Efficacy Study of Andrographis Paniculata Purified Standardized Extract (ApE) in Patients With Multiple Sclerosis (MS)

Overview

To evaluate the efficacy of ApE coated tablets, on the relapse rate in a group of relapsing remitting multiple sclerosis (RRMS) patients, as compared to a placebo group in a period of 12 months. This study will also determine the safety and tolerability of the drug administered over interferon beta vs. administration of a placebo formulation (also over interferon) during the evaluation period. Response will be assessed and measured by daily self patient recording, monthly clinical neurologist, and every three months serological and magnetic resonance parameters. Place of Study: National study in Chile with one center at the Regional Hospital in the city of Valdivia, including 30 patients enrolled by their respective neurologists.

Introduction: Multiple sclerosis is a chronic inflammatory demyelinating disease of the central nervous system that predominantly affects young adults (1). Although its etiology has not yet been elucidated, evidence points to an autoimmune pathogenesis where it is thought that self-reactive and myelin-specific cluster of differentiation four and eight (CD4)and (CD8) T cells, play an important role by reacting and destroying the myelin sheath (2). No plasma biomarkers to determine disease activity by routine clinical measurements, the existence a pattern of pro-inflammatory cytokines has been described, with range increased Interferon (IFN), Tumoral Necrosis Factor alpha (TNFa) and Interleukin 12 (IL-12), as well as a decline in Interleukin10 (IL10) and Interleukin 4 (IL4) anti-inflammatory cytokines (3). To date, the most common treatment for MS is Interferon beta immunomodulation, although its cost / effectiveness has been questioned4. Regardless of the progressive form and the existence of outbreaks, the fatigue symptom is one of the most frequent and disabling one in patients with MS. The proposed pathogenic mechanisms are multiple, although its exact pathophysiology is unknown. Also, there is still no treatment that has proven to be completely effective in stopping the progression of the disease (5). Description of the botanical drug to be used in this clinical research: The botanical drug to be used in this clinical research, is a phytopharmaceutical tablet made by Good Manufacturing Practices (GMP) containing a purified, standardized and patented extract of Andrographis paniculata Nees (Acanthaceae) {U.S. Patent: 8,084,495 B2; Date: Dec. 27, 2011} (ApE). This is a medicinal annual plant, native to India and China whose active compounds are bitter diterpenoid lactones such as and especially 14-deoxyandrographolide, Neoandrographolide and specially Andrographolide, which has proven particularly effective in regulating the immune response (7, 9). The cellular and molecular mechanisms responsible for the immunomodulatory and anti-inflammatory properties of Andrographolide, are for the most part still unknown. However, recent studies with in vitro and in vivo assays indicate that 10 micromol (µM) per liter inhibits Tumoral Necrosis Factor Beta (NF-kB). Specifically, Andrographolide at concentrations of 10 micromol (uM) per liter interferes with DNA binding of NF-kB (10), by reducing the expression of COX-2 in neutrophils induced with Formyl-Methionyl-Leucyl-Phenylalanine (fMLP) and Platelet Activating Factor (PAF). Moreover, Andrographolide reduces Interferon gamma (IFNg) and IL-2 production in Concanavalin A (Con A) induced T-cells, without affecting cell viability or inducing apoptosis, also diminishing thymocyte apoptosis induced by corticosteroids. Furthermore, Andrographolide and 14-deoxyandrographolide are capable of inhibiting extracellular signal-regulated kinases 1/2 (ERK1/2) phosphorylation in T cells and neutrophils, respectively (11, 12). Security settings: Toxicity and Tolerance Analysis of acute and sub-chronic toxicity of ApE in rodents and pigs, using the basic component of ApE have been carried out in our laboratory at the Institute of Pharmacology and Toxicology, Universidad Austral de Chile, and according to the guidelines of Good Laboratory Practice (GLP) of the Food Administration Agency (FDA). Also, clinical phase I and II clinical studies have been performed, plus controlled daily treatment of 12 patients with different rheumatoid conditions and other 8 patients with Recurrent Remitting Multiple Sclerosis (RRMS) for more than five years. All these observations have proven a wide range of dosage safety without any detected toxic effects at therapeutic dose of 2 milligrams per kilogram of body weight. Hypothesis: In experimental inflammatory and human autoimmune diseases, such as Rheumatoid arthritis and related conditions (17, 19), and also in animal models in which Experimental Autoimmune Encephalitis (EAE) is induced, we have recently shown that Andrographolide can significantly reduce the clinical symptoms and outcome of this diseases (6), for which we have now proposed this clinical study in RRMS.