Echinacea (Echinacea angustifolia, Echinacea pallida, Echinacea purpurea)

• Background
• Related terms
• Evidence
• Dosing
• Safety
• Methodology
• Selected references

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Echinacea (Echinacea angustifolia, Echinacea pallida, Echinacea purpurea)

Background

Echinacea species are perennials that belong to the Asteraceae (aster) family and originated in eastern North America. Traditionally used for a range of infections and cancers, the roots and herb (aboveground parts) of Echinacea species have attracted scientific interest for their reported use in enhancing the immune system.

Natural medicine experts frequently recommend oral extracts of echinacea for the treatment of the common cold and for other conditions requiring immune stimulation. It is occasionally recommended for topical treatment of wounds.

Traditionally, echinacea roots and herbs were used by indigenous Americans for a wide variety of conditions, ranging from snakebites to cancers. Echinacea does not have U.S. Food and Drug Administration (FDA) Generally Regarded as Safe (GRAS) status.

Echinacea was adopted by central U.S. settlers in the 1800s. However, after the introduction of antibiotics, echinacea use fell out of favor. Echinacea's historical use as a treatment for infections has found renewed interest due to recent rises in antibiotic resistance and the limitations of available antiviral drugs.

Related terms

Alkamides, American coneflower, Asteraceae (family), black sampson, black susan, cichoric acid and polysaccharides, cock-up-hat, combflower, Echinacea angustifolia , Echinacea pallida , Echinacea Plus, Echinacea purpurea , Echinacin®, Echinacin® EC31, Echinaforce®, Echinaforce® Forte, Echinaguard®, Echinilin® (Factors R & D Technologies, Burnaby, BC, Canada), hedgehog, Igelkopf (German), Indian head, Kansas snake root, Kegelblume (German), narrow-leaved purple coneflower, Pascotox®, purple coneflower, red sunflower, rudbeckia, SB-TOX, scurvy root, snakeroot, solhat, sun hat.

Evidence

These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Grading rationale

Uses based on tradition or theory

The below uses are based on tradition or scientific theories. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Abscesses (puss), acne, antioxidant, attention-deficit hyperactivity disorder (ADHD), bacterial infections, bee stings, boils, burn wounds, catarrh (runny nose), diphtheria, dizziness, dyspepsia (indigestion), eczema (skin rashes), gingivitis (inflammation of the gums), hemorrhoids, herpes simplex virus, HIV infection, influenza (flu), insect bites, malaria, menopause, migraine headache, mouth sores, nasal congestion, nasopharyngeal catarrh (runny nose), pain, periodontitis / gingivitis (gum disease), psoriasis, respiratory infections in dogs, rheumatism (muscle or joint stiffness), septicemia (bacterial infection of the blood), skin ulcers, skin wounds, snake bites, Staphylococcal infections, stomachache, Streptococcal infections, syphilis, tonsillitis, typhoid (typhoid fever), urinary disorders, urinary tract infection, whooping cough, wound healing.

Dosing

The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.

Adults (18 years and older)

For cancer, 300 milligrams of cyclophosphamide per square meter has been given intravenously every 28 days, followed by 60 milligrams of Echinacin® per square meter and 30 milligrams of thymostimulin per square meter given intramuscularly on days 3-10 after cyclophosphamide and then twice weekly.

For genital herpes, a dose of 800 milligrams of echinacea extract has been taken by mouth twice daily for six months

For upper respiratory infection or common cold prevention, a 1.5 milliliter tincture containing the equivalent of 300 milligrams of Echinacea angustifolia root has been taken by mouth three times daily in a clinical trial either for a seven-day course prior to experimental infection, or for five days after infection. Echinacea (2.5 milliliters) has been taken by mouth three times daily for seven days before and after viral inoculation in a clinical trial. A dose of four milliliters of Echinacea purpurea juice has been taken by mouth twice daily for eight weeks. Three 300-milligram Echinacea purpurea capsules have been taken by mouth twice daily for eight weeks. Echinaforce® Forte (dose and frequency unclear) has also been taken by mouth in a clinical trial.

For upper respiratory infection or common cold treatment, the dose recommended most often by experts is 500-1,000 milligrams by mouth three times daily for 5-7 days. Total daily doses of 900 milligrams and 450 milligrams have been taken by mouth. The recommended dose of expressed juice is 6-9 milliliters daily in divided doses for 5-7 days, according to most experts. The recommended tincture dosage is 0.75-1.5 milliliters, gargled then swallowed, 2-5 times daily for 5-7 days. The recommended dose of Echinacea tea is typically two teaspoons (four grams) of coarsely powdered herb simmered in one cup of boiling water for 10 minutes, daily for 5-7 days, according to most experts.

