A Standardized SupplementFor The Treatment of Psoriasis

InflammationInflammation

• Inflammation (Latin, inflamatio, to set on fire) is the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants

• Root causes of many chronic and sub chronic disorders

• Medical science recommended the control on various pro-inflammatory cytokines especially TNF-, as an option of controlling inflammatory disorders

Cytokine Targets

IFN-

IL-17

IL-16

IL-15

IL-12

IL-10

IL-8

IL-6

IL-1

TNF-

TNF - TNF - • Tumor necrosis factor (TNF-alpha) is a

cytokine involved in systemic inflammation

• TNF-alpha is a member of a group of cytokines, that stimulate the acute phase reaction

• The primary role of TNF- is in the regulation of immune cells

• TNF- is also able to induce apoptotic cell death that induces inflammation

• Overproduction of TNF- causes many of the clinical problems associated with autoimmune disorders

Crystal structure of TNF-alpha

Cytokine involvement in Inflammation

TNF - TNF -

Atherosclerosis

COPD

Rheumatoid Arthritis

Psoriasis IBD

AnkylosingSpondylitis

Diseases related to TNF - Diseases related to TNF -

• The global market for Arthritis / Psoriasis drugs was worth $35 billion in 2008 out of which TNFα Inhibitors accounted for sale of $18 billion

• Biologics have have become the main treatment option for RA patients by providing 50-60% response rate to delay the progression of the disease

• Enbrel - $7.4 billion was the market leader followed by Remicade - $6.5 billion and Humira - $4.5 billion with annual gain of over $ 1 billion

• The cost of biologic treatment is $20,000 per year

• Cimzia - new drug approved in 2008; Actemra and Stelara - likely to be approved in 2009 by FDA 

Treatment MarketTreatment Market

There is scope for holistic medicine with proven TNF- inhibition activity

Global Arthritis Market Review 2008 (World Top Ten RA Drugs)

Medicinal Plants in InflammationMedicinal Plants in Inflammation

• Described in age old textbooks of Ayurveda under the topic of VRANA (wounds and ulcers); SHWAS (respiratory diseases); GRAHANI (IBDs); HRIDROGA (cardiac diseases) and GALAGANDA / GANDAMALA (Goitre, Lymphadenitis etc.)

• Taking a lead from these references, we prepared and screened about 75 plant extracts.

• The best one from S. indicus was studied and evaluated in detail

Botanical name: Sphaeranthus indicusEnglish Name: East Indian Globe-Thistle Indian Name: Gorakhmundi

A much branched, strongly-scented annual with winged stem and the wings toothed. Flowers compound heads, globose avoid, glandular hairy

Traditional uses: Time tested herb and widely used in AyurvedaUsed in Indigestion, Bronchitis, Spleen diseases, Elephantiasis, Inflammatory conditions of pelvis in women, Piles, Asthma, Treatment of glandular swelling in the neck

Sphaeranthus indicusSphaeranthus indicus

Fruiting & flowering Inflorescence head

Herb in nature

Pharmacognostically standardized &

Extraction process developed to obtain holistic extract

• The system provides better separation of active marker

• Simple, accurate, reproducible, precise and specific HPTLC method for quantification of active marker

Marker

ExtractMarker

Overlay chromatograph of three different batches of extract

HPTLC comparison – TinefconHPTLC comparison – Tinefcon

Safety Check

Efficacy Check

Quality Check

Certificate of Analysis with SpecificationCertificate of Analysis with Specification

• Inhibits the release of production of hPBMC-derived proinflammatory cytokines (TNF-, IL-1, IL-6 and IL-8)

In vitroIn vitro activity activity

• Blocks NFkB activation, IkBa phosphorylation and degradation

• Inhibits monocytic adhesion to TNF- treated endothelial cells

• Inhibits the production of intracellular adhesion molecules (ICAM-1, VCAM-1 and E-Selectin) by TNF- stimulated HUVEC cells

