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Fundamentals of Pharmacognosy and Phytotherapy 3Rd Edition Heinrich Full Chapter
Fundamentals of Pharmacognosy and Phytotherapy 3Rd Edition Heinrich Full Chapter
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FUNDAMENTALS OF
Pharmacognosy
AND Phytotherapy
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THIRD
EDITION
FUNDAMENTALS OF
Pharmacognosy
AND Phytotherapy
Michael Heinrich Dr rer nat habil MA(WSU) Dipl. Biol. FLS
Professor and Head, Centre for Pharmacognosy and Phytotherapy, UCL School of Pharmacy,
University of London, London, UK
FOREWORDS BY
A. Douglas Kinghorn BPharm MSc PhD DSc FRPharmS FAAAS FAAPS FLS FSP
Professor and Jack L. Beal Chair of Natural Products Chemistry and Pharmacognosy,
College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
The rights of Michael Heinrich, Joanne Barnes, Simon Gibbons and Elizabeth M. Williamson to be iden-
tified as authors of this work have been asserted by them in accordance with the Copyright, Designs
and Patents Act 1988.
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or mechanical, including photocopying, recording, or any information storage and retrieval system,
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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
ing and using any information, methods, compounds or experiments described herein. Because of
rapid advances in the medical sciences, in particular, independent verification of diagnoses and
drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by
Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.
ISBN: 9780702070082
Printed in China
Contents
Dedication
ix
Foreword
A. DOUGLAS KINGHORN
Worldwide, drugs derived from organisms continue Pharmacognosy has evolved relatively recently to
to be important for the treatment and prevention of include the topics of phytotherapy and nutraceuti-
many diseases. Pharmacognosy, which is defined in cals. Also, the teaching of pharmacognosy has become
this book as ‘the science of biogenic or nature-derived more relevant than previously over the last 20 years, as
pharmaceuticals and poisons’, has been an established a result of a substantially increased use of herbal rem-
pharmaceutical science taught in institutions of phar- edies (phytomedicines) by the public, particularly in
macy education for well over a hundred years. Europe, North America and Australasia. If the United
The subject area has changed considerably since States is taken as an example, community pharmacists
its initiation, having metamorphosed from a largely have to deal with the availability of a rather bewilder-
descriptive botanical and mycological field in the late ing array of thousands of ‘botanical dietary supple-
19th and early 20th centuries, to having much more of ment’ products, of which many were introduced soon
a chemical and biological focus within approximately after the passage of the Dietary Supplement Health
the last 60 years. Today, pharmacognosy embraces the and Education Act of 1994. There are now many pub-
scientific study of mainly small-molecule organic com- lications in the biomedical literature describing the
pounds from plants, animals and microbes, of both ter- biological properties and mechanistic parameters of
restrial and marine origin. It has been estimated that purified constituents of dietary supplements of natural
almost 50% of new drugs introduced into medicine in origin. Therefore, societal interest in pharmacognosy is
Western countries over the last 70 years were either likely to increase in the future as the biochemical role
obtained directly from an ever more diverse range of of phytomedicines, nutraceuticals and drugs of natural
organisms, or were otherwise derived from natural origin in general becomes more clearly defined.
products. Even in an age of biotechnology, computer The third edition of this volume, Fundamentals of
chemistry and refinements in chemical synthesis, there Pharmacognosy and Phytotherapy, by Michael Heinrich,
continues to be a steady stream of new natural product- Joanne Barnes, José Prieto Garcia, Simon Gibbons and
derived drugs approved by the U.S. Food and Drug Elizabeth Williamson, aims to provide a contemporary
Administration. Most of the new natural product- perspective of natural product drugs providing an in-
derived drugs that have reached the market over the troduction into this field. The book is organized into
last decade and a half have been obtained from terres- two major parts, ‘Fundamentals of pharmacognosy’
trial microbe sources, but there are several other exam- (Part A) and ‘Important natural products and phyto-
ples of both higher plant and marine animal origin. In medicines in medicine and pharmacy’ (Part B). Part A
the United States, the first two examples of ‘botanical is divided into five sections, dealing, in turn, with: the
drug products’ (sinecatechins from green tea – Camellia history and importance of pharmacognosy and phyto-
sinensis (L.) Kuntze and crofelemer from Croton lechleri therapy in pharmacy and medicine; relevant principles
Müll. Arg.) have received official approval within the of botany and ethnobotany; the chemistry and analy-
last 10 years. Natural products continue to be widely sis of secondary metabolites of organisms pertinent to
utilized as laboratory probes for many different targets drug therapy; the characterization and standardization
to help better understand cellular processes. of phytomedicines and nutraceuticals; and the use of
x Foreword
medicinal plants in Oriental and South Asian systems classical botanical pharmacognosy, natural product and
of traditional medicine, as well as in Western comple- analytical chemistry, phytochemistry, phytotherapy and
mentary and alternative medicine. Part B provides clinical pharmacy.
coverage of the use of phytomedicines in various thera- This new edition may be confidently recommend-
peutic categories, affecting, respectively: the gastroin- ed for purchase by undergraduate and professional
testinal system and biliary system; the cardiovascular doctoral students in pharmacy, as well as beginning
system; the respiratory system; the central nervous sys- graduate students in programmes in the pharmaceuti-
tem; infectious diseases; the endocrine system (includ- cal sciences and related areas. It will also be of great
ing effects on diabetes); the reproductive tract; the mus- interest for use in continuing education courses for
culoskeletal system and bones; the skin; the eyes; the pharmacists, dentists, nurses and physicians. In ad-
ears, nose and orthopharynx; weight loss supplements; dition, all those with a scientific interest in herbalism
and miscellaneous supportive therapies. Some of these and traditional medicine will find the content of value.
categories are new for this third edition of the book. The book will moreover serve as a reliable source of
This comprehensive pharmacognosy textbook inte- information on natural product drugs for the interest-
grates very effectively the various traditional elements of ed lay reader. The previous editions of Fundamentals
pharmacognosy and phytotherapy. The five talented co- of Pharmacognosy and Phytotherapy have proven to be
authors have been successful in this endeavour in large very highly regarded by readers. This updated and
part because they have contributed their collective and partially reorganized volume will be especially warm-
complementary technical expertise in several diverse ly welcomed by educators of future pharmacists and of
areas, including ethnobotany and ethnopharmacology, other healthcare professionals.
