PRESCRIBING INFORMATION

Actions

Vulnerary, antiinflammatory, lymphatic, styptic (hemostatic), antimicrobial, antiviral (topically), antifungal (topically)

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing Calendula in formulations in the context of: • Internal and topical treatment for inflammation of the oral and pharyngeal mucosa (4) • Internal treatment for gastric and duodenal ulcers; enlarged or inflamed lymph nodes, acne, sebaceous cysts (5) • Internal treatment for spasmodic conditions, including dysmenorrhea (5) • Topical treatment for burns (2) • Topical treatment for inflammation of the skin and mucosa, wounds, especially poorly healing wounds (4,5) • Topical treatment for leg ulcers, venous circulatory problems, scalds; to help control bleeding (4) • Topical treatment for eczema, varicose veins, hemorrhoids, acne, vaginal discharges (5)

Contraindications Known allergy.¹ Warnings and Precautions The likelihood of Calendula preparations causing a contact allergy is low. However, people with known sensitivity to other members of the Compositae family (e.g., ragweed, daisies, chrysanthemums) should avoid topical application of Calendula or Calendula products.¹ Sensitization to Calendula and allergic contact reactions have been reported.^2,3 Anaphylactic shock after gargling with an infusion of Calendula has also been reported.⁴ Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects Allergic reaction occurs rarely following topical application.¹ Dosage Dose per day^* Dose per week^*   1.5–4.5 ml of 1:2 liquid extract 10–30 ml of 1:2 liquid extract

* This dose range is extrapolated from the British Pharmaceutical Codex 1934, the British Herbal Pharmacopoeia 1983, and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Enlarged or inflamed lymph nodes, sebaceous cysts, gastric or duodenal ulcer, acute or chronic inflammatory skin lesions5 • Amenorrhea, dysmenorrhea; nosebleed5 • Spasmodic conditions, fever, chronic suppuration, capillary enlargement, varicose veins, chronic ulcers, stubborn acne, splenic and hepatic enlargement6 • Topically for wounds, acne, chaffed skin in infants, cracked nipples, eczema, leg ulcers, varicose veins, hemorrhoids, anal eczema and inflammation, vaginal discharges, lymphadenoma, inflamed skin lesions, conjunctivitis5,6
Pharmacologic Research	• Various Calendula extracts and Calendula essential oil have demonstrated antibacterial, antifungal, and trichomonacidal activity in vitro.7 • Calendula extract enhanced the proliferation of lymphocytes in vitro.8 Polysaccharides from Calendula stimulated phagocytosis of human granulocytes in vitro.9 This finding may be relevant to topical application. • Calendula flavonoids inhibited the activity of lipoxygenase in vitro.10 Calendula extract suppressed the inflammatory process and leukocyte infiltration caused by carrageenan and prostaglandin E1 (route unknown).11 Oral dose of aqueous ethanolic extract of Calendula produced antiinflammatory activity in carrageenan-induced rat paw edema. The activity was much milder than that with indomethacin.12 • Using the croton oil dermatitis mouse ear model, both the total extract of Calendula and the extract obtained after supercritical carbon dioxide extraction (which contains the lipophilic phytochemicals) demonstrated antiinflammatory activity after topical application. Fractionation and testing revealed that the triterpene alcohols caused the antiinflammatory activity, with the carotenoids and sterols almost inactive.13 The most active topical antiinflammatory constituent is the triterpenoid compound faradiol monoester.14 • Calendula extract has demonstrated angiogenic activity (formation of new blood vessels, such as within a wound) in an in vitro assay. Calendula-treated tissue was positive for hyaluronan, a tissue glycan associated with neovascularization, unlike the control tissue, which lacked the presence of hyaluronan.15 This finding is possibly relevant to topical use of Calendula. • Topical application of an ointment containing Calendula fractions and allantoin stimulated physiological regeneration and epithelialization in experimentally induced wounds.16 A Calendula ointment improved wound healing in experimentally induced wounds.17 Calendula facilitated the collagen maturation phase of wound healing and influenced epithelial cell proliferation and migration.18 Topical application of a Calendula glycetract had a vasoprotective activity on normal animal skin by decreasing capillary activity.19 • Antiulcer activity was demonstrated in three experimental models after administrating an isolated saponin from Calendula. Antiinflammatory and sedative activities were also observed.20,21 Fractions isolated from Calendula also showed activity (route unknown).22 • Calendula demonstrated antipyretic and analgesic activities in experimental models (route unknown).23 • The saponin fraction of Calendula normalized experimentally induced hyperlipidemia after oral administration over a 12-week period7 but was without effect in normolipemia.24 • Oral administration of Calendula extract exhibited antitumor activity in experimentally induced carcinoma.25
Clinical Studies	• An herbal preparation containing Calendula, dandelion, St. John’s wort, lemon balm, and fennel reduced intestinal pain in an uncontrolled trial in patients with chronic colitis. Defecation was normalized in these patients with diarrhea syndrome.26 • Calendula extract accelerated the healing time of an artificially induced skin abrasion in volunteers (most likely by topical application).27 An evaluation of aerosol formulations designed to provide a protective film over wounds in human volunteers found that addition of Calendula tincture was satisfactory at controlling bleeding.28 • In a small, uncontrolled trial, Calendula was successful in treating periodontal inflammation.29 • Calendula ointment has been positively used in uncontrolled trials for treating bedsores, venous circulatory problems, and skin conditions such as leg ulcers and thrombophlebitis.7 Calendula demonstrated benefit as an adjuvant therapy for rendering scar tissue more supple in patients with cleft lip and palate who were undergoing dermatography.30 • Calendula gel applied for 13 to 14 days provided good results for the healing of burns and scalds in 30 patients.31 The effects of three ointments on managing burns were investigated in a randomized, controlled, multicenter clinical study involving 156 patients. Calendula and the proteolytic ointment showed similar efficacy, both superior to Vaseline. However, the Calendula ointment was better tolerated than the proteolytic ointment.32 • Improved outcomes and faster healing of ulceration were obtained when acyclovir treatment was combined with an herbal formula containing Calendula, burdock, and Geranium robertianum in patients with herpetic keratitis (most likely by topical application).33 • In Germany, the Commission E supports using Calendula to treat inflammation of the oral and pharyngeal mucosa internally and topically. Externally, Calendula is recommended for poorly healing wounds and leg ulcers.34 • ESCOP recommends Calendula for treating inflammations of the skin and mucosa and as an aid to wound healing.1

