Research Progress on Material Basis, Pharmacological Effect and Clinical Application of Danggui Shaoyao Powder

Lanqingqing ZHAO, Na LI, Zhe LI, Jinxin LIU, Yongzhou YU, Haifeng PAN, Zhenhua LIU, Hui XIONG*

1.Hebei Key Laboratory of Study and Exploitation of Chinese Medicine, Chengde Medical University, Chengde 067000, China; 2.Hebei Key Laboratory of Nerve Injury and Repair, Chengde Medical University, Chengde 067000, China; 3.Institute of Basic Medicine, Chengde Medical University, Chengde 067000, China; 4.Affiliated Hospital of Chengde Medical University, Chengde 067000, China

Abstract The research of modern pharmacology displays that main material basis of Danggui Shaoyao Powder exerting efficacy includes ligustilide, paeoniflorin, poria acid, ferulic acid, ligustrazine and so on, and its efficacy is mainly realized by regulating neural receptor-ligand interaction, cytokine release, and TNF-α inflammatory pathway.Systematic study of metabonomics, serum pharmacochemistry and network pharmacology of Danggui Shaoyao Powder sufficiently clarifies its potential pharmacodynamic mechanism, and it could provide scientific theoretical basis for its clinical application.In this paper, by systemically analyzing material basis of Danggui Shaoyao Powder, and exploring its complex pharmacological mechanism and clinical application in vivo, it could comprehensively understand the clinical value of Danggui Shaoyao Powder, so as to provide beneficial reference for further development of the material basis, quality control and classical prescription of Danggui Shaoyao Powder.

Key words Danggui Shaoyao Powder, Material basis, Pharmacological effect, Clinical application

1 Introduction

Danggui Shaoyao Powder was first recorded in theSynopsisofGoldenChamberwritten by Zhang Zhongjing, with the functions of fortifying spleen, removing dampness, nourishing blood, and regulating liver[1].Danggui Shaoyao Powder was originally used to treat "women’s abdominal diseases and pain", and it was classified as blood regulating agent in modernPrescriptionsofTraditionalChineseMedicine.Because of its exquisite formula, it has been deeply studied and widely used by doctors of past dynasties.It has a good therapeutic effect on gynecological diseases, endocrine system diseases, nervous system diseases and urinary system diseases, and is often used as the main prescription for soothing the liver and strengthening the spleen[2].In recent years, Danggui Shaoyao Powder is more and more in-depth in clinical application and basic research, and great progress has been made in the study of pharmacodynamic material basis and pharmacological mechanism.In this paper, the pharmacodynamic material basis, pharmacological action and clinical application progress of Danggui Shaoyao Powder in recent years were systematically reviewed, so as to provide a basis for follow-up research of Danggui Shaoyao Powder.

2 Component analysis

The whole prescription of Danggui Shaoyao Powder includes six traditional Chinese medicines: Angelicae Sinensis Radix, Paeoniae Radix Alba, Chuanxiong Rhizoma, Macrocephalae Rhizoma, Poria and oriental waterplantain rhizome, and it has the efficacy of "conditioning liver and spleen, and simultaneously treating blood and water".The original prescription puts Paeoniae Radix Alba in a important position, which can not only nourish blood, soften the liver, and relieve pain, but also dredge blood vessels and facilitate urination.Angelicae Sinensis Radix can nourish blood, activate blood circulation, regulate menstruation, and relieve pain.Angelicae Sinensis Radix and Paeoniae Radix Alba are commonly used as a principal medicine.Macrocephalae Rhizoma is dry dampness with warmth and bitterness, making dampness internalized.Poria is sweet, light, and excreting dampness, making the wet go from the bottom.Macrocephalae Rhizoma and Poria serve as adjuvant drug.Chuanxiong Rhizoma could promote blood and Qi circulation, and cooperate with principal drug to promote blood circulation and relieve pain.Oriental waterplantain rhizome could clear damp and promote diuresis, and enhance the function of increasing urine of Poria, and they are both adjuvants.The whole prescription uses Angelicae Sinensis Radix, Paeoniae Radix Alba and Chuanxiong Rhizoma regulating, nourishing and activating blood; Macrocephalae Rhizoma, Poria and oriental waterplantain rhizome eliminating, infiltrating and removing dampness, and they commonly play the effect of nourishing blood, regulating liver, strengthening spleen, and removing dampness.

