Community herbal monograph on
Vitis vinifera
L., folium
To be specified for the individual finished product.
Well-established use
Traditional use
With regard to the marketing authorisation
application of Article 10(a) of Directive
2001/83/EC as amended
With regard to the registration application of
Article 16d(1) of Directive 2001/83/EC as
amended
Vitis vinifera
L.,
folium
Vitis vinifera
L.,
folium
i) Herbal substance
i) Herbal substance
Not applicable.
Not applicable.
ii) Herbal preparation
ii) Herbal preparation
Dry extract (DER 4-6:1); extraction solvent
water
a) Comminuted herbal substance
b) Powdered herbal substance
c) Soft extract (DER 2.5-4:1); extraction solvent
water
Well-established use
Traditional use
Herbal preparation in solid dosage forms for oral
use.
Comminuted herbal substance as herbal tea for
oral use.
Herbal preparation in solid dosage forms for oral
use.
Herbal preparation in semi-solid dosage forms for
cutaneous use.
The pharmaceutical form should be described by
the European Pharmacopoeia full standard term
1 The material complies with the Ph. Eur. monograph (ref.: 01/2008:1374).
2 The declaration of the active substance(s) for an individual finished product should be in accordance with relevant herbal
quality guidance.
3 and 4 The material complies with the monograph of the Pharmacopée Française X., 1996
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L., folium
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4.1.
Therapeutic indications
Well-established use
Traditional use
Herbal medicinal product for treatment of chronic
venous insufficiency, which is characterised by
swollen legs, varicose veins, a feeling of
heaviness, pain, tiredness, itching, tension and
cramps in the calves.
Indication 1)
Traditional herbal medicinal product to relieve
symptoms of discomfort and heaviness of legs
related to minor venous circulatory disturbances.
Indication 2)
Traditional herbal medicinal product for
symptomatic relief of itching and burning
associated with haemorrhoids.
Indication 3)
Traditional herbal medicinal product for
symptomatic treatment of cutaneous capillary
fragility.
The product is a traditional herbal medicinal
product for use in specified indications exclusively
based upon long-standing use.
4.2.
Posology and method of administration
Well-established use
Traditional use
Posology
Posology
Adults and elderly
Indication 1)
Dry extract (DER 4-6:1; water)
Single dose: 360-720 mg
Daily dose: 360-720 mg
Adults and elderly
Oral use
Use in children and adolescents
a) Comminuted herbal substance as herbal tea
5-10 g/250 ml, 2 times daily.
The use in children and adolescents under
18 years of age is not recommended (see section
4.4 ‘Special warnings and precautions for use’)
b) Powdered herbal substance
270-350 mg, 3-5 times daily.
Duration of use
Cutaneous use
The recommended duration of use is 12 weeks.
Two to three weeks of treatment may be required
before beneficial effects are observed.
c) Soft extract (DER 2.5-4:1; water) in a cream
base (10 g contain 282 mg soft extract).
Apply a thin layer on the affected area 1-3 times
daily.
Long term use is possible in consultation with a
doctor.
Indication 2) and 3)
Adults and elderly
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Vitis vinifera
L., folium
EMA/HMPC/16635/2009
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Well-established use
Traditional use
Method of administration
Oral use
Oral use.
a) Comminuted herbal substance as herbal tea
5-10 g/250 ml, 2 times daily.
b) Powdered herbal substance
270-350 mg, 3-5 times daily.
Duration of use
Indication 1)
The recommended duration of use is 4 weeks.
If the symptoms persist for more than 2 weeks
during the use of the medicinal product, a doctor or
a qualified health care practitioner should be
consulted.
Indications 2) and 3)
If the symptoms persist for more than 1 week
during the use of the medicinal product, a doctor or
a qualified health care practitioner should be
consulted.
The use in children and adolescents under
18 years of age is not recommended (see section
4.4 ‘Special warnings and precautions for use’).
Method of administration
Oral use.
Cutaneous use.
4.3.
Contraindications
Well-established use
Traditional use
Hypersensitivity to the active substance.
Hypersensitivity to the active substance.
4.4.
Special warnings and precautions for use
Well-established use
Traditional use
If there is inflammation of the skin,
thrombophlebitis or subcutaneous induration,
severe pain, ulcers, sudden swelling of one or
both legs, cardiac or renal insufficiency, a doctor
should be consulted.
Indication 1)
If there is inflammation of the skin,
thrombophlebitis or subcutaneous induration,
severe pain, ulcers, sudden swelling of one or
both legs, cardiac or renal insufficiency, a doctor
should be consulted.
The product should not be used on broken skin,
In the event of inadequate or unsatisfactory
symptomatic response within 2 weeks, a doctor
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Vitis vinifera
L., folium
EMA/HMPC/16635/2009
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Well-established use
Traditional use
should be consulted as oedema may have
alternative causes.
around the eyes or on mucous membranes.
Oral use: In the event of inadequate or
unsatisfactory symptomatic response within 2
weeks, a doctor should be consulted as oedema
may have alternative causes.
In the absence of sufficient safety data, the use in
children and adolescents below 18 years of age is
not recommended.
Indication 2)
If rectal bleeding occurs during the treatment of
haemorrhoids a doctor or a qualified health care
practitioner should be consulted.
In the event of inadequate or unsatisfactory
symptomatic response within 1 week, a doctor
should be consulted.
Indication 3)
In the event of inadequate or unsatisfactory
symptomatic response within 1 week, a doctor
should be consulted as oedema may have
alternative causes.
In the absence of sufficient safety data, the use in
children and adolescents below 18 years of age is
not recommended.
4.5.
Interactions with other medicinal products and other forms of
interaction
Well-established use
Traditional use
Not known.
Not known.
4.6.
Pregnancy and lactation
Well-established use
Traditional use
Safety during pregnancy and lactation has not
been established. In the absence of sufficient
data, the use during pregnancy and lactation is
not recommended.
Safety during pregnancy and lactation has not
been established. In the absence of sufficient
data, the use during pregnancy and lactation is
not recommended.
4.7.
Effects on ability to drive and use machines
Well-established use
Traditional use
No studies on the effect on the ability to drive and
use machines have been performed.
No studies on the effect on the ability to drive and
use machines have been performed.
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Vitis vinifera
L., folium
EMA/HMPC/16635/2009
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4.8.
Undesirable effects
Well-established use
Traditional use
Hypersensitivity reactions of the skin (itching and
erythema, urticaria) have been reported. The
frequency is not known.
Indication 1), 2) and 3)
Contact allergy and/or hypersensitivity reactions
of the skin (itching and erythema, urticaria) have
been reported. The frequency is not known.
Nausea, gastrointestinal complaints and headache
may occur. The frequency is not known.
Oral use
Nausea, gastrointestinal complaints and headache
may occur. The frequency is not known.
If other adverse reactions not mentioned above
occur, a doctor or a pharmacist should be
consulted.
If other adverse reactions not mentioned above
occur, a doctor or a qualified health care
practitioner should be consulted.
Well-established use
Traditional use
No cases of overdose have been reported.
No case of overdose has been reported.
5.1.
Pharmacodynamic properties
Well-established use
Traditional use
Pharmacotherapeutic group:
Herbal medicinal product for venous diseases
ATC code:
C05 CP02
Not required as per Article 16c(1)(a)(iii) of
Directive 2001/83/EC as amended.
The efficacy of orally administered dry extract of
red vine leaves (4-6:1) in reducing oedema has
been studied in patients suffering from chronic
venous insufficiency (CVI, grade I or II).
Grapevine leaf extract improves the microvascular
blood flow in CVI patients.
5.2.
Pharmacokinetic properties
Well-established use
Traditional use
Not known.
Not required as per Article 16c(1)(a)(iii) of
Directive 2001/83/EC as amended.
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Vitis vinifera
L., folium
EMA/HMPC/16635/2009
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5.3.
Preclinical safety data
Well-established use
Traditional use
No signs of acute toxicity in rats or mice after oral
administration of 10,000 mg/kg body weight.
Not required as per Article 16c(1)(a)(iii) of
Directive 2001/83/EC as amended, unless
necessary for the safe use of the product.
No sub-acute toxicity in rats, in doses up to
250 mg/kg body weight daily for 90 days.
Tests on genotoxicity and reproductive toxicity do
not give any reason for concern for the cutaneous
use of the soft extract (2.5-4:1; water).
In the micronucleus test, the gene mutation test
in V79 cells of Chinese hamsters and the Ames
Salmonella
/microsome plate incorporation test the
extract of grapevine leaf proved not to be
mutagenic.
Tests on genotoxicity, carcinogenicity and
reproductive toxicity have not been performed for
comminuted and powdered preparations.
The teratogenicity study in rabbits (treatment
from 6
th
-18
th
day of pregnancy) did not reveal any
toxic effects in doses up to 3.000 mg/kg body
weight.
Tests on genotoxicity and reproductive toxicity do
not give any reason for concern.
Tests on carcinogenicity have not been performed.
Well-established use
Traditional use
Not applicable.
Not applicable.
15 July 2010
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Vitis vinifera
L., folium
EMA/HMPC/16635/2009
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Assessment Report
Table of contents
Table of contents
................................................................................................................... 2
1. Introduction....................................................................................................................... 4
2. Historical data on medicinal use ...................................................................................... 11
2.1. Information on period of medicinal use in the Community ...................................... 1
1
preparations and indications..................................................................................... 1
5
3. Non-Clinical Data ............................................................................................................. 15
preparation(s) and relevant constituents thereof ......................................................... 1
5
3.1.1. Assessor’s overall conclusions on pharmacology................................................. 2
3
preparation(s) and relevant constituents thereof ......................................................... 2
3
3.2.1. Assessor’s overall conclusions on pharmacokinetics ............................................ 2
3
preparation(s) and constituents thereof ..................................................................... 2
4
3.3.1. Assessor’s overall conclusions on toxicology ...................................................... 2
6
4. Clinical Data ..................................................................................................................... 26
4.1. Clinical Pharmacology ....................................................................................... 2
6
including data on relevant constituents ...................................................................... 2
7
4.1.1.1. Assessor’s overall conclusions on pharmacodynamics....................................... 2
7
including data on relevant constituents ...................................................................... 2
7
4.1.2.1. Assessor’s overall conclusions on pharmacokinetics ......................................... 2
8
4.2. Clinical Efficacy ................................................................................................ 2
8
4.2.1. Dose response studies.................................................................................... 2
8
4.2.2. Clinical studies (case studies and clinical trials).................................................. 2
9
4.2.3. Clinical studies in special populations (e.g. elderly and children)........................... 3
5
4.3. Overall conclusions on clinical pharmacology and efficacy ...................................... 3
5
5. Clinical Safety/Pharmacovigilance................................................................................... 36
5.1. Overview of toxicological/safety data from clinical trials in humans.......................... 3
6
5.2. Patient exposure .............................................................................................. 3
6
5.3. Adverse events ................................................................................................ 3
6
5.4. Serious adverse events and deaths..................................................................... 3
8
5.5. Laboratory findings .......................................................................................... 3
8
5.6. Safety in special populations and situations ......................................................... 3
8
5.7. Intrinsic (including elderly and children) /extrinsic factors ...................................... 3
8
5.8. Drug interactions ............................................................................................. 3
9
5.9. Use in pregnancy and lactation........................................................................... 3
9
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Vitis vinifera
L., folium
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5.12. Withdrawal and rebound.................................................................................. 3
9
5.14. Overall conclusions on clinical safety ................................................................. 3
9
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L., folium
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1.
Introduction
The aim of this report is to assess the preclinical and clinical available data on Vitis viniferae
folium for
preparing a Community herbal monograph and Community List entry. This report is based on the
documentation provided by the European Medicines Agency (EMA) completed by additional searches
and information taken from recent international literature on Vitis viniferae folium.
Bibliographic searches have been performed in MEDLINE (1966-2008); EMBASE (1974-2008). The
search terms were: Plant extracts; Plant leaves; Red vine leaf extract; Roter Weinlaubextrakt; Extract
Red vine / wine Leaf / Leaves
Vitis vinifera
; Folia
Vitis
vinifera.
Only preparations of
Vitis vinifera
as a single ingredient
are considered for the monograph, while the
studies performed with combinations are not discussed in this report.
1.1.
Description of the herbal substance(s), herbal preparation(s) or
combinations thereof
The plant originates from North Africa, South Africa or South West Europe.
Vitis vinifera
L., Grape vine,
is a perennial, defoliating limber with a wooden often twisted stem which can reach a length of 30
meters, but it is usually cut back to 1-3 meters. The shrub develops climbing branches forking to twigs
from where the long-stemmed, alternating arranged leaves protrude. The vine leaf is heart-shaped,
thin, long-stemmed, cordate with palmate venation and with 5-7 dentate lobes, divided by more or
less deep and open sinuses. It can be up to 15 cm long and 12 cm across at its widest point, its colour
is a uniform dark red. The upper surface is glabrous, but the lower surface may be pubescent. The
venation is prominent on the lower surface. At the lower tendrils the flower panicles with numerous
yellow-greenish flowers are formed. The fruits, arranged in large and long clusters are soft and pulpy
berries with yellow-green, reddish or purplish dark-blue skin [Pharm. Franc. X., 1996].
Vitis vinifera
belongs to the
Vitaceae
family. Several subspecies and varieties are distinguished among
which is the subspecies
sylvestris
(Gmelin) Berger, recognised as the spontaneous form of
V. vinifera
L., the subspecies
caucasica
Vavilov, occurring in both wild and cultivated form. It is supposed that
from these two, the cultivated form
Vitis vinifera
ssp.
sativa
DC has been grown [Bombardelli &
Morazzoni 1995, Bombardelli et al. 1997].
Herbal substance
The herbal substance consists of the dried leaves of the black to pulp-red grape and has a faintly
perceptible odour. The herbal drug is harvested by hand in the autumn following the grape harvest.
Drying takes place under natural conditions in accordance with local climatic conditions.
Latin Name: Vitis viniferae folium (
Vitis vinifera
L., var.
tinctoria
,
Vitaceae
) "Vitis vinifera" or "Vitis
folium";
Common Names: vine leaves or vineleaves or vine leaf or vineleaf or grape leaf (English);
Feuilles de vigne (French), Rebenblätter, Weinlaub (German), Fogli della vite (Italian), Hogas de la vid
(Spanish), Folhas da videira (Portuguese), Wijnstok bladeren (Dutch), liść winorośli właściwej (Polish),
Φύλλo Αμπέλου (Greek).
The crude herbal substance complies with the monograph “Vigne Rouge” French Pharmacopoeia
[Pharm. Franc. X., 1996]. The powder is reddish-brown. Examined under the microscope, the
powdered red vine leaf shows the following characteristics: more or less dense, unicellular, long,
tapering, covering trichomes, thick-walled, with bulbous or truncated base and a lumen divided into
loculi; numerous raphides of calcium oxalate are contained in these cells or scattered about; fragments
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
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of parenchyma containing twinned crystals of calcium oxalate; a few fragments of epidermis with
polygonal cells and some reticulate venation.
Since the beginning of the last century in many studies the chemical constituents of the different parts
of grape vine have been investigated. Fruit acids, tannins and pigments are the substances mainly
responsible for taste, odour and colour [PDR for Herbal Medicines, 2004].
Herbal preparation(s)
Comminuted herbal substance
Powdered herbal substance
Soft extract (DER 2.5-4:1); extraction solvent water
Dry extract (4-6:1; water)
See also market overview in 1.2
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.
