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Efficacy and safety of Sulfad tablets in supporting patientswith viral …

Efficacy and safety of Sulfad tablets in supporting patientswith viral
hepatitis:Aprospective,double-blind,randomized, placebo-controlled,
phase III clinical trial

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  • 1. 2010Prof. Dr. P. Rohdewald , M.D., D.N.B.1,and Prof.Dr. Adolf Nahrstedt, PhD ,*21Gastroenterologist, University of Muenster-Central Hospital-Muenster2Institut of Pharmacy-University of Muenster-Germany[*Corresponding author]ABSTRACTViral hepatitis (A, B, C, D, E and G) is aglobal public health problem, which isresponsible for a major chunk of morbidityand mortality. Viral hepatitis occursendemically and sporadically throughout theworld, depending on the endemicity ofinfection. The primarygoal in themanagement of acute viral hepatitis is earlyrenormalization of hepatic functions withsymptomatic and clinical recovery. Thisstudy was planned to evaluate the efficacyand safety of Sulfad tablets viral hepatitis.This study was a prospective, double-blind,randomized; placebo-controlled, phase IIIclinical trial conducted as per theDeclaration of Helsinki, with strictadherence with the GCP ethical guidelinesand was approved by the institutional ethicscommittee. A total of 20 patients withdiagnosis of symptomatic acute viralhepatitis, and who were willing to giveinformed consent were included in the study.Pregnant women, patients with chronichepatitis, patients with malignant jaundice,patients with other causes for acuteand chronic hepatitis, and those who wereunwilling to give informed consent wereexcluded from the study.At the initial visit, informed written consentwas obtained from all the enrolled patients,and randomization and double blinding wasdone. A detailed medical history wasobtained from all the enrolled patients, whichwas followed by thorough clinicalexamination All patients were subjected tohematological and biochemicalinvestigations,., which included CBC, LFTs,ESR and tests for viral markersABBREVIATIONSALP : Alkaline phosphatase ALT: Alanine aminotransferaseAST : Aspartate aminotransferaseCBC : Complete blood countCCl4 : Carbon tetrachlorideDLC : Differential leucocyte countDNA : Deoxyribonucleic acidESR : Erythrocyte sedimentation rateET-NANBH : Enterically transmitted non-Anon-B hepatitisGCP : Good clinical practiceHA : Hepatitis AHAV : Hepatitis A virusHb : HemoglobinHBC : Hepatitis B core (antigen)HBeAg : Hepatitis Be antigenHBsAg : Hepatitis B surface antigenHBV : Hepatitis B virusHCV : Hepatitis C virusHDV : Hepatitis D virusHEV : Hepatitis E virusHGBV-C/GB-C : Hepatitis GB virus-CHGV : Hepatitis G virusIgG : Immunoglobulin GIgM : Immunoglobulin MLFT : Liver function testPC : Platelet countRNA : Ribonucleic acidSA : Serum albumin SB: Serum bilirubinSG : Serum glutathioneSGOT : Serum glutamic oxaloacetictransaminaseSGPT : Serum glutamic pyruvictransaminaseTB : Total bilirubinTLC : Total leucocyte countTP : Total proteinWBC : White blood cellsPhytopharmacy;Efficacy and safety of Sulfad tablets in supporting patients with viralhepatitis:Aprospective,double-blind,randomized, placebo-controlled,phase III clinical trial
  • 2. (IgM antiHAV, IgM antiHBc, HBsAg, IgM antiHEV). The drug group received Sulf adta ble ts and the other group received placebo, in a dose of 3 tablets three times-a-day,orally, for 4 months. Patients were not allowed to take any other medication, which wouldhave any significant effect on LFT. All patients were followed up every month for a periodof 4 months. At each follow-up visit, the investigator recorded any information aboutadverse events, and a symptomatic evaluation was conducted, which was followed bythorough clinical examination. The subjective symptomatic improvement was assessed on apredefined 0 to 3 score scale.At the end of 4 months, changes in the hematological and biochemical parameters frombaseline values to the values at the end of the study, the duration of recovery, incidence ofadverse events and patient compliance to the drug treatment were recorded. All adverseevents either reported or observed by patients were recorded with information about severity,duration and action taken regarding the study drug. The predefined primary efficacyendpoints were rapid symptomatic improvement, renormalization of hematological andbiochemical parameters, and total duration of clinical recovery. The predefined secondarysafety endpoints were incidence of adverse events during the study period and overallcompliance to the drug treatment. Statistical analysis was done according to intention-to-treat principles. The minimum level of significance was fixed at 99% confidence limit and a 2-sided p value of <0.001 was considered significant.A total of 20 patients were enrolled in the trial. The demographic and clinical profile,hematological and biochemical profile were similar in Sulfad tablets and placebo groups andthe patients were equally distributed in both the study arms. The mean age of theenrolled patients was 37.55 years. The common symptoms reported by patients werejaundice, anorexia, nausea, vomiting, fever