Cascara Sagrada - Uses, Side Effects, Interactions and Benefits

INTRODUCTION
Cascara sagrada is a large shrub recognized in the scientific community with the botanical name of Rhamnus purshiana. It is commonly found in North America, Europe, and Western Asia but currently considered as one of the endangered species.

The term “cascara” is derived from the Spanish language that means a "sacred bark." Alternate names of cascara sagrada are California buckthorn, yellow bark, bitter bark,chittem, and chitticum.

HISTORY
Since the 19th century, the dried bark of cascara sagrada is used as a laxative in the treatment of constipation. Initially, the United States Food and Drug Administration (FDA) approved it for its use as an over-the-counter laxative, and it was one of the most commonly used laxatives in the United States.

But later in 2002, the FDA withdraw the decision due to the lack of clinical trials and long-term safety concerns. Therefore, cascara sagrada is currently classified as a "dietary supplement" and is used in multiple herbal and dietary products.

CASCARA SAGRADA' BARK'S ACTIVE COMPOUNDS & MECHANISM OF ACTION
Anthraquinone glycosides (cascarosides A, B, C, and D) are the main compounds present in Cascara Sagrada that exert the laxative effects. The anthraquinone glycosides are further metabolized within the gut by intestinal microflora to form aglycone anthranoid compounds, which stimulate intestinal motility, increase intestinal secretions, and inhibit intestinal absorption of water and electrolytes.

All these effects lead to an increase in the stool bulk and volume. The increased stool volume exerts pressure to the intestinal wall and promotes muscle contractions (peristalsis). The laxative action typically occurs after 6–10 hours of use.

The cascara bark has a very bitter taste and is non-palatable; hence, it is generally not popular in the form of tea.  It is typically used in the form of extract, powder, and oral capsules. The cascara bark should be collected at least one year before its use as a mild laxative.

The freshly dried cascara bark works as a very strong laxative and is not considered safe for human use. The consumption of freshly dried cascara bark will result in severe abdominal cramps and severe diarrhea.

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 HEALTH BENEFITS AND USES

• Constipation

Cascara sagrada is primarily used as a gentle laxative to treat constipation. It works by stimulating intestinal motility (peristalsis), increasing intestinal secretions, and inhibiting absorption of water and electrolytes within the intestines. Because of the mild action, it is generally considered safe and causes fewer watery stools.

Cascara sagrada is also suggested to be beneficial in the following medical conditions, although the medical evidence is lacking to support these claims:

• Anal fissures
• Dyspepsia
• Gallstones
• Hemorrhoids
• Liver disorders
• Urinary stones
• Gastrointestinal Cancers
• Parasitic infestations
• Due to its very bitter taste, some parents apply cascara to the fingernails of their children to discourage nail-biting.
• Some people use cascara sagrada as a weight loss agent. It should be remembered that cascara does not burn fat tissue to decrease weight, but it may give a false impression of weight loss by causing dehydration and decreasing the water content of our body. Therefore, it should never be used for weight loss.

 
Disclaimer: The uses as mentioned earlier of cascara sagrada are based on its traditional uses. You may also find other uses of cascara. Valid clinical data is not available for their use. Safety and efficacy in humans have also not been proven. You should contact your healthcare provider before starting cascara sagrada.

ADVERSE EFFECTS OF CASCARA SAGRADA

• Short-term Adverse Effects

Cascara sagrada is generally considered safe and well-tolerated if used for a short-term period, i.e. seven or less than seven days. The common side effects of short-term use of cascara are:

• Nausea and vomiting
• Frequent loose stools
• Abdominal pain, and
• Cramping 

 
Long-term Adverse Effects
The frequent and excess use of cascara sagrada may cause a variety of different adverse effects. This was one of the concerns for the withdrawal of FDA approval as clinical trials and research regarding the long term safety was lacking. When taken long-term, the following adverse effects have been noticed:

• Dehydration
• Electrolyte imbalance with depletion of sodium, potassium (more common), chloride, magnesium, and calcium.
• Laxative dependence
• Muscle weakness
• Muscle spasms or cramps
• Palpitations and Cardiac arrhythmia (Irregular heartbeat)
• Reduced urine output and Renal failure
• Peripheral neuropathy (Numbness or tingling of the hands or feet)
• Hepatitis (liver inflammation)
• Seizures
• Encephalopathy
• Pseudomelanosis coli (A benign reversible condition associated with pigmentation of the intestinal lining)
  

CONTRAINDICATIONS
It is contraindicated in individuals with a known allergy or hypersensitivity to cascara sagrada or the Rhamnaceae family. Allergic reactions may vary from mild itching to life-threatening anaphylactic reactions.

