Superseded: Committee On Herbal Medicinal Products (HMPC)

European Medicines Agency
Evaluation of Medicines for Human Use
London, 3 July 2008

Doc. Ref. EMEA/HMPC/354183/2007
ed
COMMITTEE ON HERBAL MEDICINAL PRODUCTS
(HMPC)
Melilotus officinalis (L.) Lam., herba
ed
ASSESSMENT REPORT FOR THE DEVELOPMENT OF COMMUNITY MONOGRAPHS AND
FOR INCLUSION OF HERBAL SUBSTANCE(S), PREPARATION(S) OR COMBINATIONS
THEREOF IN THE LIST
rs
pe
Su
7 Westferry Circus, Canary Wharf, London, E14 4HB, UK

Tel. (44-20) 74 18 84 00 Fax (44-20) 75 23 70 51
E-mail: mail@emea.europa.eu http://www.emea.europa.eu
© European Medicines Agency, 2008. Reproduction is authorised provided the source is acknowledged
ASSESSMENT REPORT
FOR HERBAL SUBSTANCE(S), HERBAL PREPARATION(S) OR COMBINATIONS THEREOF
WITH TRADITIONAL USE
BASED ON ARTICLE 16D(1) AND ARTICLE 16F AND 16H OF DIRECTIVE 2001/83/EC AS
AMENDED (TRADITIONAL USE)
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Herbal substance(s) (binomial scientific name of
the plant, including plant part)
Comminuted herbal substance

Powdered herbal substance
Dry extracts (3 - 5:1), water
Fluid extracts (1:1), ethanol 30 % V/V
Herbal preparation(s)
ed Dry Extracts (5-7:1), ethanol 50 % V/V

Dry extracts (4-8:1), ethanol 25 % m/m
Dry extracts (4-8:1), methanol 50 % V/V
Dry extracts (4-8:1), ethanol 35 % V/V
Dry extracts (6-9:1), ethanol 90 % V/V
Dry extracts (7-9:1), methanol 30 % V/V
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Oral use:
Tea infusion, liquid or solid preparations
Pharmaceutical forms
Topical use:
Tea infusions for external use
Emplastrum Meliloti
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Dr. Ulrike Wissinger-Gräfenhahn

Rapporteurs
Prof. Olavi Pelkonen
Dr. Konstantin Keller
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© EMEA 2008 2/38

1 INTRODUCTION
This assessment report reviews the scientific data available for Meliloti herba. We also take into
account the literature presented by the ESCOP to the monograph “Meliloti herba”, the WHO
monograph, and regarding the traditional use the French Avis aux fabricants and the German list of
traditional medicinal products according to § 109 a AMG. Additionally all Member States were
asked to give information about what kind of products containing Melilotus are on their market
including pharmaceutical forms, indications, posology and methods of administration.
Database search
This document is based on publications supplied by ESCOP and a DIMDI-based data search
(xtoxlitall and xmedall) with the keywords “Melilotus” and “human” from 1900 in all text fields.
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The databases searched are listed in Appendix I.
Market situation in the Member States

Not in all Member States melilot containing herbal medicinal products are on the market. In some
Member States melilot is only used in homeopathic medicinal products. Melilot also seems to be
quite popular as a food supplement. Detailed information is given in section 4.
1.1 Description of the traditional herbal substance(s), herbal preparation(s) or combinations

thereof
Herbal substance(s) 1 2
Melilot (Meliloti herba)

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The European Pharmacopoeia (01/2008:2120) monograph Meliloti herba (melilot) provides the
following definition: Whole or cut, dried aerial parts of Melilotus officinalis (L.) Lam. Content:
rs
minimum 0.3 per cent of coumarin (C9H6O2; Mr 146.1) (dried drug).
The definition formerly given by the Pharmacopèe Francaise was as follows:

Melilot consists of the dried flowering tops of Melilotus officinalis Desr.
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The main characteristic constituents of melilot are cinnamic acid / coumarin derivates /(Hager
1994) (see table 1). Dicoumarol and the antifungal isoflavonoid medicarpin, which can be formed
in melilot due to fungal infection and spoilage, should be absent from properly dried material
(British Herbal Compendium).
Table 1: Main characteristic constituents of melilot
Constituent Abundance Aspects with relevance for Remarks

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the benefit / risk

assessment
Cis-O-coumaric β- 0.5 % Lactonises to coumarin Not assessed as
glucoside after hydrolysis such (in vivo
(melilotoside) exposure is actually
as coumarin)
Coumarin 0.9 % (min. 0.3 % Because of an almost Assessed in this
Ph.Eur.) complete first-pass effect monograph
in humans, 7-
hydroxycoumarin is
thought to be “the active
principle”
1
According to “Note for guidance on Quality of herbal medicinal products” (CPMP/QWP/2819/00)
2
According to “Note for guidance on Specifications: Test procedures and acceptance criteria for herbal drugs, herbal preparations
and herbal medicinal products” (CHMP/QWP/2820/00)
© EMEA 2008 3/38
3,4-Dihydrocoumarin Toxicologically less active Not assessed*
(melilotin) than coumarin in vitro and
animal studies
Scopoletin Not assessed*
7- Hydroxycoumarin At least in primates, the Not assessed as
(Umbelliferone) primary in vivo exposing such
substance of coumarin.
Umbelliferone is rapidly
glucuronidated during first
pass.
Kaempferol Rapid hydrolysis in GI- Not assessed*
glycosides tract
ed
Quercetin glycosides Rapid hydrolysis in GI- Not assessed*
tract
*a minor component with probably no toxicological significance, or is rapidly inactivated or converted to
another derivative.
Problems in risk assessment of other substances than coumarin
ed
It is difficult to treat Cinnamic acid derivates / “coumarins” as a homogeneous group from
pharmacology and toxicology point of view. Even relatively small structural changes result in
considerable changes in kinetics and dynamics. A case in point is a difference between coumarin
and its dimeric 4-hydroxyderivatives. Many oral anticoagulants are dimeric 4-hydroxycoumarin
derivatives, whereas coumarin and many of its simple derivatives are devoid of effect on
coagulation. The same is true in kinetic comparisons. These differences lead to a necessity to deal
with different derivatives on their own rights.
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Herbal preparation(s)1,2
i) Preparations corresponding to a known coumarin content for oral and topical use
(Commission E, ESCOP, British Herbal Compendium). On the basis of the data given by the
Member States so far a clear definition of the preparations on the market is not possible.
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ii) Emplastrum Meliloti: prepared by extraction of 10 parts of pulverized drug, wetted with
2 parts of ethanol, to 90 parts of semi-solid base (Rapae oleum, Cera flava, Colophonium)
Final DER 0,11:1. (Polish Pharmacopoeia, VI edition)
Combinations of herbal substance(s) and/or herbal preparation(s) 3

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Meliloti herba and preparations thereof are mainly used in combinations with other herbal
substances / herbal preparations or various chemically defined substances. Although bibliographic
data to combinations were assessed in the assessment report to some extent this monograph refers
exclusively to Meliloti herba.
Vitamin(s) 4
Not applicable
Mineral(s)3
Not applicable
3
According to the Guideline on the clinical assessment of fixed combinations of herbal substances/herbal preparations
(EMEA/HMPC/166326/2005)
4
Only applicable to Community monographs
© EMEA 2008 4/38
2 TRADITIONAL MEDICINAL USE
2.1 Information on period of medicinal use in the Community regarding the specified indication
References regarding use in folk medicine are going back to Plinius and Hippokrates. Emplastrum
Meliloti , Emplastrum Meliloti comp. and Oleum Meliloti are mentioned in “Neues
Pharmazeutisches Manual” dated 1904 (Dieterich, 1904). Herba Meliloti and Emplastrum Meliloti
are also included in the “Deutsche Arzneitaxe” from 1936 and in the DAB 6 (1951).
Melilot and preparations thereof are licensed as traditional medicinal products in Germany, France,
Latvia and Poland for oral and topical use. Therefore for melilot and the mentioned preparations a
period of at least 30 years in medical use as requested by Directive 2004/24 EC for qualification as
a traditional herbal medicinal product is fulfilled.
ed
2.2 Type of tradition, where relevant
European tradition
2.3 Bibliographic/expert evidence on the medicinal use
2.3.1 Evidence regarding the indication/traditional use
Symptomatic treatment of problems

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The following indications have been reported for Meliloti herba:
related to varicose veins, such as painful

and heavy legs, nocturnal cramps in the
legs, itching and swelling
Symptomatic treatment of problems

German Commission E (1986), ESCOP monograph
(2003), Wichtl (1984/2004), Weiß (1985), British
Herbal Compendium (Bradley 2006), Enciclopedia of
Medicinal Plants (2001), Agence du Medicament
(1998)
German Commission E (1986), Weiß (1985)
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related to phlebitis and postthrombotic
syndrome.
Symptomatic treatment of problems German Commission E (1986)
related to haemorrhoids (topical use)
Symptomatic treatment of problems German Commission E (1986), Weiß (1985)
related to lymphoedema
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External use: Bruises, sprains and German Commission E (1986)

superficial bleeding
Use in folk medicine:

Plinius summarizes the use of melilot as constricting and softening agent for hot tempered ulcera of
eyes, anus and genitals. Orally taken it was used against stomach ache, gastric ulcer and disorders
of uterus and liver.
Hippokrates used melilot flowers externally for septic ulcers.
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Fuchs (1543) mentions external use of melilot in honey for facial spots as well as oral use of
chopped drug in vine for bladder disorders.
Bock (1565) summarizes the use of melilot as constricting, softening and analgetic agent externally
used for ulcers of the eyes, earache, hardening and swelling of uterus.
Matthiolus (1626) describes external use of melilot in case of stomach ache or headache and skin
rash due to mycosis.
Leclerc (1976) numbers melilot to be among antispasmodics and recommends it in case of
insomnia in children or elderly.
Hager (1938, 1949, 1975) mentions external use of melilot in herbal pillows, as constricting agent
for ulcers and rheumatic disorders, internal use as a diuretic agent as well as use as aromatic
adjuvant internal use for varices, thrombotic diseases, haemorrhoids, leg ulcera, oedema and
brachialgia is added.
Madaus (1938) summarizes the external use of melilot on ulcers, tumours, swelling of rheumatic
joints and inflamed breasts of breastfeeding women.
© EMEA 2008 5/38

According to Wichtl (1984), Hoppe (1977) and Berger (1949) melilot was also used as a diuretic in
folk medicine. Additionally, the use of melilot as an expectorant is described by Karsten, Weber,
Stahl (1962).
Melilot is also widely used in homeopathic medicinal products in the Member States.
The indications currently on the market in the Member States are tabled in Annex 4.
Based on the available literature and the known actions of coumarins, the following text on the
indication is recommended:
Internal use
1) “Traditional herbal medicinal product to relieve symptoms of discomfort and heaviness of legs
ed
related to minor venous circulatory disturbances.
The product is a traditional herbal medicinal product for use in specified indication(s) exclusively
based upon long-standing use.”
Topical use
2) “Traditional herbal medicinal product to relieve symptoms of discomfort and heaviness of legs
related to minor venous circulatory disturbances.
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3) “Traditional herbal medicinal product used for external use of symptomatic treatment of bruises
and sprains.
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4) “Traditional herbal medicinal product used for symptomatic treatment of insect bites.
The use of eye drops in case of eye irritation or discomfort due to various causes (smoky
atmospheres, sustained visual effort, swimming in the sea or swimming pools) cannot be supported
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because no data on exposure or on local tolerance are available. The safety of eye drops with
Melilotus infusions can not be assessed for this reason.
The use in digestive disorders seems to be no longer claimed by any preparation on the EU market.
2.3.2 Evidence regarding the specified strength
Preparations for oral use are quantified on 0.3 % to 20 % coumarin or on a certain content of
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coumarin varying from 3 mg to 15 mg coumarin. Extracts should be quantified for coumarin and
the total exposure in adults should not exceed 5 mg coumarin/day.
© EMEA 2008 6/38

