The Clinical And Molecular Biological Mechanism Study Of Ningdong Granule On Tourette's Syndrome

BackgroundTourette's syndrome (TS) is a chronic, childhood-onset neuropsychiatric disorder, which is characterized by multiple motor and vocal tics, including involuntary or semi-voluntary, sudden, brief, intermittent, repetitive movements or sounds. The prevalence of TS is estimated to be 0.4-3.8%for children and adolescents. The motor tics include headshakes, violent clonic tics consisting of thrusting head jerks and orofacial tics such as facial grimacing, eye blinking and throat clearing. It dosen't occur regularity. The symptoms will decrease by divert attention, vanish after sleep, and aggravate after actuation. In addition to tics, it often associates with obsessive-compulsive disorder (OCD), motor tics and attention-deficit hyperactivity disorder (ADHD), in which the incidence of OCD is 25-60%. The symptoms are alternating, recurrent, persistent unhealed, which seriously affect the children and adolescents'lives and study in the growth and developmental stages. Therefore, it is important to treat TS early and effectively.For a long time, typical antipsychotics (e.g. haloperidol, pimozide, and fluphenazine) are the standard therapy for TS, and haloperidol is the first-choice neuroleptic. Many patients treated with haloperidol experience adverse events, such as akathisia, bradykinesia, dystonia, Parkinsonism, and somnolence. Only a minority of patients continue to use haloperidol for extended periods. Recently, several atypical antipsychotics (e.g. risperidone, olanzapine, and quetiapine) have recently been used instead of classical antipsychotics in an attempt to improve the clinical course of TS and to minimize side-effects. None of these atypical antipsychotics are curative and all have some common and troublesome side-effects, such as sedation, increasing body weight, and depression. Thus, there is a need for alternative effective and mild side effects pharmacotherapy for TS. Selective serotonin reuptake inhibitors (SSRI), such as fluoxetine, paroxetine, fluvoxamine, are primarily used for the treatment of OCD associated with TS.ND granule, a Chinese herbal compound preparation, was made by modern technology according my advisor's prescription for TS. Previous research by the authors demonstrated that ND granule improved the stereotypical behaviour of apomorphine-induced TS rats, an animal model of TS, by suppressing the dopamine (DA) system. However, the efficacy of ND granule for OCD associated with TS and comparison with the efficacy of SSRI drugs remain unknown. Thus, the controlled clinical trial was done.Objective1. To investigate the effect and security of ND granule and fluoxetine on TS and OCD associated with it.2. To evaluate relative value of ND granule and fluoxetine on TS and OCD associated with it.Method66 patients of TS with OCD were randomly divided into 2 groups.33 patients in the ND granule group were treated with ND granule lg/kg/d, and 33 patients in the fluoxetine group were treated with fluoxetine, the initial dose of fluoxetine was 10mg/d, and maximum dose was 60mg/d. All of the participants with history of medication had to be medication-free for≥4 weeks prior to the study. In order to investigate the effect of ND granule and fluoxetine on TS and OCD, the severity of tics and OCD were evaluated at baseline and at end point, with Yale Global Tic Severity Scale (YGTSS) and Yale-Brown Obsessive Compulsive Scale (Y-BOCS). To evaluate the security of ND granule and fluoxetine on TS and OCD, Side-effects were evaluated according to an adverse event chart produced by this study team. Alanine transferase (ALT), aspartate transaminase (AST), blood urea nitrogen (BUN), creatinine, electrocardiogram, and body mass index (BMI) were measured at baseline and at end point.Results 1. Study populationSixty-six subjects were recruited to participate in this study. One patient in the ND granule group and two patients in the fluoxetine group missed the full course of treatment, so they were excluded from this analysis. The remaining subjects in the two groups were similar with regard to age, gender, BMI, previous use of pharmacotherapy for tics, baseline YGTSS total tic score and Y-BOCS score (P> 0.05).2. Comparison of YGTSS tic scoresCompared with YGTSS total tic score, YGTSS motor tic score and YGTSS vocal tic score at baseline, the scores of both two groups at end point reduced significantly (P< 0.01). Compared with fluoxetine group, the YGTSS total tic score and motor tic score in ND granule group reduced more significantly (P<0.05或P <0.01). The difference of YGTSS vocal tic score reduction between the two groups was not significant.3. Comparison of YGTSS overall impairment scoresCompared with overall impairment score at baseline, the scores of both two groups at end point reduced significantly (P< 0.01). The difference of YGTSS overall impairment scores reduction between the two groups was not significant.4. Comparison of total effective rate of ticsThe total effective rate (66.7%) in ND granule group were higher than that (46.7%) in fluoxetine group (P< 0.01).5. Comparison of Y-BOCS scoreCompared with Y-BOCS score at baseline, in the trail group, Y-BOCS score after 6 months medication significantly decreased (P<0.05). the reduction of Y-BOCS score in fluoxetine group was more significant than that in ND granule (P= 0.01)6. Comparison of total effective rate of OCDThe total effective rate (80.0%) in fluoxetine granule group were higher than that (56.2%) in ND group (P< 0.05)6. Side effectsOnly two subjects reported loss of appetite and constipation in the ND granule, while 9 subjects experienced adverse reactions, Nausea, anorexia, insomnia, anxiety, mania, etc., in fluoxetine group. The incidence of adverse reactions in ND granule was lower than that in in fluoxetine group. Moreover, no abnormalities on the liver or renal function tests, or cardiac toxicity were observed after administration of ND granule.ConclusionBoth ND granule and fluoxetine could improve the syndrome