Controllable Vitamin K Deficiency Under High-Dose Oral Menatetrenone Administration ‒ a Case Report

ORIGINAL ARTICLES

Department of Pharmacy 1, Department of Hematology2, Ogaki Municipal Hospital; Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University3; Gifu, Japan

Controllable vitamin K deficiency under high-dose oral menatetrenone administration ‒ a case report

E. USAMI1,*, M. KIMURA1, K. FURUKAWA2, H. TERAMACHI3 , T. YOSHIMURA1

Received November 30, 2017, accepted December 29, 2017 * Corresponding author: Eiseki Usami, Department of Pharmacy, Ogaki Municipal Hospital, 4-86 Minaminoka- wa-cho, Ogaki-shi, Gifu, 503-8502, Japan [email protected] Pharmazie 73: 234–236 (2018) doi: 10.1691/ph.2018.7994

Vitamin (V) K deficiency may cause severe bleeding tendencies, which necessitates extreme caution. We report a case of a 30-year-old man diagnosed with VK deficiency of unknown etiology. He was treated with intravenous menatetrenone three times a week in an outpatient setting for about 1 year and 9 months. Eventually, he developed an allergic reaction to intravenous menatetrenone and was under steroid therapy. In order to reduce his hospital visits and discontinue steroid use, the pharmacist proposed to change the method of menatetrenone administration from intravenous to oral (high dose). The change in treatment method has greatly improved the patient’s quality of life.

1. Introduction ized ratio (PT-INR) from an unmeasurable state to 1.82. This result Vitamin (V) K deficiency is more frequent in newborns and infants suggests that the treatment was effective. Thus, IV menatetrenone (Zipursky 1999), where extreme caution is necessary as it causes was continued. Although the main cause of VK deficiency was severe bleeding tendencies. VK deficiency in adults is caused by still unknown, it could be associated with intake of drugs such prolonged inadequate dietary intake, malabsorption syndromes as aspirin (he had taken two weeks ago), hepatobiliary disorders, due to the suppression of intestinal microflora caused by long-term inadequate dietary intake, or VK absorption disorder. At day 6, PO antibiotic therapy, and cholestatic liver disease (Shearer 2009). We menatetrenone (45 mg) was given as a supplemental therapy. After report a case of VK deficiency with occasional nasal bleeding. discontinuing IV menatetrenone for 3 days, PT increased from Patient had adequate diet intake and no history of antibiotic 21.5 to 75.2 s, APTT from 43.9 to 52.7 s, and PT-INR from 1.90 to therapy or biliary tract abnormality. He was treated with intra- 6.42, indicative of a worsening VK deficiency. Consequently, we venous (IV) menatetrenone three times a week in an outpatient had to resume IV menatetrenone therapy. However, VK deficiency setting for 1 year and 9 months. However, he developed an allergic could not be controlled by twice-weekly administration of IV reaction to intravenous menatetrenone, and hence, he was started menatetrenone. Thus, IV menatetrenone treatment was continued on steroid therapy. In order to reduce his hospital visits and discon- at minimum dosage intervals for three times a week until the tinue steroid use, the pharmacist proposed to change his treatment patient’s condition was stabilized. method from intravenous to high dose oral (PO) menatetrenone. Anaphylactoid symptoms such as nausea, fever, low blood pres- The change greatly contributed towards improving the patient’s sure, and respiratory failure were observed during IV menatetre- quality of life (QOL). none treatment (total 500 mg). The activities of the coagulation-in- hibiting factors protein C (41%, normal range: 70-140%) and protein S (33%, normal range: 60-150%) subsequently decreased. 2. Case report Hence, patient was placed under long-term IV menatetrenone 2.1. Case presentation treatment combined with steroid (hydrocortisone 100 mg (IV)) as In 2015, a 30-year-old male patient (181 cm, 109 kg) with a a premedication for allergy prevention. Prolonged steroid administration exacerbated patient’s DM (HbA of 7.8%). Thus, patient past medical history of ventricular septal defect, Wolff-Parkin- 1c son-White syndrome, and diabetes mellitus (DM) was referred to was given insulin as advised by a DM specialist. the department of hematology, Ogaki Municipal Hospital (Gifu, After about 1 year and 9 months of IV menatetrenone treatment, Japan) for nasal bleeding. The patient was under home treatment patient experienced dizziness and poor DM control, prompting with metformin (1000 mg/day) for DM and aspirin for headache his admission in the hospital. During patient’s hospitalization, his (as needed). history of irregular eating habits and poor medication compliance was noted. Thus, treatment for VK deficiency was reconsidered. Initially, he received 45 mg of PO menatetrenone, but the patient 2.2. Clinical course remained unresponsive to treatment. The dose was subsequently The result of his otolaryngology examination revealed right nasal increased to 135 mg per day. The medication was given twice a bleeding. The day after the examination, he had uncontrollable day (after lunch and dinner) to ensure medication compliance and gingival bleeding, which prompted him to undergo oral surgery. thus facilitate the absorption of VK. Previously, when IV mena- He was then referred to the department of hematology due to his tetrenone was discontinued for two days, the PT-INR increased abnormal blood test values. Before and after receiving 20 mg of from 1.80 to 6.42 and thus treatment was resumed. Although PO IV menatetrenone at the initial visit, his prothrombin time (PT) menatetrenone dose was increased, PT-INR remained stable (from decreased from >100 to 21.7 s, activated partial thromboplastin 1.20 to 1.81). Due to the change in patient’s treatment method, time (APTT) from 112.3 to 59.7 s, and PT-international normal- prophylactic administration of steroids was discontinued, HbA1c 234 Pharmazie 73 (2018) ORIGINAL ARTICLES

