Elder (Sambucus nigra L. (Caprifoliaceae))

HERBAL

MEDICINAL

PLANT

 

S A M B U C U S

ELDER  (Sambucus nigra L.) (Caprifoliaceae)

ELDERBERRY  (Sambucus canadensis L.) +++

DWARF ELDER (Sambucus ebulus L.) ++

SCARLET ELDER

(Sambucus racemosa L. subsp. pubens (Michx.) House) +

by

RETTODWIKART THENU

ELDER

Sambucus nigra L. (Caprifoliaceae)

Figure 1. Elder (Sambucus nigra).

SUMMARY AND PHARMACEUTICAL COMMENT

Phytochemical details have been documented for elder, with flavonoids and triterpenes representing the main biologically active constituents. Anti-inflammatory, antiviral and diuretic effects have been observed in in vivo studies, thus supporting the herbal uses of elder. No documented studies in humans were found. Potentially toxic compounds have been reported for the bark (lectins) and the leaves (cyanogenetic glycosides); the flowers are suitable for use as a herbal remedy.

ORIGIN

Elderberry is a shrub found in the United States and Europe.

SPECIES (FAMILY)

Sambucus nigra L. (Caprifoliaceae)

SYNONYM(S)

Black Elder, European Elder, Sambucus Sambucus canadensis L. refers to American Elder

S. nigra f. alba (Weston) Rehder, f. aurea (Sweet) Schwer., f. lanciniata (L.) Zabel, and f. pendula Dippel.

PART(S) USED

Flower and Fruit

PHARMACOPOEIAL AND OTHER MONOGRAPHS

BHC 1992(G6)

BHP 1996(G9)

BP 2007(G84)

Complete German Commission E(G3)

Martindale 35th edition(G85)

Ph Eur 2007(G81)

LEGAL CATEGORY (LICENSED PRODUCTS)

GSL(G37)

CONSTITUENTS

The following is compiled from several sources, including General References G6, G41, G62 and G75.

Flavonoids Flavonols (kaempferol, quercetin), quercetin glycosides (1.5–3.0%) including hyperoside, isoquercitrin and rutin.

Triterpenes a- and b-amyrin, oleanolic and ursolic acids.

Volatile oils 0.3%. 66% fatty acids (primarily linoleic, linolenic and palmitic) and 7% alkanes (C19, C21, C23 and C25). Numerous other constituent types have been identified including ethers and oxides, ketones, aldehydes, alcohols and esters.(1)

Other constituents Chlorogenic acid, tannin, mucilage, plastocynin (protein),(2) pectin and sugar. Other plant parts Leaf Sambunigrin (0.042%), prunasin, zierin and holocalin (cyanogenetic glycosides),(3) choline, flavonoids (rutin, quercetin), sterols (sitosterol, stigmasterol, campesterol), triterpenes (a- and b-amyrin palmitates, oleanolic and ursolic acids), alkanes, fatty acids, tannins and others.(G41) Bark Lectin (mol. wt 140 000) rich in asparagine/aspartic acid, glutamine/glutamic acid, valine and leucine,(4) phytohaemagglutinin,( 5) triterpenoids (a-amyrenone, a-amyrin, betulin, oleanolic acid, b-sito sterol).(6)

FOOD USE

Elder is listed by the Council of Europe as a source of natural food flavouring (categories N1 and N2). Category N1 refers to the fruit and indicates that there are no restrictions on quantities used. Category N2 refers to the restrictions on the concentrations of hydrocyanic acid that are permitted, namely 1 mg/kg in beverages and foods, 1 mg/kg for every per cent proof of alcoholic beverages, 5 mg/kg in stone fruit juices, 25 mg/kg in confectionery and 50 mg/ kg in marzipan.(G16) Previously, the flowers have had a regulatory status of GRAS (Generally Recognised As Safe).(G41)

Figure 2. Elder – dried drug substance (flower).

HERBAL USE

Elder is stated to possess diaphoretic and anticatarrhal properties. Traditionally, it has been used for influenza, colds, chronic nasal catarrh with deafness and sinusitis.(G8) Elder is also stated to act as a diuretic, laxative and local anti-inflammatory agent.(G2, G6– 8, G41,G49, G64)

Uses

Elderberry is used as a gargle for rhinitis, colds, flu in combination with sage, honey, and vinegar. It is also used as a treatment for diaphoresis, toothache, headache, sinusitis, hay fever, wounds, skin disorders, hepatic conditions, and infl ammation.

