Contact Us    Contact Us     |     Feedback
MOBILE VIEW  | 

VALERIAN

Export To Excel

Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Valerian is comprised of the underground parts of Valeriana officinalis, an herbaceous perennial found in the temperate regions of North America, Europe, and Asia. Although the genus Valeriana consists of approximately 200 species, in medicine, valerian officinalis is intended whenever valerian is mentioned.

Specific Substances

    1) Baldrianwurzel
    2) Valer
    3) Valerian rhizome
    4) Valerian root
    5) Valerianae radix
    6) Valeriana officinalis
    7) Valeriana officianalis
    8) Garden heliotrope
    9) All heal
    10) Amantilla
    11) Setwall
    12) Theriacaria
    13) Herba benedicta
    14) CAS 8057-49-6 (valerian extract)

Available Forms Sources

    A) FORMS
    1) Valerian is available in the form of teas, tinctures, capsules, and tablets and may be found in combination products with skullcap, hops, passiflora, or hyoscine and cyproheptadine (Wagner et al, 1998) Yaniv et al, 1995; (Chan et al, 1995).
    B) USES
    1) Valerian is used as a sedative, hypnotic, and anticonvulsant (Willey et al, 1995; Heiligenstein & Guenther, 1998).
    2) The ancient greeks used valerian as an antiperspirant, an antidote for poisons, treatment for vaginal yeast infections, and for potions and warming ointments (Hobbs, 1989).
    3) In the 19th century, valerian was commonly used as an anxiolytic and for nervous afflictions in women, and during World War I, valerian was often used in the treatment of shell-shock (Willey et al, 1995).
    4) Valerian extracts and the root oil are used as food and beverage flavorings (DerMarderosian, 1991).

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) BACKGROUND: Valerian is comprised of the underground part of the Valeriana officinalis, an herbaceous perennial found in the temperate regions of North America, Europe, and Asia. There are approximately 200 species of valerian; however, valerian officinalis is often used. USES: Valerian is a dietary supplement used as a sedative, hypnotic, and anticonvulsant and is often used to treat sleep disorders and anxiety. It is available in the form of teas, tinctures, capsules, and tablets and may be found in combination with other products including skullcap, hops, lemon balm, passiflora, or hyoscine. During World War l, valerian was often used to treat soldiers that experienced post traumatic stress. Today, valerian extracts and the root oil can also be found in food and beverage flavorings.
    B) PHARMACOLOGY: Its postulated that valerian's sedative effects are caused by a combination of depression of specific centers of the CNS and by direct relaxation of smooth muscle and that the components responsible are the valepotriates, the essential oil components and unidentified water-soluble components.
    C) EPIDEMIOLOGY: Exposure can occur. Significant toxicity is unlikely to develop.
    D) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: In general, there are very few side effects reported with valerian use in the medical literature. Nausea, vomiting, and agitation have been reportedly infrequently and required no intervention.
    2) COMBINATION PRODUCTS: Hepatotoxicity has been associated with a combination product containing valerian and skullcap.
    3) CHRONIC INGESTION: Chronic use of valerian may cause headaches, excitability, uneasiness, and insomnia.
    4) WITHDRAWAL: Abrupt withdrawal of long-term valerian therapy may result in cardiac disturbances and delirium.
    E) WITH POISONING/EXPOSURE
    1) OVERDOSE: Limited data. Overdose is anticipated to be an extension of adverse events reported with therapeutic use. Fatigue, lightheadedness, mydriasis, chest tightness, crampy abdominal pain and tremors of the hands and feet were reported following intentional ingestion of valerian root. Chest pain, hypotension, mydriasis, electrolyte disturbances and drowsiness occurred after intentional intravenous administration of valerian root extract by a young adult; recovery occurred within 12 hours.
    0.2.20) REPRODUCTIVE
    A) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.

