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Therapeutic Actions of Garlic

Constituents
muhammad yaqoob

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Effect of garlic on cardiovascular disorders: a review

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Allicin and Ot her Funct ional Act ive Component s in Garlic: Healt h Benefit s and Bioavailabilit y
Sh Sult an

Garlic and onions: t heir effect on eicosanoid met abolism and it s clinical relevance
M. Afzal
 zyxwv
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Therapeutic Actions of Garlic Constituents

zyxwvutsrqp Kailash C. Agarwal

11. Antithrom
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zy
Department of Molecular Pharmacology and Biotechnology, Brown University School of Medicine,

I. Introduction . . . . . . . . . .
Providence, Rhode Island 02912

.................................
......................................

fur Compounds . . . . . . . . . . . . . .
...........
111
113

................. 115

F. Adenosine Deaminase Inhibitor ........................

111. Lipid-Lowering and CardiovascularEffects

VI. Acknowledgments ........................ ....................... 122

VII. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I. INTRODUCTION
Garlic is perhaps the most widely quoted herb with medicinal potentials known in the
literature. Its medicinal uses are mentioned in the world’s oldest surviving medical text,
the Ebers Papyrus. Garlic powder, extracts, and oils have been employed in folk medicine
for various disorders by the Chinese, Egyptians, Greeks, Indians, Koreans, Romans,
etc.1-3 In China and India, garlic is known as D u - s u m and La-sum, respectively. The
word garlic originates from the Anglo-Saxon gar-leac or spear-plant.* Garlic is a member of
the family Lilaceue and has botanical name Alliurn sativurn. The word, Alliurn, the Latin
name for garlic, is derived from the Celtic word al, meaning pungent or burning. The
species name sativurn means planted, cultivated, or sown. Garlic contains high levels of
phosphorus, potassium, sulfur, and zinc; moderate levels of selenium, vitamin A and C;
and low levels of calcium, magnesium, sodium, iron, manganese, and B-complex vita-
mins. In addition, many compounds have been identified and isolated from garlic ex-
tracts including 33 sulfur compounds (some included in Fig. 1) and 17 amino acids,5,6
which include alanine, arginine, aspartic acid, asparagine, histidine, leucine, meth-
ionine, phenylalanine, proline, serine, threonine, tryptophan, and valine. Egyptian
medical papyrus, the Codex Ebers, which dates as far back as 1550 B. C., includes 800
therapeutic formulae of which 22 are for garlic in a variety of disorders, e.g., heart
disease, headaches, bites, intestinal parasites, and tumors.
Sir John Harington once wrote in ”The Englishman’s Doctor,”
Garlic then have power to save from death
Bear with it though it maketh unsavory breath
And scorn not garlic like some that think

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It only maketh men wink and drink and stink.

Garlic is one of the most researched medicinal plants. Over the past 100 years, more
than 1300 research articles have been published. Approximately 75% of these were
Medicinal Research Reviews, Vol. 16, No. 1, 111-124 (1996)
0 1996 John Wiley & Sons, Inc. CCC 0198-6325/96/010111-14
112 z
zyxwvuts
- !?J
Alliin

0
,CH3
z
COOH

zyxwvutsrq
Allyl methanethiosulfinate

Allyl methyl trisulfide

2-Vinyl-4H-1 ,I-dithiin

NH2

Ht) OH

Adenosine
e S - s

:
Allicin
W

Diallyl disulfide

S-Allyl-mercaptocysteine

3-Vinyl4H-1 ,Pdithiin

Allixin zyxwvut
0
,CH3

Diallyl trisulfide

Ajoene

S-Allylcysteine

Figure 1. Structure formulae of biologically active compounds of garlic.

published since 1980, and were focused primarily on the fields of cardiovascular system,
malignancies, and antimicrobial properties of garlic. Several excellent reviews have been
published on garlic studies after 1986 in the cardiovascular7-~~ and cancer12-15 areas of
AGARWAL

Allyl rnethanethiosulfinate

research. Due to continuous interest in the therapeutic potential of garlic in many dis-

zyxwvuts
eases, three International Symposia were held: Luneberg, Germany in 1989; Washing-
ton, D.C. in 1990; and Berlin in 1991.

