DENNIS J. CADA, PharmD, FASHP

Executive Editor, The Formulary Editor in Chief, Hospital Pharmacy

TIMOTHY R. COVINGTON, PharmD, MS

Anthony and Marianne Bruno Professor of Pharmacy Director, Managed Care InstituteSchool of Pharmacy, Samford University

DANIEL A. HUSSAR, PhD

Remington Professor of PharmacyPhildelphia College of PharmacyUniversity of the Sciences in Philadelphia

DAVID S. TATRO, PharmD

Drug Information AnalystSan Carlos, California

DATE OF ISSUE: MAR 1994

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REPLACES MONOGRAPH DATED: OCT 1992

SCIENTIFIC NAME(S): Acacia senegal (L.) Willd. (syn. with A. verek Guill et Perr.). Other species of Acacia have been used in commerce. Family: Leguminosae orFabaceae

COMMON NAME(S): Acacia gum, acacia vera,¹ Egyptian thorn,¹ gummi africanum,² gum Senegal, gummae mimosae, kher, Sudan gum arabic, Somali gum, yellow thorn

BOTANY: The acacia tree (A. senegal) is a thorny, scraggly tree that grows to heights of about 15 feet. It grows most prolifically in regions of Africa, in particular in theRepublic of Sudan. During times of drought, the bark of the tree splits, exuding a sap that dries in small droplets or "tears."³ In the past, these hardened sap tears served as the major source of acacia gum, but today commercial acacia gum is derived by tappingtrees periodically and collecting the resin semi-mechanically. At least three grades ofacacia gum are available commercially and their quality is distinguished by the color and character in the collected tears.⁴ There is considerable variation in gum qualitydepending on whether it is obtained by natural flow secondary to extreme drought, obtained by tapping or induced by the boring of beetles at sites of branch injury.⁵ Gums derived from Combretum are readily available at low prices in East and West Africa andare often offered for sale as "gum arabic." Because there is no toxicologic datasupporting the safety of these gums, they are not recognized as food additives by most countries.¹⁴ Similarly, trees of the genus Albiziaare often confused with Acacia and should not be used as acacia substitutes.¹⁵

HISTORY: Acacia gum has long been used in traditional medicine and in everyday applications. The Egyptians used the material as a glue and as a pain-reliever base.Arabic physicians treated a wide variety of ailments with the gum, resulting in its current name.³ Today, it is used widely in the pharmaceutical industry as a demulcent and inthe cooking industry to give body and texture to processed food products. It also is used to stabilize emulsions. The fibers of the bark are used to make cordage.⁶

CHEMISTRY: Acacia gum is a brittle, odorless and generally tasteless material that contains a number of neutral sugars, acids, calcium and other electrolytes.⁷ The main component of the gum is arabin, the calcium salt of arabic acid.⁴ The structure of the

gum is complex and has not yet been fully explained. A comprehensive analysis, including NMR spectra for 35 samples of gum arabic, has been published to serve as the basis for international standardization of acacia gum.¹¹ The gum is built upon a

backbone of D-galactose units with side chains of D-glucuronic acid with L-rhamnose orL-arabinose terminal units. The molecular weight of the gum is large and estimates suggest the weight lies in the range of 200,000 to 600,000 daltons.⁷ It is very soluble in

water, but does not dissolve in alcohol.

PHARMACOLOGY: Acacia gum has no significant systemic effects when ingested. Although related gums have been shown to be hypocholesterolemic when ingested,there is no evidence for this effect with acacia. When administered to hypercholesterolemic patients for periods ranging from 4 to 12 weeks, acacia gum had

no effect on the level of any plasma lipid evaluated.^9,12 Some studies suggest that ingestion of acacia gum may increase serum cholesterol levels in rats.⁷ In the past, the

gum has been administered intravenously to counteract low blood pressure followingsurgery and to treat edema associated with nephrosis, but this administration caused renal and liver damage and allergic reactions, and its use was abandoned.⁵

Acacia gum is a demulcent, and soothes irritated mucous membranes. Consequently, itis used widely in topical preparations to promote wound healing and as a component of cough and some gastrointestinal preparations. Whole gum mixtures of acacia havebeen shown to inhibit the growth of periodontic bacteria, including Porphyromonas gingivalis and Prevotella intermediain vitro when added to culture medium in

concentrations ranging from 0.5% to 1.0%.⁸ At a concentration of 0.5%, acacia whole gum mixture also inhibited bacterial protease enzymes, suggesting acacia may beuseful in limiting the development of periodontal disease. In addition, chewing an acacia-based gum for 7 days has been shown to reduce mean gingival and plaquescores compared to a sugar-free gum; the total differences in these scores wassignificant (P < 0.05) between groups suggesting that acacia gum primarily inhibits the

early deposition of plaque.¹³

TOXICOLOGY: Acacia is essentially nontoxic when ingested. Allergic reactions to the gum and powdered forms of acacia have been reported and include respiratory problems and skin lesions.⁷

Acacia contains a peroxidase enzyme, which is typically destroyed by brief exposure toheat. If not inactivated, this enzyme forms colored complexes with certain amines andphenols and enhances the destruction of many pharmaceutical products including

alkaloids and readily oxidizable compounds such as some vitamins.^5,7 Acacia gumreduces the antibacterial effectiveness of the preservative methyl-p-hydroxybenzoateagainst Pseudomonas aeruginosa, presumably by offering physical barrier protection to

the microbial cells from the action of the preservative.¹⁰ A trypsin inhibitor also has been identified, but the clinical significance of the presence of this enzyme is not known.⁶

SUMMARY: Gum acacia has been used in commerce for millennia. Because of its soothing properties, it is included in cough and cold remedies and it is used topically inwound healing preparations. It is used as a stabilizer for foods. Although generally considered safe for internal use, some persons have developed severe allergic reactions following exposure to the gum.

PATIENT INFORMATION — Acacia Gum

Uses: Acacia gum has been used in food as a stabilizer and in pharmaceuticals as a demulcent. It is used topically for healing wounds and has been shown to inhibit thegrowth of periodontic bacteria and the early deposition of plaque.

Side Effects: Ingestion may raise serum cholesterol. Intravenous administration causes renal and liver damage. Various forms of acacia gum can cause allergic reactions, including respiratory problems and skin lesions.

REFERENCES

¹ Meyer JE. The Herbalist. Hammond, IN: Hammond Book Co., 1934:13.

² Osol A, Farrar GE Jr. eds. The Dispensatory of the United States of America. 25th ed. Philadelphia: J.B. Lippincott, 1955:1. ³ Dobelis IN, ed. Magic and Medicine of Plants. Pleasantville, NY: Reader's Digest

Association, Inc., 1986.

⁴ Evans WC. Trease and Evans' Pharmacognosy, 13th ed. London: Bailliere Tindall, 1989. ⁵ Morton JF. Major medicinal plants. Springfield, IL: C.C. Thomas Publisher, 1977. ⁶ Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press, 1985. ⁷ Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and

Cosmetics, New York, NY: J. Wiley and Sons, 1980.

⁸ Clark DT, et al. The effects of Acacia arabica gum on the in vitro growth and protease activities of periodontopathic bacteria. J Clin Periodontol 1993;20:238. ⁹ Jensen CD, et al. The effect of acacia gum and a water-soluble dietary fiber mixture

on blood lipids in humans. J Am Coll Nutr 1993;12:147.

¹⁰ Kurup TR, et al. Interaction of preservatives with macromolecules: Part I- natural hydrocolloids. Pharm Acta Helv 1992;67:301. ¹¹ Anderson DM, et al. Gum arabic (Acacia senegal ); Unambiguous identification by

13C-NMR spectroscopy as an adjunct to the Revised JECFA Specification, and the application of 13C-NMR spectra for regulatory/legislative purposes. Food Addit Contam 1991;8:405.

¹² Haskell WL, et al. Role of water-soluble dietary fiber in the management of elevated

plasma cholesterol in healthy subjects. Am J Cardiol 1992;69:433. ¹³ Gazi MI. The finding of antiplaque features in Acacia arabica type of chewing gum. J Clin Periodontol 1991;18:75.

¹⁴ Anderson DM, Morrison NA. The identification of Combretum gums which are not

permitted food additives, II. Food Addit Contam 1990;7:181. ¹⁵ Anderson DM, Morrison NA. Identification of Albizia gum exudates which are not permitted food additives. Food Addit Contam 1990;7:175.

Document Bibliographic Information:

DATE OF ISSUE: MAY 2001

REPLACES MONOGRAPH DATED: JAN 1993

SCIENTIFIC NAME(S): Malpighia glabra L. and M. emarginata (previously M. punicifolia L.) Family: Malpighiaceae

COMMON NAME(S): Acerola, Barbados cherry, West Indian cherry, Puerto Rican cherry, Antilles cherry, cereso, cereza, cerisier, semeruco

BOTANY: Acerola is native to the West Indies, but is also found in northern South America, Central America, Texas, and Florida. It grows as small shrubs or trees from 5 to 15 m in height. The branches are brittle and the leaves are glossy and dark to lightgreen. The 5-petaled flowers range from pink to white in color. Acerola fruit ischerry-like, 3-lobed, bright red, and 1 to 2 cm in diameter, containing several small seeds. Mature fruits are soft, pleasant-tasting, and contain 80% juice. The fruits

deteriorate rapidly once removed from the tree.^1,2,3

HISTORY: Acerola is believed to originate from the Yucatan.³ Traditionally, the fruits have been used to treat dysentery, diarrhea, and liver disorders. Both species of Malpighiahave been reported to be excellent sources of vitamin C. However, the fruit of

M. emarginata is known more accurately as acerola and is one of the richest sources of vitamin C known.¹

CHEMISTRY: Acerola contains from 1% to 4.5% vitamin C (1000 to 4500 mg/100 g) as ascorbic and dehydroascorbic acids in the edible portion of the fruit. This far exceeds the content of vitamin C in peeled oranges (about 0.05% or 50 mg/100 g).¹ The content of vitamin C in acerola varies with ripeness (highest in green and lowest in fully ripenedfruit), season, and climate. M. emarginata fruit (native to the West Indies) is the richest known source of vitamin C.¹

Vitamin C analysis regarding acerola storage after picking finds freezing (-18°C) the fruits to be the best way to preserve vitamin C percentage, as compared with room temperature or refrigeration.⁴ Older reports evaluating ascorbic acid content in acerola

are available.^5,6

In addition, acerola contains vitamin A (4300 to 12,500 IU/100 g), at about the samelevel as in carrots. Other constituents include thiamine, riboflavin, niacin, calcium, iron, bioflavonoids, phosphorus, malic acid, pantothenic acid, potassium, magnesium, and

sugars dextrose, fructose, and sucrose.^1,2,7 Acerola analysis in another report finds protein, fiber, lipids, fatty acids, zinc, and other minerals present as well.⁸

PHARMACOLOGY: Acerola is used as a source of food and juice. Because of its high concentration of vitamin C, it also is sold as a natural health supplement.⁷

Vitamin C is an essential coenzyme that is required for normal metabolic function. Whilemany animals can synthesize vitamin C from glucose, humans must obtain the vitamintotally from dietary sources. Deficiencies of this water-soluble vitamin result in scurvy, a potentially fatal disease with multisystem involvement. Dietary supplements havetraditionally provided adequate protection against the development of this disease.

However, controversy has focused on whether vitamin C derived from "natural" sourcesis more physiologic than that produced synthetically or semisynthetically (as ascorbicacid). To date, there is no clear evidence that naturally derived vitamin C is superior in its clinical effectiveness than synthetic ascorbic acid. A potential advantage to usingacerola as a source of vitamin C is that one receives not only ascorbic acid, but alsoseveral other useful vitamins and minerals from the fruit. Whether this is superior to the use of a multiple vitamin preparation has not been determined.

Vitamin C is known to strengthen the immune system, build collagen cells, support the respiratory system, and to be an effective antioxidant.⁷ The antioxidative qualities of acerola make it an ideal ingredient in skin care products to fight cellular aging.² In

another report, acerola extract was shown to enhance the antioxidant activity of soy and alfalfa extracts, acting synergistically, which may be beneficial in coronary artery disease.⁹

Acerola possesses antifungal properties. In one report, M. glabra was among the mostactive antifungal in 26 plants studied. The most susceptible fungi were E. floccosumand

10

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T. rubrum.

Ethnobotanical uses of acerola include use as an astringent and for diarrhea, dysentery, hepatitis, and fever.²

TOXICOLOGY: No specific adverse effects have been associated with the ingestion of acerola. Because vitamin C is a water-soluble compound, it is readily excreted by the body, and it is not typically associated with toxicity. However, the ingestion of largedoses may induce GI side effects, including diarrhea. Prolonged use of massive doses

of ascorbic acid may predispose to the development of renal calculi.^1,7

SUMMARY: Acerola, or Barbados cherry, is one of the richest sources of vitamin C known. It is high in vitamin A, and contains other important nutrients as well. It is used as a food and in supplementation for its vitamin C content. Vitamin C is an importantantioxidant, which also supports the immune system. Acerola also has been found topossess antifungal properties. No specific adverse effects have been associated with acerola.

PATIENT INFORMATION — Acerola

Uses: Acerola provides natural vitamin C and other useful vitamins and minerals. It is used as an astringent and for diarrhea, dysentery, hepatitis, and fever, although clinicaltrials are lacking.

Side Effects: Large doses may produce GI distress. Prolonged, massive dosage may predispose to formation of renal calculi.

REFERENCES

¹ Leung A, et al. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics. 2nd ed. New York, NY:J. Wiley and Sons, 1996:6-7. ² http://rain-tree.com/acerola.htm

³ http://www.crfg.org/pubs/ff/acerola.html ⁴ Visentainer J, et al. Vitamin C in Barbados cherry Malpighia glabra L. pulp submitted to processing and to different forms of storage. Arch Latinoam Nutr 1998 Sep;48(3):256-59.

⁵ de Medeiros R. Proportion of ascorbic, dehydroascorbic and diketogulonic acids in green or ripe acerola (Malpighia punicifolia). Rev Bras Med 1969;26(7):398-400. Portuguese.

⁶ Leme J, et al. Variation of ascorbic acid and beta-carotene content in lyophilized cherry from the West Indies (Malpighia punicifolia L.). Arch Latinoam Nutr 1973 Jun;23(2):207-15. Portuguese.

⁷ http://nattrop.com/gated/acerola.html ⁸ Visentainer J, et al. Physico-chemical characterization of acerola (Malpighia glabra L.)

produced in Maringa, Parana State, Brazil. Arch Latinoam Nutr 1997 Mar;47(1):70-72. Portuguese. ⁹ Hwang J, et al. Soy and alfalfa phytoestrogen extracts become potent low-density

lipoprotein antioxidants in the presence of acerola cherry extract. J Agric Food Chem 2001 15 Jan;49(1):308-14.

¹⁰ Caceres A, et al. Plants used in Guatemala for the treatment of dermatophyticinfections. 2. Evaluation of antifungal activity of seven American plants. J Ethnopharmacol 1993 Dec;40(3):207-13.

Document Bibliographic Information:

DATE OF ISSUE: SEP 2001

REPLACES MONOGRAPH DATED: NOV 1991

SCIENTIFIC NAME(S): Lactobacillus acidophilus

HISTORY: For several decades, health and nutritional benefits have been claimed for products containing Lactobacillus cultures. The topical or intravaginal application ofyogurt products has been reported to control yeast and bacterial infections, and the ingestion of these preparations has been recommended to reduce the symptoms of antibiotic-induced diarrhea or sore mouth caused by Candida infections.¹ Other reportshave indicated that the ingestion of acidophilus-containing products can reduce serum cholesterol levels, improve lactose intolerance, and slow the growth of experimental tumors.² L. acidophilus has been referred to as a probiotic, defined as microorganismsthat have a beneficial effect on the host by improving the properties of the indigenous microflora.³

PHARMACOLOGY

Replenishment of normal bacterial flora: Products containing live cultures have been investigated for their ability to compete with pathogens in the microenvironment, therebypermitting the reestablishment of normal bacterial flora. Lactobacilli have been shown toinhibit the growth of other vaginal microorganisms including Escherichia coli, Candida albicans, and Gardnerella vaginalis.⁴ Several factors may contribute to the possibleactivity of Lactobacillus, including the ability to generate lactic acid, hydrogen peroxide,and exogenous antibacterial compounds, to influence the production of interferon by target cells,⁵ and to alter the adherence of bacteria. Lactacin F, an antibacterial compound produced by L. acidophilus, has been isolated and partially characterized as

a heat-stable protein with at least 56 amino acid residues.^6,7

Lactobacillus has long been considered to be a component of the protective flora in thevagina. Recently, Lactobacillus species that produce hydrogen peroxide have been found in normal vaginal flora. Consequently, the therapeutic benefits of Lactobacillus products have been investigated in women with vaginal and urinary tract infections.Women who used acetic acid jelly, an estrogen cream, a fermented lactobacillus-containing milk product, or metronidazole (eg, Flagyl) were evaluated todetermine the effects of intravaginal therapy on bacterial vaginosis. Clinical cures wereobtained for 13 of 14 women receiving metronidazole but for only 1 of 14 using the fermented milk product. This latter intervention did not influence the predominance of

lactobacilli in the vagina.⁸ An evaluation of 16 commercially available productscontaining Lactobacillus in the form of capsules, powders, and tablets (in addition to yogurt and milk) found that all 16 products contained lactobacilli, of which 10 strains produced hydrogen peroxide. At least one contaminant was detected in 11 of the products, including Enterococcus faecium, Clostridium sporogenes, and Pseudomonas species. Only 4 of the products contained L. acidophilusand, therefore, the authors concluded that most commercially available products may not be appropriate for

recolonization of the vagina.⁴ The American Medical Association proposed guidelinesfor manufacturers to state on yogurt containers the number of viable L. acidophilus organisms contained therein.⁹ Vaginal tablets containing L. acidophilus and estriol were shown to cure bacterial vaginosis.¹⁰ A study showed decreased candidal vaginitis after ingestion of yogurt containing L. acidophilus.¹¹ However, ingestion of yogurt containing

L. acidophilus increased colonization of the vagina and showed a reduction in the

episodes of bacterial vaginosis but not in episodes of candidal vaginitis when compared to pasteurized yogurt.¹² Lactobacillusspecies that are strong producers of hydrogenperoxide and are highly adherent to vaginal epithelial cells effectively treat bacterial

vaginosis.^13,14 Specific isolates of Lactobacillus with these characteristics are potential probiotics for vaginal recolonization.¹⁴ The weekly instillation of Lactobacillus has been shown to reduce the recurrence rate of uncomplicated lower urinary tract infections in

women, and the use of a strain that is resistant to nonoxynol-9, a spermicide that killsprotective vaginal flora, may have potential for use in women with recurrent cystitis using this contraceptive agent.¹⁵

L. acidophilus is normally found in the human alimentary tract. Because of itsacid-resistance, it persists in the stomach much longer than other bacteria do. Consequently, the oral administration of products containing L. acidophilusmay beuseful in the management of a variety of conditions associated with altered GI flora.Their beneficial effects may be related to the ability to suppress the growth of pathogens. In vitro, L. acidophilus has been shown to suppress the growth of Campylobacter pylori, a pathogen implicated as a causative factor in acid-peptic

disease, although the therapeutic implications of these findings are not clear.^16,17 In vivo, inactivated L. acidophilus added to the triple regimen of an acid-suppressor plustwo antibiotics increased eradication rates of Helicobacter pylori, another pathogenimplicated in myriad upper GI diseases. Larger clinical trials are necessary to validate

this finding.¹⁸

No consensus has been reached regarding the effectiveness of Lactobacillus-containing products in ameliorating antibiotic-induced diarrhea. When Lactinex granules, acombination of L. acidophilus and L. bulgaricus, were given 4 times daily for 10 days tochildren concomitantly with amoxicillin (eg, Amoxil) therapy under double-blind conditions, 70% of the patients receiving placebo and 66% of those taking Lactinex experienced diarrhea. Closer analysis suggested that the incidence of diarrheadiminished during the last 4 days of therapy for the Lactinex patients, while it remained

constant for those given placebo.¹⁹ However, in a study of 40 children who receivedamoxicillin concomitantly with fermented Lactobacillus milk products, the treated groupshowed a lower frequency of stool passages and more fully formed feces compared

with no treatment.²⁰ In a study of 27 patients randomized to amoxicillin/clavulanate (eg, Augmentin) with or without Lactinex, there were fewer episodes of diarrhea reported inthe Augmentin-only group, although the addition of Lactinex resulted in reduction of nausea, cramping, flatulence, and yeast superinfection.²¹

Addition of lyophilized, heat-killed L. acidophilus LB to oral rehydration therapydecreased duration of diarrhea in a randomized clinical trial of children not on antibiotic therapy.²² However, L. acidophilusdid not prevent traveler's diarrhea.²³

The ingestion of these products has been associated with decreases in the concentration of several fecal enzymes that have the capacity to convertprocarcinogens to carcinogens in the colon. This suggests that consumption of Lactobacillus-containing products may have beneficial health effects, although no

further data are available to support this hypothesis.²⁴ The combination of L. acidophilus and lactulose appears beneficial in the therapy of radiotherapy-related intestinal side effects.²⁵

Effect on cholesterol levels: It has been suggested that appropriately selected strains of Lactobacillus may be useful adjuncts for the control of hypercholesterolemia inhumans, by virtue of the bacteria's ability to assimilate cholesterol and to grow well in the presence of bile.²⁶ The results of one study, in which 354 subjects took Lactinex tablets or placebo 4 times a day for 3 weeks in a crossover fashion, found no clinically significant changes in lipoprotein concentrations for either group.²⁷ Serum LDL-cholesterol was lowered in a study of healthy male patients consuming low-fat milk fermented with 2 strains of Lactobacillus and fructo-oligosaccharides (which could have contributed to the results).²⁸ Yogurt enriched with L. acidophilus did not lower serum cholesterol in another study of men and women.²⁹ Conflicting results remain concerning Lactobacillusspecies' effect on serum cholesterol levels.

