Note: This Assessment Report is published to support the release for public consultation of the draft
Community herbal monograph on
Chelidonium majus
L. . It should be noted that this document is a
working document, not yet fully edited, and which shall be further developed after the release for
consultation of the monograph. Interested parties are welcome to submit comments to the HMPC
secretariat, which the Rapporteur and the MLWP will take into consideration but no ‘overview of
comments received during the public consultation’ will be prepared in relation to the comments that
will be received on this assessment report. The publication of this
draft
assessment report has been
agreed to facilitate the understanding by Interested Parties of the assessment that has been carried
out so far and led to the preparation of the draft monograph.
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Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Table of contents
Table of contents
................................................................................................................... 3
1. Introduction....................................................................................................................... 5
2. Non-Clinical Data ............................................................................................................. 12
2.1. Pharmacology.................................................................................................. 1
2
and relevant constituents thereof.............................................................................. 1
2
2.1.2. Assessor’s overall conclusions on pharmacology................................................. 2
0
2.2. Pharmacokinetics ............................................................................................. 2
1
and relevant constituents thereof.............................................................................. 2
1
2.2.2. Assessor’s overall conclusions on pharmacokinetics ............................................ 2
2
2.3. Toxicology....................................................................................................... 2
2
and constituents thereof .......................................................................................... 2
2
2.3.2. Assessor’s overall conclusions on toxicology ...................................................... 2
3
3. Clinical Data ..................................................................................................................... 24
3.1. Clinical Pharmacology ....................................................................................... 2
4
3.1.1. Pharmacodynamics........................................................................................ 2
4
including data on constituents with known therapeutic activity. ..................................... 2
4
3.1.1.2. Assessor’s overall conclusions on pharmacodynamics....................................... 2
4
3.1.2. Pharmacokinetics .......................................................................................... 2
4
including data on constituents with known therapeutic activity. ..................................... 2
4
3.1.2.2. Assessor’s overall conclusions on pharmacokinetics ......................................... 2
4
3.2. Clinical Efficacy ................................................................................................ 2
4
3.2.1. No dose-finding studies. ................................................................................. 2
4
3.2.2. Clinical studies (case studies and clinical trials).................................................. 2
4
3.2.3. Clinical studies in special populations (e.g. elderly and children)........................... 2
6
3.2.4. Assessor’s overall conclusions on clinical efficacy ............................................... 2
6
3.3. Clinical Safety/Pharmacovigilance....................................................................... 2
6
3.3.1. Patient exposure ........................................................................................... 2
6
3.3.2. Adverse events ............................................................................................. 2
7
3.3.3. Serious adverse events and deaths .................................................................. 2
9
3.3.4. Laboratory findings........................................................................................ 2
9
3.3.5. Safety in special populations and situations....................................................... 2
9
3.3.5.1. Intrinsic (including elderly and children) /extrinsic factors................................. 2
9
3.3.5.2. Drug interactions ........................................................................................ 2
9
3.3.5.3. Use in pregnancy and lactation ..................................................................... 2
9
3.3.5.4. Overdose................................................................................................... 2
9
3.3.5.5. Drug abuse................................................................................................ 2
9
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Chelidonium majus
L., herba
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L., herba
EMA/HMPC/369801/2009
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1.
Introduction
1.1.
Description of the herbal substance(s), herbal preparation(s) or
combinations thereof
Herbal substance(s)
Chelidonium majus
L.
The European Pharmacopoeia (01/2008:1861) monograph Chelidonii herba provides the following
definition: dried, whole or cut aerial parts of
Chelidonium majus
L. collected during flowering. Content:
minimum 0.6 per cent of total alkaloids, expressed as chelidonine (C
20
H
19
NO
5
; Mr 353.4) (dried drug).
Chelidonium majus
L. is known under the synonyms:
English:
greater celandine, devil’s milk, rock poppy, tetterwort, swallow-wort
Italian:
celidonia, erba di porri, cinerognola, erba maistra, erba nocca
German:
Schöllkraut, Schellkraut, Schwalbenkraut, Goldwurz, Blutkraut, Gelbes Millkraut
French
: chélidoine, herbe d’éclaire, herbe de l’hirondelle, felougue, herbes de Sainte Claire, herbe
hirondalle
Dutch:
stinkende gouwe
Spanish:
celidonia
Portugal:
celidonia
Polish:
ziele glistnika, złotnik, jaskółcze ziele, glistnik pospolity
There are over 20 different
Chelidonium
alkaloids identified. Here are the different groups of chemical
molecules who are present in the herb of
Chelidonium majus
(
Barnes et al, 2007; Bruneton, 1999
)
Benzylisoquinoline type (0.01-1%):
with at least three subgroups,
Benzophenanthridines: chelerythrine, chelidonine, sanguinarine, isochelidonine
Protoberberines: berberine, coptisine, dihydrocoptisine, stylopine
Protopine
Acids:
chelidonic, malic, citric, caffeic (0.4%) ferulic (0.02%), p-coumaric (0.06%), gentisic and p-
hydroxybenzoic acids
Hydroxycinnamic acid derivates:
(-)-2-(E)-caffeoyl-D-glyceric acid, (-)-4-(E)-caffeoyl-L-
threonic acid, (-)-(2)-(E)-coffeoyl threonic acid lactone, (+)-(E)-caffeoyl-L-malic acid
Others:
a saponine, carotenoids, a phytocytostatin (chelidocystatin), sparteine and flavonoids.
Chelidonium majus
L. belongs to the family of the
Papaveracecae
and is widely distributed across the
world. It can be found in Europe, Asia, Northwest Africa and North America. It is a typical ruderal plant
that grows on nitrogenous ground.
Historically
Chelidonium majus
was already used in the middle ages. It was mentioned by Plinius and
Dioscorides. The name Chelidon (
) in Greek means swallow because the plant begins to flower
when the swallows return.
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Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Figure 1.
Alkaloids of
Chelidonium majus
(
Barnes et al, 2007
)
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Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Figure 2. Acids of
Chelidonium majus
(
Barnes et al, 2007
)
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Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Herbal preparation(s)
Internal use
Chelidonii herba comminuted: 1.2-3.6 g as a tea infusion (ESCOP, 2003)
Chelidonii tincture (ethanol 45% V/V): 2-4 ml of a 1:5 preparation daily or 2-4 ml of a 1:10
preparation three times a daily (
Barnes et al, 2007
)
Chelidonii extractum fluidum (ethanol 25% V/V): 1-2 ml of a 1:2 preparation daily or 1-2 ml of
a 1:1 preparation three times daily (
Barnes et al, 2007
)
Chelidonii extractum siccum (concentration not specified): 100-200 mg three times daily
(
Van Hellemont, 1985; Delfosse 1998
)
Chelidonium majus
mother tincture (M.T. (ø)): 15 drops three times daily (
van Hellemont,
1985; Delfosse 1998
)
External use
Eye-drops: one drop three times daily (Kommission C, 1992)
Chelidonium,
volatile grade of dilution D4 to D30
Chelidonium
Rh
,
volatile grade of dilution D4 to D30
Chelidonium
Flos (ethanol)
,
volatile grade of dilution D4 to D30
Chelidonium
Flos
Rh
,
volatile grade of dilution D4 to D30
Ointment,: apply 1-2 times daily on rash (Kommission C, 1992)
Chelidonium majus
M.T. (ø)
Chelidonium
e radice ferm 34b, volatile grade of dilution D3 to D30
Chelidonium
ex herba cum radice ferm, volatile grade of dilution D3 to D30
Combinations of herbal substance(s) and/or herbal preparation(s) including a description of
vitamin(s) and/or mineral(s) as ingredients of traditional combination herbal medicinal products
assessed, where applicable.
