ACLINICALGUIDEtoBLENDINGLIQUIDHERBS

HerbalFormulationsfortheIndividualPatient

KerryBoneMediHerbPtyLtd,Warwick,Qld,Australia

CHURCHILLLIVINGSTONE

FrontMatter

ACLINICALGUIDEtoBLENDINGLIQUIDHERBSHerbalFormulationsfortheIndividualPatient

KerryBone

MediHerbPtyLtd

Warwick,Qld,Australia

AnImprintofElsevier

Copyright

AnImprintofElsevier11830 Westline Industrial Drive St. Louis, Missouri

63146AClinicalGuidetoBlendingLiquidHerbs:Herbal

FormulationsfortheIndividualPatientISBN0-443-06632-9Copyright©2003,ElsevierScience(USA).Allrights

reserved.No part of this publication may be reproduced or

transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or anyinformationstorageandretrievalsystem,withoutpermissionin writing from the publisher. Permissions may be soughtdirectlyfromElsevier’sHealthSciencesRightsDepartmentin Philadelphia, PA,USA: phone: (+1) 215 238 7869, fax:(+1)2152382239,e-mail:healthpermissions@elsevier.com.Youmayalsocompleteyourrequeston-lineviatheElsevierScience homepage (http://www.elsevier.com), by selecting“CustomerSupport”andthen“ObtainingPermissions”.

Distributed in the United Kingdom by ChurchillLivingstone, Robert Stevenson House, 1-3 Baxter’s Place,Leith Walk, Edinburgh EH1 3AF, Scotland, and by

associated companies, branches, and representativesthroughouttheworld.

Churchill Livingstone and the sailboat design areregisteredtrademarks.

NOTICE

ComplementaryandAlternativeMedicineisanever-changing field. Standard safety precautions must befollowed, but as new research and clinical experiencebroaden our knowledge, changes in treatment and drugtherapymaybecomenecessaryorappropriate.Readersareadvised to check the most current product informationprovided by the manufacturer of each drug to beadministeredtoverifytherecommendeddose,themethodanddurationofadministration,andcontraindications.Itisthe responsibility of the licensed prescriber, relying onexperience and knowledge of the patient, to determinedosagesandthebesttreatmentforeachindividualpatient.NeitherthePublishernortheauthorassumesanyliabilityfor any injury and/or damage to persons or propertyarisingfromthispublication.

THEPUBLISHER

InternationalStandardBookNumber0-443-06632-9PublishingDirector:LindaDuncanAcquisitionsEditor:KellieWhiteSr.DevelopmentalEditor:KimFons

PublishingServicesManager:LindaMcKinleyProjectManager:EllenKunkelmannDesigner:JuliaDummittPrintedinChinaLastdigitistheprintnumber:987654321

Preface

When Simon Mills and I published Principles andPracticeofPhytotherapy(PPP)in1999,itwashailedasthefirsttextbookofmodernherbalpractice.Sincethen,severalother herbal texts have been released for the professionalreader. However, most of these publications contain onlyherbalmonographsandseemtobebasedontheassumptionthat knowing about the properties of herbs is all that isnecessary tounderstandherbalpractice.Furthermore,manyof these materia medica textbooks are not written bypracticing herbalists and, rather than acting as workingmanuals or references for the herbal clinician, are quitenegative about the worth and safety of many herbaltreatments(undertheguiseofanevidence-basedevaluation).

Very few, if any, modern texts reflect the current coreactivityofmostwesternherbalpractitioners:namelyarrivingat an individual prescription after an extensive consultationandthendispensingthisprescriptionasacompoundedliquidformulation.Herbalists in theU.K.,Australia, and theU.S.havefunctionedinthiswayformorethan100years,yetthismode of practice is regarded by many as on the fringe ofmedicine. This contrasts strongly with traditional Chinesemedicinewherethetextbooksdoreflectcurrentpracticeanddrawstrongly from the traditionalknowledgebase.Noone

inChinabelittlesthetraditionalbasisoftheirherbalpractice,unlikemanywesternherbaltexts.

For some time now, I have felt the need for a textreflecting the western herbalist’s art of formulating liquidsfor the individual patient. This need, coupled with thecommoncriticism thatPPPcontained too fewherbs, led tothe development of this book. In one sense, this text is anappendage to and update of PPP; this is particularlyreflectedinthewaythemonographsarewritten.

This book contains threemain sections.The first sectiondealswithallthepracticalissuesinvolvedinprescribinganddispensing liquid herbal products. The second sectionoutlines, with many worked examples, the rationale andthought processes behind using individual prescribingwithliquidherbsforthetreatmentofavarietyofhealthissues.Inthethirdsectionthereaderwillfindup-to-datemonographsonmorethan100herbs.Inparticular,thesemonographsarewrittenfromtheperspectiveofaprescribingherbalclinicianand contain indications from both traditional sources andscientific investigations. (One feature of themonographs isthat the level of evidence behind each indication is clearlystated.)

Thisbookwaswrittenforbothherbalstudents(whomayfindPPP rather daunting early on in their studies) and anyclinicianwhowishes to understand and apply in amodernscientific context the fascinating, flexible, and (in myexperience) clinically effective methodology of the

traditionalwesternherbalist.

KerryBone,Warwick,Australia,2003

Foreword

Many herbal texts are currently available. However,well-written guidelines to the actual practice of herbalmedicine are extremely rare. In most books, herbs aredescribed in general terms, reflecting their use in massmarketing. Those who are required in their work to giveherbal advice to individuals soon learn that the informationin monographs only goes part way to help make the rightdecisionsinpractice.

There is nothing more fascinating than the individualstory.Evensuccumbingtoillnessisapersonalpassagethatrequires a unique resolution. Each case of migraine orarthritisisunprecedented.Thosewhofindthemselvesusingherbs tohelppeople through their illnesses find themselvesinwonderfullyrewardingwork,butinanareathatisbarelycharted.

In our book Principles and Practice of Phytotherapy,Kerry Bone provided many illuminating case histories toindicatehowthegeneralherbalinformationcouldbeappliedtotheparticularneed.InAClinicalGuidetoBlendingLiquidHerbs, he goes much further. He combinesmany years ofherbalresearchandapersonalcommitmenttoproducingthehighest-qualityherbal remedieswithanequalexperience intheconsultingroomwithrealpatients.Withthiscombination

ofskills,hehasproducedthemostimportantguidetoherbalprescriptionsofar.

He introduces each medical condition with broadtreatment strategies and goals, and links this with relevantherbalactivity.Examplesofformulationsthatmightbeusedare given. However, it is clear that this is not a book ofrecipes. What Kerry has provided are tools for individualadaptation. The key is the choice of liquid preparations.Liquidextractsofherbsarethemostsuitableforblendingtoindividual needs. Among other advantages, liquids arecompact and convenient, involve minimal processing, andtruly reflect the chemical spectrum of the original herb.Unlike solid forms, a liquid has all these phytochemicalconstituents already in solution and does not need to bedissolved or subjected to the digestive processes to beavailableforabsorption.

Tomake the clinical guidelines particularly useful, noless than125herbmonographsareprovided.Each includesfullprescribinginformationandreferences.

The book is an essential prescribing reference for allserious herbal clinicians, including physicians, naturopaths,pharmacists,andotherswhowishtouseherbsproductivelyintheirworks.Thisbookwillserveasanexcellent textforherbalstudents.

SimonMills,UniversityofExeter,U.K.,May2003

Acknowledgments

Michelle Morgan, assisted by Janice McMillan, AllanKeith Baldock, Mark Walker, and Rob Santich, made asubstantial contribution to the monograph section of thisbook.Theirassistancewithliteratureresearchanddraftingisgratefullyacknowledged.Thanksalso toJanFroushegerandPetra Moroney for typing and corrections and to AmandaWilliamsandBerrisBurgoyneforproofreading.

TableofContents

FrontMatter

Copyright

Preface

Foreword

Acknowledgments

I:Overview

CHAPTER1:FundamentalConcepts

CHAPTER2:FormulatingfortheIndividualPatient

CHAPTER3:HowtoUsetheMonographs

II:Monographs

A

B

C

D

E

F

G

H

J

K

L

M

N

O

P

R

S

T

U

V

W

Y

DosageSummaryChart

GlossaryofHerbalActions

GlossaryofClinicalTrialTerms

HerbListingbyActions

ActionListingbyHerbs

HerbsPossiblyContraindicatedinPregnancy

Index

IOverview

CHAPTER1

FundamentalConcepts

WHYUSEHERBALLIQUIDS?If a person walks into any retail outlet that sells herbalproducts, from supermarkets to health food stores, simpleobservation will reveal that the vast majority of productsoffered are in solid-dose form, mainly as tablets and hard-shell capsules. Clearly the contemporary consumer of self-prescribed herbal supplements prefers these modern doseforms.Incontrast,healthcareprofessionals trainedinherbaltherapygenerallyemphasizetraditionalliquidpreparations.

This preference is not an anachronism. Herbal liquidpreparations confer considerable advantages. The mainadvantage,whichwillbeemphasizedinthisbook,istheeasypreparationofauniqueformulationaccordingtotheneedsofeach patient (extemporaneous dispensing). Anotherconsiderableadvantageofliquidsisthat,ifproperlyprepared,theyinvolveminimalprocessingduringtheirmanufactureandthereby truly reflect the chemical spectrum of the originalherbinacompactandconvenientform.

Superior bioavailability is also an underresearchedadvantageofherballiquids.Whenasolid-dosepreparationisingested,itmustfirstdisintegrate.Theplant’sphytochemicalsneed to dissolve in digestive juices (and the water that issimultaneously imbibed with the tablet or capsule) to beabsorbed by the body. Research has demonstrated that arelationshipexistsbetweentherateanddegreeofdissolution

of the phytochemicals in a solid-dose preparation and theirultimate absorption into the bloodstream. The advantage ofherbal liquids is that the all-important phytochemicalconstituentsarealreadyinsolution.

Herballiquidsconferconsiderabledoseflexibility,whichisespecially relevant when prescribing low doses for smallchildren. Additionally, children generally find liquids easierto take, although the taste can sometimesbe a challenge forthem.

TASTEISSUE

A perceived disadvantage of herbal liquids is their taste,althoughinthecaseofbitters, thetaste isanessentialfactorinthetherapeuticresponse.Thetasteissuecanbesomewhatexaggeratedbyaminorityofpractitionersandpatients.Thisauthor has found that only a minor percentage of patientsactuallycannotcopewith the tasteofherbal liquids.Askingeach patient before prescribing if they mind taking strong-tasting liquids is helpful. This practice will draw acommitment from people who say the taste issue is not aproblem.Thehealthcareprovidershouldprescribetabletsorcapsulestopatientswhosaytheydomind.

Most patients will grow accustomed to the taste of theirmixture, and the feedback is that someevengrow to like it.Flavoring preparations are available that are particularlyusefulforchildren.

The way an herbal liquid is taken can minimize theexperience of any unpleasant taste. The most importantfactors are the contact timeof the remedy in themouth andthe intensity of the contact. Some practitioners claim thatabsorptionfromtheoralcavityisoftenpartoftheactivityofherbalpreparations, thusprolonging thecontact timemay infactbepreferable.However,fromthepointofviewof taste,contacttimeinthemouthshouldbeminimized.

To reduce the intensity of the contact, the herbal liquid

must be diluted.However, if the liquid is diluted toomuch,the contact time will be too long. Thus a trade-off existsbetween intensity and contact time. The recommendation isthata5-mldosebedilutedwithapproximately10mlofwaterorfruitjuice.Thismixturecanbeeasilyswallowedinonego,making the contact time minimal. Another way to furtherreduce the intensity of the contact is to suck on some icebeforehand, which deadens the taste buds and the olfactorynerve. Chilling the medicine beforehand and adding chilledwaterisanotherwaytoreducethetasteintensity.

Contacttimecanbefurtherreducedbyimmediatelyrinsingthe mouth with water or fruit juice. Approximately 50 mlshould be quickly consumed immediately after the liquid istaken.Tobestachievethiseffect,thedilutedliquidshouldbein one hand and the rinse in the other. The two liquids arethen consumed in a one-two action, as quickly as possible.Using this technique, taste can be dramatically minimized,and fewpatientscomplainofanyproblem.Forherbswithalingeringaftertaste,eatingsomethingafterwardswillhelp.

Anotheroption to avoid the tasteof anherbal liquid is toput the liquid (undiluted) intoahardgelatincapsuleusingadropper. The capsulewill soften slowly over the next hour,thus it can be conveniently consumed well before thishappens.

HOWHERBALLIQUIDSAREMADESome of the factors involved in the preparation of herballiquidsareusefultoconsiderindetail.

STRENGTHORRATIO

The strength of an herbal liquid preparation is usuallyexpressedasaratio.Forexample,1:2meansthat2mlofthefinal preparation is equivalent to 1 g of the dried herb fromwhichthepreparationwasmade.Whenfreshherbsareused,theratiocanbebasedonthefreshweight,inwhichcase,thisinformation should be additionally specified. Herbal liquidpreparations weaker than 1:2 are usually called tinctures,whereas1:1and1:2preparationsarecalledextracts.Tincturesareusuallymadebyasoakingprocessknownasmaceration,whereas extracts are bestmade using percolation.However,tinctures can also be adequately manufactured by apercolationprocess.Thesedays,1:1 liquidextractsareoftenmadebyreconstitutingsoftorpowderedconcentratesandasaresultcanbeofinferiorquality.

SOLVENTUSED

Ethanol (or alcohol) has been used for hundreds of years toprepareherballiquidpreparations,andethanol-watermixturesdoappear tobequiteefficient for theextractionof thewidevarietyofphytochemicalsfoundinmedicinalplants.Oldtextsdescribe steeping herbs in wine for long periods and thenusingtheresultantliquid.

Anumberofstudieshavehighlightedtheimportanceofthecorrect choice of the ethanol percentage in terms ofmaximizingthequalityofherballiquidpreparations.ASwissstudyfoundthat55%ethanolwastheoptimumpercentagefortheextractionoftheessentialoilfromchamomile(Matricariachamomilla).1 Higher percentages of ethanol did not extractany additional oil, and the solids content of the extractwasdecreased, indicating that other componentswere being lessefficientlyextracted.Morerecently,Meierfoundthat40%to60%ethanolwastheoptimumrangeforachievingthehighestextractionefficiencyfortheactivecomponentsofavarietyofherbs.2Forexample,at25%ethanol,noneofthesaponinsinivyleaves(Hederahelix)wereextracted,butat60%ethanol,they were maximally extracted. Similarly, the alkylamides,which give the oral tingling sensation from Echinacea, arebetter extracted at higher ethanol percentages. Extracts ofmilkthistle(Silybummarianum)preparedin25%ethanolwillnot contain any silymarin because it is insoluble at thisconcentration.

Practitioners shouldkeep this consideration inmindwhenassessingahigh-ethanolicextractofanherb.Inmanycases,theproductmaybemoreactive(becauseofthecorrectchoiceof a high ethanol percentage), thus less liquid needs to beprescribedforaneffectivedose.Thepatient’sethanol intakemayactuallybelowerthanwhenprescribedahigherquantityofalow-ethanolextractofthesameherb.

Higher ethanol percentages do not always confer higheractivity.FrenchresearchersfoundthatViburnumprunifoliumbark extracted at 30% ethanol was five times morespasmolyticcomparedwitha60%extract.3

The basic guidelines for the choice of the ethanolpercentage tooptimize theactivityof the final liquidextractareasfollows:

•25%:Water-solubleconstituentssuchasmucilage,tannins,andsomeglycosides(includingsomeflavonoidsandafewsaponins)

•45%to60%:Essentialoils,alkaloids,mostsaponins,andsomeglycosides

•90%:ResinsandoleoresinsGlycetracts or glycerites are herbal liquid preparations

madeusingglycerolandwater insteadofethanolandwater.Glycetracts are useful preparations when the activecomponents are water soluble, for example, marshmallowroot(Althaeaofficinalis),becausetheydonotcontainalcohol,

and the sweetness of the glycerol gives them a better taste.However,theimportanceofthesepreparationsshouldnotbeoverrated.Glycerol is a poor solvent formanyof the activecomponents found in herbs, and glycetracts are less stablecompared with alcoholic extracts (see the later discussion).Moreover,becauseof theviscosityofglycerol, concentratedpreparations are difficult to make by percolation. Themanufacture of 1:1 or 1:2 glycetracts therefore invariablyrequires the use of a concentration step involving theapplicationofheatorvacuum,whichrisksdeteriorationoftheproduct.

Somepractitioners are concerned about possible exposureoftheirpatientstothetoxiceffectsofethanol,suchasduringpregnancy.However, thesetoxiceffectsaredoserelatedanddonotoccurforthesmallquantitiesofalcoholinvolved.Foradverseeffectstoariseafterethanolintake,thebloodalcohollevelmustrisetoacertainlevel.A5-mldoseofherbalextractcontainsasmuchethanolasdoesapproximatelyonesixthofastandardglassofbeerorwine.Theliverrapidlymetabolizessuchasmallintakeofethanol,andconsequentlyitseffectonthebloodalcohollevelmightnotevenbemeasurable.Onlyamuch higher intake of ethanol will overload the liver’smetabolizing capacity and lead to significant blood alcohollevels.Moreover,thebodyisnaturallyconditionedtoasmallexposure to ethanol from ripe fruit and the naturalfermentation of food. Refrigeration has minimized thisexposureinindustrializedcountries.However,humanbeings,betheychildrenoradults,haveevolvedandadaptedtolevels

ofethanol intake throughfood thataresimilar to thosefromherbalextracts.

Onlyasmallminorityofpatientsaregenuinelysensitivetoethanol.Inotherindividuals,apresumedsensitivityisonlyanexaggerated reflex response to the medicine, which canusuallybe alleviatedbyprescribing lowerdoses at agreaterfrequency, taken with food or water. Recovering alcoholicsandMuslimsareadvisedto taketabletpreparations.Patientswithmildliverconditionsshouldnotbeadverselyaffectedbyasmallethanolintake.

Herbal liquid preparations based on alcohol can exhibitsuperior bioavailability. Results of a double-blind, placebo-controlled, crossover study on children with chronicobstructed airways were reported in the “Industry News”sectionof theZeitschrift fürPhytotherapie.4 The therapeuticeffectsofethanolicandethanol-freegalenicalextractsof ivyleaves (Hedera helix) were compared. Spirometric testingshowed a significant improvement in lung function for bothproducts,whichwassuperiortoconventionalbronchodilators.However,resultsindicatedthattheadditionofalcoholtothepreparationyieldedanincreaseinthebioavailabilityofactivecomponents.Thedoseofthealcohol-freepreparationneededtobeadjustedtoahigherleveltoobtainthesameeffect.

GLYCEROL-WATERCOMBINATIONS

Recently, glycerol-water preparations have become popular,resultingfromsomeperceiveddisadvantagesofethanol-watercombinations (see thepreviousdiscussion).A less importantreason in real terms is that glycerol is seen to be less toxicthanisethanol.However,glycerolischemicallyclassifiedasanalcoholandisalsotoxicathighlevels.The26theditionofMartindale’sExtraPharmacopoeiastates that largedosesofglycerol by mouth can exert systemic effects such asheadache,thirst,andnausea.Theinjectionoflargedosesmayinduce convulsions, paralysis, and hemolysis. A 2.6%solutionofglycerolwillcause100%hemolysisofredbloodcells. Glycerol has an irritant effect on the gastric mucosawhengivenatconcentrationsgreaterthan40%,andlargeoraldoses of glycerol caused signs that were misdiagnosed ascardiac arrest in one elderly patientwith hypertension.5Theauthorsconcludedthattheseelderlypatientswereliabletobedehydratedandthattheeffectsfromglycerolingestiononanemptystomachmaybeacute.5

However, it must be stressed that, similar to ethanol, thelow intake of glycerol involved in using herbal preparationswillnotcausenegativehealtheffects.

Mostimportantly,glycerolorglycerol-watercombinationsarepoorsolventsformanyoftheactivecomponentsfoundinherbs. For example, essential oil components, resins, andmany saponins will not extract well into glycerol-water

combinations. Some companies have developed a specialprocesstoovercomethisproblem.Theherbisfirstextractedwith an ethanol-watermixture.The ethanol is then removedand replaced with glycerol. However, quantitative andqualitative analyses have been initiated usinghighperformanceliquidchromatography(HPLC),whichshowthat if this process is not performed correctly, considerablelossesofactivitycanresult.Theremovaloftheethanolmaycause loss of volatile components and may also causeprecipitationofactivecomponentsbecausetheyarenolongersolubleoncetheethanolisremovedortheglycerolisadded.These problems can sometimes be overcome but only withgreat care in manufacture, dealing with each problem on acase-by-casebasis.

Glycerol is a poor preservative. Several instances ofhomemadeorcommercialherbalpreparationshavedevelopedbacteriaormoldgrowths.Additionally,fewstudieshavebeenconducted on the long-term chemical stability of glycerol-basedherbalproducts.

MACERATION

As previously mentioned, the two most common extractionmethodsusedtoprepareherballiquidproductsaremacerationandpercolation.Witheither technique, thesolvent is termedthe menstruum, and the inert, fibrous, or other insolublematerial remainingafter themenstruumhasdone itswork iscalledthemarc.

Withmaceration:

•Themenstruumisusuallyanethanol-watermixture.

•Theherbismaintainedincontactwiththemenstruumforarelativelylongperiod.

•Theprocessisconductedatordinaryroomtemperature.

•Afterstraining,theliquidremaininginthemarcispressedoutandmixedwiththestrainedliquid.(Themarcoftensoaksupaconsiderablequantityofmenstruumthatcanonlybesatisfactorilyrecoveredbypressing.)The form of the herb varies. Although the whole herb is

sometimesused,thecutherbandinsomecasesthepowderedherbaremoreoftenused.Therequiredamountofherb(say1kg)isplacedinavessel;therequiredamountofmenstruumisalsoputinthevessel(say5L,tomakea1:5tincture);andthevessel is closed toprevent the lossof alcohol.Thevessel isshakenandthecontentsturnedregularly,preferablydaily,for

alengthoftimethatdependsontheherb,butisusuallyfrom7 to 10 days. The direction to shake or stir daily must bestrictly adhered to so as to disperse the saturated layer ofmenstruum that surrounds the marc, thereby allowing freshliquidtocomeintocontactwiththemarc.Aftertheprescribedtime, the liquid is drained from the residue or marc.Whendrainingiscompleted,themarcisputinapresstoobtainthatpartofthemenstruumthatthemarcabsorbed.

Thepressingofthemarccanbedoneinvariousways.Oneofthemostbasicistoenclosethemarcinaclothandthentomanually squeeze out the menstruum. The best way ofexerting pressure is to put the marc into a press. Theexpressed liquid is mixed with the strained liquid and themixturelefttostanduntilitisclear,whereuponitisfiltered.Normally, no final adjustment to a definite volume isrequired.Thereasonforthisomissionisthatthefinalvolumeof liquid extract depends on the type and efficiency of thepress.Additionally, the liquid retained in themarc is of thesameconcentrationasistheliquidthatwasstrainedoff.Thustheactofmakingthevolumeuptoasetamount,forexample,the same amount of menstruum that was originally used,would give a final product of varying concentration,dependingontheamountofmenstruumleftinthemarcafterpressing.Moreover,anyadjustmentwoulddestroytheratioofthetincture,whichmustbepreservedfordoseconsistency.

PERCOLATION

Inthemajorityofinstances,percolationisconsideredthebestmethod for obtaining a solution of the active principles ofherbs. Briefly, percolation consists of allowing a liquid, themenstruum, to trickle slowly through a column of the herbthat has been previously ground into a more or less finepowder. The liquid is carried out in a vessel called apercolator in suchaway that every solidparticle is, in turn,submittedtothesolventactionofthegravitatingfluid.

The process of percolation, as laid down in variouspharmacopeias, is carried out as follows: the crude herb isreduced to a degree of fineness,which is specified for eachcase, and it ismoistenedwith an amountof themenstruum,again specified for each case. The herb is evenlymoistenedwith this amount ofmenstruum and then placed in a closedvesselfor4 to24hours.Thisprocedure isusedtoallowtheparticlesoftheherbtoabsorbthemenstruumandtoswelltoacertain degree. If dried herb was placed directly into thepercolatorandthenbroughtintocontactwiththemenstruum,itmayinsomecasesswellsufficientlytocompletelyobstructthe flowof themenstruum through the percolator.After thedesignatedtime,themoistpowderispassedthroughacoarsesievetobreakupanymassesformed.

Before the percolator is packed, the bottom of thepercolator must be loosely plugged with a wad of somematerialsuchasglasswooltopreventthepowderfromfalling

through the outlet and blocking it. The moist herb is nowintroduced into the percolator, each layer of 2 to 3 cm inthicknessbeing lightlypresseddownbymeansof a suitableimplement. The technique of packing the percolator isfundamental to the quality of extract at the end. Thepercolatorisnowplacedinposition,andasufficientquantityofthemenstruumispouredon.Ifalltheconditionshavebeenproperly observed, themenstruumwill penetrate the wettedpowder equally until it has passed to the bottom of thepercolator.

Theoutlet is closed, and thepercolator isnowcovered topreventevaporationandlefttostand(usuallyfor24hours)toallowtheherbtomacerateinthemenstruum.Thismacerationfacilitates the extraction process. Percolation is thencommenced by opening the outlet to such a degree that theliquiddropsfromitatarateof10to30dropsperminute.Alayerofmenstruummustbeconstantlymaintainedabovethepowder. Percolation is continued until three quarters of thevolume of finished product has been collected or until theherb is exhausted.The fluid collected from thepercolator iscalled the percolate. When the percolation is finished, themarc is often removed from the percolator and pressed, theexpressed liquid is then mixed with the percolate, and asufficient amount of menstruum is added to produce therequiredvolume.Inthecaseinwhichthemarciscompletelyexhausted by percolation, pressing themarc is not required.Theresultingpercolateisthenfiltered.

This percolation process is sometimes described as cold

percolation because it is conducted at room temperaturewithouttheapplicationofheat.

WHYARE1:2HERBALLIQUIDSGENERALLYRECOMMENDED?Evenusingpercolation,manufacturinga1:1liquidextract(1kg of dried herb extracted into 1 L of liquid) is difficultwithoutusingsomeformofconcentrationstep.Thisproblemoccursbecausethebulkynatureofmostherbsmeansthatthevolume of 1 kg generally far exceeds the volume of 1L ofliquid.Additionally,manymanufacturersarenotinterestedinthe labor-intensive and costly requirements of doingpercolationproperly.Hence1:1 liquid extracts are producedinefficiently because phytochemicals are lost or changedduringaconcentrationstep,ortheherbispoorlyextractedina vain attempt to produce a highly concentrated product bylimitingtheamountofsolvent,orboth.

This problem was the main reason why herbaliststhroughouttheworldinthe1970smovedtoadopttincturesastheir preferred liquid products.However, because traditionaldose information was typically based on high-quality 1:1extracts,theuseofthesemoredilutepreparationsresultedinareductionoftheactualdosegiventopatients.

Approximately 20 years ago the author of this text chose1:2 liquid extracts made by cold percolation as a preferredpreparationbecausetheyrepresentedthebestofbothworlds.Similar to tinctures, liquid extracts donot needheatingor aconcentrationstepintheirmanufacture,thusnoriskoccursto

the delicate balance of the phytochemical spectrum of theoriginal herb. However, liquid extracts are sufficientlyconcentrated to allow the convenient use ofpharmacologicallyeffectivedoses.Atrue,well-extracted1:1liquid extract cannot bemadewithout using a concentrationstep (meaning that at least 2 L of percolate needs to beproduced forevery1kgofherb,which is thenconcentratedback to 1 L). In contrast, 1:2 extracts can achieve high-extractionefficiencies.

Theargumentholdsthat1:2extractsarerelativelynew,arenot mentioned in the British Herbal Pharmacopoeia 1983(BHP) or other pharmacopeias, and therefore should not beused.Infact,1:2extractsarementionedinnineteenthcenturytexts6,7andaredescribedintheseventheditionoftheGermanpharmacopeia (Deutsches Arzneibuch [DAB], published in1968).8 The seventh edition of the DAB actually defines aliquid extract as a 1:2 extract.9 Therefore the precedent fortheiruseisample.

FRESHPLANTTINCTURES

Inrecenttimes,theuseoftincturesmadefromthefreshplanthas become popular among some herbalists. The belief isoften that a fresh plant tincture better reflects the plant’s“vitality”or“energy”andthereforewillbeamoretherapeuticpreparation. Other practitioners believe that a fresh planttincturewillbetterpreservethedelicateactivecomponentsoftheplant.

On the other hand, the following observations need to beconsidered:

•Theevidencefromphytochemicalanalysisthatfreshplanttincturescontainbetterlevelsofactivecomponentsthandodriedplanttincturesisgenerallylacking.Infact,freshplanttincturesareusuallypreparedinalow-alcoholenvironment(seelaterdiscussion),whichmeansthatsomelesspolar(morelipophilic)componentsmaybeonlypoorlyextracted.Furthermore,theenzymaticactivityoftheplantmaterialmaynotbeinhibitedinthislow-alcoholenvironment,meaningthatkeyphytochemicalsmayactuallybedecomposedduringthemacerationprocess.ThisfactwasdramaticallyillustratedbyBauer,whofoundthatcichoricacidinfreshplantpreparationsofEchinaceapurpureawaslargelydecomposedbyenzymaticactivity.10ThereforewhatcanbefoundinthelivingEchinaceaplantwasnotpreservedinthefreshplanttincture.

•Freshplanttinctureswereneverofficial.Althoughfreshplantpreparationswereincludedinhomeopathicpharmacopeias(whichisunderstandable,giventheenergeticconsiderationsinhomeopathy),theywereneverlistedinconventionalpharmacopeiasotherthanafewentriesforstabilizedfreshjuicesknownassucci(singular:succus).Hencetheuseofawiderangeoffreshplanttincturesistravelintounknownterritory.

•Becauseofthewatercontentoffreshplanttinctures,makingpreparationsthatarestrongerthana1:5onadry-weightbasisisdifficult.Thisproblemcanbereadilyillustratedbythefollowingexample.Aleafy,freshplantmaterialtypicallycontains80%moisture.Therefore100gofthismaterialrepresents20gofdriedherb.Tomakea1:5tincture,this20-gequivalentofdriedherbmustbemixedwith100mlofliquidmenstruum.However,80mlofwateralreadyexistsfromtheherbitself.Thereforetopreservethe1:5ratio,only20mlof96%ethanolcanbeadded.This20mlofethanolisnotenoughtophysicallyextractthebulky100goffreshplantmaterial.However,whatisprobablyjustasdetrimentalisthattheeffectiveethanolpercentageisonly20%(20mlofethanoland80g[orml]ofwaterfromthefreshplant).Thisamountistoolowtoextractlipophiliccomponentsandbarelyenoughtopreservethetincture.Someauthorssuggestusingmultiplemacerationtoovercomethisproblem,wherebytheresultanttinctureismaceratedwithanewbatchoffreshherb,butthisonlymakesthesituationworse,dilutingthealcoholtobelowthelevelthatcan

stabilizethefinaltincture.Insummary:

•100gofafreshplantcontaining80%moistureismaceratedin20mlofsolvent(alcohol-water).

•Thedriedherbweightis20g.

•Theamountofliquidis80ml(moisturefromthefreshplant)+20ml(solvent)=100ml.

•Hencetheresultisequivalenttoa1:5tinctureonadry-weightbasis(20-gdriedherb:100-mlliquid).

•However,theresultmaybeevenweakerbecauseoftheenzymaticdecompositionandtheloweffectiveethanolpercentage.Clearly from thepreviousdiscussion,given that thewater

contentoffreshleafyplantmaterialvariesfrom75%to90%,theonlypracticalwaytomakeareliablefreshplanttinctureistoworkonanequivalentdriedherbratioof1:10.(Perhapsa1:5 ratio can be achieved for roots, barks, and seeds thatcontain lessmoisture.)However, because the use of 1:10oreven 1:5 tinctures makes therapeutic doses of most herbsdifficult, theherbalpractitionerwhoendorsespharmacologicdosingwillgenerallyfindlittleadvantageinusingfreshplanttinctures.Someexceptionsoccurbasedon traditionaluseorinstanceswhentheherbissopotentthatitisnormallyusedasatincture(e.g.,pokeroot,Thuja),butthesearefew.

From the previous discussion, a fresh plant tincture willneverbeasstrongaswilla1:1or1:2liquidextract,providedthat:

a.Theliquidextracthasbeenmadefromcarefullyharvestedanddriedrawmaterialofhighquality.

b.Thecorrectethanolpercentagewasusedtoextractthedriedherb.

c.Nostepswereusedinmanufacturing(e.g.,exposuretohightemperatures)thatwilldamagethedelicateactivecomponentspectrumoftheplant.Dried plant preparations made in such a way will still

preservethe“vitality”or“energy”oftheoriginalplant,whichis embodied in its chemical complexity. Fig. 1-1 gives avisual comparison of a dried plant extract (A) with a freshplant tincture (B) using a paper chromatography techniqueknown as vertical capillary dynamolysis. Adherents to theanthroposophy movement believe this technique candemonstrate the “vitality” of a preparation under test.Althoughtheanalysisofthechromatogramsissubjective,thefiguredoesshowthata“vitality”todriedplantextractsexists.

Fig. 1-1 A visual comparison of a dried plant extract (A)and fresh plant tincture (B) obtained by a paperchromatographytechnique(verticalcapillarydynamolysis).

Somepractitionersusefreshplantpreparationsthatare1:3or1:5 (or even1:10)basedon freshweight in themistakenbeliefthattheyareusinghighlyactivepreparations.However,a simple mathematical calculation shows that thesepractitioners are deceiving themselves. Taking a 1:5 freshweightratioasanexampleandassumingagainthat theherbcontains 80% moisture, the following calculations can bemade. If 100 g of fresh herb is macerated in 500 ml of

menstruum,thedry-weightequivalentofherbis20g,andthetotalamountofliquidis500mlplusthe80mlfromtheplant,which equals 580 ml. Hence the so-called 1:5 tincture isactually 1:29 on a dry-weight basis—completely unsuitablefortherapeuticherbaldoses.

GALENICALEXTRACTSANDTHECONCEPTOFSYNERGYAgalenicalextractisatraditionalpharmacopeialextractofanherb.Guidelineswerelaiddowninthevariouspharmacopeias(e.g., earlier versions of the British Pharmaceutical Codex)thatdefinedthemethodofpreparation,theextractingsolvent(whichwasusuallyacombinationofethanolandwater),andtheratioofthestartingmaterial(theherb)tofinishedproduct(the extract). Galenical extracts are usually in liquid form,typicallythetincturesandliquidextractsalreadydescribedinthis chapter. However, with the modern trend to solid-doseforms, quite often, a galenical extract is dried to its solidresidueandincorporatedintoatabletorcapsule.

Herbalists often regard galenical extracts as “whole”extractsinthattheyextractacomprehensivespectrumofthephytochemicalcontentof theplant.Although thispractice isgenerally the case, the reader should keep in mind thatalcohol-watermixturesarestillselectivesolventsanddonotequally extract everything from the plant that is extractable.Something will always be left behind, depending on thepercentage of ethanol that is chosen for the solvent. Theethanolpercentageslaiddowninthepharmacopeiasthereforerepresent what was thought to be the optimum solvent forextracting thewidest activity from the herb in question. Asmentionedpreviously,thepercentageswereoftenchosenwith

regardtotheparticularphytochemicalclassesknowntooccurin the plant; for example, a higher ethanol percentage waschosenforherbscontainingresinsoressentialoilsandsoonasalreadymentioned.

Themainreasonwhyherbalistsprefer“whole”orgalenicalextracts is their belief that the active component is the herbitself. In otherwords, all of the phytochemicals in the plantact together to confer the therapeutic benefit. According toSharma:11

…the active ingredientmodel does not stem from astrength of the scientific method, as often supposed;ratheritstemsfromaweakness—fromtheinabilityofthe reductionist methods to deal with complexsystems.

One of the underlying motivations for using galenicalextracts is the concept of synergy. Synergy is an importantconcept inherbalpharmacology. In thecontextofamixtureof chemicals (e.g., an herbal extract), synergy applies if thetherapeuticactionofthechemicalmixtureisgreaterthanthearithmeticsumoftheactionsofthemixture’scomponents.Inother words, the whole is greater than the sum of theindividual parts. A well-known example of synergy isexploited in the use of insecticidal pyrethrins. A chemicalsynergist known as piperonyl butoxide, which has littleinsecticidal activity of its own, interferes with the insect’sability to break down the pyrethrins, thereby substantiallyincreasing their toxicity. This example emphasizes what is

probably an important mechanism behind the synergyobserved for medicinal plant components: increased orprolongedlevelsofkeycomponentsattheactivesite.Inotherwords, components of plants that are not active themselvescanact to improvethestability,solubility,bioavailability,orhalf-life of the active components. Hence a particularchemical might, in pure form, have only a fraction of thepharmacologic activity that it has in its plant matrix. Thisimportant example of synergy therefore has apharmacokineticbasis.

Anexcellentdiscussionofsynergyinthecontextofherbaltherapywas provided by E.M.Williamson.12 According tothe author, “It is almost inescapable that these interactionsbetweeningredientswilloccur;however,whethertheeffectsaretrulysynergisticormerelyadditiveisopentoquestion…”In other words, the more likely interaction between thecomponents of a galenical extract is an addition of theirpharmacologiceffects, rather than truesynergy.Even in thiscase, the “whole”will still be better than a selection of theparts.

As previously inferred, one area in which synergisticinteractions probably apply is that of the enhancedbioavailability of key components. Eder and Mehnertdiscussedthebasicissues,andexamplescanbefoundinthescientificliterature.13The isoflavoneglycosidedaidzingivenin crude extract of Pueraria lobata achieves much greaterconcentrations in plasma thandoes equivalent doses of puredaidzin.14 Ascorbic acid in a citrus extract was more

bioavailablethanwasascorbicacidalone.15CoadministrationofprocyanidinsfromHypericumperforatum(St.John’swort)significantly increased the in vivo antidepressant effects ofhypericin and pseudohypericin.This effectwas attributed tothe observed enhanced solubility of hypericin andpseudohypericin in the presence of procyanidins. The resultalso indicates that pure hypericin and pseudohypericin haveconsiderably less antidepressant activity than do theirequivalentamountsinSt.John’swortextract.16

However,synergycanalsohaveapharmacodynamicbasis.Oneexampleistheantibacterialactivityofmajorcomponentsof lemon grass essential oil. Although geranial and neralindividually elicit antibacterial action, the third maincomponent, myrcene, did not show any activity. However,myrcene enhanced antibacterial activities when mixed witheitherof theother twomaincomponents.17SennosideAandsennoside C from senna have similar laxative activities inmice.However,amixtureofthesecompoundsintheratio7:3(which somewhat reflects the relative levels found in sennaleaf)hasalmostdoublethelaxativeactivity.18

Additional examples of synergy for galenical extracts areprovidedbyWilliamsonandincludekava,valerian,dragon’sblood,andArtemisiaannua.12

QUALITYISSUESFORHERBALLIQUIDS

NECESSITYFORPHARMACEUTICALGOODMANUFACTURINGPRACTICE

Inanumberofcountries, including those inEurope,aswellas Japan andAustralia, all herbal productsmust, by law,bemade according to the code of pharmaceutical goodmanufacturingpractice(GMP).Thiscodeisafail-safesystemofqualityassuranceandqualitycontrolthatdefinesanumberofproceduresandobservances,including:

•Validationofequipmentandprocesses

•Documentedstandardoperatingprocedurescoveringeveryaspectofmanufacture

•Documentedcleaningandcalibrationlogsforequipment

•Controlofthemanufacturingenvironment,air,andwater

•Quarantininganduniqueidentificationandtestingofrawmaterials,labels,andpackaging

•Discretebatchidentification

•Comprehensivebatchrecorddocumentation

•Reconciliationofrawmaterials,product,packaging,andlabels

•Quarantiningandtestingoffinishedproducts

•Documentedreleaseforsaleprocedures

•Testingofstabilityoffinishedproduct

•DocumentationofcustomercomplaintsandrecallproceduresAlthoughsomelargeherbalmedicinemanufacturersinthe

United States voluntarily comply with close to fullpharmaceuticalGMP,therecentlyproposedlegalrequirementisthatlessthanfullGMP(thesmallerGMPs)willneedtobeadhered to (at the timeofwriting,notyet law in theUnitedStates). The smaller GMPs are a series of qualityrequirements that, taken together, do not amount to fullpharmaceutical GMP. Currently, most herbal companies intheUnitedStatesoperateunderfoodGMP,whichisanevenlowerqualitystandard.

In practice, herbal manufacturing under pharmaceuticalGMP is probably more complex than it is for conventionaldrugsbecauseanherbisbiologicallydefinedand:

•Maybeincorrectlyidentified

•Mayvaryinchemicalcontentandhenceefficacy

•Carrieswithitahistory(e.g.,maybecontaminatedwithunwantedsubstances)

•Processingofherbsmayenhanceorimpairtheirsafetyandefficacy

•StabilitymaybedifficulttodefineandmeasureNevertheless, all of these considerations point strongly to

the importance of herbal products being made underappropriate pharmaceutical GMP. However, a specializedphytochemicalknowledge isalso required todealwith theseissues.

As part of pharmaceutical GMP, herbal raw materialsshouldbesubjectedtoabatteryofteststoensuretheirqualityand purity. These tests are outlined in BOX 1-1. The BHPprovidesausefulguidetotheBritishandEuropeanstandardsintheseareas.19

BOX1-1 HerbalRawMaterialTesting

•Identityandqualitywiththin-layerchromatography(TLC)

•Microscopicanalysis

•Macroscopicanalysisandorganolepticassessment

•Pesticideresidues

•Microbiallevels

•Aflatoxins

•Heavymetals

•Foreignmaterial

•Infestation

•Radiationlevels

•Activeormarkercompounds(quantitative)

Thin-layer chromatography (TLC) is a particularly usefultechnique for the identification of plant material. TLC canalso be used to quantify plant constituents. The process ofperformingTLCisoutlinedinBOX1-2.

BOX1-2 Thin-LayerChromatography(TLC)

•Anextractofanherbisspottedatthebottomofathinlayerofsilicagelonaglassplate.

•Theplateisdippedinasolventmixture.

•Thesolventdrawsupthelayerandcarriesthecomponentsintheherbfordifferentdistances.

•Sprays,ultravioletlight,orbothareusedtoviewthecomponents,givingacharacteristicpatternofspots.

•Eachspotcorrespondstoacomponentintheherb.

•Differentsolventsystemsdrawoutdifferentclassesofcomponentsintheherb.

Finished herbal products also need to undergo testingbefore their release.BOX1-3providesexamplesofpossibletestingprotocolsforfinishedherballiquids.

BOX1-3 QualityConsiderations forFinishedHerbalLiquidProducts

•Extractionefficiency

•Identitya.Organolepticassessmentb.TLCorHPLCfingerprint

•Activeormarkercomponents

•Microbialtestinga.Totalcountb.Pathogensc.Yeastandmold

•Pesticides

MARKERCOMPOUNDSANDACTIVECONSTITUENTS

InBoxes1-1and1-3, reference ismade toactiveormarkercompounds.Theopinionofthisauthorholdsthatproducingagalenicalliquidextractthatissettocontainaminimumlevelof a carefully chosenmarker compound or group ofmarkercompounds is often advantageous. In fact, setting thisminimumlevelismorethanjustadvantageous;itisapositivestep in the development of herbal quality, provided that theconsiderations discussed later are observed. Serious herbalclinicians should prefer such quantified activity liquidextracts.

Markercompoundsarecharacteristicphytochemicalsfoundinaplant thatarechosentorepresentastandardforquality.Hence in the case of say passion flower (Passifloraincarnata), the marker compound is often chosen to be theflavonoid isovitexin.Marker compounds are not necessarilyactive compounds (see later discussion). However, if wellchosen, marker compounds do serve a useful function interms of quality, such as the purposes of identification andensuring appropriate drying, handling, and extraction of theherbalstartingmaterial.

To achieve a consistent level of a marker compound (orcompounds) in a liquid extract, the starting herbal rawmaterialwill usually need to contain aminimum acceptablelevel. This measure implies consistent quality practices in

terms of harvesting, drying, and storage of the herb.Additionally,thewayinwhichtheherbisprocessed,suchasextraction conditions and choice of solvent, will need to becarefully controlled. As a consequence, fixing a galenicalextract to a consistent level of marker compound orcompounds will also likely render the extract more or lessconsistent in terms of other phytochemical components, atleast for that particularmanufacturer. This aspect underpinsmuchoftheutilityofsuchextractsasconsistentproducts.

Active constituents are phytochemicals, which areimportant for agiven therapeutic effectof anherbal extract.Although this issue is highly complex, one proposition issimple and clear: marker compounds are not necessarilyactive compounds. Hence when Ginkgo biloba leafstandardized extract (GBE) was originally manufactured tocontain 24% ginkgo flavone glycosides, no unequivocalevidenceexisted that thesecompoundsconferred thevariousand exciting therapeutic activities that had been discoveredfortheextract.Laterresearchsuggestedthatadifferentgroupofphytochemicals,theginkgolidesandbilobalide,weremoreimportant, and GBE is now standardized for these as well.However,intermsof,forexample,itseffectsinAlzheimer’sdisease,resultsdidnotshowwhicharetheactivecompoundsinGBE.Eveniftheginkgolidesandbilobalidewerefoundtobe important (this might be achieved by a clinical trialcomparing twoGinkgo extractswith high and low levels ofthesecompoundswhichwereotherwiseidentical),itwouldbeunlikely that they were the only compounds important for

activity.

Such a dilemma supports the basic premise of herbaliststhat the true active component is the herbal extract itself.Nonetheless, also likely is that an extract low in markercompounds, which from pharmacologic experiments havebeenfoundtohavesomerelevantactivity,willbelesslikelytoconferatherapeuticeffectandhencebeofpoorerquality.

This last point underlies an important issue with markercompounds:theyshouldbechosencarefully.Preferencemustbe given to phytochemicals that (on the basis of currentknowledge)are likely tohavepharmacologicactivity,whichisrelevanttotheproposedclinicaluseoftheextract.Ontheother hand, if a marker compound is chosen that has noknown useful pharmacologic activity, it should not beoptimized in the extract at the expense of otherphytochemicals. For example, selecting for and optimizingechinacoside levels inEchinaceaangustifolia at theexpenseofalkylamidesislikelytoleadtoalessactiveproduct.Whenthemarkercompoundisinactive(oncurrentknowledge),thesafest approach to take is to produce a normal galenicalextract using the marker as a quality guide only. However,selectingadifferentmarkerispreferable.

Thegreatbodyofpharmacologicandclinicalevidencethatresearchershaveforanherbsometimesrelatesonlytotheuseof one isolated, purified constituent. Good examples areephedrinefromEphedraandberberinefromBerberisspecies.Clearly, believing that extracts of these herbs should be

quantified for these compounds makes sense. On the otherhand,thetemptationtoregardtheherbalextractinquestionasmerely a carrier of this constituent should be resisted. Thewholeextractwillconfermatrixeffects,whichmightmodifytheactivityofthesekeycompounds.

STANDARDIZEDEXTRACTS

In the herbal context, a standardized extract is an herbalextractthatismadetoaconsistentstandard.Thisstandardcanbe quite simple, such as the ratio of the starting herbal rawmaterialtothefinishedextract.Hencea4:1extract,whereby4kgofdriedherb isextracted toyield1kgof finalextract,can technically be called a standardized extract. Generallyhowever, the term has a more specific meaning: astandardizedextract isone that ismanufactured tocontainaconsistent level of one or more phytochemical constituentsthatarederivedfromtheoriginalstartingmaterial.

The aim of standardized extracts is to achieve consistentactivityofanherbalproductfrombatchtobatch.Dependingonthecircumstances,thisconsistencyisnotalwaysthecase.If compounds other than the chosenmarker compounds areimportant for activity, and these are not also fixed atconsistent levels by the manufacturing process, then astandardizedextractwillnotachieveconsistentactivity.Iftheanalyticalmethodchosen isnot specific enough towards thedesiredmarkercompounds,theresultwillbefailureofbatch-to-batchconsistency,eventhoughthecertificateofanalysisoftheextractwillprovidedatatosuggestthesame“activity”foreachbatch.

Standardizedextractsarenotaguaranteeofquality,astheyare often represented. Inappropriate choice of markercompounds, poordesignor executionof analyticalmethods,

spiking with pure phytochemicals or other substances, orfailure to demonstrate phytoequivalence (that is, containingthe equivalent phytochemical spectrum) can mean that thestandardized extract is poorer in quality or less effectivecompared with a well-made galenical extract. Only themanufacturers who practice good science and have acomprehensive understanding of the many complex issuesthataffectherbalqualitywillbeable toproducemeaningfulstandardizedextracts.

Many standardized extracts are nothing more than“improved” galenical extracts. Provided these extracts areproduced carefully from good quality starting herb and theethanol percentage, marker compounds, and analyticalmethodology are appropriately chosen, this development ispositiveinherbaltherapy,whichistobecommended.

Standardizedextractsother thanthegalenical typeincludeselective phytochemical extracts (in which one particularphytochemical group is selectively extracted from the herb)and highly concentrated extracts (usually greater than 10:1).Both of these extracts aremade by processes different fromthoseused in themanufactureofgalenical typestandardizedextracts.Theymayinvolveextractionwithsolventsdifferentthanethanol-watermixtures(e.g.,acetone,chloroform,liquidcarbon dioxide), multiple solvent extraction steps, andstandardchemicalisolationtechniques(e.g.,chromatographycolumns,ionexchangeresins,precipitation).

Selective phytochemical extracts and highly concentrated

extractsarealsocoveredbythegeneraltermof“standardizedextracts”; but these products are quite different fromstandardizedgalenicalextracts.Inafewcases,whethertheseproducts can even be called herbal products is arguable.However, provided these extracts are supported by soundclinical and safety data, they do have a role in modernphytotherapy.Thetemptationamongscientistsandphysiciansis to regard theseproductsas true“herbal therapy”when, infact, they are only aminor part of a therapeutic system thatdraws from many hundreds, if not thousands, of galenicalextracts.

ADVANCEDMETHODSFORQUALITYCONTROLOFHERBALLIQUIDS

The accurate determination of active or marker compoundsrequires advanced methods of chemical analysis.Chromatography, particularlyHPLC, is ideally suited to theanalysisofherballiquids;butgaschromatographycanalsobeavaluabletechnique.

HighPerformanceLiquidChromatography.

Chromatographic techniques incorporate a means ofseparatingthechemicalcomponentsofamixtureandameansof detecting these components. In the case of HPLC, theseparation technique is a narrow column packed with asuitablechemicalthroughwhichaliquid(mixtureofsolvents)containingthe testmixture isdrivenathighpressure.Astheseparated chemical components of themixture emerge fromthecolumnonebyone,theyaredetectedusinganappropriatetechnique.Theresultsaredisplayedgraphically:eachpeakonthegraphcorrespondstoacomponentofthemixture(e.g.,anherbal extract).The area of each peak is proportional to theamountofchemicalcomponentpresent.Thistestcanbeusedto measure each chemical compound, provided a suitablechemical reference material (which is often the compounditself) is available. Under the same chromatographicconditions, a given compound will take the same time totravelthroughthecolumn.Thischaracteristicisknownasthe

retentiontimeandprovidesinformationabout theidentityofthecompound.

Themost common detection systemused inHPLC is theabsorption of light by the compound as it passes a detector.This light can cover a wide spectrum from ultraviolet tovisiblewavelengths, referred toasUV-VIS in the jargon. Inmore sophisticatedmodernmachines, the completeUV-VISspectrumofthecompoundcanbedeterminedasitpassesthedetector.Thedetectionsystemcapableofperformingthistaskiscalledadiodearraydetector.This spectrumalsoprovidesvaluableinformationabouttheidentityofthecompound.

Other detection systems used in HPLC that can alsoprovide information about the amount of the compoundpresentanditsidentityaswellincludemassspectrometryand,in highly expensive and sophisticated equipment, nuclearmagneticresonance.

GasChromatography.

Inthecaseofgaschromatography(GC),thechemicalmixtureisdriventhroughalongglasscapillarycolumnbyaninertgassuch as nitrogen.This technique is suitableonly for volatilesubstances, such as essential oils. Alternatively, nonvolatilesubstances can bemade volatile by first reacting themwithanotherchemical,atechniqueknownasderivatization.

ThedetectionsystemoftenusedinGCisflameionizationdetection (FID). As each compound emerges from thecolumn,itiscombustedinaflame,whichgeneratesionsthat

aretransformedintoanelectricalsignal.Again,theresultsaredisplayedgraphically(oftenreferredtoasthetrace)witheachpeak on the graph corresponding to a compound in themixture(e.g.,anessentialoil).

FIDdoesnotprovideanyinformationabouttheidentityofeachcompoundpeakinthetrace(otherthanthatprovidedbytheindividualretentiontimes).Thereforeamoresophisticatedtechnique that is capable of providing this additionalinformation is being increasingly used. This technique isknown as gas chromatography with mass spectrometrydetection(GC-MS).

EXAMPLESOFCOMMONLYENCOUNTEREDQUALITYPROBLEMS

Substitution.

Theissueofsubstitutionis themostsignificantquality issuefor herbal medicine today, and some relatively commonproblemsforherballiquidsarediscussedhere.

Arnica.

Arnica montana is becoming increasingly rare in the wild;hencesubstitutionwithArnicachamissonis isnowpermittedin the pharmacopeias. The therapeutic properties are quitesimilar. However, another substitution is more widespread,presumably because of the high cost of authentic Arnicaspecies. This substitution is with Heterotheca inuloides(Mexicanarnica),whichresemblesArnicaverycloselyinthedried form.TheGerman Pharmacopeia (DAB 10) providesmethods for the ready differentiation between authentic andMexican arnica. Heterotheca inuloides contains theflavonoids rutin and hyperoside, whereas authentic Arnicadoesnot.20

Brahmi.

BothCentellaasiatica(gotukola)andBacopamonnierihavethe same common name of Brahmi in India, and they areoften interchanged.20 Detection of gotu kola’s characteristic

compoundsisreadilyachievedbyHPLC,whichallowseasydifferentiationbetweenthetwoherbs(Fig.1-2).

Fig.1-2 HPLCtraceofBacopa(Bacopamonnieri)andgotukola (Centella asiatica) extracts showing the peaks of themajoractiveconstituentsingotukola.

Devil’sclaw.

Harpagophytumprocumbens(devil’sclaw)isaslow-growingtuber from southwest Africa, traditionally wild crafted, butcultivation is now underway. Substitution with the relatedspeciesHarpagophytum zeyheri has been widespread, withmost of the pre-1990s clinical work apparently beingperformed on a variable mixture of the two species. Thesubstitution is made during harvesting when the tubers are

collected from thewild.A proposal to allow this admixturewasput forth in the literaturebutwas rejected.HPLCusingdiode array detection enables ready differentiation betweenthetwomixturesanddetectionofadmixtures.Thecompound8-para-coumarylharpagide(8-PCHG)ispresentinonlysmallamounts in H. procumbens, but in larger amounts in H.zeyheri.Thekeymarkercompoundharpagosideispresentinbothspecies. Ifa ratioofharpagoside to8-PCHGofgreaterthan10 is set as aquality standard forH.procumbens, thensubstitution with or admixture with H. zeyheri is readilydetected.AnalysisofliquidproductsontheAustralianmarketindicated the presence of products containing significantamountsofH.zeyheri.21

Goldenseal.

Golden seal root (Hydrastis canadensis) is a very expensiveand endangered herb. Responsible practitioners should usethis herb only fromcultivated sources.The expense and theenvironmental issue has naturally led to the search forsubstitutions, some openly stated and others not. Commonsubstitutions for golden seal are golden thread (Coptischinensis), barberry (Berberis vulgaris), Indian barberry(Berberisaristata), andOregongrape (Berberisaquifolium).All of the varieties have the intense yellow color of goldensealbecauseoftheirberberinecontentbutarelackingthekeyand characteristic alkaloid of golden seal, namelyhydrastine.20 In fact, hydrastine is probably found only ingoldenseal.

Authenticliquidextractortinctureofgoldensealisreadilydifferentiated from its substitutes (or admixtures with them,whichisalsocommon)byHPLCusingdiodearraydetection(Fig. 1-3). A small peak for a berberine-related compoundappears before berberine in the substitutes. If this peak ispresent, then golden seal has been mixed with a substituteherb.Ifhydrastineisabsent,thenthesubstitutionis100%.

Fig.1-3 HPLCtraceofgoldenseal,goldenthread,Oregongrape, and an adulterated commercial herbal extract. Theconstituent hydrastine is contained only in the authenticgoldensealextract.

ArecentsurveyofeightgoldensealrootsamplesandtwoproductsintheUnitedStatesfoundthatonlyfiveoftheeight

root samples and neither of the products containedhydrastine.22 Surprisingly, one of the eight root samplescontained no berberine. Hence, of the 10 “golden seal”productsor root samples, only fivewere authentic.Someoftheauthenticfivemighthavealsobeenmixedwithsubstituteherbs,whichwasnotdeterminedinthestudy.

OneenterprisingcompanyhassuggestedthatitcansupplyIndian golden seal (Hydrastis mamira) as an alternative toHydrastis canadensis. However,Hydrastis mamira does notexist botanically. In fact, Hydrastis canadensis is the onlyknown speciesof thegenusHydrastis (theonly reference toanother Hydrastis species is to Hydrastis caroliniana in1788). A species of Coptis (Coptis teeta) is found in India,which has theHindi namemamira. The product in questionwasfoundtocontainberberinebutnothydrastine.

Skullcap.

Skullcap(Scutellarialateriflora) isawidelyusedbutpoorlyinvestigated herb (Fig. 1-4). Until quite recently, itscharacteristic flavonoidprofilewasunknown.Now,skullcaphas been shown that baicalin (also the main flavonoid inBaical skullcap—Scutellaria baicalensis) is the mainflavonoidinS.lateriflora,notscutellarin,whichisreportedinthetraditionalliterature.23TheAustralianTherapeuticGoodsAdministration(TGA)recognizedadulterationproblemswithskullcap and enforced product recalls on severalmanufacturers in the 1990s. Substitution is oftenwith otherspeciesofScutellaria.However,amoresinistersubstitutionis

that with Teucrium chamaedrys (germander) and otherspecies of Teucrium. This is a significant issue becausegermanderhasbeenlinkedtorarebutfatalliverdamage.

Fig. 1-4 HPLC trace of skullcap and Baical skullcapshowingthemainflavonoidspresentineachherbalextract.

StephaniaorAristolochia.

Aristolochia is commonly substituted for several Chineseherbs,butparticularlyStephaniatetrandra.Theproblemwiththis substitution is that Aristolochia is highly toxic and cancause renal failure. Aristolochia contains aristolochic acid,whereas Stephania contains tetrandrine, which allows readydifferentiation by HPLC using diode array detection. Asurvey of eight products sold as Stephania tetrandra byChineseherbwholesalersinAustraliaandHongKongfoundthat only one was authentic.24 Authorities such as the U.S.Food andDrugAdministration (FDA), theAustralian TGA,

and the British Medicines Control Agency (MCA) haveissuedhigh-levelwarningsaboutthiswidespreadsubstitution.OtherChineseherbssuchasAsarumarealsosubstitutedwithAristolochiaspecies.

Valerian.

European valerian (Valeriana officinalis) is substituted withcheaperformsofvaleriansuchasIndianvalerian(Valerianawallichii). Only European valerian contains valerenic acid,whichallowsthepositiveidentificationofthisspecies.20

KeyMarkerCompoundsAbsentfromtheHerb.

Keymarkercompoundsthatareknowntooccurinanherbatsignificant levels are sometimes absent in a product madefrom that herb. This absence may be a result of poor rawmaterialor inappropriateprocessing.For example, as shownin Fig. 1-5, an Andrographis extract (lot IWTC/5929/11)supposedly standardized to andrographolide (by aninappropriategravimetric technique)was foundbyHPLC tocontainvirtuallynoandrographolide.24

Fig. 1-5 HPLC trace showing key marker compoundspresent and absent in two herbal extracts ofAndrographispaniculata.

ThespeciesColeusforskohliiexhibitsvarietiesthatdonotcontain the important marker compound forskolin. SomeEchinacea products on the market lack the presence ofalkylamides(whichareoftenlostinprocessing).TheChineseherbPaeonialactiflora (whitepeony)contains the importantmarkercompoundpaeoniflorin.However,dependingonhowtheherbisprocessed(accordingtotraditionaldictates),allthepaeoniflorincanbelost(Fig.1-6).24

Fig. 1-6 HPLC trace of two white peony (Paeonialactiflora)extractsindicatingthepresenceorabsenceofthemarkercompoundpaeoniflorin.

WideVariationsinMarkerCompounds.

This problem is typically common in the galenical extractsthat are not quantified activity extracts. The problem alsoexistsinotherproductsmanufacturedfromgalenicalextractssuchastabletsandcapsules.

One example has been chosen from the literature. ThefollowingisasurveyofEchinaceapurpureaproductsontheAustralianmarket carried out by Professor R.Wills and D.Stuart.Theseresearchers testedforalkylamidesandcaffeoylphenols(mainlycichoricacid)andfoundahugevariationinthelevelsofthesecompounds(Table1-1).25

TABLE1-1 AlkylamideandCaffeoylPhenolLevels (mg)inDifferentTypesofManufacturedEchinaceaProducts25

STABILITYISSUESFORHERBALLIQUIDS

Someeducatorshavesuggested thatherbal liquidsarea lessdesirable dose form because they are less stable than aresolid-dosepreparations.However,objectiveevidencetobackup this assertion is scarce. Some companies now undertakestability studies on their herbal liquids as a requirement ofpharmaceutical GMP, and this author’s experience in thisfieldindicatesthatmostliquidsmaintaintheirphytochemicalprofiles within the normal shelf-life requirements of 2 to 3years.

ThereforeprovidedherballiquidsarepurchasedthroughanherbalmanufacturerthatoperatesunderpharmaceuticalGMPandhasacomprehensivestabilityprograminplace,keepingtowithinexpirydatesissufficienttoensureretainedactivity,provided of course that the manufacturer’s recommendedstorage conditions are observed. Sunlight is particularlydamagingtothephytochemicalsinanherballiquid,thustheymust be stored in amber glass bottles away from directsunlight.Temperature isalsoan important factor.Generally,storage below 30°C (86°F) is recommended (temperaturesoccasionally above 30°C (86°F) will not cause a problem,providedthattheaverageisbelowthislevel).Additionally,aminimal storage temperature of 10°C (50°F) should bemaintained.Someherballiquidssuchasceleryandwildyamwillformintoageliftheybecometoocold.Althoughgentlereheating will generally make these gels liquid again,

irreversible changes may occur if the cold conditions areprolonged.

Many herbal liquids develop a sediment over time.Provided that the extract has not been heated during itsmanufacture, sedimentation is a natural occurrence thatgenerally has only a minor impact on quality. A commonquestionamongpractitionersiswhetherthissedimentshouldbe rejected or redispersed into the liquid (for mixtures ofseveral herbal liquids, the sediment should always beredispersed; see laterdiscussion).Althoughnohardand fastrules exist here, a general guide is that if the sediment hastended to aggregate or concrete into a hard mass, then itshouldberejected.If,however,thesedimentisfineandeasilyredispersed,thenthebottleshouldbeshakentodothisbeforedispensing.

Ifdecantingisusedtoavoiddispensinganysediment,thiscanleadtowastageofliquid,becauseasmallbutsignificantamount of liquid in association with the sediment will berejectedwhen thebottle is almost empty.Oneway to avoidthiswastage is to instead filter the dregs to recover the lastamount of liquid. This procedure need not be done using afinefilterpaper.Afinecleanclothwilloftensuffice,andtherate of filtration will be much quicker than that through afilterpaper.

Whether to reject or redisperse a sediment is really at thediscretionofthepractitioner.However,thefollowinglistcanserve as a guide. The herbs listed are those for which the

authorbelievesthesedimentshouldberejected.Althoughthislist is not comprehensive, it does include several herbs thatarenotcoveredinthistext.

Product BotanicalNameAlbizia AlbizialebbeckAngelica AngelicaarchangelicaBaicalskullcap ScutellariabaicalensisBayberry MyricaceriferaBearberry Arctostaphylosuva-ursiBethroot TrilliumerectumBloodroot SanguinariacanadensisCascara RhamnuspurshianaCranesbill GeraniummaculatumElderflower SambucusnigraEphedra EphedrasinicaGlobeartichoke CynarascolymusGoat’srue GalegaofficinalisJambul SyzygiumjambolanumLadiesmantle AlchemillavulgarisMarshmallowleaf AlthaeaofficinalisPhyllanthus PhyllanthusamarusPinellia PinelliaternataRaspberryleaf RubusidaeusRhubarbroot RheumpalmatumRosemary RosmarinusofficinalisRue RutagraveolensSage SalviaofficinalisSennapods CassiasppSkullcap Scutellarialateriflora

St.John’swort HypericumperforatumWhitepeony PaeonialactifloraWildcherry PrunusserotinaYellowdock Rumexcrispus

DOSAGEISSUESFORHERBALLIQUIDSThedosageflexibilityofferedbyusingherballiquidshasledto considerable disparity over what is considered to be atherapeutic dose. This problem is generally not the case forsolid-dose forms such as tablets for which a minimumpossible dose exists (one half or one tablet), and themanufacturer usually provides specific doserecommendations.

This disparity can be illustrated by the example of St.John’swort. The effective dose of St. John’swort in tabletform fordepressionhasbeenestablishedbyclinical trials atthreedosesof300mgofdryextractperday.Thedryextractis standardized to 0.3% hypericin and usually represents atleastafivetimestheconcentrationoftheoriginaldriedherb.HencetheclinicallyeffectivedoseofSt.John’swortequatesto approximately4.5gof herb (900mgof extract) per day.Now,thecorrespondingamountof1:5driedherbtinctureperday is 5×4.5 g,which equals 22.5ml (almost one ounce oftincture). As an aside, this example further illustrates thevalueof 1:2 extracts, given that the equivalent dailydose isonly9ml,whichismuchmoreachievable.

Despite the fact that the clinically establishedantidepressant dose for a St. John’s wort tincture is in theregion of 22.5 ml of tincture per day, some herbalistsroutinelyprescribe10to20drops,threetofourtimesaday;

and some of these practitioners also occasionally use St.John’s wort tablets at the correct (clinically established)doses! Clearly, such a difference in dosage approaches isdifficulttorationalize.

Thepreviousexamplehighlightsanother issuewith liquiddosing: theuseofdropsasadosagemeasure.Although thismethod can be valid for highly potent herbs such asTylophoraandPhytolacca,ingeneral,similartoounces,usingdrops is an archaic dose measure that should not be used.Recently, a National Aeronautics and Space Administration(NASA)Marsprobemisseditstargetbecauseofanerrorthatwas made between the conversion of pounds and feet intokilograms and meters. As in space, anachronisms have noplace inmodernherbal therapy.Althoughallsoliddosesareexpressed in metric for both drugs and herbal products, forsomereason,thisisnotthecasewithsomeherballiquids.

This problem is further compounded by the fact that thedrop is an inherently imprecise measure of volume. Mostherbalistsdonothaveanaccurateappreciationoftheamountand the variability of the drops per ml of an herbal liquid.Glib calculations are based on 20 drops per ml, but somemanufacturersevenclaimitisaslowas12dropsperml.

The author of this text conducted a simple experiment.Acomparisonofthedropspermlforfivealcoholicextractsandone glycetract was conducted using two different dropperssupplied by manufacturers, one with a larger bore and theother with a smaller bore. The results are summarized in

Table1-2.

TABLE 1-2 Comparison of Drop Numbers for SeveralExtractsUsingSmallandLargeBoreDroppers

These results indicate that the number of drops per mldependsonthealcoholstrengthoftheherballiquid,which,inturn, influences its viscosity. The approximate differencebetweenthetwoalcoholextremesisalmosttwofold,andthedrops perml varies between 28 and 65 drops. For themilkthistle glycetract, which was by far themost viscous liquidtested, the number of drops permlwas nowhere near 12 or20,evenusingthedropperwiththelargerbore.Clearly,therecanbenogeneralroleforthedropasareliableandconsistentmeasureofdose.

However, the other important issue is that the use of thedropasameasureencourageslow,subtherapeuticdoses.Howthen can people arrive at the right doses of herbal liquids?Coming back to the St. John’s wort example, the clinicallyproven therapeutic dosewould equate to approximately 900

dropsperday.

The subject of appropriate dose is probably the mostcontroversial aspect of contemporary Western herbalmedicine. Among Western herbal practitioners, manydifferent dosage approaches are found from country tocountry and within countries. Underlying these differentapproaches are different philosophies about the therapeuticactionofmedicinalplants.

Atoneextremeistheassumptionthatthetherapeuticeffectreliesonaspecificdoseoftheactivechemicalscontainedineachparticularplant.Attheotherextreme,emphasisisoftenplaced on the assumption that an herbal medicine, beingderived from a living organism, carries a certain energy orvitalforce.Thequalityofthisenergyconfersthetherapeuticeffect, and hence the amount of actual herb is not asimportant, as long as some is present. Other practitionersbelievethatperhapstheactivecomponentsactascatalyststorestorehealthanddonotneedtobepresentinwhatwouldbeconsidered to be pharmacologic quantities in the sensitivepatient.

The low-dose approach should not be confused withhomeopathy,although ithasbeen influencedby thissystem.One important difference from homeopathy is that thetherapeutic indications are not derived from the principal ofsimilarsandmainlycomefromtraditionalindications.

Both the high- and low-dose approaches have theiradherents who maintain that their respective systems give

goodresultsintheclinic.Althoughlabelingoneapproachascorrectand theother incorrect is inappropriate (indeed,evenhigh doses of herbs possibly also act in part through theenergy factor or as catalysts), reviewing and contrastingcurrent andhistoricaldosageapproaches isuseful.Bydoingso,onecanarriveatanappropriatedosagesystemformodernphytotherapyinthatitisconsistentwith:

•Doserangesusedinotherimportantherbaltraditions,suchasChinaandIndia

•DosesusedbyimportanthistoricalmovementsinWesternherbalmedicine,suchastheEclectics

•Dosescurrentlyrecommendedinpharmacopeias

•DosesestablishedfrompharmacologicandclinicalresearchIn any discussion of herbal doses, the influence of dose

formandqualityofpreparationsmustalsobeconsidered,asshouldthemechanicsofformulationandprescriptionwriting.

REVIEWOFDOSAGEAPPROACHES

TraditionalChineseMedicine.

The daily dose for individual nontoxic herbs in traditionalChinesemedicine(TCM)isusuallyintherangeof3to10g,given as a decoction, or in pill or powder form.26 Often,higher doses are prescribed by decoction than for pills, asmight be expected given that not all active componentsreadilydissolveinhotwater.27 (Pillsgenerallyconsistof thepowdered herb incorporated into a suitable base.)Herbs areinvariably prescribed in formulations. Doses for suchformulations in pill or granule form are typically 3 to 9 gtakenthreetimesdailybutcanbemuchhigherinthecaseofdecoctions.

For each individual herb, a wide dose range is usuallygiven in textsandappliesforallherbalsystems.Onereasonforthiswiderangeisthatifanherbisusedbyitself,orwithjust a fewother herbs, a larger dose is used thanwhen it iscombined with many other herbs.27 Dose also variesaccordingtotheweightandageofpatientsandtheseverityoracuteness of their condition. Some herbs, or closely relatedspecies, are used in both Chinese and Western herbalmedicine. Table 1-3 compares dosages for a few of theseherbs.

TABLE 1-3 Comparison of Dosages Used in Traditional

ChineseandWesternHerbalMedicine

Herb ChineseDosage26(g/day)

WesternDosage28,29(g/day)

Ephedrasinica 3–9 3-12(decoction)

3-9(extract)

Zingiberofficinale(ginger) 3–9 0.75-3.0(decoction)

0.38-0.75(tincture)

Taraxacummongolicum(dandelion) 9–30 6-24(decoction)

3-6(tincture)

Glycyrrhizauralensis(licorice) 3–12 3-12(decoction)

6-12(extract)

Rheumpalmatum(rhubarb) 3–6 2.3-4.5(decoction)

1.8-6.0(extract)

Note:Fordosagesoftincturesandextractsgiventhreetimesdaily,thecorrespondingamountofdriedherbperdayhasbeencalculated.

In general, the similarity in the dose range between thedifferentsystemsisstriking.Discrepanciesdoexistforgingerand dandelion root, which in the case of ginger can beexplainedbyahighercontentoftheactivecomponentsinthealcoholictincturecomparedwiththedecoctionandinthecaseofdandelionmaybeareflectionofthedifferentspeciesused.

EclecticMedicine.

Eclecticmedicinewasalargelyempiricalschoolofmedicinethat developed in the United States during the nineteenthcentury.28 The movement was most prominent for a briefperiod from the late nineteenth to the early twentiethcenturies,when several teachinguniversities offered coursesand many eminent scholars studied eclectic medicine.AlthoughtheEclecticsusedsimplechemicalmedicinessuchas phosphoric acid, they mainly prescribed herbs. TheEclectics’ knowledge of materia medica was their greatestcontribution to Western herbal therapy. For example, theEclectics made herbs such as Echinacea and golden sealpopularafterobservingtheirusebynativeAmericans.

The Eclectics tended to use higher doses compared withthose recommended in current texts and pharmacopeias,although the ranges tend to overlap. Table 1-4 comparesdosagescurrentlyusedwiththosefoundinEclectictexts29,30foralcoholicextractsofherbs.

TABLE1-4 ComparisonofDosagesUsedby theEclecticswithModernDosages

Herb EclecticDosage31,32(g/day)

CurrentDosage28,29(g/day)

Euphorbiahirta 1.8–10.8 0.36–0.90Echinaceaangustifolia 0.9–5.4 0.75–3.00Hydrastiscanadensis(goldenseal) 0.9–10.8 0.9–3.0

Passifloraincarnata(passionflower) 1.8–10.8 1.5–3.0

Valerianaofficinalis(valerian)

2.1–6.0 0.9–3.0

Rumexcrispus(yellowdock) 1.8–10.8 6.0–12.0Viburnumopulus(crampbark) 3.6–10.8 6.0–12.0

Sabalserrulata(sawpalmetto) 2.7–10.8 1.8–4.5

Note:Thecorrespondingamountofdriedherbperdayhasbeencalculatedfromtherecommendeddosagesforliquidextracts.

TheBritishHerbalPharmacopoeia.

The BHP 1983 carries extensive dose information forindividual herbs and is generally regarded as an importantreference on this subject for Western herbal practitioners.DosesgivenintheBHPwerederivedfromearliertexts,suchas the British Pharmacopoeia (BP) and the BritishPharmaceuticalCodex(BPC),butalsoresultedfromasurveyof herbal practitioners. More recently, the British HerbalCompendium (BHC) has been published with doseinformationfor thepractitioner.Both theBHPand theBHChave been used to derive the doses for 1:2 extractsrecommendedinthisbook(viaappropriatecalculationmainlyfrom tincture doses). In some cases, the 1:2 dose has beenderivedfromthe1:1dose.

ThedosesgivenintheBHPcontainsomeinconsistencies.The main problem is that doses for tinctures often do notcorrelatetocorrespondingdosesforliquidextracts.Fora1:1extract and a1:5 tinctureof a particular herb to correlate intermsofdose, thedose range for the tincture shouldbe five

times thatof theextract,given that the tincture is five timesweaker. This problem contrasts with other pharmacopeiassuch as theBPC1934 inwhich the correlation is generally,butnotexactly,observed.Someexamples thathighlight thisproblemareprovidedinTable1-5.

TABLE1-5 Comparison ofExtract andTinctureDosagesintheBHP1983

ThispoorcorrelationdemonstratedinTable1-5,which,inthecaseforEupatoriumpurpureum(gravelroot),thetincturedoseisactuallylessthantheextractdose,isprobablyfortworeasons:

•Aspreviouslystated,theBHPdoseswerederivedinpartfromasurveyofherbalpractitioners.Thatdifferentdosephilosophiesexistedbetweenpractitionersusingextractscomparedwiththoseusingtincturesisprobable.Henceacorrelationshouldnotbeexpected.

•Tincturesaremanufacturedusingdifferenttechniquesto

1:1liquidextracts.Thisaspectisparticularlyimportant.Liquidextractsatthattimewereoftenpreparedbyreconstitutingmoreconcentratedextracts,ratherthanthetraditionalmethodofreservedpercolation.Ineithercase,theheatorvacuumusedinconcentrationcanrobthepreparationofimportantactivechemicals.Tincturesbetterpreservetheactivityofthewholeplantbecausetheyaremadewithoutheatoraconcentrationprocedure.Liquidextractsarealsooftenmanufacturedusingloweralcoholstrengthscomparedwithtinctures,andimportantactivecomponentsmaythereforenotbeextractedfromthestartingplantmaterial.Theresultoftheseconsiderationsisthata1:1liquidextractcanhaveanactivitythatismuchlessthanfivetimesthatofa1:5tincture.(Thisagainunderlinesthevalueofusing1:2extracts,whichofferthebestofbothworlds.)Becausetincturesbetterpreservethechemicalprofileofthe

dried herb, more credibility should be given to the tincturedoses when using the dose ranges in the BHP. (The 1:5tincture dose multiplied by 0.4 gives the corresponding 1:2dose.)

COMPARINGDOSES

Comparingdosesbetweenliquidandsolidpreparationsmadewith various types of extracts is often difficult forpractitioners. The concept of “dried herb equivalent” is ausefulwayforcomparingdosesbetweendifferentstrengthsofherballiquidsorbetweenliquidsandtablets.Usingtheextractorproductratio,thedriedherbequivalentofagivenamountof product can be calculated. The extract or product ratioexpressestheweightoforiginaldriedherbstartingmaterialtothevolumeorweightof finishedproduct (in thatorder), forexample,5:1,1:4,1:1,andsoforth.

Forexample,adriedherbequivalentof1gmightbe:

•2mlofa1:2liquidextract

•1mlof1:1liquidextract

•250mgof4:1softextract

•200mgofa5:1spray-driedpowder

DOSEINFORMATIONSUMMARYThedosesummarychart(seeAppendixA)containsalistingoftheherballiquidscoveredinthisbook.Listedfromlefttorightis:

•Commonnameoftheherb

•Botanicalnameoftheherb

•Partoftheplantusedtomaketheherballiquid

•Percentageofethanolrecommendedinthemanufactureoftheherballiquid

•Strengthorratiooftheliquid(expressedasdriedherbtofinalliquid)

•Minimumandmaximumdoseinmilliliterstobeprescribedperday

•MinimumandmaximumdoseinmilliliterstobeprescribedperweekThe reader shouldnote that thesedoses are calculated for

adults for long-term use. For short-term use, as in acuteconditions, the daily dose may be increased above themaximum for a week or so (but never in the case ofTylophoraandPhytolacca).

CHILDREN’SDOSES

Forcalculatingdoses forchildren,anumberofmethodscanbeused.Thesevaluesareonlyapproximations,becauseofthecomplex metabolic changes that occur during growth andmaturation.TheauthorofthistextprefersAusberger’sweightrulebecause it is basedonweight rather than age and takesinto account the faster metabolism of children. Thiscalculationisasfollows:

(1.5×weight inkg+10) is thepercentageoftheadultdose for the child. Expressed in terms of pounds, theformulabecomes:

Therefore ifachildweighs20kg(44 lbs), thenheorsheshould receive (1.5×20)+10=40%of the adult dose.A childweighing10kg(22lbs)wouldreceive25%oftheadultdoseandsoon.Clark’sruleismorebasicandisasfollows:

Various rules based on age have been established. Forexample,Young’sruleis:

For young infants, applying Fried’s rule rather thanAusberger’sweightruleissometimesmoreprudent.Thisruleisasfollows(forinfantsaround1to2years):

HERBALLIQUIDINCOMPATIBILITIES

Incompatibilitiescan resultwhen twoormoreherbal liquidsare mixed together. This incompatibility can be eitherphysical or chemical and can affect the efficacy of theresultantformulation.Generally,whenmixingherballiquids,avoidinganyprecipitationisimpossible.Forthisreason,suchliquidmixturesshouldalwayscarrythedirections,“Shakethebottlewellbeforepouring”orwordstothateffect.

Some simple rules that have been established can befollowed:

1.Herbscontainingtannins,suchascranesbillroot,areincompatiblewithherbscontainingalkaloids,suchasgoldenseal.Ifthetwosubstancesaremixedtogether,aprecipitatewillform.Hencetanninsandalkaloidsshouldbedispensedseparatelyandtakenatdifferenttimes.

2.Herbsextractedinahigh-percentagealcohol,suchasgingerandmyrrh,oftencontainresinsthatprecipitatewhentheextractismixedwithotherherballiquidswithlowalcohol.Onewaytominimizethisprecipitationistoincludeasmallquantity(10%)oflicoriceintheformula.Thesaponinsinthelicoriceactasanemulsifyingagentandcankeepeverythinginsuspension.Thelicoriceshouldbeaddedfirstbeforeaddingtheresinousliquid.

3.Bladderwrackisalsonotcompatiblewithtannin-

containingherbs.

4.Herballiquidsaregenerallymixedinascendingorderintermsoftheirethanolcontent.

5.Mucilaginousherbs,suchasmarshmallowrootandaloejuiceconcentrate,arenotcompatiblewithhighethanolextracts.

PRESCRIPTIONRECORDSANDDISPENSINGThe following has been adapted from course material fromtheCollegeofPhytotherapyintheUnitedKingdom.

PRESCRIPTIONRECORDS

Keepingfull recordsofeachpatient’scase isessential.Suchrecords should include the case history and previoustreatments, presenting symptoms, signs, diagnosis,prescriptions,progressreports,alterationsandadjustmentstotreatment,andsubsequentresponse.Datingeachentryonthecard is most important. Although each practitioner will, nodoubt, develop his or her own style and system of recordkeepingaftersomeexperience,atriedandtestedschemeisagoodstartingplace.

A number of practitioners keep the information of theirpatientsonarecordcard(A)andonanotherseparatecardorsheet(B).Thefirstrecordcardcontainsthenameandaddressof the patient, including the patient’s number. This cardservesmainlytoholdtheinformationabouttheprescription.

The diagnosis, case history, and all medical and privateinformation is kept on card or sheet (B), which carries nonamebutonlythepatient’snumber,thesamenumberasthatontheprescriptioncard.Theadvantagesofthissystemarethefollowing:

•Therecordcardwiththeprescriptionsiskeptinthedispensaryandfiledundername.Whenthepatientphonesforrepeatprescription,appointment,oradvice,thecardiseasilytraced,andallvitalinformationisreadilyavailabletothedispenser,telephoneoperator,orsecretary,without

revealinganyconfidentialinformation.

•Bynothavingallthemedicalinformationonthecard,thecardcanbekeptsimple.Sufficientspaceisprovidedforseveralrepeatprescriptions,andallinformationonthecardiseasilytraced.

•Bykeepingthesecondcardorsheet(B)intheconsultingroom,filedundernumber,completeconfidentialityisensured.Thedatacanbeaddedtoduringeachvisit,andmorecardsorsheetscanbeaddedasrequired.

PRESCRIPTION

Using anything but the metric system in dispensing isinappropriate. Consequently, any remedy must be issued inmetric.Fortheherbs,theproperLatinnamesarebestused.Ifonlyonespeciesofanygenusisinyourdispensary,thenthegenericnamewillsuffice.However,ifmorethanoneherbina genus is used, the specific name should be used as well.Generic names always start with a capital letter, and thespecificnamealwaysfollowswithasmallletter;forexample,with Rumex crispus (yellow dock) “Rumex” is the genericname and “crispus” is the specific name. Record therecommended strength of the preparation, such as 1:2, 1:1,1:5,andsoon.

Theprescriptionisdividedintoseveralparts:

•Theinscriptiondesignatesingredientsandquantities,suchasHypericum1:230ml.

•Thesubscriptiongivesdirectionstothedispenserastotheformormodeofpreparation,quantitytobesent,andthemannerinwhichtobesent.

•Signature,meaning“letitbelabeled,”includesdirectionsforthepatient,methodofapplicationordose,timeofadministration,vehicleormeansofadministration,andthepartofthebodytowhichitistobeadministered.The prescription is best written for 1 week’s supply of

medicine.Ifseeingthepatientagainin3weeksisnecessary,thenthewholeprescriptionistrebledbythedispenser;thisisindicatedattheendoftheprescriptionbywriting3weeks.Iftheamountofherballiquidtobedispensedfor1weekisshortof 100 ml per week, the bottle is filled with syrup, water,dilutedalcohol,orglycerol,asappropriate.

The normal or average dose is 5ml (1metric teaspoon),usually 3 times a day (tds or tid). (Note: a normal modernteaspoonis3to4ml,muchsmallerthanametricteaspoon.)Dosagecanbevariedwidelyaccording to theneedsofeachindividual case. Including some form of sweetening in achild’smedicine (e.g., a flavoringmix) is common, and thedoseisthenoftenwithoutwater.

DISPENSINGPROCEDURESFORHERBALLIQUIDS

A set of preferably classA,metric, conical, glassmeasuresareusedbydispensingchemists.Thesizesavailable include10, 50, and 100ml. Thesemeasures can be used for herbaldispensing,althoughmeasuringcylindersusedinlaboratoriesarealsosuitable.

The following is the traditional technique for dispensing.The measure is held in the left hand (even if left-handed)around the base. Holding themeasure at eye level achievesaccuratemeasuring.Therighthandtakesthedispensingbottlefromtheshelf;thestopperisremovedandheldwiththelittlefinger of the left hand. The correct amount of tincture isdispensedintothemeasurefromwhichitistransferredtothemedicinebottle.

The stopper is then replaced in the dispensing bottle andreturned to the shelf (the stopper is never put down, but isheld all the time by the little finger). Note: this traditionaltechnique requires stopperedbottles. If screwcaps are used,thenthetechniquemustbemodifiedaccordingly.

The surfaceof a liquid in avessel is always curved.Thispropertyisknownasameniscus.Ameniscusisreadwiththemeasurehorizontal,ateyelevel,andfromthehighestpointona convexmeniscus and the lowest point on a concave one.(Herballiquidswillgenerallybeconcave.)

Errorsinreadingameniscusarisefrom:

•Dirtyorgreasymeasures

•Liquidspoureddownthesideofameasureinsteadofintoitscenter;withaviscousliquid,alargeproportioncanstillbecrawlingdownthesidesofameasurewhenthecorrectmeniscusreadinghasbeenreached

•Ameasurenotbeingheldorstoodhorizontally

•Themeniscusnotbeingviewedateyelevel(parallaxeffects)Small volumes can be measured using metric calibrated

droppers,pipettes,orsyringes.Thedropperorpipetteshouldbe checked to see if it is made to be completely emptied;somearenot.

LABELING

Alldispensedmedicinesmustbecorrectlylabeled,givingthepatient clear and concise instructions on how to take or usethe preparation. Neat and careful labeling is importantbecause this helps reinforce the patient’s confidence in themedicine.Abadlypresentedbottleofmedicinemaygivethepatientdoubtsastotheefficacyofthecontents.

InformationProvidedontheLabel

1.Directionsforuse.Writingthenameofthetypeofpreparationdispensedatthetopofthelabel,suchas“TheHerbalMixture,”“TheTablets,”andsoon,isusualpracticeindispensing.Thispracticeisnotessentialinherbaldispensing.Belowthisinformationshouldbewrittentheinstructionstothepatient,forexample,“one5-mlspoonfultobetakenthreetimesdailyinalittlewaterbeforemeals,”or“twotabletstobetakenthreetimesdailyaftermeals.”Stating“5ml”ratherthan“oneteaspoonful”ismoreprecise,particularlyifthepatienthasbeensuppliedwitha5-mlplasticspoonormeasure.Thewords“asdirected”maybeenteredonthelabelifthepatienthasbeensuppliedwithseparatewritteninstructions.

2.Patient’sname.

3.Date.Alwayswritingthedatewhenamedicineis

dispensedonthelabelisgoodpractice.Thedatesofallmedicinesdispensedmustalwaysbeenteredonthepatient’scasehistory.Anexpirydateisalsoagoodidea.

4.Batchcode.Thenumbercorrelateswithaseparaterecordofthebatchesofindividualherbsusedintheformulation.

5.Thevolumeofherballiquidinthebottle.

6.Basicstorageinformation.

7.Anyotherinstructions.Thefollowingisanexampleofasuitabledispensinglabel.

REFERENCES

MunzelK,HuberK.Extractionproceduresinthepreparationofchamomilefluidextract.PharmActaHelv.1961;36:194.

MeierB.Theextractionstrengthofethanol/watermixturescommonlyusedfortheprocessingofherbaldrugs.PlantaMed.1991;57(suppl2):A26.BalansardG,etal.SelectioncriteriaforaViburnumextract,ViburnumprunifoliumL.,asafunctionofitsveino-tonicandspasmolyticaction.PlantMedPhytother.1983;17(3):123.[Noauthorlisted.]Industrie.ZPhytother.1997;18(5):296.D’AlenaP,FergusonW.Adverseeffectsafterglycerolorallyandmannitolparenterally.ArchOphthalmol.1966;75(2):201.LyleTJ.Physio-medicaltherapeutics,materiamedicaandpharmacy.London:NationalAssociationofMedicalHerbalistsofGreatBritain,1897.reprinted1932ScudderJM.Specificmedicationandspecificmedicines.Cincinnati:ScudderBrothers,1913.EllingwoodF,LloydJU.Americanmateriamedica,therapeuticsandpharmacognosy.Portland:EclecticMedicalPublications,1983.BundesministeriumdesInnern,WestGermany.DeutschesArzneibuch,ed7.Stuttgart:DeutscherApotheker-Verlag,1968.ausg7

10BauerR,etal.Beeinflussungderphagozytose-aktivitätdurchEchinacea-extrakte.ZPhytother.1989;10:43.

11SharmaH.Phytochemicalsynergism:beyondtheactiveingredientmodel.AltTherClinPract.1997;May/June:91.

12WilliamsonEM.Synergy:mythorreality?In:ErnstE,

editor.Herbalmedicine:aconciseoverviewforprofessionals.Oxford:Butterworth-Heinemann,2000.

13EderM,MehnertW.Bedeutungpflanzlicherbegleitstoffeinextrakten.Pharmazie.1998;53(5):285.

14KeungW,etal.PotentiationofthebioavailabilityofdaidzinbyanextractofRadixpuerariae.ProcNatlAcadSciUSA.1996;93:4284.

15VinsonJA,BosePB.Comparativebioavailabilitytohumansofascorbicacidaloneorinacitrusextract.AmJClinNutr.1988;48:601.

16ButterweckV,etal.SolubilizedhypericinandpseudohypericinfromHypericumperforatumexertantidepressantactivityintheforcedswimmingtest.PlantaMed.1998;64:291.

17OnawunmiGO,YisakW,OgunlanaEO.AntibacterialconstituentsintheessentialoilofCymbopogoncitratus(DC)Stapf.JEthnopharmacol.1984;12:279.

18KisaK,etal.PotentiatingeffectofsennosideConpurgativeactivityofsennosideAinmice.PlantaMed.1981;42:302.

19BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia,ed4.Bournemouth,UK:BHMA,1996.

20LehmannR,PenmanK,HalloranK:Informationonfile(2003).MediHerbResearchLaboratory,UniversityofQueensland,St.Lucia,Queensland4072,Australia.

21PeltzK,PenmanK,LehmannR:Devil’sclawauthentication

byHPLC.HerbalMedicine:PracticeandScienceInternationalConference1999,Brisbane,September3-5,1999.

22GovindanM,GovindanG.Aconvenientmethodforthedeterminationofthequalityofgoldenseal.Fitoterapia.2000;71:232.

23LehmannRetal:IdentificationofthemajorflavonoidfromScutellarialateriflora.InternationalCongressand48thAnnualMeetingoftheSocietyforMedicinalPlantResearch.SixthInternationalCongressonEthnopharmacologyoftheInternationalSocietyforEthnopharmacology,September3-7,2000,P1E/11.

24LehmannR,PenmanK.Qualityassessmentintheherbalindustry:asillustratedbyChineseandAyurvedicherbs.MediHerbClinicalUpdate:ChineseandAyurvedicHerbsinWesternClinicalPractice,Brisbane.St.Lucia,Queensland4072,Australia:InformationavailablefromMediHerbResearchLaboratory,UniversityofQueensland,April-May,2000.

25WillsRBH,StuartDL.LevelsofactiveconstituentsinmanufacturedEchinaceaproducts.ChemAust.1998;September:17.

26BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.

27YanchiL.TheessentialbookoftraditionalChinesemedicine,vol2,ClinicalPractice.NewYork:ColumbiaUniversityPress,1988.

28BritishHerbalMedicineAssociation’sScientificCommittee.BritishHerbalPharmacopeia.Bournemouth:BHMA,1983.

29PharmaceuticalSocietyofGreatBritain.BritishPharmaceuticalCodex1934.London:ThePharmaceuticalPress,1941.

30GriggsB.Greenpharmacy.London:JillNormanandHobhouse,1981.

31FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983

32FelterHW,LloydJU.King’sAmericandispensatory,ed18,rev3.Portland:EclecticMedicalPublications,1905.reprinted1983

CHAPTER2

FormulatingfortheIndividualPatient

ASYSTEMATICAPPROACHTheWestern herbal systemof prescribing for the individualpatient is simpler than that for traditional Chinese andAyurvedic medicine and does not necessarily requiretraditionaldiagnostictechniquessuchasthepulseandtongue.Nevertheless, theWestern system can be powerful, and theauthor of this text has seen theWestern herbal prescriptionsucceedwhenotherapproacheshave failed.Thesystematicsof theWestern herbal approach are summarized here. For afullexpositiononthistopic,thereaderisreferredelsewhere.1

ThegoalsofWesternherbalprescribingfor theindividualpatientareto:

•Raisevitality,whichiscentraltotheindividual’scapacitytoresistdisease.

•Neutralizetheperceivedcausesthateitherpredisposeapersontoorprovokethediseaseprocess.

•Neutralizethesustainingcausesthatmaintainthediseaseprocesses;chronicinflammationcanbeasustainingcause.

•Promoteandnourishthehealthyfunctioningofbodilytissues,organs,andsystems(asappropriatetotheconditionsbeingtreated).

•Controlcounterproductivesymptoms.Forexample,anitchyrashcaninterferewithsleepanddebilitatethepatientandisthereforecounterproductive—thustheitchshouldbealleviatedwithoutexcessivelysuppressingtherash.Informationaboutthecausesofapatient’shealthproblems

cancomefromseveralsources:

•Clinicalexperienceofthehealthcareprofessionalandtheircolleagues

•Traditionalperspectiveonthedisorder

•Epidemiologicstudies,whichcanprovideparticularinformationaboutthepredisposingcauses

•Knowledgeofthepathologicprocessesinvolvedinthedisorderthatcanprovideparticularinformationaboutprovokingandsustainingcauses

•Clinicalstudiesonpatientswiththedisorder,whichmightprovideinformationaboutalinkwithaparticularpathogen,anabnormalityinbowelflora,oranassociationwithanothercondition,suchasthelinkbetweenasthmaandsinusitisThis information needs to be filtered according to the

individualcasehistory.Usingtheexamplegiven,ifapatientwithasthmadoesnotexhibitsignsandsymptomsofsinusitis,thenfocusingtreatmentonhisorhersinusispointless.Oncethe processing of the information that an extensive casehistory provided is done, a series of treatment goals can be

established. These treatment goals are then linked to thechosenherbsviatherequiredactions.

The actions are traditional herbal concepts, but scientificresearchalsoyieldsinformationabouttheactionsofanherb.The stepwise process in linking the treatment goals to thechoiceofherbsfortheprescriptionisthenasfollows.

1.Treatmentgoalsshouldbedecidedbasedon:•Traditionalherbalconcepts•Theorthodoxmedicalunderstandingofthedisorderandthepatient’scase•Thehistoryandneedsoftheindividualpatient

2.Thegoalsshouldbeindividualizedtotherequirementsoftheindividualcase(aftertakinganextensivecasehistory).

3.Theimmediateprioritiesoftreatmentshouldbedetermined.

4.Requiredactionsaredeterminedarebasedontheimmediatetreatmentgoals.

5.Reliableherbsthathavetheseactionsaredetermined,withasmuchoverlapofactionsaspossible.Forexample,ifantiinflammatoryandantispasmodicactionsarerequiredforthegut,chamomilecaneffectivelycoverbothoftheserequirements.Theseherbsarematchedtothepatient’sconstitutionandgeneralcondition.

6.Ifaparticularactionneedstobereinforced,morethanoneherbwiththisactionischosen,oraneffectiveherbisusedinahigherdose.

7.Theliquidherbsarecombinedinaformulawithappropriatedoses.Choosingtoomanyherbsshouldbeavoidedbecausethiswillcompromisethepatient’sindividualdosesintheformulaandmayleadtoundefinedinteractions.To facilitate this process, the practitioner needs a clear

understanding of herbs in terms of their reliable, well-established actions. For this reason, an actions index isincluded as an important part in this book. The reader willalso find the system of prescribing inweekly doses to be aconvenientadjuncttothisprocess.(Seelaterdiscussion.)

Theremainingpartofthischapterthensetsoutexamplesofthe process previously described for a number of commondisordersunderthefollowingheadings:

•Background(eachdisorderisbrieflydescribedasappropriateintermsofpossiblecauses,counterproductivesymptoms,andsustainingcausesandorgansortissuesrequiringoptimizationoffunction)

•TreatmentStrategy:Goals,Actions,andHerbs

•ExampleFormula

•CaseHistory(presentedforsomedisorders)

This approach ismissing one important element: the casehistoryoftheindividualpatient.Thereforetheseexamplesaredesigned to illustrate the process and are not intended toprovideadefinitivestatementabouthowaparticulardisordershouldbetreated.Theneedsoftheindividualareparamount.

HOWTOPREPAREAFORMULATIONACCORDINGTOWEEKLYDOSES

Theherbalformulationorprescriptionisanimportantaspectof herbal therapy; it allows the health care professional tomakeupamixtureusingherbsthatarespecifictothepatient.Arrivingataformulationcanbedoneinmanyways;oneofthesimplestwaysistouseweeklydoses.

Ifthepatientistotake5mlofaformulationthreetimesaday (15mlper day), the total amounts to 105mlperweek,which can be rounded down to 100 ml. The herbs in theformulation can then be assigned appropriate doses byreferring to their weekly dose ranges in the dosage tableprovidedinAppendixAorintheindividualmonographs.Thetotalshouldaddupto100ml.Thepatientisthenadvisedtotake5mlthreetimesperday,therebyautomaticallyreceivingtherequiredamountofeachherb.

When prescribing for children, the practitioner can stillworkon the100-ml-per-week approach and still include thefulladultweeklydosesintheformulation.Adjustmentisthenmadetotheformulationdose;forexample,itmaybecome2mlthreetimesperdayratherthan5ml.Thewayinwhichthisadjustment can be made for children has already beenoutlined.

Anexampleprescriptionfor1weekmightbesimilartothatshowninTable2-1.

TABLE2-1

In this example, the herbs were selected, and then theappropriatedoseofeachherbwaschosenbyconsideringtheweeklydoserangeinconjunctionwiththepurposeoftheherbintheformula.Eachoftheherbsselectedfallswithinitsdoserange,andthetotalalsoaddsupto100ml.If thetotal turnsout to be greater than 100 ml, then the formula wouldnormallybeadjusted(byloweringthedoseofindividualherborherbs—butnotbelowtheminimuminthedoserange—orby reducing the number of herbs or by substituting an herbthathasalowerdoserange).Alternatively,thetotalmightbeadjustedto105or110mlwithoutcompromisingthedosesofindividualherbs.

Theprevioussampleprescriptionprovidesenoughformulafor 1 week. When dispensing for more than 1 week, theweeklydosesaremultipliedbythenumberofweeksrequired.Forexample,seeTable2-2.

TABLE2-2

Generally,formulationsshouldnotcontainmorethansixorsevenherbs.Ifusing1:5tinctures,fewerherbsmustbeusedin the formulation to ensure that no less than theminimumweekly dose is prescribed for each herb. Prescribing herbsbelow theminimum in the dose range, for example, at lessthan5mlperweekofginger1:2(doserange:5to15mlperweek),meansthatatherapeuticeffectmaynotbeachieved.

When preparing formulations for patients that are to betakenoverextendedperiods,themaximumdoseisusuallynotexceeded for safety reasons. When prescribing for acuteconditions,themaximumdosemayneedtobeexceeded,butusually not for long (1 to 2 weeks). Following the normalweeklydosesystemandincreasingthefrequencyofthe5mldosetosay5or6timesperdayachievesthisgoal.

If more than six or seven herbs are required in aformulation,thenthetotalmaybesetat150ml.Thedosagefor the patient then becomes 7.5ml (or 8ml) three times aday.

THERAPEUTICS

ACUTEBRONCHITIS

Background.

Acute bronchitis, a bacterial infection of the trachea andbronchi, commonly follows the common cold, influenza,measles,orwhoopingcough.Patientswithchronicbronchitisare particularly prone to developing episodes of acutebronchitis (when their sputum turns from gray or white toyelloworgreen).Otherfactorsthatcanpredisposeapersontothiskindofbacterialinfectionincludecold,damp,anddustyconditions,aswellascigarettesmoking.

Initially, an irritating, unproductive cough occurs, whicheventually progresses over a few days to copious,mucopurulent sputum. Infection usually starts in the tracheaand progresses to the bronchi accompanied by a generalfebriledisturbancewithtemperaturesof38°to39°C(100°to102°F).Gradual recovery should occur over the next 4 to 8days.However,theconditionmayprogresstobronchiolitisorbronchopneumonia.

TreatmentStrategy:Goals,Actions,andHerbs

•ImmunefunctioncanbeimprovedwithimmuneenhancingherbssuchasEchinacearootandAndrographis,andrespiratoryinfectioncanbecontrolledwithrespiratoryantisepticherbssuchaselecampaneandthyme.Theseherbsshouldbeprescribedthroughoutthecourseoftheinfection

andpreferablyshouldbecontinued1weekintorecoverytopreventrelapse.

•Duringthedry,unproductivecoughphase,reflexdemulcentssuchasmarshmallowrootshouldbeprescribedtoalleviatetheresultantirritationanddebilitationfromanunproductivecough.

•Diaphoreticherbsareindicatedduringthefebrilephase,particularlypleurisyroot,whichisalmostaspecificforacutelowerrespiratorytractinfections.Theherbisoftencombinedwithgingertoenhanceitseffectiveness.Otherdiaphoreticssuchaslimeflowersandyarrowcanalsobeprescribed.

•Expectorantherbs,whichincludeelecampane,thyme,licorice,fennel,andwhitehorehound,canhelpclearmucoussecretionsandalleviatecough.Theseherbscanbeprescribedthroughoutthecourseofthedisorder.Pleurisyrootwillalsoactasanexpectorant.

•Anticatarrhalherbs,especiallymulleinandgoldenseal,maybeindicatedwhenthesputumisparticularlycopiousoriftheproductivecoughlingersbeyondtheacutestage.

•AntitussiveherbssuchasBupleurumandlicoriceshouldbeusedtohelpthecough,especiallyatnight,andwildcherryisparticularlyindicatedtoallaycoughiftracheitispredominates.

ExampleFormula.

SeeTable2-3.

TABLE2-3

Echinacearoot(E.angustifoliaorE.purpurea) 1:2 25mlPleurisyroot 1:2 20mlGinger 1:2 5mlElecampane 1:2 20mlLicorice 1:1 15mlFennel 1:2 20mlTotal 105ml

Dosage:5mlwith40mlwarmwaterfivetosixtimesaday.

ALLERGICRHINITIS

Background.

Allergicrhinitisistriggeredbyinhaledallergensandmaybeperennial or seasonal (hay fever). In the herbal treatment ofrhinitis, identifyingwhetherinhaledallergensareinvolvedisimportantbecausethisdeterminestheapproachtotreatment.

Allergic rhinitis is usually characterized by sneezing,itching,nasaldischarge,conjunctivitis,andnasalcongestion.Afamilyhistoryofallergy isusuallypresent,andsecretionsareoftencopious,clear,andthin.Apositiveskinpricktestorradioallergosorbenttest(RAST)toaeroallergensconfirmsthediagnosis.

The acute allergic response in rhinitis results from theinteraction of inhaled allergen with a specificimmunoglobulinEantibodyonthesurfaceofmastcellsandbasophils. This interaction leads to the release of histamineandotherfactors,whichcausestheacutesymptoms.

Althoughallergensinvolvedinseasonalallergicrhinitisareusually grass pollens, pollens from other plants, includingtrees,maybeimplicated.Inperennialallergicrhinitis,housedustmite,molds,cockroaches,andcatsarecommonsourcesofallergen.

TreatmentStrategy:Goals,Actions,andHerbs.

Theapproach to theherbal treatmentof rhinitis is tocontrolsymptomsandremovecauses.Avoidancemeasurestoreduceexposuretoaeroallergensshouldbepartofthistreatment.

Dietary exclusions should be trialed for both allergic andnonallergic rhinitis. Herbalists believe that diet can create astate of hypersensitivity and catarrh of the mucousmembranes, which predisposes the individual to rhinitis.Importantly, the dietary components that contribute to thisprocess do not necessarily give a positive reaction on theRAST or skin prick test. These components include dairyproducts,wheat,salt,andrefinedcarbohydrates.Patientswithrhinitis should avoid excessive consumptionof thesedietarycomponents,andcompleteexclusionofonecomponent(e.g.,dairy)shouldbetrialedforatleast3months.

Thegoalsofherbaltreatmentincludethefollowing:

•Immunesystemcanbebalancedwithimmunemodulatingherbs,especiallyEchinacearoot.

•Integrityofmucousmembranescanbeimprovedwithmucousmembranetrophorestoratives(goldenseal)andanticatarrhalherbs(eyebright,goldenrod),whichwillhelppreventtheallergenfromreachingthemastcellsthataredeeperinthemucousmembranes.

•AllergicresponsecanbetoneddownwithantiallergicherbssuchasAlbiziaandBaicalskullcap.

•Effectsofstress(whichcanexacerbaterhinitis)canbealleviatedwithadaptogens(ashwaganda,Eleutherococcus),anxiolytics(valerian,kava,passionflower),andnervinetonics(St.John’swort,skullcap).

•Treatmentofrhinitisatadeeperlevelmayinvolvetheuseofdepuratives,particularlyblueflag,burdock,cleavers,sarsaparilla,andyellowdock.

•Whentreatingseasonalallergicrhinitis(hayfever),treatmentmustbecommenced6weeksbeforetheseasonstartsandcontinuedthroughouttheseason.Anyhelpfuldietaryexclusionsshouldalsofollowthistimepattern.

ExampleFormula.

SeeTable2-4.

TABLE2-4

Echinacearoot(E.angustifoliaorE.purpurea) 1:2 35mlEyebright 1:2 20mlGoldenseal 1:3 20mlBaicalskullcap 1:2 30mlTotal 105ml

Dosage:5mlwithwaterthreetimesadaybeforemeals.

The reader shouldnote that the tannins inAlbizia arenotcompatiblewiththealkaloidsingoldenseal,henceithasnotbeenusedinthisparticularexample.

ANXIETY

Background.

Anxietydisorderscanbeclassifiedasfollows:

•Panicdisorder,whichischaracterizedbythepresenceofrecurrentandunpredictablepanicattacks

•Phobicdisorders,whichinvolvemarkedandpersistentfearofobjectsorsituations,exposuretowhichresultsinanxiety,suchasclaustrophobia

•Generalizedanxietydisorderinwhichthepatientsufferspersistentandoftenunrealisticworrytogetherwithsymptomssuchasmuscletension,impairedconcentration,restlessness,anddisturbedsleep

•Posttraumaticstressdisorder,whichfollowsextremetraumasuchasalife-threateningeventPatientswithanxietyshouldbetreatedasawhole.Aspects

of lifestyle and diet should be considered and extremescorrected when possible, for example excessive use ofalcohol, recreational drugs, sexual indulgence, imbalanceddiet, excessive tea and coffee intake, and cigarette smoking.Suchcorrectionswillneedtobecarefullyconsideredbecausepatients often use these factors to allay anxiety, and theirabruptwithdrawalmightexacerbatesymptoms.

Appropriateprofessionalguidanceandcounseling,withtheintroduction of simple techniques for relaxation, can bebeneficial.

TreatmentStrategy:Goals,Actions,andHerbs

•Anxiolyticandsedativeherbssuchaskava,valerian,andpassionflowercanhelpdampensymptomsofanxiety.

•OtherherbsinthesecategoriesthatcanprovidevaluableassistanceareCaliforniapoppy,spinyjujube(Zizyphusjujubavar.spinosa),andCorydalis.

•Nervinetonicherbsalsohavearole(theseherbsarecalming,butalsoliftmood)inthetreatmentofanxiety.TheseherbsincludeSt.John’swort,vervain,lemonbalm,skullcap,oats,anddamiana.

•Spasmolyticherbscanbeusedtoalleviatespasm.Crampbarkandchamomilemaybeusefulforanyvisceralsymptomsassociatedwiththeanxiety,andhawthornberrycanbeprescribedwhencardiacsymptomsarepresent.

•Anxiouspatientsstresstheirbodiesanddepletetheiradrenalreserves,whichcancreateaviciouscycle.Hencetonicandadaptogenicherbsmayberequired.Theherbofchoiceinthiscontextisashwagandabecauseofitscalmingproperties.

ExampleFormula.

SeeTable2-5.

TABLE2-5

Valerian 1:2 20mlPassionflower 1:2 20mlAshwaganda 1:2 35mlSt.John’swort 1:2 25mlTotal 100ml

Dosage:5mlwithwaterthreetimesaday.

ASTHMA

Background.

Asthma has been defined as the occurrence of dyspneicbronchospasmodic crises that are linked to a bronchialhyperreactivity(BH).2Similartoautoimmunedisease,asthmaisachronicdisturbanceofimmunologicfunction,whichcanbe controlled to some extent but not eradicated by moderndrug therapy. In other words, asthma is not just the attacks(crises). Asthma is a chronic disturbance of the immunesystem. The attacks are the “tip of the iceberg.”Hence anytreatment aimed only at relaxing airways and relievingsymptoms,beitorthodoxorherbal,issuperficialandwillnotchangethechronicityofthedisease.

Recent research has identified many factors that maycontributetothecausesandmorbidityofasthma.Traditionalherbal medicine also recognizes the role of inefficientdigestion, poor immunity, stress, inadequate diet, andunhealthy mucous membranes in the development of thedisease. Contributing factors identified from research onpatients with asthma include inhaled allergens (exposure towhichcontributestothechronicityofthedisease,notjusttheattacks), dietary allergens, poor air quality, concurrentsinusitis,3,4 poor hydrochloric acid production,5gastroesophageal reflux (GER),6,7 coexisting or episodicinfections,8-10 excessive salt intake,11 poor immunity,12,13

stress,14,15andantioxidantstatus.16-18Platelet-activatingfactor(PAF) may be involved in the inflammatory response.(Ginkgohasanti-PAFactivity.)

TreatmentStrategy:Goals,Actions,andHerbs.

Tables2-6and2-7outlinethetreatmentstrategyforasthma.

TABLE 2-6 Treating theUnderlying Factors That CreatedtheAsthmaticCondition

Goal RequiredActions HerbsControltheallergicresponse Antiallergic Baicalskullcap,

Albizia

Treatsinusitis Anticatarrhal,antiallergic,immuneenhancing

Eyebright,Andrographis

Increasegastricacid Bittertonic,digestive Gentian,

Andrographis

Controlreflux Antispasmodic,demulcent,antacid,mucoprotective

Meadowsweet,marshmallowroot,licorice

Eliminateinfection Immuneenhancing,antiviral,antibacterial

Echinacearoot,Andrographis

Reducethephysicaleffectsofstress

Adaptogen Astragalus,Eleutherococcus

Reduceanxietyandtension Sedativeandnervinetonic Valerian,St.

John’swortBoostthehypothalamic-pituitary-adrenalaxis

Tonic,adrenaltonic Ashwaganda,Rehmannia

Echinacearoot,

Balanceimmunity Immunemodifying,immunedepressant

Hemidesmus,Tylophora

Improveantioxidantstatus Antioxidant Ginkgo,rosemary

Improvethehealthofmucousmembranes

Anticatarrhal,mucousmembranetrophorestorative,lymphatic,depurative

Eyebright,goldenseal

TABLE2-7 Treating theSymptomsandSustainingCausesofAsthma,SuchasInflammation

Goal RequiredActions HerbsControltheallergicresponse Antiallergic Baicalskullcap,Albizia

Controlacuterespiratoryinfection

Diaphoretic,immuneenhancing

Seeinformationforcommoncoldandinfluenza

Reduceinflammation

Antiinflammatory,reflexdemulcent

Ginkgo,Bupleurum,marshmallowroot

Cleartheairways Expectorant Elecampane,fennelRelaxbronchialsmoothmuscle Bronchospasmolytic Elecampane,Grindelia,Coleus

Allaydebilitatingcough

Expectorant,demulcent,antitussive

Elecampane,marshmallowroot,Bupleurum,licorice

ExampleFormulas

•Forbothsymptomatictreatmentanddealingwithunderlyingfactorswhenconcurrentsinusitisisinvolved(seeTable2-8)

•FornightcoughandGER(Table2-9)

•Whenstressandanxietyaresignificantfactors(Table2-10)

TABLE2-8

Baicalskullcap 1:2 30mlGinkgo(standardizedextract) 2:1 25mlEyebright 1:2 15mlEchinacearootblend 1:2 30mlTotal 100ml

Dosage:5mlwithwaterthreetofourtimesaday.

TABLE2-9

Licorice 1:1 15mlMeadowsweet 1:2 20mlMarshmallowrootglycetract 1:5 65mlTotal 100ml

Dosage:3to5mlundilutedasrequireduptosixtimesaday.

TABLE2-10Astragalus 1:2 30mlValerian 1:2 15mlRehmannia 1:2 30mlAshwaganda 1:2 35mlTotal 110ml

Dosage:5mlwithwaterthreetofourtimesaday.

BENIGNPROSTATICHYPERPLASIA

Background.

Benignprostatichyperplasia(BPH)isanandrogen-dependentdisorderwithin theprostate. (Androgen is amale hormone.)Asmenage,significantchangesinhormonelevelsoccur:

•Testosteroneandparticularlyfreetestosteroneisdecreased.

•Prolactin,estradiol,sexhormone–bindingglobulin,luteinizinghormone(LH),andfollicle-stimulatinghormone(FSH)areincreased.Theultimateeffectisincreaseddihydrotestosterone(DHT)

within the prostate. New generation drugs for BPH such asProscar (finasteride) inhibit the enzyme 5-alpha-reductase,whichconvertstestosteroneintoDHT.

Many other factors are likely involved inBPH, includingincreased DHT receptors in the prostate (which may resultfrom the increased estradiol), reduced metabolism oftestosterone and DHT, accumulation of cholesterol, andinflammatorychangesintheprostate.

A dynamic component to the symptoms of urethralobstructionisalsopresent,whichisknownas“prostatism.”19Alpha-adrenergic (sympathetic) nerve fibers innervate thesmooth muscle of the prostatic urethra and bladder neck.Some of the symptoms of BPH are related to the state of

contraction of this smooth muscle, which explains whysymptoms can vary in severity at any given time for amanwith BPH. Alpha-adrenergic blocking drugs such asMinipress (prazosin hydrochloride) are often prescribed toalleviatethesymptomsofprostatism.

TreatmentStrategy:Goals,Actions,andHerbs

•Prostatefunctioncanbeimprovedwithantiprostaticherbs,whichactbyvariousmechanismsandincludesawpalmetto,nettleroot,andwillowherb.

•MalehormonalfunctioncanbecorrectedwithmaletonicssuchasKoreanginseng.

•CompromisedbladderfunctioncanbeimprovedwiththebladdertonicCrataeva.

•Prostatismcanbealleviatedwithspasmolyticherbs,especiallycrampbark,kava,andvalerian.

ExampleFormula.

SeeTable2-11.

TABLE2-11Sawpalmetto 1:2 30mlNettleroot 1:2 30mlCrataeva 1:2 40ml

Total 100ml

Dosage:5mlwithwaterthreetimesaday.

CHRONICFATIGUESYNDROME

Background20.

Chronic fatigue syndrome (CFS) can be viewed as a subtleimmune dysfunction possibly resulting from a complexinteraction among emotional, infectious, and environmentalstressors. This immune dysfunction leads to a state ofautotoxicity,whichcanbefurtherexacerbatedbypreviousorcurrent exposure to environmental toxins. For each patient,the particular factors that may be contributing to thisinteraction need to be identified and dealt with through thetherapeuticregime.Inaddition,theabnormalitiesthatarenowknowntooccurinCFSshouldbecounteredorcorrected.

Patients with CFS were usually devitalized before theycontracted the disorder. This conditionmight have been theresult of emotional pressures, work pressures, familypressures,ambition,toxins,pregnancy,orevenabaddiet;butthe end result is the same. The finding that stress is asignificant predisposing factor in CFS supports thisobservation.21Anystressor,beitchemical,physical,biologic,or emotional, then acts to aggravate the condition. Thisreducedcapacitytocopewithstressisakeyfactorincreatingtheviciouscycle,whichperpetuatesthesyndrome.

The devitalization then leads to weakened immunity andfinallytoanabnormalimmuneresponsetoaviralinfection.Astalemate is reached when the resultant hyperimmune state

causesautotoxicitybutisnotsufficientlyfocusedtoresolveaviral presence, or any other cause, and to restore health.Devitalizationisacuriousstateinwhichsomecompartmentsoftheimmunesystemareoveractive,butothercompartmentsaredeficient.

Other causative factors might add either to the immunedysfunctionortotheautotoxicity,ortheymayactasstressorstoincreasedevitalization.Thesefactorsinclude:

•Intestinaldysbiosis,endotoxemia,orsimilarsyndromes

•Allergiesorfoodintolerances

•Toxins(e.g.,dentalamalgam,hairdyes,pesticides)

•ChronicinflammationorinfectionTheseadditionalfactorswillnotapplyineverypatient;itis

amatterofindividualizationandappropriatetreatment.

Possible factors identified in the cause or progression ofCFS include viruses, immune abnormalities, circulatoryabnormalities(includingreducedbloodflowtosomepartsofthe brain), brain abnormalities, pituitary abnormalities, andsleepdisorders,aswellasmuscle,metabolic,andbiochemicalabnormalities.20Depressionisacommonfeaturethatistobeexpected given the morbidity of this disorder and itsassociationwithpoorvitality.

TreatmentStrategy:Goals,Actions,andHerbs

•EnergylevelscanberevitalizedwithtonicssuchasKoreanginseng,ashwaganda,andAstragalus;theresponsetostresscanbeimprovedwithadaptogenssuchasEleutherococcus.

•Depletedadrenalreservescanberestoredwithadrenaltonics,specificallylicoriceandRehmannia.

•Immunefunctioncanbebalancedwithimmunemodulators,specificallyEchinacearootand,whennecessary,immune-depressingagentssuchasHemidesmusandevenTylophora.

•AnyviralassociationcanbemanagedwithantiviralherbssuchasSt.John’swortandThuja.

•MoodandvitalitycanbeboostedwithnervinetonicssuchasSt.John’swort,oats,Bacopa,andskullcap.

•CerebralbloodflowandgeneraltissueperfusioncanbeimprovedwithGinkgo.

•BacopaandGinkgowillalsoimprovememory.

•Sleeppatternscanbeimprovedandrestorativesleepcanbereestablishedwithhypnoticherbssuchasvalerian,spinyjujube,andkava.

ExampleFormula.

SeeTable2-12.

TABLE2-12

Koreanginseng 1:2 10mlAshwaganda 1:2 35mlSt.John’swort(highhypericin) 1:2 15mlGinkgo(standardizedextract) 2:1 20mlAstragalus 1:2 30mlTotal 110ml

Dosage:5mlwithwaterthreetimesaday.

COMMONCOLDANDINFLUENZA

Background.

Thecommoncold(acuterhinitis)isabenignviralinfectionofthe upper respiratory tract that usually occurs in the wintermonths. Viruses commonly involved are rhinovirus,adenovirus, influenza virus, and parainfluenza virus. Acuterhinitis usually begins with a sore throat, nasal congestion,sneezing with clear discharge, and mild fever. After a fewdays, a mucopurulent discharge occurs resulting fromsecondarybacterialinfection.Afewdaysofbedrestmaybenecessary,andfullrecoveryusuallyoccurs7to10daysafteronset.Complicationsorsequelaeincludeacutesinusitis,sorethroat,tonsillitis,andotitismedia.

In contrast, influenza is often a more severe respiratoryinfectionthatcanresultinlossoflife.Themainvirusesthatcause influenzaareenvelopedvirusesknownas influenzaAand B.22 These viruses are capable of mutating, and newstrains constantly appear. Influenza is also mainly a winterdisease. The influenza virus can produce a range of diseasestates, from a mild common cold to fatal pneumonia(especially in older adults or people who are severelydebilitated). True influenza is usually differentiated fromother “flulike” illnesses by its marked systemic symptoms,withhighfever,malaise,andmusclepain.Bedrestisusuallyalwaysrequired.

TreatmentStrategy:Goals,Actions,andHerbs

•Immunefunctioncanbeimprovedwithimmune-enhancingherbssuchasEchinacearootandAndrographis.

•Fevercanbemodifiedtooptimizeitsfightagainsttheinvadingpathogen.Diaphoreticsareusedforthiseffectandincludeelderflower,limeflowers,peppermint,andyarrow.Theseagentsworkbestwhenadministeredhot(hotwaterisaddedtotheherballiquid)andinconjunctionwithginger,actingasadiffusecirculatorystimulant.Chamomileisagooddiaphoreticforchildren.

•Excessivedischargeofmucusandupperrespiratorycongestioncanbereducedwithanticatarrhalherbssuchaselderflower,eyebright,andgoldenseal.Traditionalwriterssaythatgoldensealwascontraindicatedintheacutestageofinfection,23thusitsusemaybebestinthelaterstagesofthesecondarybacterialinfection,whenathickyellowishnasaldischargeoccurs.

•Theviruscanbecontrolledwithantiviralherbs,especiallySt.John’swort,whichisactiveagainsttheenvelopedvirusesthatareofteninvolved.

ExampleFormula.

SeeTable2-13.

TABLE2-13

Echinacearoot(E.angustifoliaorE.purpurea) 1:2 35mlGinger 1:2 5mlLimeflowers 1:2 20mlEyebright 1:2 20mlElderflower 1:2 20mlTotal 100ml

Dosage:5mlwith40mlhotwaterfivetosixtimesaday.

DEPRESSION

Background.

Unipolardepressivedisorders(depressionwithoutamanicorhypomanicphase)thatarenotassociatedwithmedicalillnessareclassifiedasfollows:

•Majordepression,whichcanbecharacterizedbysadness,apathy,irritability,disturbedsleep,disturbedappetite,weightloss,fatigue,poorconcentration,guilt,andthoughtsofdeath

•Dysthymicdisorder,whichconsistsofapatternofchronic,ongoingmilddepressivesymptomsthatarelessseverethanarethoseofmajordepression

•Seasonalaffectivedisorder(SAD),whichismorecommoninwomenandrelatedtoseasonalchanges;prevalenceincreaseswithincreasinglatitudeandcanbetreatedbylighttherapy;symptomsincludelackofenergy,weightgain,andcarbohydratecravingDepression may be associated with prolonged anxiety or

stress. Hypersecretion of adrenocorticotropin hormone(ACTH) from the pituitary is often a feature. Some writerstheorize that this excess of ACTH may be related to aconditioned response resulting from traumatic events inchildhood.24

Impaired circulation to the brain, especially in elderly

patients,isacauseofdepression.Lowsystolicbloodpressurewas also associatedwith a poor perception ofwell being in50-year-old men25 and depression in men aged 60 to 89years.26

The general considerations outlined in the treatment ofanxiety also apply here. Patients with depression should betreated as awholewith due attention to lifestyle, diet, druguse,andmentalhygiene(productiveattitudesforcopingwithlife events). Professional guidance and counseling is oftenappropriate, rather than regulating depression to just abiochemical imbalance to be corrected with pharmacologicagents.

TreatmentStrategy:Goals,Actions,andHerbs.

Herbal treatment is most appropriate for mild to moderateepisodes of depression, dysthymic disorder, and SAD.Episodes ofmajor depressionmay require themore stridenttherapythatconventionaldrugscanoffer,althoughherbscanhaveasupportiverole,especiallyintermsofboostingvitality.Herbs can also be relevant when the patient improves andwishestodiscontinuedrugtherapy.

•Thenervinetonicherbsarethemainstayoftreatment,especiallySt.John’swort,whichisawell-proventreatmentformildtomoderatedepression.Otherimportantherbsinthiscategoryincludevervain,damiana,oats,andskullcap.

•Patientswhoarealsoanxiousshouldbeprescribed

anxiolyticherbs.KavacombineswellwithSt.John’swort.Valerianisalsouseful,buthopiscontraindicated.

•Depressedpatientsarelowinvitality,thusadrenaltonic(licoriceandRehmannia),tonic,andadaptogenicherbsareoftenindicated.Koreanginsengmayhaveantidepressantactivity,butitshouldbeusedcautiouslyifanxietyispresent.AshwagandaorEleutherococcusarepreferredchoicesinthesecases.LicoriceandSchisandraalsohaveexhibitedsomeantidepressantactivityinanimalmodels.Suchherbswillalsohelpcorrecttheadverselong-termeffectsofstressonthephysiologyofthestressresponse.

•Ifrequired,herbsthatimprovecirculationtothebrainshouldbeprescribed,especiallyGinkgo.

ExampleFormula.

SeeTable2-14.

TABLE2-14

Valerian 1:2 20mlSt.John’swort 1:2 25mlSkullcap 1:2 20mlDamiana 1:2 20mlLicorice 1:1 15mlTotal 100ml

Dosage:5mlwithwaterthreetimesaday.

ECZEMA(ATOPICDERMATITIS)

Background.

Eczema,ordermatitis,isapruriticinflammatoryskinreactionthat demonstrates with variable clinical pictures. Atopicdermatitisisadermatitisthatislinkedtotheatopicstate.Thepatient is much troubled by itching skin, and a history ofchronic or chronically relapsing dermatitis, worse on theflexures (elbows, back of knees), and a family or personalhistoryofatopy(e.g.,asthma,hayfever,urticaria)ispresent.

Factors involved in the cause or pathogenesis of atopicdermatitisarediscussedhere.

FamilyHistory.

Atopic syndrome isgeneticallydeterminedand is associatedwith high plasma levels of immunoglobulin E (IgE).Whenboth parents have the same atopic disease, their child hasapproximately a 70% risk of expressing this disease.However, the increasing prevalence of atopic dermatitis isdifficulttoexplainbasedongeneticsalone.27

BiochemicalAbnormalities.

The skin of patients with atopic dermatitis is typically dry,whichmaybelinkedtoanabnormalityofessentialfattyacidmetabolism.Someresearchhasproposedthatadeficiencyintheenzymeδ-6desaturasemay imbalance theessential fatty

acid content of the skin and reduce the production ofimportant antiinflammatory prostaglandins. These postulatesunderpin the use of oral and topical eveningprimrose oil inthetreatmentofatopicdermatitis.

AllergenExposure.

Along-standingcontroversyexistsas towhetherallergyisamajorpathogenicfactorinatopicdermatitis.Insomepatients,studies have associated food allergy, inhalant allergens, andskincontactwithairborneallergenswithatopicdermatitis.28

Even in the absence of specific IgE for house dustmites,infants with atopic dermatitis have proliferative T-cellresponsestotheseantigens.28Adouble-blind,controlledtrialfoundthatmeasurestoavoidhousedustmitegreatlyreducedthe activity of atopic dermatitis, especially in children.29Responsestothistherapyvariedconsiderably,despitethefactthat allergic reactivity to house dust mite antigens can beestablished by prick-test challenge in virtually all patientswithatopicdermatitis.

These observations highlight a potential misconceptionconcerningallergenexposureinthisdisorder:apositiveskinprick test (which tests for an IgE-based response) does notnecessarily identify the particular allergens that might becontributing to the underlying immunologic disturbance.Somepatientswithapositiveskinreactiontodustmitedonotrespond to reduced exposure. A corollary is that foodallergens are not necessarily identified by a prick test

challenge,althoughitcanbeausefulguide.

ImmunologicAbnormalities.

For atopic dermatitis, a definite defect is present in cell-mediated immunity within the skin and increasedsusceptibility to cutaneous viral and fungal infections, yetpatientsarenotsystemicallyimmunosuppressed.28

Althoughmany typesof inflammatorycellsarepresent inskin lesions, the major abnormality is thought to involvehyperstimulatoryTcells.28Much interesthas focusedon theshiftinT-helper-cellactivitytowardaT-helper2(Th-2)typeresponse. Both Th-1 and Th-2 cells can induce B cells toproduceimmunoglobulins,butonlyTh-2cellsinduceIgE.28

LinktoInfectionorAbnormalMicroflora.

The cutaneous microbial flora of patients with atopicdermatitis showstrikingdifferences in termsof thepresenceofStaphylococcusaureus.The relative rarityof colonizationonnormal skin is in sharpcontrast to thehigh rate found inpatients with atopic dermatitis, ranging from 76% onunaffected areas up to 100% on acute, weeping lesions.30Staphylococcusaureuscaninduceinflammatoryreactionsviaa range of activities, including toxin and protein secretion.Among these toxins and secretions are the superantigens,which have potent inflammatory and immunologic effects.30(Superantigensbinddirectly tomacrophageswithoutantigenprocessing, which can have profound pathologic effectscaused by the release of cytokines by these cells or via the

subsequentactivationofTcells.31)

The superantigen S. aureus enterotoxin B (SEB) inducesthe expansion of Th-2 cells, leading to increased IgEsynthesis.30 In addition, several alternativemechanismshavebeen proposed for the pathogenic role of bacterialsuperantigens in atopic dermatitis.31 Some conventionalapproaches to atopicdermatitis arenowadvocatingoral andtopical antibiotic therapy aimed against S. aureus, withimprovedresultsbeingclaimed.30

DigestiveFunction.

Some early studies found a low gastric production ofhydrochloric acid was correlated with incidence of atopicdermatitis, for exampleAyers in 192932 andBrown and co-workersin1935.33Therapywithhydrochloricacidresultedina dramatic improvement in some cases.32 A Russian studyfoundmarkedly reduced activity ofmembrane-bound small-intestinal enzymes in 346 patients with atopic dermatitis.Correctionofthisdysfunctionresultsinimprovementsinbothdigestionandskin.34Arelatedstudyfoundasimilarproblemin infants with atopic dermatitis. Reduction of disaccharideintake(e.g.,lactose,sucrose,maltose)wasinstituted.35

TreatmentStrategy:Goals,Actions,andHerbs

•Theimmuneresponsecanbebalancedwithimmunemodifiers,particularlyEchinacearoot.Experienceshowsthattheherbdoesnotaggravateatopicdermatitis(andmayeven

shiftresponsesawayfromTh-2typetoTh-1).BoostingtheimmuneresponsewithEchinacearoot,Astragalus,andAndrographis,mayhelpcontrolS.aureusinfection.

•Theallergicandinflammatoryresponsescanbecontrolledwithantiallergicherbs(e.g.,Albizia,Baicalskullcap,nettleleaf)andantiinflammatoryherbs(e.g.,licorice,gotukola,Bupleurum).

•Bitterherbsandaromaticdigestiveswillimprovedigestion(ifindicated).

•Long-termtreatmentwithdepurativessuchasburdock,nettleleaf,cleavers,yellowdock,andsarsaparillaisaimedatcorrectingthemetabolicimbalancesunderlyingthisdisorder.

•Bacterialcolonizationoftheskincanbecorrectedandinflammationallayedbytopicaltreatmentwithantiinflammatoryandantisepticherbs.TheantisepticherbswillhelpcontrolskinmicrofloraimbalanceandinfectionwithS.aureus.Calendulahasbothantisepticandantiinflammatoryproperties.Myrrhhasantisepticproperties,andtopicaltreatmentwithmyrrhandEchinacearootmayimprovethecutaneousimmuneresponse.Goldensealcontainsantimicrobialalkaloids(itshouldnotbecombinedwithtannins).

•Inseverecases,TylophoracanbeusedtosuppresstheTh-2cellresponse.Tylophorashouldbeusedcautiouslyin

children(withappropriatelowdoses)andinadultsonlyafterexperiencehasbeengainedwithitsapplication.

CaseHistories

CaseHistory1.

An 8-year-old girl had eczema that started approximately 4yearsearlier.Theconditionwasworseeachsummer,perhapsas a result of swimming in the local pool. The mother hadtried removing dairy products from her diet, without muchsuccess. The girl seemed to be eating quite a few sweetbiscuits, thus it was suggested that these be reduced. Thechild’s physician had prescribed a topical steroid. Onexamination, the lesions on her face showed signs of asecondaryinfection.

See Table 2-15 for the prescribed formula and dosage(basedonherweightof25kg).

TABLE2-15

Echinacearootblend 1:2 50mlBaicalskullcap 1:2 25mlNettleleaf 1:2 25mlTotal 100ml

Dosage:3mlwithwatertwiceaday.

Topical application of a chickweed cream was alsorecommended for the lesions, and one capsule of eveningprimroseoilwastobebrokenandtakeninternallyorapplied

topically (on the abdomen where the skin is thinner, fordermalabsorption)twiceaday.

On review after 4 weeks, the rash had improvedsubstantially, and her face was clear. Using the localswimmingpooldidnotseemtoaggravatetheconditionasitdidpreviously.Treatmentwascontinuedforseveralmonths,andimprovementwasmaintained.

CaseHistory2.

A woman, age 23 years, had severe atopic dermatitis. Theskinwas itchy and infected, andher hands, legs, scalp, face(around the lips), and chest were affected. The conditionstarted approximately 6 years ago and was currently beingtreated with topical steroids. The condition was worsepremenstrually, and she had a family history of atopy andsufferedherselffromasthma.

The subject was prescribed the formula in Table 2-16,whichincludedfeverfewforantiallergicandantiinflammatoryeffects:

TABLE2-16

Astragalus 1:2 25mlEchinacearootblend 1:2 25mlGotukola 1:2 20mlFeverfew 1:5 10mlBupleurum 1:2 20mlTotal 100ml

Dosage:5mlwithwaterthreetimesaday.

In addition, the woman was advised to avoid all dairyproducts, take2mlof chaste tree1:2 liquid (becauseof thepremenstrualaggravation)withwateronrisingeachmorning,and 3×1000 mg evening primrose oil capsules per day. Achickweedcreamwasprescribedfortopicalapplication.

Four weeks later, her condition was about the same. Shehadmade a decision (without seeking advice) to completelystop her steroid cream, and her rash grew much worse (acharacteristic rebound effect). Since then, the condition hadstabilized,butdidnotimprove.Treatmentwascontinued(butnotthesteroidcream).

After another 8 weeks of treatment, her skin conditionshowedasignificant improvement.Treatmentwascontinuedover severalmoremonths, afterwhich her atopic dermatitishadmoreorlesssubsided.

GASTROESOPHAGEALREFLUX

Background.

Major factors thought to be involved in the cause ofgastroesophagealreflux(GER)are:36

•Inappropriaterelaxationoftheloweresophagealsphincter(LES),perhapstriggeredbygastricdistension

•PoorfunctioningoftheLESthroughlowbasalsphinctertone,afactorthatappliesparticularlyinpatientswhoalsohaveirritablebowelsyndrome37

•Increasedacidityorirritanteffectfromthecontentsofthestomach

•Delayedesophagealclearance

•Delayedgastricemptying

•PoorsalivaoutputandpoormucosalresistanceThe previously recognized association between hiatus

herniaandGERisdownplayedinmodernthinking.

TreatmentStrategy:Goals,Actions,andHerbs

PracticalMeasures

•Theheadofthebediselevatedby10to15cm,whichimprovesesophagealclearanceatnight.

•Regularmealtimesareadheredto,andeatingontherunorduringstressfulsituationsisavoided.

•FoodsthatreduceLEStone,includingchocolate,carminatives(e.g.,peppermint,spearmint),fattyfoods,coffee,tomatoconcentrates,andonions,areavoided;thesefoodswillvaryfromindividualtoindividual.Spicyfoodsmayalsoaggravatethecondition.

•Individualintolerancetocertainfoods(e.g.,dairyproducts)mayaggravaterefluxandshouldbeavoided.

•DrugsthatreduceLEStone,suchastheophylline,calciumchannelblockers,andprogesterone,areavoided.

•Thepatientshouldgiveupsmokingandexcessivealcoholintake(thesereduceLEStone).

•Thepatientshouldrefrainfromovereating.

•Thepatientshouldavoideatingatbedtime.

•Thepatientshouldloseweight,ifoverweight.

HerbalTreatment

•Mucosalresistancecanbeimprovedwithdemulcentherbs

suchaslicoriceandmarshmallowroot.Theseherbsarebesttakenaftermealsandbeforebedtime.Additionalsupplementationwithslipperyelmpowdercanbeuseful.Forbestmucoprotectiveeffect,alicoriceliquidhighinglycyrrhizinisused.

•LEStonecanbeincreasedandgastricemptyingandsalivaoutputcanbeimprovedwithbitterherbsatlowdoses.However,gastricacidcanalsoincrease,thuscautionshouldbeused.Gentianandwormwoodarethestrongestbitters.Iftheuseoftheseherbsaggravatesthecondition,thengentlerbitterssuchasdandelionroot,globeartichoke,oryarrowmightbetried.Goldensealasamucousmembranetrophorestorativeandbittercanbeuseful.

•Inappropriatelevelsofgastricacidcanbereducedusingantacidherbs—thebestismeadowsweet.

•Healingcanbeenhancedandinflammationcanbeallayedwithvulneraryherbs(e.g.,Aloejuiceconcentrate,Calendula,chamomile,gotukola)andantiinflammatoryherbs(particularlychamomile).Forbestresults,chamomileliquidhighinbisabololisused.

•Effectsofstressonthefunctioningoftheautonomicnervoussystemcanbealleviatedwithanxiolyticherbs(e.g.,passionflower,valerian,andkava)andnervinetonics(especiallyskullcapandSt.John’swort).

•Anyassociateddyspepsiacanbetreatedwithlowdosesofcarminativesgivenbeforefood(becausehighdoseswillaggravateGER).Fennelandpeppermintareamongthebestcarminatives.

ExampleFormula.

SeeTable2-17.

TABLE2-17

Passionflower 1:2 20mlChamomile 1:2 25mlMeadowsweet 1:2 25mlLicorice 1:1 15mlYarrow 1:2 15mlTotal 100ml

Dosage:5mlwithwater three timesadayaftermeals.Anextradosecanbe takenbefore retiring in theevening.

HERPESSIMPLEX

Background.

Herpes simplex skin outbreaks are characteristicmucocutaneouslesionsthatarecausedbynewinfectionwithherpessimplexvirus1(HSV1)or2(HSV2)orbyreactivationof latent virus residing in the nervous system. Typically,HSV1affects the face, lips,ormouth,andHSV2affects thegenitals,althougheitherviruscaninfecteitherlocation.

HSV is a double-stranded, deoxyribonucleic acid (DNA),envelopedvirus.HSV infectionof someneuronal cells doesnot result in cell death. Instead, the cell maintains the viralgenomesinarepressedstatethatiscompatiblewithsurvivaland normal activities of the cell, a condition known aslatency.

TreatmentStrategy:Goals,Actions,andHerbs

•Immune-enhancingherbswillassistthefightagainstthevirusinacuteoutbreaksandwillpreventreactivationoflatentvirus.KeyherbsincludeEchinacearoot,Andrographis,andAstragalus.Astragalusshouldnotbeusedinacuteoutbreaks.

•InternaltreatmentwithSt.John’swortpreparationsthatarehighinhypericinappearstoexertasignificantactivityagainstthevirus(whichisenveloped).

•Debilitatedpatientswithrecurrentoutbreaksmaybenefitfromadrenaltonics,tonics,adaptogenicherbs,andnervinetonicsbetweenoutbreaks.KeyherbsinthesecategoriesincludeRehmannia,ashwaganda,Eleutherococcus,andSt.John’swort.

•TopicaltreatmentoflesionsincludesCalendulaextract(appliedneattothelesions)andlemonbalmandlicoriceinointmentorcreamform.Clinicalstudieshaveshownthatusinglemonbalmointmentonlesionshelpspreventfutureoutbreaks.

ExampleFormula.

For acute outbreaks, the formula in Table 2-18 has helpedseveral patients in conjunction with topical application ofCalendulaextract.

TABLE2-18

Echinacearootblend 1:2 70mlSt.John’swort(highhypericin) 1:2 30mlTotal 100ml

Dosage:5mlwithwaterfourtofivetimesadayuntilthelesionsheal.

HYPERTHYROIDISM

Background.

Graves’ disease (hyperthyroidism) is an inflammatory,autoimmune disease affecting the thyroid gland. Thyroid-stimulatingantibodiesarepresent.Symptomsincludeweightloss, tremor, tachycardia, heat intolerance, palpitations,restlessness,andirritability.

TreatmentStrategy:Goals,Actions,andHerbs

•Thyroidfunctioncanbedampenedwiththyroid-stimulatinghormone(TSH)antagonists,specificallybugleweed.

•Cardiacsymptomssuchastachycardiaandpalpitationscanbecontrolledwithantiarrhythmicherbs,particularlymotherwort,whichreputedlyhasantithyroidactivityaswell.

•Immunesystemfunctioncanbebalancedwithimmune-modifyingherbssuchasEchinacearootandimmunedepressingherbssuchasHemidesmusandTylophora.

•InflammationcanbereducedwithantiinflammatoryherbssuchasRehmanniaandBupleurum.

•AnysuspectedviralcausecanbetreatedwithantiviralherbssuchasSt.John’swort(activeonlyagainstenvelopedviruses)andThuja.

ExampleFormula.

SeeTable2-19.

TABLE2-19Bugleweed 1:2 20mlMotherwort 1:2 20mlEchinacearoot(E.angustifoliaorE.purpurea) 1:2 20mlBupleurum 1:2 25mlSt.John’swort(highhypericin) 1:2 20mlTotal 105ml

Dosage:5to8mlwithwaterthreetimesaday.

MALEIMPOTENCE

Background.

Impotence is the failure to achieve erection, ejaculation, orboth.Avarietyofcomplaintsmaybedemonstrated,includinglow libido, inability to initiate or maintain an erection,inability to ejaculate, and premature ejaculation. Althoughprevious beliefs concluded that psychologic causespredominated, possible organic or functional problemsoccupy current thinking. Thus a multifactorial approach toassessmentandtreatmentisrequired.

Androgen deficiency, lowered vitality, psychologicdisturbance (particularly anxiety and depression), andprescribed or recreational drugsmay cause a loss of desire.Failureoferectionmaybetheresultofthesefactorsorfactors

beyond herbal treatment such as penile diseases andneurologic damage. In contrast, a number of herbs can helpimpotencerelatedtocirculatoryproblems.

TreatmentStrategy:Goals,Actions,andHerbs

•Anxietycanbetreatedwithanxiolyticherbssuchaskavaandvalerian.Nervinetonicsareoftenrequired,particularlydamiana,skullcap,andSt.John’swort.

•DevitalizationisoftenafactorthatcanbeattenuatedbytonicherbssuchasKoreanginseng,ashwaganda,andEleutherococcus.Ifthedevitalizationischronic,thenadrenaltonicswillberequired,suchaslicoriceandRehmannia.

•Malehormonelevelscanbeimprovedwithmaletonics:sawpalmettoandKoreanginseng.

•Improvingcirculationwillalwaysprovideabenefittomaintainerection,andcirculatoryherbs,particularlyginger,Ginkgo,andpricklyash,willassistthistreatmentgoal.HawthornberryandAstragalusmayberequiredifheartfunctionispoor.

ExampleFormula.

SeeTable2-20.

TABLE2-20

Ginkgo(standardizedextract) 2:1 20mlKoreanginseng 1:2 15mlSawpalmetto 1:2 25mlDamiana 1:2 20mlEleutherococcus 1:2 20mlTotal 100ml

Dosage:5mlwithwaterthreetimesaday.

MENOPAUSE

Background.

Not all women who undergo menopause experiencesymptoms. This fact highlights that menopause is a normalevent in a woman’s life. Approximately 70% of womenexperiencehotflashes,and40%sufferfromdepression.Othersymptoms such as sweating, fatigue, irregularmenstruation,and insomnia occur in 20% to 40% of perimenopausalwomen.

Theaimofherbaltreatmentisto:

•Assisttheadjustmenttothisimportantchange.

•Providesymptomaticalleviationoftheeffectsofestrogenwithdrawal.Herbal treatment should not be prescribed indefinitely,

althoughitmayberequiredforseveralyears.

Inrecenttradition(thelast60orsoyears),herbalistshaveemphasized herbs containing steroidal saponins or similar

compounds(e.g.,falseunicornroot,wildyam,blackcohosh)formanagingmenopausalsymptoms.Toregardtheseherbsasovertlyestrogenicinthepostmenopausalwomanisamistake.Such phytochemicals possibly act by interacting withhypothalamicestrogen receptors, therebyallaying theeffectsofestrogenwithdrawal.

The oral use ofwild yam is therefore relatedmore to itssubtle estrogenic properties and not to any reputedprogesterogenic properties. In fact, no evidence exists thatwildyam,theherbalextract,canproduceprogesteroneinthebody.Anylinkbetweenwildyamandprogesterogeniceffectsis a confusing coincidence derived from the fact thatprogesterone can bemade (in a factory or laboratory) fromwildyam.

TreatmentStrategy:Goals,Actions,andHerbs.

The main aims of herbal assistance with the menopausalchangeareto:

•Assistthebodytoadapttothenewhormonallevelsbyreducingtheeffectsofestrogenwithdrawal.Prescribingsaponin-containingherbssuchasfalseunicornroot,wildyam,andblackcohoshachievesthisgoal.Koreanginsengisatonicsaponin-containingherbwithsomeevidenceforestrogenicactivity.However,irritabilityandinsomniamaybeaggravated,thusKoreanginsengshouldbeusedcautiouslyandatlowerdoses.

•Thenervoussystemcanbesupportedwithtonicandnervinetonicherbs.St.John’swortisalmostaspecificformenopausaldepression;skullcapandoatsarealsopopular.

•Theintensityofthehotflashesorsweatingshouldbeabated.Theimportantherbhereissage,althoughcardiovascularherbssuchashawthornberryandmotherwortcanalsobeuseful.Chaste tree has a role to play for the perimenopausal

womanwhoexperiencesPMS-likesymptoms(whichmayormay not be premenstrual resulting from menstrualirregularity). Some herbalists are of the opinion that chastetreealsohelpsallayothermenopausalsymptomssuchashotflashes. The influence of chaste tree on pituitary functionmightbethekeyhere.

ExampleFormula.

SeeTable2-21.

TABLE2-21

Wildyam 1:2 20mlFalseunicornroot 1:2 20mlSage 1:2 20mlSt.John’swort 1:2 25mlChastetree 1:2 15mlTotal 100ml

Dosage:5mlwithwaterthreetimesaday.

OSTEOARTHRITIS

Background.

Despitebeingthemostcommondisorderaffectingthehumanspecies, osteoarthritis (OA) is still poorly understood.Approximately60%ofmenand70%ofwomenwhodiedintheir 60s and 70s had signs of OA.38 The prevalence ofradiographicOAincreaseswithageforalljoints.38Upto35%ofmenand49%ofwomenovertheageof65reportdisabilityrelatedtoarthritis.38

Aging and genetic factors can lead to abnormalities incartilage, which, in conjunction with obesity, trauma, andpoorjointalignment,leadstoabnormalstressonjoints.Theseabnormalities result in inflammation and cartilageremodeling. Cells in the synovial lining release cytokines,which, in complex and poorly understood reactions, lead tocartilage degradation, synovitis, and changes in bone(thickeningandosteophyteformation).38

ConventionalmedicinenowrecognizesthatdietmayplayaroleindevelopingOA.Inparticular,antioxidantvitaminsandvitaminDmayplaya role inslowing theprogressionof thedisease.39

AlthoughOAisaslowlyprogressivedisease,somepatientscanimprove.Thecorrelationbetweenradiologicfindingsandthe patient’s symptoms is often poor—indicating that thedisorder is related to more than just the mechanicalfunctioningofthejoint.38,40

AnumberofdistinctsubsetsofpatientswithOAhavebeenidentified,includingthosewith40:

•Mechanicaljointderangement,forexample,postinjury

•UnilateralhipOA

•GeneralizednodalOA(Heberden’sandBouchard’snodes),seenmostcommonlyinwomenwithsymptomsstartingaroundmenopausePain is the earliest and most consistent manifestation of

early OA and tends to be associated with joint activity.Cartilagehasnonerveendings,thusthepainmustcomefromother sources, such as ischemia in bone, psychologic stress,inflammationinligaments,andpressureonnerves.41

TreatmentStrategy:Goals,Actions,andHerbs.

Antirheumaticherbsaregenerallyprescribedforthetreatmentofarthritisandrheumatism.

•HerbsthatmakethebodymorealkalineareakeypartofthetreatmentforOA,andthemainherbinthiscategoryiscelery.Celeryisconsideredbysomeherbaliststoincreasetheexcretionofacidicmetabolitesintheurine.Celeryprobablyalsohasantiinflammatoryactivity.OtherherbsusedforOAinthiscategoryincludedandelionleafandmeadowsweet.

•Depuratives,whicharebelievedtoaidintheclearanceof

metabolicwastefromthebody,arealsooftenprescribed.Theseherbsincludeburdockandyellowdock;butthekeyherbisnettleleaf,whichhasrecentlybeenfoundtoalsohaveantiinflammatoryactivityinarthritis.

•Bladderwrackisusedforobesepatientswitharthritisbecauseofitsthyroid-stimulatingactivity,butitmayalsohaveothereffects.

•St.John’swortisprescribedwhennerveentrapmentispresent.Becauseofitspositiveeffectonthenervoussystem,particularlyincasesofdepression,St.John’swortcanalsohelpcompensatefornegativepsychosocialfactorsandimprovesleepquality.

•Antiinflammatoryherbsareoftenused,andtheseincludedevil’sclaw,blackcohosh,willowbark,feverfew,ginger,andturmeric.

•Herbalistshavelongrecognizedtheimportanceofimprovingthecirculationtoaffectedjoints,andtraditionaltreatmentssuchaspricklyashandcayennecanbesupplementedwithmoderntreatmentssuchasGinkgo.

•Althoughcrampbark,kava,andvalerianaresometimesusedtorelaxthemusclesaroundanarthriticjoint,whethertheycanreallyactinthiswayisdebatable.Thevalueoftheseherbsmaybemoreintheirabilitytorelaxthepatientandimprovesleepquality.

•AnalgesicherbsmaybeusefulandincludeCaliforniapoppyandJamaicadogwood.

ExampleFormula.

SeeTable2-22.

TABLE2-22

Celeryseed 1:2 30mlDevil’sclaw 1:2 40mlGinger 1:2 10mlNettleleaf 1:2 25mlTotal 105ml

Dosage:5mlwithwaterthreetimesaday.

CaseHistory.

A66-year-oldmanhadbeendiagnosedwith spinal stenosis,withatendencytocalcificationinhisbody,forexample,thelower aorta. He was experiencing pain in the left side(referredpain)andalsopaininhislefthip(OAofthehipwasconfirmed by x-ray diagnosis). He was taking nonsteroidalantiinflammatory drug (NSAID) pain-killers and waspreviouslyalong-termsmoker.

HewasprescribedtheformulationinTable2-23.

TABLE2-23Ginkgostandardizedextract 2:1 20ml

St.John’swort 1:2 25mlCeleryseed 1:2 35mlDandelionleaf 1:1 20mlTotal 100ml

Dosage:8mlwithwatertwiceaday.

Nettle leaf andbirch leaf decoctionof one to twoheapedmetricteaspoonsperdose,twiceadaywasalsoprescribed.

After7monthsof treatment,hewasnotexperiencinganysymptoms and was no longer taking the NSAID. Hecontinued with the treatment at one half the initiallyprescribed doses for another 6 months, after which hediscontinued herbal treatment because hewas pain free. Heremainsfreeofpain4yearslater.

Nettle leaf and birch leafwere prescribed for the arthritisand calcification tendency. Ginkgo was to improvemicrocirculation to joints and nerves (history of smoking),andSt.John’swortwasfornerveentrapmentpain.

PREMENSTRUALSYNDROME

Background.

Recent experiments have examined the relationship betweenpremenstrual syndrome (PMS) and hormones.42-44 Inhibitionof the luteal phase with a progesterone-receptor antagonistdoes not alter symptoms of PMS.42 However, ovariansuppressionusuallyreducesPMS.43

Taken together, this finding implies thatPMS is triggered

by hormone-related events in the follicular or periovulatoryphases.Ovariansuppressionunderdouble-blindconditionsinwomenwithPMSdecreased the severity and eliminated thecyclicity of symptoms in approximately 50% of women.44Symptoms returned when either progesterone or estradiolwere replaced at physiologic levels in these women.Unfortunately, the study does not elaborate on whetherestrogen and progesterone (not taken at the same time)returnedsymptomsinthesamewomen.

