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Volume 8 No 1 2003 Modern Phytotherapist FOR PROFESSIONAL USE ONLY. NOT FOR PUBLIC DISTRIBUTION © MEDIHERB 2003 Effective Herbal Treatment of Allergies BY TRACEY COOK Most herbalists will not treat severe acute allergic reactions, as in these life-threatening cases urgent medical intervention is essential. They do however see a large proportion of people with hypersensitivity reactions and intolerances where herbal treatment can be most beneficial. A detailed and comprehensive case history is essential, and where foods are suspected, a food diary or elimination diet can be useful. The term allergy is often used to describe immediate hypersensitivity reactions and atopic diseases where there is IgE antibody involvement. Most manifestations are produced by mast cell degranulation as outlined below.1 Allergic individuals have been sensitized to a specific allergen/antigen. Their mast cells and basophils are “armed” with receptor sites for IgE-antibodies specific to the allergen. Exposure to the allergen results in an interaction between the allergen and receptor-bound IgE triggering mediator release. The mediators released from mast cells and basophils are responsible for the subsequent allergic reaction. These mediators can be divided into three broad categories of action, the kind that:2 Contents • increase vascular permeability and contract smooth muscle (e.g. histamine and PAF (platelet activating factor)); Clinical Anecdotes: Use of Anthelmintic Herbs 20 • are chemotactic for or activate other inflammatory cells (e.g. leukotriene B4); Prostate Problems and Solutions 22 • modulate the release of other mediators including PAF. Clinical Monitor 29 Effective Herbal Treatment of Allergies Editorial: Understanding and Practising Effective Phytotherapy – More than Herbal Monographs 2 Herbal Treatment for Intestinal Parasites continued page 3 ➔ This Modern Phytotherapist is for educational purposes only. MediHerb and Standard Process do not recommend or suggest that any herb discussed is for use in the diagnosis, cure, mitigation or treatment of any disease or disease-related condition. MediHerb and Standard Process are not responsible for any recommendations or suggestions health care practitioners make for any medical uses. Health care practitioners should refer to the Contraindications & Cautions Book for MediHerb botanicals before recommending any products to patients. 1 Modern Phytotherapist 1 13 Editorial Editorial Understanding and Practising Effective Phytotherapy is About More than Herbal Monographs BY KERRY BONE Phytotherapy (PPP) by Simon Mills and myself was published in 1999 it was hailed as the first textbook of modern herbal practice. Since then several other herbal texts have been released for the professional reader. However, most of these publications contain only herbal monographs and seem to be based on the assumption that knowing about the properties of herbs is all that is necessary to be an effective herbal clinician. Furthermore, many of these materia medica textbooks are not written by practising herbalists and, rather than acting as working manuals or references for the herbal clinician, are quite negative about the worth and safety of many herbal treatments (under the guise of an evidence-based evaluation). W HEN Principles and Practice of Very few, if any, modern texts reflect the current core activity of most Western herbal practitioners: namely arriving at an individual prescription after an extensive consultation and then dispensing this prescription as a compounded liquid formulation. Herbalists in Australia, New Zealand, the UK and the USA have functioned in this way for more than 100 years, yet this mode of practice is regarded by many as on the fringe of medicine. This contrasts strongly with traditional Chinese medicine where the textbooks do reflect current practice and draw strongly from the traditional knowledge base. No one in China belittles the traditional basis of their herbal practice, unlike the case for many Western herbal texts. For some time now I have felt that a text which reflects the Western herbalist’s art of formulating liquids for the individual patient was needed. This need, coupled with the common feedback on PPP that it contained too few herbal monographs, led to the development of a new book entitled The Clinical Guide to Blending Liquid Herbs: Herbal Formulations for the Individual Patient which will be published later this year by ChurchillLivingstone. In one sense this text is an appendage to and update of PPP and this is particularly reflected in the way the monographs are written. I have drawn upon my 18 years of herbal practice to write the clinical guide. It contains three main sections, the first section deals with all the practical issues involved with prescribing and dispensing liquid herbal products. The second section outlines, with many worked examples, the rationale and thought processes behind using individual prescribing with liquid herbs for the treatment of a variety of health issues. In the third section, the reader will find comprehensive up-todate monographs on more than 100 herbs. In particular, these monographs are written from the perspective of a prescribing herbal clinician and contain indications from both traditional sources and scientific investigations. (One feature of the monographs is that the level of evidence behind each indication is clearly stated.) Effective herbal therapy is more than just knowing about the properties of herbs. Any clinician who wishes to understand and apply in a modern scientific context the fascinating, flexible and (in my experience) clinically effective methodology of the traditional Western herbalist should explore the art of individual phytotherapeutic prescribing. Editors: Kerry Bone and Amanda Williams Managing Editor: Michelle Morgan Publisher: MediHerb Pty Ltd A.C.N. 006 454 717 P.O. Box 713, Warwick, Queensland, 4370, Australia. Telephone: +61 7 4661 0700 Facsimile: +61 7 4661 0788 email: [email protected] web site: www.mediherb.com Contents copyright © MediHerb Pty Ltd 2003 2 Modern Phytotherapist MH/293 For professional use only. Not for Public Distribution. Clinical Effective Herbal Treatment of Allergies …continued from page 1 The T helper cells that drive immediate hypersensitivity responses are usually of the TH2-type. TH2 helper cells induce the inflammatory interleukins IL-4, IL-5, IL-6 and IL-10. Interferon-gamma production is associated with TH1 responses which include contact dermatitis.2 Classification of urticaria with angioedema:2 • - Atopic diathesis - Specific antigen sensitivity (e.g. pollens, foods, drugs, fungi, moulds) - Physical (e.g. dermographism, cold, light, vibratory, exercise-related) Types of Allergic Reaction Anaphylaxis Systemic anaphylaxis occurs within minutes after administration of a specific antigen by injection. In rare cases, anaphylaxis can occur after ingestion of antigen in highly sensitized individuals. Varying degrees of severity of reaction will occur with respiratory distress, pruritis, urticaria and sometimes angioedema. Vascular collapse and shock can occur in severe cases. There may also be abdominal pain, nausea, vomiting and diarrhoea. IgE-dependent • Complement-mediated - Hereditary angioedema (type 1, type 2) - Acquired angioedema (type 1, type 2) - Necrotising vasculitis - Serum sickness - Reactions to blood products • Nonimmunologic Antigens capable of causing an anaphylactic reaction in humans include:2 - Direct mast cell-releasing agents (e.g. opiates, antibiotics, radiocontrast media) • - Agents which presumably alter arachidonic acid metabolism (e.g. aspirin, NSAIDs (nonsteroidal anti-inflammatory agents), azo dyes, benzoates) drugs such as antibiotics (e.g. penicillins), local anaesthetics (e.g. procaine), vitamins (e.g. thiamine) and diagnostic agents (e.g. sulfobromophthalein), • pollen extracts (e.g. ragweed, grass, trees), • nonpollen extracts (e.g. dust mite, cat dander), • foods (e.g. eggs, seafood, nuts, grains, beans), • occupational proteins (e.g. rubber products) and chemicals (e.g. ethylene oxide), • Hymenoptera venom (e.g. hornets, wasps, bees, fire ants), • antiserum (e.g. antilymphocyte gamma globulin), • hormones and enzymes (e.g. insulin, penicillinase, trypsin). Angioedema and Urticaria Angioedema may appear as localised oedema (nonpitting) or it may occur with urticaria. Urticaria presents as well circumscribed wheals with erythematous borders but the centres are blanched. These wheals may coalesce to form giant wheals and they are intensely pruritic. They can appear on the body but most commonly the extremities, external genitalia and face particularly the eyes and lips. Not all urticaria is caused by immune reactions. For professional use only. Not for Public Distribution. • Idiopathic Allergic Rhinitis Symptoms include sneezing; profuse, clear, running mucus; obstruction of nasal passages; conjunctive, nasal and pharyngeal itching and lacrimation. It most commonly occurs seasonally as in hay fever but it can also occur perennially. Allergic rhinitis is most common in atopic patients who have a personal history or family history of eczema, asthma and urticaria. Most medical texts state that food sensitivity reactions are rare and the antigen is far more likely to be an airborne pollen or mould. In the case of perennial allergic rhinitis the culprit is more likely to be animal dander, chemicals or dust. Many patients with allergic rhinitis will react when there is no obvious allergen present. Nasal polyps can be a feature of allergic rhinitis, particularly in the perennial type. They often coincide with the mucosal oedema and/or infection and this exacerbates the nasal congestion. Polyps are mucosal protrusions containing chiefly oedema fluid with variable degrees of eosinophilic infiltration. Modern Phytotherapist 3 Clinical Eczema/Dermatitis2 Allergic contact dermatitis occurs when the skin comes into contact with an allergen that the skin is sensitive to. Common symptoms include redness, itching, swelling, blistering and weeping, and this usually occurs within 48 hours of contact. The allergen can be a substance used for years, but more commonly it is in reaction to contact with plants. Atopic eczema is an itchy skin rash characterised by scaly, red, itchy lesions which may weep. It usually occurs in skin flexures (especially behind the knees and inside the elbows) but can occur on other areas of the body as well. It is more common in infants and during childhood but may continue into adulthood. Patients may have an increased blood eosinophil count. Its aetiology is unknown, however people with atopic eczema and their families have a greater incidence of asthma and hayfever, raising the possibility of a genetic basis to the condition. Nummular eczematous dermatitis (discoid) is a stubborn rash which forms circular lesions on the skin. As the lesions progress, they may clear in the centre – resembling a ring worm. It tends to be a chronic condition, sometimes being less active than others. It is easily misdiagnosed and I have seen patients who have been treated for ring worm, impetigo and herpes instead of nummular eczema. Asteatotic eczema (winter itch) occurs commonly on the lower legs of elderly individuals during dry times of the year. It appears as fine cracks resembling the cracks (crazing) seen in china or porcelain. Hand eczema may occur with other skin problems such as atopic eczema or psoriasis or may occur alone. Excessive exposure to irritants may initiate the disorder and aggravate it as well. Often the dermatitis begins under rings where water and irritants are trapped. affected by the other organs including the nervous system. This is not to say that medical treatment of the symptoms is not at times valid. There are times when it is essential, especially in severe cases where the majority of the skin is affected. In such cases, the integrity of the skin is so at risk as to leave the individual susceptible to systemic and local infection. For this reason, the “healing crisis” is best avoided. With this in mind herbs with antiallergic activity are vital in the treatment of allergic conditions. As the skin is an organ of elimination, it is useful to assess the other eliminatory channels i.e.: bowels, lungs and kidneys. Increasing the efficiency of these organs will help to reduce the stress placed on the skin by an overloaded toxic system. This will also reduce the risk of exacerbation of symptoms and reduce reactivity. The Role of Food Sensitivities and Gut Function There are many studies indicating that food hypersensitivity plays a role in cutaneous skin lesions. It is common that sensitivity to food and increased intestinal permeability go hand in hand and must be addressed. Many patients who have intolerances to certain foods also have a history of some gastrointestinal tract insult such as Salmonella poisoning, giardiasis or multiple antibiotic therapy – this can lead to a malabsorption syndrome and chronic inflammation of the gut. There are also studies indicating that the immune factors of expectant mothers are passed on to infants. One such study indicates that infants have nearly twice the risk of developing eczema if their mothers had asthma or eczema during their pregnancy.3 It may therefore be worthwhile for expecting mothers to take care with their diet if they have food sensitivities so as to reduce the infant's risk of developing sensitivities too. Medical treatment is topical corticosteroids for severe, widespread reactions, if more than 30% of the body is involved or if there is involvement of the hands, face or genitals. Such treatment includes the glucocorticoid dexamethasone. Antibiotic therapy (often prophylactically) and antipruritics are also prescribed. Dermatitis herpetiformis (a variant of coeliac disease) will usually respond to the removal of gluten from the diet, however, there have been case reports where the gluten content of the diet had been removed but the dermatitis only cleared when dairy products were also removed from the diet. In one study this also controlled the patient’s dyspepsia.4 Holistic Treatment of Allergic Conditions Seventy-five percent of patients with dermatitis herpetiformis in one study were found to have significantly increased prevalence (p<0.001) of serum IgG antibodies reactive with wheat gliadin, bovine milk or ovalbumin compared to controls. IgA anti-milk antibodies were detected in patients irrespective of whether they were on a gluten-free diet.5 Most inflammatory skin diseases, including eczema and dermatitis, are multifactorial and if treated holistically, usually respond well. The skin must never be seen in isolation but as a tissue intimately connected to and 4 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical Assessing Gut Function Nervous System Involvement Treatment with herbs will be needed if there is: Most patients with skin problems will report that stress exacerbates the condition. The effects of the hormones released from the adrenal and pituitary glands can have deleterious effects on the body if the stress state is prolonged. This can result in a lowered resistance generally and can stimulate the inflammatory process. Noradrenalin stores can be depleted in depression and stress. Nervine herbs such as Scutellaria