Bromelain

Classified as an herb, 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.

Synonyms

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

Evidence

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.

Uses based on scientific evidence	Grade^*
Inflammation Several preliminary studies suggest that when taken by mouth, bromelain can reduce inflammation or pain caused by inflammation. Better quality studies are needed to confirm these results.	B
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
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 (OA) In one study of a combination product ERC (enzyme-rutosid combination -rutosid, bromelain, trypsin) results showed that ERC may be considered as an effective and safe alternative to prescription anti-inflammatory drugs (NSAIDs) such as diclofenac in the treatment of painful episodes of OA of the knee. Further well-designed clinical trials of bromelain alone are needed to confirm these results.	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

*Key to grades
A: Strong scientific evidence for this use;
B: Good scientific evidence for this use;
C: Unclear scientific evidence for this use;
D: Fair scientific evidence against this use;
F: Strong scientific evidence against this use.

Grading rationale

The below uses are based on tradition or scientific theories. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Acquired immune deficiency syndrome (AIDS), acute lateral ankle sprain, allergic rhinitis (hay fever), amyloidosis, angina, appetite suppressant, anthelmintic effects. atherosclerosis ("hardening" of the arteries), autoimmune disorders, back pain, blood clot treatment, bronchitis, bruises, bursitis, cancer prevention, carpal tunnel syndrome, cellulitis/skin infections, colitis, common cold, cough, diarrhea, epididymitis, episiotomy pain (after childbirth), food allergies, food lodged in the esophagus, frostbite, gout, heart disease, hemorrhoids, immune system regulation, antibiotic absorption problems in the gut, infections, indigestion, injuries, joint disease, "leaky gut" syndrome, menstrual pain, pain (general), pancreatic problems with food digestion, Peyronie's disease (abnormal curvature, pain, and scar tissue in the penis), platelet inhibition (blood thinner), pneumonia, poor absorption of digested food, poor blood circulation in the legs, upper respiratory tract infection, sciatica, scleroderma, shingles pain/post-herpetic neuralgia, shortening of labor, smooth muscle relaxation, sports or other physical injuries, staphylococcal bacterial infections, stimulation of muscle contractions, stomach ulcer/stomach ulcer prevention, swelling (after surgery or injury), tendonitis, thick mucus, thrombophlebitis, treatment of scar tissue, ulcerative colitis, varicose veins, wound healing.

Dosing

The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.

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 a 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

The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.

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

Most herbs and supplements have not been thoroughly tested for interactions with other herbs, supplements, drugs, or foods. The interactions listed below are based on reports in scientific publications, laboratory experiments, or traditional use. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy.

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 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 , fewer cases with garlic, and less cases with saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases.