year 24, Issue 93 (5-2025)                   J. Med. Plants 2025, 24(93): 53-67 | Back to browse issues page

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Leite P M, Miranda A P N, Amorim J M, Duarte R C F, Faraco A A G, Carvalho M D G et al . Citrus sinensis: Antithrombotic potential and safety concerns involving possible interactions based on in vitro coagulometric tests. J. Med. Plants 2025; 24 (93) :53-67
URL: http://jmp.ir/article-1-3740-en.html
1- Department of Pharmaceutical Products, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, Minas Gerais, Brazil
2- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, Minas Gerais, Brazil
3- Department of Pharmaceutical Products, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, Minas Gerais, Brazil , roc2006@farmacia.ufmg.br
Abstract:   (247 Views)
Background: Citrus sinensis, popularly called sweet orange, is widely used in Brazil for its calming properties, particularly in treating anxiety and insomnia, even among patients using warfarin. However, there is no scientific data supporting the safe concurrent use of both. Objective: To access the in vitro activity of C. sinensis ethanolic extract (EtEXT) and its fractions on blood clotting. Methods: The study used activated partial thromboplastin time (aPTT), prothrombin time (PT) and plasma fibrinogen measurement (PF), and thrombin generation test (TGT) to evaluate the effects. TGT, a highly sensitive assay, investigates overall changes in the hemostatic system and can evaluate the qualitative micromolecular chemistry of C. sinensis EtEXT and its fractions. Results: The EtEXTs of sweet orange leaves and their fractions were added to plasma pools at concentrations of 1.67 mg/ml, 2.26 mg/ml, and 2.86 mg/ml. Presence of phenolics as coumarins, flavonoids and tannins, as well as triterpenes was confirmed. At all concentrations, the extract increased PT and aPTT while decreasing PF and TGT, except for the hexane fraction. Conclusion: Our findings provide scientific evidence supporting both patient care in the context of warfarin use and the potential development of new antithrombotics. The leaves of sweet orange exhibited in vitro anticoagulant effects, likely due to interference in both extrinsic (EXT-path) intrinsic (INT-path) coagulation pathways. The function of the identified substances in these effects was also discussed, as well as the potential for using this extract in developing antithrombotic agents.
Full-Text [PDF 552 kb]   (74 Downloads)    
Type of Study: Research | Subject: Pharmacognosy & Pharmaceutics
Received: 2024/09/23 | Accepted: 2025/03/17 | Published: 2025/05/14

References
1. Favela-Hernández JMJ, González-Santiago O, Ramírez-Cabrera MA, Esquivel-Ferriño PC, Camacho-Corona M del R. Chemistry and Pharmacology of Citrus sinensis. Molecules 2016; 21: 1-24. [DOI:10.3390/molecules21020247]
2. Chaudhari SY, Ruknuddin G and Prajapati P. Ethno medicinal values of Citrus genus: A review. Med. J. Dr DY. Patil. Univ. 2016; 9(5): 560-565. [DOI:10.4103/0975-2870.192146]
3. Mannucci C, Calapai F, Cardia L, Inferrera G, D'Arena G, Pietro Md, Navarra M, Gangemi S, Spagnolo EV and Calapai G. Clinical pharmacology of Citrus aurantium and Citrus sinensis for the treatment of anxiety. Evid. Based Complement Altern. Med. 2018; 2018(2018): 3624094. [DOI:10.1155/2018/3624094]
4. Iglesias-Carres L, Mas-Capdevila A, Bravo FI, Aragones G, Muguerza B, Arola-Arnal A. Optimization of a polyphenol extraction method for sweet orange pulp (Citrus sinensis L.) to identify phenolic compounds consumed from sweet oranges. PLoS One 2019; 14: 1-17. [DOI:10.1371/journal.pone.0211267]
5. Haggag E. Flavonoids from the leaves of Citrus aurantium (Sour Orange) and Citrus sinensis (Sweet Orange). Asian J. Chem. 1999; 11(3): 707-714.
