Doxorubicin is one of the most important wide spectrum chemotherapeutic agents which are in frequent clinical use to manage numerous neoplasias either alone or in conjunction with other chemotherapeutic drugs. However, induction of cardiotoxicity, hepatotoxicity, pulmonary toxicity and nephrotoxicity along with bone marrow toxicity is the major limiting factor for its optimum use in cancer treatment. This indicates the need to reduce its toxic implication that could help the optimum utilization of doxorubicin in the treatment of cancer. The present review describes the effect of Naringin, a grapefruit bioflavonoid on the management of Doxorubicin induced toxicities in several preclinical studies. Naringin has been found to reduce cardiotoxicity, hepatotoxicity, nephrotoxicity, lung toxicity and DNA damage. The preclinical reports indicate that Naringin deserves clinical application in conjunction with Doxorubicin for the benefit of cancer patients as it is part of daily diet in the form of citrus fruits and juices.

Keywords: Doxorubicin, Naringin, DNA damage, Cardiotoxicity, Reactive oxygen species

Doxorubicin (DOX) 7~{S},9~{S})-7-[(2~{R},4~{S},5~{S},6~{S})-4-amino-5-hydroxy-6-methyloxan-2-yl]oxy-6,9,11-trihydroxy-9-(2-hydroxyacetyl)-4-methoxy-8,10-dihydro-7~{H} -tetracene-5,12-dione or Adriamycin is an anthracycline group of antibiotic, which was isolated from Streptomyces peucetius [1]. DOX is a broad spectrum antineoplastic agent and it has been clinically used either alone or in conjunction with other chemotherapeutic drugs to treat several antineoplastic disorders including Hodgkin's and non-Hodgkin's lymphomas, liver cancers, childhood solid tumors, breast cancer, multiple myelomas, thyroid carcinomas, ovarian cancer, gastric carcinoma, osteosarcoma, acute myeloblastic leukemias, myelogenous leukemia; small cell lung cancer, neuroblastoma, Wilms tumor, Kaposi’s sarcoma and soft tissue sarcomas (Figure 1) [2-14].

Despite its high efficacy increasing adverse side effects are major stumbling block in the efficient use of DOX. DOX is known to induce adverse side effects in the form of lacrimation, diarrhea, conjunctivitis, hypersensitivity (fever, chills and urticaria), mucositis, hyperpigmentation of the nails, nausea and vomiting, myelosuppression, alopecia, and discoloration of urine [15,16]. DOX therapy produces tissue toxicity in the bone marrow, brain, kidney and liver [17,18]. Apart from this, the clinical use of DOX is associated with life threatening cardiotoxicity in the surviving patients [19-21]. Despite the fact that it has several side effects, it is clinically successful in treating several neoplasias either alone or in combination with other chemotherapeutic drugs [2-14]. The optimum utilization of DOX in the treatment of cancer can be achieved by concurrent administration of natural products, which may reduce its toxicity without compromising its anticancer activity. The natural products may be more acceptable due to their biologic origin and their use may be also able to counter drug-induced resistance against cancer cell kill.

Naringin (7-(2-O-(6-deoxy-α-L-mannopyranosyl)-β-D-glucopyranosyloxy)-2,3-dihydro-4',5,7-trihydroxyflavone) or Naringenin 7-O-neohesperidoside is synthesized as a secondary metabolite by several plants belonging to citrus family (Figure 2). The origin of word Naringin can be traced to Sanskrit word Narangi (orange). Naringin is a disaccharide with a molecular formula of C₂₇H₃₂O₁₄ and molecular weight of 580.539 g/mol. Naringin contains two rhamnose units, which are linked to its aglycone portion, Naringenin, at the 7-carbon position. Naringin was first discovered in the flowers of grapefruit tree in Jawa by DeVry in 1857 [22]. Naringin is a bitter tasting, white-beige coloured powder soluble at a concentration of 1 mg/ml in warm water. It is abundant in Citrus paridisi (grapefruit), the peels, seeds and membrane of which contain about 0.75% naringin [23]. One liter of grapefruit juice usually contains 800 mg of naringin [24]. Naringin is also synthesized by various other citrus fruits that include Citrus nobilis (Tangore), Citrus junos (pomelo), Citrus unshiu (mandarin orange), Citrus sinensis (sweet orange), Citrus tachibana (tachibana orange), Poncirus trifoliata (bitter orange or hardy orange) and other plants including Artemisia stolonifera (wormwood), aerial parts of Thymusherba barona (caraway thyme) and roots of Cudrania cochinchinensis (cockspur thorn) [25-28]. Naringin forms part of daily diet in the form of various fruits and fruit juices. It has been reported to neutralize various free radicals in vitro [29,30]. Naringin also possesses metal chelating activity [31-33]. It possesses a broad-spectrum activity against cardiotoxicity, cancer, carcinogenesis, viral and bacterial infections, liver and nervous system toxicities [34-41]. Naringin has been reported to act as a chemopreventive agent against fore stomach carcinoma triggered by benzo-a-pyrene [42]. It protected against the iron-induced oxidative stress in vivo and in vitro [32,43,44]. The naringin is active against fibrosis, diabetes, dyslipidemia, inflammation, osteoporosis, lipodystrophy and cognitive damages [45-48]. Naringin has been reported to kill HeLa, AGS and breast cancer cells and also effective against Walker’s carcinoma in rats [49-52]. Naringin also protected against LPS-induced lung damage in mice [53]. It has been found to protect against radiation-induced DNA and chromosome damage [30,54]. Naringin has been also reported to reduce radiation-induced oxidative stress in irradiated mice [55]. Naringin has been reported to protect against the bleomycin-induced DNA damage and cell survival in V79 cells [56]. The aim of this review is to focus on the protective effects of naringin against the doxorubicin-induced toxicity.

