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Herbs (elderberry, echinacea, astragalus, black seed, turmeric, oregano oil, ginseng, garlic, ginger, etc)
elderberry (Sambucus nigra), Sambucol, black elder There’s no scientific evidence that elderberry or any other herbal remedy is effective for COVID-19 prevention/tx1 Media trends - Has been suggested for COVID-19 tx/prevention based on historical use in cold/flu sx relief
- Cytokine storm media debate. Some suggest OK for prevention, but should d/c @ COVID-19 sx onset, due to possible immune inflammatory up-regulation;2 theory based on in vitro S nigra (Sambucol) study on ↑inflammatory cytokine production in human monocytes3
Reports on non-COVID-19 use - Flu sx. Elderberry extract 175 mg lozenge PO qid x2 days (HerbalScience). RCT (N=64; ages 16-60 yo) flu sx ≤24h, China 2009. Improved fever, HA, nasal congestion in elderberry group4
- Influenza A/B sx. Standardized elderberry syrup 5.7 g per 15 mL PO qid x5 days (Sambucol). RCT (N=60; ages 18-54 yo); flu-like sx ≤48h, winter 1999-2000, Norway. Sx relieved ~4 days earlier, rescue meds less used5
- Influenza B sx. Standardized elderberry syrup 5.7 g per 15 mL PO qid x2-3 days (Sambucol). RCT in kibbutz influenza B/Panama outbreak 1993. Significant sx improvement (fever, time to cure) vs controls6
- Colds in air travelers. Elderberry extract 600-900 mg PO qd (BerryPharma). RCT (N=312) economy-class overseas airline passengers. # cold episodes not significantly different, but duration/severity better in elderberry group 4 days post-travel7
Potential adverse effects reported - Allergy: allergic rhinoconjunctivitis, dyspnea after contact w/ dietary products/ flowers8
- GI: N/V, abdominal cramps (fresh wild elderberry juice crushed w/ leaves, branches)9
- Neuro: weakness, dizziness, numbness, stupor (fresh wild elderberry juice crushed w/ leaves, branches)9
- Potential drug interactions: none confirmed10
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 3/31/20
2 COVID-19 FAQ. The University of Arizona Andrew Weil Center for Integrative Medicine. Accessed 3/28/20
3 Barak V, et al. The Effect of Sambucol, a Black Elderberry-based, Natural Product, on the Production of Human cytokines: I. Inflammatory cytokines. Eur Cytokine Netw. 2001. Apr-Jun;12(2):290-6. Accessed 3/28/20
4 American Botanical Council. HerbClip. 2009. Accessed 3/28/20
5 Zakay-Rones Z, et al. Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment of Influenza A and B Virus Infections. J Int Med Res. 2004. Mar-Apr;32(2):132-40. PubMed abstract
6 Zakay-Rones Z, et al. Inhibition of Several Strains of Influenza Virus in Vitro and Reduction of Symptoms by an Elderberry Extract ( Sambucus nigra L.) During an Outbreak of Influenza B Panama. J Altern Complement Med. 1995. Winter;1(4):361-9. PubMed abstract
7 Tiralongo E, et al. Elderberry Supplementation Reduces Cold Duration and Symptoms in Air-Travellers: A Randomized, Double-Blind Placebo-Controlled Clinical Trial. Nutrients. 2016. Mar 24;8(4):182. Free full-text PDF
8 Forster-Waldl E, et al. Type I Allergy to Elderberry ( Sambucus nigra) is Elicited by a 33.2 kDa Allergen With Significant Homology to Ribosomal Inactivating Proteins. Clin Exp Allergy. 2003. Dec;33(12):1703-10. PubMed abstract
9 Centers for Disease Control and Prevention. Poisoning From Elderberry Juice--California. Morb Mortal Wkly Rep. 1984. Apr 6;33(13):173-174. Accessed 3/28/20
10 The American Botanical Council. The ABC Clinical Guide to Elder Berry. 2003. Accessed 4/03/20
echinacea (E angustifolia, E purpurea, E pallida) There’s no scientific evidence that echinacea or any other herbal remedy is effective for COVID-19 prevention/tx1 Media trends - Has been suggested for COVID-19 prevention based on historical use in cold/flu sx relief
- Cytokine storm media debate. Some suggest OK for prevention, but should d/c @ COVID-19 sx onset, due to possible immune inflammatory up-regulation;2 theory based on in vitro E purpurea study on ↑inflammatory cytokine production in human macrophages3 and other limited data4
Reports on non-COVID-19 use - Cold sx. Echinacea extract 2400 mg/day PO divided tid x4mo, then incr. @ cold sx onset to 4000 mg/day PO divided 5x/day (Echinaforce) used in RCT (N=755, age >18 yo): ↓ # cold episodes, cumulative episode days vs placebo; safety noninferior to placebo.5 Mixed results from other trials of various doses/forms:6 1 meta-analysis found possible weak benefit for cold incidence prevention, no benefit for cold tx7
- Flu sx. Combo product of E purpurea extract (1140 mg herb + 60 mg root) + elderberry juice concentrate 1383 mg, as 5 mL PO 3-5x/day x10 days (Echinaforce Hot Drink). RCT (N=473, age 12-70 yo) showed noninferiority to oseltamivir 75 mg PO bid, however no placebo control8
Potential adverse effects reported - Allergy: allergic rxn risk incr. if atopic dz hx;9 rash in peds pts10
- GI: nausea, epigastric pain, constipation11,12
- Neuro: fatigue, dizziness, HA11,13
- Other case reports: hepatotoxicity, thrombocytopenia13
- Potential drug interactions: CYP1A2 substrates (may inhibit),14 3A4 substrates (may induce),15 immunosuppressants (may antagonize)16
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 3/31/20
2 COVID-19 FAQ. The University of Arizona Andrew Weil Center for Integrative Medicine. Accessed 4/2/20
3 Burger RA, et al. Echinacea-Induced Cytokine Production by Human Macrophages. Int J Immunopharmacol. 1997 Jul;19(7):371-9. Accessed 4/2/20
4 American Botanical Council. Excerpt from Herbal Medicine: Expanded Commission E Monographs. Integrative Medicine Communications. 2000. Echinacea Angustifolia herb and root/Pallida herb. Accessed 4/1/20
5 Jawad M, et al. Safety and Efficacy Profile of Echinacea Purpurea to Prevent Common Cold Episodes: A Randomized, Double-blind, Placebo-controlled Trial. Evid Based Complement Alternat Med. 2012. 2012:841315. PubMed abstract | Free full-text PDF
6 Allan GM, et al. Prevention and Treatment of the Common Cold: Making Sense of the Evidence. CMAJ. 2014. Feb 18;186(3):190-199. PubMed abstract | Free full-text PDF
7 Karsch-Völk M, et al. Echinacea for Preventing and Treating the Common Cold. Cochrane Database Syst Rev. 2014;(2):CD000530. Accessed 4/2/20
8 Raus K, et al. Effect of an Echinacea-based Hot Drink versus Oseltamivir in Influenza Treatment: A Randomized, Double-blind, Double-dummy, Multicenter, Noninferiority Clinical Trial. Curr Ther Res Clin Exp. 2015;20;77:66-72. Accessed 4/2/20
9 NIH. National Center for Complementary and Integrative Health. Echinacea. Updated 2016. Accessed 4/1/20
10 Taylor JA, et al. Efficacy and Safety of Echinacea in Treating Upper Respiratory Tract Infections in Children: A Randomized Controlled Trial. JAMA. 2003;290:2824-30. Accessed 4/2/20
11 Grimm W, et al. A Randomized Controlled Trial of the Effect of Fluid Extract of Echinacea purpurea on the Incidence and Severity of Colds and Respiratory Infections. Am J Med. 1999. Feb;106(2):138-43. Accessed 4/2/20
12 Huntley AL, et al. The Safety of Herbal Medicinal Products Derived From Echinacea Species: A Systematic Review. Drug Saf. 2005;28(5):387-400. Accessed 4/3/20
13 Echinacea. About Herbs. Memorial Sloan Kettering Cancer Center. Last updated 3/16/20. Accessed 4/1/20
14 Gorski JC, et al. The Effect of Echinacea (Echinacea purpurea root) on Cytochrome P450 Activity in Vivo. Clin Pharmacol Ther. 2004. Jan;75(1):89-100. Accessed 4/3/20
15 Penzak SR, et al. Echinacea Purpurea Significantly Induces Cytochrome P450 3A Activity But Does Not Alter Lopinavir-Ritonavir Exposure in Healthy Subjects. Pharmacotherapy. 2010. Aug;30(8):797-805. PubMed abstract | Free full-text PDF
16 Lee AN, et al. Activation of Autoimmunity Following Use of Immunostimulatory Herbal Supplements. Arch Dermatol. 2004. Jun;140(6):723-7. Accessed 4/14/20
astragalus (A membranaceus, huang qi) There’s no scientific evidence that astragalus or any alternative remedy is effective for COVID-19 prevention/tx1 Media trends - Has been suggested for COVID-19 tx/prevention based on immunostimulatory effects & ↓inflammatory cytokines,2,3 though others raise theoretical concerns about cytokine storm potential4
- Traditionally used in Chinese medicine for immune boosting against cold/flu, now suggested w/ or w/o other herbs for COVID-19,5 but standardization of regimens lacking
