- Andrographis is considered a powerful remedy for respiratory infections
- ‘With its goals of healing, it emphasises an individualised holistic approach’
“We are heading rapidly towards a world in which our antibiotics no longer work”
Alma Tildesley hates having to take antibiotics for the frequent coughs, colds and sore throats to which she is vulnerable, but this is the downside of using steroid inhalers for the asthma that has affected her since childhood.
“Antibiotics are necessary sometimes to halt a serious infection,” explains the retired catering manager from Southsea, Hampshire. “But they cause horrible side effects including indigestion, nausea and diarrhoea. And there’s the extra worry now that my frequent use of antibiotics will add to the risk of antimicrobial resistance.”
Fortunately, says Alma, she has an alternative that prevents at least half of her respiratory infections. Known as the “king of bitters” because of its taste, Andrographis paniculata – commonly known as andrographis – is a popular salad leaf in China as well as being a linchpin of both Ayurvedic and Chinese traditional medicine. It has been regarded as a powerful remedy for respiratory infections for centuries. It’s even claimed by some to have saved lives in India during the 1919 flu epidemic that killed millions globally.
Alma takes it as a tincture, prescribed by an Ayurvedic practitioner, whenever she feels she’s about to get a cough or a sore throat. “It is certainly bitter. I’d never put it in whisky, it would ruin a good malt. But I can swallow it in a warm honey drink or in fruit juice.”
With the British public spending millions of pounds every year on herbal remedies, Alma’s experience might seem less than newsworthy. What’s different about andrographis is that it could be about to become an alternative to antibiotics in UK medical general practices.
Research and trials
An ongoing trial among NHS family doctors, due to report later this year, is testing andrographis to see if both patients and doctors regard it as an acceptable alternative to antibiotics. If the findings are positive, the next step will be “a well-designed trial in the UK to evaluate the effectiveness, efficacy and safety to confirm these findings”, explains Michael Moore, professor of primary care and population science at the University of Southampton where the research is being carried out.
Other herbal remedies are also being tested – with a handful already showing promise as an alternative.
The researchers have shown that pelargonium, an extract of geranium, is effective in treating long-lasting coughs. And a number of Ayurvedic and Chinese herbal remedies appear to combat the symptoms of urinary tract infection, another common disorder for which antibiotics are widely prescribed.
Southampton is one of 15 British universities to sign up to a newly established multimillion UK-China collaboration to tackle antimicrobial resistance in both human health and agriculture, headed here by Innovate UK and the Department of Health. Herbal remedies are one of the priority areas for investigation.
Changing attitudes to medicine use
Known locally as kalmegh, meaning “dark cloud”, the Ayurveda herb andrographis is widely cultivated in southern and south-eastern Asia, with its roots and leaves used for medicine.
The World Health Assembly, the governing body of the World Health Organisation, included a chapter on traditional medicine last month in its influential global compendium for the first time.
The threat of antimicrobial resistance is “a silent tsunami”, Haileyesus Getahun, the director of the UN’s Interagency Coordination Group on Antimicrobial Resistance, said in April. “We don’t see the effects of it yet, but what is coming will be a catastrophe,” he added. Arguing that the problem could be averted through public education, he added: “We are calling for people to come together.”
So what’s behind this interest in traditional remedies that have been dismissed by mainstream medicine until now?
It is a case of needs must – as antibiotic resistance “poses a threat as big as climate change”, according to Dame Sally Davies, chief medical officer of the NHS.
How can we reduce use of antibiotics?
In January, NHS England announced a five-year plan to cut antibiotic prescribing by 20 per cent by 2024 in an effort to reduce the risk of antimicrobial resistance. “We are heading rapidly towards a world in which our antibiotics no longer work,” warned the Environment Secretary, Michael Gove, and the Health Secretary, Matt Hancock, in a joint foreword to the plan.
In April, Dame Sally even called for an Extinction Rebellion-style campaign to save people from antibiotics becoming ineffective in the face of overuse and a lack of regulation.
“It would be nice if activists recognised the importance of this,” she said. “This is happening slowly and people adjust to where we are but this is the equivalent danger to extreme weather.”
It’s a complex issue. On the one hand, overuse of antibiotics is allowing bacteria to evolve to repel them – with antimicrobial resistance creating what many regard as a global emergency. Experts predict that this could cost 10 million lives globally by 2050, at a point where common infections could kill and surgery would become impossible.
