Volume 7-2.new

Larch and Echinacea Original Research
Immunological Activity of Larch
Arabinogalactan and Echinacea: A
Preliminary, Randomized, Double-blind,
Placebo-controlled Trial
Linda S. Kim, ND, Robert F. Waters, PhD,
and Peter M. Burkholder, MD
Abstract
complement properdin may be an indication
OBJECTIVE: The immunomodulating effects of
of one aspect of immune system stimulation
two Echinacea species, E. purpurea and E.
in patients treated with either E. purpurea/E.
angustifolia and larch arabinogalactan
angustifolia or E. purpurea/E. angustifolia plus
extracted from Larix occidentalis were
larch arabinogalactan.
examined in a randomized, double-blind,
(Altern Med Rev 2002;7(2):138-149)
placebo-controlled, prospective four-week
clinical trial at a naturopathic medical school
Introduction
research center. SUBJECTS/MATERIALS:
Both Echinacea purpurea and Echinacea Forty-eight healthy female volunteers (22-51 y)
angustifolia appear to activate non-specific cellu- were randomly assigned to one of six groups:
lar and humoral immunity and the complement standardized extract of E. purpurea (EP); ultra-
system.1-5 Both of these species stimulate the im- refined E. purpurea/E. angustifolia (urEPA); E.
mune system by increasing the production and purpurea/E. angustifolia (EPA); E. purpurea/E.
activity of leukocytes, lymphocytes, and mono- angustifolia plus larch arabinogalactan
cytes, as well as cytokines.6-11 E. purpurea and E. (EPALA); larch arabinogalactan (LA); or
angustifolia have been shown to enhance the im- placebo. METHODS: Immunological tests with
mune system in both animal models and clinical enumerative measurements, stool cultures for
Lactobacillus acidophilus and yeast, and
health-related quality of life (HRQoL) using the
Medical Outcomes Study derived SF-36 self-
Linda S. Kim, ND – Medical Director of Southwest CollegeResearch Institute, the research division of Southwest administered questionnaire were assessed at
College of Naturopathic Medicine & Health Sciences; baseline and at four weeks. RESULTS:
member of the Institutional Review Board, ResearchAdvisory Board and Assistant Professor in the Research Complement properdin increased by 21
percent in the EPA group (p<0.05) and by 18
Correspondence address: 2140 E. Broadway Road, Tempe,AZ 85282. E-mail: l.kim@scnm.edu percent in the EPALA group (p<0.05), compared
to the placebo group (p>0.05). SF-36 showed
Peter M. Burkholder, MD – Professor Emeritus, Departmentof Basic Sciences at Southwest College of Naturopathic improvements in overall physical health,
Medicine & Health Sciences; clinical professor of vitality, and emotional health in the same two
pathology at the University of Arizona MedicalSchool,Tucson, Arizona; and consults on a National groups (EPA and EPALA). DISCUSSION:
Institutes of Health study section for Complementary and Volunteers in the EPA and EPALA groups had
increased production of complement properdin
Robert F. Waters, PhD – Chair of Department of Research, after four weeks of intervention. The increased
Southwest College of Naturopathic Medicine & HealthSciences; doctorate in genetics with graduate minors inbiochemistry and statistics.
Page 138 Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002
Copyright2002 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission Original Research Larch and Echinacea
trials.12-16 The enhanced immune function and pha- IL-1β, and IL-6.40-45 Larch arabinogalactans are a gocytic activities have been documented with natu- class of long, densely branched high-molecular ral killer (NK) cells, macrophages, and neutrophils of the reticuloendothelial system. Cytokine pro- daltons).46 High-grade arabinogalactan extracted ductions of gamma-interferon (IFN-γ), tumor ne- form Larix occidentalis is composed of 90-98 per- crosis factor-alpha (TNF-α), interleukin-1 beta cent arabinogalactan, and experimental analysis (IL-1β), and interleukin-6 (IL-6) are some of the has determined larch arabinogalactan to be a immune modulators released and stimulated by highly branched molecule of 3,6-beta-D-galac- E. purpurea and E. angustifolia.17-20 In clinical tan.46,47 There are numerous patents identified in studies, Echinacea reduced symptoms of common product development using larch arabinogalactan.
cold, influenza, and acute respiratory infections.21- According to the Generally Recognized as Safe 24 Randomized controlled trials demonstrate sig- (GRAS) Notice No. GRN 000047 (FDA, Center nificant reduction in cold symptoms, increased for Food Safety & Applied Nutrition, Office of length of time between infections, and more rapid Premarket Approval), functional properties of resolution of viral infections.21-23 There have been larch arabinogalactan permit its use as a film- studies that did not find statistically significant former, foam adhesive, additive, thickener, bulk- improvement in treating the common cold with ing agent, emulsifier, and as a therapeutic agent.
