Health Care Professional Information

Scientific Name
Boswellia serrata
Common Name

Indian frankincense

Clinical Summary

Boswellia serrata is a tree prevalent in India, the Middle East and North Africa. The gummy exudate or the resin obtained by peeling away the bark is commonly known as “frankincense” or “olibanum.” Also known as Indian frankincense, Bowellia is used widely in Ayurveda to treat arthritis, ulcerative colitis, coughs, sores, snakebite, and asthma.
The major component is boswellic acid (1), which was shown in animal studies to be a potent 5-lipoxygenase inhibitor with anti-inflammatory and antiarthritic effects (1) (2) (3). It also demonstrated cytotoxic properties (4) (5) (6) (7), and prevented intestinal tumorigenesis in a mice model (26).

Data from clinical trials indicate effectiveness of Boswellia for bronchial asthma (8) and ulcerative colitis (9). However, evidence is mixed for its benefits for osteoarthritis (10) (11) and collagenous colitis (12) (13) (14). Boswellia was also investigated for its role in maintenance of Crohn's disease remission, but it demonstrated no significant benefit (15).
Preliminary findings suggest boswellia's effectiveness in reducing cerebral edema in patients with brain tumors following radiotherapy (23).

Although similar in many functions, boswellia should not be confused with guggul or myrrh.

Purported Uses
  • Arthritis
  • Asthma
  • Colitis
  • Inflammation
  • Menstrual cramps
Constituents

Triterpene Acids: Boswellic acid and its isomers
Essential oils: Mainly alpha-thujene and p-cymene
(24) (25)

Mechanism of Action

Boswellic acid, the major constituent of boswellia, is thought to contribute to most of the herb's pharmacological activities. In vitro studies and animal models show that boswellic acid inhibits 5-lipoxygenase selectively (1) (3) and has anti-inflammatory (13), antiarthritic, and anti-proliferative effects (2). It also inhibits the signaling pathways of the transcription factor, nuclear factor (NF-KappaB), in macrophages in mouse model of psoriasis, markedly decreasing the production of the pro-inflammatory key cytokine tumor necrosis factor (TNF-alpha) (17). Unlike other non-steroidal anti-inflammatory drugs, however, boswellic acid fails to show analgesic or antipyretic effects (16); it does not cause gastric ulcers in animals. This suggests that it acts through other mechanisms and not by inhibiting prostaglandin synthesis.

Research on the cytotoxic effects of boswellic acid indicates that it induces p21 expression through a p53-independent pathway and causes apoptosis in glioma (4) (6) and leukemia (5) cell lines. In addition, a Boswellia extract induced apoptosis in a cervical cancer cell line by inducing endoplasmic reticulum (ER) stress (18); another apoptotic mechanism exhibited by Boswellia is via oxidative stress by early generation of nitric oxide and reactive oxygen species that up regulate time-dependent expression of p53/p21/PUMA (19).
A semisynthetic analog of boswellic acid, 3-alpha-Butyryloxy-beta-boswellic acid, demonstrated significant growth inhibition in Ehrlich Ascitic Tumour (EAT), Ehrlich Ascitic Carcinoma (EAC) and Sarcoma- 180 tumour models, via down-regulation of NF-KappaB and by induction of poly (ADP-ribose) polymerase (PARP) cleavage (27).

In other studies, acetyl-boswellic acids was shown to inhibit topoisomerases by competing with DNA for binding sites (20). Whereas acetyl-11-keto-beta-boswellic acid (AKBA) inhibited the activation of signal transducers and activators of transcription-3 (STAT-3), which has been linked with survival, proliferation, chemoresistance, and angiogenesis of tumor cells (21). Conversely, AKBA was found to inhibit human prostate tumor growth via inhibition of angiogenesis induced by VEGFR2 signaling pathways (22). Further research is needed to resolve this discrepancy and to clarify the role of AKBA.