Consumption of yogurt containing L. acidophilusin 15 asthmatic patients showed trends in decreased eosinophilia and increased interferon gamma, however, without improving

clinical parameters.³⁰ Viability might be a prerequisite for effects on the immune system.³¹ Further studies are necessary to ascertain if L. acidophilus has an effect on immunity.

Effect on lactose intolerance: Acidophilus milk containing L. acidophilushas been used in hospitals to treat patients with lactose intolerance, although controversy remains regarding effectiveness on lactose digestion.³² In a randomized trial of 18 patients, symptoms were not significantly improved after ingestion of L. acidophilus.³³

TOXICOLOGY: Endocarditis caused by Lactobacillusspecies, including L. acidophilus

has been reported.³⁴ This is a rare infection seen in patients with abnormal heart valves who have recently experienced dental manipulation.³⁴ Neurological sequelae

from D-lactic acidosis, caused by consumption of acidophilus tablets and yogurt

containing L. acidophilus, was observed in a child with short-bowel syndrome.³⁵ Complete avoidance of L. acidophilus in children with short-bowel syndrome may help prevent episodes of D-lactic acidosis.³⁵

SUMMARY: Preparations containing L. acidophilusinclude yogurt, milk, tablets, capsules, and granules. They are used most frequently to restore normal flora to the GItract and vagina. However, the data supporting the efficacy of these products for theseuses are conflicting. Use of L. acidophilus is generally considered safe. Rare adverse events include endocarditis in susceptible patients and lactic acidosis in children withshort-bowel syndrome.

PATIENT INFORMATION — Acidophilus

Uses: L. acidophilus has been used to restore normal oral, GI, and vaginal flora in those affected by antibiotics or by Candida and bacterial infections. Its value in treating theseinfections, lower urinary tract infections, and lactose intolerance remains unclear. In vitro, it suppresses growth of C. pylori, implicated in acid-peptic disease. In vivo, itsuppresses growth of H. pylori, also implicated in upper GI diseases.

Side Effects: L. acidophilus is generally considered safe, as it is normally found in the human alimentary tract. However, in patients with abnormal heart valves who have recently experienced dental manipulation, endocarditis caused by Lactobacillus specieshas been reported. Complete avoidance of L. acidophilusin children with short-bowel syndrome may help prevent episodes of D-lactic acidosis.

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REFERENCES

¹ Lewis WH. Medical Botany. New York, NY: J. Wiley and Sons, 1977.² Gorbach SL. Lactic acid bacteria and human health. Ann Med 1990;22(1):37.³ Holzapfel WH, Haberer P, Geisen R, et al. Taxonomy and important features of

probiotic microorganisms in food and nutrition. Am J Clin Nutr 2001;73(2 AMAsuppl):365S-373S.

⁴ Hughes VL, Hillier SL. Microbiologic characteristics of Lactobacillus products used for

colonization of the vagina. Obstet Gynecol 1990;75(2):244. ⁵ Mihal V, et al. Immunobiologic properties of lactobacilli. Cesk Pediatr 1990;45(10):587.

⁶ Muriana PM, Klaenhammer TR. Purification and partial characterization of Lactacin F, a bacteriocin produced by Lactobacillus acidophilus 11088. Appl Environ Microbiol 1991;57(1):114.

⁷ Muriana PM, Klaenhammer TR. Cloning, phenotypic expression and DNA sequence of the gene for Lactacin F, an antimicrobial peptide produced by Lactobacillus spp. J Bacteriol 1991;173(5):1779.

⁸ Fredricsson B, et al. Bacterial vaginosis is not a simple ecological disorder. Gynecol

Obstet Invest 1989;28(3):156. ⁹ Podolsky S, Tauber AI. Yogurt for candidal vaginitis [editorial]. Ann Intern Med 1992;117(4):345-6.

¹⁰ Parent D, Bossens M, Bayot D, et al. Therapy of bacterial vaginosis usingexogenously-applied Lactobacilli acidophiliand a low dose of estriol: a placebo-controlled multicentric clinical trial. Arzneimittel-Forschung 1996;46(1):68-73.

¹¹ Hilton E, Isenberg HD, Alperstein P, et al. Ingestion of yogurt containing Lactobacillus

acidophilus as prophylaxis for candidal vaginitis. Ann Intern Med 1992;116(5):353-7. ¹² Shalev E, Battino S, Weiner E, et al. Ingestion of yogurt containing Lactobacillus

acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis. Arch Fam Med 1996;5(10):593-6. ¹³ Hallen A, Jarstrand C, Pahlson C. Treatment of bacterial vaginosis with lactobacilli.

Sexually Transmitted Diseases 1992;19(3):146-8. ¹⁴ McLean NW, Rosenstein I. Characterisation and selection of a Lactobacillus species

to re-colonise the vagina of women with recurrent bacterial vaginosis. J Med Microbiol2000;49:543-52. ¹⁵ Reid G, et al. Is there a role for lactobacilli in prevention of urogenital and intestinal

infections? Clin Microbiol Rev 1990;3(4):335.

¹⁶ Bhatia SJ, et al. Lactobacillus acidophilusinhibits growth of Campylobacter pylori in vitro. J Clin Microbiol 1989;27:2328. ¹⁷ Gismondo MR, et al. Competitive activity of a bacterial preparation of colonization

and pathogenicity of C. pylori. A clinical study. Clin Ter 1990;134(1):41. ¹⁸ Canducci F, Armuzzi A, Cremonini F, et al. A lyophilized and inactivated culture of Lactobacillus acidophilus increases Helicobacter pylori eradication rates. Aliment Pharmacol Ther 2000;14(12):1625-9.

¹⁹ Tankanow RM, et al. A double-blind, placebo-controlled study of the efficacy of Lactinex in the prophylaxis of amoxicillin-induced diarrhea. DICP Ann Pharmacother 1990;24(4):382.

²⁰ Contardi I. Oral bacteria therapy in prevention of antibiotic-induced diarrhea in

childhood. Clin Ter 1991;136(6):409. ²¹ Witsell DL, Garrett CG, Yarbrough WG, et al. Effect of Lactobacillus acidophilus on antibiotic-associated gastrointestinal morbidity: a prospective randomized trial. J Otolaryngol1995;24(4):230-3.

²² Simakachorn N, Pichaipat V, Rithipornpaisarn P, et al. Clinical evaluation of the addition of lyophilized, heat-killed Lactobacillus acidophilus LB to oral rehydration therapy in the treatment of acute diarrhea in children. J Pediatr Gastroenterol Nutr2000;30(1):68-72.

²³ Katelaris PH, Salam I, Farthing MJG. Lactobacilli to prevent traveler's diarrhea? N Engl J Med 1995;333(20):1360-1.

²⁴ Marteau P, et al. Effect of chronic ingestion of a fermented dairy product containing Lactobacillus acidophilus and Bifidobacterium bifidum on metabolic activities of the colonic flora in humans. Am J Clin Nutr 1990;52(4):685.

²⁵ Salminen S, Salminen E. Lactulose, lactic acid bacteria, intestinal microecology and

mucosal protection. Scand J Gastroenterol1997;222:45-8. ²⁶ Gilliland SE, Walker DK. Factors to consider when selecting a culture of Lactobacillus acidophilus as a dietary adjunct to produce a hypocholesterolemic effect in humans. J Dairy Sci 1990;73(4):905.

²⁷ Lin SY, et al. Lactobacillus effects on cholesterol: In vitro and in vivo results. J Dairy

Sci1989;72(11):2885. ²⁸ Schaafsma G, Meuling WJ, van Dokkum W, et al. Effects of a milk product, fermented by Lactobacillus acidophilusand with fructo-oligosaccharides added, on blood lipids in male volunteers. Eur J Clin Nutr 1998;52:436-440.

²⁹ de Roos NM, Schouten G, Katan MB. Yoghurt enriched with Lactobacillus acidophilus does not lower blood lipids in healthy men and women with normal toborderline high serum cholesterol levels. Eur J Clin Nutr 1999; 53(4):277-80.

³⁰ Wheeler JG, Shema SJ, Bogle ML, et al. Immune and clinical impact of Lactobacillus

acidophilus on asthma. Ann Allergy Asthma Immunol 1997;79(3):229-33. ³¹ de Roos NM, Katan MB. Effects of probiotic bacteria on diarrhea, lipid metabolism, and carcinogenesis: a review of papers published between 1988 and 1998. Am J Clin Nutr 2000;71:405-11.

³² Lin MY, Yen CL, Chen SH. Management of lactose maldigestion by consuming milk

containing lactobacilli. Dig Dis Sci 1998;43(1):133-7. ³³ Saltzman JR, Russell RM, Golner B, et al. A randomized trial of Lactobacillus acidophilus BG2FO4 to treat lactose intolerance. Am J Clin Nutr 1999;69:140-6.

³⁴ Griffiths JK, Daly JS, Dodge RA. Two cases of endocarditis due to Lactobacillus species: antimicrobial susceptibility, review, and discussion of therapy. Clin Infect Dis 1992;15(2):250-5.

³⁵ Day AS, Abbott GD. D-lactic acidosis in short bowel syndrome. N Z Med J 1999;112(1092):277-8.

Document Bibliographic Information:

DATE OF ISSUE: DEC 2003

REPLACES MONOGRAPH DATED: OCT 2002

SCIENTIFIC NAME(S): Blighia sapida, K. Konig. Family: Sapindaceae

COMMON NAME(S): Ackee, akee, aki, arbre a' fricasser,¹ seso vegetal,² yeux de crabe,¹ merey del diablo,¹ ris de veau,¹ fruto de huevo,¹ arbol de seso,¹ pero roja,¹ pan y quesito¹

BOTANY: Ackee is the national fruit of Jamaica and is widely found throughout the West Indies and has been naturalized to parts of Central America, Florida, and Hawaii.This tall, leafy tree grows to approximately 12 meters and produces fruit 2 times/year, between January and March, and June and August.¹ Its oval, compound leaves have 5 pair of leaflets, the longest of which is approximately 15 centimeters at the tip. The plantproduces small, greenish-white flowers. The red fruit pods split open at maturity, exposing 3 shiny, black seeds embedded in a white, waxy aril.²

HISTORY: The ackee tree was imported to Jamaica from West Africa in the late 1700s and is often grown as an ornamental.³ Although the unripened walnut-like seeds are toxic, the ripe fruits are used in traditional island cooking.² The ackee is a major food in Jamaica and is noted for its high protein and fat content.⁴ Fresh ackee berries

are available in season in markets and canned fruit is available throughout the year. Poisonings have long been associated with the use of the ackee, and published reports of Jamaican intoxications date back to 1904.⁵ In South America, the fruit is used to treat colds, fever, and diseases as varied as edema and epilepsy.³

CHEMISTRY: Hypoglycin A and hypoglycin B are potent hypoglycemic compounds.¹ The most toxic is the cyclopropyl amino acid hypoglycin A and its metabolitemethylenecyclopropylacetic acid, found in the aril and the seeds of the unripe ackee

fruit.^1,6,7 The unripe ackee fruit contains hypoglycin A at concentrations 100 times

higher than those in ripe ackee fruit.^7,8 In addition, other hypoglycemic compounds,including hypoglycin B and cyclopropanoid amino acids, are found in the seed. CNSactive carboxycyclopropylglycines found in the unripened fruit are reported to be potent

group II metatrophic glutamate receptor agonists.⁹

PHARMACOLOGY: Hypoglycin A is a water-soluble liver toxin that induces hypoglycemia by inhibiting gluconeogenesis by limiting the activity of cofactor mimics (CoA and carnitine) that are required for the oxidation of long-chain fatty acids.⁵ Methylenecyclopropylacetyl-CoA also causes secondary inhibition of gluconeogenesis by inactivating several acyl-CoA dehydrogenases involved with the oxidation of fatty acids and several amino acids.¹⁰ The pink raphe (the portion of the seed that attachesto the ovary wall) and the aril in the immature plant are poisonous because of the

presence of the hypoglycins. The arils become edible when the fruit ripens; hypoglycin A is efficiently removed from the edible arils when the ackee fruit is boiled in water for approximately 30 minutes.⁷ Hypoglycin A appears to be approximately twice as toxic as hypoglycin B.⁶ The powdered fruits are used in Africa as a fish poison.³

More than 5000 people have died from ackee poisoning since 1886.^6,10 In the past,large-scale poisonings appeared to be limited to the island of Jamaica where they reached epidemic proportions during the winter months under the name of "Jamaican

vomiting sickness."² In Jamaica, 28 patients who had symptoms of ackee poisoningwere identified during the period between January 1989 through July 1991. Six of these patients died. The most common symptoms were vomiting, coma, and seizures. Sevenof the patients had confirmed hypoglycemia. Most of the cases occurred between

January and March.⁵

A case-control, retrospective study of health-service records and interviews with familymembers, village chiefs, and local healers in a rural area in west Africa identified 29 cases of fatal encephalopathy in preschool children (2 to 6 years of age) during Januaryto May 1998. All children died within 48 hours of onset of symptoms. The clinicalpresentation was similar to that of Jamaican vomiting sickness and toxic hypoglycemic

syndrome; most common symptoms included hypotonia, convulsions, and coma.⁸

Eighty cases with symptoms consistent of ackee poisoning (ie, continuous vomiting,

abdominal pains, loss of consciousness, convulsions within 24 hours) were recorded in 2 districts of Haiti's Northern Province between November 2000 and March 2001.¹ Retrospective analysis confirmed 31 of the 80 cases were related to consumption of ackee. The mean age of the victims ranged from 6 months to 88 years, with a median of

7 and an average of 16. The case fatality rate was 52%.¹

Poisonings may be present in 1 of 2 distinct forms. In the first case, vomiting is followedby a remission period of 8 to 10 hours, followed by renewed vomiting, convulsions, andcoma. The second type is characterized by convulsions and coma at the onset. Additional symptoms associated with chronic fruit ingestion include cholestatic jaundice,

abdominal pain, and elevated liver function values.¹¹ Diarrhea and fever are usuallyabsent. Six to 48 hours may elapse between ingestion of the fruit and the onset of symptoms.¹² Severe hypoglycemia develops² and blood glucose levels as low as 3 mg/dL are observed in many cases.⁵

Management of ackee intoxication consists of fluid therapy and the administration ofglucose and electrolytes. Because patients with preexisting nutritional deficits andchildren may be more sensitive to the toxic effects of the fruit, vitamin and nutritional

supplements should be administered.^2,5,12

SUMMARY: The ripe ackee fruit is traditionally used in Jamaican cooking. However, the unripened fruit is toxic, causing severe hypoglycemia often accompanied by convulsions and death.

PATIENT INFORMATION — Ackee

Uses: The ackee is a major food in Jamaica. In South America, the fruit has been used to treat colds, fever, and diseases as varied as edema and epilepsy, although there areno clinical trials to support these uses.

Side Effects: Six to 48 hours may elapse between ingestion of the unripened fruit and the onset of symptoms. Symptoms of ackee poisoning include cholestatic jaundice, vomiting, hypoglycemia, convulsions, coma, and potentially death.

Drug Interaction/Disease-State Concerns: Hypoglycemia caused by ackee may be masked in patients on beta-blockers because these suppress epinephrine-mediatedwarning signs of imminent hypoglycemia; monitor patients with diabetes.

REFERENCES

¹ Moya J. Ackee (Blighia sapida) poisoning in the Northern Province, Haiti, 2001.

Epidemiol Bull. 2001;22:8-9. ² Lampe KF. AMA Handbook of Poisonous and Injurious Plants. Chicago, IL: Chicago Review Press; 1985.

³ Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press, 1985. ⁴ Ashurst PR. Toxic substances of ackee. Review. J Sci Res Counc Jam. 1971;2:4-16. ⁵ Toxic Hypoglycemic Syndrome-Jamaica, 1989-1991. MMWR. 1992;41:53. ⁶ Farnsworth NR, Segelman AB. Hypoglycemic Plants. Tile and Till. 1971;57:52. ⁷ Golden KD, Williams OJ, Bailey-Shaw Y. High-performance liquid chromatographic

analysis of amino acids in ackee fruit with emphasis on the toxic amino acid hypoglycin

A. J Chromatogr Sci. 2002;40:441-446. ⁸ Meda HA, Diallo B, Buchet JP, et al. Epidemic of fatal encephalopathy in preschool

children in Burkina Faso and consumption of unripe ackee (Blighia sapida) fruit. Lancet. 1999;353:536-540.

⁹ Natalini B, Capodiferro V, De Luca C, Espinal R. Isolation of pure (2S,1'S, 2'S)-2-(2'-carboxycyclopropyl) glycine from Blighia sapida (Akee). J Chromatogr A. 2000;873:283-286.

