Download Safety and efficacy of Ganoderma lucidum (lingzhi) and San Miao

Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 57, No. 7, October 15, 2007, pp 1143–1150
DOI 10.1002/art.22994
© 2007, American College of Rheumatology
ORIGINAL ARTICLE
Safety and Efficacy of Ganoderma lucidum
(Lingzhi) and San Miao San Supplementation in
Patients With Rheumatoid Arthritis: A DoubleBlind, Randomized, Placebo-Controlled Pilot Trial
EDMUND K. LI,1 LAI-SHAN TAM,1 CHUN KWOK WONG,1 WAI CHING LI,1 CHRISTOPHER W. K. LAM,1
SISSI WACHTEL-GALOR,2 IRIS F. F. BENZIE,3 YI XI BAO,3 PING CHUNG LEUNG,4 AND
BRIAN TOMLINSON1
Objective. To examine the efficacy of popular Chinese herbs used in a traditional Chinese medicine (TCM) combination
of Ganoderma lucidum and San Miao San (SMS), with purported diverse health benefits including antioxidant properties
in rheumatoid arthritis (RA).
Methods. We randomly assigned 32 patients with active RA, despite disease-modifying antirheumatic drugs, to TCM and
33 to placebo in addition to their current medications for 24 weeks. The TCM group received G lucidum (4 gm) and SMS
(2.4 gm) daily. The primary outcome was the number of patients achieving American College of Rheumatology (ACR) 20%
response and secondary outcomes included changes in the ACR components, plasma levels, and ex vivo–induced
cytokines and chemokines and oxidative stress markers.
Results. Eighty-nine percent completed the 24-week study. Fifteen percent in the TCM group compared with 9.1% in the
placebo group achieved ACR20 (P > 0.05). Pain score and patient’s global score improved significantly only in the TCM
group. The percentage, absolute counts, and CD4ⴙ/CD8ⴙ/natural killer/B lymphocytes ratio were unchanged between
groups. CD3, CD4, and CD8 lymphocyte counts and markers of inflammation including plasma interleukin-18 (IL-18),
interferon-␥ (IFN␥)–inducible protein 10, monocyte chemoattractant protein 1, monokine induced by IFN␥, and RANTES
were unchanged. However, in an ex vivo experiment, the percentage change of IL-18 was significantly lower in the TCM
group. Thirteen patients reported 22 episodes (14 in placebo group and 8 in TCM group) of mild adverse effects.
Conclusion. G lucidum and San Miao San may have analgesic effects for patients with active RA, and were generally safe
and well tolerated. However, no significant antioxidant, antiinflammatory, or immunomodulating effects could be
demonstrated.
KEY WORDS. Rheumatoid arthritis; Ganoderma lucidum; Cytokines.
INTRODUCTION
Ganoderma lucidum or lingzhi, which in Chinese means
“herb of spiritual potency,” is one form of the mushroom
ClinicalTrials.gov identifier: NCT00432484.
1
Edmund K. Li, FRCP(C), Lai-Shan Tam, MD, Chun Kwok
Wong, PhD, Wai Ching Li, RN, Christopher W. K. Lam, PhD,
Brian Tomlinson, FRCP: Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; 2Sissi WachtelGalor, PhD: The Hong Kong Polytechnic University, Hong
Kong; 3Iris F. F. Benzie, DPhil, Yi Xi Bao, PhD: Chongqing
University of Medicine Science, Chongqing, China; 4Ping
Chung Leung, DSc: The Institute of Chinese Medicine, Chinese University of Hong Kong, Hong Kong.
Address correspondence to Edmund K. Li, FRCP(C), Department of Medicine & Therapeutics, Prince of Wales Hospital,
New Territories, Shatin, Hong Kong. E-mail: edmundli@cuhk.
edu.hk.
Submitted for publication December 15, 2006; accepted in
revised form April 18, 2007.
Ganoderma lucida, which has been used to treat all forms
of ailments, and is the oldest mushroom known to have
been used in ancient Chinese medicine. Lingzhi allegedly
has multiple health benefits for a broad range of conditions
from arthritis to cancers, and has therefore attained an
unparalleled reputation in the East as the ultimate herbal
substance. From the spores of G lucidum, 6 highly oxygenated lanostane-type triterpenes have been isolated called
ganoderic acid, which is the active ingredient. G lucidum
is widely cultivated nowadays and is sold as raw material
or lingzhi extracts in many Asian markets and Western
health shops.
