Boswellia serrata

Blessed Relief for Inflamed
Bowels, Lungs, and Joints

An ancient treasure fights inflammation of three different kinds

I hav finally kum to the konklusion that a good reliable set ov bowels
iz worth more to a man than enny quantity ov brains.
-- Henry Wheeler Shaw (Josh Billings)

hat's sticky, smells great when it's burned, and can make you smell great - and, furthermore, can relieve the pain of arthritis, soothe your inflamed bowels, and allow you to breathe easier? Give up? It's frankincense, one of the three Gifts of the Magi. For thousands of years, frankincense has been used primarily as incense and in the making of perfume, but various medicinal benefits have also been ascribed to it. Folkloric knowledge of those benefits goes back a long time, probably before the Christian era began, and it may have contributed to the high value placed on this exotic essence, making it a gift to rival gold, and worthy of a king.

Frankincense is the aromatic gum resin from African and Asian trees of the genus Boswellia. True frankincense comes from Boswellia carteri, which is found in Somalia and parts of Saudi Arabia, but the term is also used for the gum resins of other Boswellia species, including Boswellia serrata, which is found in the dry, hilly areas of India. The traditional Ayurvedic medicine of India, in fact, was for centuries the chief source of our knowledge about the healing properties of frankincense, which was used to treat such conditions as asthma, arthritis, rheumatism, dysentery, ulcers, and skin disorders.1*


*Frankincense is also known by the more exotic names olibanum and salai guggul. In the English name, by the way, the "frank" part has nothing to do with hot dogs; it comes from the Old French franc, meaning free or pure.


Although the Three Wise Men (one of whom may have come from what is now Afghanistan, by the way) could hardly have known it, this particular gift of theirs was destined to join a host of other natural substances from around the world in our modern medical treasure chest of healing botanicals. We now know that the principal active ingredients in frankincense are a number of related compounds called boswellic acids, which have shown antimicrobial activity in laboratory experiments. That, however, is not what has aroused the interest of modern scientists.

BOSWELLIA HELPS ARTHRITIS AND INFLAMMATORY BOWEL DISEASE
The main interest in boswellic acids stems from their anti-inflammatory action, which is believed (based largely, but not exclusively, on animal studies) to be beneficial in the treatment of both osteoarthritis and rheumatoid arthritis.2,3 This action is similar to that of conventional nonsteroidal anti-inflammatory drugs (NSAIDs), but without the danger of irritation or ulceration of the stomach. In fact, the side effects of boswellic acids are nearly nil.


The anti-inflammatory action of
the boswellic acids is believed to
be beneficial in the treatment of
both osteoarthritis and
rheumatoid arthritis.

Boswellic acids inhibit the production of a class of compounds called leukotrienes.4 These molecules are involved in the inflammatory process in numerous disorders, including inflammatory bowel disease, of which there are two main kinds: ulcerative colitis and Crohn's disease. About 2 million Americans are affected - men and women about equally - by inflammatory bowel disease, which most often strikes between the ages of 15 and 40. The peak occurs in our 20s, but a second peak occurs as we get older, between the ages of 50 and 80.5

ULCERATIVE COLITIS IS NOT A GLAMOROUS DISEASE
Colitis is inflammation of the colon. (So why is it not called colonitis? This is one of life's little mysteries. If you look up colonitis in the dictionary, it says "See colitis.") No matter what you call it, it's a miserable condition, and it's likely to stay unless you do something about it. We'll get to that in a moment.

Colitis should not be confused with irritable bowel syndrome (spastic colon), a different and much less serious condition that is aggravating but that does not entail inflammation. In colitis, furthermore, inflammation is typically accompanied by ulceration, which damages or destroys patches of the mucosal lining of the colon or rectum. Ulcerative colitis - the standard term for the most common form of the disease - causes bloody diarrhea, and stools may contain mucus and pus. There may also be fever and abdominal pain.

