Taxonomic Class

Juglandaceae

Common Trade Names

None known.

Common Forms

Available as a decoction, an extract, and a tincture and used externally as a bath additive and a compress.

Source

The leaves of the deciduous tree (Juglans regia), the bark, the hull of the nut, and the nut itself have been used for various preparations.

Chemical Components

The leaves contain about 10% tannins of the ellagitannin type; naphthalene derivatives, especially the monoglucosides of juglone (=5- hydroxy-1,4-naphtholquinone) and hydrojuglone; more than 3% flavonoids (such as quercetin, quercitrin, hyperoside, and kaempferol derivatives); 0.8% to 1% ascorbic acid, plant acids, including gallic, caffeic, and neochlorogenic acids; and 0.001 % to 0.03% volatile oil, mainly germacrene D. The main active components are the tannins and juglone.

Actions

J. regia is mainly used externally as an astringent, based on its tannin content (10%). Juglone and the essential oils may have in vitro antifungal activity and, possibly, antitumorigenic effects in mice. The actual nut has been studied as a substitute (replacing 20% to 35% of monounsaturated fat foods) in cholesterol-lowering diets with success in further reducing total cholesterol and LDL levels in human subjects .

Reported Uses

Walnut preparations have been used externally for acne, eczema, eyelid inflammation, excessive perspiration of the hands and feet, pyodermia, tuberculosis, and various skin ulcers. It has been used internally for catarrhs of the GI tract and as an anthelmintic and a blood-purifying agent.

Dosage

Dosing is highly dependent on various factors. Because no standard production exists, dosage ranges must be viewed as relative guidelines.

External: 3 to 6 g/day; 100 g per full bath.

Extracts: 2 to 3 g P.O. once to several times a day.

Tincture: 1 to 3 ml P.O. once to several times a day.

Adverse Reactions

Hepatic: hepatotoxicity (caused by tannin content).

Other: carcinogenic effects (potential with long-term use of J. regia as an external preparation).

Interactions

None reported.

Contraindications and Precautions

Excessive oral ingestion and topical application of walnuts should be avoided in pregnant or breast-feeding patients.

Special Considerations

• Caution the patient who is at risk for heptatotoxicity about ingesting considerable quantities of walnut because the tannin content may increase the risk of hepatic injury.
• Advise the patient who is looking for a natural agent to reduce serum cholesterol levels to pursue more stringently studied and proven alternatives.
• Inform the patient that walnut preparations that contain juglone compounds can discolor the skin or mucous membranes yellowish brown.
• Caution the patient that daily topical application of walnut preparations may increase the risk of tongue cancer and leukoplakia of the lips.

Commentary

Little, if any, evidence exists other than in vitro studies to support most of the claims for the use of walnut. Larger human trials are needed to demonstrate its effectiveness in hypercholesterolemic men and Women. More research is needed before definitive recommendations can be put forward.

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Taxonomic class

Rosaceae

Common Trade Names

Alvita Teas Hawthorne Berry, Cardio Health Hawthorne Berry #6 Syrup, Cardiplant, Gaia Herbs Hawthorn Berry A/F, Gaia Herbs Hawthorn Berry Solid, Gaia Herbs Hawthorn Supreme, Gaia Herbs Hawthorn Supreme SFSE, Hawthorne Berry, Hawthorne Formula, Hawthorne Heart, Hawthorne Phytosome, Hawthorne Power, Heart Foods Company Hawthorne plus, Heart Foods Company Power Caps Hot Cayenne with Hawthorne and Ginger, Herbalist and Alchemist Hawthorn-Cactus Extract, Herbalist and Alchemist Hawthorn­Fruit/Flower Extrac, Natrol Hawthorne Berry Capsules, Nature’s Answer Hawthorne Berry Low Alcohol, Nature’s Answer Hawthorne C+ Combo, Standardized Full Potency Hawthorne Berry Extract Vegicaps

Common Forms

Available as biological extracts (4 mg/ml of vitexin-2-0-rhamnoside); capsules of berries (510 mg) or leaves (80 mg) standardized to 15 mg of oligomeric procyanidines; and extended-release capsules (300 mg of 1.8% vitexin-2-rhamnoside and hyperoside).