The most striking finding in this study is that althoughwomen with PMS had few symptoms during ovariansuppression and recurrence of symptoms during ovariansteroid hormone replacement, normal women had noperturbation of mood during either manipulation. Theseobservations suggest that normal plasma concentrations ofgonadal steroids can trigger an abnormal response—deterioration in mood state—in susceptible women. Thisfinding highlights the importance in PMS of treating thenervoussystem,aswellastheendocrinesystem.(Thecurrentuse of antidepressant drugs to treat PMS underlines thisconsideration.)

Elevatedlevelsofprolactinmaybeinvolved,forexample,causingbreasttenderness.Prolactinmaynotberaisedallthetime:withtheconditionknownaslatenthyperprolactinemia,it is only elevated during stress. This theory may haveparticularrelevancetotheuseofchastetreeinPMS.

Until recently, theway chaste tree acted in the bodywas

poorly understood. Some theories suggested that chaste treeacted on the pituitary to regulate a relative progesteronedeficiency, but this was based on 40-year-old research.Modernstudieshavefoundthatsomechastetreeextractsaredopaminergic (prolactin from the pituitary is inhibited bydopamine).HencechastetreemayactinPMSbytreatingthepresence of latent hyperprolactinemia. A chaste tree extractoptimizedfordopaminergicphytochemicalswaseffectiveinadouble-blind,placebo-controlled,clinicaltrialinwomenwithPMS.45

TreatmentStrategy:Goals,Actions,andHerbs

•Anyhormonalimbalancecanbecorrectedwithchastetreeandisusuallyprescribedthroughoutthecycleonalong-termbasis.Usualdoseis2mlofa1:2extracttakenwithwateronrising.

•Treatingemotionaldisturbances,whichcanoftenbethemostimportantpartofthetherapy,shouldbeapriority.Treatmentisusuallymaintainedthroughoutthecycle.Fordepression,nervinetonicssuchasSt.John’swortareused,andforanxietyorinsomnia,mildsedativessuchaskavaorvalerianareused.

•Themainphysicalsymptomsshouldbetreatedastheyoccur:fluidretentioncanbetreatedwithdiureticssuchasdandelionleaf,achesandpainswithanherbalanalgesicsuchasCaliforniapoppy,andsweatswithsage.Ginkgo

throughoutthecyclewasfoundtobeusefulforbreastsymptoms.Sometimessymptomatictreatmentwillnotbenecessaryiftheotheraimsareaddressed.

•TheadverseeffectsofstressonthebodycanberelievedbyusingadaptogenicherbssuchasEleutherococcusandashwaganda.

•Thelivershouldbetreatedifsignsofsluggishnessareapparent(e.g.,difficultydigestingfats,tendencytoconstipation,historyofliverdisease,tendencytonausea,preferenceforlightornobreakfasts).Theliveristhesiteofthebreakdownoffemalehormones,andasluggishlivermaycontributetohormonalimbalance.HerbstouseincludeSchisandraandmilkthistle.

•Ifthepreviousprotocolisunsuccessful,estrogen-modulatingherbscontainingsteroidalsaponinssuchasfalseunicornrootandwildyammaybeincludedinthetreatment.

ExampleFormula.

Chastetree1:2,2mlwithwateronrising(seeTable2-24).

TABLE2-24

St.John’swort 1:2 20mlSchisandra 1:2 25mlAshwaganda 1:2 30mlSkullcap 1:2 25ml

Total 100ml

Dosage:8mlwithwatertwiceaday.

If fluid retention is present as a predominating symptom,dandelion leaf at 8 ml once a day may be included in thesecondhalfofthecycle.

POORDIGESTIVEFUNCTION

Background.

Poor upper gastrointestinal function may be the result ofinefficient functioning of the salivary glands, stomach,pancreas, liver or gallbladder, or a combination of these.Symptomsincludeanorexia,aprolongedsensationoffullnessorstagnationaftereating,undigestedfoodinstools,belchingorflatulence,intoleranceoffattyfoods,andnausea.

However, although poor upper digestive functionmay belargely asymptomatic in itself, it may contribute to otherconditions such as food intolerance or allergies, intestinaldysbiosis (abnormal bowel flora), constipation, nutrientdeficiencies,andmigraineheadaches.Herbalistsbelieve thatmanychronicdiseasesbeginwithpoordigestivefunctionandthat good upper digestive function is a prerequisite for ahealthydigestivesystem.

Poorupperdigestivefunctioncanalsobeaconsequenceofprolongedorseriousillnessorcanoccurwithconvalescence.Thecondition isalso reflected inchildrenby their failure tothrive, anemia, and susceptibility to infections. Digestive

function also deteriorates with age, particularly gastric acidandpancreaticenzymeoutput.

TreatmentStrategy:Goals,Actions,andHerbs

•Allaspectsofupperdigestivefunctioncanbeimprovedwithbitterssuchasgentian.

•Salivaandgastricacidoutputcanbeimprovedwitharomaticdigestives,includingcinnamonandColeus,andpungentherbs,especiallyginger.

•Bileproductionbythelivercanbeimprovedwithcholereticherbssuchasdandelionroot,milkthistle,andglobeartichoke.

•Gallbladderfunctioncanbeimprovedwithcholagogueherbs,especiallyfringetree,peppermint,andgreatercelandine.

•Indebilitatedpatients,orinchildrenfailingtothrive,tonicherbs,especiallyashwaganda,areincluded.

ExampleFormula.

AnexampleformulaforimprovingupperdigestivefunctionisfoundinTable2-25.

TABLE2-25

Gentian 1:2 10mlCinnamon 1:2 25mlColeus 1:1 40mlGinger 1:2 25mlTotal 100ml

Dosage:20drops(approximately0.5ml)withwater20minutesbeforemeals.

Thereadershouldnote thatwhenusingadropper, itmustbeapharmaceuticallycalibrateddropper.

POORLIVERFUNCTION

Background.

Symptomsthatmaybecausedbypoorliverfunctionincludesluggish digestion, fat intolerance, nausea, and chronicconstipation,aswellaschemical, food,ordrug intolerances.Apoorlyfunctioninglivermayalsocontributetoanumberofdiseasestates,suchaspsoriasis,autoimmunedisease,irritablebowelsyndrome,allergies,andcancer.Patientsmightrevealahistoryofpast liver infection, infestationordamage,alcoholordrugabuse,orexposuretomedicaldrugsorenvironmentalpollutantssuchaspesticides.Drugsideeffectsaremorelikelytooccurinpatientswithpoorliverfunction.

TreatmentStrategy:Goals,Actions,andHerbs

•Hepatoprotectiveandhepatictrophorestorativeherbscanimprovetheliver’scapacitytowithstandtoxicinsultandcanhelpalleviateprevioustoxicdamage,especiallyifahistoryofliverdamageorexposuretotoxinsispresent.Principal

herbsincludemilkthistleandglobeartichoke.Schisandraisparticularlyusefulbecauseitalsoenhancesthedetoxifyingcapacityoftheliver.Theseherbswillassistincasesofnauseaandintolerancesfromanycause.

•Cholereticherbsboostbileproduction,hencethedigestiveroleoftheliverareparticularlyindicatedifdigestivesymptomsarepredominant.Cholereticherbswillalsoboostdetoxificationviathebileandthereforecanbevaluableinconditionssuchaspsoriasisandcancer.Thehepatoprotectiveherbspreviouslylistedpossessagentlecholereticactivityasdoesdandelionroot,butstronglycholereticherbsincludegoldenseal,barberry,greatercelandine,andbitterherbs.Thesestronglycholereticherbswillcausenauseaandirritabilityinapatientwhohassomehistoryofliverdamage.Thereforecholereticherbsshouldbeavoidedatfirstinthesecircumstancesandonlyintroducedafterpriortreatmentwithhepatictrophorestorativesandgentlecholeretics.

•Depurativeherbsarealsoindicatedincasesinwhichhepaticdetoxificationmaybeinadequate.Herbsthatactprincipallyviatheliveranddigestivetractincludeburdock,yellowdock,fringetree,andOregongrape.

•LiverphaseIandphaseIIdetoxificationcanbetreatedwithSchisandra,rosemary,andturmeric.

ExampleFormula.

SeeTable2-26.

TABLE2-26

Milkthistle 1:1 30mlGlobeartichoke 1:2 25mlSchisandra 1:2 25mlFringetree 1:2 20mlTotal 100ml

Dosage:5mlwithwaterthreetimesadaybeforemeals.

CaseHistory.

A female patient, age 38, wished to take the contraceptivepill. She found that even a low-dose pill still causedsymptoms of female hormone excess such as abdominalbloating, weight gain, nausea, and depression. She had ahistory of liver damage caused by hydatid cysts duringchildhood.

SeeTable2-27forthetreatment.

TABLE2-27

Milkthistle 1:1 30mlDandelionroot 1:2 35mlSchisandra 1:2 35mlTotal 100ml

Dosage:5mlwithwatertwiceaday.

Thepatientfoundthatshewasabletotakethepillwithoutany adverse effects as long as she also took the herbaltreatment.

REACTIVEHYPOGLYCEMIA(DYSGLYCEMIA)

Background.

Reactivehypoglycemiaisacontroversialsyndromethatisnotacknowledged as a true hypoglycemic condition inconventional medical literature.46 Reactive hypoglycemia ischaracterized by hunger and autonomic symptoms such asanxiety,trembling,andsweating,aswellasthosethatmayberelated to low blood sugar, such as dizziness and poorconcentration.Thesesymptomstypicallyoccur in themidtolatemorningsandafternoonsandarerelievedbyeating.Othertermstodescribethissyndromehavebeensuggested,suchasdysglycemiaoridiopathicpostprandialsyndrome.46

What may be at work is that these individuals are moresensitivetoadropinbloodsugar,perhapsfromtheeffectsofcaffeine,stress,poorcerebralbloodflow,oranycombination.The effect of caffeine intake on recognition of andphysiologic responses to hypoglycemia was studied inpatients with insulin-dependent diabetes mellitus (IDDM).47For the patient with diabetes, hypoglycemia unawareness ispotentially dangerous. The study looked at the effect ofingestionof250mgofcaffeine(2to3cupsofcoffee)onthehypoglycemic response at 3.8 and 2.8 mmol/L (68 and 50mg/dl)bloodglucoseunderdouble-blindconditions.

Caffeinecausedanimmediateandsustainedfallincerebralblood flow. At a blood glucose of 3.8 mmol/L (68 mg/dl),plasma epinephrine (adrenaline) levels were twice as high

after caffeine compared with placebo. When glucose waslowered to 2.8 mmol/L (50 mg/dl), caffeine was associatedwith agreater awarenessofhypoglycemiawith significantlymore intense autonomic and neurologic symptoms (forexample, hunger, palpitations, sweating, irritability, anddizziness). Levels of epinephrine, cortisol, and growthhormonewerealsoraised.

The same research group previously found that if bloodglucoselevelsfallintothe“low-normal”rangeinindividualswithout diabetes, prior caffeine intake augments both thesymptomaticandhormonalresponsestoamodestreductioninblood glucose.48 This finding is of particular interest. Themedicalorthodoxyconsiderstruereactivehypoglycemiatoberare.However, some health care professionalsmaintain thathypoglycemiaisrelativelycommon.Theconfoundingfactorsmaybecaffeineintake,giventhatitstronglyaccentuatesthesymptoms of even mild hypoglycemia, or just a greatersensitivity to low blood sugar. Patients with symptoms ofreactive hypoglycemia should certainly avoid caffeine in allitsforms.

In true hypoglycemia, glucose counter-regulatorymechanismsareactivatedwhenbloodsugarfallsbelow3.75mmol/L. These mechanisms comprise the release of thehormones glucagon, epinephrine, growth hormone, andcortisol. The release of epinephrine causes many of thesymptoms of true hypoglycemia. In reactive hypoglycemia,some of these mechanisms may also be inappropriatelyactivated,which underlies the role of adrenal support in the

herbaltreatmentofthecondition.

TreatmentStrategy:Goals,Actions,andHerbs

Diet.

Refined carbohydrates should be avoided because they canoverstimulateinsulinrelease(whichmaybeoneaspectofthesyndrome). Intakeofcaffeineshouldalsobeavoided.Mealsshould ideally be smaller and more often, and substantialproteinintakeshouldbepartofeachmeal(proteinstimulatesgluconeogenesis, which results in a consistent output ofglucosefromtheliver).

HerbalTreatment

•AdrenalglandfunctioncanbesupportedwithadrenalrestorativeherbssuchaslicoriceandRehmannia.OnlyRehmanniashouldbeusedifthepatienthashighbloodpressure.

•Detrimentaleffectsofstressontheadrenalglandscanbereducedwithadaptogenssuchasashwaganda,Koreanginseng,andEleutherococcus.

•AdrenalfunctioncanbeboostedwithtonicssuchasKoreanginseng.

•CerebralcirculationcanbeimprovedwithrosemaryandGinkgo.

•LowerdosesofGymnemainliquidpreparations(10mlof1:1extractper100mlformula)canhelpcontrolreactivehypoglycemiaandsugarcraving,ascanbitterherbssuchasgentian.

•LiverfunctioncanbesupportedwithSchisandraandmilkthistlebecausetheliveralsohasaroleinregulatingbloodsugar.

ExampleFormula.

SeeTable2-28.

TABLE2-28

Rehmannia 1:2 30mlLicorice 1:1 15mlGymnema 1:1 10mlSchisandra 1:2 25mlEleutherococcus 1:2 25mlTotal 105ml

Dosage:5mlwithwaterthreetimesadaybeforemeals.

VARICOSEVEINS

Background.

Invaricoseveins (VV), thevalvesdonot functionproperly,whichresultsindilated,tortuoussuperficialveinsinthelegs.PrimaryVVoriginate in the superficial vein systemand are

more common in women. Approximately one half of thesepatients have a family history of VV. Secondary VV resultfromvenousinsufficiencyinthedeepveinsandindicatemoreseriousvenousreflux(compromiseofvenousreturn).

Symptomsincludeadullacheorpressuresensationinthelegs, especially after prolonged standing, and restless legsyndrome (restless legs in bed). Signs, other than the veinsthemselves, include atrophic changes in the skin of the footand ankle, mild ankle edema, and discoloration of the skincausedby the ruptureof avaricosity.Complications includeskinulcerationandsuperficialveinthrombosis.

VV can occur during pregnancy because of hormonalchanges and increased pressure caused by the expandinguterus. Obesity, menopause, aging, and repeated abdominalstrain, aswith heavy lifting or constipation,may contribute.Long periods of standing or sitting with the legs bent orcrossedshouldbeavoided.

Weaknessoftheveinwallandpoorvenoustonecanleadtovalves becoming incompetent, and natural treatments stresstheneedtomaintaingoodvenousandconnectivetissuetone.

TreatmentStrategy:Goals,Actions,andHerbs.

No known herbal treatment has been found that will returnVV to normal veins. However, herbal treatment can correctsymptomsandpreventfurtherdeteriorationorcomplications.

•Venousreturn,veinfunction,andconnectivetissuetone

canbeimprovedwithvenotonicherbs,particularlyhorsechestnut,collagen-stabilizingherbs(hawthornberry),andvasoprotectiveherbs(bilberry).

•Circulatoryfunctioncanbeimprovedwithcirculatorystimulants,especiallyGinkgo.

ExampleFormula.

SeeTable2-29.

TABLE2-29

Horsechestnut 1:2 30mlGinkgo(standardizedextract) 2:1 20mlBilberry 1:1 30mlHawthornleaf 1:2 20mlTotal 100ml

Dosage:5mlwithwaterthreetimesaday.

TOPICALUSEOFLIQUIDHERBS

MAKINGHERBALCREAMSFROMLIQUIDS

Althoughthetopicaluseofherbsisoftenaneffectivemeansof treatment, the available range of prepared creams andointments is quite limited. Practitioners who wish to use awider range to fully tap thehealingpotential of avarietyofherbs can manufacture their own herbal creams by usingherbal liquids mixed into a suitable neutral base. Aninexpensive and convenient way to make herbal creams isdescribedhere.

Althoughonecanhavephilosophicobjections to theiruse(and sometimes practical objections because they can act asirritants), thecreambaseshouldcontainadequate levelsofasyntheticpreservative,largelybecause:

•Creamsareusedrepeatedly,andeachtimethepatienttouchesthecream,heorsheintroducesmicrobesthatcangrowandmultiply,unlesspreservativesarepresent.

•Theadditionofliquidstoacreambasemightalsointroducemicrobesthathavethepotentialtospoilthecreamorevenrenderitharmful(especiallyifappliedtobrokenskin).Aseptic technique*48 must be used when making herbal

creams.

ExampleFormulations.

Afewexamplesofhowtomakedifferentherbalcreamsareprovided. However, the possibilities are many, and specificformulations containing several herbs can be prepared forindividual patients. Information on the topical use ofindividual herbs is provided in the various monographsprovidedinthistext.

AntisepticCream.

Tomakean antiseptic cream, the following ingredientsmaybecombined:

100gcreambase

5mlthyme1:2extract

5mlmyrrh1:5tincture

5mlCalendula1:2extractCream is stirred thoroughly until a smooth consistency is

obtained.

Comment.

This method can be used to incorporate small quantities oftincturesorextractsintothecreambase.Becausethetincturesand extracts are incorporated directly without removal ofalcohol, the resultant cream will sting if applied to brokenskin.

HerpesCream.

100mloflemonbalmextract1:2isreducedonlowheat(over1hour) to15to20ml.Thisconcentrate ispouredwhilehotonto 100 g of cream base and mixed thoroughly until theresultant cream has an even color. The cream is applied tolesionseveryfewhours.

Comment.

This technique is a generalmethod formaking creamswithhigh levels of activity by incorporating large quantities ofextracts into the creambase.The alcohol is removedduringtheconcentration step.Thismethod isnot suitable forherbscontaining essential oils (volatile oils) because they willevaporateduringtheconcentrationstep.(Theantiviralactivityoflemonbalmisnotaresultoftheessentialoil.)

Inthecaseofthelemonbalmcream,100mlof1:2extracthas been recommended as the initial volume. However, formostotherherbs,30to50mlof1:2extractconcentratedto10to15mlissufficienttomakeacreamwithgoodactivity(seelaterdiscussion).LessextractcanbeusedwhenmakingupanArnicacreamgiventhatitisquiteactive.

VaricoseVeinCream.

30 ml of horsechestnut 1:2 is reduced on low heat toapproximately 10 ml. This concentrate is poured while hotonto 100 g of cream base and mixed thoroughly until theresultantcreamhasanevencolor.Themixture isapplied tovaricose veins twice a day.The cream is also beneficial forsofttissueinjuries,butitshouldnotbeappliedtobrokenskin.

HealingCream.

10mlofCalendula1:2and20mlofgotukola1:2isreducedonlowheattoapproximately15ml;30mlofAloeverajuiceconcentrate is added to the hot liquid and continued toconcentrate until the final mixture is 15 to 20 ml. Thisconcentrateispouredwhilehotonto100gofcreambaseandmixedthoroughlyuntiltheresultantcreamhasanevencolor.Thiscreamcanbeappliedtowounds,abrasions,andulcers.

OTHEREXAMPLESOFTHETOPICALUSEOFLIQUIDS

ThroatSyrup

30mlEchinaceapurpureaglycetract1:3

34mlmarshmallowglycetract1:5

15mlelecampane1:2

10mlwildcherrybark1:2

10mllicorice1:1

1mlginger1:2Blendingredientstogetherandtake3mluptosixtimesa

day.

FeminineDouche

2cupswarmwater(orCalendulatea)

1tbspapplecidervinegar

2dropsteatreeoil

5mlOregongrape

5mlpaud’arco

3mlEchinaceapurpureaorangustifoliaroot1:2Mixtogetheranddoucheusingaveryslow,gentleflow.

NasalRinseorNetiPot

½cupwarmwater

½tspseasalt

1mlBaicalskullcap1:2

1mleyebright1:2

1mlgoldenseal1:3

1mlchamomile1:2(optional)Dissipatingthealcoholforthisprocedureisnotnecessary,

because the alcoholwill not irritate the tissue.This solutioncan be placed in aNeti Pot (similar to amini-teapot and isdesignedfornasalrinsing)orinsertedintoalargedropperandgently poured into one nostril at a time, over a sink, while

holding the other nostril closed. The solution will rinse thenasal passageways and run down the back of the throat andintothemouthfordiscarding.

Mouthwash

½cupofwater(orpeppermintteaforflavor)

3mlOregongrape

3mlsage

3mlEchinaceapurpureaorangustifoliaroot1:2Ingredientsaremixedtogetherandswishedandswallowed

threetimesadayaftermeals.

SalineNasalSpray

Base:

30mlpurifiedwater

¼tspseasalt

5mlglycerinIngredientsaremixedtogether.

Thefollowingherbsareadded:

2mlBaicalskullcap1:2

2mleyebright1:2

2mlgoldenseal1:3The base and herbs aremixed together and poured into a

clean,empty,saline,nasal-spraybottleandsprayedintoeachnostrilasneeded.

Caution:Potentialallergicreactioncouldoccurwithuse.

Contraindicatedininfectionorblockageofthesinuses.

SoothingEyebath

8dropseyebright1:2

8dropschamomile1:2(cautionifallergytothedaisyfamily)Herbsareplacedinheatresistantcontainer.Pour½cupof

boiling water over this mixture to dissipate the alcohol.Mixture is allowed to cool, and eyebath cup is filled. Thisamount will be enough to fill several eyebath cups. Freshsolution should be used for each eye and should be usedwithin 4 hours. If a stronger solution is needed, 8 drops ofgoldenseal1:3canbeusedinsteadofchamomile.

Note to the reader:Herbal extracts,oncediluted inwater,willhavea limitedshelf life.Recommendationssuggest thatforoptimalefficacy,anywater-mixformulasusedshouldbeasfreshaspossibleandnotstored.

Acknowledgment.

The assistance of herbalist Linda Ryan in preparing thissection on the topical use of liquids is gratefullyacknowledged.

REFERENCES

MillsS,BoneK.Principlesandpracticeofphytotherapy:modernherbalmedicine.Edinburgh:ChurchillLivingstone,2000.GermoutyJ,etal.Doesextrinsicasthmaexist?AllergImmunol.1988;22(suppl10):32.BrugmanSM,etal.Increasedlowerairwaysresponsivenessassociatedwithsinusitisinarabbitmodel.AmRevRespirDis.1993;147(2):314.FridayGAJr,FiremanP.Sinusitisandasthma:clinicalandpathogeneticrelationships.ClinChestMed.1988;9(4):557.BrayGW.Thehypochlorhydriaofasthmainchildhood.QuartJMed.1931;24:181.BarberioG,etal.Gastro-esophagealrefluxandasthma.Clinicalexperience.MinervaPediatr.1989;41(7):363.GiudicelliR,etal.Gastroesophagealrefluxandrespiratorymanifestations:diagnosticapproach,therapeuticindicationsandresults.AnnChir.1990;44(7):552.SlyPD,HibbertME.Childhoodasthmafollowinghospitalizationwithacuteviralbronchiolitisinfancy.PediatrPulmonol.1989;7(3):153.SzczeklikA.Aspirin-inducedasthmaasaviraldisease.ClinAllergy.1988;18(1):15.

10HahnDL,DodgeRW,GolubjatnikovR.AssociationofChlamydiapneumoniae(strainTWAR)infectionwith

wheezing,asthmaticbronchitis,andadult-onsetasthma.JAMA.1991;266(2):225.

11BurneyP.Adietrichinsodiummaypotentiateasthma.Epidemiologicalevidenceforanewhypothesis.Chest.1987;91(suppl6):143S.

12LockK,etal.ImmunoglobulinGsubclassdeficiencyinpatientswithasthmaandchronicobstructivebronchitis.ImmunInfekt.1990;18(5):157.

13LoftusBG,etal.IgGsubclassdeficiencyinasthma.ArchDisChild.1988;63(12):1434.

14RumbakMJ,etal.Perceptionofanxietyasacontributingfactorofasthma:indigentversusnonindigent.JAsthma.1993;30(3):165.

15MrazekDA,etal.Earlyasthmaonset:considerationofparentingissues.JAmAcadChildAdolescPsych.1991;30(2):277.

16BoljevicS,DaniljakIG,KoganAH.Changesinfreeradicalsandpossibilityoftheircorrectioninpatientswithbronchialasthma.VojnosanitPregl.1993;50(1):3.

17GreeneLS.Asthmaandoxidantstress:nutritional,environmental,andgeneticriskfactors.JAmCollNutr.1995;14(4):317.

18HatchGE.Asthma,inhaledoxidants,anddietaryantioxidants.AmJClinNutr.1995;61(suppl3):625S.

19MoulJW.Benignprostatichyperplasia.PostgradMed.1993;94(6):141.151

20BoneK.Chronicfatiguesyndromeanditsherbaltreatment.ModernPhytotherapist.1995;1(3):12.MediHerbPtyLtd,Warwick,Queensland,Australia.

21StricklinA,SewellM,AustadC.Objectivemeasurementofpersonalityvariablesinepidemicneuromyastheniapatients.SAfrMedJ.1990;77(1):31.

22HarrisonTR,FauciAS,editors.Harrison’sprinciplesofinternalmedicine,ed14,NewYork:McGraw-Hill,1998.

23FelterHW,LloydJU.King’sAmericandispensatory,ed18,rev3.Portland:EclecticMedicalPublications,1905.reprinted1983

24NemeroffCB.Theneurobiologyofdepression.SciAm.1998;278(6):42.

25RosengrenA,TibblinG,WilhelmsenL.Lowsystolicbloodpressureandselfperceivedwellbeinginmiddleagedmen.BMJ.1993;306(6872):243.

26Barrett-ConnorE,PalinkasLA.Lowbloodpressureanddepressioninoldermen:apopulationbasedstudy.BMJ.1994;308(6926):446.

27BosJD,KapsenbergML,SillevisSmittJH.Pathogenesisofatopiceczema.Lancet.1994;343(8909):1338.

28RudikoffD,LebwohlM.Atopicdermatitis.Lancet.1998;351(9117):1715.

29TanBB,etal.Double-blindcontrolledtrialofeffectofhousedust-miteallergenavoidanceonatopicdermatitis.Lancet.1996;347(8993):15.

30AbeckD,MempelM.Staphylococcusaureuscolonizationinatopicdermatitisanditstherapeuticimplications.BrJDermatol.1998;139(suppl53):13.

31LeungDYM,etal.Theroleofsuperantigensinhumandiseases:therapeuticimplicationsforthetreatmentofskindiseases.BrJDermatol.1998;139(suppl53):17.

32AyersS.Gastricsecretioninpsoriasis,eczemaanddermatitisherpetiformis.ArchDermatolSyphilol.1929;20:854.

33BrownWH,SmithMS,McLachlanAD.Fractionalgastricanalysisindiseasesoftheskin.Furtherobservationin316caseswithspecialreferencetorosacea.BrJDermatolSyphilis.1935;47:181.

34NikitinaLS,ShinskyGE,TrusovVV.Contributionofthemembranousdigestionandthesmallintestineabsorptiontothepathogenesisofeczema.VestnikDermatolVenerol.1989;(2):4.

35VasilievYV.Digestiveactivityofintestinaldisaccharidasesininfantssufferingfromeczema.VestnikDermatolVenerol.1984;10:16.

36RobinsonM.Gastroesophagealrefluxdisease.Selectingoptimaltherapy.PostgradMed.1994;95(2):88.

37SmartHL,NicholsonDA,AtkinsonM.Gastro-esophagealrefluxintheirritablebowelsyndrome.Gut.1986;27(10):1127.

38BrooksPM,MarchLM.Newinsightintoosteoarthritis.MedJAust.1995;163(7):367.

39McAlindonT,FelsonDT.Nutrition:riskfactorsforosteoarthritis.AnnRheumDis.1997;56(7):397.

40SchnitzerTJ.Osteoarthritistreatmentupdate;minimizingpainwhilelimitingpatientrisk.PostgradMed.1993;93(1):89.

41AltmanRD.Osteoarthritis:differentiationfromrheumatoidarthritis,causesofpain,treatment.PostgradMed.1990;87(3):66.

42SchmidtPJ,etal.Lackofeffectofinducedmensesonsymptomsinwomenwithpremenstrualsyndrome.NEnglJMed.1991;324(17):1174.

43MuseKN,etal.Thepremenstrualsyndrome.Effectsof“medicalovariectomy,”.NEnglJMed.1984;311(21):1345.

44SchmidtPJ,etal.Differentialbehavioraleffectsofgonadalsteroidsinwomenwithandinthosewithoutpremenstrualsyndrome.NEnglJMed.1998;338(4):209.

45SchellenbergR.Treatmentforthepremenstrualsyndromewithagnuscastusfruitextract:prospective,randomised,placebocontrolledstudy.BMJ.2001;322(7279):134.

46ServiceFJ.Hypoglycemicdisorders.NewEnglJMed.1995;332(17):1144.

47DebrahK,etal.Effectofcaffeineonrecognitionofandphysiologicalresponsestohypoglycemiaininsulin-dependentdiabetes.Lancet.1996;347(8993):19.

48KerrD,etal.Effectofcaffeineontherecognitionofandresponsestohypoglycemiainhumans.AnnInternMed.1993;119(8):799.

* Bacteria and mold will grow in a cream if introducedunder certain conditions. If fingers are dipped into thecream,orifanywaterorothercontaminantgetsintothecream,bacteriaandmoldmaygrow.Whenformulatingcreams,thefollowingtechniqueissuggested:Handsarewashedwithsoapandwarmwateranddriedthoroughlybefore using the cream.A sterile instrument is used totake cream from the jar and transfer it to a sterilizedcontainer.Creamisstoredbelow30°C(86°F)andawayfrom direct sunlight. In summer, it is stored in arefrigerator.The lid is replaced firmlyaftereachuse toensurethecontentsaresealed.

CHAPTER3

HowtoUsetheMonographs

These monographs are aimed at providing the herbalclinician with accessible and clinically relevant informationon more than 100 well-known and widely used herbs. Theinformationispresentedas125herbalmonographsthatcover137liquidherbalextracts.

Eachmonographisstructuredinthefollowingway:

•Informationthatdefinestheherbbycommonnames,botanicalnames,plantfamily,andplantpartused

•Prescribinginformationthatcontainsasummaryofclinicallyrelevantinformation,includingactions,potentialindications,contraindications,warningsandprecautions,interactions,useinpregnancyandlactation,sideeffects,anddosage

•Supportinginformationthatprovidesfurtherdetailtosupporttheprescribinginformationandincludestraditionalprescribing,pharmacologicresearch,clinicalstudies,andreferences

The information in eachmonograph is covered under thefollowingheadings.

COMMONNAMESCommon names of the herb are used throughout themonographsandarepresented in lowercase.Exceptionsarewhen thebotanical nameof thegenus is used as a commonnameinwhichcaseitiscapitalized,asinEchinacea,orwhenthecommonnamecontainsalocality,asinKoreanginseng.

OTHERCOMMONNAMESThis section lists other common names of the herb that arefrequentlyused,particularlyintheliterature.

BOTANICALNAMESThe botanical name consists of two Latin names: a genericname, which comes first, plus a specific epithet, both ofwhich are italicized, as in Lycopus virginicus. The genericname, which is capitalized, defines the genus to which theplantbelongsandmaybeabbreviatedtoitsinitialletter(e.g.,L.virginicus).Themembersofaspeciesmaybegroupedintosubspecies or varieties, such as Arnica chamissonis subsp.foliosaorViburnumopulusvar.americanum.

Botanical names other than the current or preferredbotanicalname,whichmaybecommonlyencounteredinthescientificorherballiterature,arealsolisted.Thesenamesaredenotedby the superscript symbol # as an alternativename.Botanical nomenclature is being frequently updated, thusspecies and even genus names may change over time.Taxonomistsandbotanicalauthoritiesoftendisagree,andthestatusof a botanical namemaychange (an “old”namemaybecome the “new”name).Thebotanical name listed first inthis section of the monographs is not necessarily the mostcurrent botanical synonym but is usually the most widelyused.Themonographsdonotcontainacomprehensivelistingofallbotanicalsynonyms.Onlythemorerecentorfrequentlyencounteredonesareincluded.

The American Herbal Products Association (AHPA) hasreviewed the taxonomy of the most commonly used and

important therapeutic herbs in use in theUnited States. TheAssociation’s findings are reflected in the book Herbs ofCommerce(2ndedition,October,2000),adocumentthatmaysupersedethepreviousHerbsofCommercedocumentthattheU.S. Food and Drug Administration uses for the labelingrequirementsoftheDietarySupplementHealthandEducationAct1994.TherecommendedchangesbyAHPAfortheherbsfeaturedinthisbookare:

CommonName OldBotanicalName NewBotanicalName

Blackcohosh Cimicifugaracemosa Actaearacemosa

Couchgrass Agropyronrepens Elymusrepens

Eyebright Euphrasiaofficinalis

Euphrasiarostkoviana,Euphrasiastricta

Jamaicadogwood Piscidiaerythrina Piscidiapiscipula

Lavender Lavandulaofficinalis Lavandulaangustifolia

Oregongrape Berberisaquifolium Mahoniaaquifolium

Note: Anemone pulsatilla has been incorrectly assigned in this publication as Pulsatilla patens andPulsatillapratensisinsteadofPulsatillavulgaris.

A medicinally interchangeable species refers to anotherspecies,subspecies,orvarietyofanherbthathasverysimilartherapeutic action or actions and may be clinically used inplace of the preferred or official species. This species isdenotedbythesuperscriptplussymbol+.

Example:Lycopusvirginicus,Lycopuseuropaeus+

Lycopus virginicus is the preferred species for the usesdescribed for the herb bugleweed, but Lycopus europaeus(gypsywort) can also be used for the same clinicalapplications.

Occasionally, assigning the status of the species asmedicinally interchangeable or as alternative is not easilyresolved,andthealternativebotanicalnameislistedwithbothsymbols, for example, eyebright: Euphrasia officinalis,Euphrasiarostkoviana#/+.

FAMILYTheplantfamilyisthehighergroupingafterthegenusintheoverall hierarchy of the plant kingdom.When investigatingbotany,an importantaspect is todrawadistinctionbetweennomenclature (naming) and taxonomy (classification in ahierarchical system). Taxonomy in particular is a constantlychanging field in which plants are often reclassified into adifferentgenusorfamily.

For simplicity, one authority was chosen as the primaryreference:MabberleyDJ:ThePlantBook, ed2,Cambridge,1997, Cambridge University Press. In this book, the authorfollowsprimarily thesystemofCronquist (1981),whichhasbeenmodifiedbyKubitzki(1990).Althoughthisbookisnotthe most recent source of taxonomic information, it isconvenient forsearching. (More recentclassificationsdonotallow searching by genus.) Therefore changes in taxonomythathaveoccurredafter thepublicationofMabberley(1997)will not necessarily be represented here. Currently, theScrophulariaceae and Malvaceae are undergoing revision,which is likely to affect severalmedicinal plants, especiallyRehmanniaglutinosa.

FamilyName AlternativeFamilyNamePalmae ArecaceaeGramineae Poaceae

Cruciferae BrassicaceaeLeguminosae FabaceaeGuttiferae ClusiaceaeUmbelliferae ApiaceaeLabiatae LamiaceaeCompositae Asteraceae

Mabberley uses the family names recognized by theInternational Association of Botanical Nomenclature (St.Louis Code, 1999). However, alternative family names arealsovalid.Mabberleyisoutlinedasfollows:

Thiscodeindicatesthatbothsetsoffamilynamesarevalid,with “Compositae” not out of date compared with“Asteraceae.”The issueofwhich familyname tousecomesdowntotheindividual’spreference.Thefamilynameslistedinthefirstcolumnhavebeenchosenforuseinthistext.

PLANTPARTSUSEDThepartorpartsoftheplantthatareusedtherapeuticallyaredefined.

PRESCRIBINGINFORMATION

ACTIONS

Thisfieldcontainsalistingofthemostrelevantactionsoftheherb.Herbshaveactivityonthebodyeitherwhentakenorallyor applied topically. This information comes mainly fromtraditional texts, but sources also include recent clinical useandestablishedpharmacologicactions.Aglossaryattheendof the book provides definitions for these terms, and theappendix contains two action indexes that are categorizedaccordingtoeithertheherbcommonnameortheaction.

POTENTIALINDICATIONS

Recommended potential indications, considering the uniqueneedsof thepatient,are listed inaneasy-to-read list.At theend of each indication, a number (or series of numbers) isdisplayed that denotes the level of evidence for thatindication.Thiscodeisnotareferenceorcitationintheusualsense. (Reference numbers are found throughout the rest ofthemonographdenotedbysuperscriptednumbers.)Thelevelof evidence code is presented as italic numerals inparentheses.

The aim of the code is to provide the reader with apowerfulandconcisesummaryofthesupportingevidencefortherecommendeduseoftheherbbysummarizingataglancethe traditional, pharmacologic, and clinical informationcontainedthroughouttherestofthemonograph.

Definition NotesLevel1

Evidenceobtainedfromasystematicreviewofallrelevantrandomized,controlledtrials

Includessystematicreview(ofrandomized,controlledtrials)andmeta-analysis.

Level2

Evidenceobtainedfromatleastoneproperlydesigned,randomized,controlledtrial

Trialsmustbecontrolledbutnotnecessarilyplacebocontrolled.Controlsmayincludeacontrolleddiet,compressionstockings,orotherphysicaltreatmentsor

conventionalmedication.Level3

•Evidenceobtainedfromwell-designed,controlledtrialswithoutrandomization,or

•Evidenceobtainedfromwell-designedcohortorcase-controlanalyticalstudiespreferablyfrommorethanonecenterorresearchgroup,or

•Evidenceobtainedfrommultipletimeserieswithorwithouttheintervention(Dramaticresultsinuncontrolledexperimentsmayalsoberegardedasbeingofthislevelofevidence.)

Includesepidemiologicstudiesandpharmacologicstudiesinhealthyhumans,regardlessofwhethertheywerewelldesignedorrandomized.

Level4

Opinionsofrespectedauthorities,basedonclinicalexperience,descriptivestudies(suchasuncontrolledtrials,postmarketingstudies),orreportsofexpertcommittees

Includes:

•GermanCommissionEmonographs(see“ClinicalStudies”sectionforanexplanation)

•ESCOPmonographs(see“ClinicalStudies”sectionforanexplanation)

•UniversityleveltextbooksLevel4aClinicaltrialinformationofanylevel,testingaconstituentisolatedfromanherbwhenthedoseandbioavailabilityaresufficienttobeextrapolatedtooraluseoftheherb(Examplesincludeclinicaltrialsusingescin,thetriterpenoidsaponinisolatedfromAesculushippocastanum.)

Iftheconstituentispresentwithintheherbalextractatthetesteddose,thenahigherlevelofevidencemaybeassigned,dependingonthestudydesign.

Level5

Sourcesofthisinformationincludepharmacopeiasandauthoritativetexts:

•PharmacopoeiaCommissionofthePeople’sRepublicofChina:PharmacopoeiaofthePeople’sRepublicofChina,Englished,Beijing,1997,ChemicalIndustryPress

•BritishHerbalMedicineAssociation’sScientificCommittee:Britishherbalpharmacopoeia,Bournemouth,UK,1983,BMHA

•BritishHerbalMedicineAssociation:Britishherbalcompendium,Bournemouth,1992,BHMA

OthertraditionalWesternherbalmedicinetexts:

•FelterHW,LloydJU:King’sAmericandispensatory,ed18,rev3,Portland,1905,reprinted1983,EclecticMedicalPublications

•FelterHW:Theeclecticmateriamedica,pharmacologyandtherapeutics,Portland,1922,reprinted1983,Eclectic

Well-establishedtraditionaluseofmorethan50yearsinamajorsystem,suchasWesternherbalmedicine,Ayurveda,orTCM,whichisreflectedincurrentpractice

MedicalPublications

•EllingwoodF,LloydJU:Americanmateriamedica,therapeuticsandpharmacognosy,ed11,Portland,1983,EclecticMedicalPublications

•OsolAetal:ThedispensatoryoftheUnitedStatesofAmerica,ed24,Philadelphia,1947,JBLippincott

ClinicalTCMtexts:

•BenskyD,GambleA:Chineseherbalmedicinemateriamedica,Seattle,1986,EastlandPress

•ChangHM,ButPP:PharmacologyandapplicationsofChinesemateriamedica,Singapore,1987,WorldScientific

ClinicalAyurvedictexts:

•ChopraRNetal:Chopra’sindigenousdrugsofIndia,ed2,Calcutta,1958,reprinted1982,AcademicPublishers

•ThakurRS,PuriHS,HusainA:MajormedicinalplantsofIndia,Lucknow,1989,CentralInstituteofMedicinaland

AromaticPlants

•KapoorLD:CRChandbookofAyurvedicmedicinalplants,BocaRaton,1990,CRCPress.

Forotherethnicsystems,thislevelisusedwhenprimaryreferencesarecited.

Level6Othertraditionalwritings,particularlythosethataresecondarysources;reportsofprimarytraditionaluse,ornotlikelytobereadilyusedinmodernclinicalpractice

Includesallotherbooksorsourcesnotcoveredinlevel5.

Level7Extrapolationfrominvivoanimalstudies,withemphasisonstudiesusingoraladministration

TCM,TraditionalChinesemedicine.

Theselevelsofevidencearebasedonthoserecommendedby the Australian government’s Therapeutic GoodsAdministration for the purposes of registering claims forherbalproducts.Thelevelshavebeenextendedinthisbooktofurther distinguish traditional sources of information and toallowinclusionofclinicaltrialsinvolvingherbalconstituentsand, in some instances, pharmacologic studies. The level ofevidencecodesaredefinedinthetableonpages51-52.Thistable is best referred to regularly until the reader becomesfamiliarwithitscontents.

Inmost cases,when a higher level of evidence exists forusinganherb,anylowerlevelsforthesameusearenotlisted:

•Iflevel1evidenceforrandomized,controlledtrialsispresent,thelowerlevelclinicaltrialevidence(2,3,4)isnotlistedbesidetheindication(andsimilarlyforlevels2and3).Theexceptionisthatlevel4isstilllistedwithahigherlevelofevidencewhenitcorrespondstorespectedauthoritiesandexpertcommittees(e.g.,CommissionE,EuropeanScientificCooperativeonPhytotherapy[ESCOP]).

•Whenlevel4evidencefromanuncontrolledtrialexistsforanherb,level4a(trialinformationononeofitsconstituents)isnotlisted.

•Level6traditionalinformationisnotlistedwhenlevel5occurs.However,ifbothtraditionalandclinicalsupportexistsforusinganherb,bothlevelsofevidencearenoted.

•Level7isnotlistedwhenclinicalevidenceexists(levels1through4)becausepharmacologicanimalstudiesareusuallyconductedbeforeclinicaltrialsarebegun.Otherpointsworthnotingincludethefollowing:

•Onlysystematicreviewsevaluatingrandomized,controlledtrialsareincludedaslevel1evidence.(Areviewofpharmacologicactivity[invivostudies]doesnotcountaslevel1.)Areviewofuncontrolledtrialsortrialswithoutrandomizationwouldbelevel3or4evidence.•Wheninformationregardingthequalityofthetrialisinsufficient,alowerlevelofevidencehasbeenassigned.Forexample,acontrolledtrialnotstatedasrandomized

wouldbelistedaslevel3,notlevel2.When a clinical trial used specialized extracts, such as

standardizedextractsthatcontainacertainamountofmarkeroractivecompoundorcompounds,thelevelofevidencecodereflects the abilityof a liquidherbal product todeliver suchlevels of these phytochemicals. For example, in trials usingstandardized hawthorn leaf and flower extract, 30 to 45mg/dayofoligomericprocyanidins(OPCs)wasadministered.ThisamountofOPCisachievablefromagoodqualityextractin the recommendeddose range (3 to6ml/dayof1:2 liquidextractdelivering10mg/mlofOPCs).Hencetheindicationsthatclinicaltrialinformationestablishedcarrytheappropriatelevel of evidence, depending on the quality of the trial ortrials. Indications in this example would be cardiacinsufficiency, particularly corresponding toNewYorkHeartAssociationstagesIandII,withlevel1evidence.(Thereadershouldnote that regular,galenical liquidextractswith loweror unknown amounts of OPCs may not duplicate the trialresults, and therefore level 1 evidence would not beappropriateforsuchproducts.)

Ontheotherhand,whenanextractisunabletodelivertherequired amount of active ormarker constituents, a level 4acodeisapplied(thusdenotingclinical trial informationforaconstituent). For example, a number of clinical studies haveinvestigated the use of silymarin (a complex of activeconstituentswithinmilkthistle[Silybummarianum])with420mgper daybeing themost commonly administereddose.Agoodqualitystandardized1:1ethanolicextractofmilkthistle

should contain not less than 25mg/ml of silymarin.With arecommendeddailydoserangeof4.5 to8.5ml, thisamountof 420mgwould not be reached (8.5ml× 25mg/ml=212.5mgsilymarin/day).Thereforethepotentialindicationsderivedfromtheseclinicaltrialscarryalevel4aratingofevidence.

CONTRAINDICATIONS,WARNINGSANDPRECAUTIONS,INTERACTIONS,USEINPREGNANCYANDLACTATION,SIDEEFFECTS

Ingeneral, thesafetyinformationcontainedinthesesectionsis drawn from the text Principles and Practice ofPhytotherapy or from relevant papers in peer reviewedjournals. However, the opinions of expert committees(CommissionE,ESCOP)areincludedwhenappropriate.Ifastatement concerning safety ismade that is not drawn fromany of these sources, it represents the author’s subjectiveevaluation of the available information. Appropriate safetyinformationfromtraditionalsourcesisalsoincluded.

Ageneralprincipleholdsthatcliniciansshouldrefrainfromgiving medicines to a pregnant woman unless clearlynecessary.Althoughpregnantwomenhaveusedsomeherbs,particularcareshouldbeusedwhenprescribingtheseherbsinthe crucial first trimester during fetal organ development.Additional doubt exists as to how secondary plantmetabolites, many of which pass easily and evenpreferentially into breast milk, affect the breast-fed infant.The recommendations listed in the “Use in Pregnancy andLactation” section are based on an informed evaluation ofcurrent research and regulatory and traditional sources ofinformation.

Doseperday* Doseperweek*

Minimumtomaximummlofx:yliquidextract/tincture

Minimumtomaximummlofx:yliquidextract/tincture

DOSAGE

Doses are provided for both daily and weekly intervals. Inmost cases, thedoses arepresented in an easy-to-read table,with the minimum and maximum values in ml and thestrengthoftheliquidextractortincture(x:y).

The weekly dose is convenient when preparing herbalformulationstobedispensedoveraperiodofweeks(seetheabove box). The daily dose has been calculated from theweekly dose and has been rounded off (hence it is not an“exact”division).

Further informationabout the literaturesourceof thedoserange is listed as a footnote (*) on the same page as is thedose table. The literature sources include traditional texts,clinicalstudies,expertcommittees,orotherwritings.

Withregardtotraditionalsourcesofdoseinformation,therange given in themonograph is not an exactmathematicalextrapolation. Rather, the range is an interpretation of theinformation available from a variety of traditional sources,recent clinical and scientific studies, and the author’seducation and clinical experience. Traditional sources forWestern herbal medicine include the British HerbalPharmacopoeia (BHP), British Herbal Compendium, andsomeolder documents towhich authors refer (such as earlyeditions of the British Pharmacopoeia and BritishPharmaceuticalCodex).

ThediscussionondosageinChapter1(p.18)indicatesthatbecause tinctures better preserve the chemical profile of thedried herb, more credibility should be given to the tincturedoseswhenusingthedoserangesoutlinedintheBHPratherthan the liquid extract doses (1:1). (The 1:5 tincture dosemultiplied by 0.4 gives the corresponding 1:2 dose. In theabsenceofa1:5 tincturedose, the1:10 tincturedosecanbemultipliedby0.2.)

SUPPORTINGINFORMATIONThe information in thissectionhasbeensummarizedfor thereader’s convenience. That the reader should wade throughextensiveandlengthymonographsisnottheintentionofthisbook.

TRADITIONALPRESCRIBING

Thissectionincludesinformationabouttraditionalprescribingcovering several traditional systems. Words with specificmeaning in Ayurveda and traditional Chinese medicine(TCM) are italicized (e.g.,medharasayan, damp heat). Thereader is advised to consult appropriate texts for furtherunderstandingofthesetraditionalterms.

TheUnitedStatesPharmacopeia(USP)wasestablishedin1820, and the National Formulary (NF) was initiallypublished in 1888 as a sister compendium to thePharmacopeia.TheNFhasbeenpublishedwiththeUSPinasinglevolumesince1980(USP-NF).Theeditionpublishedin2000-2001isUSP24-NF19.EarlyeditionsoftheUSPandNFcontainedentriesonherbsthatreflectedtheiruseasorthodoxmedicines at the time. As modern orthodox medicinedeveloped, most herbs were dropped from these officialpublications.Recently,manyherbshavebeenreinstatedwithquality standards included. Informationhasbeen included inthissectionfromoldUSPandNFeditions,whichisdeemedtobeindicativeoftraditionalprofessionaluse.

PHARMACOLOGICRESEARCH

Pharmacologic research relevant to the major activities andindications of each herb is presented in a concise form,including in vitro studies and in vivo animal studies(experimentalmodels).All pharmacologic studies conductedinvolving human volunteers are listed in the “ClinicalStudies”section.Whenavailableforinvivostudies,therouteofadministrationoftheherborconstituenthasbeenincluded,suchasorallyorbyinjection.

Extrapolationfromanimalor invitro studies tohumans isfraught with difficulties, and this information is providedmainly to give the reader an indication of what is knownabout the possible pharmacologic properties of each herb.Given thatall theherbs in thisbookareapprovedforuse inmostcountries, themostrelevantpharmacologic informationwouldbe revealedorconfirmedbystudies involvinghumanvolunteers.

CLINICALSTUDIES

The doses administered in clinical trials were generallyincluded when such information was readily available. Forconcentrated extracts, the dose has been translated into anequivalent amount of herb based on the concentration ratio.Thus 900 mg of a 6:1 extract is listed as “equivalent toapproximately 5.4 g/day of dried herb” (900 mg×6). In thecase when the concentrated extract is listed as a range, thedoseiscalculatedfromtheaverageoftherange.Thus900mgofa3:1to6:1extractislistedas“equivalenttoapproximately4g/dayofdriedherb”(900mg×((3+6)÷2)).

The terms“effective”and“efficacious”aredefined in theglossary of clinical terms (AppendixC) and are used in thefollowingwayinthemonographs:

•Efficacious:proveninwell-designed,randomized,double-blind,placebo-controlledtrials

•Effective:provenincase-control,postmarketingordrugmonitoringtrials,particularlywhenapatient’sassessmentisrecordedandinotherlesswell-designedtrialssuchasuncontrolledtrialsInadditiontoclinicalorpharmacologicstudiesinhumans,

this section includes indications recommended by expertcommittees,suchas theGermanCommissionEandESCOP(seelaterdescription).IndicationsfromtheCommissionEare

listed for its approvedherbsonly.Becauseof the regulatorynatureof the information, herbs that havebeen reinstated intheUSP-NFarealsolistedinthissection.

German Commission E: In 1978 the German FederalHealth Department established an expert committee(CommissionE)withastrongclinicalbackgroundtoreviewand approve the safety and efficacy of selected herbs. TheCommissionEmonographswere based on extensive reviewof the scientific data and traditional information, as well asthe interdisciplinary expertise of the members of theCommission.Eachherb investigatedwasgivenapositiveornegative assessment, and an unpublished justification wasattached to each monograph (with the reference materialstored at theGermanHealthDepartment). TheCommissionwas discontinued after the early 1990s, but much of theinformationremainsvalid.

ESCOP: The European Scientific Cooperative onPhytotherapy was founded in June 1989 as an umbrellaorganization representing national phytotherapy associationsacrossEurope,especiallyforliaisonwithEuropeanmedicineregulators.ESCOP’saimsaretoadvancethescientificstatusof phytomedicines and to assist with the harmonization oftheir regulatory status at the European level. An importantobjective of the organization is to produce referencemonographs on the therapeutic use and safety of herbalremedies.TheESCOPmonographswerepreparedinasimilarway to that of the Commission E monographs. To date,ESCOP has published a total of 60 monographs. More

information is available from the following web page:http://www.escop.com/.

REFERENCES

REFERENCESarecitedtosupporttheinformationinthemonographs,exceptwhenthereaderisreferredtothetextMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.Inmonographswhenthisisthecase,onlyresearchpublishedsubsequenttothePrinciplesandPracticeofPhytotherapyisreferenced.

IIMonographs

ALBIZIA

BotanicalNames: Albizialebbeck,Albizzialebbeck#,A.lebbek#

Family: LeguminosaePlantPartUsed: Stembark

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antiallergic,hypocholesterolemic,antimicrobial

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingAlbiziainformulationsinthecontextof:

•Allergicrhinitis(5,7)

•Allergicrespiratorydisordersespeciallyasthma(4,5)

•Eczema(5)

•Possiblebenefitinhypercholesterolemia(7)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3.5–8.5mlof1:2liquidextract

25–60mlof1:2liquidextract

* This dose range is extrapolated from traditional Ayurvedic medicine1 and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Bronchitis,asthma,allergicdisorders,leprosy,eczema,pruritus,paralysis,guminflammation,worminfestation1-4

•Asanantiinflammatoryagent5

PharmacologicResearch

•StudiesfoundAlbiziatohaveantiallergicandantianaphylacticactivity.5-7Earlyprocessesofsensitizationwereinhibited,levelsofallergy-inducingantibodiesweredepressed,aswasT-lymphocyteandB-lymphocyteactivity.Astabilizingeffectonmastcellscomparedwithdisodiumcromoglycateandprednisolonewasexhibited.3,6

•AprotectiveeffectontheadrenalglandswasdemonstratedfororaladministrationofAlbiziaextractordecoction.Anincreaseinadrenalactivitywasalsoobserved.3,8,9

•OraldosesofAlbiziasignificantlydecreasedserumcholesterolinvivo.3,6

•Albiziademonstratedantiulceractivityinvivobutnotinnonsteroidalantiinflammatorydrug(NSAID)modelsofulcerinduction(indomethacinandacetylsalicylicacid).10

•Albiziahasdemonstratedantimicrobialactivity11andanthelminticactivity12invitro.Inanuncontrolledstudyinvolving20patientswithasthma,theresponsetoAlbiziawasexcellentforasthma

ClinicalStudies

ofrecentonset(lessthan2years)butlesspredictableinmorechroniccases.Improvementinclinicalandbiochemicalparameterssuchasplasmacortisol,catecholamine,histaminase,andbloodhistaminewereobserved.ThesignificantincreaseinplasmacortisollevelsaftertreatmentsuggeststhatAlbiziamightprovidebenefitthroughsupportingtheadrenalcortex.Albiziawasadministeredasadecoction(25mlfourtimes/day)for3weeks.13

REFERENCES

KapoorLD.CRChandbookofayurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.KirtikarKR,BasuBD.Indianmedicinalplants,vol2.SNBasu,Allahabad,India,1933.TripathiRM,SenPC,DasPK.JEthnopharmacol.1979;1(4):385-386.ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinalandAromaticPlants,1989.TripathiRM,DasPK.IndianJPharmacol.1977;9:189-194.TripathiRM,SenPC,DasPK.JEthnopharmacol.1979;1:397-406.JohriRK,etal.IndianJPhysiolPharmacol.1985;29(1):43-46.TripathiSN,ShuklaP.IndianJExpBiol.1979;17:915-917.TripathiP,etal.IndianJPhysiolPharmacol.1983;27(2):176-

178.10ChatterjeeSS,JaggyH:4thInternationalCongressonPhytotherapy,Munich,September10-13,1992;AbstractSL75.

11GanguliNB,BhattRM.IndianJExpBiol.1993;31:125-129.12KaleysaRajR.IndianJPhysiolPharmacol.1975;19:47-49.13TripathiSN,etal.QuartJSurgSci.1978;14:169-176.

ALOEVERA

OtherCommonName: AloeBotanicalName: Aloespp.Family: AsphodelaceaePlantPartUsed: Juicefromtheleaf

PRESCRIBINGINFORMATION

Actions Immuneenhancing,antiviral,vulnerary,antiinflammatory,antitumor

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingAloejuiceconcentrateinformulationsinthecontextof:

•Non-insulin–dependentdiabetesmellitus,hypertriglyceridemia(3)

•Adjuvanttherapyforthetreatmentofhumanimmunodeficiencyvirus(HIV)infectionandacquiredimmunodeficiencysyndrome(AIDS)(4)

•Improvingtheresponseoftheimmunesystem(7)

•Topicaltreatmentforgenitalherpes(2)

•Topicaltreatmentforpsoriasisandseborrheicdermatitis(3)

•Topicaltreatmentforchroniclegulcers(4)

•Topicaltreatmentforburns(4)

•Topicaltreatmentformouthulcers(4a,6)

•Topicaltreatmentforwoundsandabscesses(6)

Contraindications IndividualswithknownhypersensitivityshouldavoidusingAloejuiceproducts.1,2

WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Aloeproductshavecausedhypersensitivityreactionssuchasdermatitiswhenusedtopicallyandorally.1,2

Dosage

25mlofAloejuiceconcentrate(4.5:1)istakenonetofourtimesperday.Aloejuiceconcentratecanbetakeninorangeorpineapplejuice.*Aloejuiceconcentrateisbestgivenonitsownandnotmixedwithherbalextracts.

* Thisdoserangeisextrapolatedfrompharmacologicandclinicaltrialdata.3

Leafconcentratesprovidingquantifiedlevelsofacemannanare recommended and should ideally contain not less than11.25 mg/ml of acemannan. Additionally, the safetyassessments in this monograph apply only for Aloe liquidsthat contain low levels of anthraquinones (usually by aremovalprocess).

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesfromtraditionalAyurvedicandThaimedicineinclude:

•Pepticulcers4

•Topicallyforburns,wounds,abscesses,mouthulcers,4andinflamedareas5

PharmacologicResearch

•ImportantconstituentsinAloeleaves,apartfromtheanthraquinoneglycosides,arethepolysaccharides,inparticular,acetylatedgalactomannan.Thislong-chainpolysaccharidewasgiventhenameacemannan.6

•Short-termexposureofperitonealmacrophagestoacemannanupregulatedtheirrespiratoryburst,phagocytosis,andkillingofCandidaalbicans.7

•Severalstudieshaveshownacemannantohaveabeneficialeffectintreatingandpreventingtumors.8,9InjectionofAloepowder(undefined)stimulatedcell-mediatedresponsesinanexperimentaltumormodel.10

•Oraladministrationorinjectionofacemannanwasbeneficialfortreatingfelineimmunodeficiencyvirusinfectioninvivo.11ExperimentalstudiessuggestthatacemannanhassomebenefitsinthemanagementofHIV.12-14

•Acemannanwasshowntoincreasesplenicandperipheralbloodcellularityandlevelsofhematopoieticprogenitorsinthespleenandbonemarrowinexperimentalstudies.15

•OraladministrationofAloegelwasactiveasanantiinflammatoryagentinseveralmodelsofinflammation.Theactivitywassaidtodependonthepresenceofanthraquinones.16

•Inlaboratorystudies,woundsweretreatedeitherbytopicalapplicationorbyoraladministrationofAloegel,withbothtreatmentsproducingbeneficialresults.17-19Aloecreamdemonstratedbenefitinfirst-andsecond-degreeburns,20whichmaybearesultofinhibitionofthromboxaneB2andprostaglandinF2αformation,therebypreservingdermalcirculationanddecreasingburnwoundtissue.21

•GastrointestinaltreatmentwithAloejuice(170ml/day)resultedinimprovedgastricandintestinalfunction.22

TheAloeleafyieldstwoproductsthathavemedicinal,pharmaceutical,andcosmeticuses:AloeresinandAloegel(oftenmadeintoajuice).

Aloeresinisasolidresidueobtainedfromthelatexorsapthatexudesfromthecutleaf.Theresincontainsanthraquinonecomponentsandiswellknownforitslaxativeactivity.Aloegelisamucilaginousmaterialobtainedmainlyfromthecentralpartoftheleaf,knownparticularlyforhealingwounds.Boththeresinandthegelhavebeenusedtraditionally.

Recently,theAloegelintheformofextractsorjuiceshasdemonstratednewmedicalapplications.Inmanyoftheclinicalstudieslistedhere,theAloeextractisnotdefined,butassumptionsarethattheextractdoesnotcontainlargeamountsofanthraquinones.

•SeveralclinicalstudiesusingacemannanintreatingHIVandAIDShavebeenconducted.23,24Inanuncontrolledclinicalstudy,29patientswithAIDSreceivedAloeverawholeleafjuice(containing1200mg/dayofacemannan),

ClinicalStudies

essentialfattyacids,andnutrients.Karnofskyscoresimprovedinallofthesepatientsover180days.25

•Seventytwopatientswithrecentlydiagnosednon-insulin–dependentdiabetesreceivedeitherAloejuiceorplaceboover6weeksinanopentrial.Fromday14,thebloodsugarlevelsofpatientstreatedwithAloeweresignificantlyreducedcomparedwiththecontrolgroupandcontinuedtofallsteadilyoverthetreatmentperiod.Bloodtriglyceridelevelsweresignificantlyreducedfromday28.Cholesterollevelswereunaffected.26Inasingle-blind,placebo-controlledtrial,Aloejuiceincombinationwithglibenclamidesignificantlyreducedlevelsoffastingbloodglucosewithin2weeksandtriglycerideswithin4weekscomparedwithglibenclamidealone.Evenafter6weeksoftreatmenthowever,bloodsugarlevelshadnotfallentonormalvalues.27Inbothtrials,1tablespoonof80%Aloejuicepreparedfromgelwastakentwiceperday.

•OraladministrationofanAloeextractfor6monthsdemonstratedbenefitinpatientswithchronicasthma.Onethirdofthe33patientswereregardedaseffectivelytreatedbasedonpatients’impressionsandphysicians’observations.Aloewasnotbeneficialforpatientswhohadpreviouslybeenadministeredasteroiddrug.Thedailydoseprescribedwas10mlofa20%solutionofAloeextractinsaline.Theextractwasnotdefinedexceptthatitwasstoredinthedarkat4C(39°F)for7days.28

•Inadouble-blindtrial,topicalapplicationofAloeextract(0.5%)inahydrophiliccreamwassignificantlymorebeneficialthanwastheplacebointreatingpsoriasis.29TopicalapplicationofanAloeemulsion(containing30%Aloeextract)wasanefficacioustreatmentforpatientswithseborrheicdermatitisinadouble-blind,placebo-controlledtrial.30

•Aloegelwasbeneficialintreatingpartial-thicknessburnsinacontrolledtrialcomparedwithgauzecontaining

whitepetroleumjelly.31Inanopentrial,Aloewasbeneficialfortreatingchroniclegulcers.PatientsreceivedanAloedrink(60ml/dayof98%stabilizedgel)andappliedaloegeltopically.32

•Aloeextract(0.5%)inahydrophiliccreamwasmoreefficaciousthanwasplaceboinarandomized,double-blindtrialinvolving60menwithgenitalherpes.ThegrouptreatedwithAloehadshortermeantimetohealingcomparedwiththeplacebogroupandcontainedahighernumberofhealedpatients.33

•Patientswithahistoryofrecurrentaphthousstomatitis(mouthulcersorcankersores)weretreatedwithanacemannanhydrogel.Patientsusingtheacemannanhydrogelshowedasignificantreductioninthehealingtimeofmouthulcerscomparedwithanactiveover-the-counterpreparation.34

REFERENCES

MorrowDM,RapaportMJ,StrickRA.ArchDermatol.1980;116(9):1064-1065.HoganDJ.CMAJ.1988;138(4):336-338.PlaskettLG.ThehealthandmedicaluseofAloevera.Tacoma,Wash:LifeSciencesPress,1996.FarnsworthNR,BunyapraphatsaraN,editors.Thaimedicinalplants.Bangkok:MedicinalPlantInformationCenter,1992.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982PelleyRP.Aloepolysaccharidesandtheirmeasurement.In:

InsideAloe.Irving,Tex:InternationalAloeScienceCouncil;1997.StuartRW,etal.IntJImmunopharmacol.1997;9(2):75-82.PengSY,etal.MolBiother.1991;3(2):79-87.KingGK,etal.JAmAnimHospAssoc.1995;31(5):439-447.

10CorsiMM,etal.IntJTissueReact.1998;20(4):115-118.11YatesKM,etal.VetImmunolImmunopathol.1992;35(1-2):177-189.

12McDanielHR,RosenbergLJ,McAnalleyBH.IntConfAIDS.1993;9(1):498.

13YatesKM,etal.IntConfAIDS.1993;9(1):196.14KempMC,etal.IntConfAIDS.1990;6(2):315.15EggerSF,etal.CancerImmunolImmunother.1996;43(4):195-205.

16DavisRH,etal.JAmPodiatrMedAssoc.1989;79(6):263-276.

17ChithraP,SajithlalGB,ChandrakasanG.MolCellBiochem.1998;181(1-2):71-76.

18ChithraP,SajithlalGB,ChandrakasanG.JEthnopharmacol.1998;59(3):195-201.

19ChithraP,SajithlalGB,ChandrakasanG.JEthnopharmacol.1998;59(3):179.

20BunyapraphatsaraN,etal.Phytomed.1996;2(3):247-251.21HeggersJP,etal.JSurgRes.1980;28(2):110-117.

22BlandJ.PrevMed.1985;March/April:1.23MontanerJS,etal.JAcquirImmuneDeficSyndrHumRetrovirol.1996;12(2):153-157.

24Scrip–WorldPharmaceuticalNews.1996;(1530):23.25PulseTL,UhligE.JAdvancementMed.1990;3(4):209-230.26YongchaiyudhaS,etal.Phytomed.1996;3(3):241-243.27BunyapraphatsaraN,etal.Phytomed.1996;3(3):245-248.28ShidaT,NishimuraH.ProcSympWakanyaku.1980;13:47-51.ShidaT,etal.PlantaMed.1985;51(3):273-275.

29SyedTA,etal.TropMedIntHealth.1996;1(4):505.30VardyDA,etal.JDermatolTreat.1999;10:7-11.31VisuthikosolV,etal.JMedAssocThai.1995;78(8):403-409.

32AthertonP.NursStand.1998;12(41):49-52.5433SyedTA,etal.JDermatolTreat.1997;8(2):99-102.34PlemonsJM,etal.Wounds.1994;6(2):40-45.

ANDROGRAPHIS

BotanicalName: AndrographispaniculataFamily: AcanthaceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

ActionsBittertonic,choleretic,immuneenhancing,hepatoprotective,antipyretic,antiinflammatory,antiplatelet,antioxidant,anthelmintic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingAndrographisinformulationsinthecontextof:

•Bacterialandviralrespiratorytractinfections(includingthecommoncold)andreducingassociatedfever(2,5)

•Preventingthecommoncoldandpharyngotonsillitis(2)

•Preventingurinarytractinfections*followingshockwavelithotripsy(3)

•Entericinfections(4,5)

•Infectivehepatitis(4)

•Lossofappetite,dyspepsia,flatulence,diarrhea,dysentery,gastroen-teritis,bowelcomplaintsinchildren(5)

•Infestationwithintestinalworms(5)

Contraindications Possiblyinpregnancy(See“UseinPregnancyandLactation.”)

WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

Theantifertilityeffectinfemalemice(albeitathighdoses)suggeststhatAndrographisshouldnotbeusedduringhumanpregnancy,especiallyinthefirsttrimester.

SideEffects

Highdosesmaycausegastricdiscomfort,anorexia,andemesis(vomiting),butgenerally,fewsideeffectsassociatedwithitsuseoccur,anditisnottoxic.Generally,Andrographishasbeenwelltoleratedinclinicaltrials.Twocases(8%ofpatients)ofurticariawerereportedinonetrialinvestigatingrespiratoryinfections,1andinanothertrial,onepatientinatreatmentgroupof90reportedadverseeffects(unpleasantsensationsinthechestandintensifiedheadache).2AhighincidenceofadverseeffectswasreportedinatrialinvolvingpatientswithHIV,3butthedoseofpureandrographolidethatwasadministeredwasveryhighcomparedwiththenormaltherapeuticdosesofAndrographisextract.

Dosage Doseperday† Doseperweek†

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

Upto12mlperdayof1:2liquidextractmaybetakenduringinfection.Quantificationofandrographolidesispreferabletoensurethattheliquidextractdeliversanadequatelevelofactivity.

BecauseAndrographisisenergeticallycold,itispreferablytakenincombinationwithwarmherbswhenusedduringwinterasapreventativetreatment,especiallyiftheuserhasacoldconstitution.Warmingherbsincludeginger,Astragalus,andholybasil(Ocimumtenuiflorum).

* Andrographishas alsobeenused in traditionalherbalmedicine for treatingurinary tractinfections.(5)

† This dose range is extrapolated from traditional Ayurvedic medicine4 and the author’s

educationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Flatulence,lossofappetite,bowelcomplaintsinchildren,dysentery,dyspepsia,4,5diarrhea,sluggishliver,4liverdisorders6

•Generaldebility,4,5convalescenceafterfever,neuralgia4

•Asafebrifuge,tonic,depurative,anthelmintic5

UsesandpropertiesfromtraditionalChinesemedicine(TCM)include:

•Bitterandcold,usedtoclearheatfromthebloodanddetoxifyfirepoison7,8

•Influenzawithfever,acuteorchroniccough,sorethroat,mouthulcers8

•Colitis,dysentery,urinaryinfectionwithdifficultandpainfulurination8

•Carbuncles,sores,snakebite8

TraditionalThaiandIndonesianmedicineusesinclude:

•Fever,stomachache,dysentery,typhoid,9diarrhea10

•Abscesses,herpessimplex,herpeszoster10

•Asafebrifuge,tonic,diuretic,hypoglycemic9

•Topicallyforsnakebiteandotherpoisonousbitesandforitching9

TheaerialpartsofAndrographiscontainditerpenoidlactones,collectivelyreferredtoasandrographolidesandconsistofaglycones(suchasandrographolideitself)andglucosides(suchasneoandrographolideandandrographiside).

•AnexperimentalstudydemonstratedactivityforAndrographisalcoholicextractagainstanEscherichia-coli-enterotoxin–inducedsecretoryresponse(whichcausesdiarrhea).Andrographisandtheenterotoxinwereco-administeredintoisolatedilealtissue.However,severalinvitroandinvivostudieshavefailedtoshowanybactericidalactivity.

•AndrographisrootextractdemonstratedstronginvitroanthelminticactivityagainsthumanAscarislumbricoides,andsubcutaneousadministrationofadecoctionoftheleavesreducednematodelarvaeinthebloodofdogsby85%.

•OraladministrationofAndrographisextractandisolatedandro-grapholidestimulatedbothantigen-specificandnonspecificimmuneresponsesinanexperimentalmodel.Andrographisdecoctionandandrographolideshavedemonstratedanimmunostimulantaction,especiallyonphagocytosis,invitro.Andrographolidesbyinjectionenhancedphagocytosisinanimalmodels.

•OraldosesofAndrographisextractdemonstratedprotectiveactivityagainstchemical-andalcohol-inducedtoxicliverdamageinexperimentalmodels.Andrographolideshowedhepatoprotectiveactivityinchemical-inducedacutehepatitisafteroralandintraperitonealadministration.

•Andrographolideincreasedbileflow,bilesalts,andbile

PharmacologicResearch

acidsdose-dependentlyafteroralandintraperitonealadministrationinexperimentalmodels.

•Andrographisextractreducedmeanarterialbloodpressurewithoutdecreasingheartrateinanexperimentalmodel(routeunknown)andexhibitedadose-dependenthypotensiveeffectinbothspontaneouslyhypertensiveandnormotensivemodels(intraperitonealroute).

•Andrographisalleviatedmyocardialischemia-reperfusioninjuryandatheroscleroticarterialstenosisinexperimentalmodels(routeunknown).Andrographisloweredtherestenosisrateafterexperimentalangioplasty.

•OraladministrationofAndrographisleafpowdertomaleratsproducedanantifertilityeffectandbiochemicalchangesinthetestesandmaleaccessoryorgans.However,theseresultswerenotduplicatedinasimilarstudyusingastandardizeddriedethanolicextract.Pregnancywaspreventedin100%offemalemicefeddriedAndrographispowder.

•Severalstudieshaveshownantipyreticandantiinflammatoryeffectsforandrographolides(byoraladministrationorinjection)inanumberofanimalmodels,includingadjuvant-inducedarthritis.Andrographolidedemonstratedantiallergicactivityafteroral11andintraperitonealadministration.12

•Andrographisextractreducedfastingserumglucoseandincreasedtheactivityofantioxidantenzymesinanexperimentalmodelofdiabeteswhengivenorally.Nondiabeticanimalswerenotaffected.Resultswerecomparabletometformin(ahypoglycemicdrug).13

•Andrographisextractpreventedglucose-inducedhyperglycemia(routeunknown)butfailedtopreventglucoseabsorptionfromthegut.Oraladministrationactivatedintestinalenzymes(lactase,maltase,and

sucrase),suggestingAndrographisacceleratesintestinaldigestionandabsorptionofcarbohydrate(ratherthanabsorptionofsimpleglucose).

•Adrugderivedfromandrographolide(dehydroandrographolidesuccinicacid[DASM])hasbeenfoundtoinhibitHIVinvitro.However,invitrostudieswithaqueousextractsofAndrographisshowedlittleornoinhibitionofHIV-1.(However,seethepilotstudymentionedunder“ClinicalStudies.”)

•AndrographisandandrographolideshaveshownimmunostimulantactivityduringthetreatmentofbacterialandviralrespiratoryinfectionsinseveraluncontrolledclinicaltrialsinChina.Inonestudy,Andrographistreatmentloweredbodytemperatureduringthecommoncold.

•SeveraluncontrolledChinesestudiesassessingoraladministrationofAndrographisorandrographolidesinacutebacillarydysenteryandenteritisfoundamarkedbenefit.AThaistudyfoundthatAndrographispowderedleafandstem(2g/dayfor2days)reducedtheShigellapopulationinpatientswithacutediarrheabutwaslessbeneficialthanwastetracyclineforcholera.

•Arandomized,double-blindstudyinvolving152patientswithpharyngotonsillitisfoundAndrographistreatment(6g/dayfor7days)wasasefficaciousaswasacetaminophen(paracetamol)inprovidingreliefoffeverandsorethroatcomparedwithchangesfrombaselinevalues.

•Tiredness,sleeplessness,sorethroat,andnasalsecretionsweresignificantlydecreasedbytheseconddayoftreatmentwithAndrographisextract(1200mg/dayfor5days;standardizedto5%andrographolides)comparedwithplaceboinarandomized,double-blindtrialinvolving158patientswiththecommoncold.Byday4,all

ClinicalStudies

measuredsymptoms(includingheadache,earache,expectoration,frequencyofcough,andintensityofcough)weresignificantlydecreasedcomparedwithplacebo.14

•Andrographisextract(1200mg/dayfor4days,standardizedto4%andrographolides)significantlyreducedthemanifestationsofthecommoncold(strengthofdisease,tiredness,sweatingandshivering,sorethroat,andmuscularache)comparedwithplaceboandsignificantlyreducedclinicalsigns(lymphaticswellings,rhinitis,sinuspain,andheadaches)inadouble-blindtrial.

•Andrographisextract(200mg/day,standardizedto5.6%andro-grapholides)giventohealthychildrenfor3monthsoverthewinterseasonsignificantlydecreasedtheincidenceofthecommoncoldcomparedwithaplacebotreatmentinarandomized,double-blindtrial.

•Inarandomized,double-blind,placebo-controlledpilotstudy,subjectiveevaluationofoutpatientswiththecommoncolddemonstratedasignificantlyreducednumberofsickdays,improvedsymptoms,andhastenedrecoveryaftertherapywithstandardizedAndrographisextract(1020mg/dayfor5days;levelofandrographolidenotstated).SubsequentstudiesofsimilardesignbythesamegroupfoundthatherbaltabletscontainingAndrographisextract(1020mg/day;standardizedto6.2%andrographolidesandsubtherapeuticlevelsofEleutherococcus)significantlyimprovedthetotalsymptomscoreandtotaldiagnosisscore,asratedbypatientsandphysiciansrespectively,comparedwithplaceboinpatientswithuncomplicatedupperrespiratorytractinfection.Throatsymptomsandsignsdemonstratedthemostsignificantimprovement.2

•AcontrolledstudyfoundthatAndrographistreatment(3g/dayfor5days)wasasbeneficialaswastheantibioticscotrimoxazoleandnorfloxacinforreducingpyuriaandhematuria(associatedwithurinarytractinfection)in

patientsundergoingdissolutionofkidneystones(shockwavelithotripsy).

•Eightypercentofcasesofinfectivehepatitiswerecured,and20%wererelievedaftertreatmentwithAndrographisdecoction(40gofherb/dayfor24days)inanuncontrolledtrial.Significantdecreasesfrombaselinevaluesofvariousliverfunctionparameterswerealsoobserved.

•Andrographolide(5mg/kgfor3weeks,then10mg/kgfor3weeks)significantlyincreasedmeanCD4+lymphocytelevelsfrombaselinein13HIV-positivepatients.MeanplasmaHIV-1ribonucleicacid(RNA)levelsdidnotsignificantlychange.Patientsdidnotusetheantiretroviralmedicationsduringthetrial.Twelveofthethirteenpatientsreportedatleastoneadverseeventduringthetreatment.3

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.MelchiorJ,PalmS,WikmanG.Phytomed.1996-1997;3(4):315-318.MelchiorJ,etal.Phytomed.2000;7(5):341-350.CalabreseC,etal.PhytotherRes.2000;14(5):333-338.KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.

ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982BharatiyaVidyaBhavan’sSwamiPrakashanandaAyurvedaResearchCentre.SelectedmedicinalplantsofIndia.Bombay:Chemexcil,1992.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.DharmaAP.Indonesianmedicinalplants.Jakarta:BalaiPustaka,1987.

10FarnsworthNR,BunyapraphatsaraN,editors.Thaimedicinalplants.Bangkok:MedicinalPlantInformationCenter,1992.

11MadavS,etal.IndianJPharmSci.1998;60(3):176-178.12GuptaPP,TandonJS,PatnaikGK.PharmaceutBiol.1998;36(1):72-74.

13ZhangXF,TanBK.ClinExpPharmacolPhysiol.2000;27(5-6):358-363.

14CaceresDD,etal.Phytomed.1999;6(4):217-223.

ARNICA

BotanicalNames: Arnicamontana,Arnicachamissonissubsp.foliosa+

Family: CompositaePlantPartUsed: Flower

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Topicalonly:antiinflammatory,antiecchymotic(againstbruises),analgesic,antimicrobial

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingArnicaforexternaluseinthecontextof:

•Chronicvenousinsufficiency,particularlyforfeelingsofheavinessinthelegs,edema(2)

•Muscleache(3,5)

•Bruises,sprains(4,5)

•Inflamedinsectbites(4,5)

•Hematomas,dislocations,edemaresultingfromfracture,rheumaticmuscleandjointproblems,superficialphlebitis(4)

•Furunculosis(4)

•Painfulswellings,unbrokenchilblains,alopecianeurotica(5)

Contraindications

Nottobetakeninternally.Arnicashouldbeappliedonlytounbrokenskinandwithdrawnonfirstsignofdermatitis.ContraindicatedinpeoplewithknownallergytoArnica.

WarningsandPrecautions

Notforinternaluse.Notforprolongedexternalapplication.PeoplewithknownsensitivitytoothermembersoftheCompositaefamily(suchasragweed,daisies,andchrysanthemums)shouldavoidusingArnica.

Interactions Noneknown.UseinPregnancyandLactation Notforinternaluse.Fortopicaluseonly.

SideEffects

TopicalapplicationofArnica,mostlythetincture,hasbeenknowntocauseallergicorirritantcontactdermatitissince1844.Cross-reactivitytootherCompositaeplantshasalsobeenreported.Arnicaointmentsandplastersareconsideredtoposeamuchlowerriskcomparedwithothertypesofapplications.

TheCommissionEadvisesthatprolongedtreatmentofdamagedskincancauseedematousdermatitiswiththeformationofpustules.Extendedusemaycauseeczema.Intreatmentsinvolvinghigherthannormaltherapeuticconcentrations,primarytoxicskinreactionswiththeformationofvesiclesorevennecrosismayoccur.

AfterrepeateduseofArnicatinctureforrosacea,a66-year-oldpatientdevelopedacuteallergiccontactdermatitisafterasingleapplicationofthetincturetothehand.Patchtestingprovedcontactallergyofthedelayedtype.1

Dosage

Dilutea1:5tincturefivetimeswaterandapplytwotothreetimesperdaytotheaffectedarea.Ointmentshouldcontain10%to25%tinctureappliedtwotothreetimesperday.*

* Thisdoserangeisextrapolatedfromclinicaltrialinformation.

SUPPORTINGINFORMATION

TraditionalPrescribing

ExternalusesfromtraditionalWesternherbalmedicineinclude:

•Bruises,sprains,2-4painfulswellings,cuts,lacerations,insectbites2

•Musclesoreness,especiallyfromstrainandexertion4

•Unbrokenchilblains,alopecianeurotica3

PharmacologicResearch

Arnicaflowerscontainsesquiterpenelactonesofthepseudoguaianolidetype(0.2%to1.5%),includinghelenalinand11α,13-dihydrohelenalinandtheiresters,flavonoids,andanessentialoil.

•ResultsfrominvitrostudiessuggestthatseveralpossiblemechanismsexistbehindtheantiinflammatoryactivityofArnica:

1.Uncouplingofoxidativephosphorylationinpolymorphonuclearneutrophils

2.Elevationofcyclicadenosinemonophosphate(cAMP)inneutrophilsandlivercells

3.Inhibitionoflysosomalenzymaticactivityinneutrophilsandlivercells

4.InhibitionoftheactivationoftranscriptionfactorNF-kappaB,whichisresponsibleforthetranscriptionofgenesencodingvariousinflammatorymediators5•SesquiterpenelactonesfromArnicahavedemonstrated

analgesicandantiinflammatoryactivitiesinexperimentalmodels,suchascarrageenan-inducedpawedemaandchronicadjuvantarthritis(afterintraperitonealadministration).•Arnicaextractsappliedtoanimalsmoothmuscleinvitroinhibitedexperimentallyinducedspasm.•ComponentsoftheessentialoilofArnicahavedemonstratedpotentactivityagainstgram-positiveandgram-negativebacteriaandagainstCandidaspp,invitro.Helenalinandhelenalinacetatewerealsoactiveinvitroagainstgram-positivebacteriaandProteusvulgaris.•ArnicaextractstimulatedphagocytosisinvitroandinvivoafterinjectionandprotectedagainstListeriamonocytogenesinfectioninanexperimentalmodelfollowinginjection.•SesquiterpenelactonesofArnicainhibitedWalker26carcinosarcomaandEhrlichascitestumorgrowthinvivo.

ClinicalStudies

•Inaplacebo-controlled,double-blind,randomizedstudyofpatientswithpronouncedsymptomsofchronicvenousinsufficiency,Arnicagel(containing20%Arnicatincture)improvedthefeelingofheavinessinthelegscomparedwithplacebo,improvedvenoustone,andreducededema.

•Arnicagelwasmoreeffectivethanwasaplacebogelwhenappliedexternallyformuscleacheinmalevolunteers.

•InGermany,theCommissionEsupportstheexternaluseofArnicaflowerforinflammationoftheoralandthroatregion,furunculosis,inflammationcausedbyinsectbites,superficialphlebitis,hematoma,dislocations,contusions(bruises),edemaresultingfromfracture,andrheumaticmuscleandjointproblems.6

•TheEuropeanScientificCooperativeonPhytotherapy(ESCOP)recommendsexternaluseofArnicaflowerfortreatingbruises,sprains,inflammationcausedbyinsectbites,gingivitis,aphthousulcers,andthesymptomatic

treatmentofrheumaticcomplaints.7

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.HormannHP,KortingHC.Phytomed.1995;4:315-317.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983LybG,etal.PharmPharmacolLett.1999;9(1):5-8.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.ScientificCommitteeofEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Arnicaeflos.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UK:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.

ASHWAGANDA

OtherCommonNames: Withania,ashwagandhaBotanicalName: WithaniasomniferaFamily: SolanaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Tonic,adaptogenic,mildsedative,antiinflammatory,immunemodulating,antianemic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingashwagandainformulationsinthecontextof:

•Promotinggrowthinchildren(2,5)

•Conditionsassociatedwithaging(2)

•Increasinghemoglobinandredbloodcountinhealthyelderlymalesandincreasinghemoglobinandserumironinchildren(2)

•Alleviatingmalesexualinadequacy(2,5)

•Improvingstaminainathletes(4)

•Insomnia(4)

•Arthritis(4,5)

•Adjunctivetreatmentfornon-insulin–dependentdiabetesandhyper-cholesterolemia(3)

•Inflammatoryconditionssuchasasthma,bronchitis,psoriasis,andrheumaticpains(5)

•Seniledementia(5,7)

•Promotinglearningandmemory(5,7)

•Conditionsexacerbatedbystress(5,7)

•Convalescenceafteracuteillness,asageneraltonicfordiseaseprevention(5,7)

•Enhancingimmunefunctionandfordepressedwhitebloodcellcount(7)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

5–13mlof1:2liquidextract

35–90mlof1:2liquidextract

* This dose range is extrapolated from traditional Ayurvedic medicine1 and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Inflammatoryconditionssuchasbronchitis,asthma,psoriasis,andulcers(undefined)2

•Wastinginchildren,insomnia,seniledebility2

•Leukoderma,lumbago,arthritis,2rheumatism,lumbarpains3

•Promotingconception2

•Providingfreshenergyandvigorforasystemwornoutbyanyconstitutionaldisease1

•Asanutrientandtonicforpregnantwomenandolderadults1

•Regardedasamedharasayanorpromoteroflearningandmemoryretrieval4

Accordingtoothertraditionalsystems,suchasthoseofTibetandtheMiddleEast,usesinclude:

•Asasedativeandhypnotic,takenforrheumaticpains5

•Asageneraltonicinseminaldiseases,asanervinetonic6

AshwagandaisalsousedintraditionalherbalmedicineofSoutheastAsiatotreatheadachesandconvulsionsandtopromotelactation.7

PharmacologicResearch

Majorconstituentsofashwagandarootincludesteroidalcompounds(lactonesandglycosides).Alkaloidsarealsopresent.

•Oraldosesofashwagandademonstratedsignificantantistressactivity,increasedendurance,andenhancedgrowthanddevelopmentinexperimentalmodels.

•ApharmacologiccomparisonofashwagandaandKoreanginsengdemonstratedthatashwagandahadsimilarpotencytoKoreanginsengintermsofadaptogenic,tonic,andanaboliceffects.However,ashwagandalacksthestimulatingeffectsofKoreanginsengandisthereforeideallysuitedtothetreatmentofpatientswhoareoveractivebutdebilitated,forwhomKoreanginsengwouldtendtocauseoverstimulation.

•Ashwagandaenhancedlearningandmemoryinbothyoungandoldratswhengivenorally.

•Ashwagandawasshowntosignificantlyincreasethetotalwhitebloodcellandneutrophilcountswhengivenorally,bothbeforeandaftercyclophosphamidetreatment,andtoreduceleukopeniainducedbygammaradiationinvivo.

•Afteroraldosesofashwaganda,hemoglobinconcentration,redbloodcellcount,whitebloodcellcount,plateletcount,andbodyweightweresignificantlyraisedininvivolaboratorymodelsofimmunosuppression.

•Ashwagandahasimmunomodulatoryactivity.Extractswereshowntoincreasemobilization,activation,phagocytosis,andsecretoryactivityofmacrophagesinvitroandtosignificantlyinhibitexperimentallyinducedimmunosuppressioninvivoafteroraladministration.Incontrast,ashwagandalactoneshavedemonstratedimmunosuppressiveeffectsinvitroandinvivo.

•Ashwagandalactonesexhibitedantitumorand

radiosensitizingactivityinseveraltumorcellmodelsinvitroandinvivoafterintraperitonealandoraladministration.

•Intraperitonealandsubcutaneousadministrationofashwagandaproducedanantiinflammatoryeffectinseveralstudies.Furthermore,ashwagandawasshowntobebetteratdecreasingbiomarkersofinflammationthanwerestandardantiinflammatorydrugsattherelativedosestested.

•Ashwagandaalkaloidsdemonstrateddepressantactivityonhighercerebralfunctionsandcausedprolongedhypotensive,bradycardic,respiratorystimulant,andsedativeeffects.AshwagandaextractexhibitedsignificantantiepilepticactionandcognitionenhancementwhenadministeredorallyinmodelsofepilepsyandAlzheimer’sdisease,respectively.

•Oralandintraperitonealdosingwithashwagandasuppressedthedevelopmentoftolerancetomorphine-inducedanalgesiaandmorphinewithdrawaljumps,suggestingthatitmaybeusefulinthetreatmentofmorphinewithdrawal.

•Arandomized,double-blind,placebo-controlledtrialfoundthatmilkfortifiedwithashwaganda(2g/dayofherbfor60days)significantlyincreasedmeancorpuscularhemoglobinandserumalbuminandtendedtoincreasebloodhemoglobin,serumiron,bodyweight,andstrengthofhandgripinchildrenaged8to12years.Theplacebogroupdidnotshowanysignificantchangeortendencytochange.

•Whentestedon101healthymalepatientsaged50to59years,ashwaganda(3g/dayfor1year)significantlyimprovedhemoglobin,redbloodcellcount,seatedstature,andhairmelanincontent.Ashwagandaalsocausedadecreaseinserumcholesterolanderythrocyte

ClinicalStudies

sedimentationrateandcountereddecreasednailcalcium.Thetrialwasofrandomized,double-blind,placebo-controlleddesign.About71%ofvolunteersreceivingashwagandareportedimprovementinsexualperformance.

•Inanuncontrolledtrial,ashwaganda(1g/dayfor29days)improvedsleeppatterns,responsiveness,alertness,stateofawareness,andphysicalcapabilitiesintraineemountaineersovera29-daytrek,whichincludeda5200m(over17,000ft)altitudegain.

•Ashwaganda(3g/dayfor30days)decreasedbloodsugarlevelsfrombaselineinsixpatientswithnon-insulin–dependentdiabetes.Thehypoglycemiceffectwassimilartothatobtainedinthecontrolgrouptreatedwithglibenclamide.Inaddition,ashwagandaincreaseddiuresis,asevidencedbydecreasedserumpotassiumandincreasedurinaryexcretionofsodiumandpotassium.Inagroupofsixpatientswithhypercholesterolemia,ashwagandasignificantlydecreasedserumtotalcholesterol,triglycerides,low-densitylipoprotein(LDL),andverylow-densitylipoprotein(VLDL)cholesterolcomparedwithbaselinevalues.Lipidprofilesremainedlargelyunchangedintheuntreatedcontrolgroup.Themeancalorieandfatintakesofthetreatmentgroupswerehigherthanthoseofthecontrolgroups.8

•Ashwaganda(4to9g/day)wasbeneficialforpatientswithacuterheumatoidarthritis(andsomecasesofnonarticularrheumatismandchronicrheumatoidarthritiswithacuteexacerbations)inanuncontrolledtrialconductedinthelate1960s.9

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicand

clinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinalandAromaticPlants,1989.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982BhattacharyaSK,KumarA,GhosalS.PhytotherRes.1995;9(2):110-113.MillerAG,MorrisM.PlantsofDhofar.ThesouthernregionofOman.Traditional,economicandmedicinaluses.DiwanofRoyalCourtSultanateofOman:TheOfficeoftheAdviserforConservationoftheEnvironment,1988.ChauhanNS,UniyalMR,SanndBN.Nagarjun.1979;22:190-193.WorldHealthOrganization.Theuseoftraditionalmedicineinprimaryhealthcare:amanualforhealthworkersinSoutheastAsia.NewDelhi:WHORegionalOfficeforSoutheastAsia,1990.AndalluB,RadhikaB.IndianJExpBiol.2000;38:607-609.BectorNP,PuriAS,SharmaD.IndianJMedRes.1969;56:1581-1583.

ASTRAGALUS

BotanicalNames:

Astragalusmembranaceus,Astragalusmembranaceusvar.mongholicus+

Family: LeguminosaePlantPartUsed: Root

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Immuneenhancing,tonic,adaptogenic,cardiotonic,diuretic,hypotensive,antioxidant

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingAstragalusinformulationsinthecontextof:

•Impairedimmunity,prophylaxisofthecommoncold,chronicviralinfections(4)

•Generaldebility,excessivesweating,decreasedappetite,chronicdiarrhea(5)

•Leukopenia(2)

•Ischemicheartdisease,anginapectoris(3)

•Atonicforelderlypatients,incombinationwithSalviamiltiorrhizaPolygonummultiflorum(3)

•Postpartumfeverandrecoveryfromseverelossofblood,uterinebleeding,organprolapse(5)

•Topicaladjuvanttherapyforchronicviralcervicitis(3)

Contraindications Notadvisableinacuteinfections.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

Noneexpectediftakenwithintherecommendeddose

SideEffects range.

Dosage Doseperday* Doseperweek*

4.5–8.5mlof1:2liquidextract

30–60mlof1:2liquidextract

* ThisdoserangeisadaptedfromdriedplantdosesadministeredbydecoctioninTCM.3Theauthor’sexperienceandthefactthatethanol-waterisamoreeffectivesolventthaniswaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Tonifiesqi,blood,andspleen1

•Postpartumfeverandrecoveryfromseverelossofblood,fatiguelinkedtodecreasedappetite,diarrhea,andanemia1-3

•Organprolapse,abnormaluterinebleeding;spontaneoussweatingresultingfromweakenedresistance;promotesurination,tissuehealing,thedischargeofpus;removesedema1-3

PharmacologicResearch

•Astragalusstimulatesnaturalkillercellactivityinvitro.PositiveeffectsonotheraspectsofimmunitysuchasthymusweightandprotectionfromimmunesuppressionwerenotedinexperimentalmodelsafteroraladministrationofAstragalus.

•TheinvitroantiviralactivityofAstragalusismostlikelyaresultofthepositiveeffectsonimmunefunctionandpossiblyfollowsfromenhancedinterferonproduction.

•Enhancedtolerancetostress,betterlearningability,increasedendurance,andimprovedenergymetabolismhavebeenshowninexperimentalmodels.

•InvivostudiessupportthetraditionaluseofAstragaluswithorganprolapseandpromotingurinarytractfunction.

•Astragalusextractdemonstratedaprotectiveeffectonerythrocytedeformabilityexvivoforbloodtakenfrom

ClinicalStudies

normalvolunteersandpatientswithsystemiclupuserythematosus.

•HighoraldosesofAstragalusdecoctiongiventoparticipantssusceptibletothecommoncoldenhancedimmuneprotection.Aprophylacticeffectforthecommoncoldwasobservedinanotheruncontrolledstudy,asevidencedbydecreasedincidenceandshorteneddurationofinfectionafterAstragalustreatment.

•CombinedtreatmentofTCMherbs(suchasAstragalus,Panaxginsengleaf,andothers)raisedthesurvivalratesinpatientswithsmallcelllungcancerundergoingchemotherapy,radiotherapy,andimmunotherapy.

•AveragewhitebloodcellcountsincreasedsignificantlyintwogroupsofpatientswithleukopeniaaftertreatmentwithconcentratedAstragaluspreparations(equivalentto10g/dayand30g/dayofAstragalus)for8weeks.Theresultsweredose-dependent.PatientswererandomizedtoreceiveeithertheloworhighdoseofAstragalus.

•Inacomparativeclinicalstudy,Koreanginseng-Astragalusinjectionreducedtoxicchemotherapyeffects,increasedbodyweight,andincreasedcellularimmunefunctioncomparedwithchemotherapyaloneinpatientswithmalignanttumorsofthedigestivetract.

•AdministrationofAstragalus(routeundefined)toalargenumberofpatientswithchronicviralhepatitisresultedinasuccessrateof70%.Inmostcases,elevatedserumglutamic-pyruvictransaminase(GPT)levelsreturnedtonormalafter1to2months.(InTCM,Astragalusisoftenadministeredbyinjectionforthetreatmentofhepatitis.4)

•NaturalkillercellactivityincreasedsignificantlyinpatientswithCoxsackieBviralmyocarditiswhoweretreatedwithintramuscularinjectionsofAstragalusfor3to4months.

•Inacomparativetrial,92patientswithischemicheartdiseaseweretreatedwithAstragalus,Salviamiltiorrhiza,ortheantianginaldrugnifedipine.ResultsweresuperiorfortheAstragalus-treatedgroup,asdemonstratedbymarkedrelieffromanginapectorisandimprovementinseveralobjectiveclinicalparameters.

•Inadouble-blind,placebo-controlled,clinicaltrialof507elderlypeople,oraladministrationofAstragalusincombinationwithPolygonummultiflorumandSalviamiltiorrhizademonstratedsignificantantiagingeffects.

•Intwodouble-blind,clinicaltrials,topicalapplicationofAstragaluscombinedwithinterferonwasbeneficialtreatingchroniccervicitisassociatedwithviralinfection.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.HanDW,XuRL,YeoungSCS.AbstChinMed.

1988;2(1):105-134.

BACOPA

BotanicalNames:

Bacopamonnieri,Bacopamonniera#,Herpestismonnieri#

Family: ScrophulariaceaePlantPartUsed: Aerialparts

# Alternativename.

PRESCRIBINGINFORMATION

Actions Cognitionenhancing,nervinetonic,mildsedative,mildanticonvulsant,anxiolytic,possiblyadaptogenic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingBacopainformulationsinthecontextof:

•Improvingconcentrationinhealthyindividuals(4)

•Improvingmentalperformanceandmemory(3)

•Nervousdisorders,nervousdebility(5)

•Insomnia(4,6)

•Epilepsy,anxiety(4,5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsAswithallsaponin-containingherbs,oralusemaycauseirritationofthegastricmucousmembranesandreflux.

Dosage Doseperday* Doseperweek*

5–13mlof1:2liquidextract

35–90mlof1:2liquidextract

* This dose range is extrapolated from traditional Ayurvedic medicine4 and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Asanervinetonicforthetreatmentofnervousdisorders,especiallynervousbreakdown,epilepsy,insanity;debility,aphonia(lossofvoice),hoarseness;forasupposeddirectcardiactonicactivity,2-4forurinaryincontinence,particularlyaccompaniedbyconstipation1

•Asatonicfordiseasesoftheskin,nervoussystem,andblood2

Brahmioil,whichconsistsmainlyofbrahmijuice,coconutoil,andothermedicinalplants,isconsideredamosteffectivebraintonic.Brahmioilissaidtostrengthenmemoryandrevivehairgrowthandisusedasacoolingremedyinsteadoficeinepidemicfevers.Brahmioilisalsoemployedinheadache,insomnia,andepilepsy.3,4

•AnearlystudydemonstratedBacopatohavecardiotonic,vasoconstricting,andsedativeactivities.5

•AlaboratorystudyusingaformulationcontainingBacopa(knownasBrahmiRasayan)foundhighdoseshavesedative(withoutaffectingmotorcoordination),analgesic,andanticonvulsantactivities.6

•StandardizedextractofBacopa(25%bacosideA)producedananxiolyticeffectinvivothatwasqualitativelycomparablewiththatoflorazepam(abenzodiazepinedrug).StatisticallysignificantresultswereelicitedwithhigherdosesofBacopa,which,unlikelorazepam,didnotproduceanysignificantmotordeficit.7

PharmacologicResearch

•AnearlystudycomparedtheeffectsofanalcoholextractofBacopaandthetranquilizerchlorpromazineonthelearningprocessinrats.Bothsubstancesreducederrorsandimprovedperformanceinthelearningphase,buttheeffectofBacopawasmoremarked.Chlorpromazinedepressedmotorefficiency,butnosuchdeleteriouseffectwasobservedwithBacopatreatment.Infact,Bacopaimprovedmotorefficiencycomparedwithcontrols.8Inlaterstudies,learningandmemoryretentionwereimprovedinratsinanumberofexperimentalmodelsafteroralandintraperitonealadministrationofBacopa.9,10

•OraldosesofBrahmiRasayanwerefoundtosuppressexperimentallyinducedinflammationinananimalmodel.TheactivitywascomparabletothatoftheNSAIDindomethacin.Theherbalformuladidnotproducegastricirritation.11

•Inanuncontrolledtrial,35patientswithanxietyneurosisweretreatedwiththeequivalentof12gperdayofdriedBacopafor1month.Asignificantreductionoccurredinanxiety,aswellasimprovementsinmentalperformanceandmemory.Thisresultwasaccompaniedbyareductioninmentalfatigue,ageneralfeelingofenhancedwellbeing,improvedsleepandappetite,andanincreaseinbodyweight.12,13

•Bacopahadapositiveeffectonconcentration,butnotonshort-termmemory,inasmallnumberofvolunteerstestedinthemid-1960s.14Bacopa(1g/dayfor3months)improvedintellectualfunctionssuchasvisualmotorfunction,short-termmemory,andmentalreactiontimesinchildren.UnlikeindividualswhoweretreatedwithBacopa,theplacebogroupdidnotimprovefrombaselinevalues.15

•Anuncontrolledclinicalstudyon13patientswithepilepsyusingadefattedethanolicextractofBacopa(2to

ClinicalStudies

4mg/kgbodyweight/day)demonstratedreductionsinthefrequencyoffittingover2to5months.Theonsetofepilepticfitswascompletelycheckedinfivecases.16

•AnAustralianclinicaltrialexaminedthelong-termeffectsofaBacopaextractoncognitivefunctionin46healthyhumanvolunteers.17Thestudywasofdouble-blind,placebo-controlleddesigninwhichsubjectswererandomlyallocatedtoreceiveBacopaorplacebo.Neuropsychologictestingwasconductedbeforetreatmentandat5and12weeksaftertreatment.After12weeks,thelargestcognitivechangefromBacopatreatment(whichwasalsostatisticallysignificantcomparedwithplacebo,p<0.05)wasatimereductionfortheinspectiontime(IT)test(64.516.7minvs.75.925.3min).ITisregardedasameasureoftheintegrityoftheearlystagesofinformationprocessingandmayactasarate-limitingfactorforcognition.ThisfindingindicatesthatBacopasignificantlyimprovedthespeedofvisualinformationprocessing.VerballearningrateandmemoryconsolidationasassessedbytheReyAuditoryVerbalLearningTestwerealsosome-whatimprovedagainstplaceboat12weeks(p<0.05).However,themoststrikingfindingwasthehighlysignificant(p=0.001)reductioninanxietyinvolunteersreceivingBacopa.Thepercentageofadverseeffectswassimilarforbothgroups,exceptthatahigherincidenceofnausea,drymouth,andfatigueoccurredintheBacopagroup.

REFERENCES

KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982

SanduDV.Indiantherapeutics,ed2.Delhi:SriSatguruPublications,1987.APanelofVaidyas.ClinicalapplicationofAyurvedicremedies,ed4.Delhi:SriSatguruPublications,1998.MalhotraCL,DasPK.IndianJMedRes.1959;47:294-305.ShukiaB,KhannaNK,GodhwaniJL.JEthnopharmacol.1987;21(1):65-74.BhattacharyaSK,GhosalS.Phytomed.1998;5(2):77-82.PrakashJC,SirsiM.JSciIndRes.1962;21C:93-96.SinghHK,DhawanBN.JEthnopharmacol.1982;5:205-214.

10SinghHK,DhawanBN.IndianJPharmacol.1978;10:72.11JainP,etal.IndianJExpBiol.1994;32(9):633-636.12UdupaKN,SinghRH.ClinicalandexperimentalstudiesonrasayanadrugsandPancakarmatherapy,ed2.NewDelhi:CentralCouncilforResearchinAyurvedaandSiddha,1995.

13SinghRH,SinghL.JResAyurvedaSiddha.1980;1:133-148.14GhoshS,KarSK.JExpMedSci.1966;10(1):12-13.15SharmaR,ChaturvediC,TewariPV.JResEducIndianMed.1987;6:1-10.

16MukherjeeGD,DeyCD.JExpMedSci.1968;11(4):82-85.17StoughC,etal.Psychopharmacol.2001;156(4):481-484.

BAICALSKULLCAP

BotanicalName: ScutellariabaicalensisFamily: LabiataePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Antiinflammatory,antiallergic,antibacterial

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingBaicalskullcapinformulationsinthecontextof:

•Chronicinflammatoryconditions,allergy,asthma,arthritis(7)

•Hypertension(4,5)

•Infections,includingbronchitis,thecommoncold,bacillarydysentery,scarletfever(4)

•Highfevers,coughwiththicksputum,pneumonia(5)

•Nausea,vomiting,hemoptysis,jaundice,diarrhea,ordysentery-likediseases(5)

•Hepatitis(6)

•Adjuvanttherapyforcancer(4)

Contraindications Contraindicatedincoldconditions(Chinesetraditionalunderstanding).1

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

4.5–8.5mlof1:2liquidextract

30–60mlof1:2liquidextract

* ThisdoserangeisadaptedfromdriedplantdoseadministeredbydecoctioninTCM.3Theauthor’sexperienceandthefactthatethanol-waterisamoreeffectivesolventthaniswaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Clearingheatanddrainingdampheat1

•Highfevers,coughwiththicksputum,pneumonia;nausea,vomiting,hemoptysis,jaundice,1-3viralhepatitis4

•Diarrheaordysentery-likediseases,painfulurinarydysfunction,hypertension,restlessfetus,carbuncles1-3

PharmacologicResearch

Baicalskullcaprootcontainsanumberofflavonederivatives,includingbaicalin,wogonin,andbaicalein.5

•Flavonesandflavonolsinhibitedthereleaseofhistaminebymastcellsinvitro.6Baicalinandbaicaleindemonstratedantiallergicandantiasthmaticactivityinvivo.2

•OraldosesofanextractofBaicalskullcapandbaicalin,baicalein,andwogonindemonstratedmildantiinflammatoryactivityanddecreasedlong-termbonedestructioninadjuvant-inducedarthritis.7

•Baicalinandbaicaleinhavedemonstratedsignificantantiplateletactivityafteroraldosesinanexperimentalmodel,butnotanticoagulantactivity.8

•Baicaleindemonstratedantioxidantactivityinvitro.9Baicaleindemonstratedantiepilepticandneuronalprotectiveeffectsinvivo(byinjection),probablybecauseoffreeradicalquenchingandantioxidantactivity.10Baicaleinreducedoxidativestressduringhypoxia,

ischemia,andreperfusioninvitro.11

•Acombinationofbaicalinandlicoriceextractdramaticallyreducedsorbitollevelsinredbloodcellsinexperimentalmodelswithoutaffectingbloodglucoselevels.12Thisfindinghasimplicationsforpreventingdiabeticcomplications.

•Baicalskullcapreducedthetoxicityofanticancerdrugsanddecreasedcancercellviabilityinexperimentaltumors.13

ClinicalStudies

•Baicalskullcapextractpromotedanincreaseintheimmunoregulationindex(increasedimmunoglobulinA[IgA]atstableIgGlevels)ofpatientswithlungcancerwhowerereceivingantineoplasticchemotherapy.14

•Positiveresultshavebeendemonstratedinuncontrolledtrialsforacutebronchitis,thecommoncold,bacillarydysentery,scarletfever,hepatitis(baicalin;routeunknown),andcholecystitis(baicalin;byinjection).Thedailydoseforrespiratorydisordersrangedfrom6mlto8to10mlofa50%decoctiondependingontheageofthechild.2A70%successratewasshowninchronichepatitiswithimprovementsinsymptomsandliverfunctiontests(routeandpreparationundefined).15

•Inanuncontrolledtrialinvolving255patientsinChinawithallergicrhinitis,BaicalskullcapandPaeoniasuffructicosawereaddedtotheTCMherbalprescriptionforpatientswithnasalinflammation.16

•Anantihypertensiveeffectwasdemonstratedinanuncontrolledstudyinvolving51cases.2

REFERENCES

BenskyD,GambleA.Chineseherbalmedicinemateria

medica.Seattle:EastlandPress,1986.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.LuLX.ShaanxiJChinTradMed.1987;8(5):228-229.TangW,EisenbrandG.Chinesedrugsofplantorigin.Berlin:Springer-Verlag,1992.AmellaM,etal.PlantaMed.1985;51(1):16-20.KuboM,etal.ChemPharmBull(Tokyo).1984;32(7):2724-2729.KuboM,etal.ChemPharmBull(Tokyo).1985;33(6):2411-2415.HaraH,etal.EurJPharmacol.1992;221(2-3):193-198.

10HamadaH,etal.ArchBiochemBiophys.1993;306(1):261-266.

11ShaoZH,etal.AcadEmergMed.2001;8(5):562-563.12ZhouYP,ZhangJQ.ChinMedJ(Eng).1989;102:203-206.13RazinaTG,etal.VoprOnkol.1987;33(2):80-84.14Smol’ianinovES,etal.EkspKlinFarmacol.1997;60(6):49-51.

15ChangHM,etal,editors.AdvancesinChinesemedicinalmaterialsresearch.Singapore:WorldScientific,1985.

16LinWS.ShanghaiJTradChinMed.1987;1:22-24.

BAPTISIA

OtherCommonName: WildindigoBotanicalName: BaptisiatinctoriaFamily: LeguminosaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Depurative,antipyretic,immuneenhancing

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingBaptisiainformulationsinthecontextof:

•Treatingandpreventingnonspecificupperrespiratorytractinfections,incombinationwithanumberofherbs,includingEchinaceaspp.rootandThuja(2)

•Sinusitis,incombinationwithanumberofherbs,includingEchinaceaspp.rootandThuja(3)

•Tonsillitis,pharyngitis,pneumonia,fevers,thecommoncold,influenza(5)

•Septicconditions,boils,mouthulcers,inflammationofthemouthorteeth(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2–6mlof1:2liquidextract

15–40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Infectionsoftheupperrespiratorytract,particularlytonsillitis,pharyngitis;diphtheria,acutecatarrhalinfection,lymphadenitis,fevers,pneumonia1,2

•Sepsis,furunculosis,typhoidconditions,enfeebledcirculation,mouthulcers,gingivitis,stomatitis1,2

NativeAmericansadministeredBaptisiatochildrenwhoseemeddrowsyandlifelessandatthepointofbecomingsick.Externally,Baptisiawasusedtobathewoundsandcuts.BaptisiawasofficialintheUnitedStatesPharmacopeia(USP)from1831to1842,theNationalFormulary(NF)from1916to1936,andwasusedasanemetic,cathartic,stimulant,astringent,andantiseptic.3

PharmacologicResearch

•GlycoproteinderivativesfromBaptisiaroothavedemonstratedimmunomodulatingactivityinvitrobyprovokingthestimulationofBlymphocyteswithaconcomitantincreaseofinterferonrelease.4

•FractionsofBaptisiaextracthavedemonstratedimmune-enhancingactivityinvitroandinvivo(byinjection).5

NoclinicalstudieshavebeenconductedusingBaptisiaalone.

•ThreeherbalformulationscontainingBaptisiahavebeenusedsuccessfullyfortreatingandpreventingnonspecific

ClinicalStudies

upperrespiratorytractinfectionsinrandomized,double-blind,placebo-controlledtrials.6,7Theseformulationsconsistedof:(a)Baptisia,Echinaceaspp.root,andThuja;(b)thesesameherbscombinedwithhomeopathicremedies;and(c)E.angustifoliaaerialpartsandrootwithboneset,Baptisia,andhomeopathicArnica.Inmostofthesetrials,thedailydoseofherbswasbelowthenormaltherapeuticlimit(andwassimilartoahomeopathicprotocol).Onlyintrialsconductedwiththelastformulationdidpatientsreceiveherbsapproachingthenormaltherapeuticrange.Thedailydoseinthesetrialsrangedfrom1.2to3.0gofthetotalformulation(dryweightequivalent),includinghomeopathicArnica,forperiodsrangingfromseveraldaysintreatmenttrialsto8weeksinapreventiontrial.6,8

•Acontrolledtrialfoundcombineduseofthefirstformulationpreviouslylistedwiththeantibioticdoxycyclinehadbettersuccessthandiddoxycyclinealoneinthetreatmentofacutesinusitis.9

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.BeuscherN,etal.PlantaMed.1989;55:358-363.BeuscherN,etal.AngewandteBotanikBerichte.1997;6:46-61.

BarrettB,VohmanM,CalabreseC.JFamPrac.1999;48(8):628-635.Henneicke-vonZepelinHH,etal.CurrMedResOpin.1999;15(3):214-227.MelchartD,etal.Phytomed.1994;1:245-254.ZimmerM.Therapiewoche.1985;35:4024-4028.

BARBERRYANDINDIANBARBERRY

CommonName: BarberryOtherCommonNames: Commonbarberry,EuropeanbarberryBotanicalName: BerberisvulgarisFamily: BerberidaceaePlantPartsUsed: Root,stembark,orbothCommonName: IndianbarberryBotanicalName: BerberisaristataFamily: BerberidaceaePlantPartsUsed: Root,stembark,orboth

PRESCRIBINGINFORMATION

Actions

Barberry:antimicrobial,cholagogue,choleretic,antiemetic,mildlaxative,bittertonic

Indianbarberry:antimicrobial,cholagogue,choleretic,antiemetic,mildlaxative,bittertonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingbarberryorIndianbarberryinformulationsinthecontextof:

•Acuteinfectiousdiarrhea(4a,5)

•Gastritis,pepticulcer(involvingHelicobacterinfection),giardiasis,hypertyraminemia(4a)

•Adjuvanttherapyfornon-insulin–dependentdiabetesmellitus(4a)

•Jaundice(5)

•Topicaltreatmentformouthulcers(5)

Practitionersshouldalsoconsiderprescribingbarberryfor:

•Improvingdigestivefunction(bileproductionandrelease)(5)

•Gallbladderinflammation,gallstones,intestinaldyspepsia(5)

•Topicaltreatmentforlipsores,chronicophthalmia(5)

PractitionersshouldalsoconsiderprescribingIndianbarberryfor:

•Improvingdigestivefunction(bileproductionandrelease)(5)

•Enlargementoftheliverandspleen,colitis(5)

•Topicaltreatmentforskinulcersandabrasions,hemorrhoids,boils,acne(5)

Contraindications Berberine-containingplantsarenotrecommendedforuseduringpregnancyorforjaundicedneonates.

WarningsandPrecautions Nonerequired.

Interactions

Berberinemayreinforcetheeffectsofotherdrugsthatdisplacetheproteinbindingofbilirubin.Ratherthanpossibleuterine-contractingeffects,thisactivitymightexplainthetraditionalcontraindicationforberberine-containingherbsinpregnancy.

UseinPregnancyandLactation Contraindicatedinpregnancy.

SideEffects

Atdailydoseshigherthan0.5g,berberinemaycausedizziness,nose-bleeds,dyspnea,skinandeyeirritation,gastrointestinalirritation,nausea,diarrhea,nephritis,andurinarytractdisorders.Suchdosesofberberinewillnotbereachedusingtheliquiddosesrecommendedhere.

DosageItispreferabletouseliquidextractsquantifiedfortheirberberinecontent.

Barberry: Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

Indianbarberry:

Doseperday† Doseperweek†

2.0–4.5mlof1:1liquidextract

15–30mlof1:1liquidextract

Fortopicaluseofberberine-containingherbs(suchasfortreatmentofophthalmia),asolutionofabout5to6dropsofa1:2extractispreparedinaneyebathofrecentlyboiledwaterorsaline.Theliquidshouldbeallowedtocoolbeforeapplyingtotheeye.(Allowingthealcoholtoevaporatethroughthisprocessisimportantbeforeapplyingtotheeye.)

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

† Thisdose range is extrapolated from traditionalAyurvedicmedicine4,5 and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesofbarberryroot,stembark,orbothinclude:

•Gallbladderinflammation,gallstones,1jaundice,1,2chronicdiarrhea,dysentery,cholerainfantum,intestinaldyspepsia2

•Renalcalculi,sorenessandburningoftheurinarytract2

•Leishmaniasis,malaria,1fever2

•Asateaforbloodpurification,asatonic2

•Topicallyasadecoctionformouthulcersandlipsores,chronicophthalmia2

BarberrywasusedbyNativeAmericanstotreatsorethroat,ulceratedgums,andulceratedstomach.BarberrywasofficialintheUSPfrom1863to1882.3

TraditionalAyurvedicusesofIndianbarberryrootbarkinclude:

•Debility,remittentandintermittentfever,4especiallymalarialfever4,6

•Skindiseases,inflammation7

•Neuralgia,dysentery,colitis4

•Enlargementoftheliverandspleen,jaundice4

•Diseasesoftheeye,ear,andface4

•Topicallyfororientalsores,mouthsores,skinulcersandabrasions,pimples,boils,affectionsoftheeyelids,chronicophthalmia,piles,4muscularorrheumaticpain8

Keyconstituentsofbarberrybarkincludealkaloids,comprisingthoseoftheisoquinolinegroup:protoberberines(berberine,jateorrhizine,andpalmatine)andbisbenzylisoquinolines(includingoxyacanthine).Theprincipalalkaloidisberberine.Indianbarberryrootbarkalsocontainsberberine.9

TherootbarkisthepreferredplantpartfortherapeuticuseforbothbarberryandIndianbarberry.Therootbarkhasbeenpreferredtraditionallyandishigherinalkaloidsthanthestembark.However,giventhattheentireplantiskilledintheharvestingprocess,thestembarkisamoreenvironmentallysustainableoption.Thestembarkalsocontainstheactivealkaloids,albeitatlowerconcentrations,andisavalidtherapeuticoption.SeveralotherplantpartsofIndianbarberryhavebeenusedinAyurvedicmedicine,includingthefruit.

Thefollowinginformationpertainstotherootbark(exceptwhentheplantparthasnotbeendefinedinthestudy,asnoted).Pharmacologicinformationonberberine,thesignaturecomponentofbarberryandIndianbarberry,hasalsobeenprovidedwhenrelevant.

•Invitroandinvivostudieshavedemonstratedthatberberinehasantimicrobialactivityagainstawidevarietyofmicroorganisms,includingbacteria,fungi,andparasites.Barberrytincturewasbetterthanwasberberinechloride(0.2%)atinhibitingthegrowthofvariousmicroorganismsinvitro.Indianbarberryextract(partundefined)displayedinhibitoryactivityagainstSalmonellatyphiinvitro.10

•PustularskinlesionsfromStaphylococcusaureusandS.

PharmacologicResearch

pyogenesinfectionwerehealedwithin2weekswhenacombinationofIndianbarberry(partundefined)andCedrusdeodorawastakeninternallyandalsoappliedasagelinanexperimentalmodel.Thecombinedtreatmentwasmorebeneficialthanwasthetopicalapplicationalone.11

•BerberinecombinedwithGeraniumleafextract(oraldoses)significantlyinhibiteddiarrhea.OralberberinesignificantlyreducedintestinalfluidaccumulationtriggeredbyEscherichiacolienterotoxininvivo.

•Berberineincreasedthrombocytes,decreasedfactorXIIIactivity,inhibitedplateletaggregationandadhesiveness,andinhibitedclotretractioninvivo(routeunknown).Indianbarberryrootextractinhibitedplateletactivatingfactor(PAF)aggregationofplateletsinadose-dependentmannerandbindingofradiolabeledPAFtoplateletsinvitro.

•Berberinehasdemonstratedcytotoxicactivityinseveralinvitromodels.Indianbarberryextract(partundefined)demonstratedanticanceractivityagainsthumanepidermalcarcinomaofthenasopharynxinvitro.12

•Intraperitonealadministrationofbarberryextractdemonstratedhigherantiinflammatoryactivitythandidisolatedberberineandthreedifferentalkaloidalfractionsinexperimentalmodelsofacuteandchronicinflammation.

•Barberrytinctureincreasedcontractionsinisolatedintestinaltissueanddemonstratedcholagogueandcholekineticactivityinexperimentalmodels.Oraladministrationofberberinehydrochloridesignificantlyincreasedbilirubinexcretioninexperimentalhyperbilirubinemiawithoutaffectingthefunctionalcapacityoftheliver.

•Oralpretreatmentorposttreatmentwithberberine(4mg/kg)preventedchemical-inducedliverdamage,indicatinghepatoprotectiveactivity.13

•Berberineprolongedpentobarbital-inducedsleepingtimeandincreasedstrychnine-inducedtoxicityafteroraladministration,suggestinganinhibitoryeffectonliverdrugmetabolizingenzymes(cytochromeP-450).13

•Lipogenesiswassuppressedinisolatedsebaceousglandsbyberberine.

•Berberinesignificantlydecreasedscopolamine-inducedamnesiainanexperimentalmodel.

•Indianbarberryrootextractdemonstratedhypoglycemicactivityinanexperimentalmodel(routeunknown).12Formoreinformationonthepharmacologicparametersofberberine,seethemonographongoldenseal(Hydrastiscanadensis).

NoclinicalstudiesusingbarberryorIndianbarberryhavebeenfound.Clinicaltrialsusingberberineareoutlinedhere.Theberberinedosesusedinmanyofthesetrialswerehigherthanwhatcouldbeachievedusingherballiquidextracts.

•Berberine(100mg/day)demonstratedanantidiarrhealactionandcomparedwellagainststandardantidiarrhealdrugsinanuncontrolledstudyinvolvingchildrenwithgastroenteritis.Inrandomized,controlledtrials,berberinehasexhibitedbenefitintreatingdiarrheacausedbyEscherichiacoliinfectionbutwasoflittlevalueagainstVibriocholeraeinfectiousdiarrhea(cholera).ThetrialswithpositiveoutcomesforE.colidiarrheawereconductedusingeitheruntreatedcontrols(activetherapy:400mgofberberinesulfateasasingledose)orcomparedrehydrationtherapyagainstonlyrehydrationtherapywithberberine(200mg).Inanothertrial,neitherberberine

ClinicalStudies

(400mg/day)nortetracyclineexhibitedanybenefitoverplaceboinpatientswithnoncholeradiarrhea.

•Berberine(900mg/day)wasmoreefficaciousthanwasranitidineinclearingHelicobacterpyloriandimprovinggastritisinH.pylori-associatedduodenalulcerinarandomized,comparativeclinicaltrial.Ranitidinewasthesuperiortreatmentforulcerhealing.

•Intwocontrolledtrials,berberine(5to10mg/kg/dayfor6to10days)wassuperiortoplaceboandcomparedfavorablywithestablisheddrugsintreatinggiardiasisinchildren.

•Inanuncontrolledtrial,berberine(600to800mg/day)correctedhypertyraminemiaandpreventedtheelevationofserumtyramineaftertyraminestimulationinpatientswithlivercirrhosis.(Hypertyraminemia[i.e.,elevatedbloodlevelsoftyramine]iscommoninhepaticcirrhosis.)

•Inanuncontrolledtrialberberine(0.9to1.5g/dayfor1to3months)incombinationwithatherapeuticdietimprovedthemajorsymptomsofpatientswithnon-insulin–dependentdiabetes.Berberinetreatmentimprovedpatients’strength,normalizedbloodpressure,decreasedbloodlipids,andin60%ofpatients,normalizedfastingglycemiclevels.

•Berberinebisulfate(15mg/dayfor15days)increasedplateletcountsinpatientswithprimaryandsecondarythrombocytopeniainanuncontrolledclinicaltrial.

•Inarandomized,controlledtrial,berberinechloride(1.5g/day)wasmoreefficaciousthanwerebothtetracyclineandasulfamethoxazole-trimethoprimcombinationinclearingasexualparasitemiainpatientswithchloroquine-resistantmalaria(allagentswereusedinconjunctionwithpyrimethamine).

•Weeklyintralesionalinjectionofberberinesaltsolution

(1%)healedcutaneousleishmaniasisafter4to8weeksinasmall,uncontrolledtrial.(CutaneousleishmaniasisisaprotozoalskininfectioncausedbyspeciesofLeishmania.)

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.BritishHerbalPharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinalandAromaticPlants,1989.KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982KumarS,etal.JEthnopharmacol.2000;70(3):191-195.JoshiAR,JoshiK.JEthnopharmacol.2000;73:175-183.

ChauhanSK,SinghBP,AgrawalS.IndianDrugs.1998;35(8):468-470.

10SohniYR,PadmajaK,BhattRM.JEthnopharmacol.1995;45(2):141-147.

11ChakkrabartiA,GuhaC,SenTB.IndianVetJ.1999;76(5):432-434.

12DharML,etal.IndianJExpBiol.1968;6(4):232-247.13JanbazKH,GilaniAH.Fitoterapia.2000;71:25-33.

BILBERRY

BotanicalName: VacciniummyrtillusFamily: EricaceaePlantPartUsed: Fruit

PRESCRIBINGINFORMATION

Actions Vasoprotective,antiedema,antioxidant,antiinflammatory

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingbilberrythatcontainsanthocyanins(e.g.,freshordriedfruit,standardizedtablets)aspartofanoveralltreatmentprograminthecontextof:

•Visiondisorders,myopia,retinitis,hemeralopia,simpleglaucoma(4)

•Venousinsufficiency,especiallyofthelowerlimbs(1)

•Peripheralvasculardisorders,diabeticretinopathy(3)

•Hypertensiveretinopathy,nosebleedcausedbycapillaryfragility(3)

•Chronicprimarydysmenorrhea(3)

•Raynaud’ssyndrome(4)

•Venousdisordersduringpregnancy,includinghemorrhoids(4)

•Postoperativecomplicationsfromnosesurgery(4)

•Decreasedcapillaryresistance(bruising,petechiae,fecaloccultblood)(4)

•Nonspecific,acutediarrhea(4)

•Topicaltreatmentformildinflammationofthemouthandthroat(4)Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingbilberrythatcontainsnoanthocyanins(e.g.,liquidextracts)informulationsinthecontextofdigestivedisorders,includingdiarrhea,dyspepsia,gastrointestinalinfections,andinflammations;scurvy,urinarycomplaints,vaginaldischarges(6)

Contraindications Noneknown.

WarningsandPrecautions

Veryhighdosesofthestandardizedtabletsshouldbeusedcautiouslyinpatientswithhemorrhagicdisordersandinthosetakingwarfarinorantiplateletdrugs.(Inhibitionofplateletaggregationwasdemonstratedfromthebloodofhealthyvolunteersafteroraladministrationofanextractcontaining173mg/dayofanthocyaninsfor30to60days.)

Interactions Possibleinteractionmayoccurwithwarfarinandantiplateletdrugsbutonlyforveryhighdoses.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsAsurveillancestudyreportedmildsideeffectsinasmallpercentageofpatientsaffectingthegastrointestinal,cutaneous,ornervoussystems.

Dosage Doseperday* Doseperweek*

3–6mlof1:1liquidextract

20–40mlof1:1liquidextract

Tabletsproviding50to120mgperdayofanthocyanins(equivalenttoabout20to50goffreshfruit)havebeentypicallyusedinclinicaltrials.

* This dose range is extrapolated from traditional herbal texts1 and pharmacologic andclinicaltrialdata.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Digestivedisorders(diarrhea,dyspepsia,gastrointestinalinfections,andinflammations),hemorrhoids1

•Scurvy,urinarycomplaints1

•Vaginaldischarges,todryupbreastmilk1

PharmacologicResearch

Bilberryfruitcontainsarangeofanthocyanins,someofwhicharebluepigmentsresponsibleforthecoloroftheripeberries.

•Bilberryextracthasdemonstratedvasoprotectiveandantiedemaeffectsinvivo.

•Invitrostudieshavedemonstratedtheantioxidantactivityofbilberryanditsanthocyanins.

•Antiplateletactivityhasbeendemonstratedinvitro,invivo,andexvivo.ThemechanismofactionmaydependonanincreaseintheconcentrationofcAMP,adecreaseintheconcentrationofplateletthromboxane,orboth.

•Anthocyaninsfrombilberryprotectedcollagenagainstnonenzymaticproteolyticactivityinvitroandthereforemayprotectcollagenfromdegradationduringinflammatoryprocesses.

•Bilberryextractdemonstratedsignificantdose-dependentantiulceractivityinvivo.

ClinicalStudies

Allclinicalstudieshavebeenconductedusingbilberrypreparationsthatwerestandardizedforanthocyanincontent.Theoraldosesusedinthefollowingclinicalstudiesrangedfrom54to288mgperdayofanthocyanins,withdosesof115mg/dayand173mg/dayofanthocyaninsmostcommonlyadministered.

•Areviewofuncontrolledtrialsfrom1979to1985concludedthatbilberryextractcausedrapiddisappearanceofsymptomsandimprovementsinvenousmicrocirculationandlymphdrainageforpatientswithvenousinsufficiency.

•Inadouble-blind,placebo-controlledtrial,patientswithperipheralvasculardisordersofvariouscausesexperiencedareductioninsubjectivesymptoms,includingparesthesia,pain,heaviness,andedema,aftertreatmentwithbilberryfor30days.MobilizationoffingerjointswasimprovedinpatientswithRaynaud’ssyndrome.

•Bilberryextractprovidedreliefforpatientswithvenousdisorders,includinghemorrhoidsduringpregnancyinanopentriallasting2to3months.

•Inadouble-blind,placebo-controlledtrial,bilberrysignificantlyreducedsymptomsofdysmenorrhea,suchaspelvicandlumbosacralpain,mammarytension,headache,nausea,andheavinessofthelowerlimbs.

•Inuncontrolledtrials,bilberryextractimprovedsymptomscausedbydecreasedcapillaryresistanceandreducedthemicrocirculatorychangesinducedbycortisonetherapyinpatientswithasthmaandchronicbronchitisafter6months’treatmentandimproveddiabeticretinopathywithamarkedreductionorevendisappearanceofretinichemorrhages.Othercontrolledstudiessupporttheuseofbilberryforthetreatmentofbothdiabeticandhypertensiveretinopathy.

•Inaplacebo-controlledtrial,bilberryextractreducednosebleedcausedbyabnormalcapillaryfragilityofthemucousmembranes.

•Studieshavealsoshownthebenefitsofbilberryinpatientswithvisualdisorders,suchasmyopia,defectivevisioninbrightlight,simpleglaucoma(incombinationwithretinol),andpoordarknessadaptation.Bilberryalsoimprovednightvisioninhealthyvolunteers,althoughasmalldouble-blind,placebo-controlledtrialpublishedin2000castdoubtonthisaspectofitsefficacy.2

•Postoperativecomplicationsfromsurgeryofthenosewerereducedinpatientswhoreceivedbilberryextractadministeredfor7daysbeforeand10daysaftersurgery.

•InGermany,theCommissionEsupportstheuseofbilberrydriedfruitandpreparationstotreatnonspecificacutediarrheaandexternallyforlocaltherapyofmildinflammationofthemucousmembranesofthemouthandthroat.3

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.MuthER,LaurentJM,JasperP.AlternMedRev.2000;5(2):164-173.

BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

BLACKCOHOSH

BotanicalNames: Cimicifugaracemosa,Actaearacemosa#^

Family: RanunculaceaePlantPartUsed: Rootandrhizome

# Alternativename.

^ AdoptedbytheAmericanHerbalProductsAssociationasthenewbotanicalname.1

PRESCRIBINGINFORMATION

Actions Antirheumatic,spasmolytic,estrogenmodulating,uterinetonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingblackcohoshinformulationsinthecontextof:

•Symptomsassociatedwithmenopause(2,4)

•Dysmenorrhea(4,5)

•Premenstrualsyndrome(4)

•Ovariandysfunctionandovarianinsufficiency(4)

•Amenorrhea,ovarianpain,femaleinfertility;arthritis,rheumatism,neuralgia,myalgia,sciatica;whoopingcough,tinnitus(5)

Contraindications

Blackcohoshshouldnotbetakenduringpregnancyorlactation2exceptduringthelastmonthtoassistwithbirth.3Untilmoreinformationisavailable,womenwithestrogen-dependenttumorssuchasbreastcancershouldavoidusingblackcohosh.

WarningsandPrecautions

Traditionalsourcesnotethatoverdosehascausednauseaandvomitingandmayproducevertigo,aswellasvisualandnervousdisturbance.

Interactions

Theantiproliferativeeffectofblackcohoshextractincombinationwithtamoxifenwasassessedinvitroon17β-estradiol–stimulatedMCF-7humanbreastcancercells.Blackcohoshaugmentedtheantiproliferativeactionoftamoxifen.Whetherthisinteractionalsoappliesinvivohasnotbeenestablished.

UseinPregnancyandLactation

Contraindicatedinpregnancyandlactation,exceptforassistingbirthduringthelastmonth.

SideEffectsHighdosescausefrontalheadache.Stomachcomplaintshavebeenobservedwithalowfrequencyinclinicaltrials.

Dosage Doseperday* Doseperweek*

1.5–3.0mlof1:2liquidextract

10–20mlof1:2liquidextract

Blackcohoshmaybetakenlongtermwithintherecommendeddose,althoughtheCommissionErecommendsnotmorethan6months,perhapsbecausecontrolledstudiesoverlongerperiodsarelacking.

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbal Pharmacopoeia 1983, clinical trial information, and the author’s education andexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Myalgia,chorea,arthritis,rheumatism,neuralgia,sciatica3,4

•Femalereproductivedisorders,dysmenorrhea,amenorrhea,ovarianpain,femaleinfertility,partuspreparator,leukorrhea4,5

•Whoopingcough,tinnitus4

PharmacologicResearch

•Experimentalstudieshaveshowntheluteinizinghormone(LH)suppressiveeffectofblackcohoshwhentheextractwasgivenbothorallyandviainjection(thelatterrouteproducedgreateractivity).Atleastthreecompoundswerefoundtobeinvolved.BlackcohoshextracthasalsoincreasedLHsecretioninvivo(oralroute).6

•Althoughestrogeniccompoundsarepresentinblackcohosh,noestrogenicactivitywasfoundinvivoafteroralorsubcutaneousadministration.Blackcohoshextractsreducedthenumberofskinflushesinanexperimentalmenopausalmodel,whichwasconsideredtobeindicativeofanestrogeniceffect.7Researchpresentedin2000highlightsthedebateconcerningthenatureofanyestrogenicactivityofblackcohosh.8

•Blackcohoshisnotovertlyestrogenic,butthecompoundswithinitactasphyto-SERMs(plantsubstancesthatactasselectiveestrogen-receptormodulators)thatinteractwithcertaintypesofestrogen

receptorssuchasErβ,whichispresentinmanytissues.

•Blackcohoshhadnoeffectonuterineweightinvivooronanyoftheestrogen-regulatedgenesintheuterus,whereasitmimickedmanyoftheeffectsofestradiolinbone,liver,andtheaorta.

•Oraladministrationofblackcohoshextractdidnotpromoteestro-gen-dependentmammaryglandtumorsinvivo.9

•Blackcohoshextractinhibitedmonoamineoxidaseinthestriatumafterlong-termpretreatmentinvivo.10

TheclinicalstudiesoutlinedherewereconductedusingaGermanpro-prietarymedicineandreflectlowerdosescomparedwiththoseusedtraditionally.Thetabletsarequotedascontaining1mgofamarkertriterpeneglycoside(27-deoxyactein).Currentregulatoryinformationindicatesthatthesetabletsnowcontain24.8to42.7mgdriedherbequivalentand0.8to1.2mgtriterpeneglycosides.

•Areviewofclinicaldataindicatesthatblackcohoshappearstohavetherapeuticefficacyformoderatetosevereneurovegetativesymptomsofmenopause.Goodtolerabilityandalowriskofsideeffectshavebeenconfirmed.11Thedatareviewedincludescasereportsdatingbacktothe1950s,adrug-monitoringstudyofover700individualsandclinicaltrials.Threeofthetrialswererandomizedandcontrolledandadministeredadosecontaining4mg/dayofmarkertriterpeneglycoside.Intherandomized,double-blind,placebo-controlledtrial,blackcohoshwassuperiorinefficacytothatofconjugatedestrogens(0.625mg/day)after3months.Inthistrial,theblackcohoshtreatmentgroupalsoshowedsignificantimprovementintheproliferationstatusofvaginalepithelium.However,theadministereddoseofestrogenswasconsideredtoolow.Apharmacologicstudyinvolving

ClinicalStudies

menopausalwomenobservedthatblackcohosh(4tablets/day)significantlyreducedthemeanserumLHlevelcomparedwithaplacebogroup.ThisstatisticalreductionofLHwasnotobservedinanearlierrandomized,controlledtrialusingthesamedose.

•Treatmentwithahighdoseofblackcohoshextractwasnotassociatedwithchangesinendometrialthickness,vaginalcellstatus,orhormonelevelsinadrug-monitoringstudyinvolving28menopausalwomen.HormonesmeasuredincludedLH,follicle-stimulatinghormone(FSH),prolactin,andestradiol.Approximately80%ofpatientsdemonstratedgoodorverygoodefficacyinrelationtothemenopausalsymptomsmeasured.Thedosageofextract(similartothatdiscussedhere)was136mg/day.Themeandurationoftreatmentwas98days.12

•Treatmentwithblackcohosh(2tablets/day)wasnotsignificantlybetterthanwasplaceboformostmenopausalsymptomsinarandomized,double-blindtrialinvolvingwomenwithahistoryofbreastcancer.Ofthesevenmenopausalsymptomsassessed,sweatingwastheonlysymptomforwhichtheimprovementreportedbythetreatmentgroupwasstatisticallysignificantfromplacebo.13Thedoseadministeredwaslowerthanthatusedinotherclinicaltrials.

•Inanopen,multicenter,postmarketingsurveillancestudy,acombinationofSt.John’swortandblackcohoshdemonstratedimprovementin90%ofpatientsforthepsychologiccomplaintsexperiencedinmenopause,withimprovedconcentrationandareductioninhotflashes.14ThesameSt.John’swortandblackcohoshcombinationsignificantlyreducedmenopausalsymptomscomparedwithplaceboinarandomized,double-blindtrialinvolving179women.Thedailydosecontained0.5mgoftotalhypericinand2mgof27-deoxyactein(theactivecompoundinblackcohosh).15

•InGermany,theCommissionEsupportsusingblackcohoshtotreatpremenstrualdiscomfort,dysmenorrhea,andmenopausalsymptoms.16

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.McGuffinM,editor.HerbsofCommerce,ed2,Bethesda,Md:AmericanHerbalProductsAssociation,1998.[draft3.3]BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983KnuvenerE,KorteB,WinterhoffH.Phytomed.2000;7(supp2):12.LohningA,VerspohlEJ,WinterhoffH:InternationalConference:2000YearsofNaturalProductResearch–Past,

PresentandFuture,Amsterdam,July26-30,1999;Abstract327.ThirdInternationalCongressonPhytomedicine,Munich,October11-13,2000.Phytomed.2000;7(supp2):11-12.FreundensteinJ,DasenbrockC,NissleinT.Phytomed.2000;7(supp2):13.

10LohningA,WinterhoffH.Phytomed.2000;7(supp2):13.11LiskeE.AdvTher.1998;15(1):45-53.12NesselhutT,LiskeE:10thAnnualMeetingoftheNorthAmericanMenopauseSociety,NewYork,September23-25,1999;Poster8.

13JacobsonJS,etal.JClinOncol.2001;19(10):2739-2745.14GerhardI,LiskeE,WustenbergP.ZPhytotherAbstractband.1995:21-22.

15BoblitzN,etal.FocusAlternatComplementTher.1995;5(1):85-86.

16BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

BLACKHAW

BotanicalName: ViburnumprunifoliumFamily: CaprifoliaceaePlantPartUsed: Bark

PRESCRIBINGINFORMATION

Actions Uterinesedative,bronchospasmolytic,antiasthmatic,hypotensive,astringent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingblackhawinformulationsinthecontextof:

•Dysmenorrhea(5)

•Falselaborpains,threatenedmiscarriage,postpartumhemorrhage(5)

•Asthma,hiccup,legcramps(5)Contraindications Noneknown.

WarningsandPrecautions

AccordingtotheAmericanHerbalProductsAssociation,1individualswithahistoryofkidneystonesarecautionedagainstusingblackhawbecauseofthepresenceofoxalateoroxalicacidinthedriedbark.Oxalate,asthepotassiumorcalciumsalt,ispresentinthecellsapofmanyplantsandvegetables.Calciumoxalateispracticallyinsolubleinwater2andisunlikelytobepresentinaqueousethanolicliquidextractsofblackhawinsufficientquantitiestojustifythisprecaution.

Interactions

Blackhawcontainsscopoletin(acoumarin),andsuggestionsarethatitmaypotentiatetheeffectsofanticoagulantmedicationsorcausehemorrhagicproblems.3However,noevidencehasbeenfoundtosuggestthatanticoagulantactivityinvivo4andsimpleplantcoumarinsdonotnecessarilyincreasetheriskofbleeding.

UseinPregnancy

andLactation Noadverseeffectsexpected.

SideEffectsNoneexpectediftakenwithintherecommendeddoserange.Atraditionaltextreportsthatnauseaandvomitingmayoccurwithlargedoses.5

Doseperday* Doseperweek*

1.5–4.5mlof1:2liquidextract

10–30mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1949, theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Asauterinetonic,foruterineirritationandinflammation5,6

•Dysmenorrhea,severelumbarandbearing-downpains;cramplike,expulsivemenstrualpains5,6

•Threatenedmiscarriage,5,6especiallywithariseinbloodpressure6

•Falselaborpains,5,6postpartumhemorrhage;menorrhagia,uterinehemorrhageinmenopause,amenorrhea5

•Nervousdisordersassociatedwithmenses,includingepilepsy5

•Legcramps,especiallyatnight5

•Asthma,6hiccup,heartpalpitations5

•Diarrhea,dysentery,jaundice5

•Sterility,spermatorrhea5

•Alcoholichangover5

•Topicallyforindolentulcersandophthalmicdisorders5

NativeAmericansusedblackhawforstomachtroubles,dysentery,femalereproductiveproblems,beforeandduringparturition,andasanantispasmodic,diaphoretic,

andtonic.BlackhawwasofficialintheUSPfrom1882to1926andNFfrom1926to1960.3,7

PharmacologicResearch

Blackhawbarkcontainsflavonoids(includingthebiflavoneamentoflavone),iridoidglycosides,triterpenesandtriterpenicacids,andcoumarins(includingscopoletin).3

Thevalueofpublishedresearchconductedbefore1940onViburnumspp.mustbequestionedbecauseofpossibleimproperidentificationofthevariousspeciesandpossibleadulterationwithotherspecies.8

•Earlystudiesinvestigatingtheuterinespasmolyticeffectforblackhawhadvaryingresults.9-15Tworeviewsofthesestudiesconcludedthatthefindingswerescientificallyinvalidbecauseofsignificantdesignlimitations.16,17Morerecentstudieshaveconfirmedtheuterinespasmolyticactivityofblackhawethanolicextractsinvitro.18-21

•Blackhawhasalsodemonstratedspasmolyticactivityinisolatedintestinaltissues.21

•Hypotensiveandhypertensiveeffectshavebeenreportedforblackhaw.Anindirect,dose-dependent,vasoconstrictingeffectwasobservedinisolatedaortictissue.22Intravenousadministrationofthetotalextractinducedaslowbutprolongedincreaseinmeanbloodpressureinvivo.22Conversely,earlyinvivostudiesdemonstratedahypotensiveeffectforblackhaw(intravenousroute).15,23Theoriessuggestthatthehypotensiveeffectwasaresultoftheabsenceofiridoidcompoundsintheextractsusedintheearlystudies.21Moreover,becausetheherbwasadministeredbyinjectioninallthesestudies,theirrelevanceisquestionable.

•Inanearlystudy,dietaryblackhawrootbarkdidnothaveasignificantappetite-enhancingeffectinan

experimentalmodel,suggestingalackofbitteraction.24(Thisfindingisnotsurprisingbecausemodernherbalcliniciansdonotregardblackhawasabittertonic.)

ClinicalStudies Noclinicalstudiesusingblackhawhavebeenfound.

REFERENCES

McGuffinM,etal,editors.AmericanHerbalProductsAssociation’sbotanicalsafetyhandbook.BocaRaton,Fla:CRCPress,1997.BudavariS,etal,editors.TheMerckindex:anencyclopediaofchemicals,drugsandbiologicals,ed12,WhitehouseStation,N.J.:MerckandCo.,1996.AmericanHerbalPharmacopoeia.Blackhawbark–Viburnumprunifolium:analytical,qualitycontrol,andtherapeuticmonograph.SantaCruz,Calif:AmericanHerbalPharmacopoeia,June2000.PattersonDSP,RobertsBA,O’NeillPA.VetRec.1971;89(20):544-545.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.AmericanHerbalPharmacopoeia.Crampbark–Viburnum

opulus:analytical,qualitycontrol,andtherapeuticmonograph.SantaCruz,Calif:AmericanHerbalPharmacopoeia,February2000.PilcherJD,DelzellWR,BurmanGE.ArchInternMed.1916;18(5):557-583.

10PilcherJD,DelzellWR,BurmanGE.JAmMedAssoc.1916;67(7):490-492.

11PilcherJD.ArchIntMed.1917;19(9):53-55.12PilcherJD,MauerRT.SurgeryGynecolObstet.1918;27:97-99.

13HagerBH,BechtFC.JPharmacolExpTher.1919;13(1):61-70.

14MunchJC.JAmPharmAssoc.1939;28(11):886-887.15MunchJC,PrattHJ.PharmArch.1941;12:88-91.16WoodburyRA.DrugStand.1951;19(7-9):143-151.17BaldiniL,BrambillaG,ParodiS.ArchItalSciFarmacolog.1963;3(14):55-63.

18BalansardG,etal.MedPlantsPhytother.1983;17(3):123-132.

19JarboeCH,etal.Nature.1966;212(64):837.20JarboeCH,etal.JMedChem.1967;10:488-489.21TomassiniL,etal.ProceedingsoftheSocietaItalianadiFitochimica9thNationalCongress.Florence:SocietaItalianadiFitochimica,May27-30,1988.

22CometaMF,TomassiniL,PalmeryM.Fitoterapia.1998;69(5):23.

23EvansWEJr,HarneWG,KrantzJCJr.JPharmacol.1942;75:174-177.

24GarbS,CattellM.DrugStand.1956;24(3):94-99.

BLADDERWRACK

OtherCommonName:

Kelp(thiscommonnameisappliedtoseveralseaweedspecies,includingbladderwrack)

BotanicalName: Fucusvesiculosus

Family: FucaceaePlantPartUsed: Thallus(plantbody)

PRESCRIBINGINFORMATION

Actions Weightreducing,thyroidstimulant,demulcent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingbladderwrackinformulationsinthecontextof:

•Obesityassociatedwithiodinedeficiency(3,5)

•Thyroidconditionsresultingfromiodinedeficiency(5,7)

•Rheumaticconditions,includingarthritis(5)

Contraindications Hyperthyroidism,pregnancy,lactation,andcardiacproblemsassociatedwithhyperthyroidism1

WarningsandPrecautions Nonerequired.

Interactions Bladderwrackmayinteractwiththyroidreplacementtherapies(thyroxine).

UseinPregnancyandLactation Contraindicatedinpregnancyandlactation.

Kelp(speciesundefined)hascausedtransienthyperthyroidism(estimatediodineintakeof2.8to4.2mg/day)2,3andraisedlevelsofthyroidstimulatinghormone(doseundefined).4

Whenconsumedasafood,kelp(probablynotbladderwrack)hascausedsubclinicalhypothyroidism5

andHashimoto’sthyroiditis.6Rareextrathyroidaleffectsmayalsooccurinsusceptibleindividualsasaresultofiodineintake,suchastheallergicreactionsofedema(dosesupto25mg/dayiodine),iodinefever

SideEffects

(50to500mg/dayiodine),andeosinophilia(dosenotdefined).However,iodineintakefromiodine-richfoodsandsupplementsareunlikelytoreachthesehighlevels.7

Othercasesofsideeffectsfrombladderwrackorkelpingestionhavebeenrecorded(includingkidneydamage)andwereattributedtohighlevelsofheavymetals,particularlyarsenic.Inonecase,theingestedkelptabletscontained20gofarsenicpertablet(27.8g/g).Thedosetakenwasnotindicated.Physicianslinkedacaseofseveredyserythropoiesisandautoimmunethrombocytopeniatoingestionofakelptablet(probablynotbladderwrack).Analysisofthetabletsshowedthattheycontained1.3μg/gofarsenic.Thepatienthadbeeningesting2.2gofarsenicdailyfromthissource.8-10Thereadershouldnotethatmarineorganisms,includingbladderwrack,naturallyaccumulatearsenic.

However,thearsenicismainlyorganicallyboundandrapidlyexcreted.Forthisreason,theWorldHealthOrganizationhasestablishedatolerableweeklyintakeforinorganicarseniconly,whichispresentinbladderwrackatconsiderablylowerlevels.11

Dosage Doseperday* Doseperweek*

4.5–8.5mlof1:1liquidextract

30–60mlof1:1liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Obesity,particularlyassociatedwithhypothyroidism.12(Eclectictextsnotethatbladderwrackmaybebeneficialfortreatingobesitybutonlyincaseswhenthedietisdeficient,presumablyoftheiodinethatbladderwrackcontains.13)

•Myxedema(aconditionresultingfromadvancedhypothyroidism),lymphadenoidgoiter(mostlikelyofthesimpletyperesultingfromiodinedeficiency,ratherthantheexophthalmictype,whichisindicativeofhyperthyroidism)12

•Rheumatismandrheumatoidarthritis(internallyandtopically)12

BladderwrackwasthoughtbytheEclecticstotonemuscularfibers,toactpowerfullyontheglandularsystemasadepurative,andtoreducerenalcongestionandbladderinflammation.13

Bladderwrackthalluscontainstraceminerals(particularlyfreeandprotein-boundiodide)andpolysaccharidesofseveraltypes(includingalginicacidandfucanssuchasfucoidan).Otherconstituentsincludepolyphenols,lipids,andsterols.1

•Experimentalstudiesconductedandreportedin1910foundoraldosesofbladderwrackhaveastimulatoryactivityonthethyroidgland.14

•Whenadministeredbyinjection,apolysaccharide

PharmacologicResearch

fractionofbladder-wrackdemonstratedhypoglycemicactivityinanormoglycemicmodelandloweredserumlipidlevelsinhyperlipidemia.15,16

•Bladderwrackextractpromotedcollagengelcontractionbyincreasingtheexpressionofintegrinmoleculesonthesurfaceoffibroblastsinaninvitromodelofdermaltissue.17Polysaccharidesfrombladderwrackdemonstratedstrongadhesiontoepithelialtissueinvitro.18

•Lowmolecularweightfucoidanfractionfrombladderwrackdemonstratedpotentanticoagulantandfibrinolyticpropertiesinvitro,withonlyminorplatelet-activatingeffects.19

•Fractionsofbladderwrackextractdemonstratedanti-HIVactivityinvitro.20

ClinicalStudies

•Aclinicaltrialinvestigatingseveralweight-reducingtreatmentsinmoderatelyoverweightSwedishwomenwasconductedovera2-yearperiod.Mostofthetreatments,includingthekelp-lecithin-vitamincombination,producedpoorresults.21(Thespeciesusedwasprobablynotbladderwrack.)

•Ahypocaloricdietcombinedwithspirulina,bladderwrack,andgelatindidnotchangeanyofthemeasuredparametersinhypertensiveobesepatients.22

•Inacontrolledclinicaltrial,obesevolunteerstakingbladderwrackextractinadditiontoacontrolleddietachievedasignificantlygreateraverageweightlossthandidthoseondietalone.23

REFERENCES

BritishHerbalMedicineAssociation.Britishherbal

compendium.Bournemouth:BHMA,1992.EliasonBC.JAmBoardFamPract.1998;11(6):478-480.ShiloS,HirschHJ.PostgradMedJ.1986;62:661-662.KeyTJA,etal.JHumNutrDiet.1992;5:323-326.KonnoN,etal.JClinEndocrinolMetab.1994;78(2):393-397.OkamuraK,InoueK,OmaeT.ActaEndocrinol.1978;88:703-712.deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1997.ConzPA,etal.NephrolDialTransplant.1998;13:526-527.WalkiwO,DouglasDE.ClinToxicol.1975;8(3):325-331.

10PyeKG,etal.Lancet.1992;339(8808):1540.11deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1992.

12BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

13FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

14HuntR,SeidellA.JPharmacol.1910;2:15-47.15Vazquez-FreireMJ,LamelaM,CallejaJM.PhytotherRes.1996;10(supp1):S184-S185.

16LamelaM,Vazquez-FreireMJ,CallejaJM.PhytotherRes.1996;10(supp1):S175-S176.

17FujimuraT,etal.BiolPharmBull.2000;23(3):291-297.18SchmidgallJ,SchnetzE,HenselA.PlantaMed.2000;66(1):48-53.

19DurigJ,etal.ThrombRes.1997;85(6):479-491.20BeressA,etal.JNatProd.1993;56(4):478-485.21BjorvellH,RossnerS.IntJObes.1987;11(1):67-71.22MonegoET,etal.ArqBrasCardiol.1996;66(6):343-347.23CurroF,AmadeoA.ArchMedInterna.1976;28:1343-1349.

BLUECOHOSH

BotanicalName: CaulophyllumthalictroidesFamily: BerberidaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Spasmolytic,uterineandovariantonic,emmenagogue,oxytocic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingbluecohoshinformulationsinthecontextof:

•Disordersofthefemalereproductivetractincludingamenorrhea,dysmenorrhea,menorrhagia,ovarianoruterinepainorinflammation,uterineprolapseoratony(5)

•Spasmodicconditionsofsmoothmuscle,includingabdominalcramping(5)

•Rheumaticconditions,muscularweakness,nervousdebility(5)

Contraindications

Becauseofpossibleteratogeniceffects,bluecohoshiscontraindicatedinearlypregnancyandlactation.TraditionaltextssuchastheBritishHerbalPharmacopoeia1983supportthiscontraindicationbyrecommendingthatonlysmalldosesareadvisableduringthefirsttrimesterofpregnancy.Useinlatepregnancyhasbeenlinkedtoadverseeventsandshouldbeundertakenonlybycliniciansexperiencedwithbluecohoshforthisapplication.