Kailash C. Agarwal, Ph. D. is Professor of Molecular Pharmacology and Biotechnology (Research),

Brown University School of Medicine, Providence, RlO2912. He has been a faculty member at Brown since
1968. Dr. Agarwal has contributed extensively in the development of antithrombotic drugs both from synthet-
ic sources and medicinal plants. Dr. Agarwal is an active member of several National and International
Scientific Societies.
THERAPEUTIC ACTIONS OF GARLIC CONSTITUENTS

TABLE I
z
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Garlic Biochemicals with Antithrombotic, Lipid-Lowering, and Anticancer Activities
113

Antithrombotic Lipid-Lowering Anticancer

Alliin
Allicin
Diallyl disulfide
Diallyl trisulfide
Methyl ally1 trisulfide
1,5-Hexadienyl trisulfide
2-Vinyl-1,3-dithiene
3-Vinyl-1,2-dithiene
S-Allyl-2-propene thiosulfinate
Alliin
Allicin
Diallyl disulfide
Diallyl trisulfide
Allyl propyl disulfide zyxwv
S-Methyl cysteine sulfoxide
Ajoene
Alliin
Allicin
Diallyl disulfide
Diallyl trisulfide
Dimethyl trisulfide
Dipropyl disulfide
Allyl mercaptan
S-Ally1 cysteine
Allyl propyl disulfide
Allyl-l,5-Hexadienyl trisulfide Diallyl sulfide
Ajoene Ajoene
(-)-N-(1'-deoxy-1'-PD-fructopyranosy1)-S-allyl- Dimethyl disulfide
L-cySteinesulfoxide (a novel amino acid glycoside) Allixin
Adenosine

Specific enzyme inhibitors

Adenosine deaminase inhibitor
cAMP phosphodiesterase inhibitor

This review focuses primarily on the therapeutic actions of garlic and its constituents
in relation to antithrombotic, lipid-lowering cardiovascular, and anticancer effects. The
active principles that have been identified by various investigators are listed in Table I.
Structural formulae of some of these active biochemical molecules are included in Fig. 1.

11. ANTITHROMBOTIC ACTIONS

A. Alliin
Alline (S-ally1cysteine sulfoxide), an odorless precursor of allicin, present in amounts
of 5-14 mg/gm of garlic. 16-18 Alliin inhibits collagen-induced platelet aggregation both in
human platelet-rich plasma and whole blood with an IC,, value of 1.2 mM.19 Alliin
metabolite, allicin, in comparison to alliin, demonstrates a much greater inhibition (15-
fold) of platelet aggregation both in platelet-rich plasma and whole bl00d.l~

B. Allicin and Other Organosulfur Compounds

Alliin is separated from the enzyme alliinase (alliin alkyl sulphinate lyase, EC 4.4.1.4)
by a cellular membrane.20.21 When garlic is chopped or crushed, alliinase acts on alliin
(Fig. 2) to produce allicin (diallyl thiosulfinate), a thermally unstable antibacterial and
antithrombotic agent, which possesses the characteristic smell of garlic.20.21 Lawson et
al. estimated that 3.7 mg of allicin is released per gram of fresh garlic by the enzymatic
action.1 8 ~
Allicin was isolated as an antibacterial principle of garlic oil in 1944.23The antithrom-
botic activity of garlic oil and pure allicin has been studied by several laboratories.24-28
Allicin is strongly inhibitory to platelet aggregation in vitro without affecting platelet
cyclooxygenase, thromboxane synthetase activity, or cAMP levels.27 Allicin, at a concen-
tration of 10 JLM,completely inhibits collagen-induced platelet aggregation and seroto-
nin release from platelet dense granules.27 In contrast, another laboratory reported a
114 AGARWAL zy
zyxwvutsrqp
Alliin

- NHZ
zyxw 0
+ NH3

zyxwvutsrqponmlkjihgfedc
II. ACOOH A O O "

111.

Allicin

Figure 2. Enzymatic conversion of alliin into allicin

much lower inhibition of collagen-induced platelet aggregation by allicin (IC50,86 pM) in