xi
Foreword
MARK BLUMENTHAL
Consumer interest in and use of herbs, teas, medicinal a utumnale) and the analgesic and anodyne opiates –
plants, phytomedicines, plant-derived ingredients and codeine and morphine – from the opium poppy (Papa-
so-called ‘nutraceuticals’ has been growing worldwide ver somniferum). The latter (morphine) is the very first
over the past four decades. Scientific and clinical re- plant-based drug (isolated in 1804). In relatively rapid
search on the chemistry, pharmacology, toxicology, succession, in the early 19th century other plant-derived
and clinical applications of medicinal plants and re- single-chemical entity drugs were isolated from their
lated products is accelerating at a significant rate. The plant sources: strychnine (from Strychnos nux-vomica),
growth of publications on such research increased al- the antimalarial quinine (from the South American cin-
most 700% in a 30-year period from 1977 to 2007, and chona bark, Cinchona officinalis), and numerous others,
if such growth in research publications were measured giving rise to the modern pharmaceutical industry.
today (2017), the rate of the continued increase might In recent years there has been some debate among
be even higher. researchers as to whether the search for new pharma-
Accordingly, the corresponding need for reliable ceutical drugs from plants is a worthwhile endeavour.
professional educational materials on these increas- Chemists normally prefer the purity of single-chemical
ingly popular natural products has never been more entity (SCE) drugs, whether natural or synthetic, and
compelling. chemical synthesis has often been the preferred route
Consumers continue to purchase and utilize herbs of discovery, when appropriate, usually due to the
and medicinal plant products in growing numbers. lower cost and chemical simplicity of SCEs, i.e. when
They are regulated in a variety of ways, either as a compared to the chemically complex botanical materi-
form of food or as various types of medicines: dietary als – roots, leaves, barks, flowers, seeds, etc., and their
supplements in the US and food supplements in the extracts.
European Union (EU), so-called Traditional Herbal Investigations into the long history of the use of
Medicines in the EU, Natural Health Products in Can- medicinal plants in indigenous cultures – the sciences
ada, and other names for a wide spectrum of product of ethnobotany and ethnopharmacology – has often
formulations that are regulated under a variety of reg- produced excellent leads for the development of new
ulatory regimes. medicines. Although now dated, the most-cited study
Pharmacognosy is the study of drugs of natural of this process was published by the World Health
origin, whether they are derived from plants, bacte- Organization in 1979 in which 119 modern plant-
ria, fungi, or animals. Many modern drugs are de- derived drugs were listed (including, of course, all
rived directly from plants – a truism that is commonly those mentioned above). Not surprisingly, the mod-
known among pharmacists, physicians, researchers, ern applications of 74% of these drugs correlated di-
and even many educated consumers. Classic exam- rectly with the traditional ethnobotanical uses of their
ples include the still-employed cardiac drug digoxin source plants.
(from the toxic foxglove plant, Digitalis purpurea and Lest anyone think that the ethnobotanical approach
D. lanata), the anti-inflammatory drug colchicine (from to drug discovery is an archaic and/or futile endeav-
the also toxic Mediterranean autumn crocus, Colchicum our, one only need review the blockbuster news in
xii Foreword
the medical plant community in 2015 that Chinese by consumers for a variety of traditional and clinically
researchers were granted the Nobel Prize in Physiol- documented health benefits. Conventional foods, such
ogy or Medicine for discovery of the highly successful as cranberry (Vaccinium macrocarpon), bilberry (Vaccin-
antimalarial drug artemisinin, derived from the tradi- ium myrtillus, an anthocyanin-rich type of blueberry),
tional Chinese herb quinghao (Artemisia annua, some- pomegranate (Punica granatum), soy (Glycine max),
times referred to as sweet wormwood). Traditional and/or their extracts have gained significant popu-
uses of this plant for reducing intermittent fevers led to larity as dietary supplements and phytomedicines in
its being investigated by Chinese scientists in the 1970s various countries, again based on the growing amount
when seeking leads for the development of a new an- of clinical research demonstrating their obvious safety,
timalarial drug. as well as their activity/efficacy in published clinical
Further interest is generated by the recent develop- trials.
ment and official United States government approval This brings a relatively new spectrum of plants
of two new plant-derived chemically complex medi- to the pharmacognosist for study of their chemistry,
cines, a tannin-rich extract of green tea (Camellia sinen- pharmacology, toxicology, and various ways that these
sis) in an ointment for the topical treatment of human substances in raw, dried, powdered form, or as extracts
papilloma virus and an oligomeric proanthocyanidin- (and essential oils) can be formulated for optimal con-
rich extract of the exudate of the bark of a South Amer- sumption by a growing consumer base interested in
ican tree sangre de drago (Croton lechlerii, dragon’s safe, effective, reliable natural products.
blood) for symptomatic relief of diarrhoea in HIV/ With the increased acceptance of the health-
AIDS patients on antiretroviral therapy. Approval of promoting benefits of many food items, one can fore-
new chemically complex plant-derived medicines is cast that future pharmacognosy educational materials
probably inevitable and may constitute a new era in will recognize the field of nutritional biochemistry as
pharmacy and medicine. an equally important area of research. The growing
Medicinal plants have played and will continue to trend of ‘food as medicine’ is rife with opportunities
play a significant role in the development of modern for pharmacists, physicians, and dietitians/nutrition-
medicines, and will continue to be used by the pub- ists to share vitally important information for the ben-
lic as self-selected medicines and supplements. Cor- efit of health consumers.
respondingly, a growing number of licensed health While consumer demand for natural health prod-
professionals also recommend or prescribe medicinal ucts continues to grow and the market responds with
plant-based supplements and related natural products. an almost dizzying array of natural products, one of
Of particular interest is the increased consumer ac- the most important recent developments is the grow-
ceptance and use of herbs and medicinal plant prod- ing concern of botanical experts regarding the quality
ucts in industrialized nations. In the U S market, retail and identity of botanical raw materials, extracts, and
sales of herbs and other plant-based dietary supple- essential oils.
