Randomized, double-blind placebo-controlled trial with Bryophyllum pinnatum versus placebo for the treatment of overactive bladder in postmenopausal women

Phytomedicine 20 (2013) 351–358

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Phytomedicine journal homepage: www.elsevier.de/phymed

Randomized, double-blind placebo-controlled trial with Bryophyllum pinnatum versus placebo for the treatment of overactive bladder in postmenopausal women夽 Cornelia Betschart a,∗ , Ursula von Mandach b , Burkhardt Seifert c , David Scheiner a , Daniele Perucchini a , Daniel Fink a , Verena Geissbühler d,e a

Department of Gynecology, University Hospital Zurich, CH-8091 Zurich, Switzerland Department of Obstetrics, University Hospital Zurich, CH-8091 Zurich, Switzerland c Division of Biostatistics, ISPM, University of Zurich, CH-8001 Zurich, Switzerland d Department of Obstetrics and Gynecology, Cantonal Hospital Winterthur, CH-8401 Winterthur, Switzerland e Department of Obstetrics and Gynecology, Cantonal Hospital Fribourg, CH-1708 Fribourg, Switzerland1 b

a r t i c l e

i n f o

Keywords: Bryophyllum pinnatum Micturition frequency Overactive bladder (OAB) Placebo Quality of life (QoL)

a b s t r a c t Introduction: Overactive bladder syndrome (OAB) is a chronic disorder that often requires long-term treatment. There is a growing interest in new substances. In vitro experiments of Bryophyllum pinnatum (BP) on porcine bladder muscle have shown a muscle-relaxing effect. In this clinical trial we evaluated BP versus placebo regarding efficacy and safety. Materials and methods: Prospective, double-blind randomized, placebo-controlled study with 20 patients (10 BP, 10 placebo); medication over 8 weeks; dosage 3 × 2 capsules BP 50% (350 mg)/day or placebo (lactose). Primary aim: reduction of the micturition frequency/24 h. Secondary aim: change in quality of life, alterations of parameters in the bladder diary and adverse events (AE). Statistical analysis was performed with IBM SPSS Statistics 20. The groups were compared using Fisher’s exact test and the Mann–Whitney test; the visits using the Wilcoxon signed ranks test. Results: Both groups did not differ significantly in demographical data. For the primary endpoint, a trend in the reduction of the micturition frequency/24 h in the BP group was found: 9.5 ± 2.2 before and 7.8 ± 1.2 after BP versus 9.3 ± 1.8 before and 9.1 ± 1.6 after placebo, p = 0.064. From visit 2 to visit 4, micturition frequency/24 h improved in 8/10 patients in the BP group (p = 0.037). In the placebo group, micturition frequency/24 h improved in 5/9 patients (p = 0.89). Improvement of the QoL did not differ between the two groups. The incidence of AE was similar in both groups, no SAE occurred. Conclusion: The successful safety outcome and positive trend for efficacy permits BP to be further evaluated as a favorable treatment option for OAB. © 2012 Elsevier GmbH. All rights reserved.

Introduction Overactive bladder syndrome (OAB) is a common disease whose prevalence increases with age which in turn influences the choice of treatment (Irwin et al. 2006). OAB is characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary

夽 Ethics committee of Fribourg: 005-CER-FR; Ethics committee of Zurich: KEK-ZH 2009-0075/4; Swissmedic notification number: 2010DR2216; Clinical trial registration number: NCT01127126. ∗ Corresponding author at: Department of Gynecology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland. Tel.: +41 44 255 11 11; fax: +41 44 255 44 33. E-mail address: [email protected] (C. Betschart). 1 Until 30.09.2011. 0944-7113/$ – see front matter © 2012 Elsevier GmbH. All rights reserved. http://dx.doi.org/10.1016/j.phymed.2012.10.007

tract infection or other obvious pathology (Haylen et al. 2010). OAB is associated with an impairment of quality of life (Milsom et al. 2001). Behavioral modifications, bladder training, pelvic floor physiotherapy and pharmacologic treatment with anticholinergic drugs are the first-line options in the OAB treatment (Dmochowski and Gomelsky 2011). Anticholinergic drugs have been used therapeutically since 1973 and new galenic forms reduce side effects. Nevertheless many women still do not continue with medical therapy for OAB due to side effects, lack of efficacy, or unfulfilled treatment expectations (Benner et al. 2010). In a US nation-wide survey lower urinary tract symptoms are after anxiety disorders and back problems, one of the strongest predictors that patients will seek complementary and alternative medicine (CAM) care (Astin 1998). Especially the urogynecological

