Combination treatment of inflammatory bowel disease:Present status and future perspectives

The treatment of patients with inflammatory bowel disease(IBD),especially those with severe or refractory disease,represents an important challenge for the clinical gastroenterologist.It seems to be no exaggeration to say that in these patients,not only the scientific background of the gastroenterologist is tested,but also the abundance of“gifts”that he should possess(insight,intuition,determ-ination,ability to take initiative,etc.)for the successful outcome of the treatment.In daily clinical practice,depending on the severity of the attack,IBD is treated with one or a combination of two or more pharmaceutical agents.These combin-ations include not only the first-line drugs(e.g.,mesalazine,corticosteroids,antibiotics,etc)but also second-and third-line drugs(immunosuppressants and biologic agents).It is a fact that despite the significant therapeutic advances there is still a significant percentage of patients who do not satisfactorily respond to the treatment applied.Therefore,a part of these patients are going to surgery.In recent years,several small-size clinical studies,reviews,and case reports have been published combining not only biological agents with other drugs(e.g.,immunosuppressants or corticosteroids)but also the combination of two biologi-cal agents simultaneously,especially in severe cases.In our opinion,it is at least a strange(and largely unexplained)fact that we often use combinations of drugs in a given patient although studies comparing the simultaneous administration of two or more drugs with monotherapy are very few.As mentioned above,there is a timid tendency in the literature to combine two biological agents in severe cases unresponsive to the applied treatment or patients with severe extraintestinal manifestations.The appropriate dosage,the duration of the administration,the suitable timing for checking the clinical and laboratory outcome,as well as the treatment side-effects,should be the subject of intense clinical research shortly.In this editorial,we attempt to summarize the existing data regarding the already applied combination therapies and to humbly formulate thoughts and suggestions for the future application of the combination treatment of biological agents in a well-defined category of patients.We suggest that the application of biomarkers and artificial intelligence could help in establishing new forms of treatment using the available modern drugs in patients with IBD resistant to treatment.

Advancements in sequential and combination treatments for osteoporosis

Osteoporosis,a prevalent systemic degenerative disease,poses significant challenges to China’s national health,particularly due to complications such as fractures.Therapeutic interventions for osteoporosis primarily involve bone resorption inhibitors(antiresorptive)and bone formation promoters(anabolic).Numerous studies underscore the importance of sequential and combination treatments using diverse drug types.Such approaches have shown considerable efficacy in increasing bone mineral density,reducing fracture risk,and preventing the progression of osteoporosis.This article aimed to consolidate various sequential treatment schemes,offering valuable insights for clinicians in their practice.

Anlotinib in combination with Envolizumab plus Etoposide for the treatment of EX-SCLC:a case report

Background:Small cell lung cancer(SCLC)is an aggressive malignant tumor with strong immunosuppressive effects,characterized by rapid doubling time and poor prognosis.Currently,effective therapeutic options are urgently needed for Extensive-stage small-cell lung Cancer.Case description:In the present case,a combination therapy of anlotinib,envolizumab,and etoposide was administered to treat an 80-year-old female patient with extensive-stage SCLC accompanied by mediastinal lymph node and bone metastasis.After two cycles of treatment,the tumor lesions in the right lungs decreased from 5.04*3.44 cm to 1.65*1.42 cm.As of now,no significant mass is seen there and no serious adverse reactions in this patient.Until September 2023,she has survived for 18 months with no disease progression.Conclusions:Research shows that Alectinib,in combination with evolocumab plus etoposide,could be an original,viable therapeutic option for the treatment option of patients with extensive-stage SCLC.

