Anaphylactic reactions after therapeutic injection of mistletoe (Viscum album L.)

[Anaphylactic shock after mistletoe therapy]

Life-threatening side effects of mistletoe therapy are mostly negated by physicians working in complementary medicine. This article reports on a case of life-threatening anaphylactic shock after carrying out mistletoe therapy. In patients with a carcinoid syndrome (flushes, diarrhea, bronchoconstriction) the diagnosis of anaphylactic shock can be masked by the findings of a neuroendocrine neoplasm. Before a planned complementary medicine mistletoe therapy patients should also be well-informed on rare life-threatening side effects.

The Anti-Inflammatory Activity of Viscum album

The therapeutic story of European mistletoe (Viscum album L.) presents a seesawing profile. In ancient times, this hemiparasitic plant was considered a panacea and even to be endowed with exceptional beneficial properties. In more recent times, despite its multiple uses in traditional medicines, some parts of the plant, in particular the berries, were considered poisonous and dangerous, including concerns of cytotoxicity, which spread serious suspicion on its medicinal utility. However, since the last century, medical interest in mistletoe has come back in force due to its utilization in clinical cancer treatments, based on its selective action on tumor cells. In Central Europe, the hydro-alcoholic extracts of European mistletoe register a relevant and continuous utilization in anthroposophic medicine, which is a holistic system that includes the utilization of phytomedicinal substances. In Switzerland and Germany, most physicians and patients use these products as complementary therapy in oncological treatments. However, despite its increasing use in this field, the results of mistletoe's use are not always convincing, and other aspects have appeared. Nowadays, products that contain mistletoe are utilized in several fields, including diet, phytotherapy, veterinary medicine and homeopathy, but in particular in cancer therapies as coadjuvant factors, in consideration of several positive effects including effects in the improvement of quality-of-life conditions and reinforcement of the immune system. In this review, based on the understanding of the association between cancer and inflammation, we propose a relationship between these recent uses of mistletoe, based on its antioxidant properties, which are supported by phytochemical and pharmacological data. The unicity of mistletoe metabolism, which is a direct consequence of its hemiparasitism, is utilized as a key interpretation element to explain its biological properties and steer its consequent therapeutic uses.

[Complementary or alternative medicine in oncology : Chances or risks?]

BACKGROUND

Approximately half of all cancer patients use complementary or alternative medicine.

AIM

The results of the German S3 guidelines on complementary oncology are presented and placed into the context of patient consultation.

MATERIAL AND METHODS

The core recommendations of the S3 guidelines are summarized including an overview of the evidence.

RESULTS

Selected methods of complementary medicine can be used with the aim of improving the quality of life and reducing side effects. Comprehensive data are available for physical activity with respect to survival, quality of life and supportive therapy. For most other methods the evidence is relatively low. Therefore, weighing up the benefits and risks more frequently resulted in negative recommendations in the guidelines, especially for methods based on substances. Exceptions to this are three micronutrients (vitamins B12, D and selenium), as even in the case of a well-balanced diet, deficiency symptoms are possible. Therefore, routine measurement of the blood levels of these micronutrients is recommended.

CONCLUSION

The questions from patients on what they can do by themselves should be answered respectfully and based on evidence. The benefits and risks of complementary methods must be carefully considered. To do this, regular questioning of patients on the interest in complementary methods is recommended. The decisive benefit of complementary medicine is the chance for patients to become active themselves. Therefore, all recommendations refer to the discussion with the patient, which do not formulate a therapy but are consultation recommendations: should be recommended instead of should be done.

European Mistletoe (Viscum album) Extract Is Cytotoxic to Canine High-Grade Astrocytoma Cells In Vitro and Has Additive Effects with Mebendazole

Malignant gliomas are associated with extremely poor clinical outcomes in both humans and dogs, and novel therapies are needed. Glioma-bearing canine patients may serve as promising preclinical models for human therapies, including complementary medicine. The objective of this study was to evaluate the effects of mistletoe extract (Viscum album) alone and in combination with mebendazole in an in vitro model of canine high-grade astrocytoma using the cell line SDT-3G. SDT-3G cells were exposed to a range of concentrations of mistletoe extract alone to obtain an IC50. In separate experiments, cells were exposed to mebendazole at a previously determined IC50 (0.03 µM) alone or in conjunction with varying concentrations of mistletoe extract to determine the additive effects. The IC50 for mistletoe alone was 5.644 ± 0.09 SD μg/mL. The addition of mistletoe at 5 μg/mL to mebendazole at 0.03 µM led to increased cell death compared to what would be expected for each drug separately. The cytotoxicity of mistletoe in vitro and its additive effect with mebendazole support future expanded in vitro and in vivo studies in dogs and supply early evidence that this may be a useful adjunct therapeutic agent for use in glioma-bearing dogs. To the authors’ knowledge, this is the first published report of Viscum album extract in canine glioma.

