Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Effect of Indole-3-carbinol and/or Metformin on Female Patients with Ulcerative Colitis (Premalignant Condition): Role of Oxidative Stress, Apoptosis and Proinflammatory Cytokines

Ahmed M. Kabel*, Mohamed S. Omar, Sultan N. Alotaibi, Mohammed H. Baali

Department of Pharmacology, Faculty of Medicine, Tanta University, Tanta, Egypt

Abstract: Ulcerative colitis is an inflammatory bowel disease that causes long-lasting inflammation and ulcers in the gastrointestinal tract. It affects the innermost lining of the colon and rectum. The aim of this work was to study the effect of indole-3-carbinol (I3C) or metformin alone and in combination on female patients suffering from ulcerative colitis. Forty female patients were divided as follows: 10 patients represent the normal control group and the other 30 patients with ulcerative colitis were divided into 3 equal groups; metformin treated group, I3C treated group and metformin + I3C treated group. A colonoscopic biopsy was homogenized for determination of tissue tumor necrosis factor alpha (TNF-α), transforming growth factor beta-1 (TGF-β1), malondialdehyde (MDA), catalase (CAT) and myeloperoxidase (MPO). The biopsy was also subjected to histopathological and immunohistochemical examination. Administration of each of metformin or I3C alone and in combination to ulcerative colitis patients induced significant increase in tissue CAT with significant decrease in the colonic endoscopic score, tissue TNF-α, TGF-β1, MDA and MPO and alleviated the histopathological and immunohistochemical changes compared to the same parameters before treatment. Metformin/I3C combination produced significant improvement in the biochemical, histopathological and immunohistochemical parameters compared to the groups that received either metformin or I3C alone. In conclusion, metformin and I3C had protective effects on female patients suffering from ulcerative colitis but their combination had the upper hand.

Keywords: indole-3-carbinol, metformin, ulcerative colitis, female, patients

Citation: Ahmed M. Kabel, Mohamed S. Omar, Sultan N. Alotaibi, Mohammed H. Baali, Effect of Indole-3-carbinol and/or Metformin on Female Patients with Ulcerative Colitis (Premalignant Condition): Role of Oxidative Stress, Apoptosis and Proinflammatory Cytokines. Journal of Cancer Research and Treatment, 5 (1). 1-8. January 2017. doi:10.12691/jcrt-5-1-1

1. Introduction

Ulcerative colitis (UC) is a premalignant condition of the colon that includes characteristic ulcers [1]. It usually arises due to a combination of environmental and genetic variations together with alteration in bacterial flora which can drive a dysregulated immune response resulting in chronic intestinal inflammation [2]. Several studies reported that the increased production of proinflammatory cytokines together with induction of oxidative stress may play a crucial role in the pathogenesis of UC [3,4]. Treatment of UC usually includes anti-inflammatory drugs, immunosuppressive drugs, biological therapy and even surgical removal of a part of the colon in severe resistant cases [5]. The agents used in treatment of UC may cause serious adverse effects which necessitate the search for alternative drugs with less severe deleterious effects [6].

Metformin is one of the biguanides used widely in treatment of type 2 diabetes mellitus [7]. Recently, Metformin was proven to decrease the harmful effects of the reactive oxygen species in various tissues of the body. Also, metformin has the ability to modulate the expression of the proinflammatory cytokines at both the biochemical and gene expression levels [8]. These properties may create a potential role for metformin in management of UC, possibly through suppression of nuclear factor-κB activation in intestinal epithelial cells and inhibition of the STAT3 signaling pathway [9,10].

Indole-3-carbinol (I3C) is produced by the breakdown of the glucosinolate glucobrassicin, which can be found at relatively high levels in cruciferous vegetables such as broccoli, cabbage, cauliflower and kale. It is also available in dietary supplements [11]. Recent studies suggested that I3C might have potent protective effects against colitis, possibly due to its antioxidant and anti-inflammatory properties together with its ability to decrease the level of immune cell infiltration found in the large intestine of cases with colitis [12]. Moreover, this effect was suggested to be sex-specific, being more pronounced in females than males [13]. The aim of this work was to study the effect of I3C or metformin alone and in combination on female patients suffering from UC.