lateriflora, Avena sativa, Hypericum perforatum and adaptogens such as Withania somnifera and Eleutherococcus senticosus would be of benefit. • Reduced gastric acid secretion, use bitters – barberry (Berberis vulgaris), gentian (Gentiana lutea), golden seal (Hydrastis canadensis). • Feeling of food sitting there, especially after eating proteins – use bitters (as above). • Excessive burping, bloating, flatulence – use bitters (as above). • Heartburn, reflux – use demulcents, golden seal, marshmallow root (Althaea officinalis) glycetract, meadowsweet (Filipendula ulmaria), slippery elm (Ulmus rubra). • Sluggish bowels/constipation – use bitters + bulk laxatives e.g. butternut (Juglans cinerea), cascara (Rhamnus purshiana), dandelion root (Taraxacum officinale), golden seal, flaxseed (Linum usitatissimum), psyllium (Plantago psyllium), yellow dock (Rumex crispus). • Explosive bowels/loose diarrhoea – use meadowsweet, chamomile (Matricaria recutita), slippery elm. • Abdominal cramping, pain – use chamomile, cramp bark (Viburnum opulus), licorice (Glycyrrhiza glabra). • Irritable bowel syndrome – use Boswellia (Boswellia serrata), chamomile, cramp bark, Mexican valerian (Valeriana edulis), wild yam (Dioscorea villosa). The above herbs and nervine tonics such as skullcap (Scutellaria laterifolia), St John’s wort (Hypericum perforatum), and valerian (Valeriana officinalis), are prescribed as necessary according to the individual's needs. An interesting study looked at noradrenalin levels in eczema sufferers. Physical stress-induced secretion of adrenal and pituitary hormones in patients with atopic eczema was compared with normal controls. Patients with atopic eczema and an age-matched control group performed exhausting incremental graded bicycle exercise to evaluate the release of cortisol, adrenocorticotropin (ACTH), beta-endorphin, adrenalin and noradrenalin induced by physical stress. Patients with severe eczema displayed a significantly lower increase in noradrenalin levels when compared with the less affected patient group.6 Salicylate Sensitivity When patients complain of an exacerbation of symptoms in summer I always suspect salicylates due to the abundance of wonderful salicylate-rich foods at that time of the year e.g. strawberries, tomatoes, peaches and apricots. Symptoms associated with salicylate sensitivity include a history of: • sinus problems, sinus congestion, multiple sinus infections, sinus headaches, • gut problems, heartburn, abdominal cramping pain, diarrhoea, burning anus, Common sensitivities: Wheat and/or gluten, dairy, yeast (very common). But also: Additives, flavourings, colourings (especially in children), salicylates. • skin symptoms – hives, pimple-like rash (especially on the face, neck and arms), itchy skin with no rash, Patients can be hypersensitive to any substance and in rare cases there will be those who seem to react to almost everything. In this case the treatment of the gut generally with anti-inflammatory gut herbs, berberinecontaining herbs and bitters, in conjunction with treatment of nervous system and hepatic detoxification processes is extremely effective. • joint pains – generalised polyarthralgia or may be limited to one or two joints, • asthma. Food Sensitivities For professional use only. Not for Public Distribution. The patient may present with all of these symptoms or a combination of any of the above or indeed just one symptom. Modern Phytotherapist 5 Clinical It is easy to exacerbate the symptoms with the use of herbal medicines and therefore I will generally put the patient on a low salicylate diet for two weeks and prescribe L-glutamine (for gut function, repair and absorption). After this time I will often start a herbal formula using herbs which are known to be low in salicylates – such as Rehmannia (antiallergic herb), dandelion root (to assist the liver), celery seed (Apium graveolens) for inflammation, and this is usually well tolerated. If patients react to the herbal formula it will usually occur after a few days, as the salicylate sensitivity is cumulative which is why it is difficult to diagnose. (For a discussion of salicylates in herbs refer to Modern Phytotherapist 1995; 1(3): 1-7.) Lower Gastrointestinal Herbs – for sluggish bowels. Also bulk laxatives. Butternut (Juglans cinerea) Dandelion (Taraxacum officinale) Flaxseed (Linum usitatissimum) Licorice (Glycyrrhiza glabra) Psyllium husks (Plantago psyllium) Slippery elm powder (Ulmus rubra) Yellow dock (Rumex crispus) Anti-inflammatory Herbs Boswellia (Boswellia serrata) Bupleurum (Bupleurum falcatum) Gluten Sensitivity Licorice (Glycyrrhiza glabra) The classical symptoms of gluten sensitive patients are diarrhoea, abdominal cramping, bloating and debilitating fatigue. However, there are many people that are gluten sensitive but have no symptoms (or they may merely have fatigue) and the gluten sensitivity is diagnosed only after they are found to have recurring anaemia. I have known a couple of patients to complain only of pruritis ani. Dermatitis herpetiformis is also associated with gluten sensitivity. Rehmannia (Rehmannia glutinosa) Most symptoms disappear rapidly with the withdrawal of gluten from the diet. Repair of gastrointestinal tissue is essential to ensure the absorption of nutrients and particularly minerals. For patients with a long history of suspected gluten intolerance bone densitometry may be indicated, as lack of calcium absorption (and indeed other minerals making up the bone matrix) can often cause osteoporosis. I have had some patients whose first indication of a problem was anaemia, but they had no gut symptoms. Adaptogens Nervine Tonics Chamomile (Matricaria recutita) Passion flower (Passiflora incarnata) Skullcap (Scutellaria lateriflora) St John’s wort (Hypericum perforatum) Valerian (Valeriana officinalis) Wood betony (Stachys betonica) Bupleurum (Bupleurum falcatum) Eleuthero (Eleutherococcus senticosus) Gotu kola (Centella asiatica) Licorice (Glycyrrhiza glabra) Rehmannia (Rehmannia glutinosa) Metabolic Alteratives/Depuratives/Blood Purifiers – these herbs increase elimination of toxic waste. Burdock (Arctium lappa) Herbs to Consider for Allergic Conditions or Intolerances Dandelion root (Taraxacum officinale) The following table outlines herbs with specific and/or appropriate actions to address the factors discussed above. Fringe tree (Chionanthus virginicus) Figwort (Scrophularia nodosa) Oregon grape (Berberis aquifolium) Red clover (Trifolium pratense) Upper Gastrointestinal Herbs (bitters and specific herbs) Herbs which increase Detoxification through Urinary Tract – this eases the burden of elimination from the skin. Barberry (Berberis vulgaris) Burdock (Arctium lappa) Fumitory (Fumaria officinalis) Cleavers (Galium aparine) Gentian (Gentiana lutea) Dandelion leaves (Taraxacum officinale) Golden seal (Hydrastis canadensis) Figwort (Scrophularia nodosa) Indian barberry (Berberis aristata) Heartsease (Viola tricolor) Meadowsweet (Filipendula ulmaria) Red clover (Trifolium pratense) 6 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical Antiallergic Herbs Albizia (Albizia lebbek) Baical skullcap (Scutellaria baicalensis) Licorice (Glycyrrhiza glabra) Rehmannia (Rehmannia glutinosa) Antioxidant Herbs – to reduce the oxidative damage from the inflammation. Cat's claw (Uncaria tomentosa) Chaparral (Larrea tridentata) Crataeva (Crataeva nurvala) Ginger (Zingiber officinale) Ginkgo (Ginkgo biloba) CASE 1: SEVERE HYPERSENSITIVITY TO WHEAT Patient: 52-year-old woman. Teacher in a very stressful job. Presented with allergic shiners. Eczema on legs and waking every night with a streaming nose and irritated eyes. Bowels: Increased flatulence and bloating over the last 12 months. Diet: Typical Western diet. Treatment Dietary changes: increase fruit and vegetables, increase water intake and avoid dairy and wheat. Herbal Formula 1 Milk thistle (Silybum marianum) 1:2 40 mL Green tea (Camellia sinensis) Albizia (Albizia lebbek) 1:2 20 mL Propolis Licorice (Glycyrrhiza glabra) 1:1 40 mL Reishi (Ganoderma lucidum) Dandelion root (Taraxacum officinale) 1:2 20 mL Mexican valerian (Valeriana edulis) 1:2 20 mL Skullcap (Scutellaria lateriflora) Meadowsweet (Filipendula ulmaria) 1:2 40 mL Milk thistle (Silybum marianum) Eyebright (Euphrasia officinalis) 1:2 20 mL Turmeric (Curcuma longa) Flavouring mix Grape seed (Vitis vinifera) Rosemary (Rosmarinus officinalis) Schisandra (Schisandra chinensis) Topical Application of Herbs in Skin Damage – these herbs can be tremendous for reducing inflammation locally, increasing patient comfort and reducing pruritis. 10 mL 210 mL Dose: 5 mL t.i.d. Aloe leaf/gel (Aloe barbadensis) The formula contained: Calendula (Calendula officinalis) • Milk thistle for its antioxidant activity and ability to support the liver with detoxification. Chickweed (Stellaria media) • Albizia for its antiallergic activity. Comfrey (Symphytum officinale) – Caution: not on broken skin. • Licorice to support the adrenal glands due to the long-term stress experienced, and for its antiinflammatory activity. • Dandelion root because it is high in vitamin A, great for skin conditions and assists liver detoxification. • Mexican valerian is one of the few herbs which patients can feel the effect of within about half an hour. I use it extensively in cases of stress and although it is commonly used as a sedative for insomnia, I use it at lower doses during the day and find it is brilliant for stress without causing the patient to fall asleep. • Meadowsweet for its healing and protective effects on the gut wall as the patient had experienced increased flatulence over the last 12 months. Chamomile (Matricaria recutita) extract or essential oil Lavender (Lavandula officinalis) essential oil St John’s wort (Hypericum perforatum) macerated oil Other Antioxidants: Foods Garlic (Allium sativum) Linoleic acid – enhances the function of the fat soluble antioxidants Olive oil (Olea europaea) Plums – very high Red wine Sesame seeds (Sesamum indicum) Tempeh Wheat grass For professional use only. Not for Public Distribution. Modern Phytotherapist 7 Clinical • Herbal Formula 3 Eyebright for its calming effects on irritated mucous membranes. Echinacea purpurea root and E. angustifolia root blend 1:2 40 mL Licorice (Glycyrrhiza glabra) 1:1 40 mL Milk thistle (Silybum marianum) 1:2 40 mL Cleavers (Galium aparine) 1:2 20 mL Korean ginseng (Panax ginseng) 1:2 20 mL Third Consultation (4 weeks later) Indian barberry (Berberis aristata) 1:1 20 mL Eyes absolutely back to normal. Felt very well, more energy, more relaxed. Rash on legs still improving. Rehmannia (Rehmannia glutinosa) 1:2 40 mL Second Consultation (2 weeks later) Eyes looked much better, not oedematous now. Nose had stopped streaming. The rash on both legs improving slowly. Herbal formula as above was repeated. Herbal Formula 2 220 mL Dose: 5 mL b.i.d. Milk thistle (Silybum marianum) 1:1 40 mL Albizia (Albizia lebbek) 1:2 20 mL Licorice (Glycyrrhiza glabra) 1:1 40 mL Greater celandine (Chelidonium majus) 1:2 20 mL Black walnut hulls (Juglans nigra) 1:2 20 mL Cleavers (Galium aparine) 1:2 20 mL Rehmannia (Rehmannia glutinosa) 1:2 40 mL Flavouring mix 10 mL 210 mL Dose: 5 mL b.i.d. Greater celandine, black walnut and cleavers were all used for their ability to increase the expulsion of waste products through the various eliminatory organs. I tend to use these herbs only when the eliminative organs have had some support from the previous herbs, so an exacerbation of symptoms is often avoided altogether. Fourth Consultation (7 weeks later) In the intervening time period the patient had called in for more herbal formula. In this consultation the patient reported severe urticaria, spreading right up to her thighs. The most amazing oedema I’ve ever seen, legs looked like elephantiasis. The patient had eaten wheat 24 hours earlier (one slice of bread). I didn’t think it was the wheat as it was such a severe reaction. Additionally: evening primrose oil (Oenothera biennis) 1 g capsule b.i.d. and vitamin B complex. Echinacea was added to strengthen the immune system. Korean ginseng has warming properties and is an adaptogen. The patient was a very cold woman who was lacking energy and I felt this adaptogenic herb would be beneficial. Subsequent Consultation A day later the patient saw her medical doctor. A biopsy was performed on the leg tissue. The pathology results from the biopsy showed severe allergic reaction, possibly due to a spider bite. In due course, the allergic reaction in the legs subsided and the urticaria disappeared. Approximately one month later the patient forgot to avoid wheat and ate one triangle of a sandwich with wheat-containing bread. The above reaction occurred again to the same severity. Two months later the allergic reaction occurred again and the suspect this time was a licorice confectionery containing wheat. She continued on the above herbal formula. Eczema slowly cleared completely and the patient felt well and has now remained well for two years. She was gradually able to reintroduce wheat into her diet 2 to 3 times per week without a reaction but an increase above this would cause her to react. CASE 2: ALLERGIC RHINITIS Patient male, aged 51 with headaches, CAT scan showed six out of seven sinuses totally blocked. This patient also 8 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical complained of stress. He had copious amounts of tenacious mucus and postnasal drip, snored at night and woke totally exhausted every morning. He had previous septoplasty for deviated septum with a poor result. Current medications: budesonide nasal spray, an analgesic containing paracetamol (acetaminophen), codeine and doxylamine for headaches. Headaches less frequent and less intense. Much easier to manage and less medication needed. Mucus significantly reduced to just a little in the morning. Slight energy improvement. Patient was not taking the analgesic tablets and found that sleep was not as good. Treatment Herbal Formula 2 Dietary changes: increase orange-coloured vegetables (contains beta-carotene is great for the skin) and avoid dairy. Echinacea purpurea root and E. angustifolia root blend 1:2 40 mL Golden seal (Hydrastis canadensis) 1:2 20 mL Eyebright (Euphrasia officinalis) 1:2 30 mL Schisandra (Schisandra chinensis) 1:2 40 mL Fenugreek (Trigonella foenum-graecum) 1:2 40 mL Ashwaganda (Withania somnifera) 1:2 40 mL Herbal Formula 1 Echinacea purpurea root and E. angustifolia root blend 1:2 40 mL Golden seal (Hydrastis canadensis) 1:3 20 mL Fenugreek (Trigonella foenum-graecum) 1:2 40 mL Second Consultation (2 weeks later) 210 mL Eleuthero (Eleutherococcus senticosus) 1:2 40 mL Dose: 5 mL b.i.d. Schisandra (Schisandra chinensis) 1:2 40 mL Ginger (Zingiber officinale) 1:2 20 mL Tablets containing 500 mg Mexican valerian (Valeriana edulis): 2–3 nocte (nightly). 