Journal of Herbal Medicine 9 (2017) 60–67

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Journal of Herbal Medicine

journal homepage: www.elsevier.com/locate/hermed

Research paper

BG1261 phytodrug improves urinary tract infection treatment with

nitrofurantoin in adult women in a double-blind randomized clinical
trial
M.E. Leteliera,* , F. Hidalgo-Castroa , M. López-Valladaresa , N. Ibacachea , C. Péreza ,
J. Brunnera , J. Gonzáleza , R. Gutmanna , C. Lazo-Henríqueza , C. Gallardo-Garridoa ,
A. Molina-Berríosb , E. Ossandónc
a
Laboratorio de Farmacología y Toxicología, Departamento de Química Farmacológica y Toxicológica, Facultad de Ciencias Químicas y Farmacéuticas,
Universidad de Chile, Santiago, Chile
b
Instituto de Investigación en Ciencias Odontológicas, Facultad de Odontología, Universidad de Chile, Santiago, Chile
c
Hospital Clínico Universidad de Chile, Santiago, Chile

A R T I C L E I N F O A B S T R A C T

Article history:
Received 31 March 2016 Nitrofurantoin (NFT), an antimicrobial drug used for the treatment of uncomplicated lower urinary tract
Received in revised form 27 February 2017 infections, produces gastrointestinal adverse effects that compromise treatment compliance. These
Accepted 6 March 2017 adverse effects are related to oxidative stress generated by the enzymatic reduction of NFT.
Available online 7 March 2017 Objectives: Evaluate the effect of Buddleja globosa Hope standardized extract (BG1261) exhibiting a high
content of antioxidant molecules, upon gastrointestinal adverse effects exerted by NFT.
Keywords: Design of study: Placebo-controlled, double-blind, randomized-trial at the Hospital Clínico Universidad de
Urinary tract infections Chile, between April and October 2011.
Herbal extract
Subjects: Non-pregnant women, aged between 18 and 80 years old, diagnosed with urinary tract infection
Antimicrobial drugs
sensitive to NFT.
Nitrofurantoin
Buddleja globosa Hope Methods: 56 patients were randomized to receive NFT + BG1261 (n = 28) or NFT + placebo (n = 28) for 10
days. Every 2 days, patients answered a survey to assess occurrence of adverse reactions. The authors
analyzed ferric reducing ability of plasma, plasma malondialdehyde and complete blood count to
evaluate homeostasis changes due to treatments and urine samples for treatment efficacy.
Results: At the 10th day of treatment, patients receiving BG1261 had a 47% reduction of nausea
occurrence (90% CI; p < 0.001) compared to NFT + placebo group. Abdominal pain frequency decreased
from the start until the end of the treatment with a mean reduction of 38% (90% CI; 30,9%–44.6%). At the
end of treatment 19% of NFT + placebo group presented a positive uroculture, in contrast with BG1261
group in which all were negative. Complete blood count and clinical chemistry showed no difference
between groups.
Conclusion: BG1261 associated to NFT reduced adverse effects, improving the quality of patient’s life
during treatment.
© 2017 Elsevier GmbH. All rights reserved.

1. Introduction

Abbreviations: NFT, nitrofurantoin; BG1261, Buddleja globosa Hope (matico)
standardized extract; UTI, urinary tract infections; HCUCH, Hospital Clínico de la
Universidad de Chile; GSH, glutathione; ROS, reactive oxygen species; CFU, colony-
forming unit; CBC, complete blood count; FRAP, ferric reducing ability of plasma;
MDA, malondyaldehyde.
* Corresponding author.
E-mail address: mel@ciq.uchile.cl (M.E. Letelier).
Nitrofurantoin (N-(5-nitro-2-furfurylidene)-1-aminohydan-
toin) is an antimicrobial drug used in the treatment and
prophylaxis of uncomplicated lower urinary tract infections (UTIs)
(Gleckman et al., 1979; McOsker and Fitzpatrick, 1994; Valdevenito
S, 2008). The mechanism of action of nitrofurantoin (NFT) is poorly
understood, but is believed to act by inhibiting various enzymatic
mechanisms involved in the bacterial protein synthesis (McOsker
and Fitzpatrick, 1994). The UTI is presented with a high frequency
in women, with an incidence between 10 and 15% annually (Guay,

