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Fitoterapia 92 (2014) 133147

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journal homepage: www.elsevier.com/locate/fitote


Synergy effects of herb extracts: Pharmacokinetics and

pharmacodynamic basis
Yong Yang a,, Zaiqi Zhang a, Shuping Li a, Xiaoli Ye b, Xuegang Li c, Kai He a,
Biomedical Research Center, Huaihua Medical College, Huaihua 418000, China
School of Life Science, Southwest University, Chongqing 400715, China
College of Pharmaceutical Sciences, Southwest University, Chongqing 400716, China

a r t i c l e i n f o a b s t r a c t

Article history: Herbal medicine, especially traditional Chinese medicine and Ayurvedic medicine have played and
Received 20 July 2013 still play an important role in fighting against various diseases. Emerging clinical studies regarding
Accepted in revised form 17 October 2013 traditional Chinese medicine have provided convincing evidence for the first time to gain credibility
Available online 28 October 2013 and reputation outside China. Although synergistic therapeutic actions of herbal ingredients have
been frequently reported, few reports have offered clear underlying mechanisms. This might be the
Keywords: main reason for the conflicting views with respect to the therapeutic efficacy of medicinal herbs.
Traditional Chinese medicine Therefore, this paper reviews the herb synergisms reported in the recent literature and discusses
Synergy effects thoroughly the mechanisms underlying synergistic actions of herbal ingredients. The authors
conducted an electronic literature search to detect articles published mainly in the last five years.
Articles were included if they pertained to synergy research of ethnomedicines or the active
Drug resistance
Pharmacokinetics and pharmacodynamic compounds derived from them, included verification of synergy effects using modern analytical tools
basis and molecularbiological methods. Results have revealed that the multi-component nature of
medicinal herbs makes them particularly suitable for treating complex diseases and offers great
potential for exhibiting synergistic actions. The mechanisms underlying synergistic therapeutic
actions of herb medicines are (1): different agents may regulate either the same or different target in
various pathways, and therefore cooperate in an agonistic, synergistic way; (2): regulate the
enzymes and transporters that are involved in hepatic and intestinal metabolism to improve oral
drug bioavailability; (3): overcome the drug resistance mechanisms of microbial and cancer cells;
and (4): eliminate the adverse effects and enhance pharmacological potency of agents by
processing or by drugdrug interaction. The exploration of synergistic mechanisms of herbal
ingredients will not only help researchers to discover new phytomedicines or drug combinations but
also help to avoid the possible negative synergy. Further clinical research is required for verifying
these reported drug combinations and discovered synergistic mechanisms.
2013 Elsevier B.V. All rights reserved.

Abbreviations: TCM, traditional Chinese medicine; RC, Rhizoma Coptidis; HPLCSPENMR, high-performance liquid chromatographysolid-phase extraction
nuclear magnetic resonance spectroscopy; TUNEL, terminal deoxynucleotidyl transferase dUTP nick end labeling; 5-HT, 5-hydroxytryptamina; PKC, protein kinase C; PKA,
protein kinase A; MAPK, mitogen-activated protein kinase; ERK, extracellular signal-regulated kinase; PC, phosphatidylcholine; FDA, US Food and Drug Administration; DTL,
docetaxel; YCHT, yin-chen-hao-tang; ALT, alanine amino transferase; AST, aspartate amino transferase; ALP, alkaline phosphatase; MRT, mean residence time; SLC, solute
carrier family; ABC, ATP-binding cassette; OAT, organic anion transporter; OATPs, organic anion-transporting polypeptides; P-gp, p-glycoprotein; BCRP, breast cancer
resistance protein; CYPs, cytochrome P450 enzymes; MDR, multidrug resistance; ROS, reactive oxygen species.
Corresponding author. Tel.: +86 13974530358; fax: +86 0745 2380023.
Corresponding author. Tel.: +86 15115162159; fax: +86 745 2380023.
E-mail addresses: hnyyong@163.com (Y. Yang), hekai69@126.com (K. He).

0367-326X/$ see front matter 2013 Elsevier B.V. All rights reserved.
134 Y. Yang et al. / Fitoterapia 92 (2014) 133147


1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
2. Synergistic multi-target effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
3. Improvement of oral bioavailability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
3.1. Drug targeting to intestinal transporters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
3.2. Inhibition and induction of cytochrome P450 enzymes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
4. Agents that reverse drug resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
4.1. Interactions of agents with resistance mechanism of microorganism . . . . . . . . . . . . . . . . . . . . . . . . 139
4.2. Interactions of agents with multidrug resistance mechanism in cancer . . . . . . . . . . . . . . . . . . . . . . . 139
5. Eliminate the adverse effects and enhance pharmacological potency of agents in herb extracts . . . . . . . . . . . . . . . 141
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Conict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

1. Introduction due to its potential treatment effects by synergy. For instance,

polyphenols and terpenoids are two groups of constituents
The last decade has witnessed an emergence and rapid shift which are contained in many plant extracts; the former possess a
of the paradigm in chemotherapy, involving the gradual strong binding ability to different molecular structures like
transition from the mono-substance therapy that had long proteins or glycoproteins, while the latter have great affinities for
been advocated with great vehemence to a multidrug therapy. cell membranes and therefore, a high potential to permeate
This is mainly because of the ineffectiveness, resistance through cell walls of the body or bacteria [7]. Epigallocatechin
problems and side effects may appear when using synthetic gallate (EGCG), the most abundant catechin in tea, is able to
mono-drugs, especially in the treatment of chronic diseases enhance the therapeutic efficacy of temozolomide in patients
such as cancer, atherosclerosis, diabetes and inflammation [1]. with glioblastoma. Chen et al. [8] have revealed that EGCG can
The basis of using multidrug therapy for various disorders is the cross the bloodbrain barrier enough to cause chemo-
recognition that for each, more than one mechanism and gene sensitization in a mouse glioma model. When combined with
is identified. For instance, a global genomic analysis has temozolomide, EGCG could significantly reduce the expression
demonstrated 12 partially overlapping processes that are levels of glucose-regulated protein 78 in temozolomide-treated
genetically altered in the great majority of pancreatic cancers. animals, which is a key pro-survival component of the
In addition, the pathway components that are altered in any endoplasmic reticulum stress response system (EGCG alone did
individual tumor vary widely [2]. This has also been docu- not provide survival benefit). Another interesting finding is that
mented in the context of human glioblastoma multiforme, terpenes provided significant enhancements for the flux and
which is the most common and lethal type of brain cancer [3]. cumulative amounts of the four model drugs. Among the tested
These results indicated that it is difficult to suppress cancer and terpenes, nerolidol provided the highest increase in the flux of
other diseases by targeting a single gene or a single pathway the evaluated drugs. The flux of nicardipine hydrochloride,
that may alter amongst patients and that can be subject to hydrocortisone, carbamazepine and tamoxifen were increased
mutations. These assays also lend credence to the use of a mixture approximately 135-fold, 33-fold, 8-fold and 2-fold respectively
of several drugs or herbs to achieve an overall therapeutic [9]. Hence, under certain conditions, even polyphenols and
biological effect. Since many leading researchers have advocated terpenoids have not contributed directly to the pharmacological
using combination approaches to pursue the optimum therapeu- therapy achieved by the total herb extracts, but the polyvalence
tic efficacy and to improve the patient's overall health status [4,5], of these compounds can enhance the overall efficacy when
the utilization of herbal medicine, which is considered as a co-administrated with other active compounds. Rhizoma
multi-target herb [6], should be optimized. Coptidis (RC), also known as Huang Lian, is extensively used by
As one of the largest biodiversity regions in the world, China Chinese people for clearing heat as well as purging fire, resolving
has abundant medicinal and aromatic plant species, well phlegm to activate meridians and promoting blood circulation to
documented traditional knowledge, a long-standing practice of remove blood stasis. It is estimated that 1760 prescriptions, in 13
traditional medicine, and the potential for social and economic ancient prescription books before Chinese Song Dynasty,
development of medicinal and aromatic plants. Owing to their contained RC for the treatment of various diseases [10].
reduced side effects, high efficacy and a wide range of pharma- Previously, we recognized that the anti-diabetic effects of RC
ceutical activities, the use of TCM is gaining a reputation as a total extract were greater than alkaloid-rich fraction, thus the
modern alternative to western medicine or as a complementary alkaloids including palmatine, berberine, coptisine, epiberberine,
product to maintain health or treat aspects of diseases. Because columbamine, jatrorrhizine and the minor polar constituents
the herb extracts consist of complex mixtures of major com- such as magnoflorine, ferulic acid and choline was purified from
pounds, concomitant agents and other substances, the complex RC and the bioactivity of these compounds were preliminarily
multi-component nature of medicinal herbs may serve as a studied [11]. Modern pharmaceutical research have demon-
valuable resource for network-based multi-target drug discovery strated that each of these compounds could mediate multiple
Y. Yang et al. / Fitoterapia 92 (2014) 133147 135

