补肾活血中药治疗膝骨关节炎的循证、临床及实验研究

发布时间：2018-04-25 02:10

本文选题：补肾活血 + 膝骨关节炎　；参考：《广州中医药大学》2016年博士论文

【摘要】：目的1.循证医学研究评价补肾活血中药治疗膝骨关节炎的有效性及安全性。2.临床研究评价补肾活血中药龙鳖胶囊治疗膝骨关节炎的临床疗效、患者生活质量及安全性。3.动物实验研究依据龙鳖胶囊对膝骨关节炎(KOA, Knee Osteoarthritis)大鼠的膝关节肿胀度及大鼠体重、脏器指数和关节滑膜、软骨病理形态学的改善作用,观察龙鳖胶囊对大鼠膝骨关节炎的治疗作用；观察龙鳖胶囊对膝骨关节炎大鼠血清白细胞介素-1 β(IL-Iβ)、白细胞介素-6(IL-6)、白细胞介素-6(IL-I0)水平及膝关节病变组织中P38MAPK、 NF-κB信号传导通路中MEK-3/6、p38、ATF2、NF-κBp65和P-MEK-3/6、P-p38、P-ATF2、 P-NF-κ Bp65表达水平的影响,进而探讨龙鳖胶囊治疗膝骨关节炎的可能作用机制。方法：1.循证医学研究计算机检索中国生物医学文献数据库(CBM)、相关期刊论文(CNKI)、万方资源数据库、维普期刊数据库、Pubmed、Embase 和 Cochrane Library中关于补肾活血中药对比非甾体类抗炎药(Nonsteroidal Anti-inflammatory Drugs, NSAIDs)治疗膝骨关节炎的随机对照试验文献。对纳入研究的文献采用Jadad量表和Cochrane Handbook 5.1评估文献质量和偏倚性风险,采用软件RevMan 5.3.5进行数据分析,并运用GRADE系统对本研究得到的证据进行质量评价。2.临床研究采用简单随机对照将符合纳入标准的88例患者,随机分为龙鳖胶囊组44例和塞来昔布组44例,分别给予口服龙鳖胶囊和塞来昔布,两组均以4周为观察期,对两组患者治疗后的临床疗效、VAS评分、Lequesne指数、胃肠道不良反应及关节炎影响测定量表评分进行评价。3.动物实验研究建立膝骨关节炎大鼠模型,于造模后开始给予低、中、高剂量的龙鳖胶囊灌胃(0.3125,0.625,0.9375g·kg-1),连续4周,观察龙鳖胶囊对KOA大鼠的膝关节肿胀度及大鼠体重、脏器指数的影响,HE染色观察光镜下关节滑膜、软骨的一般形态,并对滑膜组织的病理学进行评分,Masson染色观察光镜下关节软骨的一般形态,并对软骨进行Mankin's评分；ELISA法检测血清白细胞介素-1 β(IL-I β)、白细胞介素-6(IL-6)及白细胞介素-10(IL-I0)水平,免疫组化SP法检测滑膜和软骨组织中MEK-3/6、p38、ATF2、NF-κ Bp65和P-MEK-3/6、P-p38、P-ATF2、P-NF-κ Bp65的表达情况。结果：1.循证医学研究纳入22篇随机对照试验文献,共2029例,其中补肾活血中药1022例,NSAIDs组1007例。Meta分析提示：与NSAIDs相比,补肾活血中药具有更高的总有效率(RR=1.10,95%CI[1.06,1.15],P0.00001)和临床控制率(RR=1.48,95%CI[1.19,1.84],P=0.0003),更低的胃肠道不良反应(RR=0.18,95%CI[0.09,0.35],P0.00001)。补肾活血中药和NSAIDs在改善WOMAC评分、Lequesne指数、KSS评分、Lysholms评分和VAS评分方面比较,差异均无统计学意义(P005)。GRADE证据质量评价提示：补肾活血中药的总有效率高于NSAIDs(低质量证据),补肾活血中药的临床控制率高于NSAIDs(氏质量证据),补肾活血中药与NSAIDs在改盖WOMAC评分、Lequesne指数、KSS评分、Lysholms评分和VAS评分方面无差异(极低质量证据),补肾活血中药的胃肠道不良反应低于NSAIDs(低质量证据)。2.临床研究龙鳖胶囊组总有效率92.25%,塞来昔布组总有效率90.00%,两组总有效率差异无统计学意义(P0.005)。与治疗前比较,龙鳖胶囊组和塞来昔布组的VAS评分、Lequesne旨数、关节炎影响测定量表评分均较前明显改善,差异均有统计学意义(P001)。治疗后组间比较,龙鳖胶囊组和塞来昔布组在VAS评分、Lequesne旨数方面差异均无统计学意义(P005)；龙鳖胶囊组的关节炎影响测定量表评分低于塞来昔布组,差异有统计学意义(P0.01)。治疗期间,龙鳖胶囊组出现胃肠道反应4例,塞来昔布组出现胃肠道反应3例,两组不良反应发生率比较,差异无统计学意义(P0.05)。3.动物实验研究造模后,造模组的膝关节肿胀度高于对照组(P0.01)。给药2周后,与造模组及龙鳖低、高剂量组比较,龙鳖中剂量组的膝关节肿胀度消退较快(P0.01)。给药3周后,龙鳖低、中、高剂量组的膝关节肿胀度消退均快于造模组(P0.01),其中,龙鳖中剂量组的膝关节肿胀已消退至对照组水平(P0.05)。给药4周后,与对照组比较,龙鳖低、中、高剂量组的膝关节肿胀度均己消退(P0.05)。造模后,造模组的体重和胸腺指数低于对照组(P0.05),造模组的脾脏指数与对照组比较,差异有统计学意义(P0.05)。给药2周后,龙鳖中剂量组的体重重于对照组(P0.05)；而龙鳖低、高剂量的体重与对照组比较,差异均无统计学意义(P0.05)。给药4周后,龙鳖低、中、高剂量的体重均重于对照组(P0.05),而龙鳖中剂量组的体重又重于龙鳖低、高剂量组(P0.05)。给药2周后,各组之间的脾脏指数两两比较,差异均无统计学意义(P0.05)。给药4周后,龙鳖低、中、高剂量组的脾脏指数均高于同期对照组和造模组(P0.05)。给药2周后,龙鳖低、中、高剂量组的胸腺指数均高于同期造模组(P0.05)。给药4周后,各组组间的胸腺指数比较,差异无统计学意义(P0.05)。给药2周、4周后,龙鳖低、中、高剂量组的软骨结构破坏程度和滑膜炎症程度均较造模组轻,龙鳖低、中、高剂量组的膝关节滑膜组织病理评分值均低于造模组(P0.01)。给药4周后,龙鳖中剂量组的膝关节滑膜组织病理评分值与龙鳖高剂量组比较,差异有统计学意义(P0.05)。给药2周、4周后,龙鳖低、中、高剂量组的膝关节软骨M ankin评分值均低于造模组(P0.01),同期龙鳖低、中、高剂量组的膝关节软骨Mankin评分值组间两两比较,差异均无统计学意义(P0.05)。造模后,造模组的IL-1 β、IL-6水平均高于对照组(P0.01),而IL-10水平低于对照组(P0.01)。给药2周、4周后,造模组的IL-1 β水平均高于同期对照组及龙鳖低、中、高剂量组(P0.05)；龙鳖低、中、高剂量组的IL-1β水平均高于同期对照组(P0.05)；龙鳖中剂量组IL-1 β水平均低于同期龙鳖低、高剂量组(P0.05)。给药2周、4周后,造模组IL-6水平均高于同期对照组及龙鳖低、中、高剂量组(P0.01)；龙鳖低剂量组IL-6水平均低于同期龙鳖中、高剂量组(P0.01)。