Coffee and Other Caffeine-Containing Herbs and Supplements
Caffeine-containing herbs and supplements are consumed around the world. Of these, coffee is the most popular. The caffeine in coffee increases alertness and decreases fatigue, as anyone who enjoys a morning cup of coffee is well aware. Despite widespread caffeine use, no rigorous, well designed study has evaluated caffeine-containing substances in people with MS.
One study was published examining a therapy known as Prokarin in people with MS. Prokarin contains caffeine as well as histamine, which makes the results of this study difficult to interpret. Further information on Prokarin is available in the Prokarin section of this site (see Prokarin page).
Coffee has been studied in the general population. These studies suggest that coffee improves mental, but not physical, fatigue. Coffee increases mental alertness, but not physical power or endurance. Timing and dose for maximal benefit for MS-related fatigue has not been determined.
Caffeine is known to alter the immune system, an issue of possible relevance to people with MS. Some research suggests caffeine decreases the activity of immune system cells known as lymphocytes. Theoretically, these alterations in immune system function could be beneficial for people with MS.
Caffeine can also be found in many other herbal sources. Tea contains caffeine. Black and green teas are both derived from Camellia sinensis. Chocolate and other products derived from the cacao plant contain caffeine. Guarana, another caffeine-containing herb, may be consumed in tablet form or as a tea. Maté (yerba maté) and cola nut (bissy nut) also contain caffeine. Caffeine itself may also be consumed in tablet form; it is available as a dietary supplement.
Caffeine-containing herbs, including coffee, are considered to be generally safe. However, caffeine may have effects on a developing fetus, so the FDA recommends that pregnant women limit their use. Also, maté is believed to increase the risk of certain forms of cancer. Therefore, the FDA has classified two forms of mate, Ilex cassine and Ilex vomitoria, to be unsafe.
People with MS may be especially prone to some caffeine side effects. MS may increase osteoporosis risk, and caffeine may increase this osteoporosis risk further. Caffeine also increases urination and may cause irritation of the urinary tract, thus possibly exacerbating MS-associated bladder problems.
High doses of caffeine may produce insomnia, heart palpitations, anxiety, nausea, vomiting, increased blood pressure, muscle twitching, tremors, and increased cholesterol levels. Chronic use of high doses of caffeine can lead to tolerance, which causes the body to need larger doses in order to produce the same effect. When these high doses are stopped, withdrawal symptoms may be experienced, including irritability, dizziness, headache, and anxiety. Usually, the suggested maximum daily dose is between 250 to 300 mg. This is approximately four to five cups of tea or two to three cups of coffee.
Cranberry and Other Herbal Therapies for Urinary Tract Infections
Some people with MS are prone urinary tract infections (UTIs). As such, cranberry juice, a common remedy for UTIs, is of possible interest to those with MS. Cranberry juice has long been used for both treating and preventing UTIs. Until the 1970s, it was believed that cranberry juice increased the acidity of urine, which was thought to destroy bacteria. It is now believed, however, that fructose and proanthocyanidins (a class of chemicals) in the cranberry juice prevent bacteria from attaching to the lining of the urinary tract. Cranberry juice may also kill certain bacteria.
The limited clinical studies available suggest that cranberry juice may be protective against UTIs in some people. Those who appear to benefit in these studies have normal bladder function. These benefits do not appear to be seen with in those with abnormal bladder function, which may occur in MS. More rigorous studies still need to be conducted to examine the effectiveness of cranberry, and how it compares to antibiotics.
UTIs may lead to very serious complications, especially in people with MS. Cranberry juice should not be used for treating these infections; people need to use conventional antibiotics. However, it may be reasonable for people to use cranberry juice as a preventative measure against UTIs.
Exact dosing recommendations have yet to be established. Dosages may be around 1 to 10oz. of juice, 6 capsules of dried powder, or 0.5 to 5oz. of fresh or frozen cranberries. Some people find it difficult to eat cranberries, fresh or frozen, due to the sour taste. Cranberry juice cocktail is only about one-quarter to one-third juice.
Generally, cranberry is well tolerated. It is possible for cranberry to interact with blood-thinning medication. Long-term use of large amounts of cranberry may result in nausea, stomach discomfort, loose stools, or kidney stones. It is not known if cranberry is safe for pregnant women or women who are breast-feeding.
