Anticancer Potential of Natural Isoquinoline Alkaloid Berberine

doi:10.14218/JERP.2021.00005

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Anticancer Potential of Natural Isoquinoline Alkaloid Berberine

Ganesh C. Jagetia^*

Journal of Exploratory Research in Pharmacology 2021;6(3):105-133

doi: 10.14218/JERP.2021.00005

Received: March 3, 2021

Revised: April 12, 2021

Accepted: April 14, 2021

Published online: April 26, 2021

Author information

Citation: Jagetia GC. Anticancer Potential of Natural Isoquinoline Alkaloid Berberine. J Explor Res Pharmacol. 2021;6(3):105-133. doi: 10.14218/JERP.2021.00005.

Abstract

Despite the availability of several therapeutic strategies and many drugs, the ability to cure most cancers remains a challenge. Natural products have been used for the treatment of numerous diseases, including cancer. The present review delineates various preclinical studies performed in vitro and in vivo that explore the anticancer potential of berberine, an isoquinoline alkaloid found in numerous plants as a secondary metabolite. Berberine can kill various types of human cancer cells in an optimal concentration- and duration-dependent manner and inhibit the growth of various types of cancers in animal models by elevating oxidative stress. In addition, berberine suppresses cell migration, invasion and epithelial-to-mesenchymal transition in different types of cancer cells. Mechanistically, berberine can induce cancer cell DNA fragmentation/apoptosis through extrinsic and intrinsic pathways, autophagy and necrosis. The cytotoxic effects of berberine in different types of cancer cells are mediated by its ability to induce oxidative stress and cell cycle arrest, and inhibit cell migration, invasion and epithelial-to-mesenchymal transition as well as matrix metalloproteinases through the modulation of Wnt and β-catenin signaling. A single clinical study has shown some promise in gastric cancer patients. Though berberine is a relatively safe compound, it should not be prescribed to pregnant or lactating women to avoid adverse effects on developing fetuses and neonates.

Keywords

Berberine, Apoptosis, Cylins, Reactive oxygen species, beta-catenin, Caspase

Introduction

The word cancer evokes fear among patients, their families, and loved ones since effective cures remain elusive for many types of cancer. The incidence of cancer has been consistently increasing due to lifestyle changes and increasing environmental pollution. Modern electronic devices have also added to the increasing global cancer burden. In the United States, 1,806,590 new cancer cases were diagnosed, and 606,520 cancer patients died from the disease in 2020 alone.¹ In India, approximately 1,392,179 cases were detected in 2020 and 880,000 cancer patients died, and this figure is expected to increase fivefold by the year 2025.^2,3 The global cancer scenario is much higher, where the number of expected cancer cases was 19.3 million and mortality due to cancer reached 10 million in the year 2020.⁴ The availability of state of art treatment regimens in modern therapy has not significantly reduced the cancer burden in society. The cost of cancer treatment has seen a phenomenal increase in recent years due to the approval of high-cost oncology drugs and other related expenditures.⁵ Modern cancer treatment regimens put a heavy economic burden on the families of cancer patients as it drains the majority of their financial resources, and the cost of cancer treatment will still see an upward trend moving forward. Therefore, it is necessary to search for new cost-effective chemotherapeutic agents with fewer toxic implications.

Many modern cancer chemotherapeutic drugs were initially derived from natural resources before the chemical synthesis was undertaken.⁶ Natural products may be a great resource to aid in the search for novel cancer treatments as they may be more economic than high-cost exotic chemotherapeutic drugs. Moreover, they may also overcome the drug resistance induced by modern chemotherapeutic agents, which is a major cause of treatment failure. Berberine is a natural isoquinoline alkaloid synthesized by numerous plants including goldenseal (Hydrastis canadensis), yellowroot (Phellodendron amurense), Chinese goldthread (Rhizoma coptidis), Oregon grape (Berberis aquifolium), goldthread or savoyane (Coptis groenlandica), Indian goldthread (Coptis teeta), Indian barberry (Berberis aristata), bayberry (Berberis vulgaris), barberry (Berberis napalensis), Baical skullcap root (Radix scutellariae), Amur cork tree (Coptis chinensis), tree turmeric (Berberis aristata), giloe (Tinospora cordifolia), Californian poppy (Eschscholzia californica), Lopez root or Forest pepper or wild orange tree (Toddalia aculeata), false calumba (Coscinium fenestratum) and prickly poppy (Argemone mexicana).^7,8

Berberine (natural yellow 18), also known as 7,8,13,13a-tetradehydro-9,10-dimethoxy-2,3-(methylenedioxy)berbinium or 5,6-dihydro-9,10-dimethoxybenzo(g)-1,3-benzodioxolo(5,6-a) quinolizinium, is an isoquinoline alkaloid with a molecular weight of 336.367 g/mol (Fig. 1). Berberine chloride is soluble in warm water at a concentration of 3.2 mg/mL, but its solubility is less in cold water (2 mg/mL). The solubility in organic solvents is 75 mg/mL in DMSO, greater than 50 mg/mL in methanol, and greater than 2 mg/mL in ethanol; however, it is sparingly soluble in chloroform. Berberine belongs to the family of protoberberine alkaloids. It is a bright yellow fluorescent powder, which has been used in India and other countries to dye wool, wood, and leather.⁹ Berberine possesses yellow fluorescence under ultraviolet light and it is also used as a stain for histological examinations.^10,11

Fig. 1 Chemical structure of berberine.

7,8,13,13a-tetradehydro-9,10-dimethoxy-2,3-(methylenedioxy) berbinium.

Berberine-containing plants have been used in traditional Indian Ayurvedic and Chinese systems of medicine to treat various disorders in humans for a long time.^7,12–14 Berberine acts as an antimicrobial, anti-oxidant, antibacterial, anti-inflammatory, antidiarrheal, antidepressant, antidiabetic, antihypertensive, anti-arrhythmic, anti-osteoarthritic, chemo-sensitizing, hepatoprotective, and neuroprotective agent.^15–22 It is active against ischemia-reperfusion injury,^23,24 and clinical trials have shown that berberine can control dyslipidemia, dementia, ocular Behcet’s disease, hyperlipidemia, and non-fatty liver disease.^21,25–29 The focus of this review will be to delineate the anticancer activities of berberine alone in vitro and in vivo.

In vitro studies

The anticancer potential of berberine has been studied in vitro using numerous neoplastic cell lines of different tissue origins with specific studies detailed below (Table 1).

Table 1

Anticancer activity of berberine in various cultured cell lines and its mechanism of action

