Traditional Chinese medicine research in the post-genomic era: good practice, priorities, challenges and opportunities

Background and aims

GP-TCM is the 1st EU-funded Coordination Action consortium dedicated to traditional Chinese medicine (TCM) research. This paper aims to summarise the objectives, structure and activities of the consortium and introduces the position of the consortium regarding good practice, priorities, challenges and opportunities in TCM research. Serving as the introductory paper for the GP-TCM Journal of Ethnopharmacology special issue, this paper describes the roadmap of this special issue and reports how the main outputs of the ten GP-TCM work packages are integrated, and have led to consortium-wide conclusions.

Materials and methods

Literature studies, opinion polls and discussions among consortium members and stakeholders.

Results

By January 2012, through 3 years of team building, the GP-TCM consortium had grown into a large collaborative network involving ∼200 scientists from 24 countries and 107 institutions. Consortium members had worked closely to address good practice issues related to various aspects of Chinese herbal medicine (CHM) and acupuncture research, the focus of this Journal of Ethnopharmacology special issue, leading to state-of-the-art reports, guidelines and consensus on the application of omics technologies in TCM research. In addition, through an online survey open to GP-TCM members and non-members, we polled opinions on grand priorities, challenges and opportunities in TCM research. Based on the poll, although consortium members and non-members had diverse opinions on the major challenges in the field, both groups agreed that high-quality efficacy/effectiveness and mechanistic studies are grand priorities and that the TCM legacy in general and its management of chronic diseases in particular represent grand opportunities. Consortium members cast their votes of confidence in omics and systems biology approaches to TCM research and believed that quality and pharmacovigilance of TCM products are not only grand priorities, but also grand challenges. Non-members, however, gave priority to integrative medicine, concerned on the impact of regulation of TCM practitioners and emphasised intersectoral collaborations in funding TCM research, especially clinical trials.

Conclusions

The GP-TCM consortium made great efforts to address some fundamental issues in TCM research, including developing guidelines, as well as identifying priorities, challenges and opportunities. These consortium guidelines and consensus will need dissemination, validation and further development through continued interregional, interdisciplinary and intersectoral collaborations. To promote this, a new consortium, known as the GP-TCM Research Association, is being established to succeed the 3-year fixed term FP7 GP-TCM consortium and will be officially launched at the Final GP-TCM Congress in Leiden, the Netherlands, in April 2012.     

Good practice in reviewing and publishing studies on herbal medicine, with special emphasis on traditional Chinese medicine and Chinese materia medica

Ethnopharmacological relevance

Studies on traditional Chinese medicine (TCM), like those of other systems of traditional medicine (TM), are very variable in their quality, content and focus, resulting in issues around their acceptability to the global scientific community. In an attempt to address these issues, an European Union funded FP7 consortium, composed of both Chinese and European scientists and named “Good practice in traditional Chinese medicine” (GP-TCM), has devised a series of guidelines and technical notes to facilitate good practice in collecting, assessing and publishing TCM literature as well as highlighting the scope of information that should be in future publications on TMs. This paper summarises these guidelines, together with what has been learned through GP-TCM collaborations, focusing on some common problems and proposing solutions. The recommendations also provide a template for the evaluation of other types of traditional medicine such as Ayurveda, Kampo and Unani.

Materials and methods

GP-TCM provided a means by which experts in different areas relating to TCM were able to collaborate in forming a literature review good practice panel which operated through e-mail exchanges, teleconferences and focused discussions at annual meetings. The panel involved coordinators and representatives of each GP-TCM work package (WP) with the latter managing the testing and refining of such guidelines within the context of their respective WPs and providing feedback.

Results

A Good Practice Handbook for Scientific Publications on TCM was drafted during the three years of the consortium, showing the value of such networks. A “deliverable – central questions – labour division” model had been established to guide the literature evaluation studies of each WP. The model investigated various scoring systems and their ability to provide consistent and reliable semi-quantitative assessments of the literature, notably in respect of the botanical ingredients involved and the scientific quality of the work described. This resulted in the compilation of (i) a robust scoring system and (ii) a set of minimum standards for publishing in the herbal medicines field, based on an analysis of the main problems identified in published TCM literature.

