Echinacea-associated anaphylaxis

Diagnostic Workup in IgE-Mediated Allergy to Asteraceae Weed Pollen and Herbal Medicine Products in Europe

Anemophilous weeds from the Asteraceae family are highly allergenic and represent a significant source of aeroallergens in late summer and autumn. Ragweed and mugwort pollen allergies have become a significant health burden in Europe. Some people with respiratory allergies to weed pollen may also suffer hypersensitivity reactions to herbal medicines obtained from certain cross-reactive plants in the Compositae family, such as chamomile, marigold, and purple coneflower. General physicians, ear, nose, and throat (ENT) specialists, and pulmonologists need to be familiar with the diagnostic tests used by allergists in clinical practice to support accurate diagnosis in such patients. Allergists must also be aware of the suggestions of the European Medicines Agency (EMA)'s Herbal Medicinal Products Committee and the broad spectrum of herbal therapies to educate their patients about potential risks.

Assessment of clinical chemistry and hematological parameters in female Sprague-Dawley rats following a 7-day oral exposure to three different species of Echinacea

Echinacea has grown in popularity due to its broad therapeutic benefits. Despite its popularity, comprehensive safety evaluations for three medicinal species are limited. In this study, female Sprague-Dawley rats received oral doses (0, 25, 50, 100, 200 mg/kg/d) of 75% (v/v) ethanol extract from the aerial parts of 9 Echinacea samples of three species - Echinacea purpurea, Echinacea angustifolia, and Echinacea pallida - over a 7-day period. Blood and serum samples, collected twenty-four hours post the final dose, were analyzed for hematology and clinical chemistry parameters. The results revealed varied effects across the tested samples, with many parameters showing no discernible impacts at administered doses. Subtle alterations were observed in parameters such as relative liver weight, alkaline phosphatase (ALP), and platelet count. Parameters like relative spleen weight, alanine transaminase (ALT), glucose, urea, hematocrit, hemoglobin, and RBC count exhibited effects in only one out of the nine samples tested. These findings emphasize the heterogeneity in the effects of Echinacea. While the results suggest that Echinacea samples might be considered relatively safe, potential clinical implications warrant caution and underscore the importance of extended testing. A comprehensive toxicity profile assessment remains paramount to conclusively ascertain the safety of three Echinacea species.

Echinacea in hepatopathy: A review of its phytochemistry, pharmacology, and safety

BACKGROUND

Echinacea, one of the most popular herbs with double function of immunity and anti-inflammatory activity, has now attracted much interest for a possible alternative for the treatment of hepatopathy. This review is aimed at providing a comprehensive overview of Echinacea regarding its chemical composition, pharmacological action against various hepatopathy, and safety.

METHODS

A comprehensive search of published articles was conducted to focus on original publications related to Echinacea and hepatopathy till the end of 2020 using various literature databases, including China National Knowledge Infrastructure, PubMed, and Web of Science database.

RESULTS

Echinacea exhibited excellent activities in resisting a variety of hepatopathy induced by different causes in preclinical experiments and clinical trials by regulating cell proliferation and apoptosis, antioxidant defense mechanism, voltage-gated sodium channels, lipid metabolism, circadian rhythm, p38 MAPK signaling pathway, JNK signaling pathway, Nrf2/HO-1 signaling pathway, PI3K/AKT signaling pathway, and Akt/GSK3 beta signaling pathways. The high efficacy of Echinacea is related to its immunomodulatory and anti-inflammatory activities. The main ingredients of Echinacea include caffeic acid derivatives, alkylamides, and polysaccharides, which have been well established in preclinical studies of liver diseases. Studies on acute and subacute toxicity show that Echinacea preparations are well-tolerated herbal medicines.

CONCLUSION

Echinacea may offer a novel potential strategy for clinical prevention and treatment of liver diseases and related diseases. Extensive studies are necessary to identify the underlying mechanisms and establish future therapeutic potentials of this herb. Well-designed clinical trials are still warranted to confirm the safety and effectiveness of Echinacea for hepatopathy.

The effects of immunostimulatory herbal supplements on autoimmune skin diseases

The use of herbal supplements that promise to improve immune health has gained popularity among dermatology patients. However, there is little to no evidence that herbal supplements improve dermatologic conditions. Several in vitro and in vivo studies have shown that Spirulina platensis, Aphanizomenon flos-aqua, Chlorella, Echinacea, and alfalfa activate immune cells via certain cytokines and chemokines. Case reports suggest the association of ingesting immunostimulatory herbs and the clinical onset or flares of diseases characterized by an exaggerated immune response such as lupus erythematosus, dermatomyositis, and autoimmune blistering disorders. Therefore, it is imperative to investigate the prevalence of herbal supplement use in this patient population. In addition, in vitro studies should examine the underlying mechanisms by which herbs stimulate immune pathways that are already overactive in autoimmune patients.