Echinacea.25 In general, however, extensive stud- Based on food grade status and numerous studies ies support the immune-stimulating, antitumor, supporting the safety of larch arabinogalactan, it and anti-inflammatory activities of Echinacea.26- is considered to be extremely safe with minimum 30 Echinacea is generally considered to be safe with no significant toxicity or adverse effects.31,32 bination of Echinacea and larch arabinogalactan polysaccharides, echinacin, echinacoside, fla- have been reported.48 Healthy donor blood treated vonoids, caffeic acid derivatives, essential oils, with a combination of larch arabinogalactan, E. polyacetylenes, alkylamides, and assorted other purpurea, and E. angustifolia in 24-hour incuba- chemicals. E. angustifolia and E. purpurea are the tion showed significant increase in macrophage most widely used and extensively studied for their cell density, and the greatest immune cell stimu- active components in analytical chemistry and lation and proliferation when compared to single clinical application. However, due to the various agent vitamins and minerals. The same study extraction processes (alcohol, glycerin, standard- showed the combination Echinacea and larch ized extracts, whole plant extracts) and delivery arabinogalactan had a greater immune-enhancing methods (capsule, tablet, tincture, tea) currently effect than the individual effects of either available, and the various parts of the Echinacea Echinacea or larch arabinogalactan alone.
plant with unknown pharmacodynamics and phar-macokinetics (leaf, stem, flower, root, and their Objectives
respective biologically active/marker compo- In this study, the immune-stimulating ef- nents), it is difficult to determine what form of fects of combination Echinacea and larch the botanical is the most effective, safe, and valu- arabinogalactan observed in previous in vitro stud- ies using healthy donor blood samples were tested in healthy volunteers. A randomized, double-blind, occidentalis was shown to increase circulating placebo-controlled trial was conducted to address peripheral blood monocytes.40 Tumor cells pre- the following: (1) to compare the combination treated with larch arabinogalactan enhanced NK therapy to monotherapies of Echinacea and larch cell cytotoxicity and phagocytic capacities of arabinogalactan; (2) to assess immunological out- macrophages and lymphocytes, and increased re- comes following a treatment period of four weeks; lease of various cytokines, such as IFN-γ, TNF-α, and (3) to assess quality of life outcomes of the Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002 Page 139
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intervention. In this report, the immunomodulating recruited with newspaper advertisements and effects of different E. purpurea whole herb and E. posted announcements. A potential 128 female participants were interviewed in a preliminary arabinogalactan 90-percent concentration ex- screening; of these, 48 were selected to partici- tracted from Larix occidentalis, and combination pate and randomly assigned to one of six groups.
Echinacea and larch arabinogalactan are presented.
Only females were included in the study to re-duce variability of both outcomes and analysis of Subjects
results. Subjects with major illness (cancer, dia- Subject Population
betes, or cardiovascular or autoimmune/immunediseases), acute illness at enrollment and during The clinical trial was approved by the In- study period (upper respiratory tract infections, stitutional Review Board (Human Subject Protec- sinusitis, and other acute infections), or subjects tion Review Committee) of Southwest College of taking any known immune-enhancing or altering Naturopathic Medicine & Health Sciences. Sub- supplements or medication were excluded from jects were selected according to the study inclu- the study. All subjects were followed at Southwest sion and exclusion criteria (Table 1). Subjects were Naturopathic Medical Center inScottsdale, Arizona. Each subject pro-vided written, informed consent to par- Table 1. Clinical and Demographic Data of Subjects
ticipate, and were informed of possiblerare transient reactions from takingherbal supplements, such as nausea and CHARACTERISTIC
OF SUBJECTS
Evaluation of Subjects
tal signs were recorded at the beginningof the study. Subjects were interviewed Race or ethnic group
Hispanic
verse effects or changes in health or daily activities. Lifestyle changes inconsistent Non-smoker
Healthy*
No major illness
No acute illness
take, recreational drug or new prescrip-tion/non-prescription drug use, strenu- ous exercise, diet changes, and inclusion therapies that could affect the immunesystem.