200 mL Dose: 5 mL t.i.d. The formula contained: • Echinacea for cases of blocked sinuses even when there is only evidence of allergy and no infection because the sinuses are so prone to chronic low grade infection due to the thick copious mucus produced by the allergic patient. It is advisable to use root only preparations of Echinacea in cases of potential allergy to pollen from the aerial part. • Golden seal as a mucous membrane tonic and as an antibacterial. • Fenugreek for its demulcent activity on mucous membranes. • Eleuthero as an adaptogenic to increase vitality generally. • Schisandra as it increases both phase I and II liver detoxification. • Ginger as a herb providing anti-inflammatory activity. For professional use only. Not for Public Distribution. Eyebright was added for its effects on strengthening mucous membranes and ashwaganda as a long-term adaptogenic. Third Consultation (4 weeks later) Improvement again, feeling much better, mucus gone and headaches occurring only occasionally. CASE 3: ECZEMA & ASTHMA Twin boys aged 4 years. History: Asthma since age 2. Eczema since birth. Breastfed for 4 months, very allergic to pet hair. The boys had received multiple antibiotic treatment. On examination: Erythema in skin folds, cracked, dry and flaky; trunk – rough like sandpaper. Current medical treatment: A corticosteroid cream every night. Treatment Dietary changes: avoid preservatives, colourings, dairy, changed to a heavy rye bread; increase orange-coloured vegetables. Modern Phytotherapist 9 Clinical Herbal Formula 1 Herbal Formula 2 Licorice (Glycyrrhiza glabra) 1:1 15 mL Rehmannia (Rehmannia glutinosa) 1:2 40 mL Figwort (Scrophularia nodosa) 1:2 15 mL Figwort (Scrophularia nodosa) 1:2 40 mL Skullcap (Scutellaria lateriflora) 1:2 20 mL Burdock (Arctium lappa) 1:2 20 mL Grindelia (Grindelia camporum) 1:2 20 mL Echinacea purpurea root and E. angustifolia root blend 1:2 40 mL Burdock (Arctium lappa) 1:2 20 mL Grindelia (Grindelia camporum) 1:2 40 mL Albizia (Albizia lebbek) 1:2 15 mL Skullcap (Scutellaria lateriflora) 1:2 40 mL 105 mL Dose: 2 mL b.i.d. The best way to get children to take the dose is to mix it into thick apricot nectar. Red grape juice, jam or honey can also be used. If all else fails, the dose can be administered by drawing into a plastic syringe and squirting down the throat! Other supplements taken daily: evening primrose oil (Oenothera biennis) 1 teaspoon (5 mL, equivalent to 1 x 500 mg capsule) and a magnesium supplement. The formula contained: • Licorice for its anti-inflammatory, antiallergic and adrenal tonic action. • Figwort as a gentle eliminative herb specifically for the skin. • Skullcap as a nervine tonic. (Eczema in children is often exacerbated by stress or anxiety. Highly excitable children are also susceptible to eczema flare-ups.) • Grindelia as a gentle respiratory spasmolytic. • Burdock as an alterative herb to increase the elimination of toxins. • Albizia for its antiallergic activity. Second Consultation (6 weeks later) Skin much improved, the inflammation totally gone, but skin still dry in places. No asthma. 220 mL Dose: 2 mL b.i.d. Evening primrose oil dose was doubled (1 teaspoon twice per day, 2 x 500 mg capsules). Rehmannia was added for its antiallergic effects and as an adrenal tonic herb and Echinacea to boost the immune system to reduce the risk of infection thereby reducing the risk of asthma. Third Consultation (6 weeks later) Their mother was very pleased with progress – occasional flare-ups but not using the corticosteroid cream now, using rose hip oil instead. CASE 4: ALLERGIC RHINITIS This 23-year-old patient complained of allergy problems. She seemed to react to dust mites, cats, dogs and perfume. Her reactions were characterised by sneezing, itchy eyes, nasal congestion and blotchy red skin. She often woke with headaches and generally had plentiful tenacious mucus and postnasal drip. She also complained of bloating and bad history of bronchial asthma. She had a fairly good diet and had eliminated a lot of mucus-causing foods. Treatment Herbal Formula 1 Pau d’arco (Tabebuia avellanedae) 1:2 40 mL Eyebright (Euphrasia officinalis) 1:2 40 mL Albizia (Albizia lebbek) 1:2 40 mL Skullcap (Scutellaria lateriflora) 1:2 40 mL Golden seal (Hydrastis canadensis) 1:3 40 mL 200 mL Dose: 5 mL t.i.d. Additionally: vitamin C with bioflavonoids. 10 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical The formula contained: • Pau d’arco to boost the immune system and reduce Candida levels. • Eyebright as a mucous membrane tonic to strengthen the irritated and reactive mucous membranes. skin was exceptionally dry, she had severe eczema on most of her body which was intensely pruritic. Her hands were shedding pieces of skin and she could not stop scratching. She was a smoker (10 cigarettes per day) and had been on an elimination diet. • Albizia for its antiallergic activity. Current medications: Promethazine to sleep, evening primrose oil at night, fish oil and lecithin. • Skullcap as a nervine tonic. Treatment • Golden seal as a mucous membrane tonic. Dietary changes: increase orange-coloured vegetables and water intake. Second Consultation (2 weeks later) She had been consistent with treatment and diet and had experienced three flare-ups associated with dusting/housekeeping. Herbal Formula 2 Golden seal (Hydrastis canadensis) 1:3 40 mL Albizia (Albizia lebbek) 1:2 30 mL Elder flower (Sambucus nigra) 1:2 30 mL Herbal Formula 1 Rehmannia (Rehmannia glutinosa) 1:2 80 mL Licorice (Glycyrrhiza glabra) 1:1 40 mL Ashwaganda (Withania somnifera) 1:2 60 mL Dandelion root (Taraxacum officinale) 1:2 20 mL Mexican valerian (Valeriana edulis) 1:2 20 mL 220 mL Echinacea purpurea root and E. angustifolia root blend 1:2 40 mL Dose: 5 mL t.i.d. Licorice (Glycyrrhiza glabra) 1:1 40 mL The formula contained: Valerian (Valeriana officinalis) 1:2 20 mL • Rehmannia for its antiallergic effect and because it is particularly good for allergic skin conditions. • Licorice mostly as an adrenal tonic but also for its antiallergy activity. • Ashwaganda an adaptogenic and tonic herb. • Dandelion root for liver support. • Mexican valerian as a nervine relaxant. 200 mL Dose: 5 mL b.i.d. The formula contained: • Elder flowers to dry up the sinuses. • Echinacea to boost the immune system. • Licorice as a demulcent. Third Consultation (4 weeks later) Second Consultation (2 weeks later) The patient was generally better – less mucus, less sneezing and less itchy eyes. She took a course of antibiotics for bronchitis (she had an infection). No flare-up of eczema. Herbal formula repeated and Acidophilus added to regime. Rehmannia (Rehmannia glutinosa) 1:2 80 mL Licorice (Glycyrrhiza glabra) 1:1 40 mL Fourth Consultation (6 weeks later) Mexican valerian (Valeriana edulis) 1:2 30 mL The patient was pleased with the reduction of allergy symptoms and has not suffered from influenza despite those around her contracting it. Ashwaganda (Withania somnifera) 1:2 50 mL CASE 5: CHRONIC ECZEMA This patient is a 44-year-old woman who had a history of eczema for 15 to 16 years. When I first saw her, her For professional use only. Not for Public Distribution. Herbal Formula 2 200 mL Dose: 5 mL b.i.d. Tablets containing valerian (Valeriana officinalis), passion flower (Passiflora incarnata) and spiny jujube (Zizyphus spinosa): 1 tablet t.i.d. Modern Phytotherapist 11 Clinical Third Consultation (2 weeks later) Eczema had improved, not as much redness, significantly less pruritis. She was trying to give up smoking. Started with an initial 10 mL dose and followed hourly with 5 mL, for 4 hours. The above herbs were prescribed for their antiallergic action. Rehmannia (Rehmannia glutinosa) 1:2 80 mL Licorice (Glycyrrhiza glabra) 1:1 40 mL Mexican valerian (Valeriana edulis) 1:2 15 mL Patient went home and came back around 2 hours later – face was visibly improved, eyes not as swollen and the chest not as tight. In this situation the patient would normally have had to take antihistamines but did not need to in this case. She continued taking the herbal formula the following day at 5 mL t.i.d., and reduced the dose thereafter over 2 days. St John’s wort (Hypericum perforatum) 1:2 50 mL REFERENCES Herbal Formula 3 1 Edwards CRW et al (eds). Davidson’s Principles and Practice of Medicine, 17th Edn. Churchill Livingstone, Edinburgh, 1995. Dose: 5 mL b.i.d. 2 Harrison TR, Isselbacher JK. Harrison's Principles of Internal Medicine, 14th Edn. McGraw-Hill, New York, 1994. St John’s wort was added to relieve symptoms of depression (she displayed some evidence of anxiety and depression over the course of consultations). 3 Kurzius-Spencer M, Halonen M, Holberg CJ et al. American Thoracic Society’s 98th International Conference, Georgia, May 20, 2002, Poster J50. 4 Werbach M. Nutritional Influences on Illness. Third Line Press, 1996. 5 Barnes RM, Lewis-Jones MS. J Clin Lab Immunol 1989; 30(2): 87-91 6 Rupprecht M, Salzer B, Raum B et al. Exp Clin Endocrinol Diabetes 1997; 105(1): 39-45 185 mL Fourth Consultation (4 weeks later) Skin considerably better. Occasional flare-ups but mild in comparison. Much less itchy and very pleased with her progress. This patient remained on herbal treatment. She did have a flare-up of eczema after running out of the herbal formula, which was controlled after her going back on the herbs. I saw this patient recently for another health issue, and was pleased to note that her skin remains clear. CASE 6: ACUTE ALLERGIC REACTION In this case of acute allergic reaction, herbal treatment provided remarkable results. A 32-year-old female presented as highly allergic to cat dander. She had been exposed approximately 1/2 hour before, by the time I saw her, her eyes were so oedematous they were slitting. Her face was swollen, puffy, red and blotchy and she was audibly wheezing and finding it difficult to breathe. Treatment Herbal Formula Rehmannia (Rehmannia glutinosa) 1:2 40 mL Albizia (Albizia lebbek) 1:2 60 mL Licorice (Glycyrrhiza glabra) 1:1 60 mL 160 mL Ms Tracey Cook ND, MNHAA, MATMS Tracey Cook was a registered nurse for a number of years before undertaking a career change to naturopathy. She has over 12 years' experience in Naturopathy and has a busy practice in a multidisciplinary natural health clinic in Adelaide. Tracey has lectured extensively in colleges and a number of hospitals in Adelaide and also on radio. She treats many patients with allergies and sensitivities and began naturopathy due to her experience with 20 years of severe atopic eczema which completely disappeared after naturopathic treatment. Dose: 5 mL hourly (as follows). 12 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical Herbal Treatment for Intestinal Parasites BY KERRY BONE AND MICHELLE MORGAN Spring is traditionally a time for cleaning. This was well recognised by European herbalists who used a number of herbs as “spring tonics” or “spring cleansers”. Many of these spring tonics provided much needed vitamins after a lengthy period of consuming stored foods. But they also included the depurative herbs (which cleanse the blood by yet unknown mechanisms) and herbs for promoting digestion, including the bitter herbs wormwood and gentian. Wormwood, as the name implies, was also traditionally used to treat gastrointestinal worm infestation. We may conclude that this aspect was also part of the use of spring tonics. Whether this is the case or not, it is true to say that the plant world has long provided options to assist in the control of intestinal parasites. A few of the more popular of these herbs are reviewed below, together with a significant and highly active anthelmintic herb from traditional Chinese medicine (TCM). But the main thrust of this review is to suggest that synergistic activity via a combination of these key herbs (with other herbal treatments as well to support digestion and immunity for example) will yield the best results. Stemona Stemona radix, the tuberous root of Stemona sessilifolia, Stemona tuberosa or Stemona japonica, is used in TCM mainly for the treatment of acute and chronic cough. Externally it is used for the treatment of fungal infections, lice infestation and as an enema for pinworm infestation.1,2,3 In addition to its primary use for the treatment of cough, in Vietnam Stemona japonica root is prescribed for Ascaris infestation and is used externally to treat scabies (mite infestation).4 Plant extracts from the Stemonaceae have also been used in Japanese traditional medicine in the treatment of respiratory diseases and as anthelmintics.5 Key Constituents A series of complex alkaloids have been isolated from the root of these Stemona species.6 The unusual and complex alkaloids exist only in Stemona plants and in a few related species and include tuberostemonine and stemonine.7 Anthelmintic Activity The experimental anthelmintic activity of crude extract For professional use only. Not for Public Distribution. of Stemona may be due to the action of its alkaloids. Tuberostemonine, an alkaloid isolated from Stemona sessilifolia, S. tuberosa and S. japonica root,6 paralysed the motility of Angiostrongylus cantonensis in vitro and showed contractive effects on the motility of Dipylidium caninum and Fasciola hepatica.8 Tuberostemonine was inactive in vitro as an anthelmintic against a species of tapeworm.9 One hundred and forty cases of ancylostomiasis (hook worm infestation) were treated with the herb. After 3 months, follow-up examination of 110 cases revealed a negative rate of 94.5%. Another group of 48 cases was effectively treated with the herb decoction; 116 worms, all from the duodenum, were expelled. However, the same method did not show any anthelmintic effects in later trials.2 Alcoholic extracts may have greater efficacy than decoction. A suppository prepared from Stemona root tuber was used to treat 40 children with oxyuriasis (infestation with a type of nematode); 16 of them were cured. Twenty-seven out of 63 cases were cured by the herb powder.2 Dosage: • Suppository (12.5 g each), one suppository was inserted into the rectum at 8 pm, another at 10 pm every night for one week, then every other night for another week. • Powder: 1.5 g, 3 times daily for 3 days. Wormwood Artemisia absinthium is well known to herbalists with particular application to treating nematode infestation, especially infestation with Enterobius or Ascaris.10,11 Wormwood has been used as an anthelmintic since ancient times and is currently utilised in many countries throughout the world for this purpose. Wormwood tincture is employed in the West Indies as a worm preventative.12 Wormwood has also been used for the de-worming of horses, cows and sheep.13,14 Key Constituents Constituents of the aerial parts of wormwood include bitter substances (sesquiterpene lactones, mainly absinthin) and an essential oil containing mainly Modern Phytotherapist 13 Clinical terpenes. The essential oil contains the potentially toxic monoterpene thujone and for this reason the recommended therapeutic doses of wormwood should not be exceeded.15 Anthelmintic Activity In vitro wormwood aqueous extract demonstrated anthelmintic activity towards the nematode Trichostrongylus colubriformis,16 and wormwood oil was active in the Toxocara assay (defined below).17 Thujone is also implicated in the anthelmintic activity of wormwood. Experiments carried out in Edinburgh in 1955 indicated the efficacy of thujone in eliminating Ascaris lumbricoides.18 Other Related Activity Wormwood aqueous extract and alcohol extract strongly inhibited the in vitro growth of the parasitic protozoa Naegleria fowleri. The sesquiterpene lact one fraction isolated from the alcohol extract was also active.19 Wormwood powder (1.5 g/day) provided effective treatment for acute intestinal amoebiasis in an uncontrolled trial of 20 patients. Symptoms were relieved and 70% of cases were cleared of the protozoa Entamoeba