Investigational Uses

Elderberry may be used orally for infl uenza. It is being studied as an antidiabetes agent.

DOSAGE

Dosages for oral administration (adults) for traditional uses recommended in standard herbal reference texts are given below.

·         Dried flower 2–4 g by infusion three times daily.(G6,G7)

·         Liquid extract 2–4mL (1 : 1 in 25% alcohol) three times daily.(G6, G7)

·         Adult PO: use only cooked berries; bark and leaves are poisonous

·         Adult topical: apply ointment to affected area prn

·         Child PO syrup: 1-2 tsp up to tid (Romm, 2000)

·         Child PO tea: 1⁄2-1 cup up to qid; serve hot (Romm, 2000)

·         Child PO tincture: 1⁄2-1 tsp up to qid (Romm, 2000) 

·         2 tsp flowers/cup water several ×/day (APA); 2–4 g dry flower (PNC); 2–5 g dry flower as tea 3 ×/day (CAN; SKY); 2–4 ml liquid flower extract (1:1 in 25% ethanol) 3 ×/day (CAN);

·         5–15 g fluid (KOM; MAD); 1.5–3 g fluid extract (KOM); 2.5–7.5 g tincture (KOM); 2–10 ml liquid extract 1–2 ×/day (PNC; SKY).

GENERAL GUIDE

Flowers

·         Tea: 10–15 g flowers/day.

·         Liquid extract: 2–6 mL of 1:2 extract/day.

Berries

·         Elderberry syrup: usually contains 30–38% elderberry; dose at 15 mL, 3 times daily (Sambucus nigra (elderberry) 2005).

·         Powdered extracts: often available in 500 mg capsules, dose 2–3 times daily (Sambucus nigra (elderberry)

2005).

ACCORDING TO CLINICAL STUDIES

·         Influenza: 15 mL of the syrup, 4 times daily.

DOSAGE AND DURATION OF USE

·         Tea: Steep 2 teaspoons (3–4 g) of elder flower in 150 mL of boiled water for 5 minutes.

• Dosage: One to two cups of the tea, as hot as possible, several times a day (especially in the second half of the day).

·         Daily dose: 10–15 g drug.

·         Fruit and syrups: Infuse 1 teaspoon in 1 cup of freshly boiled water for 30 minutes, and drink 1 cup 2 or 3 times daily. For syrups, 2 to 3 teaspoons daily.

PHARMACOLOGICAL ACTIONS

IN VITRO AND ANIMAL STUDIES

Elder is stated to possess diuretic and laxative properties.(G41) Moderate (27%) anti-inflammatory action in carrageenaninduced rat paw oedema has been documented for an elder preparation given one hour before carrageenan (100 mg/kg, by mouth).(7) Indometacin as a control exhibited 45% inhibition at a dose of 5 mg/kg.(7) An infusion made from the flowers of elder, St John's wort herb and root of soapwort (Saponaria officinalis) has exhibited antiviral activity against influenza types A and B (in vivo and in vitro) and herpes simplex virus type 1 (in vitro).(8) A diuretic effect in rats exceeding that exerted by theophylline has been reported for elder.(9) An infusion and extracts rich in potassium and in flavonoids all caused diuresis. Greatest activity was exerted by the combined potassium- and flavonoid-rich extracts. In vitro antispasmodic activity (rat ileum, rabbit/guinea-pig intestine) and spasmogenic activity (rat uterus) have been reported for lectins isolated from elder.(10) A lectin isolated from elder bark was found to be a lactosespecific haemagglutinin with a slightly higher affinity for erythrocytes from blood group A.(4) Unlike many other plant lectins, the lectin did not inhibit protein synthesis.(4) The carbohydrate-binding properties of a lectin isolated from elder ba rk have been studied.(11) Phytohaemagglutinins are biologically active extracts isolated from various plants and represent a class of lectin. They are associated with haemagglutination and mitogenic, antigenic and immunosuppressant properties.(5) In vitro, phytohaemagglutinin has been found to stimulate production of an interferon-like substance in human leukocytes.(G45) Hepatoprotective activity against carbon tetrachloride-induced toxicity has been reported for triterpenes isolated from Sambucus formosana Nakai.(12)

