Discovery of a traditional Chinese herbal combination for the treatment of atopic dermatitis: saposhnikoviae radix, astragali radix and cnidium monnieri.

Atopic dermatitis (AD) is a skin disease characterized by pruritus. The present study aimed to discover a herbal combination with anti-allergic and anti-inflammatory activities to treat AD. First, the anti-allergic and anti-inflammatory activities of herbs were evaluated by RBL-2H3 degranulation and HaCaT inflammatory models. Subsequently, the optimal proportion of herbs was determined by uniform design-response surface methodology. The effectiveness and synergistic mechanism was further verified. Cnidium monnieri (CM) suppressed ß-hexosaminidase (ß-HEX) release, saposhnikoviae radix (SR), astragali radix (AR), and CM inhibited the release of IL-8 and MCP-1. The optimal proportion of herbs was SR∶AR∶CM = 1: 2: 1. The in vivo experiments results indicated that the topical application of combination at high (2 ×) and low (1 ×) doses improved dermatitis score and epidermal thickness, and attenuated mast cell infiltration. Network pharmacology and molecular biology further clarified that the combination resisted AD by regulating the MAPK, JAK signaling pathways, and the downstream cytokines such as IL-6, IL-1ß, IL-8, IL-10, and MCP-1. Overall, the herbal combination could inhibit inflammation and allergy, improving AD-like symptoms. The present study discovers a promising herbal combination, worthy of further development as a therapeutic drug for AD.

Ellagic Acid: A Review on Its Natural Sources, Chemical Stability, and Therapeutic Potential.

Ellagic acid (EA) is a bioactive polyphenolic compound naturally occurring as secondary metabolite in many plant taxa. EA content is considerable in pomegranate (Punica granatum L.) and in wood and bark of some tree species. Structurally, EA is a dilactone of hexahydroxydiphenic acid (HHDP), a dimeric gallic acid derivative, produced mainly by hydrolysis of ellagitannins, a widely distributed group of secondary metabolites. EA is attracting attention due to its antioxidant, anti-inflammatory, antimutagenic, and antiproliferative properties. EA displayed pharmacological effects in various in vitro and in vivo model systems. Furthermore, EA has also been well documented for its antiallergic, antiatherosclerotic, cardioprotective, hepatoprotective, nephroprotective, and neuroprotective properties. This review reports on the health-promoting effects of EA, along with possible mechanisms of its action in maintaining the health status, by summarizing the literature related to the therapeutic potential of this polyphenolic in the treatment of several human diseases.

Suppression on allergic airway inflammation of dehulled adlay (Coix lachryma-jobi L. var. ma-yuen Stapf) in mice and anti-degranulation phytosterols from adlay bran.

Adlay (Coix lachryma-jobi L. var. ma-yuen Stapf) seeds have been used in Asia for thousands years to treat warts, chapped skin, rheumatism, and neuralgia. The anti-allergic activity of dehulled adlay (DA) seeds was identified, and the bran (AB) is regarded as the main functional constituent in the edible part. However, no study has focused on in vivo acute anti-allergic airway inflammation. In the present report, we investigated DA methanolic extract (DAM) reversed ovalbumin (OVA)/methacholine (Mch)-induced airway hypersensitivity, decreased interleukin (IL)-4, IL-5, and IL-13 levels from splenocytes, suppressed tumor necrosis factor (TNF)-α, IL-1ß, and IL-13 levels and reduced eosinophil counts and eotaxin in bronchoalveolar lavage fluid (BALF), which imply that the modulatory effects of DA should involve allergic degranulation. Further, seven phytosterols were isolated from AB ethanolic extract (ABE); among them, 3-O-caffeoyl-5ß-sitostan-3-ol, ß-sitosterol 3-O-glucopyranoside and ß-sitosterol inhibited ß-hexosaminidase release from A23187-stimulated RBL-2H3 cells with percentages of 54.1%, 52.0% and 48.5%, respectively, at 50 µM. In addition, ß-sitosterol reduced immunoglobulin (Ig)E-stimulated degranulation on RBL-2H3 cells in a dose-dependent manner. The phytosterols were the predominant components based on gas chromatography (GC) analysis. This is the first study to demonstrate that DA suppressed OVA/Mch-induced acute airway inflammation. The phytosterols in AB showed significant anti-degranulation activities, and may be regarded as the indicative components of AB for anti-allergy effects.