and pruritus. The common clinical findingswere icterus and hepatomegaly. Laboratory investigations confirmed that 20% patientswere suffering from hepatitis E, 20% from hepatitis B, 20 % from hepatitis C, 10% fromhepatitis A and 30% from hepatitis non A-E. There was a highly significant (p<0.0001) andrapid symptomatic improvement in the mean scores for loss of appetite, weight loss, fatigueand jaundice in Sulfad group, as compared to the placebo. There was a significantrenormalization of the biochemical parameters of liver functions, after 2 months in Sulfadgroup and after 3 months in the placebo group. There was a highly significant (p<0.0001)improvement in the blood proteins, and the levels of SA, SG and TP were renormalized. Theincreased level of ESR and WBC were significantly (p<0.0001) reduced in Sulfad group, ascompared to the placebo group, at the end of the study. There were no clinically significant(p<0.0001) changes in other biochemical parameters such as Hb levels and PC. There were noclinically significant adverse effects during the entire study period and the overall complianceto the drug treatment was excellent.Therefore, it may be concluded that, Sulfad tablets are clinically effective and safe in themanagement of acute and chronic viral hepatitis.INTRODUCTIONViral hepatitis (A, B, C, D, E and G) is a global public health problem, which is responsiblefor a major chunk of morbidity and mortality. Viral hepatitis occurs endemically andsporadically throughout the world, depending on the endemicity of infection. Based on theprevalence of infection, various regions of world have been classified into areas of highendemicity (8% and above - Africa, South East Asia, South America and Middle East), areas
  • 3. of intermediate endemicity (2% to 8% - Australia, USA and Western Europe) and areas oflow endemicity (below 2% - Northern Europe and Japan).Hepatitis A is an acute, but benign form of viral hepatitis and is the least serious (self-limiting) disease. Hepatitis B can range from subclinical disease to fulminant hepatic failureand individuals with chronic hepatitis B are at increased risk for the development ofhepatocellular carcinoma. Despite the discovery of hepatitis C, a permissive cell culturesystem for propagating HCV has yet to be established and a non-primate animal model doesnot exist. As a result, the production of specific drugs against HCV has been impededalthough excellent diagnostic methods have been developed. The HDV infection occurs onlyin the presence of hepatitis B infection (co-infection or super-infection). Hepatitis E virus isET-NANBH, which is clinically indistinguishable from hepatitis A disease and the disease isusually is mild expect in pregnant women, who appear to be exceptionally susceptible tosevere disease and excessive mortality. The HGV/GBV-C is a recently characterizedflavivirus, that may cause acute and chronic hepatitis and the precise role of HGV/GBV-C inhuman disease is currently under investigation.The primary goals for managing viral hepatitis are to provide adequate nutrition (with restrictedprotein and fat intake), to prevent further damage to the liver, and to prevent transmission ofinfection to others. Therefore, early renormalizations of hepatic functions with symptomaticand clinical recovery are the primary objectives in the clinical management of chronichepatitis. There are no established drugs for hepatitis A-E and hepatitis G. However, theavailable treatment options for hepatitis B, hepatitis C and hepatitis D have various limitations,such as dependable clinical efficacy, associated adverse effects and affordability issues.Sulfad tablet is a polyherbal formulation, which have been used extensively in the managementof HA. Each Sulfad tablet contains extract mixture of Cynara scolymus, Curcuma longa,Silybum marianum and Glycyrrhiza glabra. This study was planned to evaluate the efficacyand safety of Sulfad tablets in viral hepatitis.Aim of studyThe study was planned to evaluate the clinical efficacy, and short- and long-term safety ofSulfad tablets in viral hepatitis.Study designThis study was a prospective, double blind, randomized, placebo-controlled, phase III clinicaltrial conducted a t t h e H o s p i t a l o f t h e W W U - M u e n s t e r i n G e r m a n y ,from February 2008 to June 2009, as per the Declaration of Helsinki, with strict adherencewith the GCP ethical guidelines. The study protocol, case report forms, regulatory clearancedocuments, product related information and informed consent form (in German and English)were submitted to the Institutional Ethics Committee, and were approved by the same.MATERIALS AND METHODSInclusion criteriaA total of 20 patients with diagnosis of symptomatic viral hepatitis, and who were willing togive informed consent were included in the study.Exclusion criteriaPregnant women, patients with malignant jaundice, patients with other causes for acutehepatitis (drug-induced), and those who were unwilling to give informed consent wereexcluded from the study.Study procedureAt the initial visit, informed written consent was obtained from all the enrolled patients, afterexplaining to them the nature of the study; after which randomization and double blindingwas done. A person unconnected with the study did randomization by using computer
