DOI QR코드

DOI QR Code

Review of cases of patient risk associated with ginseng abuse and misuse

  • Paik, Doo Jin (Department of Anatomy and Cell Biology, College of Medicine, Hanyang University) ;
  • Lee, Chang Ho (Department of Pharmacology, College of Medicine, Hanyang University)
  • Received : 2014.11.10
  • Accepted : 2014.11.24
  • Published : 2015.04.15

Abstract

Ginseng has long been used as a functional food or therapeutic supplement and it is empirically known to be safe and nontoxic. During recent decades, a number of in vitro and in vivo experiments, as well as human studies have been conducted to prove the safety of various types of ginseng samples and their components. Clinical trials, case reports, and in vitro and in vivo research articles addressing the safety, toxicity, and other adverse events of ginseng application were selected and reviewed. Patient risks associated with ginseng abuse and misuse such as affective disorder, allergy, cardiovascular and renal toxicity, genital organ bleeding, gynecomastia, hepatotoxicity, hypertension, reproductive toxicity, and anticoagulant-ginseng interaction were reviewed and summarized. There are some cases of patient risk associated with ginseng abuse and misuse depending on patients' conditions although further investigation in more cases is required to clarify these issues.

Keywords

References

  1. Shishtar E, Sievenpiper JL, Djedovic V, Cozma AI, Ha V, Jayalath VH, Jenkins DJ, Meija SB, de Souza RJ, Jovanovski E, et al. The effect of ginseng (the genus Panax) on glycemic control: a systematic review and meta-analysis of randomized controlled clinical trials. PloS one 2014;9:e107391. https://doi.org/10.1371/journal.pone.0107391
  2. Chen S, Wang Z, Huang Y, O'Barr SA, Wong RA, Yeung S, Chow MS. Ginseng and anticancer drug combination to improve cancer chemotherapy: a critical review. Evid Based Complement Alternat Med 2014;2014:168940.
  3. Wu H, Hoiby N, Yang L, Givskov M, Song Z. Effects of radix ginseng on microbial infections: a narrative review. J Tradit Chin Med 2014;34:227-33. https://doi.org/10.1016/S0254-6272(14)60083-2
  4. Siddiqi MH, Siddiqi MZ, Ahn S, Kang S, Kim YJ, Sathishkumar N, Yang DU, Yang DC. Ginseng saponins and the treatment of osteoporosis: mini literature review. J Ginseng Res 2013;37:261-8. https://doi.org/10.5142/jgr.2013.37.261
  5. Choi J, Kim TH, Choi TY, Lee MS. Ginseng for health care: a systematic review of randomized controlled trials in Korean literature. PloS one 2013;8:e59978. https://doi.org/10.1371/journal.pone.0059978
  6. Kim HJ, Kim P, Shin CY. A comprehensive review of the therapeutic and pharmacological effects of ginseng and ginsenosides in central nervous system. J Ginseng Res 2013;37:8-29. https://doi.org/10.5142/jgr.2013.37.8
  7. Kim MS, Lim HJ, Yang HJ, Lee MS, Shin BC, Ernst E. Ginseng for managing menopause symptoms: a systematic review of randomized clinical trials. J Ginseng Res 2013;37:30-6. https://doi.org/10.5142/jgr.2013.37.30