EFFECT OF NARINGIN ON DOXORUBICIN DISTRIBUTION

The plasma clearance was studied at 0, 1, 2, 3 and 4 h in rats administered with 50 mg/kg Naringin 30 min before 2 mg/kg doxorubicin infusion. The results from this study indicate that oral administration of naringin did not significantly alter the DOX clearance in rat plasma. Similarly, naringin treatment did not alter the excretion of doxorubicin in the rat urine and bile [57]. This study has reported high accumulation of DOX in heart, liver and kidney and naringin administration did not significantly change the distribution of DOX in these tissues [57].

EFFECT OF NARINGIN ON DOX-INDUCED CARDIOTOXICITY

The cardioprotective action of 2.5, 5, 7.5 or 10 mg/kg naringin was investigated in mice treated with 15 mg/kg DOX. The Naringin was orally administered consecutively for five days before DOX treatment and the serum enzymes and antioxidants were studied at 30 h post DOX treatment in the heart homogenate. The results of this study showed that Naringin significantly reduced the cardiotoxicity as indicated by the decline in the lactate dehydrogenase (LDH), aspartate aminotransferase (AST/GOT) and alanine aminotransferase (ALT/GPT) in a dose dependent manner and the maximum reduction was observed for 10 mg/kg body weight of Naringin (Table 1). The study of antioxidants revealed that naringin elevated glutathione (GSH), and activities of catalase and superoxide dismutase (SOD) in a dose dependent manner in the heart of mice treated with DOX (Table 1). This was followed by a significant reduction in the DOX induced lipid peroxidation [40]. A study in Wistar rats has shown that 100 mg/kg Naringin treatment given for 14 days and 15 mg DOX reduced DOX-induced lipid peroxidation and elevated catalase and SOD activities and GSH contents in the heart tissue (Table 1). The histological evaluation of heart has shown that DOX induced inflammation, severe vacuolization, myofibrillar loss, and extensive diffused fibrosis at 96 h after DOX treatment, whereas Naringin administration restored the histology of rat heart to normal [58].Embryonic rat heart cells H9c2 treated with 5 μmol/l DOX for 24 h induced cytotoxicity in these cells, whereas pretreatment of H9c2 cells with 0.1, 1, 10 and 20 μmol/l Naringin for two h before DOX treatment significantly reduced  the  DOX-induced  cytotoxicity  in  a  Naringin

concentration dependent manner. The optimum effect was observed at 1 μmol/l Naringin. 1 μmol/l Naringin also reduced the formation of reactive oxygen species (ROS) triggered by DOX treatment (Table 1). Naringin treatment of H9c2 cells also reduced DOX-induced apoptosis in these cells by suppressing p38MAPK [59].

EFFECT OF NARINGIN ON DOX-INDUCED LIVER TOXICITY

Albino rats injected with 5 mg/kg DOX led to a significant increase in lipid peroxidation and reduction in the GSH contents and activities of GST, catalase and SOD, whereas pretreatment of rats with 2 mg/kg body weight of naringin before DOX administration significantly increased the amount of GSH and activities of GST, catalase and SOD and decreased lipid peroxidation in their livers (Table 1) [60]. In another study mice injected with 1, 5 or 10 mg/kg of DOX and treated with Naringin at a dose of 10 mg/kg one h before or after DOX treatment showed that DOX treatment enhanced the lipid peroxidation in a dose dependent manner and reduced the GSH contents and activities of catalase, GST and SOD in a similar fashion. Treatment of mice with Naringin 1 h before or after DOX administration significantly reduced lipid peroxidation and augmented the activities of catalase, GST and SOD and GSH contents (Table 1). The effect of pretreatment of Naringin was greater than the post treatment [61].

EFFECT OF NARINGIN ON DOX-INDUCED LUNG TOXICITY

The effect of 2 mg/kg Naringin was studied in albino rats administered with 5 mg/kg DOX. The DOX administration induced biochemical toxicity in the rat lung indicated by a time dependent decline in the GSH concentration and decrease in the GST, catalase and SOD activities, where a maximum reduction in all biochemical endpoints was detected at 2 h post-DOX treatment. Treatment of rats with 2 mg/kg Naringin significantly increased the activities of GST, catalase and SOD followed by a rise in the glutathione contents (Table 1). A greatest elevation was observed at 2 h post-DOX treatment [62].

