- How It Works
- Purported Uses
- Research Evidence
- Patient Warnings
- Do Not Take If
- Side Effects
- Special Point
- Dosage (Inside MSKCC Only)
Scientific Name
Aesculus hippocastanum
Common Name
Chestnut, marron europeen, escine, escin, aescin
Brand Name
Venastat™
Clinical Summary
Horse chestnut, a tree native to the Balkan peninsula, has been used in traditional medicine for centuries. The seed extract is a popular dietary supplement used to support vascular functions. Horse chestnut should not be confused with sweet chestnut.
Escin, also known as Aescin, a natural mixture of triterpenoid saponins isolated from the seed of the horse chestnut and the major active principle, was shown to have anti-inflammatory (1), neuroprotective (1), and antitumor effects (2) (3). Data from clinical trials suggest efficacy of horse chestnut seed extract against chronic venous insufficiency (CVI) (4) (5). Conclusions from systematic reviews and meta analysis state that horse chestnut extract is a safe and well tolerated treatment for CVI (6) (7) (8).
Escin may also be effective in improving sperm quality in patients with varicocele-associated infertility (14).
Patients with compromised renal or hepatic function should not consume horse chestnut products.
Purported Uses
- Circulatory disorders
- Diarrhea
- Hemorrhoids
- Phlebitis
- Varicose veins
Constituents
- Coumarins: Aesculetin, fraxin, scopolin
- Flavonoids: Flavonol (kaempferol, quercetin) glycosides including astragalin, isoquercetrin, rutin, and leucocyanidin
- Saponins: Several saponins collectively referred to as aescin
- Tannins
- Other constituents: Allantoin, amino acids, choline, citric acid, phytosterol
(9)
Mechanism of Action
Anti-inflammatory actions have been documented for the saponins (aescin) found in horse chestnut. Aescin reduces transcapillary filtration of water and protein and increases venous tone by increasing the vasoconstrictor, prostaglandin F2 alpha. It stabilizes cholesterol-containing membranes of lysosomes and limits the release of enzymes, which is typically increased in chronic pathologic conditions of the vein. It also improves vascular resistance and aids toning of vein walls (10). The triterpene glycosides and steroid saponins decrease venous capillary permeability and appear to have a tonic effect on the circulatory system (11) while aesculetin (esculin), a hydroxycoumarin, may increase bleeding time. A synergistic inhibitory effect on human hepatocellular carcinoma SMMC-7721 cells observed with the combined administration of beta-aescin and 5-fluorouracil may be due to synergistic cell-cycle arrest, induction of apoptosis, activation of caspases-3, 8 and 9, and down-regulation of Bcl-2 expression (17).
Pharmacokinetics
Orally administered aescin has an absorption half-life of about 1 hour and an elimination half-life of about 20 hours. (12)
Warnings
Horse chestnut seed is classified by the FDA as an unsafe herb. Many of the constituents are considered toxic, such as the glycosides and the saponins.
Contraindications
Should not be consumed by patients with hepatic or renal insufficiency.
Adverse Reactions
- Common: GI upset, nausea, and vomiting
- Toxicity: (Chestnut poisoning) Diarrhea, muscle twitching, dilated pupils, depression, and paralysis
Chestnut bezoar (well-defined, ovoid-shaped, intraluminal mass with mottled gas pattern) causing intestinal obstruction and abdominal pain was reported in a 68-year-old woman following consumption of excessive amounts of horse chestnut for several months. The bezoar was removed by surgery (15).
Life-threatening kidney rupture was observed in a patient with angiomyolipoma (AML), a benign fat-containing mesenchymal tumor of the kidney, after taking horse chestnut seed extract for venous insufficiency. Her symptoms improved after an emergency embolization (16).
Herb-Drug Interactions
Anticoagulants / Antiplatelets: Horse chestnut may have an additive anticoagulant effect due to aesculin, a hydroxycoumarin.
Herb Lab Interactions
May prolong APTT, PTT, INR
Literature Summary and Critique
Pittler MH, et al. Horse-chestnut seed extract for chronic venous insufficiency. A criteria-based systematic review. Arch Dermatol. 1998;134:1356-60.
