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Study of pharmacodynamic interaction of Phyllanthus emblica extract with clopidogrel and ecosprin in patients with type II diabetes mellitus.

ABSTRACT

Background: Diabetes mellitus is associated with oxidative stress which impairs the platelet function. Phyllanthus emblica extract a rich source of vitamin C plays an important role in scavenging free radicals. The effect of vitamin C on platelet aggregation in healthy and coronary artery disease patients has been demonstrated. The present study attempts to study the pharmacodynamic interactions of P. emblica extract with clopidogrel and ecosprin.

Materials and methods: This was a randomized open label crossover study of 10 type II diabetic patients. The dosage schedules were either single dose of 500 mg P. emblica extract or 75 mg clopidogrel or 75 mg ecosprin or 500 mg P. emblica + 75 mg clopidogrel or 500 mg P. emblica + 75 mg ecosprin. After single dose study and washout period, patients received either 500 mg P. emblica extract twice daily or 75 mg clopidogrel or 75 mg ecosprin once daily or combinations for 10 days. Platelet aggregation was measured at baseline and at 4 h of treatment after single and multiple dose study along with recording of bleeding and clotting time.

Results: After single and multiple dose administration of the three treatments and with combinations there was statistically significant decrease of platelet aggregation compared to baseline. Further, the mean percent inhibition of platelet aggregation was significant, when compared between single and multiple doses of P. emblica. The bleeding and clotting time was prolonged with single and multiple dose administration of all treatments compared to baseline. All treatments were well tolerated.

Conclusion: P. emblica extract demonstrated significant antiplatelet activity with both single and multiple dose administration.

Keywords:

Phyllanthus emblica

Clopidogrel

Ecosprin

Platelet aggregation

Introduction

Cardiovascular disease is the leading cause of morbidity and mortality in patients with diabetes (King et al., 1998). There are multiple risk factors which contribute to enhanced atherosclerosis in diabetic patients, and one of the important risk factor is abnormal platelet function (Nesto, 2004). Platelet plays a central role in atherogenesis and thrombotic complications and thus blocking the platelet activation and aggregation through various drugs are pivotal in reducing ischemic events in diabetic patients (Colwell and Nesto, 2003; Angiolillo, 2007). There are three different classes of platelet-inhibiting drugs: cyclooxygenase-1 (COX-1) inhibitors (aspirin), ADP P2Y12 receptor antagonists (thienopyridines), and platelet glycoprotein (GP) IIb/IIIa inhibitors, which are mostly used for the prevention and treatment of atherothrombotic disorders (Angiolillo, 2007). As glycoprotein (GP) IIb/IIIa inhibitors are parenteral drugs, aspirin and clopidogrel represent the cornerstone of treatment for secondary prevention of ischemic events in patients, including diabetic patients presenting with atherosclerotic cardiovascular disease (Dominick, 2009). Despite the use of these drugs, ischemic events recur in considerable number of patients due to development of antiplatelet drug resistance. A weak response to clopidogrel is clinically relevant, since it is associated with increased risk of cardiovascular mortality and morbidity and it is common (around a third of patients), because the ratio between the recommended clopidogrel dose and the minimum dose required to obtain its maximum pharmacodynamic effect is around one, which means that the usual dose only partially inhibits P2Y12 receptors (Patrono et al., 2008).

In Unstable Angina to Prevent Recurrent Events (CURE) study, the dual antiplatelet (clopidogrel + aspirin) therapy reduced ischemic events, but was associated with a higher incidence of major bleeding (3.7 vs. 2.7%; p< 0.001). Further in this study, there were 2840 diabetic patients and the dual antiplatelet therapy provided beneficial effects. It was also seen that the event rate was much higher in the diabetic than in the nondiabetic subgroup despite more intense antiplatelet therapy with the adjunctive use of clopidogrel (Yusuf et al., 2001). The results from the above study thus reflect a need for more specific antiplatelet treatment regimens especially in diabetic subjects, which may include more potent agents or a combination with other antiplatelet drugs.

The use of herbal supplements has become increasingly popular in recent years. Approximately 80% of the population of developing countries relies on traditional medicines for their primary health care needs (Bhattacharjee, 1998). A large proportions of the world's population, is involved in recognition and development of the medicinal and economic benefits of these plants in both developing and industrialized nations. These medicinal plants contain several phytochemicals such as Vitamins (A, C, E and K), flavonoids, polyphenols, tannins, and minerals etc. These phytochemicals possess antioxidant activities, which can be used in the treatment of multiple ailments (Veena et al., 2011). Several other factors also contribute to the increased use of herbal products, namely easy accessibility, perception of herbs as safe alternate treatment, desire for self-medication and cost. With the increasing use of herbal drugs, there have been concerns regarding the safety of these natural products mainly in the potentiation of adverse interactions with conventional drugs. These interactions can go unnoticed until the patient experiences a serious life threatening event. It has been established from the previous published reports that as many as 31% of patients use herbal supplements concurrently with the prescribed conventional drugs. Most of the patients do not report the use of these products to their healthcare providers (Abebe, 2002).

