Family

Sapindaceae (classified in Hippocastanaceae until 1998).

Parts Used

Seeds.

The bark and leaf of the tree are separate remedies, little used today. ^1,2

Common Forms

• Tincture:   Fresh or dried seed, 65% alcohol.

• Standardized Extract:   Horse chestnut standardized extract (HCSE)—5:1 to 8:1 standardized to 16% to 20% triterpene glycosides, tablets or capsules (Aesculoforce, Bioforce AG; Venostat, Pharmaton Natural Health Products).

• Topical:   Ointments, gels containing extracts at 2% aescin.

Strategic Considerations

Horse chestnut preparations have been popular in Europe for several decades, used for a variety of conditions of the venous system, both chronic (venous insufficiency, varicosities, hemorrhoids, leg ulcers, and edema) and acute (postoperative and posttraumatic edema, including elevated intracranial pressure, traumatic hematoma, contusions, and soft tissue swelling; sports injuries, especially involving edema). Aesculus seed is well described by Weiss ³ under diseases of the venous system and has monographs by the German Commission E ⁴ (1994, revised from an earlier unapproved monograph of leaf and flower in 1984), World Health Organization (WHO) in 2002, and European Scientific Cooperative on Phytotherapy (ESCOP) in 2003, as well as a recent literature review by McKenna et al. ⁷ Clinical trials for horse chestnut in chronic venous insufficiency (CVI) have been subjected to meta-analysis for the Cochrane database by Pittler and Ernst, ⁸ who found positive evidence for short-term efficacy in treating CVI.

Pharmacological attention has focused on the activity of the triterpene saponin fraction, a complex mixture of triterpenoids usually described as escin (aescin), which has venoactive anti-inflammatory and antiedematous properties, with some in vitro antioxidant, antiproliferative, and immunomodulatory activities. ^9,10Available controlled clinical trials (13 total, 8 placebo controlled) of HCSE for venous insufficiency were systematically reviewed by Pittler and Ernst, ¹¹ who concluded HCSE was safe, effective, and superior to placebo for short-term treatment of CVI. European use has also involved parenteral preparations of aescin (sodium escinate) and extensive use of a proprietary topical product Essaven which is a combination of aescin with pharmaceutical ingredients, heparin and phospholipids.

The monographs by German Commission E ⁴ and ESCOP ⁶ list no known interactions between horse chestnut seed and pharmaceutical drugs. (See, however, the later precaution regarding gentamicin from WHO.) Interactions reports in the literature are lacking. Positive clinical reports and trials of the topical combination product Essaven since the 1970s suggest a potential benefit of the combination in a wide range of conditions, and this is therefore accorded the status of a beneficial interaction (heparin + phospholipid; see later). Earlier European studies provide some basis for considering a potentially beneficial interaction with corticosteroid therapy; this is also assigned a potential interaction status here despite a lack of recent data. Speculative interactions include warfarin and hypoglycemics. Pharmacokinetic data are not currently available, and effects on drug-metabolizing enzymes, if any, have not been established.

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