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patients are more prone to seek help in CAM in comparison to general gynecological patients, and among the alternative options herbal medication is one of the most preferred treatment choices (Slavin et al. 2010). However, the effectiveness of CAM in the treatment of OAB has not yet been adequately and objectively evaluated, even if the interest in alternative drugs and phytotherapy is appreciated by a growing number of patients and physicians, and randomized controlled trials are strongly recommended to prove efficacy of herbal treatments. In Switzerland alternative treatment options will be covered by the basic health insurance for a time period of 5 years (2012–2017). Permanent coverage will be possible if efficacy, safety and cost-effectiveness of the treatment are demonstrated. Plants that have been previously investigated for their in vitro inhibitory properties on detrusor contractility are Ylang Ylang (Cananga odorata) (Kim et al. 2003), St. John’s Wort (Hypericum perforatum) (Capasso et al. 2004), European gold rod (Solidago virgaurea) (Borchert et al. 2004) and sweet sumach bark (Rhois aromatica) (Borchert et al. 2004). However, none of these herbal drugs have been further developed toward a novel treatment option for OAB, and the need for effective and well-tolerated phytopharmaceuticals remains. Phytochemical studies from Bryophyllum pinnatum (BP) press juice led to the identification of bufadienolides (steroids), flavonoids and several other organic acids (Yamagishi et al. 1989). BP studies have shown the following in vitro effects in rodent tissue: positive inotropism, sedation, analgesic activity, H1 antagonism (ileum, bronchial muscle, peripheral vasculature), and antimicrobial activity (Oliver-Bever 1983; Pal et al. 1999). The pharmaceutical characterization of the press juice of fresh (or fresh frozen) B. pinnatum leaves (BPJ) which is the component of the chewing tablets (leaf press juice 50% on lactose) manufactured as blinded capsules, revealed the presence of flavonoids, cinnamic acid derivatives and bufadienolides (Wächter et al. 2011). Among these substances the flavonoids led to the highest reduction of uterine smooth muscle activity. This is in accordance to a study of Gwehenberger et al. in 2004 where the aqueous extract of B. pinnatum leaves was found to be pharmacologically active in myometrial smooth muscle relaxation experiments. The same mechanism of action on smooth muscle cells would be favorable in relieving the smooth muscle contractions and symptoms in patients with OAB. In a preliminary work flavonoid glycosides were the characteristic constituents of the MeOH extract of fresh frozen B. pinnatum leaves. The extract also contained phenolic acid derivatives and lysophosphatidylcholine derivatives (Fürer et al. 2012). In the same study potentially toxic bufadienolides were only found in trace amounts. In earlier studies by Yamagishi et al., the H2 O extract of the whole plant was partitioned between CHCl3 and H2 O. After several separation steps, bersaldegenin-3-acetate and bryophyllin A, were isolated from the CHCl3 fraction and bryophyllin B from the H2 O fraction (Yamagishi et al. 1988, 1989). Bryophyllin A was shown to be a cytotoxic agent inhibiting in vitro effectively the growth of KB tissue culture cells (Yamagishi et al. 1988). A recent study by Mahata et al. a dose-dependent cytotoxic activity in a CHCl3 extract of the pulverized leaves and its fraction F4 was observed. The fraction F4 was supposed to contain bryophyllin A and showed a growth-inhibitory activity on cervical cancer cell cultures (Mahata et al. 2012). The origin of the BP plant as well as the used part of the plant and furthermore the extraction procedure seem to be crucial for studying the constituents of BP and to gain in-depth knowledge for clinical applications as well as for safety and quality control. Preparations of BP are studied in tocolysis by both clinical (Plangger et al. 2006) and experimental evidence on myometrium cells (Simões-Wüst et al. 2010) and uterine strips (Gwehenberger et al. 2004). In previous studies BP produced few and only moderate

side effects in vivo (Plangger et al. 2006). In a recent in vitro study BP inhibited contractions induced by electrical field stimulation and relaxed carbachol-induced contractions on porcine detrusor muscle, though to a lesser extent than oxybutynin (Schuler et al. 2012). These findings were the rationale for the first clinical application of BP in the treatment of OAB in a limited number of postmenopausal patients. The present study is the first published randomized clinical trial (RCT) on BP. We examined the effect on OAB of Bryophyllum pinnatum (BP) versus placebo, characterizing measurement parameters and safety profile of leaf press juice in the treatment of OAB. The primary endpoint is the change in the micturition frequency/24 h after 8 weeks of treatment, secondary endpoints are quality of life measurements, change of bladder diary parameters, and the incidence of adverse events (AE) and adverse drug reactions (ADR). Methods Trial design RCT (multicenter, double-blind randomized, placebocontrolled) of phase II with BP versus placebo in a randomization of 1:1. The study was conducted at the Department of Gynecology of the Cantonal Hospital of Fribourg, Switzerland and the Department of Gynecology of the University Hospital of Zurich, Switzerland from December 2010 to November 2011. A sample randomization schedule with a block size of four women was implemented using a centralized system at the Zurich University Hospital Pharmacy where also the randomization schedule was generated, secured, distributed and stored. The blinded medication pack was dispensed at visit 2 and visit 3 by the pharmacy to the investigator who handed it to the patient. Neither the investigator nor the patients were aware of which treatment was being administered. The study was approved by the Ethics committee of Fribourg and Zurich (005-CER-FR, KEK-ZH 2009-0075/4) as well as by the Swiss Medical Agency (Swissmedic) (2010DR2216), and registered at ClinicalTrials.gov (NCT01127126, http://clinicaltrials.gov/ct2/ show/NCT01127126?term=bryophyllum&rank=1). All patients provided oral and written informed consent, and the trial was conducted in accordance with the study protocol, the International Conference on Harmonization (ICH), the Good Clinical Practice (GCP) guidelines, and all applicable local regulatory requirements and laws. The reporting of the randomized trial followed the Consort 2010 checklist. The study was designed as a proof of concept; for this phase II study a convenient sample size of 20 patients undergoing at least 4 of 5 visits was chosen. Participants Twenty-two women were included in this study. The eligibility criteria for participants at baseline visit were: postmenopausal women with OAB or urgency-dominant mixed urinary incontinence (MUI) (>8 micturitions/day and at least one urgency urinary incontinence eposide/24 h in the 2-days bladder diary completed at baseline) for ≥3 months in the personal history before screening; cystoscopy to exclude a bladder malignancy; in case of prior incontinence or prolapse operation the operation had to date back ≥12 months; German or French speaking patients. Exclusion criteria were: urinary tract infection in an intermittent catheter asservated sample (>1000 bacteries/ml); intake of bladder affecting drugs like anticholinergics, diuretics, muscle relaxing medications and phytotherapeutics in the last 3 months; neurological conditions such as stroke, multiple sclerosis, spinal cord injury, or Parkinson’s

