Enhanced passive safety surveillance of Influvac® and Influvac® Tetra: Results from seven consecutive seasons.

BACKGROUND AND OBJECTIVES: In 2014, the European Medicines Agency (EMA) set out requirements for an enhanced safety surveillance for seasonal influenza vaccines. This paper presents data from the yearly Enhanced Passive Safety Surveillance (EPSS) implemented for Influvac® since season 2014/15 and continued for Influvac® Tetra from season 2018/19 onwards. METHODS: In seven consecutive seasons, an EPSS, aiming for at least 1,000 vaccinees (additional target of 100 vaccinees per five predefined age groups), was conducted in Germany, where market characteristics were expected to allow for a quick generation of representative data. Reactogenicity data in terms of reporting rates, severity and duration of pre-specified local and systemic adverse events of interest (AEI) were collected using response cards, which were completed by vaccinees and returned seven days after vaccination via regular mail. In addition, response cards contained a call center number to enhance reporting of other than pre-specified adverse events. RESULTS: The primary target of at least 1,000 vaccinees was surpassed in all seasons, as was the additional target of 100 adults and elderly. Reactogenicity data were in line with known safety profile of Influvac® and Influvac® Tetra. In children, the target was mostly met in seasons when the EPSS was conducted for Influvac®, but not in seasons when it was conducted for Influvac® Tetra. Although the data for Influvac® Tetra are based on a low number of paediatric vaccinees, they do not indicate a different reactogenicity profile of Influvac® Tetra compared with Influvac®. No signals were identified. CONCLUSION: The EPSS set up for Influvac® and Influvac® Tetra proved a robust and effective methodology to comply with the objectives of EMÁ's guidance on enhanced safety surveillance of seasonal influenza vaccines. Safety data from seven consecutive seasons confirmed the favourable safety profile of both vaccines.

Increased Prevalence of Polyneuropathy in Parkinson's Disease Patients: An Observational Study.

BACKGROUND: The independent contribution of levodopa exposure and Parkinson's disease (PD) to the risk of polyneuropathy is not established. OBJECTIVE: This study investigated whether patients with newly diagnosed PD without previous exposure to antiparkinsonian drugs have higher prevalence of polyneuropathy than the general population. METHODS: Using the UK General Practice Research Database, presence of polyneuropathy in the previous 3 years was assessed. RESULTS: Of 5089 PD patients and 19,897 controls, polyneuropathy was confirmed in 15 PD patients (0.29% ) and 24 controls (0.12% ). Polyneuropathy prevalence was 2.4-fold higher in PD patients than controls. CONCLUSIONS: In this observational study, PD patients had a higher prevalence of preexisting polyneuropathy that cannot be explained by adverse effects of antiparkinsonian drugs.

[Herb-drugs interactions]. / Wechselwirkungen mit Phytopharmaka.

Herbal therapeutics are increasingly associated with herb drug interactions. The vast majority of the purported cases is unsubstantiated and misinterpreted. Pharmacological and clinical studies should only be demanded in cases of reliable evidence. First steps to be taken by manufacturers of herbal drugs should be in vitro studies with metabolizing systems like CYP and P-gp. Manufacturers of drugs that are metabolized by modulated systems should be requested to conduct drug specific interaction studies as necessary.

Effects of black cohosh on estrogen biosynthesis in normal breast tissue in vitro.

OBJECTIVES: To investigate the effect of black cohosh on the estrogen biosynthesis in the breast in vitro. METHODS: Steroid sulfatase (STS) activity was studied in normal breast tissue obtained from pre- and postmenopausal women undergoing reduction mammoplasty. STS protein expression was studied by immunohistochemistry and western blotting. Breast tissue was incubated in vitro without or with black cohosh (iCR) at concentrations ranging from 0.1mg/ml to 1 ng/ml. STS activity was evaluated by incubating homogenized breast tissue with [3H]-estrone sulfate, separating the formed products, estrone (E1) and estradiol (E2), by thin layer chromatography and measuring the amounts of E1 and E2 by scintillation counting. RESULTS: STS protein expression and enzymatic activity were detected in all specimens investigated. In all groups, significantly more E1 than E2 was produced. Local estrogen formation was decreased in premenopausal breast tissue by treatment with iCR at 0.1mg/ml (p

Inhibitory effect of an isopropanolic extract of black cohosh on the invasiveness of MDA-mB 231 human breast cancer cells.

