Network analysis to explore the pharmacological mechanism of Shenmai injection in treating granulocytopenia and evidence-based medicine approach validation : Medicine

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Research Article: Systematic Review and Meta-Analysis

Network analysis to explore the pharmacological mechanism of Shenmai injection in treating granulocytopenia and evidence-based medicine approach validation

Hou, Xianbing MMa,*; Chen, Dandan MMb; Wang, Yao MBa; Cui, Bixian MBa; Xu, Hui MMa; Wang, Yuanyuan MMa; Chen, Hongzhou MBa; Wang, Dan MBc; Chen, Ying MBc; Cheng, Tongfei MBc; Dai, Xiaojun MBc

Author Information
Medicine 102(20):p e33825, May 19, 2023. | DOI: 10.1097/MD.0000000000033825
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1. Introduction

Granulocytopenia is one of oncology patients’ most common adverse reactions after chemotherapy. In most cases, leukopenia results from a reduction in neutrophils as the components of leukocytes are mainly neutrophils and lymphocytes, with neutrophils being the most predominant. Chemotherapy-induced neutropenia is defined as a decrease in absolute neutrophil count in peripheral blood following the use of myelosuppressive chemotherapeutic agents, i.e., laboratory-based routine blood results suggesting absolute neutrophil count < 2.0 × 109/L.[1] The incidence of granulocytopenia in patients undergoing radiation and chemotherapy for oncology can be as high as 30% to 50%.[2] Granulocytopenia can seriously affect the efficacy of chemotherapy in oncology patients and even cause treatment failure, which may be combined with severe infections or even life-threatening.[3] The granulocyte colony-stimulating factor is mainly used in clinical practice for post-chemotherapy leukopenia and granulocytopenia due to myelosuppression. Although the therapeutic effect is rapid, it does not last long and needs to be repeated several times, and the therapeutic effect decreases with the number of doses. Chinese botanical drugs have been used clinically as an adjunctive therapy to prevent and treat post-chemotherapy granulocytopenia in tumors. Shenmai injection is one of the most commonly used drugs. It can be used to treat granulocytopenia and aplastic anemia. It can enhance the immune function of tumor patients and, when combined with chemotherapeutic drugs, synergistic effects and suppression of toxic side effects are more prominent.[4–6] Granulocytopenia belongs to the category of “consumptive disease” in Chinese medicine.[7] Chinese medicine theory believes that the key cause of granulocyte deficiency after chemotherapy is “toxic evil” (chemotherapy drugs or radiation), and its occurrence and progression is a dynamic pathological change process, and is closely related to the body’s qi, blood, yin and yang, and the functional state of the internal organs. The “poisonous evil” initially damages the qi and blood, involving the heart and spleen; later, the “poisonous evil” damages the yin and blood and essence and blood, involving the liver, spleen and kidney; finally, the essence and marrow are empty and the new blood is biochemically lacking.[8,9] Shenmai injection is commonly used in clinical practice to prevent and treat granulocytopenia after radiotherapy and chemotherapy. Shenmai injection originated from ginseng ophiopogon japonicus decoction, it comes from “Dialectical Record,” composed of ginseng, ophiopogon japonicus. Ginseng sweet-warm, greatly tonify the original qi, for the sovereign medicinal. Ophiopogon japonicus sweet-cold, nourishing yin and moistening lung, for the minister medicinal. The compatibility of the 2 medicines has the functions of nourishing qi and yin. A large number of clinical and experimental studies have confirmed that Shenmai injection has remarkable advantages and effects in preventing granulocytopenia.[10–12] Pharmacological studies have shown that Shenmai injection has anti-inflammatory, anti-shock, anti-tumor, immune regulation, inhibition of tumor angiogenesis and other effects.[13–17] However, the molecular mechanism of Shenmai injection in granulocytopenia treatment remains unclear, which limits its promotion and development.

