Add-on therapy of herbal formulation rich in standardized fenugreek seed extract in type 2 diabetes mellitus patients with insulin therapy: An efficacy and safety study

Abstract

Objective: To assess the safety and efficacy of herbal formulation rich in standardized fenugreek seed extract (IND-2) add-on therapy in type 2 diabetes mellitus (T2DM) patients who were on insulin treatment in prospective, single arm, open-label, uncontrolled, multicentre trial. Methods: T2DM patients (n=30) with aged 18-80 years who were stabilized on insulin treatment with fasting blood sugar (FBS) level between 100-140 mg/dL received IND-2 capsules (700 mg, thrice a day) for 16 weeks. The primary endpoints were an assessment of FBS at week 2, 4, 6, 8, 12 and 16. Secondary end-points include post-prandial blood sugar level, glycosylated Hb (HbA1c), reduction in the dose of insulin and number of hypoglycemic attacks, and improvement in lipid profile at various weeks. Safety and adverse events (AEs) were also assessed during the study. Results: Study was completed in twenty T2DM patients, and there was no significant reduction in FBS and post-prandial blood sugar level after addon therapy of IND-2. However, add-on therapy of IND-2 significantly reduced (P

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446
doi: 10.4103/2221-1691.242288 ©2018 by the Asian Pacific Journal of Tropical Biomedicine.
Add-on therapy of herbal formulation rich in standardized fenugreek seed extract in
type 2 diabetes mellitus patients with insulin therapy: An efficacy and safety study
Amit Kandhare1, Uday Phadke2, Abhay Mane3, Prasad Thakurdesai1, Sunil Bhaskaran1
1Department of Scientific Affairs, Indus Biotech Private Limited, 1, Rahul Residency, Off Salunke Vihar Road, Kondhwa, Pune - 411048, India
2Ruby Hall Clinic, 40, Sassoon Road, Pune 411001, India
3Tulip, Opp. Camp Education Society’s High School, Camp, Pune-411001, India
ART ICLE IN FO ABSTR ACT
Article history:
Received 2 July 2018
Revision 1 August 2018
Accepted 5 September 2018
Available online 27 September 2018
Keywords:
Add-on therapy
Dietary supplement
Glycaemic control
HbA1c
Standardized fenugreek seed extract
Type 2 diabetes
First and corresponding author: Amit Kandhare, Department of Scientific Affairs,
Indus Biotech Private Limited, Rahul Residency, Off Salunke Vihar Road, Kondhwa,
Pune - 411 048, Maharashtra, India.
Tel: +020 2685 1239; 020 2685 2139
E-mail: amit.kandhare@indusbiotech.com
Foundation project: This work was funded by Indus Biotech Pvt. Ltd., Pune.
1. Introduction
Type 2 diabetes mellitus (T2DM) is a complex, chronic
progressive disease which is most common amongst the various
forms of diabetes. It is manifested by hyperglycemia, disturbance
in the metabolism of carbohydrate, fat, and protein which could
be the result from deficiency secretion of insulin or its actions[1].
It is a long-term metabolic disorder which is associated with
multiple comorbidities as well as microvascular and macrovascular
Objective: To assess the safety and efficacy of herbal formulation rich in standardized
fenugreek seed extract (IND-2) add-on therapy in type 2 diabetes mellitus (T2DM) patients
who were on insulin treatment in prospective, single arm, open-label, uncontrolled, multicentre
trial. Methods: T2DM patients (n=30) with aged 18-80 years who were stabilized on insulin
treatment with fasting blood sugar (FBS) level between 100-140 mg/dL received IND-2
capsules (700 mg, thrice a day) for 16 weeks. The primary endpoints were an assessment of
FBS at week 2, 4, 6, 8, 12 and 16. Secondary end-points include post-prandial blood sugar
level, glycosylated Hb (HbA1c), reduction in the dose of insulin and number of hypoglycemic
attacks, and improvement in lipid profile at various weeks. Safety and adverse events (AEs)
were also assessed during the study. Results: Study was completed in twenty T2DM patients,
and there was no significant reduction in FBS and post-prandial blood sugar level after add-
on therapy of IND-2. However, add-on therapy of IND-2 significantly reduced (P<0.01)
the HbA1c values, requirements of insulin and hypoglycemic events as compared with
baseline. Total cholesterol, high-density lipoproteins-cholesterol, and low-density lipoprotein-
cholesterol levels were significantly increased (P<0.01) after IND-2 add-on therapy. Body
weight and safety outcomes did not differ significantly in IND-2 add-on therapy group at
week 16. Additionally, add-on therapy of IND-2 did not produce any serious adverse events.
Conclusions: The results of present investigation suggest that add-on therapy of IND-2 with
insulin in T2DM patients improves glycaemic control through a decrease in levels of HbA1c
and number of insulin doses needed per day without an increase in body weight and risk of
hypoglycemia. Thus, IND-2 may provide a safe and well-tolerated add-on therapy option for
the management of T2DM.
