FWD 2 Expanded Commission E: Echinacea Pallida root

Herbal Medicine: Expanded Commission E

Echinacea Pallida root

Latin Name: Echinacea pallida
Pharmacopeial Name: Echinaceae pallidae radix
Other Names: pale-flowered echinacea, pale purple coneflower root

Overview

One of the most popular herbs in the United States marketplace is the native American medicinal plant echinacea. The term refers to several plants in the genus Echinacea, derived from the aboveground parts and roots of Echinacea purpurea (L.) Moench, E. angustifolia D.C., and E. pallida (Nutt.) Nutt. [Fam. Asteraceae]. Herbalists and pharmacognosists point out the irony that almost all of the scientific research on this medicinal plant has been conducted not in the United States but in Germany. Echinacea preparations have become increasingly popular in Germany since the early 1900s. The herb was first analyzed and tested for homeopathic purposes in Germany and its medical use was later investigated by Dr. Gerhard Madaus in 1938. Echinacea was formerly used in the United States by native Americans and by Eclectic physicians in the late 1800s and early 1900s. Preparations made from various plants and plant parts of the genus Echinacea constituted the top-selling herbal medicine in health food stores in the United States from 1995 to 1998, with an estimated 9.6% of the total health-food dollar spent on herbs, according to a survey of about two hundred independent stores in 1996 (Richman and Witkowski, 1996, 1997, 1998).

Echinacea is used for preventing and treating the common cold, flu, and upper respiratory tract infections (URIs). It is also used to increase general immune system function and to treat vaginal candidiasis. The clinical literature tends to support the treatment for symptoms of colds, the flus, and URIs. Recent studies do not support its use to prevent URI.

Of the four echinacea monographs published by Commission E, two are positive (i.e., approved) (E. pallida root and E. purpurea herb) and two are negative (i.e., unapproved) (E. purpurea root and E. angustifolia root). The latter were given negative assessments due to lack of clinical trials for the specific plant parts. Work on the chemistry of vouchered Echinacea species from 1988 onward by Rudolf Bauer and Hildebert Wagner at the Institute for Pharmaceutical Biology in Munich revealed clear chemical profiles for E. angustifolia and E. pallida (Bauer and Wagner, 1991). It became obvious that earlier pharmacological studies of E. angustifolia actually involved E. pallida. Historically, E. pallida and E. angustifolia have been offered to the trade in mixed lots as "Kansas snake root." Therefore, lack of current pharmacological and clinical studies on E. angustifolia root and E. angustifolia/E. pallida aerial parts resulted in the issuance of a negative monograph until further supporting scientific information becomes available (Leung and Foster, 1996).

However, despite previous problems concerning the botanical identity of Echinacea species in commercial preparations and research materials, another reason for the disparity in approvals by Commission E is based on the availability of the research on the respective species. According to Prof. Heinz Schilcher, vice president of Commission E, at the time the monographs were being considered for publication, experimental and clinical studies were available only on the flowering tops and roots of E. purpurea, roots of E. pallida, and roots of E. angustifolia. The Commission decided that only the results from the research conducted on the fresh plant juice from the flowering herb of E. purpurea and from the water-alcohol extract of E. pallida roots were adequate for a positive monograph. In the meantime, there have been additional studies based on the alcoholic extract of the roots of E. purpurea that in Schilcher's opinion should support a positive monograph (Schilcher, 1997). A clinical trial was carried out in 1992 on an extract of the root of E. purpurea, suggesting therapeutic benefits in patients with colds and flu (Brunig et al., 1992). The same year Commission E published a monograph on E. purpurea root as an Unapproved Component Characteristic, based on the lack of research of this species and part, although not all members of the Commission supported this decision (Schilcher, 1997).

Since there is a variety of echinacea preparations derived from either one plant or plant part or a variety of plant parts (root, leaf, flower, seed) from various species (E. purpurea, E. pallida, E. angustifolia), it is necessary to clarify which plants and plant parts were used in each clinical trial. Professor R. Bauer of the Institute for Pharmaceutical Biology at Heinrich-Heine University inin vitro and in vivo for the expressed juice of the aboveground parts of E. purpurea (i.e., Echinacin®) and for alcoholic extracts of the roots of E. pallida, E. angustifolia, and E. purpurea (Bauer, 1996). The effects act mainly on the nonspecific cellular immune system. He reports several active constituent groups: polysaccharides, glycoproteins, caffeic acid derivatives (cichoric acid), and alkamides.