  • 4. generated random number allocation and each arm of the study had 10 patients. Due to doubleblinding procedure, neither the patient nor the investigators were aware of the drug identityand therefore were unable to predict the treatment allocation. The drug identity codes werekept in sealed envelopes at a secure location to ensure the double blinding of treatmentallocation.A detailed medical history was obtained from all enrolled patients, which was followed bythorough clinical examination. All patients were subjected to hematological and biochemicalinvestigations, which included CBC (Hb, TLC, DLC, PC), LFTs (SGOT, SGPT, SB, SA, SG,TP), ESR and tests for viral markers (IgM antiHAV, IgM antiHBc, HBsAg, IgM antiHEV).Study drugsThe daily dose of 6 tablets of Sulfad has been shown to be potentially effective and safe in themanagement of viral hepatitis and was considered adequate for this study. The drug groupreceived Sulfad and the other group received placebo. Both groups were advised to consumethe drugs in doses of 2 tablets three times-a-day, orally, for 4 months. Patients were notallowed to take any other medication, which would have any significant effect on LFT.Follow-up and monitoringAll patients were followed up every month for a period of 4 months. At each follow-up visit(1st, 2nd, 3rdand 4thmonth), the investigator recorded any information about adverse events(either reported or observed), and symptomatic evaluation was conducted, which was followedby thorough clinical examination. The subjective symptomatic improvement (jaundice,anorexia, nausea, vomiting, fever and pruritus) was assessed on a predefined 0 to 3 score scale(0=poor, 1=average, 2=good, 3=excellent). At the end of 4 months, changes in thehematological and biochemical parameters from baseline values to the values at the end of thestudy, the duration of recovery (symptomatic, hematological, biochemical and clinical),incidence of adverse events (either reported or observed) and patient compliance to the drugtreatment were recorded.Adverse eventsAll adverse events either reported or observed by patients were recorded with informationabout severity, duration and action taken regarding the study drug. Relation of adverse eventsto the study medication was predefined as “Unrelated” (a reaction that does not follow areasonable temporal sequence from the time of administration of the drug), “Possible”(follows a known response pattern to the suspected drug, but could have been produced by thepatient’s clinical state or other modes of therapy administered to the patient), and “Probable”(follows a known response pattern to the suspected drug that could not be reasonablyexplained by the known characteristics of the patient’s clinical state).For patients recorded as withdrawing from the study, efforts were made to ascertain thereason for dropout. Non-compliance (defined as failure to take less than 80% of themedication) was not regarded as treatment failure, and reasons for non-compliance wererecorded.Primary and secondary endpointsThe predefined primary efficacy endpoints were rapid symptomatic improvement,renormalization of hematological and biochemical parameters, and total duration of clinicalrecovery. The predefined secondary safety endpoints were incidence of adverse events (eitherreported or observed) during the study period and overall compliance to the drug treatment.Statistical analysisStatistical analysis was done according to intention-to-treat principles. “Repeated MeasuresANOVA Test” and “Bonferroni’s Multiple Comparison Test” analyzed the mean score formonthly symptomatic improvement. Changes in various parameters from baseline values andvalues at the end of the study were pooled and analyzed cumulatively by “Paired ‘t’ Test”.
  • 5. The minimum level of significance was fixed at 99% confidence limit and a 2-sided p valueof <0.001 was considered significant.RESULTSA total of 20 patients were enrolled in this trial and there was male preponderance in the studypopulation (12 males and 8 females). The demographic profile, clinical profile,hematological and biochemical profile were similar in the Sulfad and placebo groups and thepatients were equally distributed in both the study arms.The mean age of the enrolled patients was 37.55 years (minimum=18, maximum=63,SD=13.76, SEM=1.95, Lower 99% CI of M=28.19 and Upper 99% CI of M=38.65). Thecommon symptoms reported by patients were jaundice (100%), anorexia (80%), nausea(74%), vomiting (40%), fever (28%) and pruritus (2%). The common clinical findings wereicterus (100%) and hepatomegaly (36%). Laboratory investigations confirmed that 20%patients were suffering from hepatitis E, 20% from hepatitis B, 20% from hepatitis C, 10%from hepatitis A, and 20% from hepatitis non A-E.There was a highly significant (p<0.0001) and rapid symptomatic improvement in the meanscores for loss of appetite, weight loss, fatigue and jaundice in the Sulfad group, as comparedto the placebo. In the Sulfad