Xi-Feng-Hua-Shi granules for diarrhea-predominant irritable bowel syndrome:protocol for a randomized,double-blind,placebo-controlled multi-center clinical trial

Hui Li,Kai-Li Luo,Dan Wang,Yun Huang,Xiao-Mei Xu,Xue Zou,Ren-Jing Qiu,Ting Chen,Chuan-Wang Zhu,Jie Li,Yong-Shuang Wang,Han-Lin Wang,Zu Yang,Yong-Yue Wei,Yao-Zhou Tian*,Xu-Dong Tang*

1Department of Gastroenterology,Affiliated Hospital of Integrated Traditional Chinese and Western Medicine,Nanjing University of Chinese Medicine,Nanjing 210028,China.2Nanjing University of Chinese Medicine,Nanjing 210000,China.3The Third People’s hospital of Zhenjiang,Zhenjiang 212021,China.4Department of Biostatistics,School of Public Health,Nanjing Medical University,Nanjing 211166,China.5Department of Gastroenterology Xiyuan Hospital,China Academy of Chinese Medical Sciences,Beijing 100091,China.

Abstract Background: Irritable bowel syndrome (IBS) is a common functional bowel disorder that can severely affect the quality of life of patients.Limited drugs have been reported for modern medical IBS treatment.The advantages of traditional Chinese medicine (TCM)treatment are gradually becoming prominent.Xi-Feng-Hua-Shi granules have been clinically used for diarrhea-predominant IBS (IBS-D) treatment for many years in TCM practice.Thus,this study aimed to further verify the effectiveness and safety of Xi-Feng-Hua-Shi (XFHS)granules in IBS-D treatment through a randomized,double-blind,placebo-controlled multi-center clinical trial and provide high-quality evidence for its effectiveness and safety in treatment,as well as provide a basis for clinical rational drug use and explore new clinical IBS-D treatment plans.Methods: A randomized,double-blind,placebo-controlled multi-center clinical trial will be performed in 23 hospitals.A total of 300 participants will be randomly divided into the experimental group (prescribed with XFHS granules) and the control group (prescribed with the placebo granules),with 150 participants in each group.The appearance,shape,color,and taste of the placebo granules are the same as those of XFHS granules.All participants will receive a 4-week treatment and a 6-month follow-up.The primary outcome is the overall clinical efficacy;the secondary outcomes are the IBS-Symptom Severity Score (IBS-SSS),TCM Syndrome Evaluation,and the IBS-Quality of Life (IBS-QoL) score,mental state assessment,and recurrence rate.Outcome measures(including primary and secondary outcome measures) are collected at baseline,as well as 2,4,16,and 28 weeks post-intervention.Discussion: This randomized,placebo-controlled,multi-center trial may provide high-quality evidence for the clinical XFHS granule efficacy in IBS-D treatment.Additionally,this study will conduct safety evaluations to provide a basis for clinical rational drug use.

Keywords: Xi-Feng-Hua-Shi granules;diarrhea-predominant irritable bowel syndrome;Randomized,double-blind,placebo-controlled multi-center clinical trial;protocol

Background

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder and is the most common reason for visiting a gastroenterologist.Epidemiological surveys show that the global IBS incidence is 3.8% and 2.3% in China [1].Moreover,females have higher IBS incidence than males [2].IBS signs and symptoms include changes in bowel movement appearance or frequency,accompanied by abdominal discomfort or pain.According to the Bristol stool trait scale,patients with IBS can be subdivided into diarrhea-predominant IBS (IBS-D),constipation-predominant IBS (IBS-C),mixed IBS (IBS-M),and unspecified IBS (IBS-U) based on the main stool traits of patients with abnormal defecation [3].IBS-D is characterized by loose or watery stools(Bristol classification Type 6 or 7)for ＞25%of the time and hard stools (Bristol classification Type 1 or 2) for ＜25% of the time[3].

