Solaray Continence with Flowtrol by Nutraceutical Corp.

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Chronic obstructive pulmonary disease (COPD). Oral alpinia has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A moderate-sized clinical study in adults with COPD shows that taking a combination product containing extracts of alpinia, ginger, cardamom, cinnamon, and saffron in honey 3 times daily for 8 weeks improves confidence in leaving home and the ratio of forced exploratory volume per second to forced vital capacity of the lungs (FEV1/FVC) when compared with placebo. However, the combination product does not improve most measures of respiratory function or symptoms such as cough, phlegm, chest tightness, dyspnea, reduced energy levels, sleeping disorders, or activity limitations when compared with placebo (111542). It is unclear if these effects are due to alpinia, other ingredients, or the combination.
• Male infertility. It is unclear if oral alpinia is beneficial for improving sperm function in males with infertility. Details: Preliminary clinical research in males with idiopathic infertility shows that taking alpinia extract 100 mg three times daily for 12 weeks increases sperm count and morphology when compared with placebo (102094). Whether alpinia can improve the rates of successful pregnancies is unclear.
• Mental alertness. It is unclear if oral alpinia is beneficial for improving mental alertness in healthy adults. Details: Preliminary clinical research in healthy adults with a history of moderate caffeine intake shows that taking a specific alpinia extract (EnXtra, Enovate Biolife), 300 mg orally twice daily, or the same extract plus caffeine 200 mg orally twice daily for 12 weeks, increases mental alertness three hours after the dose to a similar extent in both active groups when compared with placebo (106740).
• Minor bleeding. Oral alpinia has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Some preliminary clinical research shows that applying 4 mL of a specific product (Ankaferd blood stopper) containing alpinia, licorice, thyme, stinging nettle, and common grape vine reduces bleeding during surgery, but does not improve the surgical time for episiotomy repair, when compared with saline (31010). Other preliminary clinical research suggests that topical application of this same product reduces bleeding in postsurgical dental patients with increased bleeding tendency (31002). More evidence is needed to rate the effectiveness of alpinia for these uses.

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POSSIBLY EFFECTIVE

• Depression. A small meta-analysis in patients with moderate depressive disorder shows that taking oligosaccharides extracted from the root of ba ji tian at doses of 300-800 mg daily for 6-8 weeks reduces depressive symptom scores, as measured on the Hamilton Depression Scale 17-items, similarly to an antidepressant control. The antidepressants controls used in the studies were fluoxetine 20-40 mg daily, duloxetine 120 mg daily, or escitalopram 10-20 mg daily (106542). There is insufficient reliable information available about the effectiveness of ba ji tian for its other uses.

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POSSIBLY EFFECTIVE

• Allergic rhinitis (hay fever). A specific butterbur leaf extract may be effective for symptoms of allergic rhinitis when taken orally, but a specific butterbur root extract appears to lack these effects. Details: Clinical research shows that taking a specific butterbur leaf extract called Ze 339 (Tesalin, Zeller AG), up to 6 tablets daily in up to three divided doses for 1-2 weeks, seems to decrease nasal inflammatory mediators and nasal symptoms in patients with allergic rhinitis (7595,10336,14414,19383,19384). Some evidence also suggests that this extract might be as effective as cetirizine 10 mg daily (7595) or fexofenadine 180 mg daily (11941,14414). Taking whole butterbur root extract (Petaforce, Bioforce) 50 mg twice daily for 2 weeks seems to reduce the response to an adenosine monophosphate challenge in patients with allergic rhinitis when compared with placebo (10337,11941). However, taking this extract for 2 weeks does not seem to improve peak nasal inspiratory flow, nasal and eye symptoms, or quality of life (11942).
• Migraine headache. A specific butterbur rhizome extract seems to prevent migraine headache in adults and children when taken orally. Details: Clinical research shows that taking a specific butterbur rhizome extract, which is pyrrolizidine alkaloid (PA)-free and standardized to 15% petasin and isopetasin (Petadolex, Weber & Weber, GmbH & Co), 75 mg once or twice daily for up to 16 weeks, reduces the frequency of migraine headache by about 48%. It also reduces the intensity and duration of the headaches (7230,12840,13003,19381). Clinical studies in children aged 6-17 years show that taking this specific butterbur rhizome extract for up to 4 months decreases the frequency of migraine headache when compared with placebo (13121,19382). Doses used in one study were 50-75 mg daily in divided doses for ages 8-9 years, and 100-150 mg daily in divided doses for ages 10-12 years (19382).

POSSIBLY INEFFECTIVE

• Atopic dermatitis (eczema). Oral butterbur root extract does not seem to improve atopic symptoms. Details: Clinical research shows that taking a specific whole butterbur root extract (Petaforce, Bioforce Ltd) 50 mg by mouth twice daily for one week does not reduce histamine wheal and flare responses when compared with placebo in atopic patients (19388).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Anxiety. Although there is interest in using oral butterbur for anxiety, there is insufficient reliable information about the clinical effects of butterbur for this condition.
• Asthma. It is unclear if oral butterbur is beneficial in patients with asthma. Details: Clinical research shows that taking butterbur root extract (Petaforce, Bioforce Ltd.) 25 mg twice daily for 1 week reduces measures of inflammation in patients with asthma when compared with placebo (19385). Taking a different butterbur root extract (Petadolex, Weber & Weber, GmbH & Co.) daily for 2-4 months reduces the number, duration, and severity of asthma attacks when compared with baseline. The extract was taken as 150 mg daily in 3 divided doses by adults, or 50-150 mg daily in 3 divided doses by children aged 6-17 years (19386). The validity of these findings is limited by the lack of a comparator group.
• Chronic bronchitis. Although there is interest in using oral butterbur for chronic bronchitis, there is insufficient reliable information about the clinical effects of butterbur for this condition.
• Cough. Although there is interest in using oral butterbur for cough, there is insufficient reliable information about the clinical effects of butterbur for this purpose.
• Insomnia. Although there is interest in using oral butterbur for insomnia, there is insufficient reliable information about the clinical effects of butterbur for this purpose.
• Peptic ulcers. Although there is interest in using oral butterbur for peptic ulcers, there is insufficient reliable information about the clinical effects of butterbur for this condition.
• Somatic symptom disorder. Adding oral butterbur to a combination of other herbs may reduce anxiety and depression associated with somatic symptom disorder. Details: Clinical research shows that taking a specific combination product called Ze 185 (Relaxane, Max Zeller Söhne AG), containing butterbur root extract 90 mg, valerian root 90 mg, lemon balm leaf 60 mg, and passionflower herb 90 mg, two to three times daily for 2 weeks improves anxiety and depression in people with somatoform disorders when compared with a product containing the same ingredients, but without butterbur (19701). More evidence is needed to rate butterbur for these uses.