Laboratory Monitoring

    A) Monitor vital signs and mental status.
    B) Routine laboratory studies are not needed unless otherwise clinically indicated.
    C) Monitor liver enzymes as needed following a significant exposure or chronic use of valerian alone or in combination with other herbals.
    D) Obtain a baseline ECG and institute continuous cardiac monitoring in symptomatic patients.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive. Monitor vital signs and mental status; large doses may result in CNS depression. Evaluate for hypoxia in patients that develop significant CNS depression. For mild/moderate asymptomatic hypotension, pharmacologic treatment is generally not necessary. Initially treat hypotension with IV fluids.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Limited human data. Severe toxicity is not anticipated. Monitor vital signs and mental status. Obtain a baseline ECG and continuous cardiac monitoring following a significant exposure. There have been rare reports of chest pain and hypotension following exposure. Treat severe hypotension with IV 0.9% NaCl at 10 to 10 mL/kg. Add dopamine or norepinephrine if unresponsive to fluids.
    C) DECONTAMINATION
    1) PREHOSPITAL: GI decontamination is unlikely to be necessary following a minor ingestion due to a lack of toxicity. Activated charcoal may be considered, if a large potentially toxic dose has been ingested and the patient is alert, not vomiting, and able to maintain their airway.
    2) HOSPITAL: Activated charcoal may be indicated following a recent very large ingestion.
    D) AIRWAY MANAGEMENT
    1) Airway management is unlikely to be necessary following a minor exposure; airway support may be needed if a patient develops significant drowsiness, CNS depression or rarely cardiac instability.
    E) ANTIDOTE
    1) There is no known antidote.
    F) ENHANCED ELIMINATION
    1) It is unknown if hemodialysis would be of value following a valerian exposure.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: An asymptomatic child or a child with only mild drowsiness following a minor exposure (eg, one herbal supplement) can be managed at home with adult supervision. Adults with an inadvertent overdose and minor symptoms can be managed at home.
    2) OBSERVATION CRITERIA: Patients with persistent clinical effects (eg, drowsiness, somnolence) or more than mild toxicity should be referred to a healthcare facility. They may require supportive measures including monitoring and IV fluids.
    3) ADMISSION CRITERIA: Due to the minimal adverse effects reported with limited human exposures, it is unlikely that patients would require hospital admission following an exposure. Patients with evidence of significant neurologic toxicity (i.e. drowsiness, CNS depression) or cardiac conduction disturbances should be admitted.
    4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.

Range Of Toxicity

    A) TOXIC DOSE: A toxic dose has not been established. INGESTION: Valerian overdoses of up to 23.5 g resulted in NO serious toxic effects. INTRAVENOUS: Intentional intravenous administration of an unknown amount of valerian root extract produced hypotension, lethargy, substernal chest pain, abdominal pain and mydriasis in a young woman. She recovered completely within 12 hours following supportive care.
    B) THERAPEUTIC DOSE: VALERIAN EXTRACT: The recommended dose for insomnia is 400 to 450 mg of valerian extract administered within 30 minutes of bedtime; maximum duration of therapy is 2 weeks. VALERIAN ROOT: Oral doses of 200 mg to 12 g have been reportedly used to treat insomnia.