http://dx.doi.org/10.1016/j.hermed.2017.03.001
2210-8033/© 2017 Elsevier GmbH. All rights reserved.
 M.E. Letelier et al. / Journal of Herbal Medicine 9 (2017) 60–67
2008). In Chile, it is postulated that 40% to 50% of the female
population suffer lower urinary tract infection at least once in their
life (Cortés et al., 2007). These infections represent a public health
problem mainly due to two reasons: antibiotic resistance and
recurrence (Cortés et al., 2007; Guay, 2008). Most UTIs are caused
by Escherichia coli (70–95%) and the remaining percentage is
caused by Proteus mirabilis, klebsiella spp. and Staphylococcus
saprophyticus (Guay, 2008; Salvatore et al., 2011). The incidence of
UTIs in women increases with age due to disorders associated with
aging, such as decreased cellular immunity, alteration of the
defenses of the bladder due to obstructive uropathy, neurogenic
dysfunction of the bladder and the increase receptivity of
uroepithelial cells to bacteria (Richards, 2004). Moreover, in
healthy postmenopausal women, the reduced levels of estrogenic
hormones appear to contribute to the occurrence of recurrent UTI.
This phenomena can be explained by the changes in the urogenital
tract provoked by estrogen deficiency (Salvatore et al., 2011).
Therefore, UTIs also have high significance in the field of geriatric
Public Health.
Recurrence of UTIs in women in Chile (30%) also affects
public health, reaching 53% in women over 55 years (Valdevenito
S, 2008). This recurrence is caused among other factors, by re-
infection or by a persistent focus of infection (relapse), and is
believed to be due not only to the resistance of certain bacterial
strains to antibiotics but also to increased capacity of the bacteria
to adhere to uroepithelial cells (Bryce et al., 2016; Hooton, 2001;
Salvatore et al., 2011). While resistance increases for cotrimox-
azole, amoxicillin and ampicillin, one of the few antimicrobial
drugs that retains its antibacterial effectiveness in patients that
suffer uncomplicated UTIs is NFT (Cortés et al., 2007). In this
respect, prophylactic prescribing is common, which involves the
administration of antibacterial drugs in low doses to prevent
events of re-infection. Prophylactic treatment with NFT has
proved to be more effective than those achieved with cotrimox-
azole, amoxicillin and ampicillin (Hooton, 2001; Salvatore et al.,
2011). NFT displays a high bioavailability at the urinary tract and a
low frequency of development of resistance by pathogenic
bacteria (Cortés et al., 2007). Unfortunately, NFT treatment is
also associated to several gastrointestinal adverse reactions, such
as nausea, vomiting, abdominal pain, and diarrhea, effects that
appear even within the first 24 h of treatment and are especially
frequent with the microcrystal formulation of the drug (Karpman
and Kurzrock, 2004). Consequently, the treatment adherence of
patients decreases, increasing the probability of infection
recurrence and generation of resistance. On the other hand, its
prolonged use has been associated with respiratory dysfunction
(Bialas et al., 1997; Goemaere et al., 2008 Witten, 1989), liver
damage (Paiva et al., 1992; Penn and Griffin, 1982), peripheral
polyneuropathy (Jacknowitz et al., 1977) and hematological
disorders (Gait, 1990). With the purpose of reducing the
gastrointestinal adverse reactions, NFT has been formulated as
macrocrystal coated capsules, which improve absorption rates
and blood peak levels, but its market value is significantly higher
than monohydrate NFT and represents an important drug access
barrier to public health system (Brumfitt and Hamilton-Miller,
1998).
In humans, pulmonary and hepatic toxicity have been
attributed to the reactive intermediates generated by nitro-
reduction of NFT (Martin, 1983a,b; Minchin et al., 1986; Rossi
et al., 1988; Viodé et al., 1999). In virtue of their nitro group, these
drugs can be metabolized by mammalian one-electron reductases
generating a nitroanion radical intermediate ( NO2 ) (Olea-
Azar et al., 2003). This nitroanion can react, in a futile cycle, with
molecular oxygen producing superoxide anion (O2 ) and regen-
erating the nitro-drug (Bartel et al., 2009; Fernandez Villamil et al.,
1990; Moreno et al., 1984; Sreider et al., 1990). In contrast to
61
mammalian cells, two-electron reductases occur in bacteria and
parasites. These enzymes can catalyze the reduction of the nitro
group present in nitrofuran ring to nitrous derivative and then to
hydroxylamine (Boiani et al., 2010; Hall et al., 2011; Squella et al.,
1996; Symons et al., 1991). The latter is an electrophilic compound
that can bind to glutathione (GSH) and to other thiolic
biomolecules, altering their function. This phenomenon has been
proposed as the mechanism of antibacterial action of NFT
(McOsker and Fitzpatrick, 1994). GSH is the most abundant
non-enzymatic antioxidant agent of animal cells. When GSH form
covalent adducts with electrophilic molecules such as the
hydroxylamine derived of NFT reduction, a decrease of cellular
antioxidant capacity occurs. Then, it is possible that an agent
with antioxidant properties might mitigate or alleviate the
adverse reactions of NFT without compromising its antibacterial
activity.
Antioxidant capacity of various natural preparations is widely
recognized, especially those rich in polyphenols (Bors and Michel,
2002; Fraga, 2007). Their use in pathologies associated with
oxidative stress may be significantly beneficial (Gurib-Fakim,
2006; Masella et al., 2005; Middleton et al., 2000; Newman and
Cragg, 2007). Therefore, co-administration of NFT with a phyto-
drug rich in polyphenols might mitigate or alleviate the adverse
reactions of this drug. Buddleja globosa Hope (matico) is a Chilean
native plant largely used as a wound-healing and anti-inflamma-
tory agent in traditional medicine (Backhouse et al., 2008;
Houghton, 1984). In addition, extracts from matico leaves display
antioxidant properties (Backhouse et al., 2008; Vogel et al., 2011).
Thus, in this study we proposed that BG1261, a phytodrug
developed from matico leaves, alleviates the gastrointestinal
adverse reactions associated with oral administration of NFT. To
test this postulataion, a standardized hydroalcoholic extract from
matico leaves, with previously tested antioxidant activity, was
selected for this clinical study (Letelier et al., 2008). The authors
have recently formulated a phytodrug, BG1261 (name registered at
the Chilean Ministry of Economy) from this standardized matico
extract, which shows a wide safety profile when orally adminis-
tered to rats in acute toxicity studies (Letelier et al., 2012).
The authors postulate that NFT consumption decrease the
antioxidant capacity of patients. Co-administration of this drug
with BG1261 could avoid this phenomenon, with a consequent
reduction of the gastrointestinal adverse reactions associated to
NFT treatment. Results are discussed from the pharmacokinetic
and toxicological point of view.
2. Methods
2.1. Drugs
Capsules containing BG1261 or excipient were provided by
Laboratorios Ximena Polanco (Santiago, Chile). BG1261 consists of
a hydroalcoholic extract of the leaves of Buddleja globosa Hope
standardized to its polyphenolic content expressed in mg catechin
by mg extract. The standardized dry extract is obtained by
dehydrating the liquid extract with maltodextrin by spraying and
then the dry extract is quantified giving rise to the raw material of
the capsules, without any other additive. Each capsule contains an
amount of extract equivalent to 9 mg of total polyphenols
(expressed as mg catechin by mg extract) and maltodextrin to
complete 256 mg per capsule. Placebo capsules contain 256 mg of
maltodextrin. Formulation and manufacturing of BG1261 soft
capsules corresponds to proprietary information of the company
(Supplementary online data). Placebo capsules contained only
maltodextrin. Capsules containing either BG1261 or Placebo, as
well as the packages containing them were identical in design and
shape.
62 M.E. Letelier et al. / Journal of Herbal Medicine 9 (2017) 60–67
Nitrofurantoin tablets (100 mg) were acquired from Mintlab
Laboratories (Santiago, Chile).
2.2. Trial design
This was a phase III single center, double-blind, randomized
controlled parallel group study, comparing oral NFT + BG1261 with
NFT + placebo in patients diagnosed with uncomplicated lower
UTI. The trial was conducted at Hospital Clínico Universidad de
