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January 2000
M o d u l e
by Dorothea C. Rudorf, Pharm.D., M.S.
Assistant Professor of Clinical PharmacyMassachusetts College of Pharmacy and Health Sciences This module was produced in association with Massachusetts College of Pharmacy and Health Sciences This module was made possible by a This module is approved for 2 credits toward a New Hope Institute of Retailing Certificate of Completionin Natural Healing.
This module is approved for 1 contact hour (0.1 CEUs) of continuing pharmaceutical education credit. Massachusetts College of Pharmacy and Health Sciences is approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education. ACPE# 026-999-99-163-H01 Ginseng
Continuing Education Module
by Dorothea C. Rudorf, Pharm.D., M.S.
Goal:
The goal of this module is to examine the role of ginseng in health and disease, and to identify its
therapeutic usefulness.
Objectives:
Following the successful completion of this module, the participant will be able to:
• Explain ginseng’s historical use, nomenclature and current status in the United States and abroad.
• Identify the constituents found in ginseng plants and explain their pharmacological activity.
• Compare clinical research data with ginseng preparations and identify limitations.
• List potential adverse effects of ginseng and possible drug interactions.
• Relate advice to patients on the use of ginseng.
Introduction
drug. Its safety and efficacy has been eval- other natural products to treat illnesses, i m p rove body functions and prevent dis- the Federal Health Agency officially rec- decades, the development of synthetically side effects, interactions, dosages, mod e s m a n u f a c t u red drugs had substantially effects of ginseng. Ginseng is also includ- ucts, especially in the United States. The recent renewed interest in altern a t i v e can tribes in the US have used ginseng for p roduction of herbs and plant prod u c t s , pain relief during childbirth, to incre a s e and these products are now sold in natural officially regulated as a dietary supplement f e rtility and to treat shortness of bre a t h , with no proven therapeutic pro p e rt i e s .
other retail outlets. However, this has led Quality standards for ginseng prod u c t s kee knew the herb as a t a l e - k u l e and uti- have not been established, and this leads lized it primarily as a remedy for female fessionals as to product choice and appro- p roblems (i.e. headaches, pre m e n s t ru a l syndrome).6 Interestingly, until 1882 gin- ing strong public interest is ginseng. Gin- Scientific Nomenclature
in the United States Pharmacopoeia.7 the US ($ 86 million in 1997), and is one of the 10 most frequently purchased herbs eties are commercially available. This can t roversial re p o rts about ginseng’s tradi- terpretation. See Table 1 for a breakdown sands of years. In Asia, where it is consid- ered almost a universal therapeutic agent, it is believed to improve vitality into old g i n s e n g C.A. Meyer, also re f e rred to as stated in a J A M A a rticle over one hun- Panax quinquefolium L., commonly called situations “wherever a tonic or heating medicine is needed.” One of its most pop- wild in rich, cool wooden areas in the US widely accepted among health care profes- ular uses has been as an aphrodisiac. How- sionals, and is sold as an over-the-counter ever, this article also mentioned that the Nomenclature of Ginseng
Scientific Name
Common Name
Korean ginseng ,Chinese ginseng, Panax, ginseng root, ori- ental ginseng, ren shen, Panax schinseng Nees American ginseng, Western ginseng, rhen shen San qi ginseng, tienchi ginseng, sanchi ginseng Siberian ginseng, Devil’s shrub, eleuthera, taiga-root, Acanthopanax senticosus., Hedera senticosa eleutherococ, shigoka, touch-me-not, wild pepper * most commonly usedhas been labeled an endangered species with regulations on collection and sale.1 1 seng (s h e n - s e n g) means ‘man-root’ and mixtures of compounds called ginsenosides l a rge quantities and shipped abroad, pri- root; this suggests the claim that ginseng or panaxosides.8 More than two dozen gin- senosides have been isolated, and different refers to a goddess believed to “heal all.” different forms: white ginseng is the peeled R followed by a subscript letter or letter Panax pseudoginseng and mostly available and numeral, e.g. Ra or R b-1. Other phar- macologically active substances include a Panax ginseng.8 Steaming is considered an volatile oil, polyacetylenes, stero l s , seng family is E l e u t h e rococcus senticosus effective method of stabilizing the prod- flavonoids, polysaccharides, peptides, vita- Maxim. or Acanthopanax senticosus., uct, but some scientists think that doing so which is also known as Siberian ginseng.
