|Year : 2016 | Volume
| Issue : 1 | Page : 19-27
A Randomized Single Blind Parallel Group Study Comparing Monoherbal Formulation Containing Holarrhena antidysenterica Extract with Mesalamine in Chronic Ulcerative Colitis Patients
Sarika Johari, Tejal Gandhi
Department of Pharmacology, Anand Pharmacy College, Anand, Gujarat, India
|Date of Web Publication||9-Dec-2016|
Department of Pharmacology, Anand Pharmacy College, Anand, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Incidences of side effects and relapses are very common in chronic ulcerative colitis patients after termination of the treatment. Aims and Objectives: This study aims to compare the treatment with monoherbal formulation of Holarrhena antidysenterica with Mesalamine in chronic ulcerative colitis patients with special emphasis to side effects and relapse. Settings and Design: Patients were enrolled from an Ayurveda Hospital and a private Hospital, Gujarat. The study was randomized, parallel group and single blind design. Materials and Methods: The protocol was approved by Institutional Human Research Ethics Committee of Anand Pharmacy College on 23rd Jan 2013. Three groups (n = 10) were treated with drug Mesalamine (Group I), monoherbal tablet (Group II) and combination of both (Group III) respectively. Baseline characteristics, factors affecting quality of life, chronicity of disease, signs and symptoms, body weight and laboratory investigations were recorded. Side effects and complications developed, if any were recorded during and after the study. Statistical Analysis Used: Results were expressed as mean ± SEM. Data was statistically evaluated using t-test, Wilcoxon test, Mann Whitney U test, Kruskal Wallis test and ANOVA, wherever applicable, using GraphPad Prism 6. Results: All the groups responded positively to the treatments. All the patients were positive for occult blood in stool which reversed significantly after treatment along with rise in hemoglobin. Patients treated with herbal tablets alone showed maximal reduction in abdominal pain, diarrhea, and bowel frequency and stool consistency scores than Mesalamine treated patients. Treatment with herbal tablet alone and in combination with Mesalamine significantly reduced the stool infection. Patients treated with herbal drug alone and in combination did not report any side effects, relapse or complications while 50% patients treated with Mesalamine exhibited the relapse with diarrhea and flatulence after drug withdrawal. Conclusion: Thus, monoherbal formulation alone and with Mesalamine was efficacious than Mesalamine alone in UC.
Keywords: Clinical study, Holarrhena antidysenterica, mesalamine, ulcerative colitis
|How to cite this article:|
Johari S, Gandhi T. A Randomized Single Blind Parallel Group Study Comparing Monoherbal Formulation Containing Holarrhena antidysenterica Extract with Mesalamine in Chronic Ulcerative Colitis Patients. Ancient Sci Life 2016;36:19-27
|How to cite this URL:|
Johari S, Gandhi T. A Randomized Single Blind Parallel Group Study Comparing Monoherbal Formulation Containing Holarrhena antidysenterica Extract with Mesalamine in Chronic Ulcerative Colitis Patients. Ancient Sci Life [serial online] 2016 [cited 2017 Apr 27];36:19-27. Available from: http://www.ancientscienceoflife.org/text.asp?2016/36/1/19/195409
| Introduction|| |
Inflammatory bowel disease (IBD) is a chronic inflammatory intestinal disorder, with two main forms viz. Ulcerative colitis (UC) and Crohn's Disease (CD). As many as 1.4 million persons in the US and 2.2 million persons in Europe suffer from IBD. However, there are reports of increasing incidence and prevalence from other areas of the world such as southern or central Europe, Asia, Africa, and Latin America. Clinically patients suffering from IBD display features of fever, diarrhea, rectal bleeding, abdominal cramps, loss of appetite, weight loss and sometimes microbial growth in the intestine.