Asian Pacific Journal of Tropical Biomedicine 2018; 8(9): 446-455
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How to cite this article: Kandhare A, Phadke U, Mane A, Thakurdesai P, Bhaskaran
S. Add-on therapy of herbal formulation rich in standardized fenugreek seed extract
in type 2 diabetes mellitus patients with insulin therapy: An efficacy and safety study.
Asian Pac J Trop Biomed 2018; 8(9): 446-455.
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Amit Kandhare et al./ Asian Pacific Journal of Tropical Biomedicine 2018; 8(9): 446-455
complications such as retinopathy, nephropathy, neuropathy,
cardiomyopathy[2,3]. Numerous epidemiological studies have suggested
that obesity, insulin resistance, hyperlipidemia, hypertension, and
smoking are the risk factors associated with T2DM[4,5]. The prevalence
of T2DM is fast-growing worldwide and now become a major public
health problem. The projected prevalence of T2DM is predicted to
affect more than 350 million people by 2025 worldwide[6,7]. It also
produces significant economic burdens, and in a developing country
like India, the cost of illness for diabetic care is estimated at USD
336[8].
Due to a progressive increase in the costs of treatment, the intensive
lifestyle modifications have been suggested as a treatment alternative
to decrease the risk for diabetes development[9,10]. However, it
is difficult to achieve a targeted glycaemic control with lifestyle
modification alone. Hence, a strategic escalation of antidiabetic
therapy has suggested by the American Diabetes Association and
European Association for the Study of Diabetes[1]. Thus, metformin
has been recommended by the American Diabetes Association
and European Association for the Study of Diabetes as first-line
therapy in combination with lifestyle modifications for patients
with T2DM[1]. However, metformin may not be able to effectively
control glycaemic goals in the patients with higher baseline glycated
hemoglobin (HbA1c) levels. Thus, in such patient management of
diabetes needs multiple pharmacological treatments[1,11].
Dipeptidyl-peptidase-4 inhibitors and sulfonylureas are another
optional pharmacological therapies now available[5,12,13] that
increases insulin secretion by acting on pancreatic 毬-cells[14].
However, these treatment regimens are associated with decreased
毬-cell function along with concern for weight management. Thus,
adequate control of glycemia is difficult over a long period[15].
Thiazolidinediones (such as pioglitazone, rosiglitazone) is another
class of oral antihyperglycemic agents that act by regulating glucose
and lipid metabolism via modulation of peroxisome proliferator-
activated receptor 毭[16]. However, clinical evidence showed the
association of use of these agents with myocardial events risk and
nephrotoxicity[17].
It has been suggested that the failure in the maintenance of the
targeted level of glycated hemoglobin (HbA1c) is a major cause for
the worsening nature of T2DM[18,19]. Thus, the advanced therapy
of insulin has been recommended for improvement in glycaemic
control[1,20,21]. It has been showed that initiation of the insulin
therapy in the patients with metformin-alone helps to achieve the
glycaemic control with HbA1c reduction[22]. However, additional
risk such as weight gained and hypoglycemia need to be considered
while management of T2DM using insulin[23]. Furthermore, cost
of insulin, unavailability of insulin by the oral route, medication
compliance and insulin resistance are the major obstacles in insulin
therapy for the management of T2DM. The add-on therapy with
insulin may provide sustained glycaemic control along as well as a
decrease in the frequency of use of insulin[24,25]. Therefore, interest
in add-on therapies to insulin is increasing amongst diabetic patients.
Herbal medicine can be considered as an efficacious and safe
treatment alternative for the fulfillment of the unmet medical need as
an “add-on therapy” along with insulin in the long-term management
of T2DM[26-28]. A wide range of phytoconstituents isolated from
herbal origin can act by multiple mechanisms including stimulation
of insulin production, increase on insulin sensitivity, reduction in
HbA1c, modulation of insulin action, reduction of carbohydrate
absorption amongst others[28]. The traditional Indian and Chinese
medicines have documented an array of such medications for
the T2DM treatment with proven clinical safety and efficacy[29].
Camellia sinences, Emblica officinalis, Gymnema sylvestre, Linum
usitatissimum, Salacia reticulata, Tribulus terrestris, etc. are few
amongst them which showed clinical efficacy and safety in the
management of T2DM[30-40].
Trigonella foenum-graecum Linn. (Fabaceae) (fenugreek) has
ancient traditional uses in the treatment of diabetes. Fenugreek
possesses a broad spectrum of pharmacological and therapeutic
properties including anti-hyperlipidemic, antidiabetic, anticancer,
anti-arthritic, antioxidant, antimicrobial, antinociceptive and anti-
inflammatory potential[41-47]. Fenugreek plays a vital role in
the prevention of heart, liver, kidney and spleen diseases[48-53].
