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Herbal Medicine and the Gastrointestinal System

HERBAL MEDICINE AND THE GASTROINTESTINAL SYSTEM..................1


THE SOURCE OF ALL ILLNESS............................................................................5
Digestion & Asthma ..............................................................................................6
Digestion & Skin....................................................................................................6
HCL, HERBS & SPICES ............................................................................................6
DIGESTIVE BITTER FORMULATION ..............................................................................7
HERBS FOR THE GIT...............................................................................................8
MAIN CATEGORIES .....................................................................................................8
Bitter herbs.............................................................................................................8
Carminative herbs ..................................................................................................8
Anti-inflammatory herbs........................................................................................8
Sedative herbs ........................................................................................................8
Liver herbs .............................................................................................................8
SELECECTED MONOGRAPHS ............................................................................10
DIETARY FIBRE .........................................................................................................10
Soluble Fibre........................................................................................................10
Insoluble Fibre .....................................................................................................10
Resistant Starch....................................................................................................10
What are the benefits?..........................................................................................10
Fibre for young and old........................................................................................10
Getting the most out of your fibre........................................................................10
Ways to increase the fibre in your daily diet .......................................................11
SLIPPERY ELM (ULMUS RUBRA/ ULMUS FULVA) .......................................................11
CHAMOMILE .............................................................................................................12
Other actions ........................................................................................................15
Clinical use...........................................................................................................16
Other Uses............................................................................................................17
Dosage range........................................................................................................18
External application .............................................................................................18
Adverse reactions.................................................................................................18
Significant interactions ........................................................................................18
Practice points/patient counselling ......................................................................19
Answers to patients frequently asked Questions .................................................19
PEPPERMINT ..............................................................................................................24
Description...........................................................................................................24
Latin binomial/class .............................................................................................24
Plant part used......................................................................................................24
Chemical components..........................................................................................24
Main actions.........................................................................................................24
Clinical use...........................................................................................................26

 Michael Thomsen
Other uses.............................................................................................................29
Dosage range........................................................................................................29
Adverse reactions.................................................................................................30
Significant interactions ........................................................................................30
Contraindications and precautions.......................................................................31
Pregnancy use ......................................................................................................31
Practice points/patient counseling........................................................................31
Answers to patients’ frequently asked Questions ................................................31
References............................................................................................................32
GINGER .....................................................................................................................35
Historical note......................................................................................................35
Scientific name.....................................................................................................35
Other names .........................................................................................................35
Plant part used......................................................................................................35
Chemical components..........................................................................................36
Main actions.........................................................................................................36
Clinical use...........................................................................................................39
Musculoskeletal disorders....................................................................................41
Other uses.............................................................................................................42
Dosage range........................................................................................................42
Adverse reactions.................................................................................................42
Significant interactions ........................................................................................42
Contraindications and precautions.......................................................................42
Pregnancy use ......................................................................................................43
Practice points/patient counseling........................................................................43
Answers to patients’ frequently asked Questions ................................................43
References............................................................................................................43
PROBIOTICS – TO IMPROVE INTESTINAL FLORA .........................................................50
Historical note......................................................................................................50
Background and relevant pharmacokinetics ........................................................50
Clinical note – Prebiotics .....................................................................................51
Clinical note – The hygiene hypothesis ...............................................................51
Chemical components..........................................................................................52
Food sources ........................................................................................................52
Deficiency signs and symptoms...........................................................................52
Main actions.........................................................................................................52
Clinical use...........................................................................................................53
Urogenital infections............................................................................................55
Irritable bowel syndrome (IBS) ...........................................................................56
Inflammatory bowel diseases...............................................................................56
Helicobactor pylori infection...............................................................................57
Other uses.............................................................................................................57
Dosage range........................................................................................................59
Clinical note – dosage forms tailored to increase probiotic survival...................59

 Michael Thomsen
Adverse reactions.................................................................................................59
Contraindications and precautions.......................................................................59
Pregnancy use ......................................................................................................60
Practice points/patient counseling........................................................................60
Answers to patients’ frequently asked Questions ................................................60
HERBAL THERAPY OF GIT DISORDERS.........................................................65
MOUTH ULCERS ........................................................................................................65
Mouth Ulcers: Sample formulation ....................................................................65
NAUSEA ....................................................................................................................65
GASTRO-OESOPHAGEAL REFLUX (GER) ..................................................................66
Herbs for GER .....................................................................................................66
PEPTIC ULCER ...........................................................................................................66
Herbal Treatment for Ulcers ................................................................................67
Gastric Ulcer : Sample Formulation ....................................................................67
Duodenal Ulcer : Sample Formulation................................................................67
IRRITABLE BOWEL SYNDROME .................................................................................68
Treatment of IBS..................................................................................................68
IBS: Sample Formulation ....................................................................................68
Faeces Report.......................................................................................................69
INTESTINAL INFECTIONS: SAMPLE FORMULATION ....................................................69
ACUTE DIVERTICULITIS: SAMPLE FORMULATION ....................................................69
HERBAL TREATMENT OF CONSTIPATION...................................................................70
Constipation: Sample Formulation .....................................................................70
HAEMORRHOIDS .......................................................................................................70
INFLAMMATORY BOWEL DISEASE ............................................................................71
Ulcerative Colitis: Sample Formulation .............................................................71
Case: ulcerative colitis .........................................................................................71
History..................................................................................................................71
Treatment and rationale .......................................................................................72
Crohn’s Disease: Sample Formulation ...............................................................73
COELIAC DISEASE AND GLUTEN SENSITIVITY ..........................................................73
Symptoms of CD..................................................................................................73
LIVER DISORDERS.................................................................................................76
LIVER DETOXIFICATION ............................................................................................76
Liver Toxins & Disease .......................................................................................76
Processing of Toxins by the Body .......................................................................76
Beneficial Action of Herbs to the Liver...............................................................76
Biotransformation of Toxins by the Liver ...........................................................76
Phase I Reactions .................................................................................................76
Phase II Reactions................................................................................................77
Bioactivation ........................................................................................................77
Phase l & ll Balance.............................................................................................77
IMPORTANT LIVER HERBS.........................................................................................77
Schisandra chinensis ............................................................................................77

 Michael Thomsen
Curcuma longa (Turmeric) ..................................................................................77
Silybum marianum...............................................................................................78
DIETARY FACTORS....................................................................................................78
The Brassicas .......................................................................................................78
POOR LIVER FUNCTION & GALL STONES..................................................................78
ACUTE VIRAL HEPATITIS ..........................................................................................79
CHRONIC VIRAL HEPATITIS ......................................................................................79
CIRRHOSIS OF THE LIVER ..........................................................................................79

 Michael Thomsen
The source of all illness
There is a common saying amongst natural therapists that “all disease begins in the
gut”. This is because many seemingly unrelated diseases such as autoimmune
disorders, skin diseases, and even chronic fatigue syndrome have their origin in
gastrointestinal disorders.
Gut health may be key to allergy prevention
- Changes in gut microflora caused by widespread use of antibiotics and
17/01/2005
today’s high-fat, low-fibre diet could be responsible for a major increase in allergies in
recent years, say researchers.

A US team is the first to link gut health to an allergic response in the lung.

Their results, published in the current issue of Infection & Immunity (73, pp30-38), show that
changes in the gut microflora of mice following antibiotic use caused an overzealous allergic
response.

The findings have implications for foods and supplements that can help balance gut health,
already worth some £111 million in the UK alone during 2002, and forecast by Datamonitor to
reach £159.3 million by 2007.

“Our research indicates that microflora lining the walls of the gastrointestinal tract are a major
underlying factor responsible for the immune system's ability to ignore inhaled allergens,” said
Gary Huffnagle, an associate professor of internal medicine and of microbiology and
immunology at the University of Michigan.

“Change the microflora in the gut and you upset the immune system's balance between
tolerance and sensitization.”

To test their hypothesis, Huffnagle and colleagues gave normal Balb/C laboratory mice a five-
day course of antibiotics, which killed their gut bacteria, followed by a single oral introduction of
the yeast Candida albicans. Increased growth of C. albicans in the gut is a common side-effect
of antibiotics.

After stopping the antibiotics, they inserted ovalbumin – a commonly used experimental
allergen derived from egg whites – via the nasal cavities of all the mice in the study.

The antibiotic-treated mice showed increased airway hypersensitivity to ovalbumin compared to


mice that had not received antibiotics.

The results confirmed previous experiments, in which the researchers used a genetically
different strain of laboratory mice [C57BL/6] and a different type of allergen – mold spores -
instead of ovalbumin.

This research, published in the August issue of the same journal, was the first study linking
changes in GI tract microflora to an allergic response in the lung.

“In our new study, we found that differences in host genetics and the type of allergen used
didn't matter. The immune responses were literally identical,” Huffnagle said.

“It confirms our earlier findings that gut microflora are the key to maintaining a balanced
immune response, that changing the composition of microflora in the gut predisposes animals to
allergic airway disease, and that allergic sensitization can occur outside the lungs.”

Over the last few decades, asthma and allergies have increased significantly throughout Europe,
with an average 10 per cent of children now suffering from asthmatic symptoms. But in western
Europe, the symptom rate is up to ten times that in eastern countries.

 Michael Thomsen
For 1995-1996, the International Study of Asthma and Allergies in Childhood (ISAAC) found
prevalence of self-reported asthma symptoms in children aged 13–14 years at 2.6–4.4 per cent
in Albania, Romania, Georgia, Greece and the Russian Federation. But these rates reached 32
per cent in Ireland and the United Kingdom. This suggests that a western lifestyle is associated
with allergic diseases in childhood.

“If lungs are repeatedly exposed to an allergen, regulatory T cells learn to recognize the
allergen as not dangerous and something that can be safely ignored,” Huffnagle said.

“Most researchers think that tolerance develops in the lungs, but we believe it actually occurs in
the gut. When immune cells in the GI tract come in contact with swallowed allergens, that
interaction triggers the development of regulatory T cells, which then migrate to the lungs.”

The researchers believe that dietary changes like taking antibiotics, switching from breast milk
to formula, or eating a high-sugar, low-fat diet can impact tolerance.

“One short course of antibiotics is not going to give everyone allergies,” Huffnagle explained.
“But if you are taking antibiotics while your diet consists of white bread and fried food, you are
not going to maintain the healthy microflora balance you need to maintain tolerance. If you
inhale mold spores or pollen during this period, our studies indicate you are much more likely to
become sensitized to them.”

The researchers are planning to investigate whether changing only the diet of the experimental
mice will alter gut microflora and change the immune response to allergens in the same way as
antibiotics.

They will also look at how probiotic supplements can affect this microbial balance.

Source: NutraIngredients [newsletter@NutraIngredients.com]


Digestion & Asthma
In some circumstances asthma is related to disorders of upper gastrointestinal
function, as vagal stimulation is connected to broncho-constriction. 36 to 80% of
asthmatics have been shown to have low HCl, whereas only 20% of non-asthmatics
have low HCl. Therefore giving bitter tonics to improve digestion and absorption of
nutrients is a useful protocol to employ as an adjunct in the treatment of asthma.
Other respiratory disorders may also be linked to poor digestion. In addition to the
bitter tonics, Slippery Elm bark which is high in mucilage and has a soothing effect on
the GIT, has been shown to have a reflex action on the lungs.
Digestion & Skin
Most herbalists will begin the treatment of skin disorders by treating both the GIT and
the liver. For example, acne rosacea has also been shown to be associated with low
HCl as well as poor oral hygiene, oral infection, tonsillitis, and decreased pancreatic
lipase with fat intolerance. Chronic low HCl and low pancreatic enzymes have also
been linked to dermatitis and eczema.

HCl, Herbs & Spices


Herbalists focus on the upper digestion, ie. the mouth and stomach, or the lower
intestinal GIT, or in some cases both. Such protocol would include improving vagal
stimulation which:
• increases HCl
• increases pepsin
• increases gall-bladder motility
• primes pancreatice enzymes.

 Michael Thomsen
The use of bitter tonics on to the tongue stimulates the vagus nerve. The hormone
gastrin stimulates HCl and pepsin. Additionally the level of HCl has been shown to
decline with age. Most menopausal women demonstrate decreased HCl. Herbal
bitters and digestive tonics are especially useful in treating elderly patients.
Bitter tonics increase gastrin, tighten the cardiac sphincter, increase cholegogue
activity (ie increase bile flow from the gall bladder), improve vagal stimulation by
their bitter taste, and thereby increase HCl. Aromatic spices such as Ginger,
Cardamom, Cinnamon and Cayenne increase gastrin and lipase. The herb Coleus has
been shown to increase pancreatic digestion, pancreatic enzymes and HCl. Capsicum
may stimulate gastric activity by vagal stimulation or may activate H2 receptors.
Angelica and Vervain are also bitter herbs but milder tasting and therefore may be
useful when treating children.
Alcohol increases gastric acid and gastrin, therefore herbalists often use aromatic and
bitter herbs in alcohol. The mixture is best sipped slowly before meals. In gastric
hyperacidity a herbalist would also employ mucous membrane tonics and anti-
inflammatory herbs with the bitter tonics. This would therefore normalise gastric
secretion. Generally speaking, a herbalist will try to maximise production and release
of gastric enzymes rather than giving these in tablet form.
Digestive Bitter Formulation
Gentiana lutea (Gentian) 1:5 10 mL
Coleus forskohlii (Coleus) 1:1 65 mL
Zingiber officinale (Ginger) 1:2 25 mL
Total 100 mL
Dose: 2 mL with water 20 minutes before meals. Best results are obtained if the bitter
taste is experienced on the tongue - this is where vagal stimulation occurs.

 Michael Thomsen
Herbs for the GIT
Main Categories
Bitter herbs
Bitter herbs, eg. Gentian, at low doses can increase lower oesophageal sphyncter
(LOS) tone and improve gastric emptying.
Carminative herbs
Carminative herbs and essential oils in high doses will aggravate GER by reducing
LOS tone, but they may be indicated in the treatment of functional dyspepsia. Given
in lower doses they can improve gastrointestinal motility.
• Anethum graveolens (dill)
• Angelica archangelica (archangelica)
• Chamomilla recutita (chamomile)
• Cinnamomum zeylanicum (cinnamon quills)
• Foeniculum vulgare (fennel)
• Melissa officinalis (lemon balm)
• Mentha x piperita (peppermint)
• Nepeta cataria (catmint)
• Pimpinella anisum (aniseed)
Anti-inflammatory herbs
Anti-inflammatory herbs such as Filipendula ulmaria (Meadowsweet), Stellaria
media (Chickweed), Calendula (Marigold) and Matricaria chamomila (Chamomile)
are of benefit. Chickweed is high in mucilage, and it can also be given as a fresh juice
in the treatment of gastric ulceration.
Sedative herbs
Sedative herbs or nervine tonics would be indicated as stress is usually a contributing
factor. These may include Valeriana spp (Valerian), Piper methysticum (Kava) and
Scutellaria lateriflora (Skullcap).
Liver herbs
Hepatoprotective
• Andrographis paniculata (andrographis)
• Angelica sinensis (dong quai)
• Bupleurum falcatum (bupleurum)
• Curcuma longa (turmeric)
• Cynara scolymus (globe artichoke)
• Panax ginseng (korean ginseng)
• Phyllanthus amarus (phyllanthus)
• Picrorrhiza kurroa (picrorrhiza)
• Salvia miltiorrhiza (dan shen)
• Schisandra chinensis (schizandra)
• Silybum marianum (St. Mary’s thistle)

 Michael Thomsen
Hepatorestorative
• Cynara scolymus (globe artichoke)
• Silybum marianum (St. Mary’s thistle)

Hepatotonic
• Andrographis paniculata (andrographis)
• Berberis aquifolium (oregon grape )
• Berberis vulgaris (barberry)
• Bupleurum falcatum (bupleurum)
• Cynara scolymus (globe artichoke)
• Panax ginseng (korean ginseng)
• Peumus boldus (boldo)
• Phyllanthus amarus (phyllanthus)
• Picrorrhiza kurroa (picrorrhiza)
• Salvia miltiorrhiza (dan shen)
• Schisandra chinensis (schizandra)
• Silybum marianum (St. Mary’s thistle)
• Taraxacum officinale radix (dandelion root)

 Michael Thomsen
Selecected Monographs
Dietary Fibre
By Melanie Koeman, Naturopath and former technical writer for Nutrimedicine.

Dietary fibre is essential for health. It is found only in plant foods – animal foods such
as meat, cheese and eggs have no fibre. There are two major types - soluble and
insoluble.
Soluble Fibre
Soluble fibre is often described as mucilaginous or slippery, since it has the capacity
to absorb and carry lots of water. This fibre can help lower LDL ('bad') cholesterol,
while maintaining the HDL ('good') cholesterol and help constipation and irritable
bowel. Soluble fibre is found in fruit and vegetables, some cereals (e.g. oats, barley),
psyllium, linseed, slippery elm and in legumes (dried peas, beans and lentils).
Insoluble Fibre
Insoluble fibre is often described as ‘roughage’. This fibre is more resistant to
digestion, and is fermented by bacteria to produce special fatty acids for the health of
the gut wall. Insoluble fibre is found mainly in wholegrain foods (especially wheat
bran and rice bran), the skins of fruits and vegetables, nuts and dried beans. It helps
prevent constipation by producing bulky stools.
Both types of fibre are beneficial and most plant foods contain a mix of both types.
Resistant Starch
Resistant starch is found in whole grains, cold cooked potatoes, lentils, firm bananas
and as ‘Hi Maize’, which is added to bread and breakfast cereals. Resistant starch is
fermented in the gut in a similar way as other fibres, resulting in beneficial effects on
the bowel and blood cholesterol levels.
What are the benefits?
Foods high in fibre tend to be low in fat and low in glycaemic index and so fit well
into weight reduction, low fat and diabetic diets.
A high fibre diet helps prevent constipation, haemorrhoids and diverticular disease
and may be protective against bowel polyps and cancer. A high fibre diet is also
associated with a lower risk of heart disease and gallbladder disease, obesity and
diabetes.
Fibre for young and old
Most Australians don't consume enough fibre at around 20g daily. The Australian
Heart Foundation recommends adults consume approximately 30 - 35g daily.
Children should eat 10g of fibre a day plus an additional gram for every year of age.
Eg. a 10 year old child should eat 15-20g of fibre per day. A high fibre diet is
important for the elderly due to a slowing of the digestive system with age.
Getting the most out of your fibre
If your current diet is low in fibre increase it slowly to help avoid abdominal
discomfort or wind. A high fibre diet may not prevent or cure constipation unless you
drink enough water every day – Aim for at least 8 glasses a day. If you suffer from
constipation regular exercise is important.

 Michael Thomsen
Large amounts (more than 2 Tbsp/day) of unprocessed brans are undesirable. They
can bind essential minerals like iron, and also produce excessive abdominal
flatulence, pain and loose bowel actions.
To reduce the gas when using dried beans, soak the beans for 18 hours to remove a
large percentage of the oligosaccharides (these ferment in the colon to release gas).
Throw away the soaking water and cook in fresh water.
Always try to increase your fibre from food sources rather than from supplements
since food contains other important nutrients. You may need a supplement if you have
particular needs.
Ways to increase the fibre in your daily diet
• Add dried peas, beans and lentils to soups, casseroles, salads and as a side dish
• Switch to wholemeal or multigrain breads, brown rice and wholemeal flours over their white
counterparts
• Eat baked beans on wholegrain toast for breakfast
• If you eat cereal, aim for those containing oats, linseed, barley, psyllium or nuts
• Eat nuts, seeds & fresh or dried fruit as a snack
• Snack on hummous and carrot sticks before dinner instead of Jatz and cheese
• Eat the fruit instead of the fruit juice (which has lost all its fibre)
• Aim for 2/3rds of your plate covered by plant food, and meat or animal foods to 1/3
• Add an extra vegetable to every evening meal.
• Check out the fibre content of foods with a nutritional panel to inform yourself of high fibre
food options
• Avoid excessive intake of meat, fatty foods, fast foods and sugar as these are very low in fibre

Slippery elm (Ulmus rubra/ Ulmus fulva)


Slippery elm bark contains both soluble and insoluble fibre. Soluble fibres decrease
blood lipids and cholesterol. It is broken down by intestinal bacteria and has little
bulking effect on the stool. Insoluble fibre has a bulking effect on the stool but no
known effect on blood lipids. The soluble fibre consists primarily of mucilage (the
main polysaccharides being a linear polymer of D-galacturonic acid and L-rhamnose
residues with side branches, on the rhamnose residues, of galactose or 3-0-methyl-
galactose). Mucilages are very efficient at absorbing and retaining water due to their
branched structures and the presence of glucuronic acid, which has a high affinity for
water. It also contains starch, small amount of minerals and tannin. Mucilage does not
dissolve in alcohol and absorbs water at many times its own weight. Slippery Elm is
therefore most effectively used as a powder.
Actions
Demulcent, emollient, nutrient, bulk laxative (in large doses)
Pharmacology
• Slippery Elm Bark mucilage has excellent demulcent and emollient properties,
and taken orally, it protects and soothes any irritation or inflammation of the
mucous membranes in the digestive tract.
• Slippery Elm has considerable nutritive value and has a long reputation of benefit
to convalescents.
• Slippery Elm lubricates bowel contents due to its ability to retain water and the
‘slimy’ nature of mucilage, and therefore has a laxative action.

 Michael Thomsen
• It has a reflex soothing effect on other mucous membranes, for example in the
respiratory and urinogenital systems.
• Slippery Elm slows the intestinal absorption of sugar, inhibits the activity of
pancreatic enzymes (slows down the metabolism of di- and polysaccharides
(starches)) and delays gastric emptying, giving a more gradual release of sugars
into the blood stream, so having a beneficial effect on blood sugar disorders such
as diabetes mellitus.
• A recent study found that slippery elm has antioxidant properties and may
scavenge peroxyl and superoxide free radicals. Slippery elm was found to reduce
oxygen free radical release in mucosal biopsies from patients with active
ulcerative colitis. It was concluded that slippery elm may be beneficial for
inflammatory bowel diseases. Langmead L, Dawson C, Hawkins C, Banna N, Loo
S, Rampton DS: Antioxidant effects of herbal therapies used by patients with
inflammatory bowel disease: an in vitro study. Aliment Pharmacol Ther
2002;16:197-205.
Indications
• Inflammation and ulceration of gastrointestinal tract, such as gastritis, colitis,
oesophagitis, gastric or duodenal ulcers
• Intestinal Dysbiosis
• Diarrhoea
• Irritable bowel syndrome
Contraindications
None known
Dosage
One heaped teaspoon (4 g) twice daily.
Chamomile
Reference: Braun L, Herbs & Natural Supplements - An Evidence-based Guide
Common name
German chamomile
Scientific name
Chamomilla recutita (L.), family Asteraceae (Compositae).
There has been considerable confusion over botanical classification since the plant,
formerly known as Matricaria recutita L., was added to the genus Chamomilla in
1974. Matricaria chamomilla L. is also used.
Other names
Wild chamomile, single chamomile, Hungarian chamomile, pin heads matricaria, blue
chamomile Flos chamomillae vulgaris (Lat).
Plant part used
Flowerheads, gathered in summer when they are dry, and carefully dried at low
temperatures. Essential oil: extracted by steam distillation of the flower heads.
Clinical note
The difference between German and Roman chamomile
Chamomilla recutita is widely distributed in waste lands and in the neglected fields of
Europe, particularly in Croatia and Hungary. Selected varieties are
cultivated.(Bruneton J. 1995) Many plants are referred to as chamomile or have the

 Michael Thomsen
word ‘chamomile’ as part of their common name. Of the large number of species of
chamomile growing in Europe, North Africa and the temperate region of Asia, five
grow wild in the United Kingdom and Europe. Wild varieties are German chamomile
(Chamomilla recutita), Roman chamomile (Chamaemelum nobile (L.)), foetid or
stinking mayweed (Anthemis cotula), corn chamomile (Anthemis arvensis), and
yellow chamomile.(Grieve M. 1976)
Roman chamomile, or Chamaemelum nobile (L.); Anthemis nobile L. is the
‘chamomile’ often referred to in English herbals. It has similar uses as the German
chamomile such as an aromatic bitter for digestive conditions, antispasmodic agent,
mild sedative, and topically for its anti-inflammatory and mild analgesic properties.
The Eclectics, a group of American Herbalists who combined physiomedicalism with
orthodox medicine in the late 19th Century, were disinclined to use it.
History and Traditional Use
Chamomiles have been used as medicines since antiquity and have been traditionally
grouped in botanical texts under the same general heading. They were probably used
interchangeably during this time. Roman chamomile was reportedly used to embalm
the Egyptian Pharaoh, Rhamses II, and is thought to have been introduced into Britain
by the Romans during their conquests. The Anglo-Saxons used chamomile,
presumably the Roman chamomile, as one of their nine sacred herbs. Culpeper lists
numerous ailments for which chamomile was used such as jaundice, fevers, kidney
stones, colic, retention of urine and inflammation of the bowel.(Culpeper N. 1995) It
was also widely used to treat common conditions in children including colic in
infants, teething pains and fever.(Grieve M. 1976) It is used in the treatment of gout
and to reduce the severity of sciatic pain, either taken internally or applied as a
poultice externally.(Culpeper N. 1995) Today, chamomile tea is one of the most
popular herbal teas in Australia and New Zealand and extracts are also used in
cosmetics as bath preparations, in hair dye for blonde hair, shampoos, mouthwashes
and preparations to prevent sunburn.(Foster S. & Leung A. 1996)
Chemical components
• Essential oil (see below) 0.24–1.9%
• Flavonoids (including flavonols and methoxylated flavones) apigenin (other
flavonols are partially hydrolysed to apigenin leading to concentrations of up to
8%), apigetrin (apigenin-7-D-glucoside), apigenin-7-acetylglucoside, apiin
(apigenin-7-apiosylglucoside), rutin (quercetin-3-rutinoside), luteolin,
quercimeritrin (quercetin-7-D-glucoside), quercetin and isorhamnetin.
• Coumarins – umbelliferone (7-hydroxycoumarin) and herniarin (methyl ether of
umbelliferone).
• Proazulenes (sesquiterpene lactones) including matricin, matricarin and
desacetlymatricarin.
• Plant acids (acidic mucilage), fatty acids, polysaccharide, choline, amino acids.
Essential Oil
Chamomile extract produced by a cold extraction process is yellow; steam distillation
produces the blue essential oil. This is derived from matricine, also known as
proazulene or prochamazulene, a precursor of chamazulene.
Chamazulene (1–15%), farnesene, alpha-bisabolol and bisabolol oxides A and B (up
to 50% of the essential oil; proportions vary depending on the chemotype), bisabolone
oxide, chamazulene (from matricin on distilation), matricin, chamaviolin, spathulenol
and cis and trans -enyne dicylo ethers (spiroether, polyacetylenes).

 Michael Thomsen
German chamomile has four chemotypes (variations of the plant product according to
chemical composition). These relate to slight variations in the bisabolol oxide content
of the essential oil.(Gasic et al. 1986) Chemotypes which contain highest levels of α-
bisabolol (known as C & D chemotypes) should be sourced when an essential oil is
required for antiphlogistic or spasmolytic properties.
Main actions
Anti-inflammatory activity
Chamomile extract and various isolated constituents within chamomile have
demonstrated anti-inflammatory activity in a variety of tests.
Chamomile extract showed anti-inflammatory effects when applied topically in
animal models of inflammation.(Al-Hindawi et al. 1989;Plevova 1999;Shipochliev,
Dimitrov, & Aleksandrova 1981) In a comparative trial, hydro-alcoholic extracts of
chamomile produced anti-inflammatory actions when applied topically in the croton
ear test in the mouse. The hydro-alcoholic extract reduced oedema in a dose-
dependent manner and was equivalent in effectiveness to benzydamine at twice the
usual clinical dose, but hydrocortisone was found to be the most effective
treatment.(Tubaro et al. 1984)
Another comparative study investigated the anti-inflammatory effects of i) an extract
prepared from dried flowers, ii) an extract based on fresh flowers, and iii) the volatile
oil, in croton oil-induced dermatitis of mouse ear. The activity of fresh chamomile
equalled the activity of the reference drug (benzydamine).
The anti-inflammatory activity of the herb appears to be due to several different
constituents, chiefly apigenin, matricine, chamazulene and alpha-bisabolol, although
others may also exist.
The previous study determined that apigenin exerts the strongest anti-inflammatory
action which is ten times greater than matricine, which is ten times greater than
chamazulene.(Della Loggia et al. 1990) Alpha-bisabolol has demonstrated anti-
inflammatory and analgesic effects in a number of experimental inflammatory
models: rat paw oedema, adjuvant arthritis of the rat, ultraviolet erythema of the
guinea pig, and yeast fever of the rat.(Jakovlev et al. 1979)
Most studies have investigated the effects of topically applied chamomile or isolated
constituents; however, one study using the carrageenin inflammation test on rat paw
showed that orally administered matricine produces anti-inflammatory activity which
was greater than chamazulene and almost as effective as (-)-α-bisabolol.(Jakovlev,
Isaac, Thiemer, & Kunde 1979;Shipochliev 1981a)
Chamazulene has been found to inhibit leukotriene B4 formation and blocks chemical
peroxidation of arachidonic acid.(Safayhi et al. 1994)
Antispasmodic effect
Chamomile extract and several constituents demonstrate a dose-dependent
antispasmodic effect in vitro. The major activity is related to bisabolol, spiroethers,
and apigenin. (-)-α-bisabolol has an effect equal to papaverine; apigenin was the most
potent flavonoid, being significantly more potent than papaverine. The extract of
chamomile also has a good spasmolytic activity.(Achterrath-Tuckermann et al. 1980)
Sedative effects
Extracts of chamomile showed sedative activity on the mouse CNS(Della Loggia,
Tubaro, & Redaelli 1981) and extracts of chamomile as well as isolated apigenin have
been shown to bind to the central benzodiazepine receptor in vitro. Apigenin showed

 Michael Thomsen
anti-anxiety and sedative activity with intraperitoneal injection in mice.(Viola et al.
1995)
Ovariectomised rats given inhalations of chamomile oil showed decreased levels of
stress-induced ACTH levels compared with controls; the experiment suggested an
activity similar to benzodiazepine agonists.(Yamada et al. 1996)
Antimicrobial activity
According to in vitro studies the essential oil has bactericidal and fungicidal activities
against Gram-positive bacteria (Bacillus subtilis, Staphylococcus aureus) and
Candida albicans in concentrations above 0.05 % v/v but has no effect against Gram
negative bacteria (Escherichia coli, Pseudomonas aeruginosa).(Aggag & Yousef
1972) In contrast, extracts of chamomile have demonstrated antimicrobial activity
against E. coli.(Ceska et al. 1992) The growth of Staphylococcus aureus,
Streptococcus mutans, group B Streptococcus was inhibited by chamomile extract at
concentrations of 10 mg/mL.(Cinco et al. 1983) In vitro tests using apigenin have
identified inhibitory activity against HIV activation, possibly by affecting viral
transcription.(Critchfield et al. 1997;Trovato et al. 2000) Additionally, a semi-purified
extract of chamomile has been shown to inhibit herpes virus in vitro.(Suganda et al.
1983)
Antiulcer effect
Chamomile extract protected rats from developing experimentally induced ulcers.
Bisabolol (and extracts of chamomile) have been shown to prevent the formation of
ulcers in experimental animals exposed to indomethacin (NSAID) stress, and alcohol;
and to reduce the healing time of ulcers induced by chemical stress (acetic acid) or by
heat coagulation. Alpha-bisabolol promotes granulation and tissue regeneration in
burns, ulcers, and protects against their formation.(Szelenyi, Isaac, & Thiemer 1979)
Other actions
Immune enhancement
Chamomile extract increased T-lymphocyte rosette formation in vitro in blood
samples taken from ENT patients with immunodeficiency.(Kliachko et al. 1994) The
polysaccharides (heteroglycans) showed significant immunostimulating activities
according to the granulocytes and carbon clearance tests.(Wagner H., Proksch A., &
Riess-Maurer I. 1985)
Antioxidant
Chamazulene is also antioxidant. It has been found to inhibit lipid
peroxidation(Goeters et al. 2001) and has been shown to inhibit lipid peroxidation in
vitro in a concentration and time dependent manner.(Rekka, Kourounakis, &
Kourounakis 1996)
Choleretic action
Chamomile increases production of bile by the liver.(Pasechnik 1966)
Drug dependence
Chamomile extract was shown to inhibit the development of morphine dependence
and expression of abstinence syndrome in rats. Chamomile reduced frequencies of
behaviours associated with withdrawal (paw tremor, rearing, teeth chattering, body
shakes, ptosis, diarrhoea and urination) and weight loss.(Bonnafoux-Clavere, Clavere,
& Bonnetblanc 2003)
Anticarcinogenic

 Michael Thomsen
Apigenin has been shown inhibit carcinogenesis in a number of in vitro and animal
studies.(Aguilera, Souza, & Miglioranza 2000;Ali-Shtayeh, Yaniv, & Mahajna
2000;Birt et al. 1986;Birt et al. 1997;Lepley et al. 1996;Lepley & Pelling 1997;Panes
et al. 1996;Umezu 1999;Wei et al. 1990)
Uterine effects
Water extracts of chamomile increased uterine tonus in isolated rabbit and guinea pig
uterine horn.(Shipochliev 1981b)
Pigmentation
Chamomile extract has been found to decrease UV-induced pigmentation as well as
the hyperpigmentation found in lentigo senilis (aged or liver spots). Endothelin-1 is a
cytokine responsible for stimulating melanocyte function leading to
hyperpigmentation. Chamomile has been shown to interrupt the endothelin-1 induced
signalling, thereby reducing the ability of melanocytes to proliferate and to synthesise
melanin.(Ichihashi et al. 1999)
Clinical use
Chamomile is most widely taken as a tea, often after meals or as an alternative to
caffeine-containing beverages. In clinical practice, the oral dose form most often used
is a concentrated extract, in order to produce stronger therapeutic effects.
Skin conditions
Chamomile is used topically for a variety of dermatological conditions. The most
tested topical product is known commercially as Kamillosan®.
Wound healing
According to a double-blind trial, external application of a chamomile extract
improves wound healing. In the study, chamomile extract significantly decreased
weeping and improved wound healing after dermabrasion of tattoos.(Glowania,
Raulin, & Swoboda 1987)
Eczema
In one comparative study, 161 patients with eczema on the arms and lower legs were
treated with 0.25 % hydrocortisone, 5 % bufexamac (NSAID), 0.75 % fluocortin
(glucocorticoid) or a chamomile cream known commercially as Kamillosan®. The
chamomile cream was as effective as hydrocortisone and was superior to the other
two treatments(Aertgeerts et al. 1985) (Kamillosan® is reportedly made from a high
bisabolol-containing chemotype of chamomile).
Dermatitis
Another study involving experimentally-induced toxic dermatitis found that
chamomile ointment (Kamillosan®) produced a more soothing effect on human skin
than a chamomile ointment base or hydrocortisone ointment 0.1 %. (Note: the
hydrocortisone cream used in this study was quite weak compared to the usual
strength of 0.5–2.5%.)(Nissen, Biltz, & Kreysel 1988)
Chamomile cream helped protect against skin radiation damage in breast cancer
patients receiving radiation.(Maiche, Grohn, & Maki-Hokkonen 1991) Chamomile
cream (Kamillosan®) has been shown to be slightly less effective than 0.25%
hydrocortisone, but superior to fluocortin butyl ester and 5% bufexamac in relieving
inflammation associated with dermatoses.(Aertgeerts 1984;Aertgeerts, Albring,
Klaschka, Nasemann, Patzelt-Wenczler, Rauhut, & Weigl 1985)

 Michael Thomsen
Commission E approves the external use of chamomile for inflammation of the skin
and mucous membranes, as well as for bacterial skin diseases, including those of the
oral cavity and gums.
Sedation
Both oral dose forms and the essential oil of chamomile are used for this indication.
A placebo-controlled study involving 22 volunteers found that inhalation of
chamomile oil produced sedative effects and improved mood.(Roberts & Williams
1992) Chamomile tea (two teabags in 150 ml of hot water given to 12 patients during
cardiac catheterisation induced a deep sleep in 10 patients, even though the procedure
usually causes pain and anxiety.(Gould, Reddy, & Gomprecht 1973)
Gastrointestinal conditions
Chamomile is widely used to relieve stomach cramping, dyspepsia and flatulence.
The herb’s anti-spasmodic and relaxant effects provide a theoretical basis for its use
in these conditions.
In an open, multicentre study, 104 patients with gastrointestinal complaints including
gastritis, flatulence and minor spasms of the intestines were treated for 6 weeks with
5‫ٱ‬mL/day of an oral chamomile preparation (standardised to contain 50‫ٱ‬mg alpha-
bisabolol and 150–300‫ٱ‬mg apigenin-7-glucoside per 100‫ٱ‬g). By self-evaluation, all
patients improved with 44.2% becoming symptom free.(Stiegelmeyer 1978)
Diarrhoea in children
In Europe, chamomile is widely used to treat a variety of paediatric complaints.
A prospective, double-blind, randomised trial was used to document the efficacy of a
preparation containing chamomile extract and pectin in children aged 6 months to 5.5
years with uncomplicated diarrhoea. The chamomile preparation reduced the duration
and severity significantly faster than placebo.(de la Motte et al. 1997)
The German Commission E approves chamomile for gastrointestinal spasms and
inflammatory diseases of the gastrointestinal tract.
Antibacterial preparations – Negative studies
A Phase III, double-blind, placebo-controlled clinical trial of 164 patients assessed the
efficacy of chamomile mouthwash in preventing 5-flurouracil induced stomatitis and
found no difference between chamomile and placebo.(Fidler et al. 1996)
Chamomile extract spray administered before intubation was not able to prevent
postoperative sore throat and hoarseness compared to saline spray in a randomised,
double-blind study.(Chan, Rappaport, & Kemper 2003)
Other Uses
Haemorrhagic cystitis
Chamomile extract decreased the symptoms of haemorrhagic cystitis. Thirty-two
patients were randomly assigned to receive either the antibiotic cotrimoxazole
(trimethoprim/sulfamethoxazole) alone or with a chamomile extract administered on
day one as a bladder instillation, followed by daily hipbath use. Symptoms were
evaluated after 10 days and indicated that the chamomile group experienced more
rapid alleviation of symptoms than the group treated with only cotrimoxazole. The
product used was Kamillenextrakt, an ethanolic extract of chamomile
flowers.(Barsom, Mossmayr, & Sakka 1993)
The British Herbal Pharmacopoeia recommends chamomile for flatulent nervous
dyspepsia, travel sickness, nasal catarrh, nervous diarrhoea and restlessness.
Externally, chamomile is recommended for haemorrhoids, mastitis and leg ulcers. The

 Michael Thomsen
specific indication is for gastrointestinal disturbance with nervous irritability in
children and for teething and colic in infants.
Commission E approves the use of inhalations for inflammation and irritation of the
respiratory tract and baths and irrigations for anogenital inflammation.
Dosage range
German chamomile is used either as a tea made from the dried flower heads, or as an
extract.
• Dried flower heads: 2–8‫ٱ‬g 3 times daily by infusion.
• Fluid extract (1:2): 3–4‫ٱ‬mL/daily.
The quality of chamomile varies greatly. For maximum efficacy, use high-grade
chamomile (high in α-bisabolol). Standardised extracts are usually standardised to
either bisabolol or apigenin.
External application
• The dried flowers can also be made into a poultice with the addition of hot water
and applied directly to the skin; or the tea can be used to bathe inflamed skin and
eyes.
• Essential oil (external use): 5 drops per 100‫ٱ‬mL of oil, or per 100‫ٱ‬g of cream or
ointment.
• In baths and water for compresses, the dose should not exceed 10 drops.
• Inhalation: 5 drops of essential oil in 1‫ٱ‬L hot water.
Adverse reactions
Allergic reactions
Occasional rare cases of allergic skin reactions have been reported. However, a
bibliographic review of 50 reports of ‘chamomile’ sensitivity revealed that in only 5
papers was the botanical identification of the plant material correlated with
Chamomilla recutita. In the majority of other instances, the effects were caused by
species of the genus Anthemis, frequently also called chamomile. Experimental
studies on pigs using a rigorous testing technique proved that Chamomilla recutita
possesses low sensitising capacity. The suspected allergen is the sesquiterpene
lactone, anthecotulide, found in Anthemis cotula L. (stinking mayweed), which only
occurs in trace amounts in the bisabolol oxide B-chemotype of genuine
chamomile.(Hausen, Busker, & Carle 1984) Allergic conjunctivitis has been reported
with the use of chamomile tea eyewashes, and the pollens contained in the teas have
been identified as the allergens responsible. The reaction occurred after first exposure
and was thought to be due to cross-reactivity to Artemesia pollen.(Subiza et al. 1989)
Pollens are not likely to be present or active in aqueous alcohol extracts of
chamomile.
German chamomile is thought to be less allergenic than Roman chamomile, but any
variety of chamomile can potentially cause allergic reactions. An enema made from
German chamomile (Kamillosan®) given during labour to a 35-year-old woman with
no history of atopy resulted in life-threatening anaphylaxis and fatal asphyxia of the
newborn.(Jensen-Jarolim et al. 1998) Chamomile enemas are not a usual form of
administration.
Significant interactions
Controlled studies are not available, therefore interactions are based on evidence of
activity and are largely theoretical and speculative.

