Garlic

• How It Works

  Garlic was shown to lower blood cholesterol and triglyceride levels. It is associated with decreased risk of some cancers, but there is no evidence that it can treat cancer.

  Raw garlic contains compounds called alliin and allicin. In laboratory studies, these compounds and their breakdown products have been found to kill bacteria directly, reduce the number of platelets in the blood and slow clotting, and reduce the level of lipids in the blood. Compounds called ajoenes are also responsible for garlic’s ability to prevent blood clots. Garlic may also reduce blood pressure. Garlic intake may protect against certain cancers possibly by decreasing tumor cell growth or stimulating the immune system.

  Processing can have a significant effect on the amount of active compounds in garlic: Garlic powder and garlic essential oil do not contain allicin or ajoene, compounds believed to be responsible for garlic’s cholesterol-reducing and blood-thinning properties.

  Because garlic has blood thinning property, patients taking warfarin or other blood thinners should ask their doctor before taking garlic supplements.

• Purported Uses
  • To fight skin infections
    Laboratory studies show that raw garlic has antibacterial, antiviral, antiparasitic, and antifungal activity.
  • To prevent and treat cancer
    A few clinical trials suggest that high garlic consumption may lower the risk of stomach and colorectal cancers. But a recent study did not find such benefit.
  • To treat heart disease
    Several clinical trials show that use of garlic supplements reduces cholesterol and triglyceride levels in the blood, which may reduce the risk of heart disease, but a handful of clinical trials contradict these findings. Clinical trials studying the effect of garlic on blood pressure and risk of heart disease have shown mixed results.
  • As an antioxidant
    No scientific evidence supports this use.
  • To treat atherosclerosis
    Several clinical trials show that use of garlic supplements reduces blood pressure as well as cholesterol and triglyceride blood levels, which are risk factors for developing atherosclerosis, but a handful of clinical trials contradict these findings. Clinical and laboratory studies support garlic’s antiplatelet activity, which may help prevent blood clots in patients with atherosclerosis.
  • To lower high cholesterol
    Several clinical trials show that use of garlic supplements reduces cholesterol and triglyceride levels in the blood, but some clinical trials contradict these findings.
  • To lower high blood pressure
    Clinical trials studying the effects of garlic on blood pressure have shown mixed results.
  • To treat circulatory disorders
    Clinical and laboratory studies support garlic’s antiplatelet activity, which may help prevent blood clots in patients with circulatory disorders.
• Patient Warnings

  Garlic supplements should be discontinued a week or two before undergoing surgery because of their potential for increasing bleeding time.

• Do Not Take If
  • You are taking warfarin or other blood thinners (Garlic may increase the risk of bleeding or bruising).
  • You take cyclosporine (Garlic can reduce its effectiveness and potentially cause transplant rejection).
  • You take protease inhibitors such as saquinavir (Fortovase®, Invirase®) (Garlic can significantly reduce their levels in the blood and reduce their effectiveness).
  • You are taking insulin (Dose adjustments may be required because of the occasional blood sugar-lowering effect of garlic supplements. Take with caution and consult your doctor).
  • If you are taking drugs that are substrates of Cytochrome P450  2C9, 2C19, 3A4 (Garlic may increase the risk of side effects of these drugs).
  • If you are taking drugs that are substrates of P-Glycoprotein (Garlic may reduce the activity of such drugs).
• Side Effects
  • Headache
  • Fatigue
  • Altered platelet function with potential for bleeding
  • Offensive odor, bad breath
  • Stomach upset
  • Diarrhea
  • Changes in the natural bacteria found in the intestines
  • Sweating
  • Low blood sugar
  • Contact dermatitis (inflammation, redness of the skin) when used topically.
  • Following excessive use of garlic supplements, one patient experienced prolonged bleeding time, diminished platelet blood clotting activity, and spinal epidural hematoma (collection of blood in the spinal canal).
  • A 51-year-old man developed renal hematoma after extracorporeal shock-wave lithotripsy (SWL) that occurred due to excessive odorless garlic ingestion. He was treated with antibiotics and fluids. His hematoma went into remission after five months.
  • Chemical burn of oral mucosa has been reported following consumption of crushed garlic.
  • Two episodes of severe, near-fatal anaphylaxis were reported in a 52-year-old man following ingestion of garlic.
  • Topical application of garlic to treat a facial wart resulted in a burn in a 23-year-old woman. 
  • Topical application of garlic and salt paste under occlusion caused a severe chemical burn in a 41-year-old man. His symptoms resolved after treatment and discontinuation of garlic use.
  • Use of an external garlic poultice for toothache resulted in significant chemical burn to the face.
  • An unusual garlic burn was reported on the neck of a patient, following application of crushed raw garlic to address symptoms of a sore throat.
• Brand Name

