THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 9, Number 6, 2003, pp. 877B896
8 Mary Ann Liebert, Inc.
Review of Sangre de Drago (Croton lechleri)CA South
American Tree Sap in the Treatment of Diarrhea,
Inflammation, Insect Bites, Viral Infections, and Wounds:
Traditional Uses to Clinical Research
KENNETH JONES
ABSTRACT
Objective: The objective of this review is to provide an overview of the pharmacologic evidence
that may or may not support clinical and ethnomedical uses of the sap of sangre de drago
(dragon=s blood; Croton lechleri Müll. Arg.). Data sources used were BIOSIS, EMBASE, PubMed,
TOXLIT, International Pharmaceutical Abstracts, manual searches, papers on file from peer-reviewed
journals, textbooks available at Armana Research, Inc., and researchers in the field of
South American botanical medicine.
Conclusions: The results of in vitro and in vivo studies largely support the majority of ethnomedical
uses of sangre de drago including the treatment of diarrhea, wounds, tumors, stomach
ulcers, herpes infection, the itching, pain and swelling of insect bites, and other conditions.
Clinical studies of sangre de drago products have reported positive results in the treatment of
traveler=s and watery diarrhea and the symptoms of insect bites. Because the sap has shown
low toxicity and preparations used in clinical studies were well tolerated, further clinical and
pharmacologic studies are anticipated. Acknowledgment of the diversity in the chemical
makeup of the sap from one geographic area to another and the recent characterization of alkaloid
chemotypes of sangre de drago will require that materials developed for clinical use are
standardized.
877
Armana Research, Inc., Halfmoon Bay, British Columbia, Canada.
BOTANICAL DATA
Classification and nomenclature
The scientific name of sangre de drago
(dragon=s blood) is Croton lechleri Müll.
Arg. (syn. C. draconoides Müll. Arg.). Closely related
South American species known as sangre
de drago include Croton palanostigma Klotzsch
(syn. C. benthamianus Müll.-Arg.) (Brako and
Zarucchi, 1993), and C. erythrochilus Müll.-
Arg., both found in Peru (Pieters et al., 1990).
Some Peruvian botanists classify C. draconoides
(Müll. Arg.) as synonymous with C. palanostigma
(Klotzschs) (Pieters et al., 1990). In central
Peru (Oxapampa, Pasco), two other species
known locally as sangre de drago are C. perspeciosus
Croizat and the recently reported C. rimbachii
Croizat (Meza, 1999). C. urucurana Baillon
occurs in southeast Brazil (Peres Marize et
al., 1997), Paraguay (Portillo et al., 2001), and
in Brazil. In Brazil, the herb is also known as
sangre de drago or Sangra d=Água (Lopes Pereira
Peres et al., 1998). Brazilian populations of this
species are in rapid decline (Peres Marize et al.,
1997).
From the family Euphorbiaceae, some common
names include Croton lechleri (dragon=s
blood, [English]), Sangre de Dragón (Soukup,
1970), sangre de drago (Duke and Vasquez,
1994), Sangre de Grado (blood of the tree) (Milanowski
et al., 2002), and Palo de Grado (tree of
gladness; Peruvian mestizo) (Peres Marize et
al., 1997). The American Herbal Products Association
assigns the common names Adragon=s
blood croton@ and Sangre-de-Drago as acceptable
names for use in U.S. commerce (McGuffin
et al., 2000). Aboriginal names for Croton
species that produce a red latex are far more
numerous. In eastern Ecuador, Quechua names
are arleiia and lan huiqui.* In Ayacucho, Peru,
the Quechua name is yawar gradwascca. Among
the Asháninka, the largest Indian tribe in Peru,
the tree is known by the names irariki, irari, and
quirari, depending on the geographical area of
the tribe. In Peru there are at least 20 other indigenous
names for sangre de drago trees, some
translating to wood=s blood or tree=s blood
(Meza and Pariona, 1999).
Dragon=s blood is a name of Old World extraction,
earlier applied to the plant proper or
the sap derived from Dracaena draco L. (Liliaceae)
of the Canary Islands (a palm tree that
produces a red resin used in varnishes), and to
the Arabian D. cinnabari Balf., the red resin of
which was also used in varnishes and in medicine
to stop hemorrhages. Other plants known
as dragon=s blood include the rattan palm of
Malaya, Daemonorops draco Blume (Palmaceae),
which supplied a resin used in photoengraving,
etching and in the varnishes of Italian violins
during the eighteenth century; and in
Guyana, Pterocarpus draco L. (Leguminosaceae)
or padauk supplied West Indian Dragon=s Blood
(Emboden, 1974; Uphof, 1968).
Description
- lechleri is described as a medium-sized tree
that occurs in forests and disturbed areas from
sea level to 1000 meters in the eastern lowlands
of the Peruvian Amazon and low mountainous
areas of the Peruvian Andean region, as well
as Colombia, Bolivia, and Ecuador (Brako and
Zarucchi, 1993). In northwest Amazonia, C.
lechleri is most commonly found at elevations
of 100B600 meters. In Ecuador, C. lechleri occurs
in the primary rain forest as an understory tree
where it reaches a height of 15 meters. Much
like alder trees (Alnus spp.) in the northern
hemisphere, C. lechleri is a fast-growing (10B15
meters in 3 years) (Miller et al., 2001) pioneer
species and is one of the first plants to appear
in recently cleared areas and along roadsides
(Ubillas et al., 1994). It has heart-shaped (cordate),
alternate leaves that range in size from
15B30 cm in width and length and appear with
6B8 parallel veins diverging diagonally from
the leaf midvein. The fruits are three-celled and
the small flowers appear on a tall thin spike
that measures 30B50 cm in length. When cut,
the trunk produces a bright red latex that may
appear orangeish (Castner et al., 1998).
The yield of latex from C. lechleri is greatest
in the rainy season and also depends on the age
of the tree. The traditional method of slashing
the bark produces a maximum yield of several
liters of sap from a tree up to 6 years old with
a diameter of, on average, 25 cm at breast
height. Felling the tree and scoring the bark
produces 5B6 L of sap. Because the sap is slowly
released from a standing tree, felling and scoring
is the preferred method for industrial scale
production (Ubillas et al., 1994).
HISTORY AND TRADITIONAL USES
The main part of C. lechleri used medicinally
in South America is the blood-red latex or sap,
which is a common household remedy used in
Peru, other Latin American countries, and
among the Latin American population of the
United States. Although its medicinal uses are
still largely unrecognized outside of Latin
JONES 878
*Marles R. The Ethnopharmacology of the Lowland
Quichua of Eastern Ecuador [dissertation]. Chicago: University
of Illinois at Chicago, 1988.
America, sangre de drago recently became available
in the United States as a dietary supplement.
The sap of C. lechleri is widely sold in the local
markets of Ecuador and Peru where it is
popularly used to treat diverse illnesses in
adults, children, and infants. Internal ethnomedical
uses include the treatment of diarrhea,
dysentery, cholera (Carlson and King
2000), coughs, flu, lung problems, stomach ulcers,
(Ubillas et al., 1994), and hives, the latter
being treated by taking the sap in pineapple
juice (20 drops per 200 mL). In the upper Amazon,
the sap is taken diluted in hot water to
speed internal healing after an abortion, and
used as a vaginal douche after childbirth (Castner
et al., 1998). Others report that the sap is
used in Amazonia in vaginal baths taken before
childbirth (Duke and Vasquez, 1994) and
another refers to the danger of irritating tissues
by applying sangre de drago after childbirth
(Soukup, 1970). These uses probably followed
the so-called doctrine of signatures; however,
it is noted that Croton species are extensively
used all over the world for pain- and blood-related
health problems, and especially those associated
with menstruation.*
In upper Amazonia, the sap is taken to treat
tuberculosis and bone cancer (Castner et al.,
1998) and may be combined with other medicinal
plants to treat other types of cancer (e.g.,
Uña de Gato or Uncaria tomentosa [Willd.) DC.])
(Maxwell, 1990). The sap of a closely related
species, also known in Peru as sangre de drago
(Duke and Vasquez, 1994) (Croton palanostigma
Klotsch), has been popularly used by indigenous
people of the region of Pucallpa, Peru, to
treat tumors (Hartwell, 1969; Rutter, 1990).
External use of the sap to stop bleeding of
cuts and wounds led to the common rural
name in Peru of Aliquid bandage.@ While in
Peru I learned that it was not unusual to find
the sap in the household medicine cabinet next
to the iodine, which has a similar appearance.
From what I could tell, it was just as common
an item in the cities as in the countryside. In
the suburbs of Lima, I witnessed the application
of the sap to a 6.35-cm wound on the inside
arch of the foot of a young man who incurred
the injury while surfing nearby. He said
that the fin of the board had cut his foot during
a fall. His mother applied a few drops of
the sap and applied a small bandage. Six hours
later at a nightclub in the city, I found him
dancing. When I enquired about the wound he
claimed to not have any pain (Jones, 1995). On
further questioning, he claimed to have taken
nothing that would relieve pain except for the
distraction of the music and a couple of beers.
Other external ethnomedical uses of the sap
in Peru and Ecuador include the topical treatment
of bites and particularly stings, for which
the sap is said to stop itching and pain in a matter
of minutes and to subsequently reduce the
attendant redness and swelling (Miller et al.,
2000).
The sap is also used in the healing of open
sores (oral and otherwise), herpes infections,
surgical operations (urban areas) (Ubillas et al.,
1994), and infected gums. The Quijos Quichua
of eastern Ecuador soak a piece of cotton with
the sap, which is applied to alleviate the pain
of tooth extractions and cavities.* C. palanostigma,
the closely related species noted above,
is also used to treat pain. In the region of Manaus,
Brazil, the sap of this tree is used topically
in the treatment of painful boils and ulcers
(Schultes and Raffauf, 1990). Still other ethnomedical
uses of the sap of C. lechleri in Peru
are found in the treatment of bone fractures,
leucorrhea, piles, hemorrhoids (Soukup, 1970),
and rheumatism (Persinos Perdue et al., 1979;
Phillipson, 1995).
- lechleri is a fast-growing pioneer species
(Miller et al., 2001; Ubillas et al., 1994), growing
as much as 3B4.5 meters per year. Because
repeated tapping of the sap renders the trees
susceptible to fungal infections, one of the current
practices of commercial harvest involves a
2B3-year cycle of felling the trees, draining
them of sap, and replanting (Miller et al., 2001).
The practice of replanting requires careful management
and conservation in conjunction with
the indigenous peoples who reside in the
forests where they grow (Ubillas et al., 1994).
In the course of sustainable management studies
of sangre de drago in Ecuador and Peru, it
REVIEW OF SANGRE DE DRAGO 879
*Marles R. The Ethnopharmacology of the Lowland
Quichua of Eastern Ecuador [dissertation]. Chicago: University
of Illinois at Chicago, 1988.
was learned that unlike the related rubber tree
(Hevea spp; family Euphorbiaceae), the compartments
in the bark of Croton species that
produce the latex (lactifers) are nonregenerating,
which explains why the latex of standing
trees does not flow continuously after tapping
(King et al., 1997; Ubillas et al., 1994; Castro and
Meza, 1999). These studies also found that 10
months after tapping the bark of standing trees
to obtain the latex (300 mL), there was a high
rate of mortality (44%) or impending death
(35%). Only a few trees (2.5%) showed the appearance
of surviving. Similar results were
seen in populations from different locales in
which the amount of sap obtained ranged from
200 to 300 mL (King et al., 1997).
CHEMISTRY
Alkaloids
The leaves of C. lechleri contain the morphinandienone
alkaloid, sinoacutine (Carlin et al.,
1996). The sap contains the phenanthrene alkaloid
taspine (Persinos Perdue et al., 1979),
which is also found in the sap (Itokwa et al.,
1991) and leaves of C. palanostigma (Bettolo
and Scarpati, 1989). Magnoflorine, isoboldine,
norisoboldine, taspine (Milanowski et al., 2002),
glaucine, and thaliporphine were identified in
the leaves (Bettolo and Scarpati, 1989). The content
of taspine in the sap varies widely. A recent
survey in northwest Peru and central
Ecuador of 493 trees in 20 sites (February/
March 1996, March/April, 1999 and September
1997), along with multiple samplings at 13 of
the sites indicates that the content of taspine in
the latex of C. lechleri ranges from 1.3%B20.4%
with an approximate mean level of 9% (dry
weight), but that it is only found in mature
trees. Samplings from a few trees calculated to
be a year old contained other alkaloids. Based
on analyses of leaves from 264 trees, the survey
also found evidence to suggest that there
may be three alkaloid chemotypes of C. lechleri.
The leaves of chemotype 1 contained glaucine,
isoboldine, and thaliporphine. Those of chemotype
2 contained isoboldine and thaliporphine
while the leaves of chemotype 3 contained only
isoboldine. Yet both the content of taspine and
the alkaloid profile of the latex of mature trees
of the three proposed chemotypes showed no
significant difference (Milanowski et al., 2002).
Phenolic compounds
Lignans. Dihydrobenofuran lignan (39,4-Odimethylcedrusin)
and a coniferyl alcohol previously
found in species of pine (Pinus) were
isolated from the sap of C. erythrochilus (Pieters
et al., 1990).
Tannins. The major constituents of the sap of
- lechleri are proanthocyanidins and flavonols
(Cai et al., 1991). The sap is abundant in soluble
proanthocyanidins (also referred to as procyanidins,
condensed tannins or procyanidin
oligomers or PCOs), containing up to 90% by
dry weight (Cai et al., 1991). Upon heating in
acid medium, PCOs yield cyanidin. A mixture
of PCOs known as SP-303 (molecular weight
,2100 da) isolated from the sap of C. lechleri is
largely composed of (2)-galloepicatechin and
(1)-gallocatechin with lesser amounts of (2)-
epicatechin and (1)-catechin (Ubillas et al.,
1994). SP-303 has the appearance of a dark reddish-
brown powder (Ubillas et al., 1994). Other
related compounds found in the sap of C. lechleri
(Ecuador) are procyanidins B1 and B4 (Cai
et al., 1991).
Terpenoid compounds
Diterpenes. Diterpenes isolated from the bark
of C. lechleri (Ecuador) were found in minor
amounts in the sap: bincatriol, crolechinol,
crolechinic acid, hardwickiic acid, and koberins
A and B (Cai et al., 1993).
Steroids. The bark of C. lechleri (Ecuador) contains
b-sitosterol-b-D-glucopyranoside and bsitosterol
(Cai et al., 1993).
To date, procyanidins and alkaloids are considered
to be the most active constituents of the
sap.
PRECLINICAL STUDIES
Gastrointestinal functions
Antisecretory activity against diarrhea. A survey
of local ethnomedical uses of the latex in
the area of Iquitos, Peru, in 1996 by ethnob-
JONES 880
otanist Franklin Ayala and Peruvian registered
nurse Dina Ayala, found that 57% of the randomly
interviewed populace reported its use
in the treatment of diarrhea (Carlson et al.,
2000). While this application was already
known (Ubillas et al., 1994),* no one had reported
any frequency of use. The fact that sangre
de drago was also taken orally in Peru to treat
watery diarrhea (dysentery and cholera) encouraged
researchers to initiate studies on its
potential use against this illness (Carlson et al.,
2000).
Using a mixture of procyanidin (proanthocyanidin)
oligomers derived from the latex and
designated SP-303, researchers examined antidiarrheal
activity in a mouse model for secretory
diarrhea with cholera toxin as the inducer.
In the form of enteric-coated beads,
SP-303 (100 mg/kg by gavage) administered at
the same time as the cholera toxin caused a significant
and dose-dependent reduction in the
amount of toxin-induced fluid accumulation in
the small intestine. Levels of fluid were nearly
restored to normal. Administered 3 hours after
mice were treated with the cholera toxin, SP-
303 again produced a dose-dependent inhibition
of fluid accumulation. At the highest dose
tested (50 mg/kg), fluid accumulation levels
were not significantly different from those of
controls. The half-maximal inhibitory amount
of SP-303 against cholera toxin-induced fluid
accumulation was approximately 10 mg/kg
(Gabriel et al., 1999).
In vitro studies to determine the mechanism
involved were performed by elevating cyclic
adenosine monophosphate (cAMP) levels in intestinal
epithelial cells using a potent activator
of adenylate cyclase (forskolin, derived from
Coleus forskohlii Briq. syn. C. barbatus Benth.),
thereby modeling the effects of cholera enterotoxin.
Binding of the enterotoxin to intestinal
cells leads to modification of a stimulatory protein
(G protein) and subsequent activation of
adenylate cyclase which in turn elevates cAMP.
Consequently, a chloride channel is activated
which causes a high volume of chloride and resultant
fluid secretion in the intestine. Left untreated
this state can result in dehydration and
death. SP-303 was shown to inhibit cAMP-mediated
chloride secretion in intestinal epithelial
cells (Caco-2 cells and T84 cells). Maximal inhibition
of forskolin-stimulated chloride secretion
in the intestinal cells was found from the
addition of 300 mM of SP-303. The concentration
that inhibited the chloride secretion by
50% (IC50) was approximately 50 mM (Gabriel
et al., 1999).