PRESCRIBING INFORMATION

Actions

Anxiolytic, mild sedative, analgesic, hypnotic

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing California poppy in formulations in the context of: • Painful conditions involving the irritation or stimulation of pain fibers (similar to when morphine or codeine might be used) (5) • Disturbed sleep, in combination with Corydalis cava (3) • Disturbed sleep (5) • Anxiety and conditions in which anxiety plays a major role (6,7)

Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Whether California poppy will interfere with standard drug tests for opiate alkaloids is unclear. However, this interference is unlikely. Dosage Dose per day^* Dose per week^*   3–6 ml of 1:2 liquid extract 20–40 ml of 1:2 liquid extract

* This dose range is extrapolated from traditional Western herbal medicine and the author’s education and experience.¹

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Reducing pain and producing calm sleep without the dangers of opiates2 • Enhancing sleep, particularly for children with whooping cough3 • Relieving pain of colic in children4 • Migraine, nervous bowel, neuralgia, anxiety, depression, stress1 • Topically for treating sores and ulcers4
	Native Americans and native Hispanics used the aerial parts, leaves, or flowers of California poppy for sedative and analgesic activity, to promote sleep, and for relief of toothache, particularly in children.4
	California poppy was of interest to medical practitioners of the United States in the late nineteenth century, with the liquid extract entered into the Park-Davis catalog in 1890. California poppy was referred to in 1892 as an “excellent soporific (sleep inducing) and analgesic, above all harmless” and in 1893, reporting that,“…the effect produced by Eschscholtzia californica upon patients is the same as that of morphine, without the inconveniences of the latter drug.”5
Pharmacologic Research	The aerial parts of California poppy contain isoquinoline alkaloids (mainly eschscholtzine and californidine, with smaller amounts of sanguinarine and chelerythrine)6 and flavonol glycosides.7 • California poppy extract inhibits the enzymatic degradation of catecholamines and the synthesis of epinephrine (adrenaline) in vitro. Preserving high levels of catecholamines may explain the sedative and antidepressant activity of California poppy.8 An extract formula containing 80% California poppy and 20% Corydalis cava has demonstrated the ability to interact with opiate receptors in vitro,9 which indicates potential analgesic activity. • Alkaloids from California poppy enhanced gamma-aminobutyric acid (GABA) binding to rat brain synaptic membrane receptors. This finding may indicate a benzodiazepine-like activity.10 Constituents of California poppy exhibited dose-dependent binding to benzodiazepine receptors and displaced the benzodiazepine flurazepam from the receptor.11 • A sedative effect was observed for California poppy extract after injection in experimental models in terms of both behavioral effects and promotion of sleep.12,13 At lower doses, an anxiolytic effect was observed.12 Sedative effects have also been observed after treatment with high oral doses.14 The sedative and anxiolytic effects of California poppy are most likely linked to benzodiazepine-receptor activation because they were antagonized by the benzodiazepine-receptor antagonist flumazenil in vivo (by injection).15 • Isoquinoline alkaloids are known to possess in vivo sedative activity.9 • Muscle relaxant and analgesic activities have been reported in vivo,11 although no muscle relaxant activity was observed in vivo in a later study. Dose-dependent peripheral analgesic activity was demonstrated for California poppy in vivo (by injection), but central analgesic activity was not recorded.15 • California poppy tincture inhibited experimentally induced contractions of isolated smooth muscle.13 • Two alkaloids isolated from California poppy, chelerythrine and sanguinarine, exhibited affinity for vasopressin receptors and demonstrated competitive inhibition of vasopressin binding in vitro.16 Substances that have this activity have been used pharmacologicly as renal agents, vasoconstricting agents, and hemostatics.
Clinical Studies	• Single administration of a California poppy extract (equivalent to 6.7 g of herb) to volunteers resulted in a quantitative electroencephalographic (EEG) recording that was distinguishable from that obtained from placebo. Results from the self-rating assessment of alertness, however, did not differ from placebo.17 An acute sedative effect was not demonstrated, but analysis after ongoing administration may demonstrate a sedative effect. • In two controlled clinical trials, the combination of California poppy and Corydalis cava normalized disturbed sleeping behavior without evidence of carry-over effects or addiction. This preparation consisted of alcoholic extracts of California poppy (standardized for protopine) and Corydalis (standardized for bulbocapnine) in the ratio of 4:1. The dosage was not defined.14

PRESCRIBING INFORMATION

Actions

Laxative

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing cascara in formulations in the context of: • Constipation,* flatulence, abdominal fullness, in combination with boldo (3) • Dyspepsia,* stimulating gastric secretion, loss of appetite, asthenia, postprandial bloating, coated tongue, itching of skin, in combination with gentian, rhubarb, and boldo (3) • Headache resulting from constipation or intestinal weakness (5) • Conditions other than constipation in which easy defecation with a soft stool is desirable, such as with hemorrhoids and anal fissure (5) • Gastrointestinal conditions with hepatic involvement (5)

Contraindications Intestinal obstruction,¹ intestinal inflammation, such as Crohn’s disease, ulcerative colitis, and appendicitis; abdominal pain of unknown origin. Children under 12 years of age should not be prescribed cascara.² Warnings and Precautions Although short-term use of anthraquinone glycoside–containing laxatives is generally regarded as safe, long-term use is not recommended.³ Stimulating laxatives should not be used over an extended period (more than 2 weeks) without medical advice. Using stimulating laxatives longer than is recommended can lead to intestinal sluggishness, although concurrent intake of fiber in sufficient quantities of water can counteract this condition. Cascara should be used only if no benefit can be obtained through change of diet or use of bulk-forming products.² As with all laxatives, cascara should not be prescribed when any undiagnosed acute or persistent abdominal symptoms are present.⁴ Fresh or inadequately prepared cascara bark should not be used because severe vomiting and intestinal spasm can result.² Interactions Use in Pregnancy and Lactation According to the British Herbal Compendium, cascara is contraindicated in pregnancy and lactation.¹ However, this caution seems excessive provided that the dosage recommendations here are observed. Doses that cause an excessively loose stool should not be used during pregnancy. Side Effects Dosage Dose per day^** Dose per week^**   3–8 ml of 1:2 liquid extract 20–55 ml of 1:2 liquid extract

* Cascara has also been used in traditional herbal medicine for treating constipation and dyspepsia and is recommended by both the Commission E and ESCOP for the short-term treatment of constipation. (4,5)