2.3.3 Evidence regarding the specified posology
Posology in adults:
Dried herb
Single dose Daily dose
Madaus (1938) Orally
add 2 teaspoons of chopped drug in 2 --------- 4.0 g
cups of cold water and let it extract for 8
hours. To drink during daytime in case of
insomnia.
Externally
ed
Ear vapouration
2 tablespoonful of mixture per ½ l water.
In case of otitis and otorhoe for ear
vapouration.
Herba Meliloti 25
melilot 25 %
Flores Malvae arboreae 25
Flores Chamomillae 25
Herba Equiseti 25
Wichtl M
(1984)
Orally
ed
1 - 2 teaspoons of finely chopped drug per
cup of decoction, 2 – 3 times daily
Externally
For sores and haemorrhoids and as a
poultice: the drug is thoroughly soaked
with the same amount of hot water,
2-4g 4 – 12 g
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wrapped in linen, and placed on the
affected part.
Weiß RF Orally
(1985) in herbal teas 1 – 2 teaspoons per cup of 2-4g 6 – 16 g
decoction, 3- 4 times daily
Commission E According to 3 – 30
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Orally
(1986) mg coumarin
(based on a content
of 0.5% coumarin
this would
correspond to 0.6-
6 g of herbal drug)
ESCOP Orally According to 3 – 30
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mg coumarin
(see above)
DAB VI 2 tablespoonful per 2 cups of decoction
(10-15 minutes).Used for gargling and as 0.8 g
a poultice.
• Species emmollientes
Folia Altheae 20 g
Foliae Malvae 20 g
Herba Meliloti 20 g
Flores Chamomillae 20 g
Semen Lini 20 g
Polish 2.5 – 3 g of pulvered drug per 200 – 300 2.5 - 3 g --------------
Pharmacopoeia ml of boiling water for infusions
VI edition
© EMEA 2008 7/38
Preparations
Single dose Daily dose
Commission E Preparations for oral use According to 3 – 30
(1986) mg coumarin (based
on a content of 0.5%
coumarin this would
correspond to 0.6-6
g of herbal drug)
ESCOP (2003) Preparations for oral use According to 3 – 30
mg coumarin
External use: Extracts in semi-solid (see above)
ed
preparations.
Hager 1938 / • Emplastrum Meliloti
1949 Cerae flavae 500 melilot 15 %
Madaus 1938 Olei olivi 45
Res. Pini 45
Sebi ovilis 45
Res. Gumm. Ammon. 20
sol. in Oleum Terebinthini 45
British Herbal
Compendium
M.f. Unguentum
ed
Herba Meliloti pulv.
Herba Absinthii pulv.
Flor. Chamomillae pulv.
Fol. Lauri nob. pulv.
Preparations containing the

125
8
8
8
equivalent of up to 10 g dried herb;

Up to 10 g in divided
doses
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(Bradley 2006) For preparations of known Up to 30 mg of
coumarin content. coumarin (see above)
or up to 1 mg/kg
body weight (based
on a content of 0.5%
coumarin for a
pe
person of 70 kg b w
this would
correspond to 1.4-14
g of herbal drug)
Polish Emplastrum Meliloti is prepared by For single use
Pharmacopoeia, extraction of 10 parts of pulverized
VI edition drug, wetted with 2 parts of
ethanol, to 90 parts of semi-solid
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base (Rapae oleum, Cera flava,

Colophonium) Final DER 0,11:1.
© EMEA 2008 8/38

Preparations on Fluid extracts (1:1), ethanol 30 % 1.14 g extract 3 times daily
the German V/V (1.14 mg
Market coumarin)
Dry Extracts (5-7:1), ethanol 50 % 160 mg 3 times daily

V/V extract (1.1
mg coumarin)
Dry extracts (4-8:1), ethanol 25 % 100 mg 3 times daily

m/m extract (7.3 -
10.1mg
coumarin)
ed
Dry extracts (4.2-7.5:1), methanol 200 mg 3 times daily (3-5 mg
50 % V/V extract coumarin)
Dry extracts (4-8:1), ethanol 35 % 252 mg onces daily

V/V extract (3-5
mg coumarin)
Preparations on
the French Market
V/V
30 % V/V
ed
Dry extracts (6-9:1), ethanol 90 %
Dry extracts (7-9:1), methanol
Powdered herbal substance

24 mg extract
30 mg extract
250 mg
2-3 times daily (1-1.5
mg coumarin)
2-3 times daily (1.5

mg coumarin)
3 times daily
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Powdered herbal substance 1.6 g Once daily
(suspension)
Powdered herbal substance 500 mg Twice daily
Dry extract with water (3-5:1) 200 mg Twice daily

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Tea infusion (1 g/ 100 ml) for eye 1-2 drops 3-4 times daily
drops
Posology in children:
There are no data for internal and external use of melilot in children.
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According to the “NOTE FOR GUIDANCE ON CLINICAL INVESTIGATION OF MEDICINAL

PRODUCTS IN THE PAEDIATRIC POPULATION” (CPMP/ICH/2711/99) of 27 July 2000 and
other monographs age limit for children should be determined to “adolescents over 18 years of
age” for oral and topical administration.
2.3.4 Evidence regarding the route of administration
Oral and topical administrations of melilot and preparations thereof are used in the recommended
traditional indications. Parenteral use is documented but it is not suitable for traditional herbal
medicinal products.
© EMEA 2008 9/38

2.3.5 Evidence regarding the duration of use
No restriction on the duration of use has been reported for Meliloti herba. As persistent symptoms
require medical diagnosis and supervision, the use is limited to 2 weeks. In case of insect bites,
medical diagnosis is requested if symptoms persist for more than 3 days.
2.4.1. Assessor’s overall conclusion on the traditional medicinal use
Meliloti herba and preparations thereof have been used orally and topically for symptomatic
treatment of problems related to varicose veins, such as painful and heavy legs, nocturnal cramps in
the legs, itching and swelling, for gastric upsets in oral dosage forms and for external use in blunt
traumata for many decades. The traditional use is made plausible by the consistent, long-standing
ed
use and, with some limitations, by the pharmacological data regarding to coumarin and to a minor
degree to Melilotus extracts.
Melilot or preparations thereof are licensed with a traditional indication in Germany, France, Latvia
and Poland for oral and topical use.
Since the clinical documentation for melilot as a mono preparation is poor and no controlled
clinical studies are available, the use of Meliloti herba preparations has to be regarded as
2.5.1
2.5.1
traditional.
ed
Bibliographic review of safety data of the traditional herbal medicinal substances
Patient exposure
No exact data on patient exposure are available.

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2.5.2 Adverse events
In general melilot was well tolerated in clinical trials. In some studies adverse events as
gastrointestinal complaints, allergic reactions and photosensitivity are mentioned. Adverse events
in Member States that have preparations on the market have not been recorded so far. However, a
precise question for adverse events was not included in the request for information from the
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Member States.
2.5.3 Serious events and deaths
None known for Meliloti herba and preparations thereof for oral or topical administration.
Due to reports of hepatotoxicity associated with coumarin intake (for details see below)
pharmacovigilance action was taken in 1997 in Germany for herbal and homeopathic medicinal
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products for oral use containing preparations of melilot, woodruff or tonka beans. After assessing
the data the BfArM concluded in 1998 that there is no evidence of an increased hepatotoxic risk for
these herbal or homeopathic medicinal products if certain limits with respect to coumarin are
guaranteed. Melilot and preparations thereof for oral use are included in the German traditional list
according to § 109 a AMG up to doses corresponding to 5 mg coumarin per day. With a content of
0.3 to 1 % of coumarin in the herbal drug this amount would correspond to 0.5 to 1.5 g of herbal
drug and thus would be far less than the posology used traditionally.
During the consultation phase this issue has been raised by interested parties. Several options were
considered by the HMPC:
a) to reduce the posology to exclude exposures of more than 5 mg Coumarin under a worst-case
scenario,
b) not to accept or to go below the minimum specification of Ph.Eur.,
c) to require additional release / extraction data or accept only herbal substance with a low-content
of coumarin.
© EMEA 2008 10/38
As restriction of the posology just to "5 mg of Coumarin" is not acceptable, because Coumarin is
not a substance with generally accepted therapeutic activity in the traditional indications of melilot.
It was concluded that both requirements (amount of herbal preparation and limit for coumarin)
have to be fulfilled. If no herbal drug with a lower content in the range of 0.3% Coumarin can be
found, or if no data are presented that demonstrate that the finished dosage form or preparation
taken by the patient, e.g. tea infusions, contains less than 5 mg of coumarin, the daily dose of the
herbal preparation needs to be reduced to the minimum daily dose or single dose of the herbal
preparation.
Coumarin
Treatment of humans in connection with various clinical conditions (lymphoedema, various
cancers) has been associated with cases of hepatotoxicity. In 1997 up to 82 case reports of liver
ed
damage possibly associated with Coumarin intake were published. However, a clear relationship
between the dose of coumarin and the hepatotoxic responses observed has not been established. It
is important to note that it in the majority of cases coumarin doses have been from 90 mg to several
grams but in 5 cases a daily dosage of 25 to 30 mg coumarin is reported. Pharmacovigilance action
was taken by Germany, France, Switzerland, Luxemburg and Australia followed by withdrawal of
marketing authorizations for Coumarin preparations in different member states (e.g. Australia
1995, France 1997, Germany 1998).
ed
In 1994 a threshold value of a daily intake of coumarin in food was set by 0.5 mg/kg bw by the
European Commission (Scientific Committee for Food 1997). The use of coumarin in food was re-
evaluated by EFSA in 2004. Regarding hepatotoxicity the Panel concluded from recent
comparative studies that liver toxicity is not directly correlated to coumarin 3,4-epoxide/ ortho-
hydroxy phenyl acetic acid, but rather the balance between bioactivation and detoxification likely
dictates the susceptibility of the animal species to coumarin-mediated liver toxicity. The Panel
came to the conclusion that the data now available allow the derivation of a Tolerable Daily Intake
(TDI); a TDI of 0 – 0.1 mg coumarin/kg body weight was established (EFSA 2004). According to
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this a daily intake of 7 mg coumarin corresponding to approx. 1.5 g of herbal drug would be
acceptable for a person with 70 kg of body weight. Taking into account the additional exposure
through food, a limit 5 mg Coumarin / day provides sufficient safety for traditional use.
2.5.4.1 Intrinsic (including elderly and children)/extrinsic factors

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None known
2.5.4.2 Drug-drug interactions and other interactions

There is one case report of a young woman in whom hemorrhagic diathesis (abnormal clotting
function and mild menometrorrhagia) caused by drinking large amounts of a “seasonal tonic”
herbal tea for approximately 2 months occurred. The major ingredients of the patients tea were
tonka beans (1/2 lb), melilot (2 oz), and sweet woodruff (3 oz). Natural coumarins are found in all
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three of them with the highest content in tonka beans (1 to 3 % coumarin). Additionally the patient
was taking medications, which might potentiate the effect of oral anticoagulant drugs, e.g.
propoxyphene, vitamin A in “fairly large daily doses” and bromelain (Hogan (1983).
There is also a report of a possible interaction between oral anticoagulant treatment and topical
treatment with a cream containing extracts of ruscus and melilot (Cyclo 3®). A 66 year-old woman
with cardiac arythmia received acebutolol 200 mg/day and acenocoumarol 3 tab/day for years. She
also had a current treatment with thyroxine 100 mg/day. 10 days after she started topical treatment
with Cyclo 3® for venous insufficiency, 3 times daily, the INR increased from 2 to 5.82. Cyclo 3®
was discontinued and the INR returned to the usual values. Seven month later, a rechallenge with
Cyclo 3® Crème was attempted. After one week the INR was again increasing from 2.56 to 4.06.
The patient denied any changes in treatment or alimentation. She did not use occlusive dressing but
she strongly massaged her legs 3 times per day when two time per day is recommended (Chiffoleau
et al (2000).
© EMEA 2008 11/38