 Michael Thomsen
Benzodiazepines
Theoretically, an additive effect can occur with concurrent use, so observe patients
taking this combination.
Drugs metabolised by CYP 3A4
Chamomile has been shown to inhibit cytochrome P450 enzymes in vitro,(Budzinski
et al. 2000) although no human drug interaction data is available to determine the
clinical significance of this finding. Observe patients taking such drugs and
chamomile.
Contraindications and precautions
Chamomile is contraindicated in hypersensitivity or known allergy to chamomile or
other members of the Compositae family (e.g. yarrow, tansy, feverfew, artemesia).
Pregnancy use
Safety has not been established scientifically.
Practice points/patient counselling
• German chamomile has demonstrated anti-inflammatory, antispasmodic, sedative
and antimicrobial activity.
• It is taken orally either as a tea or tincture, used externally as a poultice, cream or
ointment or inhaled as an essential oil.
• Internally, it is used to relieve flatulence, gastrointestinal spasm, dyspepsia and
induce a sense of relaxation. It is also used for infants with teething pain and colic.
• Externally, chamomile preparations are used to treat dermatitis, enhance wound
healing, and soothe irritated skin. Comparative studies show it has an anti-
inflammatory effect equivalent to low-dose hydrocortisone preparations.
• There is some evidence from clinical trials to support the use of chamomile in the
treatment of wounds, eczema, dermatitis, nervousness and tension, diarrhoea in
children and for the symptoms of haemorrhagic cystitis (in association with
antibiotic therapy).
Answers to patients frequently asked Questions
What can this herb do for me?
Chamomile is taken to relieve stomach spasms and flatulence, to induce relaxation
and promote sleep. It is also popular for children with teething pain and digestive
complaints such as colic or diarrhoea. Applied externally as a cream, ointment or
poultice, it is used to reduce skin irritation and inflammation.
When will it start to work?
Chamomile relieves gastrointestinal symptoms quickly, within several minutes. For
more chronic problems, it may need to be used long term.
Are there any safety issues?
Chamomile is considered a very safe herb. While there have been reports of allergic
reactions, the majority have been due to adulteration with other herbs. Chamomile tea
is more likely to cause allergic reactions than either extracts or essential oil.
Chamomile should not be used by persons with hypersensitivity or known allergy to
chamomile or other members of the Compositae family (e.g. yarrow, tansy, feverfew,
artemesia).
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 Michael Thomsen
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 Michael Thomsen
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Trovato, A., Monforte, M. T., Forestieri, A. M., & Pizzimenti, F. 2000, "In vitro anti-
mycotic activity of some medicinal plants containing flavonoids", Bollettino Chimico
Farmaceutico, vol. 139, no. 5, pp. 225-227.

Tubaro, A., Zilli, C., Redaelli, C., & Della Loggia, R. 1984, "Evaluation of
antiinflammatory activity of a chamomile extract topical application", Planta Med,
vol. 50, no. 4, p. 359.

Umezu, T. 1999, "Anticonflict effects of plant-derived essential oils", Pharmacology,


Biochemistry & Behavior, vol. 64, no. 1, pp. 35-40.

Viola, H., Wasowski, C., Levi de Stein, M., Wolfman, C., Silveira, R., Dajas, F.,
Medina, J. H., & Paladini, A. C. 1995, "Apigenin, a component of Matricaria recutita

 Michael Thomsen
flowers, is a central benzodiazepine receptors-ligand with anxiolytic effects", Planta
Med, vol. 61, no. 3, pp. 213-6.

Wagner H., Proksch A., & Riess-Maurer I. 1985, "Immunostimulating action of


polysaccharides (heteroglycans) from higher plants", Arzneimittelforschung, vol. 35,
no. 7, pp. 1069-1075.

Wei, H., Tye, L., Bresnick, E., & Birt, D. F. 1990, "Inhibitory effect of apigenin, a
plant flavonoid, on epidermal ornithine decarboxylase and skin tumor promotion in
mice", Cancer Res, vol. 50, no. 3, pp. 499-502.

Yamada, K., Miura, T., Mimaki, Y., & Sashida, Y. 1996, "Effect of inhalation of
chamomile oil vapour on plasma ACTH level in ovariectomized-rat under restriction
stress", Biol Pharm Bull, vol. 19, no. 9, pp. 1244-6.
Peppermint
Reference: Braun L, Herbs & Natural Supplements - An Evidence-based Guide
Description
Peppermint has been used for generations as a digestive aid and carminative. More
recently, enteric-coated peppermint oil capsules have been widely prescribed for the
relief of irritable bowel syndrome (IBS).
Latin binomial/class
Mentha x piperita
Plant part used
Leaf or steam – essential oil is distilled from the above-ground parts.
Chemical components
Peppermint leaves contain about 2.5% essential oil, 19% total polyphenolic
compounds, 12% total flavonoid compounds (eriocitrin, luteolin-7- rutinoside,
hesperidoside) and 7% total hydroxycinnamic compounds (including rosmarinic acid)
(Duband et al 1992).
Essential oil
Over 100 constituents have been identified in Peppermint oil. The principal
constituents are menthol (35–55%), menthones (10–35%), isomenthone, menthyl
acetate, menthofuran and cineole. To comply with the European Pharmacopoeia, the
oil must not contain more than 4% pulegone and not more than 1% carvone.
Main actions
The actions of the leaf as an infusion or liquid extract are largely dependent on the
essential oil content. Other compounds such as the flavonoids also contribute to the
overall activity, especially the antioxidant and antiallergic activities.
Antispasmodic activity
Both the ethanol extract and the essential oil have demonstrated antispasmodic
(spasmolytic) effects. Studies have examined the effects of Peppermint on isolated gut
preparations. Ethanol extract, as well as flavonoids isolated from the leaf, has been
shown to have antispasmodic effects on the isolated guinea pig ileum (ESCOP 1997)
and peppermint oil has been shown to relax gastrointestinal smooth muscle in vitro by
interacting with smooth muscle calcium channels (Hills and Aaronson 1991).

 Michael Thomsen
In the peripheral nerves, this effect may be responsible for the characteristic cooling
sensation experienced on the oral ingestion of mint. In healthy volunteers, intragastric
administration of a dose equivalent to 180 mg peppermint oil, reduced
intraoesophageal pressure within 1–7 minutes of infusion (Kingham 1995).
Enteroplant, an enteric-coated capsule containing 90 mg peppermint and 50 mg
caraway oil as well as its constituents was shown to act locally in the stomach and
duodenum to produce smooth muscle relaxation (Micklefield et al 2003).
Carminative activity
Peppermint also has a carminative activity, which refers to its ability to relax the
tonus of the gastrointestinal sphincters. Carminatives are thought to alleviate
symptoms of bloating and gas by facilitating eructation and passage of flatus. The
classic carminatives are essential oils, such as spearmint and Peppermint. Studies
from the 1950s on the effect of carminatives on the gut suggest that they work by
inducing relaxation of the lower oesophageal sphincter (Massey 2001). A later study
has shown that peppermint oil canalised into the gallbladder and duodenal areas was
able to counteract morphine hydrochloride-induced constriction of the sphincter of
Oddi (Giachetti et al 1988)
Choleretic activity
Choleretic activity has been demonstrated for peppermint tea, flavonoids and the
essential oil in dogs and rats (ESCOP 1997). Peppermint oil and caraway oils have
shown a relaxing effect on the gall bladder and peppermint oil has been shown to
slow small intestinal transit time in 12 healthy volunteers. The gastric emptying time
did not differ significantly between placebo, peppermint oil and caraway oil
(Goerg & Spilker 2003).
Antimicrobial activity
Peppermint oil has shown evidence in several studies of having antimicrobial activity.
Peppermint oil has been shown to inhibit Helicobactor pylori, Staphyllococcus aureus
(Imai et al 2001), E. coli (Pattnaik et al 1995), Salmonella enteritidis, Listeria
monocytogenes, Shigella sonei and Micrococcus flavus (Mimica-Dukic et al 2003)
and a variety of fungi (Anon 1998, Pattnaik et al 1996). Peppermint oil, and its
constituents menthone and isomenthone, have also been shown to be antioxidant
(Mimica-Dukic et al 2003).
Anti-allergic effects
The flavonoid luteolin-7-O-rutinoside isolated from the aerial part of Peppermint has
been shown to inhibit histamine release from rat peritoneal mast cells in a dose-
dependent manner (100–300 mg/kg) and to reduce antigen-induced allergic nasal
symptoms (Inoue et al 2002). It would be difficult to achieve such doses of luteolin
with a commercially available Peppermint extract or oil. However, an extract of the
whole herb may be beneficial in alleviating nasal symptoms associated with allergic
rhinitis in association with other medicines. A 50% hydro-ethanolic extract of
Peppermint leaves has been shown to inhibit chemically induced histamine release
from rat peritoneal mast cells in vitro. The Peppermint extract was also shown to
reduce nasal symptoms (sneezing and nasal rubbing) in rats with experimentally
induced allergic rhinitis. Significant inhibition of sneezing and nasal rubbing was
observed at oral doses of 300 and 1000 mg/kg, respectively (Inoue et al 2001).
Other actions
Stimulant effect

 Michael Thomsen
Intraperitoneal and intravenous injections of peppermint oil and its constituents, 1,8-
cineol, menthone, isomenthone, menthol, pulegone, menthyl acetate and
caryophyllene, dramatically increased ambulatory activity in mice. It is thought that
the effect is mediated via a dopaminergic effect of menthol. This may explain the
traditional use of Peppermint for mental fatigue (Umezu and Morita 2003, Umezu et
al 2001).
A combination of peppermint oil, eucalyptus oil and ethanol was shown in a cross-
over, double-blind study to increase cognitive performance, relax muscles and
mentally relax 32 healthy subjects (Gobel et al 1994).
Coolant effect
Peppermint oil has been shown to interact with smooth muscle calcium channels
(Hills and Aaronson 1991). In the peripheral nerves this effect may be responsible for
the characteristic cooling sensation experienced on oral ingestion of mint.
Diuretic effect
A spray dried peppermint infusion has been found to be mildly diuretic (Della et al
1990).
Sedative effects
A spray dried peppermint infusion produced weak sedative action in several tests
when administered orally to mice (Della et al 1990).
Analgesic effect
A significant analgesic effect with a reduction in sensitivity to headache was produced
by a combination of peppermint oil and ethanol applied externally in 32 healthy males
undergoing artificial pain stimulation in a double-blind, placebo-controlled,
randomised, 7-day crossover study (Gobel et al 1994).
Clinical use
In practice, Peppermint and its derivatives are used in many forms and administered
by various routes. This review will focus only on those methods which are commonly
used by the public and preparations which are available over the counter, such as oral
dose forms, topical applications and inhalations.
Irritable Bowel Syndrome
There have been several studies examining the effects of peppermint oil in the
treatment of IBS (Rees et al 1979, Dew et al 1984). Newer studies have tended to use
an enteric-coated peppermint oil capsules. Enteric coating prevents dissolution of the
capsules until it has reached the target site in the intestines. This allows administration
of a higher dose than would otherwise be possible to tolerate and, importantly, avoids
the risk of excessively relaxing the lower oesophageal sphincter, thus causing reflux.
A prospective, randomised, double-blind, placebo-controlled clinical study of 110
outpatients with IBS found that one enteric-coated peppermint oil capsule
(Colpermin) taken 3–4 times daily, 15–30 minutes before meals significantly, reduced
symptoms compared to placebo (P<0.05; Mann-Whitney U-test). Of the 41 patients
taking the peppermint capsule, 79% experienced an alleviation of the severity of
abdominal pain (29 were pain free); 83% had less abdominal distension, 83% had
reduced stool frequency, 73% had fewer borborygmi, and 79% had less flatulence.
One patient experienced heartburn (because of chewing the peppermint capsules) and
one developed a mild transient skin rash. There were no significant changes in liver
function test results (Liu et al 1997).

 Michael Thomsen
Pittler and Ernst published a critical review and meta-analysis of peppermint oil for
IBS in 1998. They found eight randomised, controlled trials of which five were also
double blind. Although they noted some methodological flaws in the studies and that
more studies are needed, the authors concluded that the meta-analysis of the five
placebo-controlled, double blind trials seems to support peppermint oil as efficacious
for symptom relief in IBS (Pittler and Ernst 1998).
Since this time there have been further positive studies. A randomised, double-blind
controlled trial of 42 children with IBS found that treatment with enteric-coated
peppermint oil capsules reduced the severity of the pain associated with IBS in 75%
of the children (Kline et al 2001).
Bacterial overgrowth of the small intestine is associated with a number of functional
somatic disorders, including IBS, fibromyalgia and chronic fatigue syndrome. There
have been two reports of successful treatment of IBS due to intestinal overgrowth
with enteric-coated peppermint oil capsules. The effect may in part be associated with
the antimicrobial activities of peppermint oil (Gaby 2003, Logan and Beaulne 2002).

Clinical note – The pathophysiology of IBS


The pathophysiology of IBS is poorly understood, but it is believed to occur when the
intestinal muscles are contracting faster or slower than normal. Colonic contractions
cause abdominal pain, cramping, wind and diarrhoea or constipation. It has been
proposed that IBS may result from dysregulation of gastrointestinal motor and
enhanced sensory functions, as modulated by the central nervous system. However,
clinical and laboratory investigations have failed to uncover any histological,
microbiological, or biochemical abnormalities in IBS patients. Patients with IBS
demonstrate increased motility and abnormal contractions of the intestinal muscles
when faced with an emotionally or physically stressful situation (Greenberg et al
2002). It is likely that IBS is also associated with dietary habits, poor upper digestion
and intestinal dysbiosis (bacterial overgrowth of the bowels).
Common symptoms of IBS (Greenberg et al 2002)
• Cramping pain in the lower abdomen
• Bloating and excess gas (wind)
• Changes in bowel habits
• Diarrhoea or constipation, either one dominant or both alternating
• Immediate need for a bowel movement on awakening or during or after meals
• Relief of pain after bowel movements
• Feeling of incomplete emptying after bowel movements
• Mucus in the stool
Dyspepsia
An enteric-coated capsule (Enteroplant) containing 90 mg peppermint oil and 50 mg
caraway oil has been shown in a double-blind, placebo-controlled multicentre trial
with 45 patients to improve symptoms of non-ulcer dyspepsia. The primary outcome
variables were changes in the intensity of pain and the global clinical impression.
Nearly 90% of patients experienced a reduction in pain, and after 4 weeks nearly 95%
had improved Clinical Global Impression scores compared to placebo (P=0.015 and
0.008, respectively). Before the start of treatment all patients in the test preparation
group reported moderate to severe pain, while by the end of the study 63.2% of these
patients were free of pain. The peppermint/caraway oil combination was well

 Michael Thomsen
tolerated. There were a total of 7 adverse events reported (4 in the active group) and
only one being causally associated with the active treatment (May et al 1996)
Since then there have been two further trails of this particular peppermint oil
combination.
In a prospective, randomised, reference and double-blind controlled multicentre trial
with 223 patients with non-ulcer dyspepsia and irritable bowel syndrome, the
peppermint oil combination was found to significantly reduce pain (P<0.001) (Freise
and Kohler 1999).
In a study of 96 outpatients, the same Peppermint formulation was found to
significantly improve symptoms of functional dyspepsia compared to placebo. After 4
weeks, the average intensity of pain was reduced by 40% vs. baseline in the active
group and by 22% in the placebo group. The Peppermint combination also reduced
pressure, heaviness and fullness. Six patients (5 in the active group and 1 in the
placebo group) reported adverse events. These were found to be either unrelated to the
trial, or attributable to an aggravation of the disease under investigation.(May et al
2000).
Comparative studies
The same peppermint oil combination has been compared to cisapride. Cisapride
(Prepulsid) increases the lower oesophageal sphincter pressure, thereby reducing the
risk of reflux. Cisapride is also used to treat irritable bowel syndrome dominated by
constipation. Cisapride has, however, been linked to serious cardiac arrhythmias and
should be used with caution. In the 4- week study, the Peppermint and caraway oil
combination (Enteroplant, 2 capsules daily) was shown to be as effective as cisapride
in reducing both the magnitude and frequency of pain. Physicians rated the two
treatments comparable in regard to other dyspeptic symptoms in addition to intestinal
and extra-intestinal autonomic symptoms as measured by the Dyspeptic Discomfort
Score and Clinical Global Impressions scale. Corresponding results were also found
in Helicobacter pylori-positive patients and patients who initially presented with
intense epigastric pain in the two treatment groups. Both medications were tolerated
well (adverse events were reported in 12 patients of the PCC group and in 14 patients
of the CIS group) (Madisch et al 1999).
In a systematic review of herbal medicines for functional dyspepsia, Thompson Coon
and Ernst found 17 randomised clinical trials, nine of which involved Peppermint and
caraway combination preparations. Symptoms were reduced by all treatments; 60–
95% of patients reported improvements in symptoms (Coon and Ernst 2002).
Diffuse Oesophageal Spasm
Diffuse oesophageal spasm (DES) is a relatively rare motor disorder. Associated
manometric abnormalities may include hypertensive and repetitive contractions. The
lower oesophageal sphincter (LES) may also be hypertensive. Although LES
relaxation with deglutition is generally normal, disturbances in LES function are often
seen. These abnormalities are, however, not required for the diagnosis (Massey 2001).
In a study of eight DES patients with chest pain or dysphagia, peppermint oil had no
effect on lower oesophageal sphincter pressures or contractile pressures and durations
in the oesophagus. However, the peppermint oil completely eliminated simultaneous
oesophageal contractions in all patients (P<0.01). The number of multiphasic,
spontaneous and missed contractions also improved. Two of the eight patients had
chest pain that resolved after the peppermint oil (Pimentel et al 2001).
Headache

 Michael Thomsen
A solution of 10% peppermint oil in ethanol has been shown in a randomised,
placebo-controlled, double-blind, crossover study to efficiently alleviate tension-type
headache. The study analysed 164 headache attacks in 41 patients of both sexes
ranging between 18 and 65 years of age, suffering from tension-type headache. The
peppermint oil was spread largely across forehead and temples and repeated after 15
and 30 minutes. Using a headache diary, the headache parameters were assessed after
15, 30, 45 and 60 minutes. Compared to the application of a placebo, the peppermint
oil significantly reduced the intensity of the headache after 15 minutes (P<0.01). The
analgesic effect of the peppermint oil was comparable to 1000 mg paracetamol
(acetaminophen). Simultaneous ingestion of 1000 mg of paracetamol and application
of 10% peppermint oil in ethanol solution leads to an slight additive effect (Gobel et
al 1996).
Other uses
Post-herpetic neuralgia
A case report describes the treatment of post-herpetic neuralgia with the application of
undiluted peppermint oil containing 10% menthol directly to the affected area. The
pain relief persisted for 4–6 hours after application of the oil. At a 2-months follow-up
the patient had only minor side effects and continued to use the medication (Davies et
al 2002)
Postoperative nausea
Inhalation of peppermint oil vapors has been shown in a study to reduce postoperative
nausea in gynaecological patients. The study used a three-condition experimental
design using statistical analysis to compare groups. The control, placebo and
experimental groups of gynaecological patients were compared, using variables
known to affect postoperative nausea. They were found to be homogeneous for the
purposes of the study.
There was a significant reduction in nausea in the Peppermint group compared to
placebo (P=0.02). The patients were free to inhale the peppermint oil as frequently as
desired. In view of the increased number of intra-abdominal procedures, the increased
amount of opioids, the reduced amount of anti-emetics and the qualitative data
obtained from patients, the authors concluded that there is evidence to suggest that
peppermint oil may improve postoperative nausea in gynaecological patients (Tate
1997). A hot peppermint oil compress is used in China to prevent abdominal
distension in postoperative gynaecological patients (Feng 1997).
Respiratory tract infections
Peppermint and menthol have an established tradition in the treatment of respiratory
infections. Chest rubs containing menthol are frequently used to treat coughs and
bronchitis. Inhalation of various antiseptic and anti-inflammatory essential oils are
often used in the treatment of respiratory infections including bronchitis (Shubina et al
1990). Peppermint oil has been found to have a pronounced antimycobacterial effect
in vitro and long-term use of peppermint oil in a humidifier has been used in the
Ukraine as an adjunctive treatment to multidrug therapy for pulmonary tuberculosis
(Shkurupii et al 2002).
Dosage range
Leaf
• Infusion: 3–6 g 3 times daily (Blumenthal et al 2000)
• Liquid extract (1:2): 10–30 mL weekly

