Efficacy and Safety of the Juan Bi Pill Combined with Methotrexate for Treating Active Rheumatoid Arthritis

doi:10.21203/rs.3.rs-1980301/v1

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Efficacy and Safety of the Juan Bi Pill Combined with Methotrexate for Treating Active Rheumatoid Arthritis

https://doi.org/10.21203/rs.3.rs-1980301/v1

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Objective: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by swelling and pain in the joints, which eventually lead to joint destruction. The Juan Bi pill is a Chinese medicine that has been widely used to treat RA in China for hundreds of years. This study demonstrated the effect of the Juan Bi pill on the management of active RA.

Methods: Participants received a dose (4 g, twice a day p.o.) of the Juan Bi pill or placebo (tid p.o.) for 12 weeks. Participants were required to take the Juan Bi pill for 3 months with follow-up visits at 6 and 12 months, attending seven assessment visits. Participants will undergo disease activity and safety assessments seven times (at baseline and at 1, 2, 3, 6, and 12 months). The primary endpoint was the 28-joint Disease Activity Score (DAS28-ESR and DAS28-CRP). The secondary endpoints included blood sampling for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), Health Assessment Questionnaire Disability Index, clinical disease activity index (CDAI), visual analog scale, Short Form-36 score, and morning stiffness.

Results: Altogether, 213 participants were screened, and 115 participants were randomized into two groups (Juan Bi pill group, n = 57; placebo group, n = 58); four dropped out. After 12 weeks of treatment, the DAS28-ESR and DAS28-CRP scores of the two groups were significantly reduced. The Juan Bi pill group had significantly reduced DAS28-ESR and DAS28-CRP scores and a significantly higher standard rate of the European League Against Rheumatism score than the placebo group (P < 0.05). After treatment, the number of tenderness/swelling joints, CDAI score, and serum ESR and CRP levels in the two groups demonstrated a decreasing trend, which were all reduced compared with those before treatment. In the electrocardiogram, routine blood tests, liver and kidney functions, and other indices before and after treatment, the adverse reaction rate of the two groups did not increase.

Conclusions: The Juan Bi pill combined with methotrexate can effectively reduce disease activity in participants with RA in the active stage, reduce the symptoms of arthritis, and improve the quality of life, while ensuring safety, reliability, and fewer adverse effects.

Trial registration: ClinicalTrials.gov, NCT02885597. Registered on 30 August 2016.

Traditional Chinese medicine

Juan Bi pill

methotrexate

active rheumatoid arthritis

randomized controlled trial

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by pain, swelling, synovial inflammation, joint damage, and bone destruction, which results in severe disability and increased mortality rate.^1,2 The worldwide prevalence of RA is estimated to be 0.5–1%, with a mean annual incidence of 0.05%.^3,4

The disability rates of patients with RA in China for 1–5 years, 5–10 years, 10–15 years, and > 15 years were 18.6%, 43.5%, 48.1%, and 61.3%, respectively.⁵ Moreover, Chinese patients have higher disease activity indicated by erythrocyte sedimentation rate and C-reactive protein, more rheumatoid factors, less satisfaction in both dominant and non-dominant hand appearances, and greater dominant hand deformity.⁶ The number of therapeutic resources available for the treatment of RA has increased tremendously over the past 30 years.⁷ The currently available drugs include non-steroidal anti-inflammatory drugs, glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs) of synthetic (conventional DMARDs or targeted DMARDs) or biological origin (biological DMARDs).⁸ Nevertheless, the therapeutic methods for RA remain limited.⁹ Resistance or inadequate response to RA is a more difficult problem encountered in clinical treatment, which is the consensus of the rheumatology community.¹⁰ Therefore, the situation of patients not adapting to drugs, more evident side effects of drugs, or failure of drug treatment need to be considered.¹¹ Identifying new drug combinations to treat RA and reduce drug consumption, adverse effects, and drug resistance is an urgent problem.

In traditional Chinese medicine (TCM), RA is known as Bi syndrome, and the Juan Bi (which indicates eliminating the Bi syndrome in Chinese) decoction from “Yi Xue Xin Wu” of the Qing Dynasty was specially designed to treat Bi syndrome.¹² The Juan Bi pill is composed of Radix Angelica pubescens, Notopterygium incisum, Cinnamomum cassia, Gentiana macrophylla Pall, Angelica sinensis Diels, Ligusticum chuanxiong Hort, Glycyrrhiza uralensis Fisch, Caulis Piperis Kadsurae, Morus alba L, Olibanum, and Radix Aucklandiae. In China, we used the Juan Bi pill combined with DMARDs to treat RA, which can often achieve better results in pain relief and swelling.^13–15 Our previous data revealed that the Juan Bi pill clearly attenuated inflammation of the ankle joints in an arthritis mouse model by suppressing synovitis and cartilage and bone damage. Pathology demonstrated that the Juan Bi pill not only inhibited inflammatory synovium volume, but also protected cartilage integrity on the joint surface. Micro-computed tomography data revealed that the Juan Bi pill attenuated bone erosion around the joint and inhibited osteoclast differentiation, as demonstrated by tartrate-resistant acid phosphatase (TRAP) staining.¹⁶ However, the efficacy of the Juan Bi pill needs to be confirmed in clinical trials.

Therefore, we conducted this randomized, double-blind, placebo-controlled trial to estimate the effectiveness and safety of the Juan Bi pill for RA.