Immunosuppressants, corticosteroids, aminosalicylates, antibiotics and antidiarrhoels are conventionally prescribed for treating IBD. Surgery is recommended in resistant and severe cases of complications. The patients complain of severe side effects and relapse and the cost of hospitalization adds to the misery. Alternatively, poly herbal formulations are also used for the treatment of IBD. Typically, herbal formulations comprising plants or plant extracts of Bombax malabaricum, Aloe vera gel, Aegle marmelos, liquorice, Commiphora wightii, Coriandrum sativum, Thinopyrum intermedium juice, Boswellia serrata, Ocimum tenuiflorum, Abelmoschus esculentus, Allium sativum, Curcuma longa etc., are in use.,, Despite their widespread use, polyherbal formulations face problems in standardization and quality control due to use of multiple ingredients, inconsistency of finished formulations, overlapping of chemical and chromatographic profiles, stability of formulations, difficulty in developing standards along with safety issues., In view of these issues, it becomes difficult to say exactly as to which plant is responsible for the efficacy and which plant is responsible for the side effects. Hence, development of monoherbal formulation with robust scientific evidence can offer faster and more economical alternatives.
Holarrhena antidysenterica (Linn.) Wall. of the family Apocynaceae is also known as connessi bark in English, kuṭaja in Sanskrit, kura or kurchi in Hindi. Its bark and seeds have been used in the treatment of dysentery and diarhhoea, anemia, epilepsy, stomach pain and cholera. Kurchicin, an active principle of Holarrhena antidysenterica is highly effective against causative microorganisms of diarrhea, dysentery specially amoebic types.
The study aims to compare the treatment using a monoherbal formulation containing extracts of Holarrhena antidysenterica with Mesalamine, which is the most frequently prescribed allopathic drug in chronic ulcerative colitis patients with a special emphasis on side effects and relapse.
| Materials and Methods|| |
Preparation of monoherbal formulation using methanolic extract of Holarrhena antidysenterica
Tablets were prepared in WHO certified cGMP manufacturing unit Pharmanza Herbals Pvt. Ltd. Each tablet weighing 750 mg was prepared using necessary excipients in the following composition (per 900 gm approx.) [Table 1]. Disintegration time of the tablet was 20 minutes. It was tested using Veego Digital tablet disintegration test apparatus.
Subject recruitment procedure
The study was randomized, parallel group and single blind in design. Randomization was done to ensure that the study was unbiased. The protocol No. APC/IHREC/1302 was approved by Institutional Human Research Ethics Committee of Anand Pharmacy College on 23rd Jan 2013. Patients were enrolled from an Ayurveda Hospital, Anand, Gujarat, India and Gastroentrology Department of a Private Hospital, Anand, Gujarat, India between January 2013 and May 2013.
- Patients of either sex and above 18 years of age
- Ability to understand and the willingness to sign a written informed consent document at the screening visit before any protocol-specific procedure was performed
- Patients meeting the criteria for ulcerative colitis confirmed by clinical diagnosis, stool test, blood tests along with established colonoscopic evidences of ulcerative colitis. Clinical diagnosis was done on basis of signs and symptoms, patient history and scoring pattern [Annexure I]. Stool test was done for presence of occult blood and infections if any. Blood tests were done for routine CBC, Erythrocyte sedimentation rate, Hemoglobin and blood group.
- Severe CVS disease (as per guidelines recommended by American Heart Association and American College of Cardiology)
- Renal or hepatic disease, gall stones, pancreatitis, diabetes mellitus, sepsis, infection, pneumonia
- Pregnant or nursing women
- Patients who had undergone surgeries
- Patients who had complications such as anal fistula
- Patients with extra-intestinal complications associated with IBD such as pyoderma gangrenosum, erythema nodosum, mouth ulcers, arthritis, episcleritic, uveitis etc
- Patients with acute ulcerative colitis
- Patients with history of advanced Sulpha reactions.
Methodology of the study
Patients were allocated to groups (10 in each group) by using simple randomization method. The trial was monitored and balanced at the end with number of subjects on each treatment over time. Sample size calculation was done using G Power engine software. The dosage was based on marketed preparations and preclinical studies done.
- Group I: Standard Allopathic formulation Mesalamine (Mesalazine), 2 tabs orally per day (1 after lunch, 1 after dinner)
- Group II Monoherbal test formulation, 2 tabs orally per day (1 before lunch, 1 before dinner)
- Group III Standard Allopathic formulation + Monoherbal test formulation, 1 tab each orally per day of (Mesalamine after lunch, test formulation before supper).
Duration of treatment and evaluation schedule
Duration of treatment was of 4 weeks. Follow up visits were scheduled on 2nd and 4th week during treatment and then on 2nd and 4th week after completion of treatment.