In recent years, there has been an increasing number of
reports of the biologic effects of G lucidum in the scientific
literature. Many suggest that G lucidum has antioxidant
properties as a free radical scavenger (1,2), indicating that
some of the antioxidant components are well absorbed,
resulting in a significant increase in the total antioxidant
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power in the plasma as assessed by the ferric-reducing/
antioxidant power (FRAP) test (3). Other studies suggest
that G lucidum can improve immunologic functions (4,5),
with potential bidirectional effects exhibiting both immunoreactive and immunomodulatory activity. G lucidum
was shown to inhibit histamine release from mast cells (6),
to reduce production of antibodies and suppress cytokine
production, and to up-regulate adhesion molecules (7,8),
but it was also found to activate mitogen-activated protein
kinase and reduce cytotoxicity, oxidative damage, and apoptosis in some in vitro studies (7,9). Its growing popularity in patients with cancer may be supported by its suppressive effects of tumor growth in vitro (10 –13).
Despite the large amount of scientific literature on G
lucidum, we could find no published studies in the English language literature of its effects on inflammatory
arthritic diseases. Clinical studies in general are limited,
despite the widespread use of this product. Recently, there
has been increased interest in the role of an enzyme, secretory phospholipase A2 (sPLA2), as a mediator in the
inflammatory pathway in various types of arthritis including rheumatoid arthritis (RA) (14). This enzyme can serve
as a critical modulator of cytokine-driven inflammation. In
ex vivo synovial cell cultures, sPLA2 enhances tumor necrosis factor ␣ (TNF␣) induction of prostaglandin production, in part via increased expression of cyclooxygenase 2
and cytosolic phospholipase A2. Mononuclear cells from
peripheral blood and synovial fluid of patients with RA
respond to sPLA2 with enhanced release of TNF␣ and
interleukin-6 (IL-6) (15). Selective inhibition of sPLA2 has
yielded variable results in an adjuvant-induced arthritis
model in rats (16). Its combined antioxidant, putative antiinflammatory properties and our preliminary unpublished data using an in vitro test system showing inhibition of the enzyme phospholipase A2 from bee venom and
from hog pancreas suggest that G lucidum may have a role
in the treatment of patients with RA.
In addition to G lucidum, San Miao San (SMS; translated
as Powder of Three Wonderful Drugs) is another herbal
remedy that is of relevance and interest in RA. In traditional Chinese medicine (TCM), RA belongs to the category Bi Zheng, which is defined as a syndrome marked by
arthralgia and dyskinesia of the joints and limbs due to
attack of the meridians of the limbs by wind, dampness,
and heat or cold pathogens. SMS is a traditional Chinese
medicinal formula that has been used empirically to treat
Bi Zheng for hundreds of years. It is composed of the herbs
Rhizoma atractylodis (Cangzhu), Cotex phellodendri
(Huangbai), and Radix achyranthes Bidentatae (Niuxi). In
recent years, pharmacologic studies have confirmed antiinflammatory and pain-relieving properties of SMS in animal models, along with some preliminary clinical observations from the Chinese literature that reported that SMS
had a therapeutic effect in the treatment of children with
RA. Furthermore, use of the combination of SMS and G
lucidum for the analgesic and antiinflammatory effects
was a common practice according to the experts in TCM.
They believed that this combination may have additive
effects. The goal of this pilot study was to investigate the
potential efficacy of a combined standard formulation of G
Li et al
lucidum and SMS as a therapeutic adjunct for patients
with active RA.
PATIENTS AND METHODS
Patients. A total of 65 patients who fulfilled the American College of Rheumatology (ACR; formerly the American Rheumatism Association) 1987 revised criteria for the
classification of RA (17) were recruited from the rheumatology outpatient clinic at the Prince of Wales Hospital, the
teaching hospital of The Chinese University of Hong Kong.
Patients taking disease-modifying antirheumatic drugs
(DMARDs) including hydroxychloroquine, sulfasalazine,
methotrexate, and leflunomide were eligible for inclusion
if they were receiving a stable dose for at least 3 months
before screening and remained on this regimen throughout
the study. Patients receiving stable doses of one nonsteroidal antiinflammatory drug or prednisone in dosages up to
10 mg daily were also included. The dosage of methotrexate ranged between 12.5 and 17.5 mg/week with folic acid
supplementation. All patients were instructed not to make
any changes in their background therapies during the
study. Intraarticular or pulse corticosteroids were not permitted during the study because they may inhibit phospholipase activities. Exclusion criteria were as follows:
⬍18 years of age, pregnancy, use of intraarticular corticosteroids within 4 weeks preceding the study, any severe
chronic or uncontrolled comorbid disease, or wheelchair
bound with restricted mobility. Ethical approval was obtained from the Ethics Committee at The Chinese University of Hong Kong. All patients gave written informed
consent at the time of enrollment.
