Treatment Chart: Botanicals for Acute Respiratory Health

KEY: Recommended May be useful Not recommended

Cold, Flu or Prevention:

Andrographis (Andrographis paniculata)

Andrographis leaves have been used in traditional Ayurvedic, Thai, and Chinese medicine to treat fever associated with infectious diseases for centuries. The leaves contain numerous active compounds, including andrographolide and deoxyandrographolide, which have immunostimulatory properties in vitro: specifically, increasing macrophage motility and splenic lymphocyte proliferation, and stabilizing mast cell membranes. Pharmacological studies have demonstrated anti‐inflammatory, antipyretic, antiviral, and immunostimulatory properties for andrographis.

There is strong clinical evidence to support the use of andrographis in the treatment of upper respiratory infections. It has been shown to reduce both the severity and duration of symptoms in URI's. Most studies have been done with the product Kan Jang® (Swedish Institute), which is available with andrographis extract (60 mg) alone and in combination with Eleutherococcus senticosus extract (120 mg). Treatment needs to be started within 48 hrs of symptom onset, and improvement can be seen as early as 2 days later. Preliminary studies suggest that prophylactic use of andrographis might decrease the risk of developing a cold by about 50% after 2 months of continuous treatment, however more studies are needed.

Side effects using the whole extract are minimal and comparable to placebo. Because the herb is very bitter and increases gastric acid production, it is generally contraindicated in those with peptic ulcer disease. Safety in pregnancy is not known. Finally, it may increase bleeding risk in patients using warfarin or anticoagulants.

Andrographis is generally available in capsules of dried herb and taken at a dose of 1000‐2000 mg three times daily for acute infection or taken at 500 mg 2‐3 times per day as a preventive. A standardized, proprietary blend of a specific andrographis (60 mg leaf extract standardized to contain 4‐5.6 mg andrographolide), plus Eleuthero (120 mg root extract) three times daily has been used for the treatment of the common cold and influenza (Kan Jang, Swedish Herbal Institute).

Representative Products: Kan Jang by Swedish Herbal Institute; Quick Defense by Gaia Herbs; Andrographis Plus by Metagenics; Stimuliv by Jarrow Formulas.

Cold, Flu, OM, Sinusitus, or Prevention

Astragalus

Astragalus root (Astragalus membranaceus, Astragalus mongholicus) is used for diverse immunological and infectious conditions. The root contains numerous bioactive compounds including: astragaloside (among 50 other saponins), bioflavonoids, coumarins, and polysaccharides. The polysaccharides act as immunostimulatory lectins, binding to B cells and promoting cell division. Astragalus increases immunoglobulin levels in nasal secretions, as well as IL‐2 levels. In cases of immunodeficiency, this increase in antibody concentration may be clinically significant. Finally, astragalus was shown to increase the number of activated T cells following daily ingestion for a week, based upon the fraction of CD69+ T cells in peripheral blood.

While there have been no carefully controlled studies examining astragalus‐mediated recovery from upper respiratory infections, there is suggestive in vitro and animal studies that suggest a protective benefit from the herb. It is given as a tonic, usually mixed with other herbs. The thought is that by "priming" or activating the humoral and cellular immune systems, potential pathogens are more likely to be cleared before they can infect.

Astragalus tea or soup is generally made by simmering 5‐15 grams of dried root for 15‐20 minutes. There are also numerous tinctures and sometimes products are standardized to contain 0.3% astragolides. Astragalus is regarded as generally safe.

Cold, Flu, or Prevention

Echinacea

While there are numerous species of echinacea, the primary ones used in are Echinacea angustifolia, E. purpurea, or E. pallida. All three are used as supportive therapy for upper respiratory infections, including the common cold and flu, although neither ESCOP nor the German Commission E recognize the use of E. angustifolia. Extracts from all three species are reported to have antiviral and immune stimulatory effects, and both above ground parts and roots are used in the preparation of extracts.

With respect to respiratory infections, the assessment of the effectiveness of echinacea is complicated by the fact that different products are used in the cited clinical trials; different parts are used, different extraction methods are employed, and some preparations are combined with other herbs or homeopathic remedies – all making comparisons between trials difficult.