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disease; postvoid residual volume ≥100 ml; symptoms of incontinence being predominantly stress UI; bladder training or pelvic floor muscle training 4 weeks before the screening; intolerance against a substance or a compound, lactose intolerance; diabetes mellitus; drug or alcohol abuse; participation in another study 4 weeks prior to inclusion. Two patients were excluded, one right after randomization before intake of study medication due to a non registered exclusion criteria (use of diuretics) and one because of an unknown lactose intolerance with onset 3 days after medicine intake. Twenty patients, 10 in each group, finished the study drug phase, 1 patient did not show up to the follow-up control 6 weeks after the end of the medication period, due to personal circumstances and moving to another country. The baseline and study data were collected in the patients chart and the online database secuTrial® Version 3.1. Interventions The 5 patients’ visits were over a time span of 15 weeks: baseline at week 0 (visit 1), 1 week later for randomization and start of medicine intake (visit 2), 2 weeks after drug intake (visit 3), 8 weeks after the start of drug intake (visit 4, end of study drug intake) and 6 weeks later for follow-up (visit 5) (Fig. 1). Previous work using the press juice of fresh (or fresh frozen) B. pinnatum leaves (BPJ) which is also the component of the chewing tablets (leaf press juice 50% on lactose) manufactured as blinded capsules for the present study, showed a promising inhibitory effect on the contractility of the detrusor muscle in a porcine bladder model (Schuler et al. 2012). At visit 2, patients were treated either with Bryophyllum pinnatum in form of the commercially available Bryophyllum tablets (Weleda AG, Arlesheim, Switzerland) blinded into capsules of 350 mg by the Cantonal Pharmacy of Zurich (BP: 3 × 2 capsules/day), or with lactose capsules of 350 mg (placebo:

353

3 × 2 capsules/day). There were 10 women in each group. The duration of the drug intake was 8 weeks. A total of 8 vials plus one in reserve were distributed to the patients, each containing the dosage of 1 week (42 capsules). Storage of the vials was at room temperature, controlled weekly and recorded in a log book. Measurements Patients completed a 2-day bladder diary comprising fluid intake/24 h, micturition frequency/24 h, micturition time, urine volume measured in milliliters per voiding, urgency urinary incontinence (UUI) episodes, urgency intensity in a 3-point Likert scale and the pad use/24 h at baseline, visit 3, visit 4 and visit 5. Quality of life and OAB bother were assessed with the King’s Health Questionnaire (KHQ) (Bjelic-Radisic et al. 2005) and the International Consultation on Incontinence Modular Questionnaire for OAB (ICIQ-OAB) (Avery et al. 2004) at baseline, visit 3, visit 4 and visit 5. The primary endpoint corresponded to changes in micturition frequency/24 h from baseline (visit 2) to week 9 (visit 4). The primary endpoint is an accepted and distributed outcome value for OAB (http://www.nice.org.uk/nicemedia/pdf/CG40fullguideline.pdf). Secondary endpoints were quality of life measurement assessed with the King’s Health Questionnaire (KHQ) and the International Consultation on Incontinence Modular Questionnaire for OAB (ICIQ-OAB), and change of the following bladder diary parameters: volume per micturition, fluid intake/24 h, urgency eposides/24 h, urgency intensity, UUI eposides/24 h and the pad use/24 h, and the incidence and kind of AE during the study phase. The KHQ and ICIQ-OAB are two questionnaires, validated for the German and French language, for women with urinary incontinence. The KHQ consists of 32 items that address ten domains of quality of life (QoL). Each domain is scored using a range between 0 and 100, while higher scores indicate greater impairment of QoL.

Fig. 1. Consolidated Standards of Reporting Trials (CONSORT) flow chart of enrolment and follow-up showing progress of patients through trial.

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In addition, a visual analog scale (VAS), where 0 represents no urinary complaints and 10 unbearable urinary complaints, was used to assess symptom bother at baseline and at follow-up. The ICIQ modular questionnaire was developed by an international advisory board to meet the need for a universally applicable standard in quality of life measurement (www.iciq.net). Meeting the criteria for our secondary endpoints, ICIQ-OAB assesses symptoms of OAB and associated bother with four items that comprise frequency, nocturia, urgency and urgency urinary incontinence. Each item has in addition a visual analog scales (VAS) to assess the symptom bother where 0 represents no urinary complaints and 10 unbearable urinary complaints. Safety assessments Adverse events (AEs) and adverse drug reactions (ADR) were evaluated for patients at visits 2–5. Patients reported any kind of AE in a protocol, subdivided in visits and organ-specific complaints. At each clinic visit any AE reported in response to general and non-specific questioning by the investigator, and any report in the patients individual AE protocol, were recorded in the case report form and online in the database secuTrial® . An AE was defined as occurring between visit 2 and visit 5. The severity of AEs was determined by the investigator according the following guidelines: a mild AE caused discomfort but no disruption of normal daily activities; a moderate AE caused discomfort sufficient to reduce or affect normal daily activities; a severe AE was one that resulted in an inability to work or perform daily activity or needed hospitalization. The discontinuation rate due to AEs was also recorded. Midstream urine dipstick test was done at every visit, and any positive result for leucocytes, nitrite or erythrocytes was further checked by an intermittent catheter-asservated sample. If in the urine culture >1000 bacteries/ml were detected antibiotics after an antibiogram was given. Statistical analysis Statistical analysis was performed with IBM SPSS Statistics 20 (SPSS Inc., Chicago, IL). The groups were compared at baseline using independent samples t-test, and Fisher’s exact-test. Baseline characteristics were evaluated for the 20 patients that finished the study (10 BP versus 10 placebo). Two-sided p-values less than 0.05 are considered statistically significant. Treatment differences between the groups for changes in micturition frequency/24 h (primary endpoint) and quality of life parameters in the KHQ and ICIQ-OAB (secondary endpoint) were assessed using the Mann–Whitney test. Changes within treatment groups were analyzed using Wilcoxon signed ranks test. Comparison between the two groups for the primary endpoint and the quality of life parameters is expressed as mean ± standard deviation (SD), and analyzed with the Mann–Whitney test at visits 2, 4 and 5. Comparison of the incidence of AE is expressed as number of patients (percentage) and analyzed with the Fisher’s exact test at visits 2–5. Medication compliance was 100% by intake of a total of 336 capsules (8 × 42). The compliance is expressed as mean ± SD and analyzed with the Mann–Whitney test. Results A total of 44 patients with OAB were screened for the study. Of 22 patients randomized, 21 (11 BP, 10 placebo) received one or more dose of study medication (Fig. 1). Among these patients, ten in the BP and ten in the placebo group finished the study medication intake. One patient in the BP group was excluded 3 days after drug intake due to an unexpected lactose intolerance. One patient randomized to the placebo group was excluded before drug intake due

