Clinical Trial of Areca Nut Seed (Areca catechu L.

) Extract Tablets
In Schoolchildren infested by Intestinal Worms
in Mumbulsari sub-district Jember

ABSTRACT
*Utami, W.S., **Nuri, **Wicaksono, Y, ***Palupi, I.R, ***Gemawan, T
Email: wiwien.dr@gmail.com
*Lecturer in Faculty of Medicine, Jember University
**Lecturer in Faculty of Pharmacy, Jember University
***Medical Students in Faculty of Medicine, Jember University

INTRODUCTION
Worm infection is a disease that can be suffered by all ages. Many people thinks
that this disease is uncommon. Recent studies, however, have demostrated the huge
burden of chronic infection caused by worms. According to WHO data, patients with
worm disease accounts for 1 billion people in the world, and 40-60% Indonesian
population are infected with worms. According to Millennium declaration, one
disease that comes to attention is soil transmitted helminthiasis, such as ascariasis,
trichuriasis, dan ancylostomiasis (Molyneux, 2004).
Worm infection can result in declining health, nutritional status, intellectuality
and productivity which could be financially disadvantageous. The loss of
carbohydrates, proteins, and blood caused by worm infection results in lower quality
of human resources. In addition to inhibiting the development of physical, intellectual
and labor productivity, it can lower the body's defenses so the patients become prone
to other diseases (Supari, 2006). Ascariasis patients generally show no symptom, but
with a considerable number of worms (hyperinfection), especially in children,
infection will lead to malnutrition (Rasmaliah, 2001). In tricuriasis patient, mild
infections are asymptomatic. However, in severe infections, especially in children,
there are symptoms of diarrhea which is often interspersed with dysentery syndrome,
and symptoms of anemia, weight loss and sometimes accompanied by rectal prolapse
(Spears, 2007). Hookworms infestation can cause anemia and impaired intellectual
development (Haburchak, 2008).
 Indonesia is a tropical country so many parasites thrive in their cycles so they
can easily infect human (Istiqomah, 2007). Helminthic infection is a chronic infection
most commonly found in toddlers and school age children (Faust and Russel, 1964).
Results from worms survey in elementary schools in several provinces in the years
1986-1991 showed the prevalence of worm infection is about 60% - 80% (Supari,
2006). One research in Jember conducted prevalence analysis of ascariasis and
trichuriasis in Kalikotok slums and RSS Argopuro settlements (control group). It was
found that prevalences of ascariasis and trichuriasis at those settlement were 63% and
5% and 3% and 0%, respectively (p <0.05) (Nurdian, 2002). In Mumbulsari
Subdistrict, Jember, parasitic worm egg contamination level is 52% in Suco villages
and 68% at Lengkong village (Kurniawati, 2008). In another study in Jember, from
60 samples from Kemiri 3 elementary school students, 29 samples (48.33) were
found to be positive for helminth eggs. Ascaris lumbricoides eggs with the tallest
percentage (68.96%), Enterobius vermicularis (34.48%), and hookworms (17.24%)
(Eden, 2008).
District of Mumbulsari is one district which most of the territory comprised of
plantations. Five of the seven villages in the district Mumbulsari are plantation
region. The villages are village Mumbulsari, karang Kedawung, Kawang Rejo, Suco
and Lengkong (Armiyanti et al., 2003:43). According to research conducted by
Herlina (2005:21) on the grounds of houses in the Suco and Lengkong village,
percentage of positive soil samples was 52% for eggs of A. lumbricoides, while in the
Lengkong village was 68%.
Eradication of helminth infection is not an easy thing to do. Although it has
been done with the treatment and eradication and others, prevalence remains high.
Reinfection problems and low socioeconomic levels, result in obstacle of the use of
modern medicine still have problems. Therefore it is necessary to find an alternative
drug for use by non-governmental organizations combating this worm disease. Drugs
commonly used to combat intestinal worm's life cycle are pirantel pamoate, piperazin
citrate and mebendazol. People had also recognized various natural material
(medicinal plants) that can be used to treat intestinal worms, one of them is Areca
(Areca catechu L.) (Ahmad and Ismail, 2003).
Nut seed extract has been proven in vitro to have ovicidal and vermicidal
activity against Ascaris suum, in its in vivo vermicidal activity test in pigs infected
with Ascaris suum. The results show, at a dose of 2.4 grams for 3 consecutive days,
the drug was able to remove the worm Ascaris suum from pig intestine along with
feces. Subsequently areca seed extract was formulated as tablet and was tested for
acute toxicity in experimental animals (Nuri, 2007). Furthermore, for official use in
healthcare, the drug must then go through series of clinical trials in humans.