Non-COVID-19 use - Acute respiratory infxn prevention. Insufficient evidence to assess safety/effectiveness of oral astragalus alone to prevent frequent infxn in children <14 yo, per meta-analysis6
- Although trialed in myocarditis, kidney/liver dz, lung cancer, etc, no high-quality human studies on astragalus exist for any condition7
Potential adverse effects reported - Mild GI adverse effects;7 fatigue, malaise, HA, ↓BP reported8
- Potential drug interactions: immunosuppressants (may antagonize)7,9
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 5/1/20
2 Weil A. COVID-19: What You Should Know About Coronavirus. DrWeil.com. Accessed 5/1/20
3 Alschuler L, et al. Integrative Considerations During the COVID-19 Pandemic. Explore (NY). 2020. March 26. pii:S1550-8307(20)30113-0. Accessed 5/1/20
4 Consumer Lab. Natural Remedies & Supplements for Coronavirus (COVID-19). Accessed 5/1/20
5 Yang Y, et al. Traditional Chinese Medicine in the Treatment of Patients Infected With 2019-New Coronavirus (SARS-CoV-2): A Review and Perspective. Int J Biol Sci. 2020. March 15;16(10):1708-1717. PubMed abstract | Free full-text PDF
6 Su G, et al. Oral Astragalus (Huang Qi) for Preventing Frequent Episodes of Acute Respiratory Tract Infection in Children. Cochrane Database Syst Rev. 2016. Dec 1;12(12):CD011958. PubMed abstract | Free full-text PDF
7 NIH. National Center for Complementary and Integrative Health. Astragalus. Updated Sept 2016. Accessed 5/1/20
8 Denzler K, et al. Characterization of the Physiological Response Following In Vivo Administration of Astragalus membranaceus. Evid Based Complement Alternat Med. 2016;2016:6861078. PubMed abstract | Free full-text PDF
9 Astragalus. About Herbs. Memorial Sloan Kettering Cancer Center. Last updated 3/13/20. Accessed 5/1/20
black seed (Nigella sativa) There’s no scientific evidence that black seed or any alternative remedy is effective for COVID-19 prevention/tx.1 Nigella sativa plant seeds, oil, extract have been used in traditional medicine as an antioxidant remedy for a variety of conditions Media trends - Has been suggested for COVID-19 tx/prevention based on immunomodulatory effects2-5 w/ speculations characterizing it as a “disinfectant,” “antimicrobial” home remedy based on historical anecdotal use for URI & other infxns6,7
- Purported antiviral effects based on preclinical & other limited data8,9
Trial in COVID-19 - COVID-19 tx trial. Nigella sativa seed powder 2 g + honey 30 mL PO bid in COVID-19 pts, placebo-controlled RCT in Pakistan10
Non-COVID-19 use - Acute tonsillopharyngitis. Nigella sativa capsules 360 mg + Phyllanthus niruri 50 mg extracts PO tid x7 days vs placebo improved sore throat pain, swallowing difficulty (RCT, N=186)11
- HCV. Limited evidence, eg, ↓viral load w/ Nigella sativa seed oil 450 mg PO tid (N=30, no control) & w/ Nigella sativa 500 mg PO bid vs control (N=60)12,13
- Asthma. Evidence mixed,14 1 meta-analysis finds potential benefits in ↑asthma control scores & FEV1, but no clear effect on PEF15
Potential adverse effects reported - Allergic contact dermatitis w/ topical use;16 nausea, bloating, burning sensation w/ oil form, slight ↑liver/kidney enzymatic markers reported w/ oil & crushed seeds14
- Potential drug interactions: may inhibit CYP2D6 substrates, CYP3A4 substrates17
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 5/7/20
2 Fox 5 Atlanta. Doctor Offers Coronavirus Protection Advice. Published March 24, 2020. Updated April 6, 2020. Accessed 5/7/20
3 Leo Galland MD. Coronavirus Handbook. April 17, 2020. Accessed 5/7/20
4 Mark Hoch MD. COVID 19: Treatment and Updates – Based on What We Now Know. March 25, 2020. Accessed 5/7/20
5 Moidin S. The Cognate. Nigella Sativa: Every Disease Has A Cure – Decelerating The COVID-19 Pandemic. March 22, 2020. Accessed 5/7/20
6 Wasway Y. Nature’s Blend. Black Seed Oil: An All-Natural Defense Against COVID-19. April 24, 2020. Accessed 5/7/20
7 Kundu C. India Today. Fact Check: Do Kalonji Seeds Have the 'Miracle Drug' US Is After? April 10, 2020. Accessed 5/7/20
8 Ruggia T. Elite Healthy Living. Black Seed Oil (Nigella Sativa) Can Kill the Coronavirus. March 27, 2020. Accessed 5/7/20
9 Tello C. Could Black Cumin Seed Help With COVID-19? April 14, 2020. Selfhacked.com.
10 Efficacy of Nigella Sativa and Natural Honey Against COVID-19 (WUHAN). ClinicalTrials.gov. Accessed 5/7/20
11 Dirjomuljono M, et al. Symptomatic Treatment of Acute Tonsillo-Pharyngitis Patients With a Combination of Nigella sativa and Phyllanthus niruri Extract. Int J Clin Pharmacol Ther. 2008. Jun;46(6):295-306. PubMed abstract
12 Barakat EM, et al. Effects of Nigella sativa on Outcome of Hepatitis C in Egypt. World J Gastroenterol. 2013. April 28;19(16):2529‐2536. PubMed abstract | Free full-text PDF
13 Abdel-Moneim A, et al. Beneficial Therapeutic Effects of Nigella sativa and/or Zingiber officinale in HCV Patients in Egypt. EXCLI J. 2013. Nov 11;12:943‐955. PubMed abstract | Free full-text PDF
14 Tavakkoli A, et al. Review on Clinical Trials of Black Seed ( Nigella sativa)
and Its Active Constituent, Thymoquinone. J Pharmacopuncture. 2017. Sep;20(3):179-193. PubMed abstract | Free full-text PDF
15 He T, et al. The Influency of Nigella sativa for Asthma Control: A Meta-analysis. Am J Emerg Med. 2019. Nov 29;doi:10:1016/j.ajem.2019.11.036. PubMed abstract
16 Nigella Sativa. About Herbs. Memorial Sloan Kettering Cancer Center. Last updated 5/13/20. Accessed 5/30/23
17 Al-Jenoobi FI, et al. Effect of Black Seed on Dextromethorphan O- and N-demethylation in Human Liver Microsomes and Healthy Human Subjects. Drug Metab Lett. 2010. Jan;4(1):51-5. PubMed abstract
There’s no scientific evidence that turmeric or any alternative remedy is effective for COVID-19 prevention/tx.1,2 Common spice & dietary supplement available as capsule, tablet, tea, powder, extracts; used historically for various conditions Media trends - Has been suggested for COVID-19 tx/prevention based on anti-inflammatory & antiviral effects of turmeric’s curcumin constituent3,4
- Some influencers allude to immune-boosting potential,5 others warn turmeric supplements may disrupt immune system6
- Theorized to enhance ACE2 cell receptor “resilience” and reduce COVID-19-related “ACE2 exhaustion,” thereby reducing COVID infxn7
Trial in COVID-19 - COVID-19 tx trial. Oral spray (ArtemiC) w/ artemisinin 6 mg, curcumin 20 mg, boswellia 15 mg, vitamin C 60 mg per day divided bid x2 days, placebo-controlled RCT in Israel8
Non-COVID-19 use - Infxn. Purported use as anti-infective,9 but clinical studies limited. 1 study found no evidence of ↓viral load or ↑CD4 count in HIV pts (N=40)10
- Inflammation. No strong clinical studies support claims that curcuminoids ↓inflammation11
- Cold prevention. Combo product containing extracts of ginger 5 mg, turmeric 50 mg, pomegranate 20 mg (Phyto-relief CC) used in early sx onset showed ↓cold episodes & duration, & reduced use of other OTC remedies vs control, in a small study (N=124)12
- Perennial allergic rhinitis. Curcumin 500 mg/day vs placebo alleviated nasal sx/congestion by ↓nasal airflow resistance in RCT (N=241)13
- Has been studied for Alzheimer dz, rheumatoid arthritis, prostate & colon cancer11
Potential adverse effects reported - Generally safe when administered orally/topically, high-dose/long-term use may cause GI adverse effects.11 Potential hepatotoxicity risk per case reports.14,15 Various clinical trials using curcumin 1125-2500 mg/day found it to be safe; 1 trial w/ curcumin 8000 mg/day x3mo found no toxicity per safety review16
- Potential drug interactions: may inhibit CYP1A2 substrates,17 BCRP substrates,18 ENT1 substrates,19 P-gp substrates20
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 5/13/20
2 WHO 2020. World Health Organization. Coronavirus Disease (COVID-19) Advice for the Public: Myth Busters. Accessed 5/13/20
3 The University of Arizona. Andrew Weil Center for Integrative Medicine. Integrative Medicine Doctors Offer Approaches to Combat COVID-19. UA News. March 30, 2020. Accessed 5/12/20
4 Consumer Lab. Natural Remedies & Supplements for Coronavirus (COVID-19). Accessed 5/12/20
5 Kubala J. Healthline. The 15 Best Supplements to Boost Your Immune System Right Now. May 7, 2020. Accessed 5/12/20
6 Chu W. ANSES Warns of Turmeric-based Supplements’ Effect on Immune Response. NUTRAingredients.com. April 21, 2020. Accessed 5/12/20
