Efficacy and safety of Danhong injection in the treatment of arteriosclerosis obliterans:a meta-analysis of randomized controlled trials

Weijing Fan,Qiuyan Zhang,Changgeng Fu,Xiao Jin,Tong Xing,Zeji Chen,Xin Zhao,Zhonghui Zhao,Lina Miao,Baozhong Yang*

1Beijing University of ChineseMedicine,Beijing 100029,China;2Dongfang hospital affiliated toBeijing university of Chinesemedicine,Beijing100078,China;3Puning People'sHospital Affiliatedto Southern Medical University,Puning 515300,China;4Shangcai County People's Hospital,Henan,China.

Introduction

Atherosclerotic occlusion is a common degenerativediseaseinclinicalpractice,mostly occurringwithlargeandmedium-sized arteries.The main manifestations of the lesions are thickening of the vascularwall,accompaniedby atherosclerosisandcalcification,which leads to stenosisorocclusion ofthearteriesandleads to ischemia in the limbs.Anklebrachial index(ABI)isacommonlyused clinical examination method to evaluate the development of arteriosclerosis obliteransin lower extremities,andis currently recognizedas an indicator toreflect the degree of arteriosclerosis[1,2]studies have showna strong correlationbetween homocysteine levelsandthe occurrence of vascular diseases[3]danhong injectioniscurrently a common Chinese medicine preparation for thetreatment ofarteriosclerosis.Some studies have suggested that danhong injection has obvious effect on the treatment of arteriosclerosis occlusion,cansignificantly improve the degree ofarteriosclerosis and delay the developmentofarteriosclerosis.In thisstudy,literature wasscreened by strictinclusionand exclusioncriteria,andstudiesof different quality andsample sizeswere combined formetaanalysis,so as to systematically evaluatetheefficacyand safetyof danhong injectionin thetreatment of arteriosclerotic occlusion,so astoguidethe clinical practice.

Methods

ThePreferred Reporting Itemsfor Systematic Reviewandmeta-analysesStatement(PRISMA)were strictly followed in this study,and prism-p and PRISMAchecklist were used.

Inclusioncriteria Research type

Randomizedcontrolledtrials(RCTs)are chosen;The medical records arebasically complete and intact.

Research subjects

The diagnostic criteriaforatherosclerotic occlusion in thisstudy are defined asall clinicallyrecognized diagnosticcriteria andguidelinedocuments,such as the diagnosticcriteriaforarteriosclerotic occlusion in lowerextremities designated bytheChinese academy of foreign sciences.

Typeof intervention

The treatmentgroup in the experimentused danhong injection alone or combined with conventional treatment drugs. At least 40 participants were included in the experiment.At least 2 weeks of experimental treatment;The control group was treated with either placebo or conventional medicine.

Outcome indicators

The mainoutcomeindicatorsweredefinedas clinicalefficiencyandsafety.Secondaryoutcome therapyisdefinedas an indicatorthat reflects the degreeof atherosclerosisin thelowerextremity,such asankle brachial index(ABI).Homocysteine;It reflects hemorheologicalindicators,suchas plasma viscosity,etc.

Exclusioncriteria

Data errors andrepeatedpublicationof research data were excluded.

Data extraction

These data were extractedwhich included the author'sname,publicationtime,study samples,experimental andcontrolintervention measures,efficacy evaluationindicators,treatment process,follow-up time,randomized methods,baseline balance,blind trials,adversereactionreportsand results.According to the presetcriteria,two researchers independently screened eligible studies.

Methodological qualityassessment

According tothe criteria recommended by the Cochranemanual,theevaluation includes the following seven aspects: random sequence generation (selection bias);Allocation hiding(selection bias);Blindnessto researchersand implementers(implementationbias);Resultsof blind evaluation(measurement bias);Results data integrity(follow-upbias);Selective reporting of results(report bias);Othersources(otherbias).Eachprojectisdivided intothreerisk levels(low risk,unclear risk,high risk).The tworesearchers independently evaluated the inclusion ofthe literature and resolvedtheir differences through consultation with a third party.