Distinct Modulatory Effects of Fever-Range Hyperthermia on the Response of Breast Cancer Cells and Macrophages to Mistletoe (Viscum album L.) Extract

Heat utility as a critical component of fever is often ignored, although the symptom is observed in many medical conditions. Mistletoe extract (ME) is an adjunctive medication prescribed to cancer patients. The increase in body temperature is frequently observed in patients following ME administration. Nevertheless, the impact of this fever on the effectiveness of therapy is unknown. Therefore, we aimed to investigate the effect of fever-range temperatures on ME-treated breast cancer cells and macrophages. The cells were simultaneously stimulated with ME and subjected to fever-range hyperthermia (FRH; 39 °C or 41 °C). After co-treatment, the cell viability, generation of reactive oxygen species (ROS), cell cycle distribution, and production of pro-inflammatory factors (interleukin (IL)-1β, IL-6, and cyclooxygenase (COX)-2) were evaluated. The results showed that the exposure of ME-treated breast cancer cells to FRH at 39 °C resulted in a slight decrease in their viability, whereas FRH of 41 °C enhanced this effect. Only FRH of 41 °C induced minor changes in ROS level in ME-treated breast cancer cell lines. In ME-treated macrophages, FRH stimulated cell proliferation. The cell cycle distribution analysis showed a difference between cells cultured at 39 °C and 41 °C in all examined cell lines. Moreover, hyperthermia at 41 °C completely inhibited the ME-induced increase in IL-1β and IL-6 expression in MCF-7 breast cancer cells, whereas this effect was not observed in 4T1 breast cancer cells. In contrast, in ME-treated macrophages, FRH of 41 °C strongly up-regulated expression of the pro-inflammatory factors. We conclude that fever is an important component of ME therapy that differentially affects cancer and immune cells.

Anthroposophic Medicine: A Short Monograph and Narrative Review-Foundations, Essential Characteristics, Scientific Basis, Safety, Effectiveness and Misconceptions

INTRODUCTION

Anthroposophic medicine is a form of integrative medicine that originated in Europe but is not well known in the US. It is comprehensive and heterogenous in scope and remains provocative and controversial in many academic circles. Assessment of the nature and potential contribution of anthroposophic medicine to whole person care and global health seems appropriate.

METHODS

Because of the heterogenous and multifaceted character of anthroposophic medicine, a narrative review format was chosen. A Health Technology Assessment of anthroposophic medicine in 2006 was reviewed and used as a starting point. A Medline search from 2006 to July 2020 was performed using various search terms and restricted to English. Books, articles, reviews and websites were assessed for clinical relevance and interest to the general reader. Abstracts of German language articles were reviewed when available. Reference lists of articles and the author's personal references were also consulted.

RESULTS

The literature on anthroposophic medicine is vast, providing new ways of thinking, a holistic view of the world, and many integrating concepts useful in medicine. In the last ∼20 years there has been a growing research base and implementation of many anthroposophical concepts in the integrated care of patients. Books and articles relevant to describing the foundations, scientific status, safety, effectiveness and criticisms of anthroposophic medicine are discussed.

DISCUSSION

An objective and comprehensive analysis of anthroposophic medicine finds it provocative, stimulating and potentially fruitful as an integrative system for whole person care, including under-recognized life processes and psychospiritual aspects of human beings. It has a legitimate, new type of scientific status as well as documented safety and effectiveness in some areas of its multimodal approach. Criticisms and controversies of anthroposophic medicine are often a result of lack of familiarity with its methods and approach and/or come from historically fixed ideas of what constitutes legitimate science.

Mistletoe in oncological treatment: a systematic review : Part 1: survival and safety

PURPOSE

Mistletoe treatment of cancer patients is discussed highly controversial in the scientific literature. Aim of this systematic review is to give an extensive overview about current state of research concerning mistletoe therapy of oncologic patients regarding survival, quality of life and safety.

