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Echinacea

Scientific Name(s): Echinacea angustifolia DC, Echinacea pallida (Nutt.) Britton, Echinacea purpurea (L.) Moench
Common Name(s): American coneflower, Black Sampson, Black Susan, Comb flower, Echinacea, Echinaceawurzel, Hedgehog, Igelkopfwurzel, Indian head, Kansas snakeroot, Narrow-leaved purple coneflower, Purple coneflower, Purpursonnenhutkraut, Racine d'echininacea, Radix Echinaceae, Rock-up-hat, Roter sonnenhut, Scurvy root, Snakeroot, Sonnenhutwurzel

Medically reviewed by Drugs.com. Last updated on Oct 22, 2024.

Clinical Overview

Use

Use of echinacea as prophylaxis for upper respiratory tract infections has been reported, but evidence of efficacy is limited. Traditionally, echinacea has been used to prevent and treat the common cold; however, quality clinical trial data are lacking. Anxiolytic and immunomodulatory effects have been investigated. Specific recommendations for use for any indication are unreliable due to variations in composition of commercial echinacea products and inconsistent clinical trial results.

Dosing

A major limitation reported in meta-analyses of available trial data is the lack of standardization of echinacea preparations, making dosing recommendations difficult. Commercial preparations contain echinacea components derived from different plant parts, species, and varieties. Long-term use of echinacea or use for longer than 10 days for acute infections in otherwise healthy individuals is not recommended. Parenteral use is not recommended.

Contraindications

Avoid use in individuals with known hypersensitivity to plants of the Asteraceae/Compositae family. Echinacea is also contraindicated in individuals with an autoimmune disease, rheumatoid arthritis, systemic lupus erythematosus, leukosis, multiple sclerosis, tuberculosis, and HIV infection.

Pregnancy/Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking. Limited clinical evidence, expert opinion, and long-term traditional use suggest that oral echinacea is safe during pregnancy at typical dosages. Echinacea should be used with caution during lactation.

Interactions

Specific case reports of interactions are limited, with one report describing an interaction with etoposide. Data regarding echinacea's effects on the CYP-450 enzyme system are conflicting. Interactions with clozapine, etoposide phosphate, nimodipine, selpercatinib, and ubrogepant are possible.

Adverse Reactions

Adverse reactions with echinacea are rare. The most commonly reported reactions are allergy, GI upset, and rash. A case report of leukopenia, possibly caused by long-term echinacea use, has been published. Because of conflicting data, echinacea should not be used in any condition potentially affected by immune stimulation or suppression, such as HIV, tuberculosis, multiple sclerosis, and use of immunosuppressive agents. Use with caution in patients with hepatic impairment.

Toxicology

There is little evidence regarding toxicity with echinacea, despite its widespread use. Echinacea has not been associated with acute or chronic toxic effects. However, individuals with hepatic impairment should use echinacea with caution, as case reports of hepatotoxicity exist.

Scientific Family

Botany

Echinacea is a member of the Compositae family (also called the Asteraceae family), which is native to eastern and central North America. "Kansas snakeroot" or "snakeroot" should not be confused with white snakeroot (Ageratina altissima).USDA 2020 There are at least 9 species of echinacea, with E. purpurea, E. pallida, and E. angustifolia most commonly used for medicinal purposes.Ross 2001, USDA 2020 Because of the difficulty in identifying echinacea species, much of the early European research, particularly regarding E. angustifolia, may have actually been conducted on E. pallida.WHO 1999

Echinacea species are perennial herbs that grow up to 1.2 m in height. The plant has narrow leaves and stout stems that blossom into large, solitary flower heads with lavender or purple florets and central rigid bracts. The traditional Radix Echinaceae preparation consists of the fresh or dried roots (either single taproots or fibrous roots) of E. angustifolia.WHO 1999 When chewed, the root has a pungent taste and causes tingling of the lips and tongue.Ross 2001, WHO 1999 Additional plant parts used include fresh or dried flowering tops and fresh pressed juice from the flowering tops of E. purpurea.

