Harsha Hegde & Subarna Roy, ICMR-National Institute of Traditional Medicine, Indian Council of Medical Research, Dept. of Health Research, Government of India

Abstract

Background: Traditional medicines (TMs), deeply rooted in indigenous knowledge and culture, are widely used globally. Despite their growing popularity, they lack sufficient scientific validation in the context of modern science, raising concerns about their safety and efficacy.

Objective: This review discusses the role of the ICMR-National Institute of Traditional Medicine (ICMR-NITM) in validating TMs, particularly herbal medicines commonly practiced in India, using modern scientific tools.

Methods: ICMR-NITM employs a reverse pharmacology approach, with a focus on documenting traditional practices, pharmacognostic analysis, phytochemistry, toxicology, preclinical and mechanistic studies and finally, clinical evaluation. Emphasis is placed on community-based validation cycles.

Results: Various medicinal plants were scientifically validated for safety and efficacy. Significant advancements have been made in pharmacognostic studies, chemical profiling, and toxicity assessments.

Conclusion: Validation of TMs through modern science is crucial for their integration into healthcare. ICMR-NITM’s efforts provide a framework for future research and the sustainable use of traditional knowledge in modern medicine.

Traditional Medicines

Traditional Medicine (TM) refers to the health practices, approaches, knowledge, and beliefs developed over generations within various cultures (WHO, 2013). It is often used to prevent, diagnose, and treat illnesses. Unlike modern medicine, TM is rooted in cultural traditions and may include a holistic view of health. Though TMs are not the mainstay for treating major diseases, they are invaluable in preventing and managing chronic ailments and addressing the health demands of ageing populations. According to some estimates, over 80% of the world’s population uses TM products in some form, and the tendency is growing (Thakkar et al., 2020). The increasing usage of TM products is attributed to a preference for ‘natural or holistic’ approaches, a desire for a high degree of autonomy in self-management, and a perception of ultimate safety (Hirschkorn et al., 2006; Hassan et al., 2009).

Traditional Medicines as rich legacy of Traditional Knowledge across the world

Traditional medicines have long been a rich source of indigenous knowledge across the world, playing an essential role in the health and well-being of numerous communities. Indigenous systems of medicine are often deeply rooted in cultural, spiritual, and ecological knowledge, passed down through generations, often in oral forms. These practices and remedies are typically based on local flora, fauna, and natural elements, tailored to suit local environmental conditions and/or diseases.

Traditional medicine is often connected to rituals, customs, and spiritual beliefs, providing not only physical healing but also cultural continuity and identity for indigenous groups. Indigenous communities have a deep understanding of the medicinal properties of local plants, animals, and minerals. This knowledge is highly specific to local ecosystems, guiding the sustainable use of biodiversity. Indigenous medicine often views health holistically, focusing on the balance between mind, body, spirit, and community, rather than merely treating symptoms. The balance of energies and prevention are central.

Some of the global examples are:

-       India (Ayurveda and Unani): Ayurvedic practices use herbs like turmeric, ginger, and ashwagandha for healing, integrating principles of balance and energy.

-       China (Traditional Chinese Medicine): Herbal medicine, acupuncture, and qigong are key components of Traditional Chinese Medicine, drawing on ancient texts like the Huangdi Neijing.

-       Africa: Various African countries have rich traditions of using herbal remedies and spiritual healing practices. For example, in South Africa, sangomas (healers) use herbs like buchu for treating ailments.

-       South America: Indigenous groups in the Amazon use a vast array of plants, many of which have not been fully studied by modern science. Ayahuasca, a brew with psychoactive properties, is used in spiritual ceremonies.

-       North America: Native American tribes, like the Navajo or Lakota, have herbalists and spiritual healers who utilize plants such as sage, echinacea, and bearberry for various health conditions.

Many pharmaceutical drugs used today have origins in traditional medicines. Indigenous knowledge has contributed to the discovery of compounds in plants like quinine (used for malaria), aspirin (from willow bark), and many others. Traditional medicine often emphasizes the sustainable use of natural resources and many indigenous practices involve the conservation of plants and careful harvesting to maintain ecosystems.

Present day challenges include the erosion of knowledge due to globalization, industrialization, and the loss of natural habitats that threaten indigenous knowledge systems. Younger generations are often found to be less exposed to traditional medicine practices. There are also issues with biopiracy and commercialization of indigenous knowledge without proper compensation or recognition of the original source become remain contentious. Pharmaceutical companies are often accused of patenting medicinal ingredients used by indigenous communities for centuries.

There is increasing recognition of the value of traditional medicine in complementing modern healthcare, leading to integrative approaches in many countries. However, tensions remain between traditional practitioners and modern medical systems across the globe.