Clinical Effects

Summary Of Exposure

    A) BACKGROUND: Valerian is comprised of the underground part of the Valeriana officinalis, an herbaceous perennial found in the temperate regions of North America, Europe, and Asia. There are approximately 200 species of valerian; however, valerian officinalis is often used. USES: Valerian is a dietary supplement used as a sedative, hypnotic, and anticonvulsant and is often used to treat sleep disorders and anxiety. It is available in the form of teas, tinctures, capsules, and tablets and may be found in combination with other products including skullcap, hops, lemon balm, passiflora, or hyoscine. During World War l, valerian was often used to treat soldiers that experienced post traumatic stress. Today, valerian extracts and the root oil can also be found in food and beverage flavorings.
    B) PHARMACOLOGY: Its postulated that valerian's sedative effects are caused by a combination of depression of specific centers of the CNS and by direct relaxation of smooth muscle and that the components responsible are the valepotriates, the essential oil components and unidentified water-soluble components.
    C) EPIDEMIOLOGY: Exposure can occur. Significant toxicity is unlikely to develop.
    D) WITH THERAPEUTIC USE
    1) ADVERSE EFFECTS: In general, there are very few side effects reported with valerian use in the medical literature. Nausea, vomiting, and agitation have been reportedly infrequently and required no intervention.
    2) COMBINATION PRODUCTS: Hepatotoxicity has been associated with a combination product containing valerian and skullcap.
    3) CHRONIC INGESTION: Chronic use of valerian may cause headaches, excitability, uneasiness, and insomnia.
    4) WITHDRAWAL: Abrupt withdrawal of long-term valerian therapy may result in cardiac disturbances and delirium.
    E) WITH POISONING/EXPOSURE
    1) OVERDOSE: Limited data. Overdose is anticipated to be an extension of adverse events reported with therapeutic use. Fatigue, lightheadedness, mydriasis, chest tightness, crampy abdominal pain and tremors of the hands and feet were reported following intentional ingestion of valerian root. Chest pain, hypotension, mydriasis, electrolyte disturbances and drowsiness occurred after intentional intravenous administration of valerian root extract by a young adult; recovery occurred within 12 hours.

Heent

    3.4.3) EYES
    A) MYDRIASIS
    1) EXPOSURE: Mydriasis (6 mm bilaterally) was reported following an overdose ingestion of valerian capsules (total amount ingested 18.8 to 23.5 g) (Willey et al, 1995).
    2) EXPOSURE: Mydriasis occurred in a 25-year-old woman who injected an unknown amount of valerian root extract (Wells, 1995).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) CHEST PAIN
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: An 18-year-old woman complained of chest tightness 30 minutes after ingesting approximately 18.8 to 23.5 g of 100% powdered valerian root in a suicide attempt. Following activated charcoal administration, the patient recovered within 24 hours (Willey et al, 1995).
    b) CASE REPORT: A 25-year-old woman complained of substernal chest pain after intentional intravenous administration of an unknown amount of valerian root extract. Following supportive care, the patient recovered 12 hours later (Wells, 1995).
    B) HEART FAILURE
    1) WITH THERAPEUTIC USE
    a) CASE REPORT: A 58-year-old man developed sinus tachycardia, oliguria, and an increasing oxygen requirement after a lung biopsy. Administration of naloxone resulted in tremulousness, carbon dioxide retention, hypoxia, worsening tachycardia (150 bpm), and signs of delirium. Swan-Ganz catheterization revealed high-output cardiac failure (cardiac output of 7 L/min, pulmonary artery pressure 48/27 mmHg, and wedge pressure 30 mmHg). The patient's medical history included coronary artery disease, hypertension, congestive heart failure, and long-term administration of valerian root extract (530 mg to 2 g per dose) 5 times daily. Following benzodiazepine therapy, symptoms improved and the patient was discharged 7 days later. Because of the reversal of signs and symptoms following benzodiazepine therapy, it was speculated that abrupt valerian root withdrawal may have caused the cardiac complications and delirium (Garges et al, 1998).
    C) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 25-year-old woman presented to the ED with hypotension (60/40 mmHg) and lethargy after intentional intravenous administration of an unknown amount of valerian root extract. The patient's blood pressure returned to baseline approximately 12 hours later following supportive treatment (Wells, 1995).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) FATIGUE
    1) WITH POISONING/EXPOSURE
    a) Fatigue is likely to occur following overdose administration of valerian due to its normal sedative effects.
    b) CASE REPORT: Fatigue was reported in an 18-year-old woman following an intentional overdose ingestion of valerian root (Willey et al, 1995).
    c) CASE REPORT: A 25-year-old woman became drowsy but alert to voice after injecting an unknown amount of valerian root extract into her left antecubital vein. The patient recovered approximately 12 hours later (Wells, 1995).
    B) CENTRAL NERVOUS SYSTEM DEPRESSION
    1) WITH THERAPEUTIC USE
    a) Drowsiness is anticipated following the use of valerian, but sedation may also develop (Dennehy et al, 2005).
    C) DIZZINESS
    1) WITH POISONING/EXPOSURE
    a) Lightheadedness has been reported following an overdose ingestion of 100% powdered valerian root. The total amount ingested was approximately 18.8 to 23.5 g (Willey et al, 1995).
    D) HEADACHE
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Headaches may occur with chronic administration of valerian (Hobbs, 1989).
    E) TREMOR
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: An 18-year-old woman ingested approximately 18.8 to 23.5 g of powdered valerian root in a suicide attempt and, 30 minutes later, developed tremor of the hands and feet. The physical exam conducted upon presentation to the ED, 3 hours postingestion, showed evidence of a fine hand tremor. Symptoms resolved within 24 hours after activated charcoal administration (Willey et al, 1995).
    F) CENTRAL STIMULANT ADVERSE REACTION
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Excitability, uneasiness, and insomnia may occur following chronic ingestions of valerian (Hobbs, 1989). Agitation has also been reported following the use of valerian (Dennehy et al, 2005).
    G) DELIRIUM
    1) WITH THERAPEUTIC USE
    a) CHRONIC USE: Abrupt withdrawal of chronic valerian root extract therapy was associated with signs of delirium in a 58-year-old man. The delirium resolved following benzodiazepine administration (Garges et al, 1998).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) DIARRHEA
    1) WITH THERAPEUTIC USE
    a) Diarrhea has been reported with valerian use (Bent et al, 2006).
    B) ABDOMINAL PAIN
    1) CASE REPORT: An 18-year-old woman complained of crampy abdominal pain 30 minutes after an intentional overdose ingestion of powdered valerian root (Willey et al, 1995).
    2) CASE REPORT: A 25-year-old woman complained of abdominal pain following an intentional intravenous administration of an unknown amount of valerian root extract. The patient recovered, with supportive care, approximately 12 hours later (Wells, 1995).
    C) NAUSEA AND VOMITING
    1) WITH THERAPEUTIC USE
    a) Nausea and vomiting have been reported infrequently with valerian use (Dennehy et al, 2005).
    D) DRUG-INDUCED GASTROINTESTINAL DISTURBANCE
    1) WITH POISONING/EXPOSURE
    a) A decrease in intestinal motility and tone may occur with very large doses of valerian (Hobbs, 1989).

