Psyllium (Plantago ovata, Plantago isphagula)
  
Psyllium (Plantago ovata, Plantago isphagula)
Background
Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata . Psyllium contains a high level of soluble dietary fiber, and is the chief ingredient in many commonly used bulk laxatives, including products such as Metamucil® and Serutan®.
Psyllium has been studied as a "non-systemic" cholesterol-lowering agent, with generally modest effects seen on total cholesterol and high-density lipoprotein levels. Several psyllium-containing cereals such as Heartwise® and Bran Buds® have appeared in the U.S. marketplace during the last fifteen years, and have been touted for their potential lipid lowering and "heart health promoting" effects.
Allergic reactions, including anaphylaxis have been reported, particularly in healthcare workers with previous experience preparing psyllium-containing bulk laxatives. Obstruction of the gastrointestinal tract by such laxatives has also been reported, particularly in patients with prior bowel surgeries or anatomic abnormalities, or when mixed with inadequate amounts of water.
Synonyms
Bran Buds® cereal, Effersyllium®, Fiberall®, flea seed, Fybogel®, Heartwise® cereal, Hydrocil®, I-so-gel®, ispaghula, ispaghula husk, ispaghula seed, Konsyl®, Lunelax®, Metamucil®, Minolest®, Natural Vegetable Laxative, Perdiem®, Plantago arenaria , Plantago psyllium , Prodiem Plain®, psyllion, psyllios, psyllium husk, psyllium seed, Regulan®, Serutan®, Vi-Siblin®, Yerba Prima® Psyllium hush powder.
Evidence
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.
Uses based on scientific evidenceGrade*High cholesterol
Psyllium is well studied as a lipid-lowering agent with generally modest reductions seen in blood levels of total cholesterol and low-density lipoprotein ("bad cholesterol"). Effects have been observed following eight weeks of regular use. Psyllium does not appear to have significant effects on high-density lipoprotein ("good cholesterol") or triglyceride levels. Because only small reductions have been observed, people with high cholesterol should discuss the use of more potent agents with their healthcare provider. Effects have been observed in adults and children, although long-term safety in children is not established.
A
Constipation
Psyllium has long been used as a chief ingredient in "bulk laxatives." Studies exploring the mechanisms of the laxative effects of psyllium are somewhat conflicting, but have generally revealed an increase in stool weight, an increase in bowel movements per day, and a decrease in total gut transit time.
B
Diarrhea
Psyllium has been studied for the treatment of diarrhea, particularly in patients undergoing tube feeding. It has also been studied in addition to Orlistat® therapy in hopes of decreasing gastrointestinal effects (diarrhea and oily discharge) of this weight loss agent. An effective stool bulking effect has generally been found in scientific studies.
B
Hyperglycemia (high blood sugar levels)
Several studies have examined the administration of psyllium with meals or just prior to meals in order to measure effects on blood sugar levels. Measurements have been done immediately after meals and throughout the day. Effects of regular (chronic) psyllium use have also been investigated. In general, no immediate (acute) changes in blood sugar levels have been reported. Long-term effects have been inconsistent across studies, although modest reductions have been reported in some research. Better evidence is necessary before a firm conclusion can be drawn.
C
Irritable bowel syndrome
Psyllium preparations have been studied for more than 20 years in the treatment of irritable bowel syndrome symptoms. Results of these trials have been conflicting. Better research is necessary before a firm conclusion can be reached.
C
Inflammatory bowel disease
There is limited and unclear evidence regarding the use of psyllium in patients with inflammatory bowel disease.
C
Fat excretion in stool
Early Research shows that dietary psyllium and chitosan supplementation may help to increase the excretion of fat in the stool.
C
* Key to grades
A: Strong scientific evidence for this use;
B: Good scientific evidence for this use;
C: Unclear scientific evidence for this use;
D: Fair scientific evidence against this use (it may not work);
F: Strong scientific evidence against this use (it likely does not work).
Uses based on tradition or theory
The below uses are based on tradition or scientific theories. 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.
Abscesses, anti-parasitic, atherosclerosis, bleeding hemorrhoids, boils, bronchitis, Crohn's disease, colon cancer prevention, cystitis, demulcent, diverticular disease, duodenal ulcer, dysentery, excessive menstrual bleeding, fecal (stool) incontinence, gallstones, hearing damage, high blood pressure, incontinence, leishmaniasis, obesity, poison ivy rash, primary biliary cirrhosis, psoriasis, radiation-induced colitis/diarrhea, sclerosing cholangitis, stomach ulcer, urethritis, wound healing (used on the skin).
Dosing
The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.
