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GINSENG

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Ginseng is derived from the root of several species of the Panax genus of plants. Ginseng contains complex mixtures of saponins called ginsenosides or panaxosides.

Specific Substances

    1) Ginseng Radix
    2) Ninjin
    3) Panax
    4) Pannag
    5) Panax ginseng C A Meyer (Korean ginseng)
    6) Panax japonicus (Japanese ginseng)
    7) Pfaffia paniculata (Brazil ginseng)
    8) Panax pseudo ginseng benth (Indian ginseng)
    9) Panax quinquefolium (American ginseng)
    10) Panax notoginseng
    11) Panax schinseng
    12) Rumex hymenosepalus (desert ginseng)

Available Forms Sources

    A) FORMS
    1) Ginseng is available as powders, liquid extract, creams, vaginal douches, tablets, and capsules.
    2) Chinese, Korean, or red ginseng (Panax ginseng), American ginseng (Panax quinquefolium), and Russian or Siberian ginseng (Eleutherococcus senticosus) are marketed as herbal remedies (Engelberg et al, 2001).
    B) SOURCES
    1) Ginseng is derived from the root of several species of the Panax genus of plants.
    C) USES
    1) Ginseng is reported to enhance the natural resistance and recuperative power of the body and to reduce fatigue (Sweetman, 2000).
    2) Brazil ginseng has been used as a tonic aphrodisiac and for antidiabetic purposes as a folk medicine (Subiza et al, 1991).
    3) Chinese ginseng purportedly acts on the central nervous and cardiovascular systems and endocrine glands to promote the immune function, eliminate stress, and delay the aging process (Dega et al, 1996).
    4) Ginseng extract douche has been used to treat vaginal yeast infections (Hoffman et al, 2001).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Ginseng, an herbal product, reportedly provides energy and reduces fatigue. It is available in powders, liquid extract, creams vaginal douches, tablets and capsules. Brazil ginseng has been used as both a tonic aphrodisiac and for antidiabetic purposes as a folk medicine. Chinese ginseng purportedly acts on the CNS and cardiovascular systems and endocrine glands to promote immune function, eliminate stress, and delay the aging process. Ginseng extract douche is used to treat vaginal yeast infections.
    B) PHARMACOLOGY: Ginseng is derived from the root of several species of the Panax genus of plants. Ginseng contains complex mixtures of saponins called ginsenosides or panaxosides. A specific pharmacologic mechanism of action is unknown, but it is believed that one or more these ginsenosides are responsible for ginseng's reported tonic, stimulant, and aphrodisiac properties. It is believed to be an "adaptogen" because it helps the body adapt to stress and correct adrenal and thyroid dysfunction.
    C) EPIDEMIOLOGY: Exposure has occurred and is usually associated with long term use with only mild to moderate events reported. Severe toxicity following exposure is rare.
    D) WITH THERAPEUTIC USE
    1) ACUTE EFFECTS: COMMON: The most common adverse events reported with short-term Panax ginseng use include dyspepsia, hot flash, insomnia and constipation. OTHER: Headache, dizziness, nausea, abdomina pain, diarrhea, epistaxis, low energy and skin disorders have also developed with short-term therapy. All of these events were infrequent. RARE: Cerebral arteritis has been reported following a large acute ingestion of ginseng extract. Stevens-Johnson Syndrome occurred in an adult after taking ginseng for several days; recovery was uneventful.
    2) CHRONIC TOXICITY: Chronic administration of ginseng has been associated with hypertension, diarrhea, insomnia, vaginal bleeding (a case of life-threatening hemorrhage has occurred), mastalgia, mental status changes (ie, CNS stimulation, mania) and fixed drug eruption. Hypotension has been reported as a rare occurrence following long-term administration of ginseng.
    3) GINSENG ABUSE SYNDROME has been reported following long-term ingestion of ginseng and may include the development of hypertension, nervousness, insomnia, skin eruptions, and morning diarrhea.
    E) WITH POISONING/EXPOSURE
    1) OVERDOSE: There is very little overdose information in humans. Overdose events are anticipated to be an extension of adverse events.
    0.2.3) VITAL SIGNS
    A) Alterations in blood pressure have been reported. Hypertension has occurred as part of the Ginseng Abuse Syndrome following chronic oral administration of ginseng.
    0.2.20) REPRODUCTIVE
    A) Hirsutism and rapid weight gain, have been reported in a male neonate following maternal ingestion of ginseng throughout pregnancy and early lactation.