6. Kawaii S, Tomono Y, Katase E, Ogawa K, Yano M, Koizumi M, Ito Ch and Furukawa H. Quantitative study of flavonoids in leaves of citrus plants. J. Agric Food Chem. 2000; 48(9): 3865-71. [DOI:10.1021/jf000100o]
7. Ribeiro AB, Abdelnur PV, Garcia CF, Belini A, Severino VGP, da Silva MF das GF, Fernandes JB, Vieira PC, de Carvalho SA, de Souza AA and Machado MA. Chemical characterization of Citrus sinensis grafted on C. limonia and the effect of some isolated compounds on the growth of Xylella fastidiosa. J. Agric. Food Chem. 2008; 56(17): 7815-22. [DOI:10.1021/jf801103p]
8. Pimenta F, Tavares N de AC, Neto GC, Alves M, Pimenta MF, Diniz JM, de Medeiros AC and Diniz MM. Pharmacological actions of Citrus species. Citrus Pathol., InTech; 2017. [DOI:10.5772/66464]
9. Leite PM, de Freitas AA, Mourao A de OM, Martins MAP, Castilho RO. Warfarin safety: A cross-sectional study of the factors associated with the Consumption of Medicinal Plants in a Brazilian anticoagulation clinic. Am. J. Cardiovasc Drugs 2018; 18: 231-43. [DOI:10.1007/s40256-018-0268-1]
10. Mendonça LP, Oliveira CR, Pinho RAL and Parreiras MMA. Consumption of medicinal plants by patients with heart diseases at a pharmacist-managed anticoagulation clinic in Brazil. Int. J. Clin. Pharm. 2016; 38(2): 223-7. [DOI:10.1007/s11096-016-0270-0]
11. Leite PM, Martins MAP and Castilho RO. Review on mechanisms and interactions in concomitant use of herbs and warfarin therapy. Biomed. Pharmacother. 2016; 83: 14-21. [DOI:10.1016/j.biopha.2016.06.012]
12. Leite PM, Martins MAP and Castilho RO. Herbs-warfarin interactions: potential targets and biochemical implications approach. 1st ed. Balti: Editorial Academica Espanola; 2017.
13. Ge B, Zhang Z and Zuo Z. Updates on the clinical evidenced herb-warfarin interactions. Evidence-Based Complement. Altern. Med. 2014; 2014(1): 957362. [DOI:10.1155/2014/957362]
14. Mallick N, Khan RA, Riaz A and Afroz S. Anticoagulant, antiplatelet and antianemic effects of Citrus paradisi (Grape fruit) juice in rabbits. Pharmacol. Pharm. 2016; 7(10): 397-406. [DOI:10.4236/pp.2016.710047]
15. Brandin H, Myrberg O, Rundlof T, Arvidsson A-K and Brenning G. Adverse effects by artificial grapefruit seed extract products in patients on warfarin therapy. Eur. J. Clin. Pharmacol. 2007; 63: 565-70. [DOI:10.1007/s00228-007-0289-1]
16. Mouly S, Lloret-Linares C, Sellier P-O, Sene D and Bergmann J-F. Is the clinical relevance of drug-food and drug-herb interactions limited to grapefruit juice and Saint-John's Wort? Pharmacol. Res. 2017; 118: 82-92. [DOI:10.1016/j.phrs.2016.09.038]
17. Riaz A, Khan RA, Mirza T, Mustansir T and Ahmed M. In vitro/in vivo effect of Citrus limon (L. Burm. f.) juice on blood parameters, coagulation and anticoagulation factors in rabbits. Pak. J. Pharm. Sci. 2014; 27: 907-15.
18. Assefa AD, Ko EY, Moon SH and Keum Y-S. Antioxidant and antiplatelet activities of flavonoid-rich fractions of three citrus fruits from Korea. 3 Biotech. 2016; 6: 109. [DOI:10.1007/s13205-016-0424-8]
19. Leite PM, Miranda APN, Amorim JM, Duarte RCF, Bertolucci SK V, Carvalho MdG and Castilho RO. In vitro anticoagulant activity of Mikania laevigata: deepening the study of possible interaction between guaco and anticoagulants. J. Cardiovasc Pharmacol. 2019; 74(6): 574-83. [DOI:10.1097/FJC.0000000000000745]
20. Leite PM, Miranda APN, Amorim JM, Duarte RCF, Faraco AAG, Carvalho MDG and Castilho RO. Thrombin generation test with the calibrated automated thrombogram and anticoagulant activity of Mentha crispa. Blood Coagul Fibrinolysis. 2020; 31(1): 101-106. [DOI:10.1097/MBC.0000000000000859]
21. Wagner H, Bladt S and Zgainski EM. Plant drug analysis: A thin layer chromatography atlas. Springer-Verlag Berlin Heidelberg; 1st ed, 1984. [DOI:10.1007/978-3-662-02398-3_1]
22. You JJ, Singer DE, Howard PA, Lane DA, Eckman MH, Fang MC, Hylek EM, Schulman S, Go AS, Hughes M, Spencer FA, Manning WJ, Halperin JL and Lip GYH. Antithrombotic therapy for atrial fibrillation: Antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012; 141(Supp. 2): 531-75. [DOI:10.1378/chest.11-2304]