Table 1 Basic demographics. Datas of the 20 patients finishing study medication intake. HRT, hormone restitution therapy (9 patients vaginal replacement, 1 patient systemic replacement). Data are expressed as mean ± SD, or number of patients. Independent sample-t-test, Fisher’s exact test.

Age (years) BMI (kg/m2 ) Race Caucasian Hispanic Asian Distribution of the urodynamically proven incontinence form UUI MUI Parity Vaginal delivery (n) 0 vaginal delivery 1 vaginal delivery 2 vaginal delivery 3 vaginal delivery Forceps (n) 0 forceps delivery 1 forceps delivery 2 forceps delivery C-sections (n) 0 C-section 1 C-section Recurrent urinary tract infection Concomitant disease Other than incontinence medicine intake HRT Prior incontinence therapies Anticholinergics Reason for withdrawal: Side effects No or less effects Midurethral sling Botox intravesical (>1 year ago)

Bryophyllum pinnatum (n = 10)

Placebo (n = 10)

p-Value

64.5 ± 14.1 28.8 ± 4.9

65.5 ± 10.9 25.9 ± 4.3

0.86 0.18 1.0

9/10 0/10 1/10 5/10

9/10 1/10 0/10 3/10

0.65

5/10

7/10

0.65

9/10

8/10

1.0 1.0

2/10 1/10 6/10 1/10

3/10 0 6/10 1/10

8/10 0 2/10

9/10 1/10 0

10/10 0 3/10 9/10 7/10

9/10 1/10 3/10 10/10 9/10

1.0 1.0 0.58

4/10

6/10

0.66

7/10

4/10

0.37

7/10 2/10 3/10 3/10

0/10 4/10 1/10 0/10

0.003 0.63 0.58 0.21

0.47

1.0

to unreported diuretic use. Between visit 4 and visit 5, one patient in the BP group was lost to follow up. Both groups (BP versus placebo) did not differ significantly in demographical and clinical data as age, BMI, race, parity, mode of delivery, co-morbidities, recurrent urinary tract infection, concomitant drug medication, and previous incontinence procedures. Previous anticholinergic treatment was high in both groups; the withdrawal due to side effects was significantly higher in the BP group (7/10 versus 0/10), p = 0.003 (Table 1). Efficacy For the primary endpoint (mean reduction in micturition frequency/24 h), a trend toward Bryophyllum between the beginning of study medication intake (visit 2) and the end of study medication intake (visit 4) was found [BP 9.5 ± 2.2 before and 7.8 ± 1.2 after intake, placebo 9.3 ± 1.8 and 9.1 ± 1.6 respectively, p = 0.064] (Table 2). Also for the average micturition frequency/24 h at visit 4, BP is in favor over placebo, 7.8 ± 1.2 versus 9.1 ± 1.6, p = 0.058 (Table 2 and Fig. 2). From visit 2 to visit 4, micturition frequency/24 h improved in 8/10 patients in the BP group leading to a significant improvement in micturition frequency/24 h (p = 0.037). In the placebo group, micturition frequency/24 h was only improved in 5/9 patients (p = 0.89). One patient in the placebo group did not fill in the bladder diary at visit 4; also at follow-up (visit 5) in each group, 1 patient did not

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Table 2 Bladder diary parameters. Parameters at baseline, end of study medication and at follow-up after 6 weeks for the 20 patients intended to receive treatment. Urine volume/micturition and fluid intake in milliliters, mean ± SD, Mann–Whitney test. Baseline (visit 2)

Frequency/24 h Urine volume/micturition Fluid intake/24 h Urgency episodes/24 h Urgency intensity UUI episodes/24 h Pad use/24 h

9.5 195 1913 7.8 2.0 2.6 2.2

± ± ± ± ± ± ±

2.2 69 526 4.1 0.5 2.1 0.8

Placebo (n = 10) 9.3 183 1776 6.2 2.3 1.5 2.0

± ± ± ± ± ± ±

1.8 45 466 3.6 0.5 0.9 1.6

p-Value

Bryophyllum (n = 10)

0.9 0.65 0.6 0.27 0.33 0.22 0.42

7.8 205 1736 5.6 2.1 1.4 1.4

micturition rate/24hours

fill in the bladder diary. The micturition volumes increased in both groups between visit 2 and visit 4, though not significantly. The UUI episodes/24 h decreased, and the urgency intensity remained comparable throughout the study phase. The improvement of the QoL (secondary endpoint) for the KHQ and the ICIQ-OAB between visit 2 and visit 4 as well as visit 5 did not differ between the groups (Table 3). The placebo group showed at baseline a significantly higher bother of urgency on the VAS of 8.0 ± 1.9 versus 5.1 ± 3.2, p = 0.03. At visit 5, two patients of the BP group did not fill in the questionnaires. Patient compliance was very high with 99% in the BP and 104% in the placebo group (Table 4).