3 Material basis research

As main form and means of clinical medication of traditional Chinese medicine, traditional Chinese medicine compound has a far-reaching impact.Each medicine in the compound also includes many kinds of chemical components, and the inherent chemical components in the medicine are the important material basis for the efficacy of traditional Chinese medicine compound.Therefore, an all-round analysis of the material basis of traditional Chinese medicine compound is a prerequisite for exploring the material basis of the efficacy of Danggui Shaoyao Powder.

3.1 Qualitative analysis of compositionAs conventional means of component analysis, HPLC-MS analysis has been widely used in the qualitative analysis of components of traditional Chinese medicine compound.Song Zhenyanetal.[3]used HPLC-MS/MS to identify that ferulic acid, paeoniflorin and poria acid were respectively main active ingredients of Angelicae Sinensis Radix, Chuanxiong Rhizoma, Paeoniae Radix Alba and Poria in Danggui Shaoyao Powder, and the stability of their contents was the key factor affecting the efficacy of Danggui Shaoyao Powder.Chenetal.[4]used HPLC-DAD-ESI-MS/MS to qualitatively analyze main components of Danggui Shaoyao Powder extract, and successfully identified 41 components in the compound, containing monoterpene glycosides, phenols, phthalates, sesquiterpenes and triterpenoids.

Based on component database, it could more rapidly conduct qualitative analysis of the components in the compound.Through TCMSP database, Xiao Yaoetal.[5]collected and obtained 534 chemical compositions of Danggui Shaoyao Powder in total.TakingOB≥30% andDL≥0.18 as screening standard, 51 chemical compositions of Danggui Shaoyao Powder were finally obtained, and 2 chemical compositions were from Angelicae Sinensis Radix; 13 chemical compositions were from Paeoniae Radix Alba; 7 chemical compositions were from Chuanxiong Rhizoma, 15 chemical compositions were from Poria, and 10 chemical compositions were from oriental waterplantain rhizome.

Each component activity in Danggui Shaoyao Powder is clear, and it relies on gradual development of screening technology for active components of natural products.Through TCMSP database, He Jinyietal.[6]screened out active ingredients and potential targets of Danggui Shaoyao Powder, and String platform was used to construct PPI network.Finally, software AutoDock was used for molecular docking of Danggui Shaoyao Powder with four key target proteins of irritable bowel syndrome.Core active ingredients of Danggui Shaoyao Powder treating irritable bowel syndrome were kaempferol, stigmasterol, myricetone, and camptothecin.

3.2 Content determinationNowadays, a variety of detection techniques can be used to determine the composition content of traditional Chinese medicine compounds, such as HPLC, UFLC and LC-MS.Fu Xinetal.[7]used HPLC to detect contents of representative components(paeoniflorin and paeoniflorin)in Danggui Shaoyao Powder.Under chromatographic column COSMOSIL 5C18-MS-II(4.6 mm×250 mm, 5 μm), 0.1% H3PO4solution-acetonitrile of mobile phase, 230 nm of wavelength, and 1 mL/min of flowing velocity, it was determined that content of paeoniflorin was between 7.24 and 36.20 μg/mL, while content of paeoniflorin was between 4.08 and 20.40 μg/mL.Guan Jiaoetal.[8]used UFLC to detect the content of ferulic acid in Danggui Shaoyao Powder.Under Shim-Pack XR-ODS colume(75 mm×3.0 mm, 2.2 μm), acetonitrile-0.1% phosphoric acid aqueous solution of mobile phase, 0.4 mL/min of flowing velocity, and 232 nm of wavelength, it was determined that the content of ferulic acid was 0.2 μg/mL.

