Clinical And Network Pharmacological Study Of Xianshen Decoction In The Treatment Of Radiation-induced Oral Mucositis In Nasopharyngeal Carcinoma

1 OBJECTIVEThe prospective single arm observation trials was conducted to determine the efficacy and safety of "Xianshen Decoction" in the treatment of radiation-induced oral mucositis of nasopharyngeal carcinoma.By using network pharmacology research to carry on the screening and the target prediction to the active components of "Xianshen Decoction",the known disease targets related to radiation-induced oral mucositis in nasopharyngeal carcinoma and key targets of "Xianshen Decoction" Treatment were screened,the molecular biological functions and pathways were analyzed,the bionetwork of component-key target-pathway was constructed,to explore the pharmacological mechanism of "Xianshen Decoction" in the treatment of radiation-induced oral mucositis in nasopharyngeal carcinoma and provide molecular theoretical basis for subsequent clinical and experimental research.2 METHODS2.1 clinical studyThrough the prospective single arm observation trials,80 patients who were diagnosed as nasopharyngeal carcinoma and received radiotherapy for the first time were included."Xianshen Decoction" gargle and oral administration+ radiotherapy ±concurrent chemotherapy regimen was used in the trials.The patients were interviewed before radiotherapy,after the end of 1,2,3,4,5,6 weeks of radiotherapy.The main observation index was the incidence of acute radiation-induced oral mucositis of grade III or above,while the secondary observation indexes included: occurred time of acute radiation-induced oral mucositis for the first time,grades III or above(the first mucositis is the initial symptom of oral mucositis),grading of acute radiation-induced oral mucositis,planned completion rate of radiotherapy,quality of life QLQ-C30 scores.The Safety indexes included detailed record of changes in blood routine,liver and kidney function,EBV-DNA,occurrence and severity of adverse events.The follow-up data were collected and the statistical analysis were used to evaluate the efficacy and safety of "Xianshen Decoction" in the treatment of radiation-induced oral mucositis of nasopharyngeal carcinoma.2.2 network pharmacology researchThrough network pharmacology research,TCMSP,TCMID,Uniprot databases were retrieved to screen the active components of "Xianshen Decoction" and predict targets;the disease target gene databases of Geencards,Malacards,TTD and OMIM were retrieved to screen the disease targets related to radiation-induced oral mucositis in nasopharyngeal carcinoma;the intersection of the active components targets of "Xianshen Decoction" and the disease targets was selected to obtain the active components-disease common target data set,and use Cytohubba plug-in to select the key target;the molecular biological functions and pathways were analyzed by David database;the bio-network of component-key target-pathway was constructed by string online software and Cytoscape software.3 RESULTS3.1 clinical study(1)Among the 80 patients included,77 cases developed the first mucositis,3 cases did not occur,and the incidence rate was 96.3%.The earliest occurrence of the first mucositis was on the 7th day,and the average occurrence time was 20.14 ±8.89 days,which was concentrated between the 12 th day and the29 th day.Grade III or above mucositis occurred in 11 cases,with an incidence of 13.8%.(2)The single-factor COX regression analysis showed that the time of taking traditional Chinese medicine was a possible influencing factor of the occurrence of the first mucositis;the age and taking time of traditional Chinese medicine were the possible influencing factors of the occurrence of grade III or above mucositis.Multi-factor COX regression analysis showed that the time of taking traditional Chinese medicine was an independent factor affecting the occurrence of the first mucositis and grade III or above mucositis.(3)The smoothing function and threshold effect analysis showed that there was a curvilinear relationship between the time of taking traditional Chinese medicine and the risk of grade III or above mucositis,and there was an turning point.When the time of taking traditional Chinese medicine was ≥ 42 days,it was the protective factor of grade III or above mucositis,and the risk of grade III or above mucositis showed a downward trend.(4)Before and after the treatment of traditional Chinese medicine and the taking time of that in groups,the quality of life QLQ-C30 scores was carried out.The results showed that the relevant items were statistically significant before and after treatment,but had no clinical value.There was no difference between the different medication time groups.The quality of life had the same degree of improvement and change in each group.(5)In the radiotherapy completion plan,only one case extended the radiotherapy program due to grade III mucositis,and no case terminated the radiotherapy program because of severe oral mucositis.