Who monographs on selected medicinal plants vol 1 - Farmacognosia (2025)

Prévia do material em texto

Bulbus Allii CepaeiWHOmonographson selectedmedicinal plantsVOLUME 1World Health OrganizationGeneva1999WHO monographs on selected medicinal plantsiiWHO Library Cataloguing in Publication DataWHO monographs on selected medicinal plants.—Vol. 1.1.Plants, Medicinal 2.Herbs 3.Traditional medicineISBN 92 4 154517 8 (NLM Classification: QV 766)The World Health Organization welcomes requests for permission to reproduce or translate itspublications, in part or in full. Applications and enquiries should be addressed to the Office ofPublications, World Health Organization, Geneva, Switzerland, which will be glad to provide thelatest information on any changes made to the text, plans for new editions, and reprints andtranslations already available.© World Health Organization 1999Publications of the World Health Organization enjoy copyright protection in accordance with theprovisions of Protocol 2 of the Universal Copyright Convention. All rights reserved.The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of the Secretariat of the World Health Organiza-tion concerning the legal status of any country, territory, city or area or of its authorities, orconcerning the delimitation of its frontiers or boundaries.The mention of specific companies or of certain manufacturers’ products does not imply that theyare endorsed or recommended by the World Health Organization in preference to others of asimilar nature that are not mentioned. Errors and omissions excepted, the names of proprietaryproducts are distinguished by initial capital letters.Designed by WHO GraphicsTypeset in Hong KongPrinted in Malta97/11795-Best-set/Interprint-6500Bulbus Allii CepaeiiiContentsAcknowledgements vIntroduction 1Monographs (in alphabetical order of plant name)Bulbus Allii Cepae 5Bulbus Allii Sativi 16Aloe 33Aloe Vera Gel 43Radix Astragali 50Fructus Bruceae 59Radix Bupleuri 67Herba Centellae 77Flos Chamomillae 86Cortex Cinnamomi 95Rhizoma Coptidis 105Rhizoma Curcumae Longae 115Radix Echinaceae 125Herba Echinaceae Purpureae 136Herba Ephedrae 145Folium Ginkgo 154Radix Ginseng 168Radix Glycyrrhizae 183Radix Paeoniae 195Semen Plantaginis 202Radix Platycodi 213Radix Rauwolfiae 221Rhizoma Rhei 231Folium Sennae 241Fructus Sennae 250Herba Thymi 259WHO monographs on selected medicinal plantsivRadix Valerianae 267Rhizoma Zingiberis 277AnnexParticipants in the WHO Consultation on Selected MedicinalPlants 288ContentsBulbus Allii CepaevAcknowledgementsSpecial acknowledgement is due to Professors Norman R. Farnsworth, HarryH. S. Fong, and Gail B. Mahady of the WHO Collaborating Centre for Tradi-tional Medicine, College of Pharmacy, University of Illinois at Chicago, USA,for drafting and revising the monographs.WHO also acknowledges with thanks the members of the advisory groupthat met in Beijing, China, in 1994, to draw up a list of medicinal plants forwhich monographs should be prepared, the more than 100 experts who pro-vided comments and advice on the draft texts, and those who participated inthe WHO Consultation held in Munich, Germany, in 1996 to review themonographs (see Annex). Finally, WHO would like to thank the Food andAgriculture Organization of the United Nations and the United Nations Indus-trial Development Organization for their contributions and all those whosubmitted comments through the World Self-Medication Industry, a nongov-ernmental organization in official relations with WHO.WHO monographs on selected medicinal plantsviBulbus Allii Cepae1IntroductionDuring the past decade, traditional systems of medicine have become a topic ofglobal importance. Current estimates suggest that, in many developing coun-tries, a large proportion of the population relies heavily on traditional practi-tioners and medicinal plants to meet primary health care needs. Althoughmodern medicine may be available in these countries, herbal medicines(phytomedicines) have often maintained popularity for historical and culturalreasons. Concurrently, many people in developed countries have begun to turnto alternative or complementary therapies, including medicinal herbs.Few plant species that provide medicinal herbs have been scientificallyevaluated for their possible medical application. Safety and efficacy data areavailable for even fewer plants, their extracts and active ingredients, and thepreparations containing them. Furthermore, in most countries the herbal medi-cines market is poorly regulated, and herbal products are often neither regis-tered nor controlled. Assurance of the safety, quality, and efficacy of medicinalplants and herbal products has now become a key issue in industrialized and indeveloping countries. Both the general consumer and health-care professionalsneed up-to-date, authoritative information on the safety and efficacy of medici-nal plants.During the fourth International Conference of Drug Regulatory Authorities(ICDRA) held in Tokyo in 1986, WHO was requested to compile a list ofmedicinal plants and to establish international specifications for the mostwidely used medicinal plants and simple preparations. Guidelines for the as-sessment of herbal medicines were subsequently prepared by WHO andadopted by the sixth ICDRA in Ottawa, Canada, in 1991.1 As a result ofICDRA’s recommendations and in response to requests from WHO’s MemberStates for assistance in providing safe and effective herbal medicines for usein national health-care systems, WHO is now publishing this first volumeof 28 monographs on selected medicinal plants; a second volume is inpreparation.Preparation of the monographsThe medicinal plants featured in this volume were selected by an advisorygroup in Beijing in 1994. The plants selected are widely used and important in1 Guidelines for the assessment of herbal medicines. In: Quality assurance of pharmaceuticals: acompendium of guidelines and related materials. Volume 1. Geneva, World Health Organization,1997:31–37.WHO monographs on selected medicinal plants2all WHO regions, and for each sufficient scientific information seemed availableto substantiate safety and efficacy. The monographs were drafted by the WHOCollaborating Centre for Traditional Medicine at the University of Illinois atChicago, United States of America. The content was obtained by a systematicreview of scientific literature from 1975 until the end of 1995: review articles;bibliographies in review articles; many pharmacopoeias—the International,African, British, Chinese, Dutch, European, French, German, Hungarian, Indian,and Japanese; as well as many other reference books.Draft monographs were widely distributed, and some 100 experts inmore than 40 countries commented on them. Experts included members ofWHO’s Expert Advisory Panels on Traditional Medicine, on the InternationalPharmacopoeia and Pharmaceutical Preparations, and on Drug Evaluation andNational Drug Policies; and the drug regulatory authorities of 16 countries.A WHO Consultation on Selected Medicinal Plants was held in Munich,Germany, in 1996. Sixteen experts and drug regulatory authorities fromMember States participated. Following extensive discussion, 28 of 31 draftmonographs were approved. The monograph on one medicinal plant was re-jected because of the plant’s potential toxicity. Two others will be reconsideredwhen more definitive data are available. At the subsequent eighth ICDRA inBahrain later in 1996, the 28 model monographs were further reviewed andendorsed, and Member States requested WHO to prepare additional modelmonographs.Purpose and content of the monographsThe purpose of the monographs is to:• provide scientific information on the safety, efficacy, and quality control/quality assurance of widely used medicinal plants, in order to facilitate theirappropriate use in MemberStates;• provide models to assist Member States in developing their own mono-graphs or formularies for these or other herbal medicines; and• facilitate information exchange among Member States.Readers will include members of regulatory authorities, practitioners of ortho-dox and of traditional medicine, pharmacists, other health professionals, manu-facturers of herbal products, and research scientists.Each monograph contains two parts. The first part consists of phar-macopoeial summaries for quality assurance: botanical features, distribution,identity tests, purity requirements, chemical assays, and active or major chemi-cal constituents. The second part summarizes clinical applications, pharmacol-ogy, contraindications, warnings, precautions, potential adverse reactions, andposology.In each pharmacopoeial summary, the Definition section provides the Latinbinomial pharmacopoeial name, the most important criterion in quality assur-ance. Latin pharmacopoeial synonyms and vernacular names, listed in theIntroductionBulbus Allii Cepae3sections Synonyms and Selected vernacular names, are those names used in com-merce or by local consumers. The monographs place outdated botanical no-menclature in the synonyms category, based on the International Rules ofNomenclature.For example, Aloe barbadensis Mill. is actually Aloe vera (L.) Burm. Cassiaacutifolia Delile and Cassia angustifolia Vahl., often treated in separate mono-graphs, are now believed to be the same species, Cassia senna L. Matricariachamomilla L., M. recutita L., and M. suaveolens L. have been used for many yearsas the botanical name for camomile. However, it is now agreed that the nameChamomilla recutita (L.) Rauschert is the legitimate name.The vernacular names listed are a selection of names from individual coun-tries worldwide, in particular from areas where the medicinal plant is in com-mon use. The lists are not complete, but reflect the names appearing in theofficial monographs and reference books consulted during preparation of theWHO monographs and in the Natural Products Alert (NAPRALERT) database (adatabase of literature from around the world on ethnomedical, biological andchemical information on medicinal plants, fungi and marine organisms, locatedat the WHO Collaborating Centre for Traditional Medicine at the University ofIllinois at Chicago).A detailed botanical description (under Description) is intended for qualityassurance at the stages of production and collection, whereas the detaileddescription of the drug material (under Plant material of interest) is for the samepurpose at the manufacturing and commerce stages. Geographical distribution isnot normally found in official compendia, but it is included here to provideadditional quality assurance information.General identity tests, Purity tests, and Chemical assays are all normalcompendial components included under those headings in these monographs.Where purity tests do not specify accepted limits, those limits should be set inaccordance with national requirements by the appropriate Member Stateauthorities.Each medicinal plant and the specific plant part used (the drug) containactive or major chemical constituents with a characteristic profile that can beused for chemical quality control and quality assurance. These constituents aredescribed in the section Major chemical constituents.The second part of each monograph begins with a list of Dosage forms and ofMedicinal uses categorized as those uses supported by clinical data, those usesdescribed in pharmacopoeias and in traditional systems of medicine, and thoseuses described in folk medicine, not yet supported by experimental or clinicaldata.The first category includes medical indications that are well established insome countries and that have been validated by clinical studies documented inthe world’s scientific literature. The clinical trials may have been controlled,randomized, double-blind studies, open trials, or well-documented observa-tions of therapeutic applications. Experts at the Munich Consultation agreed toinclude Folium and Fructus Sennae, Aloe, Rhizoma Rhei, and Herba EphedraeIntroductionWHO monographs on selected medicinal plants4in this category because they are widely used and their efficacy is well docu-mented in the standard medical literature.The second category includes medicinal uses that are well established inmany countries and are included in official pharmacopoeias or national mono-graphs. Well-established uses having a plausible pharmacological basis andsupported by older studies that clearly need to be repeated are also included.The references cited provide additional information useful in evaluating specificherbal preparations. The uses described should be reviewed by local expertsand health workers for their applicability in the local situation.The third category refers to indications described in unofficial pharma-copoeias and other literature, and to traditional uses. The appropriateness ofthese uses could not be assessed, owing to a lack of scientific data to support theclaims. The possible use of these remedies must be carefully considered in thelight of therapeutic alternatives.The final sections of each monograph cover Pharmacology (both experimentaland clinical); Contraindications such as sensitivity or allergy; Warnings; Precautions,including discussion of drug interactions, carcinogenicity, teratogenicity andspecial groups such as children and nursing mothers; Adverse reactions; andPosology.Use of the monographsWHO encourages countries to provide safe and effective traditional remediesand practices in public and private health services.This publication is not intended to replace official compendia such aspharmacopoeias, formularies, or legislative documents. The monographs areintended primarily to promote harmonization in the use of herbal medicineswith respect to levels of safety, efficacy, and quality control. These aspects ofherbal medicines depend greatly on how the individual dosage form is pre-pared. For this reason, local regulatory authorities, experts, and health workers,as well as the scientific literature, should be consulted to determine whether aspecific herbal preparation is appropriate for use in primary health care.The monographs will be supplemented and updated periodically as newinformation appears in the literature, and additional monographs will beprepared. WHO would be pleased to receive comments and suggestions, to thisend, from readers of the monographs.Finally, I should like to express our appreciation of the support providedfor the development of the monographs by Dr H. Nakajima and Dr F. S.Antezana during their time as Director-General and Assistant Director-General,respectively, of WHO.Dr Xiaorui ZhangMedical OfficerTraditional MedicineWorld Health OrganizationIntroductionBulbus Allii Cepae5Bulbus Allii CepaeDefinitionBulbus Allii Cepae is the fresh or dried bulbs of Allium cepa L. (Liliaceae) or itsvarieties and cultivars.SynonymsAllium esculentum Salisb., Allium porrum cepa Rehb. (1).Selected vernacular namesIt is most commonly known as “onion”. Basal, basl, cebolla, cebolla morada,cepa bulb, cepolla, cipolla, common onion, cu hanh, hom hua yai, hom khaao,hom yai, hu-t’sung, hu t’sung t’song, hua phak bhu, i-i-bsel, kesounni, khtim,Küchenzwiebel, l’oignon, loyon, Madras oignon, oignon, palandu, piyaj, piyaz,pyaz, pyaaz, ralu lunu, red globe onion, sibuyas, Spanish onion, tamanegi, umbibawang merah, vengayan, yellow Bermuda onion, white globe onion, Zwiebel(1–5).DescriptionA perennial herb, strong smelling when crushed; bulbs vary in size and shapefrom cultivar to cultivar, often depressed-globose and up to 20cm in diameter;outer tunics membranous. Stem up to 100cm tall and 30mm in diameter,tapering from inflated lower part. Leaves up to 40cm in height and 20mm indiameter, usually almostsemicircular in section and slightly flattened on upperside; basal in first year, in second year their bases sheathing the lower sixth ofthe stem. Spathe often 3-valved, persistent, shorter than the umbel. Umbel 4–9cm in diameter, subglobose or hemispherical, dense, many-flowered; pedicelsup to 40mm, almost equal. Perianth stellate; segments 3–4.5 � 2–2.5mm,white, with green stripe, slightly unequal, the outer ovate, the inner oblong,obtuse or acute. Stamens exserted; filaments 4–5mm, the outer subulate, theinner with an expanded base up to 2mm wide and bearing short teeth on eachside. Ovary whitish. Capsule about 5mm, 2n � 16 (6).Plant material of interest: fresh or dried bulbsGeneral appearanceMacroscopically, Bulbus Allii Cepae varies in size and shape from cultivar tocultivar, 2–20cm in diameter; flattened, spherical or pear-shaped; white orcoloured (7 ).WHO monographs on selected medicinal plants6Organoleptic propertiesOdour strong, characteristic alliaceous; taste strong; crushing or cutting the bulbstimulates lachrymation.Microscopic characteristicsThe external dried leaf scales of the bulbs show a large-celled epidermis withlightly spotted cell walls; the cells are elongated longitudinally. The underlyinghypodermis runs perpendicular to the epidermis and contains large calciumoxalate crystals bordering the cell walls. The epidermis of the fleshy leaf scalesresembles that of the dried leaf scales, and the epidermal cells on the dorsal sideare distinctly longer and more elongated than the epidermal cells on the ventralside. Large calcium oxalate crystals are found in the hypodermis; stomata rare;large cell nuclei conspicuous; and spiral vessel elements occur in the leaf meso-phyll (8).Powdered plant materialContains mainly thin-walled cells of the mesophyll with broken pieces of spiralvessel elements; cells containing calcium oxalate crystals are scarce (8).Geographical distributionBulbus Allii Cepae (“onion”) is probably indigenous to western Asia, but it iscommercially cultivated worldwide, especially in regions of moderate climate(1).General identity testsMacroscopic inspection, microscopic characteristics and microchemical exami-nation for organic sulfur compounds (9); and thin-layer chromatographic analy-sis for the presence of cysteine sulfoxides (10, 11).Purity testsMicrobiologyThe test for Salmonella spp. in Bulbus Allii Cepae products should be negative.The maximum acceptable limits of other microorganisms are as follows (12–14). Preparations for oral use: aerobic bacteria—not more than 105/g or ml;fungi—not more than 104/g or ml; enterobacteria and certain Gram-negativebacteria—not more than 103/g or ml; Escherichia coli—0/g or ml.Total ashNot more than 6% (3).Bulbus Allii Cepae7Acid-insoluble ashNot more than 1.0% (3).Water-soluble extractiveNot more than 5.0% (3).Alcohol-soluble extractiveNot more than 4.0% (3).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Bulbus Allii Cepae is not morethan 0.05mg/kg (14). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (12) and guidelines for predicting dietaryintake of pesticide residues (15).Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (12).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137 andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (12).Other purity testsChemical, foreign organic matter, and moisture tests to be established in accor-dance with national requirements.Chemical assaysAssay for organic sulfur constituents, cysteine sulfoxides and sulfides by meansof high-performance liquid chromatographic (16, 17) or gas–liquid chromato-graphic (18) methods, respectively. Quantitative levels to be established byappropriate national authority.Major chemical constituentsSulfur- and non-sulfur-containing chemical constituents have been isolatedfrom Bulbus Allii Cepae; the sulfur compounds are the most characteristic (1, 4,7).The organic sulfur compounds of Bulbus Allii Cepae, including thethiosulfinates, thiosulfonates, cepaenes, S-oxides, S,S�-dioxides, monosulfides,WHO monographs on selected medicinal plants8disulfides, trisulfides, and zwiebelanes occur only as degradation products ofthe naturally occurring cysteine sulfoxides (e.g. (�)-S-propyl-L-cysteine sulfox-ide). When the onion bulb is crushed, minced, or otherwise processed, thecysteine sulfoxides are released from compartments and contact the enzymealliinase in adjacent vacuoles. Hydrolysis and immediate condensation of thereactive intermediate (sulfenic acids) form the compounds as indicated below(1). The odorous thiosulphonates occur (in low concentrations) only in freshlychopped onions, whereas the sulfides accumulate in stored extracts or steam-distilled oils. Approximately 90% of the soluble organic-bound sulfur is presentas γ-glutamylcysteine peptides, which are not acted on by alliinase. Theyfunction as storage reserve and contribute to the germination of seeds. How-ever, on prolonged storage or during germination, these peptides are acted onby γ-glutamyl transpeptidase to form alk(en)yl-cysteine sulfoxides, which inturn give rise to other volatile sulfur compounds (1).Bulbus Allii Cepae9Dosage formsFresh juice and 5% and 50% ethanol extracts have been used in clinical studies(1). A “soft” extract is marketed in France but is not recognized as a drug byFrench authorities (7 ). Dried Bulbus Allii Cepae products should be stored inwell-closed containers, protected from light, moisture, and elevated tempera-ture. Fresh bulbs and juice should be refrigerated (2–10 °C).Medicinal usesUses supported by clinical dataThe principal use of Bulbus Allii Cepae today is to prevent age-dependentchanges in the blood vessels, and loss of appetite (19).Uses described in pharmacopoeias and in traditional systems ofmedicineTreatment of bacterial infections such as dysentery, and as a diuretic (2, 7). Thedrug has also been used to treat ulcers, wounds, scars, keloids (3), and asthma(20, 21). Bulbus Allii Cepae has also been used as an adjuvant therapy fordiabetes (4, 22, 23).Uses described in folk medicine, not supported by experimental orclinical dataAs an anthelminthic, aphrodisiac, carminative, emmenagogue, expectorant, andtonic (3), and for the treatment of bruises, bronchitis, cholera, colic, earache,fevers, high blood pressure, jaundice, pimples, and sores (3).PharmacologyExperimental pharmacologyAn aqueous extract or the juice of Bulbus Allii Cepae inhibited the in vitrogrowth of Escherichia coli, Serratia marcescens, Streptococcus species, Lactobacillusodontolyticus, Pseudomonas aeruginosa, and Salmonella typhosa (24–28). A petro-leum ether extract of Bulbus Allii Cepae inhibited the in vitro growth ofClostridium paraputrificum and Staphylococcus aureus (24). The essential oil hasactivity against a variety of fungi including Aspergillus niger, Cladosporiumwerneckii, Candida albicans, Fusarium oxysporium, Saccharomyces cerevisiae,Geotrichum candidum, Brettanomyces anomalus, and Candida lipolytica (5, 29).The hypoglycaemic effects of Bulbus Allii Cepae have been demonstrated invivo. Intragastric administration of the juice, a chloroform, ethanol, petroleumether (0.25g/kg) or water extract (0.5ml), suppressed alloxan-, glucose- andepinephrine-induced hyperglycaemia in rabbits and mice (30–35).Inhibition of platelet aggregation by Bulbus Allii Cepae has been demon-strated both in vitro and in vivo. An aqueous extract inhibited adenosinediphosphate-, collagen-, epinephrine- and arachidonic acid-induced plateletWHO monographs on selected medicinal plants10aggregation in vitro (36, 37). Platelet aggregation wasinhibited in rabbits afteradministration of the essential oil, or a butanol or chloroform extract of thedrug (38–40). An ethanol, butanol or chloroform extract or the essential oil(10–60µg/ml) of the drug inhibited aggregation of human platelets in vitro (41,42) by decreasing thromboxane synthesis (39). Both raw onions and the essen-tial oil increased fibrinolysis in ex vivo studies on rabbits and humans (1). Anincrease in coagulation time was also observed in rabbits (1).Intragastric administration of the juice or an ether extract (100mg/kg) of thedrug inhibited allergen- and platelet activating factor-induced allergic reactions,but not histamine- or acetylcholine-induced allergenic responses in guinea-pigs(43). A water extract of the drug was not active (43). A chloroform extract ofBulbus Allii Cepae (20–80mg/kg) inhibited allergen- and platelet aggregationfactor-induced bronchial obstruction in guinea-pigs (44). The thiosulphinatesand cepaenes appear to be the active constituents of Bulbus Allii Cepae (1).Both ethanol and methanol extracts of Bulbus Allii Cepae demonstrateddiuretic activity in dogs and rats after intragastric administration (45, 46).Antihyperlipidaemic and anticholesterolaemic activities of the drug wereobserved after oral administration of minced bulbs, a water extract, the essen-tial oil (100mg/kg), or the fixed oil to rabbits or rats (47–52). However, onestudy reported no significant changes in cholesterol or lipid levels of the eye inrabbits, after treatment of the animals for 6 months with an aqueous extract(20% of diet) (53).Oral administration of an ethanol extract of the drug to guinea-pigs inhibitedsmooth muscle contractions in the trachea induced by carbachol and inhibitedhistamine-, barium chloride-, serotonin-, and acetylcholine-induced contrac-tions in the ileum (20).Topical application of an aqueous extract of Bulbus Allii Cepae (10% in agel preparation) inhibited mouse ear oedema induced by arachidonic acid (54).The active antiallergic and anti-inflammatory constituents of onion are theflavonoids (quercetin and kaempferol) (55). The flavonoids act as anti-inflammatory agents because they inhibit the action of protein kinase, phos-pholipase A2, cyclooxygenase, and lipoxygenase (56), as well as the release ofmediators of inflammation (e.g. histamine) from leukocytes (57).In vitro, an aqueous extract of Bulbus Allii Cepae inhibited fibroblast prolif-eration (58). A 0.5% aqueous extract of onion inhibited the growth of humanfibroblasts and of keloidal fibroblasts (enzymically isolated from keloidal tis-sue) (59). In a comparative study, an aqueous extract of Bulbus Allii Cepae (1–3%) inhibited the proliferation of fibroblasts of varying origin (scar, keloid,embryonic tissue). The strongest inhibition was observed with keloid fibro-blasts (65–73%) as compared with the inhibition of scar and embryonicfibroblasts (up to 50%) (59). In human skin fibroblasts, both aqueous andchloroform onion extracts, as well as thiosulfinates, inhibited the platelet-derived growth factor-stimulated chemotaxis and proliferation of these cells(60). In addition, a protein fraction isolated from an onion extract exhibitedantimitotic activity (61).Bulbus Allii Cepae11Clinical pharmacologyOral administration of a butanol extract of Bulbus Allii Cepae (200mg) tosubjects given a high-fat meal prior to testing suppressed platelet aggregationassociated with a high-fat diet (62).Administration of a butanol extract to patients with alimentary lipaemiaprevented an increase in the total serum cholesterol, �-lipoprotein cholesterol,and �-lipoprotein and serum triglycerides (63, 64). A saponin fraction (50mg) orthe bulb (100mg) also decreased serum cholesterol and plasma fibrinogen levels(65, 66). However, fresh onion extract (50g) did not produce any significanteffects on serum cholesterol, fibrinogen, or fibrinolytic activity in normal sub-jects (67, 68).Antihyperglycaemic activity of Bulbus Allii Cepae has been demonstrated inclinical studies. Administration of an aqueous extract (100mg) decreased glu-cose-induced hyperglycaemia in human adults (69). The juice of the drug(50mg) administered orally to diabetic patients reduced blood glucose levels(22). Addition of raw onion to the diet of non-insulin-dependent diabetic sub-jects decreased the dose of antidiabetic medication required to control thedisease (70). However, an aqueous extract of Bulbus Allii Cepae (200mg) wasnot active (71).The immediate and late cutaneous reactions induced by injection of rabbitanti-human IgE-antibodies into the volar side of the forearms of 12 healthyvolunteers were reduced after pretreatment of the skin with a 50% ethanolonion extract (1). Immediate and late bronchial obstruction owing to allergeninhalation was markedly reduced after oral administration of a 5% ethanolonion extract 1 hour before exposure to the allergen (1).In one clinical trial in 12 adult subjects, topical application of a 45%ethanolic onion extract inhibited the allergic skin reactions induced by anti-IgE(72).ContraindicationsAllergies to the plant. The level of safety of Bulbus Allii Cepae is reflected by itsworldwide use as a vegetable.WarningsNo warnings have been reported.PrecautionsCarcinogenesis, mutagenesis, impairment of fertilityBulbus Allii Cepae is not mutagenic in vitro (73).Other precautionsNo general precautions have been reported, and no precautions have beenreported concerning drug interactions, drug and laboratory test interactions,WHO monographs on selected medicinal plants12nursing mothers, paediatric use, or teratogenic or non-teratogenic effects onpregnancy.Adverse reactionsAllergic reactions such as rhinoconjunctivitis and contact dermatitis have beenreported (74).PosologyUnless otherwise prescribed: a daily dosage is 50g of fresh onion or 20g of thedried drug; doses of preparations should be calculated accordingly (14).References1. Breu W, Dorsch W. Allium cepa L. (Onion): Chemistry, analysis and pharmacology.In: Wagner H, Farnsworth NR, eds. Economic and medicinal plants research, Vol. 6.London, Academic Press, 1994:115–147.2. Kapoor LD. Handbook of Ayurvedic medicinal plants, Boca Raton, FL, CRC Press, 1990.3. Materia medika Indonesia, Jilid VI. Jakarta, Departemen Kesehatan, RepublikIndonesia, 1995.4. Wagner H, Wiesenauer M. Phytotherapie. Stuttgart, Gustav Fischer, 1995.5. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois atChicago, IL, August 8, 1995 production (an on-line database available directlythrough the University of Illinois at Chicago or through the Scientific and TechnicalNetwork (STN) of Chemical Abstracts Services).6. Tutin TG et al., eds. Flora Europea, Vol. 5. Cambridge, Cambridge University Press,1980.7. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.8. Gassner G. Mikroskopische Untersuchung pflanzlicher Lebensmittel. Stuttgart, GustavFischer, 1973.9. African pharmacopoeia, Vol. 1, 1st ed. Lagos, Organization of African Unity, Scientific,Technical & Research Commission, 1985.10. Wagner H, Bladt S, Zgainski EM. Plant drug analysis. Berlin, Springer-Verlag, 1984.11. Augusti KT. Chromatographic identification of certain sulfoxides of cysteine presentin onion (Allium cepa Linn.) extract. Current science, 1976, 45:863–864.12. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.13. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.14. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.15. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).16. Bayer T. Neue schwefelhaltige Inhaltsstoffe aus Allium Cepa L. mit antiasthmatischerundantiallergischer Wirkung [Thesis]. Germany, University of Munich, 1988.17. Breu W. Analytische und pharmakologische Untersuchungen von Allium Cepa L. undneue 5-Lipoxygenase-Inhibitoren aus Arzneipflanzen [Thesis]. Germany, University ofMunich, 1991.18. Brodnitz MH, Pollock CL. Gas chromatographic analysis of distilled onion oil. Foodtechnology, 1970, 24:78–80.Bulbus Allii Cepae1319. German Commission E Monograph, Allii cepae bulbus. Bundesanzeiger, 1986, 50:13March.20. Dorsch W, Wagner H. New antiasthmatic drugs from traditional medicine? Interna-tional archives of allergy and applied immunology, 1991, 94:262–265.21. Sharma KC, Shanmugasundram SSK. Allium cepa as an antiasthmatic. RRL jammunewsletter, 1979:8–10.22. Sharma KK et al. Antihyperglycemic effect of onion: Effect on fasting blood sugar andinduced hyperglycemia in man. Indian journal of medical research, 1977, 65:422–429.23. Mathew PT, Augusti KT. Hypoglycemic effects of onion, Allium cepa Linn. ondiabetes mellitus: a preliminary report. Indian journal of physiology and pharmacology,1975, 19:213–217.24. Didry N, Pinkas M, Dubreuil L. Activité antibactérienne d’espèces du genre Allium.Pharmazie, 1987, 42:687–688.25. Arunachalam K. Antimicrobial activity of garlic, onion, and honey. Geobios, 1980,7:46–47.26. Elnima EI et al. The antimicrobial activity of garlic and onion extracts. Pharmazie,1983, 38:747–748.27. Sangmachachai K. Effect of onion and garlic extracts on the growth of certain bacteria[Thesis]. Bangkok, Chiangmai University, 1978.28. Abou IA et al. Antimicrobial activities of Allium sativum, Allium cepa, Raphanus sativus,Capsicum frutescens, Eruca sativa, Allium kurrat on bacteria. Qualitas plantarum etmateriae vegetabiles, 1972, 22:29–35.29. Conner DE, Beuchat LR. Effects of essential oils from plants on growth of foodspoilage yeasts. Journal of food science, 1984, 49:429–434.30. El-Ashwah ET et al. Hypoglycemic activity of different varieties of Egyptian onion(Allium cepa) in alloxan diabetic rats. Journal of drug research (Egypt), 1981, 13:45–52.31. Karawya MS et al. Diphenylamine, an antihyperglycemic agent from onion and tea.Journal of natural products, 1984, 47:775–780.32. Mossa JS. A study on the crude antidiabetic drugs used in Arabian folk medicine.International journal of crude drug research, 1985, 23:137–145.33. Augusti KT. Studies on the effects of a hypoglycemic principal from Allium cepa Linn.Indian journal of medical research, 1973, 61:1066–1071.34. Jain RC, Vyas CR. Hypoglycaemic actions of onion on rabbits. British medical journal,1974, 2:730.35. Gupta RK, Gupta S. Partial purification of the hypoglycemic principle of onion. IRCSmedical science library compendium, 1976, 4:410.36. Srivastava KC. Effects of aqueous extracts of onion, garlic and ginger on plateletaggregation and metabolism of arachidonic acid in the blood vascular system: an invitro study. Prostaglandins and leukotrienes in medicine, 1984, 13:227–235.37. Srivastava KC. Aqueous extracts of onion, garlic and ginger inhibit platelet aggrega-tion and alter arachidonic acid metabolism. Biomedica biochimica acta, 1984, 43:S335–S346.38. Chauhan LS et al. Effect of onion, garlic and clofibrate on coagulation andfibrinolytic activity of blood in cholesterol fed rabbits. Indian medical journal, 1982,76:126–127.39. Makheja AN, Vanderhoek JY, Bailey JM. Inhibition of platelet aggregation andthromboxane synthesis by onion and garlic. Lancet, 1979, i:781.40. Ariga T, Oshiba S. Effects of the essential oil components of garlic cloves on rabbitplatelet aggregation. Igaku to seibutsugaku, 1981, 102:169–174.41. Vanderhoek JY, Makheja AN, Bailey JM. Inhibition of fatty acid oxygenases byonion and garlic oils. Evidence for the mechanism by which these oils inhibit plateletaggregation. Biochemical pharmacology, 1980, 29:3169–3173.42. Weissenberger H et al. Isolation and identification of the platelet aggregation inhibi-tor present in onion. Allium cepa. FEBS letters, 1972, 26:105–108.WHO monographs on selected medicinal plants1443. Dorsch W et al. Antiasthmatic effects of onion extracts—detection of benzyl- andother isothiocyanates (mustard oils) as antiasthmatic compounds of plant origin.European journal of pharmacology, 1985, 107:17–24.44. Dorsch W et al. Anti-asthmatic effects of onions. Alk(en)ylsufinothioc acid al(en)yl-esters inhibit histamine release, leukotriene and thromboxane biosynthesis in vitroand counteract PAF and allergen-induced bronchial spasm in vivo. Biochemical pharma-cology, 1988, 37:4479–4486.45. Kaczmarek F et al. Preparation of a diuretic fraction from dried onion scales. Bulletinof the Institute of Roslin Leczniczych, 1961, 7:157–166.46. De A, Ribeiro R et al. Acute diuretic effects in conscious rats produced by somemedicinal plants in the state of São Paulo, Brazil. Journal of ethnopharmacology, 1988,24:19–29.47. Sharma KK, Chowdhury NK, Sharma AL. Studies on hypocholesterolaemic activityof onion. II. Effect on serum cholesterol in rabbits maintained on high cholesteroldiet. Indian journal of nutrition and diet, 1975:388–391.48. Vatsala TM, Singh M. Effects of onion in induced atherosclerosis in rabbits. 2.Reduction of lipid levels in the eye. Current science, 1982, 51:230–232.49. Ahluwalia P, Mohindroo A. Effect of oral ingestion of different fractions of Alliumcepa on the blood and erythrocyte membrane lipids and certain membrane-boundenzymes in rats. Journal of nutrition science and vitaminology, 1989, 35:155–161.50. Sebastian KL et al. The hypolipidemic effect of onion (Allium cepa Linn.) in sucrosefed rabbits. Indian journal of physiology and pharmacology, 1979, 23:27–29.51. Adamu I, Joseph PK, Augusti KT. Hypolipidemic action of onion and garlic unsatur-ated oils in sucrose fed rats over a two-month period. Experimentia, 1982, 38:899–901.52. Bobboi A, Augusti KT, Joseph PK. Hypolipidemic effects of onion oil and garlic oilin ethanol-fed rats. Indian journal of biochemistry and biophysics, 1984, 21:211–213.53. Vatsala TM, Singh M. Effects of onion in atherosclerosis in rabbits. 4. Maintenanceof normal activity of aortic enzymes. Current science, 1982, 51:276–278.54. Untersuchung von Contractubex® auf antiphlogistische Wirkung. Münster, Merz, 1989(internal research report).55. Alcaraz MJ, Jimenez MJ. Flavonoids as antiinflammatory agents. Fitoterapia, 1988,59:25–38.56. Middleton E. The flavonoids. Trends in pharmacological sciences (TIPS), 1984, 5:335–338.57. Amellal M et al. Inhibition of mast cell histamine release by flavonoids andbioflavonoids. Planta medica, 1985:16–20.58. Majewski S, Chadzynska M. Effects of heparin, allantoin and Cepae Extract on theproliferation of keloid fibroblasts and other cells in vitro. Dermatologische Monatsschrift,1988, 174:106–129.59. Untersuchung der Contractubex®-Inhaltsstoffe auf anti-proliferative Wirkung von humanenHautfibroblasten. Münster, Merz, 1989 (internal research report).60. Dorsch W. Effect of onion extract and synthetic thiosulfinates on chemotaxis and proliferationof human fibroblasts. Münster, Merz, 1994 (internal research report).61. Avuso MJ, Saenz MT. Antimitotic activity of a protein fraction isolated fromviscum-cruciatum on the root meristems of Allium cepa. Fitoterapia, 1985, 56:308–311.62. Doutremepuich C et al. Action de l’oignon, Allium cepa L., sur l’hémostase primairechez le volontaire sain avant et après absorption d’un repas riche en lipides. [Effectsof onion, Allium cepa L., on primary haemostasis in healthy voluntary person beforeand after high fat meal absorption.] Annales pharmaceutiques françaises, 1985, 43:273–280.63. Jain RC, Vyas CR. Onion and garlic in atherosclerotic heart disease. Medikon, 1977,6:12–14.Bulbus Allii Cepae1564. Singhvi S et al. Effect of onion and garlic on blood lipids. Rajasthan medical journal,1984, 23:3–6.65. Sainani GS et al. Effect of garlic and onion on importantlipid and coagulationparameters in alimentary hyperlipidemia. Journal of the Association of Physicians inIndia, 1979, 27:57–64.66. Sharma KK, Gupta S, Dwivedi KK. Effect of raw and boiled onion on the alterationsof blood cholesterol, fibrinogen and fibrinolytic activity in man during alimentarylipaemia. Indian medical gazette, 1977, 16:479–481.67. Sharma KK, Sharma SP. Effect of onion and garlic on serum cholesterol on normalsubjects. Mediscope, 1979, 22:134–136.68. Sharma KK, Sharma SP. Effect of onion on blood cholesterol, fibrinogen andfibrinolytic activity in normal subjects. Indian journal of pharmacology, 1976, 8:231–233.69. Jain RC, Vyas CR, Mahatma OP. Hypoglycaemic action of onion and garlic. Lancet,1973, ii:1491.70. Bhushan S et al. Effect of oral administration of raw onion on glucose tolerance testof diabetics: a comparison with tolbutamide. Current medical practice, 1984, 28:712–715.71. Sharma KK et al. Antihyperglycemic effects of onion: Effect on fasting blood sugarand induced hyperglycemia in man. Indian journal of medical research, 1977, 65:422–429.72. Dorsch W, Ring J. Suppression of immediate and late anti-IgE-induced skin reactionsby topically applied alcohol/onion extract. Allergy, 1984, 39:43–49.73. Rockwell P, Raw I. A mutagenic screening of various herbs, spices, and food addi-tives. Nutrition and cancer, 1979, 1:10–15.74. Valdivieso R et al. Bronchial asthma, rhinoconjunctivitis, and contact dermatitiscaused by onion. Journal of allergy and clinical immunology, 1994, 94:928–930.WHO monographs on selected medicinal plants16Bulbus Allii SativiDefinitionBulbus Allii Sativi consists of the fresh or dried bulbs of Allium sativum L.(Liliaceae) (1, 2).SynonymsPorvium sativum Rehb. (1, 3).Selected vernacular namesIt is most commonly known as “garlic”. Ail, ail commun, ajo, akashneem,allium, alubosa elewe, ayo-ishi, ayu, banlasun, camphor of the poor, daitóan, dasuan, dawang, dra thiam, foom, Gartenlauch, hom khaao, hom kía,hom thiam, hua thiam, kesumphin, kitunguu-sumu, Knoblauch, kra thiam,krathiam, krathiam cheen, krathiam khaao, l’ail, lahsun, lai, lashun, lasan, lasun,lasuna, Lauch, lay, layi, lehsun, lesun, lobha, majo, naharu, nectar of the gods,ninniku, pa-se-waa, poor man’s treacle, rason, rasonam, rasun, rustic treacles,seer, skordo, sluôn, stinking rose, sudulunu, ta-suam, ta-suan, tafanuwa,tellagada, tellagaddalu, thiam, toi thum, tum, umbi bawang putih, vallaip-pundu, velluli, vellulli (1–13).DescriptionA perennial, erect bulbous herb, 30–60cm tall, strong smelling when crushed.The underground portion consists of a compound bulb with numerous fibrousrootlets; the bulb gives rise above ground to a number of narrow, keeled, grass-like leaves. The leaf blade is linear, flat, solid, 1.0–2.5cm wide, 30–60cm long,and has an acute apex. Leaf sheaths form a pseudostem. Inflorescences areumbellate; scape smooth, round, solid, and coiled at first, subtended bymembraneous, long-beaked spathe, splitting on one side and remainingattached to umbel. Small bulbils are produced in inflorescences; flowersare variable in number and sometimes absent, seldom open and may wither inbud. Flowers are on slender pedicels; consisting of perianth of 6 segments,about 4–6mm long, pinkish; stamens 6, anthers exserted; ovary superior,3-locular. Fruit is a small loculicidal capsule. Seeds are seldom if ever produced(8, 9).Bulbus Allii Sativi17Plant material of interest: fresh or dried bulbsGeneral appearanceBulbus Allii Sativi consists of several outer layers of thin sheathing protectiveleaves which surround an inner sheath. The latter enclose the swollen storageleaves called “cloves”. Typically, the bulb possesses a dozen sterile sheathingleaves within which are 6–8 cloves bearing buds making a total of 10–20 clovesand 20–40 well-developed but short and embedded roots. The cloves are asym-metric in shape, except for those near the centre (1).Organoleptic propertiesOdour strong, characteristic alliaceous (1, 6, 8); taste very persistently pungentand acrid (1, 6, 8).Microscopic characteristicsThe bulbs show a number of concentric bulblets; each is 5–10mm in diameterand consists of an outer scale, an epidermis enclosing a mesophyll free fromchlorophyll, a ground tissue and a layer of lower epidermal cells. Dry scalesconsist of 2 or 3 layers of rectangular cells having end walls with a broadlyangular slant. These cells contain many rhomboid crystals of calcium oxalate.The upper epidermal cells next to the dry scale layer consist of a single layer ofrectangular to cubical cells next to which are several layers of large parenchyma-tous cells. Among these cells are interspaced many vascular bundles, each ofwhich consists of xylem and phloem arranged alternately. Lower epidermisconsists of cubical cells which are much smaller than the upper epidermal cells.The same arrangement of tissues is met within different bulblets, 2 or 3 ofwhich are arranged concentrically (1, 6).Powdered plant materialPale buff to greyish or purplish white, with characteristic aromatic alliaceousodour and taste. It is characterized by the presence of sclereids of the epidermisof protective leaves, thin epidermis of storage cells, latex tubes, swollen paren-chyma cells with granular contents, and lignified narrow spiral and annularvessels (1).Geographical distributionBulbus Allii Sativi is probably indigenous to Asia (1, 7 ), but it is commerciallycultivated in most countries.WHO monographs on selected medicinal plants18General identity testsMacroscopic and microscopic examinations and microchemical analysis areused to identify organic sulfur compounds (1), thin-layer chromatographicanalysis to determine the presence of alliin (14).Purity testsMicrobiologyThe test for Salmonella spp. in Bulbus Allii Sativi products should be negative.The maximum acceptable limits of other microorganisms are as follows (2, 15,16). Preparations for internal use: aerobic bacteria—not more than 105/g or ml;fungi—not more than 104/g or ml; enterobacteria and certain Gram-negativebacteria—not more than 103/g or ml; Escherichia coli—0/g or ml.Total ashNot more than 5.0% (2).Acid-insoluble ashNot more than 1.0% (4).Water-soluble extractiveNot less than 5.0% (4).Alcohol-soluble extractiveNot less than 4.0% (4).MoistureNot more than 7% (2).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Bulbus Allii Sativi is not morethan 0.05mg/kg (2). For other pesticides, see WHO guidelines on quality controlmethods for medicinal plants (15) and guidelines for predicting dietary intake ofpesticide residues (17).Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (15).