histolytica according to stool analysis.20 Wormwood is also used to treat other gastrointestinal conditions such as appetite loss, disturbed digestion, flatulence11 and disordered bile flow.21 Clinical trials have demonstrated the ability of wormwood to increase the flow of gastric enzymes, pancreatic enzymes and bile.22,23 Black Walnut Hulls A globular fruit is produced from the black walnut tree which contains a corrugated nut in its yellowish-green hull (also called husk or fruit wall). Upon ripening the hull softens and turns dark brown to black due to chemical oxidation. A decoction of the hull of Juglans nigra fruit has been used traditionally to expel worms.11 Key Constituents The unripe, green hulls of Juglans nigra contain 1,4naphthoquinones including juglone and plumbagin.24 The juglone content in green hulls varies with different cultivars and different months of growth.25 Anthelmintic Activity In vitro studies indicate that plumbagin inhibited the motility of and hatching of Haemonchus contortus first 14 Modern Phytotherapist stage larvae. Plumbagin was larvicidal towards Ascaris suum at the highest test concentration (100 mM). Partial inhibition of embryonic development of A. suum occurred with plumbagin.26 The authors suggested that because of the relatively high doses required for the maximal effect on inhibiting the development of larval stages, plumbagin may not find practical application. The combination with other anthelmintic herbs would however, boost the activity of plumbagin. Clove Bud Essential Oil The dried, unopened flower bud of Syzygium aromaticum (Eugenia caryophyllus) has been used in Ayurveda and Western herbal medicine as a carminative and aromatic.11,27 It has recently been popularised as a worm treatment. Therapeutic indications for clove bud include nausea, flatulence, dyspepsia and to assist the action of other herbal remedies.11,27,28 In traditional Thai medicine the essential oil is used as a carminative and to treat stomach ache, in addition to the well-known topical application of toothache.29 In Indonesian traditional medicine clove oil is taken with beer to protect against abdominal pain! Clove bud is also used in this traditional system to alleviate flatulence.30 Key Constituents Key constituents of clove bud include an essential oil (15–20%, consisting mainly of eugenol, eugenol acetate, beta-caryophyllene), flavonoids, tannins and phenolic acids.31 Eugenol is a major constituent of clove bud essential oil (80–85%).32 Anthelmintic Activity Clove powder demonstrated potent anthelmintic activity in vitro towards Pheretima spp. (earthworms). At the time of the study, earthworms were used as a model to investigate anthelmintic activity. Suspension of clove powder was more than 5 times more potent than a water extract of cloves, and clove powder was 4.5 times more potent than powdered fresh garlic. Suspension of clove powder was 7.3 times more active than the anthelmintic drug piperazine, whereas the water extract of clove was of similar potency.33 Piperazine is an anthelmintic drug which has been used to treat pinworm and roundworm infections in humans for decades. Both water extract and methanol extract of clove bud were strongly active in a nematocidal assay.34 The assay used the second-stage larva of the roundworm Toxocara canis, which at the time of the study was highly resistant For professional use only. Not for Public Distribution. Clinical to anthelmintic drugs. The relative movability (RM) value compares the extent of movement of the test population which has been exposed to the anthelmintic agent with the movability of the control sample. Strong activity was defined as a RM value of 0 (at which all larvae are dead). A value of 100 indicates no activity (no disabling effect on the larvae), and increasingly lower RM values approaching 0 indicate stronger activity of the extracts against the larvae. A value of 0 was obtained for clove methanolic extract tested at both concentrations (1 mg/mL, 10 mg/mL) and at both time frames (6 h, 24 h) and for water extract (10 mg/mL) at 24 hours. Piperazine produced a RM value of 32 for 1 mg/mL after 24 hours of incubation in the same assay and other anthelmintic drugs such as phenothiazine produced a RM value of 0 under the same conditions. Eugenol produced a RM value of 0 at 1 mg/mL at 24 h, and a value of 50 at the lower concentration of 0.1 mg/mL after the same time period.34 In another study using the same assay a RM value of 0 was obtained for clove bud oil at 1 mg/mL for both time frames (6 h, 24 h), and for eugenol at the same concentration at 24 h.17 Clove oil killed Anisakis spp. larva in vitro.35 Eugenol also demonstrated potent anthelmintic activity towards Substance Caenorhabditis elegans in vitro36 and Rhabditis macrocerca and Ascaris suum in vitro and in vivo in mice (route unknown).37 Potential for Synergistic Anthelmintic Activity The phenomenon known as bursting of worm larvae occurs when the outer covering of the larva is torn, resulting in protrusion of its intestine. Nematocidal assays can discover active principles that cause the killing and/or bursting of worm larvae. A constituent that has no nematocidal activity may produce bursting when combined with a nematocidal agent. Eugenol caused bursting of worm larvae in the Toxocara assay described above. The activity of eugenol on its own was relatively weak (11%) but it caused marked bursting of worms (90–91%) when combined with tannins (hydrolysable tannin and condensed tannins respectively).34 Tannins are not larvicidal by themselves, but they cause bursting when combined with a larvicidal compound, as has been demonstrated in the same assay previously.38 This is visually represented in the following table. Nematocidal Activity § Bursting Activity § clove bud methanol extract √ (strong) x eugenol √ (strong) √ (weak, 11%) tannins* x x √ (strong) √ (strong, 90–91%)† eugenol + tannins* Table 1. The presence of an inactive substance increases the bursting activity of weakly active substances.34,38 Note: All substances tested at 1 mg/mL and 24 h incubation, except the tannins when tested alone (0.2–10 mg/mL). For the constituent-tannin combination eugenol = 1 mg/mL, tannins = 0.1 mg/mL. § Strong nematocidal activity is defined as RM = 0 at 1 mg/mL, 24 h; strong bursting activity: 50–100%. * Two sets of tannins tested: a hydrolysable tannin (tannic acid) and condensed tannins (mixture from Areca catechu (betel nut)). † Range expresses hydrolysable tannin and condensed tannin mixture respectively. In order to cause bursting, coexistence of both the anthelmintic compound and the bursting factor is necessary. The bursting activity of tannins (when combined with the suitable larvicidal substance) increased with increasing degree of condensation for condensed tannins and with increasing proportion of phenolic groups for hydrolysable tannins.38 The types For professional use only. Not for Public Distribution. of tannins found in green tea extract were not tested but could be expected to be active based on the significant activity seen for complex hydrolysable tannins. Grape seed extract could also be expected to be active but this activity would only be due to the tannins with a higher degree of condensation (tetramers or more) found in these extracts. Modern Phytotherapist 15 Clinical Eugenol in combination with tannins can cause, even at lower concentration than its minimum lethal concentration (MLC), the bursting of worms if a large amount of (another) nematocidal constituent is Eugenol present. (MLC was defined as the lowest concentration producing a RM value of 0 after 24 hours incubation, determined for eugenol as 0.33 mg/mL.)34 This is highlighted in the following table. Methyleugenol + Tannins Bursting Activity – weak, 11% – weak, 13% 0.1 mg/mL strong, 90–91% 1 mg/mL 0.1 mg/mL inactive, 0–4% 0.9 mg/mL 0.1 mg/mL strong, 55–92% 1 mg/mL 1 mg/mL 1 mg/mL 0.1 mg/mL Note: Experimental conditions as per Table 1 (previous page). Conclusions from these and further studies using the Toxocara assay indicate: • a balance between the hydrophilicity (watersoluble) and hydrophobicity (fat-soluble) of the constituents is important for the larvicidal activity;39 • the bursting activity may be caused not only by tannins but also by other nonvolatile34 and volatile constituents;17 • that a different bursting feature was observed for the tannin-nematocide mixture compared to the bursting caused by essential oil alone17 suggesting a different mechanism of action; • the synergistic action of tannins and an anthelmintic not only damages the worms irreversibly, but also, in some instances markedly reduced the required amount of the anthelmintic.38 Methanol extract of turmeric rhizome (Curcuma longa) demonstrated anthelmintic activity in the Toxocara assay described above. RM values of 0 were obtained at 24 h for concentrations of 0.1–10 mg/mL.34,40 The curcuminoids curcumin, demethoxycurcumin and bisdemethoxycurcumin were ineffective when tested individually. When they were mixed in equal proportions (1:1:1), a strong nematocidal activity was demonstrated.40 This research suggests the value of combining various herbal agents for a synergistic anthelmintic activity. It also implies that combination of anthelmintic herbs with tannin-containing herbs such as green tea and particularly herbs containing condensed tannins such as grape seed extract will enhance their activity. As seen in 16 Modern Phytotherapist the turmeric research the activity of an individual herb depends on several of its constituents working in synergy. Recent Anthelmintic Research In vitro tests conducted at a government laboratory in Brisbane in 2002 using a number of herbal extracts and essential oils have indicated that clove bud and Stemona have definite positive anthelmintic activity towards a sheep intestinal nematode prevalent in this locality.41 The testing included egg hatch assay, larval development assay and infective larvae assay. At the tested dosage, clove bud gave a convincing kill of the larvae population, rather than just immobilisation. A field trial testing a number of herbs and essential oils for the treatment of worm infestation in sheep is pending. Suggested Combinations for Increased Activity The following treatments would combine well and provide synergistic anthelmintic activity with the wormwood, black walnut hulls, Stemona and clove bud essential oil mentioned above. These treatments should be taken together (i.e. at the same time). The list includes: • holy basil (Ocimum sanctum) essential oil, since the leaf has been used in traditional Ayurvedic medicine as an anthelmintic and the essential oil has demonstrated potent anthelmintic activity in vitro towards Caenorhabditis elegans.36 In the worm bursting assay outlined above34 methyleugenol demonstrated nematocidal activity but was devoid of worm bursting activity. The presence of even a For professional use only. Not for Public Distribution. Summary of Anthelmintic Activity: Toxocara Assays Substance RM values Burst 10 mg/mL 10 mg/mL 1 mg/mL 1 mg/mL 0.1 mg/mL 6h 24 h 6h 24 h 6h 0 0 67 0 0.1 mg/mL 1 mg/mL 24 h Anthelmintic Study 1: Spices, Constituents, Standard Drugs1 clove methanol extract 0 clove water extract 0 0 garlic methanol extract 44 0 turmeric water extract 34 0 turmeric methanol extract 33 0 eugenol † 0 50 11% methyleugenol † 0 56 13% piperazine 32 phenothiazine 0 0 Anthelmintic Study 2: Essential Oils, Constituents2 clove bud oil wormwood oil 0 0 67 0 24% eugenol § 0 100 5% methyleugenol § 0 97 9% Anthelmintic Study 3: Turmeric & Turmeric Constituents3 turmeric methanol extract 84 0 curcumin 100 100 demethoxycurcumin 100 100 bisdemethoxycurcumin 100 100 curcumin + demethoxycurcumin + bisdemethoxycurcumin 9 0 Nematocidal activity determined using the second-stage larvae of Toxocara canis. Note: A smaller RM (relative movability) value indicates a stronger nematocidal activity, and when all larvae die, this value is 0. Moderate activity is defined as RM < 50, a value of 100 indicates the test substance is inactive. The lower the concentration and the shorter the time of incubation the stronger the activity. The table is adapted from the indicated studies and does not include all results. † Extracted from the dried fruit of allspice (Pimento dioica). § Purchased or obtained by fractional distillation from appropriate essential oils. References 1 Kiuchi F, Nakamura N, Miyashita N et al. Shoyakugaku Zasshi 1989; 43(4): 279-287. 2 Nakamura N, Kiuchi F, Tsuda Y et al. Shoyakugaku Zasshi 1990; 44(3): 183-195. 3 Kiuchi F, Goto Y, Sugimoto N et al. Chem Pharm Bull 1993; 41(9): 1640-1643. For professional use only. Not for Public Distribution. Clinical small amount of eugenol (5–10%) in the methyleugenol-tannin mixture caused the bursting of the worms, particularly when the tannin was of the condensed type.34 Both eugenol and methyleugenol occur in holy basil essential oil; the amount of each varies depending upon the chemotype.42 • • • • • tannin-containing herbs especially preparations containing green tea (Camellia sinensis) and grape seed (Vitis vinifera) extract. These herbs should be taken concomitantly with the anthelmintic herbs. turmeric (Curcuma longa), because the rhizome has been used as an anthelmintic in Thai traditional medicine43 and has demonstrated in vitro anthelmintic activity (outlined above).34,40 immune enhancing herbs such as Echinacea, and also preparations containing Andrographis paniculata and holy basil essential oil, to enhance the body’s natural immune function and assist in the immune response to worm infestation. (Eosinophilia (increased number of eosinophils in the blood) and elevated serum IgE (gamma-E globulin) levels are features of many helminthic infections.) garlic (Allium sativum) which has been used as an anthelmintic in Western herbal medicine,10 for example, as a decoction or freshly mashed and administered to children on an empty stomach.44 Garlic extract containing alliin/allicin was effective against Rhabditis spp. and the eggs of Ascaris suum in vitro.45 laxative herbs to promote elimination of the worm infestation (or worm debris) via the bowel including preparations containing cascara (Rhamnus purshiana) and yellow dock (Rumex crispus). • bitter herbs to promote the gastric acid barrier to resist reinfestation. Gentian (Gentiana lutea) liquid extract is recommended. • digestive enzyme preparations, such as the latex of Ficus spp. which contains ficin has been used traditionally in neotropical areas such as the Amazon as an anthelmintic.46 However, concomitant intake of digestive enzymes with tannins may result in the inactivation of the enzymes. For professional use only. Not for Public Distribution. Example Treatments Herbal Liquid Formula Echinacea purpurea root and E. angustifolia root blend 1:2 30 mL Wormwood (Artemisia absinthium) 1:5 15 mL Black walnut hulls (Juglans nigra) 1:10 20 mL Cranesbill root (Geranium maculatum) 1:2 20 mL Thyme (Thymus vulgaris) 1:2 25 mL 110 mL Dose: 5 mL with water 4 to 6 times a day for 10 days. After a 10-day break, repeat treatment for 10 days. The second treatment is to kill any larvae which may have hatched after treatment, since herbal anthelmintics are not very effective at killing eggs. Note: These are adult doses. Use appropriate calculations based on body weight for children’s doses. Tablet or Combined Protocols Note that the doses for products given below represent adult doses. Use appropriate calculations based on body weight for children’s doses. Core Treatment Herbal tablets containing Andrographis, Echinacea angustifolia root and holy basil leaf plus essential oil. Dose: 4 tablets per day as a continuous treatment for immune support. AND Herbal tablets containing Stemona spp., wormwood, black walnut hulls, and clove oil. Dose: 4 to 6 tablets per day for 10 days. After a 10-day break, repeat treatment for 10 days. Additional Treatments (as required) • Garlic tablets (3 per day on the same days as the wormwood tablets) for stubborn parasites. • A herbal formulation to promote digestion containing chamomile (Matricaria recutita), dandelion (Taraxacum officinale), Echinacea angustifolia root, milk thistle (Silybum marianum) and gentian (4 mL with water before meals) if a low gastric acid barrier and poor digestion are thought to contribute to reinfestation. Modern Phytotherapist 17 Clinical • Herbal tablets containing rosemary (Rosmarinus officinalis), green tea, turmeric and grape seed (2 tablets per day on the same days as the wormwood tablets but at different times) to provide synergistic worm-killing activity. 