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HAWTHORN

*Botanical Names:*	Crataegus monogyna, Crataegus laevigata⁺ (Crataegus oxyacantha^#)
*Family:*	Rosaceae
*Plant Parts Used:*	Leaf, berry

+ Medicinally interchangeable species.

# Alternative name.

PRESCRIBING INFORMATION

Actions	Hawthorn leaf and berry:cardioprotective, mild cardiotonic, hypotensive, peripheral vasodilator, antiarrhythmic, antioxidant, mild astringent, collagen stabilizing
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing hawthorn leaf and berry in formulations in the context of: • Cardiac insufficiency, particularly corresponding to New York Heart Association (NYHA) stages I and II (1,4,5) • Other mild heart conditions, such as minor angina pectoris (2,5) • Low heart rate variability (2) • Hypertension (3,5) • Cardiac arrhythmias, tachycardia, nervous heart complaints, circulatory support (4) • Arteriosclerosis, Buerger’s disease (5)

Contraindications None known. Warnings and Precautions None required. Interactions Hawthorn may act in synergy with digitalis glycosides, beta-blockers, and other hypotensive drugs. Modification of drug dosage may be required. Use in Pregnancy and Lactation No adverse effects expected. Side Effects

None expected if taken within the recommended dose range.

In a postmarketing surveillance study involving 3664 patients with cardiac insufficiency corresponding to NYHA stages I and II, hawthorn extract (corresponding to 2.7 g/day of dried leaf and flower, containing 19.8 mg flavonoids) was well tolerated. Adverse reactions with a causal relationship to hawthorn therapy were confirmed in 22 cases and probable in another 4 (a total of 0.7%).

Reported side effects included gastrointestinal disorders, palpitations, headache, dizziness, circulatory disturbances, sleeplessness, and inner agitation.

Dosage Hawthorn berry: Dose per day^* Dose per week^* 3-7 ml of 1:2 liquid extract 20-50 ml of 1:2 liquid extract Extracts providing quantified levels of oligomeric procyanidins (OPCs) are recommended. Ideally, aqueous ethanol extracts should contain not less than 4 mg/ml of OPCs. Hawthorn leaf: Dose per day^** Dose per week^** 3-6 ml of 1:2 liquid extract 20-40 ml of 1:2 liquid extract Extracts providing quantified levels of OPCs are recommended. Ideally, aqueous ethanol extracts should contain not less than 10 mg/ml of OPCs. Higher doses than those outlined here may be necessary for effective control of hypertension.

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

** This dose range is extrapolated from clinical studies.

SUPPORTING INFORMATION

Traditional Prescribing

Traditional Western herbal medicine uses of hawthorn berry include myocardial weakness, hypertension, angina pectoris, tachycardia, and other circulatory disorders, such as arteriosclerosis and Buerger’s disease.¹

Traditional Western herbal medicine uses of hawthorn leaf include as an astringent and tonic.²

Native Americans used Hawthorn fruit and bark for women’s medicine, and the chewed leaves were used as a poultice for swellings.³ Eclectic physicians used hawthorn fruit and bark for cardiac problems, particularly those of a functional nature, and as a general tonic as well.²

Pharmacologic Research

Key constituents of hawthorn include OPCs, especially procyanidin B-2, and flavonoids. The levels vary with the species of hawthorn and also within the plant part. The flowers contain the highest levels of flavonoids, and the leaves contain the highest levels of OPCs. The ripe berries are the lowest in OPCs and flavonoids. Therefore a fair assumption would be that the leaf is more active than the traditionally preferred berry.

• Studies have shown (many in vitro) hawthorn extracts or fractions to increase coronary blood flow, to be positively inotropic (increasing the force of contraction), negatively chronotropic (decreasing the heart rate), and cardioprotective. Oral administration also found an increase in coronary blood flow in an experimental model.

• Purified flavonoids from hawthorn leaf produced a smaller necrotic focus and improved revascularization of finer vessels (after myocardial infarction) when compared with controls.

• In experimental models, the following has been observed:

• Improved myocardial performance (OPCs, by injection)

• Increased coronary blood flow (OPCs, by both oral and injected routes)

• Decreased blood pressure (extract, OPCs, by both oral and injected routes)

• Antiarrhythmic effect (extract, oral route)

• In laboratory studies, when compared with a digoxin preparation, hawthorn extract increased the erythrocyte flow rate in all the vascular networks examined and reduced both leukocyte endothelial adhesion and diapedesis in the venular network of mesenteric vessels.

