Immunity: The New Priority for the Modern Patient

Immunity: The New Priorityfor the Modern Patient Kerry BoneCo-Founder and Director Research and DevelopmentMediHerbAdjunct Associate Professor,University of New England, Australia

The Immune Challenge • Modern epidemics, viruses jumping species • Antibiotic-resistant bacteria • High costs, long lead times for new antibiotic drugs • Antibiotic-induced changes in human flora and the modern epidemic of Clostridium perfringens • The rising incidence of atopic allergy, for example anaphylaxis to peanuts • The rising incidence of many autoimmune diseases, including type 1 diabetes • Immunosenescence

Antibiotic Resistance According to the World Health Organization(March 2012), “Antimicrobial resistance threatens a return to the pre-antibiotic era” 440,000 new cases of multidrug-resistant tuberculosis (MDR-TB) emerge annually (150,000 deaths). MDR-TB reported in 64 countries to date Resistance to earlier generation antimalarial medicines is widespread in most malaria-endemic countries http://www.who.int/mediacentre/factsheets/fs194/en/index/html

Antibiotic Resistance Many hospital-acquired infections are causedby highly resistant bacteria such as methicillin- resistant S. aureus (MRSA) and vancomycin-resistant enterococci(VRE)1 In the US, more than 18000 peopledie each year (50 every day!) from MRSA2 and up to 30000 from antibiotic-resistant Clostridium3 1 http://www.who.int/mediacentre/factsheets/fs194/en/index/html 2 Klevens RM et al. JAMA 2007; 298(15): 1763-1771 3 Tenover FC. http://www.hhs.gov/asl/testify/2008/06/t20080624e.html accessed July 4, 2012

The Post-Antibiotic Era Dr Margaret Chan, director general of WHO: “A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as Strep. throat or a child’s scratched knee could once again kill. We are losing our first-line antimicrobials. Replacement treatments are more costly, more toxic, need much longer durations of treatment, and may require treatment in intensive care units.” http://www.who.int/dg/speeches/2012/amr_20120314/en/index.html access July 4 2012

Three Key Immune Herbs • Echinacea angustifolia and/or Echinacea purpurea root, mainly for prevention and to counter immunosenescence • Andrographis paniculata for acute viral or bacterial infections • Astragalus membranaceus for chronically depleted immunity and supporting the immune system under adverse conditions, especially the immune cells themselves. Also for immunosenescence

My Favorite Herb • Echinacea root has much to offer the modern naturopathic physician, but it is so confused and misunderstood • There are a multitude of products using different species, plant parts and manufacturing methods • A lack of consensus over what phytochemicals in Echinacea are responsible for its immune activity • A rudimentary understanding of its exact mode of action on the immune system, but with intriguing new developments • Many myths about how Echinacea should and should not be used

A Brief History of Echinacea • Information about the therapeutic value of Echinacea first came from Native American tribes • Their use of Echinacea was then adopted by the Eclectic physicians • By 1921 Echinacea (specificallythe root of E. angustifolia) wasby far the most populartreatment prescribed byEclectic physicians Wagner H. Z Phytother 1996; 17(2): 79-95

Lloyd JU. Echinacea angustifolia. Lloyd Brothers, Cincinnati, 1923. In: Bauer R, Wagner H. Echinacea: HandbuchfürÄrzte, Apotheker und andereNaturwissenschaftler. WVG, Stuttgart, 1990, p 16.

A Brief History of Echinacea • The Eclectics were responsible for Echinacea’s reputation as an immune herb and they used the root extracted in a high percentage of alcohol (lipophilic extracts or tinctures) • They felt that the tingling (due to alkylamides) was the indicator of good quality • In Europe during the 1930s the German herbalist Madaus introduced E. purpurea tops as a stabilized fresh juice (hydrophilic tincture) • This eventually led to the investigation of polysaccharides as Echinacea active components Bauer R, Wagner H. In Wagner H, Farnsworth NR eds. Economic and Medicinal Plant Research, Vol 5, Academic Press, London, 1991.

How the EclecticsUsed Echinacea Root

How the EclecticsUsed Echinacea Root References for the previous slides • Felter HW, Lloyd JU. King’s American Dispensatory. 18th Edn, 3rd revision, Volume 1. First published 1905, reprinted Eclectic Medical Publications, Portland, 1983. • Ellingwood F, Lloyd JU. American Materia Medica, Therapeutics and Pharmacognosy. 11th Edn. Naturopathic Medical Series: Botanical Volume 2. First published 1898, reprinted Eclectic Medical Publications, Portland, 1983.

How the EclecticsUsed Echinacea Root Points of Note • The Eclectics often used quite high doses of Echinacea root • They were not adverse to using Echinacea root long-term • For example according to Ellingwood, Echinacea was recommended for the following chronic conditions: cancer, chronic mastitis, chronic ulceration, tubercular abscesses, chronic glandular indurations and syphilis • With regard to syphilis, Ellingwood writes: “The longest time of all cases yet reported, needed to perfect the cure, was nine months.” Ellingwood F. American Materia Medica, Therapeutics and Pharmacognosy, EclecticMedical Publications, Portland, 1993.

Early Encounters withEchinacea: Real or Not? • As a student at the Jacka’s Naturopathy clinic, Melbourne, Australia 1976 • As a herbal student, Tunbridge Wells, UK 1982 • At a US herbal trade show, 1987 • Real Echinacea gives you “asthma”, 1988

Learning the Power ofReal Echinacea • The Eclectic writings in King’s Dispensatory and Ellingwood, early 1990s • Teaching Echinacea tonaturopathy undergraduatesand student feedback, early 1990s • Feedback from patients andlearning the power of prevention,early 1990s

The Four Key Echinacea Myths • Echinacea can only be taken for short periods. Long-term use will wear out the immune system (tachyphylaxis) • The polysaccharides are the true active constituents, hence the root must be extracted with water, or better still use only the tops • Echinacea is the best herb to treat winter viral infections once they have occurred • Echinacea is dangerous in autoimmune disease

Echinacea Root: Shortor Long-Term Jurcic K et al. Z Phytother 1989; 10: 67-70 18

Problems with Polysaccharides • Polysaccharides (PS) in Echinacea (tops or root) have received research attention as active components • However, much of this research is in vitro and has been confounded by endotoxin (lipopolysaccharide) contamination of the samples used1 • The term “polysaccharide” is generic and includes starches and other potentially inert plant compounds, but these are often measured by the crude analytical techniques used 1 Tamta H et al. J Agric Food Chem 2008;56(22): 10552-10556

Problems with Polysaccharides • Hence commercial Echinacea products claiming quantified levels of PS should be viewed with considerable caution • Research has found that true polysaccharides are extremely difficult to extract from Echinacea (top or root) and they are unstable in the harvested dried plant • Ethanol strengths 40% or higher cannot extract the PS from Echinacea, while less than 4% of PS1 and 17% of PS2 was extracted by hot water from any dried plant part Stuart DL et al. Optimisation of polysaccharides in processed Echinacea purpurea. RIRDC Publication No. 04/118, 2004.

Problems with Polysaccharides • PS are common to all plants, being components of plant cell walls • PS are large molecules with limited bioavailability • The Eclectics never gave EchinaceaPS to patients, since they onlyused high ethanol extracts

Echinacea Root:What is Active? • Echinacea root extracted with alcohol mainly contains alkylamides and caffeic acid derivatives • Herbal in vitro research is meaningless if the extracts being tested do not contain bioavailable phytochemicals • What is active must be bioavailable, what is bioavailable must be active: the model of undertaking all quality research on herbs • But subsequent clinical proof of activity of any product optimized to these phytochemicals is paramount

Echinacea Root: Pharmacokinetics Study Design: 11 healthy individuals Age: 18 to 26 years BMI: 19 to 30 Blood samples takenover 12 hours Dose: 4 Echinacea root tablets as a single dose

What Compounds WereFound in Bloodstream • No caffeic acid conjugates • No caffeic acid conjugate degradation products • No alkylamide degradation products • No polysaccharides The only compounds identified in human plasma were alkylamides from the Echinacea ingested, at approximately the same ratio as the initial product tested Matthias A, Addison RS, Penman KG, Bone KM et al. Life Sci 2005; 77: 2018-2029

Echinacea - Liquid vs Solid Dose Pharmacokinetics Matthias A, Addison RS, Agnew L, Bone KM et al, Phytomedicine 2007; 14(9): 587-590

Liver First Pass Metabolism • The pharmacokinetic study suggested that alkylamides were being degraded by the liver on first pass after absorption in the GIT • When liver decomposition of alkylamides was investigated a surprisingfact was found • Some alkylamides inE. angustifolia aredegraded at a slowerrate and protect otheralkylamides (found inE. angustifolia and E. purpurea) from degrading

Enhancing Bioavailability • 2-ene protects the 2,4-diene • increasing amounts of 2-ene alkylamide gives less degradation of the 2,4-diene Matthias A, Gillam EMJ, Penman KG, Bone KM et al. Chem Biol Interact 2005; 155: 62-70

What Do Echinacea Alkylamides Do? • Exert anti-inflammatory effects • Some bind strongly to cannabinoid receptors • Others may inhibit breakdown of endogenous cannabinoids • Possibly upregulate dendritic cell maturation • Possibly responsible for positive effects on natural killer (NK) cell function and numbers and increased white cell phagocytic activity seen in several in vivo studies • Possibly responsible for effects on heat shock proteins seen in human studies Bone KM, Mills SY. Principles and Practice of Phytotherapy: Modern Herbal Medicine.Elsevier, UK. 2nd Edition, In press.