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancyandlactation.

SideEffects

Highlevelsoftheisolatedalkaloidanagyrineingoat’smilkhavebeenassociatedwithteratogeniceffectsinanimalsandinonehuman.1Therelevanceofthisfindingtouseofbluecohoshisunclear.

Severaladverseeventshavebeenassociatedwithmaternalingestionofbluecohosh.Amidwifeattemptedtheinductionoflaborusingacombinationofbluecohoshandblackcohoshgivenorally(doseundefined)ataround42weeksofgestation.2Afternormallabor,thefemalebabywasunabletobreathespontaneouslyandsustainedcentralnervoussystemhypoxic-ischemicdamage.3Profoundneonatalcongestiveheartfailurewaslinkedtomaternalconsumptionofbluecohoshtabletsabout1monthbeforedelivery.Thedosageandcontentofthetabletswasundefined.Thewomanhadbeenadvisedtotake1tabletperday,butshetookthreetimesthatdose(3tablets/day)for3weeksbeforedelivery.4Theinfantexhibitedsignsofseverecardiacinjuryandwashospitalized.Follow-upat2yearsofageindicatedthatcardiomegalyandmildlyreducedleftventricularfunctionwereevident.

TheU.S.FoodandDrugAdministration’s(FDA)SpecialNutritionalsAdverseEventMonitoringSystemdatabase(whichlistsadverseeventsbutisnotsubjecttopreconditions,analysis,orpeerreview)alsocontainstwocasespossiblyassociatedwithbluecohosh,includingstrokeinaninfant.

Toxiceffectshaveoccurredfromoverdoseofbluecohoshtincture(citedas10to20doses/dayinrelationtoattemptedabortion).Symptomsincludedhyperthermia,hypertension,tachycardia,hyperventilation,diaphoresis,andweakness.5

ThepresenceofoxytocicquinolizidinealkaloidssuchassparteineorN-methylcytisineinbluecohoshmight

explainbothitsoxytocicactivityanditsoccasionaltoxicity.Adverseeffectsmaybetheresultofaninabilitybysomepeopletometabolizesparteineandalkaloidsofrelatedstructure.About5%ofmaleandfemalesubjectsstudiedinatrialwereunabletometabolizesparteinebyN-oxidation,6andthisdefectappearstohaveageneticbasis.7

Dosage Doseperday* Doseperweek*

1.5–3.0mlof1:2liquidextract

10–20mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Uterinepain,amenorrhea,dysmenorrhea,irregularmenstruation;threatenedmiscarriage,falselaborpains,asapartuspreparator;uterineatony8,9

•Rheumaticpain,muscularweakness,debilityofthenervoussystem,epilepsy9

•Abdominalcramping,indigestion;dullfrontalheadache9

BluecohoshwasusedbyNativeAmericanstoexpediteparturitionandmenstruation,forlingeringparturition,andforsuppressingprofusemenstruation,genitourinarycomplaintsinbothsexes,colic,sorethroat,rheumatism,anddropsy.However,themodernunderstandingarguesagainstusingbluecohoshtofacilitatelaborexceptperhapsinpractitionersalreadyexperiencedwithitsuseinthiscontext.Bluecohoshwasconsideredaneffectivefeverremedy.BluecohoshwasofficialintheUSPfrom1882to1905andtheNFfrom1916to1950andwasusedforantispasmodic,emmenagogue,anddiureticpurposes.10

PharmacologicResearch

Bluecohoshrootcontainsquinolizidinealkaloids,includingsparteine,methylcytisine,andanagyrine.11Bluecohoshalsocontainssaponinssuchascaulosaponin.12

•Uterinestimulanteffectswereobservedfortheliquidextract,hotwaterextractandsaponinfraction,andisolatedcaulosaponininvitro.12-14

•Methylcytisinehasdemonstratedhypertensiveactivity

whenadministeredbyinjection.Caulosaponindemonstratedvasoconstrictiveactivityonisolatedarteriesandacardiotoxiceffectoncardiacmuscle.12

•Nicotinicactivitywasobservedafteroralingestionofmethylcytisinebyahumansubject.5

ClinicalStudies

•Asurveypublishedin2000reportedthatherbaltherapywasrecommendedby73.2%of82NorthCarolina–certifiedmidwivesforpregnantandpostpartumpatients.Bluecohoshwasamongtheherbscommonlyprescribedforwomenpasttheirduedates.15Similarfindingswereobtainedinasurveyconductedayearearlierinwhich64%of90midwivesreportedusingbluecohosh.Thissurveyrecordedthefollowingdosages:5dropsoftinctureevery4hoursforinductionoflaboror10dropsoftinctureevery2hoursinhotwater.16

REFERENCES

OrtegaJA,LazersonJ.JPediatr.1987;111(1):87-89.GunnTR,WrightIM.NZMedJ.1996;109(1032):410-411.WrightIMR.JPediatr.1999;134(3):384-385.JonesTK,LawsonBM.JPediatr.1998;132:550-552.RaoRB,etal.JToxicolClinToxicol.1998;36(5):455.EichelbaumM,etal.EurJClinPharmacol.1979;16:183-187.VinksA,etal.ClinPharmacolTher.1982;31(1):23-29.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.

Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

10VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

11KennellyEJ,etal.JNatProd.1999;62(10):1385-1389.12ChandlerF,editor.Herbs:everydayreferenceforhealthprofessionals.Ottawa:CanadianPharmacistsAssociation,2000.

13PilcherJD,DelzellWR,BurmanGE.JAMA.1916;67:490-492.

14FergusonHC,EdwardsLD.JAmPharmAssoc.1954;43(1):16-21.

15AllaireAD,MoosMK,WellsSR.ObstetGynecol.2000;95(1):19-23.

16McFarlinBL,etal.JNurseMidwifery.1999;44(3):205-216.

BLUEFLAG

BotanicalNames: Irisversicolor,Iriscaroliniana+

Family: IridaceaePlantPartUsed: Rhizome

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Depurative,laxative,cholagogue,lymphatic,diuretic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingblueflaginformulationsinthecontextof:

•Skin,liver,andgallbladderdisorders,particularlywhenchronicinnature(5)

•Constipation,headache,ordigestiveproblemsrelatedtopoorliverfunction(5)

•Enlargedlymphnodes,enlargedthyroid,enlargedspleen,enlargedovaries(5)

•Obesity(7)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Skindiseases1,2

•Biliousnesswithconstipationandliverdysfunction,1jaundice,poorgallbladderfunction,chronicliverdisorders,includinghepatitis;constipation;nausea,vomiting,headache,ordigestiveproblemsrelatedtopoorliverfunction2

•Reflexmuscularpainsresultingfromgastricirritation2

•Enlargedlymphnodes,enlargedthyroid,enlargedspleen;chronicpancreatic,splenic,orrenaldisorders2

•Syphilis,scrofula(tuberculousinfectionofthecervicallymphnodes)2

•Enlargeduterusorovary;leukorrhea,dysmenorrhea;prostaticdischarges,nocturnalemissions2

•Vomitingwithpregnancy;regardedasanemetic,butwithantiemeticactivityinsmalldoses3

BlueflagwasheldinhighregardbyNativeAmericansandwasoneofthemostwidelyusednativemedicines.Blueflagwasusedasapowerfulcatharticandemployedinternallytotreatthecommoncoldandlungproblems.Externally,blueflagwasusedasapoulticeandwashforsores,bruises,andburns.Thesteamedrootwastakeninternallytokeepdiseaseawaybecauseofitsimportanceasaphysicandpanacea.Thesteepedrootwasaspecificforcholera.BlueflagwasofficialintheUSPfrom1820

to1895andintheNFfrom1916to1942,withuseslistedascathartic,emetic,anddiuretic.4

PharmacologicResearch

Blueflagrootsignificantlyincreasedplasmalevelsoffreefattyacidsandglycerolafteroraladministration(20mg/kg)inanexperimentalmodel,demonstratingmobilizationoffattissue.5

ClinicalStudies Noclinicalstudiesusingblueflaghavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.BambholeVD.AncientSciLife.1988;8:117.

BUCHU

BotanicalNames: Agathosmabetulina,Barosmabetulina#

Family: RutaceaePlantPartUsed: Leaf

# Alternativename.

PRESCRIBINGINFORMATION

Actions Urinaryantiseptic,milddiuretic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingbuchuinformulationsinthecontextofurinarytractinfection,dysuria,cystitis,urethritis,andprostatitis.(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

Somewriterssuggestthatbuchuiscontraindicatedinpregnancy.However,thisprecautionwouldonlybethecaseforbuchusubstitutions(e.g.,Agathosmacrenulata),whichcontainmuchhigherlevelsofpulegoneintheiressentialoil.

SideEffects Occasionalgastrointestinalirritationmayoccuriftakenonanemptystomach.

Dosage Doseperday* Doseperweek*

2.0–4.5mlof1:2liquidextract

15–30mlof1:2liquidextract

* ThisdoseisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Diseasesofthegenitourinarytract,especiallyinflammationofthemucousmembranesofthelowerurinarysystemandprostate(e.g.,cystitis,urethritis,prostatitis);urinarydischarges,urinarygravel1,2

•Incontinenceassociatedwithadiseasedprostate,desiretourinatewithlittlerelieffrommicturition2

•Improvingappetite,relievingnauseaandflatulence2

TraditionalSouthAfricanmedicinalusesincludestomachcomplaints,kidneyandurinarytractdiseases,andrheumatism.3

PharmacologicResearch

Analcoholicextractofbuchudemonstratedactivityagainstmicrofloratypicalofurinarytractinfectionsinvitro.Onlytheessentialoilshowedconsiderableactivityagainstallthetestorganisms.

ClinicalStudies Noclinicalstudiesusingbuchuhavebeenfound.

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationthathasnotbeenreferencedhereMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983vanWykB-E,vanOudtshoornB,GerickeN.MedicinalplantsofSouthAfrica.Arcadia,SouthAfrica:BrizaPublications,1997.

BUGLEWEED

BotanicalNames: Lycopusvirginicus,Lycopuseuropaeus+

Family: LabiataePlantPartUsed: Aerialparts

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Thyroid-stimulatinghormone(TSH)antagonist,antithyroid,reducesheartrate,mildsedative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingbugleweedinformulationsinthecontextofhyperthyroidism,especiallyGraves’diseaseandassociatedsymptoms,suchastachycardia,rapidpulse,andexophthalmia.(4,5)

Contraindications Thyroidhypofunction,enlargementofthethyroidwithoutfunctionaldisorder;1pregnancyandlactation.2

WarningsandPrecautions Nonerequired.

Interactions

Bugleweedshouldnotbeadministeredconcurrentlywithpreparationscontainingthyroidhormoneandmayinterferewithadministrationofthyroiddiagnosticproceduresthatuseradioactiveisotopes.1

UseinPregnancyandLactation

Contraindicatedinpregnancyandlactationbecauseofpotentialantigonadotropicactivity.

SideEffects

Inrarecases,extendedtherapyandhigh(undefined)dosesofbugle-weedpreparationshaveresultedinanenlargementofthethyroid.Suddendiscontinuationofbugleweedpreparationscancauseincreasedsymptomsofthedisease.1Thefollowingsideeffectshavebeenreportedintheliteraturefromclinicaluseofbugleweedpreparationspublishedbetween1941to1968:headache,increaseinsizeofthyroid,andoccasionallyanincreaseinhyperthyroidsymptoms,includingnervousness,tachycardia,andlossofweight.Theincreaseinthyroidsizewasobservedinpatientswithgoiternotlinkedtothyroidmalfunction.2

Dosage Doseperday* Doseperweek*

2–6mlof1:2liquidextract

15–40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Nervoustachycardia,Graves’diseasewithcardiacinvolvement;thyro-toxicosiswithdifficultbreathing,tachycardia,andtremor;3exophthalmicgoiter4

•Organicandfunctionalcardiacdisease;abnormallyactivecirculation,rapidpulsewithhightemperature4

•Chroniccough,irritatingandwetcough,pneumonia,bronchitis3,4

•Restlessness,insomnia,anxiety4

BugleweedisconsideredinEuropeanherbalmedicineashavingantithyroidactivity.Beinglesspowerfulthanorthodoxdrugs,bugleweedisrecommendedformildthyroidhyperfunctionandcanbeusedasalong-termtreatment.5

•Lycopuseuropaeusaqueousethanolicextracthasdemonstratedantithyrotropicandantigonadotropicactivityinexperimentalmodelsinvivo(bothafterinjectionandoraladministration).6Thefollowingactivitieshavebeenobserved:•Decreasedtriiodothyronine(T3)levels,possiblyresultingfromreducedperipheralthyroxin(T4)deiodination•DecreasedT4andTSHlevels•DecreasedLHlevels

•Inthisseriesofexperiments,testosteronelevelswere

PharmacologicResearch

reduced,butprolactinremainedunchangedafteroraladministrationofbugleweedextracts.6Inanearlierstudy,L.virginicusaqueousethanolicextractstronglyloweredprolactinlevelsafterintravenousinjection.7Thisactivitywasdemonstratedatadosemuchhigherthanwasthedosethatproducedthepreviouslynotedantithyrotropicactivity.8L.virginicusextractreducedtheweightofthetestes,butLH-dependenttestosteronesynthesiswasnotsignificantlychanged(routeunknown).9

•InjectionofbugleweedextractreducedserumTSHandpituitaryTSHlevelsundernormalthyroidconditionsbutcausedanincreaseinpituitaryTSHlevelsunderhypothyroidconditions(alsowithdecreasedserumTSH).8

•AnantigonadotropicactivityhasbeendemonstratedforL.virginicusandL.europaeusextractsandforsomeoftheirconstituents.7,10TheantithyrotropicactivityisprobablyexertedbytheabilityofphytochemicalsinbugleweedtoformadductswithTSHandinhibititsabilitytobindtotheTSHreceptor.ThisinhibitoryinteractionhasalsobeendemonstratedfortheGraves’autoantibodyinvitro.10,11Anintracellularmechanismofinhibitionmayalsobepresent.12

•L.europaeusextractdemonstratedantioxidantactivityinvitro.13

ClinicalStudies

•LycopuseuropaeusinhibitediodinemetabolismandthyroidT4outputinhumanvolunteers.14

•Lycopuseuropaeusextracthasbeenbeneficialfortreatinghyperthyroidisminuncontrolledtrialsconductedinthe1940sand1950s.15-18

•InGermany,theCommissionEsupportsusingbugleweedtotreatmildthyroidhyperfunctionwithdisturbancesoftheautonomicnervoussystemand

mastodynia(breastpainortenderness).1

REFERENCES

BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1993.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983WeissRF.Herbalmedicine.InMeussAR,editor:Lehrbuchderphytotherapie,ed6,Beaconsfield,U.K.:BeaconsfieldPublishers,1988.WinterhoffH,etal.ArzneimForsch.1994;44(1):41-45.SourgensH,etal.IntJCrudeDrugRes.1986;24(2):53-63.SourgensH,etal.PlantaMed.1982;45:78-86.SourgensH,etal.ActaEndocrinolSuppl.1980;234:49.

10Auf’mkolkM,etal.Endocrinology.1985;116(5):1687-1693.11Auf’mkolkM,etal.Endocrinology.1984;115(2):527-534.12KleemanS,WinterhoffH.PlantaMed.1990;56:683P.13LamaisonJL,Petitjean-FreytetC,CarnatA.PharmActa

Helv.1991;66(7):185-188.14HillerE,DeglmannH.ArzneimForsch.1955;5:465-470.15MattauschF.Hippokrates.1943;14:168-171.16LeppertH.Therapiewoche.1951;952:2.571-57217FrankJ.MunchMedWschr.1959;101:203-204.18FiegelG.MedKlin.1954;49:1221.

BUPLEURUM

BotanicalNames: Bupleurumfalcatum,Bupleurumscorzonerifolium+

Family: UmbelliferaePlantPartUsed: Root

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Antiinflammatory,hepatoprotective,diaphoretic,antitussive

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingBupleuruminformulationsinthecontextof:

•Chronicinflammatorydisorders(7)

•Poorliverfunction(5)

•Feverishconditions,influenza,thecommoncold(4,5)

•Prolapseofuterusandrectum,irregularmenstruation(5)

Contraindications

AccordingtoTCM,Bupleurumiscontraindicatedindeficientyincough(coughwithdebility)orliverfireascendingtothehead,suchassomecasesofheadacheandhypertension.Bupleurumcanoccasionallycausenauseaorvomiting,inwhichcasethesmallestdosepossibleisused.

WarningsandPrecautions Bupleurumhasasedativeeffectinsomepatients.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

Largedosesmaycauseasedativeeffectinsomepatients,increasebowelmovements,andflatulence.Bupleurumcanoccasionallycausenauseaandrefluxinsensitivepatients,apropertycommontomost

SideEffects saponin-richherbs.

AtraditionalChineseherbalformula,whichincludedBupleurum,hasinducedpneumonitisinsomepatientsandliverdamageinrarecases.WhetherthisconditionwasaresultofBupleurumoroneoftheotherherbspresentisunclear.

Dosage Doseperday* Doseperweek*

3.5–8.5mlof1:2liquidextract

25–60mlof1:2liquidextract

* ThisdoserangeisadaptedfromdriedplantdosesadministeredbydecoctioninTCM.1Theauthor’sexperienceandthefact thatethanol-water isamoreeffectivesolvent thanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Bitterandcold,actingasadiaphoretic(infevermanagement),toregulateandrestoregastrointestinalandliverfunction2

•Alternatingchillsandfever(e.g.,malaria),liverenlargement,prolapseoftheuterusandrectum,menstrualproblems,epigastricpain,nausea,indigestion1-3

PharmacologicResearch

Bupleurumrootcontainstriterpenoidsaponins,includingthesaikosaponins.

•Theantiinflammatoryactivityofthesaikosaponinsappearstoberelated,atleastpartially,totheirabilitytobothinducesecretionofendogenouscorticosteroneandpotentiateitsantiinflammatoryactivity.Orally,saikosaponinsmaybeusedtoreducethedoseofglucocorticoiddrugsandtopreventglucocorticoid-inducedadrenalsuppression.

•Theabilityofsaikosaponinstoraisebloodglucoselevelswasdemonstratedinseveralpharmacologicstudiesfollowingbothoralandinjecteddoses.Thisresultmaybeadirectconsequenceoftheabilityofsaikosaponinstoincreasethelevelsofendogenousglucocorticoids.Becausesaikosaponinsalsoincreaseliverglycogenstores,Bupleurummayprovetobeusefulintreatingreactivehypoglycemia.

•Inexperimentalmodels,injectionofsaikosaponinsstimulatedimmunefunction.

•Saikosaponinshaveincreasedhepaticproteinsynthesisinvitroandinvivo.

•Saikosaponins(byinjection)havedemonstratednephroprotectiveactivity.Thisactivitywaspartlytheresultofantiplateletandcorticosterone-releasingactivities,aswellasaninhibitionofthedecreaseinfree-radicalscavengerssuchasglutathioneperoxidase.

•Saikosaponinshavereducedgastriculcerdevelopment,loweredcholesterol,andexertedantipyreticactivity.

•Injectionofsaikosaponinsdemonstratedapotentantitussiveeffectinanexperimentalmodel.

ClinicalStudies

•Inanuncontrolledclinicalstudyof143patientstreatedwithBupleurum,feversubsidedwithin24hoursin98%ofinfluenzacasesandin88%ofpatientswiththecommoncold.

•Inanotherstudyinvolving40patientswithpathologicalfever,Bupleurumproducedanantipyreticeffectin97.5%ofpatientsandachievedareductionof1°to2°C(1.8°to3.6°F)inbodytemperaturein77.5%ofallpatients.

•IntravenousinjectionofBupleurumgavepositiveresultsintreatinginfectioushepatitis.

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationthathasnotbeenreferencedhereMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.

PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.BenskyD,GambelA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.

BURDOCK

BotanicalName: ArctiumlappaFamily: CompositaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Depurative,milddiuretic,mildlaxative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingburdockinformulationsinthecontextof:

•Skindisorders,particularlyeczema,psoriasisandotherchronicskindisorders;boils(5)

•Disordersrequiringincreasedeliminationfromthebody,suchasgoutandrheumatism(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectedwhentakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

1.5–3.5mlof1:2liquidextract

10–25mlof1:2liquidextract

* This dose range is extrapolated from British Herbal Pharmacopoeia 1983, the BritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Skineruptions,particularlywhenweakcirculationandimpairednutritionexist;eczema,venereal,andleprousdisorders,longtermuseforpsoriasis;boils,styes1,2

•Rheumatism,cystitis,gout1,2

•Anorexianervosa,dyspepsia1,2

•Consideredoneofthebestdepuratives3

NativeAmericansusedburdockforawidevarietyofapplications,includingasageneraltonicandbloodpurifierandasaningredientintreatmentsforstomachpainandduringlabor.BurdockwasofficialintheUSPfrom1831to1842and1851to1916andintheNFfrom1916to1947andwaslistedasadiureticanddiaphoretic.4

PharmacologicResearch

•Burdockextractantagonizedplatelet-activatingfactorinvitro.5

•Burdockextracthasdemonstratedfree-radicalscavengingactivityinvitroandinhibitedcarrageenan-inducededemaandcarbontetrachloride–inducedhepatotoxicityinvivoafterinjection.6Isolatedcaffeoylquinicacidderivativesfromburdockhavebeenverifiedasantioxidants.7

•Methanolextractofburdockadministeredbyinjectiondemonstratedantitumoractivity.8

ClinicalNoclinicalstudiesusingburdockhavebeenfound.

Studies

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.IwakamiS,etal.ChemPharmBull.1992;40(5):1196-1198.LinCC,etal.AmJChinMed.1996;24(2):127-137.MarutaY,KawabataJ,NikiR.JAgricFoodChem.1995;43:2592-2595.DombradiCA,FoldeakS.Tumori.1966;52(3):173-175.

CALENDULA

OtherCommonName: MarigoldBotanicalName: CalendulaofficinalisFamily: CompositaePlantPartUsed: Flower

PRESCRIBINGINFORMATION

ActionsVulnerary,antiinflammatory,lymphatic,styptic(hemostatic),antimicrobial,antiviral(topically),antifungal(topically)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingCalendulainformulationsinthecontextof:

•Internalandtopicaltreatmentforinflammationoftheoralandpharyngealmucosa(4)

•Internaltreatmentforgastricandduodenalulcers;enlargedorinflamedlymphnodes,acne,sebaceouscysts(5)

•Internaltreatmentforspasmodicconditions,includingdysmenorrhea(5)

•Topicaltreatmentforburns(2)

•Topicaltreatmentforinflammationoftheskinandmucosa,wounds,especiallypoorlyhealingwounds(4,5)

•Topicaltreatmentforlegulcers,venouscirculatoryproblems,scalds;tohelpcontrolbleeding(4)

•Topicaltreatmentforeczema,varicoseveins,hemorrhoids,acne,vaginaldischarges(5)

Contraindications Knownallergy.1

ThelikelihoodofCalendulapreparationscausingacontactallergyislow.However,peoplewithknownsensitivitytoothermembersoftheCompositaefamily

WarningsandPrecautions

(e.g.,ragweed,daisies,chrysanthemums)shouldavoidtopicalapplicationofCalendulaorCalendulaproducts.1SensitizationtoCalendulaandallergiccontactreactionshavebeenreported.2,3AnaphylacticshockaftergarglingwithaninfusionofCalendulahasalsobeenreported.4

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Allergicreactionoccursrarelyfollowingtopicalapplication.1

Dosage Doseperday* Doseperweek*

1.5–4.5mlof1:2liquidextract

10–30mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Enlargedorinflamedlymphnodes,sebaceouscysts,gastricorduodenalulcer,acuteorchronicinflammatoryskinlesions5

•Amenorrhea,dysmenorrhea;nosebleed5

•Spasmodicconditions,fever,chronicsuppuration,capillaryenlargement,varicoseveins,chroniculcers,stubbornacne,splenicandhepaticenlargement6

•Topicallyforwounds,acne,chaffedskinininfants,crackednipples,eczema,legulcers,varicoseveins,hemorrhoids,analeczemaandinflammation,vaginaldischarges,lymphadenoma,inflamedskinlesions,conjunctivitis5,6

•VariousCalendulaextractsandCalendulaessentialoilhavedemonstratedantibacterial,antifungal,andtrichomonacidalactivityinvitro.7

•Calendulaextractenhancedtheproliferationoflymphocytesinvitro.8PolysaccharidesfromCalendulastimulatedphagocytosisofhumangranulocytesinvitro.9Thisfindingmayberelevanttotopicalapplication.

•Calendulaflavonoidsinhibitedtheactivityoflipoxygenaseinvitro.10CalendulaextractsuppressedtheinflammatoryprocessandleukocyteinfiltrationcausedbycarrageenanandprostaglandinE1(routeunknown).11OraldoseofaqueousethanolicextractofCalendula

PharmacologicResearch

producedantiinflammatoryactivityincarrageenan-inducedratpawedema.Theactivitywasmuchmilderthanthatwithindomethacin.12

•Usingthecrotonoildermatitismouseearmodel,boththetotalextractofCalendulaandtheextractobtainedaftersupercriticalcarbondioxideextraction(whichcontainsthelipophilicphytochemicals)demonstratedantiinflammatoryactivityaftertopicalapplication.Fractionationandtestingrevealedthatthetriterpenealcoholscausedtheantiinflammatoryactivity,withthecarotenoidsandsterolsalmostinactive.13Themostactivetopicalantiinflammatoryconstituentisthetriterpenoidcompoundfaradiolmonoester.14

•Calendulaextracthasdemonstratedangiogenicactivity(formationofnewbloodvessels,suchaswithinawound)inaninvitroassay.Calendula-treatedtissuewaspositiveforhyaluronan,atissueglycanassociatedwithneovascularization,unlikethecontroltissue,whichlackedthepresenceofhyaluronan.15ThisfindingispossiblyrelevanttotopicaluseofCalendula.

•TopicalapplicationofanointmentcontainingCalendulafractionsandallantoinstimulatedphysiologicalregenerationandepithelializationinexperimentallyinducedwounds.16ACalendulaointmentimprovedwoundhealinginexperimentallyinducedwounds.17Calendulafacilitatedthecollagenmaturationphaseofwoundhealingandinfluencedepithelialcellproliferationandmigration.18TopicalapplicationofaCalendulaglycetracthadavasoprotectiveactivityonnormalanimalskinbydecreasingcapillaryactivity.19

•AntiulceractivitywasdemonstratedinthreeexperimentalmodelsafteradministratinganisolatedsaponinfromCalendula.Antiinflammatoryandsedativeactivitieswerealsoobserved.20,21FractionsisolatedfromCalendulaalsoshowedactivity(routeunknown).22

•Calendulademonstratedantipyreticandanalgesicactivitiesinexperimentalmodels(routeunknown).23

•ThesaponinfractionofCalendulanormalizedexperimentallyinducedhyperlipidemiaafteroraladministrationovera12-weekperiod7butwaswithouteffectinnormolipemia.24

•OraladministrationofCalendulaextractexhibitedantitumoractivityinexperimentallyinducedcarcinoma.25

ClinicalStudies

•AnherbalpreparationcontainingCalendula,dandelion,St.John’swort,lemonbalm,andfennelreducedintestinalpaininanuncontrolledtrialinpatientswithchroniccolitis.Defecationwasnormalizedinthesepatientswithdiarrheasyndrome.26

•Calendulaextractacceleratedthehealingtimeofanartificiallyinducedskinabrasioninvolunteers(mostlikelybytopicalapplication).27AnevaluationofaerosolformulationsdesignedtoprovideaprotectivefilmoverwoundsinhumanvolunteersfoundthatadditionofCalendulatincturewassatisfactoryatcontrollingbleeding.28

•Inasmall,uncontrolledtrial,Calendulawassuccessfulintreatingperiodontalinflammation.29

•Calendulaointmenthasbeenpositivelyusedinuncontrolledtrialsfortreatingbedsores,venouscirculatoryproblems,andskinconditionssuchaslegulcersandthrombophlebitis.7Calendulademonstratedbenefitasanadjuvanttherapyforrenderingscartissuemoresuppleinpatientswithcleftlipandpalatewhowereundergoingdermatography.30

•Calendulagelappliedfor13to14daysprovidedgoodresultsforthehealingofburnsandscaldsin30patients.31Theeffectsofthreeointmentsonmanagingburnswere

investigatedinarandomized,controlled,multicenterclinicalstudyinvolving156patients.Calendulaandtheproteolyticointmentshowedsimilarefficacy,bothsuperiortoVaseline.However,theCalendulaointmentwasbettertoleratedthantheproteolyticointment.32

•ImprovedoutcomesandfasterhealingofulcerationwereobtainedwhenacyclovirtreatmentwascombinedwithanherbalformulacontainingCalendula,burdock,andGeraniumrobertianuminpatientswithherpetickeratitis(mostlikelybytopicalapplication).33

•InGermany,theCommissionEsupportsusingCalendulatotreatinflammationoftheoralandpharyngealmucosainternallyandtopically.Externally,Calendulaisrecommendedforpoorlyhealingwoundsandlegulcers.34

•ESCOPrecommendsCalendulafortreatinginflammationsoftheskinandmucosaandasanaidtowoundhealing.1

REFERENCES

ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy(ESCOP).ESCOPmonographs:Calendulaeflos.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.WrangsjoK,RosAM,WahlbergJE.ContactDermatitis.1990;22(3):148-154.HausenBM,OestmannG.DermBerufUmwelt.1988;36(4):117-124.GoldmanII.KlinMed.1974;52(4):142-143.

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983.IsaacI.DieRingelblume:Botanik,Chemie,Pharmakologie,Toxikologie,PharmazieundtherapeutischeVerwendung;Handbuchfürärzte,apothekerundanderenaturwissenschaftler.Stuttgart:WissenschaftlicheVerlagsgesellschaft,1992.AmirghofranZ,AzadbakhtM,KarimiMH.JEthnopharmacol.2000;72(1-2):167-172.VarljenJ,LiptakA,WagnerH.Phytochem.1989;28(9):2379-2383.

10BezakovaL,etal.Pharmazie.1996;51:126-127.11ShipochlievT,DimitrovA,AleksandrovaE.VetMedNauki.1981;18(6):87-94.

12MascoloN,etal.PhytotherRes.1987;1:28-31.13DellaLoggiaR.ZPhytother.2000;21:149-150.14DellaLoggiaR,etal.PlantaMed.1994;60(6):516-520.15PatrickKFM,etal.Phytomed.1996;3(1):11-18.16Klouchek-PopovaE,etal.ActaPhysiolPharmacolBulg.1982;8(4):63-67.

17AnsariMA,etal.IndianVetJ.1997;74(7):594-597.

18RaoSG,etal.Fitoterapia.1991;62(6):508-510.19RussoM.RivItalEPPOS.1972;54:730.20YatsunoAI,BelovaLF,LipkinaGS.PharmacolToxicolSSSR.1978;41:193-198.

21IatsynoAI,etal.FarmakolToksikol.1978;41(5):556-560.22ManolovP,etal.ProblVatrMed.1983;11:70-74.23AhmadS,etal.PakJSciIndRes.2000;43(1):50-54.24WojcickiJ,SamochowiecL.HerbaPol.1980;26:233-237.25Boucaud-MaitreY,AlgernonO,RaynaudJ.Pharmazie.1988;43:220-221.

26ChakurskiI,etal.VutrBoles.1981;20(6):51-54.27FleischnerAM.CosmetToiletries.1985;100:54-55.28GargS,SharmaSN.Pharmazie.1992;47(12):924-926.29GasiorowskaI,etal.CzasStomatol.1983;36(4):307-311.30vanderVeldenEM,vanderDussenMFN.JOralMaxillofacSurg.1995;53(1):9-12.

31BaranovAP.DtschApothZtg.1999;139:61-66.32LievreM,etal.ClinTrialsMeta-Analys.1992;28:9-12.33CorinaP,etal.Oftalmologia.1999;46(1):55-57.34BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

CALIFORNIAPOPPY

OtherCommonName: Californianpoppy

BotanicalNames: Eschscholziacalifornica,Eschscholtziacalifornica#

Family: PapaveraceaePlantPartUsed: Aerialparts

# Alternativename.

PRESCRIBINGINFORMATION

Actions Anxiolytic,mildsedative,analgesic,hypnotic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingCaliforniapoppyinformulationsinthecontextof:

•Painfulconditionsinvolvingtheirritationorstimulationofpainfibers(similartowhenmorphineorcodeinemightbeused)(5)

•Disturbedsleep,incombinationwithCorydaliscava(3)

•Disturbedsleep(5)

•Anxietyandconditionsinwhichanxietyplaysamajorrole(6,7)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Noneexpectediftakenwithintherecommendeddoserange.WhetherCaliforniapoppywillinterferewithstandarddrugtestsforopiatealkaloidsisunclear.However,thisinterferenceisunlikely.

Dosage Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtraditionalWesternherbalmedicineandtheauthor’seducationandexperience.1

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Reducingpainandproducingcalmsleepwithoutthedangersofopiates2

•Enhancingsleep,particularlyforchildrenwithwhoopingcough3

•Relievingpainofcolicinchildren4

•Migraine,nervousbowel,neuralgia,anxiety,depression,stress1

•Topicallyfortreatingsoresandulcers4

NativeAmericansandnativeHispanicsusedtheaerialparts,leaves,orflowersofCaliforniapoppyforsedativeandanalgesicactivity,topromotesleep,andforreliefoftoothache,particularlyinchildren.4

CaliforniapoppywasofinteresttomedicalpractitionersoftheUnitedStatesinthelatenineteenthcentury,withtheliquidextractenteredintothePark-Daviscatalogin1890.Californiapoppywasreferredtoin1892asan“excellentsoporific(sleepinducing)andanalgesic,aboveallharmless”andin1893,reportingthat,“…theeffectproducedbyEschscholtziacalifornicauponpatientsisthesameasthatofmorphine,withouttheinconveniencesofthelatterdrug.”5

TheaerialpartsofCaliforniapoppycontainisoquinolinealkaloids(mainlyeschscholtzineandcalifornidine,withsmalleramountsofsanguinarineandchelerythrine)6and

PharmacologicResearch

flavonolglycosides.7

•Californiapoppyextractinhibitstheenzymaticdegradationofcatecholaminesandthesynthesisofepinephrine(adrenaline)invitro.PreservinghighlevelsofcatecholaminesmayexplainthesedativeandantidepressantactivityofCaliforniapoppy.8Anextractformulacontaining80%Californiapoppyand20%Corydaliscavahasdemonstratedtheabilitytointeractwithopiatereceptorsinvitro,9whichindicatespotentialanalgesicactivity.

•AlkaloidsfromCaliforniapoppyenhancedgamma-aminobutyricacid(GABA)bindingtoratbrainsynapticmembranereceptors.Thisfindingmayindicateabenzodiazepine-likeactivity.10ConstituentsofCaliforniapoppyexhibiteddose-dependentbindingtobenzodiazepinereceptorsanddisplacedthebenzodiazepineflurazepamfromthereceptor.11

•AsedativeeffectwasobservedforCaliforniapoppyextractafterinjectioninexperimentalmodelsintermsofbothbehavioraleffectsandpromotionofsleep.12,13Atlowerdoses,ananxiolyticeffectwasobserved.12Sedativeeffectshavealsobeenobservedaftertreatmentwithhighoraldoses.14ThesedativeandanxiolyticeffectsofCaliforniapoppyaremostlikelylinkedtobenzodiazepine-receptoractivationbecausetheywereantagonizedbythebenzodiazepine-receptorantagonistflumazenilinvivo(byinjection).15

•Isoquinolinealkaloidsareknowntopossessinvivosedativeactivity.9

•Musclerelaxantandanalgesicactivitieshavebeenreportedinvivo,11althoughnomusclerelaxantactivitywasobservedinvivoinalaterstudy.Dose-dependentperipheralanalgesicactivitywasdemonstratedforCaliforniapoppyinvivo(byinjection),butcentral

analgesicactivitywasnotrecorded.15

•Californiapoppytinctureinhibitedexperimentallyinducedcontractionsofisolatedsmoothmuscle.13

•TwoalkaloidsisolatedfromCaliforniapoppy,chelerythrineandsanguinarine,exhibitedaffinityforvasopressinreceptorsanddemonstratedcompetitiveinhibitionofvasopressinbindinginvitro.16Substancesthathavethisactivityhavebeenusedpharmacologiclyasrenalagents,vasoconstrictingagents,andhemostatics.

ClinicalStudies

•SingleadministrationofaCaliforniapoppyextract(equivalentto6.7gofherb)tovolunteersresultedinaquantitativeelectroencephalographic(EEG)recordingthatwasdistinguishablefromthatobtainedfromplacebo.Resultsfromtheself-ratingassessmentofalertness,however,didnotdifferfromplacebo.17Anacutesedativeeffectwasnotdemonstrated,butanalysisafterongoingadministrationmaydemonstrateasedativeeffect.

•Intwocontrolledclinicaltrials,thecombinationofCaliforniapoppyandCorydaliscavanormalizeddisturbedsleepingbehaviorwithoutevidenceofcarry-overeffectsoraddiction.ThispreparationconsistedofalcoholicextractsofCaliforniapoppy(standardizedforprotopine)andCorydalis(standardizedforbulbocapnine)intheratioof4:1.Thedosagewasnotdefined.14

REFERENCES

BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,England:GracePublishers,1995.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

CheneyRH.QuartJCrudeDrugs.1963;3:413-416.BrinkerFJ.Eclecticdispensatoryofbotanicaltherapeutics,vol2.EclecticMedicalPublications,Sandy,Oregon,1995.DavisGS.Thepharmacologyofthenewermateriamedica.Davis,Detroit,1892.BenderGA.PharmHist.1980;22(2):49-59.TomeF,ColomboML,CaldiroliL.PhytochemAnal.1999;10:264-267.BeckMA,HaberleinH.Phytochem.1999;50(2):329-332.KleberE,etal.ArzneimForsch.1995;45(2):127-131.ReimeierC,etal.ArzneimForsch.1995;45(2):132-136.

10KardosJ,BlaskoG,SimonyiM.ArzneimForsch.1986;36(6):939-940.

11RollandA.Doctoralthesis,UniversityofMetz,France,1988.CitedinSchaferHLetal.ArzneimForsch.1995;45(2):124-126.

12RollandA,etal.PlantaMed.1991;57(3):212-216.13VincieriFF,etal.PharmacolResCommun.1988;20(suppl5):41-44.

14SchaferHL,etal.ArzneimForsch.1995;45(2):124-126.15RollandA,etal.PhytotherRes.2001;15:377-381.16GrangerI,etal.PlantaMed.1992;58(1):35-38.17SchulzH,JobertM,HubnerWD.Phytomed.1998;5(6):449-458.

CASCARA

OtherCommonName: Cascarasagrada

BotanicalNames: Rhamnuspurshiana,Rhamnuspurshianus,#Frangulapurshiana#

Family: RhamnaceaePlantPartUsed: Bark

# Alternativename.

PRESCRIBINGINFORMATION

Actions Laxative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcascarainformulationsinthecontextof:

•Constipation,*flatulence,abdominalfullness,incombinationwithboldo(3)

•Dyspepsia,*stimulatinggastricsecretion,lossofappetite,asthenia,postprandialbloating,coatedtongue,itchingofskin,incombinationwithgentian,rhubarb,andboldo(3)

•Headacheresultingfromconstipationorintestinalweakness(5)

•Conditionsotherthanconstipationinwhicheasydefecationwithasoftstoolisdesirable,suchaswithhemorrhoidsandanalfissure(5)

•Gastrointestinalconditionswithhepaticinvolvement(5)

Contraindications

Intestinalobstruction,1intestinalinflammation,suchasCrohn’sdisease,ulcerativecolitis,andappendicitis;abdominalpainofunknownorigin.Childrenunder12yearsofageshouldnotbeprescribedcascara.2

Althoughshort-termuseofanthraquinoneglycoside–containinglaxativesisgenerallyregardedassafe,long-termuseisnotrecommended.3Stimulatinglaxativesshouldnotbeusedoveranextendedperiod(morethan2weeks)withoutmedicaladvice.Using

WarningsandPrecautions

stimulatinglaxativeslongerthanisrecommendedcanleadtointestinalsluggishness,althoughconcurrentintakeoffiberinsufficientquantitiesofwatercancounteractthiscondition.Cascarashouldbeusedonlyifnobenefitcanbeobtainedthroughchangeofdietoruseofbulk-formingproducts.2Aswithalllaxatives,cascarashouldnotbeprescribedwhenanyundiagnosedacuteorpersistentabdominalsymptomsarepresent.4Freshorinadequatelypreparedcascarabarkshouldnotbeusedbecauseseverevomitingandintestinalspasmcanresult.2

Interactions

Anthraquinoneglycoside–containinglaxativesmaypotentiallydecreasethetransittimeofconcomitantlyadministeredoraldrugsandtherebydecreasetheirabsorption.5

Excessiveuseofcascaracancausedisturbanceoffluidandelectrolytebalance(especiallypotassiumdeficiency).Potassiumdeficiencypotentiatestheactionofcardiacglycosides5andinterfereswithantiarrhythmicdrugs.2Simultaneousapplicationofthiazidediuretics,corticosteroids,orlicoricewillincreasepotassiumloss.2,4Speculationssuggestthatabuseoflaxativessuchassenna(Cassiaspp.)maypotentiatethedevelopmentofanalgesicnephropathy(resultingfromdehydration).5

UseinPregnancyandLactation

AccordingtotheBritishHerbalCompendium,cascaraiscontraindicatedinpregnancyandlactation.1However,thiscautionseemsexcessiveprovidedthatthedosagerecommendationshereareobserved.Dosesthatcauseanexcessivelyloosestoolshouldnotbeusedduringpregnancy.

Cramplikediscomfortofthegastrointestinaltractmayoccuratnormaltherapeuticdoses.Thesecasesrequireadosereduction.2Diarrhearesultingfromabuseofcascarahasbeenreported.6

SideEffects

Long-termuseorabusemaycausedisturbancesofelectrolytebalance,includingpotassiumdeficiency,whichcanleadtodisordersofheartfunctionandmuscularweakness.Aharmlesspigmentationoftheintestinalmucosa(pseudomelanosiscoli)mayoccurwithchronicuseandusuallyreversesafterdiscontinuingcascara.2Chronicintakeofanthraquinonelaxativeshasbeenassociatedwithanincreasedriskofcolorectalcancer,3althoughthisconnectionhasbeendebated.7,8

Acaseofcascara-inducedintrahepaticcholestasiscausingportalhyper-tensionhasbeenreported.Thedosagewasonecapsulethreetimesperdayfor3days.Eachcapsulecontained425mgofagedcascarabark,standardizedto5%cascarosides(1.3gbarkcontaining64mgcascaro-sidesperday).9

Dosage Doseperday** Doseperweek**

3–8mlof1:2liquidextract

20–55mlof1:2liquidextract

* Cascara has also been used in traditional herbal medicine for treating constipation anddyspepsia and is recommended by both the Commission E and ESCOP for the short-termtreatmentofconstipation.(4,5)

** ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934,theBritishPharmacopoeia1932,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Constipation,10particularlywhenhabitualorchronicinnatureandwhenatonicfortheintestinesisrequired11

•Dyspepticconditionsrelatedtoconstipationandcausedbyintestinalweakness;headacheresultingfromsimilarcauses11

•Lossoftoneintherectum11

•Conditionsinwhichasoftstoolisdesirable,suchasanalfissureorhemorrhoids1

•Rheumatism;gastric,duodenal,orbiliarycatarrhwithjaundice;chronicdiseasesoftheliver11,12

NativeAmericansusedcascaraasacathartic.NativeSouthAmericansalsousedcascara.13

Keyconstituentsofcascarabarkincludehydroxyanthracenederivativesinacomplexmixture(approximately8%)consistingmainlyofanthroneglycosides,especiallycascarosides.Otherconstituentsincludealoins,deoxyaloins,andO-glycosidesoftheanthraquinonesaloe-emodin,emodin,andchrysophanol.1,14

•Thehydroxyanthracenederivativesarecarriedunabsorbedtothelargebowel,wheremetabolismviaglycosidasesfromintestinalfloraresultsintheformationoftheactiveaglycones.3,15(Becauseofthismetabolism,defecationoccursseveralhoursafteringestion.)These

PharmacologicResearch

aglyconesexerttheirlaxativeeffectbylocalactivityintheintestinebythefollowingmechanisms:modificationofintestinalmotility(bystimulatingintestinalmuscle)andaccumulationoffluid.8Theincreaseinmotilityisafasterresponsethanistheeffectresultingfromtheincreaseinfecalwater.Anumberofchemicalmediatorsareimplicatedinproducingtheseeffects,includingreleaseofprostaglandins,16inhibitionofintestinaltoneandsegmentation,8andproductionofhighconcentrationsofnitricoxidesynthase(whichevokesnetintestinalfluidsecretion).17

•Afterabsorption,theanthraquinonesaretransformedmainlytotheircorrespondingglucuronideandsulfatederivatives,whichfinallyappearinurineandbile.Therapywithanthraquinoneglycosidessuchasthosefoundincascaraandsennaisregardedaspreferabletotherapywithfreeanthraquinonesbecausetheglycosidesarelessreadilyabsorbedfromthegastrointestinaltractandareactiveatmuchlowerdoses.15Anthraquinoneglycosideshencehavelowerpotentialtoxicity.

•TheadditionofapreparationcontainingCurcumaaromaticarhizome,wholerootsofCurcumaamara,andcascaratoahigh-cholesteroldietwasfoundtolowerbothserumandlivercholesterolinrats.18

•Apreparationcontainingcascara,gentian,rhubarb,andboldowastestedin24healthyvolunteersandin80patientswithmildgastroin-testinaldisturbances.Theherbalpreparationinducedasignificantincreaseinsalivarysecretionfrom1to30minutesafteroraladministration,similartotheactivecontrol(citricacid)andunlikeplaceboorplaceboplusalcohol.Inthisdouble-blindstudy,theherbalpreparationwassignificantlybetterthanplaceboforthefollowingsymptoms:asthenia,lossofappetite,coatedtongue,postprandialbloating,difficultdigestion,constipation,flatulence,abdominalfullness,

ClinicalStudies

anditchingofskin.Thetestpreparationwasmoreefficaciousthanthetwopairsofitscomponents(cascaraandboldo;gentianandrhubarb).19Thefollowingherbequivalentswereprobablyadministeredforthepairedpreparations:cascara(200mg/day)andboldo(100mg/day);gentian(40mg/day)andrhubarb(200mg/day).

•Asurveyof3257elderlypatientsadmittedto58hospitalsinItalyin1991recordedthatplantanthranoidlaxativeswerethesecondmostfrequentlyprescribedlaxative(1.9%inhospital,3.3%prehospital).20

•InGermany,theCommissionEsupportsusingcascaratotreatconstipation.2

•ESCOPrecommendscascaraforshort-termuseincasesofoccasionalconstipation.4

•CascarahasremainedofficialintheUSPsincethefirstentryinearly1890andiscurrentlyofficialintheUSP24-NF19.

REFERENCES

BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.vanGorkomBA,etal.AlimentPharmacolTher.1999;13(4):443-452.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Rhamni

purshianicortex.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,June1997.deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1993.CummingsJH,etal.BrMedJ.1974;1:537-541.NuskoG,etal.Gut.2000;46(5):651-655.MascoloN,etal.PhytotherRes.1998;12(supp1):S143-S145.NadirA,ReddyD,VanThielDH.AmJGastroenterol.2000;95(12):3634-3637.

10BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

11FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

12EllingwoodF,LloydJU.Americanmateriamedicam,therapeuticsandpharmacognosy,ed11.Portland:EclecticMedicalPublications,1983.

13VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

14WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.

15deWitteP,LemliL.Hepatogastroenterol.1990;37(6):601-605.

16GeboesK.VerhKAcadGeneeskdBelg.1995;57(1):51-74.

17IzzoAA,MascoloN,CapassoF.DigDisSci.1998;43(8):1605-1620.

18BeynenAC.Artery.1987;14(4):190-197.19BorgiaM,etal.CurrTherRes.1981;29(3):525-536.20PahorM,etal.Aging(Milano).1995;7(2):128-135.

CAT’SCLAW

OtherCommonName: UñadegatoBotanicalName: UncariatomentosaFamily: RubiaceaePlantPartUsed: Stembark

PRESCRIBINGINFORMATION

Actions Immuneenhancing,antiinflammatory,antioxidant

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcat’sclawinformulationsinthecontextof:

•Poorimmunity,tendencytoinfections(7)

•Inflammatoryconditionssuchasarthritis,gastritis,cystitis(6)

•Convalescence,debility(6)

•Adjuvanttherapyforcancer(3,6)

•HIVinfection,AIDS(4)Ascat’sclawhasbeentraditionallyusedasatonic(6)andmayalsobeusedtotreatotherhealthissuesrequiringthisaction,includingchronicfatiguesyndrome.

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

Cat’sclawshouldbeusedwithcautioninpregnancyandlactation.(TherootofUncariatomentosahasbeenusedtraditionallyasacontraceptive;pharmacologicresultshavedemonstratedanantifertilityeffectinoneanimalmodel.1OraluseofthebarkdecoctionistraditionallyprescribedinBoliviaforirregularmenstruation.2)

SideEffects

Diarrheaandindigestionhaveoccurredinseveralpatientstakingcat’sclaw.Inonecase,ahigh(undefined)dosehadbeenconsumed.3

Acuterenalfailurecausedby“cat’sclaw”wasreportedina35-year-oldPeruvianfemalewithsystemiclupuserythematosus(SLE).Thecontentsofthecapsuleswerenotanalyzed,andthedurationoftreatmentwasnotstated.Onemonthafterdiscontinuingtheherbalpreparation,herconditionhadimproved.Thepatientinalllikelihoodexperiencedanidiosyncraticadversereactiontotheherbalpreparation.4

Dosage Doseperday* Doseperweek*

4.5–11.0mlof1:2liquidextract

30–75mlof1:2liquidextract

Itisrecommendedthatonlythepentacyclicoxindolealkaloid-predominanttypeofcat’sclawbeusedintherapy.

* Thisdoserangeisextrapolatedfromtraditionaluseofdecoctionofthebark.3

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalPeruvianmedicinalusesincludedegenerativeprocesses(e.g.,cancer),inflammatoryconditions(e.g.,arthritis,gastritis,inflammationofthegenitourinarytractandskin),gastriculcers,diabetes,asthma,convalescence,anddebility.3,5

Cat’sclawisalsoregardedintraditionalPeruvianmedicineasatonicorrestorative.3

Cat’sclawisoneofthepowerfulplantsthattheAsháninkapriestsexclusivelyusedtoeliminatedisturbanceinthecommunicationbetweenbodyandspirit.6

PharmacologicResearch

Cat’sclawstembarkcontainsanumberofoxindolealkaloids.7TwodifferentchemotypesofU.tomentosathathavebeenidentifiedarelikelytohavedistinctlydifferentpharmacologicproperties.Onechemotypecontainsonly,orpredominantly,pentacyclicoxindolealkaloids(POA);theothercontainsPOAandsignificantquantitiesoftetracyclicoxindolealkaloids(TOA).Intriguingly,indigenouspriestsaresaidtobeabletoidentifythecorrectchemotypeandharvestexclusivelythechemotypecontainingPOA,eventhoughthetwochemotypesarebotanicallyidentical.6,7

•Cat’sclawextracthasexhibitedantioxidantactivityinvitro8andantiinflammatoryactivityinexperimentalmodelsafteroraladministration.9-11Resultsofaninvitrostudysuggestedthattheantiinflammatoryactionmaybearesultofimmunomodulationviasuppressionoftumornecrosisfactor-alphasynthesis.12

•Cat’sclawextracthassignificantlystimulatedinterleukin-1andinterleukin-6productioninvitro.13Cat’sclawextractsandPOAstimulatedphagocytosisinvitroandbyinjection.14-16POAwerefoundtoinduceendothelialcellstoreleaseafactorthatinfluencestheproliferationoflymphocytes.6,17TheTOAantagonizedtheeffectsofthePOA.6ThesestudiesindicateimmuneenhancementforthePOAchemotypes.

•POAdemonstratedantitumoractivityinvitro.18

•Cat’sclawwasshowntoexhibitantiestrogeniceffectsinvitro.19

ClinicalStudies

•Adouble-blind,randomizedstudyassessedtheeffectsofafreezedriedaqueousextractofU.tomentosaonthemutagenicactivityofurinecollectedfrom12smokersand12nonsmokers.Aprogressivedecreaseinmutagenicactivityinthesmokers’urinewasobservedwithincreasingdose.20

•Inanuncontrolledtrial,13patientswithHIVtook20mg/dayofanaqueoushydrochloricacidextractofU.tomentosaroot(containing12mgtotalPOA/g)for2.2to5.0months.Althoughthetotalwhitebloodcellcountremainedunchangedwithinthegroup,resultsindicatedthatlowvalueswereraisedandhighvalueswerelowered.Thelymphocytecountincreasedsignificantlytoanaverageofapproximately35%.However,nosignificantchangesinT4/T8cellratioswereobserved.6

•StandardizedU.tomentosarootextractwasusedinalong-term,openstudyinvolving44patientswithAIDS.1Thedailydosevariedfrom20to60mgperday(thedriedherbequivalentwouldbemuchhigher),withsomepatientsalsotakingazidothymidine(AZT).PatientswhohadCD4lymphocytecountsof200to500×106/Ldemonstratedthebestresultsforimmunologicparameters:•CD4cellsincreasedsignificantlyforthefirstyearof

therapy,andtheincreasepersistedforthefirst3years.Patientscontinuedtoshowstablecountsforaslongas4and5yearsafterbeginningtreatment.•p24antigenlevelsdecreased.•Blymphocytecountsincreased.

REFERENCES

JonesK.Cat’sclaw:healingvineofPeru.Seattle:SylvanPress,1995.BourdyG,etal.JEthnopharmacol.2000;70(2):87.ObregónVilches,LidaE.Cat’sclaw:Uncariagenus.Botanical,chemical,andpharmacologicalstudiesofUncariatomentosaandUncariaguianensis.Lima:InstitutodeFitoterapiaAmericano,1995.HilepoJN,BellucciAG,MosseyRT.Nephron.1997;77(3):361.MaxwellN.Witchdoctor’sapprentice,ed3.NewYork:CitadelPress,1990.KeplingerK,etal.JEthnopharmacol.1999;64:23.LausG,BrossnerD,KeplingerK.Phytochemistry.1997;45(4):855.DesmarchelierC,etal.PhytotherRes.1997;11(3):254.SandovalM,etal.AilmentPharmacolTher.1998;12(12):1279-1289.

10MillerMJS,etal.PeditrRes.1999;45:114A.11AquinoR,etal.JNatProd.1991;54(2):453-459.

12SandovalM,etal.FreeRadicBiolMed.2000;29(1):71-78.13LeMaireI,etal.JEthnopharmacol.1999;64(2):109-115.14WagnerH,etal.PlantaMed.1985;51(2):139.15WagnerH,KreutzkampB,JurcicK.PlantaMed.1985;51(5):419.

16UnitedStatesPatent5302611,April12,1994.17WurmM,etal.PlantaMed.1998;64(8):701-704.18StuppnerH,etal.PlantaMed.1993;59(Suppl):A583.19SalazarEL,JaymeV.ProcWestPharmacolSoc.1998;41:123-124.

20ReinhardKH.JAlternComplementMed.1999;5(2):143-151.

CELERYSEED

BotanicalName: ApiumgraveolensFamily: UmbelliferaePlantPartUsed: Fruit(sometimesreferredtoasseed)

PRESCRIBINGINFORMATION

Actions Diuretic,antiinflammatory,antirheumatic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingceleryseedinformulationsinthecontextof:

•Reliefofosteoarthritisandrheumatism(4,5)

•Preventionofgout(5)

Contraindications

Noevidencehasbeenfoundthatceleryseediscontraindicatedinpregnancy.Thisattributioncomesfromthemistakenassumptionthattheessentialoilcontainssignificantlevelsofapiol.

WarningsandPrecautions

Cautionisadvisedinkidneydisorders,inparticularinflammationofthekidneys,becausetheessentialoilmayincreasetheinflammationbycausingepithelialirritation.1,2

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsAllergicreactionispossiblebutrare.1Thefuranocoumarinsincombinationwithultravioletlightmaycausephotodermatitis.2

Dosage Doseperday* Doseperweek*

4.5–8.5mlof1:2liquidextract

30–60mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Rheumatism,arthritis,gout3

•Inflammationoftheurinarytract,retentionofurine,dropsy3,4

•Restlessness,nervousdisorders,insomnia5

TheEclecticsconsideredceleryseedasanervinetonic.4

Apiumgraveolensseedscontainanessentialoilconsistingofterpenesandphthalides(especially3-n-butylphthalide).1

•OralceleryseedoilsignificantlyelevatedglutathioneS-transferaseactivityinvivocomparedwithcontrols.6,7Twogroupsofcomponentswithinceleryseedoil(limonene-typemonoterpenesandbutylphthalides)appearedtoberesponsibleforthisactivity.Furthertestingshowedthatthephthalidecompoundsweremoreactivethanthelimonene-typemonoterpenes.8

•Celeryseedoiladministeredorallyincreasedlivertissueregeneration.9Methanolicextractofceleryseeddemonstratedsignificanthepatoprotectiveactivityafteroraladministrationinacetominophen(paracetamol)-inducedandthioacetamide-inducedhepatotoxicity.10

•Comparedwithcontrols,aqueousceleryextractdemonstratedasignificantreductioninserumtotalcholesterol,LDLcholesterol,andtriglyceridesinamodelofhyperlipidemia.11

PharmacologicResearch

•Ethanolicextractofceleryseeddemonstratedanalgesicactivityintwoexperimentalmodels(byoralandinjectedroutes).Antiinflammatoryactivitywasalsodemonstratedinchronicinflammation(whengivenorally).12

•Theessentialoilhasshowntranquilizing13andanticonvulsanteffectsonthecentralnervoussystem.13-15Phthalidesarereportedtopossessantispasmodic,sedative,anddiureticactions.16

•Inexperimentallyinducedtumorigenesis,essentialoilofceleryseedmarkedlyreducedtumorincidenceandtumormultiplicity.7

•3-n-butylphthalideinhibitedplateletaggregationinvitro17anddemonstratedantispasmodicactivityonisolatedtissue.18

•3-n-butylphthalidedemonstratedhypotensiveactivityafterintraperitonealinjection.19Oraladministrationof3-n-butylphthalideresultedinaselectiveantianginaleffect,withoutchangingbloodpressureorheartrate.18Oraladministrationof3-n-butylphthalide(80to240mg/kg)preventedexperimentallyinducedbrainedemainvivo.20

ClinicalStudies

Inanuncontrolled,preclinicaltrialinAustralia,15patientswithlong-runningrheumaticpainreceivedceleryseedextractover12weeks.Theparametersmeasuredwereusualpain,currentpain,andusualandcurrentbodyareasexperiencingpain.Patientsreportedsignificantreductioninpainintensityforusualpainafterweeks3and6andforcurrentpainafterweeks3and12.Thenumberofjointsatwhichpainwasexperiencedwassignificantlydecreasedovereach3-weekperiod.21

REFERENCES

BritishHerbalMedicineAssociation.Britishherbal

compendium.Bournemouth:BHMA,1992.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BanerjeeS,etal.NutrCancer.1994;21(3):263-269.ZhengGQ,etal.NutrCancer.1993;19(1):77-86.RenS,LienEJ.ProgDrugRes.1997;48:147-171.GershebinLL.FoodCosmetToxicol.1977;15(3):173-181.

10SinghA,HandaSS.JEthnopharmacol.1995;49(3):119-126.11TsiD,DasNP,TanKH.PlantaMed.1995;61(1):18-21.12AttaAH,AlkofahiA.JEthnopharmacol.1998;60:117-124.13KohliRP,etal.IndianJMedRes.1967;55(10):1099-1102.14YuS,YouS.YaoHsuehHsuehPao.1984;19(8):566-570.15YangJ,ChenY.YaoxueTongbao.1984;19:670-671.16GijbelsMJM,etal.RivItalEPPOS.1979;61:335-341.17TengCM,etal.BiochimBiophysActa.1987;924(3):375-382.

18KoWC,etal.PlantaMed.1998;64(3):229-232.19TsiD,TanBKH.PhytotherRes.1997;11(8):576-582.20DengW,FengY.ChinMedSciJ.1997;12(2):102.21AustralianPatent99469910-A,January1995.

CHAMOMILE

OtherCommonName: Germanchamomile

BotanicalNames: Matricariarecutita,Matricariachamomilla,#Chamomillarecutita#

Family: CompositaePlantPartUsed: Flower

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antiinflammatory,spasmolytic,carminative,mildsedative,antiulcer,vulnerary,diaphoretic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingchamomileinformulationsinthecontextof:

•Gastrointestinalspasm,inflammatorydiseasesofthegastrointestinaltract,irritablebowelsyndrome,flatulence,bloating(4,5)

•Acute,uncomplicateddiarrhea,incombinationwithpectin*(2)

•Infantilecolic,**incombinationwithlemonbalm,vervain,licorice,andfennel(3)

•Anxiety(4)

•Travelsickness,nervousdiarrhea(5)

•Dysmenorrhea,amenorrhea(5)

•Restlessness,anxiety(5)

•Teethingproblemsinchildren(5)

•Topicaltreatmentforeczemaandwoundhealing(2,5)

•Topicaltreatmentforlegulcers(3,5)

•Topicaltreatmentforskininflammation(3,5)

•Topicaltreatmentformucousmembraneinflammations,includingthoseoftheoralcavityandgums;anogenitainflammation(4,5)

•Topicaltreatmentforbacterialskindiseases(4)Contraindications Knownallergy.

WarningsandPrecautions

Despitereportsofskinreactionsanddermatitisfromtopicaluseofchamomile,thelikelihoodofchamomilepreparationscausingacontactallergyislow.However,peoplewithknownsensitivitytoothermembersoftheCompositaefamily(e.g.,ragweed,daisies,chrysanthemums)shouldavoidoralandtopicalapplicationofchamomileorchamomileproducts.

Interactions

Chamomiletea(comparedwithawatercontrol)reducedtheabsorptionofironby47%followingabreadmealinadultvolunteers.Theinhibitionwasdose-dependentandrelatedtoitspolyphenolcontent(phenolicacids,monomericflavonoids,andpolymerizedpolyphenols).Inhibitionofironabsorptionbyblackteawas79%to94%.1Thisfindingindicatesapotentialinteractionforconcomitantadministrationofchamomileduringironintake.Inanemiaandcasesinwhichironsupplementationisrequired,chamomileshouldnotbetakensimultaneouslywithmealsorironsupplements.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Contactdermatitisandskinreactionshavebeenreportedfromthetopicaluseofchamomilepreparations.Onecaseofsevereanaphylacticreactionafteringestingchamomileteahasbeenreported.Giventhewidespreadconsumptionofchamomileteaandthefewreportedcasesofanaphylaxis,thistypeofreactionisextremelyrare.Additionally,usingethanolicextractsdenaturestheproteinsandrendersthistypeofreactionunlikely.

Eyewashingwithchamomileteacaninduceallergicconjunctivitis;thepollencontainedintheseinfusionsappearstoberesponsiblefortheallergicreaction.Pollensandtheirproteinsareunlikelytobepresentoractiveinaqueousalcoholextractsofchamomile.

Dosage Doseperday*** Doseperweek***

3–6mlof1:2high-gradeliquidextract

20–40mlof1:2high-gradeliquidextract

High-gradeliquidextractsprovidingquantifiedlevelsofbisabololarerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan0.4mg/mlofbisabolol.

* Applemaybeaddedtothepatient’sdiettosupplypectin.

** Chamomilehasalsobeenusedintraditionalherbaltherapyfortreatingcolic.(5)

*** This dose range is extrapolated from theBritishHerbalCompendium 1992 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Flatulentornervousdyspepsia,travelsickness,nervousdiarrhea,nervousdisordersofthestomachandbowel,flatulentcolicwithdistention,catarrhalconditionsofthebowel;dysmenorrhea,amenorrhea2,3

•Restlessness,nervousirritabilityinchildren,teethingproblems,infantileconvulsions,rheumaticandneuralgicpain2,3

•Catarrhalconditionsofthenose,ears,andeyes;forearache,asadiaphoretic2,3

•Topicallyforinflammationsandirritationsoftheskinandmucosa,includinghemorrhoids,mastitis,leukorrhea,andlegulcers2-4

Pharmacologic

Activeconstituentsofchamomileflowersincludeanessentialoil(containingα-bisabololandchamazulene)andflavonoids.Chamomilepreparationsusedinresearchareoftenstandardizedforα-bisabololandchamazulenecontent.

•Invitrostudiesshowedchamomileextractstohaveantiinflammatoryandantioxidanteffects.Experimentalstudiesofbothoralandtopicalapplicationofchamomileextractalsodemonstratedthisantiinflammatoryaction.

•Experimentalmodelsshowedchamomileextracttohaveanantispasmodicactioninvitro.

Research •Injectionoftheflavonoidapigenindemonstratedclearantianxietyactivityandslightsedativeactivitywithoutmusclerelaxanteffects.

•Chamomileextractandα-bisabololdemonstratedantiulceractivityinexperimentalmodelsafteroraladministration.

•Chamomileextract,essentialoil,andisolatedconstituentshavedemonstratedantimicrobialactivityinvitro.

•Thewound-healingactivityofchamomileiscloselylinkedtoitsantiinflammatoryactivity.Chamomileextractanditsisolatedconstituentsdemonstratedwound-healingactivityinseveralexperimentalmodels.

•Oraladministrationofchamomileteaduringcardiaccatheterizationinducedadeepsleepin10of12patientstested,despitethepainandanxietyexperiencedfromthemedicalprocedure.Twochamomileteabagswereusedina6-oz(175-ml)cupofhotwater.Thepatientsdranktheteainlessthan10minutes.

•Acombinationofachamomileextractandpectinshowedsuperiorresultstoplacebointreatingacute,uncomplicateddiarrheainadouble-blind,randomizedtrial.Thepreparationcontained2.5%ofchamomileextractstandardizedto0.0035%chamazuleneand0.05%α-bisabololand3.2%pectin.

•Adouble-blindstudyonbabiesapproximately3weeksofagewithinfantilecolicinvestigatedtheeffectofaninstantherbteacontainingchamomile,lemonbalm,vervain,licorice,andfennel.After7days,theimprovementincolicscoreswassignificantlybetterintheherbalteagroup.Morebabiesinthetreatmentgrouphadtheircoliceliminated.Theteapreparationwasofferedwitheveryepisodeofcolic,upto150mlperdose,butnot

ClinicalStudies

morethanthreetimesperday.Theexactcompositionofthepreparationwasnotdefined.

•Uncontrolledtrialsdemonstratedthatastandardizedchamomilemouthwashwasbeneficialfortreatingchronicoralinflammations(exceptinthecaseofglossodynia)andoralmucositiscausedbyheadandneckirradiationandsystemicchemotherapy.Thechamomilerinseacceleratedtheresolutionofmucositis,andprophylacticusewasalsofavorable.However,chamomiledidnotdecreasetheincidenceofstomatitisinpatientsundergoingchemotherapy.Themouthwashcontained50mgofα-bisabololand150to300mgapigenin-7-glucosideper100gandwasappliedthreetimesdaily.

•Topicalapplicationofstandardizedchamomilepreparationshasshownbenefitintreatingeczema,varicoseeczema,andvaricoseulcersinuncontrolledtrials,surveys,andcontrolledtrials.Standardizedchamomilecreamshowedmildsuperiorityover0.5%hydrocortisonecreamandmarginalimprovementcomparedwithplaceboinmedium-degreeatopiceczema.Thistrialwasapartiallyblinded,randomizedtrialcarriedoutasahalf-sidecomparison(onesideofthebodycomparedwiththeother).5

•Standardizedchamomilecreamwascomparedwithsteroidalandnonsteroidaldermalpreparationsinthemaintenancetherapyofeczema.Chamomilecreamshowedsimilarefficacyto0.25%hydro-cortisoneandwassuperiortothenonsteroidalantiinflammatoryagent(5%bufexamac)andaglucocorticoidpreparation(0.75%fluocortinbutylester).

•Standardizedchamomileextractdemonstratedastatisticallysignificantbenefitonwoundhealingfollowingtattoodermabrasioninarandomized,double-blind,placebo-controlledclinicaltrialinvolving14patients.Inarandomized,controlledtrial,standardized

chamomilecreamwaspreferredoveralmondcreambypatientsfortreatingtheerythemaandmoistdesquamationacquiredafterreceivingradiotherapy.

•Standardizedchamomileointmenthadsimilarefficacyas5%dexpanthenolcreaminhealingepisiotomywoundsinanopen,randomizedtrial.6Anopen,randomizedtrialthatcomparedseveralproceduresforsecond-degreehemorrhoidtreatmentfoundbestresultsinthegroupreceivingapplicationofastandardizedchamomileointmentinconjunctionwiththesurgicalprocedures(ligatureandanaldilation).7

•InGermany,theCommissionEsupportsusingchamomileinternallytotreatgastrointestinalspasmandinflammatorydiseasesofthegastrointestinaltract.Chamomileisrecommendedexternallytotreatskinandmucousmembraneinflammations,bacterialskindiseases,includingthoseoftheoralcavityandgums,inflammationandirritationoftherespiratorytract(byinhalation),andanogenitalinflammation(bybathorenema).8ESCOPalsorecommendschamomilefortheseindications,specificallyindicatinginternaluseforthefollowinggastrointestinalcomplaints:minorspasm,epigastricdistension,flatulence,andbelching.9

•ChamomilehasbeenreinstatedtotheUSPandisofficialintheUSP24-NF19.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.

HurrellRF,ReddyM,CookJD.BrJNutr.1999;81(4):289-295.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.Patzelt-WenczlerR,Ponce-PoschlE.EurJMedRes.2000;5(4):171-175.KaltenbachFJ.NasemannTh,Patzelt-WenczlerR,editors.Kamillosanimspiegelderliteratur.Frankfurt:pmiVerlag,1991.CitedinForsterCF,SussmannHE,Patzelt-WenczlerR.SchweizRundschMedPrax.1996;85(46):1476-1481.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Matricariaeflos.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,October1999.

CHASTETREE

BotanicalName: Vitexagnus-castusFamily: LabiataePlantPartUsed: Fruit

PRESCRIBINGINFORMATION

Actions Prolactininhibitor,dopaminergicagonist,indirectlyprogesterogenic,galactagogue

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingchastetreeinformulationsinthecontextof:

•Premenstrualsyndrome,especiallywithmastalgiaandfluidretention(2,4,5)

•Progesteronedeficiency,corpuslutealinsufficiency,latenthyperprolactinemia(3)

•Cystichyperplasiaoftheendometrium,infertilityresultingfromdecreasedprogesteronelevelsorhyperprolactinemia(4)

•Acne(3)

•Secondaryamenorrhea(4,5)

•Metrorrhagia(fromfunctionalcauses),menorrhagia,polymenorrhea,oligomenorrhea(4,6)

•Insufficientlactation(3,5)

•Possiblebenefitinmenopausalsymptoms,withdrawalfromhormonereplacementtherapy,andconditionsinwhichunopposedestrogenplaysarole(e.g.,fibroids,endometriosis,follicularovariancysts)becauseofitssupposedprogesterone-favoringeffect(7)

•Possiblebenefitinconditionsinwhichraised

prolactinsecretionisimplicated(e.g.,breastcysts,fibrocysticbreastdisease,benignprostatichyperplasia)(7)

Contraindications Nonerequired.

WarningsandPrecautions

Ingeneral,chastetreeisbestnottakeninconjunctionwithprogesteronedrugs,contraceptivepill,orhormone-replacementtherapy(HRT).Chastetreemayaggravatepurespasmodicdysmenorrheanotassociatedwithpremenstrualsyndrome(PMS).

Interactions Chastetreemayinteractantagonisticallywithdopaminereceptorantagonists.

UseinPregnancyandLactation

Chastetreeshouldbeusedcautiouslyduringpregnancyandonlyintheearlystagesfortreatinginsufficientcorpuslutealfunction.

Althoughthedopaminergicactivitymightsuggestthatchastetreeisbestavoidedduringlactation,clinicaltrialshavedemonstrateditspositiveactivityonmilkproduction,albeitatlowdoses.

SideEffects

Rareoccurrencesofgeneralizeditchingandurticariahavebeenreported.Herbalistshavereportedthatchastetreecanrarelycauseheadache.

Inseveraltrials,sideeffectswerenotedin1%to13%ofparticipants.Thesesideeffectscenteredonthegastrointestinaltractandwerenotconsideredsignificant.

A45-year-oldwomanwhohadbeentakingherbalpreparationscontainingblackcohosh,chastetree,andeveningprimroseoilfor4monthshadthreeseizureswithina3-monthperiod.Theherbalpreparationswerestopped,andthepatientwastreatedwithanticonvulsants.

Dosage Doseperday* Doseperweek*

1.0–2.5mlof1:2liquidextract

6to18mlof1:2liquidextract

* This dose range is extrapolated from a published survey of United Kingdom herbalistsconductedin1997.1

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•AsagalactagogueandemmenagoguebytheEclectics;saidto“repressthesexualpassions”;forimpotence,sexualmelancholia,sexualirritabilitywithnervousness,melancholia,ormilddementia2

•Gynecologicproblemsandinsufficientlactation(Europeanuse)3,4

PharmacologicResearch

Constituentsofchastetreeberriesincludeessentialoil,diterpenesofthelabdane-andclerodane-type,includingrotundifuran,6β,7β-diacetoxy-13-hydroxy-labda-8,and14-diene,flavonoids(e.g.,casticin),andiridoidglycosides,includingaucubinandagnuside.

•Invitrostudiesindicatethatchastetreehasadopaminergiceffect,inhibitingprolactinreleasefromtheanteriorpituitary.

•Labdanediterpenesinhibitedspiperone5andsulpiride6bindingatdopamineD2receptorsinvitro.Chastetreeextractproducedsimilarinhibitionofbindingastheisolatedditerpenes.Agnuside,aucubin,casticin,andotherflavonoidsdidnotshowaninhibitoryeffectinthisassay.5

•Rotundifurandose-dependentlyinhibitedprolactinsecretionfromculturedpituitarycells.Bothrotundifurananddopamineinhibitedforskolin-inducedprolactinsecretionandcAMPformationinpituitarycellsinvitro.6

•Anearlyexperimentalmodelfoundthatloworaldoses

ofchastetreeproducedadecreaseofestrogeneffectsandapromotionofprogesteroneeffects,whichwaspresumablymediatedthroughthepituitarygland.Athighdoses(upto20timesthelowdose),aninhibitionofallgonadotropichormonesandgrowthhormoneresulted.

ThedosesusedinmostoftheGermanclinicaltrialssummarizedhere(around40mg/day)aremuchlowerthanthosethatWesternherbaliststypicallyuse.Recenttrialswithchastetreehaveusedhigherdoses(around200mg/day).

•Inanopen,placebo-controlled,crossovertrial,20malevolunteersreceivedspecialextractofchastetree(equivalentto120,240,or480mg/daydriedextract)orplacebofor14days.Theresultssuggestedthattheactivityofchastetreeonprolactinsecretionwasdependentondosageandtheinitialleveloftheprolactinconcentration.Menwereusedinthistrialbecausetheirhormonesareunderlesscyclicalinfluencecomparedwithwomen.Chastetreecausedanincreaseinprolactinsecretionatthelowestdoseandadecreaseatthehighestdose.ChastetreedidnotaltertheserumconcentrationsofLH,FSH,ortestosterone.

•Chastetreeextract(equivalentto40mg/dayofdriedfruitfor1month)reducedprolactinlevelsinwomenwithhyperprolactinemiainanuncontrolledstudy.7

•Earlyuncontrolledclinicalstudiesonchastetreeobservedimprovementinpatientswithavarietyofmenstrualdisorders.Resultswereparticularlymarkedforpatientssufferingfromcystichyperplasiaoftheendometrium(whichiscausedbyarelativeprogesteronedeficiency).Chastetreewasparticularlyindicatedinpatientswithdeficientcorpusluteumfunction.Thedosagemostoftenusedwasequivalentto36mg/dayofdriedfruit.

•Observationby153gynecologistsof551patientswithsymptomsofcorpuslutealinsufficiency,cyclicdisorders,orPMSoverseveralmenstrualcyclesrevealedthatchastetreetreatmentwasbeneficialin68.8%ofcases.Theaveragedoseofchastetreewasequivalentto36mg/dayofdriedfruit.Over80%ofpatientswererelievedofcomplaintsorstatedthattheirconditionhadimproved.

•Thirty-sevenwomenwithlutealphasedefectscausedbylatenthyperprolactinemiacompletedadouble-blind,placebo-controlledtrialtestingtheefficacyofachastetreepreparation(equivalentto20mg/dayofdriedfruitfor3months).Withchastetreetreatment,prolactinreleasefollowingadministrationofthyroxin-releasinghormonewassignificantlyreduced.Shortenedlutealphaseswerenormalized,andlutealphaseprogesteronedeficiencieswerecorrected.Twowomenreceivingchastetreebecamepregnant,andPMSsymptomsweresignificantlyreducedinthechastetreegroup.

•Chastetreeextract(equivalentto180mg/dayofdriedfruitforthreecycles)improvedPMSsymptoms(irritability,moodalteration,anger,headache,breastfullness,andbloating)andclinicalglobalimpressionscoresinarandomized,double-blind,placebo-controlledtrial.8

•Inacontrolledclinicaltrial,significantbenefitwasobservedforalltypesofPMSexcepttypePMS-C(characterizedbysymptomssuchasheadache,cravingforsweets,palpitations,anddizziness).

•Incontrast,93%of1634patientswithPMSreportedadecreasein,orcessationof,symptomsinallfourPMSsymptomcomplexes,includingPMS-C,aftertreatmentwithchastetreeextract(equivalentto40mg/dayofdriedfruitforthreecycles)inarecentpostmarketingstudy.Eighty-fivepercentofphysiciansratedchastetreeasgoodorverygood.9

ClinicalResearch

•Inamulticenter,randomized,double-blind,comparativetrial,175womenwithPMSreceivedeitherchastetreeorvitaminB6(100mgpyridoxine)overthreecycles.Patientsreceivedchastetreeextract(equivalentto40mgdriedfruit)eachdayoronecapsuleofplacebotwicedailyondays1to15,andonecapsuleofpyridoxine(100mg)twicedailyondays16to35ofthemenstrualcycle.PMSscoresdecreasedforbothtreatments,however,chastetreetreatmentwassuperiortopyridoxineoverall.Comparedwithpyridoxine,chastetreeshowedasignificantimprovementinreducingcharacteristicsymptomssuchasbreasttenderness,edemas,abdominaltension,headaches,constipation,anddepressedmood.

•Inaprospective,multicentertrialonPMS,chastetreeextract(equivalentto180mg/dayofdriedfruitforthreecycles)reducedpatient’ssymptomscores.Globalefficacywasratedasmoderatetoexcellentby88%ofpatients.Improvementwasmaintainedforuptothreecyclesaftermedication.Nodifferenceswereseenbetweenpatientstakingoralcontraceptivesandthosewhowerenot.Noeffectwasobservedonrestinglevelsofbloodprolactin.10

•Intwouncontrolledstudies,theinfluenceofchastetreeoncorpuslutealfunctionwasinvestigated.Thewomenwereconsideredtobecapableofreproduction,hadnormalprolactinemia,butshowedpathologicallylowserumprogesteronelevelsatday20ofthemenstrualcycle.After3months,chastetreetreatment(equivalentto36mg/daydriedfruit)wasconsideredtobesuccessfulin39of45cases.Sevenwomenbecamepregnant,25womenhadnormalserumprogesteronelevelsatday20,andanothersevenwomentendedtowardsnormallevels.

•Inarandomized,double-blind,clinicaltrial,160patientswithpremenstrualmastalgiareceivedahomeopathicformulaalsocontainingchastetreetincture,gestagentherapy(lynestrenol),orplacebo.Treatmentwiththechastetree–homeopathiccombinationgavegoodreliefof

symptomsin74.5%ofpatientsandalowerincidenceofsideeffects.Improvementswere82.1%forlynestrenoland36.8%forplacebo.Chastetreesolutionorchastetreetablets(bothequivalentto32mg/daydriedfruit)forthreecyclesreducedmastalgiaandprolactinlevelsinarandomized,double-blind,placebo-controlledtrial.11Inanearliertrialinvolving20patientsthatusedthesamedesignbutincludedcrossover,astatisticallysignificantreductionofsymptomswasobservedforchastetreetreatment(equivalentto32mg/daydriedfruit).Short-livednauseawasreportedinsomecases.

•Afavorableeffectwasobservedonmilkproductionforparticipantstreatedwithchastetreeinacaseobservationstudy.Inacontrolledtrial,averagemilkproductionwasapproximatelythreetimesthatofcontrolsafter20daysoftreatment(equivalentto40mg/daydriedfruit).Thisfindingsuggests,consistentwiththestudyinmencitedpreviously,thatlowdosesmightincreaseprolactinandpromotemilkproduction.

•Inacontrolledtrialof161maleandfemalepatientswithacne,aminimumof3months’treatmentwithchastetreeresultedinanimprovementfor70%ofpatients,whichwassignificantlybetterthanplacebo.Patientsweretreatedwithchastetree(equivalentto36mg/dayofdriedfruit)for4to6weeks,followedbyalowerdosefor1to2years.Themechanismforthebeneficialeffectofchastetreeonacneisnotknownbutmaybearesultofamildantiandrogeniceffect.

•InGermany,theCommissionEsupportsusingchastetreetotreatirregularitiesofthemenstrualcycle,premenstrualcomplaints,andmastodynia.12

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.ChristieS,WalkerAF.EurJHerbMed.1997-1998;3(3):29-45.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983MillsSY.Outoftheearth:theessentialbookofherbalmedicine.London:VikingArkana(Penguin),1991.MillsSY.Women’smedicine:Vitexagnuscastus,theherb.Christchurch,UK:Amberwood,1992.MeierB,etal.Phytomed.2000;7(5):373-381.ChristoffelV,etal.LoewD,BlumeH,DingermannTH,editors.Phytopharmakav,ForschungundKlinischeAnwendung.Darmstadt:Steinkopff,1999.CitedinGorkowC.ZPhytother.1999;20:159-168.SchellenbergR.BMJ.2001;322:134-137.LochEG,SelleH,BoblitzN.JWomensHealthGendBasedMed.2000;9(3):315-320.

10BergerD,etal.ArchGynecolObstet.2000;264(3):150-153.11WuttkeW,etal.GebFra.1997;57(10):569-574.12BlumenthalM,etal,editors.ThecompleteGerman

CommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

CHICKWEED

BotanicalName: StellariamediaFamily: CaryophyllaceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Demulcent,astringent,refrigerant,antiulcer(peptic)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingchickweedinformulationsinthecontextof:

•Rheumaticandgoutyconditions,gastrointestinalulceration(5)

•Topicaltreatmentforskindisorders,especiallyeczemaandpsoriasis,itchyskin,rashes,burns,ulceration,andboils;inflammationoftheeye(5)

•Topicaltreatmentforhemorrhoids(6)Contraindications Knownallergy.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Allergicrashesmayrarelyresultfromtopicaluse.Dosage Doseperday* Doseperweek*

3–6mloffreshplantsuccus

20–40mloffreshplantsuccus

* Thisdose range isextrapolated from thedriedherb tincturedosages listed in theBritishHerbalPharmacopoeia1983andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Rheumatism1,2

•Constipation,cough,hoarseness3

•Topicallyforeczema,psoriasis,skininflammation,poorlyhealingulcers,carbuncle,abscess1,2

•Hemorrhoids3

PharmacologicResearch

Theaerialpartsofchickweedcontainflavonoids,phenolicacids,triterpenoidsaponins,phytosterols,andcarotenoids.4

Nopharmacologicinformationhasbeenfoundforchickweed.

ClinicalStudies Noclinicalstudiesusingchickweedhavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,

1971.KitanovGM.Pharmazie.1992;47:470-471.

CINNAMON

BotanicalNames: Cinnamomumzeylanicum,Cinnamomumverum#

Family: LauraceaePlantPartUsed: Bark

# Alternativename.

PRESCRIBINGINFORMATION

Actions Carminative,aromaticdigestive,astringent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcinnamoninformulationsinthecontextof:

•Lossofappetite,dyspepticcomplaints,bloating,flatulence,mild,spasticconditionsofthegastrointestinaltract(4,5)

•Thecommoncoldandinfluenza(5)

•Nausea,vomiting,diarrhea(5)

•Conditionsrequiringwarmthandcirculatorystimulation,suchascoldhandsandfeet(5)

•Uterinehemorrhage,menorrhagia(5)

Contraindications

KnownallergytocinnamonandPeruvianbalsam.1Cross-reactionswithPeruvianbalsamhavebeenobservedforpeoplewhoaresensitivetocinnamicaldehyde.2

WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

TheGermanCommissionErecommendsthatcinnamoniscontraindicatedinpregnancy.However,areviewofthesafetyliteraturesuggeststhatcinnamondoesnotpresentanyspecialriskinpregnancy.3

SideEffectsAllergicreactionsoftheskinandmucosahavebeenreported.1Thisfindingismostlikelyaresultofcinnamicaldehyde,whichisapotentcontact

sensitizer.3

Dosage Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1949, theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Flatulentdyspepsia,anorexia,intestinalcolic,infantilediarrhea,nauseaandvomiting4,5

•Thecommoncold,influenza,4coldextremities5

•Uterinehemorrhage,menorrhagia5

•Correctingtheeffectsofcertainremedies(e.g.,thenauseacausedbyCinchona)andimprovingtheflavorofotherherbs5

PharmacologicResearch

Cinnamonbarkcontainsanessentialoil,withthemajorconstituentbeingcinnamicaldehyde(cinnamaldehyde).6

•Theoralpungencyofcinnamicaldehydewasfoundtobearesultofburning,tingling,andnumbing,withquickonsetandrapiddecay.7

•Cinnamonoilhasdemonstratedantibacterialandantifungalactivitiesinvitro,8includingactivityagainstarangeofdermatophytes.9Cinnamicaldehydehasbeenidentifiedasanactivefungitoxicconstituent.10

•Cinnamonoilhasdemonstratedantispasmodicactivityonisolatedsmoothmuscletissue,11decreasedstomachandintestinalmotility,andreducedstress-inducedgastriculcersinvivo.8Theinvivostudiesusedrelativelylargedosesofoiladministeredbyinjection.

•Cinnamonextractdemonstratedanalgesicactivityintwo

experimentalmodelstestingcentralandperipheraleffects(400mg/kgpretreatmentbyinjection;200mg/kgoralpretreatment,respectively).12

•Cinnamonhasdemonstratedantioxidantactivityinvitro13andexertedantioxidantactivityinratsfedahigh-fatdiet.Theantioxidantprotectionoccurredthroughitsabilitytoactivateantioxidantenzymes.14Cinnamondidnotlowercholesterolininducedhypercholesterolemia.15

•Invitrostudiesindicatethatcinnamonandacompoundextractedfromitpotentiateinsulinactivity.16,17Similartoinsulin,thecompoundaffectsproteinphosphorylationintheintactfatcell.17Theinsulin-potentiatingactivityofcinnamonwasnotcorrelatedwithitstotalchromiumcontent.16

ClinicalStudies

•Administrationofacinnamontreatmentfor1weekimprovedoralcandidiasisinfivepatientswithHIVinfection.18

•InGermany,theCommissionEsupportsusingcinnamontotreatlossofappetite,dyspepticcomplaints(e.g.,mild,spasticconditionsofthegastrointestinaltract),bloating,andflatulence.1

REFERENCES

BlumenthalM,etal,editors.TheCompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.CollinsFW,MitchellJC.ContactDermatitis.1975;1(1):43-47.deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.

Berlin:Springer-Verlag,1992.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.CliffM,HeymannH.JSensoryStud.1992;7(4):2792-2798.WorldHealthOrganization.WHOmonographsonselectedmedicinalplants.Geneva:WHO,1999.LimaEO,etal.Mycoses.1993;36(9-10):333-336.

10SinghHB,etal.Allergy.1995;50(12):995-999.11ReiterM,BrandtW.ArzneimForsch.1985;35(1A):408-414.12AttaAH,AlkofahiA.JEthnopharmacol.1998;60(2):117-124.

13HirayamaT,etal.ShokuhinEiseigakuZasshi.1986;27(6):615-618.

14DhuleyJN.IndianJExpBiol.1999;37(3):238-242.15SambaiahK,SrinivasanK.Nahrung.1991;35(1):47-51.16KhanA,etal.BiolTraceElemRes.1990;24(3):183-188.17Imparl-RadosevichJ,etal.HormoneRes.1998;50(3):177-182.

18QualeJM,etal.AmJChinMed.1996;24(2):103-109.

CLEAVERS

OtherCommonNames: Clivers,GaliumBotanicalName: GaliumaparineFamily: RubiaceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Diuretic,depurative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcleaversinformulationsinthecontextof:

•Skindiseases,includingpsoriasisandeczema(5)

•Enlargedorinflamedlymphnodes(5)

•Painfulordifficulturination,cystitis(5)

•Kidneystones(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3.5–7.0mlof1:2liquidextract

25–50mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Painfulordifficulturination,inflammationofkidneysandbladder,lymphadenitis,enlargedlymphnodes,scrofula(tuberculousinfectionofthecervicallymphnodes)1,2

•Skindiseasesanderuptions,especiallypsoriasisandeczema2

•Cancer2

•Kidneystones3

PharmacologicResearch

Theiridoidglycosidesoftheaerialpartsofcleavershaveshownmildlaxativeactivityinvivo.4

ClinicalStudies Noclinicalstudiesusingcleavershavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.

SteineggerE,HanselR.Lehrbuchderpharmakognosieundphytopharmazie.Berlin:Springer-Verlag,1988.

CODONOPSIS

BotanicalName: CodonopsispilosulaFamily: CampanulaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Tonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingCodonopsisinformulationsinthecontextof:

•Fatigue,lossofappetite,shortnessofbreathassociatedwithchroniccoughorpalpitation(5)

•Coronaryheartdisease(4)

•Improvingredbloodcellproductionandhemoglobinconcentration(7)

•Adjuvanttherapyforcancer(3)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

4.5–8.5mlof1:2liquidextract

30–60mlof1:2liquidextract

* ThisdoserangeisadaptedfromdriedplantdosesadministeredbydecoctioninTCM.1Theauthor’sexperienceandthefact thatethanol-water isamoreeffectivesolvent thanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Reinforcingqiandinvigoratingthefunctionsofthespleenandlung1,2

•Lackofappetite,fatigue,tiredlimbs,diarrhea,vomiting2

•Chroniccoughandshortnessofbreath,shortnessofbreathwithpalpitation2,3

•Symptomsofprolapseoftheuterus,stomach,andanus2

CodonopsisisregardedinTCMashavingsimilarfunctionstothoseofKoreanginsengroot,althoughnotasstrong.2CodonopsiscontainsdifferentconstituentstoKoreanginsenganddoesnotcontaintriter-penoidsaponins.4

PharmacologicResearch

•Codonopsisextractweaklystimulatedhumanlymphocytesinvitro.5

•Codonopsisdemonstratedthefollowingeffectsinexperimentalmodels:3

•Promotedphagocyticactivityofperitonealmacrophages(invitro,invivo)

•Increasedredbloodcellproductionandhemoglobinconcentration(oral)

•Elevatedbloodglucose(oral)

•Codonopsisextractdemonstratedprotectiveactivityin

experimentallyinducedgastriculcers,includingthestress-inducedmodel.Pepsinsecretionwasalsoreduced.6Inanothermodel,oraldecoctionofCodonopsisincreasedserumgastrinlevelswithnochangeingastricacidityorplasmasomatostatin.7

•CodonopsisprolongedlifespaninanexperimentalmodelofSLE.Productionofanti-double-strandeddeoxyribonucleicacid(DNA)antibodieswasalsoinhibited.8

ClinicalStudies

•PreliminarystudiesindicatethatCodonopsiscanimprovethedefectiveinvitrointerleukin-2productioninpatientswithSLE.8

•Codonopsisliquorsignificantlydecreasedplateletaggregationinpatientswithcoronaryheartdiseasewithbloodstasisafter4weeksoftreatment.Theinhibitionofplateletaggregationdidnotoccurviaelevationoffibrinolyticactivity.9

•SomebenefitwasobservedforpatientswithcancerwhoweretreatedwithCodonopsisasanadjuvantduringradiotherapy.Comparedwithcontrols,Codonopsisreducedtheimmunosuppressiveeffectofradiotherapybuthadnoeffectonmosthumoralimmuneparameters.AslightincreaseinimmunoglobulinM(IgM)wasobservedinthetreatedpatients.10

REFERENCES

PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.

ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.WongMP,ChiangTC,ChangHM.PlantaMed.1983;49(1):60.ShanBE,etal.IntJImmunopharmacol.1999;21(3):149-159.WangZT,etal.GenPharmacol.1997;28(3):469-473.ChenSF,etal.ZhongguoZhongyaoZazhi.1998;23(5):299-301.ChenJR,etal.AmJChinMed.1993;21(3-4):257-262.XuX,WangSR,LinQ.ChungKuoChungHsiIChiehHoTsaChih.1995;15(7):398-400.

10ZengXL,LiXA,ZhangBY.ChungKuoChungHsiIChiehHoTsaChih.1992;12(10):607.581

COLEUS

BotanicalNames: Coleusforskohlii,Plectranthusforskohlii#

Family: LabiataePlantPartUsed: Root

# Alternativename.

PRESCRIBINGINFORMATION

ActionsHypotensive,antiplatelet,bronchospasmolytic,spasmolytic,cardiotonic,digestivestimulant,aromaticdigestive

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingColeusinformulationsinthecontextof:

•Congestiveheartdisease(4a)

•Asthma,psoriasis(4a)

•Topicaltreatmentforglaucoma*(4a)

•Hypertension,ischemicheartdisease,thrombosis(resultingfromantiplateletactivity)(7)

Contraindications Givenitshypotensiveeffect,Coleusiscontraindicatedinpatientswithhypotension.

WarningsandPrecautions

Coleusshouldbeusedcautiouslyinpatientstakingprescribedmedicationandthosewithpepticulcer.

Interactions

Becauseofitsuniquepharmacologicactivity,forskolin,theactiveconstituentofColeus,hastheabilitytopotentiatemanydrugs.Coleusshouldthereforebeusedcautiouslyinpatientstakingprescribedmedication,especiallyhypotensiveandantiplateletdrugs.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday** Doseperweek**

6–13mlof1:1liquidextract

40–90mlof1:1liquidextract

Extractsprovidingquantifiedlevelsofforskolinarerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan2.5mg/mlofforskolin.

Forglaucoma,asolutionofapproximately4to6dropsofa1:1extractispreparedinaneyebathofrecentlyboiledwaterorsaline.Liquidshouldbeallowedtocoolbeforeapplyingtotheeye.(Allowingthealcoholtoevaporatebeforeputtingneartheeyeisimportant.)**

* The alcohol must be evaporated before putting the liquid extract near the eye. (See“Dosage”sectioninthismonograph.)

** Thisdoserangeisextrapolatedfromscientificandclinicalinvestigationsofforskolin.1

SUPPORTINGINFORMATION

TraditionalPrescribing

AlthoughcloselyrelatedspeciesofColeusareusedintraditionalAyurvedicmedicine,ColeusforskohliihasbeenusedonlyasacondimentinIndia,withtherootspreparedasapickle.2

Coleusrootcontainsthediterpeneforskolin.3

Forskolinhasdemonstratedextensivepharmacologicactivity(usuallyinvitroorinvivobyinjection).Forskolinisknowntoactivateadenylatecyclase,whichcatalyzestheproductionofcAMP.3Mostofthepharmacologicpropertiesdescribedhereareaconsequenceofthisproperty.Forskolin:

•Lowerednormalorelevatedbloodpressureinvivo(injection,oral)byrelaxingarteriolarsmoothmuscle4

•Demonstratedpositiveinotropicaction(increasedforceofcontraction)onisolatedheartmuscle4andinvivo(byinjection)5

•Inhibitedplateletaggregationinvitro4andinvivo6(OraladministrationofColeusforskohliiextract[standardizedforforskolin]demonstratedantithromboticactivityinvivo.)6

•Increasedcerebralbloodflowinvivo(byinjection),havingadirectvasodilatoreffect7

•Relaxedisolatedbronchialsmoothmuscle8andpreventedexperimentallyinducedbronchospasminvivo(byintravenousandintraduodenalinjection)9

PharmacologicResearch

•Stimulatedlipolysisinvitro10andinhibitedglucoseuptakeinvitro11

•Potentiatedthesecretagogueeffectsofglucoseinvitro12andstimulatedthereleaseofsomatostatinandglucagonfromisolatedpancreaticisletcells13

•Stimulatedthyroidfunctionwithincreasedthyroidhormoneproductionintheisolatedorgan14(However,lowconcentrationsofforskolininhibitedthyroidfunctioninvitro[thyroidcells].)15

•Enhancedsecretionofacidandpepsinogenfromthegastricmucosaofisolatedtissue16

•Stimulatedamylasesecretionfromparotidglandtissue17andactedsynergisticallywithcholecystokinininstimulatingamylasereleasefromexocrinepancreatictissue18

•ActedsynergisticallywithFSHandLHonestrogenandprogesteroneproductionandwithadrenocorticotropinhormone(ACTH)oncorticosteroidproductioninvitro19

•Inhibitedmelanomacell–inducedplateletaggregationandreducedpulmonarytumorcolonizationinvivo(byinjection)20

•Loweredintraocularpressure19

•Inhibitedthereleaseofinflammatorymediatorsinvitro21andpartiallyinhibitedB-lymphocyteactivationinvitro22

NoclinicalstudieshavebeenconductedusingColeus.Thefollowingstudieshavebeenconductedusingforskolinorawater-solublederivative.

•Humanstudiesconfirmedthattopicalapplicationof

ClinicalStudies

forskolin(50μlofa1%solution)lowersintraocularpressure23,24byreducingtheflowofaqueoushumor.InIndia,theclinicalvaluebytopicalapplicationofforskolinforglaucomahasbeenconfirmed.25

•Forskolinimprovedsymptomsinasmallnumberofpatientswithpsoriasis.26

•Initialstudiesonpatientswithcongestivecardiomyopathyandcoronaryarterydiseaseconfirmedthatforskolinimprovedcardiacfunctionandmyocardialcontractility.25Inanothertrial(open,controlleddesign),noincreaseinmyocardialcontractilityatthetestedintravenousdoseofforskolinwasobserved,butleftventricularfunctionwasimproved.Althoughhigherdosesofforskolindidincreasemyocardialcontractility,theaccompanyinglargereductioninbloodpressuremayprecludesuchdosesincongestiveheartfailure.27Althoughthesetrialsusedforskolinbyinjection,clinicaltrialshavesuccessfullyusedoraldosesofawater-solubleforskolinderivativetotreatacuteheartfailure.28

•Clinicalstudiesdemonstratedabronchodilatingeffectinpatientswithasthma,aswellasthosewithandwithoutchemicallyinducedbron-choconstriction.Forskolinwasinhaledatadoseof1to10mgperpuffand,bythisroute,causednosideeffects,althoughitsactionwasshort-lived.29,30Forskolinalsocounteredchemicallyinducedbronchoconstrictioninadouble-blind,placebo-controlled,crossover,comparativetrialinvolvinghealthyvolunteers.Theadministereddoseswere2mgand10mgofforskolinbyinhalation.31

REFERENCES

WagnerH,HikinoH,FarnsworthNR,editors.Economicandmedicinalplantresearch.London:AcademicPress,1988.

ValdesLJ,MislankarSG,PaulAG.EconBot.1987;41(4):474-483.SeamonKB,DalyJW.JCyclicNucleotideRes.1981;7(4):201-224.deSouzaNJ,DohadwallaAN,RedenJ.MedResRev.1983;3(2):201-219.DubeyMP,etal.JEthnopharmacol.1981;3(1):1-13.deSouzaNJ.JEthnopharmacol.1993;38(2-3):177-180.WyshamDG,BrothertonAF,HeistadDD.Stroke.1986;17(6):1299-1303.BurkaJF.JPharmacolExpTher.1983;225(2):427-435.ChangJ,etal.EurJPharmacol.1984;101(3-4):271-274.

10HoR,ShiQH.BiochemBiophysResCommun.1982;107(1):157-164.

11LaurenzaA,SutkowskiEM,SeamonKB.TrendsPharmacolSci.1989;10(11):442-447.

12HenquinJC,MeissnerHP.Endocrinology.1984;115(3):1125-1134.

13HermansenK.Endocrinology.1985;116(6):2251-2258.14LaurbergP.FEBSLett.1984;170(2):273-276.15BrandiML,etal.ActaEndocrinol.1984;107(2):225-229.16HerseySJ,OwiroduA,MillerM.BiochimBiophysActa.1983;755(2):293-299.

17WatsonEL,DowdFJ.BiochemBiophysResCommun.

1983;111(1):21-27.18WillemsPH,etal.BiochimBiophysActa.1984;802(2):209-214.

19SeasonKB,DalyJW.GreengardP,RobisonGA,editors.Advancesincyclicnucleotideandproteinphosphorylationresearch,vol20.NewYork:RavenPress,1986.Citedin

20AgarwalKC,ParksREJr.IntJCancer.1983;32(6):801-804.21MaroneG,etal.BiochemPharmacol.1987;36(1):13-20.22HolteH,etal.EurJImmunol.1988;18(9):1359-1366.23BursteinNL,SearsML,MeadA.ExpEyeRes.1984;39(6):745-749.

24CaprioliJ,SearsM.Lancet.1983;1(8331):958-960.25RuppRH,deSouzaNJ,DohadwallaAN,editors.FromtheproceedingsoftheInternationalSymposiumonForskolin:ItsChemical,BiologicandMedicalPotential,Bombay,January28-29,1985.Bombay:AlfredoBorgesAssociates,1986.

26BonczkowitzH,MethnerGF.AktDermatol.1984;10:12.27KramerW,etal.ArzneimForsch.1987;37(3):364-367.28HosonoM.NipponYakurigakuZasshi.1999;114(2):83-88.29LicheyI,etal.Lancet.1984;2(8395):167.30BauerK,etal.ClinPharmacolTher.1993;3(1):76-83.31KaikG,WittePU.WienMedWochenschr.1986;136(23-24):637-641.

CORNSILK

BotanicalName: ZeamaysFamily: GramineaePlantPartUsed: Styleandstigma

PRESCRIBINGINFORMATION

Actions Diuretic,antilithic,urinarydemulcent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcornsilkinformulationsinthecontextof:

•Cystitis,urethritis,bedwetting,bladderdisordersofchildren,urinarycalculi,prostatitis(5)

•Stimulatingdiuresis,improvingrenalfunction(4,5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2–6mlof1:1liquidextract

15–40mlof1:1liquidextract

* This dose range is extrapolated from British Herbal Pharmacopoeia 1983, the BritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Cystitis,urethritis,pyelitis,nocturnalenuresis,urinarycalculiorgravel,strangury,prostatitis,gonorrhea1,2

•Bladderdisordersofchildren2

UsesandpropertiesfromTCMincludeedema,hepatitis,nephritis,cholelithiasis,jaundice,andhypertension.3,4

CornsilkhasalsobeenusedtraditionallyasadiureticandfortreatingdropsyinIndonesia5andurinaryretentioninFiji.6

CornsilkwasofficialintheUSPfrom1894to1906andNFfrom1916to1946andwasusedasadiuretic.Fromasfarbackasthesixteenthcentury,NativeAmericansusedcornproductsformedicinalpurposes.7

PharmacologicResearch

•Diureticactivityhasbeenconfirmedinvivo.8

•Cornsilkextractinhibitedtumornecrosisfactor-alpha–inducedandbacteriallipopolysaccharide–inducedepithelialcelladhesioninvitro.9

ClinicalStudies

•Eightto10gramsofcornsilkdecoctionproducedamilddiureticeffectinnormalvolunteers.2

•InuncontrolledtrialsinChina,cornsilkdecoctionproduceddiureticeffectsinrenaledema,ascites,andnutritionaledemaandimprovedrenalfunctionandalbuminuriainpatientswithchronicnephritisandnephroticsyndrome.Decoctionof50goffreshherbwasrecommended,withthedosenotexceedingthedailyurine

output.2

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.DharmaAP.Indonesianmedicinalplants.Jakarta:BalaiPustaka,1987.CambieRC,AshJ.Fijianmedicinalplants.Melbourne,Australia:CSIROPublishing,1994.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.RebueltaM,etal.PlantesMedPhytother.1987;21:2672-2675.HabtemariamS.PlantMed.1998;64(4):314-318.

COUCHGRASS

BotanicalNames: Agropyronrepens,Elymusrepens,#^Elytrigiarepens#

Family: GramineaePlantPartUsed: Rhizome

# Alternativename.

^ AdoptedbytheAmericanHerbalProductsAssociationasthenewbotanicalname.1

PRESCRIBINGINFORMATION

Actions Soothingdiuretic,urinarydemulcent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcouchgrassinformulationsinthecontextof:

•Inflammationandinfectionoftheurinarytract,preventingkidneygravel(4,5)

•Prostatitis,benignprostatichyperplasia(5)

•Gout,rheumatism,jaundice(5)

Contraindications

TheCommissionErecommendscopiousfluidintaketoassistinreducingmicroorganismsintheurinarytract,butthisshouldnotbeundertakenifedemaresultingfromimpairedcardiacorrenalfunctionispresent.2

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3–6mlof1:1liquidextract

20–40mlof1:1liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Irritationorinflammationoftheurinarytract,includingcystitis,urethritis,prostatitis,benignprostatichyperplasia,andurinarycalculi3,4

•Gout,rheumatism,jaundice2

PharmacologicResearch

Oraladministrationofcouchgrassinfusiondemonstratedthefollowingresultsinacalciumoxalateurolithiasismodel:adecreaseincitraturiawhencombinedwithahighcarbohydratedietandanincreaseincalciuriaanddecreaseinmagnesiuriawhencombinedwithastandarddiet.5

ClinicalStudies

Noclinicalstudiesusingcouchgrasshavebeenfound.

InGermany,theCommissionEsupportsusingcouchgrasswithcopiousfluidintaketotreatinflammatorydiseasesoftheurinarytractandforpreventingkidneygravel.2

REFERENCES

McGuffinM,editor.Herbsofcommerce,ed2,Bethesda,Md:AmericanHerbalProductsAssociation,1998.[draft3.3]BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.BritishHerbalMedicineAssociation’sScientificCommittee.

Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrasesF,etal.JEthnopharmacol.1995;45(3):211-214.

CRAMPBARK

BotanicalNames: Viburnumopulus,Viburnumopulusvar.americanum+

Family: CaprifoliaceaePlantPartUsed: Bark

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Spasmolytic,mildsedative,astringent,hypotensive,peripheralvasodilator

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcrampbarkinformulationsinthecontextof:

•Uterinepain,dysmenorrhea(5)

•Crampsofbothskeletalandsmoothmuscle(5)

•Threatenedmiscarriage,preparationforparturition(5)

•Hypertension(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2.0–4.5mlof1:2liquidextract

15–30mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheAmericanHerbalPharmacopoeiaandtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Crampsandspasmsofallkinds;crampsinthelegs1,2

•Uterinedysfunction,uterinepain,withspasmodicaction;ovarianpain1,2

•Dysmenorrhea,bearing-down,expulsivepains;menopausalmetror-rhagia,paininthighsandback1,2

•Convulsionsduringpregnancyorlabor;threatenedmiscarriage;asapartuspreparator1,2

•Spasmodiccontractionofthebladder,infantileenuresis;asthma1,2

•Angina,palpitations,3hypertension4

NativeAmericansusedcrampbarkasatreatmentforstomachcramps,othercramps,“painoverthewholebody,”anduterineprolapse.Crampbarkwasalsousedasafebrifuge,emetic,andtonic.CrampbarkwasofficialintheUSPfrom1894to1916andNFfrom1916to1960andwaslistedasasedativeandantispasmodic.4,5

Theconstituentsofcrampbarkarenotwelldefined,butthepresenceofcatechinandepicatechinandtheabsenceofamentoflavoneisconsideredcharacteristic(fordifferentiationfromViburnumprunifolium[blackhaw]).Thecoumarinsscopoletinandscopolinarealsopresent,althoughapparentlyonlyintraceamounts.4

PharmacologicResearch

•Laboratorystudiesconductedsubsequentto1940haveshowncrampbarkextractanditsconstituentstohaverelaxingeffectsonisolateduterinetissueandorgan.6-8AninvitrostudyfoundthemethanolextractofcrampbarktobethemostactiveuterinespasmolyticcomparedwithotherViburnumspecies,includingblackhaw.7(Pharmacologicstudiesconductedbefore1940cannotbetrustedforthecorrectidentificationofplantmaterial.4)

•Intravenousinjectionofasesquiterpenedialdehydefractionofcrampbarkloweredheartrateandbloodpressureinvivo.Theauthorssuggestedthatcrampbarkhadadirectmusculotrophicactioninadditiontoweaklypotentiatingtheactionofacetylcholinesterase.9

•Alcoholicextractsofcrampbarkincreasedbloodcoaguabilityanddemonstratedhemostaticactivityinexperimentalmodels(routeunknown).10

•Aqueousextractsofcrampbarkexhibitedadigitalis-typecardiotoniceffectintheisolatedheart,butcrampbarkdoesnotcontaincardiacglycosides.11

•Crudeaqueous-alcoholicextractsofcrampbarkwerefoundtohaveinhibitoryeffectsontheenzymeselastase,trypsin,α-chymotrypsin,andangiotensinIinvitro.Thisactivitywasattributedtothepolyphenoliccomponent(stannins)suchascatechin.12

ClinicalStudies

Noclinicaltrialshavebeenconducted,althoughcasereportsfromthemid-1800sintheUnitedStatesindicatethatcrampbarkwaseffectiveasauterinesedative.13

REFERENCES

FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.AmericanHerbalPharmacopoeia:Crampbark—Viburnumopulus:analytical,qualitycontrol,andtherapeuticmonograph.SantaCruz:AmericanHerbalPharmacopoeia,February2000.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.CostelloCH,LynnEV.JAmPharmAssoc.1943;32:20-22.JarboeCH,etal.Nature.1966;212(64):837.JarboeCH,etal.JMedChem.1967;10:488-489.NicholsonJA,DarbyTD,JarboeCH.ProcSocExpBiolMed.1972;140(2):457-461.

10SmirnovaAS,YadrovaVM.Farmatsiya.1968;17(4):42-45.11VladL,MuntaA,CrisanIG.PlantaMed.1977;31:228-231.12JonadetM,etal.PharmActaHelv.1989;64(3):94-96.13MunchJC.PharmArch.1940;11(3):33-37.

CRANESBILL

BotanicalName: GeraniummaculatumFamily: GeraniaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Astringent,antidiarrheal,antihemorrhagic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingcranesbillrootinformulationsinthecontextof:

•Diarrhea,dysentery,gastrointestinalulcerationorbleeding(5)

•Menorrhagia,metrorrhagia(5)

•Topicaltreatmentforleukorrhea,indolentulcers(5)Contraindications Noneknown.

WarningsandPrecautions

Becauseofthetannincontentofthisherb,long-termuseshouldbeavoided.Cranesbillshouldbeusedcautiouslyinhighlyinflamedorulceratedconditionsofthegastrointestinaltract.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2–5mlof1:2liquidextract

15–35mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Diarrhea,dysentery,hemorrhoids,pepticandduodenalulceration,hematemesis,melena,chronicmucousdischarges1,2

•Menorrhagia,metrorrhagia1

•Topicallyforleukorrhea,indolentulcers1

NativeAmericansusedcranesbillrootforhemoptysisandvenerealdisease.Externally,cranesbillrootwasusedforbleedingwounds,burns,leukorrhea,intestinalailments,diarrhea,soregums,gumdisease,toothache,neuralgia,andhemorrhoids.CranesbillrootwasofficialintheUSPfrom1820to1916,theNFfrom1916to1936,andwasusedasatonicandastringent.3

PharmacologicResearch

Nopharmacologicinformationrelevanttothecurrentuseofcranesbillroothasbeenfound.

ClinicalStudies Noclinicalstudiesusingcranesbillroothavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

CRATAEVA

BotanicalNames: Crataevanurvala,Cratevanurvala#

Family: Capparidaceae(=Capparaceae)PlantPartUsed: Bark

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antilithic,bladdertonic,antiinflammatory

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingCrataevainformulationsinthecontextof:

•Chronicandacuteurinarytractinfections(4)

•Hypotonic,atonicorneurogenicbladder(4)

•Incontinenceandpossiblyenuresis(4)

•Preventionandtreatmentofkidney,ureter,andbladderstones(4,5)

•Otherurinarysystemdisorders(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

6–14mlof1:2liquidextract

40–100mlof1:2liquidextract

Crataevamayalsobeadministeredasadecoctionofthedriedbark.

* This dose range is extrapolated from traditional Ayurvedic medicine1 and the author’s

educationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Disordersofurinarysystem,especiallykidneyandbladderstones1

•Deep-seatedsuppurativeinflammation,smalljointdiseases,osteomyelitis2

•Intestinalandhepaticinfestation2

•Snakebite;alsousedasanantiperiodic(totreataperiodicillnesssuchasmalaria)1

KeyconstituentsofCrataevabarkincludesterols(especiallylupeol,apentacyclictriterpene)andflavonoids.TheCapparidaceaefamilyisalsocharacterizedbythepresenceofglucosinolates.3

•Crataevaincreasedthetoneofsmoothandskeletalmuscleinvitro.4

•ThepetroleumetherextractofCrataevawasshowntoinhibitbothacuteandchronicinflammationinvivo(routeunknown).5Orallupeolexertedsignificantdose-dependentantiinflammatoryactivityinseveralmodelsofacuteandchronicinflammation.Analgesicorantipyreticpropertieswerenotdisplayed.6

•Lupeolreducedfootpadthickness(ameasureofinflammation)andcomplementactivityinanexperimentalmodelofarthritis(routeunknown).7Lupeolreducedpawswelling,lossofbodyweight,andcellular

PharmacologicResearch

infiltrationintothesynovialcavityofproximalinterphalangealjointsinamodelofadjuvant-inducedarthritis(oraladministration).8

•Crataevasignificantlydecreasedbladderstoneformationandreducedbladderedema,ulceration,andcellularinfiltrationcomparedwithcontrolsinanexperimentalmodel(routeunknown).9Oraltreatmentincreasedbladdertone9anddecreasedthetendencytoformcalciumoxalatekidneystones.10

•OraldosesofanalcoholicextractofCrataevademonstratedsignificantdose-dependentprotectiveactivityagainstexperimentalurinarystoneformationandreversedthebiochemicalparametersassociatedwithurolithformationtowardnormallevels.11

•Crataevadecoctionloweredtheinducedlevelsofsmallintestinalsodiumandpotassium-adenosinetriphosphatase(Na+,K+-ATPase)comparedwithcontrolsinanimalsfedacalculi-producingdiet.ChangesinNa+,K+-ATPaselevelsmayregulatetheuptakeofminerals.12

•ChangesintheactivitiesofNa+,K+-ATPase,aspartateaminotransferase,andglychollateoxidase(themajoroxalate-synthesizingenzyme)werereducedbytreatmentwithCrataevadecoctioninanexperimentalmodelofcalciumoxalateurolithiasis.13

•Oraladministrationoflupeolinhibitedstoneformation,exhibitedstone-dissolvingactivity,andfacilitatedthepassageofverysmallcalculifromthebladder.Alteredlevelsofureaandcreatinine,indicativeofkidneydysfunction,wererestoredtonormal.14Orallupeolalsodose-dependentlyreducedtheweightofurinarystones,preventedformationofvesicalcalculibyreducingcalciumphosphateandoxalatelevelsintheurine,normalizedserumandurinebiochemicalparameters,andreducedinflammationandotherdamageinthebladder

andkidneysinanexperimentalmodelofurolithiasis.15

•Lupeolreducedmarkersofcrystaldepositioninthekidneysandminimizedrenaltubulardamageinexperimentalmodelsofcalciumoxalatestoneformation.16,17Orallupeoladministrationreducedkidneyoxalatelevelsandcounteractedfree-radicaltoxicity(indicatingcytoprotectiveandantioxidantactions)inexperimentalurolithiasis.18Lupeolalsorestoredrenalthiolstatusandrestoredantioxidantenzymesinthekidneyandbladderofstone-forminganimals.Themechanismbehindtheprotectiveactivitymayinvolveinhibitingcalciumoxalatecrystalaggregationandenhancingdefensesystems.19

•Lupeolproducedimprovementinrenalantioxidantstatuswhencoadministered(routeunknown)withcadmium(anephrotoxin)inachronictoxicitymodel.20

ClinicalStudies

•Crataevadecoctionrelievedfrequency,incontinence,pain,andurineretention,increasedbladdertone,andincreasedtheforceofurinationinpatientswithhypotonicbladderresultingfrombenignprostatichyperplasia.Bladdertone,residualvolume,andsymptomsalsoimprovedincasesofpersistenthypotonia,atony,andneurogenicbladderafterCrataevatreatment.9

•Theurineofpatientsbecamelesslithogenic(urinarycalciumwasreduced,andurinarysodiumandmagnesiumsignificantlyincreased)aftertreatmentwithCrataevadecoction.9

•Twentysixoffortysixpatientswithkidney,ureter,orbladderstonesnotrequiringsurgerypassedthestoneswithin10weeks’treatmentwithCrataevadecoction.Themajorityoftheremainingpatientsexperiencedsymptomrelief.9

•Eightyfivepercentofpatientswithprovenchronic

urinarytractinfectionsweresymptom-freeafter4weeks’treatmentwithCrataevadecoction.9

REFERENCES

ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982BharatiyaVidyaBhavan’sSwamiPrakashanandaAyurvedaResearchCentre.SelectedmedicinalplantsofIndia.Bombay:Chemexcil,1992.PrabhakarYS,SureshKumarD.Fitoterapia.1990;61(2):99-111.PrasadDN,DasPK,SinghRS.JResIndMed.1966;1:120.DasPK,etal.JResIndMed.1974;9:49.SinghS,etal.Fitoterapia.1997;68(1):9-16.GeethaT,VaralakshmiP.GenPharmacol.1999;32(4):495-497.GeethaT,VaralakshmiP.Fitoterapia.1998;69(1):13-19.DeshpandePJ,SahuM,KamurP.IndianJMedRes.1982;76(suppl):46-53.

10VaralakshmiP,ShamilaY,LathaE.JEthnopharmacol.1990;28(3):313-321.

11AnandR,etal.Fitoterapia.1993;64:345.12VaralakshmiP,etal.JEthnopharmacol.1991;31(1):67-73.13BaskarR,SaravananN,VaralakshmiP.IndianJClin

Biochem.1995;10(2):98-102.14AnandRetal:Fromtheproceedingsofthe24thIndianPharmacologicSocietyConference,Ahmedabad,Gujarat,India,December29-31,1991,abstractA10.

15AnandR,etal.PhytotherRes.1994;8(7):417-421.16MaliniMM,BaskarR,VaralakshmiP.JpnJMedSciBiol.1995;48(5-6):211-220.

17VidyaL,VaralakshmiP.Fitoterapia.2000;71(5):535-543.18BaskarR,etal.Fitoterapia.1996;67(2):121-125.19MaliniMM,LeninM,VaralakshmiP.PharmacolRes.2000;41(4):413-418.

20NagarajM,SunithaS,VaralakshmiP.JApplToxicol.2000;20(5):413-417.

DAMIANA

BotanicalNames: Turneradiffusa,Turneraaphrodisiaca#

Family: TurneraceaePlantPartUsed: Leaf

# Alternativename.

PRESCRIBINGINFORMATION

Actions Nervinetonic,tonic,mildlaxative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingdamianainformulationsinthecontextof:

•Nervousness,anxiety,depression(5)

•Sexualinadequacy:impotence,frigidity(5,7)

•Nervousdyspepsia,constipation(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Anxiety,depression,nervousdyspepsia,constipation1

•Impotenceandfrigidityinbothsexes,1,2irritationoftheurinarymucousmembranes,renalcatarrh2

NativeBraziliansandMexicansuseddamiana,withearlydocumentedusebytheMayanpeople.UsesbynativenorthernMexicansincludedmuscularandnervousdebility,asanaphrodisiacandemmenagogue,formenstrualdisorders,toaidinchildbirth,andforspermatorrhea,orchitis,nephritis,andirritablebladder.Inadditiontotheaphrodisiacuses,HispanicherbalistsofMexicouseddamianaforsterility,nervousdisorders,anddiabetes.3-5DamianawasalsoconsumedinMexicoasapleasant,stimulating,tonicbeveragewithoutthesideeffectsofteaorcoffeeandwasemployedtherapeuticallyasahotdrinkforsuppressedmenstruation.6

DamianawasofficialintheNFfrom1916to1942andwasreferredtoasastimulantandlaxative,withareputationasanaphrodisiac.7

•Apostulatedexplanationfortheaphrodisiaceffectofdamianaisthatitsvolatileoilmightirritatetheurethralmucousmembranes.4

•Amethanolextractofdamianainducedrelaxationofisolatedsmoothmusclefromthecorpuscavernosum.8Oraladministrationofdamianaextract(0.25to1.0ml/kg)demonstratedastimulatingeffectonthesexualbehaviorofmalerats.Copulatoryperformancewasimprovedin

PharmacologicResearch

sexuallysluggishorimpotentanimals,butnotinpotentanimals.9

•Oraladministrationofdamianainfusionresultedinhypoglycemicactivityinanexperimentalmodel.10Aqueousalcohol(70%)and100%alcoholextractsofdamianainhibitedtheformationofgastriclesionsinseveralexperimentalmodelsafteroralorintragastricadministration.11

•Damianaextractdecreasedpsychomotoractivityinanexperimentalmodel(administeredbyinjection).12

ClinicalStudies Noclinicalstudiesusingdamianahavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.TylerVE.PharmHist.1983;25(2):55-60.BrinkerFJ.Eclecticdispensatoryofbotanicaltherapeutics,vol2.EclecticMedicalPublications,Sandy,Oregon,1995.LloydJU.PharmRev.1904;22:126.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

HnatyszynOetal:FromtheInternationalCongressand48thAnnualMeetingoftheSocietyforMedicinalPlantResearchandthe6thInternationalCongressonEthnopharmacologyoftheInternationalSocietyforEthnopharmacology,Zurich,September3-7,2000,abstractP2A/39.ArlettiR,etal.Psychopharmacology.1999;143(1):15-19.

10PerezRM,etal.JEthnopharmacol.1984;12(3):253-262.11GraciosoJS,etal.Phytomed.2000;7(supp2):92-93.12JuiJ.Lloydia.1966;29(3):250-259.

DANDELION

BotanicalName: TaraxacumofficinaleFamily: CompositaePlantPartsUsed: Leaf,root

PRESCRIBINGINFORMATION

ActionsDandelionleafandrootareconsideredtohavesimilaractions:bittertonic,choleretic,diuretic(especiallyleaf),mildlaxative,andantirheumatic.

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingdandelionleafordandelionrootinformulationsinthecontextof:

•Cystitis,incombinationwithuvaursi(2)

•Restorationofhepaticandbiliaryfunction,dyspepsia(4,5)

•Lossofappetite,flatulence,intestinalbloating,tostimulatediuresis(4)

•Edema(5,7)

•Oliguria,jaundice,gallstones,constipation,muscularrheumatism,chronicskindiseases(5)Boththetraditionalprescribinginformationandtheinformationobtainedfrompharmacologicresearchsuggestthatdandelionleafhasthestrongerdiureticactivityanddandelionroothasthestrongercholereticandcholagogueactivities.Thisdatashouldbereflectedinthepreferreduseofthespecificplantparts.

Contraindications

Dandelionleafandrootarecontraindicatedinclosureofthebileducts,cholecystitis,intestinalobstruction,1andknownallergy.(Asesquiter-penelactonefoundinbothleafandrootisresponsibleforcausingallergicdermatitis.Otherconstituentswithindandelionmayalsobeallergenic.2)

WarningsandPrecautions

Dandelionleaf:despitereportsofskinreactionsanddermatitisfromtopicaluseofdandelionaerialparts,thelikelihoodofdandelionleafpreparationscausingacontactallergyislow.However,peoplewithknownsensitivitytoothermembersoftheCompositaefamily(e.g.,ragweed,daisies,chrysanthemums)shouldavoidtopicalapplicationofdandelionleafordandelionleafproducts.

Dandelionroot:cautionisrequiredifgallstonesarepresent.3

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Dandelionleaf: Doseperday* Doseperweek*

6.0–11.5mlof1:1liquidextract

40–80mlof1:1liquidextract

Dandelionroot: Doseperday* Doseperweek*

3to6mlof1:2liquidextract

20to40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesofdandelionrootinclude:

•Cholecystitis,gallstones,jaundice;atonicdyspepsiawithconstipation,muscularrheumatism,oliguria4

•Sluggishnessandenlargementoftheliverorspleen;impaireddigestion,constipation5

•Dropsy,uterineobstruction,chronicskindiseases5

IntraditionalWesternherbalmedicine,theusesofdandelionleafaresimilartothoseofdandelionroot,buttheleafwasconsideredtobeweakerinactivitythantheroot(exceptfordiureticactivity).4

NativeAmericansuseddandelionrootforheartburnandasabittertonic.DandelionrootwasofficialintheUSPfrom1831to1926andremainedofficialintheNFuntil1965.Dandelionrootwasusedasadiuretic,tonic,andmildlaxative.6

NativeAmericansalsouseddandelionleafasatonic.6

Dandelionleaf:

•Inanearlyexperimentalstudy,adecoctionofdandelionleafadministeredbyinjectionwasshowntoincreasebilesecretion.7

•Oraladministrationofdandelionleafextracthadastrongdiureticeffect(evencomparedwithfrusemide)inanexperimentalmodel.Usinghighdoses,long-termweightlossresultingfromdiuresiswasobserved.Because

PharmacologicResearch

dandelionleafcontainspotassium,depletionofthismineralisnotaproblem.Infact,thediureticactivitymaybetheresultofthepotassiumcontent(seelaterdiscussion).Dandelionleafdemonstratedstrongeractivitythandiddandelionroot.8

Dandelionroot:

•Dandelionrootdecoctionincreasedbilesecretioninvivowhenadministeredbyinjection.Theactivitywasstrongerthanthatobservedfordandelionleaf.7

•Aspreviouslymentioned,dandelionrootextractalsodemonstratedamilddiureticeffectinanexperimentalmodel.8Diureticactivitywas,however,notobservedinanotherstudyaftereitheroralorintraperitonealadministrationduringa2-hourobservationperiod.9

•Fromtheresultsoftheirexperimentalstudy,theauthorsconcludedthatnoorganicsecondarymetabolitesshowingmajordiureticactivitywerepresentindandelionroot.Thehighpotassiumcontentofdandelionwasconsideredtobetheagentresponsibleforanydiureticactivity.10

•Ethanolextractofdandelionrootdemonstratedanalgesicandantiin-flammatoryactivitywhenadministeredbyinjection.9

•Oralpreadministrationofanaqueous-ethanolicextractofdandelionrootinhibitedexperimentallyinducededema.11Inanotherexperiment,intraperitonealtreatmentalsodemonstratedpartialinhibition.9

•Anethanolicextractofdandelionrootcausedadose-dependentinhibitionofadenosinediphosphate(ADP)–inducedaggregationinapreparationofhumanplatelet-richplasma.Arachidonicacid–andcollagen-inducedplateletaggregationwerenotinfluenced.12

Dandelion(partundefinedorcombined):

•Inaninvitrostudy,extractsofdandelionreducedenzymaticallyinducedlipidperoxidationandcytochromec(withandwithoutthereducedformofnicotinamide-adeninedinnucleotidephosphate[NADPH])inadose-dependentmanner.13

•Dandelioninhibitedtheproductionoftumornecrosisfactor-alpha(TNF-α)fromprimaryculturesofastrocytesbyinhibitinginterleukin-1production.14Inanearlierinvitrostudy,aqueoussolutionofdandelionrestoredthenitricoxideproductionfromγ-interferon-primedperitonealmacrophagesasaresultofTNF-αsecretion.15

•Dandelionextractswereshowntoincreasebilesecretioninexperimentalmodels.Acholereticeffectwasdescribedafteradministeringthedoseofdandelionbycannula.16,17

•Oraladministrationofdandelionrootandleafdidnotsignificantlyaffectglucosehomeostasisineithernondiabeticanimalsorstreptozotocin-induceddiabetes.18Inanotherstudy,oraldosesofwholedandelionproducedahypoglycemiceffectinnormalanimals,withoutasignificantresponseinalloxan-induceddiabetes.19

•Dandelionextractincreasedtheactivityofcytostaticandsurgicaltreatmentsinatransplantabletumormodel.Anindependentinhibitoryactiononthetumorandmetastaseswasalsoshown.Thetoxiceffectofcyclophosphamideonredbloodcellswaslessened.20Ahotwaterextractfromdandelionalsoshowedantitumoractivityfollowingintraperitonealadministration.21

•AnherbalpreparationcontainingCalendula,dandelion,St.John’swort,lemonbalm,andfennelreducedintestinalpaininanuncontrolledtrialinvolvingpatientswithchroniccolitis.Defecationwasnormalizedinpatientswithdiarrheasyndrome.22

ClinicalStudies

•Inarandomized,prospectivestudy,treatmentofuretericcalculiwitheitherspasmoanalgesictherapyoranherbalpreparationwascompared.Thepreparationcontaineddandelionrootandleaf,goldenrod,Rubiatinctorum,Ammivisnaga,andasmallamountofescin(aconstituentofhorsechestnutseed).Nosignificantdifferencewasobservedwithregardtothetransittimesofthestonesbetweenthetwogroups,butsideeffectsandtreatmentcostswerelessintheherbaltherapygroup.Thestrengthoftheherbalextractsinthesecapsuleswasnotdefined.23

•Inadouble-blind,placebo-controlled,randomized,clinicaltrial,57womenwithrecurrentcystitisreceivedeitherherbaltreatment(standardizeduvaursiextractanddandelionleafandrootextract)orplacebo.Treatmentfor1monthsignificantlyreducedtherecurrenceofcystitisduringthe1-yearfollow-upperiod,withnoincidenceofcystitisintheherbalgroupanda23%occurrenceintheplacebogroup.Nosideeffectswerereported.Thedoseoftheindividualherbswasnotspecified.24

•InGermany,theCommissionEsupportsusingdandelionleaftotreatlossofappetite,dyspepsia,bloating,andflatulence.Dandelionrootwithleafisrecommendedtotreatdisturbedbileflow,lossofappetite,anddyspepsia.Thiscombinationisalsousedtostimulatediuresis.3

•ESCOPrecommendsdandelionleafasadjuvanttherapyfortreatmentswhenenhancedurinaryoutputisdesirable,forexample,incasesofrheumatismandforpreventingrenalgravel.25

•ESCOPrecommendsdandelionrootforrestoringhepaticandbiliaryfunction,dyspepsia,andlossofappetite.25

REFERENCES

BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1993.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.ChabrolE,etal.CRSocBiol.1931;108:1100-1102.Racz-KotillaE,RaczG,SolomonA.PlantaMed.1974;26:212-217.TitaB,etal.PharmacologyResearch.1993;27(suppl1):23-24.

10HookI,McGeeA,HenmanA.IntJPharmacog.1993;31(1):29-34.

11MascoloN,etal.PhytotherRes.1987;1:28-31.12NeefH,etal.PhytotherRes.1996;10:S138-S140.13HagymasiK,etal.PhytotherRes.2000;14(1):43-44.

14KimHM,etal.ImmunopharmacolImmunotoxicol.2000;22(3):519-530.

15KimHM,etal.ImmunopharmacolImmunotoxicol.1998;20(2):283-297.

16BussemakerJ.Naunyn-SchmiedArchExperPatholPharm.1936;181:512-513.

17BohmK.ArzneimForsch.1959;9:376-378.18Swanston-FlattSK,etal.DiabetesRes.1989;10(2):69-73.19AkhtarMS,KhanQM,KhaliqT.JPMAJPakMedAssoc.1985;35(7):207-210.

20RazinaTG,etal.Rastitel’nyeResursy.1998;34(1):64-68.21BabaK,AbeS,MizunoD.YakugakuZasshi.1981;101:538-543.

22ChakurskiI,etal.VutrBoles.1981;20(6):51-54.23BachD,etal.ForschrMed.1983;101(8):337-342.24LarssonB,JonassonA,FianuS.CurrTherResClinExp.1993;53(4):441-443.

25ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Taraxacifolium/radix.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

DEVIL’SCLAW

OtherCommonNames: Harpagophytum,grappleplantBotanicalName: HarpagophytumprocumbensFamily: PedaliaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Antiinflammatory,antirheumatic,analgesic,bittertonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingdevil’sclawinformulationsinthecontextof:

•Rheumaticandarthriticconditions(2,4,5)

•Osteoarthritis(2,4)

•Chronicbackpain(2,5)

•Tendinitis(4)

•Lossofappetite,dyspepsia(4,6)

•Topicaltreatmentforskinlesions,suchaswoundsandulcers(6)

Contraindications

TheCommissionEadvisesthefollowingcontraindications:gastricandduodenalulcersandgallstones.However,anyhealthrisksaretheoreticalinnature,beingprojectedfromthebittertonicactivity.

WarningsandPrecautions Nonerequired.

Interactions

Acaseofpurpureawasreportedinapatienttakingwarfarinanddevil’sclaw.1However,keydetailsofthiscase,includingthepatient’smedicalcondition,othermedications,andthedosesanddurationofthewarfarinanddevil’sclawingestionwerenotreported.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsMildgastrointestinaldisturbancesmayoccurinsensitiveindividuals,especiallyatthehigherdoselevels.

Dosage Doseperday Doseperweek

6.0–11.5mlof1:2liquidextractforanalgesicandantirheumaticactivity*

40–80mlof1:2liquidextractforanalgesicandantirheumaticactivity*

3mlof1:2liquidextractforgastrointestinalcomplaints**

20mlof1:2liquidextractforgastrointestinalcomplaints**

Pharmacologicstudieshaveindicatedthatstomachaciditymightdecreasetheanalgesicandantiinflammatoryactivity.However,arecentstudyhasestablishedthatthisindicationisnotthecase.2

* Thisdoserangeisextrapolatedfromclinicalstudies.

** ThisdosageisextrapolatedfromtheGermanCommissionE.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Rheumatism,arthritis,gout,myalgia,fibrositis,lumbago,pleurodynia3

•Asageneraltonic,lossofappetite,digestivedisorders4

TraditionalSouthAfricanmedicinalusesinclude:

•Asapurgativeandbittertonic5

•Asananalgesic,especiallyduringandafterchildbirth5

•Febrilediseases,allergicreactions5

•Topicallyforulcers,wounds,cutaneouslesions,andafterchildbirth5

Keyconstituentsofdevil’sclawrootincludeiridoidglycosides(0.5%to3.0%),primarilyharpagoside,whichhasabittertaste.

•Devil’sclawextractreducedsubacuteinflammationinaninvivomodelofarthritisafteroralandintraperitonealadministration.Resultswerecomparabletophenylbutazone.Anotherstudyusingdifferentbutsimilarmodelsfoundthatdevil’sclawdidnotproducesignificanteffectsoneitherprimaryorsecondaryinflammatoryreactions.

•Oraldosesofdevil’sclawaqueousextractandharpagosidedemonstratedlittleornoactivityinacute

PharmacologicResearch

modelsofinflammation,suchascarrageenan-inducededema.However,intraperitonealpretreatmentwithdevil’sclawextractproducedsignificant,dose-dependent,antiin-flammatoryeffectsinthismodel.Devil’sclawroottreatedwithacidatlevelssimilartothatinthestomachlostallactivity(whenadministeredbyintraperitonealinjection).However,morerecentexperimentswithsimulatedstomachconditionsfoundthatharpagosidewasstable.2

•Theiridoidsfromdevil’sclawmaypossiblybetransformedintoalkaloidsinthegastrointestinaltract.Invitrotestsindicatethatseveralofthedevil’sclawiridoids,includingharpagoside,undergomicrobialtransformationtoformthealkaloidaucubinineB.6

•Bothinvitroandinvivostudieshavedemonstratedthatdevil’sclawhasminimaleffectonprostaglandinbiosynthesis.Thesestudiesindicatethatdevil’sclawisunlikelytoactbyasimilarmechanismtoNSAIDs.Hencetheherbwillnothavethesameirritanteffectsonthestomach.

•Injectionsofdevil’sclawextractandharpagosideexhibiteddose-dependentperipheralanalgesiceffectscomparabletoaspirin.Intraperitonealadministrationofharpagosideproducedananalgesiceffectcomparabletophenylbutazone.However,theaglyconeofharpagosidewasinactive.Noconsistentanalgesiceffectswerefoundinanexperimentalmodelafteroraldosesofdevil’sclawextract.

•Devil’sclawextractinhibitedthesynthesisofprostaglandinsbyinhibitingcyclooxygenase-2andinhibitedthereleaseofTNF-αfromprimaryhumanmonocytes(aninvitromodelofperipheralinflammation).7

•Afteroraladministration,devil’sclawextractloweredarterialbloodpressuredose-dependently,witha

concomitantdecreaseinheartrate,inanexperimentalmodel.8Devil’sclawextractprotectedagainstexperimentallyinducedarrhythmiainvitroandinvivoafteroralandintraperitonealadministration.8,9

ClinicalStudies

•Inarandomized,double-blind,controlled,multicenterstudy,devil’sclawpowdertakenoveraperiodof4monthssignificantlyreducedbothspontaneouspainandfunctionaldisability,anditwasasefficaciousaswasdiacerhein(ananthroneanalgesic)inpatientswithosteoarthritisofthekneeandhip.ThenumberofpatientsusingNSAIDsandotheranalgesicdrugsatthecompletionofthestudy,andthefrequencyofadverseevents,wassignificantlylowerinthedevil’sclawgroup.Thedailydosewas2.6goffreeze-driedpowdercontaining87mgoftotaliridoidand57mgofharpagoside.10,11

•Inpatientswitharthrosisandarticularpain,devil’sclawextractdecreasedtheseverityofpainwhencomparedwithplacebointworandomized,double-blindstudies.Improvementsweremorefrequentinmoderatecasesofarthrosisthantheywereinseverecases.Spinalmobilitywasalsoincreasedcomparedwithplacebointhearticularpaintrial.Thearthrosispatientsreceived2.4gperdayofanextract(containing36mg/dayofiridoidglycosides)for3to9weeksandthosewitharticularpainreceived2.0gperdayofanextract(containing60mg/dayofiridoidglycosides)for8weeks.

•Inanotherrandomizedstudyinpatientswithchronicbackpain,treatmentwithdevil’sclawextract(equivalentto6g/dayofrootandcontaining50mg/dayofharpagoside)for4weeksdemonstratedagreaterreductioninabackpainindexthandidplacebo.Thereductioninpain,however,wasconfinedalmostexclusivelytothesub-groupofpatientswhosepaindidnotradiatetooneorbothlegs.Morepatientsinthetreatmentgroupwerepain-freecomparedwiththeplacebogroupattheendofthetreatment.Asubsequentstudyofsimilardesignconfirmed

thatmorepatientsreceivingdevil’sclawextract(equivalentto4.5g/dayor9g/dayofrootandcontaining50mg/dayor100mg/dayofharpagoside,respectively)for4weekswerepain-freecomparedwithplacebo.12

•Inalarge,uncontrolledstudyofpatientswithvariousrheumaticill-nesses,42%to85%ofpatientsshowedsignificantimprovementafter6months’treatmentwithdevil’sclawextract(75to225mg/dayofiridoidglycosides).However,oneopenstudyof13patientswithrheumatoidarthritisandpsoriaticarthropathyfoundnobenefitfromdevil’sclawtreatment.

•InGermany,theCommissionEsupportsusingdevil’sclawtotreatlossofappetiteanddyspepsiaandassupportivetherapyfordegenerativedisordersofthemusculoskeletalsystem.13

•ESCOPrecommendsdevil’sclawfortreatingpainfularthrosis,tendinitis,lossofappetite,anddyspepsia.14

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.HeckAM,DewittBA,LukesAL.AmJHealth-SystPharm.2000;57(13):1221-1227.LoewD,PuttkammerS.ChrubasikS,RoufogalisBD,editors.Herbalmedicinalproductsforthetreatmentofpain.Lismore,NSW,Australia:SouthernCrossUniversityPress,2000.

CitedinBritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.vanWykB-E,vanOudtshoornB,GerickeN.MedicinalplantsofSouthAfrica.Arcadia,SouthAfrica:BrizaPublications,1997.RagusaS,etal.JEthnopharmacol.1984;11(3):245-257.FleurentinF.ChrubasikS,RoufogalisBD,editors.Herbalmedicinalproductsforthetreatmentofpain.Lismore,NSW,Australia:SouthernCrossUniversityPress,2000.CitedinKammererN,FiebichB.ChrubasikS,RoufogalisBD,editors.Herbalmedicinalproductsforthetreatmentofpain.Lismore,NSW,Australia:SouthernCrossUniversityPress,2000.CitedinCircostaC,etal.JEthnopharmacol.1984;11(3):259-274.CostadePasqualeR,etal.JEthnopharmacol.1985;13(2):193-194.

10ChantreP,etal.Phytomed.2000;7(3):177-183.11LeblanD,ChantreP,FournieB.JointBoneSpine.2000;67(5):462-467.

12ChrubasikS,etal.EurJAnaesthesiol.1999;16(2):118-129.13BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

14ScientificCommitteeoftheEuropeanScientificCooperative

onPhytotherapy[ESCOP].ESCOPmonographs:Harpagophytiradix.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

DONGQUAI

BotanicalNames: Angelicasinensis,Angelicapolymorphavar.sinensis#

Family: UmbelliferaePlantPartUsed: Root

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antiinflammatory,antianemic,antiplatelet,femaletonic,mildlaxative,antiarrhythmic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingdongquaiinformulationsinthecontextof:

•Dysmenorrhea,*incombinationwithCorydalis,whitepeony,andLigusticum(4)

•Femalereproductivedisorders,irregularmenstruation,amenorrhea(5)

•Chronichepatitisandcirrhosis(4)

•Constipation,abdominalpain,swellings,bruising(5)

•Tinnitus,blurredvision,palpitations(5)

•Adoucheforinfertility(4)

Contraindications

ThefollowingcontraindicationsapplyfromTCM:diarrheacausedbyweakdigestion,hemorrhagicdisease,bleedingtendencyorveryheavyperiods,firsttrimesterofpregnancy,tendencytospontaneousabortion,andacuteviralinfectionssuchasthecommoncoldandinfluenza.

WarningsandPrecautions Nonerequired.

Interactions Cautionisadvisedforpatientsreceivingchronictreatmentwithwarfarin.

UseinPregnancyandLactation

Contraindicatedinthefirsttrimesterofpregnancy,especiallyinhigherdoses.

SideEffects

Acaseofamanwhodevelopedgynecomastia(mammaryglandularhyperplasia)afteringestionofdongquaicapsuleshasbeenreported.Thelabelindicated“100%dongquai(Angelicasinensis)rootpowder.Nofillersoradditives.”1

Dosage Doseperday** Doseperweek**

4.5–8.5mlof1:2liquidextract

30–60mlof1:2liquidextract

* DongquaihasalsobeenusedinTCMfortreatingdysmenorrhea.(5)

** ThisdoserangeisadaptedfromdriedplantdosesadministeredbydecoctioninTCM.2Theauthor’sexperienceandthefactthatethanol-waterisamoreeffectivesolventthanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Strengtheningtheheart,lung,andlivermeridians,lubricatingthebowel,invigoratingandharmonizingtheblood,treatingcongealedbloodconditions1

•Irregularmenstruation,amenorrhea,dysmenorrhearesultingfrombloodstasisoranemia2-4

•Constipation,abdominalpain;tissuetrauma,swellings,bruising,boils,rheumatism;headache,tinnitus,blurredvision,palpitations.2-4

PharmacologicResearch

•Thewholeroothasshownastimulanteffectinvivo.Otherstudieshaveshownthatdongquaicanrelaxorcoordinateuterinecontractions,dependingonuterinetone.Therootisdevoidofestrogenicaction.

•Dongquaicanprolongtherefractoryperiodandcorrectexperimentalatrialfibrillation.Boththeaqueousextractofdongquaiandferulicacidinhibitedplateletaggregationandserotoninreleaseinvitro.

•Inexperimentalmodels,dongquaiwasshowntopreventcoronaryatherosclerosis,lowerbloodpressure,dilatethecoronaryvessels,increasecoronaryflow,reducebloodcholesterol,andreducerespiratoryrate.

•Dongquaiexertedastimulatingeffectonhematopoiesisinbonemarrow.

•Dongquaimightsomewhatcounterthe

immunosuppressiveeffectsofhydrocortisoneinvivobutisnotaseffectiveasisAstragalus.

•Dongquaihadaproliferativeeffectonmusclecellsinvitro.

•Dongquaihasdemonstratedhepatoprotectiveeffects,astimulatingeffectontheliver,anantiinflammatoryeffect,andmusclerelaxantproperties,allinvivo.

ClinicalStudies

•Acombinationofdongquai,Corydalis,whitepeony,andLigusticumwallichiishoweda93%improvementratefortreatingdysmenorrheainanuncontrolledtrial.

•Infertilityresultingfromtubalocclusionwastreatedforupto9monthswithuterineirrigationofdongquaiextractinanuncontrolledtrial.Nearly80%ofpatientsregainedtubalpatency,and53%becamepregnant.

•Inanuncontrolledtrial,dongquaiimprovedabnormalproteinmetabolism,improvedabnormalthymolturbiditytestresults,andincreasedplasmaproteinlevelsin60%ofpatientswithchronichepatitisorhepaticcirrhosis.

•InChina,aninjectioncontainingdongquaihasbeensuccessfullyusedtotreatBuerger’sdiseaseandconstrictiveaortitis.

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.GohSY,LohKC.SingaporeMedJ.2001;42(3):115-116.

PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.

ECHINACEA

OtherCommonName: PurpleconeflowerBotanicalNames: Echinaceaangustifolia,EchinaceapurpureaFamily: CompositaePlantPartsUsed: Root,aerialparts

PRESCRIBINGINFORMATION

Actions Immunemodulating,immuneenhancing,depurative,antiinflammatory,vulnerary,lymphatic,sialagogue

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingEchinacearootinformulationsinthecontextof:

•Treatingandpreventingupperrespiratorytractinfections(1,4,5)

•Treatingandpreventinginfectionsingeneral(5)

•Enhancingimmuneresponseinhealthyindividuals(4)

•Nasopharyngealcatarrh,respiratorycatarrh,chronicbronchitis(5)

•Sinusitis,incombinationwithThujaandBaptisia(3)

•Adjuvanttherapyforcancer(5)

•Abscess,boils,poorlyhealingwounds,furunculosis,eczema,psoriasis,mouthulcers,venomousbites,skinandglandularinflammations(5)

Contraindications

NoconclusiveevidencehasbeenfoundthatusingEchinaceaforlongperiodsisdetrimentalorthatitiscontraindicatedindisorderssuchasautoimmunedisease,allergies,andasthma.TheriskofallergicreactiontoEchinaceaitselfisverysmall,especiallyifpreparationsoftherootareused,giventhatthesearefreeofpollens.

WarningsandPrecautions

Cautionisadvisedfortransplantpatientstakingimmunosuppressivedrugs;short-termtherapyonlyissuggested.MisinformationexiststhatEchinaceaispotentiallyhepatotoxicbecauseofthepresenceofpyrrolizidinealkaloids(PAs).However,thePAsfoundinEchinaceapossesschemicalstructuresthatareknowntobenontoxic.

Allergicreactions,mainlycontactdermatitis,mayoccurrarelyinsusceptiblepatientssensitizedtoEchinaceaaerialpartsandplantsfromtheCompositaefamily.ThelikelihoodofEchinacearootpreparationscausingallergyisverylow.

Interactions Seethe“WarningsandPrecautions”sectioninthismonograph.

UseinPregnancyandLactation

Noadverseeffectsexpected.

Aprospective,controlledstudypublishedin2000concludedthatgestationaluseofEchinacea(generallyfor5to7days)duringorganogenesiswasnotassociatedwithanincreasedriskofmajormalformations.Nosignificantdifferenceswerefoundinpregnancyoutcomebetweenthestudygroup,including206womenwhohadusedEchinaceaduringpregnancy(112womeninthefirsttrimester)andtheirmatchedcontrols.1

SideEffects Sideeffectsaregenerallynotexpectedfororalortopicaladministration.

Dosage

Floweringtops,aerialparts,root,andwholeplantofEchinaceaareusedmedicinally.Intraditionalherbalmedicine,therootwasthepreferredplantpartthatNativeAmericansandtheEclecticphysiciansused.OnlydosesfortheuseoftherootofthepreferredEchinaceaspeciesareprovidedhere.

Echinaceapurpurearoot: Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

4.5–8.5mlof1:3glycetract 30–60mlof1:3glycetract

Echinaceaangustifoliaroot: Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

PreparationscontainingablendofEchinaceapurpurearootandEchinaceaangustifoliaroot:

Doseperday* Doseperweek*

3–6mlofblended1:2liquidextracts

20–40mlofblended1:2liquidextracts

* This dose range is extrapolated from the British Herbal Compendium 1992 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.GalloM,etal.ArchInternMed.2000;160(20):3141-3143.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983EllingwoodF,LloydJU.Americanmateriamedica,

therapeuticsandpharmacognosy,ed11.Portland:EclecticMedicalPublications,1983.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.AwangDVC.AlternTherWomen’sHealth.1999;July:57-59.RehmanJ,etal.ImmunLett.1999;68(2-3):391-395.BarrettB,VohmanM,CalabreseC.JFamPrac.1999;48(8):628-635.MacIntoshAetal:Publicationinpress.LindenmuthGF,LindenmuthEB.JAlternComplementMed.2000;6(4):327-334.

10TurnerRB,RikerDK,GangemiJD.AntimicrobAgentsChemother.2000;44(6):1708-1709.

11ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Echinaceaepurpureaeradix.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,October1999.

ELDERFLOWER

BotanicalName: SambucusnigraFamily: CaprifoliaceaePlantPartUsed: Flower

PRESCRIBINGINFORMATION

Actions Diaphoretic,anticatarrhal

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingelderflowerinformulationsinthecontextof:

•Thecommoncold(4,5)

•Conditionsrequiringdiaphoresis,suchasfeversandinfluenza(5)

•Acuteandchronicsinusitis,hayfever(5)

•Pleurisy,bronchitis,sorethroat,measles(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2–6mlof1:2liquidextract

15–40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Asadiaphoreticinanyconditionrequiringfevermanagement,includingthecommoncoldandinfluenza(particularlyintheearlystages);sinusitis,chronicnasalcatarrhwithdeafness,1pleurisy,bronchitis,sorethroat,measles,fevers,scarletfever2

•Topicallyforinflammationoftheeyes,skindisorders,wounds,2andburns3

EclecticphysiciansregardedwarminfusionsofSambucuscanadensis,asimilarherb,asdiaphoreticandwarmingandcoldinfusionsasdiureticanddepurative.ThereforeSambucuscanadensiswasalsousedtotreatskininfectionsandliverdisorders.3

PharmacologicResearch

•Aqueousextractofelder(partundefined)demonstratedaninsulinreleasingandinsulinlikeactivityinvivo(routeunknown).Thefollowingisolatedconstituentsdidnotstimulateinsulinsecretion:lectin,rutin,lupeol,andβ-sitosterol.4Inanearliertrial,oraladministrationofaqueousextractofelder(partunknown)didnotaffectglucosehomeostasisundereithernormalorinduceddiabeticconditions.5

•Aqueousextractofelder(partunknown)increasedurineflowandurinarysodiumexcretioninvivo(routeunknown).6Adiureticeffectwasobservedafterintragastricadministrationofelderflowerinfusionandanextracthighinpotassiumandflavonoids.7

•Amethanolicextractofelderflowerinhibitedthe

biosynthesisofthefollowingcytokinesinvitro:interleukin-1α,interleukin-1β,andTNF-α.8Mildantiinflammatoryactivitywasdemonstratedafterintragastricadministrationofelderflowerextractinanexperimentalmodel.9

•Intraperitonealadministrationofanunsaponifiablefractionofelderflowermoderatelyenhancedphagocytosisinvivo.10

•Earlystudiesreportedthatelderflowerincreasedtheresponseofthesweatglandstoheatstimuli.11,12

ClinicalStudies

•Anincreaseindiaphoresisinhealthyvolunteershasbeenreported,12althoughtheoriessuggestedthattheeffectwascausedbythelargeamountofhotfluidconsumed.13

•InGermany,theCommissionEsupportsusingelderflowertotreatthecommoncold.14

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrayAM,Abdel-WahabYH,FlattPR.JNutr.2000;130(1):15-20.Swanston-FlattSK,etal.DiabetesRes.1989;10(2):69-73.