• Hawthorn leaf and berry extracts exhibited antioxidant activity in vitro. Hawthorn tincture inhibited in vitro oxidation of LDL and VLDL from the plasma of patients with non-insulin–dependent diabetes mellitus.⁴

• Although studies have not been conducted specifically on the OPCs found in hawthorn, hawthorn OPCs will likely share many of the known pharmacological properties of OPCs. These indications might include prevention of cancer, atheroma, and any cell damage occurring under hypoxic conditions. Hawthorn OPCs have also stabilized collagen in vitro.

Clinical Studies

The NYHA classifies loss of cardiac output:for stage I, the patient is symptom-free when at rest and on treatment; for stage II, patients have loss of capacity with medium effort.

• A meta-analysis reviewing eight clinical trials from 1989 to 1994 found standardized hawthorn leaf and flower extract to be efficacious for treating heart failure (mostly of NYHA stage II). A significant effect was observed for subjective findings in all but one trial, for pressure-rate product (which measures cardiac work performance) in four trials, and for work tolerance in three trials. Two trials were open, five were randomized, double-blind, and placebo-controlled, and one was a multicenter, double-blind, comparative trial with the drug captopril. Information available indicates that for four trials, a dose range equivalent to 0.9 to 2.7 g per day of dried leaf and flower standardized to 6.6 to 19.8 mg per day of flavonoids was administered. In two trials, a dose range equivalent to 0.8 to 1.2 g per day of dried leaf and flower standardized to 30 to 45 mg per day of OPC was administered. The randomized, double-blind, placebo-controlled trial that failed to find significant improvement for pressure-rate product had used a lower dose of hawthorn extract (equivalent to 0.9 g/day of leaf and flower and containing 6.6 mg/day of flavonoids).

• In a randomized, double-blind, placebo-controlled study, hawthorn leaf and flower extract (equivalent to 1.2 g/day leaf and flower standardized to 45 mg/day OPC) administered for 12 weeks increased exercise tolerance in patients with NYHA class II congestive heart failure. Exercise tolerance was reduced in the placebo group. No adverse reactions were reported in the hawthorn group. A number of biochemical indices were monitored, and these either remained within their normal ranges or did not differ in a clinically significant manner during therapy.⁵

• Significant benefit in cardiac parameters was achieved in a multicenter, double-blind, placebo-controlled trial using hawthorn leaf and berry extract in 80 patients with mild congestive heart disease resulting from ischemia or hypertension. No adverse interactions with conventional medication were observed.

• In a randomized, double-blind, placebo-controlled study, hawthorn extract significantly increased heart rate variability (HRV) in geriatric patients compared with placebo. (Low HRV is a risk factor in coronary heart disease, and a positive correlation exists between HRV and life expectancy.)

• In a randomized, double-blind, placebo-controlled clinical study, hawthorn extract (equivalent to 900 mg/day of dried herb for 3 weeks) was shown to improve pathology in patients with angina pectoris.

• In a postmarketing surveillance study, standardized hawthorn leaf and flower extract (equivalent to 2.7 g/day leaf and flower standardized to 19.8 mg/day of flavonoids for 8 weeks) was shown to be well tolerated and improved the symptom score on average by 66.6% in patients with heart disease (NYHA stages I and II). Clinicians rated overall efficacy as better than 90%. Patients with borderline hypertension, tachycardia, and cardiac arrhythmias exhibited excellent results, with blood pressure, heart rate, and incidence of arrhythmias being reduced. A large number of patients previously unsuccessfully treated with digoxin alone were compensated for rest and slight stress with relatively low oral doses of the glycoside in combination with hawthorn.

• In an uncontrolled trial, hawthorn berry tincture (equivalent to 4.3 g/day of berry) significantly reduced systolic and diastolic blood pressure. When treatment was stopped, blood pressures returned to their initial values over a 2-week period.

• In a randomized, double-blind, placebo-controlled study, hawthorn leaf and flower extract in combination with passion flower was efficacious in treating patients with dyspnea commensurate with NYHA stage II. The dosage of hawthorn corresponded to 1.6 g per day of leaf and flower and contained 15 mg per day of flavonoids and 28 mg per day of OPCs. The preparation was administered for 6 weeks.