Lactic Acid Bacteria Fermented Cordyceps militaris (GRC-SC11) Suppresses IgE Mediated Mast Cell Activation and Type I Hypersensitive Allergic Murine Model.

Cordyceps militaris (C. militaris) has various biomedical applications in traditional oriental medicine for different diseases including inflammatory and immune-dysregulated diseases. It is a reservoir of nutritional components such as cordycepin, polysaccharides, and antioxidants. To improve its bioactivity, we fermented C. militaris with a Pediococcus pentosaceus strain isolated from a salted small octopus (SC11). The current study aimed to evaluate whether P. pentosaceus (SC11) fermentation could enhance the anti-allergic potential of C. militaris cultured on germinated Rhynchosia nulubilis (GRC) against a type I hypersensitive reaction in in vitro and in vivo studies. Total antioxidant capacity and cordycepin content were significantly increased in GRC after SC11 fermentation. GRC-SC11 showed significantly enhanced anti-allergic responses by inhibiting immunoglobulin E (IgE)/antigen-induced degranulation in RBL-2H3 cells, compared to GRC. The results demonstrated the significant inhibition of phosphorylated spleen tyrosine kinase (Syk)/ p38/GRB2-associated binding protein 2 (Gab2)/c-jun in IgE/Ag-triggered RBL-2H3 cells. Furthermore, suppressed mRNA levels of interleukin-4 (IL-4) and tumor necrosis factor-α (TNF-α) in IgE/Ag-activated RBL-2H3 cells were observed. GRC-SC11 significantly ameliorated IgE-induced allergic reactions by suppressing the ear swelling, vascular permeability, and inflammatory cell infiltration in passive cutaneous anaphylaxis (PCA) BALB/c mice. In conclusion, GRC fermented with P.pentosaceus exerted enhanced anti-allergic effects, and increased the cordycepin content and antioxidants potential compared to GRC. It can be used as bio-functional food in the prevention and management of type I allergic diseases.

Oral Administration of Fucoidan Can Exert Anti-Allergic Activity after Allergen Sensitization by Enhancement of Galectin-9 Secretion in Blood.

A previous study revealed that fucoidan inhibited mast cell degranulation through the upregulation of galectin-9 in blood. The purpose of this study is to elucidate its mechanism using ovalbumin (OVA) induced anaphylaxis model mice (BALB/c, Female, 5-week-old) and mast cell line (RBL-2H3 cells). Oral administration of fucoidan after sensitization with OVA/Al(OH)3 inhibited reduction of rectal temperature induced by activation of mast cells. Fucoidan increased galectin-9 mRNA expression only in colonic epithelial cells. These results suggested that fucoidan could suppress the allergic symptoms in sensitized mice by inducing galectin-9 production from colonic epithelial cells. In addition, to check the influence of galectin 9 on the degranulation of mast cells, RBL-2H3 cell lines were treated directly with recombinant galectin-9. As expected, galectin-9 inhibited degranulation of RBL-2H3 cells pre-bound with IgE. Moreover, the residual amounts of IgE on RBL-2H3 cells were decreased by an addition of galectin-9. It was demonstrated that galectin-9 could remove IgE even if IgE was already bound to mast cells and suppress the mast cells degranulation induced by antigen. This study shows that fucoidan might become an effective therapeutic agent for patients already developed type I allergic diseases.

Dietary Omega-3 Fatty Acid Dampens Allergic Rhinitis via Eosinophilic Production of the Anti-Allergic Lipid Mediator 15-Hydroxyeicosapentaenoic Acid in Mice.

The metabolism and generation of bioactive lipid mediators are key events in the exertion of the beneficial effects of dietary omega-3 fatty acids in the regulation of allergic inflammation. Here, we found that dietary linseed oil, which contains high amounts of alpha-linolenic acid (ALA) dampened allergic rhinitis through eosinophilic production of 15-hydroxyeicosapentaenoic acid (15-HEPE), a metabolite of eicosapentaenoic acid (EPA). Lipidomic analysis revealed that 15-HEPE was particularly accumulated in the nasal passage of linseed oil-fed mice after the development of allergic rhinitis with the increasing number of eosinophils. Indeed, the conversion of EPA to 15-HEPE was mediated by the 15-lipoxygenase activity of eosinophils. Intranasal injection of 15-HEPE dampened allergic symptoms by inhibiting mast cell degranulation, which was mediated by the action of peroxisome proliferator-activated receptor gamma. These findings identify 15-HEPE as a novel EPA-derived, and eosinophil-dependent anti-allergic metabolite, and provide a preventive and therapeutic strategy against allergic rhinitis.