Laboratory Monitoring

    A) Routine laboratory studies are not needed unless otherwise clinically indicated.
    B) Monitor fluid and electrolyte levels as indicated in patients with severe diarrhea.
    C) Monitor blood pressure for possible hypertension (more likely to occur) or hypotension.
    D) Vaginal bleeding has been reported after long term use as a vaginal douche. If severe vaginal bleeding occurs, obtain a pregnancy test, monitor patient's hematocrit, hemoglobin, partial thromboplastin time, INR, and platelet count.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive; severe toxicity is not anticipated in most cases. Monitor vital signs and mental status. Hypertension has been reported following long-term use. Monitor blood pressure routinely. For mild/moderate asymptomatic hypertension (no end organ damage), pharmacologic treatment is generally not necessary.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. Monitor vital signs and mental status. HYPERTENSION: For moderate to severe symptoms, sedation with benzodiazepines may be helpful in agitated patients with hypertension and tachycardia. For severe hypertension sodium nitroprusside is preferred. Labetalol, nitroglycerin, and phentolamine are alternatives. CNS EFFECTS: Chronic ingestion of ginseng has resulted in CNS stimulation, mania and excitation in some individuals. Monitor neurologic function frequently. Provide a reassuring, quiet environment. Two patients taking high doses of ginseng (15 to 20 g) daily were treated with a short course of antipsychotics (eg, risperidone) and manic psychosis symptoms completely resolved. BLEEDING RISK: There have been rare reports of vaginal bleeding with chronic use. Obtain a CBC and monitor for bleeding in patients on chronic therapy or at risk for increased bleeding. CEREBRAL ARTERITIS: There have been rare repots of cerebral arteritis following therapeutic use. Monitor neurologic function. Imaging studies may be indicated to evaluate symptoms.
    C) DECONTAMINATION
    1) PREHOSPITAL: Most cases of toxicity reported have involved chronic ingestion of ginseng. Gastrointestinal decontamination is generally not necessary after acute exposure.
    2) HOSPITAL: Gastrointestinal tract and toxicity is generally self-limited. Activated charcoal should only be considered following a large significant ingestion or following a potentially toxic coingestant.
    D) AIRWAY MANAGEMENT
    1) Airway management is unlikely to be necessary following mild or moderate exposure. Airway support may be indicated in patients that develop significant CNS symptoms.
    E) ANTIDOTE
    1) There is no known antidote.
    F) ENHANCED ELIMINATION
    1) There is no available information. Hemodialysis in unlikely to be necessary.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: Asymptomatic children with a minor ingestion (1 tablet or capsule) can be monitored at home with adult supervision.
    2) OBSERVATION CRITERIA: Children with persistent minor symptoms (ie, diarrhea, abdominal pain) or alterations in CNS function (adult or child) need to be evaluated in a healthcare setting.
    3) ADMISSION CRITERIA: Patients should be admitted, if symptoms persist or fail to respond to therapy (ie, ongoing CNS effects).
    4) CONSULT CRITERIA: Consult a toxicologist or poison center if the diagnosis is unclear.

Range Of Toxicity

    A) TOXIC DOSE: A toxic dose has not been established. ADULT: Depression was reported following doses of ginseng of greater than 15 mg. Cerebral arteritis was associated with the ingestion of approximately 25 g dry weight ginseng root; the patient recovered following discontinuation of ginseng. Vaginal bleeding occurred following the ingestion of 200 mg. Two patients taking high doses of ginseng (15 to 20 g) daily developed manic psychosis symptoms.
    B) THERAPEUTIC DOSE: ADULT: GINSENG ROOT: Recommended daily dose is usually 0.5 to 2 g. Doses of 2 to 3 g are recommended to achieve behavioral stimulation.