Various doses have been used in clinical trials. Eight doses of five milliliters of Echinacea purpurea extract (Echinilin®) diluted with half a glass of water have been taken by mouth on day 1, followed by three doses on days 2-7. Echinaforce® (6.78 milligrams of Echinacea purpurea crude extract) and a 7X concentration (48.27 milligrams) have been taken by mouth. Twenty drops of Echinaguard® (squeezed sap of Echinacea purpurea ) in water have been taken by mouth every two hours for the first day and then three times daily, for up to a total of 10 days. Echinacea pallida radix (90 drops) has been taken by mouth over 8-10 days, but it was unclear whether one or several doses were taken. Five to six cups of "Echinacea Plus®" tea (equivalent of 1.275 milligrams of dried herb and root per tea bag) have been taken by mouth on day 1 and decreased by one cup daily for the next five days. Pascotox® ( Echinacea pallida radix) (900 milligrams daily) has been taken by mouth for 8-10 days. Echinacea purpurea radix (450 or 900 milligrams of a 50% ethanolic extract) has been taken by mouth daily. One milliliter of extract from the root of Echinacea angustifolia or Echinacea purpurea in 30% alcohol has been taken by mouth twice daily for 12 weeks. Pressed juice of Echinacea purpurea (Echinacin® EC31) has been taken by mouth for 28 days. An encapsulated mixture of unrefined Echinacea purpurea herb (25%) and root (25%) plus Echinacea angustifolia root (50%) has been taken by mouth. A dose of one gram of Echinacea has been taken by mouth six times on the first day of symptoms, then three times daily on each additional day of illness, for as long as 10 days.

For wound or ulcer healing, the dose recommended most often by experts is 15% pressed herb (nonroot) juice applied to the affected area daily.

For uveitis, 150 milligrams of Echinacea purpurea has been taken by mouth twice daily, and the follow-up duration was nine months.

Injectable preparations of echinacea are no longer approved for use in Germany and are generally not available commercially. Severe reactions have been reported following injection.

Children (under 18 years old)

Note : In a study of echinacea for the treatment of cold symptoms in children ages 2-11, an increased incidence of rash was reported.

There is no proven safe or effective dose for echinacea in children.

For otitis media (ear infection), an alcohol extract of Echinacea purpurea roots and seeds has been taken by mouth for 10 days at the first sign of a common cold.

For upper respiratory infection or common cold prevention, a 1.5 milliliter tincture containing the equivalent of 300 milligrams of Echinacea angustifolia root has been taken by mouth three times daily in a clinical trial either for a seven-day course prior to experimental infection, or for five days after infection. Echinacea (2.5 milliliters) has been taken by mouth three times daily for seven days before and after viral inoculation in a clinical trial. A dose of four milliliters of Echinacea purpurea juice has been taken by mouth twice daily for eight weeks. Three 300-milligram Echinacea purpurea capsules have been taken by mouth twice daily for eight weeks. Echinaforce® Forte (dose and frequency unclear) has also been taken by mouth in a clinical trial.

For whooping cough, 1-2 milliliters of squeezed aqueous extract (0.1 grams per two milliliters) has been given intramuscularly twice daily for 3-21 days. Parenteral preparations of echinacea are no longer approved for use in Germany.

Safety

The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.

Allergies

Avoid with known allergy or hypersensitivity to Echinacea , its constituents, or any members of the Asteraceae (Compositae) family (including ragweed, chrysanthemum, marigold, and daisy).

Individuals with asthma may be predisposed to allergic reactions to echinacea.

Anaphylaxis (a life-threatening allergic reaction), bronchospasm, hives, itching, elevated blood pressure, rash, swelling of both hands, and swelling under the skin have been reported.

Side Effects and Warnings

Echinacea has been well tolerated in clinical practice and in trials, with few, primarily gastrointestinal, adverse events reported.

Echinacea may cause abdominal pain, acute kidney failure, allergic rash, atrial fibrillation (irregular heartbeat), dizziness, drowsiness, ear infection (in children), headache, hives, low white cell count, mild nausea, rash, sore throat, tender red nodules under the skin, thrombotic thrombocytopenic purpura (a blood clotting disorder) and vomiting.

Use cautiously in patients with asthma or those prone to allergic skin reactions, due to a high likelihood of allergic reactions with oral or topical echinacea.

Use injectable preparations of echinacea (no longer approved for use in Germany) cautiously. Safety has not been established, and in diabetics, injectable administration may worsen blood sugar control.

Use tinctures cautiously with alcoholic patients or in patients taking disulfiram or metronidazole, as many tinctures contain significant concentrations of alcohol (range: 15-90%). This combination may elicit a disulfiram (strong nausea and vomiting) reaction.

The German Commission has warned against the use of echinacea in patients with AIDS/HIV, collagen vascular diseases, multiple sclerosis, or tuberculosis, due to theoretical adverse effects on immune function.

Some natural medicine experts also discourage the use of echinacea by people with conditions affecting the immune system, such as HIV/AIDS, some types of cancer, multiple sclerosis, tuberculosis, and rheumatologic diseases (such as rheumatoid arthritis or lupus).

Use cautiously in patients with hemochromatosis (iron storage disease), based on a lack of reports on liver function. Numerous reports of hepatitis have been associated with echinacea use.

