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Table 12.2 Antimicrobial activity of various parts of CQ.
Plant part Extract Method Organism Standard Observation Ref.
Stem Ethyl acetate,
methanol,
aqueous
Agar well diffusion B. subtilis
B. cereus
S. aureus
P. aeruginosa
Streptococcus sp.
E. coli
Tetracycline Ethyl acetate extract
showed better activity
Gram-positive bacteria are
highly susceptible
59
Whole
plant
Aqueous/protease
effect
Agar well diffusion B. cereus
B. subtilis
B. megaterium
B. licheniformis
None reported Effective protease action 25
Stems Aqueous
Biosynthesized
CaO nanoparticles
using the extract
Agar well diffusion S. aureus
E. coli
P. aeruginosa
K. pneumoniae
S. typhi
Shigella dysenteriae
V. cholera
None reported Effective against Gram-
positive and Gram-
negative bacteria
60
Not
specified
Cissus quadrangularis
(CQ–silver
nanoparticles)
Agar well diffusion B. licheniformis
B. pumilus
P. aeruginosa, Vibrio
parahaemolyticus
None reported Effective against Gram-
negative bacteria
61
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Stem Methanol
Ethanol
Petroleum ether
Aqueous
Disc diffusion Escherichia species
Klebsiella species
Salmonella sp.
Pasteurella sp.
Staphylococcus
Ciprofloxacin Methanol extract showed
potential activity against
all the tested organisms
62
Stem Methanol
Ethanol
Petroleum ether
Aqueous
Clinical and Laboratory
Standard Institute (CLSI)
method using potato
dextrose
Aspergillus Ketoconazole Methanol extract showed
potential antifungal
activity
62
Leaf Aqueous
Biosynthesized
CuO nanoparticles
using the extract
CLSI method using
potato dextrose
niger
A. flavus
Carbendazim Better fungicidal activity
than standard
63
Stem Methanol Dye uptake assay Herpes simplex
virus (HSV)
Type 1 and 2
Vero cells
None Active against HSV1 and 2
at 1 : 400 dilution
64
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induced by quinalphos. The extract further brought the testosterone levels
and sperm count to normal through their androgenic activity. Phytochemical
analysis of the extract showed the presence of high levels of steroids. The high
content of ascorbic acid plays a significant role in spermatogenesis. The plant
extract was also involved in scavenging ROS generated by quinalphos and
elevating the levels of the antioxidant enzymes such as GPx, catalase (CAT),
SOD, and ascorbic acid. The plant extract increased the levels of testicular
cholesterol and activated the cholesteryl ester hydrolase and steroidogenic
acute regulatory protein (StAR) expression and steroidogenic enzymes.
68
The
ethyl acetate fraction of fresh and dry CQ stems showed 61.6% antioxidant
activity in a 2,2 diphenyl picrylhydrazyl (DPPH) assay and 64.8% antioxidant
activity in a b-carotene–linoleic acid model. The antioxidant activity of
methanol, n-hexane, and aqueous extracts were comparatively less than ethyl
acetate extract.
59
An ethanol extract of the aerial part of CQ showed prominent
dose-dependent free radical scavenging activity with IC
50
values of 98, 125,
and 96 mgmL
1
and the isolated flavonoid fraction showed 10, 12, and 14
mgmL
1
against NO, DPPH, and OH radicals.
69
Ethanolic extract of CQ was
able to reverse the decrease in the activities of antioxidant enzymes such as
SOD, GPx, GST, ALKP, and collagen in ovariectomy rats. The extract also de-
creased the lipid peroxidation and tartrate resistant acid phosphatase (TRAP)
(a marker of the osteoclast in bone resorption). The osteoclast bone resorption
generates high levels of H
2
O
2
and superoxide anions. These free radicals
modulate both inter- and intra-cellular signaling for bone loss.
70
12.3.5 Antidiabetic Activity
Methanolic extract of CQ stems produced protective action against insulin
resistance and maintained an oxidant–antioxidant balance in rats fed with a
high fat–high fructose diet. The protective action such as improvement in
insulin sensitivity, reduction in liver damage, and restoring the levels of
antioxidant and lipids to normal could be due to the high content of poly-
phenols, vitamins C and E. The total polyphenolic contents estimated were
585.40 0.16 mg gallic acid equivalent (GAE) per 100 g and the levels of
vitamin C and E were 327 mg per 100 g and 697 mg per 100 g of the powdered
extract.