Network pharmacology is a powerful tool for analyzing the complex relationships between drug components, protein targets, diseases, and genes. This methodology has been applied extensively in the analysis of traditional Chinese medicine preparations. In this study, we utilized network pharmacology to screen the active ingredients of Shenmai injection, identify their targets, and analyze the genes associated with granulocytopenia. The purpose of this study is to investigate the potential link between the active components of Shenmai injection and the targets of granulocytopenia, as well as the mechanism of action of traditional Chinese medicine in preventing and treating this condition through the use of network pharmacology. The ultimate goal of this research is to provide valuable insights into Shenmai injection’s clinical application and efficacy in treating granulocytopenia. At the same time, from an evidence-based medicine perspective, we conducted a meta-analysis to verify the efficacy of Shenmai injection in preventing and treating granulocytopenia.

2. Materials and Methods

2.1. Network analysis

2.1.1. The focus of this study was on gathering information about the chemical composition and targets of action found in Chinese medicines.

To do so, researchers utilized the TCMID (Traditional Chinese Medicines Integrated Database) platform ( The platform was used to search for the active ingredients present in red ginseng and ophiopogon japonicus. They then used SuperPred ( to predict molecular targets and create a comprehensive database of Shenmai injection ingredients and their corresponding targets.

2.2.1. Acquisition and collection of disease targets.

The keywords “granulocyte deficiency,” “granulocytopenia,” “neutropenia,” and “leukopenia” were used to search for disease gene targets in GeneCard (, OMIM (, and DisGeNET ( databases were searched for disease gene targets to build up a database of disease targets. The database of disease targets was compiled.

3.2.1. Construction of drug-active-component-critical-target networks.

With the support of Microbiology’s online platform (, the corresponding target genes of the active ingredient of Red Ginseng-Ophiopogon Japonicus were crossed with those of the associated target genes of granulocytopenia to obtain the common target genes of the drug and the disease. Cytoscape software (Version 3.7.1) was used to construct the “drug-co-active ingredient-critical target gene” relationship network. The network showed the drug-active ingredient-disease target association, and the mechanism of the effect of red ginseng-ophiopogon japonicus on granulocytopenia was investigated by constructing the network.

4.2.1. Construction of a network of key target protein-related actions.

Protein interaction relationships were predicted on the STRING database platform ( The protein interaction relationship network was obtained by analyzing the common targets of red ginseng-ophiopogon japonicus-granulocytopenia in the String database. The results were exported in the form of TSV.

5.2.1. Key target GO enrichment analysis and KEGG pathway analysis.

Enter the common target in the DAVID 6.8 database (, set the identifier “OFFICIAL GENE SYMBOL,” select “homo sapiens” for the species, leave the rest as default and perform the gene ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. “, leave the rest as default and perform GO function and KEGG pathway enrichment analysis. The enrichment results were visualized with the support of the Microbiology online platform. On this basis, predictions were made regarding the possible mechanisms of Shenmai injection in the treatment of granulocytopenia. The study flow chart is shown in Figure 1.

Figure 1.:
The study design and analysis workflow are shown in both the flow chart and study results. These visual aids provide a clear overview of the study’s methodology and findings. PPI = protein-protein interaction.

2.2. Meta-analysis

This study has been registered on PROSPERO ( The registration number is CRD42022367132. Ethical approval is unnecessary because this is a literature-based study.

2.2.1. Databases and search strategies.

We searched PubMed, Web of Science, Cochrane library, CBM, Wan Fang, VIP and CNKI databases and the China Clinical Research Registry for clinical randomized controlled studies of previous applications of Shenmai injection for post-chemotherapy leucopenia, with no restrictions on language and using keyword and free word search A combination of keyword and free word searches were used. The search terms included “Shenmai,” “Chinese medicine,” “traditional Chinese medicine,” “oncology,” “chemotherapy,” “leucopenia” “granulocytopenia,” “randomized controlled trial,” or “clinical controlled trial,” or “randomized trial” or “placebo,” “clinical trial” or “controlled trial,” etc. All of these searches have been completed by October 2022.

2.2.2. Inclusion criteria.

Type of research All papers are randomized controlled trials investigating the effectiveness and safety of Shenmai injection in treating post-chemotherapy granulocytopenia without time or language restrictions. Participants Patients with granulocytopenia after chemotherapy; Expected survival ≥3 months; No cardiac severe, pulmonary, hepatic or renal dysfunction; No allergy to ginseng and wheat injection or other Chinese herbal injections; No use of granulocyte-stimulating factor or other white-raising drugs within 2 weeks before treatment; Leukocytes > 0.5*109/L, without severe co-infection. Interventions The dose of Shenmai injection is not restricted for the treatment of post-chemotherapy granulocytopenia, and the chemotherapy regimen is not limited. Control The control group included conventional Chinese and Western medical treatment other than Shenmai injection and placebo. In addition, other symptom-supporting treatments were unrestricted in both groups.

