, Gushibao Capsule, Bushen Zhuanggu Formulation, please refers to Lili Wang et al’s review. a
Rehmanniae Radix, Cornus officinalis, Diocoreae Rhizoma, Alismatis Rhizoma, Poria, Astragali Radix (dosage information is not available).
b
Same as a.
c
Rehmanniae Radix preparata, Epimedii Brevicornus Herba, Cornus officinalis, Diocoreae Rhizoma, Astragali Radix (dosage information is not
available). d
Cuscutae Semen 15 g, Morindae Officinalis Radix 15 g, Polygoni Multiflori Radix 15 g, Cistanches Deserticolae Herba 15 g, Astragali Radix 30 g,
Drynariae Rhizoma 20 g, Psoraleae Fructus 20 g, Angelicae Sinensis Radix 20 g, Rehmanniae Radix preparata 20 g, Placenta Hominis 10 g, Cornu Cervi Degelatinatum 10 g, Atractylodis Macrocephalae Rhizoma 10 g, Achyranthis Bidentatae Radix 10 g, Glycyrrhiizae Radix preparata 6 g. If patients show blood stasis, removed Cistanches Deserticolae Herba, Psoraleae Fructus, Rehmanniae Radix preparata and Cuscutae Semen from the above-mentioned prescription, then added Epimedii Brevicornus Herba 15 g, Polygonati Sibirici Rhizoma preparata15 g, Codonopsis Radix 20 g, Eucommiae Cortex 20 g, Dipsaci Asperoidis Radix 20 g, Spatholobi Caulis 30 g, and Achyranthis Bidentatae Radix 10 g to the above-mentioned prescription. e
Anemarrhenae Rhizoma, Phellodendri Chinensis Cortex, Diocoreae Rhizoma, Cornus officinalis, Astragali Radix, Alismatis Rhizoma, Poria,
Rehmanniae Radix preparata, Testudinis Carapax et Plastrum (dosage information is not available). f
Rehmanniae Radix preparata, Epimedii Brevicornus Herba, Placenta Hominis, Alismatis Rhizoma, Os Draconis (dosage information is not
available). g
Rehmanniae Radix 20 g, Diocoreae Rhizoma 15 g, Cornus officinalis 15 g, Alismatis Rhizoma 15 g, Poria 20 g, Cinnamomi Cassiae Cortex 5 g,
Epimedii Brevicornus Herba 15 g, Colla Cornus Cervi 5 g, Cnidii Fructus 15 g, Testudinis Carapax et Plastrum 10 g, Morindae Officinalis Radix 25 g, Drynariae Rhizoma 15 g. h
Rehmanniae Radix preparata, Acanthopanacis Radicis Cortex, Cuscutae Semen, Cistanches Deserticolae Herba, Lycii Fructus, Ligustri Lucidi
Fructus, Aconiti Lateralis Radix preparata, Diocoreae Rhizoma, Poria, Alismatis Rhizoma, Astragali Radix, Cinnamomi Cassiae Cortex (dosage information is not available). i
Rehmanniae Radix preparata 20 g, Diocoreae Rhizoma 15 g, Cornus officinalis 12 g, Lycii Fructus 12 g, Eucommiae Cortex 15 g, Psoraleae
Fructus 15 g, Drynariae Rhizoma 15 g, Codonopsis Radix 20 g, Astragali Radix 20 g, Atractylodis Macrocephalae Rhizoma 10 g, Poria 10 g, Glycyrrhiizae Radix preparata 10 g. j
Bupleuri Chinensis Radix 10 g, Paeoniae Alba Radix 15 g, Cyperi Rhizoma 10 g, Aurantii Immaturus Fructus 10 g, Pinelliae Rhizoma 10 g, Poria
10 g, Rehmanniae Radix preparata 10 g, Cornus officinalis 10 g, Testudinis Carapax et Plastrum 12 g, Cibotii Rhizoma 12 g, Chaenomelis Speciosae Fructus 10 g, Olibanum 10 g, Myrrha 10 g, Chuanxiong Rhizoma 8 g. k
Rehmanniae Radix preparata, Angelicae Sinensis Radix, Cornus officinalis, Salviae Miltiorrhizae Radix et Rhizoma, Paeoniae Alba Radix,
Puerariae Lobatae Radix, Anemarrhenae Rhizoma, Lycii Fructus, Epimedii Brevicornus Herba, Cuscutae Semen. If patients show blood stasis due to stagnation of Qi, added Astragali Radix, Atractylodis Macrocephalae Rhizoma, Aurantii Immaturus Fructus, and Aucklandiae Radix to the above-mentioned prescription. l m
Rehmanniae Radix preparata, Diocoreae Rhizoma, Eucommiae Cortex, Cistanches Deserticolae Herba (dosage information is not available). Psoraleae Fructus, Cistanches Deserticolae Herba, Epimedii Brevicornus Herba, Cuscutae Semen, Rehmanniae Radix preparata, Paeoniae Alba
Radix. n
Rehmanniae Radix preparata 15 g, Cornus officinalis 9 g, Diocoreae Rhizoma 12 g, Lycii Fructus 15 g, Testudinis Carapax et Plastrum 15 g, Colla
Cornus Cervi 15 g, Cuscutae Semen 12 g, Achyranthis Bidentatae Radix 15 g, Dipsaci Asperoidis Radix 15 g, Drynariae Rhizoma 15 g, Magnetitum preparata 15 g. If patients show hyperactivity of fire due to Yin deficiency, added Gardeniae Fructus 12 g to the above-mentioned prescription. If patients show hot flash due to Yin deficiency, added Stellariae Radix 9 g, Lycii Radicis Cortex 12 g, and Testudinis Carapax et Plastrum 12 g to the above-mentioned prescription. If patients show hyperactivity of Yang due to Yin deficiency, added Margaritifera Usta Concha 30 g, Os Draconis preparata 15 g, and Ostreae Concha preparata 15 g to the above-mentioned prescription.. o
Puerariae Lobatae Radix, Rehmanniae Radix preparata, Angelicae Sinensis Radix, Paeoniae Alba Radix, Cornus officinalis, Salviae Miltiorrhizae
Radix et Rhizoma, Anemarrhenae Rhizoma, Cuscutae Semen, Epimedii Brevicornus Herba, Lycii Fructus. p
Polygoni Multiflori Radix, Epimedii Brevicornus Herba, Rehmanniae Radix preparata, Testudinis Carapax et Plastrum, Morindae Officinalis Radix,
Eucommiae Cortex, Dipsaci Asperoidis Radix, Drynariae Rhizoma, Angelicae Sinensis Radix, Diocoreae Rhizoma. q
Pyrolae Callianthae Herba 30 g, Rehmanniae Radix preparata 12 g, Ipomoea batatas 10 g, Spatholobi Caulis 30 g, Achyranthis Bidentatae Radix
15 g, Chaenomelis Speciosae Fructus 15 g, Angelicae Sinensis Radix 12 g, Astragali Radix 20 g, Brassicae Junceae Semen 10 g. If patients show low back pain, added Cibotii Rhizoma to the above-mentioned prescription. If patients shows limbs pain, added Notopterygii Rhizoma et Radix, Angelicae Biserratae Radix to the above-mentioned prescription. If patients feel body heavy and ache, added Atractylodis Macrocephalae Rhizoma to the above-mentioned prescription. If patients show blood stasis and body pain, added Carthami Flos to the above-mentioned prescription. r
Psoraleae Fructus, Dipsaci Asperoidis Radix, Rehmanniae Radix preparata, Cornus officinalis, Astragali Radix, Acanthopanacis Senticosi Radix et
Rhizoma Sue Caulis, Rhei Radix et Rhizoma, Persicae Semen, Salviae Miltiorrhizae Radix et Rhizoma et Rhizoma, Puerariae Lobatae Radix, Bovine-derived powder (dosage information is not available). s
Angelicae Sinensis Radix 10 g, Rehmanniae Radix preparata 10 g, Astragali Radix 30 g, Poria 22 g, Atractylodis Macrocephalae Rhizoma 13 g,
Paeoniae Alba Radix 15 g, Glycyrrhiizae Radix preparata 10 g, Citri Reticulatae Pericarpium 10 g, Diocoreae Rhizoma 12 g, Coicis Semen 15 g, Achyranthis Bidentatae Radix 12 g, Psoraleae Fructus 10 g, Morindae Officinalis Radix 10 g, Testudinis Carapax et Plastrum 10 g. t
Anemarrhenae Rhizoma, Testudinis Carapax et Plastrum, Paeoniae Alba Radix, Astragali Radix, Atractylodis Macrocephalae Rhizoma, Lycii Fructus,
Cynomorii Songarici Herba, Eucommiae Cortex, Aconiti Lateralis Radix preparata, Angelicae Biserratae Radix, Saposhnikoviae Radix, Achyranthis Bidentatae Radix, Phellodendri Chinensis Cortex, Rehmanniae Radix preparata, Angelicae Sinensis Radix, Ginseng Radix, Poria, Cuscutae Semen, Psoraleae Fructus, Dipsaci Asperoidis Radix, Notopterygii Rhizoma et Radix, Gentianae Macrophyllae Radix, Chaenomelis Speciosae Fructus, Panthera tigris Linnaeus. u
Psoraleae Fructus 16 g, Codonopsis Radix 16 g, Drynariae Rhizoma 16 g, Eucommiae Cortex 16 g, Rehmanniae Radix preparata 20 g, Astragali
Radix 20 g, Glycyrrhiizae Radix preparata 6 g. v
Rehmanniae Radix preparata, Cornus officinalis, Astragali Radix, Acanthopanacis Senticosi Radix et Rhizoma Sue Caulis, Rhei Radix et Rhizoma,
Persicae Semen, Puerariae Lobatae Radix (dosage information is not available). w
Rehmanniae Radix preparata, Cornu Cervi Degelatinatum, Epimedii Brevicornus Herba, Dipsaci Asperoidis Radix, Drynariae Rhizoma,
Eupolyphaga seu Steleophaga, Homalomenae Rhizoma, Clematidis Chinensis Radix et Rhizoma, Spatholobi Caulis (dosage information is not available). x
Rehmanniae Radix preparata 12 g, Angelicae Sinensis Radix 12 g, Cornus officinalis 12 g, Poria 12 g, Dipsaci Asperoidis Radix 12 g, Eucommiae
Cortex 10 g, Achyranthis Bidentatae Radix 10 g, Paeoniae Alba Radix 10 g, Acanthopanacis Radicis Cortex 10 g, Citri Grandis Exocarpium 5 g, Manis Squama 6 g, Cornu Cervi Degelatinatum 6 g, Pyritum 6 g. y
Colla Cornus Cervi 18 g, Psoraleae Fructus 18 g, Rehmanniae Radix preparata 10 g, Lycii Fructus 10 g, Colla Cornus Cervi 8 g, Testudinis
Carapax et Plastrum 8 g, Ligustri Lucidi Fructus 8 g, Poria 8 g, Angelicae Sinensis Radix 8 g, Cuscutae Semen 8 g, Dipsaci Asperoidis Radix 8 g, Achyranthis Bidentatae Radix 5 g, Astragali Radix 5 g, Chuanxiong Rhizoma 5 g, Jujubae Fructus 4 pieces. z
Atractylodis Macrocephalae Rhizoma 15g, Poria 15 g, Angelicae Sinensis Radix 15 g, Chuanxiong Rhizoma 15 g, Glycyrrhiizae Radix preparata 15
g, Paeoniae Alba Radix 15 g, Ginseng Radix 30 g, Pinelliae Rhizoma 9 g, Aconiti Lateralis Radix preparata 9 g, Cinnamomi Cassiae Cortex 9 g, Ophiopogonis Radix 25 g, Astragali Radix 25 g, Cistanches Deserticolae Herba 25 g, Rehmanniae Radix preparata 25 g. aa
Epimedii Brevicornus Herba, Psoraleae Fructus, Cornus officinalis, Rehmanniae Radix preparata, Chuanxiong Rhizoma, Notoginseng Radix et
Rhizoma (dosage information is not available). ab
Angelicae Biserratae Radix 12 g, Taxilli Herba 12 g, Notopterygii Rhizoma et Radix 12 g, Eucommiae Cortex 10 g, Achyranthis Bidentatae Radix
10 g, Rehmanniae Radix preparata 10 g, Chuanxiong Rhizoma 10 g, Angelicae Sinensis Radix 10 g, Paeoniae Rubra Radix 10 g, Codonopsis Radix 10 g, Poria 10 g, Gentianae Macrophyllae Radix 10 g, Chaenomelis Speciosae Fructus 10 g, Saposhnikoviae Radix 10 g, Cinnamomi Cassiae Cortex 10 g, Asari Radix et Rhizoma 6 g, Glycyrrhiizae Radix preparata 6 g. If patients show Qi Deficiency, added Astragali Radix to the above-mentioned prescription. If patients show Yin deficiency, added Lycii Fructus, Cornus officinalis to the above-mentioned prescription. If patients show Yang deficiency, added Morindae Officinalis Radix and Epimedii Brevicornus Herba to the above-mentioned prescription. If patients feel pain, added Aconiti Radix, and Aconiti Kusnezoffii Radix to the above-mentioned prescription. If patients feel cold, added Aconiti Lateralis Radix preparata, and Cistanches Deserticolae Herba to the above-mentioned prescription. If damp evil invades body, added Stephaniae Tetrandrae Radix and Coicis Semen to the above-mentioned prescription. If patients show dyspepsia, added Jiao Sanxian (Shenqu, Crataegi Pinnatifidae Fructus preparata, and Hordei Germinatus Fructus preparata) to the above-mentioned prescription. If disease occurs with long duration, added Scolopendra and Scorpio to the above-mentioned prescription. ac
Rehmanniae Radix preparata 30 g, Cornus officinalis 12 g, Epimedii Brevicornus Herba 12 g, Eucommiae Cortex 12 g, Cuscutae Semen 12 g,
Spatholobi Caulis 30 g, Salviae Miltiorrhizae Radix et Rhizoma et Rhizoma 30 g, Dipsaci Asperoidis Radix 15 g, Colla Cornus Cervi 15 g, Drynariae Rhizoma 15 g, Diocoreae Rhizoma 15 g, Angelicae Sinensis Radix 15 g, Achyranthis Bidentatae Radix 15 g, Chuanxiong Rhizoma 15 g, Angelicae Biserratae Radix 10 g, Hirudo 10 g, Alismatis Rhizoma 10 g, Glycyrrhiizae Radix preparata 6 g. ad
Rehmanniae Radix preparata, Diocoreae Rhizoma, Cornus officinalis, Poria, Moutan Radicis Cortex, Alismatis Rhizoma, Cinnamomi Ramulus,
Aconiti Lateralis Radix Preparata, Achyranthis Bidentatae Radix, Plantaginis Semen. ae
Aconiti Lateralis Radix preparata, Cinnamomi Ramulus, Rehmanniae Radix preparata, Cornus officinalis, Diocoreae Rhizoma, Alismatis Rhizoma,
Moutan Radicis Cortex, Poria. af
Rehmanniae Radix preparata, Diocoreae Rhizoma, Cuscutae Semen, Epimedii Brevicornus Herba.
ag
Rehmanniae Radix preparata, Phryma leptostachya L. subsp. asiatica (Hara) Kitamura, Drynariae Rhizoma, Epimedii Brevicornus Herba,
Alismatis Rhizoma. ah
Curculiginis Rhizoma 10 g, Epimedii Brevicornus Herba 10 g, Cornu Cervi Degelatinatum 10 g, Morindae Officinalis Radix 10g, Dipsaci
Asperoidis Radix 10 g, Drynariae Rhizoma 10 g, Rehmanniae Radix preparata 10 g, Atractylodis Macrocephalae Rhizoma preparata 10 g, Achyranthis Bidentatae Radix 10 g, Salviae Miltiorrhizae Radix et Rhizoma 10 g, Lycii Fructus 15 g, Placenta Hominis 5 g, Testudinis Carapax et Plastrum 30 g, Astragali Radix preparata 30 g, Os Draconis 30 g, Ostreae Concha 30 g.
ai
Astragali Radix 30 g, Rehmanniae Radix preparata 24 g, Curculiginis Rhizoma 12 g, Epimedii Brevicornus Herba 12 g, Angelicae Sinensis Radix
15 g, Anemarrhenae Rhizoma 9 g, Phellodendri Chinensis Cortex 6 g, Morindae Officinalis Radix 9 g, Pyritum 24 g, Os Draconis 24 g, Ostreae Concha 24 g, Galli Gigeriae Endothelium Coreneum 9 g, Colla Cornus Cervi 12 g, Myristicae Semen 6 g. If patients show Yang deficiency, added Cistanches Deserticolae Herba to the above-mentioned prescription. If patients show deficiency of both Qi and blood, added Codonopsis Radix, Poria, Asini Corii Colla, and Placenta Hominis to the above-mentioned prescription. If patients show blood stasis, added Eupolyphaga, Notoginseng Radix to the above-mentioned prescription. aj
Anemarrhenae Rhizoma, Phellodendri Chinensis Cortex, Rehmanniae Radix preparata, Cornus officinalis, Moutan Radicis Cortex, Diocoreae
Rhizoma, Poria, Alismatis Rhizoma. ak
Epimedii Brevicornus Herba 15 g, Curculiginis Rhizoma 10 g, Psoraleae Fructus 15 g, Rehmanniae Radix preparata 15 g, Cornus officinalis 10 g,
Ligustri Lucidi Fructus 15 g, Lycii Fructus 15 g, Ginseng Radix 10 g, Atractylodis Macrocephalae Rhizoma 10 g, Poria 10 g, Cuscutae Semen 15 g, Eucommiae Cortex 15 g, Angelicae Sinensis Radix 12 g. al
Rehmanniae Radix preparata 30 g, Lycii Fructus 30 g, Carthami Flos 10 g, Chuanxiong Rhizoma 12 g, Dipsaci Asperoidis Radix 15 g, Cornus
officinalis 12 g, Eucommiae Cortex 15 g, Paeoniae Rubra Radix 15 g, Astragali Radix 20 g, Angelicae Sinensis Radix 12 g, Diocoreae Rhizoma 15 g, Astragali Radix 15 g, Cuscutae Semen 15 g, Colla Cornus Cervi 25 g, Testudinis Carapax et Plastrum 15 g, Salviae Miltiorrhizae Radix et Rhizoma 15 g, Achyranthis Bidentatae Radix 10 g, Cornus officinalis 10 g, Epimedii Brevicornus Herba 10 g, Atractylodis Macrocephalae Rhizoma 10 g. am
Rehmanniae Radix preparata, Lycii Fructus, Colla Cornus Cervi, Cornus officinalis, Eucommiae Cortex, Angelicae Sinensis Radix, Paeoniae Alba Radix,
Cinnamomi Ramulus, Achyranthis Bidentatae Radix, Diocoreae Rhizoma, Citri Reticulatae Pericarpium, Amomi Fructus. an
Rehmanniae Radix, Diocoreae Rhizoma, Cornus officinalis, Alismatis Rhizoma, Poria, Cinnamomi Cassiae Cortex, Epimedii Brevicornus Herba,
Colla Cornus Cervi, Colla Carapacis et Plastri Testudinis, Morindae Officinalis Radix, Drynariae Rhizoma, Sparganii Rhizoma, Hirudo (dosage information is not available). ao
Epimedii Brevicornus Herba, Rehmanniae Radix preparata, Diocoreae Rhizoma, Cornus officinalis, Morindae Officinalis Radix, Aconiti Lateralis
Radix preparata, Colla Cornus Cervi, Cuscutae Semen, Eucommiae Cortex, Cinnamomi Cassiae Cortex, Lycii Fructus (dosage information is not available). ap
Rehmanniae Radix preparata 9 g, Glycyrrhiizae Radix preparata 9 g, Eucommiae Cortex 15 g, Achyranthis Bidentatae Radix 15 g, Paeoniae Alba
Radix 15 g, Poria 15 g, Diocoreae Rhizoma 10 g, Astragali Radix 10 g, Alismatis Rhizoma 10 g, Cornus officinalis 10 g, Cibotii Rhizoma 10 g, Angelicae Sinensis Radix 10 g, Chuanxiong Rhizoma 10 g, Coicis Semen 30 g, Angelicae Biserratae Radix 12 g. If patients shows deficiency of kidney essence, added Colla Cornus Cervi, Psoraleae Fructus, Lycii Fructus, Dipsaci Asperoidis Radix, Epimedii Brevicornus Herba, Curculiginis Rhizoma, Cuscutae Semen, and Drynariae Rhizoma to the above-mentioned prescription. If patients show deficiency of Qi and blood, added Codonopsis Radix, Astragali Radix, Atractylodis Macrocephalae Rhizoma, and Salviae Miltiorrhizae Radix et Rhizoma to the above-mentioned prescription. If patients feel pain, added Corydalis Yanhusuo Rhizoma, Myrrha, and Spatholobi Caulis to the above-mentioned prescription. If patients show spontaneous sweating, added Os Draconis to the above-mentioned prescription. If patients show Yin deficiency and fire hyperactivity, added Anemarrhenae Rhizoma, and Phellodendri Chinensis Cortex to the above-mentioned prescription. aq
Drynariae Rhizoma 15 g, Psoraleae Fructus 15 g, Paeoniae Alba Radix 15 g, Rehmanniae Radix preparata 12 g, Chuanxiong Rhizoma 12 g,
Clematidis Chinensis Radix et Rhizoma 9 g, Epimedii Brevicornus Herba 9 g, Angelicae Sinensis Radix 9 g, Pyrolae Callianthae Herba 9 g, Glycyrrhiizae Radix preparata 6 g. ar
Rehmanniae Radix preparata 30 g, Diocoreae Rhizoma 15 g, Cornus officinalis 15 g, Epimedii Brevicornus Herba 18 g, Testudinis Carapax et
Plastrum 15 g, Cistanches Deserticolae Herba 10 g, Cuscutae Semen 10 g, Lycii Fructus 18 g, Drynariae Rhizoma 10 g, Colla Cornus Cervi 10 g, Achyranthis Bidentatae Radix 10 g, Notoginseng Radix 3 g, Salviae Miltiorrhizae Radix et Rhizoma 15 g. If patients with heat due to Yin deficiency, added Anemarrhenae Rhizoma, and Phellodendri Chinensis Cortex to the above-mentioned prescription. If patients show Yang deficiency, added Morindae Officinalis Radix, Aconiti Lateralis Radix preparata, and Cinnamomi Cassiae Cortex to the above-mentioned prescription. If patients show Qi deficiency, added Astragali Radix to the above-mentioned prescription. If patients show blood deficiency, added Angelicae Sinensis Radix, and Asini
Corii Colla to the above-mentioned prescription. If patients show lumbar genu aching and limp, added Eucommiae Cortex, and Dipsaci Asperoidis Radix to the above-mentioned prescription. If patients feel pain, added Olibanum, Myrrha to the above-mentioned prescription. as
Anemarrhenae Rhizoma 20 g, Phellodendri Chinensis Cortex 10 g, Diocoreae Rhizoma 15 g, Cornus officinalis 15 g, Astragali Radix 20 g, Alismatis
Rhizoma 15 g, Poria 20 g, Rehmanniae Radix preparata 10 g, Testudinis Carapax et Plastrum 10 g. If patients show lumbago, added Dipsaci Asperoidis Radix, Eucommiae Cortex, and Taxilli Herba to the above-mentioned prescription. If patients feel whole body pain, added Notopterygii Rhizoma et Radix, Angelicae Biserratae Radix, Spatholobi Caulis, and Trachelospermi Jasminoidis Caulis to the above-mentioned prescription. If patients show hot flashes and night sweats, added Os Draconis, Ostreae Concha, and Gentianae Macrophyllae Radix to the above-mentioned prescription. If patients feel dizzy, added Uncariae Ramulus cum Uncis, and Tribuli Fructus to the above-mentioned prescription. at
Epimedii Brevicornus Herba, Rehmanniae Radix preparata, Angelicae Sinensis Radix, Psoraleae Fructus, Achyranthis Bidentatae Radix, Cornus
officinalis (dosage information is not available). au
Rehmanniae Radix preparata 15 g, Diocoreae Rhizoma 15 g, Astragali Radix 15 g, Lycii Fructus 15 g, Cuscutae Semen 15 g, Colla Cornus Cervi
15 g, Testudinis Carapax et Plastrum 15 g, Salviae Miltiorrhizae Radix et Rhizoma 15 g, Achyranthis Bidentatae Radix 10 g, Cornus officinalis 10 g, Epimedii Brevicornus Herba 10 g, Atractylodis Macrocephalae 10 g.
Table 2. TCM herbs frequent clinically co-prescribed with Rehmanniae Radix (preparata) for the management of osteoporosis.
Accepted medicinal plant name
Latin name of herb
Frequency
Epimedium Brevicornu Maxim.
Epimedii Brevicornus Herba
75
Astragalus Mongholicus Bunge
Astragali Radix
51
Cornus officinalis Siebold & Zucc.
Cornus officinalis
46
Angelica Sinensis (Oliv.) Diels
Angelicae Sinensis Radix
42
Drynaria Roosii Nakaike
Drynariae Rhizoma
42
Salvia Miltiorrhiza Bunge.
Salviae Miltiorrhizae Radix et Rhizoma
40
Dioscorea Opposita Thunb.
Diocoreae Rhizoma
40
Poria cocos˄Schw.˅Wolf
Poria
38
Achyranthes Bidentata Blume
Achyranthis Bidentatae Radix
35
Cullen Corylifolium (L.) Medik.
Psoraleae Fructus
34
4. Phytochemistry of Rehmanniae Radix Currently, there have been more than 140 compounds isolated and characterized from Rehmanniae Radix that included monoterpenoids, phenethyl alcohol glycosides, triterpenes, flavonoid glycosides, phenolic acid glycosides, lignans, and Rehmannia glutinosa polysaccharides, etc (Fu and Du, 2015; Li and Meng, 2015; Liu, 2013). The main constituents are listed in Figure 2. Iridoid glycosides are considered to be one of abundant monoterpenoids and responsible for the pharmacological actions of Rehmanniae Radix. The identified monoterpenoids are also listed as the followings: catalpol (1), rehmannioside A (2), rehmannioside B (3), rehmannioside C (4), rehmaionoside A (5), rehmaionoside B (6), rehmaionoside C (7), rehmaglutin A (8), rehmaglutin B (9), rehmaglutin D (10), rehmaglutin C (11), ajugol (12), rehmannioside D (13), and geniposide (14), gentistic acid (15), versulin (16), oleanolic acid (17). These identified new compounds may provide novel chemical scaffolds for the development of novel anti-osteoporotic drugs, and also offer great potential for compound drugs which may exhibit better anti-osteoporotic effects compared to the individual compounds. Catalpol is one of most studied ingredients of Rehmanniae Radix and has been reported to exhibit protective effects on diabetes (Bao et al., 2016; Zhou et al., 2015a), neurovascular diseases (Huang et al., 2016a), osteoporosis (Lai et al., 2015), breast cancer (Liu et al., 2015), ovarian cancer (Gao et al., 2014), atherosclerosis (Liu and Zhang, 2015) and lung injury (Fu et al., 2014) in animals.
In addition, among the isolated constituents from Rehmanniae Radix, Rehmannia glutinosa polysaccharides are also one of the main active constituents of Rehmanniae Radix and composed of monosaccharides such as rhamnose, glucose, galactose, mannose, xylose and arabinose (Wang et al., 2015b). So far, it has been demonstrated that Rehmannia glutinosa polysaccharides exhibited beneficial activities in improving glucolipid metabolism (Wu et al., 2011; Zhou et al., 2015b), immunology (Huang et al., 2013b; Huang et al., 2014) and redox hemostasis (Zhang et al., 2012). Furthermore, rehmannioside C (4), rehmaionoside A (5) and oleanolic acid (17) (Pollier and Goossens, 2012) have been demonstrated to possess hepatoprotection activities. Ajugol (12), gentistic acid (15) (Liu, 2013) and oleanolic acid (17) (Anouar el et al., 2015) have the ability of anti-oxidation. Versulin (16) (Zhang et al., 2015b) and oleanolic acid (17) (Zhang et al., 2014) have the capacity of inhibiting tumor growth. Oleanolic acid (17) (Mengoni et al., 2002) has been demonstrated to exhibit weak anti-HIV activity. Moreover, the art of processing may affect the constituents of Rehmannia Radix. It has been demonstrated that the total amount of Rehmannia glutinosa polysaccharides was decreased from 16.59% in Rehmanniae Radix to 3.33% in Rehmanniae Radix preparata determined by phenol-sulphuric acid method (Ji et al., 1999). The content of total sugar was reduced from 44.93% in Rehmanniae Radix to 16.29% in Rehmanniae Radix preparata. However, the art of processing significantly contributes to increasing the extraction ratio of crude polysaccharide (17.14% in the
Rehmaniae Radix and 26.72% in Rehmanniae Radix preparata) (Liu et al., 2009). In addition, the level of acteoside was decreased from 0.093% in Rehmanniae Radix to 0.04% in Rehmanniae Radix preparata. The contents of stachyose, iridoid glycoside and catalpol were gradually decreased, while 5- hydroxymethylfurfural was increased after processing (Kubo et al., 1996; Liu et al., 2007). As for trace elements, the contents of Cl, K, Na, Sr and Mn were marginally decreased after processing, but the content of Cu was increased (Lu, 2008). 5. The pharmacokinetics of Rehmanniae Radix Various studies have been performed to investigate the pharmacokinetics profiles of Rehmanniae Radix and its active ingredients in animal experiments. Tables 3 summarized the recent pharmacokinetic studies on Rehmanniae Radix with the emphasis on the most abundant components of iridoid glucosides, such as catalpol, aucubin and acetoside. The pharmacokinetics of the water extract of Rehmanniae Radix in normal (Zhong et al., 2013) rats and in rats with chronic kidney disease (CKD) (Zhao et al., 2015), the results revealed that the ingredients were widely distributed after administration. Furthermore, catalpol, ajugol and acetoside were easily detected in the plasma and accepted as main active ingredients of Rehmanniae Radix. The concentrations of aucubin, dihydrocatalpol, rehmannioside A (or rehmannioside B/melittoside) and rehmannioside D were very low in plasma in rats (Zhong et al.,
2013). Rehmannia glutinosa polysaccharides were not detected in the plasma owing to that they are vulnerable to be digested by gut microorganisms in rats. The advantage of plasma concentration of catalpol and acteoside in CKD rats over in normal rats accounts for improving kidney function of this herb (Zhao et al., 2015). In an experiment performed by Dr. Ju et al. demonstrated that different administration approaches significantly affected the absorption, distribution and elimination of Rehmanniae Radix (Liu, 2014). They found that T1/2 of catalpol via oral administration (T1/2z=1.39 ± 0.22 h) was much longer than via intramuscular injection (T1/2z=0.84 ± 0.41 h) and intravenous injection (T1/2z=0.68 ± 0.24 h). The Tmax of intramuscular administration (0.25 ± 0.1 h) was much shorter than that of intragastric administration (1.66 ± 0.58 h). The intramuscular administration has a better bioavailability (71.63%) than that of oral gavage (49.38%). The results indicated that catalpol was unstable in the gastrointestinal tract in rats. The impacts of different administration routes on catalpol metabolism were also been confirmed by two independent labs (Lu et al., 2009; Wang et al., 2012). In addition, the pharmacokinetics properties of the mixed substances (2.0 mg/kg aucubin, 2.0 mg/kg ajugol and 10.0 mg/kg catalpol) revealed that the mixture was also widely distributed in the kidney, liver, heart, spleen and lung (Wang et al., 2012). And the kidney had the highest concentrations. Further studies demonstrated that catalpol and aucubin could pass the blood brain barrier (Wang et al., 2012), but ajugol could
not (Xue et al., 2015). The aucubin was absorbed slowly (T1/2=7.38 ± 2.9 h) (Xu et al., 2012), and verproside was rapidly eliminated (T1/2=5.5 ± 1.1 min) (Park et al., 2009). In short, the ingredients of Rehmanniae Radix were widely distributed after administration. Catalpol, ajugol and acetoside were assumed as the main contributors to pharmacological effects of this herb. However, emerging evidence indicates that Rehmannia glutinosa polysaccharides may also play important roles in the treatment of diseases. Therefore, the future pharmacokinetic studies are required to analyze the absorption, distribution, metabolism and elimination of Rehmannia glutinosa polysaccharides by improving the sensitivity of the analytic approach.
Table 3. The pharmacokinetics properties of Rehmanniae Radix and its ingredients in animals Spices
Administration route Main pharmacokinetics parameters and dose
Findings
Ref.
SD rats, male
Gavage (p.o.);
Catalpol and ajugol were found to
(Zhong al., 2013)
and female.
For catalpol: −1
6 g/kg body weight (BW),
Cmax (ng·mL ): 2349.05 ± 1438.34
be the main compounds after
water extracts of Rehmanniae
Tmax (h): 1.00 ± 0.00
Rehmanniae
Radix
−1
AUC0-∞ (ng·h·mL ): 4407.58 ± 2734.89 −1
AUC0−t (ng·h·mL ): 4401.39 ± 2732.72 −1
Radix
administration, and both of them excreted
rapidly. of
Plasma
Ke (h ): 0.90 ± 0.29
concentrations
T1/2 (h): 0.86 ± 0.32
dihydrocatalpol, rehmannioside A
MRT0−∞ (h): 1.72 ± 0.12
(or rehmannioside B/ melittoside)
−1
aucubin,
V/F (L·kg ): 2.51 ± 0.95
and rehmannioside D were very
CL/F (L·h−1·kg−1): 2.40 ± 1.44
low.
For ajugol:
polysaccharides −1
Rehmannia
glutinosa were
not
Cmax (ng·mL ): 104.25 ± 82.05
detected in the plasma owing to
Tmax (h): 1.00 ± 0.00
that they are vulnerable to be
−1
AUC0-∞ (ng·h·mL ): 226.66 ± 188.38
et
digested by gut microorganisms.
−1
AUC0−t (ng·h·mL ): 219.77 ± 187.43 Ke (h−1): 0.82 ± 0.31 T1/2 (h): 0.96 ± 0.37 MRT0−∞ (h): 1.98 ± 0.26 V/F (L·kg−1): 15.30 ± 13.0 CL/F (L·h−1·kg−1): 11.27 ± 7.55 Normal
and
chronic
kidney
disease
(CKD)
male SD rats
p.o.;
For Catalpol:
8.0 g/kg BW, water extracts of
Normal Rats:
Rehmanniae Radix
Rapid absorption and elimination,
(Zhao
wide distribution in both CKD
al., 2015)
−1
and normal rats.
−1
Faster
AUC0−t (μg·min·mL ): 439.71 ± 42.34 AUC0-∞ (μg·min·mL ): 444.46 ± 40.70 −1
rates
of
Cmax (μg·mL ): 2.14 ± 0.13
metabolism
Tmax (min): 60.50 ± 15.00
normal rats.
T1/2 (min) : 84.00 ± 13.42
Higher plasma concentration in
CLZ/F (L·min−1·kg−1): 0.02 ± 0.00
CKD rats.
CKD rats˖ AUC0−t (μg·min·mL−1): 1627.83 ± 241.40 AUC0-∞ (μg·min·mL−1): 1658.49 ± 252.24 Cmax (μg·mL−1): 7.94 ± 1.06 Tmax (min): 54.00 ± 8.22 T1/2 (min): 118.28 ± 39.13 CLZ/F (L·min−1·kg−1): 0.01 ± 0.00 For Acetoside: Normal Rats:
and
elimination, excretion
in
et
AUC0−t (μg·min·mL−1): 32.69 ± 7.63 AUC0-∞ (μg·min·mL−1): 34.01 ± 7.64 Cmax (μg·mL−1): 0.19 ± 0.05 Tmax (min) : 15.00 ± 7.45 T1/2 (min) : 150.56 ± 59.97 CLZ/F (L·min−1·kg−1): 0.55 ± 0.14 CKD rats˖ AUC0−t (μg·min·mL−1): 61.15 ± 10.56 AUC0-∞ (μg·min·mL−1): 73.27 ± 15.50 Cmax(μg·mL−1): 0.31 ± 0.05 Tmax (min): 24.00 ± 13.42 T1/2 (min): 298.61 ± 96.47 CLZ/F (L·min−1·kg−1): 0.27 ± 0.07 Male
Sprague
Dawley rats
Intravenous injection (i.v.);
AUC0−t (μg·min·mL−1): 31.2 ± 20.8
The percentage of verproside
(Park et al.,
2mg/kg of verproside.
T1/2 (min): 5.5 ± 1.1
excreted in urine for 24 h as an
2009)
−1
−1
CL (mL·min ·kg ): 89.8 ± 55.1 −1
Vss (mL·kg ): 489 ± 264
intact drug was 6.5 ± 2.9% of the original dose.
MRT (min): 5.5 ± 1.1 Male
Sprague
Dawley rats
i.v.;
In cerebrospinal fluid (CSF):
Rapidly distributed into the CSF;
(Wang
6 mg/kg of catapol.
AUC0−5 (ng·h·mL−1): 594.5 ± 81.3
Slow elimination;
al., 2012)
−1
AUC0-∞ (μg·min·mL ): 671.5 ± 109.1 −1
Cmax(ng·mL ): 675.9 ± 198.4
et
Easily passed the blood–brain barrier (BBB).
Tmax (h): 0.08 ± 0.02 T1/2 (h) : 1.52 ± 0.74 MRT0-∞ (h): 2.12 ± 1.0 In plasma: AUC0−5 (ng·h·mL−1): 11432.3 ± 1582.5 AUC0-∞ (μg·min·mL−1) : 11532.9 ± 1643.0 Cmax (ng·mL−1):23617.4 ± 914.7 T1/2 (h) : 0.71 ± 0.23 MRT0-∞ (h): 2.12 ± 1.0. SD rats
i.v.; 1 mL/100 g mixed substances
For Aucubin: −1
AUC0−t (μg·h·L ): 1951.409 ± 242.802 −1
Widely distributed in kidney,
(Xue et al.,
heart, liver, spleen and lung.
2015)
containing 2.0 mg/kg Aucubin,
AUC0−∞ (μg·h·L ): 1953.956 ± 241.516
Tissue distributions in order of
2.0 mg/kg Ajugol and 10.0
MRT (h): 0.577 ± 0.104
Ckidney > Cliver.
mg/kg Catalpol
T1/2 ( h) : 1.073 ± 0.241
Slow elimination;
−1
V (L·kg ): 1.621 ± 0.528
Aucubin and Catalpol could pass
CL (L·h−1·kg−1): 1.035 ± 0.122
BBB.
For Ajugol:
No Ajugol was found in brain. −1
AUC(0−t) (μg·min·L ): 5743.547 ± 795.734 AUC0−∞ (μg·h·L−1): 5747.104 ± 796.556
MRT (h): 0.804 ± 0.064 T1/2 ( h) : 0.746 ± 0.099 V (L·kg−1): 0.380 ± 0.075 CL (L·h−1·kg−1): 0.354 ± 0.054 For Catalpol: AUC (0−t) (μg·min·L−1): 5951.125 ± 1247.247 AUC0−∞ (μg·h·L−1): 5954.076 ± 1248.205 MRT (h): 0.0454 ± 0.140 T1/2 ( h) : 0.984 ± 0.229 V (L·kg−1): 0.348 ± 0.075 CL (L·h−1·kg−1): 0.348 ± 0.075 Wistar rats, male and female
p.o; 50 mg/kg of Catalpol
T1/2 (h): 1.212 ± 0.388
Short half-life (less than 1.5 h).
(Lu et al.,
−1
V1/F (L·kg ): 1.428 ± 0.681 −1
2009)
−1
CL/F (L·h ·kg ): 0.824 ± 0.317 T1/2Ka (h): 0.53 ± 0.302 AUC0−∞ (ng·h·mL−1) : 69520 ± 22927 MRT0−∞ (h): 3.273 ± 0.365 Tmax (h): 1.333 ± 0.408 Cmax (ng·mL-1) : 23318 ± 10468 Male
Sprague–
Dawley rats
p.o.; 50 mg/kg of Aucubin
Tmax (h): 1.08 ± 0.5
Rapid
−1
Cmax (ng·mL ) :4016 ± 2394
absorption
and
slow
(Xu et al.,
elimination.
2012)
T1/2: p.o.> i.v.> intramuscular
(Liu, 2014)
−1
AUC0–24 (ng· h·mL ) : 11026 ± 4671 AUC0–1 (ng h·mL−1): 11305 ± 4627 T1/2 (h): 7.38 ± 2.9 MRT0–24 (h): 3.16 ± 2.9 MRT0–1 (h): 4.08 ± 0.9 Male
Sprague–
Dawley rats
p.o.; 50mg/kg of Catalpol
Tmax (h): 1.66 ± 0.58 −1
Cmax (mg·mL ) :24.83 ± 0.58 −1
AUC0–24 (ng· h·mL ) : 95.23 ± 10.15 T1/2 (h): 1.39 ± 0.22
Bioavailability: i.m.> p.o.