Several investigators have reported the hypocholesterolemic and
anti-diabetic potential of defatted fenugreek seed[43,54]. Studies
carried out by various researchers have reported the anti-diabetic
potential of fenugreek in an array of animal models[41,42,55] as
well as in human subjects[43,54]. These effects are related to the
presence of constituents such as alkaloid (Trigonelline) and amino
acid (2S,3R,4S, 4-hydroxyisoleucine (4-HI))[56-59]. In this view,
the herbal formulation (IND-2) has been developed which is rich
in standardized fenugreek seed extract. Previously, the researcher
also showed the beneficial effect of herbal formulation rich in
standardized fenugreek seed extract in the management of T2DM
patients inadequately controlled with a sulphonylurea[60]. However,
to our knowledge, add-on therapy of herbal formulation rich in
standardized fenugreek seed extract (IND-2) for its the efficacy and
safety have not been evaluated in a patient with T2DM who were
stabilized on insulin treatment. Hence, present investigation aimed
to assess the safety and efficacy of IND-2 add-on therapy in T2DM
patients on insulin treatment in prospective, single arm, open-label,
uncontrolled, multicentre study.
2. Materials and methods
2.1. Study design and protocol
The study was designed as a prospective, open-label, single arm,
uncontrolled, multicentre study to assess the safety and efficacy
of herbal formulation rich in standardized fenugreek seed extract
(IND-2) (Table 1) 700 mg, thrice a day as add-on therapy in T2DM
patients who were stabilized on insulin treatment. All patients
received 3 capsules of IND-2 per day, one in the morning (preferably
at 7 am), one in the afternoon (preferably at 3 pm), and one at night
(preferably at 11 pm). The capsules were administered one hour before
of taking the food or two hours after taking the food. The dose of
IND-2 was to be adjusted only when the blood sugar level < 80 mg/dL
or 20% less than the previous value. Patients who complained about
hypoglycemic attacks were discontinued from the study.
The study comprised a screening and enrolment period namely
week (-2) (visits 1) and week 0 i.e. baseline (visit 2), during which
patients continued background medication consisting of a stable dose
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448 Amit Kandhare et al./ Asian Pacific Journal of Tropical Biomedicine 2018; 8(9): 446-455
of insulin, and a treatment period, during which patients received 700
mg thrice a day as add-on therapy of IND-2 added to background
medication for 16 weeks. Total eight study visits occurred viz., week
2 (visits 3), week 4 (visit 4), week 6 (visit 5), week 8 (visit 6), week
12 (visit 7) and week 16 (visit 8, i.e., treatment end) (Figure 1).
Table 1
Composition of IND-2.
Sr. no. Name of the ingredient Standardised to marker Quantity
1. Trigonella foenum-graecum 20% 4-HI and 20% Trigonelline 500 mg
2. Salacia reticulata 20% Saponins 10 mg
3. Camellia sinences 50% Polyphenols 15 mg
4. Emblica officinalis 20% Tannins 70 mg
5. Gymnema sylvestre 25% Gymnemic acid 15 mg
6. Tribulus terrestris 20% Saponins 70 mg
7. Piper nigrum 95% Piperine 10 mg
8. Linum usitatissimum 40% Alpha linolenic acid 10 mg
Figure 1. Study design.
E: Enrolment; EOT: End of treatment; IOT: Initiation of treatment; V: Visit.
2.2. Inclusion and exclusion
Eligible patients were: (1) male or female subject aged 18-80 years,
(2) T2DM (Non-insulin dependent) patients who were stabilized on
insulin treatment, (3) fasting blood sugar (FBS) level between 100
mg/dL and 140 mg/dL including both (100 mg/dL and 140 mg/dL),
(4) difference between two blood sugar level readings (Visit 1 and
Visit 2) should not be more than 30 mg/dL, (5) written informed
consent from the subject, (6) stabilized at the same dose of insulin
for a minimum period of 8 weeks, (7) no participation in any other
clinical studies during last 60 days.
Exclusion criteria were subjects with conditions such as (1) severe
renal insufficiency defined by a creatinine value above 1.5 mg/dL,
(2) severe hepatic insufficiency defined by an SGOT (serum glutamic
oxaloacetic transaminase) or SGPT (serum glutamic pyruvic
transaminase) value equal or higher than the threefold normal values
of the respective laboratory safety value, (3) pregnant, willing to get
pregnant or nursing women, (4) participation in a clinical trial during
the 60 days before the present trial, (5) simultaneous participation in
another clinical trial, (6) cardiovascular disorder.
2.3. Withdrawal criteria
The participation in a clinical trial by the subjects may be
terminated at any time under the following conditions:
•At the discretion of the investigator: subjects can be withdrawn
on the discretion of the investigator at any time during the trial if
the possibility of any impairment of the subjects’ health cannot be
excluded.
•At the subject’s request: the subject can withdraw himself from the
trial without any reason.
•If an adverse event (AE) occurs: if a subject is withdrawn due to an
AE, this should be followed up until it has resulted in a stabilized
medical condition (recovered, recovered with residual damage,
death).
•Patients who did not get performed their laboratory testing within 7
days from the end of treatment visit
•If patients failed to come within 7 days of the scheduled follow-up
visit
•If patients become pregnant during the study
•If the major protocol violation occurred by the patients: like missing
two consecutive visits, not taking medication for 1 week, etc.
2.4. Compliance with ethics
All patients provided written and informed consent. The study
protocol was approved by the institutional review board of each
center (The protocol No. IBHM02/2002). The study was conducted
in compliance with the Declaration of Helsinki and the International
Conference on Harmonization Guideline for Good Clinical
Practice guidelines as defined by the International Conference on
Harmonization.