Oncolytic virus-based hepatocellular carcinoma treatment:Current status,intravenous delivery strategies,and emerging combination therapeutic solutions

Current treatments for advanced hepatocellular carcinoma(HCC)have limited success in improving patients’quality of life and prolonging life expectancy.The clinical need for more efficient and safe therapies has contributed to the exploration of emerging strategies.Recently,there has been increased interest in oncolytic viruses(OVs)as a therapeutic modality for HCC.OVs undergo selective replication in cancerous tissues and kill tumor cells.Strikingly,pexastimogene devacirepvec(Pexa-Vec)was granted an orphan drug status in HCC by the U.S.Food and Drug Administration(FDA)in 2013.Meanwhile,dozens of OVs are being tested in HCC-directed clinical and preclinical trials.In this review,the pathogenesis and current therapies of HCC are outlined.Next,we summarize multiple OVs as single therapeutic agents for the treatment of HCC,which have demonstrated certain efficacy and lowtoxicity.Emerging carrier cell-,bioengineered cell mimetic-or nonbiological vehicle-mediated OV intravenous delivery systems in HCC therapy are described.In addition,we highlight the combination treatments between oncolytic virotherapy and other modalities.Finally,the clinical challenges and prospects of OV-based biotherapy are discussed,with the aim of continuing to develop a fascinating approach in HCC patients.

Dual-targeted treatment for inflammatory bowel disease:Whether fecal microbiota transplantation can be an important part of it

Inflammatory bowel disease(IBD)is a chronic gastrointestinal inflammatory disease.With the emergence of biologics and other therapeutic methods,two biologics or one biologic combined with a novel small-molecule drug has been proposed in recent years to treat IBD.Although treatment strategies for IBD are being optimized,their efficacy and risks still warrant further consideration.This editorial explores the current risks associated with dual-targeted treatment for IBD and the great potential that fecal microbiota transplantation(FMT)may have for use in combination therapy for IBD.We are focused on addressing refractory IBD or biologically resistant IBD based on currently available dual-targeted treatment by incorporating FMT as part of this dual-targeted treatment.In this new therapy regimen,FMT represents a promising combination therapy.

Combination treatment with chondroitinase ABC in spinal cord injury—breaking the barrier

After spinal cord injury （SCl）, re-establishing functional circuitry in the damaged central nervous system （CNS） faces multiple challenges including lost tissue volume, insufficient intrinsic growth capacity of adult neurons, and the inhibitory environment in the damaged CNS. Several treatment strategies have been developed over the past three decades, but successful restoration of sensory and motor functions will probably require a combination of approaches to address different aspects of the problem. Degradation of the chondroitin sulfate proteoglycans with the chondroitinase ABC （ChABC） enzyme removes a regeneration barrier from the glial scar and increases plasticity in the CNS by removing perineuronal nets. Its mechanism of action does not clash or overlap with most of the other treatment strategies, making ChABC an attractive candidate as a combinational partner with other methods. In this article, we review studies in rat SCI models using ChABC combined with other treatments including cell implantation, growth factors, myelin-inhibitory molecule blockers, and ion channel expression. We discuss possible ways to optimize treatment protocols for future combinational studies. To date, combinational therapies with ChABC have shown synergistic effects with several other strategies in enhancing functional recovery after SCI. These combinatorial approaches can now be developed for clinical application.

Combination strategies for pharmacologic treatment of nonalcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is defined as hepatic steatosis, inflammation,and hepatocyte injury with or without fibrosis. It has emerged as thesecond leading indication for liver transplantation with a rising death rate in thenon-transplantable population. While there are many drugs in evaluation,currently no approved therapies are on the market for this condition. Given thisimportance, the Food and Drug Administration has provided formal guidanceregarding drug development for stopping or reversing NASH or NASH associatedfibrosis. The complex pathogenesis of NASH and its bidirectional relationshipwith metabolic syndrome has highlighted multiple drugs of interest thataddress metabolic, inflammatory, and fibrotic factors. A few promising liverspecific targets include farnesoid X receptor agonists and peroxisome proliferatoractivatedreceptor agonists. Previously studied drug classes such as glucagon-likepeptide-1 analogs or sodium/glucose transport protein 2 inhibitors have alsodemonstrated ability to improve hepatic steatosis. Here we discuss currentrationale, scientific work, and preliminary data in combining multiple drugs forthe purposes of a multimodal attack on the pathogenesis of NASH. We highlightmultiple Phase 2 and Phase 3 studies that demonstrate the potential to achieve aresponse rate higher than previously assessed monotherapies for this condition.Ultimately, one of these combination strategies may rise above in its safety andefficacy to become a part of a standardized approach to NASH.

