treatment of the common cold with echinacea christopher theberge
TRANSCRIPT
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Treatment of the Common Cold with Echinacea
Christopher Theberge
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Outline
Introduction
Background
Negative Echinacea Findings
Positive Echinacea Findings
Future Research Recommendations
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Introduction
2002 herbal-supplement sales of $4.28 billion dollars
Echinacea was 3rd leading supplement sold
Grossed $188 million in sales
“Immune system boosting” function
(Nutrition Business Journal, San Diego, CA; www.nutritionbusiness.com; Hobbs, C (1994) HerbalGram, 30, 33-47)
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History
Plains Indians’ therapy for treatment of Colds
Respiratory tract infections
Sore throats
Topically for burns and snakebites
(Hobbs, C (1994) HerbalGram, 30, 33-47; Percival, SS (2000) Biochemical Pharmacology, 60, 155-158)
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History
Plains Indians introduced it to European settlers 1920’s in National Formulary Interest dwindled with advent of anti-biotics
Brought to Europe where heavily studied
Gerhard Madaus early 1900’s First to report pharmacological activity Pharmaceutically prepared Echinacin®
(Borchers et al (2000) The American Journal of Clinical Nutrition, 72, 339-347)
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Echinacea
Coneflower
Spiny flower heads, and cone-like receptacle
Greek for “echinos” meaning hedgehog
Part of the Native American Daisy Family
(Hobbs, C (1994) HerbalGram, 30, 33-47)
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Genus includes 9 species in US and Canada
Three primary species used medicinally Echinacea purpurea (E. purpurea)
Echinacea angustifolia (E. angustifolia)
Echinacea pallida (E. pallida)
Echinacea
(Borchers et al (2000) The American Journal of Clinical Nutrition, 72, 339-347)
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Most common forms taken include Liquid extracts
Fresh juice of E. purpurea tops in ethanol
Spray or freeze-dried extracts in caps or tabs
Simple herb powders
Echinacea
(Hobbs, C (1994) HerbalGram, 30, 33-47)
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Pharmacology
Not standardized
“Active” components include Caffeic and ferulic acid derivatives
Cichoric acid Echinacoside
Polysaccharides Alkylamides Glycoproteins
(Hobbs, C (1994) HerbalGram, 30, 33-47; Percival, SS (2000) Biochemical Pharmacology, 60, 155-158)
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Pharmacology
The stimulation of non-specific defense capacities Polymorphonuclear (PMN) neutrophil proliferation Phagocytic and macrophage activity Interferon production Cytokine production
Anti-inflammation
(Hobbs, C (1994) HerbalGram, 30, 33-47; Percival, SS (2000) Biochemical Pharmacology, 60, 155-158)
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Echinacea
Three parts used medicinally E. purpurea root and herb
Most commonly studied
E. angustifolia root
E. pallida root
(Borchers et al (2000) The American Journal of Clinical Nutrition, 72, 339-347)
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Echinacea
Formulations vary by preparation Parts from roots, herb, or both, and leaves
Either 3 echinacea species
Extraction procedures Alcohol, pressed juice, tea
Addition of other plant extracts or herbals Commonly adulterated with Parthenium
(Borchers et al (2000) The American Journal of Clinical Nutrition, 72, 339-347)
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Plants vary by Growing conditions
Harvest time
Genetics
Storage methods and conditions
Echinacea
(Borchers et al (2000) The American Journal of Clinical Nutrition, 72, 339-347)
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Previous Research: Human Studies
Positive results include Immune system stimulation Reduction in cold symptom severity and duration Prophylaxis of infection and colds Anti-inflammation
Injectible Echinacin® Topical Liquid extracts (most useful?) Oral administration with other plant extracts
(Hobbs, C (1994) HerbalGram, 30, 33-47; O’Hara et al (1998) Archives of Family Medicine, 7, 523-536
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The majority of research conducted in Germany
Mostly clinical reports
Few well-controlled human clinical trials
Heterogeneity of supplements
Previous Research: Human Studies
(O’Hara et al (1998) Archives of Family Medicine, 7, 523-536)
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Major flaws in research by improper use or description of Diagnostic criteria Randomization process Treatment interventions Methods for assessing outcomes Blinding assurance Detail of results Quality statistics
Previous Research: Human Studies
(O’Hara et al (1998) Archives of Family Medicine, 7, 523-536)
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1992 Commission E approved only use of Alcoholic root extracts of Echinacea pallida Juice pressed from E. purpurea
External wounds Upper respiratory tract infections Urogenital infections
(O’Hara et al (1998) Archives of Family Medicine, 7, 523-536)
Say: So I chose these studies
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Treatment of the Common Cold with Unrefined Echinacea
A Randomized, Double-Blind, Placebo-Controlled Trial
Barrett et al., 2002
Annals of Internal Medicine, 137(12), 939-945
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Purpose
To determine if a dried, encapsulated, echinacea preparation would be efficacious towards treatment of the common cold
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Methods
Designed for 150 subjects
At least 80% power to detect 2 day duration benefit Average 2 point reduction in cold symptoms on a 9-
point severity scale No valid measures for common cold Considered clinically significant
(Jaeschke et al (1989) Controlled Clinical Trials, 10, 407-415)
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Methods: Inclusion Criteria
Registered students
Answer “Yes” to the question “Do you believe you are coming down with a cold?”
