Kava

Botanical name: Piper methysticum

Parts used and where grown

Kava is a member of the pepper family and is native to many Pacific Ocean islands. The rhizome (underground stem) is used in modern herbal preparations.

Warning: Kava should be taken only with medical supervision. Kava is not for sale in certain parts of the world.

Historical or traditional use (may or may not be supported by scientific studies)

A nonalcoholic drink made from the root of kava played an important role in social ceremonies in some Pacific islands, including welcoming visiting royalty and at meetings of village elders. Kava was valued both for its mellowing effects and to encourage socializing. It was also noted for initiating a state of contentment, a greater sense of well-being, and enhanced mental acuity, memory, and sensory perception. Kava has also been used traditionally by healers in the Pacific islands to treat pain.

Active constituents

The kava-lactones, sometimes referred to as kava-pyrones, are the most important active constituents in kava extracts. High-quality kava rhizome contains 5.5–8.3% kava-lactones.¹ Medicinal extracts used in Europe contain 30–70% kava-lactones. Kava-lactones are thought to have anti-anxiety, mild analgesic (pain-relieving), muscle-relaxing, and anticonvulsant effects.² ³ Some researchers speculate that kava may directly influence the limbic system, the ancient part of the brain associated with emotions and other brain activities.⁴ Kava is a unique anti-anxiety alternative because it does not seem to impair reaction time or alertness when used in the amounts recommended below.⁵

Kava has been extensively studied as a treatment for anxiety.⁶ The amount often used in clinical trials is 100 mg of an extract (standardized to 70% kava-lactones) three times per day. Double-blind trials, including one that lasted six months, have shown that kava effectively reduces symptoms of anxiety in people with mild to moderate anxiety.⁷ ⁸ One trial found that kava also reduced symptoms of anxiety in menopausal women,⁹ and in another study kava enhanced the anti-anxiety effect of hormone replacement therapy.¹⁰ One trial found kava to be just as effective as benzodiazepines (a common class of drugs prescribed for anxiety) in treating mild anxiety over the course of six weeks.¹¹

How much is usually taken?

For treatment of mild to moderate anxiety, kava extracts supplying 120–240 mg of kava-lactones per day in two or three divided doses are commonly recommended.¹² Alternatively (although it has not been researched), 1–3 ml of fresh liquid kava tincture can be taken three times per day. Kava should not be taken for more than three months without the advice of a physician, according to the German Commission E monograph.¹³

Are there any side effects or interactions?

In November 2001, German authorities announced that 24 cases of liver disease (including hepatitis, liver failure, and cirrhosis) associated with the use of kava had been reported in Germany; of these, one person died and three required a liver transplant.¹⁴

Prior to this report, it had been widely believed that kava did not cause any serious side effects. The 1998 edition of the German Commission E Monographs, considered to be an authoritative source on herbal medicines, does not mention liver disease in its discussion of kava’s side effects.¹⁵ Since that time, four case reports of kava-related liver toxicity have appeared in medical journals.¹⁶ ¹⁷ ¹⁸ ¹⁹ In two of these cases, severe liver failure resulted in the need for a liver transplant. Most, though not all, of the individuals who developed liver damage while taking kava were also taking at least one other medication that has been associated with liver injury.²⁰ That raises the possibility that these other drugs, rather than kava, may have been responsible for the problem in some cases. It is also conceivable that kava interacts with some of these drugs, thereby increasing their toxicity. However, some of the cases of kava-related liver disease cannot be explained by the concomitant use of other drugs.

The possibility that kava can cause liver damage is supported by a survey of an Aboriginal community in Australia. Although occasional users of kava in this community generally had normal liver function, laboratory evidence of liver injury was quite common among heavy users of the herb.²¹ Furthermore, the risk of liver damage was directly related to the amount of kava consumed. It is not clear how relevant these findings are to other communities, since the overall health of the Aborigines who were studied was relatively poor.

It is also unclear whether kava is safe when taken in “normal” amounts. A recent survey of 400 German medical practices revealed that 78% of the kava prescriptions that were written significantly exceeded the recommended amount.²² However, some of the 24 patients reported to German authorities were not exceeding the manufacturer’s recommended level of intake when they developed liver disease. In addition, in two of the four published case reports, the amount of kava used was equal to or only slightly higher than the manufacturer’s recommendation.²³ Therefore, one cannot assume that the recommended level of intake of kava is safe for all individuals.

Health authorities worldwide are considering or implementing a ban on kava. Until additional information clarifies the extent of the risk involved, it is strongly recommended that all individuals consult their physician before taking kava. In addition, based on the available information, it seems that people with liver disease and those taking medications that have the potential to damage the liver should not take kava.

In recommended amounts, the most common side effect from kava use is mild gastrointestinal disturbances in some people. Kava may temporarily turn the skin yellow, according to some case studies.²⁴ If this occurs, people should discontinue kava use. In rare cases, an allergic skin reaction, such as a rash, may occur.²⁵ Enlargement of the pupils has also been reported after long-term use of kava.²⁶ In the amounts discussed above, kava does not appear to be addictive.

Kava is not recommended for use by pregnant or breast-feeding women. It should not be taken together with other substances that also act on the central nervous system, such as alcohol, barbiturates, antidepressants, and antipsychotic drugs. One study found that large amounts of a traditional kava preparation did worsen cognitive impairment caused by alcohol consumption.²⁷ However, at the amounts recommended above, kava does not appear to impair cognitive performance. Kava has also been reported to cause excessive sedation and grogginess when combined with benzodiazepines.²⁸ One study found it was safe to drive after taking kava at the amounts listed above.²⁹ However, the German Commission E monograph states that kava, when taken at the recommended levels, may adversely affect a person’s ability to safely drive or operate heavy machinery.³⁰

Caution: Aside from the reported interactions, kava inhibits a number of the cytochrome P450 enzymes that play a role in the breakdown of many medications.³¹ Therefore, kava has the potential to interact with a wide range of medications, even if such interactions have not yet been reported. Individuals taking any medication who wish to use kava should check with their physician or chemist to determine whether inhibiting cytochrome P450 could cause an adverse drug interaction.