BACKGROUND: The isopropanolic extract of black cohosh (iCR)b has recently been reported to exert antiproliferative and apoptosis-inducing effects on estrogen receptor-positive MCF-7, as well as estrogen receptor-negative MDA-MB 231 human breast cancer cells. To broaden observations, the anti-invasive effects of iCR and its two major fractions triterpene glycosides (TTG) and cinnamic acid esters (CAE) were tested in highly invasive MDA-MB 231 cells. MATERIALS AND METHODS: The effect of drugs upon the invasive potential of MDA-MB231 cells was studied in BD Biocoat Matrigel invasion chambers over a period of 24 h. RESULTS: The suppression of invasion reached 51.8% at 77.4 microg/ml of iCR, an extract concentration where 89% of MDA-MB231 cells were viable. TTG and CAE reduced cell invasion by 34% and 25.5%, respectively, at a dose of 5 microg/ml. The motility of cells was only moderately reduced. CONCLUSION: In this study iCR was found to suppress tumor cell invasion without affecting cell viability. This result together with the antiproliferative and apoptosis-inducing effect of iCR suggest its use as a secure agent in postmenopausal hormone replacement therapy with additional chemopreventive activity.

Coadministration of the aromatase inhibitor formestane and an isopropanolic extract of black cohosh in a rat model of chemically induced mammary carcinoma.

Non-steroidal as well as steroidal aromatase inhibitors are currently being discussed as alternatives to tamoxifen in the first-line treatment of patients with hormone-dependent breast cancer. Many of these women are in a postmenopausal state and additionally troubled by climacteric complaints. Naturally occurring symptoms like hot flushes and night sweats can be triggered or augmented by anti-hormonal drugs. At the aromatase molecule, steroidal inhibitors like exemestane and formestane compete with the hormonal precursors for the substrate binding site and inactivate the enzyme irreversibly. An isopropanolic extract of the rootstock of black cohosh (iCR), which is a common comedication of aromatase inhibitors in breast cancer patients suffering from climacteric symptoms, contains triterpene glycosides and cinnamic acid esters, both of which possess structural similarities to steroids. We therefore tested a high dose of iCR, guaranteeing an effective uptake of 60 mg herbal substance per kg body weight and shown to influence rat bone and uterus, for putative interactions with two low dosing regimens of 3.5 mg or 5.0 mg formestane per animal and day. We chose a rat model of chemically induced breast cancer and evaluated tumor growth and serum estrogen levels. Compared to a tumor area of 1400 mm2 after 21 days of unopposed tumor growth, formestane treatment, irrespective of concomitant black cohosh application, significantly reduced neoplastic growth by 50%. Formestane also significantly reduced serum estrogen levels, an effect which was also not abolished by iCR. Therefore, in this experimental setting, when challenging two low doses of formestane with a high dose of iCR, our data do not raise concerns against combining aromatase inhibitors with black cohosh.

Isopropanolic extract of black cohosh stimulates osteoprotegerin production by human osteoblasts.

UNLABELLED: An isopropanolic extract (iCR) from the rhizomes of Cimicifuga racemosa (black cohosh) is used an alternative in the treatment of menopausal symptoms, and animal studies suggest positive skeletal effects. iCR stimulated osteoblastic OPG protein secretion by 3- to 5-fold as early as 12 h without affecting RANKL expression. The iCR effect, abrogated by the pure estrogen receptor antagonist ICI 182,780, also enhanced ALP activity (4-fold) and osteocalcin expression (3-fold), possibly contributing to the skeletal effects of black cohosh. INTRODUCTION: Despite its positive effects on the skeleton, estrogen replacement therapy is no longer recommended as first-line therapy for the prevention and treatment of postmenopausal osteoporosis because it increases cardiovascular, thromboembolic, and breast cancer risk. Recently, herbal therapeutics such as an isopropanolic extract (iCR) from the rhizomes of Cimicifuga (=Actaea) racemosa (black cohosh) are gaining interest as an alternative in the treatment of menopausal symptoms. Whereas animal studies in rats suggest positive skeletal effects, the mechanism of its actions on bone cells remain unclear. RANKL is essential for osteoclast formation and activation, while osteoprotegerin (OPG) neutralizes RANKL. MATERIALS AND METHODS: In this study, we assessed the effects of iCR on OPG and RANKL mRNA steady-state levels by semiquantitative RT-PCR and on protein production by an ELISA system in human osteoblasts (hOBs). RESULTS: Under serum-free conditions, treatment with iCR increased OPG mRNA levels and protein secretion of hOBs by 2- to 3-fold in a dose-dependent manner, with a maximum effect at a 10(6)-fold dilution of iCR (p < 0.001) after 24-48 h. Time-course experiments indicated a stimulatory effect of iCR on osteoblastic OPG protein secretion by 3- to 5-fold (p < 0.001) as early as 12 h, whereas RANKL expression was very low and was not found to be modulated by iCR. Of note, the stimulatory effect of iCR on OPG production was abrogated by the pure estrogen receptor antagonist ICI 182,780. Moreover, iCR enhanced two osteoblastic differentiation markers, bone-specific alkaline phosphatase activity and osteocalcin expression, by up to 4- and 3-fold, respectively (p < 0.001). CONCLUSIONS: Our data suggest that iCR enhances differentiation and increases the OPG-to-RANKL ratio of normal human osteoblasts. These effects may contribute to the positive skeletal effects of black cohosh.