A few herbal preparations in combination with
Chelidonium majus
are described in the
Deutschen
Receptformeln:
Tinctura Cholagoga (DRF) (a combination of
Chelidonium majus
tincture with
Silybum marianum
tincture and
Strychnos nux-vomica
tincture) and Tinctura Cholagoga Fortis (DRF)
(a combination of
Chelidonium majus
tincture,
Silybum marianum
tincture,
Atropa belladonna
tincture
and Mint oil). (
van Hellemont, 1985; Weiss & Fintelman, 1999
)
Iberogast®, also known as STW 5, is a prokinetic liquid formulation of nine herbs indicated for Irritable
bowel syndrome and dyspepsia. It contains a fixed combination of hydroethanolic herbal extracts from
bitter candy tuft (
Iberis amara totalis
), peppermint leaves (
Menthae piperitae folium
), chamomile
flower (
Matricariae flos
), liquorice root (
Liquiritiae radix
), angelica root (
Angelicae radix
), caraway fruit
(
Carvi fructus
), milk thistle fruit (
Silybi mariani fructus
), lemon balm leaves (
Melissae folium
) and
greater celandine herbs (Chelidonii herba). Each of which is reported to have multiple pharmacological
properties relevant in gastrointestinal pathophysiology. (
Wegener & Wagner 2006
)
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Iberogast® The composition of 100 ml liquid is the following:
Extracts from:
Iberis amara (fresh whole plant)
Extraction solvent: ethanol 50% (V/V)
(1:1.5-2.5)
15.0 ml
Angelicae radix
(1:2.5-3.5)
10.0 ml
Matricariae flos
(1:2.0-4.0)
20.0 ml
Carvi fructus
(1:2.5-3.5)
10.0 ml
Cardui mariae fructus
(1:2.5-3.5)
10.0 ml
Melissae folium
(1:2.5-3.5)
10.0 ml
Menthae piperitae folium
(1:2.5-3.5)
5.0 ml
Chelidonii herba
(1:2.5-3.5)
10.0 ml
Liquiritiae radix
Extraction solvent for all: ethanol 30% (V/V)
(1:2.5-3.5)
10.0 ml
Vitamin(s)
Not applicable
Mineral(s)
Not applicable
Information on period of medicinal use in the Community regarding the specified indication
See specific country-linked information.
Chelidonium majus
has been used since the middle ages. It
was used for biliary and liver disorders. The fresh latex was used in the treatment of warts but also for
other skin complaints such as corns, tinea infections, eczema and tumours of the skin. Therefore the
fresh latex was dabbed on the warts. (
Barnes et al, 2007; Hager et al, 1999
)
In other literature it was mentioned that in 1896 a Russian doctor injected 1.50-5 g of an extract
(concentration not specified) in combination with equal parts glycerine and distilled water in a tumour
of the skin. The tumour was decreased partialy or disappeared completely. Further research showed
that this painful method did not have an effect on the tumour but did only decreased secretion and
hemorrhages. (
Leclerc, 1954
)
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Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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1.2.
Information about products on the market in the Member States
Austria
See composition of Iberogast
®
under 1.1.
Belgium
Preparation
Aporil
®
contains tincture of
Chelidonium majus
45 mg, tincture of Thuja species 45 mg, acetic acid
80 mg, lactic acid 20 mg, salicylic acid 135 mg in 9 ml solvent.
Indication
Topical treatment of warts.
Regulatory
According to the Royal Decree of 1997 Chelidonium is included in list 3: it can be used in medicines as
well as in food supplements. There is no restriction with regard to maximal doses specified.
Bulgaria
Combination product with Chelidonii herba extractum fluidum (1:2,5-3,5): 10 ml/100 ml
Czech Republic
See composition of Iberogast
®
under 1.1.
Estonia
See composition of Iberogast
®
under 1.1.
Germany
See composition of Iberogast
®
under 1.1.
Slovenia
See composition of Iberogast
®
under 1.1.
Spain
Preparations
Combination of an extract of Chelidonium with a tincture of Thuja (1:10), salicylic acid, iodine and
acetic acid.
Indication
Topical treatment of warts.
Regulatory
There are other combined preparations with 7 to 9 herbal substances for use as a herbal tea. The
herbal substance is included in a list of plants restricted to be used as medicinal products and should
not be used in food supplements.
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Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Regulatory status overview
Member State Regulatory Status
Comments (not
mandatory field)
Austria
MA
TRAD
Other TRAD
Other Specify:
Combination prep
Iberogast
®
Belgium
MA
TRAD
Other TRAD
Other Specify: Combination prep.
Aporil
®
External use
Bulgaria
MA
TRAD
Other TRAD
Other Specify: Combination product on
the market
Cyprus
MA
TRAD
Other TRAD
Other Specify:
Czech Republic
MA
TRAD
Other TRAD
Other Specify: Combination prep
Iberogast
®
Denmark
MA
TRAD
Other TRAD
Other Specify: No authorised or
registered preparations
Chelidonium not allowed
in food supplements
Estonia
MA
TRAD
Other TRAD
Other Specify: Combination prep.
Iberogast
®
Finland
MA
TRAD
Other TRAD
Other Specify:
France
MA
TRAD
Other TRAD
Other Specify:
Germany
MA
TRAD
Other TRAD
Other Specify: Combination prep.
Iberogast
®
Greece
MA
TRAD
Other TRAD
Other Specify:
Hungary
MA
TRAD
Other TRAD
Other Specify:
Iceland
MA
TRAD
Other TRAD
Other Specify: No authorised or
registered preparations
Ireland
MA
TRAD
Other TRAD
Other Specify: Voluntary withdrawal of
products for oral use
Italy
MA
TRAD
Other TRAD
Other Specify: Not allowed in food
supplements
Latvia
MA
TRAD
Other TRAD
Other Specify:
Liechtenstein
MA
TRAD
Other TRAD
Other Specify:
Lithuania
MA
TRAD
Other TRAD
Other Specify: Comminuted
Chelidonium for tea
infusion
Luxemburg
MA
TRAD
Other TRAD
Other Specify:
Malta
MA
TRAD
Other TRAD
Other Specify: No authorised or
registered preparations
The Netherlands
MA
TRAD
Other TRAD
Other Specify: No authorised or
registered preparations
Norway
MA
TRAD
Other TRAD
Other Specify: Herb can be sold on
prescription
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L., herba
EMA/HMPC/369801/2009
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Member State Regulatory Status
Comments (not
mandatory field)
Poland
MA
TRAD
Other TRAD
Other Specify:
Portugal
MA
TRAD
Other TRAD
Other Specify:
Romania
MA
TRAD
Other TRAD
Other Specify:
Slovak Republic
MA
TRAD
Other TRAD
Other Specify: No authorised or
registered preparations
Slovenia
MA
TRAD
Other TRAD
Other Specify: Combination prep
Iberogast
®
Spain
MA
TRAD
Other TRAD
Other Specify:
No authorised or
registered preparations
for internal use
Topical preparation only
Sweden
MA
TRAD
Other TRAD
Other Specify: No authorised or
registered preparations
United Kingdom
MA
TRAD
Other TRAD
Other Specify: No authorised or
registered preparations
MA: Marketing Authorisation
TRAD: Traditional Use Registration
Other TRAD: Other national Traditional systems of registration
Other: If known, it should be specified or otherwise add ’Not Known’
This regulatory overview is not legally binding and does not necessarily reflect the legal status of the
products in the MSs concerned.
2.
Non-Clinical Data
2.1.
Pharmacology
2.1.1.
Overview of available data regarding the herbal substance(s), herbal
preparation(s) and relevant constituents thereof
In vitro
studies
Antiviral effect
Amoros
et al,
1977:
Extracts of the whole plant of
Chelidonium majus
were tested for their antiviral
properties. Alcoholic (96° ethanolic extract, 1 ml of the aqueous solution corresponds to 1 g of the
fresh plant.) and alkaline (50 g of the dried and pulverised plant was eluted with ammonia solutions
and extracted with chloroform) extracts were tested on the herpes simplex and the polio virus. The
alkaline extract showed activity against herpes simplex virus but not against the polio virus, whereas
the alcoholic extract didn’t show any inhibitory effect. The authors note that this is only a preliminary
search to antiviral properties of certain plants.
Sethi, 1981-1983-1985:
Protoberberine and benzophenanthridine alkaloids were tested for inhibition
of reverse transcriptase (RT) activity of RNA tumour viruses. Inhibition of reverse transcriptase activity
was correlated with the structure and antileukemic activity of the protoberberine alkaloids,
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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inhib of RT-activity
(50% inhibition)
Antileukemic activity
µg/ml
µM
%
Dose
(mg/kg)
coralyne acetosulfate
30
60
176
100
8-Et coralyne ethosulfate
35
72
219
100
8-Pr coralyne proposulfate
95
170
100
100
2,3-Me dioxy-10,11dimethoxy
dibenzoquinolizinium
acetosulphat
50
103
122
50
2,3-dimethoxy-10,11methylene
dioxydibenzo quinolizinium
acetosulphat
45
92
121
100
10-demethoxycoralyne
acetosulphat
45
92
145
100
13-methylpalmatine iodide
80
158
116
100
palmatine chloride
60
124
107
12,5
norcoralyne chloride
30
70
/
/
stracoralyne acetosulfate
45
111
154
80
isocoralyne acetosulfate
60
115
180
80
fagaronine chloride
70
139
177
40
isomers of fagorine
6
16
265
100
isomers of fagorine
80
209
107
100
isomers of fagorine
12
32
147
100
Table 1:
Comparison of inhibition of reverse transcriptase and antileukemic activities of protoberberine
and benzophenanthridine alkaloids. (
Sethi, 1985
)
The phenolic and methoxy groups on the structure of the benzophenanthridine are important for anti-
RT activity, so individual members of alkaloids show very different activity. The presence of
the quaternary nitrogen in the molecule is necessary for activity. Compounds like chelidonine
(IC
50
=200 μg/ml) who do not have a quaternary nitrogen are very weakly active against RNA tumour
viruses.