24 Binder RG, Benson ME, Flath RA. Phytochem 1989; 28(10): 2799-2801. 25 Lee KC, Campbell RW. HortScience 1969; 4(4): 297-298. 26 Fetterer RH, Fleming MW. Comp Biochem Physiol C 1991; 100(3): 539-342. 27 Chopra RN, Chopra IC, Handa KL et al. Chopra’s Indigenous Drugs of India, 2nd Edn, 1958, reprinted Academic Publishers, Calcutta, 1982, pp 172-173. 28 Pharmaceutical Society of Great Britain. British Pharmaceutical Codex 1934. The Pharmaceutical Press, London, 1941, pp 288-289. 29 Farnsworth NR, Bunyapraphatsara N (eds). Thai Medicinal Plants. Medicinal Plant Information Center, Bangkok, 1992, pp 233-236. 30 Dharma AP. Indonesian Medicinal Plants. Balai Pustaka, Jakarta, 1987, pp 52-54. 31 See the following article for clinical anecdotes on the treatment of worm infestation. Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals: A Handbook for Practice on a Scientific Basis. Medpharm Scientific Publishers, Stuttgart, 1994, pp 130-131. 32 Battaglia S. The Complete Guide to Aromatherapy. Virginia, Queensland, The Perfect Potion, 1995, pp 235-236. REFERENCES 33 Krishnakumari MK, Majumder SK. J Sci Indust Res 1960; 19C: 202-204. 34 Kiuchi F, Nakamura N, Miyashita N et al. Shoyakugaku Zasshi 1989; 43(4): 279-287. Oishi K, Mori K, Nishiura Y. Nippon Suisan Gakkaishi 1974; 40(12): 12411250. • Laxative herbs, such as herbal tablets containing cascara, dandelion root, yellow dock, dill (Anethum graveolens) seed and chamomile (2–6 tablets before bed twice a week during treatment with the wormwood tablets) to assist the expulsion of worms. The dose should be sufficient to create a very loose stool. 1 Pharmacopoeia Commission of the People’s Republic of China. Pharmacopoeia of the People’s Republic of China, English Edn, Volume I. Chemical Industry Press, Beijing, 1997, p 173. 35 2 Chang HM, But PP. Pharmacology and Applications of Chinese Materia Medica. Volume I. World Scientific, Singapore, 1987, pp 484-488. 36 Asha MK, Prashanth D, Murali B et al. Fitoterapia 2001; 72(6): 669-670. 37 Valette G, Cavier R, Debelmas J. Ann Pharm Franc 1953; 11: 649-653. 38 Kiuchi F, Tsuda Y, Kondo K et al. Chem Pharm Bull 1988; 36(5): 1796-1802. 39 Kiuchi F, Miyashita N, Tsuda Y et al. Chem Pharm Bull 1987; 35(7): 28802886. 3 Bensky D, Gamble A. Chinese Herbal Medicine Materia Medica. Eastland Press, Seattle, 1986, pp 297-298. 4 World Health Organization. Medicinal Plants in Viet Nam. WHO Regional Office for the Western Pacific, Manilla, 1990, pp 354-355. 5 Pilli RA, Ferreira de Oliveira MC. Nat Prod Rep 2000; 17(1): 117-127. 6 Tang W, Eisenbrand G. Chinese Drugs of Plant Origin. Springer-Verlag, Berlin, 1992, pp 957-961. 40 Kiuchi F, Goto Y, Sugimoto N et al. Chem Pharm Bull 1993; 41(9): 1640-1643. 7 Qin GW, Xu RS. Med Res Rev 1998; 18(6): 375-382. 41 8 Terada M, Sano M, Ishii AI et al. Nippon Yakurigaku Zasshi 1982; 79(2): 93-103. Information on file. MediHerb Research Laboratory, University of Queensland, St. Lucia, Queensland 4072, Australia. 42 9 Wiesner KF (ed). Alkaloids, MTP International Review of Science, Organic Chemistry, Series 1, Volume 9. Butterworths, London, 1975, p 144. Lawrence BM. Essential Oils 1988-1991. Allured Publishing Corporation, Carol Stream, 1993, pp 200-201. 43 10 British Herbal Medicine Association’s Scientific Committee. British Herbal Pharmacopoeia. BHMA, Bournemouth, 1983. Farnsworth NR, Bunyapraphatsara N (eds). Thai Medicinal Plants. Medicinal Plant Information Center, Bangkok, 1992, pp 130-138. 44 Guarrera PM. J Ethnopharmacol 1999; 68(1-3): 183-192. 11 Felter HW, Lloyd JU. King’s American Dispensatory. 18th Edn, 3rd revision, Volume 1. First published 1905, reprinted Eclectic Medical Publications, Portland, 1983. 45 Chybowski J. Herbal Pol 1997; 43(4): 383-387. 46 Hansson A, Veliz G, Naquira C et al. J Ethnopharmacol 1986; 17(2): 105-138. 12 Quinlan MB, Quinlan RJ, Nolan JM. J Ethnopharmacol 2002; 80(1): 75-83. 13 Waller PJ, Bernes G, Thamsborg SM et al. Acta Vet Scan 2001; 42: 31-44. 14 Uncini Manganelli RE, Camangi F, Tomei PE. J Ethnopharmacol 2001; 78(2-3): 171-191. 15 Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals. Medpharm Scientific Publishers, Stuttgart, 1994, pp 45-48. 16 Bara S, Zaragoza C, Valderrabano J. SEMh Congreso 1999: Sociedad Espanola de Malherbología, Longrono, Spain, November 23-25, 1999, pp 233-240. Glossary Angiostrongylus cantonensis Species of parasitic nematode. Human infection, caused by consumption of raw slugs and land snails, results in eosinophilic meningitis. Anisakis 17 Nakamura N, Kiuchi F, Tsuda Y et al. Shoyakugaku Zasshi 1990; 44(3): 183-195. Genus of roundworm. Human infection results from the consumption of fish harbouring roundworm larvae. 18 Albert-Puleo M. Econ Bot 1978; 32: 65-74. Anthelmintic/antihelmintic/nematocidal 19 Mendiola J, Bosa M, Perez N et al. Trans R Soc Trop Med Hyg 1991; 85(1): 78-79. Causing the death and/or elimination of worms. 20 Tahir M, Siddiqui MM, Khan AB. Hamdard Med 1997; 40(3): 24-27. Ascaris spp. 21 Blumenthal M et al (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. American Botanical Council, Austin, 1998, pp 232-233. 22 Glatzel H, Hackenberg K. Planta Med 1967; 3: 223-232. 23 Baumann IC, Glatzel H, Muth HW. Z Allgemeinmed 1975; 51(17): 784-791. Ascaris lumbricoides is the largest nematode found in the human intestine. Ascaris suum is a species of parasitic nematode usually found in domestic pigs and a few other animals. Human infection can also occur from handling pig manure. 18 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical Caenorhabditis elegans Species of nematode that is widely used in biological, biochemical, and genetic studies. Dipylidium caninum Species of tapeworm of which the dog and cat are definitive hosts, and humans are an occasional host. Entamoeba histolytica Species of parasitic protozoa causing amoebiasis and amoebic dysentery. Enterobius Genus of intestinal nematode including the pinworm or threadworm Enterobius vermicularis. Fasciola hepatica Species of helminth commonly called the sheep liver fluke. Occasionally seen in humans, it is most common in sheep and cattle. Haemonchus spp. Haemonchus is a genus of parasitic nematode which infests herbivores e.g. sheep, which ingest it with the grasses they eat. Infestation of man is accidental. Helminths Parasitic worms, and includes the Acanthocephala, Nematoda and Platyhelminths (which includes tapeworms (Cestoda)). Larva Mr Kerry Bone BSc (Hons), Dip Phyto, FNIMH, FNHAA, MCPP Kerry Bone was an experienced research and industrial chemist before studying herbal medicine full-time in the UK where he graduated and joined the National Institute of Medical Herbalists. Kerry is the founder of, and Director of Research and Development at MediHerb and from 1990–1997 was appointed to the Traditional Medicines Evaluation Committee of the Therapeutic Goods Administration. He is a prolific writer and presenter in Australia, New Zealand and the USA. He has written and co-authored several authoritive herbal medicine textbooks. Kerry is also a practising herbalist with 18 years’ experience. Immature, grublike stage, following the egg in the life cycle of insects, worms, and other metamorphosing animals. Nematode Any worm of the phylum Nematoda (smooth-skinned, unsegmented worms with a long cylindrical body shape tapered at the ends). Naegleria fowleri Species of parasitic protozoa. Infection with this pathogen produces primary amoebic meningoencephalitis. Rhabditis Genus of nematode, a few species of which are parasitic in humans. Toxocara canis Species of parasitic nematode found in the intestine of dogs. Infection in humans has consequences to tissues beyond the intestines. Trichostrongylus colubriformis Nematode which is parasitic in the digestive tract of herbivorous animals and occurs only as incidental infections in humans. For professional use only. Not for Public Distribution. Ms Michelle Morgan BSc, Dip App Sci (Herbalism) Michelle Morgan has a Bachelor of Science degree majoring in Chemistry from the University of Queensland (1987) and worked in the scientific field as a laboratory technician for many years. She has expertise in Quality Assurance, working for over 3 years as a Quality Assurance Chemist in building products manufacture. Michelle has worked for 8 years at MediHerb as Technical Writer where she is responsible for information gathering, technical writing and organising technical publications. Michelle has also completed studies in herbal medicine. Modern Phytotherapist 19 Clinical Use of Anthelmintic Herbs Clinical Anecdotes by Dr Ella M McElwee Case 1 Therapy Female aged 69. General health: good. Digestive problems, tightness in abdomen, moderate lightheadedness, sleep disturbances. Symptoms were not previously experienced until about three months ago. No prescription medications used at present. No digestive stool analysis done. On a wheat- and dairyfree diet. Therapy Completed the following purification programme: • A whole food and botanical supplement mixed with water to make a shake with a balance of macro- and micronutrients from plant sources in a highly bioavailable form Dose: 2 rounded tbsps in 2 cups of water with 2 tsps of unheated flaxseed oil • Vitamin complexes, minerals, and phytonutrients enlisting the detoxifying properties of over 20 different whole foods and botanicals in a vegetarian nutritional supplement Dose: 7 capsules t.i.d. on an empty stomach for 7 days • Dietary fibre containing phytonutrients from 5 different whole foods and botanicals that function synergistically Dose: 3 capsules t.i.d. on an empty stomach for 16 days Goal to restore proteolytic activity and eliminate parasites. The comprehensive protocol of superior quality Echinacea purpurea root and E. angustifolia root blend, black walnut hulls, pau d’arco, wormwood and ginger was given as the following formula: Herbal Formula Echinacea purpurea root and E. angustifolia root blend 1:2 Black walnut hulls (Juglans nigra) 1:10 50 mL Pau d’arco (Tabebuia avellanedae) 1:2 50 mL Wormwood (Artemisia absinthium) 1:5 30 mL Ginger (Zingiber officinale) 1:2 10 mL 60 mL 200 mL Dose: 5 mL t.i.d. for two weeks. Rest one week. Repeat for two more weeks. All the above problems were eliminated after six weeks of herbal treatment. Case 2 Female aged 65. General health: fair. Itching of skin, grinding of teeth at night. Symptoms present for over 90 days. Using prescription medications for heart etc. Involved in automobile accident two years ago. In hospital for three months with multiple fractures, including skull. In rehabilitation hospital for six months. 20 Modern Phytotherapist During the above programme the following were avoided: wheat, dairy, refined sugars, caffeine, alcohol, carbonated beverages, eggs, chicken, red meat, peanuts, and shellfish. Diet included organic fresh fruits and vegetables; brown, Thai, wild or Basmati rice; rice-based foods, for example rice cakes, crackers, bread made with rice flour, pasta, pancake mix, etc; non-medicinal herbal or green teas; bottled organic fruit juices; unheated cold pressed flaxseed oil. However, itching of skin continued, along with grinding of teeth at night, so I prescribed the comprehensive protocol for parasites: each tablet containing a blend of Stemona spp. (1000 mg), wormwood (100 mg), black walnut hulls (100 mg) and clove oil (20 mg). Dose: 4 tablets per day for 14 days, 10 day break and repeat for 14 days. The patient’s skin cleared and the grinding of teeth stopped. For professional use only. Not for Public Distribution. Clinical Clinical Anecdote by Dr Bruce Bond IDDM My daughter, Marissa, is 15.5 years old and has been dealing with IDDM for 2.5 years. Actually, up until recently her sugar has been fairly constant but I suspect hormonal issues are taking effect during certain times of the month. She is a remarkable girl in that her diet is phenomenal. She told me a while ago that she will take care of her body and her diet mirrors this. She eats no refined foods other than what her mother makes for her (which has very low glycaemic index and is organic). Our diet at home is all organic and free-range. We actually had a doctor tell us to let her eat whatever she wants and just adjust the insulin accordingly. To them it’s all about the number, nothing about the long-term effects of spiking blood levels. She was given the following tablets to see if an antiparasitic protocol would improve her condition. • Tablets containing a blend of Stemona spp. (1000 mg), wormwood (100 mg), black walnut hulls (100 mg) and clove oil (20 mg). Dose: 2 tablets b.i.d. (Referred to below as worming tablets.) • Capsules containing fig, papain, bromelain, amylase, lipase and cellulose. Dose: 2 capsules t.i.d. Part of her regular diabetic regimen also included a Gymnema tablet (4 g, standardised for gymnemic acid content). Dose: 1 tablet t.i.d. We saw a change in the sugar reading with the introduction of the antiparasitic tablets, within a few days Marissa’s blood sugar levels had stabilised. While on these tablets her blood glucose remained around 90135 mg/dL. She had been experiencing wide swings prior to beginning these tablets. The glucose readings would range anywhere from 50 to 250 and occasionally as high as 300. Once off the protocol for the 10-day rest period, her blood glucose would gradually become less stable. When beginning the antiparasitic tablets again, she would quickly even out and would not have the dramatic swings in blood glucose readings. For professional use only. Not for Public Distribution. Dr Ella M McElwee ND, HMD, PhD Dr Ella McElwee has been utilising the concept of homoeopathy and naturopathy in her clinic since the early 1970s. Dr McElwee is the owner and President of Health By Choice, a health food store and nutritional counselling centre situated in the Morrison’s Cove area of western Pennsylvania which draws clients from all over the United States, Canada, and beyond. Dr McElwee uses the Carey Reams theory of ionisation (which determines the state of homoeostasis biochemically within the body) combined with other disciplines such as iridology to suggest a nutritional program that is unique to the client’s body’s