homeonews - Farmacia Natural
Transcription
homeonews - Farmacia Natural
HOMEONEWS Edición N° 9 Enero – Febrero - Marzo de 2008 Director: Farm. Fernando Estevez Castillo PUBLICACION BIMESTRAL DISTRIBUCION GRATUITA PARA PROFESIONALES DE LA SALUD Homeonews 2 Edición N° 9 – Enero – Febrero - Marzo de 2008 Edición n° 9 Enero – Febrero - Marzo de 2008 Registro de la Propiedad Intelectual n°: 505276 Director: Fernando Oscar Estevez Castillo Propietario: Fernando Oscar Estevez Castillo (C.I.: 10.103.605) Dirección postal: Pte. Quintana 414 – Lanús Oeste – Pcia de Buenos Aires (B1824NVJ), Argentina Tel.: (54-11) 4241-4441 E.Mail: [email protected] ó [email protected] Director: Fernando Estevez Castillo Homeonews 3 Edición N° 9 – Enero – Febrero - Marzo de 2008 INDICE 1- Editorial, pág. 5. 2- Fitoterapia: Actividad antiinflamatoria del Taraxacum officinale, pág. 6. 3- Alopatía: La inmunosupresión inducida por radiación UV es mayor en hombres y puede ser prevenida por nicotinamida, pág. 20. 4- Homeopatía: Tratamiento de los sofocones de calor con Homeopatía: resultados de un estudio observacional, pág. 39. 5- Nutrición: Importancia medicinal del jugo de pomelo y su interacción con ciertas drogas, pág. 52. 6- Notas de interés: -Primer Encuentro Chileno de Preparados Homeopáticos elaborados en Farmacias; pág. 70. -XVIII Congreso Farmacéutico Argentino; pág 73. -Homeopatía: Primeras Jornadas del Comahue; pág. 74. -Jornadas sobre Ejercicio Profesional Farmacéutico en la Universidad Nacional de La Plata; pág. 76. 7- Novedades: -Nuevos Productos: Dermomega®; pág. 77. -“Amigos de lo Natural”, la hora de la Naturaleza llegó a la Radio; pág. 78. 8- Cursos y Congresos: -Cursos a distancia: “Fitomedicina (2008)” y “Fitodermatología y Fitoestética (2008); pág. 80. -Curso Superior de Medicina Naturista para Profesionales; pág. 87. -VIII Curso y I Simposio Internacional sobre Inmunonutrición; pág. 89. -63º Congreso de la Liga Médica Homeopática Internacional; pág. 89. 9- Formulario de suscripción, pág. 90. Director: Fernando Estevez Castillo Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Foto de tapa: Taraxacum officinale (Asteraceae). Las opiniones vertidas en los artículos firmados son responsabilidad de sus autores. Director: Fernando Estevez Castillo 4 Homeonews 5 Edición N° 9 – Enero – Febrero - Marzo de 2008 EDITORIAL Estimados colegas del equipo de salud: Un nuevo año ha comenzado y Homeonews, a través del presente número, vuelve a comunicarse con Uds., retrasado, pero con mucho más material para suplir esta ausencia temporaria. En este número podrá encontrar mucha información y varios trabajos recientemente publicados, en cada uno de los Capítulos ofrecidos: FITOTERAPIA: “actividad antiinflamatoria del Taraxacum officinale”; ALOPATIA: “la inmunosupresión inducida por radiación UV es mayor en hombres y puede ser prevenida por nicotinamida”, HOMEOPATIA: “resultados de un estudio observacional para el tratamiento de los sofocones de calor con Homeopatía” y NUTRICION: “la importancia medicinal del jugo de pomelo y su interacción con ciertas drogas”. En NOTAS DE INTERES, los pormenores de varias actividades tales como el Primer Encuentro Chileno de Preparados Homeopáticos elaborados en Farmacias; el XVIII Congreso Farmacéutico Argentino; las Primeras Jornadas de Homeopatía del Comahue y las Jornadas sobre Ejercicio Profesional Farmacéutico realizadas en la Universidad Nacional de La Plata. Con respecto a NOVEDADES, Laboratorios Dr. Madaus, a través de su División Cosmética “OMS”, presentó más productos de la línea DERMOMEGA® y “AMIGOS DE LO NATURAL”, programa radial de FM Palermo, comenzó su segundo año en el aire, con más invitados y entrevistas exclusivas. En CURSOS Y CONGRESOS, toda la información referida a: dos Cursos ofrecidos en la modalidad a distancia por la Asociación Argentina de Fitomedicina: “Fitomedicina” y “Fitodermatología – Fitoestética”, el Curso Superior de Medicina Naturista de la Asociación Argentina de Médicos Naturistas; el VIII Curso y I Simposio Internacional sobre Inmunonutrición y el 63º Congreso de la Liga Médica Homeopática Internacional. Por último, vuelvo a agradecer a todos los lectores, que a través de diversos medios me hicieron llegar sus inquietudes y me incentivan día a día para continuar con esta publicación. Hasta el próximo número de Homeonews!!! Farm. Fernando Estévez Castillo Director: Fernando Estevez Castillo Homeonews 6 Edición N° 9 – Enero – Febrero - Marzo de 2008 FITOTERAPIA ACTIVIDAD ANTIINFLAMATORIA DEL TARAXACUM OFFICINALE Hye-Jin Jeona, Hyun-Jung Kangb, Hyun-Joo Junga, Young-Sook Kanga, ChangJin Limb, Young-Myeong Kimc, d and Eun-Hee Parka. a College of Pharmacy, Sookmyung Women's University, Cheongpa-dong, Yongsan-ku, Seoul 140-742, Republic of Korea. b Division of Life Sciences and Research Institute of Life Sciences, Kangwon National University, Chuncheon 200-701, Republic of Korea. c Department of Molecular and Cellular Biochemistry, School of Medicine, Kangwon National University, Chuncheon 200-701, Republic of Korea. d Vascular System Research Center, Kangwon National University, Chuncheon 200-701, Republic of Korea. [Journal of Ethnopharmacology 115 (2008) 82-88] RESUMEN El Taraxacum officinale ha sido ampliamente utilizado en la medicina folklórica para el tratamiento de diversas patologías. La planta seca fue extraida con alcohol 70% para obtener el extracto etanólico (TEE). Para los experimentos, se utilizaron distintas fracciones obtenidas a partir del TEE en forma sucesiva, acetato de etilo (EA), n-butanol (BuOH) y agua (Aq). TEE mostró actividad de captura de radicales libres en el ensayo con DPPH (1,1-diphenyl-2picrylhydrazyl), un efecto reductor de los niveles de las especies reactivas de oxígeno intracelulares (ROS), y una actividad antiangiogénica en el estudio de la membrana corioalantoidea del embrión de pollo (CAM). En el modelo de la bolsa de aire inducida por carragenina, TEE inhibió la producción de exudado, y redujo significativamente los niveles de óxido nítrico (NO) y leucocitos. También mostró un efecto inhibitorio sobre la permeabilidad vascular inducida por el ácido acético, así como también una inhibición dosis-dependiente en el ensayo de contorsión abdominal en ratones inducido por ácido acético. Fueron evaluados los efectos supresores del TEE en la producción de NO y la expresión de la óxido nítrico sintetasa inducible (iNOS) y la ciclooxigenasa-2 (COX-2) en macrófagos estimulados por lipopolisacáridos (LPS). Entre todas las fracciones, la de n-butanol (BuOH) resultó ser la más efectiva en el ensayo CAM. En síntesis el Taraxacum officinale posee actividades antiangiogénica, antiinflamatoria y antinoceptiva a través de la inhibición de la producción de NO y de la expresión de la COX-2 y/o su actividad antioxidante. Director: Fernando Estevez Castillo Homeonews 7 Edición N° 9 – Enero – Febrero - Marzo de 2008 Palabras clave: Taraxacum officinale; antinociceptivo; antiinflamatorio; antioxidante; ciclooxigenasa-2; óxido nítrico sintetasa inducible; óxido nítrico; especies reactivas del oxígeno. ARTICULO ORIGINAL 1-Introduction Some plants of the genus Taraxacum, known as dandelion, have long been used in folk medicine to treat hepatic disorders and some women's diseases, such as breast and uterus cancers, and as lactating, choleretic, diuretic, and anti-inflammatory remedies ([Ahmad et al., 2000] and [Kisiel and Barszcz, 2000]). Pharmacological activities of Taraxacum plants, especially Taraxacum officinale F. Weber ex Wiggers (Asteraceae), have been in part evaluated so far (Schutz et al., 2006). Taraxacum officinale was assessed to contain acute antiinflammatory activity by showing its protective effect against cholecystokinininduced acute pancreatitis in rats (Seo et al., 2005). Two flavonoid compounds, luteolin and luteolin-7-O-glucoside, rich in the ethyl acetate fraction of Taraxacum officinale suppress production of nitric oxide (NO) and prostaglandin E2 in LPS-activated RAW264.7 macrophage cells, which is attributed to the suppression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) (Hu and Kitts, 2004). On the contrary, the aqueous extract of Taraxacum officinale is able to enhance production of NO in interferon-γ (IFNγ)-activated mouse peritoneal macrophages through the induction of iNOS (Kim et al., 1999). Taraxacum officinale-induced apoptosis of human hepatoma HepG2 cells through tumor necrosis factor (TNF)-α and interleukin (IL)-1α secretion (Koo et al., 2004), and also showed cytotoxic activity in a human colon colorectal adenocarcinoma cell line Caco-2 (Hu and Kitts, 2003). However, in primary cultures of rat astrocytes stimulated with LPS and TNF-αinducing substance P, Taraxacum officinale significantly inhibits production of TNF-α by inhibiting IL-1 production, indicating an anti-inflammatory activity of Taraxacum officinale in the central nervous system (Kim et al., 2000). Additionally, other species of the genus Taraxacum were elucidated to contain various other pharmacological activities. The aqueous extract of Taraxacum mongolicum was elucidated to interact with a fluoroquinoline-type antibiotic, ciprofloxacin, which modifies its bioavailability and disposition (Zhu et al., 1999). Taraxacum japonicum exhibited strong anti-tumor-promoting activities on the two-stage carcinogenesis of mouse skin tumor induced by an initiator and a promoter, suggesting its chemopreventive activity (Takasaki et al., 1999). In the recent analysis, two new guaianolide glucosides, deacetylmatricarin 8-O-βglucopyranoside and 11β-hydroxyleukodin 11-O-β-glucopyranoside, were isolated from Taraxacum obovatum (Michalska and Kisiel, 2003), and taraxafolide and (+)-taraxafolin-B were newly identified from Taraxacum formosanum (Leu et al., 2005). Differences in constituents and pharmacological activities of various species in the genus Taraxacum remain obscure. The current work demonstrates that the ethanol extract of Taraxacum officinale possesses anti-angiogenic, anti-inflammatory and anti-nociceptive activities. It is Director: Fernando Estevez Castillo Homeonews 8 Edición N° 9 – Enero – Febrero - Marzo de 2008 also able to down-regulate production of NO and COX-2 and reduce level of reactive oxygen species (ROS) in the activated macrophage cells. 2-Materials and methods 2.1. Chemicals Indomethacin, dexamethasone, Evans blue, λ-carrageenan, 2,2-diphenyl-1picrylhydrazyl (DPPH), l-ascorbic acid, sodium dodecyl sulfate (SDS), leupeptin, pepstatin, phenylmethanosulfonyl fluoride (PMSF), Escherichia coli lipopolysaccharide (LPS), HEPES and Griess reagent were purchased from Sigma Chemical Co. (St. Louis, MI, USA). Dulbecco's-modified Eagle's medium (DMEM), fetal bovine serum (FBS), penicillin–streptomycin and trypsin–EDTA were from Gibco-BRL (Gaithersburg, MD, USA). All other chemicals used were of reagent grade or better. 2.2. Experimental animals The in vivo experiments were done using male ICR mice ( 25 g) or male Sprague–Dawley rats ( 140 g), which were purchased from Samtaco Animal Farm, Osan, Korea. The animal room was maintained at 23 ± 2 °C with a 12 h light/dark cycle. Food and tap water were supplied ad libitum. The ethical guidelines, described in the NIH Guide for Care and Use of Laboratory Animals, were followed throughout the experiments. 2.3. Plant material The dried aerial parts of Taraxacum officinale were purchased at Kyungdong Folk Medicine Market, Seoul, Korea in March 2004, and authenticated by Prof. Ki-Oug Yoo, Division of Life Sciences, Kangwon National University, Chuncheon, Korea. The voucher specimen of the plant material was deposited in the herbarium of the Division of Life Sciences, College of Natural Sciences, Kangwon National University under the acquisition no. KWNU56517. 2.4. Preparation of ethanol extract (TEE) and its fractions The dried plants were ground under liquid nitrogen and extracted for 1 month with 70% ethanol at room temperature. The ethanol extract (TEE) was evaporated in vacuo as previously described (Park et al., 2003). The yield was 18.4%. For fractionation, TEE was extracted successively with equal volumes of ethyl acetate (EA) and n-butanol (BuOH), leaving residual aqueous fraction (Aq). Each fraction was evaporated in vacuo to yield the residues of EA (10.2%), BuOH (21.7%) and Aq (68.1%) fractions, respectively. 2.5. Cell culture RAW264.7 cell line, a murine macrophage cell line, was from American Type Culture Collection (Manassas, VA, USA). The mammalian cells were cultured in Director: Fernando Estevez Castillo Homeonews 9 Edición N° 9 – Enero – Febrero - Marzo de 2008 Dulbecco's-modified Eagle's medium with 10% heat-inactivated fetal bovine serum (FBS), 25 mM HEPES (pH 7.5), 100 U/ml penicillin and 100 µg/ml streptomycin. The cells were plated at a density of 1 × 106 and preincubated for 24 h at 37 °C, and maintained in a humidified atmosphere containing 5% CO2. For all experiments, the cells were grown to 80–90% confluence, and subjected to no more than 20 cell passages. 2.6. Chorioallantoic membrane (CAM) assay Anti-angiogenic activity was determined using CAM assay as previously described (Song et al., 2004). The fertilized chicken eggs were kept in a humidified egg incubator at 37 °C. After 3.5-day incubation, about 2 ml of albumin was aspirated from the eggs through the small hole drilled at the narrow end of the eggs, allowing the small chorioallantoic membrane and yolk sac to drop away from the shell membrane. The shell covering the air sac was punched out and removed by forceps, and the shell membrane on the floor of the air sac was peeled away. In the 4.5-day-old chick embryo, a sample-loaded Thermanox coverslip was applied to the CAM surface. Two days after returning the chick embryo to the incubator, an appropriate volume of 10% fat emulsion (Intralipose, 10%) was injected into a 6.5-day-old embryo chorioallantois. The eggs were then observed under a microscope. The vascular response of each egg was graded as 0, 1+ or 2+. Convergence of a few vessels toward the CAM surface was denoted as 1+, while 2+ reflected an increased density and length of vessels toward the CAM face. 2.7. Assay for DPPH radical scavenging activity DPPH scavenging activity of TEE and its BuOH fraction was determined as previously described (Song et al., 2004). In brief, the reaction mixtures containing various concentrations of TEE or its BuOH fraction and 300 µM DPPH solution in a 96-well microtiter plate were incubated at 37 °C for 30 min, and absorbance was measured at 490 nm. 2.8. Acetic acid-induced vascular permeability According to a modification of the method of Whittle (1964), acetic acid-induced vascular permeability test was performed. Mice were divided into groups of eight. One hour after oral administration of vehicle (saline), TEE (50, 100 or 200 mg/kg) or aminopyrine (100 mg/kg), 1% Evans blue solution (0.1 ml/10 g body weight) was injected intravenously in each mouse. Thirty minutes later, 0.7% acetic acid (0.1 ml/10 g body weight) in saline was intraperitoneally injected. Thirty minutes after administration of acetic acid, the mice were sacrificed by cervical dislocation. Ten millilitres of saline was injected into the peritoneal cavity, and the washing solution was collected in a test tube. The concentration of Evans blue in the peritoneal cavity was determined by the absorbance at 630 nm in a spectrophotometer. The vascular permeability was represented in terms of the absorbance (A630) which leaked into the cavity. Experiments were performed in triplicate. Director: Fernando Estevez Castillo Homeonews 10 Edición N° 9 – Enero – Febrero - Marzo de 2008 2.9. Carrageenan-induced air pouch formation According to a modification of the procedure of Ghosh et al. (2000), λcarrageenan-induced air pouch formation was performed. Six days prior to drug treatment, the air pouch was formed in the intrascapular region of rats by initial subcutaneous injection of 20 ml sterile air and successive injections of 10 ml sterile air every 3 days to sustain its patency (Sedgwick and Lees, 1986). On day 0, vehicle (saline), TEE (1.0 mg per pouch), BuOH fraction (1.0 mg per pouch) or dexamethasone (0.01 mg per pouch) was injected into the pouch 1 h prior to the λ-carrageenan injection (0.1 ml of 1.0% solution) into the pouch. After 15 min, the pouch cavity was opened and the exudates were collected. The exudate volumes were measured using a graduate tube. Aliquots were diluted with Turk solution, and the polymorphonuclear leukocytes were counted in a standard hemocytometer chamber. Experiments were performed in triplicate. 2.10. Acetic acid-induced writhing response As described by Olajide et al. (2000), the response to an intraperitoneal injection of acetic acid solution, which manifests contraction of the abdominal muscles and stretching of hind limbs, was measured. Nociception was induced by intraperitoneal injection of 1.0% acetic acid solution at the dose of 0.1 ml/10 g body weight. Each experimental group of mice (n = 8) was orally treated with vehicle (saline), TEE (50, 100 or 200 mg/kg) or aminopyrine (100 mg/kg) as a positive control. From 10 min later, the number of writhes was counted during the 10 min period. Independent experiments were repeated three times. 2.11. Nitrite analysis Accumulated nitrite (NO2−) in the culture media and the exudates obtained from the air pouches was spectrophotometrically determined based on the Griess reaction (Sherman et al., 1993). The samples (100 µl) were incubated with 100 µl Griess reagent (6 mg/ml) at room temperature for 10 min, and then NO2− concentration was determined by the absorbance at 540 nm. The standard curve was constructed using the known concentrations of sodium nitrite. 2.12. Determination of intracellular ROS For analysis of intracellular ROS, the redox-sensitive fluorescent probe DCFHDA was used, as previously described (Royall and Ischiropoulos, 1993). Cells were incubated with 5 µM DCFH-DA for 30 min at 37 °C. The harvested cells were immediately analyzed by a flow cytometry. 2.13. Immunoblot analysis The RAW264.7 cells were incubated with LPS (1 µg/ml) in the presence or absence of TEE for 24 h and then washed twice with ice-cold phosphateDirector: Fernando Estevez Castillo Homeonews 11 Edición N° 9 – Enero – Febrero - Marzo de 2008 buffered saline (PBS). The cells were lysed in a buffer containing 20 mM HEPES (pH 7.9), 0.1 M KCl, 0.3 M NaCl, 10 mM EDTA, 1% SDS, 1 mM PMSF, 1 µg/ml leupeptin and 1 µg/ml pepstatin. Western blotting was performed as previously described (Kim et al., 2002). For immunoblotting, anti-inducible nitric oxide synthase (anti-iNOS; Transduction Laboratories, Lexington, KY, USA) and anti-cyclooxygenase-2 (anti-COX-2; Transduction Laboratories, Lexington, KY, USA) and anti-β-actin (Sigma–Aldrich, St. Louis, MO, USA) antibodies were used. 2.14. Statistical analysis The data were analyzed for statistical significance using Student's t-test. PValues less than 0.05 were considered to be significant. 3-Results and discussion Angiogenesis consists of degradation of the basement membrane of existing blood vessels, migration, proliferation and rearrangement of endothelial cells, and formation of new blood vessels (Risau, 1995). Down-regulation of angiogenesis has been considered to be advantageous for the prevention of neoplastic growth and inflammation. In reality, some anti-angiogenic substances are effective in animal models of arthritis, and several antirheumatic drugs, such as indomethacin, methotrexate and corticosteroids, contain anti-angiogenic activity (Tong et al., 2004). Current anti-angiogenic strategies are based on inhibition of endothelial cell proliferation, interference with endothelial cell adhesion and migration, and interference with metalloproteinases (Griffioen and Molema, 2000). The chick chorioallantoic membrane (CAM) assay was used for assessing the inhibitory activity of TEE and its fractions on vascular development. Retinoic acid was used as a positive control for the assay, since it inhibits angiogenesis by down-regulating the expression and release of pro-angiogenic factors (Iurlaro et al., 1998). The disk weight was unable to give any changes in vascular density, indicating that it was unable to affect the growth of blood vessels in the CAM assay (data not shown). After the 2-day treatment, retinoic acid at 1 µg per egg gave 82–90% in the branching patterns of blood vessels (Fig. 1 and Fig. 2). When 0.1, 0.3, 1.0 and 3.0 µg per egg of TEE was applied in the CAM assay, the inhibition percentages in CAM angiogenesis were measured to be 30.8, 44.4, 52.4 and 70.0%, respectively (Fig. 1). This indicates that TEE contains potent anti-angiogenic activity in a dose-dependent manner. TEE was successively fractionated using ethyl acetate and n-butanol to basically figure out the chemical characters of active anti-angiogenic principle(s) present in TEE. Among the fractions used, the BuOH fraction showed highest inhibitory activity in the CAM angiogenesis (Fig. 2A). When the BuOH fraction at 0.1, 0.3, 1.0 and 3.0 µg was applied in the assay, the inhibitory percentages were 34.2, 44.1, 60.0 and 69.2%, respectively (Fig. 2B). When luteolin, a flavonoid compound from Taraxacum officinale (Williams et al., 1996), at 0.3, 1.0 and 3.0 µg per egg was applied in the CAM assay, it gave rise to an inhibition of 52.4, 59.1 and 67.6% in the CAM angiogenesis, respectively. This Director: Fernando Estevez Castillo Homeonews 12 Edición N° 9 – Enero – Febrero - Marzo de 2008 result indicates that luteolin is one of anti-angiogenic principles in Taraxacum officinale, although it may not be a major anti-angiogenic component in Taraxacum officinale. Taken together, TEE possesses a strong antiangiogencic activity, and the BuOH fraction is most effective among the fractions. Luteolin might be partly responsible for anti-angiogenic activity of TEE. Anti-angiogenic activity of Taraxacum officinale might provide a pharmacological basis on its folkloric use for the treatment of inflammatory diseases and cancer. Fig. 1. Inhibitory effect of the 70% ethanol extract (TEE) prepared from Taraxacum officinale on the chick embryo chorioallantoic membrane (CAM) angiogenesis. Retinoic acid (RA, 1 µg per egg) was used as a positive control. Each column represents mean ± S.E. *P < 0.05; **P < 0.01; ***P < 0.001. Fig. 2. Inhibitory effects of TEE fractions (A) and dose-dependent anti-angiogenic activity of n-butanol fraction (BuOH) (B) on the chick embryo chorioallantoic membrane (CAM) angiogenesis. Retinoic acid (RA, 1 µg per egg) was used as a positive control. One microgram of each fraction was applied per egg. EA: ethyl acetate fraction; BuOH: n-butanol fraction; Aq: aqueous fraction. Each column represents mean ± S.E. *P < 0.05; **P < 0.01; ***P < 0.001. In order to assess an anti-inflammatory activity of TEE, the two inflammatory models, such as acetic acid-induced vascular permeability and carrageenaninduced air pouch models, were used. In vascular permeability assay, mediators of inflammation, released following stimulation, leads to dilation of arterioles and venules and increased vascular permeability (Vogel and Vogel, 1997). TEE at the oral doses of 50, 100 and 200 mg/kg showed an inhibition in vascular permeability, respectively (Table 1). From this finding, it is assumed Director: Fernando Estevez Castillo 13 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 that an anti-inflammatory activity of TEE arises from its protection on the release of inflammatory mediators at the first stage. The carrageenan-induced air pouch model is known to be an excellent acute inflammatory model in which fluid extravasation, leukocyte migration and various biochemical parameters in the exudate involved in the inflammatory response can be easily detected. The injection of carrageenan into a subcutaneous air pouch on the dorsal surface of rats initiates an inflammatory process. In the carrageenan-induced air pouch model, dexamethasone (0.01 mg per pouch), a nonselective cyclooxygenase inhibitor, reduced the volumes of the exudates by 53.7% (Table 2). Treatment with TEE (1.0 mg per pouch) and the BuOH fraction (1.0 mg per pouch) gave rise to an inhibition in the exudates volume, with respect to the control (Table 2). Total numbers of the polymorphonuclear leukocytes in the air pouches were also diminished by the treatment with TEE and the BuOH fraction (Table 2). Luteolin at 0.1 mg/kg also diminished the volume of exudate and total number of the polymorphonuclear leukocytes in the air pouch by 14.1 and 35.3%, respectively. Collectively, TEE is confirmed to possess an acute antiinflammatory activity. Table 1. Effect of TEE on acetic acid-induced vascular permeability in mice Group Dose (mg/kg, p.o.) A630 Inhibition (%) Control – 2.24 ± 0.08 – TEE 50 1.73 ± 0.18 23.1 TEE 100 1.18 ± 0.08** 47.5 TEE 200 0.57 ± 0.11*** 