sia, and in the 1970s was marketed to the tablets and extracts or are combined with mainly sterols, phenylpropanoids, lignans, wild desert ginseng. These names refer to before the roots reach the certain weight C a n a i g re, the root of Rumex hymenosepa- lus Torr., a plant totally unrelated to gin- ingredients. It is then that the root is har- the active ingredients of ginseng may vary vested. As the plant’s age increases so does depending on the species of the plant, the i n g redients, but promoted as the origi- its value and price. Because of this, and age of the root, growing location, harvest- because ginseng crops generate high prof- its, various problems arise. Chemicals used to protect the cultivated plants from dis- reports and study results of ginseng’s effica- cy, and can make comparisons difficult.
species belong to the family Araliaceae. H o w e v e r, few diff e rences appear in the over- all effects of the three major ginsengs.1 1 , 2 1 study analyzing fifty-four ginseng products Pharmacological Effects
two to three meters tall with a gray bark found that 60 percent of them were worth- been attributed to ginseng, and they gen- erally can be classified as up- or down-reg - herbal medicine, and different shapes dis- ulating properties. Therefore, ginseng is tinguish ginseng types; i.e. the American Chemical Components
ginseng root is more fibrous and resembles The ginseng panax species contains used primarily in the herbal literature; its a ‘beard’ while the Korean type has a more main use a general tonic to increase vital- level, sleep and sexual satisfaction were being.13 An adaptogen is a substance that helps the body during periods of physical, biological and chemical stress to regulate itself in order to regain equilibrium.21 This and physical fatigue. It can also involve counteracting stre s s - related metabolic extract had significantly higher quality-of- of these claims result from anecdotal data, life scores than those with the multivita- or from in-vitro and animal studies with various species. Ve ry few contro l l e d observation that different ginsenoides can studies investigated ginseng’s effect on psy- date, although the recent interest in gin- (Rb1) has been found to have central ner- seng may stimulate more re s e a rc h .
cluded a tendency for better mathematical F u rt h e rm o re, the observed effects may reasoning, faster reaction time and better abstract thinking related to ginseng sup- effects. It also lowers blood pressure, pro- tects against stress ulcers and accelerates glycolysis and nuclear RNA synthesis.
Effects on Stress, Fatigue
raises blood pressure, may aggravate stress and Cognitive Function
flaws were cited, and the results considered senoides to steroids such as testosterone, corticosteroids, adrenocorticotrophic hor- Commission E has permitted ginseng’s use as “tonic for invigoration and fortification explain its cort i c o s t e roid-like actions.
in times of fatigue and debility or declin- Endocrinological animal studies have sug- gested that ginsenoides may indirectly act secretion, thereby contributing to adrenal Ergogenic Effects
s t e roidogenesis, and ultimately causing higher production of stress hormones. This “heating” properties, Asian ginseng, espe- may translate into a substantial increase in cially the red form, is advocated for the re s t o res body function after intensive activity.23 Siberian ginseng has been given to Russian athletes and cosmonauts to pro- i m p rovement in psychological, physical vide energy, stimulate activity, and nor- sugar in response to sport and performance than 2000 patients in several clinical, con- ginseng is considered beneficial for those t rolled and uncontrolled studies.13 Ty l e r type A personalities as well as those with clinical trials. These trials supplemented a i m p rove submaximal or maximal aero b i c seng has been used in many different situ- e x e rcise by various measurements, e.g. oxy- bitartrate (DEAE). The results included a gen consumption, re s p i r a t o ry exchange beneficial effect on fatigue and increased ratio, blood lactic acid level, heart rate, or shown behavior modifying effects (e.g.
increased performance in learning, speed, and accuracy), stress and fatigue reducing ture review evaluating the ergogenic prop- effects, positive influences on the cardio- there is a lack of controlled research to tem, endocrine and metabolic activity, as support ginseng’s claim to reliably improve life parameters such as well-being, pain, personal satisfaction, depression, energy response relationship (increased eff e c twith higher ginseng use). However, other Potential Adverse Reactions to Ginseng
factors promoting health or risk factorswere not evaluated.