Table: First laboratory findings

Menatetrenone administration Laboratory test normal range Before After PT (seconds) ≥100 21.7 (10.5-13.5) PT (%) ≤ 5 33 (70-130) PT-INR Unmeasurable 1.82 (0.85-1.15) APTT (seconds) 112.3 59.7 (24-39) APTT (%) 18 35 (60-140) AFP (ng/mL) - 2.0 (< 20 ) α-fetoprotein rectin fraction (%) - < 0.5 (≤ 10 ) PIVKA-II (mAU/mL) - > 50,000 (< 40) Cholinesterase (IU/L) - 486 (185-431) Total cholesterol (mg/dL) - 143 (130-220) Triglyceride (mg/dL) - 218 (50-149) HDL cholesterol (mg/dL) - 53 (40-70) LDL cholesterol (mg/dL) - 65 (< 140) Thrombotest (%) - < 5 (70-130) Hepaplastin test(%) - < 10 (70-130) Vitamin K1 (ng/mL) - 0.13 (0.15-1.25) Vitamin K2(MK) (ng/mL) - ≤ 0.05 (< 0.10) Vitamin A (μg/dL) - 52.8 (27.2-102.7) 1,25 dihydroxy vitamin D3 (pg/dL) - 63 (20-60) Vitamin E (mg/dL) - 3.2 (0.75-1.41) Coagulation factor XIII (%) - 80 (70-140) Coagulation factor II (%) - 8.8 (66.0-118.0) Coagulation factor V (%) - 126.3 (73.0-122.0) Coagulation factor X (%) - 2.1 (58.0-200.0) Plasminogen activity (%) - 139 (69-111) PIC (μg/mL) - 0.9 (< 0.8) TAT (μg/L) - 2.7 (1.0-4.1) antiplasmin (%) - 135 (80-125)

PT:prothrombin time, PT-INR:PT-International Normalized Ratio, APTT:activated partial thromboplastin time, AFP:α-fetoprotein, PIVKA-II:protein induced by vitamin K absence-II, HDL:high-density lipoprotein cholesterol, LDL:low-density lipoprotein cholesterol, PIC:alpha2-plasmin inhibitor-plasmin complex, TAT:thrombin antithrombin III complex