74.8 AP 100 0.30 ± 0.04*** 86.6 The results are expressed as mean ± S.E. of n = 8. Inhibition percentages were calculated with respect to the control treated with saline only. Aminopyrine (AP) was chosen as a positive control. **P < 0.01; ***P < 0.001, compared with the control group. Table 2. Effects of TEE and its BuOH fraction on carrageenan-induced air pouch model in rats Exudate (ml) Total leukocytes (×105 cells) NO (µM) Control – 8.04 ± 0.07 1427.1 ± 74.2 25.2 ± 2.4 TEE 5.64 ± 0.27* 710.1 ± 64.5** (50.2) 14.0 ± 1.2* Group Dose (mg per pouch) 1.0 Director: Fernando Estevez Castillo 14 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Group Dose (mg per pouch) Exudate (ml) Total leukocytes (×105 cells) (29.9) NO (µM) (44.4) BuOH 1.0 5.41 ± 0.20* (32.7) 564.7 ± 22.5** (60.4) 10.9 ± 0.6* (56.7) DEXA 0.01 3.72 ± 0.29** (53.7) 343.1 ± 25.0*** (76.0) 3.7 ± 0.5* (85.3) The results are expressed as mean ± S.E. of n = 8. Figures in parentheses indicate inhibitory percentages with respect to the corresponding control. Dexamethasone (DEXA) was used as a positive control. *P < 0.05; **P < 0.01; ***P < 0.001, compared with the control group. Since TEE was identified to have anti-inflammatory activity in acetic acidinduced vascular permeability (Table 1) and carrageenan-induced air pouch (Table 2) models, its anti-nociceptive activity was examined using acetic acidinduced writhing response. As shown in Fig. 3, TEE at 50, 100 and 200 mg/kg, p.o., caused an inhibition by 35.1, 54.8 and 78.0%, respectively, in the writhing response induced by acetic acid. Its inhibitory activity appeared to be dosedependent. The degree of inhibition at 200 mg/kg was comparable to the value obtained with 100 mg/ml aminopyrine used as a positive control (Fig. 3). This finding indicates that TEE also contains potent anti-nociceptive activity in addition to anti-inflammatory activity, subsequently suggesting that prostaglandin biosynthesis might be commonly involved in the anti-inflammatory and anti-nociceptive activities of TEE. Fig. 3. Effect of TEE on the acetic acid-induced writhing response in mice. TEE (50, 100 or 200 mg/kg) was orally administered. Aminopyrine (AP, 100 mg/kg body weight) was used as a positive control. Experiments were performed in triplicate. Each column represents mean ± S.E. *P < 0.05; **P < 0.01; ***P < 0.001. Nitric oxide (NO) is one of well-known pro-inflammatory mediators in the pathogenesis of inflammation. For the expression of inducible nitric oxide synthase (iNOS), the mammalian cells should be triggered by specific stimulants such as pro-inflammatory cytokines and bacterial lipopolysaccharide (LPS; Chesrown et al., 1994). Since iNOS-derived NO is involved in inflammation (Singh et al., 2000), suppression of iNOS is closely linked with anti-inflammatory action. Inhibitory effect of TEE was examined on LPS-induced NO production in the RAW264.7 macrophages (Fig. 4). The accumulated nitrite, determined by the Griess method, in the medium was used as an index for NO Director: Fernando Estevez Castillo Homeonews 15 Edición N° 9 – Enero – Febrero - Marzo de 2008 level. After the treatment with LPS, the nitrite content markedly increased (Fig. 4). When the macrophage cells were treated with 0.25, 0.5 and 1.0 mg/ml TEE, NO production induced by LPS was significantly suppressed in a dosedependent manner (Fig. 4). No significant cytotoxic effects on the macrophages were observed at the used concentrations of TEE, which was determined by MTT assay (data not shown). With the assumption that the inhibition of NO production by TEE would be caused by a down-regulation in the iNOS protein level, the effect of TEE on the iNOS expression was examined in the macrophages cells treated with LPS. As shown in Fig. 5, TEE dose-dependently suppressed iNOS induction without changes in the levels of β-actin, an internal control, indicating the specific inhibition of iNOS expression by TEE. Suppressive effect of TEE on the production of NO was confirmed in in vivo experiments. As shown in Table 2, TEE gave rise to a marked decrease on the content of nitrite in the exudates obtained from the carrageenan-induced air pouch model, which corresponds with the in vitro results obtained with using the macrophages (Fig. 4). Luteolin was also able to decrease the nitrite level in the carrageenan-induced air pouch (data not shown), supporting that luteolin is one of anti-inflammatory principles in Taraxacum officinale. This corresponds with the in vitro finding that luteolin could suppress iNOS induction in the LPSactivated RAW264.7 macrophages (Hu and Kitts, 2004). In contrast to constitutive cyclooxygenase-1 (COX-1), inducible cyclooxygenase-2 (COX-2) is activated by tissue damage during inflammatory process. Various natural products of plant and marine origin have been shown to contain their antiinflammatory activities through suppression of COX-2 (Jachak, 2006). In a dose-dependent manner, TEE was also able to suppress COX-2 expression in LPS-stimulated RAW264.7 macrophage cells (Fig. 5). Based on this finding, TEE is assumed to show its anti-inflammatory activity via the suppression of COX-2 expression. Taken together, it is likely that TEE shows its antiinflammatory and anti-nociceptive activities through the reduction of NO production and COX-2 expression. Fig. 4. Inhibitory effect of TEE on LPS-induced NO production in RAW264.7 macrophage cells. The values are mean ± S.E. of the three independent experiments. ***P < 0.001. Director: Fernando Estevez Castillo Homeonews 16 Edición N° 9 – Enero – Febrero - Marzo de 2008 Fig. 5. Inhibitory effect of TEE on LPS-induced production of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) in RAW264.7 macrophage cells. β-Actin was used as an internal control. This blot is a representative of the three independent experiments. Many anti-inflammatory agents of medicinal herbal origin have also been known to possess antioxidant activities. TEE was able to directly scavenge the stable DPPH radical in a concentration-dependent manner (Fig. 6). The BuOH fraction showed a little higher scavenging activity (Fig. 6). Although ROS at low concentrations play the role of an intracellular messenger of various physiological events, including cell proliferation and apoptosis, the production of large amounts of ROS is considered cytotoxic and related with various disorders. As shown in Fig. 7, TEE was able to reduce ROS level, which was elevated by LPS in the macrophages. This is consistent with the previous finding that dandelion flower extract was capable of suppressing superoxide and hydroxyl radical (Hu and Kitts, 2005). Taken together, it is likely that TEE shows its anti-angiogenic, anti-inflammatory and anti-nociceptive activities through reduction of NO production, down-regulation of COX-2 expression and reduction of ROS level. Fig. 6. The DPPH scavenging activity of TEE. Vitamin C (○) was used as a positive control. DPPH concentration used was 100 µM. A representative of three independent experiments is shown. Fig. 7. Effect of TEE on reactive oxygen species (ROS) level in RAW264.7 macrophage cells activated with LPS. ROS level was represented as DCF fluorescence. *P < 0.05. 4. Conclusions Director: Fernando Estevez Castillo Homeonews 17 Edición N° 9 – Enero – Febrero - Marzo de 2008 In conclusion, the ethanol extract of Taraxacum officinale F. Weber ex Wiggers (TEE) contains anti-angiogenic, acute anti-inflammatory and anti-nociceptive activities. The BuOH fraction is most effective in the CAM assay among the fractions of TEE. TEE also possesses an inhibitory activity on in vitro NO production in the stimulated mammalian cells and in vivo NO production in the air pouch. It is capable of diminishing expression of iNOS and COX-2 in LPSstimulated RAW264.7 cells. TEE also possesses a scavenging activity on DPPH and a reducing activity on ROS level in LPS-activated macrophages. These findings provide additional pharmacological information on the therapeutic efficacy of Taraxacum officinale. It would be regarded as another starting point for the development of an anti-inflammatory therapy with fewer side effects. Acknowledgement This work was supported by the SRC program of MOST/KOSEF (R11-2005017). References Ahmad et al., 2000 V.U. Ahmad, S. Yasmeen, Z. Ali, M.A. Khan, M.I. Choudhary, F. Akhtar, G.A. Miana and M. 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Barszcz, Further sesquiterpenoids and phenolics from Taraxacum officinale, Fitoterapia 71 (2000), pp. 269–273. Koo et al., 2004 H.-N. Koo, S.-H. Hong, B.-K. Song, C.-H. Kim, Y.-H. Yoo and H.-M. Kim, Taraxacum officinale induces cytotoxicity through TNF-α and IL-1α secretion in HepG2 cells, Life Sciences 74 (2004), pp. 1149–1157. Leu et al., 2005 Y.-L. Leu, Y.-L. Wang, S.-C. Huang and L.-S. Shi, Chemical constituents from roots of Taraxacum formosanum, Chemical and Pharmaceutical Bulletin 53 (2005), pp. 853–855. Michalska and Kisiel, 2003K. Michalska and W. Kisiel, Sesquiterpene lactones from Taraxacum obovatum, Planta Medica 69 (2003), pp. 181–183. Olajide et al., 2000 O.A. Olajide, S.O. Awe, J.M. Makinde, A.I. Ekhelar, A. Olusola, O. Morebise and D.T. Okpako, Studies on the anti-inflammatory, antipyretic and analgesic properties of Alstonia boonei stem bark, Journal of Ethnopharmacology 71 (2000), pp. 179–186. Park et al., 2003 E.-H. Park, M.-H. Joo, S.-H. Kim and C.-J. Lim, Antiangiogenic activity of Gardenia jasminoides fruit, Phytotherapy Research 17 (2003), pp. 961–962. Director: Fernando Estevez Castillo Homeonews 19 Edición N° 9 – Enero – Febrero - Marzo de 2008 Risau, 1995 W. Risau, Differentiation of endothelium, FASEB Journal 9 (1995), pp. 926–933. Royall and Ischiropoulos, 1993 J.A. Royall and H. Ischiropoulos, Evaluation of 2′,7′-dichlorofluorescin and dihydrorhodamine 123 as fluorescent probes for intracellular H2O2 in cultured endothelial cells, Archives of Biochemistry and Biophysics 302 (1993), pp. 348–355. Schutz et al., 2006 K. Schutz, R. Carle and A. Schieber, Taraxacum—a review on its phytochemical and pharmacological profile, Journal of Ethnopharmacology 107 (2006), pp. 313–323. Sedgwick and Lees, 1986 A.D. Sedgwick and P. Lees, Studies of eicosanoid production in the air pouch model of synovial inflammation, Agents and Actions 18 (1986), pp. 429–438. Seo et al., 2005 S.-W. Seo, H.-N. Koo, H.-J. An, K.-B. Kwon, B.-C. Lim, E.-A. Seo, D.-G. Ryu, G. Moon, H.-Y. Kim, H.-M. Kim and S.-H. Hong, Taraxacum officinale protects against cholecystokinin-induced acute pancreatitis in rats, World Journal of Gastroenterology 11 (2005), pp. 597–599. Sherman et al., 1993 M.P. Sherman, E.E. Aeberhard, V.Z. Wong, J.M. Griscavage and L.J. Ignarro, Pyrrolidine dithiocarbamate inhibits induction of nitric oxide synthase activity in rat alveolar macrophages, Biochemical and Biophysical Research Communications 191 (1993), pp. 1301–1308. Singh et al., 2000 V.K. Singh, S. Mehrotra, P. Narayan, C.M. Pandey and S.S. Agarwal, Modulation of autoimmune diseases by nitric oxide, Immunologic Research 22 (2000), pp. 1–19. Song et al., 2004 Y.S. Song, S.H. Kim, J.H. Sa, C. Jin, C.-J. Lim and E.-H. Park, Anti-angiogenic and inhibitory activity on inducible nitric oxide production of the mushroom Ganoderma lucidum, Journal of Ethnopharmacology 90 (2004), pp. 17–20. Takasaki et al., 1999 M. Takasaki, T. Konoshima, H. Tokuda, K. Masuda, Y. Arai, K. Shiojima and H. Ageta, Anti-carcinogenic activity of Taraxacum plant. 1, Biological and Pharmaceutical Bulletin 22 (1999), pp. 602–605. Tong et al., 2004 Y. Tong, X. Zhang, W. Zhao, Y. Zhang, J. Lang, Y. Shi, W. Tan, M. Li, Y. Zhang, L. Tong, H. Lu, L. Lin and J. Ding, Anti-angiogenic effects of shiraiachrome A, a compound isolated from a Chinese folk medicine used to treat rheumatoid arthritis, European Journal of Pharmacology 494 (2004), pp. 101–109. Vogel and Vogel, 1997 H.G. Vogel and W.H. Vogel, Drug Discovery and Evaluations, Pharmacological Assays, Springer, Berlin (1997) pp. 402–403. Director: Fernando Estevez Castillo Homeonews 20 Edición N° 9 – Enero – Febrero - Marzo de 2008 Whittle, 1964 B.A. Whittle, The use of changes in capillary permeability in mice to distinguish between narcotic and nonnarcotic analgesics, British Journal of Pharmacology and Chemotherapeutics 22 (1964), pp. 246–253. Williams et al., 1996 C.A. Williams, F. Goldstone and J. Greenham, Flavonoids, cinnamic acids and coumarins from the different tissues and medicinal preparations of Taraxacum officinale, Phytochemistry 42 (1996), pp. 121–127. Zhu et al., 1999 M. Zhu, P.Y. Wong and R.C. Li, Effects of Taraxacum mongolicum on the bioavailability and disposition of ciprofloxacin in rats, Journal of Pharmaceutical Sciences 88 (1999), pp. 632–634. ALOPATIA LA INMUNOSUPRESION INDUCIDA POR RADIACION UV ES MAYOR EN HOMBRES Y PUEDE SER PREVENIDA POR NICOTINAMIDA TOPICA Diona L Damian1, Clare R S Patterson1, Michael Stapelberg1, Joohong Park1, Ross St C Barnetson1 and Gary M Halliday1 1 Department of Dermatology, Melanoma and Skin Cancer Research Institute, Sydney Cancer Centre, University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia [Journal of Investigative Dermatology (2008) 128, 447-454] RESUMEN La inmunosupresión inducida por radiación UV aumenta la carcinogénesis cutánea. La incidencia de de cancer de piel continúa aumentando a pesar del incremento del uso de los filtros solares, los cuales son menos efectivos en prevenir la inmunosupresión que las quemaduras solares. Utilizando la reacción de Mantoux como un modelo de la inmunidad de la piel, se investigó los efectos de las radiaciones UV solares simuladas (ss) y sus componentes UVA y UVB, además de ensayar la capacidad de la nicotinamida de uso tópico para proteger de la inmunosupresión inducida por radiación UV. En un ensayo a doble ciego, voluntarios sanos que dieron positiva la reacción de Mantoux, fueron irradiados sobre sus espaldas, a las cuales le aplicaron previamente, en diferentes sitios, nicotinamida 5% o el vehículo. Posteriormente la evaluación de los sitios irradiados y los adyacentes no irradiados, permitieron medir la inmunosupresión inducida por UV con y sin nicotinamida. Las dosis de suberitema ssUV produjeron inmunosupresión significativa, a diferencia de sus componentes UVB y UVA aplicados independientemente. Los hombres fueron inmunosuprimidos por dosis ssUV tres veces menores a aquellas requeridas para inmunosuprimir a las mujeres. Esta puede ser una causa importante de la Director: Fernando Estevez Castillo Homeonews 21 Edición N° 9 – Enero – Febrero - Marzo de 2008 mayor incidencia y mortalidad de cáncer de piel, observada en hombres. La nicotinamida resultó ser un agente preventivo de la inmunosupresión, cuyo mecanismo de protección puede ser dilucidado a través de estudios genéticos, sugiriendo alteraciones en las proteinas del complemento, el metabolismo energético y los caminos de la apoptosis. La nicotinamida es una droga segura y barata que podría incorporarse a los protectores solares o a los productos post-solares, para mejorar la protección contra la inmunosupresión. ARTICULO ORIGINAL Introduction Skin cancer is the most common form of malignancy in Caucasian populations (Diepgen and Mahler, 2002). Immunosuppression enhances the development of skin cancers, as seen most dramatically in transplant recipients whose skin cancer risk is severalfold higher than that of the immunocompetent population (Bordea et al., 2004). UV radiation in sunlight has profound immunosuppressive effects on the skin (Damian et al., 2001), which play a central role in cutaneous carcinogenesis (Noonan et al., 2003; Ullrich, 2005). The exact mechanisms of UV-induced immunosuppression, and the relative contribution of UVB (290– 320 nm) and UVA (320–400 nm), are as yet unclear. Various animal and human models of skin immunity have been used to demonstrate UV-induced immunosuppression in vivo. UV irradiation can impair both induction (primary sensitization) and elicitation of immune responses to cutaneous allergens (Damian et al., 2001; Wolf et al., 2003). Systemic UVinduced immunosuppression can be measured following sensitization at a site distant from the irradiated field, whereas local immunosuppression is observed when antigen is applied at the site of UV exposure. Mantoux testing with tuberculin purified protein derivative (PPD) is used in clinical practice to assess tuberculosis immunity and exposure status. Mantoux-positive subjects, who have been either exposed to tuberculosis or vaccinated with Bacille CalmetteGuerin, develop localized induration and erythema 48–72 hours after intradermal injection of PPD. The diameter of induration can be measured clinically using the "pen method" whereby a ballpoint pen is used to mark the outer aspects of the Mantoux response (Bouros et al., 1991). Erythema at reaction sites, assessed via reflectance spectrometry, provides a more sensitive measure of Mantoux intensity, which correlates well with the diameter of induration (Damian and Halliday, 2002). Men have both a higher incidence of and mortality from skin cancer (Foote et al., 2001; Molife et al., 2001) but the effect of gender on susceptibility to UVinduced immunosuppression in humans is unknown. Immunosuppression occurs with UV doses well below the sunburn threshold, and sunscreens may be less effective at preventing immunosuppression than sunburn (Damian et al., 1999; Poon et al., 2003); improved protection from the immune effects of UV is thus likely to reduce the incidence of malignant and premalignant skin lesions. Director: Fernando Estevez Castillo Homeonews 22 Edición N° 9 – Enero – Febrero - Marzo de 2008 Nicotinamide, the active form of vitamin B3, is used clinically in the treatment of a variety of inflammatory skin disorders including bullous pemphigoid, acne, and rosacea (Niren, 2006). Although the exact mechanism of action in these settings is unknown, nicotinamide is a known endogenous inhibitor of the nuclear enzyme poly-ADP-ribose polymerase (PARP), which regulates the expression of immunomodulatory proteins such as inducible nitric oxide synthase, intercellular adhesion molecule 1, major histocompatibility complex class II, and NF- B (Virag and Szabo, 2002). Nicotinamide has also been shown to prevent UV-induced immunosuppression and carcinogenesis in mice (Gensler, 1997, 1999) but its effects on UV immunosuppression in humans have not yet been investigated. We have previously shown that UV exposure attenuates Mantoux reactions in Bacille Calmette-Guerin-vaccinated volunteers (Damian et al., 1998; Friedmann et al., 2004), and now report the effects of gender and nicotinamide on UV-induced suppression of the Mantoux reaction in humans. Results Subjects: Of 75 people who started the protocol, 5 did not complete due to unrelated reasons. None of the subjects who completed the study were excluded from the results and none suffered significant adverse effects from the study. Table 1 shows the similar characteristics of volunteers who completed the various studies Mantoux-induced erythema increases in proportion to PPD dose Although all subjects had initial Mantoux tests performed the week before UV irradiation, only 12 volunteers from various study groups were initially tested with the PPD dose combination of 1, 2, and 5 U (Figure S1). The erythema index (EI) of subsequent Mantoux reactions was significantly correlated with PPD dose, as shown by a repeated measures linear regression (r=0.705, n=36, P<0.001). UV irradiation did not cause systemic immunosuppression The initial, pre-irradiation Mantoux tests (lateral lower back) were compared with those of unirradiated nicotinamide- and vehicle-treated controls adjacent to the irradiated areas (medial lower back). Subjects were excluded from this analysis if initial PPD doses were different from those subsequently used. The mean EI of the initial Mantoux tests did not significantly differ from subsequent control tests in any of the groups. Therefore, solar-simulated (ss) UV, UVB, or UVA exposure did not cause systemic suppression of Mantoux reactions. Nicotinamide in the absence of UV had no immune effects in any study, as the EI of unirradiated control sites treated with nicotinamide did not differ from the Director: Fernando Estevez Castillo Homeonews 23 Edición N° 9 – Enero – Febrero - Marzo de 2008 EI of unirradiated initial or vehicle-treated sites. Similarly, there was no significant difference in the unirradiated control EI of men and women. Topical 5% nicotinamide prevents ssUV-induced immunosuppression but not sunburn The effect of 5% nicotinamide applied before ssUV exposure in 20 volunteers (10 men, 10 women) is shown in Figure 1a. Exposure of vehicle-treated skin to 1.48 or 2.22 J/cm2 ssUV for 3 consecutive days significantly suppressed Mantoux reactions by 19.4% (mean EI=13.8, SEM=3.7; P<0.01) and 27.7% (mean EI=19.8, SEM=2.8; P<0.001), respectively. When irradiated nicotinamide-treated sites were compared with unirradiated nicotinamidetreated control sites, significant immunosuppression no longer occurred. Hence, 5% nicotinamide applied before exposure prevented ssUV-induced immunosuppression. This protective effect of nicotinamide treatment was confirmed by repeated measures analysis of variance (P<0.0001). The effect of nicotinamide applied immediately after irradiation in the second group of 20 volunteers (10 men, 10 women) is shown in Figure 1b. There were no significant differences in baseline characteristics between the two groups. Three consecutive daily exposures to 0.74 J/cm2 suppressed Mantoux reactions by 24.8% (mean EI=16.3, SEM=6.2; P<0.05) and exposures to 1.48 and 2.22 J/cm2 caused suppression of 29.1% (mean EI=19.2, SEM=6.2; P<0.05) and 43.8% (mean EI=28.8, SEM=5.7; P<0.001), respectively. At each of the three fixed doses, significant immunosuppression was prevented by application of 5% nicotinamide after irradiation. The protective effect of nicotinamide treatment was again confirmed by repeated measures analysis of variance (P<0.0001). The minimal erythema dose (MED) was unchanged by nicotinamide applied before or after ssUV exposure (Table 2; paired two-tailed Student's t-test). Mean erythema (EI) at vehicle-treated MED sites was not significantly different to the EI at the nicotinamide-treated site exposed to the same UV dose whether nicotinamide was applied before or after ssUV exposure. Hence, nicotinamide did not prevent sunburn. Spectrophotometry (Ultrospec 2100 pro UV/Visible Spectrophotometer, Biochrom Ltd, Cambridge, UK) of 5% nicotinamide in vehicle confirmed negligible absorption between 290 and 400 nm. Director: Fernando Estevez Castillo Homeonews 24 Edición N° 9 – Enero – Febrero - Marzo de 2008 Figure 1 Topical 5% nicotinamide protects from immunosuppression when applied before (a) or after (b) ssUV exposure. Results are presented as mean+SEM; * P<0.05, ** P<0.01, and *** P<0.001 (compared with unirradiated site, paired twotailed Student's t-test; Bonferroni correction applied; each n=20). Director: Fernando Estevez Castillo 25 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Table 1. Baseline characteristics of volunteers Nicotinamide and ssUV Nicotinamide before and after combined1 Characteristic Before (n=20) After (n=20) Females (n=18) Males (n=18) UVA only (n=15; 7 men) Age (years) (range) 35 (22– 63) 38 (23– 62) 41 (2563) 32 (2356) 30 (20– 54) 31 (20–50) 33 (21–50) MED J/cm2 ssUV (range) 2.15 (1.11– 3.01) 2.06 (0.74– 3.72) 2.15 (1.113.75) 2.05 (0.74– 3.7) 2.64 (0.79– 7.95) not determined 4.22 (2.69– 7.68) Skin color Melanin index in relative units (range) -76 (129 to 5) -59 (117 to 20) -79 (123 to 36) -60 (129 to 5) -35 (130 to 148) -40 (-130 to 25) -58 (-105 to 14) 5:9:6:0 5:10:5:0 4:11:3:0 6:6:6:0 6:4:4:1 3:5:7:0 2:2:0:1 Number of subjects 2 2 2 2 3 2 2 Previous NMSC3 0 2 1 1 1 0 0 UVB only (n=15; 8 men) Microarray (n=5; 4 men) Skin type I/II/III/IV2 Current smokers MED, minimal erythema dose; NMSC, non-melanoma skin cancer; ssUV, solarsimulated UV. 1 Two women and two men participated in both studies therefore one set of each of their results was excluded from analysis. 2 Fitzpatrick's skin types (Fitzpatrick, 1998): I, constitutive skin color pale, does not tan; II, pale, tans with difficulty; III, pale, tans readily; IV, light brown, tans profusely. 