IBS is a multifactorial disease.Accumulating studies have shown that abnormal gut-brain interactions [4],visceral hypersensitivity [5],abnormal bowel motility [6],mental and psychological factors [7,8],and intestinal microbial imbalance [9] play important roles in IBS pathogenesis.

IBS is not an organic mental disorder;however,it can severely affect the quality of life of patients.Currently,traditional treatment drugs for IBS include antispasmodics,antidiarrheal agents,probiotics,and antidepressants.However,these treatment methods come with certain limitations,such as poor efficacy and high symptom recurrence.Furthermore,repeated treatments may bring great socio-economic pressure to patients [10-12].Therefore,exploring novel treatment ideas is necessary.Nowadays,traditional Chinese medicine(TCM) is gaining attention in IBS treatment.

Xi-Feng-Hua-Shi granules (XFHS) is an empirical prescription of Professor Tian Yaozhou,a famous Chinese medicine doctor in Jiangsu Province.XFHS has been used for the clinical treatment of IBS-D for many years,which includes 13 TCM ingredients,namely,Paeoniae Radix Alba,Aucklandiae Radix,Coptidis Rhizoma,Zingiberis Rhizoma,Scutellariae Radix,Uncariae Ramulus Cum Uncis,Saposhnikoviae Radix,Herba Patriniae,Citri Reticulatae Pericarpium,Fructus Tribuli,Rhizoma Atractylodis Macrocephalae,Granati Pericarpium,andGlycyrrhizae Radix et Rhizoma.These ingredients are mainly used for IBS-D treatment with liver depression and spleen deficiency under TCM definitions.Saposhnikoviae Radix,Paeoniae Radix Alba,andUncariae Ramulus Cum Unciscan soothe the liver,dispel wind,and relieve stagnation.Citri Reticulatae PericarpiumandFructus Tribulican regulate qi,tonify the spleen and dispel wind,which is the main ingredients in medicine for liver-spleen disharmony.XFHS granules can relieve abdominal pain and diarrhea through the functions of these TCM ingredients to soothe the liver,dispel wind,relieve depression,clear heat,eliminate dampness,and stop diarrhea.A small-sample,single-center,randomized clinical study in the early stage of this research group showed a 94% total effective rate of XFHS granules[13].Moreover,XFHS granules have been confirmed to improve the frequency of loose stools of IBS-D model rats by reducing 5-HT and VIP content in the serum and colon [14,15].Hence,XFHS granules reduced visceral hypersensitivity and improved diarrhea symptoms.The involved mechanism of action may be associated with the reduction of the SCF-Kit system overexpression.However,the long-term efficacy and safety of XFHS granules have not been confirmed in previous studies,and the current efficacy evaluation indicators are not comprehensive.

Therefore,this study aimed to further verify the effectiveness and safety of XFHS granules in IBS-D treatment with liver depression and spleen deficiency.This study may provide high-quality evidence for XFHS granule clinical efficacy,as well as a basis for clinical rational drug use and new treatment ideas for clinical practice.

Methods

Ethics approval

The study was approved by the Ethics Committee of Jiangsu Provincial Hospital of Integrated Traditional Chinese and Western Medicine (ethics approval No.:2020LWKY025) and was registered on the Registry Platform for Evidence-Based Traditional Chinese Medicine(study No.:ChiMCTR2000004143).