improved from 8.2% to 6.7% in 1 month, and his hospital visits inadequate dietary intake, no liver and biliary diseases, and no were reduced (Fig. 1). Although he experienced muscle pain history of antibiotic and warfarin therapy. Scavenger receptor class (grade 1) when taking high dose of PO menatetrenone, his QOL B type I (SR-BI), a specific protein in the proximal part of the remained unchanged. small intestine; cluster-determinant 36 (CD36) ; and Niemann- Pick C1-like 1 (NPC1L1) (Goncalves et al. 2014; Takada et al. 2015) facilitate the absorption of VK . These proteins transport 3. Discussion 1 dietary cholesterol and VE, and VK1 absorption has conceivably VK, a cofactor for γ-glutamine carboxylase, is necessary for the the same mechanism. However, no issues related to cholesterol and synthesis of coagulation factors II, VII, IX, and X. Inadequate VK VE were found. Ezetimibe inhibits VK1 absorption via NPC1L1 intake results in the inhibition of these factors and prolonged PT (Takada et al. 2015), and patient had no history of taking this medi- and APTT, leading to bleeding tendencies. VK is classified into cation as a combined treatment. IV menatetrenone, known for its two: VK1, synthesized by plants and VK2 (menaquinone: MK), effectiveness, is the main treatment for VK deficiency. Treatment synthesized by microorganisms. VK1 is found in green leafy vege- with 20 mg IV menatetrenone was effective at initial diagnosis. tables, vegetable oils, margarine, etc. and generally accounts for However, when the patient was unresponsive to treatment with 45 90% or more of the total VK intake (Holmes et al. 2012). MK is mg PO menatetrenone; IV administration was continued. He was found in fermented food such as cheese, yogurt, natto, chicken, placed under long-term IV menatetrenone treatment with regular and egg yolk. In addition, MK is synthesized by intestinal bacteria; checkup three times a week. In addition, the use of steroids as a however, it is necessary to take up foods rich in VK (Suttie 1995). prophylactic treatment for allergy reaction worsened patient’s In recent years, it has been found that certain factors can be DM. He became unemployed as his condition required regular converted from VK1 to MK (Hirota et al. 2013). VK deficiency outpatient treatment. He gained weight (from 109 to 130 kg at the in adults is caused by prolonged inadequate dietary intake, start of VK administration) in a span of 1 year and felt desperate decreased intestinal microflora owing to long-term antibiotic about his condition. Although he had short-term hospitalizations therapy, decreased VK absorption capacity due to liver and biliary due to general malaise, his treatment regimen remained the same. tract diseases, impaired VK metabolic cycle caused by warfarin However, lifestyle modification was encouraged to manage DM administration, etc. In this study, the patient had no history of and improve QOL. Pharmazie 73 (2018) 235 ORIGINAL ARTICLES

Fig: Clinical course from initiation menatetrenone administration PO: oral administration, IV: intravenous administration, PT-INR:prothrombin time International Normalized Ratio, APTT:activated partial, PT:prothrombin time, HbA1c:Hemoglobin A1c