3 No patients had previous melanoma. Director: Fernando Estevez Castillo 26 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Table 2 Nicotinamide application Before ssUV After ssUV Vehicle (Jcm2) Nicotinamide (J/cm2) Pvalue MED 2.15 0.11 2.12 0.12 0.61 EI at MED 85 6.82 79 5.38 0.214 MED 2.06 0.19 2.12 0.21 0.46 EI at MED 89 6.85 85 6.68 0.148 EI, erythema index; MED, minimal erythema dose; ssUV, solar-simulated UV. In 20 volunteers, nicotinamide was applied 15 minutes before MED testing on one side of the back whereas at the same time base lotion was applied on the other side of the back. There was no significant difference between the mean MED (shown SEM), nor in the mean EI at skin irradiated with one vehicle-treated MED (EI at MED) between base lotion-treated sites and nicotinamide-treated sites. In 20 volunteers, nicotinamide was applied immediately after MED testing on one side of the back and base lotion was applied on the other side of the back. Again, there was no significant difference between the mean MED between base lotion-treated sites and nicotinamide-treated sites. Figure 2 Men are more immunosuppressed by ssUV than women. Results are presented as mean SEM; * P<0.01 and ** P<0.001 (compared with unirradiated site, paired two-tailed Student's t-test; Bonferroni correction applied; n=36). Director: Fernando Estevez Castillo 27 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Men are more susceptible to ssUV-induced immunosuppression than women To analyze the effects of gender, subjects from both ssUV studies, in which the irradiation protocols were identical, were combined. When the studies were analyzed separately, the results were similar and therefore we present the results of the combined studies only. Four subjects participated in both studies. One set of their results was therefore excluded, based on matching MEDs as evenly as possible for male and female volunteers. Four of the female volunteers were taking oral contraceptives, 5 were postmenopausal, and 9 were premenopausal. Because of the small numbers of women in each group, it was not possible to correlate hormonal status with susceptibility to immunosuppression. When ssUV-induced immunosuppression at vehicle-treated sites was compared between men and women, men were significantly more immunosuppressed than women (repeated measures analysis of variance P=0.0224) and the threshold dose for immunosuppression was at least three times lower in men than women (Figure 2). Among male volunteers, significant immunosuppression was observed at all doses of ssUV, whereas female volunteers were only significantly immunosuppressed by the highest dose. Although both men and women were significantly immunosuppressed by the highest ssUV dose, immunosuppression was 40% greater in men. Nicotinamide prevented suppression of Mantoux responses in both men and women (results not shown). In this combined group of volunteers, immunosuppression following exposure to the two highest ssUV doses correlated to MED (r=-0.587, P<0.001 and r=-0.353, P<0.05, respectively, using linear regression analysis); subjects who were more easily sunburned were also more susceptible to UV immunosuppression. Component UVB and immunosuppressive UVA doses were not independently The effect of irradiation with UVA or UVB alone on the Mantoux response was investigated in separate groups of 15 volunteers. Subjects were exposed to UVA or UVB on 3 consecutive days at doses equivalent to the UVA and UVB components of the previously used ssUV doses (0.75, 1.50, and 2.24 J/cm2 of UVA and 0.075, 0.150, and 0.225 J/cm2 of UVB). Comparison of Mantouxinduced erythema at irradiated and unirradiated sites showed no significant immunosuppression at any dose of UVB or UVA. Nicotinamide had no immune effects in this experiment (Figure S2). Genes involved in complement, energy metabolism and apoptosis pathways are differentially regulated in vehicle- and nicotinamide-treated irradiated skin Six healthy volunteers (five men and one woman) were recruited for ssUV irradiation, biopsy, and microarray analysis. In each volunteer, two microarrays were compared and analyzed (vehicle-treated unirradiated vs vehicle-treated Director: Fernando Estevez Castillo Homeonews 28 Edición N° 9 – Enero – Febrero - Marzo de 2008 irradiated sites; and nicotinamide-treated unirradiated vs nicotinamide-treated irradiated sites). Results from one (male) volunteer were excluded because of technical inability to extract the microarray data due to inadequate hybridization. Gene set enrichment analysis (GSEA) (false discovery rate 0.25, P<0.05) was applied to identify differentially regulated functional gene sets. In vehicle-treated skin, no significantly enriched pathways were upregulated by ssUV irradiation. Instead, a number of pathways were downregulated, including those relating to apoptosis (10 pathways), energy metabolism (5 pathways), and immune function including complement (4 pathways) (Tables S1 and S2). Highly overlapping genes in apoptosis-related pathways were protein kinase C (PRKCA), cytochrome c (CYCS), insulin-like growth factor 1 receptor (IGF1R), BAD, BCL2, AKT1, caspase 3 (CASP3), HRAS, and TP53. In energy-related pathways, the leading edge subset of genes in the electron transport chain pathway (i.e., the genes most responsible for the enrichment signal) were mitochondrial ATP synthase (ATP5A1), succinate dehydrogenase complex subunits a and b (SDHA, SDHB), and cytochrome c (CYCS), which are key genes in energy production. In the citrate pathway, the nicotinamide adenine dinucleotide (NAD+)-dependent enzymes isocitrate dehydrogenase (IDH1, IDH3B) and succinate-CoA ligase (SUCLG1, SUCLA2) were also downregulated. The leading edge subset of genes in complement pathways were C1Q, C1R, C1S, C4b, and C3. In nicotinamide-treated skin, significant downregulation of these pathways was no longer observed. Hence, nicotinamide inhibited ssUV-induced dysregulation of these genes. In nicotinamide-treated irradiated skin, there was upregulation of the cadmium induces DNA synthesis and proliferation in macrophages (cdmac) pathway with leading edge subset genes comprising PLCB1, PRKCA, PRKCB1, HRAS, CUZD1, MAP2K1 (MEK1 or MKK1), MAPK3 (ERK1), TNF, and RELA. The histone deacetylase (hdac) pathway (involved in calcium regulation; McKinsey et al., 2000) was downregulated by ssUV in the presence of both vehicle and nicotinamide (leading edge genes in nicotinamide skin AKT1, CALM2, CAMK1, HDAC5, MEF2A, MEF2C, and NFATC2). Pathways for arginine and proline metabolism were also downregulated in nicotinamide-treated irradiated skin. The genes in these pathways, involved in energy metabolism such as providing precursors to the citrate cycle (Davis, 1986) were NOS3, GOT1, CKM, ASS, SMS, AMD1, CPS1, AOC3, OAT, and CKMT2. Discussion Topical application of nicotinamide prevented UV-induced immunosuppression when applied either before or after UV exposure. The ssUV used in this study closely approximated the spectrum of natural sunlight, and was delivered at doses equivalent to those readily encountered on a daily basis. ssUV equivalent to 8 minutes of sun exposure (COLIPA, 1994) on 3 consecutive days caused more than 40% immunosuppression, and immunosuppression of 25% was caused by UV doses well below the average MED. Hence, significant immunosuppression occurred in the absence of sunburn. Director: Fernando Estevez Castillo Homeonews 29 Edición N° 9 – Enero – Febrero - Marzo de 2008 Immunosuppression was prevented at all doses tested, with no adverse effects, when nicotinamide was applied before or after UV exposure. The protective effects of nicotinamide therefore do not result from sunscreening activity. This was confirmed by the lack of effect on MED and negligible UV absorbance by spectrophotometry. Although the baseline characteristics of the two ssUV groups were similar, the second group showed higher levels of immunosuppression. This is likely to reflect normal interindividual variation in susceptibility to UV-induced immunosuppression (Damian et al., 1998; Kelly et al., 2000). Individuals who are more susceptible to UV-induced immunosuppression are at a greater risk of both melanoma and non-melanoma skin cancer (Yoshikawa et al., 1990); however, identifying these individuals is difficult as there are no clinically recognizable signs of cutaneous immunosuppression. As previously reported by Kelly et al. (2000), we found that immunosuppression was significantly correlated to sunburn threshold; palerskinned individuals were more susceptible to not only sunburn, but also UV immunosuppression. We analyzed our microarray data using the innovative, supervised computational method GSEA (Subramanian et al., 2005). Compared with unsupervised methods of analysis such as gene clustering and grouping based solely on gene expression, the pathway-oriented approach of GSEA is better able to detect relatively subtle differences between sample classes and examines entire pathways rather than single genes. For example, differential activity can be identified with a mean difference in gene expression of only 20% (Mootha et al., 2003). Leading edge analysis, showing the gene sets most responsible for the enrichment signal, provided additional clues to identify the most critical subpathways. Analysis of ssUV-regulated gene expression in vehicle-treated human skin revealed several downregulated enriched biological pathways mainly related to complement, apoptosis, and energy metabolism. Complement has been shown to be involved early in the elicitation phase of DTH reactions in mice (Tsuji et al., 1997), and is also known to be modulated by UV irradiation (Hammerberg et al., 1998). In humans exposed to 3 MED of UVB, C3 activation was observed 3–12 hours after irradiation but not at later time points (Terui et al., 2001). In our study, there was downregulation of complement pathways in vehicle-treated skin, prevented by topical nicotinamide. It is possible that ssUV may have upregulated complement in vehicle-treated skin if biopsies were performed at an earlier time point, or in response to higher UV doses. UV radiation-induced apoptosis is a protective response to cellular injury that removes potentially genetically damaged cells from the skin through the formation of sunburn cells (Melnikova and Ananthaswamy, 2005), although imunohistochemistry of human skin irradiated with very low doses of ssUV (0.5– 1 MED; within the range used in these studies) may not show any increase in apoptotic cell counts (Murphy et al., 2002). Our gene array analysis of vehicletreated skin showed ssUV-induced downregulation of the IGF-1R signaling pathway including the antiapoptotic genes IGF1R and AKT1. Also downregulated in vehicle-treated skin was the programmed cell death pathway, Director: Fernando Estevez Castillo Homeonews 30 Edición N° 9 – Enero – Febrero - Marzo de 2008 including the antiapoptotic gene BCL-2. Hence, ssUV exposure had proapoptotic effects in our transcriptional study. This is consistent with the results of Enk et al. (2006), who used unsupervised gene clustering and functional grouping to report microarray findings in human skin irradiated in vivo with supraerythemal UVB doses (4 MED) . In contrast with our findings, Enk et al. (2006) found that UVB differentially regulated several pathways including those relating to S100 protein, serine protease inhibitors, and extracellular matrix factors such as metalloproteinases as well as apoptosis. This may reflect the much higher UV dose used. Nicotinamide prevented all of these effects. The apoptotic genes BCL2, TP53, IGF1R, PRKCA, and AKT1, comprising the leading edge subset of genes in the Tel pathway, are involved in regulation of telomerase activity, which enables the addition of telomeric repeats to telomeres and is thought to be involved in the early stages of cutaneous carcinogenesis (Ueda, 2000). UV irradiation increases the rate of telomere shortening in skin cells (Kosmadaki and Gilchrest, 2004), consistent with our findings that ssUV downregulated the telomerase pathway, and suggesting a protective effect of nicotinamide on this pathway. Our observed downregulation of genes for energy production in several pathways in vehicle-treated, irradiated skin is consistent with ssUV-induced cellular energy depletion (Jacobsen et al., 2001). This pathway was no longer downregulated in nicotinamide-treated skin, suggesting that nicotinamide induces changes in energy metabolism as well as apoptosis. Intracellular nicotinamide is metabolized to NAD+, the essential coenzyme in ATP production and the sole substrate of the nuclear enzyme PARP (Hageman and Stierum, 2001). PARP is involved in multiple cellular functions, including regulation of p53 expression (Wieler et al., 2003), and is rapidly activated in response to DNA damage. Although modest PARP activation enhances DNA repair, overactivation can cause cell death. Nicotinamide is an endogenous PARP inhibitor (Hageman and Stierum, 2001); hence PARP inhibition by nicotinamide may have reduced cellular damage. Like Enk et al. (2006), we found that ssUV downregulated p53, whereas in the presence of nicotinamide, p53 downregulation was prevented. Nicotinamide has also been shown to alter p53 regulation directly, independent of PARP (McLure et al., 2004). The gene expression profile of nicotinamide-treated, irradiated skin showed upregulation of the enriched pathway cdmac, which includes genes that overlap with UVA-induced ERK activation (protein kinase C; PRKCA, PRKCB1, phospholipase C, RAS and the extracellular signal-regulated kinases 1 and 2, ERK, or MAPK3) (He et al., 2004). Direct NADH insertion is known to increase intracellular calcium (Kaplin et al., 1996). Phospholipase activation and calcium increase are required for ERK activation, which plays an important role in cell proliferation and differentiation. It is possible that a nicotinamide-induced increase in intracellular calcium might be an essential upstream signal regulator for the ERK activation (He et al., 2004). For the first time, we have shown that ssUV-induced immunosuppression is greater in men. Only the highest ssUV dose caused significant immunosuppression in female volunteers. In contrast, men were significantly Director: Fernando Estevez Castillo Homeonews 31 Edición N° 9 – Enero – Febrero - Marzo de 2008 immunosuppressed by ssUV doses three times less than the sunburn threshold, and were more immunosuppressed than women at all doses tested. Male and female volunteers were well matched for MED and skin color and were of similar ages. The incidence of smoking, which not only suppresses systemic immunity but is also associated with cutaneous squamous-cell carcinoma (Freiman et al., 2004), was the same in men and women as was previous history of skin cancer. Hence, these factors were not a cause of greater immunosuppression in men. Similar findings have been reported in mice, where UVB-induced immunosuppression was significantly greater in male than in female mice and this was reversed by injecting males with 17- -estradiol before irradiation (Hiramoto et al., 2004). In female mice, ssUV-induced immunosuppression was exacerbated by topical application of an estrogen receptor antagonist and attenuated by topical 17- -estradiol (Widyarini et al., 2006). Immune cells such as lymphocytes and macrophages are known to bear sex steroid receptors, which implies that estrogen may influence cytokine production by these cells (Kovacs and Messingham, 2002). Male gender is an independent risk factor for immunosuppression following surgical procedures (Wichmann et al., 2003), and murine studies suggest that testosterone is responsible (Wichmann et al., 1996). Our findings may explain the higher female incidence of cutaneous disorders such as polymorphous light eruption (Mastalier et al., 1998), as well as the greater skin cancer incidence and mortality observed in men (Foote et al., 2001; Molife et al., 2001). In our study, low doses of ssUV (UVA+UVB) were immunosuppressive but when the UVA and UVB components of various ssUV doses were studied individually, we found that neither UVA alone nor UVB alone was immunosuppressive. This suggests that at the very low UV doses used here, an interaction between the effects of UVA and UVB leads to immunosuppression, as has been described in studies of ssUV-induced suppression of contact hypersensitivity to nickel in nickel-allergic volunteers (Poon et al., 2005). Immunosuppressive effects may have been detected with higher individual component doses of UVA and UVB. In conclusion, we have shown that a likely interactive effect of UVB and UVA produces ssUV-induced immunosuppression at doses well below the sunburn threshold, and that men are far more susceptible to this immunosuppression than women. Nicotinamide appeared to mediate its immuno protective effects by preventing ssUV-induced changes in complement, apoptosis, and cellular energy pathways, consistent with its known roles as a PARP inhibitor, ATP precursor, and anti-inflammatory agent. Nicotinamide also influenced ssUVinduced transcriptional regulation of genes in the cdmac and arginine catabolic pathways. Whether this novel finding is related to the protective effects of nicotinamide on the skin requires further investigation with functional studies. Skin cancer incidence is rising and sunscreens can be improved by ensuring protection from immunosuppression as well as sunburn. Director: Fernando Estevez Castillo Homeonews 32 Edición N° 9 – Enero – Febrero - Marzo de 2008 Materials and Methods Participants Healthy Mantoux-positive volunteers who had previously been vaccinated with BCG were recruited and were required to cease any vitamin supplementation and avoid sun exposure on their back at least 4 weeks before and during the study. The study was conducted according to the Declaration of Helsinki Principles, and approval was obtained from the Sydney University and Central Sydney Area Health Service Ethics Committees. All volunteers provided written informed consent before inclusion. Study techniques The UV source, described in detail previously (Damian and Halliday, 2002), was a 1,000 W xenon arc solar simulator (Oriel, Stratford, CT), filtered to attenuate visible and infrared wavelengths, remove UVC (<290 nm), and modify the spectral output so that it simulated sunlight (ssUV), or comprised predominantly UVB or UVA only (Damian and Halliday, 2002). Spectra were measured at 1 nm intervals with an OL754 spectroradiometer (Optronics, Orlando, FL), which had been calibrated with standard lamps. An IL-1350 broadband radiometer with interchangeable UVA (SED 038) and UVB (SED 240) detectors (International Light, Newburyport, MA) was calibrated against the source using the spectroradiometer and this was used to enable rapid measurement of irradiance before each irradiation. One week before irradiation, volunteers were tested with three different concentrations of tuberculin PPD (CSL Limited, Parkville, Victoria, Australia), diluted in 0.9% normal saline to a volume of 0.05 ml and injected intradermally on the lower back to confirm positivity and allow selection of the most appropriate PPD dose for further testing in each volunteer. Different PPD dose ranges were used depending on the subjects' previous reactivity. The intensity of subsequent Mantoux reactions was assessed 72 hours after injection using the "pen method" for measuring Mantoux diameter (Bouros et al., 1991). Only participants with a Mantoux diameter 4 mm were eligible for the study. Mantoux reactions were also measured with a reflectance erythema meter (Diastron, Hampshire, UK), which we have previously found to provide a more sensitive and reliable measure of changes in skin immunity than diameter (Damian et al., 1998; Friedmann et al., 2004). Erythema induced by PPD was calculated as the difference between the EI of the Mantoux response and the EI of adjacent skin. Erythema meter readings were taken in triplicate and an average EI for each site was recorded. Nicotinamide (Fluka Chemie AG, Buchs, Switzerland) was prepared in 1:2:1 propylene glycol, ethanol, and distilled water vehicle at a concentration of 5%. The clear, colorless solutions, prepared fortnightly in our laboratory, were applied (2 l/ cm2) topically to test sites on the mid- to lower back in a randomized, double-blinded manner. Subjects were asked to avoid washing the test sites for at least 8 hours after each application. Director: Fernando Estevez Castillo Homeonews 33 Edición N° 9 – Enero – Febrero - Marzo de 2008 Study design The week after initial Mantoux testing, separate 2.0 2.5 cm areas on each side of the lower back were irradiated with one of three fixed doses of ssUV (0.74, 1.48, and 2.22 J/cm2) daily for 3 consecutive days. Adjacent, unirradiated sites on each side served as immunologically intact controls. Nicotinamide lotion was applied to test sites on one side of the back, and vehicle to the opposite side, 15 minutes before or immediately after each ssUV exposure in separate studies. Mantoux tests were performed at irradiated and unirradiated sites immediately after the final irradiation and measured 72 hours later. Each volunteer's MED or sunburn susceptibility was determined by exposing ten 1 cm squares on the upper back to graded ssUV doses and noting the dose that caused threshold erythema 24 hours later. The effects of nicotinamide and vehicle on MED were assessed in all subjects both visually and with the erythema meter. A separate melanin index function in the erythema meter was used to measure the skin color of the mid-back. Additional groups of Mantoux-positive volunteers were recruited to assess the immune effects of UVB and UVA doses approximating those contained within the ssUV doses, with nicotinamide applied to one side of the back and vehicle to the other immediately after irradiation as described above. Microarray study To investigate possible mechanisms of the immune effects of ssUV and nicotinamide, six volunteers were irradiated with a single, fixed dose of ssUV (2.22 J/cm2; 0.5 average MED of this group) onto two areas of their lower backs. These sites were treated with nicotinamide or vehicle immediately after irradiation, as were two adjacent, unirradiated sites. Nicotinamide was applied after irradiation to exclude completely any theoretical possibility of a sunscreening effect of nicotinamide. Twenty-four hours later, a 3 mm punch biopsy was taken from each of the four sites. Total RNA was extracted using TRIzol reagent (Gibco Invitrogen Life Technologies, Carlsbad, CA), purified and DNase-treated using the RNeasy Fibrous Tissue Mini Kit (Qiagen Sciences, Valencia, CA), and amplified using the MessageAmp II aRNA Kit (Ambion Inc., Austin, TX). Total RNA (60–70 g) was then reverse-transcribed into cDNA with direct incorporation of cyanine 3-dCTP and cyanine 5-dCTP fluorescent dyes (Perkin Elmer Life Sciences, Boston, MA). Following hybridization onto Compugen 19,000 human oligonucleotide microarray slides (Adelaide Microarray Facility, The University of Adelaide, Australia), microarrays were scanned using an Axon scanner (Axon Instruments, Sunnyvale, CA) with GenePix Pro 5.0 software. Preprocessing and normalization were applied to all microarray expression data before the assessment of differential gene expression, using GSEA methodology (Subramanian et al., 2005). To input microarray data into GSEA, the accession numbers from the microarrays of normalized treated groups were mapped to corresponding gene symbols using the EASE software in the Director: Fernando Estevez Castillo Homeonews 34 Edición N° 9 – Enero – Febrero - Marzo de 2008 Database for Annotation, Visualization, and Integration Discovery (DAVID) (Dennis et al., 2003; Hosack et al., 2003). GSEA was performed as previously described using a C2 human-specific gene set library containing 522 gene sets whose products are involved in specific metabolic and signaling pathways (Subramanian et al., 2005). We used the default setting signal-to-noise ranking metric in GSEA to rank genes. The statistical significance (P-value) of each pathway was estimated by using phenotype-based permutation estimation using 1,000 random permutations. We chose pathways with a significant enrichment score (P<0.05) that had been adjusted for multiple comparisons using the false discovery rate (q<0.25) for further interpretation. The false discovery rate is a quantity that describes for a set of tests that are deemed significant at or below a given level what proportion of them are likely to be false-positive findings (Storey and Tibshirani, 2003). Statistical analysis Immunosuppression at each site ( EI) was calculated as the difference between the EI of unirradiated control sites and the EI of irradiated test sites. Statistical comparisons were made using paired two-tailed Student's t-tests, with EI considered significant if P<0.05 following Bonferroni correction. All data sets in the immunosuppression and MED experiments showed normal distribution (Kolmogorov–Smirnov test). Results are presented as immunosuppression using Correlations were performed measures linear regression (a STATA v 9.2) as stated. mean SEM. We analyzed intervention and repeated measures analysis of variance. using linear regression analysis or repeated random intercept linear mixed model fitted using Conflict of interest The authors state no conflict of interest. References Bordea C, Wojnarowska F, Millard PR, Doll H, Welsh K, Morris PJ (2004) Skin cancers in renal transplant patients occur more frequently than previously recognised in a temperate climate. Transplantation 77:574–579 Bouros D, Zeros G, Panaretos C, Vassilatos C, Siafakas N (1991) Palpation vs pen method for the measurement of skin tuberculin reaction (Mantoux test). Chest 99:416–419 COLIPA (1994) COLIPA sun protection factor test method. The European Cosmetic, Toiletry and Perfumery Association, ref 94/289, 21 Damian DL, Barnetson RS, Halliday GM (1999) Measurement of in vivo sunscreen immune protection factors in humans. Photochem Photobiol 70:910– 915 Director: Fernando Estevez Castillo Homeonews 35 Edición N° 9 – Enero – Febrero - Marzo de 2008 Damian DL, Barnetson RS, Halliday GM (2001) Effects of low-dose ultraviolet radiation on in vivo human cutaneous recall responses. Australas J Dermatol 42:161–167 Damian DL, Halliday GM, Taylor CA, Barnetson RS (1998) Ultraviolet radiation induced suppression of Mantoux reactions in humans. J Invest Dermatol 110:824–827 Damian DL, Halliday GM (2002) Measurement of ultraviolet radiation-induced suppression of recall contact and delayed-type hypersensitivity in humans. Methods 28:34–45 Davis RH (1986) Compartmental and regulatory mechanisms in the arginine pathways of Neurospora crassa and Saccharomyces cerevisiae. Microbiol Rev 50:280–313 Dennis GJ, Sherman BT, Hosack DA, Yang J, Gao W, Lane HC et al. (2003) DAVID: database for annotation, visualization and integrated discovery. Genome Biol 9:3 Diepgen TL, Mahler V (2002) The epidemiology of skin cancer. 