Evaluation of synergism in essential oils against the cattle tick Rhipicephalus microplus in Burkina Faso.

The cattle tick Rhipicephalus microplus affects animal production economically by reducing weight gain and milk production and causing diseases, such as babesiosis and anaplasmosis. Using synthetic acaricides to reduce their incidence has caused the emergence of resistant tick populations. The present study aimed to assess the in vitro acaricidal activity of combinations of essential oils (EOs) from Ocimum americanum, Ocimum gratissimum, and Lippia multiflora against R. microplus larvae. In fact, numerous biological properties have been reported on EOs from these three plants, including acaricidal properties. Hence, a larval immersion test was performed using a population of R. microplus resistant to synthetic acaricides used in Burkina Faso. Results revealed that EO from O. gratissimum was the most effective on R. microplus larvae with LC50 and LC90 values at 10.36 and 15.51 mg/mL, respectively. For EO combinations, the most significant synergistic effect was obtained by combination 6 (1/3 O. americanum + 2/3 O. gratissimum +1/6 L. multiflora), with a combination index value of 0.44. All combinations presented dose reduction index >1, indicating a favorable dose reduction. According to the literature, this is the first study to determine the combination effect of EOs from the abovementioned plants in controlling R. microplus activity in vitro. Thus, the combination of these EOs is an alternative to control the resistant populations of invasive cattle ticks.

Effect of toxicological interaction of chlorpyrifos, cypermethrin, and arsenic on soil dehydrogenase activity in the terrestrial environment.

Soil is the most widespread area for the co-occurrence of two or more numbers of contaminants. Therefore, toxicity assessments based on contaminants mixture are urgently required to assess their combined impacts on soil enzymes. In the present study, the median effect plot and the combination index isobologram were studied to evaluate the dose-response curve for individual and interactive impacts of chlorpyrifos (Chl), cypermethrin (Cyp), and arsenic (As) on soil dehydrogenase, a potential marker of soil health. Along with these methods, a two-way ANOVA was also tested and the results showed significant changes with respect to different treatments. The results also showed that the Dm value increases in the order of As0.25 fa level. However, Chl + Cyp unveiled a synergistic impact over soil dehydrogenase on day 30th. The overall impact of applied chemicals on dehydrogenase activity was contributed by bioavailability and the nature of toxicological interactions between them. This study would be one of the exclusive studies for the agricultural sector to predict the potential risk associated with the co-existence of these or similar contaminants in the terrestrial environment.

Evaluation of joint toxicity of BTEX mixtures using sulfur-oxidizing bacteria.

Benzene (B), toluene (T), ethylbenzene (E), and xylenes (X) are petrochemicals vital in various industrial and commercial processing but identified as priority pollutants due to their high toxicity. The objective of this study was to investigate the toxicological nature of BTEX mixtures under controlled laboratory aquatic conditions using sulfur-oxidizing bacteria (SOB). Results from individual BTEX tests demonstrated that the order of toxicity among BTEX was X ≥ E > T > B. Comparisons of dose-effect curves for BTEX suggest that the biochemical mode of action of B in SOB was different from those of T, E, and X. Toxicological interactions of BTEX in mixtures were studied using concentration addition (CA), independent action (IA), and combination index (CI)-isobologram models. The CI model approximated the actual toxicity of BTEX mixtures better than the CA and IA models. In most cases, BTEX induced synergistic interactions in mixtures. However, in some B-containing mixtures, antagonism was observed at low effective levels. The effective level (fa)-CI plots and polygonograms illustrate that synergistic interactions of BTEX became stronger with an increase in effective levels. In addition, ternary and quaternary mixtures were found to provoke stronger synergism than binary mixtures. The present study suggests that the CI-isobologram model is a suitable means to evaluate diverse toxicological interactions of contaminants in mixtures.

Delphinidin-3-rutinoside from Blackcurrant Berries (Ribes nigrum): In Vitro Antiproliferative Activity and Interactions with Other Phenolic Compounds.

