Can I take bromelain every day
Bromelain for acute edema
The proteolytic enzymes derived from the pineapple plant belonging to the Bromeliaceae family are called bromelain (Pineapple comosus L.) originate and are preferably obtained from the fruit stem. They were described in 1876 and introduced as medicinal products in 1957. In a broader sense, bromelain refers to the raw extract of pineapple, which, in addition to proteolytic enzymes, contains several protease inhibitors, a peroxidase, an acid phosphatase and organically bound calcium (Rowan et Buttle 1994). The substrate spectrum of bromelain (in the narrower sense) is very large; it preferably cleaves glycyl, alanyl and leucyl bonds.
The effectiveness and mode of action of oral bromelain preparations has long been the subject of controversial discussion, as it was not considered possible that macromolecules could be absorbed via the gastrointestinal tract. However, improved biochemical and immunological detection methods have shown that bromelain and other enzymes can in part be absorbed as intact proteins via the gastrointestinal tract (Castell et al. 1997, RPR 1996).
According to the monograph of Commission E, published in Federal Gazette No. 48 of 1994, the recommended daily dose is 80 to 320 mg bromelain, corresponding to 200 to 800 F.I.P. units. "Acute swelling conditions after operations and injuries, especially of the nose and paranasal sinuses" is named as the only scientifically proven area of application. In the red list® Bromelain preparations - both mono- and combination preparations - are assigned to the anti-inflammatory drug group alone (Rote Liste 2008).
Nowadays they are used to a considerable extent as accompanying therapy for diseases with inflammatory, traumatic and postoperative soft tissue edema (Tassman et al. 1964, Masson 1995, Klein et Kullich 1999, Leipner et al. 2001).
However, there are numerous clinical studies that indicate that the range of indications should be made much more extensive due to the different mechanisms of action of bromelain. Kelly (1996) gives an overview of further therapeutic applications.
Clinical studies on the effect
The therapeutic enzyme administration has already been used in numerous studies as an effective supplement to conventional physical, analgesic and anti-inflammatory measures in post-operative and post-traumatic events. In particular, between 1960 and 1970, studies were carried out that prove the positive effects of orally administered bromelain, z. B. the reduction of edema, bruises, pain and the duration of the healing process after a traumatic or surgical event. Only a small number of more recent studies are available.
Van Eimeren et al. (1987, 1994) examined a total of twelve controlled parallel group studies in a meta-analysis with regard to the effectiveness of bromelain in trauma (Seltzer 1964, Tassman et al. 1965, Woolf et al. 1965, Cirelli 1967, Zatuchni et Colombi 1967, Späth 1968, Blonstein 1969, Dunant et Waibel 1972, Howat et Lewis 1972, Mäder 1973, Trillig 1983, Nitzschke et Leonhardt 1989). Overall, the benefit of enzyme treatment with bromelain was demonstrated in nine studies. With regard to the edema remission, a statistically significant effect could be shown in five studies, in two studies a statistically significant effect for other target parameters such as B. hematoma formation can be proven. Only in two studies were there no differences between treatment with bromelain and placebo. This meta-analysis thus underpins the superiority of bromelain therapy.
The majority of these studies were with the single drug traumanase® carried out in daily doses between 120 and 240 mg (corresponding to 300 to 600 F.I.P. units). The dosages used were therefore in the range of the monograph recommendation of 200 to 800 F.I.P. units.
Another comprehensive review article deals with the use of bromelain in sports traumatology (Berg et al. 2005). The most important controlled clinical examinations are presented below according to their area of application.
In 100 patients with swelling of the forefoot, Nitschke and Leonhardt (1989) were able to show in a randomized, placebo-controlled double-blind study that postoperative intake of 3 × 80 mg of a bromelain monopreparation resulted in significantly less swelling (p ≤ 0.05) and a significantly earlier onset Freedom from pain (p ≤ 0.001) compared to placebo. An influence on blood coagulation by bromelain was not found, the tolerance was rated by 98% of the patients as "good" or "very good".