 Michael Thomsen
• These dosages are for adults; adjust according to size for children.
Essential oil
• Digestive disorders: 0.2–0.4 mL 3 times daily in dilute preparations or in
suspension.(ESCOP 1997)
• IBS: 0.2–0.4 mL 3 times daily in enteric-coated capsules or tables. (Dew et al
1984, Rees et al 1979)
• Inhalation: 3–4 drops added to hot water
• Lozenge: 2–10 mg
• External use (for analgesic, anaesthtic or antipruritic activity): 0.1–1.0% m/m
(ESCOP 1997)
• External use (counter irritant): 1.25–16% m/m (ESCOP 1997)
Adverse reactions
A single dose of 4000 mg/kg of a spray-dried infusion did not produce any
macroscopic signs of toxicity in mice (Della et al 1990). Peppermint oil has been
shown to be minimally toxic in acute oral studies. Short-term and subchronic oral
studies reported brain lesions in rats that were given very large doses of peppermint
oil containing pulegone, pulegone alone or large amounts (>200 mg/kg/day) of
menthone. Pulegone is also a recognised hepatotoxin. Repeated intradermal dosing
with peppermint oil produced moderate and severe reactions in rabbits, although
peppermint oil did not appear to be phototoxic. Peppermint oil was negative in an
Ames test and a mouse lymphoma mutagenesis assay, but gave equivocal results in a
Chinese hamster fibroblast cell chromosome aberration assay. Although sensitisation
to peppermint oil and/or its constituents have been reported, a solution containing 8%
peppermint oil was shown not to be a sensitiser (Nair 2001). Contact dermatitis to
Peppermint and menthol has been reported (Morton et al 1995); however, as long as
the pulegone content is kept to a minimum, peppermint oil and peppermint extract is
considered to have a very good safety profile.
Significant interactions
Controlled studies are not available, therefore interactions are based on evidence of
activity and are largely theoretical and speculative.
Felodipine
Peppermint oil has been shown to increase the oral bioavailability of felodipine in
animal studies (Anon 2002). Use this combination with caution.
Simvastatin
Peppermint oil has been shown to increase the oral bioavailability of simvastatin in
animal studies (Anon 2002). Observe - monitor drug requirements – interaction may
be beneficial.
Cyclosporin
Peppermint oil has been shown to increase the oral bioavailability of cyclosporin in
animal studies (Anon 2002). Avoid concurrent use unless under medical supervision.
drugs metabolised by CYP 3A4 liver enzyme
Peppermint may increase the oral bioavailability of certain drugs by inhibition of
CYP3A4-mediated drug metabolism, which has been demonstrated in vitro but not in
test animals (Dresser et al 2002, Maliakal and Wanwimolruk 2001). Although these
studies seem to suggest that Peppermint may modulate drug metabolising enzymes,

 Michael Thomsen
the clinical significance of this is unknown and requires further investigation.
Therefore caution is advised.
Contraindications and precautions
Hypersensitivity to peppermint oil (Morton et al 1995).
Non-enteric coated peppermint may be best avoided in patients with reflux
oesophageal symptoms. Avoid chewing enteric coated capsules as it may cause
heartburn (Liu et al 1997). Avoid the use of peppermint oil on the face of infants and
small children. Capsules containing Peppermint oil is contraindicated in biliary duct
occlusion, gallbladder inflammation and sever liver damage (Blumenthal et al 2000).
Pregnancy use
Safe dosages in pregnant women have not been determined.
Practice points/patient counseling
• The clinical trials have used enteric-coated peppermint oil capsules in the
treatment of irritable bowel syndrome. The capsules contain 90 mg peppermint and
may be combined with other oils including 50 mg caraway oil.
• Although enteric-coated capsules were also used in the dyspepsia trials, traditional
extracts of Peppermint, including hydro-ethanolic and infusions, may also be
effective.
• The German Commission E approved Peppermint for spasmodic complaints in the
gastrointestinal region and of the gall bladder and bile ducts. (Blumenthal et al
2000). The British Herbal Pharmacopoeia recommends Peppermint leaf extract for
dyspepsia, flatulence, intestinal colic and biliary disorders. Note, however that
Peppermint oil is contraindicated in inflammation of the gallbladder and severe
liver disease.
• Peppermint leaf extract combines well with chamomile, caraway, liquorice, lemon
balm, angelica, St Mary’s thistle and the bitter candytuft (Iberis amara) in the
treatment of functional dyspepsia (Madisch et al 2001).
• Peppermint oil can be used as an inhalation or chest rub for coughs, sinusitis and
bronchitis. The Commission E approved peppermint oil for internal use in the
treatment of respiratory tract inflammation (Blumenthal et al 2000).
• Hot peppermint leaf infusion is used as a diaphoretic tea in the treatment of colds
and influenza.
• Pure peppermint oil can be inhaled to reduce nausea. Peppermint extract may also
be used internally.
• Peppermint or pure menthol is used in heat rub ointments for arthritis,
fibromyositis, tendonitis and other musculoskeletal conditions. The Commission E
approved peppermint oil externally for neuralgia and myalgia (Blumenthal et al
2000).
• 10% peppermint oil in ethanol solution can be applied externally for tension
headaches. Spread across the forehead and temples, and repeat after 15 and 30
minutes.
• Pure peppermint oil can be applied over affected areas for post-herpetic neuralgia.
Dilute in ethanol if necessary.
Answers to patients’ frequently asked Questions
• What can this herb do for me?

 Michael Thomsen
Peppermint is a safe herb for gastrointestinal disorders including dyspepsia and
irritable bowel syndrome. It is also safe for children, particularly as a herbal tea.
• When will it start to work?
Peppermint will generally have an immediate effect with the condition continuing to
improve with long-term use.
• Are there any safety issues?
Concentrated peppermint oil preparations may theoretically interact with a number of
different medications. It is unlikely any interaction will occur with peppermint tea or
simple liquid extracts. Avoid the use of peppermint oil on the face of infants and
small children.
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fungal and bacterial infections", Posit Health News no. No 17, pp. 26-7.

Anon. 2002, "Peppermint oil increases the oral bioavailability of felodipine and
simvastatin", Clinical Pharmacology & Therapeutics February, vol. 71, no. 2, p. P67.

Blumenthal, M., Goldberg A, & Brinckmann J. Herbal Medicine - Expanded


Commission E Monographs. 297-303. 2000. Newton, MA, USA, Integrative
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Ref Type: Generic

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 Michael Thomsen
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Gobel, H., Fresenius, J., Heinze, A., Dworschak, M., & Soyka, D. 1996,
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Ginger
Reference: Braun L, Herbs & Natural Supplements - An Evidence-based Guide
Historical note
Ginger has been used as both a food and medicine since ancient times. Records
suggest that it was widely used in ancient Rome, Greece, Arabia and China. It is still
extremely popular in the practice of phytotherapy, particularly in traditional Chinese
medicine which distinguishes between the dried and fresh root. It is widely used to
stimulate circulation, treat various gastrointestinal disorders and as a stimulant heating
agent.
Scientific name
Zingiber officinale Roscoe, family: Zingiberaceae
Other names
Jamaica ginger, African ginger, Indian ginger, common ginger, Rhizoma Zingiberis,
Shokyo (Japanese)
Plant part used

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Rhizome
Chemical components
The ginger rhizome contains an essential oil and resin known collectively as
oleoresin. The composition of the essential oil varies according to the geographical
origin, but the chief constituents, sesquiterpene hydrocarbons, which are responsible
for the characteristic aroma, are fairly constant.
The oleoresin contains:
• Sesquiterpenes: zingiberene, ar-curcumene, beta-sesquiphellandrene and beta-
bisabolene.
• Pungent phenolic compounds: gingerols and their corresponding degradation
products, known as shogaols.
• Other constituents include diarylheptanoids galanolactone (diterpenoid), 6-
Gingesulfonic acid), monoacyldigalactosylglycerols (Awang 1992;Bhattarai, Tran,
& Duke 2001;Charles, Garg, & Kumar 2000;Kikuzaki, Usuguchi, & Nakatani
1991;World Health Organisation 2003;Yamahara et al. 1992;Yoshikawa et al.
1992;Yoshikawa et al. 1993)
Main actions
Antiemetic activity
Ginger has demonstrated anti-emetic activity in both experimental models and human
studies, the exact mechanism of action of which is still unknown. It appears that
several key constituents and several different mechanisms are responsible.
Shogaols and gingerols have both been shown to have anti-emetic activity(Kawai et
al. 1994).
According to both animal and human studies, Ginger reduces emesis due to a
peripherally acting mechanism, acting on the gastrointestinal tract alone (Holtmann et
al. 1989). One constituent found in Ginger, galanolactone, is a serotonin receptor
antagonist which may partly explain the antiemetic effect (Huang et al.
1991a;Mustafa, Srivastava, & Jensen 1993;Yamahara et al. 1990). It also explains the
inhibitory effect of Ginger on serotonin-induced diarrhoea and antispasmodic effects
on visceral and vascular smooth muscle.
Ginger has been shown to blunt gastric dysrhythmias and nausea evoked by acute
hyperglycaemia in humans. The antiarrhythmic and antiemetic effects are thought to
be due to a blockade of prostaglandins rather than inhibition of their release
(Gonlachanvit 2001).
Gastrointestinal activity
Ginger exerts several effects in the gastrointestinal tract. It stimulates the flow of
saliva, bile and gastric secretions (Platel & Srinivasan 1996;Platel & Srinivasan
2001;Yamahara, Miki, & Chisaka 1985). Ginger has been shown to increase
gastrointestinal motility without affecting gastric emptying in several animal models
and human studies (Gupta & Sharma 2001;Micklefield et al. 1999;Phillips,
Hutchinson, & Ruggier 1993). These findings appear to support to the traditional use
of Ginger in the treatment of gastrointestinal discomfort and bloating.
Antiulcer activity
A number of in vivo studies have identified anti-ulcer activity for ginger extract and
several of its isolated constituents.
The orally administered acetone extract of ginger at a dose of 1000 mg/kg and
zingiberene, the main terpenoid in this extract, at 100 mg/kg significantly inhibited

 Michael Thomsen
gastric lesions by 97.5% and 53.6%, respectively. Additionally, the pungent principle,
6-gingerol at 100 mg/kg significantly inhibited gastric lesions by 54.5%. These results
suggest that both zingiberene and 6-gingerol are important constituents responsible
for the anti-ulcer activity of Ginger (Yamahara et al. 1988). Other constituents
demonstrating antiulcer properties in gastric ulcer models in rats include beta-
sesquiphellandrene, beta-bisabolene, ar-curcumene and shogaol isolated from ginger
rhizome. (Sertie et al. 1992;Yoshikawa et al. 1994).
Hypolipidemic activity
High doses of a water extract of ginger (500 mg/kg) significantly reduced serum
cholesterol according to an animal study which used oral doses of a raw aqueous
extract of ginger administered daily for a period of 4 weeks (Thomson et al. 2002).
Effects on triglyceridev levels are more difficult to determine as one study
demonstrated that 250 µg of ginger extract/day reduced serum triglyceride levels by
27% in mice (Fuhrman et al. 2000) whereas another study using a high dose of 500
mg/kg found no significant effects (Thomson, Al-Qattan, Al-Sawan, Alnaqeeb, Khan,
& Ali 2002).
An ex-vivo study found that a 250 µg/daily of a standardised ginger extract
significantly reduced plasma LDL cholesterol levels, the LDL basal oxidative state, as
well as LDL and serum cholesterols susceptibility to oxidation and aggregation
compared with placebo. Ginger also reduced aortic atherosclerotic lesions by 44% in
atherosclerotic mouse aorta (Fuhrman, Rosenblat, Hayek, Coleman, & Aviram 2000).
Anti-inflammatory and analgesic activity
The anti-inflammatory effects of Ginger may be due to its effects on the arachidonic
acid cascade as cyclo-oxygenase and lipoxygenase inhibition has been shown in vitro,
resulting in decreased prostaglandin and leukotriene formation (Kobayashi, Shoji, &
Ohizumi 1987). Additionally, ginger extract has been shown to inhibit thromboxane
synthase (Langner, Greifenberg, & Gruenwald 1998).
This has been shown in vivo with high oral doses of aqueous extract of ginger (500
mg/kg) which significantly lower serum prostaglandin E2 and thromboxane B2 levels
in rats (Thomson, Al-Qattan, Al-Sawan, Alnaqeeb, Khan, & Ali 2002).
No one single constituent seems to be responsible for the anti-inflammatory effect of
Ginger. An acetone extract containing gingerols, shogaols and minor compounds like
gingerenone A, [6]-gingerdiol, hexahydrocurcumin and zingerone have been shown
synergistically to produce a dose-dependent anti-inflammatory effect (Schuhbaum &
Franz 2000). Other studies have identified the gingerols and diarylheptanoids and
gingerdione as the key compounds responsible (Flynn, Rafferty, & Boctor
1986;Kiuchi et al. 1992).
Topical application of ginger cream or compresses produces an analgesic effect which
is likely to be due to a capsaicin-like effect on the release of the immunoreactive
substance P from primary afferent neurons (Onogi et al. 1992). In an animal study of
chemically induced inflammation, ginger extract reduced oedema which was partly
caused by serotonin receptor antagonism (Penna et al. 2003). Additionally, ginger oil
showed anti-inflammatory activity, significantly suppressing both paw and joint
swelling in severe adjuvant arthritis in rats (Sharma, Srivastava, & Gan 1994).
Antiplatelet activity
Ginger exerts an antiplatelet activity when taken in very high doses of at least 10 g
according to one human study (Bordia, Verma, & Srivastava 1997). According to one
randomised, double-blind study, lower doses up to 2 g have no effect on bleeding

 Michael Thomsen
time, platelet aggregation or platelet count (Lumb 1994). This lack of effect has been
demonstrated in healthy volunteers and those with non-insulin-dependent diabetes
mellitus or coronary artery disease (Bordia, Verma, & Srivastava 1997) or healthy
subjects (Janssen et al. 1996).
Antimicrobial activity
Ginger extract and several of its main constituents exhibit antimicrobial activity in
vitro and in vivo.
Ginger extract has been shown to have an antibacterial effect against Staphylococcus
aureus, Streptococcus pyogenes, Streptococcus pneumoniae and Haemophilus
collected from throat swaps of infected individuals. The Minimum Inhibitory
Concentration (MIC) of Ginger ranged from 0.0003–0.7 µg/mL, while Minimum
Bactericidal Concentration (MBC) ranged from 0.1.35–2.04 µg/mL (Akoachere et al.
2002). Ginger has also shown anti-schistosomal activity. Gingerol and shogaol
exhibited potent molluscicidal activity in vivo. Gingerol (5.0 ppm) completely
abolished the infectivity of Schistosoma spp. (blood flukes) in animal studies
(Adewunmi, Oguntimein, & Furu 1990).
Gingerols demonstrated antibacterial activity against Bacillus subtilis and Escherichia
coli in vitro (Yamada, Kikuzaki, & Nakatani 1992) and the essential oils of ginger
have been shown to have antimicrobial activity against Gram-positive and Gram-
negative bacteria, yeasts and filamentous fungi in vitro (Martins et al. 2001). Shogaol
and gingerol have demonstrated antinematode activities; 6.25 µg/mL 6-shogaol
destroyed Anisakis larvae within 16 hours in vitro, whereas the anti-nematodal
medication pyrantel pamoate had no lethal effect at 1 mg/mL (Goto et al. 1990).
Ginger constituents have also been shown to be antifungal and antiviral. Shogaol and
zingerone strongly inhibited Salmonella typhi, Vibrio cholerae and Tricophyton
violaceum. Aqueous extracts have also been shown to be effective against
Trichomonas vaginalis (Henry & Piggott 1987). Several sesquiterpenes, but
especially beta-sesquiphellandrene, isolated from Ginger have also been shown to
have anti-rhinoviral activity in vitro (Denyer et al. 1994).
Antioxidant
According to in vivo research, Ginger exerts significant direct and indirect antioxidant
effects. Orally administered Ginger significantly lowered levels of free radicals and
raised the activities of endogenous antioxidants superoxide dismutase and catalase
and had a sparing effect on vitamins C and E (Jeyakumar, Nalini, & Menon 1999).
Hepatoprotective activity
Ginger has significant hepatoprotective effects which are comparable to silymarin
according to research with experimental models of alcohol-induced liver damage
(Bhandari et al. 2003).
Antihistamine activity
Shogaols and certain gingerols exhibit dose-dependent inhibition of drug-induced
histamine release from rat peritoneal mast cells in vitro (Yamahara et al. 1995).
Anxiolytic
A combination of Ginger and Ginkgo biloba has been shown to reduce anxiety in an
animal model (elevated plus-maze test). The effect was similar to diazepam
(Hasenohrl et al. 1996). A highly non-polar fraction of a ginger extract has been
shown to possess anticonvulsant, anxiolytic and antiemetic activities in animals
(Vishwakarma et al. 2002).
Antifibrotic activity

 Michael Thomsen
Supplementation with 5 g Ginger not only prevented a decrease, but also significantly
increased fibrinolytic activity in 30 healthy adult volunteers who consumed 50 g of fat
in a meal in an open clinical study (Verma & Bordia 2001).
Apoptosis
A pungent phenolic substance found in Ginger ([6]-paradol) effectively inhibits
tumour promotion in mouse skin carcinogenesis. [6]-paradol and structurally related
derivatives have also been shown to induce apoptosis through a caspase-3-dependent
mechanism (caspase is a ‘suicidal’ cell protein, which, when activated, induces the
cell to kill itself) (Keum et al. 2002).
Positive inotropic activity
Gingerols and shogaols isolated from Ginger have positive inotropic activity, as
demonstrated on isolated heart muscle (Shoji, Iwasa, & Takemoto 1982;Yamahara,
Matsuda, Yamaguchi, Shimoda, Murakami, & Yoshikawa 1995). The effect of
gingerol seems to be rather specific to SR Ca2+-ATPase activity (Kobayashi, Shoji,
& Ohizumi 1987).
Immunomodulation
In vitro and in vivo research suggests ginger extract exerts some degree of
immunomodulatory activity and has been shown to prolong the survival of cardiac
allografts in mice significantly (Wilasrusmee, Bruch, & Kittur 2003).
Thermogenic activity
Ginger helps to maintain body temperature and inhibit serotonin-induced hypothermia
in vivo (Huang et al. 1991b;Kano, Zong, & Komatsu 1991). However, the addition of
a ginger-based sauce to a meal did not to produce any significant effect on metabolic
rate in humans (Henry & Piggott 1987).
Clinical use
Although Ginger is used in many forms, including fresh Ginger used in cooking or
chai (Indian spicy tea), pickled or glazed ginger, ethanol extracts and concentrated
powdered extracts, preparations made with the root are used medicinally.
Prevention of nausea and vomiting
Several clinical studies have investigated the effects of Ginger in the prevention and
treatment of nausea and vomiting under different circumstances (Arfeen et al.
1995;Bone et al. 1990;Meyer et al. 1995;Phillips, Ruggier, & Hutchinson
1993;Visalyaputra et al. 1998).
In 2000, a systematic review of six controlled studies investigating the effects of
Ginger in nausea and vomiting was published which found that although Ginger was
more effective than placebo in some studies of postoperative nausea and vomiting, a
non-significant difference was detected between the dose of 1 g Ginger (taken before
surgery) and placebo groups. More specifically, of the three studies conducted in
postoperative nausea and vomiting, two suggested that Ginger was superior to placebo
and equally as effective as metoclopramide, whereas one found no benefit.
Additionally, Ginger was found to be of benefit in seasickness, morning sickness and
chemotherapy-induced nausea compared to placebo (Ernst & Pittler 2000). More
recently, a Cochrane review involving 20 trials of antiemetic medications concluded
that Ginger might be of benefit, but that the evidence to date was weak (Jewell &
Young 2002).
Commission E approves the use of Ginger root for the prevention of motion sickness.
Clinical note – Morning Sickness