Phyllanthus emblica (Emblica officinalis, Euphorbiaceae) commonly known as Indian gooseberry or "Amla", has been used as health food since ancient times in India and other Asian countries. The hypolipidemic, antioxidant and cardioprotective activities of P. emblica has been well established in both animal and clinical studies (Muhammad et al., 2011). P. emblica is a rich source of a vitamin C, which plays an important role in scavenging free radicals (Sanhita et al., 2013). But very less data is available regarding the effect of P. emblica on platelet function. Bordia and Verma (1985) have investigated the effect of oral administration of vitamin C on platelet adhesive index and platelet aggregate ratio in healthy and coronary artery disease patients and found a significant decrease in platelet adhesiveness and platelet aggregation. The antiplatelet action of P. emblica was not demonstrated in a robust clinical trial, and the risk of pharmacodynamic interaction if used with the common antiplatelet drugs like clopidogrel or ecosprin were not established. The safety of these drugs when used concomitantly is not proven especially on prolongation of bleeding time, and the risk of hemorrhage. P. emblica is normally consumed as a dietary ingredient in India.

Therefore, the present study was conducted to evaluate the pharmacodynamic interactions of P. emblica with clopidogrel and ecosprin after single and multiple dose administration in type II diabetes mellitus patients. The primary objective of the study was to detect any significant change in platelet aggregation from baseline on administration of single and multiple doses of P. emblica, clopidogrel and ecosprin alone and in combination. More than 20% change in platelet aggregation was considered to be a positive response (Mateen et al., 2011; Hall et al., 2011; Aruna and Naidu, 2006). Secondary objective was to detect any changes in bleeding, clotting time and adverse effects profile.

Materials and methods

The present study was conducted in the Department of Clinical Pharmacology and Therapeutics of Nizam's Institute of Medical Sciences, Hyderabad. The study was approved by the Institutional Ethics Committee and registered in Clinical Trial Registry of India (CTRI/2013/07/003810). All participants gave written informed consent before the start of any study related procedures.

Study design

It was a prospective study conducted in the Department of Clinical Pharmacology and Therapeutics. Study design was a randomized, open label, cross over study. A total of 12 diabetic subjects were enrolled into the study. They were all on stable dose of their antidiabetic medication for the past three months. To avoid factors known to affect antiplatelet activity, the following exclusion criteria were applied: severe uncontrolled hyperglycemia, uncontrolled hypertension, cardiac arrhythmia, congestive heart failure, and evidence of hepatic and renal impairment or any other serious chronic disease requiring active treatment. Subjects hypersensitive to the study drugs were also excluded.

After an overnight fast and 12 h after the last dose of antidiabetic medication, subjects were given one of the following dosage regimens orally, according to prior randomization schedule after light breakfast. The study was performed in two parts: Single dose (Part I) and multiple dose study (Part II). In the first part of study, the dosage schedule was single dose of either proprietary 500 mg P. emblica extract or 75 mg Clopidogrel or 75 mg Ecosprin or proprietary 500 mg P. emblica extract + 75 mg Clopidogrel or proprietary P. emblica extract+ 75 mg Ecosprin. One week washout period was allowed between each treatment after which they were crossed over to the other treatment. In the second part (multiple dose) of the study, patients received either proprietary 500 mg P. emblica extract twice daily or 75 mg Clopidogrel once daily or 75 mg Ecosprin once daily or combination of proprietary 500 mg P. emblica extract twice daily+ 75 mg clopidogrel once daily or proprietary 500 mg P. emblica extract twice daily+ 75 mg Ecosprin once daily for 10 days. A washout period of 2 weeks was allowed between each treatment after which they crossed over to other treatment. Blood samples for platelet aggregation were taken immediately before and 4 h after the drug treatment on day one and day 10. Similarly, vital parameters, bleeding time and clotting time were measured at baseline and after 4 h of drug administration on day one and day 10. Blood sample was collected for safety lab parameters at baseline and end of treatment.

Study medication

CAPROS[R] capsules were supplied by Natreon, Inc., New Brunswick, NJ, USA. CAPROS[R] is an aqueous extract of the edible fruits of Phyllanthus emblica (Amla), containing not less than 60% of low molecular weight hydrolysable tannins comprising Emblicanin-A, Emblicanin-B, Punigluconin and Pedunculagin as the bioactives. Clopidogrel bisulphate 75 mg (Trade name: Clotsafe[R]) and Asprin 75 mg (Trade name: Ecosprin[R]) (Aruna and Naidu, 2006) tablets were procured from a pharmacy.