Pharmacokinetics

Two to three hours following administration of an oral dose of 1.2 g dry extract boswellia gum resin, plasma concentrations were measured at 10 to 32 micromolar of 11-keto-beta-boswellic acid and 18 to 20 micromolar of acetyl-11-keto-beta-boswellic acid. (8)

Adverse Reactions
  • Allergic contact dermatitis was reported following use of a topical cream containing an extract of Boswellia serrata (28).
  • A 17-year-old girl with celiac disease developed a gastric bezoar (accumulation of vegetable fiber, hair or other substances, in the stomach or small intestine) after excessive intake of olibanum (frankincense). Her symptoms, including epigastric pain and vomiting, resolved after the bezoar was surgically removed (29).


 

Herb-Drug Interactions
  • OATP1B3 (an anion transporter): Both 11-keto-beta-boswellic acid (KBA) and 3-acetyl-11-keto-beta-boswellic acid (AKBA) modulated the activity of OATP1B3 (30).
  • MRP2 (a multidrug resistant protein): Both 11-keto-beta-boswellic acid (KBA) and 3-acetyl-11-keto-beta-boswellic acid (AKBA) modulated the activity of MRP2 (30).
  • P-Glycoprotein (P-Gp): A Boswellia extract and keto-boswellic acids inhibit the activity of P-Glycoprotein in vitro, and may affect the transport of drugs mediated by this protein (31).
Literature Summary and Critique

Holtmeier W, et al. Randomized, placebo-controlled, double-blind trial of Boswellia serrata in maintaining remission of Crohn's disease: Inflamm Bowel Dis. 2011 Feb;17(2):573-82.
In this randomized, placebo-controlled, double-blind trial, patients with Crohn's disease (CD) were treated with two oral capsules of 400 mg Boswellia serrata extract (n=42) or placebo (n=40) three times daily for 12 months. Enrolled patients were currently in remission from CD but had experienced at least two documented relapses during the last 4 years. This study found that 59.9% of the Boswellia-treated and 55.3% of the placebo-treated patients maintained remission from Crohn's disease, indicating no statistically significant difference in efficacy between the active and control groups (p=0.085). Time to remission was 171 days for the active group and 185 days for placebo (p=0.69). There was also no statistically significant difference in tolerability between the active and placebo groups (p=0.087). The investigators concluded that Boswellia serrata demonstrated good tolerability in the long-term treatment of CD. However, the superiority of this treatment to placebo in the maintenance of CD remission could not be established.