A criteria-based systematic review of double-blind, randomized, controlled trials of oral horse chestnut extract for patients with chronic venous insufficiency. Thirteen studies (8 placebo-controlled) with a total of 1083 patients were reviewed. Trial length ranged from 4 to 12 weeks with a total of 63 dropouts. Use of horse chestnut seed extract was associated with a statistically significant decrease in lower-leg volume and reduction of leg circumference at the calf and ankle as compared to placebo. Symptoms such as leg pain, pruritus, fatigue, and tenseness were also reduced. Adverse effects were mild and comparable to placebo. It was the author's conclusion that short-term, symptomatic use of horse chestnut appears to be safe, but long-term studies are necessary.
Diehm C, et al. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. Lancet. 1996;347:292-4.
Comparison of therapies in 240 patients with chronic venous insufficiency. Patients were treated over a period of 12 weeks in a randomized, partially blinded, placebo-controlled, parallel study design. Lower leg volume of the more severely affected limb decreased on average by 43.8 ml with horse chestnut and 46.7 ml with compression therapy, while it increased by 9.8 ml with placebo after 12 weeks of therapy. These results indicate that compression stocking therapy and horse chestnut therapy are alternative therapies for the effective treatment of patients with edema resulting from chronic venous insufficiency.
References
- Zhang L, Fu F, Zhang X et al. Escin attenuates cognitive deficits and hippocampal injury after transient global cerebral ischemia in mice via regulating certain inflammatory genes. Neurochem Int. 2010 May 11. [Epub ahead of print]
- Zhou XY, Fu FH, Li Z, et al. Escin, a natural mixture of triterpene saponins, exhibits antitumor activity against hepatocellular carcinoma. Planta Med. 2009 Dec;75(15):1580-5.
- Harikumar KB, Sung B, Pandey MK, et al. Escin, a pentacyclic triterpene, chemosensitizes human tumor cells through inhibition of nuclear factor-kappaB signaling pathway. Mol Pharmacol. 2010 May;77(5):818-27.
- Diehm C, Trampisch HJ, Lange S, Schmidt C. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. Lancet. 1996;347:292-4.
- Diehm C, Vollbrecht D, Amendt K, Comberg HU. Medical edema protection—clinical benefit in patients with chronic deep vein incompetence. A placebo controlled double blind study. Vasa. 1992;21:188-92.
- Siebert U, Brach M, Sroczynski G, Berla K. Efficacy, routine effectiveness, and safety of horsechestnut seed extract in the treatment of chronic venous insufficiency. A meta-analysis of randomized controlled trials and large observational studies. Int Angiol. 2002 Dec;21(4):305-15.
- Pittler MH, et al.Horse-chestnut seed extract for chronic venous insufficiency. A criteria-based systematic review. Arch Dermatol. 1998;134:1356-60.
- Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003230. Review.
- Barnes J, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals. London: Pharmaceutical Press; 1996.
- Fetrow CW, Avila JR. Professional’s Handbook of Complementary and Alternative Medicines. Philadelphia: Springjouse; 1999.
- Brinker F. Herb Contraindications and Drug Interactions, 2nd ed. Sandy (OR): Eclectic Med. Publications; 1998.
- Schulz V, et al. Rational Phytotherapy: A Physician’s Guide to Herbal Medicine, 3rd ed. Berlin (Germany): Springer; 1998.
- Morrison D. Boehringer-Ingelheim Product Information Venastat™2001.
- Fang Y, Zhao L, Yan F, et al. Escin improves sperm quality in male patients with varicocele-associated infertility. Phytomedicine. 2010 Mar;17(3-4):192-6.
- Chen WT, Suk FM. Abdominal pain after consuming a chestnut. Diagnosis: Chestnut bezoar in the jejunum. Gastroenterology. 2011 Jun;140(7):e9-10.
- Snow A, Halpenny D, Mc Neill G, Torreggiani WC. Life-threatening rupture of a renal angiomyolipoma in a patient taking over-the-counter horse chestnut seed extract. J Emerg Med. 2011 Feb 9. [Epub ahead of print]
- Ming ZJ, Hu Y, Qiu YH, Cao L, Zhang XG. Synergistic effects of beta-aescin and 5-fluorouracil in human hepatocellular carcinoma SMMC-7721 cells.Phytomedicine. 2010;17(8-9):575-80.
