Sambiloto (Andrographis paniculata (Burm. f.) Wall. ex Nees. +)

HERBAL

MEDICINAL

by 

RETTODWIKART  THENU

ANDROGRAPHIS

(an-dro’graf-iz)

Andrographis paniculata (Burm. f.) Wall. ex Nees.  +

HISTORICAL NOTE (Braun, L and Cohen, M. 2010)

Andrographis has long been used in traditional medicine systems in numerous countries. It has been included in the pharmacopoeias of India, Korea and China, possibly because it grows abundantly in India, Pakistan and various parts of Southeast Asia. In TCM, andrographis is considered a ‘cold’ herb and is used to rid the body of heat, as in fevers and acute infections, and to dispel toxins from the body. In Ayurvedic medicine it is used as a bitter tonic, to stimulate digestion and as a treatment for a wide range of conditions such as diabetes and hepatitis. It is still a common household remedy and found in more than half the combination tonics used to treat liver conditions in India. Also used to treat the common cold, it is sometimes called Indian echinacea.

BOTANICAL (Sudhakaran, M.V. 2012)

Andrographis paniculata Nees (Figure 1 and 2) is a much branched annual herb, 1–1.5 m height. Stem: sharply quadrangular. Leaves: simple, opposite, lanceolate, glabrous, 5–8 cm long, 1–2 cm wide, entire, acute, upper surface is dark green, pale beneath. Inflorescence: terminal or axillary panicle. Flowers: small, white with purplish or violet markings. Calyx: 5-partite, pubescent. Corolla: bilabiate, hairy upper lip oblong, lower lip 3-lobed. Stamens: two, inserted in the throat, ovary 2-celled. Fruit: capsule, linearoblong, two celled, compressed, longitudinally furrowed on broad faces, acute at both ends, glandular-hairy. Seeds; small, 6–10, round or ovoid, yellowish brown. Root is cylindrical, curved, tapers, 5–20 cm long and 1.5–5 cm in diameter. Externally it is grayish brown, when fractured, the inside is starchy white.

Figure. 

(1) and (2). Andrographis paniculata Herba  (123RF.com and made-in-china.com)

(3). Andrographis paniculata Flower (The plant attraction. com)

(4). Andrographis paniculata Seed (eBay.com)

OTHER COMMON NAMES (Linda, S-R. 2010)

Bidara, carmantina, chiretta, Chuan Xin Lian, creat, fat ha lai jone, Indian echinacea, kalmegh, kariyat, kirta, sadilata, vizra ufar and sambiloto.

ORIGIN (Linda, S-R. 2010)

Andrographis is found growing wild in India and Sri Lanka and is cultivated in many other parts of the world.

CHEMICAL COMPONENTS (Braun, L and Cohen, M. 2010)

The main active constituent group is considered to be the bitter diterpenoid lactones known as andrographolides. This group consists of andrographolide (AP1), 14-deoxy-11,12-didehydroandrographolide (AP3) and neoandrographolide (AP4). Other constituents include diterpenoid glucosides, diterpene dimers, flavonoids (Koteswara et al 2004, Rao et al., 2003) and xanthones (Dua et al., 2004). Clinical studies show that andrographis is well absorbed, with peak plasma concentrations reached after 1.5–2 hours and a half-life of 6.6 hours (Panossian et al., 2000).

MAIN ACTIONS (Braun, L and Cohen, M. 2010)

The mechanism of action of andrographis has not been significantly investigated in clinical studies, so results from in vitro and animal tests provide most of the evidence for this herbal medicine.