Are there any drug interactions?
Certain medicines may interact with kava. Refer to drug interactions for a list of those medicines.

References
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1. Bone K. Kava: A safe herbal treatment for anxiety. Br J Phytother 1994;3:145–53.

2. Blumenthal M, Busse WR, Goldberg A, et al. eds. The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, MA: Integrative Medicine Communications, 1998, 156–7.

3. Buckley JP, Furgiuele AR, O’Hara MJ. Pharmacology of kava. In Ethnopharmacoligcal Search for Psychoactive Drugs, DH Efron, B Holmstedt, NS Kline, eds. New York: Raven Press, 1979, 141–51.

4. Holm E, Staedt U, Heep J, et al. Studies on the profile of the neurophysiological effects of D,L-kavain: Cerebral sites of action and sleep-wakefulness-rhythm in animals. Arzneimittlforschung 1991;41:673–83.

5. Munte TF, Heinze HJ, Matzke M, Steitz J. Effects of oxazepam and an extract of kava roots (Piper methysticum) on event-related potentials in a word-recognition task. Pharmacoelctroencephalog 1993;27:46–53.

6. Piscopo G. Kava kava: Gift of the islands. Alt Med Rev 1997;2:355–81 [review].

7. Lehmann EE, Kinzler J, Friedmann J. Efficacy of a special kava extract (Piper methysticum) in patients with states of anxiety, tension and excitedness of non-mental origin. A double-blind placebo-controlled study of four weeks treatment. Phytomedicine 1996;3:113–9.

8. Volz HP, Kieser M. Kava-kava extract WS 1490 versus placebo in anxiety disorders. A randomized placebo-controlled 25-week outpatient trial. Pharmacopsychiatry 1997;30:1–5.

9. Warnecke G. Psychosomatic dysfunctions in the female climacteric. Clinical effectiveness and tolerance of kava extract WS 1490. Fortschr Med 1991;119–22 [in German].

10. De Leo V, la Marca A, Morgante G, et al. Evaluation of combining kava extract with hormone replacement therapy in the treatment of postmenopausal anxiety. Maturitas 2001;39:185–8.

11. Woelk H, Kapoula S, Lehrl S, et al. Treatment of patients suffering from anxiety—double-blind study: Kava special extract versus benzodiazepines. Z Allegemeinmed 1993;69:271–7.

12. Brown DJ. Herbal Prescriptions for Better Health. Rocklin, CA: Prima Publishing, 1996, 145–50.

13. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, MA: Integrative Medicine Communications, 1998, 156–7.

14. Stafford, Ned. Germany may ban kava kava herbal supplement. Reuters, Nov. 19, 2001. http://www.reutershealth.com/frame2/eline.html

15. Blumenthal M (Ed.). The Complete German Commission E Monographs. American Botanical Council, Boston, MA, 1998:156–7.

16. Escher M, Desmeules J, Giostra E, Mentha G. Hepatitis associated with kava, a herbal remedy for anxiety. BMJ 2001;322:139.

17. Kraft M, Spahn TW, Menzel J, et al. Fulminant liver failure after administration of the herbal antidepressant Kava-Kava. Dtsch Med Wochenschr 2001;126:970–2 [in German].

18. Strahl S, Ehret V, Dahm HH, Maier KP. Necrotizing hepatitis after taking herbal remedies. Dtsch Med Wochenschr 1998;123:1410–4 [in German].

19. Russmann S, Lauterburg BH, Helbling A. Kava hepatotoxicity. Ann Intern Med 2001;135:68–9 [letter].

20. Information provided by the German Federal Institute for Drugs and Medical Devices.

21. Mathews JD, Riley MD, Fejo L, et al. Effects of the heavy usage of kava on physical health: summary of a pilot survey in an aboriginal community. Med J Aust 1988;148:548–55.

22. Schroder-Bernhardi D, Dietlein G. Compliance with prescription recommendations by physicians in practices. Int J Clin Pharmacol Ther 2001;39:477–9.

23. Escher M, Desmeules J, Giostra E, Mentha G. Hepatitis associated with kava, a herbal remedy for anxiety. BMJ 2001;322:139.

24. Jappe U, Franke I, Reinhold D, Gollnick HPM. Sebotropic drug reaction resulting from kava-kava extract therapy: A new entity? J Amer Acad Dermatol 1998;38:104–6.

25. Schmidt P, Boehncke WH. Delayed-type hypersensitivity reaction to kava-kava extract. Contact Derm 2000;42:363–4.

26. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, MA: Integrative Medicine Communications, 1998, 156–7.

27. Foo H, Lemon J. Acute effects of kava, alone or in combination with alcohol, on subjective measures of impairment and intoxication and on cognitive performance. Drug Alcohol Rev 1997;16:147–55.

28. Almeida JC, Grimsley EW. Coma from the health food store: Interaction between kava and alprazolam. Arch Intern Med 1996;125:940–1.

29. Herberg KW. Driving ability after intake of kava special extract WS 1490. Z Allgemeinmed 1993;69;271–7.

30. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, MA: Integrative Medicine Communications, 1998, 156–7.

31. Mathews JM, Etheridge AS, Black SR. Inhibition of human cytochrome P450 activities by kava extract and kavalactones. Drug Metab Dispos 2002;30:1153–7.

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The information presented in Healthnotes is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or chemist for any health problem and before using any supplements or before making any changes in prescribed medications. Information expires March 2007.