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Phytother. Res. 30: 357–366 (2016)

Published online 7 January 2016 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/ptr.5559

The Significance of Tinospora crispa in Treatment
of Diabetes Mellitus

Alex Thomas,1 E. K. Rajesh2 and D. Suresh Kumar1*

CARe Keralam Ltd, KINFRA Small Industries Park, KINFRA Park P.O., Koratty 680 309 Kerala, India
My Holdings Consultancy Pvt Ltd, First Floor, Supriya Tower, Chalakudy 680307 Thrissur District, Kerala, India

Tinospora crispa is a medicinal plant belonging to the botanical family Menispermiaceae. The plant is widely
distributed in Southeast Asia and the northeastern region of India. A related species Tinospora cordifolia is used
in Ayurveda for treating a large spectrum of diseases. Traditional healers of Thailand, Malaysia, Guyana,
Bangladesh and the southern Indian province of Kerala use this plant in the treatment of diabetes. Many diterpenes,
triterpenes, phytosteroids, alkaloids and their glycosides have been isolated from T. crispa. Cell culture and animal
studies suggest that the herb stimulates secretion of insulin from β-cells. It also causes dose-dependent and
time-dependent enhancement of glucose uptake in muscles. However, in view of the reported hepatotoxicity, this
herb may be used with caution. This article reviews the animal studies and human clinical trials carried out using this
herb. Areas of future research are also identified. Copyright © 2016 John Wiley & Sons, Ltd.
Keywords: Tinospora crispa; diabetes mellitus; traditional medicine; Thai medicine; hyperglycaemia.

Indonesia, makhamukay in the Philippines and boraphet

in Thailand. It has various synonyms like Tinospora
rumphii, Tinospora gibbericaulis, Tinospora mastersii,
The incidence of diabetes mellitus is on the rise because Tinospora thorelii, Tinospora tuberculata, Cocculus
of population growth, ageing, urbanization, increasing crispus, Cocculus coriaceus, Menispermum verrucosum,
prevalence of obesity and decreasing physical activity. Menispermum crispum and Menispermum tuberculatum
Diabetes is broadly divided into type 1 and type 2. Type (Anonymous, 2013b). A related species Tinospora
1 is caused by the lack of insulin, and type 2 is character- cordifolia is used in Ayurveda for treating a large
ized by low insulin sensitivity (Anonymous, 2013a). The spectrum of diseases (Panchabhai et al., 2008). Many
International Diabetes Federation has forecast that by diterpenes, triterpenes, phytosteroids, alkaloids and their
2025, there will be 334 million people with diabetes glycosides have been isolated from T. crispa (Pathak et al.,
globally. A coordinated global initiative is therefore 1995; Koay and Amir, 2013) (see Table 1). Literature for
required to address the diabetes epidemic (Wild et al., this review was collected by searching databases like
2004). Ever since the adoption of Alma Ata Declaration Pubmed, ScienceDirect and Google Scholar using key
in 1978 by the WHO, there is a growing global interest words such as Tinospora crispa, Thai medicine, Philippine
in the use of plants for treating diseases. This trend is en- medicine and the synonyms mentioned earlier.
couraged by the belief that herbal medicines are devoid
of adverse side effects (Kumar, 2015). Medicinal plants
are increasingly being used in the treatment of diabetes,
and nearly 800 plants are now reported to possess anti-
diabetic activity (Patel et al., 2012). Medicinal herbs or T. CRISPA IN TREATMENT OF DIABETES
products derived from them are extensively used in
developing countries. Interest in herbal and other forms Known as Akar patawali and Akar seruntum in Malay
of traditional medicine is growing all over the world language, T. crispa is used in traditional Malaysian med-
(Hong et al., 2015). icine for treating several diseases including diabetes
Tinospora crispa Hook.f. & Thomson is a member of (Gimlette et al., 1930; Aminah et al., 2015). The Murut
the family Menispermiaceae. It is a vine growing 4 to tribe in Borneo, Indonesia traditionally uses the plant
20 m high with numerous characteristic protuberances to treat the same ailment (Hirschhorn, 1983). In tradi-
on the stem (Fig. 1). Flowers are pale green and fruits tional Thai medicine also, T. crispa is used in the treat-
are orange berries (Tan, 1980). The plant is widely dis- ment of diabetes (Dweck and Cavin, 2006). The
tributed in Southeast Asia. However, in India, it grows indigenous people of Guyana use it in a different way.
only in the northeastern Himalayas of Assam (Ahmed Stems of T. crispa are macerated in rum, cognac or ab-
et al., 2006). It is known as bratawali and andawali in sinthe and mixed with the bark of Quassia amara into
a bitter beverage to control diabetes and albuminuria
(Grenand et al., 1987). T. crispa is being widely used in
* Correspondence to: D. Suresh Kumar, Research & Development, CARe
Keralam Ltd, KINFRA Small Industries Park, KINFRA Park P.O., Koratty
the southern Indian province of Kerala for treating dia-
680 309, Kerala, India. betes. A video on this subject has already been viewed
E-mail: dvenu21@yahoo.com 380,000 times (Anonymous, 2015). Kavirajas or folk
Received 29 April 2015
Revised 22 October 2015
Copyright © 2016 John Wiley & Sons, Ltd. Accepted 04 December 2015