A review of 26 controlled clinical studies (18 randomized, 11 double-blind) that investigated the immunomodulatory activity of preparations containing echinacea extracts (Melchart et al., 1994). Six of the trials used echinacea alone, and 20 tested echinacea in combination with other ingredients. The methodological quality of the trials was assessed and deemed low. However, the authors concluded that existing controlled clinical trials indicated that preparations containing the juice or extracts of echinacea can be efficacious immunomodulators. Further methodologically sound, randomized clinical trials were recommended. Commenting on this study, Professor H. Wagner, a leading figure in European pharmacognosy, commented, "Of the investigated criteria the most striking effects were the reduction in susceptibility to infection and in the incidence of catarrh and pharyngeal inflammation" (Wagner, 1997). In reviewing clinical studies on echinacea, he has written, "The conclusion that can be drawn is that remedies containing echinacea can effect an improvement in immune defense systems where those systems are temporarily weakened." He pointed out that there is not yet sufficient evidence to give "clear therapeutic recommendations as to which preparation in which dosage and type of application has the optimal effect" (Wagner, 1997).

Many clinical studies on echinacea used fresh stabilized E. purpurea juice, in the injectable form, and others have been conducted with oral applications or an externally applied salve (Hobbs, 1994). The E. purpurea aerial parts preparations are usually a proprietary fresh-pressed leaf juice (22% ethanol by volume as a preservative), marketed as Echinacin® (manufactured by Madaus AG of Cologne, Germany). Echinacea is often used in combination products such as Esberitox® (Schaper and Br ümmer, Germany), which also contains extracts of Baptisia tinctoria (wild indigo) and Thuja occidentalis (arbor vitae). Clinical studies conducted with this combination product are not reviewed here due to the presence of these presumably active additional ingredients.

In the most recent literature review of clinical trials conducted on various echinacea preparations for prevention or treatment of URIs, focusing on 9 trials designed for treatment and 4 trials for prevention, the authors found that 8 of the 9 treatment trials reported generally positive results, while 3 of the prevention trials reported "marginal benefit" (Barrett et al., 1999). The authors assessed the methodological quality of the trials as "modest." They concluded that various types of preparations from various species of Echinacea may be beneficial for the early treatment of URIs, but that there was little evidence to support the extended use of echinacea for prevention of URI. They found it difficult to make specific dosage recommendations due to the variation in composition of commercial preparations. The authors emphasized that the highest quality trials suggest that early dosing of sufficient doses is important.

Another recent review of echinacea (Melchart and Linde, 1999) has found seven placebo-controlled, double-blind, randomized clinical trials testing the efficacy of two different echinacea monopreparations and three combination products in the treatment of non-specific URIs. Combination products are not reviewed in this monograph.

Several studies have examined echinacea's usefulness in the prevention and treatment of colds. A double-blind, placebo-controlled study was conducted with 108 volunteers who had chronic URIs (more than three occurrences in a half year) (Sch öneberger, 1992). Half of the patients received a dose of 8 ml/day of fresh-pressed juice of E. purpurea (Echinacin®) for eight weeks, with the other half receiving placebo. Compared to the placebo group, in the echinacea group there was a tendancy for more patients (36%) to suffer no infections, or the time between infections increased, the duration of illness shortened, and severity of symptoms lessened. The echinacea preparation was well tolerated, and patients with diminished immune response (expressed by a low T4/T8 cell ratio) seemed to benefit most from the treatment. This same study was recently re-interpreted and re-published with a less positive assessment given by the authors (Grimm and Müller, 1999).

In a more recent randomized, double-blind, placebo-controlled study on this fresh juice preparation (Hoheisel et al., 1997), the clinical efficacy of the proprietary E. purpurea expressed juice preparation (Echinagard®, Echinacin's trade name in the United States) was tested on 120 patients with initial symptoms of common cold. The preparation was effective in that significantly fewer patients developed full disease symptoms (40% versus 60%); recovery was much quicker with the echinacea preparation than with placebo (four days versus eight days).