Not applicable.
1.2.
Information about products on the market in the Member States
Member State
Regulatory Status
Member state
products, indications
Legal status
Austria
1)
360 mg-filmcoated tablet
1 tablet contains: 360 mg dry extract (DER 4-6:1), extraction
solvent water
2)
capsules
1 capsule contains: 180 mg dry extract (DER 4-6:1),
extraction solvent water
3)
oral drops
1 ml contains 73.5 mg extract (corresponding 1.2 mg
Aesculin) in ethanolic solution (the DER and the extraction
solvent are not declared in the SPC at the moment)
Since
1) December 2005
2) January 2000
3) March 1993
1) 1 tablet daily (up to 2 tablets). Duration of use: max. 3
months
2) 2 capsules in the morning (up to 4 capsules). Duration of
use: max. 3 months
3) 30 drops in the morning in fasting state
Indications
1,2) chronic venous insufficiency grade I and II; swelling of
feet and lower leg
WEU
1
Not mandatory field
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L., folium
EMA/HMPC/16633/2009
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Member State
Regulatory Status
3) phlebitis, edemas in the legs (also during pregnancy),
varicose veins
Belgium
Hard-capsules
350 mg powder per capsule
powder, corresponding to 8% total polyphenols and minimum
0.20% of anthocyanosides
Since 2005
oral administration
Adults: 1 to 2 capsules three times daily, during the meals
with a large glass of water.
Maximal dose is 6 capsules per day. Duration of use should be
limited to 3 months. If symptoms do not improve during use,
consult a doctor
Indications
used in case of subjective symptoms of venous insufficiency in
legs, such as heavy legs, after exclusion of all serious
pathologies such as phlebitis, thrombophlebitis and
thrombosis
WEU
Bulgaria
Not known
Cyprus
Not known
Czech Republic
(WEU)
Vitis viniferae folii extractum aquosum siccum (4–6:1), 180
mg – standardized to flavonoids content 3-7%
Posology
2 capsules corresponding to 360 mg of the extract
in the morning, during first 3 weeks increase of the dose to 4
capsules is possible to reach faster relief since
2001??
Indications
Prevention and therapy of symptoms of light or starting
moderate forms of chronic venous insufficiency related to
varicose veins such as swelling of the calves, heavy legs,
tingling
Denmark
No authorized herbal medicinal products containing
Vitis
vinifera
as a single drug preparation are on the market.
Estonia
Not known
Finland
Not known
France
(WEU)
Soft extract since 1970
Posology
1 drop 2 to 8 times daily. 1 g of extract/100 ml
Indications
uninfectious conjonctival irritations
TU
Preparations
Powder since 1982
dry aqueous extract since 1987, 1990
All for oral use, in adults
Posology
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Vitis vinifera
L., folium
EMA/HMPC/16633/2009
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Member State
Regulatory Status
1) 1 hard capsule 3 times daily (5 if necessary)
350 mg of powdered drug/capsule
2) 1hard capsule 2 times daily 200 mg of extract/capsule
3) 1 hard capsule 1 to 3 times daily containing 169 mg of
extract/capsule
Indications
1); 2); 3)
- Traditionally used in the symptomatic treatment of
functional disorders of cutaneous capillary fragility, such as
ecchymosis, petechias, etc.
- Traditionally used:, in subjective signs of venous
insufficiency, such as heavy legs
- in haemorrhoidal symptoms
combination herbal preparations with
Mélilot (
Melilotus
)
Marron d’inde (
Aesculus hippocastanum
)
Hamamélis (Hamamelis)
Germany
TU
Preparations
: soft extract (2.5-4:1), extraction solvent:
water at least
since 1976
Posology
for cutaneous use in adults
10 g cream contain 282 mg soft extract
Indications
Traditionally used to relieve symptoms of tired
legs
Risks
(adverse drug effects, literature) Allergic reactions,
itching and erythema, worsening of skin irritation. Contact
allergy and/or hypersensitivity reactions
WEU
1) soft extract (4-6:1), extraction solvent: water
2), 3) dry extract (4-6:1), extraction solvent: water
In the market
1), 3) at least since
1976
2) 2005
1) oral liquid
2) film-coated tablet
3) capsule, hard
all for oral use in adults
Posology
1) 1 x daily 6 ml liquid
if necessary 1 x daily 12 ml liquid
10 ml (= 11.013 g) liquid contain 0.6 g soft extract
2) 1 x daily 1-2 containing 360 mg dry extract each
3) 1 x daily 2 containing 180 mg dry extract each
if necessary 1 x daily 4
Indications
For symptomatic treatment of chronic venous
insufficiency, which is characterised by swollen legs, a feeling
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Vitis vinifera
L., folium
EMA/HMPC/16633/2009
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Member State
Regulatory Status
of heaviness, pain, itching, cramps in the calves at night
Risks
Common gastrointestinal complaints, nausea.
Hypersensitivity reactions of the skin (itching and erythema,
urticaria) have been reported
Greece
No authorized herbal medicinal products containing
Vitis
vinifera
as a single drug preparation are on the market
Hungary
1)180 mg capsules
1 capsule contains: 180 mg dry extract (DER 4-6:1),
extraction solvent water (2008)
2) oral drops
81.4 mg Vitis viniferae rubrae folii extr. spissum(4-6:1),
corresponding to 1.2 mg aescin/ml (1997)
3) Varixinal capsules
180 mg dry native extract of
Vitis vinifera
L., folium (DER:
4-6:1) extraction solvent: water (2009)
1) 2 capsules once a day
2) 30 drops in the morning in fasting state
3) 2 capsules once a day
Indications
1) chronic venous insufficiency; at stage of C
2
, C
3
and C
4A
according to CEAP
2); 3) For alleviating the discomfort feeling (fatigability,
tension of the legs) of the lower extremities occurring in the
course of the mild venous circulation disturbance
1); 3) It is not recommended during pregnancy and lactation.
Adverse effects: Gastrointestinal disorders
(Common)
stomach and intestinal discomfort, nausea
Skin and subcutaneous tissue disorders: (Uncommon) rash,
itching, hives
Iceland
Not known
Ireland
Not known
Italy
Food supplements
only.
Latvia
Preparations
Vitis viniferae
folii extractum aquosum siccum (4–6:1)
180 mg – standardized to flavonoids content 3-7%
since 2004
Indications
Prevention and treatment of signs related to chronic venous
insufficiency
Lithuania
Not known
Luxembourg
Not known
Malta
Not known
Netherlands
Not known
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L., folium
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Member State
Regulatory Status
Norway
Not known
Poland
Vitis viniferae extractum siccum (5-7:1), extraction solvent:
water, capsule hard
Product allowed onto the market according to previous polish
pharmaceutical low (less than 10 years).
Posology
oral use: adults, 2 capsules once a day (in the
morning)
Indications
support of mild symptoms of chronic venous
insufficiency
Portugal
No authorized herbal medicinal products containing
Vitis
vinifera
as a single drug preparation are on the market
One authorised
combination
product.
Romania
Not known
Slovakia
Preparations
Vitis viniferae folii extractum aquosum siccum (4–6:1)
180 mg – standardized to flavonoids content 3-7%
since 2005
Posology
2 capsules (360 mg) once a day, in the morning
time. Total daily dose can be increased up to 4 capsules once
a day, in the morning time
Indications
1) Prevention and treatment of signs related to chronic venous
insufficiency, which is usually expressed in connection with
varicoses and oedema in the lower parts of legs, fatigue,
pins and needles and pain in legs
Risks (adverse drug effects)
Allergic reactions including generalized rash and urticaria.
Nausea, gastric complaints
Slovenia
Not known
Spain
Preparations
(WEU)
Vitis viniferae folii extractum aquosum siccum (4–
6:1), 180 mg – standardized to flavonoids content 3-7%
Posology
2 capsules (360 mg) once a day, in the morning
time. Since
2001
Indications
Prevention and treatment of signs related to chronic venous
insufficiency, which is usually expressed in connection with
varicoses and oedema in the lower parts of legs, fatigue, pins
and needles and pain in legs
(TU)
Powdered herb. substance 270 mg/caps
Sweden
No authorized herbal medicinal products containing
Vitis
vinifera
as a single drug preparation are on the market
United Kingdom Not known
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L., folium
EMA/HMPC/16633/2009
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Regulatory status overview
Member State Regulatory Status
Comments (not
mandatory field)
Austria
MA
TRAD
Other TRAD
Other Specify: (4-6.1, water extr tab,
2005, 180 mg caps,
2003,
drops 73.5 mg/ ml,
corresp. 1.2 (aesculin),
1993
Belgium
MA
TRAD
Other TRAD
Other Specify: WEU
Caps 350 mg 1- 6/d
Bulgaria
MA
TRAD
Other TRAD
Other Specify: Not known
Cyprus
MA
TRAD
Other TRAD
Other Specify: Not known
Czech Republic
MA
TRAD
Other TRAD
Other Specify: Ext aq (4-6:1)
standardized 3-7%
flavonoids. Caps 180
mg, 2001
Denmark
MA
TRAD
Other TRAD
Other Specify: No product registered
Estonia
MA
TRAD
Other TRAD
Other Specify: Not known
Finland
MA
TRAD
Other TRAD
Other Specify: Not known
France
MA
TRAD
Other TRAD
Other Specify: WEU, eye drops Aqueous
soft extract (6:1) since
1970
TU, powder(1989) or
water extr. for oral use
(1987)
Germany
MA
TRAD
Other TRAD
Other Specify: dry water extr. (4-6:1),
180mg 1976, (360 mg)
2005
oral liquid, 10 ml contain
0.6 g soft extr.
TU
soft water extr. (2.5-
4:1), 1976,
cream, 10 g contain 282
mg soft extr.
Greece
MA
TRAD
Other TRAD
Other Specify: No product registered
Hungary
MA
TRAD
Other TRAD
Other Specify: (4-6.1, water extr tab,
2005, 180 mg caps,
2008 & 2009,
drops 81.4 mg/ ml,
corresponding. 1.2
(aesculin), 1997
Iceland
MA
TRAD
Other TRAD
Other Specify: Not known
Ireland
MA
TRAD
Other TRAD
Other Specify: Not known
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L., folium
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Member State Regulatory Status
Comments (not
mandatory field)
Italy
MA
TRAD
Other TRAD
Other Specify: Food Suppl. No product
registered
Latvia
MA
TRAD
Other TRAD
Other Specify: WEU Ext aq (4-6:1)
standardized 3-7%
flavonoids caps 180 mg,
2004
Liechtenstein
MA
TRAD
Other TRAD
Other Specify: Not known
Lithuania
MA
TRAD
Other TRAD
Other Specify: Not known
Luxemburg
MA
TRAD
Other TRAD
Other Specify: Not known
Malta
MA
TRAD
Other TRAD
Other Specify: Not known
The Netherlands
MA
TRAD
Other TRAD
Other Specify: Not known
Norway
MA
TRAD
Other TRAD
Other Specify: Not known
Poland
MA
TRAD
Other TRAD
Other Specify:
Portugal
MA
TRAD
Other TRAD
Other Specify: No product registered
Romania
MA
TRAD
Other TRAD
Other Specify: Not known
Slovak Republic
MA
TRAD
Other TRAD
Other Specify: WEU Ext aq (4-6:1)
standardized 3-7%
flavonoids. Caps 180
mg, 2005
Slovenia
MA
TRAD
Other TRAD
Other Specify: Not known
Spain
MA
TRAD
Other TRAD
Other Specify: WEU Ext aq (4-6:1)
standard. 3-7% flavon.
caps 180 mg
Powdered herb.
substance 270 mg/caps
Sweden
MA
TRAD
Other TRAD
Other Specify: No product registered
United Kingdom
MA
TRAD
Other TRAD
Other Specify: Not known
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.
Historical data on medicinal use
2.1.
Information on period of medicinal use in the Community
Red grapevine leaves, from
Vitis vinifera
L. [Fam.
Vitaceae
], are rich in flavonoids including
anthocyanins, oligomeric proanthocyanidins (OPCs) etc.
The knowledge of the medicinal potential of grape vine
(Vitis vinifera
) can be traced back far in
history:
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 11/40
In Europe, the leaves of Vitis vinifera are documented in the literature of traditional medicine for
their astringent and homeostatic properties where they are utilized in the treatment of diarrhoea,
bleeding, haemorrhoids, varicose veins and other circulatory and venous diseases [Anonymous
2004; 2005; 2006; Bombardelli & Morazzoni 1995].
In Turkish folk medicine, vine leaves are known to have a diuretic effect, while the juice of leaves
have been used as an eye bath [Kosar et al. 2007].
Native North American indigenous peoples used the leaf tea of related fox grape (
Vitis labrusca
L.)
for treating diarrhoea, as well as for hepatitis, stomach aches and thrush and externally poulticed
the wilted leaves for sore breasts, rheumatism, headaches and fevers. Other closely related Vitis
species have been used similarly.
In Indian Medicine: Grape is used for headache, dysuria, scabies, skin disease, gonorrhoea,
haemorrhoids and vomiting [PDR for herbal Medicines 2004].
Since ancient times, beneficial effects on health have been ascribed to wine and vine leaves, as
confirmed by numerous "recipes" reported in Egyptian papyri, the Sumerian tablets, the writings of
Hippocrates of Cos (5th-4th century BC), Celsus (1st century AD), Galen (130-201 AD) and Paracelsus
(1493-1541). The use of vine leaves has been documented. Retracing therapeutic literature from
France showed the origin of using red leaves shortly after first incidence of the respective grape vine
varieties called "teinturiers" [Schneider, 2007i]. The herbal substance and herbal preparations have a
long history of use in folk medicine where French winegrowers collected the red vine leaves at the time
of the grape harvest to make infusions and paste-like poultices from them. The infusions were filled
into bottles and regularly ingested in small quantities. The paste from vine leaves was used for the
treatment of swollen, painful legs. Nowadays, the extracts of grapevine leaves were developed into
modern herbal medicaments mainly used against venous diseases and for its effects on
microcirculation [Rabe et al. 2005; Volonté M, Petrini, 2004; Volonté et al. 2003]. The vine, fresh and
brined or fermented are used as food (mixtures of rice and spices with or without meat are wrapped
with vine leaves) and have been widely consumed as traditional foods (Dolmas) around the
Mediterranean countries [Kosar et al. 2007]. They are also used for diarrhoea, vomiting and varicose
treatment [Gharib Naseri & Heirari 2006].
There is evidence of the use of grapevine leaf outside France, in Italy in 1957, where the Biosedra
preparation was also tested in vascular disorders in gynaecology, producing a positive effect on
capillary fragility.
As early as 1960, a clinical study was published in Germany on the venous efficacy of a product, which
contained a fluid extract of grapevine leaf, with a drug/extract ratio of 1:1. The content of anthocyanin
was set at 600 μg/ml,which was subsequently changed to 1.2 mg bioflavonoids per ml (German
Rote
Liste
1974). In 1969, a company registered the preparation as a medicinal product, with the
indications of varices, phlebitis, thrombophlebitis, calf cramps and leg oedema. The successor product,
has been marketed since 1971. The capsules and tablets contain 180 mg and 360 mg of dried extract
of grapevine leaves.