Doctors have been asked to avoid prescribing antibiotics for self-limiting illness such as respiratory infections and ensure that they are only prescribed for serious infections such as pneumonia and kidney infection.
But one in three people still takes a course of antibiotics each year – with three in four of these prescriptions for antibiotics handed out by GPs and at least one in four of these prescriptions being “inappropriately prescribed”, according to the latest statistics.
It is partly our fault. Pressure from patients, anxious to leave the surgery with a prescription to beat what can feel like a never-ending sniffle or sore throat, is a big part of the problem, even though there’s little or no evidence that antibiotics have any impact on the length or severity of respiratory infections. The busier a GP’s practice is, research shows, the more likely they are to prescribe antibiotics inappropriately.
Big pharma problems
There is a crisis over which the public have no control, however: the fact that the pharmaceutical industry has produced no new classes of antibiotics, to replace medicines that no longer work, since the 1980s.
And with “big pharma” having a monopoly on the development of new drugs, there’s little hope that this will change.
“The pharma industry is spewing out nonsense about their commitment to producing antibiotics instead of helping to develop them,” Jim O’Neill, chair of the Chatham House think tank and a former Goldman Sachs chief economist, told a conference on antimicrobial resistance organised by the Wellcome Trust in January.
There are unfortunate but understandable commercial reasons for this. “The problem is that the current business model for the pharmaceutical industry makes it very difficult to finance new antibiotics which are designed to be used as rarely as possible for as short a time as possible,” says David Partridge, research lead for the Directorate of Laboratory Medicine at Sheffield Teaching Hospitals NHS Foundation Trust.
“Yes, the need for new antibiotics is huge, but it makes more financial sense for the pharmaceutical industry to develop new drugs that will be widely used for decades such as heart or diabetes drugs,” he says.
What’s the evidence?
“With its goals of healing, it emphasises an individualised holistic approach”
Dr Xiao-Yang Hu
So can herbal remedies such as andrographis fill the gap? One Ayurvedic practitioner, Rebecca Kriese, says that her 15 years in practice, following three years of training in India, have convinced her that the remedies work well.
“I’ve taken an Ayurvedic herb for a UTI. It took perhaps five days longer than an antibiotic before the infection fully resolved but the infection has never come back,” she says. “That’s because it treats the whole body, which antibiotics don’t do.”
There is an evidence base to show this is also true for andrographis. In 2004, a review of the evidence on the herb by Edzard Ernst, former professor of complementary medicine at Exeter University, published in the journal Planta Medica, was positive. “It looks like a safe and efficacious treatment,” it said, “superior to placebo in alleviating the symptoms of uncomplicated upper respiratory tract infection” with “preliminary evidence of a preventative effect” and “few spontaneous reports of adverse events”.
Today, Professor Ernst remains cautious. “It is often the case that initial trials are encouraging and later, more rigorous studies fail to confirm the early findings. I think it is too early to say whether that is also true for andrographis.”
Reasons for optimism
Others are more positive. A 2017 systematic review of andrographis by researchers at the universities of Southampton and Beijing included data for 7,175 patients across 33 trials in six countries – and reported that the key component, known as andrographolides, had “clear anti-inflammatory, antiviral, anti-allergic and immune-stimulatory activities”.
As a result, the remedy reduced the severity of sore throats and coughs and shortened the duration of cough, sore throat and time taken off sick compared to normal care. In the lab, it has also been shown to block human and avian flu.
“The review was limited to some extent in that the quality of some of the trials was poor, but the findings are sufficiently promising to justify the current trial in general practice,” says Dr Xiao-Yang Hu, co-author of the 2017 paper and a post-doctoral research fellow at Southampton University.
Dr Hu is optimistic about the contribution of herbal medicine to healthcare. “Integrative medicine, bringing together conventional, complementary and alternative interventions, is the optimum treatment as well as being evidence-based, effective, safe and low cost,” she says.
“With its goals of healing, it emphasises an individualised holistic approach, self-management and the practitioner-patient relationship with multi-disciplinary collaborative teams.”
Ms Kriese says the trial might be even more effective if GPs were given a basic training in traditional herbal remedies. Whether that happens remains to be seen.
“Involving family doctors from the outset is welcome as GPs are on the frontline in reducing reliance on antibiotics,” says Dr Michael Dixon, NHS England’s national clinical lead for prescribing. “The prospect of offering patients a natural remedy would be a big step forward.”
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