*Major illness: cancer, diabetes,
cardiovascular, autoimmune/immune
Materials
diseases. Acute illness at enrollment and
Intervention Plan
during study period: upper respiratory
tract infections, sinusitis, and other acute
infections.
four weeks, two capsules in the morn-ing and at bedtime. There were six Page 140 Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002
Copyright2002 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission Original Research Larch and Echinacea
Table 2. Dose Description
INTERVENTION THERAPY
E. purpurea whole herb extract 4% phenols
1500 mg/d
E. purpurea whole herb extract 4% phenols 780 mg/d
Ultra refined E. purpurea whole herb and
E. angustifolia root
E. purpurea whole herb extract 4% phenols 908 mg/d
E. purpurea whole herb 464 mg/d
E. angustifolia root
E. purpurea whole herb extract 4% phenols 908 mg/d
E. purpurea whole herb
E. angustifolia root
Larch arabinogalactan 90% 1500 mg/d
Larch arabinogalactan 90%
1500 mg/d
Alfalfa and rice
1500 mg/d
groups in the study (Table 2): (1) E. purpurea and excessive alcohol (Table 3). All capsules were whole herb extract (4% phenols; 1.5 g/day) (EP); indistinguishable in size, color, and taste. Celes- (2) E. purpurea whole herb extract (4% phenols; tial Seasonings, Inc. and Larex, Inc. provided the 780 mg/day), ultra-refined E. purpurea whole investigational supplements and placebo for the herb, and E. angustifolia root (680 mg/day) (urEPA); (3) E. purpurea whole herb extract (4%phenols; 908 mg/day), E. purpurea whole herb Intervention Analytical Chemistry
(464 mg/day), and E. angustifolia root (36 mg/ The E. purpurea whole herb extract (4% day) (EPA); (4) E. purpurea whole herb extract phenols), E. purpurea whole herb, E. angustifolia (4% phenols; 908 mg/day), E. purpurea whole root, and larch arabinogalactan used in the study herb (464 mg/day), E. angustifolia root 36 mg/ were extracted from the same lot numbers. The day, and larch arabinogalactan (90%; 1.5 g/day) active components of the Echinacea preparations (EPALA); (5) larch arabinogalactan (90%; 1.5 g/ were analyzed for percent phenols and microbial day) (LA); or (6) placebo (alfalfa and rice flour; characteristics by Nutritional Laboratories Inter- 1.5 g/day). Subjects were compliant and followed national (Lolo, MT). Microbial analysis showed study instructions during the four weeks, avoid- the herbal preparations were negative for E. coli ing new alternative therapies, dietary supplements, Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002 Page 141
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Table 3. Subject Compliance
Lactobacillus acidophilusand stool fungus culture STUDY REQUIREMENTS
OF SUBJECTS
ing units per gram (cfu/g).
Culture medium selective No new physical therapies during study*
Alcohol < 3 drinks per week during study
Compliance to dosage and pill-taking 100%
No new supplements during study†
ratory (Phoenix, AZ) andSpecialty Laboratory *Physical therapies including acupuncture, chiropractic, and
other musculoskeletal/connective tissue therapies.
†Supplements including nutritional, herbal, and other
complementary/alternative therapies.
ing on HRQoL was as-sessed using the standardSF-36 and Symptoms Spe- cific Assessment (SSA) derived from Medical Out- Criteria for Response
comes Study (MOS), including gastrointestinal The effects of the investigational supple- function, sleep pattern, and mood.49-52 These in- ments on the subjects’ health and immune func- struments were self-administered by subjects at tion were assessed with immunological tests and baseline and at four weeks. The SSA was devel- subjective reporting on quality of life. Vital signs oped by the investigators to specifically address were measured (blood pressure, radial pulse, res- quality of life effects with respect to gastrointesti- piration rate, and temperature), and blood and stool nal function, sleep pattern, and mood. The SF-36 samples were collected at baseline and at four was chosen for its multi-dimensionality, brevity, and previous successful application in a variety of diseases. Reponses to the 36 items on SF-36 measurements included: total white blood cell assess a number of HRQoL domains, ranging from (WBC), neutrophils, lymphocytes, monocytes; NK predominantly social and emotional well-being to cell quantitative; complement properdin (CP); overall mental and physical health and vitality.
TNF-α; Epstein-Barr Virus viral capsid antigenIgG antibody (EBV VCA IgG Ab); cytomegalovi-rus IgG antibody (CMV IgG Ab); and aerobic Page 142 Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002
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Table 4. Mean Complement Properdin and TNF-a and their P values
COMPLEMENT PROPERDIN TNF-α
BASELINE
BASELINE
Plus-minus values are means +SD. NS denotes no significance.