MRT0−∞ (h): 3.23 ± 0.37
Catalpol
−1
Vz/F (L·kg ): 1.17 ± 0.16 F% : 49.38 ± 10.54 i.v.;
Tmax (h): 0.25 ± 0.1
50mg/kg of Catalpol
Cmax (mg·mL−1) :80.43 ± 5.59 AUC0–24 (mg· h·mL−1) : 150.23 ± 20.87 T1/2 (h): 0.68 ± 0.24 MRT0−∞ (h): 1.62 ± 0.20 Vz/F (L·kg−1): 0.40 ± 0.20 F%: 71.63 ± 10.28
i.m.;
administration˄i.m.˅ MRT: p.o.> i.v.
Tmax (h): --
was
unstable
gastrointestinal tract.
in
50mg/kg of Catalpol
Cmax (ng·mL−1) :110.82 ± 4.10 AUC0–24 (ng· h·mL−1) : 195.79 ± 20.51 AUC0–1 (ng h·mL−1): 11305 ± 4627 T1/2 (h): 0.84 ± 0.41 MRT0−∞(h): 1.71 ± 0.29 Vz/F (L·kg−1): 0.57 ± 0.19 F% : -
6. Anti-bone loss and pro-anabolic activities of Rehmanniae Radix and its constituents in osteoporosis Various in vitro and in vivo experiments were used to understand the effects of Rehmanniae Radix and its purified compounds in preventing the development of osteoporosis. We summarized the possible mechanisms of this herb involved in regulating osteoporosis in preclinical studies as shown in Figure 3. Firstly, the investigators found that the water extracts of Rehmanniae Radix (300 mg/kg treatment for 8 weeks (Lim and Kim, 2013), or 13.75 g/kg and 27.5 g/kg for 3 month (Li et al., 2015) significantly increased BMD in the femurs and lumbar (17.5% and 16.4%, respectively), and markedly enhanced integrin β1 mRNA expression, decreased the serum
alkaline
phosphatase
(ALP)
level,
urinary
Ca2+
and
urinary
deoxypyridinoline/creatinine without affecting the weights of body and uterus, and the estradiol (E2) level in ovariectomized (OVX) rats. Furthermore, the authors claimed that Rehmanniae Radix was more efficient in decreasing bone loss than that of an equivalent dose of steamed roots of Rehmannia glutinosa (Gaertn.) DC. in OVX rats (Lim and Kim, 2013). The quantitative
authentication of Rehmanniae Radix performed by a high performance liquid chromatography revealed that Rehmanniae Radix was standardized to contain 5.4 mg/g of catalpol. Therefore, the effects of Rehmanniae Radix on bone protection may be associated with its high contents of the iridoid glycosides such as catalpol. Furthermore, in another in vivo experiment demonstrated that the water extracts of Rehmanniae Radix preparata (0.132 g/rats) treatment for 4 weeks after ovariectomy were demonstrated to attenuate BMD decrease in proximal tibia metaphysis and to increase the cortical bone thickness and trabeculation of the bone marrow spaces in rats (Oh et al., 2003). In addition, Rehmanniae Radix preparata possessed the ability to reduce body weight gain and serum level of cholesterol in OVX rats (Cho, 2005). Further, the water extracts of Rehmanniae Radix preparata had also been demonstrated to promote osteoblastic cells (MG63) proliferation (0.096 to 12 μg/ml), enhance ALP activity (0.48 and 12 μg/ml) in osteoblastic cells (HOS cells), increase mRNA levels of collagen, ALP, and osteopontin in primary osteoblastic cells (12 μg/ml), increase Runx2 gene in osteoblastic cells (C2C12 cells) (60 μg/ml), and enhance osteoprotegerin expression in osteoblastic cells (60 μg/ml). In addition, treatment with the water extracts of Rehmanniae Radix (0.096 to 60 μg/ml) dose-dependently decreased the number of tartrate resistant acid phosphatase (TRAP) positive marrow mononuclear cells and reduced resorption pit formation in osteoclastic precursor cells (Cho, 2005). These results revealed that the water extracts
of Rehmanniae Radix improved osteoporosis through promoting osteoblast formation and inhibiting osteoclast activity. Moreover, in order to compare the effects of different extracts of Rehmanniae Radix on improving bone quality in OVX rats, Zhang Xin (Zhang, 2014) further divided the extracts into four parts, which included fresh Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol (FREE), fresh Rehmanniae Radix by aqueous extracted (FREW), dried Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol (DREE), dried Rehmanniae Radix by aqueous extracted (DREW). The results demonstrated that all the extracts of Rehmanniae Radix treatment for 40 weeks increased the levels of serum E2 and calcitonin (CT), and decreased the levels of serum ALP and TRAP as well as increased bone stiffness in OVX rats as compared to untreated OVX rats. In addition, the extracts of Rehmanniae Radix possessed the ability of inhibiting endometrial atrophy and loss, and of improving the relative expansion of rat bone marrow cavity and trabecular thinning and sparse in OVX rats. Among four different extracts, FREE (75, 150 and 300 mg/kg/d) and FREW (250 mg/kg/d) were significantly higher in improving the biomarkers in OVX rats than DREE (125, 250 and 500 mg/kg/d) and DREW (400 mg/kg/d). DREE (250 and 500 mg/kg/d) and FREE (300 mg/kg/d) were more efficient in improving BMD and bone mechanical strength than FREW and DREW. Overall, the investigators claimed that dried root of Rehmannia glutinosa (Gaertn.) DC. was
the preferred option to in the management of osteoporosis. This was consistent with Dr. Lim (Lim and Kim, 2013) and Dr. Li’s (Li et al., 2015) observations. To further explore the potential estrogen-like effect, Jiang et al (Jiang, 2013) evaluated the different preparations of this herb, including fresh Rehmanniae Radix, Rehmanniae Radix, Rehmanniae Radix preparata and the juice of fresh Rehmanniae Radix in alterations of uterus weights in mice as well as MCF-7 and MG63 cells proliferation. The results demonstrated that FREW and DREW as well as FREE may have estrogen-like effect evidenced by increasing uterus weights in mice. In addition, FREE (10-4mg/mL~10-1mg/mL) increased MCF-7 cells proliferation at 24h and 48h, and inhibited MCF-7 cells proliferation at 72h. Further, FREE exerted estrogen-like effect through the regulation of ERβ rather than ERα evidenced by the fact that 1 mg/mL of FREE increased ERα protein expression, whereas only 10-3 mg/mL of FREE could promote ERβ protein expression in MCF-7 cells. Moreover, FREE (10-3 mg/mL~10-1 mg/mL) induced an increase in MG63 cells proliferation at 24h and 36h. Further, FREE increased ALP activity in MG63 cells at 24h, 48h and 72h, and the addition of ICI182780 to MG63 cells, an estrogen receptor antagonist, significantly blocked the stimulatory effect of this extract. Therefore, the author claimed that FREE promoted MG63 osteoblasts differentiation and mineralization through regulation of ERβ expression. Thus, cautions must be excised that Rehmanniae Radix may have estrogen-like side effects in the management of osteoporosis.
Catalpol, one of the active compounds isolated from Rehmanniae Radix, has also been demonstrated to improve bone health in OVX mice. The authors found that oral administration of catalpol (10, 20 and 40 mg/kg) for 12 weeks pronouncedly attenuated OVX induced-bone loss by decreasing Th1/Th2 ratio via increasing the mRNA and protein expressions of T-bet and decreasing the mRNA and protein expressions of GATA-3 (Lai et al., 2015). It was reported that Th1 cells produced pro-inflammatory cytokines such as interferon-γ, interleukin (IL)-12 and tumor necrosis factor-α, which strongly promoted the formation of osteoclast. In contrast, Th2 cells secreted IL-4 and IL-10 which inhibited osteoclast formation (Fujii et al., 2012). In vitro, catalpol has also been demonstrated to promote osteoblasts proliferation (1×10 -3 M and 1×10 -7‒1×10-9 M), enhance ALP activity (1×10-3 and 1×10-7 M), improve osteocalcin synthesis and secretion (1×10-3 and 1×10-5‒1×10-6 M), and boost osteoblast mineralization in primary culture osteoblasts (Jia et al., 2015) and MC3T3-E1 cells (Wu et al., 2010). Therefore, it can be concluded that catalpol exhibited bone protective effect through promoting osteoblastogenesis and inhibiting osteoclastogenesis. In summary, in vivo and in vitro experiments demonstrated that Rehmanniae Radix was effective for preventing the development of osteoporosis. According to the results obtained from the current studies, the dried root of Rehmannia glutinosa (Gaertn.) DC was deemed as a better option for improving bone quality over Rehmanniae Radix preparata. However, classical TCM theories claimed that
Rehmanniae Radix preparata was proficiency in improving bone health owing to its strong ability of tonifying kidney and enriching blood. The most likely explanation for the low efficacy of Rehmanniae Radix preparata was that the art of processing was not strictly conformed to the protocol advised by the Chinese pharmacopeia. Although Rehmanniae Radix did not increase estrogen level at 8 weeks in OVX rats, Rehmanniae Radix treatment did upregulate estrogen level at 20 weeks and 40 weeks as well as increase uterus weights in mice. The available data may inform us that long term administration of Rehmanniae Radix still may have the potentials to increase risk of breast and cervical cancers. Catalpol is the only isolated effective compound that has been tested in the osteoporotic animal and osteoblasts model. However, the effect of catalpol on osteoclasts still remains obscure. Since Rehmannia glutinosa polysaccharides constitute the most parts of Rehmanniae Radix, it is important to figure out whether this type of compounds plays a role in preventing the development of osteoporosis. Luckily, the advanced analytical, biological and pharmacological technologies offer the possibilities to further explore its effects on osteoporosis.
7. Toxicity Currently, the toxicities of TCM herbs gained increasing attention in the clinical trials. Contrary to most of the western toxicity data directly derived from animal experiments, TCM toxicity information in old Chinese literatures have been
documented through clinical experiences. Therefore, cautions must be excised that the isolated chemicals and the extracts from the herbs are not identical to the original herbs or formulas, and the traditional properties and indications of TCM herbs and formulas are the only validated source of interpreting and extrapolating assessments of the toxicities (Leung, 2006; Ma et al., 2016). Using Sk-hep1 human hepatoma cells, Choi et al. (Choi et al., 2011) found that 50-250 μg/ml of ethanol extracts of Rehmanniae Radix preparata or water extracts of Rehmanniae Radix dose-dependently induced cellular lipid accumulation using Nile red staining. Further, 100 μg/ml of ethanol extracts of Rehmanniae Radix preparata or 50-250 μg/ml of water extracts of Rehmanniae Radix preparata dose-dependently increased the luciferase activity of sterol regulatory element. Meanwhile, 50 μg/ml of ethanol extracts of Rehmanniae Radix preparata or 250 μg/ml of water extracts of Rehmanniae Radix also decreased activity of peroxisome proliferator response element (PPRE), indicating the possibilities of enhanced fatty acid synthesis and decreased fatty acid oxidation by Rehmanniae Radix. The pomonic acid and jiocerebroside isolated from Rehmanniae Radix are the responsible components for increasing the accumulation of lipid droplets by decreasing β oxidation of fatty acid and increasing lipogenesis. However, the toxicity evidence of this herb is weaker because of lack of the data from in vivo experiments and clinical observations.
8. Conclusions and outlook Rehmanniae Radix is one of the favored TCM herbs for the clinical treatment of osteoporosis and has been identified in 107 TCM clinical trials so far. Most of clinical studies support the concept that the prescriptions contained Rehmanniae Radix has promising efficacies in the management of osteoporosis by improving BMD and reducing pain. However, the therapeutic outcomes for osteoporosis still needs to be further demonstrated by increasing patient sample size and treatment duration as well as improving clinical design. And also fracture rates should be taken into consideration for evaluating therapeutic outcome. Meanwhile, future clinical studies are also required to evaluate the real contributions of Rehmanniae Radix and its constituents in the management of patients with osteoporosis by standardizing the preparations of TCM prescriptions and employing systems pharmacology approach, which will provide more scientific evidence for the development of TCM herbs and theory. The pharmaceutical properties of Rehmanniae Radix and its ingredients have also been well studied in preclinical experiments. Among 140 structurally characterized compounds, iridoid glycosides and Rehmannia glutinosa polysaccharides are two types of the most studied compounds with diverse activities. The dried root of Rehmannia glutinosa (Gaertn.) DC. is the preferred option for improving bone hemostasis in osteoporotic animals. Pharmacokinetics studies reveal that catalpol and ajugol as well as acetoside are the main active ingredients of Rehmanniae Radix.
However, only catalpol has been well tested in osteoporotic animal and cell models. Increasing evidences prompt us to explore the roles of Rehmannia glutinosa polysaccharides in the treatment of bone diseases, which remains far less exploited owing to lack of effective measures to determine its real constituents and targets. Further experimental studies are still needed to screen the active ingredients of this herb and its involved clinical formulas in preventing the development of osteoporosis. Combination with the advances in TCM theory and clinical usage, phytochemistry, pharmacokinetics and pharmacology studies, the sweet edible herb Rehmanniae Radix will offer a new therapeutic promise in preventing the development of osteoporosis.
Conflicts of Interest The authors declare no conflict of interest regarding the publication of this paper.
Acknowledgement This work was supported by grants from National Natural Science Foundation of China
(NSFC81273995),
and
key
drug
development
program
of
MOST
(20122X09103201-005) as well as the 111 project of MOE (B07007). These funding agencies have no roles in the study design; in data collection, analysis and interpretation; in the writing of the report; and in the decision to submit the article for publication. All authors have read and approved the final manuscript.
Liu, C.Y., S.H. Gao and D.W. Zhang conceived and designed the study. Liu, C.Y., R.F. Ma, L.L. Wang, R.Y. Zhu, H.X. Liu, Y.B. Guo, B.S. Zhao, S.G. Zhao, J.F. Tang and Y. Li developed the search strategy: Liu, C.Y., R.F. Ma, L.L. Wang, S.H. Gao and D.W. Zhang identified studies. Liu, C.Y., Y Li, M. Fu, J.Z. Niu, and D.W. Zhang analyzed data. Liu, C.Y., R.F. Ma, L.L. Wang, M. Fu, S.H. Gao and D.W. Zhang drafted and revised the manuscript. D.W. Zhang is the guarantor of this work and, as such, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Sun, Y., Wang, H., Chen, L., Ji, Y., Mo, D., 2015. Clinical study of the effect of Shujin Zhuanggu decoction in treatment of postmenopausal osteoporosis. Journal of Changchun University of Traditional Chinese Medicine 31, 585-586. Tan, W., Yu, K.Q., Liu, Y.Y., Ouyang, M.Z., Yan, M.H., Luo, R., Zhao, X.S., 2012. Anti-fatigue activity of polysaccharides extract from Radix Rehmanniae Preparata. International journal of biological macromolecules 50, 59-62. Tang, P., Yin, P., Lv, H., Zhang, L., Zhang, L., 2015. The Role Of Semaphorin 3A In The Skeletal System. Critical reviews in eukaryotic gene expression 25, 47-57. Wang, H., Sun, Y., Chen, L., Ji, Y., Mo, D., Xue, R., Sun, H., Song, Y., Li, C., 2015a. Curative effect evaluation of Jiawei Shujing Zhuanggu decoction in the treatment of postmenopausal osteoporosis. Trauma and Critical Medicine 3, 301-302. Wang, J., Ma, Y., Zhang, Y., Xu, F., Wang, Q., Li, G., Yan, H., 2011. Clinical research on the treatment of primary osteoporosis with combined use of Jingui Shenqi pill and Calglucon. Chin J Osteoporos 17, 912-915. Wang, L., 2015. Clinical observation on the therapeutic effect of Gusongling decoction on osteoporosis. Shaanxi Journal of Traditional Chinese Medicine 36, 312-313. Wang, L., Li, Y., Guo, Y., Ma, R., Fu, M., Niu, J., Gao, S., Zhang, D., 2016. Herba Epimedii: An Ancient Chinese Herbal Medicine in the Prevention and Treatment of Osteoporosis. Current pharmaceutical design 22, 328-349. Wang, M., Gong, L., Xia, B., Cao, J., Zhou, P., Hu, J., 2003. Clinical observation on 96 cases of primary osteoporosis treating with Yishen Zhuanggu mixture. J TCM 44, 188-190. Wang, Q., Xing, M., Chen, W., Zhang, J., Qi, H., Xu, X., 2012. HPLC-APCI-MS/MS method for the determination of catalpol in rat plasma and cerebrospinal fluid: application to an in vivo pharmacokinetic study. Journal of pharmaceutical and biomedical analysis 70, 337-343. Wang, X., Xu, M., Zhang, C., Deng, Y., Xie, W., 1998. A Clinical Observation on the Effect of Bushen Yigu Gao on Postmenopausal Osteoporosis. Journal of Guangzhou University of Traditional Chinese Medicine 15, 84-87. Wang, Z., Wei, G., Ma, S., 2015b. Chemical and Pharmacological Effects of Rehmanniae Radix polysaccharides. Chinese Journal of Experimental Traditional Medical Formulae 21, 231-235. Wu, M., Zhao, S., Li, E., 2001. Clinical study on the effect of Kanggusong acupuncture points patche in primary osteoporosis treatment. Traditional Chinese Medicinal Research 14, 26-28. Wu, M., Zhao, Y., Li, E., Bai, X., 2010. The influences of the major active substances Catalpol on proliferation, differentiation and mineralization in mice
MC3T3-E1 osteoblast. China Pharmacological Bulletin 26, 509-513.
Wu, P.S., Wu, S.J., Tsai, Y.H., Lin, Y.H., Chao, J.C., 2011. Hot water extracted Lycium barbarum and Rehmannia glutinosa inhibit liver inflammation and fibrosis in rats. The American journal of Chinese medicine 39, 1173-1191. Xu, J., 2011. Clinical observation on the therapeutic effect of Zhibai Dihuang added another Chinese medicine in the treatment of 58 cases with osteoporosis. Jiangsu Journal of Traditional Chinese Medicine 43, 45. Xu, W., Deng, Z., Guo, H., Ling, P., 2012. A rapid and sensitive determination of aucubin in rat plasma by liquid chromatography-tandem mass spectrometry and its pharmacokinetic application. Biomedical chromatography : BMC 26, 1066-1070. Xue, B., Ma, B., Zhang, Q., Li, X., Zhu, J., Liu, M., Wu, X., Wang, C., Wu, Z., 2015. Pharmacokinetics and tissue distribution of Aucubin, Ajugol and Catalpol in rats using a validated simultaneous LC-ESI-MS/MS assay. Journal of chromatography. B, Analytical technologies in the biomedical and life sciences 1002, 245-253. Yasuda, H., 2013. Anti-RANKL antibody was approved for the treatment of osteoporosis in Japan. Japanese journal of clinical immunology 36, 209-216. Yu, P., Sun, Y., Pi, H., Peng, C., 2013. Clinical Research on Zhuanggu Capsule in Treatment of Primary Osteoporosis. Journal of Liaoning University of Traditional Chinese Medicine 15, 113-114.
