CLINICAL ABSTRACT: PHASE II Clinical Trial of Sambong as Diuretic The study evaluated the safety and efficacy of Sambong

as a diuretic, compared to hydrochlorthiazide in patients with edema. A total of 9 patients were given Sambong, while 5 were given hydrochlorthiazide. The age range in sambong group was 2 ! 59 years with a mean of "".# years, and "# ! $5 years and a mean of 5$." years for hydrochlorthiazide group, with the ma%ority being females in both groups. The causes of edema among the sub%ects were &ongestive 'eart (ailure, 'ypertension and some with undetermined etiology. 2")hour urine output, urinalysis, blood chemistry, *+, were determined pre) and post) drug administration for both groups. There was an increase in the 2")hour urine output in both treatment groups- a mean value of ../$ m0 on 1ay 2 2pre)dosing3 and .4/$ m0 on 1ay # 2post). dosing3 for Sambong was demonstrated, with a increase of /99 m0 or 59.495, which was statistically significant. 6n the Thiazide group, pre)treatment 2")hour urine volume was ..54 m0 and post)treatment was 2.9/ m0, with a mean increase of . #4 m0 or 49./5, which was also statistically significant. The serum electrolyte level changes induced by either sambong or thiazides were not statistically significant in both pre)and post)dosing determinations. 7o untoward effects on blood pressure and other vital signs were noted during sambong and thiazides administration.

8oth treatment groups yielded statistically significant results with p values9 . 5, but compared to each other, there was no statistically significant difference. This means that the efficacy of sambong as a diuretic was comparable to that of thiazides. 7 ! PHASE II: CLINICAL TRIAL "# SA$B"N% TABLET AS DI&RETIC

&linical 1esign: ;andomized, comparative, parallel, positive control 2thiazide3 among in)patients with edema. <atient inclusion: .3 <atients aged 2 )$5 years. =ith edema secondary to congestive heart failure 2&'( &lass 6)663 and>or mild hypertension with altered fluid and electrolyte states. 7 ! ' Definition: ?ild hypertension !8<@ ." )./ > 9 ). 5 mm'g 2after # determinations sitting position3 &'( &lass 6 ! symptomatic only with greater than ordinary activity. &lass 66 ! symptomatic during ordinary activity 23 =illingness to participate in the study with signed informed consent. 7 ! ! Patient E(clusion .. <atients with evidence of renal parenchymal disease. 2*levated serum 8A7 and creatinine- presence of urinary casts3.

2. 'istory and evidence of liver disease, bronchial asthma, ?oderate to severe hypertension. #. <regnant and lactating women ". 'istory of diuretic use within 2" hours and corticosteroid therapy intaBe within # months of entry into the clinical trial. 7 ! ) %eneral "b*ecti+e .. To determine the safety and efficacy of sambong tablets as diuretic in patients with altered fluid and electrolyte states manifested as edema.

7 ! , S-ecific "b*ecti+e .. To determine the dose of sambong that will reduce edema and induce sodium and chloride eCcretion and increased urinary volume. 2. To compare the effects of sambong and furosemide in increasing urinary volume and electrolytes eCcretion among patients with edema. #. To determine the adverse effects of sambong in comparison with furosemide after 2") hour dosing. 7 ! . $et/o0olog1 All patients were admitted at the <,' &linical ;esearch Anit after satisfying the inclusion criteria and laboratory screening. Dn admission patients were informed of the nature of the study and were asBed to sign consent forms. 8aseline laboratory eCaminations were undertaBen 2&8&, (8S, 8A7, &reatinine, S,DT, S,<T, Total protein, Albumin, ,lobulin, urinalysis and *&,3. The patients were then placed on limited sodium diet of 5 m*E>day. (luid intaBe was not controlled but volume of fluid intaBe and outputs were monitored. <rior to administration of either sambong or thiazide on 1ay 2, 2")hour urine collection was started for volume and electrolytes 2sodium potassium and chloride3 determination. Dn 1ay #, fasting serum electrolytes were done, after which the patients were given sambong tablets 2T613 or hydrochlorthiazide 28613 tablets. Twenty)four hour urine collection for total volume and electrolyte determination was again done. <atients were closely observed for any possible adverse effects. 8lood pressure, respiratory rate and heart rate were monitored. Serum electrolytes were determined .2 hours after the last dose of either sambong or thiazides. Dn 1ay ", patients given Sambong and those still with the need for diuretics were given standard diuretic 2furosemide3. The dosages of sambong administered ranged from #2)5 mg>Bg 8= in # divided doses 2tid3 and hydrochlorthiazide was given at 5 mg twice a day 2bid3.