Emerging roles of metabolites of ω3 and ω6 essential fatty acids in the control of intestinal inflammation.

The gastrointestinal tract is continuously exposed to the external environment, which contains numerous non-self antigens, including food materials and commensal micro-organisms. For the maintenance of mucosal homeostasis, the intestinal epithelial layer and mucosal immune system simultaneously provide the first line of defense against pathogens and are tightly regulated to prevent their induction of inflammatory responses to non-pathogenic antigens. Defects in mucosal homeostasis lead to the development of inflammatory and associated intestinal diseases, such as Crohn's disease, ulcerative colitis, food allergy and colorectal cancer. The recent discovery of novel dietary ω3 and ω6 lipid-derived metabolites-such as resolvin, protectin, maresin, 17,18-epoxy-eicosatetraenoic acid and microbe-dependent 10-hydroxy-cis-12-octadecenoic acid-and their potent biologic effects on the regulation of inflammation have initiated a new era of nutritional immunology. In this review, we update our understanding of the role of lipid metabolites in intestinal inflammation.

Fermentation-Mediated Enhancement of Ginseng's Anti-Allergic Activity against IgE-Mediated Passive Cutaneous Anaphylaxis In Vivo and In Vitro.

Ginseng (the root of Panax ginseng Meyer) fermented by Lactobacillus plantarum has been found to attenuate allergic responses in in vitro and in vivo experimental models. Ginseng has been reported to also possess various biological functions including anti-inflammatory activity. The present study was aimed at comparing the anti-allergic effect of ginseng and fermented ginseng extracts on IgE-mediated passive cutaneous anaphylaxis in vitro in a murine cell line and in vivo in mice. Fermented ginseng extract (FPG) showed higher inhibitory effect against in vitro and in vivo allergic responses when compared with ginseng extract (PG). The secretion of ß-hexosaminidase and interleukin (IL)-4 from the IgE-DNP-stimulated RBH-2H3 mast cells were significantly (p < 0.05) inhibited by FPG treatment, and this effect was concentration-dependent. Further, MKK4 activation and subsequent JNK phosphorylation were attenuated by FPG treatment. The inhibitory effect of FPG on the in vitro allergic response was verified in vivo against IgE-DNP-induced passive cutaneous anaphylaxis in a mouse model. These data indicated that the fermentation of ginseng with L. plantarum enhanced its anti-allergic effects both in vitro and in vivo. We predict that compositional changes in the ginsenosides caused by the fermentation may contribute to the change in the anti-allergic effects of ginseng. The results of our study highlight the potential of the use of FPG as a potential anti-allergic agent.

Development and evaluation of an oral fast disintegrating anti-allergic film using hot-melt extrusion technology.

The main objective of this novel study was to develop chlorpheniramine maleate orally disintegrating films (ODF) using hot-melt extrusion technology and evaluate the characteristics of the formulation using in vitro and in vivo methods. Modified starch with glycerol was used as a polymer matrix for melt extrusion. Sweetening and saliva-simulating agents were incorporated to improve palatability and lower the disintegration time of film formulations. A standard screw configuration was applied, and the last zone of the barrel was opened to discharge water vapors, which helped to manufacture non-sticky, clear, and uniform films. The film formulations demonstrated rapid disintegration times (6-11s) and more than 95% dissolution in 5min. In addition, the films had characteristic mechanical properties that were helpful in handling and storage. An animal model was employed to determine the taste masking of melt-extruded films. The lead film formulation was subjected to a human panel for evaluation of extent of taste masking and disintegration.

The Three-Herb Formula Shuang-Huang-Lian stabilizes mast cells through activation of mitochondrial calcium uniporter.