2. Patients and Methods

The studied subjects were selected from the inpatient and outpatient clinics of tropical medicine and internal medicine departments, Tanta University Hospital, Tanta, Egypt. This study was conducted in accordance with the World Medical Association Declaration of Helsinki for human subjects and was approved by the local ethics committee. All participants gave us their written informed consent before enrollment in this study.

2.1. Inclusion Criteria

This study was carried out on 30 female patients with ulcerative colitis and 10 individuals whose colonoscopic and histopathologic findings were normal as control. Ulcerative colitis patients were diagnosed on the basis of clinical, endoscopic and histological manifestations according to the criteria of American Gastroenterology Association [14]. The age of the patients ranged from 20 to 46 years with the mean age of 33±4.6 years.

2.2. Exclusion Criteria

The following categories were excluded from the study: Pregnancy, malignancy, heart failure, renal failure, thyroid disorders, acute infection, stroke and patients taking immunosuppressive drugs or traditional drugs used for treatment of UC.

2.3. Drugs Used

Metformin was purchased from Sigma Chemicals (St. Louis MO, USA). I3C was purchased from Sigma-Aldrich (St. Louis, MO). The drugs were then prepared as capsules at Taif University laboratory, Taif, Saudi Arabia. All other chemicals and reagents used were purchased from Sigma Chemical company (St. Louis MO, USA).

2.4. Study Groups

The subjects involved in this study were divided into 4 equal groups as follows:

Group I: Included ten patients with UC treated with metformin in a dose of 850 mg twice daily orally for 3 months [15].

Group II: Included ten patients with UC treated with I3C in a dose of 400 mg twice daily orally for 3 months [16].

Group III: Included ten patients with UC who were treated with metformin in a dose of 850 mg twice daily orally concomitantly with I3C in a dose of 400 mg twice daily orally for 3 months.

Group IV: Included ten individuals whose colonoscopic and histopathologic findings were normal as control.

All the patients and control were subjected to complete history taking and thorough clinical examination. Laboratory investigations including complete blood picture, blood urea and serum creatinine, erythrocyte sedimentation rate (ESR) and stool examination were performed to exclude bacterial causes of colitis.

2.5. Evaluation of Colitis

Colonoscopy was performed in all groups and the severity of the disease was determined. An endoscopic scoring system for UC of Pineton de Chambrun et al. [17] was used. Score O: Normal or inactive disease; Score 1: Mild disease (erythema, decreased vascular pattern and mild friability); Score 2: Moderate disease (marked erythema, increased vascular pattern, friability and erosion); Score 3: Severe disease (spontaneous bleeding and ulceration). Endoscopic findings were recorded before beginning treatment and at the end of the study.

2.6. Histopathological and Immunohistochemical Examination

Multiple biopsies were taken from the colon for histopathological and IL-23 p19 immunohistochemical staining. 4-μm-thick serial sections of formalin fixed, paraffin-embedded tissue were cut and stained by hematoxylin and eosin (H&E) for histopathological evaluation of the groups. The severity of UC was assessed using a histological disease score described by Hirata et al. [18] (Table 1).

Table 1. Histological disease score

Apoptotic index, which represents aggregate percentages of apoptotic cells and/or apoptotic bodies per total number of cells (1000 cells counted) in 10 randomly selected high power fields (×400), was counted by one pathologist. In 20% of randomly selected cases, the counting was repeated by another pathologist. In cases with significant disagreement between results, the counting was performed at the multiheaded microscope by both pathologists. The morphological criteria for apoptotic bodies applied in this study were followed according to Staunton and Gaffney [19].