Report at least 2 of the 15 listed cold symptoms 1 related to the respiratory tract
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Having any of the listed symptoms > 36 hours
Using antibiotics, antihistamines, or decongestants
Specified chronic diseases HIV Autoimmune disease
Methods: Exclusion Criteria
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Methods: Primary Outcomes
Defined by severity and duration of self-reported symptoms
Duration = number of days from enrollment to last day before subject answered “No” to “Do you think you are still sick today?”
Severity measured on 9-point Likert scale by “How sick do you feel today?”
Global severity measured by similar 9-point scale
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Methods: Assessments
Nine point scale used to measure severity 1 = very mild 3 = mild 5 = moderate 7 = severe 9 = extreme
Paper and electronic version of questionnaire each day
Adverse events monitored daily
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Methods: Supplements
Echinacea – unrefined dried preparation
50%
E. angustifolia root
25% E. purpurea root
25%
E. purpurea herb
ThymePeppermintCitric Acid
250 mg
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Methods: Supplements
Four capsules = 1 g of echinacea 6 g for the first 24 hours 3 g for a maximum of 10 days
Placebo contained alfalfa
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Methods: Statistical Analyses
Simple inspection Frequency analysis Analysis of variance (ANOVA) 95% confidence intervals
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Subject Characteristics
Echinacea Group Placebo Group
Entered the study, n 73 75Completed study
protocol, n69 73
Mean age ± SD, y 20.8 ± 2.4 21.0 ± 3.4Women, n (%) 50 (72%) 48 (66%)
Current tobacco users, n (%)
15 (22%) 15 (21%)
Non-protocol medications, n (%)
27 (39%) 25 (34%)
Taken echinacea before, n (%)
30 (43%) 28 (38%)
(Adapted from: Barrett et al (2002) Annals of Internal Medicine, 137(12), 939-945)
Descriptive Statistics for Subjects Assessed
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Compounds Lab 1 Lab 2
Cichoric acid 0.77% 0.84%
Echinacoside 0.26% 0.20%
Chlorogenic acid N/A 0.03%
Alkylamides 0.82% N/A
Cafeolytartaric acid N/A 0.33%
(Adapted from: Barrett et al (2002) Annals of Internal Medicine, 137(12), 939-945)
Results from Echinacea Laboratory Analysis
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Lab 3 First day dose increased tumor necrosis
factor (TNF) 189 ± 23 ng/L to 3679 ± 154 ng/L
Follow-up doses increased 2347 ± 66 ng/L
Results from Echinacea Laboratory Analysis
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Mean onset time for first symptom 27 hours
Adherence rate of 92% from pill count
Results from blinding showed that 49% in the echinacea group guessed correctly 46% in the placebo group guessed correctly P > 0.2
Results
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No difference in cold duration between both groups Trend towards longer duration in echinacea group
Durations ranged 2 to 10 days
Largest echinacea potential benefit of 0.22 days
Results
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Mean Cold Duration for Echinacea and Placebo Group
0
1
2
3
4
5
6
7
Da
ys
Echinacea Placebo
6.27 5.75
(Adapted from: Barrett et al (2002) Annals of Internal Medicine, 137(12), 939-945)
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Adverse Effects
15 Subjects22 Times
Echinacea8 Subjects13 Times
Placebo7 Subject9 Times
sleeplessness, heartburn, nausea, stomachache, upset stomach, bad taste
stomachache, nausea,belching, thirst, abdominal pain with diarrhea
(Adapted from: Barrett et al (2002) Annals of Internal Medicine, 137(12), 939-945)
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Conclusions – Study 1
Results do not support echinacea for treatment of the common cold Effect size for 2 days’ duration and two points in
average severity on 9-point scale not detected
No significant trends noted
All differences between groups could be explained by natural variability of the symptoms
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Conclusions – Study 1
The number of previous echinacea users represents its widespread use
This echinacea preparation appeared to be well-tolerated