Cell line/IC₅₀	Berberine concentration	Outcome	Mechanism	References
Neuroblastoma
T98G/134 µg/mL	50, 75, 100, 150, or 200 µg/mL	Decreased cell proliferation, increased cell death, ER stress, apoptosis	G₁ arrest, increased p27; reduced CDK2/4, cyclin D,E; increased Bax, procaspase-9, caspase-9, caspase-3, and PARP; ROS, Ca²⁺, ER kinase, ETIF-2α, GLP78, C/EBP, DDIG153, disrupted Δψm	³⁰^,³¹
C6 (rat)	50, 100, 200, or 500 µM	Increased cell death and apoptosis, DNA fragmentation, ER stress, G₂/M arrest	Increased Wee1, cytochrome c, caspase-9/3/8, Bax, GADD153,GRP 78, decreased cyclin B, CDK1, Cdc25c, Bcl-2, Δψm	³²
U87/21.76; U25/19.79; U118/35.54 µmol/L; P3	15, 25, 50, 100, or 150 µmol/L; 50, 100, 150, 200, or 250 µM	Decreased cell viability, cell proliferation, migration, invasion, EMT, increased senescence, cell death, apoptosis, autophagy	Increased DNA DSBs, Bax, cytochrome c release, caspase 3, LC3B-II, AMPK, ULK-1, Beclin-1, oxidative phosphorylation, SQSTM1/P62, decreased IL-18, IL-1β, EGFR, RAF, MEK, ERK1/2, Bcl-2, L-lactate, LDH	³³^–³⁵
Na2 (mouse); IMR-32	10 or 20 µg/mL	Decreased cell proliferation, EMT increased cell differentiation, cell cycle arrest	Decreased CD133, β-catenin, n-myc, sox2, notch2, nestin, CDK-2, CDK-4, cyclin D1/E, PI3/Akt, Ras-Raf-ERK, increased, p27, p53, NCAM, laminin, Smad, Hsp70, p38- ATP MAPK	³⁶
T98G, LN18; LN229, C6, SHG 44	25, 50, 100, 200, or 400 mg/L	Decreased cell viability, oxygen consumption rate, mitochondrial respiration, increased autophagy, apoptosis, necrosis	Decreased ATP, GSH, NADPH, aerobic oxidation, p-ERK1/2, increased aerobic glycolysis	³⁷
LN229/40 µM; U251/30 µM	5, 10, 20, 40, 80, 160, or 320 µM	Decreased cell proliferation, increased apoptosis	Increased Wif-1, decreased Bcl-2, Wnt/β-catenin signaling, β-catenin/TCF-4 transcription	³⁸
U87MG	10, 25, 100, or 250 µM	Decreased cell viability, cell proliferation, increased apoptosis	Increased ROS, thiobarbituric acid reactive substance, protein carbonylation	³⁹
Head and neck cancer
KB	1, 10, or 100 µM; 0.01, 0.1 or 1 µg/mL	Decreased cell viability, cell migration, increased apoptosis, DNA fragmentation, cell cycle arrest	Increased caspase 3/7/8/9, PARP, FasL, Bax, Bad, Apaf-1, decreased COX-2, Mcl-1, Akt, Bcl-2, Bcl-xL, MMP-2/9, p38 MAPK	⁴⁰^,⁴¹
HSC-3	5, 10, 25, 50 or 75 µM	Decreased cell growth, DNA synthesis, increased apoptosis, G₀/G₁ arrest	Increased ROS, Ca²⁺, p53, cytochrome c, decreased Bcl2	⁴²
SCC-4	65.2 or 125 µM	Decreased cell viability, cell migration, invasion, increased DNA damage, apoptosis	Decreased MMP-2/9, u-PA, FAK, pJNK, pERK, IKK, NF-κB, Bcl-2, Bcl-xL, Δψm, increased ROS, Ca²⁺, cytochrome c, Bax, Bad, Bak, caspase 8/9/3, Apaf1, Fas, FADD, AIF, EndoG	⁴³^,⁴⁴
5-8F	2.5, 5, 10, 20, 40, 80, or 100 µM	Decreased cell viability, motility, increased LDH, filopodia formation	Reduced Ezrin phosphorylation (Thr⁵⁶⁷)	⁴⁵^,⁴⁶
CNE-1	2.5, 5, 10, 20 or 40 µg/mL	Decreased cell viability, cell migration, invasion, EMT	Reduced Twist, increased caspase 3	⁴⁷
HONE1; HK1-EBV	12.5, 25, 75, 150, or 300 µM; 25, 50, 100, or 200 µM	Decreased cell proliferation, cell migration, invasion, stress fiber formation, increased apoptosis G₂/M arrest	Increased cdc2 (p-cdc2; Tyr15), PARP, caspase 3/9, decreased RhoGTPases. p-histone 3, EBNA1, STAT-3	⁴⁸^,⁴⁹
KYSE-30	1, 2, 4, 8, 16, 32, 64, 128 or 256 µM	Decreased cell viability, cell migration	Decreased CCR7, CXCR4	⁵⁰
KYSE-70; SKGT4	20, 40, 60, 80, and 100 µmol/L	Decreased cell growth, increased apoptosis, G₂/M arrest	Decreased Akt^Ser47, mTOR^Ser2448, p70S6K ^Thr389, increased AMPK^Thr172	⁵¹
KYSe-450; TE-1; Eca109	NR	Decreased cell migration, invasion, EMT	NR	⁵²
FaDu	12.5 or 25 µM	Increased cytotoxicity, nuclear condensation, apoptosis, decreased cell migration	Increased FasL, TRAIL, caspase 8/7/3, PARP, p53, Bax, Bad, Apaf-1, caspase-9, decreased Bcl-2,and Bcl-xL, VEGF, MMP-2/9, MAPK	⁵³
SSC-15/ 235, SSC-4/242 µM	100, 150, 200, 200, 250, or 300 µM	Decreased cell viability, colony formation, increased autophagy, apoptosis	Conversation LC-3I to LC-3II, decreased SQSTM1 protein p62, miR-21, increased caspase 3, PARP, miR-155	⁵⁴
Gastrointestinal cancer
SW620	5, 10, 25, or 50 µM	Decreased cell viability, increased apoptosis	Increased caspase 3/8, PARP, cytochrome c, ROS, JNK, p38 MAPK, phospho-c-Jun, FasL, t-Bid, decreased Bid, c-IAP1, Bcl-2, Bcl-XL	⁵⁵
HCT-116 SW480	1, 10, or 50 µM	Decreased cell proliferation, increased apoptosis	Increased NAG-1, ATF-3, caspase 3/7	⁵⁶
SNU5	25, 50, 75, or 100 µM	Decreased cell viability, invasion	Increased ROS, decreased NF-κB, MMP-1/2/9	⁵⁷
HCT118; SW480	1, 2, 5, 10, 20, 50, or 100 µM	Decreased cell viability and cell migration	Increased ROS, AMPK, decreased, integrin β1, Src, FAK, p130Cas	⁵⁸
SW480	0.5, 1, 2.5, 5, 10, 25, or 50 µM	Decreased cell proliferation, increased apoptosis, G₀/G₁ arrest	Increased p21, cytochrome c, Bax, caspase 8/9/3, PARP, decreased VEGF, AIF, NF-κB, COX-2	⁵⁹
HCT116	5, 10, 20, 40, or 80 µM	Decreased cell proliferation, increased apoptosis, G₁ arrest,	Decreased β-catenin	⁶⁰
HCT-8	0.03, 0.06, 0.12, 0.24, or 0.47 mmol/L	Decreased cell proliferation, S-arrest	Increased, LDH, alkaline phosphatase, acid phosphatase, TNF-α, FasL, p53, prohibitin, Fas, Bax, caspase-3, decreased Bcl-2, procaspase-3, vimentin	⁶¹
HCT116; KM12C	6.25, 12.5, 25, or 50 µM	Decreased cell proliferation, colony formation, glucose uptake	Decreased GLUT1, LDH A, hexokinases 2 mRNA, HIF1, mTOR signaling	⁶²
HCT116	1, 10, or 100 µM	Decreased cell viability, increased apoptosis	Increased caspase-3, decreased miR-21, ITGβ4, PDCD4	⁶³
DLD-1; Caco-2	6.25, 12.5, 25, or 50 µM	Decreased cell proliferation, colony formation, S-phase fraction, G₀/G₁ arrest	Decreased lipogenesis, ACC, ACL, FASN, β catenin signaling, SREBP-1, SCAP	⁶⁴
BGC-823; SGC7901	10, 25, 50, 75, or 100 µM	Decreased cell proliferation, increased apoptosis	Increased PARP, caspase-3, decreased Δψm, Akt/mTOR/p70S6/S6	⁶⁵
BGC-823/24.16 µM	14, 21, 32, 48, 72, or 108 µM	Decreased cell proliferation, increased autophagy	Increased Beclin-1, LC3-II, p-ULK1, decreased mTOR, Akt, ERK, JNK, p38, mTOR/p70S6K	⁶⁶
SNU-1/30 µM; GES-1/120 µM	6.25, 12.5, 25, 50, 100, and 200 µM	Increased cytotoxicity, apoptosis decreased cell migration, invasion	Increased caspase-3/8/9, decreased NF-κB	⁶⁷
CACO2/39.87; LOVO/23.27 µM	10, 20, 40, 60, or 80 µM	Decreased cell viability, colony formation	Increased PARP, caspase 3, citrate synthase, decreased TUFM, PTCD3, MRPL 48	⁶⁸
LOVO/40.8 µM	1.25, 2.5, 5, 10, 20, 40, 80 or 160 µM	Decreased cell growth, colony formation, G₂/M arrest	Decreased cyclin B1, cdc2/25c, DNA, protein synthesis	⁶⁹
Liver cancer
HepG2	1-50 µM	Decreased cell growth, S- and G₂/M arrest	Decreased glucocorticoid receptors, α-fetoprotein	⁷⁰
HepG2	5, 25, 50, 100, or 200 µM	Decreased cell proliferation, increased apoptosis, G₂/M arrest	Decreased SP1, CCND1, Bcl-2	⁷¹
HepG2	10, 50, or 100 µM	Decreased cell viability, increased apoptosis	Decreased NF-κB	⁷²
HepG2; SMMC-7721; Bel-7402	3.125, 6.25, 12.5, 25, 50 or 100 µM	Decreased cell viability, increased apoptosis	Increased Bax, pAMPK, pAkt, cytochrome c, caspase 9/3	⁷³
MHCC97L PLC/PRF/5 HCC	0.5 mg/mL or 50 or 100 µM	Decreased cell viability, G₂/M arrest	Increased miR-23a, p21, GADD45α	⁷⁴
HepG2; H22 (mouse)	12.5, 25, 50 or 100 µM	Decreased cell proliferation, increased apoptosis	Increased caspase 9/3, decreased cPLA2, COX-2	⁷⁵
HepG2; HepB3; SNU-182	10, 20, 50, or 100 µM	Decreased cell proliferation	Increased KLF6, ATF3, p21, decreased E2F, PTTG1	⁷⁶
Huh-7; HepG2; Hep3B	30, 60, or 120 µM; 50 µM	Decreased cell viability, colony formation, G₀/G₁ arrest	Decreased Akt, Skp2, β-catenin, p-p70S6K^Thr389, p4EBP1^Thr37/46, mTORC1, increased FoxO3a, p21^Cip1, p27^Kip1, pAKT^Ser473, pGSK3βSer9, mTORC2	⁷⁷^,⁷⁸
KKU-213; KKU-214	2, 4, 6, 8, 20 or 20 µM	Decreased cell growth, G₁arrest	Decreased STAT-3, NF-κB, ERK-1/2	⁷⁹
Breast cancer
MCF-7; MDA-MB-231	0.001, 0.01, 0.1, 1, 10, 20, 50, 100 or 500 µM	Decreased cell proliferation, invasiveness, migration, increased apoptosis, G₀/G₁ arrest	Binding with VASP, decreased actin polymerization	⁸⁰^–⁸²
MCF-7/36.91 µg/mL	0–100 µg/mL	Decreased cell proliferation	Increased ROS, protein trafficking proteins, decreased proteins involved in proteolysis, protein folding, cell signaling, redox regulation, electron transport, metabolism, increased protein trafficking protein Hsp27	⁸³
SKBR-3; BT-474; T47D; MDA-MB-231	20, 40, 60, 80, and 100 µM	Decreased cell proliferation, increased apoptosis, DNA fragmentation, G₁ arrest	Decreased cyclins D1/E, HER2/PI3K/Akt signaling, increased caspase 9/3, PARP	⁸⁴
MDA-MB-231, MCF-7	10, 25, 50, 75, or 100 µM	Increased cytotoxicity, decreased cell migration, invasion	Decreased MMP 2/9, Akt, NF-κB, c-Jun, AP-1	⁸⁵
MCF-7-memopspheres	10, 20, 30, 40, or 50 µM	Decreased cell survival, targeted berberine was more effective	Decreased ABCC1, ABCC2, ABCC3, ABCG2, Bcl-2, mitochondrial permeability, increased cytochrome c release, caspase 9/3	⁸⁶
MCF-7/106 µM; MDA-MB-231/85 µM	20, 40, 80, 120, or 160 µM; 10, 20, 40, 80, or 120	Decreased cell viability, colony formation, G₁arrest (MCF-7)	Upregulated 1318 (MCF-7), 1662 (MDA-MB-231) downregulated 2079 (MCF-7), 1044 genes (MDA-MB-231), increased CCNG1, CYP1A1, GADD45A, decreased ANGPTL4, CSF1R (MDA-MB-231), CXCR4, increased CYP1A1, GADD45A	⁸⁷
MCF-7; MDA-MB-231	10, 25, 50, 75, or 100 µM	Decreased cell viability, increased apoptosis	Increased ROS, cytochrome c, JNK, AIF, Bcl-2, caspase-3, decreased Δψm	⁸⁸
BT549/16.57 µg/mL; MDA-MB-231/18.52 µg/mL	5, 10, 20, 40, and 80 µM	Decreased colony formation, cell migration, increased apoptosis	Increased caspase-3/9, cytochrome c, Bax, decreased Bcl-2, TGF-β1, MMP-2, DNA DSBs	⁸⁹^,⁹⁰
Hs578	25 or 50 µM	Decreased cell invasion	Decreased IL-8, EGFR, MEK, ERK	⁹¹
MDA-MB-231 MCF-7	20, 40, or 80 µM	Decreased cell proliferation, G₁ arrest	Increased p2^cip1, p27^kip1, p53, p-p53^Ser15, GSK3β, decreased cyclin D1/E, CDK2/4/6, p-Akt^Thr308, total Akt, c-Myc	⁹²
MCF-7; MDA-MB-231	6.25, 12.5, 25, 50 or 100 µM	Decreased cell proliferation, increased apoptosis, necrosis	Decreased EGFR, AKT, ERK1/2, p38 kinases, Akt kinase	⁹³
MDA-MB-468; MDA-MB-231	3, 6, or 12 µM; 6.25, 12.5, or 25 µM	Decreased cell proliferation, S+G₂/M, G₀/G₁ arrest (MDA-MB-468/BT-549 cells)	Decreased cyclin A/D, CDK1/4 (MDA-MB-468/BT-549 cells)	⁹⁴
MCF-7; MCF12A	1, 10 or 100 µM	Decreased cell proliferation, G₀/G₁ arrest, increased MCF-7 death (100 µM)	Increased p53, p21, nucleolar stress, loss of ribosomal protein (RP)L5	⁹⁵
MCF-7; MDA-MB-231	25 or 50 µM	Decreased colony formation, cell migration, invasion, increased apoptosis, G₂/M arrest	Increased miR-214-3p, Bax, decreased secretin	⁹⁶
Cervical cancer
HeLa/4.8 µg/mL L1210/74.6 µg/mL	0.1, 1, 5, 10, 50, 100, or 150 µg/mL	Decreased cell growth, S-phase fraction, G₂/M arrest, increased apoptosis	Increased DNA fragmentation	⁹⁷
CaSki	50, 100, or 150 µM	Decreased cell viability, increased apoptosis	Increased ROS, Ca²⁺, p53, Bax, GADD153, caspase-3, decreased Δψm	⁹⁸
SiHa; HeLa	1-250 µg/mL	Decreased cell viability, growth, increased apoptosis	Increased caspase 3, PARP, p53, Rb, decreased AP-1, HPV oncogenes, hTERT, c-Fos, E6, E7 l	⁹⁹
HeLa/283 µM	150, 175, 200, 225, 250, 275, or 300 µM	Decreased cell viability, cell migration, wound healing, increased apoptosis, DNA fragmentation	Decreased tubulin network, Δψm, HDAC1/2, HPV-18 E7, CDKs, cyclin, NF-κB, SMAD4, increased p53	¹⁰⁰
HeLa	1, 2, 4, 6, or 8 µg/mL	Decreased colony formation	Increased LDH, DNA strand breaks, decreased glutathione transferase	¹⁰¹^,¹⁰²
SiHa; HeLa; CaSki	5, 10, 15, or 20 µM	Decreased cell viability, motility, invasion	Decreased u-PA, MMP-2, NF-κB, TGF-β1, p38, FAK, paxillin, Src, Snail-1, C23, β-catenin, increased TIMP-2	¹⁰³
SiHa; CaSki	150, 200, or 250 µM	Decreased cell viability, cell migration, invasion, EMT, increased apoptosis	Increased Bax, caspase 3, E-cadherin, KRT17, decreased Bcl-2, MMP-9, N-cadherin, vimentin	¹⁰⁴
Leukemia
HL-60	5, 10, 25, or 50 µg/mL; 10, 50, or 100 µM	Decreased cell viability, increased apoptosis, DNA fragmentation, G₂/M arrest	Complexed with DNA, decreased nucleophosmin/B23 mRNA, telomerase, NAT, 2-aminofluorene (AF)-DNA adduct, N-cadherin, increased E-cadherin	¹⁰⁵^-¹⁰⁸
HL-60; WEHI-3 (mouse)	5, 15, 30, or 60 µM	Increased cytotoxicity, apoptosis, G₀/G₁, G₂/M arrest	Increased Ca⁺², caspase-3, Bax, cytochrome c, Wee1, 14-3-3σ, decreased Δψm, Bcl-2, Cdc25c, CDK1, cyclin B1, Src	¹⁰⁹^,¹¹⁰
HL-60	2.5, 5, 10, 20, 40, 80, or 100 µM; 20, 40, 60, 80, or 100 µM	Decreased cell viability, migration, increased apoptosis, chromatin condensation, DNA fragmentation	No change in CXCR-4, increased PARP, caspase 3/8, ERK, p38	¹¹¹^,¹¹²
EU4	1, 10, 50, or 100 µM	Increased cytotoxicity, apoptosis,	Increased caspase 3/9, PARP, Bax, miR-24-3p, PIM-2, decreased XIAP, MDM2	¹¹³^,¹¹⁴
EU6	12.5, 25, 50, or 100 µM	Decreased cell viability, increased autophagy	Decreased AKT/mTORC1, p-S6, pAKT	¹¹⁵
MM.1S/15-25 µM; RPMI-8266	25, 50, 75, and 100 µM	Decreased cell viability, colony formation	Increased p16^INK4A, p73, UHRF1 degradation	¹¹⁶
Prostate cancer
DU145; PC-3; LNCaP	10-100 µM; 25, 50, 75, or 100 µM (PC-3)	Decreased cell proliferation, increased cell death, DNA fragmentation, apoptosis, G₀/G₁ arrest	Decreased cyclins D1/2E, CDK 2/4/6, Δψm, increased p21^/Cip1, p27^/Kip1 Bax, caspase 9/3, PARP, ROS, cytochrome c, Smac/DIABLO	¹¹⁷^–¹¹⁸
PC-3; LNCaP	5, 10, 20, 50, or 100 µM	Decreased cell growth, increased apoptosis, G₀/G₁ arrest	Increased Bax, caspase 3	¹¹⁹
LnCaP; PC-3	20, 100, or 200 µM	Decreased cell growth, increased apoptosis, G₁arrest	Decreased prostate-specific antigen, EGFR	¹²⁰
LNCaP; LAPC-4; 22Rv1; C4-2B, PC-3	1.56, 3.125, 6.25, 12.5, 25, 50, or 100 µM	Decreased cell proliferation, increased apoptosis	Decreased androgen receptor	¹²¹
RM-1 (mouse); PC-3	5, 10, 20, or 50 µM	Decreased cell proliferation, increased apoptosis, G₀/G_1, G₂/M arrest	Increased DNA DSBs, p53, p21, ATM/Chk1	¹²²^,¹²³
LNCaP; PC-82	1, 5, 25, 50, or 100 µM	Decreased cell viability, increased apoptosis, necrosis	Increased cyclophilin-D, p53 translocation to mitochondria	¹²⁴
PC-3; DU145; LNCaP	10, 25, 50, 75 µM	Decreased cell proliferation, motility, migration, EMT	Decreased vimentin, PDGFRβ, COL1A2, BMP7, TGF-β, NODAL, WNT1, Snail	¹²⁵
22Rv1	12.5, 25, or 50 µM	Decreased cell proliferation, increased apoptosis	Decreased C3 enzyme	¹²⁶^,¹²⁷
Ovarian cancer
OVCAR-3/10 µM; SKOV-3/100 µM	1, 10, or 100 µM	Decreased cell proliferation, G₂/M, S-arrest	Increased p27	¹²⁸
FTE187; A2780; HEY; HO8910	5, 10, or 20 µM	Decreased proliferation, colony formation, increased apoptosis	Increased ROS, PARP, ATM, p53, DNA DSBs, decreased RAD51, homologous recombination DNA repair	¹²⁹
SKOV3/9.2 µM	5, 10, 30, 50 or 100 µM	Decreased cell proliferation, cell migration, invasion	Decreased hERG1	¹³⁰
SKOV-3/50 µM; TOV-21G/25 µM; MDAH-2774/32 µM	12.5, 25, 50 and 100 µM	Decreased cell viability, colony formation, cell migration, invasion, increased cytotoxicity,	Decreased EGFR, ErbB2, cyclin D1, MMP 2/9, VEGF, PI3K, Akt	¹³¹
SKOV3/78.52 µM; 3AO/125.8 µM	2.5, 5, 10, 20, 40, 80, 160, or 320 µM	Decreased cell proliferation, cell migration, invasion	Increased miR-145, TET3, HK2, decreased MMP16, Warburg effect,	¹³²^,¹³³
Osteosarcoma
U2OS; Saos-2; HOS	1, 5, 10, 20, or 50 µg/mL	Decreased cell proliferation, increased apoptosis, G₁ arrest	Increased p53, p21, p27, Bax, PUMA, FAS, DNA DSBs, decreased cyclin E/D1	¹³⁴
U2OS	12.5, 25, or 50 µg/mL	Decreased cell proliferation, colony formation, increased apoptosis	Decreased PI3k, AKT, Bcl2, procaspase-3, increased PARP, Bax	¹³⁵
Saos-2; MG-63	10, 20, 40, 60, 80, or 100 µg/mL	Decreased cell proliferation, increased apoptosis	Decreased caspase 1, IL-1β	¹³⁶
MG-63	20, 40, 60, or 80 µM; 5, 10, 20, 40, or 80 µM	Increased cytotoxicity, apoptosis, DNA fragmentation, decreased colony formation, EMT	Increased DNA DSBs, decreased MMP-2, N-cadherin, vimentin, fibronectin, β-catenin, snail, EZH2	¹³⁷^,¹³⁸
Lung cancer
A549	2.5, 5.0, 10, 20, 40, 80, or 100 µM	Decreased cell proliferation, cell migration, invasion, G₁arrest	Increased TIMP-2, Akt, CREB, MAPK, decreased MMP-2, uPA, NF-κB, cFos, cJun, cyclin B1	¹³⁹^,¹⁴⁰
A549; H1299	25, 50, 75, or 100 µM	Decreased cell proliferation, increased DNA fragmentation, apoptosis	Increased Bax, Bak, caspase 3, decreased Δψm, Bcl-2, Bcl-xL	¹⁴¹
H460/5 µM	0.1, 1, 5, or 10 µM	Decreased cell growth, G₀/G₁ arrest	NR	¹⁴²
A549	20, 40, 80, or 160 µM; 6.25, 12.5, 25, 50, or 100 µM	Decreased cell viability, cell migration, invasion, EMT, increased apoptosis, G₀/G₁ arrest	Increased E-cadherin, p21, ROS, p21^WAF1, IL6, IL1β, TNF-α, p-NF-κB, mTOR, decreased vimentin, Snail-1, Slug, cyclin A/1/2/B1, NF-κB	¹⁴³^-¹⁴⁵
A549	20, 40, 80, 100, 120, 140, 160, 180, or 200 µmol/mL	Decreased cell viability, increased nuclear fragmentation, apoptosis, G₀/G₁ arrest	Increased ROS, p21, p53, Bax, cytochrome c, caspase 8/9/3, decreased Δψm, Bcl-xL, Bcl-2, TNF-α, COX-2, MMP-2, & MMP-9, HDAC 1/2/4	¹⁴⁷
A549	30, 60, 90, 150, or 200 µM	Decreased cell proliferation, increased apoptosis	Increased Bax, decreased MMP-2, Janus kinase-2, VEGF, NF-κB, AP-1	¹⁴⁸
A549; PC9	20, 40, 60, 80, 100, 120, 140, or160 µM	Decreased cell proliferation, colony formation, increased apoptosis	Increased Bax, TF, JNK, p38MAPK, decreased Bcl2, miR-19a	¹⁴⁹
NCI-H460/30.3 µM; A549/44.5 µM; NCI-H1299/43.8 µM	10, 20, 40 or 80 µM	Decreased cell proliferation, colony formation, increased apoptosis	Increased DNA DSBs, decreased TOP2B, Sin3A	¹⁵⁰
Pancreatic cancer
BxPC-3/62.8 µM; HPDEE6E7c7	10, 50, 100, 150, or 200 µM	Decreased cell survival, increased apoptosis, DNA damage	Increased caspase 3/7, AIF, 234 genes, decreased 33 genes related to BRCA1-mediated DNA damage response, G₁/S, G₂/M cell cycle checkpoint regulation, p53 signaling	¹⁵¹
PANC-1/15 µM; MiaPaCa-2/10 µM	NR; 1, 5, 7, 10, or 15 µM	Decreased side population of cells, cell proliferation, increased apoptosis, G₁ arrest	Decreased SOX2, POU5F1, NANOG, increased ROS	¹⁵²^,¹⁵³
PANC-1, MiaPaCa-2	0.15, 0.3, 1.5, 3, or 6 µM	Decreased cell proliferation, G₁ arrest	Decreased DNA synthesis, Δψm, ATP, mTORC1, ERK, increased AMPK, acetyl-CoA carboxylase	¹⁵⁴
PANC-1	1, 5, 7.5, 10, 15, or 30 µM	Decreased cell proliferation, migration, increased apoptosis	Decreased TNF-α, K-ras, 3726 genes, increased 3726 genes, CDKN2A, glycolysis	¹⁵⁵
Renal cancer
ACHN	10, or 20 µmol/L	Decreased cell proliferation	Decreased c-Fos	¹⁵⁶
G401	5, 10, 20, or 50 µM	Decreased cell proliferation	Increased p21, p27, AMPK, T-ACC, mTOR, S6 kinase, WTX, decreased cyclin E	¹⁵⁷
Bladder cancer
T24	0.8, 8, 80, 800, or 1,600 µM	NR	Decreased NAT	¹⁵⁸
BIU-87; T24	1, 5, 10, 25, 50, 75, or 100 µM	Decreased cell viability, increased apoptosis, G₀/G₁ arrest	Increased caspase-3/9, H-Ras, c-fos	¹⁵⁹
T24	10, 25, or 50 µg/mL	Decreased cell migration, invasion	Decreased heparanase	¹⁶⁰
Thyroid cancer
8505C/10 µM; TPC1/10 µM	1, 10, or 100 µM	Decreased cell growth, G₀/G₁ arrest	Increased p-27	¹⁶¹
FTC-133; 8305C	10, 25, 50, or 100 µM	Decreased cell viability, increased apoptosis, DNA fragmentation	Increased caspase 3, p53, p27	¹⁶²
TT/1 µg/mL	0.4, 0.8, 1.6, 3.2 and 6.4 µg/mL	Decreased cell viability, S-/G₂ phase fraction, increased apoptosis, G₁ arrest	Increased caspase 3, decreased RET, Akt, Bcl2, Rb, E2F1, cyclin E	¹⁶³
C643; OCUT1; TPC1	10, 20, 40, 80, or 160 µM	Decreased cell proliferation, increased apoptosis, arrested G₀/G₁ phase	Decreased Δψm, cyclin E1, CDK2, vimentin, p-AKT1, p-AKT1, p-ERK, p-JNK, PI3K, p-Akt, Akt, Nrf2, increased caspase 3, Bax, p21, p-ERK, p-P38, p-JNK	¹⁶⁴
K1	10, 40, or 80 µmol/L	Decreased cell proliferation	Decreased PI3K, p-Akt/Akt, Nrf2	¹⁶⁵