4-μm-thick serial sections of formalin fixed, paraffin-embedded tissue were cut and mounted on positively charged glass slides. After incubation at 60°C overnight and deparaffinization, sections were placed in 0.01 M sodium citrate buffer (pH 6.0) and heated twice for 5 minutes in a microwave oven. After inactivation of endogenous peroxidase with 0.5% metaperiodic acid in phosphate-buffered saline (PBS) for 10 minutes, sections were incubated with 10% horse serum in PBS for 1 hour. Sections were incubated at 4°C overnight with 100× diluted primary goat anti-IL-23 p19 antibody (R&D Systems, Inc.). The standard avidin-biotin peroxidase complex (ABC) technique was performed using the LabVision Secondary Detection Kit (UltraVision Detection System Anti-polyvalent, HRP). The color was visualized by incubation with chromogen 3, 3' diaminobenzidine for 5 minutes. The slides were then counterstained with Mayer hematoxylin and cover slipped with Permount (StatLab, McKinney, TX). Negative controls were set for each test without the primary antibodies. Results were expressed semi-quantitatively. Positively stained cells were counted by examining at least 10 random fields in each section and expressed as the percentage of positive cells over total cell number [20].

2.7. Assessment of the Biochemical Parameters

Parts of the colonic biopsies were homogenized in 10 volumes of ice-cold 10% trichloroacetic acid and centrifuged at 3000 rpm for 15 minutes at 4°C. The supernatant was removed and recentrifuged at 15000 rpm at 4°C for 8 min. The resulting supernatant was used for determination of tissue catalase (CAT) level according to Higgins et al. [21], tissue malondialdehyde (MDA) level according to the method of Casini et al. [22], tissue myeloperoxidase (MPO) activity according to the method of Bradley et al. [23], tissue TNF-α using ELISA kits according to the instructions of the manufacturer, tissue TGF-β1 using kits supplied by Uscn Life Science Inc. Wuhan, according to the instructions of the manufacturer and tissue total protein content according to the method of Lowry et al. [24].

2.8. Statistical Analysis

Data were presented as mean ± standard error of mean (SEM). Data were statistically analyzed by computer SPSS version 16.0 software. Data were analyzed by one way analysis of normality of variance (ANOVA). Independent sample t-test and Covariate test were used as statistical tests. Comparison of numerical variables between the study groups was performed using Mann–Whitney test to compare independent samples from two groups. Differences between the means of different groups were considered significant at a level of p-value less than 0.05.

3. Results

3.1. Effect of Different Treatments on the Clinical and Laboratory Data of the Studied Group

UC patients showed significant increase in the abdominal pain, diarrhea, blood in the stool and ESR compared to the control group. Administration of metformin and/or I3C to patients with UC resulted in significant decrease in the abdominal pain, diarrhea, blood in the stool and ESR compared to the same data of these groups before treatment. The decrease in the abdominal pain, diarrhea, blood in the stool and ESR was significant in metformin/ I3C combination group compared to the use of either metformin or I3C alone (Table 2).

Table 2. Effect of different treatments on the clinical and laboratory data of the studied group

3.2. Effect of Different Treatments on the Colonic Endoscopic Score

UC patients showed significant increase in the endoscopic score compared to the control group. Administration of metformin and/or I3C to patients with UC resulted in significant decrease in the endoscopic score compared to the endoscopic score of the same groups before treatment. The decrease in the endoscopic score was significant in metformin/ I3C combination group compared to the use of either metformin or I3C alone (Figure 1).

Figure 1. Effect of different treatments on the colon endoscopic score

3.3. Effect of Different Treatments on Tissue Antioxidant Status

UC patients showed significant increase in tissue MDA with significant decrease in tissue CAT compared to the control group. Administration of metformin and/or I3C to patients with UC resulted in significant decrease in tissue MDA with significant increase in tissue CAT compared to the same data of these groups before treatment. The decrease in tissue MDA and the increase in tissue CAT were significant in metformin/I3C combination group compared to the use of either metformin or I3C alone (Table 3).

