Bromelain is an enzyme produced by the pineapple plant family which breaks down proteins. It has been studied as a potential treatment for osteoarthritis, debridement of tissue in burns, anti-inflammatory, prevention of cancer, improved absorption of antibiotics, and ulcerative colitis. The most evidence for the use of bromelain is seen in studies which outline the treatment of osteoarthritis. The research done on bromelain is ongoing but is not complete enough to know the ideal dose or safety profile and it should not be considered for use in any health conditions until more research is available. Research has been done which outlines the use of the 3 enzymes bromelain, trypsin and rutosine in combination for osteoarthritis.
Bromelain and osteoarthritis:
Brien S et al reviewed previous clinical research performed on bromelain used for osteoarthritis. According to the review, bromelain has both anti-inflammatory and analgesic properties. For osteoarthritis of the knee, bromelain was used in studies at a dose of 540 to 1890 mg per day. Several studies did show equivalence to standard diclofenac treatment for osteoarthritis, but it was concluded by the author that studies did not treat long enough, they had concerns in methodology, the ideal dose of bromelain was not defined, and subjects were not evaluated well enough for adverse reactions but the safety reports completed revealed no serious adverse reactions, and was tolerated well by patients. Adverse effects were mainly confined to mild gastrointestinal symptoms. The author determined that bromelain was more effective in studies for knee osteoarthritis than for shoulder osteoarthritis. The author believed more trials are needed to establish the optimum effective dose, safety profile, and longer trials. (1)
Bromelin as part of combination natural therapy for osteoarthritis:
A double-blind, randomized study by Klein G et al evaluated a bromelain, trypsin, and rutoside combination painful osteoarthritis (OA) of the hip were randomly assigned to receive an oral enzyme treatment (Phlogenzym [PE]) or an NSAID (diclofenac [DC], 50 mg twice daily) for 6 weeks. Phlogenzym contains 90 mg of bromelain, 48 mg of trypsin, and 100 mg of rutosid per tablet, 2 tablets were taken 3 times daily. A similar supplement named Revozyme Forte is also available (containing 96 mg trypsin, 180 mg bromelain, 200 mg rutoside trihydrate). After 6 weeks, both groups experience improvements in pain (PE, -10.3 vs DC, -0.5) joint stiffness (PE, -3.9 vs DC, -3.6), physical functioning (PE, -31.7 vs DC, -29.7) and severity of OA (measured using Lequesne\’s index, PE, -2.89 vs DC, -2,27). The results of the study suggest that Phlogenzym in people with OA was not inferior to diclofenac. (2)
Bromelain Adverse Reactions and Interactions:
As mentioned above by Brien S et al, more safety data is needed but research thus far completed reveals no serious adverse reactions, and was tolerated well. Adverse effects were mainly confined to mild gastrointestinal symptoms. Research demonstrated that bromelain has caused reduction in prostaglandin synthesis, decreased platelet aggregation, compromised coagulation and has been shown to increase prothrombin time a small amount. (3).
Assessment and Plan: Bromelain
- The most evidence for the use of bromelain is seen in studies which outline the treatment of osteoarthritis.
- For osteoarthritis of the knee, bromelain was used in studies at a dose of 540 to 1890 mg per day. Several studies did show equivalence to diclofenac for osteoarthritis, but concerns remain by the author that studies did not treat long enough, had concerns in methodology, the ideal dose of bromelain was not defined, and subjects were not evaluated well enough for adverse reactions but the safety reports completed revealed no serious adverse reactions, and was tolerated well by patients.
- Adverse effects of bromelain were mainly confined to mild gastrointestinal symptoms.
- Bromelain is not without risks and may have the potential to cause GI bleeding due to reduced prostaglandin synthesis much like non-steroidal anti-inflammatory drugs can. Also it may increase risk of bleeding due to decreased platelet aggregation, increased prothrombin time (PT) and should not be taken by patients with bleeding disorders, by patients taking antiplatelet agents, or by patients taking anticoagulants such as the following: non-steroidal anti-inflammatory drugs (NSAIDs), warfarin (Coumadin), heparin, Plavix, ticlodipine, and aspirin.
References:
1.Brien S, Lewith G, Walker A, Hicks SM, Middleton D. Bromelain as a Treatment for Osteoarthritis: a Review of Clinical Studies. Evid Based Complement Alternat Med. 2004 Dec;1(3):251-257. Epub 2004 Oct 6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC538506/
2.Klein G, Kullich W, Schnitker J, Schwann H. Efficacy and tolerance of an oral enzyme combination in painful osteoarthritis of the hip. A double-blind, randomized study comparing oral enzymes with non-steroidal anti-inflammatory drugs. Clin Exp Rheumatol 2006;24:25-30. http://www.ncbi.nlm.nih.gov/pubmed/16539815
3.Cirelli MG, Smyth RD. Effects of bromelain anti-edema therapy on coagulation, bleeding, and prothrombin times. J New Drugs 1963;3:37-39.