给药2周后,龙鳖低、中、高剂量组IL-6水平均高于对照组(P0.01)；给药4周后,龙鳖胶囊低剂量组IL-6水平与对照组比较,差异无统计学意义(P0.05)。给药2周、4周后,龙鳖低、中、高剂量组IL-10水平均高于同期对照组和造模组(P0.01),而其中龙鳖中剂量组IL-10水平均高于同期龙鳖低、高剂量组(P0.01)。在滑膜组织中,给药2周、4周后,各组细胞均有MEK-3/6、p38、ATF2、 NF-κ Bp65 和 P-MEK-3/6、P-p38、P-NF-κ Bp65阳性表达,其中造模组MEK-3/6、p38、ATF2、NF-κ Bp65和P-MEK-3/6、P-p38、P-NF-κ Bp65阳性细胞百分比均高于对照组和龙鳖低、中、高剂量组(P0.01)。给药2周、4周后,各组细胞均有P-ATF2弱阳性表达；2周后,造模组P-ATF2阳性细胞百分比高于对照组和龙鳖低、中、高剂量组(P0.05)；4周后,各组间P-ATF2阳性细胞百分比比较,差异均无统计学意义(P0.05)在软骨组织中,给药2周、4周后,各组细胞均有MEK-3/6、p38、NF-κ Bp65和P-MEK-3/6、P-p38、P-NF-κ Bp65阳性表达,其中造模组MEK-3/6、p38、NF-κ Bp65和P-MEK-3/6、P-p38、P-NF-κ Bp65阳性细胞百分比均高于对照组(P0.01),龙鳖低、中、高剂量组MEK-3/6、p38、NF-κ Bp65和 P-MEK-3/6、P-p38、P-NF-κ Bp65阳性细胞百分比均低于造模组(P0.05)。给药2周、4周后,各组细胞均有ATF2和P-ATF2弱阳性表达,且造模组ATF2和P-ATF2阳性细胞百分比均高于对照组(P0.01)；给药2周后,龙鳖低、中、高剂量组ATF2阳性细胞百分比均低于造模组(P0.01);给药4周后,龙鳖低、中、高剂量组ATF2阳性细胞百分比与造模组比较,差异无统计学意义(P0.05)；给药2周、4周后,龙鳖低、中、高剂量组P-ATF2阳性细胞百分比均低于造模组(P005)。结论：1.循证医学研究补肾活血中药是治疗膝骨关节炎的有效方法,不良反应较少。由于纳入文献的样本量较小、方法学质量不高,本研究的结论仍亟需更多高质量的临床随机对照试验予以支持。2.临床研究采用龙鳖胶囊和塞来昔布治疗膝骨关节炎,均可有效缓解症状、改善膝关节功能,具有良好的有效性和安全性；但龙鳖胶囊在改善生活质量方面优于塞来昔布。3.动物实验研究龙鳖胶囊能消除膝骨关节炎大鼠的膝关节肿胀,抑制造模引起的大鼠体重下降,增加膝骨关节炎大鼠的体重和脾脏指数,使造模降低的胸腺指数恢复至正常水平,可减轻膝骨关节炎大鼠软骨结构破坏的范围和严重程度,显著减轻滑膜炎症,并具有促进软骨细胞增生的作用。实验表明,龙鳖胶囊缓解膝骨关节炎大鼠炎症反应与其增强大鼠免疫器官的功能密切相关。龙鳖胶囊可增强膝骨关节炎大鼠免疫器官的功能,降低血清炎性细胞因子IL-1β、IL-6的表达水平和升高抑炎细胞因子IL-I0的表达,抑制过度亢进的p38MAPK和NF-κB信号,抑制骨关节炎滑膜和软骨细胞中p38MAPK和NF-K B信号通路的活化,是龙鳖胶囊发挥治疗作用的重要机制。
[Abstract]:Objective 1. evidence-based medicine to evaluate the efficacy and safety of tonifying kidney and activating blood Chinese medicine for the treatment of knee osteoarthritis.2. clinical study on the treatment of knee osteoarthritis with dragon and turtle capsule of tonifying kidney and blood circulation, the quality of life and safety of the patients.3. animal experiment research according to long turtle capsule to KOA (Knee Osteoarthritis). The swelling of the knee joint and the weight of rats, organ index, joint synovial membrane, and cartilage pathomorphology improved the therapeutic effect of dragon shell capsule on knee osteoarthritis in rats, and observed the level of serum interleukin -1 beta (IL-I beta), interleukin -6 (IL-6) and interleukin -6 (IL-I0) in the serum of rats with knee osteoarthritis. The effect of MEK-3/6, p38, ATF2, NF- kappa Bp65 and P-MEK-3/6, P-p38, P-ATF2, P-NF- kappa expression level in the P38MAPK, NF- kappa B signal transduction pathway in the pathological tissue of the knee joint, and then to explore the possible mechanism of the action of dragon shell capsule on the treatment of knee osteoarthritis. Method: 1. evidence-based medicine research computer retrieval Chinese biomedical literature database, Chinese journal full text database (CNKI), Wanfang resource database, VIP journal database, Pubmed, Embase, and Cochrane Library for the comparison of non steroidal anti-inflammatory drugs (Nonsteroidal Anti-inflammatory Drugs, NSAIDs) in the treatment of knee osteoarthritis in comparison with non steroidal anti-inflammatory drugs (Nonsteroidal Anti-inflammatory