- Prior screening: in which the patients were explained the study procedures
- Informed consent was taken from them (English/Gujarati)
- At baseline visit the medical history; general and physical examination, clinical history, signs and symptoms, details of previous therapy against IBD and other concomitant medication were recorded in Case Record Form.
Clinical examination and diagnostic tests were done twice i.e., before and after treatment, while only clinical examination was done during both follow up visits after completion of the treatment.
Assessment of efficacy
The improvement in the patients was assessed on the basis of relief in the symptoms and signs of the disease together with laboratory investigations. All the symptoms and signs were given grade scores and assessed before, during and after treatment. Changes in body weight etc., were also recorded.
Patients were monitored for their compliance to the therapy. They were also instructed to report any adverse drug reaction during treatment and complications developed during or after the treatment.
Results were expressed as mean ± standard error of the mean (SEM). Data was evaluated using paired t test, Wilcoxon test, Mann Whitney U test, Kruskal Wallis test and ANOVA, wherever applicable, for finding statistical significance. All the tests were done using GraphPad Prism 6 (GraphPad Software, Inc. CA 92037 USA.).
| Results|| |
Patient enrollment flow chart
Refer [Annexure II].
Baseline characteristics of the patients
A total of 30 patients satisfying inclusion and exclusion criteria participated in the study. Baseline characteristics of the patients are detailed in [Table 2],[Table 3],[Table 4],[Table 5]. All the patients enrolled showed medication compliance and completed the treatment. The ratio of male to female patients was 60:40. In the patients' population, ulcerative colitis was more prevalent in 31-40 and 51-60 age groups. 73% patients were Hindus and remaining patients were Muslims and Christians. 33.33% patients were uneducated, while the remaining had studied till school or graduation.
Quality of life
The parameters of quality of life were categorized into occupation, income, type of stress, food habits, life style and smoking habits [Table 6],[Table 7],[Table 8]. 66.67 percent patients were doing private jobs, 13.33% had government jobs and 20% were self employed. 26.67 percent of the patients belonged to low income group, 40% to medium income group and 33.33% to high income group. Stress definitely has a psychological impact in these patients. Whenever there was a psychological disturbance, the symptoms of gastrointestinal tract ailments seemed to aggravate. Over 70% patients were having stress related to economic condition, over work and personal health while remaining 30% had reported to have stress related to family and social matters.
|Table 8: Distribution of the patients according to the type of stress encountered|
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Regarding the dietary habits, 66.67% patients were vegetarians, while 33.33% patients were accustomed to non-vegetarian diet. 80 percent patients lived an active lifestyle while 20 percent were sedentary. 70 percent were non-smokers [Table 9],[Table 10],[Table 11].
Chronicity and symptoms of disease before treatment
Out of 30 patients, 13.33 percent had IBD symptoms since less than a year, 30 percent had problems since 1 – 3 years and remaining were chronic cases of more than 3 – 5 years. 16.67% were asymptomatic and had stable symptoms. 56.67 percent had unstable or intermittent symptoms. 26.67 percent of chronic cases suffered from uncontrolled symptoms [Table 12] and [Table 13].
|Table 12: Distribution of the patients according to chronicity of disease|
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Effect of treatments on signs and symptoms and investigations
All the patients complained of discomfort due to abdominal pain, distressing constipation, along with intermittent episodes of diarrhea, presence of mucous in stool and flatulence. All the cases complained of frequent loose stools, which varied from 7 to 10 bowel frequency per day on an average. The stool consistency ranged from normal to liquid depending on the severity and chronicity of the disease.