METHODS

In September and October 2017 Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL and "Science Citation Index Expanded" (Web of Science) were systematically searched.

RESULTS

The search strategy identified 3647 hits and 28 publications with 2639 patients were finally included in this review. Mistletoe was used in bladder cancer, breast cancer, other gynecological cancers (cervical cancer, corpus uteri cancer, and ovarian cancer), colorectal cancer, other gastrointestinal cancer (gastric cancer and pancreatic cancer), glioma, head and neck cancer, lung cancer, melanoma and osteosarcoma. In nearly all studies, mistletoe was added to a conventional therapy. Patient relevant endpoints were overall survival (14 studies, n = 1054), progression- or disease-free survival or tumor response (10 studies, n = 1091). Most studies did not show any effect of mistletoe on survival. Especially high quality studies do not show any benefit.

CONCLUSIONS

With respect to survival, a thorough review of the literature does not provide any indication to prescribe mistletoe to patients with cancer.

Ribosome-Inactivating Proteins from Plants: A Historical Overview

This review provides a historical overview of the research on plant ribosome-inactivating proteins (RIPs), starting from the first studies at the end of eighteenth century involving the purification of abrin and ricin, as well as the immunological experiments of Paul Erlich. Interest in these plant toxins was revived in 1970 by the observation of their anticancer activity, which has given rise to a large amount of research contributing to the development of various scientific fields. Biochemistry analyses succeeded in identifying the enzymatic activity of RIPs and allowed for a better understanding of the ribosomal machinery. Studies on RIP/cell interactions were able to detail the endocytosis and intracellular routing of ricin, thus increasing our knowledge of how cells handle exogenous proteins. The identification of new RIPs and the finding that most RIPs are single-chain polypeptides, together with their genetic sequencing, has aided in the development of new phylogenetic theories. Overall, the biological properties of these proteins, including their abortifacient, anticancer, antiviral and neurotoxic activities, suggest that RIPs could be utilized in agriculture and in many biomedical fields, including clinical drug development.

A Review of Integrative Medicine in Gynaecological Oncology

In recent years complementary and alternative medicine (CAM) has increasingly been the focus of international research. Numerous subsidised trials (7903) and systematic reviews (651) have been published, and the evidence is starting to be integrated into treatment guidelines. However, due to insufficient evidence and/or insufficient good quality evidence, this has mostly not translated to practice recommendations in reviews by the Cochrane collaboration gynaecology group. There is nevertheless a not insignificant number of CAM providers and users. The percentage of oncology patients who use CAM varies between 5 and 90 %. Doctors have been identified as the main providers of CAM. Half of gynaecologists offer CAM because of personal conviction or on suggestion from colleagues. This must be viewed in a critical light, since CAM is mostly practiced without appropriate training, often without sufficient evidence for a given method - and where evidence exists, practice guidelines are lacking - and lack of safety or efficacy testing. The combination of patient demand and lucrativeness for doctors/alternative medicine practitioners, both based on supposed effectiveness CAM, often leads to its indiscriminate use with uncertain outcomes and significant cost for patients. On the other hand there is published, positive level I evidence for a number of CAM treatment forms. The aim of this article is therefore to review the available evidence for CAM in gynaecological oncology practice. The continued need for research is highlighted, as is the need to integrate practices supported by good evidence into conventional gynaecological oncology.

Preclinical and clinical effects of mistletoe against breast cancer

Breast cancer is among the most frequent types of cancer in women worldwide. Current conventional treatment options are accompanied by side effects. Mistletoe is amongst the important herbal medicines traditionally used as complementary remedies. An increasing number of studies have reported anticancer activity of mistletoe extracts on breast cancer cells and animal models. Some recent evidence suggests that cytotoxic activity of mistletoe may be mediated through different mechanisms. These findings provide a good base for clinical trials. Various studies on mistletoe therapy for breast cancer patients revealed similar findings concerning possible benefits on survival time, health-related quality of life (HRQoL), remission rate, and alleviating adverse reactions to conventional therapy. This review provides an overview of the recent findings on preclinical experiments and clinical trials of mistletoe for its cytotoxic and antitumor activity and its effect on HRQoL in breast cancer patients. Moreover, studies investigating molecular and cellular mechanisms underlying antitumor activity of mistletoe are discussed in this paper. The analyzed trials provided evidence that there might be a combination of pharmacological and motivational aspects mediated by the mistletoe extract application which may contribute to the clinical benefit and positive outcome such as improved HRQoL and self-regulation in breast cancer patients.

