Randomized controlled trial of Qing Gan Huo Xue Prescription in the treatment of alcoholic liver cirrhosis

Jie-Lu Pan, Lian-Jun Xing, Ji Zhang, Xiao Yu, Hai-Yan Zhang

Department of No.2 Digestive Department,Longhua Hospital,Shanghai University of Traditional Chinese Medicine,Shanghai 200032,China

ABSTRACT Objective: To evaluate the efficacy of Qing Gan Huo Xue Prescription(QGHXP)in the treatment of patients with alcoholic liver cirrhosis(ALC)of damp and heat stasis syndrome.Methods: A total of 69 patients with ALC were randomly divided into TCM group(n=35)and control group(n=34). The TCM group was given QGHXP 1 pack TID orally. Control group received polyene phosphatidylcholine capsule 456 mg TID for 24 weeks. The observation measurements are symptom efficacy rate,serum level of liver enzyme,and noninvasive liver cirrhosis evaluation,including liver stiffness measurement(LSM)examininged by FibroTouch,APRI score,FIB-4 index and Maddrey discriminant function. Results: The symptom efficacy rate of the experimental group and the control group was 85.70% and 61.80%(P=0.024). Liver enzyme levels(serum ALP,γ-GT, AST and ALT)of TCM group were lower than those of control group(P＜0.05). LSM of TCM group was reduced after treatment,and was significant lower than control group(14.19±1.49)vs.(15.06±1.24)(P＜0.05).The APRI scores,FIB-4 index and Maddrey discriminant functions of TCM group were lower than those of control group(P＜0.05). Conclusion: QGHXP is an effective alternative for the treatment of damp and heat stasis syndrome of ALC in improving liver function and clinical symptoms.

Keywords:Alcoholic liver cirrhosis Qing Gan Huo Xue Prescription(QGHXP)Traditional Chinese medicine treatment

1. Introduction

Alcoholic liver cirrhosis (ALC) refers to liver damage and portal hypertension caused by long-term or short-term heavy alcohol consumption, and is the benign terminal stage of alcoholic liver disease (ALD) [1,2]. Among the patients who have been drinking heavily for years, about 20%～25% of them start onset of steatosis and develop into fibrosis and cirrhosis [3]. Evidence shows that the proportion of liver fibrosis and cirrhosis in patients with ALD with steatohepatitis indicated by liver biopsy is 20%-40% and 8%-20%, respectively [4]. Research report of World Health Organization(WHO) shows that about 3.3 million deaths worldwide are related to alcohol consumption, accounting for 6% of the total number of deaths from liver disease, and alcohol abuse is a risk factor for 50%of patients with liver cirrhosis [1]. ALD has become one of the most important type of chronic liver diseases in China [5].

Since the liver still remains compensatory function in the early stage, the lack of specific clinical symptoms, or only presenting fatigue, anorexia, right upper abdominal distension and other symptoms, are usually to be ignored. With the progression of the disease, multiple organs are gradually involved in the late stage,resulting in complications such as gastrointestinal bleeding, hepatic encephalopathy, ascites, hepatorenal syndrome and even liver cancer. At present, the treatment of ALC is still imperfect, and alcohol prohibition and nutritional support are still the most basic and important treatment methods. Patients still remains hepatitis and fibrosis after treatment, and data from rigorous clinical trials of anti-inflammatory and liver protective agents are still lacking.Noninvasive liver function assessment has gained more and more attention and recognition in recent years. The transient Elastography(TE) technology, FibroTouch measurement of liver stiffness (LSM)has been widely used in clinical diagnosis and assessment of liver fibrosis and cirrhosis [6].

On the basis of clinical and literature research, this research group proposed that "damp-heat stasis" is the basic pathogenesis of ALD[7]. Qing Gan Huo Xue Prescription (QGHXP) is formulated based on the traditional Chinese formula Xiao Chai Hu Decoction, which is specially effective in smoothing liver and harmonizing stomach and not enough in promoting blood circulation. Therefore, we designed QGHXP with the principle of clearing liver and removing dampness and promote blood circulation. The formula consists of Bupleurum,scutellaria baicalensis, salvia miltiorrhiza, Carapax trimycis and Pueraria lobata, which has been clinically applied in the treatment of ALD for more than 20 years in our hospital[7,8]. Preliminary experimental studies have shown that QGHXP has a good effect on the treatment of alcoholic liver fibrosis (ALF) [9-11]. In order to further explore the clinical efficacy of QGHXP in the treatment of ALC, we used a randomized controlled method to evaluate the efficacy of ALC by non-invasive liver function assessment.