A 2006 Cochrane review found that sixteen trials (15 double blind) met their inclusion criteria. The majority had reasonable to good methodological quality. A variety of different echinacea preparations were used. None of the prevention trials showed an effect over placebo. Comparing an echinacea preparation with placebo as treatment, a significant effect was reported in nine studies, a trend in one, and no difference in six. The negative trial by Turner et al., was one of the largest studies conducted on echinacea for both the prevention and treatment of rhinovirus infection. While the study was well‐designed and adequately powered, potential drawbacks were the dose and species used. The study used three different preparations of E. angustifolia root (supercritical CO2, 60% ethanol, 20% ethanol), administered at a dose of 900 mg/d. The dose generally recommended by herbalists (and in the World Health Organization monograph) is 3000 mg/d of E. angustifolia. The 900 mg/d dose is currently recommended in the German Commission E monograph for E. pallida root, a different species. As mentioned in the Cochrane review, extracts of the fresh aerial parts of E. purpurea are the most studied type of preparation.

The German Commission E approves the use of E. purpurea as a supportive therapy in "chronic" upper respiratory infections, and many herbal practitioners believe that echinacea can help reduce the number of acute URI, particularly in children. There is limited scientific evidence to support this use; however a recent secondary analysis of data from a RDBPCT of E. purpurea for the treatment of URI in over 500 children (ages 2‐11 years) found that among the 401 children with at least one URI, 69.2% of those receiving placebo developed a second URI versus 55.8% of those who received echinacea (Weber, 2005). Use of echinacea was associated with a 28% decreased risk of subsequent URI (p = 0.01, 95% confidence interval 8%‐44% decreased risk). While this finding needs replication, there may be some preventive effect. A combination of echinacea, propolis and vitamin C decreased the number of upper respiratory infections, the duration of symptoms and the number of days of illness as compared with placebo in a group of 430 children ages 1‐5 years (Cohen et al., 2004).

Serious adverse effects from echinacea are very rare. The primary adverse effect is an allergic reaction, which seems to occur more frequently in those with atopic conditions, though some studies report an incidence of rash up to 7% (compared to 3% rash with placebo). The German Commission E contraindicates echinacea in progressive systemic diseases such as tuberculosis, leukocytosis, collagenosis, multiple sclerosis, AIDS, HIV infection, and other autoimmune diseases (Blumenthal et al., 1998). These are principally theoretical contraindications not supported by adverse events in the literature with oral use of echinacea.

Several common preparations: Echinacea Plus® tea (Traditional Medicinals: equivalent of 1.275mg of dried herb and root per tea bag); EchinaGuard® , Echinacin® , Echinagard® (Madaus AG, Germany, distributed by Nature's Way Products, Inc: all of these products are made from the juice of E. purpurea tops preserved with alcohol); Echinaforce® (Bioforce AG, Switzerland, distributed by Bioforce USA: ethanolic extract of E. purpurea tops and roots).

Flu

Elderberry

Elderberry fruit extract (Sambucus nigra) is commonly used as a treatment for influenza. The ripe fruit is a rich source of bioflavonoids (primarily anthocyanidins), tannins, and essential oils. The anthocyanidins are readily detected in the bloodstream following ingestion, and are thought to be responsible for the antiviral and immune priming effects seen in vitro. Notably, elderberry extract inhibits hemagglutinin activity and thus the replication of several strains of influenza viruses A and B.

Elderberry fruit is very safe and there are no known herb‐drug interactions. There is a theoretical cross‐reactivity between grass pollens and elderberry, but significant clinical reactions are rare. As is the case with all herbs possessing "immunomodulatory" properties, care should be used when elderberry for long periods in people taking immunosuppressive agents. The most researched commercial elderberry extract is the syrup, Sambucol, which was shown to reduce the symptoms and duration of influenza infection when given orally within 48 hours of initial symptoms. Symptomatic improvement is typically seen in 2‐4 days after starting therapy. Recommended doses are 15 ml QID for 3‐5 days in adults, and 15 ml BID for 3 days in children.