BeauxD,FleurentinJ,MortierF.PhytotherRes.1999;13(3):222-225.RebueltaM,etal.PlantesMedPhytother.1983;17:173-181.YesiladaE,etal.JEthnopharmacol.1997;58(1):59-73.MascoloN,etal.PhytotherRes.1987;1:28-31.

10DelaveauP,LallouetteP,TessierAM.PlantaMed.1980;40(1):49-54.

11SchmersahlKJ.Naturwissenschaften.1964;51:361.12WiechowskiW.MedKlin.1927;23:590-592.13BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.

14BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

ELECAMPANE

BotanicalName: InulaheleniumFamily: CompositaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Expectorant,diaphoretic,antibacterial,spasmolytic,bronchospasmolytic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingelecampaneinformulationsinthecontextof:

•Respiratorycatarrhandinfections(5)

•Thecommoncold,influenza,bronchitis,asthma(5)

•Possibletreatmentforpepticulcerdiseaseandintestinalworms(4a)

Contraindications Seethe“UseinPregnancyandLactation”sectioninthismonograph.

WarningsandPrecautions

CautionisadvisedinpeoplewithknownsensitivitytoelecampaneortoothermembersoftheCompositaefamily.

Interactions Noneknown.

UseinPregnancyandLactation

AccordingtotheBritishHerbalCompendium,elecampaneiscontraindicatedinpregnancyandlactation.1However,nosubstantialbasishasbeenfoundforthisconcern.

SideEffectsOccasionalallergicreactionsmayoccurbecauseofsensitivitycausedbythesesquiterpenelactonespresentinelecampane.2,3

Dosage Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Compendium 1992 and the

author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Catarrhalconditionsoftherespiratorytract,especiallybronchitis,irritatingcoughinchildren,tuberculosis,andasthma1,4,5

•Sustainingthestrengthofthepatientinchronicdisordersoftherespiratorytract5

•Dyspepsia,nightsweats4

•Internallyandexternallyforskinconditions4

Eclecticphysiciansregardedelecampaneasanimportantremedyforirritationofthetracheaandbronchi,thuselecampanewasusedincaseswithfreeandabundantexpectoration,teasingcough,andsubsternalpain,suchassevereformsofthecommoncoldandinfluenza.5

PharmacologicResearch

Elecampanerootcontainssesquiterpenelactonesoftheeudesmanolide-type:alantolactone,isoalantolactone,andtheirderivatives.1

•ElecampaneextractdemonstratedactivityagainstMycobacteriumtuberculosisinvitro.Theeudesmanolidesweretheactiveconstituents.6Antibacterialactivitywasdemonstratedagainstorganismsthatcausebrucellosisandanthraxforanelecampaneextract(0.5%to1.0%).Activityagainststaphylococciandhemolyticstreptococciwereweaklydisplayed.Nosignificantresultswereobtainedinvivoforbrucellosisoranthrax.7

•ElecampaneessentialoildemonstratedantibacterialactivityinvitroagainstStaphylococcusaureusand

Streptococcuspyogenesinconcentrationsaslowas1.2%.8

•Elecampaneessentialoildemonstratedarelaxanteffectonisolatedtrachealandilealsmoothmuscle.9

•Oralorintragastricadministrationofeudesmanolidesincreasedintra-gastrictemperatureinanexperimentalmodel,whichwasindicativeofincreasedbloodsupplyandbloodflowinthegastricmucosa.10

•Japanesescientistsdemonstratedtheinvivoanthelminticpropertiesoftheeudesmanolidesfromelecampane,particularlyalantolactone,inthe1940s.11,12

ClinicalStudies

•Apreparationofisolatedeudesmanolidesdemonstratedulcerhealingproperties,relievedsymptoms,andimprovedgastricmucosalcirculationinanuncontrolledtrialinvolving102patientswithpepticulcerdisease.13

•Oraladministrationofalantolactone(9to200mg)tochildrenfrom7to14yearsofageproducedasafe,favorableanthelminticeffectforAscarisinfestation.14

REFERENCES

BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.LamminpaaA,etal.ContactDermatitis.1996;34(5):330-335.AlonsoBlasiN,etal.ArchDermatolRes.1992;284(5):297-302.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983CantrellCL,etal.PlantaMed.1999;65(4):351-355.BulanovPA.IzvestAkadNaukKazakhSSRSerMicrobiol.1949;1:40-46.BoattoG,PintoreG,PalombaM.Fitoterapia.1994;65(3):279-280.ReiterM,BrandtW.ArzneimForsch.1985;35(1A):408-414.

10LuchkovaMM.FiziolohichnyiZh.1977;23(5):685-687.11Anon.JapanJMedSciIVPharmacol.1941;13(3):75-93.12Anon.JapanJMedSciIVPharmacol.1941;11(2-3):110-112.

13LuchkovaMM.VrachebnoeDelo.1978;6:69-71.14OzekiS,KotakeM,HayashiK.ProcImpAcad.1936;12:233-234.

ELEUTHEROCOCCUS

OtherCommonName: Eleuthero,Siberianginseng

BotanicalNames: Eleutherococcussenticosus,Acanthopanaxsenticosus#

Family: AraliaceaePlantPartUsed: Root

# Alternativename.

PRESCRIBINGINFORMATION

Actions Adaptogenic,immunemodulating,tonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingEleutherococcusinformulationsinthecontextof:

•Enhancingimmunefunctioninhealthyindividuals(2)

•Improvingmentalperformance(4)

•Improvingphysicalperformance(4,5)

•Environmentalandoccupationalstress(3,4)

•Minimizingtheeffectsofstressinpatientssubjecttochronicillness(4)

•Convalescence,includingafterantibiotictherapy;adjuvanttherapyfordysentery(4)

•Adjuvanttherapyforcancer,toimproveimmunefunctionanddecreasesideeffectsfromorthodoxtherapy(4)

•Exhaustion,insomnia,milddepression(4,5)

Contraindications

Eleutherococcusisbestnotusedduringtheacutephaseofinfections.AlthoughsomemedicalscientistsandregulatorybodiesconsiderEleutherococcustobecontraindicatedinhypertension,italsohasbeenusedtotreathypertension.

WarningsandPrecautions Nonerequired.

Acaseofapparentelevatedserumdigoxinlevels

Interactions

attributedtoconsumptionofanunauthenticated“Eleutherococcus”producthasbeenreported.AstowhetherEleutherococcuscausedarealincreaseinserumdigoxinlevelsratherthananinterferencewasinconclusivewiththetestmethodused.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

RussianstudiesonEleutherococcushavenotedageneralabsenceofsideeffects.However,careshouldbeexercisedinpatientswithcardiovasculardisordersbecauseinsomnia,palpitations,tachycardia,andhypertensionhavebeenreportedinafewcases.Sideeffectsaremorelikelyifnormaldosesareexceeded.“Ginsengabusesyndrome”withinsomnia,diarrhea,andhypertensionhasbeendescribed,butthestudydidnotdifferentiatebetweenKoreanginseng(Panaxginseng)andEleutherococcus.

Dosage Doseperday* Doseperweek*

2–8mlof1:2liquidextract

15–55mlof1:2liquidextract

ExtractsprovidingstandardizedlevelsofeleutherosideEarerecommended.Ideally,aqueousethanolextractsshouldcontainatleast0.5mg/mlofeleutherosideE.

Maintenancedosesforhealthyindividualsshouldbetowardthelowerendofthedoserange,buthigherdosesshouldbeusedfortreatingillnessandforhighstresssituations,includingathletictraining.

Therecommendedregimeforhealthypeopleisacourseof6weeksfollowedbya2-weekbreak.Thisregimecanberepeatedforaslongasisnecessary.Fortreatingspecificillnesses,continuoususeispreferable.

* Thisdoserangeisbasedonthoseusedinclinicaltrials.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Toreinforceqi,toinvigoratethefunctionofthespleenandkidney,tocalmthenerves1

•Poorfunctioningofthespleenandkidneymarkedbygeneralweakness,fatigue,anorexia,andachingofthelowerbackandknees1

•Insomniaanddream-disturbedsleep1

TraditionalWesternherbalmedicineusesincludetemporaryfatigue,generaldebility,andchronicinflammatoryconditions2

KeyconstituentsofEleutherococcusrootincludetheeleutherosides(achemicallydiversegroupofcompounds),triterpenoidsaponins,andglycans.

•ExperimentalstudieshaveshownthatEleutherococcus,itscomponents,orbothincreasedstaminaandresistancetostressors(heat,cold,immobilization,trauma,surgery,bloodloss,increasedordecreasedbarometricpressure,narcotics,toxins,andbacteria),protectedagainstthephysical,behavioral,functional,andbiochemicaleffectsofstress(oralroute),improvedlearningandmemory(oralroute),andexertedanimmune-enhancingeffectinimmuno-compromisedmice.

•Eleutherococcusincreasedsurvivalandpromotedtheself-repairmechanisminexperimentalirradiationstudiesafterintraperitonealororaladministration.

•Eleutherococcusinhibitedspontaneousmalignanttumorsandtumorsinducedbyanumberofcarcinogensinvivo.

PharmacologicResearch

Eleutherococcuspotentiatedtheeffectofsomecytotoxicdrugsinvitro,thusreducingtheamountofdrugneeded.

•ResistancetobacterialinfectionwasincreasedinexperimentalmodelsbypriordosingwithEleutherococcus.However,simultaneousadministrationwiththeinfectingorganismincreasedtheseverityofthedisease.AntiviralimmunitywasalsostimulatedinvivoandinvitrobyprioradministrationofEleutherococcus.

•Eleutherococcusimpededbothhypertrophyandatrophyoftheadrenalandthyroidglands,reducedbloodsugarinhyperglycemiaandincreaseditinhypoglycemia(invivobyoralroute),andnormalizedbothleukopeniaandleukocytosis.

•Eleutherococcusenhancedtheprotectiveeffectoftheanticoagulantsystemagainstcoagulantdrugsinvivobyoraladministration,increasedrepairindamagedheartmuscle,increasedthenumberofmitochondriaincardiacmuscle,increasedtheconversionoffatintoglycogenforenergy,andcounteredtheeffectsofcerebralischemiainexperimentalmodels.

•Eleutherococcusdemonstratedananaboliceffectbystimulatingweightgaininvivowhengivenorallyand,inothermodels,improvedeggweightandyieldandincreasedreproductivecapacity.

•AnantitoxiceffecthasbeendemonstratedinvivobythesimultaneousadministrationofdrugsortoxinswithEleutherococcus.

•Aplacebo-controlled,double-blindstudydemonstratedthatEleutherococcusextractimprovedmaximalworkcapacityby23.3%inmaleathletescomparedwitha7.5%increaseintheplacebogroup.Thedoseusedwasequivalentto300mg/dayofdriedrootandcontained2.12mgofeleutherosideBand0.48mgofeleutherosideE.

ClinicalStudies

Thedosewasadministeredfor8days.However,Eleutherococcusextractdidnotincreaseworkcapacityinhighlytraineddistancerunnersinarandomized,double-blind,placebo-controlledtrial.

•Arandomized,double-blind,placebo-controlled,crossovertrialinvolvingnineathletesconcludedthatEleutherococcussupplementationat1.2g/dayfor7daysbeforeeachofthetwotrialperiodsdidnotaltersteady-statesubstrateutilizationor10-kmcyclingperformancetime.3

•A40%reductioninlostworkdaysanda50%reductioningeneralillnessovera1-yearperiodwasobservedinacontrolledstudyof1000workersinaSiberianfactorywhoreceivedEleutherococcus.Themeandailytemperatureoftheregionwas−5°C(23°F).

•Thefollowingresults(comparedwithbaselinevalues)wereobtainedinhealthyvolunteerstreatedwithEleutherococcusextractfor1monthinarandomized,comparativetrial:increasedcellularimmunity,increasedoxygenconsumptionduringmaximalphysicalexercise,increasedaerobicmetabolismoftissues,anddecreasedbloodlevelsoftotalcholesterol,LDL-cholesterol,andtriglyceride.(ThecomparisonwaswithadministrationofEchinaceapurpureaaerialparts,whichdidnotproducesignificantresults.)4

•Eleutherococcusextract(equivalenttoapproximately6g/dayofdriedroot)significantlyincreasedT-helpercellandnaturalkillercellnumbersinhealthyvolunteersinadouble-blind,placebo-controlledtrial.

•Inuncontrolledtrials,Eleutherococcusextract:•Improvedtheperformanceandstaminaofexplorers,sailors,deepseadivers,mineandmountainrescueworkers,truckdrivers,pilots,factoryworkers,laborers,andcosmonauts

•Increasedenduranceandconcentrationintrackandfieldathletes,gymnasts,andweightlifters•Improvedrunningtimesbyanaverageof9%inlong-distancerunners•Improvedthestrengthoflargermusclesinathletes•Causedfasteractivationandgreaterintensityofperspirationinhealthyparticipantsexposedtoheatstress•Acceleratedreadingtimeanddecreasederrorsinproofreaders•Enhancednonspecificimmunity,minimizedthesideeffectsfromradiation,chemotherapyandsurgery,andimprovedhealingandwellbeinginpatientswithcancer•Alleviatedtheeffectsofprotracteddiseaseandlengthenedsurvivaltimeinpatientswithterminaldisease•Improvedwellbeingandlungcapacityinpatientswithchronicbronchitis,pneumoconiosis,andpneumonia•Improvedcardiovascularfunctionandgeneralwellbeinginpatientswithatheroscleroticconditionsandpatientswithrheumaticheartlesions•Loweredbloodpressureinpatientswithhypertensionandraiseditinthosewithlowbloodpressure•Significantlyraisedbloodpressureandperipheralresistanceinchildrenwithhypotension•Causedafasterresponsetomedicaltreatmentinchildrenwithdysentery•Alleviatedexhaustion,irritability,insomnia,andmilddepression•Assistedresettledpeopletoadapttotheirnewandharshenvironmentinthemountainous,desertareaofMongolia,asmeasuredbynormalizationintheparametersmeasured,includingworkcapacity5

•Patientswithantibiotic-induceddiarrheabenefitedfromEleutherococcusinapostmarketingsurveillancestudy.

•InGermany,theCommissionEsupportsusingEleutherococcusasatonicforinvigorationandfortificationintimesoffatigueanddebility,reducedcapacityforworkandconcentration,andduring

convalescence.6

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.EschbachLF,etal.IntJSportNutrExercMetab.2000;10(4):444-451.SzolomickiJ,etal.PhytotherRes.2000;14(1):30-35.ZhekalovAN.RastitResur.1995;31(4):87-91.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

EUPHORBIA

BotanicalNames: Euphorbiahirta,Euphorbiapilulifera#

Family: EuphorbiaceaePlantPartUsed: Aerialparts

# Alternativename.

PRESCRIBINGINFORMATION

Actions Expectorant,antiasthmatic,spasmolytic,antiprotozoal

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingEuphorbiainformulationsinthecontextof:

•Congestionandspasmoftherespiratorytract,especiallychronicbronchitis,laryngitis,asthma,emphysema,andwhoopingcough(5)

•Amebicdysenteryandpossiblyothergastrointestinalprotozoalinfections(4,6)

•Intestinalworms,boweldisorders(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Noneexpectediftakenwithintherecommendeddoserange.Basedontraditionalliterature,large(undefined)dosesofEuphorbiamaycausenauseaandvomiting,1anditmayoccasionallycauseepigastricdistresswithnausea.2

Dosage Doseperday* Doseperweek*

0.7–2.0mlof1:2liquidextract

5–12mlof1:2liquidextract

ClinicalstudiesshowthatEuphorbiacanremoveintestinalprotozoalparasites.3,4Inchroniccases,15to20mlof1:2extractcanbeusedforupto7days’

continuoustreatmentatatime.

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1949, theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Asthma,bronchitis,laryngealspasm,difficultbreathingofcardiacdisease,tuberculosis,emphysema,2,5thecommoncold1

•Intestinalamebiasis,5intestinalworms,boweldisorders,colic,dysentery,warts6

AboriginalAustraliansusedEuphorbiaforasthma,bronchitis,andemphysemaandasasedativeinrespiratoryconditions,althoughfindingssuggestthatitwasnotalwayseffectiveforasthma.6Adecoctionofthewholeplantwastakenasatreatmentfordebility.7

EuphorbiawasofficialintheNFfrom1916to1947andhad“somereputationasantiasthmatic.”8EclecticphysiciansregardedEuphorbiaasareliableantiasthmatic.2

Someofthepharmacologicresearchlistedhereused“wholeplant”extracts,whichprobablyincludedtheroot.TherootsofEuphorbiaspecieshavebeentraditionallyusedfortheiremeticandcatharticproperties.ThisresearchmaynotberelevanttoEuphorbiaextractmanufacturedfromaerialparts.

•Apolyphenolic-richextractofEuphorbiawholeplantdemonstratedantiamebicandspasmolyticactivityinvitro.9AqueousextractofEuphorbiawholeplantdemonstratedantibacterial,antiamebic,andspasmolyticactivityinvitro.TheseactivitiessupportthetraditionalCongoleseuseofEuphorbiaasanantidiarrhealagent.10Freeze-drieddecoctionofEuphorbiawholeplantdemonstratedantidiarrhealactivityinthreeexperimental

PharmacologicResearch

modelsofdiarrhea.Theflavonoidquercitrin,isolatedfromEuphorbia,hasdisplayedantidiarrhealactivity.11

•AstudyusinganinvitromodelverifiedinhibitoryactivityagainstAmoebaproteusforEuphorbia.Aqueousextractoffreshaerialpartsdemonstratedgreatercytotoxicactivitythandidextractsofdriedplantmaterial.12

•OraladministrationofEuphorbiawholeplantextractdemonstratedsignificantsuppressionofparasitemiainamalariamodel.13

•WaterandethanolextractsofEuphorbialeafadministeredbyintraperitonealinjectiondemonstratedadiureticeffectbyincreasingtherateofurineoutputandincreasingelectrolyteexcretion.14Freeze-driedaqueousextractofEuphorbiaaerialpartsstronglyinhibitedtheactivityofangiotensinconvertingenzyme(ACE)invitroanddecreasedwaterintakewhenadministeredbyinjection,whichisalsoindicativeofACEinhibition.15

•Euphorbiaextractreducedthereleaseofprostaglandinsandinhibitedplateletaggregationinvitro.Theextractalsodecreasedtheformationofcarrageenan-inducedpawedema(routeunknown).16Freeze-driedaqueousextractofEuphorbiahadanalgesic,antipyretic,andantiin-flammatoryactivityexperimentally(mostlikelybyinjection).Euphorbiaalsoexertedcentralanalgesicactivity.Theantiinflammatoryactivitywasstrongerinacutemodelscomparedwithchronicmodels.17Sedativeandanxiolyticeffectshavealsobeendemon-strated.17,18Theextractdidnotprotectagainstinducedconvulsions,didnotcausemusclerelaxanteffects,anddidnothaveaffinityforbenzodiazepinereceptors.Nohypnotic,neuroleptic,orsignificantantidepressantactivitywasobserved.However,theextractintensifiedtheactivityofbarbiturates.19

TheclinicalantiprotozoalactivityofEuphorbiahasbeen

ClinicalStudies

documented.Initialobservationsof53casesofamebicdysenterydemonstratedthata1:2extractofEuphorbiaquicklyandeffectivelycontrolledacutesymptoms.3Thedosageprotocolforadultswas20ml(equivalentto10gofherb)withsoupover3hours,then15ml(7.5gofherb)withsoupover3hours,followedby10ml(5gofherb)withsoupover3hours.Chroniccasesalsoshowedbenefit,thedosebeing20mlperday.AsubsequenttrialusingatablettedconcentrateofEuphorbiademonstratedasuccessfuloutcomein83%of150patientswithamebicdysentery.Disappearanceoftheparasiteandpainimprovementwererapidlyestablished,andfollow-upshowednorecurrenceafter5to12months.4

REFERENCES

GrieveM.Amodernherbal.NewYork:DoverPublications,1971.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983RidetJ,ChartolA.MedTrop.1964;24:119-143.MartinM,etal.MedTrop.1964;24:250-261.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.LassakEV,McCarthyT.Australianmedicinalplants.NorthRyde,NSW,Australia:MethuenAustralia,1983.AboriginalCommunitiesoftheNorthernTerritoryofAustralia,ConservationCommissionoftheNorthernTerritory.TraditionalaboriginalmedicinesintheNorthern

TerritoryofAustralia.Darwin,NT,Australia:ConservationCommissionoftheNorthernTerritoryofAustralia,1993.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.TonaL,etal.Phytomed.2000;7(1):31-38.

10TonaL,etal.Phytomed.1999;6(1):59-66.11GalvezJ,etal.PlantaMed.1995;59(4):333-336.12DuezP,etal.JEthnopharmacol.1991;34(2-3):235-246.13TonaL,etal.JEthnopharmacol.1999;68(1-3):193-203.14JohnsonPB,etal.JEthanopharmacol.1999;65(1):63-69.15WilliamsLAD,etal.PhytotherRes.1997;11(5):401-402.16HiermannA,BucarF.JEthnopharmacol.1994;42(2):111-116.

17LanhersMC,etal.PlantaMed.1991;57(3):225-231.18LanhersMC,etal.JEthnopharmacol.1990;29(2):189-198.19LanhersMC,etal.PhytotherRes.1996;10(8):670-676.

EYEBRIGHT

BotanicalNames:

Euphrasiaofficinalis,Euphrasiarostkoviana,#/+∧Euphrasiastricta#∧

Family: ScrophulariaceaePlantPartUsed: Aerialparts

# Alternativename.

+ Medicinallyinterchangeablespecies.

∧ AdoptedbytheAmericanHerbalProductsAssociationasthenewbotanicalname.1

PRESCRIBINGINFORMATION

Actions Astringent,anticatarrhal,mucousmembranetonic,antiinflammatory

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingeyebrightinformulationsinthecontextof:

•Catarrhalconditionsoftheupperrespiratorytract,sinusitis,chronicsneezing,hayfever,middleearproblems,sorethroat,catarrhalphaseofmeasles,thecommoncold(5)

•Inflammationorinfectionoftheeyes,includingconjunctivitis(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2.0–4.5mlof1:2liquidextract

15–30mlof1:2liquidextract

Fortopicaluseofeyebright(suchasfortreatmentofconjunctivitis),asolutionofapproximately5to6dropsofa1:2extractispreparedinaneyebathofrecentlyboiledwaterorsaline.Theliquidshouldbeallowedtocoolbeforeapplyingtotheeye.(Allowingthealcoholtoevaporatebeforeapplyingtotheeyeis

important.)

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Catarrhalconditionsoftheeyes,noseandears;sinusitis,conjunctivitis(internallyandlocally);thecommoncoldwithcopiousdischarge;thecatarrhalphaseduringandfollowingmeasles2,3

•Weaknessoftheeyesandeyesightdisorders4

•Catarrhalconditionsoftheintestinaltract;epilepsy3

PharmacologicResearch

Theaerialpartsofeyebrightcontainiridoidglycosides,includingaucubin.

•Aucubigenin,theaglyconeofaucubin,demonstratedantibacterialandantifungalactivityinvitro.

•Aucubinalonehadnoantiviralactivityinvitro.However,whenmixedwithβ-glucosidase(anenzymethatreleasestheaglyconefromtheglycoside),aucubindisplayedsignificantantiviralactivityagainsthepatitisB.

•Aucubigeninbyinjectionshowedantitumoractivityinexperimentalmodels,butaucubindidnot.

•Aucubindemonstratedantispasmodicactivityonisolatedtissue.Bothoralandtopicaladministrationresultedinanantiinflammatoryeffectinmodelsofedema.

ClinicalStudies

Noclinicalstudiesofinternaluseofeyebrighthavebeenfound.

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.McGuffinM,editor.Herbsofcommerce,ed2,Bethesda,Md:AmericanHerbalProductsAssociation,1998.[draft3.3]BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.

FALSEUNICORN

OtherCommonName: HeloniasrootBotanicalNames: Chamaeliriumluteum,Heloniasluteum#

Family: MelanthiaceaePlantPartUsed: Root

# Alternativename.

PRESCRIBINGINFORMATION

Actions Uterinetonic,ovariantonic,estrogenmodulating

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingfalseunicornrootinformulationsinthecontextof:

•Disordersofthefemalereproductivetract,includingamenorrhea,dysmenorrhea,ovarianpain,leukorrhea,prolapse,atonyofthereproductiveorgans,threatenedmiscarriage,andmorningsickness(5)

•Menopausalsymptoms,especiallyhotflashes(5)

•Infertility,sexuallassitude(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsNoneexpectediftakenwithintherecommendeddoserange.Verylarge(undefined)dosesaresaidtocausenauseaandvomiting.1,2

Dosage Doseperday* Doseperweek*

2–6mlof1:2liquidextract

15–40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Disordersofthefemalereproductivetract,especiallyamenorrhea,dysmenorrhea(particularlyofacongestivenature),anemiaassociatedwithreproductiveproblems,ovarianpain,leukorrhea,prolapse,atonyofthereproductiveorgans,threatenedmiscarriage,andmorningsickness1,3,4

•Menopausalcomplaints2

•Infertilityandsexuallassitudeinbothsexes3

TheEclecticphysiciansregardedfalseunicornrootasavaluableuterinetonic,impartingtoneandvigortothefemalereproductiveorgans,andusedittopromotenormalactivityoftheglandularorgans.3,5

NativeAmericansusedfalseunicornroot.FalseunicornwasofficialintheNFfrom1916to1947andwasusedasadiureticanduterinetonic.6

PharmacologicResearch

Falseunicornrootcontainssteroidalsaponinsthatmayexertestrogeniceffectsbybindingwithestrogenreceptorsofthehypothalamus.2Inthepremenopausalwoman,thisactionmayprovideanestrogeniceffect,andinthelow-estrogenenvironmentofmenopause,thesesaponinsmayrelievemenopausalsymptoms,especiallyhotflashes.

•Inanearlystudy,falseunicornrootextractdidnotdemonstrateanyactivityonisolateduterinetissue.7Alaterstudyconfirmedalackofstimulatoryactivityontheuterusinvivoafterinjection.8

ClinicalStudies

Noclinicalstudiesusingfalseunicornroothavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983EllingwoodF,LloydJU.Americanmateriamedica,therapeuticsandpharmacognosy,ed11.Portland:EclecticMedicalPublications,1983.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.PilcherJD.JPharmacolExpTherapeut.1916;8:110-111.PilcherJD,MauerRT.SurgGynecolObstet.1918;27:97-99.

FENNEL

BotanicalName: FoeniculumvulgareFamily: UmbelliferaePlantPartUsed: Fruit(sometimesreferredtoasseed)

PRESCRIBINGINFORMATION

ActionsCarminative,appetitestimulating,spasmolytic,galactagogue,estrogenmodulating,antimicrobial,expectorant

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingfennelinformulationsinthecontextof:

•Dyspepsia,*incombinationwithwormwood,caraway,andpeppermint(2)

•Chronicdigestiveproblems,bloating,flatulence,**incombinationwithcaraway,peppermint,andgentian(2)

•Infantilecolic,**incombinationwithlemonbalm,chamomile,vervain,andlicorice(3)

•Mildspasmodicgastrointestinalcomplaints,bloating,flatulence(4)

•Chronicnonspecificcolitis,incombinationwithdandelionroot,St.John’swort,lemonbalm,andCalendula(4)

•Upperrespiratorytractcatarrh(4)

•Abdominalpainwithanorexia,vomiting,anddiarrhea(5)

•Wheeze,shortnessofbreath,chroniccough,asagargleforpharyngitis(5)

•Suppressedlactation(5)

•Irritablebowelsyndrome(6)

•Possiblebenefitforobesity(6)

Contraindications Contraindicatedinpatientswhosufferfrom“celery-carrot-mugwort-spice”syndrome.

WarningsandPrecautions

Allergicreactionstofennelarerareandseemtobelimitedtooccupationalexposure.Apercentageofpatientswhoareallergictoceleryalsodisplayallergicreactionstofennel.Individualssensitizedtocarrot,forexample,mayalsohaveallergicreactionstoothervegetablesorspicesoftheUmbelliferaefamily(celery-carrot-mugwort-spicesyndrome).Allergicreactionsintheskinandrespiratorytracthavebeenreported.

Interactions Noneknown.

UseinPregnancyandLactation

Noadverseeffectsexpected,especiallywhenadministeredasinfusionsthatcontainaloweressentialoilcontentthandoextracts.Fennelhasalonghistoryofuseasagalactagogue.

SideEffects Allergicreactionoccursrarely,aspreviouslyindicated.Dosage Doseperday*** Doseperweek***

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

* ESCOPrecommendsfennelfortreatingdyspepsia.(4,5)

** Fennelhasbeenusedintraditionalherbalmedicinefortreatingthefollowingconditions:infantilecolic,chronicdigestiveproblems,andflatulence.(5)

*** ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983andtheauthor’s education and experience. The dosage listed in the British Pharmaceutical Codex1934indicatesthattheessentialoilisanintegralaspectofthedosage.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Flatulentcolic,especiallyininfants;flatulentdyspepsia,1,2irritablebowelsyndrome3

•Increasingreducedappetite1andsuppressionoffoodcravings4

•Wheezing,shortnessofbreath,chroniccough1

•Amenorrhea,suppressedlactation2

•Topicallytotreatconjunctivitisandblepharitis,asagargleforpharyngitis1

•Improvingthetasteofunpleasantmedicines2

UsesandpropertiesfromTCMinclude:

•Todispelcoldandrelievepain,toregulatestomachfunction5

•Abdominalpainwithanorexia,vomiting,anddiarrhea;dysmenorrheawithcoldsensation5

Fennelfruitcontainsanessentialoil,thequantityandcompositionofwhichdependsonthesubspecies:F.vulgaresubsp.vulgarevar.vulgare(bitterfennel)containsmorethan4%essentialoil;F.vulgaresubsp.vulgarevar.dulce(sweetfennel)containsmorethan2%.6

•Fenneloilandalcoholextractsoffenneldemonstratedanti-spasmodicactivityinseveralinvitromodelsusingisolatedsmoothmuscle.Thisactivitywasconfirmedinaninvivomodelfollowinginjection.

PharmacologicResearch

•Fennelwaterwasusedtodecreasethetoneandamplitudeofperi-stalsisinthestomach,smallintestine,andcoloninanexperimentalmodel.Anotherstudyfoundthatfennelappearedtorelaxsmoothmusclebyadirectlocalactivityandtostimulateitviathesympatheticnervoussystem.

•Inexperimentalmodels,acetoneextractsoffennel(routeunknown)inducedestrus(changesintheuterinemucosarelatedtothematingperiod)andcausedgrowthofmammaryglands,oviducts,thecervix,andvagina.Anantiandrogeniceffectwasalsoobserved.

•Inanexperimentalmodel,oraladministrationoffennelfruitextractcausedasignificantincreaseincollectedbilewhencomparedwithcontrols.

•Anethanolicextractoffennelfruitshowedsignificantdiureticactivitycomparedwithcontrols.Thediuresiswasnotassociatedwithchangesinsodiumorpotassiumexcretion.

•Fenneloiladministeredbyinhalationwasshowntohaveamildanti-tussiveorcoughsuppressanteffect.

•Severalstudieshavedemonstratedtheinvitroantibacterialactivityoffenneloil.

•Fenneloildisplayedafavorableinfluenceonthetotalquantityofmilk(anditsfatcontent)producedbygoats.

•Aliquidherbalformulacontainingfennel,wormwood,caraway(Carumcarvi),andpeppermintwasfoundtobesuperiortothespasmolyticdrugmetoclopramideinrelievingpain,nausea,belching,andheartburninarandomized,double-blind,clinicaltrialassessingtreatingdyspepsia.

•Inanotherrandomized,double-blind,placebo-

ClinicalStudies

controlled,clinicaltrial,patientswithmarkedchronicdigestiveproblemssuchasflatulenceorbloatingweretreatedwitheitheranherbalformulacontainingcar-away,fennel,peppermint,andgentianintabletformoraplaceboovera14-dayperiod.Significantimprovementwasachievedintheherbalgroupcomparedwithplacebo.

•Patientswithchronicnonspecificcolitisweretreatedwithacombinationcontainingdandelionroot,St.John’swort,lemonbalm,Calendula,andfennel.Bythefifteenthdayoftreatment,spontaneousandpalpablepainsalongthelargeintestinehaddisappearedin96%ofthepatients.Defecationwasnormalizedinpatientswithdiarrheasyndrome.

•Theeffectofaninstantherbalteapreparationcontainingchamomile,vervain,licorice,fennel,andlemonbalmoninfantilecolicwasassessedinaprospective,randomized,double-blindstudyinvolvingbabiesapproximately3weeksofage.After7days,colicscoresweresignificantlylowerintheherbalteagroupcomparedwiththeplacebogroup.Theteapreparationwasofferedwitheveryepisodeofcolic,upto150mlperdose,butnotmorethanthreetimesperday.Theexactcompositionofthepreparationwasnotdefined.

•InGermany,theCommissionEsupportsusingfenneltotreatmild,spasmodicgastrointestinalcomplaints,bloating,flatulence,andupperrespiratorytractcatarrh.7

•ESCOPrecommendsfennelfortreatingdyspepsiaandupperrespiratorycatarrh.8

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.

PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.EuropeanPharmacopoeiaCommission.Europeanpharmacopoeia,ed3.Strasbourg,France:EuropeanDepartmentfortheQualityofMedicineswithintheCouncilofEurope,1996.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Foeniculifructus.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

FENUGREEK

BotanicalName: Trigonellafoenum-graecumFamily: LeguminosaePlantPartUsed: Seed

PRESCRIBINGINFORMATION

Actions Appetitestimulating,galactagogue,antiinflammatory,demulcent,hypoglycemic,hypocholesterolemic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingfenugreekinformulationsinthecontextof:

•Managingdiabetesmellitus(bothinsulin-dependentandnon-insulin–dependent)(3,5)

•Lossofappetite(4,5)

•Dyspepsia,gastritis,debility,gastrointestinalinflammation(5)

•Preventingatherosclerosis(5,7)

•Promotinglactation(5)Contraindications Noneknown.

WarningsandPrecautions

Basedonarecentpharmacologicstudy(seelaterdiscussion),highdosesoffenugreekarenotrecommendedinpatientswithlowthyroidactivity.

Amedicalsourcecitesfenugreekashavingthepotentialtointeractwithwarfarinandpotentiallyincreasetheriskofbleeding.1Anothersourceindicatesthiscautionisbasedonthefactthatfenugreekcontainscoumarin.2Onescientificreferencedoescitethepresenceofcoumarininfenugreekseed.3Coumarindoesnot,however,increasetheriskofbleeding.Dicoumarol,acompoundformedfromcoumarinbybacterialactioninspoiledsweetcloverhay,haspowerfulanticoagulantactivity.Therequirementfor

Interactions

powerfulanticoagulantactivityishydroxylationofthecoumarinmoleculeinthe4position.Commonplantcoumarinsarenotsubstitutedatthispositionandthereforelacksignificantclinicalanticoagulantactivity,althoughsomedopossessmeasurableactivitywhengiventoanimalsinhighdoses.4

Aclinicaltrialhasfoundthatadministrationoffenugreekseed(5g/dayfor3months)didnotaffectplateletaggregation,fibrinolyticactivity,andfibrinogenlevels.5Acasehasbeenreportedsuggestingaprobableinteractionbetweenwarfarinandfenugreek,boldo(Peumusboldus),oranycombination.Apatientbeingtreatedwithwarfarindevelopedanincreaseininternationalnormalizedratio(indicatingdecreasedcoagulation),whichreturnedtonormalaftercessationoftheherbs.Thisherb-druginteractionwasobservedasecondtimeafterbothherbswerereintroducedafewdayslater.6

Largeorfrequentdoseoffenugreekmayinhibitironabsorption.7

UseinPregnancyandLactation

Noadverseeffectsexpected.Fenugreekistraditionallyusedtopromotelactation.

SideEffects

Noneexpectedforinternaluseiffenugreekistakenwithintherecommendeddoserange.Mildgastrointestinalupsethasbeenrecordedinasmallpercentageofpatientsduringaclinicaltrialusinghighdosesoffenugreekseed(25g/day).8

Excessiveconsumptionoffenugreekcanleadtoacurrylikebodyodorandmayberesponsiblefortheincorrectdiagnosisofmaplesyrupurinedisease.9(Thesubstanceresponsibleforthecharacteristicodorofmaplesyrupurinediseaseis4,5-dimethyl-3-hydroxy-2[5H]-furanone[sotolone],whichisalsopresentinbothfenugreekandmaplesyrup.10)

Frequentconsumptionof(dietary)fenugreekhasbeenassociatedwithanemiainEthiopianchildrenresultingfromtheinhibitionofironabsorption.7

AccordingtotheCommissionE,repeatedexternalusecanresultinundesirableskinreactions.11Twocasesofsevereallergicreactionhavebeenreportedafterinternalandtopicaluseoffenugreekseed.12

Dosage Doseperday* Doseperweek*

2.0–4.5mlof1:2liquidextract

15–30mlof1:2liquidextract

* ThisdosageisextrapolatedfromtheBritishHerbalPharmacopoeia1983.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Dyspepsia,anorexia,gastritis13,14

•Debilityandanorexiaofconvalescence1

•Toincreasemilkflowinnursingmothers15

•Uterineirritation;lowerrespiratorytractirritation2

•Topicallyforsorethroat,boils,myalgia,lymphadenitis,gout,wounds,andlegulcers;vaginalorrectalirritationorinflammation;chronicdisordersofthestomach,bowel,andliver1,2

TraditionalAyurvedicusesinclude:

•Asacarminative,tonic,andaphrodisiac16

•Dyspepsia,diarrhea,dysentery,colic,flatulence,rheumatism,enlargedliverorspleen,chroniccough17

•Asacoolingdrinkforpatientswithsmallpox(byinfusion)16

•Inagruelwithmilkandsugarasagalactagogue17

•Loweringserumcholesterol,triglyceride,andglucose;forantiathero-scleroticaction18

UsesandpropertiesfromTCMinclude:

•Coldsyndromeofthekidneyresultingfromyangdeficiencymarkedbypainandcoldnessinthelowerabdomen19

•Hernia;weaknessandedemaofthelegscausedbycolddamp19

FenugreekisalsousedinthetraditionalherbalmedicineofSoutheastAsiafortreatingfemaledisorderssuchasreducedmenstrualflow,dysmenorrhea,leucorrhea,andpostpartumpainandfever.20IntheMiddleEastandnorthernAfrica,fenugreekseedhastraditionallybeenaddedtothedietofpatientswithdiabetes.3,21,22

Constituentsoffenugreekseedsincludesteroidalsaponinsofthefuranostanolictype,alkaloids(includingtrigonelline),flavonoids,sterols,protein,aminoacids,proteinaseinhibitors,andcarbohydrates.23Coumarinisalsolistedaspresentinfenugreekseed.3Thefuranostanolglycosidesarebitterintaste.23Alcoholicextractsoffenugreekwillnotcontainasmuchcarbohydrate(includingthemucilaginousgalactomannans)aswilladecoctionofseed.Defattedfenugreekcontainssimilarlevelsofaminoacids,minerals,andvitaminsbutlessfatandsaponinthandoesfenugreekseed.

Thewholeseedsanddefattedseeds,beingrichinmucilage(solublefiber),lowerbloodcholesterollevels.Whetheralcoholicliquidextractsoffenugreekseedwillhavethiseffectisuncertain,althoughsaponinswillbepresent(whichareknowntolowercholesterolandlipids;seelaterdiscussion).

Bothfenugreekseedandfenugreekleafhaveshownhypoglycemicactivity.Inthestudiesoutlinedinthismonograph,onlyinformationontheseed(orpartundefined)islisted.(Theseedmightpossiblycontainthesamehypoglycemiccomponentsasdoestheleaf.)•Variousresultshavebeenobtainedforhypoglycemicactivityinvivousingdifferenttypesoffenugreekpreparations.Asummaryofresultsforthesepreparationsfollows:•Seedpowder:hypoglycemicactivityindiabeticand

normalmodels24•Suspension:noeffectonoralglucosetolerancetestinanormalmodel,hypoglycemiceffectinadiabeticmodel24•Decoction:hypoglycemicactivityinbothdiabeticandnormalmodels24andintransienthyperglycemia25•Defattedseed:hypoglycemicactivityinadiabeticmodelbutnoactivityinnormalmodels24•Defattedseedsubfractions:hypoglycemicactivityinadiabeticmodelforthesubfractioncontainingfiber;noactivityforthesub-fractionscontainingproteinplussaponin,protein,orsaponin24•Ethanolextract:hypoglycemicactivityinbothdiabeticandnormalmodels24•Saponins:highdosesgivenwithfoodincreasedfoodintakeandmotivationtoeatinnormalanimalsandstabilizedfoodconsumptioninadiabeticmodel26

•Themechanismbehindthehypoglycemicactivityandthecomponentsresponsibleforthisactivityarenotcertain.Thefollowingresultshavebeenobtained:•4-Hydroxyisoleucine,afreeaminoacidisolatedfromfenugreek,stimulatedglucose-inducedinsulinsecretionfrompancreaticisletcellsanddemonstratedhypoglycemicactivityinvivofollowingintravenousinjectioninnormalanddiabeticmodels.27,28•Trigonellinedisplayedhypoglycemicactivityinearlyresearch29butinmorerecenthumantrialshasbeendiscountedasanactivecomponent.24•Althoughthefibersubfractionhasdemonstratedactivity,excludingthecoexistenceofactivecompoundsotherthanfiberisnotpossible.Fiberandotherfenugreekcomponentsactingatthegastroin-testinallevelmayberesponsibleforimprovedglucoseandstarchtolerance.24•Fenugreekimprovesperipheralglucoseutilizationandmayexertantidiabeticactivityattheinsulinreceptor,aswellasatthegastrointestinallevel.24•Highdosesofanethanolextract(whichwererichinsaponins)increasedfoodintake,increasedthemotivation

PharmacologicResearch

toeat,andincreasedinsulinlevelsinnormalanimals.Thisactivityisaresultofeitheradirectstimulatoryeffectonthebetacellsoranindirecteffectrelatedtothepalatabilityandtheflavor-enhancingpropertyofthefenugreekextract.However,theextractwasinactiveagainstchemicallyinducedanorexia.24Innormalratsormice,theisolatedsaponinsalsoincreasedfoodintakeandthemotivationtoeat,whilemodifyingthecircadianrhythmoffeedingbehavior.26

•Fenugreekseedhasbeenshowninvariousanimalmodelstohavebeneficialeffectsonserumlipidprofiles.24Hypocholesterolemicactivityhasbeenassociatedmainlywithreducedintestinalreabsorptionofcholesterolandbileacids,whichhasbeenattributedtothesaponins-sapogeninsandthegalactomannangumfiber(mucilage).Hypolipidemicactivityhasonlybeenassociatedwiththesaponins-sapogeninsandnotwiththefiber.24Fenugreekalsoloweredlipidperoxidationandincreasedthelevelofantioxidantsinbloodinadiabeticmodel,comparedwithcontrols.30Fenugreekextractreducedthedepositionofcholesterolonaortawallsandreducedthenumberofaorticlesionsinanexperimentalmodelofearlyatheroscleroticprogression.31

•Fenugreek(2%ofthediet)enhancedpancreaticlipaseactivity32anddecreasedthelevelsofintestinalphosphatasesandsucrase33invivo.

•Pretreatmentwithaqueousfenugreekextractdidnotprotectagainstdrug-inducedgastriculcerationbutpromotedhealingwhenadministeredtoanimalswithulcers,possiblybecauseofitsmildanticholinergicanddemulcentproperties.34

•Dietaryfenugreekhadnoadverseeffectonfertilityorbirthoutcomeinvivo.35Thisfindingisincontrasttoearlierresearchpublishedin1969indicatingthataqueousandalcoholicfenugreekextractshadastimulatingeffect

onisolateduterus(andhighlightstheissuethatherbalresearchonisolatedorgansoftenhaslittlerelevancetoeffectsafteroralintake).36Theadditionoffenugreektothemother’sdietduringpregnancyandlactation,oronlyduringlactation,didnotincreasetheweightgainofyoungratpupscomparedwithcontrols.37

•Administrationofadried,aqueousethanolextractoffenugreekseed(0.1g/kg)tobothmiceandratssignificantlydecreasedserumT3concentrationandT3/T4ratio,butincreasedT4levels.TheinhibitioninT4toT3conversionwasnotperoxidation-mediated.Asignificantdecreaseinsuperoxidedismutaseactivitywasalsoobserved.38

•Fenugreekdecreasedthequantityofrenalcalciumoxalatedepositedinanexperimentalmodelofkidneystoneformation.39

•DietarylevelsoffenugreekstimulatedcytochromeP-450,cytochromeb5,andcytochromeP-450–dependentarylhydroxylaseinvivo.40

•Oraladministrationofanaqueoussuspensionoffenugreekseed(powderdissolvedinwater)promotedwoundhealinginthreewoundmodels.41

•Antiinflammatoryandantineoplasticactivityhasbeendemonstratedinanexperimentalmodelforalcoholicextractoffenugreekseedadministeredbyintraperitonealinjection.42

Dietaryfiberfromfenugreekhasbeenshowninopen,controlledtrialstoalleviatetheimbalancesassociatedwithlipidmetabolismdisordersandnon-insulin–dependentdiabetesmellitus.43Thebittertasteoffenugreekhasbeensuggestedasalimitationforitsuseinthedailydietsofpatientswithdiabetes,44whichmayexplainthecommonuseofdefatted(debitterized)extracts

ClinicalStudies

ofseedintrials.Manyclinicaltrialsevaluatingfenugreekhaveusedwholeseedordefattedseed,andinsomecases,highdoseswereadministered.Defattedseedcontainsmainlyfiberandprotein,withthelipidsandsaponinsremoved,andisodorlessandtasteless.Wholeseedcontainsmainlyfiberandproteinbutwithlipidsandsaponinsintact.

•Aweakandtransienthypoglycemiceffectwasobservedin50%ofpatientswithdiabetestreatedorallywith500mgoftrigonellineduringfasting.Administrationoftrigonellineatdosesof500mguptothreetimesperdayfor5daysdidnotdecreasediurnalbloodsugarlevels.29

•Fenugreek(5g/day)administeredtohealthyvolunteersfor3monthsdidnotaffectbloodsugarlevelscomparedwithbaselinevalueseitherafterfastingoraftermeals.5Inhealthyvolunteers,asingledoseofwholefenugreekseed(25g)preventedtheincreaseinbloodglucosefollowingglucoseintakeanddecreasedbloodinsulinlevels.Responsewasgreatestinvolunteerstreatedwithwholeseed,followedbythegumisolate,defattedseed,andcookedseed.Degummedseedsandcookedleavesshowednoactivity.Wholeseed,defattedseed,andgumisolatewererichingalactomannan.45

•ClinicaltrialsinvestigatingthehypoglycemicactivityoffenugreekindiabetesaresummarizedinTable1.Inmanyofthesetrials,patientscontinuedtotaketheirorthodoxmedications.

•Fenugreek(5g/day)administeredto30healthyvolunteersfor3monthsdidnotaffectbloodlipidlevelscomparedwithbaselinevalues.5ClinicaltrialsinvestigatingthehypolipidemicactivityoffenugreekinpatientswithdiabetesaresummarizedinTable2.Hypocholesterolemicactivityhasalsobeendemonstratedclinicallyforsproutedfenugreek,suggestinganactivityforthesaponins,othercomponents,orboth,butthis

informationisnotcoveredinthetable.

•InGermany,theCommissionEsupportsusingfenugreektotreatlossofappetite.Externally,adecoctionoffenugreekseedcanbeusedforlocalinflammation.11

TABLE 1 Clinical Trials Investigating the HypoglycemicActivityofFenugreek

TABLE2 ClinicalStudiesInvestigatingtheHypolipidemicActivityofFenugreek

REFERENCES

HeckAM,DewittBA,LukesAL.AmJHealthSystPharm.2000;57(13):1221-1227.NewallCA,AndersonLA,PhillipsonJD.Herbalmedicines,aguideforhealth-careprofessionals.London:PharmaceuticalPress,1996.

ShaniJ,etal.ArchIntPharmacodyn.1974;210:27-37.AroraRB,MathurCN.BrJPharmacol.1963;20:29-35.BordiaA,VermaSK,SrivastavaKC.ProstaglandinsLeukotEssentFattyAcids.1997;56(5):379-384.LambertJP,CormierA.Pharmacother.2001;21(4):509-512.AdishAA,etal.PublicHealthNutr.1999;2(3):243-252.SharmaRD,etal.PhytotherRes.1996;10(4):332-334.SewellAC,MosandiA,BohlesH.NEnglJMed.1999;341(10):769.

10PodebradF,etal.JInheritMetabDis.1999;22(2):107-114.11BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

12PatilSP,NiphadkarPV,BapatMM.AnnAllergyAsthmaImmunol.1997;78(3):297-300.

13BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

14FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

15BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.

16ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982

17KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.

18PuriD,BaralN,UpadhyayaBP.JNepalMedAssoc.1997;36(123):334-337.

19PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.

20WorldHealthOrganization.Theuseoftraditionalmedicineinprimaryhealthcare:amanualforhealthworkersinSoutheastAsia.NewDelhi:WHORegionalOfficeforSoutheastAsia,1990.

21MerzoukiA,Ed-derfoufiF,MoleroMesaJ.Fitoterapia.2000;71:278-307.

22IwuMM.HandbookofAfricanmedicinalplants.BocaRaton,Fla:CRCPress,1993.

23BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.

24Al-HaboriM,RamanA.PhytotherRes.1998;12:233-242.25Alarcon-AguilaraFJ,etal.JEthnopharmacol.1998;61:101-110.

26PetitPR,etal.Steroids.1995;60(10):674-680.27SauvaireYetal.Fromthe2ndInternationalCongressonPhytomedicine,Munich,September11-14,1996,abstractP-92.

28BrocaC,etal.AmJPhysiol.1999;277(4,pt1):E617-623.

29MishkinskyJ,JosephB,SulmanFG.Lancet.1967;2(7529):1311-1312.

30RavikumarP,AnuradhaCV.PhytotherRes.1999;13(3):197-201.

31BhandariU,GroverJK,SharmaJN.HamdardMed.1998;41(4):56-59.

32PlatelK,SrinivasanK.Nahrung.2000;44(1):42-46.33PlatelK,SrinivasanK.IntJFoodSciNutr.1996;47(1):55-59.

34Al-MeshalIA,etal.Fitoterapia.1985;56(4):232-235.35MitalN,GopaldasT.NutrRepInt.1986;33(2):363-369.36AbdoMS,Al-KafawiAA.PlantaMed.1969;17(1):14-18.37MitalN,GopaldasT.NutrRepInt.1986;33(3):477-484.38PandaS,TahilianiP,KarA.PharmacolRes.1999;40(5):405-409.

39AhsanSK,etal.JEthnopharmacol.1989;26(3):249-254.40SambaiahK,SrinivasanK.IndianJBiochemBiophys.1989;26(4):254-258.

41TaranalliAD,KuppastIJ.IndianJPharmSci.1996;58(3):117-119.

42SurP,etal.PhytotherRes.2001;15(3):257-259.43MadarZ.FromtheproceedingsoftheJointCEC-NCRDWorkshopheldinIsrael(GinozarKibbutz)inJanuary1989onlupinproductionandbioprocessingforfeed,food,and

otherby-products,EUR-PublicationNo.12641,Luxembourg,1990.

44PathakP,SrivastavaS,GroverS.IntJFoodSciNutr.2000;51(5):409-414.

45SharmaRD.NutrRes.1986;6(12):1353-1364.46SharmaRD,RaghuramTC,RaoNS.EurJClinNutr.1990;44(4):301-306.

47SharmaRD,RaghuramTC.NutrRes.1990;10(7):731-739.48SharmaRD,etal.NutrRes.1996;16(8):1331-1339.49SharmaRD,etal.PhytotherRes.1996;10(6):519-520.50NairLD,KapoorR.IndianJNutrDiet.2000;37(3):76-84.51MadarZ,etal.EurJClinNutr.1988;42(1):51-54.52RaghuramTC,etal.PhytotherRes.1994;8:83-86.53SharmaRD,RaghuramTC.PhytotherRes.1991;5:145-147.54PrasannaM.IndianJPharmacol.2000;32(1):34-36.

FEVERFEW

BotanicalNames: Tanacetumparthenium,Chrysanthemumparthenium#

Family: CompositaePlantPartUsed: Leaf

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antiinflammatory,antiallergic,bittertonic,emmenagogue(inhighdoses),anthelmintic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingfeverfewinformulationsinthecontextof:

•Prophylaxisandtreatmentofmigraineheadachesandassociatedsymptoms(2,4,6)

•Prophylaxisandtreatmentoftensionheadache(3,6)

•Possiblebenefitininflammatoryarthritis,suchasrheumatoidarthritis(4)

ContraindicationsIndividualswithaknownhypersensitivitytofeverfew,parthenolide,orothermembersoftheCompositaefamilyshouldnottakefeverfewinternally.

WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

Dosesduringpregnancyshouldbekepttoaminimum(nomorethan1.5mlofa1:5tincture/day).Noadverseeffectsexpectedduringlactationaslongastherecommendeddosagelevelsareobserved.

SideEffects

Allergiccontactdermatitishasbeennotedinmanycasesaftercontactwithfreshfeverfewleaves.Thesideeffectswereconsideredmildandincludedmouthulcers,soretongue,abdominalpain,indigestion,unpleasanttaste,tinglingsensation,urinaryproblems,headache,swollenlipsormouth,anddiarrhea.

Dosage Doseperday* Doseperweek*

1–3mlof1:5driedplant 7–20mlof1:5dried

tincture planttincture

Extractsprovidingquantifiedlevelsofparthenolidearerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan0.4mg/mlofparthenolide.

* ThisdoserangeisextrapolatedfromtheBritishHerbalCompendium1992andESCOPbutissomewhathigherthantherecommendationsfromthesesources.Thishigherdoselevelwasgiventoestablishtheprophylacticeffectatafasterrate.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Headache1

•Asabittertonictoincreaseappetite,improvedigestion,andpromotedigestivesecretions2

•Asawarminfusionforcholera,thecommoncold,febrilediseases,cleansingthekidneys,bringingonmenstruation,andexpellingworms3

•Asahoneyorsugarsweeteneddecoctionforcoughs,wheezing,anddifficultbreathing4

•Asacoldinfusion,asatonic,andtorelievefacialandearpainindyspepticorrheumaticpatients4

•Topicallyasapoulticeforpain,bowelswelling,flatulence,andcolic3

Keyconstituentsoffeverfewleafincludesesquiterpenelactonescontaininganα-methylene-γ-lactonegroup,includingparthenolide.

•Alikelymechanismfortheactionoffeverfewistheinhibitionofgranulesecretionfromplatelets(antimigraineeffect)andpolymorphs(antiarthriticeffect).Severalinvitrostudiessupportthismechanism.

•Althoughtheplateletsofpatientstakingfeverfewaggregatednormallytoadenosinediphosphateandthrombin,aggregationinresponsetoserotoninwasgreatlyreduced.Thisfindingimpliesthatalthoughnormalclottingmechanismsarestillintact,thebiochemicalchain

PharmacologicResearch

ofeventsleadingtoamigrainemightbebroken.

•FeverfewextractsmarkedlyinhibitedphagocytosisofCandidaguilliermondiiinvitro.However,intracellularkillingwasnotaffected.Thefactthatfeverfewcaninhibitphagocytosis,aswellasdegranulation,givesitpotentialasanantiinflammatoryagent.

•Invitrostudieshavedemonstratedaninhibitoryeffectoffeverfewoneicosanoidproduction.Therelevanceofthesestudiestonormaloraluseoftheherbisuncertain.

•Extractsoffreshfeverfewcausedadose-andtime-dependentinhibitionofthecontractileactivityofisolatedsmoothtissueinresponsetoreceptor-actingagonistssuchasserotoninandphenylephrine.

•Compoundscontainingtheα-methylene-γ-lactonegrouphaveinhibitedtumorgrowth,respiration,andnucleicacidsynthesisinvitroandexvivo;demonstratedantihyperlipidemicactivity;inhibitedcarrageenan-inducededemaandchronicadjuvant-inducedarthritis;anddelayedhypersensitivityreactionsinexperimentalmodels.

•Addingfeverfewextracttoisolatedtissuesamplesprotectedagainstendothelialcellperfusion–inducedinjury,indicatingthatfeverfewmayhaveavasoprotectiveeffectinadditiontoitseffectsonplatelets.

•Extractsoffeverfew,aswellastheessentialoil,havedemonstratedantimicrobialactivityinvitro.

•Asurveyofpeoplewithheadacheusingfeverfewleafrevealedthatthefrequencyandseverityofmigrainesandtensionheadacheswerereduced.Associatednauseaandvomitingdecreasedordisappeared.Theeffectivenessofconventionalpainkillersincreasedwithconcurrentfeverfewuse.Reliefofarthritissymptomswasalsoexperienced.Thedosagewaslow(2.5freshleaves/day,

ClinicalStudies

3.8cm×3.1cm,weightnotdefined),andtheonsetofanyeffectoftentookseveralmonths.

•Followingtheprevioussurvey,adouble-blind,placebo-controlledtrialinpatientswhohadbeenself-medicatingwithrawfeverfeweverydayfor3monthspriorfoundnochangeinthefrequencyorseverityofsymptomswhenthetreatmentwasswitchedtofeverfewcapsules(50mg/day).Patientswhoswitchedtoaplacebogroupexperiencedasignificantincreaseinthefrequencyandseverityofheadaches,nausea,andvomiting.

•Inarandomized,double-blind,placebo-controlled,crossoverstudy,treatmentwithpowderedfeverfew(82mg/dayfor4monthsstandardizedto2.2μmol/dayparthenolide)wasassociatedwithareductioninthenumberandseverityofattacksandasignificantreductioninthedegreeofvomitinginmigrainesufferers.

•Theseresultswerenotobservedinanotherrandomized,double-blind,placebo-controlled,crossovertrial.Feverfewdidnotexertanysignificantpreventativeeffectonthefrequencyofmigraineattacks,althoughpatientsseemedtohaveatendencytousefeweranalgesicdrugswhiletheywereusingfeverfew.Activetreatmentoccurredforonly4months,whichmightbeinsufficienttimetoestablishthepro-phylacticeffectatthedosagetested.Thedailydosewas143mgofagranulatedethanolicextractcorrespondingtoapproximately170mgoforiginaldriedherbandstandardizedto0.5mgofparthenolide.

•Adouble-blind,placebo-controlled,crossoverstudyinvolvingpeoplewithchronicmigraineobservedthatcapsulesofpowderedfeverfew(100mg/dayfor2monthsstandardizedto0.2mg/dayparthenolide)producedahighlysignificantdecreaseinpainintensity.Inthesecondphaseofthistrial,thegroupwhoremainedonfeverfewcontinuedtoexperienceadecreaseinpainintensityanda

highlysignificantreductioninvomiting,nausea,andsensitivitytonoiseandlightduringattacks.Participantswhoswitchedtoplaceboexperiencedanincreaseinpainsensitivity.Thedifferencebetweenthetwogroupswassignificant.Inphase3,transferringthefeverfew-treatedgrouptoplaceboresultedinanincreaseinpainintensityandothersymptoms,andshiftingtheplacebogrouptofeverfewtherapyresultedinanimprovementinpainandothersymptoms.

•ESCOPrecommendsfeverfewfortreatingmigraine.5

•FeverfewisofficialintheUSP24-NF19.

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.JohnsonES.Feverfew.London:SheldonPress,1984.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983leStrangeR.Ahistoryofherbalplants.London:Angus&Robertson,1977.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Tanacetipartheniherba/folium.ArgyleHouse,GandyStreet,Exeter,

Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

FRINGETREE

BotanicalName: ChionanthusvirginicusFamily: OleaceaePlantPartUsed: Rootbark

PRESCRIBINGINFORMATION

Actions Cholagogue,choleretic,mildlaxative,antiemetic,depurative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingfringetreeinformulationsinthecontextof:

•Liverandgallbladderdisorders,particularlyjaundice,cholecystitis,hepatitis,andgallstones(5)

•Skinandgastrointestinaldisordersassociatedwithreducedordisorderedliverfunction(5)

•Othergastrointestinaldisorders,suchascolic,gastritis,duodenitis,gastriculcerorpancreatitis(5)

•Splenicenlargement,portalhypertension(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3–6mlof1:2liquidextract

20–40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Jaundice,hepaticdisease,hepaticinflammation,cholecystitis,gall-stones,duodenitis,glycosuriaofhepaticoralimentaryorigin,colic,irritationofthestomach,dyspepsia(includinginfantile),nausea,vomiting,pancreaticdisease(includingpancreatitis),splenicenlargement,portalhypertension1,2

•Skinandboweldisordersresultingfromreducedordisorderedliverfunction;syphilis,scrofula(tuberculousinfectionofthecervicallymphnodes)2

NativeAmericansusedfringetreeexternallyforcuts,bruises,wounds,toothache,andinternalpains.FringetreewasofficialintheNFfrom1916to1947andwasusedasatonic.3TheEclecticphysiciansregardedfringetreeasanexcellenttonicinconvalescencefromdebilitatingdiseases.2

PharmacologicResearch

Nopharmacologicinformationhasbeenfoundforfringetree.

ClinicalStudies Noclinicalstudiesusingfringetreehavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted

1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

GENTIAN

BotanicalName: GentianaluteaFamily: GentianaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Bittertonic,gastricstimulant,sialagogue,cholagogue

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggentianinformulationsinthecontextof:

•Stimulatinggastricsecretion,bilereleasefromthegallbladder,bileproductionbytheliver(4)

•Lossofappetite,*dyspepsia,*asthenia,coatedtongue,postprandialbloating,incombinationwithrhubarb(3)

•Stimulatinggastricsecretion,constipation,flatulence,abdominalfullness,*itchingofskin,incombinationwithrhubarb,cascara,andboldo(3)

•Nausea,vomiting,heartburn,abdominalpain,constipation(4)

•Stimulatingpancreaticenzymesecretion(7)

Contraindications Gastricandduodenalulcers,1hyperacidity,2gastricinflammation3

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsVerysensitiveindividualsmayoccasionallyexperienceheadaches.1

Dosesatthehigherendoftherecommendedrangeinliquidformmaycausenauseainsomepeople.

Dosage Doseperday** Doseperweek**

0.7-2.0mlof1:2liquidextract

5-15mlof1:2liquidextract

* Gentianhasalsobeenusedintraditionalherbalmedicine.ESCOPrecommendsgentianfortreating appetite loss and dyspepsia. The Commission E also recommends gentian forabdominalfullnessandflatulence.(4,5)

** ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934,theBritishPharmacopoeia1932,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Anorexia(lossofappetite),particularlyafterfeverishconditions,toassistinassimilationoffood3

•Atonicdyspepsia,gastrointestinalatony;debility,gout,amenorrhea3,4

•Diarrhea,intestinalworms3

PharmacologicResearch

•Isolatedstomachcellsexposedtodifferentlevelsofanextractofgentianshowedaconcentration-dependentriseingastricacidproduction.5

•Inanexperimentalmodel,oraldosesofgentianwereshowntostimulatesecretionofenzymesinthesmallintestine.6

•Inanotherlaboratorystudy,gentianextractincreasedgastricsecretioninadose-dependentfashioncomparedwithcontrols.Adoseof0.5ml/kghadnoeffectongastriculceration.7

•Gentiantincturegivenorallyordirectlyintothestomachincreasedappetiteinanexperimentalmodelofcachexia(weightlossinchronicdiseases).Amarkedincreaseingastricsecretionanditsacidandpepsincontentwasdemonstratedonlywhengentianwasgivenbymouth.8

•Gentianextractelevatedbronchosecretionwhencomparedwithcontrolsinalaboratorystudy.9

ClinicalStudies

•Inoneuncontrolledstudyinvolving18volunteersusinggentiantincture,gastricemptyingwasslightlyincreasedin16ofthesecases.Gastricevacuationshowednosignificantchange.10

•NineteenpatientswithinflammatoryconditionsofthegastrointestinaltractassociatedwithelevatedIgAlevels,andahealthycontrolgroup,weregiven20dropsofagentiantincturethreetimesdailyfor8days.SecretoryIgAlevelswereloweredinbothgroups;acorrelationtoclinicalfindingswasreported,butstatisticalanalysiswaslacking.11

•Inhealthyvolunteers,gentianinducedasignificantincreaseinsalivarysecretionfrom1to30minutesafteroraladministration,similartotheactivecontrol(citricacid)andunlikeplaceboorplaceboplusalcohol.From30until120minutes,thevolumeperminuteofsalivadecreasedbutstillremainedhigherthanbaselinevalues.Inadoubleblindstudy,anherbalpreparation(containinggentian,rhubarb,cascara,andboldo)wassignificantlybetterthanplaceboforthefollowingsymptoms:asthenia,lossofappetite,coatedtongue,postprandialbloating,difficultdigestion,constipation,flatulence,abdominalfullness,anditchingofskin.Withregardtotheothersymptomsinvestigated,nosignificantdifferencewasobserved.Thetestpreparationwasmoreefficaciousthanthetwopairsofitscomponents(cascaraandboldo;gentianandrhubarb).12Thefollowingherbequivalentswereprobablyadministeredforthepairedpreparations:cascara(200mg/day)andboldo(100mg/day);gentian(40mg/day)andrhubarb(200mg/day).

•Oneoraldoseofanalcoholicextractofgentian(containing0.2groot)giventovolunteers5minutesbeforeamealstimulatedgastricsecretion,releaseofbilefromthegallbladderandbileproductionbytheliver.13

•Inamulticenter,uncontrolledstudy,205patientswere

prescribedonaveragefivegentiancapsulesperday(equivalentto600mgofroot).Rapidreliefofsymptomssuchasconstipation,flatulence,appetiteloss,vomiting,heartburn,abdominalpain,andnauseawasachieved.14

•InGermany,theCommissionEsupportsusinggentiantotreatdigestivedisorders,suchaslossofappetite,fullness,andflatulence.1

•ESCOPrecommendsgentianfortreatingappetiteloss,particularlyafterillness,anddyspepsia.2

REFERENCES

BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Gentianaeradix.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.GebhardtR.PharmPharmacolLett.1997;7(2-3):106-108.KazakovBN.CitedinScientificCommitteeofESCOP:ESCOPmonographs:Gentianaeradix.ArgyleHouse,Gandy

Street,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.LeslieGB.Medita.1978;8:31-47.MoorheadLD.JPharmacolExpTher.1915;7:577-589.ChibanguzaG,MarzR,SternerW.ArzneimForsch.1984;34(1):32-36.

10GoetzlFR.DrugStand.1956;24:111.11ZimmermanW,GaisbauerG,GaisbauerM.ZPhytother.1986;7:59-64.

12BorgiaM,etal.CurrTherRes.1981;29(3):525-536.13GlatzelH,HackenbergK.PlantaMed.1967;15(3):223-232.14WegenerT.ZPhytother.1998;19:163-164.

GINGER

BotanicalName: ZingiberofficinaleFamily: ZingiberaceaePlantPartUsed: Rhizome

PRESCRIBINGINFORMATION

ActionsCarminative,antiemetic,peripheralcirculatorystimulant,spasmolytic,antiinflammatory,antiplatelet,diaphoretic,digestivestimulant,pungent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggingerinformulationsinthecontextof:

•Prophylaxisandtreatmentofnauseaandvomitingfrommotionsickness(2,4)

•Prophylaxisandtreatmentofpostoperativenausea(2,4)

•Morningsickness(2)

•Drug-inducednausea(2)

•Osteoarthritis(2)

•Dyspepsia(4)

•Digestiveproblems,nausea,vomiting,colic,flatulentdyspepsia,cramping(5)

•Fever,thecommoncold(especiallythefreshrhizome),conditionsrequiringexpectoration(5)

•Dysmenorrhea(5)

Contraindications

AccordingtotheCommissionE,usinggingeriscontraindicatedinpatientswithgallstones,exceptunderclosesupervision.InTCM,driedgingerisusedcautiouslyduringpregnancy.Adailydoseof2gof

driedgingershouldnotbeexceededinpregnancy.

WarningsandPrecautions

Theusershouldproceedwithcautionincasesofpepticulceration,gastroesophagealreflux,orothergastricdiseases.

Interactions Gingermayincreasetheabsorptionofpharmaceuticaldrugs.

Althoughnoproblemshavebeenreportedinhumans,gingermayincreasethechanceofbleeding.Dailydosesof(dried)gingerinexcessof4gshouldbeprescribedwithcautioninpatientswhoarealreadytakingblood-thinningdrugssuchaswarfarinoraspirinorwhohaveincreasedriskofhemorrhage.

UseinPregnancyandLactation

Noadverseeffectsareexpectedwithintherecommendeddose(0.7to2.0mlof1:2liquidextract).Adailydoseof2gofdriedgingershouldnotbeexceededinpregnancy.Gingerhasbeensuccessfullyusedinclinicaltrialstotreatpregnantwomenwithnausea.

SideEffects

Atdosesapproachingorgreaterthanthemaximumrecommendeddose,ablood-thinningeffectandanincreaseingastricsecretoryactivityleadingtoheartburnispossible.Topicalapplicationofgingermaycausecontactdermatitisinsensitivepatients.Occupationalallergiccontactdermatitisfromspices,includingginger,hasbeenreported.

Dosage Doseperday* Doseperweek*

0.7-2.0mlof1:2liquidextract

5-15mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbalPharmacopoeia1983,theBritishPharmacopoeia1975,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Nausea,anorexia,colic,flatulentdyspepsia1,2

•Amenorrhea,3dysmenorrhea;2toimprovecirculation2

UsesandpropertiesfromTCMinclude:

•Fordriedginger:epigastricpainwithcoldfeeling,vomitinganddiarrheawithcoldextremities,andfaintpulse;dyspneaandcoughwithcopiousfrothyexpectoration4

•Forfreshginger:thecommoncold,vomitingcausedbycoldinthestomach,coughwiththinwhitesputum4

Majorconstituentsofgingerrhizomeincludeanessentialoil(1%to3%,containingzingibereneandsesquiphellandrene)andpungent(hot)principles(1.0%to2.5%,includinggingerolsandshogaols).

•Severalstudieshaveexaminedtheantiemeticandantinauseaeffectsofginger.Themechanismofactionresponsiblefortheantiemeticeffectisstillcontroversial,however,possibilitiesincludeacentraleffectviagastrointestinalserotoninantagonism,centralandperipheralanticholinergicandantihistaminiceffects,andadampeningofinducedvestibularimpulsestotheautonomiccentersofthecentralnervoussystem.

•Oraladministrationofspraydriedgingerextractsignificantlypreventedethanol-inducedgastricmucosal

PharmacologicResearch

damage.Gingerand6-gingerolinhibitedexperimentalgastriculcersinvivoafteroraladministration.

•Gingeranditspungentcomponentsexertanantiinflammatoryeffectbyinhibitingboththecyclooxygenaseandlipoxygenaseenzymesbelongingtotheprostaglandinandleukotrienebiosyntheticpathways,respectively.Oralintakeofgingerextractinhibitedcarrageenan-inducedpawswellingandwasasactiveasaspirininthismodel(althoughitwasdevoidofanalgesicactivity).Essentialoilofgingerinhibitedchronicadjuvantarthritiswhengivenorally.

•Feverreductioninanexperimentalmodelafteroraldosesofgingerextractwascomparabletoaspirin.

•Severalstudieshavedemonstratedthatgingerinhibitsplateletaggregationinvitro.Theinhibitionofthromboxaneformationappearstobethemaincauseofthisantiplateletactionofginger.

•Oraldosesofgingeranditsconstituentshavebeenshownto:increasesalivaproduction,gastricsecretions,andactivityandintestinaltransit;decreasepepsinactivity;inhibitgastriccontractionandserotonin-induceddiarrhea;andreversethecisplatin-induceddelayingastricemptying.

•Gingeranditscomponentswerethermogenicinperfusedisolatedtissuesandsignificantlyinhibitedserotonin-inducedhypothermia.

•Pungentprinciplesofgingerhadantihepatotoxiceffectsinvitro,inhibitedhistaminereleasefrommastcellsinvitro,andexhibitedantiallergicactivityinvivo.Ginger,gingerextract,anditspungentprincipleshavedemonstratedantioxidantactivityinvitro.

•Gingeranditsconstituentshavedemonstratedantifungalactivity,mildgrowthinhibitionofgram-positiveand

gram-negativebacteria,antirhinoviralactivity,anddirectantiparasiticactivity,allinvitro.

•Gingerasathromboxanesynthetaseinhibitorandprostacyclinagonistwaspostulatedtohavetherapeuticpotentialinalcoholwithdrawalandthecomplicationsofliverdamage,recoveryfromseriousburns,pepticulceration,Kawasakidisease,preventingagingpenilevascularchangesandimpotence,asanantidepressant,andasananalgesicindysmenorrhea.

•Asystematicreviewofrandomizedcontrolledtrialshasevaluatedtheefficacyofgingerfornauseaandvomiting.Sixtrialsconductedbeforetheyear2000wereevaluated.Thepooledabsoluteriskreductionfortheincidenceofpostoperativenauseacalculatedfromthreetrialsindicatedanonsignificantdifferencebetweenthegingerandplacebogroups.Thedosewas1gpowderedgingergivenpreoperatively.Twoofthesetrialssuggestedthatgingerwassuperiortoplaceboandequallyefficaciousasmetoclopramide.Threestudies(investigatingseasickness,morningsickness,andchemotherapy-inducednausea)collectivelyfavoredgingeroverplacebo.5TheCochraneReviewoftreatmentsforvomitingofpregnancysuggestsgingermaybeofbenefit(basedontwoclinicaltrials)butthattheevidencewasweaktodate(year2000).6

•Manyclinicalstudieshavebeenpublisheddocumentingtheantinauseaandantiemeticpropertiesofginger.However,severalclinicalstudieshavealsobeenconductedthatproducednegativefindings.Thefollowingsummaryindicatesthetrialdesign,effectonnauseaandvomiting(positive-negative),andconditioninvestigatedinthesetrials(seeMillsandBone:PrinciplesandPracticeofPhytotherapy).Someofthesetrialswereassessedinthepreviouslylistedreviews.Overall,theweightofevidencesuggeststhatgingermaybebeneficialfortreatingnauseaandvomiting.

•Apositiveeffectwasobservedforginger(0.25to1.5g/day)in:tworandomized,double-blind,placebo-controlledtrialsandonerandomized,controlledtrial7investigatingseasickness;tworandomized,double-blind,controlledtrialsinvestigatingpostoperativenausea;onerandomized,double-blind,placebo-controlled,crossovertrialinvomitingofpregnancy;onedouble-blind,controlledtrialinhyperketonaemiapatients;andoneuncontrolledtrialofpsoralen-inducednausea.

•Anegativeeffectwasobservedforginger(0.5to1.0g)in:twocontrolledtrialsandonedouble-blind,controlledtrialinvestigatingmotionsickness;andonerandomized,double-blind,placebo-controlledtrialinvestigatingpostoperativenausea.Apossiblecriticismofthesemotionsicknesstrialsisthattheywereconductedinalaboratorysettingthatusedrotatingchairsandothermachinery(althoughothersuchtrialsongingerhavebeenpositive).

•Anumberoftrialsinvolvinggingerfortreatingnauseaandmotionsicknesshavebeenconductedsincethepreviouslylistedreviews.

•Arandomized,double-blind,placebo-controlledtrialfoundthattreatmentwithginger(0.25gfourtimes/day)providedrelieffrompregnancy-inducednauseain76%ofwomentreated.Intheplacebogroup,46%reportedrelief.Thereductioninnauseawasmaintainedforthe4daysofthetrial,andreliefoftenstartedwithin30minutesoftakingthegingercapsule.8

•Astudyinvolvingasmallnumberofhealthyvolunteersconfirmedtheefficacyofginger(1g)inrelievingsymptomsofexperimentallyinducedmotionsickness.Volunteerswhotookgingerexperiencedagreaterdelayindevelopingnauseathandidtheplacebogroup.9

•Symptomsofmotionsicknesswerealleviatedinagroupofchildren(4to8yearsofage)administeredginger

ClinicalStudies

beforethestartofajourney.Inthechildrenwhowereprescribeddimenhydrinate,symptomswereonlyimproved.Thegingergroupexperiencedareductioninsymptomswithin30minutes;forthosetakingdimenhydrinatethereductionoccurredwithin60minutes.Testsubstanceswereadministered30minutesbeforethestartofthejourneyandevery4hoursthereafterasnecessary:gingerpowder250to500mg,dimenhydrinate12.5to25.0mg.Thestudywasofrandomized,double-blinddesign.10

•Seventyfivepercentofarthritispatients(rheumatoidandosteoarthritis)experiencedreliefinpainandswelling,andallofthepatientswithmusculardiscomfortexperiencedreliefofpain,inanuncontrolledclinicalstudyusingdriedginger.

•Gingerextractwascomparedwithibuprofenandplaceboinpatientswithosteoarthritisofthehiporkneeinadouble-blind,crossovertrial.Theeffectofgingerwasmildcomparedwithplaceboandwasobservedonlyinthefirsttreatmentperiodbeforecrossover.11

•AcombinationofgingerandAlpiniagalangawastestedagainstplaceboin261patientswithosteoarthritisoftheknee.Althoughsignificanteffectswereobservedfromtheherbaltreatment,suchasreductioninkneepainonstanding,theoverallbenefitwasmild.Mildgastrointestinaladverseeventsoccurredmoreofteninthegingergroupcomparedwiththeplacebogroup.12

•Oralingestionofgingerimprovedgastroduodenalmotility,bothinthefastingstateandafterastandardtestmeal,inhealthyvolunteerswhoparticipatedinarandomized,placebo-controlled,double-blind,crossovertrial.13

•Powderedginger(4g/day)giventopatientswithcoronaryarterydisease(CAD)didnotaffectplatelet

aggregation,fibrinolyticactivity,andfibrinogenlevelstestedat11/2and3months.Noinformationwasprovidedforcontrols.However,asingledoseofginger(10g)producedasignificantreductioninplateletaggregationafter4hoursinpatientswithCADinaplacebo-controlledtrial.

•Addingginger(5g)toafattymealpreventedthedecreaseinfibrinolyticactivitycausedbythefatintakeinarandomized,placebo-controlled,crossovertrialinvolvinghealthyvolunteers.Placebodidnotproducethispreventativeeffect.14

•Treatmentwithginger(approximately2g)plussodawaterdroppedtheplateletcountfrom1.8millionto240,000in1dayinacasestudyofthrombocytosisresultingfromamyeloproliferativedisorderina78-year-oldman.Theplateletcountrosetoover1.5millionwhengingertreatmentwassubsequentlywithdrawn.Inacontrolledtrial,driedginger(5g/day)significantlyinhibitedplateletaggregationinducedbydietarybuttersupplementation(100g/day)inhealthymales.

•InGermany,theCommissionEsupportsusinggingertotreatdyspepsiaandpreventmotionsickness.15

•ESCOPrecommendsgingerfortheprophylaxisofthenauseaandvomitingofmotionsicknessandasapostoperativeantiemeticforminorday-casesurgicalprocedures.16

•GingerhasbeenreinstatedtotheUSPandisofficialintheUSP24-NF19.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicand

clinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.ErnstE,PittlerMH.BrJAnaesth.2000;84(3):367-371.JewellD,YoungG.CochraneDatabaseSystRev.(2):2000.CD000145RibenfeldD,BorzoneL.HealthnotesRevComplementIntegrMed.1999;6(2):98.EdenJ:MedicalObserverJuly21,2000.LienHC,SunWM:DigestiveDiseaseWeek2000,SanDiego,May20-24,2000.

10CaredduP.HealthNotesRev.1999;6:102-107.11BliddalH,etal.OsteoarthritisCartilage.2000;8(1):9-12.12AltmanRD,MarcussenKC.ArthritisRheum.2001;44(11):2531-2538.

13MicklefieldGH,etal.IntJClinPharmacolTher.1999;37(7):341-346.

14VermaSK,BordiaA.IndianJMedSci.2001;55(2):83-86.15BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

16ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Zingiberisrhizoma.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

GINKGO

BotanicalName: GinkgobilobaFamily: GinkgoaceaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

ActionsAntioxidant,antiplateletactivatingfactor(anti-PAF)activity,tissueperfusionenhancing,circulatorystimulant,cognitionenhancing,neuroprotective

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingGinkgoinformulationsinthecontextof:

•Cerebralinsufficiency(restrictedcerebralbloodflow)anditsrelatedsymptoms,suchasmemoryandcognitiveimpairment,dizziness,tinnitus,acutecochleardeafness,headaches,anxietyanddepression,andfatigue(1,4)

•Earlystagesofprimarydegenerativedementia(Alzheimer’s-type)(1,4)

•Multiinfarct(vascular)dementia(2,4)

•Strokeofrecentonset(2)

•Atonicforolderadults(2)

•Vertigoordizzinessofvascularorigin(2)

•Tinnitusofvascularandinvolutionalorigin(4)

•Peripheralarterialocclusivedisease(FontainestageII[intermittentclaudication]orstageIII)(1,4)

•Idiopathicsuddenhearingloss(2)

•Disordersresultingfromreducedretinalbloodflow,senilemaculardegeneration(3)

•Enhancingcognitivefunction,includingworkingandlong-termmemory,abstractreasoning,andprocessingspeedinhealthyindividualsandparticularlyinolderadults(2)

•Improvingattentioninhealthyyoungindividuals(3)

•Improvingmemoryandcognitiveperformanceinhealthyindividuals(2)

•Theeffectsofhighaltitudeorhypoxia(2)

•Antioxidantactivity(3)

•Congestivedysmenorrhea(3)

•Anti-PAFactivity(4a)

•Asthma(4)Contraindications Noneknown.WarningsandPrecautions

Ginkgoshouldbeusedwithcautioninpatientsonanticoagulantorantiplateletmedication.

InteractionsBasedonsomecasereportsofpossibleinteraction,cautionshouldbeexercisedwhenprescribingGinkgowithwarfarinandaspirin.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

AnalysesofclinicaltrialshaveshownthatGinkgohasaremarkablylowincidenceofsideeffects.IsolatedepisodesofspontaneousbleedingattributedtointakeofGinkgohavebeenreported.However,aclinicaltrial(seelaterdiscussion)foundthattreatmentwithGinkgolimitedoxidativestressincardiovascularsurgerybecauseofamembrane-protectiveeffect.RecoveryofGinkgo-treatedpatientswasslightlyimprovedcomparedwithuntreatedpatients.

AcaseofStevens-JohnsonsyndromethatappearedtobeassociatedwithuseoftabletscontainingstandardizedGinkgoextract,choline,andBvitaminswasreported.TheauthorsadvisedthatthereactionwasunlikelytohavebeencausedbythecholineorBvitamins.1(Stevens-Johnsonsyndromeisanacuteinflammatoryskindiseasethataffectstheskinandmucousmembranesofthefaceandmouth.)

Dosage Doseperday* Doseperweek*

3-4mlofthestandardized(2:1)liquidextract

21-28mlofthestandardized(2:1)liquidextract

Extractsprovidingstandardizedlevelsofginkgoflavoneglycosidesarerecommended.Ideally,aqueousethanolextractsshouldcontain9.6mg/mlofginkgoflavoneglycosides.

Norestrictionwasfoundonthelong-termuseofGinkgo.However,Ginkgoshouldberecommendedforatleast6weeksbeforeanyassessmentofclinicalbenefitismade.

* Thisdoserangeisbasedonthoseusedinclinicaltrials.

SUPPORTINGINFORMATION

TraditionalPrescribing

NoinformationhasbeenfoundforthetraditionaluseofGinkgoleaf.GinkgonutswereusedinTCM.

PharmacologicResearch

PharmacologicandclinicalstudiesusuallytestedaspecialconcentratedstandardizedextractofGinkgoleaves,whichischemicallycomplex,containingatleast26identifiedcomponents.The50:1concentratedextractisstandardizedtocontain22.5%to25.0%flavonoidglycosides(ginkgoflavoneglycosides)and6%to8%terpenoids(ginkgolidesandbilobalide).

•TheginkgolidesarepotentandspecificPAFantagonists;theeffectsarelong-livedandarerapidlyestablishedafteroraldoses.

•ManyexperimentalmodelshavedemonstratedthepreventativeandprotectiveeffectsofstandardizedGinkgoextract(highdoses)andginkgolidesagainsthypoxia-orischemia-induceddamageofcerebralandcardiovasculartissues,bothinvitroandinvivoafteroraladministration.

•StandardizedGinkgoextractshavedemonstratedpotentantioxidantactivityinmanyinvitromodels.

•PriororaldosingwithstandardizedGinkgoextractenhancedtheperformanceofatestedtask,indicatingimprovedretrievalofthelearnedresponse,inawell-controlledanimalstudy.OraladministrationofstandardizedGinkgoextracttoyoungandoldratsfacilitatedbehavioraladaptationdespiteadverseenvironmentalinfluences.

•OraladministrationofstandardizedGinkgoextractin

conjunctionwithahigh-fatdietreduceddisturbancesoflipidmetabolismandtheseverityofplaqueformationinanexperimentalmodelwhencomparedwithplaceboandrutin.Ginkgoalsoaffectedmetabolicprocessesintheliverandmaymodifylipiddepositioninmajorarteries.

•ChronicadministrationofstandardizedGinkgoextractinhibitedstress-inducedcorticosteronehyposecretionthroughareductioninthenumberofadrenalperipheralbenzodiazepinereceptors.GinkgoextractandginkgolideBwerealsofoundtoactatthehypothalamiclevelandwereabletoreducecorticotropin-releasinghormoneexpressionandsecretion.

•IntragastricadministrationofacombinedpreparationofstandardizedextractsofGinkgoandgingerdemonstratedanxiolyticeffectscomparabletodiazepaminjectioninvivo.

•Ginkgoextractfractionsrelaxedpenilecorpuscavernosaltissuesinvitro,aneffectthatmayhelpmaintainerection.

•TopicalapplicationofstandardizedGinkgoextracthadantiinflammatoryactivitycomparabletoindomethacininthecrotonoiltestandpromotedhairregrowthinshavedmice.

ThefollowingclinicaltrialswereconductedusingastandardizedGinkgoextract(50:1),withthemajorityoftrialsemployingadailydoserangeof120to160mg,whichequatesto6to8goforiginaldriedherb(or3to4mlofa2:1standardizedliquidextract).

•Acriticalreviewof40clinicaltrialsconductedfrom1975to1991ontheclinicaluseofstandardizedGinkgoextractsinpatientswithcerebralinsufficiencyandrelatedconditions(primarydegenerativedementia;dizzinessassociatedwithlabyrinth,vestibulardisorders,orboth;

acutecochleardeafness;senilecognitivedecline;andtinnitus)foundthatallexceptoneofthe40trialsshowedpositiveresults,withsignificantresultsin26.Theinconclusiveresultwasobtainedforatrialonseniledementiaofvascularorigin.Inmostofthetrials,thedailydosewas120to160mgofstandardizedextract,givenforatleast4to6weeks.Meta-analysisof11randomized,double-blind,placebo-controlledtrialsconfirmedtheglobaleffectivenessofGinkgoinfivestudiesandconcludedthatstandardizedGinkgoextractprovidesabettertherapeuticeffectcomparedwithplacebointreatingcerebralinsufficiency.Inmostcases,150mg/daywasadministeredfor12weeks.AmorerecentreviewconfirmedtheseresultsandnotedthatnosignificantdifferencesinthefrequencyortypesofsideeffectswereobservedbetweenGinkgoandplacebogroups.2

•Improvementsincerebralbloodflow,motorrecovery,intellectualperformance,memory,mood,andbehaviorwereobservedinrecentstrokevictimsaftertreatmentwithstandardizedGinkgoextractinuncontrolledandinrandomized,double-blind,placebo-controlled,andcomparativetrials.Althoughthegeneraldosageusedwas120mg/dayofstandardizedextractfor1to2months,inoneofthesetrials,somepatientsreceivedupto360mg/day.

•Ameta-analysisoffourrandomized,double-blind,placebo-controlledtrialsfoundasmallbutsignificanteffectafter3to6monthstreatmentwith120to240mg/dayofstandardizedGinkgoextractonobjectivemeasuresofcognitivefunctioninpatientswithAlzheimer’sdisease.Asubsequentrandomized,double-blind,placebo-controlled,multicentertrialinpatientswithmildtosevereAlzheimer’sdiseaseormultiinfarctdementiafoundthat,comparedwithbaselinevalues,treatmentwithstandardizedGinkgoextract(120mg/dayfor26weeks)slightlyimproveddailylivingandsocialbehaviorandcognitiveassessment.Theplacebogroup

showedastatisticallysignificantworseninginalldomainsofassessment.Regardingsafety,nodifferencesbetweenGinkgoandplacebowereobserved.3Tworandomized,double-blindtrials(includedinthepreviouslymentionedmeta-analysis)demonstratedthatstandardizedGinkgoextractimprovedthecognitiveperformanceandsocialfunctionofpatientswithmildtosevereAlzheimer’sdiseaseormultiinfarctdementiacomparedwithplacebo.Nosignificantdifferencecomparedwithplacebowasobservedinthenumberofpatientsreportingadverseeventsorintheincidenceandseverityoftheseevents.Thedosageadministeredinthesetrialswas240mg/dayfor24weeksand120mg/dayfor52weeks.Arecentmeta-analysisfoundnomajordifferencesbetweenstandardizedGinkgoextractandfourcholinesteraseinhibitors(tacrine,donepezil,rivastigmine,andmetrifonate)fordelayingsymptomprogressioninAlzheimer’sdiseaseorresponseratecomparedwithplacebo.TheauthorssuggestedthatalltreatmentscomparedwereequallyefficaciousintreatingmildtomoderateAlzheimerdementia.4

•Incontrast,resultsfromarandomized,double-blind,placebo-controlled,parallel-group,multicentertrialpublishedin2000suggestthatGinkgoisnotefficaciousasisatreatmentforolderpeoplewithage-associatedmemoryimpairmentormildtomoderateAlzheimer’sorvasculardementia.PatientswererandomizedtoreceiveplaceboorstandardizedGinkgoextractinoneoftwodoses:160mg/dayor240mg/dayfor12or24weeks.5However,giventhemixednatureoftheparticipantsinthistrial,itssignificancecanbequestioned.

•SupplementationwithstandardizedGinkgoextract(120mg/dayfor4months)improvedmood,sleep,andcopingabilityfordailyactivitiesinarandomized,placebo-controlledstudyinvolving5028free-livingelderlyvolunteers.6

•Inarandomized,double-blind,placebo-controlledstudyinvolvinghealthyadults,standardizedGinkgoextract(100mg/dayfor30days)producedasignificantimprovementinawiderangeofcognitiveabilities,includinglong-termmemoryandabstractreasoning,usingthemultidimensionalaptitudebattery.StandardizedGinkgoextract(180mg/dayfor6weeks)significantlyincreasedcognitiveprocessingspeedandsubjectiveratingsofmemoryimprovement,comparedwithplacebo,incognitivelyintactolderadults(55to86yearsofage)inarandomized,double-blind,placebo-controlled,parallel-groupstudy.7TheeffectsofacutedosesofstandardizedGinkgoextractonmemoryandpsychomotorperformanceinasymptomaticvolunteersaged30to59yearswastestedinarandomized,double-blind,placebo-controlled,five-waycrossoverdesign.TheresultsconfirmthattheeffectsofGinkgooncognitionaremorepronouncedformemory,particularlyworkingmemory.Themostefficaciousdosewasasingledoseof120mgandthecognitiveenhancingeffectsweremorelikelytobeapparentinindividualsaged50to59years.8Inadouble-blind,controlled,crossovertrial,acuteadministrationofstandardizedGinkgoextract(240mgand360mg)tohealthyyoungvolunteersproducedasustainedimprovementinattentioncomparedwithplacebo.9,10Arandomized,double-blind,placebo-controlledtrialdemonstratedsignificantimprovementinspeedofinformationprocessing,workingmemory,andexecutiveprocessingforhealthyvolunteerstreatedwithstandardizedGinkgoextract.11AcombinationcontainingstandardizedextractsofGinkgo(120mg/day)andKoreanginseng(200mg/daystandardizedto4%ginsenosides)demonstratedimprovementintheworkingandlong-termmemoriesofhealthymiddle-agedvolunteersafter14weeksinamulticenter,double-blind,placebo-controlledtrial.12

•Inameta-analysisthatincludedfiveplacebo-controlledtrials,standardizedGinkgoextract(120to160mg/dayfor4to6weeks)wasfoundtohaveahighlysignificant

ClinicalStudies

therapeuticeffectoverplaceboinperipheralarterialocclusivedisease(FontainestageIIorIII).Areviewofrandomized,double-blind,placebo-controlledtrialsofeitherstandardizedGinkgoextract(120to160mg/day)orthedrugpentoxifyllineintreatingintermittentclaudicationfoundthatthetrialshadsimilarclinicaloutcomesandwereofthesamemethodologicalquality.Eightrandomized,double-blind,placebo-controlledtrialswereincludedinarecentmeta-analysis,concludingthatstandardizedGinkgoextractwassuperiortoplacebointhesymptomatictreatmentofpatientswithintermittentclaudication.Thedailydoseinthesetrialsrangedfrom120mgto160mgforaperiodof24weeksinsixofthetrialsandforashorterdurationintheothertrials.13

•AreviewofrandomizedcontrolledtrialsfoundinconsistentresultsforGinkgointreatingpatientswithtinnituswithoutaccompanyingsymptomsofcerebralinsufficiency.14Alarge,double-blind,placebo-controlledtrialpublishedinearly2001foundthatstandardizedGinkgoextract(150mg/day)wasnomorebeneficialthanwasplacebointreatingtinnitus.Thetreatmentdidnotsignificantlyaffectothersymptomsofcerebralinsufficiency.Giventhepositiveresultsofprevioustrials,theauthorssuggestedthatGinkgoappearsineffectiveintreatingtinnitusalone,butitmaybeeffectiveintreatingtinnitusinpatientswhoalsohaveothersymptomsofcerebralinsufficiency.15

•ArandomizedtrialcomparingstandardizedGinkgoextract(160mg/day)andbetahistine(avasodilator,32mg/day)demonstratedtheefficacyofbothtreatmentsonsubjectiveandobjectivemeasurementsofequilibriuminpatientscomplainingofvertigo,dizziness,orbothcausedbyvascularvestibulardisorders.TheresultsindicatedthatthesitesofactionofGinkgoandbetahistineforcompensationofequilibriumaredifferentandthatGinkgoimprovedoculomotorandvisuovestibularfunctiontoagreaterextent.16

•AsignificantborderlinebenefitforGinkgoovernaftidrofuryl(avasodilator)inidiopathicsuddenhearingloss(existingnolongerthan10days)wasshownafter3weeks’treatmentinarandomized,comparativestudy.Ginkgotreatmentwaspreferredbecauseofthelackofsideeffects.Bothtreatmentgroupsalsoreceivedinfusiontherapy.

•Arandomized,double-blind,placebo-controlledtrialfoundstandardizedGinkgotreatment(containing48mg/dayflavoneglycosidesfor10weeks)wasunabletopreventthedevelopmentofthesymptomsofwinterdepression(themostprevalenttypeofseasonalaffectivedisorder).17StandardizedGinkgoextract(240mg/day)improvedsleepinpatientswithmajordepression.Inthisopen,pilottrial,patientstakingtheantidepressanttrimipramineplusGinkgowerecomparedwiththosetakingthedrugalone.18

•Inamulticenter,double-blind,placebo-controlledstudy,Ginkgosignificantlyimprovedbreasttendernessandmarkedlyimprovededema,anxiety,depression,andheadachesin165womenwithcongestivesymptomsofPMS.StandardizedGinkgoextractwasadministeredat160mg/dayfromday16today5ofthenextmenstrualcycle.

•Inpatientswithblockageofveinsintheretina,standardizedGinkgoextractimprovedbloodvessels,visualacuity,fieldofvision,nearandfarvision,andcolorrecognitioninarandomized,double-blind,placebo-controlledtrial.Markedimprovementsinvisionin86%ofpatientswithpoorbloodsupplytotheretina(ortheareasofthebrainthatinterpretthesignalsfromtheeyes)wereobservedinanuncontrolledtrial.Thedosageofstandardizedextractwas120mg/dayfor3months.Asmall,double-blind,placebo-controlledtrialfoundstandardizedGinkgotreatment(160mg/dayfor6months)improvedvisualacuity(comparedwithplacebo)in

patientswithsenilemaculardegeneration.Arecentplacebo-controlledstudyfoundacuteadministrationofGinkgosignificantlyincreasedend-diastolicvelocityintheophthalmicarteryinhealthyvolunteers,indicatingpossiblebenefitforopticneuropathylinkedtoglaucomaandotherischemicoculardiseases.ThedosageofstandardizedGinkgoextractwas120mg/dayfor2days.19

•Inarandomized,placebo-controlledtrial,administeringstandardizedGinkgoextract(160mg/day)forthedurationofanexpeditionsignificantlypreventedacutemountainsicknessatmoderatealtitude(5400meters,orover17,700feet)anddecreasedvasomotordisordersoftheextremities.

•IngestionofstandardizedGinkgoextract(120mg/dayfor3months)byhealthyvolunteersresultedintheinhibitionofcollagen-inducedplateletaggregationandreducedurinaryexcretionof11-dehydrothromboxaneB2(ametaboliteofthromboxaneA2).20

•Ahighdoseofginkgolidemixture(120mg)inhibitedPAFactivityinhealthyhumanvolunteersinasmall,double-blind,placebo-controlledstudy.Themixturecontained40%ginkgolideA,40%ginkgolideB,and20%ginkgolideC.

•Ginkgolimitedfreeradical–inducedoxidativestressgeneratedthroughoutsurgeryinpatientsundergoingaorticvalvereplacementinadouble-blind,placebo-controlledstudy.Thedosageprescribedwas320mg/dayofstandardizedextractfor5daysbeforesurgery.

•Insmall,uncontrolledtrialsstandardizedGinkgoextracthas:

•Significantlyreducedfibrinogenlevelsandbloodviscosityinout-patientswithalonghistoryofelevatedlevels(240mg/dayfor12weeks)

•Increasedhypoxiatoleranceinhealthyvolunteers(200mg/dayfor1week)

•Decreasedclastogenic(aformofmutagenic)activityofbloodtakenfromsalvagepersonnelworkingontheChernobylreactoraccident(120mg/dayfor2months)

•Alleviatedsexualdysfunctionsecondarytoantidepressantdruguse(averagedose:207mg/dayfor4weeks)

•Improvedpeakflowratesinasthmaticchildren

•Causedsignificantclinicalimprovementinasthmaticadults

•InGermany,theCommissionEsupportsusingstandardizedGinkgoleafextractfor:21•Thesymptomatictreatmentofdementiasyndromes,includingprimarydegenerativedementia,vasculardementia,andmixedformsofboth,characterizedbythefollowingsymptoms:memorydeficit,disturbancesinconcentration,depression,dizziness,tinnitus,andheadache•Improvementinpain-freewalkingdistanceinintermittentclaudication(peripheralarterialocclusivedisease,FontainestageIIb)withinaregimenofphysicaltherapeuticmeasures•Vertigoandtinnitusofvascularandinvolutionalorigin•GinkgoisofficialintheUSP24-NF19

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:

ChurchillLivingstone,2000.DavydovL,StirlingAL.JHerbalPharmacother.2001;1(3):65-69.SoholmB.AdvTher.1998;15(1):54-65.LeBarsPL,KieserM,ItilKZ.DementGeriatrCognDiscord.2000;11(4):230-237.WettsteinA.Phytomed.2000;6(6):393-401.vanDongenMC,etal.JAmGeriatrSoc.2000;48(10):1183-1194.CockleSM,KimberS,HindmarchI.Phytomed.2000;7(supp2):21.MixJA,CrewsWD.JAlternComplementMed.2000;6(3):219-229.RigneyU,KimberS,HindmarchI.PhytotherRes.1999;13(5):408-415.KennedyDO,ScholeyAB,WesnesKA.Psychopharmacology.2000;151(4):416-423.

10KennedyDO,ScholeyAB,WesnesKA.Phytomed.2000;7(supp2):21.

11StoughC,etal.IntJNeuropsychopharmacol.2001;4(2):131-134.

12WesnesKA,etal.Psychopharmacology.2000;152(4):353-361.

13PittlerMH,ErnstE.AmJMed.2000;108(4):276-281.

14ErnstE,StevinsonC.ClinOtoloaryngol.1999;24(3):164-167.

15DrewS,DaviesE.BMJ.2001;322(7278):73-75.16CesaraniA,etal.AdvTher.1998;15(5):291-304.17LingaerdeO,ForelandAR,MagnussonA.ActaPsychiatrScand.1999;100(1):62-66.

18HemmeterU,etal.Pharmacopsychiatry.2001;34(2):50-59.19ChungHS,etal.JOculPharmacolTher.1999;15(3):233-240.

20KudoloG.AlternTherHealthMed.2001;7(3):105.21BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

GLOBEARTICHOKE

BotanicalName: CynarascolymusFamily: CompositaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

ActionsHepatoprotective,hepatictrophorestorative,choleretic,cholagogue,bittertonic,hypocholesterolemic,antiemetic,diuretic,depurative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingglobeartichokeinformulationsinthecontextof:

•Hyperlipidemia(2,6)

•Conditionsrequiringanincreaseinbileflow(2)

•Dyspepsiaandassociatedsymptoms(e.g.,constipation,abdominalpain,nausea,vomiting,flatulence,belching,fatintolerance)(4)

•Non-ulcerdyspepsia,incombinationwithboldoandgreatercelandine(2)

•Irritablebowelsyndrome(4)

•Biliaryfistula(4)

•Jaundice,gout(5)

•Conditionsrequiringadepurativeaction(suchasitchyskin)(5)

•Long-termpreventionandtreatmentofcardiovasculardisease(7)

Contraindications ClosureofthegallbladderGlobeartichokeshouldbeusedonlywithprofessionalsupervisionincholelithiasis(gallstones).The

WarningsandPrecautions

CommissionEadvisescautionforpatientswithknownallergytoglobeartichokeandtootherplantsoftheCompositaefamily.Thelikelihoodofglobeartichokepreparationscausinganallergyisverylow.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Clinicaltrialsindicatethatthesafetyandtolerabilityofglobeartichokeisgood.Contactwiththefreshplantcancausecontactdermatitis.Nocasesofallergicreactionafteroralintakehavebeenreported.

Dosage Doseperday* Doseperweek*

3-8mlof1:2liquidextract

20-55mlof1:2liquidextract

* Thisdoserangeisextrapolatedfromclinicaltrials.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Jaundice,1,2hypercholesterolemia,anorexia;asalivertonicandantitoxic2

•Clearingthecomplexion,2asadepurativeforsimpleitchinchildren3

•Rheumatism,arthritis,2gout,dropsies1

•Nephrosclerosis,urinarystones,oliguria,uremia3

PharmacologicResearch

Keyconstituentsofglobeartichokeleavesincludecaffeicacidderivatives,especiallycynarin.

•Studiesfromthe1930sindicatethatglobeartichokeincreasedbileflowfromtheliver,loweredcholesterol,andcauseddiuresis.Morerecently,globeartichokeextractdemonstratedamarkedcholereticeffectinexperimentalmodelsafterintraperitonealadministration.Cynarinalsoincreasedbilesecretioninvitroandinvivoafterintraperitonealadministration.

•Studieshavedemonstratedthehepatoprotectiveandhepatorestorativeactivityofglobeartichokeextractsagainstlivertoxinsinvitroandinvivobytheoralroute.

•Globeartichokeextractexhibitedstrongantioxidantactivityinvitro.

•Globeartichokeextractandcynarininhibitedcholesterolsynthesisinvitroandcounteredanincreaseinserum

lipidsinvivoafterintraperitonealandoraladministration.

•Anantiatheroscleroticeffectwasdemonstratedforglobeartichokeextractinvivoafteroraladministration.

•Oraladministrationofglobeartichokeextractstimulatedthemovementofgastrointestinalcontentsalongthesmallintestineinanacuteexperimentalmodel.

•Areviewoftheclinicaldatafrommostlyuncontrolledtrialsconductedfrom1936to1994indicatedthatglobeartichokeextractloweredlipidlevels(cholesterol,triglycerides,orboth)frombetweenjustbelow5%toapproximately45%.

•Inatrialofrandomized,double-blind,placebo-controlleddesign,totalcholesterollevelssignificantlydecreasedafterglobeartichokeadministrationtopatientswithbaselinevaluesabove220mg/dl.High-densitylipoprotein(HDL)cholesteroltendedtoincrease.Theseresultswereconfirmedinanothertrialofsimilardesigninwhichahighdoseofglobeartichokeconcentratedextract(equivalenttoapproximately6to8g/dayofdriedleaffor6weeks)decreasedtotalcholesterol,LDLcholesterol,andtheLDL/HDLratioinadultswithaninitialtotalcholesterolofmorethan280mg/dl.4

•Oraldosesofcynarinsignificantlyreducedlevelsoftotalserumcholesterolinpatientswithelevatedserumlipidsinuncontrolledstudies(750to1500mg/day)andadouble-blind,placebo-controlledtrial(500mg/dayfor50days).Averagebodyweightwasalsosignificantlyreducedinthecontrolledtrial.Triglyceridelevelsinelderlypatientswithhypertriglyceridemiaweresignificantlyloweredinadoubleblind,placebo-controlledstudywithcynarin(500mg/day).

•Meancholesterolandtriglyceridevaluesweresignificantlyloweredinapostmarketingsurveillance

ClinicalStudies

studyinvolving553patientswithdyspepsia.Substantialimprovementwasrecordedforvomiting,nausea,abdominalpain,constipation,flatulence,belching,andfatintolerance.Physiciansratedglobeartichokeextracttreatment(averagedoseofapproximately7g/dayofdriedleaffor6weeks)asexcellentorgoodin87%ofpatients.

•Globeartichokeextract(averagedoseofapproximately7g/dayofdriedleaffor6weeks)improvednausea,vomiting,abdominalpain,right-sidedcrampingpain,flatulence,andfatintoleranceinpatientswithfunctionalboweldisordersinapostmarketingsurveillancestudy.Meantotalcholesterolwasalsosignificantlyreduced.

•Treatmentwithastandardizedglobeartichokeextract(equivalentto8.6g/daydriedleaf)reducedtheseverityofsymptomsofpatientswithirritablebowelsyndromeinapostmarketingsurveillancestudy.Theoveralleffectivenessofglobeartichokeratedfavorablywithbothphysiciansandpatients.Ninety-sixpercentofpatientsratedtheherbasbetterthanoratleastequaltoprevioustherapies.5

•Globeartichokeextractdemonstratedcholereticandcholagogiceffectsandclinicalimprovementinanopenstudyinvolving198patientswithbiliaryfistula.Intraduodenaladministrationofglobeartichokeextract(equivalentto9.1gofdriedleaf,standardizedto1.2mgcynarin)producedasignificantincreaseinbilesecretionat120and150minutes(comparedwithplacebo)inhealthyvolunteers.Thetrialwasofrandomized,double-blind,crossoverdesign.

•Arandomized,placebo-controlled,double-blindstudyfoundanherbalformulacontainingglobeartichokeextract(50%),boldo(Peumusboldus,30%),andgreatercelandine(20%)significantlyincreasedbilesecretionandimprovedbloating,nausea,andheartburninpatientswithnon-ulcerdyspepsia.

•Prophylacticglobeartichoketreatmentsignificantlyreducedplateletaggregationinworkerschronicallyexposedtocarbondisulfide.

•InGermany,theCommissionEsupportsusingglobeartichoketotreatdyspepticproblems.6

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983LeclercH.Precisdephytotherapie,ed5.Paris:Masson,1983.RocchiettaS.MinervaMed.1959;50:612-618.EnglischW,etal.ArzneimForsch.2000;50:260-265.WalkerAF,MiddletonRW,PetrowiczO.PhytotherRes.2001;15(1):58-61.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

GOAT’SRUE

BotanicalName: GalegaofficinalisFamily: LeguminosaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Hypoglycemic,antidiabetic,galactagogue

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggoat’srueinformulationsinthecontextof:

•Non-insulin–dependentdiabetesmellitus(4,5)

•Improvinglactation(4,5)

•Possiblyassistingweightloss(7)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Noneexpectediftakenwithintherecommendeddoserange.Consumptionofgoat’sruebysheephascausedpoisoning.1,2(Toxicdosesfarexceededthoseusedtherapeuticallyinhumans.)

Dosage Doseperday* Doseperweek*

4.5-8.5mlof1:2liquidextract

30-60mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Diabetesmellitus3

•Asagalactagogue,vermifuge,nervoussystemstimulant,anddiuretic4

•Asatonicininfectiousdiseasessuchastyphoid4

PharmacologicResearch

Keyconstituentsoftheaerialpartsofgoat’srueincludethealkaloidgalegine,whichisaguanidinederivative.5In1927,findingsindicatedthatgaleginepossessedhypoglycemicproperties,whichledtothedevelopmentoftherelatedbiguanidedrugs.Biguanidedrugs,suchasmetformin,increasetheperipheraluptakeofglucosebyincreasingtheefficiencyofavailableinsulin;thatis,theyincreaseinsulinsensitivity.6

•Dietarygoat’sruereducedserumglucoseandbodyweightinbothnormalandgeneticallyobesemicewhencomparedwithcontrols.Seruminsulinwassignificantlyreducedonlyinobeseanimals.Weightlosswasassociatedwithapersistentreductioninfoodintakebyobeseanimalsandaninitialreductioninnormalanimals.However,weightlossinnormalanimalswasthenmaintained,evenwithincreasedfoodintakeabovethecontrollevel.7

•Aqueousandethanolicextractsofgoat’srueimprovedglucosetoleranceinvivoafteroraladministration.Hypoglycemicactivitywasdemonstratedforthefractionscontaininggalegine.8

•Oraldosesofgoat’srueextractandgaleginebothreducedbloodglucoseinanexperimentalmodelofdiabetes.9Anotherstudyfoundnohypoglycemiceffectfororalgoat’srueextractsinnormalordiabeticanimals.10

•Goat’sruehadaregenerativeeffectontheinsulin-producingcells(βcells)ofthepancreasinvivo(routeunknown).11

•Apurifiedgalegine-containingextractofgoat’sruedose-dependentlyinhibitedthetransportanduptakeofglucoseintohumanintestinalepithelialcellsinvitro.12

•Aqueousextractsofgoat’srueinhibitedplateletaggregationinvitro13-16andinvivobyintravenousroute.17

ClinicalStudies

•Earlyclinicalresearchdemonstratedhypoglycemicactivityforgoat’srue.18,19Unlikethebiguanidedrugs,theherbdidnothaveunpleasantsideeffects.19

•Inanearlycontrolledtrial,nursingmothersreceivingapreparationcontaininggoat’srueextractandmineralsalts(doseundefined)producedalargerincreaseincolostrumvolume(125%)betweenthethirdandfifthdaysafterdeliverythandidwomennotreceivingthepreparation(75%increase).Volumeofmilk,butnotpercentageofmilksolids,hadincreasedbythefifthdayinthetreatedgroup.20

REFERENCES

KeelerRF,etal.VetHumToxicol.1986;28(4):309-315.KeelerRF,BakerDC,EvansJO.VetHumToxicol.1988;30(5):420-423.

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.E-MIMS,version4.00.0457,St.Leonard’s,NSW,Australia,2000,MIMSAustralia.PalitP,FurmanBL,GrayAI.JPharmPharmacol.1999;51(11):1313-1319.NeefH,DeclercqHN,LaekemanG.PhytotherRes.1995;9(1):45-48.PetricicJ,KaloderaZ.ActaPharmJugosl.1982;32(3):219-223.

10PundarikakshuduK,GrayAI,FurmanBL.Fitoterapia.1994;65(5):423-426.

11SendrailM,etal.LasemainedesHopitaux.1961;37:389.12NeefH,etal.PharmPharmacolLett.1996;6(2):86-89.13AtanasovAT,SpasovV.JEthnopharmacol.2000;69(3):235-240.

14AtanasovAT,SpasovV.FoliaMed.1999;41(1):46-50.15AtanasovAT.PhytotherRes.1994;8(5):314-316.16AtanasovAT.BulgarianMed.1993;1:17-20.

17AtanasovAT.JHerbsSpicesMedPlants.1995;3(3):71.18LeclercH.PresseMed.1928;36:1634.19ParturierG,HugonotG.PresseMed.1935;43:258.20HeissH.WienMedWochenschr.1968;24:546-549.

GOLDENROD

BotanicalName: SolidagovirgaureaFamily: CompositaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Antiinflammatory,diaphoretic,diuretic,anticatarrhal

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggoldenrodinformulationsinthecontextof:

•Upperrespiratorytractcatarrhorinflammation,especiallyofachronicnature;influenza(5)

•Rheumatoidarthritisandosteoarthritis,incombinationwithFraxinusexcelsiorandPopulustremula(1)

•Promotingdiuresis(3)

•Inflammationandinfectionoftheurinarytract(4,5)

•Prophylaxisandtreatmentofkidneyorbladderstones(4,5)

Contraindications

Contraindicatedinpeoplewithknownallergytogoldenrod.Goldenrodisamediumlevelsensitizer1andhascausedallergicreactionaftersystemicadministration.2

TheCommissionErecommendscopiousfluidintaketoassistinreducingmicroorganismsintheurinarytract,butthisshouldnotbeundertakenifedemaresultingfromimpairedcardiacorrenalfunctionexists.3

WarningsandPrecautions

AllergicreactionsmayoccurinsusceptiblepatientssensitizedtoplantsfromtheCompositaefamily.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Chronicupperrespiratorytractcatarrhorinflammation,influenza;flatulentdyspepsia;4cystitis,urinarydisorders4,5

•Asasprayorgarglefornoseandthroatinfection4

•Topicallyasapowderforhemorrhage5

NativeAmericansusedtheflowersorleavesofseveralspeciesofgoldenrodasateaforfeversandpaininthechest.6

•Aproprietaryherbalformulacontaininggoldenrod,FraxinusexcelsiorandPopulustremula(1:1:3),demonstratedantiinflammatory,antipyretic,andanalgesicactivitiesinexperimentalmodels,includingcarrageenan-inducededemaandadjuvant-inducedarthritis(routeunknown).7-9Inthecaseoftheantiinflammatorymodels,eachoftheindividualherbsalsodemonstratedactivity.9Theantiinflammatoryactivityistheresult,atleastinpart,oftheantioxidantpropertiesoftheindividualherbalextractsthathavebeenestablishedinseveralinvitromodels.10SimilartomanyNSAIDs,thecombinedextractandindividualextractsinhibiteddihydrofolatereductaseinvitro.8

•Constituentsofgoldenrod(3,5-O-caffeoylquinicacidandflavonoids)haveinhibitedleukocyteelastase(anenzymeinvolvedintheprogressionofinflammation)invitro.Theestersaponinsfromgoldenrodinducedthe

PharmacologicResearch

releaseofstoredadrenocorticotropichormone(ACTH)frompituitarycorticotropiccells.TheauthorspostulatedthatthereleaseofACTHmightinfluencethereleaseofglucocorticoidsfromtheadrenalglandinvivo.11

•Theflavonoidfractionofgoldenrodflowersdemonstrateddiureticactivityafteroraladministrationinanexperimentalmodel.12Aloworaldoseofanaqueousextractofgoldenrodcontaining0.3%flavonoidsproduceddiuresisandanincreaseinelectrolyteexcretioninanexperimentalmodel.13,14

•Goldenrodextractdemonstratedspasmolyticactivityinacetylcholinepretreatedisolatedileum.15

•AninvitroantifungaleffecttowardspathogenicspeciesofCandidawasdemonstratedfortriterpenoidsaponinsfromgoldenrod.16,17Thewholeplantdidnotpossessbroad-spectrumactivitytowardCandidaspp.anddermatophytesinvitro.18Essentialoilofgoldenroddemonstratedantimicrobialactivityagainstseveralbacteria,includingStreptococcusfaecalisandEscherichiacoli,andexertedastrongfungicidaleffectondermatophytestrainsinvitro.19

•Saponinsfromgoldenrodhavedisplayedimmunomodulatoryandantitumoraleffectsinvitro.20

•Adiureticeffectwasobservedinhealthyvolunteersafterasingledoseofgoldenrodtincture(100drops,orapproximately4ml)underdouble-blind,placebo-controlledconditions.Inanuncontrolledtrial,70%ofpatientswithurinarytractinflammationorsymptomaticbacteriuriaexperiencedcompletedisappearanceofsymptomssuchasdysuria,frequency,andtenesmuswhentreatedwiththesamepreparationanddosage(durationoftreatmentnotknown).Thefreshplanttincture(0.57g/g)wasmadeaccordingtoGermanHomoeopathicPharmacopoeia(HAB).21

ClinicalStudies

•Tworeviewsassessingaformulationcontaininggoldenrod,FraxinusexcelsiorandPopulustremula,fortreatingrheumaticconditions,includingarthritis,havebeenpublished.Onereviewassessedthattherandomized,double-blind,controlledtrialswereofmediummethodologicalquality.22TheformulationdemonstratedsuperioractivitycomparedwithplaceboandwascomparabletoNSAIDdrugsbuthadamuchlowerincidenceofadverseeffects.7,23Theformulationconsistsof60%Fraxinusexcelsior,20%goldenrod,and20%Populustremulaandisstandardizedforsalicylates,flavonoids,andcoumarins.

•Inarandomized,drugprospectivestudy,treatmentofuretericcalculiwitheitherspasmoanalgesicdrugtherapyoranherbalpreparationwascompared.Thepreparationcontainedgoldenrod,dandelionrootandleaf,Rubiatinctorum,Ammivisnaga,andasmallamountofescin(aconstituentofhorsechestnutseed).Althoughnosignificantdifferencewasobservedwithregardtotransittimesofthestonesbetweenthetwogroups,sideeffectsandtreatmentcostswerelessintheherbaltherapygroup.Thestrengthoftheherbalextractsinthesecapsuleswasnotdefined.23

•InGermany,theCommissionEsupportsusinggoldenrodinconjunctionwithcopiousfluidintaketotreatinflammatorydiseasesofthelowerurinarytract,urinarycalculi,andkidneygravel.Goldenrodisalsorecommendedasaprophylaxisforurinarycalculiandkidneygravel.3

•ESCOPrecommendsgoldenrodforinflammatoryconditionsoftheurinarytract,kidneygravel,andasanadjuvanttherapyforbacterialinfectionsoftheurinarytract.24

REFERENCES

ZellerW,deGolsM,HausenBM.ArchDermatolRes.1985;277(1):28-35.SchatzleM,AgathosM,BreitR.ContactDermatitis.1998;39(5):271-272.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.Klein-GalczinskyC.WienMedWochenschr.1999;149(8-10):248-253.StrehlE,etal.ArzneimForsch.1995;45(2):174-176.el-GhazalyM,etal.ArzneimForsch.1992;42(3):333-336.

10MeyerB,etal.ArzneimForsch.1995;45(2):174-176.11MelzigMF,etal.ZPhytother.2000;21(2):67-70.12ChodeaA,etal.ActaPolPharm.1991;48(5-6):35-37.13SchilcherH.DtschApothZtg.1984;124:2429-2436.14SchilcherH,RauH.UrologeB.1988;28:274-280.15WestendorfJ,VahlensieckW.ArzneimForsch.

1981;31(1):40-43.16HillerK,BaderG:4thInternationalCongressonPhytotherapy,Munich,Sept10-13,1992,AbstractSL18.

17BaderG,etal.Pharmazie.2000;55(1):72-74.18PepeljnjakS,etal.PharmPharmacolLett.1998;8(2):85-86.19PepeljnjakSetal:InternationalCongressand48thAnnualMeetingoftheSocietyforMedicinalPlantResearchandthe6thInternationalCongressonEthnopharmacologyoftheInternationalSocietyforEthnopharmacology,Zurich,September3-7,2000;AbstractP2A/74.

20PlohmannB,etal.Pharmazie.1997;52(12):953-957.21BruhwilerKetal:4thInternationalCongressonPhytotherapy,Munich,September10-13,1992;AbstractSL20.

22ErnstE,ChrubasikS.RheumDisClinNorthAm.2000;26(1):13-27.

23BachD,etal.ForschMed.1983;101(8):337-342.24ScientificCommitteeofESCOP(EuropeanScientificCooperativeonPhytotherapy).ESCOPMonographs:Solidaginisvirgaureaeherba.Exter,UK:ESCOP,March1996.

GOLDENSEAL

OtherCommonNames: Hydrastis,goldensealBotanicalName: HydrastiscanadensisFamily: RanunculaceaePlantPartUsed: Rootandrhizome

PRESCRIBINGINFORMATION

Actions

Antihemorrhagic,anticatarrhal,mucousmembranetrophorestorative,antimicrobial,antibacterial,bittertonic,antiinflammatory,depurative,vulnerary,choleretic,reputedoxytocic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggoldensealinformulationsinthecontextof:

•Catarrhalstatesofthemucousmembraneswhenunaccompaniedbyacuteinflammation(5)

•Acuteinfectiousdiarrhea(4a,5)

•Giardiasis,hypertyraminemia(4a)

•Gastritis,pepticulcer(4a,5)

•Adjuvanttherapyfornon-insulin–dependentdiabetesmellitus(4a)

•Hepaticsymptoms,skindisorders(5)

•Disordersoftheear,nose,mouth,throat(5)

•Uterineandpelvichemorrhagicconditions,genitourinarytractdischarges(5)

•Atonicduringconvalescence(5)

Contraindications

Berberine-containingplantsarenotrecommendedforuseduringpregnancyorforjaundicedneonates.Somereportssuggestthatgoldensealiscontraindicatedinhypertensiveconditions.

WarningsandPrecautions

Nonerequired.

Interactions

Berberinemayreinforcetheeffectsofotherdrugsthatdisplacetheproteinbindingofbilirubin.Ratherthanpossibleuterine-contractingeffects,thisactivitymightexplainthetraditionalcontraindicationforberberine-containingherbsinpregnancy.

UseinPregnancyandLactation Contraindicatedinpregnancy.

SideEffects

Atdailydoseshigherthan0.5g,berberinemaycausedizziness,nosebleeds,dyspnea,skinandeyeirritation,gastrointestinalirritation,nausea,diarrhea,nephritis,andurinarytractdisorders.Suchdosesofberberinewillnotbereachedusingtherecommendedliquiddosesoutlinedinthismonograph.

Dosage Doseperday* Doseperweek*

2.0-4.5mlof1:3tincture 15-30mlof1:3tincture

Extractsprovidingquantifiedlevelsofhydrastineandberberinearerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan8mg/mlofhydrastineandnotlessthan8mg/mlofberberine.

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•GoldensealwasspecificallyindicatedbyEclecticphysiciansforsubacuteorchronicinflammationofthemucousmembranes,particularlywhenaccompaniedbydischargeorcatarrh.Ingeneral,goldensealwascontraindicatedinacuteinflammationofthemucousmembranes.However,inthecaseofotitismedia,goldensealwasindicatedforbothacuteandchronicinflammation,especiallywhencopiousdischargewaspresent.1

•Digestivedisorders,gastritis,pepticulceration,colitis,anorexia,atonicdyspepsiawithhepaticsymptoms2

•Upperrespiratorycatarrh;skindiseases,especiallywhendependentongastricdifficulties;asatonicduringconvalescence1,2

•Menorrhagia,postpartumhemorrhage,submucosalmyoma(fibroids),hemorrhagicendometriosis,dysmenorrhea1,2

•Topicallyforaffectionsofthenoseandthroat,eczema,pruritus,otorrhea,catarrhaldeafnessandtinnitus,conjunctivitis1,2

NativeAmericansusedgoldensealfordropsy,skindiseases,indolentulcers,gonorrhea,liverandstomachdisorders,andasatonic.Externally,theinfusionwasusedasaremedyforsoreeyes,andtherootwaschewedforsoremouth.GoldensealwasofficialintheUSPfrom

1831to1842and1863to1936andintheNFfrom1936to1960.Goldensealwasusedasabittertonicandanastringenttotreatinflammationofthemucousmembranes.3

PharmacologicResearch

Keyconstituentsofgoldensealincludealkaloidsoftheisoquinolinegroup,particularlyberberineandhydrastine.

•Invitroandinvivostudieshavedemonstratedthatberberinehasantimicrobialactivityagainstawidevarietyofmicroorganisms,includingbacteria,fungi,andparasites.Hydrastinehasbeenfoundtoproduce70%mortalityinthetapewormEchinococcusgranulosus,bothinvitroandinvivo.

•BerberinecombinedwithGeraniumleafextract(oraldoses)significantlyinhibiteddiarrhea.Oralberberine,givenwithEscherichiacolienterotoxin,significantlyreducedintestinalfluidaccumulationinvivo.

•Intravenousberberineblockedarrhythmiasanddecreasedtheamplitudeofdelayedafter-depolarizationsinisolatedventricularmusclesinvivoandinvitro.

•Berberineincreasedthrombocytes,decreasedfactorXIIIactivity,inhibitedplateletaggregationandadhesiveness,andinhibitedclotretractioninexperimentalmodels(routeunknown).

•Berberinehasdemonstratedcytotoxicactivityinseveralinvitromodels.

•Oraladministrationofberberinehydrochloridesignificantlyincreasedbilirubinexcretioninexperimentalhyperbilirubinemiawithoutaffectingthefunctionalcapacityoftheliver.

•Lipogenesiswassuppressedinisolatedsebaceousglandsbyberberine.

•Berberinesignificantlydecreasedscopolamine-inducedamnesiainanexperimentalmodel.

•Treatmentwithberberineinanexperimentalmodelofdiabetesledtohealthierpancreatictissuecomparedwithcontrols.

•Berberinehadanimmunosuppressiveeffectinanexperimentalmodelofrenalautoimmunedisease(routeunknown).4

•Goldensealextractanditsalkaloidsdemonstratedanantispasmodicactiononisolatedintestinalanduterinetissues.

•Althoughgoldensealextractproducedavasoconstrictiveeffect,italsoinhibitedepinephrine-(adrenaline),serotonin-,andhistamine-inducedcontractionofisolatedaorta.However,althoughisolatedberberineorhydrastinedidnotshowthisvasoconstrictiveeffect,berberinedemonstratedsomeinhibitoryactivityonaorticcontractioninducedbyepinephrine.Hydrastinewasinactive.Theobservedvasoconstrictiveeffectofgoldensealextractmayresultfromthepresenceofhydrastinine,adecompositionproductofhydrastine.

Formoreinformationonthepharmacologyofberberine,thereadershouldreviewthebarberry(Berberisvulgaris)andIndianbarberry(Berberisaristata)monographs.

Noclinicalstudiesusinggoldensealhavebeenfound.Clinicaltrialsusingberberineareoutlinedhere.

•Berberine(100mg/day)demonstratedanantidiarrhealactionandcomparedwellagainststandardantidiarrhealdrugsinanuncontrolledstudyinvolvingchildrenwithgastroenteritis.Inrandomized,controlledtrials,berberinehasexhibitedbenefitintreatingdiarrheacausedby

ClinicalStudies

EscherichiacoliinfectionbutwasoflittlevalueagainstVibriocholeraeinfectiousdiarrhea(cholera).ThetrialswithpositiveoutcomesforE.colidiarrheawereconductedwitheitheruntreatedcontrols(400mgofberberinesulfateasasingledose)orcomparingrehydrationtherapyagainstrehydrationtherapyandberberine(200mg).Inanothertrial,neitherberberine(400mg/day)nortetracyclineexhibitedanybenefitoverplaceboinpatientswithnoncholeradiarrhea.

•Berberine(900mg/day)wasmoreefficaciousthanranitidineinclearingHelicobacterpyloriandimprovinggastritisinH.pylori-associatedduodenalulcerinarandomized,comparative,clinicaltrial.Ranitidinewasthemoresuperiortreatmentforulcerhealing.

•Intwocontrolledtrials,berberine(5to10mg/kg/dayfor6to10days)wassuperiortoplaceboandcomparedfavorablywithestablisheddrugsintreatinggiardiasisinchildren.

•Inanuncontrolledtrial,berberine(600to800mg/day)correctedhypertyraminemiaandpreventedtheelevationofserumtyramineaftertyraminestimulationinpatientswithlivercirrhosis.

•Inanuncontrolledtrial,berberine(0.9to1.5g/dayfor1to3months)incombinationwithatherapeuticdietimprovedthemajorsymptomsofpatientswithnon-insulin–dependentdiabetes.Berberineimprovedpatients’strength,normalizedbloodpressure,decreasedbloodlipids,and(in60%ofpatients)normalizedfastingglycemiclevels.

•Berberine(15mg/dayfor15days)increasedplateletcountsinpatientswithprimaryandsecondarythrombocytopeniainanuncontrolledclinicaltrial.

•Inarandomized,controlledtrial,berberinechloride(1.5

g/day)wasmoreefficaciousthanbothtetracyclineandasulfamethoxazole-trimethoprimcombinationinclearingasexualparasitemiainpatientswithchloroquine-resistantmalaria(whenallagentswereusedinconjunctionwithpyrimethamine).

•Weeklyintralesionalinjectionofberberinesaltsolution(1%)healedcutaneousleishmaniasisafter4to8weeksinasmall,uncontrolledtrial.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationthathasnotbeenreferencedinthismonographMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.EkaterinaKM,etal.Immunopharmacol.2000;48(1):9-16.

GOTUKOLA

OtherCommonName: IndianpennywortBotanicalNames: Centellaasiatica,Hydrocotyleasiatica#

Family: UmbelliferaePlantPartUsed: Aerialparts

# Alternativename.

PRESCRIBINGINFORMATION

Actions Vulnerary,antiinflammatory,depurative,adaptogenic,nervinetonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggotukolainformulationsinthecontextof:

•Improvingthehealingresponseoftheskinandsubcutaneoustissue(4a,5)

•Diabeticmicroangiopathy(4a)

•Cellulitis;gastricorduodenalulcer(4a)

•Legulcers(4a,5)

•Leprosy(4,5)

•Scleroderma(4a)

•Venousinsufficiencyofthelowerlimbs(4a)

•Varicoseandpostthromboticsyndromes(4a)

•Keloidsandhypertrophicscars(4a)

•Hemorrhoids,incombinationwithbulkinglaxatives,ifrequired(4a)

•Mouthulcers(6)

•Chronicskinandrheumaticconditions(5)

•Improvingmentalfunction(2,5)

•Anxiety(4)

•Improvingadaptationtostressors(7)

•Producingarejuvenatingtoniceffect(4,5)

•Chronichepaticdisorders(4a,6)

•Topicaltreatmentforpostthromboticsyndromeandvaricoseveins(4a)

•Topicaltreatmentforpsoriasis,wounds(4,5)

•Topicaltreatmentforburns,legulcers,cellulitis(4)

•Topicaltreatmentforleprousulcers,scarformationaftersurgery,eczema(5)

•Topicaltreatmentforstretchmarks,incombinationwithα-tocopherolandcollagen-elastinhydrolysates(4a)

Contraindications Knownallergy.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Allergiccontactdermatitishasbeenreportedfromusinggotukola,butitisalowrisktreatment.Boththeextractandthetriterpeneconstituentsareweaksensitizers.1

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

Manyofthesuccessfulclinicaltrialsusedatriterpenefractionofgotukolaathigherdoses(approximatelyequivalentto2.5to7.0gofleafperday)thanthe

previouslyoutlinedliquiddoses.Hencetheseliquiddosesmaypossiblyneedtobeexceededtoachievesimilarresults.However,ontheotherhand,anadvantagemightexistfromusingthewholeextractratherthananisolatedfraction.

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983. Higherrelativedosesofthetriterpenefractionhavebeenusedinmostclinicaltrials.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Skinandrheumaticconditions,includingchroniceczema,chronicrheumatism,leprosy,ulcers2,3

•Topicallyforpoorlyhealingwounds,leprousulcers,scarformationaftersurgery2

TraditionalAyurvedicusesinclude:

•Asadepurativeandtonic4

•Asarasayana(rejuvenating)remedy,henceitisusedtoimprovememoryandprolonglifespan5

•Topicallyforeczema,leprosy,secondarysyphiliticulcers,psoriasis4,5

Gotukolahasbeentraditionallyusedinmanycountries.InThailand,thewholeplanthasbeenusedasadepurative,particularlytotreatskindiseasesandasadiureticandantidiarrhealremedy.6InIndonesia,gotukolahasbeenusedformouthulcersandoralthrush.7InFijiantraditionalherbalmedicine,gotukolawasemployedasatonicforwastingdiseases,suchastuberculosis,stomachproblems,andrheumaticswellingandpain.Gotukolawasusedbothinternallyandtopicallytorelievepain.8InTCM,gotukolaisusedfortraumaticinjuries,boils,urinarystones,andtocounteracttoxicityandreduceswelling.9InHongKong,gotukolaisalsousedforhepatitis,measles,thecommoncold,tonsillitis,bronchitis,andtotreatpoisoning.Externalusesincludetreatmentofsnakebiteandbleedingwounds.10InSouthAfrica,gotu

kolahasbeenemployedtotreatwounds,cancer,leprosy,fever,andsyphilis.11

PharmacologicResearch

Theaerialpartsofgotukolacontainpentacyclictriterpeneestersaponins,12themostabundantofwhichisasiaticoside.Thetriterpenoidcontentofgoodqualitygotukoladriedherbiscommonly2%to3%whenanalyzedbyhigh-performanceliquidchromatography(HPLC).13

•Gotukolaandasiaticosidedemonstratedactivityagainstherpessimplexvirus-1(HSV-1)andHSV-2invitro.14

•Thetriterpenefractionofgotukolahasdemonstratedwound-healingactivityinmanyexperimentalmodels(byinjection,oral,andtopicaladministration).ThemechanismofactionincludesthestimulationofmaturationofscartissuebytheincreasedproductionoftypeIcollagen(andhencecollagensynthesis)andadecreaseintheinflammatoryreactionandmyofibroblastproduction.15Theconstituentsalsostimulatedglycosaminoglycansynthesis16andactedspecificallytoshortentheimmediatephaseofhealing.17Aqueousextractofgotukola,particularlyasagelformulation,promotedhealinginexperimentalopenwounds.18Oralandtopicaladministrationofgotukolaextractproducedfasterepithelializationandahigherrateofwoundcontractioninvivocomparedwithcontrols.19

•Asiaticosidedemonstratedactivityinmodelsofbothnormalanddelayedwoundhealingafterbothtopicalandoraladministration.

Angiogenesiswaspromotedinisolatedtissue.20Topicalasiaticosideenhancedtheinductionofantioxidantsattheinitialstageofhealing.21

•Oraladministrationofgotukolaextractinhibitedgastriculcerationincold-andrestraint-inducedstressmodels.BrainGABAlevelswereincreased.22Completemucosal

cytoprotectionwasobservedinanexperimentalmodel(byoralroute).23

•Theantiulceractivitymayberelatedtoaprotectiveeffectonstress.Gotukolaextractalsopreventedtheexperimentalriseinplasmacorticosteronelevelsfollowingimmobilizationstress.24Inotherstudies,oralgotukolaextractdemonstratednormalizingeffectsagainstavarietyofstressors.25

•Thetriterpenefractionofgotukolareducedexperimentallyinducedacuteradiationdermatitisviaitsantiinflammatoryactivity(aftertopicalapplication).26

•Oraladministrationofgotukolaandthepartiallypurifiedtriterpenoidfractionretardedthedevelopmentofsolidandascitestumorsandincreasedlifespaninanexperimentalmodel.27

•Anantianxietyeffectwasdemonstratedinseveralexperimentalmodelsforanaqueousextractofgotukola(byinjection28andorally29).Sedativeandantidepressantactivityhasalsobeendemonstrated.30

Oraladministrationofanaqueousextractofgotukolacausedadecreaseintheturnoverofcentralmonoaminesandimprovedlearningandmemoryinexperimentalmodels.31

Mostoftheclinicaltrialslistedhereusedthetriterpenefractionofgotukola(TFGK),withdosesrangingfrom60to180mgperday(approximately2.5to7.0gofdriedherbequivalent).Themajorityofthesepreparationscontained40%asiaticosides,30%madecassicacid,and30%asiaticacid.

•OraladministrationofTFGKfor60daysdemonstratedefficacyinadouble-blind,placebo-controlledtrialinpatientswithvenoushypertensivemicroangiopathy.32In

anuncontrolledtrial33andinarandomized,single-blind,placebo-controlledtrial,34TFGKimprovedsymptoms,microcirculation,andcapillarypermeabilityinpatientswithvenoushypertension.Inanothertrial,symptomsandankleedemawereimprovedinpatientswithvenoushypertensionafterTFGKtreatment,withnosignificantchangeobservedintheplacebogroup.35TFGKtreatment(120mg/day)for6monthswasbeneficialfordiabeticmicroangiopathybyimprovingmicrocirculationanddecreasingcapillarypermeability.Thistrialwasofprospective,randomized,placebo-controlleddesign.36

•TFGKtreatmentproducedsignificantimprovementinsymptomsofheavinessinthelowerlimbsandedemainarandomized,doubleblind,multicenter,placebo-controlledtrialinvolvingpatientswithvenousinsufficiencyofthelowerlimbs.Twooraldosesweretrialled(60mg/dayor120mg/day)for8weeks.37BenefitwasalsodemonstratedforTFGKtreatmentofpatientswithchronicvenousinsufficiencyinanopenstudy.38Inarandomized,double-blind,comparativetrial,TFGKdemonstratedsuperiorefficacyoverhydroxyethylrutosideintreatingvenousinsufficiency.39Inanopentrial,TFGKtreatmentprovidedanincreaseinvenousreturnandimprovementofsymptomsinpatientswithvaricoseandpostthromboticsyndromes.40Inacontrolled,crossoverstudyinvolvingpatientswithpostphlebiticsyndromeandvenousinsufficiency,oraltreatmentwithTFGKprovidedbetterresultsinmicrocirculatorymeasurementsthantreatmentwiththeflavonoidsdiosminorhydroxyethylrutoside.41

•OraltreatmentwithTFGKproducedadecreaseintheelevatedmucopolysaccharideturnoverobservedinpatientswithvaricoseveins.42

•TreatmentwithTFGKcausedasignificantreductionofcirculatingendothelialcellsinpatientswithpostphlebiticsyndromecomparedwithbaselinevalues.43OraladministrationofTFGKandbulkinglaxatives(when

ClinicalStudies

required)producedabeneficialeffectinpatientswithfirst-andsecond-degreehemorrhoidsinanuncontrolledtrial.44

•Positiveresultshavebeenrecordedinuncontrolledtrialsfortreatinggastricandduodenalulcers(TFGK,oral),45,46gastritis(asiaticoside,oral),47andbladderlesionscausedbybilharzialinfection(TFGK,injection).48Nobenefitwasobservedforthehealingoflegulcersinpatientstreatedwithasiaticoside(byinjection)comparedwithplacebo.49However,positiveresultswereobtainedfororaluseofTFGKtakenfor3to8weeksin50patientswithlegulcers.50

•OraltreatmentwithTFGKforanaverageof55dayswassuccessfulintreatingpatientswithcellulitis.51After3months’oralTFGKtreatment,reducedtendencytosclerosisincellulitictissuewasobservedinadouble-blind,placebo-controlledstudy.52

•OraladministrationofTFGKhasbeensuccessfullyusedtotreatkeloidsandhypertrophicscars.Inastudyinvolving227patients,treatmentwithTFGKforaperiodof2to18monthshadtherapeuticvalueinbothpreventing(togetherwithsurgicalrevision)andreducingkeloids.AsubsetofthepatientsinvolvedinthecurativestudyconfirmedtheactivityofTFGKinadouble-blind,placebo-controlledtrial.53

•Inapreliminarytrial,TFGKtakenfor3to24monthsimprovedhistologyin5of12patientswithchronichepaticdisorders,includingalcoholiccirrhosisandcirrhosisofundeterminedorigin.54

•Gotukoladriedherb(0.5g/dayfor3months)increasedtheintelligencequotient,generalmentalability,andbehaviorinmentallydisabledchildreninarandomized,placebo-controlled,clinicaltrialinIndia.55

•Inanuncontrolledtrial,gotukolarelievedthesymptomsofpatientswithanxietyandimprovedmentalfunctioning.56

•Inadouble-blindtrial,gotukolatendedtoincreasethemeanlevelofredbloodcells,bloodsugar,serumcholesterol,vitalcapacity,andtotalproteininnormalvolunteers.Anincreaseinhemoglobinwasstatisticallysignificant.Thisfindingwasthoughttobeindicativeofacorticosteroid-likeactivity.57,58

•Gotukolahasbeenusedtotreatleprosypatientsfromveryearlytimesandinrecentyearsinbothuncontrolledtrials59-61andacontrolledtrial(gotukolapowderorasiaticosidecomparedwithdiamino-diphenylsulfoneoveraperiodof1year).62

•Asiaticosidewasnotsuccessfulintreatingsclerodermainchildren.63However,TFGKdemonstratedsymptomaticreliefinasmallgroupofpatientswithsystemicscleroderma.The13patientsreceivedTFGKbyintramuscularinjectionrangingfrom11/2monthsto11/2years.TwopatientsreceivedTFGKorallyforaportionoftheirtreatment.64Inanothersmall,uncontrolledtrial,oraldosesofTFGKimprovedarthralgiaandfingerjointmovementinsclerodermapatients.65

•Asystematicreviewpublishedin2000concludedthat,comparedwithplacebo,treatmentwithacreamcontaininggotukolaextract,α-tocopherol,andcollagen-elastinhydrolysatesisassociatedwithfewerwomendevelopingstretchmarks.Thisresultoccurredonlyforwomenwhohadpreviouslyencounteredstretchmarksduringpregnancy.66

•TopicalapplicationofgotukolaorTFGKhasbeensuccessfullyusedtotreat:•Postthromboticsyndromeandvaricoseveins(double-blind,placebo-controlledtrial;TFGK)67

•Chronicvenousinsufficiency(single-blind,controlledtrialofTFGKagainstoraladministrationofthedrugtribenoside)68•Psoriasis(uncontrolledtrial;waterandoilextractofgotukola)69•Legulcers(uncontrolledtrial;70placebo-controlledtrial,TFGKbyinjectionortopical71)•Soiledwoundsresistanttoothertreatments(standardizedgotukolaextractcombinedwithessentialoils;uncontrolledtrial)72•Burns(topical,injection,orboth;uncontrolledtrialswithTFGKorgotukolaextract)73,74•Cellulitis(uncontrolledtrial;standardizedgotukolaextract)75

REFERENCES

HausenBM.ContactDermatitis.1993;29(4):175-179.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinalandAromaticPlants,1989.FarnsworthNR,BunyapraphatsaraN,editors.Thaimedicinalplants.Bangkok:MedicinalPlantInformationCenter,1992.

DharmaAP.Indonesianmedicinalplants.Jakarta:BalaiPustaka,1987.CambieRC,AshJ.Fijianmedicinalplants.Melbourne,Australia:CSIROPublishing,1994.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.

10ChungCH,LiNH.ChinesemedicinalherbsofHongKong:Chinese-English.HongKong:Shangwuyinshukuan,1978.

11vanWykB-E,vanOudtshoornB,GerickeN.MedicinalplantsofSouthAfrica.Arcadia,SouthAfrica:BrizaPublications,1997.

12WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.

13GuntherB,WagnerH.Phytomed.1996;3(1):59-65.14YoosookC,etal.Phytomed.2000;6(6):411-419.15WidgerowAD,etal.AestheticPlastSurg.2000;24(3):227-234.

16MaquartFX,etal.EurJDermatol.1999;9(4):289-296.17PoizotA,DumezD.CRAcadSciHebdSeancesAcadSciD.1978;286(10):789-792.

18Sunilkumar,ParameshwaraiahS,ShivakumarHG.IndianJExpBiol.1998;36(6):569-572.

19SugunaL,SivakumarP,ChandrakasanG.IndianJExpBiol.1996;34(12):1208-1211.

20ShuklaA,etal.JEthnopharmacol.1999;65(1):1-11.21ShuklaA,RasikAM,DhawanBN.PhytotherRes.1999;13(1):50-54.

22ChatterjeeTK,etal.IndianJExpBiol.1992;30(10):889-891.23TanPV,NjimiCK,AyaforJF.PhytotherRes.1997;11:45-47.

24UpadhyaySC,etal.IndianDrugs.1991;25(6):388-389.25SarmaDNK,KhosaRL.PhytotherRes.1996;10:181-183.26ChenYJ,etal.BiolPharmBull.1999;22(7):703-706.27BabuTD,KuttanG,PadikkalaJ.JEthnopharmacol.1995;48(1):53-57.

28DiwanPV,KarwandeI,SinghAK.Fitoterapia.1991;62(3):253-257.

29deLuciaR,SertieJAA.Fitoterapia.1997;68(5):413-416.30SakinaMR,DandiyaPC.Fitoterapia.1990;61(4):291-296.31NaliniK,AroorAR.Fitoterapia.1992;63(3):232-237.32CesaroneMR,etal.MinervaCardioangiol.1994;42(6):299-304.

33BelcaroGV,GrimaldiR,GuidiG.Angiology.1990;41(7):533-540.

34BelcaroG,etal.CurrTherRes.1989;46:1015-1026.35BelcaroGV,RuloA,GrimaldiR.Angiology.1990;41(1):12-18.

36CesaroneMR,etal.Angiology.2001;52(supp2):S49-S54.37PointelJP,etal.Angiology.1987;38(1,pt1):46-50.38CapelliR.GiornItalAngiol.1983;1:44-48.39MonteverdeA,etal.ActaTherapeut.1987;13:629-636.40CospiteM,etal.GiornItalAngiol.1984;4(3):200-205.41AllegraC.ClinTer.1984;110(6):555-559.42ArpaiaMR,etal.IntJClinPharmacolRes.1990;10(4):229-233.

43MontecchioGP,etal.Haematologica.1991;76(3):256-259.44GuarerioF,etal.GiornItalAngiol.1986;6(1):46-52.45ShinHS,etal.KoreanJGastroenterol.1982;14:49-56.46RheeJC,ChoiKW.KoreanJGastroenterol.1981;13:35-40.47ChungJM,ChungKS.KoreanJGastroenterol.1981;13:41.48FamA.IntSurg.1973;58(7):451-452.49MayallRC,etal.RevBrasMed.1975;32:26-29.50HuriezCL,MartinP.LilleMed.1972;44(9):463-464.51BourguignonD.GazMedFr.1975;82:4579-4583.52HachenA,BourgoinJY.MedPrat.1979;738(suppl):7.53BosseJP,etal.AnnPlastSurg.1979;3(1):13-21.54DarnisF,etal.SemHop.1979;55(37-38):1749-1750.55AppaRaoMVR,SrinivasanK,KoteswaraRaoT.JResIndianMed.1973;8(4):9-15.

56SinghRH,ShuklaSP,MisraBK.JResAyurvSiddha.1981;2(1):1-10.

57AppaRaoMVR,etal.JResIndianMed.1967;2:79-85.58AppaRaoMVR,etal.Nagarjun.1969;12:33.59HerbertD,etal.IndianJLepr.1994;66(1):65-68.60BoiteauP,etal.Nature.1949;163:258.61KakkarKK.IndianDrugs.1988;26(3):92-97.62ChakrabartyT,DeshmukhS.SciCulture.1976;11:573.63FratiMunariAC,etal.BolMedHospInfantMex.1979;36(2):201-214.

64SasakiS,ShinkaiYA,KishinaraY.ActaDermVenereol.1972;52(2):141-150.

65SzczepanskiA,DabrowskaH,BlaszczykM.PrzeglDermatol.1974;61(5):701-703.

66YoungGL,JewellMD.CochraneDatabaseSystRev.(2):2000.CD000066

67AllegraC,etal.ClinTerap.1981;99(5):507-513.68MarastoniF,etal.MinervaCardioangiol.1982;4:201-207.69NatarajanS,PailyPP.IndianJDermatol.1973;18(4):82-85.70AppertiM,etal.QuadChirPrat.1982;3:115.71NeboutM.BullSocPatholExot.1974;67(5):471-478.72MorissetR,CoteNG,PanissetJC.PhytotherRes.1987;1(3):117-121.

73BoiteauP,RatsimamangaAR.BullSocSciBretagne.1959;34:307-315.

74GravelJA.LavalMed.1965;36(5):413-415.75CarraroPereiraI.FolhaMed.1979;79(5):401-414.

GREATERCELANDINE

OtherCommonName: ChelidoniumBotanicalName: ChelidoniummajusFamily: PapaveraceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

ActionsCholeretic,cholagogue,spasmolytic,mildlaxative,antiinflammatory,antiviral(topically),vulnerary(topically)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggreatercelandineinformulationsinthecontextof:

•Biliarydyskinesia,incombinationwithturmeric(2)

•Increasingbileflowandpancreaticsecretion,incombinationwithmilkthistleandturmeric(3)

•Cholangitis,gallstones,cholecystitiswithoutstones(3,5)

•Crampingpainofthegastrointestinaltractandgallducts(4,5)

•Liverdisease,jaundice,biliousdyspepsia,biliousheadache,migraine,supraorbitalneuralgia,skinconditions,especiallypsoriasis(5)

•Chronicbronchitis,whoopingcough(4)

•Anenemaforcolonicpolyposis(4)

•Topicaltreatmentforwarts(4,5)Contraindications Noneknown.

WarningsandPrecautions

Giventhenatureofthealkaloidcontentofthisherbandthereportedcasesofhepatotoxicity(seethe“SideEffects”sectioninthismonograph),long-termuseofhigherdoses(excepttopical)isnotrecommended.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Severalcasesofhepatotoxicity1-4andonecaseofhemolyticanemiahavebeenreportedafteringestinggreatercelandineorpreparationscontainingtheherb.

Intenseitchinganderythemawithpapuleswasreportedaftertopicalapplicationofthejuiceina64-year-oldwoman.Thepatientreactedpositivelytopatchtestsofthejuiceandextract,whereasnoreactionswereobservedin10controlvolunteers.5

WhengreatercelandinewasusedinTCM,variousdegreesofadversereactionssuchasdrymouth,dizziness,gastricdiscomfort,diarrhea,abdominaldistension,nausea,andmildleukopeniawerereportedinaminorityofpatients.Symptomsgenerallydisappearedwithin3to5dayswithoutdiscontinuingthetreatment.

Dosage Doseperday* Doseperweek*

1-2mlof1:2liquidextract

7-15mlof1:2liquidextract

Short-termuseofhigherdosesuptotheequivalentof3gperdaymaybenecessarytoalleviategastrointestinalorgallductcrampingpains.

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Liverandgallbladderinflammationandpain,6gallstones,6,7cholecystitis7

•Gastrointestinalconditionsresultingfrompoorliverfunction7

•Jaundice,hemorrhoids,biliousdyspepsia7

•Biliousheadache,migraine,supraorbitalneuralgia7

•Skinconditions7

•Topicallyforwarts,indolentulcers,fungalgrowths,traumaticinflammations,hemorrhoids,skinconditions7

UsesfromTCMincludeabdominalpain,pepticulcers,chronicbronchitis,andwhoopingcough.8

Keyconstituentsofgreatercelandineaerialpartsincludetheisoquinolinealkaloids(0.4%to1.3%),especiallychelidonine.

•Oraladministrationofanalcoholextractofdriedgreatercelandinedecreasedchemicallyinducedliverinjuryinexperimentalmodels,indicatingahepatoprotectiveactivity.

•Greatercelandineextractinducedbileflowwithoutincreasingthetotaloutputofbileacidsintheisolatedperfusedliver(inotherwords,theflowofadditional

PharmacologicResearch

dilutebilewasincreased).

•Oraladministrationofgreatercelandineextractsignificantlyreducedstomachtumorincidenceinexperimentalmodels.Intraperitonealinjectiondemonstratedhightumorinhibitionwithrelativelymildcytotoxicsideeffects.GreatercelandinealsoexertedanantimutageniceffectinvitroagainstseveralmutagensintheAmestest.

•Greatercelandineextractinhibited5-lipoxygenaseinvitro.Thealkaloidssanguinarineandchelerythrinearepotentinhibitorsof5-lipoxygenaseand12-lipoxygenaseandhavedemonstratedantiinflammatoryactivityinthecarrageenanratpawedematest(afteroraladministrationandsubcutaneousinjection).

•Chelerythrinechlorideexertedaninvitroantiplateleteffectthatisbelievedtobecausedbytheinhibitionofboththromboxaneformationandphosphoinositidebreakdown.

•Greatercelandineextractinhibitedhumankeratinocyteproliferationinvitro,indicatingpossibletopicalapplicationforpsoriasis.

•ExtractsofgreatercelandinewereshowntohaveinvitroantiviralactivityandantifungalactivityagainstFusariumstrains.9Fusariumstrainshaveahighresistancetoconventionalfungicides.Greatercelandinealkaloidshadsignificantantimicrobialactivityagainstfungalspeciesandgram-positivebacteria(butnotgram-negativebacteria)andinhibitedthegrowthofTrichomonasvaginalisinvitro.Thealkaloidssanguinarineandchelerythrinewereactiveagainstgram-positivebacteriaandCandidaalbicans.

•Inacontrolledtrial,greatercelandineextractexertedgoodtoverygoodresultsintwothirdsofpatientstreated

ClinicalStudies

forcholangitis,gallstones,andcholecystitiswithoutstones.Greatercelandinetreatmentwasaseffectiveastreatmentwithunspecifiedproprietarypreparationscommonlyusedfortreatingthesegallbladderconditions.Theadministereddailydosewas3mloffreshplanttincturestandardizedto0.6mg/dayalkaloidsandtakenfor43to50days.