group, significant (p<0.0001) clinical improvement inloss of appetite was observed over a period of 1 month and total renormalization of appetitewas evident by 2 months, while in the placebo group renormalization of appetite was seen onlyafter 3 months(Table 1.). Sulfad controlled weight loss significantly (p<0.0001) in a month andweight gain was evident in 2 months, while in the placebo group weight gain was seen onlyafter 3 months (Table 2). There was a highly significant (p<0.0001) improvement in fatigue inthe Sulfad group over a period of 1 month and complete improvement was observed by 3months, while in the placebo group improvement was seen only after 3 months (Table 3). In theSulfad group, significant (p<0.0001) clinical improvement in jaundice was evident by 1 monthand there was complete improvement in 2 months, while in the placebo group improvementwas seen only after 3 months (Table 4). There was significant renormalization of thebiochemical parameters of liver functions after 2 months in the Sulfad group and after 3months in the placebo group. There was a highly significant (p<0.0001) reduction in the levelsof SGOT (p<0.0001) (Table 5 ), SGPT (p<0.0001) (Table 6) and SB (p=0.0008) (Table 7) inthe Sulfad group. There was highly significant improvement in the blood proteins, and thelevels of SA (p<0.0001) (Table 8), SG (p=0.0083) (Table 9) and TP (Table 10)were renormalized. The elevated levels of ESR (p=0.002)(Table 11 and Figure 5) andWBC (p=0.0412) (Table 12) were significantly reduced in the Sulfad group, as compared tothe placebo group, at the end of the study. There were no clinically significant changes inother biochemical parameters as Hb levels (Table 13) and PC (Table 14).Table 1: Improvement in mean symptom score of loss of appetiteRepeated Measures ANOVA TestParameter Day 0 1stmonth 2ndmonthMean 2.32 0.68 0.00Std. Deviation 0.90 0.69 0.00Std. Error 0.18 0.14 0.00Lower 99% CI 1.82 0.29 0.00Upper 99% CI 2.82 1.07 0.00Significance ***F=109.9, R2=0.8208, p<0.0001, Highly SignificantBonferronis Multiple Comparison TestMean Diff. T p value 99% CI of Diff.Day 0 vs 1stmonth 1.64 12.09 p<0.001 1.219 to 2.061stmonth vs 2ndmonth 1.28 8.01 p<0.001 0.258 to 1.101
  • 6. Table 2: Improvement in mean symptom score of weight lossRepeated Measures ANOVA TestParameter Day 0 1stmonth 2ndmonthMean 0.56 0.04 0.00Std. Deviation 0.87 0.20 0.00Std. Error 0.17 0.04 0.00Lower 99% CI 0.07 -0.07 0.00Upper 99% CI 1.05 0.15 0.00Significance ***F=110.19, R2=0.298, p<0.0001, Highly significantBonferronis Multiple Comparison TestMean Diff. T p value 99% CI of Diff.Day 0 vs 1stmonth 0.52 4.76 P<0.001 0.180 to 0.8591stmonth vs 2ndmonth 0.04 0.36 p>0.05 -0.299 to 0.3792ndmonth vs 3rdmonth 0 0 p>0.05 -0.339 to 0.339Table 3: Improvement in mean symptom score of fatigueRepeated Measures ANOVA TestParameter Day 0 1stmonth 2ndmonth 3rdmonthMean 2.52 1.52 1.00 0.00Std. Deviation 0.51 0.51 0.00 0.00Std. Error 0.10 0.10 0.00 0.00Lower 99% CI 2.24 1.24 1.00 0.00Upper 99% CI 2.81 1.81 1.00 0.00Significance ***F=367, R2=0.9386, p<0.0001, Highly significantBonferronis Multiple Comparison TestMean Diff. T p value 99% CI of Diff.Day 0 vs 1stmonth 1 12.66 p<0.001 0.754 to 1.2451stmonth vs 2ndmonth 0.52 6.58 p<0.001 0.274 to 0.7652ndmonth vs 3rdmonth 0 0 p>0.05 -0.245 to 0.245Table 4: Clinical Improvement in mean symptom score of jaundiceRepeated Measures ANOVA TestParameter Day 0 1stmonth 2ndmonthMean 2.20 0.24 0.00Std. Deviation 0.65 0.52 0.00Std. Error 0.13 0.10 0.00Lower 99% CI 1.84 -0.05 0.00Upper 99% CI 2.56 0.53 0.00Significance ***F=177.5, R2=0.8809, p<0.0001, Highly significantBonferronis Multiple Comparison TestMean Diff. T p value 99% CI of Diff.Day 0 vs 1stmonth 1.96 19.18 p<0.001 1.643 to 2.2771stmonth vs 2ndmonth 1.67 12.38 p<0.001 0.077 to 0.5532ndmonth vs 3rdmonth 0.00 0.00
  • 7. Table 5: Improvement in SGOT (IU/L)levels at baseline and after 4th monthWith Sulfad treatmentParameter Day 0 4thmonthMinimum 139.00 10.00Maximum 2000.00 42.00Mean 767623.56Std. Deviation 550.60 10.68Std. Error 110.10 2.14Lower 99% CI 459.40 17.59Upper 99% CI 1075.00 29.53Mean of differences 743.999% CI 433.9 to 1054R20.6525t value 16.713p value p<0.0001p value summary ***Highly SignificantThere were no clinically significantadverse effects, either observed orreported; during the entire study period,and the overall compliance to the drugtreatment was found to be excellent.DISCUSSIONHepatitis A is an acute, but benign formof viral hepatitis caused by an RNA virusand the virus does not persist in the bloodserum. Hepatitis A virus (HAV) is anenterovirus group of the picornaviridaefamily and HAV has a single molecule ofRNA surrounded by a small (27 nmdiameter) protein capsid. Hepatitis A is afood/waterborne disease, with feco-oraltransmission. The incubation period isvariable (from 15 to 25 days) and isinversely proportional to infective dose (presumably 10-100 virus particles). Hepatitis A isusually a mild illness characterized by sudden onset of fever, malaise, nausea, anorexia andabdominal discomfort, followed in several days by jaundice. The dark urine (which precedesjaundice by 2/3 days) indicates the onset