Mast cells (MCs) are key effector cells of IgE-FcεRI- or MrgprX2-mediated signaling event. Shuang-Huang-Lian (SHL), a herbal formula from Chinese Pharmacopoeia, has been clinically used in type I hypersensitivity. Our previous study demonstrated that SHL exerted a non-negligible effect on MC stabilization. Herein, we sought to elucidate the molecular mechanisms of the prominent anti-allergic ability of SHL. MrgprX2- and IgE-FcεRI-mediated MC activation in vitro and in vivo models were developed by using compound 48/80 (C48/80) and shrimp tropomyosin (ST), respectively. Our data showed that SHL markedly dampened C48/80- or ST-induced MC degranulation in vitro and in vivo. Mechanistic study indicated that cytosolic Ca2+ (Ca2+[c]) level decreased rapidly and sustainably after SHL treatment, and then returned to homeostasis when SHL was withdrawn. Moreover, SHL decreases Ca2+[c] levels mainly through enhancing the mitochondrial Ca2+ (Ca2+[m]) uptake. After genetically silencing or pharmacologic inhibiting mitochondrial calcium uniporter (MCU), the effect of SHL on the Ca2+[c] level and MC degranulation was significantly weakened. Simultaneously, the activation of SHL on Ca2+[m] uptake was completely lost. Collectively, by activating MCU, SHL decreases Ca2+[c] level to stabilize MCs, thus exerting a remarkable anti-allergic activity, which could have considerable influences on clinical practice and research.

Synthesis and pharmacological evaluation of glycosides of resveratrol, pterostilbene, and piceatannol.

To enhance their water solubility and pharmacological activities, the stilbenes resveratrol, pterostilbene, and piceatannol were glycosylated to their monoglucosides (ß-glucosides) and diglycosides (ß-maltosides) by cultured cells and cyclodextrin glucanotransferase (CGTase). Cultured cells of Phytolacca americana and glucosyltransferase (PaGT) were capable of glucosylation of resveratrol to its 3- and 4'-ß-glucosides. Pterostilbene was slightly transformed into its 4'-ß-glucoside by P. americana cells. Piceatannol was readily converted into piceatannol 4'-ß-glucoside, with the highest yield among the three substrates. The 3- and 4'-ß-glucosides of resveratrol were subjected to further glycosylation by CGTase to give 3- and 4'-ß-maltoside derivatives. The inhibitory action of resveratrol and pterostilbene toward histamine release induced with compound 48/80 from rat peritoneal mast cells was improved by ß-glucosylation and/or ß-maltosylation (i.e., the inhibitory activity for histamine release of the 3- and 4'-ß-glucosides of resveratrol, the 3- and 4'-ß-maltosides of resveratrol, and the 4'-ß-glucoside of pterostilbene was higher than that of the corresponding aglycones, resveratrol and pterostilbene, respectively). In addition, the phosphodiesterase (PDE) inhibitory activity of resveratrol and pterostilbene was enhanced by ß-glucosylation and/or ß-maltosylation (i.e., the PDE inhibitory activities of the 3- and 4'-ß-glucosides of resveratrol, the 4'-ß-maltoside of resveratrol, and the 4'-ß-glucoside of pterostilbene were higher than those of the corresponding aglycones, resveratrol and pterostilbene, respectively).

Metabolic considerations of drugs in the treatment of allergic diseases.

INTRODUCTION: The clinical management of allergic diseases involves a number of drugs, most of which are extensively metabolized. This review aims to analyze the metabolism and the clinical implications of altered metabolism for these drugs. AREAS COVERED: The authors present an overview of current knowledge of the metabolism of: antihistamine drugs, glucocorticoids, inhaled ß-2 bronchodilators, anticholinergics and other drugs used in allergic diseases, such as cromoglycate, omalizumab, montelukast and epinephrine. Polymorphic drug metabolism is relevant for chlorpheniramine, loratadine and montelukast. Inhibition of drug metabolism is relevant for loratadine, methylprednisolone, fluticasone, mometasone, triamcinolone or prednisolone. Polymorphic pre-systemic metabolism may be relevant to budesonide, fluticasone, beclomethasone, mometasone or salmeterol. The authors also discuss the current information on gene variations according to the 1,000 genomes catalog and other databases. Finally, the authors review the clinical implications of these variations with a particular regard to drugs used in the management of allergic diseases. EXPERT OPINION: Most drugs used in allergic diseases are extensively metabolized. Drug interaction or adverse reactions related to altered metabolism are relevant issues that should be considered in the management of allergic diseases. However, much additional research is required before defining pharmacogenomic biomarkers for the management of drugs used in allergic diseases.