•Greatercelandine,incombinationwithmilkthistleandturmeric,increasedbileflowandpancreaticsecretioninaplacebo-controlledtrial.

•Inanuncontrolled,multicentertrial,ahighdoseofgreatercelandineextracthadagoodtoverygoodeffectongastrointestinalorgallductcrampingpains,withquickresponse(30minutes).Theadministereddailydosecontained14.25mgoftotalalkaloidsinitially.Thedosewasthenreducedandcontained8.55mgperdayoftotalalkaloids.

•Acombinationofgreatercelandineandturmericdriedextractsreducedrightupperquadrantpainresultingfrombiliarydyskinesiainarandomized,placebo-controlled,multicenterstudy.10

•Greatercelandinedecoctiontakenfor2weeks(madefrom60gofherbperday)causeddegenerationofcanceroustissueinpatientswithsquamouscellcarcinomaoftheesophagus.ThetrialcomparedpatientstreatedpreoperativelywithoneofthreetraditionalChineseherbs,herbscombinedwithcyclophosphamide,andcontrolpatientswhoreceivednotreatment.Thedegenerationwaslessclearinpatientstreatedwithherbspluscyclophosphamideandthecontrols.

•Greatercelandine(equivalentto15gofherbperday)givenasanextractorsyruphadan80%effectiverateinanuncontrolledtrialinvolvingpatientswithchronicbronchitis.Greatercelandinesyrupordecoctioncured

71%andimproved23%of500casesofwhoopingcoughininfantsandchildreninanotheruncontrolledtrial.

•Greatercelandineadministeredasanenemareduced,andinsomecasescleared,nonmalignantcolonicpolyposisinuncontrolledtrials.Treatmentfrequencyrangedfromonetothreecoursesof10to20enemaseach.

•Inanuncontrolledtrial,topicalapplicationofgreatercelandineextractcompletelyresolvedwarts,papillomas,condylomas,andnoduleswithin15to20daysin135of200nursingmothers.Theextractwasappliedapproximately200timesperdayfor2to3weeksoruntilimprovementwasobserved.

•InGermany,theCommissionEsupportsusinggreatercelandinetotreatspasticdiscomfortofthebileductsandgastrointestinaltract.11

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicalandclinicalinformationthathasnotbeenreferencedhereMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.deSmetPA,etal.BMJ.1996;313(7049):92.GrevingI,etal.PharmacoepidemiolDrugSaf.1998;7:S66-S69.BenningerJ,etal.Gastroenterol.1999;117(5):1234-1237.StrahlS,etal.DeutscheMedizinischeWochenschrift.1998;123(47):1410-1414.

EtxenagusiaMA,AndaA,Gonzalez-MahaveI.ContactDermatitis.2000;43(1):47.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.HuangKC.ThepharmacologyofChineseherbs.BocaRaton,Fla:CRCPress,1993.MatosOC,etal.JEthnopharmacol.1999;66(2):151-158.

10NiederauC,GopfertE.MedKlin.1999;94(8):425-430.11BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

GRINDELIA

BotanicalNames: Grindeliacamporum,Grindeliarobusta+

Family: CompositaePlantPartUsed: Aerialparts

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Expectorant,spasmolytic,bronchospasmolytic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingGrindeliainformulationsinthecontextofrespiratoryconditionsmarkedbyspasm,asthma,whoopingcough,bronchitis,dryandirritablecough,andupperrespiratorycatarrh.(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Noneexpectediftakenwithintherecommendeddoserange.TheBritishHerbalPharmacopoeia1983notesthatlargedosesarereportedtocauserenalirritation.1Thiswarningmaybetheresultofthepresenceofsaponins.

Dosage Doseperday* Doseperweek*

1.5-3.0mlof1:2liquidextract

10-20mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Bronchitis,asthma,upperrespiratorycatarrh,whoopingcough;harshanddrycough,difficultbreathingresultingfromheartdisease1,2

•Cystitis1,2

NativeAmericansusedGrindeliaspeciesforavarietyoftherapeuticpurposes,includingcoughs,thecommoncold,tuberculosis,skininfections,andcolicinchildren.ThedriedleafandfloweringtopsofGrindeliawereofficialintheUSPfrom1882to1926andtheNFfrom1926to1960.Severalspecieshavebeenofficialunderthisnameandhavebeenusedassedatives,antispasmodics,expectorants,andasremediesforpoisonivy,aliquidextractbeingusedinthelastcase.3

PharmacologicResearch

TheaerialpartsofGrindeliacontainresinandsaponins.Anantimicrobialactivityhasbeendemonstratedinvitro,whichisnottheresultofthesaponinsbutisatleastpartiallycausedbytheresinfraction.4

ClinicalStudies NoclinicalstudiesusingGrindeliahavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.

Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.KreutzerS,SchimmerO,WaibelR.PlantaMed.1990;56(4):392-394.

GYMNEMA

BotanicalName: GymnemasylvestreFamily: AsclepiadaceaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Antidiabetic,hypoglycemic,hypocholesterolemic,weightreducing

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingGymnemainformulationsinthecontextof:

•Diabetesmellitus(bothinsulin-dependentandnon-insulin–dependent)(3,5)

•Reducingthesenseoftasteforsweetfoods(3,5)

•Reducingappetiteandcalorieintake(3,5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsAswithallsaponin-containingherbs,oralusemaycauseirritationofthegastricmucousmembranesandreflux.

Dosage Doseperday*∧ Doseperweek*

3.5-11.0mlof1:1liquidextract

25-75mlof1:1liquidextract

Onetotwomlperdayisallthatisnecessaryforreducingsweet-cravingandthesweettaste.Inthelattercase,theextractshouldbeapplieddirectlytothetongue,rinsedoff,andswallowedafter1minute.Thisprocedurecanbedoneat2-to3-hourintervals.

* Thisdose range is extrapolated from traditionalAyurvedicmedicine1,3 and the author’seducationandexperience.

∧ Lessmaybeneededifcombinedwithotherantidiabeticherbs.Somecasesofdiabeteswillrespondquickly,butbestresultscomeafter6to12monthsofcontinuoususe.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Glycosuria,diabetes(knownasthe“sugardestroyer”)1,2

•Urinarydisorders,fever,cough3

AyurvedictextsnotethatchewingGymnemaleafremovestheabilitytotastesweetorbittersubstances.2

KeyconstituentsofGymnemaleavesincludesaponins,whicharepresentasbothnonacylatedglycosidesknownasgymnemasaponinsandtheacylatedgymnemicacids.4Gymnemicacidreferredtointheliteratureisoftennotdefinedandmostlikelyreferstothecrudesaponinfractionortoamixtureofgymnemicacids.

•TheantisweetprinciplesofGymnemaincludethegymnemicacids,5gymnemasaponins,6andgurmarin(apeptide).7Gymnemicacidsuppressedthesweettasteofsweetenersinchimpanzees.Gymnemicacidhadnoeffectontheresponsestobitter,salty,orsourcompounds.8,9

•OraladministrationofGymnemademonstratedhypoglycemicactivityinexperimentalmodelsofdiabetes.Gymnematreatment:

•Regulatedbloodsugarandincreasedtheactivityoftheenzymesthatfacilitatetheuseofglucosebyinsulin-dependentpathways10

•Increasedtheuptakeofglucoseintoglycogenandproteininliver,kidney,andmuscle10

PharmacologicResearch

•Correctedhyperglycemiainmilddiabeticmodelsandsignificantlyprolongedlifespaninmodelsofseverediabetes(withcompletelydestroyedpancreatictissue)11

•Reducedpostprandialserumglucoseandimprovedglucosetolerance.(Pancreasweightandcontentofinsulinwerenotchanged.)12

•Returnedfastingbloodglucoselevelstonormalafter20days.(Ariseininsulinandpancreaticisletregenerationoccurredtosomeextent.)13

•Producedhypoglycemicactivityinaslowandsteadymanner,with12to24weeksoftreatmentrequiredinmilddiabetes14

•Loweredbloodsugarlevelsinnormalanddiabeticmodelsbutwassixtimeslesspotentthantolbutamideindiabeticanimals15

•Themechanismofactionmayalsoincludeinhibitionofglucoseabsorptionintheintestine.16

•FeedingwithGymnemaaqueousextractdecreasedbodyweightinfatandleanratscomparedwiththoseconsumingonlythetestdiet.Inadditiontoloweringbloodglucoselevels,Gymnemaalsoimprovedhypertriglyceridemiabutnothypercholesterolemia.17Inanotherstudy,oraladministrationofGymnemaextractfractionsdecreasedbodyweightgainandfoodintakeandincreasedfecalexcretionofcholesterol,totalneutralsteroids,totalbileacids,andcholicacid–derivedbileacid.18Gymnemaingestionproducedasignificantloweringofcholesterolinahypertensionmodel.19

•SeveralclinicalstudiesverifythatpretreatmentwithGymnemaextract,Gymnemainfusion,andgymnemicacidsolutionreducedthesweettasteofsweeteners.20-23

ClinicalStudies

Aperiodofatleast30secondswasrequiredaftertastingtheGymnemainfusionforthefullsweet-suppressioneffecttoappear.23

•Gymnemapowder(10g/dayfor7days)demonstratedahypoglycemiceffectinmilddiabeticmodelsinanuncontrolledtrial.Serumtriglycerides,freefattyacidandcholesterollevels,andcreatinineexcretion,werealsodecreased.24

•Acontrolledstudyinvolvingpatientswithinsulin-dependentdiabetesfoundthatGymnemaextractreducedinsulinrequirements,fastingbloodglucose,glycosylatedhemoglobin,andglycosylatedplasmaproteinlevelscomparedwithpatientsreceivinginsulintherapyalone.Cholesterol,triglycerides,freefattyacids,andserumamylasewerealsolowered.Somesuggestionofenhancingendogenousinsulinproduction,possiblybypancreaticregeneration,wasdemonstrated.Gymnemaextract(400mg/day,equivalentto10to13g/dayofdriedleaf)wasadministeredfor6to30months.25

•AsecondstudybythesameresearchgroupfoundthatthesameGymnemaextract(400mg/dayfor18to20months)producedsimilarresultsforpatientswithnon-insulin–dependentdiabeteswithareductionofsimilarbiochemicalparametersandhypoglycemicdrugrequirements.FastingandpostprandialseruminsulinlevelswereelevatedintheGymnemagroupcomparedwithcontrolstakingonlyconventionaldrugs.AdministeringGymnematohealthyvolunteersdidnotproduceanyacutereductioninfastingbloodglucoselevels.26

•Clinicalresearchunderdouble-blind,placebo-controlledconditionsfoundthataconcentratedGymnemaextract(gymnemicacidcontentnotdefined)considerablydiminishedthesweettasteandsignificantlydecreasedappetiteandtheamountofcaloriesconsumedforupto90

minutesafterthesweet-numbingeffect.27

REFERENCES

ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinalandAromaticPlants,1989.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.HostettmannK,MarstonA.Chemistry&pharmacologyofnaturalproducts:saponins.Cambridge:CambridgeUniversityPress,1995.LiuHM,KiuchiF,TsudaY.ChemPharmBull(Tokyo).1992;40(6):1366-1375.YoshikawaK.TetrahedronLett.1991;32(6):789-792.ImotoT,etal.CompBiochemPhysiol.1991;100(2):309-314.HellekantG,etal.PhysiolBehav.1996;60(2):469-479.HellekantG,NinomiyaY,DanilovaV.PhysiolBehav.1998;65(2):191-200.

10ShanmugasundaramKR,etal.JEthnopharmacol.1983;7(2):205-234.

11SrivastavaY,etal.IntJCrudeDrugRes.1986;24(4):171-176.

12OkabayashiY,etal.DiabetesResClinPract.1990;9(2):143-148.

13ShanmugasundaramER,etal.JEthnopharmacol.1990;30(3):265-279.

14ShanmugasundaramKR,etal.PharmacolResCommun.1981;13(5):475-486.

15ChattopadhyayRR.JEthnopharmacol.1999;67(3):367-372.16WangLF,etal.CanJPhysiolPharmacol.1998;76(10-11):1017-1023.

17TeresawaH,MiyoshiM,ImotoT.YonagoActaMed.1994;37(2):117-127.

18NakamuraY,etal.JNutr.1999;129(6):1214-1222.19PreussHG,etal.JAmCollNutr.1998;17(2):116-123.20MinBC,SakamotoK.ApplHumanSci.1998;17(1):9-17.21FrankRA,etal.ChemSenses.1992;17(5):461-479.22GentJF,etal.ChemSenses.1999;24(4):393-403.23MeiselmanHL,HalperinBP.PhysiolBehav.1970;5(8):945-948.

24BalasubramaniamKB,etal.JNatlSciCouncSriLanka.1992;20(1):81-89.

25ShanmugasundaramER,etal.JEthnopharmacol.1990;30(3):281-294.

26BaskaranK,etal.JEthnophmaracol.1983;30(1):1-9.27BralaPM,HagenRL.PhysiolBehav.1983;30(1):1-9.

HAWTHORN

BotanicalNames:

Crataegusmonogyna,Crataeguslaevigata+(Crataegusoxyacantha#)

Family: RosaceaePlantPartsUsed: Leaf,berry

+ Medicinallyinterchangeablespecies.

# Alternativename.

PRESCRIBINGINFORMATION

Actions

Hawthornleafandberry:cardioprotective,mildcardiotonic,hypotensive,peripheralvasodilator,antiarrhythmic,antioxidant,mildastringent,collagenstabilizing

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinghawthornleafandberryinformulationsinthecontextof:

•Cardiacinsufficiency,particularlycorrespondingtoNewYorkHeartAssociation(NYHA)stagesIandII(1,4,5)

•Othermildheartconditions,suchasminoranginapectoris(2,5)

•Lowheartratevariability(2)

•Hypertension(3,5)

•Cardiacarrhythmias,tachycardia,nervousheartcomplaints,circulatorysupport(4)

•Arteriosclerosis,Buerger’sdisease(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

InteractionsHawthornmayactinsynergywithdigitalisglycosides,beta-blockers,andotherhypotensivedrugs.Modificationofdrugdosagemayberequired.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Noneexpectediftakenwithintherecommendeddoserange.

Inapostmarketingsurveillancestudyinvolving3664patientswithcardiacinsufficiencycorrespondingtoNYHAstagesIandII,hawthornextract(correspondingto2.7g/dayofdriedleafandflower,containing19.8mgflavonoids)waswelltolerated.Adversereactionswithacausalrelationshiptohawthorntherapywereconfirmedin22casesandprobableinanother4(atotalof0.7%).

Reportedsideeffectsincludedgastrointestinaldisorders,palpitations,headache,dizziness,circulatorydisturbances,sleeplessness,andinneragitation.

Dosage Hawthornberry: Doseperday* Doseperweek*

3-7mlof1:2liquidextract

20-50mlof1:2liquidextract

Extractsprovidingquantifiedlevelsofoligomericprocyanidins(OPCs)arerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan4mg/mlofOPCs.

Hawthornleaf: Doseperday** Doseperweek**

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

ExtractsprovidingquantifiedlevelsofOPCsarerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan10mg/mlofOPCs.

Higherdosesthanthoseoutlinedheremaybenecessaryforeffectivecontrolofhypertension.

* ThisdoserangeisextrapolatedfromBritishHerbalPharmacopoeia1983andtheauthor’seducationandexperience.

** Thisdoserangeisextrapolatedfromclinicalstudies.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesofhawthornberryincludemyocardialweakness,hypertension,anginapectoris,tachycardia,andothercirculatorydisorders,suchasarteriosclerosisandBuerger’sdisease.1

TraditionalWesternherbalmedicineusesofhawthornleafincludeasanastringentandtonic.2

NativeAmericansusedHawthornfruitandbarkforwomen’smedicine,andthechewedleaveswereusedasapoulticeforswellings.3Eclecticphysiciansusedhawthornfruitandbarkforcardiacproblems,particularlythoseofafunctionalnature,andasageneraltonicaswell.2

KeyconstituentsofhawthornincludeOPCs,especiallyprocyanidinB-2,andflavonoids.Thelevelsvarywiththespeciesofhawthornandalsowithintheplantpart.Theflowerscontainthehighestlevelsofflavonoids,andtheleavescontainthehighestlevelsofOPCs.TheripeberriesarethelowestinOPCsandflavonoids.Thereforeafairassumptionwouldbethattheleafismoreactivethanthetraditionallypreferredberry.

•Studieshaveshown(manyinvitro)hawthornextractsorfractionstoincreasecoronarybloodflow,tobepositivelyinotropic(increasingtheforceofcontraction),negativelychronotropic(decreasingtheheartrate),andcardioprotective.Oraladministrationalsofoundanincreaseincoronarybloodflowinanexperimentalmodel.

•Purifiedflavonoidsfromhawthornleafproducedasmallernecroticfocusandimprovedrevascularizationof

PharmacologicResearch

finervessels(aftermyocardialinfarction)whencomparedwithcontrols.

•Inexperimentalmodels,thefollowinghasbeenobserved:•Improvedmyocardialperformance(OPCs,byinjection)•Increasedcoronarybloodflow(OPCs,bybothoralandinjectedroutes)•Decreasedbloodpressure(extract,OPCs,bybothoralandinjectedroutes)•Antiarrhythmiceffect(extract,oralroute)

•Inlaboratorystudies,whencomparedwithadigoxinpreparation,hawthornextractincreasedtheerythrocyteflowrateinallthevascularnetworksexaminedandreducedbothleukocyteendothelialadhesionanddiapedesisinthevenularnetworkofmesentericvessels.

•Hawthornleafandberryextractsexhibitedantioxidantactivityinvitro.HawthorntinctureinhibitedinvitrooxidationofLDLandVLDLfromtheplasmaofpatientswithnon-insulin–dependentdiabetesmellitus.4

•AlthoughstudieshavenotbeenconductedspecificallyontheOPCsfoundinhawthorn,hawthornOPCswilllikelysharemanyoftheknownpharmacologicalpropertiesofOPCs.Theseindicationsmightincludepreventionofcancer,atheroma,andanycelldamageoccurringunderhypoxicconditions.HawthornOPCshavealsostabilizedcollageninvitro.

TheNYHAclassifieslossofcardiacoutput:forstageI,thepatientissymptom-freewhenatrestandontreatment;forstageII,patientshavelossofcapacitywithmediumeffort.

•Ameta-analysisreviewingeightclinicaltrialsfrom1989to1994foundstandardizedhawthornleafandflowerextracttobeefficaciousfortreatingheartfailure(mostlyofNYHAstageII).Asignificanteffectwasobservedfor

subjectivefindingsinallbutonetrial,forpressure-rateproduct(whichmeasurescardiacworkperformance)infourtrials,andforworktoleranceinthreetrials.Twotrialswereopen,fivewererandomized,double-blind,andplacebo-controlled,andonewasamulticenter,double-blind,comparativetrialwiththedrugcaptopril.Informationavailableindicatesthatforfourtrials,adoserangeequivalentto0.9to2.7gperdayofdriedleafandflowerstandardizedto6.6to19.8mgperdayofflavonoidswasadministered.Intwotrials,adoserangeequivalentto0.8to1.2gperdayofdriedleafandflowerstandardizedto30to45mgperdayofOPCwasadministered.Therandomized,double-blind,placebo-controlledtrialthatfailedtofindsignificantimprovementforpressure-rateproducthadusedalowerdoseofhawthornextract(equivalentto0.9g/dayofleafandflowerandcontaining6.6mg/dayofflavonoids).

•Inarandomized,double-blind,placebo-controlledstudy,hawthornleafandflowerextract(equivalentto1.2g/dayleafandflowerstandardizedto45mg/dayOPC)administeredfor12weeksincreasedexercisetoleranceinpatientswithNYHAclassIIcongestiveheartfailure.Exercisetolerancewasreducedintheplacebogroup.Noadversereactionswerereportedinthehawthorngroup.Anumberofbiochemicalindicesweremonitored,andtheseeitherremainedwithintheirnormalrangesordidnotdifferinaclinicallysignificantmannerduringtherapy.5

•Significantbenefitincardiacparameterswasachievedinamulticenter,double-blind,placebo-controlledtrialusinghawthornleafandberryextractin80patientswithmildcongestiveheartdiseaseresultingfromischemiaorhypertension.Noadverseinteractionswithconventionalmedicationwereobserved.

•Inarandomized,double-blind,placebo-controlledstudy,hawthornextractsignificantlyincreasedheartratevariability(HRV)ingeriatricpatientscomparedwith

ClinicalStudies

placebo.(LowHRVisariskfactorincoronaryheartdisease,andapositivecorrelationexistsbetweenHRVandlifeexpectancy.)

•Inarandomized,double-blind,placebo-controlledclinicalstudy,hawthornextract(equivalentto900mg/dayofdriedherbfor3weeks)wasshowntoimprovepathologyinpatientswithanginapectoris.

•Inapostmarketingsurveillancestudy,standardizedhawthornleafandflowerextract(equivalentto2.7g/dayleafandflowerstandardizedto19.8mg/dayofflavonoidsfor8weeks)wasshowntobewelltoleratedandimprovedthesymptomscoreonaverageby66.6%inpatientswithheartdisease(NYHAstagesIandII).Cliniciansratedoverallefficacyasbetterthan90%.Patientswithborderlinehypertension,tachycardia,andcardiacarrhythmiasexhibitedexcellentresults,withbloodpressure,heartrate,andincidenceofarrhythmiasbeingreduced.Alargenumberofpatientspreviouslyunsuccessfullytreatedwithdigoxinalonewerecompensatedforrestandslightstresswithrelativelyloworaldosesoftheglycosideincombinationwithhawthorn.

•Inanuncontrolledtrial,hawthornberrytincture(equivalentto4.3g/dayofberry)significantlyreducedsystolicanddiastolicbloodpressure.Whentreatmentwasstopped,bloodpressuresreturnedtotheirinitialvaluesovera2-weekperiod.

•Inarandomized,double-blind,placebo-controlledstudy,hawthornleafandflowerextractincombinationwithpassionflowerwasefficaciousintreatingpatientswithdyspneacommensuratewithNYHAstageII.Thedosageofhawthorncorrespondedto1.6gperdayofleafandflowerandcontained15mgperdayofflavonoidsand28mgperdayofOPCs.Thepreparationwasadministeredfor6weeks.

•Inaplacebo-controlled,crossoverstudy,theeffectofasingledoseofstandardizedhawthornleafandflowerextract(equivalentto2.7gofleafandflower,standardizedto19.8mg/dayofflavonoids)onthecutaneousmicrocirculationwascomparedwith0.3mgmedigoxin.Sixhoursaftertakinghawthorn,thehemocrithaddroppedbyameanof3.2%,whereas,3hoursaftertakingthedigoxin,erythrocyteaggregationincreasedsignificantlybyameanof19%.

•InGermany,theCommissionEsupportsusinghawthornleafwithflowertotreatdecreasedcardiacoutputasdescribedinNYHAstageII.6

•ESCOPrecommendshawthornleafandflowerextractfortreatingdecliningcardiacperformancecorrespondingtoNYHAstageII.

Otherpreparations,includingherbalteas,areindicatedfornervousheartcomplaintsandcirculatorysupport.7

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicalandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983

VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.RajalakshmiK,GurumurthiP,DevarajSN.IndianJExpBiol.2000;38(5):509-511.ZapfeJun.G.Phytomed.2001;8(4):262-266.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Crataegifoliumcumflore.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,October1999.

HEMIDESMUS

OtherCommonName: IndiansarsaparillaBotanicalName: HemidesmusindicusFamily: AsclepiadaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Depurative,diaphoretic,immunedepressant

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingHemidesmusinformulationsinthecontextof:

•Autoimmunediseasessuchasrheumatoidarthritis(7)

•Diseasesofthegenitourinarytract(5)

•Skindiseases,fever(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3.5-8.5mlof1:2liquidextract

25-60mlof1:2liquidextract

* This dose range is extrapolated from traditional Ayurvedic medicine1 and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Diseasesofthegenitourinarysystem2

•Lossofappetite,fever,skindiseases,chroniccough1

•Topicallyasanantiinflammatoryremedy2

HemidesmusisregardedinAyurvedicmedicineasadepurativeandtonicandisusedasasubstituteforsarsaparilla(Smilaxspp.).3

PharmacologicResearch

•Hemidesmushasdemonstratedantifungalactivityinvitro.4

•OraladministrationofHemidesmushasbeenfoundtodepressboththecell-mediatedandhumoralcomponentsoftheimmunesystem.5

•Aninhibitingeffectonleprosywasfoundinanexperimentalmodel(doserouteunknown).6

•AnorganicacidisolatedfromtherootofHemidesmusinhibitedtheactivityofsnakevenominexperimentalmodels(byinjection).Theacidinhibitedthelethalhemorrhagic,coagulant,andanticoagulantactivitiesthatthevipervenominduced.7,8Thesamecompounddemonstratedantiinflammatoryactivityinanexperimentalmodel(mostlikelybyinjection)andinvitroantioxidantactivity.9

•OraladministrationofHemidesmusextractprevented

experimentallyinducedhepatotoxicityintwomodels.10

ClinicalStudies NoclinicalstudiesusingHemidesmushavebeenfound.

REFERENCES

KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinalandAromaticPlants,1989.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982HiremathSP,RudreshK,BadamiS.IndianJPharmSci.1997;59(3):145-147.AtalCK,etal.JEthnopharmacol.1986;18(2):133-141.GuptaPN.LeprIndia.1981;53(3):354-359.AlamMI,AuddyB,GomesA.Toxicon.1994;32(12):1551-1557.AlamMI,GomesA.Toxicon.1998;36(10):1423-1431.AlamMI,GomesA.Toxicon.1998;36(1):207-215.

10PrabakanM,AnandanR,DevakiT.Fitoterapia.2000;71:55-59.

HOPS

BotanicalName: HumuluslupulusFamily: CannabaceaePlantPartUsed: Strobile(conesorfemaleinflorescences)

PRESCRIBINGINFORMATION

Actions Hypnotic,mildsedative,spasmolytic,bittertonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinghopsinformulationsinthecontextof:

•Sleepdisorders,*incombinationwithvalerian(2)

•Mooddisturbancessuchasanxiety,restlessness(4,5)

•Disordersofthenervoussystemsuchasneuralgia,headache(5)

•Indigestion,dyspepsia(5)

•Sexualactivityinmen(5)

•Bathforsleepdisorders(2)Contraindications Traditionallycontraindicatedindepression.1,2

WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

Noadverseeffectsexpected,althoughprofoundestrogeniceffectshavebeenrecordedinwomenharvestingtheplantbyhand.Thepolyphenolxanthohumolhasestrogenicactivity,andalthoughpresentinfreshlyharvestedhops,itdisappearsrapidlythroughoxidation,evenoncoldstorage.3Hopsalsocontainsestrogenicflavonoidderivatives(seethe“PharmacologicResearch”sectioninthismonograph).

SideEffectsNoneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday** Doseperweek**

1.5-3.0mlof1:2liquidextract

10-20mlof1:2liquidextract

* Hopshasalsobeenused in traditionalherbalmedicineand is recommendedbyboth theCommissionEandESCOPfortreatingsleepdisorders.(4,5)

** ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Insomnia,excitability,neuralgia,headache,deliriumtremens1,4

•Hysteria5

•Indigestion,dyspepsia,mucouscolitis;kidneystones1,4

•Topicallyforlegulcers,swellings,inflammationofinternalorgans(suchas

pleurisy,enteritis)1,4

NativeAmericansusedhopsasasedativeanddiureticandforinsomnia,fevers,andintestinalpains.Topically,hopswasappliedtotoothacheandearache.HopswasofficialintheUSPfrom1820to1926,theNFfrom1916to1947,andwasusedasastomachic,sedative,andtonic.6

•Apotentphytoestrogenwasdeterminedinhopsusingsensitiveandspecificinvitrobioassays.8-Prenylnaringeninhadanactivitygreaterthanthatofotherestablishedplantestrogens.7Inanearlierinvitrostudy,polyphenolicextractsdemonstratedactivity,butisolatedconstituents,includingthebitteracids,lackedactivity.8

•Water-solublesubstancesisolatedfromhopsdemonstratedantigonadotropicactivityinvitroandinexperimentalmodels(byinjection).9-11

•Sedative,anticonvulsant,analgesic,andhypothermic

PharmacologicResearch

activitieshavebeendemonstratedforahopsextractadministeredbyintraperitonealinjectioninexperimentalmodels.12,13Nosedativeactivitywasobservedafteroraladministrationofhopsextractorlupuloneinanearlystudythatusedanumberofexperimentalmodels.14Oraladministrationofhopsextract(400mg/kg)decreasedmotoractivityfor4hoursinratsandmice.15

•2-Methyl-3-butene-2-ol,aconstituentofhopsvolatileoil,andstoredhopsproducedacentralnervoussystem–depressanteffectwhenadministeredinhighdosesbyintraperitonealinjection.Theeffectwassimilartothatfromthesedativedrugmethylpentynolatthesamedosage.16,17Thisconstituentispresentinsmallamountsbutmaybeformedfromthemetabolismofotherhopsconstituents.18,19Theconstituentmightalsoexplainthesedativeeffectofthehopspillow.

•Hopsextractstimulatedgastricsecretionsinvivo(routeunknown).20

•PrenylatedflavonoidsisolatedfromhopsdemonstratedpotentandselectiveinhibitionofcytochromeP-450enzymesandantiproliferativeactivityinhumancancercelllinesinvitro.21,22Colupulone,aconstituentofhops,inducedthecytochromeP-450systembutwithoutpromutagenactivation(measuredexvivo).23,24

•Hopsessentialoildemonstratedactivityagainstgram-positivebacteria(e.g.,Bacillussubtilis,Staphylococcusaureus)andthefungusTrichophytonmentagrophytesvar.interdigitalisinvitrobutnotagainstEscherichiacoliorCandidaalbicans.25

•Inanearlystudy,alipophilichopsconcentratehadnosleep-inducingactivityon15volunteers.26

•AquantitativetopographicEEGshowedslightbutclearlyvisibleeffectsonthecentralnervoussystemof

ClinicalStudies

healthyvolunteersconsumingacombinationofvalerianandhopsextracts(1500mgand360mg,respectively)comparedwithplaceboinasingle-blind,crossoverdesign.27

•Thecombinationofhopsandvalerianreducedthenoise-induceddisturbanceofsleepstagepatterns(slow-wavesleepandrapideyemovement[REM]sleep)insleep-disturbedvolunteerscomparedwithbaselinevalues.Thedailydoseoftheherbalproductcontainedthedriedherbequivalentof2gofhopsand1gofvalerian.Thepreparationwastakenforseveraldays.28

•Arandomized,double-blind,paralleltrialdemonstratedequivalentefficacyandtolerabilityforahops-valerianpreparationcomparedwithabenzodiazepineinpatientsexperiencingtemporarilysleeponsetandsleepinterruptiondisorders.29Asurveillancestudyinvolving484patientsfoundahops-valerianpreparationtobeasafeandeffectivecombinationthatexertedrelevanteffectsonsleeplatency,sleepquality,andpsychovegetativesymptoms.Thecombinationdidnothaveanegativeimpactondaytimevigilance.Theaveragedailydosetakencorrespondedtoapproximately1.3gofhopsand5gofvalerianrootandwastakenonaveragefor21days.30EEGmeasurementsindicatedthatahighdoseofahops-valeriancombinationhadaneffectonthecentralnervoussystemofhealthyvolunteers.Thedailydosewasequivalenttoapproximately2.2gofhopstrobilesand7.5gofvalerianroot.31

•ApostmarketingsurveillancestudyinGermanyinvolving518patientsfoundanherbalcombinationofvalerian,hops,andlemonbalmtobeahighlyeffectivetreatmentfornervousinsomniaandrestlessness,withveryfewsideeffects.Thedoseadministeredrangedfromonetoninetablets.Onetabletcontainedvaleriandriedroot(450mg),driedhopstrobiles(126.5mg),andlemonbalmdriedleaf(225mg).32

•Arandomized,double-blind,crossoverstudyinvolvingalcoholicpatientswithsleepdisturbancesfoundconsumptionofanherbaltabletproducedimprovementinsleepparameters.Thetablet,whichwastakenforonenightandcomparedwithplacebo(alsoonenight),containedthefollowingweightsofdriedherb:valerianroot(170mg),hopstrobiles(50mg),lemonbalmleaf(50mg),andmotherwortherb(50mg).33

•Thecalmingeffectofahopsbathtakenonthreesuccessivedayswasevaluatedon40patientswithsleepdisturbancesinarandomized,double-blind,placebo-controlled,clinicaltrial.Thehopsbathconsistedofasolutionofconcentratedhopsextractequivalenttoapproximately4gofhops.Theplacebosolutionhadthesameappearanceandfoamingasthehopsbathsolution.Thebaselineusedwastheaveragesleepqualityontwonightsbeforethebaths.Resultsyieldedasignificantimprovementinsleepqualitywiththehopsextractbathsascomparedwiththeplacebobaths.34

•InGermany,theCommissionEsupportsusinghopstotreatmooddisturbancessuchasrestlessnessandanxietyandsleepdisorders.35

•ESCOPrecommendshopsfortreatingtenseness,restlessness,anddifficultyinfallingasleep.36

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.BritishHerbalMedicineAssociation.Britishherbalcompendium,vol1.BHMA,Bournemouth,1992.

VerzeleM.JInstBrew.1986;92:32-48.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983OsolA,etal.ThedispensatoryoftheUnitedStatesofAmerica,ed24.Philadelphia:Lippincott,1947.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.MilliganSR,etal.JClinEndocrinolMetab.1999;83(6):2249-2252.deKeukeleireD,etal.PharmPharmacolLett.1997;7(2-3):83-86.KumaiA,OkamotoR.ToxicolLett.1984;21(2):203-208.

10OkamotoR,KumaiA.ActaEndocrinol.1992;127(4):371-377.

11KumaiA,etal.NipponNaibunpiGakkaiZasshi.1984;60(10):1202-1213.

12LeeKM,etal.PlantaMed.1993;59(suppl):A691.13BravoL,etal.BollChimFarm.1974;113:310-315.14HanselR,WagenerHH.ArzneimForsch.1967;17(1):79-81.15SchillerHetal.PresentedattheInternationalCongressand48thAnnualMeetingoftheSocietyforMedicinalPlantResearchandthe6thInternationalCongressonEthnopharmacologyoftheInternationalSocietyforEthnopharmacology,Zurich,September3-7,2000,abstract

P4B/18.16HanselR,WohlfartR,CoperH.ZNaturforsch[C].1980;35(11-12):1096-1097.

17WohlfartR,HanselR,SchmidtH.PlantaMed.1983;48(2):120-123.

18HanselR,WohlfartR,SchmidtH.PlantaMed.1982;45:224-228.

19WohlfartR,etal.ArchPharm.1983;316:132-137.20TamasdanS,CristeaE,MiheleD.Farmacia.1981;29:71-75.21HendersonMC,etal.Xenobiotica.2000;30(3):235-251.22MirandaCL,etal.FoodChemToxicol.1999;37(4):271-285.23ShippEB,MehighCS,HelferichWG.FoodChemToxicol.1994;32(11):1007-1014.

24ManneringGJ,ShoemanJS,ShoemanDW.BiochemBiophysResCommun.1994;200(3):1455-1462.

25LangezaalCR,ChandraA,SchefferJJ.PharmWeekblSci.1992;14(6):353-356.

26StockerHR.SchweizerBrauereiRundschau.1967;78:80-89.27Vonderheid-GuthB,etal.EurJMedRes.2000;5(4):139-144.

28Muller-LimmrothW,EhrensteinW.MedKlin.1977;72:1119-1125.

29SchmitzM,JackelM.WienMedWochenschr.1998;148(13):291-298.

30PetrowiczO,DeitelhoffP,LangeP.Phytomed.2000;7(supp2):106-114.

31Vonderheid-GuthB,etal.EurJMedRes.2000;5:139.32FriedeMetal:2ndInternationalCongressonPhytomedicine,Munich,September11-14,1996,abstractP-75.

33Widy-TyszkiewiczE,SchmindaR.HerbaPolonica.1997;43(2):154-159.

34vonRosenM,etal.ZPhytotherAbstractband.1995:26.35BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

36ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Lupuliflos.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.

HORSECHESTNUT

BotanicalName: AesculushippocastanumFamily: HippocastanaceaePlantPartUsed: Seed

PRESCRIBINGINFORMATION

Actions Venotonic,antiedematous,antiinflammatory,antiecchymotic(againstbruises)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinghorsechestnutinformulationsinthecontextof:

•Varicoseveins(2,4,5)

•Chronicvenousinsufficiency,edemaofthelowerlimbs(1,4,5)

•Restlesslegsyndrome(4)

•Hemorrhoids,rectalcomplaints,neuralgia,rheumatism(5)

•Improvingcapillaryresistanceinhealthyindividuals(4a)

•Reducingtheriskofdeepveinthrombosisfollowingsurgery(3,byinjection)

•Disorderswherelocaltissueedemamaybeinvolved(4a,7)

•Topicaltreatmentforhematoma,contusions,nonpenetratingwoundsandsportsinjuriesresultinginedema(4a,oftenincombinationwithothertreatments)

ContraindicationsBecauseoftheirritanteffectofthesaponins,horsechestnutshouldnotbeappliedtobrokenorulceratedskin.

Warningsand

Precautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Aswithallsaponin-containingherbs,oralusemaycauseirritationofthegastricmucousmembranesandreflux.Thisirritationcanbeavoidedbyusingenteric-coatedpreparations.From1968until1989,nearly900millionindividualdosesofonebrandofstandardizedhorsechestnutextractwereprescribed.Inthattime,only15patientsreportedsideeffects.TheCommissionEadvisesthatpruritis,nausea,andgastriccomplaintsmayoccurinisolatedcases.

Dosage Doseperday* Doseperweek*

2-5mlof1:2liquidextract

15-35mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromESCOP.1

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Conditionsinvolvingvenouscongestion,particularlywithdull,achingpainandfullness2

•Rectalirritation,rectalneuralgia,proctitis,hemorrhoids2

•Reflexconditionsattributedtorectalirritation:dyspnea,spasmodicasthma,dizziness,headache,backache,anddyspepsia2

•Rheumatism,neuralgia2

PharmacologicResearch

Themajorconstituentsofhorsechestnutseedsaresaponins(3%to6%),collectivelyreferredtoasescin.Escinisacomplexmixtureofover30individualpentacyclictriterpenediesterglycosides.

•Horsechestnutextractandescinhavebeenshowntohaveantiexudativeandantiinflammatoryactivityinvitroandinvivobyoral,parenteral,andtopicalroutes.Bothsubstancesacttoreducecapillarypermeabilityandthelocalizededemaassociatedwithinflammation.

•Horsechestnutextractcausedcontractionofvenousvalves,increasedvenouspressureandflow,andincreasedlymphaticflowinisolatedtissuesamples.

•Oraladministrationofhorsechestnutextractimprovedthetoneofconnectivetissueandimprovedcirculationbytoningtheveinsinexperimentalmodels.

•Standardizedhorsechestnutextractreducedcutaneouscapillaryhyperpermeability,increasedskincapillaryresistance,decreasedtheformationofedemaoflymphaticorinflammatoryorigin,anddecreasedconnectivetissueformationinsubchronicinflammatorygranulomaafteroralandsubcutaneousadministration.

•Saponinconstituentsfromhorsechestnutshowedinhibitoryeffectsontheconnectivetissueenzymehyaluronidaseinvitro.

•Areviewofrandomized,double-blind,placebo-controlledtrialspublisheduptoDecember1996concludedthathorsechestnutextractissuperiortoplaceboandisasefficaciousasothermedicationsinalleviatingtheobjectivesignsandsubjectivesymptomsinpatientswithchronicvenousinsufficiency.Horsechestnuttreatmentwasassociatedwithreducededema,pain,itchiness,andfeelingoffatigue.Adosageof600mg/dayofhorsechestnutextract(containing100mgescin)wasusedfor4to12weeksinthemajorityofthesetrials.Resultsfromonecomparativetrialindicatedthatedemareductionfromhorsechestnuttreatmentwasequivalenttothatachievedbycompressiontherapywithelasticstockings.3AnupdatedreviewoftheliteratureuptoNovember2000foundthatallofthe14randomized,controlledtrialsscoredatleast3outof5pointsformethodologicalquality.Inadditiontotheseresults,horsechestnuttreatmentwasasbeneficialastreatmentwithO-β-hydroxyethylrutosides.Adverseeffectsreportedfromhorsechestnuttreatmentweremildandinfrequent.4

•Acaseobservationstudy(publishedin1996)thatinvolvedmorethan800Germangeneralpractitionersandmorethan5000patientswithchronicvenousinsufficiencyfoundthathorsechestnutextractimprovedsubjectivesymptomsmarkedly.Horsechestnutwasconsideredaneconomical,practice-relevant,therapeutictoolthathadbettercompliancethancompressiontherapy.

ClinicalStudies

•Horsechestnutsignificantlyloweredbloodviscosityinpatientswithvaricoseveinsofthelowerextremitiesinanuncontrolledtrial.Thedailydoseof1800mgofextractcontained300mgofescinandwasadministeredfor12days.Horsechestnutextract(600mg/daystandardizedto100mgescin)increasedvascularflowinhealthyvolunteersinadouble-blind,placebo-controlledtrial.Significantreductioninlegvolumewasrecordedafterhorsechestnuttreatmentwastakenfor4weeksinarandomized,double-blind,placebo-controlled,crossovertrialinvolvingwomenwithpregnancy-inducedvaricoseveins.

•Oraltreatmentofhealthyvolunteerswithstandardizedhorsechestnutextract(containing300mg/dayofescin)for14dayswasshowntosignificantlyimprovecapillaryresistanceinarandomized,doubleblind,placebo-controlled,crossoverstudy.

•Inacontrolledtrial,intravenousinjectionofacombinationofhorsechestnutextractwithvitaminBcomplex,vitaminC,andeitherstrophanthinorDigitalissignificantlyreducedtheincidenceofdeepvenousthrombosisfollowingsurgery,comparedwiththesameinjectionwithouthorsechestnut.

•Injectedescinhasbeenefficaciousintreatingcerebraledemasfollowingcranialfracturesandtraumas,cerebraltumors,intracranialaneurysms,cerebralsclerosis,subduralhematomas,encephalitis,meningitis,andcerebralabscesses.

•Topicalpreparationscontainingescinhavebeensuccessfullyused:•Fortreatingedemaandhematomainsurgicalpractice•Forpreventingandtreatingsportsinjuries(gelcontainingescinandsalicylate)•Forinflammationofveins,venousinsufficiency,varicoseveins(escincombinedwithbuphenine,heparin,

benzydamine,andlecithin)•Forhypertrophicscars,keloidscars,stretchmarks,lymphodemaaftermastectomy(escincombinedwiththyroxine),andanorectalvaricosepathologicconditions

•Topicaltreatmentoftraumacaseswithlimbbruisingusingagelcontainingescinandsalicylatefor9dayssignificantlyincreasedthemobilityoftheinjuredlimbandreducedlowerlegswelling,subjectivecomplaints,andrelapsefrequenciesinarandomized,double-blind,placebo-controlledtrial.Inastudyofsimilardesign,escingelsignificantlyreducedtendernesstopressureinexperimentallyinducedhematomainvolunteers.

•InGermany,theCommissionEsupportsusinghorsechestnuttotreatchronicvenousinsufficiency.Thissyndromemayinvolvepainandasensationofheavinessinthelegs,nocturnalcrampinginthecalves,pruritis,andswellingofthelegs.5

•ESCOPrecommendshorsechestnutfortreatingchronicvenousinsufficiencyandvaricosis.1

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicalandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Hippocastanisemen.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientific

CooperativeonPhytotherapy,ESCOPSecretariat,October1999.FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983PittlerMH,ErnstE.ArchDermatol.1998;134(11):1356-1360.PittlerMH,ErnstE.AlternTherHealthMed.2001;7(3):108.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

HORSETAIL

BotanicalName: EquisetumarvenseFamily: EquisetaceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Diuretic,astringent,styptic(hemostatic)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinghorsetailinformulationsinthecontextof:

•Posttraumaticandstaticedema,bacterialandinflammatorydiseasesofthelowerurinarytract,renalgravel(4,5)

•Nocturnalenuresis,renalcolic,hematuria,enlargedprostate,prostatitis(5)

•Hemorrhage,hematemesis(6)

•Topicaltreatmentforpoorlyhealingwounds(4)

Contraindications

TheCommissionErecommendscopiousfluidintaketoassistinreducingmicroorganismsintheurinarytract,butthisshouldnotbeundertakenifedemaresultingfromimpairedcardiacorrenalfunctionexists.1

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2-6mlof1:2liquidextract

15-40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Compendium 1992 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Cystitis,urethritis,frequenturination,nocturnalenuresis,urinarycalculi,renalcolic,hematuria,enlargedprostate,prostatitis2,3

•Edema,gonorrhea,gleet(gonorrhealurethritis)3

•Ulcerationoftheurinarytract,hematemesis,hemorrhage4

PharmacologicResearch

Themainphenoliccompoundsintheaerialpartsofhorsetailarehydroxycinnamicacidderivativessuchascaffeicacidestersandflavonoidssuchasquercetinandkaempferolglycosides.5Theherbisalsorichinsilica.

•Chloroformextractsofseveralspeciesofhorsetaildemonstrateddiureticactivityinvivo.6

•Horsetailcontainsfrom1.2%to6.9%silica.ThesolubilityofthesiliconinhorsetailwasinvestigatedinaPolishstudy.7Freshanddriedsamplesofhorsetailwereextractedwithwaterundervariousconditions.Theextractionofsolublesiliconwasslowandonlyoccurredsignificantlywiththeapplicationofheat.Therateofextractionwasmuchfasterfromthefreshherbbutwasstillsignificantforthedriedherb.Inbothcases,severalhoursofdecoctionwererequiredtoextractasignificantpercentageofsiliconfromtheplant.

•Toexaminethemetabolismandrenalexcretionofcompoundsinhorsetail,astandardizedextractwas

ClinicalStudies

administeredto11volunteersfollowingaflavonoid-freedietfor8days.Quercetinmetabolites3,4-dihydroxyphenylaceticacidor3,4-dihydroxytoluenewasundetectable,andhomovanillicacidexcretiondidnotincrease.Hippuricacid,theglycineconjugateofbenzoicacid,increasedtwofoldafterintake.Thereforedegradationtobenzoicacidderivativesratherthanphenylaceticacidderivativesappearstobeapredominantrouteofmetabolism.8

•InGermany,theCommissionEsupportsusinghorsetailtotreatposttraumaticandstaticedema,withcopiousfluidintakeforbacterialandinflammatorydiseasesofthelowerurinarytractandrenalgravel.Externally,horsetailcanberecommendedassupportivetreatmentforpoorhealingwounds.1

REFERENCES

BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.VeitM,etal.Phytochem.1995;38(4):881-891.PerezGutierrezRM,LagunaGY,WalkowskiA.J.

Ethnopharmacol.1985;14(2-3):269-272.PiekosR,PaslawskaS.PlantaMed.1975;27(2):145-150.GraefeEU,VeitM.Phytomed.1999;6(4):239-246.

HYDRANGEA

OtherCommonName: SevenbarksBotanicalName: HydrangeaarborescensFamily: HydrangeaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Diuretic,antilithic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingHydrangeainformulationsinthecontextof:

•Disordersoftheprostate,includingprostatitisandenlargedprostate(5)

•Urinary,bladderorkidneystones;inflammatoryconditionsoftheurinarysystem(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2-7mlof1:2liquidextract

15-50mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Cystitis,urethritis,urinarycalculi,difficulturination,bladdergravel,prostatitis,enlargedprostategland,chronicgleet(gonorrhealurethritis)1,2

•Improvingthenutritionoftheurinarymucousmembranes2

NativeAmericansusedHydrangeaforcalculouscomplaintsandasadecoctionwithotherplantsforwomen“whohadstrangedreamsduringtheirmenstrualperiod.”HydrangeawasofficialintheNFfrom1916to1926andwasusedfordiureticanddiaphoreticpurposes.3

PharmacologicResearch

NopharmacologicinformationhasbeenfoundforHydrangea.

ClinicalStudies NoclinicalstudiesusingHydrangeahavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:

UniversityofOklahomaPress,1970.

JAMAICADOGWOOD

OtherCommonName: JamaicandogwoodBotanicalNames: Piscidiaerythrina,Piscidiapiscipula#∧

Family: LeguminosaePlantPartUsed: Rootbark

# Alternativename.

∧ AdoptedbytheAmericanHerbalProductsAssociationasthenewbotanicalname.1

PRESCRIBINGINFORMATION

Actions Analgesic,spasmolytic,mildsedative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingJamaicadogwoodinformulationsinthecontextof:

•Insomnia,anxiety(5,7)

•Painfulconditions,neuralgia,sciatica,headache,toothache(5)

•Dysmenorrhea,muscularspasm,rheumatism(5)Contraindications Pregnancy,bradycardia,cardiacinsufficiency2

WarningsandPrecautions

Therecommendeddosemustnotbeexceeded.AlthoughJamaicadogwoodhasbeenusedasafishandinsectpoison(thecomponentrotenoneimpairsoxygenconsumptioninthesespecies),theherbhasbeenfoundtohavenegligibletoxicityinrodents.3,4

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancy.

SideEffects

TraditionaltextssuggestthatJamaicadogwoodmaycausenausea,vomiting,andheadacheinsomepatientsprescribedevensmall,therapeuticdosesandthatoverdoseproducestoxiceffects.5,6

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’s

educationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Painrelief,spasm,nervousexcitabilityandtoinducesleep6

•Neuralgia,particularlysciatica;painfulconditionsofthemouth,migraine,dysmenorrhea,muscularspasm,rheumatism,asthma6,7

•Insomnia,nervoustension6,7

PharmacologicResearch

Jamaicadogwoodrootbarkcontainsnearly60isoflavonoidconstituentsandrotenoids.2,8

•OraladministrationofJamaicadogwoodextractdemonstratedcentralnervoussystemactivityinanexperimentalmodel.Activitywasintermediatebetweentheanxiolyticactivityofpassionflowerandthesedativeactivityofvalerianandhawthorn.9

•Theisoflavonesmayberesponsiblefortheantispasmodicactivity,asdemonstratedwithisolatedtissue.10Inadditiontosedativeandantispasmodicactivity,thefollowingactivitieshavebeendemonstratedinexperimentalmodels:antipyretic,antiinflammatory,hypotensive,andantitussive.3

•Inanearlystudy,Jamaicadogwoodextractgivenbyinjectiondidnotinfluenceuterinetoneorcontractionsinvivo,11althoughalaterstudyfoundittoexertappreciablespasmolyticactivity.4

NoclinicalstudiesusingJamaicadogwoodhavebeen

ClinicalStudies

found;however,anecdotalclinicalreportsofthelatenineteenthcenturyandearlytwentiethcenturyindicateitsusefulnessintreatingtuberculosis,neuralgia,andwhoopingcough.4

REFERENCES

McGuffinM,editor.Herbsofcommerce,ed2,Bethesda,Md:AmericanHerbalProductsAssociation,1998.[draft3.3]BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.AurousseauM,BernyC,AlbertO.AnnPharmFranc.1965;23:251-257.CostelloCH,ButlerCL.JAmPharmAssoc.1948;37(3):89-97.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.TaharaS,etal.Phytochem.1993;34(1):303-315.DellaLoggiaR,TubaroA,RedaelliC.RivNeurol.1981;51(5):297-310.

10DellaLoggiaR,etal.ProgClinBiolRes.1988;280:365-368.

11PilcherJD,MauerRT.SurgGynecolObstet.1918;27:97-99.

KAYA

OtherCommonName: KavakavaBotanicalName: PipermethysticumFamily: PiperaceaePlantPartUsed: Root(rootstock)

PRESCRIBINGINFORMATION

ActionsAnxiolytic,hypnotic,anticonvulsant,mildsedative,skeletalmusclerelaxant,spasmolytic,localanesthetic,mildanalgesic,antipruritic(topically)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingkavainformulationsinthecontextof:

•Anxiety(1,4,5)

•Stress(3)

•Insomnia,*incombinationwithvalerian(3)

•Menopausalsymptoms,milddepression(2)

•Muscletension(4,5)

•Improvingcognitiveperformanceinhealthyindividualsandpatientswithanxiety(2)

•Headache,neuralgia,generaldebility,inflammationandinfectionofthegenitourinarytract(5)Giventhatkavahasbeenshowntohavesimilarefficacytocertainbenzodiazepinedrugsintreatinganxiety(3),itmaybeusefultoassistinwithdrawalfrombenzodiazepines.

Contraindications

TheGermanCommissionEliststhefollowingcontraindications:pregnancy,lactation,andendogenousdepression.However,thesecontraindicationshaveresultedfromalackofpositivedatatoshowthatuseissafeunderthesecircumstancesratherthananypublishedsafetyconcerns.

Kavaextractiscontraindicatedinpatientswithpreexistingliverconditions.Patientsprescribedkavashouldbecloselymonitoredforanysignsofararelivertoxicity.

WarningsandPrecautions

Becauseofpossibledopamineantagonism,kavashouldbeusedcautiouslyinelderlypatients,especiallythosewithParkinson’sdisease(refertothe“SideEffects”sectioninthismonograph).

Interactions

AccordingtotheCommissionE,asynergisticeffectispossibleforsubstancesactingonthecentralnervoussystem,suchasalcohol,barbiturates,andpsychopharmacologicalagents.Acaseofpossibleinteractionbetweenkavaandabenzodiazepinedrug(alprazolam)hasbeenreported.

UseinPregnancyandLactation

Noadverseeffectsexpectedatnormaltherapeuticdoses,despitethecautionfromtheCommissionE.

Twopostmarketingsurveillancestudiesinvolving3029and4049patientsfoundadverseeventsoccurredin2.3%and1.5%,respectively,ofpatientsduringtreatmentwithstandardizedkavaextract.Thedosesofkavacontained120to240mgand105mgoflactones,respectively.Ameta-analysisnotedthatstandardizedkavaextractisrelativelysafewithtwostudies,representing31%ofthestudiedpatients,notreportinganyadverseeventsinthosetreatedwithkava.1

Adry,scaly,pigmentedskinconditionknownaskavadermopathyisawell-knownsideeffectofexcessiveandchronicuseofkavabutisunlikelytooccurafternormaltherapeuticuse.Therashquicklyregressesifkavaintakeisceased.Dermatitisafteroraladministrationofkavaatthelowertherapeuticdoseshasbeenreported.

AgroupofGermanneurologistsdescribedfourcasesofpatientswhodevelopedclinicalsignssuggestiveofdopamineantagonismaftertakingkava.Overdoseof

SideEffects

kava(withoutconcurrentalcoholuseorpetrolsniffing)causinggeneralizedchoreoathetosis(involuntarymovementdisorder)hasbeenreportedinanAboriginalAustralian.2

AssociationswithheavykavausereportedintheAustralianmedicalliteraturefrom1988to1999includeischemiccardiaceventsandsuddencardiacdeath.2,3Theseeventshavenotbeendefinitivelylinkedtoexcessivekavauseandthepossibilityofconcurrentalcoholabuse,andtheinvolvementofothersocioeconomicfactorscannotberuledout.

Apilotsurveyinvestigatingtheeffectsofheavykavausepublishedin1988indicatedthatnoepidemiologicalevidencewasfoundtolinksuddendeathswithkavause.4

Areportpublishedin2000byaSwissgovernmentregulatoryagencydescribedninecasesofhepatotoxicityattributedtokava.

Allcasesinvolvedtheconsumptionofahighdoseacetoneextractstandardizedto70%kavalactones.Theproducthasbeensubsequentlybanned.Theauthorratedtheriskofhepatotoxicityasrarebutserious.5Germanregulatoryauthoritiesreportedcasesofhepatotoxicityinvolvingethanolickavaextracts,6andkavaproductsweresubsequentlyremovedfromthemarketinthisandseveralothercountries.Goodevidenceexiststhatthehepatotoxicitywasimmunemediated.Adeficiencyofthedrug-metabolizingenzymeCYP2D6(whichoccursin9%ofthepopulation)mightbeapredisposingfactor.7

Therarecasesofhepatotoxicityresultingfromkavaconsumptionarethereforelikelytobeanimmunoallergicreaction,perhapsexaggeratedbythetypeofextractconsumedanddeficienciesin

detoxifyingenzymes.Dosage Doseperday** Doseperweek**

3.0-8.5mlof1:2liquidextract

20-60mlof1:2liquidextract

Extractsprovidingquantifiedlevelsofkavalactonesarerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan20mg/mlofkavalactones.

* Kavahasalsobeenusedintraditionalherbalmedicinefortreatinginsomnia.(6)

** This dose range is extrapolated fromBritish Pharmaceutical Codex 1934, theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Neuralgia(especiallytoothache,earache,andocularpain),dizziness,chroniccatarrh,bronchitis8

•Cystitis,urethritis,dysuria,renalcolic,nocturnalincontinence8,9

•Dysmenorrhea,vaginitis,leukorrhea,gonorrhea8,9

•Anorexia,dyspepsia,intestinalcatarrh,hemorrhoids8

•Rheumatism,gout,topicallyforjointpain8,9

UsesaccordingtoothertraditionalsystemssuchasthoseofthePacificregioninclude:

•Tosoothenervesandtoinducerelaxationandsleep10

•Tocounteractfatigue;forgeneraldebility,wearymuscles,chills,thecommoncold,dysuria,headache10

•Skindiseases,leprosy,topreventsuppuration11

•Filariasis(systemicworminfestation)11,12

•Sorethroat,toothache13

•Asacontraceptiveforwomenwhohaverecentlygivenbirth;11,12topicallyforvaginalprolapse11

Keyconstituentsofkavarootincludethekavalactones(alsoknownaskavapyrones)andflavonoids

PharmacologicResearch

(flavokawains).Extractsareoftenstandardizedtothelactones.

•Kavaextractsorpurifiedlactonesdemonstratedsedativeeffectsandinducedsleepinavarietyofinvivoexperimentalmodels.Thecombinationofkavaandpassionflower(Passifloraincarnata)producedasynergisticeffectonsedation.

•Kavaextractandlactonesproducedrelaxationofskeletalmuscleinvitroandinvivo.Asynergisticeffectwasnotedwhenamixtureoflactones(similartothatfoundintheroot)wasadministeredorallyinanepilepsymodel.

•Kavalactoneshavedemonstratedanalgesicactivityvianonopiatepathwaysinseveralexperimentalmodelsandhavepotenciessimilartococaineandprocaineaslocalanesthetics.

•Kavalactonesexhibitedpotentfungistaticactivityinvitroagainstawidevarietyofpathogenicfungi,excludingspeciesofCandida.

•Kavaextractprotectedbraintissueagainstischemicdamageinexperimentalmodels.

•Kavalactonesdemonstratedantithromboticactivityinvitro.

•Ameta-analysisassessingsevenrandomized,double-blind,placebocontrolledtrialsfoundthatkavaextractsignificantlyreducedanxiety(comparedwithplacebo).Thedosageofstandardizedkavaextractprescribedvariedandcontained60to240mgperdayofkavalactones.Thedurationoftreatmentrangedfrom1to24weeks.Onetrialinvestigatedthereductioninanxietyforpreoperativepatientswhoreceivedkavaextractthenightbeforeand1hourbeforesurgery.1Theauthorsofoneofthetrials14includedinthismeta-analysisconcludedthattheefficacy

andtolerabilityofstandardizedkavaextractrecommenditasanalternativetotricyclicantidepressantsandbenzodiazepinesfortreatinganxiety.

•Kavalactonesandstandardizedkavaextractsdemonstratedactivityequivalenttooxazepamandbromazepam(benzodiazepinedrugs)inpatientswithanxietyindouble-blind,placebo-controlledtrials.Thedailydoserangedfrom210to400mgofkavalactones.Sideeffectswerehigherinthepatientgroupsassignedtheconventionaldrugs.

•Kavahasalsobeenshowntohavetherapeuticbenefitincasesofsituationalanxiety.Inarandomized,double-blind,placebo-controlledtrial,standardizedkavaextracttakenfor1weeksignificantlyreducedanxietycomparedwithplaceboinpatientsawaitingtheresultsofmedicaldiagnostictestsforsuspectedbreastcarcinoma.Fatigue,introvertedbehavior,excitability,anddepressionweredecreased,andalertnesswasincreasedinpatientsreceivingkavaextract.Theadministereddailydoseofkavacontained150mgofkavalactonesandcorrespondedtoapproximately2.5gofdriedroot.15

•Preliminaryfindingssuggestabeneficialeffectofkavaonbaroreflexcontrolofheartrate(BRC).SignificantlymorepatientswithgeneralizedanxietydisorderexhibitedimprovedBRCfollowingtreatmentwithkavacomparedwithaplacebo.Noeffectwasobservedonrespiratorysinusarrhythmia,ameasureoftheheartratechangesoccurringwithrespiration.Patientsinthestudywereasubgroupofalargerrandomized,double-blindtrialandreceivedstandardizedkavaextractorplacebofor4weeks.16

•Twopostmarketingsurveillancestudiesinvolvingover3000patientseachfoundstandardizedkavaextractimprovednervousness,restlessness,anger,sleepdisturbances,menopausalcomplaints,muscletension,and

ClinicalStudies

sexualdisturbances.Undesirablesideeffectsincludedallergicreactions,gastrointestinalcomplaints,headache,anddizziness.Thedailydoseofextractrangedfromthatcontaining105mgto240mgofkavalactonesfor4and7weeks,respectively.

•Inaplacebo-controlledtrial,standardizedkavaextract(containing105to210mgkavalactonesfor1day)improvedseveralaspectsofthesleepcycle.Themeasurementswerefavorablewhencomparedwithorthodoxsedativessuchasbenzodiazepinesandbarbiturates.

•Inapilotstudy,patientswithstress-inducedinsomniaweretreatedineachphasefor6weekswithkava,thenvalerian,thenacombinationofkavaandvalerian,withwashoutperiodsbetweeneachtreatmentphaseof2weeks.Totalstressseveritywassignificantlyrelievedbythekavaandvaleriansingletreatments(stresswasmeasuredinthreeareas:social,personal,andlifeevents).Insomniawassignificantlyrelievedbythecombinationofkavaandvalerian.17

•Arandomized,placebo-controlled,double-blindtrialofpatientswithneurovegetativesymptomsassociatedwithmenopausefoundstandardizedkavaextractfor8weeks(containing210mg/dayofkavalactones)producedasignificantreductioninanxiety(symptomsandseverityofsymptoms),depression,andmenopausalsymptoms.(Thistrialwasincludedinthepreviouslymentionedmeta-analysis.)

•KavaplusHRTsignificantlyreducedmenopausalanxietycomparedwithHRTaloneinacontrolledtrial.18

•Inasingle-blind,placebo-controlledstudywithhealthyvolunteers,kavaimprovedcognitiveperformanceandstabilizedemotionaldispositionwithoutcausingsedation.Thestudywasconductedover5weeksandincluded

washout,placebo,kava,andreboundplacebophases.Volunteerswereadministeredadailydoseofstandardizedextractcontaining210mgofkavalactones,increasingto420mgovera2-weekperiod.

•Despiteitsrelaxingproperties,asingledoseofstandardizedkavaextract(containing120mgofkavalactones)wasshowntoincreaseperformanceinmentalalertnesstestscomparedwithdiazepam(10mg)andplaceboinarandomized,double-blind,crossover,clinicalstudyinvolvinghealthyvolunteers.Inotherstudiesofsimilardesign,conflictingresultshavebeenobtained.Standardizedkavaextract(containing420mg/dayofkavalactones)for5daysdidnotsignificantlychangethequalityandspeedofresponsestopsychometrictests,whereasoxazepam(3daysofplacebo,15mgonthedaybeforetestingand75mgonthemorningoftesting)significantlydecreasedresponses.However,standardizedkavaextracthadapositiveeffectontheallocationofattentionandprocessingcapacity,comparedwithareducedresponseproducedbyoxazepaminhealthyvolunteers.

•Adouble-blindstudyinvolvinghealthyvolunteersconcludedthatpatientsarenotexposedtoadditionalsideeffectsorrisks(intermsofmentalperformanceandgeneralwellbeing)whiletakingkavaextract(containing240mg/dayofkavalactones)plusabenzodiazepine,ascomparedwithtakingthebenzodiazepinealone(9mg/daybromazepam).

•Inaplacebo-controlled,double-blindstudy,nonegativeeffectsonsafety-relevantperformancewerecausedbycombiningstandardizedkavaextractwithethanol.Infact,kavatendedtocountertheadverseeffectofalcoholonmentalconcentration.Nosignificantchangeswerefoundinperformancecapability(intermsofoperatingmachinesanddriving)inthehealthyvolunteersstudied.Thedailydoseofkavaadministeredcontained210mgofkava

lactonesandthetrialwas8daysinlength.Inamorerecentrandomized,placebocontrolledtrial,acuteadministrationofaveryhighdoseofkavacombinedwithalcoholpotentiatedboththeperceivedandmeasuredimpairmentofmotorandcognitivefunctionproducedbyalcoholalone.Kavawasadministeredasthetraditionalaqueousextract(1g/kgbodyweight);thedoseoflactoneswasnotdefined.19

•Clinicaltrialresultsindicatedthatkavaextractsandlactonesarenotsuitablealonefortreatingepilepsy.

•Anepidemiologicalstudyanalyzingdataobtainedinthe1980sfromtheSouthPacificregionsuggestsacloseinverserelationshipbetweencancerincidenceandkavaconsumption(themorekavaisconsumedbythepopulation,thelowerthecancerincidencewillbe).Theresultsimplythatkavamaybeaneffectivecancerchemoprotectiveagent,butnootherconclusionscanbemadeuntilfurtherresearchiscompleted.Kavaconsumptionisunlikelytobesolelyresponsibleforthelowcancerrateintheseislands.20

•InGermany,theCommissionEsupportsusingkavatotreatconditionsofnervousanxiety,stress,andrestlessness.21

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.PittlerMH,ErnstE.JClinPsychopharmacol.2000;20:84-89.

SpillanePK,FisherDA,CurrieBJ.MedJAust.1997;167(3):172-173.YoungMC,etal.MedJAust.1999;170(9):425-428.MathewsJD,etal.MedJAust.1988;148(11):548-555.StollerR.SchweizArztezeit.2000;81(24):1335-1336.StaffordN.Germanymaybankavakavaherbalsupplement,YahooNews.URL:http://dailynews.yahoo.com,Nov19,2001.RussmannS,LauterburgBH,HelblingA.AnnInternMed.2001;135(1):68-69.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

10TitcombM.JPolynesSoc.1948;57:105-171.11LebotV,MerlinM,LindstromL.Kava—thePacificelixir:thedefinitiveguidetoitsethnobotany,historyandchemistry.NewHaven:YaleUniversityPress,1992.

12CambieRC,AshJ.Fijianmedicinalplants.Melbourne,Australia:CSIROPublishing,1994.

13WorldHealthOrganization.MedicinalplantsintheSouthPacific.Manilla:WHORegionalOfficefortheWesternPacific,1998.

14VolzHP,KieserM.Pharmacopsychiatry.1997;30:1-5.

15NeuhausW,etal.ZentralblGynakol.2000;122(11):561-565.16WatkinsLL,ConnorKM,DavidsonJRT.JPsychopharmacol.2001;15(4):283-286.

17WheatleyD.HumanPsychopharmacol.2001;16(4):353-356.18DeLeoV,etal.Maturitas.2001;39(2):185-188.19FooH,LemonJ.DrugAlcoholRev.1997;16:147-155.20SteinerGG.HawaiiMedJ.2000;59(11):420-422.21BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

KOREANGINSENG

BotanicalName: PanaxginsengFamily: AraliaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Adaptogenic,tonic,immunemodulating,cardiotonic,maletonic,cancerpreventative,cognitionenhancing

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingKoreanginsenginformulationsinthecontextof:

•Improvingphysicalandmentalperformanceandwellbeing;improvinggeneralperformanceunderstress(2,4,5)

•Improvingimmunefunction(2,5)

•Non-insulin–dependentdiabetes(2)

•Congestiveheartfailure(3,5)

•RaisingHDLcholesterol,cerebrovasculardeficit(3)

•Impotence,malefertilityproblems(2,5)

•Preventingcancer(excludingcancersofthebreast,cervix,bladder,andthyroid);adjuvanttherapywhileundergoingradiationtherapy(3)

•Antioxidantactivity(2)

•Improvingmemoryinhealthy,middle-agedindividuals,incombinationwithGinkgo(3)

•Improvingrecoveryfrombacterialinfectioninchronicbronchitis(2)

•Psychologicalsymptomsofmenopause(2)

•Fatigue,debility,convalescence(4,5)

•Atonicforolderadults(3,4,5)

•Prostration,neuralgia,convulsions,neurosis,anxiety,palpitations,coldlimbs,spontaneoussweating,organprolapse,dyspnea,asthma(5)

Contraindications

Koreanginsengiscontraindicatedinacuteasthma,signsofheat,excessivemenstruation,ornosebleeds.Koreanginsengisbestnotusedduringacuteinfections.

GiventhattheclinicalimplicationsoftheeffectofKoreanginsengonbloodpressurearenotclear,Koreanginsengshouldbeavoidedinhypertension.

WarningsandPrecautions

Concurrentusewithstimulantssuchascaffeineandamphetaminesshouldbeavoided.Overstimulationmayoccurinsusceptiblepatients,especiallyathigherdoses.

Interactions

Koreanginsengmayinteractwiththemonoamineoxidaseinhibitorphenelzineandwithwarfarin.AnexperimentalstudyusingratsasthemodelfoundnosignificantinteractionbetweenwarfarinandKoreanginseng,1thusanysuchinteractionislikelytoberare.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

ExcessivedosesofKoreanginsengcancauseoverstimulation,andsymptomsofginsengabusesyndrome(GAS)havebeenreportedinindependentstudies.GASisdefinedashypertensiontogetherwithnervousness,euphoria,insomnia,skineruptions,andmorningdiarrheaandisthoughttoberelatedtoKoreanginseng’sinteractionwithglucocorticoidproductioninthebody.

Koreanginsengmaycausesideeffectsrelatedtoanestrogenlikeactivityinwomen,andcasesofmastalgiaandpostmenopausalbleedinghavebeenreported.

Ginsengiswidelyused,andseveralotherrareadversereactionshavebeenreportedthatare,atbest,possiblyrelatedtoginsengormayotherwisereflectcontamination,adulteration,orcoincidence.TheseconditionsincludeStevens-Johnsonsyndrome,diureticresistance,cerebralarteritis,mania,andmydriasis.

Dosage Doseperday* Doseperweek*

1-6mlof1:2liquidextract

7-40mlof1:2liquidextract

Extractsprovidingstandardizedlevelsofginsenosidesarerecommended.Ideally,aqueousethanolextractsshouldcontain11mg/mlofginsenosides,withtheratioofginsenosideRg1toginsenosideRb1greaterthanorequalto0.5(indicatingthattheproductwasmadefrommainroots,lateralroots,orboth).

TheCommissionEadvisesthatKoreanginsengcanbeusedforupto3monthswitharepeatcourseifnecessary.Continuoususeintheunwellandinolderadultsisappropriate.Dosesinexcessof2mlperdayofa1:2liquidextractmaycauseoverstimulation.

* ThisdoserangeisalsoextrapolatedfromBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andfromclinicaltrials.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Toreinforcethevitalenergy,diminishedfunctionofthespleenorlung2

•Prostrationwithimpendingcollapsemarkedbycoldlimbs,faintpulse,sweating;heartfailure,shock;palpitationwithanxiety,forgetfulness,restlessness2,3

•Generalweaknesswithirritabilityandinsomniainchronicdiseases2

•Impotenceorfrigidity2

•Wheezing,shortnessofbreath,organprolapse3

TraditionalWesternherbalmedicineusesinclude:

•Physicalormentalexhaustion,neurasthenia,stress,inadequateresistancetoinfections4,5

•Neuralgia,insomnia,hypotonia5

•Depressivestatesassociatedwithsexualinadequacy5

•Lossofappetite,nervousdyspepsia;convulsions,paralysis6

KeyconstituentsofKoreanginsengrootincludeacomplexmixtureofdammaranesaponinscalledginsenosides.

•Theabilityofginsenosidestoindependentlytarget

PharmacologicResearch

multireceptorsystemsattheplasmamembrane,aswellastoactivateintracellularsteroidreceptors,mayexplainsomeofthepharmacologicaleffectsofKoreanginseng.7

•ThepositiveeffectsofKoreanginsenginpromotingthelongevity,metabolism,andgrowthofnormalcellshavebeendemonstratedbymanystudies,bothinvitroandinvivo.ManyinvestigatingscientistshaveseentheseeffectsasconfirmingthetonicactivityofKoreanginseng.

•CountlessanimalstudieshavedemonstratedthatKoreanginsengincreasestheresistancetoawidevarietyofphysical,chemical,andbiologicalstressors.OraldosesofKoreanginsengincreasedorganandmuscleweightsandcounteredsomeoftheeffectsofaginginexperimentalmodels.

•OraldosesofKoreanginsengextractsignificantlyimprovedlearningandmemoryinexperimentalmodels.Oralginsenosidesacceleratedbrainandbodydevelopmentinyounganimals.

•KoreanginsengextractenhancedB-andT-lymphocyteandnaturalkillercellactivities,increasedproductionofinterferon,andimprovedantibodyformationinexperimentalmodelsafteroraldoses.

•OraladministrationofKoreanginsengextractsuppressedexperimentalSemlikiForestviralinfectionandprotectedagainstCandidaalbicansinfectioninvivo.

•Koreanginsengextractandginsenosideshavedemonstratedanticanceractivity,bothinvitroandinvivoviatheoralroute,byinhibitinggrowthofcancers,inducingdifferentiation,exhibitingantimutagenicactivityagainstgenotoxicagents,inhibitingmetastasis,potentiatingtheactivityofanticancerdrugs,andimprovingsurvivalinexperimentalcancermodels.

•InjectingKoreanginsengextractorginsenosides

counteredthedeleteriouseffectsofrepeatedadministrationofnarcoticdrugssuchasmorphine,cocaine,methamphetamine,orapomorphine.Morphine-inducedtoleranceandphysicaldependencewerereducedafteroraladministrationofKoreanginseng.Acceleratedethanolclearancefromtheblood,butnotthebrain,wasachievedinexperimentalmodelsafteroraldosesofKoreanginseng.

•Experimentalstudiessuggestthattheantioxidantandorgan-protectiveactionsofKoreanginsengarelinkedtoenhancednitricoxidesynthesisintheendotheliumofthelungs,heart,kidney,andcorpuscavernosum.EnhancednitricoxidesynthesismightcontributetothevasodilationandaphrodisiacactionsattributedtoKoreanginseng.

Whenreferredtointhefollowingpoints,redginsengisPanaxginsengthathasbeensteamedbeforedrying.

•Althoughsomenegativefindingshavebeenreported,themajorityofclinicaltrialshavefoundthatKoreanginsengincreasesphysicalperformance.Physicalperformanceandvisualandauditoryreactiontimesweresignificantlyincreasedinarandomized,double-blind,placebo-controlledtrialusingKoreanginsengextractadministeredfor12weekstopeopleaged22to80years.MaleathletessignificantlyincreasedtheiraerobiccapacityandsignificantlyreducedtheirbloodlactatelevelsandheartratewhiletakingKoreanginsenginrandomizedandnonrandomized,double-blind,placebo-controlledtrialsandinuncontrolledtrials.Thesetrialswereconductedbythesameresearchgroupovera9-weekperiod.ThedailydoseofKoreanginsengextractadministeredwas200mg/day(containing4%ginsenosidesandequivalenttoapproximately1g/dayofdriedroot).

•Randomized,double-blind,controlledtrialshaveshownthatKoreanginsengsignificantlyimprovesqualityoflifeandwellbeingmeasureswhileunderstress,including

alertness,relaxation,appetite,fatiguelevels,sleepquality,recoveryfromthecommoncoldandbronchitis,andsignificantlydecreasessystolicbloodpressurecomparedwithcontrols.TwoofthesetrialscomparedKoreanginsengcombinedwithvitaminsandmineralsagainstplacebo.Onetrialcomparedthiscombinationagainstvitaminsandminerals,andanothertrialcomparedKoreanginsengonitsownagainstplacebo.TheKoreanginseng,vitamin,andmineralcombinationwassuperiortothevitaminsandmineralsalone.Intwoofthesetrials,thedailydosewasequivalenttobetween0.4and1.0gofdriedroot,whichwasadministeredforupto4months.

•TheKoreanginseng,vitamin,andmineralcombinationimprovedREMsleepinelderlyvolunteersinadouble-blind,placebo-controlledtrial.Reactiontimeanddecision-makingwereimprovedinelderlyvolunteerstakingredginseng(1.5g/day)inadouble-blindcrossovertrial.

•AcombinationcontainingGinkgoextract(120mg/daystandardizedto24%ginkgoflavoneglycosides)andKoreanginsengextract(200mg/daystandardizedto4%ginsenosides)demonstratedimprovementintheworkingandlong-termmemoryofhealthy,middle-agedvolunteersover14weeksinamulticenter,double-blind,placebo-controlledtrial.8Threesingle,increasingdosesofstandardizedKoreanginsengextractproducedadose-dependentimprovementinseveralaspectsofmemorywhencomparedwithplaceboinhealthyyoungvolunteers.Thetrialwasofrandomized,double-blind,crossoverdesign.9

•Koreanginsengextractssignificantlyimprovedcell-mediatedimmunefunction(chemotaxis,phagocyticactivity,andintracellularkilling)inadouble-blind,placebo-controlledtrialinvolvinghealthyvolunteers.Astandardizedextract(200mg/day,equivalenttoapproximately1g/dayofrootandcontaining4%

ClinicalStudies

ginsenosides)wascomparedwith200mg/dayofaqueousextractfor8weeks.Arandomized,double-blind,placebo-controlledstudydemonstratedsignificantpreventionofinfluenzaandthecommoncoldforKoreanginsengoverplaceboinvolunteersalsoreceivinganantiinfluenzavaccination.TheKoreanginsenggroupdemonstratedsignificantlyhigherantibodytitersandnaturalkillercellactivity.Extractdosesequivalenttoapproximately1gperdayofrootcontaining4%ginsenosidesweregivenfor12weeks.Inamorerecentrandomized,double-blind,placebo-controlledtrial,treatmentwithKoreanginsengextractfor4monthsimprovedtheimmuneresponse(IgMandIgAantibodylevels)toinfluenzavaccinationinhealthyvolunteers.10

•Koreanginsengextract(equivalenttoapproximately1g/dayofroot)improvedtheimmuneresponseofalveolarmacrophagesisolatedfromchronicbronchitispatientsinaplacebo-controlled,single-blindtrial.Inarandomized,controlledtrialinvolvingpatientswithchronicbronchitis,Koreanginsengcombinedwithantibacterialdrugsreducedthebronchialbacterialcountfasterthanantibacterialdrugsalone.ThedailydoseofKoreanginsengextractwas200mgstandardizedtocontain4%ginsenosides.Thedurationofthetrialwas9days.11

•ControlledanduncontrolledtrialshavefoundginsengmaybeofvalueintreatingHIVinfection.Thedosageusedinoneoftheuncontrolledstudieswas5.4gperdayofredginsengpowder.

•SignificantimprovementincerebrovascularcirculationwasobservedinpatientswithmoderatecerebrovasculardeficittreatedwitheitherKoreanginsengextract(containing4%ginsenosidesandequivalenttoapproximately1g/dayofroot)orthedrughydergine(3mg/day)whencomparedwithplacebounderdouble-blindconditionsoveraperiodof3months.

•AcombinedKoreanginsengandGinkgoproduct(containing4mg/dayginsenosidesand28.8mg/dayginkgoflavoneglycosides)improvedcirculationandloweredbloodpressureinasmall,placebo-controlled,single-dosestudyinhealthyvolunteers.Acontrolledtrialinvolvingpatientswithcongestiveheartfailurefoundredginsengimprovedbiochemicalandhemodynamicparameters.Greaterimprovementwasnotedwhentheherbwascombinedwithdigoxin.ErectilefunctionandHDLcholesterolweresignificantlyimprovedinelderlymenwithpsychogenicimpotencetreatedwithredginseng(1.8gor2.7gfor2months)inaplacebo-controlledstudy.

•Redginseng(6g/day)improvedpsychologicaltestscoresinpost-menopausalwomenwithsymptomsoffatigue,insomnia,anddepressionwhencomparedwithbaselinevalues.Theimprovementwasatleastpartiallytheresultofanantistresseffect,asdemonstratedbyadecreaseinthecortisol/dehydroepiandrosterone(DHEA)ratio.12Inarandomized,double-blind,placebo-controlledtrial,postmenopausalwomenreportedimprovementinquality-of-lifemeasures,includingdepressionandwellbeing,aftertreatmentwithstandardizedKoreanginsengextract(containing4%ginsenosides,equivalenttoapproximately1g/dayofroot).Nobenefitoverplacebowasobservedforphysiologicalparameters,includingFSHandestradiollevelsandendometrialthickness.13

•EpidemiologicalstudieshavefoundaninverserelationshipbetweenKoreanginsengintakeandcancerinSouthKorea,whereKoreanginsengteaisconsumedasfrequentlyascoffee.Acase-controlledstudyon1987pairsfoundthattherelativeriskforcancerforKoreanginsenguserswas50%lowerthanforthosewhodidnotuseKoreanginseng.Theincidenceofcancersofthelung,lip,oralcavity,andpharynxweresubstantiallylowerinsmokerswhowereKoreanginsenguserscomparedwithsmokerswhowerenot.Theincidencesofcancersofthebreast,cervix,bladder,andthyroidglandwerenot

affectedbyKoreanginseng.ProspectivecohortstudiesfounddecreasedriskofcancerforparticipantswhohadconsumedKoreanginsengcomparedwithnonconsumers.Ginsengconsumptionwasalsolinkedtodecreasedriskforgastricandlungcancers.14,15

•Dailysupplementationofredginseng(1.8g)for4weeksinsmokersresultedinalinearincreaseinplasmaantioxidantconcentrationcomparedwithvaluesobtainedfromsmokersadministeredaplacebo.Inthisrandomizedtrial,KoreanginsengtreatmentalsodecreasedmarkersofDNAoxidativedamage.16

•Arandomized,double-blind,placebo-controlledstudyinvolvingpatientswithcervicalcancerwhowereundergoingradiationtherapyfoundthatKoreanginseng(5g/dayfor5weeks)exertedaprotectiveeffectonbonemarrowdepressionandsignificantlyelevatedplateletcount.

•Spermcount,spermmotility,totaltestosterone,freetestosterone,anddihydrotestosterone(DHT)rosesubstantially,andprolactinlevelsdecreasedafter3monthsofginsengtreatmentinmenwithidiopathiclowspermcountandlowspermcountassociatedwithvaricocele.Thecontrolgroupmirroredtheseresponsesonasmallerscale.Redginsengextractsignificantlyimprovederectiledysfunctioncomparedwiththedrugtrazodone,whichdemonstratedasimilareffecttoplaceboinarandomizedtrial.

•Pregnantwomentakingginsenghadasignificantlylowerincidenceofpreeclampsiathantheirmatchedcontrols.Thecontrolgrouphadhighermeanbloodpressuresinthesecondandthirdtrimesters.

•Inarandomized,double-blind,placebo-controlledstudyinvolvingpatientswithnon-insulin–dependentdiabetes,Koreanginsengextracttakenfor8weekssignificantly

improvedpatients’fastingbloodglucose,mood,vigor,wellbeing,andpsychomotorperformance.

•Onlyminorbenefitwasobservedinasingle-blind,placebo-controlledtrialinvolvingpatientswithessentialhypertensiontreatedwithredginsengroot(4.5g/dayfor8weeks).17Inasmall,controlledtrial,redginsengimprovedthevascularendothelialdysfunctioninpatientswithhypertension,possiblythroughincreasingthesynthesisofnitricoxide.18

•InGermany,theCommissionEsupportsusingKoreanginsengasatonicforinvigorationandfortificationintimesoffatigueanddebility,fordecliningcapacityforworkandconcentration,andduringconvalescence.19

•KoreanginsengisofficialintheUSP24-NF19.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicalandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.ZhuM,etal.JPharmPharmacol.1999;51:175-180.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.BritishHerbalMedicineAssociation.Britishherbal

compendium.Bournemouth:BHMA,1992.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983AtteleAS,WuJA,YuanCS.BiochemPharmacol.1999;58(11):1685-1693.WesnesKA,etal.Psychopharmacology.2000;152(4):353-361.KennedyDO,ScholeyA,WesnesKA.Phytomed.2000;7(supp2):105.

10GundlingK,etal.AlternTherHealthMed.2001;7(3):104.11ScaglioneF,WeiserK,AlessandriaM.ClinDrugInvest.2001;21(1):41-45.

12TodeT,etal.IntJGynaecol.1999;67:169-174.13WiklundIK,etal.IntJClinPharmacolRes.1999;19(3):89-99.

14YunTK,ChoiSY,LeeYS:SecondInternationalCancerChemoPreventionConference,Berlin,April28-30,1993.

15YunTK,ChoiSY.ProcAnnuMeetAmAssocCancerRes.1996;37:1906.

16LeeBM,LeeSK,KimHS.CancerLett.1998;132(1-2):219-227.

17HanKH,etal.AmJChinMed.1988;26:199-209.18SungJ,etal.AmJChinMed.2000;28(2):205-216.19BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

LAVENDER

BotanicalNames:

Lavandulaofficinalis,Lavandulaangustifolia,#∧Lavandulaangustifoliasubsp.angustifolia,#Lavandulavera#

Family: LabiataePlantPartUsed:

Flower

# Alternativename.

∧ AdoptedbytheAmericanHerbalProductsAssociationasthenewbotanicalname.1

PRESCRIBINGINFORMATION

Actions Carminative,spasmolytic,antidepressant,anxiolytic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinglavenderinformulationsinthecontextof:

•Restlessness,insomnia(4)

•Anxiety,toelevatemood(4a*)

•Depression,headache(5)

•Functionalabdominalcomplaints,suchasnervousstomachirritationsandmeteorism(i.e.,gaseousdistensionoftheabdomenorintestine)(4)

•Flatulentdyspepsia,colic,digestivedysfunction,rheumatism(5)

•Asabathforfunctionalcirculatorydisorders(4)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsNoneexpectediftakenwithintherecommendeddoserange.High(undefined)dosesaresaidtocauseabdominalpainandcolic.2,3

Dosage Doseperday** Doseperweek**

2.0-4.5mlof1:2liquid 15-30mlof1:2liquid

extract extract

* Based on the assumption that oral dosage of lavender infusion or liquid extract woulddeliverasimilarconcentrationofactiveconstituents to thebloodstreamaswould topicaluse(orinhalation)oflavenderessentialoil.

** This dose range is extrapolated from theBritishHerbalPharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Flatulentdyspepsia,colic,digestivedysfunction,headache,depressivestates2,4

•Internallyasaninfusionorextracttotreatrheumatism4

•Asastimulantforchildren2

•Topically(heated)forpainfullocalaffections2

•Regardedasamildsedativeandhavingslightcholagogueactivity5

•Asabathforvegetativedystonia5

•Asagargleforhoarsenessandlossofvoice3

Lavenderflowerscontain1%to3%essentialoil(consistingmainlyoflinalylacetateandlinalool),6phenoliccompounds(probablyderivativesofrosmarinicacid),andflavonoids.7Thepercentageofessentialoilpresentinaliquidextractdependsonthepercentageofethanolusedintheextractionwithapproximately30%oftheessentialoilextractedby45%ethanol.

•Driedlavenderstrawasbeddingmaterialdecreasedtheincidenceandseverityoftravelsicknessinpigsbutnotoveralllevelsofstress.8

•Anaqueousmethanolicextractoflavenderanditsisolatedphenoliccomponentsproducedconcentration-

PharmacologicResearch

dependentinhibitionoflipidperoxidationinvitro.9

•Thespasmolyticactivityofanaqueousmethanolicextractoflavenderwasdemonstratedforexperimentallyinducedcontractionsofisolatedcircularandlongitudinalsmoothmuscle.10Lavenderoildecreasedtoneinskeletalmuscletissue.11ThemechanismofthespasmolyticactionoflavenderoilispostsynapticandnotatropinelikeandismostlikelytobemediatedthroughcAMP.Theactivityoflinaloolreflectedthatofthewholeoil.12

•Lavenderoildemonstratedsedativeactivityafterinhalationinanexperimentalmodel.Theactivitycorrelatedtothepresenceoflinaloolintheblood.Lavenderoil,linalool,andlinalylacetateinhibitedstimulationbycaffeine.13Oraladministrationoflavenderoil(1.6%)producedsedativeandanxiolyticactivitiesinexperimentalmodels.14,15

•Inhalinglavenderoilreducedthecontentofcholesterolinaortictissueanddecreasedatherogenesisinanexperimentalmodel.Serumcholesterollevelswereunchanged.16

•Ananticonvulsiveactivityforinhaledlavenderoilwasdemonstratedinseveralexperimentalmodelsusingdrug-inducedconvulsion.17

•Lavenderoilhasalsodemonstratedthefollowingactivities:•Antimicrobialactivityinvitroforthevaporwasobserved,particularlyinrelationtofilamentousfungi.18,19Noantisporulatingeffectwasobservedwhentheoilwasappliedinsolution,indicatingthatthevaporwasspecificallyactive.19Antifungalactivityhasbeendemonstratedtowardshumanpathogenicfungi,includingTrichophytonrubrumafterdirectcontactinvitro.20•Inhibitionofimmediate-typeallergicreactionsviainhibitionofmastcelldegranulationwasobserved

followingtopicalorintradermaladministrationinseveralexperimentalmodels.21•Moderateimmunostimulatoryactivitywasexhibitedinthemodifiedcarbonclearancetestinvivo(usuallybyinjection).22

Noclinicalstudiesusinglavenderdriedflowerorlavenderextractshavebeenfound.

•Astudyofpercutaneousabsorptionoflavenderoilfollowingmassagefoundthatthemainconstituentsoftheoilweredetectedinthebloodwithin5minutesafterapplication.Followingthisrapidabsorption,mostofthelavenderoilwasexcretedwithin90minutes.23

•Inhalinglavenderoilbyvolunteersdecreasedvigilancebyapproximately20%frombaselinevalues,indicatingasedativeeffect.24

•Anopen,controlledtrialinvestigatingtheeffectofaromatherapyonpatientswithchronichemodialysisfoundlavenderaromaalleviatedanxiety(bysignificantlyreducinganxietymeanscores).25Inacontrolledstudyusingvolunteersanddesignedtolinktheeffectofodorswiththeemotionalprocess,inhalinglavenderodorelicitedmostly“happiness”asmeasuredbyevaluationandautonomicnervoussystemparameters.26Inhalinglavenderoilfor3minutesbyvolunteersproducedincreasedfrontalbetapower(suggestingincreaseddrowsiness),lessdepressedmood,relaxedfeelings,andfasterandmoreaccuratemathematiccomputationscomparedwithbaselinevalues.Thetrialwasrandomizedandcontrolled(comparedwithrosemaryoil).27

•Arandomized,controlledtrialcomparedtheuseofaromatherapywithlavenderoil,massage,andperiodsofrestinanintensivecareenvironment.Nosignificantdifferenceswereobservedinthephysiologicalstressindicatorsorpatients’abilitytocopefollowinganyofthe

ClinicalStudies

threetreatments.However,patientswhoreceivedaromatherapyreportedgreaterimprovementintheirmood.Thesepatientsalsofeltlessanxiousandweremorepositiveimmediatelyfollowingtherapy,althoughthiseffectwasnotsustainedorcumulative.28

•Lavenderoilaromatherapyresultedinanearstatisticallysignificantreductionindiastolicbloodpressureduringrecoveryfromexerciseinarandomized,controlledtrialinvolving20healthymen.(Thecontrolgroupreceivednoaromatherapy.)29Inanopentrial,inhalinglavenderoilhadanantistresseffectandreducedarousalinvolunteerssubjectedtonoisestress.Thetreatmenthadnoeffectonbloodpressureorheartrate.30

•Sixdropsofpurelavenderoilinbathwater,repeatedfor10days,producedlowermeandiscomfortscoresinwomenwithperinealdiscomfortsubsequenttochildbirth.However,nostatisticallysignificantdifferencewasobservedamongthegroups(purelavenderoil,syntheticlavenderoil,andaninertsubstance)inthisrandomized,placebo-controlledtrial.31Theauthorssuggestedthatfurtherstudiesshouldexplorevaryingthedoseandmodeofapplication.32

•Asurveyofhospitalstafffoundanimprovementintheworkenvironmentfollowingtheuseoflavenderoilburnersfor3months.33

•Lavenderoilinhalationlengthenedsleeptimeinfourgeriatricpatientswithsleepdisorders,threeofwhomhadbeentakingbenzodiazepinesandneurolepticdrugsforsometime.Inthisopentrial,thedrugswerediscontinued,andlavenderoilwasthenadministeredafterawashoutperiod.34

•Inarandomized,double-blind,placebo-controlledtrialusinglavenderbaths,amildimprovementinsleepqualitywasobservedforpatientswithsleepdisorders.(Lowand

highstrengthbathswerecompared.)35

•Inarandomized,crossovertrial,a10-minutehotfootbathwithorwithoutlavenderoilproducedanincreaseinbloodflowandparasympatheticnerveactivityinvolunteers.Thefootbathwiththeadditionoflavenderoilproducedchangesinautonomicactivitycharacteristicofrelaxation.36

•InGermanytheCommissionEsupportsoraluseoflavendertotreatmooddisturbances,suchasrestlessnessorinsomnia,andfunctionalabdominalcomplaints(e.g.,nervousstomachirritations,meteorism,nervousintestinaldiscomfort).TheCommissionEalsosupportsusinglavenderfor“functionalcirculatorydisorders.”37

REFERENCES

McGuffinM,editor.Herbsofcommerce,ed2,Bethesda,Md:AmericanHerbalProductsAssociation,1998.[draft3.3]FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.WeissRF.Herbalmedicine,Englished.Beaconsfield,UK:BeaconsfieldPublishers,1988.WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.

BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.BradshawRH,etal.JAlternComplementMed.1998;4(3):271-275.HohmannJ,etal.PlantaMed.1999;65(6):576-578.

10IzzoAA,etal.PhytotherRes.1996;10(suppl1):S107-S108.11Lis-BalchinM,HartS.JEthnopharmacol.1997;58(3):183-187.

12Lis-BalchinM,HartS.PhytotherRes.1999;13(6):540-542.13BuchbauerG,etal.ZNaturforsch[C].1991;46(11-12):1067-1072.

14GuillemainJ,RousseauA,DelaveauP.AnnPharmFr.1989;47(6):337-343.

15DelaveauP,etal.CRSeancesSocBiolFil.1989;183(4):342-348.

16NikolaevskiiVV,etal.PatolFiziolEkspTer.1990;(5):52-53.

17YamadaK,MimakiY,SashidaY.BiolPharmBull.1994;17(2):359-360.

18LarrondoJV,AgutM,Calvo-TorrasMA.Microbios.1995;82(332):171-172.

19InouyeS,etal.Mycoses.1998;41(9-10):403-410.20AdamK,etal.JAgriFoodChem.1998;46(5):1739-1745.21KimHM,ChoSH.JPharmPharmacol.1999;51(2):221-

226.22KedziaB,etal.HerbaPolon.1998;44(2):126-135.23JagerW,etal.JSocCosmChem.1992;43:49-54.24BuchbauerB,etal.TeranishiR,ButteryRG,SugisawaH,editors.Bioactivevolatilecompoundsfromplants.ACSSymposiumseries.Washington,DC:AmericanChemicalSociety,1993.Citedin

25ItaiT,etal.PsychiatryClinNeurosci.2000;54(4):393-397.26Vernet-MauryE,etal.JAutonNervSyst.1999;75(2-3):176-183.

27DiegoMA,etal.IntJNeurosci.1998;96(3-4):217-224.28DunnC,SleepJ,CollettD.JAdvNurs.1995;21(1):34-40.29RomineIJ,BushAM,GeistCR.PerceptMotSkills.1999;88(3,pt1):756-758.

30MotomuraN,SakuraiA,YotsuyaY.MemoirOsakaKyoikuUnivIIINatSciApplSci.1999;47(2):281-287.

31DaleA,CornwellS.JAdvNurs.1994;19(1):89-96.32CornwellS,DaleA.ModMidwife.1995;5(3):31-33.33TysoeP.IntJNursPract.2000;6(2):110-112.34HardyM,Kirk-SmithMD,StretchDD.Lancet.1995;346(8976):701.

35EmmerlingM,etal.ZPhytotherAbstractband.1995:25.36SaekiY.ComplementTherMed.2000;8(1):2-7.

37BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

LEMONBALM

OtherCommonName: MelissaBotanicalName: MelissaofficinalisFamily: LabiataePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Carminative,spasmolytic,mildsedative,diaphoretic,TSHantagonist,antiviral(topically)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinglemonbalminformulationsinthecontextof:

•Sleepdisturbances,incombinationwithvalerian,hops,andmotherwort(2)

•Nervoussleepingdisorders(4)

•Infantilecolic,incombinationwithchamomile,vervain,licorice,andfennel(3)

•Indigestion,flatulence,colic(4,5)

•Tenseness,irritability(4)

•Depression,nervousbreakdown(5)

•Fevers(5)

•Thecommoncold,influenza(6)

•Topicaltreatmentforherpessimplexvirusinfection(2,4)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Flatulentdyspepsia;depression,nervousbreakdown1

•Asadiaphoreticinfebrilediseases,painfulmenstruation,2thecommoncoldandinfluenza3

PharmacologicResearch

Theaerialpartsoflemonbalmcontainanessentialoilthatcontainsalargenumberofmonoterpenesandsesquiterpenes,predominantlycitronellalandcitral.4Inaddition,lemonbalmcontainsphenolicacidderivatives,whichcontributetotheantiviralactivity.

•Aqueousfreeze-driedextractoflemonbalminhibitedthebindingofTSHandthedeiodinationofthyroidhormoneT4toT3andotherproductsinvitro.5,6LemonbalmalsoinhibitedthebindingofthyroidstimulatingautoantibodiestoTSHreceptorsinvitro.5,7Injectingafreeze-driedaqueousethanolextractoflemonbalmreducedserumTSHconcentrationinanormalthyroidmodel.PituitaryTSHconcentrationwasreduced,butthyroidhormonelevelsremainedunchanged.Despiteadministeringahigherdose,lemonbalmdidnotlowerTSHlevelsinagoiter(hypothyroid)model.8

•Astrongprolactin-loweringeffectwasobservedafterasingleintravenousinjectionofaqueousfreeze-driedlemonbalmextractinvivo.9

•Lemonbalmextractdemonstratedsedativeandsleep-promotingactivityinvivo(routeunknown)andanalgesicactivityathighdose.10Theessentialoilexertedon

antispasmodicactivityonisolatedtissue,11,12butinanotherstudy,theextractwasdevoidofactivity.13

•Anaqueousethanolextractoflemonbalmstronglydisplacednicotineandscopolaminefromhumanbraincellmembranescontainingacetylcholinereceptorsinvitro.14(Acetylcholinereceptoragonistshavepotentialforuseinneurodegenerativediseasesassociatedwithaging,suchasAlzheimer’sdisease.)

•Lemonbalmextractdemonstratedantioxidantactivityinvitro.15,16

•Lemonbalmethanolicextract,essentialoil,andoilconstituents(citral,geraniol,nerol)inhibitedtheformationoftheproinflammatoryeicosanoids,leukotrieneB4,andthromboxaneB2invitro.Theaqueousextractwasdevoidofactivity.17

•Lemonbalmextractdemonstratedantiviralactivityagainstanumberofviruses,includingHSVinvitro.18Thisfindinghasrelevanceforthetopicaluseoftheherb.Theessentialoilhasdemonstratedantimicrobialactivityinvitro.19

•AsingleadministrationoflemonbalmextracttovolunteersresultedinaquantitativeEEGrecordingthatwasdistinguishablefromthatobtainedforplacebo.However,resultsfromtheself-ratingofalertnessdidnotdifferfromplacebo.Thedosewasequivalentto6.2gofdriedherb.20Anacutesedativeeffectwasnotdemonstrated,butanalysisafterongoingadministrationmayyetdemonstrateasedativeeffect.

•Theeffectofanherbalpreparationcontainingvalerianandlemonbalmonobjectivesleepparameterswascomparedwithanorthodoxsedative(triazolam)andplaceboin20volunteerscomposedofbothgoodandpoorsleepers.Theherbalpreparationinducedasignificant

ClinicalStudies

increaseinsleepefficiencyinstages3and4,andpoorsleepersbenefittedmorefromthetreatment.Noshorteningofsleeplatencyandwaketimewereobserved,andnoreboundeffectswereobserved.Theherbalcombinationandtriazolamweretestedonday3andday6,respectively,withbaselineandplaceboevaluatedondays1,2,4,5,and7.Thedailydosecorrespondedto1.4gofdriedvalerianrootand0.9gofdriedlemonbalmherb.Thetrialwasofdouble-blind,placebo-controlled,crossoverdesign.21

•Inarandomized,double-blind,placebo-controlled,multicentertrial,alemonbalm(equivalentto1.7g/day)andvalerian(equivalentto2.9g/day)preparationtakenfor3weeksproducedanimprovementinsleepparametersinambulatorypatientswithlightinsomnia.22Alatertrialwiththesamedesignproducedasignificantlyhigherqualityofsleepinhealthyvolunteerscomparedwithplacebo.Thepreparationwasadministered30minutesbeforebedandcontainedtheequivalentof1.2gperdaylemonbalmand1.6gperdayofvalerian,takenfor30days.23

•ApostmarketingsurveillancestudyinGermanyinvolving518patientsfoundanherbalcombinationofvalerian,hops,andlemonbalmtobeahighlyeffectivetreatmentfornervousinsomniaandrestlessness,withveryfewsideeffects.Thedoseadministeredrangedfromonetoninetablets.Onetabletcontains450mgofvaleriandriedroot,126.5mgofdriedhopstrobiles,and225mgoflemonbalmdriedleaf.24

•Arandomized,double-blind,crossoverstudyinvolvingalcoholicswithsleepdisturbancesfoundthatconsumptionofanherbaltabletproducedimprovementinsleepparameters.Thetabletthatwastakenforonenightandcomparedwithplacebo(alsoonenight)containedthefollowingweightsofdriedherb:valerianroot(170mg),hopstrobiles(50mg),lemonbalmleaf(50mg),and

motherwortherb(50mg).25

•Adouble-blindstudyonbabiesapproximately3weeksofagewithinfantilecolicinvestigatedtheeffectofaninstantherbalteapreparationcontaininglemonbalm,chamomile,vervain,licorice,andfennel.After7days,thecolicimprovementscoresweresignificantlybetterintheherbalteagroup,andmorebabiesinthistreatmentgrouphadtheircoliceliminated.Theteapreparationwasofferedwitheveryepisodeofcolic,upto150mlperdose,butnotmorethanthreetimesperday.Theexactcompositionofthepreparationwasnotdefined.26

•Inadouble-blind,placebo-controlledcrossoverstudy,acitronellolbathproducedadose-dependent,sedative,andsleep-promotingeffectinbothhealthyvolunteersandinpatientswithnervousorsleepdisorders.27

•Randomized,controlledclinicaltrialswithlemonbalmhaveyieldedconclusiveresultsforthetopicaltreatmentofrecurrentherpessimplexvirustypeIinfection.28-33Thesetrialsusedacreamcontaining1%lemonbalmextract(70:1).Inonetrial,thecreamwasusedontheaffectedareatwotofourtimesdailyfor5to10days.31

•InGermany,theCommissionEsupportsusinglemonbalmtotreatnervoussleepingdisordersandfunctionalgastrointestinalcomplaints.34

•ESCOPrecommendslemonbalminternallyfortreatingtenseness,restlessnessandirritability,aswellassymptomatictreatmentofdigestivedisorderssuchasminorspasms.Externally,lemonbalmisrecommendedfortreatingherpeslabialis(coldsores).35

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.

Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.Auf’mkolkM,etal.Endocrinology.1984;115(2):527-534.Auf’mkolkM,etal.HormMetabRes.1984;16(4):188-192.Auf’mkolkM,etal.Endocrinology.1985;116(5):1687-1693.SourgensH,etal.PlantaMed.1982;45:78-86.SourgensH,etal.IntJCrudeDrugRes.1986;24(2):53-61.

10SoulimaniR,etal.PlantaMed.1991;57(2):105-199.11WagnerH,SprinkmeyerL.DtschApothZtg.1973;113:1159-1166.

12DebelmasAM,RochatJ.PlantesMedPhytother.1967;1:23-27.

13ForsterHB,NiklasH,LutzS.PlantaMed.1980;40:309-319.14WakeG,etal.JEthnopharmacol.2000;69:105-114.15HohmannJ,etal.PlantaMed.1999;65(6):576-578.16LamaisonJL,Petitjean-FreytetC,CarnatA.PharmActaHelv.1991;66(7):185-188.

17HowesM,HoughtonPJ,HoultJ.PresentedattheInternationalCongressand48thAnnualMeetingoftheSocietyforMedicinalPlantResearchandthe6thInternationalCongressonEthnopharmacologyoftheInternationalSocietyforEthnopharmacology,Zurich,September3-7,2000,abstractSL16.

18KuceraLS,CohenRA,HerrmannECJr.AnnNYAcadSci.1965;130(1):474-482.

19LarrondoJV,AgutM,Calvo-TorrasMA.Microbios.1995;82(332):171-172.

20SchulzH,JobertM,HubnerWD.Phytomed.1998;5(6):449-458.

21DressingH,etal.Therapiewoche.1992;42(12):726-736.22DressingH,KohlerS,MullerWE.Psychopharmakother.1996;3(3):123-130.

23CernyA,SchmidK.Fitoterapia.1999;70:221-228.24FriedeMetal.Presentedatthe2ndInternationalCongressonPhytomedicine,Munich,September11-14,1996,abstractP-75.

25Widy-TyszkiewiczE,SchmindaR.HerbaPolonica.1997;43(2):154-159.

26WeizmanZ,etal.JPediatrics.1993;122(4):650-652.27PischelB,UehlekeB.ZPhytotherAbstractband.1995:25.28WolblingRH,RapprichK.DtschDermatol.1983;10:1318-1328.

29WolblingRH,MilbradtR.Therapiewoche.1984;34:1193-1200.

30VogtHetal.Presentedatthe4thInternationalCongressonPhytotherapy,Munich,September10-13,1992,abstractSL15.

31WolblingRH,LeonhardtK.Phytomed.1994;1(1):25-31.32KoytchevR,AlkenRG,DundarovS.Phytomed.1999;6(4):225-230.

33MohrigA.DtschApothZtg.1996;136:109-114.34BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

35ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Melissaefolium.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

LICORICE

OtherCommonName: LiquoriceBotanicalName: GlycyrrhizaglabraFamily: LeguminosaePlantPartUsed: Rootandstolon

PRESCRIBINGINFORMATION

ActionsAntiinflammatory,mucoprotective,demulcent,antiulcer(peptic),adrenaltonic,expectorant,antitussive,mildlaxative,anticariogenic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinglicoriceinformulationsinthecontextof:

•Gastricandduodenalulceration,gastroesophagealreflux(4,5)

•Polycysticovarysyndrome,infertility,musclecramps,dysmenorrhea,incombinationwithwhitepeony(4)

•Adrenalinsufficiencyandwithdrawalfromcorticosteroiddrugs(5,7)

•Inflammatoryconditions,rheumatoidarthritis,urinarytractinflammation(5,7)

•Upperrespiratorytractcatarrh(4,5)

•Cough,bronchitis(5,7)

•Addison’sdisease(4,5)

•Topicaltreatmentforeczema,melasma(increasedmelaninpigmentation)(4)

•Topicaltreatmentforrecurrentmouthulcersandherpeslesions(4a)ContraindicationslistedbytheCommissionEinclude

Contraindications

cholestaticliverdisorders,livercirrhosis,hypertension,hypokalemia,severekidneyinsufficiency,andpregnancy.Licoriceisalsocontraindicatedifedemaorcongestiveheartfailureispresent.However,licoricehasbeensafelyusedincombinationwithwhitepeony(Paeonialactiflora)inaclinicalstudyinvolvingpregnantwomen.Thewomenweresuccessfullytreatedwiththecombination(equivalentto6g/dayofeachherbfor24weeks)forinfertilityresultingfrompolycysticovarysyndrome.Anumberofpregnancieswererecordedatthe12-weekmark.Additionally,astudyoflicoriceintakeduringpregnancyfoundnosubstantialhealthrisksassociatedwithitsuse.1

WarningsandPrecautions

Patientswhoareprescribedhighglycyrrhizinlicoricepreparationsforprolongedperiodsshouldbeplacedonahigh-potassium,low-sodiumdietandcloselymonitoredforbloodpressureincreasesandweightgain.Hypokalemiaisthegreatestthreatandcanoccuratrelativelylowdoses.Specialprecautionsshouldbetakenwithelderlypatientsandpatientswithhypertensionorcardiac,renal,orhepaticdisease.Theseindividualsshouldnotreceivelicoricepreparationshighinglycyrrhizin(GL)forprolongedperiods.

Interactions

AslightchanceexiststhatGLorglycyrrhetinicacid(GA)maycounteractthecontraceptivepill.

Potassiumlossmaybesevereiflicoriceistakeninconjunctionwithpotassium-depletingdrugs(e.g.,thiazidediuretics,laxatives)leadingtoundesirablesideeffects.Withpotassiumloss,sensitivitytocardioactiveglycosidesincreases,withpotentialtoxiceffects.Theintakeoflicoricemayexaggeratetheeffectsofahigh-saltdiet.

OraladministrationofGLincreasesplasma

prednisoloneconcentrationsbyinhibitingitsmetabolism.Licoricemaytherebypotentiatethepharmacologiceffectsofprednisoloneandothercorticosteroiddrugs.

UseinPregnancyandLactation

TheCommissionEadvisesthatlicoriceiscontraindicatedinpregnancy.However,dosesupto3gperday(i.e.,upto3mlof1:1liquidextractor3mlof1:1highglycyrrhizinliquidextract)arelikelytobesafe.

SideEffects

Licoricehasbeenknowntocausehypertension,sodiumandwaterretention,andhypokalemiathroughthemineralocorticoideffectofGL.IndividualvariationinsusceptibilitytoGLishighlyvaried:inthemostsensitiveindividuals,aregulardailyintake(overseveralweeks)ofnomorethan100mgGL(correspondingtoapproximately50goflicoricecandies)canproducesymptoms;mostindividualswhoconsume400mgGLdailyexperiencesideeffects.

Excessiveconsumptionoflicoriceconfectioneryhasbeenassociatedwithcongestiveheartfailure,pulmonaryedema,myopathy,pseudoaldosteronism,hypokalemicrhabdomyolysis(secondarytochronicglycyrrhizicacidintoxication),andgeneralizededema.

Inatrialdesignedtostudytheeffectofprolongedingestion,gradeddosesofdried,aqueousextractoflicoriceroot(correspondingto108to814mgGA/day)wereadministeredtohealthyvolunteersofbothsexesfor4weeks.Onlythehighestdosesoflicorice(correspondingto380and814mgGA)ledtoadverseeffects,andinmostofthesecases,subclinicaldisease(arterialhypertension)ororalcontraceptiveusewasalsoinvolved.TheadverseeffectswerelesscommonandlesspronouncedthanwhathadbeenpreviouslyreportedaftertakingGLaloneorinconfectioneryproducts.

Dosage Doseperday Doseperweek

2-6mlof1:1liquidextract*

15-40mlof1:1liquidextract*

1.5-4.5mlof1:1high-GLliquidextract(3%to4%glycyrrhizin)**

10-30mlof1:1high-GLliquidextract(3%to4%glycyrrhizin)**

ExtractsprovidingquantifiedlevelsofGLarerecommended.Ideally,high-gradeextractsshouldcontainnotlessthan30mg/mlofGL.

Higherdosesoflicoriceshouldnotbeconsumedlongterm.TheCommissionEadvisesthatlicoriceshouldnotbetakenforlongerthan6to8weekswithoutprofessionalsupervision.

* ThisdoserangeisextrapolatedfromtheBritishPharmacopoeia1973,theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

** This dose range is extrapolated from the licorice extract dosage and literature on thepharmacologicactivityoftheconstituentGL.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Reducingtheirritationofmucoussurfacesoftheurinary,respiratory,anddigestivetracts2

•Bronchialcatarrh,bronchitis,chronicgastritis,gastricorduodenalulcer,colic3

•Adrenalinsufficiency,Addison’sdisease3

•Rheumatism,arthritis4

UsesandpropertiesfromTCMinclude:

•Deficiencyofspleenandstomachmarkedbyfatigueandweakness5

•Palpitations,arrhythmia5

•Coughing,wheezing6

•Painfulspasmsintheabdomenandlegs6

•Reducingthetoxicordrasticactionsofotherherbs6

TraditionalAyurvedicusesinclude:

•Asatonicandexpectorant;coughs7

•Asademulcentforcatarrhalconditionsofthegenitourinarytract7

•Stomachpainanddiscomfort;alsoasamildlaxative7

PharmacologicResearch

Keyconstituentsoflicoricedriedrootincludetriterpenoidsaponins,especiallyGL,intheformofpotassiumandcalciumsalts,GA,andawiderangeofflavonoidsandsterols.HighergradesoflicoriceextractscontainahigherproportionoftheGLthaniscontainedwithinstandardgradeproducts.Deglycyrrhinizedlicorice(DGL)isalicoricepreparationfromwhichmostoftheGLhasbeenremoved.CarbenoxoloneisasemisyntheticderivativeofGAdevelopedinthe1960s.

•Inanimalstudies,DGLpreventedulcerdevelopment,inhibitedgastricacidsecretion,andprotectedthegastricmucosaagainstdamagefromaspirinandbile.Licoriceandlicoricederivativesprotectedagainstgastriculcerinducedbyaspirin,ibuprofen,andethanolinexperimentalmodels.

•GAandGLexhibitedantiinflammatoryeffectsinvivoafteroraladministrationinseveralexperimentalmodels,includingarthritis.LicoriceandGLalsodemonstratedtopicalantiinflammatoryactivitythatwascomparabletoprednisoloneanddexamethasoneinanimalstudies.

•GLandGAexertapowerfulinfluenceonhumansteroidhormonefunction.OralGLinhibitedtheactivityandproductionoftheenzymethatconvertscortisolintoitsinactivemetabolites,whichleadstosignificantlyincreasedcortisollevels.BothGLandGAincreasetheantiinflammatoryactionofcortisolinvivo.GLhasalsobeenshowntoantagonizesomeofthesideeffectsofcortisol,suchasitsantigranulomatousactionanditssuppressiveeffectonACTHsynthesisandsecretionandonadrenalweight.Licoricehaswell-documentedaldosterone-likeeffects.Strongevidencesuggeststhatlicoriceanditsderivativesactinthiswaybyalteringthemetabolismofcertainsteroidhormones.

•Oraldosesoflicoricehelpedintherecoveryoftotalleukocytecount,lymphocytecount,andcellularimmunity

afterirradiationinexperimentalmodels.OraladministrationofGlycyrrhizauralensiscounteredthecarrageenan-induceddecreaseinimmunecomplexclearance.

•Licoriceextractdecreasedmutationfrequenciesinducedbyaseriesofwell-knownmutagensandcarcinogensinvitrooverarangeofconcentrationsthatwerewellbelowitstoxiclevel.Oraladministrationof1%aqueousextractoflicoriceprotectedagainstchemicalcarcinogen-inducedlungandforestomachtumorigenesisinvivo.

•Licoriceanditsderivativesdemonstratedhepatoprotectiveactivityinvivoafteroraladministration.Oraldosesoflicoriceexhibitedcholereticactivityinexperimentalmodels.

•GLhasantiviraleffectsinvitroandinvivobyintraperitonealinjection,butGAdoesnot.AsGLisconvertedtoGAafteroralingestion,onlytopicalantiviraluses,ratherthansystemic,areindicated.GLwasparticularlyactiveagainstHSV,varicella-zostervirus,andHIVinvitro.

•Licoriceflavonoidsdemonstratedsignificantantimicrobialactivityinvitro.OraladministrationofalicoriceflavonoidconferredprotectionagainstPlasmodiumyoeliiinfection.

•Carbenoxoloneenhancedthedefensemechanismofthebladderandinhibitedbacterialadherencetotheinjuredepitheliuminvivobyintramuscularinjection.

•OraldosesofGAdemonstratedanantitussiveeffectsimilartocodeine.

•Oralintakeoflicoricereducedhyperphagia,polydipsia,andsorbitollevelsindiabeticexperimentalmodels.

•Well-controlledclinicaltrialshaveshownDGL(2.3to3.8g/dayfor12to16weeks)combinedwithantacidsisasefficaciousathealinggastricandduodenalulcersascarbenoxolone,cimetidine,andranitidine.

•Earlyuncontrolledtrialsdemonstratedthecurativeeffectsoflicoriceonpepticulcers.Unfortunately,ahighpercentageofpatientsdevelopedsideeffectsassociatedwithsodiumretention.Inonetrial,approximately7goflicoricejuice-pastewasadministereddaily.Sideeffectsmighthavebeencounteredbyalow-sodiumdiet,unlessthepatientwastakingdosesinexcessof40goflicoricedaily.

•LicoriceextractdemonstratedadramaticeffectinmaintainingelectrolyteequilibriuminpatientswithAddison’sdisease.Thedailydoserangedfrom10to30goflicoriceextract.Ifadrenalcortexfunctionwasseverelyimpaired,licoricewasnotasuitabletreatmentonitsownbuthadasynergisticactionwithcortisone.

•Inuncontrolledstudies,licoricecombinedwithwhitepeonyloweredtheLH/FSHratio,reducedovariantestosteroneproduction,andinducedregularovulationinpatientswithpolycysticovarysyndrome.Thiscombinationcontainedequalamountsoflicoriceandwhitepeony.Dosesequivalentto4to8gperdayofeachherbwereprescribedfor2to24weeks.

•LicoriceandwhitepeonycombinationisapprovedforuseinclinicalpracticeinJapanandhasbeenusedtotreatacutemusclecrampsanddysmenorrhea.Dosesequivalentto6gperdayofeachherbareprescribed.8

•Asubstantialandsignificantdropinserumtestosteroneandasmallersignificantincreasein17-hydroxyprogesteronewasobservedinaclinicalstudyinwhichsevennormalmenreceived7gperdayofalicoriceextractcontaining0.5gofGL.Serumandrostenedione

ClinicalStudies

wasalsoraised,butthedifferencedidnotachievestatisticalsignificance.9Thepossibilityexiststhatexcessiveintakeoflicoricemaycausedecreasedlibido,butthisisunlikelytoresultfromitsinformeduseasatherapeuticagentatthedosesrecommendedinthismonograph.Inamorerecentclinicaltrial,researcherstwicefailedtoreplicatethepreviouslylistedresults.Theauthorsidentifieddifferencesbetweentheirmethodsandthoseofthepreviousstudyandpossiblestatisticalanomalies(includinginappropriateuseofstatisticaltests)intheearlierreport.10

•Inanuncontrolledtrial,Glyke(apatentedpreparationmadefromG.uralensis)improvedtheT-lymphocyteCD4/CD8ratioandCD4countsinpatientswithHIV.Anoraldoseof120mgperdaywasgivenfor3to6months.Inanopenstudy,HIV-positivehemophiliacstreatedwithGL(150to225mg/dayfor3to7years)remainedasymptomatic,butuntreatedcontrolsshoweddecreasesinT-lymphocytecounts.

•ResultsofaclinicaltrialinwhichGLwasadministeredintravenouslytohemophiliacswithAIDSsuggestthatGLbythisroutemightinhibitHIV-1replicationinvivo.

•Inasmalluncontrolledstudy,GL(150mg/day)wasobservedtobeasafetreatmentforhyperkalemiaresultingfromselectivehypoaldosteronisminnon-insulin–dependentdiabetesmellitus.ThisdoseofGLcorrelatestoapproximately3to5gperdayoflicorice.

•Thesuccessfultreatmentofchronicfatiguesyndromebylicoricewasreportedinacasestudy.Thedailydoseoflicoricewasdissolvedinmilk(2.5g/500ml).

•Improvementofmouthulcerswasseenafter1day,withcompletehealingin3days,whenDGLwasusedinanuncontrolledtrial.Patientswereadvisedtogarglefourtimesdailyfor7dayswithpowderedDGL(200mgper

capsule)dissolvedin200mlofwarmwater.Inadouble-blind,crossovertrial,acarbenoxolonemouthwashsignificantlyreducedthenumberofrecurrentulcersandassociateddiscomfort.

•AcontrolledtrialfoundGLapplicationafter3daysreduceddentalplaque.Onesideofthemouthwastreated,andtheothersideservedasthecontrol.

•Theantiviraldrugidoxuridine(0.2%)incorporatedinaGLgelwassignificantlybetterthanaregular0.5%idoxuridineointmentatreducingpainandincreasinghealinginpatientswithherpeslesionsofthelipsandnose.Carbenoxolonecreamwasbetterthanplacebofortreatinginitialandrecurrentherpesgenitalisinadouble-blindstudy.

•Anointmentcontainingcrudelicoricepowderyieldedgoodresultsintreatingchroniceczema.Topicalapplicationoflicoriceextractdemonstratedappreciableactivityinpatientswithmelasma(increasedmelaninpigmentation).

•InGermany,theCommissionEsupportsusinglicoricetotreatcatarrhoftheupperrespiratorytractandgastricandduodenalulcers.11

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.StrandbergTE,etal.Birthoutcomeinrelationtolicorice

consumptionduringpregnancy.AmJEpidemiol.2001;153:1085.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982YamadaK,etal.JClinPsychopharmacol.1999;19(4):380-381.ArmaniniD,BonanniG,PalermoM.NEnglJMed.1999;341(15):1158.

10JosephsRA,etal.Lancet.2001;358(9293):1613-1614.11BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

LIMEFLOWERS

OtherCommonNames: Lindenflower,limeblossomBotanicalName: Tiliaspp.Family: TiliaceaePlantPartUsed: Flower

PRESCRIBINGINFORMATION

Actions Spasmolytic,peripheralvasodilator,mildsedative,diaphoretic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinglimeflowersinformulationsinthecontextof:

•Thecommoncold,cold-relatedcoughs(4,5)

•Catarrhalrespiratoryconditions,feverishconditions(5)

•Anxiety,restlessness,insomnia,headache,hypertension(5)

•Palpitations(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions

Limeflowersinfusionreducedtheabsorptionofironby52%fromabreadmeal(comparedwithawatercontrol)inadultvolunteers.Theinhibitionwasdose-dependentandrelatedtoitspolyphenolcontent(phenolicacids,monomericflavonoids,polymerizedpolyphenols).Inhibitionbyblackteawas79%to94%.1Thisfindingindicatesapotentialinteractionforconcomitantadministrationoflimeflowersduringironintake.Inanemiaandcasesforwhichironsupplementationisrequired,limeflowersshouldnotbetakensimultaneouslywithmealsorironsupplements.

UseinPregnancy Noadverseeffectsexpected.

andLactation

SideEffects Allergiccontactsensitivitytolimeflowersextracthasbeenreported.2,3

Dosage Doseperday* Doseperweek*

2.0-4.5mlof1:2liquidextract

15-30mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Hypertension;headache,migraine;thecommoncold,fever,catarrhalconditions;nervousconditions,restlessness;dyspepsia,indigestion4,5

•Topromoterestandsleep5;palpitations6

PharmacologicResearch

ThemostcommonlyusedspeciesofTiliainWesternherbalmedicineareT.cordataandT.platyphyllos.7Tiliaeuropaea,alsoreferenced,islistedasavarietyandsubspeciesofT.platyphyllos,amongotherspecies.OtherspeciesofTiliamayalsobeappropriate;forexample,theEclecticsusedT.tomentosa(LatinAmerican)andT.americana.

Limeflowerscontainessentialoilandflavonoids.8

•PolysaccharidesfromTiliacordatashowedmoderatebioadhesiontoisolatedepithelialtissue.9Themucilageinlimeflowershasemollientactivity.10

•AcomplexfractionisolationfromtheaqueousextractofTiliatomentosademonstratedananxiolyticeffectinanexperimentalmodelafterintraperitonealinjection.Thefractionmostlikelycontainedflavonoids.11Inhalationofessentialoiloflimeflowersproducedsedativeeffectsinanexperimentalmodel.12

•Limeflowersextractmildlypromotedironabsorptioninisolatedintestinalsegment,whichcontrastswiththestudyquotedinthe“Interactions”section.13

•AqueousextractofTiliaeuropaeainhibitedmuscimolbindingtosynapticmembranesandstimulatedchlorideuptakebysynaptoneurosomes.TheseresultssuggestthattheextractcontainedacompoundwithaffinityforthecompetitivebindingsiteoftheGABAAreceptor-complex.Athighconcentrations,theextractdisplacedflunitrazepam(abenzodiazepinedrug)boundtosynapticmembranes.Benzodiazepine-likesubstancesmayberesponsibleforthisactivity.AlthoughtheGABAcontentoftheextractmightexplainthedisplacementofmuscimol,itdoesnotexplainthedecreaseinflunitrazepambindingortheinvivosedativeeffectdemonstratedforlimeflowers.14

•Inanearlierstudy,limeflowersextractsthatinhibitedthebindingofflunitrazepamtosynapticmembranewerefoundtocontainbenzodiazepine-likecompounds,asevidencedbytheirspecificinteractionwithamonoclonalantibodyagainstbenzodiazepines.15

ClinicalStudies

•Tiliasylvestrisextractacceleratedthehealingtimeofartificiallyinducedskinabrasioninvolunteers.16

•InGermany,theCommissionEsupportsusinglimeflowerstotreatthecommoncoldandcold-relatedcoughs.17

REFERENCES

HurrellRF,ReddyM,CookJD.BrJNutr.1999;81(4):289-295.PicardoM,etal.ContactDermatitis.1988;19(1):72-73.deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1993.

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.SchmidgallJ,SchnetzE,HenselA.PlantaMed.2000;66(1):48-53.

10KanschatH,LanderC.PharmZtg.1984;129:370-373.11ViolaH,etal.JEthnopharmacol.1994;44(1):47-53.12BuchbauerG,JirovetzL,JagerW.ArchPharm.1992;325(4):247-248.

13el-ShobakiFA,SalehZA,SalehN.ZErnahrungswiss.1990;29(4):264-269.

14CavadasC,etal.PhytotherRes.1997;11(1):17-21.15MedinaJH,etal.BiochemBiophysResCommun.1989;165(2):547-553.

16FleischnerAM.CosmetToiletries.1985;100:54-55.17BlumenthalM,etal,editors.ThecompleteGerman

CommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

MARSHMALLOW

BotanicalName: AlthaeaofficinalisFamily: MalvaceaePlantPartsUsed: Root,leaf

PRESCRIBINGINFORMATION

Actions Marshmallowrootandleaf:demulcent,urinarydemulcent,emollient

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmarshmallowrootinformulationsinthecontextof:

•Irritationsoftheoral,pharyngeal,orgastricmucosa,drycough(4,5)

•Gastricorpepticulcer,enteritis(5)

•Cystitis,urinarytractinfectionsingeneral(5)

•Topicaltreatmentforvaricoseulcers,wounds,burns(5)

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmarshmallowleafinformulationsinthecontextof:

•Irritationsoftheoralandpharyngealmucosa,drycough(4)

•Bronchitis,respiratorytractcatarrh(5)

•Cystitis,urethritis,urinarygravelorcalculus(5)

•Topicaltreatmentforabscesses,boils,andulcers(5)Contraindications Noneknown.

WarningsandPrecautions

Theabsorptionofothermedicationstakensimultaneouslywithmarshmallowrootmayberetarded.1Simultaneousingestionofdrugmedications

andmarshmallowrootshouldthereforebeavoided.Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Root: Doseperday* Doseperweek*

3-6mlof1:5tincture 20-40mlof1:5tincture 3-6mlof1:5glycetract 20-40mlof1:5glycetract Leaf: Doseperday** Doseperweek**

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1949, theBritishHerbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’seducationandexperience.

** This dose range is extrapolated from theBritishHerbalPharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesofmarshmallowrootinclude:

•Diseasesofthemucousmembranes,suchashoarseness,catarrh,pneumonia,andotherrespiratorycomplaints,gonorrhea,vesicalcatarrh,renalirritation,acutedysentery,diarrhea2

•Strangury(painintheurethra),inflammationofthebladder,hematuria,retentionofurine,someformsofgravel,andmostkidneyorbladderinfections2

•Gastrointestinalirritationandinflammation,2speciallygastricorduodenalulcer3

•Topicallyforvaricoseulcers,3inflammatorylesions,swellings,wounds,bruises,andscalds2

TraditionalWesternherbalmedicineusesofmarshmallowleafinclude:

•Bronchitis,respiratorycatarrh3

•Cystitis,urethritis,urinarygravelorcalculus3

•Topicallyforabscesses,boils,ulcers3

Therootsandleavesofmarshmallowcontainmucilage,consistingofacidicpolysaccharides.4Ethanol-waterextractsofbothmarshmallowleafandrootwillextractsomeofthemucilageinthestartingherb,althoughmucilageissparinglysolubleinsuchmixtures.Inthecase

PharmacologicResearch

oftheroot,whichcontainsamuchhigherconcentrationofmucilagethantheleaf,aglycerol-watercombinationispreferableforextractiongiventhatmucilageismoresolubleinthismedium.

•Theresultsofaninvitrostudysuggestthattheadhesiveeffectsofcertainplant-derivedpolysaccharidestomucousmembranesmayaccount,inpart,forthetherapeuticeffectsofmucilage-containingplantsintreatingirritatedbuccalmembranes.Polysaccharidesfrommarshmallowrootdemonstratedmoderatebioadhesiontoepithelialtissue.5

•Coldmacerateofmarshmallowrootinhibitedesophagealmucociliarytransportinvitro.6

•Inanexperimentalmodel,oraladministrationofanextractofmarshmallowrootorthepolysaccharidefractiondemonstratedsignificantantitussiveactivity,depressingthecoughresultingfrombothlaryngopharyngealandtracheobronchialstimulation.Thisstudyprovidesindirectevidencethatasoothingactionontheuppergastrointestinalmucosacausesreflexsoothingoftherespiratorytract,leadingtobronchodilationandreducedtendencytocough.7

•Extractsofmarshmallowrootdemonstratedpotentialantiinflammatoryandimmunomodulatoryeffectsinvitro,8butlackofantiinflammatoryactivitywasobservedafteroraladministrationofmarshmallowrootincarrageenan-inducedratpawedema.9Theinvivoantiinflammatoryeffectofanointmentcontainingbothmarshmallowrootextractanddexamethasonewassuperiortothatoftheindividualingredients.10

Noclinicalstudiesusingmarshmallowrootorleafhavebeenfound.

•InGermany,theCommissionEsupportsusing

ClinicalStudies

marshmallowrootandleaftotreatirritationoftheoralandpharyngealmucosaandassociateddrycoughandmarshmallowroottotreatmildinflammationofthegastricmucosa.11

•ESCOPrecommendsmarshmallowrootfortreatingdrycoughandirritationsoftheoral,pharyngeal,orgastricmucosa.1

REFERENCES

ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Althaeaeradix.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.SchmidgallJ,SchnetzE,HenselA.PlantaMed.2000;66(1):48-53.Muller-LimmrothW,FrohlichHH.FortschrMed.1980;98:95-101.Nosal’ovaG,etal.Pharmazie.1992;47:224-226.SchefferJ,KonigW:3rdPhytotherapyCongress,Lubeck-

Travemunde,October3-6,1991,abstractP9.MascoloN,etal.PhytotherRes.1987;1:28-31.

10BeauneA,BaleaT.Therapie.1966;21:341-347.11BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

MEADOWSWEET

BotanicalName: FilipendulaulmariaFamily: RosaceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Antacid,antiinflammatory,mildurinaryantiseptic,astringent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmeadowsweetinformulationsinthecontextof:

•Gastriculcer(5,7)

•Dyspepsia,hyperacidity,heartburn,diarrhea,irritablebowelsyndrome(5)

•Genitourinarytractdisorders,suchascervicitis,vaginitis,leukorrhea,cystitis,anddysuria(5)

•Fever;arthriticandrheumaticconditions(5)

•Possiblebenefitbytopicalapplicationforcervicaldysplasiaandtoprotectandrepairthemucosaofthevaginaandcervix(4)

Contraindications Noneknown.

WarningsandPrecautions

Meadowsweetcontainssalicylatesandshouldbeavoidedorusedwithcautioninpatientswithsalicylatesensitivity.

InteractionsNoneknown.Giventheexperimentalanticoagulanteffect,meadowsweetshouldbeusedwithcautionifpatientsaretakingwarfarin.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Atonicdyspepsiawithheartburnandhyperacidity;gastriculcer(prophylaxisandtreatment),diarrhea1

•Fevers;genitourinarytractirritation,acutecatarrhalcystitis,retentionofurineresultingfromenlargedprostate,chroniccervicitis,chronicvaginitiswithleukorrhea1,2

•Rheumaticmuscleandjointpains1

PharmacologicResearch

•Aninvitrostudydemonstratedthattheethylacetateextractofmeadowsweetflowersstronglyinhibitedtheclassicalpathwayofcomplementactivation.Thisactivitywasalsoobservedusingmethanolextractsoftheherbandflower.

•Theauthorsofaninvitrostudysuggestedthattheobservedimmunomodulatoryactivitymayexplainthetherapeuticbenefitofmeadowsweetpreparationsininflammatorydiseases.

•InvitrostudieshavedemonstratedantimicrobialactivityagainstStaphylococcusaureushaemolyticus,Streptococcuspyogeneshaemolyticus,Escherichiacoli,Shigellaflexneri,Klebsiellapneumoniae,andBacillussubtilis.Anotherstudysuggestedthatwaterextractsofvariouspartsofmeadowsweetshowedantibacterialactivityandmaybeusedonwounds.

•Decoctionsofmeadowsweetflowersdemonstrated

antiulcerogenicactivityinanexperimentalmodel.Alcoholextractsandwaterdecoctionsoftheflowersdecreasedthedevelopmentofexperimentalerosionandulcersinvivo.

•Anticoagulantactivityforextractsofbothmeadowsweetflowerandseedhavebeendemonstratedinvitroandinvivo(orally).Thisactionisthoughttobetheresultofaheparinlikeanticoagulantfoundintheplant.

•Inanexperimentalstudy,localadministrationofadecoctionoftheflowersresultedina39%dropinthefrequencyofsquamouscellcarcinomaofthecervixandvagina.

ClinicalStudies

In48casesofcervicaldysplasiatreatedwithanointmentcontainingmeadowsweet,apositiveresultwasrecordedin32patientsandcompleteremissionin25cases.Norecurrencewasobservedin10ofthecompletelycuredpatientswithin12months.

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

MILKTHISTLE

OtherCommonName: St.Mary’sthistleBotanicalName: Silybummarianum,Carduusmarianus#

Family: CompositaePlantPartUsed: Fruit(sometimesreferredtoasseed)

# Alternativename.

PRESCRIBINGINFORMATION

Actions Hepatoprotective,hepatictrophorestorative,antioxidant,choleretic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmilkthistleinformulationsinthecontextof:

•Hepatitis,particularlyforthehepatoprotectiveactivity(4a,6)

•Nonalcoholicandalcoholicliverdamageordisease,includingabnormalliverfunctionandfattyliver(4a)

•Exposuretochemicalpollutantsandconventionaldrugs(4a)

•Skinconditionsinvolvingliverdysfunction(4a)

•Dyspepticcomplaints(4)

•Preventinggallstoneformation(4a,6)

•Gallbladderproblems(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

Drugmonitoringstudiesin1995investigatingtheconcentratedextract(silymarin)indicatedthatadverseeffectswererecordedin1%ofpatients,mainlyasmild

SideEffects gastrointestinalcomplaints.Amildlaxativeeffectwasoccasionallyobservedwithmilkthistlepreparations.Twocasesofanaphylacticshockhavebeenreported.

Dosage Doseperday* Doseperweek*

4.5-8.5mlof1:1liquidextract

30-60mlof1:1liquidextract

4.5-8.5mlof1:1glycetract

30-60mlof1:1glycetract

Extractsprovidingquantifiedlevelsofsilymarin-silybinarerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan25mg/mlsilymarin,andaqueousglycerolextractsshouldcontainnotlessthan10mg/mlsilymarin.

Higherdosesshouldbeusedinmoreseverecasesofliverdamage.

Milkthistleglycetractwouldbeappropriateforpatientswithliverdamageinwhomadditionalalcoholisnotadvisable.Becausetheabsorptionofsilymarinisenhancedbylecithin,simultaneouslecithinsupplementationisrecommended.

* ThisdoserangeisextrapolatedfromtheGermanCommissionEmonograph.1

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesincludeliverandgallbladderproblems,includingjaundice,hepatitis,andgallstones.2,3

PharmacologicResearch

Silymarinisahighlyconcentratedextractofmilkthistleseedthatcontainsupto80%flavanolignans,suchassilybin,silychristin,andsilydianin(collectivelydescribedassilymarin).Standardizedorquantifiedextractsofmilkthistleoftenexpressthelevelofflavanolignansas“calculatedassilybin.”Almostallofthepharmacologicandclinicalresearchhasbeenconductedusingthispreparation.However,basedondosageconsiderations,extrapolatingthisdatatotheuseofthegalenicalliquidextract(providedthattheextractcontainsatleast25mgofflavanolignansassilymarinperml)isreasonable.

•Intraperitonealadministrationofsilymarinincreasedtheredoxstateandthetotalglutathionecontentoftheliver,stomach,andintestine.

•Silymarinandsilybindemonstratedbothprophylacticandcurativehepatoprotectiveactivityagainstliverdamage(chemicals,heavymetals,deathcapmushroom[Amanitaphalloides],irradiation,andviruses)innumerousinvitroandinvivostudies,viaintraperitonealandoralroutes.Activityatthenuclearlevel(involvingRNAandDNA)isprobablythepredominantmechanism.Antioxidantactivitybyscavengingfreeradicalsisalsoinvolved.

•Silybincounteredtheacetominophen(paracetamol)-inducedreductioninbileflowandbilesaltoutput.

•Silybininhibitedthegrowthofhumanovarianandbreastcancercelllinesinvitroanddemonstratedasynergisticactionwiththeantineoplasticdrugscisplatinanddoxorubicin.TopicalapplicationofsilymarinprotectedagainstcarcinogenandultravioletlightB(UVB)–inducedskintumors.

•Oraldosesofsilymarinresultedinantiinflammatoryactivityincarrageenan-inducedratpawedema.Silybininhibitedarachidonicacidmetabolitesinvitro.

•Treatmentofdiabeticratswithsilybindidnotaffecthyperglycemiabutpreventedtheinhibitionofproteinmono-ADP-ribosylation.SilybintreatmenthelpedpreventsubstanceP–likeimmunoreactivitylossinthesciaticnerve,typicalofdiabeticneuropathy.

Theoraldosagesusedinthefollowingclinicalstudiesrangedfrom140to800mgperdayofsilymarin,with420mgperdaythemostcommonlyadministereddose.

•Silymarintreatmentsignificantlyreducedserumlevelsofhepaticenzymes,significantlyimprovedplateletcounts,andimprovednausea,discomfort,andskinitchinginpatientswithtoxicliverdamageofdifferingoriginsinuncontrolledtrials.

•Silymarinimprovedbiochemical,functional,andmorphologicalterationsintheliversofpatientswithslightacuteandsubacuteliverdiseaseinadouble-blind,placebo-controlled,clinicaltrial.

•Silymarinreducedlipoperoxidationofcellmembranesandinsulinresistanceandsignificantlydecreasedinsulinoverproductionandtheneedforinsulininacontrolledstudyinvolvingpatientswithinsulin-dependentdiabetesandalcoholiccirrhosis.

•Inothercontrolledstudiesinvolvingpatientswith

ClinicalStudies

alcoholicliverdisease,silymarindemonstratedsignificantreductionofhepaticenzymesandbilirubinandimprovementsinantioxidantandlipidperoxidationparameters.Otherstudiesreportedstatisticallyinsignificantimprovements,butcontinuingalcoholconsumptionmayhaveconfoundedtheexperimentalresults.

•Silymarintreatmentsignificantlyincreasedsurvivalratesinpatientswithcirrhosisofdifferentcauses(especiallyalcoholiccirrhosis)inlong-term,randomized,double-blindtrials.

•Well-controlledclinicalstudiesofthetreatmentofvarioustypesofhepatitiswithsilymarinhaveproducedmixedresults,withsomestudiesdemonstratingsignificantreductionsinserumliverenzymesandbilirubinandothersnot.

•Silymarin,givenpreoperativelyandpostoperatively,preventedtheincreaseofserumhepaticenzymesinducedbythetoxiceffectofgeneralanesthesia.

•Inarandomized,double-blind,placebo-controlledstudy,silymarinreducedthelipoperoxidativehepaticdamagethatoccursduringpsychotropicdrugtreatment.

•Silymarinimprovedliverfunctioninpatientswithoccupationaltoxicliverdamagecausedbyexposuretohalogenatedhydrocarbons,solvents,paints,andgluesinuncontrolledandplacebo-controlledtrials.

•Silymarinprotectedagainsthistologicchangesintheliversofpregnantwomenandthosetakingoralcontraceptives.

•Inbothcholelithiasisandcholecystectomizedpatients,silymarinreducedbiliarycholesterolconcentrationandbilesaturationcomparedwithplacebo.

•InGermany,theCommissionEsupportsusinggalenicalpreparationsofmilkthistletotreatdyspepticcomplaints.Extractsstandardizedtocontainatleast70%silymarinarerecommendedfortoxicliverdamage,assupportivetreatmentinchronicinflammatoryliverdisease,andforhepaticcirrhosis.1

•MilkthistleisofficialintheUSP24-NF19.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.MadausG.Lehrbuchderbiologischenheilmittel,BandI.GeorgOlmsVerlag,Hildesheim,Germany,1976.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.

MISTLETOE

OtherCommonName: EuropeanmistletoeBotanicalName: ViscumalbumFamily: ViscaceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Hypotensive,peripheralvasodilator,mildsedative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmistletoeinformulationsinthecontextof:

•Hypertension,tachycardia,cardiachypertrophy,atherosclerosis(5)

•Epilepsy,nervousexcitability(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

Noadverseeffectsexpected.

Eclecticpractitionersusedlargeandfrequentdosesofapreparationofthefreshplanttofacilitatelabor.1

SideEffects

Noneexpectediftakenwithintherecommendeddoserange.Areviewofdatacollectedfrom1985to1992indicatedthattheaccidentalingestionofmistletoeintheUnitedStatesisnotassociatedwithprofoundtoxicity.2Theonlyliteraturereferringtosideeffectsisforfreshmistletoeextractsgivenbyinjection.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Asagentlehypotensivesuitableforlong-termuse;hypertension,arteriosclerosis,nervoustachycardia,hypertensiveheadache,chorea3,4

•Epilepsy,5nervousexcitability6

AlthoughEclecticphysiciansreferredtotheuseofViscumalbum,whetherthisspecieswasactuallybeingusedisdebatable.ThesephysicianswereprobablyusingV.flavescens,whichisbotanicallydistinctfromV.album.

PharmacologicResearch

Driedmistletoeherbcontainslectins,proteins,andpolypeptides(viscotoxins),aswellaspolysaccharides,phenylpropanes,andlignans,7althoughtheconstituentsdependonthehosttreeonwhichthemistletoegrew,thelocation,andinwhichseasonitwasharvested.Mistletoeextractsvaryintheconstituentstheycontaindependingonthetypeofextractandtheprocessusedinmanufacture.8Aqueousalcoholicextractsareunlikelytocontainthelectinsorproteins,9andiftheviscotoxinsarepresent,theyaredecomposedinthegutandnotabsorbedintact.(Thisactionsubstantiallyreducesthepotentialtoxicityofmistletoeaqueousalcoholicextractswhentakenorally.)7

Theresultsofexperimentalstudiesintothehypotensiveactivityofmistletoearecontradictory.7Manystudies,10,11ifnotall,usedadministrationbyinjection.Aqueousextractswerethemostactive,andacomparativestudyindicatedthatthehighestactivitywasdemonstratedbyanextractofmistletoegrownonSalixspp.Suggested

mechanismsofactioninvolvedinhibitingtheexcitabilityofthemedullaoblongatavasomotorcenterandcholinomimeticactivity.(Thisstudymostlikelyusedadministrationbyinjection.)12

ClinicalStudies

Aqueousmistletoeextracts(whichcontainlectins)havebeenusedclinicallybyinjectionforimmunestimulationformanyyears,particularlyinEurope.TheconceptofusingfermentedmistletoeextractsforcancertherapywasadvocatedbyRudolfSteinerin1916.However,becausetheseextractsortheirisolatedconstituentswereadministeredbyinjection,theresultsarenotrelevanttotheclinicaluseoforalaqueousalcoholicextractsofmistletoeandhavenotbeenreportedhere.

REFERENCES

EllingwoodF,LloydJU.Americanmateriamedica,therapeuticsandpharmacognosy,ed11.Portland:EclecticMedicalPublications,1983.KrenzelokEP,JacobsenTD,AronisJ.AmJEmergMed.1997;15(5):516-520.WeissRF.Herbalmedicine,Englished.Beaconsfield,UK:BeaconsfieldPublishers,1988.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.LeclercH.Precisdephytotherapie,ed5.Paris:Masson,1983.BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.

KleijnenJ,KnipschildP.Phytomed.1994;1(3):255-260.PizzornoJE,MurrayMT,editors.Atextbookofnaturalmedicine,ed2,Edinburgh:ChurchillLivingstone,1999.

10FukunagaT,etal.YakugakuZasshi.1989;109(8):600-605.11BeckerH.DtschApothZtg.1986;126:1229.12PetkovV.AmJChinMed.1979;7:197-236.

MOTHERWORT

BotanicalName: LeonuruscardiacaFamily: LabiataePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

ActionsNervinetonic,cardiotonic,hypotensive,antiarrhythmic,antithyroid,spasmolytic,emmenagogue

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmotherwortinformulationsinthecontextof:

•Adjuvanttherapyforhyperthyroidism(4,6)

•Nervouscardiacdisorderssuchaspalpitations(4,5)

•Coronaryheartdisease(4)

•Anxiety,neuralgia,chorea(5)

•Amenorrhea,dysmenorrhea,ovarianpain(5)Contraindications Pregnancy.1

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancy.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2.0-3.5mlof1:2liquidextract

15-25mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Heartdisease,cardiacdebility,tachycardia,effortsyndrome2

•Femalereproductiveproblems,includingamenorrhea,uterine,andperiodpain3

•Nervousconditions,hysteria,chorea(characterizedbyinvoluntary,jerkymovements),neuralgia,spinaldisorders3

•Antithyroidactivityformildhyperthyroidism4

MotherwortisconsideredinEuropeanherbalmedicineashavingantithyroidactivity.Beinglesspowerfulthanorthodoxdrugs,motherwortisusedformildthyroidhyperfunctionandcanbeusedforlongtermtreatment.4

PharmacologicResearch

•Motherwortextractsdemonstratedhypotensiveactivitywhenadministeredbyinjectioninnormalandhypertensiveexperimentalmodels.5

•Inearlyresearch,amildsedativeeffectwasdemonstratedformotherwortextracts.Theeffectonintestineanduteruswasveryslightstimulation.6Motherwortextracthasalsodemonstratedantispasmodicactivity.7

•Leonurine,analkaloidpresentinmotherwort,isdescribedastheuterotonicprincipleoftheLeonurusspeciesusedinTCM.8,9

•FromChineseresearch,anundefinedspeciesofLeonurusbyinjectiondecreasedthedevelopmentofacuteischemiccerebraledemaandreduceddisordersofmonoaminemetabolismandmortalityinanexperimentalmodel.10

ClinicalStudies

•MotherworthasbeenusedinChinaintreatingcoronaryheartdiseasewithfavorableresults.ThespeciesofLeonurusandrouteofadministrationwereundefined.10

•InGermany,theCommissionEsupportsusingmotherworttotreatnervouscardiacdisordersandasanadjuvanttherapyforthyroidhyperfunction.11

REFERENCES

BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983WeissRF.Herbalmedicine,Englished.Beaconsfield,UK:BeaconsfieldPublishers,1988.ArustamovaFA.IzvAkadNaukArmSSRBiolNauki.1963;16(7):47-52.ErspamerLV.ArchIntPharmacodyn.1948;76:132-152.IsaevI,BojadzievaM.NauchniTrVisshiyaMedInstSofiya.1960;37(5):145-152.

ChengKF,etal.Experientia.1979;35(5):571-572.KongYC,etal.AmJChinMed.1976;4(4):373-382.

10KuangPG,etal.JTraditChinMed.1988;8(1):37-40.11BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

MULLEIN

BotanicalName: VerbascumthapsusFamily: ScrophulariaceaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Expectorant,demulcent,anticatarrhal,vulnerary

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmulleininformulationsinthecontextof:

•Acuteorchronicbronchitis,tracheitis,thecommoncold,influenza,respiratorycatarrh,tonsillitis(5)

•Gastrointestinalconditionsrequiringdemulcency,suchasulceration,diarrhea,andhemorrhoids(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

4.5-8.5mlof1:2liquidextract

30-60mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Bronchitis,particularlywithhardcough;thecommoncold,influenza,respiratorycatarrh,inflammationofthelarynxortrachea,tuberculosis1,2

•Diarrhea,dysentery,hemorrhoids2,intestinalbleeding3

•Asapoulticeforsorethroat,tonsillitis,mumps2;oilinfusiontopicallyforinflamedmucosa,hemorrhoids,ulcers1,2

NativeAmericansusedmulleinleafmainlyinexternalapplicationsandsmokedtorelieveasthmaandsorethroat.Otherusesincludedinhalationoffumesfromsmokesmudgeforcatarrhandasaleafpoulticeforpain,swelling,sprains,bruises,wounds,andheadache.MulleinleafwasofficialintheNFfrom1916to1936andwasusedasademulcentandemollient.4

PharmacologicResearch

Nopharmacologicinformationhasbeenfoundformulleinleaf.

ClinicalStudies Noclinicalstudiesusingmulleinleafhavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.

Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

MYRRH

BotanicalNames: Commiphoramolmol,Commiphoramyrrha+

OtherspeciesofCommiphorawithcomparablechemicalcompositionmaybeused.

Family: BurseraceaePlantPartUsed: Resin(oleo-gumresin)obtainedfromthestem

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Astringent,antimicrobial,antibacterial,antiinflammatory,vulnerary

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingmyrrhinformulationsinthecontextof:

•Chronicbronchitis,thecommoncold,chroniccatarrh;inflammationofthemouthandthroat(5)

•Gastritis,dyspepsia;amenorrhea,leukorrhea(5)

•Topicaltreatmentforinflammationsofthemouthandthroat,skininflammations,wounds,abrasions(4,5)

ContraindicationsKnownallergy.

AccordingtoTCM,myrrhiscontraindicatedinpregnancyandincasesofexcessiveuterinebleeding.1

WarningsandPrecautions

Dependingonthelevelofdilutionofthetincture,atransientburningsensationontheskinormucousmembranesmaybeexperienced.

Myrrhshouldnotbeingestedforprolongedperiods(morethanafewweeks)becauseofthepotentialofallergiccontactdermatitis.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancy.

Allergiccontactdermatitishasbeenreportedfrom

SideEffects usingmyrrh.2,3Forthisreason,internaluseshouldberestrictedtoshort-termuse.