of the disease. The risk of transmission is generallylow amongst household contacts, but outbreaks occur in nurseries and institutions with attackrates around 10%-15%. The duration of viral shedding is upto 14 days; with a sharp fall offafter 5 days, but the period of infectiousness is about 8 to 17 days (the stool remainsinfectious upto 15 days). Asymptomatic infections are frequent. The serial interval betweenindex and secondary cases is either shorter or equal to incubation period, indicating thattransmission usually occurs before or around onset of jaundice. Hepatitis A virus is diagnosedby finding IgM anti-HAV in serum during the acute or early convalescent phase of disease.Moderate increase in conjugated bilirubin, with marked elevation of SGOT, SGPT and lactatedehydrogenase isoenzymes are noted in HA (low Na+and Cl-levels may be seen due tosevere vomiting). Marginal elevation of ALP is seen due to compression of intrahepatic biliarycanaliculi by swollen parenchymatous cells. Triglyceridesand cholesterol maybe temporarilyand marginally lowered. Hepatitis A virus is the least serious of the hepatitis viruses, as itdoes not kill liver cells and also, there is no risk of a chronic form. Hepatitis is a self-limitingdisease and no specific treatment is available1.The HBV is a double-stranded DNA virus in the hepadnaviridae family. Hepatitis B virus istransmitted horizontally (by blood, blood products and sexual transmission) and vertically(from mother to infant in the perinatal period, which is a major mode of transmission inendemic regions). Hepatitis B virus causes acute and chronic hepatitis and the chances ofbecoming chronically infected depend upon age (about 90% of infected neonates and 50% ofinfected young children will become chronically infected in contrast, only about 5% to 10% ofimmunocomponent adults infected with HBV develop chronic hepatitis B). Acute hepatitis Bcan range from subclinical disease to fulminant hepatic failure and about 90% of acutelyinfected adults recover without sequelae, while about 5% of acutely infected adults becomechronically infected. Chronic infection with HBV can be either "replicative" or "non-replicative." In non- replicative infection, therate of viral replication in the liver is low andserum HBV DNA concentration is low and HBeAg is not detected. In "replicative" infection,the patient usually has a relatively high serum concentration of viral DNA and detectableHBeAg. Patients with chronic hepatitis B and "replicative" infection have a worse prognosisand a greater chance of developing cirrhosis and/or hepatocellular carcinoma. Virtually allindividuals infected with HBV will have detectable serum HBsAg. In acute infection, HBsAgis detectable several weeks after infection and its appearance coincides with the onset ofclinical symptoms. At around the same time, IgM antibodies against core antigen are
  • 8. Table 6: Improvement in SGPT (IU/L) levelsthat baseline and after 4 monthwith Sulfad treatmentParameter Day 0 4thmonthMinimum 192.00 12.00Maximum 2430.00 38.00Mean 960.90 21.52Std. Deviation 742.10 8.07Std. Error 148.40 1.61Lower 99% CI 545.80 17.01Upper 99% CI 1376.00 26.03Mean of differences 939.4099% CI 523.3 to 1355R20.6243t value 16.315p value p<0.0001p value summary ***Highly SignificantTable 7: Improvement in serum bilirubinth(mg/dl) levels at baseline and after 4 monthwith Sulfad treatmentParameter Day 0 4thmonthMinimum 1.00 0.50Maximum 61.17 1.10Mean 9.76 0.83Std. Deviation 11.72 0.16Std. Error 2.34 0.03Lower 99% CI 3.20 0.74Upper 99% CI 16.31 0.92Mean of differences 8.9399% CI 2.380 to 15.47R20.3774t value 13.814p value p=0.0008p value summary ***Highly significantdetectable in serum and subsequently, IgG antibodies against core are produced. As acuteinfection resolves, IgG antibodies against core antigen persist and IgM antibodies andHBsAg become undetectable. Most people who have had acute infection that resolvescontinue to have IgG antibodies against core antigen for life. Acutely infected individuals.Figure 4: Improvement in serum bilirubin levels at Day 0 and 4thmonth with Sulfad treatmentwho do not clear HBV continue to have serum HBsAg. In most cases, the chronic infectionbecomes "non-replicative" and the subjects lose serum HBeAg and develop antibodies againstHBeAg. In some cases, "replicative" infection persists along with detectable serum HBeAg. In