BOSWELLIA HELPS COLITIS
So what can you do about all this? Well, there are drugs, of course, and they can be quite effective, although you may have to pay a price beyond mere money to obtain their benefits (see the sidebar "Drug Side Effects - A Tale of Many Colors"). If the condition affects just the rectum and lower part of the colon, the drugs of choice are aminosalicylates or corticosteroids, administered rectally. But if the condition goes farther up the pipeline, so to speak, oral medication is indicated, and the drug of first choice is usually sulfasalazine (the one in the sidebar, which may be more fun to read than you'd think).

Drug Side Effects - A Tale of Many Colors

Sulfasalazine is an anti-inflammatory sulfa drug used to prevent and treat the inflammatory bowel diseases ulcerative colitis and Crohn's disease, as well as rheumatoid arthritis. It also has antibiotic properties that may be important in changing the bacterial content of the bowel. It's a potent remedy, but, like most drugs, it comes with a passel of side effects, ranging from common to rare, and mild to serious.

The common side effects of sulfasalazine are: headache; dizziness; ringing in the ears; irritation of the mouth or tongue; gastrointestinal discomfort and cramps; diarrhea; nausea and vomiting; brownish discoloration of the urine; and (perhaps not surprisingly) loss of appetite.

Among its more serious, but less common, side effects, are (in no particular order): aching joints and muscles; pain in the back, stomach, or legs; chest pain; swollen glands; peripheral neuropathy; allergic liver damage (hepatitis); bloody diarrhea; coughing; difficulty in breathing or swallowing; hearing loss; allergic reactions such as skin rashes, hives, and itching; bone-marrow depression; drug fever; sore throat; peeling, blistering, or loosening of skin; unusual bleeding or bruising; hemolytic anemia; allergic pneumonitis; kidney damage; severe skin reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis; anaphylaxis; pancreatitis; myopathy; drug-induced lupus erythematosus; pericarditis; unusual fatigue; and sensitivity to sunlight.1,2

WE'RE NOT DONE YET
You think that's it? Not quite. Last but not least is a bizarre spectrum of side effects that are, well, colorful. Depending on God knows what, you could have: whiteness or redness of the skin; blue discoloration of the skin, lips, or fingernails; and yellow discoloration of the skin or eyes. The stuff can even turn your contact lenses yellow!

Good grief! It's almost enough to make you not want to take sulfasalazine. Adverse effects limit the use of this drug, in fact, in up to 30% of patients.3 Although these effects are no laughing matter, the temptation to indulge in a bit of silly speculation about some of them is irresistible. Let's call it black humor.

So picture this, if you will: you're taking sulfasalazine, and different portions of your skin - those that haven't peeled, blistered, or loosened (or worse), anyway - simultaneously turn red, white, and blue (you could rent yourself out as a human flag!), while your eyes turn yellow and your urine turns brown. With your blue fingernails, you scratch your patriotic rashes, hives, and itches, all the while kissing your money goodbye with your blue lips and turning green with envy for people whose doctors gave them something less costly and more user-friendly - something like Boswellia serrata. By now those lucky folks are probably, uh, in the pink.

References

  1. Edelson E, O'Sullivan M, Abrams SB. Prescription and Over-the-Counter Drugs. The Reader's Digest Association, Pleasantville, NY, 1998.
  2. Rybacki JJ, Long JW. The Essential Guide to Prescription Drugs 2001. HarperCollins, New York, 2000.
  3. Beers MH, Berkow R, eds. The Merck Manual of Geriatrics, 3rd ed., p. 1061. Merck Research Laboratories, Whitehouse Station, NJ, 2000.

But this magazine is about the use of natural dietary supplements as safe and effective substitutes for drugs. Which brings us back to Boswellia serrata, from which an alcoholic extract of the gum resin can be made and used as a medicine.

Researchers at universities in India and Germany collaborated to evaluate the effects of Boswellia on 20 patients with chronic colitis, a variant of ulcerative colitis that is less severe in nature and has a more benign prognosis (it was formerly called "nonspecific colitis").6 In this study, in fact, patients with classic ulcerative colitis were specifically excluded. Paradoxically, however, one of the manifestations of chronic colitis is . . . ulcers! The differentiation between the two conditions is based on more subtle criteria that are too technical for this article.

