Efficacy and safety of a colostrum- and Aloe vera-based oral care protocol to prevent and treat severe oral mucositis in patients undergoing hematopoietic stem cell transplantation: a single-arm phase II study

Oral mucositis is one of the worst effects of the conditioning regimens given to patients undergoing hematopoietic stem cell transplantation. It is characterized by dry mouth, erythema, mucosal soreness, ulcers, and pain, and it may impact patient outcomes. Bovine colostrum and Aloe vera contain a wide variety of biologically active compounds that promote mucosal healing. A non-randomized phase II study was designed to assess the safety and efficacy of a combined bovine colostrum and Aloe vera oral care protocol to prevent and to treat severe oral mucositis in transplant patients. Two commercially available products were given to patients in addition to the standard protocol: Remargin Colostrum OS® mouthwash and Remargin Colostrum Gastro-Gel® taken orally. Forty-six (78.0%) patients experienced oral mucositis, 40 (67.8%) developed mild-moderate forms, and 6 (10.2%) severe ones. Comparing the study group's outcomes with those of a homogeneous historical control group, severe oral mucositis decreased significantly (10.2% vs. 28.4%; P < 0.01), as did its duration (0.5 ± 1.9 vs. 1.5 ± 3.0 days; P < 0.01). Febrile neutropenia episodes (69.5% vs. 95.1%; P < 0.01) and duration (4.0 ± 4.7 vs. 6.2 ± 4.5 days; P < 0.01) also decreased. These findings show that the experimental protocol seems effective in preventing severe forms of oral mucositis. However, a randomized controlled trial is necessary to confirm this.

Oesophageal ulcer due to a herbal remedy

Herbal-induced oesophageal lesions are rare. We report the case of an 85-year-old male who presented with cough and odynophagia. An upper endoscopy showed white deposit under the proximal oesophageal sphincter. Biopsy of the lesion revealed an oesophageal ulcer with adherent plant material and ruled-out candidiasis. At this point, the patient divulged self-preparation of an herbal remedy consisting of Aloe Vera pulp, whisky, honey, ginger and turmeric. Aloe Vera, ginger and turmeric are commonly used to sooth some gastroenterological symptoms in Complementary and Alternative Medicine. Incorrect extraction of Aloe Vera pulp and adding honey to it transformed the recipe into a sticky paste that may have injured the oesophageal mucosa. Follow-up showed that the cough and odynophagia subsided after discontinuing this herbal remedy.

Review of the efficacy of green tea, isoflavones and aloe vera supplements based on randomised controlled trials

We assess the evidence for health benefits of three commonly consumed plant food supplements (PFS), green tea, isoflavone and aloe vera, based on published systematic reviews of randomised controlled trials (RCTs). Whilst the potential benefits of green tea have been reported in a wide range of health areas, it is only in the area of the metabolic syndrome that the number of RCTs is approaching sufficient to judge such efficacy. Isoflavone supplements are widely used, and RCTs indicate that they affect bone resorption at lower doses in postmenopausal women undergoing estrogen-related bone loss, but this is only translated to attenuation of bone loss at higher doses of isoflavones. A systematic review on RCTs concluded that the effects of isoflavones on hot flashes in postmenopausal women were highly variable and no conclusions could be drawn. Despite the popularity of aloe vera as a PFS, the evaluation of its efficacy as a coadjuvant therapy for certain metabolic or digestive pathologies remains scarce; it constitutes a typical example of a naturally occurring ingredient whose efficacy in topical applications presupposes its efficacy in systemic applications. Nevertheless, its possible toxic effects on oral consumption call for caution in its utility as a PFS. Since 2007, efficacy evaluation of PFS in Europe has been covered by European Union Nutrition and Health Claims legislation. The European Food Safety Authority has adopted an approach relying on RCTs, while medicinal effects are accepted based on traditional use. In general, there are insufficient RCTs for claims to be made, and conclusive results on PFS should be obtained in the future by conducting studies with more homogeneous populations, by using supplements with optimised and measured bioavailability, and by conducting larger RCTs.

Aloe-induced toxic hepatitis

Aloe has been widely used in phytomedicine. Phytomedicine describes aloe as a herb which has anti-inflammatory, anti-proliferative, anti-aging effects. In recent years several cases of aloe-induced hepatotoxicity were reported. But its pharmacokinetics and toxicity are poorly described in the literature. Here we report three cases with aloe-induced toxic hepatitis. A 57-yr-old woman, a 62-yr-old woman and a 55-yr-old woman were admitted to the hospital for acute hepatitis. They had taken aloe preparation for months. Their clinical manifestation, laboratory findings and histologic findings met diagnostic criteria (RUCAM scale) of toxic hepatitis. Upon discontinuation of the oral aloe preparations, liver enzymes returned to normal level. Aloe should be considered as a causative agent in hepatotoxicity.