Therapeutic efficacy and effects of artemisinin-based combination treatments on uncomplicated Plasmodium falciparum malaria-associated anaemia in Nigerian children during seven years of adoption as first-line treatments

Background:Artemisinin-based combination treatments(ACTs)are the first-line treatments of uncomplicated Plasmodium falciparum malaria in many endemic areas but there are few evaluation of their efficacy in anaemic malarious children.Methods:Therapeutic efficacy of 3-day regimens of artesunate-amodiaquine and artemether-lumefantrine was evaluated in 437 anaemic and 909 non-anaemic malarious children following treatment during a seven-year period(2008-2014).Patterns of temporal changes in haematocrit were classified based on haematocrit values<30%and≥30%.Kinetics of the disposition of the deficit in haematocrit from 30%following treatment were evaluated using a non-compartment model.Results:PCR-corrected parasitological efficacy 28 days after start of treatment was significantly higher in artesunateamodiaquine-compared to artemether-lumefantrine-treated children[97%(95%CI:92.8-100)versus 96.4%(95%CI:91.3-99.4),P=0.02],but it was similar in non-anaemic and anaemic children.Fall in haematocrit/1000 asexual parasites cleared from peripheral blood was significantly greater at lower compared to higher parasitaemias(P<0.0001),and in non-anaemic compared to anaemic children(P=0.007).In anaemic children at presentation,mean anaemia recovery time(AnRT)was 15.4 days(95%CI:13.3-17.4)and it did not change over the years.Declines in haematocrit deficits from 30%were monoexponential with mean estimated half-time of 1.4 days(95%CI:1.2-1.6).Anaemia half-time(t_(1/2anaemia))correlated positively with AnRT in the same patients(r=0.69,P<0.0001).Bland-Altman analysis of 10 multiples of t_(1/2anaemia) and AnRT showed narrow limit of agreement with insignificant bias(P=0.07)suggesting both can be used interchangeably in the same patients.Conclusions:Artesunate-amodiaquine and artemether-lumefantrine remain efficacious treatments of uncomplicated P.falciparum infections in non-anaemic and anaemic Nigerian children in the last 7 years of adoption as first-line treatments.These ACTs may also conserve haematocrit at high parasitaemias and in anaemic children.Trials registration:Pan African Clinical Trial Registry PACTR201508001188143,3 July 2015;PACTR201510001189370,3 July 2015;PACTR201508001191898,7 July 2015 and PACTR201508001193368,8 July 2015.

Combination Treatment with Herbal Medicines and Western Medicines in Atopic Dermatitis:Benefits and Considerations

Herbal medicines （HMs） are often used in combination with Western medicines （WMs） to improve therapeutic efficacies of orthodox medicines. This review discussed the current status of combination treatment with HMs and WMs in clinical practices. The influence of HMs on bioavailability of WMs was also discussed from the pharmacokinetic point of view. In addition, benefits and considerations of combination treatment were discussed using data obtained from clinical trials and randomized controlled trials of HMs treatment in skin diseases.