PURPOSE AND METHOD

The general objective of this study was to determine the results of clinical
trials of areca seed extract tablet (A. catechu L.) in patients with helminth infections
in Mumbulsari subdistrict, Jember.
This research was a clinical trial which tested areca seed extract on people
with intestinal worm infection, and was conducted in elementary school students in
Mumbulsari District, Jember. It was a phase III controlled clinical trial with parallel
design. Blinding type used was single blinding in which the subject did not know the
treatment given, while researchers did. The design of this research is true
experimental design with the pre and post test comparing treatment groups to take
measurements before and after treatment.
Sampling sites throughout the study was conducted in elementary schools in
Mumbulsari District, Jember, and identification of worm eggs were done at the
Laboratory of Parasitology Faculty of Medicine, University of Jember. The study
population was primary school students grades 4, 5, and 6. Study sample was selected
according to the following criteria
Inclusion criteria :
1. Primary School pupils in grade 4 to 6
2. Not currently suffering from diseases that disrupt the oral medication
3. Did not receive an anthelmintic during one previous month
4. Had Ascaris lumbricoides eggs on stool examination.
Exclusion criteria:
1. Not regularly taking medication / refusing to eat drug
2. did not participate in Stool examination in day 14 to21
3. Suffering from severe side effects such as diarrhea, vomiting, abdominal rigidity
and others
Study samples who had signed informed consent were then divided into 2
groups: group A as a treatment group was given areca seed extract tablet, whereas
group B as a control group was given standard drugs, namely pirantel pamoate.
Grouping of treatment was done by using random numeric table.
Sampling was done twice. The first sampling conducted on all primary school
students who are willing to follow the screening study in order to identify the
presence of worm eggs in stool. After screening, the ones who were positive for
worms had the egg number counted (stated as “eggs per gram”). The second sampling
was done in the two weeks after therapy, to evaluate effectiveness of treatment by
counting the number of eggs per gram after treatment. Stool samples obtained later
were identified in the Laboratory of Parasitology Faculty of Medicine, University of
Jember using Kato-Katz method.
Treatment was given to worm-positive subjects. At time of treatment, subjects
were given the drugs, and data were recorded in monitoring forms that also contained
information regarding identity, the time of taking medication, and side effects that
developed (attached).
Treatment of the test group was divided into 2 groups. The division was done
randomly with an equal number of samples. Group A received treatment with
traditional medicine preparation that had been formulated as tablets of areca seed
extract, group B received the standard treatment Pirantel pamoate 10 mg / kg / oral /
single dose. Treatment was conducted for 3 consecutive days with subjects of
children from primary school from grade IV to grade VI.
 Group A of treatment group received treatment with areca seed extract tablets,
with therapeutic dose of 500 mg. Subjects were asked to take the drug for 3 days in a
row by 1 ½ tablets / day. Group B as the control group received standard treatment of
pirantel pamoate capsules 10 mg / kg, taken orally with a single dose. After 2 weeks,
subjects were asked to submit stool samples again to monitor the treatment and count
the number of eggs per gram after treatment. To evaluate the effectiveness of the
drugs used against intestinal worm infestation healing rate parameter (AP) or the cure
rate (CR), which was the percentage of patients cured, who showed no helminth eggs
in feces.