A third study highlighted the importance of dosage in the expected effectiveness of echinacea preparations (Bräunig et al., 1992). This double-blind, placebo-controlled trial examined the effectiveness of an ethanolic extract made from the root of E. purpurea (1:5, 55% ethanol) in relieving the symptoms and duration of flu-like infections in 180 volunteers. Subjects were divided into three groups of 60 each and administered the echinacea at 450 mg/dose, 900 mg/dose, or placebo. Those who received only 450 mg/dose showed improvement only comparable to the placebo. Those receiving 900 mg/dose showed a statistically significant improvement. An effect from the higher dose was seen after three to four days, but the full effect was not seen for 8 to 10 days. It is possible that the availability of this study to the Commission E at the time the E. purpurea root monograph was given a negative assessment (published in August, 1992) may have influenced a positive (approved) assessment.

In a recent Swedish placebo-controlled double-blind study conducted over eight days with tablets (daily dose, 3x2) made from a proprietary water-alcohol extract of the fresh herb (95%) and roots (5%) of E. purpurea (extract ratio 5.9:1; Echinaforce®, Bioforce, Switzerland), 55 patients were given the herbal preparation and 64 received placebo. Thirteen of the echinacea group were allowed to use additional approved medication, such as nose drops and the fever-reducing drug paracetamol. The examining physician concluded that the echinacea preparation was effective in 68% of the patients in reducing several of 12 symptoms (nasal catarrh and/or stuffy nose, sore throat, headache/dizziness, muscle pain, fever, cough, etc.); patients self-assessed the efficacy of the echinacea at 78% of the cases (Brinkeborn et al., 1998). The preparation evoked little concern about safety.

A critical summary of studies on the immunomodulatory activity of preparations of echinacea reported on five randomized trials conducted between 1984 and 1992 (Melchart et al., 1995). A total of 134 healthy, mostly male, volunteers between the ages of 18 and 40 were studied in Germany, using five different echinacea preparations. The results were mixed; not only were different preparations administered, but methods for analyzing the activity of targeted immune cells varied as well, making interpretation difficult. Two of the five studies showed activity of the measured immune cells to be significantly stimulated, while three did not.

In a highly publicized study, researchers ran a clinical study on 302 healthy people (revised to a total of 289 after dropouts) who were divided into three groups. Each group received either an alcoholic extract of E. purpurea root, E. angustifolia root, or a placebo. Neither echinacea preparation helped prevent the onset of the common cold; cold symptoms appeared within 69 days in the E. purpurea group (29.3% with infection), 66 days for the E. angustifolia group (32.0%), and 65 days for the placebo group (36.7%). The participants were instructed to take 50 drops (about 20 microliters per drop) twice per day from Monday through Friday for 12 weeks. The two ethanolic echinacea root extracts were prepared at a 1:11 ratio and were dissolved in 30% ethanol. The conclusion was that the study could not show that echinacea helps to prevent the common cold. The study states, "Based on the results of this and two other studies, one could speculate that there might be an effect of echinacea products in the order of magnitude of 10% to 20% relative risk reduction" (Melchart et al., 1998). The conclusion to be drawn from this research is that the study could not show preventive activity with the specific preparation according to the particular study design; the authors acknowledged the need for a larger population of subjects upon which to test for potential preventive activity.

Some new research findings have come from a recent placebo-controlled trial testing the exercise-induced immunological effects of E. purpurea aboveground fresh plant juice (Echinacin®) on 42 male athletes (Berg et al., 1998). The echinacea group had marked changes in concentration of the cytokines interleukin 6 (IL-6) and soluble interleukin 2 receptor (sIL-2R), proteins that stimulate various immune functions, in serum and urine and significantly increased serum. Exercise-induced cortisol usually lowers natural killer (NK) cell levels and inhibits macrophage activity, two variables of immune function. The echinacea group did not demonstrate a significant decrease in NK cells one hour after competition, suggesting that echinacea may counteract the immune suppressant effect of cortisol. However, another result of this study was that none of the echinacea group experienced URI, while 3 of 13 in the magnesium group and 4 of 13 in the placebo group developed URI. A total of six in both the magnesium and placebo groups reported symptoms of other infections, while none on echinacea did. The authors concluded that preventive treatment of athletes with the E. purpurea juice preparation counteracts the immunosuppressant effects of exhaustive exercise and reduces risk of URI in athletes.