-23%

BP

-13%

-9%

Placebo

-25% 2.0

4.0

6.0

8.0

BP

10.0

Placebo (n = 9) 9.1 209 1771 6.6 1.9 1.4 1.8

-35%

± ± ± ± ± ± ±

1.6 68 543 2.7 0.4 0.8 1

Follow-up after 6 week (visit 5) Analysis B p-Value

Bryophyllum (n = 9)

0.058 0.93 0.69 0.7 0.44 0.91 0.91

8.6 174 1842 6.6 2.3 1.8 1.9

± ± ± ± ± ± ±

2.3 70 698 3.3 0.4 1.2 1.1

Placebo (n = 9) 8.3 220 1989 5.8 1.9 1.1 2.4

± ± ± ± ± ± ±

p-Value 2.4 70 655 4.1 0.5 1.0 2.5

The incidence of AE and ADR was similar in both groups (Table 4). AE were recorded at every visit with higher incidences at visits 4 and 5 for BP and at visits 2 and 3 for placebo, but are not statistically significant between the groups. ADR in the BP group were: diarrhea and dysentery likely due to lactose intolerance in one woman, and in a second women an exanthema of the face and upper thorax that was self-limiting. The suspected lactose intolerance was not proven by further lactose breath hydrogen test or duodenoscopy. In the placebo group, one patient reported in her AE-protocol tachycardia, tremor and dizziness before visit 3. Her

-26%

BP

-20%

-15%

Placebo

-23% 0.0

2.0

4.0

6.0

8.0

10.0

BP

12.0

-35% -0%

-0%

Placebo

-33%

-0%

-33% 0.0

visit 2

0.5

visit 4

1.0

1.5

2.0

2.5

0.93 0.19 0.48 0.68 0.17 0.36 0.85

Safety

12.0

-25%

Placebo

1.2 63 846 2.5 0.6 0.9 0.5

pad use/24 hours

incontinence episodes/24hours

0.0

± ± ± ± ± ± ±

urgency episodes/24hours

Bryophyllum (n = 10)

End of study medication (visit 4) Analysis A

3.0

3.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

visit 5

Fig. 2. Voiding diary parameters presented as median with interquartile range (IQR) at visits 2, 4 and 5. Change in percent to baseline (visit 2). No change reaches statistical significance.

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Table 3 Quality of life parameters. King’s Health Questionnaire and ICIQ-OAB parameters at baseline, end of study medication and at follow-up after 6 weeks for the 20 patients intended to receive treatment. Baseline (visit 2)

Bryophyllum (n = 10) KHQ General health perception Incontinence impact Role limitation Personal limitation Social limitation Personal relations Emotional problems Sleep and energy Severity measures VAS KHQ ICIQ-OAB Frequency VAS frequency Nocturia VAS nocturia Urgency VAS urgency Urgency incontinence VAS urgency incontinence ICIQ Score total

End of study medication Analysis A (visit 4) Placebo (n = 10)

p-Value

Bryophyllum (n = 10)

Follow-up after 6 week Analysis B (visit 5)

Placebo (n = 9)

p-Value

Bryophyllum (n = 8)

Placebo (n = 9)

p-Value

43 63 57 67 26 14 28 53 55 5.7

± ± ± ± ± ± ± ± ± ±

21 25 20 26 26 15 20 26 21 2.1

48 83 63 60 38 33 48 52 53 7.6

± ± ± ± ± ± ± ± ± ±

22 18 16 20 28 38 27 27 26 1.2

0.6 0.06 0.31 0.53 0.27 0.55 0.09 0.78 0.81 0.06

38 50 32 43 12 11 19 27 40 5.2

± ± ± ± ± ± ± ± ± ±

18 24 23 25 16 17 17 25 11 2.2

36 59 39 56 31 42 28 39 47 5.3

± ± ± ± ± ± ± ± ± ±

18 28 29 32 30 50 27 30 25 2.3

0.8 0.6 0.56 0.34 0.22 0.34 0.62 0.36 0.62 0.79

38 54 38 36 19 4 15 31 40 5

± ± ± ± ± ± ± ± ± ±

19 25 21 34 24 8 24 30 12 2

39 63 48 50 35 33 33 44 43 5

± ± ± ± ± ± ± ± ± ±

13 35 29 28 27 39 25 23 17 3

0.67 0.48 0.23 0.3 0.17 0.22 0.14 0.29 0.87 0.44

2.3 6.6 2.7 5.7 2.4 5.1 1.8 4.8 9.2

± ± ± ± ± ± ± ± ±

1.1 2.1 0.7 2.3 1.3 3.2 0.9 2.9 2.7

1.9 7.2 2.1 6.2 3.1 8.0 2.6 7.7 9.7

± ± ± ± ± ± ± ± ±

0.9 1.5 1 1.8 0.9 1.9 0.8 2.3 1.3

0.54 0.93 0.26 0.35 0.29 0.03* 0.07 0.02* 0.32

1.5 4.4 1.7 4 2.3 5.1 1.8 4.7 7.3

± ± ± ± ± ± ± ± ±

0.9 1.9 1 2.3 1.2 2.6 1.1 2.9 3.2

1.2 4.9 1.7 4.8 2.3 5.8 1.9 5.4 7.1

± ± ± ± ± ± ± ± ±

0.8 2.4 0.7 3.2 0.9 3 1.1 3.4 2.3

0.28 0.62 0.75 0.51 0.83 0.5 0.9 0.51 0.62

1.1 4 1.5 4 2.1 3.8 1.6 3.4 6.4

± ± ± ± ± ± ± ± ±

0.8 2.7 0.9 2.1 0.8 2 1.1 2.6 2.6

1.3 5 1.5 4.6 2.3 5.2 1.8 5.3 7

± ± ± ± ± ± ± ± ±

0.7 2.7 0.5 2.4 0.9 2.7 0.8 2.5 1.5

0.6 0.53 0.87 0.45 0.72 0.2 0.96 0.17 0.52

KHQ Score 0–100 (0 = not bother, 100 = maximum restraint), VAS 0–10 (0 = not bother, 10 = maximum restraint), ICIQ-OAB 0–4 (0 = normal, 4 = highest severity impact). Values in mean ± SD, Mann–Whitney test.