Clinical Effects

Summary Of Exposure

    A) USES: Ginseng, an herbal product, reportedly provides energy and reduces fatigue. It is available in powders, liquid extract, creams vaginal douches, tablets and capsules. Brazil ginseng has been used as both a tonic aphrodisiac and for antidiabetic purposes as a folk medicine. Chinese ginseng purportedly acts on the CNS and cardiovascular systems and endocrine glands to promote immune function, eliminate stress, and delay the aging process. Ginseng extract douche is used to treat vaginal yeast infections.
    B) PHARMACOLOGY: Ginseng is derived from the root of several species of the Panax genus of plants. Ginseng contains complex mixtures of saponins called ginsenosides or panaxosides. A specific pharmacologic mechanism of action is unknown, but it is believed that one or more these ginsenosides are responsible for ginseng's reported tonic, stimulant, and aphrodisiac properties. It is believed to be an "adaptogen" because it helps the body adapt to stress and correct adrenal and thyroid dysfunction.
    C) EPIDEMIOLOGY: Exposure has occurred and is usually associated with long term use with only mild to moderate events reported. Severe toxicity following exposure is rare.
    D) WITH THERAPEUTIC USE
    1) ACUTE EFFECTS: COMMON: The most common adverse events reported with short-term Panax ginseng use include dyspepsia, hot flash, insomnia and constipation. OTHER: Headache, dizziness, nausea, abdomina pain, diarrhea, epistaxis, low energy and skin disorders have also developed with short-term therapy. All of these events were infrequent. RARE: Cerebral arteritis has been reported following a large acute ingestion of ginseng extract. Stevens-Johnson Syndrome occurred in an adult after taking ginseng for several days; recovery was uneventful.
    2) CHRONIC TOXICITY: Chronic administration of ginseng has been associated with hypertension, diarrhea, insomnia, vaginal bleeding (a case of life-threatening hemorrhage has occurred), mastalgia, mental status changes (ie, CNS stimulation, mania) and fixed drug eruption. Hypotension has been reported as a rare occurrence following long-term administration of ginseng.
    3) GINSENG ABUSE SYNDROME has been reported following long-term ingestion of ginseng and may include the development of hypertension, nervousness, insomnia, skin eruptions, and morning diarrhea.
    E) WITH POISONING/EXPOSURE
    1) OVERDOSE: There is very little overdose information in humans. Overdose events are anticipated to be an extension of adverse events.

Vital Signs

    3.3.1) SUMMARY
    A) Alterations in blood pressure have been reported. Hypertension has occurred as part of the Ginseng Abuse Syndrome following chronic oral administration of ginseng.
    3.3.4) BLOOD PRESSURE
    A) Chronic ingestion of ginseng has been associated with the development of hypertension and has been referred to as a component of the Ginseng Abuse Syndrome (Siegel, 1979; Hammond & Whitworth, 1981).
    B) CHRONIC USE: Hypotension, a less common occurrence, has been reported in 5 of 133 patients (4%) involved in a 2-year study of long-term ginseng users (Siegel, 1979).

