Dr Clare Materia Medica

Also Known As:

Brown Psyllium, Dietary Fiber, Fibre Alimentaire, Fleaseed, Fleawort, French Psyllium, Graine de Psyllium, Herbe aux Puces, Œil-de-Chien, Plantain, Plantain Pucier, Psyllion, Psyllios, Psyllium, Psyllium Brun, Psyllium d'Espagne, Psyllium Noir, Psyllium Seed, Pucière, Pucilaire, Spanish Psyllium, Zaragatona.
CAUTION: See separate listings for Blond Psyllium, Buckhorn Plantain, Great Plantain, and Water Plantain.

Scientific Name:

Plantago psyllium, synonym Psyllium afra; Psyllium indica, synonym Psyllium arenaria.
Family: Plantaginaceae.

People Use This For:

Orally, black psyllium is used for chronic constipation and for softening stools in conditions such as hemorrhoids, anal fissures, anorectal surgery, and pregnancy. It is also used orally for diarrhea, irritable bowel syndrome (IBS), reducing elevated cholesterol, dysentery, and treating cancer.

Safety:

LIKELY SAFE...when used orally with appropriate fluid intake (3,6,8).
LIKELY UNSAFE ...when used orally without adequate fluid intake because it can cause esophageal obstruction (2,3,7). ...when the seeds of non-commercial preparations of black psyllium are chewed, crushed, or ground because they release a pigment that deposits in renal tubules (5) and can be nephrotoxic (6). This pigment has been removed from most commercial products (6).
PREGNANCY AND LACTATION: LIKELY SAFE ...when used orally with appropriate fluid intake (8).

Effectiveness:

Constipation. Taking black psyllium orally works as a bulk laxative and reduces constipation (8).

POSSIBLY EFFECTIVE

Hypercholesterolemia. Taking black psyllium orally seems to reduce total and LDL cholesterol, and the LDL:HDL ratio (4,5).
There is insufficient reliable information available about the effectiveness of black psyllium for its other uses.

Mechanism of Action:

The applicable part of black psyllium is the seed. Its constituents are not absorbed and have no systemic effects (1). Black psyllium seed forms a mucilaginous mass when mixed with water and has a bulk laxative effect (1,3,4). In people with diarrhea, the mucilage absorbs water, provides mass, and prolongs gastrointestinal transit (1,4). In individuals with constipation, the mucilage absorbs water, swells, and stimulates peristalsis, reducing gastrointestinal transit time (1,3,4). Black psyllium can decrease abdominal pain in people with irritable bowel syndrome (IBS) by reducing rectosigmoidal pressure (9). Psyllium reduces peak blood glucose levels by slowing carbohydrate absorption (1,4) and can decrease cholesterol by absorbing dietary fats in the gastrointestinal tract, thereby preventing systemic absorption. It can also increase cholesterol elimination in the fecal bile acids (1,4,5,6). Chewing or crushing the seeds can release a pigment that deposits in renal tubules (5) and can be nephrotoxic (4). This pigment is removed from most commercial products (4).

Adverse Reactions:

Orally, black psyllium can cause transient flatulence and abdominal distention (3). When consumed without water, it can cause esophageal (3) and bowel obstruction (3,12). Chewing or crushing the seeds can release a pigment that deposits in the renal tubules (5) and can be nephrotoxic (4). This pigment is removed from most commercial products (4). Allergic reactions to black psyllium include allergic rhinitis, conjunctivitis, urticaria, and asthma (7).
Occupational exposure to black psyllium can cause sensitization, of which symptoms include sneezing, watery eyes, chest congestion, and anaphylactoid reaction (4).

Interactions with Herbs & Supplements:

None known.

Interactions with Drugs:

ANTIDIABETES DRUGS <<interacts with>> BLACK PSYLLIUM

Interaction Rating = Moderate Be cautious with this combination.