Flu

Eleuthero

Eleutherococcus senticosus is better known in this country as Siberian , but is more correctly referred to as eleuthero, as it is not a member of the Panax (ginseng) genus. The principle bioactive compounds in the root are collectively called eleutherosides, A through M. The eleutherosides have diverse activities including antioxidant, immunostimulant, and possibly anti‐neoplastic. Insofar as respiratory tract infections are concerned, most evidence supports a synergistic role for reducing URI symptoms when taken in conjunction with andrographis (Andrographus paniculata). The combination product, Kan Jang (Swedish Herbal Institute), was evaluated in a DBPCT of nearly 200 people with acute URI. The combination of andrographis with eleutherococcus extract produced a highly significant improvement in URI symptoms in the experimental group.

Eleuthero is relatively safe. It may interfere with the lab test for digoxin, as it contains structurally similar (but inactive) glycosides.

The dose for the standardized extracts of eleuthero, typically standardized to 0.7‐1.0% eleutherosides, is 200‐300 mg BID‐TID. Typical dose for the dried root is 1‐3 grams daily. Standardized extracts are often preferred to reduce the risk of adulteration/contamination.

Representative Products: Eleuthero Extract by Enzymatic Therapy standardized extract: Eleutherococcus senticosus, containing 0.5% eleutheroside E) 200 mg. Standardized Siberian Eleuthero (Nature's Way) extract is standardized to two actives: 0.3% eleutheroside B and 0.5% eleutheroside E

Sinusitus

Esberitox®

Esberitox® is a proprietary combination of Echinacea pallida root, E. purpurea root, white cedar leaf (Thuja occidentalis), and wild indigo root (Baptisia tinctoria) root. Echinacea has well‐established anti‐viral activity in‐vitro and mixed results in clinical trials for acute treatment of URI. White cedar leaf contains polysaccharides that may have anti‐viral and immunostimulant properties. Wild ingido root contains glycoproteins that may boost the immune system. This combination of herbs has been studied in clinical trials, some of which are German‐language articles without available abstracts or translations. Placebo‐controlled trials have found a more rapid recovery and symptomatic improvement with a combination of Esberitox and antibiotics for chronic bronchitis or sinusitis, taking advantage of the products main purported effect of improving various immune system parameters. Esberitox (Enzymatic Therapy) comes in chewable tablets, generally dosed at 1‐3 tablets taken three times daily. Possible allergic reactions are possible due the presence of Echinacea and it should not be used in pregnancy as it contains white cedar leaf and wild indigo root.

Cold, OM, Sinusitus, or Pneumonia

Eucalyptus

Eucalyptus leaf (Eucalyptus globulus), also known as fever tree leaf, or gum tree leaf, contains an aromatic mixture of compounds used to treat respiratory tract infections, fevers, coughs (expectorant activity), and other inflammatory conditions. Eucalyptus essential oil is the most active preparation, followed by the leaf tincture/extract, due to the high concentration (55‐95%) of eucalyptol (1,8‐cineole). Other active compounds in eucalyptus include phenolic acids and tannins.

In respiratory illness, eucalyptus is used as an expectorant and decongestant. In vitro, eucalyptol possesses an inherent antimicrobial and antifungal activity, and inhibits key steps in the arachidonic acid inflammatory cascade. Three randomized trials have been conducted on the proprietary product Mytrol® in patients with respiratory conditions. Myrtol is standardized to 1,8‐cineole (eucalyptol). Federspil et al. conducted a double‐blind, randomized multi‐center study comparing Mytrol with placebo in acute sinusitis; Meister et al. randomized 215 patients with chronic bronchitis to 6 months of Myrtol (3 x 300 mg/d) or placebo under double‐blind conditions in a multi‐center trial; and Matthys et al. randomized 676 patients with acute bronchitis to Myrtol (4 x 300 mg/d), placebo, cefuroxime or ambroxol for 2 weeks.

All three studies demonstrated superiority of Myrtol to placebo, and equivalent to antibiotic therapy (a treatment considered inappropriate for most cases of bronchitis). A post‐marketing surveillance study of 511 children (ages 4‐12) with acute or chronic sinusitis, or bronchitis taking Myrtol (120‐300 mg/d) demonstrated the product is well‐tolerated with low incidence of adverse effects in children. Myrtol is not currently sold in the US. Eucalyptus is licensed in Germany as a medicinal tea for bronchitis or throat inflammation, and has been approved by the German expert panel, the Commission E, for "catarrh" (mucus membrane inflammation) of the respiratory tract.

