https://doi.org/10.1177/1177392819866412
Drug Target Insights
Volume 13: 1–13
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Alzheimer disease (AD) is a devastating, progressive, and
irreversible neurodegenerative disorder, which is clinically
characterized by the deterioration of memory, disorientation,
increased confusion, and other psychological as well as physical
manifestations (Figure 1).1 The appearance of extracellular
amyloid-beta (Aβ) deposits in senile plaques and the develop-
ment of intracellular neurofibrillary tangles, reactive micro-
gliosis, and astrogliosis are the primary histopathological
characteristics of AD.2 Alzheimer disease primarily affects the
elderly,3 is the most common and feared type of dementia, rep-
resents 70% of all dementia cases, and is a worldwide epidemic.
Bertram et al4 postulated that in addition to the sporadic form
of AD, for which aging is the primary factor, mutations in the
amyloid-beta precursor protein (AβPP), presenilin 1 (PSEN1),
and presenilin 2 (PSEN2) cause autosomal dominant early-
onset familial AD. Polidori et al5 found that genetic and envi-
ronmental factors, vascular pathology, and other risk factors
also play crucial roles in AD pathogenesis.
Due to the lack of effective disease-modifying treatments,
findings on pharmacological or nonpharmacological strategies
to slow disease progression are of significant importance. In
addition, the failure of potential pharmaceuticals in human
clinical trials has highlighted the need for research into early
AD diagnosis. As synaptic and neuronal loss along with brain
shrinkage has already occurred when AD’s clinical symptoms
appear, current treatments that seek to slow disease progress are
more likely to be effective before the onset of AD symptoms,
ideally at the earliest preclinical stage. The lack of effective
AD treatments and pharmaceuticals has led to the assessment
of alternative therapeutics, such as nutraceuticals. For exam-
ple, many antioxidants may enhance cognitive ability.6–8
Nutraceuticals have an effect on various neurodegenerative dis-
eases as they modulate signaling pathways.9 Nutraceuticals are
nutrients, herbals, and dietary supplements that can help in
maintaining physical wellbeing, work against various diseases,
and ensure a better quality of life. Bacosides from Bacopa mon-
nieri (B monnieri) are examples of valuable therapeutic agent
for AD due to their anti-inflammatory, antioxidant, and Aβ
aggregation inhibitor properties. This review presents current
clinical studies and scientific evidences that document the
therapeutic potential of B monnieri extracts (BME) such as
bacosides in AD.
Traditional Aspects of B monnieri
According to World Health Organization, traditional medi-
cine is defined as “the sum total of knowledge, skills and prac-
tices based on the theories, beliefs and experiences of different
cultures that are used to maintain health, as well as to prevent,
diagnose, improve or treat physical and mental illnesses.”10
Many population in the developing countries have reverted to
the use of traditional plants in maintaining their health and
wellbeing.11 In this age where migration has taken a leap,
immigrants tend to bring traditional plants from their country
of origin to use as supplements. This has caused the promotion
Bacopa monnieri, a Neuroprotective Lead in Alzheimer
Disease: A Review on Its Properties, Mechanisms of
Action, and Preclinical and Clinical Studies
Aimi Syamima Abdul Manap1, Shantini Vijayabalan2, Priya
Madhavan3 , Yoke Yin Chia1, Aditya Arya3, Eng Hwa Wong3,
Farzana Rizwan3, Umesh Bindal3 and Shajan Koshy3
1School of Biosciences, Faculty of Health and Medical Sciences, Taylor’s University, Subang
Jaya, Malaysia. 2School of Pharmacy, Faculty of Health and Medical Sciences, Taylor’s
University, Subang Jaya, Malaysia. 3School of Medicine, Faculty of Health and Medical
Sciences, Taylor’s University, Subang Jaya, Malaysia.
ABSTRACT: Alzheimer disease is a neurodegenerative disease that is signified by cognitive decline, memory loss, and erratic behavior. Till
date, no cure for Alzheimer exists and the current Alzheimer medications have limited effectiveness. However, herbal medicines may slow
down the disease’s progression, which may hopefully reduce the number of cases in the years to come. Numerous studies have been done on
characterizing the neuroprotective properties from plants belonging to Scrophulariaceae family, particularly Bacopa monnieri and its polyphenolic
compounds known as bacosides. This review presents the findings on bacosides in therapeutic plants and their impact on Alzheimer disease
pathology. These reports present data on the clinical, cellular activities, phytochemistry, and biological applications that may be used in new
drug treatment for Alzheimer disease.
KeywoRDS: Alzheimer, aging, therapeutic plant, Bacopa monnieri, bacosides
ReCeIVeD: July 5, 2019. ACCePTeD: July 8, 2019.
TyPe: Review
FuNDINg: The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was supported by Taylor’s University
Flagship Research Grant (TUFR/2017/002/04).
DeCLARATIoN oF CoNFLICTINg INTeReSTS: The author(s) declared no potential
conflicts of interest with respect to the research, authorship, and/or publication of this
article.
CoRReSPoNDINg AuTHoR: Priya Madhavan, School of Medicine, Faculty of Health
and Medical Sciences, Taylor’s University, Lakeside Campus, No. 1 Jalan Taylor’s, 47500
Subang Jaya, Selangor Darul Ehsan, Malaysia. Email: priya.madhavan@taylors.edu.my
866412DTI0010.1177/1177392819866412Drug Target InsightsManap et al
research-article2019
https://uk.sagepub.com/en-gb/journals-permissions
mailto:priya.madhavan@taylors.edu.my
2 Drug Target Insights
of such non-native plants in a foreign country, particularly the
ones used in Ayurvedic and Chinese traditional medicine.12
These plants or plant compounds are known as complementary
or alternative medicines in non-native countries. Notably, B
monnieri, otherwise known as Brahmi and Aindri (Sanskrit) is
classified into the Scrophulariaceae family and found through-
out the Indian subcontinent in moist soil, humid, and muddy
environments.13 The genus Bacopa has 146 aquatic herbal spe-
cies dispersed throughout the subtropical regions of the globe,
including Nepal, India, Sri Lanka, Taiwan, China, and
Vietnam, as well as Florida and other US southern regions.