Conclusion

Good quality, peer-reviewed literature is crucial in maintaining the integrity and the reputation of the herbal scientific community and promoting good research in TCM. These guidelines provide a clear starting point for this important endeavour. They also provide a platform for adaptation, as appropriate, to other systems of traditional medicine.     

Evidence-based toxicity evaluation and scheduling of Chinese herbal medicines

Ethnopharmacological relevance

While there is an increasing number of toxicity report cases and toxicological studies on Chinese herbal medicines, the guidelines for toxicity evaluation and scheduling of Chinese herbal medicines are lacking.

Aim

The aim of this study was to review the current literature on potentially toxic Chinese herbal medicines, and to develop a scheduling platform which will inform an evidence-based regulatory framework for these medicines in the community.

Materials and methods

The Australian and Chinese regulations were used as a starting point to compile a list of potentially toxic herbs. Systematic literature searches of botanical and pharmaceutical Latin name, English and Chinese names and suspected toxic chemicals were conducted on Medline, PubMed and Chinese CNKI databases.

Results

Seventy-four Chinese herbal medicines were identified and five of them were selected for detailed study. Preclinical and clinical data were summarised at six levels. Based on the evaluation criteria, which included risk–benefit analysis, severity of toxic effects and clinical and preclinical data, four regulatory classes were proposed: Prohibited for medicinal usage, which are those with high toxicity and can lead to injury or death, e.g., aristolochia; Restricted for medicinal usage, e.g., aconite, asarum, and ephedra; Required warning label, e.g., coltsfoot; and Over-the-counter herbs for those herbs with a safe toxicity profile.

Conclusion

Chinese herbal medicines should be scheduled based on a set of evaluation criteria, to ensure their safe use and to satisfy the need for access to the herbs. The current Chinese and Australian regulation of Chinese herbal medicines should be updated to restrict the access of some potentially toxic herbs to Chinese medicine practitioners who are qualified through registration.     

欧盟草药药品注册评价技术标准体系研究

欧盟在全球植物药市场的地位举足轻重，推动更多中成药尤其是复方产品进入欧盟药品市场，对中药国际化具有重要战略意义。立足中成药欧盟市场准入中的注册评价技术标准这一关键环节，从欧盟相关法律法规基础与技术标准体系构成，以及产品质量、安全与有效性评价技术要求等方面，系统剖析欧盟草药药品注册评价技术标准特点，并针对欧盟复方产品的要求进行专门讨论。研究结果对于我国深入认识欧盟草药药品监管体系内涵、搭建中欧植物药科学监管机制研究的“桥梁”具有良好学术价值，对指导和推动中成药开展欧盟药品注册工作具有积极地促进作用。     

欧盟草药药品监管模式对中国中药注册管理的启示＊

对药品实行注册管理制度是确保公众健康的全球通用的监管措施。中药作为承载中医药理论与用药实践的主要载体，对中药产品的注册管理又具有其特殊性。2017年正式实施的《中医药法》提出了建立符合中医药特点管理制度的发展方针，研究制定配套文件或修订现行规章以适应衔接其立法精神是当前重要的现实问题之一。欧盟在植物药监管领域取得了良好成效，本文旨在系统分析欧盟对其注册管理的法规体系，深入剖析其监管特点和对中国中药注册管理的启示，以期为当前《中医药法》背景下中药监管制度的改革提供参考。     

欧盟草药药品注册管理现状与中药欧盟注册策略

欧盟是全球最重要的区域一体化组织,也是西方最成熟的植物药市场,2004年《欧盟传统草药指令》(2004/24/EC)的颁布标志着欧盟草药药品注册管理制度的成熟和完善,不仅对统一监管草药具有里程碑式意义,而且为中药国际化发展提供了重要机遇。2004/24/EC法令颁布至今已有17年,已批准2000余件草药药品上市申请,而我国仅有极少数中药产品成功在欧盟成员国获批,中药欧盟注册仍然任重道远。旨在系统分析欧盟草药药品注册管理制度及其实施有关数据情况,并探索未来中药欧盟注册的思路与策略,以期为有关企业及政府部门提供参考。     

Systems approaches and polypharmacology for drug discovery from herbal medicines: An example using licorice

Ethnopharmacological relevance

Licorice, one of the oldest and most popular herbal medicines in the world, has been widely used in traditional Chinese medicine as a cough reliever, anti-inflammatory, anti-anabrosis, immunomodulatory, anti-platelet, antiviral (hepatitis) and detoxifying agent. Licorice was used as an example to show drug discovery from herbal drugs using systems approaches and polypharmacology.