human platelet-rich plasma.19 Allicin is also inhibitory to platelet aggregation in human
whole blood (IC50,90 pM). 19 The antiplatelet activity of allicin is rapidly destroyed above
56°C and at alkaline pH (>8.5).27 Garlic extracts, in addition to allicin, contain several
other sulfur-containing compounds (Table I), which also demonstrate antiplatelet activ-
ities.19.29 Methyl allyl trisulfide, which is a minor component of garlic oil, inhibits plate-
let aggregation at least 10-fold greater than allicin.30 A study has shown that ingestion of
fresh garlic (100-150 mg/kg) completely blocked platelet aggregation in response to
serotonin 1 h after garlic ingestion; however, no inhibitory effect was seen 2 h and 30
min after garlic ingestion.31 The study suggested that the inhibition was due to methyl
allyl trisulfide. In another study where a garlic oil preparation (7% content of garlic oil, 2
mg/kg) was orally administered to healthy humans, inhibition of platelet aggregation
was seen in arachidonic acid-induced aggregation (43-48% inhibition) 2 and 4 h after the
intake of this garlic preparation, whereas the collagen-induced aggregation remained
inhibited (21-49%) for 6 h.32
Effects of aqueous garlic extract and several organosulfur garlic compounds were
recently examined on collagen-induced platelet aggregation in human platelet-rich plas-
ma and whole bl00d.*9 The antiaggregatory activities (IC50 values) were 13.2 ? 1.3
Fg/mL for the total thiosulfinates, 190 ? 40 &mL for the total polar compounds, and
460 k 120 &mL (based on weight of whole garlic extracted per mL) for the aqueous
garlic extract. These studies show that garlic thiosulfinates particularly allicin) are re-
sponsible for virtually all the anti-aggregatory activity of garlic in human whole blood.
Although allicin is considered to be the most potent antiplatelet organosulfur constitu-
ent of garlic, it is not found in blood after garlic consumption.lY Volunteers, who in-
gested 25 g of chopped raw garlic cloves in a single dose, showed no allicin in their blood
or urine samples collected 1-24 h after the garlic ingestion.19 Allicin is a strong oxidizing
agent and reacts rapidly with cysteine to form S-ally1 mercaptocysteine (t,,,, < 1 min).33
Allicin upon incubation with human whole blood is rapidly converted into allyl mercap-
tan (t,,,, < 1 min).19 These studies suggested that allicin and some of its transformation
products are metabolized primarily to allyl mercaptan shortly after entering into the
circulation, even though they may be first metabolized to S-ally1 mercaptocysteine in the
intestinal tract.19 Daily consumption of 600 mg garlic powder in sugar-coated tablets
(equivalent to 1.7 g of garlic cloves) for four weeks showed no inhibitory effects on
platelet aggregation.34
C . Ajoene
zy
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THERAPEUTIC ACTIONS OF GARLIC CONSTITUENTS

Ajoene (4,5,9-trithidodeca-1,6,ll-triene
115

9-oxide), a colorless and odorless liquid, was

first isolated from the methanolic extracts of fresh garlic.29J5 Ajoene (ajo, pronounced as
"aho," meaning garlic in Spanish), a nonvolatile compound, is formed from allicin;35
however, ajoene is not normally present in steam distillates of garlic, different propri-
etary garlic pills, and commercial garlic powders.36 Ajoene inhibits platelet aggregation
induced by various platelet stimulators, ADP, epinephrine, collagen, arachidonic acid,
thrombin, platelet-activating factor, calcium ionophore (A23187), or an analog of cyclic
endoperoxide (U46619).36-37Ajoene is more inhibitory of platelet aggregation in human
whole blood (IC50,60 pM) than allicin (IC50,90 p,M).l9Ajoene is shown to inhibit platelet
aggregation in different species of animals (cow, dog, guinea-pig, horse, monkey, pig,
rabbit, rat).36,37 Furthermore, ajoene (15 mg/kg) is shown inhibitory to platelet loss in
dogs during extracorporeal circulation.38 The antiplatelet actions of ajoene are potenti-
ated by prostacyclin (PGI,, primarily synthesized by the vascular endothelium), for-
skolin, indomethacin, and dipyridamole.36~37Interestingly, ajoene does not modulate
the binding of aggregating agonists to their specific receptors.12J7 Ajoene strongly in-
hibits the metabolism of arachidonic acid by both cyclooxygenase and lipoxygenase
pathways,39,40 thus inhibiting the synthesis of thromboxane A, and 12-HETE (12-hy-
droxyeicosatetraenoic acid).40 Ajoene has no effect on platelet cAMP levels, cAMP phos-
phodiesterase activity, or phosphorylation of platelet protein P47 and myosin light
chain. 12,3637 In regard to a specific mechanism of ajoene's antiplatelet action, several
suggestions have been made. Studies of Jain and Apitz-Castro suggest that ajoene does
not affect any of the major pathways that trigger or modulate the platelet activati0n.4~
They believe that ajoene specifically interacts with primary agonist-receptor complex

zyxw
with the exposure of fibrinogen (GPIIb/IIIa)receptors through specific G-proteins of the
signal transduction system in the platelet membrane.41 In contrast, the studies of Jam-
aluddin et al.42 demonstrate that ajoene interacts with a purified hemoprotein implicated
in platelet activation. Ajoene modifies the binding of the hemoprotein with ligands
deemed to be physiologically relevant as effector^.^,

