JOURNAL OF NATURAL REMEDIES REVIEW ARTICLE DOI:10.18311/jnr/2019/23676 Anti-hyperglycaemic Effect of Aegle marmelos (L.) in Animal Experiments-PRISMA based Systematic Review and Meta-analysis Preethi Mohan1*, Madhumita Kumar2, Abhayakumar Misra3, P. Rammanohar4 1Department of Agada Tantra and Vyavaharayurveda (Toxicology, Jurisprudence and Forensic Medicine), Amrita School of Ayurveda, Amritapuri, Amrita Vishwa Vidyapeetham, Vallikavu – 690546, Kerala, India; [email protected] 2Department of ENT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi – 682041, Kerala, India 3Department of Rasasastra and Bhaishajya Kalpana (Medicinal Chemistry and Pharmacy), Amrita School of Ayurveda, Amritapuri, Amrita Vishwa Vidyapeetham, Vallikavu – 690546, Kerala, India 4Amrita Centre for Advanced Research in Ayurveada, Amrita School of Ayurveda, Amritapuri, Amrita Vishwa Vidyapeetham, Vallikavu – 690546, Kerala, India Abstract Aegle marmelos is a folklore medicine which is widely consumed as an anti-hyperglycaemic drug, its properties are known since prehistoric times. Plenty of cell line as well as animal research have reported the anti-hyperglycaemic activity of the drug. Even though quality researches are necessary to fulfil further human studies and marketing, no quality assessments for these studies have been undertaken till date. The aim was to critically analyse the quality standards and evaluate the anti-hyperglycaemic potential of A. marmeloes in rodent model researches. The search strategy was done using the key words ‘Aegle marmelos, along with ‘Diabetes or Hyperglycaemia,’ in different databases like PubMed (n = 45), Google Scholar (n = 43) and Science Direct (n = 46). However, the filter used during the search was ‘Animal experimentation’. All animal experimentations collected with the keyword search was analysed for the inclusion criteria like serum glucose estimation as primary outcome, timeline of publication 1997 to 2017 in English and treatments containing any part and any form of A. marmelos in single or in combination. Based on the inclusion criteria, 11 articles were selected for the review. Data extraction underwent a blind procedure independently by two reviewers. If full texts were not available, communicating the authors was also tried and all the four authors responded. All the studies selected after screening were given unique codes, to ensure blind review. Result observed indicated higher reduction of serum glucose levels in hyperglycaemia-induced rodent models. After administering the drug, significant changes were observed in total cholesterol as well as triglycerides. Rest of the LDL, HDL, SOD and serum insulin were an in-significant find. Sample size calculation was not mentioned in any of the studies. Only 9% of the studies reported on blinding and 18% reported on randomisation. This might have affected the internal validity of the studies. It can be concluded that A. marmelos is effective in lowering the serum glucose levels in experimental hyperglycaemia. Further research has to be conducted to explore its target specific mode of action. This may lead to the development of an effective anti-hyperglycaemic drug with minimal side effects. Keywords: Ayurveda, Diabetes, Prameha, Vilwa *Author for correspondence Article Received on: 08.05.2019 Revised on: 23.07.2019 Accepted on: 08.10.2019 170 Anti-hyperglycaemic Effect of Aegle marmelos (L.) in Animal Experiments-PRISMA based Systematic Review and Meta-analysis Abbreviations SGPT - Alanine Transaminase LDL - Low density lipoprotein SGOT - Serum glutamic oxaloacetic transaminase HDL - High density lipoprotein VLDL - Serum glutamic pyruvic transaminase SOD - Super Oxide Dismutase GSH - Glutathione WHO - World Health Organisation MDA - Malondialdehyde LPO - Lipid Peroxidation ROB - Risk of Bias CAT - Catalase STZ - Streptozotocin FBS - Fasting Blood Sugar AM - Aegle marmelos TBARS - Thiobarbituric Acid Reactive Substances ALT - Alanine Transaminase HP - Hydrogen Peroxide AST - Aspartate Transaminase GPX - Glutathione Peroxidase HFN - Human Fibronectin SD - Standard Deviation 1. Introduction be analysed for the maintenance of uniform standards. This meta-analysis is the first of its kind conducted in Pre-senile diabetes mellitus is the primary cause of a Ayurveda. Various pharmacological activities of the majority of the deaths in India. Diabetes will be the herb were researched pre-clinically. Analysis of these seventh pre-eminent cause of death in 2030 as per studies in terms of risk of bias and heterogeneity is WHO. Its prevalence rate has augmented from 108 essential for further clinical and marketing researches. million to 421 million in 30 years. The occurrence of Aim of this review was to analyse the effects and quality diabetes