2.1 Trial design

This study was a multicenter, randomized, double-blind, placebo-controlled clinical trial with two parallel arms. The clinical trial was conducted for 12 months, and the participants were required to take the Juan Bi pill for 3 months with follow-up visits at 6 and 12 months, attending seven assessment visits in total. Participants underwent disease activity assessment seven times (at baseline and 2 weeks, and at 1, 2, 3, 6, and 12 months) and six safety assessments (at baseline, and at 1, 2, 3, 6, and 12 months). Longhua Hospital, which is affiliated with the Shanghai University of Traditional Chinese Medicine, was responsible for quality control. The trial was approved by the ethics committee of Longhua Hospital of Shanghai University of Traditional Chinese Medicine (No. 2016LCSY033). Written informed consent was obtained from each participant prior to enrollment. The trial was registered in the Clinical Trial Registry (registration number: NCT02885597; date of registration: August 30, 2016). The study adhered to the Consolidated Standards of Reporting Trials (CONSORT) Checklist.¹⁷

2.2 Participants

This study was conducted in four centers: Longhua Hospital affiliated with Shanghai University of Traditional Chinese Medicine, Seventh People’s Hospital of Shanghai, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, and Rizhao Hospital of Traditional Chinese Medicine affiliated with Shandong University of Traditional Chinese Medicine. A total of 115 participants were enrolled, all of whom were participants with active RA admitted to the four centers between February 2017 and May 2018. All the participants provided written informed consent.

The inclusion criteria were as follows: adults (aged ≥ 18 years) with RA; satisfy the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for RA, 2010; onset of symptoms within 12 months before enrollment; active disease at the time of enrollment, as indicated by a 28-joint Disease Activity Score (DAS28) > 3.2, and no prior exposure to oral glucocorticoids at a daily dose > 10 mg or to any biological agent; and paid or unpaid employment but measurable work (e.g., caring for a family and home).

Meanwhile, the exclusion criteria were as follows: RA combined with other autoimmune disease, such as adjuvant arthritis, lupus arthritis, or osteoarthritis; RA combined with abnormal liver and kidney functions; women who were pregnant, planning pregnancy, or breast-feeding; severe chronic or acute disease interfering with attendance for therapy; alcohol or substance abuse; and unable to understand or sign an informed consent form.

All patients were randomized into the Juan Bi or placebo groups. Patients in the Juan Bi group received both the Juan Bi pill (4 g/bag, two bags per day) and methotrexate (MTX) (5 mg per week) for 3 months, whereas patients in the other group received a Juan Bi pill placebo (4 g/bag, two bags per day) and the same dose of MTX as the Juan Bi group.

2.3 Preparation of the Juan Bi pill

Herbs in the Juan Bi pill were authenticated by a pharmacognosist of Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine, in accordance with standard protocols. In line with the standard methods of the Chinese Pharmacopoeia, the Juan Bi pill and placebo were dissolved in 200 mL of hot water and taken orally twice a day for 3 months. The Juan Bi pill was manufactured, packaged, and labelled by Jiangyin Tianjiang Pharmaceutical Co., Ltd. The crude herbs, including Rhizoma Et Radix Notopterygii (Qiang Huo) 18 kg, Radix Angelicae Pubescentis (Du Huo) 18 kg, Radix Gentianae Macrophyllae (Qin Jiao) 18 kg, Caulis Piperis Kadsurae (Hai Feng Teng) 36 kg, Ramulus Mori (Sang Zhi) 54 kg, Radix Angelicae Sinensis (Dang Gui) 54 kg, Rhizoma Chuanxiong (Chuan Xiong) 12.6 kg, Olibanum (Ru Xiang) 25.2 kg, Radix Aucklandiae (Mu Xiang) 25.2 kg, Radix Glycyrrhizae (Gan Cao) 9 kg, and Ramulus Cinnamomi (Gui Zhi) 9 kg, were supplied in one batch from Haozhou Hongyu Chinese Herbal Medicine Co., Ltd. or Anhui Huizhongzhou Chinese Herbal Medicine Co., Ltd. All herbs were stored in specialized, cool, and dry places. The Juan Bi pill was prepared as follows: (1) extraction: all herbs listed were placed in a ceramic container, and 1000 L of distilled water was added to macerate the herbs for 1 h. Then, the mixture was boiled at 100°C for 1 h for the first extraction and repeated twice to obtain three extractions in total. The third extraction contained only 500 L of distilled water and had only a 30-min boiling time. (2) Concentration: the three extractions were mixed, and the mixture was concentrated at 60°C (660 mmHg). The mixture was sprayed dry to produce an extract powder, which was crushed and screened using a mesh size of 80. The pills were packed at 4 g per bag and stored in a clean room at approximately 20°C and 50% humidity. The Juan Bi pill placebo contained 10% Juan Bi pill and 90% bitterant, lactose edible essence, pigment (e.g., lemon yellow, caramel pigment, or sunset yellow), and starch, and had a shape, smell, color, and taste similar to the actual Juan Bi pill. In our previous research, 44 main active chemical components derived from 11 components of the Juan Bi pill were collected by high performance liquid chromatography (HPLC) mass spectrometry. Using accurate masses measured by HPLC–quadrupole time-of-flight (Q-TOF), a total of 44 detected peaks were identified. Among them, 24 compounds were definitively identified by comparison with standard compounds, while the remaining 20 compounds were tentatively characterized according to their formula, retention time, and fragmentation patterns.^16,18

2.4 Randomization and allocation

Randomization was conducted by a credible pharmaceutical manufacturer (Jiangyin Tianjiang Pharmaceutical Co., Ltd), which will provide both the Juan Bi pill and placebo. A random number list was generated using Excel (Office 2016, Microsoft Corporation) to randomize participants to either the Juan Bi pill group or the placebo group in a 1:1 ratio. When a participant was recruited, the investigator provided a number of pharmaceutical manufacturers, and the pharmaceutical manufacturer will randomly send the Juan Bi pill or placebo to the participant according to a random number list. The number provided and corresponding number list were recorded and stored in a locked cabinet at the pharmaceutical company.

2.5 Blinding

The pharmaceutical company staff did not participate in the trials, and the investigator, physicians, nurses, outcome measurement operator, statisticians, and the participants were blinded to the group information until the end of the trial when all the statistical analyses were completed.

