Butterbur Petasites hybridus

Background:

Butterbur is a perennial shrub, found throughout Europe as well as parts of Asia and North America. It is usually found in wet, marshy ground, in damp forests, and adjacent to rivers or streams. The leaves of the plant are responsible for its botanical and common names. The common name is attributed to the large leaves being used to wrap butter during warm weather.
Butterbur has been traditionally used as an antispasmodic and analgesic (pain reliever), specifically for conditions afflicting the stomach, bile ducts, and duodenum (part of small intestine). Butterbur is believed to help strengthen digestion and improve obstructed bile flow. Butterbur has also been given for inflammation of the urinary tract and cramps. There is compelling initial evidence from human trials to suggest benefits in prevention of migraine headache. Evidence in support of use for allergic rhinitis prevention is also promising. Benefits have not been demonstrated scientifically for any other condition.
Use should be limited to commercially available products free of pyrrolizidine alkaloids that are generally believed to be well-tolerated.

Related Terms:

Blatterdock, bog rhubarb, bogshorns, butcher's rhubarb, butterbur coltsfoot, butterburr, butter-dock, butterdock, butterfly dock, capdockin, coughwort, donnhove, European pestroot, exwort, flapper-bags, flapperdock, fuki, horsehoof, langwort, paddy's rhubarb, pestwurz, Petadolex®, Petadolor H, Petaforce®, petasites, petasites flower, petasites leaf, petasites rhizome, Petasitidis hybridus, Petasites officinalis, Petasites ovatus, Petasites vulgaris, petasitidis folium (flower), petasitidis rhizoma (rhizome), plaguewort, purple butterbur, sweet coltsfoot, Tesalin®, Tussilago farfara, Tussilago hybrida, Tussilago petasites, umbrella leaves, umbrella plant, western coltsfoot, wild rhubarb, ZE 339.

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*
Allergic rhinitis prevention Comparisons of butterbur to prescription drugs such as fexofenadine (Allegra®) and cetirizine (Zyrtec®) have reported similar efficacy. These results suggest benefits of butterbur for prevention of allergic rhinitis. Additional study is warranted before a strong recommendation can be made.	B
Migraine prophylaxis Pain relief and headache prevention are traditional uses of butterbur. Current, available evidence is compelling enough to suggest benefits of butterbur for migraine prevention, although additional evidence is necessary before a strong recommendation can be made. Comparisons to other agents used for this purpose such as beta-blockers or feverfew have not been conducted.	B
Allergic skin disease There is limited human evidence in this area, although preliminary research suggests that butterbur may not suppress allergic skin reactions when compared to the prescription drug fexofenadine (Allegra®), which does suppress these reactions. Additional study is needed.	C
Asthma Butterbur was used historically to treat asthma, and initial human research suggests possible benefits. However, additional study is needed to make a firm recommendation.	C

Dosing:

Adults (18 years and older)

Studies have reported safety and good tolerability of commercially available butterbur products (which are free of potentially carcinogenic pyrrolizidine alkaloid constituents), when used orally in recommended doses for up to 12-16 weeks.
For allergic rhinitis, 50 milligrams of standardized butterbur (Petadolex®, standardized to contain 7.5 milligrams of petasin and isopetasin per 50-milligrams tablet) has been used twice daily. A large study used one tablet of carbon dioxide extract standardized to 8.0 milligrams of total petasin per tablet (Tesalin®), taken four times daily, while a smaller study reported that 2 standardized tablets taken three times daily was effective.
Dosing for asthma is undefined due to a lack of evidence. However, 50 milligrams of standardized butterbur (Petaforce®), administered in two divided daily doses, in patients maintained on inhaled corticosteroids has been used. Petadolex® 150 milligrams daily in three divided daily doses for 2-4 months has also been studied.
For migraine prophylaxis, 50-75 milligrams Petadolex® twice daily for up to four months has been studied. One study suggested that the 75-milligram dose but not the 50-milligram dose is effective.

Children (younger than 18 years)

For asthma, 50-150 milligrams daily (depending on age) of a pyrrolizidine-free butterbur rhizome extract standardized to 7.5 milligrams of petasin and isopetasin per 50-milligram tablet (Petadolex®) may be effective. However, due to a lack of safety and efficacy data, butterbur cannot be recommended for this or any other use in children at this time.

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

Avoid in individuals with a known allergy or hypersensitivity to Petasites hybridus or other plants from the Asteraceae/Compositae family such as ragweed, marigolds, daisies, and chrysanthemums.

Side Effects and Warnings

Studies have reported safety and good tolerability of commercially available butterbur products (which are free of potentially carcinogenic pyrrolizidine alkaloid constituents), when used orally in recommended doses short-term. Raw, unprocessed butterbur plant should not be ingested due to the potential hepatotoxicity (liver damaging) of pyrrolizidine alkaloids with long-term use (specifically, concern of veno-occlusive disease). This includes any teas, capsules of raw herb, or unprocessed tinctures or extracts. Use should be limited to commercially available products that are free of pyrrolizidine alkaloids. The plant's pyrrolizidine alkaloids are also thought to be carcinogenic (cancer causing), mutagenic, and nephrotoxic (kidney damaging).
When taken by mouth, butterbur may cause headache, drowsiness, fatigue, itchy eyes, eye discoloration, breathing difficulties, skin discoloration or pruritis (severe itching).
Butterbur taken by mouth may also cause sustained constipation, discoloration of stool, dysphagia (difficulty swallowing), severe nausea, vomiting, diarrhea, or stomach upset. Butterbur may increase liver enzyme levels.