signaling pathways (summarized in Fig. 1). The possible antibiotic resistance of bacteria and eliminating the adverse
synergistic mechanisms underlying this effect will be discussed effects in herb extracts [7]. In this review, based on our early
in the following section. results, the herb synergisms reported in the recent literature
Although synergistic therapeutic actions of herbal ingredi- were summarized and notably, the pharmacokinetics and
ents have been frequently reported, few reports have offered pharmacodynamic basis underlying synergistic actions of herbal
clear underlying mechanisms [12,13]. This phenomenon has ingredients were discussed.
resulted from the absence of high-tech analytical methods and
advanced molecular biological methods. Now, thanks to the 2. Synergistic multi-target effects
development and the wide use of various detection techniques
as well as the new biological technology, it is more convenient When an extracellular signaling molecule activates a cell
and effective to elucidate the physical foundation, action surface receptor, signal transduction occurs, and this process
mechanism and prescription compatibility of TCM. For instance, involves the numerous actions of cellular messengers. Though
the introduction of high throughput technologies provides the different constituents may affect various cellular messengers, the
opportunity to determine profiles of plants and to systemati- same response may appear in a cell. On the other hand, different
cally explore the mode of action of combinatory drug regimes agents may regulate the same target, and therefore cooperate in
[14]. The hyphenated HPLCSPENMR technique provided an an agonistic, synergistic way. RC was used for clearing heat as
effective approach for the structural identification of complex well as purging fire, resolving phlegm to activate meridians,
compounds [15]. Besides, the penetration of molecular biology, promoting blood circulation to remove blood stasis, removing
gene chip, fluorescence probe, TUNEL assay and differential dampness and nourishing the kidney to replenish yin by
mRNA display technology etc. also offer new perspectives on Chinese people for thousands of years. The pharmacologically
TCM research at the level of organs, cells and molecules. active constituents of RC mainly consist of alkaloids, including
Recently, Wagner and Ulrich-Merzenich have systematically palmatine, berberine, epiberberine, coptisine, jatrorrhizine etc.
reviewed the synergistic effects of herbal combinations, and exhibited antihyperglycemic [16], anti-inflammatory [17], anti-
they concluded that the synergy effects can be achieved by Alzheimer [18] and antibacterial activity [19]. However, emerg-
multi-target effects, enhancing the bioavailability, inhibiting the ing evidence suggested that alkaloids from RC also showed

Fig. 1. Schematic of proposed biological pathways that can be mediated by the main active compounds in Rhizoma Coptidis.
136 Y. Yang et al. / Fitoterapia 92 (2014) 133147

unexpected side effects such as severe arrhythmia, extrapyrami- positively modulates the antioxidant status [25], antidiabet-
dal system reactions, liver function injury and even death ic effect by inhibiting monocyte chemoattractant protein-1,
[20,21]. In previous study, we noticed that the combination of NF-kB expression and by reducing oxidative stress [26,27].
berberine, coptisine, palmatine and epiberberine showed greatly Moreover, it has very recently been shown that administra-
enhanced anti-diabetic activity and decreased toxicity in HepG2 tion of ferulic acid increases levels of 5-hydroxytryptamina
cell and diabetic mice than berberine used alone [22]. Even so, (5-HT), norepinephrine, dopamine and activates 5-HT1A and
the median lethal dose (LD50) in mice of berberine, coptisine, 5-HT2A receptors in mice. The antidepressant-like effect
palmatine and epiberberine (713.57, 852.12, 1533.68 and of ferulic acid may be mediated through the regulation
1360 mg/kg, respectively.) was smaller than the LD50 value of of protein kinase C (PKC) as well as protein kinase A
RC total extract (2.95 g/kg) [21,23] and the antihyperglycemic (PKA), Ca2+/calmodulin-dependent protein kinase II (CaMKII),
ability of RC total extract was greater than alkaloid-rich fraction mitogen-activated protein kinase/extracellular signal-regulated
[24]. This raises the question of what contributed to the kinase (MAPK/ERK) and phosphatidylinositol-3-kinase (PI3K)
synergistic activity of RC total extract. In fact, RC was commonly signaling pathways [28,29]. Most of these pathways play a
consumed as a boiled medicinal soup or medicinal tea to treat significant role in the progression of diabetes and diabetes-
various diseases, and few side effects have been reported. associated complications. Choline, an essential nutrient, can be
Therefore, we speculated that the compounds of high polarity, obtained from diet or by synthesis de novo in tissues. Recent
which appeared in RC water solution, improved the anti-diabetic studies have indicated that dietary choline could improve animal
activity of RC alkaloids and then showed a tremendous growth, enhance digestive and absorptive ability by regulating
synergistic activity. This was demonstrated by our further target of rapamycin signaling pathway and 4E-BP2 gene
study: except for four main RC alkaloids, ferulic acid and expression in tissues [30]. Besides, choline can alleviate the
choline were separated from the polar parts of RC total extract, cytotoxic effects of interaction between folate deficiency and
and the combination of alkaloids and these minor constituents radiation exposure [31]. Choline therapy in asthma patients
in RC showed synergistic anti-hyperglycemic effects and low significantly reduced IL-4, IL-5 and TNF- level, suppressed
cytotoxicity of RC extract in HepG2 cells and rats [11] (Fig. 2). cysteinyl leukotriene, leukotriene B4 and 8-isoprostanes (a
Pharmacological studies of ferulic acid revealed that it biomarker for oxidative stress) as compared to baseline. It
has a wide range of biological activities, such as DNA should be noted that phosphatidylcholines also play a major role
protection by diminishing the lipid peroxidation and in delivering poorly soluble compounds and several other