Preserving traditional medicine involves safeguarding not just the plants and ingredients used but also the cultural practices, languages, and ecological knowledge that underpin these systems.

Codified and Non-Codified systems within Traditional Medicine practices

TMs are often classified into codified and non-codified systems based on the availability of the written scripts on TMs. The codified traditional medicine systems refer to systems of medicine that have been formally documented, standardized, and often recognised by governmental or regulatory bodies. These systems typically have written texts, guidelines, and established practices that define their use.

The non-codified system are, on the other hand, practices that are often not available in authentic written scripts, mostly comprises of knowledge handed over from generation to generation by oral and ritual means.

Most folklore and health practices of indigenous tribes and communities fall under this category. Non-codified systems form a large part of the wealth of indigenous knowledge systems that require preservation.

Traditional Medicine practices in India

In India, Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa, and Homeopathy (collectively known as AYUSH) are the codified systems of TM in practice. On the other hand, the non-codified TMs consist of practices that are primarily based on oral traditions, local customs, and community knowledge. These systems lack formal documentation and standardization, making them more varied and individualized. Folk medicines and indigenous healing practices are included among such systems.

In India, over 80% of the rural population use medicinal herbs or traditional medicines, especially for their primary healthcare (Mukherjee & Wahile, 2006). It includes both codified systems and non-codified practices. TM practices are deeply embedded in Indian culture and continue to play a vital role in healthcare, wellness, and spirituality nationwide.

A reason behind India’s strong wealth of knowledge in traditional medicines is its mega-diversity that harbours 7-8% of all recorded species; 45,000 different plant species (in addition to 91,000 animals) distributed in 15 agro-climatic zones, India boasts of the presence of 17,000 to 18,000 species of flowering plants out of which 6,000 to 7,000 are designated to have medicinal value (National Biodiversity Authority, India, 2014, NMPB http://www.nmpb.nic.in).

Surge in TM use

The past decade has witnessed a tremendous surge in acceptance and public interest in natural therapies both in developing and developed countries. Herbal remedies are available not only in drug stores but now also in food stores, supermarkets and on e-commerce platforms (Ekor, 2013). A major reason why the industry is falling back on nature is the difficulty in identifying new lead structures, the high cost of classical drug discovery, and the huge burden of drug failures in recent history. Bandaranayake (2006) has listed out some other possible reasons for the new interest in herbals, many of which are criticised largely because of a lack of data on safety and proven efficacy (Ekor, 2013).

Need for validation of TMs

Despite centuries of use, one of the major drawbacks of TMs is the scarcity of scientific literature that demonstrates and documents the safety and efficacy of these medicines. In an informed world, evidence is a prerequisite for advocacy. With the development of sophisticated tools and modern technologies, it has become imperative that TMs are tested for their use and relevance in the modern-day environment. Therefore, there is a requirement for validation (often called re-validation) of traditional medicines to establish their utility. Furthermore, because of their natural origin, there are often issues with their contents, depleting plant/natural resources, problems with misidentification/substitution/adulteration of crude drugs, microbial contamination and shelf life, undermining of safety and toxicity, there is a need to establish certain standards. There is also an urgent need for regulations to ensure the safety and efficacy of traditional medicines, which in turn require scientific evidence based on the data. Therefore, these TM practices need to be scientifically validated to provide evidence of their safety and efficacy, to ensure better patient care and reliability and for their wider acceptance.

Validation of TM at ICMR-National Institute of Traditional Medicine (ICMR-NITM), Belagavi, India

The ICMR-National Institute of Traditional Medicine (https://icmrnitm.res.in/), located at Belagavi in Karnataka State, India, is one of the Institutes of Indian Council of Medical Research under the Department of Health Research, Ministry of Health and Family Welfare, Government of India. It is a premier institution dedicated to the research, education, and promotion of traditional medicine systems in India. Established to support integrating traditional healing practices with modern scientific methodologies, ICMR-NITM plays a vital role in advancing the understanding and application of various traditional medicine systems.

ICMR-NITM works mainly in two research domains; the first one is to generate knowledge in the area of conventional medicine, including modern technologies for diseases of importance, while the second domain is to conduct research on knowledge systems of Indian TMs, including both codified and non-codified systems. The overall objective is to generate evidence on the safety and efficacy of TMs, so that those could be integrated into the health care system for better health outcomes (Fig. 1). It is also aimed to generate the required evidences on various TM systems to enable the Government to frame suitable policies and frameworks to regulate the TM systems in India.

This article is limited to the aspects of ICMR-NITM’s validation of herbal medicines, the mainstay of various forms of traditional medicines practised in India.

Herbal Medicines

Herbal medicines are medicinal products consisting of a substance produced by subjecting a plant or plants to drying, crushing or any other processes or of a mixture whose sole ingredients are two or more substances so produced. It is a mixture of herbs/plants for therapeutic value.

About 30% of the worldwide sales of drugs are based on natural products originating from traditional medicines. Even modern drugs like morphine, quinine, cocaine, tubocurarine, pilocarpine, reserpine, etc., were derived from traditional medicinal forms. Traditional medicines have also provided new lead structures, templates and scaffolds for modern drug discovery. It has been reported that 39% of 520 new approved drugs are derived from natural products. Natural products also contribute to 60-80% of antibacterial & anticancer drugs (Newman & Cragg, 2012). It has been reported that about 80% of 122 plant-derived drugs were related to their original ethnopharmacological use. Current drug discovery from plants based upon bioactivity-guided fractionation has led to the isolation of many important anticancer drugs such as paclitaxel, camptothecin, etc. The first therapeutic commercial pure natural product discovered this way was morphine (1826), while the first semi-synthetic pure drug, aspirin by Bayer, was based on salicin, isolated from the plant Salix alba. Isolation of other drugs, e.g. cocaine, codeine, digitoxin, quinine and pilocarpine, followed. Some are still in use, and others have undergone development from plant-derived compounds (Fabricant & Farnsworth, 2001).

Although animal products, minerals, etc., are also often used in various forms of traditional medicine, this paper is restricted to the validation of herbal medicines.

For the validation, ICMR-NITM follows the ‘Reverse Pharmacology’ approach. This approach of TM research is defined as the science of integrating documented clinical experiences and experimental observations into leads by transdisciplinary exploratory studies and further developing these into drug candidates through robust preclinical and clinical research (Patwardhan et al. 2008). The Reverse Pharmacology approach aims to reduce the major bottlenecks of cost, time and toxicity in TM research. The application starts with proper documentation of TM practice, including clinical observations; followed by the exploratory studies in relevant in vitro and in vivo models; and the third phase is validation through experimental studies, both laboratory and clinical setups. In this approach, the lead travels a reverse path from ‘clinics to laboratory’ rather than classical ‘laboratory to clinics’.

Validation cycle for TM at ICMR-NITM

The validation cycle, which is being followed at ICMR-NITM, starts in the community settings, traverses through various laboratory procedures and ends again in the community or clinical settings (Fig. 2). This validation cycle aims to provide the community either with a validated practice, which is safe to use and efficacious in treatment or to develop a validated product by value addition to the existing practice, which is found to be safe and effective. The first approach empowers the community directly while ensuring the safety and efficacy of the locally used TM practice, whereas the second approach adds value to the validated practice enabling further development into products for their wider utility (Fig. 3).

The details on each of the steps with the examples and the outcome so far are discussed below.

1.     Documentation of TM practices:

The first step in the research on TMs is correct documentation of TM practices, especially for those from non-codified systems. The use of medicinal plants, animal or mineral sources are properly documented through visits to the TM practitioners and through observational studies. The documentation is done through discussions and semi-structured interviews with the identified TM practitioners. The data is collected in the validated data capturing format and the corresponding herbarium specimens are preserved at the herbaria of the Institute. The perspectives from the patients attending to the practice are also documented to generate preliminary information about the clinical safety and efficacy of the practice from the patient’s point of view.

ICMR-NITM is involved in such documentation since its inception in 2006 and it coordinated the documentation of the medicinal plants employed in the TM practices of the Western Ghats in India, which has been compiled into a ‘Database on ethnomedicinal plants of Western Ghats’ (Upadhya et al., 2009a). This database has free access from the website of the Institute (https://nitmmedplantsdb.in/) (Fig. 4). Various TM practices from the Belagavi region in Karnataka (Upadhya et al., 2009b) and their present scenario (Upadhya et al. 2014a) have been studied in detail. The details of TM practices for reproductive health (Hegde et al., 2007) and bone fractures (Upadhya et al., 2012) from the region were also recorded by the Institute.

The documentation of traditional medicinal practices is vital for preserving cultural heritage and also to set the platform for their validation process. As it is not possible to validate all the documented TM practices due to the limitations of time and resources, and therefore, only a few of the practices are prioritised. The selection of TM practices for validation is a multifaceted process that requires careful consideration of the history of their use, availability of evidence base, and economic viability, in addition to empirical and practical factors. The availability of the resources and their sustenance is also a factor for selection. For example, the plants that are endangered, the plant parts leading to destructive harvesting of plants such as roots and bark, seasonal plants, etc., are normally considered not suitable for the validation process. Employing such criteria, the TM remedies that hold the most significant promise for safety and efficacy are selected for further validation.

In the process of documentation of ethnomedicinal use of plants, ICMR-NITM could also locate and report a few rare and a few new plant species from the region (Mesta et al., 2009; Mesta et al., 2011; Pai et al., 2011) contributing to set conservation priorities for medicinal plants in the region.

During the documentation process, ICMR-NITM also created a Directory of Traditional (Folk Healers in Non-codified TM practice) in the Western Ghats region with details such as their names, telephone numbers, types of conditions they treat, how they have learnt the treatment, etc. (Fig. 3). This Directory is not in the public domain as it contains the personal information of the folk healers. However, this Directory not only helps find the set of healers for a particular disease during specific research needs but also helps the Institute conduct Traditional Healers’ Meet from time to time to share knowledge between healers and scientists and understand the needs from both perspectives.

1.     Pharmacognosy and Ethnomedicine

Pharmacognosy is an invaluable tool for ensuring the quality of medicinal plants. By employing a range of scientific techniques for identification, standardization and quality testing, pharmacognosy supports the reliable use of herbal medicines in healthcare.

As examples, we take the cases of the two important medicinal plants viz. Achyranthes aspera L. and Piper nigrum L. The root of the former is used for the treatment of various fevers and poisonous bites, while the fruits of the latter are extensively used as spice and also in treating cold and cough, and inflammations. ICMR-NITM noted the instances of the adulterations of these plant drugs with other allied species of plants from the same genus. The detailed pharmacognostic evaluations of allied species in the genera Achyranthes (A. aspera L. and A. coynei Sant.) (Upadhya et al., 2014b; Upadhya et al., 2015) and Piper (P. nigrum L. and P. trichostachyon (Miq.) C.DC.) (Upadhya et al., 2016; Balekundri et al., 2024) enabled their differentiation, so that the authenticity of the raw drugs are ensured.

Saraca asoca (Roxb.) Willd., commonly known as ‘Sita ashok’ in India, is now an endangered species but is extensively used as a tonic for many gynaecological disorders. It is often found contaminated, substituted or even adulterated with materials from other plants like Polyalthia longifolia (Sonn.) Thw., Mesua ferrea L., etc. ICMR-NITM’s studies on phytochemical and genetic profiling of Saraca asoca (Roxb.) Willd. addressed the identification and differentiation issues and led to ways that help differentiate S. asoca from its adulterants even in commercial market samples (Hegde et al., 2017). The studies on seasonal variations in the chemical constituents in the bark of S. asoca revealed marked seasonal variations and helped in standardizing the right season for its collection (Ketkar et al., 2015a; Ketkar et al., 2015b).

Shikimic acid is the precursor to oseltamivir, one of the most important anti-viral drugs, mostly used for treatment of influenza, particularly suspected swine flu. Shikimic acid is conventionally isolated from medicinal plants like Illicium verum Hook.f. (Star anise). However, this particular plant rarely grows in India. ICMR-NITM screened fifty eight tree species from the Western Ghats of India for their shikimic acid content, and identified the potential plants species for downstream applications to enhance their shikimic acid content (Kshirsagar et al., 2018).

Further, studies have also been carried out to validate certain principles and practices of Ayurveda, one of the oldest TM systems in the world practised widely in India. In Ayurveda, certain toxic plants are used for their beneficial effects, after their detoxification. The study on the method of traditional detoxification (Shodhana) of two such toxic plants, Plumbago zeylanica L. and Aconitum chasmanthum Holmes, showed that the levels of toxicity have been drastically reduced following the traditional detoxification procedures (Ankad et al., 2024; ICMR-NITM Unpublished data). The classical Ayurveda preparations Panchagavya (made of five ingredients from cow-based products) and Kunapa jala (a product based on Ayurveda literature for enhanced plant growth) were found to enhance plant growth on their application to plants and also enhanced the important bioactive components in the experimental plants viz. Withania somnifera L. and Andrographis paniculata Nees (Ankad et al., 2017; Ankad et al., 2018; Ankad et al., 2020).

As interest in natural remedies continues to grow, the role of pharmacognosy will be increasingly vital in ensuring the use of correct plant drugs so that the safety and effectiveness of medicinal plants used are beneficial to both patients and practitioners alike.

2.     Phytochemistry

Phytochemical investigations help to know the chemicals and bio-actives present in the plants that are utilized in TM practices. This chemo profiling and chemical analysis is performed using various chromatographic and analytical methods and instrumentations, which include column chromatography, High Performance Liquid Chromatography (HPLC), Ultra Flow Liquid Chromatography (UFLC), High-Performance Thin Layer Chromatography (HPTLC), Gas Chromatography (GC), Mass Spectrometry (MS), Fourier Transform-Infrared Spectroscopy (FTIR) and Nuclear Magnetic Resonance (NMR) spectroscopy.