Table 3. Effect of different treatments on catalase (CAT), malondialdehyde (MDA), myeloperoxidase (MPO), tumor necrosis factor alpha (TNF-α), transforming growth factor beta 1 (TGF-β1) and histological disease score

3.4. Effect of Different Treatments on Tissue MPO

UC patients showed significant increase in tissue MPO compared to the control group. Administration of metformin and/or I3C to patients with UC resulted in significant decrease in tissue MPO compared to tissue MPO of the same groups before treatment. The decrease in tissue MPO was significant in metformin/I3C combination group compared to the use of either metformin or I3C alone (Table 3).

3.5. Effect of Different Treatments on Tissue TNF-α and TGF-β1

UC patients showed significant increase in tissue TNF-α and TGF-β1 compared to the control group. Administration of metformin and/or I3C to patients with UC resulted in significant decrease in tissue TNF-α and TGF-β1 compared to tissue TNF-α and TGF-β1 of the same groups before treatment. The decrease in tissue TNF-α and TGF-β1 was significant in metformin/I3C combination group compared to the use of either metformin or I3C alone (Table 3).

3.6. Histopathological and Immunohistochemical Results

UC patients showed significant increase in the histological disease score and IL-23 p19 expression with significant decrease in the apoptotic index compared to the control group. Administration of metformin and/or I3C to patients with UC resulted in significant decrease in the histological disease score and IL-23 p19 expression with significant increase in the apoptotic index compared to the same data in these groups before treatment. The decrease in the histological disease score and IL-23 p19 expression with the increase in the apoptotic index were significant in metformin/I3C combination group compared to the use of either metformin or I3C alone (Table 3, Table 4; Figure 2, Figure 3).

Table 4. The effect of different treatments on the apoptotic index in the studied groups

Figure 2. H&E stained sections from the colon of a) The control group showing normal appearance of the colonic mucosa, crypts and the mucosal glands; b) UC patients before treatment with mucosal ulceration, massive infiltration with neutrophils with severe destruction of the crypts and the mucosal glands; c) Metformin treated group with intact mucosal surface, mild to moderate inflammatory cellular infiltration with congested blood vessels in the submucosa; d) I3C treated group with minimal mucosal ulceration, increased goblet cell population and moderate inflammatory cellular infiltration; e) Metformin/I3C treated group with apparently normal mucosal glands and crypts with marked decrease in the inflammatory cellular infiltration (H&E X200)

Figure 3. A photomicrograph of the immunohistochemical expression of IL23p19 in a) The control group showing very minimal expression; b) UC patients before treatment showing extensive expression; c) Metformin treated group with moderate expression; d) I3C treated group with moderate expression; e) Metformin/I3C treated group with mild expression of IL23p19 (Anti-IL-23 p19 X400)

4. Discussion

Ulcerative colitis (UC) is one of the inflammatory bowel diseases that primarily involves the mucosa and submucosa of the colon. The exact etiology of UC is still unknown but overgrowth of the pathogenic microorganisms in the colon, overproduction of the pro-inflammatory cytokines, induction of oxidative stress and affection of the immune system were suggested as predisposing factors [6]. In the present study, patients with UC showed significant decrease in tissue CAT and the apoptotic index with significant increase in the colonic endoscopic score, tissue TNF-α, TGF-β1, MDA, MPO, tissue IL-23 p19 expression and the histological disease score compared to the control group which support the role of oxidative stress and inflammation in the pathophysiology of UC.

Oxidative stress was thought to play a crucial role in the pathogenesis of UC. Chronic intestinal inflammation found in UC is usually associated with overproduction of both reactive oxygen and reactive nitrogen species (ROS and RNS) leading to oxidative and nitrosative stress, respectively [25]. In UC, there is usually an imbalance between ROS and antioxidant activity which creates oxidative stress. Once they are formed, ROS interact with the molecular complexes inducing cellular oxidative damage which can affect lipids, proteins, and nucleic acids leading to formation of lipid peroxides, enzymatic dysfunction and DNA strand breaks [26]. This was in the same line with the results of the present study where UC patients showed significant increase in tissue MDA with significant decrease in tissue CAT compared to the control group.

