Health Care Professional Information

Scientific Name
Rheum palmatum, Rheum officinale
Common Name

Turkish rhubarb, turkey rhubarb, Chinese rhubarb, tai huang, da huang

Clinical Summary

Rhubarb, a perennial herb, is cultivated in many parts of the world. The stalks are consumed as food, and the rhizome and root are widely used in Chinese medicine for a variety of conditions including cancer, immunosuppression, constipation, diarrhea, gastrointestinal ulcers, and hypertension (1) (3). The anthraquinones and tannins in rhubarb are thought responsible for its laxative and constipating effects, respectively (4). But human data are limited.

Cytotoxic (5), cytostatic (6) (14) and antitumor effects have been reported in cancer cells in vitro and in mice (1).
A rhubarb extract reduced radiation-induced lung toxicity and increased pulmonary function in lung cancer patients (7).

Purported Uses
  • Cancer treatment
  • Constipation
  • Fever
  • Hypertension
  • Immunosuppression
  • Inflammation
  • Microbial infection
  • Peptic ulcers
Constituents
  • Anthraquinones: Rhein, physcion, aloe-emodin, emodin, chrysophenol, sennoside A-F
  • Tannins: Rheum tannic acid, gallic acid, glucogallin, catechin, epicatechin
  • Calcium oxalate, lindeyin, fatty acids, rutin, starch, trace volatile oils
    (10) (13)
Mechanism of Action

When used in very small doses the tannin content in rhubarb has a constipating effect. At higher doses, however, the hydrolyzed metabolites of emodin and sennidin stimulate the gastrointestinal tract and produce a laxative effect (4); in vitro tests show suppression of TNF, IL-1, and IL-6 production. The actions of anthraquinones on rheinanthrone that is transformed from sennoside A may promote the purgative effects of sennoside A (16).The anti-inflammatory activity of emodin may mediate rhubarb's hepatoprotective effects in rats with cholestatic hepatitis (11).
Lindeyin, a phenolic gallylglucoside exhibits analgesic and anti-inflammatory activity in animal models. Catechin, epicatechin, procyanidins, and gallylglucose inhibit hyaluronidase in vitro (10) (12).

Aloe-emodin also possesses anti-proliferative activity, inducing cell cycle arrest in cancer cell lines (6). Anthraquinone extracts of rhubarb were shown to induce cytotoxicity in cancer cell lines (5) and tumor necrosis in mice (sarcoma 37, mammary, and Ehrlich) (1), although this has not been demonstrated in humans.
Another study showed that emodin inhibits human cancer cell invasiveness by specifically antagonizing the adenosine 5'-triphosphate (ATP)-gated Ca(2+)-permeable channel P2X7 receptor (P2X7R) (17).

Warnings

Stimulant laxative products such as rhubarb should not be used for more than a week without medical supervision.
 

Contraindications
  • Patients with hormone-sensitive cancers should avoid rhubarb because estrogenic activity has been reported (13).
Adverse Reactions
  • A case of acute crystal-induced renal failure has been reported in a type-1 diabetic patient (with normal excretory renal function) following excessive ingestion of rhubarb (18).
Herb-Drug Interactions
  • Digoxin: Potassium loss due to stimulant laxative effect can increase potential risk for hypokalemia. (9)
  • Cytochrome P450 substrates: Rhubarb induces CYP3A and CYP2D6 and can affect the intracellular concentration of drugs metabolized by these enzymes (15) (19).
Literature Summary and Critique

Yu HM, et al. Effects of rhubarb extract on radiation induced lung toxicity via decreasing transforming growth factor-beta-1 and interleukin-6 in lung cancer patients treated with radiotherapy. Lung Cancer. Feb 2008;59(2):219-226.
In this randomized, double-blind, placebo-controlled study, 80 lung cancer patients undergoing radiation therapy received a rhubarb extract (20 mg/kg daily) or placebo for 6 weeks. Radiation-induced lung toxicity (RILT), pulmonary function, and circulating TGF-beta and IL-6 levels were measured after 6 weeks and 6 months. In the intervention group, decreased RILT, improved pulmonary function, and reduced circulating TGF-beta and IL-6 were detected as compared to the control group, suggesting that rhubarb reduces RILT through attenuation of TGF-alpha and IL-6. No adverse events were reported.
Larger studies are required to determine the mechanism by which rhubarb extracts exert their effects on RILT.