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POSSIBLY EFFECTIVE

• Urinary tract infections (UTIs). Cranberry products may possibly reduce the risk of repeat, symptomatic UTI in females with recurrent UTI, in children, and in people susceptible to UTI following kidney transplant, urogenital surgery, or radiation therapy near the urogenital system. While some positive evidence exists, most research suggests that cranberry products do not seem to reduce the risk of UTI in older adults in institutions, pregnant patients, or adults with neuromuscular dysfunction of the bladder. Cranberry is not recommended for the treatment of UTI in any population. Details: Cranberry appears to reduce the risk of UTI in some populations but not others. In healthy females at an increased risk of UTI or history of recurrent UTI, meta-analyses of clinical trials show that cranberry products decrease the overall risk of recurrent or first-time UTI by 26% to 35% (46473,92578,96739,111407). In 2019, the American Urological Association published guidelines stating that, based on low certainty evidence, clinicians may offer cranberry tablets or juice as prophylaxis for females with recurrent UTIs. Due to a lack of compelling evidence for any specific product, the guidelines recommend choosing formulations based on availability and tolerability (100855). In 2020, the US Food and Drug Administration (FDA) approved qualified health claims stating that consuming cranberry juice in doses of at least 8 ounces daily, or cranberry supplements in doses of at least 500 mg daily, may help reduce the risk of recurrent UTI in healthy females. However, the FDA has concluded that there is limited scientific evidence to support these claims (103302). The benefits of cranberry for prevention of UTI during pregnancy are unclear. Subgroup analysis of meta-analyses suggest that cranberry supplementation does not reduce the risk of UTI in pregnant adults compared with placebo or no treatment (100855,111407). A preliminary clinical study shows that drinking cranberry juice 240 mL three times daily until delivery does not reduce the frequency of asymptomatic bacteriuria or symptomatic UTI during pregnancy, although the study was not adequately powered to detect a difference in these outcomes (16415). In contrast, one preliminary clinical trial shows that UTI frequency was reduced in 70.5% of those ingesting cranberry juice 250 mL four times daily, compared with only 32% of those taking placebo (93670). In children, a meta-analysis shows that taking cranberry products probably reduces the risk of subsequent symptomatic UTIs by up to 54% compared with placebo or no treatment, but does not specify a particular formulation (111407). Clinical trials show that daily consumption of cranberry syrup (Pharmatoka), cranberry juice (Cranberry UR-50, Kikkoman Company) 100 mL, cranberry-lingonberry juice 50 mL, and cranberry extract (Anthocran) 120 mg reduce the risk of UTI recurrence in children (46452,96733,96737,108055). In contrast, another clinical trial shows that drinking cranberry juice (Ocean Spray Cranberries, Inc) 5 mL/kg daily for 6 months does not reduce the incidence of recurrent UTI when compared with placebo, although it does decrease the total number of UTI episodes and length of antimicrobial therapy per child (46470). In older, institutionalized adults, a meta-analysis of 5 studies evaluating the effectiveness of cranberry products shows little or no benefit in preventing symptomatic, culture-verified UTIs (111407). A clinical study in females residing in long-term care (LTC) facilities shows that taking a specific cranberry supplement (Ellura, Pharmatoka) once daily for 1 year does not reduce the incidence of UTI or asymptomatic bacteriuria (92517). However, clinical trials of cranberry products in elderly patients in LTC facilities suggest that cranberry may be more effective in patients at a higher risk for UTIs, such as those with diabetes, long-term catheterization, or recurrent UTIs (90041,108055), and in patients with E. coli-related UTIs (46389,46472). In one small study, providing all patients living in a LTC facility with 4 ounces of cranberry juice or six tablets of a specific concentrated cranberry product (Azo-Cranberry, i-Health, Inc.) daily for 13 months decreased the facility's overall monthly UTI rate from 27.7 to 20.7 (46492). In another clinical trial, taking cranberry juice cocktail (Ocean Spray Cranberries, Inc) 300 mL daily for 6 months decreased the rate of asymptomatic bacteriuria plus pyuria by 13% in older females living in institutional settings (7008). In another clinical trial, taking a cranberry capsule 500 mg, standardized to 1.8% PACs, twice daily for 12 months decreased the risk of UTI by around 26% in patients at high-risk for UTI, including those with catheters, diabetes, or at least one UTI in the previous 12 months (90041). Meta-analyses and clinical research show that cranberry products do not reduce the risk of UTI associated with neurogenic bladder, neuromuscular dysfunction, or insufficient bladder emptying in adults or children (2811,6759,11980,46379,46425,46473,90044,92578,96737,108055,111407). However, one study found benefit in patients with neurogenic bladder due to spinal cord injury taking cranberry capsules (Cran-Max, Proprietary Nutritionals, Inc.) 500 mg daily (46443). Cranberry products have also been evaluated in a variety of other high-risk populations, with mixed results. A meta-analysis of 7 studies shows that cranberry products reduce the risk of UTIs in people with increased susceptibility to UTI due to an intervention (e.g., kidney transplant, radiotherapy to urogenital system, or urogenital surgery) when compared with placebo (111407). Cranberry extracts do not seem to reduce the risk of UTIs in individuals undergoing hysterectomy and/or anterior vaginal repair (46465), pelvic floor surgery (104245), or in patients with multiple sclerosis (46496,111407). Taking cranberry powder capsules (NurtiCran90, Petefa AB) 550 mg three times daily for 5 days does not reduce the UTI rate at days 5 or 14 when compared with placebo in postoperative females with hip fracture receiving a urinary catheter; however, the study was not adequately powered to detect a difference in this outcome (96734). Other preliminary clinical research in elderly males with benign prostatic hyperplasia and a recent UTI shows that taking a standardized cranberry extract (Anthocran) 120 mg daily for 60 days reduces the UTI recurrence rate by about 62% when compared with placebo (96735). Cranberry supplements have been studied in a variety of formulations, but it is unclear whether certain cranberry formulations are better than others (111407). Most positive studies utilized oral cranberry EXTRACTS in tablet, powder, or capsule form (6760,17210,46366,46432,93669,111407). Some products (Cranberry Supreme, GNC; Cranpac, IPCA Laboratories), taken as 200 mg twice daily, were standardized to provide 100-120 mg of proanthocyanidins (PACs) daily (46432). Some of these studies used capsules containing 400 mg cranberry solids twice daily (6760) or Natural Cranberry Extract (Solgar Vitamin and Herb Co.) 800 mg twice daily (17210). However, a clinical study in healthy females with a history of UTIs shows that taking a specific cranberry extract product (Urophenol; Diana Food) does not reduce the risk of symptomatic UTI when taken at a dose of 120 mg twice daily, standardized to 15% PACs, or at a dose of 1 mg twice daily, standardized to 1% PACs. A subgroup analysis suggests that the high dose may have modest benefit in those with less than 5 UTIs a year (108054). Cranberry JUICE or syrup has yielded mixed results for the prevention of UTI in patients with a history of recurrent UTIs, with some showing significant benefit (8253,46366,96736,111407). These studies used cranberry juice 240-250 mL 1-3 times daily (46366,96736), cranberry syrup, or a combination beverage containing cranberry juice plus lingonberry juice (Maija) 50 