71
The ethyl acetate fraction of the CQ stem is shown to be effective
against hyperglycemia-mediated oxidative stress and inflammation in the
nicotinamide/streptozotocin diabetes mellitus rat model. The extract re-
versed the increase in blood glucose, liver toxicity markers, and lipid perox-
idation enzymes. The extract led to an increase in the activities of antioxidant
enzymes (SOD, CAT, GPx, and GSH). The histopathological studies of the liver
and pancreas revealed no alteration after treatment with the CQ extracts.
72
12.3.6 Antiarthritic Activity
Kumar et al., investigated the ability of CQ in the down-regulation of
pro-inflammatory cytokines and inhibition of angiogenesis in an
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adjuvant-induced arthritis model.
73
CQ hydroalcoholic extract produced a
dose-dependent inhibition of joint swelling in both formaldehyde-induced
and adjuvant-induced arthritis. The treatment also reduced the serum tumor
necrosis factor-a (TNF-a) level, oxidative stress, and the synovial expression
of inflammatory and angiogenesis markers. This immunomod ulatory ac-
tivity on pro-inflammatory cytokines could be attributed to the presence of
kaempferol, quercetin, and b-sitosterol.
73
The anti-arthritic effect of the ac-
tive fraction of CQ (AFCQ) has been reported. Complete Freunds Adjuvant
(CFA) induced rat arthritis model was used and analyzed for hematological
and biochemical parameters. AFCQ at the dose of 100 mg per kg body weight
demonstrated an efficient anti-arthritic effect when compared with celecoxib
and methotrexate. The results were further analyzed through histopathology
and radiography to confirm its efficacy and they were found to be effective in
the management and treatment of arthritis.
4
CQ stem and root extracts were
tested against standard drug naproxen in a mono sodium iodoacetate in-
duced experimental in vivo osteoarthritis (OA) model. CQ stem extract
showed better therapeutic activity than root extracts. The difference in the
activity could be due to the chemical nature and quantity of bioactive con-
stituents present in the stem that facilitated the recovery from joint tissue
damage and reduced the risk factors for the OA incidence and progression.
26
An ethanolic extract of CQ was subjected to immunomodulatory evaluation
through a carbon clearance test, the effect on serum immunoglobulins,
determination of delayed type hypersensitivity, and Candida albicans
phagocytosis test. The study results confirmed its immunoprophylactic po-
tential which might be due to the presence of active phytoconstituents with
immunomodulatory action.
74
12.3.6.1 CQ Clinical Studies for an Antiarthritic Effect
A clinical study investigated the effect of specialized topical phytotherapeutic
formulation considered during muscle atrophy, weakness inflammatory
disorders, and pain with chronic arthropathy in huma ns. This phytother-
apeutic formulation contained Cissus quadrangularis, Calotropis gigantea,
Zingiber officinalis, Rosemarinus officinale, Boswellia serrata, Curcuma longa,
and Withania somnifera mixed with sesame oil and beehives wax. Baseline
data were collected from 153 patients in the age group of 59.89 11.37 years
suffering from muscular dystrophy during osteoarthritic disorders (MD-
OADs) for 7.89 1.9 years. After six weeks of treatment with this topical
phytotherapeutic herbal composition, serum creatine kinase-MM and
aldolase-A levels were measured and compared with baseline levels. All the
participants underwent standard physical and radiographic examinations
and the results were also promising.
75
Kumar et al., 2020
34
analyzed 23 active
compounds identified from the ethanol extract of the stem part of CQ by
selecting the targets which have a major role in the degeneration and de-
stabilization of the knee joints. The study was carried out to identify small
molecules for the antiarthritic activity.