2. Materials and Methods

2.1 Patients

Patients diagnosed with ALC and meanwhile differentiated TCM syndrome as dampness-heat stasis syndrome were selected from June 1, 2019 to September 31, 2019 at No.2 Department of Digestive Department, Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine.

2.2 Diagnostic criteria

Western clinical diagnostic criteria: refer to “ALD diagnostic criteria formulated by Guidelines for Prevention and Treatment of Alcoholic liver Disease: a 2018 Update” [5] : (1) Have a long history of alcohol consumption, generally more than 5 years,ethanol content ≥40 g/d for male, ≥20 g/d for female; Or two weeks of heavy drinking history, ethanol content ＞80g/d. Attention should be paid to the influence of gender, genetic susceptibility and other factors. Ethanol content (g) conversion formula = alcohol consumption (mL) × ethanol content (%) ×0.8; (2) The clinical symptoms are non-specific: patients with asymptomatic or right upper abdominal distention, anorexia, fatigue, weight loss, jaundice,etc.; with the aggravation of the disease, there might be presenting neuropsychological symptoms, spider nevus, liver palm and other manifestations; (3) Serum AST, ALT, γ -GT, TBil, PT, MCV and CDT were increased; (4) Typical manifestations of liver were detected by B-type ultrasound, CT, MRI or transient elastic imaging;(5) Exclude other liver diseases. In accordance with the first item,excluding other primary causes of liver disease, and consistent with the third and fourth items, ALD can be diagnosed. The diagnostic criteria for ALC were: clinical manifestations of cirrhosis, serum biochemical indices, transient elastography and imaging changes.

Diagnostic criteria of TCM syndromes: refer to “Guidance Principles of Clinical Research of New drug of Traditional Chinese Medicine” in 2018 [12]. Differentiation of damp-heat stasis syndrome refers to “Consensus Opinions on Diagnosis and Treatment of Integrated Traditional Chinese and Western Medicine of Liver Fibrosis” [13]. Primary symptoms of damp-heat syndrome of liver and gallbladder: (1) thirst, bitter taste or halitosis; (2)hypochondrium distension or pain; (3) sticky and smelly stools, or bad bowel movement. Secondary symptoms :(1) indigestion and loss of appetite; (2) epigastric distension; (3) fatigue; (4) yellow staining on skin and sclera. Tongue and pulse: red tongue, yellow and greasy coating, string-like and high-frequency pulse, or high-frequency and or string slippery pulse. Primary symptoms of intermingled phlegm and blood stasis: (1) gloomy complexion; (2) obese body;(3) indigestion and loss of appetite and thirsty. Secondary symptoms:(1) nausea , or vomit phlegm and salivation; (2) mass under the right rib with stabbing pain or dull pain, immovable. Tongue and pulse:enlarged tongue, with teeth marks on the edge or bruising on the tongue, and string-like and smooth pulse or uneven pulse. The TCM syndrome are decided by the rules that: having 3 or more primary syndromes and 1 or 2 secondary syndromes could be differentiated as the corresponding type of syndrome.

2.2.1 Inclusion criteria

(1) age from 18-65; (2) meet the diagnostic criteria of ALC of both TCM syndromes and Western medicine; (3) those who have not taken relevant drugs within 1 week; (4) those who deny the history of hypertension, diabetes, cardiovascular and cerebrovascular diseases and have no need to take any kinds of western medicine for a long time; (5) during the study period, those who have no pregnancy plan and is postpartum but non-lactation period; (6) those who with normal mind and intelligence and can cooperate with the researchers; (7) signed for informed consent and willing to accept the treatment project.