An analysis of Echinacea chloroplast genomes: Implications for future botanical identification

Echinacea is a common botanical used in dietary supplements, primarily to treat upper respiratory tract infections and to support immune function. There are currently thought to be nine species in the genus Echinacea. Due to very low molecular divergence among sister species, traditional DNA barcoding has not been successful for differentiation of Echinacea species. Here, we present the use of full chloroplast genomes to distinguish between all 9 reported species. Total DNA was extracted from specimens stored at the National Museum of Natural History, Smithsonian Institution, which had been collected from the wild with species identification documented by experts in the field. We used Next Generation Sequencing (NGS) and CLC Genomics Workbench to assemble complete chloroplast genomes for all nine species. Full chloroplasts unambiguously differentiated all nine species, compared with the very few single nucleotide polymorphisms (SNPs) available with core DNA barcoding markers. SNPs for any two Echinacea chloroplast genomes ranged from 181 to 910, and provided robust data for unambiguous species delimitation. Implications for DNA-based species identification assays derived from chloroplast genome sequences are discussed in light of product safety, adulteration and quality issues.

Commonly Used Dietary Supplements on Coagulation Function during Surgery

BACKGROUND

Patients who undergo surgery appear to use dietary supplements significantly more frequently than the general population. Because they contain pharmacologically active compounds, dietary supplements may affect coagulation and platelet function during the perioperative period through direct effects, pharmacodynamic interactions, and pharmacokinetic interactions. However, in this regard, limited studies have been conducted that address the pharmacological interactions of dietary supplements. To avoid possible bleeding risks during surgery, information of potential complications of dietary supplements during perioperative management is important for physicians.

METHODS

Through a systematic database search of all available years, articles were identified in this review if they included dietary supplements and coagulation/platelet function, while special attention was paid to studies published after 1990.

RESULTS

Safety concerns are reported in commercially available dietary supplements. Effects of the most commonly used natural products on blood coagulation and platelet function are systematically reviewed, including 11 herbal medicines (echinacea, ephedra, garlic, ginger, ginkgo, ginseng, green tea, kava, saw palmetto, St John's wort, and valerian) and 4 other dietary supplements (coenzyme Q₁₀, glucosamine and chondroitin sulfate, fish oil, and vitamins). Bleeding risks of garlic, ginkgo, ginseng, green tea, saw palmetto, St John's wort, and fish oil are reported. Cardiovascular instability was observed with ephedra, ginseng, and kava. Pharmacodynamic and pharmacokinetic interactions between dietary supplements and drugs used in the perioperative period are discussed.

CONCLUSIONS

To prevent potential problems associated with the use of dietary supplements, physicians should be familiar with the perioperative effects of commonly used dietary supplements. Since the effects of dietary supplements on coagulation and platelet function are difficult to predict, it is prudent to advise their discontinuation before surgery.

Steviol glycoside safety: are highly purified steviol glycoside sweeteners food allergens?

Steviol glycoside sweeteners are extracted from the plant Stevia rebaudiana (Bertoni), a member of the Asteraceae (Compositae) family. Many plants from this family can induce hypersensitivity reactions via multiple routes of exposure (e.g., ragweed, goldenrod, chrysanthemum, echinacea, chamomile, lettuce, sunflower and chicory). Based on this common taxonomy, some popular media reports and resources have issued food warnings alleging the potential for stevia allergy. To determine if such allergy warnings are warranted on stevia-based sweeteners, a comprehensive literature search was conducted to identify all available data related to allergic responses following the consumption of stevia extracts or highly purified steviol glycosides. Hypersensitivity reactions to stevia in any form are rare. The few cases documented in the peer-reviewed literature were reported prior to the introduction of high-purity products to the market in 2008 when many global regulatory authorities began to affirm the safety of steviol glycosides. Neither stevia manufacturers nor food allergy networks have reported significant numbers of any adverse events related to ingestion of stevia-based sweeteners, and there have been no reports of stevia-related allergy in the literature since 2008. Therefore, there is little substantiated scientific evidence to support warning statements to consumers about allergy to highly purified stevia extracts.

Management of upper respiratory tract infections in children

Upper respiratory tract infection (URTI) occurs commonly in both children and adults and is a major cause of mild morbidity. It has a high cost to society, being responsible for absenteeism from school and work and unnecessary medical care, and is occasionally associated with serious sequelae. URTIs are usually caused by several families of virus; these are the rhinovirus, coronavirus, parainfluenza, respiratory syncytial virus (RSV), adenovirus, human metapneumovirus, influenza, enterovirus and the recently discovered bocavirus. This review will mainly focus on the rhinovirus, where significant advances have been made in understanding the epidemiology, natural history and relationship with other pathogens.

Alternative medicine and anesthesia: Implications and considerations in daily practice

Nowadays, herbal medicines are widely used by most of the people, including the pre-surgical population. These medicines may pose numerous challenges during perioperative care. The objective of the current literature review is to dwell upon the impact of the use of herbal medicines during the perioperative period, and to review the strategies for managing their perioperative use. The data was generated from various articles of different journals, text books, web source, including, Entrez Pubmed, Medscape, WebMD, and so on. Selected only those herbal medicines for which information on, safety, usage, and precautions during the perioperative period was available. Thereafter, the information about safety, pharmacokinetics, and pharmacodynamics from selected literature was gathered and analyzed. The whole review focused on the fact that these commonly used alternative medicines could sometimes pose as a concern during the perioperative period, in various ways. These complications could be due to their direct action, pharmacodynamic effect, or pharmacokinetic effect. In view of the serious impacts of herbal medicine usage in perioperative care, the anesthesiologist should take a detailed history, especially stressing on the use of herbal medicine during the preoperative anesthetic assessment. The anesthesiologist should also be aware of the potential perioperative effects of those drugs. Accordingly, steps should to be taken to prevent, recognize, and treat the complications that may arise due to their use or discontinuation.