Heent

    3.4.5) NOSE
    A) WITH THERAPEUTIC USE
    1) Epistaxis has been reported infrequently with short-term Panax ginseng use (Lee et al, 2012).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HYPERTENSIVE EPISODE
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE
    1) Hypertension has been reported following long-term ingestion of ginseng and is usually referred to as a component of Ginseng Abuse Syndrome (Siegel, 1979; Siegel, 1980).
    2) Hypertension was reported in 22 of 133 (17%) patients involved in a 2-year study of long term ginseng users (Siegel, 1979).
    3) CASE REPORT: A 39-year-old man presented with hypertension (140/100 mmHg) that gradually became more severe (154/106 mmHg). The patient had been taking various ginseng preparations for 3 years. The ginseng was discontinued and the patient became normotensive (140/85 mmHg) five days later (Hammond & Whitworth, 1981).
    4) CASE REPORT: A 63-year-old man with membranous glomerulonephritis developed edema and worsening hypertension ten days after ingesting 10 to 12 tablets per day of a germanium-containing ginseng preparation. The patient's edema and hypertension resolved following supportive care and discontinuation of the ginseng preparation. Upon rechallenge with the germanium-containing ginseng preparation, the patient's hypertension and edema returned. After discontinuation of the ginseng preparation and the initiation of intravenous furosemide, the patient's hypertension and edema again resolved (Becker et al, 1996).
    B) HYPOTENSIVE EPISODE
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Hypotension, a less common occurrence, was reported in 5 of 133 patients (4%) involved in a 2-year study of long-term ginseng users (Siegel, 1979).
    C) EDEMA
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Edema was reported in 14 of 133 (10%) patients involved in a two-year study to determine the effects of ginseng following long-term use (Siegel, 1979).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) BRONCHOSPASM
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 37-year-old woman developed symptoms of coughing, wheezing, sneezing, and shortness of breath following occupational exposure to Brazil ginseng-root dust. Skin tests showed a positive reaction to Brazil ginseng extract, indicating an allergic reaction to the ginseng (Subiza et al, 1991).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) ARTERITIS
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 28-year-old woman developed a severe headache six days after ingesting approximately 200 ml of ginseng extract (approximately 25 grams dry weight of ginseng root) to overcome physical fatigue. Cerebral angiograms showed multiple areas of constriction and dilatation of the cerebral arteries, indicating cerebral arteritis. The patient's headache gradually disappeared over several days (Ryu & Chien, 1995).
    B) FEELING NERVOUS
    1) WITH THERAPEUTIC USE
    a) Nervousness has been reported in 25 of 133 (19%) long-term ginseng users during a 2-year period and is referred to as a component of the Ginseng Abuse Syndrome (Siegel, 1979).
    C) INSOMNIA
    1) WITH THERAPEUTIC USE
    a) A randomized, double-blind, placebo controlled, and parallel group trial was conducted in healthy volunteers who received ginseng extract 500 mg twice a day, 1000 mg twice a day or placebo for 4 weeks. The most common adverse events reported were dyspepsia, hot flash, insomnia, and constipation. The difference among each of the 3 treatment arms reporting adverse events were similar and nonsignificant (p=0.895). No serious events were reported in any subject (Lee et al, 2012).
    b) CHRONIC USE
    1) Long-term ginseng users, during a two-year study, reported the occurrence of insomnia in 26 of 133 (20%) patients. Insomnia has been referred to as a component of the Ginseng Abuse Syndrome (Siegel, 1979).
    2) Insomnia has been reported following the concurrent ingestion of phenelzine with ginseng (Shader & Greenblatt, 1985; Jones & Runikis, 1987).
    3) Insomnia was reported as an adverse effect following long-term administration of ginseng (Chen, 1981). The patients recovered after discontinuation of the ginseng.
    D) CENTRAL STIMULANT ADVERSE REACTION
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: During a two-year study to determine the effects of ginseng following long- term use, all patients (n=133) experienced CNS stimulation and 18 patients (14%) experienced euphoria (Siegel, 1979).
    b) Excitation was reported as an adverse effect following long-term administration of ginseng (Chen, 1981). The patients gradually recovered after discontinuation of the ginseng.
    E) DIZZINESS
    1) WITH THERAPEUTIC USE
    a) CASE REPORT/CHRONIC USE: Dizziness and the inability to concentrate were reported in a 39-year-old man following chronic ingestion of various ginseng preparations over 3 years. The dizziness resolved after discontinuation of the ginseng (Hammond & Whitworth, 1981).
    b) Dizziness has been reported infrequently with short-term Panax ginseng use (Lee et al, 2012).
    F) HEADACHE
    1) WITH THERAPEUTIC USE
    a) Headaches have been reported following the concurrent ingestion of phenelzine with ginseng (Shader & Greenblatt, 1985; Jones & Runikis, 1987).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) DIARRHEA
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Morning diarrhea occurred in 47 of 133 (35%) patients, involved in a 2-year study to determine the effects of ginseng following long-term ingestion, with the average ginseng dose being 3 grams daily. Morning diarrhea is also referred to as a component of the Ginseng Abuse Syndrome (Siegel, 1979; Chen, 1981).