Estimation of tolerable upper intake level (UL) of active aloe

It has been reported that an active aloe polysaccharide isolated from Aloe barbadensis Miller exerted various pharmacological effects, such as anti-inflammatory, wound healing, anti-hepatitis, anti-gastric ulcer, and anti-tumorigenicity in animals. Adverse health effects of aloe are of concern in humans. Therefore, this study was conducted to investigate a tolerable upper intake level (UL) of active aloe or a maximal allowable daily intake (ADImax) of active aloe based on 4-wk oral toxicity investigation in ICR mice. An active aloe was daily administered to male and female ICR mice for 4 wk at different dose levels (0, 120, 600, 3000, or 15,000 mg/kg body weight [bw]). All animals were sacrificed at the end of the experiment and changes of body weight, food consumption, organ weights, and hematological and biochemical parameters were recorded. In this study, no changes in clinical signs, urinalysis, or hematological or biochemical analysis were observed. In females, a dose-dependent quantitative decrease in albumin (ALB) levels was observed, but it was not significant, due to wide interindividual variations. A significant decrease in male kidney weight was observed from the 120-mg/kg to the 15,000-mg/kg bw treatment groups, and blood urea nitrogen (BUN) levels were also quantitatively lower. A dose-dependent reduction in the body weight of females was also observed, which might be related to less food consumption. Based on the reduced kidney weights in males, the lowest-observed-adverse-effect level (LOAEL) of an active aloe was estimated to be 120 mg/kg bw in male ICR mice, and the UL or ADImax was 0.4 mg/kg bw/d [(120 mg/kg bw/d)/(100 for safety factor) x (3 for modifying factor)], or 24 mg for a 60-kg adult (24 mg x 200 = 4.8 g of aloe gel/d/adult), assuming that consumers utilize active aloe for a month. Data showed that an active aloe did not induce any remarkable subacute toxic effects, but decreased male kidney weights, which requires further investigation.

Allergic contact dermatitis to Aloe vera

We present the case of a 72-year-old woman observed for dermatitis on the legs followed by apperance of erythema on the eyelids. She had a past history of peripheral venous insufficiency and had been using self home-made Aloe vera juice over the legs for relief from pain. Patch tests showed positive reactions to the leaf of Aloe, the macerated Aloe jelly, and nickel sulfate. Although most manufacturers process Aloe products avoiding its irritant extracts, and probably as a consequence reports of allergic reactions are rare, one must remember that the growing popularity on the use of Aloe products may stimulate its use 'as is' by the patients. Furthermore, it is important to specifically ask patients about the use of these products, because they consider it as innocuous and thus would not spontaneously provide such information.

Oral aloe vera-induced hepatitis

OBJECTIVE

To report a case of possible oral aloe vera-induced hepatitis.

CASE SUMMARY

A 73-year-old female was admitted to the hospital for acute hepatitis. Extensive laboratory testing did not reveal the cause of the patient's disease. She was asked multiple times whether she was taking any home medications, which she initially denied. It was only after an extensive medication history done by a clinical pharmacist that the patient admitted to using oral aloe vera capsules for constipation. Upon discontinuation of the oral aloe vera, liver markers of hepatotoxicity returned to normal levels.

DISCUSSION

Herbal medications pose an increasing problem in patient safety, as the different types of these products and the number of patients who use them continue to grow. In the US, these products are not subject to the same regulatory scrutiny as prescription medications; thus, safety information can be difficult to obtain. In particular, hepatic toxicity due to herbal agents is poorly described in the medical literature. Aloe vera, often used topically for minor burns, can also be used orally as a laxative or an "anti-aging" agent. According to the Naranjo probability scale, the hepatotoxicity in this case was possibly related to ingestion of oral aloe vera. Additionally, using the Roussel Uclaf Causality Assessment Method for determining drug hepatotoxicity, the patient's symptoms were scored as probably caused by oral aloe vera. The more conservative designation was used in our report.

CONCLUSIONS

With the widespread use of oral aloe vera and other herbal products, clinicians faced with a case of acute hepatitis that is not readily diagnosed should question patients about herbal use.

Are aloe-coated gloves effective in healthcare?

The moisturising properties of aloe vera have long been known. Examination gloves with aloe coatings are now available on the UK market for use in healthcare settings. This article examines the evidence surrounding the use of these gloves in the workplace to prevent dry, sore hands.

Possible interaction between sevoflurane and Aloe vera

OBJECTIVE

To describe a patient with massive intraoperative bleeding after oral consumption of Aloe vera tablets.

CASE SUMMARY

A 35-year-old woman lost 5 L of blood during surgery as a result of a possible herb-drug interaction between Aloe vera and sevoflurane.