Herbs-are they safe enough? an overview

Drugs based on herbs have become a common form of therapy as well as for prophylaxis because they are often perceived as being natural and therefore harmless. Today they are one of the hottest trends and most sought after in the field of nutrition or herbal therapeutics. As the use of complementary medicine grows, so does the knowledge that many compounds in common use not only have a significant effect on the body but may also interact with pharmaceuticals and also with other alternative products. Concurrent use of herbs with drugs may mimic, magnify, or oppose the effect of drugs leading to herb-drug interactions. Currently, there is very little information published on herb-herb or herb-drug interactions as compared to the use of herbs which is progressively growing across the world. Many reports of herb-drug interactions are sketchy and lack laboratory analysis of suspect preparations. Health-care practitioners should caution patients against mixing herbs and pharmaceutical drugs. The article reviews the recent literature on the adverse effects of herbal remedies including the most widely sold herbal medicinal products, like liquorice, garlic, ginger, green tea, and turmeric, etc., and reinforce the safety aspect of herbal products, which are considered to be relatively safe by common people.

Hypereosinophilia associated with echinacea use

Echinacea, believed by herbal practitioners to enhance the immune system, is one of the most widely used herbal supplements in the United States. Like most herbal products, it lacks strict FDA regulation and more information is needed about its potential adverse reactions. Here, we report the case of a patient with eosinophilia of unclear etiology whose condition resolved after cessation of this supplement. We feel this likely represents an IgE-mediated allergic process to echinacea.

The use of complementary and alternative medicine by patients attending a general otolaryngology clinic: can we afford to ignore it?

BACKGROUND

There is growing interest in use of complementary and alternative medicine (CAM) among the general population. Little information is available, however, on CAM use in adults attending an otolaryngology outpatient clinic in the UK.

OBJECTIVE

The purpose of this article is to study the prevalence and pattern of CAM use among adult patients attending the ear, nose, and throat (ENT) clinic in a UK teaching hospital.

STUDY DESIGN

A cross-sectional study was used.

SUBJECTS AND METHODS

All patients on their primary visit to an ENT clinic were asked to complete an anonymous questionnaire for a 14-week period from October 2005 to January 2006.

RESULTS

Based on 1366 completed questionnaires, 53% (728/1366) were female and 47% (638/1366) were male. Twenty-nine percent (395/1366) were older than 60 years, and 56% (763/1366) were married. Twenty percent (275/1366) had a university education. Sixty-one percent (833/1366) had used CAM, almost 36% in the preceding 12 months. The popular remedies were cod liver oil (368/833), garlic (197/833), cranberry (181/833), aloe vera (176/833), primrose oil (174/833), and Echinacea (163/833). Nonherbal therapies included massage (230/833), acupuncture (186/833), aromatherapy (135/833), chiropractic (121/833), reflexology (119/833), and homeopathy (110/833). Seventeen percent (143/833) used CAM for their current illness. Only 8% (64/833) found CAM ineffective; yet, 57% (473/833) would recommend CAM to others. Fifty-one percent (421/833) failed to inform their primary physician of their CAM use.

CONCLUSION

Despite concerns over CAM efficacy, safety, and cost effectiveness, use of CAM is popular among patients attending an ENT clinic. Their use is not generally related to their presenting illness. Otolaryngologists should be aware of current trends in CAM use when managing patients, including possible interactions with other medication.

Awareness of allergy patients about herbal remedies: a cross-sectional study of residents of Ankara, Turkey

OBJECTIVE

The use of herbs in patients with allergic diseases is a special problem and still controversial. The objective of this questionnaire-based study was to determine the rate of herbal use in allergy clinic outpatients as well as to explore patient knowledge.

METHODS

Patients with respiratory and/or skin disease, either atopic or non-atopic were assigned to a prospective questionnaire study conducted in allergy clinic outpatients.

RESULTS

Three hundred and ninety-five patients enrolled in the study. The mean age was 33.50+/-12.14 years. Participants generally had a high educational level (40.5% college and 39% university graduated). The rate of herbal use was 14.2%. All characteristics were similar within herbal user and non-user patients, except gender and age. The number of female patients who use herbal products was greater than for males (p=0.043). Herbal use was common in patients in their late thirties (p=0.024). Three main rationales for herbal use were revealed: (i) acting upon advice of someone (41.1%); (ii) the belief that "herbals are always more beneficial than chemicals" (37.5%); and (iii) the trust that "herbals are always safe" (21.4%). Most of the participants have "no idea" (41.5%) or are "not sure" (33.7%) about potential harmful effects of herbs to allergic people.

CONCLUSION

People will continue to use herbals for one reason or another. Allergists and clinical immunologists need to become more knowledgeable about herbal therapies so that they can inform patients about either the benefits or possible harmful effects of herbs.