4 Pharmacological action and mechanism

4.1 Treating gynecological diseases

4.1.1Inhibiting inflammatory effect.By observing the impact of optimized Danggui Shaoyao Powder on serum inflammatory factors and histopathology of chronic pelvic inflammation disease(CPID)model rat, Liu Minetal.[9]found that the optimized prescription could promote the recovery of immune function by regulating the levels of TNF-α, IL-1β and IL-10, further playing active therapy role in CPID model rat.Dingetal.[10]used Danggui Shaoyao Powder to intervene BV-2 microglia stimulated by LPS.The results displayed that Danggui Shaoyao Powder could weaken mRNA expression of proinflammatory cytokines, TLR2 and TLR4, and decline protein level of TLR4 and TLR and phosphorylation of IκB in BV-2 cell induced by LPS.Danggui Shaoyao Powder could protect neuroinflammation of BV-2 microglia induced by lipopolysaccharide through TLRs/NF-κB signal path.

4.1.2Inhibiting uterine smooth muscle spasm.Huaetal.[11]found that prostaglandin F2α had contractile effect on uterine smooth muscle, and had close relation to primary dysmenorrhea(PD).Danggui Shaoyao Powder could obviously decline the generation of prostaglandin F2α, and improve and relieve symptoms of dysmenorrhea.

4.1.3Inhibiting transformation, proliferation and differentiation of mammary epithelial cells.The research by Wang Ting[12]showed that additional prescription of Danggui Shaoyao Powder could promote gene expression of let-7 and inhibit protein expression of p-ERK in mammary epithelial cells of mammary hyperplasia rats.By observing histopathological changes of rat mammary gland, it was found that the hyperplasia and swelling of mammary gland in rats were relieved after treatment, so as to reduce mammary gland hyperplasia.

4.2 Treating endocrine system diseasesChang Yuxinetal.[13]found that Danggui Shaoyao Powder could regulate HPA axis hyperactivity to inhibit insulin resistance.Paeoniae Radix Alba in the compound could regulate disorder of lipid metabolism and improve insulin resistance.Extract of oriental waterplantain rhizome could promote insulin release.N-butanol composition in oriental waterplantain rhizome could inhibit absorption of glucose in isolated small intestine to certain degree, and triterpenoids of oriental waterplantain rhizome is pharmacodynamic basis of hypoglycemia.Guoetal.[14]proposed that active ingredient ligustilide of Danggui Shaoyao Powder could activate AMPK pathway, play the role of easing insulin resistance in diabetic rats, and reduce pathological damage.

4.3 Treating nervous system diseases

4.3.1Effect on neurotransmitters.By observing aging mouse taking orally Danggui Shaoyao Powder for three months, Fuetal.[15]found that Danggui Shaoyao Powder could promote the increase in monoamine neurotransmitters such as NE, DA, 5-HT, making that the ultrastructure of mouse cerebral cortex was protected.Song Zhenyanetal.[16]thought that after intragastric administration of Danggui Shaoyao Powder to Alzheimer’s disease model rats, it could obviously inhibit the expression of mRNA expression of inflammatory factors IL-1β and IL-18 in rats, decline protein expression of NLRP3, Caspase-1 and IL-1β, thereby inhibiting neuroinflammatory response, protecting nerves and improving learning and memory.

4.3.2Effect on cerebral ischemia.The research by Zhou Shannietal.[17]found that refined formula of Danggui Shaoyao Powder composed of Macrocephalae Rhizoma, Angelicae Sinensis Radix and Poria could increase Na+-K+-ATP enzyme activity in brain tissue of reperfusion injury in rats with focal cerebral ischemia, improve energy depletion caused by cerebral ischemia and cerebral ischemia reperfusion.