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) TOXIC HEPATITIS
    1) WITH THERAPEUTIC USE
    a) Four cases of hepatotoxicity were reported in patients following ingestions of herbal combination products containing valerian and skullcap. Three of the 4 patients presented with dark urine and pale stools and all four patients presented with jaundice. Liver biopsies performed on 2 of the 4 patients showed acute hepatitis, one that was severe with centrilobular and bridging necrosis. After discontinuation of the herbal tablets, liver function tests in all patients returned to normal within 2 years. The duration of ingestion of the herbal tablets ranged from 3 days to 2 months (MacGregor et al, 1989).
    b) There was NO clinical evidence of acute hepatitis in 23 patients who had ingested, on the average, 2.5 g of valerian (range 0.5 to 12 g) that was in a combination product also containing hyoscine and cyproheptadine. There was also NO evidence of subclinical liver damage in 12 patients who had liver function tests obtained approximately 6 to 12 hours after ingestion. However, subclinical hepatotoxicity developing 12 to 24 hours after ingestion and after hospital discharge could not be ruled out (Chan et al, 1995).

Reproductive

    3.20.1) SUMMARY
    A) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor vital signs and mental status.
    B) Routine laboratory studies are not needed unless otherwise clinically indicated.
    C) Monitor liver enzymes as needed following a significant exposure or chronic use of valerian alone or in combination with other herbals.
    D) Obtain a baseline ECG and institute continuous cardiac monitoring in symptomatic patients.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Routine laboratory studies are not needed unless otherwise clinically indicated.
    2) Monitor liver enzymes as needed following a significant exposure or chronic use of valerian alone or in combination with other herbals.
    4.1.4) OTHER
    A) OTHER
    1) ECG
    a) ECG should be monitored in symptomatic patients.