Complementary and alternative medicine use by otolaryngology patients: a paradigm for practitioners in all surgical specialties

There is growing interest in complementary and alternative medicine (CAM) amongst the general population. Little information is available on CAM use in otolaryngology patients in the UK. Despite concerns over safety, efficacy and cost-effectiveness, CAM use is common amongst ENT patients. Patients perceive these medications as possible boosters to their immune system. It is becoming increasingly important that health care providers in all specialties ask their patients about CAM use and are aware of the implications it carries. The objective is to study the prevalence and pattern of CAM use among adult and paediatric ENT patients in a UK teaching hospital. A cross-sectional study was done by sending anonymous questionnaire to all outpatient and elective inpatients over a 3-month period. Response rate was 73% (1,789/2,440). Prominent demographics: female, married, over-50 s. Sixty percent had used CAM, 35% in last year. Most common herbs: cod liver oil (n = 481), garlic (n = 255), cranberry (n = 224); non-herbal: massage (n = 287), acupuncture (n = 233), aromatherapy (n = 170). Most commonly cited reasons for using CAM: general health, enhanced immunity and prevention/treatment of common illnesses like the common cold, asthma and bodily aches and pains.

Some commonly fed herbs and other functional foods in equine nutrition: A review

Most herbs and functional foods have not been scientifically tested; this is especially true for the horse. This paper reviews some of the literature pertinent to herbal supplementation in horses and other species. Common supplements like Echinacea, garlic, ginger, ginseng, and yucca are not regulated, and few studies have investigated safe, efficacious doses. Ginseng has been found to exert an inhibitory effect on pro-inflammatory cytokines and cyclooxygenase-2 expression. Equine studies have tested the anti-inflammatory effects of a single dose of ginger, post-exercise. Echinacea has been reported to have anti-inflammatory and antioxidant properties. Yucca contains steroid-like saponins, which produce anti-inflammatory, antioxidant, and anti-spasmodic effects. However, some herbs have drug-like actions that interact with dietary components and may contain prohibited substances like salicylates, digitalis, heroin, cocaine and marijuana. Horses fed garlic at >0.2g/kg per day developed Heinz body anaemia. Drug-herb interactions are common and caution needs to be taken when implementing 'natural product' usage.

Herbal products: active constituents, modes of action and quality control

An overview is given of the current position of medicinal herbs in general in relation to usage, market and production, types of pharmacological activity and how they differ from conventional drugs. The increasing importance of quality and manufactured products is also discussed. A more detailed consideration of these issues is given in relation to echinacea, valerian and St John's wort as these herbs are well studied, are market leaders and have widespread community usage.

The potential impact of the use of homeopathic and herbal remedies on monitoring the safety of prescription products

The purpose of this paper is to explore the possibility that adverse reactions and drug interactions arising from the use of homeopathic and herbal medicines could lead to confusion when adverse reactions to conventional medicines are reported. An extensive literature review was conducted on the occurrence of adverse reactions and drug interactions following the use of homeopathic or herbal remedies, and the potential for these to confound adverse event reporting to conventional medicines considered. The survey demonstrates the potential for herbal remedies and homeopathic products, to produce adverse drug reactions or drug interactions, and shows the scope for potential for confusion with those arising from conventional medicines. There is a need for greater awareness that adverse reactions apparently due to a conventional medicine, might in reality be due to a herbal medicine or a drug interaction between a herbal medicine and a conventional drug, particularly when a health professional is unaware of the extent of a patient's self-medication with alternative therapies.

The safety of herbal medicinal products derived from Echinacea species: a systematic review

Echinacea spp. are native to North America and were traditionally used by the Indian tribes for a variety of ailments, including mouth sores, colds and snake-bites. The three most commonly used Echinacea spp. are E. angustifolia, E. pallida and E. purpurea. Systematic literature searches were conducted in six electronic databases and the reference lists of all of the papers located were checked for further relevant publications. Information was also sought from the spontaneous reporting programmes of the WHO and national drug safety bodies. Twenty-three manufacturers of echinacea were contacted and asked for data held on file. Finally our own departmental files were searched. No language restrictions were imposed. Combination products and homeopathic preparations were excluded. Data from clinical studies and spontaneous reporting programmes suggest that adverse events with echinacea are not commonly reported. Gastrointestinal upsets and rashes occur most frequently. However, in rare cases, echinacea can be associated with allergic reactions that may be severe. Although there is a large amount of data that investigates the efficacy of echinacea, safety issues and the monitoring of adverse events have not been focused on. Short-term use of echinacea is associated with a relatively good safety profile, with a slight risk of transient, reversible, adverse events. The association of echinacea with allergic reactions is supported by the present evaluation. While these reactions are likely to be rare, patients with allergy or asthma should carefully consider their use of echinacea. The use of echinacea products during pregnancy and lactation would appear to be ill-advised in light of the paucity of data in this area.