¹⁰ Sherratt HA. Hypoglycin, the famous toxin of the unripe Jamaican ackee fruit. Trends

Pharmacol Sci. 1986;7:186-191. ¹¹ Larson J, Vender R, Camuto P. Cholestatic jaundice due to ackee fruit poisoning. Am J Gastroenterol. 1994;89:1577-1578.

¹² Henry SH, Page SW, Bolger PM. Hazard assessment of ackee fruit (Blighia sapida). Hum Ecol Risk Assess. 1998;4:1175-1187.

Document Bibliographic Information:

DATE OF ISSUE: FEB 2002

REPLACES MONOGRAPH DATED: FEB 1993

SCIENTIFIC NAME(S): Aconitum napellus L. A. columbianum Nutt. also is described in cases of aconite toxicity. Family: Ranunculaceae

COMMON NAME(S): Aconite, monkshood, friar's cap, helmet flower, soldier's cap, wolfsbane¹

BOTANY: These erect perennial plants grow to a height of 0.6 to 1.5 m (2 to 6 feet). In general, they resemble delphiniums. The characteristic helmet-shaped blue flowers grow in a raceme at the top of the stalk in summer or fall. Occasionally, the flowers may be white, pink, or peach. The seed pods dry and contain numerous tiny seeds.¹ More than 100 species of Aconitum are distributed throughout the temperate zones of the United States and Canada. These plants also are found throughout many parts of Asia,Africa, Europe, and Russia.

HISTORY: Aconite is well known because it is extremely toxic. The tuberous root has been used in traditional medicine, although all parts of the plant are considered to betoxic. While the extracts of the plant are used rarely in American medicine today, they continue to find use in liniments as rubifacients for external application. Extracts of theplant are used in homeopathic and traditional medicine as hypotensives, to decrease fever, as cardiac depressants, and to treat neuralgia.² In traditional Asian medicine, extracts of the root are typically mixed with other ingredients (eg, licorice, ginger) forailments ranging from sciatica to nephritis. Extracts also have been used as arrowpoisons.

CHEMISTRY: Alkaloids account for up to 1.5% of the dry weight of the plant. These consist primarily of the related alkaloids aconitine, picraconitine, aconine, and napelline.³ Aconitine is hydrolyzed to picraconitine, which hydrolyzes to aconine. A wide

variety of minor alkaloids have been isolated from the various species of aconite. Someexamples include the following: Species A. sinomontanum contains norditerpenoid alkaloids sinomontanitines, lappaconitine, and ranaconitine.⁴ Hypaconitine is found in roots of A. coreanum.⁵ Other plants, such as delphinium, may have similar alkaloids such as methyl-lycaconitine.⁶

PHARMACOLOGY: Some Aconitum species have been reported to exert antitumor activity in vitro and in animals, while others possess antibacterial and antifungal activity.³ In animal models, aconitine and related compounds have been shown to possess anti-inflammatory and analgesic properties.⁷

TOXICOLOGY: Aconite is a fast-acting toxin. The active principles are aconitine and related alkaloids. As little as 2 to 5 mg of aconitine (˜ 1 teaspoonful of the root) maycause death from paralysis of the respiratory center or cardiac muscle.

Toxicity from the wild plant has resulted when the plant was mistaken for wild parsley or the root for horseradish.²

Aconitine's toxicity is characterized by a burning sensation of the lips, tongue, mouth,and throat almost immediately following ingestion. Numbness of the throat may ensue with difficulty in speaking. Salivation, nausea, and vomiting may occur along with visualblurring or yellow-green color vision distortion. A single dose of 0.6 mg/kg of aconitineadministered intraperitoneally to rabbits has been shown to cause histopathologic

damage to the myelin sheath of the visual pathway, spinal cord, and peripheral nerves.⁸

Similarly, aconitine has demonstrated arrhythmogenic and cardiotoxic effects on myocardium in anesthetized cats.⁹ Weakness, dizziness, and incoordination may occur. Gastric lavage or induction of emesis following the injection of atropine has been

recommended.¹⁰ Some experiments have used aconitine to artificially induce

arrhythmias in laboratory animals to study the antiarrhythmic effects of other drugs.^11,12

Cardiac arrhythmias of unusual electrical characteristics have been observed following

aconite poisoning.¹³ These arrhythmias may not respond to procainamide and may worsen following verapamil administration. Putrescine, a compound used experimentally as a molecular probe, has been shown to attenuate aconitine-induced arrhythmias.¹⁴ Death may ensue secondary to cardiac arrhythmia,¹ which may occur unpredictably within minutes or days.² Several case reports describe poisonings with aconite or its

constituents, including ventricular tachycardia, other arrhythmias, and death.^15,16,17,18

One homicide attempt with the plant has been reported.¹⁹ Self-medication with aconite tincture resulted in severe bradycardia, sinus inactivity, hypotension, and other cardiotoxicities, all of which were reversible.²⁰ Life-threatening ventricular tachycardias were successfully treated with amiodarone.²¹ Resuscitation and percutaneous

cardiopulmonary bypass were instituted in a 41-year-old male who mistakenly consumed the plant. He was discharged ˜ 3 months after the incident.²² A postmortem

evaluation of aconitum alkaloid distribution following a suicidal ingestion of the tuber parts has been reported. High alkaloid content was found in the kidneys, liver, and ileum. Elimination of the alkaloids were via urine and feces.²³

Aconitine is classified as a neurotoxin, which can induce severe neurological symptomsand cardiovascular collapse. Alkaloid lappaconitine blocks voltage-gated sodium channels in heart tissue.²⁴

Aconitine is known to shift voltage-dependence of voltage-dependent sodium channelstoward the hyperpolarized direction, resulting in permanent activation of the channel. Structurally related alkaloids in rat hippocampi have been studied for their effects.²⁵

Aconitine produces tingling and numbness when applied to the skin and significant toxicity may develop following percutaneous absorption.

There is evidence to suggest that aconite may lose potency after undergoing certain manufacturing procedures; therefore, processed aconite may not have a similar toxicity profile to the crude plant material.²⁶

SUMMARY: Aconite and several of its related species are recognized as highly toxic. Some traditional or homeopathic uses include employment of the plant for externalliniments, hypotensives, or treatment of neuralgias. Several case studies regarding tachycardia and other cardiac toxicities have been reported.

PATIENT INFORMATION — Aconite

Uses: Aconite extracts have been used externally and homeopathically in Europe and Asia, but rarely in the United States. Research suggests a variety of possibleapplications. Use is not recommended because of its toxicity.

Side Effects: Aconite is highly toxic. As little as 2 to 5 mg may cause death from paralysis of the respiratory center or cardiac muscle. Significant toxicity also may develop following percutaneous absorption.

REFERENCES

¹ Lampe KF. AMA Handbook of Poisonous and Injurious Plants. Chicago, IL: Chicago

Review Press; 1985. ² Spoerke DG. Herbal Medications. Santa Barbara, CA: Woodbridge Press Publishing Company; 1980.

³ Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and

Cosmetics. New York, NY: J. Wiley and Sons, 1980. ⁴ Wang FP, Peng CS, Jian XX, Chen DL. Five new norditerpenoid alkaloids from Aconitum sinomontanum. J Asian Nat Prod Res. 2001;3:15-22.

⁵ Fu M, Zhang C, Mao S. Influence of processing on the content of hypaconitine in the roots of Aconitum coreanum (Levl.) Rapaics [in Chinese]. Zhongguo Zhong Yao Za Zhi. 1997;22:280-281, 319.

⁶ Gardner DR, Manners GD, Panter KE, Lee ST, Pfister JA. Three new toxic norditerpenoid alkaloids from the low larkspur Delphinium nuttallianum. J Nat Prod. 2000;63:1127-1130. (Erratum in J Nat Prod. 2000;63:1598.)

⁷ Murayama M, Mori T, Bando H, Amiya T. Studies on the constituents of Aconitum species. IX. The pharmacological properties of pyro-type aconitine alkaloids, components of processed aconite powder "kako-bushi-matsu": analgesic, anti-inflammatory, and acute toxic activities. J Ethnopharmacol. 1991;35:159-164.

⁸ Kim SH, Kim SD, Kim SY, Kwak JS. Myelo-optic neuropathy caused by aconitine in

rabbit model. Jpn J Ophthalmol. 1991;35:417-427. ⁹ Sheikh-Zade YR, Cherednik IL, Galenko-Yaroshevskii PA. Peculiarities of cardiotropic effect of aconitine. Bull Exp Biol Med. 2000;129:365-366.

¹⁰ Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press; 1985. ¹¹ Zhang HM, Li HQ. Anti-arrhythmic effects of sophoridine and oxysophoridine.

Zhongguo Yao Li Xue Bao. 1999;20:517-520.

¹² Pau A, Asproni B, Boatto G, et al. Synthesis of substituted N-(4-piperidyl)-N-(3-pyridyl)amides with antiarrhythmic activity. Note 1. Pharmazie. 2000;55:892-895.

¹³ Tai YT, Lau CP, But PP, Fong PC, Li JP. Bidirectional tachycardia induced by herbal

aconite poisoning. Pacing Clin Electrophysiol. 1992;15:831-839. ¹⁴ Bazzani C, Genedani S, Tagliavini S, Bertolini A. Putrescine reverses aconitine-induced arrhythmia in rats. J Pharm Pharmacol. 1989;41:651-653.

¹⁵ Gupta BS, Saigal R, Vottery R, Singhal N, Banerjee S. Sustained ventricular

tachycardia in a case of aconite poisoning. J Assoc Physicians India. 1999;47:455. ¹⁶ Ortuno Anderiz F, Salaverria Garzon I, Vazquez Rizaldos S, Blesa Malpica AL. Fatal poisoning caused by aconitine alkaloid [in Spanish]. Rev Clin Esp. 1999;199:861.

¹⁷ Mak W, Lau CP. A woman with tetraparesis and missed beats. Hosp Med. 2000;61:438.

¹⁸ Imazio M, Belli R, Pomari F, et al. Malignant ventricular arrhythmias due to Aconitum

napellus seeds. Circulation. 2000;102:2907-2908. ¹⁹ Dobbelstein H. Background of a toxicological emergency: homicide attempt with monk's hood [in German]. MMW Fortschr Med. 2000;142:46-47.

²⁰ Guha S, Dawn B, Dutta G, Chakraborty T, Pain S. Bradycardia, reversible panconduction defect and syncope following self-medication with a homeopathic medicine. Cardiology. 1999;91:268-271.

²¹ Yeih DF, Chiang FT, Huang SK. Successful treatment of aconitine induced life

threatening ventricular tachyarrythmia with amiodarone. Heart. 2000;84:E8. ²² Ohuchi S, Izumoto H, Kamata J, et al. A case of aconitine poisoning saved with cardiopulmonary bypass [in Japanese]. Kyobu Geka. 2000;53:541-544.

²³ Ito K, Tanaka S, Funayama M, Mizugaki M. Distribution of Aconitum alkaloids in body fluids and tissues in a suicidal case of aconite ingestion [in Japanese]. J Anal Toxicol. 2000;24:348-353.

²⁴ Wright SN. Irreversible block of human heart (hH1) sodium channels by the plant

alkaloid lappaconitine. Mol Pharmacol. 2001;59:183-192. ²⁵ Ameri A, Simmet T. Interaction of the structurally related aconitum alkaloids, aconitine and 6-benzyolheteratisine, in the rat hippocampus. Eur J Pharmacol. 1999;386:187-194.

²⁶ Thorat S, Dahanukar S. Can we dispense with Ayurvedic Samskaras? J Postgrad Med. 1991;37:157-159.

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Document Bibliographic Information:

DATE OF ISSUE: AUG 1995

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Agrimonia eupatoriaL. Family: Rosaceae

COMMON NAME(S): Cocklebur, stickwort, liverwort

BOTANY: Agrimony (of British Herbal Pharmacopoeia) is a perennial herb with small, star-shaped yellow flowers. The plant possesses a short rhizome and is supported by afirm, hairy stem. The basal leaves are arrayed in a rosette and they, as well as the alternate sessile stem leaves, are pinnate, serrate and glabrous.¹ The flowers and fruit (achene) grow at the top of the stem in a long, terminal spike. Agrimony is common ingrasslands throughout Europe. It is imported from Bulgaria, Hungary and the former Yugoslavia.²

HISTORY: The name Agrimonia may have its origin in the Greek "agremone" which refers to plants which supposedly healed cataracts of the eye. The species name eupatoria probably relates to Mithradates Eupator, King of Pontres, who is credited withintroducing many herbal remedies. Its ancient uses include treatment for catarrh(mucous membrane inflammation with discharge), bleeding, tuberculosis and skin diseases.¹ In folk medicine, it has been reported, without verification, to be useful ingallbladder disorders. Numerous other reported uses include use as a dye, flavoring,gargle for performers and speakers, antitumor agent, astringent, cardiotonic, coagulant, diuretic, sedative, antiasthmatic and for corns or warts.³

CHEMISTRY: The aerial parts of the plant contain 4% to 10% condensed tannins,

small amounts of ellagitannins and traces of gallotannins.^2,4 Also reported are some

20% polysaccharides.⁴ A triterpenoid, urosolic acid, has been isolated. Silicic acid andtraces of essential oil are listed as constituents.The flavonoids, luteolin and apigenin 7-0-ß-D-glucosides, are present.⁴ Organic acids, vitamin B₁, vitamin K and ascorbic acid are also listed as components. The fresh herb contains agrimoniolide, palmitic and

stearic acids, ceryl alcohol and phytosterols. Seeds contain 35% oil which contains

oleic, linoleic and linolenic acids.^2,3

PHARMACOLOGY: Agrimony is used widely in Europe as a mild astringent (externally and internally), particularly against inflammation of the throat, gastroenteritisand intestinal catarrh. Studies of ethanolic extracts display the anti-viral properties. Thisplant is often included in phytomedicine mixtures for "liver and bile teas," again without true scientific verification. Agrimony extracts are often used in small amounts inprepared European cholagogues and stomach and bowel remedies (eg, Neo-Gallonorm®-Dragees) and urological products (eg, Rhoival®). Agrimony is also a

component of the British product Potter's Piletabs®.^2,4,5,6

TOXICOLOGY: Agrimony has been reported to produce photodermatitis in man.³

SUMMARY: Agrimony is used as a tea and gargle for sore throats, in compresses or poultices for skin rashes and cuts, and in various bath preparations. It does appear tohave justifiable use as a mild antiseptic and topical astringent. Internal uses of this herbrequire further verification.

PATIENT INFORMATION — Agrimony

Uses: Agrimony is used as a tea and gargle for sore throat, and externally as a mild antiseptic and astringent.

Side Effects: Agrimony reportedly can produce photodermatitis.

REFERENCES

¹ Bunney S, ed. The Illustrated Encyclopedia of Herbs: Their Medicinal and Culinary

Uses. New York: Dorset Press, 1984. ² Bisset NG, ed. Herbal Drugs and Phytopharmaceuticals. Stuttgart: Medpharm Scientific Publishers, 1994.

³ Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press, 1985. ⁴ von Gizycki F. Pharmazie 1949;4:276, 463. ⁵ Hoppe HA. Drogenkunde, 8th ed., vol. 1. Berlin: Walter deGruyter, 1975. ⁶ Drozd GA, et al. Prir Soedin 1983;1:106. ⁷ Chon SC, et al. Med Pharmacol Exp 1987;16:407.

Document Bibliographic Information:

DATE OF ISSUE: APR 2002

REPLACES MONOGRAPH DATED: FEB 1996

SCIENTIFIC NAME(S): Agropyron repens (L.) P. Beauv., Elymus repens, Graminis rhizoma, Triticum repens. Family: Gramineae

COMMON NAME(S): Couch-grass root, dog grass, quack grass, triticum, twitchgrass

BOTANY: Agropyron is a weed that is widely distributed throughout the northern hemisphere. The grass grows up to 1.5 m tall with spikes up to 15 cm long containing many flowered spikelets.¹ The leaves alternate with sheaths, the blades are long and narrow, and the veins are parallel.² The grass also contains shiny, pale yellow, hollowpieces of rhizome and longitudinally grooved stems that are 2 to 3 mm thick. Thin roots and short fiber-like cataphylls are present at the unthickened nodes. Agropyron has analmost bland but slightly sweet taste. The rhizomes, roots, and stems are used to formulate the product.¹

HISTORY: In folk medicine, agropyron has been used as a diuretic in cases of bladder catarrh and bladder/kidney stones, and as a cough medicine to alleviate bronchial irritation. It has been used to treat gout, rheumatic disorders, and chronic skin disorders.The drug products are typically imported from Romania, Hungary, the Yugoslavian region, and Albania.¹

CHEMISTRY: The major constituent of agropyron is triticin (3% to 8%), a polysaccharide related to inulin. Upon hydrolysis, triticin releases the following: fructose; mucilage (10%); saponins; sugar alcohols (mannitol, inositol, 2% to 3%); essential oilwith polyacetylenes or carvone (0.01% to 0.05%); small amounts of vanilloside (vanillin

monoglucoside), vanillin, and phenolcarboxylic acids; silicic acid; and silicates.^1,3,4 Extraction of silicon species from agropyron has been studied.⁵ Lectins found in the seedlings and leaves also may be present in the rhizome.¹ However, the lectin content of the leaves varies from season to season.⁶ Other constituents found in agropyron

include agropyrene (volatile oil constituent, 95%), mucilage, thymol, menthol, iron, and

other minerals.^3,4 Albumin content in agropyron and other wheat related plants has been evaluated.⁷ Breeding potential of agropyron also has been reported.⁸

PHARMACOLOGY: In addition to the folk uses of agropyron, it has been indicated for irrigation therapy in inflammatory disorders of the urinary tract, in the prevention of renal gravel, and to supplement treatment in catarrh of the upper respiratory tract. Agropyron is said to be useful as a diuretic.¹ One study reports the effects of agropyron

on calcium oxalate urolithiasis risk in rats, finding antilithiasic effects to be more dependent on diet.⁹ Agropyron leaf lectin exhibits specificity for N-acetylgalactosamine and agglutinates, preferentially blood-group-A erythrocytes.⁶ Nutritive value of the plant has been studied in sheep.¹⁰ The essential oil has shown antimicrobial effects, and extracts of the drug are used as a dietary component for diabetic patients.¹ Broad

spectrum antibiotic activity has been documented for agropyrene and its oxidation product. Agropyron may have weak anti-inflammatory effects.⁴ Despite these indications, pharmacological and clinical studies are lacking.

TOXICOLOGY: There are no known side effects or drug interactions associated with the use of agropyron. One study reports on allergans in canine atopic dermatitis.Intradermal skin tests in 1000 dogs revealed 33% reacting to the house dust mite and 15% reacting to agropyron, suggesting these to be common allergens.¹¹ Agropyron can be consumed safely when used appropriately.¹² The limited amount of toxicologicaldata requires cautious use during pregnancy and lactation.

SUMMARY: Agropyron has been used in folk medicine for a variety of GU ailments and as a cough remedy to alleviate bronchial irritation. It has been used to treat gout,various rheumatic disorders, and chronic skin conditions. Extracts of the drug are used as a dietary component for diabetic patients. However, no clinical studies to date haveproven any of these indications for agropyron; further investigation is needed.