Blackcurrant berries (Rigrum L.) are of great interest for food scientists/technologists as a source of delphinidin-3-rutinoside (D3R). This is an uncommon phenolic compound in diets that unveils potent antiproliferative activity besides its colour. Other phenolic compounds, such as chlorogenic acid (CA) and epicatechin (EC), also known by their antiproliferative effects, are abundant in foods and beverages. To design smart food/supplements combinations containing blackcurrant and improved anticancer properties at the gastrointestinal level, there is the need for more data concerning the combined effects of those molecules. In this work, synergistic, additive, or antagonistic effects against gastric and intestinal cancers of D3R, CA, and EC were assessed in vitro. The antiproliferative activity of D3R, CA, and EC, alone and in binary combinations (D3R+CA, D3R+EC, and CA+EC) on NCI-N87 (gastric) and Caco-2 (intestinal) cells, was assessed following the Chou-Talalay theorem at equipotent contributions (i.e., (IC50)1/(IC50)2). D3R presented the strongest antiproliferative activity of the single molecules tested, with IC50 values of 24.9 µM and 102.5 µM on NCI-N87 and Caco-2 cells, respectively. The combinations D3R+CA and CA+EC were synergic against NCI-N87 until IC50 and IC75, respectively, while D3R+EC shifted from slight antagonism to synergism at higher doses. On Caco-2 cells, antagonism at low doses and synergism at high doses was observed. Therefore, the synergisms observed on the gastric cancer model at low doses occurred on the colon model only at high doses. Data herein described is vital to the targeted smart design of foods and supplements, as it is foreseen that the same combination of phenolic compounds causes different interactions/effects depending on the dose and gastrointestinal compartment.

Toxic effects of three perfluorinated or polyfluorinated compounds (PFCs) on two strains of freshwater algae: Implications for ecological risk assessments.

Perfluorinated or polyfluorinated compounds (PFCs) continue entering to the environmental as individuals or mixtures, but their toxicological information remains largely unknown. Here, we investigated the toxic effects and ecological risks of Perfluorooctane sulfonic acid (PFOS) and its substitutes on prokaryotes (Chlorella vulgaris) and eukaryotes (Microcystis aeruginosa). Based on the calculated EC50 values, the results showed that PFOS was significantly more toxic to both algae than its alternatives including Perfluorobutane sulfonic acid (PFBS) and 6:2 Fluoromodulated sulfonates (6:2 FTS), and the PFOS-PFBS mixture was more toxic to both algae than the other two PFC mixtures. The action mode of binary PFC mixtures on Chlorella vulgaris was mainly shown as antagonistic and on Microcystis aeruginosa as synergistic, by using Combination index (CI) model coupled with Monte Carlo simulation. The mean risk quotient (RQ) value of three individual PFCs and their mixtures were all below the threshold of 10-1, but the risk of those binary mixtures were higher than that of PFCs individually because of their synergistic effect. Our findings contribute to enhance the understanding of the toxicological information and ecological risks of emerging PFCs and provide a scientific basis for their pollution control.

JCI-20679 suppresses autophagy and enhances temozolomide-mediated growth inhibition of glioblastoma cells.

Glioblastoma, a type of brain cancer, is one of the most aggressive and lethal types of malignancy. The present study shows that JCI-20679, an originally synthesized mitochondrial complex I inhibitor, enhances the anti-proliferative effects of suboptimal concentrations of the clinically used chemotherapeutic drug temozolomide in glioblastoma cells. Analysis of the effects of temozolomide combined with JCI-20679 using isobologram and combination index methods demonstrated that the combination had synergistic effects in murine and human glioblastoma cells. We found that JCI-20679 inhibited the temozolomide-mediated induction of autophagy that facilitates cellular survival. The autophagy induced by temozolomide increased ATP production, which confers temozolomide resistance in glioblastoma cells. JCI-20679 blocked temozolomide-mediated increases in ATP levels and increased the AMP/ATP ratio. Furthermore, JCI-20679 enhanced the therapeutic effects of temozolomide in an orthotopic transplantation model of glioblastoma. These results indicate that JCI-20679 may be promising as a novel agent for enhancing the efficacy of temozolomide against glioblastoma.

Shifting of cell cycle arrest from the S-phase to G2/M phase and downregulation of EGFR expression by phytochemical combinations in HeLa cervical cancer cells.