4.4 Treating urinary system diseasesThe research by Yue Xiaoli[18]displayed that action mechanism of Danggui Shaoyao Powder on nephrotic syndrome may be related to Danggui Shaoyao Powder acting on AVP-V2R-AQP2 pathway.Active ingredients of Danggui Shaoyao Powder could inhibit the combination of AVP and renal collecting duct V2R, and the activity of renin-angiotensin-aldosterone system, reduce the generation and secretion of plasma endothelin 1 and angiotensin II, make AVP content decline, reduce the expression of V2R, cause that the expression and action of aquaporin AQP2 are inhibited, improve water permeability of kidney, and promote excretion of urine, thereby reducing edema symptoms.By studying the effect of Danggui Shaoyao Powder on diabetic nephropathy, and using Danggui paeoniao powder to treat streptozotocin induced diabetic rats for continuous 12 weeks, Liuetal.[19]found that the prescription can effectively reduce the blood sugar of diabetic rats, and treat diabetic nephropathy by regulating blood sugar.

5 Systems biology research

5.1 MetabonomicsSu Zhaoweietal.[20]used GC-MS to give intervence of Danggui Shaoyao Powder to simple nonalcoholic fatty liver model rats with liver depression and spleen deficiency.After intragastric administration for 30 d, it was found that Danggui Shaoyao Powder could regulate lipid metabolism disorder, energy metabolism disorder and immune function disorder induced by modeling in rat, and had a therapeutic effect on nonalcoholic fatty liver disease by regulating mechanism of metabolic disorder.Wangetal.[21]applied Danggui Shaoyao Powder to nephrotic syndrome rat model using urine metabolomics method based on UPLC-Q/TOF-MS.The results displayed that Danggui Shaoyao Powder could realize regulation of amino acid and energy metabolism by regulating TNF, IL2 and ACE, thereby reaching treatment effect.

5.2 Serum pharmacochemistryCombining research results of pharmacokinetics and serum pharmacochemistry, it could make the analysis on material basis of efficacy of traditional Chinese medicine more scientific.Chen Linlinetal.[22]used HPLC-DAD-MSn to analyze drug components in serum of rats after intragastric administration of Danggui Shaoyao Powder extract.It was found that main components of Danggui Shaoyao Powder into blood were ferulic acid, ligusticum chuanxiong lactone I, ligustilide, paeoniflorin, paeoniflorin sulfate, paeoniflorin and butylene phthalide.Zhou Yu[23]used Danggui Shaoyao Powder and its decomposed recipes to conduct study on serum pharmacochemistry of cirrhotic ascites model rats, and HPLC-DAD was used to analyze components migrating to blood of cirrhotic ascites model rats after intragastric administration of Danggui Shaoyao Powder extract.Main components into blood existed in Paeoniae Radix Alba, Chuanxiong Rhizoma, and Angelicae Sinensis Radix, in which 6 components in Paeoniae Radix Alba, 8 components in Chuanxiong Rhizoma, and 6 components in Angelicae Sinensis Radix.

5.3 Network pharmacologyNetwork pharmacology is a new research method integrating pharmacology and system network analysis.Its research shows that Danggui Shaoyao Powder has the characteristics of multi-component, multi-target and multi-channel in clinical application, which is consistent with the overall concept of traditional Chinese medicine.Zhao Zhichengetal.[24]constructed "active ingredient-action target-access" network of Danggui Shaoyao Powder treating chronic pelvic inflammatory disease.30 active ingredients and 15 signal pathways involved antioxidant response, anti-inflammatory and immunity were screened, which further proved that Danggui Shaoyao Powder acted on chronic pelvic inflammatory disease via anti inflammatory mechanism.Zhou Chengchengetal.[25]constructed "composition-target" network, screened out 38 chemical compounds in Danggui Shaoyao Powder and 9 action targets of treating Alzheimer’s disease(AD), and elaborated that pharmacological mechanism of Danggui Shaoyao Powder treating AD was mainly related to multiple signal channels, such as cholinergic synapse, neural ligand-receptor interaction, and calcium signaling pathway.When studying Danggui Shaoyao Powder treating idiopathic membranous nephropathy(IMN), Gu Mingjiaetal.[26]retrieved 28 active ingredients and 33 corresponding targets of Danggui Shaoyao Powder, and obtained that the mechanism of Danggui Shaoyao Powder treating idiopathic membranous nephropathy mainly involved TNFR/FADD endogenous apoptosis pathway, BCL-2/BAX exogenous apoptosis pathway, and TNF-α inflammatory pathway.Network pharmacology prediction and analysis of Siwu Decoction was shown in Table 1.