  Garlique®, Kwai®, Kyolic®, One-a-day Garlic®

• Scientific Name

  Allium sativum

• Clinical Summary

  Derived from the bulb or clove of the plant, garlic is used as a spice and to treat hyperlipidemia, hypertension, atherosclerosis, cancer, and infections. Because processing can have a substantial effect on the chemical content of garlic (the volatile oil components are sensitive to heat and certain enzymes are acid-labile), the best measure of the total activity of garlic is its ability to produce allicin, which in turn, results in the formation of other active constituents ⁽¹⁾. Several oral garlic formulations are available, and clinical studies have addressed a variety of the proposed claims.

  Placebo-controlled trials on the cholesterol lowering effect of garlic yielded mixed results ^{(2) (3) (4) (5) (6) (7) (31)}, but a systematic review showed that garlic is effective in lowering total cholesterol and LDL cholesterol levels ⁽³⁷⁾. Studies evaluating the antithrombotic effects repeatedly show modest reduction in platelet aggregation, but varying levels of fibrinolytic activity; and mixed effects with regard to reductions in blood glucose, blood pressure, or risk of cardiovascular disease ⁽⁸⁾. However, meta analyses show that there is consistent evidence to support use of garlic in lowering cardiovascular risk factors ⁽⁵⁰⁾; and that garlic supplements have the potential to decrease blood pressure in hypertensive individuals, to regulate cholesterol levels, and have immunostimulatory effects ⁽⁵³⁾. Garlic supplementation may also benefit patients with hepatopulmonary syndrome ⁽³²⁾. More data are needed to determine if garlic is effective against common cold ⁽³³⁾ and vaginal candidiasis ⁽⁴⁷⁾. Whether garlic is effective in reducing the risk of mortality and cardiovascular morbidity in patients diagnosed with hypertension also remains inconclusive ⁽⁴⁵⁾.

  An analysis of several case-controlled studies in Europe suggests an inverse association between garlic consumption and risk of common cancers ⁽⁹⁾. High intake of garlic may be protective against gastric ⁽¹⁰⁾ and colorectal cancers ⁽¹¹⁾; however, conflicting data indicate that long-term supplementation with garlic does not significantly reduce gastric cancer incidence nor mortality ⁽⁴³⁾. Garlic intake was inversely associated with cancer of the prostate ⁽¹²⁾ and endometrium ⁽¹³⁾. In patients with advanced cancers, aged garlic extract (AGE) improved natural killer (NK) cell number and activity, but not quality of life ⁽¹⁴⁾. In patients with a history of adenomas, supplementation with AGE reduced both the number and size of subsequent colorectal adenomas ⁽¹⁵⁾. Garlic supplementation may also be associated with reduced risk of hematologic malignancies ⁽⁴⁰⁾.

  Because garlic is known to decrease platelet aggregation and potentially elevate International Normalized Ratio (INR) values, it should not be used with anticoagulants or in patients with platelet dysfunction ⁽¹⁷⁾.

• Purported Uses
  • Atherosclerosis
  • Cancer prevention
  • Cancer treatment
  • Cardiovascular disease
  • Circulatory disorders
  • High cholesterol
  • Hypertension
  • Microbial infection
  • Skin infections
• Mechanism of Action

  The intact cells of garlic contain an odorless, sulfur-containing amino acid derivative known as alliin. When the cells are crushed, alliin comes into contact with the enzyme alliinase located in neighboring cells and is converted to allicin. Allicin is a potent antibiotic, but it is highly odoriferous and unstable. It is described as possessing antiplatelet, antibiotic, and antihyperlipidemic activities. Most authorities agree that the best measure of the total activity of garlic is its ability to produce allicin, which, in turn, results in the formation of other active constituents ⁽¹⁾.

  In patients with hyperlipidemia, garlic might lower cholesterol levels by acting as an HMG-CoA reductase inhibitor ⁽²¹⁾. For atherosclerosis, garlic is believed to reduce oxidative stress and low-density lipoprotein oxidation and have antithrombotic effects ⁽²²⁾. It is also thought to reduce blood pressure by causing smooth muscle relaxation and vasodilation by activating the production of endothelium-derived relaxation factor ⁽²³⁾.

  Garlic may stimulate both humoral and cellular immunity, causing T-cell proliferation, restoring suppressed antibody responses ⁽²⁴⁾, and stimulating macrophage cytotoxicity on tumor cells. It may increase selenium absorption with possible protection against tumorigenesis ⁽²⁵⁾. In addition, garlic may protect against certain cancers by halting cell cycle progression and inducing apoptosis of cancer cells as well as by decreasing angiogenesis and influencing carcinogen metabolism ^(26) (27).

• Warnings

  Discontinue use of garlic at least 7 days prior to surgery.
  ⁽¹⁷⁾

• Adverse Reactions
  • Case Reports:
  • Headache, fatigue, altered platelet function with potential for bleeding, offensive odor, GI upset, diarrhea, sweating, changes in the intestinal flora, hypoglycemia ⁽¹⁶⁾.
  • Prolonged bleeding time with spinal epidural hematoma and platelet dysfunction has occurred following excessive usage of garlic ⁽²⁹⁾.
  • A 51-year-old man developed renal hematoma after extracorporeal shock-wave lithotripsy (SWL) that occurred due to excessive odorless garlic ingestion. He was treated with antibiotics and fluids. His hematoma went into remission after five months ⁽³⁵⁾.
  • Chemical burn of oral mucosa has been reported following consumption of crushed garlic ⁽³⁶⁾.
  • Anaphylaxis ^(38) (54)
  • Topical application of garlic to treat a facial wart resulted in a burn in a 23-year-old woman ⁽⁴⁴⁾.
  • A 37-year-old woman who ate fresh garlic every day developed severe postoperative bleeding following hysterectomy ⁽⁴⁶⁾.
  • Topical application of garlic and salt paste under occlusion caused a severe chemical burn in a 41-year-old man. His symptoms resolved after treatment and discontinuation of garlic use ⁽⁴⁸⁾.
  • Use of an external garlic poultice for toothache resulted in significant chemical burn to the face ⁽⁵¹⁾.
  • An unusual garlic burn was reported on the neck of a patient, following application of crushed raw garlic to address symptoms of a sore throat ⁽⁵²⁾.
• Herb-Drug Interactions
  • Insulin: Dose of insulin may require adjustment due to hypoglycemic effects of garlic ⁽³⁹⁾.
  • Warfarin: Anticoagulant activity may be enhanced due to increased fibrinolytic activity and diminished human platelet aggregation ^(17) (49).
  • Saquinavir (Fortovase, Invirase): Consuming garlic can significantly decrease serum concentration levels. Garlic can decrease peak levels by 54% and mean trough levels by 49%. These reductions in levels can cause therapeutic failure ⁽¹⁸⁾.
  • Cytochrome (CYP) P450 substrates: Garlic can inhibit CYP 2C9, 2C19, 3A4 and may interfere with the drugs metabolized by these enzymes ^(41) (42).
  • P-Glycoprotein substrates: Garlic induces P-glycoprotein and can interfere with the metabolism of certain drugs ⁽³⁴⁾.
• Herb Lab Interactions
  • Insulin
  • Increased PT and INR
  • Decreased cholesterol
  • Change in blood pressure
• References

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  2. Ackermann RT, et al. Garlic shows promise for improving some cardiovascular risk factors. Arch Intern Med 2001;161:813-24.

  3. Berthold HK, et al. Effect of a garlic oil preparation on serum lipoproteins and cholesterol metabolism: a randomized controlled trial. JAMA 1998;279:1900-2.

  4. Gardner CD, et al. Effect of Raw Garlic vs Commercial Garlic Supplements on Plasma Lipid Concentrations in Adults With Moderate Hypercholesterolemia: A Randomized Clinical Trial. Arch Intern Med. 2007 Feb 26;167(4):346-53.

  5. Isaacsohn JL, et al. Garlic powder and plasma lipids and lipoproteins: a multicenter, randomized, placebo-controlled trial. Arch Inter Med 1998;158:1189-94.

  6. Kannar D, et al. Hypocholesterolemic effect of an enteric coated garlic supplement. J Am Coll Nutr 2001;20:225-31.

  7. Stevinson C, et al. Garlic for treating hypercholesterolemia: a meta-analysis of randomized clinical trials. Ann Intern Med 2000;133:420-9.

  8. Silagy CA, et al. A meta-analysis of the effect of garlic on blood pressure. J Hypertension 1994;12:463-8.

  9. Galeone C, Pelucchi C, Levi F, et al. Onion and garlic use and human cancer. Am J Clin Nutr 2006;84: 1027-32.

  10. Guercio V, Galeone C, Turati F, et al. Gastric cancer and allium vegetable intake: a critical review of the experimental and epidemiologic evidence. Nutr Cancer. 2014;66(5):757-73. doi: 10.1080/01635581.2014.904911.

  11. Ngo SN, Williams DB, Cobiac L, et al. Does garlic reduce risk of colorectal cancer? A systematic review. J Nutr. Oct 2007;137(10):2264-2269.

  12. Hsing AW, Chokkalingam AP, Gao YT, et al. Allium vegetables and risk of prostate cancer: a population-based study. J Natl Cancer Inst. Nov 6 2002;94(21):1648-1651.

  13. Galeone C, Pelucchi C, Dal Maso L, et al. Allium vegetables intake and endometrial cancer risk. Public Health Nutr. Nov 6 2008:1-4.

  14. Ishikawa H, Saeki T, Otani T, et al. Aged garlic extract prevents a decline of NK cell number and activity in patients with advanced cancer. J Nutr. Mar 2006;136(3 Suppl):816S-820S.

  15. Tanaka S, Haruma K, Yoshihara M, et al. Aged garlic extract has potential suppressive effect on colorectal adenomas in humans. J Nutr. Mar 2006;136(3 Suppl):821S-826S.

  16. Blumenthal M. Herbal Medicine, Expanded Commission E Monographs, 1^st ed. Austin: American Botanical Council; 2000.

  17. Ang-lee M, et al. Herbal Medicines and perioperative care. JAMA 2001;286:208-16.

  18. Piscitelli SC, et al. The effect of garlic supplements on the pharmacokinetics of saquinavir. Clin Infect.Dis. 2002;34:234-8.

  19. Amagase H, et al. Intake of garlic and its bioactive components. J Nutr 2001;131:955S-62S.

  20. Newall CA, et al. Herbal Medicines: A Guide for Health Care Professionals. London: Pharmaceutical Press; 1996.

  21. Qureshi AA, et al. Suppression of avian hepatic lipid metabolism by solvent extracts of garlic: impact on serum lipids. J Nutr 1983;113:1746-55.

  22. Dirsch VM, et al. Effect of allicin and ajoene, two compounds of garlic, on inducible nitric oxide synthase. Atherosclerosis 1998;139:333-9.

  23. Pedraza-Chaverri J, et al. Garlic prevents hypertension induced by chronic inhibition of nitric oxide synthesis. Life Sci 1998;62:71-7.

  24. Hodge G, et al. Allium sativum (garlic) suppresses leukocyte inflammatory cytokine production in vitro: potential therapeutic use in the treatment of inflammatory bowel disease. Cytometry 2002;48:209-15.

  25. Hirsch K, et al. Effect of purified allicin, the major ingredient in freshly crushed garlic, on cancer cell proliferation. Nutr Cancer 2000;38:245-54.

  26. Powolny AA, Singh SV. Multitargeted prevention and therapy of cancer by diallyl trisulfide and related Allium vegetable-derived organosulfur compounds. Cancer Lett. Oct 8 2008;269(2):305-314.

  27. Herman-Antosiewicz A, Powolny AA, Singh SV. Molecular targets of cancer chemoprevention by garlic-derived organosulfides.Acta Pharmacol Sin. Sep 2007;28(9):1355-1364.

  28. Song K, Milner JA. The influence of heating on the anticancer properties of garlic. J Nutrition 2001;131:1054S-7S.

  29. Rose KD, et al. Spontaneous spina epidural hematoma with associated platelet dysfunction from excessive garlic ingestion: a case report. Neurosurgery 1990;26:880-2.

  30. Brinker F. Herb Contraindications and Drug Interactions, 2^nd ed. Sandy (OR): Eclectic Med Publications; 1998.

  31. Hasani-Ranjbar S, Nayebi N, Moradi L, Mehri A, Larijani B, Abdollahi M. The efficacy and safety of herbal medicines used in the treatment of hyperlipidemia; a systematic review. Curr Pharm Des. 2010;16(26):2935-47.

  32. De BK, Dutta D, Pal SK, Gangopadhyay S, Das Baksi S, Pani A. The role of garlic in hepatopulmonary syndrome: a randomized controlled trial. Can J Gastroenterol. 2010 Mar;24(3):183-8.

  33. Lissiman E, Bhasale AL, Cohen M. Garlic for the common cold. Cochrane Database Syst Rev. 2012 Mar 14;3:CD006206.

  34. Hajda J, Rentsch KM, Gubler C, Steinert H, Stieger B, Fattinger K. Garlic extract induces intestinal P-glycoprotein, but exhibits no effect on intestinal and hepatic CYP3A4 in humans. Eur J Pharm Sci. 2010; 41(5):729-35.