** This dose range is extrapolated from the British Pharmaceutical Codex 1934, the British Pharmacopoeia 1932, and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Constipation,10 particularly when habitual or chronic in nature and when a tonic for the intestines is required11 • Dyspeptic conditions related to constipation and caused by intestinal weakness; headache resulting from similar causes11 • Loss of tone in the rectum11 • Conditions in which a soft stool is desirable, such as anal fissure or hemorrhoids1 • Rheumatism;gastric, duodenal, or biliary catarrh with jaundice; chronic diseases of the liver11,12
	Native Americans used cascara as a cathartic. Native South Americans also used cascara.13
Pharmacologic Research	Key constituents of cascara bark include hydroxyanthracene derivatives in a complex mixture (approximately 8%) consisting mainly of anthrone glycosides, especially cascarosides. Other constituents include aloins, deoxyaloins, and O-glycosides of the anthraquinones aloe-emodin, emodin, and chrysophanol.1,14 • The hydroxyanthracene derivatives are carried unabsorbed to the large bowel, where metabolism via glycosidases from intestinal flora results in the formation of the active aglycones.3,15 (Because of this metabolism, defecation occurs several hours after ingestion.) These aglycones exert their laxative effect by local activity in the intestine by the following mechanisms:modification of intestinal motility (by stimulating intestinal muscle) and accumulation of fluid.8 The increase in motility is a faster response than is the effect resulting from the increase in fecal water. A number of chemical mediators are implicated in producing these effects, including release of prostaglandins,16 inhibition of intestinal tone and segmentation,8 and production of high concentrations of nitric oxide synthase (which evokes net intestinal fluid secretion).17 • After absorption, the anthraquinones are transformed mainly to their corresponding glucuronide and sulfate derivatives, which finally appear in urine and bile. Therapy with anthraquinone glycosides such as those found in cascara and senna is regarded as preferable to therapy with free anthraquinones because the glycosides are less readily absorbed from the gastrointestinal tract and are active at much lower doses.15 Anthraquinone glycosides hence have lower potential toxicity. • The addition of a preparation containing Curcuma aromatica rhizome, whole roots of Curcuma amara, and cascara to a high-cholesterol diet was found to lower both serum and liver cholesterol in rats.18
Clinical Studies	• A preparation containing cascara, gentian, rhubarb, and boldo was tested in 24 healthy volunteers and in 80 patients with mild gastroin-testinal disturbances. The herbal preparation induced a significant increase in salivary secretion from 1 to 30 minutes after oral administration, similar to the active control (citric acid) and unlike placebo or placebo plus alcohol. In this double-blind study, the herbal preparation was significantly better than placebo for the following symptoms: asthenia, loss of appetite, coated tongue, postprandial bloating, difficult digestion, constipation, flatulence, abdominal fullness, and itching of skin. The test preparation was more efficacious than the two pairs of its components (cascara and boldo; gentian and rhubarb).19 The following herb equivalents were probably administered for the paired preparations:cascara (200 mg/day) and boldo (100 mg/day);gentian (40 mg/day) and rhubarb (200 mg/day). • A survey of 3257 elderly patients admitted to 58 hospitals in Italy in 1991 recorded that plant anthranoid laxatives were the second most frequently prescribed laxative (1.9% in hospital, 3.3% prehospital).20 • In Germany, the Commission E supports using cascara to treat constipation.2 • ESCOP recommends cascara for short-term use in cases of occasional constipation.4 • Cascara has remained official in the USP since the first entry in early 1890 and is currently official in the USP24-NF19.

PRESCRIBING INFORMATION

Actions	Immune enhancing, antiinflammatory, antioxidant
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing cat’s claw in formulations in the context of: • Poor immunity, tendency to infections (7) • Inflammatory conditions such as arthritis, gastritis, cystitis (6) • Convalescence, debility (6) • Adjuvant therapy for cancer (3,6) • HIV infection, AIDS (4)

As cat’s claw has been traditionally used as a tonic (6) and may also be used to treat other health issues requiring this action, including chronic fatigue syndrome. Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation Cat’s claw should be used with caution in pregnancy and lactation. (The root of Uncaria tomentosa has been used traditionally as a contraceptive; pharmacologic results have demonstrated an antifertility effect in one animal model.¹ Oral use of the bark decoction is traditionally prescribed in Bolivia for irregular menstruation.²) Side Effects Dosage Dose per day^* Dose per week^*   4.5–11.0 ml of 1:2 liquid extract 30–75 ml of 1:2 liquid extract   It is recommended that only the pentacyclic oxindole alkaloid-predominant type of cat’s claw be used in therapy.

* This dose range is extrapolated from traditional use of decoction of the bark.³

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Peruvian medicinal uses include degenerative processes (e.g., cancer), inflammatory conditions (e.g., arthritis, gastritis, inflammation of the genitourinary tract and skin), gastric ulcers, diabetes, asthma, convalescence, and debility.3,5 Cat’s claw is also regarded in traditional Peruvian medicine as a tonic or restorative.3 Cat’s claw is one of the powerful plants that the Asháninka priests exclusively used to eliminate disturbance in the communication between body and spirit.6
Pharmacologic Research	Cat’s claw stem bark contains a number of oxindole alkaloids.7 Two different chemotypes of U. tomentosa that have been identified are likely to have distinctly different pharmacologic properties. One chemotype contains only, or predominantly, pentacyclic oxindole alkaloids (POA);the other contains POA and significant quantities of tetracyclic oxindole alkaloids (TOA). Intriguingly, indigenous priests are said to be able to identify the correct chemotype and harvest exclusively the chemotype containing POA, even though the two chemotypes are botanically identical.6,7 • Cat’s claw extract has exhibited antioxidant activity in vitro8 and antiinflammatory activity in experimental models after oral administration.9–11 Results of an in vitro study suggested that the antiinflammatory action may be a result of immunomodulation via suppression of tumor necrosis factor-alpha synthesis.12 • Cat’s claw extract has significantly stimulated interleukin-1 and interleukin-6 production in vitro.13 Cat’s claw extracts and POA stimulated phagocytosis in vitro and by injection.14–16 POA were found to induce endothelial cells to release a factor that influences the proliferation of lymphocytes.6,17 The TOA antagonized the effects of the POA.6 These studies indicate immune enhancement for the POA chemotypes. • POA demonstrated antitumor activity in vitro.18 • Cat’s claw was shown to exhibit antiestrogenic effects in vitro.19
Clinical Studies	• A double-blind, randomized study assessed the effects of a freezedried aqueous extract of U. tomentosa on the mutagenic activity of urine collected from 12 smokers and 12 nonsmokers. A progressive decrease in mutagenic activity in the smokers’ urine was observed with increasing dose.20 • In an uncontrolled trial, 13 patients with HIV took 20 mg/day of an aqueous hydrochloric acid extract of U. tomentosa root (containing 12 mg total POA/g) for 2.2 to 5.0 months. Although the total white blood cell count remained unchanged within the group, results indicated that low values were raised and high values were lowered. The lymphocyte count increased significantly to an average of approximately 35%. However, no significant changes in T4/T8 cell ratios were observed.6 • Standardized U. tomentosa root extract was used in a long-term, open study involving 44 patients with AIDS.1 The daily dose varied from 20 to 60 mg per day (the dried herb equivalent would be much higher), with some patients also taking azidothymidine (AZT). Patients who had CD4 lymphocyte counts of 200 to 500 × 106/L demonstrated the best results for immunologic parameters: • CD4 cells increased significantly for the first year of therapy, and the increase persisted for the first 3 years. Patients continued to show stable counts for as long as 4 and 5 years after beginning treatment. • p24 antigen levels decreased. • B lymphocyte counts increased.