Further in vitro studies on the mechanism of
the antidiarrheal activity of sangre de drago were
conducted using a mixture of the whole sap collected
from C. lechleri and C. palanostigma (Upper
Huallaga River Valley, Amazonian Peru).
Pretreatment of isolated guinea pig ileum with
the sap (1:1,000) inhibited chloride secretion
evoked by capsaicin (derived from chili peppers,
Capsicum annuum L.) by approximately
70%. Because the response to capsaicin is mediated
by substance P released from sensory afferents
(inner part of nerves), these results suggest
that the sap suppressed epithelial secretion
by some direct inhibitory effect on sensory afferent
activation. The results of in vitro tests indicated
that the sap mixture does not compromise
cholinergic, substance-PBdependent
epithelial (neuron-induced) secretion, indicating
that the sap does not act as a general nerve
activation-inhibiting substance. The researchers
postulated that because of its ability
to block sensory afferents activated by capsaicin,
the sap may attenuate the pain and
cramping that attends the secretory processes
of diarrhea as well as intestinal distress. They
add that it may also have therapeutic use in
other types of neurogenic inflammation (Miller
et al., 2000).
Recent evidence indicates that fluid secretion
caused by rotavirus involves enteric nervous
system activation in the wall of the intestines
(Lundgren et al., 2000). Therefore, the ability of
the sap to block capsaicin-activated sensory afferents
(Miller et al., 2000) may represent a possible
or new means of treating rotavirus diarrhea,
which may become an important use of
the sap. Rotavirus is the major cause of severe
diarrhea in young children and infants worldwide
and by the age of 5, almost every child
will experience rotavirus gastroenteritis. The
virus causes dehydration, nausea, vomiting,
REVIEW OF SANGRE DE DRAGO 881
*Marles R. The Ethnopharmacology of the Lowland
Quichua of Eastern Ecuador [dissertation]. Chicago: University
of Illinois at Chicago, 1988.
and diarrhea, and causes an estimated 352,000B
592,000 (median, 440,000) deaths worldwide
per year largely in the developing world
(Parashar et al., 2003; World Health Organization,
1999). Worldwide, rotavirus causes approximately
2 million hospitalizations, 25 million
visits to a clinic, and 111 million episodes
of gastroenteritis every year (Parashar et al.,
2003). Since the discovery of rotavirus in the
1970s, a vaccine was developed and then withdrawn
in 1998 after producing undesirable sideeffects
(Dennehy and Bresee, 2001). Since then,
the need for effective and affordable treatment
has become more urgent (Parashar et al., 2003).
In the United States among children 5 years of
age and younger, the exact incidence of rotavirus-
associated diarrhea has yet to be determined
with any certainty. However, recent
trends in the United States incidence of diarrhea
in this age group suggest that it may be more
prevalent than previously thought. Beginning a
year after rotavirus infection was specifically
coded for in U.S. hospitals in 1993 to 3 years
later, among insured patients in the age group
the incidence increased from 6.9% to 17.7% of
all diarrhea-associated hospitalizations, resulting
in 593 children being hospitalized and more
than 6000 outpatient visits (Zimmernan et al.,
2001).
Immune functions: inflammation and disease
Cytotoxicity against cancer cells. Potent in vitro
cytotoxicity against KB cells (human oral epidermoid
carcinoma) was reported from the alkaloid
taspine. The concentration required to
inhibit KB tumor cell growth by 50% (IC50) was
0.39 mg/mL (Itokwa et al., 1991). Further tests
against the growth of KB cells were conducted
using the sap from C. lechleri collected in
Ecuador. At greater than 900 mg/mL (Chen et
al., 1994), the IC50 of the raw sap was much
higher than that obtained in an earlier study on
KB cells with sap from Peruvian C. palanostigma
(Itokwa et al., 1991), a result likely caused by
the trace amount of taspine in the sap from
Ecuador (Chen et al., 1994) versus a taspine
content of at least 10 mg/g in the Peruvian sap
(Itokwa et al., 1991). After freeze-drying the sap
from Ecuador (C. lechleri), the IC50 in the KB
cell assay was approximately 4.8 times smaller
(IC50 187 mg/mL). However, even this concentration
was hardly cytotoxic and various solvent
extracts of the sap failed to show much
higher activity. A methanolic extract of the
heartwood was more active (IC50 25 mg/mL),
but was still not cytotoxic. With an IC50 of more
20 mg/mL, various constituents isolated from
the sap also showed no cytotoxic activity. The
most active compound was 1,3,5-trimethoxybenzene
(IC50 of 7.13 mg/mL) which was still
much weaker than the control (emetine hydrochloride,
IC50 of 0.2 mg/mL). It was proposed
that if any sangre de drago sap with a low
content of taspine can produce antitumor activity,
it may be because of mechanisms other
than cytotoxicity, such as immunostimulation
(Chen et al., 1994).
More recent in vitro studies on the tumor-cell
cytotoxicity of sangre de drago examined effects
on human erythroleukemia K562 cells (Rossi et
al., 2003) and human gastrointestinal cancer
cell lines of colon (T84 and HT29) and stomach
cancer (AGS) (Sandoval et al., 2002). Dose-dependent
antiproliferative activity against K562
cells was found from reconstituted, filtered,
freeze-dried raw sap of Ecuadorian C. lechleri
(IC50 of 2.5 mg/mL) collected in Morona Santiago
province (Rossi et al., 2003). In the study
on colon and stomach cancer cell lines, the sap
of C. palanostigma (Upper Huallaga Valley,
Tingo Maria, Peru) was also reconstituted in
water from filtered, freeze-dried material and
used in all the experiments. After incubation
with the sap at a concentration of 100 mg/mL
and 200 mg/mL, but not at 10 mg/mL, cell viability,
cell adhesion, and cell proliferation
were significantly decreased in all the cancer
cell lines. Cell adhesion of the cancer cells was
shown to be irreversibly damaged with complete
loss of adhesion when the cells were taken
to another medium. Apoptosis was significantly
increased at the same concentrations of
the sap in each of the cancer cell lines and in
each experiment the effect of the sap was concentration
and time-dependent. Effects of the
sap (100 mg/mL) on microtubule morphology
were similar in each of the cancer cell lines. Exposure
to the sap caused clumps to form and
the microtubule structure to undergo significant
damage, although more so in the T84 colon
cancer cells. Coupled with the observed effects
JONES 882
of the sap on microtubule structure and damaged
adhesion ability of the cancer cell lines,
Sandoval et al. (2002) concluded that it can induce
changes similar to those of the anticancer
agent TaxolJ (Bristol-Myers Squibb, Princeton,
NJ), which also renders microtubules nonfunctional
and results in cellular apoptosis and
the inability of cancer cells to adhere. As to
what the active constituents may be, the researchers
suggested the possibility of vanilloid
compounds (Sandoval et al., 2002).
Antimicrobial activity against infectious diseases.
The freeze-dried sap of C. lechleri (Ecuador)
showed weak activity against the growth of
Bacillus subtilis (strain JTS 13) and Escherichia
coli (strain KL 16), with activity only at concentrations
of greater than 10 mg. A methanolic
extract was not much better and ethyl alcohol
and acetone extracts were less active than
the freeze-dried sap. Better activity against E.
coli was found from a chloroform extract, but
it was less active against B. subtilis. Among various
constituents of the sap, highly potent
activity against B. subtilis was found from
two compounds (2,4,6-trimethoxyphenol and
1,3,5-trimethoxybenzene at 0.0003 mg) which
showed 30-fold the activity of chloramphenicol
and penicillin. These substances were also
highly active against the growth of E. coli, although
less potently so (1.0 and 0.04 mg, respectively).
High activity was also found from
several diterpenoid constituents of the sap.
Crolechinic acid was active against E. coli and
- subtilis (1.0 and 0.2 mg, respectively), and at
0.04 and 0.05 mg, korberins A and B showed
good activity against B. subtilis (Chen et al.,
1994).
A combination of the undiluted saps of Peruvian
sangre de drago (C. lechleri and C. palanostigma)
showed 100% lethality against E. coli and
was still 90% lethal at a dilution of 1:10 (Miller
et al., 2000).
Antiviral activity against viruses. Antiviral activity
of the procyanidin preparation known as
SP-303 (molecular weight approximately 2100
- da) has been more extensively tested than any
other constituent of the sap (Ubillas et al., 1994).
SP-303 has shown in vitro activity against Herpes
simplex viruses (HSV-1 and HSV-2), inhibition
of thymidine kinase mutants of the viruses,
and pronounced activity against acyclovir-resistant
strains (Barnard et al., 1993; Safrin et al.,
1993). In the plaque reduction assay, SP-303 exhibited
greatest potency against various isolates
of HSV-2 (ED50 of 0.9B2.1 mg/mL). Evidence
of SP-303-induced interferon production
was absent (Barnard et al., 1993) and its function
was not like that of ribavirin, which inhibits
viruses during the replication stage.
Studies suggest that the mechanism of viral inhibition
of SP-303 is at the level of plasma membrane
penetration and/or adsorption at an
early stage of viral activity (Barnard et al., 1993;
Ubillas et al., 1994).
At 6 hours postinfection, guinea pigs vaginally
infected with HSV-2 showed significantly
less viral lesions after topical treatment with a
dimethyl sulfoxide (DMSO; 78% w/w)-based
ointment containing SP-303 (10%). The ointment
was approximately half as active as acyclovir
(5% ointment). Similar results were
found in mice vaginally infected with HSV-2
after treatment with a 10% SP-303 cream or SP-
303 administered orally (90 mg/kg per day for
8 days) (Ubillas et al., 1994). The mean lesion
score of mice topically treated with SP-303
(10%) was significantly reduced and 70% of the
animals survived (versus 100% of those treated
with acyclovir). Benefits from intraperitoneal
(30 mg/kg per day) and oral SP-303 (270
mg/kg twice daily) were not significantly different
from the 10% topical cream. In uninfected
control mice, no signs of irritation were
found from the topical preparation; however,
intraperitoneal (i.p.) and oral doses of SP-303
caused weight loss (Barnard et al., 1993).
Administration of SP-303 (9 mg/kg per day)
by small particle aerosol to mice infected with
influenza A produced significant increases
in survival and significantly decreased pulmonary
influenza titers, damage to lung
tissues, and development of pneumonitis.
However, neither oral or i.p. administrations of
SP-303 produced statistically significant results
(Gilbert et al., 1993).
Respiratory syncytial (RSV) and parainfluenza
viruses are leading causes of serious infections
of the lower respiratory tract of children
less than 2 years old. In infants, RSV can
cause pneumonia and bronchiolitis. It also
REVIEW OF SANGRE DE DRAGO 883
causes acute respiratory infections in the elderly.
In young children and infants, parainfluenza
viruses cause the common cold as well
as otitis media, bronchiolits, severe croup, and
pneumonia (Bennett and Plum, 1996).
SP-303 selectively inhibited several respiratory
viruses in vitro (Wyde et al., 1991) and appeared
to inhibit the cellular penetration of
RSV (Barnard et al., 1992). Against RSV infection
in rats, single doses of SP-303 (1B10 mg/kg
per day i.p.) produced significant reductions of
75% to 97% in pulmonary titers of the virus
compared to placebo. The highest dose produced
results comparable to ribavirin (90
mg/kg i.p., 99% reduction in virus titer) and
provide the only consistent results. Oral administration
of SP-303 produced variable results
against RSV infection. Significant results
compared to placebo were seen from twice
daily doses of 3 mg/kg orally (80% to 99% reductions
in viral titers, p 5 0.03). However,
doses of 1 mg or less and 30 mg or more twice
daily failed to produce consistently significant
results. Significant reductions in titers of
parainfluenza virus type 3 (PIV3) of 87% to 94%
were found in rats treated with SP-303 at single
doses of 3 mg/kg and 10 mg/kg per day
i.p. respectively, compared to placebo (Wyde
et al., 1993).
Oral dosages of SP-303 (30, 90, or 270 mg twice
daily 4 hours prior to infection for 7 days) produced
significant decreases of RSV titers in
African green monkeys infected by inoculation
(Soike et al., 1992). Administered 24 hours after
infection, oral dosages of SP-303 at 10 or 90 mg/kg
per day produced significant reductions in viral
titers of the lungs (Ubillas et al., 1994). No generalized
toxic effects or changes in clinical chemistry
were found from oral doses of 100, 300, or 900
mg/kg per day for 5 days (Soike et al., 1992).
In cultures of several tumor viruses (simian
sarcoma virus type I, Rauscher murine
leukemia virus, and avian myeloblastosis
virus), the alkaloid taspine (70B98 mg/mL) inhibited
the enzyme reverse transcriptase by
50% (Sethi, 1977).
Inflammatory response
Arthritis. In an animal model of polyarthritis,
the anti-inflammatory activity of the alkaloid
taspine was compared to that of indomethicin
(1 mg/kg per day orally). Male rats administered
the alkaloid (20 mg/kg per day
orally) for 3 days prior to adjuvant-induced
arthritis and for 17 days thereafter showed a
significant decrease in paw swelling, which
was comparable to or greater than that of indomethicin.
In a separate study on edema in
rats (carrageenan-induced pedal edema),
taspine (median effect dose [ED50] 58 mg/kg
orally) displayed 3B4 times the anti-inflammatory
potency of phenylbutazone (Persinos Perdue
et al., 1979).
Gastric ulcers. In a rat model of gastric ulcer
(acetic acid-induced), sap derived from Peruvian
- lechleri and C. palanostigma (Rainforest
Phytoceuticals, Delmar, NY) administered in
drinking water for 7 days (60 or 600 mg/ 5
1:10,000 or 1:1000 dilution) produced a significant
reduction in the size of ulcers. In contrast
to untreated rats, the gastric epithelium of the
sap-treated rats showed areas of regenerating
epithelia. At either concentration, the magnitude
of the healing from the sap was at least as
great as that from a combination of streptomycin
and penicillin. Moreover, tests revealed
a significant decrease in bacterial counts of the
ulcers in the sap-drinking rats versus controls.
Subsequently, the undiluted combination of
saps was found to kill E. coli completely. Even
at a dilution of 1:10 the sap combination was
still 90% effective. A further benefit from the
sap was seen in a significant decrease in the
granulocyte contents of the ulcers, which was
evident in greatly decreased ulcer myeloperoxidase
levels. The researchers noted that this
effect was something not found in previous
studies of ulcer-healing using probiotics or antibiotics
(Miller et al., 2000).
In the gastric epithelium of rats with gastric
ulcers, Miller et al. (2000) found highly upregulated
gene expression of the cytokines
(messengers) tumor necrosis factor-a (TNF-a),
inducible nitric oxide synthase (iNOS), interleukin-
6 (IL-6), interleukin-1b (IL-1b), and cyclo-
oxygenase-2 (COX-2). In the gastric epithelium
of the sap-treated rats, gene expression of
the proinflammatory cytokines was reduced,
especially iNOS gene expression (Miller et al.,
2000). In studies on chronic ileitis (Miller et al.,
JONES 884
1993), chronic granulomatous colitis (Grisham
et al., 1994), and Heliobacter pylori gastritis
(Mannick et al., 1996), the expression of iNOS
has been associated with locations of tissue injury.
Therefore, the ability of the sap to reduce
iNOS suggests that it may hold promise against
these conditions as well.
Neurogenic inflammation. Miller and colleagues
(2001) hypothesized that the ethnomedical
uses of sangre de drago as a woundhealing,
analgesic, and antidiarrheal agent, and
its purported ability to relieve pain and itching
quickly, might derive from a suppressive effect
on sensory afferent nerve activation. Sensory
afferent nerves are found in the skin, lungs and
gut where they act as sentinels for nerves,
transmitting impulses from the periphery to
the central nervous system. Further support for
the hypothesis came from one of the authors
who found the burning sensation caused by exposure
of his mucosal skin to capsaicin was relieved
by applying the sap (Miller et al., 2001).
The results from an ensuing series of experiments
support their hypothesis.
Increased sensitivity to pain (hyperalgesia)
induced in the paws of rats by intradermal protease
activated receptor-2 activating peptide
(PAR-2AP) was abolished by a single topical
pretreatment of the sap in the form of a balm
containing 1% sangre de drago (Zangrado Bug
Bite Balm, Rainforest Phytoceuticals, LLC). Because
this effect was absent in rats not treated
with PAR-2AP, an anesthetic action of the balm
was not indicated. Hyperalgesia induced by intradermal
prostaglandin E2 (PGE2) was completely
blocked in rats treated with the balm in
a single topical pretreatment. A single topical
application of the balm to the paws of rats with
PAR-2AP-induced edema caused the volume of
swelling to reduce by approximately 50% compared
to placebo (p , 0.01). The effect lasted 6
hours or more and the reduction in edema was
more sustained and quicker than the natural
decline evident in the placebo group. In another
experiment, phenylephrine-constricted
rat mesenteric arteries relaxed in response to
the addition of calcitonin gene-related peptide
(CGRP), one of the main neurotransmitters of
sensory afferent nerves. Upon introduction of
the sap in dilution (1:10,000), the response to
CGRP was significantly inhibited (p , 0.05), indicating
that the sap inhibited the CGRP receptor.