2.6 Clinical efficacy assessments

Briefly, the primary outcomes were the 28-joint DAS using the erythrocyte sedimentation rate (DAS28-ESR) and 28-joint DAS using C-reactive protein (DAS28-CRP).^19,20 Source data, including medical records and case report forms (CRFs), were submitted to the event adjudication committee for verification. Secondary outcomes included the ACR criteria for 20% improvement (ACR20), ACR50 and ACR70 responses²¹, blood sampling for serum ESR and CRP, Health Assessment Questionnaire-Disability Index (HAQ-DI), clinical disease activity index (CDAI), visual analog scale (VAS), Short Form-36 (SF-36) score, and morning stiffness examination. Remission was defined as DAS28-ESR < 2.6, CDAI ≤ 2.8, or simplified disease activity index ≤ 3.3.

2.7 Safety

All participants underwent clinical laboratory tests, including electrocardiogram, blood, urine, stool, and liver and kidney functions, at baseline and 12 weeks to assess drug safety and liver and kidney toxicity. The incidence and severity of all-cause adverse events (AEs), treatment-emergent AEs, serious AEs (SAEs), discontinuations due to AEs, abnormal clinical laboratory findings, and vital signs were recorded at baseline and 12 weeks. Safety outcomes included all AEs reported, drug-related adverse events, SAEs, AEs leading to drug withdrawal, and abnormal laboratory test results with clinical significance. A Safety End Point Adjudication Committee comprising external independent consultants who were blinded to the treatment sequence assignment reviewed all the safety records. Safety data for up to 12 months are presented in the supplementary data.

2.8 Statistical analysis

Efficacy and safety analyses were performed according to the intention-to-treat principle. The method of the last observation carried forward was applied to the analysis of missing values. All statistical analyses were performed using Statistical Packages of Social Sciences software (version 21.0). Continuous variables, such as demographic and clinical outcome variables, are described as means and standard deviations, whereas categorical variables, such as rate, are presented as percentages. Continuous variables following the normal distribution were analyzed using Student’s t-test; otherwise, non-parametric tests were used to compare group differences. Statistical significance was set at P < 0.05.

2.9 Data collection and monitoring

This was a 12-month clinical trial in which participants were required to take the Juan Bi pill for 3 months with follow-up visits at 6 and 12 months, attending seven assessment visits in total. Participants underwent disease activity assessment seven times (at baseline and 2 weeks, and at 1, 2, 3, 6, and 12 months) and six safety assessments (at baseline, and at 1, 2, 3, 6, and 12 months). Longhua Hospital, affiliated with the Shanghai University of Traditional Chinese Medicine, is responsible for quality control.

2.10 Quality control

All pills, including the Juan Bi pill and placebo, were provided by Jiangyin Tianjiang Pharmaceutical Co. Ltd. The pharmaceutical company randomized the participants and allocated them to the three centers. Before the clinical trial initiation, unified training was performed to ensure that the multicenter physicians, nurses, and outcome measurement operators involved in the trials fully understood the process of the entire trial. When the clinical trial started, we set investigators to supervise the three centers every month, ensuring that: (1) every center had recruited the planned number of participants; (2) all the recruited participants fully met the inclusion criteria and did not meet the exclusion criteria; and (3) all the participants had fully followed the clinical trial process, and the CRF was filled in as required in the recruitment and follow-up. Meanwhile, we called every participant to verify the CRF, and data were recorded in an electronic CRF monthly during the course of the clinical trial.

3.1 Study participants and baseline characteristics

In total, 115 participants with an average age of 56.4 years (SD, 11.6 years) were randomized and received treatment from February 2017 to May 2018 (Table 1). No significant differences in reducing the scale of RA in terms of sex, weight, BMI, duration, DAS-ESR, DAS-CRP, CDAI score, tenderness, number of swollen joints, SF-36 score, MOS score, ESR, CRP, RF positivity rate, anti-CCP positivity rate, MTX dosage, and MTX uptake, were observed between the Juan Bi Pill and placebo groups. A total of 57 and 58 participants were assigned to the Juan Bi Pill and placebo groups, respectively.

JBP, Juan Bi pill; BMI, body mass index; MTX, Methotrexate; DAS28-ESR, 28-joint Disease Activity Score-erythrocyte sedimentation rate; DAS28-CRP, 28-joint Disease Activity Score-C-reactive protein; CDAI, clinical disease activity index; MOS, ; ESR, erythrocyte sedimentation rate; CRP; C-reactive protein; CRF, case report form; anti-CCP, anti-cyclic citrullinated peptide.

3.2 Treatment adherence

Almost every participant (n = 55 [96.4%] in the Juan Bi pill group and n = 56 [96.5%] in the placebo group) had good compliance throughout the trial and had no major protocol violations. Two (3.6%) participants in the Juan Bi pill group and two participants (3.5%) in the placebo group were lost to follow-up before study completion. Nevertheless, all the participants who were lost to follow-up were included in the final analysis, with data censored at the last follow-up visit (Fig. 1).

3.3 Efficacy of Juan Bi pill therapy for the outcomes

The DAS28-ESR and DAS28-CRP scores of the two groups of participants with RA were used to evaluate changes in disease activity. The DAS28-ESR and DAS28-CRP scores in both groups demonstrated a downward trend after treatment (Table 2). After 12 weeks of treatment, the DAS28-ESR and DAS28-CRP scores of the two groups were significantly lower than those before treatment, and the group difference was significant (P<0.05) (Fig. 2A, B). After 12 weeks of treatment, the difference in the reduction of DAS28-ESR and DAS28-CRP in the Juan Bi pill group was significantly greater than that in the placebo group (Fig. 2C, D). After 4 and 12 weeks of treatment, the participants’ disease activity grade was evaluated, and the ratio of DAS28-ESR and DAS28-CRP meeting the clinical remission standard and low disease activity standard were compared between the two groups (Fig. 2E, F). The curative effect was significantly better than that in the placebo group (P<0.05).

We also used the EULAR criteria to evaluate the efficacy of the Juan Bi pill. Throughout the clinical trial, the treatment response rate of the Juan Bi pill group was significantly better than that of the placebo group both at 12 and 48 weeks after treatment (Fig. 3 and Table 3).