Estimation of low molecular weight hydrolysable tannoids (LMwHTs) in P. emblica fruit extract (Capros[R])

P. emblica fruit extract, used in this study, was standardized to contain not less than 50% w/w of bioactives, low molecular weight hydrolyzable tannoids (LMwHTs) comprising Emblicanin A, Emblicanin B, Punigluconin and Pedunculagin, by HPLC using an external standard (isolated from Emblica officinalis fruit extract by column chromatography). Briefly, P. emblica extract (50 mg) was dissolved in distilled water (50 ml) and filtered through 0.2 [micro]m syringe filter. The filtered solution (20 [micro]l) was used for HPLC analysis using the following conditions: Waters HPLC system (equipped with 515 model pump, Waters[TM] 2996 Photodiode Array Detector and Empower Software) was used. Analysis was done in NovaPak RP C18 150 x 3.9mm 4 [micro]m (Waters; WAT 086344) column using 0.1 M Sodium acetate-acetic acid buffer (pH 3.9) as mobile phase at a flow rate of 0.6 ml/min and detection wavelength 280 nm. The percentage content of the LMwHTs was calculated using area of the LMwHTs peaks and the linear regression equation (7=16232663.583 X = 206832.391) of the external standard (Fig. 1).

Method for evaluating platelet function

Measurement of platelet aggregation was done by the following procedure using the dual channel platelet aggregometer instrument by turbidometric method.

About 9 ml of blood sample was collected in a 10 ml plastic test tube containing 1 ml of 3.8% Sodium citrate from the cubital vein of the subject at baseline and after treatment in all the groups. The test was performed within 1 h of sample collection.

The samples were centrifuged at 800 rpm for 15 min to obtain platelet rich plasma. And again the same sample was centrifuged at 2500 rpm for 10 min so as to get a platelet poor plasma sample. The aggregometer was switched about 30 min before the test to allow the heating block to warm up to 37[degrees]C. Then the test was performed in duplicate by taking 0.5 ml of platelet rich plasma using 5 [micro]l of (10 [micro]Mol) adenosine di phosphate in cuvettes containing stir bars. The speed of stir bars was adjusted at 1200 rpm so as to facilitate the aggregated platelet. The platelet poor plasma sample was kept as reference. The readings were recorded at baseline and after treatment with ADP. The percentage aggregation at baseline and the percentage inhibition of platelet aggregation on post treatment with all the three treatments was calculated.

Bleeding time

Bleeding time in seconds was recorded at baseline and after 4 h of single dose administration of 500 mg P. emblica extract, 75 mg Clopidogrel, 75 mg Ecosprin and combination. Similarly, after multiple dose administration of 500 mg P. emblica extract, Clopidogrel 75 mg, 75 mg Ecosprin and 500 mg P. emblica extract + Clopidogrel 75 mg, 500 mg P. emblica extract+ 75 mg Ecosprin for 10 days, bleeding time was recorded at baseline and after 4 h of treatment by Duke's method with a normal range between 60-180 s.

Clotting time

Clotting time in seconds was recorded at baseline and after 4h of single dose administration of 500 mg P. emblica extract, 75 mg Clopidogrel, 75 mg Ecosprin and combinations. Similarly, after multiple dose administration of 500 mg P. emblica extract, 75 mg Clopidogrel, 75 mg Ecosprin and combinations, clotting time was recorded at baseline and after 4h of treatment by Capillary Tube method with a normal range of 300-480 s.

Statistical analysis

Data are represented as mean [+ or -] standard deviation. ANOVA and Paired t-test evaluations were used for analysis. The level of significance was set at p < 0.05. Being a pilot study with cross-over design 12 patients were screened.

Results

In the present study, 12 diabetic patients were screened. One patient was excluded because of abnormal lab investigation and one patient relocated, hence unable to continue the study. A total of 10 patients completed the study. The demographic characteristics of study patients are given in Table 1.

Effect of single dose

On day 1, baseline parameters were evaluated and there was no significant difference in platelet aggregation between the treatment groups. As seen in Table 2, single dose administration of P. emblica, clopidogrel 75 mg, ecosprin 75 mg and combination therapy produced a significant decrease of platelet aggregation after 4h of treatment, compared to baseline. There was significance observed with single dose of clopidogrel and ecosprin versus 500 mg P. emblica. Fig. 2 shows the mean percent inhibition of platelet aggregation with single dose administration of all the treatments. P. emblica 500 mg produced 23.95%, clopidogrel 47.73% and ecosprin 44.11 % inhibition of platelet aggregation. The percentage inhibition with the combinations groups, P. emblica + clopidogrel and P. emblica + ecosprin were 49.78% and 49.25%, respectively. There was no significance observed when compared between clopidogrel and ecosprin alone and also with the two combination groups. In the present study, when compared to baseline though there was a statistically significant change in bleeding and clotting time the results were within the normal reference range (Table 3).