Kéry et al, 1987
: The squeezed juice and a sodium chloride extract of the aerial parts of the plant
was subjected to bioassays to test activity against adenoviruses and herpes simplex virus type I
(HSV-I). Subfractions were taken from the aerial parts and the root and tested also for activity.
After incubating the fractions with cells infected with adenovirus type 12, the subfraction with
concentration of 35 μg/ml showed antiviral activity. This fraction showed also virucidal activity against
HSV-1, achieving 100% loss of virus infectivity after 90 min of incubation (after 30 min, 75% and after
60 min, only 25% of the cells were infected with the virus). Although adenoviruses 5 and 12 were less
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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sensitive, they retained 50% infectivity after 120 min incubation (75% infections after 60 and 90 min
for adenovirus 5 and 12.). This alkaloid fraction would belong to the benzophenanthridine fraction of
Chelidonium majus
.
Tan et al, 1991:
Chelidonine on itself is only a weak inhibitor against human immunodeficiency virus
type-I reverse transcriptase (IC
50
around 200 μg/ml). Berberine chloride showed moderate inhibitory
activity against the same enzyme (IC
50
around 100 μg/ml).
Rogelj et al, 1998:
Extract, with tris-HCl buffer pH 7, was taken from the green parts of a mature
Chelidonium majus
plant. The extract showed inhibitory activity, no concentrations are shown, against
cysteine proteinases. Chelidocystatin was isolated from this extract and was the inhibitor of the
cysteine proteinases cathepsin L (Ki = 5.6 x 10
-11
M), papain (Ki = 1.1 x 10
-10
M) and cathepsin
(Ki = 7.5 x 10
-9
M). The values are typical for phytocystatins since similar values were obtained for
inhibition of the papain, cathepsin L and cathepsin H with phytocystatin from
Phaseolus vulgaris
seed.
Antimicrobial activity
Mitscher et al, 1978:
Antimicrobial activity was found for pseudoalcoholates of sanguinarine and
chelerythrine, who have greater intercellular penetration than the polar benzophenanthridine itself and
are active (MIC= 6.25 μg/ml) against
Staphylococcus Aureus, Escherichia Coli, Salmonella gallinarum,
Klebsiella pneumoniae, Mycobacterium smegmatis and Candida albicans.
Lenfeld J et al, 1981:
Fractions of
Chelidonium majus
containing chelerythrine and quaternary
benzophenanthridine showed activity against some
Escherichia coli, Pseudomonas aeruginosa,
Klebsiella pneumoniae
and
Candida albicans
. There was a significant antimicrobial effect upon gram-
positive bacteria and upon
Candida
Minimal inhibitory concentrations (MIC) and minimal bactericidal
concentrations (MBC) of the quaternary benzophenanthridine fraction (QBF) and of chelerythrine are
shown in the following table.
Organism
QBF
Chelerythrine
MIC (µg/ml) MBC (µg/ml)
MIC (µg/ml)
MBC (µg/ml)
S. aureus
5
40
10
40
S. beta A
10
10
10
10
S. alfa
20
40
20
40
C. albicans
5
>160
5
>160
Table2
: MIC and MBC of QBF and chelerythrine (
Lenfeld et al, 1981
)
Mahajan et al, 1982:
Alternaria
,
Aspergillus flavus
,
A. fumigatus
,
Candida albicans, Curvularia,
Drechslera, Fusarium, Mucor, Penicillium, Rhizopus orizae and Scopulariopsis
growth was inhibited by
Berberine in concentrations of 10-25 μg/ml
Fik et al, 1997:
Drug resistant
staphylococci
and
enterococci
were found sensitive for a glycoprotein
isolated from the juice of
Chelidonium majus
leaves and roots
in vitro
. The minimal bactericidal
concentration, MBC, values of various methicillin-sensitive
S. aureus
(MSSA), methicillin-resistant
S. aureus
(MRSA), mupirocin-resistant MRSA, aminoglycoside-resistant
E. faecium
and
aminoglycoside-resistant
E. faecium
were established, and were found 31-125, 31-250, 31-125,
125-500, 250-500 mg/l, respectively.
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Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Matos et al, 1999:
Antifungal activity
in vitro
was documented for
Chelidonium majus
extracts
against
Fusarium
strains. A methanolic extract of the whole plant showed the highest antifungal
activity. After five days of inoculation, the growth of the strain was reduced to less than 40% as
compared to the control, but this was seen only in one strain with an alcoholic extract and no reduction
was seen with a water extract.
Fusarium oxyxporum cubense
strain was most sensitive to the
methanolic extract,
F. solani
was the most sensitive strain to all three extracts. Methanolic root extract
achieved a better inhibition of growth in comparison with extracts from the aerial parts: growth of
F. oxysporum cubense, F. oxysporum melonis
and
F. solani
was reduced to less than 30% of that seen
with control, although
F. culmorum
seemed rather insensitive. In further experiments, chelerythrine
and sanguinarine were found to be active against
F. solani
and
F. culmorum
.
F. solani
is sensitive to
berberine, but there was no activity found for chelidonine.
Ma et al, 2000:
Chelidonine, dihydrochelerythrine and dihydrosanguinarine, isolated out of an extract
of
Chelidonium majus
roots, have activity against
Cladosporium herbarum
. The lowest concentrations
which showed activity against
Cladosporium herbarum
were 10. 6 and 4 μg/ml respectively
(determined by TLC).
Zuo GY et al, 2008:
extracts and compounds isolated from the aerial part of
Chelidonium majus
were
tested for their antibacterial activity against strains of
methicillin-resistant Staphylococcus aureus
(MRSA). Bioassays led to the isolation of four benzophenanthridine-alkaloids (8-hydroxydihydro-
sanguinarine (hhS), 8-hydroxydihydro-chelerythridine (hhC), dihydro-sanguinarine (hS) and dihydro-
chelerythrine (hC)) who showed activity against MRSA strains, with MIC
50/90
values of 0.49/1.95;
0.98/7.81 μg/ml for hhS and hhC respectively. hS and hC showed moderate to no inhibitory effects at
concentrations up to 3 mg/ml.
Anti-tumour effect
Krey and Hahn, 1969:
Berberine has been shown to interact with nucleic acids by optical methods.
They suggested that berberine binds to DNA, because calf-thymus DNA produced changes in
absorbtion spectrum of berberine. This leads us to the fact that the planes of berberine lie parallel to
those of purine and pyrimidine pairs in DNA (double, single DNA and ribosomal RNA).
Hladon et al, 1978:
Cytotoxic activity of chelidonine, sanguinarine and berberine was tested in HeLa
cell cultures, ED
50
values were respectively 0.27; 0.54 and 3.5 to 30.0 μg/ml. ED
50
values in normal
rabbit kidney cell cultures were 1.35 μg/ml for chelidonine and 0.66 μg/ml for sanguinarine. Only weak
activity for Erlich ascites carcinoma cell cultures was observed for chelidonine and sanguinarine.
Caolo and Stermitz, 1978:
Anti-tumour activity of some quaternary benzophenantridine alkaloids
was tested to determine the structure-activity relationship. It was found likely that the iminium site
was involved in the biological activity of these compounds, a high iminium ion concentration (90-98%)
in 50% ethanol is correlated with a good anti-tumour activity. Sanguinarine and Chelerythrine (resp.
3% and 10% iminium ion at pH7 in 50% EtOH) are inactive against P388 and L1210 mouse leukaemia.
Maiti et al, 1982:
Anti-leukaemic activity of cytotoxic protoberberine alkaloids could be related to the
structural conformation of the molecule and its DNA-binding properties. Free calf thymus DNA showed
an absorption maximum of 325 nm, whereas bound DNA-sanguinarine showed an absorption of
342 nm. These results were evaluated against a control with ethidium (free showed an absorption max
of 480 nm, whereas bound ethidium-DNA showed an absorption maximum of 520 nm. The melting
points were also documented, they were 68°C and 91°C respectively. The biologic effects of
sanguinarine can be attributed to the formation of a complex of sanguinarine with DNA.