7 Leo Galland MD. Coronavirus Handbook. Accessed 5/12/20
https://drgalland.com/coronavirus-protection-protocol/
8 A Phase II, Controlled Clinical Study Designed to Evaluate the Effect of ArtemiC in Patients Diagnosed With COVID-19. ClinicalTrials.gov. Accessed 5/12/20
9 Turmeric. About Herbs. Memorial Sloan Kettering Cancer Center. Last updated 3/6/20. Accessed 5/12/20
10 James JS. Curcumin: Clinical Trial Finds No Antiviral Effect. AIDS Treat News. 1996. Mar 1;(no 242):1-2. PubMed abstract
11 NIH. National Center for Complementary and Integrative Health. Turmeric. Updated September 2016. Accessed 5/12/20
12 Luzzi R, et al. Phyto-relief CC: Prevention of Cold Episodes. Control of Signs/Symptoms and Complications. Minerva Gastroenterol Dietol. 2015 Oct 22. Online ahead of print. PubMed® abstract
13 Wu S, et al. Effect of Curcumin on Nasal Symptoms and Airflow in Patients With Perennial Allergic Rhinitis. Ann Allergy Asthma Immunol. 2016. Dec;117(6):697-702. PubMed abstract
14 Imam Z, et al. Drug Induced Liver Injury Attributed to a Curcumin Supplement. Case Rep Gastrointest Med. 2019. Oct 20;2019:6029403. PubMed abstract | Free full-text PDF
15 Lukefahr AL, et al. Drug-induced Autoimmune Hepatitis Associated With Turmeric Dietary Supplement Use. BMJ Case Rep. 2018. Sep 10;2018:pii:bcr-2018-224611. PubMed Abstract
16 Chainani-Wu N. Safety and Anti-inflammatory Activity of Curcumin: A Component of Turmeric ( Curcuma longa). J Altern Complement Med. 2003. Feb;9(1):161-8. PubMed abstract
17 Chen Y, et al. Plant Polyphenol Curcumin Significantly Affects CYP1A2 and CYP2A6 Activity in Healthy, Male Chinese Volunteers. Ann Pharmacother. 2010. Jun;44(6):1038-45. PubMed abstract
18 Kusuhara H, et al. Pharmacokinetic Interaction Study of Sulphasalazine in Healthy Subjects and the Impact of Curcumin as an In Vivo Inhibitor of BCRP. Br J Pharmacol. 2012 Jul;166(6):1793-803. PubMed abstract | Free full-text PDF
19 Revalde JL, et al. Curcumin and Its Cyclohexanone Analogue Inhibited Human Equilibrative Nucleoside Transporter 1 (ENT1) in Pancreatic Cancer Cells. Eur J Pharmacol. 2017. May 15;803:167-173. PubMed abstract
20 He X, et al. Effects of Curcumin on the Pharmacokinetics of Talinolol in Human With ABCB1 Polymorphism. Xenobiotica. 2012. Dec;42(12):1248-54. PubMed abstract
oregano oil (Origanum vulgare, carvacrol) There’s no scientific evidence that oregano oil or any alternative remedy is effective for COVID-19 prevention/tx.1 Herbal oil available as a supplement, incl capsule or tincture form; source of quercetin2 Media trends - Has been suggested for COVID-19 tx/prevention;3,4 based on preclinical antiviral effects against other enveloped viruses5 & as antioxidant, heart health support6
- Some distributors promoting products for COVID-19 reprimanded for misleading ads w/o evidence from human data7
- Used in traditional Chinese medicine for fever, lung dz, etc8
Non-COVID-19 use - Purported use in resp tract disorders, but evidence limited
- URI sx. Throat spray containing oregano, eucalyptus, peppermint, rosemary essential oils used 5x/day x3 days vs placebo ↓sore throat, hoarseness, cough, but no significant difference after 3 days in RCT (N=60)9
- Has been used topically for wound healing, orally for stomach disorders & various other conditions, but insufficient evidence overall; appropriate doses not established10
Potential adverse effects reported - Generally safe, mild adverse effects incl stomach upset;10 may ↓glucose, may ↑bleeding risk;10 allergic rxn if allergy to Lamiaceae family (eg, thyme, basil, mint, sage, lavender);11 should not be applied topically at >1% concentration d/t irritation;10 non-emulsified oregano oil may irritate digestive tract lining12
- Potential drug interactions: may ↓absorption of Cu, Fe, Zn10
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 5/1/20
2 Yunez-Behm V, et al. Personalized Nutrition & the COVID-19 Era: A Rapid Review for Health Professionals. American Nutrition Association. Updated May 5, 2020. Accessed 5/21/20
3 Advisory Board. Does Oregano Oil Cure the New Coronavirus? Misinformation Runs Rampant on Facebook, Twitter. Daily Briefing. January 29, 2020. Accessed 5/21/20
4 Jones S. As Coronavirus Panic Heats Up, So Do Sales of Snake Oil. New York Magazine. March 15, 2020. Accessed 5/21/20
5 Burris K. COVID-19 and Oregano Oil: What Does the Science Say? Burris Institute. Accessed 5/21/20
6 Aleksic A. Can Oregano Fight Coronavirus (COVID-19)? April 4, 2020. Selfhacked.com.
7 Snowdon W. Cow Urine, Bleach, Oregano Oil: Medical COVID-19 Quackery Has Big Ramifications for Public Health. CBC. April 3, 2020. Accessed 5/21/20
8 Han F, et al. Chemical Composition and Antioxidant Activities of Essential Oils From Different Parts of the Oregano. J Zhejiang Univ Sci B. 2017. Jan;18(1):79–84. PubMed abstract | Free full-text PDF
9 Ben-Arye E, et al. Treatment of Upper Respiratory Tract Infections in Primary Care: A Randomized Study Using Aromatic Herbs. Evid Based Complement Alternat Med. 2011. Nov 1;690346. Pubmed abstract | Free full-text PDF
10 NIH. MedlinePlus: Oregano. Last reviewed Jan 10, 2019. Accessed 5/21/20
https://medlineplus.gov/druginfo/natural/644.html
11 Benito M, et al. Labiatae Allergy: Systemic Reactions Due to Ingestion of Oregano and Thyme. Ann Allergy Asthma Immunol. 1996. May;76(5):416-8. PubMed abstract
12 Force M, et al. Inhibition of Enteric Parasites by Emulsified Oil of Oregano in Vivo. Phytother Res. 2000. May;14(3):213-4. PubMed abstract
Asian ginseng (Panax ginseng) & American ginseng (Panax quinquefolius) There’s no scientific evidence that ginseng or any alternative remedy is effective for COVID-19 prevention/tx.1 Panax ginseng, aka Asian or red ginseng, is a distinct species from Panax quinquefolius, aka American ginseng2 Media trends - Ginseng’s purported use for COVID-19 tx/prevention based on anti-inflammatory, antiviral effects,3 & immune-boosting effects4
Non-COVID-19 use in acute resp illness - Overall, evidence insufficient to permit conclusions on ginseng for ↓common cold incidence/severity, per meta-analysis (4 American ginseng RCTs, 1 Asian ginseng RCT; N=747);5 however, American ginseng taken preventively x8-16wk appears effective in ↓cold/acute resp illness duration5
- American ginseng. 200-400 mg PO bid (COLD-fX) has been studied in RCTs; result suggesting potential in preventing URIs; however, more study warranted6-9
- Asian ginseng. 200 mg PO qd x12wk (Ginsana) started 4wk prior to flu vaccine significantly ↓flu or common cold frequency vs placebo in RCT (N=227).10 An RCT (N=100) studying 1 g PO tid x12wk showed ↓pts reporting ≥1 acute resp illness during flu season vs pts on placebo, but no difference in sx duration11
Potential adverse effects reported - Common side effects incl insomnia, HA, & digestive problems2
- Potential drug interactions: May have additive hypoglycemia risk (eg, w/ insulin);12 Asian ginseng may induce CYP3A4 substrates13
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 9/15/20
2 NIH. National Center for Complementary and Integrative Health. Asian Ginseng. Updated September 2016. Accessed 6/24/20
3 The University of Arizona. Andrew Weil Center for Integrative Medicine. COVID-19 FAQ. Accessed 6/24/20
4 Tello C. Can Ginseng Help Fight COVID-19? April 27, 2020. Selfhacked.com.
5 Seida JK, et al. North American ( Panax quinquefolius) and Asian Ginseng ( Panax ginseng) Preparations for Prevention of the Common Cold in Healthy Adults: A Systematic Review. Evid Based Complement Alternat Med. 2011;2011:282151.
PubMed® abstract | Free full-text PDF @ PubMed® Central
6 McElhaney JE, et al. A Placebo-Controlled Trial of a Proprietary Extract of North American Ginseng (CVT-E002) to Prevent Acute Respiratory Illness in Institutionalized Older Adults. J Am Geriatr Soc. 2004;52:13-9. PubMed® abstract
7 Predy GN, et al. Efficacy of an Extract of North American Ginseng Containing Poly-Furanosyl-Pyranosyl-Saccharides for Preventing Upper Respiratory Tract Infections: A Randomized Controlled Trial. CMAJ. 2005;173:1043-8.
PubMed® abstract
8 McElhaney JE, et al. Efficacy of COLD-fX in the Prevention of Respiratory Symptoms in Community-Dwelling Adults: A Randomized, Double-Blinded, Placebo-Controlled Trial. J Altern Complement Med. 2006;12:153-7.
