Bromelain Ananas comosus Ananas sativus

Background:

Bromelain is a sulfur-containing proteolytic digestive enzyme that is extracted from the stem and the fruit of the pineapple plant (Ananas comosus, family Bromeliaceae).
When taken with meals, bromelain is believed to assist in the digestion of proteins. When taken on an empty stomach, it is believed to act medicinally as an anti-inflammatory agent.
The expert panel, the German Commission E, approved bromelain for the treatment of swelling/inflammation of the nose and sinuses caused by injuries and surgery in 1993.

Related Terms:

Ananas comosus, Ananas sativus, Ananase®, Bromelain-POS, bromeline (pleural), Bromelainum, Bromeliaceae (family), Bromelin, Bromelins, Debridase, Phlogenzym (rutoside, bromelain, and trypsin), enzyme-rutosid combination, ERC (rutosid, bromelain, trypsin), plant protease concentrate, pineapple, pineapple extract, rutosid, Traumanase®, trypsin.

Evidence Table:

These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.	Grade*
Sinusitis (sinus inflammation) It is proposed that bromelain may be a useful addition to other therapies used for sinusitis (such as antibiotics) due to its ability to reduce inflammation/swelling. Studies report mixed results, although overall bromelain appears to be beneficial for reducing swelling and improving breathing. Better studies are needed before a strong recommendation can be made.	B
Burn debridement A bromelain-derived debriding agent, Debridase, has been studied on deep second degree and third degree burns with positive results. Further results are needed to confirm these results.	C
Cancer There is not enough information to recommend for or against the use of bromelain in the treatment of cancer, either alone or in addition to other therapies.	C
Chronic obstructive pulmonary disease (COPD) There is not enough information to recommend for or against the use of bromelain in COPD.	C
Digestive enzyme/pancreatic insufficiency Bromelain is an enzyme with the ability to digest proteins. However, there is little reliable scientific research on whether bromelain is helpful as a digestive aid. Better study is needed before a firm conclusion can be made.	C
Inflammation Several preliminary studies suggest that when taken by mouth, bromelain may reduce inflammation or pain caused by inflammation. Better quality studies are needed to confirm these results.	C
Knee pain Bromelain may reduce mild acute knee pain in a dose-dependent manner.	C
Muscle soreness The effects of bromelain on muscle soreness following intense exercise are unclear.	C
Nutrition supplementation There is not enough information to recommend for or against the use of bromelain as a nutritional supplement.	C
Osteoarthritis of the knee There is conflicting evidence on the effectiveness of bromelain to treat osteoarthritis. Further well-designed clinical trials of bromelain alone are needed to confirm these results.	C
Rash Bromelain may help treat skin rash. This treatment may be effective because bromelain has been shown to decrease inflammation, regulate the immune system, and have antiviral effects.	C
Rheumatoid arthritis (RA) There is not enough information to recommend for or against the use of bromelain in rheumatoid arthritis (RA).	C
Steatorrhea (fatty stools due to poor digestion) There is not enough information to recommend for or against the use of bromelain in the treatment of steatorrhea.	C
Urinary tract infection (UTI) There is not enough information to recommend for or against the use of bromelain in urinary tract infections.	C

Dosing:

Adults (18 years and older)

A variety of doses have been used and studied. Research in the 1960s and 1970s used 120 to 240 milligrams of bromelain concentrate tablets daily (Traumanase® or Ananase®; 2,500 Rorer units per milligram) in three to four divided doses for up to one week to treat inflammation. The German expert panel, the Commission E, has recommended 80 to 320 milligrams (200 to 800 FIP units) taken two to three times per day. Some authors recommend 500 to 1,000 milligrams of bromelain to be taken three times daily, and many manufacturers sell products standardized to 2,000 GDU in 500 milligram tablets. Effects of bromelain may occur at lower doses, and treatment may be started at a low dose and increased as needed.
Cream containing 35% bromelain in an oil-containing base has been applied to the skin to clean wounds.

Children (younger than 18 years)

There is not enough scientific research to recommend safe use of bromelain in children.

Safety:

Many complementary techniques are practiced by healthcare professionals with formal training, in accordance with the standards of national organizations. However, this is not universally the case, and adverse effects are possible. Due to limited research, in some cases only limited safety information is available.

Allergies

There are multiple reports of allergic and asthmatic reactions to bromelain products, including throat swelling and difficulty breathing. Allergic reactions to bromelain may occur in individuals allergic to pineapples or other members of the Bromeliaceae family, and in people who are sensitive/allergic to honeybee venom, latex, birch pollen, carrot, celery, fennel, cypress pollen, grass pollen, papain, rye flour, or wheat flour.

Side Effects and Warnings

Few serious side effects have been reported with the use of bromelain. The most common side effects reported are stomach upset and diarrhea. Other reported reactions include increased heart rate, nausea, vomiting, irritation of mucus membranes, and menstrual problems.
In theory, bromelain may increase the risk of bleeding. Caution is advised in people who have bleeding disorders or who are taking drugs that increase the risk of bleeding. Dosing adjustments may be necessary. Bromelain should be used with caution in people with stomach ulcers, active bleeding, a history of bleeding, taking medications that thin the blood, or prior to some dental or surgical procedures.
Bromelain may increase heart rate at higher doses and should be used cautiously in people with heart disease. Some experts warn against bromelain use by people with liver or kidney disease, although there is limited scientific information in these areas. Bromelain may cause abnormal uterine bleeding or heavy/prolonged menstruation.

Pregnancy and Breastfeeding

Bromelain is not recommended during pregnancy or breastfeeding, as little safety information is available. Bromelain may cause abnormal uterine bleeding.