Herbal remedies in gastroenterology

Complementary and alternative medicine (CAM) is presently not considered to be part of conventional medicine. Nevertheless, an estimated 51% of patients with gastrointestinal disorders have tried some from of CAM. Indeed, 10% of alternative medicines are being used for digestive symptoms. After prayer or spiritual healing, herbal medicine is the second most common CAM therapy. While herbal products make numerous health-related claims, those that have been systematically evaluated are unfortunately few. The modern gastroenterologist must be up to date with the regulations, side effects, and possible benefits of specific herbal products used in patients with gastrointestinal disorders.

Defining complementary and alternative medicine in allergies and asthma: benefits and risks

In this review, the current literature discussing complementary/alternative medicine (CAM) interventions, the prevalence and pattern of use, examples of specific modalities and the risks of CAM for asthma and atopic disease are discussed. The specific risks of CAM interventions associated with the use of these modalities, omission of traditional therapeutic modalities, and the liability risk for physicians who either provide or counsel their patients regarding CAM interventions are also discussed.

Ocular side effects from herbal medicines and nutritional supplements

PURPOSE

To review the more significant herbal and nutritional agents of clinical importance to ophthalmologists and describe the ocular side effects for each. World Health Organization (WHO) classification and guidelines for clinicians are provided.

DESIGN

Retrospective observational case series.

METHODS

A retrospective observational case series of reports of ocular side effects or systemic side effects from medications used for the eye from herbal medicines and nutritional supplements. Cases were collected from spontaneous reports submitted to the WHO, the Food and Drug Administration, and the National Registry of Drug-Induced Ocular Side Effects. A review of the world's literature was performed to obtain additional case reports and insight into adverse ocular reactions. Data were collected on age, gender, duration of therapy, concomitant medications, dosage, and dechallenge and rechallenge results.

RESULTS

The National Registry of Drug-Induced Ocular Side Effects received 263 spontaneous reports, in addition to 60 case reports from the literature. Canthaxanthine, chamomile, Datura, Echinacea purpurea, Ginkgo biloba, licorice, niacin, and vitamin A are all associated with clinically significant ocular side effects.

CONCLUSION

Herbal medicines and nutritional supplements can cause ocular side effects. Clinicians need to recognize these adverse events, because a large segment of the population uses them, many times without the treating physician's knowledge.

Cytokine production by non-adherent mouse splenocyte cultures to Echinacea extracts

BACKGROUND

Echinacea is commonly used in oral dosage as an immune stimulant to increase resistance to viral, bacterial and fungal infections of the upper respiratory tract. It has been suggested that Echinacea is able to stimulate innate immune responses, including those regulated by macrophages and natural killer cells. Indeed, macrophages respond to purified polysaccharide and alkylamide preparations. However, the mechanisms for stimulation of cells responsible for adaptive immunity have not been fully elucidated for other molecules present in Echinacea purpurea preparations.

METHODS

Adherent and non-adherent mouse splenocyte populations were incubated in vitro with Echinacea, or with water or alcohol soluble Echinacea extract preparations. Supernatants were collected at 48-h post-incubation, and tested by standard ELISA for presence of secreted cytokines and proinflammatory mediators.

RESULTS

Whole splenocyte populations were capable of producing significant amounts IL-6 (1014 pg/ml) in response to Echinacea preparations. The response was primarily contained towards products isolated to the water extract preparation; no IL-6 was produced upon challenge with the alcohol extract. The IL-6 response was produced by the non-adherent cellular population, which made 4912 pg/ml IL-6 when treated with water soluble extract at 1 mg/ml. Likewise, the water soluble extract of Echinacea was able to stimulate non-adherent splenocyte populations to produce TNF-alpha (2082 pg/ml), IL-10 (892 pg/ml) and MIP-1alpha (6486 pg/ml) from non-adherent splenocytes, but only significant concentrations of TNF-alpha and MIP-1alpha mediators were produced from adherent populations at similar dose concentrations. Neither population of splenocytes was capable of stimulating significant production of IFN-gamma, IL-2 or IL-12 to any preparation of Echinacea examined.

CONCLUSIONS

The immune stimulatory ability of components contained within E. purpurea extracts offer insight into possible therapeutic potential of this product to regulate non-adherent lymphocytes in immune responses and activation events.

Regulation of human immune gene expression as influenced by a commercial blended Echinacea product: preliminary studies

Consumption of Echinacea at the first sign of symptoms has been clinically shown to reduce both the severity and duration of cold and flu. Quantitative polymerase chain reaction optimized for precision and reproducibility was utilized to explore in vitro and in vivo changes in the expression of immunomodulatory genes in response to Echinacea. In vitro exposure of THP-1 cells to 250 microg/ml of Echinacea species extracts induced expression (up to 10-fold) of the interleukin-1alpha, interleukin-1beta, tumor necrosis factor-alpha, intracellular adhesion molecule, interleukin-8, and interleukin-10 genes. This preliminary result is consistent with a general immune response and activation of the nonspecific immune response cytokines. In vivo gene expression within peripheral leukocytes was evaluated in six healthy nonsmoking subjects (18-65 years of age). Blood samples were obtained at baseline and on Days 2, 3, 5, and 12 after consuming a commercial blended Echinacea product, three tablets three times daily (1518 mg/day) for two days plus one additional dose (506 mg) on day three. Serum chemistry and hematological values were not different from baseline, suggesting that liver or bone marrow responses were not involved in acute responses to Echinacea. The overall gene expression pattern at 48 hr to 12 days after taking Echinacea was consistent with an antiinflammatory response. The expression of interleukin-1beta, tumor necrosis factor-alpha, intracellular adhesion molecule, and interleukin-8 was modestly decreased up through Day 5, returning to baseline by day 12. The expression of interferon-alpha steadily rose through Day 12, consistent with an antiviral response. These preliminary data present a gene expression response pattern that is consistent with Echinacea's reported ability to reduce both the duration and intensity of cold and flu symptoms.