Smekal et al, 1984; Smekal & Kubova, 1984; Faddejeva et al, 1984:
DNA is intercalated by
sanguinarine, the neutral form intercalates partially while cationic form intercalates totally into the DNA
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double helix. There is a strong interaction with DNA, this indicates (like ethidium) that sanguinarine is
involved into the DNA base pairing. Ethidium and sanguinarine are affecting the circular dichroism
spectrum of DNA in the same manner.
Smekal et al, 1985:
Chelerythrine binding differs from sanguinarine which suggests steric-hindrance
effects of the substituents on ring D.
Ishii et al, 1985:
Anti-tumour activity of chemically synthesized and natural non phenolic
benzophenanthridine occurring alkaloids was evaluated for sarcoma 180 cell lines. Results showed the
iminium site in the molecule was determinant for activity against these cells. Chelerythrine was found
less active than sanguinarine, when tested
in vitro
against Kb cells and
in vivo
against L1210 and P288
leukaemia’s. Chelerythrine, used in doses of 3 and 1 mg/kg/5days, gave resp. 26% and 81% tumor
growth relative to the control. Sanguinarine, used in doses of 10 and 3 mg/kg/5days gave 1 and 87%
tumor growth respectively (also when compared with the control).
Vavreckovà et al, 1996a and 1996b:
Chelidonium majus
antiproliferative effects were subjected
into
in vitro
studies with rapidly multiplying human keratinocyte cell lines (HaCaT cells). A dry
extract (0.68% alkaloids calculated as chelidonine) inhibited HaCaT cell growth with an IC
50
value of
1.9 μmol/l. Sanguinarine, chelerythrine and chelidonine respectively gave IC
50
values of 0.2; 3.2 and
3.3 μmol/l. The potency of sanguinarine was similar to that of the antipsoriatic agent anthralin
(IC
50
= 0.7 μmol/l), whereas berberine showed a low potency (IC
50
= 30 μmol/l). Further investigation,
by following lactate dehydrogenase release in the culture, showed more evidence for cytostatic activity
than cytotoxic activity.
Song et al, 2002:
A polysaccharide fraction from a water extract inhibited the proliferation of several
tumour cell lines
in vitro
. A 100 μg/ml fraction showed over 50% cytotoxicity for the P815 and B16F10
cell lines.
Antispasmodic activity
Kardos et al, 1986:
Protopine, cryptopine and allocryptopine enhance [
3
H
]-GABA binding to rat brain
synaptic membrane receptors, this in comparison with diazepam binding. The following table gives the
concentrations and enhancement (%) of the GABA binding. The effect of diazepam is more significant
than the effect with the protopine alkaloids, indicating that the enhancement of GABA binding and
binding to benzodiazepine receptor may be independent phenomena.
Conc (µmol/l)
% of control
Diazepam
Protopine
Cryptopine Allocryptopine
0.01
1%
/
/
/
0.1
5%
0%
0%
0%
1
14%
7%
5%
10%
10
39%
31%
24%
30%
100
46%
/
/
/
Table3
: Effect of diazepam and protopine alkaloids on
3
H-GABA binding (
Kardos et al, 1986
).
Boegge et al, 1996:
An aqueous-methanolic extract of the flowering aerial parts of
Chelidonium
majus
and the isolated constituents coptisine and (+)-caffeoylmalic acid, have been evaluated for its
antispasmodic activity.
In vitro
tests involving isolated rat ileum was used. The extract contained
0.81% alkaloids, 2.00% flavonoids, 1.20% hydroxycinnamic acid derivates and 0.06% (+)-
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caffeoylmalic acid. The extract showed a antispasmodic activity of 12.7% (SEM=4.0) in comparison to
that of control group (Ach). Coptisine (at concentration of 1.0x10
-5
g/ml organ bath) and (+)-
caffeoylmalic acid (at concentration of 2.5x10
-5
g/ml) were found to be the two constituents who
contribute to the total antispasmodic activity of the extract, They exert a mean antispasmodic activity
of 16.5% (SEM=3.0) and 6.9% (SEM=2.6) at these concentrations respectively. A lower concentration
of coptisine (0.5x10
-5
g/ml organ bath) did not exhibit any statistically antispasmodic activity.
Häberlein et al, 1996:
In vitro
tests demonstrated effects of an extract of
Chelidonium majus
herb
and certain constituent alkaloids at GABA
A
receptors. Radio receptor assays were evaluated with high
concentrations of a dry ethanolic extract of the herb, who inhibited 50% of specific [
3
H
]-muscimol
binding. At lower concentrations, specific binding of 115% indicated induction of positive co-operation.
The alkaloid content (mg/100 mg dry extract) of the extract was determined allocryptopine 0.076,
chelerythrine 0.009; protopine 0.465; sanguinarine 0.003 and stylopine 0.154. Further studies showed
allocryptine, stylopine and protopine are responsible for the positive cooperative effect, mainly
contributed by protopine. Concentration of chelerythrine and sanguinarine were considered to be too
low to contribute.
Hiller et al, 1998:
Two hydro alcoholic (ethanol 70% w/w) extracts of
Chelidonium majus
(at
concentration of 5x10
-4
g/ml organ bath) relaxed, isolated guinea-pig ileums who were contracted using
barium-chloride. The alkaloid content of both extracts was determined (by HPLC), containing
chelidonine (0.38%), protopine (0.41%) and coptisine (0.32%) and extract two contained 0.59%;
0.48%; 0.26% respectively. Individual constituents were tested also and the mean percent of
relaxation was 68.8% and 54.8% for chelidonine and protopine both at concentrations of 1x10
-5
g/ml
organ bath. Coptisine up to a concentration of 3x10
-5
g/ml organ bath, showed no significant relaxation.
Further experiments using these two active substances together and individual produced a
concentration-dependent reduction of carbachol and electric-field-induced contractions. These results
indicate that the antispasmodic effects of the herb comprise both musculotropic and neurotropic
mechanisms.
Choleretic activity
Vahlensieck et al, 1995:
Total ethanolic (70% EtOH) extract (total alkaloid content 1.6%; caffeic
acid esters 1.9%), the phenolic and alkaloid fraction of
Chelidonium majus
herb were evaluated for
their choleretic activity using isolated perfused rat livers. Choleresis was induced by the total extract
(concentration of 10 mg/ml/minute), there was a significantly increased bile flow and after 40 min, the
amount of bile was doubled as compared to the pre-treatment value. The two other fractions showed a
slight increase of the bile flow, but it was not-significant. Even when used together they gave an
increase of 20% over pre-treatment value, which was not significant.
Anti-inflammatory effect
Chung et al, 2004:
effects related to anti-inflammatory activity have been evaluated for
Chelidonium
majus
extract, specific plant parts not showed, the yield of the decocttion was approximately 9%, and
for some alkaloids. Mouse peritoneal macrophages were used
in vitro
, nitric oxide production levels
showed a significant increase when these cells were incubated with water extracts of the herb at
different concentrations (0.01; 0.1; 1 mg/ml) together with recombinant murine interferon-gamma.
This was compared to treatment with recombinant murine interferon-gamma only. The increased NO
level indicates there is a cooperative induction of NO production. The increased NO levels were
progressively inhibited by incubation with increasing levels of N-monomethyl-L-arginine and by
addition of the antioxidant compound pyrrolidine dithiocarbamate (PDTC) (concentration: 100 μM).
Furthermore, incubation of mouse peritoneal macrophages induced by
Chelidonium majus
extract plus
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rIFN-gamma increased tumour-necrosis-factor-alpha (TNF-a) production in a concentration dependent
manner. When nuclear factor kappa B inhibitor PDTC was added, there was a significant decrease in
production of TNF-a, so
Chelidonium majus
extract increases TNF-a production via NF-kB activation.
Vavreckovà et al, 1996:
The alkaloids sanguinarine and chelerythrine and a total extract of the herb
showed inhibition of 5-lipoxygenase (5-LO) in isolated bovine polymorphonuclear leukocytes (PMNL)
with IC
50
values of 0.4; 0.8 and 1.9 μmol/l respectively. Sanguinarine and chelerythrine also inhibit 12-
LO (from mouse epidermis; IC
50
values 13 and 33 μmol/l respectively) whereas
Chelidonium majus
extract was inactive at a concentration of 170 μg extract/ml test solution. Chelidonine was tested also,
but didn’t show any activity against LO (IC
50
= >100 μmol/l).