Chile (HCUCH), Chile, between April and October 2011. All patients
provided written informed consent; ethical approval was obtained
from Ethical Committee from HCUCH (identification number OAIC
N 377/09) and conducted in accordance with the Declaration of
Helsinki.
2.3. Inclusion and exclusion criteria
Women between 18 and 80 years of age requiring treatment
due to UTI that attend the Urology Department of HCUCH Santiago,
Chile. Patients with positive urocultures (over 100,000 CFU)
sensitive to NFT after an orientation session and mandatory signing
of an informed consent were recruited. Exclusion criteria included
being a smoker, pregnancy or participation of an ongoing clinical
trial. The clinical trial was supervised by an urologist of the HCUCH,
who also enrolled participants. Patient care and orientation was
performed by a team of health professionals, including a registered
nurse and a pharmacist. Protocol was approved by the IRB
(Institutional Review Board or Ethics Committee) at the same
Institution (Approval 377/09).
2.4. Treatment scheme and randomization
Recruited patients were simply randomly distributed to NFT +
Placebo or NFT + BG1261. Patients of both groups received a
complete 10-day generic NFT (microcrystals) treatment, with
100 mg tablets to be taken every 12 h (200 mg per day) associated
to placebo (capsules containing 256 mg of maltodextrin) or
BG1261 (each capsule contains an amount of extract equivalent
to 9 mg of total polyphenols and maltodextrin to complete 256 mg
per capsule). Randomization was performed by an independent
accountant using a simple randomization sequence in Excel 2007
(Microsoft, Redmond, WA, USA). The treatments were stored in
numbered opaque sealed bags to achieve allocation concealment.
In addition, both treatments (BG1261 and placebo) were
contained in identical plastic white containers. Treatments were
dispensed to patients by the assistant nurse at the urology
department of HCUCH who was blinded to the intervention and
allocation as were the rest of the study team (study investigators,
research coordinators, attending care teams) (Consort Flow
Diagram Fig. 1).
2.5. Samples
At the beginning and the end of their treatments, blood and
urine samples were obtained from each patient. Initial and final
urocultures were used to confirm the UTI and to evaluate the
efficacy of the NFT treatment, respectively. Blood samples were
used to evaluate plasma oxidative stress, assessed as Ferric
reducing ability of plasma (FRAP), Plasma malondialdehyde
(MDA) and for Complete Blood Count and clinical chemistry
analysis as outlined. Data in this study correspond to patients that
fully completed the treatment and provided all samples required.
2.5.1. Complete blood count (CBC)
CBC parameters were analyzed at the Central Laboratory of
HCUCH. These parameters included red blood cell count,
hematocrit, total hemoglobin, mean corpuscular volume (MCV),
mean corpuscular hemoglobin (MCH), mean corpuscular hemo-
globin concentration (MCHC), hem sedimentation rate (HSR),
white cell count, leucocyte distribution (lymphocytes, monocytes,
neutrophils, and eosinophils), and platelet count.
2.5.2. Clinical chemistry analysis
Clinical chemistry parameters were analyzed at the Central
Laboratory of HCUCH. These parameters included calcium,
phosphorus, glucose, blood ureic nitrogen, cholesterol, total
protein, albumin, total bilirubin, alkaline phosphatase (AP), lactic
dehydrogenase (LDH), and oxaloacetic transaminase (GOT).
2.5.3. Ferric reducing ability of plasma (FRAP)
Ability of plasma to reduce Fe3+ to Fe2+ is an indicator of the
antioxidant state of this extracellular fluid. Blood samples at the
beginning and end of the treatment were employed to determine
FRAP, according to the method of Benzie and Strain (Benzie and
Strain, 1996), using a Fe2+ solution as a standard.
2.5.4. Plasma malondialdehyde (MDA)
MDA is a product of lipid peroxidation and its plasma level is an
indicator of the oxidative status of plasma. Blood samples at the
beginning and end of treatment were used to determine MDA
plasma levels by derivatization with thiobarbituric acid in
deproteinized plasma, employing HPLC as previously described
(Buege and Aust, 1978).
2.6. Study endpoints
2.6.1. Primary outcome
Once treatment started, a pharmacist monitored the patients by
telephone every day, as well as four days after successfully
finishing the treatment. The aim of this discussion was to report
the presence, frequency and intensity of any gastrointestinal
adverse reactions. Those were: nausea, abdominal pain, diarrhea,
epigastralgy and vomiting. Intensity of each adverse reaction was
evaluated with a subjective scale and depending on its interference
with daily activities were classified as follows: i) “None”: absolute
absence of adverse reaction; ii) “Mild”: adverse reaction recorded,
but without compromising daily activities; iii) “Moderate”:
adverse reaction that limits the ability to perform daily activities
or iv) “Severe”: adverse reaction that prevented daily activities.
Patients who presented with adverse reactions were evaluated by
the entire clinical team: in any case if adverse reactions were
reported, patients were excluded from the clinical trial.
2.6.2. Secondary outcome
Through clinical chemistry analyses and CBC we wanted to
prove that BG126 does not modify the human metabolism. FRAP,
MDA and LDH levels were used to quantify the antioxidant state of
the extracellular space, the oxidative status of plasma and the cell
damage, respectively.
2.6.3. Statistical analysis
Each parameter of CBC, clinical chemistry analysis and redox
state of plasma is presented as the 95% confidence interval (95%CI).
Differences between intervals were analyzed through Wilcoxon
paired tests (intervals from each group over time). For this analysis,
differences were considered statistical significant when p < 0.05.
Adverse drug reactions were evaluated with Chi-squared test. Due
to the small sample size, we establish statistical significance at
p < 0.1 in order to observe differences between groups. Sample size
calculation: according to clinical staff experience we assumed a
50% proportion for placebo group and an 80% reduction in the
frequency of adverse drug reactions with BG1261. The last
 M.E. Letelier et al. / Journal of Herbal Medicine 9 (2017) 60–67
Fig. 1. Consort Flow Chart. Inclusion and exclusion criteria, treatment scheme and randomization are indicated in methods.
assumption was based on previous pilot studies in animals
(unpublished results), with a level of confidence of 95% and
statistical power of 90%.
3. Results and discussion
3.1. Characterization of patient groups
A total of fifty-six patients were recruited, distributed into two
groups of twenty-eight patients each, receiving either placebo or
BG1261 capsules in addition to a 10-day NFT treatment course
(200 mg/day). Out of this total, six patients from the group treated
with NFT + placebo and three patients from the group treated with
NFT+ BG1261 were excluded from the study due to experiencing
severe adverse reactions. Prior to making this decision, each case
was re-evaluated by the entire clinical team. The difference in
the number of patients that suffered from several adverse drug
reactions suggests that BG1261 is likely to be effective in
minimizing the apparition of severe gastrointestinal adverse drug
63
reactions during the NFT treatment. However, the number of
patients is insufficient to establish the statistical significance of
that event.
The remaining forty-seven patients were included in the final
analysis, out of which twenty-two received NFT + placebo capsules
and twenty-five, NFT + BG1261. Age distribution of patients was
very similar between groups (Fig. 2), showing that the double blind
randomization method employed most likely avoided biasing
patient selection. More than 50% of the patients included were
between 56 and 80 years of age, consistent with the reported
increase of UTI incidence in women over 55 years-old (Richards,
2004; Valdevenito S, 2008).
3.2. Effects on the occurrence and severity of gastrointestinal adverse
reactions associated to NFT
As described in the methods, patients were surveyed every day
from the start of treatment as well as four days after finishing the
treatment. Surveys were designed to evaluate the experience and
64 M.E. Letelier et al. / Journal of Herbal Medicine 9 (2017) 60–67

