Ruscus aculeatus – butcher’s broom

Ruscus aculeatus – butcher’s broom – Monograph

Description

Ruscus aculeatus (butcher’s broom) is a member of the Liliaceae family and is native to Mediterranean Europe and Africa. It has tough, green, erect, striated stems that send out numerous short branches and very rigid leaves that are actually extensions of the stem and terminate in a single sharp spine. The small greenish-white flowers grow from the center of the leaves and bloom in the early spring. The thick root, typically collected in autumn, is used medicinally. The root has no odor, but has an initially sweetish taste that then turns slightly acrid.

Constituents and Mechanisms of Action

The primary active ingredients are the steroidal saponins ruscogenin and neoruscogenin, but other constituents have been isolated, including steroidal sapogenins and saponins, sterols, triterpenes, flavonoids, coumarins, sparteine, tyramine, and glycolic acid. (1-5) Although both the above- and below-ground parts of the plant contain ruscogenins, the concentration is higher in the root, (6) the part traditionally used medicinally.

One animal study (7) and numerous in vitro studies (8-13) indicate butcher’s broom reduces vascular permeability. The ruscogenins from butcher’s broom showed remarkable anti-elastase activity in vitro but were inactive against hyaluronidase. (14) These actions help explain the herb’s apparent utility in patients with chronic venous insufficiency.

Animal and in vitro studies show butcher’s broom to have a vasoconstrictive effect. The mechanism of this effect remains somewhat unclear. Some studies indicate direct postjunctional alpha-1 and alpha-2 adrenergic receptor activation by its steroidal saponins; (7) others indicate vasoconstriction is due to alpha-adrenergic blockade. (8) Hamster cheek pouch studies show that prazosin and diltiazem block butcher’s broom’s inhibition of histamine-induced permeability increase while rauwolscine does not, indicating that butcher’s broom’s venoconstrictive effect is mediated by calcium and alpha 1-adrenergic receptors at the microcirculatory level. (15,16)

Clinical Indications

The best-researched indications for butcher’s broom are venous insufficiency, edema, premenstrual syndrome (PMS), and hemorrhoids. A single trial indicates butcher’s broom may be useful in preventing diabetic retinopathy.

Venous Insufficiency/Varicosities

Four double-blind, placebo-controlled trials, and five open trials demonstrated an improvement in venous insufficiency symptoms such as itching, ankle diameter, tension of the leg, cramping, and malleolar edema. (17-24) One open-label, randomized clinical trial showed butcher’s broom to be safe and more effective than rutoside in the treatment of patients with chronic venous insufficiency. (25) Most of these studies have insufficient sample sizes and other design flaws.

Edema

Butcher’s broom may be beneficial for patients with edema of various types. One double-blind, placebo-controlled (26) and one open trial (27) showed butcher’s broom to have a significant, positive effect in patients with lymph edema. In a small, uncontrolled trial, butcher’s broom significantly improved symptoms in patients with edema secondary to calcium antagonist treatment (nifedipine and nicardipine) for hypertension. (10) In a randomized, double-blind, multi-center study of healthy volunteers (20 volunteers) and patients with chronic venous insufficiency (80 patients) or post-thrombotic syndrome (60 patients), butcher’s broom alone appeared to increase lymphatic drainage and capillary sealing action. (12) Patients on butcher’s broom showed a continuous decrease in ankle and leg volume over the course of the study, and the authors concluded this indicated a slow, reparative process that was not complete at the end of the study. Finally, a meta-analysis of three randomized, double-blind, cross-over studies of various products concluded butcher’s broom both increases venous tone and reduces capillary filtration, resulting in an increase in lymph flow in patients with edema. (13) This action may explain the results of a small, double-blind, randomized study of butcher’s broom’s ability to speed healing of sprains and contusions. (28) In this study, using a butcher’s broom/sweet clover cream, the swelling of the injured leg measured against the uninjured leg was significantly reduced. The cream also significantly reduced the subjective perception of pain.

Premenstrual Syndrome

In a randomized, double-blind trial involving women with PMS, butcher’s broom rapidly reduced symptoms of mastalgia and mood disorders, and showed a trend toward improving ankle edema. (11)

Hemorrhoids

Butcher’s broom has been shown to have a significant effect on patients with hemorrhoids in an open trial, with 75 percent of participating physicians rating butcher’s broom’s efficacy as good or excellent. (29)

Diabetic Retinopathy

Butcher’s broom was shown to be as or more effective than troxerutin for microangiopathic complications, including retinopathy, in 60 patients with type 2 diabetes. (30)

Orthostatic Hypotension

Researchers have theorized that Ruscus, because of its proven venotonic effects, may be helpful as a treatment for chronic orthostatic hypotension. (31) Unlike many of the drug therapies for orthostatic hypotension, butcher’s broom does not cause supine hypertension.