Suppresses the production of pro-inflammatory cytokines (TNF-, IL-1, IL-6 and IL-8)

by synovial cells obtained from Rheumatoid Arthritis patients

• Regulates signal transducer and activator of transcription (STAT) expression

Tinefcon

Tinefcon inhibits LPS-induced TNF- release in mice

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LPS 1 S. indicus 30 S. indicus 100 S. indicus 300 Rolipram 30Dose (mg/kg)

Mea

n TN

F- (p

g/m

l)

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Bar graph: Mean + SEM; * p<0.0005 Student’s T-test

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LPS 1 S. indicus 30 S. indicus 100 S. indicus 300 Rolipram 30

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Tinefcon inhibits LPS-induced IL-1 release in mice

In vivo In vivo activityactivity

In vivo In vivo activity – Histopathology activity – Histopathology

Protects cartilage degradation in joints

Rectal Bleeding

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Disease Activity Index

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Colon Length

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Stool Consistency

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N: Naïve mice

D: DSS-fed mice

Sp: DSS-fed mice + Tinefcon (400 mg/kg p.o.)

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*

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Tinefcon reduces the severity of experimental colitis in mice

In vivo In vivo studies – Ulcerative Colitis modelstudies – Ulcerative Colitis model

Naïve

Well preserved architecture

Tinefcon (400 mg/kg p.o.)DSS

Complete loss of architecture Protection from mucosal erosions

Tinefcon treated mice reduces DSS-induced alterations in mucosal architecture and colonic damage

In vivo In vivo studies – Ulcerative Colitis modelstudies – Ulcerative Colitis model(Histopathology analysis)(Histopathology analysis)

Tinefcon extract reduces development and progression of atherosclerosis in LDLr-deficient mice

Bar graph: Mean + SEM; * p<0.05 vs vehicle, ANOVA

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345

Veh Feno (100mpk)

Sphira (100mpk)

Sphira (300mpk)

% o

f Tot

al A

rea

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% o

f Tot

al A

orta

Veh Feno Tinefcon Tinefcon 100 mg/kg 100 mg/kg 300mg/kg

-26% -22% -21%* * *Atherosclerotic lesion quantitation

In vivo In vivo studies – Atherosclerosis modelstudies – Atherosclerosis model

**p<0.01 by ANOVA (Dunnett’s Test)

  Vehicle Fenofibrate TinefconMean 0.5025 0.0834 0.2736

STD 0.2151 0.1131 0.1482

SEM 0.06487 0.03577 0.04686

% Change   -84 -45

Tinefcon Inhibits Atherosclerosis Progression in Hyperlipidemic Hamsters

In vivo In vivo studies – Atherosclerosis modelstudies – Atherosclerosis model

Vehicle Fenofibrate Tinefcon (100 mpk) (200 mpk)

Vehicle Fenofibrate Tinefcon (100 mpk) (200 mpk)

PsoriasisPsoriasis A Chronic, inflammatory skin disease

characterized by erythema, induration and scaling

Psoriasis affects approximately 3% of the world’s population

Almost 74% psoriasis cases are mild

Equal frequency in males and females

May occur at any age from infancy to the 10th decade of life

First signs of psoriasis– Females mean age of 27 years– Males mean age of 29 years

Psoriasis patients diagnosed by type

Psoriasis skin

~ 5%

~ 3%~ 2.6 %

~ 2.0 %

~ 2.5%

~ 1 %

~ 1%

~ 1.5 %

~ 2 %

Psoriasis - PrevalencePsoriasis - Prevalence

Worldwide estimated 125m people suffer from psoriasisSources; International Federation Psoriasis Association (IFPA) 2007

Treatment Options for PsoriasisTreatment Options for Psoriasis

MILD• Topical Agents- Calcipotriene, Steroids, Tazarotene, Coal

Tar, Diathranol• Supplementary Treatment- Keratolytics, Moisturizers

MODERATE• Combination Of Calcipotriene/Steroids/Tazarotene• UVB/ PUVA, PUVA + Calcipotriene

SEVERE• Acitretin, Methotrexate, Cyclosporine, Acitretin+ PUVA• TNF -Inhibitor- Etanercept, Infliximab, Adalimumab• T Cell Inhibitor- Alefacept• IL-12/23 Inhibitor- Ustekinumab