Effect of multiple dose

The results of multiple dose administration are shown in Table 4. Ten days treatment produced significant decrease of platelet aggregation compared to baseline with clopidogrel, P. emblica 500 mg, ecosprin, P. emblica + clopidogrel and P. emblica + ecosprin, respectively. There was significant difference observed when P. emblica 500 mg was compared to clopidogrel and ecosprin alone, with P. emblica + clopidogrel and P. emblica + ecosprin. However, there was no significant change when clopidogrel and ecosprin alone was compared to combination treatment (P. emblica + clopidogrel and P. emblica + ecosprin) and between clopidogrel vs. ecosprin in multiple dose study also.

Fig. 3 shows the mean percent inhibition of platelet aggregation on multiple dose administration with clopidogrel 49.75%, P. emblica 36.08%, ecosprin 50.20% and combinations P. emblica + clopidogrel 75 mg 53.42% and P. emblica + ecosprin 75 mg 56.65%. There was statistically significant change observed when combination treatments were compared to P. emblica alone. Though there was apparent increase in inhibition of platelet aggregation with P. emblica + clopidogrel Vs clopidogrel alone and P. emblica+ ecosprin vs. ecosprin alone, this difference was not however statistically significant.

Effect of treatments on bleeding and clotting time are shown in Table 5. As seen from Table 5, though there was an apparent increase in bleeding and clotting time, the values were within normal range.

Discussion

Platelet non-responsiveness plays a major role in worsening of cardiovascular outcome in patients with cardiovascular disease despite treatment. The need for effective and safer antiplatelet treatment regimens is required in diabetic patients. The safety of P. emblica is well established from a number of studies conducted for several indications of the herbal drug. The effect of P. emblica on platelet aggregation is not well documented in literature and its antioxidant action is proposed to be responsible for anti-platelet action. In the present study, we attempted to evaluate the effects of administration of single and multiple doses of P. emblica on platelet aggregation. Both single and multiple dose administration of P. emblica produced significant inhibition of platelet aggregation induced by 10 [micro]Mol of ADP at 4 h when compared to baseline. The mean percent inhibition of platelet aggregation after single and multiple doses of P. emblica 500 mg were 23.95% and 36.08%, respectively which, were above the thienopyridine hyporesponsiveness defined as inhibition of platelet aggregation (IPA) with 20mol/l ADP <20% based on previous work done by Brandt et al. (2007).

The mean percent inhibition of platelet aggregation after single dose of clopidogrel was 47.73% and after multiple doses of P. emblica 500 mg when co administered was 53.42%. Bochsen and colleagues in 43 healthy blood donors found that platelet ADP receptor inhibition ranged from 0% to 58%, respectively, in healthy controls (Bochsen et al., 2007). The inhibition of platelet aggregation obtained in the present study with single or multiple doses of P. emblica 500 mg alone or after co-administration with clopidogrel lies within the above range. The risk of bleeding and the protection from major adverse cardiac events do not appear to be correlated with the type of P2Y12 antagonist but rather with the degree of platelet inhibition that is achieved independently of the drug that was used. Platelet inhibition by 10 [micro]mol/L ADP-induced platelet aggregation, on 4-7 days of clopidogrel treatment resulted in only 60% inhibition (Storey et al., 2002), which is less than that achieved with co administration of P. emblica 500 mg and clopidogrel 75 mg in the present study. Dual antiplatelet therapy (clopidogrel + asprin) is the cornerstone in the management of patients with acute coronary syndrome. There are several reports which suggest that antiplatelet drugs are associated with incidence of bleeding (Aruna and Naidu, 2006). Therefore a careful evaluation of the patient's bleeding risk pattern is warranted due to the higher risk of bleeding complications. Further, a study by Serebruany et al. (2010) to correlate inhibition of platelet aggregation (1PA) with bleeding events in a large cohort of patients with coronary artery disease (CAD) and ischemic stroke (IS) treated with chronic low-dose aspirin plus clopidogrel showed that there is no correlation between Inhibition of Platelet Aggregation and duration of antiplatelet therapy. Inhibition of platelet aggregation >50% strongly correlated with bleeding events. The single doses of all the three test medications did not produce more than 50% inhibition of platelet aggregation and in combination these drugs only slightly raised the percentage platelet inhibition more than 50% with no bleeding episodes reported in the present study.