PubMed® abstract
9 McElhaney JE, et al. Efficacy and Safety of CVT-E002, a Proprietary Extract of Panax quinquefolius in the Prevention of Respiratory Infections in Influenza-Vaccinated Community-Dwelling Adults: A Multicenter, Randomized, Double-Blind, and Placebo-Controlled Trial. Influenza Res Treat. 2011;2011:759051. PubMed® abstract
10 Scaglione F, et al. Efficacy and Safety of the Standardized Ginseng Extract G115 for Potentiating Vaccination Against the Influenza Syndrome and Protection Against the Common Cold. Drugs Exp Clin Res. 1996;22:65-72. PubMed® abstract
11 Lee CS, et al. Preventive Effect of Korean Red Ginseng for Acute Respiratory Illness: A Randomized and Double-Blind Clinical Trial. J Korean Med Sci. 2012;27(12):1472-8. PubMed® abstract | Free full-text PDF
12 Oh MR, et al. Postprandial Glucose-Lowering Effects of Fermented Red Ginseng in Subjects With Impaired Fasting Glucose or Type 2 Diabetes: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. BMC Complement Altern Med. 2014. Jul 11;14:237. PubMed® abstract | Free full-text PDF @ PubMed® Central
13 Malati CY, et al. Influence of Panax Ginseng on Cytochrome P450 (CYP)3A and P-glycoprotein (P-gp) Activity in Healthy Participants. J Clin Pharmacol. 2012. Jun;52(6):932-9. PubMed® abstract | Free full-text PDF @ PubMed® Central
There’s no scientific evidence that garlic or any alternative remedy is effective for COVID-19 prevention/tx.1,2 Used to flavor foods & as dietary supplement available as capsule or tablet Media trends
- Has been suggested for COVID-19 prevention based on immune-boosting potential & antiviral properties3-5
Non-COVID-19 use - Cold prevention. Allicin supplement 180 mg cap PO qd x12wk showed significantly ↓cold frequency vs placebo in RCT (N=146).6 Overall, insufficient clinical evidence to validate garlic use in preventing/treating common cold7
Potential adverse effects reported - May be more noticeable w/ raw garlic consumption & may incl: breath & body odor, heartburn, GI upset, allergic rxn8 & reports of chemical burn w/ prolonged, topical admin9-11
- Potential drug interactions w/ supplemental garlic: May have additive bleeding risk (eg, w/ warfarin), hypoglycemia risk (eg, w/ insulin), & may interfere w/ certain CYP 450 substrates;12 may have additive hypotensive effects w/ certain drugs.9 (Details at epocrates Plus interaction check)
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 11/20/20
2 WHO 2020. World Health Organization. Coronavirus Disease (COVID-19) Advice for the Public: Myth Busters. Accessed 11/24/20
3 Weil A. COVID-19: What You Should Know About Coronavirus. DrWeil.com. Accessed 11/24/20
4 Consumer Lab. Natural Remedies & Supplements for Coronavirus (COVID-19). Accessed 11/24/20
5 Kubala J. Healthline. The 15 Best Supplements to Boost Your Immune System Right Now. May 7, 2020. Accessed 11/24/20
6 Josling P. Preventing the Common Cold With a Garlic Supplement: A Double-blind, Placebo-controlled Survey. Adv Ther. 2001;18(4):189-93. PubMed® abstract
7 Lissiman E, et al. Garlic for the Common Cold. Cochrane Database Syst Rev. Nov; 2014(11):CD006206. PubMed® abstract | Free full-text PDF @ PubMed® Central
8 NIH. National Center for Complementary and Integrative Health. Garlic. Updated September 2016. Accessed 11/24/20
9 Ried, K, et al. Aged Garlic Extract Reduces Blood Pressure in Hypertensives: A Dose–Response Trial. Eur J Clin Nutr. 2013. Jan;67(1):64–70. PubMed® abstract | Free full-text PDF @ PubMed® Central
10 Bagga S, Thomas BS, Bhat M. Garlic Burn as Self-inflicted Mucosal Injury--A Case Report and Review of the Literature. Quintessence Int. 2008;Jun;39(6):491-4. PubMed® abstract
11 Karabacak E, et al. An Unusual Garlic Burn Occurring on an Unexpected Area. BMJ Case Rep. 2014. Apr 7;2014:bcr2013203285. PubMed® abstract | Free full-text PDF @ PubMed® Central
12 Garlic. About Herbs. Memorial Sloan Kettering Cancer Center. Updated 11/18/22. Accessed 5/30/23
ginger (Zingiber officinale) There’s no scientific evidence that ginger or any alternative remedy is effective for COVID-19 prevention/tx.1 Used to flavor foods & as dietary supplement available as capsule, tablet, liquid extract, dried root, or teas Media trends - Has been suggested for COVID-19 prevention as a home remedy and cure-all on social media,2 to boost immunity based on potential anti-inflammatory & antioxidant properties3-5
Non-COVID-19 use - Cold prevention. Combo product containing extracts of ginger 5 mg, turmeric 50 mg, pomegranate 20 mg (Phyto-relief CC) used in early sx onset showed ↓cold episodes & duration, & reduced use of other OTC remedies vs control, in a small study (N=124)6
- Acute respiratory distress syndrome (ARDS). Enteral diet supplemented w/ ginger showed significant difference in mechanical ventilation duration & length of ICU stay vs placebo, but no difference in mortality, in small RCT (N=32)7
Potential adverse effects reported - Generally safe when used as spice; mild adverse effects incl abdominal discomfort, heartburn, diarrhea, gas8
- Potential drug interactions w/ supplemental ginger: May have additive bleeding risk (eg, w/ warfarin),9 however, studies show mixed results for effect on platelet aggregation10
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 11/20/20
2 Wintle T. CGTN. Enjoy Ginger, But It's Not a 'Cure' for COVID-19, Says WHO. April 3, 2020. Accessed 11/24/20
3 Thakur A. India.com. Benefits of Ginger in COVID-19: Fight Lung Infection By Adding Ginger in Kadha or Tea. September 6, 2020. Accessed 11/24/20
4 Curley B. Healthline. What Experts Say You Can Do to Treat Yourself at Home If You Have a Mild Case of COVID-19. March 23, 2020. Accessed 11/24/20
5 Zupec-Kania B. Keto Lifestyle. Beef Up Your Immunity Against COVID-19. March 13, 2020. Accessed 11/24/20
6 Luzzi R, et al. Phyto-Relief CC: Prevention of Cold Episodes. Control of Signs/Symptoms and Complications. Minerva Gastroenterol Dietol. 2015 Oct 22. Online ahead of print. PubMed® abstract
7 Vahdat Shariatpanahi Z, et al. Effect of Enteral Feeding With Ginger Extract in Acute Respiratory Distress Syndrome. J Crit Care. 2013. Apr;28(2):217.e1-6. PubMed® abstract
https://pubmed.ncbi.nlm.nih.gov/22884532/
8 NIH. National Center for Complementary and Integrative Health. Ginger. Updated September 2016. Accessed 11/24/20
9 Ginger. About Herbs. Memorial Sloan Kettering Cancer Center. Updated 3/27/20. Accessed 11/24/20
10 Marx W, et al. The Effect of Ginger ( Zingiber officinale) on Platelet Aggregation: A Systematic Literature Review. PLoS One. 2015. Oct 21;10(10):e0141119. Erratum in: PLoS One. 2015;10(11):e0143675. PubMed® abstract | Free full-text PDF @ PubMed® Central
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Vitamins & minerals (vitamin C, vitamin D, zinc, selenium, silver)
vitamin C (ascorbic acid, Emergen-C, etc) There’s no scientific evidence that vit C or any alternative remedy is effective for COVID-19 prevention/tx1
Media trends - Media spotlight on high-dose IV use in COVID-19 inpts2
- “Immune-boosting” cold/flu remedy based on anti-oxidant, immune fxn properties; humans require exogenous vit C, plasma levels may ↓w/ infxn3
Trial in COVID-194 - Outpt tx. No significant difference in pt-reported sx duration between high-dose vit C (8 g/day PO divided bid-tid x10 days), or zinc gluconate (50 mg PO qhs x10 days), or combo, vs usual care in a randomized open-label clinical trial (N=214)
Other reports on COVID-19 use - High-dose IV vit C (50-200 mg/kg/day) suggested for severe/critically ill COVID-19 inpts to ↑oxygenation, prevent cytokine storm, per Chinese expert opinion.5 Clinical trials in pneumonia inpts underway in China (12 g IV q12h x7 days),6 Italy (10 g IV x1)7
Reports on non-COVID-19 use - Cold prevention. No benefit of regular vit C ≥200 mg PO qd use on cold incidence (29 trials, N=11,306), except in athletes/soldiers exposed to brief severe exercise (5 trials, N=598), per meta-analysis8
- Cold duration/severity. Regular use of ≥200 mg PO qd assoc w/ 8% ↓cold duration in adults, 14%↓ in children (31 trials, N=9,745 episodes); 1-2 g/day ↓duration by 18% in children, per meta-analysis.8 Cold severity (16 trials, N=7,209) also↓ (eg, by 5% in 1 RCT). However, data inconsistent for high dose vit C started @ cold sx onset8
- Pneumonia prevention. 2 g PO qd in 8-wk RCT (N=674 US marine recruits) assoc w/ ↓pneumonia incidence vs placebo (OR, 0.23)3
- Acute lower resp tract infxn tx. 200 mg PO qd in older inpts w/ bronchitis or pneumonia RCT (N=57; ages 66-94 yo; some vit C deficient): severity scores @ 4wk marginally significantly improved vs placebo--but only in most severely ill inpts, a group w/ lower initial plasma vit C. Higher dose (0.5-1.6 g/day) vs lower dose (250-800 mg/day) PO assoc w/ ↓pneumonia duration in 1 trial (N=70 adult male inpts, some vit C deficient)3
Potential adverse effects reported - Generally safe; diarrhea, nausea, abdominal cramps reported at high doses;9 oral doses equivalent to clinical trial IV doses could lead to serious GI adverse effects10
- See ascorbic acid (vitamin C) adverse events and drug interaction check in epocrates
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 3/31/20
2 New York Hospitals Treating Coronavirus Patients With Vitamin C. New York Post. Mar 24, 2020. Accessed 4/3/20
3 Hemila H, et al. Vitamin C for Preventing and Treating Pneumonia. Cochrane Database of Syst Rev. 2013. Aug 8;(8):CD005532. Accessed 4/4/20
4 Thomas S, et al. Effect of High-Dose Zinc and Ascorbic Acid Supplementation vs Usual Care on Symptom Length and Reduction Among Ambulatory Patients With SARS-CoV-2 Infection. The COVID A-Z Randomized Clinical Trial. JAMA Netw Open. 2021;4(2):e210369. Accessed 2/12/21
5 Shanghai Expert Group on Clinical Treatment of New Coronavirus Diseases. Expert Consensus on Comprehensive Treatment of Coronavirus Diseases in Shanghai in 2019. Chin J Infect Dis. March 20, 2020. 38: Epub ahead of print. Accessed 5/30/23
6 Vitamin C Infusion for the Treatment of Severe 2019-nCoV Infected Pneumonia. ClinicalTrials.gov. Accessed 4/4/20
7 Use of Ascorbic Acid in Patients With COVID 19. ClinicalTrials.gov. Accessed 4/3/20
8 Hemila H, et al. Vitamin C for Preventing and Treating the Common Cold. Cochrane Database Syst Rev. 2013. Jan 31;(1):CD000980. Accessed 4/3/20
9 Vitamin C Fact Sheet for Health Professionals. NIH. Feb 27, 2020. Accessed 4/1/20
10 Addressing Questions About High-Dose Vitamin C for COVID-19. News. April 2020. Natural Medicines Inc. Accessed 4/04/20
vitamin D (D3/cholecalciferol, D2/ergocalciferol) There’s no scientific evidence that vit D or any alternative remedy is effective for COVID-19 prevention/tx1 Media trends - Vit D proposed for fighting COVID-19, providing protection for vulnerable pts, per former CDC Dir. Tom Frieden via Twitter,2 news3
- Hypotheses: ↑D deficiency prevalence in pts w/ factors assoc w/ ↑COVID risk—older, obesity, smoker, lung dz4—as well as winter, ↓sun, dark skin, certain latitudes, poor diet;5 vit D’s role in immunity;5 non-COVID resp infxn studies6
- Megadoses (eg, 150,000 IU D3 qd x3 days) to prevent/tx COVID-19 promoted by some media influencers,7 based on vit D use as immune-booster, anti-inflammatory for ↓“inflamm-aging”4
- Cytokine storm debate. Some suggest vit D may ↓cytokine storm immune up-regulation linked to severe COVID-19;4 others suggest vit D could exacerbate it, if taken after sx onset8
Trial in COVID-19 - Mild COVID-19 tx trial. Vit D 25,000 IU PO x1 w/ toast + olive oil (for absorption) in pts 40-70 yo w/ non-severe COVID-19 sx, RCT in Spain9
- NICE rapid review. Currently no evidence to support vit D supplements ↓COVID-19 risk/severity specifically10
Reports on non-COVID-19 use - Resp tract infxn. ↓acute resp tract infxn (ARTI) seen w/ daily/weekly vit D3 or D2 supplementation (not w/ bolus doses); strongest protective effect in vit D-deficient pts, per meta-analysis (25 RCTs, N=10,933, ages 0-95 yo).11 Smaller meta-analysis (5 trials) showed ↓resp tract infxn w/ vit D 400-2000 IU/day vs controls, but depending on model, results significant only in children (OR, 0.58);12 however, per recent SACN rapid review, subsequent evidence doesn’t support vit D supplementation to prevent ARTI13
- Flu in children. Vit D3 1200 IU/day PO in winter linked to ↓influenza A vs placebo (RR, 0.58) in RCT (N=334 school children)14
- Pneumonia. Vit D deficiency (<20 ng/mL) linked to ↑CAP risk (OR, 1.64) in meta-analysis of 8 observational studies (N=20,966, ages 0-94 yo)15
- Critical illness. Mortality, LOS not better w/ high-dose vit D3 (540,000 IU PO/NGT x1 then 90,000 IU qmo x5mo) vs placebo in D-deficient pts in RCT (N=475 adult white ICU pts w/ D ≤20 ng/mL); however, ↓hospital mortality (not 6-mo mortality) noted in severely deficient pts (≤12 ng/mL).16 Vit D3 (incl up to 600,000 IU x1) “might” ↓mortality vs placebo, per meta-analysis (7 RCTs, N=716)17
Potential adverse effects reported - Vit D toxicity: anorexia, ↓weight, polyuria, cardiac arrhythmias, vascular/tissue calcification (incl kidney damage). Calcium + vit D in postmenopausal women linked to 17% ↑kidney stones. Tolerable upper-intake levels vary by age (eg, 4,000 IU/day for age 9+ yo)5
- See cholecalciferol (vitamin D3), ergocalciferol (vitamin D2), adverse events and drug interaction check in epocrates
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 4/8/20
2 @DrTomFrieden. Twitter. 8/23/20. Accessed 4/8/20
3 Tom Friedan. CNN Health. 3/22/20. Accessed 4/8/20
“Of all of the various proposed measures to increase your resistance to infection, regular physical activity and adequate vitamin D levels probably have the most scientific evidence to support them—and can be done safely.”