  • 9. Table 8: Improvement in serum albumin(gm/dl)levels at baseline and after 4thParameterSulfad PlaceboDay 0 4thmonthDay 0 4thmonthMinimum 3.60 3.50 3.50 3.80Maximum 4.90 4.75 4.79 4.70Mean 4.38 4.28 4.32 4.32Std. Deviation 0.28 0.28 0.29 0.25Std. Error 0.06 0.06 0.06 0.05Lower 99% CI 4.22 4.13 4.15 4.17Upper 99% CI 4.54 4.44 4.49 4.47Mean ofdifference0.0968 *-0.005699% CI 0.0313 to 0.1623 *-0.2018 toR2 0.4162 0.0002t value 4.137 0.08123p value p<0.0001 p=0.936p valuesummar*** HighlySignificantNon-significantTable 9: Improvement in Serum globulin(gm/dl)levels at baseline and after 4thParameterSulfad PlaceboDay 0 4thmonthDay 0 4thmonthMinimum 2.00 2.20 2.50 2.50Maximum 4.50 4.80 4.30 4.10Mean 3.48 3.75 3.48 3.54Std. Deviation 0.60 0.52 0.42 0.56Std. Error 0.12 0.10 0.08 0.11Lower 99% CI 3.15 3.46 3.25 3.22Upper 99% CI 3.82 4.04 3.72 3.85Mean ofdifference0.2656 -0.05299% CI 0.0072 to 0.5239 -0.4406 to 0.3366R2 0.2563 0.0058t value 2.876 0.3743p value p=0.0083 p=0.7115p valuesummar***HighlyNon-significantchronically infected individuals, infection can switch from "non-replicative" to"replicative" and vice-versa. One goal of treatment is to convert patients with chronichepatitis B from a "replicative" (HBeAg positive) to "non-replicative" (HBeAg negative)state. Individuals with chronic hepatitis B are at increased risk for the development ofhepatocellular carcinoma, and should be screened by serum alpha-fetoprotein andultrasonography examination.Prior to the discovery of HCV, hepatitisfollowing blood transfusion that wasnot caused by hepatitis A or hepatitis Bwas referred to as non-A, non-Bhepatitis. Hepatitis C virus is a single-stranded RNA virus in the flaviviridaefamily. Primarily blood, blood productsand sexual transmission transmit thevirus (perinatal transmission isrelatively low). About 85% ofindividuals acutely infected with HCVbecome chronically infected and mostinstances of acute infection areclinically undetectable.The naturalhistory of chronic HCV infection canvary dramatically between individuals.About 20% of individuals withhepatitis C develop cirrhosis, whichleads to end-stage liver disease; andthere is an increased risk of developinghepatocellular carcinoma. History,serological testing and liver biopsymake the diagnosis of chronic hepatitisC. The presence of anti-HCVantibodies in a person with a risk factoror evidence of liver disease suggeststhe diagnosis of chronic hepatitis C.Tests for HCV RNA in blood in thoseindividuals with anti-HCV antibodiesconfirms the diagnosis. The HDV (alsocalled delta virus) is a small circularRNAvirus and in humans, HDVinfection only occurs in the presence ofhepatitis B infection, as the HDV isreplication defective and thereforecannot propagate in the absence ofanother virus. Hepatitis D virusinfection is transmitted by blood andblood products; and the risk factors forinfection are similar to those for HDVinfection.
  • 10. Table 10: Improvement in serum total proteins (gm/dl)levels at baseline and after 4thmonthParameterSulfad PlaceboDay 0 4thmonth Day 0 4thmonthMinimum 6.60 6.80 6.70 7.00Maximum 9.00 9.00 8.60 8.30Mean 7.88 8.11 7.87 7.71Std. Deviation 0.60 0.61 0.47 0.38Std. Error 0.12 0.12 0.09 0.08Lower 99% CI 7.55 7.77 7.61 7.50Upper 99% CI 8.22 8.45 8.13 7.92Mean ofdifferences0.2288 0.162499% CI -0.0097 to 0.4674 -0.1733 to 0.4981R20.2307 0.0708t value 2.683 1.353p value p=0.013 p=0.1886p valuesummary*** HighlysignificantNon-significantTable 11: Improvement in ESR (mm/hr) levels atbaseline and after 4thmonthParameterSulfad PlaceboDay 0 4thmonth Day 0 4thmonthMinimum 5.00 5.00 2.00 2.00Maximum 75.00 62.00 80.00 42.00Mean 22.64 14.44 25.04 12.04Std. Deviation 16.83 11.28 19.19 7.66Std. Error 3.37 2.26 4.00 1.60Lower 99% CI 13.22 8.13 13.76 7.54Upper 99% CI 32.06 20.75 36.32 16.55Mean ofdifferences8.2 1399% CI 1.589 to 14.81 114 to 23.89R20.334 0.34t value 3.469 3.366p value p=0.002 p=0.0028p valuesummary*** HighlysignificantNon-significantA patient can acquire co-infectionwith HDV and HBV; and a patientwith hepatitis B can be infectedwith HDV at any time after acutehepatitis B virus infection (super-infection). Hepatitis D virus super-infection should be suspected in apatient with chronic hepatitis B whosecondition suddenly worsens and aparticularly aggressive acute hepatitisB infection could suggest hepatitis Dco-infection. Co- infection or super-infection with HDV in a patient withhepatitis B is diagnosed by thepresence of antibodies against theHDV and IgM antibodies indicateacute infection. The enrolled patientsin this study were suffering fromdifferent types of hepatitis likehepatitis B, hepatitis C, hepatitis Eand hepatitis non A-E). specificsignificance in natural history ofhepatitis. Most adult acquired liverdiseases cause impairment in bilirubinsecretion from liver, which causeelevation of SB in the blood and inacute liver disease, the SB is usuallyelevated relative to the severity of theacute process. Blood levels of SGOT(also referred as AST) and SGPT(also referred as ALT is elevated inall types of hepatitis (viral, alcoholic,drug-induced, etc.). Albumin andglobulin are the major proteinssynthesized in the liver, whichcirculate in the bloodstream, and lowSA, SG, TP concentrations indicatepoor liver function.This study observed a highly significant and rapid symptomatic improvement in the meanscores for loss of appetite, weight loss, fatigue and jaundice in Sulfad group, as compared tothe placebo. There was a significant and rapid renormalization in the biochemical parameters ofliver functions (SGOT, SGPT, SB), and the levels of SA, SG, and TP were renormalized. Theincreased levels of ESR and WBC were significantly reduced in Sulfad group, as compared tothe placebo group, at the end of the study. There were no clinically significant changes inother biochemical parameters such as Hb levels and PC, which indicate excellent short-andlong-term safety profile of Sulfad.