2.2.3. Exclusion criteria.

Case reports; animal studies; basic research; personal experience and review articles; incomplete data; duplication of literature; baseline conditions not assessed, etc.

2.2.4. Results primary outcome.

Objective Response Rate (ORR): The effective rate was the sum of complete response (CR) and partial response (PR). Other results: post-treatment leukocyte count, adverse effects.

2.2.5. Risk of bias assessment.

Two authors independently assessed the risk of bias as described in the Cochrane Handbook for the systematic review of interventions. We categorized potential bias as high, low or unclear. The following items were assessed: Random sequence generation, Allocation concealment, Blinding of participants and personnel, Blinding of outcome assessment, Incomplete outcome data, Selective reporting, other biases.

2.2.6. Research selection and statistic collection.

After excluding duplicate publications, both authors first screened articles based on title and abstract. Full-text versions of papers that meet the inclusion criteria are then retained, and data on patient characteristics, treatment details and clinical outcomes are extracted independently. Disagreements, if any, will be resolved by a third author.

2.2.7. Statistical analysis and data synthesis.

Meta-analysis was performed according to the RevMan 5.3 software provided by the Cochrane Collaboration Network. The mean difference (MD) and its 95% CI were used for measurement data, and the relative risk (RR) and its 95% CI were used for count data. The χ2 test was used to test for heterogeneity. If P ≤ .1 or I2 ≥ 50% indicated heterogeneity between the results of the included studies, the sources and causes of heterogeneity were analyzed, and a random-effects model was used for the combined analysis. If P > .1 and I2 < 50%, there was no or little heterogeneity among the included studies, and a fixed-effects model was used for the combined analysis. If heterogeneity was significant, sensitivity analysis could be used to assess the stability of the results, and if ≥ 10 studies were included, funnel plots would be used to assess reporting bias.

3. Results

3.1. Screening of the active ingredients

Nine chemical components of red ginseng and 56 chemical components of ophiopogon japonicus were searched through the TCMID platform database, excluding parts for which no corresponding targets were found, resulting in 8 active parts of red ginseng and 34 active components of maidenhair. The OB and DL values were not considered for the intravenous drugs (Table 1).

Table 1 - Chemical composition of Shenmai injection (MD–MD34 represent the 34 active ingredients of Ophiopogon Japonicus; HS1–HS8 represent the 8 active ingredients of Red Ginseng).
Number Ingredient name Degree Number Ingredient name Degree
MD1 2′-hydroxymethylophiopogonone a 82 MD22 ophiopogonanone c 107
MD2 5,7,2′-trihydroxy-6-methyl-3-(3′,4′-methylene-dioxybenzyl) chromone 82 MD23 ophiopogonanone d 103
MD3 5,7-Dihydroxy-6,8-dime thyl-3-(4′-hydroxy-3′-methoxybenzyl) chroman-4-one 96 MD24 ophiopogonanone e 97
MD4 5-hydroxy-7,8-dimethoxy-6-methyl-3-(3′,4′-dihydroxybenzyl) chroman-4-one 90 MD25 ophiopogonanone f 97
MD5 6-aldehydo-isoophiopogone a 101 MD26 ophiopogonone a 100
MD6 6-aldehydo-isoophipogonone a 102 MD27 ophiopogonone b 93
MD7 Adenine nucleoside 6 MD28 ophiopogonone c 96
MD8 borneol-2-o-beta-d-glucopyranoside 156 MD29 ophiopogonoside a 169
MD9 guanosine 110 MD30 orchinol 137
MD10 isoophiopogonone a 102 MD31 stigmasterol 142
MD11 jasmololone 107 MD32 stigmasterol-beta-d-glucoside 138
MD12 methy-lophiopogonone b 84 MD33 uridine 96
MD13 Methyl beta-orcinol caroxylate 98 MD34 β-patchoulene 165
MD14 Methyl ophiopogonanone a 99 HS1 beta-elemene 153
MD15 Methyl ophiopogonanone b 92 HS2 ginsenoside rb1 2
MD16 n-(trans-p-coumaroyl)tyramine 110 HS3 ginsenoside rb2 2
MD17 n-trans-feruloyltyramine 3 HS4 ginsenoside rc 2
MD18 n-[β-hydroxy-β-(4-hydroxyphenyl)]ethyl-4-hydroxy cinnamide 106 HS5 ginsenoside re 162
MD19 oleanolicacid 111 HS6 ginsenoside rf 163
MD20 ophiopogonanone a 4 HS7 ginsenoside rg1 161
MD21 ophiopogonanone b 97 HS8 ginsenoside rh2 153