ments in 2015 reached almost US$7 billion – a new Quality issues related to herbal ingredients have
record for sales in the United States. These sales data come under increased scrutiny due to increased re-
do not reflect similar growth in other countries. This ports of problems related to the first issue noted above,
does not reflect the additional sales volume related to i.e. the adulteration of the raw materials, extracts, or
the use of herbal teas or the growing use of botanical essential oils with undisclosed lower-cost ingredients.
ingredients in cosmetics and, more recently, in conven- While adulteration with another plant can be a re-
tional foods, e.g. nutrition bars. sult of accidental misidentification of the plant in the
What should be immediately clear from examining field or in processing and/or inadequate training of
a list of top-selling herbs (at least as it represents con- harvesting and processing personnel, reliable reports
sumer demand in the United States) is the presence of continue to confirm the highly lamentable practice of
many botanicals that have a long history of food use, intentional adulteration of botanical materials used as
either as spices and food flavourings and/or as con- ingredients in consumer products meant for health ef-
ventional foods. fects, e.g. dietary/food supplements. Adulterated bo-
Popular spices such as turmeric root and rhizome tanical materials are also found in cosmetic products
(Curcuma longa), the top-selling supplement in the and other items for topical use.
United States in the natural food store channel for the There are generally two areas of concern when it
past 4 years, garlic (Allium sativum), ginger (Zingiber comes to medicinal plant quality: (1) identity and au-
officinale), and red pepper (Capsicum annuum) are used thenticity, and (2) purity. With respect to the former,
Foreword xiii
the first priority in any effective quality-control system continually offer training programmes on these tech-
for herbs and medicinal plants is ensuring the proper niques in order to serve the increasingly specialized
identity of the raw plant material, whether it is to be quality-control needs of the global botanical industry.
used as simply raw material for a consumer product Accordingly, there is a growing need in the burgeoning
(e.g. a herbal tea or capsule), or whether it is to be used botanical industry for well-qualified technicians and
as the starting material for the creation of a botanical scientists with adequate training in medicinal plant
extract (made with one or more solvents) or distilled identity, authentication, and other means of appro-
into an essential oil. The second priority of purity deals priate qualification, e.g. botanists, pharmacognosists,
with ensuring that the raw material does not contain natural product chemists, and others. This textbook
any excessive levels of other plant materials (pharma- presents as an excellent reference contributing to such
copeias usually allow up to 2% of foreign organic ma- education and training.
terial in herbal starting materials used for medicinal While earlier pharmacognosy texts tended to be
purposes), excessive levels of pesticides or other agri- organized on a phytochemical basis (e.g. alkaloids,
cultural chemicals or excessive levels of heavy metals glycosides, tannins, etc.), this text takes the rational
(often derived from soil or water), and that there is no approach of organizing the content based on a thera-
microbial contamination. peutic and clinical basis – physiological systems upon
Adulteration of foods, spices, botanical drugs, and which the natural medicines have their primary ac-
medicinal products is not a recent phenomenon. Recent tions and uses (e.g. cardiovascular system, nervous
publications document the problem of substitution system, digestive system, etc.). The authors, all experts
with undisclosed lower-cost materials and/or dilution in pharmacognosy, also provide essential and ratio-
with such ingredients going as far back as 2000 years, nal information for the appropriate use of medicinal
and probably even earlier. It was for this reason that plants in therapy, especially as practiced by licensed
the first pharmacopeia was initiated in the late 15th health professionals.
century – as a means to compile methods to ensure the This book, the third edition of a work that has gained
proper botanical identity of herbal drugs and to detect significant prominence and respect as a leading text-
known adulterants. book, contains highly valuable and authoritative infor-
As a section of this book demonstrates, botanical mation for anyone who is a student of pharmacy and/
authentication is a necessary first step in any robust or pharmacognosy. It is also a valuable reference for
and effective quality-control system used in the vari- industry quality-control personnel, herbalists, natural
ous areas of the supply chain and manufacturing in product researchers, and others in the health profes-
the botanical industry. Plant species identification sionals who wish to learn about the growing popularity
and authentication is conducted using various tech- of herbs and medicinal plants and how natural botani-
niques – macroscopic and organoleptic, microscopic, cal preparations can provide a growing range of safe
chemical and genetic. Industry and nonprofit groups and effective health benefits for c onsumers w
orldwide.
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xv
Preface
In the last few decades, pharmacognosy (the study The book combines sections on the scientific study
of drugs of natural origin) as an academic discipline, of plant drugs – phytochemistry, ethnopharmacy and
and its application in healthcare, has changed re- botany – with descriptions of traditional medicine sys-
markably but still focuses on the quality of products tems, such as Western medical herbalism, traditional
and the development of new medicines Anagnostou Chinese medicine (TCM), and Ayurvedic medicine.
and Heinrich, 2017. There has been a revival of in- For this edition, a new chapter covering the analysis of
terest in natural products as sources of new drugs, complex plant mixtures has been added (phytochemi-
phytotherapy and herbal medicines highlighting the cal analysis) and summaries of Australian Aboriginal
responsibilities of healthcare professionals. This has medicine, Rongoā Māori (Aotearoa New Zealand),
created the need to provide teaching and learning in Kampo (Japan), Unani (India, Pakistan, Middle East),
these topics for students of pharmacy, medicine, nurs- Jamu (Indonesia, Malaysia) and the traditional medi-
ing and other health professions, including medical cine of the Americas, have also been included. This
herbalism. Knowledge about plant-derived medici- new material is introduced and supported by a new
nal products is essential in all areas of healthcare, not overview of medicinal plants in healthcare systems.
only because these forms of treatment are a popular As in previous editions, a separate chapter covers ‘in-
healthcare choice (often used as self-medication) but tegrative’ or ‘complementary/alternative’ therapies,
because of the importance of them in many tradi- such as aromatherapy, homoeopathy and others, if it
tional medical systems globally. This text aims to pro- involves the use of plant-derived substances.