In 2 clinical studies an influence of melilot extract administered intravenously on parameters of
blood clotting (prothrombin time respectively “coagulation analysis”, details not given) was not
seen (Völker 1961, Mayer and Sukthaworn (1963). Additionally no influence on bleeding time,
thromelastogram and prothrombin time was seen in 2 clinical trials with 60 mg coumarin daily
given to pregnant and breastfeeding women (Krajnovic et al. 1974 /1977a/1977b).
Taking into account that in the above mentioned case reports combination products and/or co-
medication which might potentiate the effect of oral anticoagulant drugs was taken a causal
relationship of melilot can not be unequivocally deduced. Although there is no mechanistic basis
for interactions with anticoagulants, i.e. coumarin is not an inhibitor of CYP 2C9 responsible for
warfarin clearance and coumarin itself is not an anticoagulant, Meliloti herba contain a number of
coumarin derivates which might affect coagulation. However, taking into account the use of melilot
in a setting of self-medication a concomitant anticoagulant therapy should be a contraindication
ed
with respect to patients’ safety.
2.5.4.3 Use in pregnancy and lactation
Safety during pregnancy and lactation has not been established systematically. Use of melilot
extracts in combinations is mentioned by various authors. No adverse effects have been reported
from the use of these combinations as a medicinal product during pregnancy and lactation.
2.5.4.4 Overdose ed
Information about the delivered babies is lacking. As there are no appropriate data available, use is
not recommended during pregnancy and lactation.
According to Hager’s Handbuch intake of 4 g of melilot extract triggers nausea, vomitus, headache
and weakness. Data on the extract and on details are missing.
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2.5.4.5 Drug abuse
None known
2.5.4.6 Withdrawal and rebound

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None known
2.5.4.7 Effects on ability to drive or operate machinery
None known.
2.5.4.8 Contra indications (hypersensitivity and allergic potential to be both covered)

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Hypersensitivity to melilot or to coumarin.
Not to be used together with anticoagulant therapy.
2.5.5 Non-clinical safety data
For the most part, coumarin is dealt with here, because a large database exists. Other constituents are
mentioned only sporadically, because less useful studies are available in the literature.
2.5.5.1 Overview of available data regarding the herbal substance(s), herbal preparation(s) and
relevant constituents thereof
(e.g. single/repeat dose toxicity, genotoxicity, carcinogenicity and reproductive and developmental toxicity,
local tolerance, other special studies)
© EMEA 2008 12/38

Melilot and combinations
Single dose toxicity
No data available (ESCOP 2003). The ip LD50 of a melilot/rutin preparation in mice was too high to be
determined (ESCOP 2003).
Repeated dose toxicity
No data available (ESCOP 2003).
Reproductive toxicity
ed
The teratogenic effects of a combination of coumarin and rutin have been investigated in white New Zealand
rabbits. Iv administration of either coumarin alone or a coumarin/rutin combination at 10 and 100 times the
therapeutic dose did not result in any increase in malformation rates compared to controls, nor increased
number of resorptions or fetal mortality (ESCOP 2003).
Tests on reproductive toxicity, genotoxicity and carcinogenicity of clearly defined herbal preparations have
not been performed.
Coumarin
(Lake 1999; IARC 2000; NTP 2004).
Single dose toxicity

ed
Several extensive assessments concerning coumarin toxicity have been published during the past few years
LD50 values (mg/kg body weight) for coumarin have been determined for mice (oral 196; ip 220;
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subcutaneous 242), rats (oral 293) and guinea pigs (oral 202) (ESCOP 2003).
Repeat dose toxicity
An in-depth survey of coumarin toxicity was carried out in connection with the NTP coumarin
carcinogenicity study (NTP 2004) and these studies are summarized below.
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NTP toxicity and carcinogenicity studies were conducted by administering coumarin (97% pure) in corn oil
by gavage to groups of male and female F344/N rats and B6C3F1 mice for 16 days,
13 weeks, and 2 years.
In 16-day dose-finding studies in rats and mice, all female rats and most male rats receiving
400 mg/kg, and all mice receiving 600 mg/kg died. There were no clinical signs of organ-specific toxicity,
and the mean body weight gains and final mean body weights of surviving dosed male and female animals
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were similar to those of the controls.

13-week study in rats and mice liver seemed to be the principal target for toxicity at the higher dose levels
(150 and 300 mg per kg body weight). Serum enzymes indicating liver involvement were increased, the
absolute and relative liver weights were significantly greater than those of the controls, and centrilobular
hepatocellular hypertrophy and/or degeneration and/or necrosis, chronic active inflammation, and bile duct
hyperplasia were observed.
2-year study in rats and mice. Groups of 60 male and 60 female rats were administered coumarin in corn oil
by gavage at doses of 0, 25, 50, or 100 mg per kg body weight. Groups of 70 male and 70 female mice were
administered coumarin in corn oil by gavage at doses of 0, 50, 100, or 200 mg per kg body weight. After 15
months, 10-20 animals from each group were evaluated. Male rats in two high-dose groups died prematurely
primarily due to chemical-related exacerbation of spontaneously occurring renal disease. The principal
lesions occurred in the liver, kidney, and forestomach. While the hepatic lesions were seen in all groups of
male rats, they occurred only in the 50 and 100 mg/kg females. The lesions consisted of a spectrum of
changes including hepatocellular necrosis, fibrosis, cytologic alteration, and increased severity of bile duct
© EMEA 2008 13/38
hyperplasia. The principal toxic lesions to mice occurred also in the liver. The incidences of centrilobular
hypertrophy in 100 and 200 mg/kg males and 200 mg/kg females were significantly greater than those of
controls. The incidences of syncytial alteration in all male dose groups and in 200 mg/kg females were also
significantly greater than controls.
There was a chemical-related increase in the average severity of nephropathy in all groups of dosed male and
female rats. There were corresponding increased incidences of parathyroid gland hyperplasia in all groups of
dosed males, probably as a result of compromised renal function. The incidences of forestomach ulcers in all
groups of dosed male rats and in 100 mg/kg female rats were significantly greater than those of the controls.
The hepatic lesions produced by 9 or 15 months of exposure were reversible. In contrast to the liver lesions,
the severity of nephropathy in male rats following the recovery period was significantly greater than that of
males examined at the 9- and 15-month interim evaluations.
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In summary, the administration of coumarin to rats was also associated with an increased severity of
nephropathy in the kidney and of bile duct hyperplasia in the liver, increased incidences of ulcers of the
forestomach, and necrosis, fibrosis, and cytologic alteration of the liver. Administration of coumarin to mice
was also associated with centrilobular hypertrophy, syncytial alteration, and eosinophilic focus in the liver.
Genotoxicity
Genotoxicity of coumarin has been studied in a number of relevant tests (NTP 2004; IARC 2000). Coumarin
did not induce micronuclei in mice in vivo and was not mutagenic in Drosophila melanogaster. It was
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weakly positive in induction of micronuclei in human cells in vitro, but failed to induce unscheduled DNA
synthesis in human liver cells in vitro. Coumarin induced sister chromatid exchanges without metabolic
activation and chromosomal aberrations with metabolic activation, but not micronuclei or gene mutations in
mammalian cells in vitro. It was mutagenic in only two out of 11 Salmonella typhimurium strains tested, with
metabolic activation. Coumarin was antimutagenic in various assays, but also had co-mutagenic properties.
The weight of evidence suggests that coumarin is not a clear genotoxicant. However, there are some
inconsistencies in the data basis, which should be kept in mind. On this basis it can be concluded
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provisionally, that coumarin is not a genotoxic carcinogen.
Carcinogenicity
No data on human carcinogenicity are available. However, coumarin has been adequately tested by oral
administration in two experiments in mice and in one experiment in rats. In mice of one strain, it produced
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increases in lung tumours (adenomas and carcinomas) in both males and females and in hepatocellular
adenomas in females. There was no increase in tumour incidences in another strain of mouse. In one study in
rats, coumarin produced a low incidence of renal tubule adenomas in males, seen only after step-sectioning
of the kidney. Three other studies in rats could not be evaluated (IARC 2000). The IARC Working group
concluded, that no epidemiological data relevant to the carcinogenicity of coumarin were available, whereas
there is limited evidence in experimental animals for the carcinogenicity of coumarin. The overall evaluation
was that coumarin is not classifiable as to its carcinogenicity to humans (Group 3). EPA became to the same
conclusion (NTP 2004).
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Regarding the potency of coumarin, the dose-response relationships for coumarin-induced toxicity and
carcinogenicity are non-linear, with tumour formation only being observed at high doses which are
associated with hepatic and pulmonary toxicity (Lake 1999). The tentative conclusion regarding the
carcinogenicity mechanism and potency of coumarin is that it is a non-genotoxic carcinogen in only those
animal species in which it can cause tissue toxicity because of its peculiar species-specific metabolic features
(see below).
Species differences in toxicity
The target organs for coumarin toxicity are primarily the liver in rats and the liver and lung in mice. There
are marked species differences in these responses, with the mouse being particularly susceptible to coumarin-
induced Clara cell injury. Coumarin is hepatotoxic in rats and mice. Hamsters and gerbils are resistant to
acute coumarin-induced hepatotoxicity. In vitro, coumarin is toxic in either hepatocytes or liver slices from
rats, mice, rabbits and guinea-pigs, whereas monkey and human cells and/or slices appear to be resistant. By
© EMEA 2008 14/38
and large, these species differences seem to be associated with metabolic differences, i.e. those species with
predominant ring-opening pathway and postulated epoxide formation seem more susceptible to tissue
damage than species with 7-hydroxylation predominating (Lake 1999), although also the rate of
detoxification of a putative reactive intermediate seems to be of importance (Vasallo et al. 2004).
Reproductive and developmental toxicity
No studies were available.
Local tolerance
No studies were available.
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Assessor’s overall conclusions on toxicology
Only general information is available concerning melilot preparations. These data do not indicate any serious
toxicities. However, tests on reproductive toxicity, genotoxicity and carcinogenicity of clearly defined herbal
preparations have not been performed. Toxicity of coumarin has been studied rather extensively. The
primary target organ in rats and mice is liver. In addition, coumarin causes toxic manifestations in kidneys
and lungs. Approximate no effect levels (if they can be reliable calculated) in rats and mice are in a range of
2.5.6
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10-50 mg/kg regarding tissue toxicity. Thus, toxic outcomes are due to relatively high doses of coumarin. It
seems probable that the mechanism of coumarin-induced tumour formation in rodents is associated with
metabolism-mediated tissue toxicity only at very high doses.
Assessor’s overall conclusions on safe use
Humans are one of the species with predominating 7-hydroxylation by CYP2A6 and therefore seem in
general less susceptible to hepatotoxicity due to coumarin intake. However, a high interindividual variability
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in coumarin 7-hydroxylation is documented in humans, partially due to genetic polymorphisms. Case reports
of hepatotoxicity in humans are predominantly reported in doses above 90 mg coumarin/day. However, a
few case reports after a daily intake of 25 to 90 mg coumarin are documented as well. It is not known if these
are cases of “poor metabolizers” with limited 7-hydroxylation. The frequency of CYP 2A6 poor metabolizers
(complete lack of activity) is dependent on ethic background and is reported to be between 6 % (Caucasians)
and 25 - 50 % (Orientals). Assuming a hepatotoxic risk of coumarin doses above 90 mg/day a safety factor
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of 18 is given to the proposed dosage of melilot and preparations thereof according to a maximum of 5 mg
coumarin per day. The safety factor is reduced to 5 taken into account potential toxic doses above a cut point
of 25 mg coumarin/day. Basically this threshold also complies with the TDI given by EFSA in 2004.
2.6 PHARMACOLOGICAL PROPERTIES 5
2.6.1 Overview of pharmacological effects of herbal substance(s), herbal preparation(s) and

relevant constituents thereof on the basis of long-standing use and experience
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Melilot
There are many studies with combinations of coumarin and rutosid that are, historically, linked to melilot
preparations. The combinations derived from studies with the extract and were thought to represent the
“active principles”. At least these studies might come closer to melilot than those dealing with coumarin as a
single ingredient.
Coumarin
Because of a large volume of investigations, old and newer, this chapter is based on mostly secondary
sources (see reviews of Egan et al. 1990: O'Kennedy and Thornes 1997). Coumarin and its principal
5
Not required as per Article 16c(1)(a)(ii) of Directive 2001/83/EC as amended
© EMEA 2008 15/38
metabolite 7-hydroxycoumarin have been studied in a large number of experimental systems and numerous
effects on many functions have been observed (see table 2).
Table 2. Some pharmacological properties of coumarin and 7-hydroxycoumarin in in vitro, cellular and
animal investigations (see O’Kennedy and Thornes 1997)
Action Implicated Effective concentrations Reference
mechanism(s) of action
based on preclinical
investigations
Anti-oedematous action increased proteolysis by minimally effective Casley-Smith’s in op.cit.
macrophages; about 150 uM up to 1
lymphokinetic mM
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properties
anticarcinogenic action cell cycle arrest, apoptosis and Seliger in op.cit.,
oncogene expression, cytotoxicity >500 uM Ebbinghaus et al in op.cit.
induction of apoptosis Mohler et al in op.cit.
Immunomodulatory effects on monocytes about 50 uM Zlabinger in op.cit.
action and macrophages
Cellular signaling gap junction about 500 uM Zänker in op.cit.
communication;
analgesic and anti-

inflammatory action
Vasodilator activity
endothelial protection
choleretic action
migration
prostaglandin and
properties
no information
no information
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leukotriene production
haemorheological
very high
not known
not known
not known
see Weinmann in op.cit.

