Ginseng   

James Meschino DC, MS, ROHP

General Features
Asian Ginseng is a member of the Araliaceae family, which also includes the closely related American Ginseng and less similar Siberian Ginseng.  The root of the plant is used for medicinal purposes, preferably from plants older than six years of age.  There are three distinct types of Ginseng in the commercial market:

1. Panax Ginseng (Asian, Chinese, Korean Ginseng)
2. Siberian Ginseng (Eleuthero Ginseng)
3. American Ginseng (Panax quinquefolius, Canadian Ginseng)

Panax Ginseng is the most widely used and most extensively studied species of Ginseng.  Primarily the roots of the plant are used for medicinal purposes with standardized extracts available containing up to 5 percent ginsenoside content, in a high quality root extract product.  Ginsenosides, which are triterpenoid saponins, vary between Panax, and American Ginseng.  There are at least 13 different ginsenosides, some occurring more in one type of Ginseng than the other, or not at all as is sometimes the case.  At this time, insufficient research exists to determine which type of Ginseng or ginsenoside complex is best suited to treat or prevent specific health conditions.  However, studies reveal that the most consistent and reliable results occur when using high-quality extracts, standardized for active constituents.  Siberian Ginseng contains seven eleutherosides (A-G), not ginsenosides.

Principle Active Constituents

1. Triterpenoid Glycosides (saponins), which are known as ginsenosides, and include:
   RO, Rb1, Rb2, Rb3, Rc, Rd, Re, Rf, 20-gluco-Rf, Rg1, and Rg2, R91, Ra2, Rh1, Rh4. These are found in Korean and American Ginseng only. Korean Ginseng contains significant concentrations of Rb1, Rb2, Rc, Re and Rg1.
   American Ginseng contains primarily Rb1 and Re, and does not contain Rb2, Rf or in some instances Rg1.
2. Eleutherosides (A-G) – found only in Siberian Ginseng
   Eleutherosides are a collection of specific coumarins, lignans, phenylpropanoids, polysaccharides, sterols, triterpenes and miscellaneous compounds.^{1, 2}

Siberian Ginseng is considered to be a milder type of Ginseng compared to Panax Ginseng²

Clinical Application and Mechanism of Action

As there is considerable overlap in the clinical use of the three types of Ginseng they are presented here collectively:

1. Adaptogen

There is some suggestion that Panax Ginseng has the ability to increase both ascorbic acid and cholesterol stores in the adrenal gland, while decreasing the 17-ketosterol and increasing ACTH excreted in the urine.  An increase in plasma ACTH and corticosteroids following administration of Ginseng is well documented.  These features may explain its use as a substance to help restore homeostasis under periods of stress and its use as an anti-fatigue supplement and general tonic.^{2, 3, 4, 5, 6, 7, 8}
An adaptogen is thought to work in a non-specific manner, helping to re-establish balance and homeostasis at a physiological level.

In Russia, Siberian Ginseng is used by deep sea divers, mine and mountain rescue workers, soldiers, factory workers, cosmonauts, and athletes primarily for its perceived ability to increase endurance and promote the body’s ability to tolerate stressful conditions.⁹

Studies with Panax Ginseng suggest that anti-fatigue effects may be mediated by stimulation of nerve impulses, direct affect on the hypothalamus-pituitary-adrenal axis, glycogen sparing in exercising muscle, and improved oxygen utilization.  In animal studies, lower lactic acid and pyruvic acid levels in the blood were noted upon exercise, compared to the placebo group – indicating a glycogen – sparing effect through increased fatty acid oxidation during exercise.^{1, 2}

These effects may be beneficial for endurance athletes and weight loss patients employing an exercise program.^{10, 11, 12}  A few studies have noted a performance-enhancing effect with the use of Panax Ginseng.¹²