Severity = Moderate • Occurrence = Possible • Level of Evidence = B

Black psyllium can reduce blood glucose levels in patients with type 2 diabetes (22) and might have additive effects on glucose levels when used with antidiabetes drugs. Monitor blood glucose levels closely. Medication dose adjustments may be necessary. Some antidiabetes drugs include glimepiride (Amaryl), glyburide (Diabeta, Glynase PresTab, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), and others.

CARBAMAZEPINE (Tegretol) <<interacts with>> BLACK PSYLLIUM

Interaction Rating = Moderate Be cautious with this combination.

Severity = Moderate • Occurrence = Probable • Level of Evidence = D

Black psyllium can reduce carbamazepine absorption (10).

DIGOXIN (Lanoxin) <<interacts with>> BLACK PSYLLIUM

Interaction Rating = Moderate Be cautious with this combination.

Severity = Moderate • Occurrence = Probable • Level of Evidence = D

Concomitant use might reduce digoxin absorption (1), requiring dose adjustment (6).

LITHIUM <<interacts with>> BLACK PSYLLIUM

Interaction Rating = Moderate Be cautious with this combination.

Severity = Moderate • Occurrence = Probable • Level of Evidence = D

Black psyllium use can reduce serum lithium levels (11). The fiber in lithium might decrease the absorption of lithium. 

Interactions with Foods:

NUTRIENT ABSORPTION: The long-term use of black psyllium with meals can reduce nutrient absorption requiring vitamin or mineral supplementation (6). 

Interactions with Lab Tests:

BLOOD GLUCOSE: Theoretically, black psyllium might lower postprandial blood glucose levels and test results (1,4,13).
SERUM CHOLESTEROL: Black psyllium can lower total cholesterol and LDL cholesterol levels, LDL:HDL ratio, and test results (1,4,13).

Interactions with Diseases or Conditions:

DIABETES: Black psyllium can lower blood glucose levels in people with type 2 diabetes by retarding carbohydrate absorption (13,17). Monitor blood glucose levels closely. Doses of conventional antidiabetes medications may require adjustment. Also, warn patients with diabetes that some commercial blond psyllium products can contain added sugars and other absorbable carbohydrates which might increase blood glucose levels.

GI CONDITIONS: Black psyllium is contraindicated in people with fecal impaction, GI atony (1), GI tract narrowing, and obstruction or conditions that can lead to obstruction, such as spastic bowel (1,2,3,6,7).
HYPERSENSITIVITY: Some patients can have severe hypersensitivity reactions to black psyllium. This is more likely to occur in patients with previous occupation exposure to black psyllium (14,15,16,18,21). Blond psyllium is contraindicated in these patients.
PHENYLKETONURIA: Avoid products containing aspartame (Nutrasweet) (8).
SURGERY: Black psyllium might affect blood glucose levels. Theoretically, black psyllium might interfere with blood glucose control during and after surgical procedures. Tell patients to discontinue black psyllium at least 2 weeks before elective surgical procedures.
SWALLOWING DISORDERS: Patients with swallowing disorders might be at greater risk for esophageal obstruction when using blond psyllium. Blond psyllium is contraindicated in these patients (19,20).

Dosage/Administration:

ORAL: As a laxative, the typical dose of black psyllium seed is 10-30 grams per day (2,7), in divided amounts. Mix 10 grams seed in 100 mL water, to be followed by at least 200 mL water (7). Avoid chewing or crushing the seeds which can release a pigment that deposits in renal tubules (5). Adequate fluid intake is necessary and should be at least 150 mL water for each 5 grams of drug. The FDA labeling recommends at least 8 ounces (a full glass) of water or other fluid with each dose. Taking this product without enough liquid can cause choking (6). Black psyllium should be taken 30-60 minutes after a meal or the administration of other drugs (8). 