7 ! 2 Result:

7 ! 2 ' Patient Demogra-/ic C/aracteristics

<atients administered sambong tablets numbered 9 while 5 were given hydrochlorthiazide. The age range in the sambong group was 2 )59 years while those in the thiazide was "#)$5 with mean age of "".# years for the sambong and 5$." years for the thiazide group. ?a%ority of the patients were females with only one male in each of the group. As to the cause of edema in the sambong group, # were with the congestive heart failure 2&lass 6)663, 2 with mild hypertension and " with edema of unBnown etiology. Among group 66 patients, " were with &'(, &lass 6)66 and one with edema of unBnown etiology. 2Table 63. &omparison of baseline laboratory results showed mean values within normal limits for all parameters used. 'owever, one patient in the sambong group had elevated S,<T while in the thiazide group one patient had slightly elevated S,DT and another patient with slightly elevated S,DT level. Arinalysis results were within normal limits for the two groups. *&, in siC 2/3 of the sambong groups were within normal limits, 2 showed non)specific ST changes and one with borderline right atrial dilatation. 6n the thiazide group, *&, was normal in ., 2 with non)specific ST changes and 2 showed left ventricular hypertrophy by voltage. 2Table 23. 7 ! 2 ! &rinar1 "ut-ut an0 #lui0 Inta3e There was increased 2")hour)urinary output after either sambong or thiazide treatment. 6n the sambong group a mean value of ../$ m0 urinary volume was obtained on 1ay 2 and .4/$ m0 by 1ay # resulting in and increase of 59.495 or /99 m0 which was statistically significant <F@ . 5. Among the thiazide)treated the 1ay 2 1ay # urinary volumes were ..54 m0 and 2.9/ m0 respectively, with a mean increase of 49./5 2. #4 ml3, which was also statistically significant. Analysis of the mean increase of urinary output effected by sambong compared with thiazide) induced did not show any significant statistical difference at p F@ . 5. This implies that at the doses used, sambong can induce an increase in urinary volume comparable with that produced by thiazide 2Table #3 2 (igure .3. *valuation of mean 2" hour fluid intaBe before and after treatment with sambong or thiazide and showed sambong effected an increased intaBe of 5#.# m0 while post)thiazide fluid intaBe amounted to /92 m0, both of which were statistically significant 2Table "3.

7 ! 2 ) &rinar1 an0 Serum Electrol1tes Sambong treatment among patients with water and electrolyte retention produced increased eCcretion of sodium, potassium and chloride at 2 .95, ./.95 and ##.55 respectively. Statistical analysis showed that the only increase which was statistically significant was the chloriuresis at pF@ . 5. Thiazide administration produced urinary increase in the # electrolytes: 2..5 for sodium, .""5 for potassium and . 45 for chloride, which were all statistically significant. &omparison of the natriuresis and Baliuresis induced by sambong and thiazide showed significantly greater eCcretion of sodium and potassium by thiazides. 'owever, the chloride eCcretion induced by sambong was not statistically different from that effected by thiazides and the chloriuresis by the two were therefore comparable. The electrolyte serum level changes induced by either sambong or thiazide administration was not statistically significant when pre and post)dosing values were compared. 7 ! 2 , "nset of Effect The time interval from sambong intaBe to time of first urine voiding was recorded for each patient. Sambong showed demonstrable diuretic effect from as early as 2# minutes to as long as # hours and $ minutes 2.4$ minutes3 with a mean time interval of /5 minutes.

7 ! 2 . A0+erse Effects ?onitoring for any untoward effects showed that a patient complained of only flatulence. 8lood pressures and other vital signs remained within baseline normal limits during sambong or thiazide administration.