  8. Gao YL, Liu ZF, Li CM, Shen JY, Yin HX, Li GS. Subchronic toxicity studies with ginsenoside compound K delivered to dogs via intravenous administration. Food Chem Toxicol 2011;49:1857-62. https://doi.org/10.1016/j.fct.2011.05.003
  9. Lee JY, Lim KM, Kim SY, Bae ON, Noh JY, Chung SM, Kim K, Shin YS, Lee MY, Chung JH. Vascular smooth muscle dysfunction and remodeling induced by ginsenoside Rg3, a bioactive component of ginseng. Toxicol Sci 2010;117: 505-14. https://doi.org/10.1093/toxsci/kfq201
  10. Lee SR, Kim MR, Yon JM, Baek IJ, Lee BJ, Ahn B, Kim YB, Kwack SJ, Lee RD, Kim SS, et al. Effects of ginsenosides on organogenesis and expression of glutathione peroxidase genes in cultured rat embryos. J Reprod Dev 2008;54: 164-70. https://doi.org/10.1262/jrd.19152
  11. Liu P, Xu Y, Yin H, Wang J, Chen K, Li Y. Developmental toxicity research of ginsenoside Rb1 using a whole mouse embryo culture model. Birth Defects Res B Dev Reprod Toxicol 2005;74:207-9. https://doi.org/10.1002/bdrb.20038
  12. Sivakumar G, Yu KW, Lee JS, Kang JK, Lee HL, Kim WJ, Paek KY. Tissue cultured mountain ginseng adventitious $roots^{TM}$: safety and toxicity evaluation. Eng Life Sci 2006;6:372-83. https://doi.org/10.1002/elsc.200520139
  13. Liu JP, Lu D, Nicholson RC, Li PY, Wang F. Toxicity of a novel anti-tumor agent 20(S)-ginsenoside Rg3: a 26-week intramuscular repeated administration study in Beagle dogs. Food Chem Toxicol 2011;49:1718-27. https://doi.org/10.1016/j.fct.2011.04.017
  14. Shin S, Jang JY, Park D, Yon JM, Baek IJ, Hwang BY, Nam SY, Yun YW, Kim KY, Joo SS, et al. Korean red ginseng extract does not cause embryo-fetal death or abnormalities in mice. Birth Defects Res B Dev Reprod Toxicol 2010;89: 78-85.
  15. Kang KS, Yamabe N, Kim HY, Okamoto T, Sei Y, Yokozawa T. Increase in the free radical scavenging activities of American ginseng by heat processing and its safety evaluation. J Ethnopharmacol 2007;113:225-32. https://doi.org/10.1016/j.jep.2007.05.027
  16. Siegel RK. Ginseng abuse syndrome. Problems with the panacea. JAMA 1979;241:1614-5. https://doi.org/10.1001/jama.1979.03290410046024
  17. Kiefer D, Pantuso T. Panax ginseng. Am Fam Phys 2003;68:1539-42.
  18. Chang YS, Seo EK, Gyllenhaal C, Block KI. Panax ginseng: a role in cancer therapy? Integr Cancer Ther 2003;2:13-33. https://doi.org/10.1177/1534735403251167
  19. Coon JT, Ernst E. Panax ginseng: a systematic review of adverse effects and drug interactions. Drug Saf 2002;25:323-44. https://doi.org/10.2165/00002018-200225050-00003
  20. Ernst E. Panax ginseng: an overview of the clinical evidence. J Ginseng Res 2010;34:259-63. https://doi.org/10.5142/jgr.2010.34.4.259
  21. Lee NH, Son CG. Systematic review of randomized controlled trials evaluating the efficacy and safety of ginseng. J Acupunct Meridian Stud 2011;4: 85-97. https://doi.org/10.1016/S2005-2901(11)60013-7
  22. Vazquez I, Aguera-Ortiz LF. Herbal products and serious side effects: a case of ginseng-induced manic episode. Acta Psychiatr Scand 2002;105:76-8.