TGF-β1 is considered as the cornerstone mediator of UC. It was proven to induce ROS production by suppressing antioxidants defenses such as CAT and reduced glutathione and activates oxidases in cell membranes and mitochondria leading to release of H₂O2 to the extracellular space which contributes to the development of UC [27]. Moreover, TGF-β1 may induce the production of proinflammatory cytokines such as TNF-α, IL-23 and IL-17 which in turn contributes to the inflammatory process encountered with UC [28]. This was in agreement with the results of the present study where UC patients showed significant increase in tissue TGF-β1 with in turn increases the levels of tissue TNF-α and IL-23 compared to the control group.

Interleukin 23 (IL-23) is a member of the proinflammatory cytokines, consisting of a p19 subunit and a common p40 subunit. IL-23 plays a critical role in the pathogenesis of a number of immune-mediated inflammatory diseases including UC by recruitment of several inflammatory cells [29]. IL-23 is essential for the differentiation of Th17 lymphocytes which are implicated in chronic inflammatory/autoimmune diseases. IL-23 was proven to promote TNF-α, IL-17 and IL-6 production by Th17 cells which are associated with the induction of autoimmune inflammation [30]. Our study showed significant increase in the expression of IL-23p 19 protein associated with significant increase in tissue TNF-α in patients with UC compared with the control group which was similar to the results reported by Liu et al. [20] and El-Bassat et al. [31].

MPO is an enzyme contained within neutrophils, monocytes and macrophages. It is a member of the peroxidases that produces hypochlorous acid from hydrogen peroxide (H₂O₂) and chloride anion during the neutrophil's activity. Hypochlorous acid is cytotoxic and may cause oxidative damage in host tissues [32]. Moreover, the release of MPO in UC was correlated to an enhanced release of the neutrophil activating peptide interleukin-8 (IL8) which plays a vital role in the inflammatory bowel diseases. The levels of MPO in active UC patients were increased significantly and correlated with laboratory parameters and endoscopic grade of inflammation. A paired analysis showed a decrease in MPO levels after the resolution of disease exacerbation [33]. This was in accordance with the results of our study where patients with UC showed significant increase in tissue MPO compared with the control group.

Metformin is one of the biguanides that is considered the most widely used drug for treatment of type 2 diabetes. In the present study, administration of metformin to UC patients resulted in significant increase in tissue CAT with significant decrease in colonic endoscopic score, tissue TNF-α, TGF-β1, MDA and MPO and alleviated the histopathological and immunohistochemical changes compared to the same parameters before treatment. These effects might be attributed to the antioxidant, anti-inflammatory and apoptosis inducing properties of metformin [34]. Lee et al. [10] reported that metformin ameliorates inflammatory bowel disease by suppression of the STAT3 signaling and regulation of the balance between Th17/Treg. Park et al. [35] found that metformin, by activating AMP kinase enzyme, reduces TGF-β1 expression which in turn may affect the expression of TNF-α and IL-23 leading to amelioration of the inflammatory process encountered in UC. Moreover, metformin may inhibit the inflammatory angiogenesis through attenuation of the main components of the fibrovascular tissue and inhibition of the expression of TGF-β1 and MPO [36].

I3C is one of the phytochemicals that is found in large amounts in cruciferous vegetables. In the present study, I3C administration to UC patients resulted in significant increase in tissue CAT with significant decrease in colonic endoscopic score, tissue TNF-α, TGF-β1, MDA and MPO and alleviated the histopathological and immunohistochemical changes compared to the same parameters before treatment. These results were in agreement with Busbee et al. [12] and Benson et al. [13] who reported that I3C has antioxidant, anti-inflammatory, antiproliferative and apoptosis inducing properties.