Eucalyptus tincture (1‐2 ml) can be added to juice or hot water and taken two to three times per day for congestion, cough and colds. Lozenges containing eucalyptus essential oil are useful for increasing salivation, prompting more swallowing and decreasing cough.

Eucalyptus essential oil is best used as an inhalant and topical ointment. Several drops of eucalyptus oil may be used in a vaporizer or steam tent as a decongestant. This can also be useful for ear pain as the inhaled steam can help open eustachian tubes. Topical preparations are popular for relieving arthritis and muscle pain. Caution should be exercised with pure eucalyptus essential oils, as ingestion of 10 ml or greater can be associated with significant risk of toxicity.

From Dr. Low Dog: Inhalation Therapies

Using herbs or herbal essential oils as inhalation therapy can provide symptomatic relief for sinus congestion. Here are a couple of hints: 1) if using the pure essential oil, start with a few drops (3‐5) in a pan of hot water. People react differently to the essential oils and it can make the eyes burn if too strong; 2) make sure children do not put their face too close to the pan (risk of burning) and 3) you can use a variety of essential oils for a steam including eucalyptus, , basil, wintergreen, lavender. WARNING: Eucalyptus oil poisoning can be very serious, especially in children. Toxicity is primarily associated with use of eucalyptus essential oil, not tea or tincture preparations. Eucalyptus oil was a leading agent associated with hospitalization for poisoning among children less than five years of age in Victoria, Australia (Day, 1997). The majority of cases were the result of access to a vaporizer at ground level that contained eucalyptus oil. Significant depression of conscious state can occur with the ingestion of as little as 5 mL of 100% eucalyptus oil. Minor depression of consciousness may occur after ingestion of as little as 2‐3 mL of the oil (Tibballs, 1995).

Cold, Flu, Sinusitus, or Pneumonia

Garlic

Garlic (Allium sativum) is a key ingredient in many ethnic cuisines, but also enjoys a rich history as an herbal medicine. In addition to its role in cardiovascular and gastrointestinal health, it has been used in the treatment of upper respiratory conditions for hundreds of years.

Garlic contains many active ingredients including allicin, ajoene, and other organosulfur compounds such as S‐allyl‐L‐ cysteine. It is the odiferous allicin and its metabolites, that are thought to account for much of the antimicrobial activity of garlic.

Fresh garlic, but not aged garlic, has in vitro activity against Escherichia coli, methicillin‐resistant Staph aureus, Candida albicans, as well as rhinovirus and parainflenza virus type 3. An in vitro study found the crude aqueous extract of garlic to significantly inhibit several pneumonia‐causing bacteria, including Streptococcus pneumoniae and Klebsiella pneumoniae. However, the concentrations required are likely supraphysiological, and not readily achieved with oral dosing. Nonetheless, a partial inhibition (bacteriostatic effect) may occur.

The European Scientific Cooperative on Phytotherapy (ESCOP) recommends 2 to 4 grams of dried bulb or 2 to 4 milliliters of tincture (1:5 strength; 45% ethanol), by mouth three times a day for upper respiratory tract infections. ESCOP also noted that garlic has been used traditionally for relief of cough, colds, catarrh, and rhinitis, although there are few clinical trials to support these uses. No significant toxicity has been seen, although there is a theoretical effect on bleeding times with doses of 4 grams or higher, so caution should be exercised prior to surgery or in chronically anticoagulated patients. Garlic has also been shown to lower serum levels of isoniazid and protease inhibitors.

Cold

Ginger

Ginger (Zingiber officinale) has a long history of use in gastrointestinal disorders, including nausea and dyspepsia, as well as certain respiratory disorders. The active compounds in the rhizome consist of gingerol, gingerdione, shogaol, and several volatile oils (i.e., terpenes).

Although ginger enjoys a rich traditional use in the therapy of respiratory infections, owing to its warming effect on the upper respiratory tract and its mucolytic properties, there have been very few clinical studies to substantiate its benefit. Ginger has in vitro activity against several respiratory pathogens, including Streptococcus pneumoniae and Haemophilus influenzae, as well as having antirhinoviral activity. Ginger inhibits airway contraction in an animal model of airway hypersensitivity, a hallmark of asthma. Its presumptive mechanism is via AA blockade of plasma membrane Ca(2+) channels.