• In a placebo-controlled, crossover study, the effect of a single dose of standardized hawthorn leaf and flower extract (equivalent to 2.7 g of leaf and flower, standardized to 19.8 mg/day of flavonoids) on the cutaneous microcirculation was compared with 0.3 mg medigoxin. Six hours after taking hawthorn, the hemocrit had dropped by a mean of 3.2%, whereas, 3 hours after taking the digoxin, erythrocyte aggregation increased significantly by a mean of 19%.

• In Germany, the Commission E supports using hawthorn leaf with flower to treat decreased cardiac output as described in NYHA stage II.⁶

• ESCOP recommends hawthorn leaf and flower extract for treating declining cardiac performance corresponding to NYHA stage II.

Other preparations, including herbal teas, are indicated for nervous heart complaints and circulatory support.⁷

REFERENCES

Except when specifically referenced, the following book was referred to in the compilation of the pharmacological and clinical informationMills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Edinburgh: Churchill Livingstone, 2000.

1 British Herbal Medicine Association’s Scientific Committee. British herbal pharmacopoeia. Bournemouth: BHMA, 1983.

2 Felter HW. The eclectic materia medica, pharmacology and therapeutics. Portland: Eclectic Medical Publications, 1922. reprinted 1983

3 Vogel VJ. American Indian medicine. Norman, Okla: University of Oklahoma Press, 1970.

4 Rajalakshmi K, Gurumurthi P, Devaraj SN. Indian J Exp Biol. 2000;38(5):509-511.

5 Zapfe Jun. G. Phytomed. 2001;8(4):262-266.

6 Blumenthal M, et al, editors. The complete German Commission E monographs: therapeutic guide to herbal medicines. Austin: American Botanical Council, 1998.

7 Scientific Committee of the European Scientific Cooperative on Phytotherapy [ESCOP]. ESCOP monographs: Crataegi folium cum flore. Argyle House, Gandy Street, Exeter, Devon, EX4 3LS, United Kingdom: European Scientific Cooperative on Phytotherapy, ESCOP Secretariat, October 1999.

HEMIDESMUS

*Other Common Name:*	Indian sarsaparilla
*Botanical Name:*	Hemidesmus indicus
*Family:*	Asclepiadaceae
*Plant Part Used:*	Root

PRESCRIBING INFORMATION

Actions	Depurative, diaphoretic, immune depressant
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing Hemidesmus in formulations in the context of: • Autoimmune diseases such as rheumatoid arthritis (7) • Diseases of the genitourinary tract (5) • Skin diseases, fever (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^* 3.5-8.5 ml of 1:2 liquid extract 25-60 ml of 1:2 liquid extract

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

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Ayurvedic uses include: • Diseases of the genitourinary system ² • Loss of appetite, fever, skin diseases, chronic cough ¹ • Topically as an antiinflammatory remedy ² Hemidesmus is regarded in Ayurvedic medicine as a depurative and tonic and is used as a substitute for sarsaparilla (Smilax spp.).³
Pharmacologic Research	• Hemidesmus has demonstrated antifungal activity in vitro.⁴ • Oral administration of Hemidesmus has been found to depress both the cell-mediated and humoral components of the immune system.⁵ • An inhibiting effect on leprosy was found in an experimental model (dose route unknown).⁶ • An organic acid isolated from the root of Hemidesmus inhibited the activity of snake venom in experimental models (by injection). The acid inhibited the lethal hemorrhagic, coagulant, and anticoagulant activities that the viper venom induced.^7,⁸ The same compound demonstrated antiinflammatory activity in an experimental model (most likely by injection) and in vitro antioxidant activity.⁹ • Oral administration of Hemidesmus extract prevented experimentally induced hepatotoxicity in two models.¹⁰
Clinical Studies	No clinical studies using Hemidesmus have been found.

HOPS

*Botanical Name:*	Humulus lupulus
*Family:*	Cannabaceae
*Plant Part Used:*	Strobile (cones or female inflorescences)

PRESCRIBING INFORMATION

Actions	Hypnotic, mild sedative, spasmolytic, bitter tonic
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing hops in formulations in the context of: • Sleep disorders,^* in combination with valerian (2) • Mood disturbances such as anxiety, restlessness (4,5) • Disorders of the nervous system such as neuralgia, headache (5) • Indigestion, dyspepsia (5) • Sexual activity in men (5) • Bath for sleep disorders (2)