vide a contemporary, therapeutics-oriented perspective on The fully revised and updated Part B continues
plants as medicines, as well as a general overview of to provide a comprehensive summary of the use of
the topic that non-specialist readers will find interest- and evidence for herbal medicines and pure natural
ing and useful. This book is not a guide to treatment, substances in different medical conditions, organized
rather, it is a textbook presenting the scientific prin- into therapeutic categories based on the British Na-
ciples and summarizing the traditional, preclinical tional Formulary (BNF) classification. Numerous me-
and clinical evidence underpinning the use of herbal- dicinal plants and a new section on superfoods have
and other plant-derived medicines. The content has been added. Natural product-derived drugs include
arisen, in part, from new lecture courses developed those produced by biotechnology and from animal
by the authors, as well as from developments in the and microbial sources; these are vast and important
analysis, evidence-based practice and regulation of subjects, so comprehensive coverage was not possible
herbal medicines. The book covers all fundamental in this text.
aspects of pharmacognosy, as well as topics relating Our intention is to equip the reader with the infor-
to the therapeutic use of plant drugs, known as phy- mation and knowledge necessary to understand the
totherapy. The text is unique in covering the subject role of natural products in the drug discovery pro-
of m
edicinal plants as an important element of con- cess, and to enable the assessment of potential benefits
temporary healthcare, an approach that reflects the and harms of plant-based medicines when advising
current public interest in it. patients who wish to use them. We aim to provide a
xvi Preface
strong foundation in the scientific principles of plant- Pharmacognosiaceae. Finally, from our plant family to
derived drugs, focusing on their chemistry, with chem- our own families, as ever, our deepest and warmest
ical structures where necessary and appropriate. thanks are for you.
In this new edition, we have increased the refer- Last, but not least, Dr José Prieto Garcia has joined
ences and further reading material in each section, the team of authors.
so the reader can delve further into the subject, and Michael Heinrich
consult the original work from which our informa- Joanne Barnes
tion was taken. We thank all those who have contrib- José M. Prieto Garcia
uted advice, suggestions and support, including our Simon Gibbons
colleagues, both present and former, and the wider Elizabeth M. Williamson
Reference
Anagnostou, S., Heinrich, M., 2017. Pharmacognosy – from
Pharmacographica to DNA-based techniques’? Planta
Medica. doi.org/10.1055/s-0043–108999.
1
PART A
Fundamentals
of pharmacognosy
Why are plants and their extracts still important in medicines and foods (‘nutraceuticals’) to help combat the
pharmacy and medicine? In 2015, the scientific impor- symptoms and problems of ageing. This public demand
tance of pharmacognosy and natural product research was is an enormous challenge for all health professionals,
highlighted globally. Prof. Youyou Tu (* 1930, China) was many of whom have little specialist knowledge of natural
awarded the Nobel Prize in Physiology or Medicine ‘for her medicines.
discoveries concerning a novel therapy against malaria’ This book is divided into two parts. The first part ad-
and more specifically for the discovery and development of dresses the concepts that help in the understanding of
artemisinin, one of the most important antimalarial drugs the pharmacognostical basis of such medical products,
we have today (Tu 2016) and to Prof. William C. Campbell including pharmaceutical, pharmacological, toxicological
(* 1930, Northern Ireland / USA) and Prof. Satoshi Ōmura and phytochemical aspects. The second part is devoted to
(* 1935, Japan) ‘for their discoveries concerning a novel important plant-derived medicines, which are arranged in
therapy against infections caused by roundworm para- therapeutic categories.
sites’. These two scientists led the development of aver- Part A is devoted to the basic scientific principles un-
mectins, fungal metabolites from Streptomyces avermitilis derlying the use of medicinal plants, and the extracts and
and their derivatives (Campbell 1991, Ōmura and Shiomi pure compounds (sometimes referred to as ‘natural prod-
2007). ucts’) derived from them. This part is selective, and high-
Historically, plants have yielded some of our most lights those aspects most relevant to everyday practice. In
important drugs, but, with the great advances in medicinal the first chapter, a general introduction to the scientific
chemistry of the last century, in many drug discovery pro- field of pharmacognosy, and one of its main applications,
grammes synthetic drugs superseded them as the main fo- phytotherapy, is given. Chapter 2 provides an overview
cus of research. However, the development of drugs using of the historical development of plants in pharmacy and
natural products as ‘lead’ molecules continues, and many medicine, showing how the modern use of medicinal
plant-derived pure compounds (or natural products) are plants has evolved. In Chapters 3–5 the botanical basis
used in modern, conventional medicine; other compounds of the discipline is summarized, covering classification
are potentially useful to humans or are of toxicological and the use of plants by people with little or no access
relevance. to modern medicine – known as ethnobotany and ethno-
There has also been a huge rise in the use of phyto- pharmacy. Chapters 6–8 deal mainly with phytochemistry.
pharmaceuticals and herbal medicines in recent years, Here, the types of compounds that may be present are
especially in North America, Europe and Australasia. Tra- discussed, together with their isolation and identification,
ditional medicine, which uses many plant remedies, re- using chromatographic and spectroscopic techniques. In
mains an important (and in some cases, the only) form of Chapter 9 a very short overview of the process is given,
treatment in many developing countries but is increasing from agricultural production or collection from the wild,
throughout the world. People in many countries now want to the processing of the pharmaceutical product or
to cure minor health problems with something ‘natural’ health-food supplement. Phytomedicines have particular
and ageing populations have an increasing demand for attributes not encountered using synthetic drugs or single
2
compounds, in that the botanical drug or an extract de- and North America. These are non-science-based ap-
rived from it may be combined with other herbal drugs or proaches to healing, to which pharmacists and members
extracts. This may involve synergistic and other interac- of the medical professions are now being more frequently
tions; this is discussed in Chapter 10. Some ancient writ- exposed. More detailed information on these topics can be
ten traditions, such as Chinese and Ayurvedic medicine, found in the further reading sections of each chapter. Due
have been passed on for centuries, and their practical to lack of space, there is no section on biotechnology (e.g.
use and philosophical basis are presented in Chapter 11. fermentation and tissue culture), which is a more special-
Chapter 12 looks at the complementary and alternative ized area and of less relevance to practising pharmacists
therapies that are currently popular in Europe, Australasia and medical doctors.
