“ West Meets East” Chinese Medicine Could be a Cornerstone for Developing Future Medicine

1. “West Meets East” Chinese Medicine Could be a Cornerstone for Developing Future Medicine Yung-Chi Cheng Henry Bronson Professor of Pharmacology Yale School of Medicine

2. Scope of Medicine - For treatment of disease - For improving use of other medicine - For prevention of disease - For enhancement of “quality of life” of patients and “healthy” individuals

3. The Current Paradigm of Mainstream Pharmaceutical Discovery • Reductionist approach • To identify a target associated with disease • To identify a single compound that can regulate a given target associated with a disease. Such compounds are expected to have potency and selectivity for the treatment of the disease targeted.

4. Chemicals Discovered in this Laboratory (In Collaboration with Others) Under Different Stages of Clinical Development

5. Challenges of Current Mainstream Drug Discovery Approach • For a given disease, it can be caused by multiple reasons, it will be difficult to find one chemical with defined target related to diseases - To treat the majority of patients - To prevent a majority of the population contracting the disease • For a given treatment, multiple side effects could occur, it will be difficult to find one drug to relieve all the side effects • For different patients with the same disease caused by the same etiological factor, the response to a given treatment could be different. Host factors need to be taken into consideration • Many of potent drugs for the treatment or prevention of chronic diseases may require long-term use, delayed toxicity may occur

6. New Paradigm for Future Medicine • Multiple targets • Polychemical medicine instead of one chemical medicine with system biology approach in mind

7. Two Approaches to Polychemical Medicine • Conventional “Step by step” • Revisiting history as the basis of reinventing medicine Traditional Chinese medicine and other Folk medicine

8. Chinese herbal medicine has many chemicals which could target on multiple sites or act on a single site additively or synergistically through direct or indirect interaction. • Chinese Medicine has multiple medical usage for the treatment of complicated diseases or multiple symptoms as well as disease prevention and improving quality of life. • Chinese Medicine takes a holistic approach and is an early form of “system biology” and “integrated medicine”. • Chinese Medicine is prescribed on an individual basis to optimize its usage. It is “individualized medicine”. Chinese Medicine Could Meet Some of the Current Unmet Medical Needs and Serve as the Basis for Future Medicine”

9. Botanical Drugs: A new area for the US FDA • Guidelines for the Botanical Drug Industry: (June 2004) • Waive the combination rule • May enter Phase I,II clinical studies with a documented history of use • Requirements for approval will include: • Safety • Efficacy • Product Consistency • “Botanical drug” and drug interaction • Mechanism(s) of Action(s) & Active Ingredients

10. How to Make Preparations of Herbal Medicine with Consistency • Authentication of herb • Good agricultural practices (GAP) • Good manufacturing practices (GMP)

11. Authentication of Herb • Micro-morphological analysis • Gene sequence analysis • Chemical analysis • In vitro (solution state) • In situ (solid state)

12. StemTissue Coated Stem Tissue A schematic Diagram Showing the determination a chemical image of herbal tissue by Matrix-Assisted Laser Desorption / Ionization Mass Spectrometry (MALD-HS)

13. Direct Desorption / Ionization of Morphinane Alkaloids from the Stem Tissue of Sinomenium acutum by MALDI By: K.M. Ng (HKU) and Z. Zhao (BU)

14. Spatial distribution of two metabolites from within stem tissue of Sinomenium acutum collected from different growing areas ◊ 0311007 and □ 0311008 are two different samples from Shaanxi province ▲ 0311011 and ●0312032 are from Anhui province and Chongqin city, respectively. K.M. Ng et al. (Unpublished Results)

15. Botanical Quality Control Good Agricultural Practicesconsistency of raw ingredients • Botanical authentication • Macro and micro histology • Agricultural contaminants • Heavy metals, pesticides, fungicides, herbicides … • Bacterial, plant, fungal contaminants • Harvest time • “Raw Plant” fingerprints Good Manufacturing Practiceconsistency of drug substance and product • PhytomicsQC • Chemical Analysis • Biological Analysis • Informatics / Data mining