An overview of grapevine leaf components and its supposed pharmacological action as well as the
polyphenol composition of
Vitis vinifera
can be found in the literature [Anonymous 2003; 2004; Petrini
et al. 2003; Schneider, 2007i; 2007ii; Schneider et al. 2008; Schaefer & Red 2003].
Nonclinical
in vitro
and
in vivo
studies suggested protective effects of components from extracts of
grapevine leaves on the venous system; e.g. procyanidines [Maffei et al. 1994; Constantini et al.
1999], and flavonoids [Nees et al. 2003]. For the extract preparation
(Extractum Vitis viniferae foliae
aquosum siccum, 4-6:1)
, dried leaves of red varieties of
Vitis vinifera
L. (Vitis viniferae folium) which
comply with the monograph described in Pharmacopée Français (10ème edition) for “vigne rouge” are
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 12/40
used. Thus, the herbal substance consists of the dried leaves of the black to pulp-red grape which
finally undergo a specific production process resulting in a defined flavonol content in the dry extract
preparation. While the whole dry extract preparation as such is considered as active agent, it is
particularly characterized by its content of flavonol glycosides and glucuronides, i.e. quercetin-3-O-β-
D-glucuronide, quercetin-3-O-β-glucoside, and kaempferol-3-glucoside. These flavonoids are
considered to contribute predominantly to pharmacological effects. The extract AS 195 contains a total
of 4-7% of flavonol glycosides, quantified as quercetin-3-O-β-D-glucuronide.
Grapevine leaves and extracts thereof have been traditionally used for the treatment of symptoms
associated with venous insufficiency for more than 70 years, in France. Extracts have been introduced
in a number of European countries, e.g. Austria, Belgium, Czech Republic, Spain, Switzerland, Italy,
and the United Kingdom. It is indicated for the prevention and treatment of Chronic venous
insufficiency (CVI), associated with varicose veins including oedema of the lower leg, heavy or tired
legs, sensation of tension, tingling and pain.
Based on the survey of products available in the Member states, the traditional use of red leaves
preparations has been demonstrated especially in France, Germany, Spain and Austria, for at least 30
years.
Red vine leaf has been included in the French official list entitled “Avis aux fabricants concernant les
demandes d’Autorisation de mise sur le marché” by virtue of which, the products containing it were
subjected to a simplified registration procedure before the implementation of the Directive
2004/24/EC.
In France: "Vigne Rouge" (= red vine leaf) is regarded as one of the herbal drugs whose efficacy and
safety has been proven by thorough literature studies and long-term traditional use. The Pharmacopèe
Française X ed. includes the monographs of "Vigne rouge" and "Extrait de vigne rouge (sec)" and the
traditional use of red vine leaves is discussed in "Rotes Weinlaub” [Schneider, 2007i; 2007ii].
Herbal medicinal products with red vine leaf have a long tradition in France. The official compendium
"Médicaments à base de plantes", issued by the French department "Ministère des Affaires sociales et
de la solidarité", released 1990, and comprised the long tradition of diverse herbals in France. There
are listed many herbals that have been used in France for a long time, at least for about 15–20 years.
[Les Cahiers de l'Agence 1998] state the use of red vine leaf for symptomatic relief of chronic venous
disease ("No 015+016: " Traditionellement utilise dans le traitement symtomatique des troubles
fonctionnels de la fragilité capillaire cutanée, tels que ecchymoses, pétéchies, etc."; No. 017+018:
"Traditionnellement utilisée: - dans les manifestations subjectives de l'insuffisance veineuse telles que
jambes lourdes; - dans la symptomatologie hémorroïdaire").
Different products prepared of water extracts of "Vigne Rouge" (5:1) have been available in oral forms,
in France to treat blood vessels fragility in order to reduce the feeling of heavy legs and haemorrhoids
related disorders. The posology range from 169 mg to 200 mg, two to three times a day, for four
weeks:
Vigne rouge, capsules: 1 capsule contains 200 mg of grapevine leaves dry aqueous extract is used, a
DER of about (4-6:1). The product is registered since 1987. The manufacturer recommends the use of
2 capsules per day (1 capsule mornings and one evening, with a glass of water). The product is
traditionally used to reduce fine blood vessels fragility, in order to reduce the feeling of heavy legs and
haemorrhoids related disorders.
OR
1 capsule contains 169 mg of grapevine leaves dry extract (3:1). The manufacturer recommends the
use of up to 3 capsules per day. The product is traditionally used to reduce the feeling of heavy legs,
haemorrhoids related disorder and fine blood vessels fragility.
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 13/40
An article from 'Deutsches Medizinisches Journal' published in
1960
by K. Güthenke, "Wesen und
Behandlung der Bindegewebsschwäche, insbesondere der Veneninsuffizienz mit Weinblattextrakt"
(Nature and Treatment of weak connective tissues, in particular venous insufficiency, ref.) describes
the long traditional use of grapevine leaves for treatment of diseases of the leg veins, and
demonstrates that vine leaf extracts have been already traditionally used before 1960, in Germany.
Registrations for the active ingredient
Extractum vitis viniferae foliae aquosum siccum
exist since
1969. Since 1974 a solution for oral use has been available. 20 ml contained 1-2 g of extract from
leaves of
Vitis vinifera
(1:4-5) and 0.02 g of aesculin. In 1999 aesculin was removed from the
formulation. The recommended dosage is 2-3 x 30 drops per day. The product is traditionally used to
treat diseases of the leg veins (f.e. varicose veins, chronic venous insufficiency), to reduce pains and
feeling of heavy legs, night time cramps in the calf, itching and swollen legs. The use of this product
can be proven for over 30 years.
In 1991 the galenical form of hard gelatine capsules was registered and marketed for the first time.
One capsule contained a combination of 180 mg of
Extractum vitis viniferae foliae aquosum siccum
and
3 mg aesculin (a coumarine glucoside that naturally occurs in the horse chestnut
Aesculus
hippocastanum
). This herbal medicinal product was indicated for the treatment of venous insufficiency,
varices, haemorrhoids, heavy tired legs and feet, essential oedema and calf cramps. The daily
posology was 2-3 capsules a day. In 1999, aesculin was removed from the product and the only active
substance declared was the dry extract of grapevine leaves. The capsules contain 180 mg of
Extractum
vitis viniferae
(extraction solvent: water, DER: 4–6:1), with a recommended use of 2-4 capsules per
day.
A cream (ointment) -containing soft extract (4-6:1; water) in a cream base
(10 g cream contain 282 mg soft extract)- has been traditionally used since 1976 to relieve symptoms
of tired legs applying it several times daily.
Conclusions on traditional use
Based on information obtained from Member states and data retrieved from handbooks it can be
concluded that the following extracts and uses of grapevine leaf extracts fulfil the criteria for traditional
use:
Herbal substance
Not applicable.
Herbal preparations:
Comminuted dried leaves
Powdered dried leaf
Soft extract (2.5-4:1; water) in a cream base
Concerning the preparation: dry extract (3:1; water), the product has been on the market since 1990
(France) and does not comply with the requirements of Directive 2004/24/EC for THMP. There is no
complete information on the manufacturing process and DER of this preparation, and it is not possible
to evaluate the similarity with other dry extracts under WEU.
2.2.
Information on traditional/current indications and specified
substances/preparations
Indication:
Traditional herbal medicinal product:
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 14/40
a) To relieve symptoms of discomfort and heaviness of legs related to minor venous circulatory
disturbances.
b) For symptomatic relief of itching and burning associated with haemorrhoids.
c) For symptomatic treatment of cutaneous capillary fragility.
The product is a traditional herbal medicinal product for use in the specified indication exclusively
based upon long-standing use.
2.3.
Specified strength/posology/route of administration/duration of use
for relevant preparations and indications
Posology:
-Dried leaves in herbal teas, 40 g/l. One cup (10g/250 ml) 2-4 times/day [ESCOP 2009]
-Comminuted total powder: 270-350 mg, 3 times/day (before the meals), up to 2100 mg/day
-Soft extract (2.5-4:1; water), in a cream base, (10g cream contain 282 mg soft extract), a thin layer
should be spread on the affected area 1-3 times/day
-Dry extract (DER 4-6:1; water), single dose: 360-720 mg, daily dose: 360-720 mg
3.
Non-Clinical Data
Non-clinical
in vitro
and
in vivo
studies suggested protective effects of components from extracts of
grapevine leaves on the venous system; e.g. procyanidines [Maffei et al. 1994; Constantini et al.
1999], and flavonoids [Nees et al. 2003].
3.1.
Overview of available pharmacological data regarding the herbal
substance(s), herbal preparation(s) and relevant constituents thereof
Constituents
Vine leaves contain a wide range of polyphenol flavonoids including flavon(ol)-glycosides and
glucuronides, quercetin-3-O-beta-D-glucuronide (most abundant of flavonoids), isoquercitrin,
anthocyanins, oligomeric proanthocyanidins [ Hmamouchi et al. 1997], catechin, epicatechin
monomers and dimmers and gallic acid. The phytoalexin trans-resveratrol, another polyphenolic
substance belonging to the stilbene group, can also be found in grape vine [Langcake et al. 1979]. It
has been referred in the international literature that AlCl
3
is a potent elicitor of resveratrol production
in vine leaves [Andrian et al. 1996]. In vine leaves, also organic acids appear, mainly malic and oxalic
acid but also tartaric acid. Citric, fumaric and succinic acid can be detected in the leaves only in traces.
Compared to the grape berries, grape leaves are richer in the content of carotenoids and vitamin C.
According to the French Pharmacopoeia, the dried leaves of grapevine should contain at least 4% of
total polyphenols and 0.2% of anthocyanins [Pharm. Franc. X., 1996; Jonadet 1983; Lardos & Kreuter
2000; Laparra et al. 1989].
The leaves of the red varieties are very rich in tannins from the catechin group. The composition in
tannins of leaves depends on the phase of development and on their position on the plant. In autumn,
catechin, gallocatechin and epicatechingallate can be found in the leaves. From catechins and/or
leukoanthocyanidines so called oligomeric proanthocyanidins, colourless substances, are formed. The
greatest part of anthocyans consists of malvidin glucosides but also delphinidin, cyanidin and petunidin
glucosides occur [Laparra et al. 1989]. The highest content of anthocyans can be detected in the red
leaf especially in autumn, in the time between the vintage and the shedding of leaves [Raynaud, 2006,
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 15/40
Darné & Glories 1988]. From a pharmacological point of view, the polyphenols, for example flavonoids,
are the most important substance group [Bruneton 1999; 2002; Raynaud, 2005; Diaz Lanza et al.
1995].
Analytically the following chemical compounds have been determined in the leaves of
Vitis vinifera
:
- Flavonoids
(up to 3.5% for red vine leaf, the content is higher in green leaves 4-5%): including
kampferol-3-0-glucosides, quercetin-3-O-glucosides
- Tannins
: procyanidolic oligomers (proanthocyanidins, about 4%) including constituents monomers of
cathechin epicatechin
-
Stilbenes
: resveratrol and viniferins [Chung et al. 2003]
- Fruit acids
: including tartaric acid, malic acid, succinic acid, citric acid, oxalic acid
- Phenylacrylic acid derivatives
: p-coumaroyl acid, caffeoyl acid, feruloylsuccinic acid
In a recent comparative study of 135 samples of grapevine leaves of different origin, the flavonol,
anthocyanin and polyphenol contents have been determined. Total flavonol content was found to be
between 0.6% and 3.5%, anthocyanin content between 0.2% and 1.45% and polyphenol content
between 4.6% and 18.9%. HPLC methods used for determining anthocyanins and flavonols in
grapevine leaves were validated and findings were compared to results produced by assays described
in the French Pharmacopoeia. Whereas the correlation between conventional photometric and HPLC
methods was satisfactory for anthocyanins, the correlation between the pharmacopoeia assay for total
polyphenols and the HPLC analysis for flavonols was poor. As flavonol compounds are considered
relevant for the vasoprotective effect of grapevine leaves, their content in starting material used in the
production of herbal medicines needs to be quantified [Schneider et al. 2008].
Overview on main polyphenolic compounds in Grape Vine
Flavonoids
Flavones (
Quercetin Kaempferol),
Flavanes
Anthocyans Leucoanthocyanidins, Anthocyanidins
-responsible for the blue and red coloring of leaves, flowers and fruits
-The concentration of anthocyans in the red colored leaf is high.
Catechins
• Grapevine leaf is rich in cathechins
• Concentration of cathechins is dependent on: ->the leaf’s position on the plant the
phase of development of the leaf
• In autumn cathechin, gallocathechin, epicathechingallat are present in the leaf.
Stilbenes
Resveratrol,
trans
-Resveratrol belong to the stilbenes (phenolic sub group) is a
phytoalexin= stress-induced plant metabolite resveratrol can be found only in
stressed leaves stress factors : i.e. fungal infection, UV-irritation, injury ->resveratrol
is present in different forms depending on the stage of the plant’s stress answer
R
R
OH
OH
O
+
HO
O
HO
R
1
OH
OH
anthocyan
OH
O
flavonol
OH
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
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OH
OH
OH
OH
HO
O
OH
HO
O
2
H
2
3
H
OH
gallocatechin
3
H
H
OH
OH
epicatechin
OH
OH
OH
HO
O
OH
OH
OH
OH
O
HO
OH
procyanidol
OH
Primary pharmacodynamics
In Europe, the leaves of
Vitis vinifera
are documented in the literature of traditional medicine through
several comprehensive reviews for their astringent and homeostatic properties where they are utilized
in the treatment of diarrhoea, bleeding, haemorrhoids, varicose veins and other circulatory and venous
diseases [Bombardelli 1997; Anonymous 2003; 2004; Petrini et al. 2003; Schneider, 2007i; 2007ii;
Schneider et al. 2008; Schaefer & Red 2003; Volonté & Petrini 2004; Volonté et al. 2003; Weber,
2000].
Anti-inflammatory and anti-oedematous effect
In an
in vitro
study, venular endothelial cells were isolated from Wistar rats and cultivated on porous
filters to confluent monolayers. These preparations respond to certain release products from
simultaneously activated blood platelets and polymorphonuclear granulocytes (PMN) with a rise in
hydraulic conductivity that,
in-situ
, would lead rapidly to local oedema, arteriolar constriction and
venular thrombosis. In this model, selectively activated PMN alone induced only a modest increase in
endothelial hydraulic conductivity that could be prevented by uric acid, an antioxidant. ASA prevented
the activation of the blood cells. A standardized extract from grapevine leaves (AS 195), containing in
particular the flavonoids quercetin-3-O-ß-D-glucuronide and isoquercitrin (quercetin-3O-ß-D-
glucoside), not only prevented the deleterious effect of the release products on the venular endothelial
monolayers but, applied promptly to an endothehium damaged by prior exposure to these release
products, resulted in the repair of the endothehium [Nees et al. 2003]. In another study, the scavenge
by procyanidines (polyphenol oligomers from
Vitis vinifera
seeds CAS 85594-37-2) of reactive oxygen
species (ROS) involved in the onset and the maintenance af microvascular injury has been studied in
phosphatidylcholine liposomes (PCL) using two different models of free radical generation. In an iron-
promoted (Fenton-driven) model, procyanidines had a remarkable, dose-dependent antilipoperoxidant
activity (IC50 = 2.5 µmol/l), more than one order of magnitude greater than that of the monomeric
unit catechin (IC50 = 50 µmol/l). In the second model, procyanidines were highly effective in
preventing conjugated diene formation in both the induction (IC50 = 0.1 µmol/l) and propagation
(IC50 = 0.05 µmol/l) phases. The scavenging effect of tocopherol was weaker with IC50 of 1.5 and
1.25 µmol/l [Maffei Facino et al. 1994; Wollina et al. 2006].