Table 4 Adverse events (AE) and drug accountability. Data are expressed as number of patients (percentage) or mean ± SD. Mann–Whitney test, Fisher’s exact test. Compliance = 100% if 336 capsules were intaken (8 × 42).

AE visit 2 (baseline)a AE visit 3a AE visit 4a AE visit 5a AE possibly related to study medication (=ADR reported at between visit 2 and 3 or visit 4) Capsule intake Compliance Returned capsules (including 42 capsules of the reserve vial) a

Bryophyllum

Placebo

p-Value

1/11 1/10 3/10 2/9 2/10 332 ± 49 99% 46 ± 49

3/11 3/10 0/10 1/10 3/10 349 ± 30 104% 29 ± 30

0.58 0.58 0.21 0.58 1.0 0.57 0.57

No relation to study medication.

blood pressure and pulse were normal at visit 3. Two other women in the placebo group reported dysenteria and an exanthem at the trunk and upper extremities without the need of an emergency consultation. In both groups asymptomatic urinary tract infections (UTI) were the most frequent AE, as at every visit a urine dipstick test was performed and any positivity for leucocytes was further evaluated by a uricult. All UTI (4 in the BP, 3 in the placebo group) were treated with antibiotics after having taken an antibiogram. All AE were classified as mild with one exception in the placebo group were the patient after a trip on clear ice had a wrist fracture necessitating a cast for 6 weeks. No hospitalization and no SAE occurred. Discussion Efficacy This is the first randomized clinical trial to investigate the efficacy and applicability in the treatment of OAB with BP performed by assaying for changes in micturition habits, quality of life, and safety. Health economics requires proof of efficacy, safety and cost-effectiveness of health insurance covered drugs. As OAB is a chronic disease requiring long-term treatment, the adherence and

compliance to drug usage is of importance. The poor adherence to anticholinergic medications remains a major challenge in the treatment of OAB (Benner et al. 2010) and leads to a high use of over the counter alternative substances (Slavin et al. 2010). Our study gives some answers to the efficacy and safety issues of BP in the treatment of OAB. We found a positive tendency for BP in reduction of micturition rate/24 h of −23% (−9% for placebo), and reduction of urgency episodes/24 h of −26% (placebo −15%). The reduction of UUI episodes was comparable for BP and placebo. This treatment effect obtained with the blinded product in the present trial is slightly lower than that reported of anticholinergic studies – bear in mind that efficacy outcomes can be determined and defined in many ways. Anticholinergics have been shown to reduce in controlled trials the micturition frequency by 20–30%, the UUI episodes by 70–75%. Reported voided volume increases are approximately 15%. In incontinence studies quality of life improves generally by 50% (Wein and Rackley 2006) and it also improved significantly in both of our study groups. In general the effectiveness of OAB treatment is difficult to characterize as OAB overlaps with psychological conditions that highly improve by medical care, different life circumstances, placebo administration as well as self-efficacy or -healing. These treatment effects were also found in our placebo group with a significant

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improvement of quality of life, but not in a similar improvement of the objective bladder diary parameters. This double-blind randomized, placebo-controlled clinical study was designed as a proof of concept with a sample size of 20 patients. A further study with a larger patient group is needed to test the favorable tendency of BP with sufficient power. In addition, BP as a therapeutic agent for OAB should be assessed in controlled trials in comparison with the anticholinergic mainstay treatment to test the efficacy, safety and cost-effectiveness.

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effects of BP. At the beginning of the study patients were informed that study drug intake should only be taken for 8 weeks. However the good tolerability and efficacy led to the intake of capsules of the reserve vial in 7 patients of the placebo group and 5 patients of the BP group and resulted in a compliance of 104% and 99%, respectively. Also for our clinical study it might be conjectured that the adherence to the study medication is better than it would be reported in daily clinical practice. Adverse effects

Mechanism of action of BP Previous findings of BP studies suggest that it has a muscle relaxant action in humans and a CNS-depressant action in rodents (Pal et al. 1999; Gwehenberger et al. 2004; Schuler et al. 2012). Both effects may influence the symptoms of OAB in an effective manner, as in the pathogenesis of OAB peripheral and central factors are supposed to play a role. There is some evidence that myogenic (Brading 1997), aberrant neurogenic activity (DeGroat 1997), and cerebral alterations (Griffiths et al. 2005), as well as atypical or latent bladder infections (Khasriya et al. 2010) are involved in the pathogenesis of OAB. The bufadienolides isolated from BP (as Bersadelgin-1,3,5orthoacetate and Bryophyllin-1) are lipophilic compounds which can pass easily the blood brain barrier (BBB). However, there are no studies elucidating the underlying pharmacological mode of action of BP in the central nervous system. As no anticholinergic or noradrenergic side effects of BP were reported in this or previous studies, a non-adrenergic, non-muscarinergic (NANC) pathway might be assumed. Pharmacological radio-ligand binding to muscarinic and nicotinergic receptors would bring further insight to this question. In myometrium cells BP showed an inhibition of the oxytocin-induced increase of the intracellular calcium concentration. This could be a possible pathway for the relaxation, i.e. tocolytic effect of BP (Simões-Wüst et al. 2010). Not only the widely used synthetic anticholinergic drugs, but also phytotherapeutical substances like Rhois aromatica and Solidaginis extracts, act through the antimuscarinergic receptor. Low concentrations of Rhois and Solidaginis extracts produced insurmountable inhibition of muscarinic receptor-mediated bladder contraction and, within the same concentration range, a non-competitive inhibition of radioligand binding to muscarinic receptors with no relevant selectivity for M2 relative to M3 receptors (Borchert et al. 2004). Presumably that is the reason why these substances did not find their way into clinical practice. Measurements The patients perception of the impact of symptoms on their physical and emotional well-being is a major outcome parameter of OAB treatment. Measuring patient-reported outcomes has been aided by the development of specific questionnaires as the KHQ and ICIQ-OAB. To capture bladder symptoms more objectively bladder diaries are appropriate tools. Diaries provide a reproducible, reliable and cost-effective measure of incontinence frequency before and after treatment (Martin et al. 2006). Seven-day diaries would provide the greatest reliability but are laborious for patients to keep (Locher et al. 2001). Two- or three-day diaries are commonly used in both clinical and research settings. In our patients diaries the sleeping time was not captured and the change in nocturia cannot be reported. Compliance In this study and previous publication (Plangger et al. 2006) the compliance was high thanks to the high tolerance and few side