    b) Diarrhea has been reported infrequently with short-term Panax ginseng use (Lee et al, 2012).
    B) CONSTIPATION
    1) WITH THERAPEUTIC USE
    a) A randomized, double-blind, placebo controlled, and parallel group trial was conducted in healthy volunteers who received Panax ginseng extract 500 mg twice a day, 1000 mg twice a day or placebo for 4 weeks. The most common adverse events reported were dyspepsia, hot flash, insomnia, and constipation. The difference among each of the 3 treatment arms reporting adverse events were similar and nonsignificant (p=0.895). No serious events were reported in any subject (Lee et al, 2012).
    C) INDIGESTION
    1) WITH THERAPEUTIC USE
    a) A randomized, double-blind, placebo controlled, and parallel group trial was conducted in healthy volunteers who received Panax ginseng extract 500 mg twice a day, 1000 mg twice a day or placebo for 4 weeks. The most common adverse events reported were dyspepsia, hot flash, insomnia, and constipation. The difference among each of the 3 treatment arms reporting adverse events were similar and nonsignificant (p=0.895). No serious events were reported in any subject (Lee et al, 2012).
    D) ABDOMINAL PAIN
    1) WITH THERAPEUTIC USE
    a) Abdominal pain and nausea have been reported infrequently with short-term Panax ginseng use (Lee et al, 2012).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) FINDING OF VAGINAL BLEEDING
    1) WITH THERAPEUTIC USE
    a) CASE REPORT (ORAL): A 72-year-old woman experienced vaginal bleeding after ingesting 1 tablet daily of a formula containing 200 mg ginseng (Greenspan, 1983).
    b) CASE REPORT (TOPICAL): A 44-year-old woman experienced abnormal vaginal bleeding after using a topical face cream containing ginseng. After the patient's second episode of vaginal bleeding, her FSH level was measured at 36 mIU. One month after discontinuation of the face cream, the patient's FSH level was 70 mIU. Three weeks after using the face cream daily, her FSH level was 27 mIU and the patient experienced an episode of uterine bleeding. The face cream again was discontinued and the patient's FSH level rose to 68 mIU (Hopkins et al, 1988).
    c) CASE REPORT (VAGINAL DOUCHE): A 38-year-old woman experienced a life-threatening vaginal hemorrhage (hemoglobin 7.5 g/dL) following the use of Chinese ginseng extract douche for 6 months (used every 3 days). She also developed hypotension (80/40 mmHg). After she was treated with 2 L of crystalloid and 500 mL of packed red blood cells, she was discharged the next day (Hoffman et al, 2001).
    B) BLEEDING BETWEEN PERIODS
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: Metrorrhagia developed in a 48-year-old woman after ingesting a dietary supplement, 3 capsules daily for 2 months, containing multivitamins, minerals, and standardized ginseng extract equivalent to 120 mg/day. Four days after discontinuing administration of the dietary supplement, the patient's metrorrhagia disappeared with no further complications (Palop-Larrea et al, 2000).
    C) AMENORRHEA
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Amenorrhea was reported in 4 of 133 (3%) patients involved in a 2-year study of long-term ginseng users (Siegel, 1979)
    D) EDEMA
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 63-year-old man with membranous glomerulonephritis developed edema several days after ingestion of 10 to 12 tablets daily of a germanium-containing ginseng preparation. The edema resolved following initiation of IV furosemide and discontinuation of the ginseng preparation. Upon rechallenge with the ginseng preparation, the edema returned. Initiation of intravenous furosemide and discontinuation of the ginseng preparation caused the edema to again resolve (Becker et al, 1996).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) FLUSHING
    1) WITH THERAPEUTIC USE
    a) A randomized, double-blind, placebo controlled, and parallel group trial was conducted in healthy volunteers who received Panax ginseng extract 500 mg twice a day, 1000 mg twice a day or placebo for 4 weeks. The most common adverse events reported were dyspepsia, hot flash, insomnia and constipation. The difference among each of the 3 treatment arms reporting adverse events were similar and nonsignificant (p=0.895). No serious events were reported in any subject (Lee et al, 2012).
    B) FIXED DRUG ERUPTION
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Skin eruptions were reported in 33 of 133 patients involved in a two-year study to determine the effects of ginseng following long-term use. Skin eruptions have also been classified as a component of the Ginseng Abuse Syndrome (Siegel, 1979).
    b) Skin disorders have been reported infrequently with short-term Panax ginseng use (Lee et al, 2012).
    C) STEVENS-JOHNSON SYNDROME
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 27-year-old man developed Stevens-Johnson syndrome 3 days after ingesting ginseng, 2 tablets per day for 3 days. The patient recovered completely within 30 days (Dega et al, 1996).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) CELL-MEDIATED IMMUNE REACTION
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 37-year-old woman developed sneezing, wheezing, coughing, and shortness of breath after occupational exposure to Brazil ginseng-root dust. Skin tests showed a positive reaction to ginseng extract, indicating an allergic reaction to the ginseng. Cross-sensitivity tests with Korean ginseng extract were negative (Subiza et al, 1991).