Declining responsiveness of childhood Plasmodium falciparum infections to artemisinin-based combination treatments ten years following deployment as first-line antimalarials in Nigeria

Background:The development and spread of artemisinin-resistant Plasmodium falciparum malaria in Greater Mekong Subregion has created impetus for continuing global monitoring of efficacy of artemisinin-based combination therapies(ACTs). This post analyses is aimed to evaluate changes in early treatment response markers 10 years after the adoption of ACTs as first-line treatments of uncomplicated falciparum malaria in Nigeria.Methods: At 14 sentinel sites in six geographical areas of Nigeria, we evaluated treatment responses in 1341 children under 5 years and in additional 360 children under 16 years with uncomplicated malaria enrolled in randomized trials of artemether-lumefantrine versus artesunate-amodiaquine at 5-year interval in 2009-2010 and 2014-2015 and at 2-year interval in 2009-2010 and 2012-2015, respectively after deployment in 2005.Results: Asexual parasite positivity 1 day after treatment initiation (APPD1) rose from 54 to 62% and 2 days after treatment initiation from 5 to 26% in 2009-2010 to 2014-2015(P=0.002 and P<0.0001, respectively).Parasite clearance time increased significantly from 1.6 days (95% confidence interval [CI]: 1.55-1.64) to 1.9 days (95% C,1.9-2.0) and geometric mean parasite reduction ratio 2 days after treatment initiation decreased significantly from 11 000 to 4700 within the same time period (P< 00001 for each). Enrolment parasitaemia > 75 000 μl^-1, haematocrit > 27% 1 day post-treatment initiatiortreatment with artemether-lumefantrine and enrolment in 2014-2015 independently predicted APPD1. In paralle , Kaplan-Meier estimated risk of recurrent infections by day 28 rose from 8 to 14% (P=0005) and from 9 to 15%(P=0.02) with artemether-lumefantrine and artesunate-amodiaquine, respectively. Mean asexual parasitaemia half-life increased significantly from 1.1 h to 1.3h within 2 years (P<0.0001).Conclusions:These data indicate declining parasitological responses through time to the two ACTs may be due to emergence of parasites with reduced susceptibility or decrease in immunity to the infections in these children.

Therapeutic response and safety of different treatments for cutaneous leishmaniasis in patients: A retrospective cross-sectional study

Objective:To analyze the therapeutic response and safety of different treatments for cutaneous leishmaniasis,received by patients in the Program for the Study and Control of Tropical Diseases-PECET-Medellín-Colombia.Methods:This is a retrospective cross-sectional study of patients attended at PECET Research Center during 2016-2021.Relevant information regarding sociodemographic characteristics,history of leishmaniasis,characterization of current infection,treatment received,follow-up of therapeutic response and safety was collected from the medical records.Data were analyzed with Pearson's Chi-square association tests and Mann-Whitney U test using statistical software.Results:A total of 486 clinical records of patients were analyzed,and 356 received treatment.Eight different therapeutic alternatives(systemic,local and in combination)were analyzed.The therapeutic response of the different alternatives used(except thermotherapy)was higher than 50%.Most frequent adverse events were myalgias,arthralgias and headache,and vesicles for systemic and local treatment,respectively.Conclusions:Safety profile and performance of local therapeutic alternatives and combined schemes for the treatment of uncomplicated cutaneous leishmaniasis are an interesting option for the management of the disease.

Operational Techniques and Combination Treatment for the Recurrent Sacro－coccygeal Tumor

This article presents 6 cases of recurrent sacro-coccygeal tumor with analysis of the causes of recurrence, operational technique for second-time operation and concomitant treatment.It is suggested that combined abdominal and sacro-coccygeal approaches be used to excise maximal mass of the tumor,surrounding affected tissues be curetted out and the space be filled up with adriamycin-bone-cement to destroy remaining tumor cells and to strengthen the stability of pelvis. Besides,the patients should be subject to supersegregation radiotherapy in order to minimize the possibility of recurrence.

COMMENTS ON THE STUDY OF ACUPOINT COMBINATION AND REMEDIES FOR TREATMENT OF DIABETES MELLITUS WITH ACUPUNCTURE AND MOXIBUSTION

In the present paper, the author reviews the progresses in the study on acumoxi (acupuncture-moxi-bustion) treatment of diabetes mellitus (DM) from Chinese ancient classical works, Chinese and foreign journals. The therapeutic results reveal that acupuncture treatment of DM is effective in improving DM patients' symptoms via vagal-nerve reflex, regulation of neuroendocrine and immune functions. The author holds that ① correct selection of acupoints in accordance with syndrome differentiation and the related meridians and combined application of acupuncture and Chinese herbal medicines (for oral administration) are the key points for raising the therapeutic effect; and ② acupoint combination and curative methods need to be researched further.