mL daily (8253). However, other studies found no significant improvement when compared with placebo (17524,46471,90047), although some of these studies may have been inadequately powered to detect a difference (17524,46471). Cranberry products have also been compared with other treatments including antibiotics and probiotics for preventing recurrent UTI, but the results are unclear. A meta-analysis suggests that cranberry products reduce the risk of symptomatic UTIs compared to probiotics. The analysis also showed no difference in the risk of UTI between cranberry products and antibiotics, but the precision of included studies was poor (111407). In one study, taking cranberry extract capsules (Cran-Max; Proprietary Nutritionals, Inc) 500 mg daily for 6 months was as effective as trimethoprim 100 mg daily in elderly females with recurrent UTI (16720). However, taking this same cranberry product twice daily for 12 months was less effective than trimethoprim-sulfamethoxazole 480 mg once daily in younger premenopausal individuals (17176). Additional research in children with vesicoureteral reflux (VUR) shows that daily consumption of cranberry products results in UTI recurrence rates equivalent to those obtained with prophylactic antibiotics. Cranberry juice (Cranberry UR-50, Kikkoman Company) 100 mL daily was equally effective to cefaclor 5-10 mg/kg daily; cranberry syrup (Pharmatoka) 0.2 mL/kg daily was equally effective to trimethoprim 0.2 mL/kg daily (96737).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Age-related cognitive decline. It is unclear if oral cranberry is beneficial for age-related cognitive decline. Oral cranberry may be beneficial for improving visual episodic memory in healthy, elderly adults, but its effects on other aspects of cognition are unclear. Details: A clinical study in healthy adults aged 50-80 years shows that taking a freeze-dried cranberry powder 4.5 grams twice daily (standardized to provide 281 mg proanthocyanidins daily), provided as a sachet and added to food or beverage for 12 weeks, improves visual episodic memory performance during a memory and recall test (Rey Complex Figure Test), but does not appear to affect other measures such as attention, orientation, fluency, language, processing speed, or short-term memory, when compared with placebo (108564). Cranberry supplementation also does not appear to affect grey matter structure; however, due to the low number of patients who completed a baseline and follow-up MRI, this study may not have been adequately powered to detect a difference between groups.
• Benign prostatic hyperplasia (BPH). Preliminary clinical research suggests that oral cranberry is beneficial for reducing BPH symptoms. Details: Preliminary clinical research shows that taking powdered dried cranberry fruit 500 mg three times daily for 6 months improves lower urinary symptoms and reduces prostate specific antigen (PSA) levels when compared with no treatment in patients 45 years of age or older with elevated PSA levels, a negative prostate biopsy, and clinically confirmed non-bacterial prostatitis (17126). Another small study in those 45 years of age and older without elevated PSA levels shows that taking a specific dried cranberry powder (Flowens, Naturex-DBS, LLC) 250-500 mg daily for 6 months reduces lower urinary tract symptoms and improves voiding and storage symptoms when compared with placebo (96738).
• Cancer. Although there has been interest in using oral cranberry for cancer, there is insufficient reliable information about the clinical effects of cranberry for this condition.
• Cardiovascular disease (CVD). Although some research suggests that oral cranberry may modestly improve some CVD risk factors, it is unclear if it is beneficial for CVD prevention. Details: A meta-analysis of 10 clinical studies shows that cranberry juice or cranberry extract seems to reduce systolic blood pressure by 3.6 mmHg and body mass index by 0.3 kg/m2 when compared with placebo. However, these improvements are unlikely to be clinically significant, and cranberry does not appear to improve diastolic blood pressure, lipid levels, glycemic control, or waist circumference (102849). The generalizability of these results is limited, as the study populations ranged from healthy adults to those with type 2 diabetes, metabolic syndrome, or coronary heart disease. A clinical crossover study in patients who are overweight or obese and have elevated blood pressure shows that drinking cranberry juice 250 mL twice daily for 8 weeks reduces ambulatory diastolic blood pressure by 2 mmHg during daytime hours, but does not improve systolic blood pressure, glycemic control, or lipid levels, when compared with placebo (108059). The validity of these findings is limited due to short duration of treatment and broad heterogeneity of patient baseline characteristics.
• Catheter-related infections. Although there has been interest in using oral cranberry for catheter-related infections, there is insufficient reliable information about the clinical effects of cranberry for this condition.
• Chronic fatigue syndrome (CFS). Although there has been interest in using oral cranberry for CFS, there is insufficient reliable information about the clinical effects of cranberry for this condition.
• Diabetes. It is unclear if oral cranberry is beneficial for diabetes. Details: A small clinical trial shows that taking cranberry supplements orally does not improve fasting serum glucose, glycated hemoglobin (HbA1C), fructosamine, triglycerides, high-density lipoprotein (HDL) cholesterol, or low-density lipoprotein (LDL) cholesterol levels in patients with type 2 diabetes (11328).
• Helicobacter pylori. There is conflicting evidence regarding the use of oral cranberry for Helicobacter pylori eradication, either as a standalone treatment or in combination with standard triple therapy. Details: Two small clinical studies show that taking cranberry juice 480-500 mL, containing 88 mg proanthocyanidins (PACs), daily in two divided doses for 2-3 months can modestly increase the H. pylori eradication rate at 8 weeks, but not at 2 weeks, when compared with placebo. However, the eradication rate was only 20% or less, which is much lower than that obtained with conventional triple therapy (46388,104248). Lower doses, as either cranberry juice or cranberry powder, do not seem to improve H. pylori eradication rates. Cranberry juice containing only 23 mg or 44 mg PACs or cranberry powder containing 36 mg or 72 mg PACs did not demonstrate benefit when compared with placebo (104248). Cranberry juice has also been studied in combination with standard triple therapy. Preliminary clinical research shows that taking cranberry juice 250 mL daily for 3 weeks along with omeprazole, amoxicillin, and clarithromycin for one week does not increase the eradication rate when compared with triple therapy plus placebo. However, the combination treatment increased the rate of H. pylori eradication when only females were considered (46439). A meta-analysis of 4 small clinical studies, including three studies already discussed, shows that taking cranberry, either as a juice or a dried powder, does not improve H. pylori eradication rate when compared with placebo, regardless of treatment duration (108060). The validity of these findings is limited by the high heterogeneity of the included studies and incomplete reporting. In asymptomatic children aged 6-16 years old with H. pylori, one clinical study shows that drinking cranberry juice 200 mL, with live or heat-killed Lactobacillus johnsonii 80 mL, daily for 3 weeks eradicates H. pylori in 15% to 22% of patients, compared with 1.5% of those receiving placebo. However, these rates are lower than those typically obtained with conventional triple therapy (46441).
