Steamed root of Rehmannia glutinosa Libosch (Plantaginaceae) alleviates methotrexate-induced intestinal mucositis in rats
Graphical abstract
Introduction
Chemotherapy is a major category of cancer treatment using one or more anti-cancer drugs, which not only suppresses cancer cells, but also inhibits rapidly proliferating normal cells, such as the cells in bone marrow and lining the alimentary tract, leading to myelosuppression and gut mucositis. These toxicities can substantially increase the risk of dose reduction of the chemotherapeutic agents and the frequency of infection, which in turn interfere with the timing and thus outcomes of cancer treatment (Alamir et al., 2010, Choi et al., 2007, Rodríguez-Caballero et al., 2012).
Gut mucositis is a common and debilitating side effect of high-dose chemotherapy, affecting up to 60% of patients and with the affected patients usually suffering from fatigue, mouth, throat and/or abdominal pain, nausea, vomiting, bloating and/or diarrhea, which significantly decrease their quality of life and mood status (Crawford et al., 2004, King et al., 2012, Logan et al., 2009, McCulloch et al., 2014, Qutob et al., 2013, Tooley et al., 2009). Up to now the widely accepted hypothesis on the pathobiology of mucositis includes five phases of mucositis development and resolution: initiation, primary damage response, signal amplification, ulceration and healing (Al-Dasooqi et al., 2013, Crohns et al., 2009, Gilliam and St. Clair, 2011, Il’yasova et al., 2009, Sonis, 2009). Both DNA and non-DNA damages exert on epithelial and submucosal cells following chemotherapy, which cause intricate sequential biological events, such as generation of reactive oxygen species (ROS), transcription factor activation, pro-inflammatory cytokine expression/accumulation, nitrosative stress, cell apoptosis, reduction in epithelial cell proliferation, changes in growth factor expression, proteolysis, bacterial colonization, and activation of enteric immune and nervous systems (Al-Dasooqi et al., 2013, Kolli et al., 2008, Logan et al., 2007, Logan et al., 2008, Logan et al., 2009, Qutob et al., 2013, Sonis, 2009; Xian et al., 2002, Xian et al., 1999, Xian et al., 2000; Xian, 2003; Zhan et al., 2014). Great efforts have been applied to evaluate/develop interventions that prevent or reduce the toxic effects of chemotherapy, such as intensive oral hygiene care and usage of antiseptics, antimicrobial and anti-inflammatory agents, cytokines, growth factors, antioxidants, immune modulators and homeopathic agents (McCulloch et al., 2014; Nadhanan et al., 2013; Qutob et al., 2013, Rodríguez-Caballero et al., 2012).
Paralleling with modern medicine, attempts have been made in using traditional Chinese medicine (TCM) to prevent chemotherapy-induced adverse effects (Gong and Ge, 2010, Ling, 2013, Ma, 2000, Wang, 2008). According to the theory of TCM, the symptoms of cancer patients receiving chemotherapy are commonly diagnosed as the syndrome of Qi and Yin deficiency (Wang et al., 2006). Steamed rehmannia root (SRR), derived from the dried root of Rehmannia glutinosa Libosch. (family Plantaginaceae) by steaming for one to several days, has been used as a well-known Yin-nourishing and blood-replenishing herbal medicine for more than one thousand years in Asian countries (Zhang et al., 2008). It has been frequently included in the formulas used to alleviate the adverse effects of chemotherapy in recent years (Ge, 2007, Li, 2004, Li and Liu, 2013, Wang, 2008, Xu et al., 1992, Yang and Gong, 2014, Zhang et al., 2006). However, the individual action of SRR in the formulas in attenuating chemotherapy-induced side effects has not been confirmed, although a body of pharmacological functions of SRR have been verified, such as its preventive effects on gastric ulcer (Li and Wang, 1996), immediate type allergic reaction (Kim et al., 1998), bone loss (Oh et al., 2003), depression (Zhang et al., 2009), and diabetic complications (Lau et al., 2009, Sun et al., 2013). While it remains to be confirmed, these reports imply that SSR alone might be capable of attenuating leucopenia and mucositis induced by chemotherapy.
In the present study, a rat model of chemotherapy-induced intestinal mucositis was established by intraperitoneal administration of methotrexate (MTX), an inhibitor for dihydrofolate reductase commonly used as a chemotherapeutical agent (Fijlstra et al., 2013, Kaynar et al., 2012, Kolli et al., 2008, Maeda et al., 2010). The effect of SRR on the alleviation of the adverse effects of high-dose MTX was evaluated in comparison to the effect of calcium folinate (CF), a clinical antidote of MTX (Fan et al., 2011a, Fan et al., 2011b, Madhyastha et al., 2008) and the combined effect of SRR plus CF.
Section snippets
Preparation of SRR and its water extract
Steamed rehmannia root was prepared by steaming dried rehmannia root (DRR) for 48 h according to the traditional method (Sun et al., 2013). In brief, the fresh root (45.2 kg) of Rehmannia glutinosa 'Beijing 3' was harvested in Nov 2013 in Dongping County, Shandong Province. It was dried at 80 °C and used as DRR (10.8 kg). An aliquot of the resulting DRR (5.5 kg) was steamed for 48 h followed by drying at 80 °C, which was used as SRR (5.3 kg). The samples of DRR and SRR (with reference No. 21031101 and
General condition
The rats in MTX alone group all suffered from MTX-induced sicknesses including fatigue, intake decline, fur lackluster and diarrhea, when compared to the control group. Most of these symptoms were also observed in MTX-exposed and supplement-treated groups, but they were less severe than those in the MTX alone group; and no diarrhea was found in SRR group. Meanwhile, a significant weight loss was observed in MTX alone rats (p<0.01), and SRR+CF rats (p<0.05) (Fig. 1). This might be caused by
Acknowledgement
This work was financially supported by National Natural Science Foundation of China (81072984) and China–Australia Centre for Health Sciences Research. CJX is funded by a Senior Research Fellowship of NHMRC Australia (GNT1042105).
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