Adverse events associated with complementary and alternative medicine use in ovarian cancer patients

INTRODUCTION

Many women with ovarian cancer are choosing to include complementary and alternative medicine (CAM) substances in conjunction with their conventional treatment for ovarian cancer. Many oncologists express concern that the adjunct use of CAM substances may be detrimental to the achievement of therapeutic levels of chemotherapy leading to increases in drug toxicity, under-treatment of disease or other adverse events. In an effort to ascertain the extent of the potential problem with simultaneous use of CAM with conventional treatment we undertook comprehensive systematic review of published case reports describing CAM-related adverse events among ovarian cancer patients.

STUDY DESIGN

This article describes a systematic literature review.

METHODS

The Natural Medicines Comprehensive Database (NMCD). PubMed, EMBASE® and the Cochrane Central Register of Controlled Trials (CCTR) were systematically reviewed for research articles pertaining to case reports describing adverse events in patients, and clinical trials which examined the effects of herbs and supplements used during cancer treatment.

RESULTS

Only one case report and one clinical trial were identified which met our inclusion criteria and were relevant to the current investigation.

CONCLUSION

Although there are concerns about the potential for adverse events related to concurrent use of CAM substances during conventional treatment we found few case reports and clinical trials in the literature which support this.

Sedative, antiepileptic and antipsychotic effects of Viscum album L. (Loranthaceae) in mice and rats

ETHNOPHARMACOLOGICAL RELEVANCE

Viscum album L. is claimed in traditional medical practice, to be useful in the treatment of epilepsy and insomnia in Himachal Pradesh, India.

MATERIALS AND METHODS

The effect of Viscum album L. on epilepsy, psychosis and sedative activity was evaluated in mice and rats using standard procedure.

RESULTS

The aqueous leaf extract of Viscum album L. prolonged the pentobarbital induced sleeping time and reduced the locomotor activity in actophotometer. This suggests that reduced locomotor activity facilitate GABAergic transmission. In addition the extract reduced MES, INH and PTZ-induced convulsions which suggest that there may be possibility of blocking Na(+) channels, opening of Cl(-) channels or enhancing the GABAergic system. The extract decreased the apomorphine-induced stereotyped behavior and potentiates the HAL-induced cataleptic score which suggests the extract possess antidopaminergic activity.

CONCLUSION

The results obtained in present study suggested that title plant exhibited sedative, antiepileptic and antipsychotic activity in mice and rats.

Viscum album L. extracts in breast and gynaecological cancers: a systematic review of clinical and preclinical research

BACKGROUND

Viscum album L. extracts (VAE, European mistletoe) are a widely used medicinal plant extract in gynaecological and breast-cancer treatment.

METHODS

Systematic review to evaluate clinical studies and preclinical research on the therapeutic effectiveness and biological effects of VAE on gynaecological and breast cancer. Search of databases, reference lists and expert consultations. Criteria-based assessment of methodological study quality.

RESULTS

19 randomized (RCT), 16 non-randomized (non-RCT) controlled studies, and 11 single-arm cohort studies were identified that investigated VAE treatment of breast or gynaecological cancer. They included 2420, 6399 and 1130 patients respectively. 8 RCTs and 8 non-RCTs were embedded in the same large epidemiological cohort study. 9 RCTs and 13 non-RCTs assessed survival; 12 reported a statistically significant benefit, the others either a trend or no difference. 3 RCTs and 6 non-RCTs assessed tumour behaviour (remission or time to relapse); 3 reported statistically significant benefit, the others either a trend, no difference or mixed results. Quality of life (QoL) and tolerability of chemotherapy, radiotherapy or surgery was assessed in 15 RCTs and 9 non-RCTs. 21 reported a statistically significant positive result, the others either a trend, no difference, or mixed results. Methodological quality of the studies differed substantially; some had major limitations, especially RCTs on survival and tumour behaviour had very small sample sizes. Some recent studies, however, especially on QoL were reasonably well conducted. Single-arm cohort studies investigated tumour behaviour, QoL, pharmacokinetics and safety of VAE. Tumour remission was observed after high dosage and local application. VAE application was well tolerated. 34 animal experiments investigated VAE and isolated or recombinant compounds in various breast and gynaecological cancer models in mice and rats. VAE showed increase of survival and tumour remission especially in mice, while application in rats as well as application of VAE compounds had mixed results. In vitro VAE and its compounds have strong cytotoxic effects on cancer cells.