Zeng, C., 2005. Clinical Researeh of the Treatment of Osteoporosis with Traditional Formula that supplement of Kidney. Guangzhou University of Traditional Chinese Medicine, Guangzhou, China, p. 35. Zhang, B., Jiao, Q., Zhang, H., 2015a. Clinical observation of Zuogui pill combined with medicine and pulsed magnetic therapeutic apparatus. Shanxi Journal of Traditional Chinese Medicine 36, 1003-1004. Zhang, J., Wu, L., Sun, S., Shi, G., Wang, H., Shen, L., Tao, Y., 2005. Clinical study on effect of Jintiange capsules for treatment of primary osteoporosis. Chin J Osteoporos 11, 490-495. Zhang, L., Wang, Y., Yang, D., Zhang, C., Zhang, N., Li, M., Liu, Y., 2015b. Platycodon grandiflorus-an ethnopharmacological, phytochemical and pharmacological review. Journal of ethnopharmacology 164, 147-161. Zhang, L., Zhu, B., Li, W., Peng, J., Jiang, L., Chen, H., 2002. Clinical observation of Spleen-tonifying and kidney-tonifying Shisiwei Jianzhong decoction on primary osteoporosis. Journal of Huaihai Medicine 20, 387-388. Zhang, R., Ma, M., Sun, Q., An, F., Liu, Y., Jiang, B., 2013. Effect of Bushen Zhuanggu Decoction in the Treatment of Postmenopausal Osteoporosis: A Randomized Parallel Controlled Study. Journal of Practical Traditional Chinese Internal Medicine 27, 20-22. Zhang, S., Fang, C., Huang, L., Li, Y., 2008. The effect of Qidan Dihuang formulation on postmenopausal osteoporosis: a 58-case clinical trial. Journal of New Chinese Medicine 14, 54-55. Zhang, W., Men, X., Lei, P., 2014. Review on anti-tumor effect of triterpene acid compounds. Journal of cancer research and therapeutics 10 Suppl 1, 14-19. Zhang, X., 2014. Experimental study of Selaginella and rehmannia glutinosa libosch extract on rats with osteoporosis intervention of the ovary. He'nan University of Chinese Medicine, Zhengzhou, p. 78. Zhang, Y., Wang, Y., Wang, L., Zhang, Y., Qin, Y., Chen, T., Han, W., Chen, G., 2012. Effects of Rehmannia glutinosa oligosaccharide on human adipose-derived mesenchymal stem cells in vitro. Life sciences 91, 1323-1327. Zhang, Y., Wu, X., 2008. Effect of Zhuanggu decoction in primary osteoporosis treatment: a 45-case study. Guiding Journal of TCM 14, 51-52. Zhao, M., Qian, D., Liu, P., Shang, E.X., Jiang, S., Guo, J., Su, S.L., Duan, J.A., Du, L., Tao, J., 2015. Comparative pharmacokinetics of catalpol and acteoside in normal and chronic kidney disease rats after oral administration of Rehmannia glutinosa extract. Biomedical chromatography : BMC 29, 1842-1848. Zhong, J., Tan, Z.D., Wang, T.M., Shi, R., Ma, Y.M., 2013. Absorption and pharmacokinetics of radix rehmanniae in rats. Acta pharmaceutica Sinica 48, 1464-1470. Zhou, J., Xu, G., Ma, S., Li, F., Yuan, M., Xu, H., Huang, K., 2015a. Catalpol ameliorates high-fat diet-induced insulin resistance and adipose tissue inflammation by suppressing the JNK and NF-kappaB pathways. Biochemical and biophysical research communications 467, 853-858. Zhou, J., Xu, G., Yan, J., Li, K., Bai, Z., Cheng, W., Huang, K., 2015b. Rehmannia glutinosa (Gaertn.) DC. polysaccharide ameliorates hyperglycemia, hyperlipemia and vascular inflammation in streptozotocin-induced diabetic mice. Journal of ethnopharmacology 164, 229-238. Zhou, Y., 2011. Clinical study of Liuwei Dihuang decoction combined with another Chinese Medicine in the treatment of 46 cases with senile osteoporosis. Zhejiang Journal of Traditional Chinese Medicine 46, 503. Zhou, Z., An, J., Zhang, G., 2006. Clinical observation trial on 48 cases of osteoporotic fractures treating with Shuanggu decoction Shaanxi Journal of Traditional Chinese Medicine 27, 1503-1505.
Figure 1. The representative images of Rehmannia glutinosa (Gaertn.) DC. (A), Rehmanniae Radix preparata (B), dried Rehmanniae Radix (C) and fresh Rehmanniae Radix (D), which used for the treatment of osteoporosis and isolating constituents. (Pictures are kindly provided by Zexin Ma from the Chinese Medicine and Medica Museum, Beijing University of Chinese Medicine, China). Figure 2. Chemical structures and names of compounds isolated from Rehmannia glutinosa (Gaertn.) DC. Figure 3. The revealed mechanisms targeted by Rehmanniae Radix (RR). Both RR and catalpol monomer have therapeutic effects on osteoporosis. As for RR, it could upregulate the levels of OPG, E2, Itg β1, Runx2, Col, OPN, OC, CT and ERβ, which contributed to bone-formation action. In the meanwhile, RR also inhibited osteoclastogenesis by downregulating TRAP levels. Catalpol could upregulate the levels of T-bet. On the contrary, the ratio of Th1/Th2 and GATA-3 decreased after the treatment with catalpol. Col, collagen; CT, calcitonin; E2, estradiol; ERβ, estrogen receptor β; Itg β1, integrin beta 1; OPG, osteoprotegerin; OPN, osteopontin; OC, osteocalcin; Runx2, Runt-related transcription factor 2; TRAP, tartrate-resistant acid phosphatase.
Fig 1
Fig 2
Fig 3
Graphical Abstract
PII: DOI: Reference:
www.elsevier.com/locate/jep
S0378-8741(16)30625-0 http://dx.doi.org/10.1016/j.jep.2017.01.021 JEP10668
To appear in: Journal of Ethnopharmacology Received date: 1 September 2016 Revised date: 14 January 2017 Accepted date: 14 January 2017 Cite this article as: Chenyue Liu, Rufeng Ma, Lili Wang, Ruyuan Zhu, Haixia Liu, Yubo Guo, Baosheng Zhao, Shangang Zhao, Jinfa Tang, Yu Li, Jianzhao Niu, Min Fu, Dongwei Zhang and Sihua Gao, Rehmanniae Radix in osteoporosis: A review of traditional Chinese medicinal uses, phytochemistry, pharmacokinetics and pharmacology, Journal of Ethnopharmacology, http://dx.doi.org/10.1016/j.jep.2017.01.021 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Rehmanniae Radix in osteoporosis: A review of traditional Chinese medicinal uses, phytochemistry, pharmacokinetics and pharmacology Chenyue Liu1, Rufeng Ma2, Lili Wang2, Ruyuan Zhu2, Haixia Liu2, Yubo Guo2, Baosheng Zhao3, Shangang Zhao4, Jinfa Tang5, Yu Li2, Jianzhao Niu2, Min Fu6, Dongwei Zhang7*, Sihua Gao7* 1
Chinese Material Medica School, Beijing University of Chinese Medicine, Beijing 100102, China;
2
Preclinical Medicine School, Beijing University of Chinese Medicine, Beijing 100029, China;
3
Beijing Research Institute of Chinese Medicine and Pharmacy, Beijing University of Chinese Medicine, Beijing 100029, China;
4
Touchstone Diabetes Center, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8549, USA;
5
The First Affiliated Hospital of He’nan TCM College, Zhengzhou 45000, China
6
The Research Institute of McGill University Health Center, Montreal, Quebec H4A 3J1, Canada;
7
Diabetes Research Center, Beijing University of Chinese Medicine, Beijing 100029, China
[email protected] [email protected] *
Co-correspondence to: Dr. Dongwei Zhang, MD & PhD, Diabetes Research Center, Beijing University of
Chinese Medicine, Beijing, 100029, PR China. Phone: (8610) 6428-6915. Fax: (8610) 6428-6929
*
Co-correspondence to: Dr. Sihua Gao, MD, Diabetes Research Center, Beijing University of Chinese Medicine,
Beijing, 100029, PR China. Phone: (8610) 6428-6929. Fax: (8610) 6428-6929
Abstract: Ethnopharmacological relevance: Emerging clinical usage and pharmacological effects have been achieved in using Rehmanniae Radix either singly or in combination with other herbs to treat skeletal diseases in traditional Chinese medicine (TCM) in the recent years. This study is
aimed to provide a comprehensive review about the historical TCM interpretation of the action of Rehmanniae Radix in osteoporosis, its usage in clinical trials and osteoporotic models, its main phytochemical constituents, and its pharmacokinetics. Materials and methods: Several databases included PubMed, China Knowledge Resource Integrated Database, China Science and Technology Journal Database, National Science and Technology Library and the Web of Science Database were consulted to locate the publications pertaining to Rehmanniae Radix. The initial inquiry was conducted for the presence of the following term combinations in the abstracts: Rehmanniae Radix, Dihuang, phytochemistry, pharmacokinetics, osteoporosis, bone, osteoclast and osteoblast. About 330 research papers and reviews were consulted. Results: In TCM, Rehmanniae Radix exerts the anti-osteoporotic effect via regulating the functions of kidney and liver as well as improving blood circulation. 107 clinical trials are identified that used Rehmanniae Radix in combination with other herbs to treat post-menopausal, senile and secondary osteoporosis. Most of the clinical trials are characterized by high efficacy and no obvious adverse effects. However, the efficacies of these clinical trials are limited because of small patient sample size, short treatment duration and poor clinical design. In addition, TCM herbs under the clinical study are not clear because of a lack of standardization and authentication. The pharmacokinetics data demonstrate that the ingredients of Rehmanniae Radix are
widely distributed after administration, and that catalpol and ajugol as well as acetoside are supposed to be the active constituents. More than 140 individual compounds have been currently isolated from this plant and reported to show pleiotropic effects on various diseases. Rehmanniae Radix displays bone protecting features
in
the
osteoporosis
models
via
the
delicate
balance
between
osteoclastogenesis and osteoblastogenesis through single herb extracts and its isolated compounds. Conclusions: The successful inclusion of Rehmanniae Radix in clinical trials and preclinical studies for the management of osteoporosis has attracted rising attentions for identifying potential anti-osteoporotic candidates from this plant and clinical existing TCM formulas, which will further speed up anti-osteoporosis drug discovery processes. Properly designed q~ and well controlled prospective studies are still needed to further demonstrate bone protective actions and safe use of this herb and its ingredients
Abbreviations ALP, alkaline phosphatase; BBB, blood–brain barrier; BMC, bone mineral content; BMD, bone mineral density; BW, body weight; CKD, chronic kidney disease; Col, collagen; CSF, cerebrospinal fluid ; CT, calcitonin; DREE, dried Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol; DREW, dried Rehmanniae Radix by aqueous extracted; E2, estradiol; FREE, fresh Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol; FREW, fresh Rehmanniae Radix by aqueous extracted; p.o., gavage; H/C, hydroxyproline /creatinine; IL, interleukin; i.m. ,
intramuscular administration ; Itg β1, integrin beta 1; i.v. , intravenous injection; NRS, numerical rating scale; OC, osteocalcin; OPG, osteoprotegerin; OPN, osteopontin; OVX, ovariectomized; PPRE, peroxisome proliferator response element; PTH, parathyroid hormone; RANKL, receptor activator of nuclear factor kappa-B ligand; Runx2, Runt-related transcription factor 2; TCM, traditional Chinese medicine; TRAP, tartrate-resistant acid phosphatase; UHP, urine hydroxyproline; VAS, visual analogue scale
Keywords: Rehmanniae Radix; Osteoporosis; Clinical trial; Phytochemistry; Pharmacokinetics; Pharmacology.
Chemical compounds studied: Catalpol, CID 91520; rehmannioside A, CID 78407230; rehmannioside B, CID 101654196; rehmannioside C, CID 101654197; rehmaionoside A, CID 10023290; rehmaionoside B, CID 10430488; rehmaionoside C, CID 11740990; rehmaglutin A, CID 5320903; rehmaglutin B, CID 14413769; rehmaglutin D, CID 5320906; rehmaglutin C, CID 21637649; ajugol, CID 6325127; rehmannioside D, CID 92044472; and geniposide, CID 107848; gentisic acid, CID 3469; versulin, CID 5280443; oleanolic acid, CID 10494.
1. Introduction Osteoporosis is a progressive and silent bone disease characterized by reduction of bone mass and density, and microstructural deterioration of bone tissues leading to enhanced skeletal fragility and a consequent increased risk of hip and vertebral fractures (Wang et al., 2016). According to the report from international osteoporosis foundation, an osteoporotic fracture is statistically to occur globally every 3 seconds.
Current marketed drugs include bisphosphonates (Maraka and Kennel, 2015), the receptor activator of nuclear factor kappa-B ligand (RANKL)-antibody (Diedhiou et al., 2015; Yasuda, 2013), parathyroid hormone (Li et al., 2016), estrogen replacement therapy (Gambacciani and Levancini, 2014), calcitonin (CT) (Shohrati et al., 2015), and selective estrogen receptor modulators (Andersson et al., 2015), etc. Some of novel potential drug candidates are currently in development, such as cathepsin K inhibitors, c-Src kinase inhibitors, chloride channel inhibitors, sclerostin antibody (MacNabb et al., 2016), Dickkopf-1 antibody (Montagnani, 2014), Wnt (Ohlsson, 2013) and Sema agonists (Tang et al., 2015). However, most of these drugs have been evidenced to exhibit certain side effects on patients with osteoporosis (Che et al., 2016; Guo et al., 2015; Ju et al., 2014; Leung and Siu, 2013; Liu et al., 2014a; Mukwaya et al., 2014). Meanwhile, nature products have recently appealing to researcher’s interests in the management of osteoporosis with its relatively inexpensive, low risk of adverse events and multi-targeting effects. Rehmanniae Radix, a sweet medicinal and edible herb known as Dihuang in Chinese, is derived from the root of perennial plant Rehmannia glutinosa (Gaertn.) DC. (Fig. 1A), and has been clinically used for more than 3000 years. Rehmannia glutinosa (Gaertn.) DC. mainly grows in the provinces of He’nan, Shanxi, Shandong and Hebei in China. Rehmanniae Radix (Fig. 1B) is usually harvested in every autumn and then can be used in various preparations (fresh, steamed or processed with wine) to treat patients. And it was first recorded as a “top-tier” herb (The ancient term
“top-tier” was given to herbs without observable toxicity) in the Shennong's Classic Materia Medica (Shennong Bencao Jing) written during the period from 100 BC to 200 AD. Further, Rehmanniae Radix was also described in classical traditional Chinese medicine (TCM) works such as in the Essentials of Materia Medica (Bencao Beiyao, Ming dynasty, 1368-1644 AD) and The Grand Compendium of Materia Medica (Bencao Gangmu, Ming dynasty, 1578 AD). In the text books of academic TCM, Rehmanniae Radix preparata (Fig. 1C) is characterized as a common hematologic drug with the following functions: nourishing Yin, supplementing bloods, boosting essence, and filling the marrow. And also fresh Rehmanniae Radix (Fig. 1D) has the ability of clearing heat to cool blood, nourishing Yin and promoting the production of body fluids. So far, Rehmanniae Radix has been broadly studied in more than 148,000 publications sourced from the Chinese National Knowledge Infrastructure
(www.cnki.net),
(http://www.nstl.gov.cn/),
China
National Science
Science and
and
Technology
Technology
Journal
Library Database
(http://en.cqvip.com/cstj.html) and approximate 270 from web of science database. This herb has been officially recorded in the Chinese Pharmacopoeia since 1953. Modern phytochemical research reveals that Rehmanniae Radix contains more than 140 individual compounds, such as monoterpenoids, phenethyl alcohol glycosides, and triterpenes. Pharmacological studies reveal that Rehmanniae Radix exhibits a protective role in the management of diabetes, senile osteoporosis, hematological and gynecological diseases.
Here, we review the clinical usages of Rehmanniae Radix in the treatment of osteoporosis, and the current knowledge of its phytochemistry, pharmacokinetics and bone protecting activities. Firstly, we summarize the interpretation of the action of Rehmanniae Radix in TCM, which is useful to understand the rationale of clinical trials using this herb in various combinations with other herbs to treat osteoporosis in China. 2. The bone-protective activity of Rehmanniae Radix in the theory of traditional Chinese medicine In TCM, Rehmanniae Radix is recognized as a herb with a sweet and bitter flavor (here the word flavor not only reflects the taste of the herb but also corresponds to a pathophysiological response and organ target based on ancient observations) as well as cold property (the property reflects the combined effects of the Chinese medicine felt by a patient and the outcome of the treatment) (Gao et al., 2013). However, Rehmanniae Radix preparata was considered as an herb with sweet flavor and slightly warm property after processed with yellow rice wine. According to the theory of channel tropism that describes a selective action of an herbal medicine manifested on one or several specific meridians (Liu et al., 2013), Rehmanniae Radix components can be distributed to the heart, liver and kidney, However, Rehmanniae Radix preparata only can be distributed to the liver and kidney. The readers should be alerted that organ designations in TCM are not identical with their appropriate anatomical counter parts but rather represent functional entities (Guo et al., 2014). In TCM, sweet
flavor of herb materials is traditionally associated with tonic, relaxing and harmonious effects. And bitter flavor is associated with eliminating dampness, and improving the functions of the stomach and intestine. The property of cold is able to dispel the “heat”, such as irritability, fever and inflammatory conditions in the body. And the property of warm can nourish kidney and Yin. Therefore, Rehmanniae Radix has been traditionally used to treat blood ejection and spontaneous external bleeding, menstrual disorders, blood stasis induced heartache, relative weakness in the loins and knees, diabetes, rheumatism, nocturnal emission, and premature graying hair. And Rehmanniae Radix preparata has been used to treat lumbar debility, blood deficiency and sallow complexion, metrorrhagia and metrostaxis, kidney and liver Yin deficiency, palpitations, abnormal menstruation (Tan et al., 2012). Meanwhile, in TCM, osteoporosis is described as “bone atrophy”, “bone rheumatism” or “bone loss”. The main pathogenesis of osteoporosis is attributed to deficiencies in kidney, spleen and liver, which is linked to “a ‘stagnation’ or ‘lack of flow’ of water and blood” (Guo et al., 2015). According to the TCM theory, Rehmanniae Radix may have the effect on improving the functions of the liver and kidney as well as correcting blood deficiency (Gao et al., 2013). Thus, Rehmanniae Radix can be used to treat patients with osteoporosis.
3. Rehmanniae Radix in TCM clinical trials of osteoporosis
Rehmanniae Radix has been widely used in combination with other TCM herbs to treat patients with osteoporosis. We identified 107 clinical studies of primary and secondary osteoporosis that Rehmanniae Radix was used in co-prescription with other TCM herbs such as Epimedii Brevicornus Herba, Astragali Radix, Cornus officinalis, Angelicae Sinensis Radix and Drynariae Rhizoma (Table 1 and 2). Some of clinical trials have also appeared in Dr. Liu et al’s review (Liu et al., 2014a) . The identified 107 clinical trials comprised a total of 6224 patients. The majority of 107 trials targeted the treatment of primary osteoporosis (80 trials); out of which 35 studies explicated the post-menopausal osteoporosis, 9 studies addressed the senile osteoporosis. 9 trials addressed secondary osteoporosis patients. The minority of these studies targeting diabetes-induced osteoporosis patients. Only 4 trials caused by glucocorticoid. 18 trials did not specify the disease type. The overall efficacy (with markedly and moderately improved conditions) of trials treating primary osteoporosis patients was between 65% and 100%, and that for secondary osteoporosis patients was between 73.3% and 100% (Table1). Therefore, the accumulating evidence suggests that Rehmanniae Radix may be effective for preventing the development of primary and secondary osteoporosis. However, of 107 clinical trials, 2 were randomized placebo double-blind controlled trials, 3 were randomized controlled double-blind trials, 2 were randomized single-blind and 85 were open trials. The remaining 15 trials carried on statistical analysis of the results of the self-comparison before and after treatment. Few clinical
trials meet the standards of randomized, double blind, placebo-control and multi-centered. Among all the available data on clinical osteoporosis trials containing Rehmanniae Radix, we found that all of these studies are characterized by a small patient sample size (mostly less than 100) and short treatment duration of 4 weeks to 18 months. There are difficulties in comparing overall validation of the studies because clinical trials differ in the time frame, observed biomarkers, participants’ ethnicity, and administration of the prescriptions (Liu et al., 2014a). Most of the trials were reported to observe the improvement in increasing bone mineral density, while few of the clinical trials addressed fracture rates, which is a reliable marker to make a statement on a truly clinically therapeutic effect (Guo et al., 2014). Therefore, the literatures present weaker evidence for marginal benefits of the prescriptions. Furthermore, no trials reported possible herb–herb interactions of the prescription. As there is a rising concern about the potential toxicity of TCM herbs, the future studies on the safety of the prescriptions and single herbs are badly warranted. In addition, well-designed clinical trials with strong evidence to interpret the endpoints are also urgently required. The TCM ingredients in the osteoporosis studies range from 4 to 24 individual elements. The relative weight contributions of Rehmanniae Radix in these therapeutic mixtures are ranged from 3.9% to 37.5%, and listed in Table 1. Therefore, further studies focusing on the correlation between therapeutic effects and relative
Rehmanniae Radix content are not easy due to the large variability of the herbal compositions (number of herbs used and their individual dosages). Meanwhile, non-standardized preparations of the prescriptions studied are also main grave area of concern. It should be noted that the recommended dosage of Rehmanniae Radix in Chinese Pharmacopeia (2015 version) is 10-15 g for Rehmanniae Radix, or 12-30 g for fresh Rehmanniae Radix and 9-15 g for Rehmanniae Radix preparata (2015). However, these identified prescriptions may offer a library in searching synergistic formulations and potential herbs for the management of osteoporosis. In addition, cautions should be excised as some medicinal effects of plants may be dependent upon the season, time of harvest, degree of ripening, method of preparation, etc. Furthermore, future TCM clinical studies are also required to determine the real contributions of Rehmanniae Radix in the management of patients with osteoporosis through standardizing the preparations of TCM prescriptions and employing serum pharmacological and pharmacokinetic methods (Huang et al., 2016b) as well as systems pharmacology approaches (Li et al., 2014), which will also provide strong scientific evidence for evaluation of the effects of Rehmanniae Radix on osteoporosis.
Table 1 The prescriptions containing Rehmanniae Radix used by physicians for management of osteoporosis*. Prescription name;
#
of
components
Percentage
Type
of
of
osteoporosis;
Rehmanniae
of
Radix
Treatment
(preparata)
duration
Treatment aim and biomarker measurements
Results (# of patients)
Ref.