EFFECT OF NARINGIN ON DOX-INDUCED BONE MARROW TOXICITY

Bone marrow suppression is a dose limiting factor in the optimal use of DOX as a chemotherapeutic agent. The ability of Naringin to reduce DOX-induced bone marrow toxicity has been studied in mice given different doses of DOX before and after Naringin treatment at different times. The mice injected with 1, 5 or 10 mg/kg DOX led to a significant rise in the lipid peroxidation followed by a significant decline in the GSH and activities of GST, catalase and SOD. Naringin treatment at a dose of 10 mg/kg one h before or after DOX administration resulted in a significant decline in the lipid peroxidation at different post-treatment times accompanied by a significant rise in the GSH contents and activities of GST, catalase and SOD (Table 1) [63]. The albino rats administered with 5 mg/kg DOX showed an increase in the lipid peroxidation and attrition in the GSH concentration and activities of GST, catalase and SOD from ½ to 2 h post DOX-treatment in the bone marrow. The rats treated with 2 mg/kg Naringin daily for consecutive three days before administration of 5 mg/kg DOX reduced the Lipid peroxidation at ½, 1 and 2 h post-DOX treatment. This was accompanied by a significant rise in the GSH contents, and activities of GST, catalase and SOD (Table 1) [64]. 

EFFECT OF NARINGIN ON THE ANTICANCER ACTIVITY OF DOX

DOX treatment was found to regress Ehrlich ascites tumor in Swiss albino mice accompanied by the induction of toxicity in the heart and liver. Administration of 10 mg/kg Naringin before DOX-administration reduced the cardiac and hepatotoxicity without significantly altering the anticancer activity of DOX in the tumor bearing mice (Table 1) [40]. Similarly, a study in nude mice bearing HeLa cells has revealed that treatment of mice with 5 mg/kg DOX reduced tumor volume however; it was accompanied by toxic effect on heart, liver and kidney. The treatment of tumor bearing mice with 20 mg/kg of naringin concomitantly increased the anticancer activity of DOX and at the same time reduced the DOX-induced cardiotoxicity, hepatotoxicity and nephrotoxicity. The treatment of nude mice with both DOX and Naringin was also able to arrest body weight loss triggered by DOX alone, whereas in vitro study in HeLa cells showed that combined treatment of DOX and naringin more efficiently arrested cell proliferation than either treatment alone (Table 1) [65].

EFFECT OF NARINGIN OF DOX-INDUCED DNA DAMAGE

DOX is well-known to induce damage to cellular DNA. Treatment of mice with 5, 10 and 15 mg/kg DOX caused a dose dependent rise in the micronuclei in the polychromatic and normochromatic erythrocytes of bone marrow cells followed by the reduction in the cell proliferation as indicated by a decline in the polychromatic and normochromatic erythrocyte ratio. The highest number of micronuclei was observed at 48 h in the polychromatic and 72 h post-DOX treatment in normochromatic erythrocytes. Treatment of mice with different doses of Naringin before DOX administration significantly attenuated the frequency of micronuclei in both the polychromatic and normochromatic erythrocytes at all post DOX treatment times accompanied by a significant rise in the polychromatic and normochromatic erythrocyte ratio (Table 1) [66]. The DOX has also been reported to induced DNA adducts at molecular level in the liver and heart of mice, whereas Naringin treatment attenuated the DOX-induced DNA adduct formation significantly (Table 1) [40].

MECHANISM OF ACTION

Various mechanisms are involved in the DOX induced cytotoxic effects. However, one of the most important mechanisms by which DOX induces cell killing and it is also responsible for its toxic effects in various organs is the induction of free radicals or reactive oxygen species (ROS) by DOX. The metabolic activation of DOX into free radical results in its reaction with molecular oxygen leading to the formation of superoxide radicals through redox cycling in vivo [67,68]. DOX interacts with NADPH and increase the production of superoxide radicals by activation of Nox-2-NADPH-oxidase and NADPH cytochrome P450 and downregulation of NAD(P)H:quinone oxidoreductase-1 [69,70]. The DOX is known to accumulate iron in the mitochondria [21] and the superoxide radicals thus produced react with hydrogen peroxide in the presence of iron to produce highly reactive and dangerous hydroxyl radicals by Haber-Weiss reaction. These hydroxyl radicals damage DNA and proteins and induce lipid peroxidation inflicting toxic effects to the cells [71]. The doxorubicin interacts with nucleic acids by inter strand cross-linking, equilibrium binding, permanent single covalent attachment, reversible covalent binding, DNA groove and base specific binding, metal ion sequestration and subsequent DNA binding and intercalation with concomitant supercoil relaxation and duplex extension. The redox cycling of DOX causes DNA single strand breaks by phosphotriester formation [72]. The DOX-induced oxidative stress is due to the repression of Nrf2 signaling pathway [73] leading to increased lipid peroxidation and reduction in GSH, catalase, SOD and GST. The DOX is known to mediate its toxicity on cancer cells by inhibiting topoisomerase-II enzyme, which causes DNA single as well as double strand breaks [74]. The DOX triggers the formation of 8-Oxo-2'-deoxyguanosine DNA in adducts the heart and liver of mice [40]. The DOX induces DNA adducts independent of topoisomerase II suppression. The induction of doxorubicin-DNA adducts triggers activation of caspases that leads to apoptosis [75]. DOX has been found to overexpress p38 mitogen-activated protein kinase (MAPK)/nuclear factor-κB (NF-κB), COX-2, iNOS, TNF-α, TLR4 signaling and nitric oxide causing cell killing [8,76-78]. It also activates DNA damage response by upregulating phosphorylation of ATM, P53, CHK1, CHK2 and γH2AX genes [79]. The DOX-induced hydroxyl radicals play a major role in the activation of ATM pathway and cell cytotoxicity [80]. The activation of ATM dependent Chk2-DNA damage response pathway by DOX causes arrests of cells in G2+M phase of the cell cycle leading to cytotoxicity [81]. The DOX has been reported to activate poly (ADP-ribose) polymerase (PARP) in vitro and in vivo and upregulate p53 to trigger cytotoxicity [66,82,83]. DOX also impairs electron transport in the mitochondria [84].