3
Section 1
Phytotherapy
and pharmacognosy
SECTION CONTENTS
1. Importance of plants in modern pharmacy and medicine 4
2. Pharmacognosy and its history: people, plants and natural products 13
4
Chapter 1
NUTRACEUTICALS OR ‘FUNCTIONAL FOODS’ 2009, it was estimated that the total value of the global
market of herbal medicines was around $83 billion. In
Many foods are known to have beneficial effects on 2009 in the United States alone, consumers spent a to-
health. Examples include: tal estimated $5 billion on herbal dietary supplements.
In the UK in 2007, the market for herbal medicines
l Garlic, ginger, turmeric and many other herbs and was estimated to be almost £700 million, which, com-
spices. pared with many other European countries, is rather
l Anthocyanin- or flavonoid-containing plants such low. The European market for herbal supplements and
as bilberries, cocoa and red wine. herbal medicines is currently worth about $7.4 billion.
l Carotenoid-containing plants such as tomatoes, Germany is the largest European market, with a 27%
carrots and many other vegetables. share, followed by France (24%), Italy (12%) and the
UK (9%). The Indian healthcare market is valued at
$7.3 billion, 60% of which is controlled by pharmaceu-
USE OF HERBAL MEDICINES tical drug manufacturers, while 30% is controlled by
Ayurvedic medicine manufacturers, and the Chinese
Globally, the WHO (World Health Organization) now market is worth around $8 billion (Gruenwald 2008).
advocates universal health coverage and the integra- In most continental European countries, such phyto-
tion of safe and effective traditional providers and medicines are licensed medicinal products and are
complementary services into self-care practices and used under medical supervision. However, the wide-
health service delivery, with a particular focus on herb- spread use of herbal medicines by the general public
al medicines. The use of these remedies is extensive, raises several important issues. Some of these relate
increasing and complex. In several surveys 20–33% of to how individuals, whether consumers or healthcare
the UK’s population claimed to regularly use comple- professionals, perceive and use these preparations;
mentary and alternative medicine (CAM) alone or in other concerns relate to the quality, safety and efficacy
addition to orthodox or conventional medicine and of the herbal medicines themselves.
treatments. In the UK, usage is particularly frequent As part of the primary healthcare team, pharma-
amongst those who are over-the-counter-medicines cists, as well as nurses and general practitioners, need
users. There is not, on the whole, a wide understand- to be competent in advising consumers on the safe, ef-
ing of what herbal medicines are (or are not) (IPSOS- fective and appropriate use of all medicines, including
MORI 2008). Healthcare professionals and students herbal medicines. Healthcare professionals also need
also commonly use such products. Forty-three percent to be aware that patients may be using products and
of students at a University School of Pharmacy report- making healthcare choices without their knowledge.
ed using at least one type of CAM during the last 12 There are many reasons for the increased use of
months (Freymann et al 2006). herbal medicines. These may range from the appeal
In the United States, approximately 38% of adults of products from ‘nature’ and the perception that such
and approximately 12% of children are using some form products are ‘safe’ (or at least ‘safer’ than conventional
of CAM (NIH/NCCAM). Kennedy et al (2008) showed medicines, which are often derogatorily referred to as
that in the preceding 12 months about 38 million adults ‘drugs’), to more complex reasons related to the philo-
in the United States (18.9% of the population) used sophical views and religious beliefs of individuals.
herbal medicines or supplements, but that only one- In developed countries, most purchases of HMPs
third revealed this use to their physician. Data for other are made on a self-selection basis from pharmacies and
regions are even more limited, but the usage of herbal health-food stores, as well as from supermarkets, by
medicines is widespread in countries like India, Indone- mail order and via the Internet. Normally, with the ex-
sia, Australia and China, to name just a few. ception of pharmacists, there is no requirement for a
In addition, market research data reveal high lev- trained healthcare professional to be available on the
els of expenditure on herbal medicines, although it premises to provide information and advice and, in any
is difficult to obtain precise figures for sales of such case, most HMPs can be sold or supplied without the in-
products since some are classed as food supplements volvement of a healthcare professional. Several studies
and are sold through numerous outlets. For similar have confirmed that many individuals do not seek pro-
reasons, it is usually not possible to compare proper- fessional advice before purchasing or using such prod-
ly the estimates for expenditure on herbal medicines ucts, even when purchased from a pharmacy (Barnes
using different studies and in different countries. For et al 1998, Gulian et al 2002). Rather, consumers of HMPs
6 Fundamentals of Pharmacognosy and Phytotherapy
tend to rely on their own (usually limited) knowledge, sionals to be competent with regard to herbal medicines
or are guided by advice from friends and relatives or the and other ‘complementary’ therapies are now coming
popular media. Consumers who do seek professional ad- from outside the professions.
vice (e.g. from their pharmacist or general practitioner) In summary, the use of herbal products continues to
may find that they are not able to have their question(s) be a popular healthcare choice among patients and the
answered fully. In some cases this may be because the in- general public. Most pharmacies sell herbal medicines
formation simply is not available, but it is also recognized and it is likely that pharmacists will be asked for advice
that, at present, many healthcare professionals are not ad- on such products or that they will have to consider other
equately informed about herbal medicines, particularly implications of herbal product use, such as interactions
with regard to their quality, safety and efficacy. This book with conventional medicines. This book provides the
attempts to redress that omission. scientific background to the use of plants as medicines.