PRESCRIBING INFORMATION

Actions	Diuretic, antiinflammatory, antirheumatic
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing celery seed in formulations in the context of: • Relief of osteoarthritis and rheumatism (4,5) • Prevention of gout (5)

Contraindications No evidence has been found that celery seed is contraindicated in pregnancy. This attribution comes from the mistaken assumption that the essential oil contains significant levels of apiol. Warnings and Precautions Caution is advised in kidney disorders, in particular inflammation of the kidneys, because the essential oil may increase the inflammation by causing epithelial irritation.^1,2 Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects Allergic reaction is possible but rare.¹ The furanocoumarins in combination with ultraviolet light may cause photodermatitis.² Dosage Dose per day^* Dose per week^*   4.5–8.5 ml of 1:2 liquid extract 30–60 ml of 1:2 liquid extract

* This dose range is extrapolated from the British Pharmaceutical Codex 1934, the British Herbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Rheumatism, arthritis, gout3 • Inflammation of the urinary tract, retention of urine, dropsy3,4 • Restlessness, nervous disorders, insomnia5
	The Eclectics considered celery seed as a nervine tonic.4
Pharmacologic Research	Apium graveolens seeds contain an essential oil consisting of terpenes and phthalides (especially 3-n-butyl phthalide).1 • Oral celery seed oil significantly elevated glutathione S-transferase activity in vivo compared with controls.6,7 Two groups of components within celery seed oil (limonene-type monoterpenes and butyl phthalides) appeared to be responsible for this activity. Further testing showed that the phthalide compounds were more active than the limonene-type monoterpenes.8 • Celery seed oil administered orally increased liver tissue regeneration.9 Methanolic extract of celery seed demonstrated significant hepatoprotective activity after oral administration in acetominophen (paracetamol)-induced and thioacetamide-induced hepatotoxicity.10 • Compared with controls, aqueous celery extract demonstrated a significant reduction in serum total cholesterol, LDL cholesterol, and triglycerides in a model of hyperlipidemia.11 • Ethanolic extract of celery seed demonstrated analgesic activity in two experimental models (by oral and injected routes). Antiinflammatory activity was also demonstrated in chronic inflammation (when given orally).12 • The essential oil has shown tranquilizing13 and anticonvulsant effects on the central nervous system.13–15 Phthalides are reported to possess antispasmodic, sedative, and diuretic actions.16 • In experimentally induced tumorigenesis, essential oil of celery seed markedly reduced tumor incidence and tumor multiplicity.7 • 3-n-butyl phthalide inhibited platelet aggregation in vitro17 and demonstrated antispasmodic activity on isolated tissue.18 • 3-n-butyl phthalide demonstrated hypotensive activity after intraperitoneal injection.19 Oral administration of 3-n-butyl phthalide resulted in a selective antianginal effect, without changing blood pressure or heart rate.18 Oral administration of 3-n-butyl phthalide (80 to 240 mg/kg) prevented experimentally induced brain edema in vivo.20
Clinical Studies	In an uncontrolled, preclinical trial in Australia, 15 patients with long-running rheumatic pain received celery seed extract over 12 weeks. The parameters measured were usual pain, current pain, and usual and current body areas experiencing pain. Patients reported significant reduction in pain intensity for usual pain after weeks 3 and 6 and for current pain after weeks 3 and 12. The number of joints at which pain was experienced was significantly decreased over each 3-week period.21

PRESCRIBING INFORMATION

Actions

Antiinflammatory, spasmolytic, carminative, mild sedative, antiulcer, vulnerary, diaphoretic

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing chamomile in formulations in the context of: • Gastrointestinal spasm, inflammatory diseases of the gastrointestinal tract, irritable bowel syndrome, flatulence, bloating (4,5) • Acute, uncomplicated diarrhea, in combination with pectin* (2) • Infantile colic,** in combination with lemon balm, vervain, licorice, and fennel (3) • Anxiety (4) • Travel sickness, nervous diarrhea (5) • Dysmenorrhea, amenorrhea (5) • Restlessness, anxiety (5) • Teething problems in children (5) • Topical treatment for eczema and wound healing (2,5) • Topical treatment for leg ulcers (3,5) • Topical treatment for skin inflammation (3,5) • Topical treatment for mucous membrane inflammations, including those of the oral cavity and gums; anogenita inflammation (4,5) • Topical treatment for bacterial skin diseases (4)

Contraindications Known allergy. Warnings and Precautions Despite reports of skin reactions and dermatitis from topical use of chamomile, the likelihood of chamomile preparations causing a contact allergy is low. However, people with known sensitivity to other members of the Compositae family (e.g., ragweed, daisies, chrysanthemums) should avoid oral and topical application of chamomile or chamomile products. Interactions Chamomile tea (compared with a water control) reduced the absorption of iron by 47% following a bread meal in adult volunteers. The inhibition was dose-dependent and related to its polyphenol content (phenolic acids, monomeric flavonoids, and polymerized polyphenols). Inhibition of iron absorption by black tea was 79% to 94%.¹ This finding indicates a potential interaction for concomitant administration of chamomile during iron intake. In anemia and cases in which iron supplementation is required, chamomile should not be taken simultaneously with meals or iron supplements. Use in Pregnancy and Lactation No adverse effects expected. Side Effects

PRESCRIBING INFORMATION

Actions

Prolactin inhibitor, dopaminergic agonist, indirectly progesterogenic, galactagogue