3.2. Prediction of potential targets

A total of 186 potential targets of red ginseng and 410 potential targets of ophiopogon japonicus were obtained after eliminating invalid and duplicate targets by searching the database on the SuperPred platform and using this platform to screen the corresponding potential targets of active ingredients. The database platforms of Genecard, OMIM and DisGeNET were used to search for “granulocytopenia,” and 3012 potential targets were obtained for granulocytopenia. Using an online tool (, 85 common genes were identified (Fig. 2A), suggesting that red ginseng and ophiopogon japonicus have separate and common targets for the treatment of granulocytopenia.

Figure 2.:
Analysis of target genes. (A) Venn diagram of herb target genes and disease target genes. The blue and pink circle stands for effective Chinese botanical drugs target genes. The green circle stands for granulocytopenia target genes, and the intersection genes are shown in the middle; (B) The PPI network of the intersection genes of herb targets and disease targets; (C–E) Hub genes from the intersection genes of herb targets and disease targets. PPI = protein-protein interaction.

3.3. Analysis of protein interaction networks of key target genes

Using an online tool to plot Venn diagrams between the ophiopogon japonicus and red ginseng targets and the granulocytopenia targets, we obtained 85 crossover targets. The STRING database platform ( was used to predict the PPI network for the crossover targets of ginseng and maitake injection for granulocytopenia. After hiding the free nodes, the PPI network contained 82 nodes and 428 edges (Fig. 2B). Three core functional modules were identified by CytoscapeMCODE (Fig. 2C–E), and target proteins with top 10 degree values (degree > 20) were potential key targets in the PPI network (Table 2).

Table 2 - The top 10 key targets of the degree value.
Gene name Protein name Degree
STAT3 Signal transducer and activator of transcription 3 40
HSP90AA1 Heat shock protein HSP 90-alpha 34
HIF1A Hypoxia-inducible factor 1-alpha 34
TLR4 Toll-like receptor 4 32
PIK3CA Phosphatidylinositol 4,5-bisphosphate 3-kinase catalytic subunit alpha isoform 28
MTOR Serine/threonine-protein kinase mTOR 28
ESR1 Estrogen receptor, ER (ER-alpha) (Estradiol receptor) (Nuclear receptor subfamily 3 group A member 1) 28
PIK3R1 Phosphatidylinositol 3-kinase regulatory subunit alpha 25
EP300 Histone acetyltransferase p300 24
GRB2 Growth factor receptor-bound protein 2 20

3.4. Construction and analysis of networks

Cytoscape 3.7.1 was used to construct the drug-active ingredient-critical action target-pathway network, involving 480 nodes and 229,920 edges (Fig. 3). Ophiopogonoside a had the highest degree value (degree 169), indicating that Ophiopogonoside a was the most critical component of the active substance, followed by β-patchoulene, ginsenoside rf, ginsenoside re, and ginsenoside rg1. Through the construction of the drug-active-ingredient-critical-target-pathway network, the active ingredients with the top 5 degree values (degree > 160) were the potential critical components, two of which were from ophiopogon japonicus and 3 from red ginseng.

Figure 3.:
The network diagram of the “core drugs-component-target-pathway” reflects the interaction of Shenmai injection and its potential targets with the core pathway (blue square represent herbs, yellow and green round represent active components, green rhombus substitute targets, and purple arrows represents the signal path).

