Boswellia

• How It Works

  Boswellia may be helpful for some inflammatory conditions, such as arthritis. A few studies also suggest it may reduce radiation therapy side effects, but more studies are needed.

  The gummy resin derived from the bark of Boswellia is widely used in Ayurvedic medicine. It contains the compound boswellic acid, which exhibits certain biological properties. In lab animals, boswellic acid inhibited an enzyme important to inflammation. A few clinical trials in patients with colitis and osteoarthritis have also shown anti-inflammatory effects. However, a study of boswellia for maintenance of Crohn’s disease remission showed no significant benefit.

  Even though lab studies suggest compounds in boswellia have anticancer properties, it is not known whether these effects could occur in humans. Only a few clinical studies have been done that suggest boswellia may reduce inflammation or swelling caused by radiation therapy. More studies are needed to confirm such effects.

  Even though similar in many functions, boswellia should not be confused with guggul or myrrh.

• Purported Uses
  • To treat osteoarthritis
    Although a few studies suggest benefit, the evidence is insufficient. Larger well designed trials are needed.
  • To treat asthma
    Boswellia reduced symptoms of bronchial asthma in a clinical trial, but more studies are needed to draw a conclusion.
  • To treat colitis
    Studies in animals suggest that boswellia can reduce inflammation, but small preliminary trials in humans are mixed.
  • To reduce inflammation
    Studies in animals and from clinical trials show that this herb can reduce certain inflammatory conditions.
  • To treat cancer
    Even though lab studies suggest compounds in boswellia have anticancer properties, human studies to evaluate these effects have not been conducted.
  • To reduce radiation therapy side effects
    Only a few studies have been done in humans that suggest boswellia may reduce inflammation or swelling due to radiation therapy. More studies are needed to confirm such effects. 
• Do Not Take If
  • You are taking drugs that are substrates of P-Glycoprotein (P-Gp): Boswellia may affect how these drugs are absorbed or metabolized. Clinical significance has yet to be determined.
  • You are using anticoagulant and/or antiplatelet drugs: Boswellia may increase risk of bleeding when used with these drugs.
• Side Effects

  Case reports

  • Allergic contact dermatitis was reported following use of a topical cream containing an extract of Boswellia serrata.
  • A 17-year-old girl with celiac disease developed a gastric bezoar (accumulation of vegetable fiber, hair or other substances, in the stomach or small intestine) after excessive intake of olibanum (frankincense). Her symptoms, including abdominal pain and vomiting, improved after the bezoar was surgically removed.
• Scientific Name

  Boswellia serrata

• Clinical Summary

  Boswellia serrata is a tree prevalent in India, the Middle East and North Africa. The gummy exudate or resin obtained by peeling away the bark is commonly known as frankincense or olibanum. Boswellia, also referred to as Indian frankincense, is used widely in Ayurveda for treating arthritis, ulcerative colitis, coughs, sores, wound healing, and asthma. It is marketed as a supplement to support and improve joint health and mobility.

  The major component is boswellic acid ⁽¹⁾, a 5-lipoxygenase inhibitor with anti-inflammatory and anti-arthritic effects ^{(1) (2) (3)}. It also demonstrated cytotoxic ^{(4) (5) (6) (7)} and radio-enhancing properties ⁽²¹⁾, and prevented intestinal tumorigenesis in a murine model ⁽²⁶⁾. Other animal studies suggest boswellia may improve cognitive impairment and insulin resistance ⁽⁴²⁾. Essential oil of boswellia has been shown to have antimicrobial activities ⁽²⁴⁾.