Fig. 2. The combination of Rhizoma Coptidis alkaloids and minor constituents showed synergistic anti-hyperglycemic effects and low cytotoxicity in rats.
Y. Yang et al. / Fitoterapia 92 (2014) 133147 137

benefits, which gives a rationale for selecting choline as an prolonged, total body clearance (CL) were reduced markedly.
adjunct therapy for various diseases [32]. Therefore, it can be Simultaneously, the expression of various biochemical indicators
concluded that ferulic acid and choline in RC extracts could such as alanine amino transferase (ALT), aspartate amino
enhance the anti-hyperglycemic effects and reduce the cytotox- transferase (AST), and alkaline phosphatase (ALP), malondialde-
icity of alkaloids in RC extract. More importantly, the use of hyde, GSH-PX and SOD, etc. were restored to normal levels in
mono-compound purified from RC like berberine, palmatine, hepatic injury rats by AGR combination. Pharmacokinetic study
coptisine, ferulic acid, etc, has proved to be a very powerful agent further revealed that the therapeutic effect of A on rats with liver
in modulating the numerous cellular signaling pathways injury can be improved by the addition of G and R: both G and R
including AMPK signaling [33], NF-kB signaling [34,35], PPAR can increase the Cmax, prolong MRT and reduce the elimination
signaling [36,37], JNK signaling [38], etc [29,3943]. (summa- rate constant (Ke) and CL of A when compared with A treated
rized in Fig. 1). Taken together, it is not surprising that RC rats. While, as a principal herb in this formula, A can prolong the
extracts exhibited greatly amplified pharmaceutical effects time for maximal concentration (Tmax) and MRT, increase the
compared with RC alkaloids. Cmax and reduce Ke and CL of G. Besides, in the A + R treated
Docetaxel (DTL): the US Food and Drug Administration (FDA) rats, the t1/2 and MRT of R were significantly shorter; the AUC
approved drug for the treatment of metastatic androgen- was obviously decreased; the Ke and CL were increased slightly
independent carcinoma of prostate, has contributed to improved by comparison with R group. Taken together, these results
survival and quality of life in patients suffering from prostate demonstrated that administration of AGR could significantly
cancer. Nevertheless, the dose limiting adverse effect of DTL is increase the bioavailability, slow elimination rate, prolong the lag
febrile neutropenia and anemia. Nagaprashantha et al. [44] time of A and exert a more robust therapeutic effect than any one
investigated the anticancer effects of the active compound or two of the three individual compounds by hitting multiple
vicenin-2 from an Indian herb Ocimum Sanctum as well as the targets in a rat model of hepatic injury [47]. The underlying
potential synergistic tumor regression ability due to oral DTL and mechanism of this effect remains unknown, but it is demon-
vicenin-2 combination. The results indicated that vicenin-2 and strated that both the contribution of hepatic metabolism and
DTL co-administration caused greater decrease in the levels of intestinal metabolism have been recognized as being clinically
proliferation marker, Ki67 and angiogenic marker-CD31, while important factors in the pharmacokinetics of orally administered
increasing the tumor suppressor E-cadherin expression to a drugs [48,49]. Strategies aimed at improving the drug absorption
greater extent than either of the agents alone. These results were mainly through regulating the physiology conditions of gastro-
parallelly demonstrated by in vivo mice xenografts study: intestinal tract, especially by altering the expression of intestinal
combination of vicenin-2 (1 mg/kg) and DTL (0.01 mg/kg) drug transporters as well as by inhibiting or inducing cyto-
induced synergistic effect with significant tumor regression and chrome P450 enzymes (CYPs), which expressed in the human
reduction in tumor-weight as compared to the vehicle treated hepatic and intestinal.
group. Critical signaling proteins like pIGF-1R which is important
for androgen-independent carcinoma of prostate survival and 3.1. Drug targeting to intestinal transporters
progression [45], and pAkt, proliferating cell nuclear antigen
(PCNA), cyclin D1, fibronectin were also remarkably inhibited by Targeting to transporters not only helps us understand
co-administration of vicenin-2 and DTL. The author concluded previous puzzles on clinical pharmacokinetics but also provides
that due to multi-specific anticancer effects, vicenin-2, either a unique strategy to improve drug absorption or overcome
alone or in combination with other antitumor agents, could unfavorable absorption barrier. Membrane transporters can be
provide a promising treatment for pharmacological intervention divided into two main classes: solute carrier (SLC) family and
in prostate cancer. ATP-binding cassette (ABC) transporters. The SLCs are mainly
responsible for the uptake of amino acids, peptides, ions,
3. Improvement of oral bioavailability xenobiotics, endobiotics, sugars and other biologically active
compounds [50]. Clinical and pre-clinical studies have es-
A majority of herb medicines and drugs marketed worldwide ablished that co-administration of drugs and organic anion
are administered orally. The efficacy of these drugs is dependent transporter (OAT, belong to SLC transporters) inhibitor may
on the oral bioavailability, which in turn, is dependent on drug's result in longer plasma half-life and reduced renal clearance. For
physicochemical properties, formulation design and physiolog- instance, co-administration of probenecid, a known OAT
ical conditions of gastrointestinal tract [46]. Yin-Chen-Hao-Tang inhibitor has been demonstrated to diminish the renal clearance
(YCHT), which consists of Artemisia annua L(A), Gardenia of benzyl penicillin and ciprofloxacin [51]. Yuan et al. [52] found
jasminoides Ellis(G), and Rheum Palmatum L(R), has been used that the drugdrug interaction between gemcabene and
to treat jaundice and liver disorders. According to Chinese quinapril involving inhibition of renal OAT and subsequent
medicinal practice, A used in YCHT is the monarch herb, while G elevation in plasma concentrations of quinaprilat (the pharma-
and R are the minister herb and the assistant or servant herb cologically active metabolite of quinapril) is responsible for the
respectively. To validate the therapy efficiency of YCHT, the synergistic blood pressure reduction observed with these
efficacy of combination therapy with A, G and R (AGR) was compounds. Recently, the main active components of Salvia
compared to efficacy of mono-therapy with each of the three miltiorrhiza (Dan Shen) including lithospermic acid, rosmarinic
components in a rat model of hepatic injury. Compared to the acid, salvianolic acid A, salvianolic acid B and tanshinol were
single substance or partial combination, administration of AGR to demonstrated to elicit significant competitive inhibition on
model rats produced significant increase in maximal concentra- OAT1 and OAT3-mediated substrate uptake at clinically relevant
tion (Cmax) and area under the concentrationtime curve (AUC), concentrations. The results indicated that these compounds
while the half-life (t1/2), mean residence time (MRT) were partly may interact with therapeutic drugs known to be OAT1/OAT3
138 Y. Yang et al. / Fitoterapia 92 (2014) 133147