Although it can be seen in the United States, these plants are
perceived as weeds in rice fields and abundantly grown in wet-
lands and marshes of warmer districts.14 As shown in Figure 2,
Brahmi is a succulent herb commonly grown in subtropical
nations up to 1500 m altitude. Brahmi, which is traditionally
known as “medhya rasayana,” which means brain tonic or
nootropic, or in Sanskrit word, referring to intellectual,
cognition, and rejuvenation because it enhances the brain’s
cognitive properties, is popular among Ayurveda practitioners,
who use it to treat various ailments, (ie, memory loss, inflam-
mation, epilepsy, fever, and asthma).15
Structure and Components of Bacosides
The chemical compound that has neuropharmacological proper-
ties and pseudo-jujubogenin moieties, known as aglycone units, is
Bacoside A (dammarane-type triterpenoid saponin; Figure 3).16,17
This compound is composed of bacopaside III, bacopaside X,
bacoside A3, and bacopasaponin C.15 Through structural simili-
tude analysis, 12 analogues derived from the bacosides have been
characterized and various saponin types have been identified as
essential ingredients, known as bacopasides I-XII.18 Bacopa’s
additional components include apigenin, cucurbitacin, alkaloids
brahmine, monnierin, hersaponin, monnierasides I-III, plantain
side B, d-mannitol, herpestine, and nicotine.19,20 Table 1 shows
molecular composition of Bacoside A.
Figure 1. Clinical symptoms of Alzheimer disease.
Figure 2. Bacopa monnieri plants.
Manap et al 3
The Neuropharmacological Activity of Bacoside A
Numerous studies suggested that B monnieri’s bioactive com-
ponents (ie, bacosides) protect the brain against oxidative dam-
age and age-related cognitive deterioration with several
mechanisms of action.22,23 In addition, bacosides prevent Aß
aggregation and formation of fibrils24 as well as protect neurons
against Aβ-induced toxicity.25 From high-performance liquid
chromatography (HPLC) analysis, the bioactive constituent,
bacoside A, was present in the B monnieri extract (BME)-
treated rat serum and could directly or indirectly interact with
the neurotransmitter systems to improve memory and learning
ability.26 Bacosides present in B monnieri are commonly non-
polar glycosides,27 which enable it to cross the blood-brain bar-
rier (BBB) via simple lipid-mediated passive diffusion.28
Similarly, the bioavailability in the brain has been affirmed by
the radiopharmaceuticals biodistribution.29 De et al, using an
animal model, described BME as being capable of altering the
uptake of radioactivity of 99mTc-labeled ethylene dicysteine
diethyl ester (99mTc-ECD) and 99mTc-labeled cystine dimethyl
ester (99mTc-CDM) in brain and other organs. The results
revealed an increased and significant uptake (P < .05) of 99mTc-
ECD and 99mTc-CDM in brain and other organs after treat-
ment with BME. As BME is a good antioxidant and has
cognitive function on human memory, these findings have
evaluated pharmacokinetic interactions of BME and suggested
that BME can act on the biodistribution of 99mTc-ECD and
99mTc-CDM in specific organs.29
Likewise, clinical studies also showed that oral treatment
with B monnieri was able to enhance memory in both adults
and children. The effects of B monnieri administration on
hepatic and intestinal P-glycoprotein (Pgp) as well as
Cytochrome 3A (CYP3A) expression levels were examined in
Watkins’ studies.30 According to him, individually, Pgp-
mediated efflux and Cytochrome P450 (CYP45O)-mediated
metabolism play a vital role in modulating the oral bioavailabil-
ity of corresponding drug. However, B monnieri mediating
effects on CYP3A4 and alterations in Pgp were measured
according to the mRNA expression level and functional activ-
ity in the intestine and liver of male Sprague Dawley (SD) rats
after a week of B. monnieri administration. The results showed
that B. monnieri downregulated both intestinal Pgp and
CYP3A expression levels, depending on the testosterone
hydroxylase catalytic activity in liver and intestine.31 Further
studies also showed that in vivo pharmacokinetic interaction
between digoxin (Pgp substrate) and carbamazepine (CYP 3A
substrate) along with the administration of B monnieri extract
in male SD rats could alter the pharmacokinetics of both Pgp
and CYP3A probe drugs. Probe drug is known to lessen both
biological and technical risk factors of tracking a particular tar-
get to be selective as well as potent to their target. The results
showed that treatment with B monnieri and carbamazepine
caused a change in the carbamazepine pharmacokinetic profile
with a significant increase in Cmax (maximum serum concen-
tration of the drug achieved in the plasma) and AUC (the area
under the plasma drug concentration-time curve) (0-∞) as well
reduction in CL/F (apparent total clearance of the drug from
plasma after oral administration) opposing to the vehicle con-
trol rats.
The Role of Other Compounds in BME
CDR1-08
Also known as Synapsa, or KeenMind, a nootropic CDR1-08
is a well-characterized ethanolic extract of B monnieri. Several
lines of evidence demonstrated that CDRI-08 significantly
enhances the cognitive performance in the elderly and patients
with impaired neurological functions32–34 as well as healthy
human participants.35,36 Moreover, bacosides present in the
CDRI-08 are nonpolar glycosides, and it can enter the brain by
crossing the BBB through lipid-mediated passive diffusion.28
The biodistribution in brain also has been affirmed by radiop-
harmaceuticals.29 Study by Preethi et al investigated whether
treatment with the CDRI-08 could change the methylation
Figure 3. Chemical structure of Bacoside A.1
4 Drug Target Insights
status of reelin and brain-derived neurotrophic factor (BDNF)
to enhance the memory through the interaction of N-methyl-
d-aspartate receptor (NMDAR) with synaptic proteins. Using
rat pups as a model in the study, after treatment with CDR1-
08/5-azacytidine (80 mg/kg/3.2 mg/kg), their results demon-
strate a higher discrimination toward novel objects than with
old objects during the testing. They also observed an elevated
level of unmethylated DNA in reelin and BDNF-promoted
region, which suggested that this mechanism might contribute
to the modulation of synaptic plasticity and thus can enhance
learning and memory.37 However, study by Rai et al provides
the evidence for the mechanism underlying the role of the
CDRI-08 in restoring spatial memory in amnesic mice. In
their study, upon daily oral administration of CDRI-08
(200 mg/kg body weight [BW ]) to scopolamine-treated
amnesic mice for 7 days, the spatial memory was restored,
which was found to be related with significant upregulation of
the GluN2B (ionotropic glutamate receptors) subunit expres-
sion and reduction in the acetylcholinesterase activity in pre-
frontal cortex as well as hippocampus.38
Bacognize®
The standardized extract of B monnieri (Bacognize) has been
shown to improve some aspects of cognitive functions in a
6-month trial in geriatric Alzheimer patients.39 In this study,
all patients who took 300 mg of Bacognize orally twice a day
showed a statistically significant improvement in various
components of Mini-Mental State Examination Scale
(MMSES) including orientation of time, place and person,
Table 1. Molecular composition of Bacoside-A21.