  35. Gravas S, Tzortzis V, Rountas C, Melekos MD. Extracorporeal shock-wave lithotripsy and garlic consumption: a lesson to learn. Urol Res. 2010 Feb;38(1):61-3.

  36. Bagga S, Thomas BS, Bhat M. Garlic burn as self-inflicted mucosal injury—a case report and review of the literature. Quintessence Int. 2008 Jun;39(6):491-4.

  37. Hasani-Ranjbar S, Nayebi N, Moradi L, et al. The efficacy and safety of herbal medicines used in the treatment of hyperlipidemia; a systematic review. Curr Pharm Des. 2010;16(26):2935-47.

  38. Vovolis V, Kalogiros L, Ivanova D, Koutsostathis N. Garlic-induced severe anaphylaxis in a nonatopic patient. J Investig Allergol Clin Immunol. 2010;20(4):356.

  39. Madkor HR, Mansour SW, Ramadan G. Modulatory effects of garlic, ginger, turmeric and their mixture on hyperglycaemia, dyslipidaemia and oxidative stress in streptozotocin-nicotinamide diabetic rats. Br J Nutr. 2011 Apr;105(8):1210-7.

  40. Walter RB, Brasky TM, Milano F, White E. Vitamin, mineral, and specialty supplements and risk of hematologic malignancies in the prospective VITamins And Lifestyle (VITAL) study.Cancer Epidemiol Biomarkers Prev. 2011 Jul 29.

  41. Ho BE, Shen DD, McCune JS, et al. Effects of Garlic on Cytochromes P450 2C9- and 3A4-Mediated Drug Metabolism in Human Hepatocytes. Sci Pharm. 2010 Sep 30;78(3):473-81.

  42. Foster BC, Foster MS, Vandenhoek S, et al. An in vitro evaluation of human cytochrome P450 3A4 and P-glycoprotein inhibition by garlic. J Pharm Pharm Sci. 2001 May-Aug;4(2):176-84.

  43. Ma JL, Zhang L, Brown LM, et al. Fifteen-year effects of Helicobacter pylori, garlic, and vitamin treatments on gastric cancer incidence and mortality.J Natl Cancer Inst. 2012 Mar 21;104(6):488-92.

  44. Filobbos G, Chapman T, Gesakis K. Iatrogenic burns from garlic. J Burn Care Res. 2012 Jan-Feb;33(1):e21.

  45. Stabler SN, Tejani AM, Huynh F, Fowkes C. Garlic for the prevention of cardiovascular morbidity and mortality in hypertensive patients. Cochrane Database Syst Rev. 2012 Aug 15;8:CD007653.

  46. Erian M, McLaren G. Be wary of “natural” therapy in gynecological surgery. International Journal of Women’s Health. 2013:5 345–349.

  47. Watson CJ, Grando D, Fairley CK, et al. The effects of oral garlic on vaginal candida colony counts: a randomised placebo controlled double-blind trial. BJOG. 2014 Mar;121(4):498-506.

  48. Xu S, Heller M, Wu PA, Nambudiri VE. Chemical burn caused by topical application of garlic under occlusion. Dermatol Online J. 2014 Jan 15;20(1):21261.

  49. Ge B, Zhang Z, Zuo Z. Updates on the clinical evidenced herb-warfarin interactions. Evid Based Complement Alternat Med. 2014;2014:957362.

  50. Kwak JS, Kim JY, Paek JE, et al. Garlic powder intake and cardiovascular risk factors: a meta-analysis of randomized controlled clinical trials. Nutr Res Pract. 2014 Dec;8(6):644-54.

  51. Sisson D, Balmer C. A chemical burn from a garlic poultice applied to the face to treat toothache: a case report. Prim Dent J. 2014 Feb;3(1):28-9.

  52. Karabacak E, Aydın E, Kutlu A, Dogan B. An unusual garlic burn occurring on an unexpected area. BMJ Case Rep. 2014 Apr 7;2014.

  53. Ried K. Garlic Lowers Blood Pressure in Hypertensive Individuals, Regulates Serum Cholesterol, and Stimulates Immunity: An Updated Meta-analysis and Review. J Nutr. 2016 Feb;146(2):389S-96S.

  54. Treudler R, Reuter A, Engin AM, Simon JC. A Case of Anaphylaxis After Garlic Ingestion: Is Alliinase the Only Culprit Allergen? J Investig Allergol Clin Immunol. 2015;25(5):374-5.