Drugs, NSAIDs) in the treatment of knee osteoarthritis. The table and Cochrane Handbook 5.1 assessed the literature quality and bias risk, using the software RevMan 5.3.5 for data analysis, and using the GRADE system for the quality evaluation of the evidence obtained in this study.2. clinical studies using a simple random control will be in line with the inclusion criteria of the 88 patients, randomly divided into 44 cases of dragon shell capsule group and 44 celecoxib group. The two groups were given 4 weeks as the observation period. The clinical efficacy, the VAS score, the Lequesne index, the gastrointestinal tract adverse reaction and the arthritis influence measurement scale were evaluated in the two groups. The rat model of the knee osteoarthritis was established by the.3. animal experiment. The high dose of dragon turtle capsule was gavage (0.3125,0.625,0.9375g. Kg-1) for 4 weeks. The effect of dragon and turtle Capsule on the swelling of knee joint and the body weight and organ index of rats in KOA rats was observed. The joint synovial membrane and the general shape of cartilage under light microscope were observed by HE staining, and the pathology of the synovial tissue was scored by Masson staining, and the soft joints under the light microscope were observed by Masson staining. The general morphology of the bone, and the Mankin's score of the cartilage, the ELISA assay of serum interleukin -1 beta (IL-I beta), interleukin -6 (IL-6) and interleukin -10 (IL-I0), and the immunohistochemical SP method for the detection of MEK-3/6, p38, ATF2, ATF2, ATF2, IL-I0, and cartilage tissue. 1. evidence-based medicine (EBM) included 22 randomized controlled trials in 2029 cases, including 1022 cases of tonifying kidney and activating blood and 1007 cases of.Meta in group NSAIDs: compared with NSAIDs, the traditional Chinese medicine of tonifying kidney and activating blood has higher total effective rate (RR=1.10,95%CI[1.06,1.15], P0.00001) and clinical control (RR=1.48,95%CI[1.19,1.84], P=0.0003) and lower stomach. RR=0.18,95%CI[0.09,0.35] (P0.00001). There was no significant difference in the improvement of WOMAC score, Lequesne index, KSS score, Lysholms score and VAS score in the improvement of the kidney and activating blood circulation Chinese medicine and NSAIDs (P005).GRADE evidence quality evaluation suggested that the total effective rate of the traditional Chinese medicine for reinforcing kidney and blood circulation was higher than that of NSAIDs (low quality evidence). The clinical control rate of kidney Huoxue Chinese medicine was higher than that of NSAIDs (quality evidence). There was no difference in WOMAC score, Lequesne index, KSS score, Lysholms score and VAS score for kidney invigorating and activating blood circulation Chinese medicine and NSAIDs (extremely low quality evidence). The gastrointestinal tract adverse reaction of Chinese traditional Chinese medicine for invigorating kidney and promoting blood