The chemical composition of traditional medicinal plants is critical to understanding their therapeutic properties and potential applications in healthcare. These plants contain a diverse array of bioactive compounds that contribute to their medicinal effects.

While modern techniques and methods have helped identify bioactive compounds from some medicinal plants, identification of active principles has remained elusive for most medicinal plants even today. It has often been found that multiple molecules play an important role in the activities of medicinal plants in vivo, and therefore, these molecules in isolation often fail to elicit the response that the crude drugs or their extracts/fractions elicit. Nonetheless, there are continuous efforts to identify active molecules and understand the modes of action of these medicinal plants.

As essential oils play a significant role in the biological activity of plants, several medicinal plants have been screened for the chemical compositions of their essential oils. The essential oils of various parts are from well-known plants in Indian TM practices such as Feronia elephantum Correa (Joshi et al., 2011), Tridax procumbens L. (Joshi et al., 2012), Chromolaena odorata (L.) RM King & H. Rob (Joshi et al., 2013a), Ocimum gratissimum L. and O. sanctum L. (Joshi et al., 2013b), Cyathocline purpurea (Buch.-Ham. ex D. Don) Kuntze (Joshi, 2013c), Chloroxylon swietenia DC (Ankad et al., 2014), and Saraca asoca (Roxb.) Wilde (Joshi, 2015) have been subjected to chemical profiling, along with evaluating their antimicrobial activities. The chemical profiling of extracts and quantification of known bio-active compounds were carried out for other traditionally used plants such as Achyranthes coynei Sant. (Upadhya et al., 2013), four allied species of Ocimum (Pai & Joshi, 2016) and four species of Terminalia (Bidikar et al., 2023).

The chemistry of the plants was also used to differentiate the chemotypes of Mentha spicata L. (Joshi, 2013d) and profile the aroma pattern of Mentha arvensis L. (Joshi, 2014) in the Belagavi region in India.

The development of new methods for identification, quantification and analysis of known phytocompounds from medicinal plants helps in either speeding up the process or enhancing the efficiency. Compound-specific extraction methods were developed for Camptothecin from Nothapodytes nimmoniana (Grah.) Mabb and Piperine from Piper nigrum L. (Upadhya et al., 2014), while methods for analysis were developed for betulinic and oleanolic acids from Achyranthes aspera L. (Pai et al., 2014), Nitrosamines in tobacco (Sharma et al., 2015) and piperene from Piper trichostachyon (Miq.) C.DC. (Hurkadale et al., 2021). The elite population for the production of bio-active compounds like camptothecin in Nothapodytes nimmoniana (Grah.) Mabb. (Ankad et al., 2015), mangiferin from Swertia sps. (Kshirsagar et al., 2016), and oleanolic and ursolic acids from Achyranthes aspera L. (Pai et al., 2016) were identified through the content range analysis of the desired compounds.

The chemical composition of traditional medicinal plants is complex and varied, encompassing a wide range of bioactive compounds. Understanding these constituents is crucial for validating traditional uses, ensuring safety, and discovering new therapeutic applications. Ongoing research into the chemical profiles of these plants not only enhances our knowledge of their health benefits but also supports their use in the TM systems.

3.     Toxicology and safety studies

Toxicology and safety studies of TM are crucial for ensuring their safety at the first level. This will also help establish safe dosage ranges to prevent any adverse effects of the TMs. The toxicity studies of the TMs are carried out at ICMR-NITM first in in vitro system (in cell lines), and then evaluated in suitable in vivo models (in animal models). In vivo studies are carried out in zebrafish models initially and then in rodent models, wherever required, following standard protocols and Institutional Animal Ethics Committee recommendations. The TMs are evaluated for their acute toxicity (effects of a single dose over a short period), chronic toxicity (long-term exposure and its effects), genotoxicity (potential to damage genetic information), and reproductive and developmental toxicity (effects on fertility and foetal development). Generally, the safety studies are conducted along with the efficacy studies to save time and resources, except for a few (Kumar et al., 2015), and therefore, they are discussed in sections 5 & 6 along with laboratory studies (for in vitro models) and pharmacology and pre-clinical studies (for in vivo models) respectively.

The safety and toxicological data are crucial in developing modern scientific evidence for TM to ensure their safety before the efficacy. This will also help to monitor the unsolicited adverse events of the TM practices, especially with the dose adjustments.