In this 24-week randomized, double-blind, placebo-controlled trial, patients who met the inclusion and exclusion
criteria were randomly assigned to receive either G lucidum with SMS or placebo using a computer-generated list
of random numbers in blocks of 5. The list was generated
at the Institute of Chinese Medicine, The Chinese University of Hong Kong. Study medications were dispensed as
sealed packages in consecutive numbers. A research nurse
was responsible for dispensing study medications. The
investigators, research nurse, and participants were not
aware of the treatment assignments throughout the study.
Treatment codes were only broken after completion of the
study.
Preparation of the extract. G lucidum and SMS were
supplied as capsules, containing 4.0 gm of G lucidum
extract, 2.4 gm of Rhizoma atractylodis (Cangzhu), 2.4 gm
of Cotex phellodendri (Huangbai), and 2.4 gm of Radix
achyranthes Bidentatae (Niuxi). Each patient took either 3
capsules twice daily as recommended by the TCM experts
or identical-looking placebo. The compound used in this
study was prepared in the Institute of Chinese Medicine at
The Chinese University of Hong Kong.
The herbal formula was constructed by combining G
lucidum 35.7% and SMS, which comprises 3 Chinese
herbs, namely, Rhizoma atractylodis 21.4%, Cortex phellodendri Chinensis 21.4%, and Radix achyranthes Bidentatae 21.4%. The herbal preparation was manufactured,
San Miao San and Ganoderma lucidum in RA
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Table 1. Clinical and demographic data at baseline*
Female sex
Age, mean ⫾ SD years
Duration of RA, median (IQR) years
Rheumatoid factor positive
Erosive disease
Tender joints, median (IQR)
Swollen joints, median (IQR)
Physician’s global (VAS 0–10), mean ⫾ SD
Patient’s global (VAS 0–10), mean ⫾ SD
Pain (VAS 0–10), mean ⫾ SD
ESR, median (IQR) mm/hour
C-reactive protein, median (IQR) mg/liter
HAQ, mean ⫾ SD
Prednisolone
Leflunomide
Hydroxychloroquine
Sulfasalazine
Methotrexate
Total no. of DMARDs 1:⬎1
Ganoderma lucidum ⴙ SMS
(n ⴝ 32)
Placebo
(n ⴝ 33)
27 (84)
50 ⫾ 10
9.3 (4.8, 18.0)
24 (75)
25 (78)
2 (1, 5)
3 (2, 5)
4.5 ⫾ 1.5
6.0 ⫾ 2.6
5.2 ⫾ 2.4
41 (24, 71)
9.8 (3.0, 24.5)
1.2 ⫾ 0.8
3 (9)
10 (31)
7 (22)
8 (25)
22 (69)
19 (59):13 (41)
29 (88)
50 ⫾ 13
7.8 (5.5, 11.5)
23 (70)
25 (76)
3 (2, 4)
3 (2, 6)
4.5 ⫾ 1.6
5.7 ⫾ 2.4
5.0 ⫾ 2.5
45 (20, 75)
9.7 (3.0, 39.3)
1.2 ⫾ 0.8
3 (9)
13 (39)
5 (15)
4 (12)
22 (67)
21 (64):12 (36)
* Values are the number (percentage) unless otherwise indicated. SMS ⫽ San Miao San; RA ⫽ rheumatoid
arthritis; IQR ⫽ interquartile range; VAS ⫽ visual analog scale; ESR ⫽ erythrocyte sedimentation rate;
HAQ ⫽ Health Assessment Questionnaire; DMARDs ⫽ disease-modifying antirheumatic drugs.
packaged, and labeled by a factory in Hong Kong based on
good manufacturing practice standard. The crude herbs
were supplied in one batch from reputable suppliers and
were kept and stored in a cool and dry place. Before the
water extraction procedure, the crude herbs of G lucidum,
Rhizoma atractylodes, Cortex phellodendri Chinensis, and
Radix achyranthes Bidentatae were cleaned, washed, and
cut into fragments no bigger than 6 cm in length. Rhizoma
atractylodis was ground into powder below 100 mesh for
later use. During the water extraction process, distilled
water was added to macerate the herbs for 1 hour, and then
the mixture was boiled at 100°C for 1 hour for the first
extraction. There were 3 extractions in total. The second
extraction involved adding distilled water and boiling at
100°C for 1 hour and the third extraction involved boiling
for half an hour. After extraction, the liquid extract was
concentrated at ⫺660 mm Hg and at 60°C and was spray
dried to produce a powder extract. The dry extract powder
was sieved and mixed with Rhizoma atractylodis powder.