D. Novel Amino Acid Glycoside

(-)-N-(l'-deoxy-l'-~-D-fructopyranosyl)-S-allyl-L-cysteinesulfoxide,has been recently
isolated from the leaves of garlic.43 The glycoside (1 mM) caused 40-50% inhibition of
platelet aggregation induced by ADP or epinephrine. In contrast, the glycoside did not
inhibit the collagen-induced aggregation, although it increased (50-70%) the lag-time.43
The inhibitory effect of the glycoside on platelet aggregation is comparable with the
inhibition seen with alliin (IC50,1.2 mM).l9

zy
E. Adenosine

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Adenosine, a purine nucleoside that has both potent antiplatelet and vasodilatoryu
activities, is continuously produced in the body by many tissues, including the vascular
endothelium46 and platelets.47 Makheja and Bailey reported that aqueous extracts of
garlic contain adenosine, and approximately 50% of the total antiplatelet activity in vitro
was due to the presence of adenosine in the garlic extracts.48 Garlic contains adenosine
in the amounts of 210 k g / g of fresh garlic.19 The inhibitory effects of garlic adenosine can
be abolished by treating the extracts with adenosine deaminase, an enzyme that de-
grades adenosine into inosine.48 Adenosine strongly inhibits collagen-induced platelet
aggregation in human platelet-rich plasma (IC50,0.11 p,g/mL, or 0.4 pM).19 Less inhibi-
116 AGARWAL

tory effects are seen when ADP was used to induce platelet aggregation (ICsO,1.4 pM).49
In contrast, adenosine causes no inhibition of platelet aggregation in human whole
blood due to its rapid cellular uptake and metabolism by blood cells.19,49,50 Adenosine is
rapidly metabolized in most tissues by the cellular adenosine deaminase and adenosine

zyxwvut
kinase.49.50 The t1,2 of adenosine in human blood is less than 30.50 The whole body
adenosine deaminase activity of erythrocytes (0.2 pmol units/mL of erythrocytes) alone

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can degrade 135 mg of adenosine per min.51 Similarly, other body tissues also possess
the high activity of this enzyme, making it probable that the adenosine that is present in
garlic will survive less than 1 min after absorption from the gastrointestinal tract. In
addition, several other in uitro studies suggest that adenosine is not an active garlic

zyxw
principle that demonstrates antithrombotic activity in uivo. For example, garlic extract
strongly inhibits platelet aggregation in rat platelet-rich plasma (Agarwal and Wang,
unpublished findings), whereas, adenosine is noninhibitory.52 Furthermore, the calcium
ionophore (A23187)-induced platelet aggregation can be blocked by garlic extracts but
not by adenosine.40 The above findings clearly demonstrate that garlic adenosine has no
therapeutic role in the antiplatelet effect of garlic.

F. Adenosine Deaminase Inhibitor

A recent study reports that garlic extracts prepared from garlic samples obtained from
various sources demonstrate potent inhibitory activity for adenosine deaminase.53 The
presence of an adenosine deaminase inhibitor in garlic may perhaps explain in part the
clinical antithrombotic and vasodilatory effects seen after garlic ingestion. Adenosine,
which is produced by various body tissues, is primarily metabolized by adenosine deam-
inase and adenosine kinase. However, if the adenosine deaminase activity of the body
tissues is inhibited by the garlic adenosine deaminase inhibitor, endogenous adenosine
levels may increase, as has been reported in patients treated with the adenosine deam-
inase inhibitor, 2'-deoxycoformycin.54~~5 Also, increases in endogenous adenosine con-
centrations have been reported in patients with sever-combined immuno-deficiency syn-
drome (SCID), where tissue adenosine deaminase deficiency is seen.56 Human plasma
adenosine levels range between 100-300 nM.45,57Several studies have shown that plas-
ma adenosine levels play a key role in modulation of platelet function.47,58,59For exam-
ple, if plasma adenosine is degraded by adenosine deaminase, platelet aggregating
activity in response to various platelet agonists is greatly increased.47,58,59 It would be
interesting to examine whether garlic ingestion increases plasma adenosine levels. How-
ever, an earlier study has reported that the activities of adenosine deaminase, guanase,
and uricase in the rat liver were not changed significantly following the feeding of 5%
garlic juice, but it greatly inhibited xanthine oxidase activity.60

G. Cyclic AMP Phosphodiesterase (PDE) Inhibitor

Our laboratory has recently reported that aqueous extracts of fresh garlic or a commer-
cial garlic powder strongly inhibit platelet aggregation both in human whole blood and
platelet-rich plasma.61.62 In addition, the extract that was treated with adenosine deam-
inase to degrade garlic adenosine showed inhibition of platelet aggregation. This sug-
gested that garlic extracts contain other inhibitors of platelet aggregation in addition to
adenosine. Furthermore, our data demonstrate that garlic extract strongly potentiates
antiplatelet actions of adenosine, forskolin, and PGE, (adenylate cyclase stimulators).61,62
These findings have suggested that garlic extracts contain an agent that inhibits platelet
CAMPPDE activity. In fact, both aqueous extracts of both fresh garlic and commercial
THERAPEUTIC ACTIONS OF GARLIC CONSTITUENTS 117

zyxwv
garlic powder showed potent inhibiting activity for platelet cAMP PDE.61,62 We believe
that the presence of a potent inhibitor of cAMP PDE in garlic plays an important role in
the antithrombotic and vasodilatory actions of garlic in the body. The cAMP PDE inhibi-
tor of garlic will potentiate the antithrombotic and vasodilatory effects of endogenous
adenosine, PGD,, and PGI, in the body.