2. Immunostimulating Effects

In general, all three types of Ginseng demonstrate an ability to enhance immune system function.  In particular Panax Ginseng appears to enhance antibody response, increase natural killer cell activity, stimulate macrophage activity, stimulate lymphocytes in vitro, stimulate the reticuloendothelial system, increase proliferation of T cells and B cells, and increase the production of interferon. ^{1, 2, 13, 14,} Both Panax Ginseng and Siberian Ginseng have demonstrated enhanced immune function in placebo-controlled, double blind studies, including significantly higher antibody litres and natural killer activity levels in the Panax Ginseng study.^{15, 20}

However, it should be noted that at high doses there is in vitro evidence that Ginseng may inhibit some immune functions, including lymphocyte proliferation.^{16, 17, 18, 19}

Based upon the available research in this area, some authorities suggest that Ginseng supplementation is appropriate for chronic fatigue syndrome, HIV-infection, to combat infections or to help restore immune function from a compromised state.^{1, 2, 21}

3. Female Reproductive Tissue Support

Ginsenosides exert an estrogen-like action on the vaginal epithelium, which can prevent atrophic vaginal changes associated with menopause.²²  It should be noted that breast tenderness can be a side effect of Ginseng use in women, which disappears when Ginseng is discontinued.²³

N.B.: Black cohosh also maintains the vaginal epithelium without risk of this side effect (see Black Cohosh in this document)

4. Male Reproductive Tissue Support

Panax Ginseng has been shown to increase sperm count and motility in men, as well as increasing plasma total and free testosterone, dihydrotestosterone, follicle stimulating hormone and leutinizing hormone.²⁴   An in vitro study suggests that it may relax the corpus cavernosum by releasing nitric oxide, which facilitates an erection.^{25, 31}

5. Type II Diabetes

Panax and American Ginseng have demonstrated an ability to reduce fasting and post prandial blood glucose levels in type II diabetic patients.  Its effects may alter the need or the dose of hypoglycemic medications and therefore, should only be used in this instance with knowledge of the attending physician.^{26, 27}

6. Protection from Radiation Damage

In experimental studies Ginseng has been shown to offer some protection against harmful radiation.² In particular, Siberian Ginseng is noted for its ability to provide protection in animals subjected to both single exposure and long-term x-ray radiation.  Rats given the Siberian Ginseng have been shown to survive twice or three times as long compared to rats not given Siberian Ginseng, in radiation studies.^{28, 29}

Although no human trials in North America are available, Siberian Ginseng is thought to be useful as an adjunctive treatment for those undergoing radiation treatment for a variety of cancerous conditions.¹   Preliminary studies in Russia indicate that the use of Siberian Ginseng in people undergoing chemotherapy and radiation therapy for cancer has been of benefit in reducing side effects and aiding in bone marrow recovery.³⁰

N.B.: Note that Reishi Mushroom Extract and Astragalus are also known to reduce side effects from radiation treatment (see details in related sections of this document)

Dosage and Standardized Grade

1. Immune Stimulation (Chronic Fatigue Syndrome, weakened immune status):100-500 mg per day in divided doses (std to 4-8 percent ginsenoside content) – Panax Ginseng is considered to be the best choice for this purpose.^{1, 2}
   For Siberian Ginseng – consider 100-200 mg per day in divided doses (20:1 extract)¹
2. Weight Loss or Ergogenic Athletic Aid: 200 mg per day in divided doses (Panax Ginseng std to 4-8 percent ginsenoside content)³²
3. General Anti-Stress Support: 100-200 mg per day (Panax Ginseng std to 4-8 percent ginsenoside content)³³
4. Postmenopausal Support for Women: 100-500 mg per day in divided doses. (std to 4-8 percent ginsenoside content – Panax Ginseng)¹
5. Male Infertility and Erectile Dysfunction: 100-500 mg per day in divided doses (std to 4-8 percent ginsenosides content – Panax Ginseng)¹
6. Type II Diabetes and Syndrome X: 200 mg per day (100 mg, twice daily with meals) (std to 4-8 percent ginsenoside content – Panax Ginseng)¹
   B. Must consult the attending physician prior to Ginseng use in these cases
7. Adjunct to Chemotherapy or Radiation Treatment: Siberian Ginseng 300-400 mg per day in divided doses (20:1 extract)²¹
   B. Long-term Ginseng supplementation usually involves a cycling effect with a two to three week non-use period, every 30 to 60 days^{1, 2}