Fig. 2. Age distribution of placebo and experimental groups. Histograms are depicted for the placebo (white) or experimental BG1261 (gray) groups included in the study.

persistence of any gastrointestinal adverse reactions (see Material
and Methods). In addition, patients were asked to classify the
intensity of the adverse reactions when present. Since the patients
that suffered severe adverse reactions were excluded from the
clinical trial, the data presented corresponds to the number of
patients in each group that exhibited absence or presence (as mild
or moderate) of adverse effects.
a) Abdominal pain Patients receiving NFT + placebo exhibited
higher frequency of abdominal pain compared to those patients
receiving NFT + BG1261 (upper panel in Fig. 3). The co-
administration of BG1261 was able to significantly decrease
the occurrence of abdominal pain (adverse reaction reduction
between 23% and 55%), that was observable through the entire
course of NFT treatment (upper panel in Fig. 3 and Table 1).
Moreover, four days after finishing the treatment, patients in
the NFT + placebo group still presented with this adverse
reaction, while in the NFT + BG1261 group none of the patients
complained of abdominal pain (p < 0.05) (upper panel in Fig. 3
and Table 1). On the other hand, severity of abdominal pain was
evidently lower in the NFT + BG1261 group, since the patients
complained only of “mild” abdominal pain, contrary to that
observed in the NFT + placebo group (Table 1). However, these
differences in severity were not statistically significant.