  23. Engelberg D, McCutcheon A, Wiseman S. A case of ginseng-induced mania. J Clin Psychopharmacol 2001;21:535-7. https://doi.org/10.1097/00004714-200110000-00015
  24. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson Jr NF, Bock SA, Branum A, Brown SG, Camargo Jr CA, Cydulka R, Galli SJ, et al. Second symposium on the definition and management of anaphylaxis: summary report-Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117:391-7. https://doi.org/10.1016/j.jaci.2005.12.1303
  25. Trinh HT, Shin YW, Han SJ, Han MJ, Kim DH. Evaluation of antipruritic effects of red ginseng and its ingredients in mice. Planta Med 2008;74:210-4. https://doi.org/10.1055/s-2008-1034313
  26. Kim HS, Kim DH, Kim BK, Yoon SK, Kim MH, Lee JY, Kim HO, Park YM. Effects of topically applied Korean Red Ginseng and its genuine constituents on atopic dermatitis-like skin lesions in NC/Nga mice. Int Immunopharmacol 2011;11:280-5. https://doi.org/10.1016/j.intimp.2010.11.022
  27. Zheng H, Jeong Y, Song J, Ji GE. Oral administration of ginsenoside Rh1 inhibits the development of atopic dermatitis-like skin lesions induced by oxazolone in hairless mice. Int Immunopharmacol 2011;11:511-8. https://doi.org/10.1016/j.intimp.2010.12.022
  28. Park EK, Choo MK, Han MJ, Kim DH. Ginsenoside Rh1 possesses antiallergic and anti-inflammatory activities. Int Arch Allergy Immunol 2004;133:113-20. https://doi.org/10.1159/000076383
  29. Lee KG, Son SW. Efficacy of Korean Red Ginseng in the treatment of atopic dermatitis. J Ginseng Res 2011;35:149-54. https://doi.org/10.5142/jgr.2011.35.2.149
  30. Jung JW, Kang HR, Ji GE, Park MS, Song WJ, Kim MH, Kwon JW, Kim TW, Park HW, Cho SH, et al. Therapeutic effects of fermented red ginseng in allergic rhinitis: a randomized, double-blind, placebo-controlled study. Allergy Asthma Immunol Res 2011;3:103-10. https://doi.org/10.4168/aair.2011.3.2.103
  31. Wiwanitkit V, Taungjaruwinai W. A case report of suspect ginseng allergy. MedGenMed 2004;6:9.
  32. Lee JY, Lee YD, Bahn JW, Park HS. A case of occupational asthma and rhinitis caused by Sanyak and Korean ginseng dusts. Allergy 2006;61:392-3. https://doi.org/10.1111/j.1398-9995.2006.01032.x
  33. Lee JY, Jin HJ, Park JW, Jung SK, Jang JY, Park HS. A case of Korean ginsenginduced anaphylaxis confirmed by open oral challenge and basophil activation test. Allergy Asthma Immunol Res 2012;4:110-1. https://doi.org/10.4168/aair.2012.4.2.110
  34. Kim KM, Kwon HS, Jeon SG, Park CH, Sohn SW, Kim DI, Kim SS, Chang YS, Kim YK, Cho SH, et al. Korean ginseng-induced occupational asthma and determination of IgE binding components. J Korean Med Sci 2008;23: 232-5. https://doi.org/10.3346/jkms.2008.23.2.232
  35. Morita H, Wu J, Zipes DP. The QT syndromes: long and short. Lancet 2008;372: 750-63. https://doi.org/10.1016/S0140-6736(08)61307-0
  36. Caron MF, Hotsko AL, Robertson S, Mandybur L, Kluger J, White CM. Electrocardiographic and hemodynamic effects of Panax ginseng. Ann Pharmacother 2002;36:758-63. https://doi.org/10.1345/aph.1A411
  37. Torbey E, Abi Rafeh N, Khoueiry G, Kowalski M, Bekheit S. Ginseng: a potential cause of long QT. J Electrocardiol 2011;44:357-8. https://doi.org/10.1016/j.jelectrocard.2010.08.007
  38. Liao WI, Lin YY, Chu SJ, Hsu CW, Tsai SH. Bradyarrhythmia caused by ginseng in a patient with chronic kidney disease. Am J Emerg Med 2010;28. 538.e5-6.
  39. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. New Engl J Med 2004;351:1296-305. https://doi.org/10.1056/NEJMoa041031
  40. Stavro PM, Woo M, Leiter LA, Heim TF, Sievenpiper JL, Vuksan V. Long-term intake of North American ginseng has no effect on 24-hour blood pressure and renal function. Hypertension 2006;47:791-6. https://doi.org/10.1161/01.HYP.0000205150.43169.2c
  41. Gray SL, Lackey BR, Tate PL, Riley MB, Camper ND. Mycotoxins in root extracts of American and Asian ginseng bind estrogen receptors alpha and beta. Exp Biol Med 2004;229:560-8. https://doi.org/10.1177/153537020422900615
  42. Cheema D, Coomarasamy A, El-Toukhy T. Non-hormonal therapy of postmenopausal vasomotor symptoms: a structured evidence-based review. Arch Gynecol Obstet 2007;276:463-9. https://doi.org/10.1007/s00404-007-0390-9
  43. Wong VC, Lim CE, Luo X, Wong WS. Current alternative and complementary therapies used in menopause. Gynecol Endocrinol 2009;25:166-74. https://doi.org/10.1080/09513590802549866
  44. Carroll DG. Nonhormonal therapies for hot flashes in menopause. Am Fam Physician 2006;73:457-64.
  45. Palop V, Catalan C, Rubio E, Martinez-Mir I. Gynecomastia in a male and ginseng. Med Clin 1999;112:758 [Article in Spanish].