Cannabinoid Receptors • CB1 receptors are highly localized in the central nervous system (CNS) and are believed to primarily modulate behavior • CB2 receptors predominate inimmune tissues outside theCNS, especially the spleen,and are believed to modulateimmune function • Echinacea alkylamides mainlybind to CB2 receptors Ralevic V. Cannabinoid modulation of peripheral autonomic and sensory neurotransmission. Eur J Pharmacol 2003; 472(1-2): 1-21

CB2 Binding of Alkylamide Isomers • Using alkylamides supplied from Australia it has been found that the tetraene isomers vary in terms binding to CB receptors, with the ZZ isomer showing a higher affinity than anandamide Isomer Ki CB2 (nM) ZZ 57 ± 8.5 ZE 9044 ± 2985 EZ 4535 ± 711 EE > 100000 • Alkylamides from other plants do NOT bind to CB2 Matovic N, Matthias A, Gertsch J, Bone KM et al. Org Biomol Chem 2007; 5(1): 169-174

Anandamide: an endogenous cannabinoid Z,Z tetraene alkylamide from Echinacea Alkylamides and Anandamide

CB2 Activation: Subtle but Profound • A lipophilic extract of E. purpurea strongly stimulated TNF mRNA synthesis in peripheral monocytes in vitro • TNF mRNA was upregulated (around 8-fold) by the Echinacea extract over a time-span of 24 hours, but the constituent protein level (of TNF) was not changed • However, LPS-stimulated TNF production was potently modulated by Echinacea, with inhibition (around 40%) during the first 20 hours, and a subsequent prolongation of TNF production Gertsch J, Schoop R, Kuenzle U et al. FEBS Letters 2004; 577(3): 563-569

CB2 Activation: Subtle but Profound • These effects were produced by the interaction of Echinacea alkylamides with the CB2 receptors on the monocytes • The results of this study suggest that Echinacea works more as a facilitator of the immune response. In resting monocytes it prepares them for a quicker response by inducing TNF mRNA • However, in overstimulated monocytes (as in the case of LPS) it first reduces, but then extends their response in terms of TNF production

Echinacea: A Miracle Herb? • In an extraordinarily entitled paper:“Echinacea: a Miracle Herb against Aging and Cancer?”, Canadian scientist Dr Sandra Miller reviewed her research on Echinacea, specifically Echinacea purpurea root1 • In healthy young adult mice, oral doses of Echinacea purpurea root (0.45 mg per 25 g body weight, similar to human dose rates) stimulated NK cell production by bone marrow in the first 7 days which resulted in significantly higher levels (around 25% more) of NK cells in the spleen by 2 weeks2 1 Miller SC. eCAM 2005; 2(3): 309-314 2 Sun LZ-Y, Currier NL, Miller SC. J Altern Complement Med 1999; 5: 437-446

Echinacea Boosts NK Cells • In addition, the ‘helper’ or accessory cellsfor NK cells, the monocytes, were also increased by 25% • The Echinacea treatment influenced no other white blood cell counts • Polysaccharides, even by injection, were not responsible for this effect • Dr Miller feels that alkylamides are largely responsible for the effect (personal communication) • This research tends to shift the focus for Echinacea to innate immunity and emphasizes its preventative role Currier NL, Lejtenyi D, Miller SC. Phytomedicine 2003; 10: 145-153

Echinacea Reverses Agingof Innate Immunity • NK cells decline in number and function with age and this is thought to be one factor behind the increase of various cancers with age • Experiments conducted in healthy, elderly mice found that 2 weeks of oral doses of Echinacea returned NK cell numbers in bonemarrow and spleen to the levels ofyoung adults and also resurrectedthe functional capacity (target cellbinding, lysis) of these cells1 1 Currier NL, Miller SC. Exp Gerontol 2000; 35: 627-639

Echinacea Reverses Agingof Innate Immunity • On this result Dr Miller writes1: “These observations appear to apply uniquely to this herb since we could never rejuvenate the NK cell-mediated component of the immune system in elderly mice by any of the other typical NK cell enhancers….” • In addition for mice fed Echinacea purpurea root from 7 weeks of age to 13 months lifespan was significantly extended compared to controls2 1 Miller SC. eCAM 2005; 2(3): 309-314 2 Brousseau M, Miller SC. Biogerontology 2005; 6: 157-163