• Hyperlipidemia. Oral cranberry has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Drinking a combination of cranberry, blueberry, apple, and chokeberry juice 300 mL daily for 6 weeks appears to decrease total cholesterol and increase high-density lipoprotein (HDL) cholesterol when compared to baseline in females with overweight or obesity and at least one risk factor for cardiovascular disease (111233). However, the validity of the study is limited by its small size, short duration, and lack of a comparator group. It is unclear if these effects are due to cranberry, other ingredients, or the combination.
• Kidney stones (nephrolithiasis). It is unclear if oral cranberry is beneficial for reducing the risk of kidney stones. Details: Although some preliminary clinical research shows that drinking cranberry juice 500 mL diluted in 1500 mL water daily for 2 weeks can decrease urinary excretion of oxalate in healthy males, which suggests a decreased risk of kidney stone formation (46371), other preliminary clinical research shows that both cranberry juice and concentrated cranberry extracts can increase urinary oxalate levels, suggesting an increased risk of stone formation (7074,46393).
• Memory. It is unclear if oral cranberry is beneficial for memory. Details: Preliminary clinical research in cognitively intact older adults shows that taking cranberry juice 16 ounces twice daily for 6 weeks does not improve memory when compared with placebo (46390).
• Metabolic syndrome. It is unclear if oral cranberry is beneficial for metabolic syndrome. Details: Preliminary clinical research shows that drinking cranberry juice 240 mL twice daily for 8 weeks can increase plasma antioxidant capacity when compared with placebo in adults with metabolic syndrome. However, cranberry juice does not appear to affect blood pressure, blood glucose, serum lipids, or markers of inflammation when compared with placebo in these patients (46467).
• Nonalcoholic fatty liver disease (NAFLD). It is unclear if oral cranberry is beneficial for NAFLD. Details: Preliminary clinical research in adults with NAFLD shows that adding cranberry extract 288 mg daily to a weight loss diet for 12 weeks does not appear to affect body weight, liver enzymes, lipid levels, or steatosis grade when compared with placebo. Cranberry extract may moderately reduce insulin levels and insulin resistance (104249). However, the clinical impact of these reductions is unclear. Another clinical trial in adults with NAFLD shows that taking dried cranberry powder 144 mg daily after lunch for 6 months improves steatosis grade as measured by ultrasound, insulin sensitivity, and levels of total cholesterol and triglycerides, but does not affect liver enzyme levels, when compared with placebo. All patients also consumed a reduced-calorie diet and an undefined dose of supplemental vitamin E (108058).
• Obesity. Oral cranberry has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in females with overweight or obesity and at least one risk factor for cardiovascular disease shows that drinking a combination of cranberry, blueberry, apple, and chokeberry juice 300 mL daily for 6 weeks does not reduce body weight, body mass index (BMI), or blood pressure but might improve total cholesterol and high-density lipoprotein (HDL) cholesterol when compared to baseline (111233). However, the validity of these findings is limited by the small study size, short duration, and lack of a comparator group. It is unclear if these effects are due to cranberry, other ingredients, or the combination.
• Overactive bladder. It is unclear if oral cranberry is beneficial for overactive bladder. Details: Preliminary clinical research in otherwise healthy females shows that taking dried cranberry powder 500 mg daily for 24 weeks can reduce daily micturition by 16% and urgency episodes by 57% when compared with placebo. Patients taking cranberry powder also reported an improvement in their own perception of their bladder condition when compared with placebo (104246). Limitations of this study include a short duration, lack of a run-in period, and high drop-out rate, which interfered with the ability to meet power.
• Periodontitis. Topical cranberry extract has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in adults with chronic periodontitis shows that applying a topical combination gel product containing cranberry extract 2.5 grams and garcinia extract after scaling and root planing reduces plaque index, gingival index, probing pocket depth, clinical attachment level, and salivary biomarkers of periodontal disease when compared with scaling and root planing alone and similarly to scaling and root planing with tetracycline fibers (112272). It is unclear if these effects are due to cranberry, garcinia, or the combination.
• Peristomal lesions. Although there has been interest in using oral cranberry for peristomal lesions, there is insufficient reliable information about the clinical effects of cranberry for this condition.
• Prostate cancer. It is unclear if cranberry is beneficial for preventing prostate cancer recurrence. Details: Clinical research shows that taking cranberry powder (Pacran, Naturex) 1500 mg for a mean of 30 days prior to radical prostatectomy for prostate cancer does not improve prostate tissue markers when compared with taking placebo. However, levels of prostate tissue antigen decreased by approximately 22% when compared with baseline (105127).
• Radiation-induced cystitis. Evidence for the use of cranberry juice in the prevention of radiation-induced cystitis is conflicting. Details:One small clinical study in individuals with prostate cancer shows that taking 200 mg of a cranberry extract standardized to 30% proanthocyanidins (Monoselect Macrocarpon; PharmExtracta) once daily during external beam radiotherapy for 6-7 weeks reduces the risk of lower UTI by 64% when compared with placebo (92579). However, other preliminary clinical research shows that taking cranberry capsules, standardized to contain a total of 72 mg proanthocyanidins, daily during radiation treatment for prostate cancer and for two weeks post-treatment, does not improve pain, burning, nocturia, or urinary flow symptoms from radiation-induced cystitis when compared with a beetroot placebo (104247). Additionally, preliminary clinical research in patients receiving radiotherapy for bladder or cervical cancer shows that consuming cranberry juice 250 mL daily for 2 weeks does not seem to reduce the incidence of UTIs (46469).
• Rheumatoid arthritis (RA). It is unclear if oral cranberry is beneficial in RA. Details: A clinical study in adults with RA shows that drinking reduced-calorie cranberry juice 250 mL twice daily in addition to taking fish oil 1 gram three times daily for 90 days improves disease activity score (DAS28-CRP) when compared with no supplementation. However, this combination was similarly effective to patients taking fish oil alone, suggesting that any benefits may be due to fish oil, as opposed to cranberry juice (108057). In contrast, another small study in adults with RA shows that drinking reduced-calorie cranberry juice 500 mL daily for 90 days does not improve disease activity score or clinically relevant biologic markers of RA such as rheumatoid factor, anti-cyclic citrullinated peptide antibodies, erythrocyte sedimentation rate, or C-reactive protein when compared with a control group (112273).
• Upper respiratory tract infection (URTI). It is unclear if oral cranberry is beneficial for the prevention or treatment of URTIs. Details: Clinical research shows that drinking a cranberry juice beverage 450 mL daily for 70 days does not decrease the incidence of cold or flu, but may reduce cold and flu symptoms, when compared with placebo in healthy adults (90046).
• Urinary odor. It is unclear if oral cranberry is beneficial for urinary odor. Details: Preliminary clinical research shows that cranberry juice cocktail might reduce urinary odors when given orally on a regular basis to patients with urinary incontinence (3333,3334,8254). Cranberry juice cocktail up to 237 mL three times daily for up to 4 weeks has been used (3334). More evidence is needed to rate cranberry for these uses.