An active constituent in the sap (molecular
weight 930) that appeared to be a
procyanidin oligomer was found to be just as
active as the sap itself against PAR-2AP-induced
hyperalgesia. In addition, compared to
vehicle-treated controls, excessive mucosal
blood flow in the stomach of rats (gastric hyperemia
or gastric mucosal vasodilation) induced
by capsaicin was largely prevented by
pretreatment with 1% solutions of the sap or
the active constituent (each p , 0.01). Taken together,
these results indicate that the sap directly
blocks sensory afferent nerve activation
at both the prejunctional and postjunctional
level; this is a dual action, which the researchers
claim, appears to be unique to sangre
de drago (Miller et al., 2001).
Connective tissue functions
Wound repair. The traditional use of sangre de
drago as a liquid bandage in the Amazon led
several research groups to investigate alleged
wound-healing activity. Although no one constituent
can be singled out as responsible, early
investigations attempted to do just that. Chen
and colleagues (1994) emphasized that what
became obvious in their work with the sap of
Ecuadorian C. lechleri was considerable differences
in chemical composition of sangre de drago
saps from different origins. They further concluded
that the wound-healing properties of
the sap may be the result of various factors: The
ability to form a film that protects against microbial
invasion of wounds; free radical scavenging
activity of procyanidins; the high content
of polyphenolics with their well-known
aspect of binding proteins and enzymes; and
the anti-inflammatory and strong antibacterial
action of polyphenols, which together would
facilitate improved healing of damaged tissue
(Chen et al., 1994).
Vaisberg et al. (1989) reported that twicedaily
topical application of 0.05 mL of a 10%
solution of the sap (C. lechleri) to skin wounds
of mice caused a significant 31% increase (p ,
0.05) in the rate of wound repair. Taspine was
found in the sap at a concentration of 0.1B0.2
mg/mL and through a bioassay for cicatrizant
REVIEW OF SANGRE DE DRAGO 885
activity was isolated as the active constituent.
Topical application of 0.05 mL of a 10% solution
of taspine hydrochloride every 12 hours
also produced a significant wound-healing activity
of 58.2% (p , 0.005). The effect was dosedependent
with concentrations of up to 13.2 mg
per mouse producing increasing rates of
wound healing (cicatrizant) activity. A higher
dose (40 mg per mouse) produced only a 23.1%
increase in wound-healing activity, indicating
a threshold at which the activity may be optimum
from taspine. In an in vitro test, wounding
of human fibroblasts was performed in order
to count the population of cells that migrate
to the repair the area of damage. Fibroblasts
treated with taspine showed a significant increase
in numbers of migrating cells, suggesting
that this effect may be at work in the
wound-healing activity of the sap and of
taspine (Vaisberg et al., 1989).
Pieters and colleagues (1992) also reported
that the sap was active as a wound-healing
agent. Evidence was obtained using an ethyl alcohol
extract in an assay for stimulation of human
endothelial cells (umbiblical vein). The use
of this assay is predicated upon the role of endothelial
cells in the healing process of skin tissue;
when new tissue forms, endothelial cells
proliferate to allow the formation of new blood
vessels. Cellular proliferation was measured
according to the rate that radio-labeled thymidine
(3H-thymidine) incorporated into cellular
DNA in the presence of the test substances.
From the sap of Peruvian sangre de drago (Croton
sp.), they isolated an active constituent;
a lignan known as 39,4-O-dimethylcedrusin
(4-O-methyldihydrodehydrodiconiferyl alcohol).
The concentration of the lignan in the sap
(approximately 14 mg/mL or 0.0014%) was the
same as that which produced positive activity
in the wound-healing assay. The lignan was
proposed to be the active constituent because
it also protected endothelial cells from undergoing
degradation in a starvation medium and
it stimulated endothelial cells (Pieters et al.,
1992). However, at higher concentrations (125
and 250 mg/mL) incorporation of radiolabeled
thymidine into the cells was inhibited by the
lignan, as well as by taspine (0.5 mg/mL and
more), which was otherwise inactive in the assay
(Pieters et al., 1993).
Porras-Reyes and colleagues (1993) focused
on the wound-healing activity of taspine,
which became Athe first plant alkaloid confirmed
to accelerate wound healing@ (Porras-
Reyes et al., 1993). DMSO allowed taspine to
be diluted and served as the vehicle control
treatment for in vitro and in vivo studies.
Taspine was otherwise highly insoluble. In a
linear incision model in rats, a single topical application
of taspine (250 mg dissolved in 0.1 mL
of DMSO) produced a significant increase in
the tensile strength of wounds. At 5 and 7 days
postincision, wound tensile strength showed
significant increases of 26% and 30% compared
to vehicle-treated control incisions (p , 0.005
and p , 0.0001, respectively). By day 12, however,
there was no difference in wound
strength. Smaller doses of taspine (10 and 50
mg/mL) failed to produce any increases in
wound tensile strength. A number of tests were
performed to determine how taspine accelerated
wound healing. On days 5 and 7, the influx
of mononuclear cells in the taspine-treated
(250 mg/mL) wounds was higher compared to
controls. Fibroblast infiltration was not stimulated
by taspine. Rather, cell viability was decreased
and thymidine incorporation was inhibited
(Porras-Reyes et al., 1993). The negative
effect was probably the result of in vitro toxicity,
as previously reported by Vasiberg and colleagues
(1989). A positive effect on the expression
of fibronectin was suspected as a possible
means of accelerated wound healing by
taspine, but in vitro tests showed that fibronectin
matrix disposition was not affected.
The chemotactic properties of macrophages
were likewise not affected, although fibroblast
chemotactic activity was; optimal promotion of
fibroblast migration from taspine was seen at
50 pg/mL. In conclusion, Porras-Reyes et al.
(1993) thought increased fibroblast migration
to be the likely means by which taspine enhanced
wound healing.
Chen and coworkers (1994) examined the
wound-healing activity of the sap from
Ecuadorian C. lechleri, which contained only
traces of taspine (Bettolo and Scarpati, 1989)
and no 394-methylcedrusin (Phillipson, 1995).
The assay for activity was the proliferation of
endothelial cells (bovine). They also measured
thymidine (3H-thymidine) incorporation to de-
JONES 886
termine the rate of endothelial cell proliferation,
as in the previous study. Rather than any
increase in endothelial cell proliferation, the
dried sap (20 mg/mL) inhibited proliferation/
thymidine incorporation by as much as
44%. (Whether drying the sap affected the activity
is not known.) Ethyl alcohol, chloroform,
and methanol extracts of the sap also inhibited
endothelial cell proliferation, whereas an acetone
extract was inactive either way. Testing
individual constituents of the sap, they found
endothelial cell proliferation increased by procyanidin
B-4 (10 mg/mL) and most potently by
(2)-epigallocatechin and (1)-gallocatechin
(each at 5 mg/mL) (Chen et al., 1994). At this,
Chen and coworkers pointed out a study by
PietersH in which the polyphenolic fraction of
the sap, which would contain the aforementioned
active constituents, was active in healing
the wounds of rats. After treatment with
the fraction, wound tissues were reported to
have contracted after only one day, Aand the
wound site was completely covered with a
dark crust@ (Chen et al., 1994, citing Pieters,H).
Examined under a microscope 1 month later,
Pieters reported that the newly formed tissue
was indistinguishable from unwounded tissue.
However, Chen et al. (1994) noted that such an
effect was not found by Pieters in experiments
using 394-methylcedrusin or taspine. As for the
various constituents of the Ecuadorian sap that
contributed to inhibition of endothelial cell proliferation,
they found the majority held only
slight or no inhibitory activity. The exceptions
were korberin A (10 mg/mL, $ 52% inhibition)
and 1,3,5-trimethoxybenzene (0.5 mg/mL, $
100% inhibition) that were, respectively, highly
and extremely active (Chen et al., 1994). Again,
both high and low levels of taspine were shown
to be active.
Antioxidant activity
Tests of the antioxidant activity of the sap are
lacking. In the total reactive antioxidant potential
(TRAP) index, sap collected from Peruvian
- lechleri produced results suggesting the presence
of antioxidant compounds in high concentration.
In an assay to measure effects on
free radical-mediated DNA-sugar damage (induced
with iron), low concentrations of the sap
(1 and 10 mg/mL) increased the level of oxygen
radical activity whereas high concentrations
(100 mg/mL and 1000 mg/mL) prevented
oxidant activity. In contrast, catechin inhibited
oxidative DNA damage at a concentration of 1
mg/mL. The sap (1B100 mg/mL) also increased
oxidative activity in the hydroperoxide-initiated
chemoluminescence assay using rat liver
cells. However, in aqueous reaction media the
sap prevented oxidative DNA damage and
captured hydroxyl and peroxyl radicals, indicating
that the constituents responsible are water
soluble (Desmarchelier et al., 1997).
Administered to mice by subcutaneous injection,
the freeze-dried and redissolved latex of Peruvian
- lechleri inhibited hepatic lipid peroxidation
as evident in the measurement of
malonaldehyde (MDA) thiobarbituric acid reactive
substances (TBARS) production in the livers
of the animals. However, protection against hepatic
lipid peroxidation was only found from a
dosage of 200 mg/kg subcutaneously. At 50
mg/kg, MDA levels were found to increase, at
100 mg/kg there was no significant antioxidant
activity, and at 300 mg/kg there was evidence
of toxicity (Desmarchelier and de Moraes Barros,
2003). Unfortunately, the route of administration
is incongruent with traditional uses of the sap.
Moreover, a study using the oral route of administration
could produce entirely different results
(Shanbhag et al., 1990).
Antimutagenic activity
The raw sap collected from Ecuadorian C.
lechleri prevented the mutagenicity of 2-amino
anthracene in both the TA100 (IC50 430 mg/mL)
and TA98 (IC50 of 340 mg/mL) strains of Salmonella
typhimurium by 90% and 100%, respectively
(Rossi et al., 2003).
CLINICAL STUDIES
Gastrointestinal disorders
Diarrhea. In the United States diarrhea is
more often fatal in persons aged 80 and over
REVIEW OF SANGRE DE DRAGO 887
HPieters LA. The Biologically Active Constituents of
Asangre de drago,@ a Traditional South American Drug
[dissertation]. Antwerp, Belgium: University of Antwerp,
1992.
than in other age groups. Three percent (3%) of
all U.S. hospitalizations in 1985 involving diarrhea
were comprised of this age group and the
rate was far higher than in any other, including
children under age 5 (0.05%) (Gangarosa et
al., 1992). In the developing world, the incidence
of diarrhea in children under age 5 is estimated
at 1 billion episodes annually, resulting
in an estimated 3.3 million deaths each year
(Bern et al., 1992).
As previously noted, sangre de drago is frequently
used in ethnomedicine for the treatment
of diarrhea (Carlson et al., 2000; Marles,
1992; Ubillas et al., 1994). After animal and in
vitro studies confirming an antisecretory activity
of the sap (see Diarrhea section above),
placebo-controlled clinical trials of a defined
preparation (SP-303) were initiated in traveler=s
diarrhea, watery diarrhea (Ubillas et al., 1994),
and human immunodeficiency virus (HIV)-associated
diarrhea (Holodniy et al., 1999). A review
of the research on the preparation in the
treatment of diarrhea appeared in HealthNotes
Review of Complementary and Integrative Medicine
(Carlson et al., 2000).
Traveler=s diarrhea. Traveler=s diarrhea is
classified as a syndrome comprising an increase
in the frequency of unformed stools of
200% or greater (typically, 4B5 loose stools per
day) and common symptoms of malaise,
fever, nausea, bloating, cramps, and urgency.
The episodes often begin abruptly, either
while one is traveling or not long after returning
home. Although the episodes are in
most cases self-limited, rates of attacks range
from 20%B50%. Destinations of greatest risk
are Latin America, Africa, the Middle East,
and Asia (Centers for Disease Control and
Prevention, 2001). In at least 80% of cases,
traveler=s diarrhea is caused by bacterial enteropahthogens
(DuPont and Ericsson, 1993)
including E. coli, Salmonella, Shigella, and
Campylobacter jejuni (Centers for Disease Control
and Prevention, 2001) and has a tendency
to be more severe in Americans traveling to
Mexico, for example, than it is in Mexicans
traveling in their own country (Carlson et al.,
2000). Enterotoxigenic E. coli is associated
with acute traveler=s diarrhea but not significantly
with persistent diarrhea (Schultsz, et
al., 2000).
The potential of SP-303 as an antidiarrheal
agent was evaluated in acute diarrhea in 184
travelers to Jamaica and Mexico. Entry into the
trial (double-blinded, randomized, placebo-controlled)
was limited to travelers presenting with
acute diarrhea who had at least 3 unformed
stools in the preceding 24 hours and diarrhea for
no more than 48 hours. Subjects were randomly
assigned to receive treatment with either placebo
or SP-303 at doses of 125 mg, 250 mg, or 500 mg,
twice daily for 2 days. Efficacy was determined
from 169 subjects who were observed for 24
hours after the 2-day treatment period. No adverse
effects were found compared to controls
and each dosage of SP-303 was significantly
more effective than placebo (p , 0.05). Subjects
that received 250 mg twice daily showed in more
than 90% of cases partial or complete improvement
of symptoms in the first 24 hours. Time to
the last unformed stool was 38 hours versus 54
hours in the placebo group; a highly significant
difference (p 5 0.0002) (Carlson et al., 2000, citing
Dicesare et al., 1998).
Watery diarrhea. A randomized, doubleblinded,
placebo-controlled trial of SP-303 in
the treatment of watery diarrhea was performed
in-hospital in residents of Venezuela.
Patients were included who presented with diarrhea
in moderate and severe acute watery
forms. Over a period of 48 hours, SP-303 or
placebo was administered in oral doses of either
125 mg, 250 mg, or 500 mg four times per
day. Male and female patients (n 5 140; ages
18B69 years) were enrolled who had experienced
at least 5 watery stools in the preceding
24 hours. Time to the last unformed stool was
the main endpoint for evaluation of efficacy
measured at 24, 48 and 72 hours. The results
showed that the treatment was well tolerated,
but that only the 125-mg dose was effective and
only in reducing the time to the last unformed
stool in the 48-hour treatment period versus
placebo (p 5 0.02) (Carlson et al., 2000, citing
Ettedgui et al.I). The reason for the difference
JONES 888
IEttedgui G, Schael IP, Porter S, Pennington J. A double-
blind, randomized, placebo-controlled, multi-dose,
phase II study to assess the safety and efficacy of SP-303
in the symptomatic treatment of acute diarrhea among
adult residents of Venezuela: Oral administration of 125
mg, 250 mg, or 500 mg of SP-303 given every 6 hours for
48 hours. South San Francisco, CA: Shaman Pharmaceuticals,
1998, unpublished.
in the results compared to other studies of SP-
303 in diarrhea is not clear. It may have been
because of differences in diet, enteropathogens,
study design, and/or the fact that these patients
were not suffering from traveler=s diarrhea.
HIV-associated diarrhea. In up to 90% of cases,
patients infected with HIV suffer from diarrhea.
The problem grows worse as the immune
system becomes more compromised. In the developing
world, lack of hygiene, poor sanitation,
medications, and even herbal treatments
may also cause infections of the gastrointestinal
tract. If the cause of the diarrhea can be
identified there is some hope of successful
treatment, but in up to 60% of cases it remains
unknown. In HIV-infected patients the causes
may be infectious or noninfectious. Infectious
causes include the majority of pathogens affecting
people with traveler=s diarrhea, plus
amebiasis, candidiasis, Cryptosporidium, cytomegalovirus,
giardiasis, Isospora belli, and
Mycobacterium avis complex. Noninfectious
causes of diarrhea in these patients include
malabsorption (lactose intolerance, HIV enteropathy,
HIV osmotic drink and food),
medications (therapy with multiple drugs, traditional
herbal treatments), obstruction, incontinence
of the rectum, and stress. Patient response
to drugs that control motility (e.g.,
loperamide) has been poor and some just cost
too much (e.g., octreotide) (Katabira, 1999).
Clinical trials of SP-303 in the treatment of
HIV-associated diarrhea have largely produced
positive results (Carlson and King,
2000; Holodniy et al., 1999; Koch et al., 1999;
Koch, 2000). A phase II multicenter clinical
trial (randomized, double-blinded, placebocontrolled)
of SP-303 was conducted by the
University of California, San Francisco, in 45
HIV-infected patients diagnosed with diarrhea
and acquired immune deficiency syndrome
(AIDS)-defining illness or CD4 count
less than 200 (males and females ages 18B60
years). Subjects received SP-303 (500 mg orally
every 6 hours) or placebo for 4 days. The majority
were receiving treatment with antiretroviral
agents (80%) and protease inhibitors
(77%). All patients stopped treatments for diarrhea
24 hours before enrollment in the trial.