Herbal medicines are used for general health main-
tenance, as well as for treating disease and this includes
serious conditions such as cancer, HIV/AIDS, multiple SOME FUNDAMENTAL ASPECTS OF THE
sclerosis, asthma, rheumatoid arthritis and osteoarthri- REGULATION OF HERBAL MEDICINES*
tis. Older patients, pregnant and breastfeeding women,
and children also take HMPs, and this raises concerns The regulation of herbal medicines is complex, varies
because, as with conventional medicines, precautions greatly and is constantly changing. These diverse regula-
need to be taken. For example, few medicines (whether tory frameworks form an essential basis for the activities
conventional or herbal) have been established as safe of all healthcare professionals and for research on such
for use during pregnancy and it is generally accepted products. For example, in the UK, until recently Ginkgo
that no medicine should be taken during pregnancy un- biloba was considered a food and now is, as in other Euro-
less the benefit to the mother or foetus outweighs any pean countries, regulated as a traditional herbal medical
possible risk to the foetus. Similarly, HMPs should be product. It is a herbal medical product in Germany and
used with caution in children and the elderly, who, as a food supplement in the USA. In the UK echinacea may
with conventional medicines, differ from adults in their be a traditional herbal medical product or a food supple-
response, metabolism and clearance of drugs. The use ment or a registered medicine. It is classed as a dietary
of herbal medicines by patients who are already taking supplement in the USA and in general as a medicine in
prescribed medicines is of particular concern as there Germany. Therefore a brief and selective overview of the
is the potential for drug–herb interactions to occur. For regulation of herbal medicines in key English-speaking
example, important pharmacokinetic and pharmacody- countries is given here, excluding the regulation of the
namic interactions between St John’s wort (Hypericum professions involved in their production, prescription
perforatum L.) and certain conventional medicines have and dispensing. We also include a short overview of the
been documented (Williamson et al 2009) and mecha- regulation of traditional Chinese medicines in the three
nisms for such interactions have been identified. Gen- key political entities where they are used widely: Hong
erally, information on interactions between HMPs and Kong, People’s Republic of China and Taiwan.
conventional medicines is limited, although potential
drug–herb interactions can sometimes be identified
UNITED KINGDOM
based on the known phytochemistry and pharmaco-
logical properties of the herbs involved. In essence today’s regulatory framework in the UK is
These issues illustrate once more the need for health- very similar to those in other countries of the European
care professionals, and especially pharmacists, to be Union (based on the regulation as of 2017). Historically,
knowledgeable about HMPs, and professional bodies in the UK, many of the concerns regarding herbal me-
are increasingly mindful of their responsibilities regard- dicinal products have arisen from the lack of regulation
ing herbal medicines and have taken steps to address of such products. Consequently, such products lacked
the issue. It is now recognized by the UK Committee on
Safety of Medicines and the Medicines and Healthcare
Products Regulatory Agency that pharmacists have an *Acknowledgement: We gratefully acknowledge the input
from many colleagues and their teams who provided infor-
important role to play in pharmacovigilance regarding
mation on the regulatory situation in individual countries:
HMPs; this involves reporting suspected adverse reac- Eric Brand (TCM), Pulok Mukherjee (India), Hans Wohlmuth
tions and disseminating information to patients and the (Australia), Johannes v. Staden (South Africa) and Udoa-
public about safety concerns. Calls for healthcare profes- maka Ezuruike (Nigeria).
Chapter 1 Importance of plants in modern pharmacy and medicine 7
evidence for acceptable standards for quality, safety and medicinal products have not necessarily undergone
efficacy. A range of safety problems arose as a result of stringent testing. The ‘well-established use’ directive
the use of unlicensed herbal preparations of inadequate (99/83/EC) was intended to allow greater flexibility on
pharmaceutical quality. the use of bibliographic data to demonstrate safety and
The basis for the current regulatory regime for efficacy, and it was hoped that this legislation would
the licensing of medicines in the UK is set out by the provide a regulatory framework for the many unli-
1968 Medicines Act and other regulations that have censed herbal products on the market. Unfortunately,
arisen from the implementation of relevant European interpretations of the provisions of the directive vary
Commission legislation, namely Directive 65/65/EEC, between EU member states and this directive is not
now revised as Directive 2001/83/EC. Under this leg- widely accepted in the UK.
islation, which has been in place since 2004, manufac-
turers of products, including herbal remedies, which
Traditional herbal medical products
are classed as medicinal products must hold a market-
ing authorization (MA, or product licence, PL) for that The Traditional Herbal Medicinal Products Directive
product unless it satisfies the criteria for exemption from (THMPD) 2004/24/EC (see http://www.mhra.gov
the requirement for a MA. In essence, medicinal prod- .uk) is a regulatory process established to provide a
ucts are defined as those that are medicinal by presenta- mechanism whereby manufacturers of good-quality
tion or (not and) by function. Manufacturers of products herbal medicines can register their products as medici-
comprising new chemical entities, including isolated nal products, and this allows them to make (restricted)
constituents from plant or other natural sources, are re- medicinal claims on the packaging and the patient in-
quired to submit applications for MAs for those prod- formation leaflet (PIL):
ucts, based on the full dossier of chemical, pharmaceuti-
cal, pharmacological, toxicological and clinical data. l Evidence that a corresponding herbal product
Herbal products are available on the UK market as: (i.e. one derived from the same botanical drug
and prepared in a similar way) has been used
l Licensed herbal medicines. traditionally for at least 30 years (15 years non-EU
l Traditional herbal medical products registered and 15 years in the EU, or more than 30 years in the
under the European ‘Traditional Herbal Medicinal EU).
Product Directive’ (THMPD) l Bibliographic data on safety with an expert report.
l Herbal medicines exempt from licensing. l A quality dossier specifying how the company
l Unlicensed herbal products, sold as food or dietary complies with the quality guidance requirements
supplements. of the regulators.
l Prescription-only medicines (POM); these l Details on the PIL, packaging, naming and
potentially hazardous plants may only be labelling.
dispensed by order of a prescription by a registered
doctor. Products registered under this directive can only
l Pharmacy-only medicines (P); certain others may be used for minor, self-limiting conditions. Overall, it
only be supplied by a registered pharmacist, provides an assurance that the patient is receiving not
or may be subject to dose (but not duration of only a good-quality product, but also more reliable ad-
treatment) and route of administration restrictions. vice on its use.
were initially intended to give herbalists the flexibil- unique AUST L number of the label. Medicines deemed
ity to prepare remedies for their patients, although, at to be of higher risk are entered on the register as regis-
present, there is no statutory regulation of herbalists in tered medicines and identified by an AUST R number.