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A clinical study was conducted in South India using CQ and Zingiber of-
ficinalis (ZO) to support the recommendations of clinical guidelines to use
non-pharmacological strategies as the first-line management of OA. A total
of 60 patients enrolled in the study were divided into three groups and were
treated with CQ-5g, ZO-5g, and CQ þZO-5g, respectively. Patients experi-
enced a significant reduction in cracking pain in joints after treatment with
CQ as well as ZO individually. A prominent reduction in joint pain was
noticed after treatment with the combination of CQ þZO which confirmed
the therapeutic efficacy.
76
12.3.7 Antiulcer Activity
Methanolic extract of CQ was shown to exert a protective action on an
aspirin-induced gastric ulcer. It increased the mucus production and de-
creased lipid peroxides levels and myeloperoxidase (MPO) activity. The
antioxidant phytoconstituents such as b-carotene, ascorbic acid, ketoster-
oids, triterpenoids, calcium, b-amyrin, and a-amyrin may be involved
in protecting the aspirin-induced lesions.
77
In another mechanistic study,
CQ was found to increase in levels of GSH, SOD, CAT, GPX, and
glutathione S-transferase (GST). It decreased the lipid peroxidation and
reduced oxidative damage to DNA, thus blocking cell death.
78
Different se-
lected doses of CQ extract of 250, 500, and 750 mg per kg showed 40, 71.2,
and 72.6% protection compared to standard ranitidine (30 mg per kg of
71.9% protection). It has also been stated that ascorbic acid, the major
constituent isolated from the extract of CQ was inv olved in the increase of
interleukin (IL)-1b, IL-6, TNF-a, and interferon-gamma (IFN-g) and the de-
crease in IL-10, IL-4, and prostaglandin E
2
(PGE
2
) levels. Thus, it could be
inferred that the extract prevented the aspirin-induced gastric ulcer due to
its immunomodulatory effect.
79
12.3.8 Analgesic, Anti-inflammatory, and Antihemorrhoidal
Activity
CQ root extract has been shown to inhibit the acetic acid-induced writhing’s
and increased tail-flick withdrawal responses in mice.
76
An aqueous extract
of the aerial parts of CQ was evaluated for anti-arthritis activity against
formaldehyde-induced arthritis. The extract was found to be superior to
indomethacin in inhibiting joint inflammation. It also showed a dose-
dependent increase in antioxidant markers and a decrease in levels of pro-
oxidant markers.
73
The use of methanolic extract of CQ in the treatment of
hemorrhoids is due to its analgesic, anti-inflammatory, and venotonic
effects. It also reduced ear edema formation in rats induced by phenyl
propiolate and paw edema induced by carrageenan and arachidonic acid.
The extract exerted a venotonic effect in isolated human umbilical veins like
the mixture of bioflavono ids (90% diosmin and 10% hesperidin).
80
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The active acetone fraction of CQ was found to inhibit cyclooxygenase-1
(COX-1), cyclooxygenase-2 (COX-2), and 5-lipooxygenase (5-LOX) enzyme ac-
tivities. In addition to that, it also inhibits pro-inflammatory mediators like
inducible nitric oxide synthase (iNOS) and TNF-a. It was involved in the
translocation of nuclear transcription factor nuclear transcription factor-2
(Nrf2) important for cellular protection and cell survival. The anti-
inflammatory action of CQ could be due to the presence of luteolin and b-
sitosterol.
81
The ethyl acetate fraction of CQ inhibited the lipopolysaccharide
(LPS) induced NO. It also induced heme oxygenase-1 (HO-1) gene expression
and suppressed the iNOS and nuclear translocation of p65 NF-kBF.
82
The
exact chemical responsible for the induction of HO-1 and anti-inflammatory
action remains unclear, however quercetin is known to inhibit the LPS-
stimulated NO generation. Other chemicals such as resveratrol and picea-
tannol are inducers of HO-1 expression both in vitro and in vivo.
An ethanol extract of the whole plant of CQ at the dose of 500 mg per kg
showed 50% inhibition of carrageenan induced rat paw edema and was
nearly equivalent to the standard diclofenac at 10 mg per kg. It also showed
78% venoconstrictive effect (at the dose of 1 mgmL
1
) on endothelium intact
and denuded rat veins with EC
50
values of 0.01 and 0.03 mgmL
1
.