Fig. 3. Abdominal pain and nausea occurrence during nitrofurantoin treatment in presence or absence of BG1261. Bars represent the percentage of patients in each group
that exhibited abdominal pain (upper panel) or nausea (lower panel). 14# corresponds to 4 days after finishing the10-day course treatment. *p < 0.05; **p < 0.01; ***p < 0.001;
****p < 0.0001: Statistical values relating differences between nitrofurantoin + BG1261 and nitrofurantoin + placebo groups.
 M.E. Letelier et al. / Journal of Herbal Medicine 9 (2017) 60–67 65

Table 1
Contingency analysis: abdominal pain.

Day of treatment NFT + Placebo NFT + BG1261 p value

Abs Mild Mod % patients with ADR Abs Mild Mod % patients With ADR
2 13 7 2 40.9 22 3 0 12.0 0.023
4 13 7 2 40.9 22 3 0 12.0 0.023
6 7 14 1 68.2 22 3 0 12.0 <0.0001
8 11 9 2 50.0 21 4 0 16.0 0.013
10 12 8 2 45.5 24 1 0 4.0 0.0008
14# 17 5 0 22.7 25 0 0 0.0 0.012

Data correspond to the number of patients in each group with absence (Abs) or presence of abdominal pain classified as mild or moderate (Mod) during that particular day. 14#
corresponds to 4 days after finishing the 10-day course treatment. p values were obtained through Chi-square test comparing the percentage of patients (% patients) that
suffered abdominal pain in each group. ADR: adverse drug reaction.

Table 2
Contingency analysis: nausea.

Day of treatment NFT + Placebo NFT + BG1261 p value

Abs Mild Mod % patients Abs Mild Mod % patients

2 11 9 2 50.5 15 8 2 40.0 0.491
4 10 10 2 54.4 18 5 2 28.8 0.064
6 9 11 2 59.1 19 6 0 24.0 0.215
8 9 9 4 59.2 20 5 0 20.0 0.118
10 13 7 2 40.9 22 3 0 12.0 <0.001
14# 19 2 1 13.6 25 0 0 0.0 <0.0001

Data correspond to the number of patients in each group with absence (Abs) or presence of nausea classified as mild or moderate (Mod) during that particular day. 14#
corresponds to 4 days after finishing the 10-day course treatment. p values were obtained through Chi-square test comparing the percentage of patients (% patients) that
suffered abdominal pain in each group.