Increased platelet activation and aggregation in DM have been attributed to a number of metabolic abnormalities, including hyperglycemia, insulin resistance and dyslipidemia (Jose et al., 2010). Diabetes mellitus is associated with oxidative stress and the presence of reactive oxygen species can impair platelet function (Seghieri et al., 2001). There are studies which suggest that generation of superoxide has been shown to increase platelet reactivity and limit the biological activity of nitric oxide. Increased production of reactive oxygen and nitrogen species and decreased platelet antioxidant production, results in increased platelet activation and decreased endothelial cell production of nitric oxide and prostacyclin (Freedman, 2008). In aggregate, platelet dysfunction associated with insulin resistance and DM represents an important pathobiological link between DM and increased CHD risk (Mathewkutty and McGuire, 2009).

P. emblica is used in Ayurveda as a potent rasayanas, a class of plant derived drugs reputed to promote health and longevity by improving defense against diseases (Udupa and Singh, 1995). The antioxidant, hypoglycemic and hypolipidemic properties of Emblica officinalis are well documented (Muhammad et al., 2011). The precise mechanism accounting for changes attributable to antioxidants in coronary disease remains unknown. Animal and cell culture data suggest that antioxidants preserve nitric oxide bioavailability in the face of oxidative stress. Because oxidative stress may alter platelet function, it is also conceivable that the affects of antioxidants may be a consequence of their enhancing or promoting the antiplatelet effects of NO derived from both endothelial cells and platelets (Freedman, 2008). Kumaran and Karunakaran (2006) quantitatively analyzed by in vitro method nitric oxide free radical scavenging phenolic principle. It was shown that geranin showed highest nitric oxide free radical scavenging activity among the isolated compound from amla. P. emblica is also considered as a rich source of a vitamin C, which plays an important role in scavenging free radicals (Thangaraj et al., 2007). For many years the therapeutic potential of fruits of Emblica officinalis was attributed to their high content of ascorbic acid (Sanhita et al., 2013). Bordia et al. studied the effect of vitamin C on platelet adhesiveness and platelet aggregation in coronary artery disease patients. Administration of vitamin C in a dose of 1g every 8h for 10 days decreased the platelet adhesiveness and platelet aggregation significantly. The study brings out a property of vitamin C which may be of considerable importance in prevention of chronic thrombo-atherosclerotic disease of the arteries (Bordia and Verma, 1985). The results of our study are in agreement with these previous reports. Similarly in the present study administration of P. emblica 500 mg twice daily for 10 days produced significant reduction of platelet aggregation in diabetic patients. Incontrast, Ghoshal et al. have established by comprehensive, chromatographic, spectroscopic and crucial chemical analysis that the antioxidant property of P. emblica is not due to its rich vitamin C content, but the activity is located in the low molecular weight hydrolysable tannins. These tannins namely Emblicanin A, Emblicanin B, Pedunculagin and Punigluconin have been found to provide protection against oxygen radicals induced hemolysis of rat peripheral erythrocytes (Ghoshal et al., 1996). In our study P. emblica 500 mg contains 160.4 mg of low molecular weight hydrolysable tannins, which may be responsible in producing antiplatelet action by reducing oxidative stress induced aggregation of platelets in diabetic patients.

Conclusion

Coadministration of proprietary P. emblica extract used in the present study containing Emblicanin-A, Emblicanin-B, Pedunculagin and Punigluconin as bioactives along with clopidogrel and ecosprin enhanced the antiplatelet activity compared with individual drugs. Though there was statistically significant prolongation of bleeding and clotting time with the treatments, the values however were within the normal reference range and hence may not be clinically significant. Large randomized trials are needed to evaluate the possible interaction of P. emblica and in combination with other antiplatelet drugs.

http://dx.doi.org/10.1016/j.phymed.2013.10.024

ARTICLE INFO

Article history:

Received 12 September 2013

Received in revised form 26 September 2013

Accepted 17 October 2013

Disclosure

The authors report no conflicts of interest in this work.

Acknowledgements

Authors thank Natreon Inc., for providing the proprietary extract of Phyllanthus emblica used in this study and relevant literature. The authors thank Dr. I.V. Sravanthi, Ayurvedic physician, for her expert advice.

References

Angiolillo, D.J., 2007. Antiplatelet therapy in type 2 diabetes mellitus. Curr. Opin. Endocrinol. Diabetes Obes. 14, 124-131.

Abebe, W., 2002. Herbal medications: potential for adverse interactions with analgesic drugs, J. Clin. Pharm. Ther. 27, 391-401.

Aruna, D., Naidu, M.U., 2006. Pharmacodynamic interaction studies of Ginkgo biioba with cilostazol and clopidogrel in healthy human subjects. Br. J. Clin. Pharm. 63, 333-338.

Bhattacharjee, S.K., 1998. Hand Book of Medicinal Plants. Pointer Publishers, Jaipur, India.

