ALTERNATIVE NAMES: ARECA NUT, BETAL, BETEL NUT, CHAVICA BETAL, HMARG, MAAG, MARG, PAAN, PAN MASALA, PAN PARAG, PINANG, SUPAI

Taxonomic Class

Arecaceae

Common Trade Names

No known U.S. manufacturers. Betel nuts are sold under various names in ethnic grocery stores in the United States.

Common Forms

Available as betel nuts, oil, and raw leaves.

Source

Betel palm is derived from the raw and sweetened leaves and nuts of Areca catechu, a member of the Arecaceae (Palmae) family. The plant is native to India, China, Indonesia, Sri Lanka, the Philippines, and various parts of Southeast Asia and Africa.

Chemical Components

Several compounds have been identified in leaf and nut extract: arecaidine, arecaine, arecolidine, arecoline (an alkaloid related to tobacco alkaloids such as nicotine), betel-phenol, guvacine, and phenolic compounds. A volatile oil from the leaves contains allylpyrocatechol, cadinene, chaibetol, and chavicol.

Actions

Arecoline, a parasympathomimetic (cholinergic) and sympathomimetic

agent, produces CNS and respiratory stimulation, elevated temperatures, and facial flushing. It also exerts mild psychoactive properties. Betel-phenol and chavicol are counterirritants and salivary stimulants. The dichloromethane fraction from A. catechu was found to inhibit MAO-A in the CNS of rats .

Reported Uses

Only three drugs (caffeine, ethanol, and nicotine) are consumed more widely than betel. About 200 million people throughout the western Pacific basin, Southeast Asia, India, and Indonesia chew betel nuts and leaves. Betel is used as a mild stimulant and digestive aid. An oily extract of leaves that contain phenolic compounds is claimed to be useful for respiratory symptoms and as a gargle for sore throats and cough. Arecoline is a veterinary anthelmintic and cathartic.

Dosage

The betel nut is generally sweetened with lime (calcium hydroxide), wrapped in the leaf of the betel vine, and chewed, similar to the American habit of chewing tobacco. Chewing the “quid;’ as the chewing of betel nuts is called, can take as long as 15 minutes. Users may chew as many as 15 quids daily. Chewing betel leaves and betel nuts releases a highly variable quantity of arecoline.

Adverse reactions

CNS: CNS stimulation.

CV: facial flushing.

EENT: gingivitis, periodontitis (with prolonged use), red staining of teeth and oral cavity (with prolonged use).

Musculoskeletal: resorption of oral calcium and osteomyelitis (dentition; with prolonged use; related to lime) .

Respiratory: exacerbation of asthma.

Other: fever.

Interactions

Alcoholic beverages, tobacco chewing: Increased risk of oral cancer. Avoid use with betel palm.

Antiglaucoma drugs: May increase or decrease effects. Monitor use of betel palm products in patients taking antiglaucoma drugs. Avoid administration with betel palm.

Atropine, propranolol: Abolishes temperature-elevating effects and increases CNS effects of arecoline. Avoid administration with betel palm .

Beta blockers, calcium channel blockers, digoxin: May increase heart rate-reducing effects. Avoid administration with betel palm.

MAO inhibitors, foods that contain tyramine (such as aged wine and cheese): Increased risk of hypertensive crisis. Discourage using together.

Contraindications And Precautions

Arecaidine use, arecoline use, and betel chewing are contraindicated in patients who are prone to developing oral leukoplakia, fibrosis, or cancer, particularly cancer of the esophagus and squamous cell carcinoma. Avoid using betel palm products in pregnant or breast-feeding patients .

Special Considerations

Ask the patient of Asian or Indian descent regarding his use of this product; betel chewing may be a habit considered innocuous to him.

When betel is chewed, there is copious production of blood-red saliva that can stain teeth and the oral mucosa. After years of chewing, the teeth can become stained reddish brown to black.

Alert Betel chewing may increase one’s risk of developing type 2 diabetes. This was determined from examining anthropometric testing and glycemic control of 993 Bangladeshis .

Alert Diarrhea, dizziness, nausea, seizures, and vomiting (with excessive chewing) similar to toxicity experienced from excessive nicotine use may occur .

Monitor the patient for signs and symptoms of excessive autonomic stimulation, including blurred vision, bradycardia, cold sweats, constipation, cramps, diarrhea, fasciculations, GI stimulation, hallucinations, hypersalivation, hypertension, hyperthermia (sympathomimetic), miosis, mydriasis, pallor, tachycardia, voluntary muscle paralysis, and vomiting. The patient may present with a wide variety of these symptoms.

Alert Caution the patient about the risk of oral and esophageal cancers with prolonged oral use. In a large retrospective study, Pan masala (commercial preparation of areca nuts, lime, catechu, and other undisclosed ingredients) chewing has been directly linked to the development of oral submucous fibrosis, a premalignant state of the oral mucous membrane .

Caution the patient at risk for developing diabetes that betel ingestion may increase the risk.

Advise women to avoid using betel products during pregnancy or when breast-feeding.

Commentary

Betel nut chewing in Asia and Indonesia has been compared with tobacco and alcohol use in the West; the substances are legal but potentially harmful. Chronic betel chewing may increase a persons risk of certain oral cancers and type 2 diabetes. An effort has been made in Canada to outlaw the importation of betel products but has been met with resistance . As with tobacco, there appears to be no appropriate medicinal use for betel.