For the aspect of participants' disease activity, we used the HAQ-DI and CDAI scores to evaluate the efficacy of the Juan Bi pill. The HAQ-DI and CDAI scores of both groups demonstrated a downward trend after treatment. Within 12 weeks of drug treatment, the HAQ-DI and CDAI scores of both groups were significantly lower than those before treatment (Table 4). At 24- and 48-weeks post treatment, the HAQ-DI and CDAI scores of the Juan Bi pill group were stable, and the placebo group demonstrated significantly milder recovery than that before treatment (Fig. 4A, C). To further clarify whether the Juan Bi pill group had better results than the placebo group, the differences in HAQ-DI and CDAI score reduction between the two groups of participants were compared. During the treatment, the HAQ-DI and CDAI score reduction value of the Juan Bi pill group was significantly better than that of the placebo group. At 24 and 48 weeks, the curative effect of the Juan Bi pill group was still significantly better than that of the placebo group (Fig. 4B, D).

Juan Bi pills decreased pain VAS and global VAS changes in patients with RA and physicians. Compared to placebo, the Juan Bi pill demonstrated better pain reduction from subjective feelings of patients and doctors in the treatment and follow-up periods (Fig. 5).

We also recorded morning stiffness time and MOS sleep scale of participants in the two groups at 4, 8, and 12 weeks, and follow up at 24 and 48 weeks was conducted to evaluate the efficacy of the Juan Bi pill compared with the placebo. Compared to the baseline values before treatment, the morning stiffness time was significantly reduced in both groups (Table 5). The duration significantly decreased more in the Juan Bi pill group, and even at follow-up time points of 24 and 48 weeks, and the difference between the reduction in morning stiffness time before and after treatment was significant (Fig. 6A, B). The MOS sleep scale results revealed that sleep quality improved gradually and significantly in the Juan Bi pill group from 4 weeks to 12 weeks and was maintained for 48 weeks (Fig. 6C, D and Table 6).

Regarding the efficacy of the Juan Bi pill for improving quality of life, the total SF-36 score and physical and mental health scores of the participants in the Juan Bi pill group were significantly higher at baseline than those before treatment (Table 7). Although no significant changes in the SF-36 total score and physical and mental scores were noted in the placebo group, no significant differences were observed before and after treatment (Fig. 7A, C, E). According to the SF-36 total score and physical and mental score results, the Juan Bi pill had better efficacy than the placebo (Fig. 7B, D, F).

3.4 Effect of Juan Bi pill therapy on serum ESR and CRP levels

At baseline, the serum ESR levels of the Juan Bi pill and placebo groups were 35.24 (SD, 26.68) and 29.7 (SD, 20.5), respectively; the serum CRP levels of the Juan Bi pill and placebo groups were 18.85 (SD, 32.08) and 9.63 (SD, 17.09), respectively. After 4 weeks of treatment, the reduction in ESR was −6.84±16.15 (p=0.12); after 12 weeks of treatment, the reduction in ESR is −10.51±25.03 (p=0.04). After 4 weeks of treatment, the reduction value of CRP is −5.82±23.60 (p=0.35); after 12 of weeks treatment, the reduction value of ESR is −11.61±28.45 (p=0.03). The hematology test revealed that the serum ESR and CRP levels of the participants in the two groups were significantly reduced than those at baseline, and the Juan Bi pill had a significantly better effect in reducing the serum ESR and CRP levels than the placebo (Fig. 8).

3.5 Tender joint count and swollen joint count at baseline and during the treatment period

By observing the changes in the number of tenderness and swelling of 28 joints in the two groups of participants, the number of tender and swollen joints in both groups demonstrated a gradual decrease with the progress of treatment time (Tables 8 and 9). Compared with the baseline before treatment, the number of tender and swollen joints in the two groups was significantly reduced before and after treatment (Fig. 9A, B). Regarding the therapeutic effect of the Juan Bi pill, the tenderness and swelling of the joints was significantly different before and after treatment between both groups (Fig. 9C, D).

3.6 Efficacy of Juan Bi pill therapy for the TCM syndromes scale

Regarding the efficacy of the Juan Bi pill according to the total score of six primary TCM syndromes and five secondary TCM syndromes, the total score of syndromes demonstrated a downward trend, and the scores were significantly reduced at 4, 8, and 12 weeks and 24 and 48 weeks of follow-up compared with the pre-treatment baseline (Table 10). No significant improvement in TCM syndromes in the placebo group was observed before or after treatment (Fig. 10A, B).

3.7 Safety and adverse events

Participants underwent laboratory tests, including white blood cell count, red blood cell count, hemoglobin, alanine aminotransferase, aspartate aminotransferase, bilirubin, creatinine, urea nitrogen, urine, and routine fecal tests, at baseline and 12 weeks after treatment. The changes in all indicators were within the normal reference values, with no significant differences between the two groups before and after treatment (data not shown). After 12 weeks of drug treatment, one participant in the Juan Bi pill group developed gastrointestinal discomfort. The participant was administered symptomatic treatment, such as folic acid and a gastric mucosal protective agent. After 4 days, the gastrointestinal discomfort resolved, and the patient continued to attend the trial. One participant in the placebo group had an oral ulcer. The participant was prescribed folic acid tablets and advised to maintain oral cleanliness. After 1 week, the symptoms improved, and the patient continued to attend the trial. Transaminases increased in four participants in the placebo group and in two cases in the Juan Bi pill group. This finding may be related to MTX use. Since the increase in ALT in the participants was within 3 times the safe range, the participants were recommended to reduce the amount of MTX taken or to take liver-protective drugs. A follow-up review revealed that the transaminase level became normal. No significant difference in adverse reaction rates was observed between the two groups.