CLINICAL STUDIES

There is a lack of clinical research assessing the effects of elder and rigorous randomised controlled clinical trials are required. Phytohaemagglutinin extracts have been used clinically to treat drug-induced leucopenia and some types of anaemia.(5) The blastogenic response of lymphocytes to phytohaemagglutinin has been used extensively as a measure of immunocompetence.(G45)

ACTIONS (Linda, S-R. 2010)

Initial research on elderberry has identifi ed antioxidant, insulin-like, and diuretic actions for this herb. However, multiple studies to confi rm these actions are not yet available.

Antioxidant Action

One study provides information on the antioxidant properties of elderberry, which result from the anthocyanins present in elderberry fl avonoids. These anthocyanins are responsible for scavenging in the bloodstream and the colon. Other chemical components, aglycons and glycosides, also provide antioxidant protection (Pool- Zobel et al, 1999).

Insulin-Like Action

Because elderberry has been used as a traditional treatment for diabetes mellitus, the insulin-like action of this herb has been studied. In one study, the insulin-releasing and insulin-like activity of Sambucus nigra produced a cumulative effect (Gray et al, 2000).

Diuretic Action

One study identifi ed the diuretic activity of elderberry in rats. Rats treated with the herb experienced increased urine fl ow and sodium excretion (Beaux et al, 1999).

INDICATIONS

Arthrosis (f; APA; MAD); Asthma (f; SKJ); Boil (f; FAD); Bronchosis (2; MAD; PHR; PH2); Bruise (f; FAD); Burn (f; CEB); Cancer (f; CEB); Cancer, breast (f; JLH); Cancer, liver (f; JLH); Cancer, prepuce (f; JLH); Cancer, skin (f; JLH); Cancer, spleen (f; JLH); Cancer, stomach (f; JLH); Cancer, uterus (f; JLH); Catarrh (1; BGB; MAD; SHT); Chill (f; APA); Cold (2; APA; KOM; PH2; PNC; WAM); Condyloma (f; JLH); Constipation (1; APA; EFS; HH2); Cough (2; PHR; PH2); Cramp (f; MAD); Dermatosis (f; CEB; JLH); Dropsy (f; MAD); Dyslactea (f; HH2); Dyspnea (1; HH2; PHR; PH2); Eczema (f; FAD); Edema (f; JLH; MAD; PHR); Epilepsy (f; FEL; MAD); Erysipelas (f; CEB); Exanthema (f; MAD); Fever (2; APA; BGB; EFS; MAD; PHR; PH2; PIP; WAM); Flu (1; AKT; APA; BGB; PH2; PNC; WAM); Gas (f; FAD); Gastrosis (f; JLH); Gout (f; SKJ); Headache (f; FAD); Head Cold (1; PHR; PH2); Hepatosis (f; JLH; MAD); Herpes (1; SKY); Hoarseness (f; MAD); Induration (f; JLH); Inflammation (1; AKT; APA; BGB; PHR; PH2; PNC; SKY); Influenza (1; SHT); Ischiosis (f; MAD); Laryngosis (f; MAD; PHR; PH2); Myalgia (f; MAD); Neuralgia (f; MAD; SKJ); Neurosis (f; HH2); Nightmare (f; MAD); Nipple (f; CEB); Obesity (f; APA; CEB); Otosis (f; MAD); Pain (f; FAD; MAD); Pneumonia (f; MAD); Pulmonosis (f; MAD); Respirosis (1; AKT; PH2); Rheumatism (f; APA; MAD; SKJ); Scabies (f; MAD); Scarlet Fever (f; MAD); Sclerosis (f; JLH); Scrofula (f; MAD); Sinusosis (1; AKT; SHT); Sore (f; FAD); Sore Throat (1; AKT; CEB; SKY); Splenosis (f; JLH; MAD); Stomatosis (f; CEB); Swelling (f; FAD; PH2); Toothache (f; MAD); Uterosis (f; JLH); Virus (1; AKT; BGB; SHT; WAM); Wart (f; JLH); Water Retention (1; APA; BGB; MAD; PNC; PH2); Wen (f; JLH); Worm (f; CEB).