Data analysis

RevMan 5.3 software provided by Cochrane collaboration wasadopted,and thecounting data wereOR(advantageratio),andthemeasurement data were MD (mean difference)and 95%confidenceinterval(CI).Theheterogeneitywas evaluated byI2 statistics,andI2was no morethan 50%, indicating no heterogeneity or slight heterogeneity.Thefixedeffect modelwas used to combinestatistical effects.Over 50%of I2 showed moderate severe heterogeneity,and combined statisticaleffects were performed usingthe random effect model.Publication biasisdeterminedby funnel plot analysis.If each study is uniformly distributed on both sides ofa verticalline combining OR values,there is no publication bias.

Retrievalstrategy

There are 8databases includingPubMed,Cochrane library,EMBASE,sciencenet,CNKI,Wanfang database,Chinascience and technology journal database and China biomedicalscience.The retrieval time is limited to self-builtlibrariesuntil June2018.Usethe following Chinese and English search words separatelyorincombination.Chinese search words: danhong, danhong injection,arteriosclerosis,arteriosclerosisoflowerlimbs,arteriosclerosis occlusion, occlusion of arteriosclerosis,efficacyand safety.The English search terms: Arteriosclerosis Obliterans,Obliterans, Arteriosclerosis, Cardiovascular Diseases,VascularDiseases,Danhong injection,Danhong and efficacy.

Specific retrievalstrategiesofPubMed are shown in figure 1.

Results

Literature screening results

A total of 13 studies were included,with atotal of 884 patients.All includedliteratures are Chinese literatures published from 2008 to 2018.The literature screening flow chart is shown in figure 2.

Included researchoverview

A total of 884 patients were included in the study,including 433 patients in the observation group and 451 patients in the control group.In each study,a maximum of 110 patients were included,and a minimum of40 patientswereincluded.The duration of each study ranged from 14 days to 9 months,with seven studies lasting 14 days.Seven studies included people with diabetes mellitus.See table 1 and table 2 for details.

Methodology quality evaluation

All of the 13 studies have been described as a random grouping,but only three of the studies have been done using random Numbers,and the rest of the studies have not been described in the method of generating random sequences;None of the studiesdescribed allocation hiding and blind methods.No follow-up was reported in all studies.As shown in figure 3,figure 4.

Data analysisresults Clinical efficiency

The evaluation criteria of curative effect were the diagnostic criteria of TCM diseases[20],which were divided into four grades:cure,obvious effect,effective effect and invalid.The total effective rate=(number of cure cases+number of obvious effect cases+number of effective cases)/total number of cases*100%.A total of 12 studies on Dan red injection in the treatmentof arteriosclerosis occlusion disorder efficient coverage,observation group 413 examples,the control group,431 cases of meta analysis results show that the Dan red injection treatment of arteriosclerosis occlusion diseaseclinicalcurativeeffectissuperiorto conventional drug treatment, difference was statistically significant(OR=3.08,95%CI(2.07,4.60), P < 0.00001), and no significant heterogeneity between the study(P=0.99,I2=0%).As shown in figure 5.

ABI

Six studies affectsDan redinjection for ABI,observationgroup 203 examples,the control group,223cases of meta analysis showedthat Danred injectiontherapyforABI improvearteriosclerosis occlusionsyndrome issuperiortoconventional drug treatment, difference was statistically significant(OR=0.15,95%CI(0.12,0.12),P<0.00001),but withhighheterogeneity,(P=0.003,I2=72%),sotherandomeffect modelwas adopted.Theheterogeneity of ABI changes significantly afterexcludingastudy[12](P=0.76,I2=0%).As shown in figure 6.

Homocysteine

Threestudiesof Danredinjectiononhomocysteine to reporton theinfluenceofobservation group94 examples,the controlgroup,94 cases of meta analysisresults show that theDanred injection treatmentofarteriosclerosisocclusion disease impact on homocysteine significantly greaterthan conventional drug treatment, there was no statisticallysignificant difference(OR=3.44,95%CI(6.86,0.02),P = 0.05),and have high heterogeneity(P=0.0005,I2=87%),so the random effectmodel wasadopted.Homocysteine heterogeneity changes significantly afterexcluding astudy[11](P=0.20,I2=38%).Asshown in figure 7.

Plasma viscosity

A total of 2 study affects Dan red injection on blood viscosity,observation group 70 examples,the control group,68 cases of meta analysis results show that the Dan red injection treatment of arteriosclerosisocclusion disorder,to improve blood viscosity is superior to conventional drug treatment,the difference was statistically significant(OR=0.19,95%CI(0.33,0.04),P=0.01),and high heterogeneity,(P=0.11,I2=60%),so the random effect model is adopted.As shown in figure 8.