Significant reduction in mean scores for abdominal discomfort and pain was observed in all the treatment groups. Significant relief from constipation and diarrhea was observed in Group I (Standard: Mesalazine) and Group II (test drug monoherbal tablet) treatment patients when compared to Group III (Standard + test combination) treatment. Mucous in the stool was most significantly found to be reduced in Group I and III treatment patients. Monoherbal test formulation alone and in combination with Mesalamine treatment showed relief from associated symptoms such as gas/flatulence in the patients. Frequency of bowels was significantly decreased in almost all the patients after treatment compared to before treatment. Statistically significant improvement was also recorded in consistency of stools which was watery/loose before treatment in most of the patients and became semisolid to normal after treatment in all the patients [Table 14].
|Table 14: Effects of treatment on signs and symptoms of ulcerative colitis|
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Investigations of stool samples before study confirmed the presence of occult blood in all 30 patients and presence of infection in 90 percent cases. Group I patients treated with Mesalamine for one month showed negative results for occult blood in 90 percent patients but 30% patients still were positive for infection in stool. Group II patients treated with monoherbal test formulation containing extracts of Holarrhena antidysenterica showed negative tests for occult blood and infection in the stool samples in all 10 patients. Group III patients treated with combination therapy of Mesalamine and monoherbal test formulation showed 100 percent results in control of stool infection while only 1 out of 10 showed occult blood test positive [Table 15].
None of the treatments showed any significant changes in the body weight and WBC count of the patients. Treatment with Mesalamine in Group I patients did not significantly change the ESR value of the patients, which is a prognostic marker for inflammation. Treatment with test formulation and combination therapy brought down the inflammation as can be evidently seen from the reduction in mean ESR values of the patients. Most significant effect on ESR value due to treatment was seen in Group III patients. All the 3 treatment groups showed significant improvement in the Hemoglobin levels. Most significant effect on hemoglobin level due to treatment was seen in Group III patients [Table 16].
|Table 16: Effects of treatment on investigations and body weight of ulcerative colitis|
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Cumulative scores for abdominal pain, diarrhea, stool consistency and bowel frequency/day of patients were calculated on different treatments in correlation with their baseline characteristics and quality of life [Table 17].
|Table 17: Cumulative scores of patients on different treatments in correlation with their baseline characteristics and quality of life|
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Decrease in the suffering of patients was noted as evidenced from symptomatic improvement, shown in the [Figure 1]. Relief of symptoms was seen from the 1st week onwards.
|Figure 1: Improvement in signs and symptoms and investigations after the treatment|
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Patients treated with monoherbal therapy and combination therapy did not report any side effects, relapse or complications while 5 (50%) patients treated with Mesalamine exhibited the relapse of the symptoms such as diarrhea and flatulence after drug withdrawal.
| Discussion|| |
A monoherbal formulation containing Holarrhena antidysenterica extract was used to evaluate its efficacy and safety in patients with chronic ulcerative colitis. Herbal formulations with single ingredient can be tested for their efficacy, safety and cost in comparison with modern allopathic drugs and surgical procedures. By reducing dose of Allopathic drugs, side effects can be minimised. The results from this study may offer insights for the development of novel, effective and satisfactory herbal formulations.
In our patient population, more prevalence was observed in 31-40 and 51-60 years of age and 60% patients out of total 30 patients having UC were males. The epidemiological data and theories behind the pathophysiology of IBD reported were found to be correlating with our clinical study. Kelvin Thia in 2008 and Cosnes Jacques in 2011 reported that the peak age for UC is 30–40 years with slight male predominance. 30% of patients enrolled for the study had the habit of smoking. The treatment with test drug reduced the high scores for signs and symptoms for ulcerative colitis in all smokers as well as nonsmokers. The strongest environmental risk factor for IBD is tobacco smoking but in 1998, Zijistra  reported that current smoking is protective against UC.
In our study 80% patients inspite of leading active lifestyle were suffering from UC which probably could be due to their stressful jobs, insecurity, higher workload, financial stress and a lackadaisical attitude towards personal health. People leading active life with outdoor activities have not been found to suffer from UC. In our studies, 70% patients were experiencing stress due to financial problems, overwork and poor health. Higher mortality from IBD has been reported in managerial, clerical, and sales positions, which typically involve sedentary and indoor work. All the treatments in the present study reduced mucus in stools. Stress increases the risk of developing IBD. Stress causes neuroendocrine response which decreases the mucus secretion and thereby weakens the mucosal barrier and increases the permeability. An impaired colonic mucosal barrier leading to increased intestinal permeability has been demonstrated in patients with UC. Local leaks due to apoptosis of colonic epithelium and highly permeable ulcerous lesions comprise the primary lesion in mild UC.