Standardization
Standardization involves measuring the amount of certain chemicals in products to try to make different preparations similar to each other. It is not always known if the chemicals being measured are the "active" ingredients.
Psyllium products may contain husks of Plantago ovata seeds or the seeds themselves, with the husks being more commonly used. Amounts of psyllium in products are generally reported as total grams. Seed preparations contain approximately 47% soluble fiber by weight, while husk preparations generally contain 67 to 71% soluble fiber and 85% total fiber by weight.
Adults (18 years and older)
Dietary amounts : Recommendations for dietary fiber intake for adults fall within the range of 20 to 35 grams per day, or 10 to 13 grams per 1,000 kilocalories ingested. However, popular U.S. foods are not high in dietary fiber, and common serving sizes of grains, fruits, and vegetables contain only 1 to 3 grams of dietary fiber. The usual intake of dietary fiber in the U.S. remains lower than these recommended levels, averaging only 14 to 15 grams daily.
General : It is important to take laxatives such as psyllium with sufficient amounts of water or liquid in order to reduce the risk of bowel obstruction.
Cholesterol lowering : A wide range of doses of psyllium has been studied, from 3.4 to 45 grams per day, taken daily by mouth in two or three divided doses. Studies using psyllium-enriched cereals or other food products have administered preparations providing between 3 and 12 grams of soluble fiber daily. Psyllium husk preparations have generally been used in cholesterol-lowering studies, although seed preparations have also been used.
Constipation : Doses ranging from 7 to 30 grams by mouth daily in single or divided doses have been used in studies.
Diarrhea : Doses ranging from 7.5 to 30 grams by mouth daily in single or divided doses have been used in studies.
Blood sugar lowering : Doses ranging from 2.2 to 45 grams by mouth daily in divided doses, often administered just prior to meals, have been used in studies. Blood sugar levels should be monitored by a qualified healthcare professional.
Inflammatory bowel disease : 7 grams by mouth daily in divided doses has been used in studies, although effects are not clearly established.
Irritable bowel syndrome : Doses ranging from 6 to 30 grams by mouth daily have been used in studies, although effects are not clearly established.
Children (younger than 18 years)
High cholesterol : 6 to 7 grams by mouth daily of psyllium-enriched cereal has been studied, although more research is needed to establish benefits and long-term safety.
Diarrhea : 3.4 grams by mouth daily has been studied, although more research is needed to establish benefits and long-term safety.
Inflammatory bowel disease : 16 grams by mouth daily has been studied, although effects are not clearly established. More research is needed to establish potential benefits and long-term safety.
Safety
The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.
Allergies
Serious allergic reactions including anaphylaxis, difficulty breathing/wheezing, skin rash, and hives have been reported after ingestion of psyllium products. Less severe hypersensitivity reactions have also been noted. Cross-sensitivity may occur in people with allergy to English plantain pollen ( Plantago lanceolata ), grass pollen, or melon. Plantain allergy may be associated with latex sensitivity, although it is not clear if this applies to psyllium as well. Workers in the healthcare and pharmaceutical industries can become sensitized and develop allergic respiratory (breathing) symptoms due to handling bulk laxatives containing psyllium powder. Occupational asthma associated with psyllium exposure has been observed. Reactions may also occur from breathing in the dust or from skin contact.
Side Effects and Warnings
Psyllium-containing laxatives, cereals, and other products are generally believed to be safe. Important exceptions include those with repeated psyllium exposure (such as health care workers frequently handling bulk laxatives who are at risk for hypersensitivity reactions), and patients with significant pre-existing bowel abnormalities (such as gastrointestinal strictures or impaired motility) or prior bowel surgery.
Obstruction of the gastrointestinal tract has been noted in numerous case reports of patients taking psyllium-containing laxatives, particularly in individuals with previous bowel surgery or problems, and/or when the laxatives are mixed with inadequate amounts of water.
Gastrointestinal side effects are generally mild and have not prompted discontinuation of psyllium in most clinical trials. Flatulence (gas), bloating, diarrhea, and constipation have been reported, and were all less frequent when compared to wheat bran therapy in one study. Since many patients in studies of psyllium have pre-existing bowel concerns, it is difficult to discern which symptoms are caused by psyllium specifically. Esophageal obstruction has been reported in a patient with Parkinson's disease.
Due to potential reductions in blood sugar levels caused by psyllium, blood glucose levels in diabetic patients should be closely monitored.
Pregnancy and Breastfeeding
Psyllium-containing laxatives are considered class C-2 drugs in pregnancy, meaning that they appear to be safe in all three trimesters, although studies in pregnant humans and animals have not been done. Psyllium-containing products are considered class 1 (apparently safe) during breastfeeding.
References
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