Enhancement of the Humoral Immune Response byEchinacea purpureain Female Swiss Mice

Various preparations of the plant Echinacea purpurea have been investigated for their potential to enhance immune function, primarily through activation of innate immune responses. Few studies have examined the potential for enhancement of humoral immunity. Using female Swiss mice we administered a volumetric dose of a glycerine extract of E. purpurea by oral gavage, to evaluate effects on the IgM specific antibody forming cell (AFC) response. Four days of treatment following immunization with sheep red blood cells (SRBC) produced a significant enhancement over naive controls at doses of 0.4 and 0.8 mL/kg/day. A few clinical trials and anecdotal reports have suggested that the greatest efficacy for E. purpurea occurs in acute use following onset of illness. A time course study, using the time of SRBC immunization to mimic the onset of illness, examined the effects of 8 and 4 days of E. purpurea treatment at 0.6 mL/kg/day. Only in the 4-day administration, with dosing beginning 1 hour after SRBC immunization, was there an observed enhancement of the antibody forming cell response. This supports the acute use of E. purpurea as suggested by anecdotal reports, and demonstrates the potential for enhancement of humoral immune responses as well as innate immune responses.

Side-effects of complementary and alternative medicine

Complementary and alternative medicine are increasingly used to diagnose or treat allergic diseases, and numerous studies have reported benefits of this type of medicine. This article presents a review of the literature on risks of these methods. The potential sensitizing capacity of numerous herbal remedies may lead to allergic contact dermatitis and more rarely to IgE-mediated clinical symptoms. Mechanical injuries may be observed following acupuncture leading to pneumothorax, cardiac tamponade or spinal injury. Infectious complications after acupuncture include hepatitis and bacterial endocariditis. Organ toxicity has been observed associated with various herbal preparations involving the liver, kidneys, and the heart. Some herbs may have cancerogenic properties. Severe nutritional deficiencies can occur in infants and small children given strict alternative diets, resembling 'kwashiorkor'. Finally, among other miscellaneous adverse effects, adulteration with steroids, and herbal and drug interactions are discussed. The pattern of side-effects is similar to that observed by the use of conventional medicine. Therefore, caution may be justified using both conventional and unconventional methods. Only if the benefit is proven and the side-effects are established, should a given method be chosen.

Herbs commonly used by women: an evidence-based review

OBJECTIVE

To review the evidence of herbs commonly used by women.

DATA SOURCES

Articles were located by searching Medline, Cochrane Database of Systemic Reviews, and the Combined Health Information Database and by hand searching the reference lists of recent systematic reviews. The databases were searched in January 2000 and October 2000 by using the Latin and common name of each herb.

METHODS OF STUDY SELECTION

Preference was given to randomized, placebo-controlled trials. When available, English language studies were reviewed. If not, data are presented from review articles that summarize the foreign study.

RESULTS

Many women use herbal therapies. In the United States, herbs are considered dietary supplements. The Food and Drug Administration (FDA) cannot remove them from the market unless they are proven unsafe. The herb industry plans to improve monitoring. Many prospective randomized controlled trials are being funded. Gingko biloba seems to slow the progression of dementia but increases the risk of bleeding. St John's Wort is efficacious for treating mild to moderate depression but has many drug interactions. Ginseng seems to improve well being in perimenopausal women, but it is often impure and has side effects and drug interactions. Garlic slightly lowers blood pressure and lipids. Echinacea slightly decreases the duration of colds but does not prevent them. Valerian is beneficial for insomnia, but there is no long-term safety data. Black cohosh may help the symptoms of perimenopause, and chasteberry may improve premenstrual syndrome. More study is needed on both herbs.

CONCLUSION

Some herbs are medically useful, but the American public would benefit from increased regulation. Manufacturers should be able to ensure that herbs contain pure ingredients. Side effects and drug interactions should be listed. Well-designed studies are being conducted. The results will be helpful to physicians and patients when the clinical evidence becomes available.

Medicinal properties of Echinacea: a critical review

Preparations from Echinacea purpurea are among the most widely used herbal medicines. Most uses of E. purpurea are based on the reported immunological properties. A series of experiments have demonstrated that E. purpurea extracts do indeed demonstrate significant immunomodulatory activities. Among the many pharmacological properties reported, macrophage activation has been demonstrated most convincingly. Phagocytotic indices and macrophage-derived cytokine concentrations have been shown to be Echinacea-responsive in a variety of assays. Activation of polymorphonuclear leukocytes and natural killer cells has also been reasonably demonstrated. Changes in the numbers and activities of T- and B-cell leukocytes have been reported, but are less certain. Despite this cellular evidence of immunostimulation, pathways leading to enhanced resistance to infectious disease have not been described adequately. Several dozen human experiments--including a number of blind randomized trials--have reported health benefits. The most robust data come from trials testing E. purpurea extracts in the treatment for acute upper respiratory infection. Although suggestive of modest benefit, these trials are limited both in size and in methodological quality. Hence, while there is a great deal of moderately good-quality scientific data regarding E. purpurea, effectiveness in treating illness or in enhancing human health has not yet been proven beyond a reasonable doubt.