Immunomodulating

According to in vivo research, andrographis stimulates both antigen-specific and non-specific immune responses (Puri et al 1993). One of the main constituents responsible for the immunostimulant activity is andrographolide, which has an effect on the stimulation and proliferation of immunocompetent cells and the production of key cytokines and immune markers in vitro (Panossian et al., 2002). Although important, other pharmacologically active constituents are also present, as demonstrated by a study that found that the immunostimulant activity of the whole extract is greater than that of the isolated andrographolide constituent alone. Investigation with a combination of the whole extract and Eleutherococcus senticosus in the formula Kan Jang demonstrated a more profound effect. Andrographolide was found to decrease IFNgamma and IL-2 production and was therefore shown to have an immunosuppressive effect. Burgos et al., (2005) concluded that andrographis may be useful for autoimmune disease, especially where high levels of IFN-gamma are present, for example in multiple sclerosis and RA. In vitro and in vivo data has recently shown that andrographolide has the ability to interfere with T-cell proliferation, cytokine release and maturation of dendritic cells, as well as to drastically decrease the antibody response in delayed-type hypersensitivity (Iruretagoyena et al., 2005). Additionally, andrographolide demonstrated a capacity to inhibit T-cell and antibody responses in experimental autoimmune encephalomyelitis in mice, and to protect against myelin sheath damage.

Anticancer

In vitro experiments have demonstrated the possible benefits of andrographolide on various cancer cells. The compound has been shown to increase apoptosis of prostate cancer cells and human leukaemic cells and to increase cell-cycle arrest (Cheung et al., 2005, Geethangili et al., 2008, Kim et al., 2005, Zhao et al., 2008, Zhou et al., 2006). It also inhibits the proliferation of human cancer cells and increases IL-2 induction in human peripheral blood lymphocytes in vitro (Kumar et al., 2004; Rajagopal et al., 2003). In vivo results show that andrographolide increases IL-2, interferon-gamma and T-cell activity (Sheeja et al., 2007). In certain circumstances, andrographolide has been found to decrease IFN-gamma and IL-2 and may have an immunosuppressive effect (see Immunomodulating above). Andrographis and andrographolide may also inhibit angiogenesis and cancer cell adhesion (Sheeja et al., 2007, Jiang et al., 2007).

Antimicrobial

Aqueous extract of A. paniculata has demonstrated significant antibacterial and antifungal activity in vitro when compared with standard antibiotics (Singha et al., 2003). The andrographolides from andrographis have displayed antiviral activity against herpes simplex virus type 1 in vitro (Wiart et al., 2005).

Antimalarial

In vitro and in vivo studies have identified considerable antimalarial effects (Najib et al., 1999, Siti Najila et al., 2002). Administration of andrographis immediately after infection and for an additional 4 days extended the life span of mice infected with Plasmodium berghei strain ANKA (Rahman et al., 1999). Four xanthones recently isolated from A. paniculata have demonstrated antimalarial activity against Plasmodium berghei in vivo (Dua et al., 2004). Treatment with 30 mg/kg for 4 days produced a 62% decrease in parasites in infected mice.

Cardiovascular Effects

Several in vivo studies have suggested a potential role for andrographis in cardiovascular disease.

v Prevention of Atherosclerotic Arterial Stenosis and Restenosis after Angioplasty.

According to two animal studies, andrographis significantly improved atherosclerotic iliac artery stenosis induced by both de-endothelialisation and a highcholesterol diet, and reduced the re-stenosis rate after experimental angioplasty (Wang & Zhao. 1993, 1994).

v Prevention of Myocardial Reperfusion Injury and Postoperative Malignant Arrhythmias.

Using an animal model, pretreatment with intravenous andrographis significantly protected the myocardium from ischaemic reperfusion injury and eliminated malignant arrhythmia development after reperfusion, compared with controls (Guo et al., 1996). As a result of treatment, infarct size was also smaller and myocardial damage was lessened.

v Hypertension.