circulation should be lower than NSAIDs (low quality evidence).2. clinical study long turtle capsule group The total effective rate was 92.25%, the total effective rate of celecoxib group was 90%, the total effective difference between the two groups was not statistically significant (P0.005). Compared with the pre treatment group, the VAS score of the dragon and the celecoxib group and the celecoxib group were significantly improved by the scores of Lequesne, and the difference was statistically significant (P001). There was no significant difference in the VAS score between the BIE capsule group and the celecoxib group in the Lequesne purpose (P005). The Arthritis Impact Measurement score of the Dragon shell capsule group was lower than the celecoxib group, and the difference was statistically significant (P0.01). During the treatment, 4 cases of gastric bowel reaction were found in the Dragon shell capsule group and 3 cases of the celecoxib group had gastrointestinal reaction. There was no significant difference in the incidence of adverse reactions between the two groups (P0.05) the swelling degree of the knee joint in the model group was higher than that of the control group (P0.01) after the model of.3. animal experiment. After 2 weeks of administration, the knee swelling degree of the middle dose group was faster than the model group and the low and high dose group of the soft shelled turtle (P0.01). After 3 weeks of administration, the Dragon shelled Turtle was low, middle and high. The knee swelling degree of the knee joint in the dose group was faster than the model group (P0.01), and the knee swelling of the middle dose group of the Dragon shelled turtle had subsided to the control group (P0.05). After 4 weeks of administration, the knee swelling degree of the high dose group was lower than that of the control group (P0.05). The body weight and thymus index of the model group were lower than those of the control group. P0.05), the spleen index of the model group had a significant difference compared with the control group (P0.05). After 2 weeks of administration, the weight of the medium dose group was heavier than the control group (P0.05), but the high dose weight of the dragon and soft shelled Turtle was lower than that of the control group (P0.05). After 4 weeks of administration, the low, middle and high dose weight of the dragon and soft shelled turtle were all heavier than the control group (P 0.05), and the weight of the medium dose group was heavier than the low and high dose group (P0.05). After 2 weeks of administration, the spleen index 22 was no significant difference (P0.05). After 4 weeks of administration, the spleen index of the low, middle and high dose group was higher than that of the same stage control group and the model group (P0.05). After the administration, the low, middle, and high doses of the soft shelled turtle were low, medium and high. The thymus index of the group was higher