CoMPoSITIoN FuNCTIoNAL uNIT
Bacopaside 3-O-α-l-arabinofuranosyl-(1→2)-[6-O-sulfonyl-β-d-glucopyranosyl-(1→3)]-α-l-arabinopyranoside, 3-O-ß-d-
glucopyranosyl-(1→3)-α-l-arabinofuranosyl
Bacopaside V 3-O-α-l-arabinofuranosyl-(1→2)-[6-O-sulfonyl-β-d-glucopyranosyl-(1→3)]-α-l-arabinopyranoside, 3-O-ß-d-
glucopyranosyl-(1→3)-α-l-arabinofuranosyl
Bacopaside II 3-O-α-l-arabinofuranosyl-(1→2)-[β-d-glucopyranosyl-(1→3)]-β-d-glucopyranoside
Bacopaside III 3-O-(6-O-sulfonyl-β-d-glucopyranosyl-[1→3])-α-l-arabinopyranoside
Bacopaside IV 3-O-ß-d-glucopyranosyl-(1→3)-α-l-arabinopyranosyl
3-O-{ß-d-glucopyranosyl(1→4)(α-l-arabinofuranosyl-[1→2])-ß-d-glucopyranosyl}-20-O-α-l-arabinopyranosyl
Bacopaside IX 3-O-ß-d-glucopyranosyl-(1→3)-α-l-arabinopyranosyl
3-O-{ß-d-glucopyranosyl(1→4)(α-l-arabinofuranosyl-[1→2])-ß-d-glucopyranosyl}-20-O-α-l-arabinopyranosyl
Bacopaside XI 3-O-{ß-d-glucopyranosyl(1→4)(α-l-arabinofuranosyl -[1→2])-ß-d-glucopyranosyl}-20-O-α-l-arabinopyranosyl
Bacopaside
XII-12
3-O-{ß-d-glucopyranosyl(1→3)[ß-d-arabinofuranosyl(1→2)]-ß-d-glucopyranosyl}-20-O-
Bacopasaponin A 3,20-di-O-α-l-arabinopyranoside
Bacoside A1 3-O-(α-l-arabinofuranosyl[1→3])-α-l-arabinopyranoside
Bacoside A2 3-O-α-l-arabinopyranosyl-(1→5)-[α-l-arabinofuranosyl-(1→6)]-α-d-glucofuranoside
Bacoside A3 3-O-α-l-arabinofuranosyl-(1→2)-[β-d-glucopyranosyl-(1→3)]-β-d-glucopyranoside
Bacopasaponin B 3-O-(α-l-arabinofuranosyl-[1→2])-α-l-arabinopyranoside
Bacopasaponin C 3-O-α-l-arabinofuranosyl-(1→2)-[β-d-glucopyranosyl-(1→3)]-α-l-arabinopyranoside
Bacopasaponin D 3-O-(α-l-arabinofuranosyl-[1→2])-β-d-glucopyranoside
Bacopasaponin e 3-O-α-l-arabinofuranosyl-(1→2)-[β-d-glucopyranosyl-(1→3)]-α-l-arabinopyranoside, 20- O-α-l-arabinopyranoside
Bacopasaponin F 3-O-α-l-arabinofuranosyl-(1→2)-[β-d-glucopyranosyl-(1→3)]-β-d-glucopyranoside,20-O- α-l-arabinopyranoside
Bacopasaponin
g
3-O-(α-l-arabinofuranosyl-[1→2])-α-l-arabinopyranoside
Bacopasaponin H 3-O-[α-l-arabinopyranosyl]
Manap et al 5
attention, and their language ability in terms of reading, writ-
ing, and comprehension at the end of trial. Another study
refers this extract to be safe and have sustained cognitive
effects when used for 12 weeks in healthy older adults.40
Kumar et al had evaluated the effect of Bacognize on memory
of 60 medical students with 42 days of administration. This
randomized placebo-controlled trial exhibited a significant
improvement in the tests relating to the cognitive functions
in the participants who had taken 150 mg of Bacognize.41
The poor solubility of Bacognize also has been improved by
recent study of Thakkar et al using the inclusion complex of
Bacognize (contained 16% bacosides) and β-cyclodextrin
prepared in different molar ratios of B monnieri via co-precip-
itation method. The results revealed that the inclusion of
complex at molar ratio of 1:4 can enhance threefold solubility
and stability of B monnieri in inclusion complex.42
Mechanisms as a Neuroprotective Agent
The mechanisms that underlie the progression of neuronal
degeneration are described in the following sections. Figure 4
illustrates the neuroprotective effects of bacoside from B mon-
nieri from various studies.43–45
Bacosides and Reactive Oxygen Species
Wide studies have reported the role of superoxide anion,
hydroxyl radical, hydrogen peroxide, and nitric oxide in the oxi-
dative stress-mediated neurodegeneration in AD.46,47 Neuronal
lesions can activate microglia activation, which further gener-
ates excessive superoxide radicals.48 Thus, mitochondrial
autophagy serves as a vital source of reactive oxygen species
(ROS) production.49 As mitochondria functions as both the
source and target of toxic ROS, mechanisms by which
mitochondrial dysfunction leads to neuron degeneration in
AD are believed to be associated with ROS generation, activa-
tion of mitochondrial permeability transition, excitotoxicity,
impaired production of adenosine triphosphate, and altered
calcium homeostasis.50 Various studies have shown an increased
level of 4-hydroxynonenal, the byproduct of oxidative stress in
the brain of AD patients.51,52 An increased level of lipid peroxi-
dation (LPO) marker has been reported as well.53,54 Besides
that, iron-induced oxidative stress, as demonstrated by iron
accumulation in the brain of AD, is responsible for neurode-
generation in patients diagnosed with AD.55
Extensive studies have been performed on neuroprotection
of B monnieri against ROS. The administration of B monnieri
inhibited LPO especially in the hippocampus, prefrontal cor-
tex, and striatum areas of the rat cerebrum.56 As for the rat’s
astrocytes, it significantly reduced the harm done by high con-
centrations of nitric oxide.57 Likewise, different reports recom-
mended that bioactive components from B monnieri can protect
the brain against oxidative harm and improve cognitive capa-
bility via a few mechanisms.22,23 The enhanced cognitive capa-
bility was attributed to the free radical scavenging properties of
the bacosides. Superoxide dismutase (SOD), heat shock pro-
tein 70 (Hsp70), and cytochrome P450 (CytP450) in the rat’s
cerebrum have critical role in both the production of ROS and
scavenging activity.58 The detoxification and binding of free
radical scavenging metal ions or increasing the antioxidant
properties are the mechanisms involved in the neuroprotection
from bacosides25,34,58 (Figure 5). It also reduces the formation
of lipid peroxides, divalent metals, scavenging ROS, and
restraining lipoxygenase action. As results indicated that ROS
level had declined when neurons were treated with BME, we
propose that it may control the intracellular oxidative stress.25
Figure 4. Neuroprotective effects of bacoside from Bacopa monnieri.
