Scientific Name(s): Plantago lanceolata L., P. major L., P. psyllium L., P. arenaria Waldst. & Kit. ( P. ramosa Asch.) (Spanish or French psyllium seed), P. ovata Forsk. (Blond or Indian plantago seed). Family: Plantaginaceae. (Not to be confused with Musa paradisiacae , or edible plantain.)
Common Name(s): Plantain , Spanish psyllium , French psyllium , blond plantago , Indian plantago , psyllium seed , flea seed , black psyllium .
The psyllium in plantain has been used as GI therapy, to treat hyperlipidemia for anticancer effects, respiratory treatment, and other uses.
Plantain leaves have been given as a tea for cold and cough at 3 to 6 g/day.
Contraindications have not yet been identified.
Documented adverse effects. Avoid use. Uterine activity, laxative.
Patients taking lithium or carbamazepine should avoid coadministration of plantain. Caution patients receiving lithium or carbamazepine to consult their health care provider before using herbal products.
Adverse events include anaphylaxis, chest congestion, sneezing and watery eyes, occupational asthma, and a situation involving the occurrence of a giant phytobezoar composed of psyllium seed husks.
The pollen contains allergenic glycoproteins that react with concanavalin A, as well as components that bind IgE. IgE antibodies have been demonstrated. The IgE-mediated sensitization has contributes to seasonal allergy.
Plantain is a perennial weed with almost worldwide distribution. There are about 250 species, of which 20 have wide geographic ranges, 9 have discontinuous ranges, 200 are limited to one region, and 9 have very narrow ranges. P. lanceolata and P. major are among the most widely distributed. 1 Plantain species are herbs and shrubby plants characterized by basal leaves and inconspicuous flowers in heads or spikes. They grow aggressively. Plantain is wind-pollinated, facilitating its growth where there are no bees and few other plantain plants. It is very tolerant of viral infections. P. major produces 13,000 to 15,000 seeds per plant, and the seeds have been reported to remain viable in soil for up to 60 years. P. lanceolata produces 2500 to 10,000 seeds per plant and has a somewhat shorter seed viability. Plantain seeds can survive passage through the gut of birds and other animals, facilitating their distribution. 1 Plantain, or psyllium seeds, are small (1.5 to 3.5 mm), oval, boat-shaped, dark reddish-brown, odorless and nearly tasteless. They are coated with mucilage, which aids in their transportation by allowing adhesion to various surfaces. 1 , 2
Plantain has long been associated with man and with agriculture. Certain species have been spread by human colonization, particularly that of Europeans. As such, North American Indians and New Zealand Maori refer to plantain as “Englishman's foot,'' because it spread from areas of English settlement. P. lanceolata and P. major have been used in herbal remedies and were sometimes carried to colonies intentionally for that purpose. Psyllium seed has been found in malt refuse (formerly used as fertilizer) and wool imported to England. It has been commonly used in birdseed. 1 Pulverized seeds are mixed with oil and applied topically to inflamed sites; decoctions have been mixed with honey for sore throats. The seeds and refined colloid are used commonly in commercial bulk laxative preparations. 1 , 3
Plantain constituents include acids (eg, benzoic, caffeic, chlorogenic, cinnamic, p-coumaric, fumaric, salicylic, ursolic, vanillic, ascorbic), alkaloids (boschniakine) and amino acids (eg, alanine, asparagine, histidine, lysine). 4 An analysis of 8 of 21 Egyptian species of plantain, including P. major , has identified a variety of sugar and polysaccharide components of the seed mucilage. These include galactose, glucose, xylose, arabinose, and rhamnose. In addition, galacturonic acid, planteose, plantiobiose, sucrose, fructose have been identified. 5 Other plant carbohydrates such as saccharose, stachyose, sorbitol and tyrosol have also been reported. 4 The mucilage of the seed's testa epidermis constitutes 20% to 30%. 2 Seed mucilage of one species, P. ovata was found to have better suspending and emulsifying power compared to tragacanth and methylcellulose. 6 Leaf mucilage has been reported as well and includes polysaccharides containing rhamnose, L-arabinose, mannose, galactose and dextrose. 7 The seeds also contain fixed oil, protein, iridoids and tannins. 2 , 3 The gel-forming fraction of the seed was found to be effective in prolonging release rates of tetracycline in vitro. 8
Iridoids found in plantain are aucubin, plantarenaloside and aucuboside. 4 The main iridoids aucubin and catalpol, have been isolated from P. lanceolata , P. major and P. media leaves using HPLC analysis. 10 Iridoid glycosides and phenolic acids have been found in leaf extracts of P. lanceolata and P. media . 11