  Preliminary data suggest benefit with boswellia for bronchial asthma ⁽⁸⁾, ulcerative colitis ⁽⁹⁾, mild irritable bowel syndrome ⁽³⁸⁾, and osteo-muscular pain ⁽³⁶⁾. However, these trials are mostly small and nonrandomized. In addition, current evidence is mostly unclear or negative on any benefits for collagenous colitis ^{(12) (13) (14)}, and demonstrated no significant benefit in maintaining Crohn’s disease remission ⁽¹⁵⁾. In osteoarthritis, one trial using an enriched boswellic acid extract suggests benefit ⁽¹¹⁾, and other studies report efficacy with formulations containing boswellia, Terminalia chebula, turmeric ⁽³⁹⁾, and boswellic acid along with curcumin ⁽⁴⁰⁾. However, larger well-designed studies are needed for clinical recommendation ⁽⁴¹⁾.

  Other preliminary data suggest boswellia may be effective in reducing cerebral edema in patients with brain tumors following radiotherapy ⁽²³⁾. A boswellia-based cream was found useful in preventing skin damage due to radiotherapy in breast cancer patients ⁽³²⁾. Other data suggest that a combination of boswellic acid, betaine, and myo-inositol treatment may help to reduce mammary density, a risk factor for breast cancer ⁽³³⁾.

  Although similar in many functions, boswellia should not be confused with guggul or myrrh.

• Purported Uses
  • Arthritis
  • Asthma
  • Colitis
  • Inflammation
  • Radiation therapy side effects
• Mechanism of Action

  Boswellic acid, the major constituent of boswellia, is thought to contribute to most of the herb’s pharmacological activities. In vitro and animal studies show that anti-inflammatory activity occurs via inhibition of 5-lipoxygenase ^(2) (3) and cyclooxygenase-1 ⁽³⁵⁾. It also inhibits nuclear transcription factor KappaB (NF-KappaB) signaling, markedly decreasing production of the key proinflammatory cytokine tumor necrosis factor (TNF-alpha) ⁽¹⁷⁾. Unlike other non-steroidal anti-inflammatory drugs, however, boswellic acid failed to show analgesic or antipyretic effects ⁽¹⁶⁾.

  Research on cytotoxic effects of boswellic acid indicates that it induces p21 expression through a p53-independent pathway and causes apoptosis in glioma ^(4) (6) and leukemia ⁽⁵⁾ cell lines. A boswellia extract induced apoptosis in a cervical cancer cell line by inducing endoplasmic reticulum (ER) stress ⁽¹⁸⁾. Other apoptotic mechanisms include early generation of nitric oxide and reactive oxygen species that upregulated time-dependent expression of p53/p21/PUMA ⁽¹⁹⁾, inhibition of microsomal prostaglandin E synthase-1 (mPGES-1), and decreased prostaglandin (PGE2) levels and its downstream targets ⁽³⁷⁾.

  A semisynthetic analog of boswellic acid, 3-alpha-Butyryloxy-beta-boswellic acid, demonstrated significant growth inhibition in Ehrlich Ascitic Tumour (EAT), Ehrlich Ascitic Carcinoma (EAC) and Sarcoma-180 tumor models, via NF-KappaB downregulation and induction of poly (ADP-ribose) polymerase (PARP) cleavage ⁽²⁷⁾. Acetyl-boswellic acids inhibited topoisomerases by competing with DNA for binding sites ⁽²⁰⁾. Acetyl-11-keto-beta-boswellic acid (AKBA) inhibited human prostate tumor growth via inhibition of VEGFR2-induced angiogenesis ⁽²²⁾. In vitro, antiplatelet effects of boswellia gum resin extracts are attributed to inhibition of clotting factors Xa and XIa. ⁽³⁴⁾.

• Adverse Reactions

  Generally well tolerated ⁽¹⁵⁾.