(Read more about CRANBERRY)

POSSIBLY INEFFECTIVE

• Smoking cessation. Some small clinical studies have evaluated the use of lobeline, a constituent of lobelia, for smoking cessation and stopping use of smokeless tobacco over a 48-hour period. These studies show inconsistent effects of lobelia on tobacco use, with many finding no benefit. The validity of these findings is limited by low study quality and the short duration of use (16413,16414,59987). There is insufficient reliable information available about the effectiveness of lobelia for its other uses.

(Read more about LOBELIA)

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Aging. Although there has been interest in using oral noni for aging, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Asthma. Although there has been interest in using oral noni for asthma, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Atherosclerosis. Although there has been interest in using oral noni for atherosclerosis, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Athletic performance. It is unclear if oral noni juice is beneficial for athletic performance. Details: Preliminary clinical research shows that drinking 100 mL of a specific juice (Tahitian Noni Juice (TNJ), Tahitian Noni International) containing 89% pureed noni in grapefruit and blackberry juices twice daily for 21 days can increase running time-to-fatigue by approximately 21% in trained distance runners when compared with baseline. Runners taking placebo blackberry juice did not demonstrate improved endurance when compared with baseline (65230).
• Burns. Although there has been interest in using topical noni for burns, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Cancer. It is unclear if oral noni is beneficial in patients with cancer. Details: Preliminary, low-quality clinical research shows that taking noni fruit extract 2-14 grams daily for 28 days does not improve physical function, fatigue, pain, or tumor growth in patients with various forms of advanced cancer when compared with baseline (65173).
• Cardiovascular disease (CVD). Although there has been interest in using oral noni for CVD, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Cataracts. Although there has been interest in using oral noni for cataracts, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Cervical spondylosis. It is unclear if oral noni is beneficial in patients with cervical spondylosis. Details: Preliminary clinical research shows that taking oral noni juice 15 mL twice daily in combination with physiotherapy for 4 weeks can improve neck pain and flexibility scores more than physiotherapy alone in patients with cervical spondylosis. Treatment with noni juice alone was not different than physiotherapy alone. However, the study may have been inadequately powered to detect a difference between these groups (65197).
• Colic. Although there has been interest in using oral noni for colic, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Common cold. Although there has been interest in using oral noni for the common cold, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Cough. Although there has been interest in using oral noni for cough, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Depression. Although there has been interest in using oral noni for depression, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Diabetes. Although there has been interest in using oral noni for diabetes, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Epilepsy. Although there has been interest in using oral noni for epilepsy, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Headache. Although there has been interest in using oral and topical noni for headache, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Hearing loss. It is unclear if oral noni is beneficial for hearing loss. Details: Preliminary clinical research shows that drinking 4 ounces of noni juice daily for 3 months does not improve hearing at most frequencies in hearing-impaired postmenopausal females (65146).
• HIV/AIDS. Although there has been interest in using oral noni for HIV/AIDS, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Hypertension. It is unclear if oral noni is beneficial in patients with hypertension. Details: Preliminary clinical research shows that drinking 4 ounces of a specific noni juice (Tahitian Noni Juice) daily for one month reduces blood pressure by approximately 8% when compared with baseline in individuals with hypertension (65231). The validity of this finding is limited by the lack of a comparator group.
• Insomnia. Although there has been interest in using oral noni for insomnia, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Leishmania lesions. It is unclear if topical noni is beneficial for improving the severity of leishmania lesions. Details: Preliminary clinical research shows that topical application of an ointment containing noni stem extract 1% three times daily for 6 weeks improves leishmania lesion scores when compared with baseline. A good to excellent response was reported in 80% of patients (65174). However, the validity of this finding is limited by the lack of a comparator group.
• Leprosy. Although there has been interest in using topical noni for leprosy, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Liver disease. Although there has been interest in using oral noni for liver disease, there is insufficient reliable information about the clinical effects of noni for this purpose. Additionally, there is some concern that noni might cause hepatotoxicity in some patients.
• Malaria. Although there has been interest in using oral noni for malaria, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Migraine headache. Although there has been interest in using oral noni for migraine headache, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Osteoarthritis. It is unclear if oral noni is beneficial in patients with osteoarthritis. Details: Preliminary clinical research in patients with knee or hip osteoarthritis shows that drinking 3 ounces of a specific noni juice (Tahitian Noni Juice) daily for 90 days can reduce the need for analgesic medications and improve quality of life parameters, including mobility, joint function, social activity, tension level, mood, and the ability to conduct activities of daily living when compared with baseline (65206). However, the validity of this study is limited by the lack of a comparator group.
• Parturition. Although there has been interest in using oral noni for parturition, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Postoperative nausea and vomiting (PONV). It is unclear if oral noni is beneficial in patients with PONV. Details: Preliminary clinical research shows that taking noni fruit extract 600 mg orally one hour prior to surgery reduces postoperative nausea, but not vomiting, in the first 6 hours after surgery by 40% when compared with placebo. However, taking noni fruit extract did not reduce PONV in the first 6-24 hours after the surgery. Taking noni fruit extract 150-300 mg also did not reduce PONV when compared with placebo (17169).
• Premenstrual syndrome (PMS). Although there has been interest in using oral noni for PMS, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Rheumatoid arthritis (RA). Although there has been interest in using oral and topical noni for RA, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Stroke. Although there has been interest in using oral noni for stroke, there is insufficient reliable information about the clinical effects of noni for this purpose.
• Urinary tract infections (UTIs). Oral noni has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Some observational research in females with recurrent UTIs has found that taking antibiotics with a combination of noni fruit extract 200 mg, d-mannose 500 mg, and N-acetylcysteine 100 mg orally twice daily for 2 months, then daily for 4 months, may be associated with a lower incidence of recurrent UTI when compared with antibiotics alone. Of patients without a UTI in the first 2 months, 100% of those taking the combination product remained UTI free at 6 months whereas only 6% of those taking antibiotics alone remained UTI free. This combination also seems to improve symptoms of urgency, frequency, and incontinence (97360). It is not clear if these effects are due to noni, other ingredients, or the combination.
• Wound healing. Although there has been interest in using topical noni for wound healing, there is insufficient reliable information about the clinical effects of noni for this purpose. More evidence is needed to rate noni for these uses.

(Read more about NONI)

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Aging skin. Topical red raspberry leaf has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research in females aged 30-65 years shows that applying a specific liquid (Antioxidant and Collagen Booster Serum, Max Biocare Pty Ltd.) containing red raspberry leaf cell culture extract 0.0005%, vitamin C 20%, and vitamin E 1% to the face nightly for 8 weeks, in addition to regular facial skin products, improves skin color, elasticity, radiance, smoothness, and appearance of wrinkles when compared with regular facial skin products alone (102355).
• Cardiovascular disease (CVD). Although there has been interest in using oral red raspberry leaf for CVD, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Congestive heart failure (CHF). Although there has been interest in using oral red raspberry leaf for CHF, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Diabetes. Although there has been interest in using oral red raspberry leaf for diabetes, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Dysmenorrhea. Although there has been interest in using oral red raspberry leaf for dysmenorrhea, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Hypertension. Although there has been interest in using oral red raspberry leaf for hypertension, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Influenza. Although there has been interest in using oral red raspberry leaf for influenza, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Labor pain. Some research suggests that oral red raspberry leaf does not reduce analgesic use during labor. Details: Clinical research shows that taking red raspberry leaf 2.4 grams daily, beginning at 32 weeks' gestation and continuing until delivery, does not decrease the need for analgesics in the perinatal time period when compared with placebo (9796). A systematic review of retrospective studies also supports these findings, showing no improvement in perineal outcomes in patients consuming red raspberry leaf prior to labor (108005).
• Menorrhagia. Although there has been interest in using oral red raspberry leaf for menorrhagia, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Obesity. It is unclear if oral red raspberry fruit is beneficial in patients with obesity. Details: Preliminary clinical research in overweight and obese adults shows that consuming frozen red raspberry fruit 280 grams daily for 8 weeks does not reduce body mass index or waist circumference when compared with control (105873).
• Osteoarthritis. It is unclear if oral red raspberry leaf extract is beneficial for knee osteoarthritis. Details: A moderate-sized clinical study in patients with knee osteoarthritis shows that taking red raspberry leaf extract 200 or 400 mg once daily for 12 weeks reduces pain at the higher dose when measured by the visual analog scale, but does not improve physical performance, physical activity, walking distance, or Western Ontario McMaster osteoarthritis index (WOMAC) global score or pain, stiffness, and function subscores when compared with placebo (112127).
• Parturition. Some research suggests that oral red raspberry leaf does not shorten the duration of labor. Details: Clinical research shows that taking red raspberry leaf 2.4 grams daily, beginning at 32 weeks' gestation and continuing until delivery, does not reduce the length of labor when compared with placebo (108005). Traditionally, doses of up to 4 grams daily have been recommended for this purpose; however, doses greater than 2.4 grams daily have not been evaluated for safety or efficacy. Further high-quality research is needed to determine the optimal dose, duration, and formulation, if any, of red raspberry leaf for this purpose.
• Pharyngitis. Although there has been interest in using topical red raspberry leaf for pharyngitis, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Pregnancy-induced nausea and vomiting. Although there has been interest in using oral red raspberry leaf for pregnancy-induced nausea and vomiting, there is insufficient reliable information about the clinical effects of red raspberry for this purpose.
• Respiratory tract infections. Although there has been interest in using oral red raspberry leaf for respiratory tract infections, there is insufficient reliable information about the clinical effects of red raspberry for this purpose. More evidence is needed to rate red raspberry leaf for this use.

(Read more about RED RASPBERRY)

LIKELY SAFE ...when used orally in amounts commonly found in foods. Alpinia has Generally Recognized as Safe (GRAS) status in the US (4912).

POSSIBLY SAFE ...when used orally and appropriately in medicinal amounts (12,102094). Alpinia extract 300 mg daily has been used with apparent safety for 12 weeks (102094). There is insufficient reliable information available about the safety of alpinia when used topically.

PREGNANCY AND LACTATION:
There is insufficient reliable information available about the safety of alpinia when used in medicinal amounts during pregnancy and lactation; avoid using.

(Read more about ALPINIA)

There is insufficient reliable information available about the safety of ba ji tian.

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using.

(Read more about BA JI TIAN)

POSSIBLY SAFE ...when pyrrolizidine alkaloid (PA)-free butterbur products are used orally and appropriately. Although there are some rare cases of liver injury associated with extracts that are reported to be free of PA constituents (102700), rhizome and leaf extracts that are free of PAs seem to be generally safe when used for up to 16 weeks (7230,7595,10336,10337,12840,13003,14414,19381,19383,19384,19385). Tell patients not to use butterbur products that are not certified and labeled as PA-free.

