Observation On The Efficacy Of Banxia Xiexin Decoction In The Treatment Of T2DM With Intermingled Cold And Heat Syndrome And The Related Mechanism Of GLP-1

The situation of diabetes in China is serious and the prevalence rate is rising rapidly.Clinically,we have found that there are certain limitations in the regulation of blood glucose with western medicine alone,while the treatment of traditional Chinese medicine is based on the whole,taking both samples into account,and has the advantages of protecting islet function and improving insulin sensitivity while alleviating symptoms.Diabetes belongs to the "Xiaoke disease" of TCM,the main pathogenesis was Yin deficiency and dry heat,but many patients do not have "three more and one less" symptoms,and the majority are obese or overweight.In the classification of TCM syndrome types of patients,a certain proportion of syndrome of intermingled heat and cold,among which the intermingled cold and heat syndrome of middle jiao is in the majority.Banxia Xiexin Decoction,as an important preion for the treatment of intermingled cold and heat syndrome,represents the harmonizing intestine-stomach of TCM therapeutic method.It has certain hypoglycemic effect in the treatment of T2DM,but the hypoglycemic mechanism of this prescription is not completely clear.Our previous study also confirmed that Banxia Xiexin Decoction can prevent the beta-cell apoptosis and reduce intracellular oxidative stress.However,there is still a lack of studies on the regulation of gastrointestinal hormones by Banxia Xiexin Decoction,especially GLP-1.Therefore,it is essential to reveal the diagnosis and treatment characteristics of T2DM patients with intermingled cold and heat syndrome,clarify the clinical efficacy of the harmonizing intestine-stomach of TCM therapeutic method in treating T2DM,and explore the mechanism of action of Banxia Xiexin Decoction in the treatment of T2DM.This study,supported by the National Natural Science Foundation of China(No.81373594),is of great significance in the field of TCM treatment of T2DM.Objective1.To analyze a large number of clinical data of T2DM with intermingled cold and heat syndrome based on TCM clinical pathway,summarize the characteristics of diagnosis and treatmen.2.To evaluate the clinical efficacy and safety of Banxia Xiexin Decoction in regulating serum GLP-1 level and islet ?-cell function in T2DM patients.3.To explore and predict the potential pharmacological mechanism of Banxia Xiexin Decoction in treating T2DM,and to provide reference for further experimental studies on the mechanism of Banxia Xiexin Decoction.MethodsPart one:Discussion on TCM diagnosis and treatment characteristics of T2DM with intermingled cold and heat syndromeThrough a structured inpatient record system,collected nearly six years into the clinical pathway of TCM,the clinical data of patients with intermingled cold and heat syndrome who have been included in TCM clinical pathway treatment for T2DM in recent six years were collected,including gender,nationality,age,smoking and drinking history,T2DM duration,variations,the main symptoms,diagnosis,the TCM treatment plan,physical and chemical indicators.carries on the statistical description,cluster analysis,factor analysis and curative effect evaluation.Then,statistical description,correlation analysis,cluster analysis,factor analysis and efficacy evaluation were performed on the extracted data.Part two:Clinical Study of Banxia Xiexin Decoction on Regulating Serum GLP-1 Level and Islet ?-cell Function in Patients with T2DMAn open completely RCT was conducted,in which 82 newly diagnosed subjects with tyT2DM were included and randomly divided into two groups.The intervention measures of the experimental group and the control group were Banxia Xiexin Decoction and Glimepiride,respectively.The treatment course was 12 weeks.The balance between the subjects in gender,age,waist,waist-hip ratio and other baseline indicators between the two groups was observed.The primary and secondary efficacy indicators were compared between the two groups.The primary efficacy indicators were the efficacy of TCM syndromes and the level of glucagon-like peptide-1(GLP-1).The efficacy of TCM syndromes was evaluated according to the changes in the scores of intermingled cold and heat syndrome before and after the experiment.Secondary efficacy indicators included blood glucose level indicators(HbA1c,FPG,2hPG),pancreatic ?cell function(HOMA-?),insulin resistance level(HOMA-IR),gastrointestinal hormone indexes(GIP,Gas,MLT,SS),blood lipid,blood pressure and BMI.In addition,safety indicators involving respiration,heart rate,blood routine test,urine routine test,stool routine test,liver function,kidney function,adverse events/reactions of subjects in the two groups were respectively analyzed.To evaluate the efficacy and safety of Banxia Xiexin Decoction in the treatment of T2DM with intermingled cold and heat.Part three:Study on the Molecular Mechanism of Banxia Xiexin Decoction in the Intervention of T2DM Based on Network PharmacologyThe main active components of each single herb in Banxia Xiexin Decoction were screened out by TCMSP database.The targets corresponding to the above-mentioned active ingredients of traditional Chinese medicine were obtained from TCMSP and Pharmapper database,and target integrations were carried out according to the whole Chinese medicinal formulae and subgroup.At the same time,TTD,Genecards and HPO databases were used to obtain the target of T2DM.The intersection of T2DM targets and targets of the whole prescription or each subgroup were selected.Then,the String platform was used to construct the interaction network of target proteins,and the network diagram of " effective components-disease-target" was constructed by Cytoscape software.Finally,Bioconductor and R project were used to perform enrichment analysis on the intersection of each group of targets to complete biological function annotation,including GO and KEGG pathways.ResultsPart one:Discussion on TCM diagnosis and treatment characteristics of T2DM with intermingled cold and heat syndrome1.Epidemiological data:The male and female ratio of the 150 patients included in the study was 1:1.14.The majority of the patients were Han Nationality.In terms of age distribution,the majority of patients were over 45 years old.Among them,52 had a history of smoking and 43 had a history of drinking.The average body-mass index of the patients was 26.528±4.629,and 68%of the patients had a BMI greater than 24.The course of T2DM was more than 10 years,accounting for 38.7%.Sixteen patients withdrew from the clinical pathway due to different causes of variation.The prevalence of diabetic peripheral neuropathy was the highest in complications.The prevalence of hyperlipidemia was the highest in the comorbidities.The mean HbA1c level of the patients was 8.797±1.787%,mainly in the range of 7-9%,and most patients had dyslipidemia.2.The characteristics of syndrome and treatment of intermingled cold and heat syndrome in T2DM:(1)Syndrome characteristics:In the distribution of TCM accompanied syndromes,the number of stasis syndrome is the largest,followed by damp syndrome.Symptoms of fatigue,fullness in the stomach,acid reflux and gastric discomfort appeared in the highest frequency.The most common tongue color is dark red tongue,the most common tongue coating is white thin greasy fur,yellow greasy fur and white greasy fur.The most common pulse is stringy and slippery pulse.(2)TCM treatment characteristics:Banxia Xiexin Decoction is the most frequently used prescription in TCM clinical pathway.The efficacy statistics of Chinese herbal medicine showed that tonics were used in the highest frequency,among which qi-supplementing herbs were the main ones,and heat-clearing herbs ranked second.In the distribution of herbs' nature and flavour,the four nature of herbs aremainly cold,warm and flat.The five flavors of herbs are bitter,sweet and pungent.Correlation analysis found 16 Chinese herbs combination characteristicss with strong correlation and high reliability,such as "Pinellia pinellia=>Dried ginger","Pinellia pinellia=>Dried ginger-Scutellaria baicalensis","Pinellia pinellia=>Dried ginger-Scutellaria baicalensis-Rhizoma Coptidis",etc.The cluster analysis showed that the high-frequency Chinese herbs were grouped into five categories,among which the combination of Pinellia pinelliae,Scutellaria baicalensis,Rhizoma Coptidis and Dried ginger of the first category could be applied as the main prescription for the treatment of T2DM intermingled cold and heat syndrome.A total of nine pairs of high-frequency Chinese herbs combinations were obtained by factor analysis,which respectively reflected the corresponding treatment for T2DM intermingled cold and heat syndrome and related accompanied syndrome.Additionlly,Chinese patent medicine and external treatment of TCM are also important parts of the clinical pathway treatment scheme.3.Efficacy evaluation:134 patients who completed the pathway treatment showed a significant downward trend in FPG level,blood pressure level and syndrome score,and the difference was statistically significant.Part two:Clinical Study of Banxia Xiexin Decoction on Regulating Serum GLP-1 Level and Islet ?