Horse chestnut (Aesculus hippocastanum L.)

 
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Horse chestnut
Horse chestnut

Background

Horse chestnut seed extract (HCSE) is widely used in Europe for chronic venous insufficiency (CVI), a syndrome that may include leg swelling, varicose veins, leg pain, itching, and skin ulcers. Although HCSE is traditionally recommended for a variety of medical conditions, CVI is the only condition for which there is strong supportive scientific evidence.

 

Side effects from HCSE have been similar to placebo in clinical trials. However, due an increased risk of low blood sugars, caution is advised in children and people with diabetes.

 

Horse chestnut flower, branch bark, and leaf have not been shown effective for any indication, and it is strongly advised that they be avoided due to known toxicity.

 

Synonyms

Aescin, aescine, aescule, buckeye, bongay, chestnut, conkers, Conquerors, eschilo, escin, escina, escine, fish poison, graine de marronier d'Inde, H. vulgare Gaertnhestekastanje,  Hippocastabi folium ,  Hippocastani semen , horsechestnut, horse chestnut seed extract, HCSE, Marron Europeen, Marronier, NV-101, Rokastaniensamen, rosskastanie, Spanish chestnut, Venastat®, Venoplant®, Venostasin®.

 

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*
Chronic venous insufficiency

Chronic venous insufficiency (CVI) is a condition that is more commonly diagnosed in Europe than in the United States, and may include leg swelling, varicose veins, leg pain, itching, and skin ulcers. There is evidence from laboratory, animal, and human research that horse chestnut seed extract (HCSE) may be beneficial to patients with this condition. Studies report significant decreases in leg size, leg pain, itchiness, fatigue and "tenseness." There is preliminary evidence that HCSE may be as effective as compression stockings.

A

 

*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

Uses based on tradition or theory
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.

Antiangiogenic, benign prostatic hypertrophy (BPH), bladder disorders (incontinence, cystitis), bruising, cough, diarrhea, dizziness, fever, fluid in the lungs (pulmonary edema), gall bladder infection (cholecystitis), gall bladder pain (colic), gall bladder stones (cholelithiasis), hemorrhoids, kidney diseases, leg cramps, liver congestion, lung blood clots (pulmonary embolism), menstrual pain, nerve pain, osteoarthritis, pancreatitis, rectal complaints, rheumatism, rheumatoid arthritis, skin conditions, post-operative/post-traumatic soft tissue swelling, ringing in the ears (tinnitus), ulcers, varicose leg ulcers, vein clots (deep venous thrombosis), whooping cough.

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)
Oral (by mouth): 300 milligrams every 12 hours, for up to 12 weeks (containing 50 to 75 milligrams of escin per dose), has been taken by mouth. A dose of 600 milligrams of chestnut seed extract per day has also been studied.

 

Topical (on the skin): A gel preparation of horse chestnut applied to the skin has been studied for bruising, without clear benefits.

 

Intravenous (through a vein)/intramuscular (injected into a muscle): Severe allergic reaction (anaphylactic shock) has been reported with intravenous use. Horse chestnut leaf has been associated with liver inflammation (hepatitis) after injection into muscle.

 

Children (younger than 18 years)
There is not enough scientific evidence to recommend use of horse chestnut in children. Deaths have been reported in children who ate raw horse chestnut seeds or tea made from horse chestnut leaves and twigs.

 

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.

Allergies
Horse chestnut seed extract (HCSE) may cause an allergic reaction in patients with known allergy to horse chestnuts, esculin, or any of its ingredients (flavonoids, biosides, trisides of quertins, and oligosacharides including 1-ketose and 2-ketose). Anaphylactic shock (severe allergic reaction) has been reported with intravenous (through the vein) use.

 

Side Effects and Warnings
Unprocessed horse chestnut seeds, leaves, bark, and flowers contain esculin, which has been associated with significant toxicity and death. Symptoms found with horse chestnut poisoning may include vomiting, diarrhea, headache, confusion, weakness, muscle twitching, poor coordination, coma or paralysis. Horse chestnut seed extract (HCSE) standardized to escin content should not contain significant levels of esculin, and should not have the same risks.

 

Standardized HCSE is generally considered to be safe in adults at recommended doses for short periods of time. Stomach upset, muscular (calf) spasm, headache, dizziness, nausea and itching have been reported. Contact skin irritation (dermatitis) has been reported following application of HCSE to the skin.

 

Based on animal study, HCSE may cause lowered blood sugar. Caution is advised in patients with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Serum glucose levels may need to be monitored by a qualified healthcare provider, and medication adjustments may be necessary.

 

In theory, horse chestnut may increase the risk of bleeding. Caution is advised in patients with bleeding disorders or taking drugs that may increase the risk of bleeding. Monitoring is recommended and dosing adjustments may be necessary. Liver and kidney toxicity has been associated with horse chestnut. Aflatoxins, considered to be cancer-causing agents, have been identified in commercial skin products containing horse chestnut, but not in HCSE.

 

Pregnancy and Breastfeeding
There is not enough scientific research to recommend the safe use of horse chestnut or HCSE during pregnancy and breastfeeding.

 

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, due to its esculin constituents, horse chestnut (but not horse chestnut seed extract, which when properly prepared does not contain esculin) may theoretically 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 such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®).

 

In theory, and based on limited animal study, horse chestnut seed extract (HCSE) may have an additive effect when taken with drugs that cause hypoglycemia (low blood sugar levels). Caution is advised when using medications that may also lower blood sugar. Patients taking drugs for diabetes by mouth or insulin should be monitored closely by a qualified healthcare provider. Medication adjustments may be necessary.

 

Escin in HCSE may theoretically interfere with protein-bound drugs such as phenytoin (Dilantin®), warfarin (Coumadin®) or amiodarone (Cordarone®), although human evidence is lacking.

 

Interactions with Herbs and Dietary Supplements
In theory, due to its esculin constituents, horse chestnut (but not horse chestnut seed extract, which when properly prepared does not contain esculin) may theoretically increase the risk of bleeding when taken with herbs or supplements that 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.

 

In theory, and based on limited animal study, horse chestnut seed extract may have an additive effect when taken with other herbs or supplements that may lower blood sugar. Blood glucose levels may require monitoring, and doses may need adjustment.