For 94% no pathogens were identified in stool
samples. Treatment with SP-303 resulted in
significant reductions in the frequency of abnormal
stools (p , 0.04) and of stool weight
(p , 0.008) compared to placebo, and there
were no adverse effects or laboratory abnormalities
(Holodniy et al., 1999).
A Phase III multicenter inpatient trial of SP-
303 in the treatment of HIV-associated chronic
diarrhea (stool weight . 300 g per 24 hours) by
the University of California, San Francisco was
conducted in 400 patients diagnosed with
AIDS. Subjects were men or women 18 years
of age or older, the majority of whom were
receiving treatment with antiretrovirals and
protease inhibitors (93.3% and 83.3%, respectively).
Any antidiarrheal agents were discontinued
more than 24 hours prior to patient enrollment.
After being randomly assigned to
either placebo or active treatment groups, subjects
received one of three different dosage formulations
of SP-303: 250 or 500 mg in a delayed
release tablet or 500 mg in the form of delayed
release beads (each four times per day for 6
days). Responders to SP-303 were allowed to
continue the treatment for another 21 days. The
results showed that only those who received
the 500-mg tablet benefited. For those with severe
diarrhea (stool weights of at least 1000 g
per 24 hours), treatment with the 500-mg tablet
produced a significant reduction in stool
weight (Athe primary efficacy endpoint@) compared
to placebo (p 5 0.008). No adverse effects
were found and laboratory measurements
showed no abnormalities (Koch, 2000).
A group of patients (n 5 42) pooled from the
phase III trial and from an open-label study of
SP-303 (250-500 mg four times per day) were
recruited by Koch and coworkers (1999) for a
study on changes in diarrhea-related quality of
life (QOL) scores. The researchers pointed out
that the influence of antidiarrheal therapy on
QOL was previously unknown. The QOL questionnaire
included queries on daily living activities,
ability to sleep and to perform errands,
and of effects on sexual activity. From the results,
Koch et al. (1999) concluded that QOL is
adversely affected by diarrhea; those who responded
to treatment experienced a significant
improvement (p 5 0.024) in the sum score for
daily living activities within 2B4 weeks; and
that significant improvements in Aability to
leave home@ (p 5 0.03), Atime spent resting@
REVIEW OF SANGRE DE DRAGO 889
(p 5 0.03), and sexually activity (p 5 0.01) were
associated with response to treatment. The researchers
also compared results from responders
to those of nonresponders. Responders
were classified as those who experienced a reduction
in 24-hour stool weight of 50% on day
- From those who completed the questionnaire
(74%), the improvement in QOL was statistically
significant in favor of the responders (p 5
0.024) (Koch et al., 1999).
After these studies, a product standardized to
contain 250 mg SP-303 per 350-mg tablet (SB-
300) was made available in the United States as
a dietary supplement known as NSF/Normal
Stool FormulaJ (Shaman Pharmaceuticals, Inc.,
South San Francisco, CA) (Carlson et al., 2000).
Viral infections
Herpes simplex. Orozco-Topete et al. (1997)
conducted a Phase II clinical study of SP-303
in the treatment of genital herpes simplex
virus (HSV) infections in 45 patients with
AIDS 20B54 years of age. The purpose of the
multicenter, placebo-controlled, double-blind
study was to determine efficacy and safety of
an ointment (Virend7, Shaman Pharmaceuticals,
Inc.) containing 15% SP-303 w/w in the
treatment of recurrent anogenital or genital
herpes in AIDS patients. Primary endpoints of
Acomplete healing@ and Atime to healing@ of
herpes lesions were evaluated in HSV activephase,
culture-positive patients who topically
applied an ointment containing SP-303 or a
matching placebo (ointment base, twice daily
for 21 days). Patients received instructions to
cleanse the lesions with mild soap and water
and gently blot them dry before covering the
lesions with a thin layer of the ointment, once
in the morning, afternoon, and evening. At
each visit to the clinic, specimens were obtained
for cultures of HSV to determine
changes in viral positivity. All patients were
positive for HSV-2. Blood and serum chemistry
were monitored as were vital signs. Lesions
were measured and photographed at
day 1 when patients were randomized and at
each visit. Only one patient was not taking
some kind of anti-infective drug therapy during
the trial. The agents taken were typical of
the population and included antibiotics, antiretrovirals,
antituberculosis drugs, sulfonamides,
vitamin B complex, and various medicines
used to treat nausea, diarrhea, and constipation.
Patient withdrawals from the study consisted
of 7 of 21 in the placebo group and 5 of
24 in the active treatment group. Reasons for
discontinuation were advancing HIV (1
placebo and 2 Virend), burning sensation at the
site of application (1 Virend), death (1 placebo
and 1 Virend), herpes zoster (1 placebo), concomitant
drug therapy (1 placebo), treatment
failure (1 placebo), wasting syndrome (1
Virend), esophagitis (1 Virend), patient refusal
(2 placebo), and other (1 placebo and 1 Virend)
(Orozco-Topete et al., 1997).
Apart from a burning sensation at the site of
application (2 Virend and 1 placebo), no other
adverse events were thought to be attributable
to Virend. In the resolution of lesions at day 21,
the results were significant in favor of Virend
(p 5 0.053) only when the two patients lost to
follow-up in the Virend group were excluded.
On day 21, lesions were completely healed in
41% of the Virend group and only 14% of the
placebo group. However, in this small trial,
when the two patients lost to follow-up were
included in an intent-to-treat analysis, the results
failed to reached statistical significance
(p 5 0.077). It is important to note that those
who showed complete healing of lesions had
both significantly higher levels of CD41 cells
and significantly smaller lesions at the start of
the trial (each p 5 0.03). The number who
showed decreases in lesion size ($25%) was
also not significant compared to placebo (25%
Virend versus 24% placebo), an outcome the investigators
attributed to several Virend patients
with large lesions that were only slightly
improved. No significant difference was found
in lesion pain compared to placebo, although
there was a trend towards significance in pain
intensity in the Virend group on day 4. As for
HSV-2 shedding, 19% of the placebo group became
culture-negative during the trial versus
50% of the Virend group (p 5 0.06). The investigators
concluded that the results were not superior
to those obtainable using available oral
agents (e.g., acyclovir) and planned to conduct
further studies using a more easily dissolving
formulation of SP-303 (Orozco-Topete et al.,
1997).
JONES 890
Inflammatory skin conditions
Insect bites. The potential soothing effect of
a 1% sangre de drago balm (Zangrado Bug Bite
Balm, Rainforest Phytoceuticals, LLC) on itching
and pain caused by insect bites was studied
in 10 workers from the Terminex Pest
Control Company in New Orleans, LA. The
balm base served as the placebo and both
preparations were coded. Over a period of 3
months, workers applied the preparations at
their discretion to various conditions, recording
the length of time before they experienced
relief, the number of reapplications, if any,
and the causes of the skin afflictions. Fire ant
bites became the most common affliction and
affected all 10 participants. Apart from immediate
pain, the bite of fire ants is known to
cause an intense itch and the itching can last
for weeks. Half of the participants reported
pain, 40% discomfort, 60% swelling, 60% redness,
and 100% itching. In all instances the
number of workers who preferred the active
balm over the placebo balm was significant
(itching, p , 0.001; swelling, p , 0.01; and
pain, redness, or discomfort, each p , 0.05).
The average time reported by the workers before
symptomatic relief after applying the active
balm was less than 2 minutes. These results
provided further evidence that sangre de
drago inhibits sensory nerve afferent activity.
Such an inhibitor could potentially relieve
any skin condition attended by pain, edema,
redness, discomfort, itching, or pain (Miller et
al., 2001).
Pharmacokinetics
In eight healthy adult men, Alittle or no@
gastrointestinal absorption and subsequent
uptake in the bloodstream was found from
oral administration of SP-303 in delayed-release
tablets (1250 mg oral single-dose and
500 mg four times per day for 8 days) (Carlson
et al., 2000, citing Carlson and Khandwala
‘). Another study in 6 healthy men found
that SP-303 was not absorbed into the bloodstream,
and in children and in infants 3
months of age or older, SP-303 was also not
absorbed into the bloodstream (Carlson and
King, 2000, citing Connor et al.,&).
DOSAGE
The traditional internal dosage of the sap in
Ecuador and Peru is generally 5B10 drops, once
to twice per day for 5 days. Often the treatment
is repeated for as long as 3 weeks. The sap is
taken in water (cold or warm), milk, or alcohol
(Ubillas et al., 1994).
The proprietary product SB-300, NSF/Normal
Stool FormulaJ is used to promote normal
stool formation and for relief from occasional
diarrhea. It can be taken for both acute
and chronic forms of diarrhea of various origins.
Each 350-mg tablet is standardized to contain
250 mg or 67% by weight of the oligomeric
procyanidin preparation SP-303. At minimum,
40% of the remaining constituents are composed
of unidentified polyphenolic compounds,
some of which may also possess antidiarrheal
(antisecretory) activity. SB-300 is
taken at the suggested daily dosage of 350B700
mg, twice per day to four times per day. However,
subjects with irritable bowel syndrome or
HIV-associated diarrhea may require longterm
use of the formulation (Carlson and King,
2000).
SAFETY PROFILE
Contraindications
Contraindications for SB-300 (NSF/Normal
Stool FormulaJ) are as yet undetermined and
none were found in 10 patients diagnosed with
diarrhea and HIV (Carlson and King, 2000, citing
Koch et al., 2000). In a placebo-controlled
trial, absorption of lamivudine, nelfinavir or zidovudine
(single doses) was not affected by SP-
303 at a dosage of 500 mg four times per day
REVIEW OF SANGRE DE DRAGO 891
‘Carlson T, Khandwala A. Investigator=s Brochure for
SB-300. South San Francisco, CA: Shaman Pharmaceuticals,
May 24, 1999, unpublished.
&Conner JD, Rodriguez W, Englund J. Evaluation of
Provir (SP-303) for use in infants and children. South San
Francisco, CA: Shaman Pharmaceuticals, 1995, unpublished.
(52,000 mg/d) (Carlson and King, 2000, citing
Porter et al.uu).
Drug interactions
No drug interactions from either the latex or
SP-303 have been reported. In a placebo-controlled
study of SP-303 in HIV-positive patients,
the absorption of anti-HIV agents
(lamivudine, nelfinavir, or zidovudine) was
not affected by the compound when taken at a
dosage of 500 mg four times per day for a total
daily dose of 2000 mg. SP-303 was well-tolerated
(Carlson and King, 2000 citing Porter et
al.uu).
Pregnancy and lactation
No studies were found on the safety of sangre
de drago (C. lechleri and C. palanostigma) or
extracts thereof in pregnant or lactating people
or animals.
Side-effects
No reports of side effects from internal use
of the sap in traditional medicine were found
(Ubillas et al., 1994).
Special precautions
Some members of the Euphoriaceae family
contain tumor-promoting diterpene (phorbol)
esters (Blumberg, 1988); however, these are not
found in detectable quantities in the sap of sangre
de drago (C. lechleri, C. palanostigma [5 C. draconoides],
and C. erythrochilus) (Vlietinck et al.,
1995).
Toxicology in vitro
In Chinese hamster V-79 lung fibroblasts, the
alkaloid constituent taspine (IC50 0.17 mg/mL)
showed potent growth-inhibiting/cytotoxic activity.
The sap itself, obtained from Peruvian C.
palanostigma, also showed activity against the
growth of V-79 cells (IC50 3.7 mg/mL). In the
KB (human oral epidermoid carcinoma) cell assay,
potent cytotoxic activity was also found
from taspine (IC50 0.39 mg/mL) (Itokwa et al.,
1991). Cytotoxicity against KB cells was absent
in tests of crude sap collected from C. lechleri
growing in Ecuador (IC50 900 mg/mL). The
dried sap (IC50 187 mg/mL), various
solvent extracts of the sap, and the major
constituents of the sap (procyanidins and
flavonols) also showed no evidence of cytotoxicity
in this assay. This sap contained only
traces of taspine (Chen et al., 1994).
Given the cytotoxicity of taspine, the authors
of the latter study have recommended that sangre
de drago saps containing a high content of the
alkaloid not be used for wound-healing or for internal
use (Chen et al., 1994). Evidence from in
vitro tests indicates that the precaution is prudent;
however, it remains for in vivo studies to
determine whether the toxicity of taspine is ameliorated
by other constituents in the sap and by
how much. According to the manufacturing
specification for the dietary supplement NSF
(Normal Stool FormulaJ) and NSF-IB (Normal
Stool Formula-Ion Balanced), the level of taspine
is not to exceed the limit of 5000 ppm) (S.R. King,
written communication, November 13, 2001).
Mutagenicity
The raw latex obtained from C. lechleri
growing in Ecuador showed no mutagenicity
in the Ames test, with or without S9 activation
(Rossi et al., 2003). SP-303 also showed no
mutagenic activity in the Ames test and in
Chinese hamster ovary (CHO) cells failed to
induce chromosomal aberrations (with or
without metabolic activation). Negative results
were found in the rat bone marrow micronucleus
test (Carlson and King, 2000, citing
Carlson and Khandwala’).
Toxicity in animal models
In a long-term study (17 months), topical application
of the sap derived from C. lechleri in
the two-stage mouse skin carcinogenesis sys-
JONES 892
uuPorter SB, Santos O, Charney MR, Pennington J. A
phase I, randomized, double-blind, placebo-controlled interaction
study to evaluate the effect of multiple doses of
SP-303 or placebo on the pharmacokinetics of the antiviral
drugs zidovudine, lamivudine, and nelfinavir in
healthy subjects. South San Francisco, CA: Shaman Pharmaceuticals,
May 8, 1998, unpublished.
‘Carlson T, Khandwala A. Investigator=s Brochure for
SB-300. South San Francisco, CA: Shaman Pharmaceuticals,
May 24, 1999, unpublished.
tem resulted in no carcinogenic effects. Taspine
was also devoid of carcinogenicity in this test
system (Vaisberg et al., 1989).
Toxicity studies of SP-303 in various species
of animals found no deaths from single oral
doses of up to 300 mg/kg. Neither were there
any changes in body weights or food consumption
and no clinical indications of toxicity
were evident upon examination. The acute oral
LD50 of SP-303 in the rat was determined to be
greater than 300 mg/kg. In repeated-dose toxicity
studies of SP-303, the no-observable-effect-
level (NOEL) in rats after 30 days of oral
administration was greater than 200 mg/kg per
day and less than 500 mg/kg per day. In monkeys,
the NOEL after 30 days oral administration
was greater than 30 mg/kg/day and less
than 100 mg/kg per day (Ubillas et al., 1994).
CONCLUSIONS
The results of in vitro and in vivo studies
largely support the majority of ethnomedical
uses of the sap. Pending the development of
clinically efficacious preparations, sangre de
drago has the potential of becoming a readily
sustainable medicinal resource of financial
benefit to the indigenous peoples of northwest
Amazonia and therapeutic benefit to the
world. Acknowledgement of the diversity in
the chemical makeup of the sap from one geographic
area to another and the recently proposed
alkaloid chemotypes of C. lechleri will
require that materials being developed for
clinical use are consistent after standardization
to a chemical profile providing known
quantities of one of more active constituents.
Phytochemical investigations clearly indicate
that the standardization process will involve
sourcing and standardized processing of consistent
plant material. Recent clinical studies
of products prepared from the sap in treatments
of diarrhea and symptoms of insect
bites have shown positive results that are
likely to lead to further research. The painand
itch-relieving activity of the sap may lead
to the development of a substitute for capsaicin,
the topical use of which is limited because
of its characteristic burning sensation.
Clinical research on the topical use of SP-303
against genital and anal herpes lesions in HIVpositive
patients yielded results of borderline
significance, either because of the small number
of patients enrolled, poor solubility of the
preparation used, significant differences in the
CD41 cell counts of the subjects, or a combination
of factors. The need for less costly treatments
of these infections, combined with the
unresolved clinical efficacy of SP-303 against
herpes, may entice larger, better controlled
studies utilizing preparations with greater absorbability.
Although the relative toxicity of
the content of taspine in sangre de drago requires
some additional evaluation, the sap has
shown low toxicity and preparations used in
clinical studies were well-tolerated. Larger trials
involving oral and topical preparations of
sangre de drago are warranted.
The author and many of the researchers
whose studies are cited herein are grateful to
the peoples of the northwest Amazon basin for
sharing their intellectual and medical achievements
and the teachings of their healers on sangre
de drago along with numerous other South
American medicinal plants.
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[abstract 45]. Antiviral Res 1991; (Suppl 1):67.
Zimmernan CM, Bresee JS, Parashar UD, Riggs TL, Holman
RC, Glass RI. Cost of diarrhea-associated hospitalizations
and outpatient visits in an insured population
of young children in the United States. Pediatr
Infect Dis J 2001;20:14B19.