The reduction in DOX-induced toxic effects by Naringin may be due to its ability to target several pathways triggered by DOX to induce cytotoxicity. The Naringin has been reported to scavenge various free radicals [29,30,85] and presence of Naringin would have suppressed the DOX-induced free radicals that may have reduced toxic effects of DOX. The iron chelating property of Naringin [31-33] would have restricted the availability of iron leading to inhibition of the formation of DOX-induced hydroxyl radical. This would have down modulated the ATM dependent pathway reducing the cytotoxic effect as well as DNA damage triggered by DOX. Naringin suppresses the ROS mediated MAPK (p38 MAPK, ERK1/2 and JNK) signaling pathway [86]. It also inhibits NF-κB signaling and COX-2 pathways and upregulates Nrf2 pathway [87-89] leading to abrogation in the DOX-induced decline in various antioxidants including GSH, GST, catalase, SOD, and glutathione peroxidase (GSHpx). The attenuation of DOX-induced cytochrome P450 activity by Naringin may have also contributed to reduced toxicity of the former as the Naringin has been found to inhibit cytochrome P450 activity [90,91]. The suppression of PARP activity by Naringin [40] is also responsible for attrition of DOX-induced cytotoxicity. Naringin is metabolized into its aglycone form Naringenin by human intestinal bacteria [92,93], which attenuates the expression of NF-κB, MAPK, TNF-α, IL-6, TLR4, inducible NO synthase (iNOS), NADPH oxidase-2 (NOX2) and COX-2 which are all overexpressed by DOX. The restoration of topoisomerase-II activity by Naringin may have also played an important role in reducing the DOX-induced cytotoxicity.

CONCLUSION

DOX is an important antineoplastic drug used for the treatment of several malignancies either alone or in combination with other chemotherapy agents. The main impediment in the optimum utilization of DOX in cancer therapy is induction of cardiotoxicity, myelosuppression, pulmonary, hepato- and nephro-toxicities in patients receiving this drug either alone or in conjunction with other chemotherapeutic agents. Naringin treatment has reduced toxicities in heart, lung, liver, kidney and bone marrow in preclinical systems. The main mechanism of DOX-induced toxicity is due to its ability to trigger the formation of ROS that stimulate a host of genes including NF-κB, COX-2, MAPK, iNOS, TNF-α, TLR4, ATM, p53, CHK1, CHK2, γH2AX and PARP that induce DNA damage and activation of caspase cascade causing cells death due to apoptosis or necrosis. The use of naringin has been found to reduce biochemical toxicities in heart, kidney, liver, lung and bone marrow. This reduction in the DOX-induced toxicity by Naringin is mediated by attenuation of DOX-induced free radicals and suppression of various proteins-induced by DOX listed above. The Naringin may have also suppressed DOX intercalation into the DNA and abrogated the topoisomerase-2 inhibition. The results from preclinical studies indicate that Naringin deserves attention as a drug that can be used in combination with DOX to reduce the toxic effect of latter.

ACKNOWLEDGEMENT

The author is grateful to his wife Mrs. Mangla Jagetia for her patience and encouragement during the writing of this manuscript.

CONFLICT OF INTEREST STATEMENT

Author does not have any conflict of interest statement to declare.

1.       Arcamone F, Di Marco A, Gaetani M, Scotti T (1961) Isolation of an antibiotic from Streptomyces species and its anti-tumorigenic activity. G Micriobiol 9: 83-90.

2.       Cortes EP, Ellison RR, Yates JW (1972) Adriamycin (NSC 123127) in the treatment of acute myelocytic leukemia. Cancer Chemother Rep 56: 237-243.

3.       Blum RH, Carter SK (1974) Adriamycin: A new anticancer drug with significant clinical activity. Ann Int Med 80: 2492-2459.

4.       Gottlieb JA (1975) Adriamycin (NSC-123127) used alone and in combination for soft tissue and bone sarcomas. Cancer Chemother Rep 6: 271-278.

5.       Pinedo, Kenis (1977) Chemotherapy of advanced soft-tissue sarcomas in adults. Cancer Treat Rev 4: 67-86.

6.       Gale RP (1979) Advances in the treatment of acute myelogenous leukemia. N Engl J Med 300: 1189-1199.

7.       Quiles JL, Ochoa JJ, Huertas JR, Lopes-Frias M, Mataix J (2006) Olive oil and mitochondrial oxidative stress: Studies on adriamycin toxicity, physical exercise and ageing. CABI Publishing, Oxford, pp: 119-151.