observations indicate physiological release of insulin

by β-cells (Noor et al., 1989).
The insulinotropic property of T. crispa was evaluated
using BRIN-BD11 cell line, which is a novel insulin-
secreting cell line established after electrofusion of
RINm5F cells with New England Deaconess Hospital
rat pancreatic islet cells (McClenaghan et al., 1996;
Hamid et al., 2008). Secretory characteristics of this cell
line have been described extensively, and BRIN-BD11
cell line is widely used as a model for insulin secretory
studies (Beauwens et al., 2006). In a 30-min acute static
incubation test, T. crispa showed high insulinotropic
activity. It showed an insulin-secretory response with
more than threefold insulin release at 2.0 mg/mL
(Hamid et al., 2008).
The mechanism of T. crispa-induced insulin release was
characterized by culturing HIT-T15 cells and studying the
effect of T. crispa extract and insulin-secretory antagonists
like adrenaline, somatostatin, verapamil and nifedipine
on glucose-stimulated insulin release. High glucose alone
(10 mM) induced a 4.5-fold stimulation of basal line
insulin release, and T. crispa potentiated this effect signif-
icantly by nearly 40%. Glucose-stimulated insulin release
was inhibited around 60% when the HIT-T15 cells were
incubated for 1 h with the insulin secretory antagonists.
These results suggest that the antihyperglycaemic effect
is due to stimulation of insulin release through modula-
tion of β-cell Ca2+ concentration (Noor and Ashcroft,
Pancreatic islets from Wistar and Goto–Kakizaki rats
Figure 1. A twig of T. crispa with wart-like protuberances.
were isolated and perifused in the presence of glucose
and borapetol B isolated from stems of T. crispa.
Borapetol B dose-dependently increased insulin secre-
healers of Bangladesh consider this as an important tion from Wistar and Goto–Kakizaki rat islets at 3.3
plant in the treatment of many diseases including diabe- and 16.7 mM glucose. As insulin secretion gradually
tes mellitus (Jahan et al., 2010). returned to basal level on removal of borapetol B from
the perifusion medium, it can be inferred that the com-
pound did not cause nonspecific insulin leakage by
damaging β-cells in the islets. It is evident from this
study that borapetol B stimulates the secretion of insulin
PRECLINICAL STUDIES from islets of Langerhans (Lokman et al., 2013).
Pancreatic islets from Wistar and Goto–Kakizaki rats
In vitro experiments were cultured overnight and then exposed to modula-
tors and inhibitors of insulin secretion. Borapetol B
The insulinotropic action of T. crispa was investigated seems to have an effect partly on K-ATP channels, as
using isolated rat islets of Langerhans or HIT-T15 B diazoxide partly suppressed borapetol B-induced stimu-
cells. HIT-T15 is a cell line derived from Syrian hamster lation at 16.7 mM glucose. The stimulatory effect of
pancreatic β-cells that were transformed with simian borapetol B on insulin secretion was also dependent
virus 40. These cells secrete insulin in response to a on L-type Ca2+ channels, as nifedipine suppressed the
variety of compounds, including glucose (Santerre insulin response to borapetol B at 16.7 mM glucose. This
et al., 1981; Ashcroft et al., 1986; Skelin et al., 2010). effect also seems to be partly dependent on pertussis
When incubated with rat islets and HIT-T15 B cells, toxin-sensitive Ge protein. As H89 and calphostin C
T. crispa extract caused a dose-related stimulation of did not affect the insulin response to borapetol B, it
basal and glucose-stimulated insulin secretion, respec- can be inferred that there was no modulation by protein
tively. The insulinotropic effect was also demonstrated kinase A and protein kinase C inhibitors. The major
in perifused human islets, rat islets and HIT-T15 B cells. stimulatory effect of borapetol B may be on exocytosis
This is a simple procedure that can be used for quantita- (Lokman et al., 2014).
tive studies on the rates of insulin secretion per islet, Skeletal muscle is a major consumer of blood glucose
excluding the exocrine pancreas. It provides an opportu- after meals and during exercise. The transport of glu-
nity to correlate biochemical changes in the islets at cose in skeletal muscle is regulated by both insulin-
precise intervals during the first and second phases of dependent and insulin-independent pathways (Klip
insulin secretion (Lacy et al., 1972; Shorten and Wall, and Marette, 1992; Sakamoto and Goodyear, 2002). In
2001). In all the three models, insulin secretion rates insulin-dependent pathway, the GLUT4 gene is
returned to basal levels after removal of the extract. In activated via p13 kinase and p38 map-kinase (Okada
rat islets, a second challenge with T. crispa extract et al., 1994). As it is still not clear whether T. crispa has
caused an additional stimulated response. All these a peripheral effect, Noipha et al. (2008) studied the
Copyright © 2016 John Wiley & Sons, Ltd. Phytother. Res. 30: 357–366 (2016)