Bordia, A., Verma, S.K., 1985. Effect of vitamin C on platelet adhesiveness and platelet aggregation in coronary artery disease patients. Clin. Cardiol. 8, 552-554.

Brandt, J.T., Close, S.L, Iturria, S.J., Payne, C.D., Farid, N.A., Ernest 11, C.S., Lachno, D.R., Salazar, D., Winters, K.J., 2007. Common polymorphisms of CYP2C19 and CYP2C9 affect the pharmacokinetic and pharmacodynamic response to clopidogrel but not prasugrel. J. Thromb. Haemost. 5, 2429-2436.

Bochsen, L., Wiinberg, B., Kjelgaard-Hansen, M.. Steinbruchel, D.A., Johansson, P.I., 2007. Evaluation of the TEGw platelet mapping TM assay in blood donors. Thromb J. 5, 3.

Colwell, J.A., Nesto, R.W., 2003. The platelet in diabetes: focus on prevention of ischemic events. Diabetes Care 26, 2181-2188.

Dominick, J.A., 2009. Antiplatelet therapy in diabetes: efficacy and limitations of current treatment strategies and future directions. Diabetes Care 32.4. Freedman, J.E., 2008. Oxidative stress and platelets. Arterioscler. Thromb. Vase. Biol. 28, s11-s16.

Ghoshal, S., Tripathi, V.K., Chauhan, S., 1996. Active constituents of Embilica officinalis, Part I. The chemistry and antioxidant effects of two new hydrolysable tannins, Emblicanin A and B. Indian J. Chem. 35, 941-948.

Hall, M.H., Banerjee, S., McGuire, D.K., 2011. Variability of clopidogrel response in patients with type 2 diabetes mellitus. Diab. Vase. Dis. Res. 8, 245-253.

Jose, L.F., Joan, G., Dominick, J.A., 2010. Platelet abnormalities in diabetes mellitus. Diab. Vase. Dis. Res. 7,251-259.

King, H., Aubert, R.E., Herman, W.H., 1998. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 21, 1414-1431.

Kumaran, A., Karunakaran, R.J., 2006. Nitric oxide radical scavenging active components from Phyllanthus emblica. Plant Foods Hum. Nutr. 61, 1-5.

Muhammad, S.A., Ayesha, R., Amanat, A., Ahmad, M., 2011. Effect of amla fruit (Emblica officinalis Gaertn.) on blood glucose and lipid profile of normal subjects and type 2 diabetic patients. Int. J. Food Sci. Nutr. 62, 606-616.

Mateen, A.A., Usharani, P., Naidu, M.U.R., Chandrashekhar, E., 2011. Pharmacodynamic interaction study of Allium sativum (garlic) with cilostazol in patients with type II diabetes mellitus. Indian J. Pharmacol. 43, 270-274.

Mathewkutty, S., McGuire, D.K., 2009. Platelet perturbations in diabetes: implications for cardiovascular disease risk and treatment. Expert Rev. Cardiovasc. Ther. 7, 541-549.

Nesto, R.W., 2004. Correlation between cardiovascular disease and diabetes mellitus: current concepts. Am. J. Med. 116 (Suppl. 5A), 11S-22S.

Patrono, C.. Baigent. C., Hirsh, J., Roth, G., 2008. Antiplatelet drugs. Chest 133, 199S-233S.

Sanhita, P., Chandra, K.J., Chandra, S.G., 2013. Important findings of plant having antioxidant property. A review. Int. Res. J. Pharm. 5, 72-75.

Storey, R.R, Wilcox, R.C., Heptinstall, S., 2002. Comparison of the pharmacodynamic effects of the platelet ADP receptor antagonists clopidogrel and AR-C69931MX in patients with ischaemic heart disease. Platelets 13, 407-413.

Serebruany, V., Rao, S.V., Silva, M.A., Donovan, J.L., Kannan, A.O., Makarov, L, Goto, S., Atar, D., 2010. Correlation of inhibition of platelet aggregation after clopidogrel with post discharge bleeding events: assessment by different bleeding classifications. Eur. Heart J. 31, 227-235.

Seghieri, G., Di Simplicio, P., Anichini, R., Alviggi, L., De Beilis, A., Bennardini, F., Franchoni, F., 2001. Platelet antioxidant enzymes in insulin dependent diabetes mellitus. Clin. Chim. Acta 309, 19-23.

Thangaraj, R., Rathakrishnan, S.A., Pannerselvam, M., Jayaraman, B., 2007. Antioxidant property of Emblica officinalis during experimentally induced restrain stress in rats. J. Health Sci. 53, 496-499.

Udupa, K.N., Singh, R.H., 1995. Clinical and Experimental Studies on Rasayana Drugs and Panchakarma Therapy. Central council for Research in Ayurveda and Siddha, New Delhi.