DISCUSSION

Aloe vera is a common herb used for antiinflammatory and antiarthritic activity, as well as antibacterial, hypoglycemic, and lipid-lowering effects. Compounds contained within Aloe vera can cause a reduction in prostaglandin synthesis, which may inhibit secondary aggregation of platelets. Sevoflurane inhibits thromboxane A(2) formation by suppression of cyclooxygenase activity, impairs platelet aggregation, and prolongs bleeding. Although the vascularity and size of the hemangioma were the most important factors for the massive intraoperative blood loss, concomitant use of sevoflurane and Aloe vera played a contributory role. An objective causality assessment revealed that this adverse event was possible as a result of the sevoflurane and Aloe vera interaction.

CONCLUSIONS

There is a potential herb-drug interaction between Aloe vera and sevoflurane based on the antiplatelet effects of these 2 agents. Herbal medications with antiplatelet potential should be discontinued before anesthesia and surgery.

The influence of long-term Aloe vera ingestion on age-related disease in male Fischer 344 rats

The effects of long-term Aloe vera ingestion on age-related diseases were investigated using male specific pathogen-free (SPF) Fischer 344 rats. Experimental animals were divided into four groups: Group A, the control rats fed a semi-synthetic diet without Aloe vera; Group B, rats fed a diet containing 1% freeze-dried Aloe vera filet; Group C, rats fed a diet containing 1% charcoal-processed, freeze-dried Aloe vera filet; and Group D, rats fed the control diet and given whole leaf charcoal-processed Aloe vera (0.02%) in the drinking water. This study demonstrates that life-long Aloe vera ingestion produced neither harmful effects nor deleterious changes. In addition, Aloe vera ingestion appeared to be associated with some beneficial effects on age-related diseases. Groups B exhibited significantly less occurrence of multiple causes of death, and a slightly lower incidence of fatal chronic nephropathy compared with Group A rats. Groups B and C rats showed the trend, slightly lower incidences of thrombosis in the cardiac atrium than Group A rats. Therefore, these findings suggest that life-long Aloe vera ingestion does not cause any obvious harmful and deleterious side effects, and could also be beneficial for the prevention of age-related pathology.

Herbal remedy-associated acute renal failure secondary to Cape aloes

Use of traditional herbal remedies is common in Africa, and many patients who visit traditional healers do not need to resort to Western medicine. Acute renal failure is one of the most serious complications resulting from the use of traditional remedies, however, which accounts for 35% of all cases of acute renal failure in Africa. Traditional remedies rarely have been analyzed, and little is known about their nephrotoxicity. We report a case of a 47-year-old man from Soweto, South Africa, who developed acute oliguric renal failure and liver dysfunction after ingestion of an herbal remedy. The patient's renal function recovered slowly, and dialysis was discontinued after several weeks, although serum creatinine did not return to the normal range. Mass spectrometric and chromatographic analysis of the herbal remedy used by the patient revealed the presence of Cape aloes, a previously described nephrotoxin.

Aloe vera leaf gel: a review update

Research since the 1986 review has largely upheld the therapeutic claims made in the earlier papers and indeed extended them into other areas. Treatment of inflammation is still the key effect for most types of healing but it is now realized that this is a complex process and that many of its constituent processes may be addressed in different ways by different gel components. A common theme running though much recent research is the immunomodulatory properties of the gel polysaccharides, especially the acetylated mannans from Aloe vera, which are now a proprietary substance covered by many patents. There have also been, however, persistent reports of active glycoprotein fractions from both Aloe vera and Aloe arborescens. There are also cautionary investigations warning of possible allergic effects on some patients. Reports also describe antidiabetic, anticancer and antibiotic activities, so we may expect to see a widening use of aloe gel. Several reputable suppliers produce a stabilized aloe gel for use as itself or in formulations and there may be moves towards isolating and eventually providing verified active ingredients in dosable quantities

The role of nitric oxide in aloe-induced diarrhoea in the rat

The role of nitric oxide (NO) on aloe-induced diarrhoea was studied in the rat. Nine hours after oral administration, aloe produced diarrhoea at doses of 5 g kg(-1)(20% rats with diarrhoea) and 20 g kg(-1) (100% of rats with diarrhoea). Lower doses of aloe (0.1 and 1 g kg(-1) did not produce a diarrhoeal response. Pre-treatment (i.p.) of rats with the NO synthase inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME 2.5-25 mg kg(-1) reduced the diarrhoea induced by aloe (20 g kg(-1) 9 h after its oral administration. L-NAME (25 mg kg(-1)) also reduced the increase in faecal water excretion produced by aloe (20 g kg(-1). L-arginine (1500 mg kg(-1), i.p.), administered to rats pre-treated with L-NAME (25 mg kg(-1), drastically reduced the effect of L-NAME on diarrhoea and increase in faecal water excretion induced by aloe (20 g kg(-1). Given alone, L-arginine did not modify aloe-induced diarrhoea. Basal Ca2+ -dependent NO synthase activity in the rat colon was dose-dependently inhibited by aloe (0.1-20 g kg(-1)) and by aloin (0.1-1 g kg(-1)), the active ingredient of aloe. These results suggest that endogenous NO modulates the diarrhoeal effect of aloe.