6 Drug Target Insights
Likewise, in neonatal hypoglycaemia, B monnieri has potent
neuroprotective capability in reversing the modified dopamine
D1 receptor function, BAX (BCL2 Associated X, Apoptosis
Regulator), and gene expressions, respectively. Thus, SOD level
is lowered, which in turn causes cortical cell death.59
Furthermore, in rat models of neurotoxicity incitation by
ibotenic corrosive and colchicine, B monnieri indicated a
dosage-related intellectual deficiencies.60 Acrolein is an
exceptionally active compound shaped as a LPO byproduct
and acts as an oxidative stress inducer by framing adducts of
cell nucleophilic groups. It demonstrates a significant eleva-
tion of acrolein levels in the hippocampus; B monnieri extract
is accounted to have neuroprotection in human neuroblas-
toma cell line SK-N-SH against hydrogen peroxide and
acrolein-induced toxicity.3 It also protects through ROS
scavenging, maintains the mitochondrial membrane integ-
rity, modulates the expression of several redox regulatory
proteins, that is, Sirt1 (Sirtuin 1), NF-κB (nuclear factor
kappa-light-chain-enhancer of activated B cells), p66Shc (a
member of the SHC family of protein adapters), and ERK1/2
(extracellular signal-regulated protein kinases 1 and 2), and
protects the cells from oxidative stress. The counter pressure
impact of bacosides of B monnieri was studied in adult male
SD rats. The results portrayed that it is able to de-stress the
modulation of SOD, Hsp70, and CytP450 under unfavour-
able conditions, for example, stress.58
Bacoside A and Beta Amyloid Toxicity
A significant inhibitory effect of cytotoxicity, fibrillation, and
membrane interactions of beta-amyloid (1-42) were observed
by preincubation of Bacoside A with Aβ42 in SH-SY5Y cell
line model.43 Aβ is a peptide that plays a prominent role in AD
progression and toxicity. In AD, Aβ assembles into insoluble
amyloid fibrils that aggregate in extracellular neuritic or senile
plaques61,62 and is accompanied by synaptic dysfunction, neu-
ronal deterioration, dementia, and cognitive declination.63
Therefore, it can suggest that Aβ may be directly toxic to
neuronal cells and synapses. The previous study showed that
extracts containing soluble Aβ aggregates can induce amyloi-
dosis in an animal model that otherwise never develop amyloid
plaque.64 Inhibition of Aβ aggregates and assembly is one of
the primary therapeutic strategies in AD treatment and pre-
vention. Another study reported a substantial link between the
toxic peptide of Aβ with its membrane interaction.43 In their
experiment, Aβ42 monomer initially produces oligomeric spe-
cies that were membrane-active and cytotoxic. It then aggre-
gated into fibrils, which were promoted through interactions
with the bilayer interface. However, aggregation of Aβ42 was
reduced and its membrane interaction was inhibited following
incubation with Bacoside A. Figure 6 shows the mechanism of
action of bacoside on Aβ.43,61
Synergistic Action of B monnieri
The synergistic effects of B monnieri have been investigated,
providing information on its possible neuropharmacological
effects between this herbal medicine and other plant extracts or
synthetic drugs. The synergistic action of B monnieri (320 mg),
l-theanine (100 mg), Crocus sativus (30 mg), copper (2 mg),
folate (400 µg) with vitamin B (450-9 µg) and vitamin D
(25 µg) in a cohort of elderly subjects (1 capsule per day) for
8 weeks of treatment were investigated.66 The results showed a
significant improvement of cognitive decline, perceived stress,
and depression tested with Mini-Mental State Examination
(MMSE), Perceived Stress Questionnaire (PSQ) Index, and
Self-Rating Depression Scale (SRDS) scores.
In another study done in an in vivo model, combination of B
monnieri (100 mg/kg) with rivastigmine (5 mg/kg) showed sig-
nificant protection against aluminum chloride (AlCl3)-induced
Figure 5. The action mechanism of bacoside against ROS induces mitochondrial damage. ROS indicates reactive oxygen species; SOD, superoxide
dismutase.
Manap et al 7
memory impairment in rats compared to those treated with
AlCl3 per se.67 In their study, chronic administration of AlCl3
caused functional deficits in learning and memory skills, which
were tested using the Morris water maze and Elevated Plus
Maze (EPM) tasks. However, rats treated with combination of
rivastigmine and B monnieri showed better acquisition and
retention latencies compared to groups treated only with AlCl3,
indicating significant protection against AlCl3-induced deteri-
oration in learning and memory skills. They concluded that B
monnieri and rivastigmine act through synergistic mechanisms
to prevent neuronal damage and enhance cholinergic neuro-
transmission, thus showing better therapeutic effect compared
to treatment alone.
Antidementia and anticholinesterase activities in adult male
Swiss mice also were studied using combined extracts of B
monnieri and Ginkgo biloba (GB).68 In this study, anti-dementia
activity was tested against scopolamine (3 mg/kg BW )-induced
impairment in passive avoidance (PA) test. Their results indi-
cate a significant increase in transfer latency time (TLT) and
no transfer response (NTR) after treatment of combined
extracts of B monnieri at 30 mg/kg and GB at 15, 30, and
60 mg/kg for 7 days of administration. All the extracts showed
potent effects toward attenuating the effects of dementia.