substrates and enhance their pharmacological activity [53]. compounds such as flavonoids, chalcones, terpenoids, isothio-
Organic anion-transporting polypeptides (OATPs), also belong cyanates and nonprenylated rotenoids, are known to inhibit
to the SLC family, are present in the lipid bilayer of the cell BCRP [6365]. Tamaki et al. [66] have evaluated the inhibitory
membrane, acting as the cell's gatekeepers. Each OATP is effects of 9 herbal extracts and 23 isoflavonoids on BCRP-
predicted to contain 12 transmembrane (TM) domains and mediated methotrexate (MTX) transport. The results indi-
mediates the transport of organic anions across the cell cated that extracts of soybean, Gymnema sylvestre, black
membrane. Citrus juices have been reported to reduce the cohosh, passion flower, rutin and all isoflavonoids strongly
bioavailability of orally administered fexofenadine and increase inhibited BCRP-mediated transport of MTX. Most impor-
the bioavailability of atorvastatin. These interactions are tantly, the author found that the addition of a 5-hydroxyl or
considered to be caused by the inhibition of intestinal OATPs 6-methoxyl moiety tended to potentiate the inhibition
[54,55]. Fuchikami et al. [56] evaluated the effects of 15 herbal activity [66].
extracts on the function of human OATP-B, which is expressed
on human intestinal epithelial cells and involved in the
intestinal absorption of various drugs. They suggested that 7 3.2. Inhibition and induction of cytochrome P450 enzymes
herbal extracts potently inhibited the function of OATP-B and the
inhibitory effects may be primarily attributable to flavonoid Inhibition and induction of CYPs is another main mechanism
components. Consistent with this view, recent studies have of pharmacokinetic drugdrug interactions affecting oral bio-
indicated that the apigenin, kaempferol and quercetin can inhibit availability of agents. The cytochromes P450 constitute a
the OATP1A2 and OATP2B1-mediated uptake of substrates superfamily of heme-containing mono-oxygenases that catalyze
(atorvastatin and fexofenadine) into HEK293 cells by a compet- the oxidative metabolism of a wide variety of xenobiotics,
itive mechanism [57]. Since flavonoids are abundantly occurring including drugs, plant derived or fungal-derived secondary
in plants and can reach high concentrations in the gut lumen, the metabolites and are therefore of particular relevance for clinical
inhibition of OATP-mediated drugs by flavonoids should be pharmacology [67]. Only about a dozen enzymes belonging to
considered as a possible new mechanism for fooddrug or drug the 1, 2, and 3 CYP-families are responsible for the metabolism of
drug interactions. ABC efflux transporters move a wide range of the majority of drugs and other xenobiotics. It is reported that
substrates out of cells. The important ABC transporters in CYP3 enzymes metabolize more than 50% of the currently
human include p-glycoprotein (P-gp), multidrug-resistance marketed drugs [68]; nevertheless, CYP3 have a strong effect in
associated proteins (MRPs), breast cancer resistance protein reducing the oral bioavailability and in mediating the elimination
(BCRP), cholesterol transporter (ABCG5/8) and bile salt of numerous drugs. For example, docetaxel is metabolized by
efflux pump transporter (BSEP) [58]. Among them, P-gp is CYP3A to several metabolites that are all considered to be
one of the most prevalent efflux transporters expressed in a therapeutically less effective [69]; CYP3A inhibitors could
number of cancer cells as well as in several organs such as improve the bioavailability of docetaxel [70]. CYP enzymes can
intestine, liver, kidney and the bloodbrain barrier [59]. P-gp also be inhibited by natural products and synergistic therapeutic
plays an important role in limiting the intestinal absorption actions can frequently arise when one ingredient inhibits the
of its substrates in vivo and inhibition of P-gp leads to the metabolic clearance of a specific CYP enzyme, the bioavailability
improvement of bioavailability of orally administrated drugs and exposure of other herbal ingredients or co-administered
and therapeutical agents. Ginsenosides have been found to drugs that act as substrates for the same CYP enzyme is increased
be the main components responsible for ginseng's pharma- [71]. A recent study has suggested that treatment with
cological activity. However, the low oral bioavailability of Kaempferia parviflora extract on mice showed various effects to
ginsenosides has presented a major barrier to the utilization CYP enzymes: short-term treatment significantly induced
of those drugs [60]. Recent work has revealed that the active CYP1A1, CYP1A2 enzyme activities; CYP2B enzyme activities
metabolite of ginsenoside, compound K is a solid substrate of were markedly increased during all Kaempferia parviflora extract
P-gp, and P-gp mediates the efflux of compound K in vitro treatment time points, whereas CYP2E1 activity was enhanced
and in vivo. Using P-gp inhibitor verapamil and cyclosporine only after long-term treatment. However, Kaempferia parviflora
A substantially decreased the efflux ratio of compound K in extract did not affect the CYP3A enzyme activity [72]. However,
Caco-2 cells. Administration of compound K to P-gp the authors have not further investigated which constituent is
deficiency MDR1a/b/ FVB mice also lead to large responsible for the inhibition of CYP enzymes. The following
enhancement of its absorption and bioavailability [61]. This researches may provide some useful clues: naturally occurring
synergistic reaction also occurs between phytomedicines. flavonoids that constitute the most abundant class of dietary
Sinomenine which derives from the stem of Sinomenium natural products and herbal remedies, were found to have CYP1
acutum could significantly improve the bioavailability of inhibition activities [73,74]. In addition to the inhibition of CYP1,
paeoniflorin (derived from the root of Paeonia lactiflora) in rats. flavonoids can also exert chemotherapeutic roles by undergoing
By investigating the intestinal kinetic absorptive characteristics CYP1-mediated oxidative metabolism to conversion products
of paeoniflorin as well as the absorptive behavior influenced by that inhibit tumor cell growth [75]. Thus there is strong
co-administration of sinomenine and P-gp inhibitors, Chan et al. indication that flavonoids act as CYP1 inhibitors and CYP1
[62] suggested that sinomenine in a pattern, which influenced substrates. The other secondary metabolites such as alkaloids
paeoniflorin's absorption, manifested as similar to that of P-gp (berberine, corydine) and lactones were also reported to have
inhibitors. In addition, the inhibition of intestinal breast cancer CYPs inhibitory activities [76,77]. Therefore, it is imperative to
resistance protein (BCRP), which restricts the absorption of consider the possible herb-transporter or herb-CYPs interactions
xenobiotics, may also increase the systemic availability of before we have a thorough knowledge of the mechanisms of
its substrates and various phytochemicals. Natural bioactive synergistic actions in herbal ingredients.
Y. Yang et al. / Fitoterapia 92 (2014) 133147 139