Veena, S., Sadhna, S., Pracheta. Ritu, P., 2011. Withania somnifera: a rejuvenating ayurvedic medicinal herb for the treatment of various human ailments. Int. J. PharmTech. Res. 3, 187-192.

Yusuf, S., Zhao, F., Mehta, S.R., Chrolavicius, S., Tognoni, G., Fox, K.K., 2001. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N. Engl. J. Med. 345, 494-502.

Nishat Fatima, Usharani Pingali *, N. Muralidhar

Department of Clinical Pharmacology & Therapeutics, Nizam's Institute of Medical

Sciences, Panjagutta, Hyderabad, India

* Corresponding author. Tel.: +91 9849574143.

E-mail address: ushapingali@yahoo.com (U. Pingali).

Table 1
Demographic details of study group.

Parameter            Result

Total no.            10
Age (years)          58.60 [+ or -] 10.54
Gender (M/F)         6/4
Weight (kg)          67.93 [+ or -] 6.35
BMI (kg/[m.sup.2])   24.83 [+ or -] 2.20

Table 2
Platelet aggregation Percentage after single dose administration (Data
expressed as Mean [+ or -] SD).

Treatment                           Platelet aggregation (%)

                                    Baseline

Phyllanthus emblica 500 mg           60.7 [+ or -] 15.99
Clopidogrel 75 mg                    65.3 [+ or -] 11.25
Ecosprin 75 mg                       61.5 [+ or -] 10.81
Phyllanthus emblica + Clopidogrel   64.30 [+ or -] 5.74
Phyllanthus emblica + Ecosprin       62.3 [+ or -] 10.51

Treatment                           Platelet aggregation (%)

                                    4h

Phyllanthus emblica 500 mg           44.5 [+ or -] 12.50 (a)
Clopidogrel 75 mg                   34.80 [+ or -] 9.10 (a,c)
Ecosprin 75 mg                      33.10 [+ or -] 5.61 (a,b)
Phyllanthus emblica + Clopidogrel   32.10 [+ or -] 5.43 (a,c)
Phyllanthus emblica + Ecosprin       31.1 [+ or -] 5.43 (a,c)

Nonsignificant between 4h post treatment Clopidogrel vs. Ecosprin,
Phyl-lanthus emblica + Clopidogrel vs. Phyllanthus emblica +
Ecosprin, Phyllanthus emblica + Ecosprin vs. Ecosprin.

(a) p< 0.001 compared to baseline.

(b) p < 0.05 compared between 4 h post treatment Ecosprin vs.
Phyllanthus emblica.

(c) p<0.01 compared between 4h post treatment Phyllanthus emblica vs.
Clo-pidogrel, Phyllanthus emblica+Clopidogrel vs. Phyllanthus emblica,
Phyllanthus emblica + Ecosprin vs. Phyllanthus emblica.

Table 3 Effect of treatments after single dose administration on ble

Treatment                             Bleeding time

                       Baseline               4 h

Phyllanthus emblica     82.4 [+ or -] 7.27    86.20 [+ or -] 6.98 (a)
  500 mg
Clopidogrel 75 mg       84.4 [+ or -] 10.07   97.30 [+ or -] 26.92 (b)
Ecosprin 75 mg         79.50 [+ or -] 5.53     91.6 [+ or -] 7.19 (b)
Phyllanthus emblica    81.20 [+ or -] 8.23    93.90 [+ or -] 10.85 (b)
  + Clopidogrel
Phyllanthus emblica     79.1 [+ or -] 7.52     92.8 [+ or -] 9.55 (b)
  + Ecosprin

Treatment                            Clotting time

                       Baseline               4h

Phyllanthus emblica    207.3 [+ or -] 29.33   220.0 [+ or -] 29.72 (a)
  500 mg
Clopidogrel 75 mg      207.5 [+ or -] 37.78   249.5 [+ or -] 18.63 (b)
Ecosprin 75 mg         228.3 [+ or -] 85.56   274.6 [+ or -] 76.67 (b)
Phyllanthus emblica    208.7 [+ or -] 26.63   257.20 [+ or -] 15.35
  + Clopidogrel                                 (b)
Phyllanthus emblica    233.8 [+ or -] 61.40   286.6 [+ or -] 46.40 (b)
  + Ecosprin

(a) p<0.05 compared to baseline.

(b) p< 0.001 compared to baseline.

Table 4
Platelet aggregation percentage after multiple dose administration
(Data expressed as Mean [+ or -] SD).