23. Agbabiaka TB, Wider B, Watson LK and Goodman C. Concurrent use of prescription drugs and herbal medicinal products in older adults: A systematic review. Drugs Aging 2017; 34: 891-905. [DOI:10.1007/s40266-017-0501-7]
24. Hemker HC, Wielders S, Kessels H and Beguin S. Continuous registration of thrombin generation in plasma, its use for the determination of the thrombin potential. Thromb Haemost. 1993; 70(4): 617-24. [DOI:10.1055/s-0038-1649638]
25. Hemker HC, Giesen P, Al Dieri R, Regnault V, de Smedt E, Wagenvoord R, Lecompte T and Béguin S. Calibrated automated thrombin generation measurement in clotting plasma. Pathophysiol Haemost Thromb. 2003; 33(1): 4-15. [DOI:10.1159/000071636]
26. Mann KG. Thrombin formation. Chest. 2003; 124(Sup. 3): 4S-10S. [DOI:10.1378/chest.124.3_suppl.4S]
27. Wolberg AS. Thrombin generation and fibrin clot structure. Blood Rev. 2007; 21(3): 131-42. [DOI:10.1016/j.blre.2006.11.001]
28. Duarte RCF, Rios DRA, Rezende SM, Jardim LL, Ferreira CN, Carvalho M das G. Standardization and evaluation of the performance of the thrombin generation test under hypo- and hypercoagulability conditions. Hematol Transfus Cell Ther. 2018; 41(3): 244-52. [DOI:10.1016/j.htct.2018.08.007]
29. Duarte RCF, Ferreira CN, Rios DRA, Reis HJ Dos, Carvalho M das G. Thrombin generation assays for global evaluation of the hemostatic system: perspectives and limitations. Rev. Bras. Hematol. Hemoter. 2017; 39(3): 259-65. [DOI:10.1016/j.bjhh.2017.03.009]
30. Duarte RCF, Rios DRA, Leite PM, Alves LC, Magalhaes HPB, Carvalho M das G. Thrombin generation test for evaluating hemostatic effects of Brazilian snake venoms. Toxicon. 2019; 163: 36-43. [DOI:10.1016/j.toxicon.2019.03.012]
31. Castoldi E and Rosing J. Thrombin generation tests. Thromb. Res. 2011; 127(Sup. 3): S21-5. [DOI:10.1016/S0049-3848(11)70007-X]
32. Berntorp E and Salvagno GL. Standardization and clinical utility of thrombin-generation assays. Semin Thromb Hemost. 2008; 34(7): 670-82. [DOI:10.1055/s-0028-1104546]
33. Malongane F, McGaw LJ and Mudau FN. The synergistic potential of various teas, herbs and therapeutic drugs in health improvement: a review. J. Sci. Food Agric. 2017; 97(14): 4679-89. [DOI:10.1002/jsfa.8472]
34. Dewick PM. Medicinal natural product - a biosynthetic approach 3rd ed. Switzerland: Department of Ecology - Swedish University of Agricultural Science; 2009. [DOI:10.1002/9780470742761]
35. Srikrishna D, Godugu C and Dubey PK. A review on pharmacological properties of Coumarins. Mini. Rev. Med. Chem. 2018; 18(2): 113-41. [DOI:10.2174/1389557516666160801094919]
36. Dugrand-Judek A, Olry A, Hehn A, Costantino G, Ollitrault P, Froelicher Y and Bourgaud F. The distribution of Coumarins and Furanocoumarins in Citrus species closely matches Citrus phylogeny and reflects the organization of biosynthetic pathways. PLoS One. 2015; 10: 1-25. [DOI:10.1371/journal.pone.0142757]
37. Liu L, Ma H, Yang N, Tang Y, Guo J, Tao W and Duan J. A series of natural flavonoids as Thrombin inhibitors: structure-activity relationships. Thromb. Res. 2010; 126: 365-78. [DOI:10.1016/j.thromres.2010.08.006]
38. Mabry TJ, Markham KR and Thomas MB. The systematic identification of flavonoids. New York: Springer; 1970. [DOI:10.1007/978-3-642-88458-0]
39. Navarro-Núñez L, Lozano ML, Palomo M, Martínez C, Vicente V, Castillo J, Benavente-García O, Diaz-Ricart M, Escolar G and Rivera J. Apigenin inhibits platelet adhesion and thrombus formation and synergizes with aspirin in the suppression of the arachidonic acid pathway. J. Agric. Food Chem. 2008; 56(9): 2970-3976. [DOI:10.1021/jf0723209]
40. Khan H, Jawad M, Kamal MA, Baldi A, Xiao J, Nabavi SM and Daglia M. Evidence and prospective of plant derived flavonoids as antiplatelet agents: Strong candidates to be drugs of future. Food Chem. Toxicol. 2018; 119: 355-67. [DOI:10.1016/j.fct.2018.02.014]