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing chaste tree in formulations in the context of: • Premenstrual syndrome, especially with mastalgia and fluid retention (2,4,5) • Progesterone deficiency, corpus luteal insufficiency, latent hyperprolactinemia (3) • Cystic hyperplasia of the endometrium, infertility resulting from decreased progesterone levels or hyperprolactinemia (4) • Acne (3) • Secondary amenorrhea (4,5) • Metrorrhagia (from functional causes), menorrhagia, polymenorrhea, oligomenorrhea (4,6) • Insufficient lactation (3,5) • Possible benefit in menopausal symptoms, withdrawal from hormone replacement therapy, and conditions in which unopposed estrogen plays a role (e.g., fibroids, endometriosis, follicular ovarian cysts) because of its supposed progesterone-favoring effect (7) • Possible benefit in conditions in which raised prolactin secretion is implicated (e.g., breast cysts, fibrocystic breast disease, benign prostatic hyperplasia) (7)

Contraindications None required. Warnings and Precautions In general, chaste tree is best not taken in conjunction with progesterone drugs, contraceptive pill, or hormone-replacement therapy (HRT). Chaste tree may aggravate pure spasmodic dysmenorrhea not associated with premenstrual syndrome (PMS). Interactions Chaste tree may interact antagonistically with dopamine receptor antagonists. Use in Pregnancy and Lactation

PRESCRIBING INFORMATION

Actions	Demulcent, astringent, refrigerant, antiulcer (peptic)
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing chickweed in formulations in the context of: • Rheumatic and gouty conditions, gastrointestinal ulceration (5) • Topical treatment for skin disorders, especially eczema and psoriasis, itchy skin, rashes, burns, ulceration, and boils; inflammation of the eye (5) • Topical treatment for hemorrhoids (6)

Contraindications Known allergy. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects Allergic rashes may rarely result from topical use. Dosage Dose per day^* Dose per week^*   3–6 ml of fresh plant succus 20–40 ml of fresh plant succus

* This dose range is extrapolated from the dried herb tincture dosages listed in the British Herbal Pharmacopoeia 1983 and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Rheumatism1,2 • Constipation, cough, hoarseness3 • Topically for eczema, psoriasis, skin inflammation, poorly healing ulcers, carbuncle, abscess1,2 • Hemorrhoids3
Pharmacologic Research	The aerial parts of chickweed contain flavonoids, phenolic acids, triterpenoid saponins, phytosterols, and carotenoids.4 No pharmacologic information has been found for chickweed.

Clinical Studies No clinical studies using chickweed have been found.

PRESCRIBING INFORMATION

Actions

Carminative, aromatic digestive, astringent

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing cinnamon in formulations in the context of: • Loss of appetite, dyspeptic complaints, bloating, flatulence, mild, spastic conditions of the gastrointestinal tract (4,5) • The common cold and influenza (5) • Nausea, vomiting, diarrhea (5) • Conditions requiring warmth and circulatory stimulation, such as cold hands and feet (5) • Uterine hemorrhage, menorrhagia (5)

Contraindications Known allergy to cinnamon and Peruvian balsam.¹ Cross-reactions with Peruvian balsam have been observed for people who are sensitive to cinnamic aldehyde.² Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation The German Commission E recommends that cinnamon is contraindicated in pregnancy. However, a review of the safety literature suggests that cinnamon does not present any special risk in pregnancy.³ Side Effects Allergic reactions of the skin and mucosa have been reported.¹ This finding is most likely a result of cinnamic aldehyde, which is a potent contact sensitizer.³ Dosage Dose per day^* Dose per week^*   3–6 ml of 1:2 liquid extract 20–40 ml of 1:2 liquid extract

* This dose range is extrapolated from the British Pharmaceutical Codex 1949, the British Herbal Pharmacopoeia 1983, and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Flatulent dyspepsia, anorexia, intestinal colic, infantile diarrhea, nausea and vomiting4,5 • The common cold, influenza,4 cold extremities5 • Uterine hemorrhage, menorrhagia5 • Correcting the effects of certain remedies (e.g., the nausea caused by Cinchona) and improving the flavor of other herbs5
Pharmacologic Research	Cinnamon bark contains an essential oil, with the major constituent being cinnamic aldehyde (cinnamaldehyde).6 • The oral pungency of cinnamic aldehyde was found to be a result of burning, tingling, and numbing, with quick onset and rapid decay.7 • Cinnamon oil has demonstrated antibacterial and antifungal activities in vitro,8 including activity against a range of dermatophytes.9 Cinnamic aldehyde has been identified as an active fungitoxic constituent.10 • Cinnamon oil has demonstrated antispasmodic activity on isolated smooth muscle tissue,11 decreased stomach and intestinal motility, and reduced stress-induced gastric ulcers in vivo.8 The in vivo studies used relatively large doses of oil administered by injection. • Cinnamon extract demonstrated analgesic activity in two experimental models testing central and peripheral effects (400 mg/kg pretreatment by injection; 200 mg/kg oral pretreatment, respectively).12 • Cinnamon has demonstrated antioxidant activity in vitro13 and exerted antioxidant activity in rats fed a high-fat diet. The antioxidant protection occurred through its ability to activate antioxidant enzymes.14 Cinnamon did not lower cholesterol in induced hypercholesterolemia.15 • In vitro studies indicate that cinnamon and a compound extracted from it potentiate insulin activity.16,17 Similar to insulin, the compound affects protein phosphorylation in the intact fat cell.17 The insulin-potentiating activity of cinnamon was not correlated with its total chromium content.16
Clinical Studies	• Administration of a cinnamon treatment for 1 week improved oral candidiasis in five patients with HIV infection.18 • In Germany, the Commission E supports using cinnamon to treat loss of appetite, dyspeptic complaints (e.g., mild, spastic conditions of the gastrointestinal tract), bloating, and flatulence.1

PRESCRIBING INFORMATION

Actions	Diuretic, depurative
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing cleavers in formulations in the context of: • Skin diseases, including psoriasis and eczema (5) • Enlarged or inflamed lymph nodes (5) • Painful or difficult urination, cystitis (5) • Kidney stones (6)

Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^* Dose per week^*   3.5–7.0 ml of 1:2 liquid extract 25–50 ml of 1:2 liquid extract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Painful or difficult urination, inflammation of kidneys and bladder, lymphadenitis, enlarged lymph nodes, scrofula (tuberculous infection of the cervical lymph nodes)1,2 • Skin diseases and eruptions, especially psoriasis and eczema2 • Cancer2 • Kidney stones3
Pharmacologic Research	The iridoid glycosides of the aerial parts of cleavers have shown mild laxative activity in vivo.4
Clinical Studies	No clinical studies using cleavers have been found.