Bearberry and vitamin C are also sometimes recommended for UTIs. Bearberry, or uva ursi, is not clearly effective for preventing UTIs. Furthermore, it may cause nausea or vomiting. Bearberry also contains certain chemicals that may be carcinogenic. As for vitamin C, clinical studies do not support the belief that it is effective for treating or preventing UTIs. Also, vitamin C may cause kidney stones and stimulate the immune system. (See the Vitamin A, Vitamin C, and Vitamin E section of the Vitamins, Minerals, and Other Non-herbal Supplements page for more information.)
Echinacea has a long history of treating medical conditions. It is a very popular and well-researched herb. Echinacea was used by North American Indians and, in the early 1900s, was the primary herbal treatment for infection. Despite the potential risk echinacea poses for those with MS, some popular books on alternative medicine specifically recommend echinacea for people with MS.
Echinacea may prevent or lessen the severity of viral infections. In some instances, viral infections lead to MS attacks and therefore prevention of these infections may produce benefits for people with MS. The work concerning echinacea and viral infections has produced mixed results, but some of this work does suggest echinacea may decrease their length and severity.
Echinacea may stimulate the immune system. Specifically it may stimulate T cells and macrophages, cells that are already overactive in MS. This stimulation may act in opposition to many of the conventional medications for MS, which work to depress immune system activity. It is also possible that echinacea could worsen MS.
Conventional methods, such as hand washing, flu vaccines, and newer prescription drugs, may be a safer and more effective way for people with MS to prevent and treat viral infections.
Echinacea may cause liver damage. This effect may be amplified by some conventional MS medications, known to be associated with liver injury. With the limited information available at this time, the safest course of action for people with MS is to avoid echinacea.
Ginkgo biloba is the most extensively researched herb. Numerous clinical studies have been conducted to evaluate its therapeutic value in many different conditions. In general, Ginkgo biloba refers to an extract produced from the leaves of the Ginkgo biloba tree. Some have recommended this herb as a therapy for MS.
The recent popularity of Ginkgo biloba can be attributed, in part, to a study published by the Journal of the American Medical Association (JAMA) in 1997. This investigation reported that Ginkgo biloba appeared to be an effective treatment for cognitive issues in the elderly.
While certain chemical components of Ginkgo biloba acts as antioxidants, others act to inhibit platelet-activating factor (PAF). PAF is a compound involved in blood clotting and inflammation, and so inhibiting it could reduce inflammation.
Research has been done using animals with EAE, an experimental model of MS. In these studies PAF has been associated with a worsening of the disease. Consistent with these findings, Ginkgo biloba has been associated with improvement in some studies.
A 1992 study is sometimes cited as the reasoning behind recommending Ginkgo biloba for MS. In this study, eight of the ten people with MS people using Ginkgo biloba saw improvement. However in 1995, a much larger, better-designed study found that Ginkgo biloba was not effective for treating MS attacks. For slowing down the disease process of MS, Ginkgo biloba does not appear to be effective in the short-term. The effectiveness of long-term use is unknown.
Some preliminary work has suggested Ginkgo biloba may help with MS-associated cognitive problems. However, further research is necessary to prove any definite therapeutic effects.
In general, Ginkgo biloba is well tolerated. However, it may cause bleeding issues, so people with bleeding disorders, people who are undergoing surgery, and people taking aspirin or other blood-thinning medications should avoid this herb. A few cases of spontaneous bleeding in the eye or around the brain have been reported in association with Ginkgo biloba use. This herb may also increase the risk of seizures. Other side effects include rashes, headache, dizziness, nausea, vomiting, flatulence, and diarrhea. It is not clear whether or not this herb is safe for women who are pregnant or breast-feeding.
In the preparations used for clinical research, standardized extracts are used. They are known in Germany as LI 1370 and EGb761. These preparations are 24-25% flavone glycosides and 6% terpene lactones.
Many different types of ginseng are commercially available. Among them, the most common and also the most studied type is Asian ginseng (Panax ginseng). Siberian ginseng (Eleutherococcus senticosus), also called eleuthero, is another relatively common form. Ginseng is an adaptogen, a compound claimed to increase both energy levels and resistance to stress.
The biological actions of Asian ginseng are not entirely understood. It is possible the ginsenosides are the active compounds in Asian ginseng. Ginsenosides are chemically similar to steroids, which are often used in the conventional treatment of MS attacks. But while steroids act to suppress immune activity, ginsenosides appear to stimulate immune system cells. Due to its immune-stimulating properties, Asian ginseng poses a theoretical risk to people with MS. The effects of Asian ginseng on fatigue and stress are not clear at this time.
Siberian ginseng is a completely different herb, but in studies it has produced similar results to Asian ginseng. It also appears to stimulate the immune system, and its effects on fatigue and stress are unclear.
Both of these types of ginseng have been associated with adverse effects and drug interactions. The sedating effects sometimes associated with these herbs may exacerbate MS-associated fatigue or amplify the sedating effects of certain medications. It is also possible for Asian ginseng to interact with steroids. People who have bleeding disorders, people who are undergoing surgery, and people who are taking aspirin or blood-thinning medications should avoid both of these herbs due to their ability to increase bleeding tendency.
Neither Asian ginseng nor Siberian ginseng have any proven clinical benefits and may activate the immune system. It may be reasonable for people with MS to avoid consuming these herbs on a regular basis or in large doses.
Kava kava is claimed to have relaxant effects. People in the Pacific islands have used kava kava for centuries. The active compounds in this herb, called kavalactones or kavapyrones, act on the same proteins in the nervous system as diazepam (Valium), an anti-anxiety medication. Some research suggests that kava kava may improve mild anxiety, although it does not appear to help with more severe anxiety. Kava kava is also claimed to be effective for treating insomnia; however, this claim has not been thoroughly researched. Another herb, called valerian has been more thoroughly researched for treating insomnia – see Valerian section for more information.
Anti-anxiety drugs often have sedating effects. Kava kava itself does not seem to have this side effect, although it does appear to amplify the sedating effects of alcohol and many medications. Its effects on MS-associated fatigue are not known. If kava kava is used heavily for an extended period of time it may cause red eyes, itching, skin problems, and other difficulties.
Kava kava was long considered to be relatively safe, but, in 2001, liver toxicity began to be reported in association with kava kava use. In some instances, people have required liver transplantation or died due to kava kava-associated liver toxicity. The United States FDA has since issued warnings about kava kava, while Europe and Canada have banned the herb altogether. Taking this information into consideration, it is recommended that kava kava should not be used due to serious safety concerns.
Padma 28 is a complicated mixture of herbs developed in the late 19th century. It is also called Gabyr-Nirynga and Badmaev 28. Both Tibetan and Ayurvedic medicine heavily influenced the two physicians who developed Padma 28.
Over 20 different herbs, as well as calcium, are found in Padma 28. It is usually taken orally. The mixture appears to mildly decrease immune system activity and produce some antioxidant effects.
People have claimed Padma 28 to be an effective treatment for MS as well as asthma, heart disease, and peripheral vascular disease. Padma 28 is associated with a decreased death rate and longer survival time in mice with EAE, an animal model of MS. In Poland, a study conducted in the early 1990s found that 44% of people with MS who received treatment with Padma 28 saw clinical improvement in their disease. These results are very promising. However, many details of this study’s design are not available, thus making it hard to determine its validity.
The Polish study involved one hundred people and reported no side effects associated with Padma 28. Other detailed information about the toxicity and long-term safety of this mixture are not available. The limited research that has been conducted on Padma 28 suggests it may be beneficial for treating MS, but these studies are far from conclusive.
St. John’s Wort
St. John’s wort has been used to treat various conditions for over 2,000 years. Currently it is most commonly used in treating depression. The active compounds in St. John’s wort have not been clearly established, although hypericin or hyperforin have both been suggested to produce the herb’s therapeutic effects. St. John’s wort may have multiple biological effects, but the mechanisms underlying these actions are not well understood.
The effectiveness of St. John’s wort as an antidepressant has been studied extensively. A study was published that combined the information from 27 previous studies on St. John’s wort and depression. The quality of some of these studies has been called into question. This study reported that St. John’s wort may act as an antidepressant in people with moderate or mild depression. It is not clear whether it is effective for people with severe depression.
Two recent studies have further investigated St. John’s wort as an antidepressant. One study found that the effects of St. John’s wort were similar to a placebo for people with mild or moderate depression. It is possible, however, that this study was not large enough to discriminate between the effects of these compounds. Another study looked at severe depression, using sertraline (Zoloft), St. John’s wort, and a placebo. Neither setraline nor St. John’s wort appeared to be more effective than the placebo. The effectiveness of St. John’s wort needs to be further investigated.