Table 1. Phytochemicals reported from T. crispa

Sl. no. Name of compound References

1 N-acetylnornuciferine Pachaly et al. (1992)
Bukhari et al. (2005)
2 Columbamine Hamid (2013)
Yusoff et al. (2014)
3 Cytidine Choudhary et al. (2010)
4 N-demethyl-N-formyldehydronornuciferine Choudhary et al. (2010)
5 Dihydrodiscretamine Hamid (2013)
Yusoff et al. (2014)
6 N,N-dimethylhexadecan-1-amine Hamid (2013)
7 4-13-dihydroxy-2,8,9-trimethoxydibenzo[a,g]quinolizinium Hamid (2013)
Yusoff et al. (2014)
8 N-cis-feruloyltyramine Fukuda et al. (1983)
9 N-trans-feruloyltyramine Choudhary et al. (2010)
Hamid (2013)
Yusoff et al. (2014)
10 N-formylannonaine Pachaly et al. (1992)
Choudhary et al. (2010)
Pachaly et al. (1992)
Hamid (2013)
Yusoff et al. (2014)
11 N-formyldehydroannonaine Choudhary et al. (2010)
12 N-formylnornuciferine Pachaly et al. (1992)
Choudhary et al. (2010)
Pachaly et al. (1992)
Bukhari et al. (2005)
Hamid (2013)
Yusoff et al. (2014)
13 Liriodenine Hamid (2013)
14 Lysicamine Bukhari et al. (2005)
Hamid (2013)
15 Magnoflorine Choudhary et al. (2010)
Hamid (2013)
Yusoff et al. (2014)
16 Paprazine Choudhary et al. (2010)
17 Borapetol A Fukuda et al. (1985)
18 Borapetol B Fukuda et al. (1986)
19 Borapetoside A Ruan et al. (2013)
20 Borapetoside B Fukuda et al. (1986)
Ruan et al. (2013)
21 Borapetoside C Martin et al. (1996)
Fukuda et al. (1993a)
Ruan et al. (2013)
22 Borapetoside D Fukuda et al. (1993a)
23 Borapetoside E Fukuda et al. (1993a)
24 Borapetside F Martin et al. (1996)
Fukuda et al. (1993a)
25 Borapetoside G Fukuda et al. (1993a)
26 Borapetoside H Fukuda et al. (1995)
27 Rumphioside I Martin et al. (1996)
28 Tinocrisposide Pachaly and Adnan (1992)
29 Tinotuberide Fukuda et al. (1983)
30 Cordioside Ahmed et al. (2006)
31 Diosmetin Umi Kalsom and Noor (1995)
32 N-formylasimilobine 2,O-β-D-glucopyranoside Choudhary et al. (2010)
33 N-formylasimilobine 2,O-β-D-glucopyranosyl-(1–2)-β-D-glucopyranoside Choudhary et al. (2010)
34 Genkwanin Umi Kalsom and Noor (1995)
35 Genkwanin 7-glucoside Umi Kalsom and Noor (1995)
36 Luteolin 4′-methylether 3-glucoside Umi Kalsom and Noor (1995)
37 Luteolin 4′-methylether 7-glucoside Umi Kalsom and Noor (1995)