111. LIPID-LOWERING AND CARDIOVASCULAR EFFECTS

Hyperlipidemia, obesity, smoking, stress, and hypertension are known as the risk
factors of atherosclerosis.63,~Both clinical and epidemiological studies have shown that
hyperlipidemia and hypertension are perhaps the greatest risk factor of atherosclerosis
and its complications, such as stroke and myocardial infarction.63-65 Many studies have
demonstrated that normalization of hypertension, and abnormal metabolism of lipids
and lipoproteins, including cholesterol, improves arteriosclerotic coronary artery dis-
ease .66-68
Several clinical trials using various garlic preparations have been conducted all over
the world. Most such studies have shown lipid-lowering effects; however, some studies
have found none or little lipid-lowering activity.67-71 Sticher et al.72 suggested that differ-
ences in garlic effects may be due to differences in the amount of active ingredients in
garlic, for example, variation by a factor of 13 in alliin content. In the late 1970s, a
number of studies were conducted in which raw garlic (5-10 g/day) was given orally for
2-3 months to healthy subjects and patients with ischemic heart d i ~ e a s e . ~ 3These -~~
studies demonstrated significant reductions in blood cholesterol and triglycerides levels
after the garlic ingestion. Similarly, another study that employed nonstandardized aque-
ous garlic extract in hypercholesterolemic patients for 2 months reported significant

zyx
reductions in the serum cholesterol levels.78 Also, when the essential oil constituents
extracted from 1 g of raw garlidkg were given in myocardial infarction patients for 3
months, significant increase (83-130%) in the fibrinolytic activity was observed.79 Similar
increases in fibrinolytic activity were later reported both in healthy subjects77 and pa-
tients with ischemic heart disease after giving raw or fried garlic for 4 weeks.80
In 1989, the data from a large multicenter clinical study involving various university
hospitals and research institutions was presented at the first International Garlic Sympo-
sium in Germany.67.69The main conclusion of this study was that large amounts of garlic
(up to 28 cloves) are needed to improve clinical effectiveness. Since the garlic contains
high water content (60%) accounting for much of its bulk, the amounts of active com-
pounds present are not sufficient to produce enough beneficial effects. In recent years,
several dehydrated garlic preparations with a standardized level of alliin have become
available for clinical studies as well as for human use. The data on lipid-lowering activity
from several clinical studies employing standardized garlic preparations (Kwai, Lichtwer
Pharma GmbH, Berlin, Germany) are included in Table 11.

zyxw
These studies clearly demonstrate that the treatment with standardized garlic prepara-
tions (600-900 mg/day) produced significant reductions in the serum levels of choles-
terol and triglycerides (except the triglycerides data of Jain et al.).*3 In a different study,
an aged-garlic extract preparation (Kyolic, Wakunaga Pharmaceuticals, Japan) was exam-
ined for its effects on blood cholesterol and triglycerides in humans over a 6 month
period.86 Each subject took a daily dose of 4 capsules ( 1 mL/capsule containing 250 mg
dry weight/mL). In the majority of subjects, lower levels of cholesterol, triglycerides,
low density and very low density lipoproteins (LDL, VLDL) with an increase of high
density lipoproteins (HDL) were observed. No significant changes in the cholesterol and
118 zyxwvut
zyxwvu TABLE I1
AGARWAL

zyxwvutsrq
Clinical Studies Employing Standardized Garlic Preparations on Serum Levels
of Total Cholesterol and Triglycerides

Total Cholesterol Triglycerides

First Author Garlic
(Year & Ref.) Preparation Treatment Before After Before After

Auer 12 268 230 (0.05)b 171 140 (0.05)

(1990) (81) (weeks)
Zimmerman 3 287 260 (9%) 253 206 (19%)
(1990) (82) (weeks)
Vorberg 16 294 230 (0.001) 207 156 (0.05)
(1990) (83) (weeks)
Jain 12 262 247 (0.01) 151 165 (ns)
(1993) (W (weeks)
Broschec 3 260 240 (0.001) 207 174 (0.05)
(1990) (85) (months)

aKwai: This standard preparation contains alliin 1.3% (allicin release 0.6%).
bValues in parentheses under Total Cholesterol or Triglycerides represent the p values (<); values shown in
parentheses represent % change.
cPatients aged 70 years and over.