16. Quality Control for Complex Mixtures • Regulatory and Scientific Challenge • What do you measure? • How do you measure it? • How do you compare it? A NOVEL APPROACH IS REQUIRED!! • What can be done now • Multiple parameters • Inclusive Comprehensive Quality Control Measures

17. Two Tier Approach to Botanical QC • Tier One: Individual Analysis • Specific, Absolute Quantitation • Individual Chemical Marker Compounds • Specific Enzyme/Receptor Target Activities • Tier Two: Fingerprint Analysis • Global, Relative Quantitation • Chemical Fingerprint • Bioresponse Fingerprint

18. PhytomicsQCTM LC/MS Chemical Genomic BioResponse DNA “blueprint” RNA “messenger” Protein “executioner” Animal Pharmacology

19. Phytomics Similarity Index (PSI) • Composite score function • Quantitative measure of similarity (0 => 1.0) • Combines peak pattern including peak ratios and peak intensities • Statistical comparison of pattern information • Provides a sensitive, diagnostic histogram of similarity values with rapid identification of outliers • Generally applicable for both chemical and biological data • Utility • Botanical lot consistency • Stability studies • Data mining Botanical-Activity Relationships

20. Chemotherapeutic AgentIndication • CPT-11 • Capecitabine, 5-FU • CPT-11/5-FU/LV • VP-16 • L-OddC • Gemcitabine • Oxaliplatin • Colorectal Cancer • Liver Cancer • Colorectal Cancer • Lung Cancer • Leukemia, Pancreatic • Pancreatic Cancer • Colorectal Cancer PHY906 * • Composition • Spray dried aqueous extract of four botanicals • Traditional use (since 300 A.D.) • Diarrhea, vomiting, nausea, intestinal cramping • Modern use (2000 A.D.) : An adjuvant for cancer chemotherapy * U.S. Patent 7,025,993 B2 ; IND: 62,627

21. PHY906: Identification using LC/MS Data In collaboration with PhytoCeutica Inc. (A Yale University Sponsored Company)

22. PSI Ratio vs. Intensity Intensity PSI Provided by PhytoCeutica Inc. (A Yale University Sponsored Company)

23. PSI Distribution of 15 Sources of same Formula Provided by PhytoCeutica Inc. (A Yale University Sponsored Company)

24. Biological Response for Quality Control of Herbal Medicine • Enzyme or Receptor Assays • Cell-Based Assays • Cell growth or behaviors • Functional genomics • Proteomics • Phytomics • In Vivo Assays

25. PhytomicsQCTM BioResponse fingerprint Chemical fingerprint DNA “blueprint” RNA “messenger” Protein “executioner” Mr. Mouse / Pharmacology Provided by PhytoCeutica Inc. (A Yale University Sponsored Company)

26. BioResponse Gene Expression Profiles Ginseng PHY906 G.Lucidium • Iso-IC50 drug treatment dose • Different BioResponse patterns observed for different herbals • Can distinguish different herbal preparations, herbal variants and herbal species • Conclusion: • Genomic Expression provides a sensitive, global bio-fingerprint as a unique response pattern to the herbal chemical composition Herb 2 Herb 1 American White Red Herb 2 PHY906 Ginseng Herb 1 G. Lucidium 524 “union” gene set in HepG2

27. Biological Fingerprints of Different PHY906 Batches 6 7 8 Cell growth Inhibition on HepG2 Cells Genomic Bioresponse Provided by PhytoCeutica Inc. (A Yale University Sponsored Company)

28. 4% 18% 4% 35% 7% 4% 2% 26% Pathway Analysis of Regulated Genes PHY906-6 in HepG2 cells (524 regulated genes > 1.2 fold in dChip analysis)

29. Issues of TCM Clinical Trial • Be sure that a consistent preparation of clinical trial material can be made. • Double blind and Placebo design is preferable. Other alternative designs could be considered. • A clear clinical endpoint which is acceptable worldwide should be used for efficacy. Toxicity should be closely monitored. • Statistical consideration is critical in the design.