 Michael Thomsen
Nausea and vomiting are the most common symptoms experienced in early
pregnancy, with nausea affecting between 70% and 85% of women. About half of
pregnant women experience vomiting (Jewell 2002). Hyperemesis gravidarum is
more severe and affects between 0.3% and 2% of all pregnant women. It is a
multifactorial disease in which pregnancy-induced hormonal changes associated with
concurrent gastrointestinal dysmotility and possible Helicobacter pylori infection
function as contributing factors (Eliakim, Abulafia, & Sherer 2000).
Nausea of pregnancy
A recent double-blind, placebo-controlled, randomised clinical trial found that the
ingestion of 1 g Ginger in syrup in divided doses may be useful in some patients
experiencing nausea and vomiting in the first trimester of pregnancy. After 9 days, 10
of the 13 (77%) subjects receiving Ginger had at least a 4-point improvement on the
nausea scale. In regards to vomiting, 8 of the 12 (67%) women in the ginger group
who were vomiting daily at the beginning of the treatment stopped by day 6 (Keating
& Chez 2002).
An Australian randomised, placebo-controlled trial study with 120 women less than
20 weeks pregnant, using the Rhodes Index of Nausea, Vomiting and Retching, found
that Ginger significantly reduced nausea after the first day of treatment and onwards
compared to placebo. Retching was also reduced by the ginger extract although to a
lesser extent. However, no significant effect was observed on vomiting. Follow-up of
the pregnancies revealed normal ranges of birth weight, gestational age, Apgar scores
and frequencies of congenital abnormalities compared to the general population of
infants born at the same hospital (Willetts, Ekangaki, & Eden 2003).
Motion sickness
Several clinical studies have assessed the effects of Ginger in the prophylaxis or
treatment of motion sickness. An early double-blind randomised placebo – controlled
study involving 80 naval cadets found that Ginger was significantly superior to
placebo in reducing symptoms of vomiting and cold sweats due to seasickness.
Remarkably fewer symptoms of nausea and vertigo were also reported; however, the
difference between Ginger treatment and placebo was not statistically significant in
this instance (Grontved & Hentzer 1986). In another randomised, double-blind study
of seasickness involving over 1700 tourists on a whale-watching safari 300 km north
of the Arctic cycle, 500 mg Ginger was found to be as effective for the treatment of
motion sickness as several common antiemetic medications (cinnarizine, cyclizine,
dimenhydrinate, domperidone, meclizine and scopolamine). On ethical grounds, a
placebo group was not included. Ginger treatment prevented seasickness in 80% of
the subjects during the six-hour boat trip, although the incidence of severe vomiting
did not differ significantly between treatment groups (Schmid et al. 1994).
Two clinical studies have been conducted in experimental models whereby subjects
are seated in a rotating chair to initiate motion sickness and the effects of test drugs
are documented. The first study published involved 28 volunteers and found no
significant protective effects for powdered Ginger (whole root, 500 mg or 1000 mg)
or fresh ginger root (1000 mg) (Stewart et al. 1991).
More recently, a double-blind, randomised placebo-controlled crossover study
showed positive benefits with Ginger pretreatment on prolonging time before nausea,
shortening recovery time and effectively reducing nausea (Lien et al. 2003). This
study used higher pretreatment doses of 1000 mg and 2000 mg, which were also
shown to reduce tachygastria and plasma vasopressin.
Postoperative nausea

 Michael Thomsen
Ginger may be useful for the prevention of postoperative nausea, although not all
studies have produced positive results. One randomised, double-blind study failed to
show any benefit in patients undergoing gynecological laparoscopy (Eberhart et al.
2003),whereas two other randomised, placebo-controlled, double-blind studies found
Ginger reduced the incidence of nausea and vomiting in women undergoing
gynaecological surgery (Bone, Wilkinson, Young, McNeil, & Carlton 1990;Phillips,
Ruggier, & Hutchinson 1993). These last two studies have been criticised as the use
of the propofol (Diprivan), which has antiemetic properties, was also used during
anaesthesia and may have influenced the results. No beneficial effect for Ginger (500
mg or 1000 mg) was observed in a similar study of nausea after gynaecological
surgery (Arfeen, Owen, Plummer, Ilsley, Sorby-Adams, & Doecke 1995). Alternately,
a 2003 study found that Ginger (1000 mg) taken 1 hour before surgery was
significantly superior to placebo in reducing the incidence of nausea after outpatient
gynecological laparoscopy during the first 2–4 hours after surgery. The incidence and
frequency of vomiting were lower compared to placebo, but not statistically different
(Pongrojpaw & Chiamchanya 2003).
Chemotherapy-induced nausea
Powdered ginger root effectively reduced cyclophosphamide-induced nausea and
vomiting in a randomised, prospective, crossover, double-blind study. The antiemetic
effect of Ginger was found to be equal to metoclopramide, although ondansetron was
superior to both of these treatments (Sontakke, Thawani, & Naik 2003).
In an open study, 1.5 grams of Ginger was found to decrease psoralen-induced nausea
in 11 patients treated with photopheresis for cutaneous T-cell lymphoma (Meyer,
Schwartz, Crater, & Keyes 1995).
Musculoskeletal disorders
Ginger is described in Ayurvedic (Traditional Indian) and Tibb (Traditional Arabian)
systems of medicine to be useful in inflammation and rheumatism. Ginger is
considered a dual inhibitor of the inflammatory eicosanoids by being an inhibitor of
both prostaglandin and leukotriene biosynthesis.
A randomised, double-blind, placebo controlled, multicenter, parallel-group, 6-week
study of 261 patients found that a highly purified and standardised ginger extract
moderately reduced the symptoms of osteoarthritis of the knee (Altman & Marcussen
2001). An open retrospective study involving 56 patients (28 with rheumatoid
arthritis, 18 with osteoarthritis and 10 with muscular discomfort) revealed that more
than three-quarters experienced varying degrees of relief of pain and swelling from
the long-term use of powdered ginger. Although encouraging, the lack of placebo
makes it difficult to determine the clinical significance of these effects (Srivastava &
Mustafa 1992).
Comparative study
Ginger extract was compared with placebo or ibuprofen in patients with osteoarthritis
of the hip or knee under double-blind, crossover study conditions and was found to
produce a statistically significant effect as demonstrated by explorative statistical
methods in the first period of treatment before crossover. Interestingly, a significant
difference was not observed in the study as a whole. The authors noted that Ginger
might need to be administered for longer than 3 weeks, and possibly in a higher
dosage to be clinically effective (Bliddal et al. 2000).
Dyspepsia

 Michael Thomsen
Ginger stimulates the flow of saliva, bile and gastric secretions and therefore, is
traditionally used in the symptomatic treatment of dyspepsia. Additionally, it has been
used to stimulate appetite, reduce flatulence and colic, gastrointestinal spasms and
generally act as a digestive aid.
Commission E approves the use of Ginger root for the treatment of dyspepsia.
Other uses
Ginger is also used to prevent and treat migraine headache. Its ability to inhibit
thromboxane A2 and exert antihistamine, anti-inflammatory and gastric actions make
it a theoretically attractive choice (Mustafa & Srivastava 1990b). It is also used to
treat dysmenorrhea. Externally, ginger cream or compress is used for mastitis.
Dosage range
The recommended dose ranges from 500 mg to 9 g daily of dried root or equivalent,
depending on the indication for use.
Doses according to clinical studies
• Chemotherapy-induced nausea: 1.5 g dried root (Meyer, Schwartz, Crater, &
Keyes 1995).
• Poor appetite, indigestion: 2–4 g dried root (World Health Organisation 2003)
• Hyperemesis gravidarum: 1–2 g dried root daily (Fischer-Rasmussen et al. 1991).
• Migraine: 1.5–2 g dried root (Mustafa & Srivastava 1990a).
• Motion sickness: 1 g dried root 30 minutes before travel, then 0.5–1.0 g every 4
hours (Muller JL & Clauson KA 1997).
• Nausea/vomiting: 0.5–2.0 g dried root daily (Grontved & Hentzer 1986;Schmid,
Schick, Steffen, Tschopp, & Wilk 1994).
• Postoperative nausea: 0.5–1.0 g dried root daily (Pongrojpaw & Chiamchanya
2003). Higher doses may be more beneficial (The World Health Organisation
monograph recommends 0.5 g, 2-4 times daily) (World Health Organisation 2003).
• Arthritis: 1.0–2.0 g dried root daily or higher (Srivastava & Mustafa 1992).
Adverse reactions
Gastric irritation, heartburn and bloating have been reported in clinical trials (Arfeen,
Owen, Plummer, Ilsley, Sorby-Adams, & Doecke 1995). Contact dermatitis of the
fingertips has also been reported (Seetharam & Pasricha 1987).
Significant interactions
Controlled studies are not available for many interactions; therefore they are based on
evidence of activity and are largely theoretical and speculative.
Warfarin
Due to the herb’s antiplatelet effects at high doses, a theoretical interaction exists so
caution is advised. However, there is no evidence of an interaction with warfarin
(Stenton, Bungard, & Ackman 2001;Vaes & Chyka 2000) and Ginger has been
shown not to alter prothrombin times in pooled human plasma collected from male
volunteers between the ages of 18 and 57 years (Jones, Miederhoff, & Karnes 2001).
A standardised ginger extract, EV.EXT 33 has been shown to have no significant
effect on coagulation parameters or on Warfarin-induced changes in blood
coagulation in rats (Weidner & Sigwart 2000).
Contraindications and precautions

 Michael Thomsen
Ginger is not recommended for children under 6 years of age due to the pungent
nature of Ginger.
Commission E suggests people with gallstones consult with their physician before
using Ginger.
Pregnancy use
Although Commission E suggests ginger is contraindicated in pregnancy, more recent
research in pregnant women suggests that ginger is not contraindicated in pregnancy.
Doses up to 2 g daily of dried ginger root have been used safely.
No adverse effects on pregnancy were observed in study of 70 women treated for
nausea and vomiting with 1 g Ginger for four days (Vutyavanich, Kraisarin, &
Ruangsri 2001) A study of 27 pregnant women suffering hyperemesis gravidarum
found that 1 g Ginger for four days caused no adverse reactions during pregnancy and
all infants were normal (Fischer-Rasmussen, Kjaer, Dahl, & Asping 1991).
Practice points/patient counseling
• Ginger exerts myriad different pharmacological effects in the body. However, its
anti-emetic, anti-inflammatory and gastrointestinal effects are most often employed
clinically.
• There is good clinical support for the use of Ginger in the treatment of nausea and
vomiting associated with motion sickness, vomiting in pregnancy and seasickness.
Evidence of effectiveness in postoperative nausea is less convincing.
• Ginger is traditionally used for gastrointestinal disorders including dyspepsia,
poor appetite, flatulence, colic, vomiting, diarrhoea and spasms, as well as a
diaphoretic in the treatment of the common cold and influenza.
• It is also used as an anti-inflammatory agent for arthritis, although large controlled
studies have yet to produce strong support for this use.
• Although antiplatelet effects have been reported, this requires very large doses and
is not likely to be significant in normal therapeutic doses or dietary intake levels.
Answers to patients’ frequently asked Questions
• What can this herb do for me?
Ginger may be useful in the treatment of nausea and vomiting associated with motion
sickness, postoperative nausea, vomiting in pregnancy and seasickness. It is also
useful for treating symptoms of dyspepsia and may have anti-inflammatory effects in
arthritis, although this is less certain.
• When will it start to work?
In the case of dyspepsia and motion sickness prevention, Ginger will have an almost
immediate effect, with improvement reported within 30 minutes. For motion
sickness, 0.5–1.0 g Ginger should be taken 30 minutes before travel and repeated four
hourly. For nausea of pregnancy it should be taken for at least four days.
• Are there any safety issues?
Ginger is well tolerated, although it should be used with caution by people with gall
stones.
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 Michael Thomsen
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 Michael Thomsen
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 Michael Thomsen
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 Michael Thomsen
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 Michael Thomsen
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Probiotics – to improve intestinal flora


Reference: Braun L, Herbs & Natural Supplements - An Evidence-based Guide
Historical note
The term probiotics was first coined in 1965 in reference to substances produced by
protozoa, which stimulated the growth of other organisms. It has since been applied to
those microorganisms found naturally in foods which are able to improve health by
stimulating the growth of beneficial organisms. The use of foods containing
microorganisms for improving health has a long traditional use. Metchnikoff, a Nobel
laureate, stated in 1908 that ‘ingested lactobacilli can displace toxin-producing
bacteria, promoting health and prolonging life’ (Elmer 2001). Although it has taken
the most part of a century for scientists to investigate their health benefits, there are
now over 1200 studies on probiotics on Medline, the majority published since 2000.
Background and relevant pharmacokinetics
The generally accepted definition of probiotics is ‘a live microbial food supplement
which beneficially affects the host animal by improving its intestinal microbial
balance’. This definition is, however, rather limited as some probiotics are transient
and do not take up residence in the intestinal tract. A better definition may be that
probiotics are a ‘microbial dietary supplement that beneficially affect the host
physiology by modulating mucosal and systemic immunity, as well as improving
nutritional and microbial balance of the intestinal tract’.(Salminen et al. 1998)
The gastrointestinal tract is sterile at birth. Normal gut flora develops gradually over
time and is influenced by factors such as composition of the maternal gut microflora,
diet, degree of hygiene, use of antibiotics or other medication, the environment and
possibly genetic aspects. Once established, a person’s individual gut flora remains
surprisingly constant throughout life. This is likely to be due to the fact that the gut
immune system learns to recognise and tolerate those bacterial species acquired
during early infancy. It is therefore very difficult to alter the composition of the gut

 Michael Thomsen
flora after this time. Successful colonisation with probiotics is therefore most often
transient as the gastrointestinal tract has many defenses that inhibit this
process.(Vanderhoof & Young 2002) The intestines are host to 1014 microbes
representing 400 to 500 different species.(Ouwehand, Isolauri, & Salminen 2002)
Clinical note – Prebiotics
There is another concept associated with the microflora and intestinal health: pre-
biotics. Prebiotic refers to the use of compounds that modify the environment of the
gastrointestinal tract to favour proliferation of the beneficial components of the
intestinal microflora.(Gibson & Roberfroid 1995) Herbal and nutritional prebiotics
include the fibre-supplement known as slippery elm (Ulmus fulva), oligofructose and
inulin. The prebiotic approach, while promising, has not been thoroughly tested by
controlled clinical trials.
Clinical note – The hygiene hypothesis
The intestinal tract is the largest immune organ of the body. It produces more
antibodies than any other part of the body and contains 80% of all antibody-producing
cells. The intestinal mucosa functions as a barrier against infections, but it also
provides communication between the different mucosal surfaces of the
body.(Ouwehand, Isolauri, & Salminen 2002)
At birth, the gastrointestinal tract is sterile. Normal gut flora develops gradually over
time and is influenced by factors such as composition of the maternal gut microflora,
diet, degree of hygiene, use of antibiotics or other medication, the environment and
possibly genetic aspects. Studies in germ-free mice have shown that without these
bacteria, the systemic immune system will not function normally.(Vanderhoof &
Young 2002)
In the absence of microbes, a mammal develops fewer Peyer’s patches (part of the
gut-associated lymphoid tissue (GALT)) and less than 10% of the number of IgA
producing B cells compared to a conventional animal. However, on exposure to a
normal microflora, previously germ-free animals develop their immune system very
much like conventional animals. This indicates that the intestinal microflora is
instrumental in the proper development of the immune system(Ouwehand, Isolauri, &
Salminen 2002) and has led to the emergence of the ‘hygiene theory of immune
disorders’.
More specifically, the hygiene hypothesis suggests that improved hygienic conditions
and vaccinations, which reduce early-life exposure to microbes, are associated with a
heightened risk of allergic disease and other immune disorders. This is because
reduced exposure may result in reduced stimulation of the immune system. As a
result, lymphocytes that would normally differentiate to become Th1 type,
differentiate to Th2 types cells and produce inflammatory cytokines in the allergic
response in much greater quantities. As such, very early stimulation of the immune
system is important in dampening the Th2 dominance and reducing the development
of IgE-mediated food reactions as well as other allergic reactions. In a closely
observed cohort of 329 Finnish children it was shown that the earlier an acute
respiratory infection occurred, the greater the protective effect was against atopic
eczema.(Vanderhoof & Young 2003)
The obvious solution for increasing microbial exposure without increasing the health
risk is the use of prebiotics and probiotics. Supplementation with probiotics has been
shown to both reduce the risk and treat the symptoms of childhood eczema (see
below).

 Michael Thomsen
Modulating the intestinal microflora with probiotics and prebiotics (fibre) may be an
effective and safe therapy for the natural development of a balanced immune defence
in infants and children. In adults and the elderly, prebiotica and probiotics may be
used to improve the general functioning of the immune system.
Chemical components
Probiotics include Streptococcus thermophilus, Bifidobacterium bifidum,
Lactobacillus reuteri, Lactobacillus acidophilus, Lactobacillus bulgaricus,
Lactobacillus plantarum, bifidobacteria, Lactobacillus casei, Lactobacillus strain LB,
Saccharomyces boulardii (a yeast), Streptococcus salivarius, Lactobacillus gassen and
Lactobacillus GG (named after Drs Gorbach and Goldin who first isolated the strain
in 1980).
Food sources
Yoghurt may contain probiotics, especially Lactobacillus acidophilus and
bifidobacterium strains.
Deficiency signs and symptoms
Clear deficiency signs are difficult to establish as the symptoms may vary
enormously. Local signs and symptoms of an imbalance of the intestinal flora
(intestinal dysbiosis) include bloating, flatulence, abdominal pain, diarrhoea and/or
constipation and fungal overgrowth (such as candia).
Imbalance of the intestinal flora may result from the use of antibiotics, chronic
diarrhoeal states or constipation. Additionally, babies exclusively fed on infant
formulas will have slower colonisation of the gut than those who are breastfed as
breast milk allows for the transfer of oligosaccharides to the baby. This appears to be
of particular concern in premature babies requiring intensive care as they acquire
intestinal organisms slowly, which allows for the colonisation of bacterial species
which tend to be virulent. It has been suggested that the aberrant colonisation of the
premature infant’s gut may contribute to the development of necrotising enterocolitis
and therefore probiotics supplementation may be a useful approach for
prevention.(Dai & Walker 1999)
Main actions
The positive effects of probiotics are a result of several different mechanisms at work.
Enhanced immune response
Immune system modulation and the prevention of gastrointestinal tract (GIT)
colonisation by a variety of pathogens are perhaps the most important actions of
probiotics.
Probiotics bind to intestinal epithelial cells and inhibit the binding of pathogenic
bacteria to the gut wall by production of inhibitory substances such as bacteriocins,
lactic acid and toxic oxygen metabolites. Of the toxic oxygen metabolites, hydrogen
peroxide is of major importance as it exerts a bactericidal effect on many
pathogens.(Kaur, Chopra, & Saini 2002) Binding to the gut wall also initiates
signalling events that result in the synthesis of cytokines.(Vanderhoof & Young 2003)
Studies in germ-free mice have proven that intestinal bacteria are essential for a
healthy systemic immune system.(Falk et al. 1998)
The LGG strain (Lactobacillus GG, a variant of Lactobacillus casei subsp.
Rhamnosus) has been well studied in this regard and shown to modulate intestinal
immunity by increasing the number of IgA and other immunoglobulin-secreting cells
in the intestinal mucosal and stimulates the local release of interferons.