Clinical Trials - ObjectivesClinical Trials - Objectives

Primary objectives• To evaluate safety of Tinefcon in patients with moderate to severe

psoriasis• To evaluate efficacy of Tinefcon by observing change in PASI score at

12 weeks compared to baseline

Secondary objectives• To evaluate changes in histopathology of psoriatic skin and gene

expression profile

Randomized, double-blind, placebo controlled, pilot study to evaluate the safety and efficacy of 2 doses of

Tinefcon tablets in subjects with moderate to severe psoriasis

ENROLMENT (N = 74)

WASH OUT2 wks- TOPICAL Rx

WASH OUT4 wks- PUVA Rx

RANDOMIZATION 1:1:1

Tinefcon 2.8 g/day Placebo

Tinefcon 1.4 g/day

STUDY COMPLETED (N = 48)

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Study DesignStudy Design

Efficacy parametersEfficacy parametersClinical Parameters1. Psoriasis Area Severity Index (PASI)2. Physician’s global assessment

Laboratory parameters1. Histopathology2. Gene expression profile (RTQPCR)3. Immunohistochemistry4. CRP

Safety parametersSafety parameters1. Monitoring adverse events, vital signs, physical examination 2. Clinically significant changes in laboratory parameters (Hematology,

Biochemistry and Urinalysis) 3. ECG

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Placebo 1.4g 2.8gTreatment

% P

atie

nts

75% improvement in PASI score

Effect of TinefconEffect of Tinefcon in Psoriasis Patientsin Psoriasis Patients

BASELINE AFTER 12 WEEKS OF TREATMENT

Photographic evidencePhotographic evidence

Case 1

Case 2

Gene Expression Profile for PatientsGene Expression Profile for Patients

No response Response

Significant drug response observed in patients as shown by

gene expression pattern

Biomarker for Psoriasis

KRT 16 FABP5 SKALP S100A9 SERPINB4

• TNF-α • IFN-γ

Epidermal Thickness and Drug ResponseEpidermal Thickness and Drug Response

Statistically significant reduction in epidermal thickness observed after

drug therapy

• Epidermal thickness is hallmark of psoriasis

• Patient skin tissue is measured for epidermal thickness by microscopy

Conclusion – clinical studyConclusion – clinical study

• The results of this clinical study provide initial efficacy signal of Tinefcon tablets administered over a 3 month period in patients with moderate to severe psoriasis

• Tinefcon tablets are well tolerated in subjects with moderate to severe psoriasis

at doses of up to 2.8 gm/day

Hence, a study with large sample size to further confirm its efficacy is underway

Patent StatusPatent Status

• PCT application filed on 28th September, 2006

Tinefcon is an innovative product for the treatment of inflammatory

disorders

PCT National Phase entry effected in 16 countries

(Algeria, Australia, Brazil, Canada, China, Europe, Hong Kong, Eurasia,

Georgia, India, Japan, Mexico, Morocco, South Africa, Ukraine & USA)

• E-mail received from patent office indicating the allowance of US patent

Unique Selling Property - IUnique Selling Property - I

Convenient, Effective, Safe and Inexpensive Option

Obtained from time tested and widely used herb of Ayurveda

A contaminant free, completely standardized product

Manufactured under GMP standards

Inhibits the release of pro-inflammatory cytokines

Oral administrable pharmaceutical dosage forms of Tinefcon,

Unique Selling Property – IIUnique Selling Property – II

Orally active

Does not interact with enzymes involved in drug - drug interaction

Safe & non-toxic

A new choice for psoriasis patients

Well tolerated in patients with moderate to severe psoriasis

Oral administrable pharmaceutical dosage forms of Tinefcon,

Convenient, Effective, Safe and Inexpensive Option

Histo-pathologyAnalysis

Gene expression

PASI 75% Score

Epidermal thickness

TinefconTinefcon

Tinefcon Tinefcon (An (An Efficacious Efficacious Phytopharmaceutical)Phytopharmaceutical)