Source

Active ingredients are extracted from the berries, flowers, and leaves of

Crataegus species, commonly C. laevigata, C. monogyna, or C. folium. More than 300 Crataegus species are found in the temperate regions of North America, Asia, and Europe.

Chemical components

Hawthorn is composed primarily of proanthocyanidins and flavonoids (quercetin, hyperoside, vitexin, vitexinrhamnoside, rutin); other constituents include catechin and epicatechin.

Actions

Studies on animals and in vitro models have suggested CV actions that

include ACE inhibition, beta-blocking activity, dilation of coronary arteries, hypotensive effects, and negative and positive inotropic effects. The high bioflavonoid content in some hawthorn species may show antioxidant activity and be cardioprotective in experimental ischemic animal models; the extracts decreased myocardial oxygen consumption and left ventricular work . Prophylactic antiarrhythmic potential has also been shown in rabbits that received aconitine. Mild CNS depressant effects have been documented for the hawthorn flower extract.

Reported Uses

Claims for hawthorn surround its use in arteriosclerosis, Buerger’s disease, heart failure, hypertension, and paroxysmal tachycardia. It may be therapeutically useful in the treatment of New York Heart Association (NYHA) functional class II (mild to moderate) heart failure. Patients with this class of heart failure who received a daily dose of 600 mg of hawthorn extract showed significant clinical improvement over an 8­week period .

Hawthorn, either alone or with coenzyme Q10, was found to be beneficial and also compared favorably to captopril for patients with heart failure. Other studies have noted the herb’s usefulness in patients with stable angina pectoris .

Dosage

A dose of 160 to 900 mg of a standardized extract containing 2.2% flavonoids or 18.75% oligomeric procyanidines given P.O. b.i.d. or t.i.d. The amount of flavonoid (calculated as hyperoside) is 3.5 to 19.8 mg and that of procyanidins (as epicatechin) is 30 to 168.7 mg.

Adverse Reactions

CNS: fatigue, sedation (with high doses).

CV: arrhythmias and hypotension (with high doses).

GI: nausea.

Respiratory: respiratory failure (in animals).

Skin: sweating.

Interactions

Antihypertensives, nitrates: Increased risk of hypotension. Monitor blood pressure closely.

Cardiac glycosides: Increased effects of these drugs. Use cautiously.

CNS depressants: May cause additive effects. Use cautiously.

Contraindications and precautions

Hawthorn is contraindicated in patients who are hypersensitive to other members of the Rosaceae family and in pregnant or breast-feeding patients.

Special considerations

Monitor the patient for adverse CNS effects.

Instruct the patient to use hawthorn only under medical supervision.

Caution the patient to avoid hazardous activities until hawthorn’s CNS effects are known.

Inform the patient that other proven therapies for heart failure should be pursued before taking hawthorn.

Urge the patient to seek emergency medical treatment if he becomes short of breath or if pain occurs in the heart region and spreads to the arm, lower jaw, or upper abdomen.

Urge the patient who chooses to self-medicate to seek medical advice if symptoms continue for longer than 6 weeks.

Points of Interest

Germany’s Federal Institute for Drugs and Medical Devices has approved the use of hawthorn leaf with flower extracts in the treatment of NYHA functional class II heart failure. The extract of berries has not been approved because efficacy has not been shown.

Berry preparations are commonly advertised as a supplement to strengthen and invigorate the heart and circulatory system.

Commentary

Hawthorn has long been used for heart failure in Europe. Several foreign studies suggest that it may be effective in treating NYHA functional class II heart failure. Long-term studies using hawthorn that demonstrate prolonged survival are lacking. Future studies should focus on evaluating improvements in NYHA heart failure class, hospital admission rates, quality of life measurements, and whether hawthorn extracts have an effect on mortality.