Vasopressin effect
Granger et al, 1992:
Chelerythrine and sanguinarine exhibited affinity for rat liver vasopressin
V
1
-receptors. [
3
H
]-vasopressin were inhibited by those two alkaloids within the micromolar range
(
K
i
,
inhibition constant, 4x10
-6
M and 7x10
-6
M respectively). The interaction on the V
1
-receptor is based
on the position of the alkoxy group and the quaternary ammonium function.
Immunomodulatory activity
Song et al, 2002:
Polysaccharide fractions of a water extract of
Chelidonium majus
were incubated
for five days with spleen cells. Results showed an increase in the lytic activity of spleen lymphocytes to
Yac-1 tumour cells from 0.9% to 30.0% and 34.2% for the fractions CM-Al and CM-Ala respectively.
The optimal concentration for generation of activated T
c
-cells was 5 μg/ml for both fractions. A second
test, now with mouse peritoneal macrophages cultured with CM-Ala (10-100 μg/ml) gave also an
increase in cytotoxicity, compared with the control test. The results were determined by the uptake of
radio-labelled thymidine by the tumour cells.
Analgesic activity
Kim et al, 2001:
analgesic activity was tested by testing receptor activity for GABA receptors. An
aqueous extract of
Chelidonium majus
(no details specified) was used in patch-clamp experiments
using fresh periaqueductal grey (PAG) neurons isolated from rats. Every 2 minutes the extract was
applied at concentrations of over 0.3-10 mg/ml and elicited chloride ion current in a concentration-
dependent manner. Bicuculline, a GABA
A
antagonist, reversibly inhibited this effect. Further tests
showed the same results with lower concentrations of
Chelidonii herba
(0.03 and 0.1 mg/ml).
Shin, 2002:
These tests have demonstrated that low concentrations (0.03 and 0.1 mg/ml) of a
aqueous extract of
Chelidonii herba
(no details specified) suppress glycine-activated and increase
glutamate-activated ion current in PAG (periaqueductal gray) rat neurons.
In vivo studies
Antiviral activity
Lozyuk, 1977:
In influenza-virus-induced pneumonia mice, the total alkaloid extraction was injected.
Total alkaloids given, were therapeutically effective when the quantity of virus injected in the mice was
low.
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Antimicrobial activity
Zhu and Ahrens, 1982 and Pitea and Marginanu, 1972:
Berberine has been successfully used to
control the intestinal secretions enhanced by
E. coli
enterotoxin. Berberine has positive influence
because of the quaternary ammonium group.
Anti-inflammatory activity
Lenfeld et al, 1981:
Anti-inflammatory activity was screened for sanguinarine, chelerythrine and a
quaternary benzophenanthridine fraction in assays involving carrageenan-induced rat paw oedema.
Sanguinarine, 5 mg/kg body weight, subcutaneous showed the highest anti-flogistic activity,
chelerythrine (10 mg/kg body weight) was found less active, in compare to the control, what may be
explained by the different oxygen electro-donating group.
Anti-tumour effect
Sokoloff, 1968:
Chelidonine and protopine were tested for anti-tumour therapy in the treatment of
sarcoma 180 and Erlich carcinoma. The total dose of 50 μg/kg body weight of the mouse chelidonine
administered over 7 days showed an insignificant tumour inhibition (resp. 25% and 22% with mild
cytotoxicity). Total dose of 350 μg/kg of protopine administered intraperitoneally in 7 days exerted
only a mild tumour inhibition (resp. 15% and 26%).
Kim et al, 1969:
An ethanol-water (1:1) dry extract of
Chelidonium majus
roots and rhizomes was
inactive in animal models of leukaemia (L-1210 mice) and carcinosarcoma (Walker 256 rats). In
contrary, the extract had cytotoxic activity in an assay utilising Eagle’s 9KB carcinoma of the
nasopharynx (ED
50
<15 µg/ml). Coptisine and another, not named, alkaloid has also cytotoxic activity.
Kim et al, 1997:
N-methyl-N’-nitro-N-nitrosoguanidine (MNNG, 200 mg/kg body weight), a
carcinogenic agent, was given to rats, together with a saturated sodium chloride solution or a 0.9%
saline, for three weeks. A water methanol extract of
Chelidonium majus
(0.1% or 0.2% in the diet for
16 weeks) or no further treatment was combined, after 20 weeks the rats were killed. Pepsinogen-1-
altered glands (PPAGs) in the pyloric mucosa of the stomach occurred in all groups of rats, but the
mean number of PPAGs was significantly lower in animals treated with 0.1%
Chelidonium majus
herb
extract, compared with MNNG and saturated sodium chloride alone, but the results didn’t show a
significant difference in rats with a 0.2%
Chelidonium majus
extract. There were also no significant
differences between any groups in the number of animals with papilloma and squamous cell carcinoma
lesions of the fore stomach.
Immunomodulatory activity
Song et al, 2003:
the protein bound polysaccharide, CMAla, isolated from a water extract of
Chelidonium majus
, was given to mice (50
mg/kg) intraperitoneally 24 hours before sub lethal doses of
irradiation. Results showed a significant increase in platelet numbers in mice treated with
Chelidonium
majus
extract (evaluation: 5 days post radiation), also the white blood cells were significantly
increased in CM-Ala treated mice, compared to the control (9 days post radiation). This indicates a
haematopoietic recovery. In other experiments, mice were radiated with lethal doses of irradiation
(9Gy), the survival rate for mice treated with CM-Ala (50 or 100 mg/kg) was 80% at
30 days post-irradiation, whereas all mice in the control group were dead after 15 days.
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2.1.2.
Assessor’s overall conclusions on pharmacology
Viruses
The antiviral activity of total alkaloid extracts of
Chelidonium majus
shows activity against multiple
viruses (herpes simplex virus, polio virus, several adenoviruses)
in vitro
. HIV-I virus was found to be
less or more sensitive to berberine. There was only one study (mikrobiol 1977) that investigated
activity against
influenza
virus, results showed activity in mice, when pneumonia was induced by a low
quantity of
influenza
virus. Protoberberine was found active against reverse-transcriptase enzyme of
RNA-tumour viruses, whereas its activity is dependent of the quaternary nitrogen in its structure.
Chelidocystatin on its own has proved activity against cysteine proteinases. All these findings report a
good indication for antiviral activity of
Chelidonium majus
extracts, but further investigations are
necessary, especially
in vivo
trials.
Bacteria
Multi-drug resistant bacteria and MRSA strains were submitted in trials to test their sensitivity for
Chelidonium majus
extracts. Two benzophenanthridine alkaloids were found to be responsible for the
activity, but no
in vivo
or clinical trials were conducted to date. Total extracts and pure substances
(berberine, sanguinarine, chelerythrine and chelidonine) were tested for their antimicrobial activity
against many strains (gram positive, gram negative and dermatophytes). Berberine, the quaternary
nitrogen, showed
in vivo
activity against the enterotoxin production of
E. coli
.
Cancer
Most results of
in vitro
anti-tumour activity trials are pointing towards sanguinarine, chelidonine,
chelerythrine and berberine for the anti-tumour effect of
Chelidonium majus
extracts. The iminium
group in the structure of the molecules is hold responsible for the activity. Strongest anti-tumour agent
of
Chelidonium majus
was found to be sanguinarine, who intercalates strongly with DNA, The activity is
comparable with the anti-psoriatic agent anthralin. Chelerythrine, berberine and chelidonine are also
active but are less potent. Nevertheless,
in vivo
trials didn’t show any significant result for the anti-
tumour activity, so much more trials are welcome for this indication. The results of the
in vitro
tests
are very promising but they aren’t proven in
in vivo
studies so there are additional tests needed.
Gastro-intestinal
Coptisine, chelidonine and (+)-caffeoylmalic acid, on there own and cooperative, are showing
antispasmodic activity. Studies are indicating that there is a musculotropic and neurotropic effect and
are indicating that there is also an effect at the GABA receptor. Choleretic activity was also evaluated
but did not show any significant results with the total alkaloid extract of
Chelidonium majus
, this
suggests that all the components of the total extract are necessary for activity, rather than the
alkaloids only. Sanguinarine and chelerythrine extracts also showed a vasopressin receptor activity, so
vasopressin couldn’t bind to its receptor.
Inflammation
Chelidonium majus
extract increases TNF-a production via NF-kB activation, so it plays a role in the
anti-inflammatory process. 5 and 12-lipoxygenase are inhibited by sanguinarine and chelerythrine, but
not by total extract or chelidonine. These enzymes are involved with leukotriene B
4
and
12-hydroxyeicosatetraenoic acid synthesis, so they have anti-inflammatory properties. These results
were also shown in a
in vivo
study (
Lenfeld, 1981
).