Aim of the study

Herbal medicines are becoming more mainstream in clinical practice and show value in treating and preventing diseases. However, due to its extreme complexity both in chemical components and mechanisms of action, deep understanding of botanical drugs is still difficult. Thus, a comprehensive systems approach which could identify active ingredients and their targets in the crude drugs and more importantly, understand the biological basis for the pharmacological properties of herbal medicines is necessary.

Materials and methods

In this study, a novel systems pharmacology model that integrates oral bioavailability screening, drug-likeness evaluation, blood–brain barrier permeation, target identification and network analysis has been established to investigate the herbal medicines.

Results

The comprehensive systems approach effectively identified 73 bioactive components from licorice and 91 potential targets for this medicinal herb. These 91 targets are closely associated with a series of diseases of respiratory system, cardiovascular system, and gastrointestinal system, etc. These targets are further mapped to drug–target and drug–target–disease networks to elucidate the mechanism of this herbal medicine.

Conclusion

This work provides a novel in silico strategy for investigation of the botanical drugs containing a huge number of components, which has been demonstrated by the well-studied licorice case. This attempt should be helpful for understanding definite mechanisms of action for herbal medicines and discovery of new drugs from plants.     

Value chains of herbal medicines--research needs and key challenges in the context of ethnopharmacology

Background

Value chain analyses are commonly used to understand socioeconomic and power relationships in the production chain from the initial starting material to a final (generally high value) product. These analyses help in terms of understanding economic processes but also have been used in the context of socioeconomic and socioecological research.

Aims of the study

However, there is a gap in the ethnopharmacological literature in terms of understanding what relevance a critical analysis of value chains of herbal medicines could have. Here we provide a research framework for achieving such an analysis.

Methods

An extensive review of the literature available on value chains and their analysis was conducted, based both on a systematic online search of the relevant literature and a hand search of bibliographies and discussions with experts in value chain analysis

Results

While the concept of value chains is commonly used in the relevant industries, very few studies investigate the value chains of herbal medicines and products derived from them. The studies identified mostly look at socio-ecological aspects, especially in the context of sustainable resource use. We suggest an analytical framework which can help in understanding value chains in the context of ethnopharmacology and can serve as a basis for addressing questions related to value chains and their relevance in ethnopharmacology.

Conclusions

We identified a crucial gap in current ethnopharmacological and medicinal plant research which impacts on a wide-range of factors relevant for a sustainable, socio-culturally equitable and safe supply of herbal medicines.     

突破中药欧盟注册障碍的关键因素分析

欧盟是中药国际化的桥梁,中药在欧盟成功注册具有重要的战略意义。该文简要回顾了10年来欧盟植物药政策的进展以及品种的批准情况,系统研究了欧盟植物药注册的政策法规,分析了一些中药欧盟注册的典型案例,重点从注册类别、审批程序、审批部门、申报品种、申报企业5个方面分析影响注册成败的关键因素,并提出了突破欧盟注册障碍的相应对策与建议,以期为我国中药在欧盟成功注册和实施中药国际化战略提供参考和借鉴。     

欧盟、美国和加拿大植物药管理异同剖析

从20世纪70年代起,中药/天然药物以其独特的治疗理念又重新受到推崇.欧美等发达国家在肯定植物药对疾病有预防和治疗作用的同时,也灵活调整了药品的监管方向,愿意以科学的态度重新对植物药进行系统评价,再次逐步接纳其作为治疗性产品.作者通过分析欧盟、美国和加拿大对植物药监管的历史和法规要求的异同,从国际药政的角度,提出中药未来可能的国际研发方向.     

Guidelines for randomised controlled trials investigating Chinese herbal medicine

Ethnographic relevance

Clinical trials investigating Chinese herbal medicine (CHM) have been frequently criticised for their lack of scientific rigour. As part of the GP-TCM project a team of experienced clinical researchers and CHM practitioners have developed clinical trial guidelines for CHM that combine an appreciation for traditional methods of practice with detailed and practical advice on research methodology.