Markedly improved (6)
(Zeng, 2005)
#
Patients;
in prescription; Study design Liuwei Dihuang
Not Known;
Post-menopausal
Significant
Pill
Randomized
osteoporosis
deficiency; Increase in bone mineral content
Moderately improved (58)
a
single-blind
70
(BMC); Bone mineral density (BMD) in radius
Ineffective (6)
6
trial
6 months
effect:
Disappearance
of
kidney
2
and ulna increased by ı 0.05 g/cm . Effective:
Kidney
deficiency
Overall efficacy: 91.4%. significantly
No control.
alleviated; BMD in radius and ulna increased by ˘ 0.05 g/cm2. Ineffective:
No
significant
improvement
in
symptoms of kidney deficiency, BMC and BMD. Liuwei Dihuang
Not known;
Post-menopausal
Significant
Capsule
Open trial
osteoporosis
6
b
effect:
BMD
increased;
Clinical
Markedly improved (8)
(Li,
symptoms disappeared.
Moderately improved (48)
2011)
70
Effective: Clinical symptoms alleviated; BMD
Ineffective (14)
6 months
remained the same.
Overall efficacy: 80.0%.
Ineffective: BMD and clinical symptoms remained the same. Qidan Dihuang
Not known;
Post-menopausal
Significant effect: No pain in waist, back and
Markedly improved (16)
(Zhang
Granule
Randomized
osteoporosis
chest; Work and life as usual.
Moderately improved (31)
et
single-blind
58
Effective:
Ineffective (11)
2008)
trial
3 months
significantly alleviated; Work and life as usual.
5
c
Pain
in
waist,
back
and
chest
al.,
Overall efficacy: 81.0%.
Ineffective: Prominent pain, difficult to work and life. 9.3%;
Post-menopausal
Significant effect: BMD increased; Clinical
Markedly improved (16)
(Jiao and
Open trial
osteoporosis
symptoms disappeared; Work and life as usual;
Moderately improved (11)
Yang,
Decoction
30
Effective: Clinical symptoms alleviated; BMD
Ineffective (3)
2009)
14d
3 months
remained the same; Work and life as usual.
Overall efficacy: 90.0%.
Ineffective: BMD and clinical symptoms remained
No control.
Bushen
Yipi
Zhuanggu
the same; Difficult to work and life. Zhibai Dihuang
*
Not known;
Post-menopausal
Significant effect: Pain disappeared; BMD in
Markedly improved (39)
(Bai
et
The medicinal plant names of TCM herbs used in the above-mentioned prescriptions (Table 1) are not available reliably in the papers we consulted, and therefore this information cannot be provided.
Pill 9
Open trial
e
osteoporosis
radius and ulna increased by ı 0.05 g/cm2;
Moderately improved (26)
al.,
70
Effective: Pain significantly alleviated; BMD in
Ineffective (5)
2014)
6 months
Bushen
Yigu
Gao 5
2
radius and ulna increased by ˘ 0.05 g/cm .
Overall efficacy: 92.9%.
Ineffective: Prominent pain; BMD remained the
Control treatment: Caltrate D and
same.
Gugua Extractive Injection.
Not known;
Post-menopausal
Effective: BMD and bone metabolism biochemical
Effective (27)
(Wang et
Open trial
osteoporosis
criterion tend toward bone formation; Treatment
Ineffective (3)
al.,
30
score of kidney-weakness improved between
Overall efficacy: 90.0%.
1998)
3 months
2/3̚1/2.
f
Ineffective:
BMD
and
bone
metabolism
biochemical markers tend toward bone resorption; Treatment score of kidney-weakness improved by İ 1/3. Bushen
11.4%;
Post-menopausal
Significant effect: No pain; BMD significantly
Markedly improved (21)
(Zhang
Zhuanggu
Open trial
osteoporosis
increased.
Moderately improved (12)
et
Decoction
41
Effective: Pain significantly alleviated; BMD
Ineffective (8)
2013)
12g
180 Days
increased or remained the same.
Overall efficacy: 80.5%
al.,
Ineffective: No changes in pain and signs. Jiarong Pill 12
h
Not known;
Post-menopausal
Significant effect: No pain; Clinical score
Markedly improved (10)
(Chen
Open trial
osteoporosis
decreased by ı 2/3; BMD increased by ı
Moderately improved (8)
and
2
20
0.06 g/cm .
Ineffective (2)
Huang,
6 months
Effective: Pain in back and waist significantly
Overall efficacy: 90.0%.
2001)
alleviated; 1/3 İ clinical score < 2/3; BMD
Control treatment: Caltrate D.
2
increased by < 0.06 g/cm . Ineffective: No changes in pain and BMD; Clinical score decreased by 1/3. Bushen
Jianpi
Jingu Decoction 12
11.5%;
Post-menopausal
Significant effect: No pain; No soreness and
Markedly improved (24)
(Mao,
Open trial
osteoporosis
weakness of waist and knees; BMD increased by
Moderately improved (10)
2011)
39
ı 2%.
Ineffective (5)
12 weeks
Effective: Pain and soreness and weakness of
Overall efficacy: 87.17%.
i
waist and knees significantly alleviated; BMD increased by < 2%. Ineffective: No changes in the above items. Shugan Huoxue Decoction j
14
Zishen
6.8%;
Post-menopausal
Clinical curative effect assessment: 0 score: no
Markedly improved (16)
(Han
Open trial
osteoporosis
pain; 1 score: occasionally pain; 2 scores: pain
Moderately improved (8)
al.,
25
repeatedly and alternatively, work as usual; 3
Ineffective (1)
2007)
6 months
scores: pain continuously, difficult to life and
Overall efficacy: 96.0%.
work.
Control treatment: Caltrate D and
Significant
effect:
Clinical
curative
effect
assessment reduced by 2 scores. Effective: Clinical curative effect assessment
Alendronate Sodium.
et
reduced by 1 score. Ineffective: Clinical curative effect assessment reduced by 0 score. Jiawei
Shujin
Not known;
Post-menopausal
Significant effect: No pain; BMD increased by ˚ 2
Markedly improved (13)
(Wang et
osteoporosis
0.06 g/cm .
Moderately improved (16)
al.,
Decoction
75
Effective: Pain significantly alleviated; BMD
Ineffective (1)
2015a)
10k
6 months
increased by ˘0.06 g/cm2.
Overall efficacy: 96.67%.
Ineffective: Prominent pain; BMD remained the
No control.
Zhuanggu
Open trial
same. Gengnian Anyi
Not known;
Post-menopausal
Significant effect: No pain, score increased by ı
Markedly improved (12)
(Fan
Pill
Open trial
osteoporosis
2/3.
Moderately improved (8)
al.,
22
Effective: Pain significantly alleviated; 1/3 İ
Ineffective (2)
2004)
6 months
pain score decreased by ˘ 2/3.
Overall efficacy: 90.91%.
Ineffective: Prominent pain; BMD remained the
Control treatment: Calcitrate D
4
l
et
same; Pain score decreased by ˘1/3. Jiangu
Not known;
Post-menopausal
Serum alkaline phosphatase (ALP), Ca, estradiol (E2),
Serum ALP significantly decreased,
(Ke
Formulation
Open trial
osteoporosis
BMD.
E2 significantly increased, Serum
al.,
6
m
2+
32
Ca and BMD increased.
2005)
et
3 months Jiawei
Zuogui
Pill 11
9.8%;
Post-menopausal
Cured: Main symptoms disappeared.
Cured (33)
(Huang
Open trial
osteoporosis
Significant effect: Main symptoms significantly
Markedly improved (8)
et
53
improved.
Moderately improved (7)
2013a)
6 months
Effective: Main symptoms slightly improved.
Ineffective (5)
Ineffective: No changes in main symptoms.
Overall efficacy: 90.57%
n
al.,
Control treatment: D-cal Shujin
Not known;
Post-menopausal
E2, CT, Tartrate resistant acid phosphatase (TRAP),
Markedly improved (25)
(Sun
Zhuanggu
Open trial
osteoporosis
osteocalcin (OC).
Moderately improved (13)
al.,
40
Significant effect: Disappearance of pain; BMD
Ineffective (2)
2015)
Decoction 10
o
6 months
2
increased by ı 0.06 g/cm .
Overall efficacy: 95.0%
Effective: Pain significantly alleviated; BMD
No control.
2
Hugu Granule 10
p
increased by < 0.06 g/cm .
TRAP decreased. OC, CT and E2
Ineffective: No changes in symptom and BMD.
increased.
et
Not known;
Primary
BMD in lumbar (2~4), neck, Ward’s and
Total effective rates:
(Hong et
RCT
osteoporosis
trochanter; Serum ALP; Urine hydroxyproline
BMD in lumbar: 59.8%,
al.,
placebo
338
/creatinine (H/C).
BMD in neck: 54.6%,
2008)
double-blind
6 months
BMD in Ward’s: 56.4%, BMD in trochanter: 50.7%. ALP maintained the same level, H/C significantly decreased.
Zhuanggu
7.8%;
Post-menopausal
Significant effect: Pain demoted from 3 or 2 to 0.
Markedly improved (91)
(Dong et
Qiangjin
Open trial
osteoporosis
Effective: Pain demoted from 3 or 2 to 1.
Moderately improved (20)
al., 2011)
Decoction 9
q
120
Ineffective: Pain remained the same or above level
Ineffective (9)
6 months
2.
Overall efficacy: 92.5% Control treatment: Vitamin D and Calcium.
Significant effect: Improvement of pain in back
Markedly improved (12)
(Yu
osteoporosis
and waist; Average score decreased by ı 2
Moderately improved (26)
al.,
40
scores; BMD increased byı 0.06 g/cm2.
Ineffective (2)
2013)
6 months
Effective: Improvement of pain in back and waist,
Overall efficacy: 95.0%.
Average score decreased by between 1~1.9 scores;
No control.
Zhuanggu
Not known;
Primary
Capsule
Open trial
11r
et
2
BMD increased by < 0.06 g/cm . Ineffective: No change in pain and BMD; Average score decreased by less than 1 score. Bushen
5.3%;
Primary
Significant effect: No pain; Clinical symptoms
Markedly improved (18)
(Han,
Zhuanggu
Open trial
osteoporosis
improved, and BMD significantly increased.
Moderately improved (6)
2013)
Decoction
28
Effective: Pain in limbs significantly alleviated;
Ineffective (4)
14s
6 months
BMD increased.
Overall efficacy: 85.7%.
Ineffective: No changes in pain and BMD; Bone
No control.
fracture occurred easily. Rengong Jianbu
Not known;
Primary
Significant effect: No pain; Clinical signs score
Markedly improved (35)
(Zhang
Huqian Pill
RCT
osteoporosis
decreased by ı 70%; BMD increased by ˚
Moderately improved (71)
et
double-blind
120
2%.
Ineffective (14)
2005)
3 months
Effective: Pain significantly alleviated; Clinical
Overall efficacy: 88.34%.
signs score decreased by between 30% and 70%;
No control.
24
t
al.,
BMD increased by between 1 % and 2%. Ineffective: No change in symptoms; Clinical signs score decreased by ˘30%; BMD increased by ˘1%. Yishen
18.2%;
Primary
Significant
Zhuanggu
Open trial
osteoporosis
significantly increased.
96
Effective:
6 months
significant increase in BMD.
Overall efficacy: 98.96%.
Ineffective: Pain and BMD remained the same.
No control.
Mixture 7
u
effect:
Pain
Pain
disappeared;
significantly
BMD
alleviated;
No
Markedly improved (52)
(Wang et
Moderately improved (43)
al.,
Ineffective (1)
2003)
Guben
Not known;
Primary
Cured: No symptoms; Clinical score decreased by
Cured (3)
(Dai and
Zhuanggu
Open trial
osteoporosis
ı 95 %.
Markedly improved (12)
Li, 2015)
60
Significant effect: Main symptoms significantly
Moderately improved (11)
6 months
improved; 70% İ clinical score decrease ˘
Ineffective (1)
95%;
Overall efficacy: 96.29%.
Capsule 7
v
Effective: Main symptoms improved; 30%
İ
score decrease ˘70%; Ineffective: No change in symptoms; score decrease ˘ 30%.
No control.
Xianling
Migu
Granule 9
Not known;
Primary
Cured: No symptoms; Score decrease ı 95%.
Cured:(2)
(Dai
Open trial
osteoporosis
Significant effect: Main symptoms significantly
Markedly improved (5)
and Li,
60
improved; 70% İ clinical score decrease ˘
Moderately improved (14)
2015)
6 months
95%.
Ineffective (4)
Effective: Main symptoms improved; 30% İ
Overall efficacy: 84.0%.
clinical score decrease ˘ 70%.
No control.
w
Ineffective: No change in symptoms; Clinical score decrease ˘ 30%. Jiawei
Bushen
Zhuangjin 13
9.8%;
Primary
Significant effect: No pain in waist and back;
Markedly improved (26)
(Lv
Open trial
osteoporosis
Significant increase in BMD; Disappearance of
Moderately improved (25)
al.,
56
Yin deficiency.
Ineffective (5)
2003)
3 months
Effective: Pain in waist and back significantly
Overall efficacy: 91.07%.
alleviated; No significant increase in BMD; No
No control.
x
et
significant improvement in symptoms of Yin deficiency. Ineffective: Prominent pain; BMD and symptoms of Yin deficiency remained the same. Gusongling
7.9%;
Primary
Significant effect: Disappearance of clinical
Markedly improved (23)
(Wang,
Decoction
Open trial
osteoporosis
symptoms; BMD increased by ı 20%.
Moderately improved (20)
2015)
50
Effective: Symptoms significantly alleviated;
Ineffective (7)
BMD increased by ı 20%.
Overall efficacy: 86.0%.
Ineffective: No changes in symptom and BMD.
No control.
15
y
3
months
Shisiwei
10.8%;
Primary
Significant effect: No pain in waist, back and
Markedly improved (19)
(Zhang
Jianzhong
Open trial
osteoporosis
chest; Work and life as usual.
Moderately improved (13)
et
Decoction
34
Effective:
Ineffective (2)
2002)
14z
2 months
significantly alleviated; Work and life as usual.
Overall efficacy: 94.11%.
Ineffective: Pain still existed˗Difficult to work and
No control.
Pain
in
waist,
back
and
chest
al.,
life. Bushen Tongluo
Not known;
Primary
Significant effect: Disappearance of pain; BMD
Markedly improved (13)
(Shi
Formulation
Open trial
osteoporosis
significantly increased;
Moderately improved (5)
al.,
32
Effective: Pain significantly alleviated; No change
Ineffective (4)
2007)
6 months
in BMD;
Overall efficacy: 87.5%.
Ineffective: No changes in symptom and BMD.
Control treatment: Osteoform.
6
aa
Duhuo
Jisheng
Decoction 17
6.0%;
Primary
Very good: Clinical symptoms improved by >
Very good: (20)
(Song et
Open trial
osteoporosis
75%.
Good: (10)
al.,
41
Good: Clinical symptoms improved by between
Average: (6)
2013)
3 months
50% and 74%.
Bad: (5)
ab
Average:
Clinical
symptoms
improved
between 25% and 49%.
by
Overall efficacy: 87.8%. Control treatment: Caltrate D.
Bad: Clinical symptoms improved by ˘ 25%. Bushen Huoxue
et
10.8%;
Senile
Numerical rating scale (NRS)ˈBMDˈE2
BMD
and
E2
significantly
(Jiang,
Formulation 18
Open trial
ac
osteoporosis
increased, NRS decreased.
2015)
60 3 months
Jingui
Shenqi
Pill 10
Not known;
Primary
Visual analogue scale (VAS) score.
Markedly improved (23)
(Li
Open trial
osteoporosis
Significant effect: VAS < 2, Sleep and turning
Moderately improved (10)
Chen,
45
were not affected; No pain when walk and sitting.
Ineffective (11)
2014)
6 months
Effective: VAS < 5; Sleep improved and pain
Overall efficacy: 75.6%
relieved.
Control treatment: Alendronate
Ineffective: VAS ı 6; Pain remained the same.
sodium, Calcitriol capsule, and
ad
and
Caltrate D. Jingui
Shenqi
Pill 8
Not known;
Primary
Open trial
ae
Pain scale, serum ALP, P, Ca, BMD.
Pain scale decreased obviously,
(Wang et
osteoporosis
BMD increased, serum ALP, P,
al., 2011)
30
Ca
6 months
statistically before and after the
were
not
significant
treatment, Control
treatment:
Calcium
gluconate. Kanggusong
Not known;
Primary
Serum ALP, Ca, parathyroid hormone (PTH), E2,
Markedly improved (10)
(Wu
Granule
Open trial
osteoporosis
urine hydroxyproline (UHP), BMD. CT.
Moderately improved (15)
al.,
30
Curative effect evaluation: BMD.
Ineffective (5)
2001)
3 months
Significant effect: BMD increased by > 2%.
Overall efficacy: 83.3%
Effective: BMD increased by > 1%.
No control.
Ineffective: BMD increased by < 1%.
Serum Ca, CT and E2 significantly
4
af
et
increased, UHP and PTH decreased.
Kanggusong
Not known;
Primary
acupuncture
Open trial
points patch 4
ag
Markedly improved (11)
(Wu
osteoporosis
Moderately improved (14)
al.,
30
Ineffective (5)
2001)
3 months
Overall efficacy: 83.3%
Same as above.
et
No control. Serum Ca, CT and E2 significantly increased, UHP and PTH decreased.
Qiangjin
4.2%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (12)
(Chen et
Zhuanggu Pill
Open trial
osteoporosis
significantly increased.
Moderately improved (22)
al.,
38
Effective: Pain significantly alleviated; BMD
Ineffective (4)
2015)
6 months
increased.
Overall efficacy: 89.47%
Ineffective: No changes in symptom and BMD.
No control.
16
ah
Yishen Decoction 14
ai
Jiangu
11.1%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (15)
(Huang,
Open trial
osteoporosis
significantly increased.
Moderately improved (26)
2006)
46
Effective: Pain significantly alleviated; BMD
Ineffective (5)
3 months
increased.
Overall efficacy: 89.13%
Ineffective: No changes in symptom and BMD.
No control.
Zhibai Dihuang
Not known;
Primary
Cured: Disappearance of symptoms and signs of
Cured (40)
(Sun,
Pill
Open trial
osteoporosis
TCM; Score decreased by more than 95%; BMD
Markedly improved (42)
2015)
113
significantly increased.
Moderately improved (18)
6 months
Significant effect: Symptoms and signs of TCM
Ineffective (13)
significantly alleviated; Score decreased by ı
Overall efficacy:88.5%
75%; BMD increased.
Control treatment: Caltrate D.
8
aj
Effective: Symptoms and sign of TCM improved; Clinical score decreased byı 30%. Ineffective: No changes in symptoms and BMD; Score decreased by < 30%. Zhuanggu
9.0%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (24)
(Zhang
Decoction
Open trial
osteoporosis
significantly increased.
Moderately improved (14)
and Wu,
45
Effective: Pain significantly alleviated; BMD
Ineffective (7)
2008)
3 months
increased.
Overall efficacy:84.4%
13
ak
Ineffective: No changes in symptom and BMD. Zuogui
Pill
combined
with
Taohong
Siwu
9.6%;
Primary
Significant effect: Pain disappeared; BMD
Markedly improved (45)
(Chang,
Open trial
osteoporosis
significantly increased.
Moderately improved (34)
2012)
85
Effective: Pain significantly alleviated; BMD
Ineffective (6)
6 months
increased.
Overall efficacy: 92.9%.
Decoction 20
al
Ineffective: No changes in symptom and BMD.
Dihuang
Not Known;
Primary
Cured: Disappearance of pain in limbs; Walk as
Cured (18)
(He and
Gutongkang
Open trial
osteoporosis
usual; Numbness of the limbs disappeared; No
Markedly improved (4)
Zhang,
40
dizziness.
Overall efficacy: 95%.
2014)
2 months
Significant effect: Pain in limbs; Numbness of the
Control treatment: Caltrate D and
limbs and dizziness significantly alleviated;
Rocaltrol.
Capsule 12
am
Difficulty walking occasionally appeared. Effective: Pain in limbs; Numbness of the limbs and dizzy alleviated; Difficulty walking often appears. Ineffective: No changes in main symptoms. Significant effect: No pain.
Markedly improved (85)
(Deng et
osteoporosis
Effective: Pain significantly relieved.
Moderately improved (11)
al.,
101
Ineffective: Pain remained the same.
Ineffective (5)
2006)
Bushen
Not Known;
Male
Zhuanggu
Open trial
Granule 13
an
primary
4 weeks
Overall efficacy: 95.0%. No control.
Gusong’an
Not Known;
Kidney-yang
Significant effect: Clinical score decreased by ı
Markedly improved (7)
(He,
Capsule
Open trial
deficiency
2/3.