Andrographis produced significant dose-dependent falls in mean arterial blood pressure and heart rate when administered as an intraperitoneal infusion in one animal study (Zhang et al., 1998). This study suggests a mechanism of action involving adrenoceptors, autonomic ganglia receptors and a reduction in circulating ACE. One constituent that appears to be primarily responsible for the herb’s hypotensive effects is 14-deoxy-11,12-didehydroandrographolide (AP3) which induces relaxation of vascular smooth muscle and decreases heart rate (Yoopan et al., 2007).

v Hypoglycaemic 

Andrographis has a strong dose-dependent action on insulin production in vitro (Wibudi et al., 2008). Another in vitro study indicates that inhibition of alpha-glucosidase may contribute to the hypoglycaemic effects (Subramanian et al., 2008). A recent in vivo study in alloxan-induced diabetic rats demonstrated significantly reduced blood glucose levels as compared to placebo (Reyes et al., 2006). The authors commented that andrographis may restore impaired oestrous cycle in this model. A previous animal trial concluded that andrographolide (1.5 mg/kg) lowers plasma glucose by enhancing glucose utilisation in diabetic rats (Yu et al., 2003). Andrographis may also alter glucose absorption from the gut (Borhanuddin et al., 1994). Other in vitro data suggest that andrographolide may also lower plasma glucose by increasing glucose uptake in cultured myoblast cells via the phospholipase C/protein kinase C pathway (Hsu et al., 2004).

v Hepatoprotective 

The hepatoprotective activity of andrographis has been investigated using several different experimental rat models, in which galactosamine, paracetamol and carbon tetrachloride were given to rats to test toxicity (Handa & Sharma. 1990a & b; Rana & Avadhoot. 1991). In all models, treatment led to complete normalisation of toxin-induced increases in the levels of key biochemical parameters, and significantly reduced toxin-induced histopathological changes to the liver. Andrographolide is one of the key active constituents responsible for this activity (Handa & Sharma. 1990b; Rana & Avadhoot. 1991). Results from animal studies suggest that the hepatoprotective effect of andrographolide is at least comparable and possibly more potent than that of silymarin, from the herb St Mary’s thistle (Rana & Avadhoot. 1991, Singha et al., 2007, Visen et al., 1993). Analogous to silymarin, the activity is a result of several similar mechanisms working together. Andrographis increases liver superoxide dismutase, glutathione peroxidase, glutathione reductase and catalase concentrations, thereby increasing endogenous antioxidant production by the liver (Trivedi & Rawal, 2001; Trivedi et al., 2007; Tripathi & Kamat. 2007). A hepatocyte cell-membrane-stabilising activity has also been observed (Puri et al., 1993; Upadhyay et al., 2001).

v Digestive Stimulant/Choleretic 

Andrographolide produces a significant dosedependent increase in bile flow and in bile salt and acid production (Shukla et al., 1992).

v Antipyretic and Anti-Inflammatory 

Testing in different animal models has identified antipyretic activity (Mandal et al., 2001). Clinical testing in randomised double-blind trials involving volunteers with the common cold suggests that this activity is clinically relevant. The mechanism of action is unlike that of NSAIDs, as andrographis does not influence the biosynthesis of any lipoxygenase pathways, but may involve promoting ACTH production and enhancing adrenocortical function (Amroyan et al., 1999). A. paniculata extract completely inhibited inflammation in a carageenan model in vivo (Sheeja et al., 2006). In vitro data from the same study showed that andrographis inhibited superoxide (32%), hydroxyl radicals (80%), lipid peroxidation (80%) and nitric oxide (42.8%). These antioxidant mechanisms are likely to contribute to the herb’s antiinflammatory effect.

v Antiplatelet and Antithrombotic Activity 

Several compounds found in andrographis inhibit platelet-activating-factor-(PAF)-induced human blood platelet aggregation. These have been identified as andrographolide and AP3; more recently four flavonoids have been isolated that inhibit thrombin and PAF-induced platelet aggregation (Amroyan et al., 1999; Wu et al., 2008; Thisoda et al., 2006). Andrographolide and AP3 inhibit the extracellular signal-regulated kinase 1/2 pathway in vitro. Results from in vivo studies suggest that andrographis prevents the formation of thrombi and reduces the size of myocardial ischaemia by promoting synthesis of prostaglandin I2, inhibiting production of thromboxane A2, stimulating synthesis of cyclic AMP in platelets, and inhibiting platelet aggregation (Zhao & Fang 1990, 1991). Clinical research in humans has confirmed the observed antiplatelet effect (Zhang et al., 1994).