Patients consuming large amount of echinacea have experienced elevations in their transaminases (liver function tests).

Use cautiously in patients who are taking amoxicillin, because there is one poorly described case of rhabdomyolysis and shock, followed by death.

Use cautiously in patients who are taking anticancer agents.

Echinacea may interfere with the way the body processes certain drugs, herbs, or supplements using the liver's cytochrome P450 enzyme system. As a result, the levels of these agents may change in the blood, and may cause increased or decreased effects or potentially serious adverse reactions. Patients taking any medications should check the package insert and speak with a qualified healthcare professional, including a pharmacist, about possible interactions.

Use cautiously in those taking immunostimulants or immunosuppressants, as echinacea may have immunostimulant effects.

Use cautiously in patients who are taking agents that damage the liver (e.g., anabolic steroids, amiodarone, methotrexate, or ketoconazole), due to a possible risk of hepatitis.

Use cautiously in patients who are taking kava, due to a possible risk of liver damage. The German Commission Expert panel considers echinacea in recommended doses safe for use (by mouth) during pregnancy and breastfeeding. However, most experts do not recommend injection or infusion of echinacea during pregnancy. Tinctures may not be advised due to their 15-90% alcohol content.

Avoid using echinacea in patients undergoing anesthesia. Avoid with known allergy or hypersensitivity to Echinacea , its constituents, or any members of the Asteraceae (Compositae) family (including ragweed, chrysanthemum, marigold, and daisy). Anaphylaxis (a life-threatening allergic reaction), bronchospasm, hives, itching, elevated blood pressure, rash, swelling of both hands, swelling under the skin have been reported.

Pregnancy and Breastfeeding

The German Commission Expert panel considers oral echinacea in recommended doses safe for use in pregnancy and lactation. However, most experts do not recommend injection or infusion of echinacea during pregnancy. Tinctures may not be advised due to their 15-90% alcohol content.

Methodology

This patient information is based on a professional level monograph edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Monograph methodology

Selected references

1. Barrett BP, Brown RL, Locken K, et al. Treatment of the common cold with unrefined echinacea. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2002;137(12):939-946.
2. Barrett B, Brown R, Mundt M, et al. Using benefit harm tradeoffs to estimate sufficiently important difference: the case of the common cold. Med Decis Making 2005;25(1):47-55.
3. Everett LL, Birmingham PK, Williams GD, et al. Herbal and homeopathic medication use in pediatric surgical patients. Paediatr Anaesth 2005;15(6):455-460.
4. Huntley AL, Thompson Coon J, Ernst E. The safety of herbal medicinal products derived from Echinacea species: a systematic review. Drug Saf 2005;28(5):387-400.
5. Koenig K, Roehr CC. Does treatment with Echinacea purpurea effectively shorten the course of upper respiratory tract infections in children? Arch Dis Child 2006;91(6):535-537.
6. Mishima S, Saito K, Maruyama H, et al. Antioxidant and immuno-enhancing effects of Echinacea purpurea . Biol Pharm Bull 2004;27(7):1004-1009.
7. Neri PG, Stagni E, Filippello M, et al. Oral Echinacea purpurea extract in low-grade, steroid-dependent, autoimmune idiopathic uveitis: a pilot study. J Ocul Pharmacol Ther 2006;22(6):431-436.
8. O'Neil J, Hughes S, Lourie A, et al. Effects of echinacea on the frequency of upper respiratory tract symptoms: a randomized, double-blind, placebo-controlled trial. Ann Allergy Asthma Immunol 2008;100(4):384-388.
9. Pillai S, Pillai C, Mitscher LA, et al. Use of quantitative flow cytometry to measure ex vivo immunostimulant activity of echinacea: the case for polysaccharides. J Altern Complement Med 2007;13(6):625-634.
10. Shah SA, Sander S, White CM, et al. Evaluation of echinacea for the prevention and treatment of the common cold: a meta-analysis. Lancet Infect Dis 2007;7(7):473-480.
11. Schapowal A, Berger D, Klein P, et al. Echinacea/sage or chlorhexidine/lidocaine for treating acute sore throats: a randomized double-blind trial. Eur J Med Res 2009;14(9):406-12.
12. Turner RB, Bauer R, Woelkart K, et al. An evaluation of Echinacea angustifolia in experimental rhinovirus infections. N Engl J Med 2005;353(4):341-348.
13. Taylor JA, Weber W, Standish L, et al. Efficacy and safety of echinacea in treating upper respiratory tract infections in children: a randomized controlled trial. JAMA 2003;290(21):2824-2830.
14. Wahl RA, Aldous MB, Worden KA, et al. Echinacea purpurea and osteopathic manipulative treatment in children with recurrent otitis media: a randomized controlled trial. BMC Complement Altern Med 2008;8:56.
15. Yale SH, Glurich I. Analysis of the inhibitory potential of Ginkgo biloba , Echinacea purpurea , and Serenoa repens on the metabolic activity of cytochrome P450 3A4, 2D6, and 2C9. J Altern Complement Med 2005;11(3):433-439.

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