Project objectives

To evaluate the clinical effectiveness and safety of Andrographis Paniculata for symptoms of acute RTIs.

Changes to project objectives

The original review proposal was aCochrane review onAndrographisPaniculata for acute lower respiratory tract infections (RTIs). This has been changed to a Cochrane style systematic review mainly because of delay on start date (ought to start in October 2015).

We have broadened our target conditions from acute lower RTIs to acute RTIs that covered both upper and lower tracts. This enabled us to fully cover important literature that evaluated  effectiveness and safety of using Andrographis Paniculata in cough and sore throat. 

Brief summary

Methods

English and Chinese databases were searched from their inception to March 2016 for randomised controlled trials (RCTs) evaluating oral A. Paniculata without language barriers (Protocol ID: CRD42016035679). The primary outcomes were improvement in RTI symptoms and adverse events (AEs). Random effects model was used to pool the mean differences and risk ratio with 95% CI reported. Methodological quality was evaluated using the Cochrane risk of bias; two reviewers independently screened eligibility and extracted data.

Results

Thirty-three RCTs (7175 patients) were included. Most trials evaluated A. Paniculata (as a monotherapy and as a herbal mixture) provided commercially but seldom reported manufacturing or quality control details. A. Paniculata improved cough (n=596, SMD: -0.39, 95%CI [-0.67, -0.10]) and sore throat (n=314, SMD: -1.13, 95% CI [-1.37, -0.89]) when compared with placebo. A. Paniculata (alone or plus usual care) has a statistically significant effect in improving overall symptoms of ARTIs when compared to placebo, usual care, and other herbal therapies. Evidence also suggested that A. Paniculata (alone or plus usual care) has shortened the duration of cough, sore throat and sick leave/time to resolution when compared versus usual care. No major AEs were reported and minor AEs were mainly gastrointestinal. The methodological quality of included trials was overall poor.

Conclusions

A. Paniculata appears beneficial and safe for relieving RTI symptoms and shortening time to symptom resolution. However, these findings should be interpreted cautiously owing to poor study quality and heterogeneity. Well-designed trials evaluating the effectiveness and potential to reduce antibiotic use of A. Paniculata are warranted.

Plain English summary

Antibiotics are frequently prescribed byGPs for short-term illnesses like chest infections which are a common reason why patients visit their GP.  Unnecessary use of antibiotics increases the resistance that microbes have to these medications and which is making our antibiotics far less effective.  It is important that we carry out scientific research into other treatments that could be offered to patients instead of antibiotics and which can give patients effective relief from their symptoms.Andrographispaniculata is traditionally used for cough, 

cold and influenza, but there has never been a scientific summary of the research done before.

Therefore, in this study, a thorough literature search in English and Chinese was performed. We collected and summarised information from relevant randomised controlled trials so that GPs know whether or not they can recommend this herb to patients instead of prescribing antibiotics. Information such as how this herb was used, in what dosage, whether it was in capsule or tablet, together with other herb or as a single herb were summarised in this review.

Findings of the review suggested the herb can help improve symptoms such as cough, sore throat and other general common cold symptoms. Taking this herb will also help patients reduce their length of cough, sore throat and cut down leave days. In rare cases, patients reported having minor discomfort such as dry mouth, nausea, diarrhoea, or constipatin.

Although promising evidence suggests Andrographis Panicula is an effective and safe herb to use in treating RTI symptoms, the studies included that helped us made this conclusion are of generally poor quality. Findings of this review should be used with caution also because these studies are very different in terms of what exact treatment were given, how they were given, and what measures they used to quantify the effects, therefore the combined finding of thes studies can be less reliable. High quality research in this field is desired.

Dissemination

Published articles

Hu et al. 2016. Andrographis paniculata for symptomatic relief of acute respiratory tract infections in adults and children: A systematic review and meta-analysis. European Journal of Integrative Medicine, 8, Supplement 1, 2 - 3.

Preliminary findings of this review have been presented in the European Congress for Integrated Medicine (ECIM) 2017 conference in Budapest and published in European Journal for Integrative Medicine. 

Planned articles

Full findings of this review will be presented in International Congress for Complementary & Integrative Medicine Research (ICCMR) 2017 conference in Berlin; and are currently under review by PlosOne.

Public involvement

Regional Research Design Service (RDS) team was consulted. Three PPI meetings were carried out with our patient representative Ms Margaret Bell. During the first meeting, initial proposal was presented to our PPI representative who has had experience suffering from frequent coughs and viral pneumonia.  The plain English summary provided in this application in Section B has been reviewed and clarified our representative’s input.  She has also provided invaluable insight for the project proposal by specifying that important information to collect in this review includes time to symptom relief, side-effects and effects of prescribing alongside concomitant medications such as antibiotics. These suggestions were taken in place when we further developed the review protocol.

The second and last PPI meetings were carried out at 6 and 12 months. Preliminary findings and final findings were shared during these two meetings. Margaret was very pleased to know that Andrographis Paniculata appears to be beneficial and safe for relieving RTI symptoms and shortening time to symptom resolution. Margaret will present the review’s findings to her local GP surgery patient input group, which she is presently a member of. We have sent her some finding materials and presentation slides to support her during dissemination activities.  These activities will also enable the results from this review to inform patients and GPs that Andrographis Paniculata can be considered as a promising safe and effect alternative for treating acute RTIs

Impact

This review has provided promising evidence on using Andrographis Paniculata for symptom relief of acute RTIs. It will help inform the research design and sample size calculation of a pilot feasibility trial, which will be running by our team member Martin as his PhD project. The team is also applying for the traditional herbal registration of the herb Andrographis Paniculata, to make this important herb a viable intervention that could be available to the public.

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 276)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.