8.       Carvalho C, Santos RX, Cardoso S, Correia S, Oliveira PJ, et al (2009) Doxorubicin: The good, the bad and the ugly effect. Curr Med Chem 16: 3267-3285.

9.       Otterson GA, Villalona-Calero MA, Hicks W, Pan X, Ellerton JA, et al. (2010) Phase I/II study of inhaled doxorubicin combined with platinum-based therapy for advanced non-small cell lung cancer. Clin Cancer Res 16: 2466-2473.

10.    Tam K (2013) The roles of doxorubicin in hepatocellular carcinoma. ADMET & DMPK 1: 29-44. 

11.    Calvo E, Moreno V, Flynn M, Holgado E, Olmedo ME, et al. (2017) Anti-tumor activity of lurbinectedin (PM01183) and doxorubicin in relapsed small-cell lung cancer: Results from a phase I study. Ann Oncol 28: 2559-2566.

12.    Ruckser R, Tatzreiter G, Kitzweger E, Strecker K, Hraby S, et al. (2007) Combination therapy with lenalidomide, bortezomib, liposomal doxorubicin and dexamethasone (LBlipDD) may overcome resistance to prior treatment with doxorubicin, lenalidomide and bortezomib in high-risk multiple myeloma (MM). Blood 110: 4838.

13.    Chen H, Wang Y, Yao Y, Qiao S, Wang H, et al. (2017) Sequential delivery of cyclopeptide RA-V and doxorubicin for combination therapy on resistant tumor and in situ monitoring of cytochrome C release. Theranostics 7: 3781-3793.

14.    Tikhonova IA, Jones-Hughes T, Dunham J, Warren FC, Robinson S, et al. (2018) Olaratumab in combination with doxorubicin for the treatment of advanced soft tissue sarcoma: An evidence review group perspective of a National Institute for Health and Care Excellence Single Technology Appraisal. Pharmacoeconomics 36: 39-49.

15.    Thirumaran R, Prendergast GC, Gilman PB (2007) Cytotoxic chemotherapy in clinical treatment of cancer. In: Cancer Immunotherapy, eds. Prendergast GC and Jaffe EM. Elsevier Inc., Philadelphia, PA USA, pp: 101-116.

16.    Lipshultz SE, Lipsitz SR, Kutok JL, Miller TL, Colan SD, et al. (2013) Impact of hemochromatosis gene mutations on cardiac status in doxorubicin-treated survivors of childhood high-risk leukemia. Cancer 119: 3555-3562.

17.    Tacar O, Sriamornsak P, Dass CR (2013) Doxorubicin: An update on anticancer molecular action, toxicity and novel drug delivery systems. J Pharm Pharmacol 65: 157-170.

18.    Meredith AM, Dass CR (2016) Increasing role of the cancer chemotherapeutic doxorubicin in cellular metabolism. J Pharm Pharmacol 68: 729-741.

19.    Singal PK, Iliskovic N (1998) Doxorubicin-induced cardiomyopathy. N Engl J Med 339: 900-905.

20.    Carvalho FS, Burgeiro A, Garcia R, Moreno AJ, Carvalho RA, et al. (2014) Doxorubicin-induced cardiotoxicity: From bioenergetic failure and cell death to cardiomyopathy. Med Res Rev 34: 106-135.

21.    Ichikawa Y, Ghanefar M, Wu R, Khechaduri A, Prasad SV, et al. (2014) Cardiotoxicity of doxorubicin is mediated through mitochondrial iron accumulation. J Clin Invest 124: 617-630.

22.    Hoffmann E (1879) Naringin (Hesperidin de Vry). Arch Pharm 214: 139-145.

23.    Poore HD (1934) Recovery of naringin and rectin from grapefruit residue. Ind Eng Chem 26: 637-639.

24.    Zhang J (2007) Flavonoid in grape fruit and commercially grape fruit juices: Concentration, distribution and potential health benefits. Proc Fla State Hort Soc 120: 288-294.

25.    Swiader K, Lamer-Zarawska E (1996) Flavonoids of rare Artemisia species and their antifungal properties. Fitoterapia 67: 77-78.

26.    Bocco A, Cuvelier ME, Richard H, Berset C (1998) Antioxidant activity and phenolic composition of citrus peel and seed extracts. J Agric Food Chem 46: 2123-2139.

27.    Gorinstein S, Martın-Belloso O, Park YS, Haruenkit R, Lojek A, et al. (2001) Comparison of some biochemical characteristics of different citrus fruits. Food Chem 74: 309-315.

28.    Yang X, Kang SM, Jeon BT, Kim YD, Ha JH, et al. (2011). Isolation and identification of an antioxidant flavonoid compound from citrus‐processing by‐product. J Sci Food Agric 91: 1925-1927.

29.    Russo A, Acquaviva R, Campisi A, Sorrenti V, Di Giacoma C, et al. (2000) Bioflavonoids as antiradicals, antioxidants and DNA cleavage protectors. Cell Biol Toxicol 16: 91-98.