Adverse reactions

Atotal of6studies[6-8,10,15,16]described the occurrenceofadverse reactions.No seriousadverse reactionswerefound in all studies.Study[15]reported 1 case ofmild dizziness inthetreatment group.No adverse reactionswere reported.

Publication bias

In this study,funnel plot was used to detect publication bias,and a total of 13 studies were conducted.The results showed that the included studies were basically symmetrical in distribution,indicating thatthere waslittle possibility of publication bias in this study.As shown in figure 9.

Figure 1 PubMed retrieval strategy

Figure 2 Literature screening flow chart

Studies included Sample size T/C Course/month Randomed implementation method Baseline difference Treatment group Control group Duration of treatment Outcome assessment T C Zhu 2014[5]34/34 18.12±2.47 20.41±2.74 NA NSD DH+CWM CWM 1 month a,d Yv 2018[6]20/20 NA Random number table NSD DH+CWM CWM 14 days a,b,d Zhang 2018[7]28/28 NA NA NSD DH+CWM CWM 28 days a,b Li 2008[8]30/28 NA NA NSD DH+CWM CWM 14 days a,c Cui 2015[9]55/55 NA Random number table NSD DH+CWM CWM 9 months a,b Sun 2014[10]40/40 NA NA NSD DH+CWM CWM 14 days a Ban 2014[11]40/40 4.7±2.1 4.9±2.2 Random number table NSD DH+CWM CWM 1 month a,b,d Zheng 2015[12]60/40 NA NA NSD DH+CWM CWM 28 days a,b Ma 2009[13]25/25 NA NA NSD DH+CWM CWM 14 days a Liu 2013[14]29/29 NA NA NSD DH+CWM CWM 14 days a Zhang 2008[15]32/32 NA NA NSD DH+CWM CWM 28 days a Yang 2014[16]40/40 NA NA NSD DH+CWM CWM 14 days a,e Niu 2016[17]20/20 NA NA NSD DH+CWM CWM 14 days b,e T:Treatment group,C:Control group,NA:Not available,DH:Danhong injection,CWM:Conventional medicine,NSD:No significant diffierence,a:Clinical efficacy,b:Ankle brachial index,c:Plasma viscosity,d:Homocysteine,e:TNF-α

Table 2 Basic information of the included studies

specialized committee30ml+0.9%NS250ml，qd Zhang 2008 Chinese society of integrative medicine peripheral vascular disease specialized committeeY Control group measure+danhong injection 30ml+0.9%NS250ml，qd Symptomatic treatment of basic diseases+Salvia miltiorrhiza injection 20ml+0.9%NS500ml，ivgtt，qd Yang2014 Chinese society of integrative medicine peripheral vascular disease specialized committeeY Control group measure+danhong injection 40ml+0.9%NS250ml，qd Symptomatic treatment of basic diseases Niu2016 Surgical vasculature committee of Chinese medicine societyY Control group measure+danhong injection 40ml+0.9%NS250ml，qd Symptomatic treatment of basic diseases+alprostadil injection 10μg，iv，qd

Figure 3 Bias risk analysis

Figure 4 Bias risk analysis

Figure 5 Meta analysis of clinical efficacy forest map

Figure 6Ankle-brachial index meta-analysis forest map

Figure 7 Forest map of homocysteine meta-analysis

Figure 8 Meta analysis forest map of plasma visc osity

Figure 9 Clinical efficiency funnel plot

Sensitivityanalysis

Meta analysis was carried out again after the most weighted study in this study was excluded[9],and the results did not change substantially.Meta analysis was carried out again after the possible heterogeneous sources in this study were excluded[11,12].The results did not change substantially.After changing the combined effect quantitative analysis model,it was shown that no statistically significant changes had taken place in allobservation indicators.The results show that this study is stable and reliable.