Dosage Doseperday* Doseperweek*

1.5-4.5mlof1:5tincture 10-30mlof1:5tincture

* This dose range is interpreted from the British Herbal Pharmacopoeia 1983, BritishPharmaceuticalCodex1934and1973,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Mouthulcers,pharyngitis,gingivitis,laryngitis,respiratorycatarrh,thecommoncold,chroniccatarrh,bronchitis,excessivemucoussecretion,boils4,5

•Chronicgastritis,atonicdyspepsia;amenorrhea,femalereproductivetractdisordersaccompaniedbyadraggingsensationandleukorrhea5

•Topicallyfordamagedgums,wounds,abrasions,poorlyhealingskinulcers,andsinusitis4-6

UsesandpropertiesfromTCMinclude:

•Invigoratingtheblood,dispersingcongealedblood,reducingswelling,andalleviatingpain;thususedtotreattrauma,sores,boils,swelling,abdominalmassesorpain,chestpain,amenorrhea1

•Topicallyforchronicpoorlyhealingsores1

TraditionalAyurvedicusesinclude:

•Dyspepsia,chlorosis(hypochromicanemia),amenorrhea,uterinedisorders,menstrualdisordersinyounggirls,chronicbronchitis,tuberculosis7

•Amouthwashformouthulcersandsorethroat7

Myrrholeo-gumresincontainsanessentialoilcontainingsesquiterpenesandaresinfractioncontaining

PharmacologicResearch

commiphoricacidsandesters.8

•Asesquiterpenefractionfrommyrrh(amixtureoffuranodiene-6-oneandmethoxyfuranoguaia-9-ene-8-one)demonstratedlocalanestheticactivityinvivoandshowedantibacterialandantifungalactivityagainststandardpathogenicstrainsofEscherichiacoli,Staphylococcusaureus,Pseudomonasaeruginosa,andCandidaalbicans,withminimuminhibitoryconcentrationsrangingfrom0.18to2.8g/ml.9

•Myrrhincreasedglucosetoleranceinvivounderbothnormalanddiabeticconditions.10Twofuranosesquiterpenesisolatedfrommyrrhexhibitedhypoglycemicactivityinanexperimentalmodelofdiabetes.11

•Myrrhexhibitedstrongantithromboticactivityinvivo.12

•Pretreatmentwithanaqueoussuspensionofmyrrh(250to1000mg/ml)protectedagainsttheulcerogeniceffectsofseveralnecrotizingagents,includingethanolandindomethacin.Theprotectiveeffectofmyrrhwasattributedtoitseffectonmucusproductionandanincreaseinnucleicacidandnon-proteinsulfhydrylconcentrations,whichappearstobemediatedthroughitsfreeradical–scavenging,thyroid-stimulating,andprostaglandin-inducingproperties.13

•Petroleumetherextractofmyrrh(500mg/kg,oralroute)producedsignificantantiinflammatoryactivityincarrageenan-inducedinflammationandcottonpelletgranulomamodels.Antipyreticactivitywasalsoobservedinvivo.14Myrrhdemonstratedsignificantantiinflammatoryactivityinthefollowingexperimentalmodels:xylene-inducedearedema(400mg/kgpretreatmentbyinjection)andcottonpelletgranuloma(400mg/kg,oral).15

•Ananalgesicactivitywasdemonstratedafteroraladministrationofmyrrhinvivo.Theactiveanalgesiccompoundswereidentifiedastwosesquiterpenes,particularlyfuranoeudesma-1,3-diene.Thiscompoundwasshowntobindtoopioidreceptorsinisolatedbrainmembrane.Naloxone,anopioidantagonist,completelyinhibitedtheanalgesiceffectofthiscompoundbyinjectioninvivo.Furanoeudesma-1,3-dieneexhibitedstructuralsimilaritieswithtwoopioidagonists(morphiceptinandDPDPE).16,17

•TreatmentwithmyrrhwasfoundtohaveananticarcinogeniceffectinvivoonsolidtumorsinducedbyEhrlichcarcinomacells.Theactivitywascomparabletothestandardcytotoxicdrugcyclophosphamideandwasmorepronouncedafter25dayscomparedwith50daysoftreatment.18,19Anotherstudyfoundthatpretreatmentwithmyrrhdidnotalterthebiochemicalandcytologiceffectsofcyclophosphamideanddidnotshowanyadditiveeffect.20

•Bothanextractandafractionofmyrrhstimulatedphagocytosisinvivoafterintraperitonealinjection.21

ClinicalStudies

Noclinicalstudiesusingmyrrhhavebeenfound.

•InGermany,theCommissionEsupportsusingmyrrhtopicallytotreatmildinflammationsoftheoralandpharyngealmucosa.22

•ESCOPrecommendsmyrrhforthetopicaltreatmentofgingivitis,stomatitis(mouthulcers),minorskininflammations,minorwounds,andabrasionsandasasupportivetreatmentforpharyngitisandtonsillitis.23

REFERENCES

BenskyD,GambleA.Chineseherbalmedicinemateria

medica.Seattle:EastlandPress,1986.Al-SuwaidanSN,etal.ContactDermatitis.1998;39(3):137.GalloR,etal.ContactDermatitis.1999;41(4):230-231.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW.Theeclecticmateriamedica,pharmacologyandtherapeutics.Portland:EclecticMedicalPublications,1922.reprinted1983BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.DolaraP,etal.PlantaMed.2000;66(4):356-358.

10Al-AwadiFM,GumaaKA.ActaDiabetolLat.1987;24(1):37-41.

11UbillasRP,etal.PlantaMed.1999;65(8):778-779.12OlajideOA.PhytotherRes.1999;13(3):231-232.13al-HarbiMM,etal.JEthnopharmacol.1997;55(2):141-150.14TariqM,etal.AgentsActions.1986;17(3-4):381-382.15AttaAH,AlkofahiA.JEthnopharmacol.1998;60:117-124.16DolaraP,etal.Nature.1996;379(6560):29.

17DolaraP,etal.PhytotherRes.1996;10(supp1):S81-S83.18al-HarbiMM,etal.Chemotherapy.1994;40(5):337-347.19QureshiS,etal.CancerChemotherPharmacol.1993;33(2):130-138.

20al-HarbiMM,etal.AmJChinMed.1994;22(1):77-82.21DelaveauP,LallouetteP,TessierAM.PlantaMed.1980;40(1):49-54.

22BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

23ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Myrrha.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,October1999.

NEEMLEAF

BotanicalNames:

Azadirachtaindica,Meliaazadirachta#

Note:Meliaazedarachisnotamedicinallyinterchangeablespecies.

Family: MeliaceaePlantPartUsed: Leaf

# Alternativename.

PRESCRIBINGINFORMATION

Actions

Antimicrobial,antifungal,antiviral,antipyretic,adaptogenic,antipruritic,antitussive,depurative,antiinflammatory,anxiolytic,emmenagogue,hypoglycemic,immune-enhancing

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingneemleafinformulationsinthecontextof:

•Diabetesmellitus(4)

•Psoriasis,incombinationwithtopicaltreatment(4)

•Skinconditions,fever,blooddisorders(5)

•Allergies,hypertension,gastrointestinaldisorders,hepatitis,cancer(6)

•Inflammatoryconditions,enhancingimmunity(7)

•Topicaltreatmentforscabies,aloneandincombinationwithturmeric(4)

•Topicaltreatmentforeczemaandringworminfection(4,5)

•Topicaltreatmentasacreamorpessaryforvaginosisresultingfrominfections,incombinationwithsaponinsfromSapindusmukorossiandanaromaticextractcalledcitrataoil(4)

•Topicaltreatmentforulcers,boils,andotherskinconditions(5)

Contraindications Useduringpregnancyandtreatmentsforinfertility(ofbothsexes)isnotrecommended.

WarningsandPrecautions

Extractsofneemleafshouldnotbetakenforprolongedperiodsathighdoses.Toxicologystudiesofleafextractsandsomeisolatedconstituents(limonoids)showaverylowtoxicity,especiallywhentakenorally.However,toxiceffectshavebeenobservedinanimalsgrazingonneemleaf.1

Interactions Noneknown.

UseinPregnancyandLactation

Giventheuncertainrelevancyoftheanimalexperiments,neemleafisbestavoidedduringpregnancy,especiallyinthefirsttrimester.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

1.5-3.5mlof1:2liquidextract

10-25mlof1:2liquidextract

* This dose range is extrapolated from traditional Ayurvedic medicine2 and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesofneemleafinclude:

•Asabittertonicandforbloodpurification3

•Skindiseases,fevers3

•Blooddisorders,eyediseases2

•Neuromuscularpain,diarrhea,hyperacidity,nausea;hepatitis,enlargedspleen4

•Asacoughsuppressant,tuberculosis;urinarydisorders,dysmenorrhea4

•Asanemmenagogue5

•Intestinalworminfestation,includingfilariasis4,5

•Venomousbites5

•Diabetes,hypertension,cancer,allergies4

•Topicallyforulcers,glandularswellings,boilsandotherskindiseases,suchaseczema,scabies,andpemphigus3,5,6

Indianmonksconsumedthejuiceoffreshgreenneemleavestosuppresssexualdesire.7Neemleafandleafoilareusedtraditionallyasaninsecticide,5,8butthemaininsecticidalactivityisfoundintheseeds.

TraditionalFijianmedicineusesincludeasthma,diabetes,

andsyphilis.9

Neemleafcontainslimonoids(includingaradirachtins)andsimpleterpenoids.10Limonoidsaremodifiedtriterpenes.

•Oraladministrationofneemleafextractreducedbloodsugarlevelsinnormalandstreptozocin-induceddiabeticmodels.11Thehypoglycemiceffectwascomparabletoglibenclamide(anantidiabeticdrug).12Pretreatmentwithneemleafpreventedtheriseinbloodglucoselevelscomparedwithcontroldiabeticanimals.12Neemleafextractdemonstratedanantihyperglycemiceffectagainstglucoseandepinephrine(adrenaline)-inducedmodelsofhyperglycemia13andblockedtheperipheralutilizationofglucoseandtheglycogenolyticeffectofepinephrineinnormalanddiabeticexperimentalmodels.14

•Theanxiolyticactivityofneemleafextract(upto200mg/kg)wascomparabletothatinducedbydiazepam(1mg/kg)afteroraladministration.15Neemleafextractdemonstratedanalgesic16andsedative17activityinvivoafterintraperitonealadministration.

•Aqueousextractsofneemleafdose-dependentlyreducedgastriculcerseverityinanimalssubjectedtostressanddecreasedethanol-inducedgastricmucosaldamage.Theextractappearedtopreventmastcelldegranulationandtoincreasetheamountofadherentgastricmucusinstressedrats.18

•Anaqueousextractofneemleafreducedelevationsofcholesterolandureaandattenuatedgastriculcerogenesisandsuppressionofhumoralimmuneresponseinexperimentalmodelsofstress.19

•Afteroraladministration,thewater-solubleportionofanalcoholextractofneemleafexhibitedantiinflammatoryactivityinthecottonpelletgranulomaassay.20Dose-

PharmacologicResearch

dependentantiinflammatoryactivitywasalsodemonstratedincarrageenan-inducedacuteinflammation(oral21andintraperitoneal22routes)andformaldehyde-inducedsubacuteinflammation(oralroute).21

•Anaqueousextractofneemleafaugmentedbothhumoralandcellmediatedimmuneresponsesafteroraladministration,23enhancedphagocyticactivityofmacrophagesbothinvitroandinvivo,andinducedexpressionofMHC-IIantigensonmacrophages.24Neemleaf(2g/kg,orally)enhancedantibodytitersagainstNewcastlediseasevirusantigeninchickensthathadsurvivedanoutbreakofinfectiousbursaldisease.25

•Neemleafextractdemonstratedaninhibitoryactionagainstawidespectrumofmicroorganismsinvitro,includingprotozoa(Plasmodiumfalciparum),26,27viruses,28-30bacteria31andfungi.32,33Theinvivoactivityofneemleafextractagainstmouseplasmodiawasnotconvincing.1

•AdministrationofanalcoholextractofneemleafduringtheearlyphaseoffeverdevelopmentreducedrectaltemperaturetonearnormalvaluesinEscherichiacoliendotoxin–inducedfever.Pretreatmentdidnotsignificantlyreducefever.34

•Amethanolextractofneemleafexhibiteddirectantimutagenicactivityinvitro.35Anaqueousextractinhibitedcyclophosphamide-andmitomycin-inducedchromosomalaberrationsafterintraperitonealadministration36andinhibitedchemicallyinducedoralsquamouscellcarcinomasafteroraladministration.37

•Histopathologicstudiesconfirmthatoraladministrationofanaqueousextractofneemleafprotectedagainstincreasesinserumliverenzymesinducedbyacetominophen(paracetamol).38,39Thisfindingdemonstrateshepatoprotectiveactivity.

•Oralpretreatmentwithneemleafextractdecreasedtheformationoflipidperoxidesandenhancedlevelsofantioxidantsanddetoxifyingenzymesinthestomach,liver,andcirculationofratstreatedwiththecarcinogenMNNG.40

•Neemleafextractgivenorallyattheearlypostimplantationstageterminatedpregnancyinrodentsandprimates.41Oraladministrationofaqueousneemleafextractdemonstratedantifertilityactivityinmalemice.42Neemleafpowderbytheoralrouteresultedinreversibleatrophicandbiochemicalchangesinmalereproductivetissueinvivo.43-45

•Morphologicchangesinspermatozoahavebeenobservedinratstreatedwithpowderedneemleaf,whichmaybetheresultofanantiandrogeniceffect.46Oraladministrationofaneemleafaqueousextractdecreasedserumtestosteronebutdidnotaffectthefertilityindexinmalerats.Afterintraperitonealadministration,aneemleaffractioncontainingpredominatelysteroidalcompoundsimpairedspermatogenesisandalteredthemorphologyandmotilityofsperma-tozoa,leadingtoareducedfertilityindex.7However,inanotherstudy,neemleafextractwasnotobservedtointerferewithspermatogenesisinmaleratsfedtheextract,butantiimplantationandabortifacienteffectswereobservedinfemalesmatedbythesemales.47

•Neemleafalcoholicextractproducedadose-dependenthypotensiveeffectinvivoafterintravenousadministration.48,49

•Inanuncontrolledtrial,patientswithdiabeteswereabletoreducetheirdoseofinsulinbyupto30%to50%(withoutsignificantchangesinbloodglucose)wheningestingneemleaf,whichwasprescribedeitheras5gofanaqueousleafpasteortheequivalentamountofdried

ClinicalStudies

leafincapsules.50

•Oralneemleafextractincombinationwithtopicalcoaltarreducederythema,desquamation,andinfiltrationofpsoriaticlesionsinpatientswithpsoriasisinanuncontrolledtrial.51

•PhaseIclinicaltrials,whichhavebeencompletedinIndia,Egypt,andtheDominicanRepublic,indicatethesafety,acceptability,andbeneficialactionofatopicalherbalformulationcontainingneemleaf,saponinsfromSapindusmukorossi,andanaromaticextractcalledcitrataoil,intreatinginfectiousvaginosis.52

•Inapoorlycontrolledclinicaltrial,animprovementwasobservedin16casesofacuteeczema,ringworminfection,andscabiesafterseveraldaysoftopicaltreatmentwithaconcentratedneemleafpreparation.Inthethreecasesofchroniceczema,responsewasslow,andimprovementoccurredafter15to20days.Applicationofthevehiclesolutionbyonepersonineachgroupbeforeneemtreatmentdidnotproduceanyeffect.53

•Topicaltreatmentwithfreshneemleaf(80%)andturmeric(20%)combinedinapastecured97%of814casesofscabieswithin3to15daysinanuncontrolledstudy.54

REFERENCES

vanderNatJM,etal.JEthnopharmacol.1991;35(1):1-24.KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinaland

AromaticPlants,1989.ChaturvediVS.NeeminAyurveda.Mumbai,India:ArogyaSansthan,1996.NadkarniAK.Dr.K.M.Nadkarni’sIndianmateriamedica,ed3.Bombay:PopularPrakashan,1976.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982ParshadO,etal.PhytotherRes.1997;11(2):168-170.WagnerH,etal,editors.Economicandmedicinalplantresearch.London:AcademicPress,1989.CambieRC,AshJ.Fijianmedicinalplants.Melbourne,Victoria,Australia:CSIROPublishing,1994.

10DaiJ,etal.JAgricFoodChem.2001;49(3):1169-1174.11ChattopadhyayRR.JEthnopharmacol.1999;67(3):367-372.12KhoslaP,etal.IndianJPhysiolPharmacol.2000;44(1):69-74.

13ChattopadhyayRR,etal.BullCalcuttaSchTropMed.1992;35:29-35.

14ChattopadhyayRR.GenPharmacol.1996;27(3):431-434.15JaiswalAK,BhattacharyaSK,AcharyaSB.IndianJExpBiol.1994;32(7):489-491.

16KhannaN,etal.IndianJExpBiol.1995;33(11):848-850.17ParshadO,YoungLE,YoungRE.PhytotherRes.1997;11(5):398-400.

18GargGP,NigamSK,OgleCW.PlantaMed.1993;59(3):215-217.

19SenP,MedriattaPK,RayA.IndianJExpBiol.1992;30(12):1170-1175.

20ChattopadhyayRR.IndianJExpBiol.1998;36(4):418-420.21KoleyKM,LalJ,TandanSK.Fitoterapia.1994;65(6):524-528.

22ChattopadhyayRR,etal.Fitoterapia.1994;65(2):146-148.23RayA,BanerjeeBD,SenP.IndianJExpBiol.1996;34(7):698-701.

24UpadhyayaS,DhawanS:Neem(Azadirachtaindica):immunomodulatorypropertiesandtherapeuticpotential,Bombay,February1994,abstractPR2,UpdateAyurveda.

25SadekarRD,etal.IndianJExpBiol.1998;36(11):1151-1153.

26RochanakijS,etal.SoutheastAsianJTropMedPublicHealth.1985;16(1):66-72.

27MacKinnonS,etal.JNatProd.1997;60(4):336-341.28BadamL,JoshiSP,BedekarSS.JCommunDis.1999;31(2):79-90.

29RaoAR,etal.IndianJMedRes.1969;57:495-502.30RaiA,SethiMS.IndianJAnimalSci.1972;42:1066-1070.31SohniYR,PadmajaK,BhattRM.JEthnopharmacol.1995;45(2):141-147.

32BhowmickBN,ChoudharyBK.IndianBotReport.1982;1:164-165.

33PantN,etal.Fitoterapia.1985;57:302-304.34AshorobiRB.PhytotherRes.1998;12(1):41-43.35KusamranWR,TepsuwanA,KupradinunP.MutatRes.1998;402(1-2):247-258.

36MukhopadhyayMJ,MukherjeeA.PhytotherRes.1998;12(6):409-412.

37BalasenthilS,etal.JEthnopharmacol.1999;67(2):189-195.38ChattopadhyayRR,etal.IndianJExpBiol.1992;30(8):738-740.

39BhanwraS,etal.IndianJPhysiolPharmacol.2000;44(1):64-68.

40ArivazhaganS,BalasenthilS,NaginiS.CellBiochemFunct.2000;18(1):17-21.

41TalwarGP,etal.AmJReprodImmunol.1997;37(6):485-491.

42DeshpandeVY,MendulkarKN,SadreNL.JPostgradMed.1980;26(3):167-170.

43KatsutriM,etal.IndianJPhysiolPharmacol.1997;41(3):234-240.

44KatsutriM,etal.IndianJExpBiol.1995;33(10):725-729.45JoshiAR,etal.IndianJExpBiol.1996;34(11):1091-1094.46AladakattiRH,AhamedRN.IndianJExpBiol.

1999;37(12):1251-1254.47ChoudharyDN,etal.IndianJExpBiol.1990;28(8):714-716.48KoleyKM,LalJ.IndianJPhysiolPharmacol.1994;38(3):223-225.

49ChattopadhyayRR.GenPharmacol.1997;28(3):449-451.50ShuklaR,SinghS,BhandariCR.MedSurg.1973;13:11-12.51PandeySS,JhaAK,KaurV.IndianJDermatolVenereolLeprol.1994;60:63.

52TalwarGP,etal.ImmunolCellBiol.1997;75(2):190-192.53SinghN,etal.Antiseptic.1979;70:677-680.54CharlesV,CharlesSX.TropGeogrMed.1992;44(1-2):178-181.

NETTLELEAF

OtherCommonName: NettlesBotanicalNames: Urticadioica,Urticaurens+

Family: UrticaceaePlantPartUsed: Leaf

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Antirheumatic,antiallergic,depurative,styptic(hemostatic)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingnettleleafinformulationsinthecontextof:

•Allergicrhinitis(2)

•Osteoarthritis,rheumatoidarthritis(4)

•Chronicskineruptions,especiallyeczema(5)

•Inflammatorydiseasesofthelowerurinarytract,preventionandtreatmentofkidneygravel(4,5)

•Internalbloodloss,includinguterinehemorrhage,melena(5)

•Topicaltreatmentfornosebleeds,burns,wounds,inflammationofthemouthandthroat(6)

Contraindications Patientswhoareallergictonettlestingsshouldnotapplythefreshorunprocesseddriedleavestopically.

WarningsandPrecautions

Inrarecases,nettleleafmaycauseallergicreactionsinsusceptiblepatients.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Hypersensitivityreactionstocontactwithnettlehavebeendocumented.Amanwhohaddevelopedacontactdermatitisaftertreatinghiseczemawithapoulticeofherbsincludingchamomilealsoexhibitedadiffuse

edematousgingivostomatitis;heregularlydranknettletea.Thisreactionwasbelievedtobeanallergiccontactreactiontothechamomileandthenettle(andnotanirritantreaction).

Dosage Doseperday* Doseperweek*

2-6mlof1:2liquidextract

15-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Cutaneouseruptions,particularlyeczemaofanervousorpsychologicoriginorthoseofachronicnatureandespeciallyinchildren1,2

•Chronicdiarrhea,dysentery,disordersofthebowelwithsecretionofmucus2

•Bloodlossincludinguterinehemorrhage,nosebleeds,melena1

•Bronchialorasthmaticconditions,3bladderdisorders,includingstones2

•Topically(bybeatingtheleavesorasapoultice)forrelievingjointpain(includingarthritis,rheumatism,gout,andsciatica),3,4burns,wounds,andinflammationofthemouthandthroat3

PharmacologicResearch

•Nettleleafextractoritsconstituentshavedemonstratedantiinflammatoryactivityinvitrobyinhibitingcyclooxygenase-and5-lipoxygenase–derivedreactions.

•Nettlehairsandwholeplantextractwerefoundtocontainhighlevelsofleukotrienes,aswellashistamine.Nettlehairsthereforeresembleinsectvenomsandcutaneousmastcellswithregardtotheirspectrumofmediators.

•ThesolubilityofthesiliconinnettleleafwasinvestigatedinaPolishstudy.A1:100decoctionofthe

driedleavessimmeredfor30minutesyieldsapproximately5mgofsolublesiliconforevery1gofnettleused.5

•Studieswithvolunteerssuggesttheimmediatereactiontonettlestingistheresultofhistamineintroducedbythenettle.Thepersistenceofthestingingsensationmaybecausedbythepresenceofsubstancesdirectlytoxictonervesorcapableofinducingsecondaryreleaseofothermediators.Acetylcholineispresentinthehairsandcontributestothestingingreaction.

•Lipopolysaccharide(LPS)stimulationofcytokinereleasefromthewholebloodofhealthyhumanvolunteerswasinvestigatedasanexperimentalmodel.Inthisassaysystem,LPSstimulationcausesanincreaseofTNF-αandinterleukin-1β(IL-1β)secretion,whichiscorrelatedwiththenumberofmonocytes-macrophagesinthebloodofeachvolunteer.Inconfirmationofpossibleantiinflammatoryactivity,nettleleafextractsignificantlyreducedthisreleaseofcytokinesinaconcentration-dependentmanner.Thenettleleafextractalsoindependentlystimulatedthesecretionofinterleukin-6(IL-6).BecauseIL-6actsantagonisticallytoIL-1βindecreasingprostaglandinE2synthesis,andinducesinhibitorsofproteinasesaswell,thisfindingmightalsoreflectafavorableantiinflammatoryresult.Phenolicacidderivativesandflavonoidsshowednoactivityinthisassay,thusthecytokineinhibitorycomponentsarecurrentlyunknown.

•Twentyhealthyvolunteersingested1.34gperdayofanettleleafextractfor21days.Althoughthenettleleafhadnoeffectonbasallevelsofcytokines,itdidsignificantlydecreasethereleaseofTNF-αandIL-1βafterLPSstimulationexvivo.However,theincreaseinIL-6,whichwasobservedinvitro,wasnotobservedafteroralingestion,confirmingthatinvitroresultsarenotnecessarilytranslatableintoclinicalfindings.Thisresultis

ClinicalStudies

probablybecausesomecompoundsintheplantexhibitpoorbioavailabilitiesafteroraldoses.

•Sixtyninevolunteerscompletedarandomized,double-blind,placebo-controlledstudyinvestigatingtheeffectofafreeze-driedpreparationofnettleleafonallergicrhinitis.Patientswereadvisedtotakenettleleaf(600mg)orplaceboattheonsetofsymptoms.Nettlewasratedhigherthanplacebointheglobalassessmentsbutwasonlyslightlyhigherindiarydataafter1week.

•Amulticenter,postmarketingsurveillancestudyexaminedthesafetyandtherapeuticbenefitofanettleleafpreparation(doseunknown)innearly9000patientswithosteoarthritisandrheumatoidarthritis.Aftera3-weekperiod,82%ofpatientsbelievedthatthetreatmenthadrelievedtheirsymptoms,38%indicatedthattheymighthavetheirNSAIDtherapyreduced,and26%nolongerrequiredNSAIDtherapy.

•SeveraluncontrolledstudieshaveindicatedthatusingnettleleafextractinconjunctionwithstandardNSAIDtherapymayachieveadosereductionofthelatterintreatingrheumaticcomplaints.Dosesequivalentto9.1gperdayofleafor50gperdaystewedfreshyoungleafwereprescribed.

•Thestingofnettleleafhasbeenshowntobebeneficialintreatingosteoarthriticpainatthebaseofthethumborindexfingerinarandomized,double-blind,controlled,crossovertrial.Nettleorplaceboleafwasstrokedoverthepainfulareadaily.6

•InGermany,theCommissionEsupportsusingnettleleafassupportivetherapyforrheumaticalimentsbyinternalandexternalapplication.Nettleleafisalsorecommendedinternallywithcopiousfluidintakeforinflammatorydiseasesofthelowerurinarytractandpreventionandtreatmentofkidneygravel.7

•ESCOPrecommendsnettleleafasanadjuvanttherapyforrheumaticconditionsandirrigationininflammatoryconditionsofthelowerurinarytract.8

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.SalesH.Culpeper’scompleteherbal&Englishphysician.Bath,UK:PitmanPress,1981.Reproducedfromanoriginaleditionpublishedin1826PiekosR,PaslawskaS.PlantaMed.1975;27(2):145-150.RandallC,etal.JRSocMed.2000;93(6):305-309.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Urticaefolium/herba.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.

NETTLEROOT

BotanicalNames: Urticadioica,Urticaurens+

Family: UrticaceaePlantPartUsed: Root

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Antiprostatic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingnettlerootinformulationsinthecontextof:

•Improvingurologicsymptomsinbenignprostatichyperplasia(2,4)

•Improvingurologicsymptomsinbenignprostatichyperplasia,incombinationwithsawpalmetto(2)

Contraindications Noneknown.

WarningsandPrecautions

TheCommissionEadvisesthatusingnettlerootforbenignprostatichyperplasia(BPH)shouldoccurunderprofessionalsupervision.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Occasional,mildgastrointestinaldiscomfortmayoccurfromingestingnettleroot.

Dosage Doseperday* Doseperweek*

4.5-8.5mlof1:2liquidextract

30-60mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Similarusestothosefornettleleaf,includingcutaneousskineruptions,hemorrhages,andparticularlyboweldisorders2

•Asthma3

PharmacologicResearch

•Severalstudieshaveindicatedthatthelignansintherootofnettleinhibitedthebindingactivityofhumansexhormonebindingglobulin(SHBG)invitro.

•Fivesubfractionsofanaqueous-methanolicextractofnettlerootinhibitedcellularproliferationinBPHtissue.AreductioninthecellularproliferationofBPHtissuewasobservedexvivoaftertreatingpatientswithanaqueous-methanolicnettlerootextract.

•Nettlerootextractwasshowntobeaveryweakinhibitorof5-α-reductase(whichconvertstestosteroneinto5-α-DHT)invitro.AmildinhibitionofDHTbindingtocytosolicandrogenreceptorsinisolatedratprostatewasobserved

•Otherinvitrostudiesindicatedthatnettlerootinhibitedaromatase(whichconvertstestosteroneintoestradiol).Apharmacologiceffectfornettlerootfromthelipophiliccompoundsinnettlemightoccurinfattytissueswhereandrogensarearomatized.Nettlerootandsawpalmettoeachinhibitaromatasebyadifferentmechanism.

•Nettlerootextractdemonstratedaspecificanddose-

dependentinhibitionofhumanleukocyteelastase(HLE)invitro.(ThepresenceoftheproteolyticenzymeHLEinseminalplasmaisanimportantmarkerinclinicallysilentgenitourinarytractinfectionorinflammation.)

•OraladministrationoffivenettlerootextractswastestedinexperimentallyinducedBPH.Themethanolicextractdemonstratedthegreatestinhibitionofprostategrowthcomparedwithcontrols.

•Urticadioicaagglutinin(UDA),asmall,single-chainlectin,demonstratedantifungal,antiviral,cytotoxic,immunomodulatory,andanticanceractivities,mainlyinvitroorinvivo(byinjection).However,suchactivitiesareuncertainfornormaloraldosesofnettlerootpreparationsresultingfromthepoorbioavailabilityofUDA.AninvitrostudyhasshownthatUDAbindstocellmembranesofsmoothmuscleandepithelialcellswithinBPHtissue.

•MorphologicstudiesofBPHcellswereconductedin31patientstreatedwithnettlerootextract(equivalentto6g/dayofroot)for20weeks.TheobservedchangesinthenucleusandcytoplasmofprostatecellsmayhavebeentheresultofinhibitionofthebindingcapacityofSHBG.Inarandomized,double-blind,placebo-controlledtrial,3months’improvementofInternationalProstateSymptomScore(IPSS)andamoderatereductionofresidualurinevolume.4

•Inanumberofuncontrolledclinicaltrialsconductedfrom1979to1988,nettlerootextract(equivalentto3to6g/dayofroot)administeredfor3weeksto20monthsdemonstratedimprovementinurologicsymptomsinpatientswithBPH.

•Long-termtreatmentover8to10yearsof226patientswithBPHfoundthattherapywithnettlerootextractwasabletomaintainmorethan50%ofpatientswithouttheneedforsurgery.Afterlongtermtreatment,theusual

ClinicalStudies

enlargementoftheprostatewasnotevident.

•Inarandomized,controlled,opentrial,thezinc,calcium,andsodiumlevelsinprostaticsecretionsfrompatientswithBPHwereinvestigated.Theauthorsconcludedthatnettlerootextract(equivalent9g/dayofrootfor7days)mayalterthezinc-testosteronemetabolismandlowerzincsecretioninadenomatoustissue.

•Sixtysevenpatientsexperiencedareductionofnocturnalmicturitionfrequencyafter6monthsoftreatmentwithnettleroottincture(equivalentto1g/dayofroot).Inpatientswithamildcondition,symptomswererelievedwithinapproximately3weeks.

•Nettlerootextract(equivalentto3g/dayofrootfor6to9weeks)improvedthesymptomsofBPHintwodouble-blind,placebo-controlledtrials.

•Inaplacebo-controlled,clinicaltrial,40patientswithBPHweretreatedwithcombinednettlerootandsawpalmettoextractorplaceboover24weeks.Significantimprovementinsymptomswasobservedintheherbaltreatmentgroupcomparedwithplacebo.Thedailydosewasequivalentto2.4gperdayofnettlerootand2.9gperdayofsawpalmettoberries.

•Inarandomized,double-blind,multicenter,clinicaltrial,theefficacyofcombinednettlerootandsawpalmettoextractwascomparedwiththedrugfinasterideintreatingBPHstagesItoIIover48weeks.ImprovementsinIPSSandpeakurinaryflowwereobservedforbothgroups.Althoughnosignificantdifferencewasdemonstratedbetweenthetwotreatments,feweradverseeventswerereportedfortheherbalcombination,especiallyintermsofdiminishedejaculationvolume,erectiledysfunction,andheadache.Theherbaltreatmentwasevaluatedasmorecosteffective.Thedailydosewasequivalentto2.4gperdayofnettlerootand2.9gperdayofsawpalmetto

berries.

•InGermany,theCommissionEsupportsusingnettlerootfortreatingdifficulturinationinBPHstagesIandII.1

•ESCOPrecommendsnettlerootforthesymptomatictreatingofmicturitiondisorders(e.g.,nocturia,dysuria,urineretention)inBHPstagesIandII.5

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.EngelmannU,BoosG,KresH.UrologeB.1996;36(4):287-291.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Urticaeradix.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,

UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

OATS

BotanicalName: Avenasativa

Family: GramineaePlantPartsUsed:

Oatsseed:matureseedGreenoats:aerialparts,includingseedattheimmature,milkystage

PRESCRIBINGINFORMATION

Actions Oatsseed:nervinetonic,tonic,thymoleptic Greenoats:nervinetonic,anxiolytic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingoatsseedinformulationsinthecontextof:

•Nervoussystemsupportduringnicotinewithdrawal(resultsareconflicting)(3)

•Nervousexhaustionandconditionsresultingfromnervousexhaustion,suchasinsomnia,feverishconditions;generaldebility,convalescence;depression,menopausalneurasthenia(5)

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinggreenoatsinformulationsinthecontextof:

•Nervoussystemsupportduringnicotinewithdrawal(resultsareconflicting)(2)

•Nervoussystemsupportduringdrugusewithdrawal(4)

•Nervousexhaustion(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Oatsseed: Doseperday* Doseperweek*

3-6mlof1:1liquidextract

20-40mlof1:1liquidextract

Greenoats: Doseperday** Doseperweek**

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

** This dose range is extrapolated from King’s American Dispensatory 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesofoatsseedinclude:

•Depression,menopausalneurasthenia,generaldebility1

•Spermatorrhea2

•Nervousprostration,nervousexhaustionresultingfromtyphoidandotherfevers,insomniaresultingfromnervousexhaustion2

•Enfeebledstatesoftheheartmuscle,actingasatonicandimprovingtheenergyoftheheart2

TraditionalWesternherbalmedicineusesofgreenoatsincludecalmingandregeneratingthenervoussystem.3

Greenoatsextractisrecordedinashavinglittleeffectinassistingwithopiumwithdrawal.2

PharmacologicResearch

•Freshgreenplanttinctureadministeredbystomachtubeorintraperitonealinjectionantagonizedtheanalgesiceffectofmorphineintwoseparatetests.Extractsdilutedwithwater,exposedtolight,andallowedtostandfor2weeksresultedinreducedactivity.Extractsoffreshgreenplantweresuperiortotheseed.Driedbrownleavesshowedlittleactivity.Whenmorphineandfreshplanttincturewerechronicallyadministeredtogether,physicaldependenceonmorphinewasreduced.(Thegreenoatstincturewasadministeredbystomachtube.)Thepressorresponsetointravenouslyadministerednicotineinanesthetizedratswasantagonizedbypriorinjectionoffreshgreenplanttincture.4

•Resultsfromacontrolledexperimentalstudysuggestthatoatsextract(chaff)preventedatherosclerosis.Oatchaffextractproducedamorefavorablebloodlipidprofilecomparedwithcontrolanimalsandareductionintheformationofatheroscleroticplaques.5

ClinicalStudies

•Treatingopiumaddictionbygreenoatsmayhaveoriginatedfromhomeopathy.6

•Inarandomized,placebo-controlled,clinicalstudyinvolvinghealthyvolunteersandbronchialpatientswhowerehabitualsmokers,thosegivengreenoatsextractachievedasignificantreductionintobaccousecomparedwithcontrols.Thereductionwasstillobserved2monthslater.Atincturemadefromfreshwholeoatsplant(1:5,90%ethanol)wasprescribedatadosageof1mlfourtimesperdayforaperiodof28days.7Theseresultswerenotreplicatedinalatercontrolledtrial.8

•Greenoatsplantjuiceinalcoholwasineffectiveforreducingcigarettecravingsinanuncontrolledtrialinvolving76patients.Theoatsextractanddosagewerethesameasthoseinthepreviouslynotedtrialforthefirst2monthsbutwerethenaltered.Forthefollowing2months,1Lofplantjuicewasaddedto500mlof90%ethanolandwasnotdilutedwithwateruntiljustbeforeadministrationtothepatient.Theauthornotedthatoatshadbeeneffectiveingeneralpractice(byminimizingcigarettecravings)onseveraloccasionswhenpatientsreallywantedtogiveupsmoking,butitwasonlyonefeatureofthetotaltherapeuticapproachused.9

•Oatsseedextract(15ml/dayof1:2extract)containingmalicacid(forflavoring)prescribedinapplejuiceproducedareductionof66%indailycigaretteconsumptioncomparedwithnochangeforthosereceivingplacebo(applejuicealone).10

•Inadouble-blindstudyinvolvingparticipantswantingtostopsmoking,nosignificantdifferencewasobservedbetweenthosetreatedwithgreenoatsextract(equivalentto1.2g/dayfreshoatplant)comparedwithaplacebogroup(approximately35%stoppedsmokinginbothgroups).Inboththeplaceboandoatsgroups,thelightsmokersstoppedsmokingatahigherratethanthosewithahighconsumptionofcigarettes.11Inasingle-blind,placebo-controlledstudy,oatsextractdidnotproduceareductionintobaccousebysmokerswhowerenotattemptingtoquit.Theoatsextract(1:5,90%ethanol)wasmadefromagreenplantwithfull-sizedearsandaripeplantdugup1weekbeforeharvest(rootsincluded).Thedosewas1mlfourtimesperday.12

•Inaclinicalstudyconductedin1968to1969,6outof10chronicopiumaddictsgaveupthedrugaftertreatmentwithgreenoats(27to45days).Twoaddictsreducedtheirintake.Thestatuswasmaintainedonfollow-ups(3to19monthslater).Noseriouswithdrawalsymptomsorsideeffectswerenoted.13Theadministereddosewas2mlthreetimesperdayoftincturemadefromfreshwholeplantexcludingroot(1.5:5,90%ethanol).

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelA.Thenaturedoctor.Teufen,Switzerland:VerlagA.Vogel,1977.ConnorJ,etal.JPharmPharmac.1975;27(2):92-98.

JuzwiakS,etal.HerbaPolonica.1994;40(1-2):50-58.JackRA.BrMedJ.1971;4(778):48.AnandCL.Nature.1971;233(5320):496.GeckelerK,SchmidtK,SchmidtF.MunchMedWochenschr.1974;116(11):581-582.GabrynowiczJW.MedJAust.1974;2(8):306-307.

10NetherlandsPatent7412625,1976.11SchmidtK,GeckelerK.IntJClinPharmacol.1976;14(3):214-216.

12ByeC,etal.Nature.1974;252(5484):580-581.13AnandCL.BrMedJ.1971;3(775):640.

OLIVELEAF

BotanicalName: OleaeuropaeaFamily: OleaceaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Hypotensive,antioxidant,bittertonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingoliveleafinformulationsinthecontextof:

•Hypertension(4,6)

•Anginapectoris(6)

•Possibleusesforgoutandfluidretention(4)

Themuch-publicizedclinicalantibacterialandantiviralactivitiesofoliveleafarenotsupportedbyarationalanalysisofthepharmacologicdata.Evenifanyclinicalimprovementininfectedpatientsafterusingoliveleafwasdefinitelyestablishedbycontrolledclinicaltrials,thiswouldnotbeproofofantimicrobialactivitybecauseothermechanismsofaction(suchasimmune-enhancingactivity)mightapply.

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Traditionalsourcesindicatethatoliveleafmaycausegastricupset,thusitshouldbetakenbeforemeals.1

Dosage Doseperday* Doseperweek*

3.5-7.0mlof1:2liquidextract

25-50mlof1:2liquidextract

* Thisdoserangeisextrapolatedfromtraditionaluse.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Forloweringbloodpressure;angina,possiblyassociatedwithhypertension2

•Cough,3obstinatefever,4intermittentfever5

•Asadiuretic,febrifuge,emmenagogue3

•Asaliverstimulant6;forstomachacheresultingfromacidity6

•Topicallyforsnakebite,mouthulcers3

TraditionalSouthAfricanmedicinalusesinclude:

•Asahypotensiveandtoenhancerenalfunction7

•Scrofula,intermittentfevers8

Keyconstituentsoftheoliveleaf(driedleaf)includeiridoidglycosides(oleuropein6%to9%)andflavonoids.9Inthe1960s,elenolicacid(calciumelenolate)wasisolatedfromaqueousextractsofvariouspartsofoliveplantaftermildacidhydrolysis.Variousagentscanhydrolyzeoleuropeintoproduceelenolicacidandhydroxytryrosol.Thishydrolysisalsooccursovertimeinherballiquidextracts.Hydroxytyrosolisanantioxidantconstituentofolivefruitandoliveoil.Oleuropeosideisalsoreferredtointheliterature,andthiscompoundmaybeidenticaltooleuropein(thishasnotbeenverified).

•Oliveleafextractexhibitedantihypertensiveactivityafteroraladministrationinanexperimentalmodelofhypertension.10Oleuropeinhasbeenshowntoreducebloodpressureinbothnormotensiveandhypertensivemodelsafterinjection.11

•Adecoctionofoliveleafcausedrelaxationofisolatedaortapreparations.Oleuropeosidewasshowntobeoneoftheconstituentsresponsibleforthisvasodilatingaction.12

•Oleuropeinincreasedcoronaryflowinisolatedheartpreparationsinvitro.Byinjection,oleuropeindecreasedchangesintheelectrocar-diogram(ECG)resultingfrompituitrin-inducedcoronaryspasm,indicatingcoronaryvasodilation.Oleuropeindemonstratedantiarrhythmicactivityinanumberofexperimentalmodelsafterinjection.11

•AnaqueousextractofoliveleafinhibitedACEinvitro.AstrongACEinhibitor,oleacein,wasisolatedfromoliveleaf.13

•Hypoglycemic,hypoinsulinemic,andhypocholesterolemicactivitiesweredemonstratedafteroraladministrationofaleafdecoctionofOleaeuropeavar.oleastertoratspronetodevelopobesity,insulin-resistance,hyperlipidemia,anddiabetes.14,15Oliveleaftreatmentalsoreducedcapillarywallthickeningintheskinandpancreasandpreventedthiseventinthekidney.15Thehypocholesterolemiceffectofoliveleafwassuperiortothatofsimvastatin(ahypocholesterolemicdrug).14

•Long-termadministrationofoliveleaf(routeunknown)decreasedtissueinjury,urea,cholesterol,aspartatetransaminase,andalaninetransaminaselevelsraisedbystreptozotocininanexperimentalmodelofdiabetes.16Oliveleafandoleuropeosideexhibitedhypoglycemicandantidiabeticactivityinvivo.17

PharmacologicResearch

•Anaqueousextractofoliveleafexhibitedantiinflammatoryactivityincarrageenan-inducededemaandprotectedagainstaspirin-inducedgastriculcers.Atlowdoses,oliveleafstimulatedthecentralnervoussystem,butathighdosesitcausedcentralnervoussystemdepression.18

•Topicalapplicationofoleuropeininhibitedexperimentallyinducededema.Oleuropeinalsostronglyinhibitedtheenzymemyeloperoxidase,whichisamarkeroftheaccumulationofneutrophilsininflamedtissue.19

•Oliveleafextractandisolatedflavonoidsinhibitedtheclassicalpathwayofthecomplementsysteminvitrobuthadnoeffectonthealternativepathway.20Oleuropeininhibitedleukocyte5-lipoxygenaseinvitro.21

•Oleuropeindose-dependentlyenhancednitriteproductioninLPS-challengedmacrophages.Anitricoxide(NO)synthaseinhibitorblockedthiseffect.OleuropeinalsoincreasedexpressionofNOsynthaseinmacrophages.Theseresultssuggestthatoleuropeinpotentiatesmacrophageresponseduringendotoxinchallenge,resultinginhigherNOproduction,whichisbelievedtobebeneficialforcellularprotection.22

•Oleuropeindemonstratedantioxidantactivityinvitro.23,24Oliveleafextractwasalsoantioxidantinvitroandtheactivitywasattributedtoitsoleuropeincontentandtoalesserextenttheflavonoidcontent.25Consumptionofoliveoilcontainingoleuropeinaglyconeandhydroxytyrosolresultedinadose-dependentreductionintheurinaryexcretionof8-iso-prostaglandinF2α(amarkerofoxidativestress)involunteers.26

•Dietaryoleuropeinreducedplasmalevelsoftotal,free,andestercholesterolandincreasedtheabilityofLDLtoresistoxidationinanexperimentalmodel.27

•Hydroxytyrosoldemonstratedbroadantimicrobialactivityinvitroagainstarangeofbacteriaknowntocauseintestinalorrespiratorytractinfectionsinhumans.Oleuropeininhibitedseveralofthesestrainsbutwaslessactivethanhydroxytyrosol.28Inotherinvitrostudies,oleuropeininhibitedthegrowthofanumberofpathogenicbacteria,29-31theproductionofStaphylococcusaureusenterotoxinB,31andthegerminationandoutgrowthofBacilluscereusTspores.32CalciumelenolateexhibitedvirucidalactivityagainstavarietyofRNAandDNAvirusesinvitro,33-35includingmembersofmostofthegroupsofinfluenzaandparainfluenzaviruses.Virucidalactivityandareductioninviralyieldweredemonstratedinvivoafterintranasaladministrationtoanimalsinfectedwithparainfluenza-3virus.36

•However,noinvivostudiesorrigorousclinicalstudieshavebeenfounddemonstratingantimicrobialactivityfororaldosesofoliveleafextractoroleuropein.Claimsmadeinthepopularmediaandbycertainmanufacturerssuggestingthatoliveleafhasextensiveantibacterialandantiviralactions,withtheabilitytotreatawidevarietyofmicrobialillnessesarepotentiallydangerous,unsupported,andrepresentconsiderableextrapolationsfromthepreviouslyoutlinedinvitroactivityasfollows.Suchclaimsarebasedonextrapolatingactivityfromonevirustypetoalltypesofviruses,frominvitroactivitytoinvivoactivityinhumans(withnoconsiderationofdosageissues),andfromtheactivityofcalciumelenolatetotheactivityofoliveleafextracts.Theonlyevidenceofactivityinhumansisfromanecdotalreportsandacollectionofcasereportsinappropriatelypresentedasaclinicaltrial(seethe“ClinicalStudies”sectioninthismonograph).

•Oliveleafdecreasedsystolicanddiastolicbloodpressure,glycemia,andcalcemiafrombaselinevaluesintwogroupsofpatientswithmoderateessential

ClinicalStudies

hypertension.Onaverage,totalreductionswereapproximately18mmHgforsystolicbloodpressuresandapproximately10mmHgfordiastolicbloodpressures.Onegroupofpatientswaspresentingforthefirsttime,andtheothergroupwasalreadyreceivingantihypertensivemedication(whichwasgraduallywithdrawn2weeksbeforebeginningthestudy).Thetrialwasofsingle-blinddesign;for2weeks,aplacebowasprescribedfollowedby3months’(1600mg/day).37

•Oliveleafinfusioncausedmarkeddiuresisinhypertensivepatients.38Administeringoliveleafinfusionordecoctionfor20to25daysto10patientsincreaseddailyurinaryoutput,butbloodpotassium,sodium,andchlorideremainedunchangedinmostcases.Blooduricacidwasdecreased,especiallyinhyperuricemiccases.39

•Oliveleafconcentratedextractwasclaimedtoproducebeneficialantimicrobialeffectsin500Hungarianpatientswithrespiratorydiseases,lungconditions,dentalproblems,skinconditionsofbacterialandviralorigin,Helicobacterpyloriinfection,andloweredimmunity.Noplacebowasadministered,anddosageanddurationoftreatmentwerenotindicated.Thesuccessofthetreatmentappearstohavebeenassessedonsubjectivecriteriaonly.Inothercasereports,aBulgariangynecologistdescribedthereductionofelevatedPapsmearcategoryreadingsforwomenathighriskofcervicalcancer.ThisreductionissaidtohaveoccurredbyremovingorreducingfungalinfectionofCandidaguilliermondiifollowingbothoralingestionandtopicalapplicationofoliveleafextract.Nofurtherdetailswerelisted.40

REFERENCES

WeissRF.Herbalmedicine,Englished.Beaconsfield,UK:BeaconsfieldPublishers,1988.

LeclercH.Précisdephytothérapie,ed5.Paris:Masson,1966.MillerAG,MorrisM.PlantsofDhofar.ThesouthernregionofOman.Traditional,economicandmedicinaluses.DiwanofRoyalCourtSultanateofOman:TheOfficeoftheAdviserforConservationoftheEnvironment,1988.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983LeporattiML,CorradiL.JEthnopharmacol.2001;74(1):17-40.vanWykB-E,vanOudtshoornB,GerickeN.MedicinalplantsofSouthAfrica.Arcadia,Pretoria,SouthAfrica:BrizaPublications,1997.HutchingsA.Zulumedicinalplants:aninventory.Pietermaritzburg,SouthAfrica:UniversityofNatalPressinassociationwithUniversityofZululand,NationalBotanicalInstitute,1996.WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.

10RibeiroR,etal.JEthnopharmacol.1986;15(3):261-269.11PetkovV,ManolovP.ArzneimForsch.1972;22(9):1476-1486.

12ZarzueloA,etal.PlantaMed.1999;57(5):417-419.

13HansenK,etal.Phytomed.1996;2(4):319-325.14Bennani-KabchiN,etal.AnnPharmFr.2000;58(4):271-277.

15Bennani-KabchiN,etal.Therapie.1999;54(6):717-723.16OnderogluS,etal.JPharmPharmacol.1999;51(11):1305-1312.

17GonzalezM,etal.PlantaMed.1992;58(6):513-515.18FehriB,etal.BollChimFarm.1996;135:42-49.19delaPeurtoR,Martinez-DominguezE,Ruiz-GutierrezV.ZNaturforsch[C].2000;55(9-10):814-819.

20PieroniA,etal.Pharmazie.1996;51(10):765-768.21delaPuerta,Ruiz-GutierrezV,HoultJR.BiochemPharmacol.1999;57(4):445-449.

22VisioliF,BellostaS,GalliC.LifeSci.1998;62(6):541-546.23Benavente-GarciaO,etal.FoodChem.2000;68(4):457-462.24SperoniE,etal.PhytotherRes.1998;12(suppl1):S98-S100.25leTutourB,DidierG.Phytochem.1992;31(4):1173-1178.26VisioliF,etal.BiochemBiophysResCommun.2000;278(3):797-799.

27ConiE,etal.Lipids.2000;35(1):45-54.28BisignanoG,etal.JPharmPharmacol.1999;51(8):971-974.29AzizNH,etal.Microbios.1998;93(374):43-55.30TassouCC,NychasGJ.LettApplMicrobiol.

1995;20(2):120-124.31TranterHS,TassouSC,NychasGJ.JApplBacteriol.1993;74(3):253-259.

32TassouCC,NychasGJ,BoardRG.BiotechnolApplBiochem.1991;13(2):231-237.

33RenisHE.AntimicrobAgentsChemother.1969;9:167-172.34HirschmanSZ.NatNewBiol.1972;238(87):277-279.35RenisHE.AntimicrobAgentsChemother.1975;8(2):194-199.

36SoretMG.AntimicrobAgentsChemother.1969;9:160-166.37CherifS,etal.JPharmBelg.1996;51(2):69-71.38BalansardJ,DephautJ.ActaPhytother.1953;17:197.39CaprettiG,BonaconzaE.GiornClinMed.1949;30:630-642.40WalkerM.TownsendLetterforDoctorsandPatients.2000;204:92-96.

OREGONGRAPE

BotanicalNames: Berberisaquifolium,Mahoniaaquifolium#∧

Family: BerberidaceaePlantPartUsed: Rootandrhizome

# Alternativename.

∧ AdoptedbytheAmericanHerbalProductsAssociationasthenewbotanicalname.1

PRESCRIBINGINFORMATION

Actions Antipsoriatic,antiinflammatory,depurative,antimicrobial

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingOregongrapeinformulationsinthecontextof:

•Chronicskindiseases,psoriasis,acne,eczema(5)

•Anorexia(6)

•Topicaltreatmentforpsoriasis*(2)

•Topicaltreatmentforacnevulgaris*(3)

Contraindications Berberine-containingherbsarecontraindicatedinpregnancy2,3andforjaundicedneonates.3

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancy.

SideEffects Noneexpectedwhentakenwithintherecommendeddoserange.

Dosage Doseperday** Doseperweek**

3.5-7.0mlof1:2liquidextract

25-50mlof1:2liquidextract

* TrialswereconductedusingOregongrapestembark,althoughgiventhesimilaralkaloidprofile,extractsofOregongraperootcouldnotbeexpectedtoprovidesimilareffects.

** Higherdosesmaybenecessaryinacuteconditionsforwhichtheeffectofberberine is

required. In fact, barberry is a better choice for such applications. This dose range isextrapolated from the British Herbal Pharmacopoeia 1983 and the author’s education andexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Chronicskindisease,includingpsoriasis,eczema,syphiliticdyscrasia,pimples,acne;dyspepsia,gastritis,cholecystitis,liverdisorders4-6

•Constitutionalsyphilis,leukorrhea4,5

NativeAmericansusedOregongrapeasabittertonicforappetitelossandgeneraldebility.Otherpossiblenativeusesincludedbiliousnessandtopicallyforulceratedgumsorsorethroats.OregongrapewasofficialintheUSPfrom1905to1916andNFfrom1916to1947andwaslistedasabittertonic.7

ThefollowingalkaloidshavebeenisolatedfromOregongraperoot:magnoflorine,berberine,palmatine,jatrorrhizine,columbamine,oxyacanthine,berbamine,aromoline,baluchistine,andaquifoline.8-11Oregongraperootis,however,notasrichasourceofberberineasbarberry(Berberisvulgaris)andgoldenseal(Hydrastiscanadensis).Oregongrapestembark,whichhasbeenusedtraditionally7andfeaturesinmostofthepharmacologicandclinicalstudiesconductedonOregongrape,containsthefollowingmajoralkaloids:berberine,magnoflorine,palmatine,jatrorrhizine,andminoralkaloids(e.g.,berbamine,oxyacanthine,columbamine).12Oregongraperootmaycontainalargeralkaloidcontentthanstembark.13

•Berberinedemonstratedantimicrobialactivityinvivo14andwasfoundtosynergisticallyenhancetheantibacterial

PharmacologicResearch

activityofpreviouslyinactiveplantconstituentsisolatedfromOregongrapeleafinvitro.15

•Lipogenesisinhamstersebaceousglandswassuppressed63%byberberineinvitro,indicatingthatOregongrapemaybeofbenefitforthetopicaltreatmentofacnevulgaris.16

•Oregongrapestembarkextractshavedemonstratedantiinflammatory,antioxidant,andantifungalactivitiesinvitro.12,17MethanolextractofOregongraperootdemonstratedantifungalactivityinvitro.18

•Oregongrapestembarkextractexhibitedimmunostimulatingactivityintwophagocytosisassays.12

•Oregongrapebarkextractandseveralofthemainalkaloidsinhibitedhumankeratinocytegrowthinvitro.Thisantiproliferativeactivityisrelevanttotreatingpsoriasis.19ApossiblemechanismofactioninvolvestheinterferenceofDNAsynthesisbyberberine.20

ClinicalStudies

Intheclinicaltrialslistedinthissection,theointmentorcreamcontained10%OregongrapemothertincturepreparedaccordingtotheHABfromstembark.

•Oregongrapeextractdemonstratedabeneficialeffectinaprospectivecasereportstudyandasmallplacebo-controlledclinicaltrialinvestigatingthetreatmentofacne.Treatmentproducedgoodresults,withareductioninoilinessoftheskin.Intheclinicaltrial,ninemaleandfemalepatientswithmildormoderateacneappliedeitherOregongrapecreamorthecorrespondingplacebobasetwiceperdayfor8weeks.Bothgroupsshowedadecreaseinthenumberofinflamedlesions,butonlyatendencywasshowntodiminishedsebumlevelsintheOregongrapegroup.21,22Strongerpreparationsmaybenecessarytoshowasignificantactivity.

•TopicalointmentscontainingOregongrapestembarkextractaremarketedinEuropeforpsoriasis.Severalclinicalstudieshaveconfirmedtheiractivity.Inoneopentrial,theointmentwasusedfor12weeks,withalargeproportionofpatientscontinuingtreatmentfor1yearoruntiltheirskincleared.23,24Oregongrapeointmentimprovedcellularcutaneousimmunemechanismsandreducedthehyperproliferationofkeratinocytesinacomparativetrialwith

dithranolconductedover4weeks.25Inaplacebo-controlled,intraindividualtrial,Oregongrapeointmentproducedabenefitaccordingtopatients’assessment.Improvementwasgreaterinmoreseverecases.26

REFERENCES

McGuffinM,editor.Herbsofcommerce,ed2,Bethesda,Md:AmericanHerbalProductsAssociation,1998.[draft3.3]DeSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1992.ChanE.BiolNeonate.1993;63(4):201-208.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983EllingwoodF,LloydJU.Americanmateriamedica,therapeuticsandpharmacognosy,ed11.Portland:EclecticMedicalPublications,1983.

VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.KostalovaD,BrazdovicovaB,TomkoJ.ChemZvesti.1981;35(2):279-283.SchwabeW.DtschApothZtg.1939;54:326-327.

10KostalovaD,HrochovaV,TomkoJ.ChemPap.1986;40(3):389-394.

11KostalovaD,etal.CollectCzechChemCommun.1987;52(1):242-246.

12GalleK,etal.Phytomed.1994;1(1):59-62.13NeugebauerH,BrunnerK.PharmZentralhalle.1939;80:241-245.

14MillsS,BoneK.Principlesandpracticeofphytotherapy:modernherbalmedicine.Edinburgh:ChurchillLivingstone,2000.

15StermitzFRetal:InternationalConference:2000YearsofNaturalProductResearch—Past,PresentandFuture,Amsterdam,July26-30,1999,abstractL29.

16SekiT,MorohashiM.SkinPharmacol.1993;6(1):56-60.17LampertML,AndenmattenC,SchaffnerW.ZPhytother.1998;19(2):107-118.

18McCutcheonAR,etal.JEthnopharmacol.1994;44(3):157-169.

19MullerK,ZiereisK,GawlikI.PlantaMed.1995;61(1):74-75.

20CreaseyWA.BiochemPharmacol.1979;28(7):1081-1084.21LampertML,RufliTH,SchaffnerW:2ndInternationalCongressonPhytomedicine,Munich,September11-14,1996,abstractP-71.

22Mennet-vonEiffM,MeierB.ArsMedici.1995;85(4):255-259.

23GielerU,vonderWethA,HegerM.ArsMedici.1995;85(14):1018-1019.

24GielerU,vonderWethA,HegerM.JDermatolTreat.1995;6(1):31-34.

25AugustinM,etal.ForschKomplementarmed.1999;6(suppl2):19-21.

26WiesenauerM,LudtkeR.Phytomed.1996;3(3):231-235.

PASQUEFLOWER

OtherCommonName: PulsatillaBotanicalNames: Anemonepulsatilla,Pulsatillavulgaris#

Family: RanunculaceaePlantPartUsed: Dried*aerialparts

# Alternativename.

* Thefreshplantshouldnotbeusedbecauseitcontainsaconstituent(protoanemonin)thatcausesirritantsideeffects.1

PRESCRIBINGINFORMATION

Actions Spasmolytic,analgesic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingpasqueflowerinformulationsinthecontextof:

•Painfulorinflammatoryconditionsofthemaleorfemalereproductivetract,includingdysmenorrhea,ovarianpain,orchitis,andepididymitis(5)

•Hyperactivity,insomnia,tensionheadache(5)Contraindications Pregnancyandlactation.1

WarningsandPrecautions Therecommendeddoserangemustnotbeexceeded.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancyandlactation.

SideEffectsNoneexpectediftakenwithintherecommendeddoserange.Excessive(undefined)dosescancauseviolentgastritis.1

Dosage Doseperday** Doseperweek**

0.4-1.5mlof1:2liquidextract

3-10mlof1:2liquidextract

** ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Painfulorinflammatoryconditionsofthemaleorfemalereproductivesystem,suchasdysmenorrhea,orchitis,ovarianpain,andepididymitis2

•Hyperactivity,insomnia,tensionheadache,asthma2

•Skineruptionsandboils2

Eclecticphysiciansusedonlyfreshplantpreparationsbutatlowerdoses3tothosethatBritishherbalistsadvocated,whoweremainlyadvocatingdriedplantpreparations.2

PharmacologicResearch

Nopharmacologicinformationrelevanttothecurrentuseofpasqueflowerhasbeenfound.

ClinicalStudies

Noclinicalstudieshavebeenconductedusingliquidextractofpasqueflower.

REFERENCES

BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.EllingwoodF,LloydJU.Americanmateriamedica,therapeuticsandpharmacognosy,ed11.Portland:EclecticMedicalPublications,1983.

PASSIONFLOWER

OtherCommonName: PassifloraBotanicalName: PassifloraincarnataFamily: PassifloraceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Anxiolytic,spasmolytic,mildsedative,hypnotic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingpassionflowerinformulationsinthecontextof:

•Anxiety(2,4,5)

•Achievingmildsedationinhealthyindividuals(2)

•Adjuvanttherapyforopiatewithdrawal(2)

•Insomnia,incombinationwithvalerian(3)

•Restlessnessandirritabilitywithdifficultyinfallingasleep(4,5)

•Cardiacinsufficiency(NHYAfunctionalclassII)foranxiolyticeffects,incombinationwithhawthornleafandflower(2)

•Nervoustachycardia,nervousheadache(5)

•Nervoussymptomsresultingfrommenstrualdisturbances(5)

•Spasmodicconditions,includingdysmenorrhea,asthma,whoopingcough,andepilepsy(5)

•Neuralgicpain,includingfacial,rectal,andcardiacpain(5)

Contraindications Noneknown.Warningsand

Precautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromKing’sAmericanDispensatory1983andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Restlessness,wakefulness,nervousirritability,especiallywhenresultingfromexhaustionorprolongedillness1

•Hysteria,nervoustachycardia1,2

•Insomniaininfantsandolderadultsorresultingfrommentalworryoroverwork1,2

•Spasmodicconditions,includingtetanus,chorea,andwhoopingcough1

•Generalizedseizures,2epilepsy1

•Spasmodicasthma,2oppressedbreathing1

•Neuralgicpain,2includingfacial,rectal,andcardiacpain1

•Nervousheadache1

•Nervoussymptomsresultingfrommenstrualdisturbances,spasmodicdysmenorrhea1

•Topicallyforburns,scalds,hemorrhoids,painfululcers,andtoothache1

NativeAmericansusedpassionflowertopicallyforringworm,swellings,andsoreeyes.PassionflowerwasofficialintheNFfrom1916to1936andwasrecommendedasanantispasmodicandsedative.3

PassionflowerhasalsobeenusedtraditionallyinBrazilfortreatinginsomnia.4

PharmacologicResearch

ThemaindocumentedconstituentsofdriedaerialpartsofPassifloraincarnataareflavonoids(upto1.2%),especiallyflavone-C-glycosides,includingisovitexin.5Thepresenceoftraceamountsoftheharmanealkaloidsappearstodependonthestageofdevelopmentoftheplant,andinmanysamples,theyareabsent.6TheGermanCommissionErecommendsthatpassionflowernotcontainmorethan0.01%ofharmanealkaloids.

•Experimentalstudieshaveinvestigatedthesedativeandanxiolyticactivityofpassionflowerconstituentsinanattempttofindtheactivecomponents.Anexperimentalstudyconductedin1976foundsedativeactivityformaltolafterhighdosesbyinjection.7Maltolisanartifactandispresentonlyinpassionflowerpreparationsatlowconcentrations.8Arecentstudy,whichfoundsedativeandanxiolyticactivityforanaqueousextractandaqueousalcoholextract,respectively,foundnoactivityforseveralcombinationsofconstituents(maltol+harmanealkaloids,maltol+flavonoids,ormaltolalone)atloworhighconcentrations.9(Allpreparationswereadministeredbyinjection.)Thisfindingsuggeststhatasyetunidentifiedcompoundsareresponsiblefortheactivityofpassionflower.

•Aqueousandethanolicextractsofpassionflowerdemonstratedsedativeactivityafteroralandintraperitonealadministrationinexperimentalmodels.9-14Thesedationindexwascomparabletomeprobamate(250mg/kg)andhigherthanthatofdiazepam(10mg/kg)andchlordiazepoxide(10mg/kg).12

•Oraladministrationofapassionflowerextractexhibitedanxiolyticactivityinvivo,15andanalgesicactivitywasdemonstratedinvivoafteroraladministrationofan

aqueousextractofpassionflower.10Afteroraladministration,passionflowerextractdemonstratedantiinflammatoryactivityinthreeexperimentalmodels.16

•Passionflowerextractdidnotinteractwithbenzodiazepine,dopaminergic,orhistaminergicreceptorsinvitro.17

•Inhalingtheessentialoilofpassionflower,orofitsvolatileconstituents(maltol,2-phenylethanol),didnotdecreasethemotilityofmiceundernormalconditions.Motilitywasdecreasedaftercaffeine-inducedoveragitation.18

ClinicalStudies

•Arandomized,double-blind,controlled,14-daytrialcomparedclonidine(analpha-2adrenergicagonist,maximumdose0.8mg/day)pluspassionflowerextractagainstclonidineplusplacebointheoutpatientdetoxificationofopiateaddicts.Bothtreatmentswereequallyefficaciousintreatingthephysicalsymptomsofwithdrawal,butthegroupreceivingpassionflowershowedsuperiorityoverclonidinealoneintermsofmanagingmentalsymptoms.Thedosageoftheundefinedpassionflowerextractwas60dropsperday.19

•Inapilot,randomized,double-blind,controlledtrial,passionflowerextractwasasefficaciousasoxazepam(abenzodiazepinedrug)formanaginggeneralizedanxietydisorder.However,passionflowertreatmentresultedinalowerincidenceofimpairmentofjobperformance.Thedailydoseoftheundefinedpassionflowerextractwas45drops.20

•Apassionflowerandvaleriancombinationimprovedsymptomsofinsomniainuncontrolledtrials.21,22Sideeffectscharacteristicofbenzodiazepinetranquilizerswerenotobserved.22Inacontrolledtrialwithcomparisonagainstchlorpromazine(anantipsychoticdrug),EEGrecordingsshowedsedativeactivityafter6withtheherbal

combination.21Thedosageadministeredinoneofthesetrialswas1.0to2.5dessert-spoonfulsperdayofsyrup(100gofwhichcontained25gofpassionflowerextract1:1and12.5gofvalerianextract1:1).22

•Inarandomized,double-blind,placebo-controlledstudy,asingledoseofpassionflowerextract(equivalentto7gofdriedherb)demonstratedasedativeeffectwhencomparedwithbaselinevaluesinhealthyfemalevolunteersasassessedbyaself-ratingscaleforalertness.23

•Inarandomized,double-blindtrial,hawthorn(leafandflower)combinedwithpassionflowerreducedheartrateatrest,diastolicbloodpressureduringexercise,plasmacholesterolandincreasedexercisecapacitycomparedwithplaceboinNHYAstageIIheartfailurepatients.24

•InGermany,theCommissionEsupportsusingpassionflowertotreatnervousrestlessness.25

•ESCOPrecommendspassionflowerfortreatingnervoustension,restlessness,andirritabilitywithdifficultyinfallingasleep.26

REFERENCES

FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

BernardesA.ApocketbookofBrazilianherbs:forklore,history,uses.RiodeJaneiro,Brazil:ShogunArte,1983.WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.AoyagiN,KimuraR,MurataT.ChemPharmBull.1974;22(5):1008-1013.MeierB.ZPhytother.1995;16(2):115-126.SoulimaniR,etal.JEthnopharmacol.1997;57(1):11-20.

10SperoniE,MinghettiA.PlantaMed.1988;54(6):488-491.11SopranziN,etal.ClinTer.1990;132(5):329-333.12GallianoG,Foussard-BlanpinO,BretaudeauJ.Phytotherapy.1994;(40/41):18-22.

13CapassoA,PintoA.ActaTher.1995;21(2):127-140.14SperoniE,etal.PhytotherRes.1996;10(suppl1):S92-S94.15DellaLoggiaR,TubaroA,RedaelliC.RivNeurol.1981;51(5):297-310.

16BorrelliF,etal.PhytotherRes.1996;10(suppl1):S104-S106.17BurkardW,etal.PharmPharmacolLett.1997;7(1):25-26.18BuchbauerG,JirovetzL,JagerW.ArchPharm.1992;325(4):247-248.

19AkhondzadehS,etal.JClinPharmTher.2001;26(5):369-373.

20AkhondzadehS,etal.JClinPharmTher.2001;26(5):363-367.

21KammererE,WegenerT.NaturaMed.1995;10(2):1-8.22MollenhauerC.ZPhytotherAbstractband.1995:22.23SchulzH,JobertM,HubnerWD.Phytomed.1998;5(6):449-458.

24vonEiffM,etal.ActaTher.1994;20:47-66.25BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

26ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Passifloraeherba.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.

PAUD’ARCO

OtherCommonName: Lapacho

BotanicalNames: Tabebuiaavellanedae,Tabebuiaimpetiginosa,#Tabebuiaipe+

Family: BignoniaceaePlantPartUsed: Bark

# Alternativename.

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Immune-enhancing,antitumor,antibacterial,antifungal,antiparasitic,depurative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingpaud’arcoinformulationsinthecontextof:

•Adjuvanttherapyforcancer(4a,6)

•Adjuvanttherapyforprotozoalinfections(7)

•Topicaltreatmentforskindiseases,fungalinfections,skincancer,varicoseulcers(6)

ContraindicationsPatientsonanticoagulanttherapyshouldnotbeprescribedpaud’arcobecauseofthepotentialwarfarinlikeactionofnaphthoquinonesathighdoses.

WarningsandPrecautions

Althoughpaud’arcocangeneratefreeradicalsandinterferewithmitochondrialrespirationandbloodcoagulation,noevidencehasbeenfoundthatthelong-termuseofpaud’arcothedoseshouldnotbetoohigh,andpatientsonanticoagulanttherapyshouldnottakepaud’arcolikelytobemild,anditshouldnotbetrustedasasoletreatmentforcancerorinfections.

Interactions Prescribingpaud’arcoUseinPregnancyandLactation

Cautioninpregnancyresultingfrompossibleabortiveandteratogenicactions.

SideEffects

Adverseeffectshavebeenrecordedduringclinicaltrialsusinglapachol,butnoevidencehasbeenfoundtosuggestthatpaud’arcowouldcausesimilareffects.Noadverseeffectsareexpectedwhenconsumedwithintherecommendeddosage.

Dosage Doseperday* Doseperweek*

3-7mlof1:2liquidextract

20-50mlof1:2liquidextract

* This dose range is adapted from dried plant dosages administered by decoction intraditional South American medicine.1 The ence and the fact that ethanol-water is a moreeffectivesolventthanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalSouthAmericanmedicineusesofpaud’arcoinclude

•Asadepurativeandtonic1,2

•Dysentery,fever,sorethroat,wounds,snakebites,intestinalinflammation,inflamedjoints,circulatoryanddegenerativedisorders,carcinomas2

•Topicallyfortreatingskindiseases,suchaseczema,psoriasis,fungalinfections,andskincancers2

TraditionaluseofthebarkofotherspeciesofTabebuiainclude:3

•Stomachulcers(T.insignisvar.monophylla)

•Malaria,chronicanemia,ulcerpains(T.neochrysantha)

•Rheumaticconditions(T.obscura)

Inthemid-1960s,aBraziliannewsmagazineprintedreportsofthe“miraclecures”ofcasesofterminalleukemiaandcancerfollowingtheuseofpaud’arcoSãoPaulofortreatingleukemia,diabetes,ulcers,rheumatism,andcancer.Otherinstanceswerereportedoftopicaluseofthedecoctionsuccessfullytreatingskincancerandchronicvaricoseulcers.1

Themostwidelyusedspeciesofpaud’arcoinwesterncountiesareTabebuiaimpetiginosa(T.avellanedae)andT.ipe.OtherspeciesusedincludeTabebuiarosea(T.pentaphylla),T.chrysantha,T.cassinoides,andT.

PharmacologicResearch

serratifolia.

KeyconstituentsofTabebuiaimpetiginosabarkincludenaphthoquinonesofthe1,4type(especiallylapachol)andfuranonaphthoquinones.Althoughmuchoftheactivecomponentresearchhasconcentratedonlapachol,othernaphthoquinonesandtheirfuranoderivativesarelikelytocontributesignificantlytothetherapeuticactivityofpau

•Lapachol,othernaphthoquinones,andfuranonaphthoquinoneshaveinhibitedgrowthofculturedtumorcells.Lapacholhasdemonstratedsignificantantitumoractivityinvitroandinvivo.Oraladministrationoflapacholresultedininhibitionoftumorgrowthinseveralcarcinosarcomamodels,particularlyWalker256carcinosarcoma.Statisticalanalysisrevealedalinkbetweentheredoxpotentialsofvariouscompoundsinpaud’arcoandtheirantitumeractivityTheoxidativestresstheory,inwhichquinonesarereducedtooxygen-radical-activatingcompounds,isoneexplanationfortheircytotoxicactivity.

•Paud’arcoextractsandothercomponentshavealsodemonstratedinvivoantitumoreffectsinskincarcinogenesisandleukemiaP-388models.

•InvitroinvestigationsofcompoundsisolatedfromT.impetiginosaconfirmeddose-dependent,immune-enhancingeffectsonhumangranulocytesandlymphocytes.

•Paud’arco,andsomeofitsconstituents,includinglapachol,werefoundtobeactiveagainstvarioustropicalparasitesinvitro.StudiesatHarvardMedicalSchoolconfirmedtheseresults.

•Naphthoquinonestestedagainstdrug-resistantstrainsofPlasmodiumfalciparumweresuperiortothecontrolschloroquineandquinine.Lapacholhasbeenusedasa

chemoprophylacticagainstSchistosomamansonipenetrationandinfectioninvivo.Lapacholanditsderivativeswerealsoshowntoworkbytopicalapplications.

•Paud’arcoextractsandisolatedconstituentsdemonstratedantibacterialandantifungalactivityinvitro.T.impetiginosaextractinhibitedapenicillin-resistantstrainofStaphylococcusaureus.

•Antiviralactivitywasdemonstratedinvitroforlapacholagainstanumberofviruses,includingherpesandretroviruses.ExtractsoftheinnerbarkofT.avellanedaewerefoundtoinhibitinductionofEpstein-Barrvirus(EBV)–associatedearlyantigeninEBVgenome–carryinghumanlymphoblasticcelllines.Theantiviralactivityoflapacholmayinvolveredoxreactions,stimulationofinterferonproduction,orenzymeinhibition.

•Lapacholandrelatednaphthoquinonesareknownanticoagulants.Someauthorslinkthisanticoagulantactivitytotheanticancerapplicationsofpaud’arco

•OraladministrationofaqueousextractofTabebuiaavellandaeinnerbarkdemonstratedantiinflammatoryactivityinratpawedemaandanalgesicactivityinanexperimentalpainmodel.4

ClinicalStudies

•AphaseIclinicaltrialusinglapacholwasinitiatedin1967attheBaltimoreCancerResearchCenter.Thetrialinvolved21patientswithleukemia,eachofwhomwasinitiallygivencapsulescontaining0.25or0.5glapacholandlaterswitchedtoasyrupformulation.Thetrialwasstoppedprematurelybecauseprolongedprothrombintimeswereobservedatthehighoraldosesrequiredtotestforantitumoractivity.Thesedosesalsoresultedinnauseaandvomiting,andmeasurementsofplasmalapacholshowedthatintestinalabsorptionoflapacholwasconsiderablylessthanpreviouslydeterminedinrats.

However,lapacholmaybemuchbetterabsorbedfromitsnaturalplantmatrix.

•Prescriptionoflapachol(20to30mg/kg/day)causedshrinkageoftumorsandreductioninpainforninepatientswithcancerwhowereparticipatinginasmallclinicaltrial.Threepatientsceasedthetreatmentbecauseofnauseaandvomiting;theotherpatientshadnosignificantsideeffects.Threepatientsexperiencedcompleteremissions.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.JonesK.Paud’arco:immunepowerfromtherainforest.Rochester,Vt:HealingArtsPress,1995.OswaldEH.BrJPhytother.1993-1994;3(3):112-117.EvansSchultesR,RaffaufRF.Thehealingforest:medicinalandtoxicplantsoftheNorthwestAmazonia.Portland:DioscoridesPress,1990.GoncalvesdeMirandaFG,etal.BMCPharmacology.2001;1:6.

PEPPERMINT

BotanicalName: MenthapiperitaFamily: LabiataePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions

Spasmolytic,carminative,cholagogue,antiemetic,antitussive,antimicrobial(internallyandtopically),mildsedative,diaphoretic,analgesic(topically),antipruritic(topically)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingpeppermintinformulationsinthecontextof:

•Nonulcerdyspepsia,*incombinationwithfennel,caraway,andwormwood(2)

•Chronicdigestiveproblems,bloating,flatulence,*incombinationwithfennel,caraway,andgentian(2)

•Spasticcomplaintsofthegastrointestinaltract,gallbladder,andbileducts(4,5)

•Gastritis,enteritis(4)

•Respiratorytractcatarrh,cough,thecommoncold(5)

•Nausea,vomiting,morningsickness(5)

•Nervousconditions,dysmenorrhea(5)

•Topicaltreatmentforheadaches(5)

ContraindicationsBecauseofitsabilitytoloweresophagealsphincterpressure,peppermintiscontraindicatedinpatientswithesophagealreflux.

WarningsandPrecautions

Peppermintshouldbeusedwithcareinpatientswithsalicylatesensitivityandaspirin-inducedasthma,aswellasthosewithgallstones.

Interactions

Peppermintteareducedtheabsorptionofironby84%fromabreadmeal(comparedwithawatercontrol)inadultvolunteers.Theinhibitionwasdose-dependentandrelatedtoitstannincontent.Inhibitionbyblackteawas79%to94%.1Thisfindingindicatesapotentialinteractionforconcomitantadministrationofpeppermintduringironintake.Inanemiaandcasesforwhichironsupplementationisrequired,peppermintshouldnotbetakensimultaneouslywithmealsorironsupplements.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Noneknownforpeppermintleaf.Allergicreactionstopeppermintappeartoberareorofarelativelyminornature.Skinrashes,headache,bradycardia,muscletremor,heartburn,andataxiaarerarelyreportedsideeffectsassociatedwithusingenteric-coatedcapsulesofpeppermintoil.Fibrillationhasbeenassociatedwiththeexcessiveconsumptionofpeppermint-flavoredconfectionery.Gastrointestinalirritationoraggravationofgastrointestinalcomplaints,includingstomatitis,severeesophagitis,gastritis,unexplaineddiarrhea,andpancreatitis,havebeenassociatedwithusingpeppermintpreparations,includingconfectionery.

Dosage Doseperday** Doseperweek**

1.5-4.5mlof1:2liquidextract

10-30mlof1:2liquidextract

* Peppermint has also been used in traditional herbalmedicine for treating dyspepsia andflatulenceandisrecommendedforthisusebyboththeCommissionEandESCOP.(4,5)

** ThisdoserangeisextrapolatdfromtheBritishHerbalCompendium1992andthe

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Spasmorcrampsofthestomach,2gastrointestinalpain,flatulentdyspepsia,3gallbladderdisorders4

•Nausea,vomiting,2morningsickness3

•Thecommoncold3

•Dysmenorrhea,3hysteria2

•Todisguisetheunpleasanttasteofothermedicinesandtoallaythepainfuleffectofcatharticremedies2

•Asapoulticeforupsetstomachandheadaches2

Peppermintoilsolutionhasbeentraditionallyusedasaninhalationforbronchiticcoughandpneumonia.2

Keyconstituentsofpeppermintleavesincludephenolicacids,tannins,andanessentialoil(0.5%to4.0%)consistingmostlyofmenthol(35%to45%).

•Peppermintextractproducedanalgesicactivityintwoexperimentalmodels,indicatingcentralandperipheraleffects(400mg/kgpretreatmentbyinjectionand200to400mg/kgoralpretreatment,respectively).Peppermintexhibitedantiinflammatoryactivityinacute(200mg/kg,pretreatmentbyinjection)andchronicinflammation(400mg/kg,oral).5

•Peppermintextractandessentialoilmarkedlyreduced

PharmacologicResearch

experimentallyinducedcontractileresponsesinisolatedgastrointestinalsmoothmusclepreparations.

•Oraladministrationofafractionobtainedfromanaqueousethanolicextractofpeppermintinhibitednasalsymptoms,sneezing,andnasalrubbinginanexperimentalmodelofallergicrhinitis.6

•Peppermintoilinhibitedgastrointestinalenterocyteglucoseuptakeviaadirectactionatthebrushbordermembraneinvitro.

•Peppermintoilhasexhibitedsignificantantibacterialandantifungalactivityinvitro.

•Singleoraldosesofmentholorcineoleinhibited3-hydroxy-3-methyl-glutarylcoenzymeA(HMGCoA)reductaseactivityinexperimentalmodelsbyupto70%.

•Mentholinhalationsignificantlyreducedcoughfrequencyandincreasedcoughlatencyinexperimentalmodelsofchemicallyinducedcough.

•Acetylcholine-inducedbronchospasmdecreasedby50%inexperimentalmodelswhenanointmentcontainingmenthol,camphor,andessentialoilswasinsufflatedthroughtherespiratorytract.Topicalapplicationproducedonlyslightreduction.

•Dietarymentholandlimonenesignificantlyinhibitedexperimentallyinducedmammarytumorsinexperimentalmodels.

•Mentholhascalciumion–channelblockingactivityandapharmacologicprofilesimilartothatofcalciumantagonists.

•Aliquidherbalformulacontainingpeppermint,fennel,caraway(Carumcarvi),andwormwoodwassignificantly

superiortometoclopramide(aspasmolyticdrug)intermsofrelievingsymptomsinarandomized,double-blind,controlledtrialinvolvingpatientswithdyspepsia.Atrialofsimilardesigndemonstratedasignificantimprovementinthegastrointestinalcomplaintscoresandareductioninintestinalgasinpatientswithchronicdigestiveproblems,suchasflatulenceorbloating,treatedwithatabletformulacontainingtheseingredients(butwithgentianinsteadofwormwood).

•Painintensitywassignificantlydecreasedintworandomizedtrials,7,8andpainintensityandglobalclinicalimpressionweresignificantlyimprovedinadouble-blind,placebo-controlled,multicentertrialinvolvingpatientswithnonulcerdyspepsia.Dosesof180to270mg/dayofpeppermintoiland100to150mg/dayofcarawayoilwereprescribedfor4weeks.Nosignificantdifferencewasobservedbetweenthepeppermint-carawaycombinationandthedrugcisapride(amotilitydrug;30mg/day)intermsofclinicaloutcome.7

•Ameta-analysisoffiverandomized,double-blind,placebo-controlledtrialsfoundthatpeppermintoil(0.6to1.2ml/dayfor2to4weeks)mightbeefficaciousforsymptomreliefinirritablebowelsyndromebutwasunabletoprovideadefinitivejudgmentbecauseofmethodologicflawsassociatedwithmoststudies.9Enteric-coatedcapsuleswereusedtopreventthegastricreflux,whichsuchhighdoseswillinevitablycause.Inarandomized,double-blind,multicenter,placebo-controlledtrialpublishedsincethemeta-analysis,75%ofchildrenwithirritablebowelsyndromewhoreceivedpeppermintoilexperiencedreducedseverityofpainafter2weeksoftreatment.10

•Gynecologicpatientsexperiencedasignificantreductioninpostoperativenauseaafterinhalingpeppermintoilinaplacebo-controlledtrial.Patientswereprovidedwith5mlofoilbutusednomorethanatotalof1ml.

ClinicalStudies

•Peppermintoilsolutionadministered(doseunknown)viathebiopsychannelofthecolonoscoperelievedcolonicspasmwithin30seconds

inanuncontrolledstudy,allowingeasierpassageoftheinstrument.Amorerecentplacebo-controlledtrialconfirmedthataspasmolyticeffectwasseenin89%ofpatientsundergoingcolonoscopyafterintracolonicadministrationofapproximately200mlofa0.8%peppermintoilsolution(comparedwith33%inthecontrolgroup).Inpatientswithirritablebowelsyndrome,efficacywassignificantlylower.11

•Topicalapplicationofasolutionof10%peppermintoilinethanolsignificantlyreducedheadachesensitivityandintensity,comparabletoacetaminophen(paracetamol,1g),inarandomized,double-blind,placebo-controlled,crossovertrial.

•Patientswithcholesterolgallstonesweretreatedwitheitherursodeoxycholicacid(UDCA,11.1mg/kg/day)oracombinationofUDCA(4.75mg/kg/day)andmenthol(4.75mg/kg/day)inadoubleblindtrial.After15.0to16.9months,completedissolutionofstoneswasachievedin53%ofpatientstreatedwiththecombinationand38%ofpatientstreatedwiththehigherdoseofUDCAalone.Theresponserate(complete+partialdissolution)was76%inthecombinationgroupand75%intheUDCAalonegroup.OnecaseofstonecalcificationoccurredintheUDCAalonegroup,whereasnocasesoccurredinthecombinationtreatmentgroup.

•Long-terminhalationofmenthol(20mg/dayfor4weeksviaanebulizer)significantlydecreasedairwayhyperresponsivenessinpatientswithasthmainaplacebo-controlledtrial.

•Administrationofmenthol(11mg)asalozengedecreasedthesensationofnasalcongestioninpatients

withthecommoncoldinanuncontrolledtrial.

•InGermany,theCommissionEsupportsusingpeppermintleaftotreatspasticcomplaintsofthegastrointestinaltract,gallbladder,andbileducts.Peppermintoilcanbeusedtotreatdiscomfortoftheuppergastrointestinaltractandbileducts,irritablecolon,catarrhoftherespiratorytract,andinflammationoftheoralmucosa.12

•ESCOPrecommendspeppermintleafforthesymptomatictreatmentofdigestivedisorders,suchasdyspepsia,flatulence,gastritis,andenteritis,andpeppermintoilforirritablebowelsyndromeandthesymptomatictreatmentofdigestivedisorders,coughs,andthecommoncold.13

•PepperminthasremainedofficialintheUSPsincethefirstentryin1820andiscurrentlyofficialintheUSP24-NF19.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.HurrellRF,ReddyM,CookJD.BrJNutr.1999;81(4):289-295.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.AttaAH,AlkofahiA.JEthnopharmacol.1998;60(2):117-124.InoueT,etal.BiolPharmBull.2001;24(1):92-95.MadischA,etal.ArzneimForsch.1999;49(11):925-932.FreiseJ,KohlerS.Pharmazie.1999;54(3):210-215.PittlerMH,ErnstE.AmJGastroenterol.1998;93(7):1131-1135.

10KlineRM,etal.JPediatr.2001;138(1):125-128.11AsaoT,etal.GastrointestEndosc.2001;53(2):172-177.12BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

13ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Menthaepiperitaefolium/aetheroleum.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.

PLEURISYROOT

BotanicalName: AsclepiastuberosaFamily: AsclepiadaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Diaphoretic,expectorant

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingpleurisyrootinformulationsinthecontextof:

•Respiratorydisorders,especiallyofacatarrhal,chronic,orinflammatorynature,includingthecommoncold,influenza,pneumonia,pleurisy,bronchitis,andfevers(5)

•Otherconditionsforwhichdiaphoresisisofbenefit,suchasarthriticandrheumaticconditions(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsNoneexpectediftakenwithintherecommendeddoserange.Verylarge(undefined)dosesaresaidtocausediarrheaandvomiting.1

Dosage Doseperday* Doseperweek*

1.5-3.0mlof1:2liquidextract

10-20mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Bronchitis,pneumonitis,pleurisy,influenza,pulmonarycongestion,tuberculosis,dryasthmawithfever;thecommoncold,particularlyin

•Diarrhea,dysentery,flatulentcolic;rheumatism,neuralgia,dryskinconditions2

Pleurisyrootwasregardedasalungtonic3andthebestdiaphoreticintheEclecticMateriaMedica.2

NativeAmericansusedpleurisyrootbothinternallyandexternallyforbronchialandpulmonarydisorders,includingpneumoniaandfever,andfordysentery.Pleurisyrootwasusedexternallyforwounds,sores,andbruises.PleurisyrootwasofficialintheUSPfrom1820to1905andtheNFfrom1916to1936andwasusedasadiaphoreticandexpectorantandinlargedosesasanemeticandpurgative.4

PharmacologicResearch

Nopharmacologicinformationrelevanttothecurrentuseofpleurisyroothasbeenfound.

ClinicalStudies Noclinicalstudiesusingpleurisyroothavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.

Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

POKEROOT

BotanicalNames: Phytolaccadecandra,P.americana#

Family: PhytolaccaceaePlantPartUsed: Root

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antiinflammatory,lymphatic,depurative,immune-enhancing

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingpokerootinformulationsinthecontextof:

•Skinconditions,asadepurativeactingprimarilyviathelymphaticsystem(5)

•Treatinginflammatoryconditionsorinfections,especiallyoftherespiratorytractandreproductivesystems(5)

•Mastitis,mammaryabscess(5)

•Possibletreatmentforuterineandbreastcancers(6)

•Topicaltreatmentofskinirritation,infection,orinfestation(5)

Contraindications

Pokerootiscontraindicatedin:

•Pregnancy,lactation(becauseofitspotentialtoxicity)

•Lymphocyticleukemia(resultingfromincreasedlymphocytecountinawomanconsumingthefreshrootandthelymphocyte-stimulatingactivityofthelectinsinvitro)

•Gastrointestinalirritation(resultingfromtheemeticactivityandsaponincontent)

WarningsandPrecautions

Therecommendeddosageofpokeroothasbeenexceededinsomecases(seethe“SideEffects”sectioninthismonograph)becauseofvariationinthepotencyoftherootwithresultantsideeffects.Freshplanttincturesshouldbeusedwithextremecaution,ifatall.Accuratemeasurementofdriedplanttincturevolumesisvitaltoensurethatthesafedosageisnotexceeded,becausetoxiceffectsarepossiblefromoverdose.Topicalapplicationofpokerootshouldberestrictedtodriedplanttincturesandcontactwiththeeyesshouldbeavoided.

Interactions Concurrentusewithimmunosuppressivedrugsshouldbeavoided.

UseinPregnancyandLactation Contraindicatedinpregnancyandlactation.

SideEffects

PoisoningsoccurredinNorthAmericaduringthenineteenthcenturyfollowingoverdoseofdriedplanttincturesandingestionofberriesorrootsmistakenforothervegetables.Morerecently,poisoninghasoccurredfrominappropriateuseoftheroot,suchasingestingthefreshrootwithoutboilingfirstandingestingdecoctedpowderedroot.AdverseeventshaveoccurredinAustraliaresultingfromexcessiveintake:insomecaseshospitalizationwasrequired,andinonecase,ashockreactionwithpronouncedhypotensionandtachycardiaoccurred.Topicalapplicationofpreparationsderivedfromthegreenplantandroothasproducedinflammationoftheskin.

Dosage Doseperday* Doseperweek*

0.15-0.7mlof1:5tincture 1-5mlof1:5tincture

Usingliquidextractsandfreshplanttincturesshouldbeavoidedbecauseofpotentialtoxiceffects.

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1923, theBritishHerbalPharmacopoeia1983,andtheexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Actionontheskinandtheglandularstructures,particularlyofthemouth,throat,orreproductivetract(tonsillitis,laryngitis,lymphadenitis,mumps,ovaritis,glandularswellings)andmarkedactiononthemammaryglands1,2

•Breastcancer3

•Chronicrheumatism1

•Topicallyfortreatingskinandglandulardisorders,includingscabies,tinea,acne,mastitis,andmammaryabscess1

•Uterinecancer3

NativeAmericansusedpokerootasapoultice,andtherootwasappliedtothehandsandfeetofindividualsafflictedwithfever.PokerootwasofficialintheUSPfrom1820to1916,theNFfrom1916to1947,andwasusedforemeticandpurgativepurposes,asadepurative,inskindiseases,andforreliefofpainandinflammation.4

PharmacologicResearch

•Theimmunologicactivityofpokerootmaybecausedbythepresenceoftracesofmitogeniclectins,whichmayinteractwithgut-associatedlymphoidtissueandmayevenbeabsorbedinsmallquantities.Theselectinsareusedpharmacologicallytoagglutinatesomeerythrocytes,stimulatemitosisandantibodysynthesisinlymphocytes,andinduceactivationofplasmacells.

•Thecrudesaponinsfrompokerootexhibitedantiinflammatoryactivitybyinjectioninexperimentalmodels.

ClinicalStudies Noclinicalstudiesusingpokeroothavebeenfound.

REFERENCES

Exceptwherespecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.

PRICKLYASH

BotanicalNames:

Zanthoxylumclava-herculis,Zanthoxylumamericanum,+Xanthoxylumamericanum#

Family: RutaceaePlantPartUsed: Bark

# Alternativename.

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Circulatorystimulant,diaphoretic,antirheumatic,sialogogue

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingpricklyashinformulationsinthecontextof:

•Hemorrhoidsandvaricoseveins(2)

•Conditionsrequiringcirculatorystimulation,includingperipheralcirculatoryinsufficiency,intermittentclaudication,andraynaudssyndrome(5)

•Cramps,chronicrheumaticconditions,neuralgia(5)

•Osteoarthritis(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

1.5-4.5mlof1:2liquidextract

10-30mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Conditionsofsluggishcirculation,peripheralcirculatoryinsufficiency,intermittentcaludication,raynaudssyndrome1coldhandsandfeet,andcomplaintsarisingfrombadcirculation2

•Chronicrheumaticconditions,1arthritictendency3

•Cramps,neuralgia1,4

•Conditionsofmucousmembranessuchaspharyngitisandpostnasalcatarrh4

•Asagastrointestinaltonicforatonicdyspepsia,constipation4

PharmacologicResearch

Aqueousextractofpricklyashinhibitedswellingandimprovedvascularpermeabilityinexperimentalmodelsofhemorrhoidsandvaricoseveins.5

ClinicalStudies

Ahighdoseofpricklyashextract(standardizedfortotalalkaloidsandmagnoflorine)demonstratedsymptomimprovementintreatinghemorrhoidsandvaricoseveinsintworandomized,double-blind,placebo-controlledtrials.Venouscirculationwasimprovedinvaricoseveinspatients.5

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983JiaQ,etal.Phytomed.2000;7(supp2):46.

RASPBERRYLEAF

OtherCommonName: RedraspberryleafBotanicalName: RubusidaeusFamily: RosaceaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Astringent,partuspreparator,parturifacient,antidiarrheal

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingraspberryleafinformulationsinthecontextof:

•Ensuringhealthyuterinefunctionatchildbirth(whentakenduringpregnancy)(4,5)

•Abnormalbleedingfromtheuterus,stomach,orbowels(5)

•Mouthulcers,diarrhea(5)

•Dysmenorrhea(6)

•Topicaltreatmentfortonsillitis,conjunctivitis,sorethroat(5,6)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.

UseinPregnancyandLactation

Noadverseeffectsexpectedinpregnancyorlactation,butconfiningusetothesecondandthirdtrimestersismoreappropriate.

SideEffects Noneexpectediftakenwithintherecommendeddosage.

Dosage Doseperday* Doseperweek*

4.5-14mlof1:2liquidextract

30-100mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Diarrhea,dysentery,cholera1,2

•Duringpregnancyandtofacilitatedelivery,1,2dysmenorrhea3

•Stomatitis;1hemorrhagefromthestomach,bowel,oruterus;prolapseduterus2

•Topicallyfortonsillitisandconjunctivitis,1asagargleforsorethroats4

•Stomachcomplaintsofchildren,topicallyforwoundsandulcers4

Theleavesofraspberrycontainflavonoids,gallotannins,andellagitannins.5

•Aqueousextractofraspberryleaf(1g/15ml)hadlittleornoeffectonisolateduterifromnonpregnantratsbutinhibitedcontractionsofthosefrompregnantrats.Avariableresponsewasobtainedfromuteriininducedestrus.Inhibitionlasted3to4minutes,andintrinsiccontractionswereresumed.Epinephrine(adrenaline)-likeresistancedidnotdevelopandtheinhibitoryeffectwasnotpreventedbypropranolol.Theextractcontractedstripsofhumanuterusat10to16weeksofpregnancy.Forpregnanthumanandratuteri,theintrinsicrhythm(overa20-minuteperiodwhiletheextractremainedincontactwiththetissue)appearedtobecomemoreregularinmostcases,andcontractionswerelessfrequent.6

PharmacologicResearch

•Aqueousextractofraspberryleafstimulatedisolatedsmoothmuscle,particularlytheuterus.Whenthetanninswereremovedfromthisextract,spasmolyticactivitywasexhibited.Bothstimulantandrelaxantcomponentswerepresentintheextract,withaweakanticholinesterasecomponentdemonstratingstimulation.7

•Raspberryleafextractsrelaxedisolatedintestinalsmoothmuscle.8

•Aconcentrateofraspberryleafinfusionrelaxedtheuterusandintestineinsitu(byintravenousinjection),providedthetoneoftheorganswasnormal.Fortheuterus,therelaxationwasoccasionallyfollowedbycontractionandfurtherrelaxation.Thedegreeofrelaxationincreasedwithsuccessivedoses.Secondarycontractionswereeliminated,andthosethatoccurredwereevenlyspaced.Theexperimentalmodelincludedmainlynonpregnantuteriandoneanimalinlatepregnancy.Relaxationwasalsopromotedintonicallycontractedisolated(presumablynonpregnant)uteri,butifallowedtorelax,raspberryleafcausedtheorgantocontract.Whenlittletonewaspresentinisolateduterus,raspberryleafcausedstimulation,butwhentheuteruswastoned,raspberryleafinducedrelaxation.9Thisfindingimpliesaregulatoryactiononuterinetone.

•Aretrospective,observational,controlledstudyinvolving108womenfoundthatwomencanconsumeraspberryleafduringtheirpregnancytoshortenlabor,withnosideeffectsidentifiedforthewomenortheirbabies.Ingestingraspberryleafmayalsodecreasethelikelihoodofpretermandposttermlabor,evidencedbyasmallerspreadofthegestationperiodamongtheraspberryleafgroup.Anunexpectedfindingofthestudywasthatwomenwhoingestraspberryleafmightbelesslikelytorequireartificialruptureoftheirmembranes,cesareansection,forceps,orvacuumbirth.Treatmentbeganasearlyas8weeks’gestation,withthemajority

ClinicalStudies

commencingat30to34weeks.Thedailydoserangedfrom1to6cupsofteaor1to8tablets,with6cupsortabletsperdaybeingthemostpopularintake.Theweightofthetabletswasnotdefined.10

•Afollow-uptrialofrandomized,double-blind,placebo-controlleddesignwasconductedbythesameauthorsandinvolved192womenwhowerefollowedfrom32weeksofpregnancytolabor.Thewomeninthetreatmentgroupreceived1.2gofraspberryleaftwiceaday.

Noadverseeffectswereobserved,butalso,noeffectonshorteningthefirststageoflaborwasindicated.Ashorteningofthesecondstageoflaboroccurred(adifferenceof9.6minutes)andalowerrateofforcepsdeliverieswasnotedfortheraspberryleafgroupcomparedwiththecontrolgroup(19.3%and30.4%,respectively).Theauthorssuggestedthatearlierinterventionandahigherdoseshouldbestudied.11

•Apharmacologicstudyconductedinthe1940sobservedthatuterinecontractionsdecreasedinfrequencyandstrengthinthreepregnantwomenadministeredaraspberryleafextract.Secondarycontractionswerealsoeliminated.Averyslightfallinthesystolicbloodpressurewasnoticeable.Theauthorsnotedthatraspberryleafmaybeusefulfortreatingirregularuterineactionduringlaborandmenstruation.Thedosewasrecordedas20to40grains(approximately1.3to2.6g)ofcrudeextractofdriedraspberryleaves,containingfragarine.“Fragarine”isthetermtheauthorsproposedfortheactiveprincipleofthiscrudeextractofraspberryleaves.3Thistermhasbeenusedinpopularandscientificliteratureeversince,butnoevidencehasbeenfoundtoverifytheexistenceoffragarine,letaloneitschemicalstructure.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983WhitehouseB.BrMedJ.1941;2:370-371.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.BamfordDS,PercivalRC,TothillAU.BrJPharmacol.1970;40(1):161P-162P.BeckettAH,etal.JPharmPharmacol.1954;6:785-796.PatelAV,etal.JPharmPharmacol.1990;47(12B):1129.BurnJH,WithellER.Lancet.1941;2(6149):1-3.

10ParsonsM,SimpsonM,PontonT.JAustCollMidwives.1999;12(3):20-25.

11SimpsonM,etal.JMidwiferyWomensHealth.2001;46(2):51-59.

REDCLOVER

BotanicalName: TrifoliumpratenseFamily: LeguminosaePlantPartUsed: Flower

PRESCRIBINGINFORMATION

Actions Depurative,antitumor(traditionaluse)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingredcloverinformulationsinthecontextof:

•Skindisorders,includingeczema,psoriasis,andulcers(5)

•Respiratoryconditions,especiallywithspasmodiccough,includingbronchitis(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

1.5-6.0mlof1:2liquidextract

10-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Chronicskindisease,includingeczema,psoriasis,legulcers,andburns1,2

•Bronchitis,whoopingcough,laryngitis1,2

•Cancer2

PharmacologicResearch

Redcloverflowerscontainisoflavones,includingbiochaninA,formononetin,andgenistein.3Isoflavoneshavedemonstratedweakestrogenicactivityandundercertaincircumstancesexertanantiestrogeniccompetitiveactivity.4However,in25%aqueousethanolicextractsofredcloverflowers,theseconstituentsarepresentinlowquantities.3

ClinicalStudies

Trialsusingconcentratedextractsofredcloverleafandflower,standardizedforisoflavonecontenthavebeenconducted.However,giventhattraditionalliquidextractsarelowinisoflavones,thisinformationhasnotbeenreviewedhere.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

LehmannR,PenmanK:TechnicalReport.MediHerbPtyLtd,POBox713,Warwick,Queensland4370,Australia.MessinaMJ.AmJClinNutr.1999;70(suppl3):439S-450S.

REHMANNIA

BotanicalName: RehmanniaglutinosaFamily: GesneriaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Antipyretic,adrenaltonic,antihemorrhagic,antiinflammatory

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingRehmanniainformulationsinthecontextof:

•Rheumatoidarthritis,asthma,urticaria(4)

•Chronicnephritis,incombinationwithothertraditionalChineseherbs,includingAstragalus(4)

•Fevers,hemorrhage,skinrashes,diabetes,insomnia,constipation(5)

•Benefitinsupportingadrenalfunction,particularlyifhypertensionispresent(Unlikelicorice,Rehmanniaisnotcontraindicatedinhypertension.)(5,7)

•Preventingthesuppressiveeffectsofcorticosteroiddrugsonendogenouslevelsofcorticosteroids(7)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Inasmall,opentrialinvolvingpatientswithrheumatoidarthritis,intermittenttreatmentwithRehmanniadecoctionelicitedmildedemainaminorityofpatients.Excessivedosescancausediarrhea.

Dosage Doseperday* Doseperweek*

4.5-8.5mlof1:2liquidextract

30-60mlof1:2liquidextract

* ThisdoserangeisadaptedfromdriedplantdosagesadministeredbydecoctioninTCM.1The water is a more effective solvent than water for many phytochemicals are taken intoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

InTCM,RehmanniainitsuncuredformisthedriedrootofRehmanniaglutinosa.Thecuredformconsistsoftheclean,freshrootstewedinwine.Inthisprocess,therootiswashedinwine,steamed,dried,thenresteamed,anddriedseveraltimes.Unlessstatedotherwise,liquidextractsofRehmanniausuallyconsistoftheuncuredform.

TCMusesforuncuredRehmanniainclude:

•Febrilediseaseswithreddenedtongueandthirst1,2

•Hemorrhage2

•Spittingofblood,skineruptions1

•Diabetescausedbyinternalheat1

•Conditionscausedbyheartfire:mouthsores,insomnia,low-gradefevers,constipation2

•Conditionsofyindeficiencywithinternalheat1

TCMusesforcuredRehmanniainclude:

•Toregulatemenstruation,topromotebloodproductionandtonethekidneys3

•Anemia,dizziness,weakness,tinnitus1

•Amenorrhea,metrorrhagia3

•Nightsweats1

PharmacologicResearch

PharmacologicresearchconductedusingpolysaccharidesfromRehmanniainvitroandbyinjectionhasnotbeenlisted,becausethisactivityisprobablynotrelevanttotheoraluseofRehmannialiquidspreparedwithethanol.Rehmanniarootcontainsanumberofconstituents,includingiridoidglycosidesandotherglycosides.

•UncuredRehmanniainhibitedthemetabolismofcortisolbyhepatocytesinvitro.Oraladministrationinamodelofadrenalcortexdepletion(inducedbychronictreatmentwithglucocorticoids)resultedinraisedserumcorticosteronelevels.Rehmanniatreatmentalsopreventedorreversedmorphologicchangesinthepituitaryandadrenalcortex,appearingtoantagonizethesuppressiveeffectofglucocorticoidsonthehypothalamic-pituitary-adrenalaxis.

•CuredRehmanniaabolishedthesuppressiveeffectsofcyclophosphamideanddexamethasoneonimmunefunctionanddemonstratedprotectiveeffectsondisturbancesinhematopoiesis,immunity,andheart,liver,andkidneyfunctionsduringchemotherapyinvariousexperimentalmodels.

•AninvitrostudyfoundthatthreecompoundsfromRehmanniademonstratedaldosereductaseinhibitoryactivity.

•OrallyadministereduncuredRehmanniaimprovedhemorrheologyinexperimentalmodelsofarthritisandthrombosis.

ClinicalStudies

•UncontrolledtrialsusinguncuredRehmanniaproducedtherapeuticeffectsinpatientswithrheumatoidarthritis,asthma,andurticaria.

•OraladministrationofanherbalpreparationthatincludedRehmanniaandAstragalusdemonstratedtherapeuticeffectsinpatientswithchronicnephritis.

Significantimprovementwasobservedfor91%ofthetreatmentgroupcomparedwith67%ofthecontrolgroup.Thepreparationalsodemonstratedantiallergiceffectsandpromotionandmodulationofimmunefunction.Thedesignofthisclinicalresearchwasnotrigorousanditsresultsshouldbeinterpretedwithcaution.

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.

ROSEMARY

BotanicalName: RosmarinusofficinalisFamily: LabiataePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Carminative,spasmolytic,antioxidant,antimicrobial,circulatorystimulant,hepatoprotective

PotentialIndications

1

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingrosemaryinformulationsinthecontextof:

•Increasingmentalalertnessandmemory(6)

•EnhancingphaseIandIIdetoxificationbytheliver(7)

•Achievingantioxidantandhepatoprotectiveeffects,preventingatherosclerosis(7)

•Circulatoryweakness,includinghypotension(5,6)

•Dyspepticconditionsandparticularlyforimprovementofhepaticandbiliaryfunction(4)

•Headache,depression,debility(5)

•Topicaltreatmentforpromotingwoundhealing,asamildantiseptic,foralleviatingsymptomsofrheumaticdiseasesandcirculatoryproblems(4)

•Topicaltreatmentformyalgia,sciatica,andintercostalneuralgia(5)Noknowncontraindicationshavebeenfoundforrosemary,althoughcautionmaybewarrantedinwomenwishingtoconceive,basedonthecineolecontentinitsessentialoil.Inanembryotoxicstudyinvolvingrats,rosemaryaqueousextractdidnotcause

Contraindications significantchangesinpostimplantationlossorinthenumberofmalformationoffetuses.Preimplantationlossincreasedinthetreatedgroup,althoughthedifferencewasnotsignificantcomparedwiththecontrol.1

WarningsandPrecautions Nonerequired.

Interactions

Nonhemeironabsorptionwassignificantlydecreasedinfemalevolunteerswhoconsumedaphenolic-richextractofrosemary(8.2%byweightofpolyphenols,includingcarnosicacid,carnosol,androsmarinicacid).Theextractwasadministeredviathemeatcomponentofatestmealandcomparedwithacontrolmealoveratotalof4days.2Thisfindingindicatesapotentialinteractionforconcomitantadministrationofrosemaryduringironintake.Inanemiaandcasesforwhichironsupplementationisrequired,rosemaryshouldnotbetakensimultaneouslywithmealsorironsupplements.

UseinPregnancyandLactation

Noadverseeffectsexpected.(Seealsothe“Contraindications”sectioninthismonograph.)

SideEffectsNoneexpectediftakenwithintherecommendeddoserange.Contactallergyhasbeenreportedforrosemaryandmaybetheresultoftheconstituentcarnosol.3

Dosage Doseperday* Doseperweek*

2.0-4.5mlof1:2liquidextract

15-30mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Tostimulatethemind,memory,andthesenses4,5

•Flatulentdyspepsiaassociatedwithpsychogenictension6

•Migrainousorhypertensiveheadaches6

•Depressivestateswithgeneraldebilityandindicationsofcardiovascularweakness6

•Allstatesofchroniccirculatoryweakness,includinghypotension;debility;anorexiaandpoordigestion,particularlyinolderadults7

•Topicallyformyalgia,sciatica,andintercostalneuralgia6

Rosemaryleafcontainsanessentialoil(1%to2%),consistingof1,8-cineole,borneol,bornylacetate,α-pinene,andcamphene;phenolicditerpenes,includingcarnosolandcarnosicacid;rosmarinicacid;flavonoids;andtriterpenoids.8,9(Carnosicacidisalsoknownascarnosolicacidorsalvin.)

•Rosemaryisastrongantioxidant.Theantioxidantactivityisattributedtothephenolicditerpenes(particularlycarnosicacidandcarnosol),aswellasrosmarinicacid.Thesecomponentshaveinhibitedlipidperoxidation,aregoodscavengersoffreeradicals,andprotectredbloodcellsagainstoxidativehemolysisin

vitro.10,11Rosemaryextracthasinhibitedoxidativealterationstoskinsurfacelipidsinvitroandinvivo.12

•Becauseofitsstrongantioxidantactivity,rosemaryisusedinthefoodindustryasapreservative,particularlyformeatproducts.13Aninvitrocomparisonwith15otherherbsfoundthatrosemaryexhibitedthehighestantioxidantindexinallthetestedfats,particularlyinanimalfats.14(Carnosolandcarnosicacidarefat-soluble.)Rosmarinicacidisalsoapotentantioxidant,butitssolubilityinfatislow,thusitactsbestinaqueoussystems.Thestrongantioxidantactivitytowardsaturatedfatsisunusual,giventhatmostantioxidantplantextractsandphytochemicalsdemonstrateactivityonlyinaqueoussystems.Thisactionmayindicateavaluableroleintreatingandpreventingpathologicprocessesthatinvolvelipidperoxidation,suchasthedevelopmentofatherosclerosis.

•Experimentalstudiesindicatedthatoraladministrationofrosemaryleafishepatoprotective,whichhasbeenattributedtotheantioxidantphenoliccompounds.15Oraladministrationofamethanolicextractofosemaryenhancedlivermicrosomalmetabolismofendogenousestrogens.Rosemaryalsoinhibitedtheuterotropicactionofestradiolandestrone.16

•Oralintakeofrosemaryextractreducedthedevelopmentofmammarycarcinomainvivo.17Rosemaryextractmayassistinreversingmultidrugresistanceinmammarytumors,asindicatedbyitsabilitytoinhibitthetransmembranetransportpumpactivityinisolatedbreastcancercells.18

•Rosemaryextract,oritscomponents,carnosolorcarnosicacid,arepotentinhibitorsofDNAadductformationinducedbybenzo(a)pyreneoraflatoxinB1invitro.19ThesesubstancesactbyinhibitingcytochromeP-450activity(phaseIenzymes)andinducingglutathione

PharmacologicResearch

S-transferase(phaseII).20Oraladministrationofrosemaryextract(0.25%to1.0%)inthedietofratsincreasedtheactivityofthephaseIIenzymesglutathioneS-transferaseandNADPH-quinonereductase.21Water-solubleextractofrosemaryinducedphaseIandIIenzymesinvivo(byoralroute).Thisactivitywasattributedtoflavones,monoterpenes,oranadditiveeffectofallcomponentsbutnottorosmarinicacidalone.22AfurtherinvivostudyusingoraldosesindicatedthatthefractioncontainingthediterpenesinducedphaseIIenzymes.23

•Rosemaryextractdemonstratedinvitroantimicrobialactivitytowardfood-bornemicroorganisms,24Leishmaniamexicana(80%ethanolextract),25Yersiniaenterocolitica(ethanolextract),26andHSVtype2.27

•RosemaryoilalsodemonstratedantimicrobialactivityinvitrotowardCandidaalbicans28andanumberofbacteriathatcauserespiratoryandgastrointestinaldisorders(e.g.,Pseudomonasaeruginosa,Escherichiacoli,Aspergillusfumigatus)bygaseouscontact.Rosemaryoilalsodelayedsporulationofseveralfilamentousfungi.29

•Normalanddiabeticmicewithunlimitedaccesstoarosemaryinfusionfor3monthshadlowerbloodglucoselevelscomparedwithcontrols.30

•Aqueous-alcoholicextractofrosemary(1g/kg,orally)inhibitedexperimentallyinducedgastriclesions.Thisactivitymaybetheresultofenhancedmucosaldefense.31

•Oraladministrationofrosemaryinfusiondemonstrateddiureticactivityinvivo.32

•Rosemaryoilproducedarelaxanteffectonexperimentallyinducedcontractionsinisolatedtrachealsmoothmuscle,33aorticsegments,34andintestine.35Rosemaryextractdemonstratedspasmolyticactivityon

experimentallycontractedisolatedileum.36

•Topicalapplicationofachloroformextractofrosemarydemonstratedadose-dependentantiinflammatoryactivityinthecrotonoil–inducedearedemamodel.37Rosmarinicacidinhibitedexperimentallyinducedanaphylaxis(byoralroute).Furthertestsindicatedaselectivityofthiscompoundforcomplement-dependent(inflammatory)processes.38

•Injectionoffreeze-driedrosemaryextract(floweringstems)producedanincreaseinbileflowfromboththeliverandgallbladderinvivo.39

•Bothinhalationandoraladministrationofrosemaryoilstimulatedlocomotoractivityinanexperimentalmodel.40

ClinicalStudies

Noclinicalstudiesusingrosemaryleafhavebeenfound.However,someclinicalstudieshaveusedrosemaryessentialoil.

•Inhalingrosemaryleafoilfor3minutesbyvolunteersproduceddecreasedfrontalalphaandbetapower(measuredfromelectro-encephalographic[EEG]recordings),suggestingincreasedalertness.Anxietyscoreswerelowered.Volunteersreportedfeelingmorerelaxedandalertandwerefaster(butnotmoreaccurate)atmathematicalcomputationscomparedwithbaselinevalues.Thetrialwasrandomizedandcontrolled.41

•Inanuncontrolledtrial,anaqueousemulsionofrosemaryoil(1:10)inhibitedthegrowthofCandidaalbicanswhenappliedtothemouths(fivetimesperday)of12patientswithcancer,pneumonia,andoralcandidiasis,whichwasunresponsivetonystatin.42

•InGermany,theCommissionEsupportsusingrosemaryleaftotreatdyspepticconditions.Externally,rosemaryleafcanbeusedassupportivetherapyforrheumatic

diseasesandcirculatoryproblems.43

•ESCOPrecommendsrosemaryleafandflowerforimprovinghepaticandbiliaryfunctionandindyspepticconditions.Inadditiontotherecommendationspreviouslylistedfortopicaluse,whicharealsolistedbytheCommissionE,rosemarycanbeusedexternallyforthepromotionofwoundhealingandasamildantiseptic.44

REFERENCES

LemonicaIP,DamascenoDC,di-StasiLC.BrazJMedBiolRes.1996;29(2):223-227.SammanS,etal.AmJClinNutr.2001;73(3):607-612.HjortherAB,etal.ContactDermatitis.1997;37(3):99-100.GerardJ,WoodwardM.Gerard’sherbal:theessencethereofdistilledbyMarcusWoodwardfromtheeditionofTh.Johnson,1636.London:BrackenBooks,1985.CulpeperN:Culpeper’scompleteherbal,andEnglishphysician,Manchester,1826,J.Gleave&Son,reprintedBath,1981,HarveySales.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.WeissRF.Herbalmedicine,Englished.Beaconsfield,UK:BeaconsfieldPublishers,1988.WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.

Stuttgart:MedpharmScientificPublishers,1994.10HaraguchiH,etal.PlantaMed.1995;61(4):333-336.11AruomaOI,etal.Xenobiotica.1992;22(2):257-268.12CalabreseV,etal.IntJTissueReact.2000;22(1):5-13.13SchwarzK,TernesW.ZLebensmUntersForsch.1992;195(2):95-98.

14HalliwellB,etal.FoodChemToxicol.1995;33(7):601-617.15FahimFA,etal.IntJFoodSciNutr.1999;50(6):413-427.16ZhuBT,etal.Carcinogenesis.1998;19(10):1821-1827.17SingletaryKW,NelshoppenJM.CancerLett.1991;60(2):169-175.

18PlouzekCA,etal.EurJCancer.1999;35(10):1541-1545.19OffordEA,etal.CancerLett.1997;114(1-2):275-281.20MaceK,etal.ArchToxicolSuppl.1998;20:227-236.21SingletaryK,GutierrezE.FASEBJ.1993;7(4):A866.22DebersacP,etal.FoodChemToxicol.2001;39(2):109-117.23DebersacP,etal.FoodChemToxicol.2001;39(9):907-918.24DelCampoJ,AmiotMJ,Nguyen-TheC.JFoodProt.2000;63(10):1359-1368.

25SchnitzlerAC,NolanLL,ShettyK.ActaHort.1996;426:235-241.

26BaraMTF,VanettiMCD.JHerbsSpicesMedPlant.1995;3(4):51-58.

27RomeroE,TateoF,DebiaggiM.MittGebieteLebensmHyg.1989;80:113-119.

28SteinmetzMD,Moulin-TraffortJ,RegliP.Mycoses.1988;31(1):40-51.

29LarrondoJV,AgutM,Calvo-TorrasMA.Microbios.1995;82(332):171-172.

30ErenmemisogluA,SaraymenR,UstunS.Pharmazie.1997;52(8):645-646.

31DiasPC,etal.JEthnopharmacol.2000;69(1):57-62.32HalouiM,etal.JEthnopharmacol.2000;71(3):465-472.33AqelMB.JEthnopharmacol.1991;33(1-2):57-62.34AqelMB.IntJPharmacogn.1992;30(4):281-288.35HofS,GropperB,AmmonHPT.ArchPharm.1988;321:702.

36ForsterHB,NiklasH,LutzS.PlantaMed.1980;40(4):309-319.

37BrkicDetal:InternationalCongressand48thAnnualMeetingoftheSocietyforMedicinalPlantResearchandthe6thInternationalCongressonEthnopharmacologyoftheInternationalSocietyforEthnopharmacology,Zurich,September3-7,2000,abstractP2A/1.

38EnglbergerW,etal.IntJImmunopharmacol.1988;10(6):729-737.

39MongoldJJ,etal.PlantMedPhytother.1991;25(1):6-11.

40KovarKA,etal.PlantaMed.1987;53(4):315-318.41DiegoMA,etal.IntJNeurosci.1998;96(3-4):217-224.42DurakovicZ,DurakovicS.JIndianMedAssoc.1979;72(7):175-176.

43BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

44ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Rosmarinusfoliumcumflore.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.

SAGE

BotanicalName: SalviaofficinalisFamily: LabiataePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Spasmolytic,antioxidant,astringent,antihyperhidrotic,antimicrobial

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingsageinformulationsinthecontextof:

•Inflammationsandinfectionsofthemouthandthroat(4,5)

•Dyspepsia(4,5)

•Excessivesweating(4,5)

•Menopausalhotflashes*andnightsweating,incombinationwithMedicagosativa(4)

•Reducingorstoppinglactation(5)

•Febrileconditions(5)

•Nervousdebility,nervousexhaustion(6)

•Topicaltreatmentforinflammationsofthemucousmembranesofthenose(4)

•Topicaltreatmenttostoptheflowofmilk(5)

Contraindications Pregnancyandlactation.1(Seealsothe“UseinPregnancyandLactation”sectioninthismonograph.)

WarningsandPrecautions

Therecommendeddosemustnotbeexceeded.Cautionshouldbetakenwithlong-termuse.1(Thesecautionsaremadebecauseofthepresenceofthepotentiallytoxiccomponentthujoneintheessentialoilofsage

leaf.)Interactions Noneknown.UseinPregnancyandLactation

Contraindicatedinpregnancyandlactation.However,sagehasbeenusedtraditionallytostopmilkflow.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday** Doseperweek**

2.0-4.5mlof1:2liquidextract

15-30mlof1:2liquidextract

* Sagehasalsobeenusedintraditionalherbalmedicinefortreatinghotashes.(6)

** This dose range is extrapolated from theBritishHerbalPharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Inflammationofthemouth,tongue,orthroatandtopicallyfortheseconditions2

•Flatulentdyspepsia,debilitateddigestion,2,3biliousandkidneydisorders4

•Excessivesweating,2,3hotflashesofmenopause5

•Nervousexhaustion,debilityofthenervoussystem,jointpain,tensionheadache4

•Toimprovethememoryandstimulatethesenses6

•Tostoptheflowofmilk,bothoral2andtopicaluse3

PharmacologicResearch

Theaerialpartsofsagecontain1.5%to2.5%essentialoil,thecompositionofwhichvariesdependingonitsorigin.Theessentialoilcontainsmonoterpenes,includingapproximately30%thujoneinsomevarieties.Highdosesofthujonemaycauseneurotoxicity.Otherconstituentsofsageincludeflavonoids,rosmarinicacid,andphenolicditerpenes,includingcarnosolandcarnosicacid.7,8(Carnosicacidisalsoknownascarnosolicacidorsalvin.)

•Sageextractcausedinhibitionoflipidperoxidationinvitro.9Isolatedconstituentsofsagefoundtohaveinvitroantioxidantactivityincludethephenolicditerpenescarnosol,rosmanol,andcarnosicacid.10

•Sageextractadministeredbyinjectiondemonstrated

hypotensiveandspasmolyticactivityinexperimentalmodels.11

•Sageextractandsageoilinhibitedacetylcholinesteraseinaconcentration-dependentmannerinhumanbraintissueinvitro.12DiterpenesisolatedfromsagewerefoundtointeractwiththeGABA-benzodiazepinereceptor.13

•Aqueousextractofsagedemonstratedmoderateantibacterialactivityinvitro.14

•Topicalapplicationofachloroformextractofsagedemonstrateddose-dependentantiinflammatoryactivityinthecrotonoil–inducedearedemamodel.15

ClinicalStudies

•Inanumberofopenstudies,sagehasreducedsweatproductioninpatientswithhyperhidrosis(excessivesweating).Dailydoserangedfromtheequivalentof2.6to4.5gofleaf.1

•Aproductcontainingsageandalfalfa(Medicagosativa)extractsproducedimprovementinthemenopausalsymptomsofhotflashesandnightsweatsinanopentrialconductedfor3months.Theproductappearedtoproduceaslightcentralantidopaminergicactivity.16

•InGermany,theCommissionEsupportsusingsagetotreatdyspepticsymptoms,excessiveperspiration,andexternallyforinflammationsofthemucousmembranesofthenoseandthroat.17

•ESCOPrecommendssageleaffortreatinginflammationsandinfectionsofthemouthandthroat,suchasstomatitis,gingivitis,andpharyngitis,aswellashyperhidrosis.1

REFERENCES

ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Salviaefolium.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.CulpeperN:Culpeper’scompleteherbal,andEnglishphysician,Manchester,1826,J.Gleave&Son,reprintedBath,1981,HarveySales.WagnerH,BladtS.Plantdruganalysis:athinlayerchromatographyatlas,ed2.Berlin:Springer-Verlag,1996.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.HohmannJ,etal.PlantaMed.1999;65(6):576-578.

10WangM,etal.JNatProd.1999;62(3):454-456.11TodorovS,etal.ActaPhysiolPharmacolBulg.1984;10(2):13-20.

12PerryN,etal.IntJGeriatrPsychiatry.1996;11(12):1063-1069.

13RutherfordDM,etal.NeurosciLett.1992;135(2):224-226.14BrantnerA,GreinE.JEthnopharmacol.1994;44(1):35-40.15BrkicDetal:InternationalCongressand48thAnnualMeetingoftheSocietyforMedicinalPlantResearchandthe6thInternationalCongressonEthnopharmacologyoftheInternationalSocietyforEthnopharmacology,Zurich,September3-7,2000,abstractP2A/1.

16DeLeoV,etal.MinervaGinecol.1998;50(5):207-211.17BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

SARSAPARILLA

CommonName: Sarsaparilla

BotanicalNames:

Smilaxornata,Smilaxregelii,+Smilaxfebrifuga,+Smilaxmedica+Note:Otherspecieshavealsobeenlistedintraditionaltexts,althoughtheywerelessfavored(e.g.,S.officinalis).SmilaxaristolochiifoliaisabotanicalsynonymofS.medicaandthereforeisalsoamedicinallyinterchangeablespeciesforSmilaxornata.

Family: SmilacaceaePlantPartUsed:

Rootandrhizome

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Antirheumatic,depurative,antiinflammatory

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingsarsaparillainformulationsinthecontextof:

•Psoriasis(4a,4,5)

•Chronicskindisorders(5)

•Rheumatoidarthritis(5)

•Providinggeneraltoniceffects(6)Contraindications Noneknown.

WarningsandPrecautions

TheGermanCommissionEadvisesthattakingsarsaparillapreparationsleadstogastricirritationandtemporarykidneyimpairment(diuresis).Theabsorptionofsimultaneouslyadministeredsubstances(suchasdigitalisglycosidesorbismuth)isincreased.Theeliminationofothersubstances(e.g.,hypnotics)isaccelerated.Thisactioncancauseanuncontrolledconditionofincreasedordecreasedactionoftreatmentstakensimultaneously.1However,theseconcernsaretheoreticalandnotbasedonanimalexperimentsorclinicalcasereports,andtheywouldapplyforanyherbcontainingsaponins.Suchconcernswouldbealleviatedbynottakingsarsaparillasimultaneouslywithdrugmedication.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

Noneexpectediftakenwithintherecommendeddose

SideEffects range.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

Althoughthesedosesreflectrecentmodernuse,nineteenthcenturycliniciansusedsubstantiallyhigherdoses,possiblybecauseofthentisyphiliticapplication.Forexample,theBritishPharmacopoeia1898recommended8to15mlthreetimesperdayofa1:1extract.

Theclinicaltrialwithpsoriasispatients(seelaterdiscussion)used15gperdaybydecoction,butwaterdoesnoteffectivelyextractsaponins.Hencelowerdosesofethanol-waterextractsmaystillbeaseffective.Nonetheless,acasemaybemadeforincreasingthesarsaparilladoseifthepatient’s

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Chronicskinconditions,especiallypsoriasis2,3

•Rheumatoidarthritis,syphilis,dropsy2,3

•Adjuvanttherapyforleprosy2

SmilaxregeliiroothasalsobeenusedtraditionallyinGuatemalafortreatingskindiseases,includingabscess,boils,andacne,aswellasurinarytractinfections.4,5SpeciesofSmilax(“zarzaparrilla”[S.aristolochiaefoliaandotherspecies]and“cuculmeca”[Smilaxspp.])6havebeenusedtraditionallyinCentralAmericaforbloodandskindisorders,snakebite,andasatonictoenhancevigorandtreatweakness.7

Sarsaparilla,whichwasintroducedintoNorthAmericafromSpanishAmerica,islistedinSpanishpharmacopoeiasfrom1739to1954,withthemajoractionsbeingsudorific(inducingsweating,similartoadiaphoretic),antivenereal,andantirheumatic.Sarsaparillawasusedextensivelyinthesixteenthandseventeenthcenturiesfortreatingsyphilis.8

SarsaparillafromseveralspeciesofSmilax(nottobeconfusedwiththeAmericanorwildsarsaparilla,Aralianudicaulis)wasofficialintheUSPfrom1820to1955andtheNFfrom1955to1965andwasusedasatonicandflavoringagent.NativeAmericansusedsarsaparillatotreatmanydiversediseases.9

NativesoftheAmazonhaveusedtheroot(Smilaxofficinalis)toreestablishvirilityinmenandtotreatsymptomsofmenopause.10Suchapplicationsmightwell

beanticipated,giventhesteroidalsaponincontentoftheplant.

PharmacologicResearch

Speciesofsarsaparillacontainsteroidalsaponinsforwhichsarsasa-ogeninandsmilageninhavebeenidentifiedasaglycones.11

•AqueousextractofSmilaxregeliirootinhibitedthefollowingdermatophytesinvitro:Epidermophytonfloccosum,Microsporumcanis,andTrichophytonmentagrophytes.4

•OralpretreatmentofratswithSmilaxregeliiextractinhibitedcarbontetrachloride–inducedhepatocellularmetabolicchanges.12

•Sarsaparillaproductshavebeenpopularamongathletesandbodybuildersfortestosteronesupplementation.Despitethistraditionaluse,sarsaparilladoesnotcontaintestosterone,andthesteroidalsaponinsdonotbehaveasanabolicsteroids.Astudyreviewingallclinicaltrialspublishedbetween1966and1992foundnodocumentedevidencetosubstantiateclaimsthatdiosgenin,smilagenin,andhecogeninincreasegrowthhormonereleaseinthebody.13

ClinicalStudies

•Oraladministrationofsarsaparillaimprovedpsoriasisinover50%ofpatientstreatedinopen,uncontrolledtrials.14-18Thedailydoseprovidedforoneofthesetrialswasasarsaparillarootdecoction(15gin1L).15Inmanyofthesetrials,alow-fatdietandointmentswerealsoused,andlong-termuseofsarsaparilla(2to3months)wasrequired.Saponinsfromsarsaparillaproducedgreaterimprovementinpsoriasispatientscomparedwithcontrols.Sarsaparillasaponinsweremorebeneficialforchronicplaquepsoriasis.Theaverageperiodoftreatmentwas4months,witharangeof4weeksto7months.19

•Smilaxornataextract(equivalentto30groot/day)taken

forseveralmonthswassuperiortosulfonesintreatingleprosy.20Favorableresultswereobtainedinalateruncontrolledtrialusingacombinationofsarsaparillaandsulfonesforleprosytreatment.21

•Sarsaparillarootextract(2.4g/day)producedadecreaseinserumureainbothhealthyvolunteersandpatientswithnephritis.Accordingtotheauthors,thisfindingmayhavebeentheresultofincreasedurinaryexcretion.Symptomsofacuteuremia(e.g.,headaches,appetiteloss)wererelievedwiththereductioninserumurea.22

REFERENCES

BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983CaceresA,etal.JEthnopharmacol.1991;31(3):263-276.CaceresA,etal.JEthnopharmacol.1987;20(3):223-237.Hersch-MartinezP.EconBot.1997;51(2):107-120.VillalobosR.RevForestCentroam.2000;32:39-42.FernandezNegriMA,LopezAndujarG.ArsPharm.1990;31(3-4):223-231.VogelVJ.AmericanIndianmedicine.Norman,Okla:

UniversityofOklahomaPress,1970.10EvansSchultesR,RaffaufRF.Thehealingforest:medicinalandtoxicplantsoftheNorthwestAmazonia.Portland:DioscoridesPress,1990.

11HostettmannK,MarstonA.Chemistry&pharmacologyofnaturalproducts:saponins.Cambridge:CambridgeUniversityPress,1995.

12RafatullahS,etal.IntJPharmacogn.1991;29(4):296-301.13BarronRL,VanscoyGJ.AnnPharmacother.1993;27(5):607-615.

14DenekeT.DtschMedWochenschr.1936;62:337-341.15PhilippsohnA.DermatolWochenschr.1931;93:1220-1223.16RitterH.DtschMedWochenschr.1936;62:1629-1631.17ZaunH.DtschMedWochenschr.1938;64:1073.18BairdPCJr.NEnglJMed.1939;220:794-801.19ThurmanFM.NEnglJMed.1942;227:128-133.20RollierR,etal.MarocMed.1951;30:776-780.21RollierR.IntJLeprosy.1959;27:328-340.22RittmannR,SchneiderF.KlinWochschr.1930;9:401-408.

SAWPALMETTO

BotanicalNames: Serenoaserrulata,Serenoarepens,#Sabalserrulata#

Family: PalmaePlantPartUsed: Fruit

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antiinflammatory,maletonic,antiprostatic,spasmolytic,possiblyantiandrogenic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingsawpalmettoinformulationsinthecontextof:

•MildtomoderateBPH(4,5)

•Inflammationofthegenitourinarytract,especiallycystitis,atrophyofsexualtissues;asanaphrodisiac;sexhormonedeficiency(5)

•Noninfectiousprostatitis(7)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Sawpalmettoiswelltoleratedbymostpatientsandcausesrelativelyfewsideeffects.Mostsideeffectsareminorgastrointestinalproblems,suchasnausea,whichareusuallyresolvedwhentheherbistakenwithmeals.

Onecaseofhemorrhageduringsurgery,whichwasassociatedwithintakeofsawpalmettoextract,hasbeenreported.1

Dosage Doseperday* Doseperweek*

2.0-4.5mlof1:2liquidextract

15-30mlof1:2liquidextract

Capsulescontaining160mgoftheliposterolicextract(LESP)areusuallyrecommendedattwocapsulesperday.**Thisextractisan8:1to10:1concentrateoftheoriginaldriedberries(i.e.,approximately2.88g/dayofsawpalmettoberries).HenceusingLESPreflectsahigherdosingstrategythanthatstatedhere.

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1934, theBritishHerbalPharmacopoeia1983,andtheGermanCommissionE.

** ThisdoserangeisextrapolatedfromclinicaltrialsandtheGermanCommissionE.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Prostatichypertrophy,inflammationofthegenitourinarytract(especiallycystitis),genitourinarytractdischarge,atrophyofsexualtissues,sexhormonedisorders;asanaphrodisiac2,3;enlargedovaries,undevelopedmammaryglands4

•Irritativecough,chronicbronchialcoughs,whoopingcough,laryngitis,acutecatarrh,asthma3

•Toimprovedigestion;asatonicforthenervoussystem4

NativeAmericansatesawpalmettoberries.SawpalmettowasofficialintheUSPfrom1906to1916andtheNFfrom1926to1950andwasusedasadiuretic,sedative,andanticatarrhal.5

PharmacologicResearch

Sawpalmettoberriescontainfreefattyacids,triglycerides,phytosterols(mainlyβ-sitosterol),fattyalcohols,flavonoids,andpolysaccharides.

LESPisaspeciallypreparedextractionofdriedsawpalmettoberriesusinghexane,90%ethanol,orsupercriticalcarbondioxide.Theliposterolicextractcontains85%to95%fattyacids(mostlyastriglycerides)and0.2%to0.4%totalsterols(with0.1%to0.3%β-sitosterol).Flavonoidsareunlikelytobepresent,exceptintheextractpreparedusing90%ethanol.

•AndrogendeprivationcandecreasetheobstructivesymptomsofBPH.InvitrostudiesconfirmthatthelipidcomponentofLESPweaklyinhibits5α-reductase(anenzymethatconvertstestosteronetoitsmorepotentform:

DHT),butsawpalmettoprobablydoesnotpossessclinicallysignificantactivityasa5α-reductaseinhibitor.

•InvitroresearchfoundthatLESPinhibitedtestosteroneandDHTbindinginseveraltissuespecimens,includingvaginalskinandprepuce.AnotherstudyfoundthatLESPdidnotinhibitbindingofDHTtoprostaticandrogenreceptorinanexperimentalmodel.

•LESPhadaproliferativeeffectonandrogen-responsiveprostatecancercellsatlowconcentrationsandacytotoxiceffectathigherconcentrations.Incellsunresponsivetoandrogenstimulation,LESPexertedaconcentration-dependent,antiproliferativeaction.ThisantiandrogenicactivitywasconfirmedforLESPinseveralanimalmodels.

•LESPinhibitedtheeffectsofprolactinonhamsterovarycells,suggestingthattheextractmayinhibitprolactin-inducedprostategrowth.

•Dynamicallycausedurinaryoutletobstructionisassociatedwithincreasedsmoothmuscletone.Saponifiableandethanolicliposterolicextractsofsawpalmettoproducedaspasmolyticeffectonisolateduterus,bladder,andaorta.

•BPHisassociatedwithcongestionandanoninfectiousprostatitis,whichisevidencedbywhitecellinfiltrationoftheprostate.Agentswithantiinflammatoryandedema-protectiveactivitiesmayimprovetheclinicalpicture.LESPwasfound,invitro,tobeadualinhibitorofcyclooxygenaseand5-lipoxygenase.Theactivitywasfoundtoresideintheacidiclipophilicfraction.

•Apronouncedantiedematouseffectwasobservedfororaldosesofanalcoholextractofsawpalmettoincarrageenan-inducededemaofratpaw.LESPdemonstratedantiedematousactivityinanumberof

experimentalmodels,withanantagonisticeffectobservedagainsthistamine-inducededemabutnotinrelationtoserotonin-orbradykinin-inducedweals.Theparticipationofglucocorticoidsinthisantiinflammatoryactivitywasexcluded.

•InexperimentalmodelsofBPH,highoraldosesofLESPinhibitedprostaticgrowthincastratedmicegiventestosterone.Amoderatedoseachievedasimilaroutcomeinaratmodel.AmodelofBPHthatusestransplantsofhumanprostratetissueintohairlessmicefoundhighoraldosesofLESPreversedthehormonalstimulation(byDHTandestradiol)ofprostategrowth.

ClinicalStudies

Exceptwhenspecified,alloftheclinicalstudieslistedhereused320mg/dayofLESP,whichisequivalenttoanaveragedailydoseof2.88gofsawpalmettoberries.Sawpalmettoliquidextractswillalsoprovidesuchtherapeuticbenefits,providedsimilardosageconsiderationsareobserved.

•AsystematicreviewofrandomizedclinicaltrialsfoundthatLESPimprovedurologicsymptomsandflowmeasurescomparedwithplacebo.LESPproducedsimilarimprovementinurinarysymptomsandflowcomparedwithfinasterideandisassociatedwithfeweradversereactions.6Thetrialsoutlinedinthissectionwerecoveredinthisreview.

•Severalrandomized,double-blind,placebo-controlledtrialsdemonstratedthattreatmentwithLESPfor28to90dayssignificantlyreducedsymptomsandnocturnalfrequencyandincreasedpeakurinaryflowratesandpostvoidresidual(PVR)inpatientswithBPH.Onerandomized,double-blind,placebo-controlledtrialfoundthatalthoughLESPtreatmentimprovedBPHsymptoms,equalimprovementwasobservedintheplacebogroup.

•Onehundredandseventysix(176)nonresponderstoplacebowereselectedforadouble-blind,placebo-

controlled,multicenterstudyinvestigatingBPH.LESPtreatmentsignificantlyimproveddysuria,significantlyincreasedpeakurinaryflowrate,anddecreaseddaytimeandnocturnalurinaryfrequencycomparedwithaplacebo.Thistrialhadarelativelyshortassessmentperiod(30days).

•Anumberofdouble-blind,comparativestudiesinvolvingLESPhavebeencompleted.NosignificantdifferenceswereobservedbetweenLESPandfinasteride(5mg/day)forimprovingqualityoflifeandIPSS,butfinasteridedidsignificantlyincreasepeakflowrateoverLESPinalarge-scale,randomizedtrial.Thistrialwas26weeksinduration,andfinasteridecanshowincreasingefficacyupto1yearafterinitiationoftherapy.MeanPVRandpeakurinaryflowoutcomeswerenotsignificantlydifferentbetweenLESPandalfuzosin(7.5mg/day),buttheBoyarskyandobstructivescoresweresignificantlybetterforalfuzosinina3-weektrial.(Alfuzosinisafast-actingdrug.)LESPcomparedfavorablywithmepartricin(100,000internationalunits/day)fornocturnalfrequency,dysuria,andPVRandwithprazosin(4mg/dayfor12weeks)forurinaryfrequency,meanurinaryflowrate,andPVR.

•ResultsfromseveraluncontrolledclinicaltrialsdemonstratedsignificanttherapeuticeffectsforLESPinpatientswithBPHoverthelongterm(3yearsinonestudy),withgoodtoexcellenttolerability.

•Double-blind,controlledtrialsofcombinationtherapywithLESPandotherphytotherapeuticagentshavebeenundertaken.Urinaryflow,micturitiontime,residualurine,frequencyofmicturition,andasubjectiveassessmentoftheeffectoftreatmentwereallsignificantlyimprovedoverplaceboforLESPandpumpkinseedextract(480mg/dayofextract)combinationtherapy.WhenLESPwascombinedwithnettleroot(equivalentto2.4g/dayofroot)andcomparedwithplaceboover24weeks,significant

improvementswereseeninIPSSandpeakflowbutnotPVR.WhentheLESP-nettlerootcombinationwascomparedwithfinasteride(5mg/day)over48weeks,bothtreatmentssignificantlyimprovedurinaryflowandIPSS,andnosignificantdifferenceswereobservedbetweenthetwotreatments.Theherbalcombinationhadbettertolerabilitythanfinasteride.Asubsequentanalysisofasubgroupofpatientsfromthistrialindicatedthatefficacywasunrelatedtoprostatevolume.7Arandomized,placebo-controlledtrialpublishedin2000indicatedthatablendofLESP,nettleroot,pumpkinseedoil,andlemonflavonoidextractimprovedclinicalparametersinsymptomaticBPHslightlymorethanplacebo.Theblendwasassociatedwithsignificantepithelialcontraction,especiallyinthetransitionzone,indicatingapossiblemechanismofactionfortheclinicaleffect.8ThisblendalsoinducedsuppressionofprostatictissueDHTlevelsinarandomizedclinicaltrialinvolvingpatientswithBPH.9

•InGermany,theCommissionEsupportsusingsawpalmettototreaturinationproblemsinBPHstagesIandII.10

•SawpalmettohasbeenreinstatedtotheUSPandisofficialintheUSP24-NF19.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.CheemaP,El-MeftyO,JaziehAR.JInternMed.2001;250(2):167.

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983EllingwoodF,LloydJU.Americanmateriamedica,therapeuticsandpharmacognosy,ed11.Portland:EclecticMedicalPublications,1983.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.WiltTJ,etal.JAMA.1998;280(18):1604-1609.CochraneDatabaseSystRev(2):CD001423,2000.SokelandJ.BJUInt.2000;86(4):439-442.MarksLS,etal.JUrol.2000;163(5):1451-1456.MarksLS,etal.Urology.2001;57(5):999-1005.

10BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

SCHISANDRA

OtherCommonName: SchizandraBotanicalNames: Schisandrachinensis,Schizandrachinensis#

Family: SchisandraceaePlantPartUsed: Fruit

# Alternativename.

PRESCRIBINGINFORMATION

Actions Hepatoprotective,antioxidant,adaptogenic,nervinetonic,antitussive,oxytocic,mildantidepressant

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingSchisandrainformulationsinthecontextof:

•Acuteorchronicliverdiseases,includinghepatitis(3)

•Improvingthedetoxifyingcapacityoftheliver(7)

•Improvingphysicalperformance,endurance,andresistancetotheeffectsofstress(3)

•Improvingmentalperformance(4)

•Chemicalliverdamage,poorliverfunction(7)

•Chroniccough,asthma(5)

•Spontaneousornightsweating,nocturnalemission,spermatorrhea,enuresis,frequenturination(5)

Contraindications

InTCM,Schisandraiscontraindicatedintheearlystagesofcoughorrashandinexcessheatpatterns.1Schisandraiscontraindicatedinpregnancy,exceptatbirth.

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation

Contraindicatedinpregnancy,excepttoassistchildbirth.

SideEffects

Mildgastrointestinalsymptoms(e.g.,heartburn,indigestion,nausea)andheadachehavebeenreported.Inonetrial,4outofthe107patientstreatedwiththeequivalentof1.5gperdayofdriedfruitdevelopedmildandtransientnausea,headache,andstomachache.2,3

Dosage Doseperday* Doseperweek*

3.5-8.5mlof1:2liquidextract

25-60mlof1:2liquidextract

* ThisdoserangeisadaptedfromdriedplantdosagesadministeredbydecoctioninTCM.4Theauthor’sexperienceandthefactthatethanol-waterisamoreeffectivesolventthanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Chroniccough,asthma1,4•Nocturnalemission,spermatorrhea,leukorrhea,enuresis,frequenturination1,4

•Protracteddiarrhea1,4

•Spontaneousornightsweating,impairmentofbodyfluidwiththirst1,4

•Shortnessofbreathandfeeblepulse,diabetescausedbyinternalheat,

palpitation,amnesia,andinsomnia1,4

Dibenzocyclooctenelignans(suchasschisandrin)arekeyconstituentsofSchisandrafruit.

•Numerousstudies,invitro5,6andinvivoafteroraladministration,7-14havedemonstratedthehepatoprotectiveactivityofSchisandraanditsconstituentsinresponsetotoxicchallenge.

•Schisandraanditsconstituentshaveshownantioxidantactivityinvitro7,15andinvivoviaoraladministration.13,15,16

•ThemechanismofactionofthehepatoprotectiveactivityofSchisandraislikelytoinclude:

•Antioxidantactivitywithintheliver8,17

PharmacologicResearch

•Facilitationofglutathioneregenerationviatheglutathionereductase–catalyzedandNADPH-mediatedpathways13

•Inhibitionoftheactivationofthehepatotoxin8andthebindingofitsresultantmetabolitestolivermicrosomes18

•DespitebeingapostulatedpowerfulinducerofphaseIenzymes,Schisandradoesnotincreaseharmfulbioactivation(theproductionofamoretoxiccompound)invivo(e.g.,aftercoadministrationofacetaminophen)andinvitrostudieshaveindicatedthatconstituentsofSchisandradecreasethemutagenicityofbenzo(a)pyrenebyfavorablyinfluencinghepaticmetabolism.19,20

•Schisandrawasshowntohaveadaptogenicandtoniceffectsinseveralexperimentalmodels.RenalandgonadalRNA,glycogen,andenzymelevelswereincreasedinmatureanimalscomparedwiththoseinyoungerrabbits.Reproductivecellnumberswereincreasedinbothsexes21andworkingcapacitywasincreasedinvivo,allbyoraladministration.22

•Schisandratreatmentreducedheartrate,respiratoryfrequency,andlactatelevelsandincreasedplasmaglucoseandperformanceinarandomized,double-blind,placebo-controlled,crossoverstudyinvolvingraceandshow-jumphorses.23

•Inaplacebo-controlledtrial,significantreductionsinserumlevelsofglutamicpyruvictransaminase(GPT),glutamicoxaloacetictransaminase(GOT),andcreatinekinasewereobservedafteroraladministrationofstandardizedSchisandraextractstopoorlyperforminghorseswithpersistentlyhighenzymelevels.24

•IntraperitonealinjectionofSchisandrasignificantlyreducedsleepingtimeinducedbyphenobarbital,ethanol,andetherinvivo.Thisfindingsuggestsantidepressant

activity.25

•Schisandrapreparationsstrengthenedtherhythmiccontractionsofnonpregnant,pregnant,andpostpartumuteriinisolatedtissueandinvivo.2

ClinicalStudies

•Schisandraextract(equivalentto1.5gdriedfruit/day)wasshowntobesuperiortocombinedliverextractandvitaminEintreatingpatientswithchronicviralhepatitisinanopen,controlledtrial.SerumGPTlevelsnormalizedatamuchfasterrateandremainednormalafterthewithdrawalofSchisandra.Schisandrawasalsomoreeffectiveatrelievingsymptomsofsleeplessness,fatigue,abdominaltension,anddiarrhea.3

•EarlyuncontrolledtrialsinRussiareportedthatSchisandraincreasedenduranceandphysicalefficiencyinhumansanddecreasedsicknessinfactoryworkersandchildren.26,27Flightattendantsworkingonnon-stop7-to9-hourflightstreatedwithSchisandradidnotdisplaytheincreaseinheartrateandbloodpressurethatwasexperiencedbycontrolsnotreceivingtreatment.Inaplacebo-controlledtrial,physicalworkcapacityincreasedinathletestreatedwithSchisandra.28

•StandardizedSchisandraextractsignificantlyincreasedbasallevelsofsalivaryNOinarandomized,double-blind,placebo-controlledstudyonathletes.NOisthoughttobeamarkerforadaptationtoheavyexerciseandislikelytohavearoleinnonspecificimmunity.Adailydosecontaining12.4mgofschisandrinswasadministered.29

•UncontrolledtrialsindicatethatSchisandramightincreasementalefficiencyinhumans.26Schisandrin(5to10mg)improvedconcentration,finecoordination,andenduranceinhealthyyoungmaleadults.2Schisandraisreportedtoimprovevisionandhearing,enlargethevisualfield,improveadaptationtothedark,andincreasethediscriminationofskinreceptors.2

•Schisandraliquidextractsuccessfullyinducedlaborin72of80womenwithprolongedlabor.Thedoseadministeredwas20to25dropsperhourfor3hoursof1:3extractfor3consecutivedays.30Schisandratincture(1:10,30to40drops,threetimes/day)improvedcardiovascularsymptomsinhypotensivepregnantwomen.TheSchisandra-treatedgroupexperiencedfewerbirthcomplicationsthantheuntreatedwomen.Noeffectswereobservedoncontractionoronlabor.31

REFERENCES

BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.WagnerH,HikinoH,FarnsworthNR,editors.Economicandmedicinalplantresearch.London:AcademicPress,1988.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.HikinoH,etal.PlantaMed.1984;50(3):213-218.JiaxiangN,etal.JApplToxicol.1993;13(6):385-388.MakDH,etal.MolCellBiochem.1996;165(2):161-165.IpSP,KoKM.BiochemPharmacol.1996;52(11):1687-1693.IpSP,etal.BiochemPharmacol.1997;54(2):317-319.

10IpSP,CheCT,KoKM.ChungKuoYaoLiHsuehPao.

1998;19(4):313-316.11PaoTT,etal.ChungHuaIHsuehTsaChih.1974;54:275-278.

12ZhuM,etal.JEthnopharmacol.1999;67:61-68.13KoKM,etal.PlantaMed.1995;61(2):134-137.14ChangHM,etal,editors.AdvancesinChinesemedicinalmaterialsresearch.Singapore:WorldScientific,1985.

15LuH,LiuGT.ChungKuoYaoLiHsuehPao.1990;11(4):331-335.

16LuH,LiuGT.ChemBiolInteract.1991;78(1):77-84.17IpSP,etal.FreeRadicBiolMed.1996;21(5):709-712.18LiuKT,LescaP.ChemBiolInteract.1982;41(1):39-47.19LiuKT,etal.ChemBiolInteract.1982;39(3):315-330.20LiuKT,LescaP.ChemBiolInteract.1982;39(3):301-314.21PengGR,etal.ShanghaiJTradChinMed.1989;2:43-45.22AzizovAP,SeifullaRD.EkspKlinFarmakol.1998;61(3):61-63.

23HanckeJ,etal.Fitoterapia.1994;65(2):113-118.24HanckeJ,etal.Phytomed.1996;3(3):237-240.25HanckeJL,WikmanG,HernandezDE.PlantaMed.1986;52:542-543.

26BrekhmanI,DardymovIV.AnnuRevPharmacol.1969;9:419-430.

27FulderS.Therootofbeing:ginsengandthepharmacologyofharmony.London:Hutchinson,1980.

28LupandinAV.FiziolCheloveka.1990;16(3):114-119.29PanossianAG,etal.Phytomed.1999;6(1):17-26.30TrifonovaAT.AkushGinekol.1954;4:19-22.31GaistrukAN,TaranovskijKL.UrgProblObstetGynecolL’vov.1968;1:183-186.

SHATAVARI

BotanicalNames: Asparagusracemosus,Protasparagusracemosus#

Family: Asparagaceae(broadly,Liliaceae)PlantPartUsed: Root

# Alternativename.

PRESCRIBINGINFORMATION

Actions Tonic,galactagogue,sexualtonic,adaptogenic,spasmolytic,antidiarrheal,diuretic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingshatavariinformulationsinthecontextof:

•Promotingconceptionandforsexualdebilityinbothsexes(5)

•Afemalereproductivetonicandaphrodisiac(6)

•Infertilityinbothsexes,impotence(6)

•Promotinglactation,menopause(6)

•Promotingappetiteinchildren(6)

•Infections,immunosuppression(7)

•Diarrhea(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddosage.

Dosage Doseperday* Doseperweek*

4.5-8.5mlof1:2liquid 30-60mlof1:2liquid

extract extract

* This dose range is extrapolated from traditional Ayurvedic medicine1 and the author’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Asatonicandforrejuvenativeactiononthefemalereproductiveorgans,whichissaid“togivethecapacitytohaveahundredhusbands”2

•Asanutritivetonic3

•Topromoteconception(treatingbothsexes);2sexualdebilityinbothsexes3

•Menopause2

•Leukorrhea,3gonorrhea,1herpes2

•Asagalactagogue4

•Dyspepsia,dysentery,1diarrhea,1,3stomachulcers,hyperacidity2

•Biliousness,livercomplaints1

•Lungabscesses,hematemesis,cough,convalescence,dehydration2

•Inflammation,rheumatism1

•Tumors,diseasesoftheblood,1chronicfevers2

Preparationsbasedonshatavariareoftenrecommendedforthreatenedmiscarriage.5

Shatavariisregardedasaremedyfromtherasayana

group.Rasayanaliterallymeansthatpaththatrasaortheprimordialtissuetakes.Aremedythatimprovesthequalityofrasashouldstrengthenorpromotethehealthofalltissuesofthebody.6ShatavariisusedinSoutheastAsiaforpromotingappetiteandprovidingnourishmenttochildren.7

AboriginalAustraliansusedshatavaritopically.Adecoctionoftheyoungrootwiththebarkremovedwasusedtraditionallyasawashforscabies,infectedorulceratingskinlesions,andchickenpox.Thecrushedyoungroot(barkandcortexremoved)wasappliedasapasteforbreastlumpsandbreastswelling.8

PharmacologicResearch

Steroidalsaponins,includingshatavarinI9;alkaloids,includingthepyrrolizidinealkaloidasparagamineA10;andmucilage11arekeyconstituentsofshatavariroot.(Basedonitschemicalstructure,asparagamineAwouldnotbeexpectedtobetoxic.)Thepresenceofsteroidalsaponinsinshatavarisuggestsitsactivityonthefemalereproductivesystemmaybetheresultofsubtleestrogenmodulatingactivity.