2.5. Compliance with treatment
Patients were encouraged not to skip scheduled medication intake
or reduce dosages on their own. Lapses observed during visits were
documented on the appropriate page of the Case Report Form.
Investigators evaluated treatment compliance by measuring unused
medication in the subject medication box. If more than 20% of the
total prescribed medication was not consumed by the patient during
every 2 weeks, the patient was termed as noncompliant and was
excluded from the trial.
2.6. Study endpoints
The effect of IND-2 (700 mg, thrice a day) on FBS compared with
baseline (week 0) was the primary efficacy endpoint. Whereas, the
effects of IND-2 on post-prandial blood sugar level (PPBS) and
glycosylated Hb (HbA1c), to check the feasibility of reduction in the
dose of insulin and number of hypoglycemic attacks after addition of
IND-2 and to assess improvement in lipid profile [i.e., triglycerides,
high-density lipoproteins-cholesterol (HDL-C), low-density
lipoprotein-cholesterol (LDL-C), total cholesterol (TC), and LDL-C
to HDL-C ratio] as compared with the baseline were the secondary
efficacy endpoints. Assessment of FBS, PPBS, HbA1c, insulin dose
and hypoglycemic attacks were done on all visits (Week 0, 2, 4, 6, 8,
12 and 16). The lipid profile was assessed on alternate visits (Week
0, 8 and 16).
2.7. Safety parameters
The following safety parameters were investigated to assess the
safety of IND-2:
• The clinical safely was evaluated on all visits by vital signs, ECG
recordings, and any AEs which may be spontaneously reported and
observed directly.
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• The following vital signs were considered for a measure of clinical
safety variable:
•The temperature of the body ( ̊ F)
•Respiratory rate (breath/minute)
•Systolic blood pressure (mmHg)
•Diastolic blood pressure (mmHg)
•Heart rate (beats/minute)
The laboratory safety was evaluated by determining the following
parameters at the initiation of treatment (week 0), and after 8 and
16 weeks: Haemoglobin (Hb), white blood cell (WBC): total and
differential count, red blood cell (RBC) count, platelet count,
mean corpuscular volume (MCV), mean corpuscular haemoglobin
concentration (MCHC), erythrocyte sedimentation rate (ESR), total
bilirubin, alkaline phosphatase (ALP), aspartate aminotransferase
(AST), alanine aminotransferase(ALT), lactic dehydrogenase
(LDH), serum proteins, urinalysis, blood urea nitrogen (BUN) and
creatinine.
2.8. Blood sampling and measurements
Blood samples were collected after fasting condition of at least
10 h. Then samples of blood were processed and analyzed in one
central laboratory. Samples were handled according to laboratory
routines, and the laboratory variables were analyzed according to
routine assay techniques at the laboratory.
2.9. Statistical analysis
A total of 30 participants were recruited with an assumption of a 20
percent dropout rate. Being a pilot study, no statistical method was
applied to decide the sample size. Results are represented as mean
± standard deviation (SD). Mean values of various diabetic markers
(FBS and PPBS levels, number of hypoglycemic attacks since the
last visit, amount of insulin required) and HbA1c at each visit were
compared with baseline. The secondary efficacy parameters, i.e.,
various lipid markers (TC, LDL-C, HDL-C, triglycerides, the ratio
of LDL-C and HDL-C), AEs (haematology and biochemistry) and
vital parameters at V6 as well as at V8 were compared with baseline
and analyzed using a paired t-test. The P<0.05 was considered
statistically significant. The SPSS version 16.0 software used for
statistical analysis.
3. Results
3.1. Patient recruitment, demographics and baseline
characteristics
Total 60 subjects were screened, and 30 (male = 16 and female
14) were recruited in the trial. Ten subjects were withdrawn from
the trial at various stages. The lost of follow-up [4/10 (40%)], and
AE [4/10 (40%)] were the most common reasons for treatment
discontinuation. Two subjects discontinued due to lack of compliance
and inclusion violation. Thus, 20 subjects were considered for the
study and received treatment with IND-2 add-on therapy. Figure 2
depicted the patient recruitment and selection process.
The demographics and baseline characteristics of the subjects were
represented in Table 2. At the baseline of the study, mean age was
52 years, HbA1c was 6.19%, BMI was 27.31 kg/m2, FBS levels was
121.71 mg/dL, and PPBS levels was 193.560 mg/dL.
3.2. Treatment compliance
After each visit, the unused capsules were counted from which the
treatment compliance was determined on a study population of 20. If
more than 20% of the total prescribed medication was not consumed
by the patient during every 2 weeks, the patient was termed as
noncompliant and was excluded from the trial. The mean treatment
compliance was > 98%, which was deemed acceptable.
Figure 2. Patient disposition.
Table 2
Demographic data (n = 20).