chemistry. She supports over fifty organizations, journals and research groups in the integrative healthcare field, is a Board Member of the American College of Integrative Medical Practitioners and lectures regularly. Dr Bruce Bond DC, NOAC Dr Bruce Bond has been in full-time private practice since 1988. He graduated in 1985 from the National College of Chiropractic, Illinois, USA. Before starting his own practice he had worked as an associate doctor for 2.5 years. His practice today is 95% private pay, providing chiropractic manipulation, whole food supplementation, and herbal therapy to his patients. He also lectures around the country teaching the Meridian Response Technique, nutrition, herbal therapy and practice management to practitioners approximately every other weekend throughout the year. Modern Phytotherapist 21 Clinical Prostate Problems and Solutions BY ROB SANTICH Increasing numbers of men are consulting natural therapists for solutions to a variety of prostate dysfunctions and diseases. The aim of this article is to review these diseases and dysfunctions and examine the herbal treatments available to practitioners. The prostate is a gland about the size of a walnut which encircles the urethra at the exit from the bladder. Its function is to produce, along with the seminal vesicles, a fluid in which ejaculated sperm are suspended. The secretions from the prostate contain a large number of different chemical substances, including nutrients and buffers that protect the sperm against the acidic vaginal secretions and prostaglandins.1 Benign Prostatic Hyperplasia (BPH) BPH is the result of non-malignant neoplasms of epithelial glandular tissue, which causes hypertrophy of the prostate gland. Fibroadenomatous nodes develop mostly in the periurethral prostate tissue, but may develop in the walls or middle lobe as well. The resulting enlargement of the fibromusculature of the prostate gland causes difficulty in urination and sexual function.2 Symptoms and Signs The symptoms due to BPH can be divided into voiding symptoms which include decreased force of stream, hesitancy, intermittency, straining to void, incomplete emptying and urinary retention and storage symptoms which include urgency, frequency, nocturia, dysuria and urge incontinence. These symptoms are collectively referred to as lower urinary tract symptoms. Current thinking is that not all of these are due to BPH, especially in older men, and may be the result of detrusor urinae muscle changes.3 Pathogenesis The exact pathogenesis of BPH is as yet unknown, however investigators have proposed several hypotheses to explain the development of prostate enlargement. These can be divided into hormone-dependent hyperplasia, the mechanical component, and alphaadrenergic tone (or the dynamic component). Androgen Hypothesis (Mechanical Component) Because androgen is required for prostate development, it has been proposed increased prostatic concentrations of androgen or increased androgen activity causes BPH. It is widely accepted that the growth, function and maintenance of the prostate gland are androgen dependent. In the prostate, testosterone is converted to 5-alpha-dihydrotestosterone (DHT) by the enzyme 5alpha-reductase. DHT is the active intracellular androgen and it elicits its biological activity by binding to the nuclear androgen receptor (AR) protein. This complex (DHT-AR) can bind to a specific DNA sequence, thereby initiating or inhibiting the expression of genes involved in growth regulatory pathways or the production of secretory products such as prostate specific antigen (PSA).6 Studies have shown, however, that androgens do not stimulate prostatic epithelial cell growth directly, whereas growth factors such as epithelial growth factor (EGF) and transforming growth factor alpha (TGF-alpha) do.7 These results perhaps support earlier work that concluded that androgens, although not directly involved, act to switch on proliferative processes, with a certain level of androgens required to initiate the proliferation.8 It is also interesting to note that it has been demonstrated that the levels of DHT were similar in both normal and BPH tissue.9 Prevalence Oestrogen Hypothesis The prevalence of BPH increases with age, with 50% of men in their 50s and 90% of men over 80 having histological evidence of BPH.4 Contrasting this, for the clinical diagnosis of BPH, population-based studies have shown the prevalence of BPH increases from 24% of men in their 50s to over 50% of men in their 70s.5 Oestrogens originate from testosterone and the adrenal androgen androstenedione through conversion by the aromatase enzyme system. Early evidence from experimental models, where the administration of oestrogens and androgens induced BPH, suggested that oestrogens might be involved in BPH.10 22 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical Testis Testosterone PROSTATE Testosterone 5-Reductase DHT Androgen Receptor The possible mechanism was described some years previous by a leading prostate researcher who proposed that oestrogen, mediated by sex hormone binding globulin (SHBG), participates with androgen in setting the pace of prostate growth and function. It is stated in the review that SHBG increases with age and can act like an additional androgen receptor in the prostate cell. The author suggests that when oestrogen binds to SHBG in the cell membrane, insulin-like growth factor 1 (IGF-1) is synthesised causing proliferation of prostatic epithelial cells. Accompanying this, androgens activate binding sites for growth factors, which cause further proliferation. To summarise, using the words of the researcher, oestrogen not only directs stromal proliferation and secretion, but also through IGF-1 conditions the response of the epithelium to androgen.13 Dynamic Component The term prostatism is given to the dynamic component of symptoms relating to urethral obstruction. Sympathetic nerve fibres (alphaadrenergic) innervate the smooth muscle of the prostate capsule and bladder neck. Alpha-adrenergic tone contributes to the total urethral resistance and some of the symptoms of BPH are said to be related to the corresponding state of contraction of the smooth muscle of the prostate capsule and bladder neck.3 Growth Regulation, Secretion Medical Management Action of dihydrotestosterone (DHT) on prostatic tissue. Adapted from Harrison’s Principles of Internal Medicine, 14th Edn. CD-ROM. Mc Graw Hill, New York, 1998. In recent years some light has been shed on the question of age-related oestrogen/androgen balance and BPH. One study concluded that the prostatic accumulation of DHT, oestradiol and oestrone is in part intimately correlated with ageing, leading (with increasing age) to a dramatic increase of the oestrogen/androgen ratio particularly in the stroma of the prostate.11 Further to this, it has been demonstrated that prostate size correlates with oestradiol levels and with the ratio of oestradiol to free testosterone. The researchers stated that the endocrine environment tended to be oestrogendominant with age, in particular after middle age, and that patients with large prostates have more oestrogendominant environments. They concluded that this relatively oestrogen-dominant status induces stromal proliferation by some mechanism and leads to the development of BPH.12 For professional use only. Not for Public Distribution. For mild to moderate BPH alpha-adrenergic blockers such as terazosin are used to improve voiding. Less commonly prescribed are 5-alpha-reductase inhibitors such as finasteride, which over time reduce prostate size and therefore improve voiding.3 Prostate Cancer Prostate cancer (PC) is the most common cancer (other than skin cancer) in males and caused 2449 deaths in Australia in 1997.14 The incidence of PC in Australia is 120 cases per 100 000 men15 with a mortality rate of 25 per 100 000.16 These figures imply that the majority of affected men will die with PC and not from it. The aetiological factors associated with PC are yet to be firmly established. However, studies have highlighted some trends. • There seems to be a clear difference in the prevalence and mortality between various ethnic groups. African-Americans have the highest rate, Caucasian Americans an intermediate rate, while Asian men have the lowest.17 Modern Phytotherapist 23 Clinical • The data on diet and PC has revealed a strong correlation between per capita fat intake and PC incidence and mortality.6 • The single most important risk factor for developing PC appears to be age, the chances increase dramatically after age 50.17 • Researchers have looked to the role of androgens in promoting growth of the prostate gland. As a result, pathways involved in androgen metabolism have been implicated in PC such as 5-alpha-reductase and the CYP3A4 gene. The CYP3A4 enzyme is associated with the oxidative deactivation of testosterone. A genetic variant of this gene has been identified. Such a mutation may disrupt the expression and activity of the gene. Therefore, individuals with the mutation may have less potential for oxidising testosterone, leaving greater bioavailability of the hormone to be metabolised to DHT. Studies have demonstrated an increase in prostate tumour stage in men who carry this mutation versus non-carriers.18 • At least eight prospective studies have demonstrated a correlation between PC risk and serum levels of hormones. There appears to be a strong trend of increasing PC risk and increasing levels of testosterone and an inverse trend with increasing levels of SHBG.19 Xeno-oestrogens, Phyto-oestrogens and Prostate Cancer For the past 40 years or so, evidence has been steadily accumulating that suggests environmental chemicals such as pesticides and industrial chemicals are having a hormone-like effect in humans, fish and wildlife and could possibly be a causative factor in human cancers. It is believed that the endocrine and reproductive effects of these chemicals are due to their ability to: impotent and had low sperm counts.20 Recent meta-analyses of studies concerning the incidence of prostate cancer amongst farm workers, found there was a positive association between PC and farming and concluded that this was most probably due to the exposure to hormonally active agricultural chemicals.21 The dietary intake of soy products has been associated with a decreased risk of PC. It has been proposed that the isoflavones present in soy beans are responsible for this effect. Many mechanisms of action have been identified for the isoflavone prevention of cancer. These include: oestrogenic/antioestrogenic activity, antiproliferation, induction of cell-cycle arrest and apoptosis, prevention of oxidation, induction of detoxification enzymes, regulation of the host immune system and changes in cellular signalling. It is probable that a combination of these effects is responsible for the cancer prevention activity of isoflavones.22 A number of studies performed on experimental models implanted with PC cells, using either soy or genistein (an isoflavone present in soy), have demonstrated that tumour growth was significantly retarded and that invasive tumours were fewer.23 Epidemiological studies that include populations with a wide range of PC rates and a wide variety of soy consumption patterns generally show that men who eat more soy are less likely to develop PC. For example, consumption of soy products was more protective than any other dietary factor in a study that examined nutritional and socio-economic factors related to PC mortality in 42 countries.24 • mimic the effect of endogenous hormones, • antagonise the effect of endogenous hormones, In 1997, the Medical Journal of Australia published a case study that reported significant apoptosis in a prostatic specimen from a man with adenocarcinoma who had taken isoflavones (160 mg per day) derived from red clover one week before surgery. The author described this effect as typical of a response to high dose oestrogen therapy and is suggestive of tumour regression. There were no adverse side effects.25 • disrupt the synthesis and metabolism of endogenous hormones, Human Papillomavirus (HPV) and PC • disrupt the synthesis and metabolism of hormone receptors. In 1949, the insecticide DDT was found to negatively affect sperm count in crop dusters. Some time later workers at a plant producing the insecticide kepone were found to have lost their libido, many were 24 Modern Phytotherapist Several papers have appeared in the literature suggesting that HPV may cause genetic mutations in prostatic cells leading to PC.26,27,28 Bob Flaws, a respected practitioner of traditional Chinese medicine (TCM), writing in his book Cervical Dysplasia and Prostatic Cancer, HPV, a Hidden Link?, believes from his clinical perspective that this connection is significant. For professional use only. Not for Public Distribution. Clinical Diagnosis and Medical Treatment Two investigations are used in screening patients for PC. Digital rectal examination is used for diagnosis and monitoring and measurement of blood prostate specific antigen (PSA) helps track the course of the disease and evaluate the response to treatment.3 Left untreated the 5-year survival is 91–100% for localised disease, 85–95% for regional disease and only 26–31% for those patients with distant metastases. Treatment options for prostate cancer depend on the stage and histological grade of the cancer, the age of the patient and co-morbidities. Treatment options include observation, surgery, radiotherapy, hormonal therapy and chemotherapy.3 Herbal Treatment for BPH Treatment Goals The mainstay of herbal treatment is the use of prostate specific herbs (saw palmetto, nettle root and willow herb). Secondary to these herbs, other useful strategies can be employed if indicated, such as improving bladder tone and function with Crataeva (usually indicated in the older patient) and the alleviation of prostatism with the use of antispasmodics such as valerian and cramp bark. Prostate Specifics Saw Palmetto (Serenoa repens) The use of saw palmetto berries for symptoms of BPH dates back hundreds of years and it was highly regarded by Eclectic physicians. It is widely accepted that the berries possess anti-inflammatory, spasmolytic and possibly antiandrogenic properties. Eclectic physicians used the berries in a range of disorders from inflammation of the respiratory tract to inflammation of the genitourinary tract, especially cystitis and prostatic hypertrophy as well as atrophy of sexual tissues. It has considerable tonic activity as well and is used as a sexual tonic.29 compared with placebo and that LESP produced similar improvement in urinary symptoms and flow compared to the drug finasteride and is associated with fewer adverse treatment events.31 The majority of studies in this review used 320 mg per day of LESP. Nettle Root (Urtica spp.) Stinging nettle root has a long tradition of use in Germany for the treatment of inflammations of the urinary tract, for the prevention of urinary lithiasis and for the treatment of BPH.32 The use of nettle root extract is well supported from a clinical perspective. There have been quite a number of studies using nettle root extract on males with BPH symptoms, the following is a representative sample. Clinical observations of men after long-term treatment with an alcoholic extract of