  Case reports

  • Allergic contact dermatitis was reported following use of a topical cream containing an extract of Boswellia serrata ⁽²⁸⁾.
  • A 17-year-old girl with celiac disease developed a gastric bezoar (accumulation of vegetable fiber, hair or other substances, in the stomach or small intestine) after excessive intake of olibanum (frankincense). Her symptoms, including epigastric pain and vomiting, resolved after the bezoar was surgically removed ⁽²⁹⁾.
  • In IBS patients supplemented with Casperome®, mild stypsis was the only unwanted effect recorded ⁽³⁸⁾.
• Herb-Drug Interactions
  • OATP1B3 (an anion transporter): Both 11-keto-beta-boswellic acid (KBA) and 3-acetyl-11-keto-beta-boswellic acid (AKBA) modulated the activity of OATP1B3, in vitro ⁽³⁰⁾. Clinical relevance is not known.
  • MRP2 (a multidrug resistant protein): Both 11-keto-beta-boswellic acid (KBA) and 3-acetyl-11-keto-beta-boswellic acid (AKBA) modulated the activity of MRP2, in vitro ⁽³⁰⁾. Clinical relevance is not known.
  • P-Glycoprotein (P-Gp): A Boswellia extract and keto-boswellic acids inhibit the activity of P-Glycoprotein in vitro, and may affect the transport of drugs mediated by this protein ⁽³¹⁾. Clinical significance has yet to be determined.
  • Anticoagulant and/or antiplatelet drugs: Boswellia extracts can inhibit platelet aggregation and may increase risk of bleeding when used with these drugs ⁽³⁴⁾.
• References

  1. Dahmen U, Gu YL, Dirsch O, et al. Boswellic acid, a potent antiinflammatory drug, inhibits rejection to the same extent as high dose steroids. Transplant Proc. Feb-Mar 2001;33(1-2):539-541.

  2. Safayhi H, Boden SE, Schweizer S, et al. Concentration-dependent potentiating and inhibitory effects of Boswellia extracts on 5-lipoxygenase product formation in stimulated PMNL. Planta Med. Mar 2000;66(2):110-113.

  3. Safayhi H, Mack T, Sabieraj J, et al. Boswellic acids: novel, specific, nonredox inhibitors of 5-lipoxygenase. J Pharmacol Exp Ther. Jun 1992;261(3):1143-1146.

  4. Glaser T, Winter S, Groscurth P, et al. Boswellic acids and malignant glioma: induction of apoptosis but no modulation of drug sensitivity. Br J Cancer. May 1999;80(5-6):756-765.

  5. Jing Y, Nakajo S, Xia L, et al. Boswellic acid acetate induces differentiation and apoptosis in leukemia cell lines. Leuk Res. Jan 1999;23(1):43-50.

  6. Winking M, Sarikaya S, Rahmanian A, et al. Boswellic acids inhibit glioma growth: a new treatment option? J Neurooncol. 2000;46(2):97-103.

  7. Frank MB, Yang Q, Osban J, et al. Frankincense oil derived from Boswellia carteri induces tumor cell specific cytotoxicity. BMC Complement Altern Med. 2009 Mar 18;9:6.

  8. Gupta I, Gupta V, Parihar A, et al. Effects of Boswellia serrata gum resin in patients with bronchial asthma: results of a double-blind, placebo-controlled, 6-week clinical study. Eur J Med Res. Nov 17 1998;3(11):511-514.

  9. Gupta I, Parihar A, Malhotra P, et al. Effects of Boswellia serrata gum resin in patients with ulcerative colitis. Eur J Med Res. Jan 1997;2(1):37-43.

  10. Chrubasik JE, Roufogalis BD, Chrubasik S. Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain. Phytother Res. Jul 2007;21(7):675-683.

  11. Sengupta K, Alluri KV, Satish AR, et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin(R) for treatment of osteoarthritis of the knee. Arthritis Res Ther. Jul 30 2008;10(4):R85.

  12. Kafil TS, Nguyen TM, Patton PH, et al. Interventions for treating collagenous colitis. Cochrane Database Syst Rev. Nov 11 2017;11:Cd003575.

  13. Madisch A, Miehlke S, Eichele O, et al. Boswellia serrata extract for the treatment of collagenous colitis. A double-blind, randomized, placebo-controlled, multicenter trial. Int J Colorectal Dis. Dec 2007;22(12):1445-1451.