b) Nausea: The occurrence of nausea followed a pattern similar to manner to evaluate changes in the homeostasis of patients due to
that of abdominal pain. However, the percentage of nausea NFT and/or NFT and BG1261. As summarized in Supplementary
decrease in the NFT + BG1261 group was only statistically Tables 1 and 2, none of the evaluated parameters was
significant at days 10th and 14th with a reduction of 29% significantly changed due to the NFT treatment, or NFT + BG1261.
and 14% respectively, when compared with percentage of These data indicate that NFT treatment, regardless of the
nausea in the NFT + placebo group (lower panel in Fig. 3 and addition of BG1261, generates no alteration of the clinical
Table 2). Patients receiving NFT + placebo also exhibited higher parameters evaluated. Taken together, this data indicates that the
severity of nausea than those receiving BG1261, but again this dose of NFT administered (200 mg/day), was low enough to elicit
observation was not statistically significant when compared to no detectable toxicity at the level of hemogram or clinical
severity of nausea in NFT + BG1261 group (Table 2). chemistry parameters, while maintaining its antimicrobial
c) Diarrhea: Remarkably, patients receiving NFT + BG1261 were effectiveness.
completely free of diarrhea during the entire treatment course. The authors recorded the efficacy of the NFT treatment. All
In contrast, patients receiving NFT + placebo exhibited diarrhea, recruited patients showed positive urocultures at the beginning of
even in a moderate degree towards the end of the treatment, their treatment, with over 100,000 CFU (inclusion criteria).
although these differences were not statistically different (data Escherichia coli represented 94% of all pathogens identified in
not shown). initial urocultures, while the remaining 6% corresponded to other
d) Epigastralgy and vomitting: Both adverse effects were infre- bacterial species, consistent with the reported pathogens associ-
quent among the patients in both groups. Occurrence of these ated to UTI (Guay, 2008). At the end of the treatments, 19% of
adverse effects showed no significant differences between patients receiving placebo capsules exhibited positive urocultures
groups (data not shown). with E. coli being identified in all samples. Remarkably, all final
urocultures from patients receiving NFT + capsules of BG1261
were negative (data not shown). These data indicate that
3.2.1. Effects on the plasma redox state association of NFT with capsules of BG1261 could improve
At the beginning and end of the treatments, blood samples
were drawn to determine FRAP and MDA plasma levels. As
depicted in Table 3, none of these parameters was significantly Table 3
Plasma redox state parameters.
altered following treatments. Noteworthy, NFT treatment alone
produced no significant decrease in FRAP or increase in plasma Parameter NFT + Placebo NFT + BG1261
MDA levels as it would be to expected under systemic oxidative Initial Final p value Initial Final p value
stress conditions.
MDA (mM) 0.39–0.62 0.44–0.68 0.2989 0.54–0.78 0.49–0.72 0.4352
FRAP (mM) 253–299 227–278 0.0914 253–298 264–307 0.6668
3.2.2. Effects on hemogram (CBC) and clinical chemistry analysis Ranges for each group correspond to 95% Confidence of Interval (95% CI). FRAP:
At the beginning and end of each treatment, blood samples ferric reducing ability of plasma, MDA: malondialdehyde. p values were obtained
were drawn to evaluate CBC and clinical chemistry analysis as a with Wilcoxon paired tests.
66 M.E. Letelier et al. / Journal of Herbal Medicine 9 (2017) 60–67
antimicrobial effectiveness of this drug. New experiments are in
process to probe this hypothesis
3.2.3. UTI treatment-associated adverse events
Three patients from NFT + BG1261 and six from NFT + placebo
group experienced severe abdominal pain, which resulted in
their withdrawal from the study. The nine patients received
alternative antimicrobial therapy to treat their UTI according to
HCUCH protocols. These adverse events were potentially related
to NFT.
3.3. Limitations and generalizability
Although the number of patients recruited for this study was
adequate to observe important differences on occurrence of
abdominal pain and nausea, a study with a larger group of
patients would permit to establish if BG1261 could alleviate other
adverse drug reactions related to NFT like diarrhea or epigastralgy.
On the other hand, the occurrence of adverse reactions was
recorded by a phone interview with the pharmacist through a
qualitative scale. This adds limitations to the interpretation of
symptoms and hence to results. On the other hand, intention to
treat (ITT) analysis was not performed in our study, so interpreta-
tion of our results is limited to patients suffering only non-severe
adverse drug reactions.
3.4. Discussion
Our data suggest that BG1261 exerts a local action on the
gastrointestinal tract that would prevent the probable pro-
inflammatory and oxidative reactions induced by NFT. These
observations are consistent with both antioxidant and anti-
inflammatory actions attributed to extracts from B. globosa leaves
(Backhouse et al., 2008; Vogel et al., 2011, 2010). Co-administration
of BG1261 and NFT not only decreased the frequency and severity
of most gastrointestinal adverse reactions associated to NFT, but
also seems to enhanced NFT antimicrobial action, while displaying
a safe outcome in terms of CBC, clinical chemistry analysis and
plasma redox state parameters.
During the study, nine patients suffered severe adverse events