Contraindications Traditionally contraindicated in depression.^1,² Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected, although profound estrogenic effects have been recorded in women harvesting the plant by hand. The polyphenol xanthohumol has estrogenic activity, and although present in freshly harvested hops, it disappears rapidly through oxidation, even on cold storage.³ Hops also contains estrogenic flavonoid derivatives (see the “Pharmacologic Research” section in this monograph). Side Effects None expected if taken within the recommended dose range. Dosage Dose per day^** Dose per week^** 1.5-3.0 ml of 1:2 liquid extract 10-20 ml of 1:2 liquid extract

* Hops has also been used in traditional herbal medicine and is recommended by both the Commission E and ESCOP for treating sleep disorders. (4,5)

** 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: • Insomnia, excitability, neuralgia, headache, delirium tremens ^1,⁴ • Hysteria ⁵ • Indigestion, dyspepsia, mucous colitis; kidney stones ^1,⁴ • Topically for leg ulcers, swellings, inflammation of internal organs (such as pleurisy, enteritis)^1,⁴ Native Americans used hops as a sedative and diuretic and for insomnia, fevers, and intestinal pains. Topically, hops was applied to toothache and earache. Hops was official in the USP from 1820 to 1926, the NF from 1916 to 1947, and was used as a stomachic, sedative, and tonic.⁶
Pharmacologic Research	• A potent phytoestrogen was determined in hops using sensitive and specific in vitro bioassays.8-Prenylnaringenin had an activity greater than that of other established plant estrogens.⁷ In an earlier in vitro study, polyphenolic extracts demonstrated activity, but isolated constituents, including the bitter acids, lacked activity.⁸ • Water-soluble substances isolated from hops demonstrated antigonadotropic activity in vitro and in experimental models (by injection).⁹^–¹¹ • Sedative, anticonvulsant, analgesic, and hypothermic activities have been demonstrated for a hops extract administered by intraperitoneal injection in experimental models.^12,¹³ No sedative activity was observed after oral administration of hops extract or lupulone in an early study that used a number of experimental models.¹⁴ Oral administration of hops extract (400 mg/kg) decreased motor activity for 4 hours in rats and mice.¹⁵ • 2-Methyl-3-butene-2-ol, a constituent of hops volatile oil, and stored hops produced a central nervous system–depressant effect when administered in high doses by intraperitoneal injection. The effect was similar to that from the sedative drug methylpentynol at the same dosage.^16,¹⁷ This constituent is present in small amounts but may be formed from the metabolism of other hops constituents.^18,¹⁹ The constituent might also explain the sedative effect of the hops pillow. • Hops extract stimulated gastric secretions in vivo (route unknown).²⁰ • Prenylated flavonoids isolated from hops demonstrated potent and selective inhibition of cytochrome P-450 enzymes and antiproliferative activity in human cancer cell lines in vitro.^21,²² Colupulone, a constituent of hops, induced the cytochrome P-450 system but without promutagen activation (measured ex vivo).^23,²⁴ • Hops essential oil demonstrated activity against gram-positive bacteria (e.g., Bacillus subtilis, Staphylococcus aureus) and the fungus Trichophyton mentagrophytes var. interdigitalis in vitro but not against Escherichia coli or Candida albicans.²⁵
Clinical Studies	• In an early study, a lipophilic hops concentrate had no sleep-inducing activity on 15 volunteers.²⁶ • A quantitative topographic EEG showed slight but clearly visible effects on the central nervous system of healthy volunteers consuming a combination of valerian and hops extracts (1500 mg and 360 mg, respectively) compared with placebo in a single-blind, crossover design.²⁷ • The combination of hops and valerian reduced the noise-induced disturbance of sleep stage patterns (slow-wave sleep and rapid eye movement [REM] sleep) in sleep-disturbed volunteers compared with baseline values. The daily dose of the herbal product contained the dried herb equivalent of 2 g of hops and 1 g of valerian. The preparation was taken for several days.²⁸ • A randomized, double-blind, parallel trial demonstrated equivalent efficacy and tolerability for a hops-valerian preparation compared with a benzodiazepine in patients experiencing temporarily sleep onset and sleep interruption disorders.²⁹ A surveillance study involving 484 patients found a hops-valerian preparation to be a safe and effective combination that exerted relevant effects on sleep latency, sleep quality, and psychovegetative symptoms. The combination did not have a negative impact on daytime vigilance. The average daily dose taken corresponded to approximately 1.3 g of hops and 5 g of valerian root and was taken on average for 21 days.³⁰ EEG measurements indicated that a high dose of a hops-valerian combination had an effect on the central nervous system of healthy volunteers. The daily dose was equivalent to approximately 2.2 g of hop strobiles and 7.5 g of valerian root.³¹ • A postmarketing surveillance study in Germany involving 518 patients found an herbal combination of valerian, hops, and lemon balm to be a highly effective treatment for nervous insomnia and restlessness, with very few side effects. The dose administered ranged from one to nine tablets. One tablet contained valerian dried root (450 mg), dried hop strobiles (126.5 mg), and lemon balm dried leaf (225 mg).³² • A randomized, double-blind, crossover study involving alcoholic patients with sleep disturbances found consumption of an herbal tablet produced improvement in sleep parameters. The tablet, which was taken for one night and compared with placebo (also one night), contained the following weights of dried herb:valerian root (170 mg), hop strobiles (50 mg), lemon balm leaf (50 mg), and motherwort herb (50 mg).³³ • The calming effect of a hops bath taken on three successive days was evaluated on 40 patients with sleep disturbances in a randomized, double-blind, placebo-controlled, clinical trial. The hops bath consisted of a solution of concentrated hops extract equivalent to approximately 4 g of hops. The placebo solution had the same appearance and foaming as the hops bath solution. The baseline used was the average sleep quality on two nights before the baths. Results yielded a significant improvement in sleep quality with the hops extract baths as compared with the placebo baths.³⁴ • In Germany, the Commission E supports using hops to treat mood disturbances such as restlessness and anxiety and sleep disorders.³⁵ • ESCOP recommends hops for treating tenseness, restlessness, and difficulty in falling asleep.³⁶