Dosage (Inside MSKCC Only)
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References
  1. Dahmen U, Gu YL, Dirsch O, et al. Boswellic acid, a potent antiinflammatory drug, inhibits rejection to the same extent as high dose steroids. Transplant Proc. Feb-Mar 2001;33(1-2):539-541.
  2. Safayhi H, Boden SE, Schweizer S, et al. Concentration-dependent potentiating and inhibitory effects of Boswellia extracts on 5-lipoxygenase product formation in stimulated PMNL. Planta Med. Mar 2000;66(2):110-113.
  3. Safayhi H, Mack T, Sabieraj J, et al. Boswellic acids: novel, specific, nonredox inhibitors of 5-lipoxygenase. J Pharmacol Exp Ther. Jun 1992;261(3):1143-1146.
  4. Glaser T, Winter S, Groscurth P, et al. Boswellic acids and malignant glioma: induction of apoptosis but no modulation of drug sensitivity. Br J Cancer. May 1999;80(5-6):756-765.
  5. Jing Y, Nakajo S, Xia L, et al. Boswellic acid acetate induces differentiation and apoptosis in leukemia cell lines. Leuk Res. Jan 1999;23(1):43-50.
  6. Winking M, Sarikaya S, Rahmanian A, et al. Boswellic acids inhibit glioma growth: a new treatment option? J Neurooncol. 2000;46(2):97-103.
  7. Frank MB, Yang Q, Osban J, et al. Frankincense oil derived from Boswellia carteri induces tumor cell specific cytotoxicity. BMC Complement Altern Med. 2009 Mar 18;9:6.
  8. Gupta I, Gupta V, Parihar A, et al. 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. Nov 17 1998;3(11):511-514.
  9. Gupta I, Parihar A, Malhotra P, et al. Effects of Boswellia serrata gum resin in patients with ulcerative colitis. Eur J Med Res. Jan 1997;2(1):37-43.
  10. Chrubasik JE, Roufogalis BD, Chrubasik S. Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain. Phytother Res. Jul 2007;21(7):675-683.
  11. Sengupta K, Alluri KV, Satish AR, et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin(R) for treatment of osteoarthritis of the knee. Arthritis Res Ther. Jul 30 2008;10(4):R85.
  12. Chande N, McDonald JW, MacDonald JK. Interventions for treating collagenous colitis. Cochrane Database Syst Rev. 2006(4):CD003575.
  13. Madisch A, Miehlke S, Eichele O, et al. Boswellia serrata extract for the treatment of collagenous colitis. A double-blind, randomized, placebo-controlled, multicenter trial. Int J Colorectal Dis. Dec 2007;22(12):1445-1451.
  14. Chande N, MacDonald JK, McDonald JW. Interventions for treating microscopic colitis: a Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Review Group systematic review of randomized trials. Am J Gastroenterol. 2009 Jan;104(1):235-41.
  15. Holtmeier W, Zeuzem S, PreiB, J, et al. Randomized, placebo-controlled, double-blind trial of Boswellia serrata in maintaining remission of Crohn's disease. Inflamm Bowel Dis. 2010 May 19.
  16. Singh GB, Atal CK. Pharmacology of an extract of salai guggal ex-Boswellia serrata, a new non-steroidal anti-inflammatory agent. Agents Actions. Jun 1986;18(3-4):407-412.
  17. Wang H, Syrovets T, Kess D, et al. Targeting NF-KB with a natural triterpenoid alleviates skin inflammation in a mouse model of psoriasis. J Immunol. Oct 2009;183(7):4755-63.
  18. Kim HR, Kim MS, Kwon DY, et al. Boswellia serrata-induced apoptosis is related with ER stress and calcium release. Genes Nutr. Feb 2008;2(4):371-374.
  19. Bhushan S, Malik F, Kumar A, et al. Activation of p53/p21/PUMA alliance and disruption of PI-3/Akt in multimodal targeting of apoptotic signaling cascades in cervical cancer cells by a pentacyclic triterpenediol from Boswellia serrata. Mol Carcinog. 2009 Jun 18.
  20. Syrovets T, Buchele B, Gedig E, et al. Acetyl-boswellic acids are novel catalytic inhibitors of human topoisomerases I and IIalpha. Mol Pharmacol. Jul 2000;58(1):71-81.
  21. Kunnumakkara AB, Nair AS, Sung B, et al. Boswellic acid blocks signal transducers and activators of transcription 3 signaling, proliferation, and survival of multiple myeloma via the protein tyrosine phosphatase SHP-1. Mol Cancer Res. 2009 Jan;7(1):118-28.
  22. Pang X, Yi Z, Zhang X, et al. Acetyl-11-keto-beta-boswellic acid inhibits prostate tumor growth by suppressing vascular endothelial growth factor receptor 2-mediated angiogenesis. Cancer Res. 2009 Jul 15;69(14):5893-900.
  23. Kirste S, Treier M, Wehrle SJ, et al. Boswellia serrata acts on cerebral edema in patients irradiated for brain tumors: A prospective, randomized, placebo-controlled, double-blind pilot trial. Cancer. 2011; 117(16):3788-95.