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) Due to the minimal adverse effects reported with limited human exposures, it is unlikely that patients would require hospital admission following an exposure. Patients with evidence of significant neurologic toxicity (i.e. drowsiness, CNS depression) or cardiac conduction disturbances should be admitted.
    6.3.1.2) HOME CRITERIA/ORAL
    A) An asymptomatic child or a child with only mild drowsiness following a minor exposure (eg, one herbal supplement) can be managed at home with adult supervision. Adults with an inadvertent overdose and minor symptoms can be managed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with persistent clinical effects (eg, drowsiness, somnolence) or more than mild toxicity should be referred to a healthcare facility. They may require supportive measures including monitoring and IV fluids.

Monitoring

    A) Monitor vital signs and mental status.
    B) Routine laboratory studies are not needed unless otherwise clinically indicated.
    C) Monitor liver enzymes as needed following a significant exposure or chronic use of valerian alone or in combination with other herbals.
    D) Obtain a baseline ECG and institute continuous cardiac monitoring in symptomatic patients.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) SUMMARY
    1) Gastrointestinal decontamination is unlikely to be necessary following a minor ingestion due to a lack of toxicity.
    B) ACTIVATED CHARCOAL
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
    2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
    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).
    6.5.2) PREVENTION OF ABSORPTION
    A) 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. Monitor vital signs and mental status; large doses may result in CNS depression. Evaluate for hypoxia in patients that develop significant CNS depression. For mild/moderate asymptomatic hypotension, pharmacologic treatment is generally not necessary. Initially treat hypotension with IV fluids.
    2) MANAGEMENT OF SEVERE TOXICITY
    a) Limited human data. Severe toxicity is not anticipated. Monitor vital signs and mental status. Obtain a baseline ECG and continuous cardiac monitoring following a significant exposure. There have been rare reports of chest pain and hypotension following exposure. Treat severe hypotension with IV 0.9% NaCl at 10 to 10 mL/kg. Add dopamine or norepinephrine if unresponsive to fluids.
    B) MONITORING OF PATIENT
    1) Monitor vital signs and mental status.
    2) Routine laboratory studies are not needed unless otherwise clinically indicated.
    3) Monitor liver enzymes as needed following a significant exposure or chronic use of valerian alone or in combination with other herbals.
    4) Obtain a baseline ECG and institute continuous cardiac monitoring in symptomatic patients.
    5) Cardiac disturbances may occur following large doses of valerian, therefore ECG should be monitored in symptomatic patients.
    C) HYPOTENSIVE EPISODE
    1) SUMMARY
    a) Infuse 10 to 20 milliliters/kilogram of isotonic fluid and keep the patient supine. If hypotension persists, administer dopamine or norepinephrine. Consider central venous pressure monitoring to guide further fluid therapy.
    2) DOPAMINE
    a) DOSE: Begin at 5 micrograms per kilogram per minute progressing in 5 micrograms per kilogram per minute increments as needed (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). If hypotension persists, dopamine may need to be discontinued and a more potent vasoconstrictor (eg, norepinephrine) should be considered (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    b) CAUTION: If ventricular dysrhythmias occur, decrease rate of administration (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). Extravasation may cause local tissue necrosis, administration through a central venous catheter is preferred (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    3) NOREPINEPHRINE
    a) PREPARATION: 4 milligrams (1 amp) added to 1000 milliliters of diluent provides a concentration of 4 micrograms/milliliter of norepinephrine base. Norepinephrine bitartrate should be mixed in dextrose solutions (dextrose 5% in water, dextrose 5% in saline) since dextrose-containing solutions protect against excessive oxidation and subsequent potency loss. Administration in saline alone is not recommended (Prod Info norepinephrine bitartrate injection, 2005).
    b) DOSE
    1) ADULT: Dose range: 0.1 to 0.5 microgram/kilogram/minute (eg, 70 kg adult 7 to 35 mcg/min); titrate to maintain adequate blood pressure (Peberdy et al, 2010).
    2) CHILD: Dose range: 0.1 to 2 micrograms/kilogram/minute; titrate to maintain adequate blood pressure (Kleinman et al, 2010).
    3) CAUTION: Extravasation may cause local tissue ischemia, administration by central venous catheter is advised (Peberdy et al, 2010).