4.     Laboratory studies

Laboratory studies of the TMs generally involve scientific investigations to understand the mechanisms of action of the TM as a whole or its ingredients and contents. These involve in silico studies using bioinformatics tools, microbiology and molecular biological studies, and biotechnological applications.

4.1.  In silico studies (Bioinformatics)

In silico studies refer to computational methods used to analyse biological data and simulate biological processes, particularly in the context of drug actions. Applying in silico techniques to medicinal plants has gained significant traction, providing valuable insights into their chemical properties, potential therapeutic effects, and mechanisms of action.

While working on in silico studies of medicinal plants involved in TM, ICMR-NITM developed a new concept and niche area of ‘Herbal Informatics’ in 2013 (Fig. 5). Herbal informatics is a multidisciplinary approach that links traditional knowledge to modern medicine using information technology and big data biology. It starts with information on the plants used to treat various disease conditions from the TM knowledge base (e.g., the Database of Ethnomedicinal Plants of Western Ghats, developed by ICMR-NITM). This is correlated with the modern description and definition of the identified disease condition, and information available in the medical literature (e.g. PubMed) on the disease metabolites. Then data science takes the lead with the identification of the phytocompounds in the plants and the targets for the identified disease conditions by applying various bioinformatics tools (Fig. 5). This leads to identifying the active phytocompounds from the plants, which bind to the disease-specific targets, and thus helps in predicting the action of the phytocompounds present in the plants. The plants or the phytocompounds thus selected are further subjected to their we-lab evaluations. Thus, the herbal informatics approach acts as a sieve to shortlist the plants from TM for their further evaluations, saving time, material resources and effort.

ICMR-NITM was amongst the first to use this approach of ‘Herbal Informatics’ on Reverse Pharmacology validation of TMs. Using Herbal Informatics, ICMR-NITM decoded the plant metabolite-disease target linkages in many traditionally used medicinal plants. The roles of gymnemagenin from Gymnema sylvestre (Retz.,) R.Br. in diabetes (Rathore et al., 2016); flavonoids and diterpenoids from Andrographis paniculata Nees and Thespesia populnea (L.) Sol ex Correa in hepatocellular carcinoma induced by hepatitis B (Patil et al., 2022); and efficacy of Theobroma cacao L. against doxorubicin-induced organ toxicity were predicted based on the bioinformatics studies (Patil et al., 2023a). Further, the molecular mechanism of actions of Withania somnifera (L.) Dunal against cancer (Deshpande et al., 2023a), Garcinia indica Choisy (Beerwala et al., 2024) and Bidens pilosa L. (Galagali et al., 2024) against alpha-amylase inhibitory activity, and selected phytocompounds from medicinal plants against diabetes mellitus (Patil et al., 2020), rheumatoid arthritis (Deshpande et al., 2023b), hepatitis B (Patil et al., 2023b) were deciphered employing such computational studies. The in silico approach was also found useful in predicting the phytochemical moieties from Indian TM for targeting dual hotspots on SARS-CoV-2 spike protein (Umashankar et al., 2021), and profiling a natural product, diosgenin, against breast cancer (Khanal et al., 2023).

In silico studies are transforming the field of medicinal plant research by providing powerful tools for understanding the chemical properties, biological activities, and therapeutic potentials of plant-derived compounds. The availability of tools to draw network maps in biochemical actions have helped in studying interactions between targets and potential drugs at the systems level. The use of Artificial Intelligence and Machine Learning in these areas are expected to further strengthen this field. This aspect of science is playing a crucial role in bridging the gap between traditional knowledge and modern science. It helps to validate the efficacy of herbal medicines, supports the development of evidence-based practices, and ultimately enhances our understanding of traditional medicinal practices and their applications in modern healthcare.

1.1.  Microbiology and Molecular Biology

Microbiology and molecular biology are crucial fields for research in traditional medicine, as they help elucidate the mechanisms behind the efficacy of various natural remedies.

Microbiological studies help determine the efficacy and safety of traditional medicines against various pathogens and research the antimicrobial properties of traditional remedies, which can provide alternatives to synthetic antibiotics and help combat resistance. Antimicrobial activities of Craniotome furcata (Link) Kuntze (Joshi et al., 2010) and Achyranthes coynei Sant. (Ankad et al., 2013) provided promising leads for natural antimicrobials. The investigation on anti-cholera toxin activity of selected polyphenols from Careya arborea Roxb., Punica granatum L., and Psidium guajava L. provided the important leads for further animal experimentations (Charla et al., 2023).