nettle root reported an improvement in bladder outlet obstruction symptoms and a decrease in post-voiding residual urine.32 Another study of BPH patients treated with an alcoholic fluid extract of nettle root reported a 66% decrease in residual urine, whilst another reported a decrease in nocturia frequency in patients over the age of 60 after 6 months’ treatment at 5 mL per day of a 1:5 tincture.33 Willow Herb (Epilobium parviflorum) The evidence for the use of willow herb for BPH, at least from a scientific stance is lacking. In vitro studies conducted on the plant are not convincing as to its pharmacological activity, however my own positive clinical experience is enough for me to continue prescribing this herb. There is an impressive body of pharmacological and clinical evidence that supports saw palmetto use for BPH, but to date its precise pharmacological activity remains elusive, although research is suggestive of a mild inhibition of 5-alpha-reductase, antiandrogenic activity and an inhibition of androgen binding.30 Much of the clinical work has used a liposterolic extract (LESP) dosage form and not a fluid extract. A recent review of clinical trials concluded that LESP improves urological symptoms and flow measures For professional use only. Not for Public Distribution. WILLOW HERB Modern Phytotherapist 25 Clinical Crataeva (Crataeva nurvala) Crataeva is one of the most important Ayurvedic herbs with influence in the urinary tract. The herb possesses bladder tonic and anti-inflammatory activity.34 It is now widely accepted that not all BPH symptoms are due to enlargement of the prostate, particularly in older men, where an atonic bladder can contribute significantly to symptoms. Clinical data supports such a use. Thirty patients with hypotonic bladder due to BPH were given a decoction of Crataeva. There was a marked improvement in frequency, incontinence, pain and retention of urine. Urine flow improved as well as an increase in bladder tone after therapy.34 Herbal Treatment of Prostate Cancer There are probably as many herbal treatments for cancer as there are individual cancers. Unfortunately there is no standard herbal protocol in relation to PC, as treatment depends on individual causative factors. However the following herbs may prove useful. Essiac Although not specific for PC alone, the use of Essiac formula may have some benefit. The Essiac formula (also known as sheep sorrel formula) consists of 4 herbs: burdock root, rhubarb root, sheep sorrel and slippery elm. A recent study funded by the US National Institutes of Health found widespread use and perceived benefits amongst cancer patients taking Essiac (as a tea). Just over 40% (40.6%) of the 1577 (of which 15.1% were PC patients) current and former cancer patients attributed a halt in their cancer progression to its use, whilst 22% perceived the tea to be responsible for partial or total remission of their cancer symptoms. Nearly 90% reported positive effects such as a reduction in pain, less nausea and fatigue and a return of appetite. From these results the University of Texas recommended controlled clinical trials be undertaken.35 Soy Due to the compelling evidence in relation to soy and isoflavones, an increase in soy consumption or soy supplementation is warranted. consider are saw palmetto and nettle root with support from Crataeva and willow herb. Antivirals If HPV is implicated Thuja could prove useful. (HPV is a naked virus and so St John’s wort (Hypericum perforatum) will be ineffective.) Others Although clinical evidence is lacking, several herbs or their components have displayed promising activity against PC cell lines in vitro. Epigallocatechin-3-gallate (EGCG), the major polyphenolic constituent in green tea, has demonstrated apoptosis-inducing effects in both androgen-sensitive and androgen-insensitive human prostate carcinoma cells.36 Curcumin from turmeric (Curcuma longa) was also found to possess this same activity by down-regulating apoptosis suppressor proteins.37 CASE STUDY 1: BPH Retired male 58 years of age, diagnosed with moderate BPH, 5 years previous. Had been prescribed prazosin (an alpha-adrenergic blocker) when initially diagnosed, but due to the unpleasant side effects, such as headaches, and the feeling of weakness and lack of energy, he decided to discontinue treatment. Since then he had not sought further medical treatment. In the last couple of years his symptoms had gradually worsened to the point where he was now experiencing overflow incontinence to such an extent that he had taken to wearing a sarong to spare the embarrassment of the wet stains on his trousers. It also kept him at home most of the time. Herbal Treatment Nettle root (Urtica dioica) 1:2 30 mL Willow herb (Epilobium parviflorum) 1:2 30 mL Crataeva (Crataeva nurvala) 1:2 40 mL 100 mL Dose: 10 mL t.i.d. A capsule containing Serenoa serrulata liposterolic extract: 1 capsule t.i.d. Herbal Antiandrogens Treatment Rationale A similar protocol to that used in BPH may beneficial in the initial stage of PC where the growth of the prostate gland is under androgen control. The herbs to A high priority was placed on the improvement of bladder tone, which was the main reason such a large dose of the herbal liquid was recommended. The second 26 Modern Phytotherapist For professional use only. Not for Public Distribution. Clinical priority was the prescription of all the prostate specific remedies in an endeavour to elicit maximum herbal antiprostatic activity. Course of Treatment After 8 weeks of treatment, signs of a slight improvement had begun to emerge in relation to nocturia, urgency and overflow incontinence. At this point there was no need to alter either the prescription or the dose. From this point forward we communicated by phone. The above treatment was continuous for 18 months, during which time improvement was steady, although the dose of the liquid was reduced to 5 mL t.i.d. after 6 months. After 18 months’ treatment the patient no longer experienced overflow incontinence and there was an all-round improvement in other symptoms as well. The patient’s nocturia pattern was down to twice a night. CASE STUDY 2: PROSTATE CANCER SCHISANDRA Male 61 years of age, single and working as an upholsterer. Diagnosed with PC recently through elevated PSA levels (9.3 ng/mL) and biopsy. Has a history of urinary tract symptoms and hypertension which is being managed with ramipril (2.5 mg once per day). Ceased cigarette smoking in 1983. Living alone he has found it difficult to prepare meals and will often consume take-away foods. He consumed 1–2 x 750 mL bottles of beer daily. He had already agreed to the radiotherapy recommended by his medical specialist, which was due to begin in 2 months. His main reason for coming to see me was to establish whether herbal medicines could support him through radiotherapy and if this was successful whether herbal therapies could keep the cancer at bay. After lengthy discussion the following protocol was initiated. Herbal Treatment Astragalus (Astragalus membranaceus) 1:2 30 mL Turmeric (Curcuma longa) 1:1 35 mL Schisandra (Schisandra chinensis) 1:2 35 mL his O blood group and given a dietary supplement consisting of fruit and vegetable powders as a means of increasing antioxidants such as lycopene. He also agreed to cease drinking beer. Treatment Rationale Astragalus was chosen for its adaptogenic and tonic activity; turmeric for its anti-inflammatory, anticancer, antioxidant and cholagogue properties; Schisandra for its adaptogenic and hepatoprotective properties. The sheep sorrel formula tea was chosen for its traditional use in various types of cancer. Course of Treatment The patient passed through the radiotherapy with relative ease and was largely free of any side effects. Following radiotherapy his PSA levels had dropped to 3.9 ng/mL. At this point he ceased taking the liquid herbal formula but continued with the sheep sorrel formula tea and was prescribed a soy supplement to be taken three times a day. His dietary compliance was reasonable and has continued with zero beer consumption. 100 mL Dose: 8 mL b.i.d. A tea made from a dried herb combination containing sheep sorrel, rhubarb root, burdock root and slippery elm: 60 mL b.i.d. The patient was also recommended a diet in line with For professional use only. Not for Public Distribution. In the 12 months following radiotherapy, his PSA levels have not risen above 5 ng/mL. Currently the patient is taking a tablet combination of turmeric, rosemary, green tea and grape seed (3 tablets per day), and a supplement of soy, standardised to contain 50 mg of isoflavones (3 tablets per day). There has been no significant change to his PSA levels. Modern Phytotherapist 27 Clinical REFERENCES 1 Vander AJ, Sherman JH, Luciano D.S. Human Physiology. 5th Edn. McGraw-Hill Publishing, New York, 1990, pp 605-607. 2 Walsh PC. Benign prostatic hyperplasia. In: Harrison JH, Gittes RF, Perlmutter AD et al (eds). Campbell’s Urology. WB Saunders, Philedelphia, 1979, pp 949-966. 3 Moran JA, Street PR, Rogerson JW. Aust J Hosp Pharm 2001; 31: 115-119. 4 McConnell JD. Epidemiology, etiology, pathophysiology and diagnosis of benign prostatic hyperplasia. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds). Campbell’s Urology. 7th Edn. WB Saunders, Philadelphia, 1998, pp 1429-1452. 5 Garraway WM, Collins GN, Lee RJ. Lancet 1991; 338: 469-471 6 Marcelli M, Shao TC, Cunningham GR. J Anti-Aging Med 2000; 3(2): 191-200. 7 Jones HE, Eaton CL, Barrow D et al. Prostate 1997; 30(4): 219-231. 8 Bruchovsky N, Rennie PS, Vanson A. Biochem Biophys Acta 1975; 394(2): 248-266. 9 Walsh PC, Hutchins GM, Ewing LL. J Clin Invest 1983; 72: 1772-1777. 10 Coffey DS, Walsh PC. Urol Clin Nth Am 1990; 17: 461-475. 11 Kreig M, Nass R, Tunn S. J Clin Endocrinol Metab 1993; 77(2): 375-381. 12 Shibata Y, Ito K, Suzuki K et al. Prostate 2000; 42(1): 45-55. 13 Farnsworth WE. Prostate 1996; 28(1): 17-23. 14 Australian Institute of Health and Welfare and Australian Institute of Cancer Registries. Cancer in Australia 1997: Incidence and Mortality Data for 1997 and Selected Data for 1998 and 1999. Cancer Series No. 15. AIHW, Canberra, November 2000. 15 Frydenberg M. Med J Aust 1998; 168: 477-478. 16 Hirst GHL, Ward JE, Del Mar CB. Med J Aust 1996; 164: 285-288. 17 Landis S, Murray T, Bolden S et al. CA Cancer J Clin 1999; 49: 8-31. 18 Zeigler-Johnson C. Clin J Oncol Nurs 2000; 5(4): 153-154. 19 Eaton NE, Reeves GK, Appleby PN et al. Br J Cancer 1999; 80: 939-934. 20 Sonnenschein C, Soto AM. J Steriod Biochem Mol Biol 1998; 65(1-6): 143-150. 21 Keller-Byrne JE, Khuder SA, Schaub EA. Am J Ind Med 1997; 31(5): 580-586. 22 Birt DF, Hendrich S, Wang W. Pharmacol Ther 2001; 90(2-3): 157-177. 23 Messina MJ. Am J Clin Nutr 1999; 70(suppl): 439S-450S. 24 Hebert JR, Hurley TG, Olendzki BC et al. J Natl Cancer Inst 1998; 90: 1637-1647. 25 Stephens FO. Med J Aust 1997; 167(3): 138-140. 26 McNicol PJ, Dodd JG. J Clin Microbiol 1990; 28(3): 409-412. 27 Serth J, Panitz F, Paeslack U et al. Cancer Res 1999; 59(4): 823-825. 28 Suzuki H, Komiya A, Aida S et al. Prostate 1996; 28(5): 318-324. 29 Ellingwood F, Lloyd JU. American Materia Medica, Therapeutics and Pharmacognosy. 11th Edn. Eclectic Medical Publication, Portland, 1983. 30 Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone, Edinburgh, 2000, pp 523-533. 31 Wilt T, Ishani A, Mac Donald R. Cochrane Database Syst Rev 2002; (3):CD001423. 32 Bruneton J. Pharmacognosy, Phytochemistry, Medicinal Plants. Lavoisier Publishing, Paris, 1995, p 604. 33 Scientific Committee of ESCOP (European Scientific Cooperative on Phytotherapy). ESCOP Monographs: Urticae radix. European Scientific Cooperative on Phytotherapy, ESCOP Secretariat, UK, March 1996. 34 Bone K. Clinical Applications of Ayurvedic and Chinese Herbs. Phytotherapy Press, Warwick, 1996. 35 Richardson MA, Sanders T, Tamayo C et al. HerbalGram 2000; 50: 40-46 36 Gupta S, Hussain T, Mukhtar H. Arch Biochem Biophys 2003; 410(1): 177-185. 37 Dorai T, Gehani N, Katz A. Prostate Cancer Prostatic Dis 2000; 3(2): 84-93. 28 Modern Phytotherapist Mr Rob Santich DMH, MNHAA Rob has been a practising herbalist for 18 years and runs a herbal practice in Newport, Sydney. He is the head of the Botanical Medicine Faculty at the Australasian College of Natural Therapies in Sydney and is a member of the expert advisory panel to the Complementary Medicines Evaluation Committee. He served as an examiner on the board of the National Herbalists Association of Australia for 5 years. Rob is a member of MediHerb’s practitioner support team by advising on the Clinical Support Line. His special interests are medicinal Australian native plants and essential oils and he is working with an Aboriginal land council on research and development in this field. Rob also has an interest in the use of herbs by native Americans. For professional use only. Not for Public Distribution. Clinical Clinical Monitor BY KERRY BONE Common Quality Pitfalls for Tribulus are Highlighted The herb Tribulus terrestris has become popular as a herb which boosts libido and male sexual performance. It is also used by phytotherapists to promote male and female fertility, for menopausal symptoms and to boost physical performance and fitness.1 Tribulus is a common weed found in many parts of the world and has been used for therapy in several traditional systems such as Ayurveda and Chinese medicine. But the modern uses cited above stem largely from Bulgarian research using a standardised Tribulus leaf preparation which is rich in furostanol saponins, especially the marker phytochemical protodioscin. Now two studies have highlighted that most Tribulus products on the market are quite different from the Bulgarian extract.2,3 The first study, conducted in the US, found that the level of protodioscin varied substantially with the plant part (leaf, stem or fruit) and origin (Bulgaria, India or China) of the Tribulus.2 Only leaf from Bulgaria was high in protodioscin. Analysis of products selected from the US market found deficiencies of protodioscin in the majority. The second study from Australia produced similar results.3 An Eastern European variety of Tribulus (from Slovakia) contained high levels of protodioscin in the leaf but none in the fruit. Leaf from Australia and India did not contain protodioscin. Comment The principle of phytoequivalence dictates that if the benefits demonstrated in a clinical trial are claimed for a herbal product, then that product must closely match the one used in the clinical trial. The Bulgarian clinical trials which have shown that Tribulus boosts libido and fertility and alleviates menopausal symptoms all used Tribulus leaf rich in protodioscin collected from Bulgaria. Therefore only similar products might reasonably be expected to have the same effects. If a Tribulus product is made from the root or fruit of the plant, or is sourced from anywhere else other than Eastern Europe, it will probably contain low levels of protodioscin and so will be quite different to the Bulgarian standardised extract. This is despite what For professional use only. Not for Public Distribution. might be claimed on the label for such products because often inferior methods of analysis have been used to measure the furostanol saponins, such as gravimetric or colorimetric techniques. The quality of Tribulus products is best assessed by high performance liquid chromatography as used in the two studies cited above. Coincidentally, a recent publication found that a Tribulus extract rich in protodioscin possessed aphrodisiac activity in male rats which was probably due to an androgenic effect.4 REFERENCES 1 Morgan M, Bone K. Tribulus terrestris. Professional Review Aug 2001; No. 76, pp 1-4. 