30.    Jagetia GC, Venkatesha VA, Reddy TK (2003) Naringin, a citrus flavonone, protects against radiation-induced chromosome damage in mouse bone marrow. Mutagenesis 18: 337-343.

31.    Mira L, Tereza Fernandez M, Santos M, Rocha R, Helena Florêncio M, et al. (2002) Interactions of flavonoids with iron and copper ions: A mechanism for their antioxidant activity. Free Rad Res 36: 1199-1208.

32.    Jagetia GC, Reddy TK (2011) Alleviation of iron induced oxidative stress by the grape fruit flavanone naringin in vitro. Chemico-Biol Interact 190: 121-128.

33.    Mladěnka P, Macáková K, Filipský T, Zatloukalová L, Jahodar L, et al. (2011) In vitro analysis of iron chelating activity of flavonoids. J Inorg Biochem 105: 693-701.

34.    Gammal AA, Mansour RM (1986) Antimicrobial activities of some flavonoid compounds. Zentrabl Mikrobiol 141: 561-565.

35.    Aboobaker VS, Balgi AD, Bhattacharya RK (1994) In vivo effect of dietary factors on the molecular action of aflatoxin B1: Role of non-nutrient phenolic compounds on the catalytic activity of liver fraction. In Vivo 8: 1095-1098.

36.    Gordon PB, Holen I, Seglen PO (1995) Protection by naringin and some other flavonoids of hepatocytic autophagy and endocytosis against inhibition by okadaic acid. J Biol Chem 270: 5830-5838.

37.    Celiz G, Daz M, Audisio MC (2011) Antibacterial activity of naringin derivatives against pathogenic strains. J Appl Microbiol 111: 731-738.

38.    Rajadurai M, Prince PS (2006) Preventive effect of naringin on lipid peroxides and antioxidants in isoproterenol-induced cardiotoxicity in Wistar rats. Biochem Histopathol Evid Toxicol 228: 259-268.

39.    Rajadurai M, Prince PS (2007) Preventive effect of naringin on cardiac mitochondrial enzymes during isoproterenol‐induced myocardial infarction in rats: A transmission electron microscopic study. J Biochem Mol Toxicol 21: 354-361.

40.    Jagetia GC, Reddy TK (2014) The grape fruit flavonone naringin protects mice against doxorubicin-induced cardiotoxicity. J Mol Biochem 3.

41.    Kim HD, Jeong KH, Jung UJ, Kim SR (2016) Naringin treatment induces neuroprotective effects in a mouse model of Parkinson's disease in vivo, but not enough to restore the lesioned dopaminergic system. J Nutr Biochem 28: 140-146.

42.    Jagetia GC, Reddy TK, Venkatesha VA, Kedlaya R (2004) Influence of naringin on ferric iron induced oxidative damage in vitro. Clinica Chimica Acta 347: 189-197.

43.    Singh D, Chander V, Chopra K (2004) Protective effect of naringin, a bioflavonoid on ferric nitrilotriacetate-induced oxidative renal damage in rat kidney. Toxicology 201: 1-8.

44.    Kumar A, Dogra S, Prakash A (2010) Protective effect of naringin, a citrus flavonoid, against colchicine-induced cognitive dysfunction and oxidative damage in rats. J Med Food 13: 976-984.

45.    Adebiyi OO, Adebiyi OA, Owira PM (2015) Naringin reverses hepatocyte apoptosis and oxidative stress associated with HIV-1 nucleotide reverse transcriptase inhibitors-induced metabolic complications. Nutrients 7: 10352-10368.

46.    Turgut NH, Kara H, Elagoz S, Deveci K, Gungor H, et al. (2016) The protective effect of naringin against bleomycin-induced pulmonary fibrosis in Wistar rats.

47.    Ma X, Lv J, Sun S, Ma J, Xing G, Arslanbas E (2016) Naringin ameliorates bone loss induced by sciatic neurectomy and increases Semaphorin 3A expression in denervated bone. Sci Rep 6: 24562.

48.    Camargo CA, Gomes-Marcondes MC, Wutzki NC, Aoyama H (2012) Naringin inhibits tumor growth and reduces interleukin-6 and tumor necrosis factor α levels in rats with Walker 256 carcinosarcoma. Anticancer Res 32: 129-133.

49.    Li H, Yang B, Huang J, Xiang T, Yin X, et al. (2013) Naringin inhibits growth potential of human triple-negative breast cancer cells by targeting β-catenin signaling pathway. Toxicol Lett 220: 219-228.

50.    Zeng L, Zhen Y, Chen Y, Zou L, Zhang Y, et al. (2014) Naringin inhibits growth and induces apoptosis by a mechanism dependent on reduced activation of NF-κB/COX-2-caspase-1 pathway in HeLa cervical cancer cells. Int J Oncol 45: 1929-1936.

51.    Raha S, Yumnam S, Hong GE, Lee HJ, Saralamma VV, et al. (2015) Naringin induces autophagy-mediated growth inhibition by downregulating the PI3K/Akt/mTOR cascade via activation of MAPK pathways in AGS cancer cells. Int J Oncol 47: 1061-1069.