Address reprint requests to:
Kenneth Jones
P.O. Box 1741
Gibsons, British Columbia
Canada VON 1VO
E-mail: armana@dccnet.com
JONES 896
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 9, Number 6, 2003, pp. 877B896
8 Mary Ann Liebert, Inc.
Review of Sangre de Drago (Croton lechleri)CA South
American Tree Sap in the Treatment of Diarrhea,
Inflammation, Insect Bites, Viral Infections, and Wounds:
Traditional Uses to Clinical Research
KENNETH JONES
ABSTRACT
Objective: The objective of this review is to provide an overview of the pharmacologic evidence
that may or may not support clinical and ethnomedical uses of the sap of sangre de drago
(dragon=s blood; Croton lechleri Müll. Arg.). Data sources used were BIOSIS, EMBASE, PubMed,
TOXLIT, International Pharmaceutical Abstracts, manual searches, papers on file from peer-reviewed
journals, textbooks available at Armana Research, Inc., and researchers in the field of
South American botanical medicine.
Conclusions: The results of in vitro and in vivo studies largely support the majority of ethnomedical
uses of sangre de drago including the treatment of diarrhea, wounds, tumors, stomach
ulcers, herpes infection, the itching, pain and swelling of insect bites, and other conditions.
Clinical studies of sangre de drago products have reported positive results in the treatment of
traveler=s and watery diarrhea and the symptoms of insect bites. Because the sap has shown
low toxicity and preparations used in clinical studies were well tolerated, further clinical and
pharmacologic studies are anticipated. Acknowledgment of the diversity in the chemical
makeup of the sap from one geographic area to another and the recent characterization of alkaloid
chemotypes of sangre de drago will require that materials developed for clinical use are
standardized.
877
Armana Research, Inc., Halfmoon Bay, British Columbia, Canada.
BOTANICAL DATA
Classification and nomenclature
The scientific name of sangre de drago
(dragon=s blood) is Croton lechleri Müll.
Arg. (syn. C. draconoides Müll. Arg.). Closely related
South American species known as sangre
de drago include Croton palanostigma Klotzsch
(syn. C. benthamianus Müll.-Arg.) (Brako and
Zarucchi, 1993), and C. erythrochilus Müll.-
Arg., both found in Peru (Pieters et al., 1990).
Some Peruvian botanists classify C. draconoides
(Müll. Arg.) as synonymous with C. palanostigma
(Klotzschs) (Pieters et al., 1990). In central
Peru (Oxapampa, Pasco), two other species
known locally as sangre de drago are C. perspeciosus
Croizat and the recently reported C. rimbachii
Croizat (Meza, 1999). C. urucurana Baillon
occurs in southeast Brazil (Peres Marize et
al., 1997), Paraguay (Portillo et al., 2001), and
in Brazil. In Brazil, the herb is also known as
sangre de drago or Sangra d=Água (Lopes Pereira
Peres et al., 1998). Brazilian populations of this
species are in rapid decline (Peres Marize et al.,
1997).
From the family Euphorbiaceae, some common
names include Croton lechleri (dragon=s
blood, [English]), Sangre de Dragón (Soukup,
1970), sangre de drago (Duke and Vasquez,
1994), Sangre de Grado (blood of the tree) (Milanowski
et al., 2002), and Palo de Grado (tree of
gladness; Peruvian mestizo) (Peres Marize et
al., 1997). The American Herbal Products Association
assigns the common names Adragon=s
blood croton@ and Sangre-de-Drago as acceptable
names for use in U.S. commerce (McGuffin
et al., 2000). Aboriginal names for Croton
species that produce a red latex are far more
numerous. In eastern Ecuador, Quechua names
are arleiia and lan huiqui.* In Ayacucho, Peru,
the Quechua name is yawar gradwascca. Among
the Asháninka, the largest Indian tribe in Peru,
the tree is known by the names irariki, irari, and
quirari, depending on the geographical area of
the tribe. In Peru there are at least 20 other indigenous
names for sangre de drago trees, some
translating to wood=s blood or tree=s blood
(Meza and Pariona, 1999).
Dragon=s blood is a name of Old World extraction,
earlier applied to the plant proper or
the sap derived from Dracaena draco L. (Liliaceae)
of the Canary Islands (a palm tree that
produces a red resin used in varnishes), and to
the Arabian D. cinnabari Balf., the red resin of
which was also used in varnishes and in medicine
to stop hemorrhages. Other plants known
as dragon=s blood include the rattan palm of
Malaya, Daemonorops draco Blume (Palmaceae),
which supplied a resin used in photoengraving,
etching and in the varnishes of Italian violins
during the eighteenth century; and in
Guyana, Pterocarpus draco L. (Leguminosaceae)
or padauk supplied West Indian Dragon=s Blood
(Emboden, 1974; Uphof, 1968).
Description
- lechleri is described as a medium-sized tree
that occurs in forests and disturbed areas from
sea level to 1000 meters in the eastern lowlands
of the Peruvian Amazon and low mountainous
areas of the Peruvian Andean region, as well
as Colombia, Bolivia, and Ecuador (Brako and
Zarucchi, 1993). In northwest Amazonia, C.
lechleri is most commonly found at elevations
of 100B600 meters. In Ecuador, C. lechleri occurs
in the primary rain forest as an understory tree
where it reaches a height of 15 meters. Much
like alder trees (Alnus spp.) in the northern
hemisphere, C. lechleri is a fast-growing (10B15
meters in 3 years) (Miller et al., 2001) pioneer
species and is one of the first plants to appear
in recently cleared areas and along roadsides
(Ubillas et al., 1994). It has heart-shaped (cordate),
alternate leaves that range in size from
15B30 cm in width and length and appear with
6B8 parallel veins diverging diagonally from
the leaf midvein. The fruits are three-celled and
the small flowers appear on a tall thin spike
that measures 30B50 cm in length. When cut,
the trunk produces a bright red latex that may
appear orangeish (Castner et al., 1998).
The yield of latex from C. lechleri is greatest
in the rainy season and also depends on the age
of the tree. The traditional method of slashing
the bark produces a maximum yield of several
liters of sap from a tree up to 6 years old with
a diameter of, on average, 25 cm at breast
height. Felling the tree and scoring the bark
produces 5B6 L of sap. Because the sap is slowly
released from a standing tree, felling and scoring
is the preferred method for industrial scale
production (Ubillas et al., 1994).
HISTORY AND TRADITIONAL USES
The main part of C. lechleri used medicinally
in South America is the blood-red latex or sap,
which is a common household remedy used in
Peru, other Latin American countries, and
among the Latin American population of the
United States. Although its medicinal uses are
still largely unrecognized outside of Latin
JONES 878
*Marles R. The Ethnopharmacology of the Lowland
Quichua of Eastern Ecuador [dissertation]. Chicago: University
of Illinois at Chicago, 1988.
America, sangre de drago recently became available
in the United States as a dietary supplement.
The sap of C. lechleri is widely sold in the local
markets of Ecuador and Peru where it is
popularly used to treat diverse illnesses in
adults, children, and infants. Internal ethnomedical
uses include the treatment of diarrhea,
dysentery, cholera (Carlson and King
2000), coughs, flu, lung problems, stomach ulcers,
(Ubillas et al., 1994), and hives, the latter
being treated by taking the sap in pineapple
juice (20 drops per 200 mL). In the upper Amazon,
the sap is taken diluted in hot water to
speed internal healing after an abortion, and
used as a vaginal douche after childbirth (Castner
et al., 1998). Others report that the sap is
used in Amazonia in vaginal baths taken before
childbirth (Duke and Vasquez, 1994) and
another refers to the danger of irritating tissues
by applying sangre de drago after childbirth
(Soukup, 1970). These uses probably followed
the so-called doctrine of signatures; however,
it is noted that Croton species are extensively
used all over the world for pain- and blood-related
health problems, and especially those associated
with menstruation.*
In upper Amazonia, the sap is taken to treat
tuberculosis and bone cancer (Castner et al.,
1998) and may be combined with other medicinal
plants to treat other types of cancer (e.g.,
Uña de Gato or Uncaria tomentosa [Willd.) DC.])
(Maxwell, 1990). The sap of a closely related
species, also known in Peru as sangre de drago
(Duke and Vasquez, 1994) (Croton palanostigma
Klotsch), has been popularly used by indigenous
people of the region of Pucallpa, Peru, to
treat tumors (Hartwell, 1969; Rutter, 1990).
External use of the sap to stop bleeding of
cuts and wounds led to the common rural
name in Peru of Aliquid bandage.@ While in
Peru I learned that it was not unusual to find
the sap in the household medicine cabinet next
to the iodine, which has a similar appearance.
From what I could tell, it was just as common
an item in the cities as in the countryside. In
the suburbs of Lima, I witnessed the application
of the sap to a 6.35-cm wound on the inside
arch of the foot of a young man who incurred
the injury while surfing nearby. He said
that the fin of the board had cut his foot during
a fall. His mother applied a few drops of
the sap and applied a small bandage. Six hours
later at a nightclub in the city, I found him
dancing. When I enquired about the wound he
claimed to not have any pain (Jones, 1995). On
further questioning, he claimed to have taken
nothing that would relieve pain except for the
distraction of the music and a couple of beers.
Other external ethnomedical uses of the sap
in Peru and Ecuador include the topical treatment
of bites and particularly stings, for which
the sap is said to stop itching and pain in a matter
of minutes and to subsequently reduce the
attendant redness and swelling (Miller et al.,
2000).
The sap is also used in the healing of open
sores (oral and otherwise), herpes infections,
surgical operations (urban areas) (Ubillas et al.,
1994), and infected gums. The Quijos Quichua
of eastern Ecuador soak a piece of cotton with
the sap, which is applied to alleviate the pain
of tooth extractions and cavities.* C. palanostigma,
the closely related species noted above,
is also used to treat pain. In the region of Manaus,
Brazil, the sap of this tree is used topically
in the treatment of painful boils and ulcers
(Schultes and Raffauf, 1990). Still other ethnomedical
uses of the sap of C. lechleri in Peru
are found in the treatment of bone fractures,
leucorrhea, piles, hemorrhoids (Soukup, 1970),
and rheumatism (Persinos Perdue et al., 1979;
Phillipson, 1995).
- lechleri is a fast-growing pioneer species
(Miller et al., 2001; Ubillas et al., 1994), growing
as much as 3B4.5 meters per year. Because
repeated tapping of the sap renders the trees
susceptible to fungal infections, one of the current
practices of commercial harvest involves a
2B3-year cycle of felling the trees, draining
them of sap, and replanting (Miller et al., 2001).
The practice of replanting requires careful management
and conservation in conjunction with
the indigenous peoples who reside in the
forests where they grow (Ubillas et al., 1994).
In the course of sustainable management studies
of sangre de drago in Ecuador and Peru, it
REVIEW OF SANGRE DE DRAGO 879
*Marles R. The Ethnopharmacology of the Lowland
Quichua of Eastern Ecuador [dissertation]. Chicago: University
of Illinois at Chicago, 1988.
was learned that unlike the related rubber tree
(Hevea spp; family Euphorbiaceae), the compartments
in the bark of Croton species that
produce the latex (lactifers) are nonregenerating,
which explains why the latex of standing
trees does not flow continuously after tapping
(King et al., 1997; Ubillas et al., 1994; Castro and
Meza, 1999). These studies also found that 10
months after tapping the bark of standing trees
to obtain the latex (300 mL), there was a high
rate of mortality (44%) or impending death
(35%). Only a few trees (2.5%) showed the appearance
of surviving. Similar results were
seen in populations from different locales in
which the amount of sap obtained ranged from
200 to 300 mL (King et al., 1997).
CHEMISTRY
Alkaloids
The leaves of C. lechleri contain the morphinandienone
alkaloid, sinoacutine (Carlin et al.,
1996). The sap contains the phenanthrene alkaloid
taspine (Persinos Perdue et al., 1979),
which is also found in the sap (Itokwa et al.,
1991) and leaves of C. palanostigma (Bettolo
and Scarpati, 1989). Magnoflorine, isoboldine,
norisoboldine, taspine (Milanowski et al., 2002),
glaucine, and thaliporphine were identified in
the leaves (Bettolo and Scarpati, 1989). The content
of taspine in the sap varies widely. A recent
survey in northwest Peru and central
Ecuador of 493 trees in 20 sites (February/
March 1996, March/April, 1999 and September
1997), along with multiple samplings at 13 of
the sites indicates that the content of taspine in
the latex of C. lechleri ranges from 1.3%B20.4%
with an approximate mean level of 9% (dry
weight), but that it is only found in mature
trees. Samplings from a few trees calculated to
be a year old contained other alkaloids. Based
on analyses of leaves from 264 trees, the survey
also found evidence to suggest that there
may be three alkaloid chemotypes of C. lechleri.
The leaves of chemotype 1 contained glaucine,
isoboldine, and thaliporphine. Those of chemotype
2 contained isoboldine and thaliporphine
while the leaves of chemotype 3 contained only
isoboldine. Yet both the content of taspine and
the alkaloid profile of the latex of mature trees
of the three proposed chemotypes showed no
significant difference (Milanowski et al., 2002).
Phenolic compounds
Lignans. Dihydrobenofuran lignan (39,4-Odimethylcedrusin)
and a coniferyl alcohol previously
found in species of pine (Pinus) were
isolated from the sap of C. erythrochilus (Pieters
et al., 1990).
Tannins. The major constituents of the sap of
- lechleri are proanthocyanidins and flavonols
(Cai et al., 1991). The sap is abundant in soluble
proanthocyanidins (also referred to as procyanidins,
condensed tannins or procyanidin
oligomers or PCOs), containing up to 90% by
dry weight (Cai et al., 1991). Upon heating in
acid medium, PCOs yield cyanidin. A mixture
of PCOs known as SP-303 (molecular weight
,2100 da) isolated from the sap of C. lechleri is
largely composed of (2)-galloepicatechin and
(1)-gallocatechin with lesser amounts of (2)-
epicatechin and (1)-catechin (Ubillas et al.,
1994). SP-303 has the appearance of a dark reddish-
brown powder (Ubillas et al., 1994). Other
related compounds found in the sap of C. lechleri
(Ecuador) are procyanidins B1 and B4 (Cai
et al., 1991).
Terpenoid compounds
Diterpenes. Diterpenes isolated from the bark
of C. lechleri (Ecuador) were found in minor
amounts in the sap: bincatriol, crolechinol,
crolechinic acid, hardwickiic acid, and koberins
A and B (Cai et al., 1993).
Steroids. The bark of C. lechleri (Ecuador) contains
b-sitosterol-b-D-glucopyranoside and bsitosterol
(Cai et al., 1993).
To date, procyanidins and alkaloids are considered
to be the most active constituents of the
sap.
PRECLINICAL STUDIES
Gastrointestinal functions
Antisecretory activity against diarrhea. A survey
of local ethnomedical uses of the latex in
the area of Iquitos, Peru, in 1996 by ethnob-
JONES 880
otanist Franklin Ayala and Peruvian registered
nurse Dina Ayala, found that 57% of the randomly
interviewed populace reported its use
in the treatment of diarrhea (Carlson et al.,
2000). While this application was already
known (Ubillas et al., 1994),* no one had reported
any frequency of use. The fact that sangre
de drago was also taken orally in Peru to treat
watery diarrhea (dysentery and cholera) encouraged
researchers to initiate studies on its
potential use against this illness (Carlson et al.,
2000).
Using a mixture of procyanidin (proanthocyanidin)
oligomers derived from the latex and
designated SP-303, researchers examined antidiarrheal
activity in a mouse model for secretory
diarrhea with cholera toxin as the inducer.
In the form of enteric-coated beads,
SP-303 (100 mg/kg by gavage) administered at
the same time as the cholera toxin caused a significant
and dose-dependent reduction in the
amount of toxin-induced fluid accumulation in
the small intestine. Levels of fluid were nearly
restored to normal. Administered 3 hours after
mice were treated with the cholera toxin, SP-
303 again produced a dose-dependent inhibition
of fluid accumulation. At the highest dose
tested (50 mg/kg), fluid accumulation levels
were not significantly different from those of
controls. The half-maximal inhibitory amount
of SP-303 against cholera toxin-induced fluid
accumulation was approximately 10 mg/kg
(Gabriel et al., 1999).
In vitro studies to determine the mechanism
involved were performed by elevating cyclic
adenosine monophosphate (cAMP) levels in intestinal
epithelial cells using a potent activator
of adenylate cyclase (forskolin, derived from
Coleus forskohlii Briq. syn. C. barbatus Benth.),
thereby modeling the effects of cholera enterotoxin.
Binding of the enterotoxin to intestinal
cells leads to modification of a stimulatory protein
(G protein) and subsequent activation of
adenylate cyclase which in turn elevates cAMP.