4. Agents that reverse drug resistance of the drug through the outer membrane of the cell or via
effluxing the accumulated drug out of the cell. In this context,
Considering the problems with ever growing drug resis- natural products also offer a promising strategy to overcome
tance [78], it is urgent to investigate the resistance mechanisms bacterial resistance mechanisms: 2,6-dimethyl-4-phenyl-
and to discover new combination therapies for treating pyridine-3,5-dicarboxylic acid diethyl ester, isolated from
infections and cancers. Drug resistance, a phenomenon that Jatropha elliptica, acts as an inhibitor of the NorA efflux pump
reduces the effectiveness of a drug in curing a disease or and restores the level of intracellular drug concentration [88].
improving patient symptoms can develop against antibiotics, Artesunate enhances the antibacterial effect of -lactam
antivirals or chemotherapeutic agents for cancers. Drug antibiotics against Escherichia coli by increasing antibiotic
resistance to chemotherapy remains a major challenge in the accumulation via inhibition of the multidrug efflux pump
treatment of cancer as well as various infections caused by system AcrABTolC [89]. The major catechin present in green
fungus and bacteria. Agents that reverse drug resistance may tea extracts, epigallocatechin-gallate enhances the activity of
encompass two aspects: in the first place, antimicrobials tetracycline in staphylococci by inhibiting Tet(K) and Tet(B)
combined with herbal agents that are able to suppress efflux pumps [90]. Another example of the synergistic action
microbial resistance mechanisms. In the second place, betweenherbalingredientsandantibioticsisgivenbyEumkebet
multidrug resistance (MDR) exists against every effective al.[91].Apigenin and ceftazidime have a synergistic effect
anticancer drug and can develop by numerous mechanisms on reversion of bacterial resistance by means of inhibiting
and targets, while herbal compounds used alone or in peptidoglycan synthesis and the activity of certain -lactamases,
combination with anticancer drugs represent a useful as well as altering the permeabilization of outer membrane
means of overcoming MDR. and cytoplasmic membrane of Enterobacter cloacae. The
authors claimed that the 5, 7-OH group of A ring and one
4.1. Interactions of agents with resistance mechanism 4-OH group of the B ring in apigenin and naringenin are
of microorganism important for synergistic activity.
Recently, aside from the known microbial resistance
There are mainly three defense mechanisms employed by mechanisms, chemogenomic profiling has become a power-
bacteria against the accumulation of antimicrobial drugs inside ful tool that predicts synergy between antifungal or antibac-
the cell [79]. One is to introduce mutations in the target site, terial drug combinations. Strains with reduced fitness in the
which often result from spontaneous mutation of a bacterial presence of a compound are identified, and the genes deleted
gene on the chromosome and selection in the presence of the in those strains provide information on cellular pathways
antibiotic [80], leading to a reduction in the activity of the drug targeted by the compound as well as pathways that are
towards the microbe. Methicillin-resistant Staphylococcus aureus required for conferring sensitivity to that compound [92,93].
(MRSA), which emerged due to transfer of the mecA gene If the combination of two synergizing drugs generates a
encoding the novel penicillin-binding protein 2A [81], is unique chemogenomic profile of sensitive mutants, then
spreading at an alarming rate among infected patients. Previous genes deleted in those mutants provide information on the
study suggested that baicalein exhibits synergy effects with drug synergy mechanism. Using this approach, Spitzer et al.
tetracycline and -lactam antibiotics against MRSA by inhibiting [94] have identified the synergistic interaction of six
the outwards transport of tetracyclin of bacteria due to compounds with the antifungal drug fluconazole. The result
intervention with the responsible flavonoid-borne gene Tet K suggested that fluconazole alone could perturb the genes
[82]. Chan et al. [83] further demonstrated that baicalein could which are required for ergosterol biosynthesis (the pathway
restore the antibacterial actions of ciprofloxacin against the NorA targeted by azole antifungal), vesicle-mediated transport,
efflux pump overexpressed SA-1199B, as well as inhibit the and membrane organization. Of the six compounds analyzed,
enzymatic activity of MRSA specific pyruvate kinase. Another five inhibited the growth of strains carrying deletions in
falconoid, curcumin could markedly reduce the minimal inhib- genes involved in membrane function, vesicle trafficking and
itory concentrations of the antibiotics oxacillin, ampicillin, lipid biosynthesis, suggesting that these five compounds cause
ciprofloxacin, and norfloxacin used against MRSA [84]. general membrane perturbation. Thus, these compounds may
The second is by the synthesis of enzymes that selectively exert their synergistic effect on fluconazole by altering its import
target and destroy or modify the antibiotics. For instance, the or export, or they may impair the import of exogenous
most common mode of resistance to aminoglycosides is ergosterol. The sixth compound indicated that it interfered
enzymatic modification of the drug by acetyltransferase from with sphingolipid biosynthesis, thus suggesting an interplay
Escherichia coli, resulting in reduced affinities for binding their between the ergosterol and sphingolipid biosynthetic pathways.
therapeutic target, the bacterial r RNA aminoacyl-tRNA site
[85]. Besides, inactivation of antibiotic by -lactams which 4.2. Interactions of agents with multidrug resistance mechanism
mediated by the overproduction of -lactamases is probably in cancer
the most widespread example of enzymatic degradation
resulted in bacterial resistance [86]. Clavulanic acid, which The development of MDR to chemotherapy remains a
binds with high affinity to many bacterial -lactamases, has major challenge in the treatment of cancer. Complex
exhibited great potential to reverse the extended-spectrum mechanisms are involved in the resistance of cells to
-lactamases and plasmid AmpC -lactamases in combination chemotherapy, but they may be grouped into the following
with ceftibuten or cephalosporin [87]. categories [95,96]: (1) drug uptake reduced by drug efflux
The final approach is to reduce accumulation of the pumps and modification of the lipid bilayer; (2) altered drug
antibiotic inside the microorganism via reducing permeability metabolism and drug sequestration; (3) alterations in cell
140 Y. Yang et al. / Fitoterapia 92 (2014) 133147