Food intake influences the pharmacokinetics of 15 mg PO mena- In conclusion, we reported a case of VK deficiency with unknown tetrenone. The fasting area under the concentration-time curve etiology. Patient received long-term IV menatetrenone treatment. (AUC) is 165.0 ng/h/mL, whereas after breakfast, AUC is 1114.5 During his treatment period, he experienced frequent hospital visits ng/h/mL. This result suggests that the AUC between fasting and (three times a week), had poor DM control, and received steroid after breakfast is significantly different. Additionally, absorption therapy. A pharmacist also advised the patient regarding lifestyle greatly depends on the fat content370.6±194.2 ng/h/mL for regular modification. However, patient’s VK deficiency was managed with breakfast (fat content 8.8 g) and 1,024.4±341.4 ng/h/mL for high high-dose PO menatetrenone, improving patient’s QOL. fat diet (fat content 34.9 g). Food content and fat ingestion greatly influences the absorption of medicines. Due to lack of under- Conflicts of interest: None declared. standing regarding the effects of diabetes, patient continued living an unhealthy lifestyle. He skipped breakfast, ate vegetables for References lunch or consumed light meals, and ate oily foods for dinner. With Zipursky A (1999) Prevention of vitamin K deficiency bleeding in newborns. Br J this, the absorption of 15 mg PO menatetrenone given three times Haematol 104: 430-437. a day was affected. As the patient had poor drug compliance, IV Shearer MJ (2009) Vitamin K in parenteral nutrition. Gastroenterology 137: 105-118. treatment for VK deficiency was recommended. The AUC of 10 Holmes MV, Hunt BJ, Shearer MJ (2012) The role of dietary vitamin K in the management of oral vitamin K antagonists. Blood Rev 26: 1-14. mg IV menatetrenone is 3,900 ng/h/mL; however, AUC increases Suttie JW (1995) The importance of menaquinones in human nutrition. Annu Rev to about 6,800 ng/h/mL at a dose of 20 mg, which is equivalent to Nutr 15: 399-417. 7 to 18 capsules. Although the patient received a normal dose of Hirota Y, Tsugawa N, Nakagawa K, Suhara Y, Tanaka K, Uchino Y, Takeuchi A, 45 mg of PO menatetrenone per day, his VK deficiency remained Sawada N, Kamao M, Wada A, Okitsu T, Okano T (2013) Menadione (vitamin K3) is a catabolic product of oral phylloquinone (vitamin K1) in the intestine and uncontrolled. Thus, a maximum PO menatetrenone dose of nine a circulating precursor of tissue menaquinone-4 (vitamin K2) in rats. J Biol Chem capsules (135 mg) per day, based on the Phase II study in Japan, 288: 33071-33080. was given. Fortunately, the patient experienced no side effects. Goncalves A, Margier M, Roi S, Collet X, Niot I, Goupy P, Caris-Veyrat C, Reboul E As a result, PT-INR was stabilized without IV menatetrenone and (2014) Intestinal scavenger receptors are involved in vitamin K1 absorption. J Biol Chem 289: 30743-3052. VK deficiency was managed without subsequent serious bleeding Takada T, Yamanashi Y, Konishi K, Yamamoto T, Toyoda Y, Masuo Y, Yamamoto H, tendencies. Hospital visits and steroid treatment were no longer Suzuki H (2015) NPC1L1 is a key regulator of intestinal vitamin K absorption and required, and patient’s QOL improved. a modulator of warfarin therapy. Sci Transl Med 7: 275ra23. 236 Pharmazie 73 (2018) ORIGINAL ARTICLES

Department of Pharmaceutical Medicinal Chemistry and Pharmacognosy1, Faculty of Pharmacy & Medical Sciences, University of Petra, Amman, Jordan; Herbresearch2 Germany, Tussenhausen-Mattsies, Germany

Hamamelis virginiana L. leaf extract suppositories in the treatment of hemorrhoids: non-interventional trial and stability study

K. MANSOOR1,*, F. QADAN2, M. SCHMIDT2

Received October 30, 2017; accepted December 4, 2017 *Corresponding author: Prof. Dr. Kenza Mansoor, Department of Pharmaceutical Medicinal Chemistry and Phar- macognosy, Faculty of Pharmacy & Medical Sciences, University of Petra, Amman, Jordan [email protected] Pharmazie 73: 237–240 (2018) doi: 10.1691/ph.2018.7942

Objective: The effectiveness of suppositories containing witch-hazel leaf extract (Hamamelis virginiana L.) and menthol in the treatment of hemorrhoids was assessed in a non-interventional clinical study. The stability of the test preparation was ensured through a formal accelerated stability study. Methods: Twenty patients were openly treated with witch-hazel suppositories, with visits after one, two and eight days. The effects were assessed on a total symptom score consisting of the presence or absence of rectal bleeding, constipation, mass feeling, burning, itching, edema and anal discomfort. A six-month accelerated stability study (40 °C/75 % relative humidity) was carried out in parallel. Results: The product remained stable throughout the duration of the trial. Physicochemical and microbiological properties as well as the quantification of total phenols by spectrophotometry complied with pre-defined specifications. The clinical application of the suppositories resulted in an improvement of baseline scores (reduction by 19.3 % and 43.2 % after one and two days). There were practically no more symptoms after an average treatment duration of 6.2±1.3 days (reduction by 98.8 % from baseline). No adverse reactions occurred. Conclusion: The results support the clinical applicability of hazel-witch suppositories with menthol in the treatment of hemorrhoids.