REFERENCES

1 British Herbal Medicine Association’s Scientific Committee. British herbal pharmacopoeia. Bournemouth: BHMA, 1983.

2 British Herbal Medicine Association. British herbal compendium, vol 1 . BHMA, Bournemouth, 1992.

3 Verzele M. J Inst Brew. 1986;92:32-48.

4 Felter HW, Lloyd JU. King’s American dispensatory, ed 18. Portland: Eclectic Medical Publications, 1905. rev 3, reprinted 1983

5 Osol A, et al. The dispensatory of the United States of America, ed 24. Philadelphia: Lippincott, 1947.

6 Vogel VJ. American Indian medicine. Norman, Okla: University of Oklahoma Press, 1970.

7 Milligan SR, et al. J Clin Endocrinol Metab. 1999;83(6):2249-2252.

8 de Keukeleire D, et al. Pharm Pharmacol Lett. 1997;7(2-3):83-86.

9 Kumai A, Okamoto R. Toxicol Lett. 1984;21(2):203-208.

10 Okamoto R, Kumai A. Acta Endocrinol. 1992;127(4):371-377.

11 Kumai A, et al. Nippon Naibunpi Gakkai Zasshi. 1984;60(10):1202-1213.

12 Lee KM, et al. Planta Med. 1993;59(suppl):A691.

13 Bravo L, et al. Boll Chim Farm. 1974;113:310-315.

14 Hansel R, Wagener HH. Arzneim Forsch. 1967;17(1):79-81.

15 Schiller H et al. Presented at the International Congress and 48th Annual Meeting of the Society for Medicinal Plant Research and the 6th International Congress on Ethnopharmacology of the International Society for Ethnopharmacology, Zurich, September 3-7, 2000, abstract P4B/18.