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Diuretic action no information not known see Weinmann in op.cit.
spasmolytic action no information not known see Weinmann in op.cit.
sedative and hypnotic no information not known see Weinmann in op.cit.
antimicrobial activity no information not known see Weinmann in op.cit.
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Assessor’s overall conclusions on pharmacology
Although numerous pharmacological effects on various cellular and tissue function have been unraveled in
in vitro, cellular or animal experiments, concentrations in these studies have been rather high, from tens to
hundreds of micromolar (see table 2), which makes it questionable whether many of these actions could be
demonstrated in in vivo situations. The best studied and documented effect both in vitro and in vivo seems to
be the anti-oedematous action, which could be used as a basis of traditional medicinal use.
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2.6.2 PHARMACOKINETIC PROPERTIES
2.6.2.1 Overview of available data regarding the herbal substance(s), herbal preparation(s) and
relevant constituents thereof
Melilot
There are no data on pharmacokinetic properties of melilot as a mono preparation. A combination product of
coumarin and rutin (Venalot®) has been used in pharmacokinetic studies in humans, but only the kinetic
behaviour of coumarin has been studied.
Coumarin
Pharmacokinetics of coumarin has been very thoroughly characterized since 1960’s and 1970’s and several
reviews have been published on different aspects of coumarin pharmacokinetics (Pelkonen et al. 1997;
Raunio et al. 2001). Coumarin and its principal hydroxylated metabolite (in primates) 7-hydroxycoumarin
© EMEA 2008 16/38

are relatively lipid soluble and they are rapidly absorbed from intestine. However, 7-hydroxycoumarin is
readily glucuronidated, probably already in the gut if appropriate UGT isoenzymes are present there and
finally in the liver. Thus, its first-pass metabolism is quick and extensive in most species. Bioavailability of
coumarin is dependent on the activity of 7-hydroxylation pathway in a given species. If this pathway is very
active in the liver (as in man or other primates), very little or no unchanged coumarin passes into the
systemic circulation. Readily detectable metabolites in blood in those species are free and conjugated
7-hydroxycoumarin. If this pathway is relatively minor, as it is in rats, the half-life of coumarin is greatly
increased to even 1 to 2 days. On this basis of an extensive first-pass metabolism of coumarin to
7-hydroxycoumarin in humans, it has been claimed that 7-hydroxycoumarin is actually the active principle of
coumarin therapy.
Metabolism of coumarin has been extensively studied since the 1960s. Coumarin undergoes a very extensive
metabolism along two major pathways, 7-hydroxylation and 3-hydroxylation (3,4-epoxidation) followed by
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ring-opening to ortho-hydroxyphenylacetaldehyde (Cohen 1979; Pelkonen et al 1997). There are numerous
minor metabolites, many of which are secondary products from the primary metabolites. The relative
contribution of these two major pathways, which are catalysed by different P450 enzymes, is highly variable
between species. Ring-opening predominates in rodents, while 7-hydroxylation is particularly evident in
humans. Ring-opening proceeds via an epoxide intermediate, which is thought to be a necessary prerequisite
for toxic effects. However, species differences in toxicity are thought to be due to differences in the
detoxification of the reactive intermediate. Thus, recent findings indicate that probably it is not the formation
enzymes.
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of the reactive epoxide per se, which is of importance for hepatotoxicity, but the inactivation of the epoxide
via acetaldehyde dehydrogenase (Vasallo et al. 2004). Consequently the final toxicity outcome is dependent
on a complex balance between the formation of the epoxide metabolite and the activity of detoxifying
Both in vitro and in vivo human studies have shown that coumarin is very specifically metabolized by
CYP2A6, and coumarin is thus used as a preferred in vivo probe drug for phenotyping for CYP2A6
(Pelkonen et al 2000). Because CYP2A6 is an inducible P450 enzyme and it is affected by a number of
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exogenous and host factors, the elimination of coumarin is expected to be affected accordingly (Pelkonen et
al, 2000).
Several herbal compounds have been tested for their inhibitory effects on the CYP2A6 enzyme in vitro.
Compounds that have been found to be relatively potent, although not necessarily highly selective CYP2A6
inhibitors include methoxsalen (8-methoxypsoralen), menthofuran and pilocarpine (Pelkonen et al. 2000). Of
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these inhibitors, methoxsalen can be used to suppress CYP2A6 function in vivo.
The frequency of CYP2A6 poor metabolizer phenotype due to a complete loss of functional enzyme in the
Caucasian population is <1%. The frequency is much more common in Orientals, up to 25% of the Japanese,
Korean or Chinese population (Nakajima et al 2006). More than 20 variant alleles of the CYP2A6 gene have
been characterized, including SNPs and whole gene deletion, with variable effects on enzyme activity
(http://www.cypalleles.ki.se/).
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Recent studies have shown that the pharmacokinetics of coumarin is altered in individuals carrying the
variant CYP2A6 alleles (Nakajima et al. 2006). In vitro studies with human liver microsomes have indicated
that the coumarin 7-hydroxylation is practically absent in individuals with deletion or defective genotypes.
Other metabolic pathways such as 3-hydroxylation and ring-opening are still present, but the global
metabolism of coumarin and pharmacokinetic characteristics in individuals homozygous for a CYP2A6 gene
deficiencies have not yet been investigated.
Assessor’s overall conclusions on pharmacokinetics
In humans, a relatively thorough knowledge of coumarin pharmacokinetics and the enzyme determining the
elimination has been worked out. Coumarin elimination is affected significantly by inducers, inhibitors and
genetic factors controlling the activity of CYP2A6, but it is not known whether any clinically or
toxicologically significant outcomes from coumarin elimination would ensue. The role of CYP2A6 poor
metabolizer status in coumarin hepatotoxicity is purely conjectural thus far. Because the coumarin content of
Melilot preparations is rather small, clinically significant consequences are unlikely.
© EMEA 2008 17/38
2.6.3 PHARMACODYNAMIC PROPERTIES
Overview of available data regarding the herbal substance(s)/herbal preparation(s) including data on
constituents with known therapeutic activity.
There are just a few pharmacodynamic studies conducted with extracts of melilot in combination with ruscus
or vitamins. In most of the publications the pharmacodynamic effects of benzopyrones or coumarin
(5.6-benzo—alpha-pyrone) are reported.
In part of the studies Esberiven® ampoules were investigated. In “older” trials Esberiven® ampoules are
defined as a combination of melilot extract and “vitamin P”. In more recent studies the declaration was
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changed from “vitamin P” to “rutin”. The term “vitamin P” does not comply with accepted terminology. It is
not clear if this change is just a change in declaration or a change in composition. Therefore the term
“vitamin P” is kept in quotation marks where applicable.
Melilot extracts in combinations
In a randomized, placebo-controlled, double-blind study in cross-over design the effects of a single

application of 11.5 g cream containing 184 mg melilot extract and 184 mg ruscus-extract on transcutaneous
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venoconstriction and oedema protection in 20 healthy male volunteers was investigated by measuring the
venous capacity and filtration rate using the venous occlusion plethysmography. A specification of the
extracts is not given. During the 2-hours registration period venous capacity and filtration rate were reduced
about 20% by the active cream, whereas under placebo the parameters slightly increased (approx. 5%). The
difference was statistically significant. Similar effects could be seen as a trend in the untreated leg (Rudofsky
1989). The contribution of melilot to the observed effect cannot be assessed.
Mayer and Sukthaworn (1963). tested the influence of 8 – 10 ml of an melilot extract (extract with water,
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standardized on coumarin) or Esberiven ampoules (melilot extract with water, standardized on 0.1 %
coumarin, “vitamin P”) or an melilot extract with water, standardized on 0.1 % coumarin, combined with
“vitamin P” and B1, on circulation in the lower extremities of injured patients. All preparations are reported
to improve circulation determined by a quotient of two values of “decholin time” obtained by measurements
in the elbow and in the foot following i.v. application. Additionally a coagulation analysis was done and
showed no signs of coagulotropic effects (Mayer and Sukthaworn, 1963).
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Völkner studied the influence of an injection of 2 ml Esberiven (melilot extract with water, standardized on
0.1 % coumarin, “vitamin P”) on cardiac and circulation performance in 18 volunteers. He noticed an
increase of ventricular end-diastolic volume and a decrease of tonicity in peripheral veins; blood pressure
and heart rate remained unchanged. The changes were within the standard deviation of the method of
measurement. The author concludes that melilot does not primarily influence cardiac performance but the
peripheral circulation with secondary adaptation of cardiac performance. The i.v. administration was well
tolerated, in single cases a short-term feeling of warmth was noticed. Additionally the influence of the
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melilot preparation on clotting of the blood was measured and no influence on parameters of blood clotting
was seen (Völker 1961).
Venalot (melilot extract with water standardized to 3 mg coumarin, 50 mg rutin) or rutin were administered
endolymphatically, i.v., and by i.v.-infusion to 390 patients and examined pharmacolymphographically
(dosage not given). The “lymphotropic” effects of the drugs in lymphogram were compared with a control
group of 100 patients. Both drugs improved representation of peripheral lymphatic drugs and of central
lymph nodes and improved the diagnostic statement. The authors mention that an “essential increase of the
complication rate” was not seen; details are not given (Schmidt and Keilacker 1985).
Seidel investigated the effects of “Venalot”(composition and dosage not given) or benzaron therapy during
6 weeks on lipometabolism of 41 patients. Distribution of lipometabolic parameters corresponded with the
ones of the normal population. “Venalot” showed no effect on lipometabolism (Seidel 1985).
© EMEA 2008 18/38

Blätter and Schoch (1994). tested six herbal drug preparations used in phlebology (e.g. “Venalot”, may be
ampoules= melilot extract with water standardized to 3 mg coumarin, 50 mg rutin?) and extracts of hop and
valerian for neuronal and mitochondrial benzodiazepine receptor binding activity in vitro. All phlebotropic
drug preparations interacted weakly with central and/or peripheral benzodiazepine receptors in vitro. Their
diazepam-equivalent concentrations were, however, too low to be of pharmacological relevance. No binding
activity was recovered in the blood of volunteers pretreated with phlebotropic drugs. The authors concluded
that the positive influence of the tested phlebotropic drugs on the subjective symptoms of venous disease is
not mediated through benzodiazepine receptors
Coumarin
The reducing effect of benzopyrones on high protein oedemas was in extenso investigated by Casley-Smith,
Piller and Földi (e.g. Piller 1976); Casley-Smith: (1982); Casley-Smith 1976; Földi-Böresök, Bedall and
Rahlfs 1971).
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Assessor’s overall conclusions on pharmacodynamics
There are no data on pharmacodynamic properties of melilot as a mono preparation. Except for the study of
Rudofsky (1989) the pharmacodynamic trials with melilot extracts in combination are of poor quality.
Additionally the relevance of studies where coumarin alone or coumarin combined with rutosid was
investigated for the assessment of the pharmacodynamic profile of melilot can not be assessed. The
contribution of melilot to the effects of combinations can also not be assessed.
2.6.4 CLINICAL EFFICACY STUDIES
ed
Part of the following trials deal with coumarin in combination with other substances. Under the trademarks
„Esberiven®“ and „Venalot®“ composition is depending on the pharmaceutical form, e.g. some
pharmaceutical forms contain „melilot extracts“ while others contain „coumarin“. From the literature it is not
always clear which pharmaceutical form / composition was investigated. Additionally in some publications
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observed results are not differentiated between the varying pharmaceutical forms. For the reason of safety
these data are assessed here too.
2.6.4.1 Dose response studies
There are no dose-finding studies available.