1. Introduction skin inflammations, hemorrhage, diarrhea, dysentery, hemorrhoids Hemorrhoids are predominant anorectal disorders that impact the and sore mouth (Gangemi et al. 2015). It has been reported that quality of life of patients. Hemorrhoids are highly vascularized Hamamelis virginiana L. extract exerts antiviral (Erdelmeier et connective tissue cushions in the anal canal (Sun and Migaly 2016). al. 1996; Theisen et al. 2014), antioxidant (Periera da Silva et al. Their prevalence in the United States of America was estimated 2000; Gonzalez et al. 2010; Lizarraga et al. 2008; Ola et al. 2014), with approximately 4.4 % of the population in the age of 45-65 and cytotoxic (Dauer et al. 2003a; Sanchez-Tena et al. 2012) years (Johanson and Sonnenberg 1990). However, only 5–10 % of properties. Furthermore, many studies have reported its topical patients require surgical treatment (Cintron et al. 2017). Treatment use in wound healing (Das et al. 2016b; Georgescu et al. 2017), of hemorrhoids otherwise depends on the age of the patient and the oral health (Mouchrek et al. 2015; Yarom et al. 2013), hemorrhoids severity of symptoms (Sun and Migaly 2016). Conservative treat- (Abascal and Yarnell 2005; Brown and Dattner 1998; Das et al. ment includes lifestyle changes, medical treatment with mostly 2016a; MacKay 2001; Ola et al. 2014; Yarnell and Meserole 1996), topical preparations containing flavonoids (Alonso-Coello et al. eczema (Korting et al. 1995), diaper dermatitis (Wolff and Kieser 2006) and, if necessary, surgery. 2007), inflammatory conditions of the skin (Hughes-Formella et Experience with the medicinal use of herbal preparations has a long al. 1998; Hughes-Formella et al. 2002), or scalp care (Trüeb 2014). history, much of it based on try and error (Kunle et al. 2012). Many A recent clinical trial has reported a long-acting and well-tolerated of the herbal medicinal preparations for which there is positive vaginal moisturizing activity of a witch-hazel-containing cream traditional experience are not entirely evaluated for their safety, (Henneicke-von Zepelin et al. 2017). quality and efficacy (Mansoor et al. 2017). There is traditional In spite of the long history of use of H. virginiana L. to treat experience with the use of witch-hazel (Hamamelis virginiana L., hemorrhoids (Abascal et al. 2005; Brown and Dattner 1998; Das Hamamelidaceae) in the treatment of hemorrhoids, but relatively et al. 2016b; MacKay 2001; Ola et al. 2014; Yarnell and Mese- little clinical evidence. Witch-hazel is a deciduous shrub native to role 1996), few clinical studies were reported in this indication. North America. Its ethanolic extract is rich in condensed tannins We therefore performed an orientational non-interventional clin- (Erdelmeier et al. 1996). They have been identified as epicatechins ical study to evaluate the clinical applicability in the treatment and epigallocatechins linked by 4-8 interflavan bonds (Dauer et of hemorrhoids. A basic requirement for the conduct of clinical al. 2003b). Furthermore, a procyanidin polymer containing only examinations with respect to safety and reproducibility of results one type of flavanol units, and polymers of procyanidin and is the characterization of the preparation, and a stability study to prodelphinidin containing two types of flavanol units were iden- ensure the absence of physicochemical changes that might have tified (Vennat et al. 1988). Extracts were also found to contain an impact on the clinical effects. A formal stability study under glucosides of gallates with 5-10 units of gallic acid, gallocatechin, accelerated stability conditions was therefore performed in parallel catechin, hamamelitannin, and proanthocyanidins (Gonzalez et al. to the clinical examination, based on the Guideline of the European 2010; Lizarraga et al. 2008; Sanchez-Tena et al. 2012; Vennat et al. Medicines Agency “Guideline on stability testing: Stability testing 1988; Wang et al. 2003). of existing active substances and related finished products (CPMP/ Poultices containing witch-hazel preparations were traditionally QWP/122/02, rev 1 corr)”. used by Native Americans in North America to treat swellings, Pharmazie 73 (2018) 237 ORIGINAL ARTICLES