16 Hansel R, Wohlfart R, Coper H. Z Naturforsch [C]. 1980;35(11-12):1096-1097.

17 Wohlfart R, Hansel R, Schmidt H. Planta Med. 1983;48(2):120-123.

18 Hansel R, Wohlfart R, Schmidt H. Planta Med. 1982;45:224-228.

19 Wohlfart R, et al. Arch Pharm. 1983;316:132-137.

20 Tamasdan S, Cristea E, Mihele D. Farmacia. 1981;29:71-75.

21 Henderson MC, et al. Xenobiotica. 2000;30(3):235-251.

22 Miranda CL, et al. Food Chem Toxicol. 1999;37(4):271-285.

23 Shipp EB, Mehigh CS, Helferich WG. Food Chem Toxicol. 1994;32(11):1007-1014.

24 Mannering GJ, Shoeman JS, Shoeman DW. Biochem Biophys Res Commun. 1994;200(3):1455-1462.

25 Langezaal CR, Chandra A, Scheffer JJ. Pharm Weekbl Sci. 1992;14(6):353-356.

26 Stocker HR. Schweizer Brauerei Rundschau. 1967;78:80-89.

27 Vonderheid-Guth B, et al. Eur J Med Res. 2000;5(4):139-144.

28 Muller-Limmroth W, Ehrenstein W. Med Klin. 1977;72:1119-1125.

29 Schmitz M, Jackel M. Wien Med Wochenschr. 1998;148(13):291-298.

30 Petrowicz O, Deitelhoff P, Lange P. Phytomed. 2000;7(supp 2):106-114.

31 Vonderheid-Guth B, et al. Eur J Med Res. 2000;5:139.

32 Friede M et al: 2nd International Congress on Phytomedicine, Munich, September 11-14, 1996, abstract P-75.

33 Widy-Tyszkiewicz E, Schminda R. Herba Polonica. 1997;43(2):154-159.

34 von Rosen M, et al. Z Phytother Abstractband. 1995:26.

35 Blumenthal M, et al, editors. The complete German Commission E monographs: therapeutic guide to herbal medicines. Austin: American Botanical Council, 1998.

36 Scientific Committee of the European Scientific Cooperative on Phytotherapy [ESCOP]. ESCOP monographs: Lupuli flos. Argyle House, Gandy Street, Exeter, Devon, EX4 3LS, United Kingdom: European Scientific Cooperative on Phytotherapy, ESCOP Secretariat, July 1997.

HORSECHESTNUT

*Botanical Name:*	Aesculus hippocastanum
*Family:*	Hippocastanaceae
*Plant Part Used:*	Seed

PRESCRIBING INFORMATION

Actions	Venotonic, antiedematous, antiinflammatory, antiecchymotic (against bruises)
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing horsechestnut in formulations in the context of: • Varicose veins (2,4,5) • Chronic venous insufficiency, edema of the lower limbs (1,4,5) • Restless leg syndrome (4) • Hemorrhoids, rectal complaints, neuralgia, rheumatism (5) • Improving capillary resistance in healthy individuals (4a) • Reducing the risk of deep vein thrombosis following surgery (3, by injection) • Disorders where local tissue edema may be involved (4a, 7) • Topical treatment for hematoma, contusions, nonpenetrating wounds and sports injuries resulting in edema (4a, often in combination with other treatments)

Contraindications Because of the irritant effect of the saponins, horsechestnut should not be applied to broken or ulcerated skin. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects As with all saponin-containing herbs, oral use may cause irritation of the gastric mucous membranes and reflux. This irritation can be avoided by using enteric-coated preparations. From 1968 until 1989, nearly 900 million individual doses of one brand of standardized horsechestnut extract were prescribed. In that time, only 15 patients reported side effects. The Commission E advises that pruritis, nausea, and gastric complaints may occur in isolated cases. 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 ESCOP.¹

SUPPORTING INFORMATION

Traditional Prescribing

Traditional Western herbal medicine uses include:

• Conditions involving venous congestion, particularly with dull, aching pain and fullness ²

• Rectal irritation, rectal neuralgia, proctitis, hemorrhoids ²

• Reflex conditions attributed to rectal irritation:dyspnea, spasmodic asthma, dizziness, headache, backache, and dyspepsia ²

• Rheumatism, neuralgia ²

Pharmacologic Research

The major constituents of horsechestnut seeds are saponins (3% to 6%), collectively referred to as escin. Escin is a complex mixture of over 30 individual pentacyclic triterpene diester glycosides.

• Horsechestnut extract and escin have been shown to have antiexudative and antiinflammatory activity in vitro and in vivo by oral, parenteral, and topical routes. Both substances act to reduce capillary permeability and the localized edema associated with inflammation.

• Horsechestnut extract caused contraction of venous valves, increased venous pressure and flow, and increased lymphatic flow in isolated tissue samples.

• Oral administration of horsechestnut extract improved the tone of connective tissue and improved circulation by toning the veins in experimental models.

• Standardized horsechestnut extract reduced cutaneous capillary hyperpermeability, increased skin capillary resistance, decreased the formation of edema of lymphatic or inflammatory origin, and decreased connective tissue formation in subchronic inflammatory granuloma after oral and subcutaneous administration.

• Saponin constituents from horsechestnut showed inhibitory effects on the connective tissue enzyme hyaluronidase in vitro.