NR, not reported; ACC, acetyl-CoA carboxylase; ACL, ATP citrate lyase; AIF, apoptosis-inducing factor; AMPK, AMP-activated protein kinase; AP, activator protein; Apaf, apoptotic protease activating factor; ATF, activating transcription factor; ATM, ataxia telangiectasia mutated; ATP, adenosine triphosphate; Bad, Bcl-2 agonist of cell death; Bak, Bcl2-antagonist/killer; Bax, Bcl2 associated X apoptosis regulator; Bcl, B-cell lymphoma; BID, BH3 interacting domain death agonist; BMP, bone morphogenetic protein; C/EBP, CCAAT/enhancer-binding protein; CCR, C-C chemokine receptor type; Cdc, cell division cycle; CDK, cyclin-dependent kinase; CDKIs, cyclin-dependent kinase inhibitors; COX, cyclooxygenase; CXCR, C-X-C motif chemokine receptor; DDIG, DNA damage-inducible gene; DSBs, double-strand breaks; EBNA1, Epstein–Barr nuclear antigen 1; EGFR, epidermal growth factor receptor; EMT, epithelial-to-mesenchymal transition; ER, endoplasmic reticulum; ERK, extracellular signal-regulated kinase; ETIF, eukaryotic translation initiation factor; FADD, FAS-associated death domain; FAK, focal adhesion kinase; FASN, fatty acid synthase; FoxO3a, forkhead box O3a; GADD, growth arrest and DNA damage-inducible genes; GLP, glucose-regulated protein; GSH, glutathione; HDAC, histone deacetylase; GSK, glycogen synthase kinase; hERG, human ether-à-go-go-related gene; HIF, hypoxia-inducible factor; IHCBP, immunoglobulin heavy chain binding protein; IL, interleukin; JNK, c-Jun N-terminal kinase; LC3, microtubule associated proteins 1A/1B light chain 3B; LDH, lactate dehydrogenase; MEK/MAPK, mitogen-activated protein kinase; MMP, matrix metalloproteinase; MRP, mitochondrial ribosomal protein; mTOR, mechanistic target of rapamycin; NADPH, nicotinamide adenine dinucleotide phosphate hydrogen; NAG, nonsteroidal anti-inflammatory drug activated gene; NAT, N-acetyltransferase; NCAM, neural cell adhesion molecule; Nestin, neuroectodermal stem cell marker; NF-κB, nuclear factor kappa B; Notch, neurogenic locus notch homolog protein; PARP, poly(ADP-ribose) polymerase; PCNA, proliferating cell nuclear antigen; PTCD, pentatricopeptide repeat domain; PTTG, pituitary tumor transforming gene; RAF, rapidly accelerated fibrosarcoma; Ras, retrovirus-associated DNA sequences; ROS, reactive oxygen species; SCAP, SREBP cleavage-activating protein; Skp, S-phase kinase-associated protein; SQSTM1, sequestosome-1; SREBP, sterol regulatory element-binding protein; STAT, signal transducer and activator of transcription; TCF, T-cell factor; TGF, transforming growth factor; TIF, translation initiation factor; TRAIL, tumor necrosis factor-(TNF) related apoptosis-inducing ligand; TUFM, Tu translation elongation factor; ULK, Unc-51 like autophagy activating kinase; VASP, vasodilator-stimulated phosphoprotein; VEGF, vascular endothelial growth factor; VEGFR, vascular endothelial growth factor receptor; Wif, Wnt inhibitory factor; Wnt, wingless-type MMTV integration; WTX, Wilms tumor gene on X chromosome; XIAP, X-linked inhibitor of apoptosis protein; Δψm, mitochondrial membrane potential.

Brain cancer

Treatment of human glioblastoma T98G cells with 50, 75, 100, 150, and 200 µg/mL berberine reduced cell proliferation and increased cell death in a concentration-dependent manner with an IC₅₀ of 134 µg/mL. Berberine arrested cells in the G₁ phase of the cell cycle, owing to a rise in p27 and decline in cyclin-dependent kinase (CDK) 2/4 and cyclin D/E (Table 1). Berberine triggered apoptosis in T98G cells by elevating the Bcl-2-associated X (Bax)/B cell lymphoma 2 (Bcl-2) protein ratio, in addition to procaspase-9, caspase 9/3, and poly(ADP-ribose) polymerase (PARP), and by disrupting the mitochondrial membrane potential (Δψm). T98G cells treated with berberine had increased reactive oxygen species (ROS), intracellular Ca²⁺ generation, phosphorylation of endoplasmic reticulum (ER) stress-associated ER kinase, eukaryotic translation initiation factor-2α (ETIF-2α), glucose-regulated protein (GRP)78, immunoglobulin heavy chain binding protein (IHCBP), CCAAT/enhancer-binding protein (C/EBP)-homologous protein, growth arrest and DNA damage-inducible gene 153 (GADD153), and activation of caspase 3.^30,31

Treatment of C6 rat glioma cells with 50, 100, 200, and 500 µM berberine stimulated morphological changes and increased apoptosis (Table 1). Berberine upregulated the expression of Wee1 and suppressed cyclin B, CDK1, and cell division cycle (Cdc)25c, thereby arresting the cells in the G₂/M phase of the cell cycle. Berberine triggered mitochondrial cytochrome c release and elevated caspase 9/3/8, DNA fragmentation, Bax, GADD153 and GRP78, but suppressed Bcl-2 and reduced Δψm.³²

Treatment of human glioblastoma U87, U251, and U118 cells with 15, 25, 50, 100, and 150 µM berberine reduced cell viability depending on the length of treatment time and drug concentration, and the IC₅₀ values were 21.76, 9.79, and 35.54 µM, respectively. Berberine increased senescence in U87 cells, and in U251 cells (lacking PTEN) up to day seven when the S-phase cells were minimal (Table 1). Berberine elevated DNA double-strand breaks (DSBs) indicated by a rise in phosphorylated H2A histone family member X (γ-H2AX) in U251 cells but not in U87 cells. Berberine reduced the expression of epidermal growth factor receptor (EGFR) as well as the phosphorylation of RAF, mitogen-activated protein kinase kinase (MEK), and extracellular signal-regulated kinase (ERK) in U87 and U251 cells.³³ Exposure of U87, U251, and P3 human glioma and astrocyte cells to 50, 100, 150, 200, and 250 µM berberine decreased cell proliferation in a concentration-dependent manner, but had a lesser effect on human astrocytes. Berberine treatment reduced the migration and invasion of U87 and U251 cells and induced apoptosis by upregulating Bax, cytochrome c release, caspase 3 activation, and reducing Bcl-2 protein expression. Berberine increased oxidative phosphorylation and reduced markers of glycolysis: adenosine triphosphate (ATP), L-lactate, and lactate dehydrogenase (LDH; Table 1). Berberine increased concentration-dependent autophagy by upregulating microtubule-associated protein 1A/1B-light chain 3 (LC3)-II and downregulating sequestosome-1 (SQSTM1)/p62 proteins. Berberine elevated AMP-activated protein kinase (AMPK), Beclin-1, and phosphorylated Unc-51-like autophagy activating kinase 1 (ULK-1), a downstream target for mechanistic target of rapamycin (mTOR) depending on the concentration in U87 and U251 cells.³⁴ Berberine (50 or 100 µM) induced the death of U251 and U87 cells and inhibited cell migration, production of interleukin (IL)18 and IL1β, and epithelial-to-mesenchymal transition (EMT) by reducing the activation of ERK1/2 depending on its concentration (Table 1).³⁵

Exposure of Na2 (mouse neuroblastoma) and IMR-32 (human neuroblastoma) cells to 10 and 20 µg/mL berberine reduced cell proliferation, increased cell differentiation, and alleviated changes in stemness-related markers of cancer including CD133, β-catenin, n-myc, sex determining region Y-box 2 (Sox2), Notch2, and neuroepithelial stem cell protein (Nestin). Berberine arrested cells in the G₀/G₁ phase of the cell cycle, inhibited CDK-2/4 and cyclin D1/E, enhanced the Bax/Bcl-2 ratio, and increased p27 and p53 expression (Table 1). Berberine exhibited antimigratory potential by inducing neural cell adhesion molecule (NCAM), attenuating its polysialylation, and downregulating matrix metalloproteinase (MMP)-2/9. Berberine treatment enhanced the epithelial marker laminin, Smad, and heat shock protein (Hsp)70 levels and inhibited EMT by attenuating phosphoinositide 3-kinase (PI3K)/Akt and Ras-Raf-ERK signaling and upregulating p38-mitogen-activated protein kinase (MAPK; Table 1).³⁶

Human glioma cells (T98G, LN18, LN229, C6, and SHG 44) exposed to 25, 50, 100, 200, and 400 mg/L berberine for 24, 48, and 72 h had reduced cell viability in a time- and concentration-dependent manner. An oncosis-like death was triggered, characterized by cell swelling, vacuolization of cytoplasm, plasma membrane blebbing, and intracellular ATP decline. Berberine stimulated autophagy and decreased the rate of oxygen consumption and mitochondrial respiration, and phosphorylated ERK1/2 (p-ERK1/2) in glioma cells. Berberine induced necrosis and apoptosis as indicated by annexin-V fluorescein isothiocyanate (FITC)/ propidium iodide (PI) staining but the levels of cleaved caspase/caspase 3 and cleaved PARP remained unchanged. Berberine depleted ATP, glutathione (GSH), and reduced nicotinamide adenine dinucleotide phosphate (NADPH), and decreased levels of ERK1/2 in a concentration-dependent manner (Table 1).³⁷ LN229 and U251 cells treated with 5, 10, 20, 40, 80, 160, and 320 µM berberine had decreased cell proliferation with IC₅₀ values of 40 and 30 µM, respectively. Treatment with berberine also increased apoptotic cell death, reduced Bcl-2 expression, elevated Wnt inhibitory factor (Wif)-1 transcription, and suppressed β-catenin/T-cell factor (TCF)-4 transcription and Wnt/β-catenin signaling.³⁸ Treatment of U87MG cells with 10, 25, 100, and 250 µM berberine for 24, 48, and 72 h decreased cell viability and proliferation in a concentration- and time-dependent fashion and stimulated apoptosis independent of AMPK activity, but the levels of total caspase 3 and p-p53 remained unchanged (Table 1). Berberine increased oxidative stress in U87MG cells by increasing reactive oxygen species, thiobarbituric acid reactive substance, and protein carbonylation.³⁹

Head and neck cancer

Exposure of oral squamous carcinoma KB cells to 1, 10, and 100 µM or 0.01, 0.1, and 1 µg/mL berberine caused a time- and concentration-dependent decline in cell viability and survival, increased levels of apoptosis and caspase 3, and inhibited the expression of cyclooxygenase (COX)-2, myeloid-cell leukemia 1 (Mcl-1), and Akt (Table 1).⁴⁰ Additionally, berberine elevated DNA fragmentation and upregulated expression of Fas ligand (FasL), proapototic Bax, Bcl-2 agonist of cell death (Bad), and apoptotic protease activating factor 1 (Apaf-1), increased activated caspase 3/7/8/9 and PARP, and downregulated anti-apoptotic Bcl-2 and Bcl-xL in KB cells. Berberine increased phosphorylation of p38 MAPK and decreased MMP-2 and MMP-9 expression, and suppressed cell migration (Table 1).⁴¹ Treatment of HSC-3 cells with 5, 10, 25, 50 and 75 µM berberine resulted in a concentration- and time-dependent decline in cell growth and DNA synthesis, and increased apoptosis indicated by PI and annexin V staining and caspase 3 activation. Berberine arrested HSC-3 cells in the G₀/G₁ phase of the cell cycle, triggered ROS formation, increased cytochrome c and Ca²⁺ release, increased p53 expression, and reduced Δψm and Bcl2 in HSC-3 cells (Table 1).⁴²

Exposure of SCC-4 tongue carcinoma cells to 65.2 and 125 µM berberine for 24 and 48 h decreased cell viability, cell migration, and invasion by attenuating the expression of urokinase-type plasminogen activator (u-PA), focal adhesion kinase (FAK), phosphorylated Janus kinase (pJNK), pERK, inhibitor of NF-κB kinase (IKK), nuclear factor kappa B (NF-κB), and MMP-2/9 (Table 1). Berberine increased ROS formation, Ca²⁺ release in the cytosol, DNA damage (comet assay), and apoptosis depending on its concentration. Berberine reduced Δψm, caused the release of cytochrome c, increased the proapoptotic proteins Bax, Bad and Bak, Apaf-1, Fas, Fas-associated death domain (FADD), and activated caspase 8/9 and downregulated antiapoptotic Bcl2 and Bcl-xL in SCC-4 cells. Berberine treatment also upregulated the mRNA levels of apoptosis inducing factor (AIF), caspase 8/9/3 and endonuclease G (EndoG; Table 1).^43,44

Nasopharyngeal carcinoma (NPC) 5-8F cells treated with 2.5, 5, 10, 20, 40, 80, and 100 µM berberine had a concentration-dependent reduced cell viability and increased LDH release, especially after 40 µM. Berberine inhibited the invasion and motility of 5-8F cells in a time and concentration-dependent manner by inhibiting filopodia formation and downregulating Ezrin phosphorylation at Thr⁵⁶⁷ (Table 1).^45,46 NPC CNE-1 cells treated with 2.5, 5, 10, 20 or 40 µg/mL berberine hydrochloride had reduced cell viability in a concentration- and time-dependent manner and diminished cell migration, invasion, and EMT through decreased Twist expression. Berberine triggered apoptosis and activation of caspase 3 in CNE-1 cells (Table 1).⁴⁷ NPC HONE1 cells treated with 12.5, 25, 75, 150, and 300 µM berberine reduced cell proliferation in a concentration-dependent manner and its distribution in the cells was also dependent on the concentration of berberine treated cells. Berberine also reduced cell migration, invasion, RhoGTPases, formation of stress fibers (at low concentrations), and arrested cells in the G₂/M phase of the cell cycle by activating Cdc2 (p-Cdc2; Tyr¹⁵) in addition to reducing the expression of p-histone 3. Berberine triggered apoptosis and the activation of PARP and caspase 3/9.⁴⁸ HONE1 and HK1-EBV cells treated with 25, 50, 100, and 200 µM berberine exhibited a reduction in cell viability in a concentration-dependent manner and downregulation of Epstein–Barr nuclear antigen 1 (EBNA1) and signal transducer and activator of transcription 3 (STAT3) at the mRNA level (Table 1).⁴⁹