It was then encapsulated at 500 mg per capsule and polished and packaged in a clean room at 10 –20°C and 50%
humidity. Placebo capsules, which were identical in appearance, contained starch and a coloring agent.
Assessment of clinical response. All patients were evaluated at baseline and weeks 4, 8, 16, and 24. The following
clinical and laboratory variables were assessed at each
visit: number of tender joints and swollen joints, patient’s
global assessment (using a 0 –10-cm visual analog scale
[VAS]), physician’s global assessment (using a 0 –10-cm
VAS), duration of morning stiffness, plasma C-reactive
protein (CRP) level, concentration, and erythrocyte sedimentation rate (ESR).
Primary outcome. The primary outcome was the number of patients who achieved the ACR 20% response,
which is defined as having a 20% improvement in the 5
components including the number of tender and swollen
joints and a 20% improvement in 3 of the 5 remaining core
set measures: patient and physician global assessments;
pain; disability as assessed by the Health Assessment
Questionnaire (HAQ), which is an objective self-administered questionnaire that measures the functional disability
of patients with RA (18); and an acute-phase reactant, ESR
or CRP level (19).
Secondary outcomes. Secondary outcomes included
changes in the ACR components including tender and
swollen joint count, physician’s and patient’s global assessment, HAQ score, and ESR or CRP level. The other
laboratory investigations included measurements of the
total antioxidant power of plasma by the FRAP assay and
plasma ascorbic acid concentration. Both were simultaneously measured by the FRASC (20), a modified version
of the FRAP assay (US patented) (21).
The MultiTEST IMK Kit with TruCOUNT tubes (Becton
Dickinson, San Jose, CA) and the lyse/no-wash method
were used for the assessment of the ratio and absolute
counts of CD4⫹ (T helper lymphocytes), CD8⫹ (T suppressor lymphocytes and cytotoxic T lymphocytes), natural
killer (NK) cells, and B lymphocytes in EDTA whole blood
samples using a 4-color FASCalibur flow cytometer (Becton Dickinson). The concentration in EDTA level and the
ex vivo levels of induced cytokines and chemokines were
measured after treatment with lipopolysaccharide (25 ␮g/
ml) or phytohemagglutinin (5 ␮g/ml) for 24 hours for interferon-␥ (IFN␥)–inducible protein 10 (IP-10), monocyte
chemoattractant protein 1, monokine induced by IFN␥,
1146
Li et al
Table 2. Changes in the American College of Rheumatology (ACR) core set variables and antioxidant levels after 6 months of
either Ganoderma lucidum plus SMS or placebo*
Ganoderma lucidum (n ⴝ 28)
Variables
ACR core set
Tender joints, median (IQR)
Swollen joints, median (IQR)
Physician’s global (VAS 0–10)
Patient’s global (VAS 0–10)
Pain (VAS 0–10)
ESR, median (IQR) mm/hour
C-reactive protein, median (IQR) mg/liter
HAQ
Antioxidant levels
FRAP value, ␮moles/liter
Serum ascorbic acid levels, ␮moles/liter
Placebo (n ⴝ 30)
Baseline
6 months
Baseline
6 months
2 (1, 5)
3 (2, 5)
4.3 ⫾ 1.5
5.7 ⫾ 2.5
4.9 ⫾ 2.3
40 (22, 50)
9.2 (3.0, 22.2)
1.2 ⫾ 0.8
2 (0, 4)
4 (2, 6)
4.8 ⫾ 2.2
4.7 ⫾ 2.6†
3.9 ⫾ 2.5†
33 (19, 56)
11.3 (3.0, 15.5)
1.3 ⫾ 0.7
2 (2, 3)
3 (2, 6)
4.5 ⫾ 1.7
5.4 ⫾ 2.3
4.8 ⫾ 2.4
44 (18, 76)
9.8 (3.0, 33.0)
1.1 ⫾ 0.8
1 (0, 6)
4 (2, 8)
4.8 ⫾ 2.5
4.8 ⫾ 2.5
4.5 ⫾ 2.3
42 (32, 75)
13.3 (5.1, 20.7)
1.2 ⫾ 0.7
942 ⫾ 213
46.5 ⫾ 16.0
960 ⫾ 188
48.1 ⫾ 20.8
956 ⫾ 137
51.1 ⫾ 23.1
969 ⫾ 212
46.1 ⫾ 18.7
* Values are the mean ⫾ SD unless otherwise indicated. FRAP ⫽ ferric-reducing/antioxidant power test; see Table 1 for additional definitions.