The 20 patients receiving Boswellia serrata extract (300 mg three times daily, or 0.9 g per day, for six weeks) were 13 men and 7 women of average age 25. For the duration of the study (which was not randomized or blinded), they were put on a standard diet and prohibited from taking any other medications. The control group consisted of 10 patients: 4 men and 6 women of average age 39. They did not receive a placebo, but rather the standard dosage of sulfasalazine used in medical practice. This study was thus a head-to-head contest between the botanical and the drug.

BOSWELLIA BEATS SULFASALAZINE
The botanical won! After six weeks of treatment, essentially complete remission of symptoms was found in 90% (18 of 20) of the Boswellia patients, and in 60% (6 of 10) of the sulfasalazine patients. Both of these outcomes are considered very good by any standard. Furthermore, none of the patients in either group showed any deterioration in any of the symptoms of their condition. The only side effect noted in the Boswellia group was heartburn, which affected two patients.

One year after the study began, follow-up examinations showed that 6 of the 18 improved Boswellia patients (33%) had had a relapse. In the sulfasalazine group, the percentage was the same: 2 of the 6 had suffered relapse. The authors suggested that treatment with higher dosages of Boswellia for longer periods of time might reduce this rather high relapse rate.

An earlier study by the same research group, by the way, had found that Boswellia serrata was effective against classic ulcerative colitis: after treatment with 350 mg three times per day, or 1.05 g per day, for six weeks, its efficacy was equivalent to that of sulfasalazine, with an 80% remission rate.7

CROHN'S DISEASE IS EVEN WORSE THAN COLITIS
Earlier we mentioned Crohn's disease as the other of the two kinds of inflammatory bowel disease. In Crohn's disease, the inflammation can affect any part of the gastrointestinal tract, from mouth to anus. Most commonly, however, it strikes the ileum (the lower portion of the small intestine) and the colon, but usually not the rectum. The inflammation and ulceration in Crohn's disease go much deeper through the intestinal wall than in ulcerative colitis and can cause fever, pain, bloody diarrhea, and loss of appetite. The last of these problems can be compounded by malabsorption, an impaired ability of the intestinal lining to absorb nutrients and deliver them to the bloodstream. This often results in anemia and weight loss.

Unlike ulcerative colitis, which can be corrected by surgery in severe cases, Crohn's disease is not usually amenable to surgery. It can, however, be treated with drugs, such as sulfasalazine, aminosalicylates, corticosteroids, and even antibiotics, including one that should sound eerily familiar: ciprofloxacin ("cipro"). Although corticosteroids are usually the drugs of choice for Crohn's disease, some people refuse them or cannot tolerate them. In those cases, the usual remedy is the aminosalicylate drug mesalazine (also called mesalamine), which, by the way, has a spectrum of side effects similar to that of sulfasalazine.

BOSWELLIA HELPS CROHN'S DISEASE
Researchers in Germany and Austria conducted a "noninferiority" trial (see the sidebar "Noninferiority Complex for Supplements") of Boswellia serrata vs. mesalazine, to try to demonstrate that the former was at least as effective as the latter in treating Crohn's disease.8 They set up a randomized, double-blind, placebo-controlled study in which 83 patients (41 men and 42 women of average age 36.5, with Crohn's disease of 9 years' duration, on average) were evaluated.

Noninferiority Complex for Supplements
When a drug is well accepted as an effective therapy for a given disease, it is useful to compare it with other products, such as dietary supplements, in head-to-head contests like those for Boswellia serrata vs. sulfasalazine and mesalazine, described in the article.

The desired objective in such studies is to demonstrate, at a minimum, what researchers call the noninferiority of the supplement. For the supplement to be taken seriously, in other words, it does not have to be more effective than the drug, it just has to be as effective (approximately). It must also be safe, of course - safety and effectiveness always go hand in hand, because either one without the other is worthless.