83
Fol-
lowing the preclinical study, a double-blind randomized controlled clinical
trial was carried out in hemorrhoid patients. A total of 160 patients were
involved in the trial and they were administered with enteric film-coated
tablets of CQ extract (100 mg CQ extract standardized to contain 10–11 mg
quercetin) at a dose of 200 mg twice per day for seven days. The findings
revealed CQ to be effective in the management of bleeding, pain, and pro-
lapse of hemorrhoid tissue.
83
They also concluded that CQ extract is safe and
effective in the management and treatment of hemorrhoids along with other
traditional methods of treatment.
12.3.9 Metabolic Syndromes: Weight Loss and
Obesity-related Activity
CQ extract in hot water showed anti-obesity action against 3T3-L1 adipo-
cytes. The extract inhibited lipid accumulation with an absence of any
cytotoxic effects against 3T3-L1 adipocytes. There are other studies that re-
port the presence of compounds such as friedelin, a-amyrone, resveratrol,
piceatannol, and pallidol.
3
Some evidence also supported that CQ inhibits
enzyme lipase and amylase enzyme, thus blocking the dietary uptake of the
carbohydrate and fat uptake. This helps in reducing fats, body weight, and
markers associated with metabolic disorders.
65
12.3.9.1 CQ Clinical Studies for Weight Loss and Obesity
It has been well documented that a change in homeostasis in food intake
and energy expenditure is related to obesity. Several plant-based products
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are available in the market for weight loss and the comparative effect of each
product is still in question. CQ formulation (CQR-300) was tested for its
effect on weight loss and central obesity in a randomized, double-blind,
placebo controlled clinical trial. The study involved 123 overweight and
obese subjects including males (47.2%) and females (52.8%) in the age
group of 19–50 years. They were divided into two groups based on body mass
index parameter (BMI) into CQ formulation and placebo group. All the study
participants were treated with two daily doses of formulation or placebo and
remained on a normal or calorie-controlled diet for 8 weeks. At the end of the
clinical trial, net reductions in weight and central obesity, as well as in
fasting blood glucose, total cholesterol, low density lipoprotein (LDL)-chol-
esterol, triglycerides, and C-reactive protein (CRP) were observed in partici-
pants. This study also confirmed the effect of CQ in the management of
weight loss and metabolic syndrome.
84
Similar results were also reported by
another clinical trial using CQ aqueous leaf and stem extracts at the dose
range of 300 mg per kg body weight in humans and they concluded that CQ
was effective in the management of metabolic syndromes in overweight in-
dividuals.
85
Encouraged by the results, an additional pilot clinical study for
eight weeks was conducted to confirm the effect of CQ in reducing the
percentage of body fat measured using two different methods-bioelectrical
impedance assays versus dual-energy X-ray absorptiometry (DEXA). It was a
double blinded, placebo-controlled study that enrolled 67 participants. The
participants were counseled to maintain normal exercise and diet. They were
further divided into two groups placebo (32 participants) and the CQR-300
group (35 participants) and were given 300 mg of corn starch or CQR-300
daily. After 8 weeks of the trial, the placebo group showed only a 1.05%
decrease in body fat, whereas the CQR-300 treated group showed 8.9 and
12.8% decrease in the body fat as measured by impedance and DEXA, re-
spectively. The CQR treated group also showed a significant (po0.05) de-
crease in waist and hip circumferences, systolic and diastolic blood
pressures, total cholesterol, triglycerides, fasting blood glucose, as well as
leptin levels but an increase in high density lipoprotein (HDL) cholesterol
level and adiponectin levels.
86
A preclinical in vivo study evaluated the appetite suppression efficacy of
well-known products including CQ. They tested pure caffeine, potato skin
extract, CQ extract, Garcinia cambogia extract, Crocus sativus extract, rasp-
berry ketone isolated from Rubus idaeus, one commercial product (Appetrex),
and one novel composition (UP601). The CQ extract showed a significant
reduction in food consumption at the 2 h time point with 44.3% after food
provision at an equivalent human dosage of 10 g.