Nursing Effects of Medical Treatment Combination on Patients at High Risk of Developing Pressure Ulcers at Rural Homes

Objective:To explore the nursing effects of medical treatment combination on patients at high risk of developing pressure ulcers at rural homes.Methods:From January 2018 to December 2018,86 patients at high risk of developing pressure ulcers at rural homes who were in Wenjiang Hospital were randomly divided into a control group and an observed group.The control group received the routine publicity and education and visiting,while the observed group adopted the cooperative nursing model of medical treatment combination.Then compare the healing status and nursing satisfaction of the two groups.Results:Of the 43 patients with pressure ulcers in the observed group,18 had been in the second stage of pressure ulcers and 16 had been healed;14 had been in the third stage of pressure ulcers and 8 had been healed;11 had been in the fourth stage of pressure ulcers and 5 had been healed.The nursing satisfaction of the patients in the observed group was 95.35%.Conclusion:Conducting medical treatment combination on patients at high risk of developing pressure ulcers at rural homes can effectively improve the patients’and their families’awareness of pressure ulcer nursing,standardize their nursing behaviour,help recover the patients themselves and promote the patients’satisfaction.

Successful treatment of eyebrow intradermal nevi by shearing combined with electrocautery and curettage:Two case reports

BACKGROUND An intradermal nevus is a common skin tumour,and the classical method of removal has a risk of recurrence and scarring.It is a challenge for dermatologists to treat eyebrow intradermal nevi quickly and efficiently.This study focused on investigating the efficacy and safety of shearing combined with electrocautery and curettage in the treatment of eyebrow intradermal nevi.CASE SUMMARY We describe two adult patients with eyebrow intradermal nevi treated by shearing combined with electrocautery and curettage.Both patients were followed up regularly after surgery.At follow-up,no recurrence of eyebrow intradermal nevus and no obvious scars or hypopigmentation were found in either patient.The results indicated that shearing combined with electrocautery and curettage could remove eyebrow intradermal nevus without side effects and confirmed the efficacy and safety of this modality for treating these skin lesions.CONCLUSION Shearing combined with electrocautery and curettage has superior merits,including simple operation,good cosmetic effects,and high patient satisfaction,presenting great application potential for treating intracutaneous nevus.

The Combined Effect of Botulinum Toxin Type A with a Biorevitalizing Treatment on Forehead Rejuvenation: A Case Series

Background: The forehead is particularly prone to repetitive facial expressions and hyperdynamic activity, resulting in deep wrinkles and a loss of elasticity and hydration. Although botulinum toxin type A (BoNTA) has been shown to reduce the appearance of wrinkles and allow patients to have a smoother and hence younger upper face, it cannot help to improve the other aspects that determine overall skin quality. Objective: This case series aims to evaluate the clinical efficacy of combining BoNTA injections with a biorevitalizing treatment (NCTF®135HA) on skin aging signs and quality using a split face approach. Patients and Methods: A total of eight patients from 30 to 55 years old were treated with botulinum toxin type A combined with NCTF®-135HA or alone. Results: At D60, clinical skin quality scoring showed that NCTF®135HA injection significantly reduced wrinkles and enhanced skin homogeneity, hydration, firmness, and radiance. The Global Aesthetic Improvement Scale (GAIS) by the evaluator at D60 reported mean scores of 2375 (much improved) on the side of the face treated with BoNTA + NCTF®-135HA compared to the side of the face without NCTF®135HA. According to patients, the NCTF®135HA injections resulted in a significantly better aesthetic improvement score on D60 (mean score of 2.5 compared to 0.125 without NCTF®135HA, p 0.001). Conclusions: Our findings show that combining a biorevitalizing treatment with a BoNTA injection can significantly improve the skin’s overall appearance and decrease the wrinkle score when compared to the BoNTA injections alone. The results suggest that the combinatory strategy is effective, safe, and associated with a high level of patient satisfaction.