CLINICAL USE (Braun, L and Cohen, M. 2010)

UPPER RESPIRATORY TRACT INFECTIONS (URTI) AND THE COMMON COLD

Although sometimes investigated as a sole treatment, andrographis is also tested as part of a herbal combination known as Kan Jang. This is a standardised formula of A. paniculata extract 85 mg, containing 5.25 mg andrographolide and deoxyandrographolide per tablet, and Eleutherococcus senticosus extract 9.7 mg, containing total eleutheroside B and eleutheroside E 2% (Melchior et al 2000). Although more representative of real-life practice, results obtained with Kan Jang make it difficult to assess the individual role of andrographis.

COMMON COLD — SYMPTOM RELIEF AND REDUCED INCIDENCE

In 2004, two different systematic reviews that investigated whether andrographis is a suitable treatment in acute respiratory infections were published (Coon & Ernst 2004, Poolsup et al., 2004). The one conducted by Coon and Ernst from the Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK, was a review of seven double-blind, controlled trials (n = 896), from which the authors A concluded that A. paniculata is more effective than placebo in treating uncomplicated URTI and is associated with relatively few adverse events. They also concluded that preliminary data suggested a protective effect. In five of the seven trials, the daily dose was equivalent to 60 mg of andrographolide, which was administered for 3–8 days.

The second systematic review conducted by Poolsup et al from the Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon-Pathom, Thailand, was a review of four randomised controlled trials (n = 433); they came to a similar conclusion, finding that A. paniculata, either by itself or in combination with Eleutherococcus senticosus (Kan Jang), is effective for uncomplicated acute URTI. In 2006 another systematic review was released by the Natural Standard Research collaboration (Kligler et al., 2006). This review evaluated seven clinical trials (n = 879) that were deemed to be of acceptable quality. Once again, clinical trial evidence was found to be positive but researchers commented that most of the studies have been done in conjunction with a major manufacturer of the product and further independent testing was required. Symptoms responding Double-blind studies show that numerous symptoms respond to treatment with andrographis. According to two trials that used a dose of 340 mg andrographis taken three times daily, total symptom scores improved, with throat signs and symptoms responding most strongly (Melchior et al., 2000). A third study observed a decrease in rhinitis, sinus pain and headache compared with a placebo (Hancke et al., 1995). A fourth study using a treatment dose of 1200 mg andrographis daily found a significant reduction in tiredness and sleepiness, as well as in sore throat and nasal secretions, by day 4 (Caceres et al., 1999). A double-blind placebo-controlled study (n =185) that tested Kan Jang in the treatment of acute URTI and sinusitis showed it effectively reduced headache, nasal and throat symptoms and general malaise, but had no significant effects on cough and ocular symptoms. Additionally, fever was moderately reduced with active treatment (Gabrielian et al., 2002).

Comparisons with echinacea Although no direct head-to-head study could be located, one study was found that compared the effects of Kan Jang to a product known as Immunal (containing Echinacea purpurea [L.] extract) when both were used as adjuncts to standard treatment in children with the common cold. One hundred and thirty children were divided into three groups and received either of the combination treatments or solely standard treatment over a 10-day period (Spasov et al., 2004).

The addition of Kan Jang was shown to be significantly more effective than Immunal when started at an early stage and produced better symptomatic relief. The amounts of nasal secretion and congestion were particularly improved. With regard to altering recovery time, Kan Jang was also superior to Immunal, and children who received Kan Jang required less standard medication than in the other two groups. Additionally, Kan Jang treatment was well tolerated and no side effects or adverse reactions were reported.

