Phytotherapy 4-5

Constipation
Bulk-forming
Laxatives
Stimulant
Laxatives
Osmotic
Laxatives
1- Linseed
2- Isphagula
3- Psyllium
1- Senna
2- Aloe
3- Cascara
4- Frangula
5- Rhubarb
- Fenugreek

1.Bulk-forming laxatives
(used for chronic constipation)
They contain high percentage of fibers and often rich
in polysaccharides, they swell in the GIT.
• Herbal treatment
- Increase stool bulk
 Plantago ovata (Isphaghula).
 Plantago psyllium (Psyllium).

Linseed
• The seeds contain 3-6% of mucilage, 3-8% of alimentary
fibers, 20-30% of protein and 30-45% of fatty oil, and is rich
in polyunsaturated fatty acids, e.g. linoleic acid, and lignans.
Its cyanogenic glycoside content is 0.1-1.5%.
• - treatment of habitual constipation or in conditions in which
easy defecation with soft stool is desirable. The daily dose is
20-45 g daily.
• - The traditional use as a demulcent preparation for the
symptomatic relief of mild gastrointestinal discomfort. The
daily dose is 15-30 g. It should be consumed with an enough
water intake and at least 1/2-1 hour before or after the intake
of other medicines. The effect starts 12-24 hours later. It
should not be taken immediately prior to bedtime.

Side effects, interactions & contraindications
• Although 100 g of linseed may contain cyanogenic
glycosides equivalent to 30 mg of hydrogen cyanide (the
lethal dose of which is about 50-100 mg), linseed
consumption is not dangerous from this aspect.
• The reason is that linseed contains 1- cyanide in glycosidic
form, and its release is catalyzed by the enzyme
linamarase (present in the seeds). This enzyme is
inactivated by the gastric acid and 2- the (low) amount of
cyanide released is transformed to the harmless
thiocyanate by the rhodanase enzymes. 3- Linseed should
not be used by patients with a sudden change in bowel
habit that has persisted for more than 2 weeks, with
undiagnosed rectal bleeding or with a failure to defecate
following the use of a laxative.

• Linseed should likewise not be used by patients with
abnormal constrictions in the gastrointestinal tract,
with diseases of the esophagus or cardia or with an
existing intestinal blockage (ileus), or paralysis (ileus)
of the intestine or megacolon. It should not be taken
by patients who have difficulty in swallowing or any
throat problems.
• The long-term use of linseed may have an estrogenic
effect, and its use is therefore not recommended in
women with hormonally dependent tumors.
• In order to decrease the risk of gastrointestinal
obstruction (ileus), linseed should be used together
with medicinal products known to inhibit peristaltic
movement (e.g. opioids or loperamide) only under
medical supervision.

Chemical composition and mechanism of action
• Ispaghula seeds contain 20–30% of arabinoxylan-
type polysaccharides, which are located in the
epidermis of the husks, and the husk is therefore
richer in mucilage.
• The Ispaghula husk consists of 85% water-soluble
fiber. The seeds also contain high amounts of
protein and oil. The minimal swelling index of the
seeds is 9. The husk can absorb up to 40 times its
own weight of liquid.
• Psyllium seeds contain approximately 10% of
mucilaginous polysaccharides.
Isphagula and Psylium

• The treatment of:
• habitual (chronic) constipation and
• in conditions in which easy defecation with soft
stools is desirable, e.g. in cases of painful defecation
after rectal or anal surgery, anal fissures or
hemorrhoids.

• These materials should be taken during the day at least 1/2 to 1 hour
before or after the intake of other medicines, and not immediately prior
to bed-time. The enteral absorption of concomitantly administered
medicines may be delayed. The effect starts 12-24 hours later.
• The use of Isphagula is contraindicated in cases of hypersensitivity,
undiagnosed rectal bleeding, a failure to defecate following the use of a
laxative, abnormal constrictions in the gastrointestinal tract, diseases of
the esophagus and cardia, a potential or existing intestinal blockage
(ileus), paralysis of the intestine or megacolon, and difficulties in
swallowing or throat problems. Flatulence may occur when the product
is used, but it generally disappears in the course of the treatment.
Abdominal distension and the risk of intestinal or esophageal
obstruction and fecal impaction may occur, particularly if the material is
swallowed with insufficient fluid. Use is not recommended in children
below 6 years of age because there are insufficient data on efficacy.
The use of ispaghula seeds may be considered during pregnancy and
lactation, if necessary, and if a change of nutrition is not successful.