The grapevine leaf extract is characterized by its content in flavonol glycosides and glucuronides, in
particular quercetin-3-O-β-D-glucuronide, isoquercitrin (quercetin-3-O-β-glucoside), and kaempferol-3-
O-glucoside. The most informative investigations were performed using confluent venular endothelial
cells from animal and from human origin [Nees, 2003]. An attack by release products from
simultaneously activated blood platelets (P) and polymorphonuclear granulocytes (PMN) leads to a
breakdown of the venular endothelial barrier. Clinically this would result in formation of oedema and
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 17/40
constriction of microvessels. Red vine leaf RVLE extract was able to support the repair of the venular
barrier after an attack by said release products. These effects could be demonstrated on cells of from
animal origin as well as on cells isolated from the human heart [Nees 2003i, 2003ii]. Quercetin-3-O-ß-
D-glucuronide that had been isolated from the extract and was shown to be the major metabolite
being present in human plasma after ingestion of RVLE acted in the same way. The extent to which
cellular gaps opened and allowed the supernatant to flow through could be measured as “hydraulic
conductivity”. 0.7 mg dry RVLE/ml incubation medium nearly prevented the opening of the barrier in
the presence of activated PMN/P. Preincubation of the venular cell layer with 50 µM quercetin-3-O-ß-D-
glucuronide for 7 days markedly reduced the hydraulic conductivity compared to untreated cells.
In a publication by [Jonadet et al. 1983], the authors describe studies conducted with anthocyanosides
extracted from
Vitis vinifera
(a),
Vaccinium myrtillus
(b) and
Pinus maritimus
(c). The results obtained
in vitro
indicated that these compounds inhibit elastase, a proteolytic enzyme which plays a role in the
deterioration of conjunctive tissue and elastic fibers and is involved in certain pathological vascular
conditions. The IC50 values are 0.13 mg/ml for (a), 0.20 mg/ml for (b) and 0.31 for (c). Lineweaver-
Burk curves revealed that the inhibition was not competitive. Results obtained
in vivo
show that the
angioprotective activities of these compounds can be classified in decreasing order as follows: (a), (b)
and (c).
Nees developed a measurable and reproducible
in vitro
experimental model to investigate the effect of
substances capable of modifying the hydraulic conductivity of the endothelial barrier of the venules. In
in vitro
experiments, this extract has been shown to have a "sealing" effect on the endothelium of the
venules and a protective action against fluid extravasation induced by incubation with chemical
mediators of inflammation [Nees S et al. 2003i].
Red vine leaf extract (RVLE) prevented the deleterious effect of the release products of P and PMN on
venular endothelial cells. In addition, the extract was able to support the repair of the venular barrier
after an attack by said release products [Smith, 1999].
The anti-inflammatory activity of the oligomeric stilbene a-viniferin from
Vitis
has been also tested as
well as its mode of action though inhibition of cyclooxygenase-2 and inducible nitric oxide synthase
[Chung et al. 2003].
Hepatoprotective activity
The hepatoprotective effect of ethanolic extract and its four different fractions (CHCl
3
, EtOAc, n-BuOH,
and remaining water fraction) of
Vitis vinifera
L. leaves was investigated against carbon tetrachloride
(CCl
4
)-induced acute hepatotoxicity in rats. The ethanolic extract was found active at 125 mg/kg dose
(per os). The ethanolic extract was fractionated through successive solvent-solvent extractions and the
n-BuOH fraction in 83 mg/kg dose possessed remarkable antioxidant and hepatoprotective activities.
Liver damage was assessed by using biochemical parameters (plasma and liver tissue MDA
[malondialdehyde], transaminase enzyme levels in plasma [AST-aspartate transaminase, ALT-alanine
transferase] and liver GSH [glutathione] levels). Additionally, the pathological changes in liver were
evaluated by histopathological studies. Legalon 70
®
Protect was used AS standard natural originated
drug [Orhan et al. 2007].
Antimicrobial activity
Ethanol extracts of
Vitis vinifera
(leaves, raw fruits, young branches; 2:1:1, v/v/v), were investigated
for their antimicrobial activity against 14 pathogenic bacterial species and a yeast,
Candida albicans
,
using the agar well diffusion method, 19 Turkish traditionally used medicinal plants.
Vitis
leaves
showed broad-spectrum antimicrobial activity [Oskay & Sari 2007].
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 18/40
Antioxidative activity
The effect of grape leaf extract (GLEt) on antioxidant and lipid peroxidation states in liver and kidney
alcohol induced toxicity has been evaluated.
In vitro
studies with DPPH
*
and ABTS
*
(cation radical)
showed that GLEt possesses antioxidant activity.
In vivo
administration of ethanol (7.9 g/kg bw/day)
for 45 days resulted an activity of liver marker enzymes (AST, ALT, ALP and GGT), lipid peroxidation
markers (TBARS, lipid hydroperoxides) in liver and kidney with significantly lower activity of SOD, CAT,
GPx, GST and non-enzymatic antioxidants (vitamin E, vitamin C and GSH) in liver and kidney AS
compared with control rats. Administration of ethanol along with GLEt significantly decreased the
activities of liver markers enzyme in serum towards near normal level. GLEt at a dose of 100 mg/kg
was highly effective than 25 and 50 mg/kg body weight. In addition GLEt also significantly reduced the
levels of lipid peroxidation and addition, significantly restored the enzymic and non-enzymatic
antioxidants level in liver and kidney of alcohol administration rats. This observation was supplemented
by histopathological examination in liver and kidney. These data suggest that GLEt exerts its protective
effect by decreased the lipid peroxidation and improving antioxidants status, thus proving itself AS an
effective antioxidant in alcohol induced oxidative damage in rats [Pari & Suresh 2008].
The antioxidative activity of the ethanolic extract of
Vitis vinifera
L. leaves was investigated. The
ethanolic extract of
V. vinifera
leaves at 250 mg/kg dose was found to have the highest antioxidant
activity [Sendogdu et al. 2006]. Comparable results have been published by [Kosar et al. 2007], from
extracts from fresh, dried and brined leaves of
Vitis
[Monagas M et al. 2006].
Bronchodilatory activity
It has been investigated the effect of grape leaf hydroalcoholic extract on isolated rat tracheal
contractions induced by KCl and acetylcholine. The trachea was removed from male adult Sprague-
Dawley rat and placed in an organ bath containing Krebs-Henseleit solution and contractions were
recorded isometrically. The results demonstrate that the grape leaf extract at 0.5, 1, 2, 4 and 8 mg/ml
significantly reduces the tracheal contractions induced by KCl (60 mM) dose-dependently (
P
<0.0001).
Acetylcholine (55 μM)-induced tracheal contractions were also attenuated at the same concentration of
the extract (
P
<0.0001). The grape leaf extract induced relaxation in the KCl-induced contraction in
trachea was unaffected neither by nitric oxide (NO) synthase inhibitor (L-NAME, 100 μM) nor by beta-
adrenoceptor antagonist (propranolol 1 μM). Our results suggest that the bronchodilatory effect of
grape leaf extract is mediated via the voltage dependent calcium channels on the smooth muscle cells
membrane. Furthermore, the beta-adrenergic and NO are not involved. The extract was prepared from
dried grape leaves 50 g were wixed with 230 ml of ethanol 70% for 72 hours at room temperature and
stirred four times a day. The mixture was filtered and the solvent evaporated. The obtained extract
was 9.5 g [Gharib Naseri & Heidari, 2006]
.
Vasorelaxant effect on isolated rat aorta
The relaxant effect of
Vitis vinifera
leaf hydroalcoholic extract (VLHE) on isolated rat thoracic aorta
contractions induced by phenylephrine and KCl, and the role of aorta endothelium on this action has
been investigated. Rat aorta was removed and placed in an organ bath containing Krebs-Henseleit
solution and aorta contractions were recorded isometrically. The results demonstrate that the VLHE at
0.125, 0.25, 0.5, 1 and 2 mg/ml reduces the endothelial intact aorta contracted by phenylephrine (1
mu M) significantly and dose-dependently. Endothelial denuded aorta showed the same relaxation but
in much less extent. The IC
50
of these two groups were 0.454±0.08 and 1.73±0.23 mg/ml
respectively. VLHE also reduced the aorta contractions induced by KCl (80mM). The relaxatory effect of
VHLE on KCl-induced contractions were less than those evoked by phenylephrine. Soluble guanylate
cyclase inhibitor (methylene blue, 10 mu M) and nitric oxide synthase inhibitor (L-NAME, 100 mu M)
reduced the VHLE-induced relaxation in the intact aorta significantly but, atropine (1 mu M) was unable
to decrease this vasorelaxant effect. These results suggest that the most vasorelaxant effect of VHLE
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on rat aorta is endothelium-dependent and also nitric oxide (NO) and cGMP are involved in this action
[Gharib Naseri et al. 2004].
Spasmolytic effect
The effect of grape leaf hydroalcoholic extract (GLHE) on rat colon contractions induced by some
spasmogens has been investigated. A piece of distal colon from male adult Wistar rats were dissected
and mounted in an organ bath containing Tyrode solution and colon contractions recorded by an
isotonic transducer under 1g resting tension. The GLHE (0.5- 4 mg/ml) reduced the contractions
induced by KCl (60 mM), BaCl
2
(4 mM), acetylcholine (1 mu M) dose-dependently (P<0.001). The
spasmolytic effect of GLHE on ACh-induced contraction was unaffected by propranolol (1 mu M),
phentolamine (1 mu M), L-NAME (300 mu M), and naloxone (1 mu M). In Ca
2+
-free but rich in KCl
(120 mM) Tyrode solution, cumulative concentrations of CaCl
2
induced colon contractions which, were
inhibited by the extract. Glibenclamide (3 mu M) had no effect on the extract spasmolytic activity, but
tetraethylammonium (5 mM) contracted the pre-relaxed colon induced by the extract. Results suggest
that the grape leaf hydroalcoholic extract spasmolytic effect is due to the blockade of the voltage
dependent calcium channels and activation of Ca
2+
-operated potassium channels [Gharib Naseri et al.
2006].
The effect of
Vitis vinifera
leaf hydroalcoholic extract (VLHE) on isolated rat tracheal contractions
induced by KCl and acetylcholine has been also studied. The trachea was removed from male adult
Sprague Dalwey rat and placed in an organ bath containing Krebs-Henseleit solution. The tracheal
contractions were recorded isometrically under 1.5 g initial tension.
Results: The results demonstrate that the VLHE at 0.5, 1, 2, 4 and 8 mg/ml reduces the tracheal
contractions induced by KCl (60 mM) significantly and dose-dependently (P<0.0001). Acetylchline (55
mu M)- induced tracheal contractions were also attenuated by the same extract doses significantly
(P<0.0001). The VHLE-induced relaxation in the KCl-induced contraction in trachea was not affected
neither by nitric oxide synthase inhibitor (L-NAME, 100 mu M) or beta-adrenoceptor antagonist
(propranolol 1 mu M) and by muscarinic receptors antagonist (atropine 30 mu M).
Conclusion: These results suggest that the relaxant effect of VHLE on rat trachea is evoked via voltage
dependent calcium channel blockage and beta-adrenoceptors, NO and cholinergic receptors are not
involved in this relaxant effect of VHLE [Gharib Naseri & Heidari, 2006].
Diuretic activity
Aqueous and alcoholic extracts of
Vitis vinifera
leaves were tested for diuretic activity in rats. The
parameters studied on individual rat were body weight before and after test period, total urine volume,
urine concentration of Na
+
, K
+
and Cl
-
. In the present study alcoholic and aqueous extracts of
Vitis
vinifera
leaves (100 mg/kg of body weight) showed increase in urine volume, cation and anion
excretion. Furosemide was used as a reference diuretic [Shastry et al. 2002].
Secondary pharmacodynamics
Flavonoid-containing herbal preparations and isolated flavonoids have been reported to exhibit a wide
range of biological effects, including antioxidant and enzyme-modulating actions and anti-allergic, anti-
atherosclerotic, antithrombotic, antiviral, antibacterial, anti-inflammatory, antiproliferative,
anticarcinogenic, antispasmodic and diuretic effects [Middleton et al. 1992, 1996; Hertog et al. 1996;
Hollmann and Katan 1999; Pietta 2000].
In vitro tests
In the context with Chronic venous insufficiency (CVI) it would be of interest to evaluate whether
grapevine leaf extract exhibits any effects on platelet aggregation. The effect of flavonoids on platelet
aggregation was studied
in vitro
using platelet-rich plasma from four healthy male volunteers aged 24,
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29, 35 and 47 years. The flavonol glycoside quercetin 3-O-
-D-glucoside and various flavonoid
aglycones including quercetin, apigenin and (+)-catechin were added to both platelet-rich plasma and
washed platelets at concentrations of 0, 0.25, 2.5, 25, 250 and 2500 µmol/l. Indomethacin was used
as a positive control. The results showed that the flavonoid aglycones inhibited platelet aggregation but
that quercetin-3-O-
-D-glucoside did not significantly affect aggregation at any of the concentrations
tested [Janssen et al. 1998].
In vivo tests
A randomised, placebo-controlled, multiple crossover study was conducted, in which 18 healthy
volunteers (9 men and 9 women; mean age 25
8 years; BMI 22
1 kg/m
2
) were given a preparation
of onions equivalent to 114
3 mg quercetin every day for 2 weeks in accordance with a fixed
schedule. Blood samples were taken from the participants at defined intervals and the relationship
between platelet aggregation and flavonoid concentration was plotted. The results showed that a daily
dose of 114 mg quercetin did not have any significant effect on platelet aggregation. The mean plasma
concentration of quercetin was 447
117 ng/ml during the study period [Janssen et al. 1998].
Besides the flavonoids, grapevine leaves contain the following types of compound that are likely to be
carried over to an aqueous extract [Bombardelli & Morrazoni 1995]:
- anthocyanins
- phenolic acids
- catechins and proanthocyanidins (flavanols)
- anorganic acids, sugars and mineral salts
The anthocyanins present in grapevine leaves are mainly glucosides of cyanidine, peonidine and
malvidine [Boucheny A, Brum-Bousquet 1990]. Anthocyanins have been reported to possess
antioxidant and vasoprotective properties. There are some doubts whether these effects measured in
in vitro
experiments or in animal studies using high doses are relevant for humans [Prior, 2004].
Absorption of anthocyanins appears to be low [Lapidot et al. 1998]. The amount of anthocyanins
administered with 360 or 720 mg grapevine leaf extract is considered negligible in respect of the
pharmacodynamic action of the substance.
The phenolic acids present in grapevine leaves are mainly derivatives of cinnamic acid, vanillic acid and
caffeic acid [Boucheny A, Brum-Bousquet 1990]. These compounds are ubiquitous in vegetables and
preparations of herbal origin and therefore not expected to contribute to the specific pharmacological
effects of grapevine leaf extract.