The Juan Bi pill was originally reported to treat arthritis in the book “Medical Reflections” and has been used clinically for hundreds of years in China. However, sufficient evidence to prove its effectiveness and to determine whether there are related side effects remains insufficient. This 12-month randomized controlled trial (RCT) investigated the short- and long-term efficacy and safety of the Juan Bi pill combined with MTX in participants with active RA. We found that the Juan Bi pill combined with MTX could improve the primary and secondary outcome measures, including DAS28-ESR and DAS28-CRP scores, HAQ-DI, CDAI, VAS, SF-36 score, and morning stiffness examination with few side effects detected. No symptom-type analyses were performed in this survey. According to a survey, the RA cases in the Huangpu District, Jing'an District, Pudong New Area and other places in Shanghai were mostly cold wind dampness-arthralgia type, and of the patients, 52.46% were > 70 years old, with a male:female ratio of approximately 1:3.

MTX is an immunosuppressive drug used to delay the rate at which the body's immune system produces new cells.²² Low-dose MTX has been used as the basic treatment for RA as a conventional synthetic disease-modifying antirheumatic drug (csDMARD) since the 1980s.²³ Therefore, the reason for the poor efficacy of MTX alone in the placebo group may be the participants' insufficient response to mono-csDMARD therapy. Based on the characteristics of MTX in terms of poor tolerance (nausea and fatigue) and side effects (liver fibrosis and lung lesions) for long-term treatment,^24,25 in the past 20 years, clinical studies have reported that physicians use the combination therapy of csDMARDs (such as leflunomide), biological original DMARDs (such as etanercept), or targeted synthetic DMARDs (such as baricitinib) rather than single MTX therapy to treat RA with improved clinical efficacy.^10,26−29 Combination therapy often achieves better efficacy than monotherapy. For example, after 1 year of administration to patients with RA without previous MTX treatment, the proportion of patients receiving MTX alone achieving ACR50 responses was 37%, that of patients receiving combination therapy of ADALIMUMAB and MTX was 62%,³⁰ that of patients receiving combination therapy of abatacept and MTX was 57.4%,³¹ that of patients receiving combination therapy of certolizumab pegol and MTX was 61.8%³², that of patients receiving combination therapy of etanercept and MTX was 71%³³, and that of patients receiving combination therapy of rituximab and MTX was 65%.³⁴ In our study, after 3 months of administration to patients with RA, the proportion of patients receiving MTX alone achieving ACR50 responses was 16.1%, which is not completely consistent with those of previous clinical studies, possibly because the sample size was relatively small, and the medication time was short. The proportion of patients receiving combination therapy of Juan Bi pill and MTX was 54.5%, which increased nearly to 40% proportions of ACR50 efficacy of MTX. Therefore, the Juan Bi pill plays an important role in this combination therapy as a complementary and alternative medicine.

The application of the Juan Bi pill can be traced back to 288 years. The Juan Bi pill was first reported to treat bone joint disease in the book of “Yi Xue Xin Wu” (published at 1732 AD).³⁵ In this book, Zhongling Cheng recorded the view that Bi is a pathogen of joint disease, which could be caused by environmental factors such as wind, cold, and dampness, and Juan Bi therapy could eliminate Bi from the joints of the body. In TCM theory, environmental factors may be parts of etiology, trigger immune reactions, and contribute to disease development,³⁶ and three environmental factors contributing to the origin of RA are defined as wind, cold, and dampness.³⁷ Swollen and tender joints are the main symptoms of patients with active RA, and we prescribed the Juan Bi pill for these patients in clinical practice according to TCM experience for good efficacy. The responses of the patients with active RA were good; they commonly return to ask the same recipe to extend the course of treatment for better efficacy and fewer side effects. The dosage of various drugs in the Juan Bi pill was within the scope of the safe medication guidelines of the Chinese Pharmacopoeia.

To the best of our knowledge, this is the first clinical study of the Juan Bi pill for treating RA, although several basic research papers on the mechanism of Juan Bi pill for treating RA had already been published. In terms of the mechanism of the Juan Bi pill for treating RA, we conducted a series of in vivo and in vitro experimental studies on the intervention of Juan Bi pill's prescription and its main ingredients in RA. The therapeutic mechanism of the Juan Bi pill in treating RA is multifaceted. The Juan Bi pill had a very good effect on protecting the RA joint structure and function. To confirm the accuracy of the experimental results, we used two typical RA animal models, collagen-induced arthritis and tumor necrosis factor-transgenic. Mice were orally administered Juan Bi pills (12 g/kg) once daily for 12 weeks. The results revealed that the Juan Bi pill clearly attenuated synovitis, cartilage damage, and bone damage in both RA animal models. The pathology demonstrated that the Juan Bi pill not only inhibited inflammatory synovium volume, but also protected cartilage integrity on the joint surface. Micro-computed tomography data indicated that the Juan Bi pill attenuated bone erosion around the joint and inhibited osteoclast differentiation, as demonstrated by TRAP staining.¹⁶

CRP plays an important role in the pathological process of RA, and it may have a direct role in osteoclast and osteoblast differentiation to promote bone destruction by affecting the TLR or NF-κB signaling pathway.^38,39 In this clinical study, the serum CRP level decreased significantly (− 12.04 ± 28.88 mg/L after 3 months of treatment) in the Juan Bi pill combination group compared to that of the MTX control group (− 2.09 ± 17.92 mg/L after 3 months of treatment). Therefore, the Juan Bi pill may decrease serum CRP levels to regulate osteoclast or osteoblast differentiation and protect the integrity of articular structure.

In the component analysis of the Juan Bi pill using HPLC–Q-TOF for detecting specific contents of Juan Bi pill, 44 components were identified in Juan Bi pill. By analyzing the 44 identified components with network pharmacology, 194 potential targets were predicted, which were the most relevant to the NF-kappa B signaling pathway. In the experimental study on the intervention of RA models using a single component, gentiopicroside reduced the inflammatory cytokine production of bone marrow macrophages stimulated by LPS/IFN-γ and ameliorated the phosphorylation of IKKα/β and p65, degradation of IκBα, and translocation of p65 into the nucleus.⁴⁰ Moreover, the ingredient Astragalin significantly decreased the severity of arthritis, reduced joint swelling, bone erosion, and destruction, suppressed the production of pro-inflammatory cytokines (TNF-α, interleukin [IL]-1β, IL-6, and IL-8), and inhibited the expression of matrix metalloproteinases (MMP-1, MMP-3, and MMP-13) in chondrocytes and synovial cells of mice with collagen-induced arthritis. Furthermore, astragalin suppressed the phosphorylation of p38 and Jun N-terminal kinase and the activation of c-Jun/AP-1 in TNF-α-induced MH7A cells⁴¹.