Uses and Pharmacology
The pharmacology of plantain involves gastrointestinal tract therapy, hyperlipidemia treatment, anticancer effects, respiratory and other actions.GI
Psyllium seed is classified as a bulk laxative. Mixed with water, it produces a mucilaginous mass. The indigestible seeds provide bulk for treatment of chronic constipation, while the mucilage serves as a mild laxative comparable to agar or mineral oil. The usual dose is 0.5 to 2 g of husk (5 to 15 g of seeds) mixed in 8 oz of water.Animal data
Research reveals no animal data regarding the use of plantain for GI therapy.Clinical data
A study of 10 healthy volunteers examined the effects of a 3 g ispaghula mixture (dried psyllium seed husks) given three times daily. It decreased intestinal transit time. 15 Effectiveness of psyllium seed on 78 subjects with irritable bowel syndrome (IBS) has been reported. 16 P. ovata fiber is also effective in regulating colon motility in a similar set of patients. 17 A postcholecystectomy patient with chronic diarrhea was given a 6.5 g dose of a 50% psyllium preparation, and symptoms resolved in 2 days. 18 , 19 Plantago seed as a cellulose/pectin mixture was as effective as a bulk laxative in 50 adult subjects. 20 The effects of different dietary fibers on colonic function, including plantago seed have been evaluated. 21 Gastroprotective action from plantago extract (polyholozidic substances) has also been reported. 22
In a triple-blind, crossover study of 17 female patients, P. ovata seed preparation was investigated for effects on appetite. The preparation was deemed useful in weight control diets where a feeling of fullness was desired. Total fat intake was also decreased, suggesting the product to be a beneficial weight control diet supplement. 23
A trial involving 393 patients with anal fissures found conservative treatment with psyllium effective. After 5 years of follow-up, 44% of the patients were cured without surgery within 4 to 8 weeks. There were complications (abscesses and fistulas requiring surgery) in 8% of the cases. The recurrence rate was 27%, but about one third of these were fistulas that responded to further conservative management. 24
A double-blind study of 51 patients with symptomatic hemorrhoids showed Vi-Siblin , a psyllium-containing preparation, to be effective in reducing bleeding and pain during defecation: 84% of the patients receiving the preparation reported improvement or elimination of symptoms, compared to 52% taking placebo. 25Hyperlipidemia
Many reports on psyllium have concluded that it can be helpful in treating various hyperlipidemias. 26 , 27 Issues of cereal companies including plantago seed in their products and claims of cholesterol reduction, have been addressed. 28 A polyphenolic compound from P. major leaves was found to exhibit hypocholesterolemic activity, 29 but in addition, the mechanism by which plantago reduces cholesterol may also include enhancement of cholesterol elimination as fecal bile acids. 30Animal data
In animal studies, plantain lowered total plasma lipids, cholesterol and triglycerides in arteriosclerotic rabbits. 4 Other animals may be less sensitive to psyllium's hypo- cholesterolemic actions. 31Clinical data
Attention has been focused on the cholesterol-lowering effects of psyllium preparations in human trials. Psyllium hydrophilic mucilloid ( Metamucil , Procter & Gamble ) was found to lower serum cholesterol in a study of 28 patients who took 3 doses (3.4 g/dose) per day compared with placebo for 8 weeks. After 4 weeks, the psyllium-treated patients showed decreases in total serum cholesterol levels compared with the placebo group. Decreases were also seen in LDL cholesterol and the LDL/HDL ratio. At the end of 8 weeks, values for total cholesterol, LDL cholesterol and the LDL/HDL ratio were 14%, 20% and 15%, respectively below baseline (all, P < 0.01). This study suggested that high cholesterol levels could be managed safely and easily by including psyllium preparations in the diet. 32
Similar results of cholesterol reduction have been reported, including: Psyllium colloid administration for 2 to 29 months, reducing cholesterol levels by 16.9% and triglycerides by 52%, 33 a trial of 75 hypercholesterolemic patients, evaluating adjunct therapy of psyllium seed to a low cholesterol diet, 34 a 16–week, double-blind trial, proving plantago seed improved in both total and LDL cholesterol in 37 patients, 35 and increased tolerance of psyllium seed in combination with colestipol (rather than monotherapy alone) in 105 hyperlipidemic patients. 36
Psyllium seed was found to be more effective than P. ovata husk in reducing serum cholesterol in normal and ileostomy patients. 37 A report on 20 hypercholesterolemic pediatric patients on low-fat diets, however, found psyllium seed to be ineffective in lowering cholesterol or LDL levels. 38Anticancer