Copyright © 2016 John Wiley & Sons, Ltd. Phytother. Res. 30: 357–366 (2016)

Table 1. (Continued)
Sl. no. Name of compound References

38 Tinosporaside Ahmed et al. (2006)

39 2-O-lactoylborapetoside B Lam et al. (2012)
40 6′-O-lactoylborapetoside B Lam et al. (2012)
41 Columbin Ahmed et al. (2006)
42 Crispene E Mantaj et al. (2015)
43 Tinocrispol A Lam et al. (2012)
44 Tinotufolin A Fukuda et al. (1993b)
45 Tinotufolin B Fukuda et al. (1993b)
46 Tinotufolin C Fukuda et al. (1994)
47 Tinotufolin D Fukuda et al. (1994)
Regasa et al. (2000)
48 Tinotufolin E Fukuda et al. (1994)
49 Tinotufolin F Fukuda et al. (1994)
50 Vitexilactone Regasa et al. (2000)
51 Cycloeucalenol Kongathip et al. (2002)
52 Cycloeucalenone Kongathip et al. (2002)
53 20-β-hydroxyecdysone Ahmed et al. (2006)
54 Catechin Amom et al. (2009)
55 Luteolin Amom et al. (2009)
56 Morin Amom et al. (2009)
57 Rutin Amom et al. (2009)

glucose uptake activity of T. crispa in skeletal muscle Experiments indicate that the antihyperglycaemic ef-
cells, using the skeletal muscle cell line L6 myoblasts. fect of T. crispa is not due to glucose absorption from
The myoblasts grown to the stage of fused myotubes circulation. The methyl-glucose transport into rat adipo-
were pre-incubated with and without lyophilized water cytes was assessed in the presence or absence of insulin
extract of T. crispa stems. Thereafter, a 2-[3H]-deoxy- or 1 mg/mL T. crispa water extract for 15 min at 37 °C.
D-glucose uptake test was carried out. In another set There was a significant increase in glucose uptake after
of experiments, prior to the glucose uptake study, the a 15-min incubation with insulin. Nevertheless, T. crispa
T. crispa pre-incubated cells were either treated or extract produced no effect on glucose uptake either in
untreated with specific inhibitors of the p13-kinase the presence or in the absence of insulin (Noor and
and p38 map-kinase pathways (wortmannin and SB Ashcroft, 1998a).
203580). It was observed that T. crispa extract at a While there is consensus agreement on the stimula-
dose of 4 mg/mL significantly enhanced glucose tion of insulin secretion, the reports on glucose uptake
uptake of L6 myotubes in dose-dependent and time- are conflicting. Noor and Ashcroft (1998a) reported that
dependent manner. Wortmannin and SB203580 had the antihyperglycaemic effect of T. crispa is not due to
no effect on T. crispa-stimulated glucose uptake, interference with intestinal glucose uptake or sugar up-
suggesting that the stimulatory effect of T. crispa take into peripheral cells. But Noipha and Ninla-aesong
on glucose uptake is exerted through an insulin- (2011) reported that enhancement of glucose uptake by
independent mechanism. The effect on glucose uptake T. crispa in L6 myotubes is mediated by upregulation of
was completely abolished by 10 μM of cytochalasin B. GLUT 1. Ruan et al. (2013) reported that borapetoside
This indicates that T. crispa stimulates the uptake A increases glucose utilization in peripheral cells and
of glucose through the hexose transport reaction(s) that the hypoglycaemic effects are mediated through
(Mizel and Wilson, 1972). In a subsequent study, it insulin-dependent and insulin-independent pathways.
was demonstrated that glucose transport by T. crispa A summary of the reports on in vitro experiments is pro-
in L6 myotubes is mediated by the upregulation of vided in Table 2.
GLUT1, AMPKα and PPARγ expression (Noipha
and Ninla-aesong, 2011).
C2C12 is an immortalized mouse myoblast cell line
that readily proliferates in high-serum conditions and ANIMAL STUDIES
is a very useful tool to study aspects of myogenesis, me-
tabolism and muscle biology (Yaffe and Saxel, 1977). Aqueous extract of T. crispa was administered to nor-
Borapetoside A was found to increase the glycogen mal and alloxan-induced diabetic rats through drinking
content of C2C12 skeletal muscle cells and Hep3B cells water. Significant hypoglycaemic effect and improve-
at very low concentrations. Borapetoside A also en- ment in insulinaemia were observed in moderately dia-
hanced glycogen synthesis in C2C12 cells, which were betic rats. Two-week treatment with the extract
made to be insulin resistant by treatment with IL-6 improved the glucose tolerance of these animals. Acute
(Ruan et al., 2013). intravenous administration of the extract (50 mg/kg)
Copyright © 2016 John Wiley & Sons, Ltd. Phytother. Res. 30: 357–366 (2016)