Interactions:

Interactions with Drugs

In theory, bromelain may increase the risk of bleeding when taken with drugs that increase the risk of bleeding. Some examples include aspirin, anticoagulants ("blood thinners") such as warfarin (Coumadin®) or heparin, anti-platelet drugs such as clopidogrel (Plavix®), and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®). In addition, bromelain theoretically may add to the anti-inflammatory effects of NSAIDs.
Human studies suggest that bromelain may increase the absorption of some antibiotics, notably amoxicillin and tetracycline, and increase the levels of these drugs in the body. Bromelain may increase the actions of the chemotherapy (anti-cancer) drugs 5-fluorouracil and vincristine, although reliable scientific research in this area is lacking. In theory, use of bromelain with blood pressure medications in the "ACE inhibitor" class, such as captopril (Capoten®) or lisinopril (Zestril®), may cause larger drops in blood pressure than expected.
Some experts suggest that bromelain may cause drowsiness or sedation and may increase the amount of drowsiness caused by some drugs. Examples include benzodiazepines such as lorazepam (Ativan®) or diazepam (Valium®), barbiturates such as phenobarbital, narcotics such as codeine, some antidepressants, and alcohol. Caution is advised while driving or operating machinery.
Bromelain may also interact with heartbeat regulating medications, magnesium, and nicotine.

Interactions with Herbs and Dietary Supplements

In theory, bromelain may increase the risk of bleeding when taken with herbs and supplements that are believed to increase the risk of bleeding. Multiple cases of bleeding have been reported with the use of Ginkgo biloba, and fewer cases with garlic and saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases.
Bromelain and the enzyme trypsin are suggested to have stronger anti-inflammatory effects when combined, based on preliminary animal research. It has been suggested that zinc might block the effects of bromelain in the body while magnesium may increase the effects, although scientific research in these areas is lacking.
Bromelain may also interact with herbs and supplements that effect the heart, antibacterials, soy, sedatives, and tobacco.

Attribution:

This information is based on a professional level monograph edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com): Ethan Basch, MD, MSc, MPhil (Memorial Sloan-Kettering Cancer Center); Dawn Costa, BA, BS (Natural Standard Research Collaboration); Cynthia Dacey, PharmD (Northeastern University); Mary McGarry, PharmD (University of Rhode Island); Shaina Tanguay-Colucci, BS (Natural Standard Research Collaboration); Catherine Ulbricht, PharmD (Massachusetts General Hospital); Mamta Vora, PharmD (Northeastern University); Wendy Weissner, BA (Natural Standard Research Collaboration); Jen Woods, BS (Natural Standard Research Collaboration).

References:

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

Balakrishnan V, Hareendran A, Nair CS. Double-blind cross-over trial of an enzyme preparation in pancreatic steatorrhoea. J Assoc Physicians India 1981;29(3):207-209.
Brien S, Lewith G, Walker AF, et al. Bromelain as an adjunctive treatment for moderate-to-severe osteoarthritis of the knee: a randomized placebo-controlled pilot study. QJM. 2006 Dec;99(12):841-50.
Braun JM, Schneider B, Beuth HJ. Therapeutic use, efficiency and safety of the proteolytic pineapple enzyme Bromelain-POS in children with acute sinusitis in Germany. In Vivo 2005;19(2):417-421.
Cirelli MG. Five years of clinical experience with bromelains in therapy of edema and inflammation in postoperative tissue reaction, skin infections and trauma. Clinical Medicine 1967;74(6):55-59.
Cowie DH, Fairweather DV, Newell DJ. A double-blind trial of bromelains as an adjunct to vaginal plastic repair operations. J Obstet Gynaecol Br Commonw 1970;77(4):365-368.
Howat RC, Lewis GD. The effect of bromelain therapy on episiotomy wounds--a double blind controlled clinical trial. J Obstet Gynaecol Br Commonw 1972;79(10):951-953.
Klein G, Kullich W, Schnitker J, et al. Efficacy and tolerance of an oral enzyme combination in painful osteoarthritis of the hip. A double-blind, randomised study comparing oral enzymes with non-steroidal anti-inflammatory drugs. Clin Exp Rheumatol 2006 Jan-Feb;24(1):25-30.
Massimiliano R, Pietro R, Paolo S, et al. Role of bromelain in the treatment of patients with pityriasis lichenoides chronica. J Dermatolog Treat 2007;18(4):219-22.
Mader H. [Comparative studies on the effect of bromelin and oxyphenbutazone in episiotomy pains]. Schweiz Rundsch.Med Prax 8-28-1973;62(35):1064-1068.
Mori S, Ojima Y, Hirose T, et al. The clinical effect of proteolytic enzyme containing bromelain and trypsin on urinary tract infection evaluated by double blind method. Acta Obstet Gynaecol Jpn 1972;19(3):147-153.
Rosenberg L, Lapid O, Bogdanov-Berezovsky A, et al. Safety and efficacy of a proteolytic enzyme for enzymatic burn debridement: a preliminary report. Burns 2004;30(8):843-850.
Ryan RE. A double-blind clinical evaluation of bromelains in the treatment of acute sinusitis. Headache 1967;7(1):13-17.
Seligman B. Oral bromelains as adjuncts in the treatment of acute thrombophlebitis. Angiology 1969;20(1):22-26.
Seltzer AP. Adjunctive use of bromelains in sinusitis: a controlled study. Eye Ear Nose Throat Mon 1967;46(10):1281, 1284, 1286-1288.
Weiss S, Scherrer M. [Crossed double-blind trial of potassium iodide and bromelain (Traumanase) in chronic bronchitis]. Schweiz Rundsch Med Prax 10-24-1972;61(43):1331-1333.

Disclaimer :

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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