Cervical cancer is a major human papillomavirus-related disease and is the fourth leading cause of death by cancer among women. Plants are an important source of anticancer compounds and many of them are currently used in the treatment of cancer. Several reports suggest the efficacy of plant-derived compounds increases when used in combination. This study was carried out to evaluate the effect of four plant-derived compounds such as curcumin (C), ellagic acid (E), quercetin (Q), and resveratrol (R) when used alone or in combinations using HeLa cervical cancer cells. All four phytocompounds showed effective cytotoxic activities in targeting HeLa cervical cancer cells as determined by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium assay. The selected phytocompound combinations C + E, C + Q, and Q + R work synergistically while the combination C + R shows additive effects. All four phytocompounds reduce cell migration as determined by in vitro wound-healing assay. The expression level of the epidermal growth factor receptor is significantly downregulated both in individual and combination. The flow cytometry analysis of cell cycle indicates that individual drugs curcumin, ellagic acid, quercetin, and resveratrol, each with 20 µM effectively arrested cell cycle at the S-phase while the combination of drugs (10 + 10 µM) at the G2/M phase.

Synergy in Nanomedicine: What It Is Not, and What It Might Be.

Interactions between nanoformulations delivering two or more drugs-or a drug and some other therapeutic modality-are often described as synergistic. In fact, synergy is a specific term of art, with important therapeutic implications. The term is often misused in the nanoscience literature. Here we discuss what synergy is and an approach to demonstrating it rigorously.

High-Throughput 3D Tumor Spheroid Array Platform for Evaluating Sensitivity of Proton-Drug Combinations.

Proton beam therapy (PBT) is a critical treatment modality for head and neck squamous cell carcinoma (HNSCC). However, not much is known about drug combinations that may improve the efficacy of PBT. This study aimed to test the feasibility of a three-dimensional (3D) tumor-spheroid-based high-throughput screening platform that could assess cellular sensitivity against PBT. Spheroids of two HNSCC cell lines-Fadu and Cal27-cultured with a mixture of Matrigel were arrayed on a 384-pillar/well plate, followed by exposure to graded doses of protons or targeted drugs including olaparib at various concentrations. Calcein staining of HNSCC spheroids revealed a dose-dependent decrease in cell viability for proton irradiation or multiple targeted drugs, and provided quantitative data that discriminated the sensitivity between the two HNSCC cell lines. The combined effect of protons and olaparib was assessed by calculating the combination index from the survival rates of 4 × 4 matrices, showing that Cal27 spheroids had greater synergy with olaparib than Fadu spheroids. In contrast, adavosertib did not synergize with protons in both spheroids. Taken together, we demonstrated that the 3D pillar/well array platform was a useful tool that provided rapid, quantitative data for evaluating sensitivity to PBT and drug combinations. Our results further supported that administration of the combination of PBT and olaparib may be an effective treatment strategy for HNSCC patients.

Apoptosis, Proliferation, and Autophagy Are Involved in Local Anesthetic-Induced Cytotoxicity of Human Breast Cancer Cells.

Breast cancer accounts for almost one quarter of all female cancers worldwide, and more than 90% of those who are diagnosed with breast cancer undergo mastectomy or breast conservation surgery. Local anesthetics effectively inhibit the invasion of cancer cells at concentrations that are used in surgical procedures. The limited treatment options for triple-negative breast cancer (TNBC) demonstrate unmet clinical needs. In this study, four local anesthetics, lidocaine, levobupivacaine, bupivacaine, and ropivacaine, were applied to two breast tumor cell types, TNBC MDA-MB-231 cells and triple-positive breast cancer BT-474 cells. In addition to the induction of apoptosis and the suppression of the cellular proliferation rate, the four local anesthetics decreased the levels of reactive oxygen species and increased the autophagy elongation indicator in both cell types. Our combination index analysis with doxorubicin showed that ropivacaine had a synergistic effect on the two cell types, and lidocaine had a synergistic effect only in MDA-MB-231 cells; the others had no synergistic effects on doxorubicin. Lidocaine contributed significantly to the formation of autophagolysosomes in a dose-dependent manner in MDA-MB-231 cells but not in BT-474 cells. Our study demonstrated that the four local anesthetics can reduce tumor growth and proliferation and promote apoptosis and autophagy.

Synergistic Anti-Inflammatory Activity of Ginger and Turmeric Extracts in Inhibiting Lipopolysaccharide and Interferon-γ-Induced Proinflammatory Mediators.