4 Laird E, et al. Vitamin D Deficiency in Ireland – Implications for COVID-19. Results from The Irish Longitudinal Study on Ageing (TILDA). Trinity College Dublin. April 2020. Accessed 4/8/20
5 Vitamin D Fact Sheet for Health Professionals. NIH. Updated 3/24/20. Accessed 4/8/20
6 Grant WB, et al. Evidence That Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths. Nutrients. 2020. April 2;(12)4.pii:E988. PubMed abstract
7 Lopez C, et al. Wellness Influencers Are Telling Followers Potentially Toxic Doses of Vitamins Will Protect Them From the Coronavirus. Business Insider. Feb 26, 2020. Accessed 4/8/20
8 Alschuler L, et al. Integrative Considerations During the COVID-19 Pandemic. Explore (NY). 2020. March 26. pii:S1550-8307(20)30113-0. Accessed 4/8/20
9 Vitamin D on Prevention and Treatment of COVID-19 (COVITD-19). ClinicalTrials.gov. Accessed 4/8/20
10 NICE. Covid 19 Rapid Evidence Summary: Vitamin D for Covid-19. June 29, 2020. Accessed 7/2/20
11 Martineau AR, et al. Vitamin D Supplementation to Prevent Acute Respiratory Tract Infections: Systematic Review and Meta-analysis of Individual Participant Data. BMJ. 2017. Feb 15;356:i6583. PubMed abstract
12 Charan J, et al. Vitamin D for Prevention of Respiratory Tract Infections: A Systematic Review and Meta-analysis. J Pharmacol Pharmacother. 2012. Oct;3(4):300–303. PubMed abstract
13 SACN. Scientific Advisory Commission on Nutrition. Rapid Review: Vitamin D and Acute Respiratory Tract Infections. June 2020. Accessed 7/2/20
14 Urashima M, et al. Randomized Trial of Vitamin D Supplementation to Prevent Seasonal Influenza A in Schoolchildren. Am J Clin Nutr. 2010. May;91(5):1255-60. PubMed abstract
15 Zhou YF, et al. The Association Between Vitamin D Deficiency and Community-acquired Pneumonia: A Meta-analysis of Observational Studies. Medicine (Baltimore). 2019. Sep;98(38):e17252. PubMed abstract
16 Amrein K, et al. Effect of High-Dose Vitamin D3 on Hospital Length of Stay in Critically Ill Patients With Vitamin D Deficiency: The VITdAL-ICU Randomized Clinical Trial. JAMA. 2014. Oct 15;312(15):1520-30. PubMed abstract
17 Putzu A, et al. Vitamin D and Outcomes in Adult Critically Ill Patients. A Systematic Review and Meta-analysis of Randomized Trials. J Crit Care. 2017. Apr;38:109-114. PubMed abstract
zinc (Zn acetate, Zn gluconate, Zicam, Cold-EEZE, etc) Essential mineral; Zn deficiency linked to ↓immune fxn, pneumonia (eg, in developing countries).1 There’s no scientific evidence that Zn or any alternative remedy2 is effective for COVID-19 prevention/tx Media trends - Zn purported to be an immune booster, incl for resp tract, w/ anti-coronaviral effects based on SARS-CoV in vitro studies3
- Excessive immune response has been suggested in media as a reason for severe COVID dz. Zn is thought to be anti-inflammatory/antioxidant,4 which might “put the brakes” on immune overreaction5
Trial in COVID-196 - Outpt tx. No significant difference in pt-reported sx duration between zinc gluconate (50 mg PO qhs x10 days), or high-dose vit C (8 g/day PO divided bid-tid x10 days), or combo, vs usual care in a randomized open-label clinical trial (N=214)
Reports on non-COVID-19 use - Cold tx. Conflicting data. 2020 RCT (N=253 adults) on zinc acetate lozenge 78 mg/day x5 days starting w/ sx wasn’t effective in common cold.7 However, a meta-analysis (N=199) on 80-92 mg elemental zinc per day (zinc acetate lozenges taken every few hrs starting w/ in 24h of cold sx onset) suggested 3-fold ↑recovery rate at day 58
- Infxn prevention. An RCT (N=81 geriatric center pts, 2/3 had Zn, Se deficiency). Pts given zinc 20 mg + selenium 100 ug x6mo (w/ or w/o Vit C, other vitamins) had significantly fewer infxn events9
Potential adverse effects reported - Intranasal Zn shouldn’t be used;10 linked to irreversible anosmia/loss of smell11
- Oral Zn: bad taste. N/V, loss of appetite, abdominal cramps, diarrhea, HA.1 Intake 150–450 mg/ day linked to ↓copper, altered Fe, ↓immune function, ↓HDL1
- Drug interactions (oral Zn): abx (quinolones, tetracyclines), penicillamine;1 see zinc acetate or zinc gluconate for drug interaction check in epocrates
Footnotes 1 NIH. Office of Dietary Supplements. Zinc. Fact Sheet for Health Professionals. March 6, 2020. Accessed 3/31/20
2 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 3/31/20
3 Weil A. COVID-19: What You Should Know About Coronavirus. DrWeil.com. Accessed 3/31/20
4 Prasad AS. Zinc Is an Antioxidant and Anti-inflammatory Agent: Its Role in Human Health. Front. Nutrit. Sept 1, 2014. Accessed 3/31/20
5 Liu MJ, et al. Ohio State University. Zinc Helps Against Infection by Tapping Brakes in Immune Response. ScienceDaily. Feb 7, 2013. Accessed 3/31/20
6 Thomas S, et al. Effect of High-Dose Zinc and Ascorbic Acid Supplementation vs Usual Care on Symptom Length and Reduction Among Ambulatory Patients With SARS-CoV-2 Infection. The COVID A-Z Randomized Clinical Trial. JAMA Netw Open. 2021;4(2):e210369. Accessed 2/12/21
7 Hemila H, et al. Zinc Acetate Lozenges for the Treatment of the Common Cold: A Randomised Controlled Trial. BMJ Open. 2020. Jan 23;10(1):e031662. Accessed 3/31/20
8 Hemila H, et al. Zinc Acetate Lozenges May Improve the Recovery Rate of Common Cold Patients: An Individual Patient Data Meta-Analysis. Open Forum Infect Dis. 2017. Apr 3;4(2):ofx059. Accessed 3/31/20
9 Girodon F, et al. Effect of Micronutrient Supplementation on Infection in Institutionalized Elderly Subjects: A Controlled Trial. Ann Nutr Metab. 1997;41(2):98-107. Accessed 3/31/20
10 NIH. National Center for Complementary and Integrative Health. 5 Tips: Natural Products for the Flu and Colds: What Does the Science Say? Accessed 3/31/20
11 Quackwatch. FDA Warning Letter to Matrixx Initiatives. January 31, 2010. Accessed 5/30/23
selenium (selenate, selenite, selenomethionine, selenocysteine) There’s no scientific evidence that selenium or any alternative remedy1 is effective for COVID-19 prevention/tx. Trace mineral in brazil nuts, seafood, meat, grains, dairy, eggs, etc. Deficiency (rare in U.S.) linked to poor immunity; excess may cause serious dz2 Media trends - COVID-19. Media claims link COVID-19 cure rates to soil selenium levels in China, suggesting highest death rates in zones where Se is lowest in world;3 based on letter correlating recovery & death rates to a dataset of residents’ hair Se levels by province4
- Non-COVID. Influencers suggest low Se ups viral infxn risk (eg, flu, RSV, coxsackie);5 coxsackie infxn proposed contributor to endemic cardiomyopathy seen in Se-deficient Keshan, China6
Reports on non-COVID-19 dz - URI prevention. No benefit for Se supplements in 9-mo RCT (N=1533, ages 25-64 yo)7
- Infxn prevention, older pts. Se 100 ug + Zn 20 mg daily linked to fewer infxn events in 2-yr RCT (N=81 geriatric center pts, 2/3 w/ Zn & Se deficiency)8
- HIV-1. Se often low d/t intake/losses, etc. Studies link low Se to transmission, complications; some RCTs show Se benefits viral load, hospital risks,2 but meta-analysis questions consistency of results on micronutrient supplements9
- Critical illness. Se supplementation disputed, study methodologies inadequate, per meta-analysis;10 a 2019 RCT showed no effect on survival, ventilator duration, ICU stay11
Potential adverse effects reported - Acute toxicity. Severe GI sx, neuro sx (tremors, lightheadedness), ARDS, MI/cardiac failure, hair loss, facial flush, kidney failure, muscle tenderness, rarely death. Tolerable upper intake depends on age (eg, >400 ug for 14+ yo assoc w/ ↑adverse events).2 Link to epocrates Dietary Reference Intakes: Selenium
- Chronic selenosis. Garlicy breath, metallic taste, hair & nail loss/brittleness, skin rash, nervous system issues, nausea, diarrhea, mottled teeth, fatigue, irritability2
- Drug interactions: cisplatin;2 hi-dose Se may ↓vit C absorption12
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments.Accessed 5/5/20
2 NIH. Office of Dietary Supplements. Selenium. Fact Sheet for Health Professionals. March 11, 2020. Accessed 5/7/20
3 Meredith N. Science News. Link Identified Between Dietary Selenium and Outcome of COVID-19 Disease. April 29, 2020. Accessed 5/8/20
4 Zhang J, et al. Association Between Regional Selenium Status and Reported Outcome of COVID-19 Cases in China. Am J Clin Nutr. 2020. Apr 28;doi:10.1093/ajnc/nqaa095. PubMed abstract | Free full-text PDF