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (15).Bulbus Allii Sativi19Other purity testsChemical tests and tests for foreign organic matter to be established in accor-dance with national requirements.Chemical assaysQualitative and quantitative assay for sulfur constituents (alliin, allicin etc.)content by means of high-performance liquid chromatography (18–22) or gaschromatography–mass spectroscopy (23) methods.Major chemical constituentsThe most important chemical constituents reported from Bulbus Allii Sativi arethe sulfur compounds (7, 9, 24, 25). It has been estimated that cysteine sulfox-ides (e.g. alliin [1]) and the non-volatile γ-glutamylcysteine peptides make upmore than 82% of the total sulfur content of garlic (25).The thiosulfinates (e.g. allicin [2]), ajoenes (e.g. E-ajoene [3], Z-ajoene [4]),vinyldithiins (e.g. 2-vinyl-(4H)-1,3-dithiin [5], 3-vinyl-(4H)-1,2-dithiin [6]), andsulfides (e.g. diallyl disulfide[7], diallyl trisulfide [8]), however, are not naturallyoccurring compounds. Rather, they are degradation products from the naturallyoccurring cysteine sulfoxide, alliin [1]. When the garlic bulb is crushed, minced,or otherwise processed, alliin is released from compartments and interacts withthe enzyme alliinase in adjacent vacuoles. Hydrolysis and immediate condensa-tion of the reactive intermediate (allylsulfenic acid) forms allicin [2]. One milli-gram of alliin is considered to be equivalent to 0.45mg of allicin (26). Allicinitself is an unstable product and will undergo additional reactions to form otherderivatives (e.g. products [3]–[8]), depending on environmental and processingconditions (24–26). Extraction of garlic cloves with ethanol at �0 °C gave alliin[1]; extraction with ethanol and water at 25°C led to allicin [2] and no alliin; andsteam distillation (100 °C) converted the alliin totally to diallyl sulfides [7], [8](24, 25). Sulfur chemical profiles of Bulbus Allii Sativi products reflected theprocessing procedure: bulb, mainly alliin, allicin; dry powder, mainly alliin,allicin; volatile oil, almost entirely diallyl sulfide, diallyl disulfide, diallyl trisul-fide, and diallyl tetrasulfide; oil macerate, mainly 2-vinyl-[4H]-1,3-dithiin, 3-vinyl-[4H]-1,3-dithiin, E-ajoene, and Z-ajoene (18–22, 24). The content of alliinWHO monographs on selected medicinal plants20was also affected by processing treatment: whole garlic cloves (fresh) contained0.25–1.15% alliin, while material carefully dried under mild conditions con-tained 0.7–1.7% alliin (18–21).Gamma-glutamylcysteine peptides are not acted on by alliinase. On pro-longed storage or during germination, these peptides are acted on by γ-glutamyltranspeptidase to form thiosulfinates (25).Dosage formsFresh bulbs, dried powder, volatile oil, oil macerates, juice, aqueous or alcoholicextracts, aged garlic extracts (minced garlic that is incubated in aqueous alcohol(15–20%) for 20 months, then concentrated), and odourless garlic products(garlic products in which the alliinase has been inactivated by cooking; or inwhich chlorophyll has been added as a deodorant; or aged garlic preparationsthat have low concentrations of water-soluble sulfur compounds) (18, 24).The juice is the most unstable dosage form. Alliin and allicin decomposerapidly, and those products must be used promptly (18).Dried Bulbus Allii Sativi products should be stored in well-closed containers,protected from light, moisture, and elevated temperature.Medicinal usesUses supported by clinical dataAs an adjuvant to dietetic management in the treatment of hyperlipidaemia,and in the prevention of atherosclerotic (age-dependent) vascular changes (5,27–31). The drug may be useful in the treatment of mild hypertension (11, 28).Uses described in pharmacopoeias and in traditional systems ofmedicineThe treatment of respiratory and urinary tract infections, ringworm and rheu-matic conditions (1, 4, 7, 9, 11). The herb has been used as a carminative in thetreatment of dyspepsia (32).Uses described in folk medicine, not supported by experimental orclinical dataAs an aphrodisiac, antipyretic, diuretic, emmenagogue, expectorant, and seda-tive, to treat asthma and bronchitis, and to promote hair growth (6, 9, 13).PharmacologyExperimental pharmacologyBulbus Allii Sativi has a broad range of antibacterial and antifungal activity (13).The essential oil, water, and ethanol extracts, and the juice inhibit the in vitrogrowth of Bacillus species, Staphylococcus aureus, Shigella sonnei, Erwiniacarotovora, Mycobacterium tuberculosis, Escherichia coli, Pasteurella multocida, ProteusBulbus Allii Sativi21species, Streptococcus faecalis, Pseudomonas aeruginosa, Candida species, Cryptococ-cus species, Rhodotorula rubra, Toruloposis species, Trichosporon pullulans, andAspergillus niger (33–40). Its antimicrobial activity has been attributed to allicin,one of the active constituents of the drug (41). However, allicin is a relativelyunstable and highly reactive compound (37, 42) and may not have antibacterialactivity in vivo. Ajoene and diallyl trisulfide also have antibacterial and antifun-gal activities (43). Garlic has been used in the treatment of roundworm (Ascarisstrongyloides) and hookworm (Ancylostoma caninum and Necator americanus) (44,45). Allicin appears to be the active anthelminthic constituent, and diallyldisulfide was not effective (46).Fresh garlic, garlic juice, aged garlic extracts, or the volatile oil all loweredcholesterol and plasma lipids, lipid metabolism, and atherogenesis both in vitroand in vivo (18, 43, 47–64). In vitro studies with isolated primary rat hepato-cytes and human HepG2 cells have shown that water-soluble garlic extractsinhibited cholesterol biosynthesis in a dose-dependent manner (48–50).Antihypercholesterolaemic and antihyperlipidaemic effects were observed invarious animal models (rat, rabbit, chicken, pig) after oral (in feed) orintragastric administration of minced garlic bulbs; water, ethanol, petroleumether, or methanol extracts; the essential oil; aged garlic extracts and the fixedoil (51–64). Oral administration of allicin to rats during a 2-month periodlowered serum and liver levels of total lipids, phospholipids, triglycerides, andtotal cholesterol (65). Total plasma lipids and cholesterol in rats were reducedafter intraperitoneal injection of a mixture of diallyl disulfide and diallyltrisulfide (66). The mechanism of garlic’s antihypercholesterolaemic andantihyperlipidaemic activity appears to involve the inhibition of hepatichydroxymethylglutaryl-CoA (HMG-CoA) reductase and remodelling of plasmalipoproteins and cell membranes (67). At low concentrations (�0.5mg/ml),garlic extracts inhibited the activity of hepatic HMG-CoA reductase, but athigher concentrations (�0.5mg/ml) cholesterol biosynthesis was inhibited inthe later stages of the biosynthetic pathway (68). Alliin was not effective, butallicin and ajoene both inhibited HMG-CoA reductase in vitro (IC50 � 7 and9mmol/l respectively) (49). Because both allicin and ajoene are converted toallyl mercaptan in the blood and never reach the liver to affect cholesterolbiosynthesis, this mechanism may not be applicable in vivo. In addition to allicinand ajoene, allyl mercaptan (50mmol/l) and diallyl disulfide (5mmol/l) en-hanced palmitate-induced inhibition of cholesterol biosynthesis in vitro (50). Itshould be noted that water extracts of garlic probably do not contain any ofthese compounds; therefore other constituents of garlic, such as nicotinic acidand adenosine, which also inhibit HMG-CoA reductase activity and cholesterolbiosynthesis, may be involved (69, 70).The antihypertensive activity of garlic has been demonstrated in vivo. Oral orintragastric administration of minced garlic bulbs, or alcohol or water extractsof the drug, lowered blood pressure in dogs, guinea-pigs, rabbits, and rats (52,71–73). The drug appeared to decrease vascular resistance by directly relaxingsmooth muscle (74). The drug appears to change the physical state functions ofWHO monographs on selected medicinal plants22the membrane potentials of vascular smooth muscle cells. Both aqueous garlicand ajoene induced membrane hyperpolarization in the cells of isolated vesselstrips. The potassium channels opened frequently causing hyperpolarization,which resulted in vasodilation because the calcium channels were closed (75,76). The compounds that produce the hypotensive activity of the drug areuncertain. Allicin does not appear to be involved (43), and adenosine has beenpostulated as being associated with the activity of the drug. Adenosine enlargesthe peripheral blood vessels, allowing the blood pressure to decrease, and is alsoinvolved in the regulation of blood flow in the coronary arteries; however,adenosine is not active when administered orally. Bulbus Allii Sativi mayincrease production of nitricoxide, which is associated with a decrease in bloodpressure. In vitro studies using water or alcohol extracts of garlic or garlic powderactivated nitric-oxide synthase (77 ), and these results have been confirmed byin vivo studies (78).Aqueous garlic extracts and garlic oil have been shown in vivo to alter theplasma fibrinogen level, coagulation time, and fibrinolytic activity (43). Serumfibrinolytic activity increased after administration of dry garlic or garlic extractsto animals that were artificially rendered arteriosclerotic (79, 80). Althoughadenosine was thought to be the active constituent, it did not affect wholeblood (43).Garlic inhibited platelet aggregation in both in vitro and in vivo studies. Awater, chloroform, or methanol extract of the drug inhibited collagen-, ADP-,arachidonic acid-, epinephrine-, and thrombin-induced platelet aggregation invitro (81–87). Prolonged administration (intragastric, 3 months) of the essentialoil or a chloroform extract of Bulbus Allii Sativi inhibited platelet aggregation inrabbits (88–90). Adenosine, alliin, allicin, and the transformation products ofallicin, the ajoenes; the vinyldithiins; and the dialkyloligosulfides are respon-sible for inhibition of platelet adhesion and aggregation (4, 42, 91–93). Inaddition methyl allyl trisulfide, a minor constituent of garlic oil, inhibitedplatelet aggregation at least 10 times as effectively than allicin (94). Inhibition ofthe arachidonic acid cascade appears to be one of the mechanisms by which thevarious constituents and their metabolites affect platelet aggregation. Inhibitionof platelet cyclic AMP phosphodiesterase may also be involved (91).Ajoene, one of the transformation products of allicin, inhibited in vitro plate-let aggregation induced by the platelet stimulators—ADP, arachidonic acid,calcium ionophore A23187, collagen, epinephrine, platelet activating factor, andthrombin (95, 96). Ajoene inhibited platelet aggregation in cows, dogs, guinea-pigs, horses, monkeys, pigs, rabbits, and rats (95, 96). The antiplatelet activityof ajoene is potentiated by prostacyclin, forskolin, indometacin, anddipyridamole (95). The mechanism of action involves the inhibition of themetabolism of arachidonic acid by both cyclooxygenase and lipoxygenase,thereby inhibiting the formation of thromboxane A2 and 12-hydroxyeicosatetraenoic acid (95). Two mechanisms have been suggested forajoene’s antiplatelet activity. First, ajoene may interact with the primaryagonist–receptor complex with the exposure of fibrinogen receptors throughBulbus Allii Sativi23specific G-proteins involved in the signal transduction system on the plateletmembrane (92). Or it may interact with a haemoprotein involved in plateletactivation that modifies the binding of the protein to its ligands (96).Hypoglycaemic effects of Bulbus Allii Sativi have been demonstrated in vivo.Oral administration of an aqueous, ethanol, petroleum ether, or chloroformextract, or the essential oil of garlic, lowered blood glucose levels in rabbits andrats (24, 97–104). However, three similar studies reported negative results (105–107). In one study, garlic bulbs administered orally (in feed) to normal orstreptozotocin-diabetic mice reduced hyperphagia and polydipsia but had noeffect on hyperglycaemia or hypoinsulinaemia (107). Allicin administered orallyto alloxan-diabetic rats lowered blood glucose levels and increased insulinactivity in a dose-dependent manner (24). Garlic extract’s hypoglycaemic actionappears to enhance insulin production, and allicin has been shown to protectinsulin against inactivation (108).Intragastric administration of an ethanol extract of Bulbus Allii Sativi de-creased carrageenin-induced rat paw oedema at a dose of 100mg/kg. The anti-inflammatory activity of the drug appears to be due to its antiprostaglandinactivity (109, 110).A water or ethanol extract of the drug showed antispasmodic activity againstacetylcholine, prostaglandin E2 and barium-induced contractions in guinea-pigsmall intestine and rat stomach (111). The juice of the drug relaxed smoothmuscle of guinea-pig ileum, rabbit heart and jejunum, and rat colon and fun-dus (112, 113). The juice also inhibited norepinephrine-, acetylcholine- andhistamine-induced contractions in guinea-pig and rat aorta, and in rabbit trachea(112, 113).Clinical pharmacologyThe efficacy of Bulbus Allii Sativi as a carminative has been demonstratedin human studies. A clinical study of 29 patients taking two tablets daily(~1000mg/day) of a dried garlic preparation demonstrated that garlic relievedepigastric and abdominal distress, belching, flatulence, colic, and nausea, ascompared with placebo (32). It was concluded that garlic sedated the stomachand intestines, and relaxed spasms, retarded hyperperistalsis, and dispersed gas(32).A meta-analysis of the effect of Bulbus Allii Sativi on blood pressure re-viewed a total of 11 randomized, controlled trials (published and unpublished)(113, 114). Each of the trials used dried garlic powder (tablets) at a dose of 600–900mg daily (equivalent to 1.8–2.7g/day fresh garlic). The median duration ofthe trials was 12 weeks. Eight of the trials with data from 415 subjects wereincluded in the analysis; three trials were excluded owing to a lack of data. Onlythree of the trials specifically used hypertensive subjects, and many of thestudies suffered from methodological flaws. Of the seven studies that comparedgarlic with placebo, three reported a decrease in systolic blood pressure, andfour studies reported a decrease in diastolic blood pressure (115). The results ofWHO monographs on selected medicinal plants24the meta-analysis led to the conclusion that garlic may have some clinicalusefulness in mild hypertension, but there is still insufficient evidence to recom-mend the drug as a routine clinical therapy for the treatment of hypertension(115).A meta-analysis of the effects of Bulbus Allii Sativi on serum lipids andlipoproteins reviewed 25 randomized, controlled trials (published and unpub-lished) (116) and selected 16 with data from 952 subjects to include in theanalysis. Fourteen of the trials used a parallel group design, and the remainingtwo were cross-over studies. Two of the studies were conducted in an open-label fashion, two others were single-blind, and the remainder were double-blind. The total daily dose of garlic was 600–900mg of dried garlic powder, or10g of raw garlic, or 18mg of garlic oil, or aged garlic extracts (dosage notstated). The median duration of the therapy was 12 weeks. Overall, the subjectsreceiving garlic supplementation (powder or non-powder) showed a 12% re-duction (average) in total cholesterol, and a 13% reduction (powder only) inserum triglycerides. Meta-analysis of the clinical studies confirmed the lipid-lowering action of garlic. However, the authors concluded that the overallquality of the clinical trials was poor and that favourable results of better-designed clinical studies should be available before garlic can be routinelyrecommended as a lipid-lowering agent. However, current available data sup-port the hypothesis that garlic therapy is at least beneficial (116). Another meta-analysis of the controlled trials of garlic effects on total serum cholesterolreached similar conclusions (117). A systematic review of the lipid-loweringpotential of a dried garlic powder preparation in eight studies with 500 subjectshad similar findings (118). In seven of the eight studies reviewed, a daily doseof 600–900mg of garlic powder reduced serum cholesterol and triglyceridelevels by 5–20%. The review concluded that garlic powder preparations dohave lipid-lowering potential (118).An increase in fibrinolytic activity in the serum of patients suffering fromatherosclerosis was observed after administration of aqueous garlic extracts, theessential oil, and garlic powder (119, 120). Clinical studies have demonstratedthat garlicactivates endogenous fibrinolysis, that the effect is detectable forseveral hours after administration of the drug, and that the effect increases asthe drug is taken regularly for several months (43, 121). Investigations of theacute haemorheological (blood flow) effect of 600–1200mg of dry garlic pow-der demonstrated that the drug decreased plasma viscosity, tissue plasminogenactivator activity and the haematocrit level (118).The effects of the drug on haemorheology in conjunctival vessels wasdetermined in a randomized, placebo-controlled, double-blind, cross-over trial.Garlic powder (900mg) significantly increased the mean diameter of the arteri-oles (by 4.2%) and venules (by 5.9%) as compared with controls (122). Inanother double-blind, placebo-controlled study, patients with stage II periph-eral arterial occlusive disease were given a daily dose of 800mg of garlic powderfor 4 weeks (123, 124). Increased capillary erythrocyte flow rate and decreasedplasma viscosity and plasma fibrinogen levels were observed in the groupBulbus Allii Sativi25treated with the drug (123, 124). Determinations of platelet aggregation ex vivo,after ingestion of garlic and garlic preparations by humans, suffers from meth-odological difficulties that may account for the negative results in some studies(24). In one study in patients with hypercholesterolinaemia treated with agarlic–oil macerate for 3 months, platelet adhesion and aggregation decreasedsignificantly (125). In a 3-year intervention study, 432 patients with myocardialinfarction were treated with either an ether-extracted garlic oil (0.1mg/kg/day,corresponding to 2g fresh garlic daily) or a placebo (126). In the group treatedwith garlic, there were 35% fewer new heart attacks and 45% fewer deathsthan in the control group. The serum lipid concentrations of the treated patientswere also reduced (126).The acute and chronic effects of garlic on fibrinolysis and platelet aggrega-tion in 12 healthy patients in a randomized, double-blind, placebo-controlledcross-over study were investigated (30). A daily dose of 900mg of garlic powderfor 14 days significantly increased tissue plasminogen activator activity ascompared with placebo (30). Furthermore, platelet aggregation induced byadenosine diphosphate and collagen was significantly inhibited 2 and 4 hoursafter garlic ingestion and remained lower for 7 to 14 days after treatment (30).Another randomized, double-blind, placebo-controlled study investigated theeffects of garlic on platelet aggregation in 60 subjects with increased risk ofjuvenile ischaemic attack (29). Daily ingestion of 800mg of powdered garlicfor 4 weeks significantly decreased the percentage of circulating platelet aggre-gates and spontaneous platelet aggregation as compared with the placebo group(29).Oral administration of garlic powder (800mg/day) to 120 patients for 4weeks in a double-blind, placebo-controlled study decreased the average bloodglucose by 11.6% (30). Another study found no such activity after dosing non-insulin-dependent patients with 700mg/day of a spray-dried garlic preparationfor 1 month (127).ContraindicationsBulbus Allii Sativi is contraindicated in patients with a known allergy to thedrug. The level of safety for Bulbus Allii Sativi is reflected by its worldwide useas a seasoning in food.WarningsConsumption of large amounts of garlic may increase the risk of postoperativebleeding (128, 129).PrecautionsDrug interactionsPatients on warfarin therapy should be warned that garlic supplements mayincrease bleeding times. Blood clotting times have been reported to double inpatients taking warfarin and garlic supplements (130).WHO monographs on selected medicinal plants26Carcinogenesis, mutagenesis, impairment of fertilityBulbus Allii Sativi is not mutagenic in vitro (Salmonella microsome reversionassay and Escherichia coli) (131, 132).Pregnancy: non-teratogenic effectsThere are no objections to the use of Bulbus Allii Sativi during pregnancy andlactation.Nursing mothersExcretion of the components of Bulbus Allii Sativi into breast milk and its effecton the newborn has not been established.Other precautionsNo general precautions have been reported, and no precautions have beenreported concerning drug and laboratory test interactions, paediatric use, orteratogenic or non-teratogenic effects on pregnancy.Adverse reactionsBulbus Allii Sativi has been reported to evoke occasional allergic reactions suchas contact dermatitis and asthmatic attacks after inhalation of the powdereddrug (133). Those sensitive to garlic may also have a reaction to onion or tulip(133). Ingestion of fresh garlic bulbs, extracts, or oil on an empty stomach mayoccasionally cause heartburn, nausea, vomiting, and diarrhoea. Garlic odourfrom breath and skin may be perceptible (7 ). One case of spontaneous spinalepidural haematoma, which was associated with excessive ingestion of freshgarlic cloves, has been reported (134).PosologyUnless otherwise prescribed, average daily dose is as follows (7): fresh garlic,2–5g; dried powder, 0.4–1.2g; oil, 2–5mg; extract, 300–1000mg (as solidmaterial). Other preparations should correspond to 4–12mg of alliin or about2–5mg of allicin).Bulbus Allii Sativi should be taken with food to prevent gastrointestinalupset.References1. African pharmacopoeia, Vol. 1, 1st ed. Lagos, Organization of African Unity, Scien-tific, Technical & Research Commission, 1985.2. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.3. Iwu MM. Handbook of African medicinal plants. Boca Raton, FL, CRC Press,1993:111–113.4. Materia medika Indonesia, Jilid VI. Jakarta, Departemen Kesehatan, RepublikIndonesia, 1995.Bulbus Allii Sativi275. British herbal pharmacopoeia, Vol. 1. London, British Herbal Medicine Association.1990.6. The Indian pharmaceutical codex. Vol. I. Indigenous drugs. New Delhi, Council ofScientific & Industrial Research, 1953:8–10.7. Bradley PR, ed. British herbal compendium, Vol. 1. Bournemouth, British HerbalMedicine Association, 1992.8. Youngken HW. Textbook of pharmacognosy, 6th ed. Philadelphia, Blakiston, 1950:182–183.9. Farnsworth NR, Bunyapraphatsara N, eds. Thai medicinal plants. Bangkok,Prachachon, 1992:210–287.10. Kapoor LD. Handbook of Ayurvedic medicinal plants. Boca Raton, FL, CRC Press,1990:26.11. Hsu HY. Oriental materia medica, a concise guide. Long Beach, CA, Oriental HealingArts Institute, 1986:735–736.12. Olin BR, ed. Garlic. In: The Lawrence review of natural products. St. Louis, MO, Factsand Comparisons, 1994:1–4.13. Medicinal plants in Viet Nam. Manila, World Health Organization, 1990 (WHORegional Publications, Western Pacific Series, No. 3).14. Wagner H, Bladt S, Zgainski EM. Plant drug analysis. Berlin, Springer-Verlag,1984:253–257.15. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.16. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.17. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva, WorldHealth Organization, 1997 (unpublished document WHO/FSF/FOS/97.7; availablefrom Food Safety, WHO, 1211 Geneva 27, Switzerland).18. Lawson LD et al. HPLC analysis of allicin and other thiosulfinates in garlic clovehomogenates. Planta medica, 1991, 57:263–270.19. Iberl B et al. Quantitative determination of allicin and alliin from garlic by HPLC.Planta medica, 1990, 56:320–326.20. Ziegler SJ, Sticher O. HPLC of S-alk(en)yl-L-cysteine derivatives in garlic includingquantitative determination of (�)-S-allyl-L-cysteine sulfoxide (alliin). Planta medica,1989, 55:372–378.21. Mochizuki E et al. Liquid chromatographic determination of alliin in garlic andgarlic products. Journal of chromatography, 1988, 455:271–277.22. Freeman F, Kodera Y. Garlic chemistry: Stability of S-(2-propenyl)-2-propene-1-sulfinothioate (allicin)in blood, solvents and simulated physiological fluids. Journalof agriculture and food chemistry, 1995, 43:2332–2338.23. Weinberg DS et al. Identification and quantification of organosulfur compliancemarkers in a garlic extract. Journal of agriculture and food chemistry, 1993, 41:37–41.24. Reuter HD, Sendl A. Allium sativum and Allium ursinum: Chemistry, pharmacology,and medicinal applications. In: Wagner H, Farnsworth NR, eds. Economic and medici-nal plants research, Vol. 6. London, Academic Press, 1994:55–113.25. Sendl A. Allium sativum and Allium ursinum, Part 1. Chemistry, analysis, history,botany. Phytomedicine, 1995, 4:323–339.26. Block E. The chemistry of garlic and onions. Scientific American, 1985, 252:94–99.27. German Commission E Monograph, Allii sativi bulbus. Bundesanzeiger, 1988, 122:6June.28. Auer W, Eiber A, Hertkorn E. Hypertension and hyperlipidemia: garlic helps inmild cases. British journal of clinical practice, 1990, 44:3–6.29. Kiesewetter H et al. Effect of garlic on platelet aggregation in patients with in-creased risk of juvenile ischaemic attack. European journal of clinical pharmacology,1993, 45:333–336.WHO monographs on selected medicinal plants2830. Kiesewetter H et al. Effect of garlic on thrombocyte aggregation, microcirculation,and other risk factors. International journal of clinical pharmacology, therapy and toxicol-ogy, 1991, 29:151–155.31. Legnani C et al. Effects of dried garlic preparation on fibrinolysis and plateletaggregation in healthy subjects. Arzneimittel-Forschung, 1993, 43:119–121.32. Damrau F, Ferguson EA. The modus operandi of carminatives. Review of gastroenter-ology, 1949, 16:411–419.33. Fitzpatrick FK. Plant substances active against Mycobacterium tuberculosis. Antibioticsand chemotherapy, 1954, 4:528–529.34. Sharma VD et al. Antibacterial property of Allium sativum. In vivo and in vitro studies.Indian journal of experimental biology, 1980, 15:466–469.35. Arunachalam K. Antimicrobial activity of garlic, onion and honey. Geobios, 1980,71:46–47.36. Moore GS, Atkins RD. The antifungistatic effects of an aqueous garlic extract onmedically important yeast-like fungi. Mycologia, 1977, 69:341–345.37. Caporaso N, Smith SM, Eng RHK. Antifungal activity in human urine and serumafter ingestion of garlic (Allium sativum). Antimicrobial agents and chemotherapy, 1983,5:700–702.38. Abbruzzese MR, Delaha EC, Garagusi VF. Absence of antimycobacterial synergismbetween garlic extract and antituberculosis drugs. Diagnosis and microbiology ofinfectious diseases, 1987, 8:79–85.39. Chaiyasothi T, Rueaksopaa V. Antibacterial activity of some medicinal plants.Undergraduate special project report, 1975, 75:1–109.40. Sangmahachai K. Effect of onion and garlic extracts on the growth of certain bacteria[Thesis]. Thailand, University of Bangkok, 1978:1–88.41. Farbman et al. Antibacterial activity of garlic and onions: a historical perspective.Pediatrics infectious disease journal, 1993, 12:613–614.42. Lawson LD, Hughes BG. Inhibition of whole blood platelet-aggregation by com-pounds in garlic clove extracts and commercial garlic products. Thrombosis research,1992, 65:141–156.43. Koch HP, Lawson LD, eds. Garlic, the science and therapeutic application of Alliumsativum l. and related species. Baltimore, Williams and Wilkins, 1996.44. Kempski HW. Zur kausalen Therapie chronischer Helminthen-Bronchitis.Medizinische Klinik, 1967, 62:259–260.45. Soh CT. The effects of natural food-preservative substances on the developmentand survival of intestinal helminth eggs and larvae. II. Action on Ancylostomaduodenale larvae. American journal of tropical medicine and hygiene, 1960, 9:8–10.46. Araki M et al. Anthelminthics. Yakugaku zasshi, 1952, 72:979–982.47. Mader FH. Treatment of hyperlipidemia with garlic-powder tablets. Evidence fromthe German Association of General Practitioner’s multicentric placebo-controlled,double-blind study. Arzneimittel-Forschung, 1990, 40:1111–1116.48. Gebhardt R. Multiple inhibitory effects of garlic extracts on cholesterol biosynthe-sis in hepatocytes. Lipids, 1993, 28:613–619.49. Gebhardt R, Beck H, Wagner KG. Inhibition of cholesterol biosynthesis by allicinand ajoene in rat hepatocytes and HepG2 cells. Biochimica biophysica acta, 1994,1213:57–62.50. Gebhardt R. Amplification of palmitate-induced inhibition of cholesterol biosyn-thesis in cultured rat hepatocytes by garlic-derived organosulfur compounds.Phytomedicine, 1995, 2:29–34.51. Yeh YY, Yeh SM. Garlic reduces plasma lipids by inhibiting hepatic cholesterol andtriacylglycerol synthesis. Lipids, 1994, 29:189–193.52. Petkov V. Pharmacological and clinical studies of garlic. Deutsche Apotheker Zeitung,1966, 106:1861–1867.Bulbus Allii Sativi2953. Jain RC. Onion and garlic in experimental cholesterol induced atherosclerosis.Indian journal of medical research, 1976, 64:1509–1515.54. Qureshi AA et al. Inhibition of cholesterol and fatty acid biosynthesis in liverenzymes and chicken hepatocytes by polar fractions of garlic. Lipids, 1983, 18:343–348.55. Thiersch H. The effect of garlic on experimental cholesterol arteriosclerosis ofrabbits. Zeitschrift für die gesamte experimentelle Medizin, 1936, 99:473–477.56. Zacharias NT et al. Hypoglycemic and hypolipidemic effects of garlic in sucrose fedrabbits. Indian journal of physiology and pharmacology, 1980, 24:151–154.57. Gupta PP, Khetrapal P, Ghai CL. Effect of garlic on serum cholesterol and electro-cardiogram of rabbit consuming normal diet. Indian journal of medical science, 1987,41:6–11.58. Mand JK et al. Role of garlic (Allium sativum) in the reversal of atherosclerosis inrabbits. In: Proceedings of the Third Congress of the Federation of Asian and OceanianBiochemists. Bangkok, 1983:79.59. Sodimu O, Joseph PK, Angusti KT. Certain biochemical effects of garlic oil on ratsmaintained on high fat–high cholesterol diet. Experientia, 1984, 40:78–79.60. Kamanna VS, Chandrasekhara N. Effect of garlic (Allium sativum Linn.) on serumlipoproteins and lipoprotein cholesterol levels in albino rats rendered hyper-cholesteremic by feeding cholesterol. Lipids, 1982, 17:483–488.61. Kamanna VS, Chandrasekhara N. Hypocholesterolic activity of different fractionsof garlic. Indian journal of medical research, 1984, 79:580–583.62. Chi MS. Effects of garlic products on lipid metabolism in cholesterol-fedrats. Proceedings of the Society of Experimental Biology and Medicine, 1982, 171:174–178.63. Qureshi AA et al. Influence of minor plant constituents on porcine hepatic lipidmetabolism. Atherosclerosis, 1987, 64:687–688.64. Lata S et al. Beneficial effects of Allium sativum, Allium cepa, and Commiphora mukulon experimental hyperlipidemia and atherosclerosis: a comparative evaluation.Journal of postgraduate medicine, 1991, 37:132–135.65. Augusti KT, Mathew PT. Lipid lowering effect of allicin (diallyl disulfide-oxide) onlong-term feeding to normal rats. Experientia, 1974, 30:468–470.66. Pushpendran CK et al. Cholesterol-lowering effects of allicin in suckling rats. Indianjournal of experimental biology, 1980, 18:858–861.67. Brosche T, Platt D. Garlic. British medical journal, 1991, 303, 785.68. Beck H, Wagnerk G. Inhibition of cholesterol biosynthesis by allicin and ajoene inrat hepatocytes and Hep62 cells. Biochimica biophysica acta, 1994, 1213:57–62.69. Platt D, Brosche T, Jacob BG. Cholesterin-senkende Wirkung von Knoblauch?Deutsche Medizinische Wochenschrift, 1992, 117:962–963.70. Grünwald J. Knoblauch: Cholesterinsenkende Wirkung doppelblind nachgewiesen.Deutsche Apotheker Zeitung, 1992, 132:1356.71. Ogawa H et al. Effect of garlic powder on lipid metabolism in stroke-pronespontaneously hypertensive rats. Nippon eiyo, shokuryo gakkaishi, 1993, 46:417–423.72. Sanfilippo G, Ottaviano G. Pharmacological investigations on Allium sativum. I.General action. II. Action on the arterial pressure and on the respiration.BollettinoSocieta Italiana Biologia Sperimentale, 1944, 19:156–158.73. Foushee DB, Ruffin J, Banerjee U. Garlic as a natural agent for the treatment ofhypertension: A preliminary report. Cytobios, 1982:145–152.74. Ozturk Y et al. Endothelium-dependent and independent effects of garlic on rataorta. Journal of ethnopharmacology, 1994, 44:109–116.75. Siegel G et al. Potassium channel activation, hyperpolarization, and vascular relax-ation. Zeitschrift für Kardiologie, 1991, 80:9–24.WHO monographs on selected medicinal plants3076. Siegel G et al. Potassium channel activation in vascular smooth muscle. In: FrankGB, ed. Excitation-contraction coupling in skeletal, cardiac, and smooth muscle. New York,Plenum Press, 1992:53–72.77. Das I, Khan NS, Sooranna SR. Nitric oxide synthetase activation is a uniquemechanism of garlic action. Biochemical Society transactions, 1995, 23:S136.78. Das I, Khan NS, Sooranna SR. Potent activation of nitric oxide synthetase by garlic:a basis for its therapeutic applications. Current medical research opinion, 1995, 13:257–263.79. Bordia A et al. Effect of essential oil of onion and garlic on experimental atheroscle-rosis in rabbits. Atherosclerosis, 1977, 26:379–386.80. Bordia A, Verma SK. Effect of garlic on regression of experimental atherosclerosisin rabbits. Artery, 1980, 7:428–437.81. Mohammad SF et al. Isolation, characterization, identification and synthesis of aninhibitor of platelet function from Allium sativum. Federation proceedings, 1980,39:543A.82. Castro RA et al. Effects of garlic extract and three pure components from it onhuman platelet aggregation, arachidonate metabolism, release reaction and plateletultrastructure. Thrombosis research, 1983, 32:155–169.83. Srivastava KC. Aqueous extracts of onion, garlic and ginger inhibit platelet aggre-gation and alter arachidonic acid metabolism. Biomedica biochimica acta, 1984,43:S335–S346.84. Makheja AN, Bailey JM. Antiplatelet constituents of garlic and onion. Agents andactions, 1990, 29:360–363.85. Srivastava KC. Effects of aqueous extracts of onion, garlic and ginger on plateletaggregation and metabolism of arachidonic acid in the blood vascular system: invitro study. Prostaglandins and leukotrienes in medicine, 1984, 13:227–235.86. Srivastava KC, Justesen U. Isolation and effects of some garlic components onplatelet aggregation and metabolism of arachidonic acid in human blood platelets.Wiener Klinische Wochenschrift, 1989, 101:293–299.87. Sendl A et al. Comparative pharmacological investigations of Allium ursinum andAllium sativum. Planta medica, 1992, 58:1–7.88. Chauhan LS et al. Effect of onion, garlic and clofibrate on coagulation and fibrinolyticactivity of blood in cholesterol fed rabbits. Indian medical journal, 1982, 76:126–127.89. Makheja AN, Vanderhoek JY, Bailey JM. Inhibition of platelet aggregation andthromboxane synthesis by onion and garlic. Lancet, 1979, i:781.90. Ariga T, Oshiba S. Effects of the essential oil components of garlic cloves on rabbitplatelet aggregation. Igaku to seibutsugaku, 1981, 102:169–174.91. Agarwal KC. Therapeutic actions of garlic constituents. Medical research reviews,1996, 16:111–124.92. Jain MK, Apitz-Castro R. Garlic: A product of spilled ambrosia. Current science,1993, 65:148–156.93. Mohammad SM, Woodward SC. Characterization of a potent inhibitor of plateletaggregation and release reaction isolated from Allium sativum (garlic). Thrombosisresearch, 1986, 44:793–806.94. Ariga T, Oshiba S, Tamada T. Platelet aggregation inhibitor in garlic. Lancet, 1981,i:150–151.95. Srivastava KC, Tyagi OD. Effects of a garlic-derived principal (ajoene) on aggrega-tion and arachidonic acid metabolism in human blood platelets. Prostaglandins,leukotrienes, and essential fatty acids, 1993, 49:587–595.96. Jamaluddin MP, Krishnan LK, Thomas A. Ajoene inhibition of platelet aggregation:possible mediation by a hemoprotein. Biochemical and biophysical research communi-cations, 1988, 153:479–486.97. Jain RC, Konar DB. Blood sugar lowering activity of garlic (Allium sativum Linn.).Medikon, 1977, 6:12–18.Bulbus Allii Sativi3198. Jain RC, Vyas CR, Mahatma OP. Hypoglycaemic action of onion and garlic. Lancet,1973, ii:1491.99. Jain RC, Vyas CR. Garlic in alloxan-induced diabetic rabbits. American journal ofclinical nutrition, 1975, 28:684–685.100. Osman SA. Chemical and biological studies of onion and garlic in an attempt toisolate a hypoglycemic extract. In: Proceedings of the fourth Asian Symposium ofMedicinal Plants and Spices. Bangkok, 1980:117.101. Zacharias NT et al. Hypoglycemic and hypolipidemic effects of garlic in sucrose fedrats. Indian journal of physiology and pharmacology, 1980, 24:151–154.102. Srivastana VK, Afao Z. Garlic extract inhibits accumulation of polyols and hydra-tion in diabetic rat lens. Current science, 1989, 58:376–377.103. Farva D et al. Effects of garlic oil on streptozotocin-diabetic rats maintainedon normal and high fat diets. Indian journal of biochemistry and biophysics, 1986, 23:24–27.104. Venmadhi S, Devaki T. Studies on some liver enzymes in rats ingesting ethanol andtreated with garlic oil. Medical science research, 1992, 20:729–731.105. Kumar CA et al. Allium sativum: effect of three weeks feeding in rats. Indian journalof pharmacology, 1981, 13:91.106. Chi MS, Koh ET, Stewart TJ. Effects of garlic on lipid metabolism in rats fedcholesterol or lard. Journal of nutrition, 1982, 112:241–248.107. Swanston-Flatt SK et al. Traditional plant treatments for diabetes. Studies in normaland streptozotocin diabetic mice. Diabetologia, 1990, 33:462–464.108. Mathew PT, Augusti KT. Studies on the effects of allicin (diallyl disulfide-oxide) onalloxan diabetes. Part I. Hypoglycemic action and enhancement of serum insulineffect and glycogen synthesis. Indian journal of biochemistry and biophysics, 1973,10:209–221.109. Mascolo N et al. Biological screening of Italian medicinal plants for anti-inflammatory activity. Phytotherapy research, 1987, 1:28–31.110. Wagner H, Wierer M, Fessler B. Effects of garlic constituents on arachidonatemetabolism. Planta medica, 1987, 53:305–306.111. Gaffen JD, Tavares IA, Bennett A. The effect of garlic extracts on contractions of ratgastric fundus and human platelet aggregation. Journal of pharmacy and pharmacology,1984, 36:272–274.112. Aqel MB, Gharaibah MN, Salhab AS. Direct relaxant effects of garlic juice onsmooth and cardiac muscles. Journal of ethnopharmacology, 1991, 33:13–19.113. Rashid A, Hussain M, Khan HH. Bioassay for prostaglandin-like activity of garlicextract using isolated rat fundus strip and rat colon preparation. Journal of thePakistan Medical Association, 1986, 36:138–141.114. Neil HA, Silagy CA. Garlic: its cardioprotectant properties. Current opinions inlipidology, 1994, 5:6–10.115. Silagy CA, Neil A. A meta-analysis of the effect of garlic on blood pressure. Journalof hypertension, 1994, 12:463–468.116. Silagy CA, Neil A. Garlic as a lipid lowering agent: a meta-analysis. Journal of theRoyal College of Physicians of London, 1994, 28:39–45.117. Warshafsky S, Kamer RS, Sivak SL. Effect of garlic on total serum cholesterol. Ameta-analysis. Annals of internal medicine, 1993, 119:599–605.118. Brosche T, Platt D. Garlic as a phytogenic lipid lowering drug: a review of clinicaltrials with standardized garlic powder preparation. Fortschritte der Medizin, 1990,108:703–706.119. Harenberg J, Giese C, Zimmermann R. Effects of dried garlic on blood coagulation,fibrinolysis, platelet aggregation, and serum cholesterol levels in patients withhyperlipoproteinemia. Atherosclerosis, 1988, 74:247–249.120. Bordia A et al. Effect of essential oil of garlic on serum fibrinolytic activity inpatients with coronary artery disease. Atherosclerosis, 1977, 26:379–386.WHO monographs on selected medicinal plants32121. Chutani SK, Bordia A. The effect of fried versus rawgarlic on fibrinolytic activityin man. Atherosclerosis, 1981, 38:417–421.122. Wolf S, Reim M. Effect of garlic on conjunctival vessels: a randomised, placebo-controlled, double-blind trial. British journal of clinical practice, 1990, 44:36–39.123. Kiesewetter H, Jung F. Beeinflusst Knoblauch die Atherosklerose? MedizinischeWelt, 1991, 42:21–23.124. Jung H, Kiesewetter H. Einfluss einer Fettbelastung auf Plasmalipide und kapillareHautdurchblutung unter Knoblauch. Medizinische Welt, 1991, 42:14–17.125. Bordia A. Klinische Untersuchung zur Wirksamkeit von Knoblauch. Apotheken-Magazin, 1986, 6:128–131.126. Bordia A. Knoblauch und koronare Herzkrankheit: Wirkungen einer dreijährigenBehandlung mit Knoblauchextrakt auf die Reinfarkt- und Mortalitätsrate. DeutscheApotheker Zeitung, 1989, 129:16–17.127. Sitprija S et al. Garlic and diabetes mellitus phase II clinical trial. Journal of theMedical Association of Thailand, 1987, 70:223–227.128. Burnham BE. Garlic as a possible risk for postoperative bleeding. Plastic and recon-structive surgery, 1995, 95:213.129. Petry JJ. Garlic and postoperative bleeding. Plastic and reconstructive surgery, 1995,96:483–484.130. Sunter WH. Warfarin and garlic. Pharmaceutical journal, 1991, 246:722.131. Schimmer O et al. An evaluation of 55 commercial plant extracts in the Amesmutagenicity test. Pharmazie, 1994, 49:448–451.132. Zhang YS, Chen XR, Yu YN. Antimutagenic effect of garlic (Allium sativum) on4NQO-induced mutagenesis in Escherichia coli WP2. Mutation research, 1989,227:215–219.133. Siegers CP. Allium sativum. In: De Smet PA et al., eds. Adverse effects of herbal drugs,Vol. 1. Berlin, Springer-Verlag, 1992:73–76.134. Rose KD et al. Spontaneous spinal epidural hematoma with associated plateletdysfunction from excessive garlic ingestion: A case report. Neurosurgery, 1990,26:880–882.Aloe33AloeDefinitionAloe is the dried juice of the leaves of Aloe vera (L.) Burm. f. or of A. ferox Mill.and its hybrids with A. africana Mill. and A. spicata Baker (Liliaceae) (1–6).SynonymsAloe vera (L.) Burm. f.Aloe barbadensis Mill., Aloe chinensis Bak., A. elongata Murray, A. indica Royle, A.officinalis Forsk., A. perfoliata L., A. rubescens DC, A. vera L. var. littoralis König exBak., A. vera L. var. chinensis Berger, A. vulgaris Lam. (7).In most formularies and reference books, Aloe barbadensis Mill. is regarded asthe correct species name, and Aloe vera (L.) Burm. f. is considered a synonym.However, according to the International Rules of Botanical Nomenclature, Aloevera (L.) Burm. f. is the legitimate name for this species (8–10). The genus Aloehas also been placed taxonomically in a family called Aloeaceae.Aloe ferox Mill.Aloe horrida Haw., A. perfoliata Thunberg., A. pseudoferox Salm. Dyck, A. socotrinaMasson., A. supralaevis Haw., Pachydendron ferox Humb. & Bonpl., P. supralaeveHaw. (7).Selected vernacular namesAloe capensis, aloe curacao, aloe vera, aloes, aloès, aloès du Cape, aloèsfèroce, aloes vrai, aloès vulgaire, alovis, Barbadoes aloe, Barbadoes aloes,Barbados aloe, Bergaalwyn, Bitteraalwyn, Cape aloe, chirukattali, Curacaoaloe, Curacao aloes, Curacao alos, Echte Aloe, ghai kunwar, ghai kunwrar,gheekuar, ghikanvar, ghikuar, ghikumar, ghikumari, ghikwar, ghiu kumari,ghrita kumari, ghritakumari, grahakanya, gwar-patha, haang takhe, hlaba,Indian aloe, jadam, korphad, kumari, kumaro, kunvar pata, kunwar, laloi,laluwe, lo-hoei, lo-hoi, lou-houey, lu wei, luchuy, manjikattali, Mediterraneanaloe, murr sbarr, musabar, rokai, sabbara, saber, sábila, sabilla, sabr, saibr,savila, savilla, semper vivum, shubiri, sibr, siang-tan, star cactus, tuna, umhlaba,waan haang charakhe, wan-hangchorakhe, yaa dam, yadam, zábila, zambila (1,7, 11).WHO monographs on selected medicinal plants34DescriptionAloe vera (L.) Burm. f.Succulent, almost sessile perennial herb; leaves 30–50cm long and 10cm broadat the base; colour pea-green (when young spotted with white); bright yellowtubular flowers 25–35cm in length arranged in a slender loose spike; stamensfrequently project beyond the perianth tube (12).Aloe ferox Mill.Arborescent perennial shrub with a single stem of 2–3m in height, crowned bya large rosette of numerous leaves which are glaucous, oval-lanceolate, 40–60cm in length, thorny on the ridge and the edges; inflorescence an erectraceme 60cm in height; flowers with perianth 2.5cm in length, red, yellow, ororange (2).Plant material of interest: dried juiceSolidified juice originating in the cells of the pericycle and adjacent leaf paren-chyma, and flowing spontaneously from the cut leaf, allowed to dry with orwithout the aid of heat.It is not to be confused with Aloe Vera Gel, which is the colourless mucilagi-nous gel obtained from the parenchymatous cells in the leaves of Aloe vera (L.)Burm. f. (13).General appearanceCuracao or Barbados Aloe, derived from Aloe vera (L.) Burm. f.The dried juice occurs in dark chocolate-brown usually opaque masses; frac-ture, dull waxy, uneven, and frequently conchoidal (2, 6).Cape Aloe, derived from A. ferox Mill. and its hybrids withA. africana Mill. and A. spicata BakerThe dried juice occurs in dark brown or greenish brown glassy masses, oftencovered with a yellowish powder; in thin fragments it is transparent andexhibits a yellowish, reddish brown or greenish tinge; fracture, smooth, even,and glassy (2, 6).Organoleptic propertiesAloe is marketed as opaque masses that range from reddish black to brownishblack to dark brown in colour. Odour, characteristic and disagreeable; taste,somewhat sour, nauseating and very bitter (2, 7, 12).Aloe35Microscopic characteristicsSee “Powdered plant material” below.Powdered plant materialPowdered aloes are yellowish brown to dark reddish brown. Microscopically,Cape Aloe appears as transparent brown or greenish brown irregular andangular fragments; Curacao Aloe shows fragments with numerous minuteacicular crystals embedded in an amorphous matrix (1–3, 12, 14).Geographical distributionNative to southern and eastern Africa, and subsequently introduced into north-ern Africa, the Arabian peninsula, China, Gibraltar, the Mediterranean coun-tries, and the West Indies (15). It is commercially cultivated in Aruba, Bonaire,Haiti, India, South Africa, the United States of America, and Venezuela (2, 7, 12,14, 15).General identity testsMacroscopic and microscopic examinations (1–3, 7, 12, 14); solvent solubility(hot alcohol, boiling water, and ether) determination (2, 4–6); chemical reac-tions (1–6, 8, 12–14); and thin-layer chromatographic analysis employingbarbaloin as the reference standard (4–7).Purity testsMicrobiologyThe test for Salmonella spp. in aloe products should be negative. The maximumacceptable limits of other microorganisms are as follows (16–18). For prepara-tion of decoction: aerobic bacteria—not more than 107/g; fungi—not morethan 105/g; Escherichia coli—not more than 102/g. Preparations for internal use:aerobic bacteria—not more than 105/g or ml; fungi—not more than 104/g or ml;enterobacteria and certain Gram-negative bacteria—not more than 103/g or ml;Escherichia coli—0/g or ml.Foreign organic matterAdulterants: Aloe in commerce may sometimes be adulterated with blackcatechu, pieces of iron, and stones. These can be detected by examining alco-hol-soluble extracts under ultraviolet light which gives a deep brown colourwith aloe and a black colour with catechu (14).Total ashNot more than 2% (3–5).WHO monographs on selected medicinal plants36Water-soluble extractsNot less than 50% (1, 2, 14).Alcohol-insoluble extractsNot more than 10% (1–3, 14).MoistureNot more than 10% for Cape Aloe (6), and not more than 12% for Curacao orBarbados Aloe (2–6, 14).Pesticide residuesTo be established in accordance with national requirements. Normally,the maximum residue limit of aldrin and dieldrin for Aloe is not more than0.05mg/kg (18). Forother pesticides, see the WHO guidelines on quality controlmethods for medicinal plants (16) and guidelines for predicting dietary intake ofpesticide residues (19).Heavy metalsRecommended lead and cadmium levels are not more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (16).