Enhanced Elimination

    A) LACK OF INFORMATION
    1) It is unknown if hemodialysis would be of value following a valerian exposure.

Range Of Toxicity

Summary

    A) TOXIC DOSE: A toxic dose has not been established. INGESTION: Valerian overdoses of up to 23.5 g resulted in NO serious toxic effects. INTRAVENOUS: Intentional intravenous administration of an unknown amount of valerian root extract produced hypotension, lethargy, substernal chest pain, abdominal pain and mydriasis in a young woman. She recovered completely within 12 hours following supportive care.
    B) THERAPEUTIC DOSE: VALERIAN EXTRACT: The recommended dose for insomnia is 400 to 450 mg of valerian extract administered within 30 minutes of bedtime; maximum duration of therapy is 2 weeks. VALERIAN ROOT: Oral doses of 200 mg to 12 g have been reportedly used to treat insomnia.

Therapeutic Dose

    7.2.1) ADULT
    A) GENERAL
    1) The USP recommended dose of valerian for insomnia relief is 400 to 450 milligrams of valerian extract ingested 30 minutes before bedtime. The maximum duration of therapy is 2 weeks (Thompson, 1998).
    2) Doses of valerian root have ranged from 200 milligrams to 12 grams ingested prior to bedtime (Heiligenstein & Guenther, 1998; Wagner et al, 1998).
    3) Due to the potential for hepatotoxicity following valerian therapy, it is not recommended in patients with liver dysfunction (Wagner et al, 1998).

Maximum Tolerated Exposure

    A) CASE REPORTS
    1) ORAL: An intentional valerian overdose ingestion of approximately 20 g resulted in fatigue, abdominal pain, chest tightness, and tremors of the hands and feet. The patient recovered within 24 hours after activated charcoal administration (Willey et al, 1995).
    3) COMBINATION PRODUCT: Hepatitis was reported in patients ingesting an herbal combination product containing valerian and skullcap. Liver function tests returned to normal several months after discontinuation of the herbal product (MacGregor et al, 1989).
    4) INGESTION: An 18-year-old woman complained of chest tightness, crampy abdominal pain approximately 30 minutes after ingesting approximately 18.8 to 23.5 g of 100% powdered valerian root in a suicide attempt. Other symptoms included drowsiness and tremors of the hands and feet. Following activated charcoal administration, the patient recovered within 24 hours (Willey et al, 1995).
    5) INTRAVENOUS: A 25-year-old woman presented to the ED with hypotension (60/40 mmHg), lethargy, mydriasis and complaints of substernal chest pain and abdominal pain after intentional intravenous administration of an unknown amount of valerian root extract. Following supportive care, the patient recovered 12 hours later (Wells, 1995).

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) LD50- (ORAL)MOUSE:
    1) greater than 4600 mg/kg (Hobbs, 1989)

Pharmacology Toxicology

Pharmacologic Mechanism

    A) It is believed that valerian's sedative effect is caused by a combination of depression of specific centers of the CNS and by direct relaxation of smooth muscle and that the most likely active components, contained within valerian, are the valepotriates, the essential oil components, and unidentified water- soluble components (Hobbs, 1989).

Toxicologic Mechanism

    A) In vitro, some of the major valepotriates, such as valtrate and didrovaltrate, have shown alkylating, cytotoxic, and mutagenic activity due to an alkylating epoxide ring. This toxicity has not been demonstrated in vivo due to poor absorption and distribution of the compound (Hobbs, 1989; Wagner et al, 1998).

