PRESCRIBING INFORMATION

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Marshmallow root and leaf:demulcent, urinary demulcent, emollient

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing marshmallow root in formulations in the context of: • Irritations of the oral, pharyngeal, or gastric mucosa, dry cough (4,5) • Gastric or peptic ulcer, enteritis (5) • Cystitis, urinary tract infections in general (5) • Topical treatment for varicose ulcers, wounds, burns (5) Based on appropriate evaluation of the patient, practitioners should consider prescribing marshmallow leaf in formulations in the context of: • Irritations of the oral and pharyngeal mucosa, dry cough (4) • Bronchitis, respiratory tract catarrh (5) • Cystitis, urethritis, urinary gravel or calculus (5) • Topical treatment for abscesses, boils, and ulcers (5)

Contraindications None known. Warnings and Precautions The absorption of other medications taken simultaneously with marshmallow root may be retarded.¹ Simultaneous ingestion of drug medications and marshmallow root should therefore be avoided. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects None expected if taken within the recommended dose range. Dosage Root:   Dose per day^* Dose per week^*   3-6 ml of 1:5 tincture 20-40 ml of 1:5 tincture   3-6 ml of 1:5 glycetract 20-40 ml of 1:5 glycetract   Leaf:   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, the British Herbal Compendium 1992, and the author’s education and experience.

** 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 of marshmallow root include: • Diseases of the mucous membranes, such as hoarseness, catarrh, pneumonia, and other respiratory complaints, gonorrhea, vesical catarrh, renal irritation, acute dysentery, diarrhea2 • Strangury (pain in the urethra), inflammation of the bladder, hematuria, retention of urine, some forms of gravel, and most kidney or bladder infections2 • Gastrointestinal irritation and inflammation,2 specially gastric or duodenal ulcer3 • Topically for varicose ulcers,3 inflammatory lesions, swellings, wounds, bruises, and scalds2 Traditional Western herbal medicine uses of marshmallow leaf include: • Bronchitis, respiratory catarrh3 • Cystitis, urethritis, urinary gravel or calculus3 • Topically for abscesses, boils, ulcers3
Pharmacologic Research	The roots and leaves of marshmallow contain mucilage, consisting of acidic polysaccharides.4 Ethanol-water extracts of both marshmallow leaf and root will extract some of the mucilage in the starting herb, although mucilage is sparingly soluble in such mixtures. In the case of the root, which contains a much higher concentration of mucilage than the leaf, a glycerol-water combination is preferable for extraction given that mucilage is more soluble in this medium. • The results of an in vitro study suggest that the adhesive effects of certain plant-derived polysaccharides to mucous membranes may account, in part, for the therapeutic effects of mucilage-containing plants in treating irritated buccal membranes. Polysaccharides from marshmallow root demonstrated moderate bioadhesion to epithelial tissue.5 • Cold macerate of marshmallow root inhibited esophageal mucociliary transport in vitro.6 • In an experimental model, oral administration of an extract of marshmallow root or the polysaccharide fraction demonstrated significant antitussive activity, depressing the cough resulting from both laryngopharyngeal and tracheobronchial stimulation. This study provides indirect evidence that a soothing action on the upper gastrointestinal mucosa causes reflex soothing of the respiratory tract, leading to bronchodilation and reduced tendency to cough.7 • Extracts of marshmallow root demonstrated potential antiinflammatory and immunomodulatory effects in vitro,8 but lack of antiinflammatory activity was observed after oral administration of marshmallow root in carrageenan-induced rat paw edema.9 The in vivo antiinflammatory effect of an ointment containing both marshmallow root extract and dexamethasone was superior to that of the individual ingredients.10
Clinical Studies	No clinical studies using marshmallow root or leaf have been found. • In Germany, the Commission E supports using marshmallow root and leaf to treat irritation of the oral and pharyngeal mucosa and associated dry cough and marshmallow root to treat mild inflammation of the gastric mucosa.11 • ESCOP recommends marshmallow root for treating dry cough and irritations of the oral, pharyngeal, or gastric mucosa.1

PRESCRIBING INFORMATION

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Antacid, antiinflammatory, mild urinary antiseptic, astringent

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing meadowsweet in formulations in the context of: • Gastric ulcer (5,7) • Dyspepsia, hyperacidity, heartburn, diarrhea, irritable bowel syndrome (5) • Genitourinary tract disorders, such as cervicitis, vaginitis, leukorrhea, cystitis, and dysuria (5) • Fever; arthritic and rheumatic conditions (5) • Possible benefit by topical application for cervical dysplasia and to protect and repair the mucosa of the vagina and cervix (4)

Contraindications None known. Warnings and Precautions Meadowsweet contains salicylates and should be avoided or used with caution in patients with salicylate sensitivity. Interactions None known. Given the experimental anticoagulant effect, meadowsweet should be used with caution if patients are taking warfarin. 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 1:2 liquid extract 20-40 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: • Atonic dyspepsia with heartburn and hyperacidity; gastric ulcer (prophylaxis and treatment), diarrhea1 • Fevers;genitourinary tract irritation, acute catarrhal cystitis, retention of urine resulting from enlarged prostate, chronic cervicitis, chronic vaginitis with leukorrhea1,2 • Rheumatic muscle and joint pains1

Pharmacologic Research

• An in vitro study demonstrated that the ethyl acetate extract of meadowsweet flowers strongly inhibited the classical pathway of complement activation. This activity was also observed using methanol extracts of the herb and flower. • The authors of an in vitro study suggested that the observed immunomodulatory activity may explain the therapeutic benefit of meadowsweet preparations in inflammatory diseases. • In vitro studies have demonstrated antimicrobial activity against Staphylococcus aureus haemolyticus, Streptococcus pyogenes haemolyticus, Escherichia coli, Shigella flexneri, Klebsiella pneumoniae, and Bacillus subtilis. Another study suggested that water extracts of various parts of meadowsweet showed antibacterial activity and may be used on wounds. • Decoctions of meadowsweet flowers demonstrated antiulcerogenic activity in an experimental model. Alcohol extracts and water decoctions of the flowers decreased the development of experimental erosion and ulcers in vivo. • Anticoagulant activity for extracts of both meadowsweet flower and seed have been demonstrated in vitro and in vivo (orally). This action is thought to be the result of a heparinlike anticoagulant found in the plant. • In an experimental study, local administration of a decoction of the flowers resulted in a 39% drop in the frequency of squamous cell carcinoma of the cervix and vagina.

Clinical Studies In 48 cases of cervical dysplasia treated with an ointment containing meadowsweet, a positive result was recorded in 32 patients and complete remission in 25 cases. No recurrence was observed in 10 of the completely cured patients within 12 months.

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Hepatoprotective, hepatic trophorestorative, antioxidant, choleretic

Potential Indications

Based on appropriate evaluation of the patient, practitioners should consider prescribing milk thistle in formulations in the context of: • Hepatitis, particularly for the hepatoprotective activity (4a, 6) • Nonalcoholic and alcoholic liver damage or disease, including abnormal liver function and fatty liver (4a) • Exposure to chemical pollutants and conventional drugs (4a) • Skin conditions involving liver dysfunction (4a) • Dyspeptic complaints (4) • Preventing gallstone formation (4a, 6) • Gallbladder problems (6)

Contraindications None known. Warnings and Precautions None required. Interactions None known. Use in Pregnancy and Lactation No adverse effects expected. Side Effects Drug monitoring studies in 1995 investigating the concentrated extract (silymarin) indicated that adverse effects were recorded in 1% of patients, mainly as mild gastrointestinal complaints. A mild laxative effect was occasionally observed with milk thistle preparations. Two cases of anaphylactic shock have been reported.