Inhibitory effect of unicellular green algae (Chlorella vulgaris) water extract on allergic immune response.

BACKGROUND: Chlorella is used as a functional food in East Asia and has been shown to enhance immune system function. However, there has been no direct evidence of the suppressive effect of a hot water extract of Chlorella vulgaris (CVE) on histamine-mediated allergic responses. RESULTS: The antihistamine activity of CVE was analysed using rat peritoneal mast cells (RPMCs) stimulated by compound 48/80. For in vivo verification, ovalbumin (OVA)-immunised BALB/c mice were treated with CVE orally. Serum immunoglobulin E (IgE) levels and splenocyte cytokine levels were determined by enzyme-linked immunosorbent assay (ELISA). CVE prevented histamine release through degranulation of mast cells by blocking the uptake of extracellular Ca²âº into RPMCs. Moreover, CVE administration inhibited serum IgE overproduction by OVA via induction of T helper 1 (Th1) skewing that was dependent on interferon-γ (IFN-γ) and interleukin 12 (IL-12) secretion. CONCLUSION: The results of this study clearly demonstrate that CVE acts as an antiallergic dietary agent by suppressing histamine release via its enhancive effect on Th1-related responses.

Lactic acid bacterial fermentation increases the antiallergic effects of Ixeris dentata.

Ixeris dentata (ID, family Asteraceae), called Seumbakuy in Korea, was fermented with lactic acid bacteria (LAB) and their antiallergic activities were investigated. Fermentation of ID with Bifidobacterium breve or Lactobacillus acidophilus increased its inhibition of degranulation in RBL-2H3 cells induced by the IgE-antigen complex. Oral administration of these extracts to mice inhibited the passive cutaneous anaphylaxis (PCA) reaction induced by the IgE-antigen complex and scratching behaviors induced by compound 48/80. The fermented ID more potently inhibited the PCA reaction and scratching behaviors than the non-fermented one. These extracts also inhibited mRNA expression of TNF-alpha and IL-4, as well as NF-kappaB activation in RBL-2H3 cells induced by the IgE-antigen complex. These findings suggest that LAB fermentation improves ID-mediated inhibition of IgE-induced allergic diseases such as rhinitis and asthma, and that ID works by inhibiting degranulation and NF-kB activation in mast cells and basophils.

Voltage-dependent N-type Ca2+ channel activity regulates the interaction between FGF-1 and S100A13 for stress-induced non-vesicular release.

1. The Ca(2+)-mediated regulation of interaction between FGF-1 and S100A13 in NG108-15 cells was studied. When the stress by depriving B27 supplement from the culture was given, cellular levels of both proteins were decreased, while their releases were significantly increased within 3 h. These stress-induced changes were all abolished by amlexanox, an anti-allergic drug. 2. These releases were significantly inhibited by the addition of EGTA or BAPTA-AM, cellular or extracellular Ca(2+)-chelating agent, respectively. The addition of omega-conotoxin GVIA, a N-type Ca(2+)-channel blocker caused a complete inhibition of the release, while increased the cytosolic levels of both proteins. However, omega-conotoxin MVIIC, the non-N-type Ca(2+)-channel blocker was ineffective. 3. In NG108-15 cells, which had been transfected with Venus-FGF-1 and CFP-S100A13, the supplement-deprivation stress caused several spike-type fluorescence resonance energy transfer (FRET) signals, suggesting that both proteins showing interaction would be immediately released. These spikes were completely abolished by the addition of omega-conotoxin GVIA. However, the addition of amlexanox caused bell-shaped FRET signals without spikes. 4. Thus, it is suggested that the interaction between FGF-1 and S100A13 responsible for stress-induced non-vesicular release is dependent of Ca(2+)-influx through N-type Ca(2+)-channels.

Anti-allergic activity of 18beta-glycyrrhetinic acid-3-O-beta-D-glucuronide.