AE are of importance for the adherence to which the patients’s behavior coincides with medical or health advice. To catch the AE in a comprehensive way the AE and ADR of the drop out patients were also reported at visit 2, though lactose intolerance was a predefined exclusion criterion. In our study ADR were comparable between BP and placebo that is one of the major advantages of BP. In a real life setting, the discontinuation rate of the mainstay drugs in the treatment of OAB was high of up to 88.2% after 1 year (Shaya et al. 2005). No anticholinergic side effects were reported by our postmenopausal women of an average age of 65 years. Clinical trials of anticholinergic drugs report promising results in the elderly population but often these studies include healthy elderly patients and exclude the morbid, frail elderly patients that are more likely to be taking concomitant anticholinergic drugs in up to 30%, and often suffer from pre-existing cognitive disorders (Feinberg 1993). In a large study of a cohort comparable to our patient sample, the OAB population had more CNS disorders than the non-OAB patients. Additionally it was found that the OAB group – of the same age as the patients in our study – had a higher collateral use of medications with anti-muscarinic effects (Asche et al. 2011). As the integrity of the blood brain barrier is influenced by advancing age, diabetes mellitus, Parkinson’s disease, multiple sclerosis, cerebrovascular disease and Alzheimer’s disease (Kay and Ebinger 2008), especially the elderly patients are prone to suffer more from the undesirable effects of traditional therapy. The successful safety outcome and positive trend for efficacy permits BP to be further evaluated as a favorable treatment option for OAB. New substances in the treatment of OAB are desirable and the value of BP might be best found in the context of a multimodal treatment. Funding Gottfried and Julia Bangerter-Rhyner Funds, Berne, Switzerland. Conflict of interest None. References Asche, C.V., Kim, J., Kulkarni, A.S., Chakravarti, P., Andersson, K.E., 2011. Presence of central nervous system, cardiovascular and overall co-morbidity burden in patients with overactive bladder disorder in a real-world setting. BJU International 109 (4), 572–580. Astin, J.A., 1998. Why patients use alternative medicine: results of a national study. The Journal of the American Medical Association 279 (19), 1548–1553. Avery, K., Donovan, J., Peters, T.J., Shaw, C., Gotoh, M., Abrams, P., 2004. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourology and Urodynamics 23 (4), 322–330. Benner, J.S., Nichol, M.B., Rovner, E.S., Jumadilova, Z., Alvir, J., Hussein, M., Fanning, K., Trocio, J.N., Brubaker, L., 2010. Patient-reported reasons for discontinuing overactive bladder medication. BJU International 105 (9), 1276–1282. Bjelic-Radisic, V., Dorfer, M., Tamussino, K., Greimel, E., 2005. Psychometric properties and validation of the German-language King’s Health Questionnaire in women with stress urinary incontinence. Neurourology and Urodynamics 24, 63–68.

