Motherwort Capsules by Classical Remedia Ltd

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Atopic dermatitis (eczema). Although there is interest in using oral dong quai for atopic dermatitis, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Chronic kidney disease (CKD). There is limited evidence on the use of dong quai in patients with CKD. Details: A large propensity score-matched observational study over 15 years in Taiwanese adults with CKD suggests that taking dong quai is associated with a 5.1% risk of end-stage renal disease (ESRD) and 38% risk of overall mortality when compared with 7% and 56%, respectively, in controls. Higher cumulative doses (i.e., 15 grams or more) and longer duration of exposure (i.e., > 60 days) are also associated with fewer ESRD events (112362). However, the interpretation of these findings is limited by the lack of exact dosage information and retrospective study design.
• Coronary heart disease (CHD). Intravenous dong quai has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in patients with CHD shows that injecting 20 mL of an intravenous solution containing dong quai, ginseng, and astragalus (Yi-qi Huo-xue Injection) daily for 2 weeks reduces the frequency and severity of angina episodes when compared with placebo. It also seems to increase exercise tolerance and improve left ventricular function when compared with placebo (33046). It is unclear if these benefits are due to dong quai, other ingredients, or the combination.
• Dysmenorrhea. Although there is interest in using oral dong quai for dysmenorrhea, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Hypertension. Although there is interest in using oral dong quai for hypertension, there is insufficient reliable information about the clinical effects of dong quai for this purpose.
• Idiopathic interstitial pneumonia. Oral dong quai has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A meta-analysis of 17 studies conducted in China in patients with idiopathic interstitial pneumonia concludes that adding traditional Chinese medicine combinations containing dong quai root and astragalus root to treatment with conventional medicines improves pulmonary function index, six-minute walking distance, and the Borg scale of perceived exertion when compared with conventional treatment alone (103618). The included studies are of low quality, include a range of treatment durations from 1-12 months, and vary in the conventional medicines and Chinese herb combinations used. The doses of dong quai used were not stated.
• Infertility. Although there is interest in using oral dong quai for infertility, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Iron deficiency anemia. Although there is interest in using oral dong quai for iron deficiency anemia, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Menopausal symptoms. There is inconsistent and contradictory evidence about the effect of dong quai on menopausal symptoms. Benefits have only been seen when it is used in combination with other ingredients; its effect when used alone is unclear. Details: Some clinical research shows that taking dong quai, 1.5 grams three times daily for 24 weeks, does not affect menopausal symptoms (738). Other clinical research shows that dong quai improves menopausal symptoms when used in combination with other constituents. In one clinical trial, taking five chewable tablets of a specific combination of dong quai and chamomile (Climex) daily for 12 weeks reduced the frequency and severity of hot flushes when compared with placebo (48445). In another trial, taking a combination providing dong quai 75 mg, along with American ginseng, black cohosh, milk thistle, red clover, and vitex agnus-castus (Phyto-Female Complex) twice daily for 3 months reduces menopausal symptoms, including the number and intensity of hot flushes, the number of night sweats, and sleep quality (19552). Taking another combination product containing dong quai, burdock root, licorice root, motherwort, and Mexican wild yam root, 500 mg three times daily for 3 months, also reduces menopausal symptoms when compared with placebo (48522). It is unclear if the beneficial effects in these studies were due to dong quai, other ingredients, or a combination of ingredients.
• Migraine headache. Oral dong quai has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in patients with menstrual migraine shows that taking a combination of soy isoflavones 60 mg, dong quai 100 mg, and black cohosh 50 mg daily for 24 weeks reduces the frequency of attacks when compared with placebo (35797). It is unclear if this effect is due to dong quai, other ingredients, or the combination.
• Osteoporosis. Although there is interest in using oral dong quai for osteoporosis, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Peptic ulcers. Although there is interest in using oral dong quai for peptic ulcers, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Premature ejaculation. Topical dong quai has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: In one preliminary clinical trial in patients with premature ejaculation, a multi-ingredient cream preparation (SS Cream) containing dong quai, Panax ginseng root, Cistanches deserticola, Zanthoxyl species, Torlidis seed, clove flower, Asiasari root, cinnamon bark, and toad venom was applied to the glans penis 1 hour prior to intercourse and washed off immediately before intercourse. Patients using the cream had significantly improved ejaculatory latency when compared with placebo cream (2537). It is unclear if this effect is due to dong quai, other ingredients, or the combination.
• Premenstrual syndrome (PMS). Although there is interest in using oral dong quai for PMS, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Psoriasis. Although there is interest in using oral dong quai for psoriasis, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Pulmonary hypertension. Preliminary clinical research shows that intravenous dong quai may be effective in patients with pulmonary hypertension. Details: Some preliminary clinical research in patients with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension shows that intravenous administration of 250 mL of a solution containing dong quai 25%, once daily for 5-10 days, reduces pulmonary arterial pressure and pulmonary vascular resistance when compared to baseline (48438,48442,48443). The validity of these findings is limited by the lack of comparator groups.
• Rheumatoid arthritis (RA). Although there is interest in using oral dong quai for RA, there is insufficient reliable information about the clinical effects of dong quai for this condition.
• Stroke. Preliminary evidence does not support the use of intravenous dong quai for acute ischemic stroke. Details: Preliminary clinical research in patients with acute ischemic stroke shows that administering 200 mL of a solution containing dong quai 25% intravenously daily for 20 days does not improve neurological symptoms when compared with dextran-40 (48483). More evidence is needed to rate dong quai for these uses.