3.5. Analysis of the biological functions and pathways of key target genes

To further elucidate the biological functions of the 85 intersection genes, we imported the 85 common genes into the DAVID database and performed the GO function and KEGG pathway enrichment analysis. Using P < .05 as the screening condition, the top 10 genes of biological process, cell composition, and molecular function were selected for the GO enrichment analysis and visualized using the online microbiology platform. A total of 206 enrichment items were obtained from the biological process function enrichment analysis, with the targets positively regulating inflammatory response, phosphatidylinositol-mediated signaling, positive regulation of RNA polymerase II promoter transcription, positive rule of cytosolic calcium concentration, positive regulation of gene expression, phosphatidylinositol phosphorylation, T cell receptor signaling pathway, negative regulation of apoptosis, B cell differentiation, protein autophosphorylation process molecular function analysis yielded a total of 118 enrichment items, with targets significantly involved in ATP binding, kinase activity, protein binding, phosphatidylinositol-4,5-bisphosphate 3-kinase activity, phosphatidylinositol 3-kinase activity, enzyme binding, 1-phosphatidylinositol-4-phosphate 3-kinase activity, insulin receptor substrate binding, protein kinase activity, 1-phosphatidylinositol-3-kinase activity. Cell composition analysis yielded a total of 31 enrichment items; targets were mainly enriched in the nucleoplasm, phosphatidylinositol 3-kinase complex, cytoplasm, plasma membrane, cytoplasm, cell surface, intrinsic components of the plasma membrane, lysosomal compartments, and nuclear adhesion patches (Fig. 4A). 166 items were returned from KEGG pathway analysis, with the top 20 items ranked from smallest to most significant P value including prostate cancer, thyroid hormone signaling pathway, proteoglycans in cancer, acute myeloid leukaemia, pathways in cancer, central carbon metabolism in cancer, sphingolipid signaling pathway, HIF-1 signaling pathway, T-cell receptor signaling pathway, choline metabolism in cancer, PI3K-Akt signaling pathway, hepatitis B, chemokine signaling pathway, small cell lung cancer, glioma, FoxO signaling pathway, chronic granulocytic leukaemia, non-small cell lung cancer, EBV infection, apoptosis (Fig. 4B).

Figure 4.:
(A) GO enrichment analysis of intersection genes of red ginseng, ophiopogon japonicus and granulocytopenia; (B) KEGG enrichment analysis of intersection genes of red ginseng, ophiopogon japonicus and granulocytopenia. BP = biological process, CC = cell composition, GO = Gene ontology, KEGG = Kyoto encyclopedia of genes and genomes, MF = molecular function.

As shown in the flow chart of the meta-analysis of study selection (Fig. 5). We searched 7 databases and the Chinese Clinical Research Registry based on a comprehensive search strategy. A total of 355 publications were retrieved. After excluding 166 duplicates, 18 reviews and systematic reviews, 10 animal studies, and 119 studies with different study aims and diseases, we recovered the full text of 42 articles for full-text evaluation, of which 31 studies were excluded for inappropriate interventions, non-RCTs, failure to describe baseline conditions, incomplete results, and low quality. Ultimately, 11 randomized controlled trials[18–28] involving 1121 patients were included in this study, and the baseline characteristics of the included trials were comparable between the treatment and control groups. Two trials[19–27] were concomitant with chemotherapy, and one was a blank control and had exfoliated cases.[27] All literature reported on treatment effectiveness, with 7 accounting for pre- and post-treatment leukocyte count.[18,22–27] No adverse events due to Shenmai injection were reported in all the literature. The characteristics are shown in Table 3. The bias risk assessment of the included studies is shown in Figure 6. Figure 6A shows the proportion of studies assessed as low, high or unclear risk of bias for each risk of bias indicator. Figure 6B shows the risk of bias indicators for individual studies.