LIKELY UNSAFE ...when products containing pyrrolizidine alkaloid (PA) constituents are used orally. Repeated exposure to low concentrations of PAs can cause hepatotoxicity and severe veno-occlusive disease. PAs might also be carcinogenic and mutagenic (12841,12842). ...when products containing PAs are used topically on abraded or broken skin. Absorption of PAs through broken skin can lead to systemic toxicity (12841).

CHILDREN: POSSIBLY SAFE
when used orally and appropriately. There is some evidence that a specific pyrrolizidine alkaloid (PA)-free butterbur rhizome extract (Petadolex, Weber & Weber, GmbH & Co) can be used with apparent safety in children aged 6-17 years for up to 4 months (13121,19382,19386).

PREGNANCY: LIKELY UNSAFE
when butterbur preparations containing pyrrolizidine alkaloid (PA) constituents are used orally. These constituents might be teratogenic and hepatotoxic (12841,12842). There is insufficient reliable information available about the safety of using butterbur products that do not contain PAs during pregnancy.

LACTATION: LIKELY UNSAFE
when butterbur preparations containing pyrrolizidine alkaloid (PA) constituents are used orally. PAs are excreted in breast milk (12841,12842). There is insufficient reliable information available about the safety of using butterbur products that do not contain PAs during lactation.

(Read more about BUTTERBUR)

LIKELY SAFE . .when used orally and appropriately. Cranberry juice up to 300 mL daily and cranberry extracts in doses up to 800 mg twice daily have been safely used in clinical trials (3333,3334,6758,6760,7008,8252,8253,8254,8995,11328) (16415,16720,17100,17126,17176,17210,17524,46379,46388,46389)(46390,46425,46439,46443,46465,46456,46466,46467,46469,46471)(46496,46499,90044,102847,111407).

CHILDREN: LIKELY SAFE
when cranberry juice is consumed in amounts commonly found in the diet (2811,6759,46441,46452,46470,111407). There is insufficient reliable information available about the safety of cranberry when used in medicinal amounts in children.

PREGNANCY AND LACTATION: LIKELY SAFE
when consumed in amounts commonly found in the diet. There is insufficient reliable information available about the safety of cranberry when used therapeutically during pregnancy or lactation; avoid using.

(Read more about CRANBERRY)

LIKELY UNSAFE ...when used orally (3,11). Lobelia leaf can be toxic in doses of 600-1000 mg; 4000 mg of the leaf may be fatal (18). There is insufficient reliable information available about the safety of lobelia when used topically.

PREGNANCY AND LACTATION: LIKELY UNSAFE
when used orally due to its emetic effects (4,12). There is insufficient reliable information available about the safety of lobelia when used topically during pregnancy and lactation.

(Read more about LOBELIA)

POSSIBLY SAFE ...when used orally and appropriately. Noni juice has been used in doses of up to 200 mL daily with apparent safely in small clinical studies for up to 3 months (11944,17169,65173). However, there have been several case reports of increased liver enzymes and hepatotoxicity in people taking some noni products (13107,14341,14468,17170,17171,17172). In three reports, hepatotoxicity was linked to a specific brand of noni juice (Tahitian Noni Juice, Tahitian Noni International) (14341,17171). It is unclear if potential contaminants or hypersensitivity reactions may be the cause of these events. More evidence is needed to determine if noni increases the risk for hepatotoxicity. There is insufficient reliable information available about the safety of noni fruit extract when used orally or the safety of noni when used topically.

PREGNANCY AND LACTATION:
While animal research is conflicting on the teratogenic effects of noni (65205,65206), there is insufficient reliable information available about the safety of noni in humans; avoid using.

(Read more about NONI)

LIKELY SAFE ...when the fruit is used orally in amounts commonly found in foods (13622).

POSSIBLY SAFE ...when the fruit is used orally and appropriately in medicinal amounts (6481,9796). There is insufficient reliable information available about the safety of red raspberry leaf when used orally or topically.

PREGNANCY: LIKELY SAFE
when the fruit is used orally in amounts commonly found in foods (13622).

PREGNANCY: POSSIBLY SAFE
when red raspberry leaf is used orally and appropriately in medicinal amounts during late pregnancy under the supervision of a healthcare provider. Red raspberry leaf is used by nurse midwives to facilitate delivery. There is some evidence that red raspberry leaf in doses of up to 2.4 grams daily, beginning at 32 weeks' gestation and continued until delivery, can be safely used for this purpose (6481,9796). Make sure patients do not use red raspberry leaf without the guidance of a healthcare professional.

PREGNANCY: LIKELY UNSAFE
when red raspberry leaf is used orally in medicinal amounts throughout pregnancy or for self-treatment. Red raspberry leaf might have estrogenic effects (6180). These effects can adversely affect pregnancy. Tell pregnant patients not to use red raspberry leaf at any time during pregnancy without the close supervision of a healthcare provider.

LACTATION: LIKELY SAFE
when the fruit is used orally in amounts commonly found in foods (13622). There is insufficient reliable information available about the safety of red raspberry leaf; avoid using.

(Read more about RED RASPBERRY)

ANTACIDS Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, alpinia might decrease the effectiveness of antacids.  Details There are some reports suggesting that alpinia increases stomach acid (19).

H2-BLOCKERS Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, alpinia might decrease the effectiveness of H2-blockers.  Details There are some reports suggesting that alpinia increases stomach acid (19).

INDOMETHACIN (Tivorbex) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, alpinia might reduce the levels and clinical effects of indomethacin.  Details In animals, giving an alpinia extract orally reduces systemic exposure to indomethacin, reduces its retention time in plasma, and accelerates its elimination in the bile and feces (106738). This interaction has not been reported in humans.

PROTON PUMP INHIBITORS (PPIs) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, alpinia might decrease the effectiveness of PPIs.  Details There are some reports suggesting that alpinia increases stomach acid (19).

(Read more about ALPINIA)

(Read more about BA JI TIAN)

CYTOCHROME P450 3A4 (CYP3A4) INDUCERS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, CYP3A4 inducers might increase the toxicity of butterbur.  Details The pyrrolizidine alkaloid (PA) constituents found in some butterbur products are substrates of CYP3A4 (12841,12860). Theoretically, drugs that induce CYP3A4 might increase the conversion of PAs to toxic metabolites.

(Read more about BUTTERBUR)

ATORVASTATIN (Lipitor) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, cranberry might increase levels and adverse effects of atorvastatin.  Details In one case report, a patient taking atorvastatin experienced upper back pain, rhabdomyolysis, and abnormal liver function after drinking cranberry juice 16 ounces daily for 2 weeks. Theoretically, this may have been caused by inhibition of cytochrome P450 3A4 (CYP3A4) enzymes by cranberry juice, as atorvastatin is a CYP3A4 substrate. Creatinine kinase and liver enzymes normalized within 2 weeks of stopping cranberry juice (90042). Patients taking atorvastatin should avoid large quantities of cranberry juice.

CYTOCHROME P450 2C9 (CYP2C9) SUBSTRATES Interaction Rating = Minor Be watchful with this combination. Severity = Moderate •  Occurrence = Unlikely •  Level of Evidence = B Theoretically, cranberry might increase the levels and adverse effects of CYP2C9 substrates. However, research is conflicting.  Details There is contradictory evidence about the effect of cranberry on CYP2C9 enzymes. In vitro evidence suggests that flavonoids in cranberry inhibit CYP2C9 enzymes (10452,11115,90048). However, clinical research shows that cranberry juice does not significantly affect the levels, metabolism, or elimination of the CYP2C9 substrates flurbiprofen or diclofenac (11094,90048). Also, in patients stabilized on warfarin, drinking cranberry juice 250 mL daily for 7 days does not significantly increase the anticoagulant activity of warfarin, a CYP2C9 substrate (15374). Additional pharmacokinetic research shows that cranberry juice does not increase peak plasma concentrations or area under the concentration-time curve of warfarin (15393).