RESULTS
Total number of samples obtained was 457 samples. A total of 75 samples or
16.41% of them contain eggs or were positive for intestinal worm infestation. Highest
number of infestation was found in Karang Kedawung 2 elementary school. A total of
37 of 130 stool samples or 28.46% were positive for worm eggs, while the infestation
was at its least of 3.4% in Suco 4 elementary school. Distribution of intestinal worm
infestation in Primary Schools in District Mumbulsari is presented in Table 1.
Number Number of Ascaris Trichuris Percentage
Elementary Hookworm
No of stool positive lumbricoides trichiura (%)
schools infestation
samples infestations infestation infestation
1 ES Lengkong 1 39 7 4 3 0 9.34
2 ES Mumbulsari 1 43 5 5 0 0 6.66
3 ES Mumbulsari 2 46 6 6 0 0 8
4 ES Suco 1 86 6 6 0 0 8
5 ES Suco 4 29 1 1 0 0 1.33
6 ES Lampeji 1 42 7 4 0 3 9.34
ES 49.33
7 Karangkedawung 130 37 23 6 8
2
SD 8
8 Karangkedawung 42 6 4 1 1
3
Jumlah total 457 75 53 10 12 100
Largest infestation of 75 pieces of samples was A. lumbricoides. A total of 53 people
(71%) stools were examined containing Ascaris eggs, followed by Hookworm
infestation as many as 12 people or 16%, and Trichuris trichiura as many as 10
people or 13%.
Treatment with areca seed extract tablet sample number of 40 children, after
treatment there were four children in a positive ascariasis so the numbers of 85.71%
cure and egg reduction rate 94.3%. Pirantel pamoate treatment with the number of
samples of 35 children, after treatment there were two children in a positive
ackariasis, so that 91.60% cure rate and egg reduction rate of 93.1%.
Based on research data obtained, the analysis was performed using non-parametric
statistical test Chi-Square, a significance value of 0.503 is obtained. P value> 0.05
then says that the average cure rate for each drug material is the same or treatment
with areca seed extract tablets are able to heal patient with ascariasis in accordance
with the standard treatment that used such as pirantel pamoate.
To find out the specific differences in follow-up test conducted using Tukey HSD
homogeneous subsets of tables that are useful to assess the dependent variable in the
equation of worms types of factors and Average combinations factor Egg Reduction
Rate as follows:
Tabel 2. T homogeneous subset table to worm types

Subset
Worm type
b a
TT 0,5741
Ascaris 0,9467
Hookworm 1,000

Tabel 3. homogeneous subset table to drug combination and worm

type
combination Subset
 b a
Pirantel-TT 0,2500
Pinang- TT 0,6667 0,6667
Pirantel-Ascaris 0,9417
Pinang-Ascaris 0,9510
Pinang-Hookworm 1,0000
Piarantel- 1,0000
Hookworm

Types of worms in the table shows the average Egg Reduction Rate on
Ascaris and Hookworm are similar and different from the TT. Egg Reduction Rate on
the subset A is greater than the subset b.
The combination Pirantel-Ascaris, Ascaris-Areca, Areca- hookworm, Pirantel-
Hookworm Egg had an indifferent average reduction rate . However, these groups
differ with Pirantel-TT. While the combination of Areca-TT showed similarities with
the second subset. Can be obtained that the average Egg Reduction Rate on the subset
A larger than subset group b.