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(2001) Occurrence of neutrophils and activated Th1 cells in UVB-induced erythema. Acta Derm Venereol 81:8–13 Tsuji RF, Geba GP, Wang Y, Kawamoto K, Matis LA, Askenase PW (1997) Required early complement activation in contact sensitivity with generation of local C5-dependent chemotactic activity, and late T cell interferon : a possible initiating role of B cells. J Exp Med 186:1015–1026 Director: Fernando Estevez Castillo Homeonews 38 Edición N° 9 – Enero – Febrero - Marzo de 2008 Ueda M (2000) Telomerase in cutaneous carcinogenesis. J Dermatol Sci 23:S37–S40 Ullrich SE (2005) Mechanisms underlying UV-induced immunosuppression. Mutat Res 571:185–205 Virag L, Szabo C (2002) The therapeutic potential of poly(ADP-ribose) polymerase inhibitors. Pharmacol Rev 54:375–429 Wichmann MW, Muller C, Meyer G, Adam M, Angele MK, Eisenmenger SJ et al. (2003) Different immune responses to abdominal surgery in men and women. Langenbecks Arch Surg 387:397–401 Wichmann MW, Zellweger R, DeMaso CM, Ayala A, Chaudry IH (1996) Mechanism of immunosuppression in males following trauma-hemorrhage. Critical role of testosterone. Arch Surg 131:1186–1192 Widyarini S, Domanski D, Painter N, Reeve VE (2006) Estrogen receptor signaling protects against immune suppression by UV radiation exposure. Proc Natl Acad Sci USA 103:12837–12842 Wieler S, Gagne J-P, Vaziri H, Poirier GG (2003) Poly(ADP-ribose) polymerase1 is a positive regulator of the p53-mediated G1 arrest response following ionizing radiation. J Biol Chem 278:18914–18921 Wolf P, Hoffmenn C, Quehenberger F, Grinschgl S, Kerl H (2003) Immune protection factors of chemical sunscreens measured in the local contact hypersensitivity model in humans. J Invest Dermatol 121:1080–1087 Yoshikawa T, Rae V, Bruins-Slot W, Van den Berg JW, Taylor JR, Streilein JW (1990) Susceptibility to effects of UVB radiation on induction of contact hypersensitivity as a risk factor for skin cancer in humans. J Invest Dermatol 95:530–536 Acknowledgments We are grateful to our participating volunteers, and to Drs Lesley Francis and Patrick FitzGerald for statistical advice and analysis. This study was funded by the Cancer Institute New South Wales, the University of Sydney Cancer Research Fund, and the Dermatology Research Foundation. Associate Professor Damian is supported by a Cancer Institute New South Wales Fellowship. Supplementary material Table S1. Summary of GSEA results with FDR<0.25. Table S2. Genes regulated by ssUV and nicotinamide: rank in gene list. Director: Fernando Estevez Castillo Homeonews 39 Edición N° 9 – Enero – Febrero - Marzo de 2008 Figure S1. Mantoux-induced erythema index (EI) increases with the dose of tuberculin purified protein derivative (PPD). Figure S2. Low-dose UVB (A) or UVA (B) did not suppress Mantoux-induced erythema. HOMEOPATIA TRATAMIENTO DE LOS SOFOCONES DE CALOR CON HOMEOPATIA. RESULTADOS DE UN ESTUDIO OBSERVACIONAL MF Bordet1, A Colas1, P Marijnen2, JL Masson3 and M Trichard4 1 Boiron, Sainte-Foy-lès-Lyon, France ; 2Reims, France ; 3Ecully, France ; 4Lyon, France. [Homeopathy, Volume 97, Issue 1, January 2008, pages 10-15] RESUMEN Objetivo Existe una gran controversia con respecto al tratamiento de los síntomas de la menopausia. Se evaluó el tratamiento homeopático para los sofocones de calor y sus efectos sobre la calidad de vida de las mujeres menopáusicas. Métodos Estudio observacional, abierto, multinacional, prospectivo, pragmático y no comparativo, de tratamientos homeopáticos prescriptos y su efectividad, observando el impacto sobre la calidad de vida. Resultados Noventa y nueve médicos, en ocho países, tomaron parte en este estudio e incluyeron cuatrocientos treinta y ocho pacientes con un promedio de edad de 55 años. Los medicamentos homeopáticos fueron prescriptos a todos los pacientes; 98% de los productos prescriptos fueron homeopáticos. Los más prescriptos fueron: Lachesis mutus, Belladonna, Sepia officinalis, Sulphur y Sanguinaria canadensis. Tratamientos no homeopáticos y suplementos dietarios fueron utilizados en el 5% de los pacientes. Director: Fernando Estevez Castillo Homeonews 40 Edición N° 9 – Enero – Febrero - Marzo de 2008 Este estudio observacional reveló una reducción significativa (p<0.001) en la frecuencia de los sofocones de calor por día y noche y en las molestias diarias que ellos causan (caída promedio de 3.6 y 3.8 puntos respectivamente, en una escala visual analógica de 10 cm; p<0.001). 99% de las mujeres informaron la desaparición o disminución de sus síntomas, ocurriendo esto comúnmente dentro de los 15 días de comienzo del tratamiento homeopático. Conclusiones Los resultados de este estudio observacional, sugieren que el tratamiento homeopático para los sofocones de calor en las mujeres menopáusicas, es efectivo. Se deberán realizar otros estudios, incluyendo estudios controlados y randomizados. Palabras clave: homeopatía; sofocones de calor; tratamiento homeopático; estudio observacional; menopausia. ARTICULO ORIGINAL Introduction The menopause is defined by at least 12 months of amenorrhea in women aged at least 50 (with or without a measured increase in serum level of FSH), negative testing for progesterone in women aged at least 451 or bilateral oophorectomy in women of child-bearing age. Hot flushes (or flashes) are sudden sensations of intense heat, mainly affecting the upper part of the body and lasting for 1–5 min on average. They may be accompanied by facial redness, perspiration that is sometimes heavy, palpitations, anxiety, irritability and nocturnal sweating. The physiological mechanism governing hot flushes is not precisely known. During the menopause has started, 8 women in 10 report hot flushes of varying intensity, which may affect their sleep and quality of life.[1] and [2] These hot flushes are the main reason for instigating hormone replacement treatment (HRT). According to the survey undertaken in April 2004 by the “Société Française d’études par Sondage” (Sofres—French Society for Studies via Surveys), on behalf of the “Agence Nationale d’accréditation et d’évaluation en Santé” (Anaes—National Agency for Health Accreditation and Evaluation), 25.5% of menopausal women aged 45–70 in December 2003 were taking hormone replacement treatment. The iatrogenic consequences of these treatments is a major public health issue.3 Although they may have an effect on hot flushes, soya derivatives, specifically phyto-oestrogens’ are products for which the risks have not been evaluated and are not monitored, and which do not meet health and safety requirements for medicinal substances. The “Agence Française de Sécurité Sanitaire des Director: Fernando Estevez Castillo Homeonews 41 Edición N° 9 – Enero – Febrero - Marzo de 2008 Produits de Santé” (Afssaps—French Health Products Safety Agency) does not recommend soya derivatives alone to treat hot flushes.3 Hot flushes and their consequences in menopausal women can be treated with homeopathic treatment. Lachesis mutus, Sulphur, Sepia officinalis, Belladonna, Glonoinum, Sanguinaria canadensis and Amylium nitrosum are the medicines most commonly indicated for the treatment of hot flushes in menopausal women.4 Several studies have been published evaluating homeopathy (individualized or not) in menopausal symptoms, particularly in women who have suffered from breast cancer.[1], [5], [6] and [7] Jacobs et al's study was a randomized, doubleblind study versus placebo performed over 1 year with 83 women suffering from breast cancer; patients received either individualized homeopathic treatment or a homeopathic complex or a placebo. This study did not show any significant difference between the three patient groups relative to the severity and frequency of hot flushes although there was a positive trend in the “individualized homeopathic treatment” group during the first 3 months of the study. But there was a significant improvement in quality of life in the 2 groups of patients taking homeopathic treatment compared with the group who received the placebo.5 Thompson et al conducted a prospective observational study with 45 women suffering from breast cancer. The homeopathic approach (individualized treatment) was evaluated in this study. The authors concluded that there was a significant reduction in symptoms linked to oestrogen deficiency between the start and end of the study.6 A second study by Thompson et al was a randomized, double-blind study versus placebo which was performed over 4 months with 57 women suffering from breast cancer; individualized homeopathic treatment was compared with a placebo: this study did not show any significant difference between the 2 patient groups for the criteria evaluated.7 Literature reviews and observational studies have also been published on alternative and complementary treatments for menopausal symptoms[8], [9] and [10] and hot flushes.[2], [11] and [12] These studies show that some complementary treatments can be beneficial to patients and recommend that further randomized clinical studies be performed to confirm these results. The homeopathic strategy is therefore a valid part of the therapeutic arsenal, particularly in the current context where hormone replacement therapy is being questioned and vigilance required on the use of food supplements based on soya isoflavones alone.[13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23] and [24] In this context, we decided to perform an observational study with physicians prescribing homeopathic medicines. The study objective was to evaluate homeopathic treatment for hot flushes in menopausal women in terms of prescribed medical treatment, effectiveness and impact on quality of life. Director: Fernando Estevez Castillo Homeonews 42 Edición N° 9 – Enero – Febrero - Marzo de 2008 Method Study design An open, multi-national pragmatic, prospective, non-comparative observational study of the practice of physicians prescribing homeopathic drugs was organized in 2005 with physicians from 8 different countries. Recruitment of investigating physicians This observational study was proposed to 157 physicians who prescribe homeopathic medicines. The physicians, GPs or gynaecologists, were recruited on a voluntary basis if they were interested. This study was observational and each physician remained totally free regarding to his prescriptions and his treatment choices so it was not necessary to ask the advice of an ethics committee. Patient selection Inclusion criteria: • women aged over 45; • established menopause; • suffering from hot flushes; • not taking either homeopathic treatment or hormone treatment to reduce their hot flushes; • not taking Raloxifene. Patients using topical hormone treatment for vulvo-vaginal trophic disorders linked to the menopause were included in the study. We defined established menopause as follows: • at least 12 months of amenorrhea in women aged at least 50; • or testing negative for progesterone (ie the absence of withdrawal bleeding after administration of a progestational drug for 10 days per month over at least 3 consecutive months) in women aged at least 45; • or when a bilateral oophorectomy had been performed on a previously menstruating woman. Exclusion criteria: • patients not meeting the inclusion criteria; • patients suffering from hormone-dependent cancer. Evaluation criteria The patients were assessed twice during the study: at the inclusion visit and at the final visit. Director: Fernando Estevez Castillo Homeonews 43 Edición N° 9 – Enero – Febrero - Marzo de 2008 Clinical effectiveness The evolution of clinical symptoms and the diurnal and nocturnal frequency of hot flushes was evaluated as follows: (1) The evolution of the patients’ clinical condition was measured at final visit by a question with four responses: disappearance (no symptom), improvement (lessening of symptoms), no change (same symptoms) or aggravation (deterioration of symptoms). (2) Diurnal frequency of hot flushes, compared at the inclusion visit and the final visit. We measured the percentage of patients who reported 0 to 5, 6 to 10 or more than 10 hot flushes per day, at each visit. (3) Nocturnal frequency of hot flushes, compared at the inclusion visit and at the final visit. We measured the percentage of patients who reported 0 to 5, 6 to 10 or more than 10 hot flushes at night, at each visit. (4) The percentage of patients who suffered from daily hot flushes was compared at the inclusion visit and at the final visit of the study. (5) These measures were recorded by physicians who questioned patients for retrospective recall. Quality of life The evolution of the impact of hot flushes on quality of life was measured by two different visual analogue scales, graded from 0 to 10. One scale measured the discomfort caused during daytime with the question: “When you have a hot flushes during the day, how would you describe the discomfort in your life ” A score of 10 indicates the most disturbed day life. The other scale measured the effect on sleep by using the question: “When you have hot flushes at night, how would you describe the consequences on your sleep ” A score of 10 indicates the most disturbed sleep. These scales were recorded by patients at the inclusion visit and at the final visit of the study. These scales were specifically developed for the study but were not validated. Duration of the study The period of inclusion in the study was from 17 January to 30 June 2005. Follow-up was provided between 2 and 6 months following the inclusion visit, depending on the physician's practice. Statistical analysis Director: Fernando Estevez Castillo Homeonews 44 Edición N° 9 – Enero – Febrero - Marzo de 2008 The results analysis was per protocol because it concerns all patients who adhered strictly to the protocol, particularly relative to respecting the inclusion criteria. The statistical analysis was performed using tests appropriate for the variables, ie: • for qualitative variables: Chi-squared test (χ2); • for quantitative variables: Student's test. Alpha risk was set at 5%. No subgroup analysis was performed. Results The physicians Ninety-nine physicians in 8 countries took part in this observational study: 53 French, 23 Tunisian, 9 Brazilian, 5 Polish, 3 Bulgarian, 3 Portuguese, 2 Moroccans and 1 Italian. The patients A total of 489 patients were included in this study. We analysed the data for 438 case files. The 51 case files excluded are explained by: • 33 lost to follow-up; • 18 cases did not meeting the inclusion criteria; The geographical distribution of the patients was as follows: 241 France (55%), 102 Tunisia (23%), 32 Brazil (7%), 32 Poland (7%), 14 Bulgaria (3%), 7 Morocco (2%), 5 Portugal (1%) and 5 Italy (1%). The average age of the patients was 55 (45–76). The patients were followed at the inclusion visit and at the final visit depending on the physician's practice. The average duration of follow-up was 98 days. 11% of patients were followed-up in 60 days, 66% of patients were followed-up from 60 to 120 days, 17% of patients were followed-up from 120 to 180 days and 6% of patients were followed-up later than 180 days. Medical treatments Since this was an observational study, each physician remained totally free regarding to his prescriptions and treatment choices. Participating physicians prescribed a total of 1506 prescription lines for 438 patients, ie 3.4 medications per patient, on average. One prescription line corresponds to one medication prescribed to one patient at the inclusion visit. Medications were given simultaneously or sequentially depending on the physician's practice. Homeopathic treatment was prescribed for all the patients. Homeopathic treatments covered 98% of the prescribed medication (1475 prescription lines). Five percent of patients (22 patients) also received non-homeopathic medication (notably minerals) and/or food supplements (notably soya-based). These treatments covered 2% of the total prescriptions (31 prescription lines). Table 1 shows the 12 homeopathic medications most prescribed during this study; the main ones are: Lachesis mutus, Belladonna, Sepia officinalis, Director: Fernando Estevez Castillo 45 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Sulphur, Sanguinaria canadensis and Glonoinum. Lachesis mutus, Sepia officinalis and Sulphur were most often prescribed at a dilution of 9 cH, whereas Belladonna, Sanguinaria canadensis and Glonoinum were more frequently prescribed at a dilution of 15 cH. Sixty-five percent of the 438 patients received Lachesis mutus and 43% received Belladonna. Sepia officinalis, Sulphur, Sanguinaria canadensis and Glonoinum were prescribed for 26%, 25%, 21% and 15% of the patients, respectively. Table 1. The 12 most prescribed homeopathic medications Names of homeopathic medications Number of lines Total medications Total homeopathic medications % Total (%) % Total (%) Lachesis mutus 298 19.79 19.79 20.20 20.20 Belladonna 190 12.62 32.40 12.88 33.08 Sepia officinalis 130 8.63 41.04 8.81 41.90 Sulphur 110 7.30 48.34 7.46% 49.36 Sanguinaria canadensis 92 6.11 54.45 6.24 55.59 Glonoinum 67 4.45 58.90 4.54 60.14 FSH 66 4.38 63.28 4.47 64.61 Folliculinum 63 4.18 67.46 4.27 68.88 Ignatia amara 53 3.52 70.98 3.59 72.47 LH-RH 46 3.05 74.04 3.12 75.59 Thuja occidentalis 45 2.99 77.03 3.05 78.64 Amylium nitrosum 40 2.66 79.68 2.71 81.36 Others 275 18.26 97.94 18.64 100.00 Total homeopathic medications 1475 97.94 – 100.00 – Total medications 1506 100.00 – – – Table 2 shows the 16 homeopathic medications most prescribed for the 83 patients who noted a disappearance of their symptoms. Lachesis mutus, Director: Fernando Estevez Castillo 46 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Belladonna, Sepia officinalis, Folliculinum, Sanguinaria canadensis, Sulphur and FSH were the main homeopathic treatments prescribed for these patients. Table 3 shows the 16 homeopathic medications most prescribed for the 301 patients who noted an improvement in their symptoms. Lachesis mutus, Belladonna, Sulphur, Sepia officinalis, Sanguinaria canadensis, Glonoinum and FSH were the main homeopathic treatments prescribed for these patients. Table 2. The 16 most prescribed homeopathic medications for the 83 patients who noted a disappearance of their symptoms Names of homeopathic medications prescribed for the patients who noted a disappearance of their symptoms Number of lines % Total (%) Lachesis mutus 51 18.35 18.35 Belladonna 41 14.75 33.09 Sepia officinalis 35 12.59 45.68 Folliculinum 15 5.40 51.08 Sanguinaria canadensis 15 5.40 56.47 Sulphur 14 5.04 61.51 FSH 13 4.68 66.19 Glonoinum 12 4.32 70.50 Thuja occidentalis 11 3.96 74.46 Ignatia amara 8 2.88 77.34 LH-RH 8 2.88 80.22 Natrum muriaticum 5 1.80 82.01 Luteinum 5 1.80 83.81 Progesteronum 4 1.44 85.25 Amylium nitrosum 4 1.44 86.69 Lycopodium clavatum 3 1.08 87.77 Others 34 12.23 100.00 Total homeopathic medications 278 100.00 – Director: Fernando Estevez Castillo 47 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Table 3. The 16 most prescribed homeopathic medications for the 301 patients who noted an improvement in their symptoms Homeopathic medications prescribed for patients with improved symptoms Number of lines % Total (%) Lachesis mutus 217 21.34 21.34 Belladonna 121 11.90 33.24 Sulphur 81 7.96 41.20 Sepia officinalis 78 7.67 48.87 Sanguinaria canadensis 70 6.88 55.75 Glonoinum 45 4.42 60.18 FSH 42 4.13 64.31 Folliculinum 40 3.93 68.24 Ignatia amara 38 3.74 71.98 LH-RH 30 2.95 74.93 Thuja occidentalis 30 2.95 77.88 Amylium nitrosum 28 2.75 80.63 Nux vomica 16 1.57 82.20 Pulsatilla 11 1.08 83.28 Natrum muriaticum 10 0.98 84.27 Actaea racemosa 10 0.98 85.25 Others 150 14.75 100.00 Total homeopathic medications 1017 100.00 – Clinical effectiveness At the inclusion visit, 89% of patients suffered from daily hot flushes. This percentage was reduced to 39% at the final visit (p<0.001). Thus more than 50% of the patients suffering from daily hot flushes at the beginning of the study, no longer suffered daily from them at the final visit. At the inclusion visit, 46%, 38% and 16% of the patients experienced 0 to 5, 6 to 10 and more than 10 hot flushes per day respectively, compared to 90%, 8% and 2% of patients, respectively at the final visit (see Figure 1). The number of diurnal hot flushes fell significantly between the inclusion and follow-up visits (p<0.001). At the inclusion visit, 69%, 23% and 8% of the patients, experienced 0–5, 6–10 and Director: Fernando Estevez Castillo 48 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 more than 10 hot flushes per night respectively, compared to 93%, 5% and 1% of patients, respectively, at the final visit (see Figure 2). The number of nocturnal hot flushes fell significantly between the inclusion and follow-up visits (p<0.001). Ninety percent of the women (384 patients) noted either the disappearance or lessening of their symptoms (Table 4). Favourable evolution was determined by disappearance or improvement of patients’ symptoms (selfassessment). This favourable evolution occurred most frequently within 15 days of starting the treatment (Table 5). Figure 1. Diurnal frequency of hot flushes Figure 2. Nocturnal frequency of hot flushes Table 4. Evolution of the patients' clinical condition Evolution of clinical condition Patients % Disappearance 83 19.39 Improvement 301 70.33 Director: Fernando Estevez Castillo 49 Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 Evolution of clinical condition Patients % No change 34 7.94 Deterioration 10 2.34 Total 428 100.00 Missing values 10 Table 5. Time taken for favourable evolution of clinical condition Time taken for favourable evolution of clinical condition Patients % Within 15 days 152 40.64 15 days to 1 month 134 35.83 More than 1 month 88 23.53 Total 374 100.00 Missing values 10 Quality of life Concerning the discomfort caused during daytime, the mean score was 6.1 (SD=2.3) at the inclusion visit and 2.5 (SD=2.0) at the final visit (p<0.001). Concerning the disturbance to sleep, the mean score was 6.2 (SD=2.6) at the inclusion visit and 2.4 (SD=2.3) at the final visit (p<0.001). Quality of life therefore significantly improved during the study period, with a fall of 3.6 and 3.8 points, respectively, in the 2 items measured on a visual analogue scale. Discussion and conclusión We performed an observational study with physicians who prescribe homeopathic treatments; this was not a comparative study of two groups of patients receiving different treatment, which is its main limitation. During the study, patients were allowed to take other medication and products in addition to those prescribed by the participating physicians. Of the 83 patients who noted a disappearance of their symptoms, 32 (39%) had taken other products, mainly soya/yam-based phytotherapies (10 patients). Of the 301 patients who noted a lessening of their symptoms, 137 (46%) had taken other products, mainly soya/yam-based phytotherapies (48 patients). Of the 44 patients who noted no change or an aggravation of their symptoms, 18 (41%) had taken other products again, mainly soya/yam-based phytotherapies (11 patients). Director: Fernando Estevez Castillo Homeonews 50 Edición N° 9 – Enero – Febrero - Marzo de 2008 These last data lead us to suppose that the consumption of products other than the homeopathic medication did not affect the results because the proportion of patients who took other products was comparable in each group of results. It would be interesting to perform a randomized, double-blind comparative study using an appropriate method to evaluate the homeopathic medication effectiveness (with a validated tool like Greene Climateric Scale for example) in the treatment of hot flushes in menopausal women. In conclusion, the results of this observational study suggest that homeopathic treatment is effective for hot flushes. Further investigation is justified. Acknowledgements We would like thank all the physicians who took part in this study as well as Boiron laboratories local representatives who enabled this observational study to be followed outside France. We would also like to thank Gilles Chaufferin for his support and assistance in performing this study. This study was financed by Boiron laboratories. The authors have no conflicts of interests directly concerning the content of this study. Referentes 1 A.H. Boekhout, J.H. Beijnen and J.H. Schellens, Symptoms and treatment in cancer therapy-induced early menopause, Oncologist 11 (6) (2006), pp. 641– 654. View Record in Scopus | Cited By in Scopus (4) 2 H.A. Philp, Hot flashes–a review of the literature on alternative and complementary treatment approaches, Altern Med Rev 8 (3) (2003), pp. 284– 302. View Record in Scopus | Cited By in Scopus (11) 3 Afssaps/Anaes. Rapport d’orientation. Traitements hormonaux substitutifs de la ménopause. 