Artichoke

Metadata

• Common Names: Globe Artichoke (English), Artischocke (German)
• Botanical Name: Cynara cardunculus L. subsp. scolymus (L.) Hayek (syn. Cynara scolymus L.)
• Plant Family: Asteraceae (Compositae)
• Part Used: Leaf (Cynarae folium)
• Evidence Quality Rating: Moderate

Approved Indications

Commission E

• Dyspeptic complaints
• Documented choleretic activity (bile-stimulating)

ESCOP

• Symptomatic relief of digestive disorders such as dyspepsia with sensation of fullness, bloating, and flatulence
• Adjunct therapy in mild hyperlipidemia
• Hepatobiliary complaints

EMA/HMPC

• Traditional use: Symptomatic relief of digestive disorders such as dyspepsia with sensation of fullness, bloating, and flatulence
• Traditional use: To facilitate digestive function
• The EMA classified artichoke as a traditional herbal medicinal product; while clinical data is supportive, the HMPC considered it insufficient to grant “well-established use” status

Agreement/Disagreement Between Bodies

• All three bodies agree on dyspepsia and digestive complaints as primary indications
• Commission E specifically documented the choleretic (bile-stimulating) activity
• ESCOP uniquely includes adjunct therapy for mild hyperlipidemia
• The EMA is more conservative, limiting to traditional use status only
• All bodies agree artichoke is primarily a hepatobiliary and dyspepsia remedy

Conditions Treated

• Functional dyspepsia
• Bloating / Flatulence
• Sensation of fullness
• Hepatobiliary disorders
• Mild hyperlipidemia / Elevated cholesterol
• Loss of appetite
• Nausea

Mechanism of Action

• Chlorogenic acid: Antioxidant; inhibits cholesterol biosynthesis by inhibiting HMG-CoA reductase; stimulates bile secretion
• Cynarin (1,3-dicaffeoylquinic acid): Choleretic activity; stimulates bile production by hepatocytes; modest cholesterol-lowering effect (though recent data suggests cynarin alone may be less important than previously thought)
• Luteolin and luteolin-7-O-glucoside (cynaroside): Primary compounds responsible for cholesterol-lowering effects; inhibit cholesterol synthesis in hepatocytes; antioxidant protection of LDL from oxidation
• Cynaropicrin (sesquiterpene lactone): Bitter principle that stimulates digestive secretions; anti-inflammatory activity
• Overall choleretic mechanism: Increases bile acid production and bile flow, thereby improving fat digestion and reducing dyspeptic symptoms associated with biliary insufficiency
• Hepatoprotective effects: Antioxidative protection of liver cells; enhanced regeneration capacity in animal models

Clinical Evidence Summary

Dyspepsia

• Holtmann et al. (2003): Large RCT (n=247) of artichoke leaf extract vs placebo for functional dyspepsia; ALE was significantly more effective than placebo for alleviating dyspeptic symptoms (p<0.001) [Aliment Pharmacol Ther]
• Marakis et al. (2002): Open study (n=553) with standardized ALE (320-640 mg three times daily); >70% of patients reported reduction in nausea, abdominal pain, constipation, and flatulence after 6 weeks
• Walker et al. (2001): Open multicenter study (n=279); 96% of patients rated ALE as effective or very effective for functional dyspepsia symptoms

Cholesterol / Lipid Lowering

• Englisch et al. (2000): RCT (n=143); 1800 mg/day standardized ALE for 6 weeks resulted in 18.5% reduction in total cholesterol and 22.9% reduction in LDL-cholesterol vs placebo
• Bundy et al. (2008): RCT (n=75); 1280 mg/day ALE for 12 weeks; total cholesterol decreased 4.2% in treatment group vs 1.9% increase in placebo (statistically significant)
• Review of 11 clinical studies (1936-1994): Mean decrease in total cholesterol or triglycerides ranged 5-45% across studies (variable quality)
• Cochrane-quality evidence for cholesterol lowering is limited; most trials have relatively small sample sizes

IBS

• One RCT (n=208) showed artichoke leaf extract reduced IBS symptom severity and improved quality of life compared to placebo after 6 weeks

European vs US/Anglophone Consensus

• Artichoke leaf extract is a standard pharmacy product in Germany and widely prescribed for dyspepsia and mild hyperlipidemia
• In the US, artichoke is primarily known as a food/dietary supplement; therapeutic use for dyspepsia is not mainstream
• The choleretic/hepatobiliary indication is central to European practice but rarely discussed in US gastroenterology
• European physicians commonly use artichoke where US physicians might prescribe PPIs or prokinetics
• The lipid-lowering data is recognized in Europe (ESCOP indication) but not reflected in any US clinical guideline

Safety Profile

Contraindications

• Bile duct obstruction: Choleretic activity could exacerbate obstruction
• Gallstones: May stimulate gallstone movement; use with caution
• Allergy to Asteraceae/Compositae: Cross-reactivity possible (ragweed, daisies, marigolds, chrysanthemums)
• Liver disease: Caution in severe hepatic impairment

Drug Interactions

• May increase levels of drugs metabolized by CYP2B6
• May decrease levels of drugs metabolized by CYP2C19
• No known severe or serious drug interactions in clinical reports
• Theoretical additive effect with cholesterol-lowering medications (statins)

Side Effects

• Generally well tolerated
• Mild GI complaints: flatulence, bloating (paradoxically), hunger sensations
• Allergic reactions in individuals sensitized to Compositae family
• No significant adverse effects reported in controlled clinical trials

Pregnancy/Lactation

• No adequate safety studies during pregnancy or lactation
• EMA advises against use during pregnancy and lactation due to insufficient data
• Not recommended for children under 12 years

Clinical Dosage

Forms and Ranges

• Dried leaf extract: 300-640 mg three times daily (standardized to caffeoylquinic acids)
• Dried leaf: 6 g daily in divided doses
• Fresh juice from aerial parts: 6-12 mL daily
• Dry extract (DER 4-6:1): 600 mg, 2-3 times daily
• For cholesterol lowering: 1280-1800 mg/day of standardized extract for minimum 6-12 weeks

Key Standardized Products

• Hepar-SL forte (standardized artichoke leaf extract, Germany)
• Cynarin (German phytopharmaceutical)
• Various PhEur-compliant ALE products standardized to chlorogenic acid content (minimum 0.8% chlorogenic acid according to PhEur)

Sources

• EMA/HMPC Herbal Monograph on Cynara cardunculus L. (syn. Cynara scolymus L.), folium
• EMA Assessment Report on Cynara scolymus L., folium
• Commission E Monograph: Cynarae folium
• ESCOP Monograph: Cynarae folium, 2nd edition
• Holtmann G, et al. Efficacy of artichoke leaf extract in the treatment of patients with functional dyspepsia. Aliment Pharmacol Ther. 2003;18(11-12):1099-1105
• Bundy R, et al. Artichoke leaf extract reduces plasma cholesterol in otherwise healthy hypercholesterolemic adults. Phytomedicine. 2008;15(9):668-675
• Englisch W, et al. Efficacy of artichoke dry extract in patients with hyperlipoproteinemia. Arzneim-Forsch/Drug Res. 2000;50:260-265
• Wider B, et al. Artichoke leaf extract for treating hypercholesterolaemia. Cochrane Database Syst Rev. 2013

Connections

• Related to Milk Thistle as hepatoprotective agents in European phytotherapy
• Compare with Gentian and Wormwood as bitter digestive tonics
• Part of the European tradition of “hepatobiliary” remedies not widely recognized in US practice
• Milk thistle is included as a component of STW 5/Iberogast