41. Choi J, Kim Y, Shin C, Lee H and Kim S. Antithrombotic activities of Luteolin In vitro and In vivo. J. Biochem. Mol. Toxicol. 2015; 29: 552-8. [DOI:10.1002/jbt.21726]
42. Vilahur G, Ben-Aicha S, Diaz-Riera E, Badimon L and Padro T. Phytosterols and inflammation. Curr. Med. Chem. 2019; 26: 6724-34. [DOI:10.2174/0929867325666180622151438]
43. Othman RA and Moghadasian MH. Beyond cholesterol-lowering effects of plant sterols: clinical and experimental evidence of anti-inflammatory properties. Nutr. Rev. 2011; 69(7): 371-82. [DOI:10.1111/j.1753-4887.2011.00399.x]
44. de Almeida PDO, Boleti AP de A, Rudiger AL, Lourenco GA, da Veiga Junior VF, Lima ES. Anti-inflammatory activity of Triterpenes isolated from Protium paniculatum oil-resins. Evid Based Complement Alternat Med. 2015; 2015: 293768. [DOI:10.1155/2015/293768]
45. Ríos JL, Recio MC, Maáñez S and Giner RM. Natural Triterpenoids as anti-inflammatory agents. Studies in Natural Products Chemistry 2000; 22(Part C): 93-143. [DOI:10.1016/S1572-5995(00)80024-1]
46. Yang B, Zhu J-P, Rong L, Jin J, Cao D, Li H, Zhau X-H and Zhao Z-X. Triterpenoids with antiplatelet aggregation activity from Ilex rotunda. Phytochem. 2018; 145: 179-86. [DOI:10.1016/j.phytochem.2017.11.005]
47. Osunsanmi FO, Zaharare GE, Oyinloye BE, Mosa RA, Ikhile MI, Shode FO, Ogunyinka IB and Opoku AR. Antithrombotic, anticoagulant and antiplatelet activity of betulinic acid and 3β-acetoxybetulinic acid from Melaleuca bracteata "Revolution Gold" (Myrtaceae) Muell leaf. Trop. J. Pharm. Res. 2018; 17(10): 1983-9. [DOI:10.4314/tjpr.v17i10.13]
48. Mosa RA, Ndwandwe T, Cele NF and Opoku AR. Anticoagulant and anti-inflammatory activity of a triterpene from Protorhus longifolia stem bark. J. Med. Plant. Res. 2015; 9: 613-9. [DOI:10.5897/JMPR2015.5740]
49. Witt DM, Clark NP, Kaatz S, Schnurr T and Ansell JE. Guidance for the practical management of warfarin therapy in the treatment of venous thromboembolism. J. Thromb. Thrombolysis 2016; 41: 187-205. [DOI:10.1007/s11239-015-1319-y]
50. Ageno W, Gallus AA, Wittkowsky A, Crowther M, Hylek EM and Palareti G. Antithrombotic therapy and orevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012; 141(2): 44-75. [DOI:10.1378/chest.11-2292]
51. Vazquez SR. Drug-drug interactions in an era of multiple anticoagulants: a focus on clinically relevant drug interactions. Blood 2018; 132(21): 2230-9. [DOI:10.1182/blood-2018-06-848747]
52. Ha NB, Yang K, Hanigan S, Kurtz B, Dorsch MP, Mak H and Nagel J. Impact of a guideline for the management of antimicrobial/Warfarin interactions in the inpatient setting and across transition of care. Ann. Pharmacother. 2016; 50(9): 734-40. [DOI:10.1177/1060028016653765]
53. Esmon CT. Basic mechanisms and pathogenesis of venous thrombosis. Blood. Rev. 2009; 23(5): 225-9. [DOI:10.1016/j.blre.2009.07.002]
54. Kim K and Park K-I. A review of antiplatelet activity of traditional medicinal herbs on integrative medicine studies. Evid. Based. Complement Alternat Med. 2019; 2019(1): 7125162. [DOI:10.1155/2019/7125162]
55. Esmon CT. Inflammation and thrombosis. J. Thromb. Haemost. 2003; 1(7): 1343-8. [DOI:10.1046/j.1538-7836.2003.00261.x]
56. Garcia-Lafuente A, Guillamon E, Villares A, Rostagno MA and Martinez JA. Flavonoids as anti-inflammatory agents: implications in cancer and cardiovascular disease. Inflamm. Res. 2009; 58: 537-52. [DOI:10.1007/s00011-009-0037-3]
57. Gomes A, Fernandes E, Lima JLFC, Mira L and Corvo ML. Molecular mechanisms of anti-inflammatory activity mediated by flavonoids. Curr. Med. Chem. 2008; 15(16): 1586-605. [DOI:10.2174/092986708784911579]
58. Nijveldt R, van Nood E, van Hoorn D, Boelens PG, van Norren K, van Leeuwen PA. Flavonoids: a review of probable mechanisms of action and potential applications. Am. J. Clin. Nutr. 2001; 74(4): 418-25. [DOI:10.1093/ajcn/74.4.418]

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