There is evidence to suggest that echinacea is a reliable supportive therapy for people with recurring candidiasis, particularly when antifungal therapy is failing (Brown, 1996). The positive effect of E. purpurea leaf juice was demonstrated in a study of 203 women with recurrent vaginal yeast infections (Coeugniet and K ühnast, 1986). All the women were being treated with a topical econazole nitrate cream (a commonly prescribed antifungal/antiyeast medication). Women using the econazole nitrate alone experienced a 60.5% recurrence rate, while the women taking echinacea (oral Echinacin®) had a recurrence rate lowered to 16.7%.

In a study in the United States the pharmacological basis for the immunological activity of echinacea was investigated by researchers at the Department of Medicine, University of California at Irvine Medical Center at Orange (See et al., 1997). Extracts of both E. purpurea (plant part not noted) and Panax ginseng root were tested for their capacity to stimulate cellular immune function by peripheral blood mononuclear cells (PBMC) from normal individuals and patients with either chronic fatigue syndrome or acquired immunodeficiency syndrome. Results indicated that the extracts enhanced cellular immune function of PBMC from both normal individuals and patients with depressed cellular immunity.

Bauer and Wagner note that various preparations of echinacea enhance leukocyte activity, have antibacterial properties, inhibit the enzyme hyaluronidase (thus retarding breakdown of hyaluronic acid, a gelatinous component of intercellular spaces), provide an interferon-like effect on viruses, and have (relatively mild) anti-inflammatory properties (Bauer and Wagner, 1991). Another potential use of echinacea preparations is for the treatment of otitis media in small children, an application that is gaining a small number of adherents among some pediatricians and naturopathic physicians in the United States (Blumenthal, 1993).

The monograph on E. pallida root is an example of a case where specifications based on a proprietary extract of an herb were approved. This preparation consists of a tincture (1:5) with 50% (v/v) ethanol from native dry extract (50% ethanol, 7–11:1) corresponding to 900 mg of the herb, i.e., dried root. A placebo-controlled, double-blind trial conducted on 160 adults indicated that a daily dose of 900 mg of the extract of E. pallida root was effective in shortening the duration of URIs (sinusitis, cough, pharyngitis) in infected adults, whether of bacterial or viral origin (Dorn et al., 1997).

There has been some confusion regarding the contraindications and side effects listed in the monographs, most of which are for injectible preparations. The contraindications noted below for echinacea preparations in cases of HIV and AIDS, tuberculosis, leukosis, collagenosis, and multiple sclerosis have been misinterpreted to mean that echinacea use can exacerbate such conditions; however, there is no clinical evidence to support this concern. The reason for the Commission's caution was based on theoretical concerns and because such conditions are not amenable to self-medication. A cogent argument by an Australian phytotherapist suggests that there is no rational basis for this contraindication and in fact, current clinical practice, previous prolonged use by Eclectic physicians in the United States in the latter nineteenth and early twentieth centuries, and proper evaluation of modern scientific data support long-term use of echinacea preparations for autoimmune disorders (Bone, 1997–1998).

Regarding the issue of Commission E's contraindication of echinacea preparations for various types of autoimmune disorders, Professor Bauer, the world's leading researcher on echinacea, writes, "As far as I know, these contraindications have only been included because of theoretical considerations. There is a paper by Shohan (1985) in which the possible risks of immunostimulating agents in general are discussed. These recommendations for Echinacea are as far as I know not based on any reported adverse effect in such indications. There is a recent paper by Parnham (1996) which reports that long-term treatment, e.g., with the expressed juice of E. purpurea, is well-tolerated" (Bauer, 1999b).

It should also be noted that in Germany, physicians previously had access to injectable (parenteral) drug products made from either a monopreparation of E. purpurea herb juice or a fixed combination that contained E. pallida. Thus, the monographs for E. purpurea herb and E. pallida root both note adverse side effects associated with injectable forms of these echinacea products.