Butcher’s Broom in Combination with other Botanicals

Many of the clinical trials on butcher’s broom use commercial products that combine butcher’s broom with trimethylhesperidine chalcone and ascorbic acid. Some studies combine butcher’s broom with Melilotus officinalis (sweet clover, melilot) extract. This, of course, confuses the scientific evidence of butcher’s broom’s actual effect. While studies indicate butcher’s broom has an action independent of these added compounds, and some studies indicate butcher’s broom alone may have a stronger effect, (32) other studies indicate the combinations may have a positive synergistic effect. (33)

Dose and Toxicity

Dosage for the alcoholic extract of the whole plant is 0.5-1.5 mL three times daily. (34) Dosage for capsules standardized for ruscogenins (as determined by the total of neoruscogenin and ruscogenin) is 7-11 mg, (35) although some experts recommend a higher dose of 16.5-33 mg of total rucogenins three times daily. (36) Commercial butcher’s broom capsules (known variously as Cyclo 3 Fort[R], Phlebodril[R] or Fabroven[R] and containing butcher’s broom root combined with trimethylhesperidine chalcone and ascorbic acid) are used in many of the clinical studies. These products contain between 30-150 mg of butcher’s broom per capsule, and a typical dose is 2 to 3 capsules three times daily.

Most reviewers consider butcher’s broom to be safe and list no contraindications. (35,37) Contact dermatitis has occasionally been reported in patients topically exposed to butcher’s broom. (38,39) Nausea is uncommon with butcher’s broom. (37) In one study of Cyclo 3 Fort (3 capsules three times daily), patients experienced edema, nausea, and abdominal pain significant enough to prompt volunteers to discontinue Cyclo 3 Fort in 3.5 percent of the patients. (24)

There may be theoretical reasons to avoid combining butcher’s broom with alpha-adrenergic antagonist antihypertensive/spasmolytic drugs such as prazosin and terazosin. (1) Tyramine from butcher’s broom could theoretically precipitate a hypertensive crisis when combined with these drugs. Similarly, tyramine-containing herbs should theoretically not be combined with monoamine oxidase inhibitors to avoid hypertensive crises. Preclinical information about butcher’s broom’s pharmacodynamics also suggests the possibility of interference with the efficacy of alpha-blockers. No clinical trials have directly addressed this issue.

There is insufficient data on the use of butcher’s broom in pregnancy, although one uncontrolled trial of 20 pregnant women taking butcher’s broom daily for venous insufficiency followed both fetal and post-birth indices and found no embryotoxic or other adverse effects. (19)

References

(1.) Fetrow CW, Avila JR. Professional’s Handbook of Complementary and Alternative Medicines. Springhouse, PA: Springhouse Corp.; 1999.

(2.) Rauwald HW, Grunwidi J. Ruscus aculeatus extract: unambiguous proof of the absorption of spirostanol glycosides in human plasma after oral administration. Planta Med 1991;57 :A75-A76.

(3.) Dunouau C, Belle R, Oulad-Ali A, et al. Triterpenes and sterols from Ruscus aculeatus. Planta Med 1996;62:189-190.

(4.) Duke, J. Dr. Duke’s phytochemical and ethnobotanical databases. Http://www.ars-grin.gov/cgi-bin/duke/ farmacy2.pl; 2001.

(5.) Mimaki Y, Kuroda M, Kameyama A, et al: New steroidal constituents of the underground parts of Ruscus aculeatus and their cytostatic activity on HL-60 cells. Phytochemistry 1998;48:485-493.

(6.) St. Nikolov, Joneidi M, Panova D. Quantitative determination of ruscogenin in Ruscus species by densitometric thin-layer chromatography. Pharmazie 1976;31:611-612.

(7.) Svensjo E, Bouskela E, Cyrino FZ, et al. Antipermeability effects of Cyclo 3 Fort[R] in hamsters with moderate diabetes. Clin Hemorheol Microcirc 1997;17:385-388.

(8.) Bouskela E, Cyrino FZGA, Marcelon G. Effects of Ruscus extract on the internal diameter of arterioles and venules of the hamster cheek pouch microcirculation. J Cardiovasc Pharmacol 1993;22:221-222.

(9.) Miller VM, Marcelon G, Vanhoutte PM. Ruscus extract releases endothelin derived relaxing factor in arteries and veins. In: Vanhoute PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:31-42.

(10.) Lagrue G, Behar A, Chaabane A, Laurent J. Edema induced by calcium antagonists. Effects of Ruscus extract on clinical and biological parameters. In: Vanhoute PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:105-109.

(11.) Monteil-Seurin J, Ladure PH. Efficacy of Ruscus extract in the treatment of the premenstrual syndrome. In: Vanhoute PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:43-53.

(12.) Rudofsky G. Efficacy of Ruscus extract in venolymphatic edema using foot volumetry. In: Vanhoute PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:121-130.

(13.) Rudofsky G. Effect of Ruscus extract on the capillary filtration rate. In: Vanhoute PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:219-224.

(14.) Facino RM, Carini M, Stefani R, et al. Anti-elastase and anti-hyaluronidase activities of saponins and sapogenins from Hedera helix, Aesculus hippocastanum, and Ruscus aculeatus: factors contributing to their efficacy in the treatment of venous insufficiency. Arch Pharm (Weinheim) 1995;328:721-724.

