Pomegranate (Punica granatum)

Category

Herbs & Supplements

Synonyms

Ellagic acid, ellagitannins, Granada, Grenade, Grenadier, hydroalcoholic extract (HAE), PJ, polyphenols, POM Wonderful® variety pomegranate juice, pomegranate extracts, POMx, Punica proto-punica, Punicaceae (family), Punica Granatum, Shi liu gen (Chinese), Shi liu gen pi (Chinese), Shi liu pi (Chinese), tannins.

Background

One pomegranate delivers approximately 40% of an adult's daily vitamin C requirement and is high in polyphenol compounds. These compounds are thought to reduce 'silent inflammation,' which is at the root of diseases such as cancer, heart disease, and diabetes.

Although pomegranate juice has been commonly consumed for atherosclerosis (hardening of the arteries), evidence of its effectiveness is inconclusive. Pomegranate juice may have antioxidant properties, but its effects have not been widely studied; more evidence is needed. More research is needed for the use of pomegranate as an antifungal agent before a firm recommendation can be made.

Pomegranate has a long history of use as a food and medicine in Asia and South America. In the United States, pomegranate is typically juiced or the seeds are used as food. Pomegranate may have medicinal benefit as an anthelmintic (expels worms) and antidiarrheal agent, although reports conflict. The seeds may have phytoestrogenic qualities and may be used in hormonally-related conditions such as menopause.

Evidence

DISCLAIMER: These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Antifungal: An extract of pomegranate was shown to be as effective as a commonly used oral (by mouth) gel when used topically (applied on the skin) to treat candidiasis (yeast infection) associated with denture stomatitis (mouth sores). Additional study is needed to confirm pomegranate's antifungal effects and make a strong recommendation.
Grade: C

Antioxidant: Early studies suggest that pomegranate juice may have antioxidant properties, but the effects in humans are still unclear. Additional studies, including those in specific disease states in which free radical oxidation is prominent (such as diabetes and cancer), are warranted.
Grade: C

Atherosclerosis (hardening of the arteries): Preliminary study of pomegranate for atherosclerosis is mixed. Pomegranate juice may decrease serum angiotensin converting enzyme (ACE) activity and lower blood pressure in elderly hypertensive (high blood pressure) patients. However, additional study is warranted to confirm these findings.
Grade: C

Dental conditions: Extracts from pomegranate fruits may be beneficial in dental plaque accumulation and gum disease. Additional studies are warranted.
Grade: C

Erectile dysfunction: Pomegranate juice has been studied in the treatment of mild to moderate erectile dysfunction. Early study is unclear, and more studies are needed to make a firm recommendation.
Grade: C

High blood pressure: Pomegranate juice may lower blood pressure in patients with high blood pressure.
Grade: C

High cholesterol: Consumption of a juice containing a combination of fruits, including pomegranate, was found to have a beneficial effect on blood cholesterol levels. Additional studies in which pomegranate alone is used are needed.
Grade: C

Lung disease (COPD, chronic obstructive pulmonary disease): It is unclear whether pomegranate juice is helpful for chronic obstructive lung disease. In theory, pomegranate may be beneficial because of its antioxidant effects, but studies in humans do not support this theory. Additional studies in this area are warranted.
Grade: C

Menopausal symptoms: There is currently not enough evidence to support the use of pomegranate in the reduction of menopausal symptoms.
Grade: C

Prostate cancer: Consumption of pomegranate juice may be beneficial to patients with prostate cancer. Although early study is promising, more study is needed to a make a strong recommendation.
Grade: C

Sunburn: Taking ellagic acid-rich pomegranate extract by mouth may reduce damage to the skin caused by exposure to UV rays. Additional studies in this area are warranted.
Grade: C

Tradition

WARNING: DISCLAIMER: The below uses are based on tradition, scientific theories, or limited research. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. There may be other proposed uses that are not listed below.
Abortion, aging, anthelmintic (expels worms), astringent, bronchitis, colic, colitis (inflamed colon), diarrhea, dysentery (severe diarrhea), earache, headache, hemorrhoids, inflammatory bowel disorders, leprosy, leukorrhea (vaginal discharge), menorrhagia (heavy menstrual bleeding), mumps, nasal discomfort, paralysis, prolapse (dropping of the uterus), rectocele (dropping of the rectum), sore throat, tooth retention, ulcers of mouth and genitals.

Dosing

Adults (18 years and older)

No dosing consensus exists. Doses range from 50 to 1,000 milliliters of pomegranate juice taken by mouth daily for 2-5 weeks. Pomegranate extracts with 100 to 200 milligrams of ellagic acid have also been taken. Pomegranate extracts in the form of gels and mouthwashes have also been used to treat dental conditions short-term.