The exposure of esophageal carcinoma cells KYSE-30 to 1, 2, 4, 8, 16, 32, 64, 128, or 256 µM berberine decreased cell viability and cell migration in a time- and concentration-dependent way by significantly reducing the expression of chemokine receptor 7 (CCR7) and C-X-C chemokine receptor type 4 (CXCR4; Table 1).⁵⁰ Likewise, KYSE-70 and SKGT4 cells treated with 20, 40, 60, 80, and 100 µM berberine suppressed cell growth in a concentration- and time-dependent manner, increased apoptosis, and arrested cells in the G₂/M phase of the cell cycle. Berberine treatment repressed Akt (Ser⁴⁷), mTOR (Ser²⁴⁴⁸) and p70S6K (Thr³⁸⁹) phosphorylation but increased phosphorylation of AMPK at Thr¹⁷² (Table 1).⁵¹ Berberine suppressed the microRNA-212-induced cell migration, invasion, and EMT in KYSe-450, TE-1, and Eca109 cells (Table 1).⁵²

Exposure of head and neck squamous cell carcinoma (HNSC) FaDu cells to 12.5 or 25 µM berberine induced cytotoxicity, whereas the viability of primary human normal oral keratinocytes was unaffected. Berberine elevated nuclear condensation, apoptosis, FasL and TNF-related apoptosis-inducing ligand (TRAIL), activation of caspase 8/7/3, and PARP in FaDu cells. Berberine triggered the mitochondria-dependent apoptotic signaling pathway by elevating p53 and proapoptotic factors including Bax, Bad, Apaf-1, caspase-9, and downregulating Bcl-2 and Bcl-xL. Berberine inhibited FadU cell migration by downmodulating vascular endothelial growth factor (VEGF), MMP-2/9, and suppressing the MAPK pathway (Table 1).⁵³ HNSC SSC-15 and SSC-4 cells treated with 200, 250 or 300 µM berberine had significantly reduced cell viability depending on the concentration, with IC₅₀ values of 235 and 242 µM for SSC-4 and SSC-15 cells, respectively. SSC-15 cells exposed to 100, 150, 200, and 250 µM berberine had significantly reduced clonogenic potential that was concentration-dependent, and autophagy was stimulated by the conversation of microtubule-associated protein 1 light chain 3β-I (LC3-I) to microtubule-associated protein 1 light chain 3β-II (LC3-II), a distinctive hallmark of autophagosome maturation. Berberine drastically reduced SQSTM1/p62 expression and triggered apoptosis by activating caspase 3 and PARP1 cleavage at higher concentrations. Berberine upregulated tumor suppressor microRNA (miRNA)-155 and downregulated oncogenic miR-21 in SSC-15 cells (Table 1).⁵⁴

Gastrointestinal cancer

Berberine at 5, 10, 25, and 50 µM reduced cell viability and increased apoptosis in a concentration-dependent manner in SW620 cells, and 50 µM berberine activated caspase 3/8, PARP cleavage, and increased cytochrome c release with a subsequent decline in BH3 interacting domain death agonist (Bid), and antiapoptotic factors cellular inhibitor of apoptosis 1 (c-IAP1), Bcl-2, and Bcl-xL expression. Berberine increased ROS generation, phosphorylation of JNK and p38 MAPK, and increased levels of phospho-c-Jun, FasL and t-Bid levels due to JNK and p38 MAPK signaling (Table 1).⁵⁵ Treatment of HCT-116 and SW480 cells with 1, 10, and 50 µM berberine for 1, 2, and 4 days reduced cell proliferation concentration-dependently and SW480 cells responded more quickly compared to HCT-116 cells. Berberine elevated the expression of nested antisense gene 1 (NAG-1) protein in HCT and CaCo-2 cells, and activating transcription factor 3 (ATF-3) in HCT-116 and SW480 cells depending on p53 activation. Berberine increased apoptosis and caspase 3/7 activity in HCT-116 cells due to activation of NAG-1 and ATF-3 genes (Table 1).⁵⁶ SNU5 cells treated with 25, 50, 75, and 100 µM berberine showed a reduction in cell viability and cell invasion in a concentration-dependent manner. Berberine treatment also enhanced ROS formation up to 6 h and downregulated the protein expression of NF-κB and MMP-1/2/9, but not MMP-7, which remained unaltered at the mRNA level (Table 1).⁵⁷

Berberine treatment (1, 2, 5, 10, 20, 50, or 100 µM) reduced cell viability and cell migration and increased ROS generation, activated AMPK, and significantly decreased integrin β1 levels, phosphorylation of Src, FAK, and p130Cas in SW480 and HCT116 cells (Table 1).⁵⁸ Exposure of SW480 cells to 0.5, 1, 2.5, 5, 10, 25, and 50 µM berberine decreased cell proliferation depending on the concentration and length of treatment time, and did not induce cytotoxicity in normal CCD-CoN112 colon cells up to 200 µM. Berberine arrested cells in the G₀/G₁ phase of the cell cycle, depleted Δψm, and decreased the expression of p21 (CDK), cytochrome c, and Bax/Bcl2. Berberine activated caspase 9/3/8, AIF, and cleaved PARP, and reduced VEGF, NF-κB, and COX-2 expression; however, survivin and TRAIL expression remained unaffected (Table 1).⁵⁹

HCT116 cells treated with berberine (5, 10, 20, 40, and 80 µM) showed reduced proliferation and elevated apoptosis in a concentration-dependent fashion, cells were arrested in the G₁ phase of the cell cycle, and mRNA expression of β-catenin was inhibited in both the nucleus and cytoplasm (Table 1).⁶⁰ Exposure of HCT-8 cells to 0.03, 0.06, 0.12, 0.24, or 0.47 mM berberine for 12, 24, 48, and 72 h resulted in reduced cell proliferation in a concentration and time-dependent manner and cells were arrested in the S-phase of the cell cycle. Berberine increased tumor necrosis factor alpha (TNF-α), alkaline phosphatase, acid phosphatase, the LDH levels, the expression of FasL, p53, and prohibitin (PHB), and mRNA levels of Fas, FasL, and Bax, as well as the activation of caspase-3. Berberine reduced the expression of Bcl-2, procaspase-3, and vimentin (Table 1).⁶¹ Treatment of HCT116 and KM12C cells with 6.25, 12.5, 25, and 50 µM berberine reduced cell proliferation and colony formation in a concentration-dependent manner by inhibiting glucose uptake as indicated by the mRNA suppression of glucose transporter 1 (GLUT1), lactate dehydrogenase A, and hexokinases 2 (HK2), in addition to the expression of hypoxia inducible factor 1 (HIF1) protein and mTOR signaling; however, analysis by reverse transcription-polymerase chain reaction (RT-PCR) did not show any change in HIF1 mRNA (Table 1).⁶² Similarly, 1, 10, and 100 µM berberine depleted cell viability, increased levels of apoptosis, activated caspase-3, integrin β4 (ITGβ4), and programmed cell death 4 (PDCD4) protein expression, and inhibited miR-21 mRNA expression in HCT116 cells (Table 1).⁶³

Berberine (6.25, 12.5, 25, and 50 µM) concentration-dependently reduced cell proliferation and colony formation and arrested DLD-1 and Caco-2 cells in the G₀/G₁ phase of the cell cycle and also depleted the S-phase fraction. Berberine also decreased glucose-induced lipogenesis in these cells and inhibited the mRNA expression of acetyl-CoA carboxylase (ACC), ATP citrate lyase (ACL), and fatty acid synthase (FASN), and decreased sterol regulatory element-binding protein-1 (SREBP-1) activation, SREBP cleavage-activating protein (SCAP) expression, and β-catenin signaling (Table 1).⁶⁴

Exposure of BGC-823 and SGC7901 cells to 10, 25, 50, 75, and 100 µM berberine slowed cell proliferation in a time- and concentration-dependent manner, and also elevated apoptosis, expression of PARP, and caspase-3 while reducing Δψm. The BCG-823 cells were more sensitive to berberine than SGC7901 cells. Berberine downregulated the Akt/mTOR/p70S6/S6 pathway in BGC-823 cells indicating that the Akt-related mitochondrial pathway may be involved in berberine-induced apoptosis (Table 1).⁶⁵ Exposure of BGC-823 cells to 14, 21, 32, 48, 72, and 108 µM berberine for 6, 12, 24, 36, and 48 h attenuated cell proliferation depending on the length of treatment time and concentration with an IC₅₀ value of 24.16 ± 1.03 µM (48 h). Berberine (25 µM) induced autophagy, increased the number of autolysosomes, increased the expression of Beclin-1, LC3-II, and p-ULK1, and attenuated the phosphorylation of Akt, ERK, JNK, and p38 depending on the treatment duration. (Table 1).⁶⁶

Treatment of SNU-1 neoplastic and GES-1 non-cancerous cells with 6.25, 12.5, 25, 50, 100, and 200 µM berberine induced cytotoxicity and inhibited cell migration and invasion in a concentration-dependent manner, and its effect was more pronounced in SNU-1 cells (IC₅₀ of 30 µM) than in GES-1 cells (IC₅₀ of 120 µM). Berberine triggered apoptosis, activation of caspase-3/8/9, and repressed the activation of NF-κB depending on its concentration in SNU-1 cells (Table 1).⁶⁷ Exposure of Caco-2 and LoVo cells to 10, 20, 40, 60, and 80 µM berberine concentration-dependently reduced cell viability and colony formation with IC₅₀ values of 39.87 and 23.27 µM for Caco-2 and LoVo cells, respectively. Berberine increased levels of cleaved-PARP and activated caspase 3 but did not decrease cyclin D1 expression. Proteomic profiling revealed that 503 and 277 proteins were differentially expressed (DEPs) in Caco-2 and LoVo cells, out of 8051 identified proteins, and there was an overlap of 83 downregulated DEPs. Analysis of citrate synthase (CS), Tu translation elongation factor (TUFM), pentatricopeptide repeat domain 3 (PTCD3), and mitochondrial ribosomal protein L48 (MRPL 48) showed a decline, whereas CS protein expression was greater in Caco-2 and LoVo cells than in normal specimens (Table 1).⁶⁸ Treatment of LoVo cells with 1.25, 2.5, 5, 10, 20, 40, 80, or 160 µM berberine for 24, 48, and 72 attenuated cell growth and colony formation in a concentration-dependent manner with an IC₅₀ of 40.8 ± 4.1 µM. Berberine arrested the cells in the G₂/M phase of the cell cycle and inhibited the protein expression of cyclin B1, Cdc2, and Cdc25c in addition to DNA and protein synthesis (Table 1).⁶⁹

Liver cancer

Human hepatocellular carcinoma (HCC) HepG2 cells treated with 1–50 µM or 5, 25, 50, 100, and 200 µM or 10, 50 and 100 µM berberine for 12, 24, and 48 h berberine have shown a concentration-dependent decline in cell growth through the stimulation of apoptosis, and cells were arrested in the S- and G₂/M phases of the cell cycle. There was also reduced glucocorticoid receptor expression, α-fetoprotein secretion, and decreased levels of specificity protein 1 (SP1), cyclin D1, Bcl-2 and NF-κB (Table 1).^70–72 Berberine (3.125, 6.25, 12.5, 25, 50, and 100 µM for 24 or 48 h) depleted cell viability depending on the length of treatment time and concentration in HepG2, SMMC-7721, and Bel-7402 HCC cells when compared to normal hepatocytes (HL-7702 cells). Berberine increased apoptosis, the ratio of Bax/Bcl-2, activation of caspase 9/3, phosphorylation of AMPK and Akt and cytochrome c released from the mitochondria (Table 1).⁷³ Berberine stimulated the expression of miR-23a in MHCC97L and PLC/PRF/5 HCC cells depending on its concentration and it transcriptionally activated p21 and GADD45 leading to p53 activation (Table 1).⁷⁴ Human HepG2 and Bel-7404 and H22 (murine) hepatoma cells and normal hepatic embryo HL-7702 cells treated with 0, 12.5, 25, 50, or 100 µM berberine for 24 h showed a concentration-dependent decline in cell proliferation, and increased apoptosis and activation of caspase 9/3 in HepG2 cells. Berberine suppressed cytosolic phospholipase A₂ (cPLA2) and COX-2 expression in H22 and HepG2 cells (Table 1).⁷⁵

The exposure of HepG2, HepB3, and SNU-182 cells to 10, 20, 50, and 100 µM berberine concentration-dependently arrested cell proliferation and upregulated the expression of Krüppel-like factor 6 (KLF6), ATF3, and p21 at 100 µM in HepG2 cells, whereas no such effect was detected in HepB3 or SNU-182 cells. Berberine decreased the expression of the E2F transcription factor 1 (E2F1) and pituitary tumor transforming gene 1 (PTTG1; Table 1).⁷⁶ Berberine (30, 60, and 120 µM for 12–72 h) treatment of Huh-7 and HepG2 cells reduced cell viability and clonogenicity in a concentration -dependent manner, and Huh-7 cells were more sensitive than HepG2 cells. Berberine arrested Huh-7 and HepG2 cells in the G₀/G₁ phase of the cell cycle depending on the concentration and deactivated the Akt pathway, inhibited the S-phase kinase-associated protein 2 (Skp2) expression, and elevated the expression and translocation of Forkhead box O3a (FoxO3a) into the nucleus, which promoted the transcription of the cyclin-dependent kinase inhibitors (CDKIs) p21^Cip1and p27^Kip1 (Table 1).⁷⁷ Likewise, 50 µM berberine induced a concentration- and time-dependent reduction in β-catenin (independent of APMK activation) and suppressed p-p70S6K^Thr389 and p4EBP1^Thr37/46 levels in addition to the mTORC1 axis in Huh7 and Hep3B cells. Berberine increased pAKT^Ser473 and pGSK3βSer9 (downstream) levels due to activation of mTORC2.⁷⁸ Treatment of human cholangiocarcinoma cells KKU-213 and KKU-214 with 2, 4, 6, 8, 20, and 20 µM berberine inhibited cell growth depending on the concentration, arrested cells in the G₁ phase of the cell cycle, and suppressed the activation of STAT-3, NF-κB, and phosphorylation of ERK-1/2 (Table 1).⁷⁹

Breast cancer

Exposure of MCF-7 and MDA-MB-231 cells to 0.001, 0.01, 0.1, 1, 10, 20, 50, and 100 or 500 µM berberine decreased cell proliferation in a concentration- and time-dependent fashion and elevated apoptosis. Berberine arrested cells in the G₀/G₁ phase of the cell cycle, attenuated cell migration and invasion, and interacted with vasodilator-stimulated phosphoprotein (VASP) to inhibit actin polymerization (Table 1).^80–82 Similarly, 0–100 µg/mL berberine reduced cell proliferation in a concentration-dependent manner (IC₅₀ 36.91 µg/mL) and increased ROS generation in MCF-7 cells. MCF-7 cells treated with berberine (36.91 µg/mL) expressed 1800 well-defined proteins, out of which 96 proteins were DEPs as indicated by matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) analysis. In MCF-7 cells, berberine downregulated the proteins involved in proteolysis, protein folding, cell signaling, redox regulation, electron transport, and metabolism, and upregulated the proteins involved in protein trafficking including Hsp27 (Table 1).⁸³

Exposure of SKBR-3 (human epidermal growth factor receptor 2 [HER2]^high), BT-474 (HER2^high), T47D (HER2^low), and MDA-MB-231 (HER2^low) breast cancer cells to 20, 40, 60, 80, and 100 µM or 10, 25, 50, 75, and 100 µM berberine for 24, 48, and 72h reduced cell growth in a time- and concentration-dependent manner and arrested SKBR-3 cells in the G₁ phase of the cell cycle by downregulating the expression of cyclin D1/E. Treatment with berberine stimulated apoptosis and DNA fragmentation, attenuated Bcl-2 expression, activated caspase 9/3 and PARP, indicating the involvement of the mitochondrial/caspase pathway and the downregulation of HER2/PI3K/Akt signaling (Table 1).⁸⁴ Berberine (10, 25, 50, 75, or 100 µM) induced cytotoxicity, decreased cell migration, invasion, and expression of MMP 2/9 and suppressed expression of Akt (protein and mRNA), NF-κB, c-Jun, and activator protein 1 (AP-1) in MDA-MB-231 and MCF-7 cells (Table 1).⁸⁵ Liposomal berberine accumulated in MCF-7 cell memospheres and berberine liposomes (including targeted liposomes) reduced cell survival depending on berberine concentration (10, 20, 30, 40, and 50 µM) in MCF-7 and MCF-7 cancer stem cells (CSCs), where targeted berberine liposomes were more effective. The targeted berberine liposomes crossed the CSC membrane, suppressed ATP-binding cassette (ABC) transporters (ABCC1, ABCC2, ABCC3, ABCG2), and selectively accumulated in the mitochondria. Berberine activated Bax and reduced Bcl-2 and mitochondrial permeability. Targeted berberine liposomes enhanced the release of cytochrome c and caspase 9/3 activation (Table 1).⁸⁶