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (16).Other testsAcid-insoluble ash and chemical tests to be established in accordance withnational requirements.Chemical assaysThin-layer chromatography and microchemical analyses are employed for thequalitative analysis for the presence of anthracene glycosides (1–7, 12, 14).Quantitative analysis of total anthracene glycosides, calculated as barbaloin, isperformed by spectrophotometry (4, 5).Curacao or Barbados Aloe, derived from Aloe vera (L.) Burm. f.Contains not less than 28% of hydroxyanthracene derivatives, expressed asbarbaloin (4–6).Aloe37Cape Aloe, derived from A. ferox Miller and its hybrids withA. africana Mill. and A. spicata BakerContains not less than 18% of hydroxyanthracene derivatives, expressed asbarbaloin (4, 5).Major chemical constituentsAloe contains as its major and active principles hydroxyanthrone derivatives,mainly of the aloe-emodin-anthrone 10-C-glucoside type. The major constitu-ent is known as barbaloin (aloin) (15–40%) (8, 13). It also contains hydroxyaloin(about 3%). Barbaloin (�aloin) is in fact a mixture of aloin A (10S) [1] and B(10R) [2]. A. ferox also contains aloinoside A [3] and B [4]. Aloin A and Binterconvert through the anthranol form as do aloinoside A and B (13).Dosage formsPowdered, dried juice and preparations thereof for oral use.Medicinal usesUses supported by clinical dataShort-term treatment of occasional constipation (2, 12, 13, 15).Uses described in pharmacopoeias and in traditional systems ofmedicineNone.Uses described in folk medicine, not supported by experimental orclinical dataTreatment of seborrhoeic dermatitis, peptic ulcers, tuberculosis, and fungalinfections, and for reduction of blood sugar (glucose) levels (11, 20).OHCH 3OH OOHα-L-rhamnopyranosylor6-deoxy-α-L-mannopyranosyl10OOHOHOHCH2OHOOH OHCH2ORH[1] R = H[3] R = α-L-rhamnopyranosyl10OOHOHOHCH2OHOOH OHCH2ORH[2] R = H[4] R = α-L-rhamnopyranosylWHO monographs on selected medicinal plants38PharmacologyExperimental pharmacologyAs shown for senna, Aloe’s mechanism of action is twofold. It stimulatescolonic motility, augmenting propulsion and accelerating colonic transit, whichreduces fluid absorption from the faecal mass. It also increases paracellularpermeability across the colonic mucosa probably owing to an inhibition of Na�,K�-adenosine triphosphatase or to an inhibition of chloride channels (8, 21, 22),which results in an increase in the water content in the large intestine (21).Clinical pharmacologyThe laxative effects of Aloe are due primarily to the 1, 8-dihydroxyanthraceneglycosides, aloin A and B (formerly designated barbaloin) (23, 24). After oraladministration aloin A and B, which are not absorbed in the upper intestine, arehydrolysed in the colon by intestinal bacteria and then reduced to the activemetabolites (the main active metabolite is aloe-emodin-9-anthrone) (25, 26),which like senna acts as a stimulant and irritant to the gastrointestinal tract (27).The laxative effect of Aloe is not generally observed before 6 hours after oraladministration, and sometimes not until 24 or more hours after.ToxicityThe major symptoms of overdose are griping and severe diarrhoea with conse-quent losses of fluid and electrolytes. Treatment should be supportive withgenerous amounts of fluid. Electrolytes, particularly potassium, should bemonitored in all recipients, especially in children and the elderly (28).ContraindicationsAs with other stimulant laxatives, products containing Aloe should not be usedin patients with intestinal obstruction or stenosis, atony, severe dehydrationwith electrolyte depletion, or chronic constipation (28). Aloe should not beadministered to patients with inflammatory intestinal diseases, such as appen-dicitis, Crohn disease, ulcerative colitis, irritable bowel syndrome, ordiverticulitis, or to children under 10 years of age. Aloe should not be usedduring pregnancy or lactation except under medical supervision after evaluatingbenefits and risks. Aloe is also contraindicated in patients with cramps, colic,haemorrhoids, nephritis, or any undiagnosed abdominal symptoms such aspain, nausea, or vomiting (28, 29).WarningsAloe-containing products should be used only if no effect can be obtainedthrough a change of diet or use of bulk-forming products. Stimulant laxativeproducts should not be used when abdominal pain, nausea, or vomiting arepresent. Rectal bleeding or failure to have a bowel movement within 24 hoursAloe39after use of a laxative may indicate a serious condition. Chronic use may causedependence and need for increased dosages, disturbances of water and electro-lyte balance (e.g. hypokalaemia), and an atonic colon with impaired function(28).The use of stimulant laxatives for more than 2 weeks requires medicalsupervision.Chronic abuse with diarrhoea and consequent fluid and electrolyte losses(mainly hypokalaemia) may cause albuminuria and haematuria, and may resultin cardiac and neuromuscular dysfunction, the latter particularly in the case ofconcomitant use of cardiac glycosides (digoxin), diuretics, corticosteroids, orliquorice root (see Precautions below).PrecautionsGeneralLaxatives containing anthraquinone glycosides should not be used continuouslyfor longer than 1–2 weeks, owing to the danger of electrolyte imbalance.Drug interactionsDecreased intestinal transit time may reduce absorption of orally administereddrugs (30).Existing hypokalaemia resulting from long-term laxative abuse can poten-tiate the effects of cardiotonic glycosides (digitalis, strophanthus) and anti-arrhythmic drugs such as quinidine (30). The induction of hypokalaemia bydrugs such as thiazide diuretics, adrenocorticosteroids, and liquorice root maybe enhanced, and electrolyte imbalance may be aggravated (31).Drug and laboratory test interactionsStandard methods may not detect anthranoid metabolites, so measurements offaecal excretion may not be reliable (26).Urinary excretion of certain anthranoid metabolites may discolour the urine,which is not clinically relevant but which may cause false positive results forurinary urobilinogen, and for estrogens when measured by the Kober procedure(30).Carcinogenesis, mutagenesis, impairment of fertilityData on the carcinogenicity of Aloe are not available. While chronic abuse ofanthranoid-containing laxatives was hypothesized to play a role in colorectalcancer, no causal relationship between anthranoid laxative abuse and colorectalcancer has been demonstrated (32–35).In vitro (gene mutation and chromosome aberration tests) and in vivo (micro-nucleus test in murine bone marrow) genotoxicity studies, as well as humanand animal pharmacokinetic data, indicate no genotoxic risk from Cape Aloe(36–38).WHO monographs on selected medicinal plants40Pregnancy: teratogenic effectsNo teratogenic or fetotoxic effects were seen in rats after oral treatment withaloe extract (up to 1000mg/kg) or aloin A (up to 200mg/kg) (39).Pregnancy: non-teratogenic effectsAloe should not be used during pregnancy except under medical supervisionafter benefits and risks have been evaluated (40).Nursing mothersAnthranoid metabolites appear in breast milk. Aloe should not be used duringlactation except under medical supervision, as there are insufficient data avail-able to assess the potential for pharmacological effects in the breast-fed infant(30, 40).PaediatricuseOral use of Aloe in children under 10 years old is contraindicated.Adverse reactionsAbdominal spasms and pain may occur after even a single dose. Overdose canlead to colicky abdominal spasms and pain, as well as the formation of thin,watery stools (28).Chronic abuse of anthraquinone stimulant laxatives can lead to hepatitis(41). Long-term laxative abuse may lead to electrolyte disturbances(hypokalaemia, hypocalcaemia), metabolic acidosis, malabsorption, weightloss, albuminuria, and haematuria (30, 42, 43). Weakness and orthostatichypotension may be exacerbated in elderly patients when stimulant laxativesare repeatedly used (31). Secondary aldosteronism may occur owing to renaltubular damage after aggravated use. Steatorrhoea and protein-losinggastroenteropathy with hypoalbuminaemia have also been observed, as haveexcessive excretion of calcium in the stools and osteomalacia of the vertebralcolumn (44, 45). Melanotic pigmentation of the colonic mucosa (pseudo-melanosis coli) has been observed in individuals taking anthraquinone laxativesfor extended time periods (29, 42). The pigmentation is clinically harmless andusually reversible within 4 to 12 months after the drug is discontinued (29, 42).Conflicting data exist on other toxic effects such as intestinal-neuronal damageafter long-term use (42, 46).PosologyThe correct individual dose is the smallest amount required to produce asoft-formed stool (26). As a laxative for adults and children over 10 years old,0.04–0.11g (Curacao or Barbados Aloe) or 0.06–0.17g (Cape Aloe) of the driedjuice (6, 14), corresponding to 10–30mg hydroxyanthraquinones per day, or0.1g as a single dose in the evening.Aloe41References1. The United States pharmacopeia XXIII. Rockville, MD, US Pharmacopeial Convention,1996.2. African pharmacopoeia, Vol. 1, 1st ed. Lagos, Organization of African Unity, Scientific,Technical & Research Commission, 1985.3. The Japanese pharmacopoeia XIII. Tokyo, The Society of Japanese Pharmacopoeia,1996.4. Pharmacopée française. Paris, Adrapharm, 1996.5. European pharmacopoeia, 2nd ed. Strasbourg, Council of Europe, 1995.6. British pharmacopoeia. London, Her Majesty’s Stationery Office, 1993.7. Hänsel R et al., eds. Hagers Handbuch der Pharmazeutischen Praxis, Vol. 6, 5th ed.Berlin, Springer, 1994.8. Bradley PR, ed. British herbal compendium, Vol. 1. Bournemouth, British HerbalMedicine Association, 1992:199–203.9. Newton LE. In defence of the name Aloe vera. The cactus and succulent journal of GreatBritain, 1979, 41:29–30.10. Tucker AO, Duke JA, Foster S. Botanical nomenclature of medicinal plants. In:Cracker LE, Simon JE, eds. Herbs, spices and medicinal plants, Vol. 4. Phoenix, AR, OryxPress, 1989:169–242.11. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois atChicago, IL, August 8, 1995 production (an on-line database available directlythrough the University of Illinois at Chicago or through the Scientific and TechnicalNetwork (STN) of Chemical Abstracts Services).12. Youngken HW. Textbook of pharmacognosy, 6th ed. Philadelphia, Blakiston, 1950.13. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.14. The Indian pharmaceutical codex. Vol. I. Indigenous drugs. New Delhi, Council ofScientific & Industrial Research, 1953.15. Haller JS. A drug for all seasons, medical and pharmacological history of aloe. Bulletinof the New York Academy of Medicine, 1990, 66:647–659.16. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.17. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.18. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.19. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).20. Castleman M. The healing herbs. Emmaus, PA, Rodale Press, 1991:42–44.21. de Witte P. Metabolism and pharmacokinetics of anthranoids. Pharmacology, 1993,47(Suppl. 1):86–97.22. Ishii O, Tanizawa H, Takino Y. Studies of Aloe III. Mechanism of laxative effect.Chemical and pharmaceutical bulletin, 1990, 38:197–200.23. Tyler VE, Bradley LR, Robbers JE, eds. Pharmacognosy, 9th ed. Philadelphia, Lea &Febiger, 1988:62–63.24. Tyler VE. Herbs of choice. New York, Pharmaceutical Products Press, 1994:155–157.25. Che QM et al. Isolation of human intestinal bacteria capable of transformingbarbaloin to aloe-emodin anthrone. Planta medica, 1991, 57:15–19.26. Aloe capensis, Cape Aloes: proposal for the summary of product characteristics. Elburg,Netherlands, European Scientific Committee of Phytotherapy, 1995.27. Reynolds JEF, ed. Martindale, the extra pharmacopoeia, 30th ed. London, Pharmaceuti-cal Press, 1993:903.WHO monographs on selected medicinal plants4228. Goodman and Gilman’s the pharmacological basis of therapeutics, 8th ed. New York,McGraw Hill, 1990.29. Bisset NG. Sennae folium. In: Max Wichtl’s herbal drugs & phytopharmaceuticals. BocaRaton, FL, CRC Press, 1994:463–469.30. American Hospital Formulary Service. Bethesda, MD, American Society of HospitalPharmacists, 1990.31. United States pharmacopeia, drug information. Rockville, MD, United States Pharma-copeial Convention, 1992.32. Siegers CP et al. Anthranoid laxative abuse—a risk for colorectal cancer. Gut, 1993,34:1099–1101.33. Siegers CP. Anthranoid laxatives and colorectal cancer. Trends in pharmacologicalsciences, 1992, 13:229–231.34. Patel PM et al. Anthraquinone laxatives and human cancer. Postgraduate medicaljournal, 1989, 65:216–217.35. Loew D. Pseudomelanosis coli durch Anthranoide. Zeitschrift für Phytotherapie, 1994,16:312–318.36. Lang W. Pharmacokinetic–metabolic studies with 14C-aloe emodin after oral admin-istration to male and female rats. Pharmacology, 1993, 47(Suppl. 1):73–77.37. Brown JP. A review of the genetic effects of naturally occurring flavonoids, an-thraquinones and related compounds. Mutation research, 1980, 75:243–277.38. Westendorf J et al. Genotoxicity of naturally occurring hydroxyanthraquinones.Mutation research, 1990, 240:1–12.39. Bangel E et al. Tierexperimentelle pharmakologische Untersuchungen zur Frage derabortiven und teratogenen Wirkung sowie zur Hyperämie von Aloe. Steiner-Informationsdienst, 1975, 4:1–25.40. Lewis JH, Weingold AB. The use of gastrointestinal drugs during pregnancy andlactation. American journal of gastroenterology, 1985, 80:912–923.41. Beuers U, Spengler U, Pape GR. Hepatitis after chronic abuse of senna. Lancet, 1991,337:472.42. Muller-Lissner SA. Adverse effects of laxatives: facts and fiction. Pharmacology, 47,1993, (Suppl. 1):138–145.43. Godding EW. Therapeutics of laxative agents with special reference to the an-thraquinones. Pharmacology, 1976, 14(Suppl. 1):78–101.44. Heizer WD et al. Protein-losing gastroenteropathy and malabsorption associatedwith factitious diarrhoea. Annals of internal medicine, 1968, 68:839–852.45. Goodman and Gilman’s the pharmacological basis of therapeutics, 9th ed. New York,McGraw Hill, 1996.46. Kune GA. Laxative use not a risk for colorectal cancer: data from the Melbournecolorectal cancer study. Zeitschrift für Gasteroenterologie, 1993, 31:140–143.Aloe Vera Gel43Aloe Vera GelDefinitionAloe Vera Gel is the colourless mucilaginous gel obtained from the parenchy-matous cells in the fresh leaves of Aloe vera (L) Burm. f. (Liliaceae) (1, 2).SynonymsAloe barbadensis Mill., Aloe chinensis Bak., A. elongata Murray, A. indica Royle, A.officinalis Forsk., A. perfoliata L., A. rubescens DC, A. vera L. var. littoralis König exBak., A. vera L. var. chinensis Berger, A. vulgaris Lam. (2–5). Most formularies andreference books regard Aloe barbadensis Mill. as the correct species name, andAloe vera (L.) Burm. f. as a synonym. However,according to the InternationalRules of Botanical Nomenclature, Aloe vera (L.) Burm. f. is the legitimate namefor this species (2–4). The genus Aloe has also been placed taxonomically in afamily called Aloeaceae.Selected vernacular namesAloe vera gel, aloe gel.DescriptionSucculent, almost sessile perennial herb; leaves 30–50cm long and 10cm broadat the base; colour pea-green (when young spotted with white); bright yellowtubular flowers 25–35cm in length arranged in a slender loose spike; stamensfrequently project beyond the perianth tube (6).Plant material of interest: liquid gel from the fresh leafAloe Vera Gel is not to be confused with the juice, which is the bitter yellowexudate originating from the bundle sheath cells of the leaf. The drug Aloeconsists of the dried juice, as defined on page 33.General appearanceThe gel is a viscous, colourless, transparent liquid.Organoleptic propertiesViscous, colourless, odourless, taste slightly bitter.WHO monographs on selected medicinal plants44Microscopic characteristicsNot applicable.Geographical distributionProbably native to north Africa along the upper Nile in the Sudan, and subse-quently introduced and naturalized in the Mediterranean region, most of thetropics and warmer areas of the world, including Asia, the Bahamas, CentralAmerica, Mexico, the southern United States of America, south-east Asia, andthe West Indies (2).General identity testsTo be established in accordance with national requirements.Purity testsMicrobiologyThe test for Salmonella spp. in Aloe Vera Gel should be negative. Acceptablemaximum limits of other microorganisms are as follows (7–9). For external use:aerobic bacteria—not more than 102/ml; fungi—not more than 102/ml; entero-bacteria and certain Gram-negative bacteria—not more than 101/ml; Staphylo-coccus spp.—0/ml. (Not used internally.)MoistureContains 98.5% water (10).Pesticide residuesTo be established in accordance with national requirements. For guidance, seeWHO guidelines on quality control methods for medicinal plants (7) and guide-lines on predicting dietary intake of pesticide residues (11).Heavy metalsRecommended lead and cadmium levels are not more than 10 and 0.3mg/kg,respectively, in the final dosage form (7).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (7).Other testsChemical tests for Aloe Vera Gel and tests for total ash, acid-insoluble ash,alcohol-soluble residue, foreign organic matter, and water-soluble extracts to beestablished in accordance with national requirements.Aloe Vera Gel45Chemical assaysCarbohydrates (0.3%) (12), water (98.5%) (10). Polysaccharide compositionanalysis by gas–liquid chromatography (13).Major chemical constituentsAloe Vera Gel consists primarily of water and polysaccharides (pectins, hemi-celluloses, glucomannan, acemannan, and mannose derivatives). It also containsamino acids, lipids, sterols (lupeol, campesterol, and �-sitosterol), tannins, andenzymes (1). Mannose 6-phosphate is a major sugar component (14).Dosage formsThe clear mucilaginous gel. At present no commercial preparation has beenproved to be stable. Because many of the active ingredients in the gel appear todeteriorate on storage, the use of fresh gel is recommended. Preparation of freshgel: harvest leaves and wash them with water and a mild chlorine solution.Remove the outer layers of the leaf including the pericyclic cells, leaving a“fillet” of gel. Care should be taken not to tear the green rind which cancontaminate the fillet with leaf exudate. The gel may be stabilized by pasteur-ization at 75–80 °C for less than 3 minutes. Higher temperatures held for longertimes may alter the chemical composition of the gel (2).Medicinal usesUses supported by clinical dataNone.Uses described in pharmacopoeias and in traditional systems ofmedicineAloe Vera Gel is widely used for the external treatment of minor wounds andinflammatory skin disorders (1, 14–17). The gel is used in the treatment ofminor skin irritations, including burns, bruises, and abrasions (1, 14, 18). The gelis further used in the cosmetics industry as a hydrating ingredient in liquids,creams, sun lotions, shaving creams, lip balms, healing ointments, and facepacks (1).Aloe Vera Gel has been traditionally used as a natural remedy for burns (18,19). Aloe Vera Gel has been effectively used in the treatment of first- andsecond-degree thermal burns and radiation burns. Both thermal and radiationburns healed faster with less necrosis when treated with preparations contain-ing Aloe Vera Gel (18, 19). In most cases the gel must be freshly preparedbecause of its sensitivity to enzymatic, oxidative, or microbial degradation.Aloe Vera Gel is not approved as an internal medication, and internal adminis-tration of the gel has not been shown to exert any consistent therapeutic effect.WHO monographs on selected medicinal plants46Uses described in folk medicine, not supported by experimental orclinical dataThe treatment of acne, haemorrhoids, psoriasis, anaemia, glaucoma, petit ulcer,tuberculosis, blindness, seborrhoeic dermatitis, and fungal infections (2, 6, 19).PharmacologyWound healingClinical investigations suggest that Aloe Vera Gel preparations acceleratewound healing (14, 18). In vivo studies have demonstrated that Aloe Vera Gelpromotes wound healing by directly stimulating the activity of macrophagesand fibroblasts (14). Fibroblast activation by Aloe Vera Gel has been reported toincrease both collagen and proteoglycan synthesis, thereby promoting tissuerepair (14). Some of the active principles appear to be polysaccharides com-posed of several monosaccharides, predominantly mannose. It has been sug-gested that mannose 6-phosphate, the principal sugar component of Aloe VeraGel, may be partly responsible for the wound healing properties of the gel (14).Mannose 6-phosphate can bind to the growth factor receptors on the surface ofthe fibroblasts and thereby enhance their activity (14, 15).Furthermore, acemannan, a complex carbohydrate isolated from Aloeleaves, has been shown to accelerate wound healing and reduce radiation-induced skin reactions (20, 21). The mechanism of action of acemannan ap-pears to be twofold. First, acemannan is a potent macrophage-activating agentand therefore may stimulate the release of fibrogenic cytokines (21, 22).Second, growth factors may directly bind to acemannan, promoting theirstability and prolonging their stimulation of granulation tissue (20).The therapeutic effects of Aloe Vera Gel also include prevention of progres-sive dermal ischaemia caused by burns, frostbite, electrical injury and intra-arterial drug abuse. In vivo analysis of these injuries demonstrates that Aloe VeraGel acts as an inhibitor of thromboxane A2, a mediator of progressive tissuedamage (14, 17). Several other mechanisms have been proposed to explain theactivity of Aloe Vera Gel, including stimulation of the complement linked topolysaccharides, as well as the hydrating, insulating, and protective propertiesof the gel (1).Because many of the active ingredients appear to deteriorate on storage, theuse of fresh gel is recommended. Studies of the growth of normal human cellsin vitro demonstrated that cell growth and attachment were promoted by expo-sure to fresh Aloe vera leaves, whereas a stabilized Aloe Vera Gel preparationwas shown to be cytotoxic to both normal and tumour cells. The cytotoxiceffects of the stabilized gel were thought to be due to the addition of othersubstances to the gel during processing (23).Anti-inflammatoryThe anti-inflammatory activity of Aloe Vera Gel has been revealed by a numberof in vitro and in vivo studies (14, 17, 24, 25). Fresh Aloe Vera Gel significantlyAloe Vera Gel47reduced acute inflammation in rats (carrageenin-induced pawoedema), al-though no effect on chronic inflammation was observed (25). Aloe Vera Gelappears to exert its anti-inflammatory activity through bradykinase activity(24) and thromboxane B2 and prostaglandin F2 inhibition (18, 26). Furthermore,three plant sterols in Aloe Vera Gel reduced inflammation by up to 37% incroton oil-induced oedema in mice (15). Lupeol, one of the sterol compoundsfound in Aloe vera, was the most active and reduced inflammation in a dose-dependent manner (15). These data suggest that specific plant sterols may alsocontribute to the anti-inflammatory activity of Aloe Vera Gel.Burn treatmentAloe Vera Gel has been used for the treatment of radiation burns (27–30).Healing of radiation ulcers was observed in two patients treated with Aloe veracream (27), although the fresh gel was more effective than the cream (29, 30).Complete healing was observed, after treatment with fresh Aloe Vera Gel, intwo patients with radiation burns (30). Twenty-seven patients with partial-thickness burns were treated with Aloe Vera Gel in a placebo-controlled study(31). The Aloe Vera Gel-treated lesions healed faster (11.8 days) than the burnstreated with petroleum jelly gauze (18.2 days), a difference that is statisticallysignificant (t-test, P � 0.002).ContraindicationsAloe Vera Gel is contraindicated in cases of known allergy to plants in theLiliaceae.WarningsNo information available.PrecautionsNo information available concerning general precautions, or precautions deal-ing with carcinogenesis, mutagenesis, impairment of fertility; drug and labora-tory test interactions; drug interactions; nursing mothers; paediatric use; orteratogenic or non-teratogenic effects on pregnancy.Adverse reactionsThere have been a few reports of contact dermatitis and burning skin sensationsfollowing topical applications of Aloe Vera Gel to dermabraded skin (18, 32).These reactions appeared to be associated with anthraquinone contaminants inthis preparation (33). A case of disseminated dermatitis has been reportedfollowing application of Aloe Vera Gel to a patient with stasis dermatitis (34).An acute bullous allergic reaction and contact urticaria have also been reportedto result from the use of Aloe Vera Gel (35).WHO monographs on selected medicinal plants48PosologyFresh gel or preparations containing 10–70% fresh gel.References1. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.2. Grindlay D, Reynolds T. The Aloe vera phenomenon: a review of the properties andmodern uses of the leaf parenchyma gel. Journal of ethnopharmacology, 1986, 16:117–151.3. Newton LE . In defence of the name Aloe vera. The cactus and succulent journal of GreatBritain, 1979, 41:29–30.4. Tucker AO, Duke JA, Foster S. Botanical nomenclature of medicinal plants. In:Cracker LE, Simon JE, eds. Herbs, spices and medicinal plants, Vol. 4. Phoenix, AR, OryxPress, 1989:169–242.5. Hänsel R et al., eds. Hagers Handbuch der Pharmazeutischen Praxis, Vol. 6, 5th ed.Berlin, Springer, 1994.6. Youngken HW. Textbook of pharmacognosy, 6th ed. Philadelphia, Blakiston, 1950.7. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.8. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.9. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.10. Rowe TD, Park LM. Phytochemical study of Aloe vera leaf. Journal of the AmericanPharmaceutical Association, 1941, 30:262–266.11. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).12. Pierce RF. Comparison between the nutritional contents of the aloe gel from conven-tional and hydroponically grown plants. Erde international, 1983, 1:37–38.13. Hart LA et al. An anti-complementary polysaccharide with immunological adjuvantactivity from the leaf of Aloe vera. Planta medica, 1989, 55:509–511.14. Davis RH et al. Anti-inflammatory and wound healing of growth substance in Aloevera. Journal of the American Pediatric Medical Association, 1994, 84:77–81.15. Davis RH et al. Aloe vera, hydrocortisone, and sterol influence on wound tensilestrength and anti-inflammation. Journal of the American Pediatric Medical Association,1994, 84:614–621.16. Heggers JP, Pelley RP, Robson MC. Beneficial effects of Aloe in wound healing.Phytotherapy research, 1993, 7:S48–S52.17. McCauley R. Frostbite—methods to minimize tissue loss. Postgraduate medicine,1990, 88:67–70.18. Shelton RM. Aloe vera, its chemical and therapeutic properties. International journal ofdermatology, 1991, 30:679–683.19. Haller JS. A drug for all seasons, medical and pharmacological history of aloe. Bulletinof New York Academy of Medicine, 1990, 66:647–659.20. Tizard AU et al. Effects of acemannan, a complex carbohydrate, on wound healingin young and aged rats. Wounds, a compendium of clinical research and practice, 1995,6:201–209.21. Roberts DB, Travis EL. Acemannan-containing wound dressing gels reduceradiation-induced skin reactions in C3H mice. International journal of radiation oncology,biology and physiology, 1995, 15:1047–1052.22. Karaca K, Sharma JM, Norgren R. Nitric oxide production by chicken macrophagesAloe Vera Gel49activated by acemannan, a complex carbohydrate extracted from Aloe vera. Interna-tional journal of immunopharmacology, 1995, 17:183–188.23. Winters WD, Benavides R, Clouse WJ. Effects of aloe extracts on human normal andtumor cells in vitro. Economic botany, 1981, 35:89–95.24. Fujita K, Teradaira R. Bradykininase activity of aloe extract. Biochemical pharmacology,1976, 25:205.25. Udupa SI, Udupa AL, Kulkarni DR. Anti-inflammatory and wound healing proper-ties of Aloe vera. Fitoterapia, 1994, 65:141–145.26. Robson MC, Heggers J, Hagstrom WJ. Myth, magic, witchcraft or fact? Aloe verarevisited. Journal of burn care and rehabilitation, 1982, 3:157–162.27. Collin C. Roentgen dermatitis treated with fresh whole leaf of Aloe vera. Americanjournal of roentgen, 1935, 33:396–397.28. Wright CS. Aloe vera in the treatment of roentgen ulcers and telangiectasis. Journal ofthe American Medical Association, 1936, 106:1363–1364.29. Rattner H. Roentgen ray dermatitis with ulcers. Archives of dermatology and syphilogy,1936, 33:593–594.30. Loveman AB. Leaf of Aloe vera in treatment of roentgen ray ulcers. Archives ofdermatology and syphilogy, 1937, 36:838–843.31. Visuthikosol V et al. Effect of Aloe vera gel on healing of burn wounds: a clinical andhistological study. Journal of the Medical Association of Thailand, 1995, 78:403–409.32. Hormann HP, Korting HC. Evidence for the efficacy and safety of topical herbaldrugs in dermatology: Part 1: Anti-inflammatory agents. Phytomedicine, 1994, 1:161–171.33. Hunter D, Frumkin A. Adverse reactions to vitamin E and Aloe vera preparations afterdermabrasion and chemical peel. Cutis, 1991, 47:193–194.34. Horgan DJ. Widespread dermatitis after topical treatment of chronic leg ulcers andstasis dermatitis. Canadian Medical Association Journal, 1988, 138:336–338.35. Morrow DM, Rappaport MJ, Strick RA. Hypersensitivity to aloe. Archives of derma-tology, 1980, 116:1064–1065.WHO monographs on selected medicinal plants50Radix AstragaliDefinitionRadix Astragali is the dried root of Astragalus membranaceus (Fisch.) Bunge andAstragalus mongholicus Bunge (Fabaceae) (1, 2).SynonymsFabaceae are also known as Leguminosae.Astragalus membranaceus (Fisch.) BungeA. propinguus B. Schischk. (3).Astragalus mongholicus BungeA. membranaceus (Fisch.) Bunge var. mongholicus (Bunge) Hsiao (3).Selected vernacular namesAstragalus root, hoàng ký, huang-chi, huangoi, huangqi, huángqi, hwanggi,membranous milkvetch, milkvetch, Mongolian milk-vetch, neimeng huangqi,ogi, ougi, zhongfengnaomaitong(1, 3–9).DescriptionAstragalus membranaceus (Fisch.) BungePerennial herb, 25–40cm tall. Leaves 3–6cm long; petiole obsolete; stipules free,cauline, green, triangular ovate, sparingly vested on the outside with white hair.Leaflets oblong-obovate, oval or oblong-oval. Racemes oblong-ovoid to ovoid,4–5cm long, 10–15 flowers; bracts lanceolate. Calyx 8–9mm long, campanu-late, strongly oblique, glabrous. Corolla yellowish, 18–20mm long. Ovary gla-brous (4). Root cylindrical or nearly cylindrical with small bases of lateral rootdispersed on the surface, and usually not branched; greyish yellow to yellowishbrown epidermis and fibrous fracture (2, 5).Astragalus mongholicus BungePerennial herb, 60–150cm tall. Leaves pinnate, leaflets broadly elliptical.Raceme axillary. Calyx tubular 5mm long. Corolla yellowish; pod ovate-Fructus Bruceae59Fructus BruceaeDefinitionFructus Bruceae consists of the dried ripe fruits of Brucea javanica (L.) Merr.(Simaroubaceae) (1, 2).SynonymsBrucea amarissima Desv. ex Gomes, B. sumatrana Roxb., Gonus amarissimus Lour.,Lussa amarissima O. Ktze (2, 3).Selected vernacular namesBiji makassar, bulah makassar, Java brucea, k’u-shen-tzu, kho sam, ko-sam, ku-sheng-tzu, nha dàm tùr, raat cha dat, raat dat, ratchadat, sàu dau rùng, xoanrùng, ya tan tzu, ya-dan-zi, yadãnzi (1–7).DescriptionA shrub or small tree, 1–3m high; younger parts softly pubescent. Leavescompound-paripinnate; leaflets 5–11, oval-lanceolate, 5–10cm long by 2–4cmwide; apex acuminate, base broadly cuneate and often somewhat oblique;margin serrate; both surfaces densely pubescent, especially the underside. Flow-ers minute, purple, in numerous small cymes or clusters collected into axillarypanicles. Sepals 4, connate at the base. Petals 4, villous, glandular at the tips.Male flowers, stamens 4, pistil reduced to a stigma; female flowers, stamens 4,much reduced. Ovary with 4 free carpels. Fruit and drupe ovoid, black whenripe. Seeds, compressed, rugose, blackish brown (3–5).Plant material of interest: dried ripe fruit or seedFruit also refers to the kernel or seed with the pulp removed (3, 4).General appearanceThe fruit is ovoid, 6–10mm long by 4–7mm in diameter. Externally black orbrown, with raised reticulate wrinkles, the lumen irregularly polygonal, obvi-ously ribbed at both sides. Apex acuminate, base having a dented fruit stalkscar, shell hard and brittle. Seeds ovoid, 5–6mm long by 3–5mm in diameter,externally yellowish white, reticulate; testa thin, cotyledons milky white andoily (1, 3, 4).WHO monographs on selected medicinal plants60Organoleptic propertiesOdour slight; taste, very bitter (1, 4).Microscopic characteristicsThe pulverized pericarp is brown. Epidermal cells polygonal, with brown cellu-lar contents; parenchymatous cells polygonal, containing clusters of calciumoxalate prisms, up to 30mm in diameter. Stone cells subrounded or polygonal,14–38mm in diameter (1).Powdered plant materialPowdered seeds yellowish white. Testa cells polygonal and slightly elongated.Endosperm and cotyledon cells contain aleurone grains (1).Geographical distributionIndigenous to China, India, Indonesia, and Viet Nam (3, 4).General identity testsMacroscopic and microscopic examinations (1, 3, 4).Purity testsMicrobiologyThe test for Salmonella spp. in Fructus Bruceae products should be negative. Themaximum acceptable limits of other microorganisms are as follows (8–10). Forpreparation of decoction: aerobic bacteria—not more than 107/g; fungi—notmore than 105/g; Escherichia coli—not more than 102/g. Preparations (capsules)for internal use: aerobic bacteria—not more than 105/g; fungi—not more than104/g; enterobacteria and certain Gram-negative bacteria—not more than 103/g;Escherichia coli—0/g.Foreign organic matterNot more than 2% (2).Total ashNot more than 6% (2).Acid-insoluble ashNot more than 0.6% (2).Radix Bupleuri67Radix BupleuriDefinitionRadix Bupleuri consists of the dried root of Bupleurum falcatum L. or B. falcatumL. var. scorzonerifolium (Willd.) Ledeb. (Apiaceae) (1, 2).SynonymsBupleurum chinense D.C. and B. scorzonerifolium Willd. have been treated asdifferent species (1) but are actually synonyms of B. falcatum L. var.scorzonerifolium (3). Apiaceae are also referred to as Umbelliferae.Selected vernacular namesBeichaihu, bupleurum root, ch’ai hu, chaifu, chaihu, chaiku-saiko, Chinesethorowax root, juk-siho, kara-saiko, mishima-saiko, nanchaihu, northern Chi-nese thorowax root, radix bupleur, saiko, shi ho, shoku-saiko, wa-saiko, Yama-saiko (1–5).DescriptionA perennial herb up to 1m tall; base woody and the rhizome branching. Stemslender, flexuous, branches spreading. Basal leaves lanceolate, upper laminabroad, lower narrowed into a petiole, veins 7, apex acute, mucronate; middleand upper leaves linear to lanceolate, gradually shorter, falcate, veins 7–9, baseslightly amplexicaul, apex acuminate. Involucre of 1–3 minute bracts or lacking.Rays 5–8. Involucel of 5 minute, 3-veined bractlets, shorter than the floweringumbellet. Pedicels shorter than the fruits. Fruit oblong, 3–4mm long; furrows 3-vittate (4, 6).Plant material of interest: dried rootsGeneral appearanceSingle or branched root, of long cone or column shape, 10–20cm in length, 0.5–1.5cm in diameter; occasionally with remains of stem on crown; externally lightbrown to brown and sometimes with deep wrinkles; easily broken, and frac-tured surface somewhat fibrous (2).WHO monographs on selected medicinal plants68Organoleptic propertiesOdour, characteristic, slightly aromatic to rancid; taste, slightly bitter (1, 2).Microscopic characteristicsTransverse section reveals often tangentially extended clefts in cortex, thethickness reaching a third to a half of the radius, and cortex scattered with agood many intercellular schizogenous oil canals 1.5–3.5cm in diameter; vesselslined radially or stepwise in xylem, with scattered fibre groups; in the crownpith also contains oil canals; parenchyma cells filled with starch grains and someoil drops. Starch grains composed of simple grains, 2–10µm in diameter, orcompound grains (2).Powdered plant materialInformation not available. Description to be established by appropriate nationalauthorities.Geographical distributionIndigenous to northern Asia, northern China, and Europe (4, 6).General identity testsMacroscopic and microscopic examinations (1, 2), microchemical detection forsaponins (1, 2), and thin-layer chromatographic analysis for triterpene saponinswith reference to saikosaponins (2).Purity testsMicrobiologyThe test for Salmonella spp. in Radix Bupleuri should be negative. The maxi-mum acceptable limits of other microorganisms are as follows (7–9). For prepa-ration of decoction: aerobic bacteria—not more than 107/g; fungi—not morethan 105/g; Escherichia coli—not more than 102/g.ChemicalContains triterpene saponins (saikosaponins). Quantitative level to be estab-lished by appropriate national authorities, but should be not less than 1.5%according to literature data.Foreign organic matterNot more than 10% of stems and leaves (2). No roots of B. longiradiantumTurcz., which is toxic (1, 5). Not more than 1% of other foreign matter (2).Radix Bupleuri69Total ashNot more than 6.5% (2).Acid-insoluble ashNot more than 2% (2).Dilute ethanol-soluble extractiveNot less than 11% (2).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Radix Bupleuri is not morethan 0.05mg/kg (9). For other pesticides, see WHO guidelines on quality controlmethods for medicinal plants (7) and WHO guidelines for predicting dietaryintake of pesticide residues (10).Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (7).Radioactive residuesFor analysis of strontium-90,iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (7).Other testsTests for moisture and for water-soluble extractive to be established by nationalauthorities.Chemical assaysTotal saikosaponins determination by colorimetric analysis (11), and high-performance liquid chromatography analysis for saikosaponins A, B1, B2, and D(12, 13).Major chemical constituentsThe major constituents are triterpene saponins, including saikosaponins A,B1–4, D, E, F and H and related compounds including saikogenins A–G (5, 14).Two biologically active polysaccharides, bupleurans 2IIb and 2IIc, have alsobeen isolated from the roots of B. falcatum (15, 16). Representative structures ofsaikosaponins are presented in the figure.WHO monographs on selected medicinal plants70Dosage formsDecoction (5). Store crude plant material in a dry environment protected frommoths, light, and moisture (1, 2).Medicinal usesUses supported by clinical dataNone.Uses described in pharmacopoeias and in traditional systems ofmedicineTreatment of fever, pain, and inflammation associated with influenza, and thecommon cold (1, 2, 5). The drug is also used as an analgesic for the treatment ofdistending pain in the chest and hypochondriac regions, and for amenorrhoea(1). Extracts have been used for the treatment of chronic hepatitis, nephroticsyndrome, and autoimmune diseases (1, 5).R1R2CH3CH3HOHCH2OHCH3HCH2OHCH 3 CH3CH3HR1R2CH3CH3HOHCH2OHCH3HCH 3 CH3CH3HOHsaikogenin Gsaikogenin F R1 = OH , R2 = HR1 = H , R2 = OH3-O-β-D-glucopyranosyl-β-D-fucopyranosylor3-O-β-D-glucopyranosyl-6-deoxy-β-D-galactopyranosyl=osylOOHOHOHCH 2OHOCH 3OH OOHOR1R2CH3 CH 3HCH 2OHCH3HCH2OHCH3 CH3CH3Hosylsaikosaponin B1saikosaponin B2 R1 = H , R2 = OHOR1R2CH3 CH3HCH 2OHCH3HCH3 CH3CH3HOHosylOR1R2CH3 CH3HCH2OHCH 3HCH2OHCH 3 CH 3CH3HHH3COosylHR1 = OH , R2 = HR1 = H , R2 = OHsaikosaponin B 3saikosaponin B 4saikosaponin Asaikosaponin DR1 = OH , R2 = HR1 = H , R2 = OHsaikogenin Asaikogenin DR1 = OH , R2 = HR1 = H , R2 = OHR1 = OH , R2 = HRadix Bupleuri71Uses described in folk medicine, not supported by experimental orclinical dataTreatment of deafness, dizziness, diabetes, wounds, and vomiting (5).PharmacologyExperimental pharmacologyAntipyretic and analgesic activityA number of in vivo studies have confirmed the antipyretic activity of RadixBupleuri in the treatment of induced fevers in animals. Oral administration ofa Bupleurum decoction (5g/kg) to rabbits with a heat-induced fever decreasedbody temperature to normal levels within 1.5 hours (5). Subcutaneous injectionof an aqueous ethanol extract of Bupleurum roots (2.2ml/kg, 1.1g crude drug/ml)significantly reduced fevers in rabbits injected with Escherichia coli (17).Oral administration of saikosaponins to rats produced hypothermic andantipyretic effects (5). Furthermore, intraperitoneal injection of the volatile oil(300mg/kg) or saponins (380 and 635mg/kg) isolated from B. chinense (B.falcatum) roots effectively decreased fever in mice induced by yeast injections(18). Oral administration of 200–800mg/kg of a crude saponin fraction tomice produced sedative, analgesic, and antipyretic effects, but no anticon-vulsant effect or reduction in muscle tone was observed (14). Saikosaponins arebelieved to be the major active antipyretic constituents in Radix Bupleuriextracts.Analgesic activity of Bupleurum extracts is also supported by in vivo studies.Injections of a crude Bupleurum extract or purified sapogenin A inhibitedwrithing induced by intraperitoneal injection of acetic acid in mice (5). Thesaikosaponins appear to be the active analgesic constituents of the drug. Intra-peritoneal injection of mice with a total saponin fraction derived from B.chinense (B. falcatum) produced a marked analgesic effect on the pain induced byelectroshock (5). Moreover, orally administered saikosaponins were reported tohave an analgesic effect in mice (tail pressure test) (5).Sedative effectsIn vivo studies have also confirmed the sedative effects of Radix Bupleuri. Boththe crude saikosaponin fraction and saikogenin A are reported to have signifi-cant sedative effects (5). In vivo studies, using the rod climbing test, demon-strated that the sedative effect of the saikosaponins (200–800mg/kg) in micewas similar to that of meprobamate (100mg) (5). Oral administration ofsaikosides extracted from B. chinense (B. falcatum) or saikosaponin A has alsobeen reported to prolong cyclobarbital sodium-induced sleep (5). Furthermore,intraperitoneal injection of saikogenin A inhibited rod climbing in mice andantagonized the stimulant effects of metamfetamine and caffeine (5).WHO monographs on selected medicinal plants72Anti-inflammatory activityAnti-inflammatory activity of Radix Bupleuri has been demonstrated byin vivo studies. Intraperitoneal injection of the saponin fraction, the volatileoil, or a crude extract from B. chinense (B. falcatum) significantly inhibitedcarrageenin-induced rat paw oedema (5). The saikosaponins are the active anti-inflammatory constituents of the drug (19, 20). Oral administration of a crudesaikosaponin fraction (2g/kg) from B. falcatum inhibited dextran-, serotonin-, orcroton oil-induced rat paw oedema (5, 21). Structure–activity correlations haverevealed that saikosaponins A and D both have anti-inflammatory activity,while saikosaponin C does not (22). The potency of anti-inflammatory activityof the saikosaponins is similar to that of prednisolone (5).Immune regulation activityIn vitro studies have demonstrated that a hot-water extract from the root of B.falcatum enhanced the antibody response and inhibited mitogen-induced lym-phocyte transformation (23). An acidic pectic polysaccharide, bupleuran 2IIb,isolated from the roots of B. falcatum, was found to be a potent enhancer ofimmune complex binding to macrophages (24). The activity of this polysaccha-ride appeared to be due to its ability to enhance the Fc receptor function ofmacrophages. This study has shown that the binding of glucose oxidase–antiglucose oxidase complexes (a model of immune complexes) to murineperitoneal macrophages was stimulated by treatment with the polysaccharide(24). Bupleuran 2IIb appears to up-regulate both FcRI and FcRII receptor expres-sion on the macrophage surface in a dose-dependent manner (25). The up-regulation of the Fc receptor by bupleuran 2IIb depends on an increase inintracellular calcium and activation of calmodulin (25). Only saikosaponin Dhas been shown to enhance Fc receptor expression of thioglycollate-elicitedmurine peritoneal macrophages in vitro (26). This activity appears to be due tothe translocation of FcR from the internal pool to the cell surface. In vitro studieswith saikosaponin D have shown that this compound was able to controlbidirectionally the growth response of T lymphocytes stimulated by con-canavalin A, anti-CD3 monoclonal antibody, and calcium ionophore A23187plus phorbol 12-myristate 13-acetate (27). Saikosaponin D also promotedinterleukin-2 production and receptor expression, as well as c-fos gene tran-scription (28). The results of this study suggest that saikosaponin D exerts itsimmunostimulant effects by modification of T lymphocyte function (28).Antiulcer activityAntiulcer activity of Radix Bupleuri has been demonstrated both in vivo and invitro. A polysaccharide fraction of a hot-water extract of the root of B. falcatumwas reported to inhibit significantly hydrochloric acid- or ethanol-inducedulcerogenesis in mice (15). The polysaccharide fraction (BR-2, 100mg/kg) hadpotent antiulcer activity, and its activity was similar to that of sucralfate(100mg/kg) (29). BR-2 significantly protected againsta variety of gastric lesions,Radix Bupleuri73water-immersion stress ulcer and pylorus-ligation ulcer in mice and rats (29). Byoral, intraperitoneal, or subcutaneous administration, BR-2 was further found tobe effective against hydrochloric acid- or ethanol-induced gastric lesions sug-gesting that BR-2 acted both locally and systemically (29). The mechanism ofantiulcer action appears to be due to a reinforcement of the protective mucosalbarrier as well as an antisecretory action on acid and pepsin (30). Saponinsisolated from B. falcatum root have also been reported to have weak antiulceractivity in the pylorus-ligation ulcer model (30).Hepatoprotectant activityCrude saponins of B. falcatum, administered orally to rats at a daily dose of500mg/kg for 3 days, normalized liver functions as determined by serumalkaline phosphatase levels in rats treated with carbon tetrachloride (31). Treat-ment of rats with saikosaponins 2 hours before treatment with D-galactosamineinhibited the increase in serum aspartate aminotransferase and alanineaminotransferase levels produced by damage of liver tissues (31). Conversely,saikosaponins did not affect an increase in serum alanine aminotransferase andexperimental cirrhosis in rats caused by carbon tetrachloride intoxication (32).Clinical pharmacologyAntipyretic activityThe antipyretic activity of B. chinense (B. falcatum) has been investigated inpatients with fevers caused by the common cold, influenza, malaria, and pneu-monia (5). In one clinical study of 143 patients treated with the herb, feverssubsided within 24 hours in 98.1% of all cases of influenza, and in 87.9% of allcases of the common cold (5, 33). In another study, 40 patients with fever ofpathological origin had a significant reduction in fever (1–2°C), but theantipyretic effect of Radix Bupleuri in these patients was transient unless com-bined with antibiotic therapy (5, 34).ContraindicationsNo information available.WarningsRadix Bupleuri causes sedation when used in large doses (5); therefore, patientsshould be cautious when operating a motor vehicle or hazardous machinery.PrecautionsDrug interactionsThe use of alcohol, sedatives and other central nervous system depressants inconjunction with Radix Bupleuri may cause synergistic sedative effects. Noclinical studies have evaluated this possible interaction; however, patientsWHO monographs on selected medicinal plants74should be cautioned about taking the drug with alcohol, sedatives, or otherdrugs known to cause depression of the central nervous system.Carcinogenesis, mutagenesis, impairment of fertilityMethanolic extracts of B. chinense (B. falcatum) were not mutagenic in themodified Ames test using Salmonella typhimurium TA 98 and TA 100, in thepresence or absence of rat liver S-9 mix (35, 36). Furthermore, hot-water extractsof Bupleurum were shown to have antimutagenic activity in AFB1-inducedmutagenesis in the mouse Salmonella typhi/mammalian microsomal system(Ames test) (strain TA 98) and in the in vivo mouse bone marrow cell chromo-some aberration and mouse bone marrow eosinophil micronucleus test (37).There is one report that a hot-water extract of B. falcatum enhanced the mu-tagenic activity of Trp-P-1 with S9 mix in Salmonella typhimurium (38).Pregnancy: teratogenic and non-teratogenic effectsNo data available; therefore, B. falcatum should not be administered duringpregnancy.Nursing mothersExcretion of the drug into breast milk and its effects on the newborn infant havenot been established; therefore, Bupleurum should not be administered to nurs-ing women.Paediatric useGuidelines for the administration of the drug to children are not available.Other precautionsNo information available concerning general precautions or drug and laboratorytest interactions.Adverse reactionsMild lassitude, sedation, and drowsiness have been reported as frequent side-effects (5). Large doses have also been reported to decrease appetite and causepronounced flatulence and abdominal distension. Three incidents of allergicreactions were reported in patients given intramuscular injections of the drug(5).PosologyGenerally, doses of 3–9g/day (1).References1. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992.Radix Bupleuri752. The Pharmacopoeia of Japan XII. Tokyo, The Society of Japanese Pharmacopoeia,1991.3. Wolf H. Umbelliferae—Apioideae—Bupleurum, Trinia et reliqceae Ammineaehecteroclitae. In: Engler A, ed. Pflanzenreich IV. Leipzig, Verlag von Wilhelm Engel-mann, 1910.4. Keys JD. T, Chinese herbs, their botany, chemistry and pharmacodynamics. Rutland, VT,CE Tuttle, 1976.5. Chang HM, But PPH, eds. Pharmacology and applications of Chinese materia medica, Vol.2. Singapore, World Scientific Publishing, 1987.6. Nasir E. Umbelliferae. In: Nasir E, Ali SI, eds. Flora of West Pakistan. Karachi,Pakistan, Stewart Herbarium, 1972:60.7. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.8. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.9. European Pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.10. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva, WorldHealth Organization, 1997 (unpublished document WHO/FSF/FOS/97.7; availablefrom Food Safety, WHO, 1211 Geneva 27, Switzerland).11. Hiai S et al. A simultaneous colorimetric estimation of biologically active andinactive saikosaponins in Bupleurum falcatum extracts. Planta medica, 1976, 29:247–257.12. Shimizu K, Amagaya S, Ogihara Y. Separation and quantitative analysis ofsaikosaponins by high-performance liquid chromatography. Journal of chromatogra-phy, 1986, 268:85–91.13. Han DS, Lee DK. Separation and determination of saikosaponins in Bupleuri Radixwith HPLC. Korean journal of pharmacognosy, 1985, 16:175–179.14. Tang W, Eisenbrand G, eds. Chinese drugs of plant origins, chemistry, pharmacology anduse in traditional and modern medicine. Berlin, Springer-Verlag, 1992.15. Yamada H. Purification of anti-ulcer polysaccharides from the roots of Bupleurumfalcatum. Planta medica, 1991, 57:555–559.16. Yamada H, Hirano M, Kiyohara H. Partial structure of an anti-ulcer pectic polysac-charide from the roots of Bupleurum falcatum L. Carbohydrate research, 1991, 219:173–192.17. Zhu Y. Pharmacology and applications of Chinese medicinal materials. Beijing, People’sMedical Publishing House, 1958.18. Zhou ZC et al. Chinese pharmaceutical bulletin, 1979, 14:252 (article in Chinese).19. Yamamoto M, Kumagai A, Yamamura Y. Structure and actions of saikosaponinsisolated from Bupleurum falcatum L. I. Anti-inflammatory action of saikosaponins.Arzneimittel-Forschung, 1974, 25:1021–1023.20. Abe H et al. Pharmacological actions of saikosaponins isolated from Bupleurumfalcatum. 1. Effects of saikosaponins on liver function. Planta medica, 1980, 40:366–372.21. Shibata M et al. Pharmacological studies on the Chinese crude drug saiko, Bupleurumfalcatum. Hoshi yakka daigaku kiyo, 1974, 16:77.22. Shibata S. Medicinal chemistry of triterpenoid saponins and sapogenins. Proceedingsof the 4th Asian Symposium on Medicinal Plants and Spices. Bangkok, Mahidol Univer-sity, 1981:59–70.23. Mizoguchi Y et al. Effects of saiko on antibody response and mitogen-inducedlymphocyte transformation in vitro. Journal of medical and pharmaceutical society forWAKAN-YAKU, 1985, 2:330–336.24. Matsumoto T et al. The pectic polysaccharide from Bupleurum falcatum L. enhancesimmune-complexes binding to peritoneal macrophages through Fc receptor expres-sion. International journal of immunopharmacology, 1993, 15:683–693.WHO monographs on selected medicinal plants7625. Yamada H. Pectic polysaccharides from Chinese herbs—structure and biologicalactivity. Carbohydrate polymers, 1994, 25:269–276.26. Matsumoto T, Yamada H. Regulation of immune complex binding of macrophagesby pectic polysaccharide from Bupleurum falcatum L.—pharmacological evidence forthe requirement of intracellular calcium/calmodulin on Fc receptor up-regulation bybupleuran 2iib. Journal of pharmacy and pharmacology, 1995, 47:152–156.27. Ushio Y, Abe H. Effects of saikosaponin-D on the functions and morphology ofmacrophages. International journal of immunopharmacology, 1991, 13:493–499.28. Kato M et al. Characterization of the immunoregulatory action of saikosaponin D.Cellular immunology, 1994, 159:15–25.29. Sun XB, Matsumoto T, Yamada H. Effects of a polysaccharide fraction from theroots of Bupleurum falcatum L. on experimental gastric ulcer models in rats and mice.Journal of pharmacy and pharmacology, 1991, 43:699–704.30. Shibata M et al. Some pharmacological studies on the crude drugs possessing anti-inflammatory properties of the Bupleurum and the leaves of fig. Shoyakugaku zasshi,1976, 30:62–66.31. Arichi S, Konishi H, Abe H. Studies on the mechanism of action of saikosaponin. I.Effects of saikosaponin on hepatic injury induced by D-galactosamine. Kanzo, 1978,19:430–435.32. Zhao MQ et al. Preventive and therapeutic effects of glycyrrhizin, glycyrrhetic acidand saikosides on experimental cirrhosis in rats. Yao hsueh hsueh pao, 1983, 18:325–331.33. Nanjing Medical College. Encyclopedia of Chinese materia medica, Vol. 2. Shanghai,Shanghai People’s Publishing House, 1978:3763.34. Wuxi First People’s Hospital. Wuxi yiyao [Wuxi medical journal], 1973, 1:42 (article inChinese).35. Yamamoto H, Mizutani T, Nomura H. Studies on the mutagenicity of crude drugextracts. I. Yakugaku zasshi, 1982, 102:596–601.36. Sakai Y et al. Effects of medicinal plant extracts from Chinese herbal medicines onthe mutagenic activity of benzo[a]pyrene. Mutation research, 1988, 206:327–334.37. Liu DX. Antimutagenicity screening of water extracts from 102 kinds of Chinesemedicinal herbs. Chung-kuo tung yao tsa chih, 1990, 15:640–642.38. Niikawa M et al. Enhancement of the mutagenicity of TRP-P-1, TRP-P-2 andbenzo[alpha]pyrene by Bupleuri radix extract. Chemical and pharmaceutical bulletin,1990, 38:2035–2039.Fructus Bruceae61Water-soluble extractiveNot less than 18% (2).Dilute ethanol-soluble extractiveNot less than 26% (2).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin in Fructus Bruceae is not morethan 0.05mg/kg (10). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (8) and guidelines on predicting dietaryintake of pesticide residues (11).Heavy metalsRecommended lead and cadmium levels are no more than 10.0 and 0.3mg/kg,respectively, in the final dosage form of the plant material (8).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (8).Other purity testsChemical and moisture tests to be established in accordance with nationalrequirements.Chemical assaysContains bruceosides and related quassinoids. Quantitative content require-ment to be established. Quantitative determination of quassinoid triterpenes bya high-performance liquid chromatographic method developed for the determi-nation of bruceoside A (12).Major chemical constituentsQuassinoid triterpenes, including bruceantin, bruceantinol, bruceantinoside A,bruceins A–G and Q, brucein E 2-O-�-D-glucoside, bruceolide, bruceosides A–C, brusatol, dehydrobruceantinol, dehydrobruceins A and B, dehydrobrusatol,dihydrobrucein A, yadanzigan, yadanziolides A–D, and yadanziosides A–Ppredominate as the secondary metabolite constituents (13, 14). Representativequassinoid structures are presented in the figure.WHO monographs on selected medicinal plants62Dosage formsSeeds for decoction, or capsules (1, 3, 4). Store in airtight container, protectedfrom light and moisture (1).Medicinal usesUses supported by clinical dataNone.Uses described in pharmacopoeias and in traditional systems ofmedicineTreatment of amoebic dysentery and malaria (1, 3, 14, 15).Uses described in folk medicine, not supported by experimental orclinical dataAs a poultice on boils, to treat ringworm, whipworm, roundworm and tape-worm, scurf, centipede bites, haemorrhoids, and enlarged spleen (3–6). Theseed and seed oil have been used in the treatment of warts and corns (1, 4).Fructus Bruceae has been used in the treatment of trichomoniasis, corns andverrucae (6).OHHOOCH3OOCH3OHOOHCH3HO ROHHHOHHR- = brucein B CH3brucein COH CH3CH3CH 3brusatolCH3CH3bruceantinCH3CH3CH3brucein ACH3CH3OCH3OCH3CH3HHHHOOCH3HOCH3H3CO quassinHOHOCH 3OCH3OOHCH3HOHOHHHOHHHOHbrucein DOOHOCH3OCH3OOHCH3HOHHHHHHOHORHailanthinoneCH3CH3R- =OH CH3CH3glaucarubinoneFructus Bruceae63PharmacologyExperimental pharmacologyAmoebicidal and antibacterial activityA number of in vitro studies have indicated that extracts of Brucea javanicakernels are effective amoebicides. In one such study, a crude butanol extract ofB. javanica was highly active against Entamoeba histolytica (16). This amoebicidalactivity was associated with two polar compounds isolated from the extract,bruceantin and brucein C, which are quassinoid constituents (16). (Bruceaquassinoids were active against E. histolytica and other protozoa in vitro (17, 18).)The quassinoids were potent inhibitors of protein synthesis both in mammaliancells and in malaria parasites, and it has been suggested that this effect accountsfor their amoebicidal activity (17). In one other investigation, brusatol, anotherquassinoid isolated from the seeds of B. javanica, was also reported to beeffective in the treatment of dysentery (19). Extracts from the kernels of B.javanica have also been reported to possess antibacterial activity against Shigellashiga, S. flexneri, S. boydii, Salmonella lexington, Salmonella derby, Salmonella typhitype II, Vibrio cholerae inaba and Vibrio cholerae ogawa (20).Antimalarial activityNumerous in vitro and in vivo studies have demonstrated the antiplasmodialactivity of Fructus Bruceae extracts. In vitro studies have determined thatbruceantin, a quassinoid constituent of the drug, exhibited significant anti-plasmodial activity against Plasmodium falciparum (21, 22). Extracts of the drugwere also active in vitro against chloroquine-resistant P. falciparum (23, 24) and invivo against P. berghei (mice) (23, 25). Nine quassinoid constituents of the drughad in vitro IC50 values of 0.046–0.0008mg/ml against chloroquine-resistant P.falciparum strain K-1 (23). Four of these compounds were also active in vivoagainst P. berghei infections in mice after oral dosing (23), and three of thecompounds, bruceins A–C, had in vitro activity comparable to that of theantimalarial drug mefloquine (24). Bruceolide, another quassinoid constituent ofB. javanica, was also effective in vivo (mice) against P. berghei, and was reportedto be more effective than chloroquine (25). A recent in vitro screening ofquassinoids against various protozoa showed that brucein D and brusatol havevery selective inhibitory activity against P. falciparum (17).Quassinoids isolated from B. javanica are reported to have cytotoxic activityin vitro (17, 26, 27). Bruceantin was tested in phase I clinical cancer trials, but notumour regression was observed (28, 29).Clinical pharmacologyBrucea javanica fruit extracts have been used clinically in the treatment ofamoebic dysentery (14, 15). These investigations indicated that theantidysenteric activity of the Brucea extract was less effective than that ofemetine (14, 15).WHO monographs on selectedmedicinal plants64ContraindicationsFructus Bruceae should not be administered to children or pregnant women(6).WarningsNo information available.PrecautionsPregnancy: teratogenic and non-teratogenic effectsNo data available. Preparations containing Fructus Bruceae must not be admin-istered to pregnant women (6).Nursing mothersExcretion of Fructus Bruceae into breast milk and its effects on infants have notbeen established; therefore this drug should not be administered to nursingwomen.Paediatric useFructus Bruceae should not be administered to young children (6).Other precautionsNo information available about general precautions or precautions concerningcarcinogenesis, mutagenesis, or impairment of fertility; drug interactions; ordrug and laboratory test interactions.Adverse reactionsSome cases of anaphylaxis have been reported after external applications of thefruits of B. javanica (30).PosologyDaily dose to treat amoebiasis, 4–16g as a decoction or powder in three divideddoses for 3–7 days (3); to treat malaria, 3–6g in three divided doses after mealsfor 4 or 5 days (3).References1. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992.2. Materia medika Indonesia, Jilid I. Jakarta, Departemen Kesehatan, Republik Indonesia,1977.Fructus Bruceae653. Medicinal plants in Viet Nam. Manila. World Health Organization Regional Office forthe Western Pacific, 1990 (WHO Regional Publications, Western Pacific Series, No.3).4. Medicinal plants in China. Manila, World Health Organization, 1989 (WHO RegionalPublications, Western Pacific Series, No. 2).5. Keys JD. Chinese herbs, their botany, chemistry and pharmacodynamics. Rutland, VT, CETuttle, 1976.6. Hsu HY. Oriental materia medica, a concise guide. Long Beach, CA, Oriental HealingArts Institute, 1986.7. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois atChicago, IL, August 8, 1995 production (an on-line database available directlythrough the University of Illinois at Chicago or through the Scientific and TechnicalNetwork (STN) of Chemical Abstracts Services).8. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.9. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.10. European Pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.11. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva, WorldHealth Organization, 1997 (unpublished document WHO/FSF/FOS/97.7; availablefrom Food Safety, WHO, 1211 Geneva 27, Switzerland).12. Chi H, Wang YP, Zhou TH. Determination of the anticancer drug bruceoside A inthe Chinese drug, Yadanzi (Brucea javanica Merr.). Journal of chromatography, 1991,543:250–256.13. Polonsky J. Quassinoid bitter principles, II. In: Herz W et al., eds. Progress in thechemistry of organic natural products, Vol. 47. Berlin, Springer-Verlag, 1972.14. Tang W, Eisenbrand G. Chinese drugs of plant origin, chemistry, pharmacology and use intraditional and modern medicine. Berlin, Springer-Verlag, 1992:207–222.15. Steak EA. The chemotherapy of protozoan diseases, Vol. 1. Washington, DC, US Govern-ment Printing Office, 1972.16. Keene AT et al. In vitro amoebicidal testing of natural products, Part I. Methodology.Planta medica, 1986, 52:278–285.17. Wright CW et al. Quassinoids exhibit greater selectivity against Plasmodiumfalciparum than against Entamoeba histolytica, Giardia intestinalis or Toxoplasma gondii invitro. Journal of eukaryotic microbiology, 1993, 40:244–246.18. Wright CW et al. Use of microdilution to assess in vitro antiamoebic activities ofBrucea javanica fruit, Simarouba amara stem, and a number of quassinoids. Antimicro-bial agents and chemotherapy, 1988, 32:1725–1729.19. Sato Y, Hasegawa M, Suto N. Identity of brusatol and yatansin, an antidysentericagent. Agricultural and biological chemistry, 1980, 44:951–952.20. Wasuwat S et al. Study on antidysentery and antidiarrheal properties of extracts ofBrucea amarissima. Bangkok, Applied Science Research Center of Thailand, 1971:14(Research Project Report 17/10, 2).21. O’Neill MJ et al. Plants as sources of antimalarial drugs: in vitro antimalarialactivities of some quassinoids. Antimicrobial agents and chemotherapy, 1986, 30:101–104.22. Ayudhaya T et al. Study on the in vitro antimalarial activity of some medicinal plantsagainst Plasmodium falciparum. Bulletin of the Department of Medical Sciences (India),1987, 9:33–38.23. O’Neill MJ. Plants as sources of antimalarial drugs, Part 4. Activity of Brucea javanicafruits against chloroquine-resistant Plasmodium falciparum in vitro and against Plasmo-dium berghei in vivo. Journal of natural products, 1987, 50:41–48.24. Pavanand K et al. In vitro antimalarial activity of Brucea javanica against multi-drugresistant Plasmodium falciparum. Planta medica, 1986, 2:108–111.WHO monographs on selected medicinal plants6625. Ngo VT et al. Effectiveness of Brucea sumatrana plant against malaria. Duoc hoc, 1979,4:15–17.26. Darwish FA, Evan FJ, Phillipson JD. Cytotoxic bruceolides from Brucea javanica.Journal of pharmacy and pharmacology, 1979, 31:10.27. Ohnishi S et al. Bruceosides D, E and F, three new cytotoxic quassinoid glycosidesfrom Brucea javanica. Journal of natural products, 1995, 58:1032–1038.28. Liesmann J et al. Phase I study on Bruceantin administered on a weekly schedule.Cancer treatment report, 1981, 65:883–885.29. Bedikian AY et al. Initial clinical studies with bruceantin. Cancer treatment report,1979, 63:1843–1847.30. Zheng GQ et al. A report on three cases of anaphylaxis caused by externalapplication of the fruit of Brucea javanica. Bulletin of the Chinese materia medica,1986:11–12.Radix Astragali51oblong, glabrous, reticulate. The root is flexible and long and covered with atough, wrinkled, yellowish brown epidermis, which has a tendency to break upinto woolly fibres. The woody interior is yellowish white (6).Plant material of interest: rootGeneral appearanceRadix Astragali is cylindrical, some upper branches relatively thick, 30–90cmlong, 1–3.5cm in diameter. Externally pale brownish yellow or pale brown,with irregular, longitudinal wrinkles or furrows. Texture hard and tenacious,broken with difficulty, fracture highly fibrous and starchy, bark yellowishwhite, wood pale yellow, with radiate striations and fissures, the centre part ofold root occasionally looking like rotten wood, blackish brown or hollowed (1).Organoleptic propertiesColour, pale yellow to yellow-brown; taste, slightly sweet; odour, slight (1, 2,4, 7).Microscopic characteristicsThe transverse section shows cork consisting of many rows of cells. Phello-derm, 3–5 rows of collenchymatous cells. Outer part of phloem rays oftencurved and fissured, fibres in bundles, walls thickened and lignified or slightlylignified, arranged alternately with sieve tube groups; stone cells sometimesvisible near phelloderm. Cambium in a ring. Xylem vessels scattered singly or2 or 3 aggregated in groups; wood fibres among vessel stone cells singly or 2–4 in groups, sometimes visible in rays. Parenchymatous cells contain starchgranules (1).Powdered plant materialYellowish white. Fibres in bundles or scattered, 8–30µm in diameter, thick-walled, with longitudinal fissures on the surface, the primary walls often sepa-rated from the secondary walls, both ends often tassel-like, or slightlytruncated. Bordered-pitted vessels colourless or orange, bordered pits arrangedclosely. Stone cells occasionally visible, rounded, oblong or irregular, slightlythick-walled (1).Geographical distributionIndigenous to China, the Democratic People’s Republic of Korea, Mongolia, andSiberia (5, 6). Commercially cultivated in northern China and the DemocraticPeople’s Republic of Korea (5).WHO monographs on selectedmedicinal plants52General identity testsMacroscopic and microscopic examination and thin-layer chromatographicanalysis for the presence of triterpene saponins (astragaloside I as referencestandard) (1).Purity testsMicrobiologyThe test for Salmonella spp. in Radix Astragali products should be negative. Themaximum acceptable limits of other microorganisms are as follows (10, 11). Forpreparation of decoction: aerobic bacteria—not more than 107/g; fungi—notmore than 105/g; Escherichia coli—not more than 102/g. Preparations for internaluse: aerobic bacteria—not more than 105/g or ml; fungi—not more than 104/g orml; enterobacteria and certain Gram-negative bacteria—not more than 103/g orml; Escherichia coli—0/g or ml.Total ashNot more than 5.0% (1, 2).Acid-insoluble ashNot more than 1.0% (1, 2).Water-soluble extractiveNot less than 17.0% (1).MoistureNot more than 13.0% (2).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin in Radix Astragali is not more than0.05mg/kg (11). For other pesticides, see WHO guidelines on quality controlmethods for medicinal plants (10) and WHO guidelines on predicting dietaryintake of pesticide residues (12).Heavy metalsRecommended lead and cadmium levels are not more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (10).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (10).Radix Astragali53Other testsChemical tests and tests for alcohol-soluble extractive and foreign organicmatter are to be established in accordance with national requirements.Chemical assaysDetermination of triterpene saponins (astragalosides I–X) by thin-layer chro-matographic analysis (1). Concentration limits and quantitative methods needto be established for the triterpene saponins (e.g. astragalosides), as well as forthe polysaccharides.Major chemical constituentsMajor chemical constituents are triterpene saponins (astragalosides I–X andisoastragalosides I–IV), and polysaccharides (e.g. astragalan, astraglucanAMem-P) (3, 13).Dosage formsCrude plant material; extracts. Store in a dry environment protected frommoisture and insects (1).OR1OOOOOR4R3R5CH3OHCH3CH3OHCH3CH3HHHHCH3HOHCH3R2* glc = β-D-glucopyranosylastragaloside Iastragaloside IIastragaloside IIIastragaloside IVastragaloside Vastragaloside VIastragaloside VIIisoastragaloside Iisoastragaloside IIR1 R2 R3 R4 R5glc *Hglc *glc *glc *glc *glc *glc *glc *glc *glc *glc *glc *HHHH HHCH3COCH3COCH3COHHHHCH3COCH3COCH3COHHHHHHHHHHHHHHHHastragaloglucansOHOOOHOHCH2OHOOOHOHCH2OOOHOHCH2OHOHOOOHOHCH2OHOOOHOHCH2OOOHOHCH2OHHOOOHOHCH2OHHOnWHO monographs on selected medicinal plants54Medicinal usesUses supported by clinical dataNone.Uses described in pharmacopoeias and in traditional systems ofmedicineAs adjunctive therapy in the treatment of colds and influenza (1). The herbis used to enhance the immune system and to increase stamina and endurance(1).Also in the treatment of chronic diarrhoea, oedema, abnormal uterine bleed-ing, and diabetes mellitus (1, 4, 14, 15), and as a cardiotonic agent (6).Uses described in folk medicine, not supported by experimental orclinical dataTreatment of nephritis, chronic bronchitis, postpartum urine retention, leprosy,and the sequelae of cerebrovascular accidents (4).PharmacologyExperimental pharmacologyEffect on the immune systemBoth in vitro and in vivo investigations have confirmed that Astragalusmembranaceus enhances the immune system (14–18). In vitro studies have shownthat, at concentrations of 10mg/ml, polysaccharides isolated from the plantincreased the blastization index in mixed lymphocyte cultures and thegranulopexis of macrophages or polymorphonucleates (16). Using the localxenogenic graft-versus-host reaction (assessed in cyclophosphamide-treatedrats) as a model assay for T-cell function, investigators found that mononuclearcells, derived from cancer patients, that were preincubated with a polysaccha-ride fraction from A. membranaceus had significant immunopotentiating activity,and they fully corrected in vitro T-cell function deficiency found in cancerpatients (14). Further investigations of this extract established that the polysac-charide fraction enhanced interleukin-2 activity in the in vitro generation oflymphokine-activated killer cell activity (17). Intravenous injection of thispolysaccharide fraction also reversed cyclophosphamide-induced immunosup-pression in rats (18).A decoction of A. membranaceus given to mice by gastric lavage, daily or onalternate days for 1–2 weeks, increased the phagocytic activity of the reticu-loendothelial system (4, 5). The phagocytic index was significantly enhancedeven when the rehabilitation of the mouse reticuloendothelial system wasdisrupted by injection of carbon particles before the A. membranaceus extractwas administered (4, 5). Extracts of the crude drug enhanced antibody responseto a T-dependent antigen in vivo. Intravenous administration of a crude drugRadix Astragali55extract to normal mice, or mice immunosuppressed by cyclophosphamide,radiation treatment, or ageing, induced the antibody response to a T-dependentantigen (19). Enhancement of this response is associated with an increase in T-helper cell activity in both normal and immunosuppressed mice (19). Other invivo studies performed on cyclophosphamide-immunosuppressed mice havefurther suggested that A. membranaceus root extracts may modulate the immunesystem by activation of macrophages and splenic lymphocytes (20).The immunostimulant activity of A. membranaceus has been associated withthe polysaccharide fractions of the root extract (4, 13, 19, 21). The immune-enhancing polysaccharide molecules have relative molecular masses of ap-proximately 25000 (14, 18, 19). A polysaccharide fraction isolated from A.membranaceus reportedly antagonized the effect of cobra venom on the immunefunction of treated mice and guinea-pigs (22). The venom-treated guinea-pigshad decreased levels of complement and neutrophil phagocytotic activity, aswell as increased levels of neutrophil granular substances. Treatment of theanimals with the polysaccharides antagonized these changes in the venom-treated animals but had no effect in the normal group (22). Recently, a newglycan, named AMem-P, isolated from the roots of A. membranaceus, was shownby use of an in vivo carbon clearance test to significantly potentiate reticuloen-dothelial system activity in mice (13).Radix Astragali is reported to have cardiovascular activity. Alcohol extractsof the drug enhanced both the contractility and contraction amplitude of iso-lated frog or toad hearts (4). Intraperitoneal injection of the drug to dogs did notproduce any immediate effect on heart rate, but 3–4 hours after administrationinverted and biphasic T waves and prolonged S–T intervals were noted (4).Intravenous administration of the drug produced hypotension in rabbits, dogs,and cats (4). Furthermore, saponins isolated from the drug were reportedto exert a positive inotropic effect on isolated rat hearts (23). The saponinsalso decreased the resting potential of cultured rat myocardial cells, suggestingthat they may exert an inotropic effect through the modulation of Na�/K�-exchanging ATPase (23).ToxicologyNo adverse effects were observed in mice after oral administration of up to100g/kg, a dose several hundred times as high as the effective oral dose inhumans (4).Clinical pharmacologyOral or intranasal administration of an aqueous A. membranaceus extractto 1000human subjects decreased the incidence and shortened the course of the com-mon cold (4). Two months of oral administration of the herb significantlyincreased the levels of IgA and IgG in the nasal secretions of patients susceptibleto the common cold (4). Details of these studies were not available.A hot water extract of A. membranaceus root taken by human subjects wasWHO monographs on selected medicinal plants56reported to have a pronounced immunostimulant effect (24). Human adultstreated with an oral dose of Astragalus root (15.6g per person per day for 20days) significantly increased serum IgM, IgE, and cyclic AMP concentrations(24). Extracts of A. membranaceus have been further reported to stimulate theproduction of interferon, a protein with antiviral activity, in both animals andhumans in response to viral infections (21, 25). A hot water extract of the drugadministered intramuscularly for 3–4 months to patients with coxsackievirus Bmyocarditis enhanced natural killer cells, a response which was mediatedthrough interferon induction (15). Furthermore, both natural and recombinantinterferons enhanced the antiviral activity of an A. membranaceus extract (26).ContraindicationsNo information available.WarningsNo information available.PrecautionsCarcinogenesis, mutagenesis, impairment of fertilityExtracts of A. membranaceus root were not mutagenic in a modified Ames testusing Salmonella typhimurium TA 98 and TA 100 (27). Furthermore, an aqueousextract of A. membranaceus was reported to be antimutagenic in that it inhibitedbenzo[a]pyrene-induced mutagenesis in Salmonella typhimurium TA 100 (28,29).Pregnancy: non-teratogenic effectsNo data available; therefore Radix Astragali should not be administered duringpregnancy.Nursing mothersExcretion of the drug into breast milk and its effects on the newborn infant havenot been established; therefore the use of the drug during lactation is notrecommended.Other precautionsNo information available describing general precautions or precautions relatedto drug interactions, drug and laboratory test interactions, paediatric use, orteratogenic effects during pregnancy.Adverse reactionsNo information available.Radix Astragali57PosologyRoot: 9–30g/day for oral use (1).References1. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992.2. The pharmacopoeia of Japan XII. Tokyo, The Society of Japanese Pharmacopoeia,1991.3. Leung A, Foster S. Encyclopedia of common natural ingredients used in food, drugs, andcosmetics, 2nd ed. New York, John Wiley, 1996.4. Chang HM, But PPH, eds. Pharmacology and applications of Chinese materia medica, Vol.2. Singapore, World Scientific Publishing, 1987.5. Morazzoni P, Bombardelli E. Astragalus membranaceus (Fish.) Bge. Milan, Indena,1994.6. Medicinal plants in China. Manila, World Health Organization, 1989 (WHO RegionalPublications, Western Pacific Series, No.2).7. Hsu HY. Oriental materia medica, a concise guide. Long Beach, CA, Oriental HealingArts Institute, 1986.8. Vietnam materia medica. Hanoi, Ministry of Health, 1972.9. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois atChicago, IL, August 8, 1995 production (an on-line database available directlythrough the University of Illinois at Chicago or through the Scientific and TechnicalNetwork (STN) of Chemical Abstracts Services).10. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.11. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.12. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).13. Tomoda M et al. A reticuloendothelial system-activating glycan from the roots ofAstragalus membranaceus. Phytochemistry, 1992, 31:63–66.14. Chu DT, Wong WL, Mavligit GM. Immunotherapy with Chinese medicinal herbs I.Immune restoration of local xenogeneic graft-versus-host reactions in cancer pa-tients by fractionated Astragalus membranaceus in vitro. Journal of clinical laboratoryimmunology, 1988, 25:119–123.15. Yang YZ et al. Effect of Astragalus membranaceus on natural killer cell activity andinduction of alpha- and gamma-interferon in patients with coxsackie B viralmyocarditis. Chung-hua i hseuh tsa chih (English Edition), 1990, 103:304–307.16. Bombardelli E, Pozzi R. Polysaccharides with immunomodulating properties fromAstragalus membranaceus. Europe patent, 1991, 441:278.17. Chu DT et al. Fractionated extract of Astragalus membranaceus, a Chinese medicinalherb, potentiates LAK cell cytotoxicity generated by a low dose of recombinantinterleukin-2. Journal of clinical laboratory immunology, 1988, 26:183–187.18. Chu DT, Wong WL, Mavligit GM. Immunotherapy with Chinese medicinal herbs II.Reversal of cyclophosphamide-induced immune suppression by administration offractionated Astragalus membranaceus in vivo. Journal of clinical laboratory immunology,1988, 25:125–129.19. Zhou KS, Mancini C, Doria G. Enhancement of the immune response in mice byAstragalus membranaceus extracts. Immunopharmacology, 1990, 20:225–233.20. Jin R et al. Immunomodulative effects of Chinese herbs in mice treated with anti-tumor agent cyclophosphamide. Yakugaku zasshi, 1994, 114:533–538.WHO monographs on selected medicinal plants5821. Hou YD et al. Effect of Radix Astragali seu hedysari on the interferon system.Chinese medical journal, 1981, 94:35–40.22. Zhuang MX et al. The effects of polysaccharides of Astragalus membranaceus,Codonopsis pilosula and Panax ginseng on some immune functions in guinea-pigs.Zhongguo yaoxue zazhi, 1992, 27:653–655.23. Wang QL et al. Inotropic action of Astragalus membranaceus Bge. saponins and itspossible mechanism. Zhongguo zhongyao zazhi, 1992, 17:557–559.24. Institute of Basic Medical Sciences, The Chinese Academy of Medical Sciences.Immunity parameters and blood cAMP changes in normal persons after ingestion ofRadix Astragali. Chung hua i hsueh t’sa chih, 1979, 59:31–34.25. Finter NB. Interferons and interferon-inducers. Amsterdam, North Holland, 1973:363.26. Peng JZ et al. Inhibitory effects of interferon and its combination with antiviral drugson adenovirus multiplication. Zhongguo yixue kexueyuan xuebao, 1984, 6:116–119.27. Yamamoto H, Mizutani T, Nomura H. Studies on the mutagenicity of crude drugextracts. I. Yakugaku zasshi, 1982, 102:596–601.28. Wong BY, Lau BH, Teel RW. Chinese medicinal herbs modulate mutagenesis, DNAbinding and metabolism of benzo[a]pyrene. Phytotherapy research, 1992, 6:10–14.29. Liu DX et al. Antimutagenicity screening of water extracts from 102 kinds ofChinese medicinal herbs. Chung-kuo chung yao tsa chi li, 1990, 15:617–620.Herba Centellae77Herba CentellaeDefinitionHerba Centellae consists of the dried aerial parts or the entire plant of Centellaasiatica (L.) Urban. (Apiaceae) (1–5).SynonymsCentella coriacea Nannfd., Hydrocotyle asiatica L., Hydrocotyle lunata Lam. andTrisanthus cochinchinensis Lour. (1, 3, 6). Apiaceae are also known asUmbelliferae.Selected vernacular namesArtaniyae-hindi, Asiatic pennywort, barmanimuni, barmi, bhram buti, boa-bok, bodila-ba-dinku, bokkudu, brahma manduki, brahmi ghi, brahmi-buti,brahmi, bua bok, bua-bok, centella, chhota mani-muni, chi-hsueh-ts’ao, ghibrahmi, ghod tapre, ghodtapre, ghortapre, gotu kola, gotukola, herba pegagan,herba kakikuda, hydrocotyle, hydrocotyle asiatique, idrocotile, imsen korokla,Indian pennywort, Indian water navelwort, Indischer Wassernabel, karinga,karivana, kudangal, luei gong gen, lièn tièn tháo, mandooka parni,mandukaparni, mandukparni, manimuni, marsh pepperwort, matoyahuho,matoyahuhu, mrang-khua, mtwigahuwu, pa-na-e-khaa-doh, phác chèn,phaknok, phalwaen, rau má, saraswathiaaku, takip-kohol,thalkuri, thankuni,thol-kuri, tilkushi, titjari, tono’itahi, tsubo-kusa, tungchian, vallari, vallarei,vitovitolenge, water pennywort, waternavel, yahon-yahon, yerba de chavos(3–11).DescriptionA slender trailing herb, rooting at the nodes. Leaves 1.3–6.3cm diameter, or-bicular reniform, more or less cupped, entire, crenate or lobulate, glabrous; leafstalks 2–5cm long; peduncle about 6mm, often 2–3 nates; pedicels nil; bractssmall, embracing the flowers; inflorescence in single umbel, bearing 1–5flowers, sessile, white or reddish; fruit small, compressed, 8mm long, mericarpslonger than broad, curved, rounded at top, 7–9-ridged, secondary ridges asprominent as the primary, reticulate between them; pericarp much thickened;seed compressed laterally (1, 4, 7 ).WHO monographs on selected medicinal plants78Plant material of interest: aerial part or entire plantGeneral appearanceA slender herb. Stems long, prostrate, emerging from the leaf-axils of a verticalrootstock, filiform, often reddish, with long internodes and rooting at the nodes;leaves thin, long-petioled, several from the rootstock and 1–3 from each node ofthe stems, 1.3–6.3cm diameter, orbicular reniform, more or less cupped, entire,crenate or lobulate, glabrous; petioles very variable in length, 7.5–15cm long ormore, channelled; stipules short, adnate to the petioles forming a sheathing base(4, 5).Organoleptic propertiesColour, greyish green; odour, characteristic; taste, slightly bittersweet (4, 5).Microscopic characteristicsGreyish green with stomata on both surfaces of the leaf, 30 by 28µm, mostlyrubiaceous type. Palisade cells differentiated into 2 layers of cells, 45 by 25µm;spongy parenchyma of about 3 layers of cells with many intercellular spaces,some with crystals of calcium oxalate; midrib region shows 2 or 3 layers ofparenchymatous cells without chloroplastids; petiole shows epidermis withthickened inner walls; collenchyma of 2 or 3 layers of cells; a broad zone ofparenchyma; 7 vascular bundles within parenchymatous zone, 2 in projectingarms and 5 forming the central strand; vessels 15–23µm in diameter. Someparenchymatous cells contain crystals of calcium oxalate. Fruits, epidermis ofpolygonal cells, trichomes similar to the leaves, sheets of elongated parquetrylayer cells, bundles of narrow annular vessels, and parenchymatous cells containsingle large prisms of calcium oxalate (4).Geographical distributionThe plant is indigenous to the warmer regions of both hemispheres, includingAfrica, Australia, Cambodia, Central America, China, Indonesia, the LaoPeople’s Democratic Republic, Madagascar, the Pacific Islands, South America,Thailand, southern United States of America, and Viet Nam. It is especiallyabundant in the swampy areas of India, the Islamic Republic of Iran, Pakistan,and Sri Lanka up to an altitude of approximately 700m (1, 4, 6, 8, 10, 11).General identity testsMacroscopic and microscopic examinations; and microchemical tests for thepresence of triterpenes and reducing sugars (1, 4).Herba Centellae79Purity testsMicrobiologyThe test for Salmonella spp. in Herba Centellae products should be negative. Themaximum acceptable limits of other microorganisms are as follows (12–14). Forpreparation of decoction: aerobic bacteria—not more than 107/g; fungi—notmore than 105/g; Escherichia coli—not more than 102/g. Preparations for internaluse: aerobic bacteria—not more than 105/g or ml; fungi—not more than 104/g orml; enterobacteria and certain Gram-negative bacteria—not more than 103/g orml; Escherichia coli—0/g or ml.Foreign organic matterNot more than 2% (4).Total ashNot more than 19% (2, 3).Acid-insoluble ashNot less than 6% (2).Water-soluble extractiveNot less than 6% (2, 3).Alcohol-soluble extractiveNot less than 9.5% (2, 3).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin in Herba Centellae is not morethan 0.05mg/kg (14). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (12) and guidelines for predicting dietaryintake of pesticide residues (15).Heavy metalsRecommended lead and cadmium levels are not more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (12).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (12).WHO monographs on selected medicinal plants80Other purity testsChemical tests, and tests for drug interactions and moisture to be established bynational authorities.Chemical assaysContains not less than 2% triterpene ester glycosides (asiaticoside andmadecassoside) (10). Determination of asiaticoside and related triterpene esterglycosides by thin-layer chromatography (16) and spectroscopic analysis (17).Major chemical constituentsThe major principles in Herba Centellae are the triterpenes asiatic acid andmadecassic acid, and their derived triterpene ester glycosides, asiaticoside andmadecassoside (8, 10, 11).Dosage formsDried drug for infusion (18); galenic preparations for oral administration (10).Powder or extract (liquid or ointment) for topical application (1, 4). Package inwell-closed, light-resistant containers.Medicinal usesUses supported by clinical dataTreatment of wounds, burns, and ulcerous skin ailments, and prevention ofkeloid and hypertrophic scars (10, 18–21). Extracts of the plant have beenemployed to treat second- and third-degree burns (19). Extracts have been usedtopically to accelerate healing, particularly in cases of chronic postsurgical andpost-trauma wounds (19). Extracts have been administered orally to treat stress-induced stomach and duodenal ulcers (10).Uses described in pharmacopoeias and in traditional systems ofmedicineHerba Centellae is reported to be used in the treatment of leprous ulcers andvenous disorders (5, 6, 8, 10, 22).HCH3CH3CH3HHRCH2OHHCH 3OHOHHHOOCH 3CH3HHR2asiatic acidmadecassic acid R1 = OH , R2 = OHR1 = H , R2 = OH asiaticosidemadecassoside R1 = OH , R2 = rha-glc-glc-R1 = H , R2 = rha-glc-glc-O-α-L-rhamnopyranosyl-(1→4)-O-β-D-glucopyranosyl-(1→6)-β-D-glucopyranosylorO-6-deoxy-α-L-mannopyranosyl-(1→4)-O-β-D-glucopyranosyl-(1→6)-β-D-glucopyranosylrha-glc-glc- =OOHOHOHOOCH3OHOH OOHOOHOHCH2OHHerba Centellae81Studies suggest that extracts of Centella asiatica cause regression of inflam-matory infiltration of the liver in cirrhosis patients (10, 23). Further experimen-tation is needed to confirm these findings.Uses described in folk medicine, not supported by experimental orclinical dataTherapy of albinism, anaemia, asthma, bronchitis, cellulite, cholera, measles,constipation, dermatitis, diarrhoea, dizziness, dysentery, dysmenorrhoea,dysuria, epistaxis, epilepsy, haematemesis, haemorrhoids, hepatitis, hyperten-sion, jaundice, leukorrhoea, nephritis, nervous disorders, neuralgia, rheuma-tism, smallpox, syphilis, toothache, urethritis, and varices; and as an antipyretic,analgesic, anti-inflammatory, and “brain tonic” agent (4, 5, 7). Poultices havebeen used to treat contusions, closed fractures, sprains, and furunculosis (7).PharmacologyExperimental pharmacologyThe pharmacological activity of Centella asiatica is thought to be due to severalsaponin constituents, including asiaticoside, asiatic acid, and madecassic acid(10). In vitro, each of these compounds stimulated the production of humancollagen I, a protein involved in wound healing (24). Stimulation of collagensynthesis in foreskin fibroblast monolayer cultures by an extract from HerbaCentellae has also been reported (25). Asiaticoside accelerated the healing ofsuperficial postsurgical wounds and ulcers by accelerating cicatricial action (21).Asiaticoside stimulates theepidermis by activating the cells of the malpighianlayer in porcine skin, and by keratinization in vitro (26). Topical application ofasiaticoside promoted wound healing in rats and significantly increased thetensile strength of newly formed skin (21, 27).Extracts of C. asiatica, and in particular its major triterpene ester glycoside,asiaticoside, are valuable in the treatment of hypertrophic scars and keloids (21).Asiaticoside has been reported to decrease fibrosis in wounds, thus preventingnew scar formation (21). The mechanism of action appears to be twofold: byincreasing the synthesis of collagen and acidic mucopolysaccharides, and byinhibiting the inflammatory phase of hypertrophic scars and keloids. It hasfurther been proposed that asiaticoside interferes with scar formation by in-creasing the activity of myofibroblasts and immature collagen (21).Extract of Herba Centellae effectively treated stress-induced stomach andduodenal ulcers in humans (10, 28). Oral administration of C. asiatica extract torats produced a dose-dependent reduction in stress-induced gastric ulceration,and the antiulcer activity was similar to that of famotidine (29). The mechanismof action appears to be associated with a central nervous system-depressantactivity of C. asiatica, owing to an increase in the concentration of GABA(γ-aminobutyric acid) in the brain (29).WHO monographs on selected medicinal plants82A 70% ethanol extract of the drug administered intraperitoneally to miceproduced anticonvulsant activity (30).Clinical pharmacologyIn clinical trials, an extract of C. asiatica in a 1% salve or 2% powder acceleratedhealing of wounds (31). A formulation containing asiaticoside as the mainingredient healed 64% of soiled wounds and chronic or recurrent atony thatwas resistant to usual treatment (21). In an open clinical study, treatment of 20patients with soiled wounds and chronic or recurrent atony with a galenicalformulation containing 89.5% C. asiatica healed 64% and produced improve-ment in another 16% of the lesions studied (20). Local application of an extractof the drug to second- and third-degree burns expedited healing, prevented theshrinking and swelling caused by infection, and further inhibited hypertrophicscar formation (11).Twenty-two patients with chronic infected skin ulcers were treated with acream containing a 1% extract of C. asiatica (32). After 3 weeks of treatment,17 of the patients were completely healed and the ulcer size in the remaining5 patients was decreased (32). Another trial using the same cream pre-paration demonstrated similar results (33). A standardized extract of HerbaCentellae was reported to treat ulcus cruris (indolent leg ulcers) effectively inclinical trials (34, 35). In a double-blind study, no significant effect on healingwas observed in patients with ulcus cruris after oral treatment with asiaticoside(36).Oral administration of C. asiatica or asiaticoside and potassium chloridecapsules was reported to be as effective as dapsone therapy in patients withleprosy (37). In a controlled study of 90 patients with perforated leg lesionsowing to leprosy, application of a salve of the plant produced significantlybetter results than a placebo (11, 22, 38).Clinical trials of the drug have demonstrated its antiulcer activity after oraladministration (28, 39, 40). Fifteen patients with peptic or duodenal ulcer weretreated with a titrated extract of Herba Centellae (60.0mg/person). Approxi-mately 93% of the patients exhibited a definite improvement in subjectivesymptoms and 73% of the ulcers were healed as measured by endoscopic andradiological observations (28).Clinical studies of Herba Centellae in the treatment of various venousdisorders has demonstrated a positive therapeutic effect (11). In patients suffer-ing from venous insufficiency who were treated with a titrated extract of thedrug, venous distension and oedema improved significantly, as compared withcontrols (41).ContraindicationsAllergy to plants of the Apiaceae family.Herba Centellae83WarningsNo information available.PrecautionsCarcinogenesis, mutagenesis, impairment of fertilityAsiaticoside has been implicated as a possible skin carcinogen in rodents afterrepeated topical application (42). Further experimentation is needed to substan-tiate this claim.Other precautionsNo information was available concerning drug interactions, drug and laboratorytest interactions, teratogenic or non-teratogenic effects on pregnancy, nursingmothers, or paediatric use.Adverse reactionsAllergic contact dermatitis has been associated with topical application ofC. asiatica (21, 43, 44). However, further testing revealed that these reactionsmay be due to other ingredients in the preparations (45).PosologyOral dose: 0.33–0.68g or by oral infusion of a similar amount three times daily(4–6).References1. African pharmacopoeia, 1st ed. Lagos, Organization of African Unity, Scientific, Tech-nical & Research Commission, 1985.2. Materia medika Indonesia, Jilid I. Jakarta, Departemen Kesehatan, Republik Indonesia,1977.3. Vietnam materia medica. Hanoi, Ministry of Health, 1972.4. The Indian pharmaceutical codex. Vol. I. Indigenous drugs. New Delhi, Council of Scien-tific & Industrial Research, 1953.5. British herbal pharmacopoeia, Part 2. London, British Herbal Medicine Association,1979.6. Iwu MM. Handbook of African medicinal plants. Boca Raton, FL, CRC Press, 1993.7. Medicinal plants in Viet Nam. Manila, World Health Organization, 1990 (WHORegional Publications, Western Pacific Series, No. 3).8. Tyler VE, Brady LR, Robbers JE, eds. Pharmacognosy, 9th ed. Philadelphia, Lea &Febiger, 1988.9. Medicinal plants of India, Vol. 1. New Delhi, Indian Council of Medical Research,1976.10. Kartnig T. Clinical applications of Centella asiatica (L.) Urb. In: Craker LE, Simon JE,eds., Herbs, spices, and medicinal plants: recent advances in botany, horticulture, andpharmacology, Vol. 3. Phoenix, AZ, Oryx Press, 1988:145–173.WHO monographs on selected medicinal plants8411. Farnsworth NR, Bunyapraphatsara N, eds. Thai medicinal plants. Bangkok,Prachachon, 1992.12. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.13. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.14. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.15. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).16. Meng ZM, Zheng YN. Determination of asiaticoside contained in sanjinplan.Zhongguo yaoke daxue xuebao, 1988, 19:205–206.17. Castellani C, Marai A,Vacchi P. The Centella asiatica. Bolletin chimica farmacia, 1981,120:570–605.18. Reynolds JEF, ed. Martindale, the extra pharmacopoeia, 30th ed. London, Pharmaceuti-cal Press, 1993:756.19. Gravel JA. Oxygen dressings and asiaticoside in the treatment of burns. Lavalmedicine, 1965, 36:413–415.20. Bosse JP et al. Clinical study of a new antikeloid agent. Annals of plastic surgery, 1979,3:13–21.21. Morisset R et al. Evaluation of the healing activity of Hydrocotyle tincture in thetreatment of wounds. Phytotherapy research, 1987, 1:117.22. Chaudhuri S et al. Use of common Indian herb Mandukaparni in the treatment ofleprosy (preliminary report). Journal of the Indian Medical Association, 1978, 70:177–180.23. Darnis F et al. Use of a titrated extract of Centella asiatica in chronic hepatic disorders.Semaine hospitaux de Paris, 1979, 55:1749–1750.24. Bonte F et al. Influence of asiatic acid, madecassic acid, and asiaticoside on humancollagen I synthesis. Planta medica, 1994, 60:133–135.25. Maquart FX et al. Stimulation of collagen synthesis in fibroblast cultures bytriterpene extracted from Centella asiatica.Connective tissue research, 1990, 24:107–120.26. May A. The effect of asiaticoside on pig skin in organ culture. European journal ofpharmacology, 1968, 4:177–181.27. Rosen H, Blumenthal A, McCallum J. Effect of asiaticoside on wound healing in therat. Proceedings of the Society of Experimental Biology and Medicine, 1972, 125:279.28. Shin HS et al. Clinical trials of madecassol (Centella asiatica) on gastrointestinal ulcerpatients. Korean journal of gastroenterology, 1982, 14:49–56.29. Chatterjee TK, Chakraborty A, Pathak M. Effects of plant extract Centella asiatica L.on cold restraint stress ulcer in rats. Indian journal of experimental biology, 1992,30:889–891.30. Adesina SK. Studies on some plants used as anticonvulsants in Amerindian andAfrican traditional medicine. Fitoterapia, 1982, 53:147–162.31. Kiesewetter H. Erfahrungsbericht über die Behandlung von Wunden mit Asiaticosid(Madecassol). Wiener medizinische Wochenschrift, 1964, 114:124–126.32. Boiteau P, Ratsimamanga AR. Asiaticoside extracted from Centella asiatica, its thera-peutic uses in healing of experimental or refractory wounds, leprosy, skin tubercu-losis, and lupus. Therapie, 1956, 11:125–149.33. Boiteau P, Ratsimamanga AR. Cicatrizants of vegetable origin and the biostimulins.Bulletin de la Société Scientifique de CASSI, 1957, 32:28.34. Huriez C. Action of the titrated extract of Centella asiatica in the cicatrization of legulcers (10 mg tablets). Apropos of 50 cases. Lille medicale, 1972, 17(Suppl. 3):574–579.35. Bourde C, Bourde J. The place of cicatrizing agents in leg ulcers. Semaine des hôpitauxde Paris, 1952, 2:105–113.Herba Centellae8536. Mayall RC et al. U’lceras troficas-Acbo cicatricial do extrato titulad da Centellaasiatica. Review of Brasilian medicine, 1975, 32:26–29.37. Chakrabarty T, Deshmukh S. Centella asiatica in the treatment of leprosy. Science andculture, 1976, 42:573.38. Nebout M. Résultats d’un essai controlé de l’extrait titre de Centella asiatica(E.T.C.A.) (I) dans une population lepreuse presentant des maux perforantsplantaires. Bulletin de la Société de Pathologie exotique, 1974, 67:471–478.39. Rhee JC, Choi KW. Clinical effect of the titrated extract of Centella asiatica(madecassol) on peptic ulcer. Korean journal of gastroenterology, 1981, 13:35–40.40. Cho KH et al. Clinical experiences of madecassol (Centella asiatica) in the treatmentof peptic ulcer. Korean journal of gastroenterology, 1981, 13:49–56.41. Lythgoe B, Trippett S. Derivatives of Centella asiatica used against leprosy.Centelloside. Nature, 1949, 163:259–260.42. Laerum OD, Iversen OH. Reticuloses and epidermal tumors in hairless mice aftertopical skin applications of cantharidin and asiaticoside. Cancer research, 1972,32:1463–1469.43. Izu R et al. Allergic contact dermatitis from a cream containing Centella asiaticaextract. Contact dermatitis, 1992, 26:192–193.44. Danese P, Carnevali C, Bertazzoni MG. Allergic contact dermatitis due to Centellaasiatica extract. Contact dermatitis, 1994, 31:201.45. Hausen BM. Centella asiatica (Indian pennywort), an effective therapeutic but a weaksensitizer. Contact dermatitis, 1993, 29:175–179.WHO monographs on selected medicinal plants86Flos ChamomillaeDefinitionFlos Chamomillae consists of the dried flowering heads of Chamomilla recutita(L.) Rauschert (Asteraceae) (1–4).SynonymsMatricaria chamomilla L., M. recutita L., M. suaveolens L. (3).In most formularies and reference books, Matricaria chamomilla L. is regardedas the correct species name. However, according to the International Rules ofBotanical Nomenclature, Chamomilla recutita (L.) Rauschert is the legitimatename for this species (5). Asteraceae are also known as Compositae.Selected vernacular namesBaboonig, babuna, babunah camomile, babunj, bunga kamil, camamilla, camo-mile, chamomile, camomilla, chamomille allemande, campomilla, chamomillecommune, camomille sauvage, fleurs de petite camomille, flos chamomillae,german chamomile, hungarian chamomile, Kamille, Kamillen, kamitsure,kamiture, manzanilla, manzanilla chiquita, manzanilla comun, manzanilladulce, matricaire, matricaria flowers, pin heads, sweet false chamomille, sweetfeverfew, wild chamomile (3, 6–9).DescriptionHerbaceous annual; 10–30cm in height, with erect, branching stems and alter-nate, tripinnately divided leaves below and bipinnately divided leaves above,both types having almost filiform lobes; the capitulum (to 1.5cm in diameter)comprises 12–20 white ligulate florets surrounding a conical hollow receptacleon which numerous yellow tubular (disk) florets are inserted; the inflorescenceis surrounded by a flattened imbricated involucre; fruit small, smooth, yellow-ish (3, 7, 10).Plant material of interest: flower headsGeneral appearanceFlos Chamomillae consists of conical flower heads, each bearing a few whiteligulate florets and numerous yellowish orange to pale yellow tubular or diskflorets on conical, narrow hollow receptacles with a short peduncle; disk floretsFlos Chamomillae87perfect and without a pappus; ray florets pistillate, white, 3-toothed and 4-veined; involucre hemispherical, composed of 20–30 imbricate, oblanceolateand pubescent scales; peduncles weak brown to dusky greenish yellow, longi-tudinally furrowed, more or less twisted and up to 2.5cm long; achenes more orless obovoid and faintly 3- to 5-ribbed; pappus none, or slightly membranouscrown (7, 11).Organoleptic propertiesOdour, pleasant, aromatic; taste, aromatic and slightly bitter (1–3).Microscopic characteristicsReceptacle and bracteoles with schizogenous secretory ducts; vascular bundleswith phloem fibres; spiral, annular and reticulate but pitted vessels; lignifiedcells at the bases of the ovaries absent; nearly all parts of florets bear composite-type glandular hairs with short, biseriate stalk and enlarged head, formed ofseveral tiers, each of two cells; ovary with longitudinal bands of small mucilagecells; stigma with elongated papillae at the apex; pollen grains, spherical ortriangular, with numerous short spines (3).Powdered plant materialPowdered Flos Chamomillae is greenish yellow to yellowish brown; spinypollen grains numerous, 18–25µm in diameter; fragments of yellow or whitecorolla, with polygonal, small epidermal cells having straight or slightly wavywalls, sometimes papillosed, and sometimes bearing glandular hairs of com-posite type; fragments of the fibrous layer of anther; fragments from ovary,with glandular hairs and rows of small mucilage cells; green fragments ofparenchyma of involucre; stigma with papillae; cells of the achenes withsclariform perforations in walls; fragments of fibrovascular bundles with spiral,annular and reticulate vessels and sclerenchyma fibres; fragments of involucralbracts with epidermis having elliptical stomata up to 30µm in length, alsovessels and fibres; occasional fibre from the stems; minute cluster crystals ofcalcium oxalate, up to 10µm in diameter; fragments of lignified parenchyma ofthe filaments and occasional fragments of vessels (3, 7, 10).Geographical distributionThe plant is indigenous to northern Europe and grows wild in central Europeancountries; it is especially abundant in eastern Europe. Also found in westernAsia, the Mediterranean region of northern Africa, and the United States ofAmerica. It is cultivated in many countries (3, 7–13).General identity testsThe drug is identified by its macroscopic and microscopic characteristics, andby thin-layer chromatography (1–3).WHO monographs on selected medicinal plants88Purity testsMicrobiologyThe test for Salmonella spp. in Flos Chamomillae products should be negative.The maximum acceptable limits of other microorganisms are as follows (1, 14,15). For preparation of decoction: aerobic bacteria—not more than 107/g;fungi—not more than 105/g; Escherichia coli—not more than 102/g. Preparationsfor internal use: aerobic bacteria—notmore than 105/g or ml; fungi—not morethan 104/g or ml; enterobacteria and certain Gram-negative bacteria—not morethan 103/g or ml; Escherichia coli—0/g or ml. Preparations for external use:aerobic bacteria—not more than 102/g or ml; fungi—not more than 102/g or ml;enterobacteria and certain Gram-negative bacteria—not more than 101/g or ml.Foreign organic matterNot more than 10% stems and not more than 2% foreign organic matter (3). Noflowering heads of Anthemis cotula L. or A. nobilis L. (7).Total ashNot more than 13% (2).Acid-insoluble ashNot more than 4% (11).MoistureNot more than 12% (12).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Flos Chamomillae is not morethan 0.05mg/kg (1). For other pesticides, see WHO guidelines on quality controlmethods for medicinal plants (14) and guidelines for predicting dietary intake ofpesticide residues (16).Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (14).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (14).Flos Chamomillae89Other testsChemical, dilute ethanol-soluble extractive, and water-soluble extractive teststo be established in accordance with national requirements.Chemical assaysContains not less than 0.4% v/w of essential oil (1–3). Total volatile oil contentis determined by pharmacopoeial methods (1–3).Thin-layer (1, 2) and gas–liquid (17) chromatography for volatile oil constitu-ents, and high-performance liquid chromatography for flavonoids (18, 19).Major chemical constituentsFlos Chamomillae contains an essential oil (0.4–1.5%), which has an intenseblue colour owing to its chamazulene content (1–15%). Other major constitu-ents include α-bisabolol and related sesquiterpenes (up to 50% of the oil).Apigenin and related flavonoid glycosides constitute up to 8% (dry weight) ofthe drug (10, 18).Dosage formsDried flower-heads, liquid extract (1 :1 in 45% alcohol), tinctures and othergalenicals (11). Store in well-closed containers, protected from light (1–3).Medicinal usesUses supported by clinical dataInternal useSymptomatic treatment of digestive ailments such as dyspepsia, epigastricbloating, impaired digestion, and flatulence (3, 7, 8, 10, 11, 20, 21). Infusions ofcamomile flowers have been used in the treatment of restlessness and in mildcases of insomnia due to nervous disorders (21, 22).External useInflammation and irritations of the skin and mucosa (skin cracks, bruises,frostbite, and insect bites) (10, 23), including irritations and infections of themouth and gums, and haemorrhoids (10, 11, 20, 21, 23).chamazuleneCH3CH3CH3(�) α bisabololCH 3 OHCH3HCH3CH3OOOHOHOHapigenin- -WHO monographs on selected medicinal plants90InhalationSymptomatic relief of irritations of the respiratory tract due to the common cold(24).Uses described in pharmacopoeias and in traditional systemsof medicineAdjuvant in the treatment of minor inflammatory conditions of the gastrointes-tinal tract (24).Uses described in folk medicine, not supported by experimental orclinical dataAs an antibacterial and antiviral agent, an emetic, and an emmenagogue. It isalso used to relieve eye strain, and to treat urinary infections and diarrhoea (13).PharmacologyExperimental pharmacologyBoth camomile extract and (�)-α-bisabolol demonstrated antipeptic activity invitro (25, 26). A hydroalcoholic extract of camomile inhibited the growth ofStaphylococcus aureus, Streptococcus mutans, group B Streptococcus, and Streptococcussalivarius, and it had a bactericidal effect in vitro on Bacillus megatherium andLeptospira icterohaemorrhagiae (27). In vitro, the volatile oil of camomile alsoinhibited Staphylococcus aureus and Bacillus subtilis (28). In vitro, camomile extractsinhibited both cyclooxygenase and lipoxygenase (29), and thus the productionof prostaglandins and leukotrienes, known inducers of inflammation. Bothbisabolol and bisabolol oxide have been shown to inhibit 5-lipoxygenase, butbisabolol was the more active of the two compounds (30). Numerous in vivostudies have demonstrated the anti-inflammatory effects of the drug. The anti-inflammatory effects of camomile extract, the essential oil, and the isolatedconstituents have been evaluated in yeast-induced fever in rats and againstultraviolet radiation-induced erythema in guinea-pig models (31). The principalanti-inflammatory and antispasmodic constituents of camomile appear to bethe terpene compounds matricin, chamazulene, (�)-α-bisabololoxides A and B,and (�)-α-bisabolol (32–39). While matricin and (�)-α-bisabolol have beenisolated from the plant, chamazulene is actually an artefact formed during theheating of the flowers when an infusion or the essential oil is prepared (10). Theanti-inflammatory effects of these compounds in various animal models, suchas inhibition of carrageenin-induced rat paw oedema, have been demonstrated(30), although their activity was somewhat less than that of salicylamide (39).In the mouse model for croton oil-induced dermatitis, topical application ofeither the total camomile extract, or the flavonoid fraction only, was veryeffective in reducing inflammation (34). Apigenin and luteolin were more activethan indometacin and phenylbutazone (34). Activity decreased in the followingFlos Chamomillae91order: apigenin � luteolin � quercetin � myricetin � apigenin-7-glucoside �rutin (34). The spasmolytic activity of camomile has been attributed toapigenin, apigenin-7-O-glucoside (10, 36) and (�)-α-bisabolol, which haveactivity similar to papaverine (10, 35).Intradermal application of liposomal apigenin-7-glucoside inhibited, in adose-dependent manner, skin inflammations induced in rats by xanthineoxidase and cumene hydroperoxide (38).Intraperitoneal administration to mice of a lyophilized infusion of camomiledecreased basal motility, exploratory and motor activities, and potentiatedhexobarbital-induced sleep (40). These results demonstrated that in mice camo-mile depresses the central nervous system (40).Clinical pharmacologyA double-blind study of the therapeutic effects of a camomile extract on re-epithelialization and drying of wound weeping after dermabrasion demon-strated a statistically significant decrease in the wound size and drying tendency(41).In clinical trials, topical application of a camomile extract in a cream basewas found to be superior to hydrocortisone 0.25% for reducing skin inflamma-tion (42). In an international multicentre trial camomile cream was comparedwith hydrocortisone 0.25%, fluocortin butyl ester 0.75% and bufexamac 5%in the treatment of eczema of the extremities (42). The camomile cream wasshown to be as effective as hydrocortisone and superior to the other twotreatments, but no statistical analysis was performed. Camomile preparationshave also been found to be beneficial in the treatment of radiation mucositisowing to head and neck radiation and systemic chemotherapy (43).ContraindicationsCamomile is contraindicated in patients with a known sensitivity or allergy toplants of the Asteraceae (Compositae) such as ragweed, asters, and chrysanthe-mums (21).WarningsNo information available.PrecautionsCarcinogenesis, mutagenesis, impairment of fertilityNo mutagenic effects were found in Salmonella typhimurium strains TA 97a, TA98, TA 100 and TA 104, with or without metabolic activation (44).Pregnancy: teratogenic effectsNo adverse effects reported in vivo (45).WHO monographs on selected medicinal plants92Other precautionsNo information available concerning general precautions, drug interactions,drug and laboratory test interactions, non-teratogenic effects on pregnancy,nursing mothers, or paediatric use.Adverse reactionsThe presence of lactones in Flos Chamomillae-based preparations may causeallergic reactions in sensitive individuals and there have been reports of contactdermatitis due to camomile preparations (46–48). It should be noted that veryfew cases of allergy were specifically attributed to German camomile (49). Afew cases of anaphylactic reactions to the ingestion of Flos Chamomillae havealso been reported (50–52).PosologyInternal useAdult dose of flower head: average daily dose 2–8g, 3 times a day (7, 8, 11); offluid extract 1 :1 in 45% ethanol: dose 1–4ml, 3 times a day (6, 11). Child doseof flower head: 2g, 3 times daily; of fluid extract (ethanol 45–60%): single dose0.6–2ml (11). Should not be used by children under 3 years old.External useFor compresses, rinses or gargles: 3–10% (30–100g/l) infusion or 1% fluidextract or 5% tincture (11). For baths: 5g/l of water or 0.8g/l of alcoholicextract. For semisolid preparations: hydroalcoholic extracts corresponding to 3–10% (30–100g/kg) of the drug. For vapour inhalation: 6g of the drug or 0.8g ofalcoholic extract per litre of hot water (11).References1. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.2. Pharmacopée française. Paris, Adrapharm, 1996.3. African pharmacopoeia, 1st ed. Lagos, Organization of African Unity, Scientific, Tech-nical & Research Commission, 1985.4. Estra farmakope Indonesia. Jakarta, Cetakan Kedua, Hal 152, Departemen Kesehatan,Republik Indonesia, 1974.5. Rauschert S. Nomenklatorische Probleme in der Gattung Matricaria L. Foliageobotanica phytotaxonomica, 1990, 9:249–260.6. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois atChicago, IL, August 8, 1995 production (an on-line database available directlythrough the University of Illinois at Chicago or through the Scientific and TechnicalNetwork (STN) of Chemical Abstracts Services).7. Youngken HW. Textbook of pharmacognosy, 6th ed. Philadelphia, Blakiston, 1950.8. The Indian Pharmaceutical Codex. Vol. I. Indigenous drugs. New Delhi, Council ofScientific & Industrial Research, 1953.9. Leung A, Foster S. Encyclopedia of common natural ingredients used in food, drugs, andcosmetics, 2nd ed. New York, John Wiley, 1996.Flos Chamomillae9310. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.11. British herbal pharmacopoeia. London, British Herbal Medicine Association, 1990.12. Polish pharmacopoeia. Warsaw, 1965.13. Tyler VE, Brady LR, Robbers JE, eds. Pharmacognosy, 9th ed. Philadelphia, Lea &Febiger, 1988.14. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.15. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.16. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).17. Carle R, Fleischhauer I, Fehr D. Qualitätsbeurteilung von Kamillenölen. DeutscheApotheker Zeitung, 1987, 127:2451–2457.18. Dölle B, Carle R, Müller W. Flavonoidbestimmung in Kamillenextraktpräparaten.Deutsche Apotheker Zeitung, 1985, 125(Suppl. I):14–19.19. Redaelli C, Formentini L, Santaniello E. Reversed-phase high-performance liquidchromatography analysis of apigenin and its glucosides in flowers of Matricariachamomilla and chamomille extracts. Planta medica, 1981, 42:288–292.20. Carle R, Isaac O. Die Kamille—Wirkung and Wirksamkeit. Zeitschrift fürPhytotherapie, 1987, 8:67–77.21. Carle R, Gomaa K. Chamomile: a pharmacological and clinical profile. Drugs of today,1992, 28:559–565.22. Gould L, Reddy CVR, Gomprecht RF. Cardiac effect of chamomile tea. Journal ofclinical pharmacology, 1973, 13:475–479.23. Hormann HP, Korting HC. Evidence for the efficacy and safety of topical herbaldrugs in dermatology. Part 1. Anti-inflammatory agents. Phytomedicine, 1994, 1:161–171.24. Weiß RF. Kamille—“Heilpflanze 1987”. Kneipp-Blätter, 1987, 1:4–8.25. Thiemer VK, Stadler R, Isaac O. Biochemische Untersuchungen von Kamillen-inhaltsstoffen. Arzneimittel-Forschung, 1972, 22:1086–1087.26. Isaac O, Thiemer K. Biochemische Untersuchungen von Kamilleninhaltsstoffen.Arzneimittel-Forschung, 1975, 25:1086–1087.27. Cinco M et al. A microbiological survey on the activity of a hydroalcoholic extractof chamomile. International journal of crude drug research, 1983, 21:145–151.28. Aggag ME, Yousef RT. Study of antimicrobial activity of chamomile oil. Plantamedica, 1972, 22:140–144.29. Wagner H, Wierer M, Bauer R. In vitro inhibition of prostaglandin biosynthesis byessential oils and phenolic compounds. Planta medica, 1986:184–187.30. Ammon HPT, Kaul R. Pharmakologie der Kamille und ihrer Inhaltsstoffe. DeutscheApotheker Zeitung, 1992, 132(Suppl. 27):3–26.31. Jakovlev V et al. Pharmacological investigations with compounds of chamomile. II.New investigations on the antiphlogistic effects of (�)-α-bisabolol and bisabololoxides. Planta medica, 1979, 35:125–240.32. Jakovlev V, Isaac O, Flaskamp E. Pharmakologische Untersuchungen von Kamillen-inhaltsstoffen. VI. Untersuchungen zur antiphlogistischen Wirkung von Chama-zulen und Matricin. Planta medica, 1983, 49:67–73.33. Tubaro A et al. Evaluation of anti-inflammatory activity of chamomile extract aftertopical application. Planta medica, 1984, 51:359.34. Della Loggia R. Lokale antiphlogistische Wirkung der Kamillen-Flavone. DeutscheApotheker Zeitung, 1985, 125(Suppl. 1):9–11.35. Della Loggia R et al. Evaluation of the anti-inflammatory activity of chamomilepreparations. Planta medica, 1990, 56:657–658.WHO monographs on selected medicinal plants9436. Lang W, Schwandt K. Untersuchung über die glykosidischen Bestandteile derKamille. Deutsche Apotheker Zeitung, 1957, 97:149–151.37. Mann C, Staba J. The chemistry, pharmacology, and commercial formulations ofchamomile. In: Craker LE, Simon JE, eds., Herbs, spices, and medicinal plants: recentadvances in botany, horticulture and pharmacology, Vol. I. Phoenix, AZ, Oryx Press,1986:233–280.38. Fuchs J, Milbradt R. Skin anti-inflammatory activity of apigenin-7-glucoside in rats.Arzneimittel-Forschung, 1993, 43:370–372.39. Albring M et al. The measuring of the anti-inflammatory effect of a compound onthe skin of volunteers. Methods and findings in experimental and clinical pharmacology,1983, 5:75–77.40. Della Loggia R et al. Depressive effects of Chamomilla recutita (L.) Rausch. tubularflowers, on central nervous system in mice. Pharmacological research communications,1982, 14:153–162.41. Glowania HJ, Raulin C, Svoboda M. The effect of chamomile on wound healing—a controlled clinical-experimental double-blind study. Zeitschrift für Hautkrankheiten,1986, 62:1262–1271.42. Aertgeerts P et al. Vergleichende Prüfung von Kamillosan® Creme gegenübersteroidalen (0.25% Hydrocortison, 0.75% Fluocortinbutylester) und nichtsteroidalen(5% Bufexamac) Externa in der Erhaltungstherapie von Ekzemerkrankungen.Zeitschrift für Hautkrankheiten, 1985, 60:270–277.43. Carl W, Emrich LS. Management of oral mucositis during local radiation and sys-temic chemotherapy: a study of 98 patients. Journal of prosthetic dentistry, 1991,66:361–369.44. Rivera IG et al. Genotoxicity assessment through the Ames test of medicinal plantscommonly used in Brazil. Environmental toxicology and water quality, 1994, 9:87–93.45. Leslie GB, Salmon G. Repeated dose toxicity studies and reproductive studies onnine Bio-Strath herbal remedies. Swiss medicine, 1979, 1:1–3.46. Dstychova E, Zahejsky J. Contact hypersensitivity to camomile. Ceskoslovenskadermatologie, 1992, 67:14–18.47. Subiza J et al. Allergic conjunctivitis to chamomile tea. Annals of allergy, 1990,65:127–132.48. Paulsen E, Andersen KE, Hausen BM. Compositae dermatitis in a Danish dermatol-ogydepartment in one year. Contact dermatitis, 1993, 29:6–10.49. Hausen BM, Busker E, Carle R. Über das Sensibilisierungsvermögen vonCompositenarten. VII. Experimentelle Untersuchungen mit Auszügen undInhaltsstoffen von Chamomilla recutita (L.) Rauschert und Anthemis cotula L. Plantamedica, 1984:229–234.50. Benner MH, Lee HJ. Anaphylactic reaction to chamomile tea. Journal of allergy andclinical immunology, 1973, 52:307–308.51. Casterline CL. Allergy to chamomile tea. Journal of the American Medical Association,1980, 244:330–331.52. Subiza J et al. Anaphylactic reaction after the ingestion of chamomile tea: a study ofcross-reactivity with other composite pollens. Journal of allergy and clinical immunol-ogy, 1989, 84:353–358.Cortex Cinnamomi95Cortex CinnamomiDefinitionCortex Cinnamomi consists of the dried inner bark of the shoots grown on cutstock of Cinnamomum verum J.S. Presl. (1–5) or of the trunk bark, freed of cork,of Cinnamomum cassia Blume (6–8) (Lauraceae).SynonymsCinnamomum verum J.S. Presl.Cinnamomum zeylanicum Nees (9–11), Laurus cinnamomum L. (4).Cinnamomum verum J.S. Presl. is the correct botanical name according to theInternational Rules of Botanical Nomenclature (11).Cinnamomum cassia BlumeCinnamomum aromaticum Nees (7, 12, 13).Selected vernacular namesCinnamomum verum J.S. Presl.Abdalasini, blood-giving drops, canela, canela en raja, cannalavanga pattai,cannelle de ceylan, cannelle dite de Ceylan, cannelier, Ceylon celonzimi cinna-mon, Ceylon cinnamon, cinnamon, cinnamon bark, cinnamon tree, cortexcinnamomi ceylanici, dalchini, dalochini, dar sini quirfa, darchini, daruchini,darusila, ecorce de cannelier de Ceylan, echter Kanel, gujerati-dalchini, kannel,kuei-pi, kurundu, kurundu-potu, kulit kayumanis, ob choei, tamalpatra, wildcinnamon, Zimtrinde (2–4, 10, 14, 15).Cinnamomum cassia BlumeAnnan cinnamon, cassia, cassia bark, cassia bark tree, cassia lignea, chinazimt,Chinese cassia, Chinese cinnamon, ching hua yu-kuei, cinnamomi cassiae cor-tex, cinnamon, cinnamon bark, dalchini, guipi, guizhi, kannan keihi, keihi,keishi, kuei-chíi, lavanga-pattai, lavanga-patti, lurundu, macrophyllos cassiabark tree, rou gui, róugì, Saigon cinnamon, saleekha, taj, toko keihi, Viet Namcinnamon (6, 7, 12–17).WHO monographs on selected medicinal plants96DescriptionCinnamomum verum J.S. Presl.A moderate-sized evergreen tree; bark rather thick, smooth, pale; twigs oftencompressed; young parts glabrous except the buds which are finely silky.Leaves opposite or subopposite (rarely alternate), hard and coriaceous, 7.5–20by 3.8–7.5cm, ovate or ovate-lanceolate, subacute or shortly acuminate, gla-brous and shining above, slightly paler beneath, base acute or rounded; mainnerves 3–5 from the base or nearly so, strong, with fine reticulate venationbetween; petioles 1.3–2.5cm long, flattened above. Flowers numerous, in silkypubescent, lax panicles usually longer than the leaves; peduncles long, oftenclustered, glabrous or pubescent; pedicels long. Perianth 5–6mm long; tube2.5mm long; segments pubescent on both sides, oblong or somewhat obovate,usually obtuse. Fruit 1.3–1.7cm long, oblong or ovoid-oblong, minutely apicu-late, dry or slightly fleshy, dark purple, surrounded by the enlarged campanulateperianth that is 8mm in diameter (14).Cinnamomum cassia BlumeAn evergreen tree, up to 10m high. Leaves alternate, coriaceous, petiolate,oblong, elliptical-oval or oblong-lanceolate, 8–15cm long by 3–4cm wide, tipacuminate, base rounded, entire, 3-nerved; glabrous or underside lightly pubes-cent; petiole 10mm long, lightly pubescent. Inflorescence a densely hairypanicle as long as the leaves; panicles cymose, terminal and axillary. Flowersyellowish white, small, in cymes of 2–5. Perianth 6-lobed. No petals. Stamens6, pubescent. Ovary free, 1-celled. Fruit a globular drupe, 8mm long, red. Thebark is used in either channelled pieces or simple quills, 30–40cm long by 3–10cm wide and 0.2–0.8cm in thickness. The surface is greyish brown, slightlycoarse, with irregularly fine wrinkles and transverse lenticels. Here and there arefound scars of holes, indicating the insertion of leaves or lateral shoots; the innersurface is rather darker than the outer, with fine longitudinal striae. The fractureis short, the section of the thicker pieces showing a faint white line (pericyclicsclerenchyma) sometimes near the centre, sometimes near and parallel to theouter margin (14).Plant material of interest: dried bark, free from theouter corkGeneral appearanceCinnamomum verum J.S. Presl.The bark is about 0.2–0.8mm thick and occurs in closely packed compoundquills made up of single or double quills. The outer surface is smooth,yellowish brown with faint scars marking the positions of leaves and axillarybuds and has fine, whitish and wavy longitudinal striations. The inner surface isslightly darker and longitudinally striated. The fracture is short and fibrous (1).Cortex Cinnamomi97Cinnamomum cassia BlumeThe drug is channelled or quilted, 30–40cm long, 3–10cm in diameter, 2–8mmthick. Outer surface greyish brown, slightly rough, with irregular fine wrinklesand transverse raised lenticels, some showing greyish white streaks; innersurface reddish brown, with fine longitudinal striations and exhibiting oily traceon scratching. Texture hard and fragile, easily broken, fracture uneven, outerlayer brown and relatively rough, inner layer reddish brown and oily andshowing a yellowish brown line between two layers (6).Organoleptic propertiesOdour, characteristic and aromatic (2, 3, 4, 6); taste, characteristic, slightlysweet and fragrant (3, 4, 6).Microscopic characteristicsCinnamomum verum J.S. Presl.The outside shows a few discontinuous layers of cortical parenchyma withinwhich is a wide, continuous layer of pericyclic sclerenchyma composed ofgroups of isodiametric or tangentially elongated sclereids with thickened andpitted walls, and occasional groups of fibres. The phloem is composed of sievetissue and parenchyma with large secretion cells containing essential oil ormucilage and phloem fibres occurring singly or in small groups, individual fibres15–25µm in diameter with thickened walls; medullary rays uniseriate orbiseriate. Some of the cells contain small acicular crystals of calcium oxalate; theremainder, together with the phloem parenchyma, contain starch granules,simple or 2–4 compound, rarely more than 10µm in diameter (1, 3).Cinnamomum cassia BlumeThe transverse section shows the cork being composed of several layers of cells,the innermost layer with thickened and lignified outer walls. Cortex scatteredwith stone cells and secretory cells. Pericycle stone cells in groups arranged in aninterrupted ring, accompanied by fibre bundles at outer side, the outer walls ofstone cells usually thinner. Phloem rays 1 or 2 rows of cells wide, containingminute needle crystals of calcium oxalate; usually 2 or 3 fibres in bundles; oilcells scattered throughout. Parenchymatous cells contain starch granules (6).Powdered plant materialCinnamomum verum J.S. Presl.The powdered drug is yellowish to reddish brown and consists of groups ofrounded sclereids with pitted, channelled and moderately thickened walls;numerous colourless fibres, often whole with narrow lumen and thickened,lignified walls and few pits; rarely small acicular crystals of calcium oxalate;abundant starch granules. Cork fragments are absent or very rare (1, 3).WHO monographs on selected medicinal plants98Cinnamomum cassia BlumeReddish brown. Most fibres singly scattered, long fusiform, 195–920µm long,up to 50µm in diameter, with thickened and lignified wall, pits indistinct. Stonecells subsquare or sub-rounded, 32–88µm in diameter, the walls thickened,some thin at one side. Oil cells sub-rounded or oblong, 45–108µm in diameter.Needle crystals minute, scattered in ray cells. Cork cells polygonal, containingreddish brown contents (1).Geographical distributionCinnamomum verum J.S. Presl.Native to India and Sri Lanka (4, 11, 14); cultivated in parts of Africa, south-eastern India, Indonesia, the Seychelles, South America, Sri Lanka, and the WestIndies (4, 10, 11).Cinnamomum cassia BlumeFound in China, Indonesia, the Lao People’s Democratic Republic, and VietNam, (12, 13, 16); mostly cultivated (12).General identity testsMacroscopic and microscopic examinations (1–6); and thin-layer chromato-graphic analysis for the presence of cinnamaldehyde (1–6, 8).Purity testsMicrobiologyThe test for Salmonella spp. in Cortex Cinnamomi products should benegative.The maximum acceptable limits of other microorganisms are as fol-lows (18–20). For preparation of decoction: aerobic bacteria—not more than107/g; fungi—not more than 105/g; Escherichia coli—not more than 102/g. Prepa-rations for internal use: aerobic bacteria—not more than 105/g or ml; fungi—notmore than 104/g or ml; enterobacteria and certain Gram-negative bacteria—notmore than 103/g or ml; Escherichia coli—0/g or ml.Foreign organic matterC. verum: not more than 2% (4, 14). C. cassia: not more than 1% (16).Total ashC. verum: not more than 6% (2). C. cassia: not more than 5% (6, 8, 14, 16).Acid-insoluble ashC. verum: not more than 4% (4). C. cassia: not more than 2% (14, 16).Cortex Cinnamomi99Sulfated ashC. verum: not more than 6% (1, 3). C. cassia: to be established in accordancewith national requirements.Alcohol (90%)-soluble extractiveC. verum: 14–16% (4). C. cassia: to be established in accordance with nationalrequirements.Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Cortex Cinnamomi is notmore than 0.05mg/kg (21). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (18) and guidelines for predicting dietaryintake of pesticide residues (20).Arsenic and heavy metalsRecommended lead and cadmium levels are not more than 10mg/kg and0.3mg/kg, respectively, in the final dosage form of the plant material (18).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (18).Other testsChemical tests to be established in accordance with national requirements.Chemical assaysNot less than 1.2% v/w of volatile oil derived from C. verum (1–3) and 1–2%v/w of volatile oil derived from C. cassia (16), containing 60–80% w/w alde-hydes calculated as cinnamaldehyde (3, 16).Assay for cinnamaldehyde content by means of thin-layer (1–4, 6) or high-performance liquid chromatographic (21, 22) methods.Major chemical constituentsThe major constituent in both C. verum and C. cassia is cinnamaldehyde, atconcentrations of 65–80% (9, 10) and 90% (9) of the volatile oil, respectively.cinnamaldehydeCHOeugenolOHCH 2 OCH3O OcoumarinWHO monographs on selected medicinal plants100Cinnamomum verum also contains o-methoxycinnamaldehyde (10). Cinnamomumverum differs from C. cassia in its eugenol and coumarin content. Cinnamomumverum volatile oil contains 10% eugenol, whereas in C. cassia, only a tracequantity of this compound is found (9). Coumarin is present in C. cassia(0.45%), but not in C. verum (21).Dosage formsCrude plant material, powder, volatile oil, other galenic preparations. Store in awell-closed glass or metal container (do not use plastic), protected from lightand moisture (1–6, 10).Medicinal usesUses supported by clinical dataNone.Uses described in pharmacopoeias and in traditional systems ofmedicineThe treatment of dyspeptic conditions such as mild spastic conditions of thegastrointestinal tract, fullness and flatulence, and loss of appetite (4, 6, 7, 12).Also used to treat abdominal pain with diarrhoea, and pain associated withamenorrhoea and dysmenorrhoea (6, 12).Uses described in folk medicine, not supported by experimental orclinical dataThe treatment of impotence, frigidity, dyspnoea, inflammation of the eye,leukorrhoea, vaginitis, rheumatism, neuralgia, wounds, and toothache (15).PharmacologyExperimental pharmacologyAntibacterial and antifungal activities of the essential oil have been demon-strated in vitro (10). The essential oil of C. verum is active in vitro against thefollowing bacteria: Bacillus subtilis (23, 24), Escherichia coli, Staphylococcus aureus(24, 25), Salmonella typhimurium (26), and Pseudomonas aeruginosa (24). It was alsoactive in vitro against the following fungi: Aspergillus spp., Cladosporium werneckii(27), Geotrichum candidum, Kloeckera apivulata, Candida lipolytica and C. albicans(23, 28). The antibacterial and fungicidal effects have been attributed to o-methoxycinnamaldehyde (9).The essential oil of C. verum has carminative activity (29) and decreasessmooth muscle contractions in guinea-pig trachea and ileum (30), and in dogileum, colon and stomach (31). The active antispasmodic constituent of thedrug is cinnamaldehyde. A reduction of stomach motility in rats and dogs andCortex Cinnamomi101intestinal motility in mice and a decrease in the number of stress- and serotonin-induced ulcers in mice have been described (32–36). An ethanol extract of thedrug inhibits histamine- and barium-induced contractions in guinea-pig ileum;the hot-water extract was not active (36).ContraindicationsThe drug is contraindicated in cases of fever of unknown origin, pregnancy,stomach or duodenal ulcers (7, 9, 12), and in patients with an allergy to cinna-mon or Peru balsam (9).WarningsNo information available.PrecautionsDrug interactionsCinnamomum cassia bark extract (2g in 100ml) markedly decreased the in vitrodissolution of tetracycline hydrochloride (37). In the presence of C. cassia bark,only 20% of tetracycline was in solution after 30 minutes, in contrast to 97%when only water was used (37). However, the clinical significance of thisinteraction has not been established. The drug is reported to be incompatiblewith Halloysitum rubrum (6).Carcinogenesis, mutagenesis, impairment of fertilityThere are insufficient data to evaluate the carcinogenic potential of CortexCinnamomi (35). Reports concerning the mutagenicity of the drug are contra-dictory. Extracts of the plant and cinnamaldehyde have been reported to beboth mutagenic and non-mutagenic in Salmonella typhimurium (Ames assay) andin assays using Bacillus subtilis (38, 39). However, the results of these in vitromutagenicity studies are difficult to assess because, at the doses given, theeffects may have been due to the antimicrobial effects of the drug (35). CortexCinnamomi and cinnamaldehyde gave positive results in chromosomal aberra-tion tests using Chinese hamster cell cultures (35), and in Drosophila testsystems (40–43). An aqueous extract of the drug was also negative in theDrosophila test system (35).Pregnancy: teratogenic effectsAvailable data are not sufficient for an adequate benefit/risk assessment. There-fore, Cortex Cinnamomi should not be used during pregnancy. There is onereport of teratogenicity of cinnamaldehyde in chick embryos (35), but studies ofteratogenicity in chick embryos are of limited usefulness when evaluating theteratogenic potential for humans (35). A methanol extract of the drug given bygastric intubation was not teratogenic in rats (44, 45).WHO monographs on selected medicinal plants102Pregnancy: non-teratogenic effectsCortex Cinnamomi should not be used during pregnancy. See Contra-indications.Nursing mothersAvailable data are not sufficient for an adequate benefit/risk assessment. There-fore, Cortex Cinnamomi should not be used during lactation.Paediatric useThe safety and efficacy of the drug in children have not been established.Other precautionsNo information available concerning general precautions, or drug and labora-tory test interactions.Adverse reactionsAllergic reactions of the skin and mucosa have been reported (7, 46–49).PosologyCrude drug—average daily dose, 2–4g (7); volatile oil—average daily dose,0.05–0.2g (7); other preparations—average daily dose as above (7).References1. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.2. Pharmacopée française. Paris, Adrapharm, 1996.3. British pharmacopoeia. London, Her Majesty’s Stationery Office, 1988.4. African pharmacopoeia, 1st ed. Lagos, Organization of African Unity, Scientific, Tech-nical & Research Commission, 1985.5. Deutsches Arzneibuch 1996. Stuttgart, Deutscher Apotheker Verlag, 1996.6. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992.7. German Commission E Monograph, Cinnamomi cassiae cortex. Bundesanzeiger,1990, 22: 1 February.8. The pharmacopoeia of Japan XIII. Tokyo, The Society of Japanese Pharmacopoeia,1996.9. Bisset NG. Max Wichtl’s herbal drugs & phytopharmaceuticals. Boca Raton, FL, CRCPress, 1994:148–150.10. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995:451–453.11. Klostermans AJGH. Miscellaneous botanical notes. Herbarium Bogoriense, 1965:141–146.12. Medicinal plants in China. Manila, World Health Organization, 1989:78–79 (WHORegional Publications, Western Pacific Series, No. 2).13. Keys JD. Chinese herbs, their botany, chemistry and pharmacodynamics. Rutland, VT, CETuttle, 1976:111.Cortex Cinnamomi10314. Mukerji B. In: The Indian Pharmaceutical Codex, Vol. I. Indigenous drugs. New Delhi,Council of Scientific & Industrial Research, 1953:70–72.15. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois atChicago, IL, August 8, 1995 production (an on-line database available directlythrough the University of Illinois at Chicago or through the Scientific and TechnicalNetwork (STN) of Chemical Abstracts Services).16. British herbal pharmacopoeia, Part 2. London, British Herbal Medicine Association,1979:55–57.17. Chang HM, But PPH, eds. Pharmacology and applications of Chinese materia medica, Vol.2. Singapore, World Scientific Publishing, 1987:949–951.18. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.19. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.20. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).21. Archer AW. Determination of cinnamaldehyde, coumarin and cinnamyl alcoholin cinnamon and Cassia by high-performance liquid chromatography. Journal ofchromatography, 1988, 447:272–276.22. Sagara K et al. Determination of Cinnamomi Cortex by high-performance liquidchromatography. Journal of chromatography, 1987, 409:365–370.23. Raharivelomanana PJ et al. Study of the antimicrobial action of various essential oilextracts from Madagascan plants. II. The Lauraceae. Archives of the Institute of PasteurMadagascar, 1989, 56:261–271.24. Janssen AM et al. Screening for antimicrobial activity of some essential oils by theagar overlay technique. Pharmaceutisch Weekblad (Sci. ed.), 1986, 8:289–292.25. George M, Pandalai KM. Investigations on plant antibiotics. Part IV. Further searchfor antibiotic substances in Indian medicinal plants. Indian journal of medical research,1949, 37:169–181.26. Sivaswamy SN et al. Mutagenic activity of south Indian food items. Indian journal ofexperimental biology, 1991, 29:730–737.27. Morozumi S. A new antifungal agent in cinnamon. Shinkin to shinkinsho, 1978,19:172–180.28. Conner DE, Beuchat LR. Effects of essential oils from plants on growth of foodspoilage yeasts. Journal of food science, 1984, 49:429–434.29. Harries N, James KC, Pugh WK. Antifoaming and carminative actions of volatile oils.Journal of clinical pharmacology, 1978, 2:171–177.30. Reiter M, Brandt W. Relaxant effects on tracheal and ileal smooth muscles of theguinea pig. Arzneimittel-Forschung, 1985, 35:408–414.31. Plant OH, Miller GH. Effects of carminative volatile oils on the muscular activity ofthe stomach and colon. Journal of pharmacology and experimental therapeutics, 1926,27:149.32. Harada M, Yano S. Pharmacological studies on Chinese cinnamon. II. Effects ofcinnamaldehyde on the cardiovascular and digestive systems. Chemical and pharma-ceutical bulletin, 1975, 23:941–947.33. Plant OH. Effects of carminative volatile oils on the muscular movements ofthe intestine. Journal of pharmacology and experimental therapeutics, 1921, 22:311–324.34. Akira T, Tanaka S, Tabata M. Pharmacological studies on the antiulcerogenic activ-ity of Chinese cinnamon. Planta medica, 1986, 52:440–443.35. Keller K. Cinnamomum Species. In: DeSmet PAGM, Keller K, Hänsel R, Chandler RF,eds., Adverse reactions of herbal drugs. Berlin, Springer-Verlag, 1992:105–114.36. Itokawa H et al. Studies on the constituents of crude drugs having inhibitory activityWHO monographs on selected medicinal plants104against contraction of the ileum caused by histamine or barium chloride. Screeningtest for the activity of commercially available crude drugs and the related plantmaterials. Shoyakugaku zasshi, 1983, 37:223–228.37. Miyazaki S, Inoue H, Nadai T. Effect of antacids on the dissolution behavior oftetracycline and methacycline. Chemical and pharmaceutical bulletin, 1977, 27:2523–2527.38. Mahmoud I, Alkofahi A, Abdelaziz A. Mutagenic and toxic activities of severalspices and some Jourdanian medicinal plants. International journal of pharmacognosy,1992, 30:81–85.39. Kasamaki A et al. Genotoxicity of flavouring agents. Mutation research, 1982,105:387–392.40. Ishidate M. Primary mutagenicity screening of food additives currently used inJapan. Food chemistry and toxicology, 1984, 22:623–636.41. Venkatasetty R. Genetic variation induced by radiation and chemical agents inDrosophila melanogaster. Dissertation abstracts international B, 1972, 32:5047–5048.42. Woodruff RC, Manson JM, Valencia R, Zimmering S. Chemical mutagenesis testingin Drosophila. Results of 53 coded compounds tested for the National ToxicologyProgram. Environmental mutagenesis, 1985, 7:677–702.43. Abraham SK, Kesavan PC. A preliminary analysis of the genotoxicity of a fewspecies in Drosophila. Mutation research, 1985, 143:219–224.44. Abramovici A, Rachmuth-Roizman P. Molecular structure–teratogenicity relation-ships of some fragrance additives. Toxicology, 1983, 29:143–156.45. Lee EB. Teratogenicity of the extracts of crude drugs. Korean journal of pharmacognosy,1982, 13:116–121.46. Nixon R. Vignette in contact dermatology. Cinnamon allergy in bakers. Australianjournal of dermatology, 1995, 36:41.47. Hausen BJM. Allergiepflanzen-Pflanzenallergene. Landsberg, Ecomed, 1988:95–96.48. Calnan CD. Cinnamon dermatitis from an ointment. Contact dermatitis, 1976, 2:167–170.49. Drake TE, Maibach HI. Allergic contact dermatitis and stomatitis caused by cin-namic aldehyde-flavored toothpaste. Archives of dermatology, 1976, 112:202–203.Rhizoma Coptidis105Rhizoma CoptidisDefinitionRhizoma Coptidis is the dried rhizome of Coptis chinensis Franch, Coptis deltoidesC.Y. Cheng et Hsiao, Coptis japonica Makino (Ranunculaceae), or otherberberine-containing species of the same genus (1, 2).SynonymsNone.Selected vernacular namesCoptis chinensis FranchChinese goldthread, ch’uan-lien, coptis, coptis rhizome, gold thread, huanglian, huang-lien, huánglián, oren, Perlenschnur, weilian (1–6).Coptis deltoides C.Y. Cheng et HsiaoCoptis, gold thread, huang lian, huang-lien, huánglián, yalian (1, 4, 7).Coptis japonica MakinoCoptis, coptis rhizome, oren (2, 5).DescriptionCoptis chinensis FranchA perennial stemless herb, 20–50cm high. Leaves basal, long petiolate; bladetriangular-ovate, 3–8cm long by2.5–7cm wide, ternatisect; leaflets pinnatifid,lobes incised, the terminal leaflet longer than the others. Peduncles 1–2, 12–25cm long, bracts resembling leaves. Inflorescence a terminal cyme with 3–8whitish green flowers; sepals narrow-ovate, 9–12mm long; petals small, oblan-ceolate, 5–7mm long; stamens numerous, 3–6mm long; carpels 8–12, withcarpophores, follicles many-seeded. Seeds with black crustaceous testa. Rhi-zome shaped like a cockspur, 5–6cm long, brownish yellow, densely coveredwith numerous nodes and often with rootlets; interior yellow-orange; in trans-verse section, the central pith deeper in colour (4).WHO monographs on selected medicinal plants106Coptis deltoides C.Y. Cheng et Hsiao and Coptis japonicaMakinoDescriptions to be established by appropriate national authorities.Plant material of interest: dried rhizomeGeneral appearanceCoptis chinensis FranchThe rhizome is curved, gathered in a cluster and resembles “chicken feet”, 3–6cm long and 3–8mm in diameter. Rough, greyish yellow or yellowish brownsurface, bearing irregular protrusions, rootlets, and rootlet remnants. Apex oftenbearing remains of stem or petiole. Texture is hard and fracture uneven. Bark isorange-red or dark brown; wood brightly yellow or orange-yellow. Pith, some-times hollowed (1).Coptis deltoides C.Y. Cheng et HsiaoFrequently single, somewhat cylindrical, slightly curved, 4–8cm long and 0.5–1cm in diameter. Internodes smooth and relatively long. Apex with some stemremains (1).Coptis japonica MakinoIrregular, cylindrical rhizome, 2–4cm, rarely up to 10cm in length, 0.2–0.7cm indiameter, slightly curved and often branched; externally greyish yellow-brown,with ring nodes, and with numerous remains of rootlets; generally remains ofpetiole at one end; fractured surface rather fibrous; cork layer light greyishbrown, cortex yellow-brown, xylem yellow, and pith yellow-brown in colour(2).Organoleptic propertiesOdour, slight; taste, very bitter; colour, greyish yellow to yellowish brown,drug when chewed colours saliva yellow (1, 2).Microscopic characteristicsCoptis chinensis FranchIn transverse section cork cells occupy several layers. Cortex broader thanothers; stone cells singly or grouped together; pericycle fibres yellow, in bundlesor accompanied by stone cells; collateral vascular bundles arranged in a ring.Interfascicular cambium indistinct. Xylem yellow, lignified with well developedfibres. Pith consisting of parenchyma cells and devoid of stone cells (1).Coptis deltoides C.Y. Cheng et HsiaoTransverse section shows pith with stone cells (1).Rhizoma Coptidis107Coptis japonica MakinoTransverse section reveals a cork layer composed of thin-walled cork cells;cortex parenchyma usually contains groups of stone cells near the cork layerand yellow phloem fibres near the cambium; xylem consists chiefly of vessels,tracheae and wood fibres; medullary ray distinct; pith large; in pith, stone cellsor sometimes stone cells with thick and lignified cells are recognized; paren-chyma cells contain minute starch grains (2).Powdered plant materialCoptis japonica MakinoAlmost all elements are yellow. The powder shows mainly fragments of ves-sels, tracheids, and xylem fibres; parenchyma cells containing starch grains;polygonal cork cells. Usually, round to obtuse polygonal stone cells and theirgroups, and phloem fibres, 10–20µm in diameter, and fragments of theirbundles. Occasionally, polygonal and elongated epidermal cells, originatingfrom the petiole, having characteristic thickened membranes. Starch grains aresingle grains 1–7µm in diameter (2).Coptis chinensis Franch and Coptis deltoides C.Y. Cheng et HsiaoDescriptions to be established by appropriate national authorities.Geographical distributionCoptis chinensis Franch. and Coptis deltoides C.Y. Cheng etHsiaoChina (3, 4).Coptis japonica MakinoJapan (2).Coptis teeta Wall.Indigenous in India, where it is considered an endangered species (7). Coptisteeta Wall. has compendial status in China (1), where it is cultivated commer-cially (2).General identity testsMacroscopic, microscopic, and microchemical examinations; thin-layer chro-matographic analysis for the presence of berberine (1, 2).WHO monographs on selected medicinal plants108Purity testsMicrobiologicalThe test for Salmonella spp. in Rhizoma Coptidis products should be negative.The maximum acceptable limits of other microorganisms are as follows (8–10).For preparation of decoction: aerobic bacteria—not more than 107/g; fungi—notmore than 105/g; Escherichia coli—not more than 102/g. Preparations for internaluse: aerobic bacteria—not more than 105/g or ml; fungi—not more than 104/g orml; enterobacteria and certain Gram-negative bacteria—not more than 103/g orml; Escherichia coli—0/g or ml.Total ashNot more than 5.0% (1, 2).