Table 3 - Characteristics of included trials for meta-analysis.
Author Year Sample size (T/C) Gender [T(M/F); C(M/F)] Age (T/C) Leukocyte count [T(MD ± SD); C(MD ± SD)] Interventions (T/C) ORR [T (valid/invalid); C (valid/invalid)]
Cui and Cai[18] 2000 128 (78/50) 30/48; 20/30 56/54 4.25 ± 0.21; 3.45 ± 0.29 Shenmai injection 100 mL qd/Qianglishengbai2–4#tid, leucogen 20 mg tid 72/6; 31/19
Zheng et al[19] 2004 56 (30/26) 16/14; 16/10 42/40 Not mentioned Shenmai injection 100 mL qd/leucogen 20 mg tid 27/3; 16/10
Guo and Hu[20] 2006 75 (38/37) 21/17; 20/17 57/61 Not mentioned Shenmai injection 30–50 mL qd/Ganxuebao 40 mg tid, VB6 20 mg tid, VC 200 mg tid 36/2; 28/9
Wan and Yu[21] 2010 62 (30/32) 20/10; 21/11 57/61 Not mentioned Shenmai injection 40 mL qd + leucogen 20 mg tid/leucogen 20 mg tid 29/1; 24/8
Zhao[22] 2010 180 (90/90) 63/27; 65/25 49.43 ± 2.45/47.67 ± 3.27 5.27 ± 0.45; 4.42 ± 0.64 Shenmai injection 40 mL qd/Diyushengbai 3# tid 86/4; 69/21
Zhang et al[23] 2012 103 (58/45) 27/31; 20/25 48.5/48 4.978 ± 1.105; 4.053 ± 1.101 Shenmai injection 30–50 mL qd/leucogen 20 mg tid, VB4 20 mg tid 53/5; 28/17
Zhang[24] 2012 60 (30/30) 18/12; 18/12 45.55 ± 8.58/44.85 ± 18.68 4.58 ± 0.85; 3.20 ± 0.74 Shenmai injection 20 mL qd + leucogen 20 mg, VC 200 mg, VB 20 mg tid/leucogen 20 mg, VC 200 mg, VB 20 mg tid 23/7; 20/10
Wang et al[25] 2013 64 (32/32) 16/16; 15/17 61/59 5.54 ± 0.17; 4.76 ± 0.21 Shenmai injection 50 mL qd/Diyushengbai 0.4 g tid 30/2; 23/9
Zhang[26] 2019 80 (40/40) 14/26; 17/23 54.27 ± 6.15/53.48 ± 7.72 4.76 ± 1.25; 3.95 ± 1.02 Shenmai injection 30 mL qd/leucogen 20 mg tid + batyl alcohol 40 mg tid 34/6; 24/16
Wu et al [27] 2019 160 (80/80) 42/38; 46/34 62.31 ± 15.10/58.93 ± 15.42 3.02 ± 0.77; 2.50 ± 0.69 Shenmai injection 50 mL qd/Not mentioned 45/33; 23/52
Hu et al [28] 2022 160 (80/80) 45/35; 41/39 67.2 ± 10.1/63.6 ± 13.9 Not mentioned Shenmai injection 50 mg qd + G-CSF 200 µg qd/G-CSF200 µg qd 77/3; 71/9
ORR = overall response rate.

Figure 5.:
Study flow diagram for patient inclusion, screening, and final cohort selected for analysis.
Figure 6.:
Cochrane collaboration risk of bias summary: evaluation of bias risk items for each included study.

We finally performed a meta-analysis of efficiency versus leukocyte count to investigate the efficacy and safety of Shenmai injection in treating patients with post-chemotherapy granulocytopenia.

3.6. Overall response rate

All 11 trials counted the overall response rate (ORR) of Shenmai injection in the treatment of chemotherapy-induced granulocytopenia. All papers in this study were tested for heterogeneity, with I2 = 62%>50% and P = .003 < 0.1 for the Q-test, suggesting that the heterogeneity between the papers selected for this study was statistically significant and that a search for heterogeneity was needed. A sensitivity analysis of the 11 papers in this study revealed that Hu 2022 had a substantial effect on heterogeneity. After removing this study, a second heterogeneity test showed that the remaining 10 papers were not heterogeneous (I2 = 0%<50%, P = .47 > 0.1), and after the exclusion, a meta-analysis was conducted using fixed effects. The pooled RR value of the 10 studies was 1.38, with a 95% confidence interval of 1.28 to 1.49. It was statistically significant, Z = 8.27, P < .00001, suggesting that the efficacy of the Shenmai injection treatment was superior to that of the control group (Fig. 7). None of the 11 studies reported any adverse events due to Shenmai injection. The funnel plot was plotted to examine whether there was a publication bias in the current research, and a symmetrical funnel plot implies no publication bias. The funnel plot of the present study is shown in Figure 8: As can be seen from the figure, the funnel plot is largely symmetrical, while the results of Begg’s Test and Egger’s test are P > .05, suggesting that there is no publication bias.