Table 2. In vitro studies reported on T. crispa

Sl. Plant part Type of extract/ Duration

no. used phytochemical Cell line Dose of incubation Reference

1 Stem Freeze-dried water extract Isolated human islets, isolated 10–1000 μg 1h Noor et al. (1989)
rat islets, HIT-T15 B cells
2 Stem bark Methanolic extract BRIN-BD11 2 mg/mL 30 min Hamid et al. (2008)
3 Stem Freeze-dried water extract HIT-T15 cells 10 μg/mL 1h Noor and Ashcroft (1998a)
4 Stem Freeze-dried water extract Rat skeletal muscle L6 cell line 2 mg/mL 48 h Noipha et al. (2008)
5 — Borapetol C Isolated pancreatic islets 10 μg/mL 1h Lokman et al. (2014)
from Wistar
and Goto–Kakizaki rats
8 7
6. — Borapetoside A C2C12 and Hep 3B cells 10 –10 mol/L 30 min Ruan et al. (2013)
7. — Borapetol B Isolated pancreatic islets from 0.1, 1 and 10 μg/mL 1h Lokman et al. (2013)
Wistar and Goto–Kakizaki rats

increased plasma insulin levels, suggesting that T. crispa observed in mice treated with the vehicle. Treatment
might be improving diabetic conditions by stimulating of mice with 5 mg/kg borapetoside C twice a day for
β-cells of the endocrine pancreas (Noor and Ashcroft, 7 days caused a decrease in the level of hepatic phos-
1989). phoenolpyruvate carboxykinase (PEPCK), comparable
After 2 weeks of oral administration of T. crispa, the with that of insulin-treated mice. PEPCK is an enzyme
mean body weight of diabetic animals increased signifi- that catalyses gluconeogenesis. These observations sug-
cantly, when compared with diabetic controls. This gest that borapetoside C improves glucose utilization in
observation rules out the possibility of weight loss ame- peripheral tissues and reduces hepatic gluconeogenesis
liorating type 2 diabetes (Noor et al., 1989). (Lam et al., 2012).
Similar results were reported by Anulukanapakorn Acute treatment with borapetoside C from T. crispa
et al. (1999). Ninety-five per cent ethanolic extract of (5 mg/kg, i.p.) lowered the level of plasma glucose ele-
T. crispa given orally at doses of 250 and 500 mg/kg vated by oral glucose feeding in normal and type 2
of body weight improved oral glucose tolerance in diabetic mice. Compared with insulin (0.5 IU/kg),
normoglycaemic rats. A dose of 250 mg/kg of body weight borapetoside C caused a significant increase in glycogen
could reduce blood glucose levels of diabetic rats by content in skeletal muscle of type 2 diabetic mice. The
12.15% and 12.48% at 4 and 6 h, respectively. Ether frac- effect was less pronounced in type 1 diabetic mice. Con-
tion of the extract did not produce any hypoglycaemic comitant treatment with borapetoside C (0.1 mg/kg, i.p.)
effect in normal and alloxan-diabetic rats. However, buta- and insulin increased insulin-induced lowering of plasma
nol and aqueous fractions of the 95% ethanolic extract glucose and insulin-induced increase in muscle glycogen.
produced significant hypoglycaemic effect in alloxan- Continuous treatment with borapetoside C (5 mg/kg) for
diabetic rats. 7 days increased the phosphorylation of insulin receptor
Post-prandial hyperglycaemia can be prevented if the (IR), protein kinase B (Akt) and expression of glucose
rate of absorption of glucose from intestine into circula- transporter 2 (GLUT2) in type 1 diabetic mice. Contin-
tion can be reduced (Martin and Montgomery, 1996). ued administration of a low dose of borapetoside C
The antihyperglycaemic properties of T. crispa were (0.1 mg/kg, twice a day) and insulin for 7 days increased
characterized by studying its effect on intestinal glucose insulin-induced IR Akt phosphorylation and GLUT2 ex-
absorption. The lumen of the upper and lower parts of pression in liver of type 1 diabetic mice. This study shows
the jejunum of Wistar rats was perfused with Krebs- that borapetoside C can stimulate glucose utilization,
Ringer phosphate buffer containing 1 M glucose with delay the development of insulin resistance and enhance
or without 4 mg/mL T. crispa water extract. It was insulin sensitivity (Ruan et al., 2012).
observed that the addition of T. crispa extract into the Borapetoside A was also shown to increase glucose
perfusion fluid did not alter significantly the rate of utilization in peripheral tissues, reduce hepatic gluco-
glucose absorption into intestine (Noor and Ashcroft, neogenesis and activate insulin-signalling pathway in
1998a). mice. Borapetoside attenuated the elevation of plasma
Intraperitoneal injection of borapetosides A and C glucose induced by intraperitoneal glucose tolerance
(5 mg/kg) significantly stimulated insulin release and test. Additionally, the increased expression of PEPCK
lowered plasma glucose in a dose-dependent way in was reversed by borapetoside A treatment twice a day
non-diabetic and type 2 diabetic mice, which were made for 7 days (Ruan et al., 2013). Comparison of the
diabetic by feeding with fat-rich chow and 20% fructose- structures of borapetosides A, B and C suggests that
sweetened water for 4 weeks. The effects were not ob- the C-8 stereochemistry plays a key role in evoking
served in type 1 (streptozotocin-induced) diabetic mice. hypoglycaemic effect. The active borapetosides A
The plasma insulin level significantly rose to plateau and C possess 8-R chirality, whereas the inactive
level at 3 mg/kg of borapetoside C administration in borapetoside B possesses 8-S chirality.
non-diabetic and type 2 diabetic mice. This effect was The glycoside is located at C-3 in borapetoside A, while
comparable with glibenclamide (5 mg/kg). In the intra- it is located at C-6 in the case of borapetoside C. A lactone
peritoneal glucose tolerance test, levels of plasma glu- is formed in borapetoside A between C-4 and C-6 (Fig. 2).
cose of non-diabetic and type 2 diabetic mice treated These differences may be the cause of the difference in
with borapetoside C were lower than the levels potency between the two compounds.
Copyright © 2016 John Wiley & Sons, Ltd. Phytother. Res. 30: 357–366 (2016)