In vivo and in vitro Study on Neuroprotective Effects
of BME
Research on neuroprotective effects of BME has been widely
studied before by in vivo and in vitro models. Most of the study
conducted by in vivo were performed on male Wistar rats and
male Swiss albino mice and rats. However, for in vitro study,
different cell line models were chosen to study the effect of
BME such as PC12, SH-SY5Y, as well as primary cortical
neuron cells. Uabundit et al demonstrated protective effects of
BME in male Wistar rat model that had been induced with
2 nmol/2 μL ethylcholine aziridinium ion (AF64A). Result
showed that 20, 40, and 80 mg/kg BW of BME was able to
mitigate the memory impairment and neurodegeneration in
the rats by enhancing the escape latency time (P < .01) in the
Morris water maze test. They also observed that both choliner-
gic neuron and neuron density reduction were lessened.69
Other than that, BME administered orally at 40 mg/kg/day for
5 weeks was able to prevent the neurotoxicity in the cerebral
cortex of male Wistar rat brain exposed with aluminum chlo-
ride (AlCl3).70 Research done by Khan et al revealed that BME
given orally at 30 mg/kg BW for 2 weeks significantly improved
the memory and learning capability in intracerebroventricular-
streptozotocin (ICV-STZ)-induced male Wistar rats. Their
finding demonstrates the therapeutic efficacy of BME on cog-
nitive impairment and oxidative damage, observed by signifi-
cant reduction in LPO levels, increased GSH (glutathione)
contents, and upregulated antioxidant enzymes activity such as
SOD, GST (glutathione S-transferases), CAT (catalase), and
GPx (glutathione peroxidase) in the hippocampus infused by
ICV-STZ model.71 On a different study, BME at 100 mg/kg
BW for 180 days lessened both the sodium nitrate (NaNO2)
and d-galactose (D-Gal) levels, which improved the BW,
memory, and learning skills. B monnieri extracts also normal-
ized the ATPase system in AD-induced mice.72 Dwivedi et al73
Figure 6. Mechanism of action of bacoside against beta-amyloid (adaptation and modifications from previous works2,3).
However, Bacoside A exhibited anti-amyloid toxicity properties upon membrane interactions and bilayer-induced fibrillation of pathogenic substance
prion protein (PrP). The experimental data revealed that preincubation of PrP (106-126) with Bacoside A before addition to vesicle bilayers might
possibly enhance fibril formation and in parallel had inhibited membrane interactions of the peptide assemblies. The findings from this study
revealed a significant interaction of the compound with the amyloidogenic determinant of PrP and noticeable effects upon the structural and
functional properties of the peptide even though Bacoside A has not been explored yet in conjunction with the prion protein. In a more extensive
context, the anti-amyloid properties of Bacoside A might be discovered to its impact in ameliorating the amyloid protein toxicity via stimulating and
enhancing fibrillation.65
8 Drug Target Insights
also demonstrate attenuation of Okadoic acid (OKA)-induced
memory dysfunction in SD rats treated with BME at 40 and
80 mg/kg BW for 13 days.
Moreover, interesting extensive finding by Rastogi et al
revealed the protective effect of bacosides, against the age-asso-
ciated neurodegeneration and promotion of healthy brain
aging in female Wistar rats. In this study, bacosides were
administered orally at 200 mg/kg BW for 3 months in middle
aged and aged rats, and its impact on the prevention of Senile
Dementia of Alzheimer Type (SDAT) was evaluated. Their
findings demonstrated that bacosides was found to display sig-
nificant anti-aging property by preventing the lipofuscin
aggregation in the brain cortex of middle-aged and aged rat.
Other than that, cholinergic neurotransmission was observed
in aged-rat brain cortex, and treatment with bacosides was able
to mitigate this age-associated cholinergic degeneration. Based
on the potential findings on bacosides, they suggested that
bacosides exerted multitargeted pharmacological action by pre-
venting the lipofuscin accumulation, enhancing the synthesis
of cholinergic neurotransmitter acetylcholine, modulating the
metabolism of monoaminergic neurotransmitters, and inhibit-
ing LPO in the aged rats.74
A previous study also investigated a new nanotechnology
approach for the brain delivery of the Bacoside A for the treat-
ment of neurodegenerative disorders using poly-(d, l)-Lac-
tide-co-Glycolide (PLGA) as surfactant. Bacoside-A-loaded
PLGA nanoparticles were prepared via oil-in-water (o/w)
emulsion solvent evaporation technique. Surface of nanoparti-
cles were modified by coating with polysorbate 80 to enhance
the crossing of BBB. The ability of nanoparticles in targeting
the brain was evaluated by in vivo studies using Wistar albino
rats. Their results suggested that PLGA nano Bacoside A for-
mulation with a size range of 70-200 nm and a relatively low
polydispersity index of 0.391 ± 1.2 showed encapsulation effi-
ciency at 57.11% ± 7.11%, with a drug loading capacity of
20.5% ± 1.98%. Scanning electron microscopy (SEM) and
X-ray studies also revealed its spherical shape and low crystal-
linity. This verified that there were no chemical interactions
between both polymer and drug molecules. The in vitro study
showed a constant pattern with maximum release of
83.04% ± 2.55% in 48 hours, while in vivo study showed a
higher brain concentration of Bacoside A (23.94 ± 1.74 μg/g
tissues) that implied a significant role of surface-coated nano-
particles on brain targeting. The overall results suggested the
efficiency of surface-modified PLGA nanoparticles in delivery
of Bacoside A to the brain.75
In vitro study demonstrated that scopolamine induced
PC12 cell death was significantly ameliorated by BME pre-
treatment, and the viability was restored at 85.75% of the con-
trol with 100 µg/mL of BME. B monnieri extracts pretreated
cells also showed a decreased release of lactate dehydrogenase
(LDH) up to 22.42% of total as compared with 30% of scopol-
amine-treated group. B monnieri extracts also found to amelio-
rate scopolamine effect by downregulating acetylcholinesterase
(AChE) and upregulating BDNF as well as muscarinic-1
receptor expression.76 While pretreatment of BME with dif-
ferent doses (2.5-100 µg/mL) for 3 hours in SK-N-SH cells
prior to the addition of 200 µM of H2O2 or 15 µM of acrolein
can significantly protect against acrolein-induced cytotoxicity.