 Michael Thomsen
Helicobacter pylori infection
Several in vitro studies have shown that certain probiotics inhibit or kill H. pylori,
prevent its adhesion to mammalian epithelial cells and prevent interleukin-8 release.
In vivo models demonstrate that pretreatment with a probiotic can prevent H. pylori
infections and/or that administration of probiotics markedly reduced an existing
infection.
Digestive processes
The gut bacteria carry out a number of biochemical functions including deconjugation
and dehydroylation of bile acids, the conversion of bilirubin to urobilinogen, the
metabolism of cholesterol to coprostanol, production of vitamins K, B1, B2, B6, B12
and generation of short-chain fatty acids. Probiotics are involved in balancing colonic
microbiota and aid in the treatment of diarrhoea associated with travel and antibiotic
therapy, and control of rotavirus and Clostridium difficile-induced colitis.
Chemopreventative effects
A variety of mechanisms is responsible for the chemopreventative effect
demonstrated for some probiotics strains.
Anti-mutagenic activity against chemical mutagens and promutagens has been
demonstrated for different strains of Lactobacillus acidophilus, Bifidobacteria and of
organic acids usually produced by these probiotic bacteria, with live cells producing
the most positive results.(Lankaputhra & Shah 1998) Some probiotics also reduce
faecal enzymes implicated in cancer initiation, by producing butyric acid which
affects the turnover of enterocytes and neutralises the activity of dietary carcinogens,
such as nitrosamines. Additionally, enhancing host immunity and qualitative and
quantitative changes to the intestinal microflora and physicochemical conditions are
important contributing factors.(Hirayama & Rafter 1999)
Cholesterol lowering activity
This has been established in several clinical trials.
Allergy
High level antigen exposure during the first few months of life is suspected of
predisposing individuals to allergic sensitisation and therefore various atopic
conditions. The intestinal microflora plays a major protective role against the
development of allergy because it reduces antigen transport through the intestinal
mucosa.
Clinical use
It is generally agreed that a probiotic must be capable of colonising the intestinal tract
to influence human health. Currently, one of the most extensively studied probiotics is
Lactobacillus GG (LGG), a variant of Lactobacillus casei subsp. Rhamnosus.
Infantile diarrhoea
In a double-blind, placebo-controlled trial, infants aged five to 24 months who were
admitted to a chronic medical care hospital were randomly assogned to receive a
standard infant formula or the same formula supplemented with Bifidobacterium
bifidum and S. thermophilus; 55 subjects were evaluated for 17 months. The infant
formula supplemented with the probiotics reduced the incidence of acute diarrhoea
and sharply reduced rotavirus shedding in infants admitted to hospital.(Elmer
2001;Saavedra 2000)

 Michael Thomsen
Another study of 175 children aged six to 36 months found that children receiving
bifidobacteria-supplemented milk-based formula may be protected against
symptomatic rotavirus infection.(Phuapradit et al. 1999)
Travelers’ diarrhoea
Travelers’ diarrhea is the most common health problem in those visiting developing
countries, affecting 20% to more than 50% of tourists. Although it is usually benign,
travelers’ diarrhoea represents a considerable socioeconomic burden for both the
traveler and the host country. The most common enteropathogens are Escherichia
coli.
Some clinical studies have found various probiotics somewhat effective against
travelers’ diarrhoea, however no probiotic has been able to demonstrate clinically
relevant protection worldwide.(Rendi-Wagner & Kollaritsch 2002)
A large randomised, placebo-controlled, double-blind study was conducted on the
efficacy of Lactobacillus GG in preventing travelers’ diarrhoea which involved 820
people on holiday to Turkey to two destinations. The group was randomly assigned
either Lactobacillus GG or placebo in identical sachets. On the return flight each
participant completed a questionnaire indicating the incidence of diarrhoea and related
symptoms during the trip. Of the original group 756 (92%) subjects completed the
study. The overall incidence of diarrhoea was 43.8% (331 cases) and the total
incidence of diarrhoea in the Lactobacillus GG group was 41.0% compared to 46.5%
in the placebo group, indicating an overall protection of 11.8%. Protection rates
varied between two different destinations with the maximum protection rate reported
as 39.5% and no side effects reported.(Oksanen et al. 1990)
In another placebo-controlled, double-blind study, various doses (250‫ٱ‬mg and
1000‫ٱ‬mg) of Saccharomyces boulardii were administered prophylactically to 3000
Austrian travellers to distant regions. A significant reduction in the incidence of
diarrhoea was observed, with success depending directly on the rigorous use of the
preparation. A tendency was noted for Saccharomyces boulardii to have a varying
regional effect, which was particularly marked in North Africa and in Turkey. In
addition, the effect also proved to be dose-dependent and considered very
safe.(Kollaritsch et al. 1993)
Acute diarrhoea
Different probiotic preparations are of benefit as an addition to oral rehydration for
acute diarrhoea. L. reuteri, S. boulardii, E. faecium, SF68 and L. rhamnosus GG have
all been shown to reduce the number of days of diarrhoea in studies conducted in
various countries. The most consistent benefit was observed in patients with rotaviral
diarrhoea.(Dorren 2002) Treatment with S. boulardii was found to speed up recovery
from acute diarrhoea both in adults and infants. Two studies have found probiotics
beneficial in the treatment of AIDS-related diarrhoea. AIDS-associated diarrhoea
resolved in 10 of 18 patients given S. boulardi (3‫ٱ‬g daily of the yeast) for 1 week,
compared with 1 of 11 patients given placebo. In another study, a similar protocol
improved the condition of 7 of 11 patients in weeks 2 to 4.(Elmer 2001)
Antibiotic induced diarrhoea
According to a 2002 meta-analysis, Lactobacilli and Saccharomyces boulardii is
superior to placebo in preventing antibiotic-associated diarrhoea. Nine randomised,
double-blind, placebo-controlled trials of probiotics were identified, two of which
involved children, four using the yeast S. boulardii, four using Lactobacilli, one using
a strain of enterococcus-producing lactic acid, and three using a combination of
probiotic strains of bacteria.

 Michael Thomsen
In all nine trials, probiotics were given in combination with antibiotics whereas the
control groups received placebo with their antibiotic treatment. The odds ratio in
favour of active treatment over placebo in preventing diarrhoea associated with
antibiotics was 0.39 (P<0.001) for S. boulardii and 0.34 (P<0.01) for
lactobacilli.(D'Souza et al. 2002)
Urogenital infections
Probiotics are widely used to decrease the frequency of recurrent bacterial vaginosis
and candidal vulvovaginitis and have undergone clinical testing which supports this
use. They are administered both orally and intravaginally for this purpose.
Additionally, intravaginal administration of probiotics such as Lactobacillus GR-1
and B-54 or RC-14 strains has been shown to reduce the risk of urinary tract
infections, and improve the maintenance of normal flora.(Reid & Burton 2002)
The mechanisms by which lactobacillus reduces bacterial vaginosis and urinary tract
infections appear to involve anti-adhesion factors, byproducts such as hydrogen
peroxide and bacteriocins lethal to pathogens, and perhaps immune modulation or
signaling effects. Bifidobacteria in particular are considered well suited to this activity
and have therefore been investigated for their effects in the treatment of female
genitourinary infections.(Korshunov et al. 1999)
Oral supplementation
In a study of ten women whose vaginal bacterial flora were abnormal and had
suffered repeated bacterial vaginosis, yeast infections and/or urinary tract infections, a
regimen was prescribed of ingesting 109 viable GR-1 and RC-14 bacteria each day. In
a majority of patients with symptoms of suprapubic and micturition pains, frequency,
dysuria and urgency, or vaginal irritation, the symptoms disappeared within 1–2
weeks and all the patients remained healthy for several months following
treatment.(Reid 2001a)
In another study, forty-two healthy women were randomly assigned to receive either
Lactobacillus rhamnosus GR-1 with L. fermentum RC-14; or L. rhamnosus GG by
itself. On assessment, the vaginal flora was only normal in 40% of cases and 14
patients had asymptomatic bacterial vaginosis. Oral treatment with 108 viable L.
rhamnosus GR-1/L. fermentum RC-14 once and twice daily re-established a healthy
vaginal flora in up to 90% of patients, and 7/11 patients with bacterial vaginosis
converted to normal or intermediate scores within 1 month. Treatment with L.
rhamnosus GG failed to have an effect.(Reid et al. 2001)
A randomised, placebo-controlled study of 64 healthy women has confirmed that oral
administration of probiotics including Lactobacillus rhamnosus GR-1 and
Lactobacillus fermentum RC-14 can restore asymptomatic bacterial vaginosis
microflora to a normal lactobacilli colonised microflora and reduce pathogenic
bacteria. Significant results were obtained after 60 days’ treatment with no adverse
effects reported.(Reid et al. 2003)
It is sometimes asked how oral ingestion of probiotics can have an effect on the
urogenital tract. Recent research has discovered that orally ingested Lactobacillus
strains GR1 and RC-14 pass through the gut and ascend from the rectum to colonise
the vagina and/or enhance the indigenous vaginal lactobacilli numbers.
Probiotic enriched dairy products
A small, randomised study of 46 participants showed that ingestion of 150‫ٱ‬mL of L.
acidophilus-enriched yoghurt was associated with an increased prevalence of
colonisation of the rectum and vagina by the bacteria and may have contributed to

 Michael Thomsen
reduced episodes of bacterial vaginosis.(Dorren 2002) Another crossover study of 33
women with recurrent vaginitis found that daily ingestion of 240‫ٱ‬mg of yogurt
containing Lactobacillus acidophilus for one year decreased both candidal
colonisation and infection.(Hilton et al. 1992)
Vaginal insertion
A randomised, double-blind, study investigated the effectiveness of treatment with a
weekly suppository containing either 0.5‫ٱ‬g L. rhamnosus GR-1 and L. fermentum B-
54 or a Lactobacillus growth factor for one year in 55 premenopausal women.
Treatment resulted in the urinary tract infection rate decreasing by 73% and 79%
respectively with no adverse effects reported.(Reid 2001b)
Irritable bowel syndrome (IBS)
People suffering from IBS sometimes experience symptoms of abdominal cramping
and either diarrhoea, constipation or a combination of both. Although the aetiology of
IBS is still unknown, there is growing suspicion that it is associated with an
imbalance of intestinal flora. As such, clinical trials have been conducted to clarify
the role of probiotics in this condition, so far producing promising results.
In a 4-week, double-blind, placebo-controlled trial, 60 people with IBS were treated
with L. plantarem or placebo. The patients recorded their own gastrointestinal
function starting 2 weeks before the study and continuing throughout the study period.
Twelve months after the end of the study, all patients were asked to complete a
questionnaire. The study showed significant reductions in intestinal flatulence in the
treatment group compared to placebo. At the 12-month follow-up, patients in the test
group maintained a better overall gastrointestinal function than control
patients.(Nobaek et al. 2000)
In another study, 40 patients were randomly assigned either Lactobacillus plantarum
299V in liquid suspension or placebo over a period of 4 weeks. All patients treated
with the probiotic reported resolution of their abdominal pain as compared to 11
patients from a placebo group. There was also a trend towards normalisation of stool
frequency in constipated patients for 6 out of 10 patients treated with the probiotic
compared with 2 out of 11 treated with placebo. With regard to all IBS symptoms, an
improvement was noted in 95% of patients in the active group compared to 15% of
patients in the placebo group (P<0.0001).(Niedzielin, Kordecki, & Birkenfeld 2001)
Inflammatory bowel diseases
Clostridium difficile is the most common cause of diarrhoea from treatment with
antimicrobial/antibiotic medication and has the potential for progression to colitis,
pseudomembranous colitis, toxic megacolon and death. In spite of antimicrobial
therapy, recurrence is common. The S. boulardii strain of bacteria is being used to
restore microbial balance and inhibit C. difficile proliferation.(Elmer 2001)
A placebo-controlled study of 124 patients with documented, symptomatic C.
difficile-associated disease, compared the effects of a standard course of
metronidazole or vancomycin together with 4 weeks of 0.5‫ٱ‬g S. boulardii treatment
twice daily. Statistical analysis showed that the probiotic group had a significantly
lower relative risk of recurrence (0.43) than the placebo group.(McFarland et al.
1994)
A larger double-blind, multicentre trial of 168 patients demonstrated that S. boulardii
plus a 10-day regimen of vancomycin 2‫ٱ‬g/day reduced the rate of recurrence of C.
difficile-associated disease to 16.7% versus 50% for the placebo group.(Surawicz et
al. 2000)

 Michael Thomsen
Probiotics are also being used as adjunctive therapy for Crohn’s disease and
inflammatory bowel disease.(Goh & O'Morain 2003;Guslandi 2003a;Guslandi
2003b;Jonkers & StockbrUgger 2003;Kanauchi et al. 2003;Karthik 2003;Marteau,
Seksik, & Shanahan 2003;Rutgeerts 2003)
Pouchitis
Pouchitis is the most common long-term complication of ileal pouch-anal anastomosis
in patients with underlying ulcerative colitis. Clinical symptoms of pouchitis are not
specific, and they can be caused by other conditions such as rectal cuff inflammation
and irritable pouch syndrome. Therefore, to make an accurate diagnosis, endoscopic
evaluation together with symptom assessment is necessary. Although antibacterial
therapy can induce and maintain remission, probiotics can also be used to maintain
clinical remission and prevent relapse in patients with relapsing or chronic
pouchitis.(Kailasapathy & Chin 2000)
Helicobactor pylori infection
A review(Hamilton-Miller 1997) of thirteen clinical trials published on probiotics and
helicobactor infection summarises the results as follows:
• In six trials involving a total of 180 patients, sole treatment with probiotics
produced positive results in five studies. In three trials, there were significantly
reduced breath test readings and in two others some patients were cleared of
infection.
• In seven further trials of 682 patients in total, probiotics were added to a
therapeutic regimen of antibiotics, resulting in an increased cure rate in two
studies, and reduced side effects in four. Trials in which fermented milk products
or whole cultures of lactobacilli were used tended to show better results than when
the probiotic was taken in the form of bacteria alone.
It must be noted that not all the studies were randomised, double-blind and placebo
controlled, and some involved only small numbers of patients. However, the positive
results obtained suggest that probiotics may have a place as adjunctive treatment in H.
pylori infections and possibly in prophylaxis.
Other uses
Food allergies
High level antigen exposure during the first few months of life is suspected of
predisposing individuals to allergic sensitisation and therefore various atopic
conditions such as skin reactions and even systemic or respiratory manifestations.
Intestinal inflammation seems to be a predisposing factor in increased sensitisation of
a subject (Holt 1994) which in turn, promotes further inflammation when antigen
exposure occurs.
Considering that gut microflora is an important factor in regulating both the intestinal
and systemic immune system, probiotics are used to promote endogenous barrier
mechanisms, reduce gut permeability and alleviate intestinal inflammation in patients
with atopic dermatitis and food allergy.7,(Majamaa & Isolauri 1997) A one-month
study of 10 breast-fed infants who had atopic eczema and cow’s milk allergy found
that Lactobacillus GG reduced certain faecal inflammatory markers.
Eczema
A randomised, double-blind placebo-controlled study showed that perinatal
administration of probiotics (Lactobacillus rhamnosus GG) reduced the development
of atopic eczema in children by half during the first 2 years of life. Some 159 mothers

 Michael Thomsen
were randomly allocated to receive two capsules of placebo or 1010 viable
Lactobacillus GG daily for 4 weeks before expected delivery. After delivery, capsules
were taken postnatally for 6 months. During lactation either the mother or the infant
consumed the preparations. In a 4-year follow-up study, it was revealed that the
preventive effect of the probiotic on atopic eczema extended beyond
infancy.(Kalliomaki et al. 2003)
A recent randomised, double-blind study has found that supplementation of infant
formulas with viable but not heat-inactivated Lactobacillus GG may have benefits for
the management of atopic eczema and cow’s milk allergy.(Kirjavainen, Salminen, &
Isolauri 2003)
Immune stimulation
In a 12-week, double-blind, placebo-controlled three-stage before-and-after
intervention trial of 25 healthy elderly individuals, one-half were given milk
containing a specific strain of Bifodobacterium lactic HN019, while the other half
were given milk alone. Dietary consumption of the probiotic enhanced immune
function of two different types of leucocytes; the degree of enhancement was
increased by consuming B. lactis in an oligosaccharide-rich substrate.(Chiang et al.
2000)
In another 7-month, double-blind, placebo-controlled study of 571 children in daycare
centres in Finland, milk fortified with Lactobacillus GG reduced the number and
severity of respiratory infections. The effects of the probiotic were modest but
consistent.(Hatakka et al. 2001)
A 9-week, three-stage, pre and post-intervention trial with 52 healthy middle-aged
and elderly volunteers found that dietary consumption of L. rhamnosus HN001, in a
base of low-fat milk or lactose-hydrolysed low-fat milk, enhanced systemic cellular
immune responses. The phagocytic activity of peripheral blood polymorphonuclear
(PMN) leukocyte activity and in vitro tumoricidal activity of natural killer (NK)
leukocytes increased by 19% and 15%, respectively. The relative level of NK cell
tumour killing activity increased by 71% and 147%.(Sheih et al. 2001)
High Cholesterol
A meta-analysis of six studies of a probiotic dairy product containing Enterococcus
faecium found that the fermented yoghurt product produced a 4% decrease in total
cholesterol and a 5% decrease in LDL-cholesterol.(Agerholm-Larsen et al. 2000)
In another study, 32 subjects with serum total cholesterol ranging from 5.7 to
7.25‫ٱ‬mg/dL were randomly assigned to two treatments: 1) intake of a low-fat drinking
yogurt prepared with ordinary yogurt starters composed of S. thermophilus and L.
delbrueckii subsp. bulgaricus (placebo group) and 2) intake of a low-fat drinking
yogurt prepared with the two ordinary yogurt starters plus B. longum strain BL1
(probiotic group). After intake for 4 weeks at 3 x 100‫ٱ‬mL/day, reduction of serum
total cholesterol was observed in approximately half of the probiotic group subjects; a
particularly significant decrease in serum total cholesterol was found among subjects
with moderate hypercholesterolaemia (serum total cholesterol >6.2‫ٱ‬mg/dL). The
serum lipid concentrations in the placebo group subjects were almost stable during the
experimental periods.(Xiao et al. 2003)
A cross-over study of 29 healthy women, aged 19–56 years, found that the long-term
daily consumption of 300‫ٱ‬g of two different types of yoghurt over a period of 21
weeks increased the serum concentration of HDL cholesterol and led to the desired
improvement of the LDL/HDL cholesterol ratio. The normal yoghurt contained 3.5%
fat and starter cultures of Streptococcus thermophilus and L. lactis while the probiotic

 Michael Thomsen
yoghurt was enriched with L. acidophilus 145, B. longum 913 and 1% oligofructose.
The mean serum concentration of total cholesterol and the LDL cholesterol was not
influenced by the normal yoghurt (P>0.05). However, both the normal and the
probiotic yoghurt increased the HDL concentration significantly, by 0.3‫ٱ‬mmol/L
(P=0.002) and decreased the LDL/HDL ratio decreased from 3.24 to 2.48
(P=0.001).(Kiessling, Schneider, & Jahreis 2002)
A recent controlled, randomised, double-blind study of 36 heavy smokers found that
400‫ٱ‬mL/d of a rose-hip drink containing L. plantarum 299v (5 x 10(7) colony-forming
units/mL) led to a reduction in cardiovascular disease risk factors. Significant
decreases in systolic blood pressure and fibrinogen were recorded in the experimental
group. No such changes were observed in the control group. Decreases in F(2)-
isoprostanes (markers of oxidative stress) (37%) and interleukin-6 (42%) were also
noted in the experimental group in comparison with baseline. Monocytes isolated
from subjects treated with L. plantarum showed significantly reduced adhesion
(P<0.001) to endothelial cells.(Naruszewicz et al. 2002)
Dosage range
As more information is gathered from probiotic research, it is becoming evident that
certain strains or combination of strains are suitable for different conditions. Different
strains of probiotics are chosen and combined to produce specific products for
diarrhoea in children, antibiotic-induced diarrhoea, travellers’ diarrhoea,
inflammatory bowel diseases etc.
Probiotic doses are usually standardised in terms of the amount of living bacteria per
unit of volume. A quality product may contain 1x109 cfu/g (colonies/g). The viable
bacteria are mixed in a suitable matrix that may contain maltodextrin, amylase and
prebiotics such as fruto-oligosaccharides (FOS) and inulin.
Clinical note – dosage forms tailored to increase probiotic survival
Several attempts have been made to ensure the survival of the probiotics through the
acid environment of the stomach and exposure to bile acid. Microencapsulating the
probiotics is one method which has been used.(Kailasapathy 2002) Enteric-coated
tablets containing probiotics which are gastric acid resistant have also been
produced.(Stadler & Viernstein 2003) More studies, however, are needed to examine
the efficacy of these administration forms to deliver and release the probiotic at the
appropriate target sites in the gastrointestinal tract. Studies are also needed to
establish if such measures are actually necessary. With a suitable matrix, a probiotic
powder may survive the passage through the digestive tract without either
microencapsulation or enteric coating of tablets.
Adverse reactions
There have only been two documented adverse reactions. In a 74-year-old diabetic
with hypertension and in a 67-year-old patient with endocarditis undergoing tooth
extraction, L. rhamonosus preparations caused adverse reaction. The causality was not
established.(Sanders 2003)
Significant interactions
No drug interactions have been reported. Clinical trials have indicated that probiotics
can safely be administered with antibiotics.
Contraindications and precautions
Specific strains of probiotics are appropriated for different disorders. Certain strains
are suitable for children.