In the study of the accumulation and clearance of inflammatory factors in the joint cavity, we conducted a series of studies on the correlation between the function of the para-articular lymphatic system and the pathologic development of RA and identified that promoting the draining function of the para-articular lymphatic system could help to clear inflammatory factors in the joint cavity and attenuate the progression of RA.^42–45 We also observed that its ingredient ferulic acid improves TNF-induced inflammatory erosive arthritis by promoting the normalization of draining lymphatic function, which is associated with restored lymphatic vessel contractions, lymphatic flow, and LSMC gene expression.⁴⁶ The Juan Bi pill could also decrease the TNF-α, IL-1, and IL-6 contents of the joint fluid in the knee osteoarthritis model of rabbit.^47,48 With the support of basic experiments, the Juan Bi pill has been confirmed to protect the joints and attenuate the RA pathologic process.

The DAS28 is a system developed and validated by the EULAR to measure the progress and improvement of RA, which is often used in clinical trials to evaluate the development of RA.^19,49 This clinical trial used the DAS28 as the primary outcome measure. The participants in both groups were moderately active.^47–48 The results revealed moderate improvement in the Juan Bi pill group and no evident improvement in the placebo group at 4 weeks and good improvement in the Juan Bi pill group and moderate improvement in the placebo group at 12 weeks. The ACR20 and − 50 scale results were consistent with the DAS28 scale results. Laboratory tests of serum ESR and CRP levels at the corresponding times confirmed the results of the scale. For the serum ESR and CRP levels of the Juan Bi pill group, a sharp decline from the baseline to 1 month was observed, after which the decline eased, although the downward trend continued from 4 weeks to 12 weeks. The serum ESR and CRP levels of the placebo group slowly declined from the baseline to 4 weeks, then remained stable, and did not decrease or recover slightly from 4 weeks to 12 weeks. The SF-36 score as well as the mental and health scores revealed that the combination therapy of the Juan Bi pill and MTX significantly improved the participants’ quality of life compared with that at baseline, which suggested a comprehensive overall effect of the Juan Bi pill on RA treatment.

Several potential concerns and limitations of this study are worth mentioning. According to the TCM theory, patients with RA should be treated dialectically. In this study, to study the universal effect of JBT, we did not treat patients with RA dialectically. In the follow-up, if we only included patients with wind–cold–dampness arthralgia syndrome for random grouping treatment, we may have achieved a better curative effect. Second, the sample size of our clinical trials was small, and the intervention and follow-up times were short. For future research, we need to expand the sample size and extend the intervention and observation times. Third, much effort has been exerted on the evaluation of joint function in patients with active RA, including DAS28, HAQ-DI, CDAI, VAS, SF-36 score scales, and morning stiffness examination; however, no imaging evidence exists, and we can still combine magnetic resonance imaging, X-ray, ultrasound, and other imaging techniques with our continued in-depth research in the future. Resistance or inadequate response to RA is a more difficult problem encountered in clinical treatment, which is the consensus of the rheumatology community.¹⁰ According to the method of “treatment based on syndrome differentiation” from TCM, TCM doctors can screen patients with wind–cold–dampness arthralgia in future clinical treatments and provide various TCM groups and special indicators for wind–cold–dampness RA. We can look forward to the synergistic effect of TCM and the current first-line medications for the clinical treatment of RA, which can reduce drug consumption, side effects, and drug resistance.

This 48-week RCT in patients with active RA who received the Juan Bi pill twice daily plus MTX demonstrated that the synergistic effect had good maintenance of efficacy in these patients, including decreased serum ESR and CRP levels, pain relief, swelling dispersion, and improvement in quality of life over 12 months. No new safety signals emerged compared with the initial 12-month report or previous clinical RCTs.

Ethics approval and consent to participate

The trial was approved by the ethical committee of Longhua Hospital of Shanghai University of Traditional Chinese Medicine (No. 2016LCSY033).

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

This work was sponsored by research grants from National Natural Science Foundation (81822050, 81920108032 to LQQ, and 81873321 to XH), Shanghai "science and technology innovation action plan" medical innovation research project (21Y11921400 to LQQ), State Administration of Traditional Chinese Medicine Young Qi Huang Scholar to LQQ, Leading medical talents in Shanghai (2019LJ02 to LQQ), Dawn plan of Shanghai Municipal Education Commission (19SG39 to LQQ), the program for innovative research team of ministry of science and technology of China (2015RA4002 to WYJ), “Innovation Team” development projects (IRT1270 to WYJ).

Authors' contributions

QL, QS, and YW conceptualized and planned the clinical trial. HX, QJ and YW performed most of the clinical trial and completed the original draft. YW and QJ analyzed the data. All authors were involved in revising it critically for important intellectual content, and all authors approved the final version to be published.

Acknowledgements

The authors would like to thank the participants who were involved in this study, the ORAL Scan investigators, and the study team.