Parameter Value (Mean ± SD)
Age (Years) 52.00 ± 6.64
Male (n) 16 (53%)
Female (n) 14 (47%)
Height (cm) 155.03 ± 7.20
Weight (kg) 65.30 ± 5.81
BMI (kg/m2) 27.31 ± 3.35
FBS (mg/dL) 121.71 ± 13.90
PPBS (mg/dL) 193.56 ± 56.40
HbA1c (%) 6.19 ± 0.64
n: number of patients; BMI: body mass index; FBS: fasting blood sugar; HbA1c:
glycated hemoglobin; PPBS: postprandial blood sugar; SD: standard deviation.
3.3. Effects of IND-2 add-on therapy on glucose regulation
There was no statistically significant reduction in FBS and PPBS
level at week 2, 4, 6, 8, 12 and 16 after add-on therapy of IND-2
when compared with baseline (week 0) (Figure 3). However, add-
on therapy of IND-2 with insulin showed a significant decrease
(P<0.01) in HbA1c at week 8 compared with the baseline (Figure 4A).
Additionally, requirements of insulin (in terms of units consumed per
day) at week 2, 6, 8, 12 and 16 were also significantly less (P<0.001,
P<0.01, P<0.01, P<0.01 and P<0.01, respectively) after add-on therapy
of IND-2 as compared with from baseline (Figure 4B). Furthermore,
reductions in hypoglycemic events after add-on therapy of IND-2 at
week 2, 6 and 12 were also significantly reduced (P<0.01, P<0.01and
P<0.05, respectively) as compared with baseline (Figure 4C).
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450 Amit Kandhare et al./ Asian Pacific Journal of Tropical Biomedicine 2018; 8(9): 446-455
Blood sugar level (mg/dL)
FBS PPBS
300
200
100
0
-2 0 2 4 6 8 10 12 14 16 18
Time (in weeks)
Figure 3. Effect of add-on therapy of IND-2 on FBS and PPBS over 16 weeks.
Values are shown as the mean ± standard deviation. Data were analyzed by
paired “t” test.
Figure 4. Effect of add-on therapy of IND-2 on the HbA1c level (A), insulin
dose (B) and hypoglycemic events (C) over 16 weeks.
Values are shown as the mean ± standard deviation. Data were analyzed by
paired “t” test, *P<0.05, **P<0.01 and ***P<0.001 as compared with baseline
(week 0). HbA1c: Glycated hemoglobin.
3.4. Effects of IND-2 add-on therapy on lipid profile
LDL and TC showed a slight but significant increase (P<0.01
and P<0.05) at week 8 in the IND-2 add-on treatment group as
compared with the baseline. At 16 weeks of treatment, LDL, HDL,
and TC were also significantly increased (P<0.01) as compared with
the baseline. However, triglyceride levels and LDL: HDL ratio did
not differ significantly at week 8 and 16 when compared with the
baseline (Table 3).
Table 3
Effect of add-on therapy of IND-2 on efficacy variables of lipid profile.
Characteristic IND-2 + insulin
Week 0 (n = 30) Week 8 (n = 22) Week 16 (n = 19)
Total cholesterol (mg %) 174.05 ± 45.36 187.14 ± 40.93*185.63 ± 29.56**
LDL cholesterol (mg %) 111.61 ± 49.18 118.43 ± 51.92** 125.01 ± 44.05**
HDL cholesterol (mg %)$49.46 ± 9.29 51.91 ± 11.47 60.01 ± 9.79**
Triglyceride (mg %)$213.51 ± 52.07 217.57 ± 42.19 212.88 ± 44.86
LDL / HDL ratio 2.40 ± 1.29 2.35 ± 1.09 2.17 ± 0.97
Values are presented as the mean ± standard deviation. Data were analyzed
by paired “t” test, *P<0.05 and **P<0.01 as compared with baseline (Week 0).
$n = 20 at week 16.
LDL: Low-density lipoprotein; HDL: High-density lipoprotein.
3.5. Effects of IND-2 on safety outcomes
At week 16, there was no significant difference in body weight,
plasma AST, ALT, protein, and creatinine in add-on therapy with
IND-2 as compared with baseline (Table 4). However, treatment
with IND-2 showed significantly decreased (P<0.05) in ALP,
bilirubin, and significantly increased (P<0.05) in a BUN at week 8 as
compared with the baseline but these differences did not continue till
week 16 and remain non-significant as compared with the baseline
(Table 4).
Table 4
Effect of add-on therapy of IND-2 on safety parameters.