Consequently, a chloride channel is activated
which causes a high volume of chloride and resultant
fluid secretion in the intestine. Left untreated
this state can result in dehydration and
death. SP-303 was shown to inhibit cAMP-mediated
chloride secretion in intestinal epithelial
cells (Caco-2 cells and T84 cells). Maximal inhibition
of forskolin-stimulated chloride secretion
in the intestinal cells was found from the
addition of 300 mM of SP-303. The concentration
that inhibited the chloride secretion by
50% (IC50) was approximately 50 mM (Gabriel
et al., 1999).
Further in vitro studies on the mechanism of
the antidiarrheal activity of sangre de drago were
conducted using a mixture of the whole sap collected
from C. lechleri and C. palanostigma (Upper
Huallaga River Valley, Amazonian Peru).
Pretreatment of isolated guinea pig ileum with
the sap (1:1,000) inhibited chloride secretion
evoked by capsaicin (derived from chili peppers,
Capsicum annuum L.) by approximately
70%. Because the response to capsaicin is mediated
by substance P released from sensory afferents
(inner part of nerves), these results suggest
that the sap suppressed epithelial secretion
by some direct inhibitory effect on sensory afferent
activation. The results of in vitro tests indicated
that the sap mixture does not compromise
cholinergic, substance-PBdependent
epithelial (neuron-induced) secretion, indicating
that the sap does not act as a general nerve
activation-inhibiting substance. The researchers
postulated that because of its ability
to block sensory afferents activated by capsaicin,
the sap may attenuate the pain and
cramping that attends the secretory processes
of diarrhea as well as intestinal distress. They
add that it may also have therapeutic use in
other types of neurogenic inflammation (Miller
et al., 2000).
Recent evidence indicates that fluid secretion
caused by rotavirus involves enteric nervous
system activation in the wall of the intestines
(Lundgren et al., 2000). Therefore, the ability of
the sap to block capsaicin-activated sensory afferents
(Miller et al., 2000) may represent a possible
or new means of treating rotavirus diarrhea,
which may become an important use of
the sap. Rotavirus is the major cause of severe
diarrhea in young children and infants worldwide
and by the age of 5, almost every child
will experience rotavirus gastroenteritis. The
virus causes dehydration, nausea, vomiting,
REVIEW OF SANGRE DE DRAGO 881
*Marles R. The Ethnopharmacology of the Lowland
Quichua of Eastern Ecuador [dissertation]. Chicago: University
of Illinois at Chicago, 1988.
and diarrhea, and causes an estimated 352,000B
592,000 (median, 440,000) deaths worldwide
per year largely in the developing world
(Parashar et al., 2003; World Health Organization,
1999). Worldwide, rotavirus causes approximately
2 million hospitalizations, 25 million
visits to a clinic, and 111 million episodes
of gastroenteritis every year (Parashar et al.,
2003). Since the discovery of rotavirus in the
1970s, a vaccine was developed and then withdrawn
in 1998 after producing undesirable sideeffects
(Dennehy and Bresee, 2001). Since then,
the need for effective and affordable treatment
has become more urgent (Parashar et al., 2003).
In the United States among children 5 years of
age and younger, the exact incidence of rotavirus-
associated diarrhea has yet to be determined
with any certainty. However, recent
trends in the United States incidence of diarrhea
in this age group suggest that it may be more
prevalent than previously thought. Beginning a
year after rotavirus infection was specifically
coded for in U.S. hospitals in 1993 to 3 years
later, among insured patients in the age group
the incidence increased from 6.9% to 17.7% of
all diarrhea-associated hospitalizations, resulting
in 593 children being hospitalized and more
than 6000 outpatient visits (Zimmernan et al.,
2001).
Immune functions: inflammation and disease
Cytotoxicity against cancer cells. Potent in vitro
cytotoxicity against KB cells (human oral epidermoid
carcinoma) was reported from the alkaloid
taspine. The concentration required to
inhibit KB tumor cell growth by 50% (IC50) was
0.39 mg/mL (Itokwa et al., 1991). Further tests
against the growth of KB cells were conducted
using the sap from C. lechleri collected in
Ecuador. At greater than 900 mg/mL (Chen et
al., 1994), the IC50 of the raw sap was much
higher than that obtained in an earlier study on
KB cells with sap from Peruvian C. palanostigma
(Itokwa et al., 1991), a result likely caused by
the trace amount of taspine in the sap from
Ecuador (Chen et al., 1994) versus a taspine
content of at least 10 mg/g in the Peruvian sap
(Itokwa et al., 1991). After freeze-drying the sap
from Ecuador (C. lechleri), the IC50 in the KB
cell assay was approximately 4.8 times smaller
(IC50 187 mg/mL). However, even this concentration
was hardly cytotoxic and various solvent
extracts of the sap failed to show much
higher activity. A methanolic extract of the
heartwood was more active (IC50 25 mg/mL),
but was still not cytotoxic. With an IC50 of more
20 mg/mL, various constituents isolated from
the sap also showed no cytotoxic activity. The
most active compound was 1,3,5-trimethoxybenzene
(IC50 of 7.13 mg/mL) which was still
much weaker than the control (emetine hydrochloride,
IC50 of 0.2 mg/mL). It was proposed
that if any sangre de drago sap with a low
content of taspine can produce antitumor activity,
it may be because of mechanisms other
than cytotoxicity, such as immunostimulation
(Chen et al., 1994).
More recent in vitro studies on the tumor-cell
cytotoxicity of sangre de drago examined effects
on human erythroleukemia K562 cells (Rossi et
al., 2003) and human gastrointestinal cancer
cell lines of colon (T84 and HT29) and stomach
cancer (AGS) (Sandoval et al., 2002). Dose-dependent
antiproliferative activity against K562
cells was found from reconstituted, filtered,
freeze-dried raw sap of Ecuadorian C. lechleri
(IC50 of 2.5 mg/mL) collected in Morona Santiago
province (Rossi et al., 2003). In the study
on colon and stomach cancer cell lines, the sap
of C. palanostigma (Upper Huallaga Valley,
Tingo Maria, Peru) was also reconstituted in
water from filtered, freeze-dried material and
used in all the experiments. After incubation
with the sap at a concentration of 100 mg/mL
and 200 mg/mL, but not at 10 mg/mL, cell viability,
cell adhesion, and cell proliferation
were significantly decreased in all the cancer
cell lines. Cell adhesion of the cancer cells was
shown to be irreversibly damaged with complete
loss of adhesion when the cells were taken
to another medium. Apoptosis was significantly
increased at the same concentrations of
the sap in each of the cancer cell lines and in
each experiment the effect of the sap was concentration
and time-dependent. Effects of the
sap (100 mg/mL) on microtubule morphology
were similar in each of the cancer cell lines. Exposure
to the sap caused clumps to form and
the microtubule structure to undergo significant
damage, although more so in the T84 colon
cancer cells. Coupled with the observed effects
JONES 882
of the sap on microtubule structure and damaged
adhesion ability of the cancer cell lines,
Sandoval et al. (2002) concluded that it can induce
changes similar to those of the anticancer
agent TaxolJ (Bristol-Myers Squibb, Princeton,
NJ), which also renders microtubules nonfunctional
and results in cellular apoptosis and
the inability of cancer cells to adhere. As to
what the active constituents may be, the researchers
suggested the possibility of vanilloid
compounds (Sandoval et al., 2002).
Antimicrobial activity against infectious diseases.
The freeze-dried sap of C. lechleri (Ecuador)
showed weak activity against the growth of
Bacillus subtilis (strain JTS 13) and Escherichia
coli (strain KL 16), with activity only at concentrations
of greater than 10 mg. A methanolic
extract was not much better and ethyl alcohol
and acetone extracts were less active than
the freeze-dried sap. Better activity against E.
coli was found from a chloroform extract, but
it was less active against B. subtilis. Among various
constituents of the sap, highly potent
activity against B. subtilis was found from
two compounds (2,4,6-trimethoxyphenol and
1,3,5-trimethoxybenzene at 0.0003 mg) which
showed 30-fold the activity of chloramphenicol
and penicillin. These substances were also
highly active against the growth of E. coli, although
less potently so (1.0 and 0.04 mg, respectively).
High activity was also found from
several diterpenoid constituents of the sap.
Crolechinic acid was active against E. coli and
- subtilis (1.0 and 0.2 mg, respectively), and at
0.04 and 0.05 mg, korberins A and B showed
good activity against B. subtilis (Chen et al.,
1994).
A combination of the undiluted saps of Peruvian
sangre de drago (C. lechleri and C. palanostigma)
showed 100% lethality against E. coli and
was still 90% lethal at a dilution of 1:10 (Miller
et al., 2000).
Antiviral activity against viruses. Antiviral activity
of the procyanidin preparation known as
SP-303 (molecular weight approximately 2100
- da) has been more extensively tested than any
other constituent of the sap (Ubillas et al., 1994).
SP-303 has shown in vitro activity against Herpes
simplex viruses (HSV-1 and HSV-2), inhibition
of thymidine kinase mutants of the viruses,
and pronounced activity against acyclovir-resistant
strains (Barnard et al., 1993; Safrin et al.,
1993). In the plaque reduction assay, SP-303 exhibited
greatest potency against various isolates
of HSV-2 (ED50 of 0.9B2.1 mg/mL). Evidence
of SP-303-induced interferon production
was absent (Barnard et al., 1993) and its function
was not like that of ribavirin, which inhibits
viruses during the replication stage.
Studies suggest that the mechanism of viral inhibition
of SP-303 is at the level of plasma membrane
penetration and/or adsorption at an
early stage of viral activity (Barnard et al., 1993;
Ubillas et al., 1994).
At 6 hours postinfection, guinea pigs vaginally
infected with HSV-2 showed significantly
less viral lesions after topical treatment with a
dimethyl sulfoxide (DMSO; 78% w/w)-based
ointment containing SP-303 (10%). The ointment
was approximately half as active as acyclovir
(5% ointment). Similar results were
found in mice vaginally infected with HSV-2
after treatment with a 10% SP-303 cream or SP-
303 administered orally (90 mg/kg per day for
8 days) (Ubillas et al., 1994). The mean lesion
score of mice topically treated with SP-303
(10%) was significantly reduced and 70% of the
animals survived (versus 100% of those treated
with acyclovir). Benefits from intraperitoneal
(30 mg/kg per day) and oral SP-303 (270
mg/kg twice daily) were not significantly different
from the 10% topical cream. In uninfected
control mice, no signs of irritation were
found from the topical preparation; however,
intraperitoneal (i.p.) and oral doses of SP-303
caused weight loss (Barnard et al., 1993).
Administration of SP-303 (9 mg/kg per day)
by small particle aerosol to mice infected with
influenza A produced significant increases
in survival and significantly decreased pulmonary
influenza titers, damage to lung
tissues, and development of pneumonitis.
However, neither oral or i.p. administrations of
SP-303 produced statistically significant results
(Gilbert et al., 1993).
Respiratory syncytial (RSV) and parainfluenza
viruses are leading causes of serious infections
of the lower respiratory tract of children
less than 2 years old. In infants, RSV can
cause pneumonia and bronchiolitis. It also
REVIEW OF SANGRE DE DRAGO 883
causes acute respiratory infections in the elderly.
In young children and infants, parainfluenza
viruses cause the common cold as well
as otitis media, bronchiolits, severe croup, and
pneumonia (Bennett and Plum, 1996).
SP-303 selectively inhibited several respiratory
viruses in vitro (Wyde et al., 1991) and appeared
to inhibit the cellular penetration of
RSV (Barnard et al., 1992). Against RSV infection
in rats, single doses of SP-303 (1B10 mg/kg
per day i.p.) produced significant reductions of
75% to 97% in pulmonary titers of the virus
compared to placebo. The highest dose produced
results comparable to ribavirin (90
mg/kg i.p., 99% reduction in virus titer) and
provide the only consistent results. Oral administration
of SP-303 produced variable results
against RSV infection. Significant results
compared to placebo were seen from twice
daily doses of 3 mg/kg orally (80% to 99% reductions
in viral titers, p 5 0.03). However,
doses of 1 mg or less and 30 mg or more twice
daily failed to produce consistently significant
results. Significant reductions in titers of
parainfluenza virus type 3 (PIV3) of 87% to 94%
were found in rats treated with SP-303 at single
doses of 3 mg/kg and 10 mg/kg per day
i.p. respectively, compared to placebo (Wyde
et al., 1993).
Oral dosages of SP-303 (30, 90, or 270 mg twice
daily 4 hours prior to infection for 7 days) produced
significant decreases of RSV titers in
African green monkeys infected by inoculation
(Soike et al., 1992). Administered 24 hours after
infection, oral dosages of SP-303 at 10 or 90 mg/kg
per day produced significant reductions in viral
titers of the lungs (Ubillas et al., 1994). No generalized
toxic effects or changes in clinical chemistry
were found from oral doses of 100, 300, or 900
mg/kg per day for 5 days (Soike et al., 1992).
In cultures of several tumor viruses (simian
sarcoma virus type I, Rauscher murine
leukemia virus, and avian myeloblastosis
virus), the alkaloid taspine (70B98 mg/mL) inhibited
the enzyme reverse transcriptase by
50% (Sethi, 1977).
Inflammatory response
Arthritis. In an animal model of polyarthritis,
the anti-inflammatory activity of the alkaloid
taspine was compared to that of indomethicin
(1 mg/kg per day orally). Male rats administered
the alkaloid (20 mg/kg per day
orally) for 3 days prior to adjuvant-induced
arthritis and for 17 days thereafter showed a
significant decrease in paw swelling, which
was comparable to or greater than that of indomethicin.
In a separate study on edema in
rats (carrageenan-induced pedal edema),
taspine (median effect dose [ED50] 58 mg/kg
orally) displayed 3B4 times the anti-inflammatory
potency of phenylbutazone (Persinos Perdue
et al., 1979).
Gastric ulcers. In a rat model of gastric ulcer
(acetic acid-induced), sap derived from Peruvian
- lechleri and C. palanostigma (Rainforest
Phytoceuticals, Delmar, NY) administered in
drinking water for 7 days (60 or 600 mg/ 5
1:10,000 or 1:1000 dilution) produced a significant
reduction in the size of ulcers. In contrast
to untreated rats, the gastric epithelium of the
sap-treated rats showed areas of regenerating
epithelia. At either concentration, the magnitude
of the healing from the sap was at least as
great as that from a combination of streptomycin
and penicillin. Moreover, tests revealed
a significant decrease in bacterial counts of the
ulcers in the sap-drinking rats versus controls.
Subsequently, the undiluted combination of
saps was found to kill E. coli completely. Even
at a dilution of 1:10 the sap combination was
still 90% effective. A further benefit from the
sap was seen in a significant decrease in the
granulocyte contents of the ulcers, which was
evident in greatly decreased ulcer myeloperoxidase
levels. The researchers noted that this
effect was something not found in previous
studies of ulcer-healing using probiotics or antibiotics
(Miller et al., 2000).
In the gastric epithelium of rats with gastric
ulcers, Miller et al. (2000) found highly upregulated
gene expression of the cytokines
(messengers) tumor necrosis factor-a (TNF-a),
inducible nitric oxide synthase (iNOS), interleukin-
6 (IL-6), interleukin-1b (IL-1b), and cyclo-
oxygenase-2 (COX-2). In the gastric epithelium
of the sap-treated rats, gene expression of
the proinflammatory cytokines was reduced,
especially iNOS gene expression (Miller et al.,
2000). In studies on chronic ileitis (Miller et al.,
JONES 884
1993), chronic granulomatous colitis (Grisham
et al., 1994), and Heliobacter pylori gastritis
(Mannick et al., 1996), the expression of iNOS
has been associated with locations of tissue injury.
Therefore, the ability of the sap to reduce
iNOS suggests that it may hold promise against
these conditions as well.
Neurogenic inflammation. Miller and colleagues
(2001) hypothesized that the ethnomedical
uses of sangre de drago as a woundhealing,
analgesic, and antidiarrheal agent, and
its purported ability to relieve pain and itching
quickly, might derive from a suppressive effect
on sensory afferent nerve activation. Sensory
afferent nerves are found in the skin, lungs and
gut where they act as sentinels for nerves,
transmitting impulses from the periphery to
the central nervous system. Further support for
the hypothesis came from one of the authors
who found the burning sensation caused by exposure
of his mucosal skin to capsaicin was relieved
by applying the sap (Miller et al., 2001).
The results from an ensuing series of experiments
support their hypothesis.