Figure 7.:
Forest plot of risk ratio (RR) for ORR (Fixed effect model, RR: 1.38; 95% CI: 1.28–1.49; P < .00001). ORR = overall response rate.
Figure 8.:
Funnel plot of all the included studies for assessing publication bias. RR = risk ratio.

3.7. Leukocyte count

Seven trials counted post-chemotherapy leukocyte count, and after testing for heterogeneity, I2 = 58%>50% and P = .03 < 0.1 for the Q-test, suggesting heterogeneity between the literature selected for this study was statistically significant and that a search for heterogeneity was needed. A sensitivity analysis of the 7 papers in this study revealed that Zhang 2012 had a significant effect on heterogeneity. After removing this study, a second test for heterogeneity showed that the remaining 6 papers were not heterogeneous (I2 = 19%<50%, P = .29 > 0.1), and after the exclusion, a meta-analysis was conducted using fixed effects. 0.79, 95% confidence interval 0.73–0.85 and was statistically significant, Z = 26.57, P < .00001, suggesting that the efficacy of Shenmai injection treatment was significantly better than that of the control group (Fig. 9).

Figure 9.:
Forest plots of MD for leukocyte count (Fixed effect model, MD: 0.79; 95% CI: 0.73–0.85; P < .00001).

4. Discussion

Granulocytopenia, induced by chemotherapeutic drugs, has become a common occurrence in oncological chemotherapy. The associated risks of granulocytopenia are currently receiving heightened attention. There is growing interest in using traditional Chinese medicine alongside chemotherapy. Research shows that Chinese herbal medicine offers numerous advantages in the treatment of cancer. It can effectively inhibit tumor progression, increase sensitivity to chemotherapy and radiotherapy, and improve immune system function while reducing damage caused by these treatments.[29] The treatment of granulocytopenia in traditional Chinese medicine is centered on reinforcing healthy qi and eliminating pathogenic factors. Shenmai injection is one of the commonly used TCM preparations to eplenishing qi and enriching yin, which is widely and clinically used as an adjuvant therapy for cancer.[30]

To investigate the effectiveness and safety of Shenmai injection in treating granulocytopenia and to uncover its mechanism of action, we utilized a combination of network pharmacological analysis and meta-analysis. While previous clinical studies have shown the potential effectiveness of Shenmai injection in treating granulocytopenia, there is still some uncertainty around its efficacy due to small sample sizes and unclear drug composition and therapeutic targets. Our study showcases the potential of using Shenmai injection for granulocytopenia through extensive drug composition analysis, target prediction, and network pharmacology analysis. Additionally, we were able to confirm the efficacy of Shenmai injection for granulocytopenia through meta-analysis, further supporting the results obtained from our network pharmacology analysis.

According to the network pharmacology study, ophiopogonoside a, β-patchoulene, ginsenoside rf, ginsenoside re, and ginsenoside rg1 are likely the primary components of shenmai injection that can interfere with granulocytopenia. Research has demonstrated that both β-patchoulene and ginsenoside have anti-tumor properties.[31–33] These discoveries suggests that there may be potential clinical uses for shenmai injection. By leveraging these components, it may be possible to mitigate some of the undesirable side effects of radiotherapy and chemotherapy, thus improving the granulocytopenia caused by myelosuppression.

The top 10 targets, according to network analysis, were STAT3, HSP90AA1, HIF1A, TLR4, PIK3CA, MTOR, ESR1, PIK3R1, EP300, and GRB2. STAT3 is a signal transducer and transcriptional activator that mediates cellular responses to interleukins, and other growth factors.[34–38] TLR4 is involved in the regulation of multiple classes of interleukins and is highly expressed in placental, splenic, and peripheral blood leukocytes, and It can be detected in monocytes, macrophages, dendritic cells, and several types of T cells.[39–41] The 2 targets involve the regulation of interleukins. Research shows that interleukins was an essential regulator of neutrophil development and a potent cytokine for neutropenia treatment.[42,43] In conclusion, interleukins comprise key elements that orchestrate the TME and govern tumor–immune cell crosstalk as they are important players in large cytokine networks.[44] PIK3CA generates phosphatidylinositol 3,4,5-trisphosphate (PIP3) through a series of pathways.[45–47] PIP3 serves as a second messenger that participates in intracellular signal transduction, functioning significantly in processes such as cell proliferation, survival, migration, inflammation, and apoptosis.[48] This may be one of the reasons for improving granulocytopenia.