SIDE-EFFECTS, TOXICITY

No reported side-effects specifically for elder were located.

However, there is a lack of clinical safety and toxicity data for elder and further investigation of these aspects is required. Human poisoning has occurred with Sambucus species.(13) The roots, stems and leaves and, much less so, the flowers and unripe berries, are stated to contain a poisonous alkaloid and cyanogenic glycoside causing nausea, vomiting and diarrhoea.(13) The flowers and ripe fruit are stated to be edible without harm.(13) The effects of a lectin isolated from elder bark on mammalian embryonic and fetal development has been studied.(5) The lectin exerted mainly a toxic effect and, to a lesser degree, a teratogenic effect when administered subcutaneously to pregnant mice. In view of the high doses administered, the authors stated that the results did not indicate a potential hazard to human fetuses exposed to lectins.(5)

CONTRA-INDICATIONS, WARNINGS

Plant parts other than the flowers are reported to be poisonous and should not be ingested. There is limited evidence from preclinical studies that elder has a diuretic effect; the clinical relevance of this, if any, is unclear.

Drug interactions None documented. However, the potential for preparations of elder to interact with other medicines administered concurrently, particularly those with similar or opposing effects, should be considered.

Pregnancy and lactation The safety of elder taken during pregnancy has not been established. In view of the lack of toxicity data, the use of elder during pregnancy and lactation should be avoided.

CONTRAINDICATIONS

Class 1 herb (ripe fruit/fl owers).

Until more research is available, elderberry should not be used during pregnancy and breastfeeding. Elderberry should not be used by persons with hypersensitivity to this plant or similar plants. Elderberry bark and leaves are toxic; use only the parts of the plant that are recommended.

SIDE EFFECTS/ADVERSE REACTIONS

GI: Nausea, vomiting, anorexia, diarrhea

INTEG: Hypersensitivity reactions

SYST: Cyanide toxicity (bark, leaves, unripe berries)

INTERACTIONS

Drug

Iron salts: Elderberry tea may prevent absorption of iron salts; do not give concomitantly; space by at least 2 hours.

PREPARATIONS

PROPRIETARY SINGLE-INGREDIENT PREPARATIONS

Czech Republic: Caj z Kvetu Bezu Cerneho; Kvet Bazy Ciernej. Russia: Novo-Passit (Ново-Пассит).

PROPRIETARY MULTI-INGREDIENT PREPARATIONS

Australia: Sambucus Complex. Austria: Entschlackender Abfuhrtee EF-EM-ES; Grippetee St Severin; Krauter Hustensaft; Laxalpin; Sinupret; Tuscalman. Canada: Original Herb Cough Drops. Czech Republic: Biotussil; Cajova Smes pri Nachlazeni; Detsky Caj s Hermankem; Erkaltungstee; Novo- Passit; Perospir; Pulmoran; Reduktan; Sinupret; Species Urologicae Planta; Urcyston Planta. Germany: Sinupret; Solvopret. Hong Kong: Sinupret. Hungary: Sinupret. Russia: Sinupret (Синупрет). Singapore: Sinupret. Spain: Natusor Gripotul; Natusor Sinulan. Switzerland: Sinupret; Tisane contre les refroidissements. Thailand: Sinupret. UK: Cleansing Herbs; EP&C Essence; Hay Fever & Sinus Relief; Hayfever & Sinus Relief; Herb and Honey Cough Elixir; Life Drops; Lion Cleansing Herbs; Lustys Herbalene; Modern Herbals Cold & Catarrh; Sinotar; Summertime Tea Blend; Tabritis; Tabritis Tablets. USA: Liquid Elderberry with Ester-C.

REFERENCE

Barnes, J., Anderson, L. A., and Phillipson, J. D. 2007. Herbal Medicines Third Edition. Pharmaceutical Press. Auckland and London. 

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.

Kraft, K and Hobbs, C. 2004 . Pocket Guide to Herbal Medicine. Thieme. Stuttgart New York.

Linda S-Roth. 2010. Mosby’s Handbook Of Herbs & Natural Supplements, Fourth Edition. Mosby Elsevier. USA.