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Borchert, V.E., Czyborra, P., Fetscher, C., Goepel, M., Michel, M.C., 2004. Extracts from Rhois aromatica and Solidaginis virgaurea inhibit rat and human bladder contraction. Naunyn-Schmiedeberg’s Archives of Pharmacology 369, 281–286. Brading, A.F., 1997. Myogenic basis for the overactive bladder. Urology 50, 57–67. Capasso, R., Borrelli, F., Capasso, F., Mascolo, N., Izzo, A.A., 2004. Inhibitory effect of the antidepressant St. John’s wort (Hypericum perforatum) on rat bladder contractility in vitro. Urology 64, 168–172. DeGroat, W., 1997. A neurologic basis for the overactive bladder. Urology 50 (6A Suppl.), 36–52. Dmochowski, R.R., Gomelsky, A., 2011. Update on the treatment of overactive bladder. Current Opinion in Urology 21, 286–290. Feinberg, M., 1993. The problems of anticholinergic adverse effects in older patients. Drugs and Aging 3, 335–348. Fürer, K., Potterat, O., Raith, M., Brenneisen, R., Mennet, M., Schnelle, M., SimõesWüst, A.P., von Mandach, U., Hamburger, M., 2012. Bryophyllum pinnatum, a well regarded phytomedicine in obstetrics and gynecology – new data on its chemical composition. In: Abstract, 5th Swiss Pharma Science Day, Berne 29.08.2012. Griffiths, D., Derbyshire, S., Stenger, A., Resnick, N., 2005. Brain control of normal and overactive bladder. Journal of Urology 174, 1862–1867. Gwehenberger, B., Rist, L., Huch, R., von Mandach, U., 2004. Effect of Bryophyllum pinnatum versus fenoterol on uterine contractility. European Journal of Obstetrics, Gynecology, and Reproductive Biology 113, 164–171. Haylen, B.T., de Ridder, D., Freeman, R.M., Swift, S.E., Berghmans, B., Lee, J., Monga, A., Petri, E., Rizk, D.E., Sand, P.K., Schaer, G.N., 2010. An International Urogynecologica Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. International Urogynecology Journal 21 (1), 5–26. Irwin, D.E., Milsom, I., Hunskaar, S., Reilly, K., Kopp, Z., Herschorn, S., Coyne, K., Kelleher, C., Hampel, C., Artibani, W., Abrams, P., 2006. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC Study. European Urology 50, 1306–1314. Kay, G.G., Ebinger, U., 2008. Preserving cognitive function for patients with overactive bladder: evidence for a differential effect with darifenacin. Journal of Clinical Practice 62, 1792–1800. Khasriya, R., Khan, S., Lunawat, R., Bishara, S., Bignall, J., Malone-Lee, M., Ishii, H., O’Connor, D., Kelsey, M., Malone-Lee, J., 2010. The inadequacy of urinary dipstick and microscopy as surrogate markers of urinary tract infection in urological outpatients with lower urinary tract symptoms without acute frequency and dysuria. Journal of Urology 183 (5), 1843–1847. Kim, H., Yang, H.M., Kim, D.H., Kim, H.G., Jang, W.C., Lee, Y.R., 2003. Effects of ylang–ylang essential oil on the relaxation of rat bladder muscle in vitro and white rabbit bladder in vivo. Journal of Korean Medical Science 18, 409–414. Locher, J.L., Goode, P.S., Roth, D.L., Worrell, R.L., Burgio, K.L., 2001. Reliability assessment of the bladder diary for urinary incontinence in older women. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 56 (1), M32–M35.

Mahata, S., Maru, S., Shukla, S., Pandey, A., Mugesh, G., Das, B.C., Bharti, A.C., 2012. Anticancer property of Bryophyllum pinnata (Lam.) Oken leaf on human cervical cancer cells. BMC Complementary and Alternative Medicine 10 (12), 15. Martin, J.L., Williams, K.S., Abrams, K.R., Turner, D.A., Sutton, A.J., Chapple, C., Assassa, R.P., Shaw, C., Cheater, F., 2006. Systematic review and evaluation of methods assessing urinary incontinence. Health Technology Assessment 10 (6), 1–132. Milsom, I., Abrams, P., Cardozo, L., Roberts, R.G., Thüroff, J., Wein, A.J., 2001. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU International 87, 760–766. Oliver-Bever, B., 1983. Medicinal plants in tropical West Africa. III: antiinfection therapy with higher plants. Journal of Ethnopharmacology 9, 1–3. Pal, S., Sent, T., Nag Chaudhure, A., 1999. Neuropsychopharmacologica profile of the methanolic fraction of Bryophyllum pinnatum leaf extract. Journal of Pharmacy and Pharmacology 51, 313–338. Plangger, N., Rist, L., Zimmermann, R., von Mandach, U., 2006. Intravenous tocolysis with Bryophyllum pinnatum is better tolerated than beta-agonist application. European Journal of Obstetrics, Gynecology, and Reproductive Biology 124, 168–172. Shaya, F.T., Blume, S., Gu, A., Zyczynski, T., Jumadilova, Z., 2005. Persistence with overactive bladder pharmacotherapy in a Medicaid population. American Journal of Managed Care 11 (4 Suppl.), S121–S129. Schuler, V., Suter, K., Fürer, K., Eberli, D., Horst, M., Betschart, C., Brenneisen, R., Hamburger, M., Mennet-von Eiff, M., Schnelle, M., Simões-Wüst, A.P., von Mandach, U., 2012. Bryophyllum pinnatum inhibits detrusor contractility in porcine bladder strips – a pharmacological study toward a new treatment option of overactive bladder. Phytomedicine 19, 947–951. Simões-Wüst, A.P., Grãos, M., Duarte, C.B., Brenneisen, R., Hamburger, M., Mennet, M., Ramos, M.H., Schnelle, M., Wächter, R., Worel, A.M., von Mandach, U., 2010. Juice of Bryophyllum pinnatum (Lam.) inhibits oxytocin-induced increase of the intracellular calcium concentration in human myometrial cells. Phytomedicine 17, 980–986. Slavin, S.L., Rogers, R.G., Komesu, Y., Omotosho, T., Hammil, S., Lewis, C., Sapien, R., 2010. Complementary and alternative medicine (CAM) use in women with pelvic floor disorders: a cohort study. International Urogynecology Journal 21 (4), 431–437. Wächter, R., Brenneisen, R., Hamburger, M., Mennet, M., Schnelle, M., Worel, A.M., Simões-Wüst, A.P., von Mandach, U., 2011. Leaf press juice from Bryophyllum pinnatum (Lamarck) Oken induces myometrial relaxation. Phytomedicine 19, 74–82. Wein, A.J., Rackley, R.R., 2006. Overactive bladder: a better understanding of pathophysiology, diagnosis and management. Journal of Urology 175, 5–10. Yamagishi, T., Yan, X.Z., Wu, R.Y., McPhail, D.R., McPhail, A.T., Lee, K.H., 1988. Structure and stereochemistry of bryophyllin-A, a novel potent cytotoxic bufadienolide orthoacetate from Bryophyllum pinnatum. Chemical and Pharmaceutical Bulletin 36, 1615–1617. Yamagishi, T., Haruna, M., Yan, X.Z., Chang, J.J., Lee, K.H., 1989. Antitumor agents, 1101,2 bryophyllin B, a novel potent cytotoxic bufadienolide from Bryophyllum pinnatum. Journal of Natural Products 52, 1071–1079.