Despite safety concerns with injectable echinacea, there are few significant adverse events reported for echinacea products taken orally. One such event was a case of anaphylaxis reported with ingestion of an echinacea preparation made of E. angustifolia (whole plant) and E. purpurea root (Mullins, 1998). Animal toxicology studies indicate a high degree of safety for echinacea: in experiments using oral (greater than 15 g per kg) or intravenous (greater than 5 g per kg) administration, it was impossible to kill rats or mice (Hoheisel et al., 1997). Thus, an average lethal dose has not been determinable. Rats and mice given prolonged (4 weeks) doses of an E. purpurea preparationup to 8 g per kg did not exhibit adverse effects on numerous end points measured (blood lipids, liver enzymes, weight loss, etc.) (Mengs et al., 1991).

Based on the data presented above, there are sufficient pharmacological and clinical research studies to support the safety and probable efficacy of preparations made from both the aerial parts of E. purpurea and the roots of at least two and possibly three species of echinacea (E. pallida and E. purpurea, and possibly, E. angustifolia).


Description

Echinacea pallida root, consisting of fresh or dried root of E. pallida (Nutt.) Nutt. [Fam. Asteraceae] and its preparations in effective dosage.

Chemistry and Pharmacology

Echinacea pallida root contains caffeic acid derivatives, mainly echinacoside (0.71.0%), followed by isochlorogenic acid, 6-O-caffeoylechinacoside, and chlorogenic acid; 0.22.0% essential oil composed mainly of ketoalkynes and ketoalkenes (pentadeca-8Z-en-2-one, pentadeca-1,8Z-diene, and 1-pentadecene); polyacetylenes (trideca-1-en-3,5,7,9,11-pentayne and ponticaepoxide); polysaccharides; and glycoproteins (Bauer, 1999a; Bauer and Liersch, 1993; ESCOP, 1999; Pietta et al., 1998).

The Commission E reported that in a carbon clearance test, alcohol root extracts showed an increase in the elimination of carbon particles by a factor of 2.2. In an in vitro test: Alcohol root extracts showed an increase in phagocytic elements by 23% when tested in granulocyte smears at a concentration of 10:410:2 mg/ml.

Uses

The Commission E approved the internal use of E. pallida root as supportive therapy for influenza-like infections. The German Standard License for infusion of E. pallida root recommends it to strengthen resistance to infectious conditions in the upper respiratory tract (Wichtl and Bisset, 1994).

The WHO approved E. pallida root as supportive therapy for colds and infections of the respiratory and urinary tracts (WHO, 1999).

Contraindications

Commission E cautioned that echinacea preparations are not to be used when progressive systemic diseases such as the following exist: tuberculosis, leukosis, collagenosis, multiple sclerosis, AIDS, HIV infection, and other autoimmune diseases. (As noted above, these cautions were made based on theoretical considerations and not on any reports of adverse findings.)

Side Effects

None known.

Use During Pregnancy and Lactation

No restrictions known.

Interactions with Other Drugs

None known.

Dosage and Administration

Unless otherwise prescribed: 900 mg of root per day in liquid forms for oral administration for a period of not longer than eight weeks.

Tincture 1:5 (g/ml) with 50% (v/v) ethanol prepared from native dry extract (50% ethanol, 7-11:1): 90 drops (Bauer and Liersch, 1993; ESCOP, 1999).

Decoction: Boil 1 g in 150 ml water for 10 minutes, three times daily (Newall et al., 1996).

References

Barrett, B., M. Vohmann, C. Calabrese. 1999. Echinacea for upper respiratory tract infection. J Fam Pract 48(8):628-635.


Bauer, R. 1999a. Chemistry, analysis and immunological investigations of Echinacea phytopharmaceuticals. In: Wagner, H. (ed.). Immunomodulatory Agents from Plants. Basel, Switzerland: Birkhuser Verlag. 41-88.


—. 1999b. Personal communication to M. Blumenthal. Jan. 21; Feb. 4.


—. 1998. Echinacea: Biological Effects and Active Principles. In: Lawson, L. and R. Bauer (eds.). Phytomedicines of Europe: Chemistry and Biological Activity. Washington, D.C.: American Chemical Society. 140-157.


—. 1996. Echinacea-Drogen —Wirkungen und Wirksubstanzen [Echinacea drugs —effects and active ingredients (Review). Z ArztlFortbild (Jena) 90(2):111-115.