Parameter Baseline (Week 0)
(n = 30)
Week 8
(n = 22)
End of treatment
(Week 16) (n = 20)
Body weight (kg) 65.93 ± 14.87 66.09 ± 13.21 66.95 ± 14.87
AST (mg %) 28.82 ± 10.05 29.46 ± 10.35 26.28 ± 9.27
ALT (mg %) 28.60 ± 10.54 29.47 ± 12.64 26.23 ± 12.63
ALP (mg %) 158.28 ± 52.45 127.13 ± 37.79* 151.07 ± 63.08
Bilirubin (mg %) 0.76 ± 0.40 0.61 ± 0.25* 0.59 ± 0.32
Serum proteins (mg %) 7.76 ± 3.10 6.90 ± 3.03 6.92 ± 2.87
Serum creatinine (mg %) 0.93 ± 0.29 0.90 ± 0.26 0.96 ± 0.30
BUN (mg %) 13.14 ± 4.53 16.46 ± 3.73* 15.98 ± 4.28
Hb (mg %) 13.43 ± 4.03 14.21 ± 4.21 13.49 ± 4.34
Haematocrit 43.43 ± 12.27 45.86 ± 10.26 43.70 ± 15.28
MCV (fL/red cell) 79.10 ± 13.46 91.77 ± 10.57** 87.60 ± 10.45
MCHC (g/dL) 32.27 ± 11.83 34.23 ± 12.18 32.00 ± 10.43
RBC (in millions / cmm) 4.78 ± 0.75 4.54 ± 0.83 4.51 ± 0.86
WBC (mg %) 8 954.83 ± 3 080.28 9 934.00 ± 2 667.71 9 006.55 ± 2 914.94
Eosinophils (%) 3.40 ± 1.25 3.32 ± 1.29 3.30 ± 1.38
Neutrophils (%) 62.17 ± 12.65 58.55 ± 13.93 58.35 ± 11.38
Lymphocytes (%) 35.53 ± 9.47 39.86 ± 10.19 39.70 ± 7.18
Monocytes (%) 0.10 ± 0.31 0.09 ± 0.29 0.05 ± 0.22
Platelets (×伊1 000 / cmm) 271.20 ± 76.25 366.64 ± 99.27** 329.05 ± 75.50
Respiratory rate
(breaths per minute)
15.17 ± 3.26 12.91 ± 2.09* 13.35 ± 1.31
Values are presented as the mean ± standard deviation. Data were analyzed
by paired “t” test, *P <0.05 and **P<0.01 as compared with baseline (Week
0).
ALP: Alkaline phosphatase; ALT: Alanine transaminase; AST: Aspartate
transaminase; BUN: Blood urea nitrogen; Hb: Haemoglobin; MCV: Mean
corpuscular volume; MCHC: Mean corpuscular haemoglobin concentration;
RBCs: Red blood cells; WBC: White blood cells.
The levels of Hb, hematocrit, MCHC, RBC, WBC, eosinophils,
neutrophils, lymphocytes, and monocytes did not differ significantly
in IND-2 add-on therapy at week 8 and week 16 as compared with
the baseline. However, add-on therapy of IND-2 for 8 weeks resulted
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in a significantly increase (P<0.01) in MCV and platelets levels
when compared with baseline, but these changes were discontinued
till week 16 and remain non-significant when compared with
baseline. Similarly, the respiratory rate was decreased significantly
(P<0.05) at week 8 and remained non-significant at week 16 in
IND-2 add-on therapy group as compared with the baseline (Table
4).
3.6. AEs
Overall AEs and the most common AEs are summarized in Table 5
and Table 6. Add-on therapy of IND-2 did not produce any serious
AEs during the clinical study. Total 99 AEs were documented in the
study out of which 5 adverse events were graded as severe which
includes a cough (2), dyspnoea (1), diarrhea (1), and gastritis (1).
Seventeen events were considered as ‘related’ to the test drug, and 4
subjects were discontinued from the trial due to adverse events.
Table 5
Summary of adverse events experienced by a number of patients at least
once.
Adverse event No. of patients % of total
Abdominal pain 3 10.00
Anorexia 1 3.33
Anxiety 1 3.33
Constipation 1 3.33
Cough 2 6.66
Crystals in urine 2 6.66
Diarrhoea 6 20.00
Dry cough 2 6.66
Dyspnoea 1 3.33
ECG abnormal 5 16.66
Epithelial cells 6-8/hpf 1 3.33
Flatulence 1 3.33
Gastritis/Epigastric burning 7 23.33
Glycosuria 1 3.33
Headache 5 16.66
High BP 2 6.66
High BUN 3 10.00
High cholesterol 2 6.66
High eosinophil count 2 6.66
High ESR 8 26.66
High HDL 1 3.33
High MCHC 2 6.66
High MCV 1 3.33
High monocytes 3 10.00
High platelet count 1 3.33
High serum creatinine 3 10.00
High serum proteins 2 6.66
High total bilirubin 1 3.33
High triglycerides 1 3.33
High WBC 1 3.33
Low cholesterol 1 3.33
Low haematocrit 2 6.66
Low lymphocytes 1 3.33
Low plasma albumin 1 3.33
Low RBC 1 3.33
Nausea 3 10.00
Palpitation 1 3.33
Pus cells 4-6 hpf in urine 4 13.33
Restlessness 1 3.33
Sweating 2 6.66
Urine albumin 2 6.66
Taken individually, absolute frequency of adverse events such as
increase in ESR, gastritis/epigastric pain and diarrhea were the first
three most commonly observed adverse events. In terms of patients
experiencing the adverse events, the same adverse events were most
commonly observed. Mean values of some laboratory tests were
altered after 8 weeks and returned to normal after 16 weeks. There
were no deaths, or serious medical event reported in during this
clinical study.
Table 6
Absolute frequency of adverse events.