Effect of Dendrobium nobile powder combined with conventional therapy on mild to moderate fatty liver

BACKGROUND Nonalcoholic fatty liver disease(NAFLD)encompasses a variety of liver conditions impacting individuals who consume minimal or no alcohol.Recently,traditional Chinese medicine has been gradually used to treat mild to moderate fatty liver,among which Dendrobium nobile Lindl.powder has been affirmed by many doctors and patients to be effective.However,there is limited research on combining this treatment with standard therapies for mild to moderate NAFLD.AIM To survey the effect of combining Dendrobium nobile Lindl.powder with standard treatment on liver function and lipid metabolism disorder in patients with mild to moderate NAFLD.METHODS Eighty patients with mild to moderate NAFLD participated in this retrospective study,classified into two groups:The observation group(n=40)and the control group(n=40).In November 2020 and November 2022,the study was conducted at People’s Hospital of Chongqing Liang Jiang New Area.The control group received standard treatment,while the observation group received Dendrobium nobile Lindl.powder based on the control group.The study compared differences in traditional Chinese medicine clinical syndrome scores,liver fibrosis treatment,liver function indicators,lipid levels,and serum inflammatory factor levels before and after treatment,and we calculated the incidence of adverse reactions for both groups.RESULTS The total effective rate was 97.50%in the observation group and 72.5%in the control group.After 8 weeks of treatment,the main and secondary symptom scores remarkably decreased,especially in the observation group(P<0.05),and there was a significant reduction in the serum levels of hyaluronic acid(HA),laminin(LN),human rocollagen III(PC III),and collagen type IV(CIV).The levels of HA,LN,PC III,and CIV were significantly lower in the observation group(P<0.05).After 8 weeks,both groups indicated remarkable improvements in liver function and blood lipid levels,with the observation group having even lower levels(P<0.05).Serum levels of interleukin-1β,tumor necrosis factor-α,and interleukin-8 also dropped significantly.The observation group had a lower rate of adverse reactions(5.00%)compared to the control group(22.50%).CONCLUSION Adding Dendrobium nobile Lindl.powder to standard treatment has been found to remarkably improve symptoms and reduce inflammation in patients with mild to moderate fatty liver disease.It also enhances hepatic function and lipid profile,ameliorates liver fibrosis indices,and lowers the risk of side effects.Consequently,this therapeutic protocol shows promise for clinical implementation and dissemination.

Combining GLP-1 receptor agonists and SGLT-2 inhibitors for cardiovascular disease prevention in type 2 diabetes:A systematic review with multiple network meta-regressions