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2.6.4.2 Clinical studies (case studies and clinical trials)
Venous insufficiency
With a prevalence of 10-15% in men and up to 25% in women, chronic venous insufficiency (CVI) is one of
the most common conditions afflicting humans. The standard treatment for CVI is compression therapy, but
compliance is often poor. Therefore, amongst the therapeutic approaches available phlebotropic drugs are
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proposed to treat signs and symptoms of CVI and to prevent worsening of the disease.
Melilot mono preparations
In an open study patients suffering from chronic venous insufficiency 20 were treated with 200 mg dry
extract of melilot daily (no specification given), another 15 by ozontherapy and 20 with combined therapy
for 15 days. Melilot therapy significantly reduced malleolar oedema, nocturnal cramps and feelings of
heaviness and was superior to ozontherapy. An influence on the symptoms “pain”, “paraesthesia” and
“hyperthermia” was not seen. Details regarding the extent of the observed effects are not given. Ozontherapy
is not an accepted “gold standard”. The clinical relevance of the observed effects is doubtful (Stefanini et al
1996).
Aloisi and Scanditto (1999) treated 4536 patients suffering from chronic venous insufficiency of various
causes with 4 to 8 g of a melilot extract standardized to 20 % coumarin daily for 3 to 8 months in the years
1995 to 1998. Subjective symptoms, e.g. feeling of heavy legs, pain, nocturnal cramps, oedema and pruritus,
as well as assessment of oedema were assessed on a 3 level symptom score. Details regarding the extent of
the observed effects are not given. Good results were seen in 70 % of the patients. The symptom score is not
© EMEA 2008 19/38
validated. An objective measurement of efficacy is missing. Side effects, predominantly gastrointestinal
complaints, were seen in 55 patients (1.2 %). Allergic reactions occurred in 12 patients (0.25%) (Aloisi and
Scondotto 1999).

30 patients with venous insufficiency were treated with Esberiven drinking ampoules (1 ml contains 0.100 g
melilot extract, 0.025 g rutin, 0.0265 ml alcohol 95 %) 9 to 12 times a day for 10 to 20 days. In 23 of these
cases compression therapy and/or others (no details given) was added. Based on the symptoms feeling of
heavy legs, pain, oedema and pruritus efficacy was judged good or very good in 24 of 29 cases. Oedema
disappeared or improved in 27 from 28 patients and in 7 from 7 patients treated with melilot only. Pain
(feeling of heavy legs / pruritus) disappeared or improved in 21 (25 / 6) from 22 (25 / 7) patients and in all
patients (n= 3 / 7 / 1) treated with melilot only. Details regarding the extent of the observed effects are not
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given. An objective measurement of efficacy is not mentioned. The preparation was well tolerated in
29 patients. Vomiting was observed in 1 patient who was excluded from efficacy assessment. Only a very
small number of patients were treated with melilot only. It is not possible to assess the contribution of melilot
on treatment effects of the combination with compression therapy and/or others (Babilliot 1977) ; Desmons
and Simons 1975)).
In another double-blind study 44 patients with chronic venous insufficiency were treated with a compression
bandage in the first 4 weeks followed by 10 Venalot injections of 10 ml (15 mg coumarin, 250 mg rutosid)
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versus a control solution of weak concentration (2 mg coumarin, 100 mg rutosid) during 3 weeks.
Compression stockings were stopped and Venalot depot coated tablets or placebo tablets were taken 3 times
a day in the following 3 weeks. At the end of the trial the therapeutic results of the verum group, e.g.
reduction of oedema and refilling time in phlebodynamometry as well as physicians assessment, were more
pronounced than in the control group. Details on symptoms are not given. The author states that, however,
higher case rates will be needed to prove efficacy (Blume 1994).
1458 patients with various venous diseases were treated with a combination of a melilot extract, standardized
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to 0.05% coumarin, and 50 mg “vitamin P” administered 10 to 60 times i.m. or orally (dosage not given).
The overall therapeutic results were given as “satisfactory”. Details on symptoms are not given. An objective
measurement of efficacy is not mentioned (Klein 1967).
24 patients with varicosis with the symptoms cramps in the calf at night time and pretibial oedemas were
treated with Esberiven (melilot extracts standardized on 0.1 % coumarin, “vitamin P” and B1 (coated tablets
only) orally or rectally or in severe cases at the beginning intravenously for at least 4 weeks. A decrease in
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cramps was seen by 20 patients and oedemas were reduced (quantity not given). An objective measurement
of efficacy is not mentioned. The author mentioned that in some patients with Brachalgia paraesthetica
nocturna an improvement of symptoms after oral treatment could be seen. Treatment of leg ulcer with oral
and topical Esberiven preparations was not always successful (Völker 1961).
For prevention of thrombosis 75 patients were treated with Esberiven ampoules: 6 to 8 drinking ampoules
(1 ml contains 0.100 g melilot extract, 0.025 g rutin, 0.0265 ml alcohol 95 %) or 3 injections per day
(2 ml contain melilot extract standardized to 1 mg coumarin, 50 mg rutin) up to 3 days after operations of
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various causes. In three cases an anticoagulant had to be added. The preparation in both dosage forms was
well tolerated. Details on symptoms are not given. (Descottes 1975).
Lacativa reports of the therapeutic use of Venalot administered orally, i.m. or i.v. in 7900 patients with
various indications like venous insufficiency, lymphatic oedemas, thrombosis, post operations, hematoma,
leg ulcer, restless legs, hemi- and paraplegia. Patients with a weight greater than 50 kg were treated with
3-4 coated tablets daily (1 coated tablet contains 15 mg coumarin, 90 mg troxerutin) in the beginning.
Dosage was decreased continuously up to 3 coated tablets a week for 6 month. Patients with severe
thrombosis were treated with 1 ampoule i.v. per day (1 ampoule 2 ml/5 ml: 10 mg /25 mg melilot extract
with water standardized to 3 mg / 7.5 mg coumarin, 50 mg/ 125 mg rutin). To avoid local irritation of the
veins the ampoules were diluted with 0.9 % NaCl. An objective measurement of efficacy is not mentioned.
Details on symptoms are not given. Treatment was well tolerated. Approx. 1 % of the patients reported
gastrointestinal adverse events and approx. 1 % weak allergic reactions and photosensitivity (Lacativa 1980).
Coumarin in combination with other substances
© EMEA 2008 20/38

In a randomized placebo controlled trial 231 patients suffering from chronic venous insufficiency were
treated with medical compression stockings and 90 mg coumarin and 540 mg troxerutin per day or medical
compression stockings and placebo for the first 4 weeks. Compression stockings were stopped and the
coumarin-troxerutin combination tablets or placebo tablets were taken for the following 12 weeks. The
primary efficacy endpoint was the lower leg volume measured by water plethysmometry. 226 patients were
evaluated. Lower leg volume decreased in both medication groups under compression therapy. After ceasing
compression therapy an oedema protective effect was seen under verum by a recurrence of leg volume
increase of 6.5 ± 12.1 ml versus 36.7 ± 12.1 ml under placebo. However, the difference between verum and
placebo has no clinical relevance (Vanscheidt et al 2002).
In a six-week double blind study 41 patients with chronic venous insufficiency with and without leg ulcer
were treated with daily 3 x 2 coated tablets Venalot depot (1 coated tablet contains 15 mg coumarin, 90 mg
troxerutin) or benzaron for 6 weeks. Difference of circumference at noon, circumference of leg ulcer,
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phlebometric measurements and subjective criteria like pain, nocturnal cramps, feeling of heavy legs were
evaluated at the beginning, after 2 and 6 weeks. In both treatment groups a statistically relevant decrease in
objective and subjective parameters was seen. The question of clinical relevance of the observed effects is
not discussed (Bosse, Drieschner and Klose 1985).
In an open clinical trial 200 patients with venous insufficiency were treated with 3 x 1 coated tablet Venalot
depot (a 15 mg coumarin, 90 mg troxerutin) or 3 x 1 capsule Calcium dobesilate (a 500 mg). Both
Geiser 1980).
Conclusion
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medications improved the subjective symptoms. The combination of coumarin and troxerutin appeared to be
superior to calcium dobesilate regarding overall efficacy and the symptom heaviness of legs. 15 patients
reported side-effects, mainly gastro-intestinal symptoms and 1 case of generalized itching (Berson and
Due to the lack of an acceptable control group and of objective measurement of efficacy the 2 clinical studies
investigating the effects of melilot as a single preparation are not sufficient to show efficacy in the treatment
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of symptoms of venous insufficiency. Clinical studies with melilot extracts in combinations, mostly with
flavonoids, are also of poor quality. In clinical trials with coumarin in combination with other substances
using objective measurements of efficacy the observed effects had no clinical relevance. Overall the data are
not sufficient to show efficacy of melilot in a well-established use. However, the data can be accepted for
establishing “plausibility” of the traditional use.
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Haemorrhoidal conditions
No data available.

50 patients with haemorrhoidal conditions were treated with 6 to 8 Esberiven drinking ampoules (melilot
extract, rutin) per day (40 cases) or in combination with other local or surgical treatment (10 cases) for 10 to
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28 days. Symptoms like anal pain and pruritus disappeared in most of the cases. The treatment was generally
well tolerated. The following side effects are given: 3 x bad taste, 1 x epigastric discomfort, 1 x head ache,
1 x decrease of libido. An objective measurement of efficacy is missing. It is not possible to assess the
contribution of melilot on treatment effects (Mot 1976).
Conclusion
Due to the lack of data to melilot as a mono preparation and only insufficient data to a combination the data
is not sufficient to show efficacy of melilot in haemorrhoidal conditions. Additionally there is no traditional
use of melilot as a single substance documented in this indication.
Lymphoedema
In an open clinical trial 20 patients with lymphoedema of the lower limbs, stage I-II, were treated with
200 mg melilot extract (no specification given) daily in combination with compression therapy for 6 months.
© EMEA 2008 21/38
A clinical score for assessment of subjective symptoms, e.g. pain and tension, and objective measurements,
e.g. circumference/ ultrasonography were assessed at the beginning and after 90 and 180 days of treatment.
An improvement of all variables was seen. It is not possible to assess the contribution of melilot on treatment
effects (Martignani et al 1997).
In an open clinical trial 25 women with lymphoedema of the upper limbs due to axillary lymphadenectomy
for breast cancer were treated with 20 mg melilot extract standardized to 20 % coumarin (daily dose
equivalent to 4 mg of coumarin, no further specification given) for 12 weeks. Circumferences of the diseased
and the contra lateral arm were measured at the level of the armpit, arm, elbow, forearm, wrist and hand,
before and after 6 and 12 weeks of treatment. A statistically significant decrease in limb volume at all levels
(approx. 0.5 to 1 cm) was seen at week 6 and 12. The reductions of up to 11 cm shown in figures 1 and 2 are
not in line with the data shown in tables I and II. The clinical relevance of the findings is not discussed.
Adverse events were not reported (Muraca and Baroncelli 1999).
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Melilot extract combinations
In an open clinical trial 21 women with chronic lymphoedema of the upper limbs due to axillary
lymphadenectomy for breast cancer were included. According to the English abstract a melilot
monopreparation was given but according to the data under “Pazienti e Metodi” a combination product was
investigated. Of these patients 14 were treated with 2 capsules of a combination of melilot dry extract and
rutin once a day (daily dose: 400 mg melilot dry extract standardized to 20 % coumarin ->equivalent to
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8 mg of coumarin, no further specification given, declaration does not seem to be correct; 60 mg rutin) for
6 months, 4 patients were controls (no treatment?). 3 patients were lost to follow up; it is not mentioned,
which treatment they received. Circumferences of the diseased arm and the contra lateral arm were measured
at 5 defined points before and after 3 and 6 months of treatment and a symptom-related questionnaire for
self-evaluation was taken at every clinical control (name of questionnaire not mentioned, validated?). From
these 14 patients the median reduction in upper arm circumference was about 5 % compared to initial values;
however, looking at the individual data only 1 patient showed a relevant reduction of circumferences (20 %),
10 had only minimal changes and 3 showed no change. Lymphoedema of the 4 controls worsened during
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that time (Pastura et al.,1999).
In a randomized study the effect of Venalot intravenously (5 ml contain 25 mg melilot extract with water
standardized to 7.5 mg g coumarin, 125 mg rutin) compared to standard treatment without Venalot for the
prophylaxis of oedema following gastric operations (e.g. Billroth I / II) was investigated. From the patients
surviving the operation all 25 patients in the Venalot group were able to eat on their own latest on day
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5 whereas in the control group only 15 from 21 where able to do so. The author concludes that the
medication positively influences the function of the gastric anastomosis by reducing the volume of oedema
(Kriz 1978).
In another randomized investigation 24 patients with an acute hemorrhagic-necrotic pancreatitis were treated
with 10 ml Venalot intravenously 3 times daily or aprotinin (starting dose 500.000 unit followed by
2.000.000 unit daily) for 10 days combined with standard treatment for the prophylaxis of oedema following
pancreatic operation. All patients survived in the Venalot group, 4 died in the aprotinin group. The stay in
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hospital was shorter in the Venalot group (24 days versus 34.5 days) (Vida 1977).
In an open study 30 women with lymphoedema due to mastectomy and radiation were treated in the
beginning with 2 ml Venalot intravenously per day (10 mg melilot extract with water standardized to 3 mg g
coumarin, 50 mg rutin) for 10 days followed by 2 x 2 coated tablets (15 mg Coumarin, 90 mg troxerutin)
orally. A decrease in the circumference of the arm was seen in 14 women; in 7 patients no effect and in 9 an
increase of circumference was seen (El-Shammah 1976).
Coumarin and combinations with other substances