with type 2 diabetes who did not respond to oral

hypoglycaemic drugs and refused insulin injection. The
study population received additional T. crispa powder
at a dose of 1 g thrice daily for 6 months. Fasting blood
sugar, glycosylated haemoglobin and insulin levels of
patients in experimental and control groups were not
significantly different during the 6 months. At the con-
clusion of the study, patients in the T. crispa group had
Figure 2. Borapetoside A, borapetoside B and borapetoside C.
higher glycosylated haemoglobin and cholesterol values.
Each patient had lost approximately 2 kg of body weight
(Sangsuwan et al., 2004).
Acute oral administration of borapetol B to A clinical trial on healthy Thai volunteers was con-
normoglycaemic Wistar rats and diabetic Goto– ducted to evaluate the effect of T. crispa on blood sugar
Kakizaki rats improved blood glucose levels in treated and the safety of the treatment. Firstly, the effect of
versus control groups with areas under curves T. crispa on oral glucose tolerance was studied in nine
0–120 min being 72 ± 17 versus 344 ± 10 mmol/L, and healthy subjects. A single dose of 6 g of the herb did
492 ± 63 versus 862 ± 55 mmol/L in Wistar and Goto– not improve glucose tolerance. In the second experi-
Kakizaki rats, respectively. Plasma insulin levels were ment, the effects of T. crispa on blood glucose and insu-
increased twofold in treated Wistar and Goto–Kakizaki lin levels were studied in six healthy subjects. It was
rats (Lokman et al., 2013). observed that blood glucose concentration decreased
Consumption of high amounts of fat-rich and calorie- significantly after each subject consumed 6 g of T. crispa
rich diet leads to obesity. Through a series of steps, obe- powder. But the concentration of insulin in serum was
sity leads to insulin resistance (Kahn and Flier, 2000; not increased. Lastly, the effects of T. crispa on haema-
Qatanani and Lazar, 2007). The effects of T. crispa in tological and biochemical parameters were studied.
ameliorating insulin resistance induced in obese Wistar Twelve subjects received T. crispa at the dose of 1 g
rats were studied. After 8 weeks of oral administration thrice a day before meals for 8 weeks, and 13 subjects
of T. crispa powder in distilled water, body weight, received the drug at a dose of 1.05 g thrice daily before
adiposity index and serum levels of aspartate amino- meals for 4 weeks. The treatments did not cause any
transferase, alanine aminotransferase, total cholesterol, change in haematological parameters including serum
triglycerides, blood glucose, resistin and leptin were re- glucose. However, the liver enzyme aspartate amino-
duced significantly. These results favour the long-term transferase (AST) and alanine aminotransferase
administration of T. crispa for treating obesity in pa- (ALT) tended to increase after T. crispa administration,
tients with insulin resistance and diabetes mellitus suggesting hepatotoxicity (Rattanajarasroj et al., 2004).
(Abu et al., 2015). A summary of the reports on animal A study to determine the effect on blood glucose and
experiments is provided in Table 3. insulin levels of ten healthy subjects and ten diabetic
participants was carried out. After overnight fasting,
serum from them was collected every 30–60 min during
3 h of continued fasting and during the 3 h after inges-
HUMAN STUDIES tion of 75 g of glucose with or without ingestion of
250 mg of T. crispa powder. Glucose and insulin levels
A randomized, double-blind, placebo-controlled clinical in healthy and diabetic subjects were not different be-
trial was conducted to determine the blood sugar lower- tween with or without T. crispa powder (Klangjareonchai
ing property of T. crispa. The subjects were 20 patients and Roongpisuthipong, 2012).