Discussion

Arteriosclerotic occlusion is themanifestation of arteriosclerosisinthe lower extremities.Thelatest reportshowsthatmorethan 200 million people aroundtheworld are affected,up24 percentfrom theprevious decadeandacrossall socio-economic classes.Atherosclerotic occlusionincreasesthe risk of death and cardiovascular disease-related disability,reduces quality of life,and imposesa significantfinancial burden onfamilies and society.Western medicine for arteriosclerotic occlusion mainly includes drug therapyand surgical treatment.Westernmedicine mainly focuses on anti-platelet,anti-coagulation, lipid-lowering, fibrinolysis,thrombolysisand so on[21]thetraditionalChinese medicinedisease of atherosclerotic occlusionis degangrene,which isalwayscaused by vein occlusion and stagnation of qi and blood[22].

Danhong injection mainly consists oftwo traditional Chinese medicines, danshen and safflower.Danshen hasthe functionof activating bloodcirculation,removing blood stasis and pain,coolingbloodto eliminate carbuncle,clearing heart toremove annoyance,nourishing bloodto calm nerves,and red flower also hasthefunction of activatingblood circulationand removing blood stasisandpain.Thetwo drugs areusedtogether and have theeffectof activating blood circulationand removingblood stasis and relieving collaterals throughveins[23].ModernpharmacologythinkDan red injectionmainly containtanshinone,salvia miltiorrhiza acid,phenolic acids and salvia miltiorrhiza safflower yellowpigment,safflower phenolic glycosides and catechins and other chemical composition, can inhibit platelet aggregation,anti-inflammatory,protecting vascular endothelium,resistanceto apoptosis,andso on,can bewidelyused inallkindsofvasculardisease[24,25],andDanred injection effectonthe degree of atherosclerosis has also been confirmed by many animal experiments and clinical research[26,27].

Combined with the results of this study,salvia miltiorrhiza injection has obvious effect on atherosclerotic occlusion,can significantly improve the degree of arteriosclerosis and hemodynamic status,and has a positive effect on homocysteine level.Limitations of this study:all the studies included were described as random groups,but only three studies described the way random sequences were generated.None of the studies included in this study used allocation hiding and blind method.The results may be influenced by selection bias or observer bias.In this study,there were different reports on the same type of outcome indicators,some of which were not comprehensive enough, and there might be report bias.In this study,4 studies only used TCM symptom score to report curative effect,without any support from objective clinical examination data.The treatment cycles of the study included in the literature were quite different.

Prospectoffutureresearch:therandomized controlled trialdesignof danhonginjectionfor arteriosclerotic occlusion shouldbe more rigorous.Theobservation ofoutcomeindicators shouldnot only be limited toTCM symptom evaluation,but also be considered objective and clinically recognizedoutcome indicators.Adverse reactions should bedocumentedandfollowed upshould be reported.Basic researchshouldbepaid attentionto,and moreindicatorsthatcan trulyreflect the curative effect should be explored.

Conclusion

Salvia miltiorrhiza injection hasobvious curative effectin the treatment ofatherosclerotic occlusion.Itcannotonly improve thesymptoms of patients,but alsohave positiveeffectson the degreeof atherosclerosis and hemodynamics ofpatients,and also has goodsafety.However,theinsufficient quantityandlow qualityoftheincluded literature have reducedthe argumentation intensityofthis meta-analysis.Morescientific andrigorous highquality RCTs are still needed.

1. LinZ,WangZH,Wu YT.The diagnosticvalue of brachial-ankle pulse wave conduction velocity andmalleolar arm index forearly arteriosclerosisinhypertensivepatients.Chin J Arterioscler,2015:1149-1152.

2. Sadeghi M,Heidari R,Mostanfar B,et al.The Relation Between Ankle-Brachial Index(ABI)and Coronary Artery Disease Severity and Risk Factors: An Angiographic Study.ARYA Atheroscler,2011,7:68-73.

3. PENG Hui-yong,MAN Chang-feng,XU Juan,etal.Meta analysis ofelevated plasma homocysteine levels and cardiovascular diseases and various death risk factors.Journal of Zhejiang University-Science B(Biomedicine&Biotechnology),2015:78-86.

4. Vascularsurgery section,Chinese surgical society.Guidelinesforthe diagnosisand treatment of lower limb arteriosclerosis obliterans.Chinese Medical Journal,2015:1883-1896.

5. Zhu QX,Liu GM,Zhu LJ.34 cases of lower limb arteriosclerotic occlusion were treated by danhong combined with alprostadil injection.Chinese Medicine Modern Remote Education,2014:12-14.