Reproductive

    3.20.1) SUMMARY
    A) Hirsutism and rapid weight gain, have been reported in a male neonate following maternal ingestion of ginseng throughout pregnancy and early lactation.
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) BREAST MILK
    1) Androgenic effects, including hirsutism and rapid weight gain, have been reported in a male neonate following maternal ingestion of ginseng throughout pregnancy and early lactation (Koren et al, 1990).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Routine laboratory studies are not needed unless otherwise clinically indicated.
    B) Monitor fluid and electrolyte levels as indicated in patients with severe diarrhea.
    C) Monitor blood pressure for possible hypertension (more likely to occur) or hypotension.
    D) Vaginal bleeding has been reported after long term use as a vaginal douche. If severe vaginal bleeding occurs, obtain a pregnancy test, monitor patient's hematocrit, hemoglobin, partial thromboplastin time, INR, and platelet count.

Methods

    A) CHROMATOGRAPHY
    1) Capillary supercritical fluid chromatography (SFC) was used to determine the existence of two components of ginseng, panaxadiol and panaxatriol. This seems to be a more simple and rapid method than thin-layer chromatography (TLC) or gas chromatography(GC) that have previously been used (Li et al, 1992).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients should be admitted, if symptoms persist or fail to respond to therapy (ie, ongoing CNS effects).
    6.3.1.2) HOME CRITERIA/ORAL
    A) Asymptomatic children with a minor ingestion (1 tablet or capsule) can be monitored at home with adult supervision.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a toxicologist or poison center if the diagnosis is unclear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Children with persistent minor symptoms (ie, diarrhea, abdominal pain) or alterations in CNS function (adult or child) need to be evaluated in a healthcare setting.