and therefore had to be withdrawn from the study since their
therapy had to be modified. This confirms the need to relieve the
adverse effects of NFT, one of the antimicrobial drugs currently
having the broadest spectrum against bacteria causing UTIs
(Salvatore et al., 2011). Moreover, the reduction of recurrences
improves the quality of life of the patients with the consequent
economic benefit to them.
The authors therefore conclude that combination of NFT with
BG1261 is a safe intervention that maintains and may improve the
antimicrobial action of NFT and exhibit beneficial outcomes for the
quality of life of patients. This antimicrobial strategy is relevant for
patients because NFT is a drug selected as the first choice for the
treatment of UTI in Chile. Based on the results, administration
of B. globosa extracts to relieve the adverse effects of NFT could be a
worldwide recommendation especially in those countries where
NFT is a first line drug against UTIs.
Funding
This work was sponsored by Laboratorios Ximena Polanco1 and
FONDECYT Grant (11090150).
Conflict of interest statement
All authors have no conflict of interest to declare.
Acknowledgments
Special thanks to Mrs. Tamara Torres, registered nurse who was
in charge of samples obtaining and manipulation; and to Ximena
Polanco who graciously provided BG1261 and placebos.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.
hermed.2017.03.001.
References
Backhouse, N., Rosales, L., Apablaza, C., Goïty, L., Erazo, S., Negrete, R., Theodoluz, C.,
Rodríguez, J., Delporte, C., 2008. Analgesic, anti-inflammatory and antioxidant
properties of Buddleja globosa, Buddlejaceae. J. Ethnopharmacol. 116, 263–269.
doi:http://dx.doi.org/10.1016/j.jep.2007.11.025.
Bartel, L.C., Montalto de Mecca, M., Castro, J.A., 2009. Nitroreductive metabolic
activation of some carcinogenic nitro heterocyclic food contaminants in rat
mammary tissue cellular fractions. Food Chem. Toxicol. 47, 140–144. doi:http://
dx.doi.org/10.1016/j.fct.2008.09.069.
Benzie, I.F.F., Strain, J.J., 1996. The ferric reducing ability of plasma (FRAP) as a
measure of antioxidant power: the FRAP assay. Anal. Biochem. 239, 70–76. doi:
http://dx.doi.org/10.1006/abio.1996.0292.
Bialas, M.C., Shetty, H.G., Houghton, J., Woods, F., Routledge, P.A., 1997.
Nitrofurantoin rechallenge and recurrent toxicity. Postgrad. Med. J. 73, 519–520.
Boiani, M., Piacenza, L., Hernández, P., Boiani, L., Cerecetto, H., González, M.,
Denicola, A., 2010. Mode of action of nifurtimox and N-oxide-containing
heterocycles against Trypanosoma cruzi: is oxidative stress involved? Biochem.
Pharmacol. 79, 1736–1745. doi:http://dx.doi.org/10.1016/j.bcp.2010.02.009.
Bors, W., Michel, C., 2002. Chemistry of the antioxidant effect of polyphenols. Ann.
N. Y. Acad. Sci. 957, 57–69. doi:http://dx.doi.org/10.1111/j.1749-6632.2002.
tb02905.x.
Brumfitt, W., Hamilton-Miller, J.M., 1998. Efficacy and safety profile of long-term
nitrofurantoin in urinary infections: 18 years’ experience. J. Antimicrob.
Chemother. 42, 363–371. doi:http://dx.doi.org/10.1093/jac/42.3.363.
Bryce, A., Hay, A.D., Lane, I.F., Thornton, H.V., Wootton, M., Costelloe, C., 2016. Global
prevalence of antibiotic resistance in paediatric urinary tract infections caused
by Escherichia coli and association with routine use of antibiotics in primary
care: systematic review and meta-analysis. BMJ 352, i939. doi:http://dx.doi.org/
10.1136/bmj.i939.
Buege, J.A., Aust, S.D., 1978. Microsomal lipid peroxidation. Methods Enzymol. 52,
302–310. doi:http://dx.doi.org/10.1016/S0076-6879(78)52032-6.
Cortés, M., Salazar, A., Acuna, J., Armijo, G., Orellana, N., López de Santa María, J.,
Berner, R., Estrugo, A., Riffo, C., Moraga, V., 2007. Change in E. coli antibiotic
therapy resistance in female urinary tract infections in the last 10 years. Rev.
Chil Urol. 72, 289–291.
Fernandez Villamil, S.H., Dubin, M., Brusa, M.A., Duran, R.P., Perissinotti, L.J.,
Stoppani, A.O., 1990. Generation of radical anions of nifurtimox and related
nitrofuran compounds by ascorbate. Free Radic. Res. Commun. 10, 351–360.
Fraga, C.G., 2007. Plant polyphenols: how to translate their in vitro antioxidant
actions to in vivo conditions. IUBMB Life 59, 308–315. doi:http://dx.doi.org/
10.1080/15216540701230529.
Gait, J.E., 1990. Hemolytic reactions to nitrofurantoin in patients with glucose-6-
phosphate dehydrogenase deficiency: theory and practice. DICP 24, 1210–1213.
Gleckman, R., Alvarez, S., Joubert, D.W., 1979. Drug therapy reviews: nitrofurantoin.
Am. J. Hosp. Pharm. 36, 342–351.
Goemaere, N.N.T., Grijm, K., van Hal, P.T.W., den Bakker, M.A., 2008. Nitrofurantoin-
induced pulmonary fibrosis: a case report. J. Med. Case Rep. 2, 169. doi:http://dx.
doi.org/10.1186/1752-1947-2-169.
Guay, D.R.P., 2008. Contemporary management of uncomplicated urinary tract
infections. Drugs 68, 1169–1205. doi:http://dx.doi.org/10.2165/00003495-
200868090-00002.
Gurib-Fakim, A., 2006. Medicinal plants: traditions of yesterday and drugs of
tomorrow. Mol. Aspects Med. 27, 1–93. doi:http://dx.doi.org/10.1016/j.
mam.2005.07.008.
Hall, B.S., Bot, C., Wilkinson, S.R., 2011. Nifurtimox activation by trypanosomal type I
nitroreductases generates cytotoxic nitrile metabolites. J. Biol. Chem. 286,
13088–13095. doi:http://dx.doi.org/10.1074/jbc.M111.230847.
Hooton, T.M., 2001. Recurrent urinary tract infection in women. Int. J. Antimicrob.
Agents 17, 259–268. doi:http://dx.doi.org/10.1016/S0924-8579(00)00350-2.
Houghton, P.J., 1984. Ethnopharmacology of some Buddleja species. J.
Ethnopharmacol. 11, 293–308. doi:http://dx.doi.org/10.1016/0378-8741(84)
90075-8.