Contact sensitization from Compositae-containing herbal remedies and cosmetics

The Compositae (Asteraceae) family of plants is currently an important cause of allergic plant contact dermatitis in Europe. The family comprises some of the oldest and most valued medicinal plants, and the increasing popularity of herbal medicine and cosmetics may theoretically result in a growing number of Compositae sensitizations from these sources. According to the literature at least 15 species, including among others arnica (Arnica montana), German and Roman chamomile (Chamomilla recutita and Chamaemelum nobile), marigold (Calendula officinalis), Echinacea and elecampane (Inula helenium), have been suspected of sensitization or elicitation of Compositae dermatitis. Epidemiological data are available for 2 species only, arnica and German chamomile, the rest of the evidence being anecdotal. Based on this, sensitization seems to occur relatively frequently with a few species such as arnica and elecampane, and occurs rarely with the majority, especially the widely used German chamomile. Sesquiterpene lactones are the most important allergens, but there are a few cases of sensitization from a coumarin, a sesquiterpene alcohol and a thiophene. The risk of elicitation of dermatitis by using Compositae-containing products in Compositae-sensitive individuals is by-and-large unknown.

Dietary supplements

The amount of published information on dietary supplements mushroomed in the 1990s. In fewer than 5 years, publications increased at least 100-fold in the medical literature alone. Dietary supplements are an uncharted territory that warrants complete and accurate exploration. One should not be surprised that disease and illness may respond to dietary supplements. Nutrition is the foundation to good health, and dietary supplements may prove to be some of the most powerful medicines ever discovered. An especially exciting discovery is that dietary supplements may enhance the effects of specific drugs. This discovery may lead to more effective and safer protocols for the treatment of cancer, heart and lung disease, and a host of chronic medical conditions. Information about dietary supplements is becoming more common in the popular medical literature and is creating increased curiosity and an increased awareness. The explosion of the dietary supplement market is compelling physicians to become aware of dietary supplements. Whether or not they are used in clinical practice is a decision for the individual physician. Given the increasing number of patients who are using dietary supplements, however, it is imperative that physicians have a good understanding of this topic. Considering the increasing complexity and magnitude of this topic, physician specialization may be essential. There are many good reference books, review articles, and internet sites on specific supplements that probably should be part of every physician's reference library. The accompanying box provides a brief list of such sources.

Adverse reactions associated with echinacea: the Australian experience

BACKGROUND

Fifty percent of Australians use complementary and alternative medicines (other than vitamins) in any 12-month period, of which echinacea-containing products are increasingly popular. Recent reports have highlighted the risk of allergic reactions to complementary medicines in atopic patients.

OBJECTIVE

To determine the characteristics of adverse reactions linked to use of the popular herbal remedy echinacea.

METHODS

Five privately referred patients were evaluated by the authors in their office practice via skin prick testing (SPT) on the volar aspect of the forearm and radioallergosorbent test after adverse reactions to echinacea. As there was little published information on adverse reactions to echinacea, reports to the Australian Adverse Drug Reactions Advisory Committee were reviewed. Those suggestive of possible allergic reactions were evaluated in greater detail by anonymously surveying the healthcare professionals who had reported the cases and from one unreported case. Serum was collected for further analysis where possible.

RESULTS

Five cases of adverse reactions to echinacea were personally evaluated by the authors. Two patients suffered anaphylaxis and a third had an acute asthma attack 10 minutes after their first ever dose of echinacea. The fourth patient suffered recurrent episodes of mild asthma each time echinacea was ingested, and the fifth developed a maculopapular rash within 2 days of ingestion which recurred when rechallenged. Three of the patients had positive SPT results. Three reported repeated spontaneous "challenges" and symptoms after further ingestion of echinacea. Fifty-one Australian adverse drug reports implicating echinacea were also reviewed. There were 26 cases suggestive of possible immunoglobulin E-mediated hypersensitivity (4 anaphylaxis, 12 acute asthma, 10 urticaria/angioedema). Of these 26 patients, age ranged from 2 to 58 years, 78% were female and >50% were known to be atopic. Four were hospitalized, 4 reacted after their first known exposure, and 1 patient suffered multiple progressive systemic reactions. Twenty percent of 100 atopic subjects who had never taken echinacea also had positive SPT results to this substance when tested by one of the authors in his office practice.

CONCLUSION

Some atopic subjects have positive SPT results to echinacea in the absence of known exposure. Atopic subjects are also overrepresented in those experiencing reactions to echinacea. The possibility that cross-reactivity between echinacea and other environmental allergens may trigger allergic reactions in "echinacea-naïve" subjects is supported by the Australian data. Given its widespread (and largely unsupervised) community use, even rare adverse events become inevitable. Atopic patients should be cautioned appropriately.