Monitoring

    A) Routine laboratory studies are not needed unless otherwise clinically indicated.
    B) Monitor fluid and electrolyte levels as indicated in patients with severe diarrhea.
    C) Monitor blood pressure for possible hypertension (more likely to occur) or hypotension.
    D) Vaginal bleeding has been reported after long term use as a vaginal douche. If severe vaginal bleeding occurs, obtain a pregnancy test, monitor patient's hematocrit, hemoglobin, partial thromboplastin time, INR, and platelet count.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Most cases of toxicity reported have involved chronic ingestion of ginseng. Gastrointestinal decontamination is generally not necessary after acute exposure.
    6.5.2) PREVENTION OF ABSORPTION
    A) SUMMARY
    1) Most cases of toxicity reported have involved chronic ingestion of ginseng. Gastrointestinal decontamination is generally not necessary after acute exposure.
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) SUPPORT
    1) MANAGEMENT OF MILD TO MODERATE TOXICITY
    a) Treatment is symptomatic and supportive; severe toxicity is not anticipated in most cases. Monitor vital signs and mental status. Hypertension has been reported following long-term use. Monitor blood pressure routinely. For mild/moderate asymptomatic hypertension (no end organ damage), pharmacologic treatment is generally not necessary.
    2) MANAGEMENT OF SEVERE TOXICITY
    a) Treatment is symptomatic and supportive. Monitor vital signs and mental status. HYPERTENSION: For moderate to severe symptoms, sedation with benzodiazepines may be helpful in agitated patients with hypertension and tachycardia. For severe hypertension sodium nitroprusside is preferred. Labetalol, nitroglycerin, and phentolamine are alternatives. CNS EFFECTS: Chronic ingestion of ginseng has resulted in CNS stimulation, mania and excitation in some individuals. Monitor neurologic function frequently. Provide a reassuring, quiet environment. Two patients taking high doses of ginseng (15 to 20 g) daily were treated with a short course of antipsychotics (eg, risperidone) and manic psychosis symptoms completely resolved (Norelli & Xu, 2014). BLEEDING RISK: There have been rare reports of bleeding, including vaginal bleeding with chronic use. Obtain a CBC and monitor for bleeding in patients on chronic therapy or at risk for increased bleeding. CEREBRAL ARTERITIS: There have been rare repots of cerebral arteritis following therapeutic use. Monitor neurologic function. Imaging studies may be indicated to evaluate symptoms.
    B) MONITORING OF PATIENT
    1) Routine laboratory studies are not needed unless otherwise clinically indicated.
    2) Monitor blood pressure for possible hypertension (more likely to occur) or hypotension.
    3) Monitor fluid and electrolyte levels as indicated in patients with severe diarrhea.
    4) Vaginal bleeding has been reported after long term use as a vaginal douche. If severe vaginal bleeding occurs, obtain a pregnancy test, monitor patient's hematocrit, hemoglobin, partial thromboplastin time, INR, and platelet count
    C) HYPERTENSIVE EPISODE
    1) Monitor vital signs regularly. For mild/moderate hypertension without evidence of end organ damage, pharmacologic intervention is generally not necessary. Sedative agents such as benzodiazepines may be helpful in treating hypertension and tachycardia in agitated patients, especially if a sympathomimetic agent is involved in the poisoning.
    2) For hypertensive emergencies (severe hypertension with evidence of end organ injury (CNS, cardiac, renal), or emergent need to lower mean arterial pressure 20% to 25% within one hour), sodium nitroprusside is preferred. Nitroglycerin and phentolamine are possible alternatives.
    3) SODIUM NITROPRUSSIDE/INDICATIONS
    a) Useful for emergent treatment of severe hypertension secondary to poisonings. Sodium nitroprusside has a rapid onset of action, a short duration of action and a half-life of about 2 minutes (Prod Info NITROPRESS(R) injection for IV infusion, 2007) that can allow accurate titration of blood pressure, as the hypertensive effects of drug overdoses are often short lived.
    4) SODIUM NITROPRUSSIDE/DOSE
    a) ADULT: Begin intravenous infusion at 0.1 microgram/kilogram/minute and titrate to desired effect; up to 10 micrograms/kilogram/minute may be required (American Heart Association, 2005). Frequent hemodynamic monitoring and administration by an infusion pump that ensures a precise flow rate is mandatory (Prod Info NITROPRESS(R) injection for IV infusion, 2007). PEDIATRIC: Initial: 0.5 to 1 microgram/kilogram/minute; titrate to effect up to 8 micrograms/kilogram/minute (Kleinman et al, 2010).
    5) SODIUM NITROPRUSSIDE/SOLUTION PREPARATION
    a) The reconstituted 50 mg solution must be further diluted in 250 to 1000 mL D5W to desired concentration (recommended 50 to 200 mcg/mL) (Prod Info NITROPRESS(R) injection, 2004). Prepare fresh every 24 hours; wrap in aluminum foil. Discard discolored solution (Prod Info NITROPRESS(R) injection for IV infusion, 2007).
    6) SODIUM NITROPRUSSIDE/MAJOR ADVERSE REACTIONS
    a) Severe hypotension; headaches, nausea, vomiting, abdominal cramps; thiocyanate or cyanide toxicity (generally from prolonged, high dose infusion); methemoglobinemia; lactic acidosis; chest pain or dysrhythmias (high doses) (Prod Info NITROPRESS(R) injection for IV infusion, 2007). The addition of 1 gram of sodium thiosulfate to each 100 milligrams of sodium nitroprusside for infusion may help to prevent cyanide toxicity in patients receiving prolonged or high dose infusions (Prod Info NITROPRESS(R) injection for IV infusion, 2007).
    7) SODIUM NITROPRUSSIDE/MONITORING PARAMETERS
    a) Monitor blood pressure every 30 to 60 seconds at onset of infusion; once stabilized, monitor every 5 minutes. Continuous blood pressure monitoring with an intra-arterial catheter is advised (Prod Info NITROPRESS(R) injection for IV infusion, 2007).
    8) NITROGLYCERIN/INDICATIONS
    a) May be used to control hypertension, and is particularly useful in patients with acute coronary syndromes or acute pulmonary edema (Rhoney & Peacock, 2009).
    9) NITROGLYCERIN/ADULT DOSE
    a) Begin infusion at 10 to 20 mcg/min and increase by 5 or 10 mcg/min every 5 to 10 minutes until the desired hemodynamic response is achieved (American Heart Association, 2005). Maximum rate 200 mcg/min (Rhoney & Peacock, 2009).
    10) NITROGLYCERIN/PEDIATRIC DOSE
    a) Usual Dose: 29 days or Older: 1 to 5 mcg/kg/min continuous IV infusion. Maximum 60 mcg/kg/min (Laitinen et al, 1997; Nam et al, 1989; Rasch & Lancaster, 1987; Ilbawi et al, 1985; Friedman & George, 1985).