Although medical research is lacking regarding the possible contraindications, still it is generally suggested that Cascara sagrada should be better avoided in people suffering from any of the following health conditions:

• Inflammatory bowel disease (Ulcerative colitis and Crohn's disease)
• Recent Abdominal surgery
• Celiac disease
• Appendicitis
• Diverticulitis
• Congestive heart failure
• Gastrointestinal cancer
• Liver disease
• Kidney disease
• Anemia
  

DRUG INTERACTIONS

• Cascara sagrada affects serum electrolyte levels, which affects various drugs. For example cardiac glycosides, which includes digoxin and digitoxin. These drugs are used in the management of heart failure. The toxicity of cardiac glycosides increases with potassium disturbances.
• Cascara sagrada also decreases the absorption of many oral drugs resulting in their suboptimal blood levels.
• Cascara sagrada may increase the risk of bleeding. Therefore, it should be used with caution in patients with bleeding disorders or persons who are using drugs that may increase the risk of bleeding, such as antiplatelet and/or anticoagulant.

 
Disclaimer: The interactions of cascara sagrada with other pharmaceutical agents are not fully studied. It may adversely affect your health by either decreasing the efficacy of other drugs or potentiating the adverse effects. You should contact your healthcare provider before starting cascara sagrada.

 DOSING

Adults
The safe and effective dose of cascara sagrada is not proven by the studies; therefore, the smallest dose of cascara should be consumed to maintain soft stools. Unlike pharmaceutical drugs, dietary and herbal supplements do not undergo rigorous testing in the United States.

Hence, the quality of the supplement varies considerably. Further, cascara preparations are available in different forms causing difficulty in calculating effective dosages. Following are the traditional doses of various forms of cascara sagrada.

• Dried cascara bark is often used in a dose of 300-1,000 milligrams.
• Cascara liquid extract is often used in a dose of 2-5 milliliters.
• Aromatic fluid extract is often used in a dose of 4-6 milliliters.
• As a tea, 1000-2000milligrams of cascara bark is dissolved in 150-200 milliliters of boiling water for 5-10 minutes, but it is not a popular option due to severely bitter taste.

 
Children (younger than 18 years)
There is no proven safe or effective dose for cascara in children. Therefore, its use is not recommended in children.
 
Pregnancy
There is no proven safe or effective dose for cascara in pregnant women. Therefore, its use is not recommended during pregnancy.
 
Lactation
There is no proven safe or effective dose for cascara in lactating mothers. Maternal cascara consumption may result in loose stools in some breastfed infants. Therefore, its use is not recommended in lactating mothers.

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 REFERENCES:

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2. Marchesi M, Marcato M, Silvestrini C. Clinical experience with a preparation containing cascara sagrada and boldo in the therapy of simple constipation in the elderly. Giornale di clinica medica. 1982;63(11-12):850-63.
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7. Nusko G, Schneider B, Schneider I, Wittekind C, Hahn EG. Anthranoid laxative use is not a risk factor for colorectal neoplasia: results of a prospective case control study. Gut. 2000 May 1;46(5):651-5.
8. Jacobsen C, Semb S, Kromann-Andersen H. Toxic hepatitis following consumption of the herbal medicinal product Cascara Sagrada. Ugeskrift for laeger. 2009 Nov;171(46):3367-9.
9. Van den Berg AJ, Labadie RP. Anthraquinones, anthrones and dianthrones in callus cultures of Rhamnus frangula and Rhamnus purshiana. Planta medica. 1984 Oct;50(05):449-51.
10. Lithgow RD. Cascara Sagrada in Constipation. British medical journal. 1883 Jul 14;2(1176):68.
    

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