Symptoms
Hypertension, Palpitations, Chest pain, Edema Immunologic Effects
Skin eruptions (ginseng abuse), Pruritis, immunologic activity of ginseng, and it has tion, and increase natural killer cell and cytotoxic activity in human lympho-cytes.10,23,24 study with 36 healthy volunteers showed a Effects on Male Fertility
substantial increase in T-lymphocytes with eleutheroccus35, there were no significant regard to its effects on reproductive capac- responsible for ginseng’s aphrod i s i a c effects in leukocyte or lymphocyte counts effects, and for hepatoprotective activity found after administration of standardized ginseng extract (300 mg qd for 8 weeks) to elderly patients with chronic liver disease vaccine including a significant rise in anti- ginseng for three months. Increases in the killer cells was recently reported in 227 Hypoglycemic Effects
volunteers.34 In this multicenter, random- ized, double-blind and placebo-controlled penile function, libido and patient satisfac- constituents in ginseng are thought to be responsible for its observed hypoglycemic effects. Preliminary in vitro and animal cine at week four. The ginseng treated sub- jects experienced significantly fewer bouts Cardiovascular and Hepatic
promote insulin release, increase insulin of the common cold and cases of influenza receptors and enhance insulin sensitivity.10 beneficial effects on the cardiovascular sys- ginseng in 36 newly diagnosed non-insulin was also found to restore and increase the activity of alveolar macrophages in a con- nation of various mechanisms. Presumably, placebo-controlled trial. 100 or 200 mg of t rolled, single-blind study involving 40 increasing its metabolism, cholesterol lev- eight weeks reduced fasting blood glucose els may decrease.21 An inhibitory effect on Adverse Effects
Anticancer Effects
some have antiarrhythmic effects in vitro adverse effects when following therapeutic similar to verapamil or amiod a ro n e .1 0 indicated that the anticarcinogenicity of blood pressure is, however, mentioned as a contraindication to Eleuthero c o c c u s and increased with the age of the root (at root.1,18 This may be due to reports of a its observed antihypertensive eff e c t s .
least four years needed for red, five years for white and six years for fresh ginseng).
Siegel.38,39 In a two-year ginseng study, 26 higher ginseng doses. Antiplatelet activi- Epidemiologic data is available from sever- out of 133 psychiatric patients had devel- al case-control and one prospective cohort oped hypertension with nerv o u s n e s s , study involving several thousand adults.
sleeplessness, skin eruptions and morning digoxin was observed in 45 patients in the d i a rrhea.The study was later criticized G i n s e n g ’s card i o p rotective eff e c t s cancer types (except uterine, cervical, uri- have been linked to stimulated release of grams ginseng per day and additional other nitric oxide by endothelial cells resulting gland), and that there is a significant dose- Potential Drug Interactions
Monitoring Parameter
Conclusion
ly used for thousands of years for a variety Increased digoxin levels, Avoid concomitant use of reasons. Although well-designed clini- cal studies are sparse, anecdotal and exper- effects. Its main activity is as an adaptogen s t ress related conditions, to impro v e tal, physical and metabolic eff e c t s .
s t a n d a rds, possible adverse effects, and cautioned about potentially dangero u sinteractions with other drugs. References
reported in few cases but they appear to be 1. Blumenthal M. The complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. 1st extensions of the pharmacological or gin- ed. , Austin; American Botanical Council;1998:11-12 seng effects, or may be due to adulteration 2. Eliason BC, Kruger J, et al. Dietary supplement product was never clarified, and a poten- users: demographics, pr oduct use, and medical system inter- Cola species, Sulfites) and mislabeling.
tial effect of Periploca sepium was men- action. J Am Board Fam Pract 1997 Jul-Aug;10(4):265-71 3. Weiss RF. Herbal Medicine. Translated from the Sixth German Edition of Lehrbuch der Phytotherapie. AB cardiovascular, endocrine and antiplatelet A rcanum, Gotheburg, Sweden, Beaconsfield Publishers effects caution may be indicated with cer- hypertension refractory to furosemide after 4. JAMA 100 Years Ago (Dec 17, 1989). Ginseng in 5. Collura JO. Ginseng: Prince of Tonics. Vegetarian associated with renal toxicity, was consid- 6. Mooney J. The sacred formulas of the cherokees, Dosage Recommendations
e red responsible for the diuretic re s i s- Asheville, NC: Bright Mountain Books, 1992 (Ellison G, ed.