  24. Camarda L, Dayton T, Di Stefano V, Pitonzo R, Schillaci D. Chemical composition and antimicrobial activity of some oleogum resin essential oils from Boswellia spp. (Burseraceae). Ann Chim. 2007 Sep;97(9):837-44.
  25. Mikhaeil BR, Maatooq GT, Badria FA, Amer MM. Chemistry and immunomodulatory activity of frankincense oil. Z Naturforsch C. 2003 Mar-Apr;58(3-4):230-8.
  26. Wang R, Wang Y, Gao Z, Qu X. The comparative study of acetyl-11-keto-beta-boswellic acid (AKBA) and aspirin in the prevention of intestinal adenomatous polyposis in APC(Min/+) mice. Drug Discov Ther. 2014 Feb;8(1):25-32.
  27. Qurishi Y, Hamid A, Sharma PR, et al. NF-κB down-regulation and PARP cleavage by novel 3-α-butyryloxy-β-boswellic acid results in cancer cell specific apoptosis and in vivo tumor regression. Anticancer Agents Med Chem. 2013 Jun;13(5):777-90.
  28. Acebo E, Ratón JA, Sautúa S, et al. Allergic contact dermatitis from Boswellia serrata extract in a naturopathic cream. Contact Dermatitis. 2004 Aug;51(2):91-2.
  29. El Fortia M, Badi H, Elalem Kh, Kadiki O, Topov Y. Olibanum bezoar: complication of a traditional popular medicine. East Mediterr Health J. 2006 Nov;12(6):927-9.
  30. Krüger P, Kanzer J, Hummel J, et al. Permeation of Boswellia extract in the Caco-2 model and possible interactions of its constituents KBA and AKBA with OATP1B3 and MRP2. Eur J Pharm Sci. 2009 Feb 15;36(2-3):275-84.
  31. Weber CC, Reising K, Müller WE,  et al. Modulation of Pgp function by boswellic acids. Planta Med. 2006 May;72(6):507-13.

Consumer Information

How It Works

Bottom Line: Boswellia has been shown effective for inflammatory conditions, such as arthritis. Its anticancer effects have not been demonstrated in humans.

Boswellia, a tree gum resin often used in Ayurvedic medicine, was analyzed in the laboratory and found to contain boswellic acid, which scientists think accounts for its biological activity. In lab animals, boswellic acid inhibited an enzyme that is important in the process of inflammation, and it therefore reduces swelling caused by chemicals or arthritis. It also slowed down the replication of cancer cells and caused cell death of some cancer cells in the laboratory. Unlike other anti-inflammatory drugs , boswellic acid does not appear to reduce pain or fever, in lab animals.

Boswellia's anti-inflammatory effects were supported in a few clinical trials of patients with colitis and osteoarthritis.
Boswellia was also studied in the maintenance of Crohn's disease remission, but showed no significant benefit.
Even though similar in many functions, boswellia should not be confused with guggul or myrrh.

Purported Uses
  • To treat osteoarthritis
    A randomized controlled trial demonstrated that Boswellia serrata extract is better than a placebo for osteoarthritis, but other studies did not find the same benefit.
  • To treat asthma
    Results from a clinical trial showed that boswellia may reduce symptoms of bronchial asthma, but more studies are needed to draw a conclusion.
  • To treat colitis
    Studies done in animals suggest that boswellia can reduce inflammation, and clinical trials support this use in humans.
  • To reduce inflammation
    Studies in laboratory animals and from clinical trials show that this herb can reduce certain inflammatory conditions.
  • To relieve menstrual cramps
    No scientific evidence supports this use.
  • To treat cancer
    Lab studies have shown that compounds in Boswellia have anticancer properties.
Research Evidence

Crohn's Disease:
In a clinical trial of patients with Crohn's disease (CD) in remission, 42 patients were given two oral capsules of 400 mg Boswellia serrata extract and 40 patients received two capsules of placebo three times a day for 12 months. The study found that 59.9% of the Boswellia-treated and 55.3% of the placebo-treated patients maintained remission from Crohn's disease. The investigators concluded that Boswellia serrata demonstrated good tolerability in the long-term treatment of CD. However, the superiority of Boswellia treatment to placebo in the maintenance of CD remission could not be established.

Do Not Take If
  • You are taking drugs that are substrates of P-Glycoprotein (P-Gp): Boswellia may affect how these drugs are absorbed or metabolized.
Side Effects
  • Allergic contact dermatitis was reported following use of a topical cream containing an extract of Boswellia serrata.
  • A 17-year-old girl with celiac disease developed a gastric bezoar (accumulation of vegetable fiber, hair or other substances, in the stomach or small intestine) after excessive intake of olibanum (frankincense). Her symptoms, including abdominal pain and vomiting, improved after the bezoar was surgically removed.
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