In the context of granulocytopenia intervention, Shenmai injection’s efficacy may be linked to 5 key targets. An enrichment analysis of 85 targets suggests their potential involvement in regulating various signaling pathways, such as HIF-1 signaling, T cell receptor signaling, PI3K-Akt signaling, chemokine signaling, and FoxO signaling. Moreover, increased activation of the HIF pathway appears to be effective in inhibiting T cell proliferation in myeloid/T cell cultures.[49] This issue may stem from granulocytopenia caused by myelosuppression following chemotherapy. When the T cell receptor signaling is activated, it can lead to T cell proliferation and cytokine production, both of which are closely linked to granulocytopenia.[50] sEP has mediated through the PI3K/Akt signaling pathway to protect against myelosuppression in cyclophosphamide-treated mice.[51] The primary role of chemokines is to recruit subpopulations of leukocytes under homeostatic and pathological conditions. Some chemokines have been shown in the literature to play a directing role in bone marrow reconstitution after myelosuppression, thereby ameliorating granulocytopenia.[52]

In conclusion, the results of our study show that Shenmai injection has the potential to target critical factors like STAT3, TLR4, PIK3CA, PIK3R1, and GRB2 through the active components of ophiopogonoside a, β-patchoulene, ginsenoside rf, ginsenoside re and ginsenoside rg1. These active components have been observed to regulate the expression of diverse cytokines like interleukins, colony-stimulating factors, growth factors, and chemokines. It also interferes with granulocytopenia by working through various signaling pathways, including the HIF-1, T-cell receptor, PI3K-Akt, chemokine, and FoxO pathways.

The results of our meta-analysis indicate that the treatment group exhibited superior performance in terms of both efficiency and post-treatment leukocyte count when compared to the control group. Furthermore, patients in the treatment group experienced some alleviation of adverse effects associated with chemotherapy.

However, this study also has certain shortcomings, including the fact that none of the 11 included studies mentioned blinding and allocation concealment, only one study reported the specific randomization method, and the methodological quality of the included studies was average; only published literature was formed, and unpublished studies such as gray literature were not included, which may have some influence on the results of the Meta-analysis; the total sample size of the systematic evaluation was small; The adverse effects of Shenmai injection were not mentioned in most of the included studies, and its safety was not evaluated; the different chemotherapy regimens may lead to differences in baseline between studies; the design of clinical trials in the included literature was not perfect, and the observation and efficacy of clinical tests were reduced to a uniform standard, and the limitations of the TCMID platform database may lead to a less comprehensive collection of the active ingredients of the drug. Therefore, future studies need to design experiments more scientifically and rationally, expand the sample size, conduct detailed grouping of patients with different cancer types, and implement different chemotherapy regimens to make the evaluation more accurate and thus better demonstrate the advantages of TCM and its role in clinical practice. Finally, the specific mechanism of the results of this study still needs to be further validated through in vivo and ex vivo experiments. Finally, further verification of the specific mechanism behind the results of this study is necessary through in vivo and in vitro experiments.

5. Conclusion

In summary, studies in network pharmacology demonstrate that Shenmai injection exerts an impact on granulocytopenia via various components, targets, and mechanisms. Additionally, evidence-based studies provide strong support for the effectiveness of Shenmai injection in preventing and treating granulocytopenia.

Author contributions

Conceptualization: Xianbing Hou, Dandan Chen.

Data curation: Dan Wang, Ying Chen, Tongfei Cheng.

Investigation: Yao Wang, Xiaojun Dai.

Methodology: Bixian Cui, Yuanyuan Wang.

Supervision: Hui Xu, Hongzhou Chen.

Writing – original draft: Xianbing Hou, Dandan Chen.

Writing – review & editing: Xianbing Hou, Dandan Chen.


gene ontology
Kyoto Encyclopedia of Genes and Genomes
overall response rate
protein-protein interaction


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Chinese medicine; evidence-based medicine; granulocytopenia; network pharmacology; Shenmai injection

Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.