PATIENT INFORMATION — Agropyron

Uses: Agropyron has been used to treat gout, rheumatic disorders, chronic skin conditions, and urinary tract, bladder, and kidney disorders. Various extracts have beenused as a dietary component for diabetic patients. There is a lack of clinical studies that have proven these uses.

Side Effects: There are no known side effects.

REFERENCES

¹ Bisset NG, ed. Herbal Drugs and Phytopharmaceuticals. 2nd ed. Stuttgart, Germany:

Medpharm Scientific Publishers; 2001. ² Trease GE, Evans WC. Pharmacognosy. 12th ed. London, England: Bailliere Tindall; 1983.

³ Leung AY, Foster S. Encyclopedia of Common Natural Ingredients. 2nd ed. New York,

NY: John Wiley and Sons, Inc.; 1996. ⁴ Newell CA, Anderson LA, Phillipson JD. Herbal Medicines. London, England: Pharmaceutical Press; 1996.

⁵ Paslawska S, Piekos R. Studies on the optimum conditions of extraction of silicon

species from plants with water. IV. Agropyron repens. Planta Med. 1976;30:216-222. ⁶ Cammue B, Stinissen HM, Peumans WJ. A new type of cereal lectin from leaves of couch grass (Agropyrum repens). Eur J Biochem. 1985;148:315-322.

⁷ Konarev A, Gavriliuk IP. Identification of albumin 0.19 in wheat and other cereal

proteins [in Russian]. Biokhimiia. 1978;43:28-33. ⁸ Fatih AM. Anaysis of the breeding potential of wheat-Agropyron and wheat-Elymus derivatives. ?. Agronomic and quality characteristics. Hereditas. 1983;98:287-295.

⁹ Grases F, Ramis M, Costa-Bauza A, March JG. Effect of Herniaria hirsuta and Agropyron repens on calcium oxalate urolithiasis risk in rats. J Ethnopharmacol. 1995;45:211-214.

¹⁰ Christen AM, Seoane JR, Leroux GD. The nutritive value for sheep of quackgrass

and timothy hays harvested at two stages of growth. J Anim Sci. 1990;68:3350-3359. ¹¹ Mueller RS, Bettenay SV, Tideman L. Aero-allergans in canine atopic dermatitis in southeastern Australia based on 1000 intradermal skin tests. Aust Vet J. 2000;78:392-399.

¹² McGuffin M, ed. American Herbal Products Association Botanical Safety Handbook. Boca Raton, FL: CRC Press; 1997.

Document Bibliographic Information:

DATE OF ISSUE: AUG 1996

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Alchemilla xanthochlora Rothm. (Syn. Alchemilla vulgaris auct. non L.). Family: Rosaceae

COMMON NAME(S): Lady's mantle

BOTANY: Lady's mantle is a perennial herb with a short rhizome carrying ascending or sprawling stems, and a rosette of basal leaves with dentate lobes of a circular orkidney-shaped outline. The inflorescence is a compound terminal cyme made up of dense clusters of small hellow-green flowers. Sepals are seen in two rings of fourwithout petals. The fruit is of the achene type. Overall, the plant is softly pubescent. It isfound throughout Europe in meadows, woodland clearings, pastures and in the lowland

areas of the British Isles. Currently, it is distributed in Europe, North America and

Asia.^1,2

HISTORY: Alchemilla is one of an aggregate of species collectively referred to as lady's mantle, all possessing similar medicinal properties. Many are cultivated. Medievalalchemists collected rain water or dew collected in the leaf center and used it for its purported magical and medicinal powers. This custom derived from the plant's generic name, alchemilla, which is from the Arabic word, "alkimiya" (universal cure for disease).In medieval tradition, it was used to treat wounds and female ailments. It has long been dedicated to the Virgin Mary, since the leaf lobes resemble the edges of a mantle.Among lady's mantle's historical uses are as a mild astringent, anti-inflammatory,diuretic, menstrual cycle regulator, treatment for digestive disorders and relaxant for muscular spasms. Externally, it was widely used in bath preparations, wound healing,

skin bruises and as an herbal cosmetic.^1,2

CHEMISTRY: Lady's mantle contains 6% to 8% tannins (elligiannins, such as

pedunculagin and alchemillin) and flavonoids (quercetin 3-0-ß-D-glucuronide).^2,3

PHARMACOLOGY: The historical uses of lady's mantle as an astringent against bleeding and as a treatment for diarrhea seem justified on the bases of its tannin content.² Newer studies show that the water extract of A. xanthochlora possesses lipid peroxidation and superoxide anion scavenging activity.⁴

Several rosaceae species, including A. xanthochlora, have high tannin content and elastase inhibitin activity.⁵ In a similar vein, flavonoids extracted from Alchemilla inhibit the activity of the proteolytic enzymes elastase, trypsin and alpha-chymotrypsin.⁶ These

results suggest a possible role by these inhibitors in the protection of conjunctive and elastic tissues.

A number of traditional plant treatments have been studied for diabetes in normal and streptozotocin diabetic mice, but no useful effects for lady's mantle have been found in this disorder.⁷

A study on the mutagenic potencies of several plant extracts (including TincturaAlchemillae) containing quercetin in Salmonella typhimurium TA98 and TA100 found that the mutagenic potential of the plant extracts correlates well with their quercetin

content.⁸ The cytostatic activity of a lactone fraction from Alchemilla pastoralis has also been reported.⁹

TOXICOLOGY: No significant toxicological studies appear to have been carried out on lady's mantle and long use for various purposes (internal and external) seem to bearout the fact that it is safe in low doses. The warning in the Standard License about possible liver damage appears to be exaggerated.²

SUMMARY: The use of lady's mantle for its local astringent and anti-diarrheal properties are mildly justified by the known tannin content of the plant. Newer chemistryand pharmacological studies are sparse, revealing only possible usefulness for itsanti-oxidant properties and vague protective effects as well as mutagenic potential and cytostatic activity. More human clinical data are needed to justify its use for its historicalmedical applications.

PATIENT INFORMATION — Alchemilla

Uses: Alchemilla has been used topically and internally, as a treatment for wounds, gastrointestinal complaints and female ailments. Its tannin content appears to justifyastringent and antidiarrheal uses. It may protect conjunctive and elastic tissues and possibly be useful as an antioxidant.

Side Effects: None known for low doses, with the possible exception of liver damage.

REFERENCES

¹ Bunney S, ed. The Illustrated Encyclopedia of Herbs. New York: Dorset Press, 1984.

² Bisset NG, ed. Herbal Drugs and Phytopharmaceuticals. Stuttgart: Medpharm Scientific Publishers, 1994. ³ Lamaison JL, et al. [Quercetin-3-glucuronide, Main Flavonoid of Alchemilla, Alchemilla

xanthochlora Rothm. (Rosaceae),] [French] Ann Pharm Fr 1991;49(4):186.

⁴ Filipek J. Effect of Alchemilla xanthochlora Water Extracts on Lipid Peroxidation and Superoxide Anion Scavenging Activity. Pharmazie 1992;47:717. ⁵ Lamaison JL, et al. [Tannin Content and Inhibiting Activity of Elastase in Rosaceae.]

[Review] [French] Ann Pharm Fr 1990;48(6):335. ⁶ Jonadet M, et al. [Flavonoids Extracted From Ribes nigrum L. and Alchemilla vulgaris

L.: 1. In vitro inhibitory activities on elastase, trypsin and chymotrypsin. 2.

Angioprotective activities compared in vivo.] [French] J Pharmacologie 1986;17(1):21.⁷ Swanston-Flatt SK, et al. Traditional Plant Treatments for Diabetes. Studies in normal and streptozotocin diabetic mice. Diabetologia 1990;33(8):462.

⁸ Schimmer O, et al. The Mutagenic Potencies of Plant Extracts Containing Quercetin in

Salmonella typhimurium TA98 and TA100. Mutation Res 1988;206(2):201.⁹ Sokolowska-Wozniak A. [Cytostatic Activity of the Lactone Fraction of Alchemilla pastoralis B u s.] [Polish] Ann Univ Mariae Curie Sklodowska [Med] 1985;40:107.

Document Bibliographic Information:

DATE OF ISSUE: SEP 2003

REPLACES MONOGRAPH DATED: OCT 1993

SCIENTIFIC NAME(S): Aletris farinosa L. Family: Liliaceae

COMMON NAME(S): Unicorn root, stargrass, whitetube stargrass, crow corn, Ague grass, Aloerot, Devil's-bit, colic root, ague root, starwort, blazing star, mealy starwort,huskwort. Some of the common names are also used in connection with Helonias

(Chamaelirium luteum [L.] A. Gray).^1,2,3,4,5

BOTANY: Aletris (of NF VII) is a perennial herb with linear leaves that grow in a rosette. These leaves surround a slender stem that reaches 1 m in height. These aregrasslike, of a yellowish green color, and from 5 to 15 cm long. They surround the baseof the stem in the form of a star, in this respect differing distinctly from another starwort (Chamailirium luteum) with which it is sometimes confused. The plant is native to NorthAmerica and is distributed widely throughout the continent. Three other species ofaletris, Aletris aurea Walt., A. lutea Small, and A. obovata Nash, bear much resemblance to A. farinosa and are frequently collected with the latter.²

HISTORY: Aletris is a North American plant that is now recognized worldwide in traditional folk medicine. Aletris occurs in dry, generally sandy soil from Maine toMinnesota, Florida, and Tennessee. It had been used by American Indians in theCarolinas as an antidiarrheal tea and in Appalachia for the management of rheumatismsand as a tonic and a sedative.¹ Aletris is used in the preparation of herbalremedies designed to ameliorate discomfort. The fabled Lydia Pinkham's Vegetable Compound, which was touted as a cure-all for female discomforts, contained aletris, among other plant derivatives.⁶ It has been included in laxatives and has been used as an antiflatulent (hence the name "colic root") and antispasmodic.

The roots and rhizomes are collected in the fall and dried for preservation.

CHEMISTRY: Little is known about the chemical composition of A. farinosa with diosgenin being the only significant compound. Diosgenin has also been isolated from it, along with gentrogenin from the related Japanese species A. foliata and A. formosana.⁷ An oil derived from A. farinosa is reported to have pharmacologic activity, but this has not been well defined.¹ The plant also contains a resin and a saponin-like glycoside that may yield diosgenin on hydrolysis.¹

PHARMACOLOGY: Aletris has been reported to have estrogenic activity, although estrogenic compounds have not been isolated nor have detailed studies confirmed thisactivity. The potential estrogenic properties of aletris may be due to a diosgenin-derived steroid that has not yet been characterized. Studies have indicated the drugs examined act on the strips of the isolated human uterus in the same manner as on the guinea piguterus, but to a much lesser degree. Aletris farinosa, Pulsatella pratensis, and oil of

valerian depress the activity of the strips.⁸ Another pharmacological study shows similar results of Aletris farinosa on the isolated uterine tissue of the rat, the guinea pig, and therabbit. Studies were also conducted on the in vivo uterus of the rabbit and the cat. It exerted a definite action of depression on the isolated uterus of the rat. The antagonistic action of aletris against the stimulating effect of the oxytocic principle of the posteriorlobe of the pituitary (pitocin) was also studied on the isolated uterus of the rat. Theresults using the isolated uterine tissue of the guinea pig and of the rabbit and the in vivo rabbit uterus were inconsistent, the predominant action being stimulation. Theeffect of aletris on the decerebrate cat and the cat that was estrus induced by the

injection of a compound estrogenic preparation, was mainly pronounced sedation.⁹

TOXICOLOGY: No adverse events have been reported with the use of aletris. The plant has been reported to have narcotic properties, and in small doses can induce colic, stupefaction, and vertigo.¹⁰

SUMMARY: Aletris is a common plant in nutrient-poor locations that has been used widely in folklore for the management of female discomforts. The pharmacologic activityof the plant has not been well defined, but steroidal compounds identified in the plantmay form the basis of its purported estrogenic activity.

PATIENT INFORMATION — Aletris

Uses: Aletris has been used as a sedative, laxative, antiflatulent, antispasmodic, and as a treatment for diarrhea and rheumatism. Its potential estrogenic properties may account for its use in treating female disorders. However, there are no clinical trials tosupport these potential uses.

Side Effects: None are known, but aletris reportedly has narcotic properties and can induce colic, stupor, and vertigo.

REFERENCES

(VISIT &BUY FROM  : WWW.DRUGSWELL.COM  &WWW.LEBANONWOW.COM  order now )
 (GIVE US HELP AND WE GIVE YOU MORE INFO Mail: owner@drugswell.com OR CONTACT US, MAKE YOUR DONATION HERE (CLICK) )
 

¹ Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and

Cosmetics. New York, NY: J. Wiley and Sons; 1980.² Sievers, AF. The Herb Hunters Guide American Medicinal Plants of Commercial Importance. Washington DC: US Dept. of Agriculture; 1930. Miscellaneous PublicationNo. 77. http://www.hort.purdue.edu/newcrop/HerbHunters/hhunters.html (updated4/8/98).

³ Osol A, Farrar GE Jr. The Dispensatory of the United States of America. 25th ed. Philadelphia, PA: J.B. Lippincott; 1955:1535.

⁴ Meyer JE. The Herbalist. Hammond, IN: Hammond Book Co; 1934:244. ⁵ Dobelis IN, ed. Magic and Medicine of Plants. Pleasantville, NY: Readers Digest;1986:144.

⁶ Tyler VE. The Honest Herbal: A Sensible Guide to the Use of Herbs and Related

Remedies. Binghamton, NY: The Haworth Press; 1993. ⁷ Okanishi T, et al. Steroidal components of domestic plants. LXVI. Steroidal sapogenins of 16 liliaceae plants. Chem Pharm Bull. 1975;23:575-579.

⁸ Pilcher JD. The action of the several (female remedies) on strips of the excised human

uterus. Arch Intern Med. 1917;19:53-55. ⁹ Butler CL, Costello CH. Pharmacological studies. I. Aletris farinosa. J Am Pharm. 1944;33:177-183.

¹⁰ Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press; 1985.

Document Bibliographic Information:

DATE OF ISSUE: MAR 2001

REPLACES MONOGRAPH DATED: MAR 1991

SCIENTIFIC NAME(S): Medicago sativa L. Common cultivars include Weevelchek, Saranac, Team, Arc, Classic, and Buffalo. Family: Leguminosae

PATIENT INFORMATION — Alfalfa

Uses: No evidence supports the use of various parts of the alfalfa plant for diuretic, anti-inflammatory, antidiabetic, or antiulcer purposes. Results from 1 small human studyshowed that the plant might reduce cholesterol levels.

Side Effects: Alfalfa ingestion, especially of the seeds, has been associated with various deleterious effects, and alfalfa seeds and sprouts can be contaminated with bacteria such as S. enterica and E. coli. The FDA issued an advisory indicating thatchildren, the elderly, and people with compromised immune systems should avoideating alfalfa sprouts. Ingestion of alfalfa preparations is generally without important side effects in healthy adults.

Dosing: Alfalfa seeds are used commonly as a supplement to lower cholesterol at doses of 0.75 to 3 g/day; however, clinical trials have not been performed to validatethis dosage.

REFERENCES

¹ Duke J. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press, 1985.

² Worthinton-Roberts B, et al. Fads or Facts? A pharmacist's guide to controversial "nutrition products." Am Pharm1983;NS23(8):30-42. ³ Massiot G, et al. Reinvestigation of the sapogenins and prosapogenins from alfalfa

(Medicago sativa). J Ag Food Chem 1988;36:902.

⁴ Oleszek W. Solid-phase extraction-fractionation of alfalfa saponins. J Sci Food Ag 1988;44:43. ⁵ Malinow M, et al. Effect of alfalfa meal on shrinkage (regression) of atherosclerotic

plaques during cholesterol feeding in monkeys. Atherosclerosis 1978;30:27-43. ⁶ AHA Quarterly Newsletter 1984;3:4. ⁷ Small E, et al. The evolution of hemolytic saponin content in wild and cultivated alfalfa

(Medicago sativa, Fabaceae). Economic Botany 1990;44:226. ⁸ Malinow M, et al. Effect of alfalfa saponins on intestinal cholesterol absorption in rats.

Am J Clin Nutr 1977;30:2061-67.

⁹ Malinow M, et al. Cholesterol and bile acid balance in Macaca fascicularis. Effects of

alfalfa saponins. J Clin Invest 1981;67:156-62. ¹⁰ Wilcox M, et al. Serum and liver cholesterol, total lipids and lipid phosphorus levels of rats under various dietary regimes. Am J Clin Nutr 1961;9:236.

¹¹ Cohen B, et al. The effect of alfalfa-corn diets on cholesterol metabolism and

gallstones in prairie dogs. Lipids 1990;25(3):143-8. ¹² Story J, et al. Adsorption of bile acids by components of alfalfa and wheat bran in vitro. J Food Sci 1982;47:1276.

¹³ Story J, et al. Interactions of alfalfa plant and sprout saponins with cholesterol in vitro

and in cholesterol-fed rats. Am J Clin Nutr 1984;39:917-29. ¹⁴ Molgaard J, et al. Alfalfa seeds lower low density lipoprotein cholesterol and apolipoprotein B concentrations in patients with type II hyperlipoproteinemia.

Atherosclerosis 1987;65(1-2):173-79.

¹⁵ Levy S. New product newswire. Drug Topics 1999;19:22. ¹⁶ Dewey D. Cholestaid. NuPharma 1/1/2001. ¹⁷ Sprinz H. Factors influencing intestinal cell renewal. Cancer 1971;28:71-74. ¹⁸ Malinow M, et al. Systemic lupus erythematosus-like syndrome in monkeys fed alfalfa

sprouts: role of a nonprotein amino acid. Science1982;216:415-17. ¹⁹ Malinow M, et al. Pancytopenia during ingestion of alfalfa seeds. Lancet

1981;I(8220):615.

²⁰ Natelson S. Canavanine to arginine ratio in alfalfa (Medicago sativa), clover(Trifolium), and the jack bean (Canavalia ensiformis). J Ag Food Chem 1985;33:413. ²¹ Morimoto I. A study on immunological effects of L-canavanine. Kobe J Med Sci

1989;35:287-98.

²² Prete P. The mechanism of action of L-canavanine in inducing autoimmune

phenomena. Arthritis Rheum 1985;28:1198-1200. ²³ Morimoto I, et al. L-canavanine acts on suppressor-inducer T cells to regulate antibody synthesis: lymphocytes of systemic lupus erythematosus patients are specifically unresponsive to L-canavanine. Clin Immunol Immunopathol 1990;55:97-108.

²⁴ Roberts J, et al. Exacerbation of SLE associated with alfalfa ingestion. N Engl J Med 1983;308:1361. ²⁵ Polk I. Alfalfa pill treatment of allergy may be hazardous. JAMA 1982;247:1493.

²⁶ Brandenburg D. Alfalfa of the Family Leguminosae. JAMA1983;249:3303-304. ²⁷ Farber J, et al. Listeriosis traced to the consumption of alfalfa tablets and soft cheese. N Engl J Med 1990;322:338.

²⁸ VanBeneden C, et al. Multinational outbreak of Salmonella enterica serotype Newport

infections due to contaminated alfalfa sprouts. JAMA 1999;282(2):158-162.²⁹ Mahon B, et al. An international outbreak of Salmonellainfections caused by alfalfasprouts grown from contaminated seeds. J Infect Dis 1997;175(4):876-82.