cycle, increased repair of DNA damage, reduced apoptosis; Salvia miltiorrhiza, Panax notoginseng, Crataegus pinnatifida
(4) abnormally expressed MDR-linked genes; and (5) altered and Polygonum multiflorum [116,117], as well as the pure
signal transduction pathways. herbal-derived compound protocatechuic aldehyde can
Of these mechanisms, the one that is most commonly weaken the ability of cells to repair damage by inhibiting
encountered is the increased efflux of a broad class of hydro- DNA synthesis [118].
phobic cytotoxic drugs that is mediated by ABC transporters. As Numerous MDR-linked genes such as ABC transporters, Bcl2
discussed in Section 3.1, although MRP2MRP5 (ABCC2ABCC5) family genes, metallothionein genes and altered signal transduc-
and BSEP (ABCB11) are capable of transporting drugs, the other tion pathways were involved in MDR. In this context, the
ABC transporters, including MDR1 (ABCB1), MRP1 (ABCC1) and dominant approach to resolve MDR is based on reactivation of
ABCG2, can confer MDR to cancer cells in vitro and play a critical apoptotic signaling [119], including: (1) modulating the expres-
role in the development of MDR in cancer cells [97]. Emerging sion of inhibitor of apoptosis protein and apoptogenic factors, i.e.,
evidences have demonstrated that herb compounds could act cytochrome c, smac; (2) strategies for targeting the Bcl2 family
synergistically with anticancer agents and reverse the MDR in proteins; (3) p53 reactivation; (4) modulation of protein kinase
cancer cells. Paclitaxel was approved as a mitotic inhibitor used signaling, mainly Ras/Raf/MEK/ERK and Ras/PI3K/PTEN/Akt
to treat patients with lung, ovarian, breast, head and neck cancer. pathwaysbecause both of these pathways are thought to have
A preclinical study has demonstrated that P-gp inhibitor anti-apoptotic and drug resistance effects on cells [120]; and
zosuquidar trihydrochloride could increase penetration of (5) activation of death receptor pathways [121]. Furthermore,
paclitaxel into the brain by 2.15.6 fold [98]. A major ingredient recent data demonstrated that drug resistance is regulated not
in Ganoderma lucidum, ganoderic acid, reduces the mRNA and only by genetic and epigenetic changes, but also by microRNAs
protein expression level of ABCB1 by inhibiting the activity of (miRNAs) [122]. It has been shown that miRNAs play a critical
ABCB1 promoter, and also inhibits the expression levels of MRP1 role in modulation of survival and apoptosis pathways, drug
and MRP2. Meanwhile, ganoderic acid stimulates the decline in targets and DNA repair as well as drug transport and MDR (see
mitochondrial membrane potential and up-regulates p-p53, p53, details in the review of Giovannetti) [123]. Herb ingredients can
Bax, caspase-3, and caspase-9, leading to apoptosis in MDR cells modulate multiple pathways that are related to MDR, thus
[99]. Moreover, P-gp and MRP1-mediated MDR can also be resulting in the synergistic therapeutic response. Honokiol, an
reversed by gypenoside aglycon separated from Gynostemma active component isolated from TCM magnolia, was demon-
pentaphyllum [100], Kuguacin J isolated from Momordica strated to inhibit growth and induce apoptosis of various cancer
charantia [101], and plant sterols [102]. cell lines. Combination of honokiol with lapatinib as well as
Drug metabolism enzymes are the second line of cellular rapamycin synergistically enhanced the anticancer effects of
resistance. This process involves three phases. Phase I is honokiol. This may be achieved through the following mecha-
mediated mainly by CYPs and epoxide hydrolases [103]. Drug nisms: firstly, honokiol interrupted the cell cycle at G0/1-phase
species are metabolized and converted into highly mutagenic to S-phase via down-regulating cyclin D1, cyclin E and CDK-2
aromatic metabolites that can be conjugated by phase II which have been shown to be crucial for cell cycle progression
enzymes including GSTs, UGTs, SULTs, and NATS [104]. These through this period [124], and resulted to cancer cell apoptosis.
conjugated metabolites are then effluxed by members of the Additionally, honokiol significantly induced the activation of
ABC transporters, which can be considered as phase III of drug caspases-3, -6, and -9, these events then triggered apoptotic
metabolism [105]. Inhibition of the drug metabolism enzymes pathways. Secondly, when honokiol combined with human
could become a promising strategy for reversing MDR. Zou et epidermal growth receptor 2(HER-2) inhibitor lapatinib is able
al. [106] evaluated the effects of 25 purified components of to overcome therapy resistance which is frequently observed
commonly used herbal products on the catalytic activity of clinically in HER-2 over-expressed breast cancer and is believed
cytochrome P450 isoforms. The results showed ginkgolic acids, to be one of the reasons for the resistance to an array of anti-
dihydromethysticin, methysticin, hyperforin and quercetin, cancer agents [125]. Lastly, the expression of activated phos-
etc, significantly inhibited one or more of the human P450 phoinositide 3-kinases (Akt) has been linked to the promotion of
isoforms at concentrations of less than 10 M. Quercetin has survival and growth of breast cancer cells. Honokiol treatment
been demonstrated to increase the bioavailability of pioglita- remarkably down-regulated Akt signaling and up-regulated the
zone in rats by inhibiting CYP3A [107]. Rosemary extract expression of phosphatase and tensin homolog deleted on
enhanced antitumor effect of 5-fluorouracil by down regula- chromosome ten (PTEN) which negatively regulates Akt activity
tion of thymidylate synthetase enzyme and TK1 genes, which is [126]. 7, 8-dihyroxycoumarin (Daphnetin) also inhibits human
essential for the synthesis of dTMP and related to 5-fluorouracil renal cell carcinoma proliferation by induction of a differentia-
resistance [108]. Other enzymes including CYP1A, CYP2C and tion response that is mediated by p38 MAPK signaling [127]. Yi
UDP-glucuronosyltransferases could also be inhibited by herb Gan Kang (YGK), which consists of 15 crude herb ingredients,
ingredients or herb extracts [109111]. was recently approved by the FDA phase II clinical trials for the
Chemotherapeutic drugs have been employed to kill treatment of hepatitis and non-small cell lung cancer [128].
proliferating cells, causing extensive DNA damage that Studies have demonstrated that YGK significantly repressed E6/
ultimately leads to cell cycle arrest and cell apoptosis. E7 oncogenes at the transcriptional level, with subsequent
However, the efficacy of these therapeutic agents would be reactivation of p53 and p21 expression [129]. Ashwagandha
compromised by the ability of cells to repair DNA [95]. The extracts and its components kill cancer cells by at least five
DNA repair protein, O6-alkylguanine-DNA alkyltransferase different pathways: p53 signaling, granulocytemacrophage
and DNA methyltransferase are important cellular resistance colony stimulating factor (GMCFS) signaling, apoptosis signal-
mechanisms [112,113], their inactivation can reverse resis- ing, G2-M DNA damage regulation pathway and death receptor
tance to such agents [114,115]. The herb extracts including signaling [130]. By activating the death receptor pathway, herb
Y. Yang et al. / Fitoterapia 92 (2014) 133147 141