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Miscellaneous
A water extract of
Chelidonium majus
gave a significant increase in the cytotoxicity of C
T
cells in a few
in vitro
studies.
In vivo
trials are showing also a positive immunomodulatory effect, but there are too
few studies to conclude. Analgesic activity was evaluated with its activity on GABA receptors. Results
showed an inhibition of GABA chloride currents which indicates an indirect mechanism for analgesic
activity. The activity on glycine, an inhibitory neurotransmitter, and glutamate, an excitatory
neurotransmitter, suggests also a nociceptive activity.
2.2.
Pharmacokinetics
2.2.1.
Overview of available data regarding the herbal substance(s), herbal
preparation(s) and relevant constituents thereof
Only few studies have been executed on the pharmacokinetics of the
Chelidonium
alkaloids.
Sanguinarine and chelerythrine
In a study with adult rats they orally administered a single dose of sanguinarine (10 mg/kg body
weight) in 1 ml water. Dihydrosanguinarine was identified as a sanguinarine metabolite in the plasma
and liver and significantly higher levels of dihydrosanguinarine were found compared to levels of
sanguinarine. Sanguinarine and dihydrosanguinarine were not detected in the urine (
Psotova et al,
2005
).
In a feeding experiment on pigs, where the daily dose was 5 mg/kg body weight, Sanguinarine was
found in all body fluids and tissues except for muscles. Chelerythrine, whose proportion in the food was
lower, was detected in faeces, liver, gingival and in the intestine and plasma (
Kosina et al, 2004
).
Coptisin
Coptisine was isolated from a traditional Chinese medicine and was administrated intravenous at a
dose of 10 mg/kg in rats. The plasma-drug concentration time profile can be described as a two
compartmental model. Coptisine was quickly eliminated with systemic clearance of 0.08 l/min/kg which
is 147% of the hepatic blood flow (0.055 l/min/kg in rats), suggesting that the alkaloid was quickly
cleared via hepatic clearance. The elimination half-life of coptisine was 288 min. The volume of
distribution at terminal phase was 30.07 l/kg. This is greater than total body water at 0.67 l/kg,
suggesting that coptisine may be widely distributed into extra vascular systems. The pharmacokinetics
of coptisine after oral administration at a dose of 10 mg/kg can also be described as a two
compartmental model. The terminal elimination half-life was 307.80 min. The oral bioavailability of
coptisine was 7.80% and the time to reach the maximum plasma concentration was 14 min. The
percent of coptisine excreted in the urine was 5.16% following intravenous administration and 0.26%
after oral administration. The significantly lower excretion following oral than intravenous
administration shows that coptisine may undergo the first pass effects. This low percentage strongly
suggests either a strong first-pass effect or poor absorption (
Li HL et al, 2006
).
Berberine
The pharmacokinetic assay of berberine was executed on rabbits, using intravenous and intramuscular
administration at a dose of 2 mg/kg. The plasma concentration of berberine as function of time can be
described as a two compartmental model with a terminal elimination half-life of 5.28 h, a total plasma
clearance of 5.64 l/h and a volume of distribution of 38.30 l. The amount of berberine excreted
unchanged into urine was found to be only 4.93% of the dose given. Berberine was also excreted
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biliary into the intestine and this may be one of the other major elimination pathways. The biliary
excretion of berberine was found to be 0.5% of the dose given.
Berberine was also given by the intramuscular route. The bioavailability was evaluated by comparison
with an i.v. bolus dose of 2 mg/kg. The absolute bioavailability of i.m. administration was 99.77%.
After oral administration less than 0.1% of a dose is excreted in the urine unchanged in 24 hours. A
reason for this finding may be intensive metabolism (elimination), but also poor absorption from the
gastro-intestinal tract cannot be excluded (
Chen CM et al, 1995; Moffat et al, 2004
).
2.2.2.
Assessor’s overall conclusions on pharmacokinetics
Rats, rabbits and pigs were used as species to investigate the pharmacokinetics of
Chelidonium
alkaloids. The main alkaloids in
Chelidonium majus
may be intensively metabolized or poorly absorbed.
The plasma concentration of the alkaloids as function of time can be described as a two compartmental
model. The high volume of distribution suggests penetration into the extra vascular system. Up to now
pharmacokinetic data on the components of
Chelidonium majus
are scarce. Further investigation on
the pharmacokinetics of alkaloids and other components of
Chelidonium majus
is necessary.
2.3.
Toxicology
2.3.1.
Overview of available data regarding the herbal substance(s)/herbal
preparation(s) and constituents thereof
Single/repeated dose toxicity
In an animal experimental study the anti-tumour properties of
Chelidonium majus
L. were
investigated. It was found that the fresh plant can cause acute toxicity due to the latex. Drying of the
plant considerably reduces the toxicity. The use of therapeutic doses is safe due to the low quantity of
alkaloids in the plant preparations. Large doses can irritate the gastro-intestinal tract. Excessive use
for long periods should be avoided because of the risk of hepatotoxic effects, including severe
hepatitis, severe cholestasis and fibrosis. A mechanism for
Chelidonium majus
induced hepatotoxicity
has not been established. In literature deadly poisonings have been described with children after
eating the plant (
Hänsel et al, 1992
).
The LD
50
in mice was tested and determined as 1300 mg/kg, while in rats it was more than
2000 mg/kg (ESCOP monograph).
Genotoxicity
Sanguinarine was shown to induce DNA damage in mouse bone marrow cells. (
Ansari et al, 2006
)
In vitro
DNA adducts formation with sanguinarine and chelerythrine in the presence of rat hepatic
microsomes has been described
(Stiborova et al, 2002
).
Sanguinarine elicited weak positive responses in the
Salmonella
mutagenicity test after metabolic
activation (
Frankos et al, 1990
).
Genotoxicity
in vivo
of
Macleaya cordata
(Willd.) R.Br. (Papaveraceae) was tested. The plant species
contains sanguinarine. An isoquinoline mixture made from the plant was given to rats (5, 330 or
660 ppm isoquinoline alkaloids), mixed with the food. DNA adducts formation in liver was analyzed.
No DNA damage was seen to rat lymphocytes or hepatocytes after 90 days administration (
Stiborova
et al, 2008
).
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Cytotoxicity
This study tested the cytotoxicity of sanguinarine and chelerythrine on human hepatoma cells.
Concentrations of 0.01, 0.1, 1µM were found not to be cytotoxic.
It was also shown that these benzophenanthridine alkaloids do not interfere with the expression of the
important P450 enzyme, CYP1A1 and that they do not affect the AhR (Aryl hydrocarbon receptor)
transcriptional activity in human hepatoma cells. Chelidonine did not show a significant cytotoxicity or
DNA damage (
Zdarilova et al, 2006; Dvorak, 2005; Kaminskyy et al, 2007
).
Cytotoxicity of chelidonine and protopine were investigated and cytotoxic activity was not observed for
alcoholic and water extracts (
Saglam et al, 2003
).
Recently a hepatotoxic assessment of
Chelidonium
has been executed in primary hepatocyte cultures
of different species. The aim was to elucidate the potential hepatotoxicity of
Chelidonium
in human,
rat, canine and monkey hepatocyte cultures. For this purpose water-soluble extracts were used. The
liquid extract showed a concentration-dependent toxicity in human hepatocytes and at concentrations
of 7.5 mg/kg for animal hepatocytes (
Runge et al, 2009
).
The involvement of sanguinarine and chelerythrine was investigated in cell cycle regulation and cell
death in various cell lines. Publications were mainly published from 1995 to 2006. These alkaloids
seemed to be good candidates for chemotherapeutic regimens. They could also contribute to the
development of successful immune therapies of some carcinomas due to their apoptotic potential.
However the complete signalling cascade in which sanguinarne and chelerythrine treatment induces
apoptotic cell death is not yet understood (
Malikova et al, 2006
).
Carcinogenicity
No data available
Reproductive and developmental toxicity
The alkaloid sanguinarine potently suppresses angiogenesis by inhibition of the VEGF signalling
pathway in the angiogenic process (
Basini et al, 2007
).
Local Tolerance
Contact dermatitis has been reported in a woman who had used
Chelidonium majus
to treat warts. The
woman experienced severe itching and erythema with papules at the application site. The reaction
resolved within a few days without treatment (
Etxenagusia et al, 2000
).
2.3.2.
Assessor’s overall conclusions on toxicology
When the dried parts of
Chelidonium
are used in normal dose, the toxicity is limited. Severe and
irreversible hepatotoxicity can occur after chronic administration of high doses. Further investigation is
needed on the mechanisms of action. Four alkaloids, sanguinarine and chelerythrine, chelidonine and
protopine were not found to be cytotoxic. The other components of
Chelidonium
need more
investigation to make a conclusion of cytotoxicity of
Chelidonium.