  • 11. Table 12: Improvement in WBC (cells/cu.mm.)levels at baseline and after 4thmonthParameterSulfad PlaceboDay 0th4monthDay 0th4monthMinimum 4800 4000 4000 4000Maximum 11900 10000 10000 10000Mean 8057 7332 7378 7117Std. Deviation 1673 1494 1632 1636Std. Error 334.5 298.8 340.2 341.1Lower 99% CI 7121 6496 6419 6156Upper 99% CI 8992 8168 8337 8079Mean ofdifferences724.8 260.999% CI -214.9 to 1665 -143.5 to 665.22R 0.1624 0.1307t value 2.157 1.819p value p=0.0412 p=0.0826p valuesummary*Significant Non-significantFigure 5: Improvement in ESR levels at Day 0 and 4th month with Sulfad treatmentThere were no clinically significant adverse effects, either observed or reported; during theentire study period, and the overall compliance to the drug treatment was found to be excellent.These beneficial clinical efficacies of Sulfad in acute and chronic viral hepatitis might be due tothe synergistic action of its ingredients, which had been well documented in variousexperimental and clinical studies by various researchers.Silymarin is a mixture of flavonolignansextracted from the milk thistle. Silymarincontains several molecules, includingsilibinin A, silibinin B, isosilibinin A,isosilibinin B, silicristin, and silidianin.Intravenous infusion of silibinin inducesdose-dependent reduction of hepatitis C virus(HCV) RNA levels. Silibinin A and silibininB, as well as Legalon SIL, inhibit HCVreplicon and JFH1 replication in cell culture.This effect is at least partly explained by theability of these compounds to inhibit HCVRNA-dependent RNA polymerase activity1.SIL is well tolerated and shows a substantialantiviral effect against HCV innonresponders2. Randomised clinical trialshave assessed whether extracts of milkthistle, Silybum marianum (L) Gaertneri,have any effect in patients with alcoholicand/or hepatitis B or C virus liver diseases3,8.Several trials have studied the effects of milk thistle for patients with liver diseases, cancer,hepatitis C, HIV, diabetes, and hypercholesterolemia.
  • 12. Promising results have been reported in the protective effect of milk thistle in certain types ofcancer, and ongoing trials will provide more evidence about this effect. In addition, newestablished doses and improvement on the quality and standardization of this herb will providethe much-awaited evidence about the efficacy of milk thistle in the treatment of liver diseases.Milk thistle extracts are known to be safe and well tolerated, and toxic or adverse effectsobserved in the reviewed clinical trials seem to be minimal. The future of milk thistle research ispromising, and high-quality randomized clinical trials on milk thistle versus placebo may beneeded to further demonstrate the safety and efficacy of this herb4. Flavan-3-on-4-ols areisolated and identified as the active ingredients of Silybum marianum. This Silyarin mixture wasfound to possess potent hepatoprotective activity against CCl4, paracetamol (in vivo) andthioacetamide, galactosamine (in vitro) induced Hepatotoxicity1-11. Silymarin has potentantioxidant activity 5. In another study, it was shown that milk thistle prevents lipidperoxidation, bleaching of free radicals and autoxidation of iron ions10. Cynara scolymusleaves extracts have long been used in folk medicine for their choleretic and hepatoprotectiveactivities, that are often related to the cynarin content. These therapeutic properties are alsoattributed to mono- and di-caffeoylquinic acids and since commercial C. scolymus preparationscan differ for their activities. Cynara showed that the extract with the highest content in phenolicderivatives (GAE) exerted the major effect on bile flow and liver protection.Aktay et al. isolated and identified the major constituents of Cynara scolymus17 and Gebhardtet al. identified the other chemical constituents as cynaropicrin, quinic acid derivatives andfalvonoids.18 Adzet et al. and Seperoni et al. observed the hepatoprotective effect(confirmed by histopathological examination) of Cynara scolymus agains CCl4-inducedhepatotoxicity and reported significant prevention of the elevation of malondialdehydeformation (plasma and hepatic) and enzyme levels (AST and ALT).12-18 Aktay et al. screenedCynara scolymus for antihepatotoxic activity and measured the degree of protection usingbiochemical parameters (AST, ALT, ALP and TP). Potent antihepatotoxic activity (comparableto the silymarin) was observed with almost complete normalization of the tissues (as neitherfatty accumulation nor necrosis was observed on histopathological study)17. Maros et al.studied the effects of Cynara scolymus on the immunotoxicity of ethanol and reportedsignificant increase in the number of circulating leukocytes, the weights of concerned organs(liver, spleen and thymus), number of splenic plaque forming cells, hemagglutination titers andthe secondary IgG antibody response. There were also significant increases in delayed-typehypersensitivity reaction, phagocytic activity, natural killer cell activity, cell proliferationand