† P ⬍ 0.05.
RANTES, IL-8, IL-6, and IL-18 at baseline, and were measured by cytometric bead array using flow cytometry or
enzyme-linked immunosorbent assay at 8 and 24 weeks
after treatment (22).
Assessment of adverse reactions. At each visit, patients
were asked if there were any adverse effects. When an
adverse event was claimed, the timing relative to the administration of the drugs was noted. Blood pressure, blood
cell count, serum creatinine, and liver function test results
were recorded before study entry and at each visit during
the study.
Statistical analysis. Comparisons between the group
treated with G lucidum and SMS and the placebo group for
demographic and clinical characteristics were performed
using chi-square tests, Student’s t-test, or Mann-Whitney
U tests where appropriate. Comparisons before and after
treatment in each group were assessed using paired t-tests
or Wilcoxon’s signed rank test as appropriate. All hypotheses were 2-tailed, and P values less than 0.05 were considered significant. Analyses were performed using SPSS
for Windows, version 10.0 (SPSS, Chicago, IL).
RESULTS
The demographic features of the 65 patients are shown in
Table 1. There were no significant differences between the
2 groups. A total of 58 patients (89.2%) completed the
24-week study, with premature termination occurring in 3
patients in the placebo group (2 due to inefficacy as defined when patients required increased doses of drugs or a
change in the drugs, and 1 due to emigration) and 4 patients in the G lucidum and SMS group due to inefficacy
Table 3. Percentage change and absolute counts of lymphocyte subsets after treatment with Ganoderma lucidum plus
San Miao San and placebo*
Ganoderma lucidum (n ⴝ 28)
Immune markers
% of T lymphocyte (CD3⫹)
Absolute counts of T cell (CD3⫹; cells/␮l)
% of Ts and CTL (CD8⫹)
Absolute counts of Ts and CTL (CD8⫹;
cells/␮l)
% of Th (CD4⫹)
Absolute counts of Th cells (CD4⫹; cells/␮l)
Absolute counts of lymphocytes (cells/␮l)
% of NK cells
Absolute counts of NK cells
% of B cells
Absolute counts of B lymphocytes
Ratio of Th/Ts and CTL
Placebo (n ⴝ 30)
% change at
8 weeks
% change at
24 weeks
% change at
8 weeks
% change at
24 weeks
⫺0.59 ⫾ 0.86
5.83 ⫾ 4.05
⫺2.57 ⫾ 1.64
3.27 ⫾ 4.46
⫺1.19 ⫾ 1.34
⫺2.59 ⫾ 3.59
⫺2.27 ⫾ 2.14
⫺4.03 ⫾ 3.67
0.30 ⫾ 1.50
15.39 ⫾ 4.49
⫺0.25 ⫾ 1.73
14.90 ⫾ 5.01
1.76 ⫾ 1.39
1.45 ⫾ 4.06
⫺1.12 ⫾ 1.93
⫺0.73 ⫾ 4.67
0.12 ⫾ 1.73
5.96 ⫾ 4.38
6.64 ⫾ 4.18
1.01 ⫾ 4.92
12.26 ⫾ 7.76
7.64 ⫾ 6.82
13.89 ⫾ 8.26
3.86 ⫾ 3.79
⫺0.40 ⫾ 2.13
⫺1.34 ⫾ 4.51
⫺1.33 ⫾ 3.69
2.86 ⫾ 6.15
3.36 ⫾ 8.75
9.51 ⫾ 6.77
6.52 ⫾ 7.97
3.86 ⫾ 3.78
0.82 ⫾ 1.99
14.59 ⫾ 4.63
13.94 ⫾ 4.14
1.39 ⫾ 4.98
17.02 ⫾ 7.65
4.21 ⫾ 4.19
18.35 ⫾ 5.07
5.21 ⫾ 3.03
⫺3.17 ⫾ 2.30
1.81 ⫾ 3.84
⫺0.23 ⫾ 3.74
4.91 ⫾ 7.90
5.20 ⫾ 8.02
8.89 ⫾ 5.58
8.15 ⫾ 6.49
5.21 ⫾ 3.04
* Values are the mean ⫾ SEM. % change ⫽ [(parameter at week 8 or week 24 ⫺ parameters at baseline)/(parameter at baseline)] ⫻ 100. There were no
significant differences in the changes between groups. Ts ⫽ T suppressor lymphocytes; CTL ⫽ cytotoxic T lymphocyte; NK ⫽ natural killer cells.