Mediterranean fever  A combination of andrographolide and Eleutherococcus senticosus, Schisandra chinensis and Glycyrriza glabra inhibited neutrophil adhesion and transmigration (Shen et al., 2002) and stabilised NO and IL-6 in functional Mediterranean fever according to a randomised, double-blind trial (Panossian et al., 2003). The study involved 14 people (aged 3–15 years) with the fever and found that the herbal combination significantly reduced the frequency, severity and duration of attacks (Amaryan et al., 2003). The daily dose of andrographolide was 48 mg, divided into 3 doses for 1 month.

Cancer (in combination)  Twenty patients with various end-stage cancers were given 500 mg twice daily for 6 months. After 6 months, 16 patients were still alive with a statistically significant increase in both NK function and TNFalpha levels. Haemoglobin, haematocrit and glutathione levels were all greatly increased (See et al., 2002). Although these results are interesting, it is difficult to examine the direct effect of A. paniculata, as many other nutritional supplements were given concurrently.

Pharyngotonsillitis  One randomised double-blind study involving 152 volunteers compared the effects of paracetamol with two different doses of andrographis (3 g and 6 g) taken daily for 7 days (Thamlikitkul et al., 1991). By day 3 the symptom-relieving effects of both paracetamol treatment and high-dose A. paniculata were significant, and by day 7 andrographis was as effective as paracetamol.

Spermatogenesis  A phase 1 clinical study investigated the effects of Kan Jang (combination of andrographis and Eleutherococcus senticosus) on spermatogenesis and fertility in 14 healthy men aged between 18 and 35 years to ensure there were no ill effects (Mkrtchyan et al., 2005). The men were randomised into one of five groups to receive either Kan Jang equivalent to 60 mg andrographolide, Kan Jang equivalent to 120 mg andrographolide, Kan Jang equivalent to 180 mg andrographolide, ginseng mixture or valerian extract. They found that Kan Jang was safe if taken at the highest dose, which was three times the therapeutic dose. The researchers discovered that the mixture in fact improved semen quality by increasing the number of healthy, active sperm in the ejaculate.

OTHER USES (Braun, L and Cohen, M. 2010)

TRADITIONAL USES

The herb is traditionally given as a restorative and tonic in convalescence and used as a choleretic to stimulate bile production and flow, which improves appetite and digestion. It is often used in combination with aromatic herbs, such as peppermint, for stronger digestive effects and to prevent gastrointestinal discomfort at higher doses.

Snake bite Prolonged survival has been reported with intraperitoneal administration of andrographis before administration of cobra venom (Martz. 1992).

HIV infection  A phase 1 clinical trial involving non-medicated HIV-positive patients and healthy controls found that oral andrographolides taken for 6 weeks at increasing doses produced no significant benefits and a high incidence of adverse effects, causing the trial to be stopped prematurely (Calabrese et al., 2000).

SYNONYM (Duke, J. A et al., 2002)

Justicia paniculata Burm. f.

ACTIVITIES (Duke, J. A et al., 2002)

Abortifacient (1; KEB); Adaptogen (f; KEB); Adrenocortical Stimulant (1; KEB); Alterative (f; SKJ); Analgesic (1; MAB; WO2); Anthelmintic (1; MAB); Antiaggregant (2; KEB); Antiandrogenic (1; KEB); Antiatherosclerotic (1; MAB); Antibacterial (1; KEB); Anti-HIV (1; MAB); Antifertility (1; KEB); Antiinflammatory (2; KEB; MAB); Antiischemic (1; KEB; MAB); Antileukemic (1; MAB); Antioxidant (1; MAB); Antipyretic (2; KEB; MAB); Antiradicular (1; MAB); Antiseptic (f; WO2); Antiserotonin (2; KEB); Antispermatogenic (1; KEB); Antityphoid (1; WO2); Antiulcer (1; MAB); Bitter (2; KEB); Cholagogue (f; WO2); Choleretic (1; KEB); Contraceptive (1; KEB); Depurative (f; WO2); Fibrinolytic (1; KEB); Fungicide (1; WO2); Hepatoprotective (1; KEB; MAB); Hypoglycemic (1; KEB; MAB); Hypotensive (1; MAB); Immunostimulant (1; KEB; MAB); Phagocytotic (1; MAB); Stomachic (f; SKJ); Tonic (f; SKJ).