Casley-Smith et al reported that coumarin was effective in reducing the volume of oedema fluid and
lowering skin temperature in 31 women with postmastectomy lymphoedema of the arm and 21 men and
women with lymphoedema of the leg of various causes (Casley-Smith, Morgan and Piller (1993). Similar
findings were reported by Eggert on 17 women with postmastectomy lymphedema (Eggert et al., 1977).
© EMEA 2008 22/38

In contrast to these findings Loprinzi did not find that coumarin had any benefit in reducing arm volume or
treating symptoms or that the frequency of infections was similar during coumarin and placebo. In his
prospective, double-blind, randomized, crossover design study he investigated the effects of 2 x 200 mg oral
coumarin or placebo for six months followed by 6 months of the other therapy in 140 women with unilateral
lymphoedema attributed to earlier local or regional treatment of breast cancer on the average volume of the
affected arm. The outcome of treatment was evaluated by detailed measurements of arm volume and a
questionnaire completed by each patient. Coumarin was well tolerated, except that it resulted in serologic
evidence of liver toxicity in 6% of the women (Loprinzi et al., 1999; Ganz 1999).
In a randomized double-blind study 3 x 2 Venalot retard coated tablets (15 mg Coumarin, 90 mg troxerutin)
and suppositories (30 mg coumarin, 180 mg troxerutin) per day were tested against placebo regarding
reduction of the postreconstructive oedema of the lower extremities in 56 patients. A statistically significant
reduction of the postreconstructive oedema in the verum group could only be seen in the subgroup with a
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very distinct oedema (femoropopliteal bypass) (Becker, Niedermaier and Orend 1985).
In a prospective and double-blind investigation 134 women receiving an episiotomy after otherwise normal
deliveries were treated with 3 x 1 coated tablet Venalot depot (15 mg coumarin, 90 mg troxerutin) or placebo
for 7 days post partum. Significantly less local oedema was found in the verum group but no effects were
observed on the patient’s subjective complaints (Pedersen AKO, Kristensen OK, Gram-Hansen J 1982). In a
double-blind study the effects of the above mentioned combination in 3 different dose levels (2 x 1, 2 x 2 ,
3 x 2 coated tablets), its active components separately and of placebo in 560 women following medio-lateral
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episiotomy were investigated. The efficacy of the combination on oedema, rubor around the incision wound,
posttraumatic pain as well as consumption of analgesics was superior to the components applied separately
(Pethö 1981).
In a double-blind trial the effect of Venalot depot coated tablets (1 coated tablet contains 15 mg coumarin,
90 mg troxerutin) or placebo for the prophylaxis of oedema following operation for phimosis was
investigated. Medication started with 2 x 2 tablets the day prior operation followed by 3 x 2 coated tablets for
7 days; for patients under the age of 15 dosage was reduced to 1 tablet 3 times a day. Significantly less
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oedema under verum was observed on the first postoperative day but no difference was seen on the seventh
postoperative day. No differences in the amount of pain and discomfort were recorded and no side-effects
nor changes in blood chemistry were observed (Nielsen and Rokkjaer 1980).
148 patients with euthyroid endocrine ophthalmopathy were treated with 4 different therapies:
1. levothyroxine alone, or 2. levothyroxine and prednisone, or 3. levothyroxine, prednisone and retrobulbar
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X-radiation, or 4. levothyroxine, prednisone, retrobulbar X-radiation and Venalot Depot (15 mg Coumarin,
90 mg troxerutin) assuming that endocrine eye symptoms are manifestations of local myxooedema.
No single drug was found to be superior to any of the others (Horster and Wildmeister 1983).
Bider et al. report shortly of favourable results on the use of 3 x 2 coated tablets Venalot depot per os
(1 coated tablet contains 15 mg coumarin, 90 mg troxerutin) in the treatment of traumatic and postoperative
hemophalmia, retinal hemorrhage and turbidity of the vitreous body (Bider et al., 1975).
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In a prospective, randomized, placebo-controlled, double-blind study the effects of a coumarin /troxerutine

combination (Venalot depot) for protection of salivary glands during a head and neck irradiation on
48 radiotherapy patients (60 Gy) with head and neck cancer were investigated. During radiotherapy the
salivary glands were located in the core irradiation field. Primary efficacy parameters were sialometry,
quantitative salivary gland scintigraphy and clinical evaluation of early effects of radiotherapy (RTOC-
score). All data were assessed at 6 visits starting 1 week pre-radiation, at start, half-time and end of
irradiation, and 8 and 28 days after the end of irradiation. Early clinical effects of irradiation (RTOG-score)
were less pronounced in the active treatment group than under placebo, but the sample size was too low to
show statistically significant differences with the szintigraphic method. In the authors opinion sialometry
seems not suitable for the assessment of early radiation effects (Grötz et al., 1999).
Conclusion
The clinical data on treatment of lymphoedema from various causes show inconsistent effects of melilot
preparations or combination products. Even if statistically significant reductions of lymphoedema were seen
in some of the studies the clinical relevance of the observed effects is missing. Therefore the data are not
© EMEA 2008 23/38
sufficient to show efficacy in a well-established use. The indication is not acceptable for a traditional use as
medical intervention is always required.
Blunt Traumata
Melilot monopreparations
No data available.

In a randomized and double-blind investigation 48 patients with distorsions and contusions of the lower leg
or feet were treated with 4 g Phlebodril ointment (100 g contains 1.6 g ethanolic dry extract of ruscus
standardized on 25 mg ruscogenin, 1.6 g ethanolic liquid extract of melilot standardized on 0.32 mg
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coumarin) or placebo three times daily for a period of 14 days. Concomitant analgetic or antiphlogistic
medication and physical therapy was not allowed. Difference of circumference, skin temperature, painless
muscle force between injured and healthy leg and changes of pain symptomatics (pain at rest, pain in motion,
pain on tension) on days 3 to 5 and 14 were taken as target criterion. During treatment symptoms decreased
in both groups but faster in the verum group. It is not possible to assess the contribution of melilot on
treatment effects (Böhmer and Ambrus 1989; 1990; N.N 1990).
Coumarin in combination with other substances
ed
174 patients with sprained ankles attending a casualty department were treated with Venalot depot coated
tablets (15 mg coumarin, 90 mg troxerutin) or placebo in varying doses. In addition, rapid mobilisation was
recommended. Regarding to swelling, pain on weight-bearing, sensation of instability and days of sick-leave
no effect could be demonstrated. The incidence of side-effects was low (Jensen, Jensen 1980).
Conclusion
There are no data for melilot as a single preparation in external treatment of blunt traumata. Data from a
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randomized, double blind and placebo controlled trial of a combination of extracts of ruscus and melilot give
some evidence of efficacy of the combination studied but it is not possible to assess the contribution of
melilot on treatment effects. Therefore the data are not sufficient to show efficacy in a well-established use.
As traditional external use of melilot on bruises and sprains is well documented and plausible from
pharmacological data a traditional indication is acceptable.
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Mastalgia
Melilot monopreparations
In an open clinical trial 50 patients with cyclic or non-cyclic mastalgia were treated daily with a melilot
extract for oral use (no specification given, no dosage given) for 2 periods of months with an interval of
1 month. After 6 months efficacy was assessed by clinical examination and a compilation of a symptom-
related questionnaire for self-evaluation (name of questionnaire not mentioned, validation of the
questionnaire is questionable). Measurement of efficacy remains unclear and can’t be assessed. 31 patients
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were evaluable for response, 43 for safety assessment. It is not clear from the paper why 19 patients were not
assessed for efficacy (drop out due to lack of efficacy may have occurred) In 23 of the cases melilot was
effective, 8 had no benefit from the treatment. Side effects are not mentioned (Mazzocchi et al.,1997).

In an open clinical trial 20 patients with mastalgia were treated with 5 drinking ampoules Esberiven
(1 ml contains 0.100 g melilot extract, 0.025 g rutin, 0.0265 ml alcohol 95 %) daily on days 15 to 25 of
menstruation cycle for 3 months. Overall good therapeutic results were seen in 15 patients, side effects were
not seen (Giraud 1984).
In two overviews the use of angiotonic drugs, e.g. Esberiven, in the treatment of fibrocystic mastopathy or
mastodynia is shortly mentioned. Details are not given (Gorins 1994; et al., 1993).
Conclusion
© EMEA 2008 24/38