2.Stimulant laxatives
e.g. Anthraquinones
- Increases intestinal motility and inhibit re-absorption of
electrolytes and fluids from the colon
- Increases the volume of intestinal contents, and filling
pressure.
-This induces propulsive contraction and stimulates
peristaltic movement

• - inhibition of the Na+-K+-ATPase in the bowel
epithelium, resulting in decreased water and Na+
absorption, and
• - the increase of cyclic AMP (cAMP) in the enterocytes,
which results in the increased secretion of Na+ and
water
• - stimulation of the synthesis of certain autacoids and
neurotransmitters (NO and 5-HT), resulting in
increased intestinal motility, a shortened transit time
and decreased water and electrolyte absorption.

Senna
• The active constituents of senna are the anthranoids that are
present in the leaves of the herbal substance as dianthrones (75–
80%) and as anthrones (20–25%).
• Senna leaves contains small quantities of (toxic) aglycones, the
amount of which increases during storage. Preparations prepared
using heat (e.g. teas) contain aglycones in higher amounts,
whereas cold extracts do not contain these constituents. The
amount of aglycones should be limited in the finished products.
Anthranoid glycosides are not absorbed from the intestinal tract.
Neither the acidic milieu of the stomach nor alpha-glycosidase
enzyme in the small intestine is able to hydrolyze the beta-O-
glycosidic substituents of sennosides. However, the beta
glycosidase of the bacteria of the colon can hydrolyze glycosides,
resulting in the formation of anthrones (rhein-9-anthrone is the
most important metabolite). As regards the time of transport to
the colon and metabolization into active compounds, Senna
extracts act within 8-12 hours.

• The laxative effect is based on the increased colonic
motility (leading to reduced fluid absorption), the
inhibition of absorption and stimulation of the secretion
of water and electrolytes.
Efficacy and indications
• - short-term use in cases of occasional constipation.
• For adolescents, adults and the elderly the daily dose
should contain 15–30 mg of hydroxy-anthracene
derivatives, calculated as sennoside B (to be taken once
daily at night). Normally, it is enough to take this
medicinal product up to two to three times a week. The
maximum daily dose of hydroxy-anthracene glycosides is
30 mg. The correct individual dose is the smallest amount
required to produce a comfortable soft formed motion.
• Senna leaves should only be used intermittently and if
other actions, such as behavioral modification, dietary
changes and the use of bulk-forming agents, have failed.

Aloe
• The active constituents of Barbados and Cape aloe are anthrone-10 C -glycosides (aloin A
and aloin B), named barbaloin, and some other anthranoid derivatives. Both drugs
contain aglycones (aloe emodin and chrysophanol) in small quantities.
• The anthranoid-glycosides of aloe are not absorbed in the upper gut. The intestinal flora
can break down O -glycosides fully, but C -glycosides (the major constituents of aloe)
only to a certain extent.
• Aloe-emodin is quickly oxidized to rhein. The absorbed aglycone is conjugated with
glucuronide in the liver and excreted via the urine and the bile.
• The mechanism of action of aloe includes a direct effect on the motility, leading to a
reduced transit time, inhibition of the absorption of water, Na+ and Cl-, and an increase
of the secretion of water and electrolytes into the lumen. The increase in volume of the
intestine content increases the intraluminal pressure, which also facilitates peristalsis.
Aloe-emodin-9-anthrone inhibits Na+/K+-ATPase and the Cl- channels and increases the
paracellular permeability of the colonic mucosa, and it therefore increases the water
content of the intestine. Possible mediators of the laxative effects are NO (an enteric
inhibitory neurotransmitter), platelet-activating factor (which stimulates the anion
secretion of the colon mucosa cells) and the prostaglandins. Anthranoids of aloe increase
the production of these transmitters.

• the short-term treatment of occasional constipation.
• Interestingly, there have been no clinical studies of aloe
mono-preparations for this specified indication. The
only available study was carried out on patients with
chronic constipation, in which a multicomponent
product composed of Celandine, Aloe and Psyllium was
used.
• The postulated laxative effect of aloe is on the basis of
pharmacological data gained with anthranoids and
clinical experience. For adolescents over 12 years of age
and adults, the daily dose should contain 10– 30 mg of
anthranoid derivatives, calculated as barbaloin, to be
taken once daily at night (if necessary, 2-3 times
weekly). Use for more than 1-2 weeks requires medical
supervision.

Side-effects, interactions & contraindications
• Porolonged use or an overdosage may lead to hypokalemia which may enhance the effects of cardiac glycosides and
interfere with the antiarrhythmic agents, inducing a QT-prolongation.
• This may be triggered by the concomitant application of medicines that induce hypokalemia (corticosteroids, certain
diuretics and liquorice).
• Anthranoids may induce hyperemia in the pelvic region through the neuromuscular stimulation of the uterine
muscles, which may lead to miscarriage or preterm birth.
• Moreover, aloe-emodin can induce mutagenic effects in vitro
• contraindicated for children under 12.
• Aloe is contraindicated in cases of intestinal obstruction and stenosis, inflammatory colon diseases, abdominal
pain of unknown origin, and a severe dehydration state with water and electrolyte depletion.
• The long-term administration leads to the development of pseudomelanosis coli (pigmentation of the colonic
mucosa) and in anatomic changes in the colon, characterized by the loss of haustral folds.
• the use of anthranoid-containing laxatives is associated with an increased risk of colorectal cancer, but constipation
itself and an improper diet may also contribute. Aloe preparations may lead to colicky abdominal pain, especially in
patients with an irritable colon. A
• yellow-to-brown discoloration of the urine may occur during the treatment (this is a result of the excretion of
anthranoid metabolites in the urine and it poses no health risk).

Cascara
• The pharmacologically active constituents of the bark are the anthranoids. The
major components are the cascarosides, which are anthrone C - and O -
glycosides. The total hydroxy-anthracene complex of the dried bark consists of
60-70% of cascarosides and 10–30% of aloins.
• During (heat) drying, the mono-anthrones and their O -glycosides, which cause
undesirable emetic effects, are oxidized to dianthrone- and anthraquinone O -
glycosides. Emodin-9-anthrone and chrysophanol anthrone are the most
important metabolites of genuine anthranoids, which are produced by the
intestinal bacteria.
• The mode of action of anthranoids is based on increasing the colonic motility,
thereby reducing the transit time and fluid. The absorption of water and
electrolytes (Na+and Cl-) is decreased, whereas the leakiness of the tight
junctions and secretion of water and electrolytes into the lumen are
augmented. Cascara ex vivo significantly increases Ca2+-dependent constitutive
NO synthase activity in the rat colon, and this may also be involved in the
laxative effect.

• The efficacies of 15 mg of gluco-frangulin, 5 mg of
bisacodyl and 0.1 g of a water-soluble glucoside extract
from cascara were compared in a randomized double-
blind crossover trial. Within a period of 3 weeks, patients
with chronic constipation were treated consecutively for 5
days with each laxative. Gluco-frangulin was shown to be
most effective in cases of severe constipation; in moderate
cases, the effectiveness of the three test preparations did
not differ significantly. The amount, consistency and color
of the feces did not show any considerable differences.
Several further studies, with a positive outcome were
carried out with combination products. With regard to the
well-established efficacy of anthranoids and the clinical
data on cascara, this plant may be applied within the
frame of well-established use therapy with the following
indication: short-term use in cases of occasional
constipation. The daily dose should contain 10-30 mg of
hydroxy-anthracene derivatives, calculated as cascaroside
A, to be taken once daily at night. Normally, it is enough to
take it 2 or 3 times a week.