No estrogen-like effects of an isopropanolic extract of Rhizoma Cimicifugae racemosae on uterus and vena cava of rats after 17 day treatment.

The effects of black cohosh extracts (Rhizoma Cimicifugae racemosae) on primary estrogen target organs, like mammary gland and endometrium are better described then those on other estrogen-sensitive systems e.g. the vasculature. We therefore treated ovariectomized DA/Han rats for 17 days with an isopropanolic Cimicifuga racemosa rhizoma extract (iCR) alone and in combination with the pure antiestrogen fulvestrant. As control groups vehicle, estradiol, fulvestrant, and estradiol fulvestrant cotreatment were used. Effects of all substances were investigated by vena cava and uterine gene expression analysis using real-time-PCR. Uterus wet weight was increased after estradiol treatment compared to the negative controls but none of the other treatments including the treatment with iCR had a uterotrophic effect. While estradiol-induced changes in uterine gene expression were mainly analogous to those detectable in shorter term experiments, iCR showed no or slightly antiestrogenic effects on gene expression in the uterus. This is mirrored in the vena cava where iCR had a very minor impact on the expression of the genes analyzed. While C. racemosa is effectively used for treatment of peri- and post-menopausal symptoms for a long time its mechanism of action remains unresolved. Contrary to earlier suggestions C. racemosa does not seem to act as an estrogen agonist, but possibly as a weak antiestrogen.

Apoptosis of human prostate androgen-dependent and -independent carcinoma cells induced by an isopropanolic extract of black cohosh involves degradation of cytokeratin (CK) 18.

BACKGROUND: The inhibitory effects of black cohosh extracts (Cimicifuga syn. Actaea racemosa L.) on the proliferation of human breast cancer cells were reported recently. In this study, we turned examined another hormone-dependent, epidemiologically important tumor disease, prostate cancer. The cell growth inhibitory effect of an isopropanolic extract of black cohosh (iCR) on androgen-sensitive LNCaP and androgen-insensitive PC-3 and DU 145 prostate cancer cells was investigated. MATERIALS AND METHODS: The cytotoxic effect of the extract was determined by WST-1 assay. Apoptosis was determined by the appearance of apoptotic morphology, annexin V-FITC adherence and caspase activation. Cytokeratin (CK) 18 degradation was identified with M30 monoclonal antibody. RESULTS: Regardless of their hormone sensitivity, the growth of prostate cancer cells was significantly and dose-dependently down-regulated by iCR. The drug concentration producing 50% cell growth inhibition in all cell lines after 72h lay between 37.1 and 62.7 microg/ml. Increases in the level of M30 antigen of approximately 1.8-, 5.9- and 5.3-fold over untreated controls were observed in black cohosh-treated PC-3, DU 145 and LNCaP cells, respectively, with the induction of apoptosis being dose- and time-dependent. CONCLUSION: Black cohosh extract kills human hormone-responsive or-unresponsive prostate cancer cells by induction of apoptosis and activation of caspases. This finding suggests that the cell's hormone responsive status is not an important determinant of the response to the extract and that iCR extract may represent a novel therapeutic approach for the treatment of prostate cancer.

Evaluation of cell death caused by triterpene glycosides and phenolic substances from Cimicifuga racemosa extract in human MCF-7 breast cancer cells.

We previously reported that the antiproliferative effect of an isopropanolic-aqueous extract of black cohosh (iCR) on MCF-7 estrogen-responsive breast cancer cell line was due to the induction of apoptosis. Here we address the question to what extent apoptosis induction can be ascribed to one of the two major fractions of iCR, the triterpene glycosides (TTG) or the cinnamic acid esters (CAE). Furthermore, as black cohosh is routinely administered orally, we studied whether its pharmacological effects would withstand simulated liver metabolism. The antiproliferative activity of TTG and CAE as well as of rat liver microsomal S9 fraction-pretreated iCR on MCF-7 cells were investigated by WST-1 assay. The features of cell death induced were tested for apoptosis by flow cytometry (light scatter characteristics, Annexin V binding). Irrespective of S9-pretreatment, 72 h iCR treatment induced a dose-dependent down regulation of cell proliferation with the same IC50 of 55.3 microg/ml dry residue which corresponds to 19.3 microg/ml TTG and 2.7 microg/ml CAE. The degree of apoptotic MCF-7 cells was also comparable. Both, isolated TTG and CAE fractions inhibited cell growth, the IC50 being 59.3 microg/ml and 26.1 microg/ml, respectively. Interestingly, whereas IC50 and apoptosis induction correspond well for the whole extract, TTG and CAE fractions induced apoptosis at concentrations (25 and 5 microg/ml) well below those required for significant growth inhibition. Observation of this study firstly showed that the cell death induced by iCR withstood a metabolic activation system. In addition, TTG and CAE compounds significantly contributed to its apoptotic effect, CAE being the more potent inhibitor of proliferation and apoptosis inducer.