the UK (this is under review). While registered medicines undergo full pre-market
Traditional medicines used by ethnic groups include safety and efficacy evaluation, listed medicines are
traditional Chinese medicines (TCM) and Ayurvedic not evaluated for efficacy, but product sponsors must
medicines. These products are subject to the same leg- hold evidence to support the claims they make about
islation as ‘Western’ herbal medicines. Some toxic spe- the product. Random and targeted post-market audits
cies, like Aristolochia sp., are banned. Adulteration and of this evidence are carried out by the regulator. Indi-
poor-quality problems are, therefore, generally limited cations and claims for listed medicines are limited to
to unregulated products (mostly supplements). health maintenance, health enhancement or non-serious,
There still remain problems associated with some self-limiting conditions and may be supported by evi-
imported medicines: in addition to containing non- dence from traditional use or scientific evidence. Both
herbal ingredients such as animal parts and/or min- listed and registered medicines must be made to phar-
erals, some manufactured (‘patent’) ‘herbal’ products maceutical good manufacturing practice (GMP) stan-
have been found to contain conventional drugs that dards, and herbal ingredients must conform with the
may have POM status in the UK (e.g. dexamethasone relevant BP (also EurPhar) monograph, if one exists.
and glibenclamide) or that are banned. Non-herbal ac- Medicines extemporaneously compounded for a
tive ingredients of any type (chemically synthesized, specific patient following consultation are exempt
animal products) cannot legally be included in herbal from inclusion on the ARTG; this allows herbalists and
remedies, and inclusion of drugs with POM status rep- other practitioners to compound individualized for-
resents an additional infringement of European and mulae for their patients.
US legislation. Some ingredients, such as certain spe-
cies of plants, are also restricted under the Convention
CANADA
on International Trade in Endangered Species of Wild
Fauna and Flora (CITES). In Canada herbal medicines are classified as ‘natural
health products’ that require a product licence before
they can be marketed. The relevant agency is ‘Health
AUSTRALIA
Canada’. Since 2004 this is regulated in the ‘The
In Australia, Western herbal medicine is one of the Natural Health Products Regulations’. The system is
most popular forms of CAM and a range of ethnic intended to find an equilibrium between openness
medicines, especially TCM, are increasingly becom- towards various health paradigms (e.g. traditional
ing popular. All medicines, including herbal and Chinese medicine, Ayurveda, Western traditional
other complementary medicines, are covered by the herbalism, etc.) and scientific rigor. Hence, specific
Therapeutic Goods Act (1989) and regulated by a fed- health claims are allowed on the basis of a variable
eral agency, the Therapeutic Goods Administration evidence base that becomes more stringent with the
(TGA, http://www.tga.gov.au/). A statutory expert severity of the condition treated with a product. A
committee, the Advisory Committee on Comple- manufacturer has to submit detailed information on
mentary Medicines (formerly the Complementary the product to Health Canada, including: medicinal
Medicines Evaluation Committee) provides the TGA ingredients, source, potency, non-medicinal ingredi-
with advice on the regulation of complementary ents and recommended use(s). Once a product has
medicines. The Australian regulatory guidelines for been assessed and granted market authorization by
complementary medicines (http://www.tga.gov.au/ Health Canada, the product label will bear an eight-
docs/html/argcm.htm) provide information to help digit product licence number preceded by the distinct
producers and distributors of complementary medi- letters NPN (Natural Product Number), or, in the case
cines to meet their obligations under therapeutic of a homeopathic medicine, by the letters DIN-HM
goods legislation. (Homeopathic Medicine Number).
Australia adopts a two-tiered, risk-based approach This number on the label will inform consumers that
to the regulation of all medicines. Low-risk medicines, the product license application has been reviewed and
including most herbal and complementary medicines, approved by Health Canada to meet the standards in
are included in the Australian Register of Therapeutic terms of safety, efficacy and quality. GMPs must be guar-
Goods (ARTG) as listed medicines and identified by a anteed in the product’s production in order to ensure the
Chapter 1 Importance of plants in modern pharmacy and medicine 9
product’s quality and thus its safety. In addition, the sys- fully protected under national and international laws
tem requires that all Canadian producers and importers of Intellectual Property Rights and is maintained and
of natural health products are licensed. developed by the government. TKDL also allows au-
Similar to the UK, an Adverse Reaction Reporting tomatic conversion of information from Sanskrit into
System for natural health products is in place and is various languages. The information includes names of
used to warn the public (http://www.hc-sc.gc.ca/dhp- plants, Ayurvedic descriptions of diseases under their
mps/prodnatur/about-apropos/index-eng.php). modern names and therapeutic formulations (Mukher-
hee et al 2007).
INDIA
NEW ZEALAND
India has an ancient heritage of traditional medicine
(see Chapter 11) with a well-recorded and widely prac- In New Zealand (NZ) herbal medicines and other
ticed knowledge of herbal medicine. The Department natural health products (NHPs; or ‘complementary
of Ayurveda, Yoga & Naturopathy, Unani, Siddha and medicines’, CMs) are largely unregulated. Herbal and
Homoeopathy (AYUSH) within the Ministry of Health homeopathic remedies are defined in the NZ Medi-
& Family Welfare focuses on its regulation and on cines Act 1981, but are exempt from requirements to
the improvement of standards in the areas of quality obtain pre-market approval with respect to quality,
control and standardization of drugs, improving the safety and efficacy. Other exemptions in the Medicines
availability of raw material, research and develop- Act allow ‘natural-health’ practitioners (not defined)
ment, education/training of professionals and wider to make ‘individualised’ herbal remedies for specific
outreach about these traditional medical systems. patients in response to a consultation. Most CMs are
The Traditional Herbal Medicines Act, 2006 regulates regulated as ‘dietary supplements’ under the Dietary
the sale of the traditional herbal medicines, which are Supplement Regulations 1985 and the Food Act 1981.
marketed without any license and control on the basis of These regulations do not require adherence to GMP
being from ancient texts. According to the act, every retail- nor pre-market approval of products, but do provide
er or seller of traditional herbal medicines needs to have a some restrictions on ingredients of dietary supple-
license from the Authority to sell traditional herbal medi- ments, and don’t allow therapeutic claims to be made.