P values by two-tailed Student's t-test.
Statistical Analysis
groups and the placebo group were compared be- The two-tailed Student’s t-test was used tween baseline and four weeks. Self-administered to assess the differences between baseline and end SF-36 and SSA were also statistically analyzed of treatment. The outcomes of the five active for significance in the study groups.
Figure 1. Mean Complement Properdin
Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002 Page 143
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Results
Lab Parameters
tration increased significantly in the EPA and EPALA groups (Table 4). At four weeks the CP inthe EPA group was (mean [±SD]) 86±24 (baseline60±30) and in EPALA was 70±25 (baseline47±27), compared with 101±34 (baseline 96±29)in the placebo group (Figure 1). CP difference in the EPA group between baseline and four weeks was 26±27 (21.0% increase) (p=0.029) and in theEPALA group it was 22±19 (18.0% increase)(p=0.020); while in the placebo group it was 5±34(p=0.687). TNF-α decreased in urEPA, EPALA,and LA groups (p=0.040, p=0.034, and p=0.044, 1762 + 336
1785 + 318
1811 + 466
1408 + 386
1587 + 586
1852 + 687
respectively) (Table 4). There were no statisticallysignificant pattern changes in the hematologicalor other immunological serum chemistry (Table5). Aerobic bacterial culture for Lactobacillus aci- YMPHOCYTES MONOCYTES
dophilus and fungus culture for yeast showed no 1881 + 597
1704 + 284
1845 + 438
1547 + 308
1728 + 482
1846 + 725
Quality of Life Assessment
groups at end of treatment (p=0.042 and p=0.031, 2620 + 851
2653 + 796
3364 + 1319
2640 + 800
3647 + 1183
3469 + 1440
respectively) (Table 6), and showed enhanced vi- tality and physical, emotional and mental health.
The SSA decreased in the EPA and EPALA groups(p=0.003 and p=0.015, respectively) (Table 6). The decreases in SSA mean scores demonstrate im- 3569 + 1248
3336 + 868
3519 + 1510
2745 + 1179
3829 + 1194
3345 + 1306
provement in gastrointestinal function, sleep pat- movements (BM) and changes in stool character-istic (looser quality and larger quantity) in the fol- 4.86 + 0.90
5.06 + 1.08
5.65 + 1.48
4.49 + 0.94
5.71 + 1.36
5.85 + 2.25
lowing frequency: EP, 4 of 8 subjects (50%); urEPA, 3 of 7 (43%); EPA, 4 of 8 (50%); EPALA, WBC NEUTR
3 of 7 (43%); LA, 6 of 8 (75%); and placebo, 2 of8 (25%). The changes in BM reports were most alues are means +SD
dramatic in the larch arabinogalactan group, par- ASELINE
B
5.94 + 1.44
5.56 + 1.03
5.88 + 1.77
4.77 + 1.45
6.05 + 1.61
5.75 + 2.10
ticularly in the quality of stool consistency. The m/mm3 m/mm3 cells/mm3 cells/mm3 cells/mm3 cells/mm3 cells/mm3 cells/mm3
majority of subjects in this group experienced varying degrees of changes in their BM habits.
None of the subjects reported any discomfort and did not discontinue the study due to BM changes.
able 5.
Plus-min
T
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Adverse Reactions
Table 6. P values of SF-36 and Symptoms Specific
adverse reactions two weeks into the study.
One volunteer in the urEPA group discon-tinued due to self-reported anxiety, nervous- Symptoms
ness, and heart palpitation while taking the Specific
supplements. Another volunteer in the EPgroup reported bilateral arthritic symptoms Assessment
over her wrist, metacarpophalangeal, andproximal interphalangeal joints; however, the symptoms were similar in location and quality to arthritic symptoms experienced over 10 years previously. The symptoms of the two subjects resolved without compli- cation upon discontinuing the supplement.
Discussion
E. purpurea, E. angustifolia, and NS denotes no significance. P values by
two-tailed Student's t-test.