Table 3. In vivo studies reported on T. crispa

Sl. Plant Type of extract/ Duration of

no. part used phytochemical Animal model Dose administration Reference

1. Stem Water extract Alloxan-diabetic rat 4 g/L of drinking water 2 weeks Noor and Ashcroft (1989)
2 Stem Water extract Alloxan-diabetic rat 50 mg/kg i.v. 2 weeks Noor and Ashcroft (1989)
3 Stem Freeze-dried water extract Alloxan-diabetic rat 4 g/L of drinking water 2 weeks Noor et al. (1989)
4 Stem 95% ethanolic extract Alloxan-diabetic rat 250 and 500 mg/kg 6h Anulukanapakorn et al.
Ether fraction of 95% Alloxan-diabetic rat 25, 50 and 100 mg/kg 6h (1999)
ethanolic extract
Butanol fraction of 95% Alloxan-diabetic rat 50, 150 and 450 mg/kg 6h
ethanolic extract
Aqueous fraction of 95% Alloxan-diabetic rat 125, 250 and 500 mg/kg 6h
ethanolic extract
5. — Borapetosides A and C Streptozotocin-diabetic mice 5 mg/kg 7 days Lam et al. (2012)
6. — Borapetoside C Streptozotocin-diabetic mice 5 mg/kg 7 days Ruan et al. (2012)
7. — Borapetoside A Streptozotocin-diabetic mice 0.1–10 mg/kg 7 days Ruan et al. (2012)
8. — Borapetol B Spontaneously type 2 diabetic 10 μg/100 g 2h Lokman et al. (2013)
Goto–Kakizaki rats
9. Stem Water extract Obese Wistar rats 100 mg/kg 8 weeks Abu et al. (2015)

Copyright © 2016 John Wiley & Sons, Ltd. Phytother. Res. 30: 357–366 (2016)

The only study reporting a positive effect of T. crispa muscles (Noipha et al., 2008). Borapetosides A and C
is the one by Sriyapai et al. (2009), who conducted a ran- isolated from T. crispa improve glucose utilization in pe-
domized, double-blind, placebo-controlled, crossover ripheral tissues and reduce hepatic gluconeogenesis
study in 36 patients with metabolic syndrome. They (Lam et al., 2012; Ruan et al., 2013). A schematic dia-
received 250 mg of T. crispa dry powder, twice daily gram of mode of action of T. crispa is given in Fig. 3.
for 2 months. Patients who received T. crispa powder Results of clinical trials suggest that T. crispa induces
had significantly lower fasting blood sugar and triglycer- hepatotoxicity. Sangsuwan et al. (2004) reported that 2
ide levels. Curiously, an increase of more than three of the 20 subjects who received T. crispa in the clinical
times baseline levels of AST and ALT was observed in trials had elevated levels of the liver function marker en-
16.7% of the subjects. A summary of the clinical studies zymes SGOT and SGPT (>200 U/L), which returned to
is given in Table 4. normal values on discontinuing the herbal remedy. Sim-
ilar side effect was reported by Rattanajarasroj et al.
(2004) and Sriyapai et al. (2009).
A definite case of hepatotoxicity induced by T. crispa
CONCLUSION was recently reported (Langrand et al., 2014). A
Vietnamese man with no medical history on his return
Results of the several studies show that T. crispa is to France from Vietnam started to take daily ten pellets
a promising herb in the treatment of diabetes of a herbal medicine made up of T. crispa. Four weeks
mellitus. Cell culture and animal studies suggest that later, he developed dark urine, pale stools and right
the herb stimulates secretion of insulin from β-cells hypochondrial pain. Two months after starting the treat-
(Noor et al., 1989; Noor and Ashcroft, 1989, 1998a; ment, he was tested and was found to have high levels of
1998b; Anulukanapakorn et al., 1999; Hamid et al., bilirubin and γ-glutamyltransferase, a liver function
2008; Lam et al., 2012). It also causes dose-dependent marker enzyme. The herbal medicine was immediately
and time-dependent enhancement of glucose uptake in stopped on admission, and he recovered fully without