Dosage (Inside MSKCC Only)
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References
  1. Mantani N, et al. Rhubarb use in patients treated with Kampo medicine—a risk for gastric cancer? Yakugaku Zasshi 2002;122:403-5.
  2. Huang KC. The Pharmacology of Chinese Herbs, 2nd ed. New York: CRC Press; 1999.
  3. Zhang ZJ, Cheng WW, Yang YM. Study on low-dose of processed rhubarb in preventing pregnancy induced hypertension. Chung-Hua Fu Chan Ko Tsa Chih [Chinese Journal of Obstetrics & Gynecology] 1994;29:463-4, 509.
  4. Peigen X, Liyi H, Liwei W. Ethnopharmacologic study of chinese rhubarb. J Ethnopharmacol 1984;10:275-93.
  5. Cui XR, Tsukada M, Suzuki N, et al. Comparison of the cytotoxic activities of naturally occurring hydroxyanthraquinones and hydroxynaphthoquinones. Eur J Med Chem. Jun 2008;43(6):1206-1215.
  6. Guo JM, Xiao BX, Liu Q, Zhang S, Liu DH, Gong ZH. Anticancer effect of aloe-emodin on cervical cancer cells involves G2/M arrest and induction of differentiation.Acta Pharmacol Sin. Dec 2007;28(12):1991-1995.
  7. Yu HM, Liu YF, Cheng YF, Hu LK, Hou M. Effects of rhubarb extract on radiation induced lung toxicity via decreasing transforming growth factor-beta-1 and interleukin-6 in lung cancer patients treated with radiotherapy. Lung Cancer. Feb 2008;59(2):219-226.
  8. Newall CA, et al. Herbal Medicines: A Guide for Health-Care Professionals. London: Pharmaceutical Press; 1996.
  9. Brinker F. Herb Contraindications and Drug Interactions, 3rd ed. Sandy (OR): Eclectic Medical Publishing; 2001.
  10. Tamayo C, et al. The chemistry and biological activity of herbs use in Flor-essence herbal tonic and Essiac. Phytother Res 2000;14:1-14.
  11. Ding Y, Zhao L, Mei H, et al. Exploration of Emodin to treat alpha-naphthylisothiocyanate-induced cholestatic hepatitis via anti-inflammatory pathway. Eur J Pharmacol. Aug 20 2008;590(1-3):377-386.
  12. Blumenthal M, Goldberg A, Brinckmann J. Herbal Medicine, Expanded Commission E Monographs. Austin: American Botanical Council; 2000.
  13. Kang SC, Lee CM, Choung ES, et al. Anti-proliferative effects of estrogen receptor-modulating compounds isolated from Rheum palmatum. Arch Pharm Res. 2008 Jun;31(6):722-6.
  14. Li WY, Chan SW, Guo DJ, et al. Water extract of Rheum officinale Baill. induces apoptosis in human lung adenocarcinoma A549 and human breast cancer MCF-7 cell lines. J Ethnopharmacol. 2009 Jul 15;124(2):251-6.
  15. Tang JC, Zhang JN, Wu YT, Li ZX. Effect of the water extract and ethanol extract from traditional Chinese medicines Angelica sinensis (Oliv.) Diels, Ligusticum chuanxiong Hort. and Rheum palmatum L. on rat liver cytochrome P450 activity. Phytother Res. 2006 Dec;20(12):1046-51.
  16. Takayama K, Tsutsumi H, Ishizu T, Okamura N. The influence of rhein 8-O-β-D-glucopyranoside on the purgative action of sennoside A from rhubarb in mice.Biol Pharm Bull. 2012;35(12):2204-8.
  17. Jelassi B, Anchelin M, Chamouton J, et al. Anthraquinone emodin inhibits human cancer cell invasiveness by antagonizing P2X7 receptors.Carcinogenesis. 2013 Jul;34(7):1487-96.
  18. Albersmeyer M, Hilge R, Schröttle A, et al. Acute kidney injury after ingestion of rhubarb: secondary oxalate nephropathy in a patient with type 1 diabetes. BMC Nephrol. 2012 Oct 30;13:141.
  19. Gao J, Shi Z, Zhu S, et al. Influences of processed rhubarbs on the activities of four CYP isozymes and the metabolism of saxagliptin in rats based on probe cocktail and pharmacokinetics approaches.J Ethnopharmacol. 2013 Jan 30;145(2):566-72.