30. PHY906 in Advanced Colorectal Cancer Phase I/IIA Randomized, Double-Blind, Placebo-Controlled, Cross-over Dose Escalation Study Design • Study Sites • Shivani Kummar, M.D., Oncologist • Yale Univ/Veterans Administration CT Cancer • Center, West Haven, CT • Scott Wadler, M.D., Oncologist, • Weill Cornell Medical Center, New York, NY • Mark O’Rouke, M.D., Oncologist • Cancer Centers of the Carolinas, Greenville, SC • Leslie R. Laufman, M.D. • Hematology/Oncology Consultants, Inc., • Columbus, OH • Results: • Safe at two doses (NO SAEs) • Reduced diarrhea/nausea by one grade • No effect on metabolism of CPT-11, 5FU • Out of 17 patients, 15 patients showed either partial response or • stable disease after 2 courses of treatment Provided by PhytoCeutica Inc. (A Yale University Sponsored Company)

31. PHY906 in Hepatocellular Carcinoma Phase I/II Open Label, Dose-Escalation, Safety, and Efficacy Study • Phase I Objectives • Primary • Tolerability of PHY906 plus capecitabine • Safety of 2 consecutive courses • Evaluation of PHY906 toxicity and adverse effects • Phase II Objectives • Primary: Overall survival time (OS) • Secondary • Time to disease progression (TTP) • Quality of patient life • Safety and tolerability • Results and above • No grade 3 drug related toxicity • Clinical Study Sites • Yun Yen, M.D., Ph.D. • City of Hope National Medical Center • Michal Rose, M.D. • Yale University/ Veterans Administration CT Cancer • Center, West Haven, CT • Samuel So, M.D. • Stanford University Medical Center, Stanford, CA Provided by PhytoCeutica Inc. (A Yale University Sponsored Company)

32. Enhancement of Anti-Cancer Drug Action by PHY906 Enhances CPT-11 antitumor activity I Body Weight Loss n BDF-1 mice bearing colon 38 tumor E Enhances Gemcitabine antitumor activity in BDF-1 mice Bearing PANO2 tumor Enhances Capecitabine antitumor activity in nude Mice bearing HepG2 tumor

33. Herb Protection of Enhancement of Body Weight Antitumor Loss Effect 1 S P G Z + + + + + + - + + + - - + - + + + - + + - + - + + + + - - + BDF-1 Mice Bearing Colon 38 Tumor PHY906: Individual Herbal Contributions 1: Based on the data at day three on which the maximum CPT - 11 induced body weight loss in mice is usually observed. 2: (+) effect; ( - ) no effect. S : Scutellaria baicalensis Georgi. P : Paeonia lactiflora G : Glycyrrhiza uralensis Fisch. Z : Ziziphus jujube Mill.

34. Principles of Combined Usage of Herbs in TCM Formula • Imperial Herb ( 君 ) • The chief herb (main ingredient) of a formula; toxic and nontoxic • Ministerial Herb ( 臣 ) • Ancillary to the imperial herb, augments and promotes the action of the main ingredient • Assistant Herb ( 左 ) • Reduces side effects of the chief herb • Servant Herb ( 使 ) • Harmonizes or coordinates the actions of the other herbs

35. Mechanisms of Herb Interaction of PHY906 for Absorption of Phytochemicals into Blood Stream Inhibition of multiple drug resistant protein which could decrease the uptake of certain chemicals in the GI tract, leading to the increase of oral uptake of certain chemicals. Inhibition of CYP3A4, a predominant drug metabolic enzyme in the intestine, leading to the increase of oral uptake of certain chemicals. Inhibition of microfloral β-glucuronidase & glucosidase Stabilization and/or improvement of modification of solubility of certain chemicals.