CYTOCHROME P450 3A4 (CYP3A4) SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, cranberry might increase the levels and adverse effects of CYP3A4 substrates.  Details A case of upper back pain, rhabdomyolysis, and abnormal liver function has been reported for a patient taking atorvastatin, a CYP3A4 substrate, in combination with cranberry juice 16 ounces daily for 2 weeks. Creatinine kinase and liver enzymes normalized within 2 weeks of stopping cranberry juice (90042). Also, animal research suggests that cranberry juice, administered intraduodenally 30 minutes prior to nifedipine, a CYP3A4 substrate, inhibits nifedipine metabolism and increases the area under the concentration-time curve by 1.6-fold compared to control (46420).

DICLOFENAC (Voltaren, others) Interaction Rating = Minor Be watchful with this combination. Severity = Moderate •  Occurrence = Unlikely •  Level of Evidence = B Theoretically, cranberry might modestly increase the levels and adverse effects of diclofenac.  Details In vitro evidence suggests that cranberry juice inhibits diclofenac metabolism by human liver microsomes (90048). However, drinking cranberry juice does not seem to affect diclofenac metabolism in humans (90048).

NIFEDIPINE (Procardia) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, cranberry might increase the levels and adverse effects of nifedipine.  Details Animal research suggests that cranberry juice, administered intraduodenally 30 minutes prior to nifedipine treatment, inhibits nifedipine metabolism and increases the area under the concentration-time curve by 1.6-fold compared to control (46420). This interaction has not been reported in humans.

WARFARIN (Coumadin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, cranberry might increase the levels and adverse effects of warfarin. However, research is conflicting.  Details There is contradictory evidence about the effect of cranberry juice on warfarin. Case reports have linked cranberry juice consumption to increases in the international normalized ratio (INR) in patients taking warfarin, resulting in severe spontaneous bleeding and excessive postoperative bleeding (10452,12189,12668,21187,21188,21189,46378,46396,46411)(46415,90043). Daily consumption of cranberry sauce for one week has also been linked to an increase in INR in one case report (16816). In a small study in healthy young males, taking a high dose of 3 grams of cranberry juice concentrate capsules, equivalent to 57 grams of fruit daily, for 2 weeks produced a 30% increase in the area under the INR-time curve after a single 25-mg dose of warfarin (16416). However, 3 very small clinical studies in patients stabilized on warfarin reported that cranberry juice 250 mL once or twice daily for 7 days (27% cranberry juice or pure cranberry juice) or 240 mL once daily for 14 days does not significantly increase INR or affect plasma warfarin levels (15374,17124,90045). The reasons for these discrepant findings are unclear. It is possible that the form and dose of cranberry may play a role, as cranberry extracts and juices contain different constituents. Additionally, an in vitro study evaluating 5 different cranberry juices found varying effects, with only a cranberry concentrate, and not diluted cranberry juices, inhibiting CYP2C9. However, this concentrate did not inhibit CYP2C9 activity in humans (108062).

(Read more about CRANBERRY)

(Read more about LOBELIA)

ACE INHIBITORS (ACEIs) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, combining noni and ACE inhibitors might increase the risk of hyperkalemia.  Details Noni juice contains significant amounts of potassium, about 6 mEq/100 mL juice (1298). This may increase the risk for hyperkalemia when used in conjunction with ACE inhibitors, which can also increase potassium levels.

ANGIOTENSIN RECEPTOR BLOCKERS (ARBs) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, combining noni and ARBs might increase the risk of hyperkalemia.  Details Noni juice contains significant amounts of potassium, about 6 mEq/100 mL juice (1298). This may increase the risk for hyperkalemia when used in conjunction with ARBs, which can also increase potassium levels.

ANTIHYPERTENSIVE DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, noni may increase the risk of hypotension when used in combination with antihypertensive drugs.  Details Preliminary clinical research suggests that drinking noni juice can reduce blood pressure in individuals with hypertension (65231).

HEPATOTOXIC DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking noni with hepatotoxic drugs might increase the risk of liver damage.  Details There is concern that noni might cause hepatotoxicity in some patients (13107,14341,14468). Advise patients against combining noni with potentially hepatotoxic drugs.

PHENYTOIN (Dilantin) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking noni fruit juice concomitantly with phenytoin may lower phenytoin levels and increase the risk of seizures.  Details In one case report, an adult taking phenytoin for partial seizures experienced low serum phenytoin levels while taking noni juice 90-200 mL daily. Serum phenytoin levels increased after decreasing noni juice consumption; similarly, serum phenytoin levels decreased after increasing noni juice consumption. Some researchers believe noni juice may induce cytochrome P450 2C9 enzymes, which would decrease phenytoin levels, but this has not been well studied. Patients may need additional monitoring when starting or stopping noni juice supplementation (106057).

POTASSIUM-SPARING DIURETICS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, combing noni and a potassium-sparing diuretic might increase the risk of hyperkalemia.  Details Noni juice contains significant amounts of potassium, about 6 mEq/100 mL juice (1298). This may increase the risk for hyperkalemia when used in conjunction with potassium-sparing diuretics, which can also increase potassium levels.

RANITIDINE (Zantac) Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = B Taking noni fruit with ranitidine might increase the levels and clinical effects of ranitidine.  Details Clinical evidence shows that taking an aqueous extract of noni fruit 30 minutes prior to taking a single oral dose of ranitidine can increase the rate of absorption and plasma concentration of ranitidine (23387).

WARFARIN (Coumadin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking noni juice concomitantly with warfarin might decrease the effectiveness of warfarin.  Details In one case, a 41-year-old patient stabilized on warfarin had a decreased international normalized ratio (INR) following consumption of a specific commercial noni juice product (Noni juice 4 Everything). While the patient was still taking noni juice, an increase in warfarin dose did not produce an increase in INR (14434). However, it should be noted that this particular product contained extracts and derivatives from more than 115 components, many of which contained vitamin K. Furthermore, vitamin K was listed as a separate ingredient of the product, suggesting that the product was possibly fortified with vitamin K. It has not been verified that noni fruit alone contains a significant amount of vitamin K or interacts with warfarin.

(Read more about NONI)

ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking red raspberry leaf with anticoagulant/antiplatelet drugs might increase the risk of bleeding.  Details In vitro research suggests that red raspberry leaf extract has antiplatelet activity and enhances the in vitro effects of the antiplatelet medication cangrelor (96300). This interaction has not been reported in humans.

INSULIN Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Red raspberry leaf might reduce glucose levels in patients being treated with insulin.  Details In one case report, a 38-year-old patient with gestational diabetes, whose blood glucose was being controlled with medical nutrition therapy and insulin, developed hypoglycemia after consuming two servings of raspberry leaf tea daily for 3 days beginning at 32 weeks' gestation. The patient required an insulin dose reduction. The hypoglycemia was considered to be probably related to use of red raspberry leaf tea (96299).

(Read more about RED RASPBERRY)

General ...Orally and topically, alpinia seems to be well tolerated.

Gastrointestinal ...Orally, alpinia may cause gastrointestinal adverse effects. In one clinical trial, around 5% of patients taking alpinia extract 100 mg three times daily for 12 weeks discontinued treatment due to adverse gastrointestinal effects (102094).

(Read more about ALPINIA)

General ...No adverse effects have been reported. However, a thorough evaluation of safety outcomes has not been conducted.

