With Comments from John La Puma, MD, FACP
Source: Mullins RJ, Heddle R. Adverse reactions associated with echinacea: The Australian experience. Ann Allergy Asthma Immunol 2002;88:42-51.
Fifty percent of australians use complementary and alternative medicines (other than vitamins) in any 12-month period, of which echinacea-containing products are increasingly popular. Recent reports have highlighted the risk of allergic reactions to complementary medicines in atopic patients.
To determine the characteristics of adverse reactions linked to use of the popular herbal remedy echinacea, five privately referred patients were evaluated by the authors in their office practice via skin prick testing (SPT) on the volar aspect of the forearm and radioallergosorbent test after adverse reactions to echinacea. As there was little published information on adverse reactions to echinacea, reports to the Australian Adverse Drug Reactions Advisory Committee were reviewed. Those suggestive of possible allergic reactions were evaluated in greater detail by anonymously surveying the health care professionals who had reported the cases and from one unreported case. Serum was collected for further analysis where possible.
Five cases of adverse reactions to echinacea were personally evaluated by the authors. Two patients suffered anaphylaxis and a third had an acute asthma attack 10 minutes after their first ever dose of echinacea. The fourth patient suffered recurrent episodes of mild asthma each time echinacea was ingested, and the fifth developed a maculopapular rash within two days of ingestion, which recurred when rechallenged. Three of the patients had positive SPT results. Three reported repeated spontaneous "challenges" and symptoms after further ingestion of echinacea.
Fifty-one Australian adverse drug reports implicating echinacea also were reviewed. There were 26 cases suggestive of possible immunoglobulin E-mediated hypersensitivity (four anaphylaxis, 12 acute asthma, 10 urticaria/angioedema). Of these 26 patients, age ranged from 2 to 58 years, 78% were female, and more than 50% were known to be atopic. Four were hospitalized, four reacted after their first known exposure, and one patient suffered multiple progressive systemic reactions. Twenty of 100 atopic subjects who had never taken echinacea also had positive SPT results to this substance when tested by one of the authors in his office practice.
Some atopic subjects have positive SPT results to echinacea in the absence of known exposure. Atopic subjects also are over-represented in those experiencing reactions to echinacea. The possibility that cross-reactivity between echinacea and other environmental allergens may trigger allergic reactions in "naïve-naïve" subjects is supported by the Australian data. Given its widespread (and largely unsupervised) use, even rare adverse events become inevitable. Atopic patients should be cautioned appropriately.
Comment
An earlier summary of the Australian registry of adverse reactions to echinacea, referred to in the Annals of Internal Medicine this year, indicated only very mild concern about adverse reactions to echinacea. But either because of increasing usage or allergenicity, or both, frightening atopy seems to be emerging. Recurrent erythema nodosum associated with echinacea herbal therapy also was reported last year by Soon and colleagues.1
Practical dosing difficulties with echinacea include the usual recommendation of three times daily dosing, with either pressed juice or tincture, and variability of supplement reliability and purity. But the appearance of such specific and clear allergy, including anaphylaxis, is worrisome.
Recommendation
Patients with atopic conditions and environmental allergies should avoid echinacea; if they want to take it, they should be warned about the identified and increased incidence of reaction to it.
Reference
1. Soon SL, Crawford RI. Recurrent erythema nodosum associated with echinacea herbal therapy. J Am Acad Dermatol 2001;44: 298-299. Clinical Trials Harmed by Lack of Informed Consent
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La Puma J. Adverse reactions associated with echinacea use. Altern Med Alert 2002;5(9):112.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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