generally well tolerated. Gastrointestinalfunction, sleep pattern, mood, and emo-tional health items of SSA improved Figure 2. Mean Scores of Symptoms Specific Assessment
Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002 Page 145
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significantly in the same groups with higher SF- variance in the baseline values of the six groups, the outcomes of the study should be considered groups. Based on SF-36 and SSA outcomes re- cautiously in supporting immune effects of the lated to HRQoL, the most significant benefits to interventions. Thus, TNF-α decreases (p<0.05) in subjects’ health and vitality were observed in the the three groups – urEPA, EPALA, and LA – and complement properdin changes (increased in EPA and EPALA and decreased in LA) (Table 4) do arabinogalactan are considered a good source of not suggest immunomodulating activities of the dietary fiber, improving intestinal microflora such intervention in this study and remain suspect, re- as Bifidobacterium, Lactobacillus acidophilus, and Enterobacteriacea in human studies.53-55 Larch The preliminary nature of the project did arabinogalactan fibers are fermented by gas- not include extensive screening of the subjects trointestinal microflora resulting in the production prior to enrollment. Testing their WBC and other of short-chain fatty acids (especially butyrate and immune parameters with requisite ranges (upper propionate). These fatty acids are of particular and lower limits) and examination of their medi- value to colonocytes, and are the intestinal epi- cal records with focused subject selection criteria thelial cells’ preferred fuel for energy generation.
may have prevented such high variance in the The fiber dense quality of larch arabinogalactan baseline values. The wide age range (22-51); per- may explain the greater changes in BM from the sonal/professional background (student, working LA intervention than from the Echinacea formu- professional, etc.); diverse stress indicators, diet las or placebo. Although many of the subjects had behaviors, and daily activities of the subjects; and changes in their digestive habits, no conclusive lack of matching based on such diversity may have data pertaining to stool cultures of Lactobacillus contributed to the dissimilar lab values. Lack of acidophilus and yeast emerged from the study.
statistically significant activities of Echinacea and Vital signs collected at baseline and four weeks larch arabinogalactan formulas in this study may showed no negative or positive correlation with also be the result of methodology used – subject the treatment intervention. No statistical correla- characteristics, insufficient sample size, and in- tions or patterns were observed with blood type and outcomes of the study; the randomization of This study raises questions leading to fu- subjects to the six groups was not matched for ture proposals to further explore the immune ef- blood types at the beginning of the study.
fects of Echinacea and larch arabinogalactan. Pre- vious clinical trials have shown increased secre- concentrations in the E. purpurea/E. angustifolia tion and activity of leukocytes and cytokines (IFN- and E. purpurea/E. angustifolia plus larch γ, TNF-α, IL-1β, and IL-6), while other studies arabinogalactan groups may indicate stimulation have supported the benefits of Echinacea and larch of the complement immune system. Biological arabinogalactan in reducing symptoms and recov- activities associated with complement activation ery time from acute respiratory tract infections, include cell lysis, opsonization, enhanced phago- such as the common cold and influenza. Activa- cytosis, complement receptor activation, chemo- tion of the complement system and increased pro- taxis, activation of neutrophils and monocytes, and duction of complement properdin may be another clearance of immune complexes.56,57 The stimula- immune factor stimulated by Echinacea and com- tion by EPA and EPALA may result in enhanced bination Echinacea and larch arabinogalactan.
phagocytosis and immune function, and increased Demonstrating clinical efficacy and pharmacody- production and release of cytokines, which can namics of Echinacea and larch arabinogalactan induce expression of other cytokines and immune require more research to understand the compo- cells, further benefiting the specific and non-spe- nents involved in stimulating the natural immune cific immune system. However, due to the large Page 146 Alternative Medicine Review ◆ Volume 7, Number 2 ◆ 2002
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Wagner H, Jurcic K. Immunologic studies of complement properdin, measurement of other plant combination preparations. In-vitro andin-vivo studies on the stimulation of phagocy- components of the complement system may pro- tosis. Arzneimittelforschung 1991;41:1072- vide more conclusive evidence on complement Bauer R, Jurcic K, Puhlmann J, Wagner H.
arabinogalactan. The role of Echinacea and larch Immunologic in vivo and in vitro studies on arabinogalactan to stimulate the specific and non- Echinacea extracts. Arzneimittelforschung specific immune system should also be further explored to understand the specific antimicrobial Vomel T. Effect of a plant immunostimulant on immunomodulators. Future studies designed to reticulohistiocytary system of isolated per-fused rat liver. Arzneimittelforschung assess immune response to both short- and long- term interventions and antigen-induced immune Rehman J, Dillow JM, Carter SM, et al.
responses may provide better understanding of immunoglobulins G and M following in vivotreatment with the medicinal plants Echinacea Acknowledgments
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Immunol Lett 1999;68:391-395.
Steinmuller C, Roesler J, Grottrup E, et al.
tions, Celestial Seasonings, Inc., Larex, Inc., and Lee Dexter & Associates for research support and cultures of Echinacea purpurea enhance the assistance in the analytical chemistry evaluations.
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