INDICATIONS (Duke, J. A et al., 2002)

Anorexia (F; MAB); Atherosclerosis (1; KEB; MAB); Bacteria (1; KEB; WO2); Bronchosis (f; WO2); Cachexia (f; SKJ); Cardiopathy (f; KEB); Cholera (f; WO2); Cold (1; MAB); Debility (f; WO2); Dermatosis (F; MAB); Diabetes (f; MAB; WO2); Diarrhea (1; MAB); Dog Bite (f; SKJ); Dysentery (2; KEB; MAB); Dyspepsia (f; MAB; SKJ); Enterosis (2; KEB; MAB); Escherichia (1; WO2); Fever (2; KEB; MAB); Flu (f; WO2); Fungus (1; WO2); Gonorrhea (f; WO2); Hemorrhoid (f; WO2); Hepatosis (2; KEB; MAB); High Blood Pressure (1; MAB); HIV (1; MAB); Hyperglycemia (1; KEB; MAB); Immunodepression (1;= KEB; MAB); Infection (1; KEB; WO2); Inflammation (2; KEB; MAB); Ischemia (1; MAB); Itch (f; SKJ); Jaundice (f; WO2); Leprosy (2; KEB); Leptospirosis (2; KEB); Leukemia (1; MAB); Malaria (1; KEB); Mycosis (1; WO2); Nephrosis (2; KEB); Pain (1; MAB; WO2); Pharyngosis (2; KEB; MAB); Pyelonephrosis (2; KEB); Respirosis (2; KEB; MAB); Restenosis (1; KEB); Salmonella (1; WO2); Sinusosis (2; MAB); Snakebite (2; KEB; MAB); Sore (f; SKJ); Sore Throat (2; KEB); Splenosis (f; SKJ); Stenosis (1; KEB; MAB); Swelling (f; WO2); Syphilis (f; SKJ); Tonsilosis (2; KEB; MAB); Tuberculosis (2; KEB); Ulcer (1; MAB); UTI (2; MAB); Vitiligo (f; WO2); Worm (1; KEB).

PRODUCT AVAILABILITY (Linda, S-R. 2010)

Caps, tincture

Plant Parts Used: Leaves, Aerial parts

DOSAGES (Linda, S-R. 2010)

Common Cold

• Adult PO dried extract: 400 mg tid

Preventing the Common Cold A

• Adult PO 200 mg/day _ 5 days

Fever, Sore Throat

• Adult PO 3-6 g/day

Other

• Adult PO dried aerial parts: 1.5-6 g/day

• Adult PO dried herb: 6-9 g/day as infusion

• Adult PO: 3-6 ml/day of a 1:2 liquid extract or equivalent in tablet or cap (Mills and Bone. 2005)

DOSAGES (Duke, J. A et al., 2002)

1.5–6 g dry herb/day or 3–12 ml fluid extract (1:2) (KEB).

DOSAGE RANGE (Braun, L and Cohen, M. 2010)

URTI

Prevention dose 1200–3000 mg andrographis (standardised to contain no less than 11.2 mg andrographolides) or 4–6 mL of 1:2 liquid extract, daily in divided doses, taken for at least 3 months for preventive effects to become established.

Treatment dose for infection 1200–6000 mg/day or fluid extract (1:2): up to 12 mL/day or equivalent in solid dose form.

Dyspepsia  Andrographis can be taken as a tea before meals: 5 g of herb in 1 cup of hot water, which should be allowed to stand for 10 minutes before drinking.

Toxicity  Animal tests suggest low toxicity (Mills & Bone.v2000).