People considering St. John’s wort should discuss this herb with their physician. As depression can be a very serious condition, a person who is feeling depressed should consult a physician. St. John’s wort should not be used for severe depression. It is generally well tolerated, but may cause dizziness, sedation, upset stomach, confusion, and anxiety. In rare cases, this herb has produced photosensitivity, a hypersensitivity to sun exposure that affects the skin and nerves. This is more likely to occur in people with fair skin. St. John’s wort may cause mania or hypomania in people with depression or manic-depressive illness. Withdrawal side effects, such as dizziness, nausea, headaches, fatigue, insomnia, and confusion, may occur if use of St. John’s wort is abruptly discontinued.
St. John’s wort may also interact with many medications. This herb acts on the liver, and may actually decrease the blood concentration of certain prescription drugs, including oral contraceptives and blood-thinning medication. St. John’s wort may also affect drugs used for seizures, heart disease, depression, and cancer. Furthermore, several drugs used to treat MS-associated symptoms may be affected. St. John’s wort should not be taken while taking antidepressant medications.
St. John’s wort is generally taken in 300mg doses, three times per day. The standardized tablet contains 0.3% hypericin.
Valerian is considered by some to be “the Valium of the 19th century.” This herb has long been used for its calming and sedating effects. More recently, it has been claimed to be beneficial for those suffering from insomnia. The biological mechanisms underlying the effects of Valerian are not well understood. Due to its rather pungent odor, which is similar to the smell of dirty socks, Valerian products are sometimes evaluated by using a “stink rating.”
Sleep disorders, including insomnia, are often seen in association with MS. These disorders may be related to stress or anxiety, and may exacerbate MS-associated fatigue. People who are having sleep issues and those who are considering using valerian should discuss their complaints with a physician.
There have been ten clinical trials that suggest that valerian may be effective for treating insomnia; however, these studies are of mixed quality. Limited work has been done looking at valerian for treating depression, muscle stiffness, and anxiety, so it is unclear how effective this herb is in these conditions. Another herb, kava kava, has been more thoroughly researched for anxiety – see the Kava kava section on this page for more information.
Valerian is generally well tolerated, but long-term safety information is not available. It may worsen fatigue and increase the sedating effects of alcohol and some medications. It may also cause excitability, insomnia, headache, and liver toxicity.
Valerian may be consumed in various forms, and the dosing varies for each. Valerian extract, between 400 and 900mg, should be taken an hour before bed, whereas valerian tea (1tsp dried herb) or tincture (0.5 to 1tsp) are used several times daily. It may be necessary to use valerian daily for a few weeks in order to see therapeutic effects.
References and Additional Reading
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Bowling AC. Complementary and Alternative Medicine and Multiple Sclerosis. New York: Demos Medical Publishing, 2007, pp. 120-145.
Bowling AC, Stewart TS. Dietary Supplements and Multiple Sclerosis: A Health Professional’s Guide. New York: Demos Medical Publishing, 2004.
Brinker F. Herb Contraindications and Drug Interactions. Oregon: Eclectic Medical Publishers, 1998.
Fetrow CW, Avila JR. Professional’s Handbook of Complementary and Alternative
Medicines. Philadelphia: Lippincott, Williams, & Wilkins, 2004.
Fragakis AS. The Health Professional’s Guide to Popular Dietary Supplements. The
American Dietetic Association, 2003.
Jellin JM, Batz F, Hitchens K, et al. Natural Medicines Comprehensive Database. Therapeutic Research Faculty, 2006.
Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Healthcare
Professionals. London: The Pharmaceutical Press, 1996.
Polman CH, Thompson AJ, Murray TJ, et al. Multiple Sclerosis: The Guide to Treatment and Management. New York: Demos Medical Publishing, 2006.
Schulz V, Hansel R, Tyler VE. Rational Phytotherapy: A Physicians’ Guide to Herbal
Medicine. Berlin: Springer-Verlag, 1998.
Ulbricht CE, Basch EM, eds. Natural Standard Herb and Supplement Reference: Evidence-Based Clinical Reviews. St. Louis: Elsevier-Mosby, 2005.