• The use of cascara is contraindicated in cases of hypersensitivity, intestinal
obstruction, stenosis, atony, appendicitis, inflammatory colon diseases (e.g.
Crohn’s disease or ulcerative colitis), abdominal pain of unknown origin, or
a severe dehydration state with water and electrolyte depletion.
Hypokalemia (resulting from long-term laxative abuse) potentiates the
action of cardiac glycosides and interacts with antiarrhythmic medicinal
products, medicinal products which induce reversion to a sinus rhythm (e.g.
quinidine) and medicinal products inducing a QT prolongation.
Concomitant use with other medicinal products that induce hypokalemia
(e.g. diuretics, corticosteroids or liquorice root) may enhance an electrolyte
imbalance. Long-term use should be avoided. If stimulant laxatives such as
cascara are taken for longer periods, this may lead to an impaired function
of the intestines and a dependence on laxatives. Cascara preparations
should be used only if a therapeutic effect cannot be achieved by a change
of diet orthe administration of bulk-forming agents. Cascara may produce
abdominal pain and spasms and the passage of liquid stools, in particular in
patients with an irritable colon. Chronic use may cause pigmentation of the
intestinal mucosa (pseudomelanosis coli), which usually recedes when the
patient stops taking the preparation. Yellow or reddish-brown (pH-
dependent) discoloration of the urine by metabolites, which is not clinically
significant, may occur during the treatment. There have been no reports of
undesirable or damaging effects during pregnancy or on the fetus when
used at the recommended dosage. However, as a consequence of
experimental data indicative of a genotoxic risk of several anthranoids, use
is not recommended during pregnancy. Use during breastfeeding is not
recommended as there are insufficient data on the excretion of
metabolites in the breast milk.

Frangula
• The pharmacologically active constituents of Frangula bark are
emodin-di- (glucofrangulins) and monoglycosides
(frangulins). lt also contains small amounts of aglycones
(emodin and emodin-9-anthrone).
• The glucofrangulins are present in the fresh bark in reduced
form, and in the stored bark in oxidized form. The reduced
forms are presumed to be responsible for the gastrointestinal
side-effects seen in the stomach after oral administration.
Emodin-9anthrone, the most important metabolite, is produced
by the bacteria of the large intestine. The mode of action of the
anthranoids is based on increasing the colonic motility, thereby
reducing the transit time and fluid. The absorption of water and
electrolytes (Na+and Cl-) is decreased, whereas the leakiness of
the tight junctions and the secretion of water and electrolytes
into the lumen are augmented. The administration of a
methanolic extract of Frangula bark to mice resulted in a dose-
dependent decrease of the intestinal transit time.

• The application of this plant within the frame of well-
established use therapy in short-term use in cases of
occasional constipation.
• The daily dose should contain 10-30 mg of hydroxy-
anthracene derivatives, calculated as gluco-frangulin
A, to be taken once daily at night. Normally, it is
enough to take it 2 or 3 times a week.

• The use of Frangula is contraindicated in cases of hypersensitivity, intestinal obstructions, stenosis,
atony, appendicitis, inflammatory colon diseases (e.g. Crohn’s disease or ulcerative colitis),
abdominal pain of unknown origin, or a severe dehydration state with water and electrolyte
depletion. Hypokalemia (resulting from long-term laxative abuse) potentiates the action of cardiac
glycosides and interacts with antiarrhythmic medicinal products, medicinal products which induce
reversion to a sinus rhythm (e.g. quinidine) and medicinal products inducing a QT prolongation.
Concomitant use with other medicinal products inducing hypokalemia (e.g. diuretics,
corticosteroids or liquorice root) may enhance an electrolyte imbalance. Long-term use should be
avoided. If stimulant laxatives such as Frangula are taken for longer periods, this may lead to an
impaired function of the intestines and a dependence on laxatives. It should be used only if a
therapeutic effect cannot be achieved through a change of diet or the administration of bulk-
forming agents. Frangula may produce abdominal pain and spasm and the passage of liquid stools,
in patients with an irritable colon. Chronic use may cause pigmentation of the intestinal mucosa
(pseudomelanosis coli), which usually recedes when the patient stops taking the preparation.
Yellow or reddish-brown (pH-dependent) discoloration of the urine by metabolites, which is not
clinically significant, may occur during the treatment.
• There are no reports of undesirable or damaging effects during pregnancy or on the fetus when
used at the recommended dosage. However, because of experimental data indicative of a
genotoxic risk of several anthranoids, use is not recommended during pregnancy. Use during
breastfeeding is not recommended as there are insufficient data on the excretion of metabolites in
the breast milk.

