Written by Karen Pilkington and the CAM-Cancer Consortium.
Updated February 8, 2017

Echinacea spp

Is it safe?

Adverse events

Safety data mainly derived from clinical trials and single case reports indicates that echinacea is generally well-tolerated.40 Most frequently reported adverse effects include gastro-intestinal upsets and rashes.41,20 Individuals with atopia or sensitivity to the Asteraceae/Compositae plant family might be at increased risk of allergic reactions (urticaria, bronchospasm and anaphylaxis).41 Administration of echinacea by injection has been associated with shivering, fever and muscle weakness.1,42 Echinacea has been implicated as a possible causative agent in joint and muscle pain, liver-related problems such as raised liver enzymes and hepatitis, and Sjögren’s syndrome but this causality has not been confirmed and these have been reported only rarely.1,42

Short-term treatment with echinacea has been assessed as likely to be safe as several forms of echinacea have been used apparently safely in trials lasting up to 12 weeks.1 The EMEA recommends treatment durations for the common cold and for topical treatment of wounds of not more than 10 days and not more than a week respectively.5 Duration of treatment for other indications is unclear and there is insufficient reliable evidence about the safety of long-term treatment with echinacea.1


Use of echinacea purpurea juice has been assessed as possibly safe if used orally short-term in children from 2 to 11 years of age.1 However, it may increase the risk of rash in some children. The EMEA does not recommend the use in children and states that use below 1 year of age is contra-indicated.5

There are limited data on the safety of echinacea in pregnancy: it is insufficient to draw firm conclusions and data on the effect on the immune system of the newborn child are not available.1,42 Similarly, there is insufficient reliable information on its use in breast feeding.1 The EMEA recommends that echinacea should be avoided in pregnancy and while breast feeding.5 The EMEA also recommends that, because of its immunostimulating activity, echinacea should not be used in cases of progressive systemic disorders, autoimmune diseases, immunodeficiencies, immunosuppression and diseases of the white blood cell system.5


Echinacea appears to inhibit CYP1A2 enzymes in humans and so in theory might increase levels of drugs metabolised by CYP1A2.1 These include paracetamol, amitriptyline, diazepam, oestradiol, ondansetron, propranolol, theophylline, warfarin and others.

Preliminary evidence suggests that echinacea inhibits intestinal CYP3A4 and induces hepatic CYP3A4 enzymes.1 It is unclear how this is likely to affect drugs metabolized by CYP3A4. These include lovastatin, clarithromycin, cyclosporine, oestrogens and others. A case has been reported of a probable interaction between cytotoxic drug, etoposide, and Echinacea which resulted in trombocytopenia requiring a pplatelet transfusion.45

Echinacea purpurea did not significantly alter the pharmacokinetics of the CYP3A4 substrate docetaxel in a study of ten cancer patients receiving 135 mg, 60 min IV infusion of docetaxel before intake of a commercially available E. purpurea extract (20 oral drops three times daily) and 3 weeks later after a 14 day supplementation period with E. purpurea.47

As echinacea has immuno-stimulating activity, in theory it may interfere with immunosuppressant treatment.1

Quality issues

Products available as echinacea vary in composition depending on the species, parts of the plant used and the extraction method used in production.6 Some manufacturers standardise echinacea extracts according to echinacoside content while others standardise to chicoric acid.2 Analysis of a range of echinacea products, however, revealed that many were mislabelled, contained substances other than the herb or actually contained no echinacea.43,44 Quality of echinacea products will depend at least partially on the regulatory standards and good manufacturing requirements in the country in which the product is manufactured.

Citation Karen Pilkington, CAM-Cancer Consortium. Echinacea spp [online document]. http://ws.cam-cancer.org/The-Summaries/Herbal-products/Echinacea-spp. February 8, 2017.


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