How It Works
Bottom Line: Horse chestnut was shown to be effective for treating chronic venous insufficiency (a condition where a patient's veins are not capable of pumping blood back to their heart, resulting in blood collecting in the lower limbs and swelling of legs), but its long-term effects (more than three months) are not known.
Horse chestnut is a seed extract. There is no evidence that it can treat any other medical conditions, such as varicose veins. One of its active components is aescin, which may reduce inflammation and increase the tone of veins. It also reduces the release of enzymes, which is typically increased in chronic diseases of the vein. Other compounds in horse chestnut generally increase the tone of blood vessels and decrease their permeability. A compound called aesculetin may act as an anticoagulant and blood thinner, and is therefore often excluded from over-the-counter horse chestnut products.
Purported Uses
- To treat circulatory disorders such as chronic venous insufficiency (a condition where a patient's veins are not capable of pumping blood back to their heart, resulting in blood collecting in the lower limbs and leg swelling)
Several clinical trials support this use for up to three months, but no clinical trials have tested the long-term use of this herb. - To treat diarrhea
No scientific evidence supports this use. - To treat hemorrhoids
No scientific evidence supports this use. - To treat phlebitis
No scientific evidence supports this use. - To treat varicose veins
No scientific evidence supports this use.
Research Evidence
Chronic venous insufficiency (a condition where a patient's veins are not capable of pumping blood back to their heart, resulting in blood collecting in the lower limbs and leg swelling):
Researchers carried out a meta-analysis (systematic review) of all the randomized, controlled trials that used horse chestnut to treat chronic venous insufficiency. Overall, 13 clinical trials showed that patients who used horse chestnut had a significant decrease in leg edema (swelling) and symptoms such as leg pain, itching, tension, and fatigue. Because none of these clinical trials studied horse chestnut for more than 3 months, we can only conclude that short-term use of this herb is relatively safe and effective. Long-term studies are needed.
A large clinical trial compared horse chestnut to compression stocking therapy, which is a treatment for reducing leg edema (swelling) in patients with chronic venous insufficiency. After 12 weeks, patients taking horse chestnut had a similar reduction in leg edema to patients using the compression stocking therapy (about 45 ml), while patients taking a placebo pill had an increase in leg edema. These results indicate that horse chestnut is effective for this use, but again, we do not know how well it will work in the long-term (greater than 12 weeks).
Patient Warnings
- Horse chestnut seed is classified by the FDA as an unsafe herb. Many of the compounds in horse chestnut are considered to be toxic.
- This product is regulated by the F.D.A. as a dietary supplement. Unlike approved drugs, supplements are not required to be manufactured under specific standardized conditions. This product may not contain the labeled amount or may be contaminated. In addition, it may not have been tested for safety or effectiveness.
Do Not Take If
- You are taking warfarin, aspirin, or other blood thinners (Horse chestnut products that contain aesculin may increase the risk of bleeding. Check to make sure that your horse chestnut product is aesculin-free)
- You have liver or kidney problems.
Side Effects
- Stomach upset
- Nausea and vomiting
- Chestnut poisoning: Diarrhea, muscle twitching, dilated pupils, depression, and paralysis can occur after high doses of horse chestnut.
- Case Reports:
Chestnut bezoar (well-defined, ovoid-shaped mass) causing intestinal obstruction and abdominal pain was reported in a 68-year-old woman following consumption of excessive amounts of horse chestnut for several months. The bezoar was removed by surgery.
Life-threatening kidney rupture was observed in a patient with angiomyolipoma (AML), a benign fat-containing tumor of the kidney, after taking horse chestnut seed extract for venous insufficiency. Her symptoms improved after an emergency embolization.
Special Point
- Over-the-counter products should be standardized to 50 mg of aescin (the active ingredient) and free from aesculin, which can act as a blood thinner.
Dosage (Inside MSKCC Only)
This field is only visible to only Inside MSKCC users.
Aliases
Aesculus Hippocastanum
E-mail your questions and comments to aboutherbs@mskcc.org.