Whenreferredhere,shatavarisuspensionisthedried,powderedrootofshatavariboiledinwaterwithoutseparatingtheinsolublepart,asprescribedinAyurveda.

•Oraladministrationofshatavariincreasedtheweightofmammarylobulo-alveolartissue12andcorrectedirregular,lowmilkyields13inexperimentalmodels.Theauthorssuggestedthatshatavarimayactdirectlyonthemammaryglandorviathepituitaryandadrenalglands.12

•Shatavarin-Iinhibitedexperimentallyinducedcontractionsinisolateduterinetissueandinvivo(administeredbyinjection).14,15AntioxytocicactivitywasdemonstratedforthealkaloidasparagamineAinlaterwork.10

•Oralpretreatmentwithshatavarisuspensionhadthe

followingadaptogeniceffectsinexperimentalmodels.Shatavari:

•Reducedmortalityfromintra-abdominalsepsis16-18;onemodelusedconcurrentimmunosuppression18

•Protectedagainstneutropeniaandleukopeniafromimmunosuppression18-20withresultscomparabletotwoknownimmunomodulators(glucanandlithiumcarbonate)20

•Increasedboththephagocyticandkillingcapacityofmacrophages18,21andpossiblyneutrophils22

•Producedleukocytosiswithpredominantneutrophilia16,18,20

•Enhancedhumoralandcell-mediatedimmunity23

•Stimulatedgranulocyte-macrophagecolonyformation,indicatingthepresenceofthecytokinethatstimulatesthegrowthofthiscolony22

•Reducedbleomycin-inducedfibrosisofthelung6

•Enhancedtheclearanceofinjectedcolloidalcarbon,indicatingenhancementoftheactivityofthereticulo-endothelialsystem(amajorcomponentoftheimmunesystem)24

•Reducedstress-inducedgastricdamage,plasmasteroidincrease,andmacrophagefunctionsuppression25

•Decreasedethanol-inducedgastriculcerationandcisplatin-inducedgastroparesis6

•Shatavariextractshowedconsiderableantibacterialactivityagainstavarietyofbacteriainvitroandwascomparabletochloramphenicol(anantibiotic)initsactivity.26

•Shatavaridecreasedadhesionscoresandincreasedperitonealmacrophageactivityinanexperimentalmodelinvestigatingintraperitonealadhesions.27

•OraldosingwithanethanolicextractofshatavariinhibitedochratoxinA(carcinogen)–inducedsuppressionofbothchemotacticactivityandproductionofIL-1andTNFbymacrophages.Moreover,shatavariinducedexcessproductionofTNF-αwhencomparedwithcontrols.28Inanearlierstudy,ingestionofshatavaripowderbeforeexposuretothecarcinogenDMBAreducedtheincidenceofmammarytumorsinrats.29

•Shatavariextractdemonstratedantitussiveactivityagainstsulfurdioxide–inducedcoughafteroraladministration.Resultswerecomparabletothoseforcodeine(aprovenantitussive).30Hepatoprotectiveactivitywasalsodemonstratedforpretreatmentwithashatavariextract.23

•Oraladministrationofshatavarisuspensionincreasedweightgain,lungweight,andadrenalglandascorbicacidcontentanddecreasedbodytemperature,adrenalglandweight,andplasmacortisollevelsinyoungrats.Shatavarididnotincreaseweightgaininadultrats.Thisfindingindicatesamildgrowthpromotingactivity,whichwasmilderthanthatobtainedfromtreatmentwithashwaganda.31

•Anextractofshatavariinhibitedcarrageenan-andserotonin-inducededema,indicatingantiinflammatoryactivity.32

•Shatavariextractexhibitedpotentantioxidantactivityinisolatedlivermitochondrialmembranessubjectedtogamma-radiation.33

•Shatavarifreshrootjuiceprotectedagainstexperimentalmodelsofgastricandduodenalulcerationwhen

administeredorally.34

ClinicalStudies

•Inamulticenter,randomized,double-blind,placebo-controlledtrial,aformulationofherbscontaining68%shatavariwasnotfoundtobesuperiortoplaceboinpromotinglactationinmotherswithlactationalinadequacy.35

•ShatavaripreventedthepresenceingastricaspiratesofhemoglobinandreducedtheDNAcontentandtheriseinpepsincausedbyaspiriningestioninhealthyvolunteers.Twodosesofshatavariwereadministered(1.5g/dayand3g/day),bothofwhichproducedtheseresults.36

•Shatavarireducedgastricemptyingtimefrombaselinevaluesandhadsimilaractivitytometoclopramide(anantiemeticdrug)inasmall,controlledtrialinvolvinghealthymalevolunteers.Twogramsofshatavaripowderedrootwereadministeredfor2daysbetweenbaselineandtestreadings.37

REFERENCES

KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.FrawleyD,LadV.Theyogaofherbs:anAyurvedicguidetoherbalmedicine,ed2.SantaFe:LotusPress,1988.ThakurRS,PuriHS,HusainA.MajormedicinalplantsofIndia.Lucknow,India:CentralInstituteofMedicinalandAromaticPlants,1989.NadkarniAK.Dr.K.M.Nadkarni’sIndianmateriamedica,ed3.Bombay:PopularPrakashan,1976.

DevS.EnvironHealthPerspect.1999;107(10):783-789.RegeNN,ThatteUM,DahanukarSA.PhytotherRes.1999;13(4):275-291.WorldHealthOrganization.Theuseoftraditionalmedicineinprimaryhealthcare:amanualforhealthworkersinSoutheastAsia.NewDelhi:WHORegionalOfficeforSoutheastAsia,1990.AboriginalCommunitiesoftheNorthernTerritoryofAustralia,ConservationCommissionoftheNorthernTerritory.TraditionalaboriginalmedicinesintheNorthernTerritoryofAustralia.Darwin:ConservationCommissionoftheNorthernTerritoryofAustralia,1993.HostettmannK,MarstonA.Chemistry&pharmacologyofnaturalproducts:saponins.Cambridge:CambridgeUniversityPress,1995.

10SekineT,etal.PerkinTransactions.1995;1(4):391-393.11BharatiyaVidyaBhavan’sSwamiPrakashanandaAyurvedaResearchCentre.SelectedmedicinalplantsofIndia.Bombay:Chemexcil,1992.

12SabnisPB,GaitondeBB,JetmalaniM.IndianJExpBiol.1968;6(1):55-57.

13PatelAB,KanitkarUK.IndianVetJ.1969;46(8):718-721.14GaitondeBB,JetmalaniMH.ArchIntPharmacodynTher.1969;179(1):121-129.

15JoshiJ,DevS.IndianJChem.1988;27B:12-16.

16ThatteUM,etal.IndianDrugs.1987;25(3):95-97.17DahanukarSA,etal.IndianDrugs.1986;24:125.18ThatteUM,DahanukarSA.PhytotherRes.1989;3(2):43-49.19ThatteUM,etal.JPostgradMed.1987;33(4):185-188.20ThatteUM,DahanukarSA.MethodsFindExpClinPharmacol.1988;10(10):639-644.

21RegeNN,DahanukarSA.JPostgradMed.1993;39(1):22-25.

22ThatteUMetal:InternationalSymposiumofImmunologicalAdjuvantsandModulatorsofNonspecificResistancetoMicrobialInfections,Columbia,Md,June30-July3,1986,abstract53.

23MuruganandanS,etal.JMedAromPlantSci.2000-2001;22-23(4A-1A):49-52.

24DahanukarSA,ThatteUM.Phytomed.1997;4:297-306.25DahanukarSA,ThatteUM.IndianPract.1988;41(4):245-252.

26MandalSC,etal.PhytotherRes.2000;14(2):118-119.27RegeNN,etal.JPostgradMed.1989;35(4):199-203.28DhuleyJN.JEthnopharmacol.1997;58(1):15-20.29RaoAR.IntJCancer.1981;28(5):607-610.30MandalSC,etal.Fitoterapia.2000;71(6):686-689.31SharmaS,DahanukarS,KarandikarSM.IndianDrugs.1985;23(3):133-139.

32MandalSC,etal.NatProdSci.1998;4(4):230-233.33KamatJP,etal.JEthnopharmacol.2000;71(3):425-435.34BipulD,etal.IndianJExpBiol.1997;35(10):1084-1087.35SharmaS,etal.IndianPediatr.1996;33(8):675-677.36ThatteUM.PushpangadanP,etal,editors.GlimpsesofIndianethnopharmacology.Kerala,India:TropicalBotanicGardenandResearchInstitute,1995.

37DalviSS,NadkarniPM,GuptaKC.JPostgradMed.1990;36(2):91-94.

SHEPHERD’SPURSE

BotanicalName: Capsellabursa-pastorisFamily: CruciferaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Antihemorrhagic,urinaryantiseptic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingshepherd’spurseinformulationsinthecontextof:

•Excessiveorirregularmenstrualbleeding(4,5)

•Hematemesis,hematuria,hemorrhoids,diarrhea(5)

•Topicaltreatmentfornosebleed(4)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Menorrhagia,uterinehemorrhage,hematemesis,hematuria,hemorrhoids1,2

•Diarrhea,atopicdyspepsia1,2

PharmacologicResearch

•Exvivotestsindicatedshepherd’spurseextractsacceleratedcoagulationofblood.3However,aninvivoexperimentconductedin1969foundnohemostaticactivity.4Injectionofextractfractionsmildlyincreasedperipheralbloodflow.Contractileactivitywasdemonstratedonisolatedsmoothmuscle.5

•Invivostudiesindicatediuretic,antiinflammatory,andantiulceractivitiesforshepherd’spurseextracts.Theextractwasadministeredbyinjectioninthemajorityofthesestudies.6

•Injectionofshepherd’spurseextractcausedinhibitionofsolidtumorgrowthinanexperimentalmodel.7Inanothermodel,oraladministrationinhibitedhepatomainduction.Theactiveconstituentwasbelievedtobefumaricacid.8

ClinicalStudies

Noclinicalstudiesusingshepherd’spursehavebeenfound.

InGermany,theCommissionEsupportsusingshepherd’spurseforsymptomatictreatmentofmildmenorrhagiaandmetrorrhagiaandtopicalapplicationfornosebleeds.9

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VermathenM,GlaslH.PlantaMed.1993;59(suppl1):A670.KurodaK,KakuT.LifeSci.1969;8(1):151-155.KurodaK,TakagiK.ArchIntPharmacodyn.1969;178:382-391.KurodaK,TakagiK.ArchIntPharmacodyn.1969;178:392-399.KurodaK,etal.CancerRes.1976;36(6):1900-1903.KurodaK,etal.Gann.1974;65(4):317-321.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

SKULLCAP

BotanicalName: ScutellarialaterifloraFamily: LabiataePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Nervinetonic,spasmolytic,mildsedative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingskullcapinformulationsinthecontextof:

•Nervousexcitability,restlessness,wakefulness,anxiety(5)

•Physicalormentaltiredness(5)

•Headache,depression(6)

•Epilepsy,neuralgia,tremor(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2.0-4.5mlof1:2liquidextract

15-30mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Epilepsy,particularlygrandmalandothernervoussystemdisorders,suchashysteria,chorea(characterizedbyinvoluntary,jerkymovements),nervoustension,tremors,neuralgia,anddeliriumtremens1,2

•Asacalmativetothenervoussystemandfornervousexcitability,restlessness,wakefulness,anddisordersarisingfromphysicalormentaloverwork2

•Functionalcardiacdisordersthatresultedfromnervouscauses,particularlywithintermittentpulse2

•Asaninfusionforchildrenwithteethingpain2

•Headache,particularlyarisingfromincessantcoughingandpain3

•Depression4

PharmacologicResearch

Nopharmacologicinformationrelevanttothecurrentusageofskullcaphasbeenfound.

ClinicalStudies Noclinicalstudiesusingskullcaphavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.

SPINYJUJUBE

OtherCommonNames: Zizyphus,sourChinesedateseed

BotanicalNames: Zizyphusjujubavar.spinosa,Zizyphusspinosa,#Ziziphusspinosa#

Family: RhamnaceaePlantPartUsed: Seed

# Alternativename.

PRESCRIBINGINFORMATION

Actions Hypnotic,mildsedative,hypotensive,anxiolytic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingspinyjujubeinformulationsinthecontextof:

•Anxiety,*insomnia,*incombinationwithhoelen,Cnidium,Anemarrhena,andlicorice(3)

•Irritability,palpitations,excessivesweatingresultingfromdebility,nightsweats(5)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects A30-year-oldwomanexperiencedchills,fever,andjointpainthatwere

attributedtotakingZizyphusspinosaseeds(dosenotdefined).1

Dosage Doseperday** Doseperweek**

6.0-11.5mlof1:2liquidextract

40-80mlof1:2liquidextract

* SpinyjujubehasalsobeenusedinTCMfortreatinganxietyandinsomnia.(5)

** ThisdoserangeisadaptedfromdriedplantdosagesadministeredbydecoctioninTCM.2Theauthor’sexperienceandthefactthatethanol-waterisamoreeffectivesolventthanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Tonourishtheliver2,3andheartandcalmthespirit3

•Dream-disturbedsleep,2insomnia2,3

•Irritability,palpitationswithanxiety3

•Excessivesweatingresultingfromdebility,2,3nightsweats3

Note:ZizyphusjujubaisadifferentspeciesthatisusedfordifferenttherapeuticpurposesinTCM.Thepartusedofthisspeciesisthedatelikefruit.

PharmacologicResearch

TheactiveconstituentsofZizyphusspinosaseedincludedammarane-typesaponinscalledjujubosidesAandBandaflavoneC-glycosidecalledspinosin.4

•Oraladministrationofspinyjujubeseeddemonstratedsedativeactivityinexperimentalmodels:•Inhibitingspontaneousactivity5,6•Prolongingpentobarbitalsodium-inducedsleep5•Reducingtheresponsetosoundstimulus6•Inhibitingtheconvulsiveeffectofpentylenetetrazole6

•Spinyjujubedemonstratedimmunopotentiatingactivityinvivo.Oraladministrationoftheseedextractincreasedthelymphocytetransformationrate,hemolysinformation,andclearanceofcarbonparticles.Spinyjujubetreatmentalsoenhancedthedelayedhypersensitivityreactiontosheeperythrocytesinbothnormalandcyclophosamide-treatedmice.7

•Jujubosidesinhibitedhistaminereleasefromperitonealexudatecellsinducedbyantigen-antibodyreaction8andexhibitedpotentimmunologicadjuvantactivityinvivo(routeunknown).9(Animmuneadjuvantenhancesormodulatesimmuneresponse.)

•Spinyjujubeisalsoanticonvulsant,hypotensive,andprolongssurvivalafterburns.Theherbhasverylowtoxicity,anditimprovedhypoxiatoleranceinrats.5

ClinicalStudies

SuanzaorentangisaTCMformulacontainingZizyphusspinosa(45.5%),hoelen(Poriacocos,23%),Cnidium(Cnidiummonnieri,13.5%),Anemarrhena(Amenarrhenaasphodeloides,13.5%),andlicorice(Glycyrrhizauralensis,4.5%).

•Suanzaorentang(750mg/day)demonstratedalmostthesameanxiolyticeffectasdiazepam(6mg/day)inashort-term,double-blindtrial.Suanzaorentang,butnotdiazepam,improvedpsychomotorperformanceduringthedaytime.Moodwasimprovedandsympatheticnervoussystemsymptomsdecreased.Nosignificantsubjectivesideeffectswereobservedduringtreatment.Laboratorytestsofthemajorsystemswerenormalafter1weekofadministration.10

•Significantimprovementsinallratingsofsleepqualityandwellbeingwereobservedinpatientswithsleepdisordersduringsuanza-orentangtreatmentcomparedwiththebaselineandplaceboperiods.Patientsingestedcapsulescontaining1gofsuanzaorentangeachnight(30minutesbeforebedtime)for2weeks.11Inpatientswithanxietyandcardiacsymptoms,treatmentwithsuanzaorentangalsodemonstratedananxiolyticeffect.12

REFERENCES

ZhangL,WangH.ChinaJChinMateriaMed.1989;14(2):116.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.TangW,EisenbrandG.Chinesedrugsofplantorigin.Berlin:Springer-Verlag,1992.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.LouSN,FengBL,XiaLY.ZhongchengyaoYanjiu.1987;(2):18-19.LangX,etal.BullChinMateriaMedica.1988;13(11):683-685.YoshikawaM,etal.ChemPharmBull.1997;45(7):1186-1192.MatsudaH,etal.ChemPharmBull.1999;47(12):1744-1748.

10ChenHC,HsiehMT,ShibuyaTK.IntJClinPharmacolTherToxicol.1986;24(12):646-650.

11ChenHC,HsiehMT.ClinTher.1985;7(3):334-337.12HsiehMT,ChenHC.EurJClinPharmacol.1986;30(4):481-484.

ST.JOHN’SWORT

OtherCommonName: Hypericum

BotanicalName: HypericumperforatumFamily: Guttiferae

PlantPartUsed: Aerialparts,harvestedduringtheearlyfloweringperiod

PRESCRIBINGINFORMATION

Actions Antidepressant,nervinetonic,antiviral,vulnerary,antimicrobial(topically)

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingSt.John’swortinformulationsinthecontextof:

•Mildtomoderatedepression(1,4,5)

•Depressivesymptomsinpatientsaddictedtoalcohol(2)

•Recurrentorofacialherpes,genitalherpes(2)

•Anxiety,nervousness,restlessness(4,5)

•Obsessive-compulsivedisorder,mildpsychosomaticandsomato-formicdisorders(4)

•Seasonalaffectivedisorder(4)

•Seasonalaffectivedisorder,incombinationwithlighttherapy(3)

•Psychologicsymptomsofmenopause(4,5)

•Enhancingmoodinstressedindividuals,suchasathletes(3)

•Enhancingaerobicendurancecapacityinathletes,incombinationwithvitaminE(2)

•PMS(4)

•Conditionsrequiringincreasednocturnalmelatoninplasmalevels,suchascircadianrhythm–associatedsleepdisorders(4)

•Afflictionsofthenervoussystem,suchasspinalinjuries,neuralgia,andsciatica(5)

•Treatingandpreventingacuteandchronicinfectionscausedbyenvelopedviruses(e.g.,coldsores,herpesgenitalis,chickenpox,shingles)(7)

Contraindications

DespitethecontraindicationgivenintheBritishHerbalPharmacopoeia1983,clinicaltrialshaveshownthatSt.John’swortisefficaciousfortreatingdepression.

ConcurrentadministrationofhighdosesofSt.John’swortiscontraindicatedwiththefollowingdrugs:warfarin,digoxin,andcyclosporine,aswellasindinavirandrelatedanti-HIVdrugs.

WarningsandPrecautions

Notsuitedtotreatingseriousdepressionwithpsychoticsymptomsorsuicidalrisk.

St.John’swortisnotadvisableincasesofknownphotosensitivity.PatientstakinghigherdosesshouldavoidexcessiveexposuretosunlightandUVradiation.St.John’swortmayinteractwithanumberofdrugs,possiblyviacytochromeP-450induction.PractitionersshouldavoidprescribingSt.John’swortifpatientsaretakingthefollowingdrugs:immunesuppressants(cyclosporin),cardiacglycosides(digoxin),HIVnonnucleosidereversetranscriptaseinhibitors(nevirapine)1andotherHIVproteaseinhibitors(indinavir),thechemotherapeuticdrugirinotecan(Camptosar)2,andtheanticoagulantswarfarinandphenprocoumon.CautionshouldbeexercisedwhenprescribingSt.John’sworttopatientstakingselectiveserotoninreuptakeinhibitors(SSRIs)becauseofpotentialeffectsonserotoninlevelsandtheriskofsubsequentserotoninsyndrome(confusion,fever,

Interactionsshivering,sweating,diarrhea,andmusclespasm).SeveralreportsindicatebreakthroughbleedingoccurringinwomentakingSt.John’swortwhileontheoralcontraceptivepill(OCP)andrecentreportsfromSwedenandBritainofunwantedpregnancies.PractitionersshouldexercisecautionwithwomenwhoaretakingaverylowdoseOCP.NointeractionwasobservedbetweenSt.John’swortandalcoholintermsofcognitivecapabilitiesinaclinicaltrial.ConcernshavealsobeenraisedaboutconcurrentadministrationofSt.John’swortwiththeophylline(abronchorelaxant)andphenytoin(ananticonvulsant).AcasewasreportedinwhichSt.John’swortreducedserumlevelsoftheophylline.3However,noclinicaladverseeffectshavebeenreportedforphenytoinoranyotheranticonvulsantdrugs.Infact,anopentrialdemonstratedthatSt.John’swortextracthadnoeffectoncarba-mazepinepharmacokineticsineighthealthyvolunteers.4

Arandomized,double-blind,placebo-controlledstudyinvestigatingthepharmacokineticinteractionbetweenSt.John’swortpreparationsanddigoxininhealthyvolunteersfoundthattheinteractionwasdoserelatedandnotinherenttothestandardizedextract.Dosesequivalentto1gperdayofSt.John’swortherbproducednodifferencesinpharmacokineticparameterscomparedwithplacebo.5

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsInpatientswhoareHIV-positivereceivingoralSt.John’swort,mild,reversibleelevationsofserumliverenzymeswereobserved.

Apostmarketingsurveillancestudyof3250depressedpatientsreportedthat2.4%experiencedsideeffectsthatweremainlymildgastrointestinalcomplaintsandallergicreactions,suchaspruritis.AcaseofadynamicileusassociatedwiththeuseofSt.

John’swortbya67-year-oldwomanhasbeenreported.

Noreliableevidenceofphototoxicityinhumanshasbeenfound.Investigationsinvolvingvolunteersfoundthatthethresholddailydoseforamildincreaseinphotosensitizationwasapproximately2to4gofcommercialextract(containing5to10mgofhypericin).6Reversiblephotosensitivityhasbeenobservedinpatientsreceivingoraldosesofisolatedhypericin(0.05to0.10mg/kgofbodyweight/day).7AvoidingexcessiveexposuretosunlightorartificialUVAlightisadvisableforpatientstakinghighdoses,andSt.John’swortshouldbeusedcautiouslyinpatientswithknownphotosensitivity.

SeveralcasesofhypomaniawerereportedforindividualswithnohistoryofbipolardisorderaftertakingSt.John’swort.8,9Episodesofmaniawerealsoreportedfortwopeoplewithahistoryofbipolardepression10andinonedepressedpatientconcurrentlytakingsertraline.11Inthelastcase,theadversereactionmayhavebeentheresultofthedrugalone.ApsychoticepisodeassociatedwithusingSt.John’swortwasreportedforawomanwhowaslaterdiagnosedashavingAlzheimer’sdisease.12

Somereportsindicateaphenomenonthatappearstobeasensorynervehypersensitivity.TheevidencesuggeststhattheSt.John’swortpreparationsweremanufacturedfromlateharvestedherbcontaininghighlevelsofresinouscompoundsthatappearedassedimentintheliquids.TheproblemcanbeavoidedbynotdispensingthesedimentandbyusingSt.John’swortharvestedattheonsetoffullflowering.

Dosage Doseperday* Doseperweek*

2-6mlof1:2liquidextract

15-40mlof1:2liquidextract

2-6mlof1:2highhypericinliquidextract

15-40mlof1:2highhypericinliquidextract

Extractsprovidingquantifiedlevelsoftotalhypericinsarerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan0.2mg/mlhypericins,andhighhypericinextractsshouldcontainnotlessthan0.4mg/mlhypericins.

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Excitability,hysteria,nervousconditionswithdepression,menopausalneurosis13,14

•Neuralgia,fibrositis,sciatica,spinalinjuriesorirritations,shock,concussion,throbbingofthebodywithoutfever13,14

•Hemorrhage,menorrhagia,diarrhea,jaundice,chronicurinaryconditions14

•Internallyandtopicallyforwounds13,14

•Externallyasanoilmacerationforwounds,ulcers,andswellings14

TheEclecticphysiciansregardedSt.John’swortashaving“undoubtedpoweroverthenervoussystem,andparticularlythespinalcord.”14

KeyconstituentsoftheaerialpartsofSt.John’swortincludethenaphthodianthroneshypericinandpseudohypericin(collectivelyreferredtoastotalhypericin[TH]),flavonoids,andphenoliccompoundssuchashyperforin.

•ExperimentalstudiessuggestthatSt.John’swortistheonlyantide-pressantagentcapableofinhibitingthereuptakeofserotonin,norepi-nephrine(noradrenaline),anddopaminewithsimilarpotencies.15St.John’swortextractsmayhaveasimilarmechanismofactiontoSSRIsbutprobablytoalesserextent.16

PharmacologicResearch

•ManycompoundsinSt.John’swort,includingthehypericins,hyperforin,andflavonoids,appeartocontributetotheantidepressantactivity.17

•Hypericinandpseudohypericindemonstratedactivityagainstseveralenvelopedvirusesinvitroandagainstseveralretrovirusesinvitroandinvivo(byoraladministrationorinjection).Bothantiviralandanti-retroviralactivitywasenhancedbyexposuretolight.

•Hypericinproducedapotentantitumoractivityinvitroagainstseveraltumorcells,butdidnotshowanytoxiceffectstowardnormalcellsathigherconcentrations.Antitumoractivityinvivowasalsodemonstratedafterintraperitonealinjection.AnantimutagenicactivitywasdemonstratedforSt.John’swortextractintermsofDNArepairinEscherichiacoli.

•St.John’swortextractdemonstratedbactericidalactivityinvitroagainstanumberofgram-positiveandgram-negativebacteria,includingStaphylococcusaureus,Proteusvulgaris,Escherichiacoli,andPseudomonasaeruginosa.

•Inanexperimentalmodel,oraladministrationofanextractofSt.John’swort(26.5mg/kg)inducedasedationsimilartothatproducedbydiazepam(2mg,orally).Noneoftheisolatedfractionsfromthisextractexhibitedthesamesedativeactivityasthewholeextract.ThepreviouslydescribeddoseofconcentratedSt.John’swortextractwasequivalentto125mg/kgofdried,powderedherb.Thisamountisonlyslightlyhigherthannormaltherapeuticdosesofthestandardizedextractbutislowerthandosestypicallyusedforliquids.

•OraladministrationofSt.John’swortextractsdose-dependentlyandsignificantlyreducedalcoholintakeintwogeneticanimalmodelsofhumanalcoholism.

•OraladministrationofSt.John’sworttincturedemonstratedimprovedwoundhealinginexperimentalmodels.Inacontrolledinvivotest,oilyextractofSt.John’swortdemonstratedasignificantantiirritanteffectagainstcrotonoilappliedtotheskin.

•Meta-analysisandsystematicreviews,includingtheCochranereview,publishedfrom1996to2000concludedthatSt.John’swortextractsaremoreefficaciousthanplacebofortreatingmildtomoderatedepression.Moredataisrequiredtoassessitsefficacycomparedwithotherantidepressantmedication.Fewersideeffectswere,however,reportedforSt.John’swortextractscomparedwithstandardantidepressants.18-20Forthetrialsconsideredinoneofthepreviouslylistedreviews20andbasedonrecentformulationspecifications,themostcommondailydoseofextractprescribedcorrespondedtoapproximately5gofdriedherb,containing2.7mgofTH.Onetrialinvestigatedtheefficacyofahighdailydose(twicethisdose).

•Sincethepublicationofthesereviews,furthertrialshavebeenpublished.Tworandomized,double-blind,multicenterstudiesfoundSt.John’swortextracttobemoreefficaciousthanplaceboandatleastasbeneficialasimipramine(atricyclicantidepressant)intreatingmildtomoderatedepression.21,22St.John’swortextract(equivalentto6g/dayofdriedherbandcontaining2.6mg/dayofTHand26mgofhyperforin)wascomparedagainst100mg/dayimipramineorplacebofor8weeks.21TheothertrialcomparedtheeffectsofSt.John’swortextractcontaining1mgperdayhypericinwith150mgperdayofimipramineovera6-weekperiod.22SideeffectswerelesscommoninpatientstakingtheSt.John’swortextractinbothstudies.Thedesignofthesestudieshasbeenquestioned,23-26notablytheuseofimipramineasacomparisoninsteadofamoremodernantidepressant,theshortdurationoftreatment,andtheabsenceofa

placebogroup(inthecaseofonetrial).

•AnumberoftrialsfoundthatstandardizedSt.John’swortextractscomparedfavorablywiththeSSRIfluoxetine,27-30particularlyfortreatingdepressedpatientswithanxietysymptoms.30ThedoseofSt.John’swortusedwasequivalentto4.8gperdayofdriedherbinoneofthesetrials27andwasstandardizedtocontain1mgperdayhypericinintwoothers.28,29Durationoftreatmentwastypically6weeks.AreviewofcontrolledtrialsfoundSt.John’swortasefficaciousasfluoxetineformilddepression.31St.John’swortcomparedfavorablywiththeSSRIsertralinefortreatingmildtomoderatedepressioninarandomized,placebo-controlledpilottrialinvolvingasmallgroupofoutpatients.32

•Arandomized,double-blind,placebo-controlled,multicentertrialpublishedin2001concludedthatstandardizedSt.John’swortextractadministeredfor8weekswasnotaneffectivetreatmentforseveredepressioncomparedwithplacebo.AlthoughSt.John’swortwasfoundtobesafeandwelltolerated,nosignificantbenefitsaboveplacebowereobservedfortheHamiltonDepressionScale(HAM-D)orothermeasuresofanxietyordepression.However,thenumberofpatientsreachingremissionoftheirillnesswassignificantlyhigherintheSt.John’swortgroupcomparedwithplacebo(basedonintention-to-treatanalysis).Thiseffectwasnotregardedasclinicallysignificantbytheauthors.Thedailydosescorrespondedtoapproximately5to7goforiginaldriedherb.33Anumberofletterswerepublishedcriticizingthedesignofthistrial(seeletterspublishedinJAMA286(1):42,2001).OfrelevanceisthatatrialincludedinoneofthesystematicreviewsfoundsimilarefficacyforSt.John’swortcomparedwithimipramine(150mg/day)intreatingseveredepression.Theresponserateswerelowforbothgroups,butfewersideeffectswererecordedintheherbaltreatmentgroup.ThedailydoseofSt.John’swortextractcorrespondedto

ClinicalStudies

approximately8goforiginaldriedherbandprovided5.4mgofTH.

•Arandomized,double-blind,placebo-controlledtrialinvolvingmildtomoderatelydepressedpatients(InternationalClassificationofDiseases[ICD]-10categoriesF32.0,F32.1,F33.0,F33.1**)andpatientswithdysthymia(ICD-10categoryF34.1**)foundalargediscrepancyinresponsebetweendysthymicandnondysthymicpatients,thelatterbeingmoresensitivetoSt.John’sworttherapy.34

•TheresultsofapostmarketingsurveillancestudysuggestthatSt.John’swortisbeneficialfortreatingmildtomoderatedepressioninchildrenunder12yearsofage.The76childrenwhocompletedthestudyweretreatedwithaSt.John’swortextract,themajorityofpatientsreceivingdailydosescorrespondingtoapproximately1.7to3.3goforiginaldriedherb(containing0.9to1.8mgofTH)for4to6weeks.Noadverseeventswerereported.35

•St.John’swortextractreduceddepressivesymptomsinpatientsaddictedtoalcoholandwaswelltoleratedinarandomized,doubleblind,placebo-controlledtrialinvolving119maleandfemalepatients.Thedailydosecorrespondedto2.7mgofTH.36

•St.John’swortextractfor4weeks(containing2.7mg/dayTH)significantlyreducedHAM-Dscoresinpatientswithseasonalaffectivedisorder(SAD)whencombinedwitheitherbrightordimlighttherapyinasingle-blindtrial.Inanuncontrolledtrial,surveyresultsshowedasignificantimprovementfrombaselinevaluesforanxiety,lossoflibido,andinsomniainpatientswithSADtreatedwithSt.John’swortaloneandinthosetreatedwithbothSt.John’swortandlighttherapy.Nosignificantbetween-groupdifferenceswereobserved,exceptthatimprovementinsleepwasgreaterinthecombinedtreatmentgroup.37Newfindingssuggestthat

thephotodynamicimpactofSt.John’swortincreasestheeffectofnormallight,asifthepatientweresubjecttocontinuouslighttherapy.38

•Inanopen,pilottrial,administeringSt.John’swortextract(standardizedto2.7mg/dayhypericinfor12weeks)producedpromisingresultsintreatingobsessive-compulsivedisorder.39

•OraltreatmentwithSt.John’swortextractreducedthenumberofpatientsexperiencingherpeticepisodesandthetotalsymptomscorecomparedwithplacebointwodouble-blind,randomizedtrialslasting90days.Thetrialsincluded94patientswithrecurrentorofacialherpesand110patientswithgenitalherpes.40

•Inarandomized,double-blindtrial,St.John’swortextract(0.9mg/dayTH)didnotdemonstrateasignificanteffectoverplacebofortreatingpainfulpolyneuropathy.41However,atendencytoimprovementwasobserved,whichdidnotachievestatisticalsignificance,possiblybecauseofthelowpatientnumbersinvolved.

•Inanopen,observationalstudy,improvementinsymptomswasobservedinpremenopausalandpostmenopausalwomenafter12weeksoftreatmentwithSt.John’swort(standardizedto0.9mg/dayTH).Climactericcomplaintssuchasirritabilityandoutbreaksofsweatingdecreasedordisappearedinthemajorityofwomen.Sexualwellbeingalsoimproved.42ASt.John’swortandblackcohoshcombinationsignificantlyreducedmenopausalsymptomscomparedwithplaceboinarandomized,double-blindtrialinvolving179women.Thedailydoseofherbaltreatmentcorrespondedto0.5mgofTHand2mgof27-deoxyactein(amarkercompoundinblackcohosh).43

•Anuncontrolled,pilotstudywithSt.John’swortfoundimprovementinPMSscoresandadecreaseinsymptom

severitywhentheherbwasadministeredfortwomenstrualcycles.Thedailydoseofextractcontained0.9mgTH.44

•Inanuncontrolledtrial,St.John’swortextract(standardizedtodeliver0.5mg/dayTH)for3weeksproducedasignificantincreaseinnocturnalmelatoninplasmaconcentrationinhealthyvolunteers.

•Aplacebo-controlled,crossoverstudyfoundthat6weeksoftreatmentwithSt.John’swortextract(equivalentto2g/dayofdriedherb)significantlyimprovedvigorwhilereducinganger,fatigue,confusion,andmooddisturbanceinathletes.45Inadouble-blind,placebo-controlledtrial,athleteswererandomizedintothreegroups:St.John’swortplusvitaminE,vitaminE,andplacebo.TheSt.John’swortplusvitaminEgroupdemonstratedasignificantlybetteraerobicendurancecapacitycomparedwiththeothergroups.ThedailydoseofSt.John’swortusedwasapproximately170mgofstandardizedextract,probablycorrespondingtoapproximately1gofdriedherb.

•InGermany,theCommissionEsupportsusingSt.John’swortinternallytotreatanxiety-relatedsymptomsanddepressivemoods,aswellasanxiety,nervousunrest,orboth.OilySt.John’swortpreparationsarerecommendedinternallyfordyspepticcomplaintsandexternallyfortreatmentandposttherapyofacuteandcontusedinjuries,myalgia,andfirst-degreeburns.46

•ESCOPrecommendsSt.John’swortfortreatingmildtomoderatedepressivestates(ICD-10categoriesF32.0,F32.1**)andsomatoformicdisturbances,includingsymptomssuchasrestlessness,anxiety,andirritability.47

•St.John’sworthasbeenreinstatedtotheUSPandisofficialintheUSP24-NF19.

** International Classification of Diseases, rev 10, Chapter V (F), World HealthOrganization,1991. (Categories F32.0, F32.1, F33.0, F33.1 refer to mild to moderatedepression;F34.1referstodysthymia[chronicmooddisorder].)

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.[Noauthorslisted].TreatmentUpdate.2001;12(11):6.MathijssenHJetal:AnnualMeetingoftheAmericanAssociationforCancerResearch,SanFrancisco,April6-10,2002,abstract2443.NebelA,etal.AnnPharmacother.1999;33:502.BursteinAH,etal.ClinPharmacolTher.2000;68(6):605-612.UehlekeB,etal.Phytomed.2000;7(supp2):20.SchulzV.SchweizRundschMedPrax.2000;89(50):2131-2140.[Noauthorslisted].TreatmentUpdate.2001;12(11):4-5.SchneckC.JClinPsychiatry.1998;59(12):689.O’BreasailAM,ArgouarchS.CanJPsychiatry.1998;43(7):746-747.

10NierenbergAA,etal.BiolPsychiatry.1999;46(12):1707-1708.

11BarbenelDM,etal.JPsychopharmacol.2000;14(1):84-86.12LairdRD,WebbM.JHerbPharmacother.2001;1(2):87.13BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.

14FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983

15NathanP.MolPsychiatry.1999;4(4):333-338.16KasperS,SchulzV.WienMedWochenschr.1999;149(8-10):191-196.

17InternationalConference:2000YearsofNaturalProductResearch—Past,PresentandFuture,Amsterdam,July26-30,1999.

18StevinsonC,ErnstE.EurNeuropsychopharmacol.1999;9(6):501-505.

19LindeK,MulrowCD.CochraneDatabaseSystRev.(2):2000.CD000448

20GasterB,HolroydJ.ArchInternMed.2000;160(2):152-156.21WoelkH.BMJ.2000;321(7260):536-539.22PhilippM,KohnenR,HillerKO.BMJ.1999;319:1534-1539.23CornwallPL.BMJ.2001;322(7284):493.24SpiraJL.BMJ.2001;322(7284):493.25AlkhenizanA.BMJ.2001;322(7284):493.26VolpA.BMJ.2001;322(7284):493-494.

27HarrerG,etal.ArzneimForsch.1999;49(1):289-296.28SchraderE.IntClinPsychopharmacol.2000;15(2):61-68.29HaslerA,BrattstromA,MeierB:InternationalConference:2000YearsofNaturalProductResearch,Amsterdam,July26-30,1999,abstract413.

30FriedeM,Henneicki-vonZepelinH-H,FreudensteinJ.Phytomed.2000;7(supp2):18-19.

31VolzHP,LauxP.ComprPsychiatry.2000;41(2,suppl1):133-137.

32BrennerR,etal.ClinTher.2000;22(4):411-419.33SheltonRC,etal.JAMA.2001;285(15):1978-1986.34RandlovC,etal.AlternTherHealthMed.2001;7(3):108-109.

35HubnerWD,KirsteT.PhytotherRes.2001;15(4):367-370.36WinkelR,etal.Phytomed.2000;7(supp2):19.37WheatleyD.CurrMedResOpin.1999;15(1):33-37.38HarrerG.SchweizRundschMedPrax.2000;89(50):2123-2129.

39TaylorLH,KobakKA.JClinPsychiatry.2000;61(8):575-578.

40MannelM,KoytchevR,DundarovS.Phytomed.2000;7(supp2):17.

41SindrupSH,etal.Pain.2001;91(3):361-365.42GrubeB,WalperA,WheatleyD.AdvTher.1999;16(4):177-

186.43BoblitzN,etal.FocusAlternatComplementTher.2000;5(1):85-86.

44StevinsonC,ErnstE.BJOG.2000;107(7):870-876.45ChapmanM:AustralianDoctor,October6,2000.46BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

47ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Hypericiherba.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

THUJA

OtherCommonNames: Arbor-vitae,treeoflife,whitecedar(American)BotanicalName: ThujaoccidentalisFamily: CupressaceaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Antimicrobial,depurative,antiviral,antifungal

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingThujainformulationsinthecontextof:

•Infectionsfromwartviruses,oralandtopicaluse(5,7)

•TreatingandpreventingnonspecificURTIs,incombinationwithEchinaceaspp.rootandBaptisia(2)

•Sinusitis,incombinationwithEchinaceaspp.rootandBaptisia(3)

•Topicalapplicationforwartinfectionofthefoot(2)

•Topicalapplicationforfungalinfectionsoftheskin(5)

ContraindicationsPregnancy1andlactation(resultingfromthepresenceofthepotentiallytoxiccomponentthujoneintheessentialoilofThujaleaf).

WarningsandPrecautions

Thujashouldnotbetakeninhighdosesoveraprolongedperiod.

Cautionisadvisedinepilepsybecauseofthethujonecontentintheessentialoil.2

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancyandlactation.

Noneexpectediftakenwithintherecommendeddose

SideEffects range.

Highdosesofthujone(obtainedfromingestingtheessentialoil)havecausedconvulsionsandneurotoxicityinanimalsandhumans.2HighdosesofThujamaycauseheadachesattributedtothethujonecontent.Theaddictivesyndromeknownasabsinthism(fromtheliqueurabsinthe)hasbeenattributedtothetoxiceffectsofthujone.

Dosage Doseperday* Doseperweek*

1.5-3.0mlof1:5tincture 10-20mlof1:5tincture

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Bronchialcatarrh,bronchitiswithcardiacweakness,intermittentfever1

•Warts(oralandtopicaluse)1

•Enuresis,cystitis,1urinaryincontinence,bedwetting,urethritis3

•Psoriasis,rheumatism1

•Amenorrhea,uterinecarcinoma1

•Enlargedprostate3

•Disordersofthebloodandglands3

•Tocountertheilleffectsofsmallpoxvaccination1

•Topicallyforwounds,skinulcers,bedsores,fungalinfectionsoftheskin,carcinomatousulcerations,trachoma,rheumatism,leukorrhea;tostophemorrhagecausedbyuterinetumor3

NativeAmericansusedThujaforawidevarietyofreasons:asaremedyforcoughandheadache,asadiaphoreticandtotreatintermittentfevers,asabloodpurifier,andtoflavorothermedicines.ApoulticeofThujaleaveswasusedforswollenhandsandfeetandforheartpain.ThujawasofficialintheUSPfrom1882to1894andtheNFfrom1942to1950.Thujawasusedasastimulanttoheartanduterinemuscleandasastimulant,

irritant,andantiseptic.4

PharmacologicResearch

AnimportantcomponentofThujaleafistheessentialoil,whichcontainsmonoterpenes(especiallyterpenicketones,includingthujone)andotherterpenes.5

Pharmacologicresearchconductedusing(TPS,ahighmolecularweightpolysaccharidefractionisolatedfromThuja,isnotlistedhere.ThequantityofpolysaccharidespresentinThujapreparationscontaining50%ethanolormore(suchasThujatincture)wouldbenegligible.

•ConstituentsofThujahaveshownanticarcinogenicactivityinvitro.Theconcentrationoftumor-promotedornithinedecarboxylasewasinhibited.6

•PhagocytosisoferythrocytesbyKupffercellsinvitrowassignificantlyimprovedbyaformulationcontainingThuja,Baptisia,Echinaceaangustifolia,andE.purpurearootscombinedwithhomeopathicremedies.Singleherbalextractsalsodemonstratedactivity,withThujaextracthavingaprominenteffectonthefirstphaseofphagocytosis.7

•AntiviralactivitywasobservedusingThujaextractsagainstHSVinvitro.UsinghighlypurifiedfractionsofThuja,theminimalantiviraldosewaslowerthan50g/ml,andthe50%cytotoxicdosewas400μg/ml.8A70%ethanolicextractofThujaalsoinhibitedHSVinvitro.Usingactivity-guidedfractionation,themainactivecomponentwasfoundtobedeoxypodophyllotoxin,aknownantiviralagent.CommercialtincturesofThujawerefoundtocontainapproximately0.3mg/mlofthiscomponent.9Deoxypodophyllotoxinisalsoknowntobeactiveagainstthewartvirus.

•ThujaessentialoildemonstratedfungicidalactivityagainsttheringwormfungiMicrosporumaudouiniiiinvitro.10

ClinicalStudies

•HerbalformulationscontainingThujahavebeenusedsuccessfullyfortreatingandpreventingnonspecificURTIinrandomized,double-blind,placebo-controlledtrials.11,12TheseformulationsconsistedofThuja,Baptisia,andEchinaceaspp.rootortheseherbscombinedwithhomeopathicremedies.Intrials,thedailydoseofherbswaswellbelowthenormaltherapeuticlimit(moresimilartoahomeopathicprotocol).

•AcontrolledtrialfoundcombineduseofThuja,Baptisia,andEchinaceaspp.rootwiththeantibioticdoxycyclinehadbettersuccessthandoxycyclinealoneintreatingacutesinusitis.13

•Thujaextractappliedtopicallyfor3weeksdemonstratedbenefitfortreatingfootwartsinarandomized,double-blind,placebo-controlledclinicaltrialinvolvingchildrenandadults.14

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.MilletY,etal.ClinToxicol.1981;18(12):1485-1498.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.LeungAY,FosterS.Encyclopediaofcommonnaturalingredientsusedinfood,drugsandcosmetics,ed2.NewYork-Chichester:JohnWiley,1996.

ChangLC,etal.J.NatProd.2000;63(9):1235-1238.VomelT.ArzneimForsch.1985;35(9):1437-1439.BeuscherN,KopanskiL.PlantaMed.1986;52:555-556.4thInternationalCongressonPhytotherapy,Munich,September10-13,1992.

10YadavP,DubeyNK.IndianJPharmSci.1994;56(6):227-231.

11BarrettB,VohmanM,CalabreseC.JFamPrac.1999;48(8):628-635.

12Henneicke-vonZepelinHH,etal.CurrMedResOpin.1999;15(3):214-227.

13ZimmerM.Therapiewoche.1985;35:4024-4028.14KhanMT,etal.JEurAcadDermatolVenereol.1999;12(suppl2):S251-S252.

THYME

BotanicalName: ThymusvulgarisFamily: LabiataePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Expectorant,spasmolytic,antibacterial,antifungal,antioxidant,rubefacient(topically),antimicrobial

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingthymeinformulationsinthecontextof:

•Productivecough(2,5)

•Bronchitis,whoopingcough,catarrhoftheupperrespiratorytract(4,5)

•Stomatitisandhalitosis(4)

•Laryngitis,sorethroat,feverinthecommoncold(5)

•Dyspepsia,chronicgastritis,colic,flatulence,diarrhea(5)

•Tonsillitis,asagargle(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Inagroupof100patientswithlegulcers,5%respondedwithapositivereactiontopatchtestingwiththymeoil.Allergiccontactdermatitiscausedbythymolhasbeenreportedforaproprietaryantisepticmouthwashusedfortreatingparonychia.Thymeinhaledasdustcancauseoccupationalasthma,which

hasbeenconfirmedbyinhalationchallenges.Dosage Doseperday* Doseperweek*

2-6mlof1:2liquidextract

15-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishPharmaceuticalCodex1949, theBritishHerbalPharmacopoeia1983,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Dyspepsia,chronicgastritis,colic,flatulence,diarrhea1,2

•Bronchitis,asthma,whoopingcough,laryngitis,sorethroat,catarrh,feverinthecommoncold1,2

•Hysteria,dysmenorrhea,bedwetting1,2

•Asastimulatingtonicinconvalescenceafterexhaustingillness2

•Topicallyfortonsillitis1

PharmacologicResearch

•Thymeextractsexhibitedaspasmolyticeffectonisolatedsmoothmuscleandinhibitedagentsthatstimulatesmoothmuscle.Therelaxingeffectofbradykininwaspotentiated.

•Theantibacterialandantifungalactivityofthymoliswellrecognized.Essentialoilofthymedemonstratedantimicrobialandfungicidalactivityinvitroinseveralstudies.

•Componentsofthymeoilinhibitedthegrowthofsevenstandardstrainsofgram-positiveandgram-negativebacteriainvitro.AbroadspectrumofactivitywasobservedforthymolandcarvacrolagainstbacteriainvolvedinURTIs.AqueousandethanolicextractsofthymedemonstratedsignificantinhibitionofHelicobacterpyloriinvitro.

•Thymeextractshaveexhibitedantioxidantactivityinvitro.

ClinicalStudies

•OraltreatmentwithlargedosesofthymolresolvedKaposi’ssarcoma,dermatomyositis,andprogressivesclerodermainseparatecasestudies.Thethymolwasadministeredatadoseof1to4gperdayintwocyclesof64and169days,witha35-dayintervalwithnotreatment.

•Inconjunctionwithmaintainingacontinuousstateofdryness,topicalthymolwassuccessfullyusedintreatingparonychiaandonycholysis.

•Inarandomized,double-blindstudy,60patientswithproductivecoughreceivedeithersyrupofthymeorbromhexineforaperiodof5days.Nosignificantdifferencewasobservedbetweenthetwogroups,basedonself-reportedsymptomrelief.Bothgroupsmadesimilargains.Anonstatisticallysignificantimprovementwasobservedintherecoveryrateofnonsmokerscomparedwithsmokersinbothgroups.

•Vulvallichensclerosisintwopatientswassuccessfullytreatedwithacreamcontainingthymeextract.Nosideeffectswerereported.

•InGermany,theCommissionEsupportsusingthymetotreatsymptomsofbronchitisandwhoopingcoughandcatarrhoftheupperrespiratorytract.3

•ESCOPrecommendsthymefortreatingcatarrhoftheupperrespiratorytract,bronchialcatarrh,pertussis,stomatitis,andhalitosis.4

REFERENCES

ThefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.

PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Thymiherba.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,March1996.

TIENCHIGINSENG

BotanicalName: PanaxnotoginsengFamily: AraliaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Antihemorrhagic,cardioprotective,antiinflammatory,antiarrhythmic,hypocholesterolemic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingTienchiginsenginformulationsinthecontextof:

•Hemoptysis,hematuria(4,5)

•Anginapectoris,highbloodcholesterol(4)

•Hemorrhage,hematemesis,melena,abnormaluterinebleeding(5)

•Injuryfromtrauma,especiallywithhematoma,swelling,andbruising(5)

Contraindications Pregnancy,accordingtoTCM.1

WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancy.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3.5-8.5mlof1:2liquidextract

25-60mlof1:2liquidextract

Higherdosesmayberequiredfortraumaandseverehemorrhage.3

* ThisdoserangeisadaptedfromdriedplantdosagesadministeredbydecoctioninTCM.2Theauthor’sexperienceandthefactthatethanol-waterisamoreeffectivesolventthanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesfromTCMinclude:

•Hemorrhage,nosebleed,hemoptysis,hematemesis,metrorrhagia,hematoma,melena,sharppainofchestandabdomen2,3

•Swellingandpaincausedbytrauma2

ThemainactiveconstituentsofTienchiginsengaresaponins,includingginsenosidesandnotoginsenosides.4

•Tienchiginsengincreasedcoronarybloodflowinisolatedhearttissueandinvivo(byinjection),3,5decreasedmyocardialoxygenconsumption,andprolongedthesurvivaltimefromanoxia(byinjection).3Totalsaponinsprotectedagainstmyocardialischemiaandischemia-reperfusiondamageinvivo(routeunknown).6

•Adilutedrootextractincreasedcardiacfunctioninanisolatedheartpreparation.Ahypotensiveeffectwasdemonstratedforrootandtotalsaponinsinanexperimentalmodel(byinjection).3InjectionofTienchiginsengsaponinsprotectedagainstexperimentallyinducedhemorrhagicshock,whichwasattributedtotheimprovementinheartfunction.7

•AqueousextractofTienchiginsengloweredsystemicbloodpressureinvivo,aneffectthatwasnotblockedorreversedbymultipleantagonists.5InvitrostudiesindicatedthatTienchiginsenghadaselectiveblockingeffectoncalciumchannels.8,9

PharmacologicResearch

•Panaxatriolsaponinsexertedanantiarrhythmiceffectinvivo(routeunknown).Asignificantprotectiveeffectwasobservedtowardatrialfibrillation.10

•Tienchiginsengsaponinsdilatedcoronarybloodvesselsinvivo(byinjection).11AnantiatheroscleroticeffectwasdemonstratedexperimentallyfororalapplicationofthetotalsaponinsofTienchiginseng.12InjectionofTienchiginsengsaponinsinhibitedexperimentallyinducedabnormalincreasesinplateletaggregationandplateletadhesiveness.13

•ThesaponinfractionofTienchiginsengdemonstratedantiinflammatory,analgesic,andimmunomodulatoryactionsinexperimentalmodels(byinjection).14Antiinflammatoryactivitywasnotobservedintheadjuvant-inducedinflammationmodelafterinjectionofTienchiginsengdecoction.15

•Tienchiginsengtotalsaponinsdecreasedtotalcholesterolandtriglyceridesinvivoafteroraladministration.16

•GinsenosideRg1isolatedfromTienchiginsengloweredhyperglycemiaandactedsynergisticallywithinsulininvivo(routeunknown).Theuptakeofglucosebyhepatocyteswasincreasedinvitro.17

•OraldosesofTienchiginsengimprovedexperimentallyinducedlearningandmemorydeficit18andincreasedspontaneouslocomotoractivityinvivo.Treatedanimalsshowedlessanxiousbehaviorthancontrols.19

•InuncontrolledtrialsinChina,Tienchiginsenghassatisfactorilytreatedheartdisease,especiallyanginapectoris.Atypicaldoseis1gofpowdertakenthreetimesperday.3

•Ahemostaticeffectwasachievedforhemoptysisinan

ClinicalStudies

uncontrolledtrialinvolving10patients.Tienchiginsengpowder(6to9g,twotothreetimes/day)wasadministered.Inanotheruncontrolledtrial,successwasnotedinhematuriabythethirddayoftreatment(0.9to1.5gevery6to8hours).3

•Inatrialinvolving57patients,Tienchiginsengdemonstratedsimilarhypocholesterolemicactivitytoclofibrate.Theclinicalhypocholes-terolemicactivityofTienchiginsenghas,however,beendisputed.3

REFERENCES

BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.TangW,EisenbrandG.Chinesedrugsofplantorigin.Berlin:Springer-Verlag,1992.LeiXL,ChiouGC.AmJChinMed.1986;14(3-4):145-152.LiX,ChenJX,SunJJ.ChungKuoYaoLiHsuehPao.1990;11(1):26-29.LiLX,etal.ChungKuoYaoLiHsuehPao.1988;9(1):52-55.XiongZG,ChenJX,SunJJ.ChungKuoYaoLiHsuehPao.1989;10(2):122-125.KwanCY.ClinExpPharmacolPhysiol.1995;22(suppl

1):S297-299.10GaoBY,etal.YaoHsuehHsuehPao.1992;27(9):641-644.11WuJX,SunJJ.ChungKuoYaoLiHsuehPao.1992;13(6):520-523.

12ShiL,etal.ChungKuoYaoLiHsuehPao.1990;11(1):29-32.

13MaLY,XiaoPG.PhytotherRes.1998;12:138-140.14WangYL,ChenD,WuJL.ChungKuoChungHsiIChiehHoTsaChih.1994;14(1):5.35-36

15WeiF,etal.JAlternComplementMed.1999;5(5):429-436.16XuQ,ZhaoY,ChengGR.ChungKuoChungYaoTsaChih.1993;18(6):367-368.383

17GongYH,etal.YaoHsuehHsuehPao.1991;26(2):81-85.18HsiehMT,etal.PhytotherRes.2000;14(5):375-377.19CiceroAF,BandieriE,ArlettiR.JEthnopharmacol.2000;73(3):387-391.

TURMERIC

BotanicalName: CurcumalongaFamily: ZingiberaceaePlantPartUsed: Rhizome

PRESCRIBINGINFORMATION

ActionsAntiinflammatory,antiplatelet,antioxidant,hypolipidemic,choleretic,antimicrobial,carminative,depurative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingturmericinformulationsinthecontextof:

•Dyspepsia(2,4,5)

•Stomachulcer(3,6)

•Adjuvanttherapyforprecancerousconditions(3)

•Osteoarthritis,incombinationwithashwaganda,Boswelliaserrata,andzinc(3)

•Rheumatoidarthritis(5)

•Antioxidantactivity(4)

•Liverdysfunction(5,7)

•Hypercholesterolemia(7)

Contraindications

AccordingtotheCommissionE,turmericiscontraindicatedwhenobstructionofthebiliarytractispresentandshouldbeusedonlyafterseekingprofessionaladviceifgallstonesarepresent.

WarningsandPrecautions

Highdosesshouldnotbegiventopatientstakingantiplateletoranti-coagulantdrugs.Careshouldbeexercisedwithwomenwishingtoconceiveandpatientscomplainingofhairloss.Patientsapplyingtopicaldosesshouldnotbeexposedtoexcessive

sunlight.

InteractionsHighdosesofturmeric(greaterthan15g/day)shouldnotbegiventopatientstakingantiplateletoranticoagulantdrugs.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

5-14mlof1:1liquidextract

35-100mlof1:1liquidextract

* Thisdoserangeisadaptedfromdosesusedinclinicaltrials.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Liverdisorders,poordigestion,1,2diarrhea,vomitingofpregnancy1

•Fevers,thecommoncold,catarrhalcough1,2

•Leprosy,snakebite1

•Externallyforconjunctivitis,ophthalmia,1skininfections,ulcers,wounds,arthritis,andeczema1,2

UsesfromTCMinclude:

•Amenorrhea,dysmenorrhea3,4

•Chestandabdominalpainandabdominaldistention3,4

•Jaundicewithdarkurine3

•Impairmentofconsciousnessinfebrilediseases,epilepsy,mania3

•Traumaticinjury,swelling,andpain3

TraditionalThaimedicinalusesinclude:

•Intestinalulcer,pepticulcer5

•Promotinghealth,preventinggonorrhea,thecommoncold,dizziness5

•Analhemorrhage,hemorrhageinwomen,uremia5

•Topicallyforskindiseases,ringworm,wounds,insectbites,tostrengthenteeth5

TraditionalWesternherbalmedicineusesinclude:

•Jaundice6

•Asamild,aromaticstimulant(Eclecticphysicians)7

PharmacologicResearch

Keyconstituentsofturmericrhizomeincludeanessentialoil(containingsesquiterpeneketones)andyellowpigmentsknownasdiarylheptanoids,includingcurcumin.

•Oraldosesofcurcuminhavedisplayedsignificantantiinflammatoryactivityinbothacuteandchronicexperimentalmodels.Curcuminisadualinhibitorofarachidonicacidmetabolism,inhibitingboththeenzymes5-lipoxygenaseandcyclooxygenaseinvitro.

•Theantiplateletactivityofcurcuminissupportedbyanumberofinvitroandexvivostudies,suggestingthatcurcumininhibitsthromboxaneproductionfromplatelets.Arecentstudyfoundthatcurcumininhibitedplateletaggregationinducedbyarachidonate,epinephrine(adrenaline),andcollageninvitro.

•Theantioxidantactivityofcurcuminandextractsofturmericareconsistentlysupportedbyinvitroandoralinvivostudies.

•Dietarylevelsofcurcuminaslowas0.1%significantlyreducedtherisesinserumandlivercholesterolinanexperimentalmodelofhypercholesterolemia.AsubsequentstudyverifiedthatturmericincreasedtheratioofHDLcholesteroltototalcholesterol.

•Earlystudiesindicatedthatinjectionofturmericessentialoilorcurcuminincreasedbilesynthesis.Oraladministrationofcurcumincausedregressionof

gallstonesinanexperimentalmodelwithpreestablishedcholesterolgallstones.

•Oraldosesofturmericextractproducedsignificantprotectionagainstgastriculcerationinanumberofexperimentalmodels.Turmericextractincreasedgastricwallmucusproductionandenhanceditscytoprotectivequality.

•Hepatoprotectiveactivityforturmericextractagainstcarbontetrachloride–inducedhepatotoxicityhasbeendemonstratedinvivo.

•Numerousinvitroandinvivo(oralroute)studiesshowthatturmericandcurcuminpossessantimutagenicandantipromotionactivity,whichisprobablyrelatedtotheantioxidantandantiinflammatoryactivitiesofcurcumin.Oraladministrationofcurcuminsignificantlyinhibitedthetumorincidenceandtumorburdenofbothinvasiveandnoninvasivetumorsinvariousexperimentalmodelsofcancer.

•Turmeric,itsessentialoil,andcurcumininhibitedthegrowthofgram-positivebacteriainvitro.Theessentialoilofturmericdisplayedsignificantantifungalactivityinvitro.LowconcentrationsofcurcuminhaveshownsignificantphototoxicitytowardSalmonellainvitro.

•Inarandomized,double-blind,placebo-controlledtrial,treatmentwithturmeric(2g/dayfor7days)wassignificantlybetterthanplaceboforpatientswithdyspepsia.

•Inasmall,uncontrolledtrial,turmeric(2g/day)producedfavorableresultsfortreatingstomachulcerafter4to12weeks.8Inacontrolledtrial,88%ofparticipantstreatedwithturmeric(4g/day)showedimprovementinabdominalpaincausedbygastriculcerationcomparedwith40%inthegroupreceivingmagnesiumsilicateand

ClinicalStudies

aluminumhydroxide.9

•Inarandomized,double-blind,placebo-controlled,crossovertrial,patientswithosteoarthritisreceivedapreparationcontainingturmeric,ashwaganda,Boswelliaserrataresin,andazinccomplexorplacebofor3months.Treatmentwiththeherbal-mineralpreparationproducedasignificantdropinseverityofpainanddisability.

•Inuncontrolledtrials,turmericextract(equivalenttoapproximately50g/daydriedrootfor12weeks)dramaticallydecreasedbloodlipidperoxidelevelsinhealthymalesandloweredplasmacholesterolandtriglycerides.Thetherapeuticeffectwasatleastequivalenttoclofibrate.

•Turmericgiventochronicsmokers(1.5g/dayfor30days)significantlyreducedurinarymutagensinaplacebo-controlledstudy.

•Patientswithsubmucosalfibrosis(aprecancerouscondition)treatedorallywithturmericpreparationsfor3monthsexperiencedanormalizationinthenumberofmicronucleatedcells,bothinexfoliatedoralmucosalcellsandincirculatinglymphocytes.Resultswerecomparedwithhealthyvolunteerswhoservedasacontrolgroup.Thedoseforthetreatmentgroupwasturmericextract3gperdaygivenaloneormixedwitheitherturmericessentialoil600mgperdayorturmericoleoresin600mgperday.

•InGermany,theCommissionEsupportsusingturmerictotreatdyspepticconditions.10

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicand

clinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982KapoorLD.CRChandbookofAyurvedicmedicinalplants.BocaRaton,Fla:CRCPress,1990.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.FarnsworthNR,BunyapraphatsaraN,editors.Thaimedicinalplants.Bangkok:MedicinalPlantInformationCenter,1992.GrieveM.Amodernherbal.NewYork:DoverPublications,1971.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983PrucksunandC,etal.ThaiJPharmacol.1986;8(3):139-151.IntanontaA,etal.ReportsubmittedtoPrimaryHealthCareOffice.Thailand:MinistryofPublicHealth,1986.

10BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

TYLOPHORA

OtherCommonNames: Indianipecac,IndianlobeliaBotanicalNames: Tylophoraindica,Tylophoraasthmatica#

Family: AsclepiadaceaePlantPartUsed: Leaf

# Alternativename.

PRESCRIBINGINFORMATION

Actions Antiasthmatic,antiinflammatory,immunedepressant,antiallergic,emetic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingTylophorainformulationsinthecontextof:

•Asthma(2,6)

•Allergicrhinitis(4)

•Autoimmuneandchronicimmune-mediatedinflammatorydiseases(7)

•Providingprotectionagainstinhaledallergenchallenge(3)

ContraindicationsBecauseofthestrongpharmacologicactivityofTylophora,itiscontraindicatedinpregnancyandlactationandshouldnotbeusedlongterm.

WarningsandPrecautions

Tylophoraisbesttakenshorttermandintermittently,ratherthancontinuously.Therecommendeddosagemustnotbeexceeded.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancyandlactation.

SideEffects

Nauseaandvomitingmayoccur,evenatalowdose,especiallyinsensitiveindividuals.Soremouthandlossoftasteforsalthavealsobeenreportedinaclinicaltrialafterpatientsswallowedonechoppedfreshleafperdayfor6days.1Thefrequencyandseverityofsideeffectswerelessinasubsequenttrialconductedbythesameresearchgroup,forwhichanundefineddried

ethanolicextractofTylophoraleaf(40mg/dayfor6days)wasusedinsteadofthefreshleaf.2

Dosage

Tylophorashouldbeusedonlyforshort-termintermittenttreatment,upto4weeksatatime.ThebestwaytoprescribeTylophoraistorecommendbetween20to50dropsperdayofa1:5tincture(thehighestdoseinthatrangethatdoesnotcausenauseaforthatparticularbatchinthatparticularpatient)forthefirst10to14daysofeachcalendarmonth.*

* Thisdoserangeisextrapolatedfromclinicaltrialdata.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalAyurvedicusesinclude:

•Bronchialasthma,3chronicbronchitis,catarrh,dysentery4

•Asanemetic,diaphoreticandexpectorant;asasubstituteforIpecacuanha4

•Snakebite(inlargedoses)5

TheleavesofTylophoracontainseveralalkaloids,includingtylophorineandtylophorinine.6

•Tylophorahasshort-livedbronchodilatoractivityinvitro,butthisisprobablynotthebasisofitseffectsinasthma.7

•Studiesshowthattheantiasthmaeffectsaremorelikelytobemediatedthroughdepressionofsomeaspectsofcell-mediatedimmunity.Tylophoraextractreducedtotalleukocytecountinvivo(byinjection);and21daysafteradministration,eosinophilsandlymphocyteswerestillreduced.7OraladministrationofTylophorademonstratedapronouncedinhibitionofthecell-mediatedimmuneresponseinexperimentalmodels,asevidencedbytheincreasedsurvivaltimeofskingrafts.8

•Tylophorineenhancedadenylatecyclaseactivityinintactleukocytestakenfromchildrenwithasthmabuthadnoeffectincellsfromchildrenwithoutasthma.Theauthorssuggestedthattylophorineactsbystimulatingbeta-adrenergicreceptoractivityinpatientswithbronchial

PharmacologicResearch

asthma,possiblyinamannersimilartothatofhydrocortisone.9

•PretreatmentwithTylophorasignificantlyincreasedlungflowratesinantigen-sensitizedanimals,demonstratinganantiallergicactivity.Tylophorawasadministeredasanaqueousextractbyinjectionbeforesensitizationandchallengeordirectlybyperfusionbeforechallengebutaftersensitization.Tylophorademonstratedsimilarantiallergicactivitytothepreventativedrugdisodiumcromoglycate.Tylophoraalsoincreasedflowratesinnormalanimals,whichpossiblyindicatesabronchodilatingactivity.Insensitizedanimals,theeffectofTylophorawasgreater,possiblybecauseofanimmunosuppressiveaction.10

•Pretreatmentwithtylophorineinjection(25mg/kg)inhibitedsystemicanaphylaxisinducedbysensitizationwitheggalbumen.Theprotectionaffordedbytylophorineexceededthatofdexamethasone.Whensheepredbloodcellswereaddedtoasensitizedlymphoidcellsuspensionfromanimalstreatedwithtylophorine,immunocyto-adherencewasonly15%(comparedwith40%intheabsenceoftylophorine).Tylophorinedidnotpreventthemastcell–degranulatingeffectofagentsthatactonthesurfacemembranebutdidinhibitmastcellruptureinducedbydiazoxide(whichcausescelldegranulationbyreducingintracellularlevelsofcAMP).11

•Injectionoftylophorineexhibitedpronouncedantiinflammatoryactivitycomparedwithplacebo,dexamethasone,andphenylbutazone(antiinflammatorydrugs)inexperimentalmodelsofacuteandchronicinflammation.12

•Primaryandsecondaryresponsesofadjuvant-inducedarthritisweresignificantlyinhibitedbyinjectingtylophorine.11

•ExtractsofTylophorahavebeenshowntostimulatetheadrenalcortex,increaseplasmasteroidlevels,andantagonizesteroid-inducedsuppressionofadrenalactivityviaintraperitonealinjection.13Thisactivitymightbethebasisofitsantiinflammatoryeffects.

•Tylophorinecausedcentralnervoussystemdepression(100to300mg/kg),potentiatedphenobarbital-inducedsleepingtime(100mg/kg),andpotentiatedtheanalgesiceffectofsubanalgesicdosesofmorphine(50to100mg/kg).Thetylophorinewasadministeredbyinjection.12

•Inanopen,preliminarytrialconductedinthe1960s,chewingoneleafofTylophoradailyfor6daysproducedreliefofsymptomsinmanyofthepatientswithasthmaandallergicrhinitis.14Inarandomized,doubleblindtrial,Tylophora(onefreshleaf/day)orplacebowasadministeredfor6daystopatientswithasthma.Attheendofthefirstweek,62%ofpatientsintheactivegrouphadmoderatetocompletereliefofsymptomscomparedwith28%intheplacebogroup.Bytheendofthe12-weekfollow-upperiod,16%ofthetreatedgrouphadstillmaintainedcompletetomoderatereliefcomparedwith0%intheplacebogroup.Afterthe12-weekperiod,thecrossover(anddouble-blind)phaseofthetrialwasinitiated.PatientsonplaceboweregivenTylophoraandvice-versa.Oneweekaftercrossover,50%oftheTylophoragrouphadcompletetomoderatereliefcomparedwith11%oftheplacebogroup.1

•Inanotherrandomized,double-blind,placebo-controlledtrialinvolvingpatientswithasthma,attheendofthe6-daytreatmentperiod,56.3%oftheTylophoragrouphadcompletetomoderatesymptomimprovementcomparedwith31.6%intheplacebogroup.Attheendofthe12-weekfollow-upperiod,14.8%oftheTylophoragroupand7.2%oftheplacebogroupstillhadcompletetomoderaterelief.TheefficacyofTylophorawasverifiedinasubgroupofpatientswhowerecrossedover.Patientsin

ClinicalStudies

thetreatmentgroupreceived40mgperdayofanundefineddriedethanolicextractofTylophoraleaf.2

•Tylophora(onedryleaf/dayfor6days)providedprotectionfrominhaledallergenchallenge(administered55hoursafterthetreatmentperiod)inpatientswithasthmawhoweresymptomfreeandwhohaddemonstratedpositivebronchialsensitivity.Noprotectionwasavailableinthecontrolgroupforwhichnotreatmentwasreceived.Asubgroupofthesepatientswaschallengedfurther,andthedurationoftheprotectionwasfoundtolastfor7to9daysaftertheTylophoratreatmenthadceased.15

•Tylophora(350mgdriedleaf/dayfor7days)demonstratedgreatersymptomaticimprovementinpatientswithbronchialasthmathanplaceboandnosignificantdifferencewhencomparedwithastandardantiasthmaticdrug(containingmainlytheophylline),inrandomized,double-blind,crossovertrials.Tylophorahadamoregradualandlong-lastingeffectthanthedrugtreatment.16

•Inaplacebo-controlledtrialthatinvestigatedthetreatmentofasthma,resultswerenotsignificant,buttheydidshowatendencytoimprovementforTylophoratreatment.However,the“placebo”consistedpartlyofIpecacuanha,anherbthatisnotdevoidofbronchialactivity.17

•Inanopen,controlledstudy,Tylophoraleaf(200mg/dayfor6days)depressedabsoluteeosinophilcountandincreasedurinelevelsof17-ketosteroidinbothhealthyvolunteersandpatientswithasthma.Theauthorspostulatedthatincreasedreleaseofsteroidhormonesfromtheadrenalglandmayreducethedevelopmentofsensitivitytoforeignantigen,thusgivingrelieftopatientswithasthma.Lungfunctiontestsweresignificantlyimprovedcomparedwithbaselineinbothhealthy

volunteersandpatientswithasthmawhentestedontheseventhdayafteradministeringTylophora.Theimprovementinlungfunctionwassuperiortothatproducedbyisoprenaline(abronchodilator).18

REFERENCES

ShivpuriDN,MenonMPS,PrakashD.JAllergy.1969;43(3):145-150.ShivpuriDN,SinghalSC,ParkashD.AnnAllergy.1972;30(7):407-412.NadkarniAK.Dr.K.M.Nadkarni’sIndianmateriamedica,ed3.Bombay:PopularPrakashan,1976.ChopraRN,etal.Chopra’sindigenousdrugsofIndia,ed2.Calcutta:AcademicPublishers,1958.reprinted1982NymanP,etal.GlimpsesofIndianethnopharmacology.Kerala,India:TropicalBotanicGardenandResearchInstitute,1995.KarnickCR.PlantaMed.1975;27(4):333-336.HaranathPSRK,ShyamalakumariS.IndianJMedRes.1975;63(5):661-669.AtalCK,etal.JEthnopharmacol.1986;18(2):133-141.RainaV,RainaS.BiochemBiophysResComm.1980;94(4):1074-1077.

10NayampalliSS,ShethUK.IndianJPharmacol.1979;11(3):229-232.

11GopalakrishnanC,etal.IndianJMedRes.1980;71:940-948.12GopalakrishnanC,etal.IndianJMedRes.1979;69:513-520.13UdupaAL,UdupaSL,GuruswamyMN.PlantaMed.1991;57(5):409-413.

14ShivpuriDN,MenonMPS,ParkashD.JAssocPhysiciansIndia.1968;16(1):9-15.

15ShivpuriDN,AgarwalMK.AnnAllergy.1973;31(2):87-94.16ThiruvengadamKV,etal.JIndianMedAssoc.1978;71(7):172-176.

17GuptaS,etal.IndianJMedRes.1979;69:981-989.18GoreKV,RaoAK,GuruswamyMN.IndianJMedRes.1980;71:144-148.

UVAURSI

OtherCommonName: BearberryBotanicalName: Arctostaphylosuva-ursiFamily: EricaceaePlantPartUsed: Leaf

PRESCRIBINGINFORMATION

Actions Urinaryantiseptic,astringent,antiinflammatory

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribinguvaursiinformulationsinthecontextof:

•Inflammatoryorinfectiousconditionsofthelowerurinarytract,particularlycystitis(4,5)

•Cystitis,incombinationwithdandelionleafandroot(2)

•Urinarystones(5)

Contraindications

AccordingtotheBritishHerbalCompendium,uvaursiiscontraindicatedinkidneydisorders,butdatatosupportthisisminimal.

AccordingtotheCommissionE,uvaursiiscontraindicatedinpregnancyandlactationandforchildrenunder12yearsofage.

WarningsandPrecautions Uvaursiisnotsuitableforprolongeduse.

Interactions

Uvaursishouldnotbegivenwithtreatmentsthatwillleadtotheproductionofacidicurine,becausethiswillreducetheantibacterialeffect.

UvaursiwillworkbestwhenurinehasanalkalinepH.

Thehightanninlevelswillinterferewiththeabsorptionofvariousnutrients.

UseinPregnancyandLactation

Contraindicatedinpregnancyandlactation.

SideEffectsBecauseofthehightannincontent,internaluseofuvaursimaycausecramping,nausea,vomiting,andconstipation.

Dosage Doseperday* Doseperweek*

4.5-8.5mlof1:2liquidextract

30-60mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Compendium 1992 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Inflammatorydiseasesofthebladderandkidneys,includingcystitis,urethritis,andpyelitis;dysuria,chronicirritationofthebladder,enuresis,excessivemucusandbloodydischargesintheurine,strangury,urinarystones,chronicgonorrhea1,2

•Specificallyindicatedforlackoftone,feeblecirculation,andlackofinnervationintheurinarytract2

•Chronicdiarrhea,dysentery,menorrhagia,leukorrhea,diabetes2

PharmacologicResearch

Uvaursileavescontainhydroquinoneglycosides(includingarbutin)andtannins.

•UvaursiextractshaveshownantimicrobialactivityinvitroagainstEscherichiacoli,Proteusvulgaris,Enterobacteraerogenes,Streptococcusfecalis,Staphylococcusaureus,Salmonellatyphi,andCandidaalbicans.

•Althoughthebactericidalactivityofuvaursidecoctionwasrelativelylow,itmarkedlyincreasedthehydrophobicityofthemicrobialspeciestested,whichincludedE.coli.Uvaursimaythereforeinfluencethemicrobe’ssurfacecharacteristics.3

•Uvaursiextractismosteffectiveagainstbacterialinfectioninanalkalineenvironment.Alkalineurineindicatesthepresenceofcertainmicroorganismsthatare

capableofureasplitting,suchasProteusspp.,Klebsiellaspp.,someCitrobacterspp.,someHemophilusspp.,Bilophilawadsworthia,theyeastCryptococcusneoformans,andseveralotherbacteriaandfungi.Basedontheresearchhighlightedhere,infectionwiththeseorganismsshouldbesusceptibletotreatmentwithuvaursi.Alkalinizationoftheurinewithbufferingagentscontainingsodiumbicarbonate,sodiumcitrate,citricacid,andtartaricacidinconjunctionwithuvaursiintakeisdesirableinthesecircumstances.

•Arbutin,inconjunctionwithantiinflammatorydrugs,showedaninhibitoryeffectonswellinginadelayed-typehypersensitivitymodel.Theeffectwassuperiortothedrugsusedalone.ArbutinmaythereforehaveasynergisticantiinflammatoryactivityontypeIVreaction–inducedinflammation.

ClinicalStudies

•Inadouble-blind,placebo-controlled,randomized,clinicaltrial,57womenwithrecurrentcystitisreceivedeitherherbaltreatment(standardizeduvaursiextractanddandelionleafandrootextract)orplacebo.Treatmentfor1monthsignificantlyreducedtherecurrenceofcystitisduringthe1-yearfollow-upperiod,withnoincidenceofcystitisintheherbalgroupanda23%occurrenceintheplacebogroup.Nosideeffectswerereported.Thedoseoftheindividualherbswasnotspecified.

•InGermany,theCommissionEsupportsusinguvaursitotreatinflammatorydisordersoftheefferent(descending)urinarytract.4

•ESCOPrecommendsuvaursifortreatinguncomplicatedinfectionsofthelowerurinarytract,suchascystitis,whenantibiotictreatmentisnotconsideredessential.5

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.TuriM,etal.ActaPatholMicrobiolImmunolScand.1997;105(12):956-962.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Uvaeursifolium.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,June1997.

VALERIAN

CommonName: ValerianBotanicalName: ValerianaofficinalisFamily: ValerianaceaePlantPartUsed: RootandrhizomeCommonName: MexicanvalerianBotanicalName: ValerianaedulisFamily: ValerianaceaePlantPartUsed: Rootandrhizome

PRESCRIBINGINFORMATION

Actions ValerianandMexicanvalerian:anxiolytic,mildsedative,hypnotic,spasmolytic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingvalerianinformulationsinthecontextof:

•Insomnia(2,4,5)

•Insomnia,incombinationwithlemonbalmorhops(2)

•Depression,incombinationwithSt.John’swort(2)

•Stress(3)

•Anxiety,incombinationwithSt.John’swort(3)

•Restlessness,nervoustension(4,5)

•Depression,anxiety,migraine,nervousheadache,cramps,intestinalcolic,dysmenorrhea,rheumaticpains,chorea,mildspasmodicmovements,epilepsy(5)

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingMexicanvalerianinformulationsinthecontextof:

•Anxiety(4a,6)

•Insomnia(2,6)Contraindications Noneknown.

WarningsandPrecautions

Nonerequired.

Interactions

Althoughnoreportstodatehavebeenpresented,valerianmayincreasetheeffectsofcentralnervoussystemdepressantsoralcoholwhentakentogether,accordingtotheU.S.Pharmacopeia.Despitethiswarning,earlyanimalstudiesindicatedthatvalepotriatesdonotaddtothedepressanteffectofalcohol.AhumanstudyconfirmedthatsimultaneousintakeofalcoholwithavalerianandSt.John’swortcombinationdidnotincreasetheeffectsoftheherbalproduct,andamixtureofvalepotriates(valtrate,acevaltrate,anddidrovaltrate[200to400mg])combinedwithethanoldidnotcauseareductionofefficiency.

Valerianrootextractmayattenuatesomesymptomsofbenzodiazepinewithdrawal,basedonanimalmodels.1

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects

Insomeindividuals,valeriancanaggravateasensationoftirednessordrowsiness,particularlyinhigherdoses,butthisisusuallymoreacaseofanincreasedawarenessofthebody’sneedsratherthananegativedepressanteffect.Afewindividualsfindvalerianstimulatingandshouldavoiditsuse.Headacheshavebeenreportedafteroverdosewithvalerian.

Amalepatienttakingmultiplemedicationsexperiencedseriouscardiaccomplicationsanddeliriumfollowingasurgicalprocedure.2Themanhadself-medicatedfor“manyyears”withvalerianrootextract(530mgto2g/dose,fivetimesdaily).However,giventheperson’smultiplemedications,valeriancannotbecausallylinkedtohissymptoms.Theseotherfactorsmayhaveincreasedtheriskofawithdrawalreaction.

Dosage Valerian: Doseperday* Doseperweek*

2-6mlof1:2liquidextract

15-40mlof1:2liquidextract

Mexicanvalerian: Doseperday** Doseperweek**

1.5-4.5mlof1:2liquidextract

10-30mlof1:2liquidextract

* This dosage is extrapolated from the British Pharmaceutical Codex 1949, the BritishHerbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’seducationandexperience.

** This dose range is extrapolated from the pharmacologic and clinical informationavailableonvalepotriates.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesofvalerianinclude:

•Insomnia,hystericalstates,excitability,hypochondria,nervousness;migraine,nervousheadache,depressivestates,reducedcerebralcirculation3,4

•Cramps,intestinalcolic,dysmenorrhea,rheumaticpains,chorea,mildspasmodicmovements,epilepsy3,4

MexicanvalerianisusedtraditionallyinMexicoforitstranquilizingandsedativeeffects.5NativeAmericansusedMexicanvalerianinternallyforhemorrhagesandtapeworminfestationandtopicallyforrheumatism,swollenandbruisedparts,wounds,andtodrawoutboils.6-8

Valerianrootcontainsiridoids(knownasvalepotriates),essentialoil,andcyclopentanesesquiterpenes(e.g.,valerenicacid).Mexicanvalerianroothasahigherpercentageofvalepotriates(andalargervaltrate-isovaltratecontent)thanvalerian;itdoesnotcontainvalerenicacid.

Valepotriatesareunstablecompounds;theydecomposeunderacidoralkalineconditionsorinalcoholicsolutions(suchasliquidextracts).

However,theinitialdecompositionproductsofvalepotriatesareactiveassedativesandareprobablyamongtheactiveproductsinthehumansystemafteringestionofvalerian.

PharmacologicResearch

•AqueousextractofvalerianinducedthereleaseofGABAfrombraintissue.Manyinvitrostudieshaveinvestigatedtheinteractionofvalerianoritscomponentswithreceptorsmediatingsedation,suchasGABA,adenosine,and5-hydroxytryptamine(5-HT1A,serotonin)receptors.

•Thesedativeeffectofthevalepotriateshasbeendemonstratedinseveralexperimentalmodels.Oralvalepotriatesimprovedcoordination,and(byunknowndoseroute)valepotriatesdecreasedanxietyandaggression.Inanexperimentalmodel,intraperitonealadministrationofvalerenicaciddemonstratedsedativeactivityresemblingcentralnervoussystemdepression,ratherthanmusclerelaxationoraneurolepticeffect.

•Antispasmodiceffectsonsmoothmuscletissue(ileum)wereobservedforvalepotriatesandanessentialoilcomponentofvalerianinvitroandinvivo(byinjection).9

•ThesedativeeffectsofvalepotriatesonhumanswasconfirmedanumberoftimesinGermanresearchconductedinthelate1960s.

•Arandomized,placebo-controlled,double-blindtrialdemonstratedsingleorrepeatedadministrationsofvaleriandidnothaveanegativeimpactonreactiontime,alertness,andconcentrationthemorningafterintake.Thedoseusedwasequivalentto3gperdayofrootandwasprescribedfor2weeks.10

•Inarandomized,double-blindtrial,valeriantabletsdemonstratedsimilarefficacytooxazepam(10mg/day)fortreatinginsomnia.Thedailydoseofvaleriancorrespondedtoapproximately3goforiginalroot.11

•Arandomized,double-blind,placebo-controlled,crossoverstudyusingvalerianextract(equivalentto3g/dayofrootfor14days)confirmedpositiveeffectson

sleepstructureandsleepperceptioninpatientswithmildpsychophysiologicinsomnia.12TheeffectofMexicanvalerian(MV)andvalerian(V)extractswereinvestigatedusingpolysomnographicrecordingsinadouble-blind,crossovertrialinvolving20patientswithinsomnia.Patientsreceivedasingledoseofextractintabletform:theMVextractdosecontained2.4mgvalepotriates;theVextractdosecontained0.3mgvalerenicacid.

Thefollowingresultswereobtained:13

•Decreaseinwakingepisodes(MVonly)

•IncreaseinREMsleep(bothextracts,butVbetter)

•Increaseinsleepefficiencyindex(comparedwithbaseline;Vbetter)

•Decreasedtimeforstages1and2innon-REMsleepandanincreaseindeltasleep(MVbetter)

•Decreaseinmorningsleepiness(Vbetter)

•Noresidualhypnoticeffect(MVbetter)

•Inalarge,uncontrolled,multicentertrialinvolvingover11,000patients,treatmentwithaqueousvalerianextract(equivalentto0.25g/daydriedroot)wasratedassuccessfulintreatingdifficultyinfallingasleep(72%),discontinuoussleep(76%),andrestlessnessandtension(72%).

•Inadouble-blind,placebo-controlled,crossovertrial,acombinationofvalerian(equivalentto400mgofroot)withhopsandlemonbalmdemonstratedasignificantsubjectiveeffectonpoorsleepcomparedwithplacebo(whichalsocontainedhopsandlemonbalm)over2consecutivenights.Goodsleepwasreportedin44%and89%ofpatientsreportedimprovedsleep.

ClinicalStudies

•ASwissstudyfoundthatafreeze-driedaqueousvalerianextractimprovedsleeplatencyandsleepqualitywithoutincreasingsleepinessthenextmorning,comparedwithplacebo.Thegroupofparticipantswhoratedthemselvesasgoodsleeperswerelargelyunaffectedbyvalerian,butthepoororirregularsleepersreportedasignificantimprovement.Valeriandidnotincreasethefrequencyof“moresleepythanusual(thenextmorning)”responses.Adosageofapproximately1.2gofvalerianrootperdaywasgivenover3nonconsecutivenights.

•Arandomized,double-blindstudywasconductedonpatientswithdiagnosedinsomnia.Practitionersratedsleepimprovementhigherfollowingvaleriantherapythantheydidafterplacebo.Patientspreferredvalerian,withsignificantimprovementsbeingnotedinsleepqualityandthefeelingofbeingrestedaftersleep.Thedosewasequivalenttoapproximately2.4gofdriedrootperdayandadministeredfor4weeks.

•Tworandomized,double-blind,placebo-controlledtrialscomparedanumberofherbalextracts,includingdriedethanolicextractofvalerian(equivalentto6gofroot),insleep-disturbedvolunteers.Incontrasttodiazepam(10mg),valeriandisplayedanincreaseindeltaandthetafrequenciesandadecreaseinbetafrequencyonelectro-encephalographicrecordings.Incontrasttoplacebo,mostoftheherbalextracts(aswithdiazepam)inducedanincreaseinsubjectivelyevaluatedsleepiness.

•Adouble-blind,placebo-controlledcrossovertrialonhealthyvolunteersshowedvaleriantendedtonormalizethesleepprofile,lowerperiodsofwakefulness,andincreasetheefficiencyofthesleepperiod.Valerianwasadministeredasasingledose(equivalentto6g)andasarepeateddose(equivalentto3g/dayfor14days).

•Acombinationofvalerianandhopsextractsreducedthenoiseinduceddisturbanceofsleepstagepatterns(slow-

wavesleepandREM)insleep-disturbedvolunteers.Thecombination(equivalentto1g/dayofvalerianrootand2g/dayofhops)wasgiventovolunteersduringthesecondorthirdof3consecutivenightsdisturbedbyheavytrafficnoise.Arandomized,double-blind,controlledtrialdemonstratedequivalentefficacyandtolerabilityforahops-valerianpreparationwhencomparedagainstabenzodiazepinedruginpatientswithtemporarysleep-onsetandsleep-interruptiondisorders.14

•Arandomized,double-blind,placebo-controlled,multicentertrialinvestigatedtheuseofacombinationofdriedaqueousethanolextractsofvalerianandlemonbalminambulatorypatientswithlightinsomnia.Improvementsinsleepquality,dailycondition,timetofallasleep,totaldurationofsleep,concentration,andabilitytoperformoccurredwithnohangover,withdrawal,orreboundphenomenainthetreatedgroup.Dosesequivalentto2.9gperdayofvalerianrootand1.7gperdayoflemonbalmherbweregivenfor3weeks.

•Inarandomized,controlled,double-blindstudy,acombinationofvalerianandSt.John’swortextracts(containing0.45to0.9mg/dayofTH)wasshowntohavecomparablebenefitstotheantidepressantamitriptyline(75to150mg/day)intreatingdepressionover6weeks.Comparedwithanimprovementrateof77%intheamitriptylinegroup,benefitwasobservedfor82%ofpatientsintheherbalgroup,withoutthehighfrequencyofsideeffectsofamitriptylinesuchasdrymouthandlethargy.

•Inapilotstudy,patientswithstress-inducedinsomniaweretreatedwithkava,thenvalerian,thenacombinationofkavaandvalerian,withwashoutperiodsinbetweeneachtreatment.Totalstressseveritywassignificantlyrelievedbykavaandvaleriansingletreatments.Stresswasmeasuredintheareasofsocial,personal,andlifeevents.Thecombinationofkavaandvaleriansignificantly

relievedinsomnia.15

•Inadouble-blind,multicentertrial,avalerian-St.John’swortcombinationdemonstratedacomparablereductioninsymptomsoffearanddepressivemoodcomparedwithamitriptyline(75to125mg).Thedailydosewas3to6capsules.Eachcapsulecontainedvalerianextractcorrespondingtoapproximately0.3gofdriedrootandSt.John’swortextractcontaining0.15mgofTH.Inanotherdoubleblindtrial,thesamecombinationdemonstratedsignificantimprovementcomparedwiththeantidepressantdesipramine.

•Adouble-blindstudyfoundthat2weeksofdailytreatmentwithavalerian-St.John’swortcombination(containingapproximately0.2gofvalerianrootand0.3to0.6mg/dayofTH)wasmoreeffectivethandiazepam(2mg)inpatientswithmoderateanxiety.Fewersideeffectswereobservedintheherbaltreatmentgroup(4%)comparedwithdiazepamtreatment(14%).

•Adouble-blind,placebo-controlledtechniqueexaminingactivation,performance,andmoodinhealthyvolunteersshowedthatvalerianextractinfluencedsubjectivefeelingsofsomaticarousal,despitehighphysiologicactivation.Nosedativeeffectsweredemonstrated,andsuggestionswerethatvalerianhasthymolepticactivity.

•Adouble-blind,placebo-controlled,three-waycrossovertrialinvestigatedtheeffectofavalerianandSt.John’swortextractcombinationonsafety-relatedperformancein12volunteers.Theherbalproductwasshowntobecomparabletoplacebowithrespecttosafetyintermsofperformanceandwellbeing.Theeffectswhentakenwithalcoholwerenotgreaterthanthoseofalcoholalone.

•InGermany,theCommissionEsupportsusingvaleriantotreatrestlessnessandsleepingdisordersbasedonnervousconditions.16

•ESCOPrecommendsvalerianrootfortreatingtenseness,restlessness,andirritabilitywithdifficultyinfallingasleep.17

•ValerianhasbeenreinstatedtotheUSPandisofficialintheUSP24-NF19.

REFERENCES

Exceptwhenspecificallyreferenced,thefollowingbookwasreferredtointhecompilationofthepharmacologicandclinicalinformationMillsS,BoneK.PrinciplesandPracticeofPhytotherapy:ModernHerbalMedicine.Edinburgh:ChurchillLivingstone,2000.AndreatiniR,LoireJR.EurJPharmacol.1994;260:233-235.GargesHP,VariaI,DoraiswamyPM.JAMA.1998;280(18):1566-1567.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983Valerianaedulis,SecretariadeMedioAmbiente,RecursosNaturalesyPesca(SEMARNAP,aMexicangovernmentenvironmentaldepartment).InformationavailableviaURL:http:www.semarnap.gob.mx/.ChamberlinRV.MemAmAnthropolAssoc.1911;2(5):331-405.

SmithHH.BullPublicMusCityMilw.1923;4:1-174.SmithHH.BullPublicMusCityMilw.1928;4:175-326.HazelhoffB,MalingreTM,MeijerDK.ArchIntPharmacodynTher.1982;257(2):274-287.

10KuhlmannJ,etal.Pharmacopsychiatry.1999;32(6):235-241.11DornM.ForschKomplementarmedKlassNaturheilkd.2000;7(2):79-84.

12DonathF,etal.Pharmacopsychiatry.2000;33(2):47-53.13Herrera-ArellanoA,etal.PlantaMed.2001;67(8):695-699.14SchmitzM,JackelM.WienMedWochenschr.1998;148(13):291-298.

15WheatleyD.PhytotherRes.2001;15(6):549-551.16BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

17ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Valerianaeradix.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKingdom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.

VERVAIN

BotanicalName: VerbenaofficinalisFamily: VerbenaceaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Nervinetonic,mildantidepressant,milddiaphoretic,astringent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingvervaininformulationsinthecontextof:

•Infantilecolic,incombinationwithlemonbalm,chamomile,licorice,andfennel(3)

•Anorexia,gastrointestinalirritation,jaundice(5)

•Depression,nervousbreakdown,epilepsy(5)

•Feverishconditionsincludinginfluenza,debilityfollowingillnessesorfever(5)

•Promotionoflactation(5)

Contraindications

Vervainissometimesrecommendedascontraindicatedduringpregnancy,resultingfrominvitroChineseresearchconductedin1975andearlierinvivostudiesusingoneofitsconstituents(verbenalin).ThiscontraindicationisnotcarriedinmosttraditionalWesternherbalmedicinetexts,TCMtexts,ortheGermanCommissionEmonographs.

WarningsandPrecautions Nonerequired.

Vervainteareducedtheabsorptionofironby59%fromabreadmeal(comparedwithawatercontrol)inadultvolunteers.Theinhibitionwasdose-dependentandrelatedtoitspolyphenolcontent(phenolicacids,monomericflavonoids,polymerizedpolyphenols).

Interactions Inhibitionbyblackteawas79%to94%.1Thisfindingindicatesapotentialinteractionforconcomitantadministrationofvervainduringironintake.Inanemiaandcasesforwhichironsupplementationisrequired,vervainshouldnotbetakensimultaneouslywithmealsorironsupplements.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Depression,nervousbreakdown,epilepsy2

•Asagalactagogue,2amenorrhea3

•Feverishconditions,debilityfollowingacuteconditions,especiallyinfluenza2,3

•Anorexia,intestinalcolic,4gallbladderpain,jaundice2

•Asapoulticeforheadache,earache,rheumatism,hemorrhoids4

UsesfromTCMincludeamenorrheaanddysmenorrhea,aswellasmalaria,abdominalmasses,inflammationofthethroat,boils,acuteinfectionsoftheurinarytract,andedema.5

TheEclecticsregardedVerbenahastata,aspeciesofVerbena,ashavingsimilarpropertiestoV.officinalis.VerbenahastatawasofficialintheNFfrom1916to1926andwasusedasadiaphoreticandexpectorant.NativeAmericansusedVerbenahastatatotreatstomachacheandasabeverage.6

Theaerialpartsofvervaincontainanumberofconstituents,includingiridoidglycosides(e.g.,verbenalin)andcaffeicacidderivatives.7

•SynergisticeffectswereobservedoncontractionofisolateduterusbythecombinationofvervainwitheitherprostaglandinE2orprostaglandinF2α.TheChinese

PharmacologicResearch

researcherssuggestedusingvervainpreparationswithprostaglandinE2forinducingabortion.8Verbenalinhasbeenreportedtoexhibituterinestimulation-contractioninvivo(routeunknown).9,10

•Vervainextractswereactiveagainstthefollowingvirusesinvitro:influenzaA,parainfluenzatype1,andrespiratorysyncytialvirus.StimulationofphagocytosisandincreasedsecretionofIL-6wasalsoobserved.11However,thisobservedactivitymightbecausedbythepolyphenolsandmaynottranslatetoinvivoactivity.

•Verbenalinbyoraladministrationdemonstratedhepatoprotectiveactivityinacutecarbontetrachloride–inducedliverinjury.12

•Antiinflammatoryactivitywasobservedforvervainextractinexperimentalmodelsaftertopicalandoraladministration(inhighdoses).13

ClinicalStudies

•Adouble-blindstudyonbabieswithcolicinvestigatedtheeffectofaninstantherbteapreparationcontainingvervain,lemonbalm,chamomile,licorice,andfennel.After7days,thecolicimprovementscoresweresignificantlybetterintheherbalteagroup,andmorebabiesinthetreatmentgrouphadtheircoliceliminated.Theteapreparationwasofferedwitheveryepisodeofcolic,upto150mlperdose,butnotmorethanthreetimesperday.Theexactcompositionofthepreparationwasnotdefined.14

•InanuncontrolledtrialconductedinChina,ahighdoseofvervaindecoction(60g/day)wassuccessfulintreatingmalaria.15

REFERENCES

HurrellRF,ReddyM,CookJD.BrJNutr.1999;81(4):289-295.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.ResearchGrouponReproductivePhysiology,PekingMedicalCollege.TungWuHseuhPao.1974;20(4):340-345.ZufallCJ,RichtmannWO.PharmArch.1943;14:65-93.

10FarnsworthNR,etal.J.PharmSci.1975;64(4):535-598.11Mende-WeberRetal:2ndInternationalCongressonPhytomedicine,Munich,September11-14,1996,abstractSL-118.

12SinghB,etal.Fitoterapia.1998;69(2):135-140.13CalvoMI,etal.Phytomed.1998;5(6):465-467.

14WeizmanZ,etal.JPediatrics.1993;122(4):650-652.15HuangKC.ThepharmacologyofChineseherbs.BocaRaton,Fla:CRCPress,1993.

WHITEHOREHOUND

BotanicalName: MarrubiumvulgareFamily: LabiataePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Expectorant,spasmolytic,bittertonic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingwhitehorehoundinformulationsinthecontextof:

•Acuteorchronicbronchitis,nonproductivecough,thecommoncold,asthma(5)

•Dyspepsia(4,5)

•Lossofappetite,bloating,flatulence(4)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2-6mlof1:2liquidextract

15-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Acuteorchronicbronchitis,whoopingcough,respiratoryconditionswithnonproductivecough,thecommoncold,asthma1,2

•Asawarminfusionfordiaphoresis,jaundice,hoarseness,amenorrhea,excitability,andasthma2

•Dyspepsia,intestinalworms2

PharmacologicResearch

Theaerialpartsofwhitehorehoundcontainbitterprinciples,includingthediterpenemarrubiin.3

•Experimentalstudiesindicatethatwhitehorehoundhasanexpectorantaction(routeunknown),whichwasattributedtomarrubiinandthevolatileoil.4

•Extractofleaves,stems,androotsdemonstratedantispasmodicactivityinseveralisolatedsmoothmusclepreparationsbyinhibitingtheactionofsomeneurotransmitters.5

•Marrubiin,byinjection,exhibitedpotentanalgesiceffectsintwoexperimentalmodels.Thefindingssuggestmarrubiinandthewholeplantextractdonotinteractwithopioidsystems.6

ClinicalStudies

Noclinicalstudiesusingwhitehorehoundhavebeenfound.

•InGermany,theCommissionEsupportsusingwhite

horehoundtotreatlossofappetiteanddyspepsia,includingbloatingandflatulence.7

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicaPublications,1905.rev3,reprinted1983BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.SchlemperV,etal.Phytomed.1996;3(2):211-216.deJesusRA,etal.Phytomed.2000;7(2):111-115.BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

WHITEPEONY

OtherCommonName: PaeoniaBotanicalName: PaeonialactifloraFamily: PaeoniaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Spasmolytic,mildskeletalmusclerelaxant,anticonvulsant,antiinflammatory,cognition-enhancing

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingwhitepeonyinformulationsinthecontextof:

•Polycysticovarysyndrome,infertility,dysmenorrhea,*incombinationwithlicorice(4)

•Skeletalmusclecrampsandspasm,incombinationwithlicorice(3)

•Fibroids,incombinationwithPaeoniasuffruticosa,Poriacocos,Cinnamomumcassia,andPrunuspersica(4)

•Angina,incombinationwithSteviarebaudianaandginsenosides(4)

•Epilepsy,incombinationwithlicoriceandfossilizedmammaliantooth(4)

•Rheumatoidarthritis(4a)

•Menstrualdysfunction(5)

•Assistingmemoryandlearning(7)Contraindications Noneknown.

WarningsandPrecautions

Becauseoftheanticoagulantfindingsinexperimentalmodels,cautionshouldbeexercisedinpatientstakingwarfarinandotheranticoagulantmedication.

Interactions Noneknown.

UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday** Doseperweek**

4.5-8.5mlof1:2liquidextract

30-60mlof1:2liquidextract

* WhitepeonyhasalsobeenusedinTCMfortreatingdysmenorrhea.(5)

** ThisdoserangeisadaptedfromdriedplantdosagesadministeredbydecoctioninTCM.1Theauthor’sexperienceandthefactthatethanol-waterisamoreeffectivesolventthanwaterformanyphytochemicalsaretakenintoaccount.

SUPPORTINGINFORMATION

TraditionalPrescribing

UsesandpropertiesfromTCMinclude:

•Toinvigorateandcooltheblood,dispelcongealedblood,andclearheatandliverfire2

•Dysmenorrhea,amenorrhea,gynecologicalproblemsfromhotblood;abdominalpainorimmobilemasses,chestpain2

•Swellings,trauma,abscess,boils;swollenpainfuleyes1,2

•Nosebleed,hematemesis1

Whitepeonyrootcontainstheunusualconstituentpaeoniflorin,whichisaglucosidewithacagelikemonoterpenestructure.3

•Theresultsofinvitrostudiessuggestthatpaeoniflorininhibitstestosteronesynthesisinovariesbutdoesnotaffectestradiolsynthesis.Bindingtoglucocorticoidreceptorswasmoderate,butbindingwasabsentforprogesteronereceptors.4,5Whitepeonyreducestestosteroneproductionfromovariesbutnotfromadrenalglands.6,7Oraladministrationofawhitepeonyandlicoricecombinationresultedinalowerincidenceofexperimentaluterineadenomyosiscomparedwithcontrols.8Inanovariectomizedmodel,thiscombinationincreasedDHEAandbroughtaboutanincreaseinserumestrogenconcentration.9

•Whitepeonyhasexhibitedsmoothmusclerelaxant

PharmacologicResearch

activityinisolatedtissue(ileumanduterus)fromseveralanimalspecies.10Paeoniflorinandrelatedcompoundsinhibitedtwitchresponsesofskeletalmuscleinresponsetodirectandindirectstimulation.10ThiseffectwaspotentiatedbyGLfromlicoriceandwasconfirmedinvivo.10

•Intragastricadministrationofwhitepeonydecoctionexhibitedantiin-flammatoryactivityintheadjuvant-inducedarthritismodel.11

•Oraladministrationofwhitepeonydecoctionorpaeoniflorinattenuatedtheperformancedeficitproducedbyscopolamine,12andpaeoniflorinreducedlearningimpairment13inexperimentalmodels.

•Aqueousextractofwhitepeonyinhibitedtheconvulsantactivityofthedrugpentylenetetrazolinisolatedneuronaltissue.Themostactiveconstituentswerealbiflorinandthegallotanninfraction.14Whitepeonyshowedaclearinhibitoryeffectontheburstingactivityofneuronsinducedbypentylenetetrazolinvitro.15

•Anaqueousmethanolextractofwhitepeonydemonstratedanti-cholinergicactivityinvivo.Paeoniflorinwasoneoftheactiveconstituentsinvivobuthadnoeffectonisolatedtissue,16probablybecausetheactiveformisametaboliteofpaeoniflorin.

•Whitepeonyandlicoricedecoctiondemonstratedantidiarrhealactivityincisplatin-induceddiarrhea.17

•Whitepeony,whichwasfoundtoinhibitninetypesofcommonpathogenicbacteria,alsoenhancedthephagocyticactivityofmacrophagesandincreasedTlymphocytes.18

•Whitepeonyinhibitedplateletaggregation,increasedfibrinolyticactivity,andprolongedprothrombintimein

vitro.19Anticoagulantactivitywasdemonstratedinvivoforpaeoniflorin.20

•Anantiatherogenicactivitywasdemonstratedafteroraladministrationofwhitepeonyinanexperimentalmodelofhypercholesterolemia.21

•OraladministrationofShimotsu-to,anherbalformulacontainingequalamountsofwhitepeony,Rehmanniaroot,Angelicaacutilobaroot,andCnidiumofficinalerhizomepreventedthedevelopmentofbraininfarctionandrarefactioninducedbychronicbrainischemiainananimalmodel.22

Thewhitepeonyandlicoricecombination(TJ-68,Shakuyaku-kanzo-to[Japanese];ShaoyaoGancaoTang[Chinese])referredtohereisapprovedforuseinclinicalpracticeinJapanandhasbeenusedtotreatpainaccompanyingacutemusclespasms,includingdysmenorrhea.TJ-68isagranularextract,7.5gofwhichcontainsadriedconcentratemadefrom6gofdriedwhitepeonyrootand6gofdriedlicoriceroot.

•Eightinfertile,hyperandrogenic,andoligomenorrheicwomenwereinvestigatedfortheloweringofserumtestosteronelevelsandinducingregularovulationbytreatmentwithTJ-68(5to10g/dayfor2to8weeks).23Afterthetreatmentperiod,serumtestosteronelevelshadnormalizedinsevenpatients,andsixpatientswereovulatingregularly.Twoofthesesixpatientssubsequentlybecamepregnant.

•Theeffectofwhitepeonyandlicoricecombination(TJ-68,7.5g/dayfor24weeks)inpatientswithpolycysticovarysyndrome(PCOS)wasstudiedovera24-weekperiod.Serumtestosteroneandfreetestosteronelevelsweresignificantlydecreasedafter4weeks.However,testosteronelevelsafter12weekswereloweronlyinthepatientswhobecamepregnant.After24weeks,the

ClinicalStudies

LH/FSHratiowassignificantlylowerinthetreatedgroup.24Inanearlieruncontrolledtrial,theeffectoftreatmentwiththesameherbalcombinationvariedaccordingtothetypeofPCOStreated.Overallplasmatestosteronewasdecreasedin90%ofwomentreatedand25%becamepregnant.PlasmatestosteronetendedtoremainhigherinPCOSofthegeneralcystictypethanintheperipheralcystictype,andthepregnancyrateinindividualswiththegeneralcystictypewaslower.25

•Inanuncontrolledstudy,110premenopausalpatientswithfibroidsweretreatedwithatraditionalChineseformulacontainingwhitepeony,Paeoniasuffruticosa,Poriacocos,Cinnamomumcassia,andPrunuspersica.Clinicalsymptomswereimprovedin90%ofcases,andthefibroidsshrunkinapproximately60%ofcases.26

•TJ-68hasshownbenefitinclinicaltrialsfortreatingmusclespasm.Inamulticenter,double-blind,placebo-controlledtrial,treatmentwiththecombination(7.5g/dayfor2weeks)resultedinsignificantlygreaterimprovementinmusclespasm(mainlyofthecalfmuscle)thanplacebotreatmentforpatientswithlivercirrhosis.27

•Whitepeonycombinedwithlicoriceandfossilizedmammaliantoothprovidedbenefitforalmostonehalfof43casesofepilepsy.28

•Thetotalglucosidesofwhitepeony(TGP)havebeenusedclinicallyfortreatingrheumatoidarthritis.29ThisuseofTGPcapsuleswasapprovedinChinain1995.30

•Tabletscontainingmainlywhitepeony,Steviarebaudiana,andginseno-sideswereusedtotreatpatientswithangina,witha93%successrateinsymptomsandimprovementinECGin53%.Microcirculationwasalsosignificantlyimproved.31(GinsenosidesarepresentinPanaxginseng.)

•Incaseobservationstudies,TJ-68waseffectiveintreatingthefollowingcaseswithoutsideeffects:neuroleptic-inducedhyperpro-lactinemia,reducedsexualdesireinmaleschizophrenicpatients,andrisperidone-inducedamenorrheainaschizophrenicwoman(7.5g/day).32

REFERENCES

PharmacopoeiaCommissionofthePeople’sRepublicofChina.PharmacopoeiaofthePeople’sRepublicofChina,Englished.Beijing:ChemicalIndustryPress,1997.BenskyD,GambleA.Chineseherbalmedicinemateriamedica.Seattle:EastlandPress,1986.TangW,EisenbrandG.Chinesedrugsofplantorigin.Berlin:Springer-Verlag,1992.TakeuchiT,etal.AmJChinMed.1991;19(1):73-78.TamayaT,SatoS,OkadaH.ActaObstetGynecolScand.1986;65(8):839-842.TakeuchiT.NipponNaibunpiGakkaiZasshi.1988;64(11):1124-1139.TakeuchiT,etal.AmJChinMed.1991;19(1):73-78.MoriT,etal.AmJChinMed.1993;21(3-4):263-268.KatoT,OkamotoR.NipponSankaFujinkaGakkaiZasshi.1992;44(4):433-439.

10HikinoH.Orientalmedicinalplants.In:FarnsworthNR,etal,editors.Economicandmedicinalplantresearch.London:

AcademicPress,1985.11ChoS,etal.ShoyakugakuZasshi.1982;36:78-81.12OhtaH,etal.PharmacolBiochemBehav.1993;45(3):719-723.

13OhtaH,etal.PharmacolBiochemBehav.1994;49(1):213-217.

14SugayaA,etal.JEthnopharmacol.1991;33(1-2):159-167.15SugayaA,etal.PlantaMed.1985;51(1):60-61.16KobayashiM,etal.YakugakuZasshi.1990;110(12):964-968.

17XuJD,LiuZH,ChenSZ.ChungKuoChungHsiIChiehHoTsaChih.1994;14(11):673-674.

18LiangMR,etal.NewJTradChinMed.1989;21(3):51.CitedinAbstChinMed.1989;3(3):274.

19WangY,MaR.ChungHsiIChiehHoTsaChih.1990;10(2):101.70

20IshidaH,etal.ChemPharmBull.1987;35(2):849-852.21ZhangYZ,YanXF.ChungHsiIChiehHoTsaChih.1990;10(11):669.645

22WatanabeH,ShibuyaT,editors.Pharmacologicresearchontraditionalherbalmedicines.Amsterdam:HarwoodAcademicPublishers,1999.

23YaginumaT,etal.NipponSankaFujinkaGakkaiZasshi.1982;34(7):939-944.

24TakahashiK,KitaoM.IntJFertilityMenopausalStud.1994;39(2):69-76.

25TakahashiK,etal.NipponSankaFujinkaGakkaiZasshi.1988;40(6):789-792.

26SakamotoS,etal.AmJChinMed.1992;20(3-4):313-317.27KumadaT,etal.JClinTherapeutMed(Jpn).1999;15:499-523.

28LinWB.HunanZhongyizazhi.1986;(3):6.CitedinAbstChinMed.1987;1(3):417.

29LaoZY,etal.HsinYaoYuLinCh’uang.1995;14:193-197.30PrendergastHDV,editor.Plantsforfoodandmedicine.Kew,UK:RoyalBotanicGardens,1998.

31HuJX,HuangGM.ChinJIntegrTradWestMed.1988;8(7):427.

32YamadaK,etal.JClinPsychopharmacol.1999;19(4):380-381.

WILDCHERRY

BotanicalName: PrunusserotinaFamily: RosaceaePlantPartUsed: Bark

PRESCRIBINGINFORMATION

Actions Antitussive,mildsedative,astringent

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingwildcherryinformulationsinthecontextof:

•Respiratoryconditions,especiallycough,bronchitis,pleurisy,andpneumonia(5)

•Tracheitisissaidtobeaspecificindication(5)

•Thecommoncold(6)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2.0-4.5mlof1:2liquidextract

15-30mlof1:2liquidextract

* This dose range is extrapolated from the British Pharmaceutical Codex 1934 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Persistentcough,whoopingcough,bronchitis,pleurisy,pneumonia,tracheitis,tuberculosis1,2

•Lossofappetite,nervousdyspepsia1,2

NativeAmericansusedinfusionofwildcherrybarktorelievepainsandsorenessinthechest,aswellasforcoughsandthecommoncold.3

PharmacologicResearch

Wildcherrybarkcontainsthecyanogenicglycosideprunasin,whichisbelievedtoconfertheantitussiveactivity.4

ClinicalStudies Noclinicalstudiesusingwildcherryhavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.LeungAY,FosterS.Encyclopediaofcommonnatural

ingredientsusedinfood,drugsandcosmetics,ed2.NewYork-Chichester:JohnWiley,1996.

WILDYAM

OtherCommonNames: Colicroot,rheumatismrootBotanicalName: DioscoreavillosaFamily: DioscoreaceaePlantPartUsed: Rootandrhizome

PRESCRIBINGINFORMATION

Actions Spasmolytic,antiinflammatory,antirheumatic,estrogen-modulating

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingwildyaminformulationsinthecontextof:

•Anyconditionsofgastrointestinalspasmorirritation,includingintestinalcolic,diverticulitis,cholecystitis(5)

•Uterineorovariancramping,includingdysmenorrhea(5)

•Alleviationofmenopausalsymptoms(6,oraluseonly)

•Rheumatoidarthritis(5)Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffectsAswithallsaponin-containingherbs,oralusemaycauseirritationofthegastricmucousmembranesandreflux.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

Extractsprovidingquantifiedlevelsofsteroidal

saponinsasdioscinarerecommended.Ideally,aqueousethanolextractsshouldcontainnotlessthan15mg/mlofthesesteroidalsaponins.

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Allformsofcolic,gastrointestinalirritation,andspasm(inmenaswell),includingdiverticulitis,cholecystitis1,2

•Dysmenorrhea,ovarian,anduterinepain,2nauseaofpregnantwomen;uterinepaininthelatterstagesofpregnancy,falselaborpains,postpartumpain3

•Neuralgicaffectionsandasthma1

•Rheumatoidarthritis(particularlyintheacutephase)andmuscularrheumatism2NativeAmericansusedwildyamforcolicandtorelievethepainofchildbirth.WildyamwasofficialintheNFfrom1916to1942andwasusedasadiaphoreticandexpectorant.4

AmorerecentWesterntraditionaluseofwildyamincludesthehormonalimbalanceassociatedwithmenopause.5

IntraditionalJapanesemedicine(Kampo),mixturescontainingDioscoreajaponicahavebeenusedforcenturiestotreatinfertility.6Highdosesofyamscancauseinfertility,butthisisconsistentwithanestrogeniceffect.Lowerdosescanhavetheoppositeeffect(seelaterdiscussion)consistentwiththistraditionaluse.

Wildyamrootcontainssteroidalsaponinswithdiosgeninastheaglycone.ManyspeciesofDioscoreahavebeencultivatedfortheindustrialmanufactureofsteroidalhormones.Theaglyconediosgeninismanufacturedfromdioscinandthenundergoesaseriesofreactionsto

PharmacologicResearch

produceprogesterone,hydrocortisone,andsoon.7Despitethiswell-knownindustrialprocess,noevidencehasbeenfoundtosuggestthatdiosgeninismetabolizedinthebodytoproducethesesteroidalhormones,particularlyprogesterone.Additionally,diosgenindoesnotnormallyoccurinuntreatedwildyamrhizome,althoughitisprobablyformedasaresultofbowelflorametabolismafteringestion.

Steroidalsaponinsortheirmetabolitesmayexertestrogeniceffectsbybindingwithestrogenreceptorsofthehypothalamus,whicharepartofthenegative-feedbackmechanismofestrogencontrol.Inthepremenopausalwoman,interactionofthesecompoundswithreceptorsinthehypothalamusorpituitarydisplacesestrogenfromreceptorsandblocksestrogenfeedback.ThebodythinksthatestrogenlevelsarelowerthanwhattheyreallyareandrespondsbyincreasingFSHandhenceestrogen.Inthelowestrogenenvironmentofperi-andpost-menopause,wildyammayalleviatesymptomsofestrogenwithdrawalthroughthebindingofitssteroidalcompoundstovacantreceptorsinthehypothalamus.Becausesomemenopausalsymptoms(e.g.,hotflashes)arethoughttobeinitiatedviathehypothalamus,thisselectivebindingmightbesufficienttoreducesuchsymptomsbyconvincingthebodythatmoreestrogenispresentinthebloodstreamthanwhatactuallyis.(Negative-feedbackmechanismswouldnotcomeintoplaybecauseovarianfunctionisminimalaroundmenopause.)

•Estrogenicactivityforwildyamhasbeendemonstratedinvitro.Wildyamextractenhancedestradiolbindingtoestrogenreceptorsandenhancedestrogenreceptor–mediatedgeneexpressioninestrogen-responsivecellsaloneandinthepresenceofestradiol.8Inanexperimentalmodel,subcutaneousadministrationofdiosgenin(20to40mg/kg)demonstratedestrogenicpropertiesandlackedprogesteroniceffects.9Wildyamproductswerefoundtobeinactiveinaprogesteronereceptorassay.10

•Oraladministrationofdiosgenin:

•Reducedtheacutecholestaticeffectinducedbyestradiolinrats11

•Reducedintestinalinflammationandnormalizedbilesecretioninanexperimentalmodel(dose:80mg/kg)12

•Tocholesterol-fedrats,resultedinincreasedfecalexcretionofcholesterol(neutralsterols)withoutaffectingtheexcretionofbileacids13

•Decreasedplasmacholesterollevelsinexperimentallyinducedhypercholesterolemia14

Claimshaveariseninthepopularliteraturethatthefemalebodycanmanufactureprogesteronefromdiosgenin,particularlyifawildyamcreamisappliedtotheskin.Noinformationiscurrentlyavailableaboutthedermalabsorptionofdioscin.Convincingevidencepublishedinapeerreviewjournalforaprogesterogeniceffectofwildyaminpost-menopausalwomenisyettobeprovided.

•Analysisofsalivasamplesfromwomenwhowereusingwildyamcreamortabletsindicatedthattheirprogesteronelevels,DHEAlevels,andtotalprogestinactivitieswerenodifferentfromthoseofuntreatedwomen.Thewomentestedweretakingproductsthatdidnotcontainaddedhormones,andforthemostpart,specimenswerecollectedwithin12to24hoursofproductuse.10Inanotherstudybythesameresearchgroup,thesalivaofwomenwhoreportedconsumingherbalproductscontainingyamspecieswasfoundtocontainverylowlevelsofprogesterone.WomentakingthesyntheticprogestinMPAalsohadverylowlevelsofprogesteroneintheirsaliva,andtheauthorssuggestedthatthediosgeninandMPAappearedtosuppressprogesteronesynthesis.Furtherinvitrotestingindicatedthatthesalivafromwomenreportingconsumptionofyamproductsdid

ClinicalStudies

notpossessanyprogesteronebioactivitydespitetheoccurrenceofhighlevelsofprogesteronereceptor–bindingcomponentsinsomesamples(20%to30%).Theresearchersconcludedthat,“diosgeninisnotconvertedtoprogesteroneinthehumanbody.”15

•Atrialpublishedin2001hasfoundawildyamcreamtohavelittleeffectonmenopausalsymptoms.Twentythreewomencompletedtreatmentinthisrandomized,double-blind,placebo-controlled,crossovertrial.Aftera4-weekbaselineperiod,eachwomanwasgiventhetreatmentcreamandmatchingplacebofor3monthseach.Salivaryprogesteronelevelsdidnotonanyoccasionexceedthedetectionlimitoftheassay.Innearlyalltheparametersthatregisteredasignificantdifferencefrombaselinevalues,theresultsoftheplacebocreamexceededthatofthewildyamcream,andnostatisticaldifferencewasobservedbetweentheresultsforplaceboandherbaltreatment.OnegramoftheactivecreamwassaidtocontainDioscoreavillosaextract(100mg),linseedoil(2g),geraniumoil(100mg),sageoil(100mg),andvitaminE(10mg).Thematchedplacebowasnotdefined.16Thepossibilityexiststhatiftheplacebocreamcontainedtheessentialoilspresentinthewildyamcream,thistrialrecordedeffectsthatwerecausedbytheessentialoils.

•Aclinicaltrialinvolvingsevenhealthyvolunteers(sixwomen,oneman)investigatedtheeffectofMexicanyam(Dioscoreacomposite,whichcontainsdioscin)andDHEAadministrationonserumlipoproteinsandDHEA-sulfate(DHEA-S).Participantsreceivedplacebofor3weeks,followedby3weeksofMexicanyam(dosage[undefined]doublingeachweek),followedbyanotherweekofplacebo.DHEAwasthentakeninthelastweek.NoriseinDHEA-SvalueswasrecordedaftertheMexicanyamtreatment.(AnincreasewasobservedduringDHEAadministration.)BothyamandDHEAsignificantlyreducedserumlipidperoxidationandserumtriglycerideandincreasedHDLcholesterollevels.No

changesintotalcholesterolorLDLcholesterolwereobservedforeithertreatment.17

•AnuncontrolledstudyconductedinChinasupportedthehypocho-lesterolemicactivityofDioscoreasaponinsgivenbymouthastablets(0.2to2.0g/day).18

REFERENCES

FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.CookWH.ThePhysio-medicaldispensatory.Portland:EclecticMedicalPublications,1985.Firstpublishedin1869,reprintedbyVogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.HosoyoE,YamamuraY,editors.RecentadvancesinthepharmacologyofKampomedicines.Tokyo:ExcerptaMedica,1988.BrunetonJ.Pharmacognosy,phytochemistry,medicinalplants.Paris:LavoisierPublishing,1995.EagonPKetal:91stAnnualMeetingoftheAmericanAssociationforCancerResearch,SanFrancisco,April1-5,

2000,abstract893.Aradhana,RaoAR,KaleRK.IndianJExpBiol.1992;30(5):367-370.

10DollbaumC.TownsendLetterforDoctorsandPatients.1996;159:104.

11AccatinoL,etal.Hepatology.1998;28(1):129-140.12YamadaT,etal.AmJPhysiol.1997;273(2,pt1):G355-G364.

13CayenMN,DvornikD.JLipidRes.1979;20:162.14Juarez-OropezaMA,Diaz-ZagoyaJC,RabinowitzJL.IntJBiochem.1987;19(8):679-683.

15ZavaDT,DollbaumCM,BlenM.ProcSocExpBiolMed.1998;217(3):369-378.

16KomesaroffPA,etal.Climacteric.2001;4(2):144-150.17AraghiniknamM,etal.LifeSci.1996;59(11):147-157.18ChangHM,ButPP.PharmacologyandapplicationsofChinesemateriamedica.Singapore:WorldScientific,1987.

WILLOWHERB

OtherCommonNames:

Epilobium,small-floweredwillowherb

BotanicalNames:

Epilobiumparviflorum,Epilobiummontanum,+Epilobiumcollinum,+Epilobiumroseum+

Family: OnagraceaePlantPartUsed: Aerialparts

+ Medicinallyinterchangeablespecies.

PRESCRIBINGINFORMATION

Actions Antiprostatic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingwillowherbinformulationsinthecontextofprostatedisorders.(6)

Contraindications Noneknown.WarningsandPrecautions Nonerequired.

Interactions Noneknown.UseinPregnancyandLactation Noadverseeffectsexpected.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

3-6mlof1:2liquidextract

20-40mlof1:2liquidextract

* Thisdoserangeisextrapolatedfromtraditionaluseofwillowherbtea.

SUPPORTINGINFORMATION

TraditionalPrescribing

WillowherbwasusedinEuropeanherbalmedicineinthemid-twentiethcenturyfollowingitspopularizationbythetraditionalAustrianherbalistMariaTreben.1Willowherbwasrecommendedforprostatism(chronicdisordersoftheprostate,especiallyobstructiontourinationbyprostaticenlargement).2

PharmacologicResearch

OfseveralextractsofEpilobiumparviflorumtestedinvitro,onlytheaqueousextractshowedsignificantinhibitionof5α-reductase(theenzymeresponsibleforthebiosynthesisofDHTfromtestosterone).3

ClinicalStudies Noclinicalstudiesusingwillowherbhavebeenfound.

REFERENCES

TrebenM.HealththroughGod’spharmacy,ed13.Steyr,Austria:WilhelmEnnsthaler,1989.WeissRF.Herbalmedicine,Englished.Beaconsfield,UK:BeaconsfieldPublishers,1988.LesuisseD,etal.JNatProd.1996;59(5):490-492.

WORMWOOD

BotanicalName: ArtemisiaabsinthiumFamily: CompositaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions Bittertonic,anthelmintic,antiparasitic

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingwormwoodinformulationsinthecontextof:

•Anorexia,dyspepsia(4,5)

•Conditionsinvolvinginsufficientflowofgastricorpancreaticenzymesandbile(4)

•Worminfestation(5)Contraindications Pregnancyandlactation,hyperacidity.1

WarningsandPrecautions Therecommendeddoserangemustnotbeexceeded.

PeoplewithknownsensitivitytowormwoodorothermembersoftheCompositaefamily(e.g.,ragweed,daisies,chrysanthemums)shouldavoidusingwormwood.

Interactions Noneknown.UseinPregnancyandLactation Contraindicatedinpregnancyandlactation.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Overdoseofwormwoodhasbeenreported.1

Dosage Doseperday* Doseperweek*

0.7-3.0mlof1:5tincture 5-20mlof1:5tincture

Thelowendofthedoserangeshouldbeusedforthebittereffect.

Dosesatthehighendofthedoserangeareforshort-

termuseonly.

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Nematodeinfestation2,3

•Anorexia,atonicdyspepsia,2flatulentdyspepsia,diarrhea,3debility4

•Amenorrheaandleukorrheawhenresultingfromdebility3

PharmacologicResearch

Constituentsoftheaerialpartsofwormwoodincludebittersubstances(sesquiterpenelactones,particularlyabsinthin)andanessentialoilthatcontainsthujone.Highdosesofthujonemaycauseneurotoxicity.5

Bittersaresubstancescapableofstronglystimulatingthebitterreceptorsinthetastebudsatthebackofthetongue.Bittersappliedtothemouth(tasted)beforeamealhaveaprimingeffectonupperdigestivefunction,whichisprobablymediatedbyanervereflexfromthebittertastebudsandinvolvesanincreaseinvagalstimulation.Thisvagalstimulationmeansbittersmighthaveapromotingeffectonallcomponentsofupperdigestivefunction,namelythestomach,liver,andpancreas.6

•Increasedgastricsecretoryactivityandincreasedstomachaciditywasdemonstratedafteroraldosesofisolatedabsinthininanexperimentalmodel.Wormwooddecoctionadministeredbyintravenousinjectiondemonstratedacholereticeffect.1

•Wormwooddecoctiondemonstratedanthelmintic

activitytowardthenematodeTrichostrongyluscolubriformisinvitro.7

ClinicalStudies

•Wormwoodgiventohumanvolunteers5minutesbeforeamealstimulatedgastricsecretion.8

•Anotherstudyfoundthatoraldosesofliquidwormwoodcausedadramaticincreaseinduodenallevelsofpancreaticenzymesandbile.9

•InGermany,theCommissionEsupportsusingwormwoodtotreatlossofappetite,dyspepsia,andbiliarydyskinesia10

•ESCOPrecommendswormwoodfortreatinganorexiaanddyspepsia.1

REFERENCES

ScientificCommitteeoftheEuropeanScientificCooperativeonPhytotherapy[ESCOP].ESCOPmonographs:Absinthiiherba.ArgyleHouse,GandyStreet,Exeter,Devon,EX43LS,UnitedKindom:EuropeanScientificCooperativeonPhytotherapy,ESCOPSecretariat,July1997.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.

Stuttgart:MedpharmScientificPublishers,1994.MillsS,BoneK.Principlesandpracticeofphytotherapy:modernherbalmedicine.Edinburgh:ChurchillLivingstone,2000.BaraS,ZaragozaC,ValderrabanoJ:SEMhCongreso1999:SociedadEspanoladeMalherbología,Longrono,Spain,November23-25,1999.GlatzelH,HackenbergK.PlantaMed.1967;3:223-232.BaumannIC,GlatzelH,MuthHW.ZAllgemeinmed.1975;51(17):784-791.

10BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

YARROW

OtherCommonName: AchilleaBotanicalName: AchilleamillefoliumFamily: CompositaePlantPartUsed: Aerialparts

PRESCRIBINGINFORMATION

Actions

Diaphoretic,antipyretic,peripheralvasodilator,antiinflammatory,spasmolytic,bittertonic,styptic(hemostatic),antimicrobial,anti-hemorrhagic,vulnerary

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingyarrowinformulationsinthecontextof:

•Lossofappetite,dyspepsia,gastrointestinalspasm(4)

•Amenorrhea,menorrhagia(5)

•Otherconditionsinvolvingbleeding,suchashemorrhoids,melena,andhemoptysis(5)

•Feversandconditionsinwhichfeverispresent,suchasthecommoncold(5)

•Conditionsofdisorderedcirculation(e.g.,hemorrhoids,thrombosis),hypertension(5)

•Diarrhea,dysentery(5)

•Asitzbathforpainfulcrampingoffemalereproductivetract(4)

•Topicaltreatmentforslow-healingwoundsandskinconditions(5)

Contraindications Knownallergy.

WarningsandSesquiterpenesareresponsiblefortheallergiccontactdermatitiscausedbyyarrow.1Peoplewithknown

Precautions sensitivitytoothermembersoftheCompositaefamily(e.g.,ragweed,daisies,chrysanthemums)shouldavoidusingyarrow.

Interactions Noneknown.UseinPregnancyandLactation

Noadverseeffectsexpected.However,thujone-containingvarietiesshouldbeavoided.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2-6mlof1:2liquidextract

15-40mlof1:2liquidextract

* ThisdoserangeisextrapolatedfromtheBritishHerbalPharmacopoeia1983,theBritishHerbalCompendium1992,andtheauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Fevers,feverishconditions,thecommoncold,essentialhypertension,thromboticconditions,amenorrhea,dysentery,diarrhea2,3

•Asaninfusionfordiureticactioninchronicdiseasesoftheurinarytractandurinaryincontinence4

•Hemorrhageinwhichthebleedingissmallinamount4

•Asatonicforthevenoussystemandmucousmembranesandusedfortreatingsorethroat,hemorrhoids,dysentery4

•Atonicamenorrhea,menorrhagia;flatulence4

•Topicallyforslow-healingwoundsandskinconditions3

NativeAmericansusedyarrowextensively;itwasappliedtopicallyforwounds,bruises,swellings,aches,eczema,rash,andearache.Yarrowinfusionwastakeninternallyforweakanddisordereddigestion,generalsickness,andasafevermedicine.Yarrowflowerswereburntandinhaledtobreakfevers.YarrowleafandfloweringtopswereofficialintheUSPfrom1863to1882andwereusedfortonic,stimulant,andemmenagoguepurposes.SomeEclecticsconsideredtheleavestobesuperiortotheflowers.5

Usingareliablesourceofyarrowisimportant,becausemanyvarietiesandsubspeciesofA.millefoliumthat

PharmacologicResearch

containvaryingamountsofphyto-chemicalconstituentsareavailable.6

•YarrowaqueousalcoholextractdemonstratedinvitroantimicrobialactivitytowardStaphylococcusaureusbutwasinactiveagainstS.aureusstrainsisolatedfrompatients.7Anethanolextractdemonstratedmoderateactivityagainstthefollowingspeciesinvitro:Staph.aureus,Bacillussubtillus,Mycobacteriumsmegmatis,Escherichiacoli,Shigellasonnei,andShigellaflexneri.8

•Yarrowshowedmildantipyreticactivityinvivoinearlyresearch.9

•Aqueousextractofyarrowflowerdemonstratedantiinflammatoryactivitybothtopically(skinirritationtest)andsystemically(subcutaneousadministration,mousepawedematest).Theactivefractionwasfoundtobeamixtureofprotein-carbohydratecomplexes.10

•Yarrowextractsdemonstratedspasmolyticactivityonisolatedrabbitsmallintestine.Themethanolextracthadgreateractivitythantheaqueousextract.Isolatedflavonoidswerealsoactive.11

•Oraladministrationofyarrowmethanolicextractdidnotdemonstrateanalgesicactivityinanexperimentalmodel.12

•Yarrowextractsdemonstratedhepatoprotectiveactivityincarbontetrachlorideandacetominophen(paracetamol)livertoxicitymodelswhenadministeredbyinjection.13

•Sesquiterpenesisolatedfromyarrowwereactiveagainstexperimentalleukemiainvivo.14

•Yarrowflowerextracts(ethanolicextract,byinjection;aqueousalcoholextract,orally)demonstratedantispermatogeniceffectsinmice.15

ClinicalStudies

•Inarandomized,double-blind,crossovertrial,anherbalpreparationeffectedasimilarreductioninsubjectivesymptomsofosteoarthrosiscomparedwiththeNSAIDibuprofenbutwithalowersideeffectincidence.Theherbaltabletcontainedfeverfew(110mg),Americanaspen(Populustremuloides,90mg),andyarrow(60mg).Threetabletsweretakendaily.16

•InGermany,theCommissionEsupportsinternaluseofyarrowtotreatlossofappetiteanddyspepticdisorders,suchasmild,spasticdiscomfortofthegastrointestinaltract.Asasitzbath,yarrowisrecommendedforpainful,cramplikeconditionsofpsychosomaticorigininthelowerpartofthefemalepelvis.17

REFERENCES

RuckerG,MannsD,BreuerJ.ArchPharm.1991;324(12):979-981.BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.BritishHerbalMedicineAssociation.Britishherbalcompendium.Bournemouth:BHMA,1992.FelterHW,LloydJU.King’sAmericandispensatory,ed18.Portland:EclecticMedicalPublications,1905.rev3,reprinted1983VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.BissetNG,editor.Herbaldrugsandphytopharmaceuticals.Stuttgart:MedpharmScientificPublishers,1994.

MolochkoVA,etal.VestnDermatolVenerol.1990;(8):54-56.MoskalenkoSA.JEthnopharmacol.1986;15(3):231-259.NikonorowM.ActaPolonPharm.1939;3:23-56.

10GoldbergAS,etal.JPharmSci.1969;58(8):938-941.11HoerhammerL:CongrSciFarmConfComun21st[reportoftheInternationalCongressofthePharmaceuticalScience],Pisa,September4-8,1961,abstractS578-588.

12AhmadF,KhanRA,RashidS.MedJIslamRepubIran.1996;10(2):149-152.

13GadgoliC,MishraSH.Fitoterapia.1995;66(4):319-323.14TozyoT,etal.ChemPharmBull.1994;42(5):1096-1100.15MontanariT,deCarvalhoJE,DolderH.Contraception.1998;58(5):309-313.

16RyttigK,etal.UgeskrLaeger.1991;153(33):2298-2299.17BlumenthalM,etal,editors.ThecompleteGermanCommissionEmonographs:therapeuticguidetoherbalmedicines.Austin:AmericanBotanicalCouncil,1998.

YELLOWDOCK

OtherCommonName: CurleddockBotanicalName: RumexcrispusFamily: PolygonaceaePlantPartUsed: Root

PRESCRIBINGINFORMATION

Actions Mildlaxative,cholagogue,depurative

PotentialIndications

Basedonappropriateevaluationofthepatient,practitionersshouldconsiderprescribingyellowdockinformulationsinthecontextof:

•Chronicskindisorders(5)

•Constipation,bowelsluggishness,indigestion(5)

•Rheumatism(6)

Yellowdockhasbeentraditionallyusedasamildlaxativeanddepurativeandmightalsobeusedtotreatotherhealthproblemsthatmaybecausedorexacerbatedbyconstipation,includingheadachesandperiodpain.Depurativeherbshavebeentraditionallyprescribedforchronicrheumaticconditions.(5)

Contraindications Noneknown.

WarningsandPrecautions

Yellowdockshouldbeusedwithcautionduringpregnancybecauseitcontainsanthraquinoneglycosides.

Laxativeremediesshouldnotberegardedasalong-termsolutiontodigestiveproblems.Prolongeduseisundesirable.However,thelaxativeactionofyellowdockisverymild.

Interactions Noneknown.UseinPregnancyandLactation

Yellowdockshouldbeusedwithcautionduringpregnancy.

SideEffects Noneexpectediftakenwithintherecommendeddoserange.

Dosage Doseperday* Doseperweek*

2.0-4.5mlof1:2liquidextract

15-30mlof1:2liquidextract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and theauthor’seducationandexperience.

SUPPORTINGINFORMATION

TraditionalPrescribing

TraditionalWesternherbalmedicineusesinclude:

•Constipation,1dyspepsia,particularlywithfullness,pain,andflatulence;painlessdiarrhea,2diphtheria3

•Jaundice,1biliouscomplaints3

•Chronicskindisorders,1chroniclymphaticenlargements,topicallyforskindisorders2

•Rheumatism,disordersofthespleen4

•Debilitatingconditions,includingcancer3

NativeAmericansusedRumexspeciesasapoisonantidoteandbloodpurifier.ListedintheUSPandNFinthelate1800sandearly1900s,R.crispusandR.obtusifoliuswereusedfortreatingskindiseasesandfordepurativepurposes.Later,theseherbswereusedaslaxativesandtonics.5

PharmacologicResearch

Yellowdockrootcontainsanthraquinoneglycosides,whichhavedemonstratedlaxativeactivity.6

ClinicalStudies Noclinicalstudiesusingyellowdockhavebeenfound.

REFERENCES

BritishHerbalMedicineAssociation’sScientificCommittee.Britishherbalpharmacopoeia.Bournemouth:BHMA,1983.FelterHW,LloydJU.King’sAmericandispensatory,ed18.

Portland:EclecticMedicalPublications,1905.rev3,reprinted1983GrieveM.Amodernherbal.NewYork:DoverPublications,1971.BartramT.Encyclopediaofherbalmedicine,ed1.Dorset,UK:GracePublishers,1995.VogelVJ.AmericanIndianmedicine.Norman,Okla:UniversityofOklahomaPress,1970.deSmetPAGM,etal,editors.Adverseeffectsofherbaldrugs.Berlin:Springer-Verlag,1993.

APPENDIXA

DosageSummaryChart

APPENDIXB

GlossaryofHerbalActions

Adaptogenic

Asubstancethatincreasesthebody’sresistancetophysical,environmental,emotional,orbiologicstressorsandpromotesnormalphysiologicfunction

AdrenaltonicAsubstancethatimprovesthetone,histology,andfunctionoftheadrenalglands(especiallythecortex)

Alterative SeeDepurativeAnalgesic AsubstancethatrelievespainAnodyne SeeAnalgesic

Antacid Asubstancethatcounteractsorneutralizesacidityinthegastrointestinaltract

Anthelmintic Asubstancethatkillsorassistsintheexpulsionofintestinalworms

Antiallergic Asubstancethattonesdowntheallergicresponse,oftenbystabilizingmastcells

Antiandrogenic Asubstancethatinhibitsormodifiestheactionofandrogens(malesexhormones)

AntianemicAsubstancethatpreventsorcorrectsanemia,whichisareductioninthenumberofcirculatingredbloodcellsorinthequantityofhemoglobin

AntiarrhythmicAsubstancethatpreventsoriseffectiveagainstarrhythmias,whichareanyvariationfromthenormalrhythmorrateoftheheartbeat

Antiasthmatic Asubstancethatpreventsorrelievesasthmaattacks

Antibacterial Asubstancethatinhibitsthegrowthofbacteria(bacteriostatic)ordestroysbacteria(bactericidal)

Anticariogenic Asubstancethatreducestheincidenceofdentalcaries(toothdecay)

Anticatarrhal Asubstancethatreducestheformationofcatarrhorphlegm(pathologicmucussecretion)

Anticonvulsant Asubstancethattendstopreventorarrestseizures(convulsions)

Antidepressant AsubstancethatalleviatesdepressionAntidiabetic(seealsoHypoglycemic)

Asubstancethatalleviatesdiabetesortheeffectsofdiabetes

Antidiarrheal AsubstancethatalleviatesdiarrheaAntiecchymotic Asubstancethatpreventsoralleviatesbruising

Antiedematous Asubstancethatpreventsoralleviatesedema(fluidretention)

Antiemetic Asubstancethatreducesnauseaandvomiting

Antifungal Asubstancethatinhibitsthegrowthofordestroysfungi

Antihemorrhagic Asubstancethatreducesorstopsbleedingwhentakeninternally

Antihyperhidrotic AsubstancethatreducesexcessivesweatingAntiinflammatory(seealsoAntiallergic,Antirheumatic,Antiedematous,Immunedepressant)

Asubstancethatreducesinflammation

Antilithic Asubstancethatreducestheformationofcalculi(stones)intheurinarytract

Antimicrobial(seealsoAntibacterial,Antifungal,Antiparasitic,Antiviral)

Asubstancethatinhibitsthegrowthofordestroysmicroorganisms

AntioxidantAsubstancethatprotectsagainstoxidationandfreeradicaldamage

Anti-PAFAsubstancethatinhibitstheactivityofPAF(PAFisapotentplateletaggregatingagentandinducerofsystemicanaphylacticsymptoms.)

Antiparasitic Asubstancethatinhibitstheactivityoforkillsparasites

AntiplateletAsubstancethatreducesplateletaggregation(andhenceprolongsbleedingtimeandmaypreventthrombusformation)

Antiprostatic Asubstancethatreducessymptomsfromtheprostategland

Antiprotozoal Asubstancethatkillsprotozoaorinhibitstheirgrowthandactivity

Antipruritic Asubstancethatrelievesorpreventsitching

Antipsoriatic Asubstancethattendstorelievethesymptomsofpsoriasis

Antipyretic AsubstancethatreducesorpreventsfeverAntirheumatic AsubstancethatpreventsorrelievesrheumatismAntiseptic SeeAntimicrobialAntispasmodic SeeSpasmolytic

Antithyroid Asubstancethatreducestheactivityofthethyroidgland

Antitumor Asubstancethathasactivityagainstamalignanttumor

Antitussive Asubstancethatreducestheamountorseverityofcoughing

Antiulcer Asubstancethatpreventsorrelievesulceration(usuallyinthegastrointestinaltract)

Antiviral Asubstancethatinhibitsthegrowthofordestroysviruses

Anxiolytic AsubstancethatalleviatesanxietyAperient SeeCatharticAphrodisiac AsubstancethatstimulatessexualdesireAppetitestimulating Asubstancethatstimulatesappetite

AromaticdigestiveAsubstancethatisgenerallypleasanttasting,smelling,orboththatassistsdigestion(Thesetonicsarewarmingtothebodyandarealsoknownaswarmingdigestivetonics.)

Astringent

Asubstancethatcausesconstrictionofmucousmembranesandexposedtissues,usuallybyprecipitatingproteins(Thisactionhastheeffectofproducingabarrieronthemucusorexposedsurfaces.)

Bittertonic(alsoknownasaBitter;seealsoDigestivestimulant,Gastricstimulant)

Asubstancethatisbittertastingandstimulatestheuppergastrointestinaltractviathebitter-sensitivetastebudsofthemouth,bydirectinteractionwithgastrointestinaltissue,orboth(Bittershaveapromotingeffectonallcomponentsofupperdigestivefunction,namelythestomach,liverandpancreas.Inadditiontoappetiteanddigestiontheyimprovegeneralhealthandimmunefunction.)

Bladdertonic Asubstancethatimprovesthetoneandfunctionofthebladder

Bronchospasmolytic Asubstancethatreducesspasminthelowerrespiratorytract

Cancerpreventative(seealsoAntitumor) Asubstancethatpreventstheincidenceofcancer

CardioprotectiveAsubstancethatprotectscardiactissueagainsthypoxia(oxygendeficiency)anddecreasestheriskofheartdamage

Cardiotonic Asubstancethatimprovestheforceofcontractionoftheheart

Carminative

Asubstancethatrelievesflatulenceandsoothesintestinalspasmandpain,usuallybyrelaxingintestinalmuscleandsphincters(Thesesubstancesareaddedtoherbalformulationstoeasetheintestinalspasmorpainthatmaybecausedbylaxativeherbs.)Asubstancethatassistsorinducesevacuationof

Cathartic thebowel(i.e.,havingastronglaxativeaction)(Thesesubstancesarealsoknownaspurgatives.)

Cholagogue Asubstancethatincreasesthereleaseofstoredbilefromthegallbladder

Choleretic Asubstancethatincreasestheproductionofbilebytheliver

CirculatorystimulantAsubstancethatimprovesbloodflowthroughbodytissues(Circulatorystimulantsarewarming,andtheysupportvitalityinthebodytissues.)

Cognitionenhancing Asubstancethatfacilitateslearningormemory

CollagenstabilizingAsubstancethatstabilizescollagen(e.g.,protectscollagenfromdegradation)(Connectivetissuetoneistherebyimproved.)

Counterirritant

Asubstancethatproducesasuperficialinflammationoftheskinsoastorelieveadeeperinflammation(e.g.,inmuscles,joints,andligaments)

DemulcentAsubstancethathasasoothingeffectonmucousmembranes(e.g.,withintherespiratory,digestive,andurinarytracts)

Depurative

Asubstancethatimprovesdetoxificationandaidseliminationtoreducetheaccumulationofmetabolicwasteproductswithinthebody(Thesesubstanceswereformerlyknownasalterativesorbloodpurifiersandarelargelyusedtotreatchronicskinandmusculoskeletaldisorders.)

Diaphoretic Asubstancethatpromotessweatingandtherebycontrolsafever(alsoknownassudorifics)

Digestivestimulant(seealsoGastricstimulantandBittertonic)

Asubstancethatstimulatesthefunctionofthegastrointestinalorgansinvolvedwithdigestion

Diuretic Asubstancethatincreasesurinaryoutput

DopaminergicagonistAsubstancethatbindstoandactivatesdopaminereceptors

Emetic Asubstancethatcausesvomiting

EmmenagogueAsubstancethatinitiatesandpromotesthemenstrualflow(Severaloftheseherbsarealsoregardedasabortifacients.)

Emollient Asubstanceusedtosoothe,soften,orprotectskin

Estrogenmodulating

Inthecontextofuseofherbs,asubstancethatactsbysubtle,poorlyunderstoodmechanismstopromoteestrogenproductionandeffectsinthebody(Theactivitymayinvolveinteractionwithsecondaryestrogenreceptorssuchasthoseinthehypothalamus.)

ExpectorantAsubstancethatimprovestheclearingofexcessmucusfromthelungsbyeitheralteringtheviscosityofmucusorimprovingthecoughreflex

Febrifuge SeeAntipyretic

Femaletonic Asubstancethatimprovesthetone,vigor,andfunctionofthefemalereproductivesystem

Galactagogue AsubstancethatincreasesbreastmilkproductionGastricstimulant(seealsoBittertonicandDigestivestimulant)

Asubstancethatstimulatesthefunctionofthestomach

Generalbodytonic SeeTonicHemostatic SeeStyptic

Hepatic(Hepatictonic) Asubstancethatimprovesthetone,vigor,andfunctionoftheliver

Hepatoprotective Asubstancethatprotectsthehepatocytes(livercells)againsttoxicdamage

Hepatotrophorestorative Asubstancethatrestorestheintegrityoflivertissue

HypnoticAsubstancethatinducesdrowsinessandsleep(alsoknownassoporifics)

Hypocholesterolemic(seealsoHypolipidemic)

Asubstancethatreducesthelevelofcholesterolintheblood

Hypoglycemic Asubstancethatreducesthelevelofglucosein

theblood

Hypolipidemic Asubstancethatreducesthelipidlevel(cholesterolandtriglycerides)ofblood

Hypotensive(seealsoPeripheralvasodilator) Asubstancethatreducesbloodpressure

ImmunedepressantAsubstancethatreducesimmunefunctionandisusedparticularlywhenpartoftheimmunesystemisoveractive

Immuneenhancing Asubstancethatenhancesimmunefunction

Immunemodulating Asubstancethatmodulatesandbalancestheactivityoftheimmunesystem

Laxative Asubstancethatfacilitatesevacuationofthebowel

Localanesthetic Asubstancethatremovessensationorpainwhenappliedlocally

LymphaticAsubstancethatassistsdetoxificationbyitseffectonlymphatictissueandoftenalsoimprovesimmunefunction

Maletonic Asubstancethatimprovesthetone,vigor,andfunctionofthemalereproductivesystem

Mucolytic Asubstancethathelpsbreakupanddispersestickymucusintherespiratorytract

Mucoprotective Asubstancethatprotectsthemucousmembranes,especiallyinthecontextofthegastriclining

Mucousmembranetonic

Asubstancethatimprovesthetone,vigor,andfunctionofthemucousmembranes(particularlyoftherespiratorytract)

Mucousmembranetrophorestorative

Asubstancethatrestorestheintegrityofmucousmembranes(e.g.,intherespiratoryanddigestivetracts)

Nervinetonic(Nervine)Asubstancethatimprovesthetone,vigor,andfunctionofthenervoussystem(Nervinetonicsrelaxandenergizethenervoussystem).Asubstancethathelpspreventdamagetothe

Neuroprotective brainorspinalcordfromischemia,stroke,convulsions,ortrauma

Nootropic SeeCognitionenhancing

Ovariantonic Asubstancethatimprovesthetone,vigor,andfunctionoftheovaries

Oxytocic Asubstancethatcausescontractionoftheuterinemuscleinassociationwithgivingbirth

Parturifacient Asubstancethatinduceslaborandassistsintheefficientdeliveryofthefetusandplacenta

PartuspreparatorAsubstancetakeninpreparationforlaborandchildbirth(Treatmentusuallybeginsinthesecondtrimester.)

Peripheralvasodilator

Asubstancethatdilatesorwidenstheperipheralbloodvesselsandtherebyimprovescirculationtoperipheraltissuesandmayassistinreducingbloodpressure

Progesterogenic Asubstancethatpromotestheeffectorproductionofprogesterone

Prolactininhibitor Asubstancethatinhibitsthesecretionofprolactin

Pungent

Ahot-tastingsubstancethatactsonacommongroupofnervecellreceptorshavingtheeffectofwarmingthebodyandimprovingdigestionandcirculation

Purgative SeeCathartic

Refrigerant Asubstancethathascoolingproperties,particularlywhenappliedtotheskin

Rubefacient SeeCounterirritant

Sedative(mild)

Asubstancethatreducesactivity,particularlyinthenervoussystemanddecreasesnervoustension(Asedativemayalleviatepainandspasmandinducesleep.)

Sexualtonic Asubstancethatimprovesthetone,vigor,andfunctionofthesexualorgansAsubstancethatincreasesthesecretionofthe

Sialagogue salivaryglands

Skeletalmusclerelaxant Asubstancethatrelaxesskeletalmuscletone

Spasmolytic Asubstancethatreducesorrelievessmoothmusclespasm(involuntarycontractions)

Stimulant

Asubstancethatheightensthefunctionofanorganorsystem(e.g.,acentralnervoussystemstimulantincreasestheactivityofthecentralnervoussystem,particularlybehavioralalertness,agitation,orexcitation).(Thetermhasasecond,moresubtlemeaningderivedfromtheThomsoniansystem[anearlybranchofherbaltherapyintheUnitedStates:asubstancecapableofincreasingtheactionorenergyofthelivingbody].)

Stomachic SeeGastricstimulant

Styptic Asubstancethatstopsbleedingwhenappliedlocally

Thymoleptic(seealsoAntidepressant) Asubstancethatelevatesmood

Thyroidstimulant Asubstancethatenhancestheactivityofthethyroidgland

Tissueperfusionenhancing

Asubstancethatenhancestheflowofnutrientsintoatissue

Tonic(alsoknownasGeneralbodytonic;seealsootherspecificbodytonics)

Asubstancethatimprovesthetone,vigor,andfunctionofthewholebody

Trophorestorative Asubstancethathasahealingandrestorativeactiononaspecificorganortissue

TSHantagonist AsubstancethatblockstheactivityofTSH

UrinaryantisepticAsubstancethatinhibitsthegrowthofordestroysmicroorganismswithintheurinarytract

Urinarydemulcent Asubstancethathasasoothingeffectonmucous

membranesoftheurinarytractUterinesedative Asubstancethatreducestheactivityoftheuterus

Uterinetonic Asubstancethatincreasesthetoneoftheuterinemuscle

Vasoconstrictor Asubstancethatconstrictsornarrowsthebloodvessels

Vasodilator Asubstancethatdilatesorwidensthebloodvessels

Vasoprotective Asubstancethatprotectstheintegrityofthebloodvessels

Venotonic Asubstancethatimprovesthetoneandfunctionoftheveins

Vulnerary(seealsoAntiulcer,Astringent,Demulcent)

Asubstancethatpromotesthehealingofwoundswhenappliedlocally

Weightreducing Asubstancethatassistsinthereductionofbodyweight

PAF,Platelet-activatingfactor;TSH,thyroidstimulatinghormone.

APPENDIXC

GlossaryofClinicalTrialTerms

Case-controlstudy

Usuallyincase-controlstudies,volunteerswithexistingdiagnoseddisease(thecases)areenrolledinastudyandarematchedbyidentifiablecharacteristics(e.g.,age,race,gender)todisease-freevolunteers(thecontrols).Thecasesandcontrolsareusuallyidentifiedwithoutknowledgeofanindividual’sexposureornonexposuretothefactorsbeinginvestigated.Thesefactorsaredeterminedfromexistinginformation.Case-controlstudiesusuallybeginafterindividualshavealreadydevelopedorfailedtodevelopthediseasebeinginvestigated.Hencecase-controlstudiesareusuallyretrospective,althoughinsomecircumstances,theycanalsobeprospective.Case-controlstudiesarelessreliablethaneithercohortstudiesorrandomized,controlledtrials.Oftenthefirsttypeofstudytosuggestanewmedicalconclusion,case-controlstudiesmaybedesignedtoinvestigateahypothesissuggestedbyaseriesofcasereports.