Jacknowitz, A.I., Le Frock, J.L., Prince, R.A., 1977. Nitrofurantoin polyneuropathy:
report of two cases. Am. J. Hosp. Pharm. 34, 759–762.
Karpman, E., Kurzrock, E.A., 2004. Adverse reactions of nitrofurantoin,
trimethoprim and sulfamethoxazole in children. J. Urol. 172, 448–453. doi:
http://dx.doi.org/10.1097/01.ju.0000130653.74548. d6.
Letelier, M.E., Molina-Berríos, A., Cortés-Troncoso, J., Jara-Sandoval, J., Holst, M.,
Palma, K., Montoya, M., Miranda, D., González-Lira, V., 2008. DPPH and oxygen
 M.E. Letelier et al. / Journal of Herbal Medicine 9 (2017) 60–67
free radicals as pro-oxidant of biomolecules. Toxicol. In Vitro 22, 279–286. doi:
http://dx.doi.org/10.1016/j.tiv.2007.08.002.
Letelier, M.E., Jones, R., López, C., Palma, K., Aracena, P., Polanco, X., Vogel, H., 2012.
Safety profile and wound healing properties of a standardized Buddleja globosa
Hope (matico) extract in Sprague Dawley rats. Rev. Soc. Farmacol. Chile 5, 13–19.
Martin, W.J., 1983a. Nitrofurantoin. Potential direct and indirect mechanisms of lung
injury. Chest 83, 51S–52S.
Martin, W.J., 1983b. Nitrofurantoin: evidence for the oxidant injury of lung
parenchymal cells. Am. Rev. Respir. Dis. 127, 482–486. doi:http://dx.doi.org/
10.1164/arrd.1983.127.4.482.
Masella, R., Di Benedetto, R., Varì, R., Filesi, C., Giovannini, C., 2005. Novel
mechanisms of natural antioxidant compounds in biological systems:
involvement of glutathione and glutathione-related enzymes. J. Nutr. Biochem.
16, 577–586. doi:http://dx.doi.org/10.1016/j.jnutbio.2005.05.013.
McOsker, C., Fitzpatrick, P., 1994. Nitrofurantoin: mechanism of action and
implications for resistance development in common uropathogens. J.
Antimicrob. Chemother. 33 (Suppl. A (23)), 23–30. doi:http://dx.doi.org/
10.1093/jac/33.
Middleton, E., Kandaswami, C., Theoharides, T.C., 2000. The effects of plant
flavonoids on mammalian cells: implications for inflammation, heart disease,
and cancer. Pharmacol. Rev. 52, 673–751.
Minchin, R.F., Ho, P.C., Boyd, M.R., 1986. Reductive metabolism of nitrofurantoin by
rat lung and liver in vitro. Biochem. Pharmacol. 35, 575–580. doi:http://dx.doi.
org/10.1016/0006-2952(86)90350-3.
Moreno, S.N., Mason, R.P., Docampo, R., 1984. Reduction of nifurtimox and
nitrofurantoin to free radical metabolites by rat liver mitochondria. Evidence of
an outer membrane-located nitroreductase. J. Biol. Chem. 259, 6298–6305.
Newman, D.J., Cragg, G.M., 2007. Natural products as sources of new drugs over the
last 25 years. J. Nat. Prod. 70, 461–477. doi:http://dx.doi.org/10.1021/
np068054v.
Olea-Azar, C., Rigol, C., Mendizabal, F., Morello, A., Diego Maya, J., Moncada, C.,
Cabrera, E., di Maio, R., González, M., Cerecetto, H., 2003. ESR spin trapping
studies of free radicals generated from nitrofuran derivative analogues of
nifurtimox by electrochemical and Trypanosoma cruzi reduction. Free Radic.
Res. 37, 993–1001. doi:http://dx.doi.org/10.1080/10715760310001598141.
Paiva, L.A., Wright, P.J., Koff, R.S., 1992. Long-term hepatic memory for
hypersensitivity to nitrofurantoin. Am. J. Gastroenterol. 87, 891–893. doi:http://
dx.doi.org/10.1111/j.1572-0241.1992. tb02896.x.
67
Penn, R.G., Griffin, J.P., 1982. Adverse reactions to nitrofurantoin in the United
Kingdom, Sweden, and Holland. Br. Med. J. (Clin. Res. Ed.) 284, 1440–1442.
Richards, C.L., 2004. Urinary tract infections in the frail elderly: issues for diagnosis,
treatment and prevention. Int. Urol. Nephrol. 36, 457–463.
Rossi, L., Silva, J.M., McGirr, L.G., O’Brien, P.J., 1988. Nitrofurantoin-mediated
oxidative stress cytotoxicity in isolated rat hepatocytes. Biochem. Pharmacol.
37, 3109–3117. doi:http://dx.doi.org/10.1016/0006-2952(88)90308-5.
Salvatore, S., Salvatore, S., Cattoni, E., Siesto, G., Serati, M., Sorice, P., Torella, M., 2011.
Urinary tract infections in women. Eur. J. Obstet. Gynecol. Reprod. Biol. 156, 131–
136. doi:http://dx.doi.org/10.1016/j.ejogrb.2011.01.028.
Squella, J.A., Letelier, M.E., Lindermeyer, L., Nuñez-Vergara, L.J., 1996. Redox
behaviour of nifuroxazide: generation of the one-electron reduction product.
Chem. Biol. Interact. 99, 227–238. doi:http://dx.doi.org/10.1016/0009-2797(95)
03672-5.
Sreider, C.M., Grinblat, L., Stoppani, A.O.M., 1990. Catalysis of nitrofuran redox-
cycling and superoxide anion production by heart lipoamide dehydrogenase.
Biochem. Pharmacol. 40, 1849–1857. doi:http://dx.doi.org/10.1016/0006-2952
(90)90366-S.
Symons, T., Tocher, J.H., Tocher, D.A., Edwards, D.I., 1991. Electrochemical studies of
nitroheterocyclic compounds of biological interest. VII. Effect of electrode
material. Free Radic. Res. Commun. 14, 33–40.
Valdevenito, J.P., 2008. Infección urinaria recurrente en la mujer. Rev. Chil.
infectología 25, 268–276. doi:http://dx.doi.org/10.4067/S0716-
10182008000400004.
Viodé, C.E., Bettache, N., Cenas, N., Krauth-Siegel, R.L., Chauvière, G.E., Bakalara, N.,
Périé, J., 1999. Enzymatic reduction studies of nitroheterocycles. Biochem.
Pharmacol. 57, 549–557. doi:http://dx.doi.org/10.1016/S0006-2952(98)00324-
4.
Vogel, H., Razmilic, I., Polanco, X., Letelier, M.E., 2010. Effect of different provenances
and production conditions on antioxidant properties in Buddleja globosa leaves.
Bol. Latinoam. plantas Med. aromáticas 9, 333–342.
Vogel, H., Jeldres, P., Razmilic, I., Doll, U., 2011. Morphological characters, yields and
active principles in wild and cultivated accessions of the Chilean medicinal
plant Buddleja globosa Hope. Ind. Crops Prod. 34, 1322–1326. doi:http://dx.doi.
org/10.1016/j.indcrop.2010.12.004.
Witten, C.M., 1989. Pulmonary toxicity of nitrofurantoin. Arch. Phys. Med. Rehabil.
70, 55–57.