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Taxonomic Class

Rutaceae

Common Trade Names

Multi-ingredient preparations: Jaborandi, Origin Hair and Scalp Therapy, Wonder Gel, X-Tablets

Common Corms

The leaves from the jaborandi tree are available as essential oil, fluidextract, a powder, and tincture. Combination products are found as gels and tablets. Pilocarpine, the main active ingredient, is available in many prescription products:

Ocular insert: 20 mcg, 40 mcg

Ophthalmic gel: 4%

Ophthalmic solution: 0.25%, 0.5%, 1 %,2%,3%,4%,5%,6%,8%, 10%

Tablets: 5 mg

Source

Pilocarpus, or jaborandi, consists of the leaves of Pilocarpus jaborandi (Pernambuco jaborandi), Pilocarpus microphyllus (Maranham jaborandi), or Pilocarpus pinnatifolius (Paraguay jaborandi). The plant is native to the northern and northeastern parts of Brazil.

Chemical Components

Three alkaloids are found in jaborandi: pilocarpine, pilocarpidine, and isopilocarpine. Also reported are jaborine, pilosine, volatile oils (including dipentene), and jaboric, pilocarpic, and tannic acids.

Actions

When applied topically to the eye, pilocarpine stimulates muscarinic receptors; this causes the pupil to constrict and the ciliary body to contract, thus improving the outflow of aqueous humor. Muscarinic alkaloids, when administered orally, stimulate the smooth muscles of the GI tract, increasing motility and tone. The tone and motility of other organs or organ systems (such as the ureter, bladder, gallbladder, and biliary ducts) may also be increased. Pilocarpine causes increased sweating and salivation in humans. It acts on the CV and respiratory systems as well (decreases blood pressure, heart rate, and vital capacity). In cats, pilocarpine has caused cortical stimulation .

Jaborine, a component found in the leaves, may actually be antagonistic to pilocarpine. Tannic acid has local astringent properties that act on the GI mucosa and has shown anti ulcerative and antisecretory effects within the GI tract.

Reported Uses

Although jaborandi has several reported uses, pilocarpine is usually extracted and used to stimulate saliva secretion or as a diaphoretic or myotic . Pilocarpine is primarily used to treat glaucoma or xerostomia. Other reported uses of the jaborandi plant include treatment of Bright’s disease, deafness, diabetes, edema, intestinal atony, jaundice, nausea, nephritis, pleurisy, psoriasis, rheumatism, syphilis, and tonsillitis. A decoction of the leaf applied locally has been used as a treatment for baldness.

Dosage

For glaucoma, 1 or 2 gtt applied t.i.d. or q.i.d. Refer to package insert for pilocarpine for specific dosing information.

For xerostomia, 15 to 30 mg P.O. daily; a dose of 100 mg P.O. is considered fatal.

The following daily doses have been suggested: powdered leaves, 5 to 60 grains (0.324 to 3.9 g); fluidextract, 10 to 30 gtt; tincture, Y, to 1 dram (1.75 to 3 ml).

Adverse Reactions

CNS: headache.

CV: bradycardia.

EENT: increased salivation, lacrimation, visual changes.

GI: nausea, vomiting.

Skin: sweating.

Interactions

Anticholinergics (atropine, ipratropium, scopolamine, other belladonna­type alkaloids): May decrease effects of these drugs. Avoid administration with jaborandi.

Beta blockers: May cause conduction problems. Monitor the patient.

Glycosides, iron-containing compounds, other alkaloids: Tannic acid may interact with these drugs. Do not use together.

Other prescription products containing pilocarpine, other muscarinic agonists (arecoline, methacholine, muscarine), cholinesterase inhibitors (do­nepezil, edrophonium, physostigmine): May have additive effect when used concomitantly. Use cautiously to avoid toxicity.