Molecular biology tools, like gene expression analysis, can reveal how the bioactive compounds interact at the cellular level, including their effects on specific biological pathways. ICMR-NITM also utilized the molecular biology techniques for quality assurance of the medicinal plants, by differentiating the adulterants from the genuine plant drugs based on their genetic profiles. Molecular identification of Saraca asoca (Roxb.) Willd. in combination with RP-HPLC analysis effectively differentiated the genuine samples from its adulterant (Hegde et al., 2017; Hegde et al., 2018). Further, the same tools were utilized to assess the genetic diversity of Saraca asoca (Roxb.) De Wilde (Saini et al., 2018), and for understanding their population variability to develop conservation strategies (Hegde et al., 2018).

TM research benefits greatly from the integration of microbiology and molecular biology tools and techniques. This multidisciplinary approach not only helps to validate and enhance traditional practices but also opens avenues for developing new therapeutic strategies grounded in ancient knowledge.

1.2.  Biotechnology

Plant tissue culture is one of the biotechnological tools which is being employed at ICMR-NITM for rapid multiplication of medicinal plants and for enhancing the production of identified secondary metabolites. The protocols were developed for the enhanced production of phenolic antioxidants from Jasminum malabaricum Wight (Gadkar et al., 2015), and triterpinoids from Achyranthes aspera Linn. (Pai et al., 2018). Protocol was also developed for rapid multiplication of vulnerable plant Curcuma pseudomontana J. Graham (Vaze et al., 2024). The antibacterial activity was found to be enhanced in leaf-callus extracts of Alophyllus cobbe L., when compared to that of the leaves (Hegde et al., 2010).

Plant tissue culture is providing a rapid way for multiplication for the plants, especially those with conservation concerns. In addition, the developed protocols for enhancing the production of bioactive compounds in vitro will reduce the dependency on natural resources, thereby enhances sustainability.

2.     Pharmacology & pre-clinical studies

Pharmacology and preclinical studies in TM are essential for understanding how the medicine works, their safety, and their potential therapeutic effects. This involves studying their effects on biological systems and comparing them with conventional treatments. Animal models are used to evaluate the safety and efficacy of TMs, that forms a living model. This phase helps in understanding how the body responds to the treatment and allows for the observation of side effects. Preclinical studies support the development of a regulatory framework for TM, before their clinical trials in humans.

The first level of pre-clinical studies are in vitro evaluations, wherein various biological models other than animals are used. This may include bacteria, fungus, proteins, cell lines and models mimicking the actions of the biological system. Along with identifying the chemical composition of the plants used in TM, many of the plants are screened for their preliminary biological activities, such as antimicrobial and antioxidant activities. In one such study, a thermo-reversible gel of cranberry juice concentrate was formulated and evaluated for its biocompatibility and its antimicrobial activity against periodontal pathogens (Rajeshwari et al., 2017). Various plant extracts have been tested for their antiviral activity against dengue and chikungunya viruses in vitro (Alagarasu et al., 2022), which provided potential leads for evaluation of their antiviral activities. The leaf extracts of Anacardium occidentale L. showed promising antimalarial activity against Plasmodium falciparum Transketolase (Kaushik et al., 2023). Medicinal plants traditionally used against diarrhoeas were evaluated against toxin-induced cyto- and entero-toxicities in cholera (Charla et al., 2022) and selected polyphenols from Careya arborea Roxb., Punica granatum L., and Psidium guajava L. have shown Anti-Cholera toxin activities, which are promising (Charla et al., 2023). This has implications in use during outbreaks, thereby reducing unnecessary use of antibiotics and serving to reduce emergence of Anti-Microbial Resistance (AMR) which is a global concern. Glaucarubinone, a natural product, was found to sensitise KB cells to paclitaxel by inhibiting ABC transporters via ROS-dependent and p53-mediated activation of apoptotic signaling pathways (Karthikeyan et al., 2016), while Piperlongumine was found to induce ROS mediated cell death. It showed synergistic activity along with paclitaxel in human intestinal cancer cells (Rawat et al., 2020). It is also found that Gymnemogenin, one of the major compound from Gymnema sylvestre R.Br., reduces the risk factor by promoting lipid metabolism in type 2 diabetes (DasNandy et al., 2022).

