Fitoterapia 82 (2011) 34–37

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Fitoterapia
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / f i t o t e

Review

Synergy research: Approaching a new generation of phytopharmaceuticals

Hildebert Wagner ⁎
Department of Pharmacy, Center of Pharma-Research, Ludwig-Maximilians-University Munich, Butenandtstr. 5-13, 81377 Munich, Germany

a r t i c l e i n f o a b s t r a c t

Article history: The longstanding, successful use of herbal drug combinations in traditional medicine demands
Received 6 November 2010 that we find a rationale for their comparative pharmacological and therapeutic superiority to
Accepted 8 November 2010 isolated single constituents. The synergistic efficacy of these combinations can be evaluated
Available online 12 November 2010
and verified by Berenbaum's isobole method, followed by clinical studies performed in
comparison with synthetic standard drugs. There are many examples of mono- and multi-
Keywords: extract combinations used presently, which exhibit synergistic efficiency based on multi-target
Synergy effects mechanisms of action. Among the natural products, gallocatechins of green tea and
Multi-target therapy curcuminoids of ginger are the presently favoured polyphenols for a possible future use in
Isobologram
co-medication with antibiotics and standard anticancer drugs. The main targets were found to
Polyphenols
Multi-resistance NF-κB
be COX 1 + 2, NF-κB, and membrane glycoproteins that belong to the ATP-binding cassette
Transporter glycoproteins (ABC) transporter family.
© 2010 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2. Pharmacological approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3. What are the possible mechanisms underlying the synergy effects? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4. Synergy effects in interference with resistance mechanisms of bacteria, fungi [8] and tumor cells . . . . . . . . . . . . . . . 36
4.1. Antimicrobial synergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.2. Anti-tumor synergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5. Clinically proven synergy efficacies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

1. Introduction therapeutic superiority of many multidrug combinations in

Synergy assessment has become a key area in phytomedi-
cine research in recent years. It is the aim of this research to find
a scientific rationale for the centuries-old, often-observed
⁎ Tel.: +49 89 2180 77050; fax: +49 89 2180 77051.
E-mail address: H.Wagner@cup.uni-muenchen.de.
traditional medicine over single constituents. Chemotherapy
has also seen a gradual transition from the long and passionately
advocated mono-substance therapy toward a multidrug ther-
apy. It is becoming increasingly obvious through observation
that many diseases possess a multi-causal etiology and a
complex pathophysiology, which can be treated more effec-
tively with well-chosen drug combinations than with a single
drug. Today multidrug therapy is practiced worldwide in the