All the patients of our study, vegetarian or non-vegetarian, were regular consumers of street food. They had complaints of intermittent diarrhea and constipation along with flatulence. They expelled mucus and blood in their feces and suffered gastrointestinal infections. These symptoms were reduced after the treatment with test drug. The scores were significantly different before and after the treatment. IBD is most prevalent in developed regions. It is postulated that this is the result of “westernization” of lifestyle, such as changes in diet, smoking and variances in exposure to sunlight, pollution, and industrial chemicals. Higher intake of fatty acids, sucrose, and fast food increases the risk of IBD.
Most of the patients had complaints of loose motions or watery diarrhea before treatment. All the patients showed positive result for occult blood test done in stool samples which reversed significantly in all the treatment groups. Rise in hemoglobin levels of the patients after the trial treatments could be due to decreased blood loss through feces. The clinical studies conducted in 30 patients of ulcerative colitis, irrespective of their etiology showed a marked reduction in the frequency and consistency score of the stools after the test drug treatment. Patients suffering from several years with chronic diarrhea responded positively to the trial treatments. Patients treated with monoherbal tablets alone showed maximal reduction in abdominal pain, diarrhea, and bowel frequency per day and had better stool consistency scores and the results were better than Mesalamine treated patients. The treatment reduced the colonic inflammation as evident from ESR value. Patients with UC have also demonstrated decreased colonic mucin. An in-vitro study demonstrated a possible interaction between bacterial peptides and the mucosa in UC, resulting in depletion of mucus secretion by goblet cells  and excessive mucus expulsion in stool after colonic damage. Microbes are considered as antigens which lead to activation of intestinal immune system and epithelial cells. Release of various inflammatory mediators cause local mucosal damage. Blood is almost always present in stools of IBD patients. Medical therapy leading to remission improves gut barrier integrity. Thus, the results were similar to our pre-clinical studies in which the methanolic extract of Holarrhena antidysenterica showed beneficial effects and reduced stool consistency scores.
In the present study, patients were found to have stool infection on the day of enrollment for study. Treatment with Monoherbal tablet alone and in combination with Mesalazine significantly reduced the stool infection while Mesalamine alone could not resolve the infection. This property of controlling infection in monoherbal treatment will be an additional benefit over Mesalamine alone. Gastrointestinal infections such as amoebic dysentery are the major and most frequent problems found in IBD patients. Traditionally Holarrhena antidysenterica has been useful in amoebic dysentery and diarrhea. Holarrhena antidysenterica showed promising activity against experimental amoebiasis in rats and hamsters, The fruit extract (50% ethanolic) showed antiprotozoal effect against Enta. histolytica strain STA and Trypanosoma evansi. Clinical tests with connessine, which is the important alkaloid of Holarrhena antidysenterica showed anti amoebic activity with intestinal and hepatic amoebiasis patients. All the treatments significantly reduced the cumulative scores for abdominal pain, diarrhea, stool consistency and bowel frequency/day in all the patients irrespective of their smoking habit, type of stress, age, food habits or chronicity of symptoms. In the context of these reports and the observations obtained in our study, we can conclude that the monoherbal test formulation alone and in combination with Mesalamine showed significant improvement in combating the clinical symptomatology of IBD.
Patients treated with monoherbal therapy and combination therapy did not report any side effects, relapse or complications while 50% patients treated with Mesalamine exhibited relapse of the symptoms such as diarrhea and flatulence after drug withdrawal. The most common problem existing with Aminosalicylates class of drugs prescribed quite often for the treatment of IBD is relapse on stoppage of treatment even after the regression of the symptoms. Any therapy which provides relief from symptoms and treats the disease at basic level and improves the quality of life of patients suffering from distressing disease like IBD would be easily acceptable. Thus, the monoherbal preparation had a low overall cost of treatment along with benefits of similar efficacy, safety and less chances of relapse when compared to available conventional treatments like salicylates, steroids, antidiarrheals etc., Thus, the efficacy observed in ulcerative colitis patients treated with monoherbal formulation containing extracts of Holarrhena antidysenterica and the group treated with both herbal and Mesalamine was found to be better than the group treated with Mesalamine alone.
| Conclusion|| |
The clinical study supports the efficacy of investigational drug Holarrhena antidysenterica extract in resolving chronic ulcerative colitis with fewer chances of relapse and side effects. “Monoherbal” therapies may be used if found safe and effective as it will be easier to analyze the constituents as well as the mechanism of action. The results obtained in the present study can be used to conduct Phase II and III clinical trials with larger sample size and determine the problems associated with the management of IBD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loftus EV Jr. Clinical epidemiology of inflammatory bowel disease: Incidence, prevalence, and environmental influences. Gastroenterology 2004;126:1504-17.