Bauer, R. and R. Liersch. 1993. Echinacea. In: H änsel, R., K. Keller, H. Rimpler, G. Schneider (eds.). Hagers Handbuch der Pharmazeutischen Praxis, 5th ed. Vol. 5. Drogen E-O. New York: Springer Verlag. 1-34.


Bauer, R. and H. Wagner. 1991. Echinacea species as potential immunostimulatory drugs. In: Wagner, H. and N.R. Farnsworth (eds.). 1991. Economic and Medicinal Plants Research, Vol. 5. New York: Academic Press. 253-321.


Berg, A. et al. 1998. Influence of Echinacin (EC31) treatment on the exercise-induced immune response in athletes. J Clin Res 1:367-380.


Blumenthal, M. 1993. Echinacea Highlighted as Cold and Flu Remedy. HerbalGram 29:89.


Bone, K. 19971998. Echinacea: When Should it be Used? Eur J Herb Med 3(3):13-17.


Bradley, P.R. (ed.). 1992. British Herbal Compendium, Vol. 1. Bournemouth: British Herbal Medicine Association.


Bräunig, B., M. Dorn, E. Knick. 1992. Echinacea purpurea radix for strengthening the immune response in flu-like infections. Z Phytotherapie 13:7-13.


Brinkeborn, R.M, D.V. Shah, S. Geissbuhler, F.H. Degenring. 1998. Echinaforce in the treatment of acute colds. Schweiz Zschr Ganzheits Med 10:26-29.


Brown, D.J. 1996. Herbal Prescriptions for Better Health. Rocklin, CA: Prima Publishing. 63-68.


Coeugniet, E. and R. Kühnast. 1986. Recurrent candidiasis: Adjutant immunotherapy with different formulations of Echinacin ®. Therapiewoche 36:3352-3358.


Dorn, M., E. Knick, G. Lewith. 1997. Placebo-controlled, double-blind study of Echinacea pallidae radix in upper respiratory tract infections. Complement Ther Med 5:40-42.


ESCOP. 1999. "Echinacea—Proposal for the Summary of Product Characteristics." Monographs on the Medicinal Uses of Plant Drugs. Exeter, U.K.: European Scientific Cooperative on Phytotherapy.


Galea, S. and K. Thacker. 1996. Double-blind prospective trial investigating the effectiveness of a commonly prescribed herbal remedy in altering the duration, severity and symptoms of the common cold. Unpublished.


Grimm, W. and H.H. Müller. 1999. A randomized controlled trial of the effect of fluid extract of Echinacea purpurea on the incidence and severity of colds and respiratory infections. Am J Med 106(2):138-143.

Hobbs, C. 1994. Echinacea: A literature review. HerbalGram 30:33-48.


Hoheisel, O., M. Sandberg, S. Bertram, M. Bulitta, M. Schäfer. 1997. Echinagard treatment shortens the course of the common cold: a double-blind, placebo-controlled clinical trial. Eur J Clin Res 9:261-269.


Leung, A.Y. and S. Foster. 1996. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics, 2nd ed. New York: John Wiley & Sons, Inc.


Melchart, D. and K. Linde. 1999. Clinical investigations of Echinacea phytopharmaceuticals. In: Wagner, H. (ed.). Immunomodulatory Agents from Plants. Basel: Birkhauser Verlag.


Melchart, D. et al. 1995. Results of five randomized studies on the immunomodulatory activity of preparations of Echinacea.J Altern Complement Med 1(2):145-160.


Melchart, D., K. Linde, F. Worku, R. Bauer, H. Wagner. 1994. Immunomodulation with EchinaceaA systematic review of controlled clinical trials. Phytomed 1:245254.


Melchart, D., E. Walther, K. Linde, R. Brandmaier, C. Lersch. 1998. Echinacea root extracts for the prevention of upper respiratory tract infections: a double-blind, placebo-controlled randomized trial. Arch Fam Med 7(6):541-545.


Mengs, U., C.B. Clare, J.A. Poiley. 1991. Toxicity of Echinacea purpurea. Arzneimforsch/Drug Res 41(10): 1076-1081.


Mullins, R.J. 1998. Echinacea-associated anaphylaxis [letter]. Med J Aust 168(4):584.


Newall, C.A., L.A. Anderson, J.D. Phillipson. 1996. Herbal Medicines: A Guide for Health-Care Professionals. London: The Pharmaceutical Press.


