Shaoyao-Gancao decoction for the treatment of muscle cramps in maintenance hemodialysis: A prospective randomized crossover controlled trial

Abstract

Ethnopharmacological relevance: Shaoyao-Gancao Decoction (SG), a traditional Chinese herbal formula comprising Paeoniae Radix Rubra (Paeonia lactiflora Pall., root) and Glycyrrhizae uralensis (Glycyrrhiza uralensis Fisch., root and rhizome), is renowned for its effectiveness in alleviating muscle cramps and pain. Significantly, both preclinical and clinical studies have unveiled its exceptional potential as a pain-relieving agent and muscle relaxant. Moreover,its efficacy and safety in patients undergoing maintenance hemodialysis (HD) related muscle cramps remain undetermined.

Aim of the study: To verify the effectiveness and safety of SG in patients with HD-related muscle cramps.

Materials and methods: A randomized, crossover controlled design was conducted in this trial. This study involved patients aged 18-80 undergoing HD at the hemodialysis center of Guangdong Provincial Hospital of Traditional Chinese Medicine, experiencing muscle cramps at least twice weekly. Following a 2-week run-in period, patients who provided informed consent were randomly allocated to Group A and Group B. During study period 1, Group A patients received SG while Group B continued their standard HD treatment for 4 weeks. After a 2-week washout period, the treatments were switched in study period 2, with Group B receiving SG and Group A acting as the control for another 4 weeks. Data from participants in Group A during period 1 and from Group B during period 2 comprised the SG sequence, whereas the control sequence include data from Group A during period 2 and Group B during period 1. The primary efficacy endpoint was the change in frequency of cramps (FC), while secondary endpoints including changes in cumulative time of cramps (CT), average time of cramp (AT), cumulative VAS score (C-VAS), time-average VAS score (A-VAS), worst VAS score (W-VAS) and Cumulative affected body regions (CR). The safety evaluation of SG involved monitoring adverse events (AEs), serious adverse events (SAEs), and conducting serological testing, which included the serum uric acid, AST, CO2CP, creatine kinase (CK), Creatine Kinase- Myocardial Band (CK-MB), LDH, HBDH, potassium, sodium, chloride, calcium, magnesium and phosphorus as safety indices. The results of the serological testing were submitted to a specialized data analyst to identify AEs according to the Medical dictionary for Regulatory Activities (MedDRA) central coding dictionary. Statistical analyses were conducted using paired t-test, repeated measures analysis of covariance (RANCOVA) models and generalized linear mixed models. The post-hoc analysis utilizing independently measured continuous laboratory data for CK, CK-MB, LDH, potassium, calcium, and magnesium, employing both unadjusted and adjusted linear mixed-effects models to assess the effects of SG and obtain the objective results.

Results: This study was conducted from November 8th, 2021 to November 1st, 2022. Of the 81 patients screened, 62 were randomly assigned to Group A (32 cases) and Group B (30 cases). No statistically significant differences were found in demographic and clinical characteristics between Group A and Group B. A total of 60 participants completed the study. The baseline level of FC was 5.92 (standard error [SE] 0.39) for the SG sequence and 4.37 (SE 0.39) for the control sequence. The unadjusted slope for FC was -2.37 (SE 0.34) in the SG sequence and -0.28 (SE 0.33) in the control sequence, with a statistically significant difference of -2.08 (95 % confidence interval [CI]: -3.16, -1.00; p < 0.001) between sequences over the 4-week intervention period. Statistical analyses also favored SG in terms of A-VAS, C-VAS and CR between sequences, indicating a significant reduction in muscle cramps among HD patients. Subgroup analyses revealed a subtle yet statistically significant interaction among participants without diabetes who underwent the SG intervention, with an odds ratio of 12.50 (95 % CI: 2.23, 70.19, P = 0.049). The safety analysis indicates that SG is well-tolerated in patients receiving high doses and has a reliable safety profile. The results of the post-hoc analysis revealed a modest effect on reducing potassium levels in both pre- and post-dialysis, particularly in pre-dialysis, with a difference of -0.27 (95 % confidence interval [CI]: -0.45, -0.09; p = 0.004) in the unadjusted slopes for pre-dialysis potassium.

Conclusions: This study supports the significant effectiveness of SG in alleviating muscle cramps among maintenance HD patients. These effects may be attributed to the moderate reduction of potassium levels while maintaining them within the ideal range achieved by SG. Our study provides valuable evidence on the safety and efficacy of using Chinese medicine to mitigate adverse symptoms of HD.

Keywords: Hemodialysis (HD); Muscle cramps; Randomized crossover trial; Shaoyao-Gancao decoction (SG).