Materials and methods

This paper presents an executive summary of this work. It introduces the practice of CHM and the key considerations that need to be addressed whilst researching this traditional medical system.

Results

These guidelines emphasise the importance of identifying best practice, and then developing and applying appropriate and rigorous research methodologies to investigate CHM as a whole system.

Conclusions

It is hoped that this will encourage a thoughtful and meticulous process of investigation that will clarify the contribution that CHM can make to our future healthcare. Innovative new approaches are considered including the application of the new “omic” technologies and systems biology as a way of enhancing our understanding of traditional practice     

Pharmacovigilance practice and risk control of Traditional Chinese Medicine drugs in China: current status and future perspective

Ethnopharmacological relevance

Traditional Chinese Medicine (TCM), including Traditional Chinese Medicine drugs (TCM drugs), has been playing a very important role in health protection and disease control for thousands of years in China. Relying on natural products, mainly of herbal origin, used either as raw materials for decoction, as prepared herbal medicines or as formulated traditional medicines, TCM is still widely accepted by Chinese people, especially for chronic diseases treatment. This extensive use warrants safety measures and so TCM drug safety monitoring and risk management are becoming increasingly important tasks for the Chinese State Food and Drug Administration (SFDA).

Methods

The Adverse Drug Reaction (ADR) monitoring system in China was established both for western and TCM drugs in 1989 as a voluntary reporting system with a National Center collecting and compiling reports. Serious or multi-case reports on individual TCM drug or formulated products are detailed in the Chinese ADR Information Bulletin to inform the public and Drug Administrative authorities for risk management.

Results

About 10–15% of the ADR reports received by the National Center are related to TCM drugs and mainly pertaining to the formulated products. In certain cases, the suspension of a particular TCM preparation is decided by SFDA China.

Conclusion

The model of safety monitoring and risk management of TCM drugs is still under exploration. Indeed, the characteristics and risk factors associated with these drugs require both proper understanding and control of the risk by strengthening standardization of clinical applications, basic science research, quality control in manufacturing, exploration of the actives monitoring methodology and enhancement of international communication and cooperation.     

Current Status and Future Perspective in the Globalization Of Traditional Chinese Medicines

Globalization of traditional Chinese medicines started around the 1996, which was initiated by the Chinese government. However, some substantial progress was only achieved in recent years including the adoption of TCM quality monographs in the western pharmacopoeias (United States Pharmacopoeia and European Pharmacopoeia) and registration in main stream drug regulatory agencies such as US Food and Drug Administration (FDA) and European Medicines Agency (EMA). So far, several TCM herbal quality monographs were adopted by the United States Pharmacopoeia including China Salvia, Ganoderma lucidum and Panax notoginseng, etc. Over 45 TCM quality monographs were recorded in the European Pharmacopoeia with 20 more in the progress. After the successful registration of the first TCM product named Di Ao Xin Xue Kang as traditional medicine in Medicines Evaluation Board of the Netherlands, several other TCM herbal products are in the registration process in several European member states. So far, there has been still no any TCM product registered as a drug in FDA despite of a few products in phase III or phase II clinical trials. This review summarized the progress made in the globalization of traditional Chinese medicines in the recent years and the future issues in this regard were also projected.     

Prescription pattern of Chinese herbal products for hypertension in Taiwan: A population-based study

Ethnopharmacological relevance

Traditional Chinese medicine (TCM) has been commonly used in Asia country. The aim of this study is to analyze the utilization of TCM among hypertensive patients in Taiwan.

Materials and methods

The use of TCM for primary hypertensive patients was evaluated using a randomly sampled cohort of 1,000,0s recruited from the National Health Insurance Research Database in 5-year period from 2006 to 2010.

Results

Overall, 49.7% (n=42,586) of primary hypertension utilized TCM and 12.1% (n=5132) of them used TCM for the treatment of hypertension. Among the top 10 most frequently prescribed herbal formulae, Tian-Ma-Gou-Teng-Yin, Gout-Teng-San, Liu-Wei-Di-Huang-Wang and its derivatives were found to be the most common herbal formulae prescribed by TCM doctors for the treatment of hypertension in Taiwan.

Conclusion

This study showed the utilization pattern of Chinese herbal product in patients with hypertension. Further researches and clinical trials are needed to evaluate the efficacy of these Chinese formulae or its ingredients in treating hypertension.     