Due to the lack of controlled studies and objective measurements of efficacy the data is not sufficient to
show efficacy of melilot in mastalgia. Additionally there is no traditional use of Melilot documented in this
indication.
Others
In an open study 25 patients with rosacea were treated with a cream containing extracts of melilot (2%, no
specification of extracts given) and ruscus aculeatus (8%) twice daily for 3 month. In each patient
teleangiectasias were studied by optic videocapillaroscopy (number of venous ansas by field, diameter of
ansas) and the intensity of erythema by colometry was assessed at the beginning, every two weeks during
treatment and at the end of treatment. During treatment a gradual and continuous improvement of
teleangiectasias (number and diameter) and erythema was observed, while papules and pustules remained
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unchanged. After an 8-month follow-up slight relapses of erythema and teleangiectasias were observed. The
author states that topical treatment with melilot extract cream can give a reduction of vassal lesions of
rosacea. Side effects were not observed (Iurassich, Bianco and Pascarella 1999).
Older literature gives a short overview about medical use of medicinal products containing melilot extracts
standardized on 0.1 % coumarin, vitamin P and B1 for oral use in solid and liquid dosage forms, creams and
suppositories for melilot in patients with various indications like thrombosis, venous insufficiency,
haemorrhoids, haematomas, arthritis, apoplex, heart attack, endangitis obliterans, bursitis and tendovaginitis.
Duration of treatment varied from 10 up to 240 days. 2 patients reported gastric complaints. An objective
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measurement of efficacy is missing in all given indications (von Blumröder 1960; Becker 1956).
An overview about the therapeutic use of Esberiven drinking ampoules in gynaecology is given by Cluzan
and Kieffer (1979). 308 women with dysmenorrhoea, pelvipathia, premenstrual syndrome, venous
insufficiency, haemorrhoids and others were treated with 6 drinking ampoules (1 ml contains 0.100 g melilot
extract, 0.025 g rutin, 0,0265 ml alcohol 95 %) per day or i.v. injections (2 ml contain melilot extract
standardized to 1 mg coumarin, 50 mg rutin; dosage per day not given) from 3 weeks up to 2 months with
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good or excellent results in about 70% of the patients. An objective measurement of efficacy is missing in all
given indications. Side effects were seen in 5 patients (1.6%).
According to an English abstract of a Japanese publication 55 patients with chronic prostatitis were given
Esberiven (content, dosage form and dose not mentioned) with or without Cotrimoxazole daily for more than
8 weeks. Efficacy was evaluated by improvement of subjective symptoms and objective findings including
transrectal ultrasonography and urodynamic measurements. An overall therapeutic effect of Esberiven alone
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was seen in 12 of 16 cases (75%) in contrast to 35 from 39 cases (87 %) treated with the combination.
Because detailed information is not included in the abstract an evaluation of the data is not possible
(Akiyama et al., 1980).
Conclusion
The fragmentary data given in the overviews are not sufficient to show efficacy of melilot in the studied
combinations in any of the mentioned indications. Additionally it is not possible to assess the contribution of
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melilot on the reported treatment effects.
Clinical studies in special populations (such as elderly and children)
Use in children
There are no clinical data for use of melilot in children.
Conclusion
According to the “NOTE FOR GUIDANCE ON CLINICAL INVESTIGATION OF MEDICINAL
PRODUCTS IN THE PAEDIATRIC POPULATION” (CPMP/ICH/2711/99) of 27 July 2000 and other
monographs age limit for children should be determined to “adolescents over 18 years of age”.
Use during pregnancy and lactation
a) Pregnancy
© EMEA 2008 25/38
Leng treated 25 pregnant women with venous insufficiency and thrombosis with Esberiven drinking
ampoules and 5 patients post partum with Esberiven injections, i.m. 2 times daily, for 6 to 7 days. (melilot
extracts standardized on 0.1 % coumarin, “vitamin P”). In 17 cases out of 25 pregnant women an
improvement of symptoms was noticed, in 5 cases no change and in 3 cases the medication was judged to be
ineffective. Tolerance was good in all cases. An objective measurement of efficacy is missing. Information
about the delivered babies is lacking (Leng et al., 1974).
Oral use and topical application of melilot combinations in pregnancy is also mentioned by various authors
(Lacativa 1980; N.N. 1990; Eyraud 1982; Tran 1981; Krajnovic 1977a). Detailed information, especially on
the outcome of the delivered babies, is missing in these reports.
Coumarin combinations
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10 healthy pregnant women were treated with 4 Venalot depot coated tablets (15 mg coumarin, 90 mg
troxerutin) starting approx. 2 weeks before delivery to 4 days post partum. All women delivered without
complications. Haemoglobin, bleeding time, thrombelastogram and prothrombin time of the women and their
infants were within normal range before and after treatment (Krajnovic, Vranes and Djuric 1974).
b) Lactation
Melilot
There is no data available.
Coumarin combinations
ed
The influence of daily 4 Venalot depot coated tablets (15 mg coumarin, 90 mg troxerutin) for 3 weeks on
hematological parameters of 20 breastfeeding mothers and their infants was investigated. Erythrocytes,
haemoglobin, thrombocytes, thrombelastogram, prothrombin time, blood-clotting and bleeding time were
within normal range before and after treatment. (Krajnovic 1977a).
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Assessor’s overall conclusions on clinical efficacy
There are just few clinical data for melilot or preparations thereof as a single ingredient. However, a wide
use of melilot is documented in literature and there is some evidence of efficacy of some melilot containing
combination products that have been evaluated in various indications. In the majority of the studies
combinations of Meliloti herba with rutosid, troxerutin, extracts with Horse chest nut or Ruscus aculeatus
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and vitamins were investigated.
In most of the publications the declaration of the investigated medicinal products is incomplete or missing,
e.g. the drug-extraction-ratio or the extraction solvent is not given. Usually the preparations were
investigated in different dosage forms and several indications under “real life conditions” and not in a
controlled clinical trial setting. In the majority of the studies an objective measurement of efficacy is missing
or not mentioned.
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Therefore, the published clinical studies available on meliot as a single preparation are not convincing and
not sufficient to demonstrate a well-established use.
Due to the hepatotoxic potential of coumarin in daily doses from 30 mg to several grams the content of
coumarin in melilot preparations should not exceed 5 mg coumarin per day. This limit takes into account
additional exposure through food and the additional exposure to other cinnamic acid derivates that have not
yet been fully investigated. Because pharmacodynamic effects have been described after topical use and
because the systemic availability of coumarin after topical application has not been studied, the same limit is
recommended for topical use. To minimize potential risks children and adolescents up to the age of 18 years
as well as pregnant and breastfeeding women should not take melilot or preparations thereof.
© EMEA 2008 26/38

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© EMEA 2008 27/38

3 USE IN MEMBER STATES
Member State Medicinal product Food supplement

Austria Only in homeopathic No information
Belgium Melilotus officinalis: Melilotus officinalis:
Herbal substance Herbal preparation
o Pharmaceutical form: 2 teas o Pharmaceutical form: Oral solutions,
(combination products; registrations drops, tablets, capsules,
dating for the '60s)
o Composition: hydro-alcoholic extracts,
o Posology: containing 150mg/g and tinctures, granules, (ampoules : drinkable I
0.08mg/g, respectively would think- I will check)
ed
o Indication: bronchopulmonary , o Posology: corresponding to 0.054mg -
stomach/biliary function, respectively 5mg coumarin per day
o Indications (if mentioned): supporting

blood circulation, heavy legs, "rols of fat"
Bulgaria
ed
One medicinal product, containing
Melilotus extract is on the Bulgarian
market (”Cyclo 3”, cream, (Pierre Fabre
Medicament).
Melilotus altissimus
o Pharmaceutical form: Capsules,
o Posology: corresponding to 10.8mg
coumarin per day
No information
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Herbal preparation:
o Pharmaceutical form: cream
o Composition: dry extract of the roots of

Ruscus aculeatus and liquid extract of the
herb of Melilotus officinalis..
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o Posology: -
o Indication: for treatment of varicose

veins (ATC: C05C “Capillary tonic
preparations”
Czech Republic Not on the market No information
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Cyprus No reply No information

Denmark Not on the market No information
Estonia Only in homeopathic No information
Finland Only in homeopathic No information
© EMEA 2008 28/38

France Herbal substance: No information
4 products containing only melilot,
12 products containing melilot and other
herbals
Herbal preparation:
1 product containing only Melilotus,
10 products containing Melilotus and
other herbals
o Pharmaceutical form: capsule, hard,

herbal tea, oral solution, oral suspension,
ed
coated tablet, eye drops and cream
o Composition: -
o Indication:
A) Oral use
- Traditionally used in symptomatic
ed
treatment of functional disorders of
cutaneous capillary fragility, such as
ecchymosis petechias, etc...
- Traditionally used in subjective signs of
venous insufficiency, such as heavy legs,
in haemorrhoidal symptoms.
- Traditionally used in the symptomatic
treatment of digestive upsets such as :
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epigastric distension, slow digestion,
eructation, flatulence.
- Traditionally used as an adjuvant
treatment for painful component of
functional digestive disorders.
- Traditionally used in the symptomatic
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treatment of neurotonic conditions of

adults and children, notably in cases of
mild disorders of sleep.
B) Topical use
- Tradidionally used in symptomatic
treatment of functional disorders of
cutaneous capillary fragility, such as
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ecchymosis petechias, etc...

- Traditionally used in subjective signs of
venous insufficiency, such as heavy legs.
- Traditionally used in haemorrhoidal
symptoms.
- Traditionally used in cases of eye
irritation or discomfort due to various
causes (smoky atmospheres, sustained
visual effort, swimming in the sea or
swimming baths, etc...).
© EMEA 2008 29/38

Germany 5 medicinal products with a traditional No information
indication according to § 109a AMG are
licensed. Two of them are combinations
with extracts of horse chestnut.
o Pharmaceutical form: capsules, tablets,

solutions for oral use
o Composition: hydroethanolic or
hydromethanolic dry or fluid extracts of
the herb of Melilotus officinalis.. DEV
from 1:1 to 5:8
ed
o Posology: The daily dosage contains
1 to a maximum of 5 mg Coumarins
o Indication: Traditionally used for relief

of the feeling of heavy legs.
Hungary There are two tea-mixtures on the market
ed
as paramedicines which contain Meliloti
herba (Melilotus officinalis).
o Pharmaceutical form: herbal tea
o Posology: 200 or 700 mg Meliloti

herba in one dose corresponding to about
5-19 mg coumarin/day.
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o Indication: Helps to protect the liver
against toxic materials. They can be used
after hepatitis, or to complement the drug
treatment.
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Iceland Not on the market No information

Ireland Not on the market No information
Italy Not on the market o Herbal substance: whole, leaves, apical
flowers
o Pharmaceutical form: capsules, tablets,

scirop, solutions, herbal tea for oral use
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o Composition: hydroethanolic dry or fluid

extracts of the herb of Melilotus officinalis.
o Posology: each product has a different

posology (see attached list)
o Indication:
Melilotus increases blood vessels
permeability, therefore it can treat varicose
veins and haemorrhoids. Use of the plant
also helps to reduce the risk of phlebitis and
thrombosis. The flowering plant is also
used as antispasmodic, aromatic,
carminative, diuretic, emollient, mildly
expectorant and mildly sedative. In form of
© EMEA 2008 30/38
infusion is used in the treatment of
sleeplessness, nervous tension, neuralgia,
palpitations, varicose veins, painful
congestive menstruation, in the prevention
of thrombosis, flatulence and intestinal
disorders.
Latvia In Latvia Melilotus officinalis is No information
authorized in 3 medicinal products for
oral use.
Species pro gynaecologicum morbum

o Composition: 11 medicinal plants,
Melilotus 8%
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o Posology: 1 tablespoon of mixture to
glass of boiling water for infusion.
½ glass of infusion twice daily: in the
morning – before meal, in the evening –
before bedtime.
o Indication: traditional medicinal tea on
inflammation in gynecology.
ed
Species anticlimactericae
o Composition: 14 medicinal plants,
Melilotus 10%
o Posology: 1 tablespoon of mixture to
glass of boiling water for infusion.
½ glass of infusion twice daily: in the
morning – before meal, in the evening –
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before bedtime.
o Indication: traditional medicinal tea to
prevent climacteric symptoms.
Toning up tablets
o Composition:
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Flores Crataegi 150 mg

Fructus Crataegi 30 mg
Herba Leonuri 100 mg
Herba Meliloti 40 mg
o Posology: 3 tablets a day
o Indication: Restorative on blood

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circulation.
Lithuania No reply
Luxembourg There is 1 product registered in No information
Luxembourg containing Melilotus
(ARKOGELULES MELILOT 190mg
capsules).
Pharmaceutical form: capsules for oral

use
o Composition: -
o Posology: 3 capsules per day (1 in the
morning, 1 at noon, 1 in the evening)
together with the meal and 1 glass of
water. Maximum 5 capsules per day.
© EMEA 2008 31/38
o Indication: (French original text):"
Traditionnellement utilisé dans le
traitement symptomatique des troubles
fonctionnels de la fragilité capillaire
cutanée, tel que ecchymoses, pétéchies.
Traditionnellement utilisé dans les
manifestations subjectives de
l'insuffisance veineuse
telles que jambes lourdes et dans la
symptomatologie hémorroidaire."
Netherlands No reply
Malta Not on the market No information
ed
Poland Meliloti Herba is described in Polish No information
Pharmacopoeia (ed.VI). According to the
pharmacopoeia it contain dried herb of
Melilotus officinalis (L.) Desrousseaux or
M. altissima Thuilier, (Leguminosae).
Meliloti Herba can be distributed as
pharmaceutical raw material for use in
pharmacies.
ed
The common pharmacopoeial prescription
is Emplastrum Meliloti described by
Polish Pharmacopoeia V. It
is traditionally used topically, in a form of
poultice on furuncles as a medium
improving lymph circulation in tissues
surrounding. It is also used in oedemas
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after injuries. Emplastrum Meliloti can be
also registered in Poland according to
Regulation from 9.06.2003. All other
products containing Meliloti Herba
preparations have to be authorised.
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Pharmaceutical form: tablets and herbal

tea for oral use,
emplastrum and infusion for topical use
o Composition:
pulvered drug for oral use;
Meliloti emplastrum, according to last VI
edition of Polish Pharmacopoeia is
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prepared by extraction of 10 parts of

pulverized Meliloti herba, wetted with 2
parts of ethanol, to 90 parts of semi-solid
base (Rapae oleum, Cera flava,
Colophonium). Final DER in Meliloti
emplastrum is (0,11:1).
o Posology:
Infusions are prepared of 2,5 - 3 g of
Meliloti herba in 200 - 300 ml of boliling
water.
© EMEA 2008 32/38

o Indication:
- Oral use: traditionally as a component
improving symptoms of chronic
venous insufficiency and peripheral
circulation insufficiency.
- topical use:
Emplastrum is used as facilitating of skin
healing.
Infusions of Meliloti herba are used
traditionally externally, on skin, in a form
of warm poultice (cataplasms)
for purulent skin inflammations or
furunculosis. Infusions were also used
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traditionally on eyelid inflammations
(fresh prepared warm infusion on gauze
swab) but this indication is under
revision.
Portugal Not on the market No information
Romania No reply
use.
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Slovak Republic Pharmaceutical form: granules, tablets,
oral drops, oral solution, powder for oral
Ointment and suppository for topical use.
o Composition: -
o Posology: depends on physican