  14. Chande N, MacDonald JK, McDonald JW. Interventions for treating microscopic colitis: a Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Review Group systematic review of randomized trials. Am J Gastroenterol. 2009 Jan;104(1):235-41.

  15. Holtmeier W, Zeuzem S, PreiB, J, et al. Randomized, placebo-controlled, double-blind trial of Boswellia serrata in maintaining remission of Crohn’s disease. Inflamm Bowel Dis. 2011 Feb;17(2):573-82

  16. Singh GB, Atal CK. Pharmacology of an extract of salai guggal ex-Boswellia serrata, a new non-steroidal anti-inflammatory agent. Agents Actions. Jun 1986;18(3-4):407-412.

  17. Wang H, Syrovets T, Kess D, et al. Targeting NF-KB with a natural triterpenoid alleviates skin inflammation in a mouse model of psoriasis. J Immunol. Oct 2009;183(7):4755-63.

  18. Kim HR, Kim MS, Kwon DY, et al. Boswellia serrata-induced apoptosis is related with ER stress and calcium release. Genes Nutr. Feb 2008;2(4):371-374.

  19. Bhushan S, Malik F, Kumar A, et al. Activation of p53/p21/PUMA alliance and disruption of PI-3/Akt in multimodal targeting of apoptotic signaling cascades in cervical cancer cells by a pentacyclic triterpenediol from Boswellia serrata. Mol Carcinog. 2009 Dec;48(12):1093-108.

  20. Syrovets T, Buchele B, Gedig E, et al. Acetyl-boswellic acids are novel catalytic inhibitors of human topoisomerases I and IIalpha. Mol Pharmacol. Jul 2000;58(1):71-81.

  21. Conti S, Vexler A, Edry-Botzer L, et al. Combined acetyl-11-keto-beta-boswellic acid and radiation treatment inhibited glioblastoma tumor cells. PLoS One. 2018;13(7):e0198627.

  22. Pang X, Yi Z, Zhang X, et al. Acetyl-11-keto-beta-boswellic acid inhibits prostate tumor growth by suppressing vascular endothelial growth factor receptor 2-mediated angiogenesis. Cancer Res. 2009 Jul 15;69(14):5893-900.

  23. Kirste S, Treier M, Wehrle SJ, et al. Boswellia serrata acts on cerebral edema in patients irradiated for brain tumors: A prospective, randomized, placebo-controlled, double-blind pilot trial. Cancer. 2011;117(16):3788-95.

  24. Camarda L, Dayton T, Di Stefano V, Pitonzo R, Schillaci D. Chemical composition and antimicrobial activity of some oleogum resin essential oils from Boswellia spp. (Burseraceae). Ann Chim. 2007 Sep;97(9):837-44.

  25. Mikhaeil BR, Maatooq GT, Badria FA, Amer MM. Chemistry and immunomodulatory activity of frankincense oil. Z Naturforsch C. 2003 Mar-Apr;58(3-4):230-8.

  26. Wang R, Wang Y, Gao Z, Qu X. The comparative study of acetyl-11-keto-beta-boswellic acid (AKBA) and aspirin in the prevention of intestinal adenomatous polyposis in APC(Min/+) mice. Drug Discov Ther. 2014 Feb;8(1):25-32.

  27. Qurishi Y, Hamid A, Sharma PR, et al. NF-κB down-regulation and PARP cleavage by novel 3-α-butyryloxy-β-boswellic acid results in cancer cell specific apoptosis and in vivo tumor regression. Anticancer Agents Med Chem. 2013 Jun;13(5):777-90.

  28. Acebo E, Ratón JA, Sautúa S, et al. Allergic contact dermatitis from Boswellia serrata extract in a naturopathic cream. Contact Dermatitis. 2004 Aug;51(2):91-2.