A recent study also suggested that
human hepatocytes seemed to be more sensitive to
Chelidonium
extracts than canine, rat and monkey
hepatocytes. Further evaluation of possible toxicological effects on human hepatocytes is needed. It
was found that sanguinarine and chelerythrine can induce DNA damage in rat and mouse cells. One
case of contact dermatitis has been reported after topical application so it could be a hypersensitivity
to one of the components. In summary, from the data available, the toxicity of
Chelidonium majus
can
be assumed to be low and the plant can be considered as relatively safe to use. Nevertheless further
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
Page 23/30
investigation is needed to exclude some toxic effects when the substance is used under normal
administration.
3.
Clinical Data
3.1.
Clinical Pharmacology
3.1.1.
Pharmacodynamics
3.1.1.1.
Overview of available data regarding the herbal substance(s)/herbal
preparation(s) including data on constituents with known therapeutic activity.
There are no intentional pharmacodynamic studies undertaken.
3.1.1.2.
Assessor’s overall conclusions on pharmacodynamics
No studies available.
3.1.2.
Pharmacokinetics
3.1.2.1.
Overview of available data regarding the herbal substance(s)/herbal
preparation(s) including data on constituents with known therapeutic activity.
No data available on humans.
3.1.2.2.
Assessor’s overall conclusions on pharmacokinetics
Not applicable.
Dose response studies.
3.2.1.
No dose-finding studies.
3.2.2.
Clinical studies (case studies and clinical trials)
Boulwere et al, 1985:
The
Chelidonium majus
alkaloids sanguinarine and chelerythrine were found
effective in the control of the production of bacterial sulphur compounds responsible for a halithosis.
Subjects (five females, two males, average age of 34 years old) were asked to use a oral rinse (15 ml
rinse for 15 sec each day at 9 AM). Saliva samples were taken at 8 minutes, 15 minutes and one hour
after application. The subjects couldn’t use any products like coffee, tea or couldn’t have any morning
mouth hygiene. Saliva samples were then worked on and incubated. The reduction of thiols available
to react with reagents was evaluated for the different substances. Results are aligned into the following
table.
1
In case of traditional use the long-standing use and experience should be assessed.
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
Page 24/30
Substance
Concentration
% of thiol reduction
Sanguinarine extract + ZnCl
0.030% / 0.20% 65.4%
ZnCl
0.22%
44.5%
Cetylpyridinium chloride + Domiphen
Bromide
0.045% / 0.005% 43.9%
Essential oils
16.4mM
15.6%
Table 5
: percent reduction of measurable volatile sulphur compounds from fermenting saliva by four
commercial mouth rinses.
Thus, rinses capable of lowering populations of anaerobic bacteria, who produce volatile sulphur
compounds, or those who are capable of covalently trapping sulphur, can be used to reduce bad breath
compounds.
Southard et al, 1987:
Benzophenanthridine alkaloids are used in the treatment of periodontal
disease, they are integrated into toothpastes and mouth rinses The subjects (five females, eight males,
with a average age of 29 years old) received a test irrigation fluid containing 22.5 µg/ml and 90 µg/ml
or a oral rinse solution with a concentration of 0.03% or placebo. The subjects used the solutions twice
a day for 14 days, without any other oral hygiene preparation. After day 4, 7 and 14, plaque and
gingivitis score was evaluated in comparison with day 0. After this first period, the test persons did a
cross over with the other test solution after a two week resting period that included optimal oral
hygiene. Results are aligned in the following table, containing the kind of used preparation and the
plaque and gingivitis score.
Plaque score
Gingivitis score
Day 0 Day 4 Day 7 Day 14 Day 0 Day 4 Day 7 Day 14
oral rinse
0.03%
0
0.37 0.53 0.74 0.17 0.33 0.47 0.79
PLACEBO 0
0.68 1.00 1.28 0.17 0.65 0.95 1.48
supragingival
irrigation
22.5 µg/ml 0
0.37 0.56 0.83 0.4
0.34 0.42 0.67
90 µg/ml 0
0.29 0.33 0.55 0.4
0.25 0.26 0.37
Table 4
: Preparations in order to the concentration and the plaque and gingivitis score
Ritter et al, 1993:
Tablets containing
Chelidonium majus
extract (containing 66.0 to 167.2 mg native
dry extract, equivalent to 4 mg total alkaloids, calculated as chelidonine) or placebo pills were
evaluated in a randomised, double-blind, placebo-controlled trial on 60 patients with functional
epigastric complaints. The patients received two tablets, three times daily for six weeks. The reduction
in symptom score, assessed using the Zerssen list, at the end of the trial was evaluated and was
significantly greater in the
Chelidonium majus
group, compared with the placebo group (p=0.003).
Physician’s assessment of efficacy was that 18/30 patients in the treatment group were improved or
symptom free, compared with 8/30 in the placebo group.
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
Page 25/30
3.2.3.
Clinical studies in special populations (e.g. elderly and children)
No data available.
3.2.4.
Assessor’s overall conclusions on clinical efficacy
Data from clinical studies are scarce. There is only one study with an extract of
Chelidonium majus
, the
dose given to patients with epigastric pain being equivalent to 4 mg total alkaloids. Although the
symptom score was positively influenced according to the Zerssen list as well as to the physicians’
assessment, the number of patients is too low to support a well established use.
3.3.
Clinical Safety/Pharmacovigilance
3.3.1.
Patient exposure
In Germany there is a graduated plan (grade II) concerning Chelidonium-containing medicinal products
for internal use which came into force on 09 April 2008.
The report is only available in German. Therefore only the key elements are mentioned.
1.
All marketing authorisations for medicinal products are withdrawn which lead to a daily intake of
more then 2.5 mg alkaloids from
Chelidonium majus
according to the posology of the SPC.
2.
For medicinal products which lead to a daily intake of 2.5 µg to 2.5 mg alkaloids from
Chelidonium
majus
according to the posology of the SPC the marketing authorization will be changed.
The following chapters of the package leaflet and the SPC are affected:
Contraindications
It is to quote that the intake of the medicinal product is contraindicated for persons which suffer from
liver diseases or which had liver diseases in history or in cases of concomitant intake of other liver
damaging medicinal products.
Special warnings and precautions for use
It is to quote that if signs of liver damage occur, the intake of the product should be stopped
immediately and medical advice should be sought.
Undesirable effects
It is to quote that cases of liver damage (increase of liver enzymes and bilirubin up to drug-mediated
hepatitis) as well as cases of liver failure occurred.
Pregnancy and lactation
It is to quote that the intake during pregnancy and lactation is contraindicated.
Duration of use
It is to quote that if the duration of use is longer than 4 weeks liver function test (transaminases)
should be conducted.
For those medicinal products that are also authorized for the use in children, the maximum limit of
alkaloids is to adjust according to the body weight (starting from 2.5 mg for a 70 kg adult).
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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The necessity for the graduated plan was justified with several cases of undesirable effects connected
to liver diseases reported after the intake of Chelidonium-containing medicinal products. The maximum
permissible value base on preclinical studies (
Notox project 320211 and 330222; Weleda 2002
). It is
emphasized that for the dosage 2.5 µg-2.5 mg alkaloids/day no valid studies for the proof of efficacy
exist.
3.3.2.
Adverse events
(
Barnes et al, 2007
)
Spontaneous reporting can be illustrated by published case reports.
Acute hepatitis
A woman (42y) was diagnosed with severe acute hepatitis 2 weeks after she started using a
preparation with herbal ingredients (a.o.
Chelidonium majus herba
and
Curcuma longa rhizoma
) for
dermatological conditions.
The following complaints were reported: high fever (40.5°C), epigastral pain, headache,
hypersensitivity of the eyes, muscle pain and tiredness. The patient became icteric, her urine had a
dark colour and faeces were discoloured. The patient declared that she had only taken 1 tablet of 500
mg paracetamol as co-medication.
Transaminases strongly increased: aspartate aminotransferase (ASAT): 838 U/l (0-40); alanine
aminotransferase (ALAT): 1490 U/l (0-30); lactatedehydrogenase (LDH): 389 U/l (114-235); gamma
glutamyltransferase (
-GT) 286 U/l (0-65). Total bilirubine 200 µM/l (3-26). Viral infection with
hepatitis A, B or C was excluded. Paracetamol intoxication was excluded by serum analysis.
After she discontinued the medication, her situation normalised within 2 months.
Causal relationship with Chelidonium was hypothesized but no causality scale or scoring was used
(
Crijns et al, 2002
).