2. Investigations and results standards defined in the declaration of Helsinki. An approval of the Ethics Committees of the study centers as well as of the Turkish 2.1. Study design drug regulatory authority was obtained. A written informed consent The clinical part of the study was designed as an open, obser- form was obtained from all patients. vational trial. Patients with hemorrhoids were assessed upon inclusion, and after one, two and eight days of treatment. Three study centers in Turkey were involved in recruiting patients and 2.6. Statistics assessing case data during May, 2016. Data obtained from the observational, non-confirmatory clinical study was evaluated descriptively. Results from the stability study 2.2. Drug preparation and dosage were analyzed by one-way analysis of variance (Minitab 14, Minitab Inc, Coventry, United Kingdom). Data were illustrated by The study preparation consisted of suppositories composed of 400 means±standard deviation (SD), and differences were considered mg Hamamelis virginiana L. dry leaf extract (Finzelberg, Ander- significant at p < 0.05. nach, Germany; extraction solvent 30 % ethanol m/m, drug extract ratio 5-8:1, 70 % native extract) and 25 mg of menthol in a matrix of hard fat. The suppositories were applied twice daily. 2.7. Study population Twenty patients in the age of 33-58 years (mean: 45.7±8.3 years, 2.3. Assessment parameters median 44 years) were included. Fifteen patients (75 %) were males and 5 (25 %) were females. All patients completed the treat- Seven typical symptoms of hemorrhoids (rectal bleeding, consti- ment program and the 8-day follow-up. All patients were suffering pation, mass feeling, burning, itching, edema and anal discomfort) from external hemorrhoids. The average treatment duration was were assessed for their presence at baseline and after one, two 6.2±1.3 days. and eight days. The presence of each individual symptom added one point to a total individual patient score, which could reach a maximum of seven points per examination and patient. From these 2.8. Effectiveness individual patient scores a total sum score was calculated for every The total symptom score at baseline, calculated as the sum of examination day. This total sum score could reach a maximum individual patient scores, was 88 points out of possible 20 x 7 = value of n x 7 with n = number of included patients. Changes of 140 points (Fig. 1). After one day, there was already an improve- this total score were presented in percent of the total baseline score ment to a sum score of 71 points (-19.3 %), with a further, distinct value. improvement after two days to a sum score of 50 points (-43.2 %). At the end of the observational period, all symptoms were practi- 2.4. Inclusion and exclusion criteria cally resolved, with a residual sum score of 1 (-98.9 %). Patients were examined at baseline and classified according to the degree of symptoms: Grade 1: Mild (no therapy required); grade 2.9. Safety of application 2: Moderate (specific therapy recommended); and grade 3: Severe None of the patients showed a local reaction or any other adverse (long treatment and/or surgery required). Patients aged 30-60 years event. suffering from hemorrhoids of grade 2 could be included under the condition that untreated symptoms were present for at least three months prior to the presentation of the patient to the physician. 2.10. Stability results Concomitant treatment with other topical or systemic preparations No changes were noticed with the physicochemical and micro- for the treatment of hemorrhoids was not permitted, as was the oral biological properties, TLC fingerprints and quantitative analysis intake of corticosteroids or anti-inflammatory medication. Patients of total phenols in the formulation during the accelerated stability were considered ineligible if they had any clinically significant testing performed for six months at 40 °C/75% residual humidity renal, hepatic or other severe diseases. Pregnant or lactating (Table). According to the rules of interpretation of outcomes of females were excluded. stability studies by the European Medicines Agency’s guideline “Declaration of storage conditions for medicinal products partic- 2.5. Ethical approval ulars and active substance“ (CPMP/QWP/609/96/Rev. 2)”, no specific labelling is required for the storage of the suppositories. The study was planned and carried out in Turkey in accordance with the criteria of Good Clinical Practice (GCP) and the ethical

Table 1: Accelerated stability study of three batches of Hamamelis virginiana suppositories