cines. Every manufacturer of traditional herbal medicine Initial plans (2010) followed by a detailed draft pro-
needs to work under the principles of GMP and has to posal (2015) to regulate NHPs/CMs on the NZ market
list the ingredients of each medicine on the packaging of were released by the NZ Ministry of Health for a Natu-
the medicine along with their accurate quantity. Side ef- ral Health and Supplementary Products Bill. The regu-
fects and warnings of contraindications need to be stated lations will relate only to manufactured NHPs/CMs
on the package. Pharmacopoeia Committees have been sold in ‘over-the-counter’ settings; ‘natural health’
established to develop quality standards for the main practitioners preparing products for specific patients
groups of therapeutically relevant drugs of Ayurveda, will not be affected, as this is covered under the cur-
Unani, Siddha and homeopathy (Mukherhee et al 2007). rent Medicines Act exemption (although the Medicines
The Indian Government also established an inde- Act itself is due to be replaced by a new Therapeutic
pendent body – the ‘National Medicinal Plants Board’ Products Bill).
under the Ministry of Health and Family Welfare. It
is responsible for co-ordinating all matters relating to
NIGERIA
the development of medicinal plants, including poli-
cies and strategies for conservation, proper harvesting, Manufactured herbal medicinal products such as pro-
cost-effective cultivation and marketing of raw mate- cessed plant extracts in capsules or compressed as
rial in order to protect, sustain and develop this sector. tablets, as well as liquid preparations containing a spec-
Uniquely, the Indian government has established pro- ified dose, are the only forms of herbal medicine that
grammes for the documentation of traditional Indian currently are subject to regulation in Nigeria by the Na-
knowledge, which is already available in the public tional Agency for Food and Drug Administration and
domain. The political goal is to safeguard the sover- Control (NAFDAC). This applies to both those manu-
eignty of this traditional knowledge and to protect it factured locally and those that are imported, including
from being misused in patenting on non-patentable in- homeopathic products. A registration status provides
ventions. The Traditional Knowledge Digital Library a permit for it to be sold and distributed outside the
(TKDL) is an original proprietary database, which is locality of production. The quantitative list of ingredi-
10 Fundamentals of Pharmacognosy and Phytotherapy
ents either by their botanical names or common names, The regulatory framework also includes recogni-
evidence of efficacy and safety, as well as the indica- tion of the importance of traditional healers within the
tions and contraindications of the product are some of primary healthcare system and the need to conserve
the requirements for registration. Products that meet plant biodiversity. The Traditional Health Practitioners
the above requirements are assigned a NAFDAC reg- Act (No. 22 of 2007) provides a regulatory framework
istration number, which is labelled on the package. A to ensure the efficacy, safety, and quality of traditional
‘listing status’ is initially given to manufactured herbal healthcare services, and for control over the registration,
medicinal products for a period of two years, which training and conduct of traditional health practitioners.
precludes the need for rigorous assessment of good Although many studies have recommended cultiva-
manufacturing practices or laboratory evaluations of tion, the majority of medicinal plants are still harvested
efficacy. This is only valid for two years. A full registra- from wild populations. The National Management Envi-
tion licence, which is valid for five years, is then given ronmental: Biodiversity Act No. 10 of 2004 is a regulatory
after a reassessment of the safety of the product based framework for the use of indigenous biological resources
on post market surveillance and laboratory evalua- in a sustainable manner and the fair and equitable shar-
tions of safety and efficacy (NAFDAC 2016). ing of benefits arising from bioprospecting involving in-
Unfortunately, NAFDAC regulations do not apply digenous biological resources. The extent to which these
to ‘extemporaneous preparations’ that are made by regulatory policies are enforced remains unclear. Over-
herbalists themselves and directly sold to the consum- all, a plethora of herbal medicines, which have not been
ers. However, these types of preparations constitute a formally evaluated by the Medicines Control Council for
greater proportion of herbal medicines being sold in quality, efficacy and safety, are being produced and dis-
Nigeria, particularly in herbal trade fairs around the tributed in the largely unregulated South African market.
country, more so because of the huge expenses often
required for product registration. There is therefore an
UNITED STATES OF AMERICA (USA)
absence of an extensive regulatory framework encom-
passing most of the herbal medicines utilized in Nige- In the USA, herbal medicines are generally regulated
ria. Consequently, the current system is ill-suited for as ‘dietary supplements’. The U.S. Food and Drug Ad-
pharmacovigilance monitoring. ministration (FDA, www.fda.gov/Food/DietarySup
plements/) is in charge of these comparatively loose
regulations (http://nccam.nih.gov/health/suppleme
SOUTH AFRICA
nts/wiseuse.htm). Some key characteristics stand out:
South Africa has a long history of exploiting its rich
and diverse plant resources for herbal medicines. The l Prior to marketing, dietary supplements do not
extensive use of traditional medicines in South Af- have to be assessed for safety and effectiveness.
rica has led to the blossoming of an informal herbal Limited therapeutic claims may be made, e.g. that a
product industry that mainly produces semi- and dietary supplement addresses a nutrient deficiency,
full-processed mixtures. The production and trade in supports health, or is linked to a particular body
these unprocessed indigenous herbal products remain function (e.g. immunity). However, this requires
largely unregulated both in terms of Good Agricultur- supportive prior research. Such a claim must
al Practice (GAP) and GMP [as defined in the World be followed by the words ‘This statement has
Health Organization (WHO) guidelines]. However, not been evaluated by the U.S. Food and Drug
herbal medicines can go through the full drug evalu- Administration (FDA). This product is not intended
ation procedure in the Medicines Control Council to diagnose, treat, cure, or prevent any disease’.
(MCC), according to internationally accepted efficacy l Since 2008 GMPs are expected in order to
and safety standards. In South Africa, GAP guidelines, ensure that dietary supplements are processed
which would constitute the first step in quality as- consistently and meet quality standards.
surance in the cultivation and collection of medicinal l Once a dietary supplement is on the market, the
plants, have not been developed. As of 2016, the South FDA monitors the claims made and the product’s
African Bureau of Standards (SABS) is in the process of safety. If inappropriate claims are made the
developing standards for traditional medicines in line manufacturer receives a warning letter or is required
with GMP, to ensure that pharmaceutical products are to remove the product from the marketplace. If a
manufactured to a consistent quality and for the ap- product is found to be unsafe, the FDA takes similar
propriate intended use. action against the manufacturer and/or distributor.
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