Study design

This multi-center,randomized,double-blinded,placebo-controlled comparative study was conducted in the following 23 hospitals:Jiangsu Provincial Hospital of Integrated Traditional Chinese and Western Medicine,Nanjing Lishui District Chinese Medicine Hospital,Affiliated Hospital of Jiangnan University,Suzhou Hospital of Integrated Chinese and Western Medicine,Lianyungang Hospital of Traditional Chinese Medicine,Jiangsu Hospital of Traditional Chinese Medicine,Nanjing Municipal Hospital of TCM,Nanjing Integrated Traditional Chinese and Western Medicine Hospital,Jiangsu Provincial Second Traditional Chinese Medical Hospital,People’s Hospital of Quzhou,Taizhou People’s Hospital,Zhenjiang Hospital of Traditional Chinese Medicine,Suzhou Hospital of Traditional Chinese Medicine,Municipal Oriental Hospital and Foreign-Related Hospital of Lianyungang,Kunshan Traditional Chinese Medicine Hospital,Jiangyin Traditional Chinese Medicine Hospital,Wuxi Traditional Chinese Medicine Hospital,Nantong Traditional Chinese Medicine Hospital,Changzhou Traditional Chinese Medicine Hospital,Changzhou Wujin Chinese Medicine Hospital,Nanjing Jiangning Hospital of Traditional Chinese Medicine,Yancheng Traditional Chinese Medicine Hospital,and Nanjing General Hospital of People’s Liberation Army (Qinhuai Medical District).The study will be conducted following the principles of the Declaration of Helsinki(2008) [16].

The study period was 28 weeks,wherein 4 weeks for the treatment period and 24 weeks (6 months) for the follow-up period after treatment.A total of 300 participants were randomly stratified into the treatment (prescribed with XFHS granules) or control group(prescribed with placebo),with 150 participants in each group.The outcomes would be assessed at baseline and at weeks 2,4,16,and 28.The study process and schedule are presented in Figure 1 and Table 1.This clinical trial protocol design was based on The Standard Protocol Items:Recommendations for Interventional Trials (SPIRIT) 2013 Checklist (see http://www.equator-network.org/reporting-guidelines/).

Table 1 Study schedule diagram

Figure 1 Flowchart of study

Participants recruitment

Participants are recruited from the outpatient centers of the 23 participating hospitals by posting and distributing posters and flyers regarding the trial.

TCM syndrome differentiation

Disease symptom is formulated concerning the“Expert Consensus on the Diagnosis and Treatment of IBS in Traditional Chinese Medicine”approved by the Spleen and Stomach Disease Branch of the Chinese Society of Chinese Medicine in 2017 [17].

The main symptoms include (1) abdominal pain and diarrhea,accompanied by pain relief after diarrhea;(2) mood-related,which is usually characterized by high irritability and melancholy.

The secondary symptoms include (1) bilateral abdominal distension;(2) dullness;(3) fatigue.

Tongue diagnosis included puffy tongue,presence of teeth marks,thin white coating,and thready pulse.

Among these symptoms,2 main and 2 secondary are present.After referring to the tongue and pulse,IBS-D with liver depression and spleen deficiency can be diagnosed.

Inclusion criteria

The inclusion criteria were as follows:

(1) meeting the western medical ROME IV diagnostic criteria of IBS-D [3];

(2) meeting the diagnostic criteria of TCM syndromes of liver depression and spleen deficiency [17];

(3) aged 18-70 years (including 18 and 70 years old),regardless of gender;

(4) informed consent and voluntary test.The informed consent was obtained in compliance with ethical principles.

Exclusion criteria

The exclusion criteria were as follows:

(1) patients with organic gastrointestinal disorders;

(2) patients with severe heart,liver,kidney,respiratory,blood,and endocrine disorders;

(3) patients with mental illness and severe neurosis;

(4)women who are pregnant,breastfeeding,or planning pregnancy;

(5) patients taking antibiotics,probiotics,or gastrointestinal motility drugs within 1 month before inclusion in the trial;

(6) patients with poor compliance with medical advice and are allergic to this medicine;

(7) patients who are participating in other clinical studies.

Randomization and blinding

The randomization sequence was generated by the statistician (Y.W.)from the School of Public Health,Nanjing Medical University using self-rating anxiety scale (SAS) procedures.A centralized randomization scheme would be adopted,and the randomization would be implemented based on the interactive web response system.Participants in the XFHS granule group and the control group were allocated at a 1:1 ratio.Clinical investigators and patients were blinded to the allocation.Statisticians would not participate in the treatment,and the statistical analyses would be independently performed.The drugs for test and reference have been masked by numbers,repackaged,and distributed following the standardized operation steps of double-blind clinical trials.