of tics and OCD associated with TS. ND granule exhibited better effect on TS, while fluoxetine show better effect on OCD associated with TS. ND granule was superior to fluoxetine in the clinical application security. BackgroundTourette's syndrome (TS) is a chronic, childhood-onset neuropsychiatric disorder, which is characterized by multiple motor and vocal tics. The etiology and pathogenesis of TS is not yet clear. Genetic factors, central nervous system neurotransmitter imbalances, neurological and biochemical abnormalities and psychological factors may be associated with TS. It has been generally recognized that neurotransmitter imbalances of central nervous system plays an important role on pathogenesis of TS.Some animal and clinical researches indicate that over-active function of dopamine system exhibit in TS. Central DA activity is not only excessive, but also post-synaptic receptor super-sensitive, ultra-sensitive receptors caused by excessive effector cell over response. Our previous animal study also shows that over-active function of dopamine system exhibit in TS rat model. In the basal ganglia-thalamic cortical loop,5-hydroxytryptamine (5-hydroxytryptamine,5-HT) systems can be associated with DA systems, joint control body movement, cognitive, emotional.5-HT system plays a widespread role of suppression and stability in central parts of the brain and mental activities. Selective serotonin reuptake inhibitors (SSRI) is a effective medication for TS, particularly OCD associated with TS, which further shows that relative or absolute lack-activity of 5-HT system plays an important role in the pathophysiology of TS. Our clinical study shows that ND granule could significantly improve the tics and OCD syndrome with TS. Previous animal study also shows that ND granule could suppress the dopamine (DA) system, but the impact of ND granule on 5-HT system remains unknown.Objective1. Investigate the change of 5-HT system of striatum in TS rat.2. Investigate the impact of ND granule on 5-HT system, in order to further clarify the mechanism of ND granule for TS.MethodsSixty-four male (4 weeks old) wistar rats were randmy divided into 4 groups (n=16):the control group, the model (Apo) group, the low dosage NDG (NGL) group, and the high dosage (NGH) group. TS rat models were induced by intraperitoneal injection (i.p.) with Apo (2mg/kg) in the experimental groups last 4 weeks. Rats in the control group were injected with normal saline (0.9%) (3ml/kg, i.p.). After the injection of Apo (i.p.), rats were treated by intragastric administration (i.g.) with ND granule at 1.8g/(kg-d) in NGL group, with ND granule at 3.6g/(kg-d) in NGH group, with distilled water at equal Volume in Control group and Apo group, respectively, twice a day at 9am and 4 pm for 12 successive weeks.After the last administration,all rats were fasted with free access to water for 24 h, and anesthetized with intraperitoneal injection of 3% pentobarbital (30 mg/kg) which was followed by other experiments. The detection conten (1) Analysis the 5-HT2aAR protein expression by Immunohistochemical method; (2) Analysis the 5-HT2AR mRNA expression by RT-PCR; (3) Analysis the TPH2 protein expression by Western blot. (4) Determination of the content of 5-HT and 5-HIAA in striatum by Enzyme linked immunosorbent assay (ELISA);Results Comparison of the expression of 5-HT2AR proteinThe level of the expression of 5-HT2AR protein in striatum in Apo group was significant higher than that in the control group (143.10±8.01 vs 127.43±6.72, P< 0.01). The level of the expression of 5-HT2AR protein became higher after medication with ND granule. The level of the expression of 5-HT2AR protein in Both NDL group and NDH group significantly increased Compared with in Apo group (P<0.05或P<0.01). The level of the expression of 5-HT2AR protein in NDH group significantly increased, compared with that in NDL group (P <0.01)Comparison of the expression of 5-HT2AR mRNA in striatumThe level of the expression of 5-HT2AR mRNA in striatum in Apo group was significant higher than that in the control group[1.52(0.93-2.46) vs 1.00(0.77-1.3), P<0.05]. After treatment, the level of the expression of 5-HT2AR mRNA in both NDL group and NDH group became higher than that in Apo group(P<0.05或P<0.01). The difference between NDL group and NDH group was not significant (P>0.05).Comparison of the expression of TPH2 proteinThe level of the expression of TPH2 protein in Apo group was significant higher than that in the control group[1.52(0.93-2.46) vs 1.00(0.77-1.3), P<0.05]. After treatment, the level of the expression of TPH2 protein in both NDL group and NDH group became higher than that in Apo group(P<0.05或P<0.01). The level of the expression of TPH2 protein in NDH group significantly increased, compared with that in NDL group (P<0.01).Comparison of level of 5-HT in striatumThe level of 5-HT in striatum in Apo group was significant higher than that in the control group(1.98±0.14 vs 1.78±0.10 ng/ml, P<0.05). The difference between Apo group and NDL group was not significant (P>0.05). The level of 5-HT in NDH group became higher than that in Apo group(2.20±0.14 vs 1.98±0.14ng/ml, P<0.05). No difference was shown in comparison between NGL group and NDH group (P> 0.05)Comparison of level of 5-HIAA in striatumNo difference was shown in comparison of level of 5-HIAA in striatum between Apo group and control group(0.94±0.12 vs 0.97±0.10ng/ml, P>0.05). The level of 5-HIAA in both NDL group and NDH group became lower than that in Apo group (0.77±0.10 vs 0.94±0.12, P<0.05; 0.58±0.08 vs 0.94±0.12, P<0.01). the difference between NGL group and NDH group was significant(P<0.01).Conclusion1. Activity of 5-HT system enhanced in Apo-induced TS rat model; however, the enhanced activity may still be relatively insufficient.2. The mechanism of ND granule treating TS was associated with promotion of 5-HT synthesis in the striatum, depression of the 5-HT metabolism, up-regulation expression of 5-HT2AR, enhancing activity of 5-HT system and improving the activity insufficient of 5-HT system.