Clinical Studies

• A review of randomized, double-blind, placebo-controlled trials published up to December 1996 concluded that horsechestnut extract is superior to placebo and is as efficacious as other medications in alleviating the objective signs and subjective symptoms in patients with chronic venous insufficiency. Horsechestnut treatment was associated with reduced edema, pain, itchiness, and feeling of fatigue. A dosage of 600 mg/day of horsechestnut extract (containing 100 mg escin) was used for 4 to 12 weeks in the majority of these trials. Results from one comparative trial indicated that edema reduction from horsechestnut treatment was equivalent to that achieved by compression therapy with elastic stockings.³ An updated review of the literature up to November 2000 found that all of the 14 randomized, controlled trials scored at least 3 out of 5 points for methodological quality. In addition to these results, horsechestnut treatment was as beneficial as treatment with O-β-hydroxyethylrutosides. Adverse effects reported from horsechestnut treatment were mild and infrequent.⁴

• A case observation study (published in 1996) that involved more than 800 German general practitioners and more than 5000 patients with chronic venous insufficiency found that horsechestnut extract improved subjective symptoms markedly. Horsechestnut was considered an economical, practice-relevant, therapeutic tool that had better compliance than compression therapy.

• Horsechestnut significantly lowered blood viscosity in patients with varicose veins of the lower extremities in an uncontrolled trial. The daily dose of 1800 mg of extract contained 300 mg of escin and was administered for 12 days. Horsechestnut extract (600 mg/day standardized to 100 mg escin) increased vascular flow in healthy volunteers in a double-blind, placebo-controlled trial. Significant reduction in leg volume was recorded after horsechestnut treatment was taken for 4 weeks in a randomized, double-blind, placebo-controlled, crossover trial involving women with pregnancy-induced varicose veins.

• Oral treatment of healthy volunteers with standardized horsechestnut extract (containing 300 mg/day of escin) for 14 days was shown to significantly improve capillary resistance in a randomized, doubleblind, placebo-controlled, crossover study.

• In a controlled trial, intravenous injection of a combination of horsechestnut extract with vitamin B complex, vitamin C, and either strophanthin or Digitalis significantly reduced the incidence of deep venous thrombosis following surgery, compared with the same injection without horsechestnut.

• Injected escin has been efficacious in treating cerebral edemas following cranial fractures and traumas, cerebral tumors, intracranial aneurysms, cerebral sclerosis, subdural hematomas, encephalitis, meningitis, and cerebral abscesses.

• Topical preparations containing escin have been successfully used:

• For treating edema and hematoma in surgical practice

• For preventing and treating sports injuries (gel containing escin and salicylate)

• For inflammation of veins, venous insufficiency, varicose veins (escin combined with buphenine, heparin, benzydamine, and lecithin)

• For hypertrophic scars, keloid scars, stretch marks, lymphodema after mastectomy (escin combined with thyroxine), and anorectal varicose pathologic conditions

• Topical treatment of trauma cases with limb bruising using a gel containing escin and salicylate for 9 days significantly increased the mobility of the injured limb and reduced lower leg swelling, subjective complaints, and relapse frequencies in a randomized, double-blind, placebo-controlled trial. In a study of similar design, escin gel significantly reduced tenderness to pressure in experimentally induced hematoma in volunteers.

• In Germany, the Commission E supports using horsechestnut to treat chronic venous insufficiency. This syndrome may involve pain and a sensation of heaviness in the legs, nocturnal cramping in the calves, pruritis, and swelling of the legs.⁵

• ESCOP recommends horsechestnut for treating chronic venous insufficiency and varicosis.¹

REFERENCES

1 Scientific Committee of the European Scientific Cooperative on Phytotherapy [ESCOP]. ESCOP monographs: Hippocastani semen. Argyle House, Gandy Street, Exeter, Devon, EX4 3LS, United Kingdom: European Scientific Cooperative on Phytotherapy, ESCOP Secretariat, October 1999.

2 Felter HW. The eclectic materia medica, pharmacology and therapeutics. Portland: Eclectic Medical Publications, 1922. reprinted 1983

3 Pittler MH, Ernst E. Arch Dermatol. 1998;134(11):1356-1360.

4 Pittler MH, Ernst E. Altern Ther Health Med. 2001;7(3):108.

5 Blumenthal M, et al, editors. The complete German Commission E monographs: therapeutic guide to herbal medicines. Austin: American Botanical Council, 1998.