James Mooney’s History Myths and Sacred Formulas of the Panax ginseng
ated with the bark of silk vine (Periploca 7. The Herbal Regulatory Dilemma. In Tyler’s Herbs of sepium) which contains cardiac glycosides.
Choice.The Therapeutic Use of Phytomedicinals. Robbers In one report, it was associated with a case Eleutherococcus senticosus
JE, Tyler VE, eds., The Haworth Herbal Press, Inc. New 8. Abstracts of Korean Ginseng Studies (1687-1975).
Drug Interactions
Dosage and Administration
The Research Institute, Office of Monopoly, Seoul, Republic 9. Ginseng, Panax. In Herbal Medicines. A Guide for H e a l t h - c a re Professionals. Newall CA, Anderson, LA, for herbal medicines list no interactions. finely chopped ginseng root and straining Phillipson JD, eds. The Pharmaceutical Press, London, 1996: interaction with warfarin in a 47-year-old which can contain 100, 250 and 500 mg.
Phytopharmaceuticals. (Translated by Bisset NM). 2nd ed., Medpharm, Stuttgart 1994, CRC Press Ann Arbor: 236-238 extracts as well as ginseng extract (2 oz.
11. Ginseng and Related Herbs. In Tyler’s Honest Herbal. A sensible Guide to the Use of herbs and Related powder is available.16 Suggested duration Remedies. 4th ed, Foster S, Tyler VE, eds., The Haworth digoxin.44 A 74-year old man stabilized for Herbal Press, Inc., New York, 1999: 187-194 12. Ginseng. In Facts and Comparisons.The 35. Bohn B, Nebe CT, Birr C. Flow-cytometric Review of Natural Products. DerMarderosian A, ed., 23. Hamilton W, Kirchain W. Ginseng. Fact Studies with Eleutherococcus senticosus Extract as an Facts and Comparisons Publishing Group 1999 I m m u n o m od u l a t o ry Agent. Arz n e i m i t t e l f o r s c h u n g 13. Perf o rmance and Immune Deficiencies.
24. Engels HJ, Wirth JC. No ergogenic effects of Ty l e r’s Herbs of Choice.The Therapeutic Use of ginseng (Panax ginseng C.A. Meyer) during graded 36. Srisurapanon S, Rungroeng K, et al. The Phytomedicinals. Robbers JE, Tyler VE, eds., The maximal aerobic exercise. J Am Diet Assoc 1997;97 Effect of Standardized Ginseng Extract on Peripheral Haworth Herbal Press, Inc. New York, 1999: 235-241 B l o od Leukocytes and Lymphocytes Subsets: a 25. Bahrke MS, Morgan WP. Evaluation of the Preliminary Study in Young Healthy Adults. J Med Comparisons.The Review of Natural Prod u c t s .
ergogenic properties of ginseng. Sports Medicine 1994: D e r M a rd e rosian A, ed., Facts and Comparisons 37. Scaglione F, et al. Immunomod u l a t o ry Effects of Panax ginsneg C.A. Meyer (G115) on 15. Canaigre. In Tyler’s Honest Herbal. A sensi- Alveolar Macrophages from Patients Suffering with ble Guide to the Use of Herbs and Related Remedies.
efficay of Korean ginseng for erectile dysfunction. Int J 4th ed, Foster S, Tyler VE, eds., The Haworth Herbal 28. Li J, Huang M, et al. Panax quinquefolium 38. Siegel RK. Ginseng abuse syndro m e .
16. Ginseng. In Complementary & Alternative saponins protect low density lipoproteins from oxida- Medicines. Fetrow CW, Avila JR, eds. Springhouse Corporation, Springhouse, Philadelphia 1999: 284- 29. Gillis NC. Panax ginseng Pharmacology: A 39. Siegel RK. Ginseng and high blood pressure.