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POSSIBLY EFFECTIVE

• Bleeding. Intramuscular motherwort injections, alone or in combination with standard treatment such as oxytocin, might reduce volume of blood loss and duration of bleeding after vaginal delivery, caesarian section, or induced abortion. Details: In females with postpartum bleeding after vaginal birth, most research shows that adding motherwort injection to oxytocin or carboprost treatment is more effective than those treatments alone. A meta-analysis of 29 low quality trials shows that injection with motherwort 40-140 mg, in addition to varying doses of oxytocin, is more effective than oxytocin alone for reducing blood loss after vaginal delivery (101890). This combination reduces the mean blood loss within 2 and 24 hours of delivery by 55 mL and 85 mL, respectively. Also, the risk of postpartum hemorrhage, defined as an estimated blood loss of at least 400 mL within 2 hours or at least 500 mL within 24 hours, is reduced by 71%, based on meta-analysis of 18 trials. Meta-analysis of 8 trials also shows motherwort alone to be more effective than oxytocin for reducing blood loss within 24 hours of delivery, but not within 2 hours of delivery. Meta-analysis of 4 trials shows that motherwort 40-200 mg is as effective as oxytocin for reducing the risk of postpartum hemorrhage (101890). Studies were all very low to low quality, with moderate to high risk of bias, and conducted in China, the latter of which limits generalizability to other geographic regions. In females with post-caesarian bleeding, adding motherwort injection to oxytocin reduces blood loss and the rate of post-partum hemorrhage when compared with using oxytocin alone. In a large clinical trial, motherwort 40 mg was injected into the uterus during the caesarian section, followed by 20 mg intramuscular injections every 12 hours over the next 36 hours. However, motherwort injection into the uterus does not seem to be more effective than oxytocin for reducing bleeding during the caesarian section (94203). However, a meta-analysis of 8 trials shows that prophylactic injection with motherwort 60-200 mg, in addition to carboprost 250 mcg, reduces the mean blood loss within 2 and 24 hours of delivery by 127 mL and 147 mL, respectively, with a 72% decrease in the incidence of postpartum hemorrhage over carboprost alone (101891). In 7 of the 8 trials the mode of delivery was caesarian section and 1 was a vaginal delivery. A large observational study suggests that intramuscular injection of motherwort into the uterus combined with intravenous oxytocin is associated with a lower risk of post-partum hemorrhage after caesarian section when compared with intravenous oxytocin plus intramuscular injection of oxytocin into the uterus (112291). A meta-analysis of 9 clinical trials among patients undergoing induced abortion shows that motherwort injection combined with oxytocin lowers the volume of blood loss both 2 hours and 24 hours after the procedure when compared with oxytocin alone (112292). However, motherwort alone is not more effective than oxytocin for blood loss post-abortion. Meta-analysis indicates that motherwort injected alone or with oxytocin reduces the duration of blood loss compared with oxytocin or no treatment. Studies were primarily of very low quality, and all studies were conducted in China, limiting generalizability to other populations and geographic locations.