BACKGROUND Glucagon-like peptide-1 receptor agonists(GLP-1RA)and sodium-glucose co-transporter-2 inhibitors(SGLT-2I)are associated with significant cardiovascular benefit in type 2 diabetes(T2D).However,GLP-1RA or SGLT-2I alone may not improve some cardiovascular outcomes in patients with prior cardiovascular co-morbidities.AIM To explore whether combining GLP-1RA and SGLT-2I can achieve additional benefit in preventing cardiovascular diseases in T2D.METHODS The systematic review was conducted according to PRISMA recommendations.The protocol was registered on PROSPERO(ID:42022385007).A total of 107049 participants from eligible cardiovascular outcomes trials of GLP-1RA and SGLT-2I were included in network meta-regressions to estimate cardiovascular benefit of the combination treatment.Effect modification of prior myocardial infarction(MI)and heart failure(HF)was also explored to provide clinical insight as to when the INTRODUCTION The macro-and micro-vascular benefits of glucagon-like peptide-1 receptor agonists(GLP-1RA)and sodium-glucose co-transporter-2 inhibitors(SGLT-2I)are independent of their glucose-lowering effects[1].In patients with type 2 diabetes(T2D),the major cardiovascular outcome trials(CVOT)showed that dipeptidyl peptidase-4 inhibitors(DPP-4I)did not improve cardiovascular outcomes[2],whereas cardiovascular benefit of GLP-1RA or SGLT-2I was significant[3,4].Further subgroup analyses indicated that the background cardiovascular risk should be considered when examining the cardiovascular outcomes of these newer glucose-lowering medications.For instance,prevention of major adverse cardiovascular events(MACE)was only seen in those patients with baseline atherosclerotic cardiovascular disease[3,4].Moreover,a series of CVOT conducted in patients with heart failure(HF)have demonstrated that(compared with placebo)SGLT-2I significantly reduced risk of hospitalization for HF or cardiovascular death,irrespective of their history of T2D[5-8].However,similar cardiovascular benefits were not observed in those with myocardial infarction(MI)[9,10].Cardiovascular co-morbidities are not only approximately twice as common but are also associated with dispropor-tionately worse cardiovascular outcomes in patients with T2D,compared to the general population[11].Therefore,it is of clinical importance to investigate whether the combination treatment of GLP-1RA and SGLT-2I could achieve greater cardiovascular benefit,particularly when considering patients with cardiovascular co-morbidities who may not gain sufficient cardiovascular protection from the monotherapies.This systematic review with multiple network meta-regressions was mainly aimed to explore whether combining GLP-1RA and SGLT-2I can provide additional cardiovascular benefit in T2D.Cardiovascular outcomes of these newer antidiabetic medications were also estimated under effect modification of prior cardiovascular diseases.This was to provide clinical insight as to when the combination treatment might be prioritized.

Effects of hexahydrocurcumin in combination with 5-fluorouracil on dimethylhydrazine-induced colon cancer in rats