B monnieri extracts also showed to inhibit the generation of
intracellular ROS in addition to preserving the mitochondrial
membrane potential. B monnieri extracts pretreatment also pre-
vented the modifications caused by the activity of several redox
regulated protein.3 Furthermore, Limpeanchob et al revealed
the neuroprotective effect of BME against Aβ-induced cell
death in primary cortical cultured neuron cells. They found
that the cell viability of cultured cortical cells was increased
when treated with 100 µg/mL of BME. From their study, they
postulated that Brahmi extract can diminish neuronal death
induced by Aβ peptide through the suppression of AChE
activity. Brahmi extract also exhibited antioxidant properties in
both in vitro and cell-based assays.25 By using SH-SY5Y cell as
a model, BME at 0.1 to 25 µM significantly reduced neurotox-
icity of oxidized low-density lipoprotein (LDL) in a dose-
dependent manner as well as suppressed the elevation of
cellular AChE activity mediated by oxidized LDL.77 Using the
same SH-SY5Y model, Bacoside A at 50 μM exerted signifi-
cant inhibitory effects upon cytotoxicity, fibrillation, and par-
ticularly membrane interactions of Aβ (1-42) (Aβ42).43 Table 2
outlines the specific effects of bacosides on various study
designs (in vivo and in vitro) of AD.
Clinical Studies in Humans Using BME
Upon the promising neuroprotective effect of B monnieri in in
vitro and in vivo studies, numerous clinical studies on human
subjects have been performed using B monnieri for cognitive
improvement. A clinical study of standardized extract of B
monnieri (150 mg) on 60 medical students from Government
Medical College, Nagpur, India over a period of 15 days
revealed significant improvement in biochemical analyses, that
is, significant elevation in serum calcium levels and enhanced
memory test.41 Another group of researchers reported that
individual doses of B monnieri and Sideritis scardica extracts in
10 mild cognitive impairment subjects from Germany (mean
age: 61.88 ± 6.69 years) resulted in improvement in the
d2-concentration test.79 However, treatment with B monnieri
(2 × 150 mg) for 90 days in 107 participants (between ages 18
and 60 years) in Swinburne University, Australia led to an
improved performance in a structural working remembrance
task in healthy participants with no history of neurological dis-
eases, gastrointestinal disorders, as well as chronic infections.
Above it all, none of the healthy participants took any cogni-
tive-enhancing drugs.80
Besides cognitive improvement, B monnieri can also enhance
learning capability. Consumption of B monnieri for 3 months in
76 human subjects between 40 and 65 years of age in University
of Wollongong, Australia resulted in significant effects on
retention of new information.81 The consistent consumption of
Manap et al 9
Ta
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10 Drug Target Insights
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b
le
3
.
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h
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iv
e
rs
it
y
o
f
C
a
ta
n
ia
,
It
a
ly
.
D
o
u
b
le
-b
lin
d
,
ra
n
d
o
m
iz
e
d
p
la
c
e
b
o
-c
o
n
tr
o
lle
d
c
lin
ic
a
l
tr
ia
l w
it
h
a
p
la
c
e
b
o
r
u
n
-i
n
o
f
6
w
e
e
ks
B
a
c
o
p
a
e
x
tr
a
c
t,
3
0
0
m
g
d
a
ily
,
fo
r
1
2
w
e
e
ks
E
n
h
a
n
c
e
d
A
V
LT
d
e
la
ye
d
w
o
rd
r
e
c
a
ll
m
e
m
o
ry
s
c
o
re
s
re
la
ti
ve
t
o
p
la
c
e
b
o
,
s
ig
n
ifi
c
a
n
t
im
p
ro
ve
m
e
n
t
in
s
tr
o
o
p
re
su
lt
s
(P
<
.0
5
)
a
n
d
a
ls
o
d
e
c
re
a
s
e
d
in
C
E
S
D
-1
0
d
e
p
re
s
s
io
n
s
c
o
re
s
o
ve
r
ti
m
e
,
a
s
w
e
ll
a
s
d
e
c
re
a
s
e
d
in
c
o
m
b
in
e
d
s
ta
te
p
lu
s
tr
a
it
a
n
x
ie
ty
s
c
o
re
s
a
n
d
h
e
a
rt
a
tt
a
c
k
.
C
a
la
b
re
s
e
e
t
a
l3
3
H
e
a
lt
h
y
a
d
u
lt
s,
b
e
tw
e
e
n
1
8
a
n
d
6
0
y
e
a
rs
,
in
S
w
in
b
u
rn
e
U
n
iv
e
rs
it
y,
A
u
st
ra
lia
.
A
d
o
u
b
le
-b
lin
d
,
p
la
c
e
b
o
-c
o
n
tr
o
lle
d
in
d
e
p
e
n
d
e
n
t
g
ro
u
p
d
e
s
ig
n
w
a
s
e
m
p
lo
ye
d
B
a
c
o
p
a
e
x
tr
a
c
t,
3
0
0
m
g
d
a
ily
,
fo
r
9
0
d
a
ys
S
ig
n
ifi
c
a
n
t
im
p
ro
ve
m
e
n
t
in
w
o
rk
in
g
m
e
m
o
ry
(
P
=
.0
3
5
),
s
p
a
ti
a
l w
o
rk
in
g
m
e
m
o
ry
(
P
=
.0
5
1
0
),
a
n
d
s
ig
n
ifi
c
a
n
t
re
d
u
c
ti
o
n
(
P
=
.0
2
9
)
in
t
h
e
a
m
o
u
n
t
o
f
fa
ls
e
a
la
rm
s
p
ro
d
u
c
e
d
d
u
ri
n
g
R
V
IP
t
a
s
k
.
S
to
u
g
h
a
t
a
l8
0
C
h
ild
re
n
r
e
q
u
ir
in
g
in
d
iv
id
u
a
l e
d
u
c
a
ti
o
n
a
l s
u
p
p
o
rt
,
1
0
.5
y
e
a
rs
in
C
e
n
te
r
fo
r
R
e
s
e
a
rc
h
in
M
e
n
ta
l R
e
ta
rd
a
ti
o
n
(
C
R
E
M
E
R
E
),
M
u
m
b
a
i,
In
d
ia
.
T
h
e
s
tu
d
y
w
a
s
c
o
n
d
u
c
te
d
a
s
o
u
tp
a
ti
e
n
t
p
ro
c
e
d
u
re
in
h
o
s
p
it
a
l s
e
tt
in
g
s
w
it
h
c
lo
s
e
m
o
n
it
o
ri
n
g
.