Choy EH, Panayi GS. Cytokine pathways and joint inflammation in rheumatoid arthritis. N Engl J Med. 2001;344(12):907-16.
Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. Lancet. 2016;388(10055):2023-38.
van der Woude D, van der Helm-van Mil AHM. Update on the epidemiology, risk factors, and disease outcomes of rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2018;32(2):174-87.
Gabriel SE, Crowson CS, O'Fallon WM. The epidemiology of rheumatoid arthritis in Rochester, Minnesota, 1955-1985. Arthritis Rheum. 1999;42(3):415-20.
Yunshan Zhou XW YA, et al. A multicenter study of deformity and disability in rheumatoid arthritis patients in China. . Chinese Journal of Rheumatology. 2013:6.
Su B, Ma Q, Edwards CJ, Williams M, Adams J. Characteristics of hand involvement in a comparative study of two early RA cohorts from the UK and China. Int J Rheum Dis. 2017;20(10):1426-36.
Burmester GR, Bijlsma JWJ, Cutolo M, McInnes IB. Managing rheumatic and musculoskeletal diseases - past, present and future. Nat Rev Rheumatol. 2017;13(7):443-8.
Chatzidionysiou K, Emamikia S, Nam J, Ramiro S, Smolen J, van der Heijde D, et al. Efficacy of glucocorticoids, conventional and targeted synthetic disease-modifying antirheumatic drugs: a systematic literature review informing the 2016 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis. 2017;76(6):1102-7.
Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017;76(6):960-77.
Moltó A, Dougados M. Novel DMARD monotherapy in rheumatoid arthritis. Lancet. 2019;393(10188):2277-8.
Rubbert-Roth A, Szabó MZ, Kedves M, Nagy G, Atzeni F, Sarzi-Puttini P. Failure of anti-TNF treatment in patients with rheumatoid arthritis: The pros and cons of the early use of alternative biological agents. Autoimmun Rev. 2019;18(12):102398.
Zhang GG, Lee W, Bausell B, Lao L, Handwerger B, Berman B. Variability in the traditional Chinese medicine (TCM) diagnoses and herbal prescriptions provided by three TCM practitioners for 40 patients with rheumatoid arthritis. J Altern Complement Med. 2005;11(3):415-21.
Chen L, Michalsen A. Management of chronic pain using complementary and integrative medicine. Bmj. 2017;357:j1284.
The Chinese herbal remedy Tripterygium wilfordii Hook F in the treatment of rheumatoid arthritis. Ann Intern Med. 2009;151(4):I-36.
Li EK, Tam LS, Wong CK, Li WC, Lam CW, Wachtel-Galor S, et al. Safety and efficacy of Ganoderma lucidum (lingzhi) and San Miao San supplementation in patients with rheumatoid arthritis: a double-blind, randomized, placebo-controlled pilot trial. Arthritis Rheum. 2007;57(7):1143-50.
Wang T, Jia Q, Chen T, Yin H, Tian X, Lin X, et al. Alleviation of Synovial Inflammation of Juanbi-Tang on Collagen-Induced Arthritis and TNF-Tg Mice Model. Front Pharmacol. 2020;11:45.
Schulz KF, Altman DG, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Trials. 2010;11:32.
Li J, Li L, Wang Y, Zhao Y, Hu P, Xu Z, et al. Systematic investigation on the anti-rheumatoid arthritis material basis and mechanism of Juan Bi Tang. Part 1: Integrating metabolic profiles and network pharmacology. J Pharm Biomed Anal. 2021;202:114133.
Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995;38(1):44-8.
Gardiner PV, Bell AL, Taggart AJ, Wright G, Kee F, Smyth A, et al. A potential pitfall in the use of the Disease Activity Score (DAS28) as the main response criterion in treatment guidelines for patients with rheumatoid arthritis. Ann Rheum Dis. 2005;64(3):506-7.
Felson DT, Anderson JJ, Boers M, Bombardier C, Furst D, Goldsmith C, et al. American College of Rheumatology. Preliminary definition of improvement in rheumatoid arthritis. Arthritis Rheum. 1995;38(6):727-35.
Thiersch JB. Bone-marrow changes in man after treatment with aminopterin, amethopterin, and aminoanfol; with special reference to megaloblastosis and tumor remission. Cancer. 1949;2(5):877-83.
Boh LE, Schuna AA, Pitterle ME, Adams EM, Sundstrom WR. Low-dose weekly oral methotrexate therapy for inflammatory arthritis. Clin Pharm. 1986;5(6):503-8.
Hassan W. Methotrexate and liver toxicity: role of surveillance liver biopsy. Conflict between guidelines for rheumatologists and dermatologists. Ann Rheum Dis. 1996;55(5):273-5.
Barrera P, Laan RF, van Riel PL, Dekhuijzen PN, Boerbooms AM, van de Putte LB. Methotrexate-related pulmonary complications in rheumatoid arthritis. Ann Rheum Dis. 1994;53(7):434-9.
Taylor PC, Keystone EC, van der Heijde D, Weinblatt ME, Del Carmen Morales L, Reyes Gonzaga J, et al. Baricitinib versus Placebo or Adalimumab in Rheumatoid Arthritis. N Engl J Med. 2017;376(7):652-62.
Jani M, Chinoy H, Warren RB, Griffiths CE, Plant D, Morgan AW, et al. Clinical utility of random anti-tumour necrosis factor drug testing and measurement of anti-drug antibodies on long-term treatment response in rheumatoid arthritis. Lancet. 2015;385 Suppl 1:S48.
Silverman E, Mouy R, Spiegel L, Jung LK, Saurenmann RK, Lahdenne P, et al. Leflunomide or methotrexate for juvenile rheumatoid arthritis. N Engl J Med. 2005;352(16):1655-66.
Sanders S, Harisdangkul V. Leflunomide for the treatment of rheumatoid arthritis and autoimmunity. Am J Med Sci. 2002;323(4):190-3.
Breedveld FC, Weisman MH, Kavanaugh AF, Cohen SB, Pavelka K, van Vollenhoven R, et al. The PREMIER study: A multicenter, randomized, double-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment. Arthritis Rheum. 2006;54(1):26-37.