AIM:To investigate the effects of hexahydrocurcumin(HHC),and its combination with 5-fluorouracil(5-FU) on dimethylhydrazine(DMH)-induced colon cancer in rats.METHODS:Male Wistar rats weighing 100-120 g were used as subject models.Aberrant crypt foci(ACF),early preneoplastic lesions of colon cancer,were induced by subcutaneous injection of DHM(40 mg/kg) twice a week for two weeks.After the first DMH injection,rats were treated daily with vehicle(n = 12),curcumin(CUR)(50 mg/kg)(n = 12),HHC(50 mg/kg) orally(n = 12),and treated weekly with an intraperitoneal injection of 5-FU(50 mg/kg)(n = 12),or a combination of 5-FU plus CUR(n = 12) and HHC(n = 12) at the same dosage(s) for 16 wk.The total number of ACF and large ACF were assessed.Cyclooxygenase(COX)-1 and COX-2 expression were detected by immunohistochemistry in colon tissues.The quantitative data of both COX-1 and COX-2 expression were presented as the percentage of number of positive-stained cells to the total number of cells counted.Apoptotic cells in colon tissues were also visualized using the dUTP-biotin nick end labeling method.Apoptotic index(AI) was determined as the percentage of labeled nuclei with respect to the total number of nuclei counted.RESULTS:The total number of ACF was highest in the DMH-vehicle group(1558.20 ± 17.37),however,the number of ACF was significantly reduced by all treatments,5-FU(1231.20 ± 25.62 vs 1558.20 ± 17.37,P < 0.001),CUR(1284.20 ± 25.47 vs 1558.20 ± 17.37,P < 0.001),HHC(1086.80 ± 53.47 vs 1558.20 ± 17.37,P < 0.001),DMH-5-FU + CUR(880.20 ± 13.67 vs 1558.20 ± 17.37,P < 0.001) and DMH-5-FU + HHC(665.80 ± 16.64 vs 1558.20 ± 17.37,P < 0.001).Interestingly,the total number of ACF in the combined treatment groups,the DMH-5-FU + CUR group(880.20 ± 13.67 vs 1231.20 ± 25.62,P < 0.001;880.20 ± 13.67 vs 1284.20 ± 25.47,P < 0.001) and the DMH-5-FU + HHC group(665.80 ± 16.64 vs 1231.20 ± 25.62,P < 0.001;665.80 ± 16.64 vs 1086.80 ± 53.47,P < 0.001) were significantly reduced as compared to 5-FU or each treatment alone.Large ACF were also significantly reduced in all treatment groups,5-FU(111.00 ± 7.88 vs 262.20 ± 10.18,P < 0.001),CUR(178.00 ± 7.33 vs 262.20 ± 10.18,P < 0.001),HHC(186.60 ± 21.51 vs 262.20 ± 10.18,P < 0.001),DMH-5-FU + CUR(122.00 ± 5.94 vs 262.20 ± 10.18,P < 0.001) and DMH-5-FU + HHC(119.00 ± 17.92 vs 262.20 ± 10.18,P < 0.001) when compared to the vehicle group.Furthermore,in the DMH-5-FU + CUR and DMH-5-FU + HHC groups the formation of large ACF was significantly reduced when compared to CUR(122.00 ± 5.94 vs 178.00 ± 7.33,P < 0.005) or HHC treatment alone(119.00 ± 17.92 vs 186.60 ± 21.51,P < 0.001),however,this reduction was not statistically different to 5-FU monotherapy(122.00 ± 5.94 vs 111.00 ± 7.88,P = 0.217;119.00 ± 17.92 vs 111.00 ± 7.88,P = 0.619,respectively).The levels of COX-1 protein after all treatments were not different from normal rats.A marked increase in the expression of COX-2 protein was observed in the DMH-vehicle group.Over-expression of COX-2 was not significantly decreased by 5-FU treatment alone(95.79 ± 1.60 vs 100 ± 0.00,P = 0.198).However,over-expression of COX-2 was significantly suppressed by CUR(77.52 ± 1.68 vs 100 ± 0.00,P < 0.001),HHC(71.33 ± 3.01 vs 100 ± 0.00,P < 0.001),5-FU + CUR(76.25 ± 3.32 vs 100 ± 0.00,P < 0.001) and 5-FU + HHC(68.48 ± 2.24 vs 100 ± 0.00,P < 0.001) in the treated groups compared to the vehicle group.Moreover,CUR(77.52 ± 1.68 vs 95.79 ± 1.60,P < 0.001),HHC(71.33 ± 3.01 vs 95.79 ± 1.60,P < 0.001),5-FU + CUR treatments(76.25 ± 3.32 vs 95.79 ± 1.60,P < 0.001) and 5-FU + HHC(68.48 ± 2.24 vs 95.79 ± 1.60,P < 0.001) markedly decreased COX-2 protein expression more than 5-FU alone.Furthermore,the AI in all treated groups,5-FU(38.86 ± 4.73 vs 23.56 ± 2.12,P = 0.038),CUR(41.78 ± 6.92 vs 23.56 ± 2.12,P < 0.001),HHC(41.06 ± 4.81 vs 23.56 ± 2.12,P < 0.001),5-FU + CUR(49.05 ± 6.75 vs 23.56 ± 2.12,P < 0.001) and 5-FU + HHC(53.69 ± 8.59 vs 23.56 ± 2.12,P < 0.001) significantly increased when compared to the DMH-vehicle group.However,the AI in the combination treatments,5-FU + CUR(49.05 ± 6.75 vs 41.78 ± 6.92,P = 0.192;49.05 ± 6.75 vs 38.86 ± 4.73,P = 0.771) and 5-FU + HHC(53.69 ± 8.59 vs 41.06 ± 4.81,P = 0.379;53.69 ± 8.59 vs 38.86 ± 4.73,P = 0.245) did not reach significant levels as compared with each treatment alone and 5-FU monotherapy,respectively.CONCLUSION:The combined effects of HHC with 5-FU exhibit a synergistic inhibition by decreasing ACF formation mediated by down-regulation of COX-2 expression.