What defines safety is side effects, because the more side effects there are, and the more often they occur, and the greater their severity, the less safe the product is. This is where supplements usually shine compared with drugs. Supplements are natural products for which Mother Nature has better prepared our bodies than for drugs, which are synthetic products She never even imagined.

So if a supplement and a drug are about equally effective, but the supplement is safer than the drug, then the supplement is not just "not inferior" to the drug, it's better than the drug, in terms of its benefit-to-risk ratio. From the consumer's point of view, cost is another important factor, of course, but this is a matter of economics, not science, so it is not considered by researchers who conduct clinical trials. They just get the facts, and it's up to you to decide what you're willing to spend on your health.

The patients received either a standardized extract of Boswellia serrata called H15, or mesalazine, for eight weeks. The supplement dosage was three tablets of 400 mg each, taken three times daily, for a total of 3.6 g per day (i.e., 3.4 to 4.0 times the amounts used in the other studies cited in this article). The standard daily dose of mesalazine was similarly divided into nine tablets, which were indistinguishable from those containing the H15.


The botanical won! After 6 weeks
of treatment for chronic colitis,
essentially complete remission of
symptoms was found in 90% of
the Boswellia patients.

The outcome of the trial was measured primarily in terms of a standardized scale called the Crohn Disease Activity Index (CDAI), which provides a numerical value based on the number and severity of the symptoms. Participants in the trial were selected, among many other criteria, for having CDAI values between 150 and 450 at the outset. The results, after eight weeks of therapy, were that the Boswellia group had a 90-point reduction in CDAI, on average, and the mesalazine group had a 53-point reduction. Although the difference between these two values is large, and it definitely favors Boswellia, it was not statistically significant according to the mathematics of the trial protocol. Thus the conclusion was that Boswellia was as good as - and certainly not inferior to - mesalazine.

BOSWELLIA GOES FROM "NOT INFERIOR" TO BETTER THAN MESALAZINE
A comparison of the remission rates between the two groups provided further confirmation of this outcome. Using a drop below a CDAI value of 150 as the criterion for remission, it turned out that the remission rates were 36% for the Boswellia group and 31% for the mesalazine group. Again the conclusion was that Boswellia was not inferior to mesalazine. (In the coolly analytical world of science, you can use language that might not work quite so well in daily life. Consider, for example, the following answer to your wife's question about how you like her apple pie: "Well, Honey, it's not inferior to my former girl friend's apple pie." Oops.)

When safety was factored into the equation, things changed. The Boswellia group experienced eight incidents of side effects, none of which could be attributed to the therapy, whereas the mesalazine group experienced 17 incidents, of which 13 could not be attributed and four could be. The authors concluded that, taking both safety and efficacy into account, Boswellia showed a more favorable benefit-to-risk ratio than mesalazine. Finally - not just not inferior, but better! Hooray for Boswellia!

BRONCHIAL ASTHMA IS ALSO AN INFLAMMATORY DISEASE
The value of Boswellia does not stop with inflammatory bowel diseases, as was demonstrated by the same Indian/German research group mentioned earlier. They undertook a pilot study (randomized, double-blind, and placebo-controlled) to evaluate the effects of Boswellia serrata on bronchial asthma.9 Asthma is a chronic inflammatory disease of the airways, often arising from allergies, that is characterized by sudden, recurring attacks of labored breathing, chest constriction, coughing, and wheezing. The disease affects about 15 million Americans, almost one-third of whom are children.