 Michael Thomsen
Probiotics are contraindicated in those people who are hypersensitive to any
component of the probiotics-containing product.
Pregnancy use
Likely to be safe in pregnancy; however, use of concentrated forms should be
supervised by a healthcare professional.
Practice points/patient counseling
• There is good clinical evidence that probiotics may be beneficial in the treatment
of infant diarrhoea, travellers’ diarrhoea, acute diarrhoea, antibiotic-induced
diarrhoea, urogenital infections, irritable bowel syndrome, inflammatory bowel
diseases, Helicobactor pylori infections, food intolerances and allergies, leaky gut
and eczema.
• There is also some evidence that probiotics are essential for both the development
and maintenance of a healthy immune system.
• There is some evidence that probiotics have a modest effect improving the
LDL/HDL cholesterol ratio.
• Probiotics can be administered orally as a supplement of viable bacteria or
inserted intravaginally. They can also be taken as yoghurt or other cultured dairy
products. It should be noted that only products containing actual probiotic strains
would be beneficial. The so-called starter cultures do not necessarily have the
same beneficial effects.
• Although probiotics may improve the long-term bowel flora, probiotic
supplementation has other benefits not associated with direct colonisation of the
gastrointestinal tract.
Answers to patients’ frequently asked Questions
• What can probiotics do for me?
Probiotics are beneficial in the treatment of digestive disorders such as diarrhoea and
inflammatory bowel diseases and other conditions not directly connected with the
digestive tract. Clinical studies have found probiotics to be beneficial in the treatment
of antibiotic-induced and travelers’ diarrhoea, for vaginal thrush and recurrent cystitis,
irritable bowel syndrome, colitis, food allergies and eczema.
• When will it start to work?
Probiotics can start to exert beneficial effects in digestive disorders within a few days.
Long-term benefits are seen after weeks to months of continuous use. Greater results
may be obtained if the so-called prebiotics are also added to the diet. Prebiotics refer
to the use of compounds that modify the environment of the gastrointestinal tract to
favour proliferation of the intestinal microflora. Herbal and nutritional prebiotics
include the fibre known as slippery elm (Ulmus fulva), oligofructose and inulin.
• Are there any safety issues?
Many species of probiotics are integral to the production of fermented foods and have
been consumed safely as part of the daily diet for millennia. Other probiotics used as
supplements are actually normal, non-pathogenic inhabitants of the human intestinal
tract. There have been no reports of probiotics interacting with prescription
medication.
References

 Michael Thomsen
Agerholm-Larsen, L., Bell, M. L., Grunwald, G. K., & Astrup, A. 2000, "The effect
of a probiotic milk product on plasma cholesterol: a meta-analysis of short-term
intervention studies", Eur J Clin Nutr, vol. 54, no. 11, pp. 856-860.
Chiang, B. L., Sheih, Y. H., Wang, L. H., Liao, C. K., & Gill, H. S. 2000, "Enhancing
immunity by dietary consumption of a probiotic lactic acid bacterium
(Bifidobacterium lactis HN019): optimization and definition of cellular immune
responses", Eur J Clin Nutr, vol. 54, no. 11, pp. 849-855.
D'Souza, A. L., Rajkumar, C., Cooke, J., & Bulpitt, C. J. 2002, "Probiotics in
prevention of antibiotic associated diarrhoea: meta-analysis", BMJ, vol. 324, no.
7350, p. 1361.
Dai, D. & Walker, W. A. 1999, "Protective nutrients and bacterial colonization in the
immature human gut", Adv Pediatr., vol. 46, pp. 353-382.
Dorren, R. 2002, "Probiotics: a review", Pharmacy Post, vol. 10, no. 5, p. C1.
Elmer, G. W. 2001, "Probiotics: "living drugs"", Am J Health Syst.Pharm, vol. 58, no.
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 Michael Thomsen
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 Michael Thomsen
Herbal Therapy of GIT Disorders
When treating any disorders, a herbalist will generally decide on the required actions
and prescribe the herbs accordingly. For GIT disorders such actions will include
• soothing and healing to inflamed mucous membrane: for example Slippery Elm
lines the mucous membranes but is not broken down in the GIT (for babies’ colic
carminative herbs could be included)
• supporting the nervous system with nervine tonics as stress is often a major factor
in digestive disorders
• restoring digestive and absorptive mechanisms by maintaining correct secretions
• rebuilding debilitated and degenerated tissues
• correcting liver and gallbladder functions. Herbalists often treat liver function
even when there is no obvious pathology
• supporting eliminative function via liver and kidney and therefore through the
bowels and urine
• stimulatory remedies could include revitalising herbs, for example Ginger, which
is also warming to the system
Mouth Ulcers
Required actions for mouth ulcers may include
• anti-inflammatory, soothing and adaptogenic (helps to deal with stress), eg
Licorice root would fulfill all these criteria
• immune-enhancing and anti-inflammatory, for example Echinacea. Echinacea
also stimulates saliva because of its content of alkylamides.
• vulnerary and antiseptic, eg Propolis resin. Propolis, as it is a resin, is not water
soluble. It disolves in 70 to 90% alcohol and will actually coat the mouth ulcers
and be preventative against further damage.
• local anaesthetic. Kava is a strong local anaesthetic which numbs the mucous
membrane and therefore is useful for temporary relief. Kava is also an axiolytic
herb and therefore useful if stress is a factor.
• If PMS is a contributing factor, Vitex would be indicated. It is used in almost all
conditions that are worse premenstrually.
• Antiseptic and vulnerary (healing), Calendula is both antiseptic and healing,
especially to mucous membranes. It also improves lymphatic function. Rhubarb
is also antiseptic, astringent and vulnerary.
Mouth Ulcers: Sample formulation
Glycyrrhiza glabra (Licorice) 1:1 25 mL
Propolis 1:5 25 mL
Echinacea purpurea 1:2 30 mL
Calendula officinalis (Marigold) 1:2 20 mL
Total 100 mL
Dose 5 mL with water three times a day

If stress is a factor, nervine tonics or anxiolytics could be of benefit, for example


Valerian spp., Eleutherococcus senticosus, Piper methysticum (Kava).
Nausea

 Michael Thomsen
A herbal formula for the treatment of simple nausea may include
• Bitters (eg. Gentian)
• Ginger
• Peppermint
• Cinnamon
• Black Horehound
• Chamomile
• Meadowsweet
For example, for nausea in pregnancy, a combination of Ginger, Peppermint and
Cinnamon extracts is extremely effective. However if vomiting is frequent, the
Ginger in particular can be extremely unpleasant, and one of the milder tasting herbs,
such as Chamomile, may be more appropriate.
Gastro-Oesophageal Reflux (GER)
In the treatment of GER, lifestyle measures may include
• Raising the head of the bed by 10 to 15 cm.
• Avoiding stress whenever possible while eating. Refrain from overeating
• Avoidance of foods which reduce lower oesophageal sphincter tone. These
include chocolate, fatty foods, coffee, tomato concentrates and onions, spicy
foods, alcohol and cigarettes. Carminative herbs relax the sphincter muscle
(therefore they are useful for flatulence as the sphincter will relax and release gas),
however they may exacerbate GER.
• Treating food intolerances.
• Avoiding drugs which reduce lower oesophageal sphincter (LOS) tone such as
theophylline, calcium channel blockers and progesterone.
• Avoidance of food or drink at bedtime.
• Losing weight if overweight, as excess weight will increase pressure on the
sphincter.
Herbs for GER
Glycyrrhiza glabra (Licorice) and mucilaginous herbs such as Ulmus rubra (Slippery
Elm) and Althaea officinalis (Marshmallow Root) will assist mucoprotection.
Slippery Elm absorbs excess fluid from the bowel and is therefore useful in the
treatment of diarrhoea. As Slippery Elm also soothes and coats the mucous
membrane, it is effective in the treatment of ulcerative colitis. Slippery Elm is best
given as a powder as the mucilage is not well extracted in alcohol because the
mucopolysaccharides are water soluble.

Peptic Ulcer
General lifestyle measures may include:
• Regular meal times and not eating on the run.
• Giving up smoking and/or excessive alcohol intake.
• High protein foods should be kept to a minimum as protein stimulates gastric acid.
• Duodenal ulcer patients should have regular meals but should avoid bedtime
snacks which will stimulate acid secretion during the night.
• NSAID’s which damage the mucosal barrier should be avoided.

 Michael Thomsen
Herbal Treatment for Ulcers
• Soothing, anti-inflammatory and healing herbs for the mucous membranes: Chickweed,
Chamomile, Licorice, Slippery Elm
• Restore function of mucous membranes with Hydrastis canadensis (Golden Seal).
For some time Golden Seal was threatened as a wildcrafted species. The herb is
now cultivated and therefore herbalists can use it with a free conscience. It is also
strongly antiseptic and therefore protective against further damage.
• Antiseptic treatments such as Propolis and raw crushed Garlic. Some patients
may find the Garlic difficult to take, however Propolis is generally well tolerated.
• Treat poor immunity with Echinacea or Andrographis. Andrographis is a
Chinese/Indian bitter and immune system tonic.
• Improve ulcer healing with astringents. In herbal medicine astringent herbs are
known as those which tighten and draw in the surrounding tissue. Examples of
astringent herbs include Bistort, Agrimony and Meadowsweet. These herbs
would be useful in diarrhoea treatment as they tighten the tissue and decrease fluid
loss in the bowel.
• Treat pain and spasm with spasmolytic and carminative herbs such as Crampbark
or Fennel
• Treat stress and anxiety with nervine tonics such as Skullcap, Valerian,
Eleutherococcus senticosus (Siberian Ginseng).
The benefit of using herbs in a formula is that we create a synergistic effect. This
means that the individual benefits are enhanced by the other herbs in the formula.
Gastric Ulcer : Sample Formulation
Gentiana lutea (Gentian) 1:2 02 mL (very low dose)
Filipendula ulmaria (Meadowsweet) 1:2 20 mL (anti-inflammatory,
reduces gastric acid secretions)
Glycyrrhiza glabra (Licorice) 1:1 15 mL
Matricaria chamomilla (Chamomile) 1:2 20 mL
Calendula officinalis (Marigold) 1:2 15 mL
Echinacea purpurea 1:2 20 mL
Hydrastis canadensis (Golden Seal) 1:3 10 mL (mucous membrane
tonic)
Total 102 mL
Dose 5 mL with water three times a day before meals.
Slippery Elm powder: 1 teaspoon before meals
Duodenal Ulcer : Sample Formulation

Filipendula ulmaria (Meadowsweet) 1:2 20 mL


Matricaria chamomilla (Chamomile) 1:2 25 mL
Glycyrrhiza glabra (Licorice) 1:1 15 mL
Echinacea purpurea 1:2 20 mL
Propolis 1:5 10 mL
Hydrastis canadensis (Golden Seal) 1:3 10 mL
Total 100 mL

 Michael Thomsen
Dose 5 mL with water three times a day half an hour before meals
Slippery Elm powder: 1 teaspoon after meals
In this formula there is a greater emphasis on preventing infection. The Propolis resin
in the formula is anti-inflammatory, soothing, healing and antiseptic. It aids
restoration of function to mucous membranes, especially when given with tonics such
as Golden Seal.
Irritable Bowel Syndrome
20 to 25% of the population are said to suffer from IBS which is also known as
mucous colitis. The female to male ratio is 2.5:1, although it is often true that more
women report symptoms. IBS is a chronic disorder which causes abdominal pain,
distension and disturbed bowel habits, and frequently alternation of constipation and
diarrhoea.
15% of sufferers have disturbed bile acid absorption and therefore malabsorption of
fats. Intestinal motility is abnormal and can be either increased or decreased. Food
intolerance is a common factor in IBS, and sufferers may need to avoid specific
allergens, at least while undergoing treatment. 25% of cases are associated with a
specific episode of gastroenteritis.
Treatment of IBS
• Treat food allergies with exclusion diet
• Spasmolytics (antispasmodics). These relax intestinal smooth muscle.
• Sedatives, nervine tonics and adaptogens for stress
• Hepatorestoratives (improve liver function) and choleretics
• Treat constipation/diarrhoea
• GIT antiseptics: golden seal, propolis
• GIT anti-inflammatories: eg, Meadowsweet, Chamomile, Calendula, Chickweed,
Slippery Elm
IBS: Sample Formulation
Filipendula ulmaria (Meadowsweet) 20 mL (anti-inflammatory)
Matricaria chamomilla (Chamomile) 25 mL (anti-inflammatory, healing,
nervine tonic)
Silybum marianum (St Mary’s Thistle) 20 mL (liver tonic, hepatorestorative)
Viburnum opulus (Cramp Bark) 20 mL (spasmolytic)
Hydrastus canadensis (Golden Seal) 15 mL (anti-inflammatory, antiseptic,
restores mucous membrane
function)
Total 100 mL
Slippery Elm: one tablespoon, BD
Probiotics
Should be taken between meals to recolonise gut with friendly bacteria.
Bitter tonics, eg Gentian, Ginger, Angelica, Vervain: to improve digestion in upper
GIT.
Assc. Prof. Tim Roberts, University of Newcastle is conducting research into
chronic fatigue syndrome. Roberts maintains that the majority of CFS sufferers
have a history of IBS. The University have instigated a series of tests which
validate this:

 Michael Thomsen
Bioscreen Pathology Tests
www.bioscreen.com.au
Tel: 02 4961 6513
• Urine test: anomalies in the excretion of amino and organic acids
• Blood lipid test: anomalies in fatty acid homeostasis
• Faeces test: anomalies in bowel flora and fat malabsorption
• Coagulase Negative Staphyloccocal test (membrane-damaging toxins associated
with chronic pain)
• Organochlorine Pesticide test
Faeces Report
These test for:
• Short and medium chain fatty acids. A high degree of these are associated with
colonic dysfunction
• High levels of C18 fatty acids indicate fat malabsorption
• Total bacterial count
• Aerobes: common feature is low E. Coli (One finding is that autistics have been
demonstrated to have almost no E. Coli present.)
• Anaerobes: predominence of bacteroides (lack of probiotics)
• Aerobes/anaerobes Balance: should be 95% aerobes
• Level of fungal infection
Intestinal Infections: Sample Formulation
Echinacea purpurea 1:2 25 mL
Andrographis panculata 1:2 20 mL
Hydrastis canadensis (Golden Seal) 1:2 15 mL
Propolis 1:5 10 mL
Calendula officinalis (Marigold) 1.2 15 Ml
Matricaria chamomilla (Chamomile) 1:2 15 mL
Total 100 mL
Dose 5 mL with water three times a day
Echinacea and Andrographis stimulate immune function but are not antiseptic. The
Propolis and Calendula are, however, antiseptic, while the Calendula and Golden Seal
are anti-inflammatory. The emphasis in treament is on immune stimulants and
antiseptics.
Fresh Garlic
Lactobacillus culture between meals
Slippery Elm
If the Garlic is taken with the Slippery Elm, it should reduce burning and irritation.
While Garlic is highly antiseptic and antimicrobial, it is also a mucous membrane
irritant. Hein Zeylstra, an experienced British herbalist, successfully treats both
ulcerative colitis and Crohn’s disease with just Slippery Elm and Garlic in high doses.
Acute Diverticulitis: Sample Formulation
Echinacea purpurea 1:2 25 mL
Hydrastis canadensis (Golden Seal) 1:3 20 mL

 Michael Thomsen
Viburnum opulus (Crampbark) 1:2 20 mL
Matricaria chamomilla 1:2 20 mL
Propolis 1:5 15 mL
Total 100 mL
Dose 5 mL with water three times a day.
Slippery Elm powder, 1 tablespoon with water before meals
The Echinacea and Golden Seal in this formula will help prevent any infection in the
diverticulae. The Chamomile is anti-inflammatory while the Propolis is antiseptic.
Herbal Treatment of Constipation
• Cholagogues would be part of the treatment here, to improve production and flow
of bile. For example, Taraxacum officinale (Dandelion), Silybum marianum (St
Mary’s Thistle, Milk Thistle), Cynara scolymus (Globe Artichoke)
• Gastrointestinal spasmolytics (antispasmodics), eg. Chamomile, Mentha spp.
(Peppermint), Viburnum opulus (Crampbark)
• Improve GI lubrication with linseeds or psyllium seeds or husks
• Anthraquinone glycoside containing herbs, eg. Rumex crsipus (Yellow Dock),
Juglans cinera (Butternut), Cassia spp. (Senna), Cascara. Both Cassia and
Cascara are strong laxatives and may need to be used with antispasmodics.
• Bulk laxatives, eg. Slippery Elm and psyllium husks
• Drink lots of water and increase excercise
Constipation: Sample Formulation
Taraxacum officinale (Dandelion root) 1:2 20 mL
Silybum marianum (St Mary’s Thistle) 1:1 20 mL
Viburnum opulus (Crampbark) 1:2 15 mL
Mentha piperita (Peppermint) 1:2 10 mL
Cassia spp. (Senna) 1:2 20 mL
Glycyrrhiza glabra (Licorice) 1:1 15 mL
Total 100 mL
Slippery Elm powder, increase water intake, increase exercise.
Stronger laxatives should only be used in the short-term. In the long-term, liver
herbs, diet and digestive tonics would be the preferred treatment.
Haemorrhoids
The treatment of haemorrhoids would include measures to improve bowel function,
but importantly the tone of venous and connective tissue needs to be improved.
• Slippery Elm and psyllium, contain mucilage which is healing and soothing,
making the stool soft and bulky
• Increase dietary fibre
• Choleretic and hepatoprotective herbs improve constipation by reducing liver
congestion.
• Venous and connective tissue tone can be improved with herbs such as Aesculus
hippocastanum (Horsechestnut), Ruscus aculeatus (Butcher’s Broom), Polygonum
multiflorum, Gingko biloba, Bilberry and Vitis vinifera (Grape Seed)
• Topically, healing and astringent herbs such as Witch Hazel, Comfrey and
Calendula can be employed. Horse Chestnut also works well topically, but should

 Michael Thomsen
not be applied if the piles are bleeding, because it contains saponins which are
haemolytic.
Inflammatory Bowel Disease
Indications to consider in the treatment of inflammatory bowel disease would include:
• Anti-inflammatory, eg. Matricaria chamomilla, Calendula officinalis
• Astringents, eg. Agrimony officinalis, Hamamelis virginiana
• Mucous membrane tonics, eg. Hydrastis canadensis, Plantago lanceolata
• Demulcents, eg. Ulmus rubra, Althae officinalis
• Adaptogenics, eg. Rehmannia glutinosa
• Antiallergics, eg. Albizia lebeck, Scutellaria baicalensis
• Liver tonics, eg. Silybum marianum
• Immunenhancing, eg. Echinacaea spp
• Haemostatics, eg, Achillea millifolium, Panax notoginseng
Ulcerative Colitis: Sample Formulation
Achillea millefolium (Yarrow) 1:2 20 mL
Dioscorea villosa (Wild Yam) 1:2 20 mL
Calendula officinalis (Marigold) 1:2 20 mL
Matricaria chamomilla 1:2 20 mL
Echinacea spp. 1:2 20 mL
Total 100 mL
5 mL TDS
If there is blood in the stool the Yarrow will act as an astringent. The Wild Yam is
anti-inflammatory and antispasmodic. The Calendula and Chamomile are healing and
anti-inflammatory. The Echinacea is of course immune stimulating.
Bitter tonic before meals
Slippery Elm: one tablespoon before meals
Fresh Garlic (improves immune function and is antiseptic against various organisms).
Dietary restriction: bland, simple food, check allergies
Restore bowel flora
Case: ulcerative colitis
By Naturopath Jenny Adams
Reference: Phytomedicine Focus, No 2, 2001
Joan, aged 52, was referred by her GP for treatment of ulcerative colitis. She was
somewhat desperate for help, being unable to use the standard medical treatment
sulfasalazine because of interaction with warfarin. Symptoms had begun four months
before with cramping abdominal pain, flatulence and explosive diarrhoea every few
days with loose bloody stools, alternating with periods of constipation. She was
feeling very fatigued and “thoroughly sick” of having to race to the toilet 4-5 times
daily during the episodes of diarrhoea.
History
The combination of a congenital heart defect and rheumatic fever in childhood had
lead to the necessity for an aortic valve replacement two years ago combined with
long term treatment with warfarin. A painful bilateral sciatica started at the same time