0367-326X/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.fitote.2010.11.016
 H. Wagner / Fitoterapia 82 (2011) 34–37
treatment of AIDS and other infectious diseases, hypertension,
numerous types of cancer and rheumatic diseases.
2. Pharmacological approach
How can we prove the existence of synergistic efficacy of a
given mixture of drugs? Among the many methods proposed,
the “isobole method” of Berenbaum [1] seems to be one of the
most practicable in terms of experimental design, and also the
most effective in demonstrating synergy.
Fig. 1 shows an example for the verification of a synergistic
effect resulting from the combination of the two known
natural products, ginkgolides A and B, of Ginkgo biloba, using
the PAF-induced in vitro thrombocyte aggregation inhibition
test [2,3]. As shown in the chart, the interaction index is b1
and therefore corresponds to the isobole that is concavely
curved towards the zero point. In this case, we have a real
synergistic or potentiated (over-additive) effect which can be
expressed as E (da, db) N E (da) + E (db), meaning that the
effects of the two drugs A and B applied together as a mixture
are larger than what would be expected from the sum of the
two separate effects [4].
3. What are the possible mechanisms underlying the
synergy effects?
Based on results from the latest classical pharmacological
and clinical investigations, the following four mechanisms
can be described:
1. Synergistic multi-target effects, in which the single consti-
tuents of a mono- or multi-extract combination affect not
only one single target, but several targets such as enzymes,
substrates, metabolites, receptors, ion channels, transport
proteins, DNA/RNA, ribosomes or monoclonal or antibodies
[5].
2. Pharmacokinetic or physicochemical effects based on
improved solubility, or physico-chemical effects based on
Fig. 1. Isobole curve for 50% inhibition of a combination of ginkgolides A and B; IC50 values (μg/ml) of PAF-induced in vitro thrombocyte aggregation are shown for
various dose combinations [2,3].
35
Table 1
Examples of botanical mono-extracts which exhibit synergistic effects
according to the definition of Berenbaum [1] (selected examples from [4]).
Herbal drug Investigated mono-extract mixtures and single
constituents
Ginkgo biloba Ginkgolide mixtures, Ginkgo extract
Piper methysticum Kava lactones/mixtures of Kava lactones and
extract fractions
Glycyrrhiza glabra Liquorice extract potentiates other substances
and acts as detoxifier
Cannabis sativa Cannabis extract/THC
Valeriana officinalis Valeriana extract, individual constituents
Zingiber officinalis Zingiber extract/mixture of volatile terpenoids
and mixtures
improved solubility of constituents of an extract by one or
several other components of the same extract [6,7].
3. Antagonization of resistance mechanisms of pathogenic
microorganisms (bacteria, fungi) or tumor cells by natural
products (e.g., polyphenols such as epigallocatechingallate
or curcuminoids) that are applied together with antibiotics
[8] or cancer drugs. In current cancer therapy, this multi-
drug concept has been designated as “biomodulatory-
metronomic chemotherapy” [5].
4. The respective elimination or neutralisation of toxic or
adversely acting substances by one agent that has been
added to an extract. This is a frequent procedure in
traditional Chinese medicine, aimed at improving the
efficacy of an herbal drug preparation and resulting in
“pre-treated drugs” [9].
Table 1 lists examples of mono-extracts which, according
to the definition of Berenbaum [1], exhibit synergistic effects.
This postulation is based on detailed pharmacological and
molecular-biological investigations of subfractions and iso-
lated compounds of the single extracts. Which of the four
mechanisms described earlier are involved in these effects
36 H. Wagner / Fitoterapia 82 (2011) 34–37
Table 2
Examples of synergistic natural products that block bacterial efflux-pumps
(selected examples from [8]).
Compound Plant source
EGCg (epigallocatechin gallate) Camellia sinensis
Catechin Camellia sinensis
Tellimagrandin I, Rugosin B Rosa canina
Corilagin Arctostaphylos uva-ursi
Baicalin Scutellaria omoena
cannot be specified exactly; however, it appears that in most
extracts multi-target effects predominate [3].
4. Synergy effects in interference with resistance
mechanisms of bacteria, fungi [8] and tumor cells
4.1. Antimicrobial synergy
The best-known example of such a combination is the co-
medication of the ß-lactam antibiotic (BLA) penicillin with
clavulinic acid, which successfully antagonizes penicillinase
resistance. In a similar fashion, the epigallocatechingallate
seems to be an adequate natural product for maintaining the
activity of penicillin versus Staphylococcus aureus. The natural
products listed in Table 2 are able to block the efflux-pumping
system developed by several bacteria in order to inhibit
agents from penetrating the bacteria, or to extrude antibiotics
that have already penetrated the bacterial cell. Typically, the
inhibitors themselves are only weak antimicrobial agents.
4.2. Anti-tumor synergy
Synergistic effects also play a role in antagonizing the
multidrug resistance of tumor cells and combating tumors in
general. Polyphenols, such as the curcuminoids, seem to be
the most promising substances. Curcumins have significant
immunomodulating and anti-inflammatory effects. They
inhibit the activation of the nuclear factor-kappa-B (NF-κB)
family of transcription factors which are known to be
activated in a wide variety of solid tumors, lymphomas and
leukemias [10]. In vitro, curcuminoids induce apoptosis and,
thus, inhibit tumor growth in a broad range of tumor cells.
Curcuminoids also inhibit new vessel formation induced by
growth factors, such as fibroblast growth factor-2 and
vascular endothelial growth factor (VEGF) in human mela-
noma cells. Curcuminoids as polyvalent polyphenols are also
able to inhibit P-glycoproteins (P-gp) which act as multidrug
resistance (MDR) factors in tumor cells by transporting
Table 3
Therapeutic equivalence of standardized plant extracts with synthetic drugs for a given indication, as evidenced by comparative placebo controlled clinical studies [3].
Botanical Chemical/synthetic drug
Crataegi flos + folium Captopril
Boswellia (incense) Sulfasalazine
Hypericum perforatum (St. John's Wort) Imipramine, Amitripyline, Citalopram, Sertalin
Hedera helix Ambroxol®
Iberogast® (phytopharmaceutical containing 9 extracts) Metoclopramide Cisapride
Sabal (Saw palmetto) Proscar® (Finasteride)
Salix spec. Aspirin
Sinupret® (Phytopharmaceutical containing 5 extracts) Ambroxolw
anticancer agents out of the cell, resulting in a decreased
intracellular substrate accumulation. In a human breast
cancer xenograft model in nude mice, curcumin potentiated
the cytotoxic effects of the Taxus alkaloid paclitaxel against
human breast cancer MDA-MB-435 cells. Additionally, the
same combination also inhibited breast cancer metastasis in
lung tissue [11]. These results indicate that curcumin has
therapeutic potential for preventing breast cancer metastasis,
possibly through suppression of NF-κB and NF-κB-regulated
gene products.
5. Clinically proven synergy efficacies
It is important that pharmacological investigations of
synergistic effects are confirmed by clinical trials and
particularly in comparison with synthetic standard drugs,
using the same indication and equivalent dosages. Within the
last 25 years, more that 200 comparative, double-blind,
placebo-controlled trials have been performed using stan-
dardized mono- and multi-extract combinations against well-
known standard drugs. These standardized phytodrugs
showed therapeutic equivalence to the standard drugs, with
the additional advantage of having fewer or no side effects
relative to synthetic drugs. These results are good evidence
that synergistic effects are the cause of this therapeutic
equivalence (Table 3).
Two additional examples of drug combinations with
clinically proven synergy effects are as follows: First, the
phytopharmaceutical preparation Iberogast®, sold in Germany,
consists of 9 plant extracts and is used for the treatment of
functional dyspepsia and motility related disorders. The prep-
aration showed therapeutic equivalence when compared with
the synthetic drugs cisapride and metoclopromide, with the
additional advantage that the phytopreparation showed fewer
or no side effects [12]. Second, combinations of artemisinine
(artesunate, artemether, arteether and dihydroartemisinine)
and mefloquine, lumefantrine, doxycycline or tetracycline are
successfully used in Thailand for the treatment of both
uncomplicated and severe Falciparum malaria [13].
6. Conclusions
From in vitro and in vivo data available so far, it can be
concluded that progress in synergy research will not only
provide new legitimation for phytotherapy, but also enhance the
possibility of using new phytodrugs alone or in co-medication
with chemotherapeutics for the treatment of diseases which
have been treated previously through chemotherapy only.
Indication
Work intolerance, cardiac insufficiency grade II
Morbus Crohn
Mild, moderate and moderately severe depression
Chronic bronchitis
Functional dyspepsia, irritable bowel disease
Benign prostate hyperplasia I + II
Osteoarthritis
Sinusitis
 H. Wagner / Fitoterapia 82 (2011) 34–37
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