Table 1 Network pharmacology prediction and analysis of Siwu Decoction

5.4 Intestinal floraModern research showed that fatty liver disease or liver cirrhosis were related to the changes of intestinal flora.Yinetal.[27]used 16S rRNA sequencing test to evaluate the pharmacodynamics of chemical substances in Danggui Shaoyao Powder, and found that Danggui Shaoyao Powder could regulate blood lipid, resist inflammation and reduce blood sugar by improving imbalance of intestinal microbiota in fructose fed rats, liver gene expression, and metabolites, thereby relieving pathological state of metabolic syndrome(MS).When Danggui Shaoyao Powder adding turtle shell and oyster was used to continuously treat patients with liver cirrhosis for 30 d, the level of bifidobacteria in the intestinal tract increased, while the level of Escherichia coli decreased.The clinical symptoms were improved significantly, and the liver function basically returned to normal.It showed that main action mechanism of Danggui Shaoyao Powder treating cirrhosis may be to improve the imbalance of intestinal flora and repair intestinal mucosal barrier[28].

6 Clinical research

According to records of ancient Chinese medical classics, Danggui Shaoyao Powder has the effects of invigorating spleen, removing dampness, nourishing blood, and regulating the liver.It is mainly used to treat pregnant or menstrual women, the patient with deficiency of liver and spleen, acute abdominal arrest and continuous pain[29].With the more in-depth study of Danggui Shaoyao Powder, its clinical application scope has gradually expanded.Now it has been widely used in the improvement and treatment of gynecological diseases, nervous system diseases, urinary system diseases and other diseases.

6.1 Application in gynecological diseases

6.1.1Treating primary dysmenorrhea.Zhang Yue[30]studied 38 patients with primary dysmenorrhea(14-35 years old), and the overall effective rate after treatment with Danggui Shaoyao Powder Decoction was 89.47%.Via clinical observation, it was proved that Danggui Shaoyao Powder was effective in the treatment of primary dysmenorrhea.Liu Geetal.[31]studied 30 patients with primary dysmenorrhea, and their average age was 25 years old, and average menstrual period was more than 3 years.The effective rate of oral Danggui Shaoyao Powder Decoction was 90%, and PGF2ɑ/PGE2 in peripheral blood significantly declined.It was proved that Danggui Shaoyao Powder was effective in the treatment of primary dysmenorrhea.

6.1.2Treating CPID.By studying treatment effect of Danggui Shaoyao Powder on 68 patients with chronic pelvic inflammatory disease(21-67 years old), Zhang Hua[32]found that Danggui Shaoyao Powder could effectively improve patients with menstrual disorders, abnormal leucorrhea, lumbosacral or lower abdominal pain and other clinical symptoms.While helping patients eliminate inflammation, it can also achieve the purpose of regulating Qi and blood and harmonizing liver and spleen.In the research, overall efficiency was 65%, showing that Danggui Shaoyao Powder had definite therapeutic effect on chronic pelvic inflammatory disease.

6.1.3Treating mammary hyperplasia.Liu Chenetal.[33]used Danggui Shaoyao Powder adding Radix Bupleuri, Nutgrass Galingale Rhizome, Fritillariae Cirrhosae Bulbus, and fried Hordei Fructus Germinatus to treat 100 female patients with liver depression and phlegm coagulation type of breast hyperplasia as well as overflow symptoms.The patients were 20-50 years old, and one menstrual cycle was one course of treatment.After three consecutive courses of treatment, total effective rate reached 94%.Danggui Shaoyao Powder can soothe the liver, relieve depression and pain, and has a good effect on breast hyperplasia patients with overflow.