History

Echinacea is a popular herbal remedy in the United States. The plant was used in traditional medicine by American Indians and was quickly adopted by settlers. During the 1800s, claims of curative properties of the plant ranged from blood purification to treatment of dizziness and rattlesnake bites. During the early 20th century, extracts of echinacea were used as anti-infectives; however, use of these products fell out of favor after the discovery of modern antibiotics. The plant and its extracts continue to be used topically for wound healing and internally to stimulate the immune system.Barnes 2005, Ross 2001, WHO 1999

Chemistry

The chemical constituents of echinacea are well described. Biologically active constituents include a volatile oil (containing pentadecadiene, pentadecene, ketoalkynes, and ketoalkenes), alkamides (mainly a mixture of isobutylamides), polyalkenes, polyalkynes, caffeic acid derivatives, and polysaccharides.Barnes 2005, Duke 1992, Ross 2001, WHO 1999 It has been reported that the alkamides found in echinacea are available following oral administration, but that caffeic acid derivatives are not.Barnes 2005

Toxic pyrrolizidine alkaloids (isotussilagine and tussilagine) have been identified at low levels.Duke 2002, WHO 1999

Uses and Pharmacology

Data comparisons and pooling are difficult due to trial methodology concerns, including variations in plant species, plant parts, preparations, and dosages, as well as high dropout rates and a lack of intention-to-treat analyses.(Karsch-Volk 2014, Wolsko 2005)

Adipogenesis

In vitro data

Effects of an ethanol extract of E. purpurea on adipogenesis (ie, insulin-induced adipocyte differentiation of 3T3-L1 preadipocytes) were observed in vitro, suggesting a potential role in the treatment or prevention of obesity or diabetes.(Shin 2014)

Alcoholic liver disease

Animal data

Chicoric acid extracted from E. purpurea was protective against alcohol-induced hepatic steatosis in mice.(Landmann 2014)

Anti-inflammatory effects

Animal and in vitro data

Antihyaluronidase activity,(Facino 1993) inhibition of prostaglandins,(Guiotto 2008, Hinz 2007) and reduction in proinflammatory mediators in vitro(Moazami 2015) and in rodents(Dogan 2014) have been demonstrated. When injected intravenously (IV) and applied topically, echinacea inhibited induced inflammation in rodents.(Tubaro 1987)

Antitussive/Bronchodilatory effects

Animal data

Extracts of the flowering parts of echinacea demonstrated antitussive and bronchodilatory effects in rodents.(Capek 2015)

Cancer

Animal and in vitro data

Root extracts from 3 echinacea species (E. purpurea, E. angustifolia, and E. pallida) produced concentration- and time-dependent induction of apoptosis in human pancreatic and colon cancer cell lines.(Chicca 2007) In mice, 8 weeks of echinacea therapy prolonged mean survival age and suppressed thymic lymphoma enlargement; other experiments demonstrated elevated natural killer cell levels and prolonged survival times in leukemic mice.(Currier 2001, Miller 2005) In a study in rats, coadministration of cadmium and echinacea led to increased concentrations of cadmium in certain organs and in blood.(Zitkevicius 2007) In an in vitro study, typical constituents of echinacea species applied topically were effective in the prevention and/or treatment of skin damage caused by ultraviolet/ultraviolet B radiation. Another study suggested radioprotection following oral administration of echinacea.(Joksić 2009)

Clinical data

In a trial investigating the effects of an IV administered polysaccharide fraction of echinacea in 15 patients with advanced gastric cancer, increases in median number of leukocytes occurred; however, differences from a historical control group were not considered clinically relevant.(Melchart 2002) Another study of 23 patients with tumors showed no effect on cytokines or leukocytes after use of an E. angustifolia preparation.(Elsässer-Beile 1996)

CNS effects

Animal data

Anxiolytic activity of echinacea has been demonstrated in limited animal studies.(Hájos 2012, Haller 2010, Sarris 2013)

Clinical data

An open-label study investigated anxiolytic activity of E. angustifolia extract in healthy individuals (N=33) with elevated anxiety scores. The study did not include a placebo group; participants were randomized to receive 1 or 2 capsules (each capsule containing 20 mg of extract) daily for 1 week. Only the higher dose resulted in a reduction in anxiety scores during treatment and for 2 weeks after.(Haller 2013) The observed effect may be due to lipophilic alkylamide constituents interacting with cannabinoid receptors.(Sarris 2013) A double-blind, randomized, placebo-controlled study enrolled 108 physically healthy adults 18 to 65 years of age with symptoms of mild to moderate anxiety to explore the effects of E. anugustifolia standardized extract on anxiety, positive and negative affect symptoms, insomnia, and quality of life (QOL). Recruitment occurred between May and June 2020 in Australia, and the extract was administered at a low (40 mg/day) and high (80 mg/day) dose. At week 6, all groups demonstrated significant improvement in anxiety total scores (by 31% to 35%) as well as psychological and somatic sub-scale scores from baseline with no differences observed between groups. Negative affect scores were also significantly improved in all groups; however, significant increases in positive affect scores were only seen in the echinacea groups compared to baseline (P≤0.001 each dose). Compared to placebo, positive and negative affect changes were significant in the echinacea low- and high-dose groups (P=0.001 and P=0.041, respectively). In the QOL scores, both echinacea groups demonstrated better emotional well-being than placebo (P=0.043 and 0.046, respectively, for the low and high dose). Additionally, the high-dose group was found to have better social functioning (P=0.043) and general health (P=0.049) scores than placebo. No significant differences were observed among the groups for insomnia. Mild digestive complaints were reported more frequently in the echinacea high-dose group (n=4); 1 participant from each echinacea group withdrew from the study due to mild digestive complaints.(Lopresti 2021)

Dental applications

Clinical data

According to a prospective, cross-sectional survey (N=250) analyzing use of 31 complementary and alternative medicine (CAM) remedies for dental or mouth issues, echinacea was recommended by 36% of German dentists and maxillofacial surgeons. As would be expected, perceived effectiveness was rated higher among CAM proponents than opponents.(Baatsch 2017)

Immunomodulatory effects

Many studies investigating the immunomodulatory properties of various echinacea species, extracts, and plant parts have been conducted. Reviews of the literature generally show agreement that echinacea extracts exert effects on markers of the immune system.(Barnes 2005, Barrett 2003)

Animal and in vitro data

In a study evaluating the effects of oral echinacea hydroethanolic extract on the dog immune system, appreciable immunostimulatory activity was suggested; further studies are needed to confirm findings. In vitro and animal studies are ongoing.(Fonseca 2014, Torkan 2015)

Clinical data

Clinical studies have been conducted largely in healthy adults(Brush 2006, Coeugniet 1987, Dapas 2014, Guiotto 2008, Hall 2007, Ritchie 2011, Schwarz 2005) or to investigate echinacea's potential in preventing or treating specific infections (see Infections/Common cold section).(Barnes 2005, Barrett 2003) Effects such as enhanced macrophage function, stimulation of cytokine production (including certain interleukins and tumor necrosis factor alpha), enhanced natural killer cell function, and increased mean circulating total white blood cell counts have been demonstrated; however, the impact of these effects on clinical outcomes has not been established.(Barnes 2005, Barrett 2003, Walsh 2011) Reviews note that overt stimulation of immune functions is not without the potential for harm(Barnes 2005, Barrett 2003); a case report exists of potential activation of autoimmune disease (Sjogren syndrome) with echinacea use.(Logan 2003)

Infections/Common cold

Animal and in vitro data

Antifungal, antibacterial, and antiviral (herpes simplex virus, HIV, and influenza) properties have been studied in vitro(Barnes 2005, Birt 2008, Cruz 2014, Sharma 2009, Sharma 2011); however, widespread traditional use of echinacea for infections, especially for the common cold, as well as the availability of clinical trial data make animal data largely irrelevant.(Karsch-Volk 2014)

Clinical data

According to a Cochrane review of quality clinical trials (conducted up to mid 2013) evaluating echinacea products in the treatment of the common cold, only 1 of 7 studies showed a reduction in duration of infection.(Karsch-Volk 2014) A pooled analysis was not conducted because of the strong clinical heterogeneity of the studies, making definitive statements regarding effects difficult.(Karsch-Volk 2014, Shah 2007) A placebo effect was reported in a clinical study (N=719) that used echinacea to treat new-onset common cold.(Barrett 2011) In another clinical study (N=90), risk of acute otitis media was possibly increased in echinacea-treated otitis-prone children.(Wahl 2008) Efficacy as well as safety and tolerability of echinacea have been studied in children with upper respiratory infections, with equivocal results.(Saunders 2007, Taylor 2003)