Rhubarb
• Rhubarb roots contain 3-12% of hydroxyanthracene
derivatives, mainly comprising anthraquinone mono- and
diglycosides (55-80%), and dianthrone glycosides (sennosides,
10-20%); aglycones and anthrone glycosides are present in
only small amounts. Rhubarb also contains a noteworthy
amount (5%) of gallotannins.
• The mode of action of the anthranoids is based on increasing
the colonic motility, thereby reducing the transit time and
fluid. The absorption of water and electrolytes (Na+and Cl-) is
decreased, whereas the leakiness of the tight junctions and
the secretion of water and electrolytes into the lumen are
augmented. Tannins may counteract the laxative effect of the
anthraquinones, and rhubarb is therefore considered to be a
milder laxative than other anthraquinone-containing plants.

• Although there are no convincing clinical findings
concerning Rheum mono-preparations, in view of
the results gained with combination products and
the knowledge on the mechanisms of action of
anthranoids, this plant may be applied in therapy in
short-term use in cases of occasional constipation.
• The daily dose should contain 10-30 mg of hydroxy-
anthracene derivatives, calculated as rhein, to be
taken once daily at night. It is normally enough to
take it 2 or 3 times a week.

• The use of Rheum is contraindicated in cases of hypersensitivity, intestinal
obstruction and stenosis, atony, appendicitis, inflammatory colon diseases
(e.g. Crohn’s disease or ulcerative colitis), abdominal pain of unknown
origin, or a severe dehydration state with water and electrolyte depletion.
Hypokalemia (resulting from long-term laxative abuse) potentiates the
action of cardiac glycosides and interacts with antiarrhythmic medicinal
products, medicinal products which induce reversion to a sinus rhythm (e.g.
quinidine) and with medicinal products inducing a QT prolongation.
Concomitant use with other medicinal products inducing hypokalemia (e.g.
diuretics, corticosteroids or liquorice root) may enhance an electrolyte
imbalance. Long-term use should be avoided. If stimulant laxatives such as
rhubarb are taken for longer period of treatment, this may lead to an
impaired function of the intestines and dependence on laxatives. Rhubarb
preparations should be used only if a therapeutic effect cannot be achieved
through a change of diet or the administration of bulk-forming agents.
Rheum may produce abdominal pain and spasm and the passage of liquid
stools, in patients with an irritable colon. Chronic use may cause
pigmentation of the intestinal mucosa (pseudo-melanosis coli), which
usually recedes when the patient stops taking the preparation. A yellow or
reddish-brown (pH-dependent) discoloration of the urine by metabolites,
which is not clinically significant, may occur during the treatment. There
have been no reports of undesirable or damaging effects during pregnancy
or on the fetus when used at the recommended dosage. However, because
of experimental data indicating a genotoxic risk of several anthranoids, use
is not recommended during pregnancy. Use during breastfeeding is not
recommended as there are insufficient data on the excretion of metabolites
in the breast milk.

Examples of formulae used for treatment of constipation:
• Chamomile flowers Caraway seeds 20 g
• Fennel fruits Peppermint leaves 30 g
• Frangula barks Senna leaves 10 g
• Senna leaves Frangula barks 30 g
equal parts to make 100 g
• 1-2 teaspoons added to a cup of boiling water, leave to infuse for 10
minutes, to be taken at night.
For spastic constipation with flatulence:
• Caraway oil 2 ml
• Frangula fluid extract 6 ml
• Fennel tincture 8 ml
• Belladonna tincture to make 30 ml