B
a
c
o
p
a
e
x
tr
a
c
t,
2
2
5
m
g
d
a
ily
,
fo
r
1
6
w
e
e
ks
S
ig
n
ifi
c
a
n
t
c
h
a
n
g
e
in
t
h
e
b
a
s
e
lin
e
v
a
lu
e
o
f
w
o
rk
in
g
m
e
m
o
ry
a
n
d
s
h
o
rt
-t
e
rm
v
e
rb
a
l m
e
m
o
ry
f
ro
m
5
.2
1
±
0
.3
2
t
o
6
.3
8
±
0
.2
5
(
P
⩽
.0
5
)
a
n
d
5
.3
3
±
0
.4
4
t
o
6
.5
4
±
0
.3
5
(
P
⩽
.0
5
).
S
ig
n
ifi
c
a
n
t
im
p
ro
ve
m
e
n
t
(P
⩽
.0
5
)
w
a
s
a
ls
o
s
e
e
n
in
l
o
g
ic
a
l m
e
m
o
ry
,
m
e
m
o
ry
r
e
la
te
d
t
o
p
e
rs
o
n
a
l l
if
e
a
n
d
a
ls
o
in
v
is
u
a
l a
s
w
e
ll
a
s
a
u
d
it
o
ry
m
e
m
o
ry
.
U
s
h
a
e
t
a
l8
5
N
in
e
ty
e
ig
h
t
h
e
a
lt
h
y
su
b
je
c
ts
,
a
g
e
⩾
5
5
y
e
a
rs
in
L
is
m
o
re
,
N
e
w
S
o
u
th
W
a
le
s,
A
u
st
ra
lia
.
D
o
u
b
le
-b
lin
d
,
ra
n
d
o
m
iz
e
d
p
la
c
e
b
o
-c
o
n
tr
o
lle
d
d
e
s
ig
n
w
a
s
e
m
p
lo
ye
d
B
a
c
o
p
a
e
x
tr
a
c
t,
3
0
0
m
g
d
a
ily
,
fo
r
1
2
w
e
e
ks
S
ig
n
ifi
c
a
n
tl
y
e
n
h
a
n
c
e
d
t
h
e
m
e
m
o
ry
a
c
q
u
is
it
io
n
,
ve
rb
a
l l
e
a
rn
in
g
,
a
n
d
d
e
la
ye
d
r
e
c
a
ll
m
e
a
su
re
b
y
R
e
y
A
u
d
it
o
ry
V
e
rb
a
l L
e
a
rn
in
g
T
e
st
(
A
V
LT
);
T
ri
a
l a
4
(
P
=
.0
0
0
),
T
ri
a
l a
5
(
P
=
.0
1
6
);
T
ri
a
l a
6
(
P
=
.0
0
0
);
T
ri
a
l a
7
(d
e
la
ye
d
r
e
c
a
ll,
P
=
.0
0
1)
;
T
o
ta
l l
e
a
rn
in
g
(
P
=
.0
11
)
a
s
w
e
ll
re
tr
o
a
c
ti
ve
in
te
rf
e
re
n
c
e
(
P
=
.0
4
8
).
S
c
o
re
s
in
c
lu
d
in
g
M
A
C
-q
,
T
M
T
,
a
n
d
C
F
T
im
p
ro
ve
d
t
h
e
g
ro
u
p
d
if
fe
re
n
c
e
s
a
n
d
n
e
ve
rt
h
e
le
s
s
w
e
re
n
o
t
s
ig
n
ifi
c
a
n
t
8
2
S
ix
ty
h
e
a
lt
h
y
a
d
u
lt
s,
m
e
a
n
a
g
e
:
6
2
.6
2
±
6
.4
6
y
e
a
rs
(
3
7
fe
m
a
le
s
a
n
d
2
3
m
a
le
s)
in
T
h
a
ila
n
d
.
D
o
u
b
le
-b
lin
d
,
ra
n
d
o
m
iz
e
d
p
la
c
e
b
o
-c
o
n
tr
o
lle
d
d
e
s
ig
n
w
a
s
e
m
p
lo
ye
d
B
a
c
o
p
a
e
x
tr
a
c
t,
3
0
0
m
g
o
r
6
0
0
m
g
d
a
ily
,
fo
r
1
2
w
e
e
ks
T
re
a
te
d
e
x
tr
a
c
t
g
ro
u
p
d
is
p
la
ye
d
a
n
e
n
h
a
n
c
e
d
w
o
rk
in
g
m
e
m
o
ry
a
s
w
e
ll
a
r
e
d
u
c
ti
o
n
in
b
o
th
P
3
0
0
a
n
d
N
1
0
0
la
te
n
c
ie
s.
T
h
e
p
la
s
m
a
A
C
h
E
a
c
ti
v
it
y
su
p
p
re
s
s
io
n
w
a
s
a
ls
o
s
e
e
n
,
w
h
ic
h
s
u
g
g
e
st
t
h
a
t
it
c
o
u
ld
e
n
h
a
n
c
e
t
h
e
c
o
g
n
it
iv
e
a
b
ili
ty
a
n
d
w
o
rk
in
g
m
e
m
o
ry
a
n
d
im
p
ro
ve
a
tt
e
n
ti
o
n
P
e
th
-N
u
i e
t
a
l8
6
S
e
ve
n
te
e
n
h
e
a
lt
h
y
vo
lu
n
te
e
rs
(
1
3
f
e
m
a
le
s
a
n
d
4
m
a
le
s)
,
m
e
a
n
a
g
e
2
5
.2
3
±
5
.9
7
in
M
e
lb
o
u
rn
e
,
A
u
st
ra
lia
.
D
o
u
b
le
-b
lin
d
,
p
la
c
e
b
o
-c
o
n
tr
o
lle
d
c
ro
s
s
-o
ve
r
st
u
d
y
w
a
s
e
m
p
lo
ye
d
B
a
c
o
p
a
e
x
tr
a
c
t,
3
2
0
m
g
o
r
6
4
0
m
g
d
a
ily
,
1
h
o
u
r
a
n
d
2
h
o
u
r
B
a
c
o
p
a
c
o
n
su
m
p
ti
o
n
s
h
o
w
e
d
a
c
h
a
n
g
e
f
ro
m
b
a
s
e
lin
e
s
c
o
re
in
d
ic
a
ti
ve
o
f
p
o
s
it
iv
e
c
o
g
n
it
iv
e
e
ff
e
c
ts
a
t
fir
st
a
n
d
s
e
c
o
n
d
h
o
u
r
p
o
st
c
o
n
su
m
p
ti
o
n
o
n
t
h
e
S
tr
o
o
p
t
a
s
ks
a
s
w
e
ll
L
e
tt
e
r
S
e
a
rc
h
.