DOSAGE (Khare, C. P. 2007)

Whole plant—5 - 10 ml juice; 50 - 100 ml decotion; 1 - 3 g powder. (CCRAS.)

ADVERSE REACTIONS (Braun, L and Cohen, M. 2010)

Generally well tolerated, but high doses may cause vomiting, anorexia and gastrointestinal discomfort.

One source states that urticaria is also possible  (Ernst, 2001).

SIGNIFICANT INTERACTIONS (Braun, L and Cohen, M. 2010)

Controlled studies are not available; therefore, interactions are theoretical and based on evidence of pharmacological activity with uncertain clinical significance.

Anticoagulants  Increased risk of bruising and bleeding is theoretically possible, because andrographolide and other constituents in andrographis inhibit PAF-induced platelet aggregation. However andrographis used together with warfarin did not produce any significant effects on the pharmacokinetics of warfarin, and had even less effect on its pharmacodynamics in vivo (Hovhannisyan et al., 2006). Caution should still be exercised until further research is available.

Antiplatelet drugs  Additive effects are possible, because the herb exhibits antiplatelet activity — observe the patient.

Barbiturates  Additive effects are possible, according to an animal study (Mandal et al., 2001) — observe the patient. Beneficial interaction is theoretically possible under professional supervision.

Hepatotoxic drugs (paracetamol, tricyclic antidepressants)  Hepatoprotection is possible, according to studies in various experimental models — interaction is beneficial.

Hypoglycaemic agents  Additive effects are theoretically possible — andrographis has hypoglycaemic activity comparable to that of metformin in vivo. Use together with caution; however, interaction may be beneficial.

Drugs metabolised chiefly via the cytochrome p450 system  It is currently unclear whether there is a significant interaction between andrographis and these medications, as in vivo evidence is suggestive of enzyme induction, but this observation has not yet been investigated in clinical studies (Singh et al., 2001). Recently andrographolide was shown to strongly induce the CYP 1A1 induction pathway; however, the clinical significance of this is unknown (Jaruchotikamol et al., 2007). Another in vitro study has demonstrated an inhibitive effect of andrographis extract and andrographolide on CYP3A and 2C9 pathways (Pekthong et al., 2008). It is recommended that patients be observed to ensure that drug effectiveness is not compromised.

Immunosuppressants  Reduced drug activity is theoretically possible, as immunostimulant activity has been demonstrated in vivo (Puri et al., 1993) — use caution in the immunosuppressed.

Kaalmegha, officinal in IP, consists of dried leaves and tender shoots, which yield not less than % andrographolide on dry-weight basis. Several active constituentshave been identified from the leaf and rhizome, including andrographolide, deoxyandrographolide and other diterpenes.

Andrographolide exhibited strong choleretic action when administered i.p. to rats. It induces increase in bile  flow together with change in physical properties of bile secretion. It was found to be more potent than silymarin. Andrographolide was found to be almost devoid of antihepatitis-B virus surface antigen-like activity (when compared with picroliv.) The leaf and stem extracts of Kaalmegha/andrographolide given s.c. or orally did not change blood sugar level of normal or diabetic rats. Alcoholic extract of the plant exhibited antidiarrhoeal activity against E. coli enterotoxins in animal models.

Clinical evidence of effectiveness of andrographis in humans is limited to the common cold. Preliminary evidence suggests that it might increase antibody activity and phagocytosis by macrophages, and might have mast cell-stabilizing and antiallergy activity. (Natural Medicines Comprehensive Database,...) Theherb is contraindicated in bleeding disorders, hypotension, as well as male and female sterility (exhibited infertility in laboratory animals) (Khare, C. P. 2007).

CONTRAINDICATIONS, INTERACTIONS, AND SIDE EFFECTS  (Duke, J. A et al., 2002)

CLASS 2B (abortifacient); large oral doses may cause GI distress, anorexia, and emesis (AHP; KEB). Contraindicated in pregnancy (KEB). Urticaria is a rare side effect (4%) (MAB). Andrographolides LD50 = 13,400–40,000 mg/kg orl (MAB).