I3C was reported to have anti-inflammatory effects by inhibiting production of the proinflammatory cytokines, thereby inhibiting the expression of nuclear factor-κB, TNF-α and inducible nitric oxide synthase [37]. Moreover, I3C has the ability to act as a scavenger of free radicals and to induce the activity of various antioxidant enzymes such as CAT, superoxide dismutase and glutathione peroxidase [38]. Also, I3C was reported to inhibit MPO activity and TGF-β1 expression which may contribute to its anti-inflammatory effects in cases of UC [39,40].

In the present study, the improvement in the biochemical, histopathological and immunohistochemical parameters was significant in the group that received metformin/I3C combination compared to the groups that received either metformin or I3C alone. This might be due to the synergistic anti-inflammatory and antioxidant properties of metformin/I3C combination together with their ability to inhibit TGF-β1 and IL-23 p19 expression and to affect apoptosis of colonic mucosal cells.

5. Conclusion

The present study demonstrated that metformin and I3C have protective effect in female patients with UC due to their anti-inflammatory and antioxidant properties together with their inhibitory effects on TGF-β1 and IL-23 p19 expression in the colon with affection of apoptosis but metformin/I3C combination had the upper hand. So, it is recommended to use metformin/I3C combination as an adjuvant agent in treatment of UC to increase the efficacy and decrease the adverse effects of the traditional drugs.

Conflict of Interest

The authors declare that there is no conflict of interest.

Acknowledgements

Many thanks to Dr. Mohamed El Rashidy, Pathology Department, Faculty of Medicine, Tanta University, Egypt, for his kind help in the histopathological and immunohistochemical study.