Parameter Specification Start 3 Months 6 Months Appearance Brown, homogeneous, torpedo-shaped suppositories Conforms Conforms Conforms Identity by TLC (Ph. Eur. 2.2.27) Complies with the reference solution Conforms Conforms Conforms Average weight per suppository 2000 mg ± 5% 1983 mg 1977 mg 1987 mg (1900-2100 mg) 1992 mg 1987 mg 1981 mg 1992 mg 1990 mg 1985 mg Uniformity of mass (Ph. Eur. 2.9.5) Mean ± 5% Conforms Conforms Conforms Disintegration time (Ph. Eur. 2.9.2) ≤ 30 minutes 10 minutes 9 minutes 10 minutes 8 minutes 10 minutes 9 minutes 11 minutes 10 minutes 8 minutes Microbiology (Ph. Eur. 5.1.4. rectal use) cfu/g: < 25 < 25 < 25 TAMC: ≤ 103 < 25 < 25 < 25 TYMC: ≤ 102 < 25 < 25 < 25 Total polyphenols calculated as pyrogallol 40 mg ± 10 % 38.1 (95.3 %) 37.2 (93.0 %) 38.4 (96.0 %) (adapted from Ph. Eur. 2.8.14) (36.0 – 44.0) 39.1 (97.8 %) 38.3 (95.8 %) 38.9 (97.3 %) 40.0 (100.0 %) 39.5 (98.8 %) 41.2 (103.0 %) Conclusions Stable Stable

TLC: Thin-layer chromatography; TAMC: Total aerobic microbial count; TYMC: Total yeasts and moulds count; cfu: colony-forming units 238 Pharmazie 73 (2018) ORIGINAL ARTICLES

Fig. Development of symptom sum score during treatment with Hamamelis virginiana suppositories.