This contrasts with the results of a large-scale, multinational, randomized, double-blind parallel group study (Kerkhoff et al. 2004), in which a combination preparation with bromelain (Phlogenzym® ; also contains trypsin and rutoside) compared to placebo.
In 112 patients with sprains of the ankle joint, a two-armed, multicenter, double-blind parallel group comparison showed that taking bromelain for 15 days up to day 7 reduced the circumference of the injured joint by an average of 1.35 cm in the placebo group compared to 1.83 cm in the verum group. The difference to the placebo group was statistically significant. The overall effectiveness was rated 85% by the doctors in the verum group as "very good" or "good", in the placebo group it was 76% (IMF 1999).
Czech scientists were also able to show that patients with long bone fractures experienced significantly less postoperative swelling when they were given a proteolytic enzyme combination (90 mg bromelain per tablet) for several days after the operation, compared to patients who received conventional antiedematous preparations obtained on the basis of aescin (Kamenicek et al. 2001).
In a double-blind study by Woolf et al. (1965) examined the influence of bromelain (4 × 40 mg daily) on forearm swelling after injection of autologous blood. Linear and volumetric measurements showed a significantly reduced increase in arm volume and a smaller increase in arm circumference in the verum group compared to placebo. The differences were statistically significant.
Nascuiti and Benini (1977) carried out a randomized double-blind study and compared the effect of a bromelain monopreparation with that of a non-steroidal anti-inflammatory drug (oxyphenbutazone) in 40 patients with limb fractures. For six days, patients received either 40 mg bromelain or 100 mg oxyphenbutazone three times a day. Overall, a statistically significantly stronger effect of bromelain compared to the non-steroidal anti-inflammatory drug could be determined. Bromelain was also clearly superior to NSAID therapy in terms of side effects. The excellent tolerability of bromelain compared to two non-steroidal anti-inflammatory drugs (oxyphenbutazone or a combination of oxyphenbutazone and propyphenazone) was also confirmed in a study by Trillig (1983).
Oral and maxillofacial surgery
Studies by Tassman et al. (1964, 1965) showed that bromelain can reduce swelling, pain and the time it takes for wounds to heal after dental surgery. In a placebo-controlled crossover study in which 32 patients took part, it was shown that taking bromelain (4 × 40 mg / day) over a treatment period of three days reduced the duration of swelling after tooth extraction (bromelain: 3.8 Days, placebo: 7 days) and the duration of pain (bromelain: 5 days, placebo: 8 days) was significantly reduced. These results are confirmed by two open studies (Lorber 1967, Graber 1970) in which the undesirable side effects of dental surgery such as severe swelling in the facial area and pain could be significantly reduced with a bromelain monopreparation.
Pöllmann and Häussler (1983) used a bromelain monopreparation in their studies prophylactically before major surgical interventions in the mouth and jaw area. In the verum group there was a faster decrease in swelling than in the placebo group.
Studies by Tschaika (1999) show that bromelain can be used effectively in oral surgery. In a prospective, multicentre, placebo-controlled study with 105 patients who had osteotomies in the jaw area, a better effect of the enzyme preparation with regard to swelling, metric measurements of the cheek circumference and the speed of swelling regression was demonstrated. The differences compared to placebo, however, were not statistically significant. Hotz et al. (1989) in a placebo-controlled double-blind study in which 100 patients had wisdom teeth extracted, also found no significant differences in the intensity of the swelling compared to placebo. However, the intensity of the swelling was significantly lower in the bromelain-treated group than in the placebo group.
The only randomized, placebo-controlled study in the field of facial surgery was carried out by Seltzer in 1964. Bromelain was compared with placebo in 49 patients with post-traumatic swelling after rhinoplasty and other surgical face operations. The test parameters were the inflammation of the nasal mucosa, the secretion of mucus and the assessment of the airway passage. In 90% of the treated patients a good success was achieved, in the placebo group the success rate was only 9.5%. In another controlled study, Seltzer (1962) examined the effects of bromelain in 53 patients who had undergone plastic nasal surgery. Swelling and ecchymosis had subsided after seven days in the placebo group, while they had subsided after two days in the verum group. After rhinoplasty surgery, Baumgartner (1970) observed a significant decrease in swelling after just two days in 36 patients who were already taking bromelain at a dose of 120 to 160 mg per day before and after the surgery, while this was in the placebo group took place a day later. The remission of the hematomas was accelerated in all cases compared to the placebo group, the tension on the suture lines was less, and the inflammatory processes in the suture area subsided more quickly. Vogt-Suter (1970) and Pasha (1974) achieved comparably good results.