Adverse Side Effects and Toxicity

1. Panax Ginseng: The most common side effects include insomnia,diarrhea, skin eruptions, vaginal bleeding and breast tenderness. “Ginseng Abuse Syndrome” may exist in which over stimulation from Ginseng may cause hypertension, restlessness, nervousness, euphoria, insomnia, diarrhea and skin eruptions – from overuse. This description has been criticized due to the fact that most studied subjects also ingested high levels of caffeine.¹
2. Siberian Ginseng: The most common side effects include insomnia, irritability, melancholy, anxiety Patients with rheumatic heart disease have reported pericardial pain, headaches, palpitations, and elevations in blood pressure.²
3. American Ginseng: The most common side effects include insomnia and irritability²¹

Contraindications and Precautionary Measures for all Forms of Ginseng

Ginseng should not be given in the following cases:

• Hypertension
• Acute illness and fever
• Insomnia – (not to be taken at night by these individuals)
• Asthma
• Emphysema
• Cardiac disorders
• Patients suffering from mania, schizophrenia
• Insulin dependent diabetes mellitus
• Fibrocystic Breast Desease^1,2,33

Caution must be exercised when administering Ginseng supplements:

• to type II diabetics
• as an adjunct to chemotherapy or radiation therapy^{1, 2, 33}

at the same time as caffeine-containing beverages due to potential over stimulation effects.^{21, 38}

Drug-Nutrient Interactions

Ginseng is contraindicated in patients on the following medications:

1. Drugs affecting brain neurotransmitters, especially monoamine oxidase inhibitors (MAO-inhibitors): Ginseng can potentiate the drug effect leading to headache, euphoria, Central Nervous System stimulation and tremors, mania symptoms.³⁴
2. Phenobarbital ⁵
3. Warfarin – Ginseng has been shown to antagonize the clotting effects of warfarin, altering the prothrombin time or INR.^{35, 36}
4. Ticlopidine – a platelet-inhibiting drug. Similar effects on clotting due to Ginseng intake may counter effect of this drug, used by patients with intermittent claudication or to prevent stroke.²¹
5. Digoxin or Digitalis – Ginseng has been shown to elevate serum levels of digoxin, potentiating the drugs effect on the heart.^{35, 37} This occurred in one case and no clear relationship exists, but caution should be exercised.³⁷

N.B.: Several studies performed in various countries have repeatedly shown that a high percentage of commercially available Ginseng supplement products do not meet the label claim for the amount of Ginseng, ginsenosides or active constituents they claim to possess.  Furthermore, several cases of athletes consuming adulterated Ginseng products (i.e. ephedrine, pseudoephedrine) have occurred in which athletes have incurred doping charges against them and disqualification.^{39, 40, 41, 42, 43}

As such, it is recommended that Ginseng products used for the intended purposes mentioned here, have available to health practitioners and consumers, “certificate of analysis” on each  new batch of product formulated, to ensure potency and purity of the product.^39-43

High quality Ginseng raw materials are expensive and thus may encourage some manufacturers to use inferior grades or to adulterate their products with cheaper ingredients (e.g., ephedra, caffeine) to simulate the anti-fatigue, performance-enhancing effects of Ginseng.

Use with caution with patients on anti-asthmatic and antihypertensive drugs, as Ginseng may potentiate the effects of these drugs.  As such, appropriate patient monitoring under these conditions is recommended^.11,19

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