The antitumor effects of plantain have been studied in animals. The isolate “plantagoside,” from seeds of related species P. asiatica , has been found to suppress immune response in mouse tissue. 39 P. major has also inhibited carcinogen synthesis in induced toxic liver damage and has decreased tumor incidence in rats. 40 In mice given P. major subcutaneous injections, mammary cancer tumor formation frequency was 18%, as compared to 93% with placebo, suggesting prophylactic therapy for cancer of this type. 41 Immunotropic activity of P. lanceolata extract on murine and human lymphatic cells in vivo and in vitro has also been demonstrated. 42Clinical data
Research reveals no information regarding the use of plantain as an anticancer agent.Respiratory
An aqueous extract of plantain may possess bronchodilatory activity in guinea pigs; however, it is less active and of shorter duration than salbutamol or atropine. 4Clinical data
A report by a physician described the topical use of crushed plantain leaves to treat poison ivy in 10 people. Although the trial was not conducted scientifically, the treatment eliminated itching and prevented spread of the dermatitis in all cases, one to four applications being required. 43 Fresh leaves of the plant have been poulticed onto herpes sores, ulcers, boils and infections. Plantain has been used for insect bites and gout. 3 Leaf extracts have wound healing activity in rabbits, which was associated with the chlorogenic and neochlorogenic acid content. 4
Plantain oils may exhibit therapeutic action on chemical burns of rabbit eyes. 44
Aqueous extracts of plantain leaves possess antimicrobial activity caused by aglycone and aucubigenin. 2
Aerial parts of plantago have been used as an anti-inflammatory and as a diuretic in folk medicine. 45 A report on P. lanceolata 's phenylethanoids, acteoside and plantamajoside have been evaluated for inhibitory effects on arachidonic acid-induced mouse ear edema. 46 Plantain extract has decreased arterial blood pressure by 20 to 40 mm Hg in normotensive dogs. 4 Reports such as these and others may help support plantain's use in folk medicine.
Psyllium administration had no effect on postprandial plasma glucose in one report. 47
Plantain leaves have been given as a tea for cold and cough at 3 to 6 g/day. 48
Documented adverse effects. Avoid use. Uterine activity, laxative. 49
Plantain may decrease the GI absorption of lithium, reducing lithium plasma concentrations and decreasing the pharmacologic effect. Decreased lithium plasma levels were reported in a 47-year-old woman receiving lithium and a bulk-forming laxative, ispaghula husk (ie, plantain, psyllium husk, psyllium hydrophilic mucilloid). 50 Four days after starting lithium treatment and 2 days after starting liquid ispaghula husk, the lithium plasma level was 0.53 mmol/L. Subsequently, the dose of lithium was increased; however, lithium levels continued to decrease. Within 4 days of stopping the ispaghula husk, lithium levels increased.
There are many reported incidences of varying degrees of psyllium allergy including: Nurses experiencing symptoms such as anaphylactoid reaction, chest congestion, sneezing and watery eyes (some of these reactions taking several years to acquire); 51 , 52 a case report describing severe anaphylactic shock following psyllium laxative ingestion, linked occupational respiratory allergies in pharmaceutical workers exposed to the substance; 53 consumption of plantago seed in cereal, responsible for anaphylaxis in a 60-year-old female (immunoglobulin E-mediated sensitization was documented, and patient was successfully treated with oral diphenhydramine); 54 and a report on workers in a psyllium processing plant evaluated for occupational asthma and IgE sensitization to psyllium. 55
Another unusual adverse situation involves the occurrence of a giant phytobezoar composed of psyllium seed husks. The bezoar, located in the right colon, resulted in complete blockage of gastric emptying. 56 All psyllium preparations must be taken with adequate volumes of fluid. The seeds contain a pigment that may be toxic to the kidneys, 14 but this has been removed from most commercial preparations. 57
Plantain pollen has been found to contain at least 16 antigens, of which 6 are potentially allergenic. The pollen contains allergenic glycoproteins that react with concanavalin A, as well as components that bind IgE. 58 Antigenic and allergenic analysis has been performed on psyllium seed. All three fractions, husk, endosperm and embryo, contained similar antigens. 59 Formation of IgE antibodies to psyllium laxative has been demonstrated. 60 In addition, IgE-mediated sensitization to plantain pollen has been performed, contributing to seasonal allergy. 61
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