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Limitations – Study 1
This study only shows that this preparation of echinacea was not effective Preparation used not previously tested
May be ineffective because of bioavailability and phytochemical properties
Previous trials have used extracts rather than whole plant parts, and combinations with other herbs
Phytochemicals vary depending on harvest time, growing conditions, etc…
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Limitations – Study 1
Subjects studied may not benefit from echinacea Previous trials have used older adults and
those with a history of frequent colds Echinacea may benefit only those who are
immunocompromised
Smokers?
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Limitations – Study 1
No valid measurements for assessing the common cold
Self-reported assessments subject to bias
Alfalfa been shown effective in treatment of allerigic rhinitis
(Mittman P. (1990). Planta Medica,56, 44-47)
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Modest-size trial and an effect size of 5% to 10% may be easily lost among natural variability of symptoms in type of subjects used
Subjects were studied for 10 days maximum Frequency of longer illnesses is unknown
Five had symptoms 36 hours prior to study Could have masked a benefit of echinacea given
earlier for treatment of colds
Limitations – Study 1
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The Efficacy of Echinacea Compound Herbal Tea Preparation on the Severity and Duration of Upper Respiratory and
Flu Symptoms
A Randomized, Double-Blind, Placebo-Controlled Trial
Lindenmuth, G. F. & Lindenmuth, E. B. 2000. The Journal of Alternative and Complementary
Medicine, 6(4), 327-334
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Purpose
To test the efficacy of Echinacea herbal tea preparation on duration and severity of symptoms of scratchy throat, runny nose, and fever
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Methods: Sample
Pennsylvania nursing home Registered nurses, dietary aids, physicians,
accountants, maintenance staff, administration
Eligibility criteria Subjects who had early symptoms of a cold
Ineligibility criteria Allergic to coneflowers, different flowering plants
and pollens Acute infections and being treated with antibiotics
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Methods: Assignment
Randomized into echinacea or placebo group Alternation for assignment to keep groups balanced
Echinacea group received Echinacea Plus® Leaves, flowers, and stems of organically grown E.
purpurea and E. angustifolia Water soluble dry extract of E. purpurea Flavor corrigents 1.275 g of herbs and roots per tea bag
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Methods: Assignment
Eater’s Digest® herbal preparation Peppermint leaf, sweet fennel,
ginger, rose hip, papaya leaf, alfalfa leaf, cinnamon
No caffeine or recognizable differences from echinacea blend
All tea bags individually sealed 12 lb heat sealed Saran Wrap
coating 15 lb polyethylene surlyn layer
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Supplement Instructions
Steep for 10 to 15 minutes in 8 fl. oz water
Drink 5 to 6 cups on first day of symptoms
Titrate to 1 cup by the fifth day
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Methods: Questionnaire
1. Rate the effectiveness of the tea at relieving your cold and/or flu symptoms:
1
Not effective
2
Fair
3
Medium
4
Good
5
Excellent
2. Circle the number of days your cold or flu lasted:
Less than 5 6 7 8 > 10
3. Circle the number of days it took before you began to notice a difference in your symptoms:
Immediately 2 3 4 > 5 Not at All
(Adapted from: Lindenmuth, GF & Lindenmuth, EB (2000) The Journal of Alternative and Complementary Medicine, 6(4), 327-334)
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Two tailed t tests
95% Confidence Intervals
Significance set at p < 0.05
Methods: Statistical Analysis
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95 subjects
Echinacea Group48 subjects
Placebo Group47 subjects
41 Women
7Men
40 Women
7Men
Mean Age = 39.7Age range = 24 to 62
(Adapted from: Lindenmuth, GF & Lindenmuth, EB (2000) The Journal of Alternative and Complementary Medicine, 6(4), 327-334)