2.2.2 Exclusion criteria

(1) combined with hepatitis B, C and other liver diseases; (2)participated in other clinical studies or other treatment regimens during the study; (3) taking other drugs during the study without doctor’s advices; (4) failed to complete the follow-up or quit the treatment for some other reasons; (5) Patients with serious cardiovascular and cerebrovascular diseases, hematopoietic system and mental diseases during the study; (6) women who were pregnant during the study; (7) Patients with autoimmune liver disease,diabetic secretory fatty liver, drug liver disease, toxic hepatitis,liver malignant tumor, non-alcoholic fatty liver, liver and kidney failure, occult hepatitis, liver disease of unknown cause; (8) allergic to polyene phosphorylcholine and/or Traditional Chinese herbal medicine; (9) Patients who could not adhere to the treatment or complete the main observation indicators.

2.2.3 Exclusion Criteria

(1) Those who did not meet the test plan after enrollment; (2)serious physical diseases were found after enrollment; (3) recurrent drinking during treatment; (4) Patients with compliance rate ＜80%or ＞120%, who do not take medicine according to the regimen.

2.2.4 Shedding criteria

(1) Lost visitors; (2) Incomplete medical records due to poor compliance; (3) Withdrawal due to adverse reactions. 1.2.5 Criteria for termination of the test (1) Maddrey's decision function ≥32 points for aggravation of the disease [common formula: 4.6×PT (s)+TBil (mg/dL)]; (2) finding one or more of the following clinical or laboratory indicators: significant hepatomegaly; fever; white blood cell count ＞12000/mm3accompanied by obvious neutrophil differentiation; hepatic encephalopathy; systolic murmurs of liver;other new symptoms, considered progressive or worsening of the disease; (3) serious adverse reactions occurred during the test; (4) be pregnant during treatment.

2.3 Study Design

This study was designed with a randomized, positive drug controlled method. The subjects were randomly divided into the TCM group and the control group by using SAS statistical analysis system with serial numbers from 001 to 073.

2.4 Treatment Methods

2.4.1 Introduction of Drugs

Qing Gan Huo Xue Prescription (QGHXP) is composed of Bupelum (9g), Scutellaria baicalensis (9g), salvia miltiorrhiza (15g),Carapax trimycis (9g) and Pueraria lobata (15g), with granule dosage form, provided by Sichuan New Green Pharmaceutical Science and Technology Development Co., LTD., purchased by Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine. Polyene phosphorylcholine capsule is produced by Sanofi Beijing Pharmaceutical Co., LTD. The specification is 228mg/ tablet(batch number: National drug approval H20059010).

2.4.2 Grouping and therapeutic regiment

TCM group: QGHXP, 150 ml each time, twice a day, washed with boiled water. Control group: polyene phosphatidylcholine capsule 456 mg tid po. All medications were taken for 24 weeks.

2.5 Measurements

2.5.1 Clinical symptoms efficacy

Measurements of relevant clinical symptoms before and after treatment were judged and scored by Glasgow Scale[14] (such as bitter taste or halitosis, hypochondrium distension or pain, fatigue,yellow staining on skin and sclera, indigestion and loss of appetite,nausea , or vomit phlegm and salivation, etc). The clinical efficacy was graded and evaluated by nimodipine method after the treatment.Efficacy index = (points before treatment - points after treatment)/points before treatment ×100%. Total effective rate = (number of clinical cured cases + number of effective cases + number of effective cases)/total number of patients ×100%. Clinical recovery refers to Efficacy index ≥90%. Significant effective refers to Efficacy index ≥70%. Effective refers to Efficacy index ≥30%;Ineffective refers to Efficacy index ＜30%.

2.5.2 Liver enzymes

The level of serum AST, γ-GT, ALT and ALP were detected by the Laboratory of Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine.

2.5.3 ALC noninvasive liver function assessment

FibroTouch LSM value; APRI score, FIB-4 index and Maddrey discriminant function were measured.

2.5.4 Adverse reactions

Follow-up was continued for 1 week after the completion of treatment in this study, and the occurrence of adverse reactions of the subjects was recorded.

2.6 Statistical analysis

SPSS21.0 was used for statistical analysis. The mean ± standard deviation (mean ± SD) was used for measurement data description.Median (P25, P75) was used for statistical description, while the data was not conform to normality. T test was used for biochemical indexes such as liver function. Rank-sum test was used for Clinical symptoms efficacy comparison. P value ＜0.05 was considered as statistically significant.