3. Discussion fluid extract, bismuth subgallate and a local anesthetic, whereas According to the results of this non-observational study, supposi- the other two contained local anesthetics and corticosteroids. The tories containing an extract of H. virginiana leaves may have clini- authors documented a similar improvement of symptoms (burning, cally promising effects in the treatment of hemorrhoids. The Herbal pruritus, pain and burning sensation) in all three groups at the Medicinal Product Committee of the European Medicines Agency end of the study (Knoch et al. 1992). Steinhart (1982) reported published two Community herbal monographs on Hamamelis the use of two witch-hazel containing ointments in an open study virginiana L., one for the leaves (EMA/HMPC/114586/2008) and conducted in 70 patients with anorectal complaints. About 60 % of one for the bark (EMA/HMPC/114583/2008 Corr.). Both confirm the symptoms were no longer present after four weeks of treatment a traditional application of semisolid preparations prepared, among with one of the two preparations. The same result was achieved in others, with 30 % ethanol m/m in the treatment of hemorrhoids. 30 % of the patients treated with the reference preparation (Stein- The preparation of the suppositories manufactured for this study hart 1982). was oriented at these community monographs. Next to the improvement of symptoms the study presented herein As outlined in the introduction, clinical effects of witch-hazel adds the observation of a quick onset of effects, with clinically preparations in the treatment of hemorrhoids have been mentioned highly important score reductions within only two days. in previously reported studies. The safety of the herbal prepa- The reliability of clinical observations depends on a reproducible ration was typically described as excellent. It has been reported quality and stability of the herbal preparation. It was previously that preparations of H. virginiana L. leaves neither caused contact reported that aqueous witch-hazel leaf extract stored at 5 °C dermatoconjunctivitis, nor were they found positive in patch testing underwent changes in the phenolic profile when exposed to light at a concentration of 10 % in 280 eczema patients (Gangemi et al. (Duckstein and Stintzing 2011). Another study showed structural 2015), or with an ointment with a distillate of witch-hazel leaves modifications of witch-hazel polyphenols and changes in their and bark in more than 100 subjects (Steinhart 1982). reducing and free radical scavenging capacities when food items There is a report of two patients having reacted to a skin patch test containing the plant material were exposed to thermal processes. with 25 % H. virginiana ointment. This reaction was, however, High concentrations of free gallic acid were set free especially in possibly due to wool-fat present as an excipient in the ointment long-term thermally processed samples, leading to an increase (Bruynzeel et al. 1992). Another case of contact allergy was reported with the application of an eye gel containing witch-hazel in the antioxidant capacity of heated H. virginiana L. extracts extract (Granlund 1994). In vivo rectal administration of H. virgin- (Gonzalez et al. 2010). Whereas this effect may be positive for iana suppositories was found safe up to 300 mg/kg (Qinna 2013). the use in food products, such changes would not be acceptable The EMA “Assessment report on Hamamelis virginiana L., cortex for medicinal products, where, once released, the constituents and folium (EMA/HMPC/114585/2008)” referred to witch-hazel supposed to contribute to clinical efficacy (or, if no active constitu- preparations as safe and effective within the concentration range ents are known, marker constituents), should not exceed the range of 10-50 %. of 90-110 % of starting values. This threshold was maintained in Knoch et al. (1992) carried out a randomized double blind study the suppositories under accelerated stability conditions. with 90 patients suffering from proctoscopically diagnosed hemor- In conclusion, the observational study lends support to the tradi- rhoids without external visibility. The patients were treated for 21 tionally known clinical usefulness of preparations with an extract days with one of three ointment preparations (each group with 30 of Hamamelis virginia L. leaves and menthol in the treatment of patients). One ointment was a combination of witch-hazel bark hemorrhoids, with no observed adverse effects. The formulated Pharmazie 73 (2018) 239 ORIGINAL ARTICLES suppositories were found stable under accelerated stability condi- Dauer A, Rimpler H, Hensel A (2003b) Polymeric proanthocyanidins from the bark of tions. Hamamelis virginiana. Planta Med 69: 89-91. Duckstein SM, Stintzing FC (2011) Investigation on the phenolic constituents in Hamamelis virginiana leaves by HPLC-DAD and LC-MS/MS. Anal Bioanal Chem 4. Experimental 401: 677-688. Erdelmeier CA, Cinatl J, Jr., Rabenau H, Doerr HW, Biber A, Koch E (1996) Anti- 4.1. Stability study viral and antiphlogistic activities of Hamamelis virginiana bark. Planta Med 62: 241-245. Stability studies were carried out according to ICH guidelines at 40 °C/75 % relative Gangemi S, Minciullo PL, Miroddi M, Chinou I, Calapai G, Schmidt RJ (2015) humidity for six months. Storage was made in electronically monitored stability Contact dermatitis as an adverse reaction to some topically used European herbal chambers (Binder, Tuttlingen, Germany). Stability testing was started immediately medicinal products - part 2: Echinacea purpurea-Lavandula angustifolia. Contact after release of the batches. Dermatitis 72: 193-205. Analytical specifications were predefined and covered the aspects typically called for Georgescu M, Chifiriuc MC, Marutescu L, Gheorghe I, Lazar V, Bolocan A, Bert- in the analysis of herbal medicinal products. They covered identity, physical charac- esteanu S (2017) Bioactive wound dressings for the management of chronic teristics, microbiology and a quantification of the active pharmaceutical ingredient wounds. Curr Org Chem 21: 53-63. (Table). Wherever a monograph was available, the specified parameter followed the Gonzalez MJ, Torres JL, Medina I (2010) Impact of thermal processing on the activity corresponding procedure defined by the European Pharmacopoeia. The stability crite- rion was a defined range of±10 % of baseline values of the quantitative determination of gallotannins and condensed tannins from Hamamelis virginiana used as func- of total polyphenols in the witch-hazel extract. tional ingredients in seafood. J Agric Food Chem 58: 4274-4283. Granlund H (1994) Contact allergy to witch hazel. Contact Dermatitis 31: 195. Henneicke-von Zepelin HH, Williams R, Havemeister W, Wigger-Alberti W, Nolte 4.2. Thin layer chromatography of H. virginiana L. extract in the KU (2017) Clinical trial shows lasting function of a new moisturizing cream against vaginal dryness. Wien Med Wochenschr 167: 189-195. suppositories Hughes-Formella BJ, Bohnsack K, Rippke F, Benner G, Rudolph M, Tausch I, Thin layer chromatography (TLC) was performed on silica gel plates R. For the test Gassmueller J (1998) Anti-inflammatory effect of hamamelis lotion in a UVB solution, four suppositories were heated in 30 mL of ethanol R (50 % v/v) for 30 erythema test. Dermatology 196: 316-322. min on a water-bath under reflux. The resulting extract was filtered from the hard fat Hughes-Formella BJ, Filbry A, Gassmueller J, Rippke F (2002) Anti-inflammatory residues after cooling. The reference solution was prepared by dissolving 30 mg of efficacy of topical preparations with 10% hamamelis distillate in a UV erythema tannic acid R and 10 mg of gallic acid R in 5 mL of methanol R, followed by dilution test. Skin Pharmacol Appl Skin Physiol 15: 125-132. to 10 mL with the same solvent. 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