The catechins found in grapevine leaves are mainly catechol and epicatechol [Boucheny A, Brum-
Bousquet 1990]. Of the condensed catechins (proanthocyanidins) procyanidins B1 and B2 are the
prevailing compounds, followed by procyanidins B3 and B4. Procyanidins have been reported to
possess antioxidant and anti-oedematous activity [Bombardelli & Morrazoni 1995]. The study did not
investigate the form in which the flavonoids were resent prior to administration. Onions are known to
be rich in quercetin glucosides, especially quercetin-4´-glucoside and quercetin-3, 4´-O-diglucoside.
After administration of fried onions quercetin glucuronides can be detected in plasma [Aziz et al. 1998;
Graefe et al. 2001]. It can be supposed that quercetin glucuronides do not influence platelet
aggregation
in vivo
.
Hypocholesterolemic effect
Oral administration of procyanidins from grape seed produced a hypocholesterolemic effect in a high-
cholesterol animal feed model (rats). Specifically it prevented an increase in total and LDL plasma
cholesterol and a decrease in HDL [Tebib, 1994].
In normal and hypercholesterolemic rabbit aortas, OPCs significantly lowered the amounts of
cholesterol bound to aortic elastin compared to controls [Wegrowski, 1984].
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Antiproliferative activity
Procyanidin-rich fractions from grape
Vitis vinifera
extract showing different mean degrees of
polymerization, percentage of galloylation (percentage of gallate esters) and reactive oxygen species-
scavenging capacity were tested on HT29 human colon cancer cells. It has been observed that the
most efficient fractions in inhibiting cell proliferation, arresting the cell cycle in G
2
phase and inducing
apoptosis were the grape fractions with the highest percentage of galloylation and mean degree of
polymerization. Additionally, the antiproliferative effects of grape fractions were consistent with their
oxygen radical-scavenging capacity and their ability to trigger DNA condensation-fragmentation
[Lizarraga et al. 2007].
Antidiabetic activity
The acute and subacute antidiabetic activities of the ethanolic extract of
Vitis vinifera
L., leaves were
investigated. The acute effect was studied on the normoglycaemic, glucose hyperglycaemic and
streptozotocin-induced diabetic rats; and the subacute effect was studied on same diabetic rats for 15
days. The blood glucose levels were measured by using blood glucose measuring strips based on
glucose-oxidase method. The ethanolic extract of
V. vinifera
leaves at 250 mg/kg dose was found to
possess a high antidiabetic activity. Mainly condensed tannins and flavonoids were suggested to
contribute in the activity [Sendogdu et al. 2006].
The acute and subacute (15 days) hypoglycaemic and antihyperglycaemic effect of the two different
doses (250, 500 mg/kg) of the aqueous extract from the leaves of
Vitis vinifera
L. were evaluated in
this study. The aqueous extract was further fractionated through successive solvent extractions and
the acute effect of different doses of its subfractions, 25 mg/kg for ethylacetate fraction, 80 mg/kg for
n-
butanol fraction and 375 mg/kg for remaining aqueous fraction were investigated using normal,
glucose-hyperglycaemic and streptozotocin-induced diabetic rats. Blood glucose levels were measured
according to the glucose oxidase method. Tolbutamide was used as a reference drug at a dose of 100
mg/kg. The antioxidant activity of the test samples was studied in the liver, kidney, heart tissues of
diabetic rats by measuring malondialdehyde (MDA) and glutathion (GSH) levels. All results were
compared to the diabetic control groups. The results showed that the EtOAc fraction was rich in
polyphenolics and possessed a significant antihyperglycaemic and antioxidant activity equipotent with
the reference hypoglycaemic agent (tolbutamide), when evaluated in diabetic rats [Orhan et al. 2006].
Other activities
The anti-herpes as well as the anti-mutagenic activities from the leaves and procyanidins from
Vitis
vinifera
have been also assayed and published in the international literature [Girre et al. 1990; Liviero
et al. 1993].
Pharmacodynamic interactions
Pharmacodynamic drug interactions of whole extracts or isolated constituents have not been reported.
Various sources in the literature have suggested that the desired therapeutic effect of many flavonoids
is usually obtained only after repeated oral intake of the respective preparations. This implies that the
flavonoids and their metabolites accumulate in the body, and do not exert the pharmacodynamic
effects seen in
in vitro
studies until a pharmacological threshold dose and relevant plasma levels has
been reached. This hypothesis was confirmed by the results of a clinical study by [Kiesewetter et al.
2002]. A significant improvement in key CVI symptoms in the active treatment groups versus placebo
could not be observed after 6 weeks, but became evident after 12 weeks of treatment. This could also
explain why earlier studies reported a "small" or "undetectable" effect following single oral
administration.
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3.1.1.
Assessor’s overall conclusions on pharmacology
The aqueous and ethanolic extracts of
Vitis viniferae
folium have been used as adjunctive therapy for
Chronic venous insufficiency (CVI), and have shown a potential benefit [Abascal & Yarnell 2007].
Based on available preclinical data, it can be concluded that the mechanism of action of orally
administered extract in CVI is not well known.
3.2.
Overview of available pharmacokinetic data regarding the herbal
substance(s), herbal preparation(s) and relevant constituents thereof
Data on the pharmacokinetics of the whole extract or relevant components are not available.
Flavonoids are the substances which are regarded as being responsible for the pharmacological
properties of grapevine leaf extract. In the plant, flavonoids are generally present in genuine form as
glycosides. Grapevine leaf extract as it has been referred previously contains as major flavonoid
components quercetin-3-O-glucuronide, isoquercitrin (quercetin-3-O-glucoside) and kaempferol-3-O-
glucoside. The substances present in blood after ingestion of plant extracts containing polyphenols
usually differ from the native compound, as they are metabolites resulting from digestive and hepatic
activity. The examination of pharmacokinetics and metabolism of the major and active constituents of
such plant extracts in humans is therefore strongly recommended [Manach et al. 2005].
Various sources in the literature have suggested that the desired therapeutic effect of many flavonoids
is usually obtained only after repeated oral intake of the respective preparations. This implies that the
flavonoids and their metabolites accumulate in the body and do not exert the pharmacodynamic effects
seen in
in vitro
studies until a pharmacological threshold dose and relevant plasma levels has been
reached. This hypothesis was confirmed by the results of a clinical study by [Kiesewetter et al. 2000].
A significant improvement in key CVI symptoms in the active treatment groups versus placebo could
not be observed after 6 weeks, but became evident after 12 weeks of treatment.
The grapevine leaf extract represents a complex mixture of different classes of compounds, having
each their own pharmacokinetic characteristics. A significant portion of the components of grapevine
leaf extract belongs to the group of polyphenols, such as anthocyanins, proanthocyanidins, catechins
and phenolic acids [Bombardelli & Morazzoni 1995; Boucheny & Brum-Bousquet 1990]. Recently,
[Manach et al. 2005] presented a review of various bioavailability studies in humans concerning
polyphenols. They came to the conclusion that anthocyanins and proanthocyanidins are absorbed to a
very low extent only. As an exception, the major circulating forms of anthocyanins are the intact
glycosides [Manach et al. 2004]. The polymeric nature and therefore high molecular weight of
proanthocyanidins should limit their absorption through the gut barrier. Hydroxycinnamic acids such as
caffeic acid are rapidly absorbed from the small intestine and are conjugated, in particular
glucuronidated in the same way as flavonoids. However these compounds are naturally esterified in
plant products (as chlorogenic acid) and this impairs their absorption. Only the colonic microflora
possesses esterases which are capable of hydrolyzing these bindings. Consequently, the efficacy of
absorption of phenolic acids is markedly reduced for their esterified forms compared with the free form
[Manach et al. 2004].
3.2.1.
Assessor’s overall conclusions on pharmacokinetics
No information is available on pharmacokinetic interactions. No information is available on metabolites.
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3.3.
Overview of available toxicological data regarding the herbal
substance(s)/herbal preparation(s) and constituents thereof
Single-dose toxicity
The toxicity of vine leaf aqueous extract (4-6:1) following a single oral dose was determined in SPF
Wistar rats (3 males and 3 females per group). The doses used were 3000, 4000 and 10.000 mg/kg.
There were no signs of toxicity and no mortalities over the 14-day observation period, and no
pathological or histological changes were seen at autopsy.
The toxicity of vine leaf aqueous extract (4-6:1) following a single oral dose was also determined in
CFI mice (3 males and 3 females per group). The doses used were 2000, 4000 and 10.000 mg/kg.
There were no signs of toxicity and no mortalities over the 14-day observation period, and no
pathological or histological changes were seen in autopsy [Rabe 2005; ESCOP, 2009].
Repeat-dose toxicity
The toxicity of vine leaf soft extract when given over a 90-day period was determined in SPF Mol-
Wistar rats (12 males and 12 females per group) in a study which was subjected to QAU inspection and
carried out in accordance with GLP standards. The animals were given oral doses of 25, 125 or 250
mg/kg/day, or a placebo. A satellite group given 250 mg/kg/day was subjected to follow-up
observation. No mortalities occurred during the study period. Observations made during the study
period on bodyweight, food intake etc. revealed no evidence of any systemic toxic effects due to the
extract. The values found during haematological and clinical chemistry testing were within biological
limits. The autopsy findings and the results of histological tests did not reveal any evidence of changes
due to the extract. The doses of extract used were therefore judged to be non-toxic in the rat.
The maximum daily dose of extract is 720 mg, which represents a dose of 10.3 mg/kg for a person
weighing 70 kg. This is about one-thousandth of the maximum dose of extract used in the single-dose
toxicity studies. As the maximum dose used in these studies did not give rise to any signs of toxicity, it
is extremely unlikely that any toxic effects will occur in man. Preparations containing vine leaf extract
have been used in European Union countries for many years and there have been no reports of any
harmful effects in man to date. On this basis, it is reasonable to assume that the products reviewed in
this report will not pose any safety risk on therapeutic administration [ESCOP, 2009].
Genotoxicity
The mutagenic potential of vine leaf extract was assessed in a range of established
in vitro
and
in vivo
test models (Ames test, point mutation assay and chromosomal aberration assay). It was assessed in
an Ames Salmonella/microsome plate assay using Salmonella typhimurium TA-100, TA-1535, TA-98,
TA-1537 and TA-1538 with and without metabolic activation; S9 mix prepared from rat liver was used
as the activation system. The assay was carried out in accordance with EU recommendations and
OECD Guideline 471. Five concentrations of the vine leaf extract ranging from 8 to 5000 µg/plate were
used, and positive and negative controls were also included. The results obtained did not provide any
evidence to suggest that vine leaf extract has any mutagenic potential [ESCOP, 2009].
Mutagenic potential of grapevine leaf extract was also assessed in two independent point mutation
assays carried out on the HGPRT locus of Chinese hamster V79 cells with and without metabolic
activation; S9 mix prepared from rat liver was used as the activation system in each case. The assays
were designed and conducted in accordance with the guidelines and recommendations on genotoxicity
testing that were current at the time. On the basis of preliminary toxicity tests, a concentration range
of 3.0 - 5000 µg/ml was selected for use in the assays. Positive EMS and DMBA controls as well as a
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vehicle control were included. Neither of the assays provided any evidence to suggest that the extract
used had any mutagenic potential in the concentration range tested [ESCOP, 2009].
A micronucleus assay was carried out on NMRI mice (5 males and 5 females per group) to establish
the potential of vine leaf soft extract for causing chromosomal aberrations. The assay, which complied
with the relevant EU and OECD guidelines, was carried out using oral doses of the extract of 1.0, 3.0
and 10.0 ml/kg. Positive controls (cyclophosphamide 40 mg/kg) and vehicle controls (sodium chloride
0.9%) were included. Under the conditions employed, there was no significant increase in micronuclei
frequencies in polychromatic erythrocytes.
The methanolic and aqueous extracts from Greek varieties of
Vitis vinifera
demonstrated
in vitro
antimutagenic effects against mutagenicity induced by bleomycin and hydrogen peroxide in Salmonella
typhimurium strain TA102 [Stagos et al. 2006].
Oligomericproanthocyanidins from grape seed demonstrated in vitro antimutagenic activity [Liviero et
al. 1993].
In addition, among the pharmacologically active flavonoids (quercetin, quercetin 3-O-
-D-glucuronide
and isoquercitrin) in the vine leaf extract used is known that quercetin has given positive results in the
Ames test. However, the mutagenic potential of quercetin has not been confirmed in
in vivo
tests
carried out in rats and mice [Hertog & Hollman 1996].
Carcinogenicity
No data is available. However, it was demonstrated that anthocyanin-rich extracts from bilberry
(
Vaccinium myrtillus
L.), chokeberry (
Aronia meloncarpa
E.), and grape
(Vitis vinifera
) inhibited
multiple biomarkers of colon cancer in rats [Lala et al. 2006].
There has also been no evidence in the literature so far to indicate that flavonoids as a whole have any
carcinogenic properties. Indeed, a large number of
in vitro
studies have been carried out which
suggest that flavonoids have anticarcinogenic effects. However, the results obtained
in vitro
have yet
to be confirmed in
in vivo
test models. Depending on the type and quantity of food consumed, the
human intake of flavonoids is between 100 and 1000 mg per day [Middleton 1996].
In toxicity and carcinogenicity studies carried out on quercetin, promoted by the FDA, four groups of
50 male and female F344 rats were given 40, 400 or 1900 mg/kg of quercetin, or a placebo, in feed
over a period of two years. There was no evidence of carcinogenic activity in the female rats and only
slight evidence of carcinogenic activity in male rats. The carcinogenic effects, which took the form of
renal tubule hyperplasia and nephropathy, were observed only in the high-dose group. No evidence of
chronic toxicity was found [NTP: Toxicology and carcinogenesis studies of quercetin (CAS No. 117-39-
5) in F344 rats (feedstudies) 1992].
Reproduction toxicity
The maternal and embryofoetal toxicity of an orally administered aqueous preparation of vine leaf soft
extract was investigated in pregnant Himalayan rabbits in a study which was carried out in accordance
with GLP standards and subjected to QAU inspection. Four groups of animals (12 per group) were
used. One group received a placebo whilst the other three groups were given doses of 300, 1000 or
3000 mg/kg/day on days 6-18 of gestation. All doses were administered in a volume of 10 ml/kg. No
signs of maternal toxicity were seen during the observation period and there was no visible evidence of
foetal retardation. Slight, non-significant skeletal retardations and variations were seen in the foetuses
of animals receiving the highest dose (3000 mg/kg of the extract per day). These variations were
within biological limits in all cases and did not occur in any of the other groups. There was no evidence
of changes due to the extract in any of the other findings, and no teratogenic effects were seen. On
the basis of the results obtained, the NOEL for the extract was defined as > 3 g.
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In the reproduction study conducted with rabbits no evidence of any teratogenic effects was found. The
recommended maximum dose is equivalent to a daily intake of 10.3 mg/kg of vine leaf extract. In the
Leuschner study up to 3000 mg/kg/day of the extract, were applied without resulting in any
teratogenic effect. The recommended maximum human dose of vine leaf extract is about 300 times
lower than the highest dose used in the Leuschner study [Leuschner F, Mitterer KE, 1993].
Examination of the influence of
Extractum vitis viniferae
on the pregnant rabbit and the fetus by oral
administration [LPT Report No. 7441/92. 1993; ESCOP, 2009].
Daily doses of 3000 mg/kg extract from grapevine leaves administered to female rabbits during
organogenesis (6th to 18th day of pregnancy) did not exhibit teratogenic effects [Antistax
®
SPC,
2005].