3- OSMOTIC LAXATIVES
Fenugreek
• Fenugreek seeds contain 30-45 % of galactomannan-type polysaccharides, saponins
(about 1%), proto-alkaloids, including trigonelline, sterols and flavonoids.
• Most of the preclinical trials focused on the blood glucose-lowering effect of fenugreek
seeds. Fenugreek seeds and water and ethanol extracts exerted a hypoglycemic effect in
normal and in diabetic rats and other animal species. It is supposed that fenugreek
polysaccharides decrease the intestinal glucose absorption. Some studies indicated the
potential stimulation of pancreatic insulin secretion. Inhibition of intestinal glycosidases
may also play a role. More recent studies concluded that fenugreek increases the
translocation of glucose transporter GLUT4 to the cell surface. However, what is quite
clear from the available data is that the whole seeds and polar extracts are active, while
the apolar extracts are void of hypoglycemic activity.
• The hypolipidemic effect of fenugreek has also been thoroughly investigated. In animals
with normal lipid levels, the contents of total cholesterol, VLDL and LDL were decreased.
The impact on HDL levels is contradictory. This activity may be related to the
polysaccharides and saponins of the seeds.

• On oral use, close of glycemic control monitoring should be
considered in patients with diabetes mellitus due to the possible
hypoglycemic effect of fenugreek.
• Gastrointestinal disorders (flatulence and diarrhea) and
dizziness may also occur. In cases of cutaneous use, allergic
reactions have been reported (facial angioedema and wheezing).
• There are not many adverse events associated with the use of
fenugreek. Mild gastrointestinal symptoms such as: increased
flatulence, nausea, fullness and diarrhea are adverse events
reported in clinical trials. Reduction of serum potassium levels
and allergic reactions have also been reported. The drug is
contraindicated during pregnancy. There is a potential for
fenugreek to exaggerate the effect of concomitantly
administered hypoglycemic drugs.
• Preparations & Dosage: The daily internal dose of the crude
drug is 6g. Whole and powdered drug is available in the form of
teas and compound preparations. Aqueous extract (2.8 g/daily)
and powder have been used in clinical studies.

Nausea and Vomiting
‘Travel sickness’ or ‘motion sickness’ is particularly common
in children and is caused by the repetitive stimulation of the
labyrinth of the ear. It is most common when travelling by
sea, but also happens in cars, aeroplanes and when horse-
riding. Vomiting, nausea, dizziness, sweating and vertigo
may occur. Prophylactic treatment includes the use of
antihistamines (mainly phenothiazines) and cinnarizine, and
natural compounds such as the antimuscarinic alkaloid
hyoscine, found the Solanaceae family. Morning sickness of
pregnancy is also common but few (if any) synthetic drugs
are licensed for such a use because of fears of toxicity to the
unborn child. Ginger can be a useful anti-emetic for this
condition, as well as for travel sickness.
• - Ginger previously discussed

1- Garlic:
• It is a successful treatment for dysentery, diarrhea,
diphtheria, tuberculosis, whooping cough, typhoid,
hepatitis and even worms and anti-cancer effect on the
gastro-intestinal tract.
• Garlic enemas are used as anthelemintic, against
round worm, hook worms, thread worms and pin
worms (Oxyuris).
(a warm tea should be taken in conjunction with the
enema to stimulate the bowel activity to expel the
worms to the lower bowel .)

2- Carrots (Daucus carota L.)
• It is used as a safe treatment for thread worms.
3- Quassia
• Quassia extract (as enema) has been used to expel thread worms.
4- Santonica [Artemisia cinae F. Asteraceae]
• It contains Santonin, it is anthelmintic for round worms which are
expelled rapidly (less effective on thread worms, no effect on tape
worms).

5- Pomegranate bark [Punica granatum F. Punicaceae]
• It contains liquid alkaloids e.g. : Pelletierine, Iso-pelletierine,
methyl pelletierine and Iso-methyl pelletierine, and crystalline
alkaloid: pseudo-pelletierine .
• Also, it contains gallo-tannic acid.
• The bark has anthelmintic effect on tape worms.

• Liver cirrhosis (cell destruction and increase in
fibrous tissue).
• Acute, chronic hepatitis (inflammatory disease).
• Hepatitis (non-inflammatory condition).
• Jaundice (yellow discoloration of the skin and eyes)
caused by bile in the blood .