In in vivo studies, animal models, such as zebra fish, mice, rats, etc. are used for evaluating the TM and their components. In a particular study, selected traditional formulations as a whole were evaluated for their spasmolytic effect in guinea pig ileum (Kumar et al., 2015) and for allergic asthma in Wistar rats (Patil et al., 2018). In another study it was demonstrated that the essential oils from Mentha arvensis L. and Angelica glauca Edgew. supress airway changes induced by histamine and ovalbumin in experimental animals (Sharma et al., 2017a; Sharma et al., 2017b). When orally administered, the partially purified protease inhibitors from Soyabean showed anti-cancer activity in animal models (Mayasa et al., 2016). The traditionally used medicinal plants, Sida rhombifolia L. and Cynodon dactylon (L.) Pers. were found to ameliorate scopolamine-induced cognitive dysfunction in rats (Pattanashetti et al., 2021a; Pattanashetti et al., 2021b). The phenol-enriched fraction and ethyl galate from Caesalpinia mimosoides Lam. were found to promote cutaneous wound healing in rat models (Bhat et al., 2022; Bhat et al., 2023).

Integrating pharmacological research and preclinical studies into the evaluation of traditional medicine will help to bridge the gap between traditional and modern medical practices, leading to the development of safe, effective, and standardized herbal treatments.

7. Clinical and Implementation Research

ICMR-NITM is conducting clinical/community-level trials of many of the TM practices, both from codified and non-codified systems. A couple of TM practices for anaemia, one each for non-alcoholic fatty liver disease (NAFLD), diabetic foot ulcers and osteoarthritis, are undergoing clinical trials. Many such TM practices are at various validation stages, which will be taken up to the clinical trials stage in due course of time.

Implementation research in traditional medicine focuses on understanding how to effectively integrate traditional practices into healthcare systems, ensuring they are safe, effective, and accessible. This research is critical for optimising health outcomes, particularly in communities that rely on traditional healing practices. However, the implementation research in TM is still evolving in India, and there is a need to address the proper framework, regulations for TM and rules for their integration with the conventional healthcare system. ICMR-NITM is trying to address a few of these issues. To identify the reported adverse drug reactions related to TM, ICMR-NITM compiled and analysed the data for the Asia region from the United Nations WHO VigiBase on Suspected cutaneous adverse drug reactions (Barvaliya et al., 2023). A similar case of suspected cutaneous allergic reactions with Ayurveda medicine Punaranava Mandura was observed at the integrative clinic of ICMR-NITM and was reported (Roseleena et al., 2024). Recognising the importance of vigilance on potential herb-drug interactions during concomitant use of conventional medicine and TM, ICMR-NITM carried out a study of reported adverse and synergistic interactions between commonly used conventional medicines and commonly used OTC drugs from TM for diabetes, arthritis and gastrointestinal disorders (unpublished). It developed a web-based resource that would not only help patients and practitioners to understand reactions between herbs and drugs that have been reported but also understand the potential reactions that are likely to happen by the concomitant use of certain herbs and drugs in these common conditions. This has been made possible by leveraging modelling predictions using bioinformatic tools. ICMR-NITM The gaps in implementing clinical trials for TM practices, such as clinical trial insurance, were also flagged by the Institute (Roy et al., 2022).

However, there is a long way to go to reach the point of successful integration of TM into the conventional healthcare system.

Thus, the implementation research links the studies back to the community, completing the cycle. Implementation research in TM is vital as it bridges the gap between traditional and modern healthcare practices. By focusing on effective integration, addressing barriers, and engaging stakeholders, this research can lead to improved health outcomes and a more holistic approach to healthcare.

Future prospects for TM research

The future of traditional medicine research holds great promise as the field continues to evolve, driven by technological advancements, growing interest in holistic health, and an increasing acceptance of integrative approaches in healthcare. The interdisciplinary approaches combining traditional knowledge with modern pharmacology, molecular biology, and biotechnology to validate and understand traditional remedies and thrust for evidence-based practices drive the research to provide credibility to TM practices and their mainstreaming in healthcare systems.

Using computational methods, such as molecular docking, big data biology, and machine learning, facilitates rapid screening and analysis of phyto-compounds, thereby enhancing the efficiency of drug discovery from TM. The establishment of comprehensive databases documenting TM practices, compounds, and their effects is facilitating research in TM. Advances in biotechnology, including genetic engineering and metabolic profiling, are facilitating the extraction and optimization of active compounds, enhancing their therapeutic efficacy and also providing sustenance to the production of bioactive compounds. However, there is a need for more focussed effort on sustainability and conservation of resources, policy and regulatory frameworks, ethical issues related to IPR, clinical trials and integration with conventional health systems, and to increase the quality and level of evidence base for public acceptance.

The future of traditional medicine research is poised for significant advancements, driven by technological innovations, interdisciplinary collaboration, and a global shift towards integrative and holistic health practices. Therefore, the scientific validation of TMs provides much-required insights into holistic health solutions, bridging the gap between ancient wisdom and modern medicine. As TM gains recognition and respect, it will play an increasingly vital role in addressing contemporary health challenges, promoting well-being, and enriching global healthcare.

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