2 Ganzera M, Bedir E, Khan IA. Determination of steroidal saponins in Tribulus terrestris by reversed-phase high-performance liquid chromatography and evaporative light scattering detection. J Pharm Sci 2001; 90(11): 1752-1758. 3 Lehmann RP, Penman KG, Halloran KG. Comparison of photometric HPLC-ELSD analytical methods for Tribulus terrestris. Revista de Fitoterapia 2002; 2(S1): 217 (Abstract B006). 4 Gauthaman K, Adaikan PG, Prasad RNV. Aphrodisiac properties of Tribulus terrestris extract (protodioscin) in normal and castrated rats. Life Sci 2002; 71: 1385-1396. Claw Therapy for Arthritis and Muscular Pain Devil’s claw (Harpagophytum procumbens) is well recognised as a herbal treatment for arthritic pain and there are several clinical trials which support its use for osteoarthritis and low back pain.1 A recent clinical trial involving 63 patients found that the herb is also useful for muscular pain in patients with slight to moderate muscular tension or slight muscular pain of the back, shoulder and neck.2 Patients received the equivalent of about 3 g per day of devil’s claw over 4 weeks or a closely-matched placebo. Devil’s claw is also generating interest for veterinary applications. The treatment of degeneration of the proximal intertarsal, distal interdistal and tarsometatarsal joints and of muscular disorders was investigated in ten race horses in comparison with a control group of ten horses treated with phenylbutazone over 60 days.3 The horses were given 0.5 mg/kg of an approximately 3:1 extract of devil’s claw. Six horses receiving the devil’s claw showed a marked improvement of symptoms, even compared to the Modern Phytotherapist 29 Clinical control group receiving the drug. What is surprising is that another “claw” herb normally used to boost immune function, namely cat’s claw, is also under investigation for the treatment of rheumatoid arthritis (RA). Forty patients undergoing conventional drug therapy for active RA were enrolled in a randomised 52-week, two phase study.4 During the first phase (24 weeks) patients were treated with cat’s claw extract or placebo under double-blind conditions. In the second phase (28 weeks) all patients received the herbal extract. Results for the first phase demonstrated a reduction of the number of painful joints for the cat’s claw group compared to placebo (by 53.2% vs. 24.1%; p=0.044). Patients previously on placebo who then received cat’s claw in the second phase of the study also experienced a highly significant reduction in the number of painful and swollen joints. Only minor side effects were observed such as pruritis and dyspepsia and there was a similar distribution of adverse events in the active and placebo groups. Comment The finding that devil’s claw is beneficial for the relief of muscular pain is a significant development and suggests that devil’s claw may have value in the treatment of fibromyalgia. The dose of devil’s claw given to the race horses (0.5 mg/kg of extract) was considerably lower than the dose used in the human trial (greater than 10 mg/kg of extract). However, it is conceivable that horses may be more sensitive to the herb. Rheumatoid arthritis is a complex and chronic disease, so it would be simplistic to suggest that cat’s claw on its own is an effective treatment for this condition. Nonetheless, the favourable clinical trial is a positive development in our understanding of phytotherapy for RA. The extract used in the trial was from the pentacyclic oxindole alkaloid chemotype of cat’s claw (tetracyclic oxindole alkaloids were absent). This chemotype is also preferred for the immune system applications of cat’s claw. REFERENCES 1 Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone, Edinburgh, 2000, pp 345-349. 2 Gobel H, Heinze A, Ingwersen M et al. [Effects of Harpagophytum procumbens LI 174 (devil’s claw) on sensory, motor and vascular muscle reagibility in the treatment of unspecific back pain]. Schmerz 2001; 15(1): 10-18. 3 Montesano D, Ferrara L. Devil’s claw root: pharmacological study in horses. Revista de Fitoterapia 2002; 2(S1): 105 (Abstract A045). 4 Mur E, Hartig F, Eibl G et al. Randomized double blind trial of an extract from the pentacyclic alkaloid-chemotype of Uncaria tomentosa for the treatment of rheumatoid arthritis. J Rheumatol 2002; 29: 678-681. 30 Modern Phytotherapist New Clinical Uses for Milk Thistle? A group of Italian scientists investigated the ironbinding capacity of silybin, a component of the complex of flavanolignans known as silymarin found in milk thistle (Silybum marianum).1 Their motivation in doing so was to find an orally-active, non-toxic alternative to the iron-binding synthetic drug desferrioxamine, which causes side effects such as bone deformities, sensory abnormalities and cerebral toxicity. Desferrioxamine, which must be administered by injection, is currently the treatment of choice for the iron overload which can follow transfusion therapy for Cooley’s anaemia (-thalassaemia major). The scientists found that silybin strongly binds the ferric ion (Fe(III)), even at acidic pH. The complex of this molecule with iron demonstrated remarkable stability. Insulin-resistance and the associated conditions of metabolic syndrome X and type I diabetes are becoming increasingly prevalent in modern communities. In this context a clinical trial published in 1997 should be revisited. The aim of the study was to determine if longterm treatment with the silymarin complex from milk thistle was effective in reducing lipid peroxidation and insulin resistance in diabetic patients with cirrhosis.2 A 12-month open, controlled study was conducted in two well-matched groups of insulin-treated diabetics with alcoholic cirrhosis. One group (n=30) received 600 mg silymarin per day plus standard therapy, while the control group (n=30) received standard therapy alone. The efficacy parameters, measured regularly during the study, included fasting blood glucose levels, mean daily blood glucose levels, daily glucosuria levels, glycosylated haemoglobin (HbA1c) and malondialdehyde levels. There was a significant decrease (p<0.01) in fasting blood glucose levels, mean daily blood glucose levels, daily glucosuria and HbA1c levels already after 4 months of treatment in the silymarin group. In addition, there was a significant decrease (p<0.01) in fasting insulin levels and mean exogenous insulin requirements in the treated group, while the untreated group showed a significant increase (p<0.05) in fasting insulin levels and a stabilised insulin need. These findings are consistent with the significant decrease (p<0.01) in basal and glucagon-stimulated C-peptide levels (an indicator of endogenous insulin production) in the treated group and the significant increase in both parameters in the control group. Another interesting finding was the significant decrease (p<0.01) in malondialdehyde levels observed in the treated group. For professional use only. Not for Public Distribution. Clinical These results show that treatment with silymarin may reduce the lipoperoxidation of cell membranes and insulin resistance, significantly decreasing endogenous insulin overproduction and the need for exogenous insulin administration. Comment For some time I have been treating patients with the iron-storage disease haemochromatosis with relatively high doses of milk thistle extract (3 to 4 tablets per day containing 200 mg of extract standardised to 168 mg of silymarin). My motive in doing so was to protect the liver against the oxidative damage caused by iron accumulation in that organ. However, the above study suggests that there could be significant additional benefits from milk thistle in this disease. If milk thistle tablets are taken with meals they will inhibit iron absorption, but also the capacity of silybin to strongly bind iron suggests that milk thistle therapy could also facilitate the removal of iron from tissues. The next question to be answered is how strongly silybin might also bind heavy metals such as lead, cadmium and mercury. The capacity of milk thistle to reduce insulin resistance could be a huge development in the therapy for this major health issue. However, this finding needs to be confirmed in patients with type II diabetes who do not also have alcoholic cirrhosis. Incidentally, a recent rat study found that silymarin had significant oestrogenic activity.3 Will this versatile herb also find a role in the management of menopausal symptoms? REFERENCES 1 Borsari M, Gabbi C, Ghelfi F et al. Silybin, a new iron-chelating agent. J Inorg Biochem 2001; 85: 123-129 2 Velussi M, Cernigoi AM, De Monte A et al. Long-term (12 months) treatment with an anti-oxidant drug (silymarin) is effective on hyperinsulinemia, exogenous insulin need and malondialdehyde levels in cirrhotic diabetic patients. J Hepatol 1997; 26(4): 871-879 3 Kummer V, Maskova J, Canderle J et al. Estrogenic effects of silymarin in ovariectomized rats. Vet Med - Czech 2001; 46(1): 17-23 Saw Palmetto for Male Pattern Baldness? Laboratory experiments have shown that the liposterolic extract of saw palmetto (LESP) is a weak inhibitor of 5--reductase (5AR). While the relevance of this weak activity to the oral use of LESP for benign prostatic hyperplasia is debatable,1 a group of scientists decided to test the effect of oral intake of LESP on male pattern baldness in a pilot study involving men between For professional use only. Not for Public Distribution. SAW PALMETTO the ages of 23 and 64 under double-blind conditions.2 The product tested also contained -sitosterol and nutrients and the dose of LESP used was 400 mg per day (equivalent to about 4 g of berry). The blinded investigative staff rated 60% of the volunteers receiving active treatment as improved, compared to only 11% for the placebo group. Self-assessment by volunteers showed a similar but less striking trend. The authors suggested that this positive pilot trial justifies the expansion to larger trials. Comment While the results of oral LESP for male pattern baldness might be significant, they are also likely to be modest. It is conceivable that topical application of LESP to the scalp could add to the observed effect since it delivers a high concentration of dose to the affected area. Soft gel capsules could be cut and massaged into the scalp at night. While on the subject of herbs to improve appearance, an interesting German study found that intake of nettle and dandelion juices improved skin parameters in healthy women.3 Both active and control groups used a moisturising cream, but only the active group took the herbal juices. Skin hydration improved significantly after 6 weeks in the experimental group (p<0.05). Elasticity was significantly improved compared to controls. After 6 weeks of treatment, volunteers in the active group rated their skin condition as significantly improved, whereas there was little change for the control group. Modern Phytotherapist 31 Clinical REFERENCES 1 Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone, Edinburgh, 2000, pp 523-533. 2 Prager N, Bickett R, French N et al. A randomized, double-blind, placebocontrolled trial to determine the effectiveness of botanically derived inhibitors of 5--reductase in the treatment of androgenetic alopecia. J Altern Complement Med 2002; 8(2): 143-152 3 Schmid D, Lang A, Allgauer T et al. Evaluation of effects of skin parameters through oral treatment with stinging nettle and dandelion extracts – an open, controlled, prospective pilot-study. Akt Dermatol 2001; 27: 25-29 Clinical Trial with Echinacea Polysaccharides In an open, prospective study with matched historical controls, a polysaccharide fraction isolated from Echinacea purpurea cell cultures was tested to see if it could counter the undesired side effects of cancer chemotherapy.1 Fifteen patients with advanced gastric cancer undergoing palliative chemotherapy with a range of cytotoxic drugs also received daily intravenous injections of 2 mg of a polysaccharide fraction from Echinacea. While the polysaccharide treatment did appear to increase white cell counts, there were no clinically relevant effects on phagocytic activity or lymphocyte subpopulations. The authors suggested that this form of treatment should be investigated in further studies. Comment While on the subject of Echinacea myths, the proponents of restricting the clinical application of Echinacea to short-term use will probably make much of a recent adverse reaction report concerning a 51year-old woman who developed mild leucopenia (reduced white cell count) after taking Echinacea and vitamin supplements over several months.3 Her white cell count returned to normal on two occasions after ceasing the Echinacea. However, this publication contains the typical deficiency of many adverse case reports for herbs, namely the failure to identify exactly what the patient was taking. No information was provided as to the Echinacea species or plant part used by the patient, nor was there any analysis of the product to determine whether it had been contaminated with other substances or actually contained Echinacea. This is an idiosyncratic adverse reaction of uncertain aetiology and does not provide any proof that the longterm use of Echinacea is deleterious in a wider population. REFERENCES 1 Melchart D, Clemm C, Weber B et al. Polysaccharides isolated from Echinacea purpurea herba cell cultures to counteract undesired effects of chemotherapy – a pilot study. Phytother Res 2002; 16: 138-142 2 Dietz B, Heilmann J, Bauer R. Absorption of dodeca-2E,4E,8Z,10E/Ztetraenoic acid isobutylamides after oral application of Echinacea purpurea tincture. Planta Med 2001; 67(9): 863-864 3 Kemp DE, Franco FN. Possible leukopenia associated with long-term use of Echinacea. JABFP 2002; 15(5): 417-419 For several years now it has been proposed by some writers that the activity of oral preparations of Echinacea can be attributed to polysaccharides. In fact, in advertising literature Echinacea has been compared to other sources of polysaccharides such as larch extracts and been found wanting (in terms of in vitro models designed to detect polysaccharide-related immune activities). While the above research has demonstrated the potential of a novel and new treatment, it also reveals a fundamental flaw behind attempts to explain the activity of Echinacea in terms of polysaccharides. In the trial, the polysaccharides were administered by injection because their oral bioavailability is uncertain. If the trial scientists had believed that the polysaccharides were orally active, then they would have administered them this way. Recently Bauer and coworkers found that the lipophilic (and therefore ethanol-soluble) alkamides could be detected in the bloodstream after oral doses of Echinacea, thus establishing their bioavailability.2 Anyone wishing to explain the activity of traditional preparations of Echinacea should be looking in this direction. 32 Modern Phytotherapist ECHINACEA For professional use only. Not for Public Distribution.