triglycerides levels were seen in subjects whose initial cholesterol levels were relatively
low. Of special interest was the initial rise of cholesterol, triglycerides, and LDL/VLDL
during the first two months with garlic supplementation, suggesting possible mobiliza-
tion of tissue lipids into the circulation. Similarly, Kyoleopin (KLE, Wakunaga Phar-
maceutical, Japan), an over-the-counter aged-garlic extract containing vitamins (2 mL
orally twice/day for 16 weeks), was studied for its effects in 20 hyperlipidemia patients

zyxwv
(total cholesterol, >250 mg/dL; triglycerides, >150 mg/dL).66Significant decreases both
in the cholesterol and triglycerides serum levels were seen after the Kyoleopin treat-
ment. In summary, most of the clinical trials in the past and recent years have proven the
lipid-lowering effects of garlic. This development is widely accepted by the public, since
most people prefer natural, as opposed to synthetic drugs, due to the advantages of
fewer side effects and lower costs. Using the Kwai garlic preparations (as used in the

TABLE I11
Clinical Studies Employing Standardized Garlic Preparations on Blood Pressure

Blood Pressure(Sis) Blood Pressure (Dia)

First Author Garlic
(Year & Ref.) Preparation Treatment Before After Before After
~ ~~~

Auer 12 171 152 (0.05)b 102 89 (0.05)

(1990) (81) (weeks)
Zimm erm an 3 137 130 (ns) 83 82 (ns)

Vorberg

Jain
zyxwvutsr
(1990) (82)

(1990) (83)

(1993) (84)
(weeks)
16
(weeks)
12
(weeks)
145

129
138 (0.001)

130 (ns)

'Kwai: This standard preparation contains alliin 1.3% (allicin release 0.6%)
bValues in parentheses under Blood Pressure represent the p values (<).
90

82
86 (0.05)

81 (ns)
THERAPEUTIC ACTIONS OF GARLIC CONSTITUENTS 119

clinical trials listed in Table II), effects were assessed on blood pressure (systolic and
diastolic) in several clinical studies (Table 111). The data from these studies suggest that
garlic treatment for a longer period of time (12-16 weeks) may prove beneficial to
patients with hypertension.
The principles primarily responsible for the lipid-lowering activity of garlic are pres-
ently not well understood. The liver is a major site of cholesterol synthesis and of
cholesterol clearance.87 Several studies have suggested that garlic-supplemented diets
can decrease the enzyme activities of various lipogenic enzymes, glucose-6-phosphate
dehydrogenase and malic dehydrogenase,@3,89 and the cholesterogenic enzyme, z
z
3-hydroxy-3-methyl-glutaryl-CoA reductase.89~90In addition, a recent study employing
cultured rat hepatocytes has demonstrated that garlic extracts (ether, methanol, or water
extraction) significantly inhibited [Klacetate and [3H]glycerolincorporation into choles-
terol and triglycerides, respectively.91 These findings suggested that the hypocholester-
olemic effect of garlic stems in part from decreased hepatic cholesterogenesis, whereas
the triglyceride-lowering effect appears to be due to inhibition of fatty acid synthesis.

IV. ANTITUMOR AND CYTOTOXIC ACTIONS

Several epidemiological studies have revealed that garlic consumption has played a
significant role in the reduction of deaths caused by malignant diseases.92-95 For exam-
ple, a study comparing populations of different regions of China reported that the
mortality rate among patients with gastric cancer was significantly lower 3.45/100,000
vs. 40/100,000 in regions with higher garlic consumption (about 20 g/day) than in re-
gions with lower garlic consumption.94 Similar beneficial effects of garlic were seen in
cases of gastric cancer in Italy,96 and also on thyroid nodularity among women in Chi-
na.97 Garlic and onion consumption has also led to decreased incidence of colorectal

zy
cancer in Japanese-Hawaiians.98 In 1949, Von Euler and Lindeman first reported that
alliin is the active principle of garlic responsible for inhibiting the tumor cell growth in
mice.99 Wesberger and Pensky later found that several alliin metabolites including allicin
showed tumor-inhibiting effects against Murphy-Sturm lymposarcoma and sar-
coma-180 cells in mice and rats.100 Since then, a number of studies have appeared on the
antitumor and cytotoxic actions of garlic and its organosulfur compounds using in nitro
or animal models.9*,93,101-106
A variety of garlic organosulfur compounds were shown to inhibit chemically induced
and transplanted tumors in experimental animals.95 Using the multi-organ carcinogen-
esis rat model, ally1 sulfide significantly reduced the incidence of hepatic hyperplastic
nodules, adenoma of the lung and thyroid, and hyperplasia of the uninary bladder in
mice.107 Similarly, ajoene, a lipid-soluble metabolite of allicin, was shown to be cytotoxic
to a tumorgenic lymphoid cell-line derived from a Burkitt lymphoma.108 This study also