7 ! 7 Discussion Sambong therapy produced significant diuresis in 9 patients which was comparable with the diuresis induced by hydrochlorthiazide treatment. 1espite restriction of dietary sodium chloride intaBe at 5 m*E> 2" hrs, sambong still produced a net increase in sodium eCcretion. 7ormally such sodium dietary restriction is associated with an immediate decrease in sodium urinary eCcretion so as to achieve sodium balance within # to 5 days. Dn statistical analysis however, the sambong)induced natriuresis was not statistically significant. <otassium eCcretion was also increased by sambong but to a much less degree than that produced by thiazide. This is in contrast with the potassium)sparing effect produced by sambong among patients without altered electrolyte states. 'owever, when the Baliuresis secondary to sambong dosing is compared with that due to thiazide which is statistically significant, sambong can be considered as having some potassium)sparing effects. Statistically significant chloride urinary eCcretion was observed with both sambong and thiazide administration and there was no statistically significant difference when these effects were compared. Serum electrolytes were not significantly altered by administration of either sambong or thiazide. &oncurrent with the diuresis and electrolyte eCcretion induced by sambong and thiazide, fluid intaBe when not restricted, was observed to be increased. This increase in fluid intaBe could be eCplained by the stimulation of the thirst mechanism caused by the decrease in intravascular fluid volume. The Euestion arises on whether the diuresis is secondary to increased water intaBe alone. =ater can induce diuresis when taBen on a bacBground of normal fluid and electrolyte state 2 i.e. patients drinBing large amounts of water without any previous dose3. 'owever, when an increased amount is taBen in the presence of a negative fluid and electrolyte balance 2i.e. patients with ,6T > renal loses3 the additional water will only fill up the contracted eCtracellular> intravascular volume and will not produce the eCpected diuresis and instead will demonstrate increase in reabsorption of urinary electrolytes 2 sodium and chloride3 because of the contracted eCtracellular fluid volume. 6n this clinical trial, all patients eChibited increase urinary output as well as increased eCcretion of sodium and chloride. Thus, the increase in fluid intaBe in the patients was the result of renal loses of water and electrolytes. &lose eCamination of the varying doses and the increase in urinary output showed that there was no dose)effect relationship. At doses of #2)#" mg>Bg the mean urinary increase was $2$.5 m0- at "5)"$ mg>Bg 8= the mean increase was /" m0 and at 5 mg>Bg the mean volume, increase was $#/./ , with wide variability for each dosage range. The mean time interval between sambong intaBe and onset of action 2 time of first voiding3 was /5 minutes. Thiazide diuretics have shown demonstrable diuretic effect one hour post)dosing. ?onitoring of vital signs showed that these were maintained at the baseline levels during sambong administration. 'owever, in the two hypertensives, sambong effected a decrease in blood pressure to normal levels as was the case in the hypertensive patient given thiazide. Dther vital signs were not significantly changed. *Ccept in one sambong treated patient, who complained of flatulence, the rest of the patients did not complain of any untoward effects.

8y definition, diuresis is an increase in urinary flow rate and any pharmacologic agent which is capable of promoting diuresis is called a diuretic. 6n general, diuretics are administered to achieve one of the two therapeutic goals: an increase in the urinary flow rate per minute or a negative balance of solute and water. 8ased on the results from this clinical trial, sambong tablet at doses of #2 to 5 mg>Bg 8= given orally in three divided doses could be classified as a diuretic by producing the following: A. Therapeutic effects in patients with edema secondary to various etiologies 2&'(, mild 'ypertension, etc3 by producing statistically significant: i. 6ncrease in urinary volume. ii. 6ncrease in chloride eCcretion 2chloriuresis3 andiii. ?oderate increase in sodium eCcretion 2natriuresis3. iv. ?inimal increase in potassium eCcretion 2possibly potassium sparing3

6f these effects are compared with other diuretics, to what classification does sambong belong9 At present, diuretics are classified according to their mechanism of action on different segments of the renal tubules. ,roup . diuretic, with acetazolamide as prototype, primarily acts by inhibiting sodium reabsorption on the proCimal convoluted tubules. ,roup 66 diuretics, act principally on the thicB ascending loop of 'enle by inhibiting active chloride reabsorption. (urosemide and bumetanide belong to this class of the most potent diuretics. The thiazide diuretics belong to the third group and produces diuretic effects by its action on the cortical diluting segment of the nephron. All these three classes can produce significant increase in sodium, potassium and chloride eCcretion at varying degrees. The fourth class or group is the only one that possesses potassium)sparing property 2amiloride, triamterene, and spironolactones are prototypes3 by its action on the distal tubule and collecting duct. To what classification does sambong belong9 Since sambong produced significant volume eCcretion and chloriuresis with some potassium) sparing effect, sambong cannot be classified in any of the " classes of diuretics and may act along more than one segment of the nephron. Sambong is also not an osmotic diuretic liBe mannitol, which produces diuretic effect by being poorly reabsorbed by the renal tubules, and also hardly absorbed from the gastrointestinal tract. Sambong induces diuresis when given orally with an onset of action /5 minutes after administration. A diuretic which has properties similar to sambong is the mercurial group which can induce increased urinary volume and combined chloriuresis and natriuresis while depressing potassium tubular secretion. The various untoward reactions produced by mercurials 2ventricular fibrillation and mercurial poisoning3 lead to its loss of value in diuretic therapy. Sambong however, did not produce any significant or harmful adverse effects.

7 ! 4 Conclusion .. Sambong tablet when administered orally at doses of #2)5 mg>Bg 8=, in three divided doses can induce diuresis in patients with altered fluid and electrolyte states. 2. Sambong produced statistically significant diuresis and chloriuresis comparable to hydrochlorthiazide given at 5 mg in 2 divided doses. #. The natriuresis produced by sambong is modest and not comparable with natriuresis produced by thiazides. The potassium loss secondary to sambong is much less compared to the Baliuretic

effect of thiazides. 6n patients without altered fluid and electrolyte states, potassium sparing was significant after sambong administration. ". There were no significant adverse reactions complained of by patients given sambong at doses of #2)5 mg>Bg 8=. Gital signs and serum electrolytes were maintained at baseline levels. 6n two patients with hypertension, blood pressure was noted to be lowered.