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CONTINUING PROFESSIONAL DEVELOPMENT
THE COMPLEMENTARY APPROACH
to exhibit virucidal activity against the
influenza virus, herpes simplex virus
type 1, and to a lesser extent respiratory
with the use of E. purpurea has also been
demonstrated in vitro towards pathogens
that are associated with respiratory
tract infections - Streptococcus pyogenes
(Group A strep), Haemophilus influenzae
and Legionella pneuophila.
Despite these promising in vitro
studies, the results of meta-analyses
of clinical trials have been unclear
12 This may be
attributed to the quality of research
methodology, the heterogeneity in
species, and the parts of the plant
used in the preparations trialled.
A 2014 Cochrane review evaluating
the efficacy of Echinacea species for
the treatment of the common cold
concluded that the overall evidence
for clinically relevant treatment effects
were weak, but acknowledged the
significant differences in the species
and preparations tested.
12 The same
review stated that prophylactic use
of echinacea may reduce the relative
risk of catching a cold by 10–20%.
This has been further supported by
a recent meta-analysis that included
2,458 participants, and found
that echinacea reduced the risk of
recurrent respiratory tract infections.
Individuals that were most susceptible
to respiratory tract infections (RTIs),
including those with a weaker immune
function and those under stress,
reduced their incidence of RTIs by
13 No significant safety issues
were observed when compared to
13 Ethanolic extracts appear to
provide superior treatment effects over
The preferred species and parts of
echinacea are E. angustifolia and
E. purpurea roots due to their higher
alkylamide content (compared to
E. pallida), which is a marker of quality
• 1.5–4.5 g per day of E. purpurea
• 1–3 g per day of E. angustifolia
• 3–6 mL per day of 1:2 liquid extract
E. purpurea or E.angustifolia.
For acute infections, echinacea should
be taken at the first sign of URTI
symptoms, and be taken for 7–14 days.
The German Commission E scientific
advisory board recommendation is that
echinacea should not be used for longer
than 8 weeks.
Echinacea is generally well
tolerated, with a slight risk of
transient, self-limiting and reversible
gastrointestinal symptoms and rashes
when used short term.
contraindicated in individuals with
allergies to members of the daisy
Allergic reactions are rare.
Between July 1996 and November 1998
the Adverse Drug Reactions Advisory
Committee (ADRAC) received 37 reports
of suspected adverse drug reactions
(ADRs) related to echinacea. Over 50%
of these (n=21) described allergic-like
effects including bronchospasm,
dyspnoea, urticaria, chest pain and
Due to the potential for
immune-related adverse consequences
not being ruled out in atopic individuals,
echinacea should be used with
caution and under the supervision
of a healthcare practitioner in these
Commission E warns against
using echinacea in progressive systemic
diseases such as tuberculosis and
autoimmune disorders (e.g. multiple
sclerosis, systemic lupus erythematosus,
and rheumatoid arthritis) based on
theoretical considerations .
Concomitant use of echinacea and
cyclophosphamide should be avoided
as it may be detrimental in the
treatment of autoimmune disease.
Due to a theoretical concern that
an antagonistic pharmacodynamic
interaction may occur between
immunosuppressive medicines and
echinacea, ideally this combination
should be avoided. Avoid combining
echinacea with etoposide due to a risk
of severe thrombocytopenia.
18 There is
some in vitro evidence indicating a
possible inhibitory effect by echinacea
on CYP3A4, CYP2C9 and CYP1A2
18 Caution is warranted with
concomitant use of midazolam, warfarin
Andrographis paniculata has a long
history of use within traditional
medicine, and is listed in a number of
South East Asian pharmacopoeias for its
use in a diverse number of conditions.
A. paniculata has gained popularity for
the treatment of URTIs and influenza.
The main active constituents are
collectively known as andrographolides,
and are found in the leaf and aerial
parts of the plant.
Knowledge of the
pharmacology of the andrographolides
has been derived from in vitro and
animal studies that have demonstrated
and antibacterial properties.
The mechanism of action has not been
fully investigated in human studies.
Collectively, seven double-blind
controlled trials have found A. paniculata
to be superior to placebo in alleviating
the symptoms of uncomplicated
URTIs.20 A recent systematic review that
investigated numerous herbal products
found six randomised control trials
for A. paniculata, which demonstrated
strong evidence for its efficacy in
alleviating the frequency and severity
of patients’ cough symptoms associated
with the common cold and URTIs
compared to placebo.21
Two controlled trials have reported that
a fixed combination of A. paniculata and
Siberian ginseng (Kan Jang) is effective
in the treatment of uncomplicated
URTIs, including sinusitis, and was
effective in improving symptoms such as
headache, nasal and throat symptoms,
and general malaise.
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