11 mai 2004, p. 78. 4 Jouanny J, Crapanne JB, Dancer H, Masson JL. La ménopause. Thérapeutique homéopathique, Possibilités en pathologie chronique. Editions Boiron, 2000, pp. 276–288 (chapter 10). 5 J. Jacobs, P. Herman and K. Heron et al., Homeopathy for menopausal symptoms in breast cancer survivors: a preliminary randomized controlled study, J Altern Complement Med 11 (1) (2005), pp. 21–27. View Record in Scopus | Cited By in Scopus (14) 6 E.A. Thompson and D. Reilly, The homeopathic approach to the treatment of symptoms of oestrogen withdrawal in breast cancer patients. A prospective observational study, Homeopathy 92 (3) (2003), pp. 131–134. 7 E.A. Thompson, A. Montgomery and D. Douglas et al., A pilot, randomized, double-blinded, placebo-controlled study of individualized homeopathy for Director: Fernando Estevez Castillo Homeonews 51 Edición N° 9 – Enero – Febrero - Marzo de 2008 symptoms of estrogen withdrawal in breast-cancer survivors, J Altern Complement Med 11 (1) (2005), pp. 13–20. 8 F. Kronenberg and A. Fugh-Berman, Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled studies, Ann Intern Med 137 (10) (2002), pp. 805–813. 9 C. Relton and E. Weatherley-Jones, Homeopathy service in a National Health Service community menopause clinic: audit of clinical outcomes, J Br Menopause Soc 11 (2) (2005), pp. 72–73. 10 E.A. Thompson, Homeopathy and the menopause, J Br Menopause Soc 8 (4) (2002), pp. 151–154. 11 D.G. Carroll, Nonhormonal therapies for hot flashes in menopause, Am Fam Physician 73 (3) (2006), pp. 457–464. 12 A. Clover and D. Ratsey, Homeopathic treatment of hot flushes: a pilot study, Homeopathy 91 (2) (2002), pp. 75–79. 13 J.E. Rossouw, G.L. Anderson and R.L. Prentice et al., Writing group for the Women's Health Initiative investigators. Risks and benefits of estrogen plus progestin in healthy post menopausal women. Principal results from the Women's Health Initiative randomized controlled Study, JAMA 288 (2002), pp. 321–333. 14 J.A. Cauley, J. Robbins and Z. Chen et al., Women's Health Initiative Investigators. Effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women's Health Initiative randomized study, JAMA 290 (13) (2003), pp. 1729–1738. 15 R.T. Chlebowski, S.L. Hendrix and R.D. Langer et al., WHI Investigators. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women's Health Initiative Randomized Study, JAMA 289 (24) (2003), pp. 3243–3253. 16 G.L. Anderson, H.L. Judd and A.M. Kaunitz et al., Women's Health Initiative Investigators. Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: the Women's Health Initiative randomized study, JAMA 290 (13) (2003), pp. 1739–1748. 17 J.E. Manson, J. Hsia and K.C. Johnson et al., Women's Health Initiative Investigators. Estrogen plus progestin and the risk of coronary heart disease, N Engl J Med 349 (2003), pp. 523–534. 18 S.A. Shumaker, C. Legault and S.R. Rapp et al., WHIMS Investigators. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled study, JAMA 289 (20) (2003), pp. 2651–2662. Director: Fernando Estevez Castillo Homeonews 52 Edición N° 9 – Enero – Febrero - Marzo de 2008 19 J. Hays, J.K. Ockene and R.L. Brunner et al., Women's Health Initiative Investigators. Effects of estrogen plus progestin on health-related quality of life, N Engl J Med 348 (2003), pp. 1839–1854. 20 S. Wassertheil-Smoller, S.L. Hendrix and M. Limacher et al., WHI Investigators. Effect of estrogen plus progestin on stroke in postmenopausal women: the Women's Health Initiative: a randomized study, JAMA 289 (20) (2003), pp. 2673–2684. 21 C.I. Li, K.E. Malone and P.L. Porter et al., Relationship between long durations and different regimens of hormone therapy and risk of breast cancer, JAMA 289 (24) (2003), pp. 3254–3263. 22 V. Beral, Million Women Study Collaborators, Breast cancer, hormonereplacement therapy in the Million Women Study (MWS), Lancet 362 (2003), pp. 419–427. 23 Afssaps. Mise au point actualisée sur le traitement hormonal substitutif de la ménopause (THS). Décembre 2003, 5p. 24 Afssaps. Mise au point. Le traitement hormonal de la ménopause (THM). Juin 2006, pp. 21. 1 Testing for progesterone is said to be negative in the absence of withdrawal bleeding after the administration of a progestational treatment for 10 days per month for at least 3 consecutive months. NUTRICION IMPORTANCIA MEDICINAL DEL JUGO DE POMELO Y SU INTERACCION CON CIERTAS DROGAS Jawad Kiani* Sardar Z Imam* *Medical College, Aga Khan University, Stadium Road, Karachi, Pakistan [Nutrition Journal 2007, 6:33] RESUMEN El jugo de pomelo se consume ampliamente en todo el mundo como preventivo de de las enfermedades cardiovasculares y del cáncer. Sin embargo, se encontró que es un inhibidor del sistema citocromo P-450 3A4 (intestino), responsable del metabolismo de primer paso de muchas drogas. La bomba Pglicoproteína, encontrada en las microvellosidades de la pared intestinal, Director: Fernando Estevez Castillo Homeonews 53 Edición N° 9 – Enero – Febrero - Marzo de 2008 encargada del transporte de muchos de los sustratos del sistema citocromo P450 3A4, también ha sido inhibida por el jugo de pomelo. Por inhibición de estos sistemas enzimáticos, el jugo de pomelo altera la farmacocinética de una variedad importante de medicamentos, dando lugar a la elevación de sus concentraciones séricas. Sus efectos más notorios se pueden ver en el grupo de drogas antagonistas de los canales de calico y las estatinas. En el caso de muchas drogas, el aumento de la concentración sérica está asociado con aumento de la frecuencia de efectos adversos dependientes de las dosis. En esta revisión, hemos discutido sobre la fitoquímica del jugo de pomelo, sus principales componentes e interacciones con otras drogas (mecanismos de acción) y sus implicancias clínicas. ARTICULO ORIGINAL Introduction The grapefruit, thought to be a cross between an orange and a shaddock, was developed in the West Indies in the early 1700s and first introduced to Florida in the 1820s. Since the early part of the 20th century, mutant strains of white grapefruit have appeared with pink to slightly reddish colour, and have been propagated by citriculturists into several strains of grapefruit. The three major types of grapefruit that exist today are white, pink/red and ruby/rio red varieties. Grapefruit juice combines the sweet and tangy flavour of the orange and shaddock and also provides up to 69% of the RDA for vitamin C along with as many as 250 mg of Potassium [1]. However, the wide consumption of grapefruit juice cannot entirely be attributed to its taste, and nutritive value. In fact, much of the enthusiasm in its use stems from medical research that has suggested that grapefruit juice reduces atherosclerotic plaque formation [2] and inhibits breast cancer cell proliferation and mammary cell tumorigenesis [3,4]. Traditionally grapefruit juice has been found to contain antioxidant, antinitrosaminic, antiseptic, aperitif, cardiotonic, detoxicant, hypocholesterolemic, sedative and stomachic activities. In the light of its above activities, it has been traditionally indicated throughout time for anorexia, bacteria, benign prostatic hypertrophy, cancers (breast, colon, prostate, lung, skin and throat), candida, cold, diabetes, dysuria, high cholesterol, infection, insomnia, mycobacterium, mycosis, nervousness, pseudomonas, rheumatism, staphylococcus and yeast. However, as many as fifteen years ago, investigators found that grapefruit juice can markedly augment oral drug bioavailability. This was an unexpected observation from an interaction study between the dihydropyridine calcium channel antagonist, felodipine, and ethanol in which grapefruit juice was used as a flavour supplement to mask the taste of the ethanol [5]. Studies that followed, confirmed that grapefruit juice significantly increased the oral bioavailability of felodipine [6,7]. Subsequent studies probed the constituents of grapefruit juice, its interaction with various other drugs and the mechanisms of action of those interactions. Several grapefruit juice-drug interactions were Director: Fernando Estevez Castillo Homeonews 54 Edición N° 9 – Enero – Febrero - Marzo de 2008 discovered and these remain a potential concern especially since the juice and drugs are often consumed together at breakfast. An increasing number of adverse drug reactions might be avoided on the basis of knowledge about the interaction of grapefruit juice and relevant drugs. Therefore, patients need to be educated about the hazards (and advantages) of grapefruit interaction with medication. In recent years, more drugs have been investigated for their interaction with grapefruit juice and new models have been proposed for the mechanism of such interaction. This article presents a simplistic summary of most examples of such interactions and also explores the phytochemistry and possible mechanisms of action involved in drug-grapefruit juice interactions in light of recent studies on this subject. Mechanism of action The mechanism of action of this interaction involves inhibition of the CYP 3A4, a member of the cytochrome P 450 (CYP) enzyme system. CYP is a large multigene family of heme-containing enzymes located in the endoplasmic reticulum of cells throughout the body. It is especially concentrated in the liver and intestinal wall where it is involved in oxidative biotransformation of various endogenous and exogenous substances. CYP 3A isoforms constitute 70% of CYP enzymes in enterocytes [8,9]. P-glycoprotein (Pgp), a member of the ABC (adenosine triphosphate-binding cassette), is another membrane transporter located in the apical brush border of enterocytes. Once taken up by the enterocytes, a lipophilic drug may be metabolized by CYP 3A4 or be pumped back into the lumen by the Pgp. Hence the oral delivery of many drugs is limited by the actions of CYP 3 A4 or Pgp. Metabolism by the CYP 3A4 will also occur in the liver before the drug finally enters the systemic circulation. Grapefruit juice causes inhibition of CYP 3A4 and thus serves to increase the bioavalability of the drug by decreasing its pre-systemic metabolism [10]. This action is in essence, similar to that caused by CYP-inhibiting drugs like itraconazole, ketoconazole and erythromycin [11-13]. Grapefruit juice causes quick and irreversible sustained inhibition of the CYP system, possibly by greatly accelerating the degradation of these enzymes while also reducing translation from its mRNA. However, the process of transcription of mRNA from the cell DNA is not affected. Overall, grapefruit juice reduces the levels of CYP 3A4 in the cells by as much as 47% within four hours of ingestion of grapefruit juice with the resultant increased bioavailability being maintained for as long as 24 hours, by which time 30% of its effect is still detectable [14-17]. It has been observed that decreased content of CYP3A4 was not associated with increased CYP3A4 mRNA, probably indicating the absence of a feedback mechanism for CYP3A4 expression. Restoration of CYP3A4 activity would therefore require denovo synthesis or enterocyte replacement, accounting for the prolonged duration of the actions of grapefruit juice [18]. Grapefruit juice shows a high variability of the magnitude of effect among individuals. This variability is dependent upon inherent differences in enteric CYP3A4 protein expression such that individuals with highest baseline CYP3A4 Director: Fernando Estevez Castillo Homeonews 55 Edición N° 9 – Enero – Febrero - Marzo de 2008 have the highest proportional increase [19,20]. However, the effects of grapefruit juice are predominantly on the intestinal CYP rather than hepatic CYP. This is shown by the fact that most of the drugs that are involved in interaction with grapefruit juice undergo their primary metabolism at the intestinal level and in usual quantity, grapefruit juice does not affect the pharmacokinetics of these drugs when they are administered intravenously. Furthermore, while it increases the area under the plasma concentration-time curve (AUC), it has no significant effect on the half life of the drugs [10,21-23]. In contrast to the clear inhibitory effects of grapefruit juice on CYP 3A4, the effects of grapefruit juice on Pgp are controversial, ranging from activation to inhibition. Earlier results have shown grapefruit juice to cause activation of Pgp in vitro [24]. Any such activation in vivo will mean a greater efflux of the drug back into the lumen, thereby decreasing the oral bioavailability of that drug and at least partially, if not completely offsetting the effects produced by the inhibition of CYP system of enzymes. This is taken as an explanation for the less-than-expected increase in the bioavailability of drugs that are established substrates of Pgp [24]. However, grapefruit juice does not change the absorption of digoxin, a prototypical P-glycoprotein substrate, likely because it has high inherent oral bioavailability [17,25]. However, recent studies have demonstrated the inhibition of Pgp by grapefruit juice both by its downregulation and inhibition of function [26,27]. For example, grapefruit juice increases the bioavailability of cyclosporine. This effect is thought to be primarily though Pgp inhibition (instead of CYP3A4 inhibition) since orange juice mediated reduction in enterocyte CYP3A4 concentrations did not produce a similar increase in bioavailability [17]. In fact, grapefruit juice has also shown inhibition of multidrug resistant protein 2 (MRP2), an efflux protein closely related to Pgp in terms of its expression and function [26]. Yet, in spite of all what is known, the mechanism of action of grapefruit juicedrug interaction requires further investigation. Investigators still need to determine for certainty any in vivo effect of grapefruit juice on Pgp. One study [28] has also reported the action of grapefruit juice independent of its actions on Pgp and CYP 3A4. This also requires further investigation. Similarly, grapefruit and even orange juice have also recently been shown to be potent in vitro inhibitors of a number of organic anion-transporting polypeptides (OATPs) that are involved in apical-to-basal transport of drugs in the small intestine [17,18,25,29]. They were also found to decrease the absorption of the nonmetabolized OATP substrate, fexofenadine hence pointing towards inhibition of intestinal uptake transporters by fruit juices to decrease drug bioavailability. This newly proposed mechanism of action and its effect vis a vis various medications also demands further investigation [25,29]. Assessment of the in vitro CYP inhibition potential for these natural products has important implications for predicting the likelihood of natural product-drug interactions if these products are taken concomitantly. The susceptibility of CYP3A4 to modulation by food constituents may be related to its high level of expression in the intestine, as well as its broad substrate specificity. Reported ethnic differences in the activity of this enzyme may be partly due to dietary Director: Fernando Estevez Castillo Homeonews 56 Edición N° 9 – Enero – Febrero - Marzo de 2008 factors. Food-drug interactions involving CYP1A2, CYP2E1, glucuronosyltransferases and glutathione S-transferases have also been documented, although most of these interactions are modest in magnitude and clinically relevant only for drugs that have a narrow therapeutic range. Recently, interactions involving drug transporters, including P-glycoprotein and the organic anion transporting polypeptide, have also been identified. Hence a lot of food varieties have the potential to require dosage adjustment to maintain drug concentrations within their therapeutic windows, especially with drugs that have a high first pass degradation [30]. Further research is needed to determine the scope, magnitude and clinical importance of food effects on drug metabolism and transport. Relevant phytochemistry Another area in which the search for definite answers continues, is the quest to find the active constituents of grapefruit juice that are responsible for its actions on CYP enzyme systems and Pgp. The components of grapefruit juice that are responsible for clinical drug interactions have yet to be fully determined but the compounds thought to be responsible for this action include flavonoid glycosides (narirutin, naringin, naringinen, quercetin, kaemferol, hesperidin, neohesperidin, didymin, and poncirin) [8,31-34], furanocoumarins (6',7'dihydroxybergamottin, bergamottin) and sesquiterpen (nootkatone)[8,22,32,35,36]. Flavanoids exist in grapefruit juice in the form of glycosides, with naringin being the most abundant. Upon ingestion, these are converted to aglycones and sugars by the action of intestinal flora. Being polyphenolic and electron rich, these compounds can theoretically inhibit the CYP enzymes. However, studies have at most shown an in vitro effect by these compounds on the these enzymes and have failed to identify any in vivo effect by them [37,38], leading to an implication that they are probably not the main active ingredients of grapefruit juice [1,39]. Studies have even failed to demonstrate any sort of activity in naringin although its metabolite naringinin was observed to be active in vitro. Yet, because of their huge quantities in grapefruit juice, and the fact that naringin is not present in other citrus juices, flavanoids remain a subject of research. The main focus at present, however, is on furanocoumarins. This group includes Bergamottin, its derivative 6' 7' dihydroxybergamottin (DHB) and a host of other compounds [40]. Controversy still exists on the degree of their role in the inhibitory effects of grapefruit juice. Several studies have shown DHB [23,35,40] and to an extent Bergamottin [23] to be important contributors to the grapefruit juice effect. In one study, the inhibitory potency of DHB and four recently isolated furanocoumarins, when mixed with one another, almost approached that of grapefruit juice. Omission of any of the components resulted in decreased potency, suggesting that all major furanocoumarins contribute to the inhibitory effects of grapefruit juice [40]. However, others have suggested that DHB and Bergamottin are not the primary substances responsible for Director: Fernando Estevez Castillo Homeonews 57 Edición N° 9 – Enero – Febrero - Marzo de 2008 inhibition of CYP activity clinically [41,42]. For now, this topic also remains a subject of intense research. Drug-grapefruit juice interactions Anti-hypertensive drugs and amiodarone 1,4-Dihydropyridine calcium antagonists are lipid soluble drugs used in the treatment of essential hypertension and angina pectoris and metabolized in vivo by CYP3A4. Since the effects of grapefruit juice were first noticed with felodipine, this class of drugs has been intensively studied with grapefruit juice. The degree to which the intestinal CYP system metabolizes this class of drugs and affects their oral bioavailability varies markedly. In a study done by Lundahl J et al., it was found that the intake of grapefruit juice led to an increase in the oral bioavailability by 112% [43]. However, this study also found out that the intravenous pharmacokinetics of felodipine were not significantly altered with grapefruit juice. The main acute effect of the grapefruit juice on the plasma concentrations of felodipine was believed to be mediated by inhibition of gut wall metabolism. Grapefruit juice-felodipine interaction increases with increasing frequency and amount of grapefruit juice ingestion, hence it has been determined that an interval of 2–3 days between grapefruit juice intake and felodipine administration is necessary if the interaction is to be avoided [44]. Blood pressure responses to felodipine with grapefruit juice have also been assessed in the elderly and the systolic and diastolic blood pressures were found to be lower with grapefruit juice in the single-dose state, whereas they were not different between treatments in the steady-state dose [45]. The different blood pressure results between the studies can be explained by felodipine concentration-blood pressure response relationships. The elderly should be particularly cautioned about concomitant grapefruit juice and felodipine ingestion. In the benzothiazepine calcium channel antagonists group, diltiazem has been found to have an increased bioavailability on co administration of a single intake of grapefruit juice. Inhibition of intestinal metabolism and/or P-glycoprotein efflux transport was believed to be possibly responsible for this effect [46]. However in contrast to this, another study showed the bioavailability to be unchanged with grapefruit juice suggesting that factors other than biotransformation may be contributing [47]. Compared with water, grapefruit juice increased the maximum concentration of nisoldipine and reduced the time to reach maximum nisoldipine concentration [48]. However, the effects of grapefruit pulp intake were smaller than those produced by grapefruit juice intake, indicating that grapefruit pulp and juice have different effects on the pharmacokinetics [49]. A clinical study was performed to see the duration of this interaction in the body. Eight healthy volunteers were given grapefruit juice at 14, 38, 72 and 96 hours. Compared with the control group, the maximum plasma concentration of nisoldipine was significantly increased after grapefruit juice intake in at 0 and 14 hours, and the plasma concentration was significantly increased at each time till Director: Fernando Estevez Castillo Homeonews 58 Edición N° 9 – Enero – Febrero - Marzo de 2008 72 hours [50]. It is therefore necessary to withhold grapefruit juice for at least 3 days before administration of the drug to prevent grapefruit juice -nisoldipine interaction. Regarding verapamil, there are conflicting reports about its interaction with grapefruit juice. One study showed an increase in its bioavailability at steady state [51] while another showed no significant change in pharmacokinetics on a single administration. ACE-inhibitors like enalapril, captopril, lisinopril and ramipril have not shown any interaction with grapefruit juice although such an interaction might be possible with angiotensin II type 1 receptor antagonists like losartan and valsartan [18]. Thiazide diuretics and alph 1 adrenergic antagonists (doxazosin, terazosin, prazosin) have also shown no interaction with grapefruit juice [18]. Amiodarone, an antiarrythmic, is metabolized by CYP3A to Ndesethylamiodarone (N-DEA), a metabolite more potent than the parent drug [17]. On interaction with grapefruit juice, there has been shown to be complete inhibition of N-DEA production [52] leading to an overall decrease in the arrythmogenic side effects of amiodarone [17]. These results are in agreement with in vitro data pointing to the involvement of CYP3A in the metabolism of amiodarone and other Ca antagonists, suggesting that this interaction should be taken into account when prescribing this antiarrhythmic drug. Similarly grapefruit juice has been found to increase oral nimodipine bioavailability [53]. The same cannot be said of amlodipine, on which grapefruit juice has no appreciable effect [54]. One of the possible active ingredients in commercial grapefruit juice is Bergamottin, as mentioned before. This was determined after studying the effects of the furanocoumarin derivative on nifedipine (NFP) pharmacokinetics, suggesting that bergamottin in grapefruit might be the substance that elevates the NFP plasma concentrations [55]. Further studies have also been done to determine if even unprocessed grapefruit could cause drug interactions. It has been shown that unprocessed grapefruit can cause a drug interaction with felodipine [56]. 