This obscure herb works for the common cold

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This obscure herb works for the common cold

J Fam Pract. 2008 March;57(3):157-160

By

Gail Patrick, MD, MPP

John Hickner, MD, MSc

References

1. Lizogub VG, Riley DS, Heger M. Efficacy of a Pelargonium sidoides preparation in patients with the common cold: A randomized, double blind, placebo-controlled clinical trial. Explore (NY) 2007;3:573-584.

2. Bladt S, Wagner H. From Zulu medicine to the European phytomedicine Umckaloabo. Phytomedicine 2007;14 (suppl 1):2-4.

3. Matthys H, Eisebitt R, Seith B, Heger M. Efficacy and safety of an extract of Pelargonium sidoides (EPs 7630) in adults with acute bronchitis: A randomized, double-blind, placebo-controlled trial. Phytomedicine 2003;10(Suppl 4):7-17.

4. Chuchalin AG, Berman B, Lehmacher W. Treatment of acute bronchitis in adults with a Pelargonium sidoides preparation (EPs 7630): A randomized, double-blind, placebo-controlled trial. Explore (NY) 2005;1:437-445.

5. Matthys H, Heger M. Treatment of acute bronchitis with a liquid herbal drug preparation from Pelargonium sidoides (EPs 7630): A randomized, double-blind, placebo-controlled multicentre study. Curr Med Res Opinion 2007;23:323-331.

6. Kolodziej H, Kiderlen AF. In vitro evaluation of antibacterial and immunomodulatory activities of Pelargonium reniforme, Pelargonium sidoides and the related herbal drug preparation EPs 7630. Phytomedicine 2007;14 (suppl 1):18-26.

7. Fendrick AM, Monto AS, Nightengale B, Sarnes M. The economic burden of non-influenza related viral respiratory tract infection in the United States. Arch Intern Med 2003;163:487-494.

8. Heikkinen T, Jarvinen A. The common cold. Lancet 2003;361:51-59.

9. Cherry DK, Woodwell DA, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2005 Summary. Adv Data 2007;387:1-39.

10. Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2004;(4):cD001831.-

11. Douglas RM, Hemila H, Chalker E, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2004;(4):cD000980.-

12. Linde K, Barrett B, Wolkart K, Bauer R, Melchart D. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev 2006;(1):cD000530.-

13. Marshall I. Zinc for the common cold. Cochrane Database Syst Rev 1999;(2):cD001364.-(With-drawn 2006, Issue 3).

14. Sutter AI, Lemiengre M, Campbell H, Mackinnon HF. Anithistamines for the common cold. Cochrane Database Syst Rev 2003;(3):cD001267.-

15. Taverner D, Latte J, Draper M. Nasal decongestants for the common cold. Cochrane Database Syst Rev 2004;(3):cD001953.-

16. De Boer HJ, Hagemann U, Bate J, Meyboom RHB. Allergic reactions to medicines derived from Pelargonium species. Drug Saf 2007;30:677-680.

17. ISO-Arzneimittel. Distributor of Umckaloabo. Available at: umckaloabo.com. Accessed January 7, 2008.

18. Taylor PW, Maalim S, Coleman S. The strange story of umckaloabo. Pharm J 2005;275:790-792.

19. African Red Tea Imports. Available at: www.africanredtea.com/pelargonium-syrup.html. Accessed January 7, 2008.

Practice changer

Offer patients Pelargonium sidoides (30 drops 3 times a day) to reduce the severity and duration of common cold symptoms and to get patients back to work sooner.¹

Strength of recommendation

B: A single well-designed randomized controlled trial

Lizogub VG, Riley DS, Heger M. Efficacy of a Pelargonium sidoides preparation in patients with the common cold: A randomized, double blind, placebo-controlled clinical trial. Explore (NY) 2007; 3:573–584.