Concomitant administration of an isopropanolic extract of black cohosh and tamoxifen in the in vivo tumor model of implanted RUCA-I rat endometrial adenocarcinoma cells.

Black cohosh is a well known herbal remedy of long traditional use against menopausal complaints. Recently published studies on postmenopausal hormone replacement with synthetic substances associated severe negative side effects with an increase in duration of administration. The subsequent popularity of alternative treatments, often herbal drugs, made investigations into the safety of these preparations more pressing. Until now, black cohosh demonstrated no estrogen-agonistic activity in mammary cells, neither in animal model nor in cell culture, i.e., no gene transcription or cell proliferation was induced. Here we tested for the influence of a standardized isopropanolic extract of black cohosh on an animal model of endometrial cancer. Ectopic growth of the primary tumor as well as the incidence and localization of metastases were examined, partly in the setting of a combination treatment with tamoxifen. In contrast to the endometrial estrogen agonist tamoxifen, black cohosh did not further growth or metastasizing potential of the primary tumor. Absence of detectable supportive or antagonistic effects between both treatments most probable come from the relatively high tamoxifen dose.

Effects of an isopropanolic extract of Cimicifuga racemosa on urinary crosslinks and other parameters of bone quality in an ovariectomized rat model of osteoporosis.

A potential bone-sparing effect of Rhizoma actaeae (= cimicifugae) racemosae (black cohosh) was evaluated in ovariectomized Sprague-Dawley rats. The rats were ovariectomized at 12 weeks of age (body weight, 219-226 g) and placed on a soy-free diet 6 days after surgery. Animals were randomly assigned the following groups: control (n = 10), soy-free diet only; RAL (n = 10), soy-free diet plus raloxifene 3 mg/kg intragastrically; and REM (n = 10), soy-free diet supplemented with an isopropanolic black cohosh extract (Remifemin) with a daily intake of 4500 micro g triterpeneglycosides. Urinary levels of pyridinoline (PYR) and deoxypyridinoline (DPY), specific markers for bone loss, were measured at baseline and at weekly intervals. At the end of the study, the animals were killed and bone loss was determined by volumetric bone mineral density (BMD) measurements and peripheral quantitative computed tomography (pQCT). Mechanical resistance to fracture was also determined. Results demonstrated that an isopropanolic extract of black cohosh significantly diminished the urinary content of PYR and DPY and the morphometric correlates of bone loss associated with ovariectomy in rats. Reversal of the effects of ovariectomy on bone loss began 2-5 weeks after the start of treatment and continued through at least 7 weeks. Results similar in quality and magnitude were obtained in the group treated with raloxifene, a known selective estrogen receptor modulator (SERM). Because extracts of black cohosh are already recognized as safe and effective in the treatment of certain gynecological disorders, a longer-term clinical trial of this herbal remedy for the treatment of osteoporosis is warranted.

Lack of promotion of estrogen-dependent mammary gland tumors in vivo by an isopropanolic Cimicifuga racemosa extract.

Cimicifuga racemosa (CR) is widely used in the treatment of menopausal symptoms. Mechanistic studies suggest that unlike hormone-replacement therapy, CR does not stimulate estrogen-receptor positive breast cancer cells. To evaluate CR safety, we performed an in vivo investigation of a clinically tested isopropanolic CR extract. Mammary tumors were induced in Sprague Dawley rats (n = 75) by the application of 7,12-dimethylbenz[a]anthracene. Five to nine weeks later, the animals were ovariectomized, allowed to recover, and administered daily doses of CR extract (0.714, 7.14, or 71.4 mg/kg body weight per day) or control substances (estrogen/positive control: 450 microg/kg/day mestranol; or CR vehicle/negative control). The animals were sacrificed 6 weeks later, and tumor number, size, plasma hormone levels, and the weight of estrogen-sensitive organs were analyzed. In contrast to mestranol treatment, CR treatment did not stimulate cancerous growth. There were no significant differences in tumor number or size between the CR groups and the vehicle control. Likewise, prolactin, follicle-stimulating hormone, and luteinizing hormone levels and organ weights and endometrial proliferation were unaffected. The lack of mammary tumor-stimulating effects of this extract is of great significance in establishing the safety of CR extracts for treatment of menopausal symptoms in women with a history of breast cancer in which hormone-replacement therapy is contraindicated.