Herfindal Eric T, Gourley Dick R. Textbook of Therapeutics. 7th
ed. Philadelphia, London: Lippincott Williams & Wilkins; 2000.
Rajasekaran A, Sivagnanam G, Xavier R. Nutraceuticals as therapeutic agents: A review. Res J Pharm Technol 2008;1:328-40.
Triantafillidis JK. The use of natural products in the treatment of inflammatory bowel disease. Ann Gastroenterol 2008;21:14-6.
Jagtap AG, Shirke SS, Phadke AS. Effect of polyherbal formulation on experimental models of inflammatory bowel diseases. J Ethnopharmacol 2004;90:195-204.
Shinde UA, Phadke AS, Nair AM, Mungantiwar AA, Dikshit VJ, Saraf MN. Studies on the anti-inflammatory and analgesic activity of Cedrus deodara
(Roxb.) Loud. wood oil. J Ethnopharmacol 1999;65:21-7.
Sahoo N, Manchikanti P, Dey S. Herbal drugs: Standards and regulation. Fitoterapia 2010;81:462-71.
Patwardhan B, Mashelkar RA. Traditional medicine-inspired approaches to drug discovery: Can Ayurveda show the way forward? Drug Discov Today 2009;14:804-11.
Sharma PC, Yelne MB, Dennis TJ. Database on Medicinal Plants Used in Ayurveda. Central Council for Research in Ayurveda and Siddha. Department of ISM & H, Ministry of Health and Family Welfare, Government of India. Reprint 2005. Vol. 2, 3. New Delhi, India: Pearl Offset Press Pvt. Ltd.; 2005.
Bhutani KK, Ali M, Sharma SR, Vaid RM, Gupta DK. Three new steroidal alkaloids from the bark of Holarrhena antidysenterica. Phytochemistry 1988;27:925-28.
Thia KT, Loftus EV Jr., Sandborn WJ, Yang SK. An update on the epidemiology of inflammatory bowel disease in Asia. Am J Gastroenterol 2008;103:3167-82.
Cosnes J, Gower-Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011;140:1785-94.
Zijlstra FJ. Smoking and nicotine in inflammatory bowel disease: Good or bad for cytokines? Mediators Inflamm 1998;7:153-5.
Hanauer SB. New lessons: Classic treatments, expanding options in ulcerative colitis. Colorectal Dis 2006;8 Suppl 1:20-4.
Gitter AH, Wullstein F, Fromm M, Schulzke JD. Epithelial barrier defects in ulcerative colitis: Characterization and quantification by electrophysiological imaging. Gastroenterology 2001;121:1320-8.
Lakatos PL, Szamosi T, Lakatos L. Smoking in inflammatory bowel diseases: good, bad or ugly? World J Gastroenterol 2007;13:6134-9.
Leiper K, Campbell BJ, Jenkinson MD, Milton J, Yu LG, Democratis J, et al.
Interaction between bacterial peptides, neutrophils and goblet cells: A possible mechanism for neutrophil recruitment and goblet cell depletion in colitis. Clin Sci (Lond) 2001;101:395-402.
Blumberg RS, Strober W. Prospects for research in inflammatory bowel disease. JAMA 2001;285:643-7.
Johari S, Joshi C, Gandhi T. Healing through cytokine regulation in DNBS induced inflammatory bowel disease in rats by Holarrhena antidysenterica.
Indian Drugs 2016;53:57-64.
Dutta NK, Iyer SN. Anti-amoebic value of berberine and kurchi alkaloids. J Indian Med Assoc 1968;50:349-52.
Dhar ML, Dhar MM, Dhawan BN, Mehrotra BN, Ray C. Screening of Indian plants for biological activity: I. Indian J Exp Biol 1968;6:232-47.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17]