桃仁承氣湯及三黃瀉心湯併用aspirin治療缺血後腦中風及降低神經行為缺陷之交互作用與引起胃出血、顱內出血和蜘蛛膜下腔出血之風險評估(2-1)

許準榕
臺北醫學大學
腦中風是血管性疾病致死及發病的主要原因之ㄧ，影響人類健康甚鉅，但由於其突發性的關係，使得腦中風治療藥物的研發，一直沒有很大的進展。中醫在腦中風的治療上，臨床方劑常用桃仁承氣湯及三黃瀉心湯；桃仁承氣湯由桃仁、桂枝、芒硝、大黃及甘草組成，研究指出其在治療缺血性腦中風方面有明顯效果。三黃瀉心湯則由大黃、黃連、黃芩所組成，其被認為也具有治療出血及心血管疾病之功效。另一方面，西醫臨床上常用抗血小板藥物來治療及預防缺血性腦中風，其中aspirin為最常使用的藥物之一；但許多研究指出aspirin具有高出血性的風險存在。目前台灣有許多患者常會同時併用傳統中藥方劑與西藥如aspirin來治療或預防腦血管疾病，因此了解其相關的交互作用與副作用是值得深入研究的重要課題。本計畫主要目的，在評估不同劑量的桃仁承氣湯和三黃瀉心湯，分別併用不同劑量aspirin下，其治療缺血後腦中風與降低因腦中風所引起之神經行為缺陷的交互作用及引起如胃出血(gastric bleeding, GB)、顱內出血(intracerebral hemorrhage, ICH)及蜘蛛膜下腔出血(subarachinoid hemorrhage, SAH)等風險評估及同時探討其可能作用機制。本計畫擬利用自體凝血塊引起中腦動脈阻塞的腦中風模式來進行療效評估(圖一)。本計畫預計以兩年的時間完成，工作項目簡述如下：
第一年度計畫：在自體凝血塊引起腦中風之老鼠，分別餵食低、中、高三種不同劑量之桃仁承氣湯(0.25, 0.5, 1.25克/公斤/天)或三黃瀉心湯(0.1, 0.2, 0.5克/公斤/天)，同時併用兩種不同劑量之aspirin (2和5毫克/公斤/天)，分別餵食1、2及3個月後(圖二)，比較其改善腦部缺血面積的差異性及神經行為缺陷的變化；同時測量手術後及餵食過程中腦部血流的變化。同時進一步分析其可能的作用機制，如測量腦組織中與細胞凋亡有關的蛋白表現(如MMP-9, caspases, HIF-1α, TNF-α 等)以及自由基(如OH˙)的變化。
第二年度計畫：進一步評估此二方劑分別併用aspirin後，其可能造成如胃出血、顱內出血及蜘蛛膜下腔出血之風險評估及可能之原因。在不同的組別中，分別測量胃液及腦組織中血紅蛋白的含量來評估胃出血及顱內出血的程度；利用影像分析系統定量蜘蛛膜下腔的出血面積及各組間的差異性。再者，分析凝血塊結構、斷尾凝血時間、血小板凝集活性及凝血酶原時間，以進一步分析其可能造成出血反應之原因。本計畫擬利用螢光顯微鏡進一步觀察腦皮質及網紋體中之血管分佈及其完整性的差異。透過本計畫的完成，將闡明桃仁承氣湯及三黃瀉心湯分別併用aspirin治療腦中風的療效及可能引起出血的原因，以提供確切的實證數據做為臨床之參考依據。
關鍵字：桃仁承氣湯、三黃瀉心湯、aspirin、缺血性腦中風、神經行為缺陷

Comparative studies of Tao-Ren-Cheng-Qi Tang or San-Huang-Xie-Xin Tang with aspirin on neuroprotection and lowering the neurobehavioral deficits in rat ischemic stroke: evaluation the risks of inducing gastric bleeding, intracerebral hemorrhage, and subarachnoid hemorrhage (2-1)

Sheu Joen-Rong
Taipei Medical University
Stroke is the third leading cause of mortality and morbidity in the world and is frequently associated with long-term disability. In traditional Chinese medicine (TCM), many formulas have been used clinically for centuries to treat stroke-induced disability. In China, a survey of treatments used in regular practice showed that over 70% of doctors believed that Chinese herb products are more effective treatments for acute ischemic stroke, and 66% of doctors used them routinely for most patients. Tao-Ren-Cheng-Qi Tang consisting of peach kernel, cassia twig, glauber salt, rhubarb, and licorice have long been used by traditional Chinese physicians to treat ischemic stroke. San-Huang-Xie-Xin Tang, another well-recognized Chinese formula composed by rhubarb, berberine, and baicalin is also reported to have therapeutic effects on bleeding and cardiovascular diseases. On the other hand, anti-platelet drugs are routinely used to prevent ischemic stroke clinically, of which aspirin is the most commonly used drug. Nevertheless, many studies indicate that taking aspirin will increase the risk of excessive bleeding. Hence, the development of new interventions geared toward a wider therapeutic window is necessary to meet the large need for this important and undertreated disorder. In Taiwan, a large amount of patients often simultaneously use TCM and aspirin to treat or prevent cerebralvascular diseases. Consequently, to investigate the interactions and possible risks of these drugs combination is important and warrant study. A combination of three doses of Tao-Ren-Cheng-Qi Tang or San-Huang-Xie-Xin Tang with two different doses of aspirin were used in this project to investigate their interactions and risks during the autologous blood clot-induced ischemic stroke and neurobehavioral deficits in rats. In addition, this project will also be performed the bleeding risk assessment of gastric bleeding (GB), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) and explores the possible mechanisms. The project is expected to be completed in two years, and the items are summarized below.
The first annual plan: the autologous blood clot-induced ischemic stroke in rats will be treated with low, medium, and high doses of Tao-Ren-Cheng-Qi Tang (0.25, 0.5, and 1.25 g/kg/d) or San-Huang-Xie-Xin Tang (0.1, 0.2, 0.5 g/kg/d) with two different doses of aspirin (2 and 5 mg/kg/d) for 1, 2, and 3 months, the improvement of brain ischemic areas and neurological behavioral deficits will be assessed. Meanwhile, the changes of blood flow will be measured. Furthermore, the expressions of apoptosis-related proteins such as MMP-9, caspases, HIF-1α, TNF-α, etc. and free radicals such as hydroxyl radical (OH˙) will be detected to clearly know the underlying mechanisms.
The second annual plan: the risks of GB, ICH, and SAH will be further evaluated during the administration of drugs. The hemoglobin levels in gastric fluid and brain tissue will be measured to evaluate the extent of GB and ICH; the quantitative image analysis system will be used to measure the SAH area. Furthermore, in order to clarify the possible mechanisms of
these bleeding responses, the assays of density of blood clot, bleeding time of rat tail, platelet aggregation activity, and prothrombin time will also be analyzed. In addition, the distribution and integrity of vessels in cerebral cortex and textured body will be observed by immunofluoresence microscope in this project. From this project, we can suggest that a combined treatment of Tao-Ren-Cheng-Qi Tang or San-Huang-Xie-Xin Tang with aspirin may provide a convenient intervention with a wider therapeutic window for treating ischemic stroke clinically.
關鍵字：Tao-Ren-Cheng-Qi Tang；San-Huang-Xie-Xin Tang；aspirin；ischemic stroke；neurobehavioral deficits