52.    Liu Y, Wu H, Nie YC, Chen JL, Su WW, et al. (2011) Naringin attenuates acute lung injury in LPS-treated mice by inhibiting NF-κB pathway. Int Immunopharmacol 11: 1606-1612.

53.    Jagetia GC, Reddy TK (2002) The grapefruit flavanone naringin protects against the radiation-induced genomic instability in the mice bone marrow: a micronucleus study. Mutat Res 519: 37-48.

54.    Jagetia GC, Reddy TK (2005). Modulation of radiation-induced alteration in the antioxidant status of mice by naringin. Life Sci 77: 780-794.

55.    Jagetia A, Jagetia GC, Jha S (2007) Naringin, a grapefruit flavanone, protects V79 cells against the bleomycin‐induced genotoxicity and decline in survival. J Appl Toxicol 27: 122-132.

56.    Park HS, Oh JH, Lee JH, Lee YJ (2011) Minor effects of the citrus flavonoids naringin, naringenin and quercetin, on the pharmacokinetics of doxorubicin in rats. Die Pharmazie 66: 424-429.

57.    Kwatra M, Kumar V, Jangra A, Mishra M, Ahmed S, et al. (2016) Ameliorative effect of naringin against doxorubicin-induced acute cardiac toxicity in rats. Pharmaceutical Biol 54: 637-647.

58.    Jian CY, Ouyang HB, Xiang XH, Chen JL, Li YX, et al. (2017) Naringin protects myocardial cells from doxorubicin-induced apoptosis partially by inhibiting the p38MAPK pathway. Mol Med Rep 16: 9457-9463.

59.    Jagetia GC, Lalnuntluangi V (2016) The citrus flavanone naringin enhances antioxidant status in the albino rat liver treated with doxorubicin. Biochem Mol Biol J 2: 1-9.

60.    Jagetia GC, Lalrinengi C (2017) Treatment of mice with naringin alleviates the doxorubicin-induced oxidative stress in the liver of Swiss albino mice. MOJ Anat Physiol 4: 00130.

61.    Jagetia GC, Lalrinpuii T (2018) Naringin protects rat lung against the doxorubicin-induced biochemical injury. MOJ Anat Physiol 5: 134-140.

62.    Jagetia GC, Lalrinengi C (2017) Naringin, a grapefruit bioflavonoid protects mice bone marrow cells against the doxorubicin-induced oxidative stress. SOJ Biochem 3: 1-9.

63.    Jagetia GC, Hmingthazuali VL (2018) Protection of doxorubicin-induced biochemical injury in the rat bone marrow by a dietary bioflavonoid Naringin. Ann Clin Lab Res 6: 224.

64.    Liu X, Yang X, Chen F, Chen D (2017) Combined application of doxorubicin and naringin enhances the antitumor efficiency and attenuates the toxicity of doxorubicin in HeLa cervical cancer cells. Int J Clin Exp Pathol 10: 7303-7311.

65.    Jagetia GC, Reddy TK (2016) The grapefruit bioflavonoid naringin protects against the doxorubicin-induced micronuclei formation in mouse bone marrow. Int J Mol Biol Open Access 1: 00006.

66.    Powis G (1989) Free radical formation by antitumor quinones. Free Radical Biol Med 6: 63-101.

67.    Olson RD, Mushlin PS (1990) Doxorubicin cardio-toxicity: Analysis of prevailing hypotheses. FASEB J 4: 3076-3086.

68.    Deng S, Kruger A, Kleschyov AL, Kalinowski L, Gutierrez-Merino C, et al. (2007) Gp91phox-containing NAD(P)H oxidase increases superoxide formation by doxorubicin and NADPH. Free Rad Biol Med 42: 466-473.

69.    Lagoa R, Gañán C, López-Sánchez C, García-Martínez V, Gutierrez-Merino C (2014) The decrease of NAD (P) H:quinone oxidoreductase 1 activity and increase of ROS production by NADPH oxidases are early biomarkers in doxorubicin cardiotoxicity. Biomarkers 19: 142-153.

70.    Gutteridge JM, Halliwell B (1989) Iron toxicity and oxygen radicals. Bailliere's Clin Haematol 2: 195-256.

71.    Lown JW (1983) The mechanism of action of quinone antibiotics. Mol Cell Biochem 55: 17-40.

72.    El-Agamy DS, El-Harbi KM, Khoshhal S, Ahmed N, Elkablawy MA, et al. (2019) Pristimerin protects against doxorubicin-induced cardiotoxicity and fibrosis through modulation of Nrf2 and MAPK/NF-kB signaling pathways. Cancer Manag Res 11: 47-67.

73.    Pommier Y, Leo E, Zhang H, Marchand C (2010) DNA topoisomerases and their poisoning by anticancer and antibacterial drugs. Chem Biol 17: 421-433.

74.    Swift LP, Rephaeli A, Nudelman A, Phillips DR, Cutts SM (2006) Doxorubicin-DNA adducts induce a non-topoisomerase II-mediated form of cell death. Cancer Res 66: 4863-4871.