Berberine treated MCF-7 (20, 40, 80, 120, and 160 µM) and MDA-MB-231 (10, 20, 40, 80, and 120 µM) cells had decreased cell viability depending on the concentration with IC₅₀ values of 106 µM and 85 µM, respectively, and decreased colony formation: MDA-MB-231 cells were more sensitive than MCF-7 cells. Berberine induced G₁ arrest in MCF-7 cells but not in MDA-MB-231 cells. Microarray analysis revealed that berberine upregulated 1318 and downregulated 2079 genes in MCF-7 cells, whereas MDA-MB-231 cells showed an upregulation of 1662 and downregulation of 1044 genes. Gene Ontology (GO) analysis indicated that berberine altered the regulation of genes related to apoptosis, cell cycle, cell migration, and drug response. Tenfold more genes were regulated in MCF-7 cells compared to MDA-MB-231 cells. Quantitative (q)PCR analysis showed that berberine upregulated cyclin G1, and downregulated angiopoietin-like 4 (ANGPTL4) and colony stimulating factor 1 receptor (CSF1R)-related genes, including at the mRNA level, in MDA-MB-231 cells but not in MCF-7 cells. The mRNA expression of cytochrome P450 family 1 subfamily A member 1 (CYP1A1) and GADD45A was significantly upregulated, whereas that of CXCR4 was downregulated in MCF-7 and MDA-MB-231 cells.⁸⁷ Berberine treated (10, 25, 50, 75, and 100 µM) MCF-7 and MDA-MB-231 cells exhibited a decline in cell viability that was time- and concentration-dependent, as well as increased apoptosis and ROS production. Berberine activated proapoptotic JNK signaling, depolarized Δψm, reduced Bcl-2 expression, and increased Bax, caspase-3 activity, cytochrome c, and AIF release from mitochondria (Table 1).⁸⁸

Exposure of BT549 and MDA-MB-231 cells to 5, 10, 20, 40, and 80 µM berberine for different times reduced cell proliferation in a concentration- and time-dependent manner with IC₅₀ values of 16.575 ± 1.219 µg/mL and 18.525 ± 6.139 µg/mL, respectively. Berberine decreased colony formation, cell migration, and Bcl-2 expression, and also increased apoptosis, DNA DSBs (γH2AX), caspase-3/9 activity, cytochrome c release, ligase 4, and Bax expression (Table 1).⁸⁹ Berberine treatment arrested cell motility by decreasing transforming growth factor beta (TGF-β)1 and MMP-2 levels, without altering TGF-β2.⁹⁰ In another study Hs578t triple-negative breast cancer cells treated with 25 and 50 µM berberine showed decreased IL8 expression, reduced invasiveness, and downregulated expression of EGFR, MEK and ERK with reduced phosphorylation of MEK and ERK (Table 1).⁹¹

MDA-MB-231 and MCF-7 cells treated with 20, 40, and 80 µM or 6.25, 12.5, 25, 50, and 100 µM berberine had reduced cell proliferation depending on the concentration and length of treatment, and increased apoptosis and necrosis. Berberine arrested cells in the G₁ phase of the cell cycle, upregulated p21^/Cip1 and p27^/Kip1 mRNAs and proteins, increased p53 protein, phospho-p53^Ser15, and GSK3β, and reduced expression of cyclin D1/E, CDK2/4/6, phospho-Akt^Thr308, total Akt, c-Myc, EGFR, Akt, ERK1/2, and p38 kinase activity and phosphorylation.^92,93 Berberine treated MDA-MB-468 (0, 3, 6, and 12 µM) and MDA-MB-231 (0, 6.25, 12.5, and 25 µM) cells showed a concentration-dependent reduction in cell proliferation. Berberine arrested MDA-MB-231 and MDA-MB-453 cells in the S- and G₂/M phases whereas MDA-MB-468 and BT-549 cells were arrested in the G₀/G₁ phase of the cell cycle. The expression of cyclin A/D and CDK1/4 were reduced in MDA-MB-468 and BT-549 cells treated with berberine (Table 1).⁹⁴

Exposure of MCF-7 and MCF12A (non-tumorigenic epithelial cells) cells treated with 1 and 10 µM berberine had slower proliferation and cells arrested in the G₀/G₁ phase of the cell cycle; however, when the berberine concentration was increased up to 100 µM, MCF7 cells exhibited cell death, but the MCF12A (non-tumorigenic) cells did not. Berberine elevated the protein expression of p53 and p21 in a time- and concentration-dependent manner in MCF-7 cells (Table 1). Berberine accumulated in the mitochondria of both cells at the higher concentration (10 or 100 µM), and the accumulation within the nucleolus was prominent after the transition to the nucleoplasm in MCF7 cells. Berberine increased nucleolar stress in MCF7 cells, as indicated by the loss of ribosomal protein (RP)L5 from the nucleolus and the nuclear aggregation of p53 protein.⁹⁵ Treatment of MCF-7 and MDA-MB-231 cells with 25 or 50 µM berberine led to a reduction in cell survival, cell migration, invasion, and cells arrested in the G₂/M phase of the cell cycle. Berberine elevated miR-214-3p expression, Bax/Bcl-2 ratio, and secretin (SCT) expression at the mRNA and protein levels (Table 1).⁹⁶

Cervical cancer

HeLa (cervical cancer) cells and L1210 (mouse leukemia) cells exposed to 0.1, 1, 5, 10, 50, 100, and 150 µg/mL berberine had inhibited growth depending on the concentration, with an IC₅₀ value of 4.8 ± 0.2 µg/mL and IC₁₀₀ value of 74.6 ± 5.1 µg/mL, respectively. Berberine treatment reduced the S-phase fraction and increased the G₂/M phase fraction, depending on its concentration. Berberine increased apoptosis in both time- and concentration-dependent manners as revealed by a DNA fragmentation assay (Table 1).⁹⁷

Berberine (50, 100, and 150 µM) decreased CaSki cell viability depending on the concentration and length of treatment time, and also elevated apoptosis, p53, Bax/Bcl-2, ROS, GADD153, Ca²⁺ release, and caspase-3 activity and reduced Δψm (Table 1).⁹⁸ Treatment of SiHa and HeLa cells with 1–250 µg/mL berberine reduced cell viability and inhibited growth. There were also increased levels of apoptosis, activated caspase 3, and cleaved PARP, and reduced Δψm and AP-1 depending on the concentration and assay time, and also altered composition of DNA binding complexes. Berberine inhibited the expression of human papillomavirus (HPV) oncogenes, telomerase protein, human telomerase reverse transcriptase (hTERT), oncogenic c-Fos, E6 and E7, which was also accompanied by a rise in p53 and retinoblastoma (Rb) expression in SiHa and HeLa cells (Table 1).⁹⁹

HeLa cells treated with 150, 175, 200, 225, 250, 275, and 300 µM berberine had reduced cell viability depending on the concentration with an IC₅₀ of 283 µM, whereas in normal HPV-negative C33a cervical cancer cells the growth inhibition was comparatively less (2–20%). The uptake of berberine by HeLa cells reached its peak at 250 µM and then declined. Berberine triggered apoptosis, disrupted the tubulin network (confocal microscopy), induced cracks and groves holes, and negatively altered membrane potential, cell migration, and wound healing in HeLa cells. Berberine bound to plasmid DNA and fragmented HeLa cell DNA, and decreased the expression of histone deacetylase 1 and 2 (HDAC1/2; possible DNA binding sites). It upregulated p53 expression and reduced the expression of HPV-18 E7, CDKs, cyclin, NF-κB, and SMAD4 (Table 1).¹⁰⁰ Berberine treatment (1, 2, 4, 6, and 8 µg/ml) reduced cell viability and colony formation, glutathione transferase activity, and increased LDH release in a time- and concentration-dependent manner in HeLa cells. Berberine also induced DNA strand breaks (comet assay) in HeLa cells (Table 1).^101,102

SiHa, HeLa, and CaSki cells treated with 5, 10, 15, and 20 µM berberine had reduced cell viability and motility according to the concentration of berberine, and 20 µM berberine had the maximum effect on cell invasion inhibition in SiHa cells. Berberine reduced the activities of u-PA and MMP-2 and increased TIMP-2 expression in SiHa cells. Berberine treatment reduced TGF-β1, EMT, phosphorylation of p38, FAK, paxillin, NF-κB, and Src, as well as the expression of Snail-1, C23, and β-catenin (Table 1).¹⁰³ Exposure of SiHa and CaSki cells to 150, 200, and 250 µM berberine concentration-dependently decreased cell viability, migration, and invasion. Berberine increased apoptosis, expression of Bax and caspase 3 and reduced Bcl-2 expression. Berberine repressed EMT in cells by reducing MMP-9, N-cadherin, and vimentin expression and increasing E-cadherin and keratin 17 (KRT17) expression (Table 1).¹⁰⁴

Leukemia

Exposure of promyelocytic leukemia HL-60 cells to 5, 10, 25, and 50 µg/mL berberine reduced cell viability and elevated apoptosis and internucleosomal DNA fragmentation in a concentration-dependent fashion, arrested cells in the G₂/M phase up to 24 h, and downregulated nucleophosmin/B23 mRNA and telomerase. In vitro studies on calf thymus DNA revealed that berberine complexed with DNA to form berberine DNA-complexes (Table 1).^105,106

Treatment of HL-60 cells with 10, 50, and 100 µM berberine inhibited N-acetyltransferase (NAT) activity, 2-aminofluorene (AF)-DNA adduct formation, and downregulated NAT mRNA depending on berberine concentration (Table 1).^107,108 Exposure of HL-60 and mouse leukemia WEHI-3 cells to 0, 5, 15, 30, and 60 µM berberine resulted in a concentration-dependent rise in cytotoxicity, apoptosis, cytochrome c release, Ca⁺² release, caspase-3 activity, and Bax levels and a reduction in Δψm and Bcl-2 levels. Berberine arrested these cells not only in the G₀/G₁-phase but also in the G₂/M-phase of the cell cycle in a concentration-dependent manner, which was followed by a rise in Wee1 and 14-3-3σ and reduction in Cdc25c, CDK1, and Src levels (Table 1).^109,110

HL-60 cells exposed to 2.5, 5, 10, 20, 40, 80, and 100 µM berberine did not show differences in cell viability up to 40 µM, but a significant decline was detected with 80 and 100 µM berberine. Berberine inhibited cell migration in a concentration-dependent (2–5 to 40 µM) manner in HL-60 cells. However, treatment of HL-60 cells with 20 µM berberine for 24, 48, and 72 h did not alter CXCR-4 expression (Table 1).¹¹¹ HL-60 cells treated with 20, 40, 60, 80, and 100 µM berberine showed decreased cell viability and proliferation due to its prompt localization into the cell nucleus within 15 min of treatment. Berberine induced apoptosis, chromatin condensation, DNA fragmentation, activation of PARP and caspase-3/8, and phosphorylation of ERK and p38 within 15 min of treatment (Table 1).¹¹²

The effect of 1, 10, 50, and 100 µM berberine treatment was studied in p53-null EU4 acute lymphoblastic leukemia cells, where berberine was able to induce cytotoxicity in a concentration-dependent manner, along with increased apoptosis, activation of caspase 3/9 and PARP, increased Bax, and reduced expression of Bcl-xL and XIAP. This downregulation of XIAP protein by berberine was due to an inhibition of mouse double minute 2 (MDM2) expression and a proteasome-dependent pathway (Table 1).¹¹³ In another study, berberine downregulated XIAP mRNA and enhanced miR-24-3p and Pim-2 proto-oncogene (PIM-2), in p53-null EU-4 and EU-6 cells.¹¹⁴ EU-6 cells exposed to 12.5, 25, 50, and 100 µM berberine chloride had reduced cell viability, autophagy, and inactivated Akt/mTORC1 signaling as indicated by the attenuated expression of p-S6 and pAkt, that was dependent on berberine concentration (Table 1).¹¹⁵

Berberine concentration-dependently reduced cell viability in human multiple myeloma MM.1S, RPMI-8266, U266, NCI-H929, and OPM2 and mouse Sp2/0 cells after treatment with 25, 50, 75, and 100 µM berberine. Berberine also significantly reduced colony formation in MM.1S and RPMI-8266 cells. However, the viability of normal human peripheral blood mononuclear cells (hPBMCs) remained unaffected at an IC₅₀ of 15–25 µM for MM.1S cells. Berberine promoted the ubiquitin-like with PHD and RING finger domains 1 (UHRF1) protein degradation through the ubiquitin-proteasome pathway, but did not have any effect on UHRF1 mRNA, and reactivated p16^INK4A and p73 (Table 1).¹¹⁶

Prostate cancer

Berberine (10–100 µM) treated DU145 and PC-3 (androgen-insensitive) and LNCaP (androgen-sensitive) prostate cancer cells had reduced cell proliferation and increased cell death depending on the concentration and length of exposure to berberine, whereas non-neoplastic PWR-1E human prostate cells remained almost unaffected. Berberine arrested DU145 cells in the G₁-phase of the cell cycle, downregulated the expression of cyclins D1/2/E and CDK 2/4/6, and increased the expression of p21^/Cip1 and p27^/Kip1. Berberine induced apoptosis and fragmented cell DNA in DU145 and LNCaP cells, and increased Bax/Bcl-2 ratio, caspase 9/3 and PARP activation, and depolarized Δψm.¹¹⁷ Similar observations were reported in PC-3 cells exposed to 25, 50, 75, and 100 µM berberine, except it also increased ROS formation, the release of cytochrome c, and second mitochondria-derived activator of caspase (Smac)/direct inhibitor of apoptosis-binding protein with low pI (DIABLO) from mitochondria (Table 1).¹¹⁸ PC-3 and LNCaP cells treated with 5, 10, 20, 50, and 100 µM berberine experienced suppressed cell growth depending on length of treatment time and concentration, but no such effect was detected in normal human prostate epithelial PWR-1E cells. Berberine arrested the cells in the G₀/G₁ phase and induced apoptotic cell death by increasing Bax and caspase 3 activation (Table 1). LNCaP (p53⁺) cells were more sensitive than PC-3 (p53⁻) cells to berberine treatment.¹¹⁹

LnCaP and PC-3 cells exposed to 20, 100, and 200 µM berberine for 24, 48, and 72 h experienced attenuated cell growth depending on the length of treatment and concentration, along with increased apoptosis and arrested cells in the G₁ phase. Berberine blocked the expression of prostate-specific antigen and the activation of EGFR (Table 1).¹²⁰ Treatment of LNCaP, LAPC-4, 22Rv1, C4-2B, and PC-3 cells with 1.56, 3.125, 6.25, 12.5, 25, 50, and 100 µM berberine reduced cell proliferation, and androgen receptor (AR)-positive cells (LNCaP and LAPC-4) were more sensitive than AR-negative cells. Berberine triggered apoptotic cell death in LNCaP cells depending on the concentration, and inhibited the transactivation of AR in AR-dependent and AR-independent cells to the same extent (Table 1).¹²¹

Berberine (5, 10, 20, and 50 µM) treated murine prostate cancer RM-1 cells exhibited a concentration-dependent reduced cell proliferation, increased DNA DSBs and apoptosis, and arrested cells in the G₁ phase of the cell cycle. Berberine activated the p53-p21 cascade at a low concentration and arrested cells in the G₂/M phase at a higher concentration (50 µM for 24 h) due to increased phosphorylation of ataxia-telangiectasia mutated (ATM)/checkpoint kinase 1 (Chk1).¹²² Treatment of PC3 human and RM-1 mouse prostate cancer cells with 5, 10, 20 or 50 µM berberine resulted in reduced cell viability depending on the concentration, and the arrest of PC3 cells in the G₀/G₁ (10 µM) or G₂/M (50 µM) phase of the cell cycle.¹²³ Treatment of LNCaP and PC-82 cells with 1, 5, 25, 50, and 100 µM berberine reduced cell proliferation and decreased cell viability in a concentration-dependent manner. Berberine increased apoptosis and programmed necrosis by increasing the release of cyclophilin-D (Cyp-D) from mitochondria and the translocation of p53 into the mitochondria in these cells, ultimately causing cytotoxicity (Table 1).¹²⁴ PC-3, DU145 and LNCaP cells treated with 10, 25, 50, and 75 µM berberine showed a concentration-dependent reduction in cell proliferation. The studies on cell motility revealed that PC3 cells were highly motile with the greatest migratory potential in comparison to DU145 and LNCaP cells. Berberine treatment suppressed the motility and migration of PC3 cells by decreasing vimentin and E-cadherin expression. Berberine suppressed the expression of EMT genes, platelet-derived growth factor receptor-beta (PDGFRβ), collagen type I alpha 2 (COL1A2), bone morphogenetic protein 7 (BMP7), and TGF-β responsive genes. Nodal growth differentiation factor (NODAL) and Wnt1 were also downregulated at the level of mRNA in PC3 and DU145 cells. Berberine also downregulated the expression of Snail (SNAI1) mRNA, indicating its ability to inhibit metastatic potential (Table 1).¹²⁵