San Miao San and Ganoderma lucidum in RA
1147
Table 4. Percentage change in the plasma concentration of cytokines and chemokines after treatment with either Ganoderma
lucidum plus SMS or placebo*
Ganoderma lucidum ⴙ SMS (n ⴝ 28)
Parameters
Cytokines
IL-18
Chemokines
IP-10
MCP-1
MIG
RANTES
IL-8
Placebo (n ⴝ 30)
% change at 8 weeks
% change at 24 weeks
% change at 8 weeks
% change at 24 weeks
⫺1.88 (⫺9.18, 17.11)
⫺3.11 (⫺14.01, 16.33)
⫺2.61 (⫺15.22, 28.8)
4.74 (⫺21.11, 30.28)
⫺25.33 (⫺32.55, 7.65)
1.85 (⫺7.18, 16.89)
⫺1.95 (⫺32.05, 24.81)
207.36 (0.81, 676.96)
0.00 (⫺31.68, 108.33)
⫺2.85 (⫺16.82, 17.95)
1.44 (⫺20.61, 37.48)
14.48 (⫺11.90, 43.03)
3.44 (⫺67.21, 273.33)
⫺2.5 (⫺32.20, 100.35)
1.95 (⫺29.51, 16.96)
10.20 (⫺8.04, 59.77)
2.28 (⫺12.69, 32.83)
236.45 (21.07, 714.68)
0.0 (⫺26.46, 66.37)
5.26 (⫺17.17, 66.18)
13.26 (⫺10.94, 52.01)
2.06 (⫺14.43, 65.58)
⫺18.28 (⫺66.61, 218.81)
15.70 (⫺21.71, 94.17)
* Values are the median (interquartile range). % change ⫽ [(parameter at week 8 or week 24 ⫺ parameters at baseline)/(parameter at baseline)] ⫻ 100.
There were no significant differences in the changes between groups. IL-18 ⫽ interleukin-18; IP-10 ⫽ interferon-␥–inducible protein 10; MCP-1 ⫽
monocyte chemotactic protein 1; MIG ⫽ monokine induced by interferon-␥; IL-8 ⫽ interleukin-8; see Table 1 for additional definitions.
that occurred at 8 weeks in 3 patients and at 12 weeks in
the other patient.
At week 24, the ACR20 response in the placebo group
and the G lucidum and SMS group was not significantly
different (9.1% and 15.6%, respectively; P ⬎ 0.05) and
there were no significant differences at earlier time points.
Patients in the G lucidum and SMS group who completed
the trial had significant improvement in the pain score
from week 4, and this was maintained at week 24 (mean ⫾
SD score 4.9 ⫾ 2.3 at baseline, 4.1 ⫾ 2.3 at week 4, 4.1 ⫾
2.3 at week 16, and 3.9 ⫾ 2.5 at week 24; P ⱕ 0.05). In
addition, the patient’s global assessment also improved
significantly at week 4 and was also maintained at week 24
(mean ⫾ SD score 5.7 ⫾ 2.5 at baseline, 5.3 ⫾ 2.5 at week
4, 4.8 ⫾ 2.6 at week 8, 4.7 ⫾ 2.4 at week 16, and 4.7 ⫾ 2.6
at week 24; P ⬍ 0.05). Other ACR components remained
unchanged in both groups (Table 2). There were no
changes in FRAP and serum ascorbic acid levels after
treatment in both groups (Table 2).
The plasma concentration of cytokines and chemokines
showed no significant differences between groups before
or after treatments and no significant differences after
treatment. The percentage, absolute counts, and ratio of
CD4⫹/CD8⫹/NK/B lymphocytes were unchanged between groups. CD3, CD4, and CD8 lymphocyte counts
were unchanged (all P ⬎ 0.05) (Table 3). However, the
plasma levels of IL-18, IP-10, and IL-8 showed a declining
trend in patients treated with G lucidum and SMS at week
8 and week 24, although the differences did not reach
statistical significance (Table 4). In ex vivo experiments,
the percentage change of IL-18 was significantly lower in
the G lucidum and SMS group (Table 5).
There were 22 episodes of adverse events reported by 13
patients, with 14 episodes occurring in patients receiving
placebo and 8 occurring in the G lucidum and SMS group
(Table 6). There were no reports of severe adverse reactions in any patients.