3. Results

3.1 General information

A total of 73 patients diagnosed with ALC and differentiated as damp and heat stasis syndrome were incorporated from June 1st, 2019 to September 31st, 2019, treated in No.2 Department of Digestive Diseases of Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine. They were divided into two groups by random numeral method. 37 cases were in the TCM group, among which 2 cases were excluded because of drinking again. 36 cases in the control group, 2 cases were excluded because of drinking again.Therefore, a total of 69 cases, 35 in the TCM group (56.86±6.76 years old) and 34 in the control group (58.03±8.27 years old).There were no significant differences in gender and age between the two groups (t=0.645, P＞0.05), indicating comparability. There were no significant differences in drinking years and daily alcohol consumption between the two groups (P＞0.05) ( Table 1). No adverse reactions were reported until the end of follow-up.

3.2 Clinical symptoms and efficacy

After treatment, the cases of clinical recovery, marked effect,effective and ineffective in TCM group were 0, 10, 20 and 5,respectively, and the total effective rate was 85.70%. There were 0,4, 17 and 13 cases in the control group, respectively, and the total effective rate was 61.80%. The total effective rate in the TCM group was better than that in the control group, and the difference was statistically significant (χ2=5.130, P＜0.05).

3.3 Liver enzyme levels

After treatment, AST, γ-GT, ALT and ALP levels in the TCM group were lower than those in the contrast group, and the differences were statistically significant (P＜0.05). Are shown in table 2.

Table 1 Comparison of baseline data between the two groups( ±s )

Table 1 Comparison of baseline data between the two groups( ±s )

Group Number(n) Age(y) Gender (n) Drinking years (y) Daily Alcohol consumption (g)(M/F)TCM group 35 56.86±6.76 33/2 22.77±6.67 62.74±24.99 Control 34 58.03±8.27 33/1 21.44±4.54 63.57±24.85 comparison between groups t 0.645 0.319 -0.965 0.121 P 0.521 0.572 0.338 0.904

Table 2 Comparison of AST、γ-GT、ALT、ALP levels between the two groups before and after treatment

3.4 ALC noninvasive liver function assessment

Fibrotouch showed no significant difference in LSM between the two groups before treatment (P=0.22). After treatment, LSM in the TCM group was lower than that in the contrast group, and the difference was statistically significant (P=0.01), as shown in Table 3.After treatment, APRI score, FIB-4 index and Maddrey discriminant function in both groups were lower than before treatment (P＜0.05),as shown in Table 4. Compared with the control group, the APRI score and FIB-4 index of the TCM group were lower after treatment,and the differences were statistically significant (P＜0.05). After treatment, Maddrey discriminant function of TCM group was lower than that of TCM group, and the difference was statistically significant (P＜0.01).

Table 3 Comparison of LSM between the two groups before and after treatment(KPA)

4. Discussion

In the theory of Traditional Chinese medicine, there is no specific name of disease corresponding to ALC, but ancient Chinese doctors have already got a deep understanding of the injury caused by alcohol drinking to human body, and classified the injury into diseases of "Shang Jiu" (injury by alcohol), "Jiu Pi " (alcohol addiction), and "Jiu Gu" (abdominal tympanites caused by alcohol).Through the study on the etiology and pathogenesis of ALC,damp-heat alcohol toxicity is the primary factor leading to the occurrence of ALC, and damp-heat stasis is the basic pathogenesis of ALC. QGHXP is consisted of five herbs, that is Radix Buhurum,Scutellaria baicalensis, Salvia miltiorrhiza, Carapax trimycis and Pueraria lobata. In TCM theory, the treatment of ALC is based on clearing the damp and heat of liver and gallbladder, promoting blood circulation and removing blood stasis. QGHXP has been found in previous animal experiments that QGHXP can significantly improve the degree of liver steatosis and liver inflammation in rats, reduce the levels of serum ALT and AST, reduce the level of endotoxin in plasma, and protect rats from alcohol injury by regulating Kuffer cells. It is suggested that QGHXP might inhibit the transformation of epithelial cells into mesenchymal cells through TGF- β1/Smad pathway [9,10].