Published reviews of echinacea for infection prevention should be considered separately from those evaluating its role in infection treatment, as prophylactic administration occurs prior to symptom onset and for a longer duration.(Karsch-Volk 2014, Schapowal 2015) A Cochrane review of quality clinical trials (N=4,631; including trials published up to mid 2013) evaluating echinacea products in the prevention of upper respiratory tract infections due to the common cold showed a nonsignificant trend in favor of echinacea as prophylaxis; the effect size was of limited clinical relevance (10% to 20% relative risk [RR] reduction).(Karsch-Volk 2014) In a meta-analysis of 6 clinical studies (N=2,458), 4 evaluating echinacea and 2 evaluating other supplements, the risk for recurrent respiratory infections was reduced with echinacea (RR, 0.649; 95% CI, 0.545 to 0.774; P<0.0001).(Schapowal 2015)

In a clinical trial investigating the effect of an echinacea extract on the severity and recurrence of genital herpes, no difference was observed compared with placebo.(Vonau 2001)

Performance enhancement

Animal data

The literature includes limited studies evaluating the effects of echinacea on exercise enhancement in animals; however, studies demonstrating anti-inflammatory and antioxidant effects have led to supplementation of horse feed with echinacea products.(Williams 2008)

Clinical data

Studies in athletes did not demonstrate enhanced performance or change in hemoglobin concentration with echinacea 8,000 mg daily over 6 weeks.(Baumann 2014, Bellar 2014, Stevenson 2016)

According to a consensus statement, evidence is lacking to support use of echinacea in athletes to maintain immune health.(Walsh 2011)

Dosing

A major limitation reported in meta-analyses of available trial data was the lack of standardization among echinacea preparations, making dosing recommendations difficult. Many products lacked active echinacea chemical compounds or were contaminated with other chemical entities.Barnes 2005, Karsch-Volk 2014

Parenteral use is not recommended; evidence of safety and effectiveness is lacking.Karsch-Volk 2014, Melchart 2002

Long-term use or use for longer than 10 days for acute infections in otherwise healthy individuals is not recommended.Bradley 1992

diphenhydramine, Benadryl, chlorpheniramine, Ginkgo Biloba, turmeric, Promethazine DM, Banophen, saw palmetto

Pregnancy / Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking.

A prospective cohort study (N=206) found no increased risk of fetal malformations with the use of echinacea during the first trimesterGallo 2000; however, the study was limited by small sample size, allowance of detection of common malformations only, and lack of standardization of preparations.Barnes 2005, Holst 2011

Evidence regarding safety of echinacea use during lactation is lacking. A case report documented breast milk concentrations that were similar to serum levels 1 to 4 hours after consumption.Amer 2015, Sachs 2013

Despite the Complete German Commission E Monographs statement that oral echinacea is safe for use during lactation at recommended dosages,Blumenthal 1998, Blumenthal 2000 echinacea should be used with caution during lactation; high-quality clinical studies are needed to determine safety.Amer 2015, Perri 2006, Sachs 2013

Interactions

Data regarding effects on the CYP-450 enzyme system are conflicting.(Colombo 2014, Gorski 2004, Haefeli 2014, Hansen 2008)

In 2 small studies, no impact of echinacea on docetaxel(Goey 2013) or etravirine(Moltó 2012) pharmacokinetics was found; however, a case report describes an interaction with etoposide.(Bossaer 2012) Due to upregulation of CYP1A2 (caffeine) and CYP3A4 (midazolam), effects on therapeutic agents such as amitriptyline, haloperidol and olanzapine, theophylline and zileuton, efavirenz and nevirapine, tamoxifen, and etoposide have been suggested.(Awortwe 2015, Grappe 2014) Echinacea was less active in inhibiting CYP2C8 enzyme activity (metabolism of antihyperglycemic agents) than were 2 of the 6 other plants tested (ie, cranberry, saw palmetto).(Albassam 2015)

Clozapine: CYP3A4 inducers (weak) may decrease the serum concentration of clozapine. Monitor therapy.(Clozaril September 2015, Jerling 1994, Joos 1998, Junghan 1993, Langbehn 2000, Miller 1991, Muller 1988, Peritogiannis 2007, Raitasuo 1994, Tiihonen 1995, Van Strater 2012)

Etoposide: Echinacea may increase the serum concentration of etoposide. Monitor therapy.(Bossaer 2012, Gorski 2004, Gurley 2004, Hansen 2008, Penzak 2010, Yale 2005)

Etoposide phosphate: Echinacea may increase the serum concentration of etoposide phosphate. Monitor therapy.(Bossaer 2012, Gorski 2004, Gurley 2004, Hansen 2008, Penzak 2010, Yale 2005)