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Alcohol use disorder. Oral motherwort has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in males experiencing alcohol withdrawal syndrome with disordered sleep, anxiety, and irritability shows that a single dose of a combination product containing motherwort 50 mg, valerian 170 mg, hops 50 mg, and lemon balm 50 mg, taken 1 hour before bedtime, improves sleep quality and decreases awakenings when compared with placebo (63884).
• Amenorrhea. Although there has been interest in using oral motherwort for amenorrhea, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Anxiety. It is unclear if oral motherwort is beneficial in patients with anxiety. Details: Preliminary clinical research in adults with anxiety and hypertension shows that taking a specific preparation of motherwort extracted in soybean oil (Farmagen Ltd.) 600 mg orally twice daily for 28 days reduces anxiety and depression scores when compared with baseline. A significant improvement occurred in 32% of subjects, and a moderate improvement occurred in 48% of subjects (94209). The validity of this finding is limited by the lack of a comparator group.
• Arrhythmia. Although there has been interest in using oral motherwort for arrhythmia, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Asthma. Although there has been interest in using oral motherwort for asthma, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Cancer. Although there has been interest in using oral motherwort for cancer, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Dysmenorrhea. Although there has been interest in using oral motherwort for dysmenorrhea, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Flatulence. Although there has been interest in using oral motherwort for flatulence, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Heart failure. Although there has been interest in using oral motherwort for heart failure, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Herpes zoster (shingles). Although there has been interest in using topical motherwort for herpes zoster, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Hypertension. It is unclear if oral motherwort is beneficial in patients with hypertension. Details: Preliminary clinical research in adults with hypertension and anxiety shows that taking a specific preparation of motherwort extracted in soybean oil (Farmagen Ltd.) 600 mg orally twice daily for 28 days reduces blood pressure when compared with baseline. In subjects with mild hypertension, systolic and diastolic blood pressure decreased by 10% and 11%, respectively. In subjects with more severe hypertension, systolic and diastolic blood pressure decreased by 7% and 11%, respectively (94209). The validity of this finding is limited by the lack of a comparator group.
• Hyperthyroidism. Although there has been interest in using oral motherwort for hyperthyroidism, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Insomnia. Although there has been interest in using oral motherwort for insomnia, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Menopausal symptoms. Oral motherwort has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in adults with menopause shows that taking a combination of motherwort, burdock, dong quai, licorice root, and wild yam three times daily for 12 weeks reduces the number and severity of menopausal symptoms, such as hot flashes, sleep problems, mood changes, and vaginal dryness, in 71% of patients, compared with 17% of patients taking a placebo (48522).
• Pruritus. Although there has been interest in using topical motherwort for pruritus, there is insufficient reliable information about the clinical effects of motherwort for this purpose.
• Wound healing. Although there has been interest in using topical motherwort for wound healing, there is insufficient reliable information about the clinical effects of motherwort for this purpose. More evidence is needed to rate motherwort for these uses.

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POSSIBLY SAFE ...when used orally and appropriately. Dong quai has been used with apparent safety in a dose of 4.5 grams daily for 24 weeks, or in combination with other ingredients in doses of up to 150 mg daily for up to 6 months (19552,35797). ...when used intravenously as a 25% solution, in a dose of 200-250 mL daily for up to 20 days (48438,48442,48443,48483).

POSSIBLY UNSAFE ...when used orally in large amounts, long-term. Theoretically, long-term use of large amounts of dong quai could be harmful. Dong quai contains several constituents such as bergapten, safrole, and isosafrole that are considered carcinogenic (7162). There is insufficient reliable information available about the safety of dong quai when used topically.

PREGNANCY: POSSIBLY UNSAFE
when used orally. Dong quai has uterine stimulant and relaxant effects (8142); theoretically, it could adversely affect pregnancy. Observational research has found that intake of An-Tai-Yin, an herbal combination product containing dong quai and parsley, during the first trimester is associated with an increased risk of congenital malformations of the musculoskeletal system, connective tissue, and eyes (15129).

LACTATION:
Insufficient reliable information available; avoid use.

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POSSIBLY SAFE ...when used orally and appropriately. A motherwort extract in soybean oil has been used with apparent safety at doses of 1200 mg daily for up to 28 days (94209) ...when administered intramuscularly, short-term. One or more intramuscular injections have been used with apparent safety in total combined doses of 40-200 mg over 48 hours or less to prevent and/or stop postpartum bleeding (94203,101890,101891,101892). Post-marketing surveillance of over 8000 females found that a specific motherwort product (Chengdu No 1 Pharma Company Ltd) has been used without significant adverse effects for a duration of 48 hours or less (104855) ...when administered by intrauterine injection, short-term. Post-marketing surveillance of over 1800 patients found that a specific motherwort product (Chengdu No 1 Pharma Company Ltd) has been used without significant adverse effects for a duration of 48 hours or less (104855).

PREGNANCY: LIKELY UNSAFE
when used orally or by injection. Alkaloids present in motherwort have uterine stimulant effects (4,12,19).