compounds inducing cancer cell apoptosis were frequently herbs: the roots of Scutellaria baicalensis (S), Glycyrrhiza
observed. Curcumin induced cell apoptosis in chondrosarcoma uralensis (G), Paeonia lactiflora (P) and the fruit of Ziziphus
cells through the extrinsic death receptor pathway: Fas, FasL, jujuba (Z), has been documented for nearly 1800 years for
and DR5 expression were up regulated and animal studies treating common gastrointestinal distress, including diarrhea,
revealed a dramatic 60% reduction in tumor volume after abdominal spasms, fever, headache, etc. Notably, all four herbs
21 days of treatment [131]. Solanum incanum extract containing of the PHY906 formulation are necessary for its biological
solamargine alkaloid as the main active ingredient, induces effects to be manifested. Experiments were conducted in which
apoptosis in human squamous cell carcinoma by up-regulating the effectiveness of herbal formulations that lacked one of the
the expressions of tumor necrosis factor receptors (TNFRs) and constituent herbs were compared with PHY906 itself in
Fas, and downstream adaptors FADD/TRADD of the TNF-a and affecting the antitumor therapeutic efficacy of CPT-11. The
Fas ligand signaling cascades [132]. results showed that both S and P play significant roles in
enhancing the antitumor activity of CPT-11, whereas G and Z
5. Eliminate the adverse effects and enhance pharmaco- play only minor roles. In terms of protecting animals from body
logical potency of agents in herb extracts weight loss induced by CPT-11, S and G appear to be the most
important herbs in the PHY906 formulation followed by Z; P
Though TCMs have been used in clinical practice for plays no role [139]. Clinical studies for colorectal, liver and
several thousands of years, Chinese practitioners also noticed pancreatic cancers have shown that PHY906 enhances the
that some herbal medicine contained toxic compounds and therapeutic indices and reduces chemotherapy-induced toxic-
adverse effects may occur when the herb medicines were ities of a broad spectrum of anticancer agents, such as
misused. Modern pharmacology studies have identified some 5-fluorouracil, etopophos, CPT-11, troxacitabine, clevudine,
herbal ingredients that are responsible for clinical side paclitaxel, etc. [140]. Previous investigations of the mecha-
effects. For example, aristolochic acid in Saristolochia fangchi nisms of PHY906's antitumor function have explored that
may lead to renal failure [133]. Dysosma versipellis, which PHY906 can suppress the CPT-11-induced inflammatory re-
contains the toxic compound podophyllotoxin, has caused sponse by decreasing the infiltration of neutrophils/macro-
several cases of thrombocytopenia and liver damage [134]. phages, decreasing TNF- expression in the intestine, and
Despite the limited information available on the chemical decreasing pro-inflammatory cytokine levels in plasma. The
structures and properties of the toxic compounds, our mechanism could be mediated through the inhibition of the
ancestors have invented a large number of pretreatment NF-kB pathway and direct inhibition of Cox-2 and iNOS
methods to reduce the toxicity of crude drugs, which is called activities by various constituent chemicals or metabolites of
processing of Chinese materia medica. Processing refers PHY906. Pharmacogenetic studies suggested that CPT-11 was
to any physical and/or chemical treatment by which crude found to have a major impact on the gene expression of the
natural drugs are transformed into materia medica. Addi- NF-kB family as well as on apoptosis, whereas PHY906 alone
tionally, processing can moderate drastic action, diminish had no significant effect on such pathways. However, PHY906
side effects, modify the energetic properties (flavor, nature, was shown to reverse the down-regulation of the expression of
action), dissipate disagreeable odors and flavors, and so on. genes related to innate immune responses resulting from
The processing methods of TCM are mainly divided into CTP-11 treatment [139]. Another example is glycyrrhizin,
cleaning, cutting, and processing practices which include which constitutes 1025% of licorice root extract and is
stir-frying, charring, steaming, boiling, calcining, etc [135]. considered as the primary active ingredient in licorice. In vivo
For instance, using processing methods (Pao zhi), the toxic and clinical studies have reported beneficial effects of both
ingredients in Aconitum including aconitine, mesaconitine licorice and glycyrrhizin consumption including anti-ulcer,
and hypaconitine can be decomposed into less or non-toxic anti-viral, and hepatoprotective responses [141]. However,
derivatives [136]. Despite these methods, the adverse glycyrrhizin also possesses side-effects including hypertension
reactions of herbal compounds can also be eliminated by and edema. Cantelli-Forti et al. [142] have studied the effects of
co-administration with other phytomedicines. Estragole and an aqueous licorice root extract on the pharmacokinetics of the
methyleugenol belong to alkenylbenzenes, are found in active component glycyrrhizin, in rats and humans. The results
many herbs and spices. These two compounds have been showed that when glycyrrhizin was provided as a component
shown to induce hepatomas in rodent bioassays, which can of the licorice extract to rats, both the AUC and the Cmax for
be ascribed to their bioactivation to alkenylbenzene metab- plasma levels were significantly reduced. Besides, the results of
olites then resulting in DNA adduct formation. Nevadensin, a clinical trials on aqueous licorice root extracts were similar to
major flavonoid constituent in the Lamiaceae family from those noted in rats: the use of licorice extracts is safer than
the genus Ocimum basilicum, has been shown to inhibit glycyrrhizin is administered alone.
sulfotransferase-mediated DNA adduct formation in HepG2 Nevertheless, it should be noted that in most cases, the
cells and rat hepatocytes exposed to the proximate car- adverse effects of TCMs are related to their desired pharmaco-
cinogen 1-hydroxyestragole and 1-hydroxymethyleugenol logical actions. A good example is arsenic, one of the oldest
[137]. The structureactivity relationship study of nevadensin drugs in the world and has been hailed as a miracle medicine: it
has revealed that the presence of C5 and C7 hydroxyl kills people, but saves lives; it can cause some cancers but
substituent on the A ring and a C23 double bond in con- cures others such as the acute promyelocytic leukemia (APL).
junction with the C4 carbonyl group on the C-ring are required Molecularly, arsenic binds thiol residues and induces the
for the inhibitory action of nevadensin on sulfonation [138]. formation of reactive oxygen species(ROS), thus affecting
PHY906, a pharmaceutical grade of traditional Chinese herbal numerous signaling pathways. It also can directly bind
formulation Huang-Qin-Tang (HQT), composed of four distinct the C3HC4 zinc finger motif in the RBCC domain of PML
Table 1
Examples of pairs of herb compounds or extracts reported to exhibit synergistic effects.