6. Yu Y,Chen HY,Sun C.Effects of tanhong injection on c-reactive protein and homocysteine levels in patients with early arteriosclerotic occlusion. World Chinese Medicine,2018:909-914.

7. Zhang QS,Wang AL.Effect of danhong injection combined with alprostadil injection on type 2 diabetes mellitus with lower limb arteriosclerotic occlusion.Modern Medicine&Health,2018:754-756.

8. Li F,Liu FQ,Tang Y,et al.Clinical observation of danhong injection combined with prostacyclin E_1 in the treatment of lower limb arteriosclerotic occlusion.Combined Chinese and Western Medicine with Cardiovascular and Cerebrovascular Diseases,2008:987-988.

9. Cui XM.Analysis of the curative effect of danhong injection combined with western medicine in the treatment of elderly patients with diabetic lower limb arteriosclerosis occlusion.New J Tradit Chin Med,2015:102-104.

10.Sun SG,Wang XM,Liu JT.Clinical observation of danhong injection in the treatment of type 2 diabetes mellitus with lower limb arteriosclerotic occlusion.Sichuan Journal of Traditional Chinese Medicine,2014:173-174.

11.Ban Y,Cui YC,Sun ZH.Clinical study on treatment of peripheral arteriosclerotic occlusion by urokinase combined with danhong injection.Med Recapit,2014:3401-3402.

12.Zheng SS,Tang Y.Clinical observation of alprostadil combined with danhong injection for the treatment of lower limb arteriosclerotic occlusion in elderly patients.China Modern Doctor,2015:56-58.

13.Marati simayi.Danhong injection for lower limb arteriosclerotic occlusion. Medical Information,2009:1958.

14.Liu LH.Clinical analysis of diabetic lower limb arterial disease.China Health Care&Nutrition,2013:775,776.

15.Zhang JD,Tang WL,Wu ZM,et al.Clinical study of danhong injection in the treatment of lower limb vascular diseases of type 2 diabetes mellitus.China Practical Medical,2008:20-22.

16.Yang LN,Tang J,Dou J.Serum HMGB1 and TNF-vaccine in patients with T2DM and lower extremity angiopathy were induced by berprost sodium combined with danhong injection.Hebei Medical Journal,2014:2107-2109.

17.Niu CX.Effectofdanhong injection on diabetic lower limb vascular disease and serum TNF-diarrhea.Inner Mongolia Traditional Chinese Medicine,2016:16.

18.Yang BH.Diagnostic and therapeutic criteria for arteriosclerosis obliterans. Beijing Traditional Chinese Medicine,2016:909-910.

19.Gersh B J,Maron B J,Bonow R O,et al.2011 ACCF/AHA guideline for the diagnosis and treatmentofhypertrophic cardiomyopathy:executive summary:a report of the American College of Cardiology Foundation/American Heart Association Task Forceon Practice Guidelines.J Am Coll Cardiol,2011,58:2703-2738.

20.Anonymity. Diagnostic criteria of TCM diseases[M].Beijing:China medical technology press,2008.

21.Fan WJ,Fu CG,Li P,et al.Meta analysis of thrombolytic combined with alprostadil in the treatment of arteriosclerotic occlusion.China J Chin Mater Med,2018:1701-1707.

22.Jia H,Yang BH.Preliminary study on Yang bo's medical treatment of gangrene.China JournalofBasic Medicine in Traditional Chinese Medicine,2012:748-749.

23.Li SJ,Tang YP,Shen J,et al.Medicine to study(Ⅷ)-salvia miltiorrhiza safflower on. .China J Chin Mater Med,2013:4227-4231.

24.Wang S,He SF,Zhai JB,et al.Advances in pharmacological action and clinical application of danhong injection.Traditional Chinese Medicine Information,2014:128-131.

25.Fu C,Luo Jm,Wang YM,et al.Simultaneous determination of 7 components in danhong injection by multi-wavelength high performance liquid chromatography.Chin J New Drugs,2012:2817-2820.

26.Fu TT,Wang CJ,Min CY,et al.Effect of danhong injection on experimental atherosclerosis in rabbits and its mechanism.Traditional Chinese Medicinal Materials,2009:1720-1722.

27.Li L,Duan W,Liu XB,et al.Danhong injection wasused to treat50 casesof arteriosclerosis obliterans.Chin J New Drugs,2011:242-244.