  29. El Fortia M, Badi H, Elalem Kh, Kadiki O, Topov Y. Olibanum bezoar: complication of a traditional popular medicine. East Mediterr Health J. 2006 Nov;12(6):927-9.

  30. Krüger P, Kanzer J, Hummel J, et al. Permeation of Boswellia extract in the Caco-2 model and possible interactions of its constituents KBA and AKBA with OATP1B3 and MRP2. Eur J Pharm Sci. 2009 Feb 15;36(2-3):275-84.

  31. Weber CC, Reising K, Müller WE, et al. Modulation of Pgp function by boswellic acids. Planta Med. 2006 May;72(6):507-13.

  32. Togni S, Maramaldi G, Bonetta A, Giacomelli L, Di Pierro F. Clinical evaluation of safety and efficacy of Boswellia-based cream for prevention of adjuvant radiotherapy skin damage in mammary carcinoma: a randomized placebo controlled trial. Eur Rev Med Pharmacol Sci. 2015 Apr;19(8):1338-44.

  33. Pasta V, Gullo G, Giuliani A, et al. An association of boswellia, betaine and myo-inositol (Eumastos(R)) in the treatment of mammographic breast density: a randomized, double-blind study. Eur Rev Med Pharmacol Sci. Nov 2015;19(22):4419-4426.

  34. Kokkiripati PK, Bhakshu LM, Marri S, et al. Gum resin of Boswellia serrata inhibited human monocytic (THP-1) cell activation and platelet aggregation. J Ethnopharmacol. 2011 Sep 1;137(1):893-901.

  35. Siemoneit U, Hofmann B, Kather N, et al. Identification and functional analysis of cyclooxygenase-1 as a molecular target of boswellic acids. Biochem Pharmacol. 2008 Jan 15;75(2):503-13.

  36. Franceschi F, Togni S, Belcaro G, et al. A novel lecithin based delivery form of Boswellic acids (Casperome®) for the management of osteo-muscular pain: a registry study in young rugby players. Eur Rev Med Pharmacol Sci. 2016 Oct;20(19):4156-4161.

  37. Ranjbarnejad T, Saidijam M, Moradkhani S, Najafi R. Methanolic extract of Boswellia serrata exhibits anti-cancer activities by targeting microsomal prostaglandin E synthase-1 in human colon cancer cells. Prostaglandins Other Lipid Mediat. 2017 May 24;131:1-8.

  38. Belcaro G, Gizzi G, Pellegrini L, et al. Supplementation with a lecithin-based delivery form of Boswellia serrata extract (Casperome®) controls symptoms of mild irritable bowel syndrome. Eur Rev Med Pharmacol Sci. 2017 May;21(9):2249-2254.

  39. Karlapudi V, Prasad Mungara AVV, Sengupta K, Davis BA, Raychaudhuri SP. A Placebo-Controlled Double-Blind Study Demonstrates the Clinical Efficacy of a Novel Herbal Formulation for Relieving Joint Discomfort in Human Subjects with Osteoarthritis of Knee. J Med Food. 2018 May;21(5):511-520.

  40. Haroyan A, Mukuchyan V, Mkrtchyan N,  et al. Efficacy and safety of curcumin and its combination with boswellic acid in osteoarthritis: a comparative, randomized, double-blind, placebo-controlled study. BMC Complement Altern Med. 2018 Jan 9;18(1):7.

  41. Bannuru RR, Osani MC, Al-Eid F, Wang C. Efficacy of curcumin and Boswellia for knee osteoarthritis: Systematic review and meta-analysis. Semin Arthritis Rheum. 2018 Dec;48(3):416-429.

  42. Gomaa AA, Makboul RM, Al-Mokhtar MA, et al. Polyphenol-rich Boswellia serrata gum prevents cognitive impairment and insulin resistance of diabetic rats through inhibition of GSK3beta activity, oxidative stress and pro-inflammatory cytokines. Biomed Pharmacother. Jan 2019;109:281-292.