PRESCRIBING INFORMATION

Actions	Tonic
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing Codonopsis in formulations in the context of: • Fatigue, loss of appetite, shortness of breath associated with chronic cough or palpitation (5) • Coronary heart disease (4) • Improving red blood cell production and hemoglobin concentration (7) • Adjuvant therapy for cancer (3)

Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^* Dose per week^*   4.5–8.5 ml of 1:2 liquid extract 30–60 ml of 1:2 liquid extract

* This dose range is adapted from dried plant doses administered by decoction in TCM.¹ The author’s experience and the fact that ethanol-water is a more effective solvent than water for many phytochemicals are taken into account.

SUPPORTING INFORMATION

Traditional Prescribing	Uses and properties from TCM include: • Reinforcing qi and invigorating the functions of the spleen and lung1,2 • Lack of appetite, fatigue, tired limbs, diarrhea, vomiting2 • Chronic cough and shortness of breath, shortness of breath with palpitation2,3 • Symptoms of prolapse of the uterus, stomach, and anus2
	Codonopsis is regarded in TCM as having similar functions to those of Korean ginseng root, although not as strong.2 Codonopsis contains different constituents to Korean ginseng and does not contain triter-penoid saponins.4
Pharmacologic Research	• Codonopsis extract weakly stimulated human lymphocytes in vitro.5 • Codonopsis demonstrated the following effects in experimental models:3 • Promoted phagocytic activity of peritoneal macrophages (in vitro, in vivo) • Increased red blood cell production and hemoglobin concentration (oral) • Elevated blood glucose (oral) • Codonopsis extract demonstrated protective activity in experimentally induced gastric ulcers, including the stress-induced model. Pepsin secretion was also reduced.6 In another model, oral decoction of Codonopsis increased serum gastrin levels with no change in gastric acidity or plasma somatostatin.7 • Codonopsis prolonged life span in an experimental model of SLE. Production of anti-double-stranded deoxyribonucleic acid (DNA) antibodies was also inhibited.8
Clinical Studies	• Preliminary studies indicate that Codonopsis can improve the defective in vitro interleukin-2 production in patients with SLE.8 • Codonopsis liquor significantly decreased platelet aggregation in patients with coronary heart disease with blood stasis after 4 weeks of treatment. The inhibition of platelet aggregation did not occur via elevation of fibrinolytic activity.9 • Some benefit was observed for patients with cancer who were treated with Codonopsis as an adjuvant during radiotherapy. Compared with controls, Codonopsis reduced the immunosuppressive effect of radiotherapy but had no effect on most humoral immune parameters. A slight increase in immunoglobulin M (IgM) was observed in the treated patients.10

PRESCRIBING INFORMATION

Actions	Hypotensive, antiplatelet, bronchospasmolytic, spasmolytic, cardiotonic, digestive stimulant, aromatic digestive
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing Coleus in formulations in the context of: • Congestive heart disease (4a) • Asthma, psoriasis (4a) • Topical treatment for glaucoma* (4a) • Hypertension, ischemic heart disease, thrombosis (resulting from antiplatelet activity) (7)

Contraindications Given its hypotensive effect, Coleus is contraindicated in patients with hypotension. Warnings and Precautions Coleus should be used cautiously in patients taking prescribed medication and those with peptic ulcer. Interactions Because of its unique pharmacologic activity, forskolin, the active constituent of Coleus, has the ability to potentiate many drugs. Coleus should therefore be used cautiously in patients taking prescribed medication, especially hypotensive and antiplatelet drugs. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^** Dose per week^**   6–13 ml of 1:1 liquid extract 40–90 ml of 1:1 liquid extract  

* The alcohol must be evaporated before putting the liquid extract near the eye. (See “Dosage”section in this monograph.)

** This dose range is extrapolated from scientific and clinical investigations of forskolin.¹

SUPPORTING INFORMATION

Traditional Prescribing	Although closely related species of Coleus are used in traditional Ayurvedic medicine, Coleus forskohlii has been used only as a condiment in India, with the roots prepared as a pickle.2
Pharmacologic Research	Coleus root contains the diterpene forskolin.3
	Forskolin has demonstrated extensive pharmacologic activity (usually in vitro or in vivo by injection). Forskolin is known to activate adenylate cyclase, which catalyzes the production of cAMP.3 Most of the pharmacologic properties described here are a consequence of this property. Forskolin: • Lowered normal or elevated blood pressure in vivo (injection, oral) by relaxing arteriolar smooth muscle4 • Demonstrated positive inotropic action (increased force of contraction) on isolated heart muscle4 and in vivo (by injection)5 • Inhibited platelet aggregation in vitro4 and in vivo6 (Oral administration of Coleus forskohlii extract [standardized for forskolin] demonstrated antithrombotic activity in vivo.)6 • Increased cerebral blood flow in vivo (by injection), having a direct vasodilator effect7 • Relaxed isolated bronchial smooth muscle8 and prevented experimentally induced bronchospasm in vivo (by intravenous and intraduodenal injection)9 • Stimulated lipolysis in vitro10 and inhibited glucose uptake in vitro11 • Potentiated the secretagogue effects of glucose in vitro12 and stimulated the release of somatostatin and glucagon from isolated pancreatic islet cells13 • Stimulated thyroid function with increased thyroid hormone production in the isolated organ14 (However, low concentrations of forskolin inhibited thyroid function in vitro [thyroid cells].)15 • Enhanced secretion of acid and pepsinogen from the gastric mucosa of isolated tissue16 • Stimulated amylase secretion from parotid gland tissue17 and acted synergistically with cholecystokinin in stimulating amylase release from exocrine pancreatic tissue18 • Acted synergistically with FSH and LH on estrogen and progesterone production and with adrenocorticotropin hormone (ACTH) on corticosteroid production in vitro19 • Inhibited melanoma cell–induced platelet aggregation and reduced pulmonary tumor colonization in vivo (by injection)20 • Lowered intraocular pressure19 • Inhibited the release of inflammatory mediators in vitro21 and partially inhibited B-lymphocyte activation in vitro22
Clinical Studies	No clinical studies have been conducted using Coleus. The following studies have been conducted using forskolin or a water-soluble derivative. • Human studies confirmed that topical application of forskolin (50 μl of a 1% solution) lowers intraocular pressure23,24 by reducing the flow of aqueous humor. In India, the clinical value by topical application of forskolin for glaucoma has been confirmed.25 • Forskolin improved symptoms in a small number of patients with psoriasis.26 • Initial studies on patients with congestive cardiomyopathy and coronary artery disease confirmed that forskolin improved cardiac function and myocardial contractility.25 In another trial (open, controlled design), no increase in myocardial contractility at the tested intravenous dose of forskolin was observed, but left ventricular function was improved. Although higher doses of forskolin did increase myocardial contractility, the accompanying large reduction in blood pressure may preclude such doses in congestive heart failure.27 Although these trials used forskolin by injection, clinical trials have successfully used oral doses of a water-soluble forskolin derivative to treat acute heart failure.28 • Clinical studies demonstrated a bronchodilating effect in patients with asthma, as well as those with and without chemically induced bron-choconstriction. Forskolin was inhaled at a dose of 1 to 10 mg per puff and, by this route, caused no side effects, although its action was short-lived.29,30 Forskolin also countered chemically induced bronchoconstriction in a double-blind, placebo-controlled, crossover, comparative trial involving healthy volunteers. The administered doses were 2 mg and 10 mg of forskolin by inhalation.31