Enhanced Elimination

    A) SUMMARY
    1) There is no available information. Hemodialysis in unlikely to be necessary.

Range Of Toxicity

Summary

    A) TOXIC DOSE: A toxic dose has not been established. ADULT: Depression was reported following doses of ginseng of greater than 15 mg. Cerebral arteritis was associated with the ingestion of approximately 25 g dry weight ginseng root; the patient recovered following discontinuation of ginseng. Vaginal bleeding occurred following the ingestion of 200 mg. Two patients taking high doses of ginseng (15 to 20 g) daily developed manic psychosis symptoms.
    B) THERAPEUTIC DOSE: ADULT: GINSENG ROOT: Recommended daily dose is usually 0.5 to 2 g. Doses of 2 to 3 g are recommended to achieve behavioral stimulation.

Therapeutic Dose

    7.2.1) ADULT
    A) GENERAL
    1) The recommended daily dose for dry ginseng root is generally 0.5 to 2 grams (Ryu & Chien, 1995).
    2) Doses of 2 to 3 grams of ginseng are recommended to achieve behavioral stimulation (Siegel, 1979).

Minimum Lethal Exposure

    A) ANIMAL DATA
    1) MICE: In mice, the lethal oral dose of purified ginseng was higher than 5 mg/kg (the exact dose was not determined) (Lee et al, 2012).

Maximum Tolerated Exposure

    A) ADULT
    1) CASE REPORTS: Two patients taking high doses of ginseng (15 to 20 g) daily were treated with a short course of antipsychotics (eg, risperidone) and manic psychosis symptoms completely resolved (Norelli & Xu, 2014).
    2) Depression was reported following doses of ginseng greater than 15 g (Siegel, 1979).
    3) Vaginal bleeding was reported following ginseng ingestion of 200 mg (Greenspan, 1983).
    4) Ingestion of approximately 25 g dry weight of ginseng root was associated with the occurrence of cerebral arteritis. The patient recovered following discontinuation of the ginseng (Ryu & Chien, 1995).
    5) In a 2-year study of volunteers (n=133), 14 developed side effects (events were not described) associated with long-term use of ginseng at levels up to 15 g per day (Lee et al, 2012).
    B) ANIMAL DATA
    1) GINSENG ROOT: The root of Panax ginseng appears to be nontoxic to rats and dogs (Lee et al, 2012).

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) ANIMAL DATA
    1) LD50- (INTRAPERITONEAL)MOUSE:
    a) 54 mg/kg (RTECS, 2000)
    2) LD50- (ORAL)MOUSE:
    a) 200 mg/kg (RTECS, 2000)
    3) LD50- (ORAL)RAT:
    a) 750 mg/kg (RTECS, 2000)

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Ginseng is comprised of complex mixtures of saponins called ginsenosides or panaxosides. A specific pharmacologic mechanism of action is unknown, but it is believed that one or more of these ginsenosides are responsible for ginseng's purported tonic, stimulant, and aphrodisiac properties (Sweetman, 2000; (Gonzalez-Seijo et al, 1995).
    B) Ginseng is believed to be an "adaptogen" because it helps the body adapt to stress and corrects adrenal and thyroid dysfunction (Siegel, 1979).

References

General Bibliography

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