(Read more about BA JI TIAN)

General ...Orally, butterbur seems to be generally well tolerated.
Most Common Adverse Effects:
Orally: Belching, diarrhea, drowsiness, fatigue, headache, itchy eyes, pruritus, rash, and stomach upset.
Serious Adverse Effects (Rare):
Orally: Hepatotoxicity due to the presence of pyrrolizidine alkaloids (PAs), although there are also rare reports of liver injury associated with butterbur supplements labeled as PA-free.

Dermatologic ...Orally, butterbur may cause pruritus and rash (12386,19382).

Gastrointestinal ...Orally, butterbur may cause abdominal pain, belching, nausea, diarrhea, regurgitation, and stomach upset (12386,13121,19382,19383).

Hepatic ...The butterbur plant contains hepatotoxic pyrrolizidine alkaloid (PA) constituents which have been associated with veno-occlusive disease, liver enlargement, and gastrointestinal symptoms (4021,12386,12841,12842). However, there is some evidence to suggest that even PA-free butterbur preparations might cause liver injury. Of 48 cases of liver injury with a specific PA-free butterbur product (Petadolex), three cases were considered likely related and 13 cases possibly related to butterbur use. An additional 12 cases of mild liver injury suspected to be related to use of butterbur have been reported in clinical trials. Of a total of 10 severe cases of liver injury, one was considered likely related and 5 were considered possibly related to butterbur use. While most patients experienced quick recovery after butterbur discontinuation, one required liver transplantation (102700).

Musculoskeletal ...Orally, butterbur may cause pain, including arthralgias and limb pain (19382).

Ocular/Otic ...Orally, butterbur causes itchy eyes (12386).

Pulmonary/Respiratory ...Orally, butterbur may cause asthmatic symptoms (12386). Also, butterbur theoretically might cause an allergic reaction in individuals sensitive to the Asteraceae/Compositae family. Members of this family include ragweed, chrysanthemums, marigolds, daisies, and many other herbs (12841).

(Read more about BUTTERBUR)

General ...Orally, cranberry seems to be well tolerated.
Most Common Adverse Effects:
Orally: Diarrhea and gastrointestinal discomfort.

Dermatologic ...Orally, skin redness and itching has been reported in one patient (46389).

Gastrointestinal ...In very large doses, for example 3-4 L per day of juice, cranberry can cause gastrointestinal upset and diarrhea, particularly in young children (46364). There are reports of abdominal and gastrointestinal discomfort after taking cranberry tablets, extracts, and juice in clinical trials (16720,46379,111407). Nausea, vomiting, and diarrhea have also been reported with consumption of lower doses of cranberry juice cocktail, 16 ounces per day, equivalent to about 4 ounces cranberry juice, for several weeks (16415).

Genitourinary ...Vulvovaginal candidiasis has been associated with ingestion of cranberry juice (46374). Clinical research suggests that ingestion of cranberry juice may be associated with vaginal itching and vaginal dryness (46471). One patient in clinical research stopped taking dried cranberry juice due to excessive urination (46437), and an isolated case of nocturia following ingestion of cranberry tablets has been reported (16720).

Hematologic ...Thrombocytopenia has been reported as an adverse event to cranberry juice (46459).

Other ...An isolated case of sensitive swollen nipples after taking cranberry tablets has been reported (16720).

(Read more about CRANBERRY)

General ...Orally, lobelia can cause nausea, vomiting, diarrhea, coughing, dizziness, tremors, and throat irritation. These adverse effects have been reported with doses as low as 50 mg (4,16414). Lobelia leaf can cause toxicity when taken in doses of 600 mg or higher. Symptoms of lobelia toxicity include sweating, tachycardia, convulsions, hypothermia, hypotension, coma, and death (4,11).

Cardiovascular ...Orally, high doses of lobelia leaf can cause toxicity. Symptoms of lobelia toxicity include tachycardia, hypotension, and death (4,11).

Gastrointestinal ...Orally, lobelia can cause nausea, vomiting, diarrhea, and throat irritation (4,16414).

Neurologic/CNS ...Orally, lobelia can cause dizziness and tremors. High doses of lobelia leaf can cause toxicity. Symptoms of lobelia toxicity include convulsions, coma, and death (4,11).

Pulmonary/Respiratory ...Orally, lobelia can cause coughing and throat irritation (4,16414).

Other ...Orally, high doses of lobelia leaf can cause toxicity resulting in death. Toxicity has been reported to occur at doses as low as 600 mg, with doses of 4000 mg or more considered to be fatal (4,11).

(Read more about LOBELIA)

General ...Orally and topically, noni seems to be generally well tolerated; however, high quality studies of adverse effects have not been conducted.
Most Common Adverse Effects:
Orally: Abdominal discomfort, nausea.
Serious Adverse Effects (Rare)::
Orally: Hepatotoxicity, including liver failure. However, studies have not conclusively identified whether noni, or contaminants in noni products, were responsible for this toxicity.

Gastrointestinal ...Orally, dehydrated noni fruit has been reported to cause nausea and abdominal discomfort (65173).

Hepatic ...Noni has been associated with several cases of hepatotoxicity in previously healthy patients ranging in age from 14 to 62 years (13107,14341,14468,17170,17171,17172). In two cases, the patients had used a tea or other herbal products containing noni (13107,17172); five had consumed noni juice, specifically Tahitian Noni Juice (Tahitian Noni International) (14341,16648,17171); and two cases involved energy drinks containing several herbal ingredients including noni (17170,90125). Symptoms of liver dysfunction and elevated liver function tests (LFTs) were seen between 2 weeks and 4 months after starting noni. The LFTs started to improve within 2 days of stopping noni and generally normalized within 1 month (13107,14468,17171). Biopsy findings included acute hepatitis, inflammation, hepatocyte necrosis, and hepatocellular cholestasis (14341,17170). One patient, who had a history of prior mild acetaminophen toxicity, had rapidly progressive liver failure after noni ingestion and required transplantation (14341).
Potential product contamination was not ruled out in these case reports. Some researchers theorize that anthraquinones contained in noni could potentially cause hepatotoxicity. Other products containing anthraquinones, such as senna, have been linked to cases of hepatotoxicity. However, analyses of a noni juice product associated with reports of liver damage (Tahitian Noni Juice, Tahitian Noni International) have not detected anthraquinone content (14444). Another analysis of noni fruit puree from which the seeds and skin had been removed had no detectable anthraquinones (92201). However, products containing seed or leaf material had detectable amounts of anthraquinones (92201). The part of the noni plant used might affect hepatotoxicity risk. More evidence is needed to determine if noni causes hepatotoxicity.

(Read more about NONI)

General ...Orally, red raspberry fruit is well tolerated. There is currently a limited amount of information on the adverse effects of red raspberry leaf.
Most Common Adverse Effects:
Orally: Diarrhea, gastrointestinal upset, and epigastric pain. However, these adverse effects do not commonly occur with typical doses.

Dermatologic ...A liquid containing red raspberry leaf cell culture extract 0. 0005%, vitamin C 20%, and vitamin E 1% (Antioxidant and Collagen Booster Serum, Max Biocare Pty Ltd.) has been reported to cause mild tingling and skin tightness (102355). It is unclear if these effects are due to red raspberry leaf, the other ingredients, or the combination.

Gastrointestinal ...Orally, red raspberry may cause gastrointestinal upset, diarrhea, and epigastric pain (112127).

Pulmonary/Respiratory ...A case of occupational asthma due to the inhalation of red raspberry powder has been reported for a 35-year-old female. Symptoms included wheezing and shortness of breath (70370).

(Read more about RED RASPBERRY)