8/6/2021 Chronic Use of Echinacea Should Be Discouraged - Letters to the Editor - American Family Physician

  
Letters to the Editor

Chronic Use of Echinacea Should Be

Discouraged
Am Fam Physician. 2003 Aug 15;68(4):617.

Dr. Kligler's review1 of echinacea was comprehensive, concise, and effectively

to the editor:

summarized the evidence behind the popular herb.1 His review commented that there are no
reported drug interactions with the use of echinacea. Although there are no reports of any
significant drug interactions with echinacea, it has been suggested that use of echinacea for
more than eight weeks could cause hepatotoxicity; therefore, echinacea should not be used
with other known hepatotoxic drugs such as amiodarone, methotrexate, and ketoconazole.2
Even the concurrent use of acetaminophen and echinacea may cause an increase in the
incidence of hepatotoxicity.3 This is particularly important because echinacea and
acetaminophen are frequently used to treat the symptoms of the common cold.

Also, in contrast to the acute immunostimulatory effects of echinacea, long-term use of

echinacea (more than eight weeks) is accompanied by the potential for immunosuppression.4
This could be one factor to explain why past studies investigating the use of echinacea for the
prevention of colds failed to show any benefits, because in the majority of trials enrolled
subjects took echinacea for more than eight weeks.

In my opinion, the use of echinacea should be restricted to a maximum of two weeks for acute
illness. I believe that the chronic use of echinacea should be discouraged because its use in
the prevention of colds has not been proved beneficial, can lead to increased risk of
hepatotoxicity, and may have the potential for immunosuppression. Even though echinacea
does not have any documented drug interactions, we must be vigilant in monitoring for
potential interactions and adverse effects.

DOSON CHUA, PHARM.D.

St. Michael's Hospital

300 Bond St.

Toronto, Ontario M5B 1W8 Canada

REFERENCES show all references

1. Kligler B.
Echinacea. Am Fam Physician.
2003;67:77–80....

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8/6/2021 Chronic Use of Echinacea Should Be Discouraged - Letters to the Editor - American Family Physician

in reply: I agree with Dr. Chua that the long-term use of echinacea should be discouraged
based on the fact that there is no evidence that such use is effective in the prevention of upper
respiratory illness. However, regarding the issue of hepatotoxicity and echinacea, evidence is
lacking. The initial concerns regarding hepatotoxicity with long-term use of echinacea arose
from the presence of alkaloids in the pyrrolizidine family in certain parts of the echinacea
plant. Pyrrolizidine alkaloids with an unsaturated nucleus, such as those found in comfrey, are
known to be hepatotoxic with long-term use. However, the pyrrolizidine alkaloids found in
echinacea, isotussilagine and tussilagine, possess a saturated nucleus.1 Currently, this
category of pyrrolizidines has not been found to be hepatotoxic. Thus, I feel that Dr. Chua's
advice to discourage the concurrent use of acetaminophen and echinacea is not based on
current evidence and may lead to unwarranted concerns for physicians and patients regarding
the use of this herb. It also is notable that there have been no published reports of significant
hepatotoxicity with echinacea, despite its widespread use.

BENJAMIN KLIGLER, M.D., M.P.H.

Beth Israel Center for Health and Healing

245 Fifth Ave.

New York, NY 10016

REFERENCES

1. Newall CA, Anderson LA, Phillipson JD. Herbal medicines: a guide for health-care
professionals. London: Pharmaceutical Press, 1996.

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