ELDERBERRY

(Sambucus canadensis L.) +++

ACTIVITIES (ELDERBERRY) —

Alterative (f; CRC); Analgesic (f; CRC); Antiinflammatory (1; JNU); Antipyretic (f; CRC); Antiseptic (1; DEM; FNF); Antiviral (1; JNU; WAM); Aperient (f; CRC); Bronchostimulant (PIP); Carminative (f; CRC; FAD); Cyanogenic (f; CRC); Depurative (f; CRC; DEM); Diaphoretic (1; CRC; FAD; PIP; WAM); Diuretic (f; CRC; FAD); Emetic (f; CRC; FAD); Hemostat (f; FAD); Hydragogue (f; CRC); Intoxicant (f; CRC); Laxative (f; CRC; DEM; FAD); Poison (f; CRC); Secretagogue (f; FEL); Sedative (f; CEB); Stimulant (f; CRC; FAD); Vulnerary (f; CRC).

INDICATIONS (ELDERBERRY) —

Abrasion (f; CRC); Ague (f; CEB); Asthma (f; CRC); Bleeding (f; FAD); Boil (f; DEM; FAD); Bronchosis (f; CRC); Bruise (f; CRC; FAD); Burn (f; CEB; CRC; FEL); Cancer (f; CRC; JLH); Cancer, breast (f; JLH); Cardiopathy (1; JNU); Catarrh (f; FEL); Chafing (f; CRC); Childbirth (f; CEB; CRC); Chill (f; CEB); Cold (1; CRC; FAD; WAM); Colic (f; CEB; DEM); Constipation (f; CRC; DEM; FAD); Cough (f; CRC); Dermatosis (f; CEB; FAD; FEL); Diphtheria (f; DEM); Dropsy (f; CRC; DEM; FEL); Dyspepsia (f; CRC); Eczema (f; FAD; FEL); Edema (f; FEL); Epilepsy (f; CRC); Erysipelas (f; CEB; FEL); Exanthema (f; FEL); Fever (1; CRC; DEM; FAD; PIP; WAM); Flu (1; JAD; JNU; WAM); Gas (f; CRC; FAD); Gastrosis (f; DEM); Gonorrhea (f; DEM); Gout (f; CRC); Headache (f; CRC; DEM); Hepatosis (f; CEB; DEM); Herpes (1; JNU); Induration (f; JLH); Infection (f; DEM); Inflammation (1; CEB; JNU); Insomnia (f; CEB); Mastosis (f; DEM; JLH); Measles (f; DEM); Migraine (f; CEB); Myalgia (f; CEB); Nervousness (f; CEB); Neuralgia (f; CEB; CRC); Neurosis (f; DEM); Pain (f; CEB; CRC; DEM); Psoriasis (f; CRC); Rheumatism (f; CEB; CRC; FEL); Rhinosis (f; FEL); Scarlatina (f; FEL); Scrofula (f; FEL); Sore (f; CEB; CRC; FAD); Sore Throat (f; CRC); Sprain (f; CRC); Stomachache (f; DEM); Stress (1; JNU); Stroke (1; JNU); Swelling (f; CRC; DEM); Syphilis (f; CRC; FEL); Toothache (f; CEB; CRC); VD (f; DEM; FEL); Virus (1; JNU; WAM); Water Retention (f; CRC; FAD); Wound (f; DEM; FAD).

DOSAGES (ELDERBERRY) —

2–10 g dry fruit; 2–3 (485 mg) capsules 2–3 ×/day; 1 (485 mg) StX capsule 3 ×/day; 10–15 g flower (PIP); 2–4 g dry flower PNC.

CONTRAINDICATIONS, INTERACTIONS, AND SIDE EFFECTS (ELDERBERRY) —

Class 1 (AHP). Parts of the plant may contain dangerous levels of HCN. Several cases of severe poisoning from several glasse of juice involved dizziness, nausea, numbness, stupor, vomiting, and weakness (LRNP, July 1992). Seeds somewhat toxic (WAM). Eat raw berries sparingly, or cook to reduce HCN content (WAM). Don’t eat red elderberries (WAM).

DWARF ELDER

(Sambucus ebulus L.) ++

ACTIVITIES (DWARF ELDER)

Antipyretic (f; DEP); Diaphoretic (f; EFS; HHB); Diuretic (1; EFS; HHB; PH2; PNC); Expectorant (1; EFS; MAD; PNC); Hypotensive (1; HH2; PNC); Laxative (f; DEP; EFS; HHB; SKJ); Poison (f; EFS; HHB); Tonic (f; DEP).