87
CQ showed significant
weight loss activity in another randomized clinical trial conducted using
seven herbal medicines. Three (C. quadrangularis, S. indicus combined with
G. mangostana, and I. gabonensis) of the seven herbal medicines showed
prominent beneficial effects and CQ was one of them. As per the consoli-
dated report of Maunder et al., this trial was conducted only for a duration
of 8–10 weeks and there existed some reporting and confirmation bias.
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Therefore, more evidence is needed to take a decision about its effect on
weight loss. They also recommended further investigation in a large popu-
lation to confirm the dose, dosage, long term safety, and efficacy because
one single clinical study is not sufficient to recommend a herbal drug for
weight loss/obesity managem ent.
88
Chatree et al., in a clinical study, elucidated the effect of CQ extract on
obesity, lipolysis, and browning of human white adipocytes (hWA). It was
observed that treatment of obese subjects with CQ significantly reduced
waist and hip circumferences at weeks 4 and 8 when compared with the
baseline value. The effective reduction in the serum leptin level, hWA as-
sociated glycerol level were also noted. They also reported that CQ extract
can enhance the UCP1mRNA expression in hWA in a dose dependent
manner suggestive of its browning effect on hWA.
89
12.3.10 Wound Healing Activity
Aqueous and methanolic extract of the whole aerial part of CQ showed an
effective wound healing property in BALB/c female mice with respect to the
standard oxytetracycline ointment. It was noted that CQ extract had a su-
perior wound healing property as the wound area completely returned to the
normal structure by day 15 of the experiment with complete epithelization
and the presence of mature collagen fibers in the skin.
90
The role of herbal
medicines in stem cell therapy is reviewed by Udalamaththa and group. They
suggested that CQ might play a prominent role in stem cell therapy in the
future based on its effect in scaffold and bone regeneration therapy.
91
12.3.11 Neurological Activity
CQ is traditionally used for its anticonvulsant effect. Neuropharmacological
effects of methanolic extract of CQ roots were evaluated in a mice model. CQ
extract at the dose of 50, 100, and 200 mg per kg showed a reduction in
exploratory behavior, motor coordination, spontaneous motor activity, and
prolonged pentobarbitone sleeping time. This study confirmed that the
methanolic root extract of CQ contains some phytoconstituents that act
centrally and produce CNS related action espe cially the sedative effect.
92
Anxiolytic and antiepileptic effects of the aqueous extract of CQ were
evaluated in mice using an elevat ed plus maze, open field paradigms model
and convulsion induced model. Four different doses of CQ extract were used
for evaluation (37.22, 93.05, 186.11, and 372.21 mg per kg, per oral) and the
effects were compared with standard drug sodium valproate (300 mg per kg).
The involvement of GABAergic neurotransmission was determined by
measuring the levels of malondialdehyde, GSH, gamma amino benzoic acid
(GABA), and GABA-transaminase in the hippocampus of sacrificed epileptic
mice. CQ extract significantly decreased the number and duration of seiz-
ures and also increased the number and time spent in the open arm and
reduced the number and time spent in the closed arm. This evaluation
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supported the anticonvulsant and anxiolytic activities of CQ and the plaus-
ible mechanism through GABA transmission.
93
12.3.12 Anticancer Activity
The ethanol extract and isolated flavonoid fraction of the aerial part of CQ
were subjected to anticancer evaluation in breast cancer cell lines (MCF-7) by
MTT assay. The results depicted that the flavonoid fraction exhibits potent
anticancer activity with an IC
50
value of 40 mgmL
1
.
69
Another study ex-
plored the genotoxic and apoptotic effects of ethanolic extract of CQ in A431
cells by 3-(4,5-dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide (MTT)
assay. CQ extract showed dose dependent cytotoxic effects and also displayed
significant production of intracellular ROS in the cells. Genotoxicity analysis
by acridine orange staining depicted significant induction of chromosomal
condensation. DNA fragmentation analysis showed that CQ extract caused
DNA damage in A431 cells in a concentration-dependent manner. The re-
sults of this study correlate the effect of CQ toward apoptosis and
genotoxicity.