³⁰ CDC. Outbreaks of Escherichia coli 0157:H7 infection associated with eating alfalfa sprouts—Michigan and Virginia, June-July 1997. JAMA 1997;278(10):809-10 and MMWR 1997;46:741-44.

³¹ Christy C. Foodborne diseases: fruits and vegetables. Pediatr Infect Dis J 1999;18(10):911-12.

³² Brown CH. Overview of drug interactions. US Pharmacistonline. (http://uspharmacist.com/oldformat.asp?url=newlook/files/feat/mar00druginteractions.ht ml).

³³ Miller LG. Herbal medicinals: selected clinical considerations focusing on known orpotential drug-herb interactions. Arch Intern Med. 1998;158:2200.

Document Bibliographic Information:

DATE OF ISSUE: APR 1996

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Alkanna tinctoria (L.) Tausch Family: Boraginaceae

COMMON NAME(S): Alkanet, alkannawurzel (German), alkermeswurzel (German), anchusa, Dyers's Bugloss, henna, orchanet (English), racine d'alcanna (French), racined'orcanette(French), radix anchusea (tinctoriae) (Latin), rote ochsenzungenwurzel (German), schminkwurzel (German)

BOTANY: Alkanna is typically a biennial or perennial herbaceous plant growing from 1 to 2 feet in height with pubescent lanceolate leaves. It bears blue to purpletrumpet-shaped flowers arranged in loose, one-sided scorpiorid racemes. The root isusually seen as a cylindrical, fissured rhizome with exfoliating, brittle and dark purple bark on the outside and remains of bristly leaf and stem pieces near the crown region.¹ While native to southern Europe, the plant is also grown in and imported from Albania, India and Turkey.¹

Alkanna should not be confused with another plant also known as alkanet, but which is

in the related genus Anchusa officinalis(L.) of the same family (Borage).² A. officinalis has had some use in the form of a decoction (tea) of the leaves and roots for coughs and chest disorders in older herbals.²

HISTORY: Alkanna and related plants have long been referred to as "henna" and used as a dye for cloth. Alkanna has also been used to impart a red color to fats, oilsand waxes. It also has medicinal historical uses as an astringent. Currently, alkanna has no medicinal importance, and many countries have prohibited its use as a food dye.¹

CHEMISTRY: Alkanna root contains a mixture of red pigments in the bark at levels up to 5% to 6%. These consist mainly of fat soluble naphthazarin (5,8-dihydroxy-1,

4-naphthaquinone) components such as alkannin and related esters.^1,3 The red pigments are soluble in fatty oils which make them useful for the detection of oily materials in microscopic powders during histological examination. Like some of theother members of the Borage family, pyrrolizidine alkaloids have been found in Alkanna

tinctoria, but levels have not been determined.¹ The alkannin esters of beta, beta=dimethylacrylic acid, beta-acetoxy-isovaleric acid, isovaleric acid and angelic acid have also been isolated from the root.⁴

PHARMACOLOGY: Currently, alkanna root has no recognized medical uses except for its older use as an astringent. Even its use as a pigment is minimal and many countries have prohibited its use as a food coloring. Today, it is used almost exclusively as a cosmetic dye.¹ The esteric pigments, however, displayed excellent antibiotic andwound-healing properties in a clinical study on 72 patients with ulcus cruris (indolent leg

ulcers).^1,4

TOXICOLOGY: No toxicological data on alkanna root are available in the current medical literature.

SUMMARY: Alkanna root has historically been used for its mild astringent properties and as a source of pigments for coloring purposes. However, except for little use as a red color in cosmetics, it is not a major pigment source or a particularly useful drug bytoday's standards. One study indicates some potential for its esteric pigments in wound healing in patients with ulcus cruris (indolent leg ulcers).¹

PATIENT INFORMATION — Alkanna Root

Uses: Alkanna is an astringent and a source of red pigment used in cosmetics. It appears to have antibiotic and wound-healing properties.

Side Effects: Unknown.

DATE OF ISSUE: DEC 1993

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Pimenta dioica (L.) Merr. synonymous with P. officinalis and Eugenia pimenta. Family: Myrtaceae

COMMON NAME(S): Allspice, pimenta, Jamaica pepper, clove pepper,

pimento.^1,2,3

BOTANY: Pimenta is a sturdy tree that grows to 13 meters. It has leathery, oblong leaves and is native to the West Indies, Central America and Mexico. The parts of the plant used medicinally are the dried, full-grown but unripe fruit and leaves.¹ Allspice powder available commercially consists of the whole ground dried fruit.²

HISTORY: The plant has been used as a carminative. Besides its use in cosmetics and toothpastes, it is used as a food flavoring. Its odor is reminiscent of a combination of cloves, cinnamon and nutmeg. Allspice has been used medicinally as a tonic, purgative, carminative and antidiarrheal³ and for rheumatisms, neuralgia and stomachache.²

CHEMISTRY: Allspice berries contain from 1% to 4% of a volatile oil, which contains

from 60% to 80% eugenol and eugenol methylether (40% to 45%).^1,2,3 The leaf oil contains more eugenol (up to 96%) and bears many similarities to the composition of

clove leaf oil.¹ The oil is known as pimenta or allspice oil, and also contains cineole, levophellandrene, caryophyllene and palmitic acid.³ Enzymes released after harvesting appear to be responsible for producing many of the volatile components from chemical

precursors.¹ More than three dozen chemical constituents have been identified in the plant.¹ In addition, small amounts of resin, tannic acid and an acrid fixed oil are present.¹

PHARMACOLOGY: Any pharmacologic activity associated with the plant is most likely due to the presence of eugenol. Eugenol has local antiseptic and anestheticproperties. Eugenol also has antioxidant properties and allspice may serve as a

potential source of new natural antioxidants.^1,4 Furthermore, allspice appears to have in

vitro activity against yeasts and fungi.^5,6

Eugenol, aqueous extracts of allspice and allspice oil, has been shown to enhance trypsin activity and to have larvicidal properties.¹

TOXICOLOGY: Allspice and extracts of the plant can be irritating to mucous membranes. Although allspice generally has not been associated with toxicity, eugenolcan be toxic in high concentrations. Ingestion of more than 5 ml of allspice oil may induce nausea, vomiting, central nervous system depression and convulsions.³

When pimento oil and eugenol were applied to intact shaved abdominal skin of the mouse, no percutaneous absorption was observed.¹

SUMMARY: Allspice is a popular spice and fragrance. The oil may induce topical irritation and ingestion of the oil may result in toxicity.

PATIENT INFORMATION — Allspice

Uses: Apart from use for spices and fragrance, allspice has been used for various gastrointestinal ills, rheumatism and neuralgia. Extracts have antiseptic, anesthetic, andantioxidant properties and efficacy in vitro against yeasts and fungi.

Side Effects: Allspice can irritate mucosa. Ingestion of extracts may produce toxicity and affect the CNS.

REFERENCES

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 (GIVE US HELP AND WE GIVE YOU MORE INFO Mail: owner@drugswell.com OR CONTACT US, MAKE YOUR DONATION HERE (CLICK) )

¹ Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics. New York, NY: J. Wiley and Sons, 1980. ² Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press, 1985.

³ Spoerke DG. Herbal Medications. Santa Barbara, CA: Woodbridge Press, Inc. 1980. ⁴ Krishnakantha TP, Lokesh BR. Scavenging of superoxide anions by spice principles. Indian J Biochem Biophys 1993;30:133-4.

⁵ Conner DE, Beuchat LR. Sensitivity of heat-stressed yeasts to essential oils of plants.

Appl Environ Microbiol 1984;47:229-33.

⁶ Hitokoto H, et al. Inhibitory effects of spices on growth and toxin production of toxigenic fungi. Appl Environ Microbiol 1980;39:818-22.

Document Bibliographic Information:

DATE OF ISSUE: OCT 2001

REPLACES MONOGRAPH DATED: APR 1992

SCIENTIFIC NAME(S): Aloe vera L., A. perryi Baker (Zanzibar or Socotrine aloe), A. barbadensis Miller (also called A. vera Tournefort ex Linne or A. vulgarisLamark; Curacao or Barbados aloe), or A. feroxMiller (Cape aloe). A. vera Miller and A. vera L. may or may not be the same species. Family: Liliaceae

COMMON NAME(S): Cape, Zanzibar, Socotrine, Curacao, or Barbados aloes, aloe vera

BOTANY: Aloes, of which there are ˜ 500 species, belong to the family Liliaceae.¹ The name, meaning "bitter and shiny substance," derives from the Arabic "alloeh." Indigenous to the Cape of Good Hope, these perennial succulents grow throughoutmost of Africa, southern Arabia and Madagascar, and are cultivated in Japan, North andSouth America, and in the Caribbean and Mediterranean regions. They do not grow in rain forests or arid deserts. Often attractive ornamental plants, their fleshy leaves arestiff and spiny along the edges and grow in a rosette. Each plant has 15 to 30 taperingleaves, each up to 0.5 meters long and 8 to 10 cm wide. Beneath the thick cuticle of the epidermis lies the chlorenchyma. Between this layer and the colorless mucilaginouspulp containing the aloe gel are numerous vascular bundles and inner bundle sheath cells, from which a bitter yellow sap exudes when the leaves are cut.²

HISTORY: Drawings of aloe have been found in the wall carvings of Egyptian temples erected in the fourth millennium BC. Called the "Plant of Immortality," it was a traditional funerary gift for the pharaohs. The Egyptian Book of Remedies (ca. 1500 BC) notes theuse of aloe in curing infections, treating the skin, and preparing drugs that were chieflyused as laxatives. The Bible (John 19:39-40) says that Nicodemus brought a mixture of myrrh and aloes for the preparation of Christ's body. Alexander is said to haveconquered the island of Socotra to obtain control of it. The Greek physician Dioscorides,in 74 AD, recorded its use to heal wounds, stop hair loss, treat genital ulcers, and eliminate hemorrhoids. In the 6th century AD, Arab traders carried it to Asia. From theMediterranean region, it was carried to the New World in the 16th century by theSpaniards. In the modern era, its clinical use began in the 1930s as a treatment for roentgen dermatitis.²

CHEMISTRY: The aloe yields 2 commercially important products. "Aloe resin" is the solid residue obtained by evaporating the latex obtained from the pericyclic cells beneath the skin.³ The bitter yellow latex contains the anthraquinone barbaloin (aglucoside of aloe-emodin) and iso-barbaloin in addition to a series of O-glycosides of barbaloin, called aloinosides, chrysophanic acid, and up to 63% resin. Filtering outresins from the exudate and concentrating the remaining anthraglycoside material

(which is up to 25% barbaloin) into crystalline form produces aloin. Aloin is a mixture of water-soluble glycosides obtained from aloe.

A second product, aloe gel, is a clear, thin, gelatinous material obtained by crushing the mucilaginous cells found in the inner tissue of the leaf. The gel is the product used mostfrequently in the cosmetic and health food industries. It is generally devoid ofanthraquinone glycosides. The gel contains a polysaccharide glucomannan, similar to guar gum. It is this component that is believed to contribute mostly to the emollienteffect of the gel. "Aloe vera gel extract" is not actually an extract, but rather thepulverized whole leaves of the plant.

Allantoin is a primary mucilaginous substance in aloe and is an important proliferating agent.

Other compounds such as tannins, polysaccharides, organic acids, enzymes, vitamins, and steroids have been identified.⁴ Aloe contains bradykininase, which relieves pain and decreases swelling and redness. Magnesium lactate, by blocking histamineproduction, may contribute to the antipruritic effect of aloe. An antiprostaglandin thatreduces inflammation also has been isolated. The anthraquinones are local irritants in the GI tract and have been used in treating certain skin diseases such as psoriasis.

Chemical composition differs among the species of aloe. For example, A. barbadensis Miller may contain 2.5 times the aloe-emodin of A. ferox Miller, and the time of harvest is a further factor in composition.

PHARMACOLOGY: Aloe latex has been used for centuries as a potent cathartic. The aloinosides exert strong purgative effects by irritating the large intestine.

The most common use of the gel remains in the treatment of minor burns and skinirritation. Early studies of its use generally were poorly controlled, and the data wereincomplete and conflicting. These reports described the use of aloe in the treatment of

radiation-induced dermatitis.⁵ A. barbadensis extracts, in a murine model, have been shown to prevent ultraviolet radiation-induced suppression of contact and delayed

hypersensitivity by reducing the production of interleukin-10.^6,7 However, a small study in 10 healthy volunteers did not support this observation.⁸ Subsequent reports of theuse of topical aloe in treating human and animal radiation burns suggested thatalthough healing occurred, a clear advantage over aggressive wound care could not be

established. However, in a study of 27 patients, aloe vera gel-treated partial thicknessburn wounds healed in an average of 12 days as opposed to the vaseline-gauze-treated area of the same burn, which healed in an average of 18 days.⁹

The activity of aloe in treating burns may stem from its moisturizing effect, which prevents air from drying the wound.¹⁰ Its activity also has been ascribed to its chlorophyll content and that of other minor components, but this has not beenadequately substantiated. Current theory suggests that healing is stimulated bymucopolysaccharides in combination with sulfur derivatives and nitrogen compounds. Topical aloe treatment for burns has not been adequately documented. Two FDAadvisory panels found insufficient evidence to show that A. vera is useful in the treatment of minor burns and cuts or vaginal irritations.

Other studies have generally found preparations containing aloe to accelerate woundhealing. In patients who underwent dermabrasion, aloe accelerated skin healing by

about 72 hours compared with polyethylene oxide gel dressing,¹¹ and aloe has been found to accelerate wound healing in patients with frostbite.¹² Aloe vera applied todebrided white or clear blisters and to intact hemorrhagic blisters every 6 hours, is part

of the treatment protocol for frostbite.^13,14 Addition of oral pentoxifylline, in a study with

rabbits, showed additional improvement in tissue survival after frostbite injury.¹⁵ However, at least 1 study found that aloe applied as standard wound therapy delayed wound healing significantly (83 vs 53 days).¹⁶

Studies of the antibacterial activity of aloe have yielded conflicting results. One study

using A. vera gel¹⁷ found no activity against Staphylococcus aureusand Escherichia coli. Other tests found that A. chinensis inhibited growth of S. aureus, E. coli, and Mycobacterium tuberculosis, but that A. vera was inactive.¹⁸ Further, these extracts lost

their in vitro activity when mixed with blood. The latex has shown some activity against

pathogenic strains.¹⁹ Two commercial preparations exerted antimicrobial activityagainst gram-negative and gram-positive bacteria as well as Candida albicanswhen used in concentrations > 90%.²⁰ Aloe has been found to be more effective than

sulfadiazine and salicylic acid creams in promoting wound healing and as effective as silver sulfadiazine in reducing wound bacterial counts.²¹

A double-blind, randomized, placebo-controlled trial demonstrated effectiveness of analoe vera crude extract emulsion in reducing scaliness, pruritus, and the number of involved sites in 44 patients with seborrheic dermatitis.²²

A double-blind, randomized, placebo-controlled trial demonstrated effectiveness of topical A. vera extract 0.5% in a hydrophilic cream in curing 25/30 vs 2/30 placebo-treated patients with psoriasis.²³

Aloe-emodin is antileukemic in vitro²⁴ and has exhibited selective activity in vitro and in a murine model against neuroectodermal tumors (eg, neuroblastoma, Ewing sarcoma).²⁵ Other studies showed A. vera gel to be less cytotoxic²⁶ than indomethacin

or prednisolone in tissue cultures. In vitro study of diethylhexylphthalate isolated from A. veraLinne demonstrated antileukemic and antimutagenic effects; however, results are

conflicting when studied in rats.^27,28 The National Cancer Institute concluded that A. vera latex was not worthy of further study as a cancer cure. However, the USDepartment of Agriculture has approved A. vera as an adjunctive treatment for

fibrosarcomas in dogs and cats.²⁹

Other health claims are generally poorly documented. An emulsion of the gel wasreported to cure 17 of 18 patients with peptic ulcers, but no control agent was used in this study.³⁰ Additionally, pretreatment with an A. vera extract reduced aspirin-induced injury in a study with rats.³¹ Further human studies are needed to establish this potential protective property.

A. vera extract 0.5% in a hydrophilic cream was shown in a placebo-controlled study to shorten time to healing in male patients with first episodes of genital herpes.³²

A gel containing A. vera extract 0.125%, allantoin 0.35%, and silicon dioxide was found effective in decreasing the duration of lesions associated with aphthous stomatitis.³³

Lyophilized A. barbadensis combined with zinc acetate has been studied in rabbits for use as a vaginal contraceptive.³⁴

In 1 laboratory experiment, rats injected with 1, 10, or 100 mg/kg SC doses of A. vera

(without anthraquinones) daily for 7 days showed improved circulation and wound healing.³⁵ Arthritic mice were injected SC with a 150 mg/kg suspension ofanthraquinones once a day for 13 days. This aloe extract caused a 48% inhibition ofinflammation, caused by anthraquinone and cinnamic acid, and a 72% inhibition of arthritis, caused by anthranilic acid, which also had an anti-inflammatory effect. A. vera

extracts have bradykininase activity in vitro.³⁶ Topical administration of aloe extracts reduced swelling in an animal model of inflammation by 29%.³⁷ Investigations have established that certain components of aloe inhibit the complement system, thereby

reducing inflammatory responses.^38,39

A small study has found that parenteral administration of aloe extract protects the liverfrom chemical injury and has been shown to ameliorate ALT levels dramatically in patients with chronic hepatitis.⁴⁰

Only the dried latex is approved for internal use as a cathartic. In some cases, A. vera is sold as a food supplement, allegedly with FDA approval. FDA has only approved A. perryi, A. vera, A. ferox, and certain hybrids for use as natural food flavorings.⁴¹

TOXICOLOGY: Because aloe is used extensively as a folk medicine, its adverse effects have been well documented. Except for the dried latex, aloe is not approved asan internal medication. Anthranoid laxative (aloe-emodin) use has not been shown to be

a risk factor for the development of melanosis coli, colorectal adenomas, or carcinomas.⁴² Aloe-emodin and other anthraquinones may cause severe gastric cramping and aloe has been associated with congenital malformations,⁴³ thus its use is

contraindicated in pregnant and nursing women,⁴⁴ children < 12 years of age,^45,46 patients with inflammatory bowel disease,⁴⁶ and elderly patients with suspected intestinal obstruction.⁴⁶ The external use of aloe has not been associated with severe

adverse reactions. The majority of adverse effects are relatively mild and reversible upon cessation of application.⁴⁷ Reports of burning skin following topical application of aloe gel to dermabraded skin have been described.⁴⁸ Contact dermatitis from the related A. arborescenshas been reported.¹ Erythema, edema, urticaria, and

eczematous rash have also been reported following A. vera application.^49,50

There has been 1 report that using the gel as standard wound therapy delayed healing.The gel may cause burning sensations in dermabraded skin, and redness and itching can also occur. Use caution with cosmetic products containing A. vera gel.⁵¹

SUMMARY: Aloe products derived from the latex of the outer skin are strong cathartics to be used with caution. Compounds derived from the inner gel intended for internal administration have not been shown to exert any consistent therapeutic effect.The effective topical use of the gel in the treatment of minor burns and wounds has notbeen established, although several human trials indicate a potential therapeutic benefit. Use of A. veracream has been placed in the protocol for frostbite treatment.

