Wormwood
Wormwood
Generic Name
Wormwood
Mechanism
- Bile acid modulation: Stimulates gallbladder contraction, enhancing excretion of hydrophobic toxins and parasites.
- Direct larvicidal activity: Contains absinthin and absinthole, which disrupt parasite cell membranes, impairing motility and inducing apoptosis.
- Cytotoxic alkaloids (e.g., thujone, camphor): Interfere with *glucose uptake* and *ATP synthesis* in parasitic cells.
- Immunomodulation: Enhances macrophage activity, increasing phagocytosis of parasitic ova.
Pharmacokinetics
| Parameter | Details |
| Absorption | Oral bioavailability ~75% (primarily in the upper GI tract). |
| Distribution | Widely distributed; highly lipophilic, accumulates in the liver and GI mucosa. |
| Metabolism | Hepatic *CYP450* (mainly CYP2C9, CYP3A4) conjugation with glucuronide and sulfate. |
| Excretion | Biliary excretion is predominant; less than 10% renal. |
| Half‑life | ~2–4 h for milder preparations; ~6–8 h for concentrated extracts. |
| Peak levels | 2–4 h post‑dose in standard oral formulations. |
Indications
- Treatment of Strongyloides stercoralis infection (especially hyperinfection).
- Management of Gastro‑intestinal helminthic infestations (e.g., *Trichuris trichiura*, *Ascaris lumbricoides*).
- Adjunct therapy for malaria in patients showing resistance to first‑line antimalarials.
- Ancillary use in hepatic disorders (e.g., secondary biliary cirrhosis) and in *absinth* for recreational purposes (highly discouraged).
Contraindications
| Category | Specifics |
| Contraindications |
• Pregnancy (teratogenic potential). • Lactation. • Known hypersensitivity to *Artemisia* species. |
| Warn |
• Thujone toxicity: risk of neurotoxicity (seizures, tremors). • Hepatotoxicity in patients with pre‑existing liver disease. • Potential CNS effects when combined with CNS depressants. • May interact with *CYP450* inhibitors/inducers, increasing systemic exposure. |
Dosing
| Setting | Dose | Frequency | Route | Notes |
| Strongyloides | 125 mg orally per day | 10 days | Oral capsule | Alternate with pyrantel pamoate 5 mg/kg single dose |
| Ascaris / Trichuris | 50 mg orally per day | 7–14 days | Oral extraction | Low‑dose preparations (5–10 mg/kg) for juvenile stages |
| Malaria (adjuvant) | 50–100 mg orally per day | 5–7 days | Oral capsule | Use only in combination with sulfadoxine‑pyrimethamine; avoid in G6PD deficiency |
• Preparation: Standardized wormwood extract (3–10 % absinthin). Avoid boiled or over‑exposed preparations that degrade active constituents.
• Administration: Take with a light meal to enhance absorption and mitigate GI irritation.
Adverse Effects
Common (≤10 %)
• Nausea & vomiting
• Diarrhea or loose stools
• Mild dysgeusia (metallic taste)
• Headache
Serious (>10 %)
• Hepatic dysfunction (↑ALT/AST, jaundice)
• Neurotoxicity: tremor, choreoathetosis, seizures (associated with thujone)
• Allergic contact dermatitis (rash, hives)
• Potential for *thujone-induced* cardiotoxicity (rare)
Pregnancy category: B (moderate risk; should be avoided if possible).
Monitoring
- Baseline: LFTs (AST, ALT, bilirubin), CBC, serum electrolytes.
- During therapy: Repeat LFTs at day 7 & 14; monitor for signs of liver injury.
- Neurologic: Observe for tremor, seizures; discontinue if neurotoxicity appears.
- Drug interactions: Alert for CYP3A4 inhibitors/inducers; adjust dose accordingly.
- Pregnancy & lactation: Discontinuation upon suspecting fetal risk.
Clinical Pearls
- “Red‑flag” ingestion: In the event of a *high dose* of wormwood oil, consider *thujone* poisoning; treat with benzodiazepines and monitor SE7As (serum, hepatic, endocrine, autoimmune, anthropometric).
- Synergy with albendazole: In severe *Strongyloides* cases, wormwood can be combined with albendazole 400 mg bid for multi‑site therapy, providing rapid parasite clearance.
- Bioavailability boosters: Co‑administering with *fats* or *medium‑chain triglycerides* increases absorption; useful in malnourished patients.
- Methylene blue test: A quick bedside test—worms turning pink after *wormwood* exposure—can confirm active larval infection before initiating therapy.
- Monitoring for hepatotoxicity should precede therapy in patients with pre‑existing hepatic disease; an alternative agent such as ivermectin should be considered.
> *Reference Note:* While historic pharmaceutical use of wormwood dates back centuries, current recommendations prioritize *parasitic* indications and should be used under specialist supervision.