DISCUSSION
The success of therapy is influenced by many things. One of the most
significant thing of course is the efficacy of the drug. Pirantel pamoate is used in this
study as a control group, the drug of first choice for treatment ascariasis (Elizabeth,
2008). Pirantel pamoate worms cause depolarization of the muscle and increase the
frequency of the impulses, so that the worms die in a state of spastic. Pirantel
pamoate also inhibit the enzyme cholinesterase effect. High cure rate with a single
dose is 10mg/kgBB. In addition, the drug pirantel elected to the majority of intestinal
worm infestation, not only ascariasis, but also ancylostosomiasis, trichuriasis and
enterobiasis. Pirantel pamoate side effects are rare, mild and temporary. The use of
this drug in pregnant women and aged less of two years is not recommended. Its use
should be caution in patients with a history of heart disease because it can increase
the SGOT (Elizabeth, 2008).
Tablet extracts of areca nuts (Areca catechu L.) has proven to be quite
effective as anthelmintic, as evidenced by preliminary tests prior to clinical trials
(Nuri, 2007) and also this study. Areca nuts (Areca catechu L.) contains alkaloids
such as pyridine groups arecolin and arecaidine. Arecolin has the effect of the central
nervous system depression and muscle paralysis caused by binding to acetylcholine
receptors (Jaiswal, 2010). This substance has chemical structure similar to nicotine is
known as acetylcholine receptor agonist muskarinis (Ghelardini, 2001). Nut seed
extract can inhibit the secretion of cholinesterase, evidenced in a trial, found that at
doses of 0.1 to 1 mmol arecolin can inhibit the secretion of cholinesterase-induced
activation of cholinergic receptors. In mediating this effect by inhibiting the calcium
influx without inhibiting the release of calcium of cytoplasm (Lim, 2005).
Acetylcholine receptor agonist properties against intestinal nematode muscle cells, as
in arecolin, have the potential to bind to the muscarinic and nicotinic receptors that
can be used in anti helmintic. Acetylcholine (ACh) is a neurotransmitter /
neuromodulator in the nervous system of nematodes and induces its effects through
interaction with both ligand-gated ion channels (LGICs) and G protein-coupled
receptors (GPCRs). The importance of structure, pharmacology and physiological
LGICs have been fairly described in the model nematode, including parasitic species
where they are targets for anthelmintic drugs (Kimber, 2009).
Another thing that also influence the therapeutic efficacy of which the body's
response to drugs that can vary from one person to another person. This can be
caused by interactions between environmental factors and genetic factors. In relation
to genetic factors, genetic polymorphisms is known term. Genetic polymorphism is a
genetic variation that causes a difference in enzyme activity and capacity in carrying
out its functions. The existence of genetic expression differences between each
individual will be able to give a different response to the fate of the drug in the body.
This we can review the particular aspects of metabolism. Metabolic processes occur
by the help of enzymes. The enzyme is a protein that existence is the result of genetic
expression (protein synthesis). The resulting enzyme capacity of each individual is
different. This is one of the spur of the differences in the body's response to the same
drug. People in a particular race for instance, it has a number of enzymes
premetabolisme more than others due to genetic variation. This leads to the presence
of drugs in the body become shortened (due to enlarged metabolism), so the effect
becomes smaller. Or conversely, other races have mutations in certain genes that
cause the body's reduced ability to metabolize the drug, so the existence of the drug in
the body increases and the effect becomes large or even toxic (Radji, 2005).
Other influencing factor is environmental factors. This includes nutritional
factors, other drugs factors which used together, and lifestyle factors. According to
research conducted by Gunawan (2010), nutritional status at the nut is in a good
nutritional status (83%). Presence of other drugs used together can also interact with
each other resulting in lower or alter the effects of other drugs, so that one's response
to the drug can be different from other people who may not have drug interactions. In
addition, the severity of disease and lifestyle, may affect a person's response to the
drug. Disease that often affects the body's response to drugs is a disease of the liver
and kidneys. This is due to the liver is the place to metabolize the drug, and the
kidney is one of the drug excretion sites of the body, so if there is damage to the
organ, it will affect the body's response to the drug. Other environmental factors are
lifestyle factors. Other environmental factor is poor hygiene in eating or hygiene after
defecation (BAB), causing recurrent ascariasis (Radji, 2005).
Analysis of research data found that administration of areca seed extract
treatment had similarities with standard drug of pirantel pamoate. This was
consistent with the hypothesis that areca seed extract tablets have equal therapeutic
results with pirantel pamoate. While analysis results on types of worm therapy,
subjects showed differences in the average egg reduction rate. This suggests that each
type of worm infestation has certain sensitivity to therapy. Further analysis showed
that the results of specific therapy on the type and Hookworm Ascaris worms were
similar, but both have different types of worms with TT. On the type of worm Ascaris
and Hookworm showed better outcome of therapeutic effectiveness than other types
of worms TT.
Therefore, in cases of intestinal worm infestation by Ascaris and Hookworm
either single or both can use a areca nut and pirantel as an alternative therapy. On
Trichuris trichiura infestation, the use of areca nut provide better therapeutic results
than pirantel pamoate.

CONCLUSION
Areca nut seed extract tablet (Areca catechu L.) have shown antelmintic
activity and is able to heal patient with intestinal worm infection, and is equivalent to
the standard treatment of pirantel pamoate.
Therapy with areca nut gives better egg reduction rate as compares to pirantel
pamoate on worm Trichuris trichiura infestation, while the worm Ascaris and
Hookworm infestation given areca nut and pirantel pamoate therapy showed the same
therapeutic results
It is expected areca nut seed extract tablet (Areca catechu L.) may be one
alternative medicine for intestinal worms infections in the future.

ACKNOWLEDGMENTS
This research was funded from Incentive Grants project for Research and
Technology Ministry of Republic Indonesia (Kemenristek RI) in 2010.

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