zyx
observed some toxic effects on nontumor cells (human fibroblast and hamster kidney
cells) with ajoene.108 Water-soluble garlic compounds may perhaps be less cytotoxic than
lipid-soluble compounds, due to rapid elimination from the body. S-Ally1 cysteine, a
derivative of aged-garlic extract, inhibited 1,2-dimethylhydrazine-inducedcolon cancer
of rats.109 More recently, S-ally1cysteine was examined for its effects on proliferation and
differentiation of LA-N-5 human neuroblastoma cells in vitro.110 Time- and dose-
dependent inhibition of the cell growth was observed in cultures containing S-ally1
cysteine, with a half-maximal response at 600 pg/mL. However, S-ally1 cysteine did not
induce differentiation in neuroblastoma cells as assessed by morphological, biochemical,
and molecular markers.110 S-Ally1cysteine is shown to inhibit the binding of the carcino-
120

zy
zyxwvut
gen 7,12-dimethylben[a]anthracene (DMBA) to rat mammary cell DNA in an in vivo
AGARWAL

study.111 The dietary raw garlic powder (2%)or its water-extract (1.5%)also significantly
reduced the DMBA binding to DNA.111,112These studies suggested that the water sol-
uble S-ally1cysteine was one of the active constituents of garlic, accounting for depressed
DMBA-DNA binding in rat mammary tissue."' Recently, S-ally1 cysteine was shown to
inhibit proliferation of several human and murine melanoma cell lines in a dose-
dependent manner.113 In comparison, an other study demonstrated that water soluble
organosulfur compounds (S-ally1 cysteine, S-ethyl cysteine, and S-propyl cysteine) did
not significantly alter the growth of canine mammary tumor cells.114 However, oil-
soluble organosulfur compounds (diallyl disulfide, diallyl disulfide, and diallyl tri-
sulfide) markedly inhibited the gr0wth.1~4The maximum inhibitory effect was seen with
diallyl trisulfide.114 Cytotoxic effects of fresh garlic and diallyl trisulfide were compared
to 5-fluorouracil on human gastric cancer cells.115 Both fresh garlic extract and diallyl
trisulfide showed greater cytotoxic activity than 5-fluorouracil.
A commercially available garlic extract (Kyolic), formulated by Wakunaga Phar-
maceutical Company of Japan, was shown to inhibit the growth of a murine bladder
tumor when it was administered directly into the tumor site.116 In addition, the Kyolic
garlic extract inhibited aflatoxin B,- and benzo[a]pyrene-induced mutagenesis.117 Af-
latoxin, a toxic metabolite produced by Aspergillus flavus B, is hepatocarcinogenic to
laboratory animals, and may be linked to increased incidences of human liver cancer in
Africa and Asia. 118,119 The garlic extract reduces the conversion of the procarcinogenic
form of aflatoxin 8, to its potentially carcinogenic metabolites, and their binding to
DNA.l17,120 Similar inhibitory effects were seen on the binding of aflatoxin B, to DNA by
diallyl sulfide and ajoene.12" A recent study demonstrated that topical applications of
diallyl sulfide or diallyl disulfide significantly inhibited skin papilloma formation in mice
and increased the rate of survival.121 The skin cancer was induced chemically by 7,12-
dimethylbenz(a)anthracene and promoted by 12,O-tetradecanoylphorbol-13-acetate.
Several suggestions have been made regarding the mechanism of action for the anti-
tumorgenic and anticarcinogenic properties of garlic and its constituents. Allicin is
shown to inhibit GSH-dependent conversion of PGH, to PGE, in mammary adenocar-
cinoma cells.122 Perchellet et a1.123 noted that garlic oil, onion oil, and dipropenyl sulfide
increase glutathione peroxidase activity and inhibit ornithine decarboxylase (ODC) in-
duction from various tumor promoters. Garlic oil also prevents the decrease in the
reduced/oxidized glutathione (GSH/GSSG) ratio. 122 In addition, garlic oil inhibits
ODC123 and lipoxygenasel24activities, which play a role in the tumor promotion stage of
carcinogenesis.124Ally1 methyl trisulfide, a constituent of garlic oil, is shown to enhance
glutathione S-transferase activity in mouse tissues (forestomach, small bowel mucosa,
liver, and lung.)125 The induction of hepatic glutathione S-transferase and DT-diaphor-
ase by synthetic thiol compounds is known to mediate the detoxification of certain
carcinogens.126 Also, the dietary garlic powder (2%) is shown to increase glutathione
S-transferase activity in rat mammary and liver tissues.lI2 This study reported that ally1
methyl trisulfide strongly inhibits (70%) benzo[a]pyrine-induced tumor formation.126
Since garlic extract contains many thiol compounds, it is likely that they may also be
involved in the induction of these hepatic enzymes and, thus, detoxify the chemical
carcinogens. Diallyl disulfide, the main constituent of garlic oil, is shown to inhibit
oxidative phosphorylation in hepatic mitochondria of mice. 127 Allixin, a nonsulfur com-
pound (Fig. 1) isolated from garlic,128 inhibits the enhanced phospholipid metabolism of
cultured cells induced by a tumor promoter 12-0-tetradecanoy1phorbo1-13-acetate (TPA).129
In addition, this study demonstrated that allixin suppresses (92%) the tumor promoting
 zyxwvu
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THERAPEUTIC ACTIONS OF GARLIC CONSTITUENTS