Consumer Information

How It Works

Bottom Line: Rhubarb acts as a stimulant laxative, but is not safe to use over long periods of time.

Rhubarb is a perennial herb, the stalks of which are consumed as food. The rhizome and roots are used as laxatives and to treat ulcers, constipation, diarrhea, hypertension, immunosuppression, and cancer in Chinese medicine. In laboratory experiments, rhubard showed biological effects, but scientists are still unsure how rhubarb works. Chemicals in rhubarb called anthraquinones cause tumor death in mice implanted with some solid tumors. Lindeyin, a chemical found in rhubarb, was found to reduce pain and inflammation in laboratory animals.
More studies are needed.

Purported Uses
  • To treat cancer
    No scientific evidence supports this use.
  • To reduce the severity of side effects from anticancer therapy
    One study suggested that a rhubarb extract may reduce side effects associated with radiation therapy in lung cancer patients, but further studies are needed to confirm such effects.
  • To relieve constipation
    Rhubarb acts as a laxative, although clinical trials have not tested this use.
  • As a fever reducer
    There is no research to validate this claim.
  • To lower high blood pressure
    One study in China found that low-dose rhubarb could prevent high blood pressure in pregnancy, but there is no other evidence that rhubarb can lower high blood pressure.
  • To suppress the immune system
    Laboratory data shows that rhubarb decreases the activity of isolated immune cells.
  • To reduce inflammation
    No scientific evidence supports this use.
  • To treat infections
    This claim is not backed by research.
  • To treat stomach ulcers
    Rhubarb is often used in traditional Chinese medicine to treat gastrointestinal disturbance, but clinical trials have not been done.
Research Evidence

Reducing side effects associated with radiation therapy
In this study, 80 lung cancer patients undergoing radiation therapy received a rhubarb extract or placebo for 6 weeks. Side effects associated with radiation therapy, such as cough, shortness of breath, fever and lung function were measured after 6 weeks and 6 months. Patients receiving rhubarb reported decreased side effects and improved lung function. No side effects were reported.

Patient Warnings
  • Rhubarb is considered to be a stimulant laxative, and therefore should not be used for more than seven days without medical supervision.
Do Not Take If
  • You are pregnant (Rhubarb may cause stimulation of the uterus and may increase the risk of miscarriage).
  • You have hormone-sensitive cancers such as breast, prostate, cervical, and uterine cancers (Rhubarb may have estrogenic activity).
  • If you are taking drugs that are substrates of Cytochrome P450 (Rhubarb may reduce the effectiveness of these drugs).
Side Effects
  • A case of acute crystal-induced kidney failure has been reported in a type-1 diabetic patient (with normal excretory renal function) following excessive ingestion of rhubarb.
Special Point
  • Rhubarb is one of the herbs found in Essiac tea.
E-mail your questions and comments to aboutherbs@mskcc.org.