 Michael Thomsen
as the colitis. There was a strong family history of ulcerative colitis and chronic
colitis.
Joan had modified her diet considerably since the onset of her symptoms, as she could
no longer tolerate meat or oily foods. She had increased fibre in her diet under the
instruction of her gastroenterologist, by including Sultana Bran for breakfast,
regular fruit, and salad vegetables.
On examination Joan demonstrated extreme tenderness in the left iliac fossa.
Colonoscopy had shown that the ulcerative colitis was limited to the distal colon.
Treatment and rationale
• Phytomedicine’s Boswellia Compound: one tablet three times daily.
• Probiotic powder containing Lactobacillus acidophilus and Bifidobacterium
bifidum: ½ teaspoon twice daily - to re-establish good gut flora and modulate
immune response.
• Slippery elm powder: 2 heaped teaspoons twice daily - a soothing mucilaginous
demulcent to the gastrointestinal tract.
Boswellia Compound contains
Boswellia serrata stem bark resin 1400 mg
Harpagophytum procumbens dry tuber 500 mg
Zingiber officinalis rhizome powder 400 mg
Guaiacum officinale resin 100 mg
Although Boswellia Compound may be more specific for arthritis, it is also suitable
for ulcerative colitis, primarily due to the fact that Boswellia serrata and
Harpagophytum procumbens are also anti-inflammatory in the GIT. Harpagophytum
procumbens normalises diarrhoea/constipation and reduces flatulence.
A basic elimination diet excluding caffeine, alcohol, wheat, dairy, meat, eggs, raw
fruit and salads (cooked fruit and vegetables were allowed) was recommended for the
first week, followed by trial reintroduction of individual foods over subsequent
weeks. A symptom diary was suggested to monitor bowel frequency and pain, and to
record exacerbations related to stress.
I notified her doctor outlining the prescribed treatment. I had some concern that the
ginger in the Boswellia Compound might potentiate the warfarin because of ginger’s
antiplatelet activity so I requested that I was kept informed of Joan’s internationalised
normalised ratio (INR) level. (INR is used to monitor the risk of bleeding for patients
on warfarin. An increased INR indicates an increased risk of bleeding).
Second appointment (2 weeks later)
Bowel movements had settled to three times weekly and stools were soft and formed.
No further diarrhoea and only one episode of mild cramping and wind, which
occurred during a particularly stressful day at work. Sciatic pain relieved. INR being
monitored fortnightly; last reading low at 1.4 (target range 2.5-3.5) possibly due to
change in diet. This was the opposite of what I had anticipated but was reassuring to
know that the ginger at this dosage did not reduce her blood clotting time. The GP
increased warfarin dose to 7 mg.
On examination, no specific abdominal tenderness was noticed.
Joan was getting bored with the diet so I suggested trial reintroduction of some of the
foods she was missing. Continue Boswellia compound 1 three times daily, and
slippery elm powder 2 tsp twice daily.
Third appointment (3 weeks later)

 Michael Thomsen
One episode of diarrhoea with rectal bleeding occurred after a meal that included
salami. By this stage Joan had successfully reintroduced the odd glass of wine, pasta
and raw fruits. INR stabilised at 2.8. Feeling much better. Continue Boswellia
compound one table twice daily.
Telephone contact 3 months later
No further episodes of diarrhoea. Recently stopped all herbal medication. Continuing
to avoid processed meats and fatty foods but otherwise enjoying wide range of foods.
Very grateful.
Crohn’s Disease: Sample Formulation
Bupleurum falcatum 1:2 25 mL (anti-inflammatory/liver tonic)
Glycyrrhiza glabra (Licorice) (HG) 1:1 15 mL
Dioscorea villosa (Wild Yam) 1:2 15 mL
Echinacea spp. 1:2 25 mL
Hydrastis canadensis (Golden Seal) 1:3 20 mL (contains berberine which is
strongly antimicrobial)
Total 100 mL
5 mL TDS
In this formula there is a great emphasis on an anti-inflammatory action via the
adrenals because of the high relationship of stress in this disorder.
Bitter tonics before meals, Slippery Elm: one tablespoon before meals, Fresh Garlic
Dietary restriction: bland, simple food, check allergies
Restore bowel flora (probiotics)

Coeliac Disease and Gluten Sensitivity


By Melanie Koeman, former technical writer for Nutrimedicine.
Gluten is a protein found in all forms of wheat (including durum, semolina, and spelt),
rye, barley and related grain hybrids such as triticale and kamut. It is present in
smaller amounts in oats and is also undisclosed in an endless variety of processed
foods.
Coeliac Disease (CD) is also known as gluten-induced enteropathy or sprue. It is an
autoimmune disease that leads to a permanent intestinal intolerance to gluten. The
gluten causes inflammation of the intestinal wall and a flattening of the villi, finger-
like projections that line the inside of the bowel. When these villi atrophy (flatten) the
surface area for absorption is greatly reduced resulting in deficiencies of a number of
nutrients. The overall prevalence of CD is estimated as 1 in approximately 130,
however if you have a family history of CD your risk is increased to approximately 1
in 10.
Gluten Sensitivity (GS) is a condition that involves a degree of gluten intolerance
without the presence of immune markers associated with CD. The treatment approach
is similar however, since removal of gluten often results in clinical improvement and
symptom relief. After a period of avoidance, small amounts of gluten-containing
foods may be well tolerated. Guidance will be given to you from your healthcare
practitioner.

Symptoms of CD

 Michael Thomsen
Although there may be no symptoms of CD, the most common ones involve the
digestive system and include abdominal bloating or pain, diarrhoea, constipation,
flatulence, heartburn, or nausea with or without vomiting.
Other possible symptoms include sinusitis, asthma, skin disorders including eczema and
dermatitis hepetiformis, fatigue, bone, joint and muscle pains, mouth ulcers, loss of tooth
enamel, mood and behavioural problems, poor growth or development in children, weight
loss, hair loss and menstrual problems.
CD is associated with a higher risk of osteoporosis, iron deficiency anaemia, menstrual
problems including amenorrhoea, miscarriage and infertility, and thyroid or other
autoimmune diseases.

Helpful hints

• Read all food labels carefully.


• The Australian food standards code requires that foods labeled as ‘gluten free’ must not
contain any detectable gluten. Food labeled as ‘low gluten’ must contain less than 0.02%
gluten.
• Lactose intolerance is a common accompanying problem to CD. Your practitioner may
recommend the removal of dairy products as part of their treatment.
• Avoid cross contamination in the kitchen by developing gluten-free kitchen habits,
storage plans and procedures for mixing, cooking and baking.
• Gluten-free breads taste better toasted and should be stored in the fridge or freezer.
• When eating out select food without crumbing, ‘creaming’, coatings, gravies and sauces.
Ideally, call ahead to notify the chef of your dietary requirements.
• Obtain your fibre from brown rice, buckwheat, unpeeled potatoes, fresh and dried beans
& legumes, fresh fruit & vegetables (see Nutrimedicine Fibre Information Sheet)
• Nutritional deficiencies are common, particularly of iron, zinc, vitamins B2, folate and
B12. (See Nutrimedicine Nutrient Food List for the best sources of these nutrients)
• Avoid skipping meals, eat slowly and chew all food thoroughly. Enjoy your food!
• Plan your meals and carry snacks with you so you are prepared for all eventualities.
What to Include What to Avoid

Grains /Flours /Roots /Tubers and Legumes


Grains: Buckwheat, brown rice, basmati rice, wild rice, Grains: Wheat (including, durum, semolina, triticale), rye,
maize (corn), quinoa, amaranth, millet, sorghum. (Some CD barley, burglur, couscous and possibly oats. (Spelt and
patients may have a secondary sensitivity to the grains kamut are ancient grains but may be suitable for people
quinoa, amaranth, buckwheat & millet) with wheat intolerance.)
Roots and Tubers: potato, tapioca, arrowroot, sweet potato. Roots and Tubers: French fries (check labels)
Legumes: Beans, soy, lentils, peanut, pea, chickpea. Legumes: Baked Beans unless gluten-free.
Flours: Any flours made from the above sources, chickpea Flours: Wheat flour, wholemeal flour, bakers flour,
flour. semolina, barley, rye (avoid battered or crumbed food).
Breads and Cereals
Breads: Gluten free breads based on buckwheat, corn, rice, Breads: Wheat breads - wholegrain or white, rye
chickpea flour and/or soya flour. bread, oat bread, barley bread, burritos,
Cereals: Gluten free muesli, homemade muesli made from pumpernickel bread. (Spelt may be suitable for
a combination of: Brown rice flakes, millet flakes, organic some people with wheat intolerance)
cornflakes, puffed corn, puffed rice, soy bran, soy grits, raw Cereals: Commercial cereals (rice bubbles, weetbix, wheat
nuts & seeds, shredded coconut. containing muesli, coco pops etc) wheat germ, wheat bran,
porridge oats, oat bran, oat germ. Any cereal containing
malt.

 Michael Thomsen
Pastas
Buckwheat noodles, rice noodles, vegetable, corn, spinach Durum wheat pasta (spaghetti, macaroni etc), egg noodles,
or quinoa pasta. hokkein noodles, barley pasta, spelt pasta. (Spelt may be
suitable for some people with wheat intolerance)
Crackers
Rice cakes, corn cakes, gluten free products. Wheat crackers, bran biscuits, ryvita, kavli, oatcakes.
Snacks and Desserts
Popcorn, dried fruit (limit), fresh fruit, carob, sesame Commercial biscuits, cookies, cakes, scones, pastries,
snacks, fruit and nut bars, gluten free biscuits or other liquorice, some lollies and ice creams, some commercial
snack. fruit pies, flavoured or frozen yoghurts, processed cheeses
& creams.
Stock, seasonings and thickeners
Bouillon stock powder, sesame salt, tamari (check label), Malt, malt vinegar, Vegemite, wheat starch, modified
mustard seeds, fresh dried herbs and spices, potato flour, starch, mustard pickles, soy sauce, gravy mixes and
apple cider vinegar, authentic balsamic vinegar, wine seasoning ‘rubs’; Hydrolyzed vegetable protein (HVP),
vinegar, maize corn flour, soy flour, arrowroot, kuzu and texturized vegetable protein (TVP); Some binders, fillers,
agar-agar. excipients, extenders etc (It is best to contact the
manufacturer or your state Coeliac Society).
Beverages
White wine, light rum, gin, tequila without dyes or Beers, ale and lager, cereal and malted beverages, malted or
additives, potato vodka; Teas, coffee, soft drinks, mineral flavoured milk drinks, instant tea, coffee substitutes.
water, fresh fruit and vegetable juices.
Other sources of gluten
Some medications use gluten as a binder. Contact your doctor or pharmacist for more information.
If ingredients are not itemised, check with the manufacturer of the product or with your state Coeliac Society.

Adult Coeliacs, parents of Coeliac children and those with Dermatitis Herpetiformis have
formed Coeliac Societies in all Australian States. These Societies provide information on the
disease, gluten free diet, ingredients, where to buy, cooking and recipes, overseas travel,
education material, etc. If you would like to become a member or would like more
information, please contact your State Society. www.coeliac.org.au

 Michael Thomsen
Liver Disorders
Liver Detoxification
Sources of toxins to liver include:
• Chemicals from the environment (xenobiotics)
• Drugs (and some herbs)
• Infectious organisms
• Normal metabolites eg. bile acids, steroid hormones
• Endogenous toxins eg. abnormal metabolites
Liver Toxins & Disease
Liver toxins can potentially have a causative effect in the aetiology of many diseases
including:
• Chronic fatigue syndrome
• Immune deficiency
• Neurological disorders
• Chronic inflammatory disorders
• Allergies
• Autoimmune diseases
• Chemical sensitivities
• Cancer
• Liver damage, kidney damage etc
• Leaky gut syndrome
• Probably almost any chronic disease process
• Hormonal imbalance
Processing of Toxins by the Body
• Storage in adipose tissue
• Direct elimination via the kidneys, lungs etc without further processing
• Elimination via the urine, bile etc after processing (biotransformation) by the liver
Beneficial Action of Herbs to the Liver
• Protect the liver from toxic damage – hepatoprotective
• Restore the liver after toxic damage – hepatic trophorestorative (restores function)
• Stimulate the flow of bile – choleretic
• Stimulate Kupffer cell function
• Stimulate hepatic detoxification processes (biotransformation) – depurative
(alterative) (traditionally known as “blood cleansers”).
Biotransformation of Toxins by the Liver
The aim of biotransformation is to render the toxin more easily excreted.
Reactions involved in the biotransformation of toxins by the liver can be divided into
two distinct categories:
Phase I Reactions
• typically involves oxidation or reduction reactions.

 Michael Thomsen
• largely dependent on enzymes associated with smooth endoplasmic reticulum (ie
microsomes) known mainly as the mixed function oxidase system (cytochrome
P450)
• generally involves exposing or adding a functional group, usually oxygen, by a
free radical mechanism.
• involves the generation of free radicals
Phase I Reactions activate Phase II
Phase II Reactions
Phase II reactions involve the coupling of a highly polar (water-soluble) endogenous
chemical to the toxin
Product is more water-soluble and less toxic.
Large molecules are excreted in the bile, smaller in the urine.
Bioactivation
Bioactivation by Phase I reactions may result in the production of a more toxic
compound, especially for xenobiotics.
• May cause tissue damage (eg hepatotoxicity, teratogenicity).
• May react with Phase II enzymes and be rendered harmless and excreted.
• May react with a cell protein forming an antigen (haptenization). This may lead to
immunological reactions such as drug-induced lupus.
• May bind with DNA causing mutation which can lead to cancer. (Many
carcinogens are first activated by hepatic microsomes).
Phase l & ll Balance
Sometimes overload of Phase II reactions can lead to a toxin being primarily
metabolised by a Phase I mechanism, with toxic consequences. The balance between
Phase I and Phase II enzymes is an important determinant of whether exposure to
xenobiotics will result in toxicity and cancer. Stimulating Phase I reactions without a
matching stimulation of Phase II reactions can be detrimental. Increased Phase II
activity probably prevents cancer.
Important Liver Herbs
Schisandra chinensis
Schisandra extract enhances hepatic glutathione status and induces Phase I enzyme
activity. Schisandrin B increases glutathione S-transferase (GST) (Phase II) and
microsomal cytochrome P450 enzymes (Phase I). Gomisin A (in Schisandra) has
been shown to:
• stimulate liver regeneration
• prevent acetaminophen toxicity (as does Schisandra)
• improve bile acid metabolism (Phase II)
• increase GST (Phase II)
Curcuma longa (Turmeric)
• Turmeric and curcumin (a constituent of Turmeric) reduce cancers by altering the
activation and/or detoxification processes in carcinogen metabolism.
• Curcumin inhibits both Phase I and II enzymes in vitro. However, turmeric in
vivo causes significant increases in Phase II enzymes (as does curcumin) and
decreases some Phase I enzyme activity

 Michael Thomsen
• Turmeric and curcumin inhibit aflatoxin-induced liver toxicity.
• Turmeric (1.5 g/day) reduces the excretion of urinary mutagens in smokers.
Silybum marianum
Silybum marianum (St Mary’s Thistle) is more protective and regenerative to the liver
than detoxifying.
• Silybin inhibits GST in vitro.
• In contrast silymarin (which is a combination of three different compounds) is an
inducer of Phase I enzymes in vivo.
• However, when 210 mg of silymarin was fed to human subjects over 28 days,
there was no influence on the metabolism of aminopyrine and phenylbutazone.
• Silymarin causes hepatic regeneration and increases hepatic glutathione in vivo.
Quality tablets are usually standardised to “silymarin calc. silybum” content. These
are the best for the treatment of actual liver damage.
Dietary Factors
• Rosemary and Sage contain carnosol which is antioxidant and inhibits
bioactivation of benzo-alpha-pyrene and induces GST and NAD(P)H:quinone
reductase (important Phase II enzymes).
• Garlic and its components have a chemopreventative activity against
carcinogenesis and increase Phase II enzyme activity and may inhibit Phase I
enzymes. Garlic oil induces Phase I enzymes in vivo.
• Myristicin in Parsley leaf oil is an active inducer of GST activity.
• Citrus fruit oils increase GST activity.
• Green Tea polyphenolics have a pronounced chemopreventative activity against
carcinogenesis and increase Phase I and Phase II enzyme activity in vivo. The
chemopreventative effects of green tea and coffee were examined in 52 male
cigarette smokers. Only for green tea drinkers (2 to 3 cups per day) were the
frequency of sister chromatid exchange (SCE, which is indicative of chromosomal
damage − possibly cancer-causing) in smokers comparable to that in nonsmokers.
The conclusion was that green tea can block the cigarette-induced increase in SCE
frequency.
Source: Shim, J S and co-workers, Cancer Epidemiol Biomarkers Prev 4, 387
(1995).
The Brassicas
Cruciferous vegetables (eg Brussels sprouts and broccoli) and herbs (eg Horseradish,
Mustard, Nasturtium, Watercress) contain sulfur glucosides known as glucosinolates. Upon
cooking, grating (damage to the plant cells), digestion or steam distillation,
glucosinolates are converted to isothiocyanates which also contain sulfur. Broccoli
and Brussels sprouts are rich in a glucosinolate called glucoraphanin which yields the
isothiocyanate sulforaphane. Sulforaphane is one of the most potent inducers of
Phase II enzymes discovered so far. Glucosinolates (via their isothiocyanate
products) have also shown anticancer and cancer-preventing activities.
Poor Liver Function & Gall Stones

Treatment is aimed at increasing and improving bile flow and therefore softening or
reducing the size of stones.

 Michael Thomsen
• Hepatoprotectives, eg. St Mary’s Thistle, Globe Artichoke
• Cholagogues (increase flow), eg. Peppermint, Calendula
• Choleretics (increase bile production), eg. Dandelion root, Golden Seal, Barberry,
Greater Celandine
• Detoxifiers, eg. Schisandra, Turmeric
• Alteratives, eg. Yellow Dock, Burdock, Fumitory
Acute Viral Hepatitis
Causes: hepatitis A, B and C viruses, Epstein-Barr virus and cytomegalovirus. These
viruses are surrounded by a protein shell so Hypericum may be of benefit.
• Diaphoretics, eg. Lime Flowers, Elder, Yarrow, Ginger
• Antivirals, eg. St John’s Wort, Phyllanthus, Thuja
• Immune-stimulants, eg. Echinacea, Picrorrhiza, Andrographis, Astragalus
• Hepatoprotectives, eg. St Mary’s Thistle, Dandelion root, Globe Artichoke,
Picrorrhiza, Schisandra, Bupleurum
Chronic Viral Hepatitis
Causes: hepatitis B or C. May have auto-immune elements.
• Antivirals, eg. St John’s Wort, Phyllanthus, Thuja
• Immune-enhancers, eg. Echinacea, Picrorrhiza
• Hepatoprotectives, eg. St Mary’s Thistle, Dandelion root, Globe Artichoke,
Picrorrhiza, Schisandra, Dan Shen
• Adaptogens, eg. Ginseng, Bupleurum, Rehmannia, Withania
Cirrhosis of the Liver
• Hepatoprotectives, eg. St Mary’s Thistle, Globe Artichoke, Picrorrhiza
• Adaptogens, eg. Ginseng, Bupleurum, Rehmannia
• Liver tonics, eg. Dandelion root
Use non-alcohol products such as Silybum marianum glycerol extract or Silymarin
tablets.

 Michael Thomsen

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