activity of TPA in 7,12-dimethylbenz(a)anthracene-initiatedmouse skin.129 Another

study has shown that allkin also inhibits aflatoxin B,-induced mutagenesis in Salmonella
typhirnuriurn strain TA100, and aflatoxin b, binding to calf thymus DNA.130 This has
suggested that allixin may mediate these effects by blocking the microsomal P-450 en-
zymes.130 Similarly, other investigators have suggested that diallyl sulfide and other
121

garlic organosulfur compounds, which inhibit chemically induced carcinogenic and toxic
responses in rodent model systems, may be involved in the inhibition of hepatic cyto-

zyx
chrome P-450 enzyme-dependent bioactivation of the procarcinogens and protoxi-
cants.131 Furthermore, garlic and its constituents have been shown to inhibit the synthe-
sis of N-nitroso compounds and chemical carcinogens, that are involved in the formation
of 7-N-methyldeoxyguanosine and 6-0-methyldeoxy-guanosine adducts to rat liver
DNA.132 The inhibition of N-nitroso compounds by garlic consumption may be related
to the reduction in gastric cancer in southern provinces of China.132

V. SUMMARY AND CONCLUSIONS

Most studies on garlic during the past 15 years have been primarily in the fields of
cardiovascular and cancer research. Cardiovascular studies have been mainly related to
atherosclerosis, where effects were examined on serum cholesterol, LDL, HDL, and
triglycerides. Although the studies were not consistent in relation to the dosage, stan-
dardization of garlic preparations, and period of treatment, most findings suggest that
garlic decreases cholesterol and triglycerides levels in patients with increased levels of

zyxwvut
these lipids. Lowering of serum lipids by garlic ingestion may decrease the ath-
erosclerosis process. The other major beneficial effect of garlic is due to its antithrombo-
tic actions. This field of garlic research has been extensively studied. Garlic extracts and
several garlic constituents demonstrate significant antithrombotic actions both in vitro
and in uivo systems. Allicin and adenosine are the most potent antiplatelet constituents
of garlic because of their in uitro effects. Since both allicin and adenosine are rapidly
metabolized in human blood and other tissues, it is doubtful that these compounds
contribute to any antithrombotic actions in the body. In addition, ajoene also seems not
to be an active antiplatelet principle, because it is not naturally present in garlic, garlic
powders, or other commercial garlic preparations. Only a small amount of ajoene can be
found in garlic oil-macerates; however, ajoene is being developed as a drug for treatment
of thromboembolic disorders. Recent findings on the identification of potent enzyme
inhibiting activities of adenosine deaminase and cyclic AMP phosphodiesterase in garlic
extracts are interesting, and may have a significant role in the pharmacological actions in
the body. Presence of such enzyme inhibitors in garlic may perhaps explain several
clinical effects in the body, including the antithrombotic, vasodilatory, and anticancer
actions. Epidemiological studies have suggested that garlic plays a significant role in the
reduction of deaths caused by malignant diseases. This had led many investigators to
examine garlic and garlic constituents for their antitumor and cytotoxic actions both in
uitro and in laboratory animals. The data from these investigations suggest that garlic
contains several potentially important agents that possess antitumor and anticar-
cinogenic properties. In summary, the epidemiological, clinical, and laboratory data
have proved that garlic contains many biologically and pharmacologically important
compounds, which are beneficial to human health from cardiovascular, neoplastic, and
several other diseases. Numerous studies are in progress all over the world to develop
effective and odorless garlic preparations, as well as to isolate the active principles that
may be therapeutically useful.
122 zyxwvuts
zyxwvutsr AGARWAL
The author is thankful to Ajay Garg, M. D. for his efforts in the literature collection, interest, and suggestions
in reviewing this article.

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