Moderately improved (14)
2001)
primary
Effective: 2/3 < Clinical score decrease ı 1/3.
Ineffective (7)
osteoporosis
Ineffective: Clinical score decreased by ˘ 1/3.
Out of touch (4)
11
ao
32 6 months
Overall efficacy: 65.0%.
Liuwei Dihuang
4.7%;
Senile
Significant effect: Disappearance of pain in back,
Markedly improved (11)
(Zhou,
Decoction
Open trial
osteoporosis
lumbar vertebra and limb; BMD significantly
Moderately improved (29)
2011)
46
increased.
Ineffective (6)
3-5 months
Effective:
15
ap
Clinical
symptoms
significantly
alleviated; BMD increased.
Overall efficacy: 86.96%. No control.
Ineffective: No change in symptoms after 3 courses of treatment. Shuanggu
10.8%;
osteoporotic
Monthly take X-ray after fracture fixation to
Excellent (25)
(Zhou et
Decoction
Open trial
fracture
check the registration situation, and fracture
Good (10)
al.,
48
healing situation.
Average (8)
2006)
10
aq
Bad (5)
Not known
Control
treatment:
Salcatonin
injection Overall efficacy: 89.6%. Bushen
Jiangu
Decoction
16.8%;
Osteoporotic
Cured: Fracture healed; Vertebral compression
Markedly improved (32)
(Liu
Open trial
vertebral
cured; No pains in chest and back; Paraplegia
Moderately improved (12)
al.,
compression
disappeared; Body function fully recovered.
Ineffective (2)
2014b)
fractures
Effective: Fracture healed; Vertebral compression
Overall efficacy: 95.7%
46
improved; Pain alleviated in chest and back;
Control treatment: D-cal and
6 months
Paraplegia disappeared; Body function
vitamin D.
13 ar
et
significantly improved.
Ineffective: No change in the above items. Jiawei
Zhibai
Dihuang Pill 9
7.4%;
Osteoporosis
Significant effect: No pain in waist and back;
Markedly improved (38)
(Xu,
Open trial
58
Significant increase in BMD; Disappearance of
Moderately improved (20)
2011)
3 months
Yin deficiency.
Ineffective (0)
Effective: Pain in waist and back significantly
Overall efficacy: 100%.
alleviated; No significant increase in BMD; No
No control.
as
significant improvement in symptoms of Yin deficiency. Ineffective: Pain, BMD and symptoms of Yin deficiency remained the same. Zishen Gukang
Not known;
Osteoporosis
Cured: Pain disappeared; BMD significantly
Cured (24)
(Quan,
Pill
Open trial
54
increased.
Markedly improved (18)
2012)
6 months
Significant effect: Pain significantly alleviated;
Moderately improved (10)
BMD increased.
Ineffective (2)
Effective: Pain significantly alleviated; No change
Overall efficacy: 96.3%.
6
at
in BMD. Ineffective: No changes in symptom and BMD. Zuogui Pill 12
au
9.4%;
Osteoporosis
Significant effect: Pain disappeared; BMD
Markedly improved (45)
(Zhang
Open trial
75
increased significantly.
Moderately improved (27)
et
6 months
Effective: Pain significantly alleviated; BMD
Ineffective (3)
2015a)
al.,
increased.
Overall efficacy: 96%.
Ineffective: No changes in symptom and BMD.
Control
treatment:
Calcium
carbonate D3, Calcitriol capsule, Allen phosphoric acid sodium and pulsed magnetic therapeutic apparatus. For other prescriptions that contained Rehmanniae Radix, such as Jiangu San, Gushukang Granule, Ziyin Bushen Zhuanggu Decoction, Qihuodan
(Guo
Jiangu prescription, Kanggusong Capsule, Shiwei Gukang Oral Liquid, Bushen Jianpi Huoxue Decoction, Kanggusong Capsule, Kanggusong
al.,
Decoction, Kanggusong Decoction plus Caltrate D, Gushukang Capsule, Bushen formulation, Kanggusong Urinary bladder meridian sticking
2014)
et
patch, Kanggusong kidney meridian sticking patch, Bushen Qianggu Huoxue Decoction, Shangke Yishen Zhuanggu pill, Bupi Yishen Huoxue Formulation, Tanggukang Decoction, Bushen Jiangu Capsule, Bushen Zhuanggu Pill, Xianling Gubao Capsule, Gukang prescription, please refers to Yubo Guo et al’s review. Bushen Qiangshen Wan, Gubi Decoction combined with western medicine, Yanghe Decoction, Bushen Qiangdu Formulation, Zhuanggu
(Wang et
Decoction, Gukang Pill, Er’xian Decoction, Jiawei Er’xian Granule, Guwei Decoction, Guwei formula, Shuanggu Decoction, Shigu Yin, Jinlong
al.,
Pill, Jiawei Liuwei Dihuang Decoction, Liuwei Dihuang Decoction and Sijunzi Decoction, Gushen Yijing Decoction, Bushen Huoxue
2016)
Formulation, Yishen Zhuanggu Formulation, Yigu Yin, Xiangu Decoction, Bushen Yijing Formula, Zishen Gukang Decoction, Gukang Tablet, Bushen Jiangu Formulation, Bushen Jiangu Formulation, Bushen Jianpi Decoction, Bushen Qianggu Formulation, Kangguzhi Shusong Pill, Jianpi Yanggu Decoction, Tangmaikang Granule, Wenyang Bushen Decoction, Yangxue Gushen Decoction, Yishen Guben Decoction, Bugu Decoction, Hugu Capsule, Gugu Granule, Gushibao Capsule, Bushen Zhuanggu Formulation, please refers to Lili Wang et al’s review. a
Rehmanniae Radix, Cornus officinalis, Diocoreae Rhizoma, Alismatis Rhizoma, Poria, Astragali Radix (dosage information is not available).
b
Same as a.
c
Rehmanniae Radix preparata, Epimedii Brevicornus Herba, Cornus officinalis, Diocoreae Rhizoma, Astragali Radix (dosage information is not
available). d
Cuscutae Semen 15 g, Morindae Officinalis Radix 15 g, Polygoni Multiflori Radix 15 g, Cistanches Deserticolae Herba 15 g, Astragali Radix 30 g,
Drynariae Rhizoma 20 g, Psoraleae Fructus 20 g, Angelicae Sinensis Radix 20 g, Rehmanniae Radix preparata 20 g, Placenta Hominis 10 g, Cornu Cervi Degelatinatum 10 g, Atractylodis Macrocephalae Rhizoma 10 g, Achyranthis Bidentatae Radix 10 g, Glycyrrhiizae Radix preparata 6 g. If patients show blood stasis, removed Cistanches Deserticolae Herba, Psoraleae Fructus, Rehmanniae Radix preparata and Cuscutae Semen from the above-mentioned prescription, then added Epimedii Brevicornus Herba 15 g, Polygonati Sibirici Rhizoma preparata15 g, Codonopsis Radix 20 g, Eucommiae Cortex 20 g, Dipsaci Asperoidis Radix 20 g, Spatholobi Caulis 30 g, and Achyranthis Bidentatae Radix 10 g to the above-mentioned prescription. e
Anemarrhenae Rhizoma, Phellodendri Chinensis Cortex, Diocoreae Rhizoma, Cornus officinalis, Astragali Radix, Alismatis Rhizoma, Poria,
Rehmanniae Radix preparata, Testudinis Carapax et Plastrum (dosage information is not available). f
Rehmanniae Radix preparata, Epimedii Brevicornus Herba, Placenta Hominis, Alismatis Rhizoma, Os Draconis (dosage information is not
available). g
Rehmanniae Radix 20 g, Diocoreae Rhizoma 15 g, Cornus officinalis 15 g, Alismatis Rhizoma 15 g, Poria 20 g, Cinnamomi Cassiae Cortex 5 g,
Epimedii Brevicornus Herba 15 g, Colla Cornus Cervi 5 g, Cnidii Fructus 15 g, Testudinis Carapax et Plastrum 10 g, Morindae Officinalis Radix 25 g, Drynariae Rhizoma 15 g. h
Rehmanniae Radix preparata, Acanthopanacis Radicis Cortex, Cuscutae Semen, Cistanches Deserticolae Herba, Lycii Fructus, Ligustri Lucidi
Fructus, Aconiti Lateralis Radix preparata, Diocoreae Rhizoma, Poria, Alismatis Rhizoma, Astragali Radix, Cinnamomi Cassiae Cortex (dosage information is not available). i
Rehmanniae Radix preparata 20 g, Diocoreae Rhizoma 15 g, Cornus officinalis 12 g, Lycii Fructus 12 g, Eucommiae Cortex 15 g, Psoraleae
Fructus 15 g, Drynariae Rhizoma 15 g, Codonopsis Radix 20 g, Astragali Radix 20 g, Atractylodis Macrocephalae Rhizoma 10 g, Poria 10 g, Glycyrrhiizae Radix preparata 10 g. j
Bupleuri Chinensis Radix 10 g, Paeoniae Alba Radix 15 g, Cyperi Rhizoma 10 g, Aurantii Immaturus Fructus 10 g, Pinelliae Rhizoma 10 g, Poria
10 g, Rehmanniae Radix preparata 10 g, Cornus officinalis 10 g, Testudinis Carapax et Plastrum 12 g, Cibotii Rhizoma 12 g, Chaenomelis Speciosae Fructus 10 g, Olibanum 10 g, Myrrha 10 g, Chuanxiong Rhizoma 8 g. k
Rehmanniae Radix preparata, Angelicae Sinensis Radix, Cornus officinalis, Salviae Miltiorrhizae Radix et Rhizoma, Paeoniae Alba Radix,
Puerariae Lobatae Radix, Anemarrhenae Rhizoma, Lycii Fructus, Epimedii Brevicornus Herba, Cuscutae Semen. If patients show blood stasis due to stagnation of Qi, added Astragali Radix, Atractylodis Macrocephalae Rhizoma, Aurantii Immaturus Fructus, and Aucklandiae Radix to the above-mentioned prescription. l m
Rehmanniae Radix preparata, Diocoreae Rhizoma, Eucommiae Cortex, Cistanches Deserticolae Herba (dosage information is not available). Psoraleae Fructus, Cistanches Deserticolae Herba, Epimedii Brevicornus Herba, Cuscutae Semen, Rehmanniae Radix preparata, Paeoniae Alba
Radix. n
Rehmanniae Radix preparata 15 g, Cornus officinalis 9 g, Diocoreae Rhizoma 12 g, Lycii Fructus 15 g, Testudinis Carapax et Plastrum 15 g, Colla
Cornus Cervi 15 g, Cuscutae Semen 12 g, Achyranthis Bidentatae Radix 15 g, Dipsaci Asperoidis Radix 15 g, Drynariae Rhizoma 15 g, Magnetitum preparata 15 g. If patients show hyperactivity of fire due to Yin deficiency, added Gardeniae Fructus 12 g to the above-mentioned prescription. If patients show hot flash due to Yin deficiency, added Stellariae Radix 9 g, Lycii Radicis Cortex 12 g, and Testudinis Carapax et Plastrum 12 g to the above-mentioned prescription. If patients show hyperactivity of Yang due to Yin deficiency, added Margaritifera Usta Concha 30 g, Os Draconis preparata 15 g, and Ostreae Concha preparata 15 g to the above-mentioned prescription.. o
Puerariae Lobatae Radix, Rehmanniae Radix preparata, Angelicae Sinensis Radix, Paeoniae Alba Radix, Cornus officinalis, Salviae Miltiorrhizae
Radix et Rhizoma, Anemarrhenae Rhizoma, Cuscutae Semen, Epimedii Brevicornus Herba, Lycii Fructus. p
Polygoni Multiflori Radix, Epimedii Brevicornus Herba, Rehmanniae Radix preparata, Testudinis Carapax et Plastrum, Morindae Officinalis Radix,
Eucommiae Cortex, Dipsaci Asperoidis Radix, Drynariae Rhizoma, Angelicae Sinensis Radix, Diocoreae Rhizoma. q
Pyrolae Callianthae Herba 30 g, Rehmanniae Radix preparata 12 g, Ipomoea batatas 10 g, Spatholobi Caulis 30 g, Achyranthis Bidentatae Radix
15 g, Chaenomelis Speciosae Fructus 15 g, Angelicae Sinensis Radix 12 g, Astragali Radix 20 g, Brassicae Junceae Semen 10 g. If patients show low back pain, added Cibotii Rhizoma to the above-mentioned prescription. If patients shows limbs pain, added Notopterygii Rhizoma et Radix, Angelicae Biserratae Radix to the above-mentioned prescription. If patients feel body heavy and ache, added Atractylodis Macrocephalae Rhizoma to the above-mentioned prescription. If patients show blood stasis and body pain, added Carthami Flos to the above-mentioned prescription. r
Psoraleae Fructus, Dipsaci Asperoidis Radix, Rehmanniae Radix preparata, Cornus officinalis, Astragali Radix, Acanthopanacis Senticosi Radix et
Rhizoma Sue Caulis, Rhei Radix et Rhizoma, Persicae Semen, Salviae Miltiorrhizae Radix et Rhizoma et Rhizoma, Puerariae Lobatae Radix, Bovine-derived powder (dosage information is not available). s
Angelicae Sinensis Radix 10 g, Rehmanniae Radix preparata 10 g, Astragali Radix 30 g, Poria 22 g, Atractylodis Macrocephalae Rhizoma 13 g,
Paeoniae Alba Radix 15 g, Glycyrrhiizae Radix preparata 10 g, Citri Reticulatae Pericarpium 10 g, Diocoreae Rhizoma 12 g, Coicis Semen 15 g, Achyranthis Bidentatae Radix 12 g, Psoraleae Fructus 10 g, Morindae Officinalis Radix 10 g, Testudinis Carapax et Plastrum 10 g. t
Anemarrhenae Rhizoma, Testudinis Carapax et Plastrum, Paeoniae Alba Radix, Astragali Radix, Atractylodis Macrocephalae Rhizoma, Lycii Fructus,
Cynomorii Songarici Herba, Eucommiae Cortex, Aconiti Lateralis Radix preparata, Angelicae Biserratae Radix, Saposhnikoviae Radix, Achyranthis Bidentatae Radix, Phellodendri Chinensis Cortex, Rehmanniae Radix preparata, Angelicae Sinensis Radix, Ginseng Radix, Poria, Cuscutae Semen, Psoraleae Fructus, Dipsaci Asperoidis Radix, Notopterygii Rhizoma et Radix, Gentianae Macrophyllae Radix, Chaenomelis Speciosae Fructus, Panthera tigris Linnaeus. u
Psoraleae Fructus 16 g, Codonopsis Radix 16 g, Drynariae Rhizoma 16 g, Eucommiae Cortex 16 g, Rehmanniae Radix preparata 20 g, Astragali
Radix 20 g, Glycyrrhiizae Radix preparata 6 g. v
Rehmanniae Radix preparata, Cornus officinalis, Astragali Radix, Acanthopanacis Senticosi Radix et Rhizoma Sue Caulis, Rhei Radix et Rhizoma,
Persicae Semen, Puerariae Lobatae Radix (dosage information is not available). w
Rehmanniae Radix preparata, Cornu Cervi Degelatinatum, Epimedii Brevicornus Herba, Dipsaci Asperoidis Radix, Drynariae Rhizoma,
Eupolyphaga seu Steleophaga, Homalomenae Rhizoma, Clematidis Chinensis Radix et Rhizoma, Spatholobi Caulis (dosage information is not available). x
Rehmanniae Radix preparata 12 g, Angelicae Sinensis Radix 12 g, Cornus officinalis 12 g, Poria 12 g, Dipsaci Asperoidis Radix 12 g, Eucommiae
Cortex 10 g, Achyranthis Bidentatae Radix 10 g, Paeoniae Alba Radix 10 g, Acanthopanacis Radicis Cortex 10 g, Citri Grandis Exocarpium 5 g, Manis Squama 6 g, Cornu Cervi Degelatinatum 6 g, Pyritum 6 g. y
Colla Cornus Cervi 18 g, Psoraleae Fructus 18 g, Rehmanniae Radix preparata 10 g, Lycii Fructus 10 g, Colla Cornus Cervi 8 g, Testudinis
Carapax et Plastrum 8 g, Ligustri Lucidi Fructus 8 g, Poria 8 g, Angelicae Sinensis Radix 8 g, Cuscutae Semen 8 g, Dipsaci Asperoidis Radix 8 g, Achyranthis Bidentatae Radix 5 g, Astragali Radix 5 g, Chuanxiong Rhizoma 5 g, Jujubae Fructus 4 pieces. z
Atractylodis Macrocephalae Rhizoma 15g, Poria 15 g, Angelicae Sinensis Radix 15 g, Chuanxiong Rhizoma 15 g, Glycyrrhiizae Radix preparata 15
g, Paeoniae Alba Radix 15 g, Ginseng Radix 30 g, Pinelliae Rhizoma 9 g, Aconiti Lateralis Radix preparata 9 g, Cinnamomi Cassiae Cortex 9 g, Ophiopogonis Radix 25 g, Astragali Radix 25 g, Cistanches Deserticolae Herba 25 g, Rehmanniae Radix preparata 25 g. aa
Epimedii Brevicornus Herba, Psoraleae Fructus, Cornus officinalis, Rehmanniae Radix preparata, Chuanxiong Rhizoma, Notoginseng Radix et
Rhizoma (dosage information is not available). ab
Angelicae Biserratae Radix 12 g, Taxilli Herba 12 g, Notopterygii Rhizoma et Radix 12 g, Eucommiae Cortex 10 g, Achyranthis Bidentatae Radix
10 g, Rehmanniae Radix preparata 10 g, Chuanxiong Rhizoma 10 g, Angelicae Sinensis Radix 10 g, Paeoniae Rubra Radix 10 g, Codonopsis Radix 10 g, Poria 10 g, Gentianae Macrophyllae Radix 10 g, Chaenomelis Speciosae Fructus 10 g, Saposhnikoviae Radix 10 g, Cinnamomi Cassiae Cortex 10 g, Asari Radix et Rhizoma 6 g, Glycyrrhiizae Radix preparata 6 g. If patients show Qi Deficiency, added Astragali Radix to the above-mentioned prescription. If patients show Yin deficiency, added Lycii Fructus, Cornus officinalis to the above-mentioned prescription. If patients show Yang deficiency, added Morindae Officinalis Radix and Epimedii Brevicornus Herba to the above-mentioned prescription. If patients feel pain, added Aconiti Radix, and Aconiti Kusnezoffii Radix to the above-mentioned prescription. If patients feel cold, added Aconiti Lateralis Radix preparata, and Cistanches Deserticolae Herba to the above-mentioned prescription. If damp evil invades body, added Stephaniae Tetrandrae Radix and Coicis Semen to the above-mentioned prescription. If patients show dyspepsia, added Jiao Sanxian (Shenqu, Crataegi Pinnatifidae Fructus preparata, and Hordei Germinatus Fructus preparata) to the above-mentioned prescription. If disease occurs with long duration, added Scolopendra and Scorpio to the above-mentioned prescription. ac
Rehmanniae Radix preparata 30 g, Cornus officinalis 12 g, Epimedii Brevicornus Herba 12 g, Eucommiae Cortex 12 g, Cuscutae Semen 12 g,
Spatholobi Caulis 30 g, Salviae Miltiorrhizae Radix et Rhizoma et Rhizoma 30 g, Dipsaci Asperoidis Radix 15 g, Colla Cornus Cervi 15 g, Drynariae Rhizoma 15 g, Diocoreae Rhizoma 15 g, Angelicae Sinensis Radix 15 g, Achyranthis Bidentatae Radix 15 g, Chuanxiong Rhizoma 15 g, Angelicae Biserratae Radix 10 g, Hirudo 10 g, Alismatis Rhizoma 10 g, Glycyrrhiizae Radix preparata 6 g. ad
Rehmanniae Radix preparata, Diocoreae Rhizoma, Cornus officinalis, Poria, Moutan Radicis Cortex, Alismatis Rhizoma, Cinnamomi Ramulus,
Aconiti Lateralis Radix Preparata, Achyranthis Bidentatae Radix, Plantaginis Semen. ae
Aconiti Lateralis Radix preparata, Cinnamomi Ramulus, Rehmanniae Radix preparata, Cornus officinalis, Diocoreae Rhizoma, Alismatis Rhizoma,
Moutan Radicis Cortex, Poria. af
Rehmanniae Radix preparata, Diocoreae Rhizoma, Cuscutae Semen, Epimedii Brevicornus Herba.