6', 7'Dihydroxybergamottin and naringin were implicated to be more important in this case because they are present in higher concentrations in grapefruit extracts. Antimicrobials With antivirals, authors concluded that concomitant administration of grapefruit juice increases gastric pH and delays indinavir absorption but does not uniformly affect the systemic bioavailability of indinavir in HIV-infected subjects [57,58]. Similarly grapefruit juice has been shown clinically to not significantly affect amprenavir pharmacokinetics [59]. It is suggested that this may be because the primary metabolism of these drugs is not in the small intestine. Director: Fernando Estevez Castillo Homeonews 59 Edición N° 9 – Enero – Febrero - Marzo de 2008 On the other hand regarding saquinavir, it has been shown that grapefruit juice increases the bioavailability of saquinavir without affecting its clearance, suggesting that inhibition of intestinal CYP3A4 may contribute [60]. And since the antiretroviral effect of saquinavir is dose-dependent, it has been suggested that inhibition of CYP3A4 may represent a way to enhance its effectiveness without increasing the dose. Amongst anti malarials, grapefruit juice significantly increases the oral bioavailability of artemether but does not prevent the time-dependent reduction in bioavailability or elimination half-life, suggesting a role for intestinal CYP3A4 in the presystemic metabolism of artemether [61,62]. Similar results have also been seen after a single oral dose of praziquantel with 250 ml of grapefruit juice [63]. Quinine appears to be unaffected in its pharmacokinetics. Since quinine is a low clearance drug with a relatively high oral bioavailability, and is primarily metabolised by human liver CYP3A4, the lack of effect of grapefruit juice on quinine pharmacokinetics again supports the view that the site of CYP inhibition by grapefruit juice is mainly in the gut [17,64]. However for quinidine, grapefruit juice reduces its total clearance and increases the elimination half-life by 19% [65]. In antibiotics, administration of grapefruit juice increased the time to peak concentration of clarithromycin but did not affect other pharmacokinetic parameters [66] while in antiparasitics, albendazole showed an increase in bioavailability upon administration of grapefruit juice [67]. Benzodiazepines and CNS drugs A marked interaction between oral midazolam and grapefruit juice has been found and the data is consistent again with a reduced first-pass metabolism of midazolam, resulting in increased bioavailability of midazolam [68,69]. The clinical importance of this is especially for patients with other causes for increased midazolam bioavailability such as advanced age, cirrhosis of the liver, and administration of other inhibitors of cytochrome P450. Thus, patients with liver cirrhosis are more dependent on the intestine for metabolism of CYP3A4 substrates than subjects with normal liver function. Another important implication of this interaction is in dentistry. Oral midazolam is a frequently used sedative in pediatric dentistry. Although an oral form of midazolam is now commercially available, some practitioners continue to use the IV midazolam as an oral medication. If the injectible form of midazolam is administered orally, its bitter taste requires the use of a flavoring agent like grapefruit juice. This results in increased blood plasma levels of midazolam causing excessive levels of sedation for the pediatric patient. Grapefruit juice therefore should be contraindicated for use with oral midazolam especially in such patients [70]. Similar results have also been seen with triazolam [71]. One study however, did show that grapefruit juice did not have any particular interaction with oral doses of 10 mg midazolam and 0.25 mg triazolam in Director: Fernando Estevez Castillo Homeonews 60 Edición N° 9 – Enero – Febrero - Marzo de 2008 healthy young subjects [72]. However, since more studies have determined increases in midazolam and triazolam bioavailbility, grapefruit juice should be administered with caution with these drugs. However, alprazolam remains unaffected in pharmacokinetics or pharmacodynamics due to its high bioavailability [73]. Among antipsychotics, clozapine remained unaffected after consumption of regular-strength grapefruit juice, usually taken as 250 mL b.i.d., for 14 days [74]. One reason for this is that enzymes other than CYP3A4 also mediate clozapine disposition. Haloperidol remains unaffected by grapefruit juice [75]. In anti convulsants, grapefruit juice increases the bioavailability of carbamazepine [76] but does not affect the pharmacokinetics of phenytoin [77]. Grapefruit juice considerably increases plasma buspirone concentrations [78] and also increases sertraline bioavailability [79]. Grapefruit juice therefore should be contraindicated during administration of buspirone and sertraline. Antihistamines and Serotonin Analogs A number of studies have shown that a single glass of grapefruit juice produced an individual-dependent, variable increase in the systemic bioavailability of cisapride by inhibition of intestinal cytochrome P450 3A4 (CYP3A4) activity. [8082] It has therefore been recommended that concomitant use of high amounts of grapefruit juice with cisapride should be avoided, at least in patients with risk factors for cardiac arrhythmia. The effect of grapefruit juice on racemic nitrendipine was also to increase its bioavailability and it was found that it inhibits the stereoselective metabolism of nitrendipine in humans [83]. Regarding terfenidine, the ingestion of grapefruit juice leads to its enhanced systemic bioavailability [84,85]. This is especially important because the raised levels of terfenidine can prolong the QT interval in the electrocardiogram sufficiently to precipitate the ventricular arrhythmia of Torsade-des-pointes [86]. Incidentally, both terfenidine and cisapride have been globally withdrawn from the market due to serious cardiac arrythmias precipitated by their interaction with other drugs if simultaneously taken. Statins and other cholesterol-lowering agents Taking simvastatin first, the active ingredient bergamottin has been shown to inhibit simvastatin (SV) metabolism and increase the serum concentrations of simvastatin and its active metabolite simvastatin acid, and, to a lesser extent, those of active and total HMG-CoA reductase inhibitors [87,88]. The probable mechanism of this interaction was also the inhibition of CYP3A4-mediated firstpass metabolism of simvastatin by grapefruit juice in the small intestine. Bergamottin (BG) and naringenin (NRG) could therefore be applied as markers in food-drug interaction studies in order to adjust posology and the dose of simvastatin should be accordingly reduced. Director: Fernando Estevez Castillo Homeonews 61 Edición N° 9 – Enero – Febrero - Marzo de 2008 Another study further found out that, when simvastatin is taken 24 hours after ingestion of "high-dose" grapefruit juice, the effect on the concentration of simvastatin is only about 10% of the effect observed during concomitant intake of grapefruit juice and simvastatin. It was also shown that the interaction potential of even high amounts of grapefruit juice with CYP3A4 substrates dissipates within 3 to 7 days after ingestion of the last dose of grapefruit juice [89]. The grapefruit juice effect has also been studied on lovastatin. Lovastatin and its active metabolite, lovastatin acid had greatly increased serum concentrations after grapefruit juice administration [90]. However, one other study has shown a minimal effect of a glass of regular-strength grapefruit juice on plasma concentration after a 40 mg evening dose of lovastatin [91]. Although grapefruit juice also increases the AUC of atorvastatin, the actual increase in activity is fairly modest, possibly due to a simultaneous effect of decreasing the AUC of active metabolites of atorvastatin [17]. Regardless, grapefruit juice should not be concomitantly ingested with atorvastatin, lovastatin or simvastatin. On the other hand, pravastatin, fluvastatin and rosuvastatin are three statin drugs that have been shown not to interact with grapefruit juice [18]. These may be useful alternatives in settings where there is a concern regarding potential interaction with grapefruit juice. Other cholesterol-lowering agents like nicotinic acid and common fibric acid derivatives and bile acid sequestrants have shown no interaction, and therefore may be safely used, with grapefruit juice [18]. Chemotherapeutics In patients with autoimmune diseases, the effect of chronic grapefruit juice administration on steady state blood concentrations of cyclosporine and metabolites is an increase in both parent and metabolite profiles [92]. This interaction was studied in renal transplant recipients. Administration of cyclosporine with grapefruit juice compared with water induced a moderate, butsignificant increase in the systemic exposure of cyclosporine [93,94]. Most of these studies involving cyclosporine were done on adult patients. However, one study was also done in the paediatric population. This study showed that alterations in cyclosporine absorption and elimination only occur with concurrent grapefruit juice ingestion when stable pediatric renal transplant patients are taking the oral cyclosporine solution, but not the microemulsion formulation [95]. Regarding prednisolone and etoposide, grapefruit juice has been found to have no significant effect on the metabolism of prednisolone [96] but in the case of etoposide, it has been shown to decrease its bioavailability [97]. Conclusion In light of the wide ranging effects of grapefruit juice on the pharmacokinetics of various drugs, physicians need to be aware of these interactions and should Director: Fernando Estevez Castillo Homeonews 62 Edición N° 9 – Enero – Febrero - Marzo de 2008 make an attempt to warn and educate their patients regarding potential consequences of concomitant ingestion of these two items. Patient-to-patient variability should be kept in mind and elderly should be particularly warned about these interactions since they are more prone to grapefruit juice-drug interactions [17]. Physicians should also consider using these effects to their own advantage in order to reduce the dosage requirements of certain drugs. However, since further research is required into the mechanism of action of grapefruit juice, it is still premature to recommend it as an adjunctive booster with other drugs. Abbreviations AUC = area under the plasma concentration-time curve CYP = cytochrome P -450 DEA = desethylamiodarone DHB = dihydroxybergamottin HMG – CoA = 3 – hydroxyl – 3 – methylglutaryl coenzyme A NFP = nifedipine OATP = organic anion-transporting polypeptides Pgp = P – glycoprotein RDA = Recommended daily allowance SV = simvastatin Competing interests The author(s) declare that they have no competing interests. Authors' contributions Both authors contributed equally. Acknowledgements This was an independent review done by the authors. References Cerda JJ, Normann SJ, Sullivan MP, et al. :Inhibition of atherosclerosis by dietary pectin in microswine with sustained hypercholesterolemia. Circulation 1994, 89:1247-1253. 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Br J Clin Pharmacol 2000, 49:373-8. Fuhr U, Maier-Bruggemann A, Blume H, Muck W, Unger S, Kuhlmann J, Huschka C, Zaigler M, Rietbrock S, Staib AH :Grapefruit juice increases oral nimodipine bioavailability. Int J Clin Pharmacol Ther 1998, 36:126-32. Vincent J, Harris SI, Foulds G, Dogolo LC, Willavize S, Friedman HL :Lack of effect of grapefruit juice on the pharmacokinetics and pharmacodynamics of amlodipine. Br J Clin Pharmacol 2000, 50:455-63. Mohri K, Uesawa Y :Effects of furanocoumarin derivatives in grapefruit juice on nifedipine pharmacokinetics in rats. Pharm Res 2001, 18:177-82. Bailey DG, Dresser GK, Kreeft JH, Munoz C, Freeman DJ, Bend JR :Grapefruitfelodipine interaction: effect of unprocessed fruit and probable active ingredients. Clin Pharmacol Ther 2000, 68:468-77. Director: Fernando Estevez Castillo Homeonews 67 Edición N° 9 – Enero – Febrero - Marzo de 2008 Shelton MJ, Wynn HE, Hewitt RG, DiFrancesco R :Effects of grapefruit juice on pharmacokinetic exposure to indinavir in HIV-positive subjects. J Clin Pharmacol 2001, 41:435-42. Penzak SR, Acosta EP, Turner M, Edwards DJ, Hon YY, Desai HD, Jann MW Effect of Seville orange juice and grapefruit juice on indinavir pharmacokinetics. J Clin Pharmacol 2002, 42:1165-70. Demarles D, Gillotin C, Bonaventure-Paci S, Vincent I, Fosse S, Taburet AM :Single-dose pharmacokinetics of amprenavir coadministered with grapefruit juice. Antimicrob Agents Chemother 2002, 46:1589-90. Kupferschmidt HH, Fattinger KE, Ha HR, Follath F, Krahenbuhl S :Grapefruit juice enhances the bioavailability of the HIV protease inhibitor saquinavir in man. Br J Clin Pharmacol 1998, 45:355-9. Van Agtmael MA, Gupta V, van der Graaf CA, van Boxtel CJ :The effect of grapefruit juice on the time-dependent decline of artemether plasma levels in healthy subjects. Clin Pharmacol Ther 1999, 66:408-14. Van Agtmael MA, Gupta V, van der Wosten TH, Rutten JP, van Boxtel CJ :Grapefruit juice increases the bioavailability of artemether. Eur J Clin Pharmacol 1999, 55:405-10. Castro N, Jung H, Medina R, Gonzalez-Esquivel D, Lopez M, Sotelo J :Interaction between grapefruit juice and praziquantel in humans. Antimicrob Agents Chemother 2002, 46:1614-6. Ho PC, Chalcroft SC, Coville PF, Wanwimolruk S :Grapefruit juice has no effect on quinine pharmacokinetics. Eur J Clin Pharmacol 1999, 55:393-8. Damkier P, Hansen LL, Brosen K :Effect of diclofenac, disulfiram, itraconazole, grapefruit juice and erythromycin on the pharmacokinetics of quinidine. Br J Clin Pharmacol 1999, 48:829-38. Cheng KL, Nafziger AN, Peloquin CA, Amsden GW :Effect of grapefruit juice on clarithromycin pharmacokinetics. Antimicrob Agents Chemother 1998, 42:927-9. Nagy J, Schipper HG, Koopmans RP, Butter JJ, Van Boxtel CJ, Kager PA :Effect of grapefruit juice or cimetidine coadministration on albendazole bioavailability. Am J Trop Med Hyg 2002, 66:260-3. Andersen V, Pedersen N, Larsen NE, Sonne J, Larsen S :Intestinal first pass metabolism of midazolam in liver cirrhosis – effect of grapefruit juice. Br J Clin Pharmacol 2002, 54:120-4. Kupferschmidt HH, Ha HR, Ziegler WH, Meier PJ, Krahenbuhl S :Interaction between grapefruit juice and midazolam in humans. Clin Pharmacol Ther 1995, 58:20-8. Director: Fernando Estevez Castillo Homeonews 68 Edición N° 9 – Enero – Febrero - Marzo de 2008 Goho C :Oral midazolam-grapefruit juice drug interaction. Pediatr Dent 2001, 23:365-6. Hukkinen SK, Varhe A, Olkkola KT, Neuvonen PJ :Plasma concentrations of triazolam are increased by concomitant ingestion of grapefruit juice. Clin Pharmacol Ther 1995, 58:127-31. Vanakoski J, Mattila MJ, Seppala T :Grapefruit juice does not enhance the effects of midazolam and triazolam in man. Eur J Clin Pharmacol 1996, 50:5018. Yasui N, Kondo T, Furukori H, Kaneko S, Ohkubo T, Uno T, Osanai T, Sugawara K, Otani K :Effects of repeated ingestion of grapefruit juice on the single and multiple oral-dose pharmacokinetics and pharmacodynamics of alprazolam. Psychopharmacology (Berl) 2000, 150:185-90. Lane HY, Jann MW, Chang YC, Chiu CC, Huang MC, Lee SH, Chang WH :Repeated ingestion of grapefruit juice does not alter clozapine's steady-state plasma levels, effectiveness, and tolerability. J Clin Psychiatry 2001, 62:812-7. Yasui N, Kondo T, Suzuki A, Otani K, Mihara K, Furukori H, Kaneko S, Inoue Y :Lack of significant pharmacokinetic interaction between haloperidol and grapefruit juice. Int Clin Psychopharmacol 1999, 14:113-8. Garg SK, Kumar N, Bhargava VK, Prabhakar SK :Effect of grapefruit juice on carbamazepine bioavailability in patients with epilepsy. Clin Pharmacol Ther 1998, 64:286-8. Kumar N, Garg SK, Prabhakar S :Lack of pharmacokinetic interaction between grapefruit juice and phenytoin in healthy male volunteers and epileptic patients. Methods Find Exp Clin Pharmacol 1999, 21:629-32. Lilja JJ, Kivisto KT, Backman JT, Lamberg TS, Neuvonen PJ :Grapefruit juice substantially increases plasma concentrations of buspirone. Clin Pharmacol Ther 1998, 64:655-60. Lee AJ, Chan WK, Harralson AF, Buffum J, Bui BC :The effects of grapefruit juice on sertraline metabolism: an in vitro and in vivo study. Clin Ther 1999, 21(11):1890-9. Desta Z, Kivisto KT, Lilja JJ, Backman JT, Soukhova N, Neuvonen PJ, Flockhart DA :Stereoselective pharmacokinetics of cisapride in healthy volunteers and the effect of repeated administration of grapefruit juice. Br J Clin Pharmacol 2001, 52:399-407. Offman EM, Freeman DJ, Dresser GK, Munoz C, Bend JR, Bailey DG :Red wine-cisapride interaction: comparison with grapefruit juice. Clin Pharmacol Ther 2001, 70:17-23. Director: Fernando Estevez Castillo Homeonews 69 Edición N° 9 – Enero – Febrero - Marzo de 2008 Kivisto KT, Lilja JJ, Backman JT, Neuvonen PJ :Repeated consumption of grapefruit juice considerably increases plasma concentrations of cisapride. Clin Pharmacol Ther 1999, 66:448-53. Soons PA, Vogels BA, Roosemalen MC, Schoemaker HC, Uchida E, Edgar B, Lundahl J, Cohen AF, Breimer DD :Grapefruit juice and cimetidine inhibit stereoselective metabolism of nitrendipine in humans. Clin Pharmacol Ther 1991, 50:394-403. Van den Anker JN, de Wildt SN :Excessive terfenadine level due to drinking grapefruit juice. Ned Tijdschr Geneeskd 1997, 141:1976-8. Rau SE, Bend JR, Arnold MO, Tran LT, Spence JD, Bailey DG :Grapefruit juiceterfenadine single-dose interaction: magnitude, mechanism, and relevance. Clin Pharmacol Ther 1997, 61:401-9. Honig PK, Wortham DC, Lazarev A, Cantilena LR :Grapefruit juice alters the systemic bioavailability and cardiac repolarization of terfenadine in poor metabolizers of terfenadine. J Clin Pharmacol 1996, 36:345-51. Le Goff-Klein N, Koffel JC, Jung L, Ubeaud G :In vitro inhibition of simvastatin metabolism, a HMG-CoA reductase inhibitor in human and rat liver by bergamottin, a component of grapefruit juice. Eur J Pharm Sci 2003, 18:31-5. Lilja JJ, Kivisto KT, Neuvonen PJ :Grapefruit juice-simvastatin interaction: effect on serum concentrations of simvastatin, simvastatin acid, and HMG-CoA reductase inhibitors. Clin Pharmacol Ther 1998, 64:477-83. Lilja JJ, Kivisto KT, Neuvonen PJ :Duration of effect of grapefruit juice on the pharmacokinetics of the CYP3A4 substrate simvastatin. Clin Pharmacol Ther 2000, 68:384-90. Kantola T, Kivisto KT, Neuvonen PJ :Grapefruit juice greatly increases serum concentrations of lovastatin and lovastatin acid. Clin Pharmacol Ther 1998, 63:397-402. Rogers JD, Zhao J, Liu L, Amin RD, Gagliano KD, Porras AG, Blum RA, Wilson MF, Stepanavage M, Vega JM :Grapefruit juice has minimal effects on plasma concentrations of lovastatin-derived 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors. Clin Pharmacol Ther 1999, 66:358-66. Ioannides-Demos LL, Christophidis N, Ryan P, Angelis P, Liolios L, McLean AJ :Dosing implications of a clinical interaction between grapefruit juice and cyclosporine and metabolite concentrations in patients with autoimmune diseases. J Rheumatol 1997, 24:49-54. Hermann M, Asberg A, Reubsaet JL, Sather S, Berg KJ, Christensen H :Intake of grapefruit juice alters the metabolic pattern of cyclosporin A in renal transplant recipients. Int J Clin Pharmacol Ther 2002, 40:451-6. Director: Fernando Estevez Castillo Homeonews 70 Edición N° 9 – Enero – Febrero - Marzo de 2008 Brunner LJ, Munar MY, Vallian J, Wolfson M, Stennett DJ, Meyer MM, Bennett WM :Interaction between cyclosporine and grapefruit juice requires long-term ingestion in stable renal transplant recipients. Pharmacotherapy 1998, 18:23-9. Brunner LJ, Pai KS, Munar MY, Lande MB, Olyaei AJ, Mowry JA :Effect of grapefruit juice on cyclosporin A pharmacokinetics in pediatric renal transplant patients. Pediatr Transplant 2000, 4:313-21. Hollander AA, van Rooij J, Lentjes GW, Arbouw F, van Bree JB, Schoemaker RC, van Es LA, van der Woude FJ, Cohen AF :The effect of grapefruit juice on cyclosporine and prednisone metabolism in transplant patients. Clin Pharmacol Ther 1995, 57:318-24. Reif S, Nicolson MC, Bisset D, Reid M, Kloft C, Jaehde U, McLeod HL :Effect of grapefruit juice intake on etoposide bioavailability. Eur J Clin Pharmacol 2002, 58:491-4. NOTAS DE INTERES PRIMER ENCUENTRO CHILENO DE PREPARADOS HOMEOPATICOS ELABORADOS EN FARMACIAS Aspectos Técnicos y Reguladores Santiago de Chile – República de Chile El 8 de noviembre del año próximo pasado tuvo lugar en el Hotel Fundador de la ciudad de Santiago, República de Chile, el Primer Encuentro Chileno de Preparados Homeopáticos elaborados en Farmacias, organizado por el Instituto de Salud Pública de dicho país, a través del Centro de Magistrales y Oficinales, con la colaboración de un grupo de trabajo de especialistas. Esta actividad fue impulsada por las directrices que señala la nueva política de Medicamentos y a modo de complementar el nuevo Reglamento que regulará este tipo de preparados, actualmente en revisión, contribuyendo así a la actualización del los Químicos Farmacéuticos, disponiendo de reglas farmacéuticas claras y precisas, conocidas por todos, que favorezcan a la Autoridad Sanitaria a la introducción de Buenas Prácticas de Elaboración en Farmacias y faciliten su cumplimiento. Esta reunión se desarrolló con la presencia de un gran número de profesionales que desarrollan su labor en los recetarios magistrales homeopáticos, quienes tuvieron la posibilidad de realizarar preguntas e intercambiar opiniones con los disertantes nacionales y los invitados extranjeros, así como también con las Autoridades Sanitarias presentes. Director: Fernando Estevez Castillo Homeonews 71 Edición N° 9 – Enero – Febrero - Marzo de 2008 La Jornada comenzó con las palabras del Dr. Q. F. Eduardo Johnson Rojas, Jefe del Departamento de Control Nacional del Instituto de Salud Pública de Chile, quien dio la bienvenida a los asistentes e invitados, y luego siguieron las disertaciones de acuerdo al programa establecido: -Aplicación de Buenas Prácticas en las distintas etapas de elaboración de un preparado homeopático, Dr. Q. F. José Paredes (Chile), Director de Laboratorio Hoschtetter. -La tintura madre y su preparación en el recetario de farmacia: Recomendaciones técnicas, Dr. Q. F. Ernesto Mickman (Chile), docente de la Universidad de Valparaíso. -Estandarización de Normas de Preparación en Homeopatía, un paso fundamental hacia la aplicación de Buenas Prácticas, Farm. Fernando Estevez Castillo (Argentina), Asesor Científico de Laboratorios Dr. Madaus y Farmacia+Natural, Director del Curso de Posgrado de Farmacia Homeopática (Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires). -Importancia de la calidad del agua, alcohol y envases en la elaboración de preparados farmacéuticos homeopáticos, Q. F. Juan Riquelme (Chile), Q. F. de Farmacia Homeopática Serey e Investigador en Esencias Florales Chilenas. -Acción de ANVISA en la regulación de preparados homeopáticos elaborados en Farmacias Brasileñas, Dra. Robelma De Oliveira (Brasil), Farmacéutica especialista en regulación y vigilancia sanitaria, ANVISA, Brasil. -Acciones del Instituto de Salud Pública de Chile frente a la nueva propuesta reglamentaria aplicable a Recetarios de Farmacia, Dra. Q. F. Gladys Chicago Cabrera (Chile), Jefe Sección Magistrales y Oficinales, Instituto de Salud Pública de Chile. De der. a izq. : Dra. Robelma De Oliveira (Brasil), Dra. Q. F. Gladys Chicago Cabrera (Chile) y Farm. Fernando Estevez Castillo (Arg.) Por último la Dra. Q. F. Gladys Chicago cerró el Encuentro agradeciendo la participación de los asistentes e invitados, así como también alentó a todos los Químicos Farmacéuticos para que participen enviando sus sugerencias y/o recomendaciones con respecto al documento “Buenas Prácticas de Director: Fernando Estevez Castillo Homeonews 72 Edición N° 9 – Enero – Febrero - Marzo de 2008 Elaboración en Farmacias de Preparados Homeopáticos” presentado en dicha oportunidad y publicado en la página web www.ispch.cl (entrar en la solapa Control Nacional y luego en Productos Magistrales) Disertantes y organizadores al terminar el Encuentro Comentarios En primer lugar