  46. Kakisaka Y, Ohara T, Tozawa H, Sato S, Katayama S, Suzuki T, Hino-Fukuyo N, Kure S. Panax ginseng: a newly identified cause of gynecomastia. Tohoku J Exp Med 2012;228:143-5. https://doi.org/10.1620/tjem.228.143
  47. Kabalak AA, Soyal OB, Urfalioglu A, Saracoglu F, Gogus N. Menometrorrhagia and tachyarrhythmia after using oral and topical ginseng. J Womens Health 2004;13:830-3. https://doi.org/10.1089/jwh.2004.13.830
  48. Palop-Larrea V, Gonzalvez-Perales JL, Catalan-Oliver C, Belenguer-Varea A, Martinez-Mir I. Metrorrhagia and ginseng. Ann Pharmacother 2000;34: 1347-8.
  49. Cho J, Park W, Lee S, Ahn W, Lee Y. Ginsenoside-Rb1 from Panax ginseng C.A. Meyer activates estrogen receptor-alpha and -beta, independent of ligand binding. J Clin Endocrinol Metabol 2004;89:3510-5. https://doi.org/10.1210/jc.2003-031823
  50. Lau WS, Chan RY, Guo DA, Wong MS. Ginsenoside Rg1 exerts estrogen-like activities via ligand-independent activation of ERalpha pathway. J Steroid Biochem Mol Biol 2008;108:64-71. https://doi.org/10.1016/j.jsbmb.2007.06.005
  51. Shim MK, Lee YJ. Estrogen receptor is activated by Korean Red Ginseng in vitro but not in vivo. J Ginseng Res 2012;36:169-75. https://doi.org/10.5142/jgr.2012.36.2.169
  52. Amato P, Christophe S, Mellon PL. Estrogenic activity of herbs commonly used as remedies for menopausal symptoms. Menopause 2002;9:145-50. https://doi.org/10.1097/00042192-200203000-00010
  53. Polan ML, Hochberg RB, Trant AS, Wuh HC. Estrogen bioassay of ginseng extract and ArginMax, a nutritional supplement for the enhancement of female sexual function. J Womens Health 2004;13:427-30. https://doi.org/10.1089/154099904323087114
  54. Bilgi N, Bell K, Ananthakrishnan AN, Atallah E. Imatinib and Panax ginseng: a potential interaction resulting in liver toxicity. Ann Pharmacother 2010;44: 926-8. https://doi.org/10.1345/aph.1M715
  55. Malati CY, Robertson SM, Hunt JD, Chairez C, Alfaro RM, Kovacs JA, Penzak SR. Influence of Panax ginseng on cytochrome P450 (CYP)3A and P-glycoprotein (P-gp) activity in healthy participants. J Clin Pharmacol 2012;52:932-9. https://doi.org/10.1177/0091270011407194
  56. Anderson GD, Rosito G, Mohustsy MA, Elmer GW. Drug interaction potential of soy extract and Panax ginseng. J Clin Pharmacol 2003;43:643-8. https://doi.org/10.1177/0091270003253636
  57. Raucy JL. Regulation of CYP3A4 expression in human hepatocytes by pharmaceuticals and natural products. Drug Metab Dispos 2003;31:533-9. https://doi.org/10.1124/dmd.31.5.533
  58. He N, Edeki T. The inhibitory effects of herbal components on CYP2C9 and CYP3A4 catalytic activities in human liver microsomes. Am J Ther 2004;11: 206-12. https://doi.org/10.1097/00045391-200405000-00009
  59. Filppula AM, Laitila J, Neuvonen PJ, Backman JT. Potent mechanism-based inhibition of CYP3A4 by imatinib explains its liability to interact with CYP3A4 substrates. Br J Pharmacol 2012;165:2787-98. https://doi.org/10.1111/j.1476-5381.2011.01732.x