than that of the same model group (P0.05). After 4 weeks of administration, the thymus index was not statistically significant (P0.05). After 2 weeks of administration, the degree of cartilage destruction and synovitis in the low, middle and high dose groups were lighter than those of the model group, and the knee joint synovitis in the low, middle and high dose group of dragon and soft shelled Turtle was low. After 4 weeks of administration, the histopathological score of the knee joint synovium in the middle dose group of the dragon and shelled Turtle was compared with the high dose group (P0.05). After 2 weeks of administration, the M ankin score of the knee cartilage in the low, middle and high dose group was lower than that of the model group (P0.01), and the low, middle and high level of the dragon and soft shelled turtle were low, middle and high in the same period. There was no significant difference between the 22 groups of the Mankin score of the knee cartilage in the dose group (P0.05). After the model, the IL-1 beta and IL-6 water in the model group were higher than the control group (P0.01), and the IL-10 level was lower than that of the control group (P0.01). The level of IL-1 beta in the model group was higher than that of the control group and the low, middle and high dose group (P0 group (P0) after 4 weeks. .05): the level of IL-1 beta in low, middle and high dose groups was higher than that in the same control group (P0.05), and the level of IL-1 beta in middle dose group was lower than that of low and high dose group (P0.05). After 2 weeks, the average IL-6 water in the model group was higher than that of the control group and the middle and high dose group (P0.01), and the average of IL-6 water in the low dose group of the dragon and the Turtle was lower than that of the same group. After 2 weeks of administration, the average IL-6 water in the low, middle and high dose group was higher than the control group (P0.01) after 2 weeks of administration. After 4 weeks of administration, the level of IL-6 in the low dose group was not statistically significant (P0.05). After 2 weeks and 4 weeks, the level of IL-10 in the low, middle and high dose group was higher than that of the control group and the model group. Group (P0.01), but the level of IL-10 in medium dose group was higher than that of low and high dose group (P0.01) in the same period. In synovial tissue, the cells were given MEK-3/6, p38, ATF2, NF- kappa Bp65 and P-MEK-3/6, P-p38, P-NF- kappa Bp65 in synovial tissue for 2 weeks. The percentage of positive cells was higher than that in the control group and the low, high dose group (P0.01). After 2 weeks of administration, the cells in each group had P-ATF2 weak positive expression. After 2 weeks, the percentage of P-ATF2 positive cells in the model group was higher than that of the control group and the low, middle and high dose group (P0.05). After 4 weeks, the percentage of P-ATF2 positive cells