quisiera agradecer al Instituto de Salud Pública de Chile por la invitación recibida para participar como disertante en dicho Encuentro, y especialmente a la Dra. Q. F. Gladys Chicago y la Q.F. Alexandra Zuñiga, como a todo el grupo encargado de la organización, por haber sido excelentes anfitriones, no sólo por haber estado pendientes de hasta el más mínimo detalle relacionado a mi estadía en Chile, sino por la calidez que demostraron hacia mi persona en cada momento que tuvieron la posibilidad de compartir alguna actividad, sea profesional o social (Restaurant con Show Folklórico de todas las regiones chilenas). En segundo lugar quisiera felicitar al Instituto de Salud Pública de Chile por la excelente organización de la actividad, la calidad de los disertantes y lo que para mí es lo más importante, el objetivo del encuentro, ya que desde la Autoridad Sanitaria se llama a los Químicos Farmacéuticos para participar en la correcta implementación de las Buenas Prácticas de Elaboración en Farmacias de Preparados Homeopáticos, a través del conocimiento de la misma, su discusión y posterior envío de sugerencias y/o propuestas, además de ofrecer la capacitación necesaria, lo cual los diferencia de otras Agencias Sanitarias (especialmente de Latinoamérica) que primero publican una regulación, aún sin tener conocimientos y sin participar a los principales actores (en éste caso los farmacéuticos que trabajan en las Farmacias Homeopáticas), y luego se pretende aplicar dicha legislación, lo cual provoca verdaderos problemas en su implementación. ¡Felicitaciones por el éxito del Encuentro y por ser un ejemplo como Autoridad Sanitaria en la implementación de Buenas Prácticas! Director: Fernando Estevez Castillo Homeonews 73 Edición N° 9 – Enero – Febrero - Marzo de 2008 XVIII CONGRESO FARMACEUTICO ARGENTINO “La Profesión Farmacéutica en el Siglo XXI: un compromiso con la salud comunitaria” Ciudad de Mendoza - Argentina Del 4 al 6 de Octubre del año pasado, se desarrolló en la Ciudad de Mendoza el XVIII Congreso Farmacéutico Argentino organizado por la Confederación Farmacéutica Argentina, con un temario muy amplio y la presencia de gran cantidad de disertantes nacionales e internacionales, así como también Autoridades Nacionales y Provinciales y legisladores tales como el Diputado Dr. Juan Héctor Sylvestre Begnis (Presidente de la Comisión de Acción Social y Salud Pública de la Honorable Cámara de Diputados de la Nación) y la Diputada Farm. Fabiana Ríos, colega autora de un proyecto de Ejercicio de la Actividad Farmacéutica y actual Gobernadora de la Provincia de Tierra del Fuego, Antártica e Islas del Atlántico Sur. Dentro del extenso temario, la Homeopatía tuvo su lugar, a través de una Mesa cuyo título fue: “Formulaciones Homeopáticas: presente y futuro”, coordinada por el Farm. Hugo Torres, y de la cual participaron la Farm. Verónica Martínez (Comisión de Homeopatía del Colegio de Farmacéuticos de la Provincia de Córdoba), la Farm. María Luz Font (Colegio de Farmacéuticos de la Provincia de Buenos Aires) y el Farm. Fernando Estevez Castillo (Director del Curso de Posgrado de “Farmacia Homeopática” de la Facultad de Farmacia y Bioquímica de la Universidad de Buenos Aires) El Farm. Fernando Estevez Castillo durante la presentación de su ponencia. La Farm. Verónica Martínez planteó la necesidad del Farmacéutico de capacitarse en Homeopatía para poder responder a los pacientes que se atienden por esta terapéutica, tanto desde el punto de vista técnico (relacionado a la preparación) como en el asesoramiento necesario para posibilitar el éxito del tratamiento (atención farmacéutica). Director: Fernando Estevez Castillo Homeonews 74 Edición N° 9 – Enero – Febrero - Marzo de 2008 La Farm. Verónica Martínez, participando como disertante Continuando con las disertaciones, la Farm. María Luz Font, se encargó de resaltar la gran cantidad de investigaciones que en la actualidad se están haciendo utilizando medicamentos homeopáticos y el aumento en el uso del mismo por parte de los pacientes, reflejado por un trabajo del Departamento de Salud Mental del Hospital de Clínicas José de San Martín de la Facultad de Medicina de la Universidad de Buenos Aires, donde el 55% de los pacientes encuestados utilizó terapias alternativas, siendo las Homeopatía y las Hierbas Medicinales las más usadas (40,8% y 37,6% respectivamente). Por último el Farm. Fernando Estevez Castillo planteó la necesidad de que se incorpore el medicamento homeopático a la Farmacopea Nacional Argentina y que se legisle al respecto, ya que lamentablemente día a día se convierte en el país más atrasado en Sudamérica en dicha materia a pesar del reconocimiento internacional de los profesionales que la ejercen (Médicos, Farmacéuticos y Veterinarios) que son invitados a dictar Cursos en todos los países del Mundo y que en el caso de la Profesión Farmacéutica, se autorregulan a través de la aplicación de Buenas Prácticas voluntarias, tomadas como referencia por otros países para la redacción de normativas sobre el particular (por ej.: Colombia y Chile). (Los videos se pueden ver libremente en la página de la Confederación Farmacéutica Argentina: www.cofa.org.ar) HOMEOPATIA PRIMERAS JORNADAS DEL COMAHUE Neuquén - Argentina El 20 y 21 de Octubre del año pasado, tuvo lugar en la Ciudad de Neuquén, las Primeras Jornadas de Homeopatía del Comahue, organizadas por Farmacia Farmacéuticos Asociados y auspiciado por la Escuela de Medicina de la Universidad Nacional del Comahue (Res 427) y Laboratorios Dr. Madaus. Director: Fernando Estevez Castillo Homeonews 75 Edición N° 9 – Enero – Febrero - Marzo de 2008 La actividad comenzó con las palabras de bienvenida del Farm. Federico Arrigoni, Director Técnico de Farmacia Farmacéuticos Asociados, empresa organizadora del evento y con una trayectoria destacada en dicha ciudad, en la preparación de medicamentos homeopáticos y dermatocosméticos. Luego, las Jornadas se desarrollaron en dos salones en paralelo, uno para profesionales que se inician en Homeopatía y otro para Avanzados, para lo cual fueron invitados como disertantes, el Dr. Ricardo Alvarez, médico homeópata de destacada trayectoria en la enseñanza de la Medicina Homeopática en nuestro país y el exterior, y el Farm. Fernando Estevez Castillo, ambos docentes de la Sociedad Argentina de Investigación, Docencia y Asistencia Homeopática (SAIDAH). El Dr. Ricardo Alvarez explicando las características de Cicuta virosa En el primer nivel, de Iniciación, se abordaron los siguientes temas: introducción a la homeopatía: doctrina y práctica médica, e investigación en homeopatía. En el segundo nivel, de Avanzados, la temática expuesta fue: enfermedades de la piel y de la boca; problemas relacionados a la práctica profesional homeopática e Investigación en Homeopatía. Por último, para ambos cursos y cerrando la última Jornada, el Dr. Alvarez se refirió a Traumatismos. Todas las actividades se destacaron por la activa participación de los asistentes, quienes a través de preguntas, inquietudes o experiencias personales, intercambiaron opiniones con los disertantes, lo cual enriqueció en gran medida a las Primeras Jornadas de Homeopatía del Comahue. Director: Fernando Estevez Castillo Homeonews 76 Edición N° 9 – Enero – Febrero - Marzo de 2008 El Farm. Fernando Estevez Castillo durante su exposición relacionada a la Investigación en Homeopatía. Al finalizar, el Farm. Federico Arrigoni, agradeció la presencia de todos los profesionales presentes, y prometió que en el futuro se organizarán más actividades relacionadas a ésta temática. Jornadas sobre el Ejercicio Profesional Farmacéutico Facultad de Ciencias Exactas – Universidad Nacional de La Plata El 27,28 y 29 de Noviembre del año pasado, la Facultad de Ciencias Exactas de la Universidad Nacional de La Plata, organizó las Jornadas sobre el Ejercicio Profesional Farmacéutico, teniendo en cuenta la incorporación de las Practicas Hospitalarias Voluntarias, a partir del año 2000, las Prácticas Farmacéuticas Obligatorias, a partir del año 2006 y las encuestas y charlas realizadas en forma permanente con los alumnos, y cuyo objetivo principal es promocionar diferentes variables de ejercicio profesional farmacéutico de acuerdos con los avances en el conocimiento farmacéutico en consonancia con los nuevos paradigmas y los avances tecnológicos existentes en nuestro país. Los ejercicios profesionales abordados fueron: Farmacia Hospitalaria, Farmacia Industrial y Farmacia Oficinal, para lo cual se invitaron a profesionales de reconocida trayectoria para que expongan sobre sus experiencias desarrolladas en nuestro país y el exterior. Dentro de la temática de Farmacia Oficinal, se incluyó a la Homeopatía, estando la disertación a cargo del Farm. Fernando Estevez Castillo, Director Técnico de Farmacia+Natural y Director del Curso de Posgrado de Farmacia Homeopática de la Facultad de Farmacia y Bioquímica de la Universidad de Buenos Aires, quién informó a los alumnos sobre las características de éste tipo de ejercicio profesional en Argentina y otros países, así como también la necesidad de incorporar la enseñanza de la Farmacotecnia Director: Fernando Estevez Castillo Homeonews 77 Edición N° 9 – Enero – Febrero - Marzo de 2008 Homeopática en las Facultades de Farmacia de nuestro país, con el fin de poder responder correctamente a una incumbencia que es propia del profesional farmacéutico y avalada por legislación nacional (ley 17565) y en algunas provincias por legislación local. Al finalizar los alumnos pudieron hacer preguntas e intercambiar un diálogo fluído con el orador invitado. ¡Felicitaciones al Colega, Farm. Miguel Hermida, por organizar y coordinar estas Jornadas, que sin lugar a dudas son muy importantes para los alumnos de la carrera de Farmacia para poder conocer las distintas modalidades del ejercicio profesional farmacéutico! NOVEDADES NUEVOS PRODUCTOS DERMOMEGA® OMS, División Cosmética de Laboratorios Dr. Madaus & Co., ha lanzado la línea DERMOMEGA®, especialmente formulada para pieles extra secas que tienden a manifestar problemas dermatológicos. Todos sus activos naturales, favorecen el restablecimiento del equilibrio lipídico de ácidos grasos esenciales Omega-3 y Omega-6, componentes fundamentales de la barrera cutánea, transportando los AGE (ácidos grasos esenciales) a las células de la epidermis, aumentando la flexibilidad de las membranas celulares y disminuyendo la pérdida transepidérmica de agua. DERMOMEGA® es una línea dermatocósmetica a base de Salvia Chía y Avena Sativa como componentes fundamentales, libre de parabenos, fragancias sintéticas y derivados animales, además de ser hipoalergénico, como toda la línea de productos OMS. DERMOMEGA® cuenta hasta este momento con tres productos: ® ! DERMOMEGA Crema fluida para rostro y cuerpo:Salvia Chía +Avena Sativa. Con Manteca de Karité y Pantenol. Previene problemas dermatológicos en pieles secas y ayuda a la pronta recuperación de la piel favoreciendo el crecimiento de tejido nuevo y la producción de colágeno. Presentación: envase por 190 ml. ! DERMOMEGA® Crema facial: Salvia Chía + Avena Sativa. Con manteca de Karité y Acido Hialurónico. Fórmula especialmente desarrollada para las necesidades del rostro. Ofrece una protección localizada en la zona más expuesta. Acelera y mejora la regeneración celular, posibilitando un mayor nivel de hidratación y la reconstitución de las fibras que sostienen los tejidos, incrementando su elasticidad y previniendo signos de envejecimiento. Presentación: envase por 50 g. ® ! DERMOMEGA Aceite de baño para rostro y cuerpo: Salvia Chía + Avena Sativa. Con tensioactivos ultrasuaves. Creado para facilitar la higiene de las pieles atópicas, sensibles y frágiles. Su delicada fórmula favorece la higiene de todo Director: Fernando Estevez Castillo Homeonews 78 Edición N° 9 – Enero – Febrero - Marzo de 2008 tipo de piel. Limpia, suaviza, calma irritaciones y restaura la barrera de protección natural. Presentación: envase por 250 ml. DERMOMEGA® Esencial para tu piel Para más información: OMS División Cosmética de Laboratorios Dr. Madaus & Co. S.A. Av. Luis María Campos 585 – Buenos Aires – Argentina (C1426BOD) Tel.: (54) (11) 4771-1734 / 4772-2428 Fax: (54) (11) 4775-4380 e.mail: [email protected] “AMIGOS DE LO NATURAL” LA HORA DE LA NATURALEZA LLEGO A LA RADIO! Desde junio del año pasado, todos los miércoles de 15 a 16 horas, “AMIGOS DE LO NATURAL”, programa radial de FM 94.7 (RADIO PALERMO), conducido por la Dra. Elba Albertinazzi y el Farm. Fernando Estevez Castillo, sale al aire, abordando temas tales como: Alimentación, Salud, Ecología y Hábitos saludables, entre otros, tratados siempre por profesionales y ofreciendo a los oyentes la posibilidad de hacer preguntas e informarse en relación a la temática abordada. Director: Fernando Estevez Castillo Homeonews 79 Edición N° 9 – Enero – Febrero - Marzo de 2008 Fueron muchos los invitados que hasta el momento participaron en “AMIGOS DE LO NATURAL”, destacando entre otros a: Dr. Jorge Alonso (médico especialista en fitomedicina), Ing. Agr. Mónica Romero (especialista en aromaterapia), Farm. Elena Ruiz Luque (Farmacéutica, Jefa de Producción de Laboratorios Dr. Madaus) Dr. Horacio Galitelli (odontólogo naturista), Lic. Susana Zurschmitten (Lic. en Nutrición), Dr. Guillermo Armesto (veterinario homeópata), Dr. Ricardo Alvarez (médico infectologo y homeópata), Dr. Alberto Gurni (Profesor Titular de Farmacobotánica de la Facultad de Farmacia y Bioquímica (UBA), Dr. José Luis Feldman (médico pediatra y homeópata), Dr. Horacio Alcorta (médico urólogo y naturista), Dr. Angel Fusaro (médico legista), Dra. Ana Soerensen (médica naturista), Dra. Perla Aizemberg (médica acupunturista), Dra. Cristina Solórzano (médica ginecóloga, obstetra y homeopata), Dra. Raquel Ferrazano (médica homeópata especialista en técnicas E.M.D.R.), Dra. Patricia Pilheu (médica pediatra especialista en medicina biológica). También fueron muchas las entrevistas realizadas, entre las cuales podemos citar: Dr. Juan Velazco, Ministro de Medio Ambiente de la Ciudad Autónoma de Buenos Aires (Gestión Telerman), por la verificación del cumplimiento de la Ley de Contaminación Sonora de la Ciudad; Dr. Adolfo Weimberg, médico especialista en Pneumonología e integrante de la Asamblea Ambientalista de Gualeguaychú, respecto a los problemas de salud que podrían aparecer con la instalación de la pastera Botnia en Fray Bentos (Uruguay); Ing. Pedro Carlos Brunetto, Director del Programa de Ensayos y Asistencia Técnica (INTI), respecto al informe publicado relativo a la calidad de las distintas marcas de puré de tomate (en envase tetrabrick) comercializados en la actualidad; Dr. Miguel Quintabani (abogado de la Asociación vecinal Pro-Vicente López), por su denuncia referida a la contaminación ambiental por cromo, proveniente de una empresa que afectaría las napas freáticas de la zona; Ing. Jorge Luis Ferrari (Ingeniero en Telecomunicaciones) de la Defensoría del Pueblo de la Ciudad Autónoma de Buenos Aires, por la instalación de antenas de celulares y su relación con ciertos problemas de salud en la población que vive en las adyacencias; Lic. Guillermo Caille, Biólogo marino y coordinador de las áreas técnicas de la Fundación Patagonia Natural, para informar sobre la contaminación provocada por el derrame de petróleo en Caleta Córdoba (Comodoro Rivadavia) y sus consecuencias sobre el medio ambiente y la fauna local. Otros momentos destacados son las columnas ofrecidas por Liliana Caputo, especialista en Cocina Natural, y René Larrea, cosmiatra de OMS, Cósmética Natural”. “AMIGOS DE LO NATURAL” El espacio que la Naturaleza recuperó en la Radio Director: Fernando Estevez Castillo Homeonews Edición N° 9 – Enero – Febrero - Marzo de 2008 “AMIGOS DE LO NATURAL” FM 94.7 RADIO PALERMO MIÉRCOLES DE 15 A 16 HS CONDUCEN DRA. ELBA ALBERTINAZZI FARM. FERNANDO ESTEVEZ CASTILLO PRODUCCION También podés escucharlo a través de la web: www.radiopalermo.com.ar CURSOS Y CONGRESOS CURSOS CURSOS A DISTANCIA “FITOMEDICINA (2008)” Y “FITODERMATOLOGIA Y FITOESTÉTICA (2008)” Asociación Argentina de Fitomedicina ¿En qué consisten los Cursos? Director: Fernando Estevez Castillo 80 Homeonews 81 Edición N° 9 – Enero – Febrero - Marzo de 2008 Se trata de un Curso a Distancia consistente en el envío de 40 módulos (Fitomedicina) ó 16 módulos (Fitodermatología y Fitoestética) en formato Acrobat PDF totalmente ilustrados, a la dirección mail del cursista. Durante el mismo, se verá un repaso fisiopatológico orientado a resaltar los aspectos más importantes que hacen al diagnóstico de las principales dolencias del ser humano, para luego avanzar en el abordaje fitoterapéutico, indicándose los mecanismos de acción de las diferentes especies vegetales, sus dosificaciones, diferencias con medicamentos de síntesis, y formulaciones respaldadas por las principales farmacopeas e instituciones académicas mundiales. El alumno podrá, a su vez, dirigir sus preguntas o dudas al director del curso, así como pedir ampliaciones de temas, y solicitud de papers o trabajos científicos sobre las áreas de interés que considere relevantes. ¿Cuándo iniciar? El curso en Abril de 2008. ¿Cuándo y cómo es la evaluación? La evaluación del alumno será realizada a partir de los seis meses de recibido todo el material. El examen consiste en la redacción de una Tesis sobre un tema o planta en particular. El alumno propondrá tres temas y la dirección del curso elegirá una de esas opciones para redactar la tesis. La misma podrá ser remitida por medio de Correo certificado a la sede de Av. Santa Fe 3553 – 2° “8” Capital Federal (1425) – República Argentina; o por documento en attach remitido al mail: [email protected]. Llegado el momento de rendir el examen, el alumno solicitará las condiciones y el formato de presentación de la tesis. A partir del envío de todo el material del curso, el alumno dispondrá de 12 meses para presentar su tesis. ¿Quiénes pueden inscribirse? Únicamente profesionales de la salud con matrícula universitaria, correspondientes a las siguientes carreras: Medicina, Farmacia y Bioquímica, Odontología, Veterinaria, Nutrición, Biología. También son aceptados los alumnos que cursen el último año de las respectivas carreras. En todos los casos, se remitirá por mail, fax o de modo personal, el certificado o carnet habilitante. Director del Curso Dr. Jorge Rubén Alonso. Médico y Presidente de la Asociación Argentina de Fitomedicina. Inversión en los Cursos El valor total de inscripción (contado) es el siguiente: 1. Para la República Argentina: El Curso de Fitomedicina tiene un valor de $ 450, pudiéndose también abonar en dos cuotas consecutivas de $ 250 cada una. En el primer caso, el alumno recibe al momento los 40 módulos que son enviados a su servidor; en el segundo caso, recibirá 20 módulos el primer mes y los restantes 20 módulos el segundo mes. Para el Curso de Fitodermatología y Fitoestética, el valor es de $ 370 (o dos cuotas consecutivas de $ 200). Los módulos se envían a razón de uno cada 14 días encualquiera de las dos formas de pago. Los inscriptos podrán realizar su pago directamente en la sede de la AAF: Av. Santa Fe 3553 – 2° “8” Capital Federal, de lunes a viernes de 10 a 19 hs. También mediante depósito en la caja de ahorros de Banco Galicia n° 4049945/5-032-2 (CBU 0070 0 320 3000 4049 9455 23 – CUIT 20-11702990-6) o por medio de envío de dinero por giro Director: Fernando Estevez Castillo Homeonews 82 Edición N° 9 – Enero – Febrero - Marzo de 2008 postal de Correo Argentino a nombre de Jorge Rubén Alonso, con domicilio Av. Santa Fe 3553 – 2° “8” Capital Federal. 2. Para los alumnos extranjeros de Latinoamérica, el valor del Curso de Fitomedicina es de u$s 170 (dólares norteamericanos ciento setenta), y el Curso de Fitodermatología y Fitoestética es de u$s 140, pudiéndose abonar por medio de la empresa Western Union o Money Pocket o similares, a nombre de Jorge Rubén Alonso, con domicilio Av. Santa fe 3553 – 2° “8” Capital Federal – República Argentina. Los alumnos de Bolivia y Perú, podrán contar además, con el sistema de pago a través de la empresa “Perú Services Courier” (consultar método de pago en [email protected] o en [email protected] ). En cualquiera de los casos, notificar su inscripción a: [email protected] y [email protected] acompañando los siguientes datos: nombre y apellidos completos, dirección completa incluyendo código postal, profesión y especialidad (si la hubiere), institución donde trabaja, teléfono de contacto, edad, estado civil y mail o blog de contacto. PROGRAMA OFICIAL CURSO DE FITOMEDICINA MÓDULO 1: Presentación. Breve introducción a la Fitomedicina. MÓDULO 2: Fitoterapia: Antecedentes Históricos (Egipto, China, India, Grecia, etc). Análisis histórico de las figuras de Teofrasto, Hipócrates, Galeno, Dioscórides, Plinio, Avicena, Paracelso, etc, sus influencias, obras y legados. La Medicina en la Edad Media, Renacentista, Contemporánea y actual. MÓDULO 3: Evolución Histórica de la Fitoterapia en Latinoamérica. El chamanismo. Significado y consecuencias del Descubrimiento de América. Conocimiento e introducción de nuevas especies. Culturas aborígenes de Latinoamérica. Las obras herbolarias de la época. MÓDULO 4: Botánica General. Origen de las Especies. Clasificación de Linneo. Fisiología vegetal. Clasificación general de las plantas. Las plantas con flores y las plantas sin flores. Su importancia medicinal. Plantas de cultivo, plantas alimenticias y plantas de uso industrial. Su importancia. Recolección de Plantas Medicinales. Conservación (poscosecha). MÓDULO 5: Control de calidad para materias primas y fitoterápicos. Concepto de calidad. Variabilidad de la misma. Concepto de seguridad y eficacia. Pasos a seguir en el control de calidad. Análisis macroscópico y microscópico (breves nociones). MÓDULO 6: La importancia del Suelo y el Clima y sus influencias en la obtención de principios activos. Tipos de suelo y especies mejor adaptadas a cada uno de ellos. Bosques tropicales, templados, praderas, herbazales y desiertos. Flora adaptada a cada situación. MÓDULO 7: Técnicas de comprobación de actividades biológicas. Ensayos in vitro, en animales y humanos. Tests para antimicrobianos, antitumorales, hipoglucemiantes, antiinflamatorios, antiulcerosos gástricos, espasmolíticos, antiasmáticos, hepatoprotectotres, antihipertensivos, antiagregantes, antitrombóticos, antiagregantes, sedantes, afrodisíacos, etc. Estudios de toxicidad (aguda, subaguda, crónica, teratogenicidad, mutagenicidad). MÓDULO 8: Farmacognosia general, Galénica. Formas de Identificación, Extracción, Preparación y Aislamiento de los Principios Activos Vegetales. Noción de Droga vegetal, Fitomedicamento o Medicamento Fitoterápico. Legislación vigente. Preparados a base de droga trozada (Tisanas). Infusión, Decocción, Maceración, Digestión. Preparados a base de droga pulverizada (polvos para encapsular). Métodos extractivos: maceración, destilación. Tratamiento con diferentes disolventes. Productos extractivos obtenidos por medio de diferentes disolventes: tinturas, alcoholaturas, extractos secos, fluidos, blandos, nebulizados, glicólicos, crioextractos, jarabes, elixires, pomadas, unguentos, etc. Director: Fernando Estevez Castillo Homeonews 83 Edición N° 9 – Enero – Febrero - Marzo de 2008 MÓDULO 9: Principios activos I. Rutas biosintéticas. Metabolitos primarios y secundarios. Hidratos de Carbono (glúcidos en general), Lípidos (ácidos grasos polinsaturados, Omega), y Proteínas (papaína, bromelaína, etc). MÓDULO 10: Principios activos II. Cardiotónicos (digitales y alternativas al digital: el espino albar), Saponinas (escina de Castaño de Indias, Ginseng, Hiedra, Regaliz), Cumarinas (Meliloto), Fenoles (salicílicos y no salicílicos), Compuestos cianogénicos (laurel cerezo, almendras amargas, etc). MÓDULO 11: Principios activos III. Antraquinonas (cáscara sagrada, sen, aloe, ruibarbo, frángula, etc), Flavonoides (Clasificación, su importancia medicinal, casos concretos: Ginkgo biloba, Vitis vinifera, etc), Taninos (sus propiedades astringentes y utilidad en aparato digestivo y dermatología, casos concretos: Te, Roble, Proantocianidinas, etc). MÓDULO 12: Principios activos IV. Los aceites esenciales. Historia. Métodos de destilación y obtención. Clasificación general de aceites esenciales según sus componentes. Ejemplos en cada caso. Propiedades Medicinales. Toxicidad de los aceites esenciales. Bases de la Aromaterapia. MÓDULO 13: Principios activos V. Alcaloides. Clasificación según el origen o ruta biosintética. Actividad en las plantas. Potencialidades terapéuticas, toxicidad. Algunos ejemplos: atropina, alcaloides del cornezuelo de centeno, efedrina, berberina, boldina, vincristina, vinblastina, sanguinarina, fisostigmina, etc. MÓDULO 14: Principios activos VI. Quinonas (ubiquinonas, naftoquinonas). Importancia medicinal. El caso de la Drosera. Las piretrinas (pelitre