Increased sensitivity to pain (hyperalgesia)
induced in the paws of rats by intradermal protease
activated receptor-2 activating peptide
(PAR-2AP) was abolished by a single topical
pretreatment of the sap in the form of a balm
containing 1% sangre de drago (Zangrado Bug
Bite Balm, Rainforest Phytoceuticals, LLC). Because
this effect was absent in rats not treated
with PAR-2AP, an anesthetic action of the balm
was not indicated. Hyperalgesia induced by intradermal
prostaglandin E2 (PGE2) was completely
blocked in rats treated with the balm in
a single topical pretreatment. A single topical
application of the balm to the paws of rats with
PAR-2AP-induced edema caused the volume of
swelling to reduce by approximately 50% compared
to placebo (p , 0.01). The effect lasted 6
hours or more and the reduction in edema was
more sustained and quicker than the natural
decline evident in the placebo group. In another
experiment, phenylephrine-constricted
rat mesenteric arteries relaxed in response to
the addition of calcitonin gene-related peptide
(CGRP), one of the main neurotransmitters of
sensory afferent nerves. Upon introduction of
the sap in dilution (1:10,000), the response to
CGRP was significantly inhibited (p , 0.05), indicating
that the sap inhibited the CGRP receptor.
An active constituent in the sap (molecular
weight 930) that appeared to be a
procyanidin oligomer was found to be just as
active as the sap itself against PAR-2AP-induced
hyperalgesia. In addition, compared to
vehicle-treated controls, excessive mucosal
blood flow in the stomach of rats (gastric hyperemia
or gastric mucosal vasodilation) induced
by capsaicin was largely prevented by
pretreatment with 1% solutions of the sap or
the active constituent (each p , 0.01). Taken together,
these results indicate that the sap directly
blocks sensory afferent nerve activation
at both the prejunctional and postjunctional
level; this is a dual action, which the researchers
claim, appears to be unique to sangre
de drago (Miller et al., 2001).
Connective tissue functions
Wound repair. The traditional use of sangre de
drago as a liquid bandage in the Amazon led
several research groups to investigate alleged
wound-healing activity. Although no one constituent
can be singled out as responsible, early
investigations attempted to do just that. Chen
and colleagues (1994) emphasized that what
became obvious in their work with the sap of
Ecuadorian C. lechleri was considerable differences
in chemical composition of sangre de drago
saps from different origins. They further concluded
that the wound-healing properties of
the sap may be the result of various factors: The
ability to form a film that protects against microbial
invasion of wounds; free radical scavenging
activity of procyanidins; the high content
of polyphenolics with their well-known
aspect of binding proteins and enzymes; and
the anti-inflammatory and strong antibacterial
action of polyphenols, which together would
facilitate improved healing of damaged tissue
(Chen et al., 1994).
Vaisberg et al. (1989) reported that twicedaily
topical application of 0.05 mL of a 10%
solution of the sap (C. lechleri) to skin wounds
of mice caused a significant 31% increase (p ,
0.05) in the rate of wound repair. Taspine was
found in the sap at a concentration of 0.1B0.2
mg/mL and through a bioassay for cicatrizant
REVIEW OF SANGRE DE DRAGO 885
activity was isolated as the active constituent.
Topical application of 0.05 mL of a 10% solution
of taspine hydrochloride every 12 hours
also produced a significant wound-healing activity
of 58.2% (p , 0.005). The effect was dosedependent
with concentrations of up to 13.2 mg
per mouse producing increasing rates of
wound healing (cicatrizant) activity. A higher
dose (40 mg per mouse) produced only a 23.1%
increase in wound-healing activity, indicating
a threshold at which the activity may be optimum
from taspine. In an in vitro test, wounding
of human fibroblasts was performed in order
to count the population of cells that migrate
to the repair the area of damage. Fibroblasts
treated with taspine showed a significant increase
in numbers of migrating cells, suggesting
that this effect may be at work in the
wound-healing activity of the sap and of
taspine (Vaisberg et al., 1989).
Pieters and colleagues (1992) also reported
that the sap was active as a wound-healing
agent. Evidence was obtained using an ethyl alcohol
extract in an assay for stimulation of human
endothelial cells (umbiblical vein). The use
of this assay is predicated upon the role of endothelial
cells in the healing process of skin tissue;
when new tissue forms, endothelial cells
proliferate to allow the formation of new blood
vessels. Cellular proliferation was measured
according to the rate that radio-labeled thymidine
(3H-thymidine) incorporated into cellular
DNA in the presence of the test substances.
From the sap of Peruvian sangre de drago (Croton
sp.), they isolated an active constituent;
a lignan known as 39,4-O-dimethylcedrusin
(4-O-methyldihydrodehydrodiconiferyl alcohol).
The concentration of the lignan in the sap
(approximately 14 mg/mL or 0.0014%) was the
same as that which produced positive activity
in the wound-healing assay. The lignan was
proposed to be the active constituent because
it also protected endothelial cells from undergoing
degradation in a starvation medium and
it stimulated endothelial cells (Pieters et al.,
1992). However, at higher concentrations (125
and 250 mg/mL) incorporation of radiolabeled
thymidine into the cells was inhibited by the
lignan, as well as by taspine (0.5 mg/mL and
more), which was otherwise inactive in the assay
(Pieters et al., 1993).
Porras-Reyes and colleagues (1993) focused
on the wound-healing activity of taspine,
which became Athe first plant alkaloid confirmed
to accelerate wound healing@ (Porras-
Reyes et al., 1993). DMSO allowed taspine to
be diluted and served as the vehicle control
treatment for in vitro and in vivo studies.
Taspine was otherwise highly insoluble. In a
linear incision model in rats, a single topical application
of taspine (250 mg dissolved in 0.1 mL
of DMSO) produced a significant increase in
the tensile strength of wounds. At 5 and 7 days
postincision, wound tensile strength showed
significant increases of 26% and 30% compared
to vehicle-treated control incisions (p , 0.005
and p , 0.0001, respectively). By day 12, however,
there was no difference in wound
strength. Smaller doses of taspine (10 and 50
mg/mL) failed to produce any increases in
wound tensile strength. A number of tests were
performed to determine how taspine accelerated
wound healing. On days 5 and 7, the influx
of mononuclear cells in the taspine-treated
(250 mg/mL) wounds was higher compared to
controls. Fibroblast infiltration was not stimulated
by taspine. Rather, cell viability was decreased
and thymidine incorporation was inhibited
(Porras-Reyes et al., 1993). The negative
effect was probably the result of in vitro toxicity,
as previously reported by Vasiberg and colleagues
(1989). A positive effect on the expression
of fibronectin was suspected as a possible
means of accelerated wound healing by
taspine, but in vitro tests showed that fibronectin
matrix disposition was not affected.
The chemotactic properties of macrophages
were likewise not affected, although fibroblast
chemotactic activity was; optimal promotion of
fibroblast migration from taspine was seen at
50 pg/mL. In conclusion, Porras-Reyes et al.
(1993) thought increased fibroblast migration
to be the likely means by which taspine enhanced
wound healing.
Chen and coworkers (1994) examined the
wound-healing activity of the sap from
Ecuadorian C. lechleri, which contained only
traces of taspine (Bettolo and Scarpati, 1989)
and no 394-methylcedrusin (Phillipson, 1995).
The assay for activity was the proliferation of
endothelial cells (bovine). They also measured
thymidine (3H-thymidine) incorporation to de-
JONES 886
termine the rate of endothelial cell proliferation,
as in the previous study. Rather than any
increase in endothelial cell proliferation, the
dried sap (20 mg/mL) inhibited proliferation/
thymidine incorporation by as much as
44%. (Whether drying the sap affected the activity
is not known.) Ethyl alcohol, chloroform,
and methanol extracts of the sap also inhibited
endothelial cell proliferation, whereas an acetone
extract was inactive either way. Testing
individual constituents of the sap, they found
endothelial cell proliferation increased by procyanidin
B-4 (10 mg/mL) and most potently by
(2)-epigallocatechin and (1)-gallocatechin
(each at 5 mg/mL) (Chen et al., 1994). At this,
Chen and coworkers pointed out a study by
PietersH in which the polyphenolic fraction of
the sap, which would contain the aforementioned
active constituents, was active in healing
the wounds of rats. After treatment with
the fraction, wound tissues were reported to
have contracted after only one day, Aand the
wound site was completely covered with a
dark crust@ (Chen et al., 1994, citing Pieters,H).
Examined under a microscope 1 month later,
Pieters reported that the newly formed tissue
was indistinguishable from unwounded tissue.
However, Chen et al. (1994) noted that such an
effect was not found by Pieters in experiments
using 394-methylcedrusin or taspine. As for the
various constituents of the Ecuadorian sap that
contributed to inhibition of endothelial cell proliferation,
they found the majority held only
slight or no inhibitory activity. The exceptions
were korberin A (10 mg/mL, $ 52% inhibition)
and 1,3,5-trimethoxybenzene (0.5 mg/mL, $
100% inhibition) that were, respectively, highly
and extremely active (Chen et al., 1994). Again,
both high and low levels of taspine were shown
to be active.
Antioxidant activity
Tests of the antioxidant activity of the sap are
lacking. In the total reactive antioxidant potential
(TRAP) index, sap collected from Peruvian
- lechleri produced results suggesting the presence
of antioxidant compounds in high concentration.
In an assay to measure effects on
free radical-mediated DNA-sugar damage (induced
with iron), low concentrations of the sap
(1 and 10 mg/mL) increased the level of oxygen
radical activity whereas high concentrations
(100 mg/mL and 1000 mg/mL) prevented
oxidant activity. In contrast, catechin inhibited
oxidative DNA damage at a concentration of 1
mg/mL. The sap (1B100 mg/mL) also increased
oxidative activity in the hydroperoxide-initiated
chemoluminescence assay using rat liver
cells. However, in aqueous reaction media the
sap prevented oxidative DNA damage and
captured hydroxyl and peroxyl radicals, indicating
that the constituents responsible are water
soluble (Desmarchelier et al., 1997).
Administered to mice by subcutaneous injection,
the freeze-dried and redissolved latex of Peruvian
- lechleri inhibited hepatic lipid peroxidation
as evident in the measurement of
malonaldehyde (MDA) thiobarbituric acid reactive
substances (TBARS) production in the livers
of the animals. However, protection against hepatic
lipid peroxidation was only found from a
dosage of 200 mg/kg subcutaneously. At 50
mg/kg, MDA levels were found to increase, at
100 mg/kg there was no significant antioxidant
activity, and at 300 mg/kg there was evidence
of toxicity (Desmarchelier and de Moraes Barros,
2003). Unfortunately, the route of administration
is incongruent with traditional uses of the sap.
Moreover, a study using the oral route of administration
could produce entirely different results
(Shanbhag et al., 1990).
Antimutagenic activity
The raw sap collected from Ecuadorian C.
lechleri prevented the mutagenicity of 2-amino
anthracene in both the TA100 (IC50 430 mg/mL)
and TA98 (IC50 of 340 mg/mL) strains of Salmonella
typhimurium by 90% and 100%, respectively
(Rossi et al., 2003).
CLINICAL STUDIES
Gastrointestinal disorders
Diarrhea. In the United States diarrhea is
more often fatal in persons aged 80 and over
REVIEW OF SANGRE DE DRAGO 887
HPieters LA. The Biologically Active Constituents of
Asangre de drago,@ a Traditional South American Drug
[dissertation]. Antwerp, Belgium: University of Antwerp,
1992.
than in other age groups. Three percent (3%) of
all U.S. hospitalizations in 1985 involving diarrhea
were comprised of this age group and the
rate was far higher than in any other, including
children under age 5 (0.05%) (Gangarosa et
al., 1992). In the developing world, the incidence
of diarrhea in children under age 5 is estimated
at 1 billion episodes annually, resulting
in an estimated 3.3 million deaths each year
(Bern et al., 1992).
As previously noted, sangre de drago is frequently
used in ethnomedicine for the treatment
of diarrhea (Carlson et al., 2000; Marles,
1992; Ubillas et al., 1994). After animal and in
vitro studies confirming an antisecretory activity
of the sap (see Diarrhea section above),
placebo-controlled clinical trials of a defined
preparation (SP-303) were initiated in traveler=s
diarrhea, watery diarrhea (Ubillas et al., 1994),
and human immunodeficiency virus (HIV)-associated
diarrhea (Holodniy et al., 1999). A review
of the research on the preparation in the
treatment of diarrhea appeared in HealthNotes
Review of Complementary and Integrative Medicine
(Carlson et al., 2000).
Traveler=s diarrhea. Traveler=s diarrhea is
classified as a syndrome comprising an increase
in the frequency of unformed stools of
200% or greater (typically, 4B5 loose stools per
day) and common symptoms of malaise,
fever, nausea, bloating, cramps, and urgency.
The episodes often begin abruptly, either
while one is traveling or not long after returning
home. Although the episodes are in
most cases self-limited, rates of attacks range
from 20%B50%. Destinations of greatest risk
are Latin America, Africa, the Middle East,
and Asia (Centers for Disease Control and
Prevention, 2001). In at least 80% of cases,
traveler=s diarrhea is caused by bacterial enteropahthogens
(DuPont and Ericsson, 1993)
including E. coli, Salmonella, Shigella, and
Campylobacter jejuni (Centers for Disease Control
and Prevention, 2001) and has a tendency
to be more severe in Americans traveling to
Mexico, for example, than it is in Mexicans
traveling in their own country (Carlson et al.,
2000). Enterotoxigenic E. coli is associated
with acute traveler=s diarrhea but not significantly
with persistent diarrhea (Schultsz, et
al., 2000).
The potential of SP-303 as an antidiarrheal
agent was evaluated in acute diarrhea in 184
travelers to Jamaica and Mexico. Entry into the
trial (double-blinded, randomized, placebo-controlled)
was limited to travelers presenting with
acute diarrhea who had at least 3 unformed
stools in the preceding 24 hours and diarrhea for
no more than 48 hours. Subjects were randomly
assigned to receive treatment with either placebo
or SP-303 at doses of 125 mg, 250 mg, or 500 mg,
twice daily for 2 days. Efficacy was determined
from 169 subjects who were observed for 24
hours after the 2-day treatment period. No adverse
effects were found compared to controls
and each dosage of SP-303 was significantly
more effective than placebo (p , 0.05). Subjects
that received 250 mg twice daily showed in more
than 90% of cases partial or complete improvement
of symptoms in the first 24 hours. Time to
the last unformed stool was 38 hours versus 54
hours in the placebo group; a highly significant
difference (p 5 0.0002) (Carlson et al., 2000, citing
Dicesare et al., 1998).
Watery diarrhea. A randomized, doubleblinded,
placebo-controlled trial of SP-303 in
the treatment of watery diarrhea was performed
in-hospital in residents of Venezuela.
Patients were included who presented with diarrhea
in moderate and severe acute watery
forms. Over a period of 48 hours, SP-303 or
placebo was administered in oral doses of either
125 mg, 250 mg, or 500 mg four times per
day. Male and female patients (n 5 140; ages
18B69 years) were enrolled who had experienced
at least 5 watery stools in the preceding
24 hours. Time to the last unformed stool was
the main endpoint for evaluation of efficacy
measured at 24, 48 and 72 hours. The results
showed that the treatment was well tolerated,
but that only the 125-mg dose was effective and
only in reducing the time to the last unformed
stool in the 48-hour treatment period versus
placebo (p 5 0.02) (Carlson et al., 2000, citing
Ettedgui et al.I). The reason for the difference
JONES 888
IEttedgui G, Schael IP, Porter S, Pennington J. A double-
blind, randomized, placebo-controlled, multi-dose,
phase II study to assess the safety and efficacy of SP-303
in the symptomatic treatment of acute diarrhea among
adult residents of Venezuela: Oral administration of 125
mg, 250 mg, or 500 mg of SP-303 given every 6 hours for
48 hours. South San Francisco, CA: Shaman Pharmaceuticals,
1998, unpublished.
in the results compared to other studies of SP-
303 in diarrhea is not clear. It may have been
because of differences in diet, enteropathogens,
study design, and/or the fact that these patients
were not suffering from traveler=s diarrhea.
HIV-associated diarrhea. In up to 90% of cases,
patients infected with HIV suffer from diarrhea.
The problem grows worse as the immune
system becomes more compromised. In the developing
world, lack of hygiene, poor sanitation,
medications, and even herbal treatments
may also cause infections of the gastrointestinal
tract. If the cause of the diarrhea can be
identified there is some hope of successful
treatment, but in up to 60% of cases it remains
unknown. In HIV-infected patients the causes
may be infectious or noninfectious. Infectious
causes include the majority of pathogens affecting
people with traveler=s diarrhea, plus
amebiasis, candidiasis, Cryptosporidium, cytomegalovirus,
giardiasis, Isospora belli, and
Mycobacterium avis complex. Noninfectious
causes of diarrhea in these patients include
malabsorption (lactose intolerance, HIV enteropathy,
HIV osmotic drink and food),
medications (therapy with multiple drugs, traditional
herbal treatments), obstruction, incontinence
of the rectum, and stress. Patient response
to drugs that control motility (e.g.,
loperamide) has been poor and some just cost
too much (e.g., octreotide) (Katabira, 1999).