5 Ristic A. Can Selenium Protect You From Coronavirus (COVID-19)? April 4, 2020. Selfhacked.com.
6 Steinbrenner H, et al. Dietary Selenium in Adjuvant Therapy of Viral and Bacterial Infections. Adv Nutr. 2015. Jan 15;6(1):73-82. PubMed abstract | Free full-text PDF
7 Raposo SE, et al. Intake of Vitamin C, Vitamin E, Selenium, Zinc and Polyunsaturated Fatty Acids and Upper Respiratory Tract Infection - A Prospective Cohort Study. Eur J Clin Nut. 2017. Apr;71(4):450-457. PubMed abstract
8 Girodon F, et al. Effect of Micronutrient Supplementation on Infection in Institutionalized Elderly Subjects: A Controlled Trial. Ann Nutr Metab. 1997;41(2):98-107. PubMed abstract
9 Visser ME, et al. Micronutrient Supplementation in Adults With HIV Infection. Cochrane Database Syst Review. 2017. May 18;5-CD003650. PubMed abstract | Free full-text PDF
10 Allingstrup M, et al. Selenium Supplementation for Critically Ill Adults. Cochrane Database Syst Review. 2015. July 27;(7):CD003703. PubMed abstract | Free full-text PDF
11 Mahmoodpoor A, et al. The Effect of Intravenous Selenium on Oxidative Stress in Critically Ill Patients With Acute Respiratory Distress Syndrome. Immunol Invest. 2019. Feb;48(2):147-159. PubMed abstract
12 Selenium. About Herbs. Memorial Sloan Kettering Cancer Center. Last updated 12/15/21. Accessed 5/30/23
silver (colloidal silver) Colloidal silver (silver particles in liquid) isn’t safe or effective for tx of any dz/condition, per FDA,1 NCCIH.2 No legally marketed prescription/OTC oral drugs contain colloidal silver2 Media trends - Companies promoting silver-containing products such as teas, essential oils, tinctures, and colloidal silver have fraudulently claimed to prevent/tx COVID-191
- FDA has issued warning letters to several entities,1 incl: Vital Silver, Quinessence Aromatherapy Ltd., Xephyr LLC dba N-Ergetics, GuruNanda LLC, Vivify Holistic Clinic, Herbal Amy LLC, The Jim Bakker Show
Potential adverse effects reported - Argyria: bluish-gray skin discoloration, esp sun-exposed areas, usually permanent2
- Drug interaction: poor absorption of some drugs (eg, certain abx, thyroxine2)
Footnotes 1 FDA. Coronavirus Update: FDA and FTC Warn Seven Companies Selling Fraudulent Products that Claim to Treat or Prevent COVID-19. FDA News Release. March 9, 2020. Accessed 3/31/20
2 NIH. National Center for Complementary and Integrative Health. Colloidal silver. Updated April 2017. Accessed 3/31/20
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Supplements (lysine, melatonin, quercetin, quinine, acetylcysteine, saline nasal irrigation, apple cider vinegar, etc)
There’s no scientific evidence that lysine or any alternative remedy is effective for COVID-19 prevention/tx.1 Essential amino acid found in protein-rich foods & available as supplement Media trends - Antiviral/immune system hypothesis: Has been proposed for COVID-19 tx/prevention based on immune-boosting & antiviral potential (eg, in HSV)2-4
- Viral replication hypothesis: Studied in HSV infxn5 (primarily cold sores), possible mechanism involves blocking arginine needed for HSV-1 replication;6 raised as theoretical means of blocking viral RNA replication, as tx for COVID-197
Non-COVID-19 use - HSV. Oral L-lysine <1 g/day appears ineffective for tx/prevention of herpes simplex lesions (oral & genital), but doses >3 g/day appear to improve subjective pt experience, per review; more studies needed to definitively test role in herpes simplex prophylaxis & determine minimum reliably effective dose.8 Topical L-lysine w/ zinc & herbals as ointment for cold sores linked to sx resolution in 40% of pts by day 3, 87% of pts by day 6, in open-label study (N=30)9
Potential adverse effects reported - GI adverse effects reported w/ doses >6 g/day, incl nausea, stomachache, diarrhea10
- Potential drug interactions: none confirmed
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 5/1/20
2 ConsumerLab. Natural Remedies & Supplements for Coronavirus (COVID-19). Last updated 5/5/20. Accessed 5/27/20
3 Diamond Physicians. How to Boost Your Immune System for Coronavirus Prevention. March 12, 2020. Accessed 5/27/20
4 Oubre Medical Functional Medicine. Three Perspectives on the Covid-19 From Dr. Oubre’s Practice. March 12, 2020.
5 New York Integrative Rheumatology. Coronavirus: What Do You Need to Know and How Can You Protect Yourself and Your Loved Ones. Accessed 5/27/20
6 O’Brien S. Healthline. 4 Impressive Health Benefits of Lysine. Oct 6, 2018. Accessed 5/28/20
7 Reply #59959. Amino Acid Blocking Inhibits Virus Replication. Drug Target Review Forum. April 13, 2020 10:42 pm.
8 Mailoo VJ, et al. Lysine for Herpes Simplex Prophylaxis: A Review of the Evidence. Integr Med (Encinitas). 2017. Jun;16(3):42-46. PubMed abstract | Free full-text PDF
9 Singh BB, et al. Safety and Effectiveness of an L-lysine, Zinc, and Herbal-Based Product on the Treatment of Facial and Circumoral Herpes. Altern Med Rev. 2005. Jun;10(2):123-7. PubMed abstract
10 Hayamizu K, et al. Safety Assessment of L-lysine Oral Intake: A Systematic Review. Amino Acids. 2019. Apr;51(4):647-659. PubMed abstract
There’s no scientific evidence that melatonin supplements or any alternative remedy is effective for COVID-19 prevention/tx1 Media trends - Proposed adjuvant COVID-19 tx2 based on anti-inflammatory, anti-oxidant effects;3 immunity booster via sleep adequacy;4 ↑COVID severity in older pts, older people have lower melatonin3,5
- Antiviral hypothesis: Melatonin could indirectly affect ACE2 expression,6 which is involved in SARS-CoV-2 cell entry
- Cytokine storm hypothesis: Observed ↓TNF-α, IL-6 in melatonin supplement users,7 anti-oxidant effects proposed to ↓excessive immune up-regulation “cytokine storm” linked to severe COVID-192
- Sleep-immunity hypothesis: Sleep <6 h/night linked to ↑susceptibility to experiment-induced rhinovirus infxn.8 Though marketed as sleep aid, AASM doesn’t support for sleep onset/maintenance insomnia, based on studies (melatonin 2 mg, pts >55 yo)9
Potential adverse effects reported: - HA, dizziness, agitation, drowsiness, enuresis,10 sleep disturbance, disorientation, bad dreams, nausea, abdominal cramps11
- Potential drug interactions: CYP1A2 inhibitors/inducers,12,13 nifedipine,14 warfarin15
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 4/10/20
2 Zhang R, et al. COVID-19: Melatonin as a Potential Adjuvant Treatment. Life Sci. 2020. Mar 23;250:117583. PubMed abstract
3 The University of Arizona. Andrew Weil Center for Integrative Medicine. Integrative Medicine Doctors Offer Approaches to Combat COVID-19. UA News. March 30, 2020. Accessed 4/10/20
4 Could Melatonin Help Symptoms of COVID-19? March 31, 2020. NBC2 News. Accessed 5/30/23
5 Carrillo-Vico A, et al. Melatonin: Buffering the Immune System. Int J Mol Sci. 2013. April 22;14(4):8638-83. Accessed 4/10/20
6 Zhou Y, et al. Network-based Drug Repurposing for Novel Coronavirus 2019-nCoV/SARS-CoV-2. Cell Discov. 2020. Mar 16(6):14. PubMed abstract
7 Zarezadeh M, et al. Melatonin Supplementation and Pro-inflammatory Mediators: A Systematic Review and Meta-analysis of Clinical Trials. Eur J Nutr. Nov 2, 2019. PubMed abstract
8 Prather AA, et al. Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Sleep. 2015. Sep 1;38(9):1353-9. PubMed abstract
9 Sateia MJ, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 15;13(2):307-349. PubMed abstract | Free full-text PDF
10 NIH. National Center for Complementary and Integrative Health. Melatonin. Updated October 2019. Accessed 4/10/20
11 Melatonin. About Herbs. Memorial Sloan Kettering Cancer Center. Last updated 11/13/19. Accessed 4/10/20
12 Hartter S, et al. Increased Bioavailability of Oral Melatonin After Fluvoxamine Coadministration. Clin Pharmacol Ther. 2000. Jan;67(1):1-6. PubMed abstract
13 von Bahr C, et al. Fluvoxamine but Not Citalopram Increases Serum Melatonin in Healthy Subjects - An Indication That Cytochrome P450 CYP1A2 and CYP2C19 Hydroxylate Melatonin. Eur J Clin Pharmacol. 2000. May;56(2):123-7. PubMed abstract
14 Lusardi P, et al. Cardiovascular Effects of Melatonin in Hypertensive Patients Well Controlled by Nifedipine: A 24-hour Study. Br J Clin Pharmacol. 2000. May;49(5):423-7. PubMed abstract | Free full-text PDF
15 Herxheimer A, et al. Melatonin for the Prevention and Treatment of Jet Lag. Cochrane Database Syst Rev. 2002;2:CD001520. Accessed 4/10/20
There’s no scientific evidence that quercetin supplements or any alternative remedy is effective for COVID-19 prevention/tx.1 Plant-based flavonoid antioxidant found in some fruits/vegetables2
