Study On The Mechanism Of Efficacy Enhancement And Toxicity Reduction Of Traditional Chinese Medicine Citrus Aurantium Total Phenol Combined With Methotrexate In The Treatment Of Rheumatoid Arthriti

Rheumatoid arthritis is a chronic systemic autoimmune disease characterized by joint synovitis.The current cause is still unclear,and is generally considered to be related to various factors such as heredity,immune system abnormalities,and infection.Methotrexate is a classic anti-rheumatic drug that is recommended by the American College of Rheumatology(ACR)and the European Union of Rheumatology(EULAR)as a first-line drug for the treatment of rheumatoid arthritis because of its excellent efficacy-price ratio.However,since the single use of MTX is often weak,the onset is slow,and the longer the cumulative use,the greater the cumulative dose,and the greater the possibility of causing hepatic and renal toxicity.Therefore,because of the complexity of RA disease and the shortcomings of MTX treatment,there is an urgent need for a combination treatment that can both increase efficacy and reduce toxicity.Zhishi is the dried young fruit of Citrus aurantium L.and is rich in diverse active polyphenols,including the unique flavans and their glycosides,polymethoxyflavones,flavonoids and their glycosides,coumarins,limonoids and anthocyanins.In the preliminary work,total phenolic extracts of Citrus aurantium L.(TPE-CA)was screened to possess strong anti-inflammatory,liver and kidney protection effects.The purpose of this study is to better combine Chinese herb and Western medicines through animal pharmacology and toxicology experiments,to reduce the cost of medication and the amount of western medicine,increase the safety and compliance of medications,and better exert the advantages of lower side effects of traditional Chinese medicine,in order to reduce adverse effects and produce better therapeutic results.In this study,animal pharmacology experiments were conducted to study the mechanism of action of TPE-CA in combination with MTX.The determination of blood routine testing,C-reactive protein(CRP)and inflammatory cytokines in the ankle joint indicate that TPE-CA combined with MTX can alleviate inflammation of the ankle joint in rats with rheumatoid arthritis.The results of micro-CT indicate that TPE-CA combined with MTX can also alleviate bone damage caused by rheumatoid arthritis.In order to further study the synergistic mechanism of TPE-CA combined with MTX in the treatment of rheumatoid arthritis,this study used western blot to detect the expression of related proteins in the NF-κB pathway.The experimental results further confirmed that TPE-CA combined with MTX can enhance anti-inflammatory effects by suppressing the NF-κB pathway.Long-term use of MTX in the treatment of rheumatoid arthritis can cause severe liver and kidney toxicity.In this study,animal toxicology experiments were conducted to study the protective effect of TPE-CA on hepatorenal toxicity caused by long-term MTX.In the experiment,the markers of liver and kidney toxicity,oxidative stress and lipid peroxidation were detected,and the pathological sections of liver and kidney tissues were observed.The results showed that TPE-CA can alleviate long-term MTX induced liver and kidney toxicity by inhibiting the production of oxidative stress.Cytochrome P450(CYP)is a class of enzymes that play a role in a variety of reactions,such as mitochondrial respiratory system and drug metabolism.CYP2E1 is one of the key enzymes in drug metabolism and is responsible for hepatotoxicity related to MTX.Nrf2 is an important mechanism of action in oxidative stress.To further investigate the mechanism by which TPE-CA attenuates the hepatotoxicity induced by long-term MTX,the expression levels of CYP2E1 and Nrf2/HO-1 pathway-related proteins were detected by western blot.The results showed that TPE-CA can inhibit CYP2E1 and modulate Nrf2/HO-1 signaling pathway.In conclusion,the results of this study suggest that TPE-CA and MTX combination therapy not only effectively enhances the anti-inflammatory effects of rheumatoid arthritis by inhibiting the NF-κB pathway,but also enhances antioxidant enzyme activity and modulates oxidative stress via CYP2E1 and Nrf2/HO-1 to reduce liver and kidney toxicity caused by long-term MTX.The combination of natural substances such as TPE-CA with conventional DMARDs such as MTX can be alternative and complementary medicine therapy for RA in future.Moreover,the combination therapy increases the safety and compliance of the medication while reducing the cost of medication and the amount of western medicine,better exerts the advantages of less side effects of traditional Chinese medicine,and reduces adverse effects to better therapeutic effects.