Editor's Comments:

Black psyllium is an aggressive-growing, perennial weed found throughout the world. The plant was spread with the colonization of the New World and was nicknamed "Englishman's foot" by the North American Indians.
The FDA requires that psyllium be labeled: "WARNING: Taking this product without adequate fluid may cause it to swell and block your throat or esophagus and may cause choking. Do not take this product if you have difficulty in swallowing. If you experience chest pain, vomiting, or difficulty in swallowing or breathing after taking this product, seek immediate medical attention" (6).

Specific References: Plantain

1          Monographs on the medicinal uses of plant drugs. Exeter, UK: European Scientific Co-op Phytother, 1997.

2          Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Trans. S. Klein. Boston, MA: American Botanical Council, 1998. 

3           Newall CA, Anderson LA, Philpson JD. Herbal Medicine: A Guide for Healthcare Professionals. London, UK: The Pharmaceutical Press, 1996.

4          The Review of Natural Products by Facts and Comparisons. St. Louis, MO: Wolters Kluwer Co., 1999.

5          Leung AY, Foster S. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics. 2nd ed. New York, NY: John Wiley & Sons, 1996. 

6        McGuffin M, Hobbs C, Upton R, Goldberg A, eds. American Herbal Products Association's Botanical Safety Handbook. Boca Raton, FL: CRC Press, LLC 1997.

7          Gruenwald J, Brendler T, Jaenicke C. PDR for Herbal Medicines. 1st ed. Montvale, NJ: Medical Economics Company, Inc., 1998.

8          Covington TR, et al. Handbook of Nonprescription Drugs. 11th ed. Washington, DC: American Pharmaceutical Association, 1996.

9          Cook IJ, Irvine EJ, Campbell D, et al. Effect of dietary fiber on rectosigmoid motility in patients with irritable bowel syndrome: A controlled, crossover study. Gastroenterology 1990;98:66-72. 

10       Etman M. Effect of a bulk forming laxative on the bioavailablility of carbamazepine in man. Drug Dev Ind Pharm 1995;21:1901-6.

11        Perlman BB. Interaction between lithium salts and ispaghula husk. Lancet 1990;335:416. 

12        Agha FP, Nostrant TT, Fiddian-Green RG. Giant colonic bezoar: a medication bezoar due to psyllium seed husks. Am J Gastroenterol 1984;79:319-21. 

13       Anderson JW, Allgood LD, Turner J, et al. Effects of psyllium on glucose and serum lipid responses in men with type 2 diabetes and hypercholesterolemia. Am J Clin Nutr 1999;70:466-73.

14      Suhonen R, Kantola I, Bjorksten F. Anaphylactic shock due to ingestion of psyllium laxative. Allergy 1983;38:363-5.

15 Vaswani SK, Hamilton RG, Valentine MD, Adkinson NF. Psyllium laxative induced anaphylaxis, asthma, and rhinitis. Allergy 1996;51:266-8.

16 Freeman GL. Psyllium hypersensitivity. Ann Allergy 1994;73:490-2. 

17 Wolever TM, Vuksan V, Eshuis H, et al. Effect of method of administration of psyllium on glycemic response and carbohydrate digestibility. J Am Coll Nutr 1991;10:364-71.

18 Lantner RR, Espiritu BR, Zumerchik P, Tobin MC. Anaphylaxis following ingestion of a psyllium-containing cereal. JAMA 1990;264:2534-6.

19 Schneider RP. Perdiem causes esophageal impaction and bezoars. South Med J 1989;82:1449-50. 

20 Shulman LM, Minagar A, Weiner WJ. Perdiem causing esophageal obstruction in Parkinson's disease. Neurology 1999;52:670-1. 

21 Kaplan MJ. Anaphylactic reaction to "Heartwise." N Engl J Med 1990;323:1072-3.

22 Frati Munari AC, Benitez Pinto W, Raul Ariza Andraca C, Casarrubias M. Lowering glycemic index of food by acarbose and Plantago psyllium mucilage. Arch Med Res 1998;29:137-41.