Media trends - Antiviral hypotheses. Theorized to interfere w/ ACE2 receptors that could ↓COVID-19 entry into cells,3 & as ionophore to ↑zinc’s general antiviral action.4 In vitro studies suggest ↓viral load for other viruses.5,6 COVID-19 human clinical trial announced,7-9 but role/dose unknown
- Immune boosting hypothesis. Has been suggested for COVID-19 tx/prevention based on immunostimulatory effects10
Reports on non-COVID-19 use - URI sx. No significant effect on URI rate or sx w/ quercetin 500 or 1000 mg/day vs placebo x12wk (N=1002, ages 18-85 yo); self-rated physically fit pts >40 yo showed 31%-36% ↓URI duration & severity w/ 1000 mg/day vs placebo11
- Exercise-assoc URI. Mixed findings on URI rates:12 quercetin 1000 mg/day vs placebo ↓URI after intense cycling in RCT (N=40),13 but not in a post-endurance run RCT (N=63)14
Potential adverse effects reported - Generally rare & mild, long term data not available;15 HA, paresthesia reported16
- Potential drug interactions: may inhibit CYP2C9 substrates,17 CYP3A4 substrates & P-gp substrates18
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 5/1/20
2 Anand David AV, et al. Overviews of Biological Importance of Quercetin: A Bioactive Flavonoid. Pharmacogn Rev. 2016. Jul-Dec;10(20):84–89. PubMed abstract | Free full-text PDF
3 Schwarcz J. Quercetin - To Take or Not to Take? Health. McGill Office for Science and Society. March 25, 2020. Accessed 5/4/20
4 Alschuler L, et al. Integrative Considerations During the COVID-19 Pandemic. Explore (NY). 2020. March 26. pii:S1550-8307(20)30113-0. Accessed 5/1/20
5 Consumer Lab. Natural Remedies & Supplements for Coronavirus (COVID-19). Last updated 4/28/20. Accessed 5/1/20
6 Polansky H, et al. Coronavirus Disease 2019 (COVID-19): First Indication of Efficacy of Gene-Eden-VIR/Novirin in SARS-CoV-2 Infection. Int J Antimicrob Agents. Published online ahead of print: 2020. Apr 10:105971. Accessed 5/5/20
7 Vermes J. CBC. As Coronavirus Spread Speeds Up, Montreal Researchers Will Trial an Anti-viral Treatment for COVID-19 in China. Feb 28, 2020. Last Updated: March 13, 2020. Accessed 5/4/20
8 Taylor-Vaisey N. Maclean’s. A Made-in-Canada Solution to the Coronavirus Outbreak? The Best Hope for an Antiviral Drug May Come From Michel Chrétien's Montreal Lab. Accessed 5/4/20
9 IRCM Montreal Clinical Research Institute. The Lazaridis Family Foundation Contributes $1 Million to the IRCM to Support Its Research on the COVID-19 Coronavirus. March 4, 2020. Accessed 5/30/23
10 Weil A. COVID-19: What You Should Know About Coronavirus. DrWeil.com. Accessed 5/1/20
11 Heinz SA, et al. Quercetin Supplementation and Upper Respiratory Tract Infection: A Randomized Community Clinical Trial. Pharmacol Res. 2010. Sep;62(3):237-42. PubMed abstract | Free full-text PDF
12 Li Y, et al. Quercetin, Inflammation and Immunity. Nutrients. 2016. Mar 15;8(3):167. PubMed abstract | Free full-text PDF
13 Nieman DC, et al. Quercetin Reduces Illness But Not Immune Perturbations After Intensive Exercise. Med Sci Sports Exerc. 2007. Sept;39:1561-9. PubMed abstract | Free full-text PDF
14 Henson D, et al. Post-160-km Race Illness Rates and Decreases in Granulocyte Respiratory Burst and Salivary IgA Output Are Not Countered by Quercetin Ingestion. Int J Sports Med. 2008. Oct;29(10):856-63. PubMed abstract
15 Andres S, et al. Safety Aspects of the Use of Quercetin as a Dietary Supplement. Mol Nutr Food Res. 2018. Jan;62(1). PubMed abstract
16 Shoskes DA, et al. Quercetin in Men With Category III Chronic Prostatitis: A Preliminary Prospective, Double-blind, Placebo-controlled Trial. Urology. 1999. Dec;54:960-3. PubMed abstract
17 Bedada SK, et al. Evaluation of the Effect of Quercetin Treatment on CYP2C9 Enzyme Activity of Diclofenac in Healthy Human Volunteers. Phytother Res. 2018. Feb;32(2):305-311. PubMed abstract
18 Choi JS, et al. Effect of Quercetin on the Pharmacokinetics of Oral Cyclosporine. Am J Health Syst Pharm. 2004. Nov 15;61(22):2406-9. PubMed abstract
quinine (Cinchona, fever tree, tonic water, etc) There’s no scientific evidence that quinine or any alternative remedy is effective for COVID-19 prevention/tx.1,2 Quinine is derived from Cinchona tree bark
Media trends - Hypothesis: Since quinine is a natural form of the compound in synthetic chloroquine and hydroxychloroquine, some media influencers hypothesize it may be as valuable as these drugs against COVID-193
- Tonic water contains quinine, so has been proposed as valuable against COVID-19; however, tonic water contains ≤83 mg/L,4 far less than therapeutic anti-malarial doses
Non-COVID-19 use - Antiparasitic. Quinine sulfate FDA-approved for malaria; has been used off-label for babesiosis (epocrates drug information: quinine sulfate)
- Anti-inflammatory. Historically used as an anti-inflammatory before synthetic derivatives were available
- Muscle cramps (not FDA-approved). Serious risks outweigh any potential benefits. In 2007, FDA halted manufacture of unapproved quinine cramp remedies d/t toxicity concerns5,6
Potential adverse effects reported:5,6 - Serious safety concerns, incl fatalities assoc w/ quinine-containing drug products, many dose-related, ↑risk in older pts
- Quinine toxicity: sx cluster incl tinnitus, dizziness, disorientation, nausea, visual changes, auditory deficits; arrhythmias, incl torsades de pointes; serious hypersensitivity rxn
- Serious adverse reactions: incl severe skin rxn, hematological events, permanent visual & hearing disturbances, hypoglycemia, renal failure, anaphylaxis
- See quinine sulfate contraindications/cautions, adverse events and drug interaction check in epocrates
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 4/10/20
2 FDA 2020. Coronavirus Update: FDA and FTC Warn Seven Companies Selling Fraudulent Products that Claim to Treat or Prevent COVID-19. FDA News Release. March 9, 2020. Accessed 3/31/20
3 The New York Times. NOT REAL NEWS: A Week of False News Around the Coronavirus. The Associated Press. April 10, 2020. Accessed 5/30/23
4 FDA 2019. CFR – Code of Federal Regulations Title 21. Part 172. Food Additives. Accessed 4/15/20
5 FDA 2010. FDA Drug Safety Communication: New Risk Management Plan and Patient Medication Guide for Qualaquin (quinine sulfate). 7/8/2010. Accessed 4/15/20
6 FDA 2007. Questions and Answers About FDA’s Enforcement Action Against Unapproved Quinine Products. Accessed 4/15/20
acetylcysteine (N-acetylcysteine, NAC) There’s no scientific evidence that acetylcysteine or any alternative remedy is effective for COVID-19 prevention/tx.1 Available as prescription drug (PO, IV, NEB) FDA-approved for mucolytic uses, acetaminophen OD, others; and as dietary supplement marketed as antioxidant, expectorant Media trends - Antiviral hypothesis. Purported to ↓ epithelial cell SARS-CoV-2 entry based on in vitro data. Nebulized heparin + NAC (“H-NAC”) proposed as COVID tx2
- Immunity hypothesis. Proposed as immune booster & detoxifier (antioxidant, free-radical fighter); anti-inflammatory (eg, for excessive immune response assoc w/ severe COVID dz); resp tract remedy3
Trials in COVID-19 - Refractory COVID-19. Phase 2 open-label study in severe/critically ill pts; NAC IV 6 g/day4
- Pulmonary fibrosis trial. Phase 2 RCT in China examining multi-herb Chinese medicine remedy Fuzheng Huayu on COVID-19 pulm fibrosis in adults; NAC capsules PO tid used in standard tx/control arm5
Non-COVID-19 respiratory dz use - Flu sx. NAC 600 mg PO bid x6mo assoc w/ ↓clinical flu sx though influenza A/H1N1 infxn rate unchanged, in RCT (N=262 pts, most 65+ yo)6
- COPD/Chronic Bronchitis. NAC PO may ↓exacerbation in certain COPD pts, per ACCP,7 GOLD;8 but doesn’t improve QOL or lung fxn, per meta-analysis9
- Bronchiectasis. Evidence as mucolytic for non-CF bronchiectasis insufficient;10 NAC NEB may preserve lung fxn in CF11
- IPF. NAC 600 mg tid showed no benefit in RCT of mild-to-mod IPF12
- ARDS. Evidence insufficient to permit conclusions, per meta-analysis13
- Inhalation injury. Combo heparin, NAC, albuterol NEB tried in burn pts w/ varying results14,15
Potential adverse effects reported: - Generally well-tolerated at ≤1200 mg bid, mostly GI,16 incl N/V; stomatitis, URI sx, fever, drowsiness, urticaria, rash, pruritus, flushing, tachycardia, hypersensitivity rxn reported17,18
- See acetylcysteine adverse events and drug interaction check in epocrates
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 4/18/20
2 Hackett DW. New Study to Eliminate Mechanical Ventilation of COVID-19 Patients. Coronavirustoday.com. March 30, 2020. Accessed 4/19/20