Ginger is safe and well‐tolerated. There is a theoretical prolongation of bleeding time, based upon in vitro platelet aggregation inhibition studies, but this has not been demonstrated in vivo. Still, caution should be exercised when treating patients with high doses of ginger, greater than 4 grams, while receiving chronic anticoagulant therapy.

Dosage and form: Dried ginger: 2‐4 grams/d. Fluid Extract: 1:1 (g/ml) 0.25‐1.0 ml three times daily; tincture 1:5 (g/ml) 1.25‐5.0 ml three times daily.

Representative Products: GingerForce® (New Chapter): Ginger rhizome supercritical extract (containing 30% pungent compounds and 8% zingiberene) and ethanolic extract (containing 3% pungent compounds). FlexAgility® (Enzymatic Therapy), Zinaxin® , Zincosamine® (both from FreeLife International LLC), all contain EV Ext 77 (Ferrosan A/S), an extract that has been clinically studied, but the final product formulations have not. Nature's Way Ginger Root is an excellent non‐standardized product containing 550 mg ginger root per capsule.

Cold, Flu, Sinusitus, or Pneumonia

Grindelia

Grindelia (Grindelia camporum, G. robusta), also known as gumweed, is considered by many herbalists to be an excellent expectorant and anti‐tussive. Grindelia contains terpenes, flavonoids, and saponins, as well as phenolic compounds that may have antimicrobial activity. It is predominantly used when there is significant postnasal drip, cough and chest congestion. It is often included in asthma formulations, particularly in combination with licorice, due to its antispasmodic effect.

The freshly picked leaves and flowers are generally tinctured in 70% alcohol, the dose is 30‐60 drops three times daily. There are some reports of mild gastrointestinal side effects with the oral use of grindelia, so monitor your patients for this during treatment.

Representative products include: Gumweed tincture by Eclectic Institute, Bronchial Wellness Syrup by Gaia Herbs (mixture of grindelia with other herbs).

Cold

Ivy

English ivy (Hedera helix, H.taurica) has been traditionally used as expectorant, and is sold in Europe under such brand names as Prospan® , a German cough syrup. The bioactive triterpene saponins, hederacoside C and alfa hederin, may have ß2 sympathomimetic activity, leading to bronchodilation and secretolysis, relevant to its use in acute bronchitis and asthma. Several clinical trials, mostly open label, have found that ivy syrup, or ivy in combination with other herbs such as thyme, and marshmallow, reduce the severity and duration of cough in acute bronchitis. Indeed, the combination of ivy and thyme fluid‐extract (5.4 mL three times daily) has been shown to significantly decrease coughing.

There are references in the German literature to a study by Gulyas et al., that noted improvements in FEV1 in children with chronic obstructive bronchitis with the use of ivy syrup.

Ivy is generally well tolerated, with most clinical trials finding a similar side effect profile to placebo, though some trials report mild diarrhea. Cases of contact dermatitis and asthma due to occupational exposure to English ivy have been reported.

Representative Products: Bronchial Soothe Ivy Leaf Syrup by Enzymatic Therapy contains ivy leaf extract standardized to hederacoside C and is alcohol free and suitable for children. This company also makes Ivy Extract, which is available in tablets.

Cold, Flu, or Sinusitus:

Licorice

Licorice root (Glycyrrhiza glabra) has been used for centuries as an anti‐inflammatory, antispasmodic, expectorant and demulcent. It soothes mucus membranes and aids in the healing of peptic ulcers, increasing local prostaglandin levels that promote mucus secretion and cell proliferation in the stomach. The root has several active components, including glycyrrhizic acid (also called glycyrrhizinic acid or glycyrrhizin), which is metabolized to glycyrrhetinic acid (also called glycyrrhetic acid) in the intestine. Glycyrrhetinic acid potently inhibits cortisol metabolism through the inhibition of 11‐ beta hydroxysteroid dehydrogenase (11β‐HSD), which blocks the conversion of hydrocortisone to the inactive cortisone. This allows endogenous corticosteroids to accumulate, making licorice root a type of "steroid sparing" intervention for asthma and COPD. Interestingly, some macrolide antibiotics were historically used for similar activity (e.g., troleandomycin). Licorice was routinely used in conventional medicine as treatment for Addison's disease until the 1950s.