interferon gamma secretion.20 M a r o s et al. reported that the presence ofC y n a r a s c o l y m u s in the reaction mixture (containing calf thymus DNA and freeradical generating system) protects DNA against oxidative damage to its deoxyribose sugarmoiety. All these studies suggest that the observed hepatoprotective effect of Cynara scolymusmight be due to its ability to suppress the oxidative degradation of DNA in the tissue debris.16-21The antioxidative activity (radical scavenging effects, inhibition of hydrogen peroxide, andiron chelation) of Cynara.19,21 Gurbuz et al. observed significant cytoprotection againstethanol-induced damage and these results were further confirmed by using histopathologicaltechniques. Curcuminoids (curcumin and curcuminoids) as the active ingredients ofCurcuma longa were identified.22-27. Curcuma longa was investigated for its hepatoprotectiveactivity against CCl4-induced hepatic damage and it has shown remarkable hepatoprotectiveactivity confirmed by evaluated biochemical parameters (AST, ALT, ALP and TB). Curcumalonga protects DNA against the oxidative damage and the results suggest that the observedhepatoprotective effect of Curcuma longa might be due to the ability to suppress theoxidative degradation of DNA in the tissue debris. Curcuma increased activity of aminopyrineN- demethylase, uridine diphosphate glucuronyltransferase and glutathione S-transferase,without any alteration in levels of ALP, ALT and gamma-glutamyltransferase levels in the
  • 13. Table 14: Total platelet count (cells) at baselineand after 4th monthParameterSulfad PlaceboDay 0 4thmonthDay 0 4thmonthMinimum 150000 150000 140000 140000Maximum 360000 360000 320000 320000Mean 229200 243600 236400 240000Std. Deviation 41120 34750 37740 36380Std. Error 8224 6949 8046 7757Lower 99% CI 206200 224200 213600 218000Upper 99% CI 252200 263000 259100 262000Mean ofdifferences-14400 -363699% CI -28390 to -407.5 -16340 to 9072R20.2566 0.0303t value 2.878 0.8101p value p=0.0083 p=0.427p valuesummaryNon-significant Non-significantTable 13: Improvement in serumhemoglobinth(gm/dl) levels at baseline and after 4ParameterSulfad PlaceboDay 0th4monthDay0th4monthMinimum 8.6 10 9 10Maximum 16.9 15.1 18.2 17.2Mean 12.96 13.1513.3713.08Std. Deviation 1.978 1.3642.4241.847Std. Error0.39570.27280.50540.3851Lower 99% CI 11.85 12.3911.9511.99Upper 99% CI 14.07 13.91 14.8 14.16Mean ofdifferences0.192 0.29599% CI-0.8016 to0.4176-0.2955 to0.8868R20.03133 0.08287t value 0.881 1.41p value p=0.3871 p=0.1725p valuesummaryNon-significantNon-significantserum22-27.The triterpene saponins are identified as active ingredients of Glycyrrhiza glabra. Liquorice isreported to have potent antioxidant activity, which might be due to its effects on lipidperoxidation. The isoflavonoids from Glycyrrhiza glabra inhibit nitric oxide production andliquititigenin isolated from the above roots decreases inducible nitric oxide synthase levels inlipopolysaccharide-stimulated peritoneal macrophages.Liquorice has a potent antiviralactivity by virtue of inhibition of viral attachment and penetration. Hepatoprotectiveeffects of liquorice are reported in chemically induced liver damage. The roots of liquoriceshowed modulates hepatic enzymes and provides hepatoprotection against inducedimmunosuppression. It was observed that liquorice protects the gastric mucosal againstaspirin-induced gastric ulcers28-35.Therefore, as discussed above, these synergistic actions (hepatoprotective, antimicrobial,antioxidant and anti-inflammatory) exhibited by the ingredients of Sulfad might explain thebeneficial mechanism of action of Sulfad in acute viral and chronic hepatitis.CONCLUSIONViral hepatitis (A, B, C, D, E and G) is a global public health problem, which is responsiblefor a major chunk of morbidity and mortality. Viral hepatitis occurs endemically andsporadically throughout the world, depending on the endemicity of infection. The primarygoal in management of acute viral hepatitis is the early renormalizations of hepatic functionswith symptomatic and clinical recovery. There are no established drugs for hepatitis A-E, thisstudy was planned to evaluate the efficacy and safety of Sulfad tablets in viral hepatitis.The enrolled patients in this study were suffering from different types of hepatitis (hepatitis A,hepatitis B, hepatitis C hepatitis E and hepatitis non A-E). This study observed a highlysignificant and rapid symptomatic improvement in the mean scores for loss of appetite, weightloss, fatigue and jaundice in Sulfad group. There was a significant and rapid renormalization inthe biochemical parameters of liver functions and the levels of SA, SG, and TP wererenormalized. The increased level of ESR and WBC were significantly reduced in Sulfadgroup. There were no clinically significant changes in the other biochemical parameters suchas Hb levels and PC, which indicates excellent short- and long-term safety profile of Sulfad.
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