PATIENT INFORMATION — Aloe

Uses: Aloe appears to inhibit infection and promote healing of minor burns and wounds, frostbite, and possibly of skin affected by diseases such as psoriasis and seborrheicdermatitis. Dried aloe latex is used, with caution, as a drastic cathartic.

Side Effects: There has been 1 report that using the gel as standard wound therapy delayed healing. The gel may cause burning sensations in dermabraded skin, and redness and itching can also occur. Use caution with cosmetic products containing A. vera gel.

Dosing: As a gel, A. vera may be applied externally ad lib. The resin product is cathartic at doses of 250 mg and is not recommended for internal use.⁵²

REFERENCES

¹ Nakamura T, Kotajima S. Contact dermatitis from Aloe arborescens. Contact Dermatitis. 1984;11:50.

² Grindlay D, Reynolds T. The Aloe veraphenomenon: a review of the properties and

modern uses of the leaf parenchyma gel. J Ethnopharmacol. 1986;16:117. ³ Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics. New York, NY: J Wiley and Sons, 1980.

⁴ Henry R. An updated review of Aloe vera. Cosmetics and Toiletries. 1979;94:42.

⁵ Row TD, Lovell BK, Parks L. Further observations on the use of Aloe vera leaf in the treatment of third degree x-ray reactions. J Am Pharm Assn. 1941;30:266. ⁶ Strickland FM, Pelley RP, Kripke ML. Prevention of ultraviolet radiation and induced

suppression of contact and delayed hypersensitivity by Aloe barbadensis gel extract. J Invest Dermatol. 1994;102:197-204.

⁷ Byeon SW, Pelley RP, Ullrich SE, et al. Aloe barbadensis extracts reduce the production of interleukin-10 after exposure to ultraviolet radiation. J Invest Dermatol. 1998;110:811-817.

⁸ Golomb C, Bartholett S, Green A, et al. Effects of Aloe barbadensis gel onultraviolet-induced immunosuppression of contact hypersensitivity in humans. J Invest Dermatol. 1997;108:633.

⁹ Visuthikosol V, Chowchuen B, Sukwanarat Y, et al. Effect of Aloe vera gel to healing

of burn wound: a clinical and histologic study. J Med Assoc Thailand. 1995;78:403-409. ¹⁰ Ship AG. Is topical Aloe vera plant mucus helpful in burn treatment? JAMA. 1977;238:1770.

¹¹ Fulton JE, Jr. The stimulation of postdermabrasion wound healing with stabilized Aloe vera gel-polyethylene oxide dressing. J Dermatol Surg Oncol. 1990;16:460. ¹² McCauley RL, Heggers JP, Robson MC. Frostbite: methods to minimize tissue loss.

Postgrad Med. 1990;88:67.

¹³ Reamy BV. Frostbite: review and current concepts. J Am Board Fam Pract. 1998;11:34-40. ¹⁴ Murphy JV, Banwell PE, Roberts AH, et al. Frostbite: pathogenesis and treatment. J

Trauma. 2000;48:171-178.

¹⁵ Miller MB, Kotlai PJ. Treatment of experimental frostbite with pentoxifylline and Aloe

vera cream. Arch Otolaryngol Head Neck Surg. 1995;121:678-680. ¹⁶ Schmidt JM, Greenspoon JS. Aloe veradermal wound gel is associated with a delay in wound healing. Obstet Gynecol. 1991;78:115.

¹⁷ Fly, Kiem. Economic Bot. 1963;14:46. ¹⁸ Gottshall, et al. J Clin Invest. 1949;28:920. ¹⁹ Lorenzetti LJ, Salisbury R, Beal JL, Baldwin JN. Bacteriostatic property of Aloe vera.

J Pharm Sci. 1964;53:1287. ²⁰ Haggers JP, et al. J Am Med Technol. 1979;41:293. ²¹ Rodriguez-Bigas, Cruz NI, Suarez A. Comparative evaluation of Aloe vera in the

management of burn wounds in guinea pigs. Plast Reconstr Surg. 1988;81:386. ²² Vardy DA, Cohen AD, Tchetov T, et al. A double-blind, placebo-controlled trial of an

Aloe vera (A. barbadensis) emulsion in the treatment of seborrheic dermatitis. J Dermatol Treat. 1999;10:7-11. ²³ Syed TA, Ahmad SA, Holt AH, et al. Management of psoriasis with Aloe vera extract

in a hydrophilic cream: a placebo-controlled, double-blind study. Trop Med Int Health. 1996;1:505-509.

²⁴ Kupchan, Karmin. J Nat Prod. 1976;39:223. ²⁵ Pecere T, Gazzola MV, Mucignat C, et al. Aloe-emodin is a new type of anticancer agent with selective activity against neuroectodermal tumors. Cancer Res. 2000;60:2800-2804.

²⁶ Fischer JM. Medical use of aloe products. US Pharmacist. 1982;7:37. ²⁷ Lee KH, Kim JH, Lim DS, et al. Anti-leukaemic and anti-mutagenic effects ofdi(2-ethylhexyl)phthalate isolated from Aloe veraLinne. J Pharm Pharmacol. 2000;52:593-598.

²⁸ Lee KH, Hong HS, Lee CH, et al. Induction of apoptosis in human leukaemic celllines K562, HL60 and U937 by diethylhexylphthalate isolated from Aloe vera Linne. J Pharm Pharmacol. 2000;52:1037-1041.

²⁹ Thor G, Terryberry J. Complementary and alternative medicines in oncology: new directions for pharmaceutical companies. D&MD Newsletter. 2001;12:99-106. ³⁰ Blitz JJ, et al. J Am Osteopath Assoc. 1963;62:731. ³¹ Maze G, Terpolilli RN, Lee M. Aloe veraextract prevents aspirin-induced acute gastric

mucosal injury in rats. Med Sci Res. 1997;25:765-766. ³² Syed TA, Afzal M, Ashfaq AS, et al. Management of genital herpes in men with 0.5%

Aloe vera extract in a hydrophilic cream: A placebo-controlled double-blind study. J Derm Treat. 1997;8:99-102. ³³ Garnick JJ, Singh B, Winkley G. Effectiveness of a medicament containing silicon

dioxide, aloe, and allantoin on aphthous stomatitis. Oral Surg Med Oral Pathol Oral

Radiol Endod. 1998;86:550-556. ³⁴ Fahim MS, Wang M. Zinc acetate and lyophilized Aloe barbadensis as vaginal contraceptive. Contraception. 1996;53:231-236.

³⁵ Davis RH, et al. Aloe vera and wound healing. J Am Podiatr Med Assoc. 1987;77:165.

³⁶ Yagi A, Harada N, Shimomura K, Nishioka I. Bradykinin-degrading glycoprotein in

Aloe arborescens var. natalensis. Planta Med. 1987;X:19. ³⁷ Davis RH, Parker WL, Samson RT, Murdoch DP. Isolation of a stimulatory system in an aloe extract. J Am Podiatr Med Assoc. 1991;81:473.

³⁸ t'Hart LA, van den Berg AJ, Kuis L, van Dijk H, Labadia RP. An anti-complementary polysaccharide with immunological adjuvant activity from the leaf parenchyma gel of Aloe vera. Planta Med. 1989;55:509.

³⁹ t'Hart LA, Nibbering PH, van den Barselaar MT, van Dijk H, et al. Effects of low molecular constituents from Aloe veragel on oxidative metabolism and cytotoxic and bactericidal activities of human neutrophils. Int J Immunopharmacol. 1990;12:427.

⁴⁰ Fan YJ, et al. Protective effect of extracts from Aloe vera L. var. Chinensis (Haw.) Berg. on experimental hepatic lesions and a primary clinical study on the injection of in patients with hepatitis. Chung Kuo Chung Yao Tsa Chih. 1989;14:746.

⁴¹ Hecht A. The overselling of Aloe vera. FDA Consumer. 1981;July-Aug:27. ⁴² Nusko G, Schneider B, Schneider I, et al. Anthranoid laxative use is not a risk factor for colorectal neoplasia: results of a prospective case control study. Gut. 2000;46:651-655.

⁴³ Schiller LR. Review article: the therapy of constipation. Aliment Pharmacol Ther. 2001;15:749-763.

⁴⁴ Briggs C. Herbal medicine: Aloe. Can Pharm J. 1995;128:48-50. ⁴⁵ Spoerke DG, Ekins BR. Aloe vera — fact or quackery. Vet Hum Toxicol. 1980;222:418.

⁴⁶ Hadley SK, Petry JJ. Medicinal herbs: a primer for primary care. Hosp Prac. 1999.

http://www.hosppract.com/issues/1999/06/cehadley.htm ⁴⁷ Ernst E. Adverse effects of herbal drugs in dermatology. Br J Dermatol. 2000;143:923-929.

⁴⁸ Hunter D, Frumkin A. Adverse reactions to vitamin E and Aloe vera preparations after dermabrasion and chemical peel. Cutis. 1991;47:193. ⁴⁹ Dominguez-Soto L. Photodermatitis to Aloe vera. Int J Dermatol. 1992;31:372.

⁵⁰ Gale AE. Hypoallergenic products. Med J Aust. 1996;165:62. ⁵¹ Pribitkin EdE, Boger G. Herbal therapy: what every facial plastic surgeon must know. Arch Fac Plas Surg. 2001;3:127-132.

⁵² Claus E, ed. Pharmacognosy. 3rd ed. Philadelphia, PA: Lea & Febiger; 1956.

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DATE OF ISSUE: OCT 1998

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): 1,2-dithiolane-3-pentanoic acid; 1,2-dithiolane-3-valeric acid; 6,8-thioctic acid; alpha-lipoic acid; 5-(1,2-dithiolan-3-yl) valeric acid.

COMMON NAME(S): Alpha-lipoic acid, lipoic acid, thioctic acid, acetate replacing factor, biletan, lipoicin, thioctacid, thioctan.

PRODUCT(S): eg, Alpha Lipoic Acid Extract (Pharmacist's Ultimate Health, et al.).

SOURCE: Lipoic acid is a fat-soluble, sulfur-containing, vitamin-like antioxidant. It is not a true vitamin because it can be synthesized in the body and is not necessary in thediet of animals. Lipoic acid functions in the same manner as many B-complex vitamins.

Good sources of lipoic acid are yeast and liver.^1,2 Other sources include spinach, broccoli, potatoes, kidney, heart, and skeletal muscle.³

HISTORY: In the 1930s, it was found that a certain "potato growth factor" was necessary for growth of certain bacteria.³ In 1951, a fat-soluble coenzyme factor was

discovered from work done on lactic acid bacteria. Reed et al, isolated this naturally occurring d-form and found it to be an important growth factor for many bacteria and protozoa. This compound was isolated and identified as "alpha lipoic acid."⁴

CHEMISTRY: Alpha lipoic acid is a molecule with 2 sulfur high-energy bonds. It functions as a coenzyme with pyrophosphatase in carbohydrate metabolism to convert pyruvic acid to acetyl-coenzyme A (Kreb's cycle) to produce energy.¹

PHARMACOLOGY: Pharmacokinetics and bioavailability of different enantiomers of alpha lipoic acid (ALA) have been performed in 12 subjects.⁵ Pharmacology of ALA has been studied in the areas of oxidation, diabetes, AIDS, cancer, and liver ailments.

Oxidation: ALA's antioxidant properties have been demonstrated. It has the ability to chelate metals and to scavenge free radicals.⁶ ALA is easily absorbed and transported

across cell membranes; thus, free radical protection occurs both inside and outside of cells. It is also water- and fat-soluble, which makes it effective against a broader range of free radicals than vitamin C (water-soluble) and vitamin E (fat-soluble) alone.² ALA administration also increases intracellular levels of glutathione, an important antioxidant.⁷ ALA regenerates or recycles antioxidant vitamins C and E³ but in one

report, had no effect on vitamin E tissue concentration in animals, contradicting this effect.⁸

The body routinely converts ALA to dihydrolipoic acid, an even more powerful

antioxidant. Both forms "quench" the dangerous peroxynitrite radicals, which are responsible in part for heart, lung, and neurological disease and inflammation as well.⁹ In oxidative stress models such as ischemia, reperfusion injury, and radiation inury, ALA

has been shown to be beneficial.^10,11

Diabetes: ALA has been shown to be beneficial in type 1 and type 2 diabetes. ALA has prevented various pathologies associated with this disease, such as reperfusion injury,

macular degeneration, cataracts, and neuropathy.^2,3,10,12 ALA reduced diabetic neuropathy in rats, which was improved in a dose-dependent manner. In part, the mechanism was suggested to be caused by reduction of the effects of oxidative stress.¹² ALA is approved in Germany to treat diabetic neuropathy. High doses (600 mg/day) improve this condition.²

ALA also improves the diabetic condition by improving blood sugar metabolism. It

facilitates better conversion of sugar into energy.² In 13 non-insulin-dependent diabetes mellitus patients, ALA increased insulin-stimulated glucose disposal. Metabolic clearance rate for glucose rose by 50% compared with the control group.¹³

ALA improves blood flow to peripheral nerves and stimulates regeneration of nerve fibers.² A German study evaluating 800 mg/day ALA in diabetics with damaged

autonomic nervous systems was compared against placebo. After 4 months, sympathetic systems showed improvement and autonomic nerve disorder decreased in the ALA group.¹⁴

Antioxidants in general may lead to regression of diabetic complications. When ALAwas compared with antioxidant vitamin E, results failed to justify the higher cost of ALA over less-expensive and equally effective nutritional antioxidants.²

AIDS: Patients with HIV have a compromised antioxidant defense system, which may benefit from ALA's role as an effective antioxidant.² A small pilot study was conducted

administering 150 mg ALA 3 times daily to HIV patients. It increased glutathione in all 10patients and increased vitamin C in most patients as well. In addition, it improved the T-helper lymphocyte to T-helper suppressor cell ratio in 6 of 10 patients.²

ALA significantly inhibits replication of HIV by reducing the activity of reverse

transcriptase, the enzyme which makes virus from DNA of lymphocytes.² In another report, ALA was found to also inhibit activation of "nuclear factor kappa-B," a substance involved in AIDS progression.¹⁵

Cancer: There is limited information available concerning ALA's role in cancer. Its mechanism of action and anticarcinogenic and cytoprotective effects have been addressed.¹⁶ ALA administration, in conjunction with cyclophosphamide, lowered the toxic effects of this anticancer drug when tested in animals.¹⁷

Liver ailments: ALA has been used as an antidote to Amanita mushroom poisoning.⁴ A review on mushroom intoxications employing ALA and other antidotes is available.¹⁸

Various: Various reports on ALA pharmacology include the following: Suppression of T-4 metabolism, exerting a lipid-lowering effect in rats,¹⁹ treatment in Wilson's disease,⁴

and cardiovascular disease.³

TOXICOLOGY: No adverse effects from ALA supplementation have been reported in either animal or human studies, even with large doses or extended use.² Its use in

diabetes may warrant a reduction in dose of insulin or other oral diabetic medications.Close monitoring of blood sugar levels must be performed. In addition, ALA use may spare vitamins C and E, as well as other antioxidants.²

SUMMARY: ALA is a vitamin-like, "universal antioxidant." It functions to produce energy and has been studied in a number of areas. Its ability to scavenge free radicals has been clearly demonstrated. Its use in diabetes, AIDS, cancer, and liver ailmentsoffer promising results such as reduction of pathologies associated with these diseases.No adverse events from ALA supplementation have been reported.

PATIENT INFORMATION — Alpha Lipoic Acid

Uses: Alpha lipoic acid has been used as an antioxidant for the treatment of diabetes and HIV. It also has been used for cancer, liver ailments, and various other conditions.

Side Effects: No adverse effects have been reported.

REFERENCES

¹ Ensminger A, et al. Foods and Nutrition Encyclopedia, 2nd edition. Boca Raton, FL:

CRC Press Inc. 1994:1318-19. ² Murray M. Encyclopedia of Nutritional Supplements. Rocklin, CA: Prima Publishing. 1996;343-46.

³ Ley B. The Potato Antioxidant, Alpha Lipoic Acid. BL Publications. 1996. ⁴ Budavari S, et al, eds. The Merck Index, 11th ed. Rahway: Merck and Co. 1989. ⁵ Hermann R, et al. European J Pharm Sci 1996;4(3):167-74. ⁶ Nichols T. Alt Med Rev 1997;2(3):177-83. ⁷ Busse E, et al. Arzneimittel-Forschung 1992;42(6):829-31. ⁸ Podda M, et al. Biochem Biophys Res Commun 1994;204:98-104. ⁹ Whiteman M, et al. Febs Letters 1996;379:74-76. ¹⁰ Schonheit K, et al. Biochimica et Biophysica Acta 1995;1271:335-42. ¹¹ Cao X, et al. Free Radical Research 1995;23:365-70. ¹² Nagamatsu M, et al. Diabetes Care 1995;18:1160-67.

¹³ Jacob S, et al. Arzneimittel-Forschung 1995;45(8):872-74. ¹⁴ Ziegler D, et al. Diabetes Care 1997;20:369-73. ¹⁵ Suzuki Y, et al. Biochemical and Biophysical Research Communications

1992;189:1709-15. ¹⁶ Dovinova I. Ceska A Slovenska Farmacie 1996;45(5):237-41. ¹⁷ Berger M, et al. Arzneimittel-Forschung 1983;33(9):1286-88. ¹⁸ Lampe K. Clinical Toxicology 1974;7(1):115-21. ¹⁹ Segermann J, et al. Arzneimittel-Forschung 1991;41(12):1294-98.