(6)After drug safety evaluation,the patients in the group were well tolerated after taking "Xianshen decoction",and there were no obvious side effects.3.2 network pharmacology research(1)In the TCMSP database and TCMID database,the reported chemical constituents of Agrimonia pilosa are 84 species,Radix scrophulariae are 120 species,Radix Ophiopogonis are 55 species,Radix glehniae are 110 species,Dried rehmannia root are 49 species,Houttuynia cordata are 123 species,Platycodon grandiflorum are 145 species,Mulberry Leaf are 364 species,Fructus ligustri lucidi are 136 species,Eclipta are 85 species,Biond Magnolia Flower are 261 species,Radix glycyrrhizae are 452 species.Remove the common constituents in the two databases and screen the active components simultaneously under the conditions of OB≥30% and DL≥0.18.There were 8active components of Agrimonia pilosa,10 of Radix scrophulariae,2 of Radix Ophiopogonis,12 of Radix glehniae,2 of Dried rehmannia root,8 of Houttuynia cordata,9 of Platycodon grandiflorum,31 of Mulberry Leaf,13 of Fructus ligustri lucidi,10 of Eclipta,19 of Biond Magnolia Flower,93 of Radix glycyrrhizae.By retrieving the public database,a total of 288 predicted targets of the active components of "Xianshen decoction" were obtained after removing the duplicates.(2)By retrieving Geencards database,Malacards database and TTD database,the disease targets of radiation-induced oral mucositis in nasopharyngeal carcinoma were screened,and 5133,129,29 were obtained respectively.After removing the duplicates,a total of 5137 known disease targets were obtained.(3)After the combination and the intersection,235 component-disease common targets were obtained,that is,the potential targets of the active components of "Xianshen decoction" in the treatment of radiation-induced oral mucositis in nasopharyngeal carcinoma.Based on the degree and betweenness scores,the Cytohubba plug-in was used to screen the key targets of the top10 scores,which are STAT3、AKT1、MAPK1、MAPK3、TP53、JUN、TNF、HSP90AA1、RELA、APP;STAT3、MAPK1、AKT1、CYP1A1、TP53、F2、HSP90AA1、APP、RXRA、JUN,respectively.(4)The top 10 COUNT numbers in BP enrichment analysis of GO annotation are positive regulation of transcription from RNA polymerase II promoter,response to drug,signal transduction,negative regulation of apoptotic process,positive regulation of cell proliferation,positive regulation of transcription,DNA-templated,negative regulation of transcription from RNA polymerase II promoter,apoptotic process,oxidation-reduction process,inflammatory response,positive regulation of gene expression,aging,response to hypoxia.The top 10 in MF enrichment analysis are protein binding,identical protein binding,enzyme binding,protein homodimerization activity,ATP binding,DNA binding,protein heterodimerization activity,protein kinase binding,transcription factor activity,sequence-specific DNA binding,zinc ion binding,transcription factor binding,protein kinase activity,sequence-specific DNA binding.The top 10 in CC enrichment analysis are plasma membrane,nucleus,cytosol,cytoplasm,nucleoplasm,extracellular exosome,extracellular space,extracellular region,membrane,integral component of plasma membrane,mitochondrion,endoplasmic reticulum,endoplasmic reticulum membrane,Golgi apparatus,perinuclear region of cytoplasm.The top ten of the KEGG pathway are Pathways in cancer 、 PI3K-Akt signaling pathway,Proteoglycans in cancer,TNF signaling pathway,HTLV-I infection,Influenza A,MAPK signaling pathway,Micro RNAs in cancer,Prostate cancer,Hepatitis C,Tuberculosis,Chagas disease(American trypanosomiasis),Toxoplasmosis,Focal adhesion,Ras signaling pathway,Fox O signaling pathway.4 CONCLUSION4.1 clinical study(1)The incidence of grade III or above mucositis was 13.8%,which was significantly lower than that in history."Xianshen decoction" could make the severity of oral mucositis reduced.(2)The average occurrence time of the first mucositis was 20.14 ±8.89 days,which was concentrated between the 12 th day and the 29 th day."Xianshen decoction" could delay the initial occurrence time of oral mucositis symptoms.(3)The time of taking traditional Chinese medicine was an independent factor affecting the occurrence of the first mucositis and grade III or above mucositis.When the time of taking traditional Chinese medicine was ≥ 42 days,it was the protective factor of grade III or above mucositis.(4)The effect of "Xianshen decoction" on the quality of life before and after treatment had no clinical significance,and the time of taking "Xianshen decoction" improved the quality of life to the same extent..(5)After drug safety evaluation,the patients in the group were well tolerated after taking "Xianshen decoction",and there were no obvious side effects,which proved that "Xianshen decoction" was safe and reliable in the treatment of radiation oral mucositis of nasopharyngeal carcinoma and was worthy of clinical transformation and promotion.4.2 network pharmacology researchThe network pharmacological mechanism of “Xianshen Decoction” may be through positive regulation of transcription from RNA polymerase II promoter,cell proliferation,DNA-templated transcription,apoptotic process,gene expression,negative regulation of transcription from RNA polymerase II promoter,apoptotic process and regulation of signal transduction,response to drug,oxidation-reduction process,inflammatory response,aging,response to hypoxia and other biological processes.Participate in the binding of protein,identical protein,enzyme,DNA,ATP,protein kinase,sequence-specific DNA,zinc ion,transcription factor and activate or inhibit the activity of protein homodimerization,protein heterodimerization,transcription factor,protein kinase and other molecular functions.Act on the major key targets such as MAPK1,STAT3,AKT1,TP53,JUN,TNF,APP and interfere with the PI3K-Akt signaling pathway,MAPK signaling pathway,Micro RNAs in cancer,Proteoglycans in cancer,etc.,to play a role in the treatment of radiation-induced oral mucositis in nasopharyngeal carcinoma.