75.    Guo RM, Xu WM, Lin JC, Mo LQ, Hua XX, et al. (2013) Activation of the p38 MAPK/NF-κB pathway contributes to doxorubicin-induced inflammation and cytotoxicity in H9c2 cardiac cells. Mol Med Rep 8: 603-608.

76.    Rathos MJ, Khanwalkar H, Joshi K, Manohar SM, Joshi KS (2013) Potentiation of in vitro and in vivo antitumor efficacy of doxorubicin by cyclin-dependent kinase inhibitor P276-00 in human non-small cell lung cancer cells. BMC Cancer 13: 29.

77.    Rehman MU, Tahir M, Khan AQ, Khan R, Oday-O-Hamiza, et al. (2014) D-limonene suppresses doxorubicin-induced oxidative stress and inflammation via repression of COX-2, iNOS and NFκB in kidneys of Wistar rats. Exp Biol Med 239: 465-476.

78.    Mai Y, Yu JJ, Bartholdy B, Xu-Monette ZY, Knapp EE, et al. (2016) An oxidative stress-based mechanism of doxorubicin cytotoxicity suggests new therapeutic strategies in ABC-DLBCL. Blood 128: 2797-2807.

79.    Kurz EU, Douglas P, Lees-Miller SP (2004) Doxorubicin activates ATM-dependent phosphorylation of multiple downstream targets in part through the generation of reactive oxygen species. J Biol Chem 279: 5272-5781.

80.    Mikhailov A, Shinohara M, Rieder CL (2004) Topoisomerase II and histone deacetylase inhibitors delay the G2/M transition by triggering the p38 MAPK checkpoint pathway. J Cell Biol 166: 517-526.

81.    Muñoz-Gámez JA, Martín-Oliva D, Aguilar-Quesada R, Cañuelo A, Nunez MI, et al. (2005) PARP inhibition sensitizes p53-deficient breast cancer cells to doxorubicin-induced apoptosis. Biochem J 386: 119-125.

82.    Shin HJ, Kwon HK, Lee JH, Gui X, Achek A, et al. (2015) Doxorubicin-induced necrosis is mediated by poly-(ADP-ribose) polymerase 1 (PARP1) but is independent of p53. Sci Rep 5: 15798.

83.    Heart EA, Karandrea S, Liang X, Balke ME, Beringer PA, et al. (2016) Mechanisms of doxorubicin toxicity in pancreatic β-cells. Toxicol Sci 152: 395-405.

84.    Cavia‐Saiz M, Busto MD, Pilar‐Izquierdo MC, Ortega N, Perez‐Mateos M, et al. (2010) Antioxidant properties, radical scavenging activity and biomolecule protection capacity of flavonoid naringenin and its glycoside naringin: A comparative study. J Sci Food Agric 90: 1238-1244.

85.    Chen J, Guo R, Yan H, Tian L, You Q, et al. (2014) Naringin inhibits ROS‐activated MAPK pathway in high glucose‐induced injuries in H9c2 cardiac cells. Basic Clin Pharmacol Toxicol 114: 293-304.

86.    Nie YC, Wu H, Li PB, Xie LM, Luo YL, et al. (2012) Naringin attenuates EGF-induced MUC5AC secretion in A549 cells by suppressing the cooperative activities of MAPKs-AP-1 and IKKs-IκB-NF-κB signaling pathways. Eur J Pharmacol 690: 207-213.

87.    Gopinath K, Sudhandiran G (2012) Naringin modulates oxidative stress and inflammation in 3-nitropropionic acid-induced neurodegeneration through the activation of nuclear factor-erythroid 2-related factor-2 signalling pathway. Neuroscience 227: 134-143.

88.    Zeng L, Zhen Y, Chen Y, Zou L, Zhang Y, et al. (2014) Naringin inhibits growth and induces apoptosis by a mechanism dependent on reduced activation of NF-κB/COX-2-caspase-1 pathway in HeLa cervical cancer cells. Int J Oncol 45: 1929-1936.

89.    Bear WL, Teel RW (2000) Effects of citrus flavonoids on the mutagenicity of heterocyclic amines and on cytochrome P450 1A2 activity. Anticancer Res 20: 3609-3614.

90.    Fujita T, Kawase A, Niwa T, Tomohiro N, Masuda M, et al. (2008) Comparative evaluation of 12 immature citrus fruit extracts for the inhibition of cytochrome P450 isoform activities. Biol Pharm Bull 31: 925-930.

91.    Fuhr U, Kummert AL (1995) The fate of naringin in humans: A key to grapefruit juice‐drug interactions? Clin Pharmacol Ther 58: 365-773.

92.    Chen T, Su W, Yan Z, Wu H, Zeng X, et al. (2018) Identification of naringin metabolites mediated by human intestinal microbes with stable isotope-labeling method and UFLC-Q-TOF-MS/MS. J Pharm Biomed Anal 161: 262-272.

93.     Liu X, Wang N, Fan S, Zheng X, Yang Y et al. (2016) The citrus flavonoid naringenin confers protection in a murine endotoxaemia model through AMPK-ATF3-dependent negative regulation of the TLR4 signalling pathway. Sci Rep 6: 39735.