Table 4 Noninvasive liver function evaluation of ALC before and after treatment

Liver biopsy is still recommended as the gold standard for evaluating the degree of liver fibrosis and cirrhosis, but it has not been fully promoted in clinical practice and has not been accepted by patients due to its invasion and potential complications. In recent years, non-invasive evaluation methods for liver fibrosis and cirrhosis have attracted more and more attention, for example, FibroScan and FibroTouch are the most widely used in TE [15]. More and more studies show that a single serological indicator will be changing with the progression of disease and individual conditions of patients,thus might not accurately reflect the degree of fibrosis. Therefore,integrating serum markers gradually become the focus of research[16]. It integrates multiple biochemical indicators and demographic information to formulate the diagnosis, evaluation and prognosis of most patients with liver disease [17]. For example, FIB-4 Index/Indices, which uses age, AST, ALT and platelet count, has been used in clinical fibrosis assessment for more than 10 years, with diagnostic specificity of 97% for patients with progressive fibrosis[18].Large sample clinical trials have shown that FIB-4 index is effective in predicting cirrhosis and liver-related adverse events in patients with chronic hepatitis B [19]. The relationship between Maddrey discriminant function and short-term mortality prognosis of patients with ALD has a certain reference value to evaluate the incidence and prognosis of ALD. AST to PLATELET ratio index (APRI) is an important reference for evaluating changes in patients with cirrhosis and the risk of HCC [20]. Both have been proved to be reasonable tools for assessing hepatic fibrosis in non-alcoholic fatty liver disease[21].

After 24 weeks of treatment, the LSM value and FIB-4 index of the TCM group were significantly decreased, indicating that the degree of liver fibrosis and cirrhosis was improved and superior to polyene phosphatidylcholine. APRI score, FIB-4 index and Maddrey discriminant function included patient age information, as well as a single biochemical index including AST, ALT, platelet count,prothrombin time and total bilirubin. Liver function evaluation and disease prognosis were obtained by scientific algorithm, all of which were better than the control group. It is further suggested that QGHXP may improve the progression and prognosis of ALC.

After treatment, the symptoms of the patients such as bitter taste or halitosis, hypochondrium distension or pain, fatigue, yellow staining on skin and sclera, indigestion and loss of appetite, nausea , or vomit phlegm and salivation, and other symptoms were significantly relieved. By calculating clinical symptom score, the clinical effective rate of the TCM group was higher than the control group, indicating that QGHXP might improve the liver function level of patients and relieve clinical symptoms. Modern pharmacological studies have shown that Radix Bupleurum has a significant antagonistic effect on experimental liver injury, and can promote the absorption of liver fiber, thus slowing down the occurrence of cirrhosis. Scutellaria baicalensis is an important liver-clearing medicine in Traditional Chinese medicine. Its active ingredients can promote bile secretion and reduce bilirubin content. Carapax trimycis can inhibit connective tissue hyperplasia, protect liver injury and improve protein synthesis in liver. So the combined effect, improve liver function. In addition,effective ingredients of Bupleurum can inhibit the over-secretion of gastric juice, so it can alleviate the epigastric abnormal symptoms.Scutellaria baicalensis, Pueraria lobata and Salvia miltiorrhiza inhibit platelet aggregation and regulate coagulation function, so Maddrey discriminant function might be reduced, in some extent.

In summary, our study used FibroTouch detecting of LSM value combined with non-invasive liver function assessment to evaluate the efficacy of QGHXP in the treatment of ALC. The study found that QGHXP can effectively improve the liver function of patients,relieve clinical symptoms, and improve the degree of liver fibrosis and cirrhosis. In some extent, it might inhibit the prognosis of the disease, which is an effective treatment. There are shortcomings in our study. The formation of liver fibrosis and cirrhosis is closely related to long-term liver damage, and the treatment cycle is relatively long. So longer treatment and follow-up period after drug withdrawal should be produced in the further study, in order to improve the efficacy evaluation of ALC, which is worthy of further exploration and application in the future.

Author's contribution

Xing Lianjun, the person in charge, provided research ideas. Pan Jielu designed the research program. Xing Lianjun and Pan Jielu performed and administered the whole study. Zhang Ji and Pan Jielu collected the case of participants, filled in the case report form and completed follow-up. Yu Xiao, Zhang Ji input and verified the data.Pan Jielu and Zhang Ji did the statistical analysis and write the paper.Zhang Haiyan is participated in the paper revision.