Parnham, M.J. 1996. Benefit-risk assessment of the squeezed sap of the purple coneflower (Echinacea purpurea) for long-term oral immuno-stimulation. Phytomed 3(1):95-102.


Pietta, P., P. Mauri, R. Bauer. 1998. MEKC analysis of different Echinacea species. Planta Med 64:649-652.


Richman, A. and J.P. Witkowski. 1996. A Wonderful Year for Herbs. Whole Foods Oct:52-60.


—. 1997. HerbsBy the Numbers. Whole Foods Oct:20-28.


—. 1998. Herb Sales Still Strong. Whole Foods Oct:19-26.


Schilcher, H. 1997. Personal communication to M. Blumenthal, Dec. 30.


Schöneberger, D. 1992. The influence of immune-stimulating effects of pressed juice from Echinacea purpurea on the course and severity of colds. Forum Immunol 8:2-12.


See, D.M., N. Broumand, L. Sahl, J.G. Tilles. 1997. In vitro effects of echinacea and ginseng on natural killer and antibody-dependent cell cytotoxicity in healthy subjects and chronic fatigue syndrome or acquired immunodeficiency syndrome patients. Immunopharmacology 35(3):229-235.


Shohan, J. 1985. Specific safety problems of inappropriate immune responses to immunostimulating agents. TIPS 6:178-182.


Wagner, H. 1997. Herbal immunostimulants for the prophylaxis and therapy of colds and influenza. Eur J Herbal Med 3(1).


WHO. See World Health Organization.


Wichtl, M. and N.G. Bisset (eds.). 1994. Herbal Drugs and Phytopharmaceuticals. Stuttgart: Medpharm Scientific Publishers.


World Health Organization (WHO). 1999. 'Herba Echinaceae Purpureae Radix Echinacea' and 'Radix Echinaceae.' WHO Monographs on Selected Medicinal Plants, Vol. 1. Geneva: World Health Organization. 136-144; 125-135.


Additional Resources

Bauer, R. 1997. Echinacea —Pharmazeutische Qualitt und therapeutischer Wert. Z Phytother 18:207-214.


—. 1993. Neue Ergebnisse zur frage der wirksubstanzen von Echinacea-drogen. Natur und G Med  6:32-40.


Bauer, R. and H. Wagner. 1988. Echinacea—Der Sonnenhut—Stand der Forschung. Z Phytother 9(5):151-159.


Bauer, R., I.A. Khan, H. Wagner. 1988. TLC and HPLC analysis of Echinacea pallida and E. angustifolia roots. Planta Med 54:426-430.


Bauer, R., P. Remiger, H. Wagner. 1988. Echinacea-vergleichende DC- und HPLC-analyse der Herba-Drogen von Echinacea purpurea, Echinacea pallida und Echinacea angustifolia. DAZ 128:174-180.


Bauer, R., K. Jurcic, J. Puhlmann, H. Wagner. 1988. Immunologische in-vivo und in-vitro untersuchungen mit Echinacea extrakten [Immunologic in vivo and in vitro studies on Echinacea extracts]. Arzneimforsch 38(2):276-281.


Bauer, R. et al. 1987. Two acetylenic compounds from Echinacea pallida roots. Phytochem 26:1198-1200.


Bodinet, C., I. Willigmann, N. Beuscher. 1996. Host-resistance increasing activity of root extracts from Echinacea species. Poster: Schaper and Brümmer, D-38251 Salzgitter, F.R.G.


Bone, K. 1999. Echinacea: Fact and Mythology. HerbalGram 49 (in press).


Bradley, P.R. (ed.). 1992. British Herbal Compendium, Vol. 1. Bournemouth: British Herbal Medicine Association. 81-83.


Brinkeborn, R.M., D.V. Shah, F.H. Degenring. 1999. Echinaforce and other Echinacea fresh plant preparations in the treatment of the common cold. A randomized, placebo-controlled, double-blind clinical trial. Phytomedicine 6(1):1-6.


Bruneton, J. 1995. Pharmacognosy, Phytochemistry, Medicinal Plants. Paris: Lavoisier Publishing.