Glycyrrhizin (18beta-glycyrrhetinic acid-3-O-beta-D-glucuronopyranosyl-(1 --> 2)-beta-D-glucuronide, GL) was transformed to 18beta-glycyrrhetinic acid-3-O-beta-D-glucuronide (GAMG) by Streptococcus LJ-22. The antiallergic activities of GL and GAMG was measured using a RBL cell assay system and contact hypersensitivity model mice. GAMG exhibited anti-allergic activity with IC50 values of 0.28 mM. GAMG, which is sweeter than GL, and 18beta-glycyrrhetinic acid, which is a GAMG metabolite by human intestinal bacteria, also inhibited the passive cutaneous anaphylaxis and skin contact inflammation. In conclusion, GAMG may be useful as a new sweet food additive and an anti-allergic agent.

Three distinct anti-allergic drugs, amlexanox, cromolyn and tranilast, bind to S100A12 and S100A13 of the S100 protein family.

To investigate the roles of calcium-binding proteins in degranulation, we used three anti-allergic drugs, amlexanox, cromolyn and tranilast, which inhibit IgE-mediated degranulation of mast cells, as molecular probes in affinity chromatography. All of these drugs, which have different structures but similar function, scarcely bound to calmodulin in bovine lung extract, but bound to the same kinds of calcium-binding proteins, such as the 10-kDa proteins isolated in this study, calcyphosine and annexins I-V. The 10-kDa proteins obtained on three drug-coupled resins and on phenyl-Sepharose were analysed by reversed-phase HPLC. It was found that two characteristic 10-kDa proteins, one polar and one less polar, were bound with all three drugs, although S100A2 (S100L), of the S100 family, was bound with phenyl-Sepharose. The cDNA and deduced amino acid sequence proved our major polar protein to be identical with the calcium-binding protein in bovine amniotic fluid (CAAF1, S100A12). The cDNA and deduced amino acid sequence of the less-polar protein shared 95% homology with human and mouse S100A13. In addition, it was demonstrated that the native S100A12 and recombinant S100A12 and S100A13 bind to immobilized amlexanox. On the basis of these findings, we speculate that the three anti-allergic drugs might inhibit degranulation by binding with S100A12 and S100A13.

A clinical overview of Tilarin.

Tilarin is a nasal spray containing 1% nedocromil sodium, a non-toxic pyranoquinoline dicarboxylate compound with potent antiallergic antiinflammatory properties. As a first-line topical treatment for seasonal allergic rhinitis (SAR) the pharmacokinetics of nedocromil sodium nasal formulation are such that it rivals sodium cromoglycate for safety. Less than 8% of the total dose of nedocromil sodium is systemically absorbed from the nasal mucosa, and this is reversibly bound to plasma proteins and is cleared rapidly from the circulation. Nedocromil sodium is eliminated unmetabolised in the urine and faeces, with an elimination half-life of 5.3 +/- 0.9 minutes. No significant adverse effects have been reported following intranasal administration of 1% nedocromil sodium four times daily, to a total of 964 patients with allergic rhinitis during clinical trials. Laboratory studies have shown that nedocromil sodium has a more wide-ranging pharmacological antiinflammatory profile than sodium cromoglycate and this is manifest in its clinical efficacy in allergic asthma and rhinoconjunctivitis. Analysis of pooled data from a series of double-blind, placebo-controlled group comparative studies in SAR patients demonstrated that, despite a significantly lower use of rescue antihistamines than with placebo treatment (31% reduction; p = 0.005), four times daily dosage with nedocromil sodium 1% nasal spray significantly reduced daily symptoms of rhinitis (p < 0.001) and was considered effective by the majority of patients (p < 0.001). Specific examples of the therapeutic efficacy of nedocromil sodium compared with placebo in patients with grass or ragweed pollen SAR can be found in the literature. One ragweed study (1) included four times daily sodium cromoglycate 4% nasal spray as an active comparator and showed a consistent, if non-significant, trend in favour of nedocromil sodium 1%, which was the more effective drug in comparison to placebo. An Italian paediatric study (2) compared nedocromil sodium 1% nasal spray with placebo in 149 children of whom 72% were under twelve years of age. After one week, the clinicians observed a significant reduction (p = 0.03) in sneezing with nedocromil sodium and after four weeks, patient (p < 0.01) and clinican (p < 0.001) opinions favoured the active treatment. Overall, the clinical profile of topical nedocromil sodium in SAR demonstrates fast relief of existing symptoms, sustained efficacy with four times daily use during peak pollen challenge, and a reduced need for concomitant symptomatic therapies. Nedocromil sodium 1% nasal spray is well tolerated, with minimal side-effects, and is acceptable to a wide age-range of patients.