HORSETAIL

*Botanical Name:*	Equisetum arvense
*Family:*	Equisetaceae
*Plant Part Used:*	Aerial parts

PRESCRIBING INFORMATION

Actions	Diuretic, astringent, styptic (hemostatic)
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing horsetail in formulations in the context of: • Posttraumatic and static edema, bacterial and inflammatory diseases of the lower urinary tract, renal gravel (4,5) • Nocturnal enuresis, renal colic, hematuria, enlarged prostate, prostatitis (5) • Hemorrhage, hematemesis (6) • Topical treatment for poorly healing wounds (4)

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 exists.¹ 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 1:2 liquid extract 15-40 ml of 1:2 liquid extract

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

SUPPORTING INFORMATION

Traditional Prescribing	Traditional Western herbal medicine uses include: • Cystitis, urethritis, frequent urination, nocturnal enuresis, urinary calculi, renal colic, hematuria, enlarged prostate, prostatitis ^2,³ • Edema, gonorrhea, gleet (gonorrheal urethritis)³ • Ulceration of the urinary tract, hematemesis, hemorrhage ⁴
Pharmacologic Research	The main phenolic compounds in the aerial parts of horsetail are hydroxycinnamic acid derivatives such as caffeic acid esters and flavonoids such as quercetin and kaempferol glycosides.⁵ The herb is also rich in silica. • Chloroform extracts of several species of horsetail demonstrated diuretic activity in vivo.⁶ • Horsetail contains from 1.2% to 6.9% silica. The solubility of the silicon in horsetail was investigated in a Polish study.⁷ Fresh and dried samples of horsetail were extracted with water under various conditions. The extraction of soluble silicon was slow and only occurred significantly with the application of heat. The rate of extraction was much faster from the fresh herb but was still significant for the dried herb. In both cases, several hours of decoction were required to extract a significant percentage of silicon from the plant.
Clinical Studies	• To examine the metabolism and renal excretion of compounds in horsetail, a standardized extract was administered to 11 volunteers following a flavonoid-free diet for 8 days. Quercetin metabolites 3,4-dihydroxyphenylacetic acid or 3,4-dihydroxytoluene was undetectable, and homovanillic acid excretion did not increase. Hippuric acid, the glycine conjugate of benzoic acid, increased twofold after intake. Therefore degradation to benzoic acid derivatives rather than phenylacetic acid derivatives appears to be a predominant route of metabolism.⁸ • In Germany, the Commission E supports using horsetail to treat posttraumatic and static edema, with copious fluid intake for bacterial and inflammatory diseases of the lower urinary tract and renal gravel. Externally, horsetail can be recommended as supportive treatment for poor healing wounds.¹

HYDRANGEA

*Other Common Name:*	Seven barks
*Botanical Name:*	Hydrangea arborescens
*Family:*	Hydrangeaceae
*Plant Part Used:*	Root

PRESCRIBING INFORMATION

Actions	Diuretic, antilithic
Potential Indications	Based on appropriate evaluation of the patient, practitioners should consider prescribing Hydrangea in formulations in the context of: • Disorders of the prostate, including prostatitis and enlarged prostate (5) • Urinary, bladder or kidney stones; inflammatory conditions of the urinary system (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^* 2-7 ml of 1:2 liquid extract 15-50 ml of 1:2 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: • Cystitis, urethritis, urinary calculi, difficult urination, bladder gravel, prostatitis, enlarged prostate gland, chronic gleet (gonorrheal urethritis)^1,² • Improving the nutrition of the urinary mucous membranes ² Native Americans used Hydrangea for calculous complaints and as a decoction with other plants for women “who had strange dreams during their menstrual period.” Hydrangea was official in the NF from 1916 to 1926 and was used for diuretic and diaphoretic purposes.³
Pharmacologic Research	No pharmacologic information has been found for Hydrangea.
Clinical Studies	No clinical studies using Hydrangea have been found.

REFERENCES

1 British Herbal Medicine Association’s Scientific Committee. British herbal pharmacopoeia. Bournemouth: BHMA, 1983.

2 Felter HW, Lloyd JU. King’s American dispensatory, ed 18. Portland: Eclectic Medical Publications, 1905. rev 3, reprinted 1983

3 Vogel VJ. American Indian medicine. Norman, Okla: University of Oklahoma Press, 1970.

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