36. Activity of Herbs from PHY906 Activities of Compounds from Herb A

37. INTERACTIONS OF INDIVIDIUAL HERBS Interaction of different ingredients of Chinese formula (described by Tao Hongjing 451-526)

38. LC-MAS Fingerprint of PHY906 and Plasma from Mice Taking PHY906 Orally 36 34 35 6g/kg 27 h 37 b i 31 c e g a 33 54 f d 32

39. No. tR identification MS A 44.9 Glucuronide of baicalin 621>445>269 B 45.1 Glucuronide of baicalin 621>445>269 C 49.2 Chrysin sulfate 333>253 D 58.9 Wogonoside sulfate 539>459 27 60.9 Baicalin 445>269 E 62.2 Baicalin sulfate 525>445 F 67.4 Chrysin glucuronide 429>253 31 69.1 Baicalin isomer 445>269 32 70.6 Hydroxyl wogonoside 475>299 33 73.3 Baicalin isomer 445 34 73.7 Wogonoside 459>283 35 74.7 Hydroxyl wogonoside 475>299 36 77.7 Baicalin isomer 445>269 37 79.1 Oroxylin A 7-O-glucuronide 459>283 G 87.3 Baicalin sulfate 349>269 H 101.1 Wogonin sulfate 363>283 54 116.6 Glycyrrhizic acid 821 I 121.1 Unknown glucuronide 725>549 Compounds Identification In Plasma of Mice taking PHY906 Orally

40. Impacts of PHY906 on blood vessels formation of HepG2 xenografts in nude mice Control PHY906 400x 100x CD31 (brown), nuclear DNA (blue)

41. Impacts of PHY906 on HIF-1 and VEGF level of HepG2 xenografts in nude mice VEGF HIF-1 VEGF HIF-1α Control PHY906 Control PHY906 400x 100x

42. The possible mechanism of PHY906 in the Reduction of gastrointestinal toxicity • Tachykinin NK-1 • Opiate γ receptors • Acetylcholine esterase

43. Botanical Data Mining: The Next Step • WHY? • Identification of active phytocompounds • Defining a biologically relevant chemical fingerprint • Development of second generation drugs • HOW? • Correlation of biological response and chemical fingerprint

46. What will it take to globalize Chinese medicine? • Experience-based claims → Evidence-based claims • Subjective quality control → Objective quality control • User unfriendly → User friendly • Preparation and Prescription • Complex formula →Simplified formula • Clarification of dosage and toxicity • Short term vs long term • Clarification of interaction with current medicine • Mechanism(s) of its action(s) and active compounds • involved. • New usage of traditional Chinese medicine or its • Derivatives.

47. INDUSTRY ACADEMIC INSTITUTE GOVERNMENT • INTRA-REGIONAL COLLABORATION • INTER-REGIONAL COLLABORATION “Collaboration is Critical” To globalize Chinese medicine, close collaboration among academia, industry and Government is needed. Given the limitation of resource (human, technology and financial) international collaboration is critical for the advancement.

48. Consortium for Globalization of Chinese Medicine (CGCM) MISSION OF CONSORTIUM • Global • Non-profit • Non-discriminatory • Non-political www.tcmedicine.org In pursuit of advancing the field of Chinese herbal medicine to benefit Human kind through joint efforts of the academic institutions, industries And regulatory agencies around the world.

49. Working Groups • Quality Control • Chinese Medicine Database • Herbal Resource • Clinical Trials Currently we have 61 members and 7 affiliate industrial members 7 Regional Consortiums: Australia, Beijing, Canada, Guangdong, Hong Kong, Shanghai, and Taiwan. www.tcmedicine.org

50. The Evolution of Medicine Traditional Chinese Medicine (TCM)  Modern Chinese Medicine (MCM) (China, Japan, Korea, etc)  Globalized Chinese Medicine (GCM)  Future New Medicine (NM) Other Folk Medicine (FM) (Tibet, India, Europe, etc)  Current Mainstream Medicine (CMM)  Western Medicine (WM)