22Rv1 cells treated with 12.5, 25, and 50 µM or 1, 2.5, 5, 10, 20, and 50 µM berberine had reduced cell proliferation, cellular testosterone formation, and C3 (aldo-keto reductase family 1) enzyme activity with no difference in mRNA levels, but also had elevated levels of apoptosis (Table 1).^126,127

Ovarian cancer

OVCAR-3 and SKOV-3 cells exposed to 1, 10, and 100 µM berberine had reduced cell proliferation with IC₅₀ values of 10 µM and 100 µM for OVCAR-3 and SKOV-3 cells, respectively. Cell cycle analysis showed that berberine accumulated the OVCAR-3 cells in the G₂/M phase and SKOV-3 cells in the S- phase of the cell cycle and upregulated p27 in these cells but did not induce apoptosis (Table 1).¹²⁸

FTE187, A2780, HEY, and HO8910 cells treated with 5, 10, and 20 µM berberine had elevated levels of ROS dependent on the concentration of berberine, and this increase was comparatively low in normal FTE187 cells. It also reduced cell proliferation and clonogenicity, and triggered apoptosis in A2780 and HO8910 cells. Berberine (10, and 20 µM) induced DNA DSBs and downregulated RAD51 and homologous recombination DNA repair in A2780, HEY, and HO8910 cells, whereas FTE187 cells remained unaffected. Berberine increased PARP, ATM, and p53 activation in A2780 and HO8910 cells (Table 1).¹²⁹ SKOV3 cells treated with 5, 10, 30, 50 and 100 µM berberine had decreased levels of proliferation depending on the length of treatment time and concentration, with IC₅₀ values of 15.2 µM (24 h), 9.8 µM (48 h), and 9.2 µM (72 h). Berberine also suppressed the expression of hERG1 protein and mRNA concentration-dependently and inhibited cell migration and invasion (Table 1).¹³⁰

Berberine (12.5, 25, 50, and 100 µM) treatment of SKOV-3, TOV-21G, and MDAH-2774 cells reduced cell viability and colony-forming ability (SKOV-3 and TOV-21G cells) in soft agar, and increased cytotoxicity (concentration-dependent) while reducing cell migration and invasiveness. The IC₅₀ values of 50, 25, and 32 µM (72 h) were reported for SKOV, TOV-21G, and MDAH-2774 cells, respectively. Berberine reduced the expression of EGFR, ErbB2, cyclin D1, MMP-2/9, and VEGF in all cell lines except ErbB2 in MDAH-2774 cells (Table 1).¹³¹

SKOV3 and 3AO cells exposed to 2.5, 5, 10, 20, 40, 80, 160, and 320 µM berberine had decreased levels of cell proliferation depending on the concentration, with IC₅₀ values of 78.52 µM and 125.8 µM, respectively. Berberine attenuated cell migration and invasion by promoting miR-145 expression and reducing MMP16, a target of miR-145 (Table 1).¹³² Treatment of SKOV3 (40 µM) and 3AO (80 µM) cells with berberine reduced the consumption of glucose and lactate production (Warburg effect), which was due to the upregulation of miR-145, and miR-145 targeted HK2 directly (Table 1). The elevation in miR-145 by berberine was due to increased expression of tet methylcytosine dioxygenase 3 (TET3) and decreased methylation in the promoter region of the miR-145 precursor gene.¹³³

Osteosarcoma

Osteosarcoma cells, including U2OS, Saos-2, and HOS, treated with 1, 5, 10, 20, and 50 µg/ml berberine had a concentration- and time-dependent reduction in cell proliferation. Berberine arrested cells in the G₁ phase of the cell cycle, which was dependent on p53 expression and an elevation in p21 and p27, whereas p53 did not have any effect on G₂/M cell cycle arrest. Berberine also reduced the levels of cyclin E depending on the concentration of berberine, whereas cyclin D1 was attenuated only at 50 µg/mL. Berberine triggered apoptosis in a concentration-dependent manner due to elevated levels of p53, Bax, p53 upregulated modulator of apoptosis (PUMA), and Fas in these cells. Berberine treatment induced DNA DSBs, as indicated by a concentration-dependent rise in γ-H2AX (Table 1).¹³⁴

U2OS cells treated with 12.5, 25, and 50 µg/mL berberine had inhibited cell proliferation and colony formation, and increased apoptosis that was concentration-dependent. Berberine suppressed PI3K/Akt, Bcl2, and procaspase-3, and upregulated PARP and Bax in U2OS cells.¹³⁵ Saos-2 and MG-63 cells exposed to 10, 20, 40, 60, 80, and 100 µg/mL berberine led to a concentration and time-dependent decline in cell proliferation and an induction of apoptosis. Berberine downregulated the mRNA and protein expression of caspase 1 and IL-1β.¹³⁶

Berberine (5, 20, 40, 60, and 80 µM) treated MG-63 cells showed reduced colony formation and concentration-dependent rise in cytotoxicity, apoptosis (DNA fragmentation analysis by flow cytometry), and DNA DSBs measured by γ-H2AX foci. Berberine also reduced EMT and MMP-2 activity (did not change MMP-9), as well as mRNA expression of N-cadherin, vimentin, fibronectin, β-catenin, and Snail, in addition to inhibiting histone-methylation via decreased expression of enhancer of zeste homolog 2 (EZH2) at the protein and mRNA levels (Table 1).^137,138

Lung cancer

A549 human lung cancer cells treated with 2.5, 5.0, 10, 20, 40, 80, and 100 µM berberine resulted in a concentration and time-dependent suppression of cell proliferation, migration, and invasion, and cells arrested in the G₁ phase of the cell cycle. Berberine inhibited the expression of cyclin B1, cAMP response element-binding protein (CREB), MAPK, MMP-2, uPA, NF-κB, cFos, cJun, and phosphorylation of Akt. Berberine treatment reduced the transcription of MMP-2 mRNA but upregulated TIMP-2 mRNA and protein expression.^139,140 Berberine treated A549 and H1299 cells showed a concentration- (25, 50, 75, and 100 µM) and time-dependent reduction in cell proliferation and increase in apoptosis and DNA fragmentation. Berberine disrupted Δψm, attenuated Bcl-2 and Bcl-xL expression, and increased Bax, Bak, and caspase 3 activation (Table 1).¹⁴¹ H460 cells treated with 0.1, 1, 5, and 10 µM berberine showed a concentration-dependent reduction in cell growth with an IC₅₀ of 5 µM and cells were arrested in the G₀/G₁ phase of the cell cycle.¹⁴² A549 cells treated with 20, 40, 80, and 160 µM berberine showed repressed cell invasion, migration, and EMT, as well as an inhibition of vimentin, Snail-1 and Slug with an increase in the expression of E-cadherin.¹⁴³ A549 cells treated with 6.25, 12.5, 25, 50, and 100 µM berberine had reduced cell viability, increased ROS and apoptosis, and cells were arrested in the G₀/G₁ phase of the cell cycle in a concentration-dependent manner. Berberine increased the expression of p21 and reduced cyclin D1.¹⁴⁴ Berberine (3.125, 6.25, 12.50, 25 or 50 µM) increased p21^WAF1 (at low concentrations), IL6, IL1β, TNF-α, p-NF-κB, and mTOR (at higher concentrations) and decreased NF-κB and cyclin A1/2/B1 expression, but had no effect on cyclin D1 expression (Table 1).¹⁴⁵

The accumulation of berberine in cells is important for its action, and one study has shown a two-to-threefold accumulation of berberine in H1650 and H1975 cells and cell organelles compared to normal BEAS-2 lung cells.¹⁴⁶ A549 cells treated with 20, 40, 80, 100, 120, 140, 160, 180, and 200 µmol/mL berberine had reduced cell viability, increased ROS generation, and cells were arrested in the G₀/G₁ phase of the cell cycle. Berberine reduced Δψm and increased nuclear fragmentation along with mRNA and protein levels of p21, p53 and Bax, increased cytochrome c release and activated caspase 8/9/3, and decreased Bcl-xL, Bcl-2, TNF-α, COX-2, MMP-2, MMP-9 and HDAC 1/2/4 (Table 1).¹⁴⁷ A549 cells exposed to 30, 60, 90, 150, and 200 µM berberine had a concentration and time-dependent reduction in cell proliferation and an increase in cell apoptosis. Berberine downregulated MMP-2, increased Bcl2/Bax signaling, and inhibited Janus kinase-2 (Jak-2), VEGF, NF-κB, and AP-1 proteins in A549 cells.¹⁴⁸ A549 and PC9 cells treated with 20, 40, 60, 80, 100, 120, 140, and 160 µM berberine had reduced cell proliferation and colony formation through increased apoptosis. Berberine reduced Bcl2 and increased the expression of Bax and TF mRNA, which was followed by the downregulation of miR-19a in a concentration-dependent manner. This was followed by increased phosphorylation of JNK and p38MAPK (Table 1).¹⁴⁹ NCI-H460, A549 and NCI-H1299 cells treated with 10, 20, 40 and 80 µM berberine had reduced cell proliferation and colony formation with IC₅₀ values of 30.3 µM, 44.5 µM, and 43.8 µM, respectively. Berberine induced DNA DSBs and apoptosis, and downregulated DNA topoisomerase 2-beta (TOP2B) and SIN3 transcription regulator family member A (Sin3A) expression, and shortened the half-life of Sin3A in human NSCLC cells (Table 1).¹⁵⁰

Pancreatic cancer

Exposure of human pancreatic cancer cells BxPC-3 and pancreatic duct HPDEE6E7c7 cells to 10, 50, 100, 150, and 200 µM berberine resulted in a concentration and time-dependent decline in cell survival with an IC₅₀ of 62.8 µM for the former, but the IC₅₀ could not be determined for the latter, indicating that BxPC-3 cells were more sensitive to berberine than HPDEE6E7c7 cells (Table 1). Berberine (150 and 200 µM) increased apoptosis, activated caspase 3/7, and stimulated the release of AIF. Microarray analysis showed that berberine treatment upregulated 234 genes and downregulated 33 genes, which were related to BRCA1-mediated DNA damage response, G₁/S and G₂/M cell cycle checkpoint regulation, and p53 signaling.¹⁵¹ Berberine treatment of pancreatic cancer stem cells PANC-1 and MiaPaCa-2 resulted in IC₅₀ values of 15 and 10 µM, respectively, and it also decreased the side population of cells. Berberine downregulated Sox2, POU class 5 homeobox 1 (POU5F1), and Nanog homeobox (NANOG) genes in both cells, but the NOTCH1 gene remained undetectable.¹⁵² PANC-1 and MiaPaCa-2 cells exposed to 1, 5, 7, 10, and 15 µM berberine had reduced cell proliferation, and cells were arrested in the G₁ phase of the cell cycle, and apoptosis was triggered by ROS production (Table 1).¹⁵³

Pancreatic duct cells PANC-1 and MiaPaCa-2 treated with 0.15, 0.3, 1.5, 3, and 6 µM berberine showed inhibited cell proliferation and DNA synthesis, and delayed progression through the G₁ phase of the cell cycle. Berberine reduced Δψm and intracellular ATP levels and increased the phosphorylation of AMPK at Thr¹⁷² and acetyl-CoA carboxylase (ACC) at Ser⁷⁹. Berberine inhibited mTORC1 (phosphorylation of S6K at Thr³⁸⁹ and S6 at Ser^240/244) and ERK activation (Table 1).¹⁵⁴ PANC-1 cells treated with 1, 5, 7.5, 10, 15, and 30 µM of berberine had reduced cell proliferation and increased apoptosis in a concentration-dependent manner. Berberine also inhibited cell migration and decreased TNF-α expression (Table 1). RNA sequencing detected 7368 differentially-expressed genes, out of which 3726 genes were downregulated and 3642 genes were upregulated after berberine treatment. Berberine downregulated K-ras genes and upregulated the tumour suppressor CDKN2A gene. Berberine treatment also increased amino acids, nucleotides metabolism and glycolysis, but reduced citric acid cycle metabolites and damaged the mitochondria (Table 1).¹⁵⁵

Renal cancer

Treatment of ACHN human renal cancer cells with 10 and 20 µmol/L berberine significantly inhibited cell proliferation and expression of c-Fos (Table 1). However, berberine did not induce the cleavage of caspase proteins, indicating that berberine did not trigger apoptosis.¹⁵⁶ G401 Wilms’ tumor cells treated with 5, 10, 20, and 50 µM berberine had reduced cell proliferation that was concentration-dependent, and upregulated mRNA and protein expression of p21 and p27. Berberine downregulated mRNA and protein expression of cyclin E, indicating that it interferes with the cell cycle. Berberine activated the phosphorylation of AMPK and T-ACC (a downstream target of AMPK) and increased the phosphorylation of mTOR and S6 kinase, as well as increased the expression of the tumor suppressor gene Wilms tumor gene on X chromosome (WTX) in G401 cells (Table 1).¹⁵⁷

Bladder cancer

The treatment of human bladder cancer T24 cells with 0.8, 8, 80, 800, and 1,600 µM berberine resulted in decreased arylamine N-acetyltransferase activity (overactivated in tumor cells) in a concentration-dependent manner (Table 1).¹⁵⁸ BIU-87 and T24 cells exposed to 1, 5, 10, 25, 50, 75, and 100 µM berberine for 24, 48, and 72 showed inhibition of cell viability in a concentration- and time-dependent manner. Berberine arrested cells in the G₀/G₁ phase of the cell cycle and induced apoptosis by activating cleaved caspase-3/9 depending on the concentration. Similarly, berberine caused concentration- and time-dependent inhibition of H-Ras and c-fos mRNA and protein expression (Table 1).¹⁵⁹ Treatment of T24 cells with 10, 25, and 50 µg/ml berberine concentration-dependently attenuated cell migration and invasion, in addition to causing the downregulation of both mRNA and protein levels of heparanase, which is linked to tumor cell migration and invasion (Table 1).¹⁶⁰

Thyroid cancer

Treating the thyroid cancer cells 8505C and TPC1 with 1, 10, and 100 µM berberine caused a concentration-dependent growth inhibition with an IC₅₀ of 10 µM for both cell types, and cells were arrested in the G₀/G₁ phase of the cell cycle. Berberine upregulated p-27 and the effect was more pronounced in TPC1 than 8505 cells.¹⁶¹ FTC-133 and 8305C cells treated with 10, 25, 50, and 100 µM berberine for 24, 48, and 72 h resulted in a concentration- and time-related reduction in cell viability. Berberine induced apoptosis, DNA fragmentation, and activation of cleaved caspase 3. Berberine treatment resulted in cell cycle arrest and overexpression of p53 and p27 in both 8505 and TPC1 cells, and the effect was more pronounced in TPC1 cells (Table 1).¹⁶² TT cells treated with 0.4, 0.8. 1.6, 3.2 and 6.4 µg/mL berberine had decreased cell viability depending on the concentration with an IC₅₀ of 1 µg/mL. Berberine decreased the S- and G₂ phase fractions, and arrested cells in the G₁ phase of the cell cycle. Berberine attenuated the phosphorylation of Akt, Rb, E2F1, and cyclin E in TT cells but did not affect the phosphorylation of MEK/ERK. Berberine reduced Bcl2 expression and 1 µg/ml increased apoptosis and caspase 3 activation. Berberine reduced the expression of the RET gene in TT cells and inhibited its promoter activity through G-quadruplex stabilization in the isogenic cell lines HEK293-WT and HEK293-MT1 (Table 1).¹⁶³