我国中药健康产品管理及市场概况

随着民众健康意识的增涨,对健康养生产品的需求不断增加,以中药为原料的保健品、药食同源产品、药膳等受到国内外的广泛关注。但是,目前对中(草)药健康产品并没有统一的定义。因此,通过对我国中药产品的法律地位以及我国中药健康产品的管理机构、市场概况等进行介绍,以期为以中药为原料的健康产品的研发提供参考。     

关于中药品种进入欧盟草药产品专论的几点建议

欧盟2004/24/EC指令,于2004年4月30日生效,7年过渡期于2011年4月结束,而我国尚无一个中药品种在欧盟作为传统草药产品成功注册.欧盟药品审评管理局颁布的"传统草药产品进入欧盟草药产品专论程序"(EMEA/HMPC/182320/2005)对草药品种进入欧盟草药产品专论具有重要指导意义.本文对这份程序文件...     

Chemical variability along the value chains of turmeric (Curcuma longa): A comparison of nuclear magnetic resonance spectroscopy and high performance thin layer chromatography

Ethnopharmacological relevance

Herbal medicine value chains have generally been overlooked compared with food commodities. Not surprisingly, revenue generation tends to be weighted towards the end of the chain and consequently the farmers and producers are the lowest paid beneficiaries. Value chains have an impact both on the livelihood of producers and on the composition and quality of products commonly sold locally and globally and consequently on the consumers. In order to understand the impact of value chains on the composition of products, we studied the production conditions for turmeric (Curcuma longa) and the metabolomic composition of products derived from it. We aimed at integrating these two components in order to gain a better understanding of the effect of different value chains on the livelihoods of some producers.

Materials and methods

This interdisciplinary project uses a mixed methods approach. Case studies were undertaken on two separate sites in India. Data was initially gathered on herbal medicine value chains by means of semi-structured interviews and non-participant observations. Samples were collected from locations in India, Europe and the USA and analysed using ¹H NMR spectroscopy coupled with multivariate analysis software and with high performance thin layer chromatography (HPTLC).

Results

We investigate medicinal plant value chains and interpret the impact different value chains have on some aspects of the livelihoods of producers in India and, for the first time, analytically assess the chemical variability and quality implications that different value chains may have on the products available to end users in Europe. There are benefits to farmers that belonged to an integrated chain and the resulting products were subject to a higher standard of processing and storage.By using analytical methods, including HPTLC and ¹H NMR spectroscopy, it has been possible to correlate some variations in product composition for selected producers and identify strengths and weaknesses of some types of value chains. The two analytical techniques provide different and complementary data and together they can be used to effectively differentiate between a wide variety of crude drug powders and herbal medicinal products.

Conclusions

This project demonstrates that there is a need to study the links between producers and consumers of commodities produced in so-called ‘provider countries’ and that metabolomics offer a novel way of assessing the chemical variability along a value chain. This also has implications for understanding the impact this has on the livelihood of those along the value chain.     

Compatibility art of traditional Chinese medicine: From the perspective of herb pairs

Ethnopharmacological relevance

Over the past decades, research of traditional Chinese medicine (TCM) mainly focused on developing potential candidates from Chinese medicinal herbs, while the wisdom of applying these traditional herbs has not been paid as much attention as it deserves. As is well-known, multi-herb therapy is one of the most important characteristics of TCM, but the modernization drive of this conventional wisdom has faced many obstacles due to its unimaginable complexity. Herb pairs, the most fundamental and the simplest form of multi-herb formulae, are a centralized representative of Chinese herbal compatibility. In light of their simplicity and the basic characteristics of complex formulae, herb pairs are of great importance in the studies of herb compatibility.

Materials and methods

A systematic search of herb pair related research was carried out using multiple online literature databases, books and monographs published in the past 20 years.

Results

A comprehensive introduction to the compatibility of TCM, the position of herb pairs in TCM and the progresses of several famous herb pairs were provided in this review. Furthermore, the clinical study and the future research trends of herb pairs were also discussed.

Conclusions

Herb pairs have played, and may continue to play a key role in full investigation of general herb compatibility for their indispensable position in TCM. Much more research is needed for the standardization, safety evaluation, and mechanism exploration of herb pairs.