INDICATIONS (DWARF ELDER)

 Angina (f; MAD); Appendicitis (f; MAD); Arthrosis (f; JLH); Ascites (f; MAD); Asthma (f; DEP); Bruise (f; KAB); Cancer (f; JLH); Cancer, flesh (f; JLH); Cancer, joint (f; JLH); Cancer, kidney (f; JLH); Cancer, skin (f; JLH); Cancer, thigh (f; JLH); Cancer, uterus (f; JLH); Constipation (f; EFS; HHB; PH2); Cough (f; MAD); Cystosis (f; MAD); Dermatosis (f; DEP; JLH); Dropsy (f; DEP; MAD; SKJ); Edema (f; PH2); Erysipelas (f; DEP); Fever (f; DEP; EFS; HHB); Gout (f; MAD); Gravel (f; MAD); High Blood Pressure (1; HH2; PNC); Hoarseness (f; MAD); Kernel (f; JLH); Malaria (f; DEP); Nephrosis (f; MAD; PH2); Obesity (f; MAD; PH2); Pulmonosis (f; DEP); Rheumatism (f; DEP; PH2); Scirrhus (f; JLH); Splenosis (f; MAD); Swelling (f; JLH; KAB; MAD); Uterosis (f; JLH); Water Retention (1; EFS; HHB; PH2; PNC).

DOSAGES (DWARF ELDER)

2.5 g root/cup water (HHB).

CONTRAINDICATIONS, INDICATIONS, AND SIDE EFFECTS (DWARF ELDER)

Not covered (AHP).“Hazards and/or side effects not recorded for proper therapeutic dosages” (PH2) (but PH2 designates no specific quantified dosage! JAD). Symptoms of poisoning: bloody diarrhea, coma, cyanosis, dizziness, headache, hematchezia, mydriasis, nausea, oral pain, or vomiting (HHB; MAD; PH2). “Cases of death are also mentioned” (PH2). Saponin diuretic (HHB). Aqueous extracts hypotensive (ipr rat) (HH2).

SCARLET ELDER

(Sambucus racemosa L. subsp. pubens (Michx.) House) +

SYNONYMS:

S. pubens Michx., S. pubens f. xanthocarpa (Cockerell) Fernald, S. pubescens Pers., S. racemosa f. xanthocarpa Cockerell.

ACTIVITIES (SCARLET ELDER)

Diaphoretic (f; HHB); Diuretic (1; HHB); Emetic (f; HHB); Laxative (f; HHB); Poison (1; HHB).

INDICATIONS (SCARLET ELDER)

Abscess (f; DEM); Alactea (f; DEM); Arthrosis (f; DEM); Boil (f; DEM); Bruise (f; DEM); Childbirth (f; DEM); Cold (f; DEM; HHB); Constipation (f; DEM; HHB); Cough (f; DEM); Cramp (f; HHB); Cystosis (f; HHB); Dermatosis (f; DEM); Diarrhea (f; DEM); Dysentery (f; DEM); Dyspnea (f; DEM); Erysipelas (f; DEM); Fever (f; HHB); Foot Ache (f; DEM); Gastrosis (f; DEM); Infection (f; DEM); Leg Ache (f; DEM); Myalgia (f; DEM); Nephrosis (f; DEM); Neurosis (f; DEM); Pain (f; DEM); Rheumatism (f; DEM); Sore (f; DEM); Stomachache (f; DEM); Swelling (f; DEM); Toothache (f; DEM); Tuberculosis (f; DEM); Water Retention (1; HHB); Wound (f; DEM).

DOSAGES (SCARLET ELDER)

Dosage not seen. Probably comparable to other species, except fruit often considered poisonous.

CONTRAINDICATIONS, INTERACTIONS, AND SIDE EFFECTS (SCARLET ELDER)

Not covered (AHP; KOM; PH2). Probably has same symptoms as reported from overdoses of S. ebulus. Symptoms with S. ebulus include bloody diarrhea, coma, cyanosis, dizziness, headache, hematochezia, mydriasis, nausea, oral pain, and vomiting (HHB; MAD; PH2).

REFERENCE

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.