Cohortstudy

Theterminologysurroundingcohortstudieshasbeensomewhatconfusedinthemedicalliterature.Arecentdefinitionis:acohortstudycomparestheexperienceofagroupofpeopleexposedtosomefactorwithanothergroupnotexposedtothesamefactor.Iftheexposedgrouphasahigherorlowerfrequencyofanoutcome(e.g.,adisease)thantheunexposedgroup,thenanassociationbetweenexposureandoutcomeisevident.Iftheexposureoccurredinthepastandtheoutcomeisinvestigatedinthepresent,itistermedretrospective.Iftheexposureoccursinthepresentandtheoutcomewillbe

monitoredinthefuture,itisaprospectiveorconcurrentcohortstudy.Cohortstudiesofdiseasedifferfromcase-controlstudiesinthatcohortstudiesbeginbyidentifyingindividualsforstudyandcontrolgroupsbeforetheinvestigatorisawareofwhethertheyhaveorwilldevelopthedisease(i.e.,exposure→disease).(Case-controlstudiesgenerallyidentifyindividualswithandwithoutthediseaseandlaterlookattheexposurestatusofthegroups[i.e.,disease→exposure].)

Controlgroup

Agroupofpeopletestedincomparisonwithatreatment-studygroup.Thecontrolgroupshouldbeidenticaltothestudygroupexceptthatithasnotbeenexposedtothetreatmentunderinvestigation.

Crossoverstudy

Astudydesigninwhichthesameindividualreceivesbothtreatmentandcontroltherapiesatdifferenttimes,andanoutcomeisassessedforeachtherapy.Asuitablewashoutperiodisrequiredbetweeneachtreatmentphase.

Double-blindWhenboththeinvestigatorandparticipantsdonotknowwhohasbeenassignedtothetreatment-studygrouportothecontrolgroup.

Effectiveness

Theextenttowhichatreatmentproducesabeneficialeffectwhenimplementedundertheusualconditionsofclinicalcare.Boththeefficacyofaninterventionanditsacceptancebythosetowhomitisofferedisconsidered.Astudyofeffectivenessasks,“Doesthemedicinehelpthepatient?”

Efficacy

Theextenttowhichatreatmentproducesabeneficialeffectwhenassessedundertheidealconditionsofaninvestigation(e.g.,inawell-designedclinicaltrial).Anefficacystudyasks,“Doesthemedicinework?”

Epidemiologicstudy

Astudydesignedtoexamineassociationsbetweendefinedparametersandadiseaseinarelativelylargepopulation.Suchastudyisusuallyconcernedwithidentifyingormeasuringtheeffectsofriskfactorsorexposures.Epidemiologicstudiescanincludecase-controlstudies,

cohortstudies,andcross-sectionalstudies(studiedatonepointintime).

Meta-analysis

Aseriesofmethodsforsystematicallycombininginformationfrommorethanoneclinicaltrialsoastodrawastrongerconclusionthanonedrawnsolelyonthebasisofeachsingletrial.Meta-analysisismorequantitativethanthesystematicreview(seelater).

Open(unblinded)study

Aclinicalstudythatmayormaynothavebeencontrolledbutwasconductedwithoutanyblinding.

PhaseItrial

Aclinicaltrialinwhichresearcherstestanewdrugortreatmentinasmallgroupofhealthypeople(20-80)forthefirsttimetoevaluateitssafety,determineasafedoserange,andidentifysideeffects.

PhaseIItrialAsmall-scale,controlledoruncontrolledtrial(involving100-300people)conductedtodetermineifadrugortreatmentiseffectiveandtofurtherevaluateitssafety.

PhaseIIItrialUsuallyarandomized,controlledtrialinvolvinglargegroupsofpeople(1000-3000)thatisconductedtounderstandthesafetyandefficacyofadrugortreatment.

PhaseIVstudy

Anuncontrolledstudyconductedafterthedrugortreatmenthasbeenmarketed.Informationisgatheredinvariouspopulationsandanysideeffectsassociatedwithlong-termusearerecorded.

Pilottrial Asmall-scaletrialoftenconductedbeforealarge-scaletrial.

Placebo

Apreparationthathasnospecificpharmacologicactivityagainstatargetedcondition.Inclinicaltrials,placebos,eitherasdummytreatmentsorprocedures,areadministeredtocontrolgroupstoprovideresultsforcomparisonwiththetesttreatment.

Postmarketingstudy

Anuncontrolledstudyconductedafterthereleaseofaproductontothemarkettosurveytheeffectivenessandtolerabilityofthepreparation(similartoaphaseIVstudy).Aprospectivestudyisconcernedwithfutureinformationandoutcomes.Theinformationcharacterizingeach

Prospectivestudy

individualisrecordedbeforetheonsetofdisease.Theinformationobtainedrelatestothevolunteersatthetimethestudyisstartedandtheyarethenfollowedthroughoutthetimeperiodofthestudy.

Thetermmaybeappliedtocohort,case-control,andpostmarketingstudies.

Randomization

Amethodofassignmentinwhichindividualshaveaknown,butnotnecessarilyequal,probabilityofbeingassignedtoatreatmentgrouporcontrolgroup.Asdistinguishedfromrandomsampling,theindividualsbeingrandomizedmayormaynotberepresentativeofalargepopulation.

Retrospectivestudy

Aretrospectivestudylooksbackonpastinformation.Aretrospectivestudygathersinformationaboutindividualswhohadexposuretoafactorunderinvestigation,andthedataisanalyzedasoraftertheoutcomeshaveoccurred.Thetermmaybeappliedtocohortandcase-controlstudies.

Single-blind Whenthepatientisunaware,buttheinvestigatorisaware,ofwhichtherapy(treatmentorcontrol)isbeingreceived.

Systematicreview

Forthepurposesofassigninglevelsofevidence,areviewofrandomized,controlledtrialsofatreatmentthatqualitativelyassessesthequalityofthetrialsandtheefficacyofthetreatmentisconducted.(Thisreviewisincomparisontoameta-analysis,whichmakesaquantitativeassessment).

Uncontrolledstudy

Aclinicalstudythatteststhetherapyonallparticipantsinthestudywithoutacontrolgroup.

Formoreinformation,refertothefollowing:

•RiegelmanRK,HirschRP:Studyingastudyandtestingatest:howtoreadthehealthscienceliterature,ed3,Boston,1996,LittleBrown.

•DollR:Cohortstudies:historyofthemethod.I.Prospectivecohortstudies,SozPraventivmed46(2):75-86,2001.

•GrimesDA,SchulzKF:Cohortstudies:marchingtowardsoutcomes,Lancet359(9303):341-345,2002.

•GreenhalghT:Howtoreadapaper:thebasicsofevidencebasedmedicine,ed2,London,2001,BMJBooks.

APPENDIXD

HerbListingbyActions

Action Herbs

Adaptogenicashwaganda,Astragalus,Bacopa(possibly),Eleutherococcus,gotukola,Koreanginseng,neemleaf,Schisandra,shatavari

Adrenaltonic licorice,Rehmannia

AnalgesicArnica(topicallyonly),Californiapoppy,devil’sclaw,Jamaicadogwood,kava(mild),pasqueflower,peppermint(topically)

Antacid meadowsweetAnthelmintic Andrographis,feverfew,wormwood

Antiallergic Albizia,Baicalskullcap,feverfew,nettleleaf,Tylophora

Antiandrogenic sawpalmetto(possibly)Antianemic ashwaganda,dongquai

Antiarrhythmic dongquai,hawthorn(leaf&berry),motherwort,Tienchiginseng

Antiasthmatic blackhaw,Tylophora

Antibacterial Baicalskullcap,barberry,elecampane,goldenseal,Indianbarberry,myrrh,paud’arco,thyme

Anticariogenic licorice

Anticatarrhal elderflower,eyebright,goldenrod,goldenseal,mullein

Anticonvulsant Bacopa(mild),kava,whitepeony

Antidepressant lavender,Schisandra(mild),St.John’swort,vervain(mild)

Antidiabetic(seealsoHypoglycemic) goat’srue,Gymnema

Antidiarrheal cranesbillroot,raspberryleaf,shatavariAntiecchymotic Arnica(topicalonly),horsechestnutAntiedematous bilberry,horsechestnut

Antiemetic barberry,fringetree,ginger,globeartichoke,Indianbarberry,peppermint

Antifungal Calendula(topical),neemleaf,paud’arco,Thuja,thyme,

Antihemorrhagic cranesbillroot,goldenseal,Rehmannia,shepherd’spurse,Tienchiginseng,yarrow

Antihyperhidrotic sage

Antiinflammatory(seealsoAntiallergic,Antirheumatic,Antiedematous,Immunedepressant)

Aloejuiceconcentrate,Andrographis,Arnica(topicalonly),ashwaganda,Baicalskullcap,bilberry,Bupleurum,Calendula,chamomile,cat’sclaw,celeryseed,Crataeva,devil’sclaw,dongquai,Echinacearoot,eyebright,fenugreek,feverfew,ginger,goldenrod,goldenseal,gotukola,greatercelandine,horsechestnut,licorice,meadowsweet,myrrh,neemleaf,Oregongrape,pokeroot,Rehmannia,sarsaparilla,sawpalmetto,Tienchiginseng,turmeric,Tylophora,uvaursi,whitepeony,wildyam,yarrow

Antilithic cornsilk,Crataeva,HydrangeaAntimicrobial(seealsoAntibacterial,Antifungal,Antiparasitic,Antiseptic,Antiviral)

Albizia,Arnica(topicallyonly),barberry,Calendula,fennel,goldenseal,Indianbarberry,myrrh,neemleaf,Oregongrape,peppermint(internallyandtopically),rosemary,sage,St.John’swort,Thuja,thyme,turmeric,yarrow

Antioxidant

Andrographis,Astragalus,bilberry,cat’sclaw,Ginkgo,hawthorn(leaf&berry),milkthistle,oliveleaf,rosemary,sage,Schisandra,thyme,turmeric

Anti-PAF GinkgoAntiparasitic Euphorbia,paud’arco,wormwood

Antiplatelet Andrographis,Coleus,dongquai,ginger,turmeric

Antiprostatic nettleroot,sawpalmetto,willowherbAntiprotozoal SeeAntiparasitic

Antipruritic kava(topically),peppermint(topically),neemleaf

Antipsoriatic Oregongrape

Antipyretic Andrographis,Baptisia,neemleaf,Rehmannia,yarrow

Antirheumaticblackcohosh,celeryseed,chamomile,dandelion,devil’sclaw,nettleleaf,pricklyash,sarsaparilla,wildyam

Antiseptic SeeAntibacterial,Antimicrobial,Urinaryantiseptic

Antispasmodic SeeSpasmolyticAntithyroid bugleweed,motherwort

Antitumor Aloejuiceconcentrate,paud’arco,redclover(traditionaluse)

Antitussive Bupleurum,licorice,neemleaf,peppermint,Schisandra,wildcherry

Antiulcer(peptic) chamomile,chickweed,licorice

AntiviralAloejuiceconcentrate,Calendula(topically),greatercelandine(topically),lemonbalm(topically),neemleaf,St.John’swort,Thuja

AnxiolyticBacopa,Californiapoppy,greenoats,kava,lavender,Mexicanvalerian,neemleaf,passionflower,spinyjujube,valerian

Aphrodisiac shatavariAppetitestimulating fennel,fenugreekAromaticdigestive cinnamon,Coleus

Astringent(seealsoAntidiarrhealandVulnerary)

blackhaw,chickweed,cinnamon,crampbark,cranesbillroot,eyebright,hawthorn(leaf&berry)(mild),horsetail,meadowsweet,myrrh,raspberryleaf,sage,uvaursi,vervain,wildcherry

Bittertonic(alsoknownasaBitter;seealsoDigestivestimulant,Gastricstimulant)

Andrographis,barberry,dandelion,devil’sclaw,feverfew,gentian,globeartichoke,goldenseal,hops,Indianbarberry,oliveleaf,whitehorehound,wormwood,yarrow

Bladdertonic CrataevaBronchospasmolytic blackhaw,Coleus,elecampane,GrindeliaCancerpreventative(seealsoAntitumor) Koreanginseng

Cardioprotective hawthorn(leaf&berry),Tienchiginseng

Cardiotonic Astragalus,Coleus,hawthorn(leaf&berry)(mild),Koreanginseng,motherwort

Carminative chamomile,cinnamon,fennel,ginger,lavender,lemonbalm,peppermint,rosemary,turmeric

Cholagoguebarberry,blueflag,fringetree,gentian,globeartichoke,greatercelandine,Indianbarberry,peppermint,yellowdock

CholereticAndrographis,barberry,dandelion,fringetree,globeartichoke,goldenseal,greatercelandine,Indianbarberry,milkthistle,turmeric

Circulatorystimulant ginger(peripheral),Ginkgo,pricklyash,rosemary

Cognitionenhancing Bacopa,Ginkgo,Koreanginseng,whitepeonyCollagenstabilizing hawthorn(leaf&berry)Demulcent(seealsoUrinarydemulcent)

bladderwrack,chickweed,fenugreek,licorice,marshmallow(root&leaf),mullein

Depurative

Baptisia,blueflag,burdock,cleavers,Echinacearoot,fringetree,globeartichoke,goldenseal,gotukola,Hemidesmus,neemleaf,nettleleaf,Oregongrape,paud’arco,pokeroot,redclover,sarsaparilla,Thuja,turmeric,yellowdock

Diaphoretic

Bupleurum,chamomile,elderflower,elecampane,ginger,goldenrod,Hemidesmus,lemonbalm,limeflowers,peppermint,pleurisyroot,pricklyash,vervain(mild),yarrow

Digestivestimulant(seealsoBittertonic) Coleus,ginger

Diuretic

Astragalus,blueflag,buchu(mild),burdock(mild),celeryseed,cleavers,cornsilk,couchgrass(soothing),dandelion(especiallyleaf),globeartichoke,goldenrod,horsetail,Hydrangea,shatavari

Dopaminergicagonist chastetree

Emmenagogue bluecohosh,feverfew(inhighdoses),motherwort,neemleaf

Emollient(seeDemulcent) marshmallow(root&leaf)

Estrogenmodulating blackcohosh,fennel,falseunicornroot,wildyam

Expectorant elecampane,fennel,Grindelia,licorice,mullein,pleurisyroot,thyme,whitehorehound

Femaletonic dongquai

Galactagogue chastetree,fennel,fenugreek,goat’srue,shatavari

Gastricstimulant(seealsoBittertonic,Digestivestimulant,Aromaticdigestive)

gentian

Hepatoprotective Andrographis,Bupleurum,globeartichoke,milkthistle,rosemary,Schisandra

Hepatotrophorestorative globeartichoke,milkthistle

Hypnotic Californiapoppy,hops,kava,Mexicanvalerian,passionflower,spinyjujube,valerian

Hypocholesterolemic(seealsoHypolipidemic)

Albizia,fenugreek,globeartichoke,Gymnema,Tienchiginseng

Hypoglycemic fenugreek,goat’srue,Gymnema,neemleafHypolipidemic turmeric

Hypotensive(seealsoAstragalus,blackhaw,Coleus,crampbark,hawthorn(leaf&berry),mistletoe,motherwort,

Peripheralvasodilator) oliveleaf,spinyjujube

Immunedepressant Hemidesmus,Tylophora

ImmuneenhancingAloejuiceconcentrate,Andrographis,Astragalus,Baptisia,cat’sclaw,Echinacearoot,neemleaf,paud’arco,pokeroot

Immunemodulating ashwaganda,Echinacearoot,Eleutherococcus,Koreanginseng

Laxative

barberry(mild),blueflag,burdock(mild),cascara,damiana(mild),dandelion(mild),dongquai(mild),fringetree(mild),greatercelandine(mild),Indianbarberry(mild),licorice(mild),yellowdock(mild)

Localanesthetic kavaLymphatic blueflag,Calendula,Echinacearoot,pokerootMaletonic Koreanginseng,sawpalmettoMucoprotective licoriceMucousmembranetonic eyebright

Mucousmembranetrophorestorative goldenseal

NervinetonicBacopa,damiana,gotukola,greenoats,motherwort,oatsseed,pasqueflower,Schisandra,skullcap,St.John’swort,vervain

Neuroprotective GinkgoOvariantonic bluecohosh,falseunicornrootOxytocic bluecohosh,goldenseal(reputed),SchisandraParturifacient(seealsoOxytocic) raspberryleaf

Partuspreparator raspberryleaf

Peripheralvasodilator crampbark,hawthorn(leaf&berry),limeflowers,mistletoe,yarrow

Progesterogenic chastetree(indirectly)Prolactininhibitor chastetree

Pungent gingerRefrigerant chickweedRubefacient thyme

Sedative(mild)

ashwaganda,Bacopa,bugleweed,Californiapoppy,chamomile,crampbark,hops,Jamaicadogwood,kava,lemonbalm,limeflowers,Mexicanvalerian,mistletoe,passionflower,peppermint,skullcap,spinyjujube,valerian,wildcherry

Sexualtonic shatavariSialagogue Echinacearoot,gentian,pricklyashSkeletalmusclerelaxant kava,whitepeony(mild)

Spasmolytic

blackcohosh,bluecohosh,chamomile,Coleus,crampbark,elecampane,fennel,ginger,greatercelandine,Grindelia,hops,Jamaicadogwood,kava,lavender,lemonbalm,limeflowers,Mexicanvalerian,motherwort,pasqueflower,passionflower,peppermint,rosemary,sage,sawpalmetto,shatavari,skullcap,thyme,valerian,whitehorehound,whitepeony,wildyam,yarrow

Styptic(hemostatic)(seealsoVulnerary) Calendula,horsetail,nettleleaf,yarrow

Thymoleptic oatsseedThyroidstimulant bladderwrackTissueperfusionenhancing Ginkgo

Tonic(alsoknownasGeneralbodytonic;seealsootherspecificbodytonics)

ashwaganda,Astragalus,Codonopsis,damiana,Eleutherococcus,Koreanginseng,oatsseed,shatavari

TSHantagonist bugleweed,lemonbalm

Urinaryantiseptic buchu,meadowsweet(mild),shepherd’spurse,uvaursi

Urinarydemulcent cornsilk,couchgrass,marshmallow(root&leaf)Uterinesedative blackhawUterinetonic blackcohosh,bluecohosh,falseunicornrootVasoprotective bilberryVenotonic horsechestnut

Vulnerary(seealsoAntiulcer,Astringent,Demulcent)

Aloejuiceconcentrate,Calendula,chamomile,Echinacearoot,goldenseal,gotukola,greatercelandine(topical),mullein,myrrh,St.John’swort,yarrow

Weightreducing bladderwrack,Gymnema

APPENDIXE

ActionListingbyHerbs

Herb ActionsAlbizia Antiallergic,hypocholesterolemic,antimicrobial.Aloejuiceconcentrate

Immuneenhancing,antiviral,vulnerary,antiinflammatory,antitumor.

AndrographisBittertonic,choleretic,immuneenhancing,hepatoprotective,antipyretic,antiinflammatory,antiplatelet,antioxidant,anthelmintic.

Arnica Topicalonly:Antiinflammatory,antiecchymotic(againstbruises),analgesic,antimicrobial.

Ashwaganda Tonic,adaptogenic,mildsedative,antiinflammatory,immunomodulator,antianemic.

Astragalus Immuneenhancing,tonic,adaptogenic,cardiotonic,diuretic,hypotensive,antioxidant.

Bacopa Cognitionenhancing,nervinetonic,mildsedative,mildanticonvulsant,anxiolytic,possiblyadaptogenic.

Baicalskullcap Antiinflammatory,antiallergic,antibacterial.Baptisia Depurative,antipyretic,immuneenhancing.

Barberry Antimicrobial,cholagogue,choleretic,antiemetic,mildlaxative,bittertonic.

Bilberry Vasoprotective,antiedema,antioxidant,antiinflammatory.

Blackcohosh Antirheumatic,spasmolytic,estrogenmodulating,uterinetonic.

Blackhaw Uterinesedative,bronchospasmolytic,antiasthmatic,hypotensive,astringent.

Bladderwrack Weightreducing,thyroidstimulant,demulcent.

Bluecohosh Spasmolytic,uterineandovariantonic,emmenagogue,oxytocic.

Blueflag Depurative,laxative,cholagogue,lymphatic,diuretic.Buchu Urinaryantiseptic,milddiuretic.

Bugleweed TSHantagonist,antithyroid,reducesheartrate,mildsedative.

Bupleurum Antiinflammatory,hepatoprotective,diaphoretic,antitussive.

Burdock Depurative,milddiuretic,mildlaxative.

CalendulaVulnerary,antiinflammatory,lymphatic,styptic(hemostatic),antimicrobial,antiviral(topically),antifungal(topically).

Californiapoppy Anxiolytic,mildsedative,analgesic,hypnotic.

Cascara Laxative.Cat’sclaw Immuneenhancing,antiinflammatory,antioxidant.Celeryseed Diuretic,antiinflammatory,antirheumatic.

Chamomile Antiinflammatory,spasmolytic,carminative,mildsedative,antiulcer,vulnerary,diaphoretic.

Chastetree Prolactininhibitor,dopaminergicagonist,indirectlyprogesterogenic,galactagogue.

Chickweed Demulcent,astringent,refrigerant,antiulcer(peptic).Cinnamon Carminative,aromaticdigestive,astringent.Cleavers Diuretic,depurative.Codonopsis Tonic.

ColeusHypotensive,antiplatelet,bronchospasmolytic,spasmolytic,cardiotonic,digestivestimulant,aromaticdigestive.

Cornsilk Diuretic,antilithic,urinarydemulcent.Couchgrass Soothingdiuretic,urinarydemulcent.

Crampbark Spasmolytic,mildsedative,astringent,hypotensive,peripheralvasodilator.

Cranesbillroot Astringent,antidiarrheal,antihemorrhagic.

Crataeva Antilithic,bladdertonic,antiinflammatory.Damiana Nervinetonic,tonic,mildlaxative.Dandelion(root&leaf)

Bittertonic,choleretic,diuretic(especiallyleaf),mildlaxative,antirheumatic.

Devil’sclaw Antiinflammatory,antirheumatic,analgesic,bittertonic.

Dongquai Antiinflammatory,antianemic,antiplatelet,femaletonic,mildlaxative,antiarrhythmic.

Echinacearoot Immunemodulator,immuneenhancing,depurative,antiinflammatory,vulnerary,lymphatic,sialagogue.

Elderflower Diaphoretic,anticatarrhal.

Elecampane Expectorant,diaphoretic,antibacterial,spasmolytic,bronchospasmolytic.

Eleutherococcus Adaptogenic,immunomodulator,tonic.Euphorbia Expectorant,antiasthmatic,spasmolytic,antiprotozoal.

Eyebright Astringent,anticatarrhal,mucousmembranetonic,antiinflammatory.

Falseunicornroot Uterinetonic,ovariantonic,estrogenmodulating.

FennelCarminative,appetitestimulating,spasmolytic,galactagogue,estrogenmodulating,antimicrobial,expectorant.

Fenugreek Appetitestimulating,galactagogue,antiinflammatory,demulcent,hypoglycemic,hypocholesterolemic.

Feverfew Antiinflammatory,antiallergic,bittertonic,emmenagogue(inhighdoses),anthelmintic.

Fringetree Cholagogue,choleretic,mildlaxative,antiemetic,depurative.

Gentian Bittertonic,gastricstimulant,sialagogue,cholagogue.

GingerCarminative,antiemetic,peripheralcirculatorystimulant,spasmolytic,antiinflammatory,antiplatelet,diaphoretic,digestivestimulant,pungent.Antioxidant,anti-PAF(anti-platelet-activatingfactor)

Ginkgo activity,tissueperfusionenhancing,circulatorystimulant,cognitionenhancing,neuroprotective.

GlobeartichokeHepatoprotective,hepatictrophorestorative,choleretic,cholagogue,bittertonic,hypocholesterolemic,antiemetic,diuretic,depurative.

Goat’srue Hypoglycemic,antidiabetic,galactagogue.Goldenrod Antiinflammatory,diaphoretic,diuretic,anticatarrhal.

Goldenseal

Antihemorrhagic,anticatarrhal,trophorestorativeformucousmembranes,antibacterial,bittertonic,antiinflammatory,depurative,vulnerary,choleretic,reputedoxytocic.

Gotukola Vulnerary,antiinflammatory,depurative,adaptogenic,nervinetonic.

Greatercelandine

Choleretic,cholagogue,spasmolytic,mildlaxative,antiinflammatory,antiviral(topically),vulnerary(topical).

Greenoats Nervinetonic,anxiolytic.Grindelia Expectorant,spasmolytic,bronchospasmolytic.

Gymnema Antidiabetic,hypoglycemic,hypocholesterolemic,weightreducing.

HawthornberryCardioprotective,mildcardiotonic,hypotensive,peripheralvasodilator,antiarrhythmic,antioxidant,mildastringent,collagenstabilizing.

HawthornleafCardioprotective,mildcardiotonic,hypotensive,peripheralvasodilator,antiarrhythmic,antioxidant,mildastringent,collagenstabilizing.

Hemidesmus Depurative,diaphoretic,immunedepressant.Hops Hypnotic,mildsedative,spasmolytic,bittertonic.

Horsechestnut Venotonic,antiedematous,antiinflammatory,antiecchymotic(againstbruises).

Horsetail Diuretic,astringent,styptic(hemostatic).Hydrangea Diuretic,antilithic.

Indianbarberry asforbarberry:Antimicrobial,cholagogue,choleretic,antiemetic,mildlaxative,bittertonic.

Jamaicadogwood Analgesic,spasmolytic,mildsedative.

KavaAnxiolytic,hypnotic,anticonvulsant,mildsedative,skeletalmusclerelaxant,spasmolytic,localanesthetic,mildanalgesic,antipruritic(topically).

Koreanginseng Adaptogenic,tonic,immunemodulator,cardiotonic,maletonic,cancerpreventative,cognitionenhancing.

Lavender Carminative,spasmolytic,antidepressant,anxiolytic.

Lemonbalm Carminative,spasmolytic,mildsedative,diaphoretic,TSHantagonist,antiviral(topically).

LicoriceAntiinflammatory,mucoprotective,demulcent,antiulcer(peptic),adrenaltonic,expectorant,antitussive,mildlaxative,anticariogenic.

Limeflowers Spasmolytic,peripheralvasodilator,mildsedative,diaphoretic.

Marshmallowleaf Demulcent,urinarydemulcent,emollient.

Marshmallowroot Demulcent,urinarydemulcent,emollient.

Meadowsweet Antacid,antiinflammatory,mildurinaryantiseptic,astringent.

Mexicanvalerian Anxiolytic,mildsedative,hypnotic,spasmolytic.

Milkthistle Hepatoprotective,hepatictrophorestorative,antioxidant,choleretic.

Mistletoe Hypotensive,peripheralvasodilator,mildsedative.

Motherwort Nervinetonic,cardiotonic,hypotensive,antiarrhythmic,antithyroid,spasmolytic,emmenagogue.

Mullein Expectorant,demulcent,anticatarrhal,vulnerary.

Myrrh Astringent,antimicrobial,antibacterial,antiinflammatory,vulnerary.

Neemleaf

Antimicrobial,antifungal,antiviral,antipyretic,adaptogenic,antipruritic,antitussive,depurative,antiinflammatory,anxiolytic,emmenagogue,

hypoglycemic,immuneenhancing.

Nettleleaf Antirheumatic,antiallergic,depurative,styptic(hemostatic).

Nettleroot Antiprostatic.Oatsseed Nervinetonic,tonic,thymoleptic.Oliveleaf Hypotensive,antioxidant,bittertonic.

Oregongrape Antipsoriatic,antiinflammatory,depurative,antimicrobial.

Pasqueflower Spasmolytic,analgesic.Passionflower Anxiolytic,spasmolytic,mildsedative,hypnotic.

Paud’arco Immuneenhancing,antitumor,antibacterial,antifungal,antiparasitic,depurative.

Peppermint

Spasmolytic,carminative,cholagogue,antiemetic,antitussive,antimicrobial(internallyandtopically),mildsedative,diaphoretic,analgesic(topically),antipruritic(topically).

Pleurisyroot Diaphoretic,expectorant.

Pokeroot Antiinflammatory,lymphatic,depurative,immuneenhancing.

Pricklyash Circulatorystimulant,diaphoretic,antirheumatic,sialagogue.

Raspberryleaf Astringent,partuspreparator,parturifacient,antidiarrheal.Redclover Depurative,antitumor(traditionaluse).

Rehmannia Antipyretic,adrenaltonic,antihemorrhagic,antiinflammatory.

Rosemary Carminative,spasmolytic,antioxidant,antimicrobial,circulatorystimulant,hepatoprotective.

Sage Spasmolytic,antioxidant,astringent,antihyperhidrotic,antimicrobial.

Sarsaparilla Antirheumatic,depurative,antiinflammatory.

Sawpalmetto Antiinflammatory,maletonic,antiprostatic,spasmolytic,possiblyantiandrogenic.

Schisandra Hepatoprotective,antioxidant,adaptogenic,nervinetonic,

antitussive,oxytocic,mildantidepressant.

ShatavariTonic,galactagogue,sexualtonic,aphrodisiac,adaptogenic,antispasmodic,antidiarrheal,diuretic.

Shepherd’spurse Antihemorrhagic,urinaryantiseptic.

Skullcap Nervinetonic,spasmolytic,mildsedative.Spinyjujube Hypnotic,mildsedative,hypotensive,anxiolytic.

St.John’swort Antiviral,nervinetonic,antidepressant,vulnerary,antimicrobial.

Thuja Antimicrobial,depurative,antiviral,antifungal.

Thyme Expectorant,spasmolytic,antibacterial,antifungal,antioxidant,rubefacient(topically),antimicrobial.

Tienchiginseng Antihemorrhagic,cardioprotective,antiinflammatory,antiarrhythmic,hypocholesterolemic.

TurmericAntiinflammatory,antiplatelet,antioxidant,hypolipidemic,choleretic,antimicrobial,carminative,depurative.

Tylophora Antiasthmatic,antiinflammatory,immunedepressant,antiallergic.

Uvaursi Urinaryantiseptic,astringent,antiinflammatory.Valerian Anxiolytic,mildsedative,hypnotic,spasmolytic.

Vervain Nervinetonic,milddepressant,milddiaphoretic,astringent.

Whitehorehound Expectorant,spasmolytic,bittertonic.

Whitepeony Spasmolytic,mildskeletalmusclerelaxant,anticonvulsant,antiinflammatory,cognitionenhancing.

Wildcherry Antitussive,mildsedative,astringent.

Wildyam Spasmolytic,antiinflammatory,antirheumatic,estrogenmodulating.

Willowherb Antiprostatic.Wormwood Bittertonic,anthelmintic,antiparasitic.

Yarrow Diaphoretic,antipyretic,peripheralvasodilator,antiinflammatory,spasmolytic,bittertonic,styptic(hemostatic),antimicrobial,antihemorrhagic,vulnerary.

Yellowdock Mildlaxative,cholagogue,depurative.

APPENDIXF

HerbsPossiblyContraindicatedinPregnancy

Herb Notes

AndrographisTheantifertilityeffectinfemalemice(albeitathighdoses)suggeststhatAndrographisshouldnotbeusedduringhumanpregnancy,especiallyinthefirsttrimester.

Arnica Notforinternaluse,fortopicaluseonly.Barberry Contraindicatedinpregnancy.

Blackcohosh Contraindicatedinpregnancyandlactation,exceptforassistingbirthduringthelastmonth.

Bladderwrack Contraindicatedinpregnancyandlactation.Bluecohosh Contraindicatedinpregnancyandlactation.

Bugleweed Contraindicatedinpregnancyandlactationbecauseofpotentialantigonadotropicactivity.

Cascara

AccordingtotheBritishHerbalCompendiumcascaraiscontraindicatedinpregnancyandlactation.However,thiscautionseemsexcessiveprovidedtherecommendedtherapeuticdosageisobserved.Doseswhichcauseanexcessivelyloosestoolshouldnotbeusedduringpregnancy.

Cat’sclaw Usewithcautioninpregnancyandlactation.

Chastetree

Usecautiouslyinpregnancyandonlyintheearlystagesfortreatmentofinsufficientcorpuslutealfunction.Althoughthedopaminergicactivitymightsuggestthatchastetreeisbestavoidedduringlactation,clinicaltrialshavedemonstrateditspositiveactivityonmilkproduction,albeitatlowdoses.

Dongquai Contraindicatedinthefirsttrimesterofpregnancy,especiallyinhigherdoses.

ElecampaneAccordingtotheBritishHerbalCompendiumelecampaneiscontraindicatedinpregnancyandlactation.Howeverthereappearstobenosubstantialbasisforthisconcern.

Feverfew

Dosesduringpregnancyshouldbekepttoaminimum(nomorethan1.5mLofa1:5tinctureperday).Noadverseeffectsexpectedduringlactationaslongastherecommendeddosagelevelsareobserved.

Ginger

Noadverseeffectsareexpectedwithintherecommendeddosage(0.7to2mLof1:2liquidextract).Adailydoseof2gofdriedgingershouldnotbeexceededinpregnancy.Gingerhasbeensuccessfullyutilizedinclinicaltrialstotreatpregnantwomenwithnausea.

Goldenseal Contraindicatedinpregnancy.Indianbarberry Contraindicatedinpregnancy.

Jamaicadogwood Contraindicatedinpregnancy.

LicoriceDosesupto3gperday(i.e.,upto3mLof1:1liquidextractor3mLof1:1highglycyrrhizinliquidextract)arelikelytobesafe.

Motherwort Contraindicatedinpregnancy.Myrrh Contraindicatedinpregnancy.

Neemleaf Avoiduseduringpregnancy,especiallyinthefirsttrimester.

Oregongrape Contraindicatedinpregnancy.Pasqueflower Contraindicatedinpregnancyandlactation.

Paud’arco Cautioninpregnancyduetopossibleabortiveandteratogenicactions.

Pokeroot Contraindicatedinpregnancyandlactation.

Raspberryleaf

Noadverseeffectsexpectedinpregnancyorlactation,butitismoreappropriatetoconfineusetothesecondandthirdtrimesters.

SageContraindicatedinpregnancyandlactation.However,sagehasbeenusedtraditionallytostopmilkflow.

Schisandra Contraindicatedinpregnancy,excepttoassistchildbirth.Tienchiginseng Contraindicatedinpregnancy,accordingtoTCM.

Tylophora Contraindicatedinpregnancyandlactation.Uvaursi Contraindicatedinpregnancyandlactation.Wormwood Contraindicatedinpregnancyandlactation.

Yarrow Noadverseeffectsexpected.Howeverthujone-containingvarietiesshouldbeavoided.

Yellowdock Usewithcautionduringpregnancy.

Index

AAbcesses

aloeveraand,61chickweedand,147echinaceaand,185echinaceaangustifoliarootand,186marshmallowand,321pokerootandmammary,376Smilaxregeliirootand,398

Abdominalcramping,bluecohoshand,106

Abortion,vervainand,454

Absinthism,thujaand,428

Abstractreasoning,ginkgobilobaand,235-236

Acemannanmedicinalattributesof,62spleenand,62

Acetominophen,neemleafand,340

Acetylatedgalactomannan,aloeveraand,62

Acetylcholine,nettleleafand,344

Acetylcholinereceptoragonists,lemonbalmand,309

Acetylcholinesterase,sageand,395

Acidiclipophilicfraction,liposterolicextractand,402

Acidicpolysaccharides,marshmallowand,322

Acnevulgarischastetreeand,142,146oregongrapeand,357,358

ACTH.SeeAdrenocorticotropichormone(ACTH)

Addison’sdisease,licoriceand,312,314,315

Adenosinediphosphate(ADP)dandelionrootand,175feverfewleafand,220

Adhesionscores,shatavariand,411

ADP.SeeAdenosinediphosphate(ADP)

Adrenalcortexalbiziaand,60rehmanniaand,387tylophoraand,442

Adrenalfunction,rehmanniaand,386

Adrenalglandalbiziaand,59eleutherococcusand,197tylophoraand,443

whitepeonyand,459

Adrenaltonic,rehmanniaas,386

Adrenocorticotropichormone(ACTH)coleusand,157goldenrodand,247

Agathosmacrenulata,pregnancyand,111

Agingashwagandaand,73astragalusand,77koreanginsengand,298

Aglycones,sarsaparillaand,398

AIDS(acquiredimmunodefiencysyndrome)aloeveraand,61,63cat’sclawand,133licoriceand,316

Albizia,monographof,59

Alcohol.SeealsoEthanolgingerand,229kavaand,291koreanginsengand,299silymarinand,328St.John’swortand,423

valerianand,447

Alcoholicsblackhawand,101hopsand,279St.John’swortand,420

Aldosereductaseinhibitoryactivity,rehmanniaand,387

Alertness,rosemaryessentialoiland,392

Alfalfa,sageand,395

Alfuzosin,liposterolicextractand,403

Alkalineurine,uvaursiand,445

AlkaloidaucuibineB6,devil’sclawand,179

Alkaloidgalegine,goat’srueand,243

Alkaloids,4californiapoppyand,124herbcompatibilityand,23oregongraperoot,358tylophoraand,441

Alkylamidesechinaceaand,187echinaceaproductsand,17t

Allergicrhinitisalbiziafor,59

backgroundof,30nettleleafand,344treatmentstrategeyfor,30tylophoraand,440

Allergybaicalskullcapand,83chamomileand,138eczema(atopicdermatitis)and,36fenneland,206fenugreek(seed)and,210,211herbaltreatmentand,30nettleleafand,343

Aloegel,63medicinalvaluesof,62

Aloejuiceconcentratehealingand,38herbcompatibilityand,23

Aloeresin,medicinalvaluesof,62

AloeveraAyurvedicapplicationsfor,62monographof,61Thaiapplicationsfor,62

Alopecianeurotica,arnicaand,70

Alzheimer’sdiseaseashwagandaand,75GBEand,11ginkgobilobaand,235lemonbalmand,309St.John’swortand,422

Amenorrheablackcohoshand,96chamomileand,137dongquaiand,182falseunicornand,204motherwortand,331TJ-68and,461yarrowand,471

AmericanHerbalProductsAssociation(AHPA)blackhawand,100HerbsofCommerceand,49

Amylase,coleusand,157

Anabolicsteroids,sarsaparillaand,399

Analgesiccompounds,myrrhand,336

Analgesicsdandelionrootas,174goldenrodand,247

peppermintand,370

Anaphylaxischamomileand,138tylophoravs,441

Androgen,sawpalmettoand,401

Andrographisacutebronchitisand,29herpessimplexand,39keymarkercompoundsand,16monographof,65-66

Andrographispaniculata,HPLCtraceand,16f

Andrographolide,HPLCtraceand,16f

Anemarrhena,spinyjujubeand,417

Anemiadongquaiand,183fenugreekand,211limeflowersand,318peppermintand,369rosemaryand,389vervainand,453

Anesthesia,silymarinand,328

Angelicaacutiloba,braininfarctionand,460

Anginapectorisastragalusand,77,79crampbarkand,164hawthornand,271oliveleafand,352Steviarebaudianaand,460tienchiginsengand,433whitepeonyand,458

Angiogenicactivity,calendulaand,121

Anibacterialeffects,cinnamonoiland,150

Animalmodels,fenugreekand,213

Anogenitainflammation,chamomileand,137

Anorexianervosaburdockand,118fenugreekand,211gentianand,224oregongrapeand,357vervainand,453wormwoodand,469,470

Anoxia,tienchiginsengand,434

Anthocyanins,bilberryand,93,94

Anthraquinoneglycosides

aloeveraand,62cascaraand,129yellowdockrootand,475

Antianaphylacticactivity,albiziaand,59

Antiandrogenicactivity,liposterolicextractand,401

Antiarrhythmicherbs,hyperthyroidism(Grave’sdisease)and,39

Antibacterialactivity,lemongrassessentialoiland,9-10

Antibiotictherapy,eleutherococcusand,195

Anticatarrhalherbs,bronchitisand,30

Anticoagulantactivity,whitepeonyand,459

Anticoagulanttherapy,paud’Arcoand,366

Antidepressants,St.John’swortand,424

Anti-fungalactivity,gingerand,229

Antihemorrhagic,rehmanniaas,386

Antiinflammatoryactivityarnicaand,71myrrhand,336vervainand,454

Antiinflammatoryherbs,eczemaand,37

Antimutagenicactivity,St.John’swortand,423

Antioxidantactivitykoreanginsengand,297lemonbalmand,309rosemaryand,389schisandraand,406shatavariand,412

Antioxidantphenoliccompounds,rosemaryand,390

Antioxidantsburdockand,118cinnamonand,150fenugreekand,213neemleafand,340

Antipyretic,rehmanniaas,386

Antisepticcream,making,46

Antispasmodiceffects,valepotriatesand,449

Antithromoticactivity,myrrhand,336

Antitussiveherbs,bronchitisand,30

Antiviralherbs,35,35t

Anxietybacopaand,80californiapoppyand,124chamomileand,137

damianaand,171herbaltreatmentand,30hopsand,277jamaicadogwoodand,289kavaand,291lavenderand,305limeflowersand,318motherwortand,331passionflowerand,362rosemaryessentialoiland,392skullcapand,415spinyjujubeand,417St.John’swortand,420valerianand,447

Anxiolyticeffect,suanzaorentangand,418

Anxiolyticherbs,31stressand,38

Aortictissues,blackhawand,101

Aphrodisiacdamianaand,171sawpalmettoas,400shatavariand,409

Aphthousstomatitis,acemannanhyrogeland,63

Appetiteblackhawand,101dandelionand,173devil’sclawand,178fenugreekand,210feverfewand,220gentianand,224gymnemaand,267yarrowand,471

Arbutin,uvaursiand,445

Aristolochia,stephaniavs.,16

Arnicaallergiesto,70casestudyof,71monographof,70-72qualityproblemsand,13

Arnica(gel),CommissionEand,72

Aromatase,nettlerootand,347

Aromatherapy,lavenderand,306

Arrhythmia,devil’sclawand,180

Arsenic,bladderwrackand,103-104

Artemisiaannua,synergyand,10

Arterialbloodpressure,andrographisand,67

Arteriosclerosis,hawthornand,270,271

Arthritisandrographisand,67ashwagandaand,73blackcohoshand,97bladderwrackand,103cat’sclawand,131devil’sclawand,178feverfewleafand,220pleurisyrootand,374rehmanniaand,387skullcapand,83tylophorineinjectionand,442

Arthritis,rheumatoidashwagandaand,75bladderwrackand,104devil’sclawand,180feverfewand,219goldenrodand,246nettleleafand,343rehmanniaand,386sarsaparillaand,397

whitepeonyand,458,459,460wildyamand,464

Arthrosis,devil’sclawand,180

Ascarisinfestation,elecampaneand,194

Aseptictechnique,herbalcreamsand,46

Ashwaganda,34Ayurvedicmedicineand,74clinicalstudiesand,75monographof,73-76oraladministrationof,75shatavariand,411tumericand,436,438

Asiaticoside,gotukolaand,255,256

Aspergillusfumigatus,rosemaryoiland,391

Aspirindeglycyrrhinizedlicoriceand,314ginkgobilobaand,232shatavariand,412vsginger,228

Asthmaalbiziafor,59,60aloeveraand,63

ashwagandaand,73,74backgroundof,31baicalskullcap,84blackhawand,100coleusand,156elecampanefor,193euphorbiaand,199forskolinand,158ginkgobilobaand,232grindeliaand,265inhalationof,372nettlerootand,346rehmanniaand,386schisandraand,405thymedustand,431treatingsymptomsandsustainingcausesof,32ttreatmentstrategyfor,31-32tylophoraand,440,441,442,443underlyingfactorscreating,32twhitehorehoundand,456

Astragalus,34herpessimplexand,39monographof,77-79

pharmacologicresearchon,78rehmanniaand,386,387

Astringent,raspberryleafas,381

Atherosclerosisfenugreekand,210mistletoeand,330oatsand,350rosemaryand,389

Aucubigenin,eyebrightand,203

Aucubin,eyebrightand,203

Australianmedicalliterature,kavaand,291

AustralianTherapeuticGoodsAdministration(TGA),skullcapand,14

Autoimmunediseaseshemidesmusand,275tylophoraand,440

Ayurvedicmedicineashwagandaand,74bacopaand,80-81barberryand,90coleusand,157crataevaand,168

fenugreekand,211gymnemaand,267hemidesmusand,275licoriceand,314myrrhand,336neemleafand,339prescribingforindividualpatientin,27shatavariand,409-410

BBacillussubtillis

meadowsweetand,325yarrowand,472

Bacopa,34clinicalstudiesof,81HPLCand,14,14fmonographof,80-82pharmacologicresearchand,81

Bacteriaherbalcreamsand,46neemleafand,340thymeand,432

BaicalskullcapChinesemedicineand,83HPLCtraceand,15fmonographof,83-85oraldosingof,84pharmacologicresearchand,83-84

BaltimoreCancerResearchCentertrial,lapacholand,368

Baptisia

clinicalresearchon,87monographof,86-87pharmacologicresearchon,87thujaand,428westernherbalmedicineand,86-87

Barberryclinicalstudiesof,91monographof,88pharmacologicresearchand,90

Barberrybark,constituentsof,90

Barbituates,euphorbiaand,200

Baroreflexcontrolofheartrate(BRC),kavaand,294

Benignprostatichyperplasia(BPH)backgroundof,32-33couchgrassand,162nettlerootand,346,348sawpalmettoand,346,348,400treatmentstrategyfor,33

Benzodiazepines(Alprazolam)hopsand,279kavaand,291,295lavenderand,306limeflowersoiland,319

passionflowerand,363valerianextractand,450

Benzo(a)pyrene,schisandraand,406

Benzydamine,escinand,283

Berberinebarberrybarkand,90geraniumleafextractand,90goldensealand,250,251,252Helicobacterpyloriand,253HPLCtraceand,15foregongraperoot,358

Berberinechloridesulfamethoxazoletrimethoprimvs,92tetracyclinevs,92

Berberinesaltsolution,cutaneousleishmaniasisand,92

Betahistine,ginkgobilobaand,237

Bilberryclinicalstudiesof,94-95monographof,93-95

Bileandrographolideand,67deglycyrrhinizedlicoriceand,314

gentianand,224greatercelandineand,261wormwoodand,469

Bileducts,dandelionand,173

Bilesynthesis,tumericand,437

Biliarycholesterolconcentration,silymarinand,328

Biliarydyskinesia,greatercelandineand,261

Biliaryfistula,globeartichokeand,240

Biliaryfunction,rosemaryand,389

Biliousdyspepsia,greatercelandineand,262

Bilirubinberberineand,252silymarinand,328

Bioactivation,schisandraand,406

BiochaninA,redcloverand,384

Bipolardisorder,St.John’swortand,423

Birthfenugreekand,213lavenderand,306schisandraand,407

Bitters

digestivetractand,43wormwoodand,470

Blackcohoshclinicalstudiesof,97estrogenicactivityand,97monographof,96-98osteoarthritis(OA)and,41,42tSt.John’swortand,426

Blackhawhypotensiveeffectsof,101monographof,100-102pharmacologicresearchon,101-102

Blacktea,limeflowersand,318

Bladdercrampbarkand,164crataevaand,168hydrangeaand,287

Bladderstones,crataevaand,168

Bladderwrack(Kelp)herbcompatibilityand,23monographof,103-105osteoarthritis(OA)and,41,42tsideeffectsof,103-104

thyroxineand,103weightlossand,105

Bladderwrackthallus,pharmacologicresearchand,104

Bleedingblackhawand,100fenugreekand,210gingerand,227raspberryleafand,381

Bleeding,uterine,tienchiginsengand,433

Blooddongquaiand,183myrrhand,336

Blood(loss),nettleleafand,343,344

Bloodglucose.SeeGlucose,blood

Bloodpressureblackhawand,101coleusand,157devil’sclawand,180eleutherococcusand,198hawthornand,272,273licoriceand,312oliveleafand,353,355

schisandraand,407

Bloodsupply,elecampaneand,194

Bloodtriglyceridelevels,aloeveraand,63

Bluecohoshmonographof,106-108pharmacologicresearchon,107-108sideeffectsof,106

Blueflagmonographof,109-110pharmacologicresearchon,110

B-lymphocytesalbiziaand,59koreanginsengand,299

Boilsburdockand,118echinaceaand,185

Boldo,cascaraand,127

Bonemarrowacemannanand,62dongquaiand,183

Botanicalnames,monographand,49

Bowel,dongquaiand,183

Bradycardia,jamaicadogwoodand,289

Bradykinin,thymeand,432

Brahmi,qualityproblemsand,13

Brahmioil,bacopaand,80

Brahmirasayan,inflammationand,81

Brain,kavaand,293

Braininfarction,whitepeonyand,460

Brainischemia,whitepeonyand,460

Brazilianherbalmedicine,damianaand,171

BritishHerbalPharmacopoeia1983(BHP)doseinformationand,20-21extractsand,7grindeliaand,265

Bromhexine,thymoland,432

Bronchialhyperreactivity(BH),immunologicfunctionand,31

Bronchitisashwagandaand,73,74baicalskullcapand,84echinaceaand,185elecampanefor,193euphorbiaand,199

grindeliaand,265koreanginsengand,297licoriceand,312marshmallowand,321,322pleurisyrootand,374redcloverand,384therapeuticsand,29-30thymeand,431whitehorehoundand,456

Bronchitis,chronicgreatercelandineand,262mullenand,333

Bronchodilation,marshmallowand,322

Buchumonographof,111-112pharmacologicresearchand,111

Buerger’sdiseasedongquaiand,183hawthornand,270,271

BugleweedCommissionEand,114monographof,113-115westernherbalmedicineand,113-114

Buphenine,escinand,283

Bupleurumclinicalstudiesof,117intravenous,117monographfor,116-117pharmacologicresearchwith,116-117saikosaponinsin,117

Burberinebisulfate,thrombocytopeniaand,92

Burdockliverfunctionand,44monographof,118-119pharmacologicresearchon,119

Burnsaloeveraand,61,62calendulaand,120,122elderflowerand,191-192gotukolaand,254spinyjujubeand,418triterpenefractionofgotukola(TFGK)and,258

CCadmium,lupeolwith,170

Caffeicacid,vervainand,454

Caffeinecerebralbloodflowand,44koreanginsengand,297reactivehypoglycemia(dysglycemia)and,44-45

Caffeoylphenol,echinaceaproductsand,17t

Calciumoxalate,blackhawand,100

Calciumoxalateurolithiasismodel,couchgrassand,162-163

Calendula(Marigold)clinicalstudiesof,122-123fenneland,206healingand,38herpessimplexand,39monographof,120-123pharmacologicresearchon,121-122warningsandprecautionsabout,120

Calendulaflavonoids,calendulaand,121

Californiapoppyclinicalstudiesof,125-126

historyof,125monographof,124-126pharmacologicresearchand,125premenstrualsyndromeand,42

Cancer.SeealsoCarcinosarcoma;SeealsoMetastasis;SeealsoSmallcell

baicalskullcapand,83cleaversand,152eleutherococcusand,198hawthornand,272kavaand,296koreanginsengand,297,299liverfunctionand,44paud’Arcoand,367

Cancer,adjuvanttherapycat’sclawand,131codonopsisand,154,155echinaceaand,185eleutherococcusand,195paud’Arcoand,366

Cancer,breastblackcohoshand,96,98pokerootand,376

rosemaryand,391silybinand,327

Cancercells,sawpalmettoand,401

Cancer,cervicalkoreanginsengand,302oliveleafand,355

Cancer,colorectal,cascaraand,128

Cancer,lung,koreanginsengand,302

Cancer,uterine,pokerootand,376

Cancer,gastric,koreanginsengand,302

Candidaaloeveraand,62goldenrodand,247kavaand,293koreanginsengand,299myrrhand,336uvaursiand,445

Capsules,tasteofherballiquidand,4

Caraway,peppermintand,369

Carbenoxolone,licoriceand,315

Carcinogens,licoriceand,315

Carcinosarcoma,lapacholand,367

Cardiacarrythmias,hawthornand,270,273

Cardiaccatheterization,chamomileand,139

Cardiacdisorders,motherwortand,331

Cardiacglycosides,St.John’swortand,421

Cardiacinsufficiencyhawthornand,270jamaicadogwoodand,289passionflowerand,362

Cardiovasculardiseasebugleweedand,114globeartichokeand,240

Cardiovascularsymptoms,schisandraand,407

Carminativesdyspepsiaand,38rosemaryas,389

Carotenoids,chickweedand,147

Carrageenan-inducededema.SeeEdema,carrageenan-induced

Carraway,fenneland,206

Cascaraclinicalstudiesof,129-130gentianand,224,225

interactionswith,127monographof,127-130pharmacologicresearchand,129warningsandprecautionsfor,127

Catchexia,gentianand,225

Catechin,crampbark,165

Cat’sclawclinicalstudiesfor,132-133monographof,131-133pharmacologicresearchwith,132

Caulosaponin,bluecohoshand,108

Cedrusdeodora,berberineand,90

Celeryseedmonographof,134pharmacologicresearchof,134-135

Celeryseedoil,pharmacologicresearchof,134-135

Cellulitisgotukolaextractand,254,258triterpenefractionofgotukola(TFGK)and,257

Centralnervoussystemceleryseedoiland,135hopsand,277,278

jamaicadogwoodand,290kavaand,291oliveleafand,353valerianand,447

Cerebralbloodflowcoleusand,157ginkgobilobaand,235

Cerebraledema,horsechestnutand,283

Cerebralinsufficiency,ginkgobilobaand,232

Cervicaldysplasia,meadowsweetand,324

Cervicitis,astragalusand,77

Ceyenne,osteoarthritis(OA)and,41,42t

Chamomileclinicalstudiesof,139-140ethanoland,4healingand,38infantilecolicand,308monographof,137-141nettleleafand,343pharmacologicresearchof,139Swissstudyand,4topicalapplicationof,140

Chastetreemonographof,142-146perimenopausalwomenand,40pharmacologicresearchon,143-144premenstrualsyndromeand,42-43

Chelerythrinechloridecaliforniapoppyand,125greatercelandineand,262

Chelidonine,greatercelandineand,262

Chemotherapyastragalusand,78baicalskullcapand,84chamomileand,139rehmanniaand,387

Chernobylreactoraccident,ginkgobilobaand,237

Chickweedmonographon,147-148pharmacologicresearchand,147-148

Childbirth.SeeBirth

Childrenandrographisand,68ashwagandaand,73

baptisiaand,86berberineand,92bladderdisordersin,160californiapoppyand,124cascaraand,127chamomileand,137cornsilkand,160dosingand,22elecampaneand,193eleutherococcusand,198ethanoland,5gingerand,230goldensealand,252greatercelandineand,263herballiquiddoseand,3nettleleafand,343-344shatavariand,409,410St.John’swortand,425tylophoraand,37

Children,mentallydisabled,gotukolaand,258

Chineseherbs,stephania(Stephaniatetrandra)and,16

Chinesemedicineandrographisand,66

arnicaand,71astragalusand,77-78baicalskullcapand,83bupleurumin,116-117codonopsisand,154dongquaiand,183dosagesin,20,20teleutherococcusand,196gingerand,228koreanginsengand,298licoriceand,314prescribingforindividualpatientin,27rehmanniaand,386-387

useofuncured,387schisandraand,405-406spinyjujubeand,417tienchiginsengand,433tumericand,437whitepeonyand,458-459

Chlordiazepoxide,passionflowerand,363

Chloroform,horsetailand,286

Chlorpromazinebacopavs,81

passionflowerand,364

Cholagogiceffects,globeartichokeand,242

Cholangitis,greatercelandineand,261

Cholecystitisdandelionrootand,174fringetreeand,222greatercelandineand,262wildyamand,464

Cholelithiasis.SeeGallstones(cholelithiasis)

Cholereticeffects,globeartichokeand,242

Cholereticherbs,liverfunctionand,44,44t

Cholesterolalbiziaand,59ashwagandaand,75diosgeninand,466dongquaiand,183fenugreekand,213globeartichokeand,241koreanginsengand,297neemleafand,339tienchiginsengand,433

Cholinergicactivity,whitepeonyand,459

Cholinesteraseinhibitors,ginkgobilobaand,235

Choreablackcohoshand,97motherwortand,331

Chromatographytechnique,verticalcapillarydynamolysisand,8

Chronicfatiguesyndrome(CFS)backgroundof,33licoriceand,316treatmentstrategyfor,33

Chronicvenousinsufficiencyamicaand,70horsechestnutand,281,284studyof,72triterpenefractionofgotukola(TFGK)and,257

Cichoricacid,Echinaceapurpureaand,7

Cigarettes,oatsand,350,351

Cimetidine,duodenalulcersand,315

Cinnamaldehyde,150

Cinnamomumcassia,fibroidsand,458

Cinnamonmonographof,149-151

pharmacologicresearchof,150

Circulatorystimulant,rosemaryas,389

Cirrohosisdongquaiand,182silymarinand,328

Cisapride,peppermintand,371

Cisplatin,silybinand,327

Citrataoil,neemleafand,338

Citrusextract,glycosidedaidzinand,9

Clark’srule,dosingand,22

Cleavers,monographof,152-153

Clinicalstudiesalbiziaand,60andrographisand,66arnicaand,71ashwagandaand,75astragalusand,78-79bacopaand,81baptisiaand,87barberryand,91berberineand,91bilberryand,94-95

blackcohoshand,97-98bladderwrackand,105bugleweedand,114-115bupleurum,117caffeineand,44-45californiapoppyand,125-126cascarain,129-130chamomileand,139-140chamomile(Matricariachamomilla)and,4childrenand,5cornsilkand,161crataevaand,169echinaceaand,188-190eczemaand,37elecampaneand,194eleutherococcusand,197-198euphorbiain,199-200fenneland,208feverfewleafand,220-221forskolinand,158gentiantincturein,225gingerand,229globeartichokeand,241goat’srueand,244

goldensealand,252hawthornand,272-274koreanginsengand,300lavenderand,305-307levelofevidencecodeand,53mistletoeand,330motherwortand,332nettleleafand,344-345nettlerootin,347-348oatsand,350-351oliveleafand,355oregongrapeand,358-359passionflowerand,364paud’Arcoand,368peppermintand,369-372pokerootand,377-378pricklyashand,380raspberryleafand,382-383redcloverand,384rehmanniaand,386,387-388sageand,395sarsaparillaand,399schisandraand,407shatavariand,411-412

thujaand,429-430tienchiginsengand,434traditionalprescribingand,54-55tylophoraand,442valerianand,449-452vervainand,454-455viburnumprunifoliumbarkand,4whitepeonyand,460-461wildyamand,466-467yarrowand,473

Clinicalstudies,Chinesemotherwortand,332spinyjujubeand,417vervainand,454

Clinicalstudies,cystitis,dandelionand,176

Clinicalstudies,German,valepotriatesand,449

Clinicalstudies,Polish,nettleleafand,344

Clinicalstudies,Russian,eleutherococcusand,195

Clinicalstudies,Swiss,valerianextractand,450

Clinicalstudy,HarvardMedicalschool,paud’Arcoand,368

Clinicalstudy,saliva,diosgeninand,466

Clofibrate,tumericvs,438

Clonidine,passionflowerand,364

Cnidiumofficinalerhizomebraininfarctionand,460spineyjujubeand,417

Coagulationdruginteractionswith,210paud’Arcoand,366shepherd’spurseand,413

CochraneReviewSt.John’swortand,423vomitinginpregnancyand,229

Codeinelicoriceand,315shatavariand,411

Codonopsismonographof,154-155pharmacologicresearchof,155

Cognitionbacopaand,82ginkgobilobaand,232,235-236

Cognitiveperformance,kavaand,295

Cold.SeeCommoncold

Coleusmonographof,156-159pharmacologicresearchon,157

Colicchamomileand,137,139lemonbalmand,310thymeand,431vervainand,453,454

Colitisbarberryand,90dandelionand,175fenneland,208

Collagen,bilberryand,94

CollegeofPhytotherapyintheUnitedKingdom,prescriptionrecordsand,23

Colonoscopy,peppermintand,371-372

Commiphoricacids,myrrhand,336

CommissionEaqueousextractofelderand,192arnica(gel)and,72bilberryand,95blackcohoshand,98bugleweedand,114

calendula(Marigold)and,121-122chamomile,140chastetreeand,146cinnamonand,150commoncoldand,319couchgrassand,162,163dandelionand,176devil’sclawand,178,180eleutherococcusand,198escinand,283fenneland,208fenugreekand,211gentianand,226gingerand,227,231ginkgobilobaand,237globeartichokeand,240,242goldenrodand,247greatercelandineand,264hawthornand,274hopsand,279horsechestnutand,281horsetailand,286kavaand,291,292,296koreanginsengand,302

lavenderand,307lemonbalmand,310licoriceand,312,317marshmallowand,322motherwortand,332myrrhand,337nettleleafand,345nettlerootand,346,348passionflowerand,364peppermintand,372rosemaryessentialoiland,392sageand,395sarsaparillaand,397sawpalmettoand,403shepherd’spurseand,414silymarinand,328St.John’swortand,426thymeand,432tumericand,436uvaursiand,445valerianextractand,452whitehorehoundand,456yarrowvs,473

Commoncoldandrographisand,65astragalusand,77backgroundof,34baptisiaand,86bupleurumand,116cinnamonand,149elderflowerand,191,192elecampanefor,193eyebrightand,202lemonbalmand,308limeflowersand,318mullenand,333peppermintand,369pleurisyrootand,374thymeand,431treatmentstrategyfor,34-35wildcherryand,462

Commonnames,monographand,49

Compositaefamily,193feverfewand,219

Compressiontherapy,horsechestnutand,282,283

Concentration,bacopaand,80

Conception,Ayurvedicmedicineand,74

Condylomas,greatercelandineand,263

Congestivecardiomyopathy,forskolinand,158

Congestiveheartdisease,coleusand,156

Congestiveheartfailurekoreanginsengand,297licoriceand,313redginsengand,301

Congestiveheartfailure,neonatal,bluecohosh,106

Conjunctivitiseyebrightand,202raspberryleafand,381

Constipationblueflagand,109cascaraand,127,128chickweedand,147damianaand,171dongquaiand,182yellowdockand,474

Constrictiveaortitis,dongquaiand,183

Contactallergy,dandelionand,173

Contactdermatitis

chamomileand,138feverfewand,219gotukolaand,255thymeoiland,431yarrowand,471

Contacttime,herbalpreparationsand,3-4

Contractions(uterine),raspberryleafand,382

Contraindications,herbaltherapyand,53

Contusions,horsechestnutand,281

Convulsions,crampbarkand,164

Cornsilkclinicalstudieson,161monographof,160-161westernherbalmedicineand,160-161

Coronaryarterydisease(CAD)codonopsisand,154gingerand,231motherwortand,331

Coronaryatherosclerosis,dongquaiand,183

Coronarybloodflowhawthornand,271-272oliveleafand,353

tienchiginsengand,433

Coronarybloodvessels,tienchiginsengand,434

Corpuslutealinsufficiency,chastetreeand,142

Corticosteroidslicoriceand,312rehmanniaand,386

Corticosterone,saikosaponinsand,117

Corticosteronelevels,gotukolaand,256

Cortisol,rehmanniaand,387

Cortisone,licoriceand,315

Cortisonetherapy,bilberryand,95

Corydaliscava,californiapoppyand,124,126

Cotrimoxazole,andrographisand,69

Couchgrassmonographof,162-163westernherbalmedicineand,162-163

Coughbugleweedand,114elecampaneand,193grindeliaand,265marshmallowand,321schisandraand,405

thymeand,431

Cough,chronic,codonopsisand,154

Coumarindruginteractionswith,210fenugreekand,212

Coumarinsscopoletin,crampbarkand,165

CoxsackieBviralmyocarditis,astragalusand,78

Crampbarkblackhawvs,165intravenousinfusionof,165monographof,164-165prostateand,33

Crampscrampbarkand,164pricklyashand,379

Cranesbill,monographof,166-167

CrataevaAyurvedicmedicineand,168bladderand,33clinicalstudieswith,169lupeoland,169monographof,168-170

pharmacologicalresearchon,168-169

Creatinine,gymnemaand,268

Curcumaaromaticarhizome,cascaraand,129

Curcuminantioxidantactivityof,437antiplateletactivityof,437oraldosesof,437tumericand,437

Cutaneousleishmaniasisberberinesaltsolutionand,92berberinevs,253

Cyclophosphamidegreatercelandineand,263myrrhand,337rehmanniaand,387

Cyclosporine,St.John’swortand,420,421

Cynarin,globeartichokeand,241

Cystichyperplasia,chastetreeand,142,144

Cystitisbuchuand,111cat’sclawand,131cleaversand,152

cornsilkand,160dandelionand,173horsetailand,285hydrangeaand,287marshmallowand,321,322sawpalmettoand,400uvaursiand,444,445

Cystitisstudy,dandelionand,176

CytochromeP-450,fenugreekand,213

Cytokinesnettleleafand,344shatavariand,411

Cytosolicandrogenreceptors,nettlerootand,347

Cytotoxicactivity,berberineand,91

Cytotoxicdrugs,eleutherococcusand,196

DDaidzin,citrusextractand,9

Damianamonographof,171-172pharmacologicresearchwith,171

Dandelioncontraindicationsfor,173monographof,173-176

Dandelionleafosteoarthritisand,41,42tpharmacologicresearchon,174

Dandelionrootdiureticeffectsof,174-175fenneland,208pharmalogicalresearchon,174

Deepveinthrombosis,horsechestnutand,281,283

Dementia,ashwagandaand,73

Deoxyandrographolide,HPLCtraceand,16f

Deoxypodophyllotoxin,thujaand,429

Depressionbackgroundfor,35

damianaand,171hopsand,277kavaand,291lavenderand,305lemonbalmand,308skullcapand,415St.John’swortand,420,423treatmentstrategyfor,35,36tvalerianand,447vervainand,453

Depurative(s)burdockand,118eczemaand,37redcloveras,384

Dermatitisaloeveraand,61arnicaand,70globeartichokeand,240kavaand,291

Dermatomyositis,thymoland,432

Desipramine,valerianextractvs,451

Devil’sclawmonographfor,178

pharmacologicresearch,179-180qualityproblemsand,13

Dexmethasonemarshmallowand,322rehmanniaand,387tylophorinevs,441

DHEA(dehydroepiandrosterone),wildyamand,467

DHEA(dehydroepiandrosterone)ratio,koreanginsengand,300

Diabetes,adjuvanttherapy,goldensealand,250

Diabetesmellitusaloeveraand,63ashwagandaand,73,75barberryand,88berberineand,92dandelionand,175fenugreekand,210,212,213goat’srueand,243gymnemaand,267,269koreanginsengand,297myrrhand,336neemleafand,338redginsengand,302

silymarinand,328

Diabetesmellitus(non-insulindependent),aloeveraand,61

Diabeticmicroangiopathy,gotukolaand,254

Diaphoresiselderflowerand,191,192pleurisyrootand,374

Diaphoreticherbs,acutebronchitisand,29

Diarrheaastragalusand,77barberryand,88,89berberineand,90,251cascaraand,128cat’sclawand,131chamomileand,137,139cinnamonand,149cranesbilland,166fenneland,208gentianand,224goldensealand,250meadowsweetand,324nettleleafand,343-344,344pleurisyrootand,374raspberryleafand,381

rehmanniaand,386shatavariand,409shepherd’spurseand,413thymeand,431whitepeonyand,459yarrowand,471

Diarylheptanoids,tumericand,437

Diazepamneemleafand,339passionflowerand,363suanzaorentangvs,418valerianextractand,450,451

Diazoxide,tylophorinevs,441

Dibenzocyclooctenelignans,schisandraand,406

Dicoumarol,druginteractionswith,210

Dietallergicrhinitisand,30licoriceand,312osteoarthritis(OA)and,40-41reactivehypoglycemia(Dysglycemia)and,45

Digestion,eczema(atopicdermatitis)and,36-37

Digestivedisorders

bilberryand,94lavenderand,305

Digestivetractbackgroundon,43treatmentstrategyfor,43

Digitalisglycosides,hawthornand,270

Digoxinhawthornand,272St.John’swortand,420

Dihydrotesterone(DHT)agingand,32-33dosagesand,33t

Diosgenincholesteroland,466hypercholesterolemiaand,466intestinalinflammationand,466oraladministrationof,466progesteroneand,466wildyamand,464

Disodiumcromoglycate,tylophoravs,441

Diterpeneforskolin,coleusand,157

Diterpenemarrubiin,whitehorehoundand,456

Diuresisfenneland,207globeartichokeand,241goldenrodand,246sarsaparillaand,397

Diureticcornsilkas,160,161dandelionrootas,174,175shepherd’spurseas,413

Diureticactivitybuchuand,111cleaversand,152goat’srueand,243horsetailand,286rosemaryand,391

Diureticherbs,premenstrualsyndromeand,42-43

Diverticulitis,wildyamand,464

DNA,rosemaryand,391

Dongquaidysmenorrheaand,182pharmacologicresearchand,182,183

Dopamine

kavaand,291St.John’swortand,423

Dopaminereceptorantagonistschastetreeand,142kavaand,291

Dosage,extract,comparisionof,21,21t

Dosing,54approachesto,19-20

reviewof,20baptisiaand,87bilberryand,93,94blackcohoshand,96childrenand,22comparing,22informationsummaryon,22preparingformulationaccordingto,28-29

Dosing,normal,24

Dosing,oralashwagandaand,74baicalskullcap,84berberineand,91tienchiginsengand,434

Doxorubicin,silybinand,327

Doxycycline,thujaand,430

Dragon’sblood,synergyand,10

Dropnumbers,dosagebasedondroppersize,19t

Drugtreatment(psychotropic),silymarinand,328

Druguse,oatsand,349

Drugsbarberryand,88-89coleusand,156gingerand,227hawthornand,270kavavs,294marshmallowrootand,321

Drugs,anticoagulant,tumericand,436

Drugs,antiplateletbilberryand,93ginkgobilobaand,232

Drugs,coagulant,eleutherococcusand,197

Drugs,corticosteroid,licoriceand,313

Drugs,immunosuppresive,echinaceaand,185

Drugs,narcotic,koreanginsengand,299

Drugs,neuroleptic,lavenderand,306

Duodenitis,fringetreeand,222

Dysentery,cranesbilland,166

Dysmenorrheablackcohoshand,96blackhawand,100-101bluecohoshand,106calendula(Marigold)and,120chamomileand,137crampbarkand,164dongquaiand,182falseunicornand,204gingerand,227jamaicadogwoodand,289licoriceand,316motherwortand,331pasqueflowerand,360peppermintand,369wildyamand,464

Dyspepsiacascaraand,127devil’sclawand,178,180elecampaneand,193fenneland,208

fenugreekand,210globeartichokeand,240hopsand,277meadowsweetand,324milkthistleand,326peppermintand,206,371tumericand,436,438whitehorehoundand,456wormwoodand,206,469,470

Dyspepsia,nonulcer,peppermintand,369

Dyspepticdisorders,yarrowand,473

Dyspnea,hawthornand,273

Dysuriabuchuand,111liposterolicextract(LESP)and,403

EE.Coli

berberineand,91goldenrodand,247meadowsweetand,325myrrhand,336rosemaryoiland,391St.John’swortand,423uvaursiand,445yarrowand,472

Echinaceaclinicalstudiesof,188-190dosingof,185monographof,185-190pharmacologicresearchand,187-188pregnancyand,185speciesof,186

Echinaceaangustifoliarooteclecticphysiciansuseof,186edemastudyand,187polyacetylenesand,187teaof,190

Echinaceapallida,studiesof,188

Echinaceaproductsalkylamidelevelsin,17tcaffeoylphenollevelsin,17t

Echinaceapurpureacichoricacidand,7Dr.GerhardMadausand,187

Echinaceapurpurearootspolyacetylenesand,187teaof,190

Echinacearoot,34acutebronchitisand,29baptisiaand,86,87eczema(atopicdermatitis)and,37

EclecticMateriaMedica,pleurisyrootand,374

Eclecticmedicinecomparisionofdosagesusedby,21toverviewof,20

Eclecticphysiciansechinaceaand,186echinaceaangustifoliarootand,186St.John’swortand,422

Eczema(atopicdermatitis)albiziafor,59arnicaand,70backgroundof,36biochemicalabnormalitiesand,36burdockand,118casehistoriesof,37-38chamomile,140chickweedand,147echinaceaand,185familyhistoryand,36gotukolaand,255licoriceand,312neemleafand,338nettleleafand,343treatmentfor,37ttreatmentstrategyfor,37

Edemaamicaand,70astragalusand,78couchgrassand,162dandelionand,173escinand,283

eyebrightand,203goldenrodand,247horsechestnutand,281,282horsetailand,285licoriceand,313oliveleafand,353rehmanniaand,386shatavariand,411triterpenefractionofgotukola(TFGK)and,257

Edema,carrageenan-induced,feverfewleafand,220

Edemastudy,echinaceaangustifoliarootsand,188

Elderflower,35insulin-releasingactivityin,191,192monographof,191-192

Elderlycascaraand,130kavaand,291koreanginsengand,297

Elecampaneclinicalstudiesof,194extractfrom,194monographfor,193-194pharmacologicresearchon,194

rootof,194

Electroencephalographic(EEG)recordingcaliforniapoppyand,125-126valerianextractand,450

Electrolytebalance,cascaraand,127

Electrolytes,licoriceand,315

Eleutherococcusclinicalstudieson,197-198maleimpotenceand,39-40monographof,195-198pharmacologicresearchof,196

EleutherosideE,dosingofeleutherococcusand,196

Ellagitannins,raspberryleafand,381

Emmenagogue,neemleafand,339

Emphysema,euphorbiaand,199

Enema,greatercelandineand,261

Entericinfections,andrographisand,65

Enteritismarshmallowand,321peppermintand,369

Enterobacteraerogenes,uvaursiand,445

Enuresis,schisandraand,405

Environmentalstress,eleutherococcusand,195

Enzymaticactivity,freshplanttincuresand,7

Enzymelevels,schisandraand,406

Eosinophil,tylophoraand,443

Epidermalcarcinoma,berberineand,91

Epidermophytonfloccosum,Smilaxregeliirootand,398

Epididymitis,pasqueflowerand,360

Epilepsybacopaand,80brahmioiland,80kavaand,293,296mistletoeand,330skullcapand,415thujaand,428valerianand,447vervainand,453

Epinephrineberberineand,252neemleafand,339

Epithelialcells,nettlerootand,347

Epstein-Barrvirus(EBV),T.avellanedaeand,368

Erectiledysfunction,redginsengand,302

Erythrocytes,thujaand,429

Escin,horsechestnutand,282,283

ESCOP(EuropeanScientificCooperativeonPhytotherapy)adjuvanttherapyand,176arnicaand,72chronicvenousinsufficiencyand,281,284echinaceapurpurearootsrecommendedby,190fenneland,208gingerand,231goldenrodand,247lemonbalmand,310marshmallowand,322nettleleafand,345nettlerootand,348passionflowerand,364peppermintand,372rosemaryessentialoiland,392sageand,395St.John’swortand,426thymeand,432valerianextractand,452

Esophagealmucocilliarytransport,marshmallowand,322

Essentialoils,4limeflowersand,319

Estersaponins,goldenrodand,247

Estradiol,agingand,32

Estrogencat’sclawand,132chastetreeand,143coleusand,157menopauseand,40rosemaryand,391shatavariand,410wildyamand,464

Estrogenreceptors,pharmacologicresearchand,205

Estrogenicactivity,redcloverand,384

Estrogeniceffects,wildyamand,464

Estrogenicflavonoidderivatives,hopsand,277

Ethanol,9freshplanttincuresand,7glyceroland,5guidelinesforpercentagesof,4herballiquidpreparationsand,4myrrhand,336

pregnancyand,5

Ethanolextract,fenugreekand,213

Eudesmanolides,elecampaneand,194

Euphorbiaclinicalstudieson,199-200monographof,199-201pharmacologicalresearchon,199wholeplantextractsof,200

Europeanherbalmedicinebugleweedand,114willowherband,468

EuropeanScientificCooperativeonPhytotherapy(ESCOP).SeeESCOP(EuropeanScientificCooperativeonPhytotherapy)

Eveningprimrose,38eczemaand,36

Evidencecode,51

Exophthalmia,bugleweedand,113

Expectorant,whitehorehoundas,456

Expectorantherbs,acutebronchitisand,29-30

Extemporaneousdispensing,3

Extractdosages.SeeDosage,extract

Eyebath,makingof,47

Eyebrightmonographof,202-203pharmacologicresearchand,203

Eyeschickweedand,147elderflowerand,191-192eyebrightand,202

FFalseunicorn

monographof,204-205pharmacologicresearchand,205

Fatigue,codonopsisand,154

Femininedouche,makingof,47

Fennelcarrawayand,206clinicalstudiesand,208infantilecolicand,308,310inhalationof,208liquidherbalformulaincluding,208monographof,206-208peppermintand,206,369pharmacologicresearchon,206wormwoodand,206

Fennel,essentialoilof,207

Fennel,ethanolextractof,207

Fenugreekdruginteractionswith,210hypoglycemicactivityof,215t

hypolipidemicactivityof,216tmonographof,210-218pharmacologicresearchon,212-214sideeffectsof,211topicaltreatmentwith,211

Fenugreek(leaf),212

Fenugreek(seed),212warfarinand,210

Fertilityindex,neemleafand,340

Feverandrographisand,65baicalskullcapand,83barberryand,90bupleurumand,117gingerand,227hemidesmusand,275lemonbalmand,308meadowsweetand,324neemleafand,340pleurisyrootand,374rehmanniaand,386thymeand,431yarrowand,471

Fever,postpartum,astragalusand,77

Feverfewclinicalstudiesof,220-221monographof,219-221pharmacologicresearchof,220sideeffectsof,219

Fibrinogen,ginkgobilobaand,237

Fibroids,whitepeonyand,458,460

Fibrosis,lung,shatavariand,411

Fijanmedicine,neemleafas,339

Filariasiskavaand,293neemleafand,339

Finasteride,liposterolicextract(LESP)and,402,403

5-α-reductase,nettlerootand,346

Flameionizationdetection(FID),gaschromatographyand,13

Flatulencechamomileand,137gentianand,224thymeand,431whitehorehoundand,456

Flatulentdyspepsia,lavenderand,305

Flavanolignans,milkthistleand,326

Flavonoidsblackhawand,101chastetreeand,143-144chickweedand,147crataevaand,168hawthornand,271licoriceand,314limeflowersand,319oliveleafand,354passionflowerand,363raspberryleafand,381rosemaryand,390St.John’swortand,423

Fluidbalance,cascaraand,127

Fluidretention,oliveleafand,352

Fluoxetine,St.John’swortand,424

Foodpreservative,rosemaryas,390

Foot,thujaand,428

Formononetin,redcloverand,384

Forskolin

clinicalstudiesof,158coleusand,156

Fossilizedmammaliantooth,whitepeonyand,458

4-Hydroxysioleucine,fenugreekand,213

Fragarine,raspberryleafand,382

Freeradicalspaud’Arcoand,366rosemaryand,390

Free-radicalscavenging,burdockand,118

Freshplanttincures.SeePlanttincures,fresh

Freshweightratio,vsfreshplanttincture,8f

Frigidity,damianaand,171

Fringetreeliverfunctionand,44monographof,222-223

FSH(follicle-stimulatinghormone)agingand,32coleusand,157

Fumaricacid,shepherd’spurseand,413

Fungalinfections,thujaand,428

Fungalspecies,greatercelandineand,263

Fungikavaand,293lavenderand,305neemleafand,340

Furanonaphthoquinones,tabebuiaimpetiginosabarkand,367

Furunculosisarnicaand,70echinaceaand,185

Fusariumstrains,greatercelandineand,263

GGABAreceptor-complex,limeflowersand,319

Galenicalextracts,12synergyand,9-10

Gallbladderbarberryand,89blueflagand,109fringetreeand,222gentianand,224globeartichokeand,240milkthistleand,326rosemaryoiland,391

Gallotannins,raspberryleafand,381

Gallstones(cholelithiasis)barberryand,89fringetreeand,222globeartichokeand,240greatercelandineand,261-262ursodeoxycholicacid(UDCA)and,372

Gaschromatography(GC),overviewof,13

Gastricacid,gentianand,225

Gastricmucosa,glyceroland,5

Gastricreflux,peppermintand,371

Gastriculcer.SeeUlcers,gastric

Gastriculcerogenesis,neemleafand,339

Gastritisbarberryand,88cat’sclawand,131fenugreekand,210peppermintand,369thymeand,431

Gastroesophagealreflux(GER)backgroundof,38herbaltreatmentfor,38,38tlicoriceand,312practicalmeasurestakenfor,38

Gastrointestinaldisorders,fringetreeand,222

Gastrointestinalinflammationfenugreekand,210pokerootand,376

Gastrointestinalprotozoalinfections,euphorbiaand,199

Gastrointestinalsmoothmuscle,peppermintand,370

Gastrointestinalspasm

chamomileand,137wildyamand,464yarrowand,471

Gastrointestinalsystemaloeveraand,62chamomile,140chamomileand,137mullenand,333

Gastroparesis,shatavariand,411

GBE(ginkgobilobaleafstandardizedextract),phytochemicalsand,11

GC-MS(gaschromatographywithmassspectometrydetection),traceand,13

Gel,herbsand,17

Genistein,redcloverand,384

Genitalherpes,aloeveraand,61,63

Genitian,cascaraand,127

Genitourinarytractbuchuand,111hemidesmusand,275kavaand,291meadowsweetand,324

sawpalmettoand,400

Genotoxicagents,koreanginsengand,299

Gensing,codonopsisand,154

Gentian,monographfor,224

Gentian,extractbroncosecretionand,225studyof,225

Gentiantincture,225clinicalstudiesof,225

Geraniumleafextract,berberineand,251

GermanHomoeopathicPharmacopeia(HAB)extractsand,7goldenrodand,247

Germander(Teucriumchamaedrys),skullcapand,14

Gestationbluecohoshand,106echinaceaand,185raspberryleafand,382

Giardiasisbarberryand,88goldensealand,250

Ginger

Alpiniagalangaand,230clinicalstudieswith,229monographof,227-231oraladministrationof,228,229pharmacologicresearchon,228-229

Ginkgobiloba.SeeGBE(ginkgobilobaleafstandardizedextract)

monographof,232-239pharmacologicresearchusing,233-234sideeffectsof,233spontaneousbleedingand,233

Ginkgolides,oraladministrationof,233

Ginsengabusesyndrome,eleutherococcusand,195

Ginsenosides,koreanginsengand,298

Glaucomabilberryand,93coleusand,156

Glibenclamide,neemleafand,339

Globeartichokeclinicalstudiesand,241monographof,240-242pharmacologicresearchon,241prophylactictreatmentwith,242

Glucose,bloodaloeveraand,63codonopsisand,155coleusand,157fenugreekand,213neemleafand,339peppermintand,370saikosaponinsand,117tienchiginsengand,434

Glucoselevels,rosemaryoiland,391

Glucosetolerance,myrrhand,336

β-glucosidase,eyebrightand,203

Glucosinolates,crataevaand,168

Glutamicoxaloacetictransminase(GOT),schisandraand,406

Glutamicpyuvictransaminase(GPT),schisandraand,406

Glutathioneperoxidase,saikosaponinsand,117

Glutathioneregeneration,schisandraand,406

Glycerol,5solventsand,4

Glycerol-waterpreparations,herbsolubilityand,5

Glycetracts,waterand,4

Glycogen

eleutherococcusand,197schisandraand,406

Glycosaminoglycansynthesis,gotukolaand,256

Glycosideshawthornand,273horsetailand,285

Glycyrrhizin(GL)licoriceand,312oralapplicationof,312

Glyke,HIVand,316

Goat’srueclinicalstudiesof,244monographof,243-244oraladministrationof,244pharmacologicresearchof,243-244

Goldenrodcontraindicationsfor,246Fraxinusexcelsiorand,247,248monographof,246-249pharmacologicresearchon,247Populustremulaand,247,248

Goldenseal

clinicalstudiesand,252HPLCtraceand,15fmonographfor,250-253pharmacologicresearchon,251-252

Goldensealroot(Hydrastiscanadensis),qualityproblemsand,13-14

Goldenthread(Coptischinensis)goldensealrootand,13-14HPLCtraceand,15f

GonadalRNA,schisandraand,406

Gonorrheacornsilkand,160-161echinaceaangustifoliarootand,186

Gonorrhealurethritis,horsetailand,285

Goodmanufacturingpractice(GMP),herbsand,10

GOT.SeeGlutamicoxaloacetictransminase(GOT)

Gotukolaclinicalstudiesof,256-258healingand,38monographfor,254-259oraladministrationof,256pharmacologicresearchon,255-256

Goutceleryseedand,134couchgrassand,162oliveleafand,352

Gram-positivebacteria,greatercelandineand,263

Gravelroot(Eupatoriumpurpureum),dosagesand,21

Gravesdisease.SeeHyperthyroidism(Gravesdisease)

Greatercelandine(cheidonium)clinicalstudiesof,263-264monographof,261-264oraladministrationof,262pharmacologicresearchon,262-263sideeffectsof,261-262

Greenoatplantjuice,350

Grindeliamonographof,265-266pharmacologicalresearchon,266

Gymnemadosageof,267foodsand,267monographof,267-269oraluseof,267

pharmacologicresearchon,268

Gynecomastia,dongquaiand,182

HHair,brahmioiland,80

HamiltonDepressionScale(HAM-D),St.John’swortand,424

Harmanealkaloids,passionflowerand,363

Harpagoside,devil’sclawand,179

Hawthornclinicalstudiesand,272-274dosageof,271monographof,270-274pharmacologicresearchon,270-271sideeffectsof,270

Hawthornberrymaleimpotenceand,40varicoseveins(VV),45-46

Hawthornleaf,passionflowerand,364

Hayfever,elderflowerand,191,192

Headacheblackcohoshand,96blueflagand,109brahmioiland,80

dongquaiand,183gentianand,224greatercelandineand,261hopsand,277kavaand,291limeflowersand,318peppermintand,369rosemaryand,389skullcapand,415valerianand,448

Headaches,migrainefeverfewand,219,221greatercelandineand,261

Healingcream,makingof,47

Healingresponse,gotukolaand,254

Hearingloss,ginkgobilobaand,232

Heartcoleusand,157hawthornand,270

Heartfailure,hawthornand,273

Heartfunction,tienchiginsengand,434

Heartmuscle,dongquaiand,183

Heartratecrampbarkand,165hawthornand,270kavaand,294koreanginsengand,300passionflowerand,364schisandraand,406,407

Heartratevariabilitly(HRV),hawthornand,273

Heartburn,meadowsweetand,324

Helicobacterpyloriberberineand,91,253oliveleafand,355thymeand,432

Hematemesisshepherd’spurseand,413tienchiginsengand,433

Hematomasamicaand,70horsechestnutand,281

Hematuriaandrographisand,69horsetailand,285shepherd’spurseand,413

tienchiginsengand,433

Hemeralopia,bilberryand,93

Hemidesmus(Indiansarsaparilla),34monographof,275-276pharmacologicresearchof,275-276

Hemmorrhoids,bilberryand,95

Hemoglobinashwagandaand,73,75codonopsisand,154

Hemoptysistienchiginsengand,433yarrowand,471

Hemorrhage.SeealsoBleedinghorsetailand,285tienchiginsengand,433

Hemorrhagicdisorders,bilberryand,93

Hemorrhagicshock,tienchiginsengand,434

Hemorrhoidscalendula(Marigold)and,121chickweedand,147horsechestnutand,281pricklyashand,379,380

shepherd’spurseand,413yarrowand,471

Heparin,escinand,283

Hepataticenzymes,silymarinand,327

Hepaticdisease,fringetreeand,222

Hepaticdisorders,triterpenefractionofgotukola(TFGK)and,258

Hepaticfunction,dandelionand,173

Hepatitisastragalusand,78baicalskullcapand,83dongquaiand,182eyebrightand,203milkthistleand,326schisandraand,405,407

Hepatitis,infective,andrographisand,65

Hepatomainduction,shepherd’spurseand,413

Hepatotoxicityhemidesmusand,276kavaand,291schisandraand,406tumericand,438

Herbalcreams,makingof,46

Herbaldoses,8-9

Herballiquidpreparationsadvantagesof,3dilutionand,3dispensingproceduresfor,24dosageissuesfor,18factorsinpreparationof,4incompatibilitiesof,22-23labelingand,24methodsforqualitycontrolof,12-13qualityissuesfor,10-18stabilityissuesfor,16-17

Herballiquidproducts,qualityconsiderationsfor,11b

Herbaltherapyliquidpreparatonsand,3standardizedextractand,12synergyand,9

Herbaltreatment,goalsof,30

Herbalists,wholeextractsand,9

Herbslevelsofevidence,53

prescribinginformationand,50-51rawmaterialtestingfor,10b

Herpeslabialis,lemonbalmand,310

Herpessimplexvirusbackgroundof,39echinaceaand,187lapacholand,368lemonbalmand,308,310treatmentstrategyfor,39

Herpessimplexviruscream,making,46

Herpessimplexvirus,genital,St.John’swortand,420,425

Herpessimplexvirus,orofacial,St.John’swortand,420,425

Hiccup,blackhawand,100

Highperformanceliquidchromatography(HPLC).SeeHPLC(high-performanceliquidchromatography)

Hilitosis,thymeand,431

Histaminebaicalskullcap,84nettleleafand,344spinyjujubeand,418

HIV(humanimmunodeficiencyvirus)acemannanand,62,63

aloeveraand,61bladderwrackand,104cat’sclawand,131cinnamonand,150redginsengand,301St.John’swortand,421U.tomentosarootand,133

HLE.SeeHumanleukocyteelastase(HLE)

Hoelen,spinyjujubeand,417

Homeopathy,oatsand,350

Hopsclinicalstudieson,278-279monographof,277-280pharmacologicresearchon,278sleepdisturbancesand,308valerianand,447

Hopsextract,valerianextractand,450

Hormone,sex,sawpalmettoas,400

Horsechestnutclinicalstudiesof,282-284monographfor,281-284sideeffectsof,281

varicoseveins(VV)and,45-46

Horsetailclinicalstudiesof,286monographof,285-286pharmacologicresearchon,285-286

Hotflashes.SeeMenopausalhotflashes

HPLC(high-performanceliquidchromatography)ethanoland,5goldensealand,14gotukolaand,256herballiquidanalysisand,12-13traceofBacopaand,14,14f

HRV.SeeHeartratevariability(HRV)

Humanleukocyteelastase(HLE),nettlerootand,347

Hyaluronan,calendulaand,121

Hyaluronidase,horsechestnutand,282

Hydergine,cerebrovascularcirculationand,301

Hydrangea(Sevenbarks),monographof,287-288

Hydrastineberberineand,252goldensealand,14HPLCtraceand,15f

Hydroquinoneglycosides,uvaursiand,445

Hydroxycinnamicacid,horsetailand,285

Hydroxytyrosol,oliveleafand,353,354

Hyperacidity,meadowsweetand,324

Hyperactivity,pasqueflowerand,360

Hypercholesterolemiaalbiziafor,59ashwagandaand,73curcuminand,437diosgeninand,466gymnemaand,268tumericand,436,438whitepeonyand,459

Hyperforin,St.John’swortand,423

Hyperglycemiaeleutherococcusand,197gymnemaand,268neemleafand,339tienchiginsengand,434

Hypericinantitumoractivityand,423St.John’swortand,421,422

Hyperlipidemiaceleryseedand,135globeartichokeand,240

Hyperprolactinemiachastetreeand,142TJ-68and,461

Hypertensionbaicalskullcapand,83coleusand,156crampbarkand,164eleutherococcusand,195fringetreeand,222gymnemaand,268hawthornand,270koreanginsengand,297licoriceand,313limeflowersand,318mistletoeand,330oliveleafand,352,353rehmanniaand,386

Hypertensiveretinopathy,bilberryand,93

Hyperthyroidism(Gravesdisease)backgroundof,39

bugleweedand,113motherwortand,331treatmentstrategyfor,39,39t

Hypertrophicscars,triterpenefractionofgotukola(TFGK)and,257

Hypertrophy,mistletoeand,330

Hypertyraminemiabarberryand,88berberineand,253goldensealand,250

Hypocholesterolemia,tienchiginsengand,434

Hypocholesterolemicactivity,fenugreekand,213

Hypoglycemiadamiana,171gymnemaand,268

Hypoglycemicactivity,fenugreekand,215t

Hypokalemia,licoriceand,313

Hypokalemicrhabdomyolysis,licoriceand,313

Hypolipidemicactivity,fenugreekand,216t

Hypomania,St.John’swortand,422

Hypotension,rosemaryand,389

Hypothalamus,pharmacologicresearchand,205

Hypotonicbladder,crataevaand,168

Hypoxiaginkgobilobaand,232spinyjujubeand,418

IIbuprofen

deglycyrrhinizedlicorice(DGL)and,314yarrowvs,473

Idoxuridine,licoriceand,317

Imipramine,St.John’swortand,424

Immunefunctioneleutherococcusand,195koreanginsengand,297,300rehmanniaand,387,388

Immuneresponseastragalusand,77causativefactorsofcompromised,34echinaceaand,185,187eczema(atopicdermatitis)and,37neemleafand,339

Immunesystemaloeveraand,61astragalusand,77cat’sclawand,131eczema(atopicdermatitis)and,36

hemidesmusand,275

Immunity,shatavariand,411

ImmunoglobulinM(IgM),codonopsisand,155

Immunoregulaitonindex,baicalskullcapand,84

Immunosuppressionashwagandaand,74,75,76shatavariand,409

Impotencedamianaand,171koreanginsengand,297

Incontinencebuchuand,111crataevaand,168

Indianbarberry(Berberisaristata)goldensealroot(Hydrastiscanadensis)and,13-14monographof,88-92

Indianbarberryrootextract,pharmacologicresearchon,90-91

Indiangoldenseal(Hydrastismamira),goldensealroot(Hydrastiscanadensis)and,13-14

Indianvalerian(Valerianawallichii),valerian(Valerianaofficinalis)vs,16

Indigestionechinaceaangustifoliarootand,186hopsand,277

Indinavir,St.John’swortand,420

Indomethacin,myrrhand,336

Indonesianmedicine,andrographisand,66

Infantilecolic,fenneland,206,208

Infection,bacterial,eleutherococcusand,197

Infectionsandrographisand,66cat’sclawand,131echinaceaand,185eczema(atopicdermatitis)and,36goat’srueand,243neemleafand,338sageand,394shatavariand,409

Infertilityblackcohoshand,96dioscoreajaponicaand,465dongquaiand,183falseunicornand,204

licoriceand,312shatavariand,409

Inflammationbaicalskullcapand,83licoriceand,312neemleafand,340

Inflammation,acute,goldensealand,250

Inflammatorydiseasesbupleurum,116meadowsweetand,325

Influenzabackgroundof,34baptisiaand,86bupleurumand,116cinnamonand,149elecampanefor,193goldenrodand,246koreanginsengand,301mullenand,333pleurisyrootand,374treatmentstrategyfor,34-35vervainand,453

InfluenzaA,vervainand,454

Inhalationforskolinand,158lavenderand,305,306limeflowersoiland,319

Injectionblackhawof,101mistletoeof,330

Insectbites,arnicaand,72

Insecticidalpyrethrins,9

Insecticide,neemleafas,339

Insomniaashwagandaand,73bacopaand,80brahmioiland,80celeryseedand,134eleutherococcusand,195hopsand,277jamaicadogwoodand,289kavaand,291,295koreanginsengand,299lavenderand,305lemonbalmand,310limeflowersand,318

menopauseand,40pasqueflowerand,360passionflowerand,363spinyjujubeand,417St.John’swortand,425valepotriatesand,449valerianand,447

Insulincinnamonoiland,150fenugreekand,213goat’srueand,243,244neemleafand,340silymarinand,328tienchiginsengand,434

Insulintherapy,gymnemawith,269

Intercostalneuralgia,rosemaryand,389

Interferonastragalusand,79koreanginsengand,299

Interleukin-1,cat’sclawand,132

Interleukin-2,codonopsisand,155

Interleukin-6,cat’sclawand,132

Intermittantclaudicationginkgobilobaand,236pricklyashand,379

Intestinalamebiasis,euphorbiaand,199,200

Intestinalinflammation,diosgeninand,466

Intestinaltissues,blackhawand,101

Intestinalworms,euphorbiaand,199

Intrahepaticcholestasis,cascarainduced,128

Intraperitonealadhesions,shatavariand,411

Iodine,bladderwrackand,104

Iodinedeficiency,bladderwrackand,103

Ipecacuanha,tylophoraand,443

Iridoidglycosidescleaversand,152oliveleafand,353vervainand,454

Iridoids,devil’sclawand,179

Irinotecan,St.John’swortand,421

Ironblackteaand,138chamomileand,137

fenugreek(seed)and,210,211limeflowersand,318peppermintand,369vervainand,453

Irritablebowelsyndromechamomileand,137fenneland,206globeartichokeand,240meadowsweetand,324peppermintand,371

Ischemicheartdisease,astragalusand,77

Ischemicocculardiseases,ginkgobilobaand,237

Isoflavones,redcloverand,384

Isoflavonoids,jamaicadogwoodand,289,290

Isoquinolinealkaloidscaliforniapoppyand,125greatercelandineand,262

Ivyleaves(Hederahelix)ethanolvsnon-ethanolpreparationsof,5lungfunctionsand,5saponins,4

JJamaicadogwood(Jamaicandogwood)

contraindicationsof,289monographof,289-290oraladministrationof,290pharmacologicresearchon,289-290

Japanesemedicine(KAMPO),wildyamand,464

Jaundicebarberryand,88couchgrassand,162dandelionand,174fringetreeand,222globeartichokeand,240greatercelandineand,262

Jujubosides,spinyjujubeand,418

KKAMPO.SeeJapanesemedicine(Kampo)

Kaposi’ssarcoma,thymoland,432

Karnofskyscores,aloeveraand,63

Kava(Kavakava)clinicalstudieson,294-296contraindicationsfor,291dosingof,293maleimpotenceand,39-40monographof,291-296pharmacologicresearchon,293-294sideeffectsof,292,294sleeppatternsand,34synergyand,10valerianextractand,451

Kavadermopathy,kavaand,291

Kavalactones(kavapyrones),kavaand,293

Kawasakidisease,gingerand,229

Keloids,triterpenefractionofgotukolaand,257,258

Kidneystonesblackhawand,100

cleaversand,152crataevaand,168goldenrodand,246hopsand,277hydrangeaand,287

Kidneysceleryseedand,134eleutherococcusand,196

Killercellsastragalusand,78eleutherococcusand,197-198koreanginsengand,299,300

Klebsiellapneumoniae,meadowsweetand,325

Koreanginseng,34ashwagandavs,74clinicalstudieswith,300contraindicationsfor,297dosingof,298,299eleutherococcusand,195epidemiologicalstudieswith,302indicationsfor,297injectionof,299malehormonalfunctionand,33

maleimpotenceand,39-40monographof,297-303oraluseof,299pharmacologicresearchon,299sideeffectsof,298

Koreanginsengtea,302

LLeuropaeusextracts,114

Lvirginicusextract,114

Labelingherballiquidsand,24informationon,24-25

Laborblackhawand,101raspberryleafand,382,383schisandraand,407

Lactatelevels,schisandraand,406

Lactationashwagandaand,73blackcohoshand,96bladderwrackand,103-104bluecohoshand,106cascaraand,128cat’sclawand,131chastetreeand,142,146elecampaneand,193fenugreekand,210

goat’srueand,243herbaltherapyand,53kavaand,291pasqueflowerand,360sageand,394shatavariand,409uvaursiand,444

Lapacholanticoagulantpropertiesof,368antiviralactivityof,368oraladministrationof,367paud’Arcoand,366tabebuiaimpetiginosabarkand,367

Largeboredropper,comparisionbasedondroppersize,19t

Laryngitis,thymeand,431

Lavenderclinicalstudieson,305-306indicationsfor,304monographof,304-307pharmacologicresearchon,305

Lavenderoilanticonvulsiveactivityfor,305inhalationof,305,306

Laxative(s)aloeresinas,62cascaraand,127yellowdockand,474

Lecithin,escinand,283

Lectins,mistletoeand,331

Legcrampsblackhawand,100,101crampbarkand,164

Leishmaniamexicana,rosemaryoiland,391

Lemonbalm(Melissa)clinicalstudieson,309-311fenneland,206,208herpessimplexand,39insomniaand,451monographof,308-311pharmacologicresearchon,309potentialindicationsfor,308prescribinginformationfor,308valerianand,447,451

Lemonbalmcream,46

Lemongrassessentialoil,pharmacodynamicbasisof,9

Leourine,motherwortand,332

Leprosy,hemidesmusand,275

Lesions,herpes,licoriceand,315

LESP.SeeLiposterolicextract(LESP)

Leukemialapacholand,368yarrowand,472

LeukemiaP-388,paud’Arcoand,367

Leukocytecountlicoriceand,315tylophoraand,441

Leukocytosis,shatavariand,411

Leukopeniaastragalusand,77shatavariand,410

Leukorrheablackcohoshand,97blueflagand,110cranesbilland,166

Leukotrienes,nettleleafand,344

LH/FSHration,whitepeonycombinationand,460

Libido

licoriceand,316St.John’swortand,425

Licorice(Liquorice),34clinicalstudiesof,315-317contraindicationsfor,312dosingof,313-314fenneland,206,208herpessimplexand,39infantilecolicand,308,310interactionsof,312-313monographof,312-317oralintakeof,315pharmacologicresearchon,314-315potentialindicationsfor,312sideeffectsof,313spinyjujubeand,417warningsandprecautionsfor,312whitepeonycombinedwith,458,460

Lifespan,codonopsisand,155

Lignans,mistletoeand,331

Ligusticumwallichii,dongquaiwith,183

Limeflowers(Lindenflower,limeblossom)interactionswith,318

monographof,318-319pharmacologicresearchwith,319

Limonene,peppermintand,371

Limonoids,neemleafand,339

Lipidlevels,globeartichokeand,241

Lipidmetabolism,ginkgobilobaand,234

Lipidperoxidesneemleafand,340sageand,395

Lipolysis,coleusand,157

Lipophilic,freshplanttincuresand,7

Lipopolysaccharide(LPS)stimulation,nettleleafand,344

Liposterolicextract(LESP)antiedematousactivityof,402overviewof,401postvoidresidualand,402

Liquidextractsfreshplanttincuresvs,7

Liquidherbs,topicaluseof,46

Liverbarberryand,88bittersand,470

blueflagand,109bupleurumand,116cascarainduced,128dongquaiand,183gentianand,224germanderand,14ginkgobilobaand,234globeartichokeand,241milkthistleand,326premenstrualsyndromeand,43rosemaryand,389rosemaryoiland,391schisandraand,405,406tumericand,436

Livercells,arnicaand,71

Livercirrhosisberberineand,92whitepeonyand,460

Liverdiseasegreatercelandineand,261,262milkthistleand,326silymarinand,328

Liverdisorders

fringetreeand,222schisandraand,405

Liverfunctionbackgroundon,43-44casehistoryand,44fringetreeand,222treatmentstrategyfor,44

Liverinjury,vervainand,454

Livermicrosomes,schisandraand,406

Livertissue,celeryseedoiland,135

Longevity,koreanginsengand,298

Lowerrespiratorytractirritation,fenugreekand,211

Lowerurinarytract,buchuand,111

Luekorrhea,falseunicornand,204

Lumbosacralpain,bilberryand,95

Lungdongquaiand,183ivyleavesand,5

Lupeol,crataevaand,169

Lupeol,oralcadmiumand,170inflammationand,169

Lupuserythematosus,astragalusand,78

Luteinizinghormone(LH)agingand,32blackcohoshand,97coleusand,157

Lycopuseuropaeusextract,114pharmacologicresearchwith,114

Lymphnodesblueflagand,109calendula(Marigold)and,120,121cleaversand,152

Lymphadenoidgoiter,bladderwrackand,104

Lymphadenoma,calendula(Marigold)and,121

Lymphaticsystem,pokerootand,376

Lymphocytes,codonopsisand,155

Lymphocyticleukemia,pokerootand,376

MMaceration

overviewof,5-6tincturesand,4

Macrophagesneemleafand,340shatavariand,410

Maculardegeneration,ginkgobilobaand,232

Malaria,vervainand,454

Maleimpotencebackgroundof,39-40treatmentstrategyfor,39-40

Maltol,passionflowerand,363

Mammarygland,shatavariand,410

Mammarylobulo-alveolartissue,shatavariand,410

Mammarytumors,373shatavariand,411

Mania,St.John’swortand,422

Maplesyrupurinedisease,fenugreekand,211

Marc

macerationand,5-6pressingof,6

Markercompounds,11-12activeconstituentsof,10-11,10bherbsand,16levelconsistancyin,11variationsin,16

Marrubiin,opioidsystemsand,457

Marshmallowdosingfor,321monographof,321-323pharmacologicresearchon,322-323rootandleafof,321-323warningsandprecautionsfor,321

Marshmallowroot(Althaeaofficinalis)herbcompatibilityand,23solublesand,4

Mastcelldegranulation,neemleafand,339

Mastcells,albiziaand,59

Mastitis,pokerootand,376

Meadowsweetclinicalstudieson,325

monographfor,324-325pharmacologicresearchon,325potentialindicationsfor,324warningsandprecautionsfor,324

Measleselderflowerand,191,192eyebrightand,202

Medharasayan,ashwagandaand,74

Medigoxin,hawthornand,274

Melasma,licoriceand,312

Melatoninlevels,St.John’swortand,420

Melena,yarrowand,471

Memoryashwagandaand,73bacopaand,80brahmioiland,80eleutherococcusand,196ginkgobilobaand,232koreanginsengand,297,299rosemaryand,389whitepeonyand,458

Meniscus

errorsinreadingand,24herballiquidsand,24

Menopausalhotflashesblackcohoshand,98falseunicornand,204sageand,394

Menopausalsymptoms,wildyamand,464

Menopausebackgroundfor,40blackcohoshand,96,97,98chastetreeand,142falseunicornand,204kavaand,291,295koreanginsengand,297sageand,395shatavariand,409St.John’swortand,420,426treatmentstrategyfor,40,41twildyamand,464

Menorrhagiabluecohoshand,106cinnamonand,149cranesbilland,166

goldensealand,250yarrowand,471

Menstrualbleeding,shepherd’spurseand,413

Menstrualdysfunction,whitepeonyand,458

Menstruationbluecohoshand,107bupleurumand,116chastetreeand,146dongquaiand,183

Menstruum,macerationand,5-6

Mentalalertness,rosemaryfor,389

Mentholinhalationof,372peppermintand,371

Metabolism,eleutherococcusand,197-198

Metastasisdandelionand,175koreanginsengand,299

Meteorism,lavenderand,305

Methanolextracts,meadowsweetand,325

Methylcytisine,bluecohoshand,108

Metoclopramide,shatavariand,412

Metrorrhagia,cranesbilland,166

Mexicanherbalmedicine,damianaand,171

Mexicanvalerian,448

Microsporumcanis,Smilaxregeliirootand,398

Micturitiontime,liposterolicextractand,403

Middleear,eyebrightand,202

Migraineheadaches.SeeHeadaches,migraine

Milkfenneland,208goat’srueand,244shatavariand,410

Milkflow,sageand,394

Milkproduction,chastetreeand,146.SeealsoLactation

Milkthistle(St.Mary’sthistle)clinicalstudiesof,327-328greatercelandineand,261liverfunctionand,44mongraphof,326-328pharmacologicresearchon,327potentialindications,326premenstrualsyndromeand,43sideeffectsof,326

Miscarriageblackhawand,100crampbarkand,164shatavariand,410

Mistletoeaqueousextractsof,331clinicalstudiesof,330monographof,329-330pharmacologicresearchand,330sideeffectswith,329

Mitogeniclectins,pokerootand,377

Moderndosages,comparisionof,21,21t

Mold,herbalcreamsand,46

Monographshowtouse,49traditionalprescribingand,54

Monoturpines,thujaand,429

Morningsicknessfalseunicornand,204gingerand,227

Morphineashwagandaand,75

oatsand,350

Motherwortclinicalstudiesof,332monographof,331-332pharmacologicresearchon,332sleepdisturbancesand,308

Motionsickness,gingerand,227,230

Motorrecovery,ginkgobilobaand,235

Mouth,bilberryand,93

Mouthwash,makingof,47

Mucilage,4

Mucilaginousherbs,herbcompatibilityand,23

Mucouscolitis,hopsand,277

Mucousmembranes,goldensealand,250,251

Mullenmongraphof,333-334traditionalprescribingfor,333

Multifarctdementia,ginkgobilobaand,232

Muscleache,amicaand,70

Musclecells,dongquaiand,183

Musclecramps,whitepeonyand,458

Myalgiablackcohoshand,97rosemaryand,389

Mycobacteriumsmegmatis,yarrowand,472

Myopathy,licoriceand,313

Myopia,bilberryand,93

Myrrhantithromoticactivityof,336aqueoussuspensionof,336monographof,335-337petroleumetherextractof,336precautionsfor,335sideeffectswith,335

Myxedema,bladderwrackand,104

NNaftidrofuryl,ginkgobilobaand,237

Nalaxone,myrrhand,337

Naphthodianthrones,St.John’swortand,423

Naphthoquinones,tabebuiaimpetiginosabarkand,367

Nasalrinse,makingof,47

Nasopharyngealcatarrh,echinaceaand,185

NationalFormulary(NF),baptisiaand,87

NativeAmericanmedicinebarberryand,89blackhawand,101blueflagand,110burdockand,118cascarausewith,129choleraand,110cornsilkand,160crampbarkand,164dandelionleafand,174echinaceaangustifoliarootand,186,187falseunicornand,205fringetreeand,222

goldenrodand,247goldensealand,250grindeliaand,265hawthornand,271hopsand,278hydrangeaand,287mullenand,333oregongrapeand,357passionflowerand,363pleurisyrootand,374pokerootand,377sawpalmettoand,400thujaand,429wildcherryand,462wildyamand,464yarrowand,472yellowdockand,475

Naturalkillercells.SeeKillercells

Nauseabaicalskullcapand,83chastetreevs,144cinnamonand,149euphorbiaand,199

gentianand,224peppermintand,369tylophoraand,440

Nausea,druginduced,gingerand,227

Nausea,postoperative,gingerand,227,230

Necrotizingagents,myrrhand,336

Neemleaf,339aqueousextractsof,339clinicalstudiesof,341contraindicationsfor,338intraperitonealadministrationof,339,340intravenousadministrationof,341monographof,338-341oraladministrationof,338,339,340pharmacologicresearchon,339-341potentialindicationsfor,338pregnancyand,338toxicityof,338

Nentian,fenneland,206

Neonates,oregongrapeand,357

Nephritis,rehmanniaand,386,387

Nephrosclerosis,globeartichokeand,241

Nervinetonics,31depressionand,35stressand,38

Nervousdisordersbacopaand,80damianaand,171

Nervousdyspepsia,damianaand,171

Nervoussystem,oatsand,349

Nettleleaf(Nettles)clinicalstudiesof,344-345monographof,343-345osteoarthritis(OA)and,42pharmacologicresearchon,344potentialindicationsfor,343sideeffectsof,343

Nettlerootclinicalstudieson,347-348liposterolicextract(LESP)and,403monographof,346-348pharmacologicresearchon,346-347potentialindicationsfor,346prostatefunctionand,33warningsfor,346

Neuralgiabarberryand,90blackcohoshand,96hopsand,277jamaicadogwoodand,289kavaand,291,293koreanginsengand,299motherwortand,331pricklyashand,379skullcapand,415

Neuropathy,diabetic,silymarinand,327

Neurotoxicity,thujaand,428

Neutropenia,shatavariand,410

Neutrophilcount,ashwagandavs,74

Neutrophilia,shatavariand,411

Neutrophilsarnicaand,71shatavariand,410

Neviropine,St.John’swortand,421

NewYorkHeartAssociation(NYHA),hawthornand,270,272,273

Newcastledisease,neemleafand,340

Nicotinamideadeninedinnucleotidephosphate(NADPH),dandelionand,175

Nicotinemethylcytisineand,108oatsand,349,350

Nightsweats,elecampaneand,193

Nitricoxide,oleuropeinand,354

Nitricoxidesynthesis,koreanginsengand,299

Nocturnalenuresis,cornsilkand,160-161

Nocturnalmicturitionfrequency,nettlerootand,347

Nonhemeiron,rosemaryand,389

Norepinephrine,St.John’swortand,423

Nosebleed,shepherd’spurseand,413,414

NSAIDtherapy,nettleleafand,345

Nystatin,rosemaryessentialoiland,392

OOatseed,349-351

Oatseedextract,351

Oatsclinicalstudieson,350-351monographof,349-351pharmacologicresearchon,350potentialindicationsfor,349

Obesitybladderwrackand,103,104,105blueflagand,109fenneland,206

Obsessive-compulsivedisorder,St.John’swortand,420,425

Ointment,calendula(Marigold)in,121

Olderadults,ginkgobilobaand,232

Oleacein,oliveleafand,353

Oleuropeinnitricoxideand,354oliveleafand,353

Oligomericprocyanidins(OPCs),hawthornand,271,272,273

Oliguria,dandelionand,173

Oliveleafclinicalstudiesof,355monographof,352-355pharmacologicresearchon,353-355potentialindicationsfor,352

Onycholysis,thymoland,432

OPCs.SeeOligomericprocyanidins(OPCs)

Opiatewithdrawal,passionflowerand,362

Opiates,californiapoppyand,124

Opioidagonists,myrrhand,337

Opium,oatsand,351

Opticneuropathy,ginkgobilobaand,237

Oralcandidiasis,cinnamonand,150

Oralcontraceptivepill(OCP)licoriceand,313silymarinand,328St.John’swortand,421

Oraldosing.SeeDosing,oral

Oralmucosa,calendula(Marigold)and,120

Oregongrape(Berberisaquifolium)

clinicalstudieson,358-359goldensealrootand,13-14HPLCtraceand,15fliverfunctionand,44mongraphfor,357-359pharmacologicresearchon,358potentialindicationsfor,357

Osteoarthritis(OA)backgroundfor,40-41celeryseedand,134devil’sclawand,178gingerand,227,230goldenrodand,246nettleleafand,343,345pricklyashand,379treatmentstrategyfor,41,42t

casestudiesassociatedwith,41-42tumericand,436,438

Osteomyelitis,crataevaand,168

Ovariesblackcohoshand,96blueflagand,109,110whitepeonyand,459

Ovarycells,liposterolicextractand,401

Oxalicacid,blackhawand,100

Oxazepamkavaand,294,295valepotriatesand,449

Oxidativestresstheory,lapacholand,367

Oxindolealkaloids,cat’sclawand,132

PPaeoniasuffruticosa,fibroidsand,458,460

Paeoniflorin,whitepeonyand,459

Paincaliforniapoppyand,124celeryseedand,135devil’sclawand,180feverfewand,220jamaicadogwoodand,289lapacholand,368osteoarthritisand,41peppermintand,371

Pain,back,devil’sclawand,178

Pain,menstrual,blackhawand,100-101

Pain,neuralgic,passionflowerand,362

Pain,ovariancrampbarkand,164falseunicornand,204motherwortand,331pasqueflowerand,360

Pain,rhuematic,ashwagandaand,73,74

Pain,uterinebluecohoshand,106crampbarkand,164

Palpitations,spinyjujubeand,417

Panaxginseng,461

Pancreasbittersand,470goat’srueand,244

Panicdisorder,herbaltreatmentand,30

Parainfluenzatype1,vervainand,454

Paritidgland,coleusand,157

Parkinson’sdiease,kavaand,291

Parthenolide,feverfewand,219

Pasqueflower(Pulsatilla)monographof,360-361potentialindicationsfor,360

Passionflower(Passifloraincarnata)clinicalstudiesof,364hawthornand,273inhalationof,364jamaicadogwoodand,290kavaand,293

markercompoundsand,11monographof,362-365pharmacologicresearchof,363-364

Paud’Arco(Lapacho)clinicalstudieson,368monographof,366-368pharmacologicresearchon,367-368sideeffectsof,366warningsandprecautionsfor,366

PCOS.SeePolycycticovarysyndrome(PCOS)

Peakurinaryflowrates,liposterolicextractand,402,403

Pectin,chamomileand,139

Penilecorpuscavernosaltissues,ginkgobilobaand,234

Pentacyclicoxindolealkaloids(POA),cat’sclawand,132

Pentobarbital,berberineand,91

Pentoxifylline,ginkgobilobaand,236

Pentylenetetrazolespinyjujubeand,418whitepeonyand,459

Peony,dongquaiwith,183

Peppermintactionsof,369

clinicalstudiesof,369-372contraindicationsfor,369fenneland,206indicationsfor,369injectionof,370interactionswith,369mentholinhalationof,371monographof,369-372oraldosesof,370,371pharmacologicresearchon,369precautionsfor,369sideeffectswith,369-370

Pepticulcers.SeeUlcers,peptic

Percolation,5overviewof,6-7processof,6-7tincturesand,4

Peripheralarterialocclusivedisease,ginkgobilobaand,232

Peripheralbloodcellularity,acemannanand,62

Peripheralbloodflow,shepherd’spurseand,413

Peripheralcirculatoryinsufficiency,pricklyashand,379

Peripheralvasculardisorders,bilberryand,93

Peritonealmacrophages,codonopsisand,155

Peruvianmedicine,cat’sclawand,132

Phagocyticactivity,whitepeonyand,459

Phagocytosisandrographisand,66aqueousextractofelder,192arnicaand,71myrrhand,337vervainand,454

Phagocytosisassays,oregongraperoot,358

PharmaceuticalGMP(goodmanufacturingpractice),overviewof,10

Pharmacologicresearchashwagandaand,74-75astragalusand,78traditionalprescribingand,54

Pharyngealmucosa,calendulaand,120

Pharyngotonsillitis,andrographisand,65

Phenelzine,koreanginsengand,297

Phenolicacidderivatives,lemonbalmand,309

Phenolicacids,chickweedand,147

Phenolicditerpenes

rosemaryand,390sageand,395

Phenprocouman,St.John’swortand,421

Phenylbutazone,devil’sclawand,179

Phenylephrine,feverfewleafand,220

Phenylpropanes,mistletoeand,331

Phenytoin,St.John’swortand,421

Phlebitis,arnicaand,70

Phobicdisorder,herbaltreatmentand,30

Phosphorylation,arnicaand,71

Photodermatitis,celeryseedand,134

Photosensitivity,St.John’swortand,420,421,422

Phototoxicity,tumericand,438

Phytochemicals,12liquidherbsand,3markercompoundsand,11yarrowand,472

Phytoestrogens,hopsand,278

Phyto-SERMS,blackcohoshand,97

Phytosterols,chickweedand,147

Piperonylbutoxide,insecticidalactivityand,9

Pituitarygland,chastetreeand,143

Plantextract,dried,vsfreshplanttincture,8f

Planttinctures,freshobservationsof,7-8plantextract,driedvs,8f

Plants,medicinalmonographand,50phytochemicalsin,4

Plaque,dental,licoriceand,316

Plasmacells,pokerootand,377

Plasmacholesterol,passionflowerand,364

Plasmacortisol,albiziaand,60

Plasmaglucose,schisandraand,406

Plasmodiumfalciparum,paud’Arcoand,368

Plateletaggregationberberineand,252codonopsisand,155dongquaiand,183gingerand,229goat’srueand,244whitepeonyand,459

Plateletthromboxane,bilberryand,94

Platelets,feverfewleafand,220

Pleurisyelderflowerand,191,192pleurisyrootand,374

Pleurisyroot,30monographof,374-375potentialindicationsfor,374traditionalprescribingfor,374

PMS.SeePremenstrualsyndrome(PMS)

Pneumoniamarshmallowrootand,321pleurisyrootand,374wildcherryand,462

Pokerootclinicalstudieson,377-378contraindicationsof,376monographof,376-380pharmacologicresearchon,377potentialindicationsfor,376sideeffectsof,376-377tinctureand,8topicalapplicationof,376warningsandprecautionsfor,376

Polyacetylenes,E.angustifoliaand,187

Polycysticovarysyndrome(PCOS)licoriceand,312,316whitepeonyand,458,460

Polygonummultiflorum,astragalusand,77

Polymorphs,feverfewleafand,220

Polyneuropathy,St.John’swortand,425

Polypeptides(viscotoxins),mistletoeand,331

Polysaccharidesechinaceaand,187mistletoeand,331rehmanniaand,387

Poriacocos,fibroidsand,458,460

Postpartumhemorrhage,goldensealand,250

Postpartumhemorrhage.SeeHemorrhage,postpartum

Postthromboticsyndromesgotukolaand,254triterpenefractionofgotukolaand,257,258

Posttraumaticstressdisorder,herbaltreatmentand,30

Postvoidresidual(PVR),liposterolicextractand,402

Potassium

cascaraand,127-128dandelionleafand,174licoriceand,313

Precancerousconditions,adjuvanttherapy,tumericand,436

Prednisolonealbiziaand,59licoriceand,313

Preeclampsia,redginsengand,302

PregnancyAgathosmacrenulataand,111albiziaduring,59andrographisand,65,67berberinecontainingplantsand,88-89blackcohoshand,96bladderwrackand,103-104bluecohoshand,106buchuand,111bugleweedand,113cascaraand,128cat’sclawand,131chastetreeand,142convulsions,164crampbarkand,164

dongquaiand,182echinaceaand,185,190elecampaneand,193ethanoland,5feverfewand,219gingerand,227goldensealand,250gotukolaand,258herbaltherapyand,53horsechestnutand,283jamaicadogwoodand,289kavaand,291licoriceand,312mistletoeand,330neemleafand,338oregongrapeand,357pasqueflowerand,360paud’Arcoand,366raspberryleafand,381,382,383sageand,394schisandraand,405silymarinand,328tienchiginsengand,433tylophoraand,440

uvaursiand,444wormwoodand,469

Premenstrualsyndrome(PMS)backgroundof,42blackcohoshand,96chastetreeand,142,144,145ginkgobilobaand,237treatmentfor,42,43ttreatmentstrategyin,42-43

Prescriptionmetricsystemand,23partsof,23-24

Preservatives,herbalcreamsand,46

Pricklyashclinicalstudieswith,380extractof,380monographof,379-380osteoarthritisand,41,42tpharmacologicalresearchon,380potentialindicationsof,379

Primarydegenerativedementia,ginkgobilobaand,232

ProcyanidinB-2,hawthornand,271

Procyanidins,St.John’swortand,9

Progesteronechastetreeand,144diosgeninand,466wildyamand,464

Progesteronedeficiency,chastetreeand,142

Progesteronedrugs,chastetreeand,142

Prolactinagingand,32chastetreeand,143lemonbalmand,309liposterolicextractand,401

Prolactinsecretion,chastetreeand,142

Prolapse,falseunicornand,204

Prolapse(anus),codonopsisand,154

Prolapse(stomach),codonopsisand,154

Prolapse(uterus)bupleurumand,116codonopsisand,154

Proscar(finasteride),dihydrotesteroneand,33

Prostatehydrangeaand,287

meadowsweetand,324nettlerootand,347

Prostatedisorders,willowherband,468

Prostatitisbuchuand,111cornsilkand,160couchgrassand,162horsetailand,285hydrangeaand,287sawpalmettoand,400

Prostrategrowth,liposterolicextractand,402

Protaglandins,euphorbiaand,200

Proteins,mistletoeand,331

Proteolyticointment,calendulavs,121-122

Proteusvulgarisarnicaand,71St.John’swortand,423uvaursiand,445

Protozoa,neemleafand,340

Protozoalinfections,adjuvanttherapy,paud’Arcoand,366

Protozoalparasites,euphorbiaand,199

Prunasin,wildcherryand,462

Prunuspersica,fibroidsand,458

Pruritis,St.John’swortand,421

Pseudomonasaeruginosamyrrhand,336St.John’swortand,423

Psoriasisaloeveraand,61,63ashwagandaand,73,74burdockand,118chickweedand,147coleusand,156echinaceaand,185gotukolaand,254greatercelandineand,261,262liverfunctionand,44neemleafand,338,340oregongrapeand,357,358sarsaparillaand,397,399

Psoriaticarthropathy,devil’sclawand,180

Puerarialobata,daidzinand,9

Pulmonarytumor,coleusand,157

Pumpkinseedextract,liposterolicextractand,403

Purpurea,devil’sclawand,178

PVR.SeePostvoidresidual(PVR)

Pyelitis,cornsilkand,160-161

Pyridoxine,chastetreevs,144

Pyrrolizidinealkaloids(PA’s),echinaceaand,185

Pyuria,andrographisand,69

QQualityproblems,examplesof,13-16

Quercitron,euphorbiaand,200

RR.crispus,nativeamericanmedicineand,475

R.obtusifolius,nativeamericanmedicineand,475

Radiation,eleutherococcusand,198

Radiotherapyastragalusand,78codonopsisand,155

Ranitidineberberineand,91duodenalulcersand,315

Rapideyemovement(REM)sleephopsand,278-279koreanginsengand,300valerianextractand,450

Rasayanagroup,shatavariand,410

Raspberryleaf(redraspberryleaf)aqueousextractof,382clinicalstudiesof,382-383monographof,381-383pharmacologicresearchon,381-382potentialindicationsof,381

Ratio,herballiquidsand,4

Raynaud’ssyndromebilberryand,94pricklyashand,379

Reactivehypoglycemia(dysglycemia)backgroundon,44herbaltreatmentfor,45,45t

Redbloodcells,dandelionand,175

Redcloverclinicalstudiesof,384monographof,384-385pharmacologicresearchon,384potentialindicationsof,384

Redginseng(Panaxginseng),koreanginsengvs,300

REFERENCES,monographand,55

Rehmannia,34clinicalstudieson,387-388constituentsof,387driedrootof,386monographof,386-388oraladministrationofuncured,387pharmacologicresearchon,387

polysaccharidesfrom,387potentialindicatonsof,386sideeffectsof,386winecuringof,386

Rehmanniaroot,braininfarctionand,460

Rehydrationtherapy,goldensealand,252

Renalagents,californiapoppyand,125

Renalcalculi,barberryand,89

Renalfailure,cat’sclawand,131

Renalfunction,cornsilkand,160

RenalRNA,schisandraand,406

Reproductivetractpasqueflowerand,360pokerootand,376

Reproductivetract(female),bluecohoshand,106

Resins,4

Respiratorycatarrhelecampanefor,193mullenand,333

Respiratoryconditionslimeflowersand,318redcloverand,384

wildcherry,462

Respiratorydisorders,pleurisyrootand,374

Respiratorysyncytialvirus,vervainand,454

Respiratorytracteuphorbiaand,199pokerootand,376

Respiratorytractinfectionsandrographisand,65,68baptisiaand,86

Reticulo-endothelialsystem,shatavariand,411

Retinitis,bilberryand,93

Retroviruseslapacholand,368St.John’swortand,423

Revascularization,hawthornand,272

Rheumaticconditionsdevil’sclawand,178meadowsweetand,324pricklyashand,379

Rheumatismblackcohoshand,96,97burdockand,118

celeryseedand,134chickweedand,147couchgrassand,162devil’sclawand,179horsechestnutand,281jamaicadogwoodand,289yellowdockand,474

Rheumatoidarthritis.SeeArthritis,rheumatoid

Rhinitis,nettleleafand,343

Rhubarbcascaraand,127gentianand,224,225

Ringwormfungi,thujaand,429

Rootbark,barberryand,90

Rosemaryaqueoussystemsand,390contraindicationsfor,389dosageof,390inhalationof,392interactionswith,389monographof,389-393oraladministrationof,390-391,392pharmacologicresearchon,390-392

potentialindicationsfor,389

Rosemaryoilanxiety,392commissionEand,392ESCOPand,392HSVtype2and,391lavenderand,306nystatinand,392

Rotenoids,jamaicadogwoodand,289

Rotundifuran,chastetreeand,143

SS.aureusenterotoxinB(SEB),eczemaand,36-37

Sageactionsof,394aqueousextractof,395chloroformextractof,395clinicalstudieson,395contraindicationsfor,394essentialoilof,395menopauseand,40monographof,394-396pharmacologicresearchon,395potentialindicationsfor,394premenstrualsyndromeand,42warningsandprecautionsfor,394

Saikosaponins,bupleurumand,117

Salicylates,meadowsweetand,324

Salinenasalspray,makingof,47

Salmonellatyphi,uvaursiand,445

Salviamiltiorrhiza,astragalusand,77

Sanguinarine,californiapoppyand,125

Saponin-containingherbs,menopauseand,40

Saponinsethanoland,4fenugreekand,212grindeliaand,265gymnemaand,268horsechestnutand,282neemleafand,338pokerootand,377sarsaparillaand,398spinyjujubeand,418tienchiginsengand,433wildyamand,464

Sarsaparillaactionsof,397clinicalstudieson,399dosagefor,397-398hemidesmusvs,275monographof,397-399pharmacologicresearchon,398-399potentialindications,397warningsandprecautionsfor,397

Sawpalmetto

actionsof,400clinicalstudieson,402-403dosageof,400-401monographon,400-404pharmacologicresearchon,401-402potentialindicationsfor,400prostatefunctionand,33sideeffectsof,400

Sawpalmettoberries,nettlerootand,348

Scabies,neemleafand,340

Schisandra(Schizandra)actionsof,405clinicalstudieson,407contraindicationsfor,405intraperitonialinjectioonof,406liverfunctionand,45monographfor,405-408oraladministrationof,406pharmacologicresearchon,406potentialindicationsfor,405sideeffectsof,405traditionalprescribingof,405-406

Schistosomamansoni,paud’Arcoand,368

Schizophrenia,TJ-68and,461

Sciaticablackcohoshand,97jamaicadogwoodand,289rosemaryand,389St.John’swortand,420

Scleroderma,thymoland,432

Scullcap,34

Seasonalaffectivedisorder,St.John’swortand,420

Seborrheicdermatitis,aloeveraand,63

Secondaryamenorrhea,chastetreeand,142

Sedationpassionflowerand,362St.John’swortand,423

Sedativesbugleweedas,113bupleurumas,116californiapoppyand,125crampbarkand,165valepotriatesvs,449

Sediment,herballiquidsand,18

Selectiveserotoninreuptakeinhibitors(SSRIs),St.John’s

wortand,421

Seniledementia,ginkgobilobaand,234

Sennacascaraand,128laxativeactivitiesinmiceand,10

SennosideA,10

SennosideC,10

Sepsisbaptisiaand,86shatavariand,410

Serotonindongquaiand,183feverfewleafand,220St.John’swortand,423

Serotonin-inducedhypothermia,gingerand,229

Serumcholesterol,fenugreekand,211

Serumdigoxinlevels,eleutherococcusand,195

Serumgastrin,codonopsisand,155

Serumglucose,goat’srueand,244

SerumT3,fenugreekand,213

Serumurea,sarsaparillarootextractand,399

Sesquiterpenelactones,elecampaneand,194

Sesquiterpenes,myrrhand,336

Sexhormonebindingglobulin(SHBG),nettlerootand,346

Sexualdesire.neemleafand,339TJ-68and,461

Sexualdysfunctionashwagandaand,73ginkgobilobaand,237

Sexualfunctionashwagandaand,75hopsand,277

Sharma,phytochemicalsinplantand,9

Shatavariactionsof,409clinicalstudieson,411-412monographfor,409-412oraladministrationof,411pharmacologicresearchon,410-411potentialindicationsof,409traditionalprescribingof,409-410

SHBG.SeeSexhormonebindingglobulin(SHBG)

Shepherd’spursemonographfor,413-414pharamacologicresearchon,413-414potentialindications,413traditionalprescribingfor,413

Shigellaflexnerimeadowsweetand,325yarrowand,472

Shigellasonnei,yarrowand,472

Shimotsu-to,oraladministrationof,460

Silica,horsetailand,285

Silicon,nettleleafand,344

Silymarinneuropathyand,327skintumorsand,327

Silymarin-silybin,milkthistleand,326,327

Simvastatin,oliveleafand,353

Sinusitisbaptisiaand,86elderflowerand,191,192eyebrightand,202

SjapuapGamcapTang,musclespasmsand,460

Skeletalmuscle,crampbarkand,164

Skinbarberryand,90blueflagand,109burdockand,118chamomileand,137chickweedand,147cleaversand,152echinaceaand,185elderflowerand,191-192elecampaneand,193fringetreeand,222gentianand,224greatercelandineand,262hemidesmusand,275kavaand,291milkthistleand,326neemleafand,338nettleleafand,343nettlerootand,346oregongrapeand,357paud’Arcoand,366pokerootand,376,377

r.crispusand,475r.obtusifoliusand,475rehmanniaand,386yarrowand,471

Skinabrasion,tiliasylvestrisand,319

Skindisordersredcloverand,384sarsaparillaand,397yellowdockand,474

Skinpricktest,allergicrhinitisand,30

SkullcapHPLCtraceand,15fmonographof,415-416potentialindicationsfor,415qualityproblemsand,14-15traditionalprescribingfor,415

Sleepcaliforniapoppyand,124,125hopsand,278,279jamaicadogwoodand,289lemonbalmand,309schisandraand,406spinyjujubeand,418

valerianand,449,450

Sleepcycle,kavaand,294

Sleepdisorderscitronelloland,310hopsand,277lavenderand,306lemonbalmand,308St.John’swortand,420valerianextractand,450,452

Smallcelllungcancer,astragalusand,78-79

Smilaxornataextract,leprosyand,399

Smilaxregeliirootaqueousextractof,398Epidermophytonfloccosumand,398Microsporumcanisand,398sarsaparillaand,398Trichophytonmentagrophytesand,398

Smokers,koreanginsengand,302.SeeCigarettes;SeealsoNicotine

Smoothmusclecrampbarkand,164elecampaneand,194fenneland,207

shepherd’spurseand,413thymeand,432

Solvent,herballiquidsand,4

Somatoformicdisorders,St.John’swortand,420

Sorethroat,raspberryleafand,381

SouthAfricanmedicinebuchuand,111devil’sclawand,179oliveleafand,353

SouthAmericanmedicine,paud’Arcoand,367

SoutheastAsiaherbalmedicine,fenugreekand,212

Spasmolytic,rosemaryas,389

Spasmolyticactivity,blackhawand,101

Spasmolyticherbs,31

Spermcount,koreanginsengand,302

Spermatorrhea,schisandraand,405

Spermatozoa,neemleafand,340

Spinalmobility,devil’sclawand,180

Spinosin,spinyjujubeand,418

Spinyjujube(Ziaphus;sourChinesedateseed)chinesestudieson,417

monographof,417-419oraladministrationof,418pharmacologicresearchon,417potentialindicationsfor,417sideeffectsof,417sleeppatternsand,34traditionalprescribingfor,417

Spleenacemannanand,62barberryand,88dandelionand,174eleutherococcusand,196

Spontaneousabortion,dongquaiand,182

Sprains,amicaand,70

Squamouscellcarcinomasgreatercelandineand,263meadowsweetand,325neemleafand,340

St.John’swort,34,39actionsof,420blackcohoshand,98clinicalstudieson,423-426coadministrationofprocyanidinsand,9

contraindicationsfor,420dosagefor,19,421-422fenneland,206interactionswith,421intraperitonealinjectionof,423maleimpotenceand,39-40monographfor,420-427oralintakeof,423osteoarthritisand,41,42tpharmacologicresearchon,423potentialindicationsfor,420sideeffectsof,421-422supportinginformationfor,421-422valerianand,447,451warningsandprecautionsfor,420

Stamina,eleutherococcusand,198

Standardizedextracts,herbalcontextof,12

Staphylococcusaureuseczemaand,36-37elecampaneand,194paud’Arcoand,368St.John’swortand,423yarrowand,472

Staphylococcusaureushaemalyticus,meadowsweetand,325

Staphylococcuscoli,myrrhand,336

Staphylococcuspyogenes,elecampaneand,194

Steiner,Rudolf,mistletoeand,331

Stembark,barberryand,90

Stephania(Stephaniatetrandra),qualityproblemsand,16

Steroidhormones,licoriceand,314

Steroidalsaponinsfenugreekand,212shatavariand,410

Sterolscrataevaand,168licoriceand,314

Stevens-Johnsonsyndrome,ginkgobilobaand,233

Steviarebaudiana,anginaand,460

Stomachbittersand,470lavenderand,305

Stomachcells,gentianand,225

Stomatitis,thymeand,431

Strength,herballiquidsand,4

Streptococcusaureus,uvaursiand,445

Streptococcusfecaelisgoldenrodand,247uvaursiand,445

Streptococcuspyogeneshaemalyticus,meadowsweetand,325

Stresscaliforniapoppyand,124eleutherococcusand,196herbaltreatmentand,30kavaand,291koreanginsengand,297,300valerianand,447

Stroke,ginkgobilobaand,232

Suanzaorentangdiazepamvs,418spinyjujubeand,418

Submucosalmyoma(fibroids),goldensealand,250

Succi,freshplanttincuresand,7

Sucrates,fenugreekand,213

Suddencardiacdeath,kavaand,291

Sulfamethoxazole-trimethoprimberberinechloridevs,92

berberinevs,253

Sunlight,herbalstorageand,17

Surgeryhorsechestnutand,283nettlerootand,347

Surgery,cardiovascular,ginkgobilobaand,233

Surgery,nasal,bilberryand,93,95

Sweatglands,aqueousextractofelder,192

Sweatingsageand,394spinyjujubeand,417

Swelling,arnicaand,70

Sympatheticnervoussystrm,fenneland,207

Synergy,galenicalextractsand,9-10

Syphilisblueflagand,109echinaceaangustifoliarootand,186fringetreeand,222sarsaparillaand,398

Systematicapproach,prescribingherbswith,27-29

Systemicscleroderma,triterpenefractionofgotukolaand,258

TTabebioaipe,367

Tabebuiacassinoides,367

Tabebuiachrysantha,367

Tabebuiaimpetiginosabark,constituentsof,367

Tabebuiaserratifolia,367

Tachycardiabugleweedand,113eleutherococcusand,195hawthornand,270,271,273mistletoeand,330passionflowerand,362

Tannins,4herbcompatibilityand,23uvaursiand,444

Tastefactorsin,3-4herballiquidsand,3

Temperature,herbalstorageand,17

Tendinitis,devil’sclawand,178

Terminaldisease,eleutherococcusand,198

Terpenoids,neemleafand,339

Testosteronemaleagingand,32neemleafand,340sarsaparillaand,399sawpalmettoand,401whitepeonyand,459

Tetracyclicoxindolealkaloids(TOA),cat’sclawand,132

Tetracyclineberberinechloridevs,92berberinevs,253

Thaimedicine,andrographisand,66

T-helpercells,eleutherococcusand,197-198

TheophyllineSt.John’swortand,421tylophoravs,442

TherapeuticGoodsAdministration,claimsforherbalproductsand,53

Therapeutics,acutebronchitisand,29-30

Thiamedicine,tumericand,437

Thin-layerchromatography(TLC),identificationofplantmaterialand,10,11b

Throat,bilberryand,93

Throatsyrup,makingof,47

Thrombin,feverfewleafand,220

Thrombocytes,berberineand,90,252

Thrombocytopenia,burberinebisulfateand,92

Thrombocytosis,gingerand,231

Thrombosis,rehmanniaand,387

Thuja(treeoflife,arbor-vitae,whitecedar)actionsof,428baptisiaand,87clinicalstudieson,429-430contraindicationsof,428essentialoilof,429monographof,428-430nativeamericanmedicine,429oraluseof,428pharmacologicresearchon,429sideeffectsof,428tinctureand,8topicaluseof,428traditionalprescribingof,428-429

Thujone

sageand,394thujaand,428wormwoodand,469

Thymeactionsof,431clinicalstudieson,432monographof,431-432pharmacologicresearchon,432potentialindicationsfor,431sideeffectsof,431traditionalprescribingfor,431-432

Thyphoid,goat’srueand,243

Thyroidglandsbladderwrackand,103bugleweedand,113coleusand,157eleutherococcusand,197fenugreekand,210

Thyroidhormonebugleweedand,113lemonbalmand,309

Thyroidstimulationhormone(TSH),bugleweedand,113

Thyroxine

bladderwrackand,103escinand,283

Thyroxin-releasinghormone,chastetreeand,144

Tibetherbalmedicine,ashwagandaand,74

Tienchiginsengactionsof,433aqueousextractof,434clinicalstudies,434injectionof,433monographof,433-435oraldosesof,434pharmacologicresearchon,433-434potentialindicationsof,433traditionalprescribingof,433

Tiliaamericana,319

Tiliacordata,319

TiliaEuropaea,319

Tiliaplatyphyllas,319

Tiliasylvestris,skinabrasionand,319

Tiliatomentasa,319

Tincturedosages,comparisionof,21,21t,22

Tinctures,70

freshplant,7-8herballiquidpreparationsand,4

Tinnitusblackcohoshand,97ginkgobilobaand,232,236-237

TJ-68amenorrheaand,461hyperprolactinemiaand,461schizophreniaand,461sexualdesireand,461

T-lymphocytesalbiziaand,59koreanginsengand,299

Tonsillitisbaptisiaand,86echinaceaangustifoliarootand,186mullenand,333raspberryleafand,381

Toxicitybluecohoshand,107cascaraand,129ethanoland,5pokerootand,376-377

Tracheities,mullenand,333

Trauma,tienchiginsengand,433

Treatmentgoals,choiceofherbsfor,27-28

Tremor,skullcapand,415

Triazolam,lemonbalmand,309,310

Trichophytonmentagrophytes,Smilaxregeliirootand,398

Trichophytonrubrum,lavenderand,305

Trichostrongyluscolubriformis,wormwoodand,470

Triglyceridevalues,globeartichokeand,241-242

Trigonelline,fenugreekand,213

Triiodothyroninelevels,lycopuseuropaeusextractand,114

Triterpenefractionofgotukola(TFGK)clinicaltrialsand,256-258oraladministrationsof,257

Triterpenoidsaponins,licoriceand,314

TSH-receptors,lemonbalmand,309

Tubalocclusion,dongquaiand,183

Tumericactionsof,436clinicalstudiesof,438constituentsof,437

contraindicationsof,436greatercelandineand,261injectionof,437interactionsof,436monographof,436-439neemleafand,338,340pharmacologicresearchof,437-438potentialindicationsof,436traditionalprescribingof,436warningsandprecautionsof,436

Tumorcells,lapacholand,367

Tumornecrosis,cornsilkand,161

Tumorsashwagandaand,75blackcohoshand,96burdockand,118dandelionand,175eyebrightand,203hypericinand,423lapacholand,368shepherd’spurseand,413tumericand,438

Tumors,malignant,eleutherococcusand,196

Tumors,skin,silymarinand,327

Turpines,thujaand,429

Tylophora(Indianipecac,Indianlobelia),34actionsof,440clinicalstudieson,441contraindicaitonsfor,440dosageof,440eczema(atopicdermatitis)and,37monographfor,440-443pharmacologicresearchon,441-442potentialindicationsfor,440sideeffectsof,440traditionalprescribingof,441

Tylophorinedexamethasonvs,441injectionwith,441,442tylophoraand,441

Typhoidpneumonia,echinaceaangustifoliarootand,186

UU.tomentosa,cat’sclawand,132

U.tomentosaroot,HIVand,133

UDCA.SeeUrsodeoxycholicacid(UDCA)

Ulcerativestomatitis,echinaceaangustifoliarootand,186

Ulcersalbiziaand,60aloeveraand,61,62Ayurvedicmedicineand,74baptisiaand,86barberryand,89blackhawand,101calendula(Marigold)and,120,122californiapoppyand,124cranesbilland,166deglycyrrhinizedlicorice(DGL)and,314devil’sclawand,178fenugreekand,211myrrhand,335,336neemleafand,339ranitidineand,91

Ulcers,duodenalgentianand,224gotukolaand,254licoriceand,312

Ulcers,gastricchickweedand,147codonopsisand,155cranesbilland,166fringetreeand,222gentianand,224gotukolaand,254licoriceand,312marshmallowand,321,322meadowsweetand,324oraldoseoftumericand,437,438rosemaryand,391saikosaponinsand,117triterpenefractionofgotukola(TFGK)and,257

Ulcers,legcalendula(Marigold)and,120gotukolaand,254hopsand,277triterpenefractionofgotukolaand,257

Ulcers,mouthlicoriceand,312,316raspberryleafand,381

Ulcers,pepticbarberryand,88coleusand,156elecampaneand,194goldensealand,250,251greatercelandineand,262licoriceand,315marshmallowand,321,322

Ulcers,stomach,tumericand,436,438

Ulcers,varicosemarshmallowand,321paud’Arcoand,366

UnitedStatesPharmacopeia(USP),baptisiaand,87

Upperrespiratorycatarrhfenneland,206,208grindeliaand,265licoriceand,312

Upperrespiratorytracteyebrightand,202goldenrodand,246

Upperrespiratorytractinfections(URTIs)echinaceaand,185studyfor,188,189

Uremia,acute,sarsaparillarootextractand,399

Uretericcalculi,dandelionand,176

Urethritisbuchuand,111cornsilkand,160horsetailand,285

Urinarycalculicornsilkand,160couchgrassand,162-163goldenrodand,247

Urinaryflow,liposterolicextractand,402

Urinaryincontinence,bacopaand,80

Urinarystones,uvaursiand,444

Urinarytractbarberryand,89celeryseedand,134couchgrassand,162crataevaand,168goldenrodand,246

horsetailand,285hydrangeaand,287nettleleafand,343,345uvaursiand,444

Urinarytractinfectionandrographisand,65buchuand,111buchuessentialoiland,111crataevaand,168,169marshmallowand,321Smilaxregeliirootand,398

Urinationcleaversand,152crataevaand,169schisandraand,405

Urine,acidic,uvaursiand,444

Urine,alkaline,uvaursiand,445

Ursodeoxycholicacid(UDCA),gallstonesand,372

Urticadioicaagglutinin(UDA),nettlerootand,347

Urticariachastetreeand,143rehmanniaand,386

U.S.FoodandDrugAdministration(FDA),bluecohoshand,107

Uterinebleedingastragalusand,77cinnamonand,149

Uterinecramping,wildyamand,464

Uterineirritiation,fenugreekand,211

Uterineprolapse,bluecohoshand,106

Uterusblackhawand,100-101dongquaiand,183

Uvaursi(Bearberry)actionsof,444clinicalstudiesof,445contraindicationsfor,444dandelionand,173interactionsof,444monographfor,444-446pharmacologicresearchon,445potentialindicationsfor,444

VVagalstimulation,bittersand,470

Vaginaldischarge,bilberryand,94

Vaginalepithelium,blackcohoshand,98

Vaginalprolapse,kavaand,293

Vaginitis,chronic,meadowsweetand,324

Valepotriates,valerianand,448,449

Valerian(Valerianaofficinalis)actionsof,447aqueousextractof,449,450clinicalstudieson,449-452hopsand,277,278interactionsof,447kavaand,291,295lemonbalmand,309,310monographof,447-452pharmacologicresearchon,448-449potentialindicationsof,447qualityproblemsand,16sideeffectsof,448sleepand,34,308

synergyand,10traditionalprescribingof,448

Valerianextract,passionflowerand,364

Varicocele,koreanginsengand,302

Varicosesyndromes,gotukolaand,254

Varicosevein(VV)cream,making,46

Varicoseveins(VV)backgroundandsymptomsof,45calendula(Marigold)and,120horsechestnutand,281pricklyashand,379,380treatmentstrategyfor,45-46,46t

Vasoconstrictionblackhawand,101californiapoppyand,125

Vasodilation,koreanginsengand,299

Vasopressinreceptors,californiapoppyand,125

Veins,horsechestnutand,282

Venom,hemidesmusand,276

Venomousbitesechinaceaangustifoliarootand,187neemleafand,339

Venoushypertensivemicroangiopathy,triterpenefractionofgotukola(TFGK)and,257

Venousinsufficiencybilberryand,93,94gotukolaand,254

Venouspressure,horsechestnutand,282

Verticalcapillarydynamolysis,chromatographytechniqueand,8

Vertigo,ginkgobilobaand,232

Vervainactionsof,453clinicalstudieson,454-455constituentsof,454infantilecolicand,308interactionswith,453monographof,453-455pharmacologicresearchon,454potentialindicationsfor,453traditionalprescribingfor,454

Vibriocholeraeinfectiousdiarrhea,goldensealand,252

Viburnumprunifolium,crampbarkvs,165

Viburnumprunifoliumbark,ethanoland,4

Virusesneemleafand,340oliveleafand,354St.John’swortand,420

Viruses,wart,thujaand,428

Vision,bilberryand,93

VitaminEschisandraand,407St.John’swortand,420,426

Vomitingblackcohoshand,96blueflagand,109cinnamonand,149codonopsisand,154gingerand,229,230peppermintand,369pleurisyrootand,374tylophoraand,440

Vuleraryherbs,healingand,38

Vulvallichensclerosis,thymeand,432

WWarfarin

bilberryand,93devil’sclawand,178fenugreek(seed)and,210gingerand,227ginkgobilobaand,232koreanginsengand,297meadowsweetand,324St.John’swortand,420

Warmingherbs,andrographisand,66

Warts,greatercelandineand,261

Water,glycetractsand,4

Watercontent,freshplanttincuresand,7,8

Weight,gymnemaand,268

Weightgaineleutherococcusand,197shatavariand,411

Weightlossbugleweedand,113dandelionleafand,174

goat’srueand,243

Westernherbalmedicinebarberryand,89bilberryand,94blackcohoshand,97blackhawand,100-101bladderwrackand,104bluecohoshand,107blueflagand,109-110burdockand,118calendulaand,121californiapoppyand,124cascarainduced,128celeryseedand,134-135chamomileand,138-139chastetreeand,143-144chickweedand,147cinnamonand,149-150cleaversand,152cornsilkand,160-161couchgrassand,162-163crampbarkand,164cranesbilland,166-167

damianaand,171dandelionand,174devil’sclawand,179dosagesin,20telderflowerand,191-192elecampaneand,193euphorbiaand,199eyebrightand,202falseunicornand,204fenneland,207fenugreekand,211feverfewand,220fringetreeand,222gentianand,224gingerand,228globeartichokeand,241goat’srueand,243goldenrodand,246goldensealand,250gotukolaand,255greatercelandineand,262grindeliaand,265hawthornand,271hopsand,277-278

horsechestnutand,282horsetailand,285hydrangeaand,287jamaicadogwoodand,289kavaand,292koreanginsengand,298lavenderand,305-306lemonbalmand,308licoriceand,314limeflowersand,318-319marshmallowrootand,321meadowsweetand,324milkthistleand,326mistletoeand,330motherwortand,331mullenand,333myrrhand,335nettleleafand,343-344nettlerootin,346oatsand,350oliveleafand,352oregongrapeand,357pasqueflowerand,360passionflowerand,362

peppermintand,370pleurisyroot,374-375pokerootand,377prescribingforindividualpatientin,27pricklyashand,379redcloverand,384rosemaryand,390sageand,394-395sarsaparillaand,398sawpalmettoand,400skullcapand,415St.John’swortand,422thujaand,428thymedustand,431tumericand,437uvaursiand,444valerianand,448vervainand,453whitehorehoundand,456wildcherryand,462wildyamand,464yarrowand,472yellowdockand,474-475

Whitebloodcells,ashwagandaand,73

Whitehorehoundactionsof,456pharmacologicresearchon,456-457potentialindicationsfor,456traditionalprescribingfor,456

Whitepeony(Paeonialactiflora)actionsof,458clinicalstudiesof,460-461intragastricadministrationof,459licoriceand,312,316oraladministrationof,459pharmacologicresearchon,459-460potentialindicationsfor,458qualityproblemsand,17ftraditionalprescribingfor,458-459warningsandprecautionsfor,458

Whoopingcough,greatercelandineand,261

Wildcherryactionsof,462monographof,462-463pharmacologicresearchon,462potentialindicationsfor,462

traditionalprescribingfor,462

Wildyam(colicroot,rheumatismroot)actionsof,464clinicalstudieson,466-467oraluseof,464pharmacologicresearchon,465-466potentialindicationsfor,464sideeffectsof,464traditionalprescribingfor,464-465

Wildyamcream,menopausalsymptomsand,466

Williamson,E.M.,herbaltherapyand,9

Willowherb(epilobium)monographof,468prostatefunctionand,33

Worminfestation,wormwoodand,469

Worms,intestinal,gentianand,224

Wormwoodactionsof,469clinicalstudiesof,470fenneland,206gastroesophagealreflux(GER)and,38peppermintand,369

pharmacologicresearchon,469-470potentialindicationsfor,469traditionalprescribingfor,469

Woundsaloeveraand,61,62baptisiaand,87calendula(Marigold)and,121,122chamomileand,139devil’sclawand,178elderflowerand,191-192fenugreekand,213gotukolaand,256horsetailand,285,286meadowsweetand,325St.John’swortand,423yarrowand,471

YYarrow

actionsof,471clinicalstudieson,473injectionof,472monographof,471-473oraladministrationof,472pharmacologicresearchon,472traditionalprescribingfor,472warningsandprecautionsof,471

Yellowdock(curleddock)actionsof,474liverfunctionand,44monographof,474-475pharmacologicresearchon,474-475potentialindicationsfor,474traditionalprescribingfor,474-475warningsandprecautionsfor,474

Yersiniaenterocolitica,rosemaryoiland,391

ZZinc

nettlerootand,347tumericand,436,438