References

[1]   | Karakoyun B, Uslu U, Ercan F, Aydin MS, Yuksel M, Ogunc AV, et al. The effect of phosphodiesterase-5 inhibition by sildenafil citrate on inflammation and apoptosis in rat experimental colitis. Life Sciences 2011; 89: 402-7.
[2]   | Kabel AM. Ameliorative Potential of Minocycline and/or Lactulose on Experimentally Induced Colitis. International Journal of Pharmacology, Phytochemistry and Ethnomedicine 2016; 2: 42-54.
[3]   | Yao J, Wang JY, Liu L, Li YX, Xun AY, Zeng WS, et al. Anti-oxidant effects of resveratrol on mice with DSS-induced ulcerative colitis. Arch Med Res 2010; 41: 288-94.
[4]   | Medhi B, Prakash A, Avti PK, Saikia UN, Pandhi P, Khanduja KL. Effect of Manuka honey and sulfasalazine in combination to promote antioxidant defense system in experimentally induced ulcerative colitis model in rats. Indian J Exp Biol 2008; 46: 583-90.
[5]   | Garrido-Mesa N, Camuesco D, Arribas B, Comalada M, Bailón E, Cueto-Sola M, et al. The intestinal anti-inflammatory effect of minocycline in experimental colitis involves both its immunomodulatory and antimicrobial properties, Pharmacol Res 2011; 63: 308-19.
[6]   | Wan P, Chen H, Guo Y, Bai AP. Advances in treatment of ulcerative colitis with herbs: from bench to bedside, World J Gastroenterol 2014; 20:14099-104.
[7]   | Nasri H, Rafieian-Kopaei M. Metformin: Current knowledge. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences 2014; 19: 658-64.
[8]   | Kabel AM, Alotaibi SN, Alswat NM, Aldajani MS, Alnefaie MS. Effect of the combination between Metformin and Vitamin D on Experimentally-Induced Diabetic Nephropathy, Int J Pharm Sci Scient Res 2016; 2: 103-9.
[9]   | Koh SJ, Kim JM, Kim IK, Ko SH, Kim JS. Anti-inflammatory mechanism of metformin and its effects in intestinal inflammation and colitis-associated colon cancer. J Gastroenterol Hepatol 2014; 29:502-10.
[10]   | Lee S-Y, Lee SH, Yang E-J, Kim E-K, Kim J-K, Shin D-Y, et al. Metformin Ameliorates Inflammatory Bowel Disease by Suppression of the STAT3 Signaling Pathway and Regulation of the between Th17/Treg Balance. Unutmaz D, ed. PLoS ONE 2015; 10(9): e0135858.
[11]   | Adwas AA, Elkhoely AA, Kabel AM, Abdel-Rahman MN, Eissa AA. Anti-cancer and cardioprotective effects of indol-3-carbinol in doxorubicin-treated mice. J Infect Chemother 2016; 22(1): 36-43.
[12]   | Busbee P, Nagarkatti M, Nagarkatti P. Mechanism of inhibition of colitis by indole-3-carbinol (96.19). The Journal of Immunology 2010; 184: 96. 19.
[13]   | Benson JM, Beamer CA, Seaver BP, Shepherd DM. Indole-3-Carbinol Exerts Sex-Specific Effects in Murine Colitis. European Journal of Inflammation 2012; 10 (3): 335-46.
[14]   | Kornbluth A, Sachar DB; Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2010; 105(3): 501-23.
[15]   | El-Sharkawy AA, Abdelmotaleb GS, Aly MK, Kabel AM. Effect of metformin on sleep disorders in adolescent girls with polycystic ovarian syndrome. J Ped Adol Gynecol 2014; 27: 347-52.
[16]   | Reed GA, Arneson DW, Putnam WC, Smith HJ, Gray JC, Sullivan DK, et al. Single-Dose and Multiple-Dose Administration of Indole-3-Carbinol to Women: Pharmacokinetics Based on 3,3′-Diindolylmethane. Cancer Epidemiol Biomarkers Prev 2006; 15: 2477.
[17]   | Pineton de Chambrun G, Peyrin-Biroulet L, Lémann M, Colombel JF. Clinical implications of mucosal healing for the management of IBD. Nat Rev Gastroenterol Hepatol 2010; 7: 15-29.
[18]   | Hirata I, Yasumoto S, Toshina K, Inoue T, Nishikawa T, Murano N, et al. Evaluation of the effect of pyrrolidine dithiocarbamate in suppressing inflammation in mice with dextran sodium sulfate-induced colitis, World J Gastroenterol 2007; 13: 1666-71.
[19]   | Staunton MJ, Gaffney EF. Tumor type is a determinant of susceptibility to apoptosis. American Journal of Clinical Pathology 1995: 103; 300-7.
[20]   | Liu Z, Yadav PK, Xu X, Su J, Chen C, Tang M, et al. The increased expression of IL-23 in inflammatory bowel disease promotes intraepithelial and lamina propria lymphocyte inflammatory responses and cytotoxicity. J LeukBiol 2011; 89: 597-606.