(15.) Bouskela E, Cyrino FZGA. Possible mechanisms for the effects of Ruscus extract on microvascular permeability and diameter. Clin Hemorh 1994;14:S23-S36.

(16.) Bouskela E, Cyrino FZGA, Marcelon G. Possible mechanisms for the inhibitory effect of Ruscus extract on increased microvascular permeability induced by histamine in hamster cheek pouch. J Cardiovasc Pharmcol 1994;24:281-285.

(17.) Parrado F, Buzzi A. A study of the efficacy and tolerability of a preparation containing Ruscus aculeatus in the treatment of chronic venous insufficiency of the lower limbs. Clin Drug Invest 1999; 18:255-261.

(18.) Cappelli R, Nicora M, Di Perri T. Use of extract of Ruscus aculeatus in venous disease of the lower limb. Drugs Exp Clin Res 1988;14:277-283.

(19.) Rudofsky VG. Venentonisierung und kapillarabdichtung. Fortschr Med 1989;107:430-434. [Article in German]

(20.) Jaeger K, Eichlisberger CH, Lobs J, et al. Pharmacodynamic effects of Ruscus extract (Cyclo 3 Fort [R]) on superficial and deep veins in patients with primary varicose veins. Assessment by duplexsonography. Clin Drug Invest 1999;111-119.

(21.) Baudet HJ, Collet D, Aubard Y, Renaudie P. Therapeutic test of Ruscus extract in pregnant women: evaluation of the fetal tolerance applying the pulse Doppler’s method of the cord. In: Vanhoutte PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:63-71.

(22.) Berg D. First results with Ruscus extract in the treatment of pregnancy related varicose veins. In: Vanhoutte PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:55-61.

(23.) Kiesewetter H, Scheffler P, Jung F, et al. Effect of Ruscus extract in chronic venous insufficiency state I, II, and III. In: Vanhoutte PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:163-169.

(24.) Weindorf N, Schultz-Ehrenburg U. Controlled study of increasing venous tone in primary varicose veins by oral administration of Ruscus aculeatus and trimethylhesperidinchalcone. Z Hautkr 1987;62:28-38. [Article in German]

(25.) Beltramino R, Penenory A, Buceta AM. An open-label, randomised multicentre study comparing the efficacy and safety of Cyclo 3 Fort versus hydroxyethyl rutoside in chronic venous lymphatic insufficiency. Angiology 2000;51:535-544.

(26.) Cluzan RV, Alliotl F, Ghabboun S, et al. Treatment of lymphedema of the upper arm after previous treatment for breast cancer. Lymphology 1996;29:29-35.

(27.) Jimenez Cossio JA, Magallon Ortin PJ, Capilla Montes MT, Coya Vina J. Therapeutic effect of Ruscus extract in lymphedemas of the extremities. In: Vanhoutte PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:111-119.

(28.) Bohmer D. Action of Ruscus extract cream in the treatment of sports injuries. In: Vanhoutte PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:171-179.

(29.) Bennani A, Biadillah MC, Cherkaoui A, et al. Acute attack of hemorrhoids: efficacy of Cyclo 3 Forte[R] based on results in 124 cases reported by specialists. Phlebologie 1999;52:89-93.

(30.) Archimowicz-Cyrylowska B, Adamek B, Drozdzik M, et al. Clinical effect of buckwheat herb, Ruscus extract and troxerutin on retinopathy and lipids in diabetic patients. Phytotherapy Res 1996;10:659-662.

(31.) Redman DA. Ruscus aculeatus (butcher’s broom) as a potential treatment for orthostatic hypotension, with a case report. J Altern Complement Med 2000;6:539-549.

(32.) Rudofsky G. Efficacy of Ruscus extract in venolymphatic edema using foot volumetry. In: Vanhoutte PM, ed. Return Circulation and Norepinephrine: An Update. Paris, France: John Libbey Eurotext; 1991:121-130.

(33.) Baurain R, Dom G, Trouet A. Protecting effect of Cyclo 3 Fort and its constituents for human endothelial cells under hypoxia. Clin Hemorh 1994;14:S14-S21.

(34.) Moore M. Herbal Materia Medica, 5th ed. Bisbee, AZ: Southwest School of Botanical Medicine;

(35.) Blumenthal M, Goldberg A, Brinckmann J, et al. Herbal Medicine, Expanded Commission E Monographs. Austin, TX: 2000.

(36.) Murray MT. The Healing Power of Herbs. Rocklin, CA: Prima Publishing Co.; 1983:35.

(37.) McGuffin M, Hobbs C, Upton R, et al. American Herbal Products Association’s Botanical Safety Handbook. Boca Raton, LA: CRC Press; 1997:100.

(38.) Landa N, Aguirre A, Goday J, et al. Allergic contact dermatitis from a vasoconstrictor cream. Contact Dermatitis 1990;22:290-291.

(39.) Elbadir S, El Ayed F, Renaud F, et al. L’allergie de contact aux ruscogenines. Rev Fr Allergol 1998;38:37-40. [Article in French]

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