3 Aleksic A. Can NAC Help Fight Coronavirus? March 26, 2020. Selfhacked.com.
4 A Study of N-acetylcysteine in Patients With COVID-19 Infection. ClinicalTrials.gov.
5 Treatment of Pulmonary Fibrosis Due to 2019-nCoV Pneumonia With Fuzheng Huayu. ClinicalTrials.gov. Summary
6 De Flora S, et al. Attenuation of Influenza-like Symptomatology and Improvement of Cell-mediated Immunity With Long-term N-acetylcysteine Treatment. Eur Resp J. 1997. Jul;10(7):1535-41. PubMed abstract
7 ACCP 2015. Prevention of Acute Exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. CHEST. 2015. Apr;147(4):894-942. PubMed abstract
8 GOLD 2020. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic Obstructive Lung Disease, Inc. PDF
9 Poole P, et al. Mucolytic Agents Versus Placebo for Chronic Bronchitis or Chronic Obstructive Pulmonary Disease. Cochrane Database Syst. Rev. 2019. May 20;5CD001287. PubMed Abstract
10 Wilkinson M, et al. Mucolytics for Bronchiectasis (Review). Cochrane Database Syst Rev. 2014. May 2;(5):CD001289. PubMed abstract | Free full-text PDF
11 Ciofu O, et al. Antioxidant Supplementation for Lung Disease in Cystic Fibrosis. Cochrane Database Syst Review. 2019. Oct 3;10:CD007020. PubMed abstract
12 Martinez FJ, et al. Randomized Trial of Acetylcysteine in Idiopathic Pulmonary Fibrosis. New Engl J Med. 2014. May 29;370(22):2093-101. PubMed abstract | Free full-text PDF
13 Lewis SR, et al. Pharmacological Agents for Adults With Acute Respiratory Distress Syndrome. Cochrane Database Syst Rev. 2019. July 23;7:CD004477. PubMed abstract
14 McGinn KA, et al. Nebulized Heparin With N-Acetylcysteine and Albuterol Reduces Duration of Mechanical Ventilation in Patients With Inhalation Injury. J Pharm Pract. 2019. Apr;32(2):163-166. PubMed abstract
15 Kashefi NS, et al. Does a Nebulized Heparin/N-acetylcysteine Protocol Improve Outcomes in Adult Smoke Inhalation? Plast Reconstr Surg Glob Open. 2014. Jul 9;2(6):e165. PubMed abstract | Free full-text PDF
16 Millea PJ, et al. N-Acetylcysteine: Multiple Clinical Applications. Am Fam Physician. 2009. Aug 1;80(3):265-269. PubMed abstract | Free full-text PDF
17 Cumberland Pharmaceuticals Inc. Acetadote (acetylcysteine) (package insert). U.S. Food and Drug Administration website. Revised October 2019. Accessed 4/20/20
18 Acetylcysteine [package insert]. Shirley, NY: American Regent. Revised May 2014. Accessed 4/20/20
There’s no scientific evidence that saline nasal irrigation or any alternative remedy is effective for COVID-19 prevention/tx1,2 Media trends - Proposed to reduce COVID-19 sx progression based on historical use as remedy to ↓cold/flu sx3-5—though not studied in SARS-CoV-2
- Other influencers recommend against nasal irrigation during COVID-19, d/t concern that nasal rinse devices could harbor infectious droplets6 or use could ↑risk of aerosolizing infectious droplets7
Reports on non-COVID-19 infxn use - URI sx. Unblinded RCT on hypertonic saline nasal irrigation & gargling w/in 48h of URI onset (N=61, mostly rhinoviruses, coronaviruses) showed ↓illness duration by 1.9 days, 36% ↓OTC remedy use, 35% ↓household transmission, ↓viral shedding.8 Previous meta-analyses showed possible benefit, but conclusions limited by studies’ methodological issues9
- Chronic rhinosinusitis sx. Low evidence quality didn’t permit conclusions in a meta-analysis10
Potential adverse effects reported - Protozoa infection. Primary amebic meningoencephalitis w/ Naegleria fowleri,11,12 cerebral Balamuthia mandrillaris13 reported from unboiled tap water nasal irrigation. Only sterile, distilled, or previously boiled water should be used14
- Generally minimal/transient adverse effects, incl ear fullness, nasal mucosa stinging, rarely epistaxis15
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 4/18/20
2 WHO 2020. World Health Organization. Coronavirus Disease (COVID-19) Advice for the Public: Myth Busters. Accessed 4/24/20
3 Medintz S. Consumer Reports. When Someone in Your Household Has COVID-19. April 8, 2020. Accessed 4/24/20
4 Hall C. Best Life Newsletter. Nasal Irrigation Is the Key to Reducing COVID-19 Progression, Doctor Says. April 20, 2020.
5 Preventive Medicine + Cancer Care. How to Prevent & Prepare for Coronavirus (COVID-19). March 15, 2020. Accessed 4/24/20
6 Henry Ford Health System. Should You Still Rinse Your Sinuses During The COVID-19 Outbreak? March 26, 2020. Accessed 4/24/20
7 Brigman L. Can Rinsing Your Nose With Saline Spray or a Neti Pot Help Remove Coronavirus? WLOS News 13. April 10, 2020. Accessed 4/24/20
8 Ramalingam S, et al. A Pilot, Open-labelled, Randomised Controlled Trial of Hypertonic Saline Nasal Irrigation and Gargling for the Common Cold. Sci Rep. 2019. Jan 31;9(1):1015. PubMed abstract | Free full-text PDF
9 King D, et al. Saline Nasal Irrigation for Acute Upper Respiratory Tract Infections. Cochrane Database Syst Rev. 2015. Apr 20;(4):CD006821. PubMed abstract | Free full-text PDF
10 Chong LY, et al. Saline Irrigation for Chronic Rhinosinusitis. Cochrane Database Syst Rev. 2016. April 26;(4):CD011995. PubMed abstract | Free full-text PDF
11 CDC. Parasites-- Naegleria fowleri--Primary Amebic Meningoencephalitis (PAM) — Amebic Encephalitis. Sinus Rinsing for Health or Religious Practice. 2/28/17. Accessed 4/24/20
12 Yoder JS, et al. Primary Amebic Meningoencephalitis Deaths Associated With Sinus Irrigation Using Contaminated Tap Water. Clin Infect Dis. 2012. Nov;55(9):e79-85. PubMed abstract | Free full-text PDF
13 Piper KJ, et al. Case Reports. Fatal Balamuthia Mandrillaris Brain Infection Associated With Improper Nasal Lavage. Int J Infect Dis. 2018. Dec;77:18-22. PubMed abstract | Free full-text PDF
14 FDA. Consumer Updates. Is Rinsing Your Sinuses With Neti Pots Safe? 1/24/2017. Accessed 4/24/20
15 Rabago D, et al. Saline Nasal Irrigation for Upper Respiratory Conditions. Am Fam Physician. 2009. Nov 15; 80(10):1117–1119. PubMed abstract | Free-full text PDF
There’s no scientific evidence that apple cider vinegar or any other alternative remedy is effective for COVID-19 prevention/tx.1 Traditional home remedy for various ailments (eg, infection, wt loss, diabetes, cholesterol), common condiment & food preservative containing acetic acid & phenolic compounds
Media trends - Antimicrobial hypothesis. Drinking/gargling w/ apple cider vinegar has been suggested for COVID-19 prevention based on historical use as antimicrobial, where some social media posts claim gargling can ↓coronavirus in the throat before it reaches lungs2,3
- Antioxidant/immune boosting hypothesis. Suggested to keep pH balanced & improve gut microbiome for optimal immunity;4 purported to downregulate proinflammatory cytokines; polyphenolic compounds may prevent formation of tissue-damaging free radicals2
Reports on non-COVID-19 use - ACV used as natural remedy for sore throats & other uses w/ inadequate evidence5
Potential adverse effects reported - Potential drug interactions: Theoretical additive risk w/ drugs that cause hypokalemia (eg, digoxin, diuretics, insulin)2,6
- Case report of hypokalemia, hyperreninemia, osteoporosis w/ high-dose use6
- Tooth enamel erosion if consumed undiluted.2 Erosive tooth wear reported w/ daily consumption of 1 cup (237 ml) undiluted ACV7,8
- Throat burns reported w/ acetic acid, a component of apple cider vinegar8,9
- Nausea reported10
Footnotes 1 NIH. National Center for Complementary and Integrative Health. In the News: Coronavirus and “Alternative” Treatments. Accessed 7/8/20
2 Richards L. Is Apple Cider Vinegar an Effective Cold Remedy? Medical News Today. April 6, 2020. Accessed 7/8/20
3 Consumer Lab. Natural Remedies & Supplements for Coronavirus (COVID-19). Accessed 7/8/20
4 CentreSpringMD. 6 Steps to Boost Your Immune System. Accessed 7/8/20
5 Weil A. Can You Lose Weight With Apple Cider Vinegar? November 12, 2009. www.drweil.com. Accessed 7/8/20
6 Lhotta K, et al. Hypokalemia, Hyperreninemia and Osteoporosis in a Patient Ingesting Large Amounts of Cider Vinegar. Case Reports. Nephron. 1998. Oct;80(2):242-3. PubMed abstract | Free full-text PDF
7 Gambon DL, et al. Unhealthy Weight Loss. Erosion by Apple Cider Vinegar. Case Reports. Ned Tijdschr Tandheelkd. 2012. Dec;119(12):589-91. PubMed abstract
8 Spritzler F. Healthline. 7 Side Effects of Too Much Apple Cider Vinegar. August 10, 2016. Accessed 7/8/20
9 Nuutinen M, et al. Consequences of Caustic Ingestions in Children. Acta Paediatr. 1994. Nov;83(11):1200-5. PubMed abstract
10 Darzi J, et al. Influence of the Tolerability of Vinegar as an Oral Source of Short-Chain Fatty Acids on Appetite Control and Food Intake. Int J Obes (Lond). 2014. May;38(5):675-81. PubMed abstract | Free full-text PDF
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