Physicochemical

Physical Characteristics

    A) Fresh valerian does not have a noticeable odor, but as the compound ages, a strong odor develops due to enzymatic hydrolysis of the compound to isovaleric acid I (Houghton, 1988).

Molecular Weight

    A) Not available

References

General Bibliography

    1) Alaspaa AO, Kuisma MJ, Hoppu K, et al: Out-of-hospital administration of activated charcoal by emergency medical services. Ann Emerg Med 2005; 45:207-12.
    2) Bent S, Padula A, Moore D, et al: Valerian for sleep: a systematic review and meta-analysis. Am J Med 2006; 119(12):1005-1012.
    3) Chan TYK, Tang CH, & Critchley JAJ: Poisoning due to an over-the-counter hypnotic, Sleep-Qik (hyoscine, cyproheptadine, valerian). Postgrad Med J 1995; 71:227-228.
    4) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    5) Dagnone D, Matsui D, & Rieder MJ: Assessment of the palatability of vehicles for activated charcoal in pediatric volunteers. Pediatr Emerg Care 2002; 18:19-21.
    6) Dennehy CE , Tsourounis C , & Horn AJ : Dietary supplement-related adverse events reported to the California Poison Control System. Am J Health Syst Pharm 2005; 62(14):1476-1482.
    7) DerMarderosian A: Valerian. The Review of Natural Products, Facts and Comparisons, St Louis, MO, 1991.
    8) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    9) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    10) Garges HP, Varia I, & Doraiswamy PM: Cardiac complications and delirium associated with valerian root withdrawal (letter). JAMA 1998; 280:1566-1567.
    11) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    12) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    13) Guenther Skokan E, Junkins EP, & Corneli HM: Taste test: children rate flavoring agents used with activated charcoal. Arch Pediatr Adolesc Med 2001; 155:683-686.
    14) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    15) Heiligenstein E & Guenther G: Over-the-counter psychotropics: a review of melatonin, St John's wort, valerian, and kava-kava. J Amer Coll Health 1998; 46:271-276.
    16) Hobbs C: Valerian. Herba/Gram 1989; 21:19-34.
    17) Houghton PJ: The biological activity of valerian and related plants. J Ethnopharmac 1988; 22:121-142.
    18) Kleinman ME, Chameides L, Schexnayder SM, et al: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 14: pediatric advanced life support. Circulation 2010; 122(18 Suppl.3):S876-S908.
    19) MacGregor FB, Abernethy VE, & Dahabra S: Hepatotoxicity of herbal remedies. British Med J 1989; 299:1156-1157.
    20) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    21) Peberdy MA , Callaway CW , Neumar RW , et al: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Part 9: post–cardiac arrest care. Circulation 2010; 122(18 Suppl 3):S768-S786.
    22) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    23) Product Information: dopamine hcl, 5% dextrose IV injection, dopamine hcl, 5% dextrose IV injection. Hospira,Inc, Lake Forest, IL, 2004.
    24) Product Information: norepinephrine bitartrate injection, norepinephrine bitartrate injection. Sicor Pharmaceuticals,Inc, Irvine, CA, 2005.
    25) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    26) Spiller HA & Rogers GC: Evaluation of administration of activated charcoal in the home. Pediatrics 2002; 108:E100.
    27) Thakore S & Murphy N: The potential role of prehospital administration of activated charcoal. Emerg Med J 2002; 19:63-65.
    28) Thompson CA: USP moves forward in providing information on botanical products. Am J Health-Syst Pharm 1998; 55:527-530.
    29) Wagner J, Wagner ML, & Hening WA: Beyond benzodiazepines: alternative pharmacologic agents for the treatment of insomnia. Ann Pharmacother 1998; 32:680-691.
    30) Wells SR: Intentional intravenous administration of a crude valerian root extract (abstract). J Toxicol Clin Toxicol 1995; 33:542.
    31) Willey LB, Mady SP, & Cobaugh DJ: Valerian overdose: a case report. Vet Hum Toxicol 1995; 37(4):364-365.