Table 4. Human studies

Sl. no. Test material Number of subjects Dose Duration of administration Reference

1 Stem powder in capsule 20 1 g t.i.d.1 6 months Sangsuwan et al. (2004)

2 Stem powder 9 4 or 6 g (single dose) 6h Rattanajarasroj et al. (2004)
6 6 g (single dose) 2h
12 1 g t.i.d.1 8 weeks
13 1.05 t.i.d.1 4 weeks
3 Stem powder in capsule 20 125 or 250 g (single dose) 3h Klangjareonchai and
Roongpisuthipong (2012)
4 Stem powder in capsule 36 250 mg b.i.d.2 2 months Sriyapai et al. (2009)
Three times a day.
Two times a day.

Figure 3. Schematic diagram of mode of action of T. crispa.

Copyright © 2016 John Wiley & Sons, Ltd. Phytother. Res. 30: 357–366 (2016)

treatment, 2 months after developing the symptoms. reasonable. For example, Anulukanapakorn et al.
Presence of T. crispa in the herbal medicine was (1999) administered orally 250 and 500 mg/kg of 95%
detected by microscopic analysis of the crushed pellets ethanolic extract, which was obtained at a yield of
and comparison with a certified reference sample of 5.50%. However, 250 mg of T. crispa powder at the
T. crispa provided by Hanoi University of Pharmacy. extraction rate yields only 13.75 mg of extract. This dose
Further evidence was available from reversed-phase is certainly too low for a phytomedicine in humans. It
TLC and reversed-phase HPLC–UV analysis of dichlo- may be recalled here that Chinese medicine recom-
romethane extract of the pellets. mends high dose range for most of the herbs. For exam-
T. crispa has a high content of furanoditerpenoids ple, Radix Astragali Membranacei (Huang Qi) is
like borapetosides (Fukuda et al., 1993a). These commonly dosed at 18–60 g per day (Flaws and
furanoditerpnoids, similar to the ones in germander Sionneau, 2005). Ayurveda considers 24–48 g as the
(Teucrium chamaedrys) (Piozzi et al., 1987), form toxic standard dose of a decoction per day. Medicinal pow-
metabolites through the action of cytochrome P 450 3A. ders are administered at the rate of 3–6 g twice or thrice
Formation of these compounds is enhanced by induction a day (Anonymous, 2011; Williamson, 2002). Therefore,
of cytochrome P 450 3A and by depletion of glutathione well-controlled clinical trials using therapeutically active
(Loeper et al., 1994; Kouzi et al., 1994). The toxic doses of crude T. crispa powder or the extract are
diterpenoids induce apoptosis of hepatocytes (Lekehal required, as animal studies show promising results.
et al., 1996; Fau et al., 1997; Stickel et al., 2005; Langrand
et al., 2014). Considering the hepatotoxic nature of
T. crispa, there is an urgent need to identify the other
hepatotoxic compounds in the herb so that methods for Acknowledgements
their removal from the extracts can be discovered.
We thank the anonymous reviewers for their valuable help in improving
While cell culture and animal studies unequivocally the quality of the manuscript.
prove that T. crispa has insulinotropic activity, three of
the four human trials failed to confirm this clinically.
This calls for a re-examination of the subject. It is evi-
dent that the doses used in these studies are too low Conflict of Interest
(125 mg, 250 mg and 1 g of herb powder). On the
contrary, the doses used in the preclinical studies are The authors declare that there is no conflict of interest.

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