Clinical trials of SP-303 in the treatment of
HIV-associated diarrhea have largely produced
positive results (Carlson and King,
2000; Holodniy et al., 1999; Koch et al., 1999;
Koch, 2000). A phase II multicenter clinical
trial (randomized, double-blinded, placebocontrolled)
of SP-303 was conducted by the
University of California, San Francisco, in 45
HIV-infected patients diagnosed with diarrhea
and acquired immune deficiency syndrome
(AIDS)-defining illness or CD4 count
less than 200 (males and females ages 18B60
years). Subjects received SP-303 (500 mg orally
every 6 hours) or placebo for 4 days. The majority
were receiving treatment with antiretroviral
agents (80%) and protease inhibitors
(77%). All patients stopped treatments for diarrhea
24 hours before enrollment in the trial.
For 94% no pathogens were identified in stool
samples. Treatment with SP-303 resulted in
significant reductions in the frequency of abnormal
stools (p , 0.04) and of stool weight
(p , 0.008) compared to placebo, and there
were no adverse effects or laboratory abnormalities
(Holodniy et al., 1999).
A Phase III multicenter inpatient trial of SP-
303 in the treatment of HIV-associated chronic
diarrhea (stool weight . 300 g per 24 hours) by
the University of California, San Francisco was
conducted in 400 patients diagnosed with
AIDS. Subjects were men or women 18 years
of age or older, the majority of whom were
receiving treatment with antiretrovirals and
protease inhibitors (93.3% and 83.3%, respectively).
Any antidiarrheal agents were discontinued
more than 24 hours prior to patient enrollment.
After being randomly assigned to
either placebo or active treatment groups, subjects
received one of three different dosage formulations
of SP-303: 250 or 500 mg in a delayed
release tablet or 500 mg in the form of delayed
release beads (each four times per day for 6
days). Responders to SP-303 were allowed to
continue the treatment for another 21 days. The
results showed that only those who received
the 500-mg tablet benefited. For those with severe
diarrhea (stool weights of at least 1000 g
per 24 hours), treatment with the 500-mg tablet
produced a significant reduction in stool
weight (Athe primary efficacy endpoint@) compared
to placebo (p 5 0.008). No adverse effects
were found and laboratory measurements
showed no abnormalities (Koch, 2000).
A group of patients (n 5 42) pooled from the
phase III trial and from an open-label study of
SP-303 (250-500 mg four times per day) were
recruited by Koch and coworkers (1999) for a
study on changes in diarrhea-related quality of
life (QOL) scores. The researchers pointed out
that the influence of antidiarrheal therapy on
QOL was previously unknown. The QOL questionnaire
included queries on daily living activities,
ability to sleep and to perform errands,
and of effects on sexual activity. From the results,
Koch et al. (1999) concluded that QOL is
adversely affected by diarrhea; those who responded
to treatment experienced a significant
improvement (p 5 0.024) in the sum score for
daily living activities within 2B4 weeks; and
that significant improvements in Aability to
leave home@ (p 5 0.03), Atime spent resting@
REVIEW OF SANGRE DE DRAGO 889
(p 5 0.03), and sexually activity (p 5 0.01) were
associated with response to treatment. The researchers
also compared results from responders
to those of nonresponders. Responders
were classified as those who experienced a reduction
in 24-hour stool weight of 50% on day
- From those who completed the questionnaire
(74%), the improvement in QOL was statistically
significant in favor of the responders (p 5
0.024) (Koch et al., 1999).
After these studies, a product standardized to
contain 250 mg SP-303 per 350-mg tablet (SB-
300) was made available in the United States as
a dietary supplement known as NSF/Normal
Stool FormulaJ (Shaman Pharmaceuticals, Inc.,
South San Francisco, CA) (Carlson et al., 2000).
Viral infections
Herpes simplex. Orozco-Topete et al. (1997)
conducted a Phase II clinical study of SP-303
in the treatment of genital herpes simplex
virus (HSV) infections in 45 patients with
AIDS 20B54 years of age. The purpose of the
multicenter, placebo-controlled, double-blind
study was to determine efficacy and safety of
an ointment (Virend7, Shaman Pharmaceuticals,
Inc.) containing 15% SP-303 w/w in the
treatment of recurrent anogenital or genital
herpes in AIDS patients. Primary endpoints of
Acomplete healing@ and Atime to healing@ of
herpes lesions were evaluated in HSV activephase,
culture-positive patients who topically
applied an ointment containing SP-303 or a
matching placebo (ointment base, twice daily
for 21 days). Patients received instructions to
cleanse the lesions with mild soap and water
and gently blot them dry before covering the
lesions with a thin layer of the ointment, once
in the morning, afternoon, and evening. At
each visit to the clinic, specimens were obtained
for cultures of HSV to determine
changes in viral positivity. All patients were
positive for HSV-2. Blood and serum chemistry
were monitored as were vital signs. Lesions
were measured and photographed at
day 1 when patients were randomized and at
each visit. Only one patient was not taking
some kind of anti-infective drug therapy during
the trial. The agents taken were typical of
the population and included antibiotics, antiretrovirals,
antituberculosis drugs, sulfonamides,
vitamin B complex, and various medicines
used to treat nausea, diarrhea, and constipation.
Patient withdrawals from the study consisted
of 7 of 21 in the placebo group and 5 of
24 in the active treatment group. Reasons for
discontinuation were advancing HIV (1
placebo and 2 Virend), burning sensation at the
site of application (1 Virend), death (1 placebo
and 1 Virend), herpes zoster (1 placebo), concomitant
drug therapy (1 placebo), treatment
failure (1 placebo), wasting syndrome (1
Virend), esophagitis (1 Virend), patient refusal
(2 placebo), and other (1 placebo and 1 Virend)
(Orozco-Topete et al., 1997).
Apart from a burning sensation at the site of
application (2 Virend and 1 placebo), no other
adverse events were thought to be attributable
to Virend. In the resolution of lesions at day 21,
the results were significant in favor of Virend
(p 5 0.053) only when the two patients lost to
follow-up in the Virend group were excluded.
On day 21, lesions were completely healed in
41% of the Virend group and only 14% of the
placebo group. However, in this small trial,
when the two patients lost to follow-up were
included in an intent-to-treat analysis, the results
failed to reached statistical significance
(p 5 0.077). It is important to note that those
who showed complete healing of lesions had
both significantly higher levels of CD41 cells
and significantly smaller lesions at the start of
the trial (each p 5 0.03). The number who
showed decreases in lesion size ($25%) was
also not significant compared to placebo (25%
Virend versus 24% placebo), an outcome the investigators
attributed to several Virend patients
with large lesions that were only slightly
improved. No significant difference was found
in lesion pain compared to placebo, although
there was a trend towards significance in pain
intensity in the Virend group on day 4. As for
HSV-2 shedding, 19% of the placebo group became
culture-negative during the trial versus
50% of the Virend group (p 5 0.06). The investigators
concluded that the results were not superior
to those obtainable using available oral
agents (e.g., acyclovir) and planned to conduct
further studies using a more easily dissolving
formulation of SP-303 (Orozco-Topete et al.,
1997).
JONES 890
Inflammatory skin conditions
Insect bites. The potential soothing effect of
a 1% sangre de drago balm (Zangrado Bug Bite
Balm, Rainforest Phytoceuticals, LLC) on itching
and pain caused by insect bites was studied
in 10 workers from the Terminex Pest
Control Company in New Orleans, LA. The
balm base served as the placebo and both
preparations were coded. Over a period of 3
months, workers applied the preparations at
their discretion to various conditions, recording
the length of time before they experienced
relief, the number of reapplications, if any,
and the causes of the skin afflictions. Fire ant
bites became the most common affliction and
affected all 10 participants. Apart from immediate
pain, the bite of fire ants is known to
cause an intense itch and the itching can last
for weeks. Half of the participants reported
pain, 40% discomfort, 60% swelling, 60% redness,
and 100% itching. In all instances the
number of workers who preferred the active
balm over the placebo balm was significant
(itching, p , 0.001; swelling, p , 0.01; and
pain, redness, or discomfort, each p , 0.05).
The average time reported by the workers before
symptomatic relief after applying the active
balm was less than 2 minutes. These results
provided further evidence that sangre de
drago inhibits sensory nerve afferent activity.
Such an inhibitor could potentially relieve
any skin condition attended by pain, edema,
redness, discomfort, itching, or pain (Miller et
al., 2001).
Pharmacokinetics
In eight healthy adult men, Alittle or no@
gastrointestinal absorption and subsequent
uptake in the bloodstream was found from
oral administration of SP-303 in delayed-release
tablets (1250 mg oral single-dose and
500 mg four times per day for 8 days) (Carlson
et al., 2000, citing Carlson and Khandwala
‘). Another study in 6 healthy men found
that SP-303 was not absorbed into the bloodstream,
and in children and in infants 3
months of age or older, SP-303 was also not
absorbed into the bloodstream (Carlson and
King, 2000, citing Connor et al.,&).
DOSAGE
The traditional internal dosage of the sap in
Ecuador and Peru is generally 5B10 drops, once
to twice per day for 5 days. Often the treatment
is repeated for as long as 3 weeks. The sap is
taken in water (cold or warm), milk, or alcohol
(Ubillas et al., 1994).
The proprietary product SB-300, NSF/Normal
Stool FormulaJ is used to promote normal
stool formation and for relief from occasional
diarrhea. It can be taken for both acute
and chronic forms of diarrhea of various origins.
Each 350-mg tablet is standardized to contain
250 mg or 67% by weight of the oligomeric
procyanidin preparation SP-303. At minimum,
40% of the remaining constituents are composed
of unidentified polyphenolic compounds,
some of which may also possess antidiarrheal
(antisecretory) activity. SB-300 is
taken at the suggested daily dosage of 350B700
mg, twice per day to four times per day. However,
subjects with irritable bowel syndrome or
HIV-associated diarrhea may require longterm
use of the formulation (Carlson and King,
2000).
SAFETY PROFILE
Contraindications
Contraindications for SB-300 (NSF/Normal
Stool FormulaJ) are as yet undetermined and
none were found in 10 patients diagnosed with
diarrhea and HIV (Carlson and King, 2000, citing
Koch et al., 2000). In a placebo-controlled
trial, absorption of lamivudine, nelfinavir or zidovudine
(single doses) was not affected by SP-
303 at a dosage of 500 mg four times per day
REVIEW OF SANGRE DE DRAGO 891
‘Carlson T, Khandwala A. Investigator=s Brochure for
SB-300. South San Francisco, CA: Shaman Pharmaceuticals,
May 24, 1999, unpublished.
&Conner JD, Rodriguez W, Englund J. Evaluation of
Provir (SP-303) for use in infants and children. South San
Francisco, CA: Shaman Pharmaceuticals, 1995, unpublished.
(52,000 mg/d) (Carlson and King, 2000, citing
Porter et al.uu).
Drug interactions
No drug interactions from either the latex or
SP-303 have been reported. In a placebo-controlled
study of SP-303 in HIV-positive patients,
the absorption of anti-HIV agents
(lamivudine, nelfinavir, or zidovudine) was
not affected by the compound when taken at a
dosage of 500 mg four times per day for a total
daily dose of 2000 mg. SP-303 was well-tolerated
(Carlson and King, 2000 citing Porter et
al.uu).
Pregnancy and lactation
No studies were found on the safety of sangre
de drago (C. lechleri and C. palanostigma) or
extracts thereof in pregnant or lactating people
or animals.
Side-effects
No reports of side effects from internal use
of the sap in traditional medicine were found
(Ubillas et al., 1994).
Special precautions
Some members of the Euphoriaceae family
contain tumor-promoting diterpene (phorbol)
esters (Blumberg, 1988); however, these are not
found in detectable quantities in the sap of sangre
de drago (C. lechleri, C. palanostigma [5 C. draconoides],
and C. erythrochilus) (Vlietinck et al.,
1995).
Toxicology in vitro
In Chinese hamster V-79 lung fibroblasts, the
alkaloid constituent taspine (IC50 0.17 mg/mL)
showed potent growth-inhibiting/cytotoxic activity.
The sap itself, obtained from Peruvian C.
palanostigma, also showed activity against the
growth of V-79 cells (IC50 3.7 mg/mL). In the
KB (human oral epidermoid carcinoma) cell assay,
potent cytotoxic activity was also found
from taspine (IC50 0.39 mg/mL) (Itokwa et al.,
1991). Cytotoxicity against KB cells was absent
in tests of crude sap collected from C. lechleri
growing in Ecuador (IC50 900 mg/mL). The
dried sap (IC50 187 mg/mL), various
solvent extracts of the sap, and the major
constituents of the sap (procyanidins and
flavonols) also showed no evidence of cytotoxicity
in this assay. This sap contained only
traces of taspine (Chen et al., 1994).
Given the cytotoxicity of taspine, the authors
of the latter study have recommended that sangre
de drago saps containing a high content of the
alkaloid not be used for wound-healing or for internal
use (Chen et al., 1994). Evidence from in
vitro tests indicates that the precaution is prudent;
however, it remains for in vivo studies to
determine whether the toxicity of taspine is ameliorated
by other constituents in the sap and by
how much. According to the manufacturing
specification for the dietary supplement NSF
(Normal Stool FormulaJ) and NSF-IB (Normal
Stool Formula-Ion Balanced), the level of taspine
is not to exceed the limit of 5000 ppm) (S.R. King,
written communication, November 13, 2001).
Mutagenicity
The raw latex obtained from C. lechleri
growing in Ecuador showed no mutagenicity
in the Ames test, with or without S9 activation
(Rossi et al., 2003). SP-303 also showed no
mutagenic activity in the Ames test and in
Chinese hamster ovary (CHO) cells failed to
induce chromosomal aberrations (with or
without metabolic activation). Negative results
were found in the rat bone marrow micronucleus
test (Carlson and King, 2000, citing
Carlson and Khandwala’).
Toxicity in animal models
In a long-term study (17 months), topical application
of the sap derived from C. lechleri in
the two-stage mouse skin carcinogenesis sys-
JONES 892
uuPorter SB, Santos O, Charney MR, Pennington J. A
phase I, randomized, double-blind, placebo-controlled interaction
study to evaluate the effect of multiple doses of
SP-303 or placebo on the pharmacokinetics of the antiviral
drugs zidovudine, lamivudine, and nelfinavir in
healthy subjects. South San Francisco, CA: Shaman Pharmaceuticals,
May 8, 1998, unpublished.
‘Carlson T, Khandwala A. Investigator=s Brochure for
SB-300. South San Francisco, CA: Shaman Pharmaceuticals,
May 24, 1999, unpublished.
tem resulted in no carcinogenic effects. Taspine
was also devoid of carcinogenicity in this test
system (Vaisberg et al., 1989).
Toxicity studies of SP-303 in various species
of animals found no deaths from single oral
doses of up to 300 mg/kg. Neither were there
any changes in body weights or food consumption
and no clinical indications of toxicity
were evident upon examination. The acute oral
LD50 of SP-303 in the rat was determined to be
greater than 300 mg/kg. In repeated-dose toxicity
studies of SP-303, the no-observable-effect-
level (NOEL) in rats after 30 days of oral
administration was greater than 200 mg/kg per
day and less than 500 mg/kg per day. In monkeys,
the NOEL after 30 days oral administration
was greater than 30 mg/kg/day and less
than 100 mg/kg per day (Ubillas et al., 1994).
CONCLUSIONS
The results of in vitro and in vivo studies
largely support the majority of ethnomedical
uses of the sap. Pending the development of
clinically efficacious preparations, sangre de
drago has the potential of becoming a readily
sustainable medicinal resource of financial
benefit to the indigenous peoples of northwest
Amazonia and therapeutic benefit to the
world. Acknowledgement of the diversity in
the chemical makeup of the sap from one geographic
area to another and the recently proposed
alkaloid chemotypes of C. lechleri will
require that materials being developed for
clinical use are consistent after standardization
to a chemical profile providing known
quantities of one of more active constituents.
Phytochemical investigations clearly indicate
that the standardization process will involve
sourcing and standardized processing of consistent
plant material. Recent clinical studies
of products prepared from the sap in treatments
of diarrhea and symptoms of insect
bites have shown positive results that are
likely to lead to further research. The painand
itch-relieving activity of the sap may lead
to the development of a substitute for capsaicin,
the topical use of which is limited because
of its characteristic burning sensation.
Clinical research on the topical use of SP-303
against genital and anal herpes lesions in HIVpositive
patients yielded results of borderline
significance, either because of the small number
of patients enrolled, poor solubility of the
preparation used, significant differences in the
CD41 cell counts of the subjects, or a combination
of factors. The need for less costly treatments
of these infections, combined with the
unresolved clinical efficacy of SP-303 against
herpes, may entice larger, better controlled
studies utilizing preparations with greater absorbability.
Although the relative toxicity of
the content of taspine in sangre de drago requires
some additional evaluation, the sap has
shown low toxicity and preparations used in
clinical studies were well-tolerated. Larger trials
involving oral and topical preparations of
sangre de drago are warranted.
The author and many of the researchers
whose studies are cited herein are grateful to
the peoples of the northwest Amazon basin for
sharing their intellectual and medical achievements
and the teachings of their healers on sangre
de drago along with numerous other South
American medicinal plants.
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