C643, OCUT1, and TPC1 cells of different aberrant genotypes and Htori3 (normal) cells were treated with 10, 20, 40, 80, and 160 µM berberine for 24, 48, and 72 h, which arrested cell proliferation in a time- and concentration-dependent manner but the Htori3 cells were the least sensitive. Berberine led to a significant increase in apoptosis, loss in Δψm, arrest of cells in the G₀/G₁ phase of the cell cycle, and depletion of cyclin E1, CDK2, and vimentin (Table 1). Berberine treatment enhanced Bax/Bcl-2, cleaved caspase 3, and p21, and reduced p-Akt1 expression markedly. Berberine increased p-ERK, p-P38, and p-JNK in C643 cells, with no changes in p-ERK and p-p38 in OCUT1 cells; however, it significantly attenuated p-ERK and p-JNK but did not change p-p38 in TPC1 cells.¹⁶⁴ K1 cells treated with 10, 40 and 80 µM berberine inhibited cell proliferation depending on the concentration and repressed the expression of PI3K, p-Akt/Akt, and Nrf2 (Table 1).¹⁶⁵

In vivo studies

Berberine has been tested for its anticancer activity in different animal models of cancer (Table 2). The in vivo anticancer activity of 2–12 mg/kg body weight berberine killed Ehrlich ascites tumor cells in tumor bearing mice in a dose-dependent manner and increased the average and mean survival time of tumor bearing mice.^166,167 BALB/c nude mice xenografted with U87 human glioblastoma cells and treated with 50 and 100 mg/kg berberine showed inhibited tumor growth, downregulated EGFR, and induced senescence.³³ Berberine (50 mg/kg) treated athymic nude mice xenografted with U87 human glioblastoma cells showed reduced tumor growth through the upregulation of p-AMPK and downregulation of p-mTOR. Histological examination showed a reduction in cell proliferation, as Ki-67 positive cells declined and LC3B levels increased.³⁴ Athymic nude mice transplanted with U87 human glioblastoma cells and treated with 50 mg/kg berberine had reduced tumor volume in the ectopic model and significantly decreased hemoglobin levels and CD31 mRNA, indicating reduced angiogenesis. Berberine also reduced the phosphorylation of VEGFR2, ERK, and p38 (Table 2).¹⁶⁸

Table 2

Anticancer activity of berberine in various animal models

Mouse	Berberine	Model	Outcome	References
BALB/c	2-12 mg/kg	Ehrlich ascites carcinoma	Increased average and mean survival time	¹⁶⁶^,¹⁶⁷
BALB/c nude	50 and 100 mg/kg	U87 human glioblastoma cells	Inhibited tumor growth, induced senescence, downregulated EGFR	³³
BALB/c nude	50 and 100 mg/kg	U87 human glioblastoma cells	Reduced tumor growth, upregulated p-AMPK, downregulated p-mTOR, LC3B, reduced Ki-67 positive cells	³⁴
Athymic nude	50 mg/kg	U87 human glioblastoma cells	Reduced tumor volume, hemoglobin level, mRNAs of CD31, VEGFR2, ERK, p38, angiogenesis	¹⁶⁸
BALB/c nude	10 mg/kg	MCF-7CSC breast cancer cells	Inhibited tumor growth, nontoxic to blood cells	⁸⁶
BALB/c nude	10 mg/kg	MDA-MB-231 breast cancer cells	Reduced tumor volume, tumor weight	⁸²
BALB/c nude	100 mg/kg	MDA-MB-231 breast cancer cells	Reduced tumor growth, cell proliferation, Ki-67 labelling, upregulated caspase 9 activity	⁸⁹
BALB/c nude	0.1% (w/v)	TNBC 4T1 breast cancer cells	Reduced tumor growth, metastasis, G₀/G₁ arrest	⁹¹
BALB/c nu/nu	10 mg/kg	BCG-823 human colon cancer cells	Reduced tumor growth, weight, p-Akt tumor tissue	⁶⁵
BALB/c nu	5, 10 or 20 mg/kg	BCG-823 human colon cancer cells	Reduced tumor growth, tumor weight, tumor cell proliferation, PCNA labelling, p-mTOR, p-p70S6K, p-Akt, p-ERK, p-JNK p-p38 increased autophagic death, LC3, Beclin-1	⁶⁶
BALB/c nu/nu	10, 30, or 50 mg kg⁻	LoVo colon cancer cells	Reduced tumor growth, tumor volume	⁶⁹
BALB/c nude	10 mg/kg	KM12C/shCtrl colon cancer cells	Reduced tumor growth, PCNA, Ki67, Cdc2, cMyc, β catenin, increased the p21^WAF1/CIP1, RXRα	¹⁶⁹
Nude	50 and 100 mg/kg	HEC-1-A human endometrial carcinoma cells	Reduced tumor growth, cell migration and invasion in the mice lungs, increased transcription of miR-101 via activator protein 1, reduced COX-2/PGE2 signaling pathways	¹⁷⁰
Athymic	50, 100 and 200 mg/kg	A459 and H1299 lung cancer cells	Reduced tumor growth	¹⁴¹
BALB/c nude	5 and 10 mg/kg	A459 lung cells	Reduced tumor growth	¹⁴³
BALB/c nude	50 mg/kg	RPMI-8266 multiple myeloma cells	Reduced tumor growth, increased mouse survival	¹¹⁶
Mouse	10 mg/kg	B16 melanoma	Reduced tumor, tumor volume, tumor weight	¹⁷¹
BALB/c nude	5 and 10 mg/kg	PC-3 and LNCaP prostate cancer cells	Reduced tumor growth, tumor volume, tumor weight, increased cleaved caspase 3, PARP activities	¹¹⁹
BALB/c	12.5, 25 and 50 mg/kg	H22 mouse HCC cells	Reduced tumor growth and volume	⁷³
BALB/c nu/nu	10 mg/kg	MHCC-97L human HCC	Reduced tumor growth, lung metastasis, HIF-1α/VEGF signaling and expression of Id-1	¹⁷²
BALB/c nude	10 mg/kg	SSC-4 tongue carcinoma cells	Reduced tumor growth, tumor volume, tumor mass	¹⁷³
Nude	5 and 10 mg/kg	C666-1 nasopharyngeal carcinoma cells	Reduced tumor growth, STAT-3 activation	¹⁷⁴

AMPK, AMP-activated protein kinase; Akt, protein kinase B; Cdc, cell division cycle; COX, cyclooxygenase; EGFR, epidermal growth factor receptor; ERK, extracellular signal-regulated kinase; HCC, hepatocellular carcinoma; HIF, hypoxia-inducible factor; Id-1, inhibitor of differentiation/DNA binding; JNK, c-Jun N-terminal kinase; LC3, microtubule-associated protein 1A/1B-light chain 3; mTOR, mechanistic target of rapamycin; PARP, poly(ADP-ribose) polymerase; PCNA, proliferating cell nuclear antigen; PGE2, prostaglandin E2; STAT, signal transducer and activator of transcription VEGF, vascular endothelial growth factor; VEGFR, vascular endothelial growth factor receptor; w/v, weight by volume.

BALB/c nude mice with a xenograft of MCF-7CSC breast cancer cells and administered intravenously with 10 mg/kg berberine, liposomal berberine, and targeted liposomal berberine had their tumor growth inhibited by 34.31 ± 8.13%, 41.91 ± 8.8%, and 71.77 ± 8.92%, respectively, indicating the efficacy of targeted liposomal berberine, which was also non-toxic to blood cells.⁸⁶ BALB/c nude mice with a MDA-MB-231 breast cancer cell xengraft were intraperitoneally administered with 10 mg/kg berberine and showed reduced tumor volume and tumor weight.⁸² Likewise, BALB/c nude mice with a MDA-MB-231 breast cancer cell xenograft were administered with 100 mg/kg berberine for 21 days and had reduced tumor growth and cell proliferation indicated by a decline in Ki-67 labeling followed by an upregulation of caspase 9 activity.⁸⁹ MDA-231-Luc cell xenografted mice given 1% berberine reduced the number of tumors and tumor volume and lung metastases.⁹⁰ The BALB/c nude mice with a xenograft of TNBC 4T1 breast cancer cells were given 0.1% berberine in their drinking water, and had inhibited tumor growth, metastasis, and cells arrested in the G₀/G₁ phase of the cell cycle (Table 2).⁹¹

BALB/cnu/nu mice with a BCG-823 human colon cancer cell xenograft were treated with 10 mg/kg body weight berberine, and showed a reduction in tumor growth and weight and also reduced expression of p-Akt in the tumor tissue.⁶⁵ In another study, female BALB/c nude mice with a xenograft of BGC-823 cells and injected with 5, 10, or 20 mg/kg berberine exhibited a dose-dependent slower tumor growth and reduced tumor weights. Berberine also reduced proliferating cell nuclear antigen (PCNA) labeling, indicating a reduction in tumor cell proliferation of the xenograft-derived tumor. Berberine induced autophagic cell death by markedly elevating LC3 and Beclin-1 followed by a reduction in p-mTOR, p-p70S6K, p-Akt, p-ERK, p-JNK, and p-p38 in the xenograft tumors.⁶⁶ BALB/c nu/nu mice with a human LoVo colon cancer cell xenograft were administered with 10, 30, or 50 mg kg⁻¹ day⁻¹ berberine by oral gavage for 10 days and experienced significantly inhibited tumor growth and reduced tumor volume.⁶⁹ Nude BALB/c mice with a xenograft of KM12C/shCtrl and KM12C/shRXRα colon cancer cells showed growth retardation after treatment with 10 mg/kg berberine in the former, whereas berberine had little effect on the latter cell type. Berberine attenuated the expression of PCNA, Ki67, Cdc2, cMyc, and β-catenin, and elevated p21^WAF1/CIP1 and retinoid X receptor alpha (RXRα) in the KM12C/shCtrl xenografts, whereas no such effect was detected in KM12C/shRXRα xenografts, indicating a direct relation between RXRα and β-catenin signaling (Table 2).¹⁶⁹

Nude mice with a xenograft of HEC-1-A human endometrial carcinoma cells were administered with 50 and 100 mg/kg berberine and had retarded tumor growth that was dose-dependent, as well as inhibited cell migration and invasion in the lungs of the mice through the upregulation of miR-101 transcription via AP-1 and the suppression of COX-2/prostaglandin E2 (PGE2) signaling pathways.¹⁷⁰ Female athymic mice that received a xenogaft of A459 and H1299 lung cancer cells and were administered with 50, 100 and 200 mg/kg of berberine had a dose-dependent slowing of tumor growth, and reduced tumor weight. The A459 xenografts were more sensitive than the H1299 xenografted tumors.¹⁴¹ A459 lung cells served as the xenograft for BALB/c nude mice, and there was an inhibition of tumor growth following treatment with 5 and 10 mg/kg berberine.¹⁴³

BALB/c nude mice with a xenograft of RPMI-8266 multiple myeloma cells and treated with 50 mg/kg berberine showed tumor growth retardation and significantly increased survival rates.¹¹⁶ Mice transplanted with B16 melanoma cells and injected with 1, 5, and 10 mg body weight berberine had reduced tumor growth in a dose-dependent manner. There was a significant reduction in tumor volume and tumor weight up to day 16 in the animals receiving 5 or 10 mg/kg body weight berberine (Table 2).¹⁷¹

BALB/c athymic nude mice with a xenograft of human PC-3 and LNCaP prostate cancer cells and injected with 5 and 10 mg/kg body weight of berberine twice a week for four weeks experienced significantly reduced tumor growth rates, volumes, and weights. Berberine treatment significantly increased the activities of cleaved caspase 3 and PARP in the mice treated with 10 mg/kg berberine, indicating the role of apoptosis in tumor shrinkage (Table 2). The LANCaP tumors were more sensitive than PC3 tumors to berberine treatment.¹¹⁹

H22 mouse HCC cells were transplanted into BALB/c mice, and mice that received 12.5, 25 and 50 mg/kg berberine had reduced tumor growth and volume that was dose-dependent.⁷⁵ The orthotopic model of MHCC-97L human HCC in BALB/c nu/nu mice treated with 10 mg/kg berberine every two days had effectively reduced tumor growth in the liver as well as the lung metastasis. Berberine treatment suppressed HIF-1α/VEGF signaling and expression of inhibitor of differentiation/DNA binding (Id-1), a key regulatory molecule for HCC development.¹⁷² The BALB/c nude mice with a xenograft of SSC-4 tongue carcinoma cells were treated with 10 mg/kg of berberine, which resulted in reduced tumor mass, volume, and growth.¹⁷³ The athymic nude mice with a C666-1 human NPC xenograft and administered with 5 and 10 mg/kg berberine every two days did not show tumor development on 30 and 36 days, respectively. However, tumors started to appear 31 ± 5 and 37 ± 5 days after the animals received 5 and 10 mg/kg berberine, respectively. Tumorigenic growth was detected in three out of five mice in 10 mg/kg berberine treatment group, indicating that berberine inhibited the growth of C666-1 nasopharyngeal carcinoma in nude mice. Berberine suppressed the activation of STAT-3 in vivo (Table 2).¹⁷⁴

Clinical studies

There is only one double-blinded multicentre clinical trial that was conducted in China, where 0.3 g berberine or placebo tablets were given twice daily to colorectal cancer patients (18–75 years of age) who had more than six histologically confirmed colorectal adenomas, including tubular, tubulovillous, and villous, which were surgically removed six months prior to recruitment. The berberine group consisted of 553 patients, whereas the placebo group consisted of 555 patients. Analysis of 429 patients from the berberine group and 462 patients from the placebo group after two years revealed that 155 (36%) patients had recurrent adenomas in the berberine group, compared to 216 (47%) patients in the placebo group (unadjusted relative risk ratio for recurrence: 0.77, 95% confidence interval (CI) 0.66–0.91; p = 0.001). The patients in the berberine-treated group did not have colorectal cancers during follow-up. Six (1%) patients complained of constipation out of 446 patients in the berberine group, which was the only adverse side effect of berberine. No other serious adverse effects were reported.¹⁷⁵

Toxicity studies

The mice injected with berberine through intravenous (i.v.) and intraperitoneal (i.p.) routes revealed LD₅₀ values of 9.0386 and 57.6103 mg/kg, respectively. However, it was not possible to determine LD₅₀ for the intragastric (i.g.) route since only 30% of deaths were recorded.¹⁷⁶ Berberine i.p. administration in rats revealed a LD₅₀ of 205 mg/kg; however, the administration of 50 mg/kg caused diarrhea in 40% of rats. The LD₅₀ in mice was 23 mg/kg following i.p. injection, whereas it was 329 mg/kg after oral administration.¹⁷⁷ Developmental toxicity of berberine was studied in pregnant rats at 6–20 days of gestation (GD) and mice at 6–17 GD. Rats were given 3,625, 7,250, or 14,500 ppm and mice were given 3,500, 5,250, or 7,000 ppm in their feed. The berberine did not cause the maternal death of any rats or mice, and the lowest observed adverse effect level (LOAEL) for rats was 7,250 ppm (531 mg/kg/day) and for mice was 5,250 ppm (841 mg/kg/day). Thirty-three percent of female mice died, and surviving animals drank more water. There was a reduction in fetal body weights of both rats and mice and no other adverse effects were seen.¹⁷⁸

Clinically diabetic patients receiving 500 mg berberine three times a day for 13 weeks exhibited transient gastrointestinal side effects including constipation, diarrhea, abdominal pain, and flatulence with no obvious alterations in liver enzymes and creatinine levels.¹⁷⁹ Four out of 12 cardiac patients receiving 0.2 mg/kg berberine infusion for 30 min exhibited ventricular tachycardia with torsade de pointes as an adverse side effect of berberine.¹⁸⁰ Administration of berberine in infants caused kernicterus with glucose-6-phosphate-dehydrogenase (G6PD) deficiency and displacement of bilirubin from binding proteins.^181,182 Though berberine has been reported to be safe clinically, it should not be given to pregnant women, breastfeeding mothers, or G6PD-deficient neonates. Individuals with severe gastrointestinal disorders should also not be given berberine to avoid further complications.