94
12.3.13 Role in Sarcopenia: Muscle Wasting Diseases
In recent years, there has been an increase in the incidence rate of sarco-
penia and muscle wasting diseases with the increase in global life expect-
ancy. In an attempt to identify a herbal formulation, a preclinical study was
conducted using a combination of Boswellia serrata, Cissus quadrangularis,
and Withania somnifera (HIM-CHX) for the management of sarcopenia with
the dose range of 120, 250, and 500 mg per kg body weight. The effect of this
formulation on muscle mass, grip strength, motor coordination, gait, and
locomotor activity in rats was evaluated. Molecular level analysis like the
measurement of inflamm atory cytokines, myokines, and growth hormone
has also been evaluated. The results showed that HIM-CHX displayed a
significant improvement in gastrocnemius muscle weight, carcass weight,
locomotor, gait, and endurance. It also reduced TNF-a, IL-6, and myostatin
with an increase in IGF-1 level. This study confirmed the potentiality of the
formulation in correcting the pathophysiological changes associated with
sarcopenia.
95
12.4 CQ in Nanotechnology
CQ plants owing to their rich content of bioactive chemical constituents
have been used extensively for the green synthesis of nanoparticles including
gold, silver, and copper oxide. The use of CQ plant extract offers a simple,
eco-friendly, and cheaper alternative method to synthesize stable, uniform,
spherical, and crystalline nanoparticles with a broad spectrum of biological
activities.
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12.4.1 Silver Nanoparticles (AgNPs)
In an eco-friendly and green syn thetic approach , aqueous extract of CQ stem
was used to synthesize AgNPs as a potential antiparasitic agent. FTIR sug-
gested the presence of phenolic compounds on the surface of AgNPs. CQ
synthesized AgNPs exhibited potent adulticidal and larvicidal activity against
Hippobosca maculate (LC
50
6.30 mg L
1
) and Rhipicephalus microplus (LC
50
7.61 mgL
1
).
96
Acute toxicity of the AgNPs of CQ against Poecilia reticulata
larvae and antibiofilm activity against Gram-positive and Gram-negative
bacteria was investigated by Sathappan et al. Treatment with the CQ nano-
particles reduced the average thickn ess in both bacteria. The toxicity study
against P. reticulata larvae showed 100% mortality in 40% CQ AgNPs
(20 mgmL
1
) wherea s no mortality was observed with CQ extract up to
500 mgmL
1
.
61
12.4.2 Gold Nanoparticles (AuNPs)
Microwave irradiation of hydrogen tetrachloroaurate with CQ aqueous ex-
tract (for just 40 s at pH 9) have been used to synthesize gold nanoparticles.
The AuNPs were of small size, stable, spherical, and crystalline in nature
which were observed to be biocompatible in a hemolysis assay. It was pro-
posed that the presence of flavonoids, stilbenes, and ascorbic acid in CQ
extract are responsible for the reduction of gold particles. Furthermore,
Fourier transform-IR and thermogravimetric analysis revealed that CQ ex-
tract components were also capping the synthesized AuNPs.
97
12.4.3 Copper Oxide Nanoparticles (CuONPs)
Devipriya and Roopan in 2017 used CQ aqueous extract for the green syn-
thesis of CuONPs. The synthesized NPs were spherical and crystalline with
65.85 and 18.98% of Cu and O, respectively exhibiting good fungicidal ac-
tivity against Aspergillus niger and A. flavus.
63
12.5 Biomedical Applications of CQ
Parvathi et al., fabricated poly-L-lactic acid (PLLA) nanofibers loaded with CQ
extract (20 and 40 w/w%) using an electrospinning technique for bone tissue
engineering and drug delivery applications. The herbal hydrophilic fibrous
sheet containing high percentages of CQ was designed to heal critical sized
segmental bone defects. The hydrophobicity of the PLLA fibers was reduced
and the power of adhesion, proliferation, and differentiation of the me-
senchymal cells was significantly increased. The fiber was also found to be
capable of promoting mineralization in one of the simulated body fluids. It
showed enhanced protein absorption and an osteoinductive property mak-
ing it an ideal biomaterial candidate for bone grafting. The improved os-
teoinductivity of nanofibers was attributed to the presence of ascorbic acid,
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