in each group was no more than that of the other groups. MEK-3/6, p38, NF- kappa Bp65 and P-MEK-3/6, P-p38, P-NF- kappa Bp65 positive expression in the cartilage tissue (P0.05) in cartilaginous tissue, and P-p38, P-NF- kappa Bp65 positive in each group. The percentage of kappa Bp65 and P-MEK-3/6, P-p38, P-NF- kappa Bp65 positive cells were lower than that of the model group (P0.05). After 2 weeks of administration, the cells all had weak positive expression of ATF2 and P-ATF2, and the percentage of ATF2 and P-ATF2 positive cells in the model group were higher than those of the control group (P0.01). After 2 weeks of administration, the percentage of the positive cells of the ATF2 cells was low in the low, middle and high dose groups of the dragon and soft shelled turtle. After 4 weeks of administration, the percentage of ATF2 positive cells in the low, middle and high dose group was compared with the model group, the difference was not statistically significant (P0.05). After 2 weeks and 4 weeks, the percentage of P-ATF2 positive cells in the low, middle and high dose group was lower than that of the model group (P005). Conclusion: 1. evidence-based medicine research on tonifying kidney and activating blood is the treatment of knee bone. The effective methods of arthritis are less adverse. Due to the small sample size and low methodological quality in the literature, the conclusion of this study still needs more high quality clinical randomized controlled trials to support.2. clinical study with the use of dragon shell capsule and celecoxib in the treatment of knee osteoarthritis, which can effectively alleviate the symptoms and improve the knee joint work. It has good effectiveness and safety, but the Dragon turtle capsule is superior to celecoxib.3. in improving the quality of life. The capsule can eliminate the swelling of the knee joint of the knee osteoarthritis rats, reduce the weight loss of rats caused by the model, increase the weight and spleen index of the knee osteoarthritis rats, and make the model cut down. The restoration of the gland index to the normal level can reduce the extent and severity of the cartilage structural damage in the knee osteoarthritis rats, significantly reduce the synovitis and promote the proliferation of chondrocytes. The experiment shows that the inflammation of the knee osteoarthritis rats by the Dragon shell capsule is closely related to the function of the immune organs of the rat. The capsule can enhance the function of immune organs of the rats with knee osteoarthritis, reduce the expression of serum inflammatory cytokine IL-1 beta, IL-6, and increase the expression of IL-I0, inhibit the excessive hyperactivity of p38MAPK and NF- kappa B signals, inhibit the activation of p38MAPK and NF-K B signaling pathway in osteoarthritis synovitis and cartilage cells. An important mechanism for the therapeutic effect.

【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R274.9

【相似文献】