Preparation and quality control of trial drugs

XFHS granules and placebo granules in this study were produced by Jiangyin Tianjiang Pharmaceutical Co.,Ltd.Ancient decoctions were combined with modern techniques to minimize the heterogeneity of drug quality.Moreover,the XFHS and placebo granules had the same color,appearance,smell,packaging,and taste.

The medicinal materials in the qualified XFHS granule prescription were weighed,washed,and subjected to other pre-treatments.Next,the crude drug is boiled into a medicinal solution following the ancient decoction method and extracted according to the technological requirements.The extract is concentrated to a specific density to obtain a clear ointment.The clear ointment is sieved and spray-dried to make a granular mixture.After passing through a 12-40 mesh,the dried granules will be packaged in aluminum foil bags.Table 2 shows the specific XFHS granules components,whereas.Table 3 shows the placebo components,including maltodextrin,food coloring,XFHS granule test drug extract,and bitterant.

Table 2 Components of XFHS granules

Table 3 Components of the placebo

Jiangyin Tianjiang Pharmaceutical is responsible for the quality control of this trial drug following the Chinese Pharmacopoeia (2020 edition) and the internal quality control standards of Jiangyin Tianjiang Pharmaceutical Co.,Ltd.Sampling is conducted in compliance with the GZ-SOP-ZK405 Traditional Chinese Medicine Formula Granule Sampling Operation Regulations.XFHS granules and placebo granules must meet the requirements in terms of properties,water content,solubility,differences in loading,and particle size,together with all the microbiological criteria specifications.

Intervention

Treatment group (XFHS granules)and control group (placebo)

Patients in the treatment group will receive XFHS granules that contain Chinese medicine compounds.They will take one dose daily for 4 weeks,with each dose washed twice with boiling water.Each XFHS granule will be packed in a medicine bag that is labeled with only a serial number,which is randomly generated by the randomization system.

Patients in the control group will be given a placebo,with similar appearance,shape,color,and taste as those of XFHS granules.The placebo was produced by Jiangyin Tianjiang Pharmaceutical Co.,Ltd.strictly following relevant national standards.Placebo is taken one dose a day for 4 weeks,with each dose washed twice with boiling water.Similarly,the outer packaging of the placebo is labeled with randomized numbers.

Withdrawal criteria

All participants,who filled in the informed consent form and have been screened as eligible for the randomized trial,are called withdrawal cases if they have not completed the observation period specified in the protocol no matter when they withdraw.The investigator should contact the subject as much as possible (e.g.,through door-to-door visits,making an appointment for follow-up,telephone),when the participant drops out,to ask the reason,record the last medication time,and complete the evaluation items as possible.The investigator shall take corresponding treatment measures according to the actual participant situation in case of withdrawal from the study due to allergic reaction,adverse reaction,or ineffective treatment.Additionally,the investigator shall fill in the attached table“Treatment Summary Table”and“Abscission Reason Table”of the study case record form.

Outcome evaluation

Primary outcome

The primary therapeutic effect of the experiment lies in the overall clinical response rate.The efficacy evaluation standards are formulated following the“Guiding Principles for Clinical Research of New Chinese Medicines.”The nimodipine method will be used for calculation:curative effect index (%)=[(integral before treatment-integral after treatment)/integral before treatment] ×100%.The drug is deemed ineffective without significant symptom and sign improvement,with symptom worsening,or symptom score reduction by ＜30%;effective with symptoms and signs improvement and symptom score reduction by ≥30%;and significantly effective with significant symptom and sign improvement and symptom score reduction by ≥70%.Clinical recovery means that the main symptoms and signs have disappeared or have almost disappeared and the curative effect index is ≥95%.The overall clinical response rate is assessed at week 4 (the end of treatment).

Secondary outcome

The secondary therapeutic effects are evaluated from the classification standard of TCM syndromes,the IBS-Symptom Severity Score(IBS-SSS),the IBS-Quality of Life (IBS-QoL),the mental state assessment,and the recurrence rate.The secondary outcome will be assessed at baseline and at weeks 2,4,16,and 28.