ILLUSTRATIVE CASE

A 39-year-old, otherwise healthy woman presents to your clinic with a sore throat, nasal congestion, and dry cough she’s had since yesterday. She wants an antibiotic, but your evaluation reveals an uncomplicated viral upper respiratory infection—a common cold. You would like to provide her with an alternative treatment, but you are aware of the lack of evidence for clear benefit of zinc lozenges, echinacea, and vitamin C. Is there any other medication that might benefit this patient?

FAST TRACK

A plausible biological mechanism is induction of the interferon system and up-regulation of cytokines important in protecting host cells from viral infection

Yes. Pelargonium sidoides, a species of South African geranium used for centuries in Zulu medicine,² shows promise as an herbal remedy for respiratory infections. Two randomized trials show that extracts of P sidoides improve symptoms of acute bronchitis which, like the common cold, is usually caused by a virus.^3-5

There is a plausible biological mechanism of action. In vitro studies show that Pelargonium extract induces the interferon system and up-regulates cytokines important in protecting host cells from viral infection.⁶

BACKGROUND: $17 billion dollar cold

Our patients want more relief from cold symptoms and are clearly willing to pay for it. Americans spend approximately $2.9 billion annually on over-the-counter (OTC) cold preparations and $1.1 billion on unnecessary antibiotics.⁷ The term “common cold” refers to a collection of symptoms, including sore throat, rhinorrhea, nasal congestion, cough, low-grade fever, and malaise, usually self-limited and lasting 10 to 14 days, caused by a number of viruses, most commonly by a rhinovirus.⁸ According to the 2005 National Ambulatory Medical Care Survey, the common cold is the third most common diagnosis in physicians’ offices behind only hypertension and well-infant/child visits.⁹ A 2001 US telephone survey determined that approximately 500 million episodes of non-influenza viral infection occur annually, resulting in direct costs of $17 billion for physician services and medications and approximately 200 million missed days of work.⁷

CLINICAL CONTEXT: Evidence proves most cold remedies don’t work

Although colds are common and result in annoying symptoms and missed work, much of the money spent on remedies is wasted. A truly effective treatment would be valuable to our patients.

Despite brisk sales, evidence for the efficacy of various cold remedies is inconclusive and contradictory. We found 6 Cochrane reviews of cold treatments, including antitussives, antihistamines, decongestants, vitamin C, echinacea, and zinc lozenges. With the exception of pseudoephedrine for nasal symptoms, the evidence that any product improves symptoms or decreases the duration of the cold is not encouraging.

FAST TRACK

This study evaluated a liquid preparation of Pelargonium sidoides vs placebo for cold symptoms

Cough medications. The 2004 Cochrane Review of OTC medications for cough¹⁰ found no consistent evidence that any of them work. Codeine was no more effective than placebo for reducing cough symptoms. Three efficacy studies of dextromethorphan for cough showed either no difference or small but possibly clinically insignificant improvement in cough over placebo. One study of guaifenesin showed benefit over placebo in reducing cough frequency; another one showed no benefit over placebo.

Vitamin C, echinacea. Three Cochrane reviews found no conclusive evidence of benefit over placebo for either vitamin C¹¹ or echinacea¹² in treating the common cold.

Zinc. A new panel has been convened by the Cochrane group to reassess the effectiveness of zinc, but a 1999 Cochrane review¹³ found no benefit for zinc over placebo.

Antihistamines are not effective for relieving cold symptoms.¹⁴

Pseudoephedrine is the only medication with good-quality evidence for effectiveness, but only for reducing nasal symptoms.¹⁵ The authors concluded that patients may be encouraged to continue pseudoephedrine for up to 5 days if found to be effective with the first dose. Nasal congestion and discharge, however, are only 2 of the many irritating symptoms of a cold.

You can be a “REALITY CHECKER”

Bernard Ewigman, MD, MSPH

If you are in full-time clinical practice, a medical director of a practice, or otherwise directly involved in decision-making about adopting new practices, join our team of “reality checkers.”

Just email me at be.editor@gmail.com