DISCUSSION
Despite claims that the extracts are of benefit to many
conditions including various types of arthritis, our study is
the first clinical trial to examine the effects of a combination of G lucidum and SMS in patients with RA. Our
findings indicate that these compounds may have analge-
Table 5. Ex vivo production of IL-6, IL-18, and chemokines upon stimulation with phytohemagglutinin and lipopolysaccharide
for 24 hours*
Ganoderma lucidum ⴙ SMS (n ⴝ 28)
Cytokines
IL-6
IL-18
Chemokines
IP-10
MCP-1
MIG
RANTES
IL-8
Placebo (n ⴝ 30)
% change at 8 weeks
% change at 24 weeks
% change at 8 weeks
% change at 24 weeks
⫺1.64 (⫺46.86, 116.57)
⫺28.89 (⫺80.25, 111.01)
⫺27.67 (⫺77.68, 20.38)
⫺62.89 (⫺77.76, 65.87)†
0.80 (⫺30.82, 41.31)
⫺16.99 (⫺56.38, 88.57)
⫺43.53 (⫺92.42, 55.71)
⫺11.26 (⫺40.43, 57.95)
⫺11.60 (⫺41.29, 89.38)
⫺36.68 (⫺61.94, 26.24)
⫺42.62 (⫺89.53, 634.59)
13.86 (⫺62.12, 242.87)
14.49 (⫺80.62, 146.49)
7.06 (⫺23.93, 94.29)†
⫺41.95 (⫺66.12, 16.76)
⫺34.11 (⫺73.49, 185.26)
⫺11.45 (⫺74.74, 176.18)
⫺4.88 (⫺64.36, 57.88)
⫺18.18 (⫺61.51, 29.38)
⫺2.99 (⫺63.54, 90.08)
10.03 (⫺75.24, 73.66)
6.7 (⫺34.76, 105.03)
12.92 (⫺59.83, 462.77)
⫺41.53 (⫺83.22, 19.94)
⫺25.90 (⫺70.94, 46.36)
⫺43.59 (⫺81.19, ⫺10.46)
0.32 (⫺40.63, 68.09)
⫺32.09 (⫺94.56, 86.69)
* Values are the median (interquartile range). % change ⫽ [(parameter at week 8 or week 24 ⫺ parameters at baseline)/(parameter at baseline)] ⫻ 100.
IL-6 ⫽ interleukin-6; IL-18 ⫽ interleukin-18; IP-10 ⫽ interferon-␥–inducible protein 10; MCP-1 ⫽ monocyte chemotactic protein 1; MIG ⫽ monokine
induced by interferon-␥; IL-8 ⫽ interleukin-8; see Table 1 for additional definitions.
† P ⬍ 0.05 by Mann-Whitney U test versus placebo group.
1148
Li et al
Table 6. Adverse events in patients treated with either
Ganoderma lucidum plus SMS or placebo*
Adverse events
Ganoderma lucidum ⴙ SMS
(n ⴝ 32)
Placebo
(n ⴝ 33)
GI upset
Palpitations
Irregular period
Insomnia
Polyuria
Headache
Sweating
Rash
Total
4
0
0
1
0
1
2
0
8
5
3
3
1
1
0
0
1
14
* GI ⫽ gastrointestinal; see Table 1 for additional definitions.
sic effects but do not appear to have any antioxidant or
antiinflammatory properties.
The dosage of G lucidum at 4 gm daily was recommended by practitioners of TCM, although the effective
dose is not really known. Dosages of 0.5–1 gm daily have
been recommended for health maintenance, 2–5 gm for
chronic health conditions, and up to 15 gm daily for serious illness. The recommended G lucidum dosage in the
Pharmacopoeia of the People’s Republic of China is 6 –12
gm (23). We chose a lower dose in the combination treatment based on the suggestion of the local TCM practitioner
and in consideration of safety aspects because the patients
were taking other medications and it is not known if interactions might occur. It is possible that higher doses may
have a more beneficial effect. The toxic dose of G lucidum
is also not clear but the median lethal dosage has been
estimated to be between 10 and 21 gm/kg, and very high
dosages (up to 38 gm/kg) have been tested in animal experiments (24,25), indicating the extracts are very safe.
