Prescribed medicines are somewhat resistant to fads. Marketing can certainly drive demand and use, but long-term use tends to be driven by effectiveness. Some medicines used routinely today are decades old (e.g., penicillin for strep throat) because nothing better has been identified. Other drugs may be used for decades, only to largely disappear as newer, more effective treatments are introduced (I’m thinking of drugs like theophylline for airway disease, largely replaced by safer and more effective treatments).
The opposite is often the case with dietary supplements. With some exceptions, supplements tend not to be supported by convincing scientific evidence. Their use is driven by marketing, word-of-mouth, and hype. In the pharmacy we used to call it the Oprah effect or the Dr. Oz effect – remember green coffee bean? Or red palm oil? These supplements surged in popularity only to disappear – because they were ineffective. Effective products have the best sales pitch of all – they work.
My usual first response to a request about the effectiveness of a new supplement is to look at the evidence base. I may go to PubMed and search directly, but I’ll more commonly look at a trustworthy tertiary reference like UpToDate, NatMed, or Examine.com for their take on the product and the evidence. In a lot of cases, there’s little to no evidence worth reviewing, which makes for a boring blog post. I was asked about a product recently that was actually assessed in multiple randomized controlled trials – which makes for better blog fodder, as there’s some science to actually consider.
Maritime Pine Bark
Maritime Pine Bark is an extract from the Pinus pinaster tree, often marketed with the trade name Pycnogenol. The maritime pine is a tree native to Mediterranean countries like 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 Landes de Gascogne, in southwest France.
One of the biggest challenges with evaluating clinical trials related to herbal remedies is that products will differ in terms of their chemical constituents. If you think of a herbal remedy as essentially an unrefined drug, the individual compounds in it will vary based on the variety of the plant, when it was harvested, what part of the plant was harvested, and how the supplements was 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 thought to be the “active” ingredients. Standardization, when it’s in place, gives the user more confidence that the results of clinical trials with that product will be relevant to the product that you’re taking and the effects you’re expecting.
The Pycnogenol brand of maritime pine bark is rich in potentially biologically active compounds like flavonoids and phenolic acids, including procyanidins, catechin, epicatechin, taxifolin, caffeic acid, and ferulic acid. Most clinical studies have been conducted with the Pycnogenol-branded extract, so I will refer to this product in the review of the evidence.
One of the general rules of drugs (and supplements) is that the more diverse the effects a product is claimed to have, the less likely that any of those claims are probably true. And there are a lot of claims for Pycnogenol: Coronary artery disease, osteoarthritis, chronic venous insufficiency, asthma, high blood pressure, diabetes, irritable bowel and male sexual dysfunction are all claimed to benefit from this supplement. While it’s not impossible for one product to have beneficial effects (and no harms) in so many conditions, it’s definitely unlikely.
Pycnogenol’s health benefits are attributed to its mix of polyphenols. After consumption, some of these compounds are broken down by gut bacteria into biologically active ingredients which are absorbed. Experimental evidence suggests that it could reduce pain and inflammation by blocking pathways that produce inflammatory compounds. As an antioxidant, Pycnogenol could be neutralizing free radicals, and boosting the effectiveness of other antioxidants like vitamins C and E. It may support blood flow and vascular health by promoting nitric oxide production and strengthening blood vessels. All of these are possible based on the chemistry, but the proof is when the effects are demonstrated in actual humans.
Evidence base
The trials themselves are generally small and prone to bias. Having said that, there are some positive findings that look interesting. Pycnogenol is felt to be possibly effective for asthma (it may reduce rescue inhaler use) when added to regular asthma medications. It may also improve leg pain and reduce feelings of heaviness in patients with chronic venous insufficiency. When taken for osteoarthritis, Pycnogenol use reduced the need for anti-inflammatory medications, compared to a placebo.
For other conditions, the evidence is less compelling. There may be some positive effects on cardiovascular conditions, but bias in trials makes the conclusions less interesting. The same can be said for effects on cognition or ADHD, skin health, and allergies. A 2012 Cochrane review of Pycnogenol for chronic disorders looked at evidence for asthma, ADHD, chronic venous insufficiency, diabetes mellitus, erectile dysfunction, hypertension and osteoarthritis. it concluded,
Due to small sample size, limited numbers of trials per condition, variation in outcomes evaluated and outcome measures used, as well as the risk of bias in the included studies, no definitive conclusions regarding the efficacy or safety of Pycnogenol are possible.
It’s worth giving credit to a supplement manufacturer for sponsoring clinical trials with their product, which is a step often skipped, when you can sell a product without any research. Certainly the product looks to have biological and potentially positive medicinal effects. It is generally well-tolerated and has been studied in trials of up to a year in adults. Rare side effects include stomach issues like nausea, headache, dizziness, drowsiness and vertigo.
“More research is required” is a common statement, but it’s applicable here. While there are some promising hints of medicinal effects, there’s no compelling research to suggest that Pycnogenol can replace medicine or delay its need. For those who are really interested in using the product, maritime pine bark supplements that contain Pycnogenol are the most studied and have the benefit of being standardized, so you can be more confident in what you’re buying.
So when it comes to Pycnogenol, I wouldn’t recommend it as a daily or routine supplement, but I wouldn’t dismiss it if someone wanted to use it for one of the more evidence-backed reasons for use. Hopefully more trials will be conducted to better establish its place in therapy.