Document Bibliographic Information:

DATE OF ISSUE: JUL 1996

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Alpinia officinarumHance

COMMON NAME(S): China root, Chinese ginger, East Indian root, galangal, rhizoma galangae

BOTANY: Galangal is a reed-like perennial herb bearing stems that grow up to 3 feet high and that are covered by sheaths of narrow lanceolate leaves. Its inflorescence is ashort raceme of white flowers which are veined and shaded in dull red. The plant has been cultivated for the rhizomes in the idland of Hainan off Southern China, and in coastal areas around Pak-hoi. Galangal rhizomes appear on the market as branched orsimple rhizome fragments and show wavy annulations of the leaf bases. These are reddish-brown in color and have an aromatic, spicy and pungent odor and flavor.¹

HISTORY: The rhizomes of galangal and its derivatives have long been used for its aromatic stimulant, carminative and condiment properties much like ginger (the driedrhizome of Zingiber officinale). Galangal oil is used to flavor French liqueurs and in some tobaccos.¹ The "ginger" of Thailand is obtained from Alipinia galanga Willd., a species related to galangal. Likewise, the large, ordinary, preserved ginger of China is also from A. galanga.² A. galanga (greater galangal), containing the volatile oil essenced'Amali, is used in China and northern India for various respiratory complaints in children, particularly bronchial catarrh (mucous membram inflammation).³

CHEMISTRY: Galanga contains a greenish-yellow volatile oil containing cineol, eugenol, sesquiterpenes, isomerides of cadinene, a resin containing galangol, kaempferide, galangin, as well as starch and other constituents.¹ Recent studies reveal sevel flavonoids,⁴ acetoxychavicol acetate (A. galanga),⁵ a cardiotonic principle (A. oxyphylla),⁶ catecquic tannins, phenols, alkalokds and essential oils (A. speciosa),⁷ nootkatone (A. oxyphylla),⁸ dehydrokawain derivatives (A. speciosa),⁹ diterpenes (A. galanga),¹⁰ essential oils (A. speciosa),¹¹ nootkatol (A. oxyphylla),¹² starch (A. galanga),¹³ monoterpenes (A. galanga),¹⁴ the pungent principle 5-hydroxy-7-(4-hydroxy-3-methoxyphenyl)-1-phenyl-3-heptanone (A. officinarum).¹⁵ The constituents in the essential oil of A. khulanjan M. Sheriff are 38.42% methylcinnamate, 20.21% cineol 1:8, 9.15% l-camphene, 8.75% l-borneol, 7.97% methylchavicol, 7.34% DELTA3-carene and 2.69% alpha-pinene.¹⁶

PHARMACOLOGY: Although the major uses of Alpinia involve its use as a carminative and condiment, there have been a number of recent interesting medical applications. Antifungals are found in A. galanga^5,10 and A. officinarum.¹⁷ A. speciosa oils are also effective anitfungal agents, inhibiting 80% of the dermatophyte strains tested in a recent in vitro study.¹⁸

A. oxyphylla (bitter cardamon) significantly inhibits gastric lesions by 57% in rats; susquiterpenois nootkatone is suggested as the active principle.⁸ Guaiacol, a cardiotonic principle, has been found in A. oxphylla.⁶ Anti-ulcer activity is found in the seeds of A. galanga.¹⁹

A. speciosa extracts have shown diuretic and hypotensive properties.^7,20,21 The dehydrokawain derivatives from A. speciosa, 5,6-Dehydrokawain (DK) anddihydro-5,6-dehydrokawain (DDK), are antiplatelets due to their inhibition of

thromboxane A2 formation.⁹

A. Galanga shows antitumor activity in mice.²² and has been found to be moderately

effective as an anthelmintic against the human Ascaris lubricoides.²³ Alpinia fructus (the fruit of A. oxyphylla) is effective as an anti-diuretic, anti-ulcerative and anti-dementia agent in rats.²⁴

A. officinarum and ginger (Zingiber officinalis) roots contain potent inhibitors againstprostaglandin biosynthesizing enzyme (PG synthetase). Gingerols and diarylheptanoidswere identified as the active constituents. The structure of these components indicates that they might also be active again arachidonate 5-lipoxygenase, an enzyme of

leukotriene (LT) biosynthesis.²⁵

A. officinarum, used as an antirheumatic in Saudi traditional medicine, does not produce significant inhibition of carrageenan-induced inflammation.²⁶

TOXICOLOGY: A hydroalcoholic extract of A. speciosa, injected intra-peritoneally (I.P.) in rats at a dose range of 100 to 1400 mg/kg, caused writhing, psychomotorexcitation, hypokinesis and pruritus. The LD-50 by I.P. injection was 0.760 ± 0.126 g/kg, and 10.0 ± 2.5 g/kg by the oral route. Subacute toxicity studies in rats revealed anincrease in transaminases and lactate dehydrogenase. Blood glucose, urea andcreatinine were normal; a histopathological study of the liver, spleen, gut, lung and heart showed no changes. The extract caused a prolongation of sleeping time and a dose-dependent fall in blood pressure in doses of 10 to 30 mg/kg.⁷

Another toxicity study on A. galangafound no significant mortality or weight gain in rats.However, the A. galanga treated animals showed a significant rise in red blood celllevels, weight gain of sexual organs and increased sperm motility and sperm counts. No

spermatotoxic effects were noted.²⁷

Cytotoxic diterpenes have been found in the seeds of A. galanga.¹⁰

SUMMARY: The rhizomes of Alpinia officinarumhave had long use as aromatic, stimulant, carminative and condiment agents. Numerous recent studies reveal the presence of many pharmacologically active compounds in various species of the genus.Among the newer activities revealed for the various Alpinia species are anthelminticeffects, antifungal properties, anti-ulcer effects in seeds, a cardiotonic property, diuretic and hypotensive effects, inhibition of gastric lesions, antiplatelet action, antitumorprinciples and inhibition against prostaglandin synthetase. Toxicity is generally low in the Alpinia species. Because most of these investigations deal with animal studies, much more is needed to verify these effects and provide proof of true clinical usefulness.

PATIENT INFORMATION — Alpinia

Uses: Beyond common use as a flavoring, aromatic stimulant, carminative, and traditional use to treat children's respiratory complaints, Alpinia species show promiseas antifungals, hypotensives, enhancers of sperm count and motility, etc. Antitumor andanti-dementia effects have been observed in rodents.

Side Effects: Toxicity is low; injections can produce psychomotor excitation and the like.

REFERENCES

¹ Youngken HW. Textbook of Pharmacognosy, 6th ed. Philadelphia: Blakiston Co.,

1950. ² Osol A. The Dispensatory of the United States of America, 25th ed. Philadelphia: J.B. Lippincott, 1955.

³ Lewis WH. Elvin-Lewis MPF. Medical Botany: Plants affecting man's health. New

York: John Wiley & Sons, 1977. ⁴ Karlsen J, Beker F. Flavonoids of Rhizoma Galangae ( Alpinia officinarum Hance). Farm Aikak 1971;80:95.

⁵ Janssen A, Scheffer JJ. Acetoxychavicol Acetate, an Antifungal Component of Alpinia

galanga. Planta Med 1985;51(6):507. ⁶ Shoji, N, et al. Isolation of a Cardiotonic Principle from Alpinia oxyphylla. Planta Med 1984;50(2):186.

⁷ Mendonca VL, et al. Pharmacological and Toxicological Evaluation of Alpinia

speciosa. Mem Inst Oswaldo Cruz 1991;86(Suppl)2:93. ⁸ Yamahara J, et al. Anti-ulcer Effect in Rats of Bitter Cardamon Constituents. Chem Pharm Bull 1990;38(11):3053.

⁹ Teng CM, et al. Antiplatelet Action of Dehydrokawain Derivatives Isolated From

Alpinia speciosa Rhizoma. Chin J Physiol 1990;33(1):41. ¹⁰ Morita H, Itokawa H. Cytotoxic and Antifungal Diterpenes From the Seeds of Alpinia galanga. Planta Med 1988;54(2):117.

¹¹ Luz AIR, et al. Essential Oils of Some Amazonian Zingiberaceae . Part 3. Genera

Alpinia and Rengalmia. J Nat Prod 1984;47:907. ¹² Shoji N, et al. Structural Determination of Nootkatol, New Sesquiterpene Isolated From Alpinia oxyphylla Miquel, Possessing Calcium Antagonistic Activity. J Pharm Sci

¹³ Misra SJ, Dixit VK. Pharmaceutical Studies on Starches of Some Zingiberaccous

Rhizomes. Indian J Pharm Sci1983;45:216. ¹⁴ Scheffer JJC, et al. Monoterpenes in the Essential Oil of Alpinia galanga (L.) Willd. Scientia Pharmaceutica 1981;49:337.

¹⁵ Inque T, et al. Studies on the Pungent Principle of Alpinia officinarum Hance. J

Pharm Soc Jap1978;98:1255. ¹⁶ Goutam MP, Purohit RM. Chemical Examination of Essential Oil Derived From Rhizomes of Alpinia khulanjan. Parfuemeric Kosmetik 1977;58:10.

¹⁷ Ray PG, Majumdar SK. Antifungal Flavonoid From Alpinia officinarum Hance. Indian

J of Exp Biol 1976;14(6):712. ¹⁸ Lima EO, et al. In Vitro Antifungal Activity of Essential Oils Obtained From Official Plants Against Dermatophytes. Mycoses1993;36(9-10):333.

¹⁹ Mitsui S, et al. Constituents From Seeds of Alpinia galanga Wild, and Their Anti-Ulcer

Activities. Chem Pharm Bull 1976;24(10):2377. ²⁰ Laranja SM, et al. Evaluation of Acute Administration of Natural Products with Potential Diuretic Effects in Humans. Mem Inst Oswaldo Cruz 1991;86(Suppl)2:237.

²¹ Laranja SM, et al. [Evaluation of Three Plants with Potential Diuretic Effect.]

[Portuguese] Revis Assoc Med Brasil 1992;38(1):13. ²² Itokawa H, et al. Antitumor Principles from Alpinia galanga. Planta Med 1987;53(1):32.

²³ Kaleysa RR. Screening of Idigenous Plants for Anthelmintic Action Against Human

Ascaris lumbricoides. Part 1. Indian J Physiol Pharmacol 1975;19:47. ²⁴ Kubo M, et al. [Study on Alpiniae Fructus. I. Pharmacological evidence of efficacy of Alpiniae Fructus on ancient herbal literature.] [Japanese] Yakugaku Zasshi 1995;115(10):852.

²⁵ Kiuchi F, et al. Inhibition of Prostaglandin and Leukotriene Biosynthesis by Gingerols

and Diarylheptanoids. Chem Pharm Bull1992;40(2):387. ²⁶ Ageel AM, et al. Experimental Studies on Antirheumatic Crude Drugs Used in Saudi Traditional Medicine. Drugs Exp & Clin Res1989;15(8):369.

²⁷ Qureshi S, et al. Toxicity Studies on Alpinia galanga and Curcuma longa. Planta Med 1992;58(2):124.

Document Bibliographic Information:

DATE OF ISSUE: FEB 2000

REPLACES MONOGRAPH DATED: DEC 1991

SCIENTIFIC NAME(S): Althaea officinalisL. Family: Malvaceae

COMMON NAME(S): Altheae radix, althea, marshmallow

BOTANY: Althea is a perennial that grows to 5 feet in salt marshes and moist regions throughout Europe, western and northern Asia, and the eastern US. Its 3-lobed leavesare velvety, and the plant resembles hollyhock (Althaea rosea). The plant blooms fromJuly to September. The family Malvaceae is known as the mallow family, and confusion may surround the common nomenclature and identification of the plants in this group.The root is collected in the fall, peeled of its brown corky layer, dried, and used incommerce. The leaves share many of the properties of the bark and have also been

used in traditional medicine.^1,2

HISTORY: Althea root has been recognized as a source of useful mucilage, which has been used for more than 2 millennia to treat topical wounds and as a remedy for sorethroats, coughs, and stomach ailments. The mucilage is incorporated into ointments tosoothe chapped skin and is added to foods in small quantities (˜ 20 ppm) to provide bulk and texture.¹ One report discusses Althea-type plants in a Neanderthal gravesite in Iraq.³

CHEMISTRY: The root contains 25% to 35% of mucilage,^1,4 but the content of the individual, purified mucilaginous polysaccharides is much lower. The mucilage content varies considerably with the season, being highest in the winter. A purified mucilage hasbeen shown to be composed of L-rhamnose:D-galactose:D-galacturonic acid:D-glucuronic acid in a molar ratio of 3:2:3:3.¹ Asparagine (2%), sugars, pectin, and

a tannin have also been identified in the root.^2,4 Fatty oil of althea has been addressed.⁵ Flavonoid compounds of the leaves, flowers, and roots have also been

described, including glucosidoesters and monoglucosides.^6,7

PHARMACOLOGY: The mucilaginous properties of the althea root yield a soothing effect on mucous membranes. Althea reduces the transport velocity of isolated ciliated epithelium cells of the frog esophagus in vitro and may be useful in the management ofcoughs and colds because of its ability to protect mucous layers in the hypopharynx along with its spasmolytic, antisecretory, and bactericidal activity.⁸ Althea extract and polysaccharide were tested for antitussive activity in cats. Although the polysaccharide component was more effective, both possessed cough-suppressing capabilities.⁹

Combinations of althea extracts with steroids have been used in the management of

dermatologic conditions,^10,11 and the plant appears to possess anti-inflammatory activity that potentiates the effect of topical steroids.¹²

TOXICOLOGY: Althea extracts have not been generally associated with toxicity.

SUMMARY: Althea root and extracts have demulcent properties that make them useful in the management of sore throats and coughs along with topical dermalirritations. The plant has a long history of use and is not associated with any important toxicity.

PATIENT INFORMATION — Althea

Uses: Althea mucilage has been used to soothe dermal irritations, sore throats, and coughs. It appears to have bactericidal and anti-inflammatory properties.

Side Effects: Long used as a food additive, althea has no observed toxicity.

REFERENCES

¹ Evans WC. Trease and Evans' Pharmacognosy, 13th ed. London: Bailliere Tindall,

1989. ² Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics . New York: J. Wiley and Sons, 1980.

³ Lietava, J. Medicinal plants in a Middle Paleolithic grave Shanidar IV? J Ethnopharmacol 1992;35(3):263-6.

⁴ Merck Index, 10th ed. Rahway, NJ: Merck & Co., Inc., 1983.

⁵ Mishina, A, et al. Fatty oil of Althea officinalis, stoloniferous valerian and golden wallflower. Farm Zh 1975;(5):92-3. Ukrainian. ⁶ Gudej, J. Flavonoid compounds of leaves of Althea officinalis L. (Malvaceae). Part 1.

Glucosidoesters and monoglucosides. Acta Pol Pharm 1985;42(2):192-8. ⁷ Gudej, J. Determination of flavonoid in leaves, flowers, and roots of Althea officinalis

L. Farmacja Polska 1990;46:153-5.

⁸ Muller-Limmroth W, et al. Effect of various phytotherapeutic expectorants on mucociliary transport. Fortschr Med 1980;98(3):95-101. German. ⁹ Nosal'ova, G, et al. Antitussive action of extracts and polysacchrides of marsh mellow.

Pharmazie 1992;47(3):224-6. German. ¹⁰ Piovano PB, et al. Mazzocchi S. Clinical trial of a steroid derivative

(9-alpha-fluoro-prednisolone-21-acetate) in association with aqueous extract of althea in the dermatological field. G Ital Dermatol Minerva Dermatol 1970;45(4):279. ¹¹ Huriez C, et al. On the association of althea and dexamethasone: Dexalta ointment.

Lille Med 1968;13(2)(suppl):121. ¹² Beaune A, et al. Anti-inflammatory experimental properties of marshmallow: Its potentiating action on the local effects of corticoids. Therapie 1966;21(2):341.

Document Bibliographic Information:

DATE OF ISSUE: MAY 1994

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Abelmoschus moschatus Medic. Family: Malvaceae

COMMON NAME(S): Ambrette, musk okra, muskmallow

BOTANY: This plant is cultivated for its seeds, which have a characteristic musk-like odor. The seeds are the source of ambrette, an aromatic oil used in perfumery. Theplant grows to about 3 feet with showy yellow flowers with crimson centers. The plant is indigenous to India and is cultivated throughout the tropics.¹

HISTORY: Several parts of the plant have been used throughout history, most notably the seed oil, which is valued for its fragrant smell. The oil is used in cosmetics and has been used to flavor alcoholic beverages, especially bitters, and coffee.² The tender leaves and shoots are eaten as vegetables and the plant is often grown as anornamental.

Philippine native have used decoctions of the plant to treat stomach cancer, andextracts of the plant have bene used to treat such diverse ailments as hysteria, gonorrhea and respiratory disorders.²

CHEMISTRY: Distillation of the plant yields farnesol and furfural. The volatile oil is high in fatty acids, including palmitic and myristic acids. The ketone ambrettolide (alactone of ambrettolic acid) is responsible for the characteristic muck-like odor. A varietyof other related compounds have also been identified in quantities of less than 1% of the oil.¹

The bark yields a fiber that is used to produce tough cloths.²

PHARMACOLOGY: Little is known about the pharmacologic activity of this plant. The related species A. manihot has been shown to limit the development of renal injury in rabbits with immune complex-induced glomerulonephritis, and A. ficulneus maycontain substances that inhibit the development of the fetal sheep brain and that may impair the health of the ewe.³

TOXICOLOGY: Although the seeds were once considered to be stimulants with antispasmodic activity, the plant has been classified as an "Herb of Undefined Safety" by the FDA.² However, the extracts are classified as GRAS (Generally Recognized asSafe) for use in baked goods, candies and alcoholic beverages. Ambrettolide is reported to be nontoxic.¹

Ambrette and related "nitro musks" are highly lipophilic and have been shown to persistin human mother's milk, presumably following absorption through the skin from dermally-applied cosmetics.⁴

Musk ambrette and musk ketone, both found in cosmetics and aftershaves, have been

shown to cause photosensitivity and dermatitis in sensitive individuals.^5,6

SUMMARY: Ambrette is commonly used as a fragrance in perfumes and cosmetics. The safety of ingesting the oil and other extracts of the seeds has been questioned andextracts and components of the plant are known to cause dermal irritation. In smallquantities, however, ambrette is safe for internal consumption as a flavor for foods and drinks.

PATIENT INFORMATION — Ambrette

Uses: Ambrette has been used as a stimulant and as treatment for a variety of ills, from stomach cancer to hysteria. It is commonly used to scent cosmetics and to flavor foodsand drinks.

Side Effects: Ambrette has been eaten as a vegetable. With the possible exception of seed extracts, ingestion of small amounts is considered safe. Ingestion or application of ambrette derivatives produces photosensitivity and dermatitis in some individuals.

REFERENCES

¹ Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics. New York, NY: J Wiley and Sons, 1980.

² Duke JA. Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press, 1985. ³ Walker D, et al. Some effects of feeding Tribulus terrestris, Ipomoea, Lonchophylla and the seed of Abelmoschus ficulneus on fetal development and the outcome of pregnancy in sheep. Reprod Fertil Dev 1992;4:135.

⁴ Liebl B, Ehrenstorfer S. Nitro-musk compounds in breast milk. Gesundheitswesen

1993;55:527. ⁵ Machet L, et al. Persistent photosensitivity: treatment with puvatherapy and prednisolone. Ann Dermatol Venereol 1992;119:737.

⁶ Gardeazabal J, et al. Successful treatment of musk ketone-induced chronic actinic dermatitis with cyclosporine and PUVA. J Am Acad Dermatol 1992;27:838.

Document Bibliographic Information:

DATE OF ISSUE: FEB 2000

REPLACES MONOGRAPH DATED: JUN 1991

SCIENTIFIC NAME(S): Ammi majus L. and A. visnaga Lam. Family: Umbelliferae

COMMON NAME(S): Ammi, visnaga, bishop's weed

BOTANY: These annual plants grow to ˜ 120 cm in height, primarily in Egypt, other regions of the Middle East, and the Mediterranean. A. visnaga has been naturalized to parts of the southeastern US. It has a slightly aromatic odor and a very bitter taste. Thedrug product of ammi consists of the dried ripe fruits, typically of A. visnaga.