Mechanism of action

Berberine employs multiple putative mechanisms to trigger cytotoxicity in various cancer cells (Fig. 2–4). One of the most important mechanisms of action of berberine is the acceleration of ROS formation in various cancer cells, which eventually leads to the stimulation of various pathways to kill cells.^{30–32,42–44,55,57,58,83,88,98,118,145,147,161} Berberine is able to kill a variety of cancerous cells by triggering apoptosis (Fig. 2) which may be: (1) ROS-dependent, (2) Fas-dependent, (3) p53-dependent, or (4) p53-independent. The acceleration of ROS formation leads to alteration in the mitochondrial membrane permeability and increased Ca²⁺ release, which subsequently activates AIF release from the mitochondria that leads to caspase-independent apoptosis by berberine (Fig. 2).^{42,44,59,88,151} The release of cytochrome c after berberine treatment also leads to apoptotic cell death by subsequent activation of Apaf-1, which causes the formation of apoptosomes and activation of caspase 9/7/3. Additionally, cytochrome c release is also mediated by the entry of Bcl2 family of proteins, especially BAX, into the mitochondria to trigger apoptosis.^{30–32,35,42–44,53,55,59,71,86,88,89,118,147} The triggering of DNA damage (DNA fragmentation, DNA strand breaks) and ER stress by berberine also induces apoptotic cell death leading to suppression of Bcl2 and BclxL, and activation of tBid, BAX and BAK.^{30–33,39,41,43,44,84,85,89,97,99,100,102,103,105,107,112,117,122,129,135,141,150,162} The secretion of Smac/DIABLO by the mitochondria after berberine treatment and subsequent activation of XIAP also induces cell death by apoptosis.^113,114,118 Berberine is also able to trigger the extrinsic pathway of apoptosis stimulated by TRAIL, FADD, FASL and TNFα that activates caspases 8/7/3 and PARP.^{30,31,37,41,43,44,48,53,55,59,61,65,69,99,112,113,117,130,136,145,155} Berberine stimulates necrosis by elevating the release of Cyp-D from mitochondria and promoting the translocation of p53 into mitochondria (Fig. 2). Berberine induces autophagy (Fig. 2) by upregulating LC3B-II and alleviating the SQSTM1/P62 proteins, and by converting LC3-I into LC3-II in various cell types (Fig. 2).^35,37,54

Fig. 2 Cytotoxic action of berberine (yellow shapes) through promotion of apoptosis, necrosis, autophagy, and cell cycle arrest (induces apoptosis).

Red color: upregulation, except caspases and BID, which are upregulated but shown in different colours. Δψm: mitochondrial membrane potential (reduction). AIF, apoptosis-inducing factor; Apaf, apoptotic protease activating factor; ATM, ataxia telangiectasia mutated; Bad, Bcl-2 agonist of cell death; Bak, Bcl2-antagonist/killer; Bax, Bcl2-associated X apoptosis regulator; Bcl, B-cell lymphoma; BID, BH3 interacting domain death agonist; Cdc, cell division cycle; CDK, cyclin-dependent kinase; ER, endoplasmic reticulum; FADD, FAS-associated death domain; LC3, microtubule associated proteins 1A/1B light chain 3B; ROS, reactive oxygen species; SQSTM1, sequestosome-1; TRAIL, tumor necrosis factor (TNF)-related apoptosis-inducing ligand; ULK, Unc-51 like autophagy activating kinase; XIAP, X-linked inhibitor of apoptosis protein.

Fig. 3 Berberine treatment suppressed epithelial-to-mesenchymal transition.

All molecules were downregulated except E-cadherin, which was upregulated. GSK, glycogen synthase kinase; HIF, hypoxia-inducible factor; IKK, inhibitor of nuclear factor-kappa B kinase; TCF, T-cell factor; TGF, transforming growth factor; Wnt, wingless-type MMTV integration.

Fig. 4 Many targets participate in the cytotoxic action of berberine in various neoplastic cells.

Red: upregulation. Blue: downregulation. ACC, acetyl-CoA carboxylase; ACL, adenosine triphosphate citrate lyase; AMPK, AMP-activated protein kinase; AP, activator protein; ATF, activating transcription factor; ATM, ataxia telangiectasia mutated; ATP, adenosine triphosphate; BMP, bone morphogenetic protein; C/EBP, CCAAT/enhancer-binding protein; CCR, C-C chemokine receptor type; CDK, cyclin-dependent kinase; COX, cyclooxygenase; CXCR, C-X-C motif chemokine receptor; DDIG, DNA damage-inducible gene; EBNA1, Epstein–Barr nuclear antigen 1; ERK, extracellular-regulated kinases; ETIF, eukaryotic translation initiation factor; FAK, focal adhesion kinase; FASN, fatty acid synthase; FoxO3a, forkhead box O3a; GADD, growth arrest and DNA damage-inducible genes; GSH, glutathione; HDAC, histone deacetylase; hERG, human ether-à-go-go-related gene; IHCBP, immunoglobulin heavy chain binding protein; IL, interleukin; JNK, c-Jun N-terminal kinase; LDH, lactate dehydrogenase; MMP, matrix metalloproteinase; MRP, mitochondrial ribosomal protein; NADPH, nicotinamide adenine dinucleotide phosphate hydrogen; NAG, nonsteroidal anti-inflammatory drug activated gene; Nestin, neuroectodermal stem cell marker; Notch, neurogenic locus notch homolog protein; PTTG, pituitary tumor transforming gene; SCAP, SREBP cleavage-activating protein; Skp, S-phase kinase-associated protein; SREBP, sterol regulatory element-binding protein; STAT, signal transducer and activator of transcription; TCF, T-cell factor; TUFM, Tu translation elongation factor; VASP, vasodilator-stimulated phosphoprotein; Wif, Wnt inhibitory factor.

Berberine arrests cells in the G₀/G₁ phase of the cell cycle by negatively altering various cyclins and CDKs, and upregulating CDK inhibitors (Fig. 2), which would also contribute to cell death by apoptosis. Berberine also arrests cell in the G₂/M phase of the cell cycle in some of the cell lines by activating Cdc2 (p-Cdc2; Tyr15) and suppressing p-histone as well as Cdc2 and Cdc25 expression.^{36,42,75–79,48,51,52,59–61,68,69,72,82,83,92–94,103,126,132,140,142,145,152,155,161,162}

Regarding the formation of complexes with berberine and DNA, polyadenylic acid (poly-A) has a stronger affinity to bind to berberine than poly U and poly C, which may contribute to its anticancer activity and neoplastic cell death (Table 1).^105,183

Berberine alters various cell signaling pathways to exert its anticancer activity in various neoplastic cells. EGF increases the clonogenic potential of cells by triggering cell proliferation, and the suppression of EGFR by berberine plays an important role in reducing cell proliferation by inhibiting downstream targets such as Akt, MEK, and ERK/1/2, and their phosphorylation levels.^{33,35,37,43,44,65,66,79,91,93,115,120,131,154} VEGF is involved in angiogenesis, which is upregulated in different cancers due to various oncogenic stimuli including hypoxia, and berberine attenuates its expression along with VEGFR-2, reducing angiogenesis in various types of neoplasia.^{53,59,131,148,168,172} PI3K/Akt and MAPK (RAF/MEK/ERK) signaling pathways play a crucial role in normal gene expression and cell proliferation, and are linked to HER-2, EGFR, and various nuclear transcription factors. Berberine downregulates HER2/PI3K/Akt, EGFR-ErbB2/PI3K/Akt, and RAF, MEK, and ERK signaling pathways to exert its anticancer effect (Tables 1, 2).^{33,84,85,91,131,135,163} mTOR controls cell division, apoptosis, and autophagy by participating in multiple signaling pathways, and its activation increases cell proliferation, gene transcription, protein synthesis, and immune cell differentiation in cancer. It also plays a crucial role in the metabolism of cancer cells.¹⁸⁴ The suppression of mTOR activation in different cell lines by berberine is also one of its anticancer mechanisms of action.^{34,51,62,65,66,78,115,145,154}

The Wnt/β-catenin signaling pathway is involved in cell adhesion and its activation is linked to cell migration and invasion (metastasis), and berberine inhibits the activation of the Wnt/β-catenin signaling and reduces cell migration and invasion. Berberine increased E-cadherin and decreased N-cadherin expression, and attenuated TGF-β.^{38,64,90,101,104,125,143,169} The P38/MAPK signaling pathway is crucial not only in Wnt/β-catenin signaling but also in EMT (Fig. 3). Berberine negatively alters N-cadherin, fibronectin, vimentin, ERK1/2, PI3K/Akt, Ras-Raf-ERK, MMP-9, PDGFRβ, COL1A2, Snail-1, and Slug to attenuate EMT.^{35,36,104,125,143}

NF-κB and STAT-3 activation lead to an increase in cell survival, inflammation, and reduction in apoptosis, and they are overexpressed in the majority of cancerous cells. Berberine suppressed IKK/NF-κB and STAT3 activation, which seems to contribute to its anticancer effect in various cells.^{49,57,59,67,72,79,100,103,139,145,174} COX-2 is also overexpressed in most cancer cells and its upregulation promotes tumour cell growth. Berberine inhibited COX-2 overexpression in different cell types to reduce their proliferation and growth rates (Tables 1, 2).^{40,59,75,147,170}

p53 activates the transcription of the CDK inhibitors p21^Cip1 and p27^Kip1. Berberine elevated p53 in different cell lines and its activation is also related to the ability of berberine to trigger DNA damage and cell cycle arrest (Fig. 2).^{36,39,42,53,56,61,72,92,95,98–100,113,114,119,122,124,129,134,135,147,151,162}

Additionally, berberine interacts with numerous other targets to exert its anticancer effects (Fig. 4). It has been shown to suppress Jak-2, miR-19a, MMP 1, 2 &16, CD133, n-myc, Sox2, Notch2, Nestin, IL-18, IL-1β, Mcl-1, FAK, pJNK, Nrf2, Rho GTPases, EBNA1, CCR7, CXCR4, c-IAP1, p70S6K, miR-21, ACC, ACL, FASN, SREBP-1, SCAP, PLA2, SP1, CCND1, E2F1, PTTG1, Skp2, p4EBP1, VASP, ANGPTL4, CSF1R,TGF-β1, p38 kinases, AP-1, hTERT, c-Fos, E6 and E7, HDAC1/ 2/4, HPV-18 E7, SMAD4, TIMP-2, paxillin, Src, C23, EZH2, BMP7, NODAL, RAD51, GLUT1, homologous recombination DNA repair, NANOG, POU5F1, ATP, lactate dehydrogenase A, HK2, GSH, NADPH, MRPL48, TUFM, PTCD3. Berberine has also been shown to elevate PUMA, Cyp-D, EndoG, ER kinase, ETIF-2, GRP-78, IHCBP, C/EBP, DNA damage-inducible gene 153, Rb, GADD153, GADD45α, KLF6, ATF3, FoxO3a, Wee1, 14-3-3σ, ATM/Chk1, Beclin-1, ULK-1, AMPK, Wif-1, TCF-4, miR-145, miR-101, miR-155, miR-23a, miR-214-3p, CCNG1, CYP1A1, KRT17, c-Jun, NAG-1, ITGβ4, PDCD4, CDKN2A, GSK3β and citrate synthase.^{30–32,34–41,43,44,48–51,53–56,58,62–64,66,68,71,72,74,76–78,82,87,90,92,94,96,98–101,104,109,110,114,122,124,129,132,133,138,139,147–149,151–157,159,163,165,170}

Future directions

It will be purposeful to investigate various molecular targets of berberine in vitro and in vivo by cellular thermal shift assay, proteomic profiling, RNA sequencing, microarray analysis, Gene ontology analysis and MALDI-TOF in future. Future studies should also be directed to investigate the toxic profile of berberine in human volunteers to establish its safety after prolonged treatment. More clinical trails in different cancer types need to be conducted in future to firmly establish the chemotherapeutic potential of berberine in cancer treatment in clinical condition.

Conclusions

Berberine triggers a cytotoxic effect in various cancer cells of different tissue origins as well as mouse/xenograft human tumor models, indicating its potential as an anticancer agent. Berberine is able to upregulate or downregulate several cellular proteins to kill various cancer cells. Berberine accelerates ROS formation in tumor cells by triggering both Fas and mitochondrial-mediated caspase-dependent and caspase-independent apoptosis, necrosis, and autophagy to kill cells. Berberine arrests cells in G₀/G₁, S- and G₂/M phases, indicating that it can act at any stage of the cell cycle by suppressing cyclins and CDKs, and upregulating p53, p21^/Cip, and p27^/Kip. The cytotoxic effect of berberine is also due to its ability to modulate various cell signaling pathways including Wnt/β-catenin, mTOR, Ras-Raf-ERK, HER2/PI3K/Akt, EGFR-ErbB2/ PI3K/Akt, JNK, ATM/Chk1, p53, NF-κB, and COX-2/PGE2. A single clinical trial has shown improvement in gastric cancer patients with berberine. Clinically, berberine has exerted adverse effects in the form of constipation, diarrhea, abdominal pain, flatulence, and ventricular tachycardia with torsade de pointes in humans. Pregnant mothers should not be given berberine as it has shown adverse effects in preclinical models. There is a need to study the toxic profile of berberine more thoroughly in preclinical and clinical conditions to prove its safety after long term use in humans.

Abbreviations

ACC:: acetyl-CoA carboxylase

ACL:: ATP citrate lyase

AIF:: apoptosis inducing factor

AMPK:: AMP-activated protein kinase

AP:: activator protein

Apaf:: apoptotic protease activating factor

ATF:: activating transcription factor

ATM:: ataxia telangiectasia mutated

ATP:: adenosine triphosphate

Bad:: Bcl-2 agonist of cell death

Bak:: Bcl2-antagonist/killer

Bax:: BCL2 associated X apoptosis regulator

Bcl:: B-cell lymphoma

BID:: BH3 interacting domain death agonist

BMP:: bone morphogenetic protein

C/EBP:: CCAAT/enhancer-binding protein

CCR:: C-C chemokine receptor type

cdc:: cell division cycle

CDK:: cyclin-dependent kinase

CDKIs:: cyclin-dependent kinase inhibitors

COX:: cyclooxygenase

CXCR:: C-X-C motif chemokine receptor

DDIG:: DNA damage-inducible gene

DSBs:: double-strand breaks

EBNA1:: Epstein–Barr nuclear antigen 1

EGFR:: epidermal growth factor receptor

EMT:: epithelial-to-mesenchymal transition

ER:: endoplasmic reticulum

ERK:: extracellular signal-regulated kinase

ETIF:: eukaryotic translation initiation factor

FADD:: FAS-associated death domain

FAK:: focal adhesion kinase

FASN:: fatty acid synthase

FoxO3a:: forkhead box O3a

GADD:: growth arrest and DNA damage-inducible genes

GLP:: glucose-regulated protein

GSH:: glutathione

GSK:: glycogen synthase kinase

HDAC:: histone deacetylase

hERG:: human ether-à-go-go-related gene

HIF:: hypoxia inducible factor

IHCBP:: immunoglobulin heavy chain binding protein

IL:: interleukin

JNK:: c-Jun N-terminal kinase

LC3:: microtubule associated proteins 1A/1B light chain 3B

LDH:: lactate dehydrogenase

MEK/MAPK:: mitogen-activated protein kinase

MMP:: matrix metalloproteinase

MRP:: mitochondrial ribosomal protein

mTOR:: mammalian target of rapamycin

NADPH:: nicotinamide adenine dinucleotide phosphate hydrogen

NAG:: nonsteroidal anti-inflammatory drug activated gene

NAT:: N-acetyltransferase

NCAM:: neural cell adhesion molecule

Nestin:: neuroectodermal stem cell marker

NF-κB:: nuclear factor kappa B

Notch:: neurogenic locus notch homolog protein

PARP:: poly(ADP-ribose) polymerase

PCNA:: proliferating cell nuclear antigen

PTCD:: pentatricopeptide repeat domain

PTTG:: pituitary tumor transforming gene

RAF:: rapidly accelerated fibrosarcoma

Ras:: retrovirus-associated DNA sequences

ROS:: reactive oxygen species

SCAP:: SREBP cleavage-activating protein

Skp:: S-phase kinase-associated protein

SQSTM1:: sequestosome-1

SREBP:: sterol regulatory element-binding protein

STAT:: signal transducer and activator of transcription

TCF:: T-cell factor

TGF:: transforming growth factor

TIF:: translation initiation factor

TRAIL:: tumor necrosis factor-(TNF) related apoptosis-inducing ligand

TUFM:: Tu translation elongation factor

ULK:: Unc-51-like autophagy activating kinase

VASP:: vasodilator-stimulated phosphoprotein

VEGF:: vascular endothelial growth factor

VEGFR:: vascular endothelial growth factor receptor

Wif:: Wnt inhibitory factor

WTX:: Wilms tumor gene on X chromosome

XIAP:: X-linked inhibitor of apoptosis protein

Δψm:: mitochondrial membrane potential

Declarations

Acknowledgement

The author wishes to acknowledge the encouragement and patience of his wife Mrs. Mangla Jagetia during the preparation of this manuscript.

Funding

NON-SAP UGC Grant No. F4-10/2010(BSR), University Grants Commission, Government of India, New Delhi.

Conflict of interest

The author has no conflict of interest statement to declare.

Authors’ contributions

This study is the sole work of GC Jagetia.

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