This study aims to investigate the combined anti-inflammatory activity of ginger and turmeric extracts. By comparing the activities of individual and combined extracts in lipopolysaccharide and interferon-γ-induced murine RAW 264.7 cells, we demonstrated that ginger-turmeric combination was optimal at a specific ratio (5:2, w/w) in inhibiting nitric oxide, tumour necrosis factor and interleukin 6 with synergistic interaction (combination index < 1). The synergistic inhibitory effect on TNF was confirmed in human monocyte THP-1 cells. Ginger-turmeric combination (5:2, w/w) also upregulated nuclear factor erythroid 2−related factor 2 activity and heme oxygenase-1 protein expression. Additionally, 6-shogaol, 8-shogaol, 10-shogaol and curcumin were the leading compounds in reducing major proinflammatory mediators and cytokines, and a simplified compound combination of 6-s, 10-s and curcumin showed the greatest potency in reducing LPS-induced NO production. Our study provides scientific evidence in support of the combined use of ginger and turmeric to alleviate inflammatory processes.

Antiviral activity of aframomum melegueta against severe acute respiratory syndrome coronaviruses type 1 and 2.

Plant-based compounds with antiviral properties against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been identified in Aframomum melegueta through computational models. The seed extract have been traditionally used to treat different illnesses. In this study, ethanolic extracts were prepared for six commercial samples of A. melegueta seeds. Antiviral activity was tested using the XTT cytotoxicity assay and cell-based SARS-CoV-1 and 2 pseudoviral models. The presence of gingerols and other non-volatile components in the seed extracts was determined using an Agilent 1290 UPLC/DAD in tandem with an Agilent 6546 QTOF-MS. Our results showed selective antiviral activity with TI values as high as 13.1. Fifteen gingerols were identified by chromatographic analysis, with 6-gingerol being the dominant component in each seed extract. A combination of 6-gingerol with techtochrysin, previously identified in computational models as a potential active ingredient against SARS-CoV-2, demonstrated additive antiviral activity with CI values between 0.8715 and 0.9426. We confirmed the antiviral activity of A. melegueta predicted through computational models and identified a different compound, 6-gingerol, as a potential active ingredient.

Preclinical activity of cobimetinib alone or in combination with chemotherapy and targeted therapies in renal cell carcinoma.

Background: The poor outcome of advanced renal cell carcinoma (RCC) necessitates new treatments. Cobimetinib is a MEK inhibitor and approved for the treatment of melanoma. This work investigated the efficacy of cobimetinib alone and in combination with anti-RCC drugs. Methods: Proliferation and apoptosis assays were performed, and combination index was analyzed on RCC cell lines (CaKi-2, 786-O, A-704, ACHN and A489) and xenograft models. Immunoblotting analysis was conducted to investigate the MAPK pathway. Results: Cobimetinib was active against RCC cells, with IC50 at 0.006-0.8µM, and acted synergistically with standard-of-care therapy. Cobimetinib at nontoxic doses prevented tumor formation, inhibited tumor growth and enhanced efficacy of 5-fluorouracil, sorafenib and sunitinib via suppressing Raf/MEK/ERK, leading to MAPK pathway inhibition. Conclusion: Our findings demonstrate the potent anti-RCC activity of cobimetinib and its synergism with RCC standard-of-care drugs, and confirm the underlying mechanism of the action of cobimetinib.

Sub-lethal effects of soil multiple contamination on the avoidance behaviour of Eisenia fetida.

Natural ecosystems are frequently exposed to complex mixtures of different chemicals. However, the environmental risk assessment is mainly based on data from individual substances. In this study, the individual and combined effects on the terrestrial earthworm E. fetida exposed to the anionic surfactant sodium lauryl ether sulphate (SLES) and the pesticides chlorpyrifos (CPF) and imidacloprid (IMI) were investigated, by using the avoidance behaviour as endpoint. Earthworms were exposed to a soil artificially contaminated with five sub-lethal concentrations of each contaminant, both as single substances and in combination of binary and ternary mixtures. Overall results showed that IMI provoked the highest avoidance effect on earthworms, with a concentration value that induced an avoidance rate of 50% of treated organisms (AC50) of 1.30 mg/kg, followed by CPF (AC50 75.26 mg/kg) and SLES (AC50 139.67 mg/kg). The application of the Combination Index (CI) method, indicated that a deviation from the additive response occurred for most of the tested chemical mixtures, leading to synergistic or antagonistic avoidance responses. Synergistic effects were produced by the exposure to the two lowest concentrations of the CPF+IMI mixture, and by the highest concentrations of SLES+CPF and SLES+CPF+IMI mixtures. On the contrary, antagonistic effects were observed at the lowest concentrations of the binary mixtures containing the SLES and at almost all the tested concentrations of the SLES+CPF+IMI mixture (with the exception of the highest tested concentration). These results show that the avoidance test is suitable to assess the detrimental effects exerted on earthworms by chemical mixtures in soil ecosystems and the use of behavioural endpoints can increase the ecological significance of environmental risk assessment procedures.

