Elderflower

Metadata

Approved Indications

German Commission E

• Elderflower (Sambuci flos): Common cold (Erkaltungskrankheiten)
• Diaphoretic (promoting perspiration)

ESCOP

• Diaphoretic for banal colds
• Fever and chills

EMA/HMPC

• Traditional use: Relief of early symptoms of common cold
• Based on long-standing traditional use

Agreement/Disagreement Between Bodies

Good agreement on the traditional diaphoretic indication for common cold. All bodies recognize the flowers for this use. The evidence gap between elderflower (traditional) and elderberry (some RCT evidence) creates an unusual situation where the part with the regulatory monograph (flower) has less modern clinical evidence than the part without a classic monograph (berry).

Conditions Treated

Elderflower (Flos)

• Common cold (primary traditional indication)
• Feverish infections (diaphoretic use)
• Upper respiratory tract infections (supportive)
• Component of Sinupret for sinusitis

Elderberry (Fructus)

• Common cold and influenza (better clinical evidence than flower)
• Upper respiratory tract infections

Mechanism of Action

Elderflower

1. Diaphoretic (Sweat-Promoting)

   • Flavonoids and phenolic acids promote peripheral vasodilation and perspiration
   • Quercetin and kaempferol are key diaphoretic compounds
   • p-Coumaric acid contributes to the effect
   • Traditional “sweat cure” (Schwitzkur) involves drinking hot elderflower tea while wrapped warmly

2. Antipyretic

   • Fever reduction through promotion of perspiration and peripheral heat loss
   • Related to but distinct from the diaphoretic mechanism

3. Diuretic

   • Mild diuretic effect attributed to flavonoid content

4. Anti-inflammatory

   • Flavonoids (particularly rutin, isoquercitrin) provide anti-inflammatory activity
   • Chlorogenic acid contributes

5. In Sinupret Combination

   • Contributes antiviral, anti-inflammatory, and diaphoretic properties to the 5-herb combination
   • Demonstrated in vitro antiviral activity against adenovirus, human rhinovirus, and RSV

Elderberry (Fructus)

1. Antiviral

   • Berry anthocyanins (cyanidin-3-glucoside, cyanidin-3-sambubioside) demonstrate antiviral activity
   • Inhibits viral hemagglutinin, preventing viral attachment to host cells
   • Active against influenza A and B viruses in vitro
   • May inhibit viral replication

2. Immunomodulatory

   • Stimulates cytokine production (IL-1beta, TNF-alpha, IL-6, IL-8)
   • Enhances immune cell activity

Key Active Constituents

Flowers: Flavonoids (rutin, isoquercitrin, hyperoside, quercetin, kaempferol), phenolic acids (chlorogenic acid, caffeic acid, p-coumaric acid), triterpenes (alpha- and beta-amyrin, ursolic acid, oleanolic acid), volatile oil, mucilage

Berries: Anthocyanins (cyanidin-3-glucoside, cyanidin-3-sambubioside), flavonoids, phenolic acids, vitamins (C, A), amino acids

Clinical Evidence Summary

Elderflower-Specific Clinical Evidence

• Limited: No large, placebo-controlled RCTs specifically for elderflower monotherapy identified
• Traditional use evidence is the primary basis for Commission E and ESCOP approvals
• Elderflower’s role in Sinupret is clinically supported (see Primrose Cowslip), but the contribution of elderflower specifically cannot be separated from the combination

Elderberry (Fruit) Clinical Evidence

Hawkins et al. (2019) — Meta-Analysis

• Included randomized controlled clinical trials of elderberry supplementation for upper respiratory symptoms
• Results: Large mean effect size for reduction of upper respiratory symptoms
• Elderberry supplementation substantially reduced upper respiratory symptoms
• [Source: PubMed 30670267]

Tiralongo et al. (2016) — RCT in Air Travelers

• Population: Air travelers
• Intervention: Elderberry extract
• Results: Reduced cold duration and severity in travelers

Zakay-Rones et al. (2004) — Influenza RCT (Sambucol)

• Population: Patients with influenza
• Intervention: Sambucol elderberry syrup started within 48 hours of symptom onset
• Results: Flu symptoms relieved on average 4 days earlier than placebo group

Evidence Limitations

• Most RCT evidence is for elderberry (fruit), not elderflower
• The diaphoretic mechanism of elderflower is not readily testable in standard RCT designs
• Elderberry trials are relatively small
• Some studies note elderberry may not help all populations (e.g., limited benefit in children under 12, or those with lung conditions)

European vs. US/Anglophone Consensus

Interesting inversion: In German tradition, the flower is the primary medicinal part for respiratory use. In Anglophone markets, the berry (fruit) has become far more popular, largely driven by the Sambucol brand and antiviral research.

Safety Profile

Contraindications

• Hypersensitivity to Sambucus nigra or related species
• No other contraindications for properly prepared elderflower

Drug Interactions

• Diabetes medications: Elderberry (fruit) may increase effects of diabetes medications (acarbose, chlorpropamide, glimepiride, glipizide) by pharmacodynamic synergism, increasing hypoglycemia risk
• Immunosuppressants: Theoretical concern due to immunostimulatory effects (elderberry) [UNCERTAIN]
• Diuretics: May potentiate diuretic effects (elderflower)
• No specific drug interactions documented for elderflower tea

Side Effects

• Elderflower tea: Very rare adverse effects at normal doses
• Elderberry supplements: Generally well-tolerated

Toxicity Warning

• RAW elderberries, bark, root, and leaves contain the cyanogenic glycoside sambunigrin, which is potentially toxic
• Raw and unripe berries can cause nausea, vomiting, and severe diarrhea
• Proper preparation is essential: Cooking/heating destroys cyanogenic glycosides
• Elderflower does not carry this toxicity concern to the same degree, but proper identification is important to avoid confusion with other species (e.g., Sambucus ebulus, which is toxic)

Pregnancy and Lactation

• Pregnancy: EMA does NOT recommend use during pregnancy due to lack of safety data
• Lactation: Not recommended due to insufficient data
• No human or animal studies of safety in pregnancy identified for Sambucus nigra
• Practical note: Elderflower tea at standard doses has been used traditionally in pregnancy without reported problems, but formal evidence is lacking [UNCERTAIN]

Clinical Dosage

Elderflower (Flos)

Traditional “Sweat Cure” (Schwitzkur) Protocol

1. Prepare strong elderflower tea (often combined with linden flower and/or peppermint)
2. Drink hot tea
3. Wrap warmly in bed
4. Allow perspiration to occur
5. Rest

• This is the traditional German home remedy for feverish colds

Elderberry (Fructus)

As Sinupret Component

• Dosing is per the Sinupret combination product (see Primrose Cowslip)

Sources

• German Commission E Monograph: Sambuci flos
• ESCOP Monograph: Sambuci flos
• Altmeyers Encyclopedia: Sambuci flos entry
• Hawkins et al. (2019). PubMed 30670267. Meta-analysis of elderberry for URTI.
• Zakay-Rones et al. (2004). Elderberry study in influenza.
• PMC 7347422: Sambucus nigra as alternative treatment for cold and flu.
• Natural Standard Research Collaboration systematic review of Sambucus nigra.
• WebMD: Elderberry overview.
• NCCIH: Elderberry usefulness and safety.
• PMC 3941201: Echinacea and elderberry in pregnancy.
• NCBI/LactMed: Elderberry in lactation.

Connections

• Component of Sinupret — see Primrose Cowslip for combination evidence
• Compare diaphoretic role with Linden Flower (both traditional diaphoretics)
• Compare antiviral mechanism with Pelargonium Sidoides