ag
Rehmanniae Radix preparata, Phryma leptostachya L. subsp. asiatica (Hara) Kitamura, Drynariae Rhizoma, Epimedii Brevicornus Herba,
Alismatis Rhizoma. ah
Curculiginis Rhizoma 10 g, Epimedii Brevicornus Herba 10 g, Cornu Cervi Degelatinatum 10 g, Morindae Officinalis Radix 10g, Dipsaci
Asperoidis Radix 10 g, Drynariae Rhizoma 10 g, Rehmanniae Radix preparata 10 g, Atractylodis Macrocephalae Rhizoma preparata 10 g, Achyranthis Bidentatae Radix 10 g, Salviae Miltiorrhizae Radix et Rhizoma 10 g, Lycii Fructus 15 g, Placenta Hominis 5 g, Testudinis Carapax et Plastrum 30 g, Astragali Radix preparata 30 g, Os Draconis 30 g, Ostreae Concha 30 g.
ai
Astragali Radix 30 g, Rehmanniae Radix preparata 24 g, Curculiginis Rhizoma 12 g, Epimedii Brevicornus Herba 12 g, Angelicae Sinensis Radix
15 g, Anemarrhenae Rhizoma 9 g, Phellodendri Chinensis Cortex 6 g, Morindae Officinalis Radix 9 g, Pyritum 24 g, Os Draconis 24 g, Ostreae Concha 24 g, Galli Gigeriae Endothelium Coreneum 9 g, Colla Cornus Cervi 12 g, Myristicae Semen 6 g. If patients show Yang deficiency, added Cistanches Deserticolae Herba to the above-mentioned prescription. If patients show deficiency of both Qi and blood, added Codonopsis Radix, Poria, Asini Corii Colla, and Placenta Hominis to the above-mentioned prescription. If patients show blood stasis, added Eupolyphaga, Notoginseng Radix to the above-mentioned prescription. aj
Anemarrhenae Rhizoma, Phellodendri Chinensis Cortex, Rehmanniae Radix preparata, Cornus officinalis, Moutan Radicis Cortex, Diocoreae
Rhizoma, Poria, Alismatis Rhizoma. ak
Epimedii Brevicornus Herba 15 g, Curculiginis Rhizoma 10 g, Psoraleae Fructus 15 g, Rehmanniae Radix preparata 15 g, Cornus officinalis 10 g,
Ligustri Lucidi Fructus 15 g, Lycii Fructus 15 g, Ginseng Radix 10 g, Atractylodis Macrocephalae Rhizoma 10 g, Poria 10 g, Cuscutae Semen 15 g, Eucommiae Cortex 15 g, Angelicae Sinensis Radix 12 g. al
Rehmanniae Radix preparata 30 g, Lycii Fructus 30 g, Carthami Flos 10 g, Chuanxiong Rhizoma 12 g, Dipsaci Asperoidis Radix 15 g, Cornus
officinalis 12 g, Eucommiae Cortex 15 g, Paeoniae Rubra Radix 15 g, Astragali Radix 20 g, Angelicae Sinensis Radix 12 g, Diocoreae Rhizoma 15 g, Astragali Radix 15 g, Cuscutae Semen 15 g, Colla Cornus Cervi 25 g, Testudinis Carapax et Plastrum 15 g, Salviae Miltiorrhizae Radix et Rhizoma 15 g, Achyranthis Bidentatae Radix 10 g, Cornus officinalis 10 g, Epimedii Brevicornus Herba 10 g, Atractylodis Macrocephalae Rhizoma 10 g. am
Rehmanniae Radix preparata, Lycii Fructus, Colla Cornus Cervi, Cornus officinalis, Eucommiae Cortex, Angelicae Sinensis Radix, Paeoniae Alba Radix,
Cinnamomi Ramulus, Achyranthis Bidentatae Radix, Diocoreae Rhizoma, Citri Reticulatae Pericarpium, Amomi Fructus. an
Rehmanniae Radix, Diocoreae Rhizoma, Cornus officinalis, Alismatis Rhizoma, Poria, Cinnamomi Cassiae Cortex, Epimedii Brevicornus Herba,
Colla Cornus Cervi, Colla Carapacis et Plastri Testudinis, Morindae Officinalis Radix, Drynariae Rhizoma, Sparganii Rhizoma, Hirudo (dosage information is not available). ao
Epimedii Brevicornus Herba, Rehmanniae Radix preparata, Diocoreae Rhizoma, Cornus officinalis, Morindae Officinalis Radix, Aconiti Lateralis
Radix preparata, Colla Cornus Cervi, Cuscutae Semen, Eucommiae Cortex, Cinnamomi Cassiae Cortex, Lycii Fructus (dosage information is not available). ap
Rehmanniae Radix preparata 9 g, Glycyrrhiizae Radix preparata 9 g, Eucommiae Cortex 15 g, Achyranthis Bidentatae Radix 15 g, Paeoniae Alba
Radix 15 g, Poria 15 g, Diocoreae Rhizoma 10 g, Astragali Radix 10 g, Alismatis Rhizoma 10 g, Cornus officinalis 10 g, Cibotii Rhizoma 10 g, Angelicae Sinensis Radix 10 g, Chuanxiong Rhizoma 10 g, Coicis Semen 30 g, Angelicae Biserratae Radix 12 g. If patients shows deficiency of kidney essence, added Colla Cornus Cervi, Psoraleae Fructus, Lycii Fructus, Dipsaci Asperoidis Radix, Epimedii Brevicornus Herba, Curculiginis Rhizoma, Cuscutae Semen, and Drynariae Rhizoma to the above-mentioned prescription. If patients show deficiency of Qi and blood, added Codonopsis Radix, Astragali Radix, Atractylodis Macrocephalae Rhizoma, and Salviae Miltiorrhizae Radix et Rhizoma to the above-mentioned prescription. If patients feel pain, added Corydalis Yanhusuo Rhizoma, Myrrha, and Spatholobi Caulis to the above-mentioned prescription. If patients show spontaneous sweating, added Os Draconis to the above-mentioned prescription. If patients show Yin deficiency and fire hyperactivity, added Anemarrhenae Rhizoma, and Phellodendri Chinensis Cortex to the above-mentioned prescription. aq
Drynariae Rhizoma 15 g, Psoraleae Fructus 15 g, Paeoniae Alba Radix 15 g, Rehmanniae Radix preparata 12 g, Chuanxiong Rhizoma 12 g,
Clematidis Chinensis Radix et Rhizoma 9 g, Epimedii Brevicornus Herba 9 g, Angelicae Sinensis Radix 9 g, Pyrolae Callianthae Herba 9 g, Glycyrrhiizae Radix preparata 6 g. ar
Rehmanniae Radix preparata 30 g, Diocoreae Rhizoma 15 g, Cornus officinalis 15 g, Epimedii Brevicornus Herba 18 g, Testudinis Carapax et
Plastrum 15 g, Cistanches Deserticolae Herba 10 g, Cuscutae Semen 10 g, Lycii Fructus 18 g, Drynariae Rhizoma 10 g, Colla Cornus Cervi 10 g, Achyranthis Bidentatae Radix 10 g, Notoginseng Radix 3 g, Salviae Miltiorrhizae Radix et Rhizoma 15 g. If patients with heat due to Yin deficiency, added Anemarrhenae Rhizoma, and Phellodendri Chinensis Cortex to the above-mentioned prescription. If patients show Yang deficiency, added Morindae Officinalis Radix, Aconiti Lateralis Radix preparata, and Cinnamomi Cassiae Cortex to the above-mentioned prescription. If patients show Qi deficiency, added Astragali Radix to the above-mentioned prescription. If patients show blood deficiency, added Angelicae Sinensis Radix, and Asini
Corii Colla to the above-mentioned prescription. If patients show lumbar genu aching and limp, added Eucommiae Cortex, and Dipsaci Asperoidis Radix to the above-mentioned prescription. If patients feel pain, added Olibanum, Myrrha to the above-mentioned prescription. as
Anemarrhenae Rhizoma 20 g, Phellodendri Chinensis Cortex 10 g, Diocoreae Rhizoma 15 g, Cornus officinalis 15 g, Astragali Radix 20 g, Alismatis
Rhizoma 15 g, Poria 20 g, Rehmanniae Radix preparata 10 g, Testudinis Carapax et Plastrum 10 g. If patients show lumbago, added Dipsaci Asperoidis Radix, Eucommiae Cortex, and Taxilli Herba to the above-mentioned prescription. If patients feel whole body pain, added Notopterygii Rhizoma et Radix, Angelicae Biserratae Radix, Spatholobi Caulis, and Trachelospermi Jasminoidis Caulis to the above-mentioned prescription. If patients show hot flashes and night sweats, added Os Draconis, Ostreae Concha, and Gentianae Macrophyllae Radix to the above-mentioned prescription. If patients feel dizzy, added Uncariae Ramulus cum Uncis, and Tribuli Fructus to the above-mentioned prescription. at
Epimedii Brevicornus Herba, Rehmanniae Radix preparata, Angelicae Sinensis Radix, Psoraleae Fructus, Achyranthis Bidentatae Radix, Cornus
officinalis (dosage information is not available). au
Rehmanniae Radix preparata 15 g, Diocoreae Rhizoma 15 g, Astragali Radix 15 g, Lycii Fructus 15 g, Cuscutae Semen 15 g, Colla Cornus Cervi
15 g, Testudinis Carapax et Plastrum 15 g, Salviae Miltiorrhizae Radix et Rhizoma 15 g, Achyranthis Bidentatae Radix 10 g, Cornus officinalis 10 g, Epimedii Brevicornus Herba 10 g, Atractylodis Macrocephalae 10 g.
Table 2. TCM herbs frequent clinically co-prescribed with Rehmanniae Radix (preparata) for the management of osteoporosis.
Accepted medicinal plant name
Latin name of herb
Frequency
Epimedium Brevicornu Maxim.
Epimedii Brevicornus Herba
75
Astragalus Mongholicus Bunge
Astragali Radix
51
Cornus officinalis Siebold & Zucc.
Cornus officinalis
46
Angelica Sinensis (Oliv.) Diels
Angelicae Sinensis Radix
42
Drynaria Roosii Nakaike
Drynariae Rhizoma
42
Salvia Miltiorrhiza Bunge.
Salviae Miltiorrhizae Radix et Rhizoma
40
Dioscorea Opposita Thunb.
Diocoreae Rhizoma
40
Poria cocos˄Schw.˅Wolf
Poria
38
Achyranthes Bidentata Blume
Achyranthis Bidentatae Radix
35
Cullen Corylifolium (L.) Medik.
Psoraleae Fructus
34
4. Phytochemistry of Rehmanniae Radix Currently, there have been more than 140 compounds isolated and characterized from Rehmanniae Radix that included monoterpenoids, phenethyl alcohol glycosides, triterpenes, flavonoid glycosides, phenolic acid glycosides, lignans, and Rehmannia glutinosa polysaccharides, etc (Fu and Du, 2015; Li and Meng, 2015; Liu, 2013). The main constituents are listed in Figure 2. Iridoid glycosides are considered to be one of abundant monoterpenoids and responsible for the pharmacological actions of Rehmanniae Radix. The identified monoterpenoids are also listed as the followings: catalpol (1), rehmannioside A (2), rehmannioside B (3), rehmannioside C (4), rehmaionoside A (5), rehmaionoside B (6), rehmaionoside C (7), rehmaglutin A (8), rehmaglutin B (9), rehmaglutin D (10), rehmaglutin C (11), ajugol (12), rehmannioside D (13), and geniposide (14), gentistic acid (15), versulin (16), oleanolic acid (17). These identified new compounds may provide novel chemical scaffolds for the development of novel anti-osteoporotic drugs, and also offer great potential for compound drugs which may exhibit better anti-osteoporotic effects compared to the individual compounds. Catalpol is one of most studied ingredients of Rehmanniae Radix and has been reported to exhibit protective effects on diabetes (Bao et al., 2016; Zhou et al., 2015a), neurovascular diseases (Huang et al., 2016a), osteoporosis (Lai et al., 2015), breast cancer (Liu et al., 2015), ovarian cancer (Gao et al., 2014), atherosclerosis (Liu and Zhang, 2015) and lung injury (Fu et al., 2014) in animals.
In addition, among the isolated constituents from Rehmanniae Radix, Rehmannia glutinosa polysaccharides are also one of the main active constituents of Rehmanniae Radix and composed of monosaccharides such as rhamnose, glucose, galactose, mannose, xylose and arabinose (Wang et al., 2015b). So far, it has been demonstrated that Rehmannia glutinosa polysaccharides exhibited beneficial activities in improving glucolipid metabolism (Wu et al., 2011; Zhou et al., 2015b), immunology (Huang et al., 2013b; Huang et al., 2014) and redox hemostasis (Zhang et al., 2012). Furthermore, rehmannioside C (4), rehmaionoside A (5) and oleanolic acid (17) (Pollier and Goossens, 2012) have been demonstrated to possess hepatoprotection activities. Ajugol (12), gentistic acid (15) (Liu, 2013) and oleanolic acid (17) (Anouar el et al., 2015) have the ability of anti-oxidation. Versulin (16) (Zhang et al., 2015b) and oleanolic acid (17) (Zhang et al., 2014) have the capacity of inhibiting tumor growth. Oleanolic acid (17) (Mengoni et al., 2002) has been demonstrated to exhibit weak anti-HIV activity. Moreover, the art of processing may affect the constituents of Rehmannia Radix. It has been demonstrated that the total amount of Rehmannia glutinosa polysaccharides was decreased from 16.59% in Rehmanniae Radix to 3.33% in Rehmanniae Radix preparata determined by phenol-sulphuric acid method (Ji et al., 1999). The content of total sugar was reduced from 44.93% in Rehmanniae Radix to 16.29% in Rehmanniae Radix preparata. However, the art of processing significantly contributes to increasing the extraction ratio of crude polysaccharide (17.14% in the
Rehmaniae Radix and 26.72% in Rehmanniae Radix preparata) (Liu et al., 2009). In addition, the level of acteoside was decreased from 0.093% in Rehmanniae Radix to 0.04% in Rehmanniae Radix preparata. The contents of stachyose, iridoid glycoside and catalpol were gradually decreased, while 5- hydroxymethylfurfural was increased after processing (Kubo et al., 1996; Liu et al., 2007). As for trace elements, the contents of Cl, K, Na, Sr and Mn were marginally decreased after processing, but the content of Cu was increased (Lu, 2008). 5. The pharmacokinetics of Rehmanniae Radix Various studies have been performed to investigate the pharmacokinetics profiles of Rehmanniae Radix and its active ingredients in animal experiments. Tables 3 summarized the recent pharmacokinetic studies on Rehmanniae Radix with the emphasis on the most abundant components of iridoid glucosides, such as catalpol, aucubin and acetoside. The pharmacokinetics of the water extract of Rehmanniae Radix in normal (Zhong et al., 2013) rats and in rats with chronic kidney disease (CKD) (Zhao et al., 2015), the results revealed that the ingredients were widely distributed after administration. Furthermore, catalpol, ajugol and acetoside were easily detected in the plasma and accepted as main active ingredients of Rehmanniae Radix. The concentrations of aucubin, dihydrocatalpol, rehmannioside A (or rehmannioside B/melittoside) and rehmannioside D were very low in plasma in rats (Zhong et al.,
2013). Rehmannia glutinosa polysaccharides were not detected in the plasma owing to that they are vulnerable to be digested by gut microorganisms in rats. The advantage of plasma concentration of catalpol and acteoside in CKD rats over in normal rats accounts for improving kidney function of this herb (Zhao et al., 2015). In an experiment performed by Dr. Ju et al. demonstrated that different administration approaches significantly affected the absorption, distribution and elimination of Rehmanniae Radix (Liu, 2014). They found that T1/2 of catalpol via oral administration (T1/2z=1.39 ± 0.22 h) was much longer than via intramuscular injection (T1/2z=0.84 ± 0.41 h) and intravenous injection (T1/2z=0.68 ± 0.24 h). The Tmax of intramuscular administration (0.25 ± 0.1 h) was much shorter than that of intragastric administration (1.66 ± 0.58 h). The intramuscular administration has a better bioavailability (71.63%) than that of oral gavage (49.38%). The results indicated that catalpol was unstable in the gastrointestinal tract in rats. The impacts of different administration routes on catalpol metabolism were also been confirmed by two independent labs (Lu et al., 2009; Wang et al., 2012). In addition, the pharmacokinetics properties of the mixed substances (2.0 mg/kg aucubin, 2.0 mg/kg ajugol and 10.0 mg/kg catalpol) revealed that the mixture was also widely distributed in the kidney, liver, heart, spleen and lung (Wang et al., 2012). And the kidney had the highest concentrations. Further studies demonstrated that catalpol and aucubin could pass the blood brain barrier (Wang et al., 2012), but ajugol could
not (Xue et al., 2015). The aucubin was absorbed slowly (T1/2=7.38 ± 2.9 h) (Xu et al., 2012), and verproside was rapidly eliminated (T1/2=5.5 ± 1.1 min) (Park et al., 2009). In short, the ingredients of Rehmanniae Radix were widely distributed after administration. Catalpol, ajugol and acetoside were assumed as the main contributors to pharmacological effects of this herb. However, emerging evidence indicates that Rehmannia glutinosa polysaccharides may also play important roles in the treatment of diseases. Therefore, the future pharmacokinetic studies are required to analyze the absorption, distribution, metabolism and elimination of Rehmannia glutinosa polysaccharides by improving the sensitivity of the analytic approach.
Table 3. The pharmacokinetics properties of Rehmanniae Radix and its ingredients in animals Spices
Administration route Main pharmacokinetics parameters and dose
Findings
Ref.
SD rats, male
Gavage (p.o.);
Catalpol and ajugol were found to
(Zhong al., 2013)
and female.
For catalpol: −1
6 g/kg body weight (BW),
Cmax (ng·mL ): 2349.05 ± 1438.34
be the main compounds after
water extracts of Rehmanniae
Tmax (h): 1.00 ± 0.00
Rehmanniae
Radix
−1
AUC0-∞ (ng·h·mL ): 4407.58 ± 2734.89 −1
AUC0−t (ng·h·mL ): 4401.39 ± 2732.72 −1
Radix
administration, and both of them excreted
rapidly. of
Plasma
Ke (h ): 0.90 ± 0.29
concentrations
T1/2 (h): 0.86 ± 0.32
dihydrocatalpol, rehmannioside A
MRT0−∞ (h): 1.72 ± 0.12
(or rehmannioside B/ melittoside)
−1
aucubin,
V/F (L·kg ): 2.51 ± 0.95
and rehmannioside D were very
CL/F (L·h−1·kg−1): 2.40 ± 1.44
low.
For ajugol:
polysaccharides −1
Rehmannia
glutinosa were
not
Cmax (ng·mL ): 104.25 ± 82.05
detected in the plasma owing to
Tmax (h): 1.00 ± 0.00
that they are vulnerable to be
−1
AUC0-∞ (ng·h·mL ): 226.66 ± 188.38
et
digested by gut microorganisms.
−1
AUC0−t (ng·h·mL ): 219.77 ± 187.43 Ke (h−1): 0.82 ± 0.31 T1/2 (h): 0.96 ± 0.37 MRT0−∞ (h): 1.98 ± 0.26 V/F (L·kg−1): 15.30 ± 13.0 CL/F (L·h−1·kg−1): 11.27 ± 7.55 Normal
and
chronic
kidney
disease
(CKD)
male SD rats
p.o.;
For Catalpol:
8.0 g/kg BW, water extracts of
Normal Rats:
Rehmanniae Radix
Rapid absorption and elimination,
(Zhao
wide distribution in both CKD
al., 2015)
−1
and normal rats.
−1
Faster
AUC0−t (μg·min·mL ): 439.71 ± 42.34 AUC0-∞ (μg·min·mL ): 444.46 ± 40.70 −1
rates
of
Cmax (μg·mL ): 2.14 ± 0.13
metabolism
Tmax (min): 60.50 ± 15.00
normal rats.
T1/2 (min) : 84.00 ± 13.42
Higher plasma concentration in
CLZ/F (L·min−1·kg−1): 0.02 ± 0.00
CKD rats.
CKD rats˖ AUC0−t (μg·min·mL−1): 1627.83 ± 241.40 AUC0-∞ (μg·min·mL−1): 1658.49 ± 252.24 Cmax (μg·mL−1): 7.94 ± 1.06 Tmax (min): 54.00 ± 8.22 T1/2 (min): 118.28 ± 39.13 CLZ/F (L·min−1·kg−1): 0.01 ± 0.00 For Acetoside: Normal Rats:
and
elimination, excretion
in
et
AUC0−t (μg·min·mL−1): 32.69 ± 7.63 AUC0-∞ (μg·min·mL−1): 34.01 ± 7.64 Cmax (μg·mL−1): 0.19 ± 0.05 Tmax (min) : 15.00 ± 7.45 T1/2 (min) : 150.56 ± 59.97 CLZ/F (L·min−1·kg−1): 0.55 ± 0.14 CKD rats˖ AUC0−t (μg·min·mL−1): 61.15 ± 10.56 AUC0-∞ (μg·min·mL−1): 73.27 ± 15.50 Cmax(μg·mL−1): 0.31 ± 0.05 Tmax (min): 24.00 ± 13.42 T1/2 (min): 298.61 ± 96.47 CLZ/F (L·min−1·kg−1): 0.27 ± 0.07 Male
Sprague
Dawley rats
Intravenous injection (i.v.);
AUC0−t (μg·min·mL−1): 31.2 ± 20.8
The percentage of verproside
(Park et al.,
2mg/kg of verproside.
T1/2 (min): 5.5 ± 1.1
excreted in urine for 24 h as an
2009)
−1
−1
CL (mL·min ·kg ): 89.8 ± 55.1 −1
Vss (mL·kg ): 489 ± 264
intact drug was 6.5 ± 2.9% of the original dose.
MRT (min): 5.5 ± 1.1 Male
Sprague
Dawley rats
i.v.;
In cerebrospinal fluid (CSF):
Rapidly distributed into the CSF;
(Wang
6 mg/kg of catapol.
AUC0−5 (ng·h·mL−1): 594.5 ± 81.3
Slow elimination;
al., 2012)
−1
AUC0-∞ (μg·min·mL ): 671.5 ± 109.1 −1
Cmax(ng·mL ): 675.9 ± 198.4
et
Easily passed the blood–brain barrier (BBB).
Tmax (h): 0.08 ± 0.02 T1/2 (h) : 1.52 ± 0.74 MRT0-∞ (h): 2.12 ± 1.0 In plasma: AUC0−5 (ng·h·mL−1): 11432.3 ± 1582.5 AUC0-∞ (μg·min·mL−1) : 11532.9 ± 1643.0 Cmax (ng·mL−1):23617.4 ± 914.7 T1/2 (h) : 0.71 ± 0.23 MRT0-∞ (h): 2.12 ± 1.0. SD rats
i.v.; 1 mL/100 g mixed substances
For Aucubin: −1
AUC0−t (μg·h·L ): 1951.409 ± 242.802 −1
Widely distributed in kidney,
(Xue et al.,
heart, liver, spleen and lung.
2015)
containing 2.0 mg/kg Aucubin,
AUC0−∞ (μg·h·L ): 1953.956 ± 241.516
Tissue distributions in order of
2.0 mg/kg Ajugol and 10.0
MRT (h): 0.577 ± 0.104
Ckidney > Cliver.
mg/kg Catalpol
T1/2 ( h) : 1.073 ± 0.241
Slow elimination;
−1
V (L·kg ): 1.621 ± 0.528
Aucubin and Catalpol could pass
CL (L·h−1·kg−1): 1.035 ± 0.122
BBB.
For Ajugol:
No Ajugol was found in brain. −1
AUC(0−t) (μg·min·L ): 5743.547 ± 795.734 AUC0−∞ (μg·h·L−1): 5747.104 ± 796.556
MRT (h): 0.804 ± 0.064 T1/2 ( h) : 0.746 ± 0.099 V (L·kg−1): 0.380 ± 0.075 CL (L·h−1·kg−1): 0.354 ± 0.054 For Catalpol: AUC (0−t) (μg·min·L−1): 5951.125 ± 1247.247 AUC0−∞ (μg·h·L−1): 5954.076 ± 1248.205 MRT (h): 0.0454 ± 0.140 T1/2 ( h) : 0.984 ± 0.229 V (L·kg−1): 0.348 ± 0.075 CL (L·h−1·kg−1): 0.348 ± 0.075 Wistar rats, male and female
p.o; 50 mg/kg of Catalpol
T1/2 (h): 1.212 ± 0.388
Short half-life (less than 1.5 h).
(Lu et al.,
−1
V1/F (L·kg ): 1.428 ± 0.681 −1
2009)
−1
CL/F (L·h ·kg ): 0.824 ± 0.317 T1/2Ka (h): 0.53 ± 0.302 AUC0−∞ (ng·h·mL−1) : 69520 ± 22927 MRT0−∞ (h): 3.273 ± 0.365 Tmax (h): 1.333 ± 0.408 Cmax (ng·mL-1) : 23318 ± 10468 Male
Sprague–
Dawley rats
p.o.; 50 mg/kg of Aucubin
Tmax (h): 1.08 ± 0.5
Rapid
−1
Cmax (ng·mL ) :4016 ± 2394
absorption
and
slow
(Xu et al.,
elimination.
2012)
T1/2: p.o.> i.v.> intramuscular
(Liu, 2014)
−1
AUC0–24 (ng· h·mL ) : 11026 ± 4671 AUC0–1 (ng h·mL−1): 11305 ± 4627 T1/2 (h): 7.38 ± 2.9 MRT0–24 (h): 3.16 ± 2.9 MRT0–1 (h): 4.08 ± 0.9 Male
Sprague–
Dawley rats
p.o.; 50mg/kg of Catalpol
Tmax (h): 1.66 ± 0.58 −1
Cmax (mg·mL ) :24.83 ± 0.58 −1
AUC0–24 (ng· h·mL ) : 95.23 ± 10.15 T1/2 (h): 1.39 ± 0.22
Bioavailability: i.m.> p.o.
MRT0−∞ (h): 3.23 ± 0.37
Catalpol
−1
Vz/F (L·kg ): 1.17 ± 0.16 F% : 49.38 ± 10.54 i.v.;
Tmax (h): 0.25 ± 0.1
50mg/kg of Catalpol
Cmax (mg·mL−1) :80.43 ± 5.59 AUC0–24 (mg· h·mL−1) : 150.23 ± 20.87 T1/2 (h): 0.68 ± 0.24 MRT0−∞ (h): 1.62 ± 0.20 Vz/F (L·kg−1): 0.40 ± 0.20 F%: 71.63 ± 10.28
i.m.;
administration˄i.m.˅ MRT: p.o.> i.v.
Tmax (h): --
was
unstable
gastrointestinal tract.
in
50mg/kg of Catalpol
Cmax (ng·mL−1) :110.82 ± 4.10 AUC0–24 (ng· h·mL−1) : 195.79 ± 20.51 AUC0–1 (ng h·mL−1): 11305 ± 4627 T1/2 (h): 0.84 ± 0.41 MRT0−∞(h): 1.71 ± 0.29 Vz/F (L·kg−1): 0.57 ± 0.19 F% : -
6. Anti-bone loss and pro-anabolic activities of Rehmanniae Radix and its constituents in osteoporosis Various in vitro and in vivo experiments were used to understand the effects of Rehmanniae Radix and its purified compounds in preventing the development of osteoporosis. We summarized the possible mechanisms of this herb involved in regulating osteoporosis in preclinical studies as shown in Figure 3. Firstly, the investigators found that the water extracts of Rehmanniae Radix (300 mg/kg treatment for 8 weeks (Lim and Kim, 2013), or 13.75 g/kg and 27.5 g/kg for 3 month (Li et al., 2015) significantly increased BMD in the femurs and lumbar (17.5% and 16.4%, respectively), and markedly enhanced integrin β1 mRNA expression, decreased the serum
alkaline
phosphatase
(ALP)
level,
urinary
Ca2+
and
urinary
deoxypyridinoline/creatinine without affecting the weights of body and uterus, and the estradiol (E2) level in ovariectomized (OVX) rats. Furthermore, the authors claimed that Rehmanniae Radix was more efficient in decreasing bone loss than that of an equivalent dose of steamed roots of Rehmannia glutinosa (Gaertn.) DC. in OVX rats (Lim and Kim, 2013). The quantitative
authentication of Rehmanniae Radix performed by a high performance liquid chromatography revealed that Rehmanniae Radix was standardized to contain 5.4 mg/g of catalpol. Therefore, the effects of Rehmanniae Radix on bone protection may be associated with its high contents of the iridoid glycosides such as catalpol. Furthermore, in another in vivo experiment demonstrated that the water extracts of Rehmanniae Radix preparata (0.132 g/rats) treatment for 4 weeks after ovariectomy were demonstrated to attenuate BMD decrease in proximal tibia metaphysis and to increase the cortical bone thickness and trabeculation of the bone marrow spaces in rats (Oh et al., 2003). In addition, Rehmanniae Radix preparata possessed the ability to reduce body weight gain and serum level of cholesterol in OVX rats (Cho, 2005). Further, the water extracts of Rehmanniae Radix preparata had also been demonstrated to promote osteoblastic cells (MG63) proliferation (0.096 to 12 μg/ml), enhance ALP activity (0.48 and 12 μg/ml) in osteoblastic cells (HOS cells), increase mRNA levels of collagen, ALP, and osteopontin in primary osteoblastic cells (12 μg/ml), increase Runx2 gene in osteoblastic cells (C2C12 cells) (60 μg/ml), and enhance osteoprotegerin expression in osteoblastic cells (60 μg/ml). In addition, treatment with the water extracts of Rehmanniae Radix (0.096 to 60 μg/ml) dose-dependently decreased the number of tartrate resistant acid phosphatase (TRAP) positive marrow mononuclear cells and reduced resorption pit formation in osteoclastic precursor cells (Cho, 2005). These results revealed that the water extracts
of Rehmanniae Radix improved osteoporosis through promoting osteoblast formation and inhibiting osteoclast activity. Moreover, in order to compare the effects of different extracts of Rehmanniae Radix on improving bone quality in OVX rats, Zhang Xin (Zhang, 2014) further divided the extracts into four parts, which included fresh Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol (FREE), fresh Rehmanniae Radix by aqueous extracted (FREW), dried Rehmanniae Radix alcohol extraction refluxing extracted by 95% ethanol (DREE), dried Rehmanniae Radix by aqueous extracted (DREW). The results demonstrated that all the extracts of Rehmanniae Radix treatment for 40 weeks increased the levels of serum E2 and calcitonin (CT), and decreased the levels of serum ALP and TRAP as well as increased bone stiffness in OVX rats as compared to untreated OVX rats. In addition, the extracts of Rehmanniae Radix possessed the ability of inhibiting endometrial atrophy and loss, and of improving the relative expansion of rat bone marrow cavity and trabecular thinning and sparse in OVX rats. Among four different extracts, FREE (75, 150 and 300 mg/kg/d) and FREW (250 mg/kg/d) were significantly higher in improving the biomarkers in OVX rats than DREE (125, 250 and 500 mg/kg/d) and DREW (400 mg/kg/d). DREE (250 and 500 mg/kg/d) and FREE (300 mg/kg/d) were more efficient in improving BMD and bone mechanical strength than FREW and DREW. Overall, the investigators claimed that dried root of Rehmannia glutinosa (Gaertn.) DC. was
the preferred option to in the management of osteoporosis. This was consistent with Dr. Lim (Lim and Kim, 2013) and Dr. Li’s (Li et al., 2015) observations. To further explore the potential estrogen-like effect, Jiang et al (Jiang, 2013) evaluated the different preparations of this herb, including fresh Rehmanniae Radix, Rehmanniae Radix, Rehmanniae Radix preparata and the juice of fresh Rehmanniae Radix in alterations of uterus weights in mice as well as MCF-7 and MG63 cells proliferation. The results demonstrated that FREW and DREW as well as FREE may have estrogen-like effect evidenced by increasing uterus weights in mice. In addition, FREE (10-4mg/mL~10-1mg/mL) increased MCF-7 cells proliferation at 24h and 48h, and inhibited MCF-7 cells proliferation at 72h. Further, FREE exerted estrogen-like effect through the regulation of ERβ rather than ERα evidenced by the fact that 1 mg/mL of FREE increased ERα protein expression, whereas only 10-3 mg/mL of FREE could promote ERβ protein expression in MCF-7 cells. Moreover, FREE (10-3 mg/mL~10-1 mg/mL) induced an increase in MG63 cells proliferation at 24h and 36h. Further, FREE increased ALP activity in MG63 cells at 24h, 48h and 72h, and the addition of ICI182780 to MG63 cells, an estrogen receptor antagonist, significantly blocked the stimulatory effect of this extract. Therefore, the author claimed that FREE promoted MG63 osteoblasts differentiation and mineralization through regulation of ERβ expression. Thus, cautions must be excised that Rehmanniae Radix may have estrogen-like side effects in the management of osteoporosis.
Catalpol, one of the active compounds isolated from Rehmanniae Radix, has also been demonstrated to improve bone health in OVX mice. The authors found that oral administration of catalpol (10, 20 and 40 mg/kg) for 12 weeks pronouncedly attenuated OVX induced-bone loss by decreasing Th1/Th2 ratio via increasing the mRNA and protein expressions of T-bet and decreasing the mRNA and protein expressions of GATA-3 (Lai et al., 2015). It was reported that Th1 cells produced pro-inflammatory cytokines such as interferon-γ, interleukin (IL)-12 and tumor necrosis factor-α, which strongly promoted the formation of osteoclast. In contrast, Th2 cells secreted IL-4 and IL-10 which inhibited osteoclast formation (Fujii et al., 2012). In vitro, catalpol has also been demonstrated to promote osteoblasts proliferation (1×10 -3 M and 1×10 -7‒1×10-9 M), enhance ALP activity (1×10-3 and 1×10-7 M), improve osteocalcin synthesis and secretion (1×10-3 and 1×10-5‒1×10-6 M), and boost osteoblast mineralization in primary culture osteoblasts (Jia et al., 2015) and MC3T3-E1 cells (Wu et al., 2010). Therefore, it can be concluded that catalpol exhibited bone protective effect through promoting osteoblastogenesis and inhibiting osteoclastogenesis. In summary, in vivo and in vitro experiments demonstrated that Rehmanniae Radix was effective for preventing the development of osteoporosis. According to the results obtained from the current studies, the dried root of Rehmannia glutinosa (Gaertn.) DC was deemed as a better option for improving bone quality over Rehmanniae Radix preparata. However, classical TCM theories claimed that
Rehmanniae Radix preparata was proficiency in improving bone health owing to its strong ability of tonifying kidney and enriching blood. The most likely explanation for the low efficacy of Rehmanniae Radix preparata was that the art of processing was not strictly conformed to the protocol advised by the Chinese pharmacopeia. Although Rehmanniae Radix did not increase estrogen level at 8 weeks in OVX rats, Rehmanniae Radix treatment did upregulate estrogen level at 20 weeks and 40 weeks as well as increase uterus weights in mice. The available data may inform us that long term administration of Rehmanniae Radix still may have the potentials to increase risk of breast and cervical cancers. Catalpol is the only isolated effective compound that has been tested in the osteoporotic animal and osteoblasts model. However, the effect of catalpol on osteoclasts still remains obscure. Since Rehmannia glutinosa polysaccharides constitute the most parts of Rehmanniae Radix, it is important to figure out whether this type of compounds plays a role in preventing the development of osteoporosis. Luckily, the advanced analytical, biological and pharmacological technologies offer the possibilities to further explore its effects on osteoporosis.
7. Toxicity Currently, the toxicities of TCM herbs gained increasing attention in the clinical trials. Contrary to most of the western toxicity data directly derived from animal experiments, TCM toxicity information in old Chinese literatures have been
documented through clinical experiences. Therefore, cautions must be excised that the isolated chemicals and the extracts from the herbs are not identical to the original herbs or formulas, and the traditional properties and indications of TCM herbs and formulas are the only validated source of interpreting and extrapolating assessments of the toxicities (Leung, 2006; Ma et al., 2016). Using Sk-hep1 human hepatoma cells, Choi et al. (Choi et al., 2011) found that 50-250 μg/ml of ethanol extracts of Rehmanniae Radix preparata or water extracts of Rehmanniae Radix dose-dependently induced cellular lipid accumulation using Nile red staining. Further, 100 μg/ml of ethanol extracts of Rehmanniae Radix preparata or 50-250 μg/ml of water extracts of Rehmanniae Radix preparata dose-dependently increased the luciferase activity of sterol regulatory element. Meanwhile, 50 μg/ml of ethanol extracts of Rehmanniae Radix preparata or 250 μg/ml of water extracts of Rehmanniae Radix also decreased activity of peroxisome proliferator response element (PPRE), indicating the possibilities of enhanced fatty acid synthesis and decreased fatty acid oxidation by Rehmanniae Radix. The pomonic acid and jiocerebroside isolated from Rehmanniae Radix are the responsible components for increasing the accumulation of lipid droplets by decreasing β oxidation of fatty acid and increasing lipogenesis. However, the toxicity evidence of this herb is weaker because of lack of the data from in vivo experiments and clinical observations.
8. Conclusions and outlook Rehmanniae Radix is one of the favored TCM herbs for the clinical treatment of osteoporosis and has been identified in 107 TCM clinical trials so far. Most of clinical studies support the concept that the prescriptions contained Rehmanniae Radix has promising efficacies in the management of osteoporosis by improving BMD and reducing pain. However, the therapeutic outcomes for osteoporosis still needs to be further demonstrated by increasing patient sample size and treatment duration as well as improving clinical design. And also fracture rates should be taken into consideration for evaluating therapeutic outcome. Meanwhile, future clinical studies are also required to evaluate the real contributions of Rehmanniae Radix and its constituents in the management of patients with osteoporosis by standardizing the preparations of TCM prescriptions and employing systems pharmacology approach, which will provide more scientific evidence for the development of TCM herbs and theory. The pharmaceutical properties of Rehmanniae Radix and its ingredients have also been well studied in preclinical experiments. Among 140 structurally characterized compounds, iridoid glycosides and Rehmannia glutinosa polysaccharides are two types of the most studied compounds with diverse activities. The dried root of Rehmannia glutinosa (Gaertn.) DC. is the preferred option for improving bone hemostasis in osteoporotic animals. Pharmacokinetics studies reveal that catalpol and ajugol as well as acetoside are the main active ingredients of Rehmanniae Radix.
However, only catalpol has been well tested in osteoporotic animal and cell models. Increasing evidences prompt us to explore the roles of Rehmannia glutinosa polysaccharides in the treatment of bone diseases, which remains far less exploited owing to lack of effective measures to determine its real constituents and targets. Further experimental studies are still needed to screen the active ingredients of this herb and its involved clinical formulas in preventing the development of osteoporosis. Combination with the advances in TCM theory and clinical usage, phytochemistry, pharmacokinetics and pharmacology studies, the sweet edible herb Rehmanniae Radix will offer a new therapeutic promise in preventing the development of osteoporosis.
Conflicts of Interest The authors declare no conflict of interest regarding the publication of this paper.
Acknowledgement This work was supported by grants from National Natural Science Foundation of China
(NSFC81273995),
and
key
drug
development
program
of
MOST
(20122X09103201-005) as well as the 111 project of MOE (B07007). These funding agencies have no roles in the study design; in data collection, analysis and interpretation; in the writing of the report; and in the decision to submit the article for publication. All authors have read and approved the final manuscript.
Liu, C.Y., S.H. Gao and D.W. Zhang conceived and designed the study. Liu, C.Y., R.F. Ma, L.L. Wang, R.Y. Zhu, H.X. Liu, Y.B. Guo, B.S. Zhao, S.G. Zhao, J.F. Tang and Y. Li developed the search strategy: Liu, C.Y., R.F. Ma, L.L. Wang, S.H. Gao and D.W. Zhang identified studies. Liu, C.Y., Y Li, M. Fu, J.Z. Niu, and D.W. Zhang analyzed data. Liu, C.Y., R.F. Ma, L.L. Wang, M. Fu, S.H. Gao and D.W. Zhang drafted and revised the manuscript. D.W. Zhang is the guarantor of this work and, as such, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Figure 1. The representative images of Rehmannia glutinosa (Gaertn.) DC. (A), Rehmanniae Radix preparata (B), dried Rehmanniae Radix (C) and fresh Rehmanniae Radix (D), which used for the treatment of osteoporosis and isolating constituents. (Pictures are kindly provided by Zexin Ma from the Chinese Medicine and Medica Museum, Beijing University of Chinese Medicine, China). Figure 2. Chemical structures and names of compounds isolated from Rehmannia glutinosa (Gaertn.) DC. Figure 3. The revealed mechanisms targeted by Rehmanniae Radix (RR). Both RR and catalpol monomer have therapeutic effects on osteoporosis. As for RR, it could upregulate the levels of OPG, E2, Itg β1, Runx2, Col, OPN, OC, CT and ERβ, which contributed to bone-formation action. In the meanwhile, RR also inhibited osteoclastogenesis by downregulating TRAP levels. Catalpol could upregulate the levels of T-bet. On the contrary, the ratio of Th1/Th2 and GATA-3 decreased after the treatment with catalpol. Col, collagen; CT, calcitonin; E2, estradiol; ERβ, estrogen receptor β; Itg β1, integrin beta 1; OPG, osteoprotegerin; OPN, osteopontin; OC, osteocalcin; Runx2, Runt-related transcription factor 2; TRAP, tartrate-resistant acid phosphatase.
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Graphical Abstract