Contraindications And Precautions

Jaborandi is contraindicated in patients who are hypersensitive to pilocarpine and in those with uncontrolled asthma, acute iritis, and angleclosure glaucoma. Avoid use in pregnant or breast-feeding patients. Avoid large doses of jaborandi because hepatic injury can occur, especially in patients with preexisting hepatic disease. Use cautiously in patients with significant CV disease, biliary tract or urogenital abnormalities (cholelithiasis, nephrolithiasis), and preexisting cognitive or psychiatric disorders.

Special Considerations

Monitor intraocular pressure in patients at risk for glaucoma.

Monitor liver transaminase levels; if they increase, the product should be discontinued immediately.

Inform the patient that excessive sweating may lead to dehydration if fluids are not replenished.

Alert Signs of pilocarpine toxicity include exaggerated muscarinic effects. Extreme cases may lead to severe bronchospasm, hypotension, pulmonary edema, and shock. Treatment consists of atropine administration and general support of the CV and respiratory systems to counteract the effects from pulmonary edema .

Urge the patient to immediately report symptoms associated with pilocarpine toxicity (excessive sweating, lacrimation, increased salivation, nausea, vomiting, hypotension, and bradycardia) or hepatic dysfunction (fever, jaundice, and pain in right upper quadrant). Instruct him to discontinue use of the product if they occur.

Caution the patient that pilocarpine may cause visual changes, especiallyat night, which may impair his ability to drive.

Advise the pregnant or breast-feeding patient not to use jaborandi.

Commentary

The jaborandi tree is regarded as a source for pilocarpine. Much information exists about the use of pilocarpine for treating glaucoma and xerostomia. No human studies are available that support the use of jaborandi leaves for any medicinal purpose. Patients with glaucoma, xerostomia, or other potentially treatable conditions should seek medical advice because self-medication with jaborandi is not advised.

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Comfrey Herb Description - Drug Interactions, Dosage and Some of its Useful Properties

Taxonomic Class

Boraginaceae

Common Trade Names

Wise Woman Comfrey Salve. Several combination products are avail­able, including Alticort, Atri-Res, Black Ointment, C&F Formula, Comfrey/Aloe Capsules, Comfrey and Fenugreek, EB5 Footcare Formula, EB5 Toning Formula, #483 Oxox Cell Activator, Goldenseal Salve, H-Complex, Heal-All Salve, Kytta-Plasma f, Kytta-Salbe F, Liniment Virtue, Muco-Plex, Mucoplex, Mustard Salve, Pain-Less Rub, Plantain Salve, Procomfrin, Respa-Herb, Simicort, Super Salve, T­ANEM, T-ASMA, T-BC, T-BF, Traumaplant, T-SLC, and T-ULe.

Common Forms

Comfrey is available as a blended plant extract also known as “green drink,” homeopathic preparations, a poultice or liniment, a tea (dried leaf and whole root), and a topical cream or ointment and in bulk roots or leaves, capsules, elixir, mucilaginous decoctions, powder, and tincture. Pyrrolizidine alkaloid (PA)-free comfrey preparations are also available. Commercial root preparations are available, but they are not recommended for internal or external use because of their high concentration of PAs. Comfrey is available in combination products in veterinary medicine for topical treatment of muscle strains and ruptures and for oral administration as an antidiarrheal.

Source

An oil is extracted from the leaves and roots of Symphytum officinale, a member of the borage family. Comfrey is a perennial herb that grows in temperate regions, including western Asia, North America, and Australia.

Chemical Components

Comfrey contains a few compounds that show medicinal activity. Mucilage, a mucopolysaccharide of fructose and glucose, is concentrated in the root up to 29%. Allantoin, asparagine, beta-sitosterol, consolicine, consolidine, isobanerenol, lithospermic acid, PAs (up to 0.7% in dried root materials), rosmarinic acid, silicic acid, stigmasterol, symphytocynoglossin, tannins, and triterpenoids (including symphytoxide A) are also found in the plant.