10 cases of acute hepatitis were observed over 2 years, probably induced by
Chelidonium majus
,
frequently described to treat gastric and biliary disorders. The course of the hepatitis was mild to
severe, with marked cholestasis observed in 5 patients. In all cases other possible causes of hepatitis
were excluded (viral, autoimmune, hereditary, alcohol) by laboratory tests and imaging procedures.
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
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Liver biopsies were consistent with drug-induced damage. After discontinuation of greater celandine,
rapid recovery was observed in all patients and liver enzymes levels returned to normal in 2-6 months.
Unintentional rechallenge lead to a second flare of hepatic inflammation in 1 patient. No causality
scales were used (
Benninger et al, 1999
).
An 82 years old male patient was admitted to the geriatric ward of a local hospital. Cognitive
impairment had become worse during the last months. There was a decline in Mini-Mental-State (MMS)
from 24/30 to 14/30. When admitted to the hospital a MMS of 12/30 was found. There were no hepatic
preconditions known. The liver had normal dimensions as was shown by sonography and by magnetic
resonance imaging. The patient used a herbal tea preparation with self-collected Chelidonium as main
component. Liver enzymes were enhanced in serum: GGT 197 U/l; GOT 687 U/l; GPT 904 U/l; LDH
297 U/l; bilirubine 2.32 mg/dl.
The diagnosis toxic hepatitis caused by Chelidonium was made. The patient declared that he prepared
and used herbal medicine as told by friends and that he probably made his tea too concentrated. Five
months after discontinuation of the herbal practice, liver enzymes were returned to normal. There were
no signs of hepatic damage (
Bichler, 2009
).
Moro et al, 2009:
investigated one case of a 65 year-old man with a sudden onset of asthenia,
dyspepsia and jaundice. The first symptoms emerged 3 days before admission to the hospital and the
patient noticed hyperchronic urine and scleral jaundice. Laboratory test showed a strong enhancement
of transaminases and bilirubin levels: e.g. AST 3253 U/l (5-38); ALT 4765 (5-41). Apart from hepatitis
C virus antibodies (HCV), the remaining for hepatic viruses were negative. The positive screening for
HCV was most probably due to contact with patient’s brother-in-law who died 5 years earlier of HCV-
related hepatic cirrhosis.
The patient was currently taking lansoprazole (15 mg/d). Because of a persistent pyrrosis patient’s
wife recommended to take daily a cup of a
Chelidonium majus
decoction (boiling 4-5 spoons of dried
leaves in 150 ml of water, straining and leaving it overnight) . This treatment went on for one month
preceding the hospital admission.
Chelidonium majus
was identified by thin layer chromatography. The
tea preparation as well as lansoprazol were discontinued after admission, infusions with normal saline
were started, as well as treatment with glutathione (600 mg i.v. 2x/d) and ursodeoxycholic acid (300
mg p.o. 2x/d for 30 days). The patient was discharged from hospital after 10 days. He recovered
completely, though a mild pyrosis persisted, and the liver parameters normalised within 2 months.
Additionally to this case, 16 cases of
Chelidonium majus
hepatitis from literature were analysed.
Typical symptoms of cholestatic hepatitis (jaundice, itching and fatigue) usually arose after 2 or more
months since the beginning of greater celandine oral consumption. The onset seems to be independent
from dosage. This suggests that the adverse reaction may be of idiosyncratic nature. Typical
manifestations are hepatomegaly, serum transaminases and bilirubin level over the normal range.
Patients mostly tested negatively for antibodies against hepatitis viruses (sometimes slight positive
hepatitis-C viruses reactions were detected). A possibility of a celandine-drug interaction must be
considered, because a majority of patients took other (herbal or conventional) medicines. When the
consumption of greater celandine was interrupted, symptoms regressed and liver parameters
normalised until complete recovery within 2 to 3 months (rarely after more than 5 months), although
recovery could also be seen after 2 weeks. Rechallenge occurred in 2 patients with liver impairment as
results (
Moro et al, 2009; Stickel et al, 2001
).
A 58-year old woman was seen on consultation because of painless jaundice with dark urine and pale
stools. The jaundice started one week before consultation. There was no medication used besides
tablets of medicinal herbs for muscular pain since 6 weeks and – started after the jaundice –
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
Page 28/30
supplements of vitamins. The patient took capsules with 50 mg of greater celandine, 50 mg of gentian
and 100 mg of curcuma root.
The abdomen revealed a palpable and tender liver edge just beneath the costal arc. The gallbladder
was also palpable. Liver enzymes were strongly increased: GOT (AST) U/l (1740 U/l; on day 14
lowered to 55 U/l); GPT (ALT) 1566 U/l; on day 14 lowered to 45 U/l). An idiosyncratic mechanism is
put forward (
Hardeman et al, 2008
).
3.3.3.
Serious adverse events and deaths
No data available.
3.3.4.
Laboratory findings
See the graduated plan (Germany) under 3.3.1.
3.3.5.
Safety in special populations and situations
See the graduated plan (Germany) under 3.3.1.
3.3.5.1.
Intrinsic (including elderly and children) /extrinsic factors
See the graduated plan (Germany) under 3.3.1.
3.3.5.2.
Drug interactions
See the graduated plan (Germany) under 3.3.1.
3.3.5.3.
Use in pregnancy and lactation
As there exist some cytotoxicity, the herbal substance or preparations thereof are not recommendable
during pregnancy. See also the German graduated plan.
No systematic data reported.
3.3.5.5.
Drug abuse
Not applicable.
3.3.5.6.
Withdrawal and rebound
Not applicable.
3.3.5.7.
Effects on ability to drive or operate machinery or impairment of mental ability
Not reported.
3.3.6.
Assessor’s overall conclusions on clinical safety
The main concern goes to possible hepatic damage. In the Vigisearch database 95 cases of hepatic
complications are indexed and hepatic toxicity has been repeatedly reported in literature. This concern
leads to a graduated plan in Germany in 2008. This plan has been communicated to European
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
Page 29/30
Medicines Agency. It essentially consists in limiting the daily intake of total alkaloids from Chelidonium
to 2.5 mg. In the only clinical study reported patients took 4 mg. Apparently there were no major side
effects, but the study was limited to 6 weeks. The German recommendations should be taken into
consideration on a European level.
4.
Overall conclusions
Chelidonium extracts have a well documented antiviral activity with perspective.
Herpes simplex
, polio
as well as several adenoviruses are affected. There is even an
in vivo
anti-Influenza activity.
Protoberberine was found active against reverse transcriptase of RNA-tumour viruses. Antimicrobial
activity was mostly tested with separate compounds of Chelidonium. The same results were obtained
for the anti-tumoral activity.
Choleretic activity seems to be linked to the totality of the components. Furthermore in different
experimental models there are indications for anti-inflammatory and analgesic properties.
The alkaloids of Chelidonium seem to be intensively metabolised. A high volume of distribution should
be taken into consideration.
Although the acute toxicology of the total extract is low, some alkaloids such as sanguinarine induced
DNA damage in bone marrow cells. The same can be stated for the cytotoxicity.
There is only one clinical study with the total extract in patients with epigastric complaints, whereas
there are warnings against possible hepatotoxicity of Chelidonium containing preparations. These
warnings were translated into registration restrictions in Germany.
A risk-benefit analysis can be made for the herbal preparations containing Chelidonium. The herbal
substance is described in the European Pharmacopoeia with a minimum of 0.6% of total alkaloids. The
herbal substance as well as the alkaloids can be characterised without too much difficulty. Adulteration
of the herbal substance is no point of concern.
Although voluntary intoxications with the herbal substance and preparations thereof are not reported,
there is a concern with regard to possible hepatotoxicity. Indications for genotoxicity or foetotoxicity
are known for single alkaloids of Chelidonium, not for the total extracts. Chelidonium preparations are
used for epigastric discomfort and superficial warts. These conditions are not serious and other herbal
as well as conventional medicines exist for internal use. Warts are mostly treated with preparations
containing several plants which complicate the characterisation of mono preparations in the
monograph. The fresh latex is traditionally used in folk medicine and cannot be considered in an
industrial context. Patients with liver diseases should be considered as patients at risk and should not
take Chelidonium containing preparations. Although the herbal substance has a long standing use in
Europe, the risk-benefit balance can be considered as negative and the use of Chelidonium containing
preparations should be restricted as type of patients and daily intake of alkaloids is concerned.
Annex
List of references
Assessment report on
Chelidonium majus
L., herba
EMA/HMPC/369801/2009
Page 30/30
Source: European Medicines Agency
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