LACTATION:
Insufficient reliable information available; avoid using.

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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, dong quai may increase the risk of bleeding when used with anticoagulant or antiplatelet drugs; however, research is conflicting.  Details Animal studies suggest that dong quai has antithrombin activity and inhibits platelet aggregation due to its coumarin components (6048,10057,96137). Additionally, some case reports in humans suggest that dong quai can increase the anticoagulant effects of warfarin (3526,6048,23310,48439). However, clinical research in healthy adults shows that taking 1 gram of dong quai root daily for 3 weeks does not significantly inhibit platelet aggregation or cause bleeding (96137). Until more is known, use dong quai with caution in patients taking antiplatelet/anticoagulant drugs.

ESTROGENS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, dong quai may reduce the effects of estrogens.  Details Dong quai has estrogenic effects (6180,7860,15108,15535,48459). Theoretically, concomitant use of large amounts of dong quai might interfere with hormone replacement therapy due to competition for estrogen receptors.

WARFARIN (Coumadin) Interaction Rating = Major Do not take this combination. Severity = High •  Occurrence = Probable •  Level of Evidence = D Dong quai may increase the risk of bleeding when used with warfarin.  Details Case reports suggest that concomitant use of dong quai with warfarin can increase the anticoagulant effects of warfarin and increase the risk of bleeding (3526,6048,23310,48439). In one case, after 4 weeks of taking dong quai 565 mg once or twice daily, the international normalized ratio (INR) increased to 4.9. The INR normalized 4 weeks after discontinuation of dong quai (3526).

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CNS DEPRESSANTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking motherwort concomitantly with other CNS depressants may increase the risk of sedation.  Details Motherwort has been reported to cause CNS depression and sedation (19,94205).

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General ...Orally, dong quai is generally well-tolerated.
Most Common Adverse Effects:
Orally: Burping and flatulence.
Intravenously: Headache.

Cardiovascular ...Orally, dong quai might cause hypertension; according to one case report, a parent and breastfed infant experienced hypertension (195/85 mmHg and 115/69 mmHg, respectively) after the parent consumed a soup containing dong quai root (48428).

Dermatologic ...Dong quai contains psoralens that may cause photosensitivity and photodermatitis (10054,10057,48461).

Endocrine ...In a case report, a male developed gynecomastia after ingesting dong quai tablets (48504).

Gastrointestinal ...Orally, burping and gas may occur with dong quai (738).

Hematologic ...In one case report, a 55-year-old female with protein S deficiency and systemic lupus erythematosus (SLE) had temporary vision loss in the left eye from hemiretinal vein thrombosis three days after taking a phytoestrogen preparation containing dong quai 100 mg, black cohosh 250 mg, wild Mexican yam 276 mg, and red clover 250 mg (13155). It is unclear if dong quai contributed to this event.

Neurologic/CNS ...Dong quai given orally or by injection may be associated with headache (738,48438).

Oncologic ...Dong quai contains constituents that are carcinogenic; however, whether these constituents are present in concentrations large enough to cause cancer with long-term or high-dose use is unknown (7162).

Pulmonary/Respiratory ...A pharmacist experienced allergic asthma and rhinitis after occupational exposure to dong quai and other herbs (48435).

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General ...Orally or via intramuscular or intrauterine injection, motherwort appears to be generally well tolerated.
Most Common Adverse Effects:
Orally: Diarrhea, stomach irritation.
Topically: Contact dermatitis, photosensitivity.
Intramuscular / Intrauterine: Abdominal pain, erythema, eyelid edema, fever, nausea, pruritus, rash.

Dermatologic ...Motherwort leaves can cause contact dermatitis, and the oil may cause photosensitivity reactions (4). Intramuscularly and via intrauterine injection, mild erythema, rash, and pruritus have been reported (101892,104855).

Gastrointestinal ...Orally, use of motherwort in amounts greater than 3 grams can cause diarrhea and stomach irritation (12). Intramuscularly and via intrauterine injection, abdominal pain and nausea have been reported (104855).

Genitourinary ...Orally, use of motherwort in amounts greater than 3 grams can cause uterine bleeding (12).

Immunologic ...Motherwort can also cause allergic reactions in sensitive individuals (4). Intramuscularly and via intrauterine injection, transient fever and chills lasting less than 24 hours have been reported (104855).

Ocular/Otic ...Intramuscularly and via intrauterine injection, transient eyelid edema lasting less than 24 hours has been reported (104855).

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