The syndrome was scored according to the TCM Syndrome Classification Standard.The main symptoms (abdominal pain,diarrhea,pain after diarrhea,impatience,irritability,sighing,and hypochondria) and secondary symptoms (bilateral abdominal distension,poor appetite,and fatigue) are observed for scoring.Following the four levels,namely,none,mild,moderate,and severe,the main symptoms are recorded as 0,2,4,and 6,respectively,and the secondary symptoms are recorded as 0,1,2,and 3,respectively.The sum of the individual symptom scores of the above TCM syndromes is the total syndrome scores.

The IBS-SSS was used to evaluate the severity of symptoms in patients.The scale is conducted from the following five aspects:the degree of abdominal pain,the frequency of abdominal pain,the degree of abdominal distension,the level of satisfaction with bowel habits,and the impact on life.During the evaluation,the maximum score for each item is 100 points,and the total score is 500 points.The evaluation criteria were as follows:(1) normal in ≤75 points;(2)mild in 76-175 points;(3) moderate in 176-300 points;(4) severe in＞300 points [18].

The QoL Scale is used to assess the quality of life of patients [19].The scale consists of 34 items in 8 areas,namely,anxiety,behavioral disorder,physical ideation,diet,health anxiety,social function,sexual behavior,and interpersonal relationship.Points 1-5 are assigned into grades 1-5,respectively.After the sum of the points is converted into a percentile system,the lower score is indicative of the worse quality of life [19].

The mental state of patients is assessed using Zung SAS and Zung self-rating depression scale (SDS).Both scales include 20 items,and each item is scored according to levels 1-4.The cumulative score is the original SAS and SDS score.The original score is multiplied by 1.25 to obtain the integer part,which is the SAS and SDS standard score.SAS of ＜50 is classified as normal,SAS of 50-59 as mild anxiety,SAS of 60-69 as moderate anxiety,and SAS of ≥70 as severe anxiety;SDS of ＜50 is classified as normal,SDS of 50-59 as mild,SDS of 60-69 as moderate,and SDS of ≥70 as severe depression.

Recurrence rate

The recurrence rate is mainly used to observe the short-and long-term efficacy evaluation.

Short-term efficacy evaluation

Participants will be followed up 3 months after the end of treatment(week 16).TCM syndromes,IBS-SSS,IBS-QOL,and the mental state will be assessed.

Long-term efficacy evaluation

Participants will be followed up 6 months after the end of treatment(week 28).TCM syndromes,IBS-SSS,IBS-QOL,and the mental state will be assessed.

Safety evaluation

Participants will undergo relevant laboratory tests at baseline and the end of treatment (week 4),including blood,urine,stool,liver,and kidney functions (alanine aminotransferase,aspartate transaminase,total bilirubin,blood urea nitrogen,serum creatinine,and GET)evaluation,and an electrocardiogram.Participants need to truthfully respond to changes in symptoms,and the treatment effects,adverse reactions,and any unexpected drug side effects would be monitored.

Adverse events (AEs)

AEs are defined as any unexpected or undesirable harmful effects related to the experimental drugs that occur during the observation period of the clinical research.Researchers need to record all the AEs,including the occurrence time,severity,termination time,correlation with the trial drug,the measures taken on the trial drug,and its outcome,in a case report form (CRF).The investigator/study doctor should promptly decide whether to stop the clinical trial of the subject and consider the correct treatment measures in time when a serious AE occurs.The researcher should break the blindness as necessary and obtain the corresponding drug information of the Participants.Moreover,the researcher should promptly report the breaking of blindness to the coordinating unit of the subject and record the reason for breaking the blindness in the CRF,indicating the date and signing the document.