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Rhizoma Coptidis is not morethan 0.05mg/kg (10). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (8) and guidelines for predicting dietaryintake of pesticide residues (11).Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (8).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (8).Other purity testsChemical tests and tests for acid-insoluble ash, dilute ethanol-soluble extrac-tive, foreign organic matter, moisture and water-soluble extractive are to beestablished in accordance with national requirements.Chemical assaysShould contain not less than 4.2% of berberine, calculated as berberine chloride,assayed by means of thin-layer chromatography or high-performance liquidchromatography (2).Major chemical constituentsThe major constituents are berberine and related protoberberine alkaloids (3, 8,10). Berberine occurs in the range of 4–8% ( C. chinensis: 5–7%; C. deltoides: 4–Rhizoma Coptidis1098%; C. japonica: 7–9%), followed by palmatine (C. chinensis: 1–4%; C. deltoides:1–3%; C. japonica: 0.4–0.6%), coptisine (C. chinensis: 0.8–2%; C. deltoides:0.8–1%; C. japonica: 0.4–0.6%), berberastine (C. chinensis: 1%; C. deltoides: 1%;C. japonica: trace) among others (12).Dosage formsCrude plant material, decoction, and powder. Store in a well-ventilated dryenvironment protected from light (1).Medicinal usesUses supported by clinical dataNone.Uses described in pharmacopoeias and in traditional systems ofmedicineTo manage bacterial diarrhoeas (1, 4). The drug is also used in the treatment ofacute conjunctivitis, gastroenteritis, boils, and cutaneous and visceral leish-maniasis (“oriental sore”) (1, 4, 13, 14).Uses described in folk medicine, not supported by experimental orclinical dataTreatment of arthritis, burns, diabetes, dysmenorrhoea, toothache, malaria,gout, and renal disease (13).PharmacologyExperimental pharmacologyNumerous reports support the antimicrobial activity of Rhizoma Coptidis. Invitro studies have shown that the crude drug and its active constituent, ber-berine, have a similar spectrum of antibacterial action (3, 15). Both inhibit the invitro growth of staphylococci, streptococci, pneumococci, Vibrio cholerae, Bacillusanthracis, and Bacillus dysenteriae, but they do not inhibit Escherichia coli, Proteusvulgaris, Salmonella typhi, S. paratyphi, Pseudomonas aeruginosa, and Shigella sonnei(3). Berberine was also active in vitro against Entamoeba histolytica, Giardia lamblia,and Trichomonas vaginalis (16).N+OOH3COOCH3berberineWHO monographs on selected medicinal plants110In vitro studies have demonstrated that V. cholerae can grow in a mediumcontaining berberine, but it fails to produce toxins (17). It has beenhypoth-esized that the antidysenteric activity of berberine is due to local effects on theintestinal tract and not due to its bactericidal activity. The mechanism bywhich berberine exerts its antidiarrhoeal effects is thought to be activation ofα2-adrenoceptors and inhibition of cyclic AMP accumulation (18), which in turndecrease intestinal motility (19). However, in vitro studies of the drug on guinea-pig ileum contractility have demonstrated that berberine (≥1µmol/l) inhibitsacetylcholinesterase, which decreases the breakdown of acetylcholine andincreases the contractility of the ileum (20). This study suggests that theantidiarrhoeal activity of berberine may be due to its antisecretory (21) as wellas its antimicrobial actions (20). Berberine inhibits in vivo and in vitro intestinalsecretions induced by cholera toxin (22–24). In addition, berberine reducesintestinal secretion induced by the heat-labile toxin of Escherichia coli in rabbitileal loop by 70% and it markedly inhibits the secretory response of the heat-stable toxin of E. coli in rats (25, 26).Intragastric administration of berberine to mice produces hypoglycaemiceffects with doses of 50–100mg/kg (27–29).Local injection of berberine into lesions caused by Leishmania braziliensispanamensis in hamsters reduced lesion size by approximately 50% (30).Clinical pharmacologyDespite the large number of published clinical studies, only two have examinedthe effect of berberine in comparison with a positive control, such as tetracy-cline, on fluid loss caused by diarrhoea in patients with cholera or in non-cholera diarrhoea (14, 31–33). In the first study, berberine chloride 100mgwas administered orally four times daily. The alkaloid did not have any signifi-cant vibriostatic effect; instead it only slightly reduced stool volume, and possi-bly reduced the vibriostatic effect of tetracycline (32). Berberine or tetracyclinewas no better than a placebo in patients with non-cholera diarrhoea of unspeci-fied etiologies (32). A randomized controlled trial of 165 patients utilized a400mg single-bolus dose of berberine sulfate for enterotoxigenic Escherichiacoli-induced diarrhoea and either 400mg as a single oral dose or 1200mg ofberberine sulfate (400mg every 8 hours) for the treatment of cholera (33).Berberine significantly reduced stool volume during enterotoxigenic E. coli(ETEC) diarrhoea regardless of strain and had a slight antisecretory activity inpatients with cholera. No adverse effects were observed in the patients receiv-ing berberine. The results of this study indicated that berberine was an effectiveand safe antisecretory drug for ETEC diarrhoea, but that it had only a modestantisecretory effect in cholera patients, where the activity of tetracycline alonewas superior (33).Berberine has been used therapeutically in the treatment of cutaneousleishmaniasis (“oriental sore”) by direct injection of the drug into local lesions.Rhizoma Coptidis111In humans, injection of a preparation containing 2% berberine into lesionscaused by Leishmania tropica was an effective treatment (34–36).ContraindicationsThe safety of berberine or extracts of Rhizoma Coptidis in pregnancy has notbeen established (14). Therefore, until such data are available the use of ber-berine during pregnancy is contraindicated.WarningsNo information available.PrecautionsCarcinogenesis, mutagenesis, impairment of fertilityThe safety of berberine or extracts of Rhizoma Coptidis has not been estab-lished with respect to fertility (14). There are conflicting reports as to themutagenicity of Rhizoma Coptidis and berberine (37–43).Pregnancy: non-teratogenic effectsThe safety of berberine or extracts of Rhizoma Coptidis has not been estab-lished with respect to pregnancy. See Contraindications, above.Nursing mothersExcretion of berberine or Rhizoma Coptidis into breast milk, and its effects onthe newborn have not been established; therefore, use of the herb duringlactation is not recommended.Paediatric useThe safety and efficacy of Rhizoma Coptidis or berberine in children have notbeen established.Other precautionsNo information available concerning general precautions, drug interactions,drug and laboratory test interactions, or teratogenic effects on pregnancy.Adverse reactionsBerberine was reported to be well tolerated in therapeutic doses of 500mg, andno serious intoxication was reported in humans (44). One report of nausea,vomiting, enterocinetic sound, abdominal distortion, diarrhoea, polyuria, andWHO monographs on selected medicinal plants112erythropenia after administration of oral Rhizoma Coptidis to human adults(45) does not state the dosage used. No systematic studies have assessed organfunction during acute or chronic administration of berberine salts or extracts ofRhizoma Coptidis (14).PosologyMaximum daily oral dosage of crude plant material: 1.5–6g (1, 3).References1. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992.2. The pharmacopoeia of Japan XII. Tokyo, The Society of Japanese Pharmacopoeia,1991.3. Chang HM, But PPH, eds. Pharmacology and applications of Chinese materia medica, Vol.2. Singapore, World Scientific Publishing, 1987.4. Medicinal plants in China. Manila, World Health Organization, 1989 (WHO RegionalPublications, Western Pacific Series, No. 2).5. Hsu HY. Oriental materia medica, a concise guide. Long Beach, CA, Oriental HealingArts Institute, 1986.6. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois at Chi-cago, IL, March 15, 1995 production (an on-line database available directly throughthe University of Illinois at Chicago or through the Scientific and Technical Network(STN) of Chemical Abstracts Services).7. Pandit MK, Babu CR. Cytology and taxonomy of Coptis teeta Wall. (Ranunculaceae).Botanical journal of the Linnean Society, 1993, 111:371–378.8. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.9. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.10. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.11. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).12. Ikuta A, Kobayashi A, Itokawa H. Studies on the quantitative analysis ofprotoberberine alkaloids in Japanese, Chinese and other countries Coptis rhizomesby thin-layer chromatography-densitometry. Shoyakugaku zasshi, 1984, 38:279–282.13. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.14. Lampe KF, Berberine. In: De Smet PAGM et al., eds. Adverse effects of herbal drugs, Vol.1. Berlin, Springer-Verlag, 1992:97–104.15. Simeon S, Rios JL, Villar A. Pharmacological activities of protoberberine alkaloids.Plantes médicinales et phytothérapie, 1989, 23:202–250.16. Kaneda Y et al. In vitro effects of berberine sulfate on the growth and structure ofEntamoeba histolytica, Giardia lamblia, and Trichomonas vaginalis. Annals of tropicalmedicine and parasitology, 1991, 85:417–425.17. Hah FE, Ciak J. Berberine. Antibiotics, 1975, 3:577.18. Uebaba K et al. Adenylate cyclase inhibitory activity of berberine. Japanese journal ofpharmacology, 1984, 36(Suppl. 1):352.Rhizoma Coptidis11319. Hui KK et al. Interaction of berberine with human platelet alpha-2 adrenoceptors.Life sciences, 1989, 49:315–324.20. Shin DH et al. A paradoxical stimulatory effect of berberine on guinea-pig ileumcontractility: possible involvement of acetylcholine release from the postganglionicparasympathetic nerve and cholinesterase inhibition. Life sciences, 1993, 53:1495–1500.21. Sack RB, Froehlich JL. Berberine inhibits intestinal secretory response of Vibriocholerae andEscherichia coli enterotoxins. Infection and immunity, 1989, 35:471–475.22. Gaitonde BB, Marker PH, Rao NR. Effect of drugs on cholera toxin induced fluid inadult rabbit ileal loop. Progress in drug research, 1975, 19:519–526.23. Sabir M, Akhter MH, Bhide NK. Antagonism of cholera toxin by berberine in thegastrointestinal tract of adult rats. Indian journal of medical research, 1977, 65:305–313.24. Swabb EA, Tai YH, Jordan L. Reversal of cholera toxin-induced secretion in rat ileumby luminal berberine. American journal of physiology, 1981, 241:G248–G252.25. Tai YH et al. Antisecretory effects of berberine in rat ileum. American journal ofphysiology, 1981, 241:G253–G258.26. Guandalini S et al. Berberine effects on ion transport in rabbit ileum. Pediatricresearch, 1983, 17:423.27. Shen ZF, Xie MZ. Determination of berberine in biological specimens by highperformance TLC and fluoro-densitometric method. Yao hsueh hsueh pao, 1993,28:532–536.28. Chen QM, Xie MZ. Studies on the hypoglycemic effect of Coptis chinensis andberberine. Yao hsueh hsueh pao, 1986, 21:401–406.29. Chen QM, Xie MZ. Effect of berberine on blood glucose regulation of normal mice.Yao hsueh hsueh pao, 1987, 22:161–165.30. Vennerstrom JL et al. Berberine derivatives as antileishmanial drugs. Antimicrobialagents and chemotherapy, 1990, 34:918–921.31. Lahiri SC, Dutta NK. Berberine and chloramphenicol in the treatment of cholera andsevere diarrhea. Journal of the Indian Medical Association, 1967, 48:1–11.32. Khin-Maung U et al. Clinical trial of berberine in acute watery diarrhoea. Britishmedical journal, 1986, 291:1601–1605.33. Rabbani GH et al. Randomized controlled trial of berberine sulfate therapy fordiarrhea due to enterotoxigenic Escherichia coli and Vibrio cholerae. Journal of infectiousdiseases, 1987, 155:979–984.34. Devi AL. Berberine sulfate in oriental sore. Indian medical gazette, 1929, 64:139.35. Das Gupta BM. The treatment of oriental sore with berberine acid sulfate. Indianmedical gazette, 1930, 65:683.36. Das Gupta BM, Dikshit BB. Berberine in the treatment of Oriental boil. Indian medicalgazette, 1929, 67:70.37. Lee HK et al. Effect of bacterial growth-inhibiting ingredients on the Ames mutage-nicity of medicinal herbs. Mutation research, 1987, 192:99–104.38. Pasqual MS et al. Genotoxicity of the isoquinoline alkaloid berberine in prokaryoticand eukaryotic organisms. Mutation research, 1993, 286:243–252.39. Faddejeva MD et al. Possible intercalative bindings of alkaloids sanguinarine andberberine to DNA. IRCS medical science and biochemistry, 1980, 8:612.40. Nozaka T et al. Mutagenicity of isoquinoline alkaloids, especially the aporphinetype. Mutation research, 1990, 240:267–279.41. Morimoto I et al. Mutagenicity screening of crude drugs with Bacillus subtilisRec-assay and Salmonella/microsome reversion assay. Mutation research, 1982, 97:81–102.42. Yamamoto K, Mizutani T, Nomura H. Studies on the mutagenicity of crude drugextracts. I. Yakugaku zasshi, 1982, 102:596–601.43. Watanabe F et al. Mutagenicity screening of hot water extracts from crude drugs.Shoyakugaku zasshi, 1983, 37:237–240.WHO monographs on selected medicinal plants11444. Roth L, Daunderer M, Kormann K. Giftpflanzen. Pflanzengifte, 3rd ed. Landsberg,Ecomed, 1988:145–146, 810.45. Bao Y. Side effects of Coptis chinensis and berberine. Chinese journal of integrated andtraditional western medicine, 1983, 3:12–13.Rhizoma Curcumae Longae115Rhizoma Curcumae LongaeDefinitionRhizoma Curcumae Longae is the dried rhizome of Curcuma longa L.(Zingiberaceae) (1).Dried rhizomes of Curcuma wenyujin Y.H. Lee et C. Ling, C. kwangsiensis S.Lee et C.F. Liang. and C. phaeocaulis Val. are also official sources of RadixCurcumae or Turmeric Root-Tuber in China (2).SynonymsCurcuma domestica Valeton., C. rotunda L., C. xanthorrhiza Naves, Amomum cur-cuma Jacq. (3–5).Selected vernacular namesAcafrao, arqussofar, asabi-e-safr, avea, cago rerega, chiang-huang, commontumeric, curcum, curcuma, dilau, dilaw, Gelbwurzel, gezo, goeratji, haladi,haldi, haldu, haku halu, hardi, haridra, huang chiang, hsanwen, hurid, Indiansaffron, jiânghuang, kaha, kakoenji, kalo haledo, khamin chan, khaminchan,kilunga kuku, kitambwe, kiko eea, koening, koenit, koenjet, kondin, kooneit,kunyit, kurcum, kurkum, Kurkumawurzelstock, luyang dilaw, mandano,manjano, manjal, nghe, nisha, oendre, pasupu, rajani, rame, renga, rhizome decurcuma, saffran vert, safran, safran des indes, skyer-rtsa, tumeric, tumeric root,tumeric rhizome, turmeric, ukon, ul gum, wong keong, wong keung, yellowroot, yii-chin, zardchob (1–3, 6–14).DescriptionPerennial herb up to 1.0m in height; stout, fleshy, main rhizome nearly ovoid(about 3cm in diameter and 4cm long). Lateral rhizome, slightly bent (1cm �2–6cm), flesh orange in colour; large leaves lanceolate, uniformly green, up to50cm long and 7–25cm wide; apex acute and caudate with tapering base,petiole and sheath sparsely to densely pubescent. Spike, apical, cylindrical, 10–15cm long and 5–7cm in diameter. Bract white or white with light green upperhalf, 5–6cm long, each subtending flowers, bracteoles up to 3.5cm long. Paleyellow flowers about 5cm long; calyx tubular, unilaterally split, unequallytoothed; corolla white, tube funnel shaped, limb 3-lobed. Stamens lateral,petaloid, widely elliptical, longer than the anther; filament united to antherWHO monographs on selected medicinal plants116about the middle of the pollen sac, spurred at base. Ovary trilocular; styleglabrous. Capsule ellipsoid. Rhizomes orange within (1, 4, 6, 15).Plant material of interest: dried rhizomeGeneral appearanceThe primary rhizome is ovate, oblong or pear-shaped round turmeric, while thesecondary rhizome is often short-branched long turmeric; the round form isabout half as broad as long; the long form is from 2–5cm long and 1–1.8cmthick; externally yellowish to yellowish brown, with root scars and annula-tions, the latter from the scars of leaf bases; fracture horny; internally orange-yellow to orange; waxy, showing a cortex separated from a central cylinder bya distinct endodermis (1, 9, 13).Organoleptic propertiesOdour, aromatic; taste, warmly aromatic and bitter (1, 9, 13). Drug whenchewed colours the saliva yellow (9).Microscopic characteristicsThe transverse section of the rhizome is characterized by the presence ofmostly thin-walled rounded parenchyma cells, scattered vascular bundles, defi-nite endodermis, a few layers of cork developed under the epidermis andscattered oleoresin cells with brownish contents. The cells of the ground tissueare also filled with many starch grains. Epidermis is thin walled, consisting ofcubical cells of various dimensions. The cork cambium is developed from thesubepidermal layers and even after the development of the cork, the epidermisis retained. Cork is generally composed of 4–6 layers of thin-walled brick-shaped parenchymatous cells. The parenchyma of the pith and cortex containscurcumin and is filled with starch grains. Cortical vascular bundles are scatteredand are of collateral type. The vascular bundles in the pith region are mostlyscattered and they form discontinuous rings just under the endodermis. Thevessels have mainly spiral thickening and only a few have reticulate and annularstructure (1, 8, 9).Powdered plant materialColoured deep yellow. Fragments of parenchymatous cells contain numerousaltered, pasty masses of starch grains coloured yellow by curcumin, fragmentsof vessels; cork fragments of cells in sectional view; scattered unicellular tri-chomes; abundant starch grains; fragments of epidermal and cork cells in sur-face view; and scattered oil droplets, rarely seen (1, 13).Geographical distributionCambodia, China, India, Indonesia, Lao People’s Democratic Republic,Madagascar, Malaysia, the Philippines, and Viet Nam (1, 13, 16). It is exten-Rhizoma Curcumae Longae117sivelycultivated in China, India, Indonesia, Thailand and throughout the trop-ics, including tropical regions of Africa (1, 7, 13, 16).General identity testsMacroscopic and microscopic examinations; test for the presence ofcurcuminoids by colorimetric and thin-layer chromatographic methods (1).Purity testsMicrobiologyThe test for Salmonella spp. in Rhizoma Curcumae Longae products should benegative. The maximum acceptable limits of other microorganisms are as fol-lows (17–19). For preparation of decoction: aerobic bacteria—not more than107/g; fungi—not more than 105/g; Escherichia coli—not more than 102/g. Prepa-rations for internal use: aerobic bacteria—not more than 105/g or ml; fungi—notmore than 104/g or ml; enterobacteria and certain Gram-negative bacteria—notmore than 103/g or ml; Escherichia coli—0/g or ml.Foreign organic matterNot more than 2% (1, 9).Total ashNot more than 8.0% (1, 15).Acid-insoluble ashNot more than 1% (1, 9, 15).Water-soluble extractiveNot less than 9.0% (1).Alcohol-soluble extractiveNot less than 10% (1).MoistureNot more than 10% (1).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin in Rhizoma Curcumae Longae isnot more than 0.05mg/kg (19). For other pesticides, see WHO guidelines onquality control methods for medicinal plants (17) and guidelines for predictingdietary intake of pesticide residues (20).WHO monographs on selected medicinal plants118Heavy metalsRecommended lead and cadmium levels are not more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (17).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (17).Other purity testsChemical tests to be established in accordance with national requirements.Chemical assaysNot less than 4.0% of volatile oil, and not less than 3.0% of curcuminoids (1).Qualitative analysis by thin-layer and high-performance liquid chromatography(1, 21) and quantitative assay for total curcuminoids by spectrophotometric (1,22) or by high-performance liquid chromatographic methods (23, 24).Major chemical constituentsPale yellow to orange-yellow volatile oil (6%) composed of a number ofmonoterpenes and sesquiterpenes, including zingiberene, curcumene, α- and �-turmerone among others. The colouring principles (5%) are curcuminoids, 50–60% of which are a mixture of curcumin, monodesmethoxycurcumin andbisdesmethoxycurcumin (1, 6, 25). Representative structures of curcuminoidsare presented below.Dosage formsPowdered crude plant material, rhizomes (1, 2), and corresponding preparations(25). Store in a dry environment protected from light. Air dry the crude drugevery 2–3 months (1).α-turmeroneCH3CH3CH3OCH3β-turmeroneCH3CH3OCH2CH3ar-turmeroneCH3CH3OH CH3CH3CH3CH3H CH3CH3HzingibereneOHOOR R'OHcurcumindesmethoxycurcuminbisdesmethoxycurcuminOCHOCH , R' = 33R =R = OCH3, R' = HR = H, R' = HRhizoma Curcumae Longae119Medicinal usesUses supported by clinical dataThe principal use of Rhizoma Curcumae Longae is for the treatment of acid,flatulent, or atonic dyspepsia (26–28).Uses described in pharmacopoeias and in traditional systems ofmedicineTreatment of peptic ulcers, and pain and inflammation due to rheumatoidarthritis (2, 11, 14, 29, 30) and of amenorrhoea, dysmenorrhoea, diarrhoea,epilepsy, pain, and skin diseases (2, 3, 16).Uses described in folk medicine, not supported by experimental orclinical dataThe treatment of asthma, boils, bruises, coughs, dizziness, epilepsy,haemorrhages, insect bites, jaundice, ringworm, urinary calculi, and slow lacta-tion (3, 7, 8–10, 14).PharmacologyExperimental pharmacologyAnti-inflammatory activityThe anti-inflammatory activity of Rhizoma Curcumae Longae has been demon-strated in animal models (3, 30–32). Intraperitoneal administration of the drugin rats effectively reduced both acute and chronic inflammation in carrageenin-induced paw oedema, the granuloma pouch test, and the cotton pellet granu-loma test (32, 33). The effectiveness of the drug in rats was reported to besimilar to that of hydrocortisone acetate or indometacin in experimentallyinduced inflammation (31, 32). Oral administration of turmeric juice or powderdid not produce an anti-inflammatory effect; only intraperitoneal injection waseffective (33). The volatile oil has exhibited anti-inflammatory activity in ratsagainst adjuvant-induced arthritis, carrageenin-induced paw oedema, andhyaluronidase-induced inflammation (32). The anti-inflammatory activity ap-pears to be mediated through the inhibition of the enzymes trypsin and hyalu-ronidase (33). Curcumin and its derivatives are the active anti-inflammatoryconstituents of the drug (34 –40). After intraperitoneal administration, curcuminand sodium curcuminate exhibited strong anti-inflammatory activity in thecarrageenin-induced oedema test in rats and mice (41). Curcumin was alsofound to be effective after oral administration in the acute carrageenin-inducedoedema test in mice and rats (41). The anti-inflammatory activity of curcuminmay be due to its ability to scavenge oxygen radicals, which have been impli-cated in the inflammation process (42). Furthermore, intraperitoneal injectionof a polysaccharide fraction, isolated from the drug, increased phagocytosiscapacity in mice in the clearance of colloidal carbon test (43).WHO monographs on selected medicinal plants120Activity against peptic ulcer and dyspepsiaOral administration to rabbits of water or methanol extracts of the drug signifi-cantly decreased gastric secretion (44) and increased the mucin contents ofgastric juice (45). Intragastric administration of an ethanol extract of the drug torats effectively inhibited gastric secretion and protected the gastroduodenalmucosa against injuries caused by pyloric ligation, hypothermic-restraint stress,indometacin, reserpine, and mercaptamine administration, and cytodestructiveagents such as 80% methanol, 0.6mol/l hydrochloric acid, 0.2mol/l sodiumhydroxide and 25% sodium chloride (30, 46). The drug stimulated the produc-tion of gastric wall mucus, and it restored non-protein sulfides in rats (46, 47).Curcumin, one of the anti-inflammatory constituents of the drug, has beenshown to prevent and ameliorate experimentally induced gastric lesions inanimal models by stimulation of mucin production (48). However, there areconflicting reports regarding the protective action of curcumin againsthistamine-induced gastric ulceration in guinea-pigs (41). Moreover, both intra-peritoneal and oral administration of curcumin (100mg/kg) have been reportedto induce gastric ulceration in rats (41, 49–51).Non-specific inhibition of smooth muscle contractions in isolated guinea-pigileum by sodium curcuminate has been reported (41).The effect of curcumin on intestinal gas formation has been demonstrated invitro and in vivo. Addition of curcumin to Clostridium perfringens of intestinalorigin in vitro and to a chickpea flour diet fed to rats led to a gradual reductionin gas formation (41).Both the essential oil and sodium curcuminate increase bile secretion afterintravenous administration to dogs (41). In addition, gall-bladder muscles werestimulated (39).Clinical pharmacologyOral administration of the drug to 116 patients with acid dyspepsia, flatulentdyspepsia, or atonic dyspepsia in a randomized, double-blind study resulted ina statistically significant response in the patients receiving the drug (27). Thepatients received 500mg of the powdered drug four times daily for 7 days (27).Two other clinical trials which measured the effect of the drug on peptic ulcersshowed that oral administration of the drug promoted ulcer healing and de-creased the abdominalpain involved (28, 29).Two clinical studies have shown that curcumin is an effective anti-inflammatory drug (52, 53). A short-term (2 weeks) double-blind, crossoverstudy of 18 patients with rheumatoid arthritis showed that patients receivingeither curcumin (1200mg/day) or phenylbutazone (30mg/day) had significantimprovement in morning stiffness, walking time and joint swelling (52). In thesecond study, the effectiveness of curcumin and phenylbutazone on postopera-tive inflammation was investigated in a double-blind study (53). Both drugsproduced a better anti-inflammatory response than a placebo (53), but theRhizoma Curcumae Longae121degree of inflammation in the patients varied greatly and was not evenlydistributed among the three groups.ContraindicationsObstruction of the biliary tract. In cases of gallstones, use only after consulta-tion with a physician (26). Hypersensitivity to the drug.WarningsNo information available.PrecautionsCarcinogenesis, mutagenesis, impairment of fertilityRhizoma Curcumae Longae is not mutagenic in vitro (54–56).Pregnancy: teratogenic effectsOrally administered Rhizoma Curcumae Longae was not tetratogenic in miceor rats (34, 57, 58).Pregnancy: non-teratogenic effectsThe safety of Rhizoma Curcumae Longae during pregnancy has not beenestablished. As a precautionary measure the drug should not be used duringpregnancy except on medical advice (59).Nursing mothersExcretion of the drug into breast milk and its effects on the newborn have notbeen established. Until such data are available, the drug should not be usedduring lactation except on medical advice.Paediatric useThe safety and effectiveness of the drug in children has not been established.Other precautionsNo information on drug interactions or drug and laboratory test interactionswas found.Adverse reactionsAllergic dermatitis has been reported (60). Reactions to patch testing occurredmost commonly in persons who were regularly exposed to the substance orwho already had dermatitis of the finger tips. Persons who were not previouslyexposed to the drug had few allergic reactions (60).WHO monographs on selected medicinal plants122PosologyCrude plant material, 3–9g daily (5, 6); powdered plant material, 1.5–3.0g daily(9, 19); oral infusion, 0.5–1g three times per day; tincture (1 :10) 0.5–1ml threetimes per day.References1. Standard of ASEAN herbal medicine, Vol. 1. Jakarta, ASEAN Countries, 1993.2. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992.3. Chang HM, But PPH, eds. Pharmacology and applications of Chinese materia medica, Vol.1. Singapore, World Scientific Publishing, 1986.4. Keys JD. Chinese herbs, their botany, chemistry and pharmacodynamics. Rutland, VT, CETuttle, 1976.5. Wren RC. Potter’s new cyclopedia of botanical drugs and preparations. Saffron Walden,C.W. Daniel, 1988.6. Bisset NG. Max Wichtl’s herbal drugs & phytopharmaceuticals. Boca Raton, FL, CRCPress, 1994.7. Ghazanfar SA. Handbook of Arabian medicinal plants. Boca Raton, FL, CRC Press,1994.8. Kapoor LD. Handbook of Ayurvedic medicinal plants. Boca Raton, FL, CRC Press, 1990.9. The Indian pharmaceutical codex, Vol. I. Indigenous drugs. New Delhi, Council of Scien-tific & Industrial Research, 1953.10. Cambie RC, Ash J. Fijian medicinal plants. CSIRO, Australia, 1994.11. Iwu MM. Handbook of African medicinal plants. Boca Raton, FL, CRC Press, 1993.12. Hsu HY. Oriental materia medica, a concise guide. Long Beach, CA, Oriental HealingArts Institute, 1986.13. Youngken HW. Textbook of pharmacognosy, 6th ed. Philadelphia, Blakiston, 1950.14. Medicinal plants in Viet Nam. Manila, World Health Organization, 1990 (WHORegional Publications, Western Pacific Series, No. 3).15. Japanese standards for herbal medicines. Tokyo, Yakuji Nippon, 1993.16. Medicinal plants in China. Manila, World Health Organization, 1989 (WHO RegionalPublications, Western Pacific Series, No. 2).17. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.18. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.19. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.20. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).21. Taylor SJ, McDowell IJ. Determination of curcuminoid pigments in turmeric (Cur-cuma domestica Val) by reversed-phase high-performance liquid chromatography.Chromatographia, 1992, 34:73–77.22. International Organization for Standardization. Turmeric—Determination ofcolouring power—Spectrophotometric method. ISO 5566, 1982.23. König WA et al. Enantiomeric composition of the chiral constituents of essential oils.Part 2: Sesquiterpene hydrocarbon. Journal of high resolution chromatography, 1994,17:315–320.24. Zhao DY, Yang MK. Separation and determination of curcuminoids in Curcuma longaL. and its preparation by HPLC. Yao hsueh hsueh pao, 1986, 21:382–385.25. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.Rhizoma Curcumae Longae12326. German Commission E Monograph, Curcumae longae rhizoma. Bundesanzeiger,1985, 223:30 November.27. Thamlikitkul V et al. Randomized double blind study of Curcuma domestica Val. fordyspepsia. Journal of the Medical Association of Thailand, 1989, 72:613–620.28. Intanonta A et al. Treatment of abdominal pain with Curcuma longa L. (Report submittedto Primary Health Care Office, Ministry of Public Health, Thailand, 1986.)29. Prucksunand C et al. Effect of the long turmeric (Curcuma longa L.) on healing pepticulcer: A preliminary report of 10 case studies. Thai journal of pharmacology, 1986,8:139–151.30. Masuda T et al. Anti-oxidative and anti-inflammatory curcumin-related phenolicsfrom rhizomes of Curcuma domestica. Phytochemistry, 1993, 32:1557–1560.31. Arora RB et al. Anti-inflammatory studies on Curcuma longa (turmeric). Indian journalof medical research, 1971, 59:1289–1295.32. Yegnanarayan R, Saraf AP, Balwani JH. Comparison of antiinflammatory activityof various extracts of Curcuma longa (Linn). Indian journal of medical research, 1976,64:601–608.33. Permpiphat U et al. Pharmacological study of Curcuma longa. In: Proceedings of theSymposium of the Department of Medical Science, Mahidol University, Bangkok, Thailand,Dec 3–4, 1990.34. Gupta SS, Chandra D, Mishra N. Anti-inflammatory and antihyaluronidase activityof volatile oil of Curcuma longa (Haldi). Indian journal of physiology and pharmacology,1972, 16:254.35. Chandra D, Gupta SS. Anti-inflammatory and antiarthritic activity of volatile oil ofCurcuma longa. Indian journal of medical research, 1972, 60:138–142.36. Tripathi RM, Gupta SS, Chandra D. Anti-trypsin and antihyaluronidase activityof volatile oil of Curcuma longa (Haldi). Indian journal of pharmacology, 1973, 5:260–261.37. Ghatak N, Basu N. Sodium curcuminate as an effective antiinflammatory agent.Indian journal of experimental biology, 1972, 10:235–236.38. Srimal RC, Dhawan BN. Pharmacology of diferuloyl methane (curcumin), a non-steroidal anti-inflammatory agent. Journal of pharmacy and pharmacology, 1973,25:447–452.39. Mukhopadhyay A et al. Antiinflammatory and irritant activities of curcumin analogsin rats. Agents and actions, 1982, 12:508–515.40. Rao TS, Basu N, Siddiqui HH. Anti-inflammatory activity of curcumin analogs.Indian journal of medical research, 1982, 75:574–578.41. Ammon HP, Wahl MA. Pharmacology of Curcuma longa. Planta medica, 1991, 57:1–7.42. Kunchandy E, Rao MN. Oxygen radical scavenging activity of curcumin. Internationaljournal of pharmacognosy, 1990, 58:237–240.43. Kinoshita G, Nakamura F, Maruyama T. Immunological studies on polysaccharidefractionsfrom crude drugs. Shoyakugaku zasshi, 1986, 40:325–332.44. Sakai K et al. Effects of extracts of Zingiberaceae herbs on gastric secretion in rabbits.Chemical and pharmaceutical bulletin, 1989, 37:215–217.45. Muderji B, Zaidi SH, Singh GB. Spices and gastric function. Part I. Effect of Curcumalonga on the gastric secretion in rabbits. Journal of scientific and industrial research, 1981,20:25–28.46. Rafatullah S et al. Evaluation of turmeric (Curcuma longa) for gastric and duodenalantiulcer activity in rats. Journal of ethnopharmacology, 1990, 29:25–34.47. Bhatia A, Singh GB, Khanna NM. Effect of curcumin, its alkali salts and Curcumalonga oil on histamine-induced gastric ulceration. Indian journal of experimental biology,1964, 2:158–160.48. Sinha M et al. Study of the mechanism of action of curcumin: an antiulcer agent.Indian journal of pharmacy, 1975, 7:98–99.WHO monographs on selected medicinal plants12449. Prasad DN et al. Studies on ulcerogenic activity of curcumin. Indian journal of physi-ology and pharmacology, 1976, 20:92–93.50. Gupta B et al. Mechanisms of curcumin induced gastric ulcers in rats. Indian journalof medical research, 1980, 71:806–814.51. Srimal RC, Dhawan BN. In: Arora BA, ed. Development of Unani drugs from herbalsources and the role of elements in their mechanism of action. New Delhi, HamdardNational Foundation Monograph, 1985.52. Deodhar SD, Sethi R, Srimal RC. Preliminary study on anti-rheumatic activity ofcurcumin (diferuloyl methane). Indian journal of medical research, 1980, 71:632–634.53. Satoskar RR, Shah Shenoy SG. Evaluation of antiinflammatory property of curcumin(diferuloyl methane) in patient with postoperative inflammation. International journalof clinical pharmacology, therapy and toxicology, 1986, 24:651–654.54. Rockwell P, Raw I. A mutagenic screening of various herbs, spices and food addi-tives. Nutrition and cancer, 1979, 1:10–15.55. Yamamoto H, Mizutani T, Nomura H. Studies on the mutagenicity of crude drugextracts. I. Yakugaku zasshi, 1982, 102:596–601.56. Nagabhushan M, Bhide SV. Nonmutagenicity of curcumin and its antimutagenicaction versus chili and capsaicin. Nutrition and cancer, 1986, 8:201–210.57. Garg SK. Effect of Curcuma longa (rhizomes) on fertility in experimental animals.Planta medica, 1974, 26:225–227.58. Vijayalaxmi. Genetic effects of tumeric and curcumin in mice and rats. Mutationresearch, 1980, 79:125–132.59. Farnsworth NF, Bunyapraphatsara N, eds. Thai medicinal plants, recommended for aprimary health care system. Bangkok, Prachachon, 1992.60. Seetharam KA, Pasricha JS. Condiments and contact dermatitis of the finger-tips.Indian journal of dermatology, venereology and leprology, 1987, 53:325–328.Radix Echinaceae125Radix EchinaceaeDefinitionRadix Echinaceae consists of the fresh or dried roots of Echinacea angustifoliaD.C. var. angustifolia or its variety strigosa McGregor, or E. pallida (Nutt.) Nutt.(Asteraceae) (1–3).SynonymsEchinacea angustifolia D.C. var. angustifoliaBrauneria angustifolia Heller, Echinacea pallida var. angustifolia (D.C.) Cronq. (4, 5).Echinacea pallida (Nutt.) Nutt.Echinacea angustifolia Hook, Rudbeckia pallida Nutt., Brauneria pallida Britt.,Echinacea pallida f. albida Steyerm (4, 5).E. angustifolia and E. pallida were regarded as varieties of the same species oreven identical plants. However, in a revision of the genus Echinacea in 1968,McGregor (4) classified them as two distinct species with E. angustifolia furtherdivided into two varieties (4, 5). A considerable amount of commercial “E.angustifolia” cultivated in Europe was, in fact, E. pallida. Data on E. angustifoliapublished prior to 1987 and based on material of commerce from Europe shouldbe reviewed with caution (5).Current commercial preparations are derived primarily from E. angustifoliaand E. pallida roots; the preparation of a monograph on E. purpurea root awaitsfurther data.Asteraceae are also known as Compositae.Selected vernacular namesEchinacea angustifolia D.C. var. angustifoliaAmerican coneflower, black sampson, cock up head, coneflower, echinacearoot, Igelkopf, Indian head, Kansas snakeroot, Kegelblume, narrow-leavedpurple coneflower root, purple coneflower, Sonnenhut, racine d’echinacea (5–10).Echinacea pallida (Nutt.) Nutt.Blasser Igelkopf, blasse Kegelblume, blasser Sonnenhut, pale coneflower root,pale purple coneflower root, pallida root (8, 10).WHO monographs on selected medicinal plants126DescriptionEchinacea species are hardy, herbaceous perennials with either simple orbranched stems. The terminal single flowering heads have fertile disc floretsthat terminate in spines (paleae). These are surrounded by infertile drooping orspreading ray flowers that have 2 or 3 teeth at each end. The leaf shape variesfrom lanceolate to ovate, its margin may be dentate and the leaf may bepubescent or smooth. Roots are either single taproot or fibrous in form (6–11).Echinacea angustifolia D.C. var. angustifoliaStems simple or occasionally branched, 10–50cm high, smooth or hirsute be-low, hirsute or tuberculate-hispid above; leaves oblong-lanceolate to elliptical,entire, dark green tuberculate-hirsute to tuberculate-hispid; basal leaves short-to long-petiolate, 5–27cm long, 1–4cm broad, lower cauline leaves petiolate, 4–15cm long, 0.5–3.8cm broad, upper cauline leaves sessile, acute; heads 1.5–3cmhigh, 1.5–2.5cm broad exclusive of ligules, phyllaries in three or fourseries, lanceolate, acute, entire, 6–11mm long, 2–3mm wide, tuberculate-hirsute or tuberculate-hispid; rays spreading, 2–3.8cm long, 5–8mm wide,white, pinkish or purplish; disc corollas 6–8.5mm long, lobes 1.2–2mm long;achenes 4–5mm long, pappus a toothed crown; pollen grains yellow, 19–26µmin diameter; haploid chromosome number n � 11 (4).Echinacea pallida (Nutt.) Nutt.Stems simple, rarely branched, 40–90cm high, sparsely hirsute below, moredensely so above; leaves oblong-lanceolate to long-elliptical, entire, dark green,hirsute on both surfaces, triple-veined; basal leaves 10–35cm long, 1–4cmbroad, the cauline leaves 10–25cm long, 1–2.5cm broad, acute, petiolate belowto sessile above; phyllaries lanceolate to narrowly oblong, 8–17mm long, 2–4mm broad, hirsute, ciliate, three or four series gradually passing into theechinaceous pales; rays reflexed, 4–9cm long, 5–8mm broad, purplish, pink, orwhite; pales 1–1.3cm long, body 8–10mm long, awn 2.5–3.5mm long; discfloret 8–10mm long, lobes 2–3mm long, achenes 3.7–5mm long, glabrous,pappus a toothed crown, teeth about even, longest 1mm; pollen grains white,24–28.5µm in diameter; haploid chromosome number n � 22 (4).Plant material of interest: fresh or dried rootsGeneral appearanceEchinacea angustifolia D.C. var. angustifoliaCylindrical or slightly tapering and sometimes spirally twisted, passing imper-ceptibly into a rhizome in the upper part; rhizome up to about 15mm indiameter, roots 4–10mm in diameter; outer surface pale brown to yellowishbrown; rhizomes crowned with remains of the aerial stem and sometimesshowing surface annulations; roots longitudinally wrinkled and deeply fur-Radix Echinaceae127rowed; fracture short when dry but becoming tough and pliable on exposure toair (12).Echinacea pallida (Nutt.) Nutt.Similar in appearance to E. angustifolia (5–7).Organoleptic propertiesOdour, mild, aromatic; taste, sweet initially but quickly becoming bitter fol-lowed by a tingling sensation on the tongue (12).Microscopic characteristicsThe roots of the two species are very similar. The transverse section shows athin outer bark separated by a distinct cambium line from a wide xylem; a smallcircular pith in the rhizome. Cork composed of several rows of thin-walled cellscontaining yellowish brown pigment; cortex parenchymatous; rhizome withoccasional small groups of thick-walled, lignified fibres in the pericycle; phloemand xylem composed of very narrow strands of vascular tissueseparated bywide, non-lignified medullary rays; xylem vessels lignified, 25–75µm in diam-eter, usually reticulate thickening but occasionally with spiral or annular thick-ening; stone cells, occurring singly or in small groups, varying considerably insize and shape from rounded to rectangular to elongated and fibre-like, up to300µm long and 20–40µm wide, with intercellular spaces containing a denseblack deposit; schizogenous oleoresin canals; spherocrystalline masses ofinulin occur throughout the parenchymatous tissue. In E. angustifolia oleoresincanals, 80–150µm in diameter and containing yellowish orange oleoresin, arepresent only outside the central cylinder, but in E. pallida they are present bothinside and outside. In E. angustifolia the narrow, 300–800µm long, lignified fibresare in scattered groups usually surrounded by phytomelanin deposits, while inE. pallida they are present only in the periphery of the cortex and they aremostly single, wider, and shorter, 100–300µm, and phytomelanin is oftenabsent (9, 12).Powdered plant materialE. angustifoliaPowdered rhizome and roots are brown with a slight aromatic odour andinitially a sweet taste, quickly becoming bitter and leaving a tingling sensationon the tongue. Thin-walled polygonal cork cells with red-brown contents;lignified reticulately thickened vessels; abundant stone cells of various shapes;fragments of oleoresin canals with reddish brown contents; abundant thin-walled parenchyma with spherocrystalline masses of inulin (12).E. pallidaDescriptions of powdered E. pallida are currently unavailable.WHO monographs on selected medicinal plants128Geographical distributionEchinacea species are native to the Atlantic drainage area of the United Statesof America and Canada, but not Mexico. Their distribution centres are inArkansas, Kansas, Missouri, and Oklahoma in the United States of America (4).E. pallida was cultivated in Europe for a number of years and was mistaken forE. angustifolia (9).General identity testsMacroscopic and microscopic examinations (5–7, 9, 12). Chemical finger-printsof lipophilic constituents, echinacosides, and other caffeic acid derivatives inmethanol extracts can be obtained by thin-layer chromatography and high-performance liquid chromatography (5, 13, 14).Purity testsMicrobiologyThe test for Salmonella spp. in Radix Echinaceae products should be negative.The maximum acceptable limits of other microorganisms are as follows (15–17). For preparation of decoction: aerobic bacteria—not more than 107/g;fungi—not more than 105/g; Escherichia coli—not more than 102/g. Preparationsfor internal use: aerobic bacteria—not more than 105/g or ml; fungi—not morethan 104/g or ml; enterobacteria and certain Gram-negative bacteria—not morethan 103/g or ml; Escherichia coli—0/g or ml.Foreign organic matterNot more than 3% (2, 3, 12). Does not contain roots of Parthenium integrifoliumL., commonly known as “American feverfew”, which have been found to beadulterants of or substitutes for Radix Echinaceae (5, 6, 9, 13).Total ashNot more than 9% (12).Acid-insoluble ashNot more than 3% (12).Water-soluble extractiveNot less than 15% (12).MoistureNot more than 10% (3).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin in Radix Echinaceae is not moreRadix Echinaceae129than 0.05mg/kg (17). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (15) and guidelines for predicting dietaryintake of pesticide residues (18).Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (15).