6.2 Application in nervous system diseases

6.2.1Treating AD.By retrieving PubMed, Embase, advanced retrieval integration system of oriental medicine, Wanfang, CiNii and J-Stage, Kimetal.[34]screened out five items of researches using decoction of Danggui Shaoyao Powder to treat AD.Average research scale was 63 patients(40-85 years old).After therapy for 4-24 weeks, Meta analysis of comparison between Danggui Shaoyao Powder group and each therapy group displayed that there was significant difference from vitamin E group and nimodipine group(P<0.001), and the probability of improving symptoms of Danggui Shaoyao Powder combining with acupuncture was 2.14 times higher than that of simple acupuncture group.Danggui Shaoyao Powder could improve patient’s memory and ability of daily living, showing that this prescription was of great significance to the rehabilitation and symptom improvement of AD.

6.2.2Treating cerebral infarction.Ren Yangetal.[35]used Danggui Shaoyao Power Decoction combining rehabilitation training to treat 30 hospitalized patients with cerebral infarction(48-85 years old).After treatment for four weeks, total effective rate was 93.3%.The neurological deficit of patients was significantly improved compared with those treated with simple rehabilitation training, and the improvement was more obvious over time.Zhao Yichunetal.[36]used the combination of conventional therapy and oral treatment of Danggui Shaoyao Power Decoction to treat 30 patients with cerebral infarction(48-85 years old).It was found that NIHSS score and MMP-9 of patients after therapy obviously declined, indicating that Danggui Shaoyao Power could play its effect of improving neurological deficit by declining MMP-9 level of patients and treat its clinical symptoms.

6.3 Application in urinary system diseases

6.3.1Treating nephrotic syndrome.Zhou Bokaietal.[37]used oral administration of prednisone combining with Danggui Shaoyao Powder in the treatment of 44 patients with deficiency of spleen and kidney of primary nephrotic syndrome.After therapy, patients’ levels of urinary protein and blood lipid decreased, and renal function was improved.The levels of urea nitrogen and creatinine decreased, and the total effective rate was 95.45%.It showed that for the patients with primary nephrotic syndrome of deficiency of spleen and kidney, the treatment method dominant by Danggui Shaoyao Powder and supplemented by western medicine was effective.

6.3.2Treating urinary calculi.Zhang Hanming[38]used Danggui Shaoyao Powder adding Lysimachiae Herba, Radix Maclurae, Galli Gigerii Endothelium Corneum, Talcum, and Succinum to treat 50 patients with urinary calculi.After treatment for two months, stone discharge efficiency reached 80%, and average effective rate of relieving pain within 6 d was 96%.It was proved that Danggui Shaoyao Powder had the functions of clearing heat, removing dampness, relieving pain, promoting blood circulation and diuresis, dissolving and discharging stones.Chen Baoguo[39]used Danggui Shaoyao Powder adding Lysimachiae Herba, Curcumae Radix, and Herba Hedyotidis to treat 60 patients with urinary calculi and renal colic, and all cases excreted stones within one month after treatment.It showed that the modified formula of Danggui Shaoyao Powder can relieve urinary spasm for a long time, relieve pain in a timely manner, and had a good stone removal effect.

7 Conclusions

As classic prescription for syndrome differentiation treatment of Qi and blood deficiency with dampness, Danggui Shaoyao Powder is widely applied in various gynecological diseases, endocrine diseases, neurological diseases and urinary diseases, with less side effect.In Danggui Shaoyao Powder, there are only more than 30 known active ingredients, and common ingredients include paeoniflorin, albiflorin, ferulic acid, and ligustilide[40].So, the development and utilization of Danggui Shaoyao Powder in above diseases are still restricted.It is necessary to strengthen the research on the pharmacological mechanism and material basis of Danggui Shaoyao Powder in combination with modern experimental techniques.Therefore, it is our future research direction to systematically study Danggui Shaoyao Powder from the aspects of metabolomics, serum pharmacochemistry, pharmacodynamic material basis and target verification.Combining clinical treatment, it could provide theoretic basis for further improving its curative effect and clarifying the effect components and mechanism.