Sample size calculation

Previous studies revealed that the response rate of the placebo group is estimated at 50%.Additionally,the response rate of the XFHS granules group is not ＜70%.The chi-square test will be used to compare the response rates of the two groups (H0:πXFHS=πPlacebo,H1:πXFHS≠πPlacebo);the significance level is 0.05;the power is 90%;the sample size ratio of the test group to the control group is 1:1.The withdrawal rate is assumed not to exceed 20%.Using PASS Version 16,300 participants are included,with 150 participants in each group.

Statistical analyses

The continuous data are expressed as mean ± standard deviation,or median,minimum,and maximum.Thet-test or Wilcoxon rank-sum test is used for comparison between groups depending on variable normality.Categorical data are described by frequency and proportion,and compared by the chi-square test,Fisher’s exact test,or the Kruskall-Wallis rank-sum test.All the statistical tests are two-tailed,and aP-value of ≤ 0.05 is considered statistically significant unless otherwise stated.All the analyses will be performed using SAS Version 9.4 software (SAS Institute Inc.,Cary,North Carolina,USA).Thet-test is used if normality and homogeneity of variances are satisfied for comparison of quantitative data between two groups;the t-test or rank-sum test is used if two groups of variances are not equal;and the rank-sum test is used if normality is not satisfied.

Data management and monitoring

Research data collection and management will be completed using the dCap EDC system maintained by Y.W.

The privacy of participants will be protected following the IRB and regulatory requirements.During the study period,CRF,protocol compliance,data management,treatment management,and AEs will be independently monitored.

Discussion

Some early,small-sample,single-center,randomized,controlled studies,and animal experimental studies have confirmed that XFHS granules are effective in relieving IBS-D symptoms,without currently recommended guidelines for IBS treatment using XFHS granules due to the lack of high-quality randomized controlled experiments.The early evaluation of the efficacy indicators,such as mental and psychological factors and quality of life evaluation,is not comprehensive enough,which may increase the uncertainty of XFHS granule effectiveness.Moreover,syndrome differentiation is the core of TCM treatment.XFHS granules aim at the main pathogenesis of IBS-D-TCM syndrome differentiation that accords with the syndrome of liver depression and spleen deficiency.This trial aimed to prove the efficacy of XFHS granules on patients with IBS-D via evaluating TCM syndrome relief,symptom severity,anxiety,and depression,and their impacts on quality of life.Previous single-center studies revealed a high heterogeneity in the composition and manufacture of XFHS granules resulting in a bias in the results of clinical studies.The design of this experiment follows a strict methodology and quality control.XFHS granules are produced through standardized processes to ensure the uniformity of active ingredients,thereby obtaining more credible results.Therefore,this multi-center study will have a more stringent methodology and a higher quality assurance.Moreover,this prescription has been used in clinical treatment for many years;however,evaluation and systematic reports of its application in clinical AEs remained inadequate.Therefore,its safety is also considered in this experiment.This study objectively reflects the safety evaluation results of the patient’s condition by monitoring AEs,comprehensive physical examination,monitoring vital signs,biochemical examination,and electrocardiogram.Considering the patient’s life and health as our priority,we have formulated corrective action plans for AEs.Additionally,sufficient sample size is adopted for study analysis to reduce the bias,and this study will be conducted as a multi-center study in Jiangsu and Zhejiang provinces.Compared with previous studies,this experiment extends the period of follow-up to allow a more comprehensive and objective long-term efficacy evaluation.Considering that IBS cannot be reliably monitored by biomarkers,the subjective evaluation scale is used as the measurement standard for the results.Hence,objective evidence and accuracy are inadequate to verify the efficacy of the given treatment.Moreover,people living in different regions of China have very different diets,and regulating the diet of patients from various regions is difficult.This large-scale multi-center study may have more difficulty in avoiding the deviation of results caused by dietary factors.Furthermore,we will also pay attention to establishing good communication with patients to avoid a high withdrawal rate in terms of the follow-up period.

This experiment is expected to further prove the effectiveness and safety of XFHS granules in IBS-D treatment.Study results will be reliable and provide high-quality evidence and a basis for clinical rational drug use.