Adverse event Absolute
frequency
Adverse event Absolute
frequency
High ESSR 10 High eosinophil count 2
Gastric / Epigastric burning 8High S. proteins 2
Diarrhea 6Anorexia 1
ECG abnormal 6Anxiety 1
Headache 5Constipation 1
Pus cells in urine 5Dyspnoea 1
Nausea 4Epithelial cells 6-8/hpf 1
Abdominal pain 3Flatulence 1
High BP 3Glycosuria 1
High BUN 3High HDL 1
High monocytes 3High MCV 1
High S. creatinine 3High platelet count 1
Low haematocrit 3High total bilirubin 1
High MCHC 3High triglycerides 1
Cough 2High WBC 1
Crystals in urine 2Low cholesterol 1
Dry cough 2Low lymphocytes 1
Sweating 2Low plasma albumin 1
Urine albumin 2Low RBC 1
High cholesterol 2Palpitation 1
High eosinophil count 2Restlessness 1
All adverse events irrespective of causality.
4. Discussion
T2DM is a chronic, complex heterogeneous condition resulted
from impairment of insulin secretion from 毬 cells of the pancreas,
insulin action, or insulin resistance in the peripheral tissues. In the
last few decades, the prevalence of T2DM increases significantly
which makes it one of the most critical growing health issues
worldwide. Therefore, the guidance of the American Association
of Clinical Endocrinologists recommended the various treatment
regimen including dipeptidyl peptidase-4 inhibitors (such as
sitagliptin), thiazolidinediones, sulfonylureas, and insulin[61,62].
However, these agents are also associated with substantially clinical
side effects including a risk of hypoglycemia, increased body
weight, lactic acidosis, the risk of myocardial events, etc[1]. Hence,
many investigators have employed various add-on therapies from
the natural origin for the treatment of T2DM[4,63]. In the present
investigation, we have also assessed the safety and efficacy of IND-2
add-on therapy in T2DM patients who were on insulin treatment.
The outcomes of the present investigation showed that addition of
IND-2 (700 mg, thrice a daily) with insulin treatment for 16 weeks
significantly improved the amount of insulin required per day along
with significant decrease in of the numbers of hypoglycemic attacks
without any serious adverse events.
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452 Amit Kandhare et al./ Asian Pacific Journal of Tropical Biomedicine 2018; 8(9): 446-455
Numerous clinical evidence suggests that control over FBS
and PPBS level are essential outcomes in the management of
T2DM and reflected as the gold standard for overall glycaemic
control[64,65]. However, FBS level determination over time course
trend failed to provide the detailed information of diabetes status
and is also non-satisfactory[66]. Hence, according to the American
Diabetes Association, glycated hemoglobin (HbA1c, with a cut-
point ≥6.5%) has been recommended over FBS (≥7.0 mmol/L) for
diabetes detection[20]. Furthermore, HbA1c provides an insight about
the individual average levels of blood glucose over the last two to
three months. Thus, HbA1c is considered as a reliable indicator of
chronic glycemia and reflected the risk of various chronic diabetes
complications such as retinopathy, neuropathy, nephropathy, etc.
Hence, currently, HbA1c is widely used as an essential test for
chronic management of diabetes. In the present investigation, we have
also determined the effect of add-on therapy of IND-2 on HbA1c and
result show that it significantly decreased HbA1c levels over 8 weeks.
Fenugreek (Trigonella foenum-graecum), E. officinalis, G. sylvestre, S.
reticulata, and C. sinensis were reported to reduce the HbA1clevel in
clinical and preclinical studies[30-36,67]. Additionally, the presence of
4-HI in standardized fenugreek seed extract may be responsible for
the reduction in HbA1c level in T2DM patients and the findings of
the previous investigator also support this notion[56-59].
The management of T2DM many time needs the combination
of oral antidiabetic therapies including sulfonylureas, DDP-4
inhibitors. However, these therapies are substantially limited by its
side effects[1]. Hence, many T2DM patients eventually moved to
insulin therapy for maintaining better glycaemic control. Although
insulin is the most effective treatment available for the management
of blood glucose levels, it is still also associated with side effects
such as weight gain and risk of hypoglycaemia[1,23]. Therefore, in
such patients, there is a need for add-on therapy with more viable
and safe option. In the present investigation, we have implicated
IND-2 as an add-on therapy along with insulin for the management
of T2DM. The finding showed that IND-2 with insulin decreased
(27% reduction) the number of insulin dose needed per day as
compared with baseline. The observed beneficial effects of IND-2 on
top of insulin are anticipated from its complementary mechanism of
action. This action of IND-2 may depend on the amount of glucose
present which caused the secretion of insulin. This mechanism of
action of IND-2 is further supported by the decrease in the number
of hypoglycemic events over 16 weeks. Whereas, sulfonylurea
has a limitation where it caused continuous stimulation of insulin
secretion, even with decreasing level of glucose which results
in hypoglycemia[1]. Thus, clinically IND-2 can be considered
as a potential add-on therapeutic agent with insulin for T2DM
management, with a decrease in hypoglycemia risk and a decrease in
the number of insulin doses needed per day.