CONCLUSION

VAE shows some positive effects in breast and gynaecological cancer. More research into clinical efficacy is warranted.

Immunologic effector mechanisms of a standardized mistletoe extract on the function of human monocytes and lymphocytes in vitro, ex vivo, and in vivo

Even though mistletoe extracts have been in clinical use for centuries their exact mode of action is still unknown. Currently, the application scheme for registered preparations is a dose-escalating scheme to thus reduce side effects. In this study, healthy controls and patients were evaluated for their immunologic response to treatment with a standardized mistletoe extract (Iscador). It shows a strong effect as adjuvant that induces TNF-alpha and IL-12, which was partly mediated via CD14. Desensitization of the TNF-alpha response could be shown after repeated application in vitro and in vivo. Furthermore, Iscador induces a specific lymphocyte sensitization upon multiple injections and production of IgG1- and IgG3 -mistletoe antibodies. Remarkably, a systemic bystander effect (heterologous immunity against other recall antigens) was observed after long-term treatment. In conclusion, dose-escalation reduces the monocyte-related clinical side effects. A T-lymphocyte sensitization stimulates mainly a specific Th1 response. The most interesting clinical long-term effect is the bystander stimulation of various memory T cells that might mediate in vivo antitumor and antiinfectious T-cell response under mistletoe-extract immunization.

Anaphylaxis to viscotoxins of mistletoe (Viscum album) extracts

BACKGROUND

Extracts of mistletoe (Viscum album) are used in many countries for adjuvant cancer therapy. These extracts contain mistletoe lectins and viscotoxins that are supposed to have immunostimulating and cytotoxic effects, respectively. The treatment is usually well tolerated.

OBJECTIVE

To report a case of severe anaphylaxis secondary to mistletoe extract administration with demonstrable anti-IgE antibodies to mistletoe.

METHODS

Skin prick tests, basophil histamine release, basophil activation test, and immunoblotting were performed to characterize the pathophysiology of this reaction.

RESULTS

The patient had immediate-type skin prick test reactions to the whole commercial preparation and to its mistletoe extract component. A histamine release test and a flow cytometric basophil activation test performed with the patient's peripheral blood leukocytes by incubation with the mistletoe extract yielded a concentration-dependent histamine release and expression of the activation marker gp53 in up to 98% of anti-IgE-positive cells. Immunoblotting revealed IgE binding to 5-kDa proteins of mistletoe in the patient's serum, which corresponds to the molecular weight of viscotoxins. The results of all these tests were negative in controls.

CONCLUSIONS

Until now, anaphylaxis to mistletoe extracts has been only rarely reported. In our patient, viscotoxin specific IgE evidently had induced an anaphylactic reaction.

Abnoba-viscum (mistletoe extract) in metastatic colorectal carcinoma resistant to 5-fluorouracil and leucovorin-based chemotherapy

A phase II trial was designed to determine whether mistletoe extract can induce objective tumor response in patients with metastatic colorectal cancer resistant to 5-fluorouracil and leucovorin (5FU/LCV)-based chemotherapy. Twenty-five patients (15 female, 10 male; median age 69 yr) were treated with commercially available mistletoe extract (Abnoba-viscum Quercus) given by three weekly subcutaneous injections with daily dose gradually increased from 0.15 to 15 mg plant extract. Treatment was discontinued if unacceptable toxicity developed or if the patient became bedridden. Median duration of treatment was 14 wk (range, 4-66 wk). Treatment was continued in 14 patients until they became bedridden, and 11 patients decided to discontinue the treatment after their illness progressed. Objective tumor response was not seen in any of the 25 patients (0%, 95% confidence interval 0-13.7%). Stable disease, lasting for a median of 2.5 mo (range, 1.5-7 mo), was noted in 21 (84%) patients. Median survival was 5.5 mo and symptomatic relief was reported by 10 (40%) patients. Toxicity was mild and included mainly local inflammatory reaction. In conclusion, mistletoe extract does not seem to be active in metastatic colorectal cancer resistant to 5FU/LCV in terms of objective tumor response.