3.3.1.
Assessor’s overall conclusions on toxicology
Several recent data on oral single-dose and repeat-dose toxicity, as well as on genotoxicity and
reproduction toxicity of vine leaf have been reported.
In vitro
and
in vivo
studies on the mutagenic potential of vine leaf extracts have not shown any
evidence of mutagenic activity. Carcinogenic effects are not expected to occur, especially as vine leaf
extract has been used in medicinal products for many years without any evidence of such effects being
reported.
4.
Clinical Data
4.1.
Clinical Pharmacology
Pathophysiology of CVI
The term Chronic venous insufficiency (CVI) describes a clinical picture in which chronic venous
diseases of diverse aetiology are manifested by similar or related symptoms and complaints. CVI is
mostly caused by venous and capillary hypertension, which causes a persistent, chronic, venous stasis
in the skin of the lower leg, manifested most characteristically upon postural challenge [Alguire &
Mathes 1997]. The impairment of venous return that is responsible for the venous capillary
hypertension can be caused by degenerative, dilating venous conditions of the superficial (primary
varices), the transfascial (insufficiency of the perforating veins), or the deep system (“deep” varicosis,
insufficiency of the main veins) [Jünger et al. 1994]. Chronically disturbed haemodynamics of deep or
superficial veins due to obstructed venous segments or valvular incompetence lead usually to trophic
changes in the inner ankle area of the lower limbs and disturbances in the microcirculation of the skin
have been considered to be major contributors for skin changes associated with chronic venous
hypervolaemia and venous hypertension. Cutaneous microangiopathy of clinical relevance such as
enlarged, tortuous capillaries surrounded by micro-oedema contributes to the skin alterations in the
lower limbs and determines the course of CVI [Fagrell 1995; Jünger et al. 1996]. CVI can be classified
according to its haemodynamic, morphological, and clinical aspects. The clinical grading system, based
on Widmer’s classification, as well as other international classification systems, e.g. CEAP (Clinical
Class, Etiology, Anatomy and Pathophysiology), [Widmer LK, 1981; Partsch H, 1994; Porter JM et al.
1995]. The most important therapeutic approaches include compression therapy, physiotherapy,
surgical treatment and sclerotherapy.
Drug therapy
Drug therapy is a treatment option in incipient and mild to moderate Chronic venous insufficiency
(CVI) (Widmer grades I and II, CEAP Clinical classes 2, 3, or 4a).
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Topical drug treatment
Antioedema drugs
are mostly plant derived substances for which an antiexudative and
antioedematous action and efficacy have been confirmed in experimental studies and clinical trials.
Experimentally, most of them have a membrane stabilising action that leads to a decrease in capillary
permeability. Some of these substances also have venotonic properties.
Long-term treatment with antioedema drugs can also be considered in primary and secondary CVI or if
invasive measures are not applicable [Gallenkemper et al. 1998]. The majority of these products
contain plant extracts or semisynthetic derivatives of plant-derived substances. The most commonly
used are coumarins (
-benzopyrone derivatives); saponins/horse chestnut seeds extracts; flavonoids
(
-benzopyrone derivatives); rutin, diosmin, and hesperidin; anthocyanins and procyanidins.
Procyanidins
, like the anthocyanins, are flavonoids that are not available as monosubstances.
Procyanidins are present in relevant amounts in standardised extracts such as grapevine leaf extracts
(
Vitis vinifera
) and are formed through condensation reactions of flavonols [Hostettmann K et al.
1994].
The complex syndrome of symptoms involved in CVI led to investigate the activity of vine leaf
preparations on two distinct parameters affecting CVI. On the one hand the effects of the product on
microcirculation, on the other on the typical objective and subjective symptoms of CVI such as the
presence of oedema and the typical CVI complaints “tired, heavy, and swollen legs”, or tension and
pain in the legs.
4.1.1.
Overview of pharmacodynamic data regarding the herbal
substance(s)/preparation(s) including data on relevant constituents
No data available.
4.1.1.1.
Assessor’s overall conclusions on pharmacodynamics
At present, the mechanism of action of vine leaf water extract in chronic venous insufficiency cannot be
considered clarified.
4.1.2.
Overview of pharmacokinetic data regarding the herbal
substance(s)/preparation(s) including data on relevant constituents
The vine leaf extract is a complex extract containing more than 200 different identified substances. The
clinical effects of the grapevine leaf extract cannot be attributed to a specific individual constituent but
can be ascribed with reasonable plausibility to the extract as a whole. It is therefore virtually
impossible to perform classical pharmacokinetic studies with the complete product and
pharmacokinetic studies of individual constituents such as flavonoids will only provide limited
information with regard to clinical efficacy.
Flavonoids (quercetin glucuronide, kaempferol glucosides) are quantitatively important constituents of
the whole extract. The systemic bioavailability of flavonoids is probably relatively low and variable.
Orally administered flavonoids are susceptible to pre-systemic metabolism by the intestinal flora. It is
likely that the absorbed metabolites formed by the microflora in the gut contribute to the biological
action of orally administered flavonoids. Systemic flavonoids are metabolised in the liver primarily by
conjugation (methylation or sulfuronidation) and/or glucuronidation. The resulting metabolites are
excreted either with the urine or with the bile into the intestine, where they undergo further
metabolism. The pharmacokinetic input function of systemic flavonoids may well be further extended
by this enterohepatic recycling process [Manach & Donovan 2004].
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4.1.2.1.
Assessor’s overall conclusions on pharmacokinetics
Data on pharmacokinetics of vine leaf extract or relevant components are not available in humans. No
reliable methods exist to determine simultaneously the plasma levels of all active ingredients present
in the whole extract.
4.2.
Clinical Efficacy
Several publications referring to human clinical studies with medicinal products containing
Vitis vinifera
were found in the literature.
Three of the published studies investigated the safety and efficacy of a dry extract of grapevine leaves
(4-6:1) extraction solvent water (AS 195).
The safety and efficacy specific information of these studies is presented below.
The clinical information available for aqueous extracts of grape vine leaf investigates the activity on
two distinct parameters affecting Chronic venous insufficiency (CVI). On the one hand the effects of
the product on microcirculation, on the other on the typical objective and subjective symptoms of CVI
such as the presence of oedema and the typical CVI complaints “tired, heavy, and swollen legs”, or
tension and pain in the legs.
Clinical parameters measured
In all clinical studies, changes in leg volume and/or calf and ankle circumference were included in the
endpoints studied. All confirmatory studies planned to show efficacy on subjective symptoms of CVI
used the lower leg volume determined by water displacement plethysmography as the primary efficacy
endpoint. Other endpoints included the lower leg diameter (at calf height and at the ankle), visual
analogue scales (VAS: 0-10 cm) for the main symptoms (“tired, heavy legs”, “sensation of tension”,
“prickling sensation”, and “pain in the legs”), and the global assessment of efficacy and tolerability by
the patient and by the doctor according to a 4-point verbal rating scale (VRS: “good”, “satisfactory”,
“not satisfactory”, and “poor”). These measurements are consistent with the guidelines of the German
Society for Phlebology.
In the double-blind, placebo-controlled cross-over study with two treatment sequences of 6 weeks
each separated by a 4-week placebo washout period, microcirculation in the most affected CVI leg was
measured by laser doppler fluxmetry (685 nm, penetration depth approximately 1 mm) and
transcutaneous oxygen monitoring.
Patients were usually questioned about their subjective well-being. They were also instructed to
spontaneously report any adverse events experienced. Laboratory tests (haematology, clinical
chemistry, and urinalysis) and blood pressure and pulse measurements were carried out in most
studies to record safety.
4.2.1.
Dose response studies
From the results of [Kiesewetter et al. 2000], a single daily dose of 360 mg of grapevine leaf extract is
as effective and well tolerated as a daily dose of 720 mg. On average, the higher dose regimen offers
greater efficacy in terms both of the extent and duration of action, but is roughly equivalent with
regard to subjective symptoms reduction. The lower dose, however, is considered to be sufficient in
the majority of patients and has been chosen to reduce the intake of extract, thus most likely
decreasing the likelihood of observing adverse events. Consequently, this is the dosage that has been
approved in some marketing authorisations.
No pharmacokinetic or pharmacodynamic studies, however, were performed to support the posology
and daily dose proposed.
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4.2.2.
Clinical studies (case studies and clinical trials)
Several publications referring to human clinical studies investigating the safety and efficacy of a dry
extract of red
Vitis vinifera
leaves (4-6:1) extraction solvent water (AS 195
)
were found in the
literature. Some others studies have been assessed in this AR, that originate from confidential in house
files of Boehringer Ingelheim. The company allowed using those data for assessment and
monograph/list entry establishment.
Double-blind, Placebo-controlled studies
[Kiesewetter et al. 2000]:
In a 12-week, randomized, double-blind, placebo-controlled, parallel-
group, multicenter study conducted in accordance with the principles of Good Clinical Practice (GCP),
the efficacy and safety of once daily doses of 360 and 720 mg RVLE (AS 195) were compared to
placebo in male and female outpatients aged between 21 and 80 years old (with 52%
60 years) with
body weights ranging from 46 to 120 kg (Broca index: median 7.3, range: -30 to +82%; this
correspond to a BMI of approx. 25 kg/m
2
). And stage I and incipient stage II Chronic Venous
Insufficiency (CVI) with no major dystrophy of the skin. The majority (72%) of the patients were
women. Compression therapy and the administration of diuretics were not permitted during the study
period.
Patients were randomly assigned to a double-blind treatment with placebo, 360 mg RVLE or 720 mg
RVLE once daily for 12 weeks, preceded and followed by a single-blind 2-week placebo treatment for
baseline run-in and end-of-trial washout, respectively. Study criteria were evaluated at baseline, after
6 and 12 weeks of treatment and 2 weeks after discontinuation of treatment. Of the
260
patients
enrolled and randomized, 219 completed the study in accordance with the protocol, 86 test subjects
took a single daily dose of 360 mg AS 195, 84 took 720 mg AS 195/day and the remaining 87 test
subjects received a placebo. During weeks 13 and 14 none of the participants received any further
medication.
Subjectively, there was an improvement in CVI symptoms at 6 weeks with all treatments, but a further
improvement at week 12 was seen only in the active treatment groups: at 12 weeks, the changes
compared to baseline were significantly greater (p < 0.001) in both active treatment groups than in
the placebo group. The study demonstrated that once daily doses of 360 and 720 mg RVLE were
effective in the treatment of mild CVI, reducing significantly lower leg edema and improved CVI-related
symptoms to a clinically relevant extent.
The treatments were well tolerated. All 260 patients who were enrolled and randomized were included
in the safety analysis. This included three patients who withdrew from the study before visit 2 (i.e.
before entering the treatment phase). 257 patients received at least one dose of the randomized study
medication. Most patients completed the study up to 84 days of treatment. The mean duration of
treatment for the 360-mg dose of AS 195 was 81.9 days (n = 86) whilst the mean duration of
treatment for the 720-mg dose of AS 195 was 79.7 days (n = 84). Placebo was taken by 87 patients
during the randomized treatment period (mean duration of treatment: 79.3 days) and by all patients
during the 14-day run-in period (n = 260) and the 14-day follow-up period (n = 246). A total of 34
adverse events (AEs) were reported in 31/260 patients: 3 AEs in 3/260 subjects treated with placebo
during the run-in phase; 3 AEs in 3/246 patients treated with placebo during the follow-up period; 10
AEs in 10/87 patients treated with 360 mg AS 195; 2 AEs in 2/85 patients treated with 720 mg AS
195; and 16 AEs in 13/88 patients treated with placebo. Most AEs were considered to be mild (n = 21)
or moderate (n = 9). Four AEs were classified as severe, three in patients taking the placebo (phlebitis
of the large saphenous vein; knee surgery; abdominal discomfort) and one in a patient taking 360 mg
AS 195 (leg hematoma following minor trauma). Six AEs were rated as likely to be causally related to
the study medication by the investigator; of these, two (mild constipation and mild hair thinning) were
Assessment report on
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EMA/HMPC/16633/2009
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reported in patients treated with 360 mg AS 195, whilst the other four occurred in patients treated
with placebo. Gastrointestinal disorders (abdominal discomfort, diarrhea, dyspepsia, dry mouth or
retching) were the most frequently cited AEs (n = 11), followed by infections (n = 6), headache (n =
4) and disorders of the musculoskeletal system (n = 4). Two AEs which occurred during treatment with
placebo required hospitalization and were labelled as „serious“; there was one incident of vaginal
hemorrhage during the run-in phase and one incident of severe acute osteoarthritic complaints in the
knee of the affected leg during the randomized treatment period. Three other patients were withdrawn
following an AE: 1 patient was withdrawn during the placebo run-in period due to moderate abdominal
discomfort; 2 patients were withdrawn from randomized treatment with the placebo, one because of
phlebitis of the greater saphenous vein and one because of severe abdominal discomfort. The clinical
laboratory data, blood pressure and pulse rate data and 12-lead ECG recordings did not indicate any
significant mean or individual changes which were likely to have been due to the study medications.
Overall tolerability was rated as follows for the 3 treatments: 360 mg AS 195: good 81%‚ satisfactory
19%; 720 mg AS 195: good 94%‚ satisfactory 6%; placebo: good 68%‚ satisfactory 30%‚ not
satisfactory 2%. The study was conducted in multicentric settings, but most measurements were
carried out by only two investigators, thus this trial can be considered basically a monocentric one
[Kalus et al. 2004]:
The effect of AS 195 on cutaneous microvascular blood flow, transcutaneous
oxygen pressure (tcpO2), and leg oedema was investigated in a randomised, double-blind, placebo-
controlled, crossover study in male and female patients, aged ≥ 18 years with an average age of 66
years, with confirmed CVI stage I or II. In this efficacy study,
71
patients (70 during the second
phase) were treated with either placebo or 360 mg AS 195 film coated tablets. The first group (n=36)
received AS 195 360mg once daily during a first 6-week treatment period, followed by a 4-week
placebo washout period and then placebo during the second 6week treatment period. The second
group (n = 35) started with placebo and received AS 195 360mg after the placebo wash-out. After 6
weeks, patients in the AS 195 group had increased microvascular blood flow values and
transcutaneous oxygen pressure (tcpO2). The active substance group showed a statistically significant
increase of 241.8±18.7 Arbitrary Units (AU), while a reduction of 41.0±18.7 AU was recorded in the
placebo group (p<0.0001).
Microcirculation, measured in arbitrary units (AU) (laser Doppler flow measurement at Doppler
frequencies of 10.1–37.2 kHz, mean ± SEM, after 10 minutes of standing)
(from [Kalus et al. 2004])
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The TcpO
2
oxygen reading also rose significantly from baseline levels in the AS 195 group, by
1.35±0.97 mmHg, contrasting with a reduction in the placebo group of 7.27±0.97 mmHg.
Transcutaneous oxygen pressure (mean ± SEM, after 10 minutes of standing)
(from [Kalus et al. 2004])
These changes in the measured parameters were associated with corresponding volume changes in the
lower leg. After just three weeks of treatment, statistically significant differences were also observed in
ankle and calf circumference. After six weeks, these circumferences had fallen by 0.39 and 0.54 cm
respectively, in the active group, compared to increases in the placebo group of 0.29 and 0.14 cm
respectively. The authors of the study concluded that the administration of AS 195 could have a
positive effect on the course of CVI. The minimum number of days of exposure was 38 in the AS 195
and 24 in the placebo group, the maximum number 46 in the AS 195 and 45 in the placebo group.