-cell Function in Patients with T2DM1.Banxia Xiexin Decoction can reduce the syndrome score of patients and make the total effective rate of TCM syndromes reach 77.78%,which is significantly better than the control group.2.Banxia Xiexin Decoction was better than glimepride in improving the secretion of GLP-1 in the early phase.3.Banxia Xiexin Decoction can reduce blood glucose level,but the glucose effect rate of control group is higher.4.HOMA-? level did not significantly change after treatment with Banxia Xiexin Decoction,but HOMA-IR level showed a downward trend in experimental group.5.In terms of other gastrointestinal hormones,Banxia Xiexin Decoction can reduce the levels of Gas and MTL,and increase the levels of GIP and SS after treatment.6.Banxia Xiexin Decoction can improve blood lipid,reduce body weight,and its effect is better than that of glimepiride,but it does not significantly improve blood pressure.7.No significant abnormalities were observed in all safety indicators,and no serious adverse events occurred to the subjects.Part three:Study on the Molecular Mechanism of Banxia Xiexin Decoction in the Intervention of T2DM Based on Network Pharmacology1.Target prediction:386 active components targets of BXXXT were obtained,including 130 targets in Xinkai group,257 targets in Kujiang group,333 targets in Ganhe group and 351 T2DM related targets,respectively.After mapping between herb targets and disease targets,58 intersection targets of BXXXT and T2DM were obtained,and the intersection targets of herbs and T2DM in the three subgroups were 20 in the Xinkai group,46 in the Kujiang group and 57 in the Ganhe group.2.Network Prediction:the active components of BXXXT,such as quercetin,kaempferol,?-sitosterol,stigmastol,baicalein,naringin,berberine,etc,which maybe the core components of this prescription in the treatment of T2DM;the intersection target genes such as PTGS2,AR,PTGS1,NOS2 and PPARG play a key role in the network.The core target proteins predicted by PPI network mainly included IL-6,Aktl,etc.3.Results of enrichment analysis:the targets mainly focused on nuclear receptor activity and other aspects of GO function.KEGG enrichment results showed that the intersection targets of BXXXT were mainly enriched in the AGE-RAGE signaling pathway,which enriched 16 target genes.BXXXT could regulate NF?B through Akt and participate in cell apoptosis.Inhibition of AGE-RAGE signaling pathway could reduce L cell apoptosis and promoted GLP-1 secretion.Relaxin pathway was the pathway with the highest target enrichment degree in Xinkai group.The AGE-RAGE pathway was the highest target enrichment pathway in the Kujiang group and the Ganhe group.4.It is speculated that the effect of BXXXT on T2DM may be correlated with GLP-1,according to the core compound berberine in the network,and AGE-RAGE signaling pathway.Conclusion1.The main prescription for the treatment of T2DM with mixed cold and heat syndrome is Banxia Xiexin Decoction.The basic composition of traditional Chinese medicine is Pinellia tuber,Coptis chinensis,Radix Scutellariae and dried ginger.At the same time,it can be used in combination with the traditional Chinese medicine combination of replenishing spleen Qi,soothing liver and regulating Qi,transporting the spleen by dryness and dampness,nourishing Yin and clearing heat,etc.2.Banxia Xiexin Decoction is safe and effective in treating T2DM.It can not only reduce the blood glucose level of T2DM patients,but also promote the secretion of GLP-1,improve symptoms,alleviate insulin resistance,regulate the disorder of some gastrointestinal hormones(GIP,GAS,MLT,SS),enhance gastric motility,correct abnormal lipid metabolism,and reduce weight,which provides objective basis for TCM and gastrointestinal therapy in the treatment of T2DM.3.The network pharmacology predicted that one of the potential targets of BXXXT in the treatment of T2DM was DDP4,and the main signaling pathway was AGE-RAGE.By acting on PI3K/Akt/NF?B to inhibit the apoptosis of L cells and promote GLP-1 secretion.