Number Herb 1 (active ingredients) Herb 2 Reported synergistic effect Possible molecular mechanism of synergy Type of synergism Reference
or drugs

1 Actein (black cohosh) Digitoxin Actein enhances the growth inhibitory Both actein and digitoxin could inhibit Na+K+-ATPase activity, Pharmacodynamic synergy [151]
effect of digitoxin on human breast actein potentiated digitoxin's inhibitory effect and the expression because facilitating actions
cancer cells of NF-B promoter, p-ERK, p-Akt and cyclin D1 protein levels could on the same target
be affect by actein
2 3-(8(Z),11(Z)-pentadecadienyl) Doxorubicin synergistic cytotoxicity with doxorubicin 3-(8(Z),11(Z)-pentadecadienyl) catechol inhibited the Pharmacodynamic synergy [152]
catechol (Semecarpus checkpoint kinases; caused blockage of cells at S-phase and G2/M because facilitating actions

Y. Yang et al. / Fitoterapia 92 (2014) 133147

anacardium) phases. The decrease in the percentage of G0/G1 population was on the same target
also noticed.
3 Coumarins and volatile oil Baicalin Coumarins and volatile could increase Both of the two compounds could increase the apparent Pharmacokinetic [153]
(Angelicae dahuricae) the intestinal absorption of baicalin permeability values and absorption rate constant of baicalin and potentiation because of
carrier-mediated active transport may involved in the absorption enhanced bioavailability
process of baicalin rather than P-gp-mediated efflux systems
4 Berberine (RC) Fluconazole Berberine exhibits synergy effect with Combination of berberine and fluconazole increased mitochondrial Pharmacokinetics [154]
fluconazole against fluconazole-resistant membrane potential, decreased intra-cellular ATP level, inhibited potentiation because of
Candida albicans ATP-synthase activity, and increased generation of endogenous facilitating actions on
ROS in fluconazole-resistant strains different targets and
5 Bisbenzylisoquinoli-ne Vinblastine, Bisbenzylisoquinoli-ne reverses the MDR Bisbenzylisoquinoline is able to inhibit the ABC transporters Pgp Pharmacokinetic [155]
paclitaxel in SW620 Ad20 cells. and MRP1 potentiation because of
and eliminated MDR
6 Paris polyphylla 5-fluorouracil Paris polyphylla exerts a synergistic Paris polyphylla caused S phase cell cycle arrest, the activation of Pharmacokinetics [156]
and antiproliferative effect by a combination pro-caspase 3, upregulation of Bax and down-regulation of Bcl-2 potentiation because of
Oxaliplatin with 5-fluorouracil and Oxaliplatin proteins expression. Combination of Paris polyphylla and facilitating actions on
5-fluorouracil or Oxaliplatin suppressed the mRNA levels of different targets and
thymidylate synthase and human excision repair pathways
7 Oxyresveratrol (Artocarpus Acyclovir Synergistic antivirus effects as tested in Oxyresveratrol exhibited the inhibitory activity at the early and late Pharmacodynamic synergy [157]
lakoocha) Vero cells infected with herpes simplex phase of viral replication and inhibited the inhibited late protein because facilitating actions
virus synthesis on the same target
8 Berberine (RC) ER Treatment of ER antagonists and the Berberine down regulated, EGFR, HER2, Bcl-2 and COX-2, while, Pharmacokinetics [158]
antagonists crude extract of coptis or berberine up-regulated IFN-b and p21. potentiation because of
conferred synergistic growth inhibitory facilitating actions on
effect on MCF-7 cells different targets and
Y. Yang et al. / Fitoterapia 92 (2014) 133147 143

(promyelocytic leukemia) and PML-RAR, inducing their another drug by inhibition of a specific CYP enzyme, drug inter-
homodimerization and multimerization [143]. In addition, actions can arise. For instance, co-administration of the azole
when the herbs are boiled together or alone for medicinal antifungal, ketoconazole, a potent inhibitor of CYP3A, can cause
usages, the hydrophobicity and ion concentration of the marked elevations in systemic exposure to compounds meta-
decoction may change. These changes may increase extraction bolically cleared by this enzyme family. Since the increased use
of constituents from other herbs within the formula and herbs of herbal products worldwide provides another opportunity for
may react within the decoction medium to create new interactions with any co-administered synthetic drugs, it is
chemical structures [144]. Astragali Radix (AR) and Rehmanniae imperative to consider the potential herbdrug interaction
Radix (RR) are two TCMs widely used in China for treating before we use CYP-metabolized drugs, especially these with a
diabetes mellitus and its complications. In the foot ulcer animal narrow therapeutic index.
model, neither AR nor RR at clinical relevant dose (0.98 g/kg) One of the most important approaches for the moderniza-
promoted diabetic wound healing. However, when they were tion of TCM is to elucidate the active component in each herbal
used in combination in the ratio of 2:1, they could significantly medicine, especially the material foundation of compound
reduce the wound area of rats when compared to water group prescriptions and their pharmacodynamic mechanisms. After
[145]. As mentioned above, this synergistic interaction may numerous efforts, a great number of drugs that originated from
attribute to the new compounds that were generated during plants, including metformin from French lilac [163], colchicine
the boiling process. Lastly, eukaryotic organelles can be used as from Colchicum autumnale, quinine from Cinchona, etc. [164]
an intracellular reaction chamber, in which two compounds have been developed and applied in clinical use. However, the
react together to form a novel product [146], or to generate a absence of holistic approaches and integrated evaluation
bioactive molecule within the organelle that can then diffuse models can result in studies that are inappropriately designed
out of it to improve the efficacy or duration of its action on or give incorrect results. This is because synergetic effects of
other targets [147]. So there is a great possibility that new components will be lost in a target driven single lead discovery
chemical drugs can be generated by the reaction of compounds program of TCM. For example,5methoxyhydnocarpin, an
in herb medicine during enterohepatic circulation. amphipathic weak acid, has no antimicrobial activity alone but
potentiated antimicrobial activity with the alkaloid berberine,
6. Conclusions which is contained in the same plant by 100 fold [165]. To identify
the bioactive components, one should bear in mind the concept of
The synergistic effect of complex agents and herb formulas systems biology, emphasizing a holistic perspective during
has already been noticed and applied in clinical practice. Its evaluation of the pharmaceutical activity of natural products.
most famous example is a cocktail of drugs that is now The exploration of synergistic mechanisms of herbal ingredients
commonly employed against HIV infection, because a vaccine will help researchers to discover both new phytomedicines and
comprising a single antigen will fail to generate broadly reactive drug combinations. Finally, it should be noted that further clinical
B-cell and T-cell responses that are able to confer protection research is required for verifying these reported drug combina-
against the diverse isolates of HIV-1[148]. Moreover, the tions and discovered synergistic mechanisms.
multidrug approach has also been applied in the treatment of
other complex diseases such as cancer, hypertension and
Conict of interest
diabetes [149,150]. This strategy is in accordance with the
TCM theory which emphasizes the attainment of health by
The authors declare that they have no conflicts of interest
maintaining a state of equilibrium between the various systems
to disclose.
and functions of the person. To achieve this goal, Chinese people
use herb prescriptions-in which each medicine can provide its
own special function and form an integrated function for treating Acknowledgement
diseases. However, due to the lack of sufficient synergy research
and the specific explanation for the underlying mechanisms, Thanks are due to Hunan Provincial Science and Technology
there have been conflicting views with respect to the therapeutic Department (2013FJ3062) and Hunan Provincial Education
efficacy of medicinal herbs. Therefore, this paper reviews the Department (13B088) for financial assistance and we would
recent literaturesreported herb synergism and discusses like to thank Beth Sample for a critical reading of the manuscript.
thoroughly the pharmacokinetics and pharmacodynamic basis
underlying synergistic actions of herbal ingredients. Moreover, References
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