Children (younger than 18 years)

There is no proven safe or effective dose of pomegranate in children, and use is not recommended.

Safety

DISCLAIMER: Many complementary techniques are practiced by healthcare professionals with formal training, in accordance with the standards of national organizations. However, this is not universally the case, and adverse effects are possible. Due to limited research, in some cases only limited safety information is available.

Allergies

Avoid in individuals with a known allergy or hypersensitivity to pomegranate. There have been reports of cross-reactivity among pomegranate, hazelnut, and peanut.

Side Effects and Warnings

Pomegranate root/stem bark should be used only under the direct supervision of an expert qualified in its appropriate use. In traditional Chinese medicine, pomegranate fruit husk is not recommended to be taken concurrently with oils or fats when used to treat parasites.

Hypersensitivity reactions including pruritus (severe itching), angioedema (swelling), and bronchospasm have occurred with the ingestion of pomegranate fruit. Pomegranate is contraindicated in patients with known hypersensitivity to pomegranate and in patients with diarrhea. People with plant allergies seem to be at greater risk of allergic reactions to pomegranate. Use cautiously in patients with asthma.

Dried pomegranate peel may contain aflatoxin, which is a potent hepatocarcinogen (may cause liver cancer) and toxin. Pomegranate root and stem contain pellertierine, and overdoses by mouth can cause strychnine-like effects in the form of reflex arousal that can escalate to paralysis. At high amounts, people may experience vomiting including bloody emesis (vomit) followed by dizziness, chills, vision disorders, collapse, and possibly death due to respiratory failure. Avoid in patients with hypertension (high blood pressure) or hypotension (low blood pressure).

Pomegranate has been reported to cause nausea, vomiting, transient total blindness, hypersensitivity characterized by urticaria ("hives"), rhinorrhea (nasal discharge), red itchy eyes, and dyspnea (difficulty breathing).

In theory, the high tannin content may also cause liver toxicity or carcinogenicity. Use cautiously in patients with liver dysfunction and in patients on hepatotoxic drugs.

Pregnancy and Breastfeeding

Pomegranate is unsafe during pregnancy when taken by mouth. The bark, root, and fruit rind can stimulate menstruation or uterine contractions. There is insufficient reliable information available about the safety of applying pomegranate on the skin during pregnancy and breastfeeding.

Interactions

Interactions with Drugs

Theoretically, concomitant use of pomegranate and other agents by mouth may cause precipitation of some drugs due to the high tannin content of pomegranate. Some experts recommend separating administration of oral drugs and tannin-containing herbs by the longest practical period of time.

Pomegranate juice may have additive angiotensin-converting enzyme (ACE) inhibitor effects. Blood pressure and potassium levels should be monitored. ACE inhibitors include captopril (Capoten®), enalapril (Vasotec®), lisinopril (Prinivil®, Zestril®), ramipril (Altace®), and others. Pomegranate juice was shown to decrease serum angiotensin converting enzyme (ACE) activity and lower blood pressure in elderly hypertensive (high blood pressure) patients. Theoretically, concomitant use with pomegranate juice may cause additive antihypertensive (blood pressure-lowering) effects; use with caution.

Pomegranate may affect the way in which the liver breaks down certain drugs.

Pomegranate may increase the risk of harmful side effects with statin drugs such as rosuvastatin (Crestor®) and simvastatin (Lipitor®), which are taken to lower blood cholesterol.

Interactions with Herbs and Dietary Supplements

The fruit husk and root/stem bark of pomegranate contain up to 28% and 25% tannins, respectively, compared to 12.9% in black tea and 22.2% in green tea. The tannin content of various herbs may interact with iron, forming non-absorbable complexes. Some have concluded that if herbs containing tannins are consumed at mealtime, non-absorbable complexes will form with iron, zinc, and copper. Concern has been raised that tannins may affect the administration of iron supplementation products. It is unknown to what extent the amount of tannin in pomegranate may affect iron absorption clinically. Until more is known, patients who need iron supplementation should be advised to separate administration times of these two compounds by one to two hours.

Pomegranate juice may have antihypertensive (blood pressure-lowering) effects. Theoretically, concurrent use of pomegranate juice with other herbs and supplements that decrease blood pressure, such as danshen, ginger, and Panax ginseng, may increase the risk of hypotension (low blood pressure).

Theoretically, herbs that contain high percentages of tannins (such as pomegranate) may cause precipitation of constituents of other herbs. Caution is advised.