PRESCRIBING INFORMATION

Actions	Diuretic, antilithic, urinary demulcent
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing corn silk in formulations in the context of: • Cystitis, urethritis, bedwetting, bladder disorders of children, urinary calculi, prostatitis (5) • Stimulating diuresis, improving renal function (4,5)

Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^* Dose per week^*   2–6 ml of 1:1 liquid extract 15–40 ml of 1:1 liquid extract

* This dose range is extrapolated from British Herbal Pharmacopoeia 1983, the British Herbal Compendium 1992, and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Cystitis, urethritis, pyelitis, nocturnal enuresis, urinary calculi or gravel, strangury, prostatitis, gonorrhea1,2 • Bladder disorders of children2
	Uses and properties from TCM include edema, hepatitis, nephritis, cholelithiasis, jaundice, and hypertension.3,4
	Corn silk has also been used traditionally as a diuretic and for treating dropsy in Indonesia5 and urinary retention in Fiji.6
	Corn silk was official in the USP from 1894 to 1906 and NF from 1916 to 1946 and was used as a diuretic. From as far back as the sixteenth century, Native Americans used corn products for medicinal purposes.7
Pharmacologic Research	• Diuretic activity has been confirmed in vivo.8 • Corn silk extract inhibited tumor necrosis factor-alpha–induced and bacterial lipopolysaccharide–induced epithelial cell adhesion in vitro.9
Clinical Studies	• Eight to 10 grams of corn silk decoction produced a mild diuretic effect in normal volunteers.2 • In uncontrolled trials in China, corn silk decoction produced diuretic effects in renal edema, ascites, and nutritional edema and improved renal function and albuminuria in patients with chronic nephritis and nephrotic syndrome. Decoction of 50 g of fresh herb was recommended, with the dose not exceeding the daily urine output.2

PRESCRIBING INFORMATION

Actions	Soothing diuretic, urinary demulcent
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing couch grass in formulations in the context of: • Inflammation and infection of the urinary tract, preventing kidney gravel (4,5) • Prostatitis, benign prostatic hyperplasia (5) • Gout, rheumatism, jaundice (5)

Contraindications The Commission E recommends copious fluid intake to assist in reducing microorganisms in the urinary tract, but this should not be undertaken if edema resulting from impaired cardiac or renal function is present.² Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^* Dose per week^*   3–6 ml of 1:1 liquid extract 20–40 ml of 1:1 liquid extract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983 and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Irritation or inflammation of the urinary tract, including cystitis, urethritis, prostatitis, benign prostatic hyperplasia, and urinary calculi3,4 • Gout, rheumatism, jaundice2
Pharmacologic Research	Oral administration of couch grass infusion demonstrated the following results in a calcium oxalate urolithiasis model:a decrease in citraturia when combined with a high carbohydrate diet and an increase in calciuria and decrease in magnesiuria when combined with a standard diet.5
Clinical Studies	No clinical studies using couch grass have been found. In Germany, the Commission E supports using couch grass with copious fluid intake to treat inflammatory diseases of the urinary tract and for preventing kidney gravel.2

PRESCRIBING INFORMATION

Actions	Spasmolytic, mild sedative, astringent, hypotensive, peripheral vasodilator
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing cramp bark in formulations in the context of: • Uterine pain, dysmenorrhea (5) • Cramps of both skeletal and smooth muscle (5) • Threatened miscarriage, preparation for parturition (5) • Hypertension (6)

Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^* Dose per week^*   2.0–4.5 ml of 1:2 liquid extract 15–30 ml of 1:2 liquid extract

* This dose range is extrapolated from the American Herbal Pharmacopoeia and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Cramps and spasms of all kinds; cramps in the legs1,2 • Uterine dysfunction, uterine pain, with spasmodic action; ovarian pain1,2 • Dysmenorrhea, bearing-down, expulsive pains; menopausal metror-rhagia, pain in thighs and back1,2 • Convulsions during pregnancy or labor; threatened miscarriage; as a partus preparator1,2 • Spasmodic contraction of the bladder, infantile enuresis; asthma1,2 • Angina, palpitations,3 hypertension4
	Native Americans used cramp bark as a treatment for stomach cramps, other cramps,“pain over the whole body,” and uterine prolapse.
	Cramp bark was also used as a febrifuge, emetic, and tonic. Cramp bark was official in the USP from 1894 to 1916 and NF from 1916 to 1960 and was listed as a sedative and antispasmodic.4,5
Pharmacologic Research	The constituents of cramp bark are not well defined, but the presence of catechin and epicatechin and the absence of amentoflavone is considered characteristic (for differentiation from Viburnum prunifolium [black haw]). The coumarins scopoletin and scopolin are also present, although apparently only in trace amounts.4 • Laboratory studies conducted subsequent to 1940 have shown cramp bark extract and its constituents to have relaxing effects on isolated uterine tissue and organ.6–8 An in vitro study found the methanol extract of cramp bark to be the most active uterine spasmolytic compared with other Viburnum species, including black haw.7 (Pharmacologic studies conducted before 1940 cannot be trusted for the correct identification of plant material.4) • Intravenous injection of a sesquiterpene dialdehyde fraction of cramp bark lowered heart rate and blood pressure in vivo. The authors suggested that cramp bark had a direct musculotrophic action in addition to weakly potentiating the action of acetylcholinesterase.9 • Alcoholic extracts of cramp bark increased blood coaguability and demonstrated hemostatic activity in experimental models (route unknown).10 • Aqueous extracts of cramp bark exhibited a digitalis-type cardiotonic effect in the isolated heart, but cramp bark does not contain cardiac glycosides.11 • Crude aqueous-alcoholic extracts of cramp bark were found to have inhibitory effects on the enzymes elastase, trypsin, α-chymotrypsin, and angiotensin I in vitro. This activity was attributed to the polyphenolic component (stannins) such as catechin.12
Clinical Studies	No clinical trials have been conducted, although case reports from the mid-1800s in the United States indicate that cramp bark was effective as a uterine sedative.13