It
p
ro
d
u
c
e
d
s
o
m
e
n
o
o
tr
o
p
ic
a
n
d
a
d
a
p
to
g
e
n
ic
e
ff
e
c
ts
.
P
o
s
it
iv
e
m
o
d
e
ff
e
c
ts
a
n
d
r
e
d
u
c
ti
o
n
in
c
o
rt
is
o
l l
e
ve
ls
(
p
h
ys
io
lo
g
ic
a
l s
tr
e
s
s
re
s
p
o
n
s
e
)
w
e
re
a
s
s
o
c
ia
te
d
w
it
h
B
a
c
o
p
a
c
o
n
su
m
p
ti
o
n
b
y
p
a
rt
ic
ip
a
n
ts
.
B
e
n
s
o
n
e
t
a
l3
5
S
ix
ty
h
e
a
lt
h
y
a
d
u
lt
s
b
e
tw
e
e
n
1
9
a
n
d
2
2
y
e
a
rs
f
ro
m
G
o
ve
rn
m
e
n
t
M
e
d
ic
a
l C
o
lle
g
e
,
N
a
g
p
u
r,
I
n
d
ia
.
D
o
u
b
le
-b
lin
d
,
ra
n
d
o
m
iz
e
d
p
la
c
e
b
o
-c
o
n
tr
o
lle
d
n
o
-c
ro
s
s
o
ve
r,
p
a
ra
lle
l t
ri
a
l
w
a
s
e
m
p
lo
ye
d
B
a
c
o
p
a
e
x
tr
a
c
t,
1
5
0
m
g
,
fo
r
1
5
d
a
ys
S
ig
n
ifi
c
a
n
t
im
p
ro
ve
m
e
n
t
in
m
e
m
o
ry
t
e
st
,
n
e
u
ro
p
sy
c
h
o
lo
g
ic
a
l t
e
st
s
(d
ig
it
s
p
a
n
m
e
m
o
ry
t
a
s
k
,
p
a
ir
e
d
a
s
s
o
c
ia
te
t
a
s
k
,
lo
g
ic
a
l m
e
m
o
ry
t
e
st
[
st
o
ry
r
e
c
a
ll]
,
m
e
m
o
ry
s
p
a
n
f
o
r
n
o
n
s
e
n
s
e
s
y
lla
b
le
s)
a
n
d
c
o
m
p
u
te
ri
ze
d
te
st
s
(fi
n
g
e
r
ta
p
p
in
g
t
e
st
,
s
im
p
le
r
e
a
c
ti
o
n
t
e
st
,
c
h
o
ic
e
r
e
a
c
ti
o
n
t
e
st
,
c
h
o
ic
e
d
is
c
ri
m
in
a
ti
o
n
t
e
st
,
a
n
d
d
ig
it
p
ic
tu
re
s
u
b
st
it
u
ti
o
n
t
e
st
(
sy
m
b
o
l d
ig
it
m
o
d
a
lit
ie
s
te
st
).
B
lo
o
d
b
io
c
h
e
m
is
tr
y
s
h
o
w
e
d
s
ig
n
ifi
c
a
n
t
e
le
va
ti
o
n
in
s
e
ru
m
c
a
lc
iu
m
l
e
ve
ls
(
st
ill
w
it
h
in
n
o
rm
a
l r
a
n
g
e
).
K
u
m
a
r
e
t
a
l4
1
T
e
n
s
u
b
je
c
ts
(
m
e
a
n
a
g
e
:
6
1.
8
8
±
6
.6
9
y
e
a
rs
)
fr
o
m
G
e
rm
a
n
y
w
it
h
m
ild
c
o
g
n
it
iv
e
im
p
a
ir
m
e
n
t.
S
id
e
ri
ti
s
e
x
tr
a
c
t,
5
0
0
m
g
c
o
m
b
in
e
d
w
it
h
B
a
c
o
p
a
e
x
tr
a
c
t,
1
6
0
a
n
d
3
2
0
m
g
S
id
e
ri
ti
s
e
x
tr
a
c
t
c
o
m
b
in
e
d
w
it
h
B
a
c
o
p
a
e
x
tr
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Manap et al 11
BME (300 mg/day) for 84 days in participants without demen-
tia aged 65 years and above in University of Catania, Italy also
showed improvement in their performance in a restraint recall
and Stroop Task, that is, evaluating the capability to bypass
unnecessary input.33 Moreover, in Lismore, New South Wales,
Australia, the administration with B monnieri (300 mg/day) in
healthy volunteers over 55 years of age showed improvement in
their oral learning, memory attainment, and suppressed recall.82
In another research done at Swinburne University of
Technology, Melbourne, Australia using higher single dose in a
double-blind, placebo-controlled trial among normal healthy
subjects between the age of 18 and 44 years demonstrated
an improved and preserved cognitive ability.36 Significant
enhancement in prompt memory and response performance
was also observed when Bacopa in the form of syrup (propor-
tionate to 10 g dried Bacopa daily) was administered in 40
school children aged between 6 and 8 years for 90 days from
rural India.83 The overall clinical trials in humans using BME
are summarized in Table 3.
Conclusions
Many traditional plants especially B monnieri have intricate
mixtures of chemical compounds, which exhibit various phar-
macological and biological activities. They have been used as
traditional medicines and for anti-aging. According to the
long-established hypothesis, plant compounds are able to
maintain the fundamental vitality in the body and have various
neuroprotective mechanisms that empower them to be used as
part of our well-being. This review reveals the effective use of
B monnieri in cognition and neuroprotection and its phytocon-
stituents that can be used in novel drug discovery.
Author Contributions
ASAM, SV and PM designed the flow and wrote sub-sections
of the manuscript. All other authors contributed to manuscript
revision, proof reading and approval of the submitted version.
ORCID iD
Priya Madhavan https://orcid.org/0000-0001-6714-1279
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