Nitric Oxide Link? Biochem Pharmacol 1997; 54:1-8 17. Ginseng, Siberian. . In Complementary & 30. Chen X. Cardiovascular protection by gin- 40. Becker BN, et al. Ginseng-induced Diuretic Alternative Medicines. Fetrow CW, Avila JR, eds.
senosides and their nitric oxide releasing action. Clin Springhouse Corporation, Springhouse, Philadelphia Exp Pharmacol Physiol 1996; 23(8): 728-32 31. Zuin M, Battezzati PM et al. Effects of a Herbal Products Association. McGuffin M, et al, eds, 18. Panax Ginseng. PDR for Herbal Medicines.
preparation containing standardized ginseng extract Medical Economics Company, Inc., Montvale, NJ, combined with trace elements and multivitamins 42. Panax Ginseng. AltMedDex.Micromedex ® against hepatotoxin-induced chronic liver disease in the elderly. J Int Med Res 1987; 15(5): 276-81 43. Janetzky K, Morreale AP. Pro b a b l e M od e rn Lifestyles: Ginseng. Health Naturally, 32. Sotaniemi E, et al. Ginseng therapy in Non- Interaction between Warfarin and Ginseng. Am J Insulin-Dependent Diabetic Patients. Diabetes Care 20. Liberti LE, Der Marderosian A. Evaluation 44. McRae S. Elevated Serum Digoxin Levels in of Commercial Ginseng Products. J Pharm Sci 1978; 33. Yun TK. Experimental and Epidemiological a Patient taking Digoxin and Siberian Ginseng.
Evidence of the Cancer-Preventive Effects of Panax 21. Li, T S.C., Harries D. Medicinal Values of ginseng C.A. Meyer. Nutrition Reviews 1996; 54(11): Ginseng. The Herb, Spice, and Medicinal Plant 34. Scaglione F et al. Efficay and Safety of the 22. Caso Marasco A, Va rgas-Ruiz R et al.
Standardized Ginseng Extract G115 for Potentiating Double-blind study of a multivitamin complex supple- Vaccination against Common Cold and/or Influenza mented with ginseng extract. Drugs Exp Clin Res Syndrome. Drugs Ex Clin Res 1997; 22(2): 65-72 ONLY PHARMACISTS NEED COMPLETE THIS SECTION
3. I am now more knowledgeable about the topic.
4. The program was educational, not commercial. 5. How long did it take you to read the material and answer the test questions? __________________.
Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Ginseng
Continuing Education Test Questions

D i rections: Select your answer and check one box for each of the test questions. When you have answered all of thequestions, please print or type all requested information and mail your completed test, along with processing fee, to thea p p ropriate address listed below.
1. Ginseng has been associated with
5. Which of the following is true of the
8. Due to presumed side effects, ginseng
many diff e rent names. The corre c t
ginseng ro o t ?
has been contraindicated by the
scientific term for Siberian ginseng is:
Commission E for which of the follow-
ing conditions?
n c. E l e u t h e rococcus senticosus.
the plant is at least six years old.
2. People have used ginseng for thou-
sands of years. Its major therapeutic
9. Ginseng should be avoided with all of
claim has been as a:
6. We l l - c o n t rolled clinical studies have
the following drugs except:
documented all of the following benefi-
cial effects from ginseng except:
n a. improvement in quality of life.
n d. remedy for male infert i l i t y.
3. An adaptogen is a substance believed
10. Several issues need to be addre s s e d
to increase body resistance to extern a l
c e rvical and urinary bladder cancer.
when evaluating ginseng’s therapeutic
influences and stimuli and to balance
role in the US t o d a y. The biggest
body functions.
obstacle seems to be:
7. Which of the following statements
n b. ginseng’s significant side eff e c t 4. The major constituents in ginseng are
regarding ginseng are correct?
called ginsenoides. All of the follow-
ing comments re g a rding ginsenoides
a re true, except that they are:
n c. specified by Rx (where x is a letter n d. identical to eleuthero s i d e s .
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For pharmacists:
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ACPE# 026-999-99-163-H01
Planned expiration date: January 2002

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