Pregnancy and Breastfeeding

Butterbur (Petasites hybridus) is not recommended in women who are pregnant or breastfeeding due to a lack of safety studies.

Interactions:

Interactions with Drugs

Administration of butterbur with anticholinergics may not be advisable. Numerous drugs and drug classes may interact with anticholinergic agents. Examples include: acetophenenazine, amantadine, amitriptyline, atropine, benztropine, bethanechol, biperiden, brompheniramine, carbinoxamine, chlorpromazine, clemastine, clindinium, clozapine, cyclopentolate, cyproheptadine, dicyclomine, diphenhydramine, dixyrazine, ethopropazine, fenotherol, fluphenazine, haloperidol, homatropine, hyosciamine, ipratropium, loxapine, mesoridazine, methdilazine, methotrimeprazine, olanzapine, oxybutynin, perazine, periciazine, perphenazine, pimozide, pipotiazine, prochlorperazine, procyclidine, promazine, promethazine, propiomazine, quinidine, scopolamine, thiethylperazine, thioridazine, thiothixene, trifluoperazine, triflupromazine, trihexyphenidyl, trimeprazine, triprolidine. Consult with a qualified healthcare professional, including a pharmacist, before taking butterbur preparations.

Interactions with Herbs and Dietary Supplements

Raw, unprocessed butterbur may contain toxic pyrrolizidine alkaloids, although commercially available products should be free of pyrrolizidine alkaloids. Nonetheless, concomitant use of other agents containing pyrrolizidine alkaloids should be avoided due to the potential for additive toxicity.
Combination use with anticholinergic agents may potentiate therapeutic and adverse effects. Examples of anticholinergic herbs include belladonna, bittersweet (Solanum dulcamara), henbane (Hyoscyamus niger), and Jimson weed (Datura stramonium).

Attribution:

This information is based on a systematic review of scientific literature, and was peer-reviewed and edited by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com): Ethan Basch, MD (Memorial Sloan-Kettering Cancer Center); Mary Giles, PharmD (University of Rhode Island); Christine Park, PharmD (Northeastern University); Karta Purkh Singh Khalsa, CDN, RH (Bastyr University); Catherine DeFranco Kirkwood, MPH, CCCJS-MAC (MD Anderson Cancer Center); Shaina Tanguay-Colucci, BS (Natural Standard Research Collaboration); Catherine Ulbricht, PharmD (Massachusetts General Hospital); Wendy Weissner, BA (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.

Brattstrom A. A newly developed extract (Ze 339) from butterbur (Petasites hybridus L.) is clinically efficient in allergic rhinitis (hay fever). Phytomedicine 2003;10 Suppl 4:50-52.
Danesch U, Rittinghausen R. Safety of a patented special butterbur root extract for migraine prevention. Headache 2003;43(1):76-78.
Danesch UC. Petasites hybridus (Butterbur root) extract in the treatment of asthma--an open trial. Altern Med Rev 2004;9(1):54-62.
Diener HC, Rahlfs VW, Danesch U. The first placebo-controlled trial of a special butterbur root extract for the prevention of migraine: reanalysis of efficacy criteria. Eur Neurol 2004;51(2):89-97.
Fiebich BL, Grozdeva M, Hess S, et al. Petasites hybridus extracts in vitro inhibit COX-2 and PGE2 release by direct interaction with the enzyme and by preventing p42/44 MAP kinase activation in rat primary microglial cells. Planta Med 2005;71(1):12-19.
Gray RD, Haggart K, Lee DK, et al. Effects of butterbur treatment in intermittent allergic rhinitis: a placebo-controlled evaluation. Ann Allergy Asthma Immunol 2004;93(1):56-60.
Grossman W, Schmidramsl H. An extract of Petasites hybridus is effective in the prophylaxis of migraine. Altern Med Rev 2001;6(3):303-310.
Grossmann M, Schmidramsl H. An extract of Petasites hybridus is effective in the prophylaxis of migraine. Int J Clin Pharmacol Ther 2000;38(9):430-435.
Jackson CM, Lee DK, Lipworth BJ. The effects of butterbur on the histamine and allergen cutaneous response. Ann Allergy Asthma Immunol 2004;92(2):250-254.
Lee DK, Carstairs IJ, Haggart K, et al. Butterbur, a herbal remedy, attenuates adenosine monophosphate induced nasal responsiveness in seasonal allergic rhinitis. Clin Exp Allergy 2003;33(7):882-886.
Lee DK, Gray RD, Robb FM, et al. A placebo-controlled evaluation of butterbur and fexofenadine on objective and subjective outcomes in perennial allergic rhinitis. Clin Exp Allergy 2004;34(4):646-649.
Lee DK, Haggart K, Robb FM, et al. Butterbur, a herbal remedy, confers complementary anti-inflammatory activity in asthmatic patients receiving inhaled corticosteroids. Clin Exp Allergy 2004;34(1):110-114.
Lipton RB, Gobel H, Einhaupl KM, et al. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology 2004;63(12):2240-2244.
Schapowal A. Randomised controlled trial of butterbur and cetirizine for treating seasonal allergic rhinitis. BMJ 2002;324(7330):144-146.
Thomet OA, Schapowal A, Heinisch IV, et al. Anti-inflammatory activity of an extract of Petasites hybridus in allergic rhinitis. Int Immunopharmacol 2002;2(7):997-1006.

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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