Multiple immune functions in rats fed Echinacea extracts

This study evaluated acquired-immune functions representing the three major branches of the immune system in male rats fed a commercially available echinacea product. An additional comparison of effects on antibody formation in male and female rats was done using the commercial echinacea product and two echinacea tinctures marketed by local herbalists. In initial testing, we found no evidence of altered natural killer cell activity, T cell-mediated delayed-type hypersensitivity, or specific antibody formation in male rats given either a 225 mg/kg or 50 mg/kg of the commercial echinacea for 6 weeks. Antibody formation was significantly suppressed in female but not male rats given 250 mg/kg for 2 weeks of the commercial echinacea. The local products tested had no effect on antibody formation. We concluded that our study provided no supporting evidence for immunostimulatory activity by the echinacea preparations we examined and, in fact, may be immunosuppressive under some conditions.

Should we be concerned about herbal remedies

During the latter part of this century the practice of herbalism has become mainstream throughout the world. This is due in part to the recognition of the value of traditional medical systems, particularly of Asian origin, and the identification of medicinal plants from indigenous pharmacopeias that have been shown to have significant healing power, either in their natural state or as the source of new pharmaceuticals. Generally these formulations are considered moderate in efficacy and thus less toxic than most pharmaceutical agents. In the Western world, in particular, the developing concept that 'natural' is better than 'chemical' or 'synthetic' has led to the evolution of Neo-Western herbalism that is the basis of an ever expanding industry. In the US, often guised as food, or food supplements, known as nutriceuticals, these formulations are readily available for those that wish to self-medicate. Within this system, in particular, are plants that lack ethnomedical verification of efficacy or safety. Unfortunately there is no universal regulatory system in place that insures that any of these plant remedies are what they say they are, do what is claimed, or most importantly are safe. Data will be presented in this context, outlining how adulteration, inappropriate formulation, or lack of understanding of plant and drug interactions have led to adverse reactions that are sometimes life-threatening or lethal.

The use of dietary supplements in pediatrics: a study of echinacea

Alternative medical therapies are commonly used and have increased in popularity. Although patients may not always disclose the use of alternative therapies, they may seek advice regarding their use, especially for children. Regulation and standardization of these modalities, especially botanicals, is incomplete. The University of Arizona has initiated a study of the use of echinacea in the prevention of recurrent otitis media. A review of echinacea preparations was undertaken, and this report discusses the complexities surrounding the use of this dietary supplement. The number and diversity of echinacea preparations are detailed; the role of the physician as "botanical" advisor to patients and families is examined.

Recurrent erythema nodosum associated with Echinacea herbal therapy

We report a case of recurrent erythema nodosum that is temporally and perhaps causally associated with use of echinacea herbal therapy. The genus Echinacea is traditionally used as an immunostimulant in the prophylaxis and treatment of upper respiratory tract infections. In vitro and in vivo studies of echinacea administration in animal and human-derived models suggest a definite stimulatory effect on the cellular immune system, although the clinical impact of echinacea is still unknown. The public's increasing use of alternative and complementary therapies necessitates that dermatologists be familiar with the cutaneous adverse effects of these agents.

Adverse effects of herbal drugs in dermatology

Herbal treatments are becoming increasingly popular, and are often used for dermatological conditions. Thus dermatologists should know about their potential to cause adverse events. This review is aimed at addressing this area in a semisystematic fashion. Some agents, particularly Chinese herbal creams, have been shown repeatedly to be adulterated with corticosteroids. Virtually all herbal remedies can cause allergic reactions and several can be responsible for photosensitization. Some herbal medicines, in particular Ayurvedic remedies, contain arsenic or mercury that can produce typical skin lesions. Other popular remedies that can cause dermatological side-effects include St John's Wort, kava, aloe vera, eucalyptus, camphor, henna and yohimbine. Finally, there are some herbal treatments used specifically for dermatological conditions, e.g. Chinese oral herbal remedies for atopic eczema, which have the potential to cause systemic adverse effects. It is concluded that adverse effects of herbal medicines are an important albeit neglected subject in dermatology, which deserves further systematic investigation.

Inflammation and Native American medicine: the role of botanicals

There is a growing interest in medicinal botanicals as part of complementary medicine in the United States. In particular, both physicians and consumers are becoming aware of the use of herbals by Native American societies; many botanicals sold today as dietary supplements in the United States were used by Native Americans for similar purposes. Yet, these supplements represent only a small number of the >2500 different plant species from vascular taxa, and >2800 species from all taxa, known to have been prized for their medicinal properties by the indigenous inhabitants of the North American continent. We review some of the studies of the immunomodulatory activities of botanicals used by native peoples of North America, the bioactive constituents responsible for those activities, and the mechanisms by which these constituents might modulate the immune system. We focus particularly on 3 species of purple coneflower (ECHINACEA:) because of the widespread use of purple coneflower in the United States to boost immunity and prevent upper respiratory infections. Seven of the 10 most common botanicals sold in the United States were used extensively by Native Americans. However, there are very few data to support such use and even less information about drug toxicity or interactions.