Mixture toxicity effects of chloramphenicol, thiamphenicol, florfenicol in Daphnia magna under different temperatures.

Acute toxicities of chloramphenicol (CAP), thiamphenicol (TAP), and florfenicol (FLO) and their mixtures on Daphnia magna under two representative temperatures of the aquatic environment (20 and 25 °C) have been examined. Their toxicities depicted with an order of 72-h EC50 values were as follows: CAP > FLO > TAP and CAP ≈ FLO > TAP under 20 and 25 °C, separately. Furthermore, the acute toxicity significantly increased with the rise of temperature from 20 to 25 °C in nearly all separate and mixture phenicol antibiotics. Meanwhile, the most toxic combination under two different temperatures was diverse. The nature of toxicological interactions of phenicol antibiotic mixtures was analyzed by Combination Index (CI) equation. In general, a dual synergism-antagonism effect was dominant in nearly all mixtures at both temperatures. The prediction suitability of Concentration Addition (CA), Independent Action (IA) models, and CI method was compared, suggesting that the CI equation seems to be more appropriate for predicting the toxicity values of phenicol drugs than CA and IA models. In brief, phenicol antibiotic mixtures with temperature variation may pose more significant hazards and risks to aquatic organisms; hence, the environment.

Pitavastatin and metformin synergistically activate apoptosis and autophagy in pancreatic cancer cells.

Pancreatic cancer is the seventh leading cause of cancer-related deaths globally. Metformin is the standard first-line of treatment for hyperglycemia in Type 2 diabetes, whereas pitavastatin is a cholesterol-lowering drug used to prevent cardiovascular diseases. Both these agents evidently exert anticancer effects on pancreatic cancer; however, it remains unclear whether cotreatment using them has additive or synergistic anticancer effects on pancreatic cancer. Thus, we herein used the ASPC-1 and PANC-1 cells and treated them with metformin and/or pitavastatin. We performed the cell viability assay, transwell migration assay, and cell cycle analysis using flow cytometry. Western blotting was used to determine protein levels. We found that cotreatment with metformin (30 mM) and pitavastatin (10 µM) significantly reduced cell viability; caused G0/G1 cell cycle arrest; upregulated the expression levels of Bax, PCNA, cleaved PARP-1, cleaved caspase-3, LC3 II, and p27 Kip1 /p21Cip1 ; and inhibited cell migration. The combination index value for cell viability indicated a synergistic interaction between metformin and pitavastatin. Moreover, cotreating the cells with metformin (30 mM) and pitavastatin (10 µM) could preserve mitochondrial function, activate AMPK, and inhibit PI3K/mTOR than treatment with metformin or pitavastatin alone. These findings clearly indicated that metformin plus pitavastatin had a synergistic anticancer effect on pancreatic cancer cells, potentially caused due to the activation of AMPK and inhibition of PI3K/mTOR signaling. Altogether, our results provide that use of metformin plus pitavastatin maybe serve as a chemotherapeutic agent for human pancreatic cancer in future.

Synergy evaluation of non-normalizable dose-response data: Generalization of combination index for the linear effect of drugs.

The study of drug synergy plays a prominent role in the search for drug combinations with beneficial interactions. Firstly, in this process, the drug-effect response of individual parts and the mixture needs to be derived. This function is usually well described by Hill (or other logistic or sigmoid) curve. Due to its boundedness, it allows the measured data to be normalized. The normalized data can then be processed by interaction analysis using the Loewe, Bliss, or other models to evaluate possible synergy or antagonism of two or more drugs. However, sometimes, the drug-effect responses observed in pharmaceutical research do not appear to be bounded. Theoretically, the drug-effect curve cannot grow to infinity, but it may be impossible to determine its upper bound within the observed region. In this case, standard models cannot be used, since they assume that data are normalized. The approach of this article bypasses the need to normalize the data, allowing its broader application and usefulness in finding potential synergies in pharmaceutical research.

