Prescription drugs are not sensitive to trends in some way. Marketing can drive demand and consumption, but long-term consumption is often driven by efficiency. Some drugs that are used regularly today are decades old (eg, penicillin for strep throat), because nothing better has been identified. Some drugs may be used for decades, only to disappear largely as new, more effective treatments are introduced (I think of drugs like theophylline for asthma, which are largely replaced by safer and more effective drugs).
The opposite is often the case with supplements. With few exceptions, supplements are often not supported by convincing scientific evidence. Their use is driven by marketing, word of mouth, and hype. In pharmacy we used to call it the Oprah effect or the Dr. effect. Oz – remember green coffee beans? Or red palm oil? These supplements rose in popularity until they disappeared – because they didn’t work. Successful brands have the best sales pitch of all – it works.
My first general response to a request about the effectiveness of a new supplement is to look at the evidence base. I might go to PubMed and search specifically, but I’ll usually look to a trusted higher education reference like UpToDate, NatMed, or Examine.com for their product coverage and evidence. In most cases, there is little evidence to review, which makes for a boring blog post. I was asked about a product recently that has been tested in multiple randomized controlled trials – which makes for better blog fodder, as there is some science to consider.
Maritime Pine Bark
Maritime Pine Bark is extracted from Pinus pinaster tree, commonly marketed under the trade name Pycnogenol. Maritime pine is native to Mediterranean countries such as Spain, France, Portugal, Italy, Croatia and Morocco. Its bark is used in supplements for various conditions. Pycnogenol, a patented extract from French maritime pine (pictured above), comes from trees grown only in the Landes de Gascogne, in southwestern France.
One of the biggest challenges in conducting clinical trials related to herbs is that products will vary in terms of their chemical composition. If you think of an herbal remedy as a crude drug, the individual compounds in it will vary based on the variety of the plant, when it was harvested, which part of the plant was harvested, and how the supplements were actually prepared. Standardization addresses this by ensuring (usually through manufacturing and testing) that there are consistent amounts of one or more specified chemicals that are considered to be “active” ingredients. Standardization, once in place, gives the user greater confidence that the results of clinical trials on that product will be useful for the product they are taking and the effects they expect.
Pycnogenol brand maritime pine bark is rich in potentially biologically active compounds such as flavonoids and phenolic acids, including procyanidin, catechin, epicatechin, taxifolin, caffeic acid, and ferulic acid. Many clinical studies have been conducted with Pycnogenol-branded extract, so I will refer to this product in the evidence review.
One of the general rules of drugs (and supplements) is that if there are very different effects that the product is claimed to have, it is unlikely that any of those claims are true. And there are many applications for Pycnogenol: Coronary artery disease, osteoarthritis, venous insufficiency, asthma, high blood pressure, diabetes, irritable bowel and male sexual dysfunction are all said to benefit from this supplement. Although it is unlikely that a single product will have beneficial effects (and no harm) in so many cases, it is definitely not possible.
The health benefits of Pycnogenol are due to its mix of polyphenols. After consumption, some of these compounds are broken down by intestinal bacteria into biologically active compounds that are absorbed. Experimental evidence shows that it can reduce pain and inflammation by inhibiting pathways that produce inflammatory compounds. As an antioxidant, Pycnogenol may scavenge free radicals, and increase the effectiveness of other antioxidants such as vitamins C and E. It may support blood flow and vascular health by stimulating the production of nitric oxide and strengthening blood vessels. All this is possible based on chemicals, but the proof is when the results are seen in real people.
Evidence base
The tests themselves are often small and often biased. That said, there are some pretty interesting findings. Pycnogenol appears to be effective in asthma (can reduce rescue inhaler use) when added to standard asthma medications. It may also improve leg pain and reduce feelings of heaviness in patients with chronic venous insufficiency. When taking osteoarthritis, the use of Pycnogenol reduces the need for anti-inflammatory drugs, compared to placebo.
In some cases, the evidence is less compelling. There may be good results for cardiovascular conditions, but test bias makes the results negative. The same can be said for cognitive effects or ADHD, skin health, and allergies. A 2012 Cochrane review of Pycnogenol for chronic conditions looked at evidence for asthma, ADHD, venous insufficiency, diabetes, erectile dysfunction, high blood pressure and osteoarthritis. concluded that,
Due to the small sample size, the limited number of trials for each condition, the diversity of the outcomes evaluated and the outcome measures used, and the risk of bias in the included studies, no definite conclusions about the efficacy or safety of Pycnogenol are possible.
You have to give credit to the supplement manufacturer for sponsoring clinical trials on their product, which is a step that is often skipped, when you can sell a product without any research. Indeed the product appears to have biological and potentially positive therapeutic effects. It is generally well tolerated and studied in trials of up to a year in adults. Rare side effects include gastrointestinal problems such as nausea, headache, dizziness, drowsiness and vertigo.
“More research is needed” is a general statement, but it applies here. Although there are promising hints of therapeutic effects, there is no compelling research to suggest that Pycnogenol can replace medication or delay its need. For those who are really interested in using the product, the ingredients of the maritime pine barks containing Pycnogenol are the most studied and have the advantage of measuring, so you can be more sure of what you are buying.
So when it comes to Pycnogenol, I wouldn’t recommend it as a daily or regular supplement, but I wouldn’t dismiss it if someone wanted to use it for one of the more evidence-based reasons for use. We hope that more trials will be conducted to better determine its place in treatment.
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