[21]   | Higgins CP, Bachner RL, McCallister J. Polymorpho-nuclear leukocyte species differences in the disposal of hydrogen peroxide (H2O2). Proc Soc Exp Biol Med 1978; 158: 478-81.
[22]   | Casini AF, Ferrali M, Pompella A, Maellaro E , Comporti M. Lipid peroxidation and cellular damage in extrahepatic tissues of bromobenzene-intoxicated mice. Am J Pathol 1986; 123: 520-31.
[23]   | Bradley PP, Priebat DA, Christensen RD, Rothstein G. Measurement of Cutaneous Inflammation: Estimation of Neutrophil Content with an Enzyme Marker. J Invest Dermatol 1982; 78: 206-9.
[24]   | Lowry OH, Rosebrough, NJ, Farr AL , Randall RJ. Protein measurement with Folin phenol reagent. J Biol Chem 1951; 193: 265-75.
[25]   | Balmus IM, Ciobica A, Trifan A, Stanciu C. The Implications of Oxidative Stress and Antioxidant Therapies in Inflammatory Bowel Disease: Clinical Aspects and Animal Models. Saudi J Gastroenterol 2016; 22(1):3-17.
[26]   | Rana SV, Sharma S, Prasad KK, Sinha SK, Singh K. Role of oxidative stress & antioxidant defence in ulcerative colitis patients from north India. Indian J Med Res 2014; 139(4):568-71.
[27]   | Jin Y, Yang J, Lin L, Lin Y, Zheng C.The Attenuation of Scutellariae radix Extract on Oxidative Stress for Colon Injury in Lipopolysaccharide-induced RAW264.7 Cell and 2,4,6-trinitrobenzene Sulfonic Acid-induced Ulcerative Colitis Rats. Pharmacogn Mag 2016;12(46):153-9.
[28]   | Roda G, Marocchi M, Sartini A, Roda E. Cytokine Networks in Ulcerative Colitis. Ulcers 2011; Article ID 391787.
[29]   | Teng MWL, Bowman EP, McElwee JJ, Smyth MJ, Casanova J-L, Cooper AM, et al. IL-12 and IL-23 cytokines: from discovery to targeted therapies for immune-mediated inflammatory diseases. Nature Medicine 2015; 21: 719-29.
[30]   | Tang C, Iwakura Y. IL-23 in Colitis: Targeting the Progenitors. Immunity 2012; 37(6): 957-9.
[31]   | El-Bassat H, Abo Ali L, El Yamany S, Al Shenawy H, Al Din RA, Taha A. Interleukin 23 P 19 Expression in Patients with Ulcerative Colitis and Its Relation to Disease Severity. J Mol Biomark Diagn 2014, 5:5.
[32]   | Garrity-Park M, Loftus EV Jr, Sandborn WJ, Smyrk TC. Myeloperoxidase immunohistochemistry as a measure of disease activity in ulcerative colitis: association with ulcerative colitis-colorectal cancer, tumor necrosis factor polymorphism and RUNX3 methylation. Inflamm Bowel Dis 2012;18(2):275-83.
[33]   | Masoodi I, Tijjani BM, Wani H, Hassan NS, Khan AB, Hussain S. Biomarkers in the management of ulcerative colitis: a brief review. Ger Med Sci 2011; 9: Doc03.
[34]   | Simon-Szabo´ L, Kokas M, Mandl J, Keri G, Csala M. Metformin Attenuates Palmitate-Induced Endoplasmic Reticulum Stress, Serine Phosphorylation of IRS-1 and Apoptosis in Rat Insulinoma Cells. PLoS ONE 2014; 9: e97868.
[35]   | Park IH, Um JY, Hong SM, Cho JS, Lee SH, Lee SH, et al. Metformin reduces TGF-β1-induced extracellular matrix production in nasal polyp-derived fibroblasts. Otolaryngol Head Neck Surg 2014; 150(1):148-53.
[36]   | Xavier DO, Amaral LS, Gomes MA, Rocha MA, Campos PR, Cota BD, et al. Metformin inhibits inflammatory angiogenesis in a murine sponge model. Biomed Pharmacother. 2010; 64(3):220-5.
[37]   | Tsai J-T, Liu H-C, Chen Y-H. Suppression of Inflammatory Mediators by Cruciferous Vegetable-Derived Indole-3-Carbinol and Phenylethyl Isothiocyanate in Lipopolysaccharide-Activated Macrophages. Mediators of Inflammation 2010; 2010; Article ID 293642.
[38]   | Fares F. The Anti-Carcinogenic Effect of Indole-3-Carbinol and 3, 3'-Diindolylmethane and their Mechanism of Action. Med chem 2014; S1: 002.
[39]   | Juvekar AR, Hule AK. In vitro immune effects of Indole-3-carbinol. Journal of Pharmacy Research 2009; 2(7): 1224-7.
[40]   | Takada Y, Andreeff M, Aggarwal BB. Indole-3-carbinol suppresses NF-κB and IκBα kinase activation, causing inhibition of expression of NF-κB-regulated antiapoptotic and metastatic gene products and enhancement of apoptosis in myeloid and leukemia cells. Blood 2005; 106(2):641-9.