Actions

Mucilage is reported to possess demulcent properties by forming a protective film to soothe irritation and inflammation. Allantoin is claimed to be a cell-growth stimulator, accounting for comfrey’s ability to stirn ulate wound healing and tissue regeneration. Tannin provides the as­tringent properties and rosmarinic acid imparts anti-inflammatory properties. The triterpenoid symphytoxide A is reported to possess hypotensive activity.

Reported Uses

The application of comfrey is limited to claims for healing wounds. Historically, comfrey was used for several internal ailments, such as ulcers of the bowel, stomach, liver, and gallbladder, but because the alkaloids are converted to toxic metabolites by liver enzymes after being ingested, internal use is no longer recommended.

External application of comfrey products is not considered as dangerous as oral administration. Externally, it is used for bruises and sprains and to promote bone healing.

The anti-inflammatory effects of comfrey were analyzed in 41 patients with musculoskeletal rheumatism. Twenty patients were treated with a PA-free ointment and the remainder received placebo for 4 weeks. Significant improvement was reported with the ointment compared with placebo in patients with epicondylitis and tendovaginitis, but no difference was found in patients with periarthritis .

Dosage

The oil from the leaves and roots can be incorporated in creams and ointments or used in a compress. Ointments and other external preparations are typically made with 5% to 20% comfrey. Comfrey should be applied topically on unbroken skin for less than 10 days or a maximum of 6 weeks per year in amounts at or below a daily dosage of 100 mcg of the unsaturated PAs.

Although comfrey has been used as a tea or taken in capsule form, it is not recommended for internal use because of its toxicity.

Adverse Reactions

CNS: chills, fever.

GI: abdominal pain, diarrhea, hematemesis, poor appetite, vomiting.

Hepatic: hepatotoxicity. exfoliative dermatitis, jaundice.

Other: weight loss, cancer (several animal studies report hepatocellular adenomas and urinary bladder tumors caused by PAs in comfrey death.

Interactions

Eucalyptus: May increase the risk of PA toxicity because of enzyme induction by eucalyptus. Avoid administration with comfrey.

Other PA-containing herbs: May increase risk of toxicity. Herbs that contain PAs include agrimony, alkanna, alpine ragwort, borage, colt’s foot, dusty miller, golden ragwort, goundsel, gravel root, ground’s tongue, hemp, petasties, and tansy ragwort. Avoid administration with comfrey.

Contraindications And Precautions

Internal use of comfrey is contraindicated because of hepatotoxicity. Because PAs are teratogenic and excreted in breast milk of animals, comfrey is contraindicated in pregnant or breast-feeding patients and in young children. It is also contraindicated in patients who are hypersensitive to comfrey and in those with a history of hepatic disease.

Special Considerations

Caution the patient not to use the root for medicinal purposes.

Instruct the patient to apply the mature leaves externally on intact skin for only a limited period; caution him not to use the leaves on open wounds.

Monitor wound appearance and size if the patient is taking comfrey to promote healing.

Assess for signs and symptoms of hepatotoxicity.

Comfrey either alone or in combination has been reported to cause abdominal pain, chills, death, diarrhea, exfoliative dermatitis, fever, hematemesis, jaundice, poor appetite, vomiting, and weight loss .

Alert Several studies report on hepatic veno-occlusive disease caused by PAs in the plant .

Caution the patient against consuming comfrey.

Advise the patient to try commercially available antiseptic ointments and creams before attempting to use comfrey to promote wound healing.

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

Points of Interest

Comfrey has been used since the time of the ancient Greeks and Romans. In the Middle Ages, it was commonly applied as a poultice for treating broken bones, giving rise to the common names of boneset, knitback, and knitbone.

The botanical genus name, Symphytum, originates from the Greek physician Disocorides some 2,000 years ago and is derived from the Greek word sympho, meaning to unite. The common name, comfrey, is derived from the Latin confirmare, which means to heal or unite.

Commentary

Although comfrey has a long history of therapeutic claims for several ailments, it is potentially hepatotoxic and thus should not be consumed. Anecdotal reports and animal studies suggest medicinal benefit for wound healing. Commercially available topical antiseptic agents are probably safer and more effective.

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