  60. Bark KM, Heo EP, Han KD, Kim MB, Lee ST, Gil EM, Kim TH. Evaluation of the phototoxic potential of plants used in oriental medicine. J Ethnopharmacol 2010;127:11-8. https://doi.org/10.1016/j.jep.2009.09.058
  61. Liu P, Yin H, Xu Y, Zhang Z, Chen K, Li Y. Effects of ginsenoside Rg1 on postimplantation rat and mouse embryos cultured in vitro. Toxicol In Vitro 2006;20:234-8. https://doi.org/10.1016/j.tiv.2005.06.029
  62. Chan LY, Chiu PY, Lau TK. Embryotoxicity study of ginsenoside Rc and Re in in vitro rat whole embryo culture. Reprod Toxicol 2004;19:131-4. https://doi.org/10.1016/j.reprotox.2004.06.001
  63. Seely D, Dugoua JJ, Perri D, Mills E, Koren G. Safety and efficacy of Panax ginseng during pregnancy and lactation. Can J Clin Pharmacol 2008;15: e87-94.
  64. Ong CO, Chan LY, Yung PB, Leung TN. Use of traditional Chinese herbal medicine during pregnancy: a prospective survey. Acta Obstet Gynecol Scand 2005;84:699-700. https://doi.org/10.1111/j.0001-6349.2005.00659.x
  65. Holst L, Nordeng H, Haavik S. Use of herbal drugs during early pregnancy in relation to maternal characteristics and pregnancy outcome. Pharmacoepidemiol Drug Saf 2008;17:151-9. https://doi.org/10.1002/pds.1527
  66. Mousa SA. Antithrombotic effects of naturally derived products on coagulation and platelet function. Methods Mol Biol 2010;663:229-40. https://doi.org/10.1007/978-1-60761-803-4_9
  67. Cheng TO. Ginseng and other herbal medicines that interact with warfarin. Int J Cardiol 2005;104:227. https://doi.org/10.1016/j.ijcard.2004.07.022
  68. Holbrook AM, Pereira JA, Labiris R, McDonald H, Douketis JD, Crowther M, Wells PS. Systematic overview of warfarin and its drug and food interactions. Arch Int Med 2005;165:1095-106. https://doi.org/10.1001/archinte.165.10.1095
  69. Milic N, Milosevic N, Golocorbin Kon S, Bozic T, Abenavoli L, Borrelli F. Warfarin interactions with medicinal herbs. Nat Prod Commun 2014;9: 1211-6.
  70. Norwood DA, Parke CK, Rappa LR. A comprehensive review of potential warfarin-fruit interactions. J Pharm Pract 2014. pii: 0897190014544823. http://dx.doi.org/10.1177/0897190014544823.
  71. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001;286:208-16. https://doi.org/10.1001/jama.286.2.208
  72. Kimura Y, Okuda H, Arichi S. Effects of various ginseng saponins on 5-hydroxytryptamine release and aggregation in human platelets. J Pharm Pharmacol 1988;40:838-43. https://doi.org/10.1111/j.2042-7158.1988.tb06285.x
  73. Park HJ, Lee JH, Song YB, Park KH. Effects of dietary supplementation of lipophilic fraction from Panax ginseng on cGMP and cAMP in rat platelets and on blood coagulation. Biol Pharm Bull 1996;19:1434-9. https://doi.org/10.1248/bpb.19.1434
  74. Lau AJ, Toh DF, Chua TK, Pang YK, Woo SO, Koh HL. Antiplatelet and anticoagulant effects of Panax notoginseng: comparison of raw and steamed Panax notoginseng with Panax ginseng and Panax quinquefolium. J Ethnopharmacol 2009;125:380-6. https://doi.org/10.1016/j.jep.2009.07.038