During an asthma attack, the airway walls become thickened as a result of inflammation. This tends to narrow the air passage, which also begins to fill with sticky mucus. In bronchial asthma, the attacks are caused by spasmodic contractions of the muscular walls of the bronchial tubes, the two tubes that branch off from the trachea (windpipe) to deliver air to the lungs. Breathing becomes difficult. Needless to say, this can be frightening - and it can be fatal. Asthma is a serious disease and should always be treated by a physician. In the last few decades, the number of hospitalizations and deaths from asthma has risen at an alarming rate, and doctors do not know why.10

Asthma is usually treated with anti-inflammatory drugs or bronchodilators. In the former category are corticosteroids and leukotriene antagonists, i.e., drugs that prevent or counteract the action of leukotrienes. Remember them? They're the principal targets of Boswellia's action.

BOSWELLIA HELPS BRONCHIAL ASTHMA
In the Indian/German study, 40 patients (23 men and 17 women, aged 18-75, with chronic bronchial asthma of 9.6 years' duration on average) were given a Boswellia preparation of 300 mg three times daily, or 0.9 g per day, for six weeks. The result was that 70% of them experienced remission of their symptoms, such as dyspnea (difficulty in breathing, resulting in shortness of breath), rhonchi (the coarse, rattling sounds caused by mucus in the bronchial tubes), the frequency of asthma attacks, and the levels of certain blood components that provide different kinds of signals of the patients' state of health.


70% of the patients on Boswellia
experienced remission of their
symptoms, such as dyspnea,
rhonchi, and the frequency of
bronchial asthma attacks.

The control group of 40 patients (16 men and 24 women, aged 14-58, with chronic bronchial asthma of 8.5 years' duration on average) received the identical treatment but with placebo instead of Boswellia. Only 27% of this group experienced remission. (It was "only" 27% only by comparison; 27% is still quite significant, after all. The placebo effect testifies eloquently to the power of mind over matter.) The authors concluded, "The data show a definite role of gum resin of Boswellia serrata in the treatment of bronchial asthma." They cautioned, however, that this was only a pilot study and that further studies are needed to confirm their results and find the most effective dose.

If you have inflammatory problems such as arthritis or inflammatory bowel disease or asthma - or if you think you may need to help prevent those conditions from developing - you might benefit from Boswellia serrata.

References

  1. Graedon J, Graedon T. The People's Pharmacy Guide to Home and Herbal Remedies, p. 275. St. Martin's Griffin, New York, 2001.
  2. Lininger SW Jr., Gaby AR, Austin S, Brown DJ, Wright JV, Duncan A. The Natural Pharmacy, 2nd ed., p. 403. Prima Publishing, Rocklin, CA,1999.
  3. Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine, rev. 2nd ed., p. 704. Prima Publishing, Rocklin, CA, 1998.
  4. Safayhi H, Mack T, Saieraj J, et al. Boswellic acids: novel, specific, nonredox inhibitors of 5-lipoxygenase. J Pharmacol Exp Ther 1992;261:1143-6.
  5. Beers MH, Berkow R, eds. The Merck Manual of Geriatrics, 3rd ed.,p. 1061. Merck Research Laboratories, Whitehouse Station, NJ, 2000.
  6. Gupta I, Parihar A, Malhotra P, Gupta S, Lüdtke R, Safayhi H, Ammon HPT. Effects of gum resin of Boswellia serrata in patients with chronic colitis. Planta Med 2001;67:391-5.
  7. Gupta I, Parihar A, Singh GB, Lüdtke R, Safayhi H, Ammon HP. Effects of Boswellia gum resin in patients with ulcerative colitis. Eur J Med Res 1997;2:37-43.
  8. Gerhardt H, Seifert F, Buvari P, Vogelsang H, Repges R. Therapy of active Crohn's disease with Boswellia serrata extract H 15 [in German]. Z Gastroenterol 2001 Jan;39:11-7.
  9. Gupta I, Gupta V, Parihar A, Gupta S, Lüdtke R, Safayhi H, Ammon HP. Effects of Boswellia serrata gum resin in patients with bronchial asthma: results of a double-blind, placebo-controlled, 6-week clinical study. Eur J Med Res 1998 Nov 17;3(11):511-4.
  10. Williams MH Jr. Increasing severity of asthma from 1960 to 1987. N Engl J Med 1989;320:1015-6.

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