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (15).Other purity testsChemical tests and tests of dilute ethanol-soluble extractive to be established inaccordance with national requirements.Chemical assaysEssential oil (0.2–2%) and echinacoside (0.4–1.7%) in both E. angustifolia and E.pallida roots (5).Quantitative analysis of echinacoside, cynarin, chicoric acid, chlorogenicacid derivatives, and other constituents by high-performance liquid chroma-tography (5, 19).Major chemical constituentsA number of chemical entities have been identified and reported to be biologi-cally active, including a volatile oil, alkamides, polyalkenes, polyalkynes, caffeicacid derivatives, and polysaccharides (5–7, 9–11).The volatile oil contains, among other compounds, pentadeca-(1,8-Z)-diene (44%), 1-pentadecene, ketoalkynes and ketoalkenes.More than 20 alkamides, mostly isobutylamides of C11–C16 straight-chainfatty acids with olefinic or acetylenic bonds, or both, are found in the roots; thehighest concentration is in E. angustifolia, followed by E. purpurea, and thelowest is in E. pallida. The main alkamide is a mixture of isomeric dodeca-2,4,8,10-tetraenoic acid isobutylamides.Caffeic acid ester derivatives present include echinacoside, cynarin, andchicoric acid. Cynarin is present only in E. angustifolia, thus distinguishing itfrom the closely related E. pallida.Polysaccharide constituents are of two types: a heteroxylan of relative mo-lecular mass about 35000 and an arabinorhamnogalactan of relative molecularmass about 45000.Other constituents include trace amounts of pyrrolizidine alkaloids(tussilagine (0.006%) and isotussilagine). At these concentrations, the alkaloidsWHO monographs on selected medicinal plants130Dosage formsPowdered roots, and galenics and preparations thereof for internal use (9).are considered to be non-toxic (7, 20), and since they lack the 1,2-unsaturatednecine ring of alkaloids such as senecionine (structure in box) from Seneciospecies, they are considered to have no hepatotoxic potential (5).Structures of representative constituents are presented below.OOCH3OHOH OOHOOOHOH OOHOOHOOHOHCH2OHOHOHechinacosideNecine ring pyrrolizidine alkaloids :1,2-saturated 1,2-unsaturatedsenecionine1234567 7a OHCH3HNHOOCH 312345677a CH 3OHHNHOOCH3tussilagine isotussilagine1234567 8OH CH 3OHCH3ONOOHHCH3(2E,4E,8Z ,10E )- and (2E,4E,8Z ,10Z)-dodeca-2,4,8,10-tetraenoic acid isobutylamidesCH3NHOCH3CH3CH3NHOCH3CH3+OOCO2HHO2COOOHOHHHOHOHchicoric acidHOHOHHOHOHOOOHOOOHHCO2Hcynarin (1,5-dicaffeylquinic acid)echinoloneOH CH3CH2CH3CH3Oor enantiomer [(+)-isomer]Radix Echinaceae131Medicinal usesUses supported by clinical dataPreparations of Radix Echinaceae are administered orally in supportive therapyfor colds and infections of the respiratory and urinary tract (1, 5–7, 9, 11, 21–23).Beneficial effects in the treatment of these infections are generally thought to bebrought about by stimulation of the immune response (5, 6, 9, 10).Uses described in pharmacopoeias and in traditional systems ofmedicineNone.Uses described in folk medicine, not supported by experimental orclinical dataTreatment of yeast infections, side-effects of radiation therapy, rheumatoidarthritis, and food poisoning (1, 5, 6, 9, 24).PharmacologyExperimental pharmacologyCurrent claims for the effectiveness of Radix Echinaceae as a stimulator of theimmune system are based on over 350 scientific studies in the past 50 years.Numerous in vitro and in vivo studies have documented the activation of animmune response after treatment with Radix Echinaceae extracts. Theimmunostimulant effect is brought about by three mechanisms: activation ofphagocytosis and stimulation of fibroblasts; increasing respiratory activity; andcausing increased mobility of the leukocytes (5, 9, 11). Chemically standardizedextracts,derived from roots and aerial parts from the three Echinacea species,have been assessed for their phagocytotic potential. All ethanolic root extractsincreased phagocytosis in vitro (25). Inhibition of hyaluronidase activity, stimu-lation of the activity of the adrenal cortex, stimulation of the production ofproperdin (a serum protein which can neutralize bacteria and viruses), andstimulation of interferon production have also been reported after Echinaceatreatments (26). The pharmacological activity of Echinacea spp. has been attrib-uted to five component fractions in addition to the essential oil, namely thealkylamides, caffeic acid derivatives, polyalkynes, polyalkenes and polysaccha-rides (6). The lipophilic amides, alkamides and caffeic acid derivatives appear tocontribute to the immunostimulant activity of the alcoholic Echinacea extractsby stimulating phagocytosis of polymorphonuclear neutrophil granulocytes (5,23, 27). High molecular weight polysaccharides, including heteroxylan, whichactivates phagocytosis, and arabinogalactan, which promotes the release oftumour necrosis factor and the production of interleukin-1 and interferon beta(24, 26), have also been implicated in the activity of the aqueous extracts andthe powdered drug when taken orally. The overall immunostimulant activity ofWHO monographs on selected medicinal plants132the alcoholic and aqueous Echinacea extracts appears to depend on the com-bined effects of several constituents (5, 9, 27).Echinacea extracts inhibit streptococcal and tissue hyaluronidase (28). Inhibi-tion of tissue and bacterial hyaluronidase is thought to localize the infection andprevent the spread of causative agents to other parts of the body. In addition tothe direct antihyaluronidase activity, an indirect effect on the hyaluronic acid–hyaluronidase system has been reported (29, 30). Stimulation of new tissueproduction by increasing the activity of fibroblasts, and stimulation of bothblood- and tissue-produced phagocytosis, appear to be involved in this mecha-nism (29).Echinacea extracts have anti-inflammatory activity. An alkylamide fractionfrom Echinacea roots markedly inhibited activity in vitro in the 5-lipoxygenasemodel (porcine leukocytes) (31). Topical application of a crude polysaccharideextract from E. angustifolia has been reported to reduce inflammation in the ratpaw oedema model (32, 33).Clinical pharmacologyOne placebo-controlled clinical study of 160 patients with infections of theupper respiratory tract has been performed (34). Significant improvement wasobserved after patients were treated with an aqueous-alcoholic tincture (1 :5) at90 drops/day (900mg roots). The duration of the illness decreased from 13 to9.8 days for bacterial infections, and from 12.9 to 9.1 days for viral infections(34).ContraindicationsExternal useAllergy to plants in the Asteraceae.Internal useShould not be used in serious conditions such as tuberculosis, leukosis,collagenosis, multiple sclerosis, AIDS, HIV infection and autoimmune disor-ders. Echinacea preparations should not be administered to people with a knownallergy to any plant of the Asteraceae (1). Parenteral administration is rarelyindicated owing to potential adverse side-effects (see Adverse reactions).WarningsNone.PrecautionsGeneralInternal use should not exceed a period of 8 successive weeks (1).Radix Echinaceae133Carcinogenesis, mutagenesis, impairment of fertilityMutagenicity and carcinogenicity tests were negative (5, 9, 35). Doses up to apolysaccharide concentration of 500µg/ml caused no increase in sister chroma-tid exchange or structural chromosome aberrations (35).Pregnancy: teratogenic effectsThere are no reliable studies on this subject. Therefore, administration of RadixEchinaceae during pregnancy is not generally recommended (1).Nursing mothersThere are no reliable studies on this subject. Therefore, nursing mothers shouldnot take Radix Echinaceae without consulting a physician (1).Paediatric useOral administration of Echinacea preparations is not recommended for children,except on the advice of a physician.Other precautionsNo information was available concerning drug interactions, drug and laboratorytest interactions, and non-teratogenic effects on pregnancy.Adverse reactionsExternal useAllergic reactions.Internal useAllergic reactions, shivering, fever, and headache.PosologyE. angustifolia rootUnless otherwise prescribed, hot water (about 150ml) is poured over about 0.5teaspoon (about 1g) of powdered plant material, allowed to steep for 10 min-utes, passed through a strainer, and taken orally three times a day betweenmeals (7).Liquid extract (1 :5, 45% ethanol), 0.5–1ml three times daily (7). Tincture(1 :5, 45% ethanol), 2–5ml three times daily (7).E. pallida rootUnless otherwise prescribed: daily dose, tincture (1 :5 with 50% ethanol byvolume) from original dry extract (50% ethanol), corresponding to 900mg ofroot (9).WHO monographs on selected medicinal plants134References1. German Commission E Monograph, Echinaceae angustifoliae radix; Echinaceaepallidae radix. Bundesanzeiger, 1992, 162:29 August.2. National formulary IX. Washington, DC, American Pharmaceutical Association, 1950.3. Deutsches Arzneibuch 1996. Stuttgart, Deutscher Apotheker Verlag, 1996.4. McGregor RL. The taxonomy of the genus Echinacea (Compositae). University ofKansas science bulletin, 1968, 48:113–142.5. Bauer R, Wagner H. Echinacea species as potential immunostimulatory drugs. In:Wagner H, Farnsworth NR, eds. Economic and medicinal plants research, Vol. 5. London,Academic Press, 1991:253–321.6. Awang DVC, Kindack DG. Herbal medicine, Echinacea. Canadian pharmaceuticaljournal, 1991, 124:512–516.7. Bradley PR, ed. British herbal compendium, Vol. 1. Bournemouth, British Herbal Medi-cine Association, 1992.8. Hänsel R et al., eds. Hagers Handbuch der pharmazeutischen Praxis, 5th ed., Vol. 6.Berlin, Springer, 19949. Bisset NG. Max Wichtl’s herbal drugs & phytopharmaceuticals. Boca Raton, FL, CRCPress, 1994.10. Foster S. Echinacea, the purple coneflowers. Austin, TX, The American Botanical Coun-cil, 1991 (Botanical Series, 301).11. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.12. British herbal pharmacopoeia. London, British Herbal Medicine Association, 1990.13. Bauer R, Khan IA, Wagner H. Echinacea-Drogen, Standardisierung mittels HPLC undDC. Deutsche Apotheker Zeitung, 1986, 126:1065–1070.14. Bauer R, Khan IA, Wagner H. Echinacea: Nachweis einer Verfälschung von Echinaceapurpurea (L.) Moench. mit Parthenium integrifolium L. Deutsche Apotheker Zeitung, 1987,127:1325–1330.15. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.16. Deutsches Arzneibuch 1996, Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.17. European Pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.18. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).19. Bauer R, Remiger P, Wagner H. Echinacea—Vergleichende DC- und HPLC-Analyseder Herba-Drogen von Echinacea purpurea, E. pallida und E. angustifolia (3. Mitt.).Deutsche Apotheker Zeitung, 1988, 128:174–180.20. Röder E, Wiedenfeld H, Hille T, Britz-Kirstgen R. Pyrrolizidine in Echinaceaangustifolia DC and Echinacea purpurea M. Isolation and analysis. Deutsche ApothekerZeitung, 1984, 124:2316–2317.21. Iwu MM. Handbook of African medicinal plants. Boca Raton, FL, CRC Press, 1993.22. Schöneberger D. The influence of immune-stimulating effects of pressed juice fromEchinacea purpurea on the course and severity of colds. Forum immunologie, 1992, 8:2–12.23. Melchart D et al. Immunomodulation with Echinacea: a systematic review of con-trolled clinicaltrials. Phytomedicine, 1994, 1:245–254.24. Viehmann P. Results of treatment with an Echinacea-based ointment.Erfahrungsheilkunde, 1978, 27:353–358.25. Bauer R et al. Immunological in vivo examinations of Echinacea extracts. Arzneimittel-Forschung, 1988, 38:276–281.26. Haas H. Arzneipflanzenkunde. Mannheim, BI Wissenschaftsverlag, 1991:134–135.Radix Echinaceae13527. Bauer R, Wagner H. Echinacea. Handbuch für Apotheker und andere Naturwissenschaftler.Stuttgart, Wissenschaftliche Verlagsgesellschaft, 1990.28. Büsing KH. Hyaluronidase inhibition by Echinacin. Arzneimittel-Forschung, 1952,2:467–469.29. Koch FE, Haase H. A modification of the spreading test in animal assays. Arzneimittel-Forschung, 1952, 2:464–467.30. Koch FE, Uebel H. The influence of Echinacea purpurea upon the hypohyseal-adrenalsystem. Arzneimittel-Forschung, 1953, 3:133–137.31. Wagner H et al. In vitro inhibition of arachidonate metabolism by some alkamidesand prenylated phenols. Planta medica, 1988, 55:566–567.32. Tubaro A et al. Anti-inflammatory activity of a polysaccharidic fraction of Echinaceaangustifolia. Journal of pharmacy and pharmacology, 1987, 39:567–569.33. Tragni E et al. Anti-inflammatory activity of Echinacea angustifolia fractions separatedon the basis of molecular weight. Pharmaceutical research communications, 1988,20(Suppl. V):87–90.34. Bräunig B, Knick E. Therapeutische Erfahrungen mit Echinaceae pallidae beigrippalen Infekten. Ergebnisse einer plazebokontrollierten Doppelblindstudie.Naturheilpraxis, 1993, 46:72–75.35. Kraus C, Abel G, Schimmer O. Untersuchung einiger Pyrrolizidinalkaloide aufchromosomenschädigende Wirkung in menschlichen Lymphocyten in vitro. Plantamedica, 1985, 51:89–91.WHO monographs on selected medicinal plants136Herba Echinaceae PurpureaeDefinitionHerba Echinaceae Purpureae consists of the fresh or dried aerial parts ofEchinacea purpurea (L.) Moench harvested in full bloom (Asteraceae) (1).SynonymsBrauneria purpurea (L.) Britt., Echinacea intermedia Lindl., E. purpurea (L.) Moenchf., E. purpurea (L.) Moench var. arkansana Steyerm., E. speciosa Paxt., Rudbeckiapurpurea L., R. hispida Hoffm., R. serotina Sweet (2, 3).Asteraceae are also known as Compositae.Selected vernacular namesConeflower, purple coneflower herb, purpurfarbener Igelkopf, purpurfarbeneKegelblume, purpurfarbener Sonnenhut, red sunflower, roter Sonnenhut (4–8).DescriptionA hardy, herbaceous perennial. Stems erect, stout, branched, hirsute or gla-brous, 60–180cm high; basal leaves ovate to ovate-lanceolate, acute, coarsely orsharply serrate, petioles up to 25cm long, blades to 20cm long and 15cm wide,blade abruptly narrowing to base, often cordate, decurrent on petiole, 3–5veined; cauline leaves petiolate below, sessile above, 7–20cm long, 1.5–8cmbroad, coarsely serrate to entire, rough to the touch on both surfaces; phyllarieslinear-lanceolate, attenuate, entire, pubescent on outer surface, ciliate, passinginto the chaff; heads 1.5–3cm long and 5–10mm broad, purplish; pales 9–13mm long, awn half as long as body; disc corollas 4.5–5.5mm long, lobes1mm long; achene 4–4.5mm long, pappus a low crown of equal teeth; pollengrains yellow, 19–21µm in diameter; haploid chromosome number n � 11(2).Plant material of interest: fresh or dried aerial partsGeneral appearanceThe macroscopic characteristics of Herba Echinaceae Purpureae are as de-scribed above under Description. An abbreviated description is currentlyunavailable.Herba Echinaceae Purpureae137Organoleptic propertiesMild, aromatic odour; initially sweet taste that quickly becomes bitter.Microscopic characteristicsA description of the microscopic characteristics of a cross-section of the aerialparts of the plant is currently unavailable.Powdered plant materialA description of the powdered plant material is currently unavailable.Geographical distributionEchinacea purpurea is native to the Atlantic drainage area of the United States ofAmerica and Canada, but not Mexico. Its distribution centres are in Arkansas,Kansas, Missouri, and Oklahoma in the United States of America (2). Echinaceapurpurea has been introduced as a cultivated medicinal plant in parts of northand eastern Africa and in Europe (9).General identity testsMacroscopic examination (2) and thin-layer chromatography and high-performance liquid chromatography (4, 10–13) of the lipophilic constituentsand chicoric acid in methanol extracts.Purity testsMicrobiologyThe test for Salmonella spp. in Herba Echinaceae Purpureae should be negative.The maximum acceptable limits of other microorganisms are as follows (14–16). For preparation of decoction: aerobic bacteria—not more than 107/g;fungi—not more than 105/g; Escherichia coli—not more than 102/g. Preparationsfor internal use: aerobic bacteria—not more than 105/g or ml; fungi—not morethan 104/g or ml; enterobacteria and certain Gram-negative bacteria—not morethan 103/g or ml; Escherichia coli—0/g or ml. Preparations for external use:aerobic bacteria—not more than 102/g or ml; fungi—not more than 102/g or ml;enterobacteria and certain Gram-negative bacteria—not more than 101/g or ml.Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin in Herba Echinaceae Purpureae isnot more than 0.05mg/kg (16). For other pesticides, see WHO guidelines onquality control methods for medicinal plants (14) and guidelines for predictingdietary intake of pesticide residues (17).WHO monographs on selected medicinal plants138Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (14).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (14).Other purity testsChemical tests and tests for acid-insoluble ash, dilute ethanol-soluble extrac-tive, foreign organic matter, moisture, total ash, and water-soluble extractive tobe established in accordance with national requirements.Chemical assaysFor essential oil (0.08–0.32%); chicoric acid (1.2–3.1%) (4). Quantitative anal-ysis of echinacoside, chicoric acid, isobutylamides, and other constituentsby high-performance liquid chromatography (4). Quantitative analysis ofalkamides and caffeic acid derivatives by thin-layer chromatography and high-performance liquid chromatography (4, 12).Major chemical constituentsA number of chemical entities have been identified, including alkamides,polyalkenes, polyalkynes, caffeic acid derivatives, and polysaccharides (3, 5–9).The volatile oil contains, among other compounds, borneol, bornyl acetate,pentadeca-8-(Z)-en-2-one, germacrene D, caryophyllene, and caryophylleneepoxide.Isobutylamides of C11–C16 straight-chain fatty acids with olefinic or acetyl-enic bonds (or both) are found in the aerial parts of Herba EchinaceaePurpureae, with the isomeric dodeca-(2E,4E,8Z,10E/Z)-tetraenoic acidisobutylamides.The caffeic acid ester derivative chicoric acid is the major active compoundof this class found in the aerial parts of Echinacea purpurea, with a concentrationrange of 1.2–3.1%. Chicoric acid methyl ester and other derivatives are alsopresent.Polysaccharide constituents from Herba Echinaceae Purpureae are of twotypes: a heteroxylan of average relative molecular mass about 35000 (e.g. PS-I),and an arabinorhamnogalactan of average relative molecular mass about 45000(e.g. PS-II).Other constituents include trace amounts of pyrrolizidine alkaloids(tussilagine (0.006%) and isotussilagine). At these concentrations, the alkaloidsHerba Echinaceae Purpureae139are considered to be non-toxic (8). Furthermore, because these alkaloids lack the1,2-unsaturated necine ring of alkaloids such as senecionine (structure in box)from Senecio species, they are consideredto be non-hepatotoxic (3).Structures of representative constituents are presented below.Dosage formsPowdered aerial part, pressed juice and galenic preparations thereof for internaland external use (1, 3).Medicinal usesUses supported by clinical dataHerba Echinaceae Purpureae is administered orally in supportive therapy forcolds and infections of the respiratory and urinary tract (1, 3, 5, 7, 8, 18).Beneficial effects in the treatment of these infections are generally thought to bebrought about by stimulation of the immune response (3, 5, 7). External usesinclude promotion of wound healing and treatment of inflammatory skin con-ditions (1, 3, 5, 7, 8, 9, 19).Uses described in pharmacopoeias and in traditional systems ofmedicineNone.OOCO2HHO2COOOHOHHHOHOHchicoric acidNecine ring pyrrolizidine alkaloids :1,2-saturated 1,2-unsaturatedsenecionine12345677a OHCH3HNHOOCH 312345677a CH 3OHHNHOOCH3tussilagine isotussilagine12345678OH CH 3OHCH3ONOOHHCH3WHO monographs on selected medicinal plants140Uses described in folk medicine, not supported by experimental orclinical dataOther medical uses claimed for Herba Echinaceae Purpureae include treatmentof yeast infections, side-effects of radiation therapy, rheumatoid arthritis, bloodpoisoning, and food poisoning (1, 5, 7, 9).PharmacologyExperimental pharmacologyCurrent claims of the effectiveness of Echinacea purpurea as a stimulator ofthe immune system are based on numerous scientific studies. Theimmunostimulant effect is brought about by three mechanisms: activation ofphagocytosis and stimulation of fibroblasts; increasing respiratory activity; andincreased mobility of the leukocytes (3, 5, 8). Phagocytic activity of standard-ized extracts of the aerial parts of E. purpurea has been determined. Alyophylisate of the expressed juice of Herba Echinaceae Purpureae significantlyincreased the percentage of phagocytizing human granulocytes and stimulatedthe phagocytosis of yeast particles in vitro (20, 21). Inhibition of hyaluronidaseactivity, stimulation of the activity of the adrenal cortex, stimulation of theproduction of properdin (a serum protein which can neutralize bacteria andviruses), and stimulation of interferon production have also been reported afterEchinacea treatments (22). The pharmacological activity of Echinacea spp. hasbeen attributed to five component fractions in addition to the essential oil,namely the alkylamides, caffeic acid derivatives, polyalkynes, polyalkenes,and polysaccharides (7). The lipophilic amides, alkamides, and caffeic acidderivatives appear to contribute to the immunostimulant activity of the alco-holic Echinacea extracts by stimulating phagocytosis of polymorphonuclearneutrophil granulocytes (3, 23, 24). High molecular weight polysaccharides,including heteroxylan, which activates phagocytosis, and arabinogalactan,which promotes the release of tumour necrosis factor and the production ofinterleukin-1 and interferon beta (19, 22), have also been implicated in theactivity of the aqueous extracts and the powdered drug when taken orally. Theoverall immunostimulant activity of the alcoholic and aqueous Echinacea ex-tracts appears to depend on the combined effects of several constituents (3, 5,23).Topical applications of Echinacea extracts have been traditionally used topromote wound healing. The first published work on the mechanism of thisaction was by Büsing (25), who investigated the effect of Echinacea spp. onstreptococcal and tissue hyaluronidase. Inhibition of tissue and bacterial hyalu-ronidase is thought to localize the infection and prevent the spread of causativeagents to other parts of the body. In addition to the direct antihyaluronidaseactivity, an indirect effect on the hyaluronic acid–hyaluronidase system hasbeen reported (26). Stimulation of new tissue production by increasingfibroblast activity, and stimulation of both blood- and tissue-produced phago-cytosis, appear to be involved in this mechanism (26). The polysaccharideHerba Echinaceae Purpureae141fraction (echinacin B) appears to promote wound healing by forming a hyalu-ronic acid–polysaccharide complex that indirectly leads to the inhibition ofhyaluronidase (27 ).In in vitro experiments, an ethanol extract (65% by volume) of HerbaEchinaceae Purpureae inhibited the contraction of collagen by mousefibroblasts, measured by the collagen lattice diameter (28).Mouse macrophages pretreated with polysaccharides that were isolatedfrom the supernatant of Herba Echinaceae Purpureae cell culture increasedproduction of tumour necrosis factor alpha, interleukin-1, and interferon beta-2 and increased cytotoxicity against tumour cells and microorganisms (Leishma-nia enreittii ) (29–31).Purified polysaccharides isolated from large-scale cell cultures of E. purpureaenhanced the spontaneous motility of human polymorphonuclear leukocytesunder soft agar and increased the ability of these cells to kill Staphylococcusaureus. Human monocytes were activated to secrete tumour necrosis factoralpha, interleukin-1, and interleukin-6 while the expression of class II humanleukocyte antigens was unaffected (32).For purified caffeic acid derivatives, antiviral activities have been demon-strated (33). Incubation of vesicular stomatitis virus (VSV) with 125µg/ml ofchicoric acid for 4 hours reduced the number of viral particles in mouse L-929murine cells by more than 50% (34).Clinical pharmacologyRecently 26 controlled clinical trials (18 randomized, 11 double-blind) weresystematically reviewed in Germany (24), Nineteen trials studied the prophy-laxis or curative treatment of infections, four trials studied the reduction of side-effects of chemotherapy, and three investigated the modulation of specificimmune parameters. The review concluded that Echinacea-containing prepara-tions are efficacious immunomodulators (24). However, it also concluded thatthere was insufficient evidence for clear therapeutic recommendations as towhich preparation or dosage to use for a specific indication (24).A large-scale longitudinal trial (4598 patients) studied the effects of anointment containing a lyophylisate of the expressed juice of Herba EchinaceaePurpureae. The ointment was used to treat inflammatory skin conditions,wounds, eczema, burns, herpes simplex, and varicose ulcerations of the legs(19). Therapeutic benefit from the ointment was observed in 85.5% of thecases. The treatment periods ranged from 7.1 to 15.5 days (19).ContraindicationsExternal useAllergy to the plant.Internal useShould not be used in serious conditions such as tuberculosis, leukosis, col-lagenosis, multiple sclerosis, AIDS, HIV infection, and autoimmune disorders.WHO monographs on selected medicinal plants142Echinacea preparations should not be administered to people with a knownallergy to any plant of the Asteraceae (1).WarningsNo information available.PrecautionsGeneralInternal or external use should not exceed a period of 8 successive weeks (1).Carcinogenesis, mutagenesis, impairment of fertilityMutagenicity and carcinogenicity test results were negative (3, 5, 35). Doses upto a polysaccharide concentration of 500mg/ml caused no increase in sisterchromatid exchange or structural chromosome aberrations (35).Pregnancy: teratogenic effectsThere are no reliable studies on this subject. Therefore, administration of thedrug during pregnancy is not recommended (1).Nursing mothersThere are no reliable studies on this subject. Nursing mothers should not takethe drug without consulting a physician (1).Paediatric useOral administration of Echinacea preparations is not recommended for smallchildren, except on the advice of a physician. Herba Echinaceae Purpureae maybe used for external treatment of small superficial wounds.Other precautionsNo information availableconcerning drug interactions, drug and laboratory testinteractions, or non-teratogenic effects on pregnancy.Adverse reactionsOccasionally allergic reactions may occur owing to allergy to plants in theAsteraceae (Compositae).PosologyOral daily dosage of Herba Echinaceae Purpureae, 6–9ml expressed juice (1) forno longer than 8 successive weeks (1). External use of semisolid preparationscontaining at least 15% pressed juice (1) for no longer than 8 successive weeks(1). Information on dosages for children is not available (7).Herba Echinaceae Purpureae143References1. German Commission E Monograph, Echinaceae purpureae radix. Bundesanzeiger,1992, 162:29 August.2. McGregor RL. The taxonomy of the genus Echinacea (Compositae). University ofKansas science bulletin, 1968, 48:113–142.3. Bauer R, Wagner H. Echinacea species as potential immunostimulatory drugs. In:Wagner H, Farnsworth NR, eds. Economic and medicinal plants research. Vol. 5. London,Academic Press, 1991:253–321.4. Hänsel R et al., eds. Hagers Handbuch der pharmazeutischen Praxis, Vol. 6, 5th ed.Berlin, Springer, 1994.5. Bisset NG. Max Wichtl’s herbal drugs & phytopharmaceuticals. Boca Raton, FL, CRCPress, 1994.6. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois at Chi-cago, IL, March 15, 1995 production (an on-line database available directly throughthe University of Illinois at Chicago or through the Scientific and Technical Network(STN) of Chemical Abstracts Services).7. Awang DVC, Kindack DG. Herbal medicine, Echinacea. Canadian pharmaceuticaljournal, 1991, 124:512–516.8. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.9. Iwu MM. Handbook of African medicinal plants. Boca Raton, FL, CRC Press, 1993.10. Bauer R, Khan IA, Wagner H. Echinacea-Drogen Standardisierung mittels HPLC undDC. Deutsche Apotheker Zeitung, 1986, 126:1065–1070.11. Bauer R, Khan IA, Wagner H. Echinacea: Nachweis einer Verfälschung von Echinaceapurpurea (l.) Moench. mit Parthenium integrifolium L. Deutsche Apotheker Zeitung, 1987,127:1325–1330.12. Bauer R, Remiger P, Wagner H. Echinacea—Vergleichende DC- und HPLC-Analyseder Herba-drogen von Echinacea purpurea, E. pallida und E. angustifolia (3. Mitt.).Deutsche Apotheker Zeitung, 1988, 128:174–180.13. Bauer R, Wagner H. Echinacea—Der Sonnenhut—Stand der Forschung. Zeitschrift fürPhytotherapie, 1988, 9:151.14. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.15. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.16. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.17. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).18. Schöneberger D. The influence of immune-stimulating effects of pressed juice fromEchinacea purpurea on the course and severity of colds. Forum immunologie, 1992, 8:2–12.19. Viehmann P. Results of treatment with an Echinacea-based ointment.Erfahrungsheilkunde, 1978, 27:353–358.20. Stotzem CD, Hungerland U, Mengs U. Influence of Echinacea purpurea on the phago-cytosis of human granulocytes. Medical science research, 1992, 20:719–720.21. Bittner E. Die Wirkung von Echinacin auf die Funktion des Retikuloendothelialen Systems[Dissertation]. Freiburg, University of Freiburg, 1969.22. Haas H. Arzneipflanzenkunde. Mannheim, BI Wissenschaftsverlag, 1991:134–135.23. Bauer R, Wagner H. Echinacea. Handbuch für Apotheker und andere Naturwissenschaftler.Stuttgart, Wissenschaftliche Verlagsgesellschaft, 1990.24. Melchart D et al. Immunomodulation with Echinacea—a systematic review of con-trolled clinical trials. Phytomedicine, 1994, 1:245–254.WHO monographs on selected medicinal plants14425. Büsing KH. Hyaluronidase inhibition by Echinacin. Arzneimittel-Forschung, 1952,2:467–469.26. Koch FE, Haase H. A modification of the spreading test in animal assays. Arzneimittel-Forschung, 1952, 2:464–467.27. Bonadeo I, Bottazzi G, Lavazza M. Essenze-Profumi-Piante. Officin–Aromi-Saponi-Cosmetici-Aerosol, 1971, 53:281–295.28. Zoutewelle G, van Wijk R. Effects of Echinacea purpurea extracts on fibroblast popu-lated collagen lattice contraction. Phytotherapy research, 1990, 4:77–81.29. Steinmüller C et al. Polysaccharides isolated from plant cell cultures of Echinaceapurpurea enhance the resistance of immunosuppressed mice against systemic infec-tions with Candida albicans and Listeria monocytogenes. International journal forimmunopharmacology, 1993, 15:605–614.30. Stempel M et al. Macrophage activation and induction of macrophage cytotoxicityby purified polysaccharide fractions from the plant Echinacea purpurea. Infection andimmunity, 1984:845–849.31. Luettig B et al. Macrophage activation by polysaccharide arabinogalactan isolatedfrom plant cell cultures of Echinacea purpurea. Journal of the National Cancer Institute,1989, 81:669–675.32. Roesler J et al. Application of purified polysaccharides from cell cultures of the plantEchinacea purpurea to test subjects mediates activation of the phagocyte system.International journal for immunopharmacology, 1991, 13:931–941.33. Cheminat A et al. Caffeoyl conjugates from Echinacea species: structures and biologi-cal activity. Phytochemistry, 1988, 27:2787–2794.34. Müller-Jakic B et al. In vitro inhibition of cyclooxygenase and 5-lipoxygenase byalkamides from Echinacea and Achillea species. Planta medica, 1993:37–42.35. Kraus C, Abel G, Schimmer O. Untersuchung einiger Pyrrolizidinalkaloide aufchromosomenschädigende Wirkung in menschlichen Lymphocyten in vitro. Plantamedica, 1985, 51:89–91.Herba Ephedrae145Herba EphedraeDefinitionHerba Ephedrae consists of the dried stem or aerial part of Ephedra sinica Stapfor other ephedrine-containing Ephedra species (Ephedraceae) (1–5).SynonymsNone.Selected vernacular namesAmsania, budshur, chewa, Chinese ephedra, ephédra, horsetail, hum, huma,joint fir, khama, ma hoàng, ma huang, máhuáng, mao, maoh, maou, mao-kon,môc tac ma hoàng, mu-tsei-ma-huang, phok, san-ma-huang, shrubby, soma,song tuê ma hoàng, trung aa hoàng, tsao-ma-huang, tutgantha (4–10).DescriptionErect or prostrate, green, almost leafless shrub, 20–90cm high. Branches erect,short, glaucous green, somewhat flat, 1.0–1.5mm in diameter, with small sparselongitudinal striae, fasciated at the nodes; nodes reddish brown; internode 2.5–5.5cm long � 2mm in diameter. Small triangular leaves opposite, reduced toscales, barely 2mm. Flowers in summer, unisexual, dioecious; male flowerspedunculate or nearly sessile, grouped in catkins composed of 4 to 8 pairs offlowers with about 8 anthers; female flowers biflorous, pedunculate with 3 or 4pairs of bracts, the naked ovule surrounded by an urn-shaped perianth sheath,fruiting with often fleshy red succulent bracts, 2-seeded (4, 7, 11).Plant material of interest: stem or aerial partGeneral appearanceMacroscopically, Herba Ephedrae occurs as thin cylindrical or ellipsoidal cylin-der, 1–2mm in diameter; 3.5–5.5cm in length of internode; light green toyellow-green; numerous parallel vertical furrows on the surface; scaly leaves atthe node portion; leaves, 2–4mm in length, light brown to brown in colour,usually opposite at every node, adhering at the base to form a tubular sheatharound the stem. Under a magnifying glass, the transverse section of the stemappears as circle and ellipse, the outer portion greyish green to yellow-green inWHO monographs on selected medicinal plants146colour, and the centre filled with a red-purple substance or hollow. Whenfractured at an internode, the outer part is fibrous and easily split vertically (1).Organoleptic propertiesOdour, slight; taste, slightly bitter and astringent, giving a slight sensation ofnumbnesson the tongue (1).Microscopic characteristicsThe epidermal cells of the stem are covered with a moderately thick granu-lar cuticle; the cells are polygonal or subrectangular, axially elongated, havingstraight anticlinal walls. The stomata are few and are of the ranunculaceoustype with lignified appendages. The epidermis of the scaly leaf is covered withsmooth (upper) or warty (lower) cuticle and consists of subrectangular to po-lygonal cells, having straight or sometimes slightly beaded anticlinal walls; fewstomata are present resembling those of stem. The epidermis of the apical andmarginal regions of the scaly leaf shows short papillae-like outgrowths.Chlorenchymatous palisade-like cells form the outer zone of the cortex;rounded ordinary parenchymatous cells form the inner zone of the cortex.Cortical parenchyma and pith cells contain an amorphous reddish brown sub-stance. Non-lignified or lignified hypodermal and pericyclic fibres, which havethick walls, bear slit-like pits and blunt, slightly tapering, occasionally forkedends. The vessels of the secondary xylem of the stem are lignified with bor-dered pits, having rounded or oval apertures. The vessel segments have muchinclined end walls, bearing foraminate perforation plates. The tracheids andfibrous tracheids of secondary xylem of the stem are lignified with bordered pitshaving oval or slit-like apertures. The fibres of the scaly leaf are lignified, usuallyirregular or nearly straight, having moderately thick walls and blunt or some-times forked ends. Few, small, rounded, simple and compound starch granuleswith indistinct hilum are present in cortical parenchyma, pith, and medullaryray cells. Few, small prisms of calcium oxalate are present in the corticalparenchyma (4).Powdered plant materialPowdered Herba Ephedrae is greyish green. Numerous thick fragments ofcutinized outer walls of epidermis vary from colourless to varying shades ofbrown or red; numerous fragments of sclerenchyma fibres with extremelythickened, non-lignified to lignified walls, narrow, frequently indistinct luminaand sharp pointed ends; fragments of vascular tissue showing tracheids withbordered pores and occasional spiral and pitted tracheae; numerous chloren-chyma cells; starch grains simple, spheroidal to occasionally ovate, averaging upto 1.2µm but occasionally up to 20µm; fragments of epidermis with rectangularcells and granular contents, some with sunken elliptical stomata; fragments ofHerba Ephedrae147lignified or non-lignified pith parenchyma, some of the cells showing mucilagesacs; papillae; granules of calcium oxalate (4, 6).Geographical distributionEphedra species are found in Afghanistan, Central America, China, India, re-gions of the Mediterranean, Mongolia, and North America (4, 6–12).General identity testsMacroscopic and microscopic examinations and microchemical tests for thepresence of alkaloids with Mayer’s reagent (1–5, 7 ).Purity testsMicrobiologyThe test for Salmonella spp. in Herba Ephedrae products should be negative. Themaximum acceptable limits for other microorganisms are as follows (13–15).For preparation of decoction: aerobic bacteria—not more than 107/g; fungi—notmore than 105/g; Escherichia coli—not more than 102/g. Preparations for internaluse: aerobic bacteria—not more than 105/g or ml; fungi—not more than 104/g orml; enterobacteria and certain Gram-negative bacteria—not more than 103/g orml; Escherichia coli—0/g or ml.Foreign organic matterWoody stems, not more than 5% (1). Does not contain stems of Equisetaceaeor Gramineae plants, nor any other foreign matter (1).Total ashNot more than 9% (3).Acid-insoluble ashNot more than 2% (1).MoistureNot more than 9% (3).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Herba Ephedrae is not morethan 0.05mg/kg (15). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (13) and guidelines for predicting dietaryintake of pesticide residues (16).WHO monographs on selected medicinal plants148Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (13).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (13).Other purity testsChemical, dilute ethanol-soluble extractive, and water-soluble extractive teststo be established in accordance with national requirements.Chemical assaysContains not less than 0.7% total alkaloids, calculated as ephedrine by high-performance liquid chromatography in the Japanese pharmacopoeia; or notless than 0.8% of total alkaloids, calculated as ephedrine in the Chinesepharmacopoeia (1, 2).Thin-layer (17), gas–liquid (18) or high-performance liquid (19) chromato-graphic analysis for ephedrine and related alkaloids are available.Major chemical constituentsThe major active principle found in Herba Ephedrae is (�)-ephedrine inconcentrations of 40–90% of the total alkaloid fraction, accompanied by(�)-pseudoephedrine. Other trace alkaloids in the alkaloid complex include(�)-norephedrine, (�)-norpseudoephedrine, (�)-methylephedrine and (�)-methylpseudoephedrine. The total alkaloid content can exceed 2% dependingon the species (20). Not all Ephedra species contain ephedrine or alkaloids.NHHH OHCH3CH3( )-ephedrine ( )-methylephedrineNHH OHCH3CH3CH3NH2HH OHCH3( )-norephedrineNHHH OHCH3CH3( )-pseudoephedrineNHH OHCH3CH3CH 3( )-methylpseudoephedrineNH2HH OHCH3( )-norpseudoephedrine� � �� � �Herba Ephedrae149Dosage formsPowdered plant material; extracts and other galenicals. Store in well closed,light-resistant containers.Medicinal usesUses supported by clinical dataHerba Ephedrae preparations are used in the treatment of nasal congestion dueto hay fever, allergic rhinitis, acute coryza, common cold, and sinusitis. Thedrug is further used as a bronchodilator in the treatment of bronchial asthma (4,8, 10, 21–23).Uses described in pharmacopoeias and in traditional systems ofmedicineHerba Ephedrae has been used for the treatment of urticaria, enuresis,narcolepsy, myasthenia gravis, and chronic postural hypotension (4, 8, 22, 23).Uses described in folk medicine, not supported by experimental orclinical dataOther medical uses claimed for Herba Ephedrae preparations include its use asan analgesic, an antiviral agent, an antitussive and expectorant, an antibacterial,and an immune stimulant (10, 24, 25).Clinical pharmacologyTwo of the main active constituents of Herba Ephedrae, ephedrine andpseudoephedrine, are potent sympathomimetic drugs that stimulate α-,�1- and �2- adrenoceptors (22, 23). Pseudoephedrine’s activity is similarto ephedrine, but its hypertensive effects and stimulation of the central nervoussystem are somewhat weaker. Part of ephedrine’s peripheral action is due to therelease of norepinephrine, but the drug also directly affects receptors.Tachyphylaxis develops to its peripheral actions, and rapidly repeated dosesbecome less effective owing to the depletion of norepinephrine stores (22).Cardiovascular actionsLike epinephrine (adrenaline), ephedrine excites the sympathetic nervous sys-tem, causing vasoconstriction and cardiac stimulation. Ephedrine differs fromepinephrine in that it is orally active, has a much longer duration of action, andhas more pronounced activity in the central nervous system, but is much lesspotent (22, 23). The drug stimulates the heart rate, as well as cardiac output, andincreases peripheral resistance, thereby producing a lasting rise in blood pres-sure. The cardiovascular effects of ephedrine persist up to ten times as long asWHO monographs on selected medicinal plants150those of epinephrine (22). Ephedrine elevates both the systolic and diastolicpressures and pulse pressure. Renal and splanchnic blood flows are decreased,while coronary, cerebral, and muscle blood flows are increased (22, 23).Bronchodilator and nasal decongestantEphedrine, like epinephrine, relaxes bronchial muscles and is a potentbronchodilator owing to its activation of the �-adrenoceptors in the lungs (22,23). Bronchial muscle relaxation is less pronounced but more sustained withephedrine than with epinephrine. As a consequence, ephedrine should be usedonly in patients with mild cases of acute asthma and in chronic cases thatrequire maintenance medication. Ephedrine, like other sympathomimetics withα-receptor activity, causes vasoconstriction and blanching when applied topi-cally to nasal and pharyngeal mucosal surfaces (22, 23). Continued, prolongeduse of these preparations (�3 days) may cause rebound congestion and chronicrhinitis (26). Both ephedrine and pseudoephedrine are useful orally as nasaldecongestants in cases of allergic rhinitis, but they may not be very effective forthe treatment of nasal congestion due to colds.Central nervous systemMydriasis occurs after local application of ephedrine (3–5%) to the eye, but theeffect lasts for only a few hours (22). Ephedrine is of little value as a mydriaticin the presence of inflammation. The activity of the smooth muscles of theuterus is usually reduced by ephedrine; consequently, the drug has been used torelieve the pain of dysmenorrhoea (22).Ephedrine is a potent stimulator of the central nervous system. The effectsof the drug may last for several hours after oral administration (23). Thus,preparations containing Herba Ephedrae have been promoted for use in weightreduction and thermogenesis (fat burning) (27, 28). The safety and effectivenessof these preparations is currently an issue of debate and requires further inves-tigation (29).Ephedrine stimulates the α-adrenoceptors of the smooth muscle cells of thebladder base, which increases the resistance to the outflow of urine (23). ThusHerba Ephedrae has been used in the treatment of urinary incontinence andnocturnal enuresis.ContraindicationsHerba Ephedrae should not be administered to patients with coronarythrombosis, diabetes, glaucoma, heart disease, hypertension, thyroid disease,impaired circulation of the cerebrum, phaeochromocytoma, or enlarged pros-tate (10, 21, 23). Co-administration of Herba Ephedrae preparations withmonoamine oxidase inhibitors is contraindicated as the combination may causesevere, possibly fatal, hypertension (23).Herba Ephedrae151WarningsDosage should be reduced or treatment discontinued if nervousness, tremor,sleeplessness, loss of appetite or nausea occurs. Not for children under 6 yearsof age. Keep out of the reach of children (30). Continued, prolonged use maycause dependency.PrecautionsGeneralInsomnia may occur with continued use of Herba Ephedrae preparations (23).Drug interactionsIn combination with cardiac glycosides or halothane, may cause heart rhythmdisturbances (21); with guanethidine, may cause an enhancement of sympatho-mimetic effect (21); with monoamine oxidase inhibitors, can cause severe,possibly fatal, hypertension (26); with ergot alkaloid derivatives or oxytocin,may increase risk of high blood pressure (21).Carcinogenesis, mutagenesis, impairment of fertilityExtracts of Ephedra sinica are not mutagenic in the Salmonella/microsome rever-sion assay (31).Pregnancy: teratogenic effectsEphedra sinica did not have any teratogenic effects in vivo (32).Pregnancy: nonteratogenic effectsEphedra sinica is not abortifacient in rats (32). Clinical studies in humans arenot available; therefore, use of the drug during pregnancy is not generallyrecommended.Nursing mothersThere are no reliable studies on this subject. Therefore, nursing mothers shouldnot take Herba Ephedrae without consulting a physician.Paediatric useHerba Ephedrae should not be administered to children under 6 years of age.Other precautionsNo information available concerning drug and laboratory test interactions.Adverse reactionsIn large doses Herba Ephedrae products can cause nervousness, headaches,insomnia, dizziness, palpitations, skin flushing and tingling, and vomiting (21).WHO monographs on selected medicinal plants152The principal adverse effects of ephedrine and Herba Ephedrae are stimulationof the central nervous system, nausea, tremors, tachycardia, and urine retention(24). Continued, prolonged use (�3 days) of topical preparations containingHerba Ephedrae, for the treatment of nasal congestion, may cause reboundcongestion and chronic rhinitis (26). Continued prolonged use of oral prepara-tions may cause dependency (21).PosologyCrude plant material: 1–6g for decoction daily (8, 21). Liquid extract (1 :1 in45% alcohol): 1–3ml daily (21). Tincture (1 :4 in 45% alcohol): 6–8ml daily (21).References1. The pharmacopoeia of Japan XII. Tokyo, The Society of Japanese Pharmacopoeia,1991.2. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992.3. Deutsches Arzneibuch 1996. Stuttgart, Deutscher Apotheker Verlag, 1996.4. African pharmacopoeia, 1st ed. Lagos, Organization of African Unity, Scientific, Tech-nical & Research Commission, 1985.5. Vietnam materia medica. Hanoi, Ministry of Health, 1972.6. Hsu HY. Oriental materia medica, a concise guide. Long Beach, CA, Oriental HealingArts Institute, 1986.7. Youngken HW. Textbook of pharmacognosy, 6th ed. Philadelphia, Blakiston, 1950.8. Medicinal plants in China. Manila, World Health Organization, 1989 (WHO RegionalPublications, Western Pacific Series, No. 2).9. The Indian pharmaceutical codex. Vol. I. Indigenous drugs. New Delhi, Council of Scien-tific & Industrial Research, 1953.10. Farnsworth NR, ed. NAPRALERT database. Chicago, University of Illinois at Chi-cago, IL, March 15, 1995 production (an on-line database available directly throughthe University of Illinois at Chicago or through the Scientific and Technical Network(STN) of Chemical Abstracts Services).11. Tyler VE, Brady LR, Robbers JE, eds. Pharmacognosy, 9th ed. Philadelphia, Lea &Febiger, 1988.12. Morton JF. Major medicinal plants: botany, culture and use. Springfield, IL, Charles CThomas, 1977.13. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.14. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.15. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.16. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).17. Zhang JS, Tian Z, Lou ZC. Detection and identification of the alkaloids in HerbaEphedra (Ma huang) by chemical tests and HPTLC. Yaowu fenxi zazhi, 1992, 12:38–41.18. Cui JF et al. Analysis of alkaloids in Chinese Ephedra species by gas chromatographicmethods. Phytochemical analysis, 1991, 2:116–119.Herba Ephedrae15319. Zhang JS, Tian Z, Lou ZC. Simultaneous determination of six alkaloids in EphedraHerba by high performance liquid chromatography. Planta medica, 1988, 54:69–70.20. Bruneton J. Pharmacognosy, phytochemistry, medicinal plants. Paris, Lavoisier, 1995.21. German Commission E Monograph, Ephedrae herba. Bundesanzeiger, 1991, 11:17January.22. Goodman and Gilman’s the pharmacological basis of therapeutics, 6th ed. New York,MacMillan, 1985:169–170.23. Goodman LS et al. Goodman and Gilman’s the pharmacological basis of therapeutics, 8thed. New York, MacMillan, 1993:213–214.24. Kim TH, Yang KS, Hwang EZ, Park SB. Effect of Ephedrae Herba on the immuneresponse in mice. Korean journal of pharmacognosy, 1991, 22:183–191.25. Konno C et al. Ephedroxane,anti-inflammatory principal of Ephedra herbs. Phy-tochemistry, 1979, 18:697–698.26. Handbook of non-prescription drugs, 8th ed. Washington, DC, American Pharmaceuti-cal Association, 1986.27. Daley PA et al. Ephedrine, caffeine and aspirin: safety and efficacy for the treatmentof human obesity. International journal of obesity, 1993, 17(Suppl. 1):S73–S78.28. Pardoe AU, Gorecki DKJ, Jones D. Ephedrine alkaloid patterns in herbal productsbased on Ma Huang (Ephedra sinica). International journal of obesity, 1993, 17(Suppl.1):S82.29. Adverse events with Ephedra and other botanical dietary supplements. FDA medicalbulletin, 1994, 24:3.30. Policy Statement on Ephedra sinica (Ma huang). Austin, TX, American Herbal Prod-ucts Association 1994.31. Morimoto I et al. Mutagenicity screening of crude drugs with Bacillus subtilis rec-assay and Salmonella/microsome reversion assay. Mutation research, 1982, 97:81–102.32. Lee EB. Teratogenicity of the extracts of crude drugs. Korean journal of pharmacognosy,1982, 13:116–121.WHO monographs on selected medicinal plants154Folium GinkgoDefinitionFolium Ginkgo consists of the dried whole leaf of Ginkgo biloba L.(Ginkgoaceae).SynonymsPterophyllus salisburiensis Nelson, Salisburia adiantifolia Smith, Salisburiamacrophylla C. Koch (1–4).Selected vernacular namesEun-haeng, gin-nan, ginkgo, ginkgo balm, ginkgo leaves, ginkyo, ginan, icho,ityo, kew tree, maidenhair tree, pei-wen, temple balm, yin guo, yinhsing (1–5).DescriptionA monotypic dioecious plant that is the only living representative of theGinkgoales. It has a grey bark, reaches a height of 35m and a diameter of 3–4m(sometimes up to 7m), and has fan-like leaves that are deciduous, alternate,lengthily petiolate, bilobate, base wedge-shaped, 6–9cm broad (sometimes upto 15–20cm), turning yellow in autumn. Venation dichotomously branching,seemingly parallel. Staminate and ovulate strobili borne on separate trees;staminate strobili consisting of naked pairs of anthers in catkin-like clusters;ovulate strobili in the form of long, slender, fused stalks bearing a single nakedovule which is fertilized by motile sperm cells, developing into 2 seeds. Seedsyellow when mature, foul-smelling, drupe-like, the middle layer of integumentbecoming hard or stone-like, the outer layer fleshy (3, 4).Plant material of interest: dried leafThe kernel (nut, seed) is used in Chinese medicine (6, 7).General appearanceThe leaves are green, grey-yellow, brown or blackish; the upper side of a leafmay be somewhat darker than the underside. The leaves are fan-shaped, long-petioled and have two lobes with forked veins radiating from the petiole end (2,4, 8).Folium Ginkgo155Organoleptic propertiesGinkgo leaves have a weak characteristic odour (2, 4, 8).Microscopic characteristicsYoung leaves have abundant trichomes that become confined to the petiolebase as the leaf ages. While the leaves have no midrib, dichotomous venationwith regular, numerous branching parallel veins arises from two vascularstrands within the petiole. Stomata occur almost exclusively on the lowersurface of the leaf. The epidermis of the upper and underside of the leaf consistsof undulated, irregular, mostly long extended cells. In the cross-section, theepidermal cells appear nearly isodiametric and from above appear to be slightlyundulated, with the upper cells appearing larger. The outer walls of the epider-mal cells are covered with a more or less thin layer of cuticle. In the area ofvascular bundles there are remarkable long extended narrow cells with slightlyundulated walls. Numerous druses of calcium oxalate occur near the vascularbundles (2, 4).Powdered plant materialThe colour of the powder agrees with that of the leaves. The powder showsfragments of the epidermis with wavelike indentations irregular in form withgenerally elongated cells; large stomal openings of the anisocytic type; mark-edly elongated, narrow cells with only weakly undulated walls in the vascularareas and without marked indentations. The equifacial mesophyll comprisesexcretory vesicles, secretory cells, and idioblasts, as well as intermittent calciumoxalate druses, in the region of the vascular fascicles (2, 8).Geographical distributionNative to China, but grown as an ornamental shade tree in Australia, south-eastAsia, Europe, Japan, and the United States of America (1–3, 6). It is commer-cially cultivated in France and the United States of America (2).General identity testsMacroscopic and microscopic examinations (2, 8). Thin-layer chromatographicanalysis for the presence of the characteristic flavonoids, ginkgolides, andbilobalide (9); high-performance liquid chromatographic analysis for flavonoids(10), ginkgolides, and bilobalide (2); and gas–liquid chromatographic evaluationof ginkgolides and bilobalide (11).Purity testsMicrobiologyThe test for Salmonella spp. in Folium Ginkgo should be negative. The maxi-mum acceptable limits of other microorganisms are as follows (12–14). Forpreparation of decoction: aerobic bacteria—not more than 107/g; fungi—notWHO monographs on selected medicinal plants156more than 105/g; Escherichia coli—not more than 102/g. Preparations for internaluse: aerobic bacteria—not more than 105/g or ml; fungi—not more than 104/g orml; enterobacteria and certain Gram-negative bacteria—not more than 103/g orml; Escherichia coli—0/g or ml.Foreign organic matterNot more than 5% of twigs and not more than 2% of other foreign matter (15).Total ashNot more than 11% (15).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin in Folium Ginkgo is not more than0.05mg/kg (14). For other pesticides, see WHO guidelines on quality controlmethods for medicinal plants (12), and guidelines for predicting dietary intakeof pesticide residues (16).Heavy metalsRecommended lead and cadmium levels are not more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (12).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (12).Other purity testsAcid-insoluble ash, acid-insoluble extractive, chemical, and moisture tests to beestablished in accordance with national requirements.Chemical assaysFlavonoids not less than 0.5% calculated as flavonol glycosides or 0.2–0.4%calculated as aglycones (17); also contains ginkgolides (0.06–0.23%) andbilobalide (up to 0.26%) (2, 17).Qualitative and quantitative determination of flavonoid glycosides is carriedout after hydrolysis to the aglycones kaempferol, quercetin, and isorhamnetin.The qualitative presence or absence of biflavones (17) is determined by high-performance liquid chromatography; and qualitative and quantitative deter-mination of the diterpene ginkgolides and sesquiterpene bilobalide byhigh-performance liquid chromatography (2, 18) or gas–liquid chromatography(11).Certain commercial products used for clinical and experimental biologicalstudies, e.g. EGb 761 and LI 1370, do not contain biflavones.Folium Ginkgo157Major chemical constituentsFolium Ginkgo contains a wide variety of phytochemicals, including alkanes,lipids, sterols, benzenoids, carotenoids, phenylpropanoids, carbohydrates, fla-vonoids, and terpenoids (18, 19). The major constituents are flavonoids ofwhich mono-, di-, and tri-glycosides and coumaric acid esters that are based onthe flavonols kaempferol and quercetin dominate. Lesser quantities of glyco-sides are derived from isorhamnetin, myricetin, and 3�-methylmyricetin. Non-glycosidic biflavonoids, catechins, and proanthocyanidins are also present (15).Characteristic constituents of this plant material are the unique diterpene lac-tones ginkgolides A, B, C, J, and M and the sesquiterpene lactone bilobalide(17). Representative structures ofthe major and characteristic constituents arepresented below.OOOHOHOHOOHOOCH3OHOOOOHOHOHROOOHOHOHRO sugar(R = H , OH , O C3)flavonoid glycosidesquercetin derivativeR = OHkaempferol derivativeR = Hkaempferol derivativequercetin derivativeflavonoid glycosidesOR1R4OR3OOHOHOOHR2amentoflavonebilobetinginkgetinsciadopitysin5'-methoxybilobetinisoginkgetinOH HOHOCH3 OCH3OO OOHR3C H3H HOOHOOR'RR2H H C(CH 3)3Hginkgolide Aginkgolide Bginkgolide Cginkgolide Jginkgolide MR R2 R3R' O OHOOHOH C(CH3) 3HOOOHbilobalideR1 R2 R3 R4O HOH OHOCH3 OH HHOCH3OHOCH3OCH3OCH3 OHOHHOCH3 OCH3 OCH3OHH HHH OHH OHOHOH OHHH OH OHHHOHOH HWHO monographs on selected medicinal plants158Dosage formsStandardized extracts (dry extracts from dried leaves, extracted with acetoneand water, drug:extract ratio 35–67:1) contain 22–27% flavone glycosidesand 5–7% terpene lactones, of which approximately 2.8–3.4% consists ofginkgolides A, B, and C and 2.6–3.2% bilobalide. The level of ginkgolic acids isbelow 5mg/kg. Coated tablets and solution for oral administration are preparedfrom standardized purified extracts (20, 21).Medicinal usesUses supported by clinical dataExtracts as described above (Dosage forms) have been used for symptomatictreatment of mild to moderate cerebrovascular insufficiency (demential syn-dromes in primary degenerative dementia, vascular dementia, and mixed formsof both) with the following symptoms: memory deficit, disturbance in concen-tration, depressive emotional condition, dizziness, tinnitus, and headache (1, 3,20–22). Such extracts are also used to improve pain-free walking distance inpeople with peripheral arterial occlusive disease such as intermittentclaudication, Raynaud disease, acrocyanosis, and post-phlebitis syndrome, andto treat inner ear disorders such as tinnitus and vertigo of vascular andinvolutive origin (20, 23–27). Extracts and doses other than those described inDosage forms and Posology are used for similar but milder indications (28, 29).Uses described in pharmacopoeias and in traditional systems ofmedicineNone.Uses described in folk medicine, not supported by experimental orclinical dataAs a vermifuge, to induce labour, for the treatment of bronchitis, chronicrhinitis, chilblains, arthritis, and oedema (3, 5).PharmacologyExperimental pharmacologyCerebrovascular insufficiency and peripheral vascular diseasesIn vitro studies. A standardized extract of Ginkgo biloba (100µg/ml) did notproduce isometrically recordable contractions in isolated rabbit aorta but didpotentiate the contractile effect of norepinephrine (30). Higher concentrations(EC50 � 1.0mg/ml) produced a concentration-dependent contraction that couldbe antagonized by the α-adrenoceptor-blocking agent phentolamine (30). Bothcocaine and desipramine, inhibitors of catecholamine re-uptake, potentiatedthe contractile effect of norepinephrine but inhibited the contractile effects of aFolium Ginkgo159standardized extract of G. biloba and tyramine (30). The results of these experi-ments indicate that the contractile action of G. biloba may be due to the releaseof catecholamines from endogenous tissue reserves, and this activity mayexplain some of the therapeutic effects of the drug in humans (e.g. improve-ment in cerebrovascular and peripheral vascular insufficiency) (1, 30). On thebasis of experiments comparing the effects of an extract of G. biloba,phentolamine, propranolol, gallopamil, theophylline, and papaverine on thebiphasic contractile response of norepinephrine in isolated rat aorta, researchersconcluded that G. biloba had musculotropic action similar to that of papaverine(31). This activity was previously reported for the flavonoids quercetin,kaempferol, and isorhamnetin, isolated from the leaves of G. biloba (32). Theflavonoids and papaverine both inhibit 3�,5�-cyclic-GMP phosphodiesterase,which in turn induces endothelium-dependent relaxation in isolated rabbitaorta by potentiating the effects of endothelium-derived relaxing factors (1).In vitro studies have demonstrated that G. biloba extracts scavenge freeradicals (33–37). Ginkgo biloba extracts have been reported to reduce free radical-lipid peroxidation induced by NADPH-Fe3� systems in rat microsomes (33), andto protect human liver microsomes from lipid peroxidation caused byciclosporin A (34). The extract also inhibits the generation of reactive oxygenradicals in human leukocytes treated with phorbol myristate acetate (35). Theantioxidant action of G. biloba extract may prolong the half-life of endothelium-derived relaxing factor by scavenging superoxide anions (36, 37). Both theflavonoid and terpenoid constituents of G. biloba appear to aid the free-radicalscavenging activity of the drug (37).Ginkgo biloba extract protected against brain tissue hypoxic damage in vitro.The ginkgolides and bilobalide were responsible for the antihypoxic activity ofthe extract (38, 39). Ginkgolides A and B have been shown to protect rathippocampal neurons against ischaemic damage, which may be due to theirability to act as antagonists to receptors for platelet-activating factor (PAF) (40–42).In vivo studies. Oral administration of G. biloba extract protected rats againstinduced cerebral ischaemia (43–45). Intravenous perfusion of a G. biloba extractprevented the development of multiple cerebral infarction in dogs injected withfragments of an autologous clot into a common carotid artery (46). These datasuggest that G. biloba extract, administered after clot formation, may have somebeneficial effects on acute cerebral infarction or ischaemia caused by embolism(1). Other experiments demonstrated that animals treated with G. biloba extractsurvived under hypoxic conditions longer than did untreated controls (47, 48).Longer survival was due not only to significant improvements in cerebral bloodflow, but also to an increase in the level of glucose and ATP (44, 48–50). Otherstudies have shown that a G. biloba extract devoid of ginkgolides but containingbilobalide had protective activity when administered intraperitoneally to micewith induced hypobaric hypoxia (51, 52). Intravenous infusion of G. bilobaextract significantly increased pial arteriolar diameter in cats (53) and improvedWHO monographs on selected medicinal plants160cerebral blood flow in rats (53). The active constituents of G. biloba responsiblefor increasing cerebral blood flow appeared to be the non-flavonoid compounds(54); ginkgolide B may be responsible for this action owing to its PAF-antagonistactivity (55, 56). Furthermore, intravenous administration of a standardizedG. biloba extract and ginkgolide B to rats showed that the extract, but notginkgolide B, decreased the brain’s use of glucose (57).The constituents of G. biloba responsible for its anti-ischaemic activity re-main undefined. The flavonoids, ginkgolides, and bilobalide have all been sug-gested, but it is possible that other constituents may be responsible.An extract of G. biloba was effective in the in vivo treatment of cerebraloedema, a condition of excessive hydration of neural tissues owing to damageby neurotoxic agents (such as triethyltin) or trauma (58–60). Bilobalide appearedto play a significant role in the antioedema effect (61, 62). Oral or subcutaneousadministration of an extract of G. biloba to rats with acute and chronic phasesof adriamycin-induced paw inflammation partially reversed the increase inbrain water, sodium, and calcium and the decrease in brain potassium associ-ated with sodium arachidonate-induced cerebral infarction (63).Mice treated with a standardized extract of G. biloba (100mg/kg, orally for4–8 weeks) showed improved memory and learning during appetitive operantconditioning (64).Vestibular and auditory effectsGinkgo biloba extract improvedthe sum of action potentials in the cochlea andacoustic nerve in cases of acoustically produced sound trauma in guinea-pigs (1,65). The mechanism reduced the metabolic damage to the cochlea. Oral orparenteral administration of a standardized G. biloba extract to mice (2mg/kg)improved the ultrastructure qualities of vestibular sensory epithelia when thetissue was fixed by vascular perfusion (66). Improvement was due to the effectsof the drug on capillary permeability and general microcirculation (1, 66).Positive effects on vestibular compensation were observed after administra-tion of G. biloba extract (50mg/kg intraperitoneally) to rats and cats that hadundergone unilateral vestibular neurectomy (67, 68).Antagonism of platelet-activating factor (PAF)The ginkgolides, and in particular ginkgolide B, are known antagonists of PAF(69–73). PAF is a potent inducer of platelet aggregation, neutrophil degranu-lation, and oxygen radical production leading to increased microvascular per-meability and bronchoconstriction. Intravenous injections of PAF inducedtransient thrombocytopenia in guinea-pigs, which was accompanied by non-histamine-dependent bronchospasm (69, 70). Ginkgolide B has been shown tobe a potent inhibitor of PAF-induced thrombocytopenia and bronchocon-striction (71, 72). PAF or ovalbumin-induced bronchoconstriction in sensitizedguinea-pigs was inhibited by an intravenous injection of ginkgolide B (1–3mg/kg) 5 minutes prior to challenge (73).Folium Ginkgo161Clinical pharmacologyCerebral insufficiencyCerebral insufficiency is an inexact term to describe a collection of symptomsassociated with dementia (21, 22). In dementia owing to degeneration withneuronal loss and impaired neurotransmission, decline of intellectual function isassociated with disturbances in the supply of oxygen and glucose. In clinicalstudies G. biloba effectively managed symptoms of cerebral insufficiency includ-ing difficulty in concentration and memory, absent-mindedness, confusion, lackof energy, tiredness, decreased physical performance, depressive mood, anxi-ety, dizziness, tinnitus, and headache (20–22). Several mechanisms of action ofG. biloba have been described: effects on blood circulation such as thevasoregulating activity of arteries, capillaries, veins (increased blood flow);rheological effects (decreased viscosity, by PAF-receptor antagonism); meta-bolic changes such as increased tolerance to anoxia; beneficial influence onneurotransmitter disturbances; and prevention of damage to membranes byfree radicals (22). Treatment of humans with G. biloba extract has been shownto improve global and local cerebral blood flow and microcirculation (74–76), toprotect against hypoxia (77), to improve blood rheology, including inhibition ofplatelet aggregation (74, 78–81), to improve tissue metabolism (82), and toreduce capillary permeability (83).A critical review of 40 published clinical trials (up to the end of 1990) usingan orally administered G. biloba extract in the treatment of cerebral insufficiencyconcluded that only eight of the studies were well performed (21, 22). Almostall trials reported at least a partially positive response at dosages of 120–160mga day (standardized extract) and treatment for at least 4–6 weeks (21, 22).In a comparison of G. biloba with published trials using co-dergocrine(dihydroergotoxine), a mixture of ergoloid mesilates used for the same purpose,both G. biloba extract and co-dergocrine showed similar efficacy. A directcomparison of 120mg of G. biloba standardized extract and 4.5mg co-dergocrine showed similar improvements in both groups after 6 weeks (84).A meta-analysis of 11 placebo-controlled, randomized double-blind studiesin elderly patients given G. biloba extract (150mg orally per day) for cerebralinsufficiency concluded that eight studies were well performed (85). Significantdifferences were found for all analysed single symptoms, indicating the superi-ority of the drug in comparison with the placebo. Analysis of the total score ofclinical symptoms indicated that seven studies confirmed the effectiveness of G.biloba extract, while one study was inconclusive (85).Peripheral arterial occlusive diseaseThe effectiveness of G. biloba extract in the treatment of intermittentclaudication (peripheral arterial occlusive disease Fontaine stage II), as com-pared with a placebo, was demonstrated in placebo-controlled, double-blindclinical trials by a statistically significant increase in walking distance (1, 23, 24).Sixty patients with peripheral arterial occlusive disease in Fontaine stage IIbWHO monographs on selected medicinal plants162who were treated with the drug (120–160mg for 24 weeks) and underwentphysical training also clearly increased their walking distance (25).Out of 15 controlled trials (up to the end of 1990) only two (23, 24) were ofacceptable quality (22–24). The results of both studies were positive andshowed an increase in walking distance in patients with intermittentclaudication after 6 months (23), and an improvement of pain at rest in patientstreated with 200mg of G. biloba extract for 8 weeks (24).After meta-analysis of five placebo-controlled clinical trials (up to the end of1991) of G. biloba extract in patients with peripheral arterial disease, investiga-tors concluded that the extract exerted a highly significant therapeutic effect(26).Vertigo and tinnitusGinkgo biloba extracts have been used clinically in the treatment of inner eardisorders such as hearing loss, vertigo, and tinnitus. In a placebo-controlled,double-blind study of 68 patients with vertiginous syndrome of recent onset,treatment with G. biloba extract (120–160mg daily, for 4–12 weeks) produceda statistically significant improvement as compared with the placebo group(27).The results of clinical studies on the treatment of tinnitus have been contra-dictory. At least six clinical studies have assessed the effectiveness of G. bilobaextract for the treatment of tinnitus. Three studies reported positive results (86,87, 88). One multicentre, randomized, double-blind, 13-month study of 103patients with tinnitus showed that all patients improved, irrespective of theprognostic factor, when treated with G. biloba extract (160mg/day for 3months) (86). Three other clinical trials reported negative outcomes (89–91).Statistical analysis of an open study (80 patients) without placebo, coupled witha double-blind, placebo-controlled part (21 patients), demonstrated that a con-centrated G. biloba extract (29.2mg/day for 2 weeks) had no effect on tinnitus(91).ContraindicationsHypersensitivity to G. biloba preparations (20).WarningsNo information available.PrecautionsCarcinogenesis, mutagenesis, impairment of fertilityInvestigations with G. biloba extracts have shown no effects that were mu-tagenic, carcinogenic, or toxic to reproduction (20).Folium Ginkgo163Pregnancy: non-teratogenic effectsThe safety of Folium Ginkgo for use during pregnancy has not been established.Nursing mothersExcretion of Folium Ginkgo into breast milk and its effects on the newbornhave not been established.Other precautionsNo information is available concerning general precautions or drug interactions,drug and laboratory test interactions, teratogenic effects on pregnancy, orpaediatric use.Adverse reactionsHeadaches, gastrointestinal disturbances, and allergic skin reactions are possibleadverse effects (20).PosologyDried extract (as described in Dosage forms), 120–240mg daily in 2 or 3 divideddoses (2); 40mg extract is equivalent to 1.4–2.7g leaves (20). Fluid extract (1 :1),0.5ml 3 times a day (1, 2).References1. DeFeudis FV. Ginkgo biloba extract (egb 761): pharmacological activities and clinicalapplications. Paris, Elsevier, Editions Scientifiques, 1991:1187.2. Hänsel R et al., eds. Hagers Handbuch der pharmazeutischen Praxis, Vol. 6, 5th ed.Berlin, Springer-Verlag, 1994.3. SquiresR. Ginkgo biloba. Australian traditional medicine society (ATOMS), 1995:9–14.4. Huh H, Staba EJ. The botany and chemistry of Ginkgo biloba L. Journal of herbs, spicesand medicinal plants, 1992, 1:91–124.5. Farnsworth NR, ed. NAPRALERT database. University of Illinois at Chicago, IL,August 8, 1995 production (an on-line database available directly through theUniversity of Illinois at Chicago or through the Scientific and Technical Network(STN) of Chemical Abstracts Services).6. Keys JD. Chinese herbs, their botany, chemistry and pharmacodynamics. Rutland,VT, CE Tuttle, 1976:30–31.7. Pharmacopoeia of the People’s Republic of China (English ed.). Guangzhou, GuangdongScience and Technology Press, 1992:64.8. Melzheimer V. Ginkgo biloba L. aus Sicht der systematischen und angewandtenBotanik. Pharmazie in unserer Zeit, 1992, 21:206–214.9. Van Beek TA, Lelyveld GP. Thin layer chromatography of bilobalide and ginkgolidesA, B, C and J on sodium acetate impregnated silica gel. Phytochemical analysis, 1993,4:109–114.10. Hasler A, Meier B, Sticher O. Identification and determination of the flavonoids fromGinkgo biloba by HPLC. Journal of chromatography, 1992, 605:41–48.11. Hasler A, Meier B. Determination of terpenes from Ginkgo biloba by GLC. Pharmacyand pharmacology letters, 1992, 2:187–190.WHO monographs on selected medicinal plants16412. Quality control methods for medicinal plant materials. Geneva, World Health Organiza-tion, 1998.13. Deutsches Arzneibuch 1996. Vol. 2. Methoden der Biologie. Stuttgart, DeutscherApotheker Verlag, 1996.14. European pharmacopoeia, 3rd ed. Strasbourg, Council of Europe, 1997.15. Sticher O. Biochemical, pharmaceutical and medical perspectives of Ginkgo prepara-tions. In: New Drug Development from Herbal Medicines in Neuropsychopharmacology.Symposium of the XIXth CINP Congress, Washington, DC, June 27–July 1, 1994.16. Guidelines for predicting dietary intake of pesticide residues, 2nd rev. ed. Geneva,World Health Organization, 1997 (unpublished document WHO/FSF/FOS/97.7;available from Food Safety, WHO, 1211 Geneva 27, Switzerland).17. Sticher O. Quality of Ginkgo preparations. Planta medica, 1993, 59:2–11.18. Van Beek TA et al. Determination of ginkgolides and bilobalide in Ginkgo bilobaleaves and phytochemicals. Journal of chromatography, 1991, 543:375–387.19. Hasler A et al. Complex flavonol glycosides from the leaves of Ginkgo biloba.Phytochemistry, 1992, 31:1391.20. German Commission E monograph, Trockenextrakt (35–67 : 1) aus Ginkgo-biloba-Blättern Extrakt mit Aceton-Wasser. Bundesanzeiger, 1994, 46:7361–7362.21. Kleijnen J, Knipschild P. Ginkgo biloba. Lancet, 1992, 340:1136–1139.22. Kleijnen J, Knipschild P. Ginkgo biloba for cerebral insufficiency. British journal ofclinical pharmacology, 1992, 34:352–358.23. Bauer U. Six month double-blind randomized clinical trial of Ginkgo biloba extractversus placebo in two parallel groups in patients suffering from peripheral arterialinsufficiency. Arzneimittel-Forschung, 1984, 34:716–720.24. Saudreau F, Serise JM, Pillet J. Efficacité de l’extrait de Ginkgo biloba dans letraitement des artériopathies obliterantes chroniques des membres inferieurs austade III de la classification de Fontaine. Journal malade vasculare, 1989, 14:177–182.25. Blume J et al. Placebokontrollierte Doppelblindstudie zur Wirksamkeit von Ginkgobiloba-Spezialextrakt EGb 761 bei austrainierten Patienten mit Claudicatiointermittens. VASA, 1996, 2:1–11.26. Schneider B. Ginkgo biloba Extrakt bei peripheren arteriellen Verschlußkrankheiten.Arzneimittel-Forschung, 1992, 42:428–436.27. Haguenauer JP et al. Traitement des troubles de l’equilibre par l’extrait de Ginkgobiloba. Presse medicale, 1986, 15:1569–1572.28. Coeur et circulation, 02.97.0 Troubles de l’artériosclérose. IKS monthly bulletin, 1994,6:532–533.29. Kade F, Miller W. Dose-dependent effects of Ginkgo biloba extraction on cerebral,mental and physical efficiency: a placebo controlled double blind study. Britishjournal of clinical research, 1993, 4:97–103.30. Auguet M, DeFeudis FV, Clostre F. Effects of Ginkgo biloba on arterial smooth muscleresponses to vasoactive stimuli. General pharmacology, 1982, 13:169–171, 225–230.31. Auguet M, Clostre F. Effects of an extract of Ginkgo biloba and diverse substances onthe phasic and tonic components of the contraction of an isolated rabbit aorta.General pharmacology, 1983, 14:277–280.32. Peter H, Fisel J, Weisser W. Zur Pharmakologie der Wirkstoffe aus Ginkgo biloba.Arzneimittel-Forschung, 1966, 16:719–725.33. Pincemail J et al. In: Farkas L, Gabor M, Kallay F, eds. Flavonoids and bioflavonoids.Szeged, Hungary, 1985:423.34. Barth SA et al. Influences of Ginkgo biloba on cyclosporin induced lipid peroxidationin human liver microsomes in comparison to vitamin E, glutathione and N-acetylcysteine. Biochemical pharmacology, 1991, 41:1521–1526.35. Pincemail J et al. Ginkgo biloba extract inhibits oxygen species production generatedFolium Ginkgo165by phorbol myristate acetate stimulated human leukocytes. Experientia, 1987,43:181–184.36. Pincemail J, Dupuis M, Nasr C. Superoxide anion scavenging effect andsuperoxide dismutase activity of Ginkgo biloba extract. Experientia, 1989, 45:708–712.37. Robak J, Gryglewski RJ. Flavonoids are scavengers of superoxide anions. Biochemicalpharmacology, 1988, 37:837–841.38. Oberpichler H et al. Effects of Ginkgo biloba constituents related to protection againstbrain damage caused by hypoxia. Pharmacological research communications, 1988,20:349–352.39. Krieglstein J. Neuroprotective effects of Ginkgo biloba constituents. European journal ofpharmaceutical sciences, 1995, 3:39–48.40. Braquet P. The ginkgolides: potent platelet-activating factor antagonists isolatedfrom Ginkgo biloba L.: chemistry, pharmacology and clinical application. Drugs of thefuture, 1987, 12:643–648.41. Oberpichler H. PAF-antagonist ginkgolide B reduces postischemic neuronal damagein rat brain hippocampus. Journal of cerebral blood flow and metabolism, 1990, 10:133–135.42. Prehn JHM, Krieglstein J. Platelet-activating factor antagonists reduce excitotoxicdamage in cultured neurons from embryonic chick telencephalon and protect the rathippocampus and neocortex from ischemic injury in vivo. Journal of neuroscienceresearch, 1993, 34:179–188.43. Larssen RG, Dupeyron JP, Boulu RG. Modèles d’ischémie cérébrale expérimentalepar microsphères chez le rat. Étude de l’effet de deux extraits de Ginkgo biloba et dunaftidrofuryl. Thérapie, 1978, 33:651–660.44. Rapin JR, Le Poncin-Lafitte M. Consommation cérébrale du glucose. Effet de l’extraitde Ginkgo biloba. Presse medica, 1986, 15:1494–1497.45. Le Poncin-Lafitte MC, Rapin J, Rapin JR. Effects of Ginkgo biloba on changes inducedby quantitative cerebral microembolization in rats. Archives of internationalpharmacodynamics, 1980, 243:236–244.46. Cahn J. Effects of Ginkgo biloba extract (GBE) on the acute phase of cerebralischaemia due to embolisms. In: Agnoli A et al., eds. Effects of Ginkgo biloba extract onorganic cerebral impairment. London, John Libbey, 1985:43–49.47. Chatterjee SS. Effects of Ginkgo biloba extract on cerebral metabolic processes. In:Agnoli A et al., eds. Effects of Ginkgo biloba extract on organic cerebral impairment.London, John Libby, 1985:5–14.48. Karcher L, Zagermann P, Krieglstein J. Effect of an extract of Ginkgo biloba on ratbrain energy metabolism in hypoxia. Naunyn-Schmiedeberg’s archives of pharmacology,1984, 327:31–35.49. Le Poncin-Lafitte M et al. Ischémie cérébrale après ligature non simultanèe desartères carotides chez le rat: effet de l’extrait de Ginkgo biloba. Semaine hopitale Paris,1982, 58:403–406.50. Iliff LD, Auer LM. The effect of intravenous infusion of Tebonin (Ginkgo biloba) onpial arteries in cats. Journal of neurosurgical science, 1982, 27:227–231.51. Duverger D. Anoxie hypobare chez la souris avec les différentsextraits de Ginkgobiloba. Le Plessis Robinson, France, Institut Henri-Beaufour, 1989 (Report no. 1116/89/DD/HK).52. Duverger D. Anoxie hypobare chez la souris avec l’un des constituants de l’EGB:leHE 134. Le Plessis Robinson, France, Institut Henri-Beaufour, 1990 (Report no. 1182/90/DD/HK).53. Krieglstein J, Beck T, Seibert A. Influence of an extract of Ginkgo biloba on cerebralblood flow and metabolism. Life sciences, 1986, 39:2327–2334.54. Beck T et al. Comparative study on the effects of two extract fractions of Ginkgobiloba on local cerebral blood flow and on brain energy metabolism in the rat underWHO monographs on selected medicinal plants166hypoxia. In: Krieglstein J, ed. Pharmacology of cerebral ischemia. Amsterdam, Elsevier,1986:345–350.55. Krieglstein J, Oberpichler H. Ginkgo biloba und Hirnleistungsstörungen.Pharmazeutische Zeitung, 1989, 13:2279–2289.56. Oberpichler H et al. Effects of Ginkgo biloba constituents related to protection againstbrain damage caused by hypoxia. Pharmacology research communications, 1988, 20:349–352.57. Lamor Y et al. Effects of ginkgolide B and Ginkgo biloba extract on local cerebralglucose utilization in the awake adult rat. Drug development research, 1991, 23:219–225.58. Chatterjee SS, Gabard B. Effect of an extract of Ginkgo biloba on experimentalneurotoxicity. Archives of pharmacology, 1984, 325(Suppl.), Abstr. 327.59. Otani M et al. Effect of an extract of Ginkgo biloba on triethyltin-induced cerebraloedema. Acta neuropathology, 1986, 69:54–65.60. Borzeix MG. Effects of Ginkgo biloba extract on two types of cerebral oedema. In:Agnoli A et al., eds. Effects of Ginkgo biloba extract on organic cerebral impairment.London, John Libbey, 1985:51–56.61. Chatterjee SS, Gabard BL, Jaggy HEW. Pharmaceutical compositions containingbilobalide for the treatment of neuropathies. US Patent no. 4,571,407 (Feb 18, 1986).62. Sancesario G, Kreutzberg GW. Stimulation of astrocytes affects cytotoxic brainoedema. Acta neuropathology, 1986, 72:3–14.63. DeFeudis FV et al. Some in vitro and in vivo actions of an extract of Ginkgo biloba (GBE761). In: Agnoli A et al., eds. Effects of Ginkgo biloba extract on organic cerebral impair-ment. London, John Libbey, 1985:17–29.64. Winter E. Effects of an extract of Ginkgo biloba on learning and memory in mice.Pharmacology, biochemistry and behavior, 1991, 38:109–114.65. Stange VG et al. Adaptationsverhalten peripherer und zentraler akustischerReizantworten des Meerschweinchens unter dem Einfluss verschiedener Fraktioneneines Extraktes aus Ginkgo biloba. Arzneimittel-Forschung, 1976, 26:367–374.66. Raymond J. Effets de l’extrait de Ginkgo biloba sur la préservation morphologique desépithéliums sensoriels vestibulaires chez la souris. Presse médicale, 1986, 15:1484–1487.67. Denise P, Bustany P. The effect of Ginkgo biloba (EGb 761) on central compensationof a total unilateral peripheral vestibular deficit in the rat. In: Lacour M et al., eds.Vestibular compensation: facts, theories and clinical perspectives. Paris, Elsevier, 1989:201–208.68. Lacour M, Ez-Zaher L, Raymond J. Plasticity mechanisms in vestibular compensa-tion in the cat are improved by an extract of Ginkgo biloba (EGb 761). Pharmacology,biochemistry and behavior, 1991, 40:367–379.69. Vargaftig BB et al. Platelet-activating factor induces a platelet-dependentbronchoconstriction unrelated to the formation of prostaglandin derivatives.European journal of pharmacology, 1982, 65:185–192.70. Vargaftig BB, Benveniste J. Platelet-activating factor today. Trends in pharmacologicalsciences, 1983, 4:341–343.71. Desquand S et al. Interference of BN 52021 (ginkgolide B) with the broncho-pulmonary effects of PAF-acether in the guinea-pig. European journal of pharmacology,1986, 127:83–95.72. Desquand S, Vargaftig BB. Interference of the PAF-acether antagonist BN 52021 inbronchopulmonary anaphylaxis. Can a case be made for a role for PAF-acether inbronchopulmonary anaphylaxis in the guinea-pig? In: Braquet P, ed. Ginkgolides, Vol.1. Barcelona, JR Prous, 1988:271–281.73. Braquet P et al. Involvement of platelet activating factor in respiratory anaphylaxis,demonstrated by PAF-acether inhibitor BN 52021. Lancet, 1985, i:1501.74. Költringer P et al. Die Mikrozirkulation und Viskoelastizität des Vollblutes unterFolium Ginkgo167Ginkgo biloba extrakt. Eine plazebokontrollierte, randomisierte Doppelblind-Studie.Perfusion, 1989, 1:28–30.75. Költringer P et al. Mikrozirkulation unter parenteraler Ginkgo biloba Extrakt-Therapie. Wiener Medizinische Wochenschrift, 1989, 101:198–200.76. Jung F et al. Effect of Ginkgo biloba on fluidity of blood and peripheral microcircula-tion in volunteers. Arzneimittel-Forschung, 1990, 40:589–593.77. Schaffler K, Reeh PW. Doppelblindstudie zur hypoxieprotektiven Wirkung einesstandardisierten Ginkgo-biloba-Präparates nach Mehrfachverabreichung an gesundenProbanden. Arzneimittel-Forschung, 1985, 35:1283–1286.78. Hofferberth B. Simultanerfassung elektrophysiologischer, psychometrischer undrheologischer Parameter bei Patienten mit hirnorganischem Psychosyndrom underhöhtem Gefässrisiko—Eine Placebo-kontrollierte Doppelblindstudie mit Ginkgobiloba-Extrakt EGB 761. In: Stodtmeister R, Pillunat LE, eds. Mikrozirkulation in Gehirnund Sinnesorganen. Stuttgart, Ferdinand Enke, 1991:64–74.79. Witte S. Therapeutical aspects of Ginkgo biloba flavone glucosides in the context ofincreased blood viscosity. Clinical hemorheology, 1989, 9:323–326.80. Artmann GM, Schikarski C. Ginkgo biloba extract (EGb 761) protects red blood cellsfrom oxidative damage. Clinical hemorheology, 1993, 13:529–539.81. Ernst E, Marshall M. Der Effekt von Ginkgo-biloba-Spezialextrakt EGb 761 auf dieLeukozytenfilterabilität—Eine Pilotstudie. Perfusion, 1992, 8:241–244.82. Rudofsky G. Wirkung von Ginkgo-biloba-extrakt bei arterieller Verschlusskrankheit.Fortschritte der Medizin, 1987, 105:397–400.83. Lagrue G, et al. Oedèmes cycliques idiopathiques. Rôle de l’hyperperméabilitécapillaire et correction par l’extrait de Ginkgo biloba. Presse médicale, 1986, 15:1550–1553.84. Gerhardt G, Rogalla K, Jaeger J. Medikamentöse Therapie von Hirnleistungsstö-rungen. Randomisierte Vergleichsstudie mit Dihydroergotoxin und Ginkgo biloba-Extrakt. Fortschritte der Medizin, 1990, 108:384–388.85. Hopfenmüller W. Nachweis der therapeutischen Wirksamkeit eines Ginkgo bilobaSpezialextraktes. Arzneimittel-Forschung, 1994, 44:1005–1013.86. Meyer B. Etude multicentrique randomisée a double insu face au placebo dutraitement des acouphènes par l’extrait de Ginkgo biloba. Presse medicale, 1986,15:1562–1564.87. Sprenger FH. Gute Therapieergebnisse mit Ginkgo biloba. Ärztliche Praxis, 1986,12:938–940.88. Witt U. Low power laser und Ginkgo-Extrakte als Kombinationstherapie. Hamburg,Germany (unpublished document; available through NAPRALERT, see reference 5).89. Coles RRA. Trial of an extract of Ginkgo biloba (EGB) for tinnitus and hearing loss.Clinical otolaryngology, 1988, 13:501–504.90. Fucci JM et al. Effects of Ginkgo biloba extract on tinnitus: a double blind study. St.Petersberg, FL, Association for Research in Otolaryngology, 1991.91. Holgers KM, Axelson A, Pringle I. Ginkgo biloba extract for the treatment of tinnitus.Audiology, 1994, 33:85–92.WHO monographs on selected medicinal plants168Radix GinsengDefinitionRadix Ginseng is the dried root of Panax ginseng C.A. Meyer (Araliaceae) (1–5).1SynonymsPanax schinseng Nees (2).Other Panax species, including P. quinquefolius L. (American ginseng), P.notoginseng Burk. (San-chi ginseng), P. pseudoginseng Wall. ssp. japonicus Hara �P. japonicus C.A. Meyer (Japanese chikutsu ginseng) and P. notoginseng ssp.himalaicus (Himalayan ginseng) have also been referred to as “ginseng” and usedmedically (6, 7). However, scientific documentation of these species is insuffi-cient to justify the preparation of a monograph atthis time.Selected vernacular namesChosen ninjin, ginseng, Ginsengwurzel, hakusan, hakushan, higeninjin,hongshen, hungseng, hungshen, hunseng, jenseng, jenshen, jinpi, kao-li-seng,korean ginseng, minjin, nhan sam, ninjin, ninzin, niuhuan, Oriental ginseng,otane ninjin, renshen, san-pi, shanshen, sheng-sai-seng, shenshaishanshen,shengshaishen, t’ang-seng, tyosenninzin, yakuyo ninjin, yakuyo ninzin, yeh-shan-seng, yuan-seng, yuanshen (1, 2, 4–10).DescriptionA perennial herb with characteristic branched roots extending from the middleof the main root in the form of a human figure. Stem erect, simple, and notbranching. Leaves verticillate, compound, digitate, leaflets 5, with the 3 termi-nal leaflets larger than the lateral ones, elliptical or slightly obovate, 4–15cmlong by 2–6.5cm wide; apex acuminate; base cuneate; margin serrulate or finelybidentate. In general, 1 leaf in the first year with 1 leaflet added annually untilthe sixth year. Inflorescence a small terminal umbel, hemispherical in earlysummer. Flowers polygamous, pink. Calyx vaguely 5-toothed. Petals 5, stamens5. Fruit a small berry, nearly drupaceous, and red when ripe in autumn (8).1 Steamed Panax ginseng root is listed in the Japanese pharmacopoeia as “Red Ginseng (GinsengRadix Rubra)” (2).Radix Ginseng169Plant material of interest: dried rootGeneral appearanceThe main root is fusiform or cylindrical, 2.5–20cm long by 0.5–3.0cm indiameter; externally greyish yellow; upper part or entire root exhibiting sparse,shallow, interrupted, and coarse transverse striations and distinct longitudinalwrinkles; lower part bearing 2–5 branching lateral roots and numerous slenderrootlets with inconspicuous minute tubercles. Rhizomes 1–4cm long by 0.3–1.5cm in diameter, mostly constricted and curved, bearing adventitious rootsand sparse depressed circular stem scars. Texture relatively hard, fractureyellowish white, cambium ring brownish yellow, starchy (1–5).Organoleptic propertiesColour, greyish white to amber-yellow; odour, characteristic; taste, slightlysweet at first, followed by a slight bitterness (1, 2).Microscopic characteristicsThe transverse section shows cork consisting of several rows of cells; cortexnarrow; phloem showing clefts in the outer part, and parenchymatous cellsdensely arranged and scattered with resin canals containing yellow secretions inthe inner part; cambium in a ring; xylem rays broad, vessels singly scattered orgrouped in an interrupted radial arrangement, and occasionally accompanied bynon-lignified fibres; parenchyma cells containing abundant starch grains and afew clusters of calcium oxalate (1, 3–5).Powdered plant materialYellowish white; fragments of resin canals containing yellow secretions; clus-ters of calcium oxalate (20–68µm in diameter), few, with acute angles; cork cellssubsquare or polygonal, with thin and sinuous walls; reticulate and scalariformvessels 10–56µm in diameter; starch granules fairly abundant, simple,subspheroidal, semicircular, or irregular polygonal (4–30µm in diameter), singlyor in groups of two to four (1–5).Geographical distributionMountain regions of China (Manchuria), the Democratic People’s Republic ofKorea, Japan, the Republic of Korea, and the Russian Federation (eastern Sibe-ria) (7, 8). It is commercially produced mainly by cultivation (6).General identity testsMacroscopic and microscopic examinations, microchemical tests, and thin-layer chromatographic analysis (1–5).WHO monographs on selected medicinal plants170Purity testsMicrobiologyThe test for Salmonella spp. in Radix Ginseng products should be negative. Themaximum acceptable limits of other microorganisms are as follows (11–13). Forpreparation of decoction: aerobic bacteria—not more than 107/g; fungi—notmore than 105/g; Escherichia coli—not more than 102/g. Preparations for internaluse: aerobic bacteria—not more than 105/g or ml; fungi—not more than 104/g orml; enterobacteria and certain Gram-negative bacteria—not more than 103/g orml; Escherichia coli—0/g or ml.Foreign organic matterNot more than 2% (2, 3).Total ashNot more than 4.2% (2).Acid-insoluble ashNot more than 1% (4).Sulfated ashNot more than 12% (5).Alcohol-soluble extractiveNot less than 14.0% (2).Pesticide residuesTo be established in accordance with national requirements. Normally, themaximum residue limit of aldrin and dieldrin for Radix Ginseng is not morethan 0.05mg/kg (13). For other pesticides, see WHO guidelines on qualitycontrol methods for medicinal plants (11) and guidelines for predicting dietaryintake of pesticide residues (14).Heavy metalsRecommended lead and cadmium levels are no more than 10 and 0.3mg/kg,respectively, in the final dosage form of the plant material (11).Radioactive residuesFor analysis of strontium-90, iodine-131, caesium-134, caesium-137, andplutonium-239, see WHO guidelines on quality control methods for medicinalplants (11).Radix Ginseng171Other purity testsChemical and water-soluble extractive tests to be established in accordancewith national requirements.Chemical assaysMicrochemical, thin-layer chromatographic, and spectrophotometric methodsare used for the qualitative and quantitative analysis of ginsenosides (1–5).High-performance liquid chromatography (15–17) and liquid chromatography–mass spectrometry (18) methods are also available.Characteristic saponins known as ginsenosides, not less than 1.5%calculated as ginsenoside Rg1 (D-glucopyranosyl-6�-glucopyranosyl-20S-protopanaxatriol, relative molecular mass 800) (3, 5).Major chemical constituentsThe major chemical constituents are triterpene saponins. More than 30 arebased on the dammarane structure, and one (ginsenoside Ro) is derived fromoleanolic acid (6, 7, 17, 19). The dammarane saponins are derivatives ofeither protopanaxadiol or protopanaxatriol. Members of the former group in-clude ginsenosides Ra1�3, Rb1�3, Rc, Rc2, Rd, Rd2, and Rh2; (20S)-ginsenosideRg3; and malonyl ginsenosides Rb1, Rb2, Rc, and Rd. Examples ofprotopanaxatriol saponins are ginsenosides Re2, Re3, Rf, Rg1, Rg2, and Rh1; 20-gluco-ginsenoside Rf; and (20R)-ginsenosides Rg2 and Rh1. Those consideredmost important are ginsenosides Rb1, Rb2, Rc, Rd, Rf, Rg1, and Rg2; Rb1, Rb2, andRg1 are the most abundant. Representative structures are presented below.CH 3CH 3OCH3CH 3CH3HCH3HCH3CH3OR1OHHHHHR2panaxadiolsCH3CH 3OCH3CH 3CH 3HCH3HCH 3CH 3OHOHHHHHOR3HR2panaxatriolsginsenoside Reginsenoside Rfginsenoside Rg1ginsenoside Rg2→→→R2 R3ginsenoside Rb1ginsenoside Rb2ginsenoside Rcginsenoside Rd→→→→→O →R1 R2β-D-glucopyranosylglc-OOHOHOHCH2OHO-glc-(1 2)-glc- O-glc-(1 6)-glc-O-glc-(1 2)-glc- -ara(p)-(1 6)-glc-O-glc-(1 2)-glc- O-ara(f)-(1→6)-glc-O-glc-(1 2)-glc- glc-glc- O-rha-(1 2)-glc-O-glc-(1 2)-glc-H-glc- glc-H- O-rha-(1 2)-glc--rhamnopyranosylα-LCH 3OHOH OOHrha-α-L-arabinopyranosylara(p)-OH OOHOHα-L-arabinofuranosylara(f)-OOHOHCH2OHWHO monographs on selected medicinal plants172Dosage formsCrude plant material, capsules and tablets of powdered drugs, extracts, tonicdrinks, wines, and lozenges. Store in a cool, dry place in well-sealed containers(20).Medicinal usesUses supported by clinical dataRadix Ginseng is used as a prophylactic and restorative agent for enhancementof mental and physical capacities, in cases of weakness, exhaustion, tiredness,and loss of concentration, and during convalescence (21–29).Uses described in pharmacopoeias and in traditional systems ofmedicineRadix Ginseng has been used clinically in the treatment of diabetes (1), butfurther clinical studies are needed. The drug is also used in the treatment ofimpotence, prevention of hepatotoxicity, and gastrointestinal disorders such asgastritis and ulcers (1, 7).Uses described in folk medicine, not supported by