Modeling dose-response functions for combination treatments with log-logistic or Weibull functions.

Dose-response curves of new substances in toxicology and related areas are commonly fitted using log-logistic functions. In more advanced studies, an additional interest is often how these substances will behave when applied in combination with a second substance. Here, an essential question for both design and analysis of these combination experiments is whether the resulting dose-response function will still be a member of the class of log-logistic functions, and, if so, what function parameters will result for the combined substances. Different scenarios might be considered in regard to whether a true interaction between the substances is expected, or whether the combination will simply be additive. In this paper, it is shown that the resulting function will in general not be a log-logistic function, but can be approximated very closely with one. Parameters for this approximation can be predicted from the parameters of both ingredients. Furthermore, some simple interaction structures can still be represented with a single log-logistic function. The approach can also be applied to Weibull-type dose-response functions, and similar results are obtained. Finally, the results were applied to a real data set obtained from cell culture experiments involving two cancer treatments, and the dose-response curve of a combination treatment was predicted from the properties of the singular substances.

Synergistic Combinations of Curcumin, Sulforaphane, and Dihydrocaffeic Acid against Human Colon Cancer Cells.

Nutraceutical combinations that act synergistically could be a powerful solution against colon cancer, which is the second deadliest malignancy worldwide. In this study, curcumin (C), sulforaphane (S), and dihydrocaffeic acid (D, a chlorogenic acid metabolite) were evaluated, individually and in different combinations, over the viability of HT-29 and Caco-2 colon cancer cells, and compared against healthy fetal human colon (FHC) cells. The cytotoxic concentrations to kill 50%, 75%, and 90% of the cells (CC50, CC75, and CC90) were obtained, using the MTS assay. Synergistic, additive, and antagonistic effects were determined by using the combination index (CI) method. The 1:1 combination of S and D exerted synergistic effects against HT-29 at 90% cytotoxicity level (doses 90:90 µM), whereas CD(1:4) was synergistic at all cytotoxicity levels (9:36-34:136 µM) and CD(9:2) at 90% (108:24 µM) against Caco-2 cells. SD(1:1) was significantly more cytotoxic for cancer cells than healthy cells, while CD(1:4) and CD(9:2) were similarly or more cytotoxic for healthy cells. Therefore, the SD(1:1) combination was chosen as the best. A model explaining SD(1:1) synergy is proposed. SD(1:1) can be used as a basis to develop advanced food products for the prevention/co-treatment of colon cancer.

Screening drug target combinations in disease-related molecular networks.

BACKGROUND: For treating a complex disease such as cancer, some effective means are needed to control biological networks that underlies the disease. The one-target one-drug paradigm has been the dominating drug discovery approach in the past decades. Compared to single target-based drugs, combination drug targets may overcome many limitations of single drug target and achieve a more effective and safer control of the disease. Most of existing combination drug targets are developed based on clinical experience or text-and-trial strategy, which cannot provide theoretical guidelines for designing and screening effective drug combinations. Therefore, systematic identification of multiple drug targets and optimal intervention strategy needs to be developed. RESULTS: We developed a strategy to screen the synergistic combinations of two drug targets in disease networks based on the classification of single drug targets. The method tried to identify the sensitivity of single intervention and then the combination of multiple interventions that can restore the disease network to a desired normal state. In our strategy of screening drug target combinations, we first classified all drug targets into sensitive and insensitive single drug targets. Then, we identified the synergistic and antagonistic of drug target combinations, including the combinations of sensitive drug targets, the combinations of insensitive drug target and the combination of sensitive and insensitive targets. Finally, we applied our strategy to Arachidonic Acid (AA) metabolic network and found 18 pairs of synergistic drug target combinations, five of which have been proven to be viable by biological or medical experiments. CONCLUSIONS: Different from traditional methods for judging drug synergy and antagonism, we propose the framework of how to enhance the efficiency by perturbing two sensitive targets in a combinatorial way, how to decrease the drug dose and therefore its side effect and cost by perturbing combinatorially a main sensitive target and an auxiliary insensitive target, and how to perturb two insensitive targets to realize the transition from a disease state to a healthy one which cannot be realized by perturbing each insensitive target alone. Although the idea is mainly applied to an AA metabolic network, the strategy holds for more general molecular networks such as combinatorial regulation in gene regulatory networks.