Burger, R.A., A.R. Torres, R.P. Warren, V.D. Caldwell, B.G. Hughes. 1997. Echinacea-induced cytokine production by human macrophages. Int J Immunopharmacol 19(7):371-379.


Der Marderosian, A. (ed.). 1999. The Review of Natural Products. St. Louis: Facts and Comparisons.

Dorn, M., E. Knick, G. Lewith. 1997. Placebo-controlled, double-blind study of Echinaceae pallidae radix in upper respiratory tract infections. Complement Ther Med 3:40-42.


Dorn, M. 1989. Mitigation of flu-like effects by means of a plant immunostimulant. Natur und Ganzheitsmedizin 2:314-319.


Dorsch, W. 1996. Klinische anwendung von extrakten aus Echinacea purpurea oder Echinacea pallida. Kritische wertung kontrollierter klinischer studien. Z Arztl Fortbild (Jena) 90(2):117, 122.


Gallo, M., W.A. Koren, G. Koren. 1998. The safety of Echinacea use during pregnancy: a prospective controlled cohort study. Proceedings of the 11th International Conference of the Organization of Teratology: San Diego, June 1921. Teratology 57:283.


Hänsel, R., K. Keller, H. Rimpler, G. Schneider (eds.). 1992-1994. Hagers Handbuch der Pharmazeutischen Praxis, 5th ed. Vol. 46. Berlin-Heidelberg: Springer Verlag.


List, P.H. and L. Hörhammer (eds.). 1973-1979. Hagers Handbuch der Pharmazeutischen Praxis, Vols. 17. New York: Springer Verlag.


McGuffin, M., C. Hobbs, R. Upton, A. Goldberg. 1997. American Herbal Product Association's Botanical Safety Handbook. Boca Raton: CRC Press.


Schulthess, B.H., E. Giger, T.W. Baumann. 1991. Echinacea: anatomy, phytochemical pattern, and germination of the achene. Planta Med 57(4):384-388.


Shalaby, A.S. et al. 1997. Response of Echinacea to some agricultural practices. J Herbs Spices Med Plants 4(4):59-67.


Skwarek, T., Z. Tynecka, K. Glowniak, E. Lutostankska. 1996. Echinacea L. Inducer of interferons. Herba Polonica 42(2):110-117.


Snow, J.M. 1997. Echinacea (Moench) spp. Asteraceae. Protocol J Botan Med 2(2):18-24.


Wichtl, M. (ed.). 1997. Teedrogen, 4th ed. Stuttgart: Wissenschaftliche Verlagsgesellschaft.


Wood, H.C. et al. The Dispensatory of the United States of America, Centennial (22nd) ed. Philadelphia: J.B. Lippincott Co. 1:402.


This material was adapted from The Complete German Commission E Monographs —Therapeutic Guide to Herbal Medicines. M. Blumenthal, W.R. Busse, A. Goldberg, J. Gruenwald, T. Hall, C.W. Riggins, R.S. Rister (eds.) S. Klein and R.S. Rister (trans.). 1998. Austin: American Botanical Council; Boston: Integrative Medicine Communications.


1) The Overview section is new information.


2) Description, Chemistry and Pharmacology, Uses, Contraindications, Side Effects, Interactions with Other Drugs, and Dosage sections have been drawn from the original work. Additional information has been added in some or all of these sections, as noted with references.


3) The dosage for equivalent preparations (tea infusion, fluidextract, and tincture) have been provided based on the following example:

  • Unless otherwise prescribed: 2 g per day of [powdered, crushed, cut or whole] [plant part]
  • Infusion: 2 g in 150 ml of water
  • Fluidextract 1:1 (g/ml): 2 ml
  • Tincture 1:5 (g/ml): 10 ml

4) The References and Additional Resources sections are new sections. Additional Resources are not cited in the monograph but are included for research purposes.

This monograph, published by the Commission E in 1994, was modified based on new scientific research. It contains more extensive pharmacological and therapeutic information taken directly from the Commission E.


Excerpt from Herbal Medicine: Expanded Commission E Monographs
Copyright 2000 American Botanical Council
Published by Integrative Medicine Communications
Available from the American Botanical Council.


This monograph, published by the Commission E in 1994, was modified based on new scientific research. It contains more extensive pharmacological and therapeutic information taken directly from the Commission E.