Westhovens R, Robles M, Ximenes AC, Nayiager S, Wollenhaupt J, Durez P, et al. Clinical efficacy and safety of abatacept in methotrexate-naive patients with early rheumatoid arthritis and poor prognostic factors. Ann Rheum Dis. 2009;68(12):1870-7.
Emery P, Bingham CO, 3rd, Burmester GR, Bykerk VP, Furst DE, Mariette X, et al. Certolizumab pegol in combination with dose-optimised methotrexate in DMARD-naïve patients with early, active rheumatoid arthritis with poor prognostic factors: 1-year results from C-EARLY, a randomised, double-blind, placebo-controlled phase III study. Ann Rheum Dis. 2017;76(1):96-104.
Emery P, Breedveld FC, Hall S, Durez P, Chang DJ, Robertson D, et al. Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active, early, moderate to severe rheumatoid arthritis (COMET): a randomised, double-blind, parallel treatment trial. Lancet. 2008;372(9636):375-82.
Tak PP, Rigby WF, Rubbert-Roth A, Peterfy CG, van Vollenhoven RF, Stohl W, et al. Inhibition of joint damage and improved clinical outcomes with rituximab plus methotrexate in early active rheumatoid arthritis: the IMAGE trial. Ann Rheum Dis. 2011;70(1):39-46.
Liang QQ, Shi Q, Wood RW, Xing LP, Wang YJ. Peri-articular lymphatic system and "Bi" theory of Chinese medicine in the pathogenesis and treatment of arthritis. Chin J Integr Med. 2015;21(9):648-55.
Zhang P, Li J, Han Y, Yu XW, Qin L. Traditional Chinese medicine in the treatment of rheumatoid arthritis: a general review. Rheumatol Int. 2010;30(6):713-8.
He W, Zhang J, Gu SZ. [Clinical observation on needle-sticking method for treatment of rheumatoid arthritis of wind-cold-damp retention type]. Zhongguo Zhen Jiu. 2006;26(5):331-4.
Jia ZK, Li HY, Liang YL, Potempa LA, Ji SR, Wu Y. Monomeric C-Reactive Protein Binds and Neutralizes Receptor Activator of NF-κB Ligand-Induced Osteoclast Differentiation. Front Immunol. 2018;9:234.
Cho IJ, Choi KH, Oh CH, Hwang YC, Jeong IK, Ahn KJ, et al. Effects of C-reactive protein on bone cells. Life Sci. 2016;145:1-8.
Wang Q, Zhou X, Yang L, Luo M, Han L, Lu Y, et al. Gentiopicroside (GENT) protects against sepsis induced by lipopolysaccharide (LPS) through the NF-κB signaling pathway. Ann Transl Med. 2019;7(23):731.
Jia Q, Wang T, Wang X, Xu H, Liu Y, Wang Y, et al. Astragalin Suppresses Inflammatory Responses and Bone Destruction in Mice With Collagen-Induced Arthritis and in Human Fibroblast-Like Synoviocytes. Front Pharmacol. 2019;10:94.
Bouta EM, Bell RD, Rahimi H, Xing L, Wood RW, Bingham CO, 3rd, et al. Targeting lymphatic function as a novel therapeutic intervention for rheumatoid arthritis. Nat Rev Rheumatol. 2018;14(2):94-106.
Zhou Q, Guo R, Wood R, Boyce BF, Liang Q, Wang YJ, et al. Vascular endothelial growth factor C attenuates joint damage in chronic inflammatory arthritis by accelerating local lymphatic drainage in mice. Arthritis Rheum. 2011;63(8):2318-28.
Zhou Q, Wood R, Schwarz EM, Wang YJ, Xing L. Near-infrared lymphatic imaging demonstrates the dynamics of lymph flow and lymphangiogenesis during the acute versus chronic phases of arthritis in mice. Arthritis Rheum. 2010;62(7):1881-9.
Guo R, Zhou Q, Proulx ST, Wood R, Ji RC, Ritchlin CT, et al. Inhibition of lymphangiogenesis and lymphatic drainage via vascular endothelial growth factor receptor 3 blockade increases the severity of inflammation in a mouse model of chronic inflammatory arthritis. Arthritis Rheum. 2009;60(9):2666-76.
Liang Q, Ju Y, Chen Y, Wang W, Li J, Zhang L, et al. Lymphatic endothelial cells efferent to inflamed joints produce iNOS and inhibit lymphatic vessel contraction and drainage in TNF-induced arthritis in mice. Arthritis Res Ther. 2016;18:62.
Yuan PW, Liu DY, Chu XD, Hao YQ, Zhu C, Qu Q. Effects of preventive administration of juanbi capsules on TNF-alpha, IL-1 and IL-6 contents of joint fluid in the rabbit with knee osteoarthritis. J Tradit Chin Med. 2010;30(4):254-8.
Wang K, Zhang D, Liu Y, Wang X, Zhao J, Sun T, et al. Traditional Chinese medicine formula Bi-Qi capsule alleviates rheumatoid arthritis-induced inflammation, synovial hyperplasia, and cartilage destruction in rats. Arthritis Res Ther. 2018;20(1):43.
van der Heijde DM, Jacobs JW. The original "DAS" and the "DAS28" are not interchangeable: comment on the articles by Prevoo et al. Arthritis Rheum. 1998;41(5):942-5.

Tables 1 to 10 are available in the Supplementary Files section

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Efficacy and Safety of the Juan Bi Pill Combined with Methotrexate for Treating Active Rheumatoid Arthritis

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Abstract

Figures

1. Background

2. Methods

2.1 Trial design

2.2 Participants

2.3 Preparation of the Juan Bi pill

2.4 Randomization and allocation

2.5 Blinding

2.6 Clinical efficacy assessments

2.7 Safety

2.8 Statistical analysis

2.9 Data collection and monitoring

2.10 Quality control

3. Results

3.1 Study participants and baseline characteristics

3.2 Treatment adherence

3.3 Efficacy of Juan Bi pill therapy for the outcomes

3.4 Effect of Juan Bi pill therapy on serum ESR and CRP levels

3.5 Tender joint count and swollen joint count at baseline and during the treatment period

3.6 Efficacy of Juan Bi pill therapy for the TCM syndromes scale

3.7 Safety and adverse events

4. Discussion

5 Conclusions

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

References

Tables

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Supplementary Files

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