among adults above 18 yrs has also risen to assessment in terms of risk of bias and calculation of about 3.7% in 30 years. The dispersion of diabetes is heterogeneity of pre-clinical anti-hyperglycaemic 1 high in developing countries . Medicinal herbs are activity of A. marmelos. the plausible source to aid treating diabetes in health care system all over the world. Ayurveda, the ancient Indian system of medicine elaborates the use of plants 2. Materials and Methods in various ailments. Chemical constituents in plants Animal experiments commenting on the anti- vary depending on the species, the plant part used, the hyperglycaemic action of A. marmelos published from 1997 storage measures use, the harvesting time, as well as October – 2017 October, were searched using the key words the tropo-geographical area etc. The finished products ‘Aegle marmelos’ and ‘Hyperglycaemia’, ‘Aegle marmelos’ may also contain constituents in varied amounts with ‘diabetes’ in databases like PubMed, Science direct and in different manufacturing batches. This variability Google scholar. Experimental studies that involved rodent accounts for the difference in pharmacological action animal models were considered for this review. The filter 2 of the herbal medicine . It is the time to expound used while searching was ‘animal experiments’. Published and conduct a pragmatic herbal research as there is researches in English language were included in the review. enormous and emergent use of the natural products. It Those studies that contained serum glucose estimation as is worth procuring an unswerving data for the health outcome measures were considered. The title may or may 3 care system . not contain the word ‘hyperglycaemia’ or ‘diabetes’. Among Aegle marmelos is extensively consumed as an anti- the selected studies, those studies that did not include hyperglycaemic drug and its properties are known serum glucose estimation as outcome measure or sub group since prehistoric times. Bark juice and leaves of analysis were excluded. Available animal publications of A. Aegle marmelos are said to hold anti-hyperglycaemic marmelos were searched irrespective of parts, dose, route, property as mentioned in classical texts of Ayurveda4. and duration of administration5. Effect and quality of these experimental studies have to Journal of Natural Remedies | ISSN: 2320-3358 http://www.informaticsjournals.com/index.php/jnr | Vol 19 (4) | October 2019 Mohan et al. 171 3. Data Analysis In the current study, if the parameter concerned was described in three or more studies, meta-analysis of that activity was performed. Serum glucose was taken as a primary parameter and serum insulin, total cholesterol, triglyceride, LDL, HDL and SOD were used as secondary parameters. All the study characteristics like inducing agent, control drug, number of groups described were taken into consideration6. Random statistic model was used in the meta-analysis. Heterogeneity was assessed using I2. Sources of heterogeneity were compared between studies. The data was analysed using MICROSOFT EXCEL-2O15. Statistical significance was defined in all studies where the P-value is < 0.05 7. 4. Results 4.1 Article Selection Based on the inclusion criteria, 11 articles were selected for the review. The search scheme and portrayals of the studies are briefed in Figure 1 and Table 1 respectively. 4.2 ROB Evaluation The ROB and quality of the included studies were evaluated individually. ROB was analysed with SYRCLE’s 8 Tool . Possible sources of risk of bias were not reported in Figure 1. Search strategy. Table 1. Study characteristics Description of Aegle Dose-mg/kg,route Authors Study description Parameters used marmelos of administration Ripe fruit purchased Wistar rats of both from a local market Serum glucose, serum insulin, 500, 1000 and sexes(n=30),STZ induced and authenticated triglyceride, cholesterol, Rahman et al [9] 2000 mg/kg body diabetes, total 5 groups, from herbarium of creatinine, ALT, AST, western wt.(oral) control (n=6),AM botany department of blot (n=6),duration-42 days karachi university Fruit and leaves Long evans rats of both Serum glucose, serum insulin, collected from a sexes, STZ induced diabetes, insulin resistance, insulin Mudi et al [10] district of Bangladesh 450 mg/kg(oral) total 3 groups, control (n=6), sensitivity, triglyceride, total and authenticated by AM(n=7),duration-21 days cholesterol, HDL pharmacognosist Drug is authenticated Long evans rats(sex not by Bangladesh mentioned) (n=20),STZ Serum glucose, serum insulin, national herbarium 250mg/kg,500mg/ Ansari et al [11] induced diabetes, total 2 sucrose by intestinal perfusion and extracted(part kg groups, control (n=10), AM technique), alpha-amylase is not mentioned by (n=10), duration=28