Heat Shock Proteins • Heat shock proteins (HSPs) are molecular chaperones that bind to large proteins to facilitate their folding (during synthesis) and to prevent mis-folding (after synthesis) • While basal levels of HSPs exist within cells, they are further induced by temperature shock or other stressors • They act to protect cells from protein denaturation and possible death under hostile conditions • Certain HSPs within immune cells also appear to facilitate the immune response (antigen presentation)

Heat Shock Proteins • Extracellularly, HSPs appear to act like cytokines (as “moonlighting proteins”) and can modulate immune responses Chen T, Cao X. Eur J Immunol 2010; 40(6): 1541-1544 Henderson B. Cell Biochem Funct 2010; 28(1): 1-14

Echinacea Root and HSPs • In an open-label pilot trial, 11 healthy volunteers were evaluated at baseline (day 1) and on day 15 after consuming 2 Echinacea root tablets/day (standardized to 4.4 mg alkylamides) for 14 days1 • Echinacea root markedly enhanced (by about 50%) the increase in white cell heat shock protein (hsp70) expression after mild heat shock (p=0.029) • White cell counts were mildly increased (p=0.043) and there was a preventative effect against free radical induced erythrocyte hemolysis (p=0.006) 1 Agnew LL et al. J Clin Pharm Ther 2005; 30(4): 363-369

Echinacea Root and HSPs • A follow-up open-label trial in 24 healthy volunteers used the same design, except the Echinacea root dose was twice the above1 • While Echinacea did not significantly change basal hsp70 expression in lymphocytes, it increased CD4, CD8 and NK cell stress-induced hsp70 expression • The effect was most marked in NK cells (p<0.05) • This implies that Echinacea root may play a role in activating and protecting the immune system via HSPs when the body encounters a challenge, such as a virus 1 Agnew L et al. Planta Med 2010; 76(12): P629, 1354

Echinacea Root for the Common Cold • In a large and well-designed US trial, the impact of taking Echinacea root shortly after common cold onset was investigated • The active intervention was10.2 g of dried Echinacearoot during the first 24 h,and then 5.1 g/day for thenext 4 days • Primary outcomes assessedwere global severitythroughout the illness and duration of infection Barrett B, Brown R, Rakel D et al. Ann Intern Med 2010; 153(12): 769-777

Echinacea Root for the Common Cold Barrett B, Brown R, Rakel D et al. Ann Intern Med 2010; 153(12): 769-777

Prevention is Better Than Cure • In a study presented by the late Dr Anna Macintosh at the 1999 Convention of the American Association of Naturopathic Physicians, an Echinacea root formulation was compared against a herbal adaptogenic formulation and a placebo in the prevention of winter colds over a 90-day period1 • The trial recruited 260 medical students who were under stress from their studies • The placebo group averaged an infection rate of 10%, whereas this dropped to as low as 2% by day 70 (p=0.013) in the Echinacea group 1 McIntosh A et al. AANP Convention, Coeur d’ Arlene, 1999.

Echinacea and Long-haul Flights • A randomized, double blind, placebo-controlled clinical trial was undertaken with 175 participants travelling return from Australia to North America, Europe or Africa for 1 to 5 weeks • Active tablets each contained extract from 1.275 g Echinacea root (4.4 mg alkylamides) • Priming dose was 2/day, travel dose was 4/day and dose when ill was 6/day • The placebo group exhibited significantly higher average respiratory infection symptom score (around double) compared with the Echinacea group (p<0.05) after return from travel Tiralongo E et al. Evid Based Complement Alternat Med 2012; 2012: 417267

Echinacea Root and Air Travellers Tiralongo E et al. Evid Based Complement Alternat Med 2012; 2012: 417267

Echinacea and Autoimmunity • The caution for Echinacea in autoimmunitywas based on theoretical grounds and the few isolated adverse events hardly provide reasonable grounds for a contraindication • Mice with autoimmune diabetes did not show adverse effects when fed Echinacea purpurea root1 • In a controlled clinical trial, patients with autoimmune uveitis were able to reduce their time on prednisone when given Echinacea purpurea2 • The role of immune herbs in autoimmunity will be revisited later in this seminar 1Delorme D, Miller SC. Autoimmunity 2005; 38(6): 453-461 2 Neri PG et al. JOcul Pharmacol Ther 2006; 22(6): 431-436

Echinacea: Conclusions and Recommendations Preferred Preparations and Key Quality Markers • The preferred parts of Echinacea to use are the roots of E. angustifolia combined with E. purpurea • The alkylamides are the important quality marker compounds (even active constituents) and MUST be present in adequate quantities • Doses must be adequate: at least 2.5 g of a root combination per day (temporarily  to ward off infection)

Immunity: The New Priority for the Modern Patient