CONTRAINDICATIONS AND PRECAUTIONS  (Braun, L and Cohen, M. 2010)

Suspend use of concentrated extracts 1 week before major surgery.

PREGNANCY USE

Not recommended for use in pregnancy. There is conflicting evidence about the safety of andrographis in pregnancy.

PATIENTS’ FAQs

What will this herb do for me?  Andrographis has been traditionally used to improve digestion, as a liver tonic and to fight off infection. Clinical studies confirm that it is an effective symptom reliever for the common cold, uncomplicated URTIs and pharyngotonsillitis. It has also been used to reduce the risk of developing the common cold in winter.

When will it start to work?  During an acute infection, effects may be seen within 3–4 days of starting the correct dose. Used in lower doses for prevention, effects are seen after 3 months’ continual use.

Are there any safety issues?  A Andrographis is not recommended in pregnancy and may interact with a range of pharmaceutical drugs, so advice from a health professional is required.

CONTRAINDICATIONS (Linda, S-R. 2010)

Pregnancy category 4; breastfeeding category 1A

Andrographis may be used in children. It should not be used in hypersensitivity.

Do not use in gallbladder disease, bleeding disorders, hypotension, hyperacidity, and duodenal ulcers.

SIDE EFFECTS/ADVERSE REACTIONS (Linda, S-R. 2010)

CV: Hypotension

GI: Nausea, vomiting, GI distress

Reproductive: Infertility

INTERACTIONS (Linda, S-R. 2010)

Drug

Anticoagulants, antiplatelets, antihypertensives: Andrographis may increase the effect of these drugs.

Immunosuppressants: Andrographis (long-term) may decrease the action of immunosuppressants (Mills and Bone. 2005).

CLIENT CONSIDERATIONS (Linda, S-R. 2010)

Assess

v  Assess the reason the client is using andrographis.

v  Assess for the use of anticoagulants, antiplatelets, immunosuppressants, and antihypertensives.

Caution the client that the effects of these drugs may be increased.

Administer

v  Keep andrographis in a dry area, away from direct sunlight.

Teach Client/Family

v  Inform the client that pregnancy category is 4 and breastfeeding category is 1A.

v  Inform the client that andrographis may be used in children under the supervision of a qualifi ed herbalist.

v  Teach the client that andrographis should not be used in bleeding disorders, gallbladder disease, or hypotension.

PRACTICE POINTS/PATIENT COUNSELLING (Braun, L and Cohen, M. 2010)

v  Several clinical studies suggest that andrographis, both as a stand-alone treatment and in combination with Siberian ginseng, is a useful treatment in cases of common cold, pharyngotonsillitis and uncomplicated URTIs, with significant symptom relief experienced after 3 days’ use.

v  Clinical studies are lacking, but animal experiments suggest that andrographis may be useful in cases of hepatotoxicity (paracetamol), to reduce myocardial reperfusion injury, improve blood glucose management in diabetes, and in hypertension.

v  Traditionally, the herb is used to increase bile production and relieve symptoms of dyspepsia and flatulence, loss of appetite and general debility.

v  Because of the extreme bitterness of the herb, solid-dose forms may be better tolerated than liquid preparations.

v  Andrographis is not recommended for use in pregnancy.

v  There are several theoretical drug interactions with this herb — check interaction data for more details.

REFERENCE

Braun, L and Cohen, M. 2010. Hebs and Natural Supplements An Evidence Based Guide 3R D Edition. Elsevier Australia. Australia.

Duke, J. A. with Mary Jo Bogenschutz-Godwin, Judi duCellier, Peggy-Ann K. Duke. 2002.  Handbook of Medicinal Herbs 2nd Ed. CRC Press LLC. USA.

Khare, C. P. 2007. Indian Medicinal Plants – An Illustrated Dictionary. Springer. New Delhi India.

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