Further, we have also investigated the effect of IND-2 on lipids
profile which showed that a moderate but significant increase in
total, HDL and LDL cholesterol over 16 weeks. It has been well
documented that elevated level of cholesterol associated with risk
for CHD (coronary heart disease) and atherosclerosis[68]. However,
a recent clinical study also reported that vildagliptin add-on therapy
with insulin improves control on glycemia with an increase in the
risk of hyperlipidemia[69]. In the present investigation, documented
increase in lipid profile might be a secondary effect resulting from
decreased HbA1c levels.
According to the ADA/EASD guidelines, the treatment approach
for T2DM therapy should be based on patient-centric which should
consider various aspects including the need for treatment, preference
of patient and values[1]. Although ADA/EASD recommends insulin
as effective treatment for the management of T2DM, weight gain is
a common side effect associated with it. Thus, weight control during
the treatment of diabetes is an important consideration for the T2DM
management therapy. In the present study, body weight in add-on
therapy of IND-2 with insulin did not differ significantly despite
significant improvement in HbA1c which can be considered an
advantage of IND-2 along with insulin treatment.
Traditional medicines are considered to be relatively safe option
with low side-effects, but their efficacy is found relatively low as
compared with Western medicines. Hence, many times the high dose
was usually needed to attend the optimal therapeutic efficacy. Thus,
their toxicity cannot be neglected in the view of their therapeutic
applications[70]. The common adverse event associated with herbal
supplementation includes complications related to gastrointestinal
tracts such as nausea, vomiting, diarrhea, and constipation[71].
Also, herb-drug interaction related to pharmacokinetics and
pharmacodynamics properties needs to be considered during their
administration. In the present investigation, add-on therapy of IND-2
with insulin was well tolerated. There was no any serious AEs were
reported during the trial. Among the reported AEs, the majority of
the events were mild and not related to the IND-2 add-on therapy.
However, discontinuation of 4 subjects from the trial due to adverse
events is a significant finding. The previous investigator also reported
similar kind of cause which lead to treatment discontinuation[72,73].
Increased ESR is reported in a maximum number of patients and
tops the list of the number of absolute adverse events. Though, the
rise in ESR was reported as not related to drugs, there is a need for
further studies with a large number of patient population to confirm
the effect of IND-2 on ESR. All the events, which were related to the
drug were gastrointestinal tract events. Six significant abnormalities
in laboratory parameters were observed which were present during
week 8 and not continued till week 16.
Recent year various researchers have investigated the effect of
polyherbal formulation on HbA1c levels[74,75]. Administration of
polyherbal formulation that contains Gymnema sylvestre extract in
T2DM for 3 months showed significant improvement in HbA1c
levels and antioxidant enzyme activities[74]. Furthermore, a
polyherbal formulation containing standardized extracts of Trigonella
foenum-graecum and Emblica officinalis also showed a decrease
in HbA1c, FBS and PPBS in the T2DM patient with uncontrolled
blood sugar despite a sulfonylurea and metformin stable dose[65].
These studies suggested that Trigonella foenum-graecum, Gymnema
sylvestre, and Emblica officinalis were most widely implemented
herbs for preparation of polyherbal formulations in the management
of diabetes. Additionally, safety and efficacy of Trigonella foenum-
graecum as an anti-diabetic medication have also been well
established clinically[76,77]. Thus, results of current investigation
along with findings of earlier researchers both substantially provide
the potential of this polyherbal formulation (IND-2) as a safe and
well-tolerated add-on treatment option for the T2DM management
in the patients with insulin treatment.
The present investigation has certain limitations. The primary
limitation of this study is a single-arm study without placebo-
control. Hence, study with placebo-control will be required to assess
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453
Amit Kandhare et al./ Asian Pacific Journal of Tropical Biomedicine 2018; 8(9): 446-455
comparative efficacy of IND-2 in T2DM subjects. Secondly, the
sample size of the present investigation is relatively too small, and
the study duration is also too short which provides only short-term
effects. Hence, analysis of long-term effect with larger sample size
remains to be evaluated. Lastly, in this study, we have not evaluated
the parameters which give an insight to the possible mechanism of
action of IND-2 such as serum insulin level, molecular markers in
blood, level of antioxidants in blood, etc.
The findings of present investigation suggest that add-on therapy
of IND-2 (herbal formulation rich in standardized fenugreek seed
extract) with insulin in T2DM patients improved glycaemic control
through a decrease in levels of glycated hemoglobin and number of
insulin doses needed per day without a change in blood sugar, body
weight and risk of hypoglycemia. Thus, IND-2 may provide a safe
and well-tolerated add-on therapy option for the management of
T2DM.
Conflict of interest statement
Amit Kandhare and Prasad Thakurdesai are the full-time employees
of Indus Biotech Pvt. Ltd., Pune.
Acknowledgments
The authors gratefully acknowledge the support of all the
investigators and medical staff at the participating centers. The
authors would also like to acknowledge Hanul Medizin Pvt. Ltd.,
Pune, India for clinical research services. This work was funded by
Indus Biotech Pvt. Ltd., Pune.
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