No information
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o Indication: -
Slovenia In Slovenia the following medicinal No information
product containing Melilotus is on the
market:
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o Pharmaceutical form: gel for cutaneous

application
o Composition: 1 g gel contains

0,35 g of liquid extract of horse-chestnut
seed (Hippocastani seminis extractum
fluidum) (stand. to 10,5 mg of aescin) and
Su
0,02 g of liquid extract of melilot

(Meliloti herbae extractum fluidum) 1:1.
o Posology: cutaneous application more

times daily
o Indication: symptomatic treatment of

varicose veins
© EMEA 2008 33/38

Spain We have one old herbal medicinal No information
product"MELILOTO
ARKOCAPSULAS" registered by
ARKOCHIM.
o Pharmaceutical form: hard capsules
o Composition: 190 mg of powdered

flowers of Melilotus officinalis L.
o Posology: 1-2 caps, 3 times a day
ed
o Indication: Short-term relief of
symptoms associated to chronic venous
insufficiency.
Sweden Not on the market No information
UK Not on the market No information
GERMANY
Extract
100 g meliloti fluid extract DER (1:1)

ed
Additional data from France and Germany (October 2007)
Pharmaceutical
Form
solution
Posology
Oral: 3 x 40 drops ( 40 drops=

rs
Extraction solvent: ethanol 30%(V/V) / 100 g 1,14 g FE= 1,14 mg coumarin
medicinal product
80 mg meliloti dry extract DER (5-7:1) tablet Oral: 3 x 2 tablets (0,55 mg
Extraction solvent: ethanol 50% (V/V) / tablet coumarin /tablets)
8,4 -11,7 g melilot dry extract DER (4-8:1) solution Oral: 3 x 1 ml (≈ 7,3 – 10,1 mg
Extraction solvent: ethanol 25% (m/m) / 100 g coumarin/ ml)
pe
medicinal product
100 mg melilot dry extract DER (4,2-7,5:1), tablet Oral. 3 x 2 tablets (daily dose 3 -
Extraction solvent: Methanol 50% (V/V) / tablet 5 mg coumarin)
252 mg melilot dry extract DER (4-8:1) Soft capsule Oral: 1x1 capsule (daily dose 3 -
Extraction solvent: ethanol 35% (V/V)/ capsule 5 mg coumarin)
4 g melilot fluid extract (1:1), solution Oral: 3 x 20 ml (daily dose < 3
Extraction solvent: ethanol 30 % (V/V) / 100 ml mg coumarin)
medicinal product
Su
24 mg melilot dry extract (6-9:1) tablet Oral: 2-3 x 1 tablet( daily dose
Extraction solvent: ethanol 90% (V/V)/ tablet 1-1,5 mg coumarin)
30 mg melilot dry extract (7-9:1) Soft capsule Oral: 2-3 x 1 capsule (daily dose
Extraction solvent: methanol 30% V/V / Kapsel 1,5 mg coumarin)
© EMEA 2008 34/38

FRANCE
d
Well-Established Use Traditional Use
Preparations (kind of extract, extraction solvent, DER)
1) 1) Powdered
de
2) 2) Powdered
3) 3) Powdered
…) 4) Dry aquous extract
5) Infusion
SINCE WHEN ARE THE PREPARATIONS ON THE MARKET?

1) 1) 1989
se
2) 2) 1990
3) 3) 1990
…) 4) 1987
5) 1991
1)
2)
3)
…)
p er Pharmaceutical form (Standard Terms)
1)
2)
3)
4
5)
hard capsule
oral suspension, single dose container
oral solution, ampoule
hard capsule
eye drops
Posology (Route of administration in Standard Terms + daily dosage)
1) 1) 1 hard capsule (250 mg) three times daily
2) 2) 10ml daily (containing 1614 mg)
Su
3) 3) 2 ampoules daily (1 containing 500 mg /5 ml)

…) 4) 1 hard capsule (200 mg) twice daily
5) 1 to 2 drops three to four times daily (5 ml of eye drops containing 50 mg
of herbal)
© EMEA 2008 35/38

Indications
1) 1) Traditionally used in the symptomatic treatment of functional disorders of
d
cutaneous capillary fragility, such as ecchymosis, petechias, etc.
Traditionally used:
- in subjective signs of venous insufficiency, such as heavy legs
de
- in haemorrhoidal symptoms.
Traditionally used:
- in haemorrhoidal symptoms.
se
…) 4). Traditionally used in the symptomatic treatment of functional disorders of
Traditionally used:
er
p - in haemorrhoidal symptoms.
5). Traditionally used in cases of eye irritation or discomfort due to various
causes (smoky atmospheres, sustained visual effort, swimming in the sea or
swimming baths, etc.).
Su
© EMEA 2008 36/38

Risks (adverse drug effects, literature)
d
1) 1)
2) 2)
3) 3)
de
Is the Herbal Substance on the market? Is the Herbal Substance on the market?
Yes No Yes No
Status Status
Authorised products Registered products Food supplements Authorised products Registered products Food supplements
se
Were pharmacovigilance actions taken on medicinal products containing the Were pharmacovigilance actions taken on medicinal products containing the herbal
herbal substance? Yes No substance? Yes No
a. Combination products b. Combination products

The herbal substance is only available in combination products. The herbal substance is only available in combination products.
Average number of combination substances:

2-3 3-5 >5
What are the main combination substances?

er
Other information on relevant combination products:
p Average number of combination substances:
2-3 3-5 >5
What are the main combination substances?
Other information on relevant combination products:

Date: Date04/10/2007
Additional comments:
Su
© EMEA 2008 37/38

4. ASSESSOR’S OVERALL CONCLUSIONS
Melilot and preparations thereof have been widely used in different member states for several decades.
The anti-oedematous effects of melilot preparations have long been recognised empirically; the uses
are made plausible by pharmacological data on coumarin and the long-standing use of melilot in those
indications. Since the clinical documentation for melilot as a mono preparation is poor and no
controlled clinical studies are available, the use of Meliloti herba preparations has to be regarded as
traditional.
In conclusion, Meliloti herba and preparations thereof can be regarded as traditional herbal medicinal
products.
Appendix I.
ed
T165 - XTOXLINE copyright NLM 2006
CC00 - CCMed copyright ZBMED
CDSR93 - Cochrane Library - CDSR copyright Cochrane
DAHTA - DAHTA-Datenbank copyright Bundesministerium für Gesundheit
AR96 - Deutsches Ärzteblatt copyright DAEB
GA03 - gms copyright gms
GM03 - gms Meetings copyright gms
ed
HG05 - Hogrefe-Verlagsdatenbank und Volltexte copyright Hogrefe-Verlagsgruppe
KR03 - Karger-Verlagsdatenbank copyright Karger-Verlag
KL97 - Kluwer-Verlagsdatenbank copyright Kluwer Academic Publishers
KP05 - Krause & Pachernegg Verlagsdatenbank copyright KuP
CDAR94 - NHS-CRD-DARE copyright Cochrane
INAHTA - NHS-CRD-HTA copyright NHS CRD 2004
SM78 - SOMED copyright LOEGD 2002
rs
SPPP - Springer-Verlagsdatenbank PrePrint copyright Springer-Verlag
SP97 - Springer-Verlagsdatenbank copyright Springer-Verlag
TV01 - Thieme-Verlagsdatenbank copyright Thieme-Verlag
VV00 - VVFM copyright editworks GbR
CCTR93 - Cochrane Library - Central copyright Cochrane
ME66 - MEDLINE copyright NLM
pe
ME60 - OldMEDLINE copyright NLM 2004

ME0A - MEDLINE Alert copyright NLM
ZT00 - AnimAlt-ZEBET copyright BfR (ZEBET) 2005
MK77 - MEDIKAT copyright ZB MED
ED93 - ETHMED copyright IDEM 2005
GE79 - GeroLit copyright DZA 2002
HN69 - HECLINET copyright IFG 2002
CV72 - CAB Abstracts copyright CAB
Su
CB85 - AMED copyright THE BRITISH LIBRARY 2003

NHSEED - NHS-EED copyright NHS EED 2003
AZ72 - GLOBAL Health copyright CAB
IA70 - IPA copyright Thomson Scientific 2005
BA70 - BIOSIS Previews copyright Thomson Scientific
EM74 - EMBASE copyright 2006 Elsevier B.V.
DH64 - Derwent Drug Backfile copyright Derwent Information
EA08 - EMBASE Alert copyright 2006 Elsevier B.V.
DD83 - Derwent Drug File copyright 2005 Thomson Derwent
II78 - ISTPB + ISTP/ISSHP copyright Thomson Scientific
IS74 - SciSearch copyright Thomson Scientific 2003
5 COMMUNITY MONOGRAPH ON MELILOTUS OFFICINALIS (L.) LAM, HERBA
© EMEA 2008 38/38

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European Medicines Agency

Evaluation of Medicines for Human Use

London, 3 July 2008

Melilotus officinalis (L.) Lam., herba

7 Westferry Circus, Canary Wharf, London, E14 4HB, UK

Melilotus officinalis (L.) Lam., herba

Comminuted herbal substance

ed Dry Extracts (5-7:1), ethanol 50 % V/V

Dr. Ulrike Wissinger-Gräfenhahn

© EMEA 2008 2/38

Market situation in the Member States

1.1 Description of the traditional herbal substance(s), herbal preparation(s) or combinations

Melilot (Meliloti herba)

The definition formerly given by the Pharmacopèe Francaise was as follows:

Table 1: Main characteristic constituents of melilot

Constituent Abundance Aspects with relevance for Remarks

the benefit / risk

Problems in risk assessment of other substances than coumarin

Combinations of herbal substance(s) and/or herbal preparation(s) 3

2.3 Bibliographic/expert evidence on the medicinal use

2.3.1 Evidence regarding the indication/traditional use

Symptomatic treatment of problems

related to varicose veins, such as painful

Symptomatic treatment of problems

External use: Bruises, sprains and German Commission E (1986)

Use in folk medicine:

© EMEA 2008 5/38

2.3.2 Evidence regarding the specified strength

© EMEA 2008 6/38

Preparations containing the

equivalent of up to 10 g dried herb;

base (Rapae oleum, Cera flava,

© EMEA 2008 8/38

Dry Extracts (5-7:1), ethanol 50 % 160 mg 3 times daily

Dry extracts (4-8:1), ethanol 25 % 100 mg 3 times daily

Dry extracts (4-8:1), ethanol 35 % 252 mg onces daily

Dry extracts (7-9:1), methanol

Powdered herbal substance

2-3 times daily (1.5

Powdered herbal substance 500 mg Twice daily

Dry extract with water (3-5:1) 200 mg Twice daily

According to the “NOTE FOR GUIDANCE ON CLINICAL INVESTIGATION OF MEDICINAL

2.3.4 Evidence regarding the route of administration

© EMEA 2008 9/38

2.4.1. Assessor’s overall conclusion on the traditional medicinal use

No exact data on patient exposure are available.

2.5.3 Serious events and deaths

2.5.4.1 Intrinsic (including elderly and children)/extrinsic factors

2.5.4.2 Drug-drug interactions and other interactions

© EMEA 2008 11/38

2.5.4.3 Use in pregnancy and lactation

2.5.4.6 Withdrawal and rebound

2.5.4.7 Effects on ability to drive or operate machinery

2.5.4.8 Contra indications (hypersensitivity and allergic potential to be both covered)

Hypersensitivity to melilot or to coumarin.

Not to be used together with anticoagulant therapy.

2.5.5 Non-clinical safety data

© EMEA 2008 12/38

Single dose toxicity