  75. Janetzky K, Morreale AP. Probable interaction between warfarin and ginseng. Am J Health Syst Pharm 1997;54:692-3.
  76. Yuan CS, Wei G, Dey L, Karrison T, Nahlik L, Maleckar S, Kasza K, Ang-Lee M, Moss J. Brief communication: American ginseng reduces warfarin's effect in healthy patients: a randomized, controlled trial. Annals Int Med 2004;141: 23-7. https://doi.org/10.7326/0003-4819-141-1-200407060-00011
  77. Lee YH, Lee BK, Choi YJ, Yoon IK, Chang BC, Gwak HS. Interaction between warfarin and Korean Red Ginseng in patients with cardiac valve replacement. Int J Cardiol 2010;145:275-6. https://doi.org/10.1016/j.ijcard.2009.09.553
  78. Lee SH, Ahn YM, Ahn SY, Doo HK, Lee BC. Interaction between warfarin and Panax ginseng in ischemic stroke patients. J Altern Complement Med 2008;14: 715-21. https://doi.org/10.1089/acm.2007.0799
  79. Martinez-Mir I, Rubio E, Morales-Olivas FJ, Palop-Larrea V. Transient ischemic attack secondary to hypertensive crisis related to Panax ginseng. Ann Pharmacother 2004 Nov;38(11):1970. http://dx.doi.org/10.1345/aph.1E213.
  80. Kong JH, Yoo SH, Lee KE, Nam SH, Kwon JM, Lee SM, Chang HJ, Choi MY, Cho MS, Mun YC, et al. Early imatinib-mesylate-induced hepatotoxicity in chronic myelogenous leukaemia. Acta Haematol 2007;118:205-8. https://doi.org/10.1159/000111092
  81. Yachoui R. Early onset imatinib mesylate-induced hepatotoxicity in a patient with gastrointestinal stromal tumors. Am J Ther 2014;21:e148-50. https://doi.org/10.1097/MJT.0b013e31826fc5d1

Cited by

  1. Cardioprotection and natural polyphenols: an update of clinical and experimental studies vol.9, pp.12, 2015, https://doi.org/10.1039/c8fo01307a
  2. Acute and Subacute Effects of Low Versus High Doses of Standardized Panax ginseng Extract on the Heart: An Experimental Study vol.19, pp.4, 2015, https://doi.org/10.1007/s12012-019-09512-1
  3. Pharmacological effects of ginseng on infectious diseases vol.27, pp.5, 2015, https://doi.org/10.1007/s10787-019-00630-4
  4. Herbal Medicine for Cardiovascular Diseases: Efficacy, Mechanisms, and Safety vol.11, pp.None, 2015, https://doi.org/10.3389/fphar.2020.00422
  5. Changes of 5‐hydroxymethyl‐2‐furfural in fresh and processed ginsengs vol.8, pp.4, 2015, https://doi.org/10.1002/fsn3.1496
  6. Nutraceutical Potential of Diet Drinks: A Critical Review on Components, Health Effects, and Consumer Safety vol.39, pp.3, 2020, https://doi.org/10.1080/07315724.2019.1642811
  7. A Review of Authenticity and Authentication of Commercial Ginseng Herbal Medicines and Food Supplements vol.11, pp.None, 2015, https://doi.org/10.3389/fphar.2020.612071
  8. Effects of Jerusalem Artichoke Extract and Inulin on Blood Glucose Levels and Insulin Secretion in Streptozotocin Induced Diabetic Mice vol.22, pp.1, 2015, https://doi.org/10.4093/jkd.2021.22.1.60
  9. Ginsenosides for cardiovascular diseases; update on pre-clinical and clinical evidence, pharmacological effects and the mechanisms of action vol.166, pp.None, 2021, https://doi.org/10.1016/j.phrs.2021.105481
  10. The use of Kampo medications that may cause heart failure in hospitalized acute heart failure patients in a Japanese hospital vol.22, pp.3, 2021, https://doi.org/10.1002/jgf2.411
  11. Pharmacological properties of ginsenosides in inflammation-derived cancers vol.476, pp.9, 2021, https://doi.org/10.1007/s11010-021-04162-w
  12. A novel strategy for the discovery and validation of allergic component and its action mechanism in Red Ginseng vol.87, pp.None, 2021, https://doi.org/10.1016/j.jff.2021.104813