One pomegranate delivers approximately 40% of an adult's daily vitamin C requirement. In theory, large doses of pomegranate in combination with vitamin C supplements may result in additive effects or side effects.

Pomegranate may affect the way in which the liver breaks down certain herbs and supplements.

Attribution

This information is based on a systematic review of scientific literature, and was peer-reviewed and edited by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com): Tracee Rae Abrams, PharmD (University of Rhode Island); Dawn Costa, BA, BS (Natural Standard Research Collaboration); Cathy DeFranco Kirkwood, MPH, CCCJS-MAC (MD Anderson Cancer Center); Nicole Giese, MS (Natural Standard Research Collaborative); Mary Giles, PharmD (University of Rhode Island); Dana Hackman, BS (Northeastern University); Jenna Hollenstein, MS, RD (Natural Standard Research Collaboration); Tamara Milkin, PharmD (Northeastern University); Kristen Rafuse, BS (Northeastern University); Shaina Tanguay-Colucci, BS (Natural Standard Research Collaboration); Catherine Ulbricht, PharmD (Massachusetts General Hospital); Wendy Weissner, BA (Natural Standard Research Collaborative); Lisa Wendt, PharmD (Albany College of Pharmacy).

Bibliography

DISCLAIMER: Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

Aviram M, Rosenblat M, Gaitini D, et al. Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation. Clin Nutr 2004;23(3):423-433.

Cerdá B, Soto C, Albaladejo MD, et al. Pomegranate juice supplementation in chronic obstructive pulmonary disease: a 5-week randomized, double-blind, placebo-controlled trial. Eur J Clin Nutr 2006 Feb;60(2):245-53.

Cerda B, Espin JC, Parra S, et al. The potent in vitro antioxidant ellagitannins from pomegranate juice are metabolised into bioavailable but poor antioxidant hydroxy-6H-dibenzopyran-6-one derivatives by the colonic microflora of healthy humans. Eur J Nutr 2004;43(4):205-220.

Forest CP, Padma-Nathan H, Liker HR. Efficacy and safety of pomegranate juice on improvement of erectile dysfunction in male patients with mild to moderate erectile dysfunction: a randomized, placebo-controlled, double-blind, crossover study. Int J Impot Res 2007 Nov-Dec;19(6):564-7.

Heber D, Seeram NP, Wyatt H, et al. Safety and antioxidant activity of a pomegranate ellagitannin-enriched polyphenol dietary supplement in overweight individuals with increased waist size. J Agric Food Chem 2007 Nov 28;55(24):10050-4.

Kawaii S, Lansky EP. Differentiation-promoting activity of pomegranate (Punica granatum) fruit extracts in HL-60 human promyelocytic leukemia cells. J Med Food 2004;7(1):13-18.

Kim ND, Mehta R, Yu W, et al. Chemopreventive and adjuvant therapeutic potential of pomegranate (Punica granatum) for human breast cancer. Breast Cancer Res Treat 2002;71(3):203-217.

Menezes SM, Cordeiro LN, Viana GS. Punica granatum (pomegranate) extract is active against dental plaque. J Herb Pharmacother 2006;6(2):79-92.

Newton KM, Reed SD, Grothaus L, et al. The Herbal Alternatives for Menopause (HALT) Study: background and study design. Maturitas 2005 Oct 16;52(2):134-46.

Pantuck AJ, Leppert JT, Zomorodian N, et al. Phase II study of pomegranate juice for men with rising prostate-specific antigen following surgery or radiation for prostate cancer. Clin Cancer Res 2006 Jul 1;12(13):4018-26.

Sastravaha G, Gassmann G, Sangtherapitikul P, et al. Adjunctive periodontal treatment with Centella asiatica and Punica granatum extracts in supportive periodontal therapy. J Int Acad Periodontol 2005 Jul;7(3):70-9.

Sastravaha G, Yotnuengnit P, Booncong P, et al. Adjunctive periodontal treatment with Centella asiatica and Punica granatum extracts. A preliminary study. J Int Acad Periodontol 2003;5(4):106-115.

Toi M, Bando H, Ramachandran C, et al. Preliminary studies on the anti-angiogenic potential of pomegranate fractions in vitro and in vivo. Angiogenesis 2003;6(2):121-128.

Vasconcelos LC, Sampaio MC, Sampaio FC, et al. Use of Punica granatum as an antifungal agent against candidosis associated with denture stomatitis. Mycoses 2003;46(5-6):192-196.

Vidal A, Fallarero A, Pena BR, et al. Studies on the toxicity of Punica granatum L. (Punicaceae) whole fruit extracts. J Ethnopharmacol 2003;89(2-3):295-300.

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.