The effectiveness of bromelain in sinusitis has been examined in numerous studies (Taub 1966, 1967, Ryan 1967, Seltzer 1967, Braun et al. 2005). Bromelain was often used as a supplement to standard therapy.
In a randomized double-blind study carried out by Seltzer (1967), 48 patients with acute sinusitis received a bromelain monopreparation. With regard to the parameters "nasal complaints", "breathing difficulties" and the assessment of the patient's condition, the verum proved to be statistically significantly more effective than placebo. The duration of treatment in the verum group (9.9 days) was also significantly shorter (p <0.001) than in the placebo group (16.5 days). Adverse drug effects did not occur.
These results were confirmed by Ryan (1967) and Taub (1967). In a double-blind study in 48 patients with acute sinusitis, Ryan demonstrated complete remission of inflammatory mucosal symptoms in 83% of cases within six days. In a similar, randomized, placebo-controlled, double-blind study, Taub examined the effectiveness of bromelain (4 × 40 mg / day) in 59 patients with acute or chronic sinusitis over a treatment period of six days. It was used in addition to basic therapy. In 69% of the patients in the verum group, a very good therapy result could be determined, whereas this was the case in only 23% of the patients in the placebo group. A current meta-analysis by Guo et al. (2006) substantiate the successful use of bromelain monopreparations in acute and chronic sinusitis.
Bromelain is classified as a food additive by the U.S. Food and Drug Administration and is on the list of substances generally considered safe (FDA 2007). In the bromelain monograph of Commission E, apart from an existing hypersensitivity to bromelain or pineapple, no contraindications or special precautions for the use of bromelain are given.
However, some authors point out that due to the anticoagulant properties of bromelain, the risk of bleeding is increased, especially if additional anticoagulants such as acetylsalicylic acid are taken (Abebe 2003).
According to Maurer (2000, 2001), side effects caused by proteases occur very rarely and can only be assessed as temporary and minor. Occasionally, in addition to gastrointestinal symptoms such as stomach problems and diarrhea, the active ingredient can also cause allergic reactions, e.g. B. rashes or asthma-like symptoms can be triggered (Baur et Fruhmann 1979, Gailhofer et al. 1988, Nietzschke et Leonhardt 1989, Brien et al. 2004). The occurrence of allergic symptoms is mostly associated with the inhalation of enzyme dust, as Zentner et al. (1997) were able to determine in ten employees of a pharmaceutical factory in which enzyme preparations were manufactured. The same is assumed by Hugo et Gall (1999), who found IgE-mediated sensitization in a 35-year-old laboratory assistant who also worked professionally with powdered bromelain. The risk potential for oral intake was also classified here as very low.
Overall, the oral intake of bromelain can be regarded as safe, but Orsani (2006) calls for further randomized, controlled studies in a current review on the effects and tolerability of bromelain in order to elucidate the clinical potential even more precisely.
The evaluated studies confirm the excellent effectiveness of bromelain in edema remission, pain relief and hematoma resorption in traumatic events. The proven anti-inflammatory and anti-edematous properties also speak in favor of prophylactic use of bromelain before performing surgical interventions. Due to its good efficacy and excellent tolerability, bromelain can be regarded as a supportive treatment measure to standard therapy with non-steroidal anti-inflammatory drugs (NSAIDs) for acute postoperative and posttraumatic edema.
Literature from the authors
Addresses of the authors:
Prof. Dr. med. Claus-Peter Siegers,
Doctor for pharmacology and toxicology,
Institute for Experimental and Clinical Pharmacology and Toxicology at the University Medical Center Schleswig-Holstein
Dr. med. Jan-Peter Siegers,
Specialist in surgery,
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