de Dalmacia), iridoides (harpagofito, llantén, valeriana), carotenoides (curcumina, azafrán), lignanos (su presencia en hongos), vitaminas (hidrosolubles, liposolubles, vitaminoides), terpenos (usos medicinales). MÓDULO 15: Aparato Digestivo I. Dispepsias. Concepto. Eupéticos, antiflatulentos o carminativos (importancia de los aceites esneciales de angélica, menta, coriandro, alcaravea, manzanilla, etc). Antiulcerosos gástricos. Concepto, fisiopatología. Investigaciones clínicas y biológicas con Regaliz, Congorosa, Cayena, Sangre de Drago, etc. Formulaciones útiles en cada caso. MÓDULO 16: Aparato Digestivo II. Constipación : tipos, etiología. Plantas útiles. Laxantes de formadores de masa o volumen, lubricantes, de contacto. Los casos de llantén, psyllums, fibras vegetales, aloe vera, frángula, sen, ruibarbo, etc. Diferencias y utilidades. Diarrea: clasificación, tipos. Astringentes vegetales: plantas con taninos (te, ratania, roble, etc). El caso de la Guayaba. Ensayos clínicos. Colon Irritable. Etiología, Sintomatología. Abordaje fitoterápico: aceite de menta, los psyllum. Formulaciones útiles en cada caso. MÓDULO 17: Aparato Digestivo III. Colagogos, coleréticos, hepatoprotectores. Los casos de: diente de león, bardana, boldo, cardo mariano, cúrcuma, phyllantus, hongos medicinales, etc. EvidencIas científicas y casos clínicos en hepatitis y cirrosis. Fórmulas apropiadas en cada caso. MÓDULO 18: Aparato Respiratorio I. Generalidades (tipos de tos, expectoración y disnea). Principios activos útiles. Plantas recomendadas en casos de resfríos, rinitis, sinusitis, faringitis. Ejemplos: equinácea, drosera. Formulaciones útiles en cada caso. MÓDULO 19: Aparato Respiratorio II. Antitusivos, expectorantes, antisépticos, antiasmáticos. Los ejemplos de: eucalipto, hiedra, guaco, ambay, anacahuita, tomillo, unckaluabo, berros, etc. Formulaciones útiles en cada caso. MÓDULO 20: Aparato Cardiovascular I. Cardiotónicos, antiarrítmicos. Fisiopatología de la Insuficiencia cardíaca congestiva. Inotrópicos vegetales: digital, estrofanto, convalaria, adonis, etc. El caso del espino albar o cratageus. Diferencias con el digital. Antiarrítmicos vegetales: retama, rauvolfia serpentina, árnica, etc. Formulaciones útiles en cada caso. MÓDULO 21: Aparato Cardiovascular II. Antihipertensivos – Antianginosos. Fisiopatología y clasificación de la hipertensión arterial. Estudios experimentales y clínicos con ajo, crataegus o espino albar, rosa de Jamaica, etc. El rol del espino albar en la angina de pecho. Formulaciones útiles. MODULO 22: Aparato Cardiovascular III. Insuficiencia venosa crónica. Fisiopatología y clasificación de drogas antivaricosas. Flebotónicos más importantes: castaño de Indias, meliloto, vid, ciprés, hiedra, centella asiática, rusco, rutósidos provenientes del eucalipto, trigo sarraceno, sófora, etc). Hemorroides. Formulaciones útiles en cada caso. Director: Fernando Estevez Castillo Homeonews 84 Edición N° 9 – Enero – Febrero - Marzo de 2008 MÓDULO 23: Sistema Génitourinario I. Diuréticos. Nociones básicas de fisiología renal. Clasificación de los agentes diuréticos. Diferencias en sus mecanismos de acción con drogas de síntesis. Principales diuréticos vegetales: equisetos o colas de caballo, zarzaparrillas, diente de león, abedul, aceites esenciales, grama de las boticas, etc. Fórmulas ütiles. MÓDULO 24: Sistema Génitourinario II. Antisépticos urinarios. Drogas con aceites esenciales. Los casos de los arándanos o mirtilos, gayuva o uva ursi, berberina, palo pichi, etc. Antiliátisicos urinarios. El caso del Phyllanthus niruri (rompepiedras). MÓDULO 25: Sistema Génitourinario III. Antiprostáticos. Fisiopatología de la Hipertrofia Benigna Prostática. Drogas vegetales útiles: Serenoa repens (Sabal serrulata), ciruelo africano, Hipoxis rooperi, Ortiga mayor. Otros activos útiles: polen, semillas de calabaza. Mecanismos de acción en todos los casos. Casos clínicos. Diferencias con el tratameinto clásico convencional. MÓDULO 26: Ginecología I. Menopausia y Climaterio. Síntomas asociados. Fitoestrógenos: clasificación y fuentes alimenticias. Fitoestrógenos de la soja (daidzeína, genisteína, etc). Otros fitoestrógenos de importancia medicinal: cimicífuga, trébol rojo, ñame, etc. Diferencias y virtudes frente a la terapia de reemplazo hormonal convencional. Trabajos clínicos. MÓDULO 27: Ginecología II. Sindrome premenstrual. Etiopatogenia, síntomas característicos. Abordaje fitoterápico en base a aceite de onagra o prímula, agnocasto, etc. Fórmulas útiles. MÓDULO 28: Aparato Locomotor I. Antiinflamatorios. Artrosis. Definición, clasificación. Etiopatogenia. Síntomas característicos. Antiinflamatorios de origen vegetal: salicilatos (sauce, ulmaria, gaulteria, álamo, etc), iridoides (harpagofito o garra de diablo), inhibidores de la COX-2 (el ejemplo de los curcuminoides de la Curcuma longa). Formulaciones útiles. MÓDULO 29: Aparato Locomotor II. Artritis Reumatoidea. Etiopatogenia. Sintomatología. Hallazgos radiológicos e histológicos. Tratamiento convencional: sus peligros y limitaciones. Abordaje fitoterápico. Los casos de Oenothera biennis (onagra) e Incienso (Boswellia serrata). Mecanismos de acción. Trabajos clínicos. Productos en el mercado farmacéutico. Formulaciones. MÓDULO 30: Sistema Nervioso I. Ansiedad e Hipnosedantes. Tipos de ansiedad. Fobias y ataques de pánico. Teorías fisiopatológicas. Drogas vegetales útiles: valeriana, kava-kava, melisa, pasionaria (pasiflora), tilo, naranjo amargo, amapola de California, etc. Diferencias respecto a drogas benzodiacepínicas sintéticas. Trabajos clínicos. Dosis en cada caso. MÓDULO 31: Sistema Nervioso II. Sindrome depresivo. Repaso fisiopatológico. Incidencia poblacional. Sintomatología. Drogas vegetales útiles. El caso de la hierba de San Juan (Hipérico). Casos en los cuales está indicado. Difererencias con los tratamientos convencionales. Ensayos clínicos. MÓDULO 32: Sistema Nervioso III. Circulación cerebral. El caso del Ginkgo biloba. Actividades en casos de déficit irrigatorio, pérdida de memoria, etc. Dosis en cada caso. Enfermedad de Alzheimer. Utilidad del Ginkgo bilob en los déficits cognitivos de estos pacientes. El caso del galanto (Galanthus nivalis, planta de donde procede la galantamina). MÓDULO 33: Sistema Nervioso IV. Alucinógenos o drogas enteógenas. Su significado dentro de las cosmovisiones indigenistas. Estudio sistemático de la hoja de coca, el Cannabis (marihuana), el peyote, la ayahuasca, la Salvia divinorum, hongos alucinógenos, etc. Posibilidades terapéuticas. Debate legal. MÓDULO 34: Metabolismo I. Diabetes. Clasificación, incidencia mundial, sintomatología. Nutrientes útiles (fibras, ajo, cebolla, arándanos, etc). Plantas investigadas como hipoglucemiantes: higuera, momórdica, sarandí (Phyllanthus sellowianus), pezuña de vaca, Gymnema sylvestre, eucalipto, estevia o yerba dulce, etc. Plantas útiles en diabetes tipo I. Investigaciones. Ensayos clínicos y preclínicos. MÓDULO 35: Metabolismo II. Obesidad. Tipos, clasificación. Recientes investigaciones en el área de la etiopatogenia. Plantas útiles (garcinia, fucus, naranjo amargo, Hoodia sp, Phaseolus sp, etc). Su verdadera utilidad. Dosis, formulaciones. Ensayos clínicos. Director: Fernando Estevez Castillo Homeonews 85 Edición N° 9 – Enero – Febrero - Marzo de 2008 MÓDULO 36: Metabolismo III. Hiperlipidemias. Clasificación. Ácidos grasos. Aceites Omega. Plantas investigadas: ajo, mirra, berenjena, fitoesteroles, chía, etc. Trabajos preclínicos y clínicos. MÓDULO 37: Fitodermatología – Fitocosmética. Breve reseña de las principales afecciones de la piel y anexos: acné, psoriasis, vitiligo, alopecías, manchas cutáneas, etc. Abordajes terapéuticos en cada caso. MÓDULO 38: Inmunología. Inmunomoduladores e inmunoestimulantes. Repaso fisiológico. Plantas destacadas: equinácea, lapacho, ginseng coreano y siberiano, hongos medicinales (shiitake, maitake, etc). MÓDULO 39: Antitumorales vegetales. Ciclo celular y modus operandi de las principales plantas estudiadas. Drogas clásicas (vincristina, vinblastina, etopósido, taxol, tenopósido, Cataranthus sp, etc). Drogas vegetales en experimentación: cúrcuma, azafrán, lapacho, graviola, uña de gato, celidonia, etc. Ensayos preclínicos y clínicos. MÓDULO 40: Interacciones entre hierbas y medicamentos de síntesis. El rol del sistema citocromal p-450. Principales interacciones de drogas sintéticas y ajo, cardo mariano, hipérico, ginseng, ginkgo, yohimbo, etc. PROGRAMA CURSO A DISTANCIA DE FITODERMATOLOGÍA Y FITOESTÉTICA (2008) Módulo 1: Generalidades de la piel. Histología. El estrato córneo: su importancia. El rol del manto hidrolipídico. Función de barerra y emuntorial. Tipos de piel. Lesiones primarias, lesiones secundarias y lesiones especiales de piel. Terminología empleada en fitodermatología: astringentes, emolientes, demulcentes, exfoliantes, etc. Módulo 2: Envejecimiento Cutáneo - Arrugas. Etiopatogenia. Papel de los radicales libres, la luz ultravioleta y la dieta. Abordaje integral en pieles envejecidas. Protectores UV. Hidratantes. Revisión de abordajes convencionales: beneficios y perjuicios del Botox, adenoxine, argilerina, DMAE, octamioxyl, myoxinal, etc. Actividad de los compuestos similBOTOX, algas marinas (Padina pavonica, etc), ácido beta-boswélico (Boswellia serrata), flavonoides (quercetina, kaempferol, etc), alfa-hidroxiácidos frutales (ácidos glicólico, málico, láctico, tartárico, etc), vitaminas, oligoelementos. ácido hialurónico (glucosaminoglicanos), beta-glucanos, ácido ursólico, extractos de Phoenix dactylifera, Kigelia africana, derivados de proteínas del trigo, etc. Sustancias antiage: raifortasa, antoxina, HPDR sodium, tiotaurina, etc. Plantas con propiedades anti-filtro solar. Módulo 3: Fitonutrientes y productos naturales en piel y faneras. Investigaciones científicas sobre ácido lipoico, ácido ursólico, avena (Avena sativum), manzanilla (Matricaria recutita), aceites esenciales (albahaca, enebro, melaleuca, azahar, etc), ceramidas, ácido glutámico, coenzima Q-10, silicio, carotenos, isoflavonas, metalotioneínas endógenas. Antiirritantes cutáneos. Sustancias naturales emolientes, rubefascientes, astringentes y demulcentes. Módulo 4: Alopecías. Etiopatogenia. Causas hormonales y medicamentosas involucradas. Clasificación (difusa, androgénica, traumática, etc). Revisión de los tratamientos medicamentosos convencionales (minoxidil, finasteride, etc). Investigaciones científicas en base a suplementos dietarios, vitaminas, minerales y oligoelementos. Plantas medicinales útiles: vasodilatadores (Ginkgo biloba, Capsicum sp), antiandrógenos (Sabal serrulata, Urtica dioica). Rol del ácido ursólico. Formulaciones. Módulo 5: Pediculosis Etiología. Datos epidemiológicos. Abordaje convencional. Permetrina (riesgos, resistencia). Plantas medicinales útiles: Quassia amara, Picrasma crenata, Melia azedarach (paraíso), Schinus molle (molle), Allium sativum (ajo), aceites esenciales de cítricos, etc. Formulaciones. Módulo 6: Caspa – Seborrea Director: Fernando Estevez Castillo Homeonews 86 Edición N° 9 – Enero – Febrero - Marzo de 2008 Etiopatogenia de la caspa y seborrea. Clasificación. Revisión del abordaje convencional (beneficios y perjuicios de queratolíticos, citostáticos, antimicrobianos, brea de Hulla o Coaltar, etc). Plantas medicinales útiles. El rol de los aceites esenciales. Formulaciones útiles. Módulo 7: Despigmentantes cutáneos Clasificación de hipercromías. Agentes blanqueadores de la piel. Inhibidores de la tirosinasa (fenoles, hidroquinonas y derivados, catecoles, ácido ascórbico, ácido kójico, luteolina-7-glucósido, arbutina, etc). Inactivadores y competidores de la tirosina (ácido azelaico, nicotinamida, etc). Fórmulas útiles. Módulo 8: Cupersosis – Rosácea Cuperosis: definición y etiopatogenia. Desencadenantes internos y externos. Productos cosméticos útiles. Plantas medicinales más empleadas: Melilotus officinalis (meliloto), Glycyrrhiza glabra (regaliz), Ruscus aculeatus (rusco), Aesculus hippocastanum (castaño de Indias), Matricaria recutita (manzanilla), etc. Rosácea. Definición, etiopatogenia. Factores de riesgo. Sintomatología clínica. Plantas medicinales útiles. Formulaciones. Módulo 9: Acné Etiopatogenia. Clínica. Clasificación. Tratamientos convencionales (beneficios y perjuicios). Tratamientos tópicos y sistémicos. Plantas medicinales y principios activos útiles: alfa-hidroxiácidos frutales, bardana (Arctium lappa), fenogreco (Trigonella foenum-graecum), pensamiento (Viola tricolor), Aloe (Aloe vera), aceite de melaleuca (Melaleuca alternifolia), etc. Normas higiénico-dietéticas. El rol de las arcillas y el ácido lipoico. Fórmulas útiles. Módulo 10: Psoriasis Etiopatogenia. Datos epidemiológicos. Clasificación. Localizaciones más frecuentes. Clínica. Abordaje convencional (ventajas y desventajas de corticoides, metrotexato, ciclosporina, hidroxiurea, antimitóticos, tratamientos P-UVA, etc). Investigaciones científicas en base a calaguala (Polypodium leucotomos), Bardana (Arctium lappa), plantas con cumarinas, crisarobina, vitaminas A, D y derivados, etc. Fórmulas útiles. Módulo 11: Vitiligo Definición. Datos epidemiológicos. Etiopatogenia. Localizaciones más frecuentes. Clínica. Tratamiento convencional (ventajas y desventajas de maquillajes, tratamientos P-UVA, tratamiento cubano con melagenina, etc ), Rol de las melaninas en la pigmentación cutánea.Plantas útiles. Investigaciones cientificas con cumarinas, calaguala (Polypodium leucotomos), Citrus bergamota, etc. Módulo 12: Dermatitis atópica Definición. Etiopatogenia. Localizaciones más frecuentes. Manifestaciones clínicas. Factores agravantes. Tratamiento convencional (ventajas y desventajas de corticoterapia, antihistamínicos, antibióticos de uso tópico, etc). Plantas medicinales útiles. Investigaciones científicas en base a la calaguala (Polypodium leucotomos), breas y queratolíticos vegetales (salicilatos), rusco (Ruscus aculeatus), aceite de onagra (Oenothera biennis), manteca de karité, etc). Módulo 13: Celulitis Definición. Clasificación. Etiopatogenia. Unidades matriciales (intersticial, neurovegetativa, microcirculatoria, lipídica). Factores incidentes y desencadenantes. Metabolismo de los lípidos y su rol en la génesis de la celulitis. Tratamientos tópicos. Plantas medicinales útiles. Investigaciones científicas en base a saponinas (de Hedra helix, Centella asiatica, beta-escina del castaño de Indias, ruscogenina del rusco, etc), metilxantinas (cafeína, teofilina, etc), citroflavonoides, etc. Otras alternativas: Hibiscus sabdariffa, Garcinia cambogia, Glycyrrhiza glabra, estimulantes de la lipasa, vitamina A, quimotripsina, hialuronidasa, etc. Formulaciones útiles. Módulo 14: Úlceras dérmicas – Escaras de decúbito - Quemaduras Director: Fernando Estevez Castillo Homeonews 87 Edición N° 9 – Enero – Febrero - Marzo de 2008 Etiopatogenia, localizaciones más frecuentes, clasificación y cuidados paliativos de úlceras de piel, escaras de decúbito y quemaduras. Empleo de ácidos grasos hiperoxigenados. Plantas re-epitelizantes y cicatrizantes: centella asiática, cola de caballo, caléndula, rosa mosqueta. Tipos de apósito. Limpieza de las zonas afectadas. Módulo 15: Miscelánea La importancia de los excipientes en las formulaciones dermatológicas. Dermatitis de pañal, grietas de pezón: abordaje fitoterápico. Preparados fitoterápicos para piernas cansadas, telangiectasias, verrugas, condilomas, lepra, leishmaniasis, cicatrizaciones imperfectas, etc. Módulo 16: Formulaciones Fórmulación de preparados para la piel y las enfermedades más relevantes vistas durante el curso. CURSO SUPERIOR DE MEDICINA NATURISTA PARA PROFESIONALES AÑO 2008 El Curso Superior de Medicina Naturista tiene como objetivo formar a profesionales del área de la Salud en: - el uso de técnicas no agresivas para prevenir y retardar la aparición de las enfermedades a través del equilibrio nutricional que nos proporciona una alimentación sana; - la incorporación de diversos métodos terapéuticos que la naturaleza nos ha proporcionado para recuperar la salud en forma suave y muy efectiva; - individualizar por parte del profesional el tipo de terapéutica más útil y económica para el paciente y para la sociedad. La duración del Curso es de 2 años, divididos en 4 módulos teóricos y 8 clases prácticas de Cocina Natural; las clases teóricas se dictarán una vez por semana, con una duración de 2 hs., se pide una presencia del 75% de cada parte; al finalizar cada parte se realizará una evaluación. Las clases de Cocina Natural se dictarán en horarios y fechas establecidas, que se notificarán antes del comienzo del curso. Los alumnos participarán de ateneos mensuales en horarios a determinar. Al finalizar el Curso, con todos los temas aprobados se tomará un examen final. Podrán inscribirse profesionales universitarios del área de la Salud: médicos, nutricionistas, odontólogos, psicólogos, psicopedagogos, enfermeros, farmacéuticos, biólogos, químicos, bioquímicos, etc. o alumnos de los últimos años de estas carreras. Horarios: Primer año: Lunes de 18 a 20 hs.- Inicia: lunes 9 de abril de 2008 Segundo año: Miércoles de 18 a 20 hs. – Inicia miércoles 31 de marzo de 2008 PROGRAMA 2008 Módulo 1: ALIMENTACIÓN NATURAL: Nutrición y biología celular – macro y micronutrientes desnutrición y desnutrición. Hidratos de carbono: absorción y metabolismo – características nutricionales de los cereales – necesidades dietarias - beneficios para la salud. Grasas saturadas y colesterol: absorción y metabolismo – excreción – importancia de sus funciones nutricionales – necesidades dietarias. Grasas insaturadas: omega 3-6 y 9 – importancia de su incorporación dietaria – funciones Director: Fernando Estevez Castillo Homeonews 88 Edición N° 9 – Enero – Febrero - Marzo de 2008 inmunológicas y constitutivas - grasas trans: problemas metabólicos surgidos a partir de su utilización masiva. Proteínas: absorción y metabolismo – características nutricionales de las Proteínas – excreción aminoácidos esenciales – necesidades dietarias. Vitaminas hidrosolubles: necesidad, funciones y absorción, alimentos que las contienen, suplementación. Vitaminas liposolubles: necesidad, funciones y absorción, alimentos que las contienen, suplementación. Minerales y oligoelementos: necesidad, funciones y absorción, alimentos que los contienen, suplementación – interacciones. Radicales libres del oxígeno (ROL) – oxidación y antioxidantes – relación con el metabolismo. Método Kousmine para protección del Sistema inmune. Nutracéuticos, prebióticos y probióticos. Alimentación sana, completa y compatible. Módulo 2: TERAPÉUTICA NUTRICIONAL y SUPLEMENTOS: Tratamiento nutricional de las dislipidemias. Tratamiento nutricional de la DBT y la obesidad. Síndrome metabólico, X o del “caos metabólico”. Estrés: aumento de las necesidades nutricionales. Alimentación en embarazo y lactancia. Alimentación infantil: trastornos del aprendizaje y la conducta - ADD – hiperactividad. Alergias alimenticias: dietas de eliminación. Alimentación en el adolescente: cómo cubrir las necesidades nutricionales. Alimentación del deportista. Candidiasis. Acidosis alimentaria y su relación con SFC, fibromialgias, fibroartrosis. Envejecimiento y restricción calórica. Módulo 3: CLÍNICA MÉDICA NATURISTA: DISTINTAS TERAPÉUTICAS: Fitoterapia: Reseña Histórica y Actualidad. Aspectos Botánicos de las plantas. Principios Activos: clasificación. Preparaciones farmacéuticas de plantas Medicinales, recolección y conservación, preservación y control de calidad. Preparaciones herbales de uso popular, especias, condimentos, germinados y brotes. Terapéuticas naturales: agua, aire y luz: baños (métodos e indicaciones). Cataplasmas y compresas: uso de la arcilla. Aromaterapia Tradicional Médica: las plantas aromáticas según el uso a través de los tiempos y su relación con el reino vegetal - las tres reglas básicas que deben cumplir los aceites esenciales (AE). Extracción de moléculas aromáticas: destilación - propiedades físicas y químicas de los AE - principios activos (P.A): reconocimiento práctico de los aceites esenciales: colores, olores, densidad. Desarrollo de cada uno de los aceites más importantes: vías de administración y aplicación terapéutica - precauciones, toxicidad y posología. Principales propiedades: calmantes, sedantes, energizantes, estimulantes, mío relajantes, anti-inflamatorios, anti-infecciosos, anti-histamínicos, inmunoreguladores, estimulantes hormonales, antibióticos, antivirales, - antifúngicos, etc. - formulaciones específicas. Psiconeuroendocrinología. Enfermedades de la mujer: modulación hormonal - alimentación y fitoterapia – fitoestrógenos. Módulo 4: MEDICINA NATURISTA: TRATAMIENTOS: Desintoxicación por el ayuno. Piel: función desintoxicante y protectora, patologías más comunes: psoriasis, dermatitis; nutrientes de la piel: AGPI, vit. Liposolubles. Intestino y aparato digestivo: gastritis, dispepsias, intolerancias alimentarias, constipación y diarrea, hemorroides. Hígado: función depurativa y digestiva, bilis y digestión, protección hepática. Páncreas: función endo y exócrina. Riñón: función depurativa y filtrado renal. HTA, artrosis y gota, nefritis y nefrosis. Pullmón: función desintoxicante y respiración; sind. nasales y de senos, broncopatías, enfisema. Boca: prevención de caries por la alimentación, higiene bucal y dental con remedios naturales. Encías y mucosa bucal: gingivitis, aftas, tipos de lengua. Sistema músculo-ósteoarticular: ejercicio físico: ventajas y beneficios - tendinitis y bursitis, artrosis, dolores musculares. Termalismo: indicaciones y beneficios, características de las distintas fuentes termales del país. Sistema nervioso central: depresión, insomnio, memoria. Sistema inmunológico: prevención y tratamiento, alimentación, fitoterapia. Informes e inscripción: Freire 2169 – Ciudad Autónoma de Buenos Aires Tel.: (54-11) 4541-0207 Fax: (54-11) 4541-3707 E.mail: [email protected] www.aamenat.org.ar Director: Fernando Estevez Castillo Homeonews 89 Edición N° 9 – Enero – Febrero - Marzo de 2008 CONGRESOS VIII CURSO – 1º SIMPOSIO INTERNACIONAL DE INMUNONUTRICION Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires 16 al 19 de Abril de 2008. HORARIO: 8:30 a 19:00 hs. DIRIGIDO A: Farmacéuticos. Farmacéutico, Bioquímico, Químico, Biólogo (con conocimientos básicos de nutrición), Nutricionista-Dietista, Médico Clínico, Médico especialista en nutrición, Lic. en Enfermería TEMARIO: Alimentación a lo largo de la vida. Generalidades del sistema inmune. Nutrientes e inmunidad: aminoácidos condicionalmente esenciales. Nucleótidos, ácidos grasos esenciales, ácido oleico, alcohol, vitaminas, oligoelementos, antioxidantes prebióticos: mecanismos de inmunomodulación, utilidad de los prebióticos en cáncer. Terapia nutricional en diferentes situaciones fisio-patológicas, alergias alimentarias. INFORMES E INSCRIPCIÓN: Facultad de Farmacia y Bioquímica (UBA), Escuela de Graduados, Junín 956 Planta Principal.(1113), Buenos Aires. Tel/Fax : 54-11-4964-8214 / 4964-8200 int. 8315 ,e-mail : [email protected] http ://www.ffyb.uba.ar. Horario de Atención: Lunes a Viernes de 13 a 18 horas ó a [email protected] Tel.: (54-11) 4546-3566 www.inmunonutricion.com.ar 63º CONGRESO DE LA LIGA MEDICA HOMEOPATICA INTERNACIONAL Ostende, Bélgica 20 al 25 de Mayo de 2008 La Homeopatía basada en la evidencia – Verificación de los síntomas homeopáticos Para más información: www.medicongress.com/homeopathy Director: Fernando Estevez Castillo Homeonews 90 Edición N° 9 – Enero – Febrero - Marzo de 2008 Si quiere que otro profesional reciba Homeonews por favor complete y envíe esta planilla al e.mail: [email protected] SUSCRIPCIÓN GRATUITA A HOMEONEWS Nombre y Apellido:........................................................................................................... Profesión:............................................................................................................................ Domicilio particular: Calle:........................................................... Nº:................................................................. Localidad:....................................................Prov.:............................................................ C.P.:……………..Tel.:.…..............................………….Fax:........................................... E.Mail:…………………………………………………………………………………… Domicilio laboral: Calle:........................................................... Nº:................................................................. Localidad:....................................................Prov.:............................................................ C.P.:……………..Tel.:.…..............................………….Fax:........................................... E.Mail:…………………………………………………………………………………… Temas de interés: ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. Director: Fernando Estevez Castillo