Tumeric
• The most characteristic components of Curcuma are
the yellow Curcuminoids (1-5%), which are present
as a mixture of di-cinnamoyl methane derivatives
such as curcumin as the main component. It also
contains volatile oil (3-10 %), composed mainly of
sesquiterpenes (e.g. xanthorrizol).

• Curcumae longae rhizome, a traditional use monograph has been
prepared with the indication of:
• - increasing the bile flow for the relief of symptoms of indigestion
(such as a sensation of fullness, flatulence, and slow digestion).
• For this purpose, the daily dose of the herbal substance (either as
powdered rhizome or as tea) is 1.5-3 g. Tinctures may be used in a
dose of 1.5-3 ml (1:10) or 10 ml (1:5) daily. The daily doses of the
different dry extracts range from 80 to 400 mg
• Side-effects, interactions & contraindications
• Curcumin and turmerone inhibit arachidonic acid-induced platelet
aggregation with IC50 values like that of acetyl salicylic acid.
Curcumin is a potent inhibitor of certain cytochrome P450 enzymes,
and in therapeutic doses the development of interactions is not
probable. Because of its possible stimulation of bile secretion, not
recommended in cases of obstruction of the bile duct, cholangitis,
liver disease, gallstones and any other biliary diseases.
• Mild gastrointestinal symptoms such as dry mouth, flatulence and
gastric irritation may occur. The safety of its therapeutic application
(which may involve the use of higher doses than as a spice) during
pregnancy and lactation has not been established.

Artichoke
• Chemical composition and mechanism of action
• The bitter taste of artichoke leaves is primarily due to the
Cynarin content. This constituent can be found in highest
concentration in the leaves. Cynarin belongs among the
phenolic acids, which constitute up to 2% of the dry weight.
Further important members of this chemical group are
chlorogenic acid and caffeic acid. Artichoke contains bitter
sesquiterpene lactones with cynaropicrin as the
predominant constituent, and a low amount of flavonoids.

- In one double-blind placebo-controlled cross-over clinical trial on 20 male volunteers
with acute or chronic metabolic disorders, the choleretic effect of a single dose of an
artichoke product was investigated. The bile secretion was 127% higher at 30 minutes
after administration, 150% after 60 minutes (the maximum effect) and 94% after 90
minutes (compared to the placebo group).
- In a multicentric open study with patients with dyspeptic complaints, 960-1920 mg of
artichoke extract daily resulted in a significant decrease of the digestive complaints
within 6 weeks of treatment. As compared with the initial values, the subjective score
reduction was approximately 66% for meteorism, 76% for abdominal pain, 82% for nausea
and 88% for emesis. In a subgroup of 302 patients, the total cholesterol level decreased by
11.5% and that of triglycerides by 12.5%. In a subgroup analysis, there was a significant
fall in the incidence of irritable bowel syndrome after treatment. A significant shift in self-
reported usual bowel pattern away from "alternating constipation/diarrhea" toward
"normal" was also observed.

- In a double-blind, randomized placebo-controlled trial with patients with functional dyspepsia, the overall
symptom improvement over the 6 weeks of treatment was significantly greater with artichoke leaf extract
than with the placebo. Blood lipid and cholesterol-lowering effects of artichoke have been reported in a
series of trials. In a randomized double-blind, placebo-controlled study, the lipid lowering effects of an
artichoke leaf extract were investigated in healthy volunteers over 12 weeks. The cholesterol level was not
significantly different after treatment with the extract as compared with placebo, but significant
efficacy in triglyceride level reduction was confirmed. In a study involving healthy elderly
subjects, decreases in cholesterol and triglyceride levels were observed after the administration of 0.45-0.9
g of artichoke extract daily for 6 weeks. In a comparative study, the efficacy of the artichoke extract was
compared with that of cynarin. The effects on the total lipid and triglyceride levels were similarly favorable
in both cases. In a multicentric, randomized, placebo-controlled, double-blind, 6-week study, the effect of
1.8 g of artichoke leaf dry extract was investigated in patients with hyperlipoproteinemia. In the verum
group, the reductions of total cholesterol (18.5%) and the LDL-cholesterol (23%) were significantly superior
to those in the placebo group (9% and 6%, respectively).