Thirteen (18.3%) subjects out of 71 experienced 16 adverse events (AEs) during the 16 week trial.
Ten AEs (14.1%) were of mild, 4 (5.6%) of moderate and 1 (1.4%) of severe intensity. None of the
AEs were assessed as related to the trial medication. One patient died from a cardiac arrest. He had
been treated with placebo and never received AS 195 in this trial. All patients assessed the overall
tolerability as good or satisfactory. Laboratory parameters did not change during the study [Kalus et
al. 2004].
[Limoni C, 1996]:
A four-week, multicentre, randomised, double-blind versus placebo, parallel-group
safety trial to evaluate the tolerability profile of certain capsules (water extr.
Vitis vinifera
siccum 4-
6:1) in male and female patients suffering from chronic venous insufficiency. The study population
consisted of
105
patients, male and female, aged between 20 and 70 years with chronic venous
insufficiency of grade I, II, and III according to Widmer. The patients received 3 capsules of that
extract or placebo per day during 28 days. Seventy-two patients were randomised into the active
treatment group and 33 into the placebo treatment group. In the absence of a strictly diagnosed CVI,
patients with a subjective feeling of heavy and tired legs were admitted as well. Primary endpoints
were the incidence of adverse events and the rating of the overall tolerability. Secondary endpoints
were laboratory tests and physical examination. There were no differences in tolerability between the
two treatment groups. The proportion of volunteers reporting adverse events was similar in both
treatment groups: 40.2% in the active treatment group and 36.4% in the placebo group. The most
frequent adverse events were mild gastrointestinal disorders, sleep disturbances, and tiredness.
Laboratory values did not change in either treatment group during the trial period. The capsules were
well tolerated by 84.9% of the volunteers. No severe adverse events were reported.
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[Vix et al. 2007]:
This 12-week, double-blind, randomised, placebo-controlled, multicentre trial was
carried out to evaluate the efficacy and tolerability of film-coated tablets, extr.
Vitis vinifera
(
4-6:1
water
) 360 mg/day orally, in male and female patients suffering from chronic venous insufficiency.
The design and methodology used closely reflected those used in BI trial by Schaefer 2004).
The time course of the change from baseline in limb volume was similar for both treatment groups with
a more marked improvement of leg oedema over time in patients treated with these tablets. After 84
days of treatment, limb volume was reduced by -21.38 (±11.30) g of displaced water in the verum
group. The adjusted mean reduction in limb volume in the placebo group was less pronounced with -
10.71 (±11.56) g. However, the difference between treatment groups (-10.67 ±14.35 g) was not
statistically significant.
For the secondary endpoint "change from baseline in calf circumference", the adjusted mean difference
to placebo after 42 days of treatment with these tablets was -0.42±0.22 cm in the FAS (p=0.0596) vs.
-0.31±0.24 cm on study day 84 (p=0.1851). In the Per-Protocol Set (PPS), the difference to placebo
was -0.47 (±0.23) cm on study day 42, with a p-value just reaching significance at 0.0445. The
evaluation of the four subjective symptoms of CVI, as assessed by VAS, yielded similar results: after
42 days of treatment, the adjusted mean differences between active treatment and placebo were -0.44
cm for “tired, heavy legs”, -0.73 cm for “sensation of tension in the legs”, and -0.48 cm for “pain in
the legs” (vs. -0.38 cm, -0.04 cm, and 0.18 cm on study day 84). There was no difference between
treatment groups regarding the symptom “tingling sensation in the legs”. Global efficacy was rated as
good or satisfactory by 70.9% of all patients treated with these tablets and 67.7% of all patients
allocated to placebo whereas the investigators' ratings were 69.0% and 62.6%, respectively. The
assessment of quality of life by the Tuebingen QoL questionnaire resulted in a better mean score for
verum group compared with placebo regarding the subscale "leg complaints", the subscale most
specifically related to CVI. The differences, however, were not statistically significant.
[Schaefer & Petrini 2004]:
This placebo controlled, randomised, parallel group study was carried out
in 2004.
247
CVI patients (CEAP-Scores 3 or 4a) were entered in the study: 121 were treated with the
grapevine leaf extract AS 195 360 mg as a single tablet and 126 with placebo for 12 weeks. For the
primary endpoint, the difference related to placebo, adjusted for centre effect and baseline values, in
changes of displaced water from baseline until Day 84 was -10.42 cm (SE: 11.84; 95% CI: -33.76,
12.92). The difference in changes between the two treatment groups was not statistically significant.
Subjective CVI symptoms diminished in both treatment arms similarly during the first three weeks. A
statistically significant difference between the two treatment groups in favour of verum, was found for
the symptoms “sensation of tension in the legs” at Day 42 (p=0.0211, ANCOVA) and “pain in the legs “
at Day 84 (p=0.0222, ANCOVA). At all other time points no statistically significant difference was
detected between the two treatment regimens for the symptoms “tired heavy legs” as well as “tingling
sensation” in the legs. After 84 days of treatment, the limb volume as measured by the water
displacement method was statistically not significantly more reduced in subjects allocated to verum
than in those randomised to placebo. Careful inspection of the results showed that the unexpected high
intra- as well as inter-individual variability of limb volume determinations contributed significantly to
the outcome of the study. The variability between 2 or 3 replicates of the limb volume determination,
for example, exceeded 20 g of displaced water in more than 20% of patients (range 0% to 44.1%) in 8
out of 23 study sites (35%). This study was negative in terms of a primary endpoint, although there
was evidence of symptomatic benefit from the active treatment.
[Schaefer E & Petrini LE, 2003]:
A 17 week, randomised, double-blind, placebo controlled cross-
over trial to evaluate the efficacy of water extr.
Vitis vinifera
4-6:1
film coated tablets (AS 195) given
as 2 capsules of 180 mg of AS 195 daily 360 mg/day p.o., in
179
male and female Japanese patients
with swellings of calf and ankle due to disorders of venous reflux belonging to Class 1 according to
Porter’s classification, in improving microcirculation of the skin in the leg of male and female patients
Assessment report on
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suffering from chronic venous insufficiency The microcirculation study has demonstrated that objective
signs associated with CVI (microvascular blood flow, tcpO
2
, ankle circumference and calf
circumference) can be improved significantly after just 3 weeks of oral treatment with a single daily
dose of 360mg of the grapevine leaf extract AS 195. These results build on those from Harrison trial
(1998) showed that AS 195 reduces lower leg oedema and calf circumference in patients suffering
from CVI treated once daily for 12 weeks. Out of the 179 evaluable subjects 38.5% experienced a
marked and 42.5% a moderate global improvement of CVI symptoms. Improvement was rated as
“moderate” by 59.8% of the patients with regards to heaviness/tiredness, 69.9% with regards to
tension, 79.2% to tingling, 74.0% to pain, and 74.4% to itching. Circumference of calf (mean±SD)
was 33.5±2.99 cm prior to treatment and 33.0±2.94 cm at 12 weeks, of the ankle (mean±SD)
22.3±1.84 cm prior to treatment and 21.9±1.82 cm at 12 weeks after treatment (p<0.05). These
differences were not statistically significantly different from baseline.
Open-label, Observational studies
[Schaefer et al. 2003]:
The 6-week, open, uncontrolled multicentre safety trial was conducted to
specifically evaluate the tolerability and safety of AS195 film-coated tablets, 360 mg/day
per os
, in
65
male and female patients, aged 25 - 82 years, suffering from chronic venous insufficiency grade I or II
(Widmer classification). The verum group received two film-coated tablets once daily for 42 days (360
mg/day). The primary objective of the study was to assess the tolerability and safety of AS 195 extr.
Vitis vinifera
siccum
4-6:1
) film-coated tablets. The observational study was conducted in accordance
with the requirements of the Swiss licensing authority (Swissmedic: application document) in a total of
11 study centres (general practitioners) between June and October 2002. Three visits (study
enrolment, baseline examination at the start of the study, final examination at the end of the study,
with a follow-up examination if necessary) were planned. The study was carried out in accordance with
GCP. At the end of the study, all subjective symptoms of CVI (tired, heavy legs, sensation of tension in
the legs, tingling sensations in the legs, pain in the legs) were statistically significantly improved. The
global assessment of efficacy by the patients and by the investigators was rated as good or satisfactory
in most of the patients. The primary variable was the number and intensity of adverse events (AEs),
with particular emphasis placed on AEs regarded by the investigator to be treatment-related.
Secondary safety variables included the global assessment of tolerability by both the patients and
investigators as well as vital sign assessments. AS 195 film coated tablets were well tolerated during
the whole study. Overall, six patients (9.2%) experienced a total of 7 AEs of mild or moderate intensity
judged by the investigator as potentially causally related to study medication. They included
gastrointestinal problems (4 patients), headache (1 patient), anorexia (1 patient), and erythematous
rash (1 patient). Four patients of whom experienced a significant AE necessitated study discontinuation
in three cases and dose reduction in one case. Most patients rated the global tolerability of AS 195
film-coated tablets as good (49 patients, 75.4%) or satisfactory (12 patients, 18.5%). Three patients
(4.6%) rated tolerability as bad. One patient (1.5%) gave no rating. The global assessment of
tolerability by the investigators was in good agreement with those of the patients. The investigators
rated the tolerability as good in 50 patients (76.9%)‚ as satisfactory in 10 patients (15.4%)‚ as not
satisfactory in one patient (1.5%)‚ and as bad in two patients (3.1%). No relevant changes of vital
signs (systolic and diastolic blood pressure, pulse rate) were measured. Patient´s compliance was
rated as good [Schaefer et al. 2003].
Assessment
The present open-label, multicentre observational study demonstrated that AS 195 film-
coated tablets were effective and well tolerated in outpatients with chronic venous insufficiency grade I
or II supervised in a setting of private practices. No change of the safety profile has been noted.
[Monsieur & Van Snick 2006]:
A small, open observational clinical study was conducted in
39
patients suffering from Chronic Venous Insufficiency (CVI), grade I or II according to the Widmer
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 33/40
classification, (grade 2 to 4 of the international CEAP classification). Patients were treated with 180 mg
of RVLE (AS 195) twice daily (360 mg in total) for six weeks. The parameters investigated were
objective measurements of lower leg volume and the circumference of the leg as well as subjective
criteria such as heaviness and pain in the leg. A clear and significant improvement of all parameters
was observed after two weeks of treatment. This effect was still present and increased slightly after
four and six weeks in all objective and subjective parameters tested in this study.
Assessment
This study has shown a fast onset of action and an efficacy of the AS 195 extract in
chronic venous insufficiency. Adverse events/side effects: not specified. In general, the treatments
were well tolerated. Three patients prematurely stopped the trial for reasons not linked to the
treatment or to the disease. No change of the safety profile.
Clinical studies with grapevine leaf extract (4-6:1, extract solvent: water) (AS 195)
Study
ID
Study
Dates
Design
Control
type
Study
objective
Study &,
Ctrl
Drugs
Dose,
Route,
&
Regimen
Subjec
ts per
Arm
treated
/
comple
ted
Dura
tion
Gender M/F
Median Age
(Range)
Diagnosis
Inclusion
Criteria
Primary
Endpoint
Outcome
Perso
ns
Kiese-
wetter,
2000
April
Sept-
1998
randomize
d, double-
blind,
parallel,
dose
response
Placebo
Efficacy,
tolerability,
safety
AS 195
caps
180mg,
per os
2-0-0
360 mg
:
86/84,
12
wks
24/62
56.2
12.4
years
(mean
SD)
CVI
Grade I, II
according to
Widmer
Baseline
adjusted
changes of
lower limb
volume
assessed by
water
displacement
plethysmograp
hy
Positive
260
27/57
55.7
13.8
years
(mean
SD)
AS 195
capsules
360 mg,
per os
2-0-0
Placebo
720 mg
:84/79
87/80
20/67
59.2
11.5
years
(mean
SD)
Schaefe
r &
Petrini
2004
2004
randomize
d, double-
blind,
parallel
AS 195
tablets
360 mg,
per os
1-0-0
Placebo
1-0-0
360 mg
:
121/11
7
12
wks,
2
wks
singl
e
blind
place
bo
20/99
53.0 years
(20–83
years)
CVI
CEAP-
Scores 3 or
4a
Baseline
adjusted
changes of
lower limb
volume
assessed by
water
displacement
plethysmograp
hy
Negative
247
Placebo
15/111
53.0 years
(23–79
years)
Efficacy,
tolerability
126/12
3
Schaefe
r &
Petrini
2003
2003
randomize
d, double-
blind,
controlled
cross over
trial
AS 195
tablets
360 mg,
per os
1-0-0
Placebo
1-0-0
360 mg 17
week
s
No data
CVI
Grade I, II
according
to Porter
Baseline
adjusted
changes of
lower limb
volume
Changes in CVI
symptoms
Negative
179
Placebo
Efficacy
Vix et
al. 2006
2006
randomize
d, double-
blind,
parallel
AS 195
tablets
360 mg,
per os
1-0-0
Placebo
1-0-0
360 mg
:
103/98
12
wks
32/71
61.0 years
(29–86
years)
26/73
61.0 years
(30–87
years)
CVI
CEAP
Scores 3 or
4a
Baseline
adjusted
changes of
lower limb
volume
assessed by
water
displacement
plethysmo-
graphy
Negative
211
Placebo
Efficacy,
tolerability
99/95
Kalus
2004
2002,
randomize
d, double-
blind,
cross-over
AS 195
tablets
360 mg,
per os
1-0-0
360 mg
: 70/70
6
wks
16/55
65.2
7.7
years
(mean
SD)
(32–76)
CVI
Grade I, II
according
to Widmer
resting flux,
change from
baseline
measured by
Laser Doppler
fluxmetry
Increase of
microvascular
blood flow
compl
eted
71
Placebo
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EMA/HMPC/16633/2009
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Study
ID
Study
Dates
Design
Control
type
Study
objective
Study &,
Ctrl
Drugs
Dose,
Route,
&
Regimen
Subjec
ts per
Arm
treated
/
comple
ted
Dura
tion
Gender M/F
Median Age
(Range)
Diagnosis
Inclusion
Criteria
Primary
Endpoint
Outcome
Perso
ns
Efficacy,
tolerability
Placebo
1-0-0
Schaefe
r et al.
2003
June
2001
Open/
Observatio
nal
Uncontrolle
d
Tolerability
, safety,
Efficacy,
AS 195
tablets
180 mg,
per os
2-0-0
360 mg
: 65/59
6
wks
7/58
CVI
Grade I, II
according
to Widmer
Incidence and
intensity of
adverse
events;
Changes in CVI
symptoms as
secondary
endpoint
Safety study
Positive
M: 65.9
years
(mean)
(56-82
years)
Oct-
2001
65
F: 56.6
years
(mean)
(25–80
years)
Monsieu
r
2
006
2006
39
Open
Tolerability
, safety,
Efficacy
AS 195
tablets
180 mg,
per os
2-0-0
360 mg 6
wks
CVI
Grade I, II
according
to Widmer
Baseline
adjusted
changes of
lower limb
volume
Changes in CVI
symptoms
Positive
Limoni
1996
Dec-
1996
May
1997
randomize
d, double-
blind,
parallel,
dose
response
Placebo
Multicentre
Tolerability
, Safety
AS 195
caps.