For SMS, the recommended dosage was 2.4 gm daily for
each component, and higher dosages of up to 10 gm daily
have been reported without any adverse effects in the
Chinese literature. The data on the appropriate doses of
SMS are more uncertain, and for both SMS and G lucidum,
there are no useful biologic markers of their activity that
can be measured in relation to dose and the active ingredients have not been fully characterized. The combination
of SMS and G lucidum for the analgesic and antiinflammatory effects is a common practice according to our Chinese medicine colleagues. Combination was chosen based
on the advice from a local Chinese medical practitioner,
and our preliminary data using an in vitro test system
demonstrated that G lucidum significantly inhibits the
enzyme phospholipase A2 from bee venom and from hog
pancreas. The lack of efficacy in terms of an antiinflammatory or immunomodulating effect in our study may be
due to a number of causes. First, in retrospect, it would be
useful to demonstrate in an experimental animal model
that G lucidum alone and/or in combination with SMS has
an inhibitory effect on phospholipase A2 in the blood and
in the synovial fluid at various concentrations. The addition of SMS to G lucidum may not cause any additional
inhibitory activity against phospholipase A2. Second, as-
suming the compounds do inhibit phospholipase A2, it is
also possible that the concentration of the active ingredient of G lucidum or SMS in the blood or synovial fluid at
the current dose was insufficient to inactivate phospholipase A2 in synovial fluid. It has been shown previously
that the concentration of phospholipase A2 in RA synovial
fluid exceeded that in plasma (26). It is possible that the
concentrations of G lucidum and SMS achieved in the RA
synovial tissue and the synovial fluid were insufficient to
achieve adequate inhibition of phospholipase A2. Currently, there is no information on the absorption and systemic distribution of the active ingredients of G lucidum in
humans. Pharmacokinetics and pharmacodynamic assessments of G lucidum and SMS components and a dosefinding study of G lucidum would be desirable in future
studies. Finally, potential interactions between G lucidum
or SMS with other DMARDs should be addressed.
In this study, significant analgesic effects were seen and
the mixture was well tolerated. The mechanisms of the
analgesic effects are unknown and deserve further study.
Despite a lack of clinical antiinflammatory effects in our
patients, the elevated ex vivo production of IP-10, a CXC
chemokine for activated T cells and NK cells during inflammatory reactions, is of interest (22). The precise explanation for the elevated IP-10 production is unclear but this
may reflect an immunoactivation effect of G lucidum.
However, an elevated level of the proinflammatory cytokine IL-18 (478 pg/ml) was detected in patients with RA
before treatment, a level much higher than that in healthy
individuals (normal range 83–195 pg/ml) (27). Increased
IL-18 has been associated with RA (28), nephrotic syndrome (29), systemic lupus erythematosus (30), and
asthma (31). The significantly lower IL-18 ex vivo production seen in patients after treatment with G lucidum and
SMS may suggest potential beneficial effects for patients
with RA. Alternatively, this may imply a reduced induction of IL-18 at the local inflammatory sites in the patients
with RA treated with G lucidum and SMS.
Not withstanding the limitations of clinical trials with
Chinese herbal medicines, and despite the large number of
in vitro studies, we believe this is the first report of G
lucidum use in humans with RA. There are 2 reports
describing a reduction of herpes zoster pain in 9 patients
(32,33), another report on healthy volunteers demonstrating a lack of impairment of hemostatic function (34) despite in vitro studies suggesting that G lucidum might
impair hemostasis, and one study demonstrating improvement of symptoms in patients with neurasthenia (35). Our
study represents the first clinical trial that explores the
efficacy of these 2 herbs in a combination that is commonly used in TCM for the treatment of rheumatic disease.
The results of this study do not support the clinical importance of G lucidum as an antiinflammatory agent via
the inhibitory effects of phospholipase A2, and are consistent with the recent finding in a much larger double-blind,
placebo-controlled study of treatment with a selective inhibitor of a secretory phospholiase A2 in patients with RA
(15). Nonetheless, the significant lowering of the proinflammatory cytokine IL-18 in patients seen after treatment
(36) and the analgesic properties without any demonstra-
San Miao San and Ganoderma lucidum in RA
1149
ble adverse side effects are noteworthy and deserve further
study.
16.
AUTHOR CONTRIBUTIONS
Dr. Edmund Li had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study design. Edmund Li, Tam, Tomlinson, Wachtel-Galor, Benzie, Leung.
Acquisition of data. Edmund Li, Wai Ching Li, Tam, Wong, Lam.
Analysis and interpretation of data. Edmund Li, Tam.
Manuscript preparation. Edmund Li, Tomlinson.
Statistical analysis. Tam.
Assessment of cytokine and cellular measurement. Wong, Lam,
Bao.
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