PRESCRIBING INFORMATION

Actions	Astringent, antidiarrheal, antihemorrhagic
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing cranesbill root in formulations in the context of: • Diarrhea, dysentery, gastrointestinal ulceration or bleeding (5) • Menorrhagia, metrorrhagia (5) • Topical treatment for leukorrhea, indolent ulcers (5)

Contraindications None known. Warnings and Precautions Because of the tannin content of this herb, long-term use should be avoided. Cranesbill should be used cautiously in highly inflamed or ulcerated conditions of the gastrointestinal tract. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^* Dose per week^*   2–5 ml of 1:2 liquid extract 15–35 ml of 1:2 liquid extract

* This dose range is extrapolated from the British Herbal Pharmacopoeia 1983.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Diarrhea, dysentery, hemorrhoids, peptic and duodenal ulceration, hematemesis, melena, chronic mucous discharges1,2 • Menorrhagia, metrorrhagia1 • Topically for leukorrhea, indolent ulcers1
	Native Americans used cranesbill root for hemoptysis and venereal disease. Externally, cranesbill root was used for bleeding wounds, burns, leukorrhea, intestinal ailments, diarrhea, sore gums, gum disease, toothache, neuralgia, and hemorrhoids. Cranesbill root was official in the USP from 1820 to 1916, the NF from 1916 to 1936, and was used as a tonic and astringent.3
Pharmacologic Research	No pharmacologic information relevant to the current use of cranesbill root has been found.
Clinical Studies	No clinical studies using cranesbill root have been found.

PRESCRIBING INFORMATION

Actions	Antilithic, bladder tonic, antiinflammatory
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing Crataeva in formulations in the context of: • Chronic and acute urinary tract infections (4) • Hypotonic, atonic or neurogenic bladder (4) • Incontinence and possibly enuresis (4) • Prevention and treatment of kidney, ureter, and bladder stones (4,5) • Other urinary system disorders (5)

Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^* Dose per week^*   6–14 ml of 1:2 liquid extract 40–100 ml of 1:2 liquid extract   Crataeva may also be administered as a decoction of the dried bark.

* This dose range is extrapolated from traditional Ayurvedic medicine¹ and the author’s education and experience.

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Ayurvedic uses include: • Disorders of urinary system, especially kidney and bladder stones1 • Deep-seated suppurative inflammation, small joint diseases, osteomyelitis2 • Intestinal and hepatic infestation2 • Snakebite;also used as an antiperiodic (to treat a periodic illness such as malaria)1
Pharmacologic Research	Key constituents of Crataeva bark include sterols (especially lupeol, a pentacyclic triterpene) and flavonoids. The Capparidaceae family is also characterized by the presence of glucosinolates.3 • Crataeva increased the tone of smooth and skeletal muscle in vitro.4 • The petroleum ether extract of Crataeva was shown to inhibit both acute and chronic inflammation in vivo (route unknown).5 Oral lupeol exerted significant dose-dependent antiinflammatory activity in several models of acute and chronic inflammation. Analgesic or antipyretic properties were not displayed.6 • Lupeol reduced foot pad thickness (a measure of inflammation) and complement activity in an experimental model of arthritis (route unknown).7 Lupeol reduced paw swelling, loss of body weight, and cellular infiltration into the synovial cavity of proximal interphalangeal joints in a model of adjuvant-induced arthritis (oral administration).8 • Crataeva significantly decreased bladder stone formation and reduced bladder edema, ulceration, and cellular infiltration compared with controls in an experimental model (route unknown).9 Oral treatment increased bladder tone9 and decreased the tendency to form calcium oxalate kidney stones.10 • Oral doses of an alcoholic extract of Crataeva demonstrated significant dose-dependent protective activity against experimental urinary stone formation and reversed the biochemical parameters associated with urolith formation toward normal levels.11 • Crataeva decoction lowered the induced levels of small intestinal sodium and potassium-adenosinetriphosphatase (Na+, K+-ATPase) compared with controls in animals fed a calculi-producing diet. Changes in Na+, K+-ATPase levels may regulate the uptake of minerals.12 • Changes in the activities of Na+, K+-ATPase, aspartate aminotransferase, and glychollate oxidase (the major oxalate-synthesizing enzyme) were reduced by treatment with Crataeva decoction in an experimental model of calcium oxalate urolithiasis.13 • Oral administration of lupeol inhibited stone formation, exhibited stone-dissolving activity, and facilitated the passage of very small calculi from the bladder. Altered levels of urea and creatinine, indicative of kidney dysfunction, were restored to normal.14 Oral lupeol also dose-dependently reduced the weight of urinary stones, prevented formation of vesical calculi by reducing calcium phosphate and oxalate levels in the urine, normalized serum and urine biochemical parameters, and reduced inflammation and other damage in the bladder and kidneys in an experimental model of urolithiasis.15 • Lupeol reduced markers of crystal deposition in the kidneys and minimized renal tubular damage in experimental models of calcium oxalate stone formation.16,17 Oral lupeol administration reduced kidney oxalate levels and counteracted free-radical toxicity (indicating cytoprotective and antioxidant actions) in experimental urolithiasis.18 Lupeol also restored renal thiol status and restored antioxidant enzymes in the kidney and bladder of stone-forming animals. The mechanism behind the protective activity may involve inhibiting calcium oxalate crystal aggregation and enhancing defense systems.19 • Lupeol produced improvement in renal antioxidant status when coadministered (route unknown) with cadmium (a nephrotoxin) in a chronic toxicity model.20
Clinical Studies	• Crataeva decoction relieved frequency, incontinence, pain, and urine retention, increased bladder tone, and increased the force of urination in patients with hypotonic bladder resulting from benign prostatic hyperplasia. Bladder tone, residual volume, and symptoms also improved in cases of persistent hypotonia, atony, and neurogenic bladder after Crataeva treatment.9 • The urine of patients became less lithogenic (urinary calcium was reduced, and urinary sodium and magnesium significantly increased) after treatment with Crataeva decoction.9 • Twenty six of forty six patients with kidney, ureter, or bladder stones not requiring surgery passed the stones within 10 weeks’ treatment with Crataeva decoction. The majority of the remaining patients experienced symptom relief.9 • Eighty five percent of patients with proven chronic urinary tract infections were symptom-free after 4 weeks’ treatment with Crataeva decoction.9