HISTORY: The plant has been cultivated for hundreds of years and was known by the Assyrians. A. majus was cultivated for the cut-flower trade, and both species have been used medicinally. These plants have been used in traditional medicine for millennia,particularly for the management of angina and respiratory diseases. Portions of the plant are made into toothpicks.¹ The fruits have been used in Egyptian folk medicine as diuretics and for the treatment of kidney and bladder stones.² Ammi has also been used for the traditional management of diabetes in Israel.³

CHEMISTRY: A. visnaga contains coumarins and furocoumarins (psoralens), the most important of which are khellin and visnagin. Khellin is present in fruits in a concentration of ˜ 1% and visnagin in a concentration of ˜ 0.3%.⁴ Biosynthesis of khellin, visnagin, furocoumarin, and visnadin have been investigated.⁵ Two furocoumarins, xanthotoxin (methoxsalen) and ammidin (imperatorin), from ammi fruits have been discovered, as well.⁶ Solubility and dissolution studies of khellin have also been described.⁷

Numerous reports regarding ammi constituents are available evaluating their

concentrations at various stages of maturity,^2,8 their presence in certain plant parts,⁹ and interactions with different plant extracts.¹⁰

Various methods for determination of ammi components have been performed including the following: Micro method (khellin and visnagin),¹¹ TLC separation (khellin and visnagin),¹² spectrometric determination (khellin and bergapten),¹³ HPLC (khellin and

visnagin),^4,14 and a polarographic method (khellinum in fruits).¹⁵ Recent improved

analyses to determine ammi components have also been performed.^16,17

Dihydroseselins have been determined from ammi fruits and extracts.¹⁸ Genetically transformed ammi cultures have been evaluated.¹⁹ In addition, marmesin, ammoidin, and ammidin have been characterized.²⁰ The fruit contains a small amount (< 0.03%) ofa volatile oil.

PHARMACOLOGY: Khellin is commercially available in several multi-ingredient European proprietary preparations for oral and parenteral administration as a vasodilator. It is used in the management of bronchial asthma and angina pectoris.⁶ The structure of cromolyn sodium, used in the management of allergic respiratory illness, was based on components derived from A. visnaga.²¹ Lipophilic extracts from the plant,including the active components visnadin, khellin, and visnagin exhibited calcium channel blocking actions, with visnadin being the most active.²² Acting at multiple sites, visnagin inhibited induced contractile responses in rat vascular smooth muscle.²³ Similarly, visnadine demonstrated peripheral and coronary vasodilatory activities in isolated rat vascular smooth muscle.²⁴

Ammi extract showed marked antimicrobial activity against gram-positive bacteria and Candida species.²⁵ Constituent khellin from ammi fruit parts inhibited the mutagenicity of certain promutagens in Salmonella typhimurium.²⁶

An ethnobotanical survey including 130 respondants reported ammi to be one of 16 species of Israeli medicinal plants used for diabetes.³ However, literature searches found no clinical trials to support this hypoglycemic action.

Extracts of A. majus seeds fed to rats with experimentally-induced kidney stones showed no beneficial effect in terms of stone passage or size reduction.²⁷

A combination product containing ammi demonstrated spasmolytic activity on guinea pig ileum in one report.²⁸ Extracts of the plants have been used to treat vitiligo and psoriasis.² When given orally in a dose of 50 mg 4 times daily, khellin increases HDL-cholesterol levels without affecting total cholesterol or triglyceride concentrations.⁷

TOXICOLOGY: A. majus has been associated with the development of severe

ophthalmologic changes, particularly pigmentary retinopathy in photosensitized

fowl.^29,30 Therefore, patients receiving ammi or its extracts should be monitored for ophthalmologic changes.

The furocoumarins (psoralens) may cause photosensitization and dermatitis.³¹ One study reports 4 irritant compounds from ammi seeds and evaluates potential for contact dermatitis.³²

In patients who received khellin to reduce blood lipids, nausea and vomiting were observed frequently. Elevated AST and ALT were also observed during therapy.³³

SUMMARY: Plants of the genus Ammi have been used for thousands of years for the treatment of urologic, dermatologic, and respiratory symptoms. Clinical evidence supports their vasodilatory actions. The plant also possesses antimicrobial activity andinhibits certain mutagens. The use of khellin, a major component of the plant, is limitedby toxicity.

PATIENT INFORMATION — Ammi

Uses: Ammi has been used for the treatment of urologic, dermatologic, and respiratory symptoms. The plant also possesses antimicrobial activity and inhibits certain mutagens.

Side Effects: Monitor for ophthalmic changes. The use of khellin is limited by toxicity (eg, elevated liver enzymes, phototoxicity, dermatitis).

REFERENCES

¹ Mabberley D. The Plant-Book. Cambridge: Cambridge University Press, 1987. ² Franchi G, et al. High performance liquid chromatography analysis of the

furanochromones khellin and visnagin in various organs of Ammi visnaga (L.) Lam. at different developmental stages. J Ethnopharmacol 1985;14(2-3):203-12. ³ Yaniv Z, et al. Plants used for the treatment of diabetes in Israel. J Ethopharmacol

1987;19(2):145-51. ⁴ Martelli P, et al. Rapid separation and quantitative determination of khellin and visnagin in Ammi visnaga (L.) Lam. fruits by high-performance liquid chromatography. J Chromatogr 1984;301:297-302.

⁵ Chen M, et al. The biosynthesis of radioactive khellin and visnagin from C14 - acetate

by Ammi visnaga plants. Planta Med 1969;17:319-27. ⁶ Le Quesne P, et al. Furocoumarins from the fruit of Ammi visnaga. J Nat Prod 1985;48:496.

⁷ Fromming K, et al. Influence of biopharmaceutical properties of drugs by natural occurring compounds as exemplified with khellin in an Ammi visnaga dry extract. Pharmazeutische Industrie 1989;51(4):439-43.

⁸ Balbaa S, et al. Study of the active constituent of Ammi visnaga fruits collected at

different stages of maturity. J Pharm Sci UAR 1968;9:15-26. ⁹ Franchi G, et al. Ammi visnaga (L.) Lam.: occurrence of khellin and visnagin in primary rib channels and endosperm, and emptiness of vittae, revealed by U.V. microscopy. Intl J Crude Drug Research 1987;25:137-44.

¹⁰ Gharbo S, et al. Modified chromatographic method of assay of Ammi visnaga L. fruits

and its galenicals. J Pharm Sci 1968;9:7-14. ¹¹ Karawya M, et al. Micro method for the estimation of khellin and visnagin in Ammi visnaga fruits and in formulations. J Pharm Sci 1969;10:189-96.

¹² Karawya M, et al. Simultaneous TLC separation of khellin and visnagin and their

assay in Ammi visnaga fruits, extracts, and formulations. J Pharm Sci 1970;59:1025-27. ¹³ Ibrahim S, et al. Use of acid-dye technique in the analysis of natural products. Part 3. Spectrophotometric microdetermination of khellin and bergapten. loydia 1979;42:366-73.

¹⁴ Mesbah M. Determinatioin of khellin and visnagin in Ammi visnaga fruits and in renal teas by high-performance liquid chromatography. Egyptian J Pharm Sci1992;33(5-6):897-904.

¹⁵ Orlov Y, et al. Polarographic determination of khellinum in Ammi visnaga fruits.

Farmatsiia1989;38(5):47-50. ¹⁶ El-Domiaty M. Improved high-performance liquid chromatographic determination of khellin and visnagin in Ammi visnaga fruits and pharmaceutical formulations. J Pharm Sci 1992;81:475-78.

¹⁷ Zgorka G, et al. Determination of furanochromones and pyranocoumarins in drugsand Ammi visnaga fruits by combined solid-phase extraction-high-performance liquid chromatography and thin-layer chromatography-high-performance liquidchromatography. J Chromatogr A 1998;797(1-2):305-09.

¹⁸ Karawya M, et al. Determination of dihydroseselins in fruits and extracts of Ammi

visnaga L. J Pharm Sci 1969;58:1545-547. ¹⁹ Kursinszki L, et al. Biologically active compounds of genetically transformed Ammi visnaga cultures. Gyogyszereszet 1997;41:84-87.

²⁰ Abu-Mustafa E, et al. Isolation of Marmesin from the Fruits of Ammi majus Linn.

Nature 1958;182(4627):54. ²¹ Evans W. Trease and Evans' Pharmacognosy, 13th ed. London: Bailliere Tindall, 1989.

²² Rauwald H, et al. The involvement of a Ca2+ channel blocking mode of action in the pharmacology of Ammi visnaga fruits. Planta Med 1994;60(2):101-05. ²³ Duarte J, et al. Vasodilator effects of visnagin in isolated rat vascular smooth muscle.

Eur J Pharmacol 1995;286(2):115-22. ²⁴ Duarte J, et al. Effects of visnadine on rat isolated vascular smooth muscles. Planta Med 1997;63(3):233-36.

²⁵ Jawad A, et al. Antimicrobial activity of sesquiterpene lactone and alkaloid fractions

from Iraqi plants. Int J Crude Drug Research 1988;26:185-88. ²⁶ Schimmer O, et al. Inhibition of metabolic activation of the promutagens, benzo[a] pyrene, 2-aminofluorene and 2-aminoanthracene by furanochromones in Salmonella typhimurium. Mutagenesis 1998;13(4):385-89.

²⁷ Ahsan S, et al. Effect of Trigonella foenum-graecum and Ammi majus on calcium

oxalate urolithiasis in rats. J Ethnopharmacol 1989;26(3):249-54. ²⁸ Westendorf J, et al. Spasmolytic and contractile effects of a combination product from plants on the smooth muscle of the guinea pigs. Arzneimittelforschung 1981;31(1):40-43.

²⁹ Shlosberg A, et al. The comparative photosensitizing properties of Ammi majus and

Ammi visnagain goslings. Avian Dis 1974;18(4):544-50. ³⁰ Shlosberg A, et al. Examples of poisonous plants in Israel of importance to animals and man. Arch Toxicol Suppl 1983;6:194-96.

³¹ Kavli G, et al. Phytophotodermatitis. Photodermatol 1984;1(2):65-75. ³² Saeed M, et al. Studies on the contact dermatitic properties of indigenous Pakistani

medicinal plants. Part 3. Irritant principles of Ammi visnaga L. seeds. Gazi Universitesi Eczacilik Farultesi Dergisi 1993;10(1):15-23. ³³ Harvengt C, et al. HDL-cholesterol increase in normolipaemic subjects on khellin: A

pilot study. Int J Clin Pharmacol Res 1983;3(5):363-66.

Document Bibliographic Information:

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DATE OF ISSUE: SEP 1996

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Andrachne cordifolia Muell. and related species viz. A. aspera Spreng. and A. phyllanthoides (Nutt.) Muell. Arg. Family: Euphorbiaceae

BOTANY: The Andrachne genus has about 20 tropical American species and a few species in North Africa, Europe and elsewhere.¹ These are generally seen as shrubs and undershrubs, possessing many ascending leafy branches, in tropical and warmregions. The leaves are oval or obovate, while the flowers are monoecious, pedicellate

and usually solitary in the axils. The fruit is dry, splitting into three 2-valved carpels. A. phyllanthoides is found in the dry hills and rocky barrens from Montana to Texas in May through October.² A. aspera is widely distributed throughout the Middle East.

CHEMISTRY: Two bisbenzylisoquinoline alkaloids, cocsuline and pendulin, have been isolated from the roots of A. cordifolia.³ Previously, the two alkaloids werereported only from the Menispermaceae family.

PHARMACOLOGY: The plants in the genus are marginally used as medicinal plants in some countries. A. aspera roots are used for treating eye inflammation in Yemen, where pieces of the crushed roots are placed on the eyelids.⁴ Some species also havepest-control properties.

TOXICOLOGY: No toxicological data have been recorded for this genus.

SUMMARY: Andrachne species have marginal folkloric use for treating eye inflammation. Some are used for controlling pests.

PATIENT INFORMATION — Andrachne

Uses: One species has been used to treat eye inflammation in Yemen. Others act as pest controls.

Side Effects: No data available.

REFERENCES

¹ Mabberley DJ. The Plant-Book. New York: Cambridge University press, 1987.² Fernald ML. Gray's Manual of Botany, ed. 8. Portland, OR: Dioscorides Press, 1950.³ Khan MI, et al. Bisbenzylisoquinoline Alkaloids from Andrachne cordifolia. Planta

Med1983;47:191. ⁴ Ghazanfur SA. Handbook of Arabian Medicinal Plants. Boca Raton, FL: CRC Press, 1994.

Document Bibliographic Information:

DATE OF ISSUE: JUL 2001

REPLACES MONOGRAPH DATED: N/A

SCIENTIFIC NAME(S): Andrographis paniculata (Burm.f.)Nees Acanthaceae (acanthus family)

COMMON NAME(S): Kalmegh (Hindi), Chuanxinlian (Chinese), Kalupnath, Kiriat, Mahatita ("King of Bitters"), Alui, Bhunimba, Yavatikta (Sanskrit), Sambiloto (Malay)

BOTANY: A. paniculata is an erect annual herb native to India, China, and Southeast Asia. The square stem has wings on the angles of new growth and is enlarged at the nodes, while the small flowers are borne on a spreading panicle. It is widely cultivated inAsia. The above-ground parts are collected in the fall. The genetic variability of the species has been examined.¹

HISTORY: The herb has been used primarily for liver complaints and to reduce fevers in the traditional medicine of India and China, as well as for its bitter tonic properties. A large variety of Indian herbal patent medicines are available in which A. paniculata is a prominent ingredient.

CHEMISTRY: The diterpene lactone andrographolide was first isolated as a major

constituent² and later characterized as a lactone.^3,4 Its full structure was determined by

Cava's group in the 1960s,^5,6 while X-ray crystallography later confirmed the structure.⁷

A number of related minor diterpenes and their glycosides have since been

identified.^8,9,10,11,12 Methods of analysis including high pressure liquid chromatography (HPLC),¹³ and nuclear magnetic resonance (NMR)¹⁴ have been published. A method for rapid isolation of andrographolide is also available.¹⁵ When callus cultures of the

plant were investigated, it was found that andrographolide and the other diterpenes were not produced. Instead, the sesquiterpenes paniculides A-C were found.¹⁶ Other constituents of the plant include various flavones.¹⁷

PHARMACOLOGY

Liver: The aqueous extract of A. paniculataprotected mice from liver damage induced by hexachlorocyclohexane,¹⁸ while andrographolide protected rat hepatocytes from damage by acetaminophen.¹⁹ Several isolated Andrographis diterpenes protected mice from liver damage by carbon tetrachloride or tert-butylhydroperoxide.²⁰ Both the extract

and andrographolide induced hepatic drug metabolizing enzymes in rats, although the extract was more effective than the isolated compound.²¹ An increase in bile flow was noted with administration of andrographolide to rats and guinea pigs, while it blocked the decrease in bile flow induced by acetaminophen.²²

Immunostimulant and anti-infective: Both antigen-specific and nonspecific immune responses in mice were stimulated by andrographolide and an ethanolic extract,although the extract was more potent than andrographolide, suggesting that other constituents were also immunostimulants.²³ Inhibition of passive cutaneous anaphylaxis and mast cell stabilization was observed in studies of the purified diterpenes in rats.²⁴ A small clinical study found the extract to shorten the duration of common colds and to reduce symptoms.²⁵ Extracts of Andrographishave shown modest activity in vitro

against HIV;^26,27,28 however, a phase ? study of andrographolide showed no effect on viral replication, while adverse effects required interruption of the trial after 6 weeks.²⁹ Succinoylated derivatives of andrographolide have been studied for their proteaseinhibitory properties, which were suggested to be involved in the anti-HIV activity in

vitro.³⁰ Activity in antimalarial screens has also been noted for Andrographis

extracts.^31,32

Other: The extract of A. paniculata has been shown to block E. coli enterotoxin-induced secretion in rabbit and guinea pig models of diarrhea.³³ Andrographolide and 3 other related diterpenes were responsible for this action.³⁴ An ethanol extract of Andrographisreversed elevation in blood glucose caused by streptozotocin in rats.³⁵

Two purified Andrographisditerpenes stimulated nitric oxide release from cultured

human endothelial cells, an effect linked to their hypotensive effect in rats.³⁶ Several fractions of Andrographis were shown to reduce mean arterial blood pressure in rats, although andrographolide was not active in this model.³⁷

A water soluble extract of the plant was reported to delay death from cobra venom in mice, in line with its folk use for snakebite in India.³⁸ Andrographolide has demonstrated

anti-inflammatory effects in several cellular systems, including prevention of phorbol ester-induced reactive oxygen species and N-formyl-methionyl-leucyl-phenylalanine (fMLP)-induced adhesion in rat neutrophils³⁹ and inhibition of TNF-induced upregulation of intercellular adhesion molecule-1 (ICAM-1) expression and monocyte adhesion.⁴⁰

Additionally, Andrographis extract blocked rat vas deferens voltage-gated calcium channels⁴¹ and induced cell differentiation in mouse myeloid leukemia cells, as did several diterpenes from the extract.⁴² The diversity of pharmacologic activities observed

for extracts of Andrographis and its diterpenes begs the question of pharmacologicspecificity, which more studies will clarify.

TOXICOLOGY: Andrographis extracts are not acutely toxic, but the male reproductive toxicology of Andrographis has been studied. Reported infertility in rats ledto a subchronic 60-day study in male rats that showed no changes in testicular weight, histology, or testosterone levels.⁴³ However, detailed studies with purifiedandrographolide in rats over 48 days have shown decreases in sperm counts and motility, linked to disruption of spermatogenesis.⁴⁴

SUMMARY: Andrographis is official in both the Indian and Chinese Pharmacopeias.

A. paniculatais a bitter-tasting medicinal plant widely used in India and China for avariety of purposes (eg, antipyretic, anti-inflammatory, immunostimulant). It has been touted as an "Indian echinacea" in herbal supplement marketing. A few human clinicalstudies tentatively support its use in colds and fevers. Trials in AIDS have not beenpromising; however more research is required to substantiate these initial findings. Testicular toxicology questions remain to be answered.

PATIENT INFORMATION — Andrographis

Uses: Andrographis has been used for liver complaints and fevers and as an anti-inflammatory and immunostimulant. In clinical trials, Andrographis extract shortened duration and reduced symptoms of colds.

Side Effects: Male reproductive side effects have been studied. In rats, Andrographis decreased sperm count and motility.

REFERENCES

¹ Padmesh P, et al. The use of RAPD in assessing genetic variability in Andrographis paniculata Nees, a hepatoprotective drug. Curr Sci 1999;76(6):833-35.

² Boorsma W. Med's Lands Plant 1896;18:63-66. ³ Gorter M. The bitter constituent of Andrographis paniculata. Rec Trav Chim 1914;33:239-43.

⁴ Schwyzer R, et al. Uber andrographolid. Helv Chim Acta 1951;34:652-77. ⁵ Cava M, et al. Tetrahedron 1962;18:397-403. ⁶ Chan W, et al. The stereochemistry of andrographolide. Chem Ind 1963;495. ⁷ Smith A, et al. Andrographolide: An X-ray crystallographic analysis. J Crystallogr

Spectrosc Res 1982;12(4):309-19. ⁸ Kleipool R. Constituents of Andrographis paniculata Nees. Nature 1952;169:33-34. ⁹ Fujita T, et al. On the diterpenoids of Andrographis paniculata: X-ray crystallographic

analysis of andrographolide and structure determination of new minor diterpenoids.

Chem Pharm Bull 1984;32(6):2117-25.

¹⁰ Balmain A, et al. Minor diterpenoid constituents of Andrographis paniculata Nees. J

Chem Soc Perkin ? 1973;1247-51. ¹¹ Chen W, et al. Deoxyandrographolide-19-ß-D-glucoside from the leaves of Andrographis paniculata. Planta Med 1982;45:245-46.