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Results from Echinacea Plus® Phenolic Compound Analysis
Compound Amount Present
2 Caffeoyl tartaric acid 10.463 mg
Cichoric acid 16.98 mg
Chlorogenic acid 0
Echinacoside 4.06 mg
Total Phenolic Compounds 31.5 mg
(Adapted from: Lindenmuth, GF & Lindenmuth, EB (2000) The Journal of Alternative and Complementary Medicine, 6(4), 327-334)
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1. Rate the effectiveness of the tea at relieving your cold and/or flu symptoms:
1
Not effective
(1)
2
Fair
(2)
3
Medium
(3)
4
Good
(4)
5
Excellent
(5)
Echinacea Group Placebo Group
4.125 ± 0.96* 2.787 ± 0.95
* P < 0.001
Results: Question 1
(Adapted from: Lindenmuth, GF & Lindenmuth, EB (2000) The Journal of Alternative and Complementary Medicine, 6(4), 327-334)
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2. Circle the number of days your cold or flu lasted:
Less than 5
(5)
6
(4)
7
(3)
8
(2)
> 10
(1)
Echinacea Group Placebo Group
4.333 ± 0.93* 2.340 ± 1.10
Results: Question 2
* P < 0.001
(Adapted from: Lindenmuth, GF & Lindenmuth, EB (2000) The Journal of Alternative and Complementary Medicine, 6(4), 327-334)
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3. Circle the number of days it took before you began to notice a difference in your symptoms:
Immediately
(5)
2
(4)
3
(3)
4
(2)
> 5
(1)
Echinacea Group Placebo Group
3.854 ± 0.97* 2.297 ± 1.20
Results: Question 3
* P < 0.001
(Adapted from: Lindenmuth, GF & Lindenmuth, EB (2000) The Journal of Alternative and Complementary Medicine, 6(4), 327-334)
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Conclusions – Study 2
Treatment with echinacea tea at the early onset of a cold or flu Effective at relieving symptoms vs placebo
Less days vs placebo
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Conclusions – Study 2
Echinacea group Symptoms subside 1 to 2 days leaving only “slight drip”
Placebo group Symptoms subside 6 to 10 days with little or no relief
No side effects were reported
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Limitations – Study 2
Flavored teas are not generally not perceived as medicinal Subjects may have needed to believe it was medicinal
Echinacea Plus® Adding any new flavor or formula changes
composition of drug in commerce
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Limitations – Study 2
Sample was not representative of the population Cannot generalize results to men because
primarily women studied Healthcare population may have better habits
Alternation of assignment process was used for simplicity but may be biased
Effectiveness of the blinding was not assessed
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Limitations – Study 2
Compliance with the tea bags not assessed
Questionnaire not validated and may have been too simple Did not quantify symptoms Subject to biases because self-reported method
Different steeping times Bioavailability not known
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Overall Conclusions
There are no validated tools to assess the common cold
Echinacea did not decrease severity and duration of cold symptoms as dried preparation Tea did have a benefit
Echinacea appears to be well-tolerated
More studies need to be conducted to determine if echinacea is efficacious
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Future Research Recommendations
Validated tools for assessing the common cold
Active compounds need to be discovered Standardization Dosage
No serious adverse effects have been noted with use Long-term use for frequent periods of time need to
be addressed
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Future Research Recommendations
Improved methodology and reporting in clinical trials
A single main outcome measure should be predefined for statistical analysis
Larger sample sizes needed
Future studies should focus on evaluation of well-characterized preparations in well-controlled studies with clearly defined endpoints
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15 symptoms
Dry cough Productive cough Cough interfering with
sleep Sore throat Scratchy throat Hoarseness Runny nose
Plugged or stuffy nose
Sneezing Headache Fever Sweats Muscle aches Feeling “run down” Loss of appetite