Nimodipine: CYP3A4 inducers (weak) may decrease the serum concentration of nimodipine. Monitor therapy.(Nimodipine April 2015, Tartara 1991)

Selpercatinib: CYP3A4 inducers (weak) may decrease the serum concentration of selpercatinib. Monitor therapy.(Retevmo May 2020)

Ubrogepant: CYP3A4 inducers (weak) may decrease the serum concentration of ubrogepant. Consider therapy modification.(Ubrelvy December 2019)

Echinacea drug interactions (more detail)

Adverse Reactions

In reviews and meta-analyses of clinical trials of echinacea in the treatment and prevention of the common cold, the most relevant adverse effects were allergic reactions, facial edema, and mild transient GI complaints.Engebretsen 2015, Karsch-Volk 2014, Schapowal 2015 In trials evaluating echinacea for the treatment of the common cold, equal dropout rates due to adverse events were reported for the control and treatment arms. In prevention studies, there was a trend toward higher dropout rates due to adverse effects in the treatment arm.Karsch-Volk 2014

Echinacea should be used with caution in individuals with hypersensitivity to ragweed, chrysanthemum, marigold, daisies, or related allergens.Barnes 2005, Blumenthal 1998, Maskatia 2010

A case report of leukopenia, possibly caused by long-term use of echinacea, has been published.Kemp 2002

There is debate regarding echinacea use in patients with autoimmune disorders. Until this issue is clarified, echinacea should not be used in any condition potentially affected by immune stimulation or suppression, such as HIV, tuberculosis, multiple sclerosis, rheumatoid arthritis, psoriasis, inflammatory bowel disease, and use of immunosuppressive agents.Barnes 2005, Tsai 2012 One case report describes potential activation of autoimmune disease (Sjogren syndrome) with echinacea use.Logan 2003

Individuals with hepatic impairment should use echinacea with caution.Tsai 2012 Acute cholestatic hepatitis likely associated with echinacea root tablets (600 mg/day for 5 days) was reported in a 44-year-old healthy Greek male. Possible product adulteration was not evaluated.Gabranis 2015 In a study of patients with advanced gastric cancer, an association between use of IV E. purpurea extract and the deaths of 2 patients could not be eliminated.Melchart 2002

Echinacea side effects (more detail)

Toxicology

There is little evidence regarding toxicity with echinacea, despite its widespread use. In general, animal studies evaluating different preparations and fractions of Echinacea species have indicated low toxicity.Barnes 2005, Barrett 2003 Echinacea has not been associated with acute or chronic toxic effects.Barnes 2005

Despite low levels of pyrrolizidine alkaloids in echinacea,Duke 2002, WHO 1999 limited case reports describe acute cholestatic hepatitis related to supplementation with echinacea in adults,Gabranis 2015, Kocaman 2008 and acute liver failure was reported in a child after 2 weeks of supplementation (total daily echinacea dose of 100.7 mg).Lawrenson 2014 Patients with hepatic impairment should use echinacea with caution.

High-dose oral and IV administration (ie, several times the standard human therapeutic dose) of the expressed juice of E. purpurea to rodents for 4 weeks produced no short-term, genotoxic, carcinogenic, mutagenic, or other toxic reactions.Mengs 1991 However, an association between the use of IV E. purpurea extract and the deaths of 2 patients with advanced gastric cancer could not be eliminated.Melchart 2002

References

Disclaimer

This information relates to an herbal, vitamin, mineral or other dietary supplement. This product has not been reviewed by the FDA to determine whether it is safe or effective and is not subject to the quality standards and safety information collection standards that are applicable to most prescription drugs. This information should not be used to decide whether or not to take this product. This information does not endorse this product as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this product. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this product. This information is not specific medical advice and does not replace information you receive from your health care provider. You should talk with your health care provider for complete information about the risks and benefits of using this product.

This product may adversely interact with certain health and medical conditions, other prescription and over-the-counter drugs, foods, or other dietary supplements. This product may be unsafe when used before surgery or other medical procedures. It is important to fully inform your doctor about the herbal, vitamins, mineral or any other supplements you are taking before any kind of surgery or medical procedure. With the exception of certain products that are generally recognized as safe in normal quantities, including use of folic acid and prenatal vitamins during pregnancy, this product has not been sufficiently studied to determine whether it is safe to use during pregnancy or nursing or by persons younger than 2 years of age.

Frequently asked questions

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