180 mg,
per os
1-0-2
540 mg
: 72/64
4
wks
6/66
45.2 years
(18.4–67.9
years)
4/29
36.7 years
(25.6–70.6
years)
CVI Grade
I, II. III
according
to Widmer
Safety
Global
improvement
Safety
105
33/27
Placebo
1-0-2
4.2.3.
Clinical studies in special populations (e.g. elderly and children)
No information available.
4.3.
Overall conclusions on clinical pharmacology and efficacy
The clinical efficacy of an extract from red vine leaves (RVLE; AS 195) was investigated in double
blind, placebo-controlled studies [Kiesewetter et al. 2000; Kalus et al. 2004] and in open observational
studies [Schaefer et al. 2003; Monsieur & Van Snick, 2006] during treatment of chronic venous
insufficiency. In these studies, the RVLE was showed an acceptable clinical efficacy and tolerability,
while there were some others with negative results [Schaefer & Petrini 2003; 2004; Vix et al. 2006].
Treatment with RVLE has been shown to lead to a reduction of leg volume, measured using both water
plethysmography and calf and ankle circumference, and of the subjective symptoms investigated in the
studies reviewed.
The extract AS 195 was consistently more effective than placebo in reducing leg oedema and
improving symptoms of Chronic Venous Insufficiency (CVI) across most efficacy parameters evaluated,
even though not always a statistically significant superiority could be shown.
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Vitis vinifera
L., folium
EMA/HMPC/16633/2009
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5.
Clinical Safety/Pharmacovigilance
5.1.
Overview of toxicological/safety data from clinical trials in humans
The safety profile of vine leaf extracts can be described as acceptable from all clinical studies in
Chronic Venous Insufficiency (CVI) patients and from its use from products on the market. The safety
results obtained from the clinical studies conducted so far show that the oral use of vine leaf extracts
are well tolerated by most patients. No drug-related serious adverse events were reported during the
clinical trials, and when reported that were mild and transient. Seven non-serious adverse events
(constipation, dermatitis, headache, hair thinning, menometrorrhagia, urticaria) or moderate
(erythematous rash) of mild intensity leading to patient withdrawals, were suspected to be related to
the active trial medication.
5.2.
Patient exposure
The controlled studies evaluated 1073 patients in total [Kiesewetter et al. 2000; Kalus et al. 2004;
Schaefer & Petrini 2004; Vix 2006, Limoni 1996]. The open studies, evaluated by [Schaefer et al.
2003] and by [Monsieur and Van Snick, 2006] comprised 104 patients.
5.3.
Adverse events
No health hazards or side effects are known in conjunction with the proper administration of
designated therapeutic dosages. A reversible inhibition of intestinal enzyme activity (alkaline
phosphatase, sucrose and dipeptidyl peptidase) was demonstrated in animal models [Tebib, 1994; PDR
for Herbal Medicines, Thomson, 2004].
Brito et al. [2008]; Mur et al. [2006]: Vine pollen allergies have been reported with
Vitis vinifera
pollen
and an extract thereof In Castilla-La Mancha, Spain, the area with the highest density of vineyards in
the world. Two cases of allegic reactions to
Vitis vinifera
pollen and grape have been previously
reported. The aim of a prospective study by Brito et al. [2008] was to determine the clinical relevance
and biochemical characteristics of vine pollen in the Spanish province of Ciudad Real. The authors
designed a prospective study of patients treated in the allergy units from Puertollano and Ciudad Real
for respiratory symptoms of 4 months' duration in the year 2000. Skin prick tests with a standard
aeroallergen battery and
V. vinifera
pollen extract were performed on all patients. The authors also
performed conjunctival and bronchial provocation tests and serum specific IgE and sodium dodecyl
sulfate-polyacrylamide gel electrophoresis immunoblotting on the patients who tested positive for
Vitis
vinifera
pollen.
The results of this prospective study show that
V. vinifera
pollen has a moderate clinical relevance from
an allergic point of view, particularly affecting those subjects who are exposed to it during the working
hours and those who perform leisure activities close to vine fields. During a period of four months, the
authors performed skin prick tests to vine pollen in patients who attended the outpatient clinic with
suspected respiratory allergy, finding sensitisation to
Vitis vinifera
pollen in 9 of the 200 patients seen
(98 patients had allergy to other pollen). In conclusion, in areas with a high density of vineyards, vine
pollen can reach midrange air concentrations and could be the cause of hay fever in those individuals
with the highest level of exposure [Brito et al. 2008; Mur et al. 2006].
Assessment:
In summary, there is no new safety specific information provided. No change of the
safety profile is suggested.
Reports on immunoglobulin E (IgE)-mediated allergic reactions to grapes and wine are limited in the
literature. Nevertheless, grapes are widely grown and consumed in Mediterranean countries. The
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
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object of a prospective study by Kalogeromitros et al. [2005] was to present clinical features,
in vivo
and
in vitro
allergy testing, and human leukocyte antigen (HLA) serotyping in patients with recurring
reactions to grapes and grape products. Eleven unrelated Greek patients, six men and five women
(aged 16-44 years; mean, 26.9 years) were enrolled based on a documented history of IgE-mediated
reactions to grapes, wine, or other grape products. Their evaluation included full history, reaction
severity, clinical examination, skin-prick tests with food allergens and molds, serum IgE, specific IgEs
to the same allergen battery, and HLA typing. Patients reported 35 grape-induced episodes of
anaphylaxis ranging from moderate to severe. The authors described several cases of repeated IgE-
mediated reactions to grapes, vine and other grape products. Similar clinical manifestations in different
courses of grape allergen, almost identical prevalent co-sensitisations to other already known
allergenic fruits, and the first determination of HLA antigens in grape-allergic patients are the core of
this study.
The authors suggest that allergy to grapes may not be as uncommon as generally believed in the
literature and should be considered as a possible offending cause in certain episodes of food-induced
anaphylaxis probably in genetically at-risk individuals. However, allergic reactions to
Vitis vinifera
are
known and reported in rare cases [Kalogeromitros et al. 2005].
Assessment:
If hypersensitivity reactions are labelled correctly in the PIL and SPC, there is no change
of the safety profile of medicinal products.
[Crowell et al. 2004]: Resveratrol-Associated Renal Toxicity. Resveratrol, (3, 5, 4'-trihydoxystilbene) a
compound found in grapes, mulberries, and peanuts, has antimycotic, antiviral, and beneficial
cardiovascular and cancer preventive activities. To evaluate the potential toxicity of resveratrol, rats
were administered by gavage 0, 300, 1000, and 3000 mg trans-resveratrol per kilogram body weight
per day for 4 weeks. Most of the adverse events occurred in the rats administered 3000 mg per
kilogram body weight per day. These included increased clinical signs of toxicity; reduced final body
weights and food consumption; elevated BUN (blood urea nitrogen), creatinine, alkaline phosphatase,
alanine aminotransferase, total bilirubin, and albumin; reduced hemoglobin, hematocrit, and red cell
counts; and increased white cell counts. Increases in kidney weights and clinically significant renal
lesions, including an increased incidence and severity of nephropathy, were observed. Diffuse epithelial
hyperplasia in the bladder was considered, equivocal and of limited biological significance. No
histological effects on the liver were observed, despite the clinical chemistry changes and increased
liver weights in the females. Effects seen in the group administered 1000 mg resveratrol per kilogram
body weight per day included reduced body weight gain (females only) and elevated white blood cell
count (males only). Plasma resveratrol concentrations in blood collected 1 h after dose administration
during week 4 were dose related but were relatively low given the high dosage levels; conjugates were
not measured. Under the conditions of this study, the no observed adverse effect level was 300 mg
resveratrol per kilogram body weight per day in rats (corresponding to 21 g in a 70 kg human)
[Crowell et al. 2004].
Assessment:
These results cannot be transferred to medical products containing Vitis vinifera or
extracts thereof.
In summary, there is no safety specific information that is relevant for medical products. The reported
adverse events / side effects were mild to moderate. The majority of the above mentioned events are
considered to be related to underlying diseases, incidental concomitant disorders or other coincidences
but not causally related to
Vitis vinifera
. From these published adverse events, no change of the safety
profile of
Vitis vinifera
can be concluded. According to current knowledge, gastrointestinal disorders
and hypersensitivity reactions should be labelled in the PIL and SPC.
The Periodic Safety Update Report for
Vitis vinifera
has been compiled within the joint BAH PSUR
project. It summarizes safety data from 01/Nov/2003 to 01/Sep/2008 [BAH 2008].
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
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In the report period no new safety relevant issues were found in the literature. There were no reports,
clinical or experimental studies identified that give reason for a change in the assessment of the safety
and benefit/risk ratio of
Vitis vinifera
.
5.4.
Serious adverse events and deaths
The case of a 51 years old female patient is reported. She was hospitalized due to an acute icterus,
which had developed over 15 days and was associated with asthenia, nausea and anorexia. Beyond the
mucocutaneous icterus, the clinical examination did not show any abnormality, especially no chronic
hepatopathy. The laboratory parameters suggested a cytolysis due to an ALAT value that was twelve
times higher than normal, γ-GT and alcalic phosphatase plasma concentrations two times higher than
normal and total bilirubine of 87 µmol/L. Normal findings in the abdominal ultrasonic examination lead
to the diagnosis of an acute hepatitis. The patient has a history of euthyroidism. The patient did not
consume alcohol and was in a good nutritional condition. The etiologic examination of this hepatitis
was negative for infections, immunological and metabolic causes. A hepatic punction-biopsy, revealed
a discrete cholangitis with focal ductal hyperplasia, a major cholestasis with numerous biliary
thromboses and intrahepatocytic biliary pigments, a focal hepatocellular necrosis, a lymphohistiocytic
infiltrate of weak intensity without significant fibrosis. Altogether this suggested an acute cholestatic
hepatitis with either viral or toxic origin. The review of the medical questionnaire revealed sporadic
intake of 1 g of acetaminophen and two repeated intakes in an interval of one week, when the first
symptoms had appeared. Additionally the patient took
Vitis vinifera
tinctoria
(extract of red wine
leaves) and Fumitory (extract of
Fumaria officinalis
) daily for two months, as "summer cure" for the
treatment of heavy legs and as a stimulant. She stopped the intake of these two products three weeks
prior to hospitalization, when the first general symptoms appeared. The patient had already taken
Vitis
vinifera tinctoria
at the same time one year before. Fumitory was used for the first time. According to
the official method used at the pharmacovigilance centres in France, this case is classified as plausible
with a chronological C2 and a semiotic S3 score of two products concomitantly used with paracetamol
[Bonnet et al. 2007].
Assessor’s comment
This case is classified as serious because of a significant medical reaction including hospitalisation.
A causal relationship with
Vitis vinifera
cannot be excluded (plausible temporal relationship). However,
the used herbal products are insufficiently described; additionally relevant information on the dosage
are lacking. Moreover, the concomitant use of acetaminophen must be considered. Acetaminophen is
well known for its hepatotoxicity.
5.5.
Laboratory findings
None reported.
5.6.
Safety in special populations and situations
The product is not suitable for patients with known hypersensitivity against the herbal substance, the
plant family, the herbal preparation or to the excipients of the final product.
5.7.
Intrinsic (including elderly and children) /extrinsic factors
Grapevine leaf is not intended for use in children, while no restrictions are known for its use in elderly.
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 38/40
5.8.
Drug interactions
No drug interactions have been reported.
5.9.
Use in pregnancy and lactation
Grapevine leaf should not be used during pregnancy and lactation as there are not data available.
No information.
5.11.
Drug abuse
No information.
5.12.
Withdrawal and rebound
No information.
5.13.
Effects on ability to drive or operate machinery or impairment of
mental ability
No information.
5.14.
Overall conclusions on clinical safety
The safety profile of grapevine leaf extracts can be judged as good from clinical studies and from its
long term use and market availability. The available literature, on pharmacological and toxicological
studies, does not give rise to safety concerns. A special focus was set on the polyphenolic constituents
of the extract (proanthocyanidins, flavonoids) that can be linked with the pharmacological effects. The
proof of an acceptable safety is not only given by the period of time over which this extract has been
used and by the quantitative aspects of their use but also by PSURs data and the safety data obtained
during the clinical trials.
Overall,
Vitis vinifera,
leaves can be considered as safe in herbal medicinal products with a positive
benefit/risk ratio.
6.
Overall conclusions
Well-established use
The clinical efficacy and safety of the dry aqueous extract of grapevine leaves (4-6:1) has been
demonstrated in appropriately designed clinical trials and is supported by extensive use of the product
in the market since 1999.
The above referred extract showed an influence to the microcirculation and transcutaneous oxygen
pressure at the predominantly affected perimalleolar area of the leg in Chronic venous insufficiency
(CVI) patients who were treated for six weeks. Moreover, the assayed grapevine leaves extract has
shown to lead to a reduction of the volume of oedema and to improvement of the typical subjective
symptoms of CVI such as tired, heavy and swollen legs or pain and tension in the legs.
Three double-blind, placebo controlled trials investigated the change in leg volume as measured by
water plethysmography as the primary endpoint, another also the changes in ankle and calf
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 39/40
circumference in the secondary endpoints investigated. In several of the clinical trials objective and
subjective symptoms of CVI appeared to be effectively reduced, while there were some others giving
negative results such as the ones of Schaefer & Petrini 2004 and Vix et al. 2006. The trials were
performed according to ICH-GCP.
An additional placebo-controlled and open safety and tolerability trial provided supportive evidence for
the efficacy.
This extract can therefore be regarded as an active substance with a well-established medicinal use.
The use of herbal medicinal products prepared with this extract is not recommended during pregnancy
and lactation and should not be taken in children and adolescents under 18 years of age, due to the
lack of adequate data.
The proposed indication is:
Herbal medicinal product for treatment of chronic venous insufficiency, which is characterised by
swollen legs, varicose veins, a feeling of heaviness, pain, tiredness, itching, tension and cramps in
the calves.
Traditional use
Other extracts and herbal preparations from grapevine leaves have been widely used. The safe use of
the extract can be stated on the basis of the well-known, long-lasting and traditional use of
preparations of grapevine leaves in the folk medicine and as registered medicaments.. Based on the
evaluation and assessment of the present documentation of the clinical efficacy and safety, the herbal
substance for use as herbal tea or in other oral dosage forms, and the aqueous extracts of grapevine
leaf are acceptable as traditional herbal medicinal products.
Sufficient data are available to develop a Community monograph on the well established and
traditional use of
Vitis vinifera
L., leaves. The indications are suitable for self-medication. The proposed
indications are:
Traditional herbal medicinal product to relieve symptoms of discomfort and heaviness of legs
related to minor venous circulatory disturbances.
Traditional herbal medicinal product for symptomatic relief of itching and burning associated with
haemorrhoids.
Traditional herbal medicinal product for symptomatic treatment of cutaneous capillary fragility.
The use of the traditional herbal medicinal products is not recommended during pregnancy and
lactation and should not be taken in children and adolescents under 18 years of age.
The minimum required data on mutagenicity (Ames test) are available for herbal preparations of
grapevine leaves.
The inclusion in the Community list of traditional herbal substances and
preparations is recommended.
Annex
Assessment report on
Vitis vinifera
L., folium
EMA/HMPC/16633/2009
Page 40/40
Source: European Medicines Agency
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