The German Commission E approves the internal use of licorice root for catarrh (inflammation of mucous membranes, especially nose and throat) of the upper respiratory tract. Licorice remains popular as an ingredient in cough syrups and lozenges and can be readily found in popular products such as Luden's Honey Licorice Cough Drops and Traditional Medicinals Throat Coat Syrup. The saponins in licorice root exert both secretolytic and antiviral activity, making it useful for bronchitis and URI (Wichtl, 1994). Saponins generally stimulate ciliary activity and reduce the surface tension of sputum, making it easier to expel. Licorice may inhibit the growth of the coronavirus, which is associated with severe acute respiratory syndrome (SARS). The exact mechanism of the antiviral effect is not known.

Licorice is often combined with other herbs as a tea or syrup for sore throats. Licorice tea can be prepared by simmering 1 tsp cut root in 8 ounces of water for 10 minutes. Strain and add honey if desired. Adults can drink 8 ounces every 4 hours. Children can drink 2‐4 ounces every 4 hours. This should be limited to 3‐4 days, or so, to prevent any risk of blood pressure elevation or potassium loss.

Due to the effects on corticosteroid metabolism, excessive licorice ingestion can produce a syndrome of apparent mineralocorticoid excess, with hypokalemia, increased urinary potassium loss, alkalosis, and hypertension. Patients with pre‐existing hypertertension or renal failure should be monitored carefully. In addition, licorice induces cytochrome P450 (CYP2C9) metabolism, and should be used with caution in patients taking drugs metabolized via this pathway (e.g., warfarin).

Lomatium

Lomatium (Lomatium dissectum), a member of the carrot family, is found throughout the Rocky mountains but due to overharvesting in the past it is on the United Plant Savers "At Risk" list. Lomatium root contains a sticky, resinous, aromatic sap, a collection of essential oils, gums, and resin that account for its anti‐viral anti‐bacterial, and expectorant activity. Lomatium gained notoriety during the 1918 influenza pandemic as it was purported to be widely and effectively used by Native Americans living in Nevada. At that time it was named Leptotaemia dissecta. There has been little research on this herb though a Canadian study found that lomatium completely inhibited the cytopathic effects of rotavirus.

Fresh, not dried, lomatium is most commonly prepared as a tincture (80% ethanol) dosed numerous times daily in acute situations (for example, 10 drops every two hours for viral pneumonia). It is difficult to find lomatium alone in an herbal product though HerbPharm and Heron Botanicals offer wildcrafted lomatium singles. While generally well tolerated, lomatium can cause a skin rash if taken in high doses or for a prolonged period of time.

Cold, Flu, OM, or Sinusitus:

Mullein

Mullein (Verbascum thapsus), also known as torch weed and candlewick, and a related species Verbascum densiflorum, is a common treatment for ear infections, the common cold, coughs and other respiratory conditions. The bioactive compounds include mucilage, iridoid glycosides (harpagoside, harpagide, aucubin), flavonoids (hesperidin, verbascoside, methylquercitin), saponins, and volatile oils. The mucilage, in particular, helps to coat mucus membranes, making it useful for sore throat, cough, and bronchitis. Mullein flowers are also steeped in olive oil and the oil than strained and used as topical anti‐inflammatory for otitis externa and pain reliever for otitis media (if the eardrum is intact). In vitro research demonstrates activity against influenza and herpes simplex viruses, as well as Klebsiella pneumoniae, Staphylococcus aureus, Staphylococcus epidermidis, and Escherichia coli. Mullein seeds can have a sedative effect.

Mullein leaves and/or flowers are dried and made into an alcohol tincture (2‐4 ml TID) or steeped in hot water to make an infusion (2‐3 cups per day). Representative Products: Mullein Leaf Tea by Alvita teas, Mullein tincture by Eclectic Institute, Ear Oil by Gaia Herbs (mullein and St. John's wort).