Treatment                        Platelet aggregation (%)

                       Baseline              4h

Phyllanthus emblica    64.90 [+ or -] 9.88   41.70 [+ or -] 10.55 (a)
  500 mg
Clopidogrel 75 mg      66.80 [+ or -] 5.67   33.60 [+ or -] 4.48 (a,b)
Ecosprin 75 mg         64.50 [+ or -] 6.87   31.80 [+ or -] 4.59 (a,c)
Phyllanthus emblica    65.10 [+ or -] 4.99   30.30 [+ or -] 6.29 (a,b)
  + Clopidogrel
Phyllanthus emblica     60.4 [+ or -] 14.24   26.8 [+ or -] 9.30 (a,d)
  + Ecosprin

(a) p<0.001 compared to baseline.

(b) p < 0.001 compared between 4 h post treatment Phyllanthus emblica
and clopidogrel, between Phyllanthus emblica + clopidogrel vs.
Phyllanthus emblica.

(c) p<0.05 compared between 4 h Phyllanthus emblica vs. Ecosprin.

(d) p<0.01 compared between 4h Phyllanthus emblica + Ecosprin vs.
Phyllanthus emblica.

Table 5
Effect of treatments after multiple dose administration on bleeding
and clotting Time (in seconds).

Treatment                            Bleeding time

                      Baseline              4h

Phyllanthus emblica   76.5 [+ or -] 11.96   82.40 [+ or -] 11.29 (b)
  500 mg
Clopidogrel 75 mg     83.10 [+ or -] 9.71   95.20 [+ or -] 8.77 (a,c)
Ecosprin 75 mg        78.5 [+ or -] 4.54    88.60 [+ or -] 5.50 (a)
Phyllanthus emblica   81.0 [+ or -] 7.32    91.50 [+ or -] 5.46 (a,c)
  + Clopidogrel
Phyllanthus emblica   75.80 [+ or -] 5.60   90.80 [+ or -] 8.69 (a)
  + Ecosprin

Treatment                         Clotting time

                      Baseline              4h

Phyllanthus emblica   225.7 [+ or -] 22.53  235.5 [+ or -] 23.22 (b)
  500 mg
Clopidogrel 75 mg     204.3 [+ or -] 37.59  250.5 [+ or -] 18.28 (a,c)
Ecosprin 75 mg        229.2 [+ or -] 66.46  281.5 [+ or -] 70.18 (a,c)
Phyllanthus emblica   210.1 [+ or -] 19.83  255.7 [+ or -] 21.94 (a,c)
  + Clopidogrel
Phyllanthus emblica   240.80 [+ or -] 66.3  288.0 [+ or -] 75.73 (a,c)
  + Ecosprin

(a) p< 0.001 compared to baseline.

(b) p < 0.05 compared to baseline.

(c) p < 0.05 between Phyllanthus emblica vs. clopidogrel and
Phyllanthus emblica + lopidogrel, ecosprin, Phyllanthus emblica +
ecosprin.

Fig. 2. Mean percent inhibition of platelet aggregation on
treatment with single dose Phyllanthus emblica (PE) 500 mg,
Clopidogrel 75 mg, Ecosprin 75 mg, PE 500 + Clopidogrel 75 mg and
PE 500 + Ecosprin 75 mg.

PE              (23.95%)
Clopidogrel   $ (47.3%)
Ecosprin      $ (49.78%)
PE+Clopi      # (44.11%)
PE+ Ecosprin  # (49.25%)

$ = p<0.01 PE Vs Clopidogrel and PE Vs Ecosprin

# = p<0.001 PEVsPE+Clopidogre! and PE VsPE+ Ecosprin

Nonsignificant Clopidogrel VsPE+Clopidogrel, Ecosprin Vs PE+ Ecosprin,
Clopidogrel Vs Ecosprin, PE+Clopidogrel Vs PE+ Ecosprin.

Note: Table made from bar graph.

Fig. 3. Mean percent inhibition of platelet aggregation after
multiple dose administration of Phyllanthus emblica (PE) 500 mg,
Clopidogrel 75 mg, Ecosprin 75 mg, PE 500 mg + Clopidogrel 75 mg
and PE 500 mg+Ecosprin 75 mg.

PE                (36.08%)
Clopidogrel     # (49.75%)
Ecosprin        # (50.20%;
PE +Clopi       $ (53.42%)
PE + Ecosprin   @ (56.65%)

# = p<0.01 PEVs Clopidogrel and PE Vs Ecosprin

$ = p<0.01 PE Vs PE+Clopidogrel

@ = p<0.001 PE Vs PE + Ecosprin

Nonsignificant Clopidogrel Vs PE +Clopidogrel, Ecosprin Vs PE +
Ecosprin, Clopidogrel Vs Ecosprin and PE+Clopidogrel Vs PE+Ecosprin

Note: Table made from bar graph.
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Author:Fatima, Nishat; Pingali, Usharani; Muralidhar, N.
Publication:Phytomedicine: International Journal of Phytotherapy & Phytopharmacology
Article Type:Report
Date:Apr 15, 2014
Words:5650
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