• On the basis on the traditional application of the
plant, the European Medicines Agency granted a
traditional use monograph for artichoke with the
indication of the symptomatic relief of digestive
disorders such as dyspepsia with a sensation of
fullness, bloating and flatulence.
• The posology is 6 g of the comminuted herbal
substance as a herbal infusion daily or 600-2400 mg of
dry or soft extract daily.

Side-effects, interactions & contraindications
• The use of the plant is contraindicated in cases of
hypersensitivity to artichoke or to plants of the
Asteraceae family, obstruction of the bile ducts,
cholangitis, gallstones and any other biliary diseases
or hepatitis.
• As adverse effects, slight diarrhea with abdominal
spasms, epigastric complaints such as nausea, and
heartburn have been reported.

Dandelion
• The root of the plant is rich in inulin, the amount of
which is highest in the autumn (up to 40%).
• The sesquiterpenes in the roots belong in the
eudesmanolides and guaianolides.
• It contains sterols, such as taraxasterol and its
derivatives, and a wide variety of phenolic acids.
• The leaves contain appreciable amounts of phenolic
acids and flavonoids, and their potassium salt content is
markedly high (up to 4%).

- The diuretic action of dandelion herb has been observed
in animal experiments. The efficacy of aqueous extracts
obtained from dandelion leaves was more pronounced
than that of those from the root extracts.
- Its saluretic effect may be due to the high potassium
salt content of the plant.
- The choleretic effect of the leaves has been confirmed
in different animal species.
- The extracts of leaves and roots proved to possess anti-
inflammatory activity in different experimental settings.
The extract of the plant inhibited ADP-induced human
platelet aggregation in vitro.
- In animal experiments, the extracts of the plant exerted
a glucose level-lowering effect. This may be a result of
the inulin content and the moderate alpha-amylase and
alpha-glucosidase-inhibitory activities.

• Traditional herbal use for the relief of symptoms related
to mild digestive disorders (such as a feeling of
abdominal fullness, flatulence, and slow digestion) and a
temporary loss of appetite, and to increase the amount of
urine to achieve flushing of the urinary tract as an
adjuvant in minor urinary complaints. With this
indication, the comminuted dried root with herb should
be used, 3-4 g as a decoction or 4-10 g as an infusion, up
to 3 times daily. Several dry and liquid extracts are also
included in the monograph. For the first indication,
expressed juice from the fresh flowering herb with root
may also be applied (10 ml, 3 times daily). For the leaves,
the use as a diuretic acceptable.
• The daily dose of the leaves is 4-10 g as an infusion, 3
times daily. The expressed juice from the fresh leaves can
be used in a dose of 10-20 ml daily.

Side effects, Interactions & Contraindications
• In cases of bile duct obstructions, cholangitis, liver
diseases, gallstones, active peptic ulcer and any other
biliary disease, or hypersensitivity to the plant or other
species of the Asteraceae family, its use is
contraindicated.
• Its use in patients with renal failure or heart failure
should be avoided because of the possible risks due to
hyperkalemia. If it is used as a diuretic, an adequate
fluid intake is required to ensure an increased amount
of urine.
• Its use in children under 12 years of age and during
pregnancy and lactation has not been established due
to lack of adequate data.
• Epigastric pain and hyperacidity may occur as adverse
effects.

Milk thistle
• From a therapeutic point of view, the most important
secondary metabolites of milk thistle are the
flavonolignans (1.5-3%, with silibinin and isosilibinin,
silicristin and silidianin as main constituents).
• The fruit contains flavonols (taxifolin, quercetin and
kaempferol) and flavones (apigenin and chrysoeriol) and
phytosterols. Its fatty oil content is 20-30%, with linoleic
and oleic acid as main components.

• The only contraindication is hypersensitivity to this or
other plants of the Asteraceae family.
• Its use is not recommended in children and adolescents
below 18 years of age, or for pregnant or lactating
women, due to the lack of data on safety and efficacy.
• Mild gastrointestinal symptoms such as dry mouth,
nausea, gastric irritation and diarrhea, headache and
allergic reactions (urticaria, skin rash, pruritus,
anaphylaxis, asthma) may occur.

Phytotherapy 4-5

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