Cold, Flu, OM, Sinusitus, Prevention or Pneumonia

Medicinal Mushrooms

Mushrooms have been used for both culinary and medicinal purposes for millennia. Various species of mushrooms (i.e., , maitake, turkey tail) demonstrate significant in vitro activity against a variety of tumor cells, and are used routinely by patients with cancer. Mushrooms are also used for inflammatory conditions and recurrent respiratory tract infections, based upon their immunomodulatory properties.

Reishi mushrooms (Ganoderma lucidum) are commonly used in Chinese medicine for the treatment of asthma, cough, and fatigue. Reishi contain numerous compounds that are thought to account for the immunomodulating, antitumor and antioxidant activities including polysaccharides, polysaccharide‐peptide complexes, polyphenols and triterpenoids. The immunostimulatory may benefit patients with respiratory infection. A hot water extract of Reishi mushroom demonstrated antibacterial activity against a variety of gram positive and gram negative organisms, as well as a synergistic activity in vitro when combined with cefazolin against Bacillus and Klebsiella species.

Shiitake mushroom (Lentinus edodes) extracts exhibit immunostimulatory effects in vitro and in animal models, presumably due to a specific polysaccharide, lentinan. Purified lentinan is considered a drug in Japan and is injected as an adjuvant treatment in patients with cancer and HIV infection. While much of the research has been done with tumor cells, animal studies demonstrate an enhancement of the humoral immune response to pathogens, with significant increases in serum immunoglobulin levels. This immune stimulation may be useful in the setting of prolonged or recurrent URI, as mushroom extracts are commonly used for long periods as adaptogens. Commercial preparations often use the powdered mycelium of the mushroom before the cap and stem grow. These preparations are referred to as Lentinus edodes mycelium extract (LEM).

There are no reports of mushroom‐drug interaction in the published literature, and only a few reports of hypersensitivity reactions. Caution should be used in individuals with known or suspected mushroom allergies.

Pneumonia:

Osha

Osha (Liguisticum porteri), a member of the carrot famly (Apiaceae), is native to western North American mountain ranges. Osha root was prized by indigenous peoples for its use in colds, coughs, pneumonia, influenza and also topically for wounds and skin infections. Osha contains numerous bioactive compounds including alkaloids, phenolics (i.e., ferulic and caffeic acids), furanocoumarin and the phthalide ligustilide, all of which likely contribute to its antimicrobial, anti‐ inflammatory and expectorant activities. However, despite its strong historical use in North America, virtually no research has been conducted on osha for any clinical purpose.

The furanocoumarins psolralen and bergapten may cause a photosensitivity when applied topically; other possible adverse effects have not been documented in the medical literature. There are concerns about overharvesting and it on the United Plant Savers "At Risk" list, though the stems contain similar compounds to the root and could likely be used medicinally instead.

Representative Products: tinctures are available from a variety of companies including Gaia, Herbs Etc, and HerbPharm. The dose is generally 0.5 grams taken 2‐3 times per day as tea, syrup or tincture.

Cold, Flu or Sinusitus

Pelargonium

Pelargonium (Pelargonium sidoides) root has an extensive history of use for treatment of sinusitis, bronchitis, and pharyngitis. Pelargonium extracts are derived from a South African species of geranium and are active against a variety of pathogens including Klebsiella pneumoniae, Escherichia coli, Streptococcus pneumoniae, Staphylococcus aureus. It is also active against Mycobacterium tuberculosis and prior to 1900 was extensively marketed as a treatment for TB. Pelargonium stimulates the release of anti‐bacterial cytokines, including TNF and interferon, and enhances phagocytosis and NK cell activity.

There are data from in vitro, animal and 18 clinical trials that support its use for a variety of respiratory conditions. It is a relatively safe herb to use, with no published adverse effects, other than rare hypersensitivity reactions. Most of the published URI studies were done using a specific extract of South African geranium named Umckaloabo (Schwabe GmBh, Germany), sold as Umcka in the United States by Nature's Way.

Representative Products: Umcka (Nature's Way). Dosing is provided for young children through adults. Contains: Pelargonium sidoides root ethanolic extract (1+10) 80 g. Other Ingredients: Glycerol 85%, and Alcohol 12%