A science-based analysis of the safety of this popular root, which is more a question of who, rather than when.
Take a clinical and herbalist/functional medicine approach · For educational purposes only
Disclaimer: This article is provided only for educational purposes and not intended to be medical advice, diagnosis or medical treatment. Any herbal supplement is recommended against for individuals suffering from an autoimmune disease or on any type of immune suppressing medication; always seek the advice of a qualified health care practitioner.
Astragalus membranaceus, or Huang Qi (which translates to "yellow leader" in Traditional Chinese Medicine), is a root that has established a strong reputation in the world of natural medicine for its ability to nourish energy, strengthen stamina and promote immune function. It has become an ever popular part of the conversation with autoimmune diagnoses and the first question that usually arises is – WHEN? Morning? Evening? With food? During a flare? Between flares?
This seems a good way to begin. It isn't. Timing is a superficial concept that is lifted from the pharmaceutical way of thinking and in the world of immune active botanicals and autoimmune biology, it barely scratches the surface. The true question – the one that truly matters and determines if Astragalus is suitable for a particular individual – is not so much about the clock, but about the terrain of a particular individual's immune system.
Mechanism: Astragalus' interaction with the immune system.
Adaptogen" is a term that's used quite liberally in the wellness community, and sometimes, inaccurately. In clinical herbalism, it has a specific meaning: an adaptogen is a compound found in a plant that helps the body to maintain balance in the physiology when it is under stress. Adaptogens do not act to stimulate or inhibit just one body system, but it is believed that they act at a level that seems to be more global, such as the HPA (hypothalamic-pituitary-adrenal) axis and the body's stress response. These include ashwagandha, rhodiola and eleuthero. Astragalus is considered to fall into this category, but its main, and most documented effect is the immune system-modulatory – measurable effects on immune system activity.
On the cellular level, Astragalus root has been shown to affect a number of important components of immune function, due to its active compounds, which include polysaccharides (such as APS), saponins and flavonoids. These involve the activation and proliferation of T-lymphocytes (the cells that coordinate immune responses), increased activity of macrophages (the "first responders" of the immune system, which eat pathogens and tell other cells to activate the immune response), and increased production of cytokines, such as interleukins that further boost the immune response. For a person with a low or compromised immune system (due to old age, illness or chemotherapy) such stimulation can be a real therapeutic measure. Immune system is stimulated with a “nudge” at a lower level.
But now, when the same stimulus is encountered by an already overactive immune system. The disease process in autoimmune diseases, whether they be lupus, rheumatoid arthritis, Hashimoto's thyroiditis, multiple sclerosis, psoriasis or any of the dozens of other autoimmune diseases, is not immune underactivity. It's a directing of the immune system. In short, the immune system no longer recognizes and discriminates between "self" and "nonself" and is now attacking "self. Balance is not restored by the addition of the compound that promotes the activity of macrophages and proliferation of T-cells in this environment. It can potentially be a catalyst to an already raging fire in the wrong direction. It is for that reason that the time of day (morning vs. evening) and whether or not it's with food makes little difference. There is no way to "beat the system" in a basic battle between a herb's mode of action and a person's immune system.
Why it's better to do individual immune mapping than timing
The "flare vs. remission" construct is very simple.
Many people think that Astragalus is safe when in remission and is dangerous when it is in a “flare”. However, autoimmune remission does not equal "immune normalization", but is a time of "relative quiet", where the underlying dysregulations are still present. In susceptible people, some immune system stimulation in the remission period can be the key to triggering the next flare. Even though there are no symptoms there is no immune resolution.
Immunosuppressant drugs are based on a fine and delicate balance.
Immunosuppressive drugs such as methatrexate, mycophenolate, azathioprine and biological drugs (TNF-alpha inhibitors) act by intentionally suppressing certain components of our immune system. Throwing an immune stimulator into the mix doesn't give a neutral effect, but a direct counter effect to the drug intended action that could compromise disease control that may have been achieved over months or years.
This is a real-life pharmacodynamic worry.
The risk calculus is very different with tissue specific vs. systemic autoimmunity.
The main pathogenesis of Hashimoto's thyroiditis is that it is an antibody-mediated attack on the thyroid tissue. Kidneys, heart, brain, skin and joints can all be affected simultaneously with SLE. The risk to the patient for immune-stimulation is not equal among these diagnoses. Any blanket recommendation (or blanket avoidance) fails to take into account the great variety of "autoimmune conditions.
Immune Phenotype is as important as diagnosis.
Two people can have the same diagnosis, the same antibody markers and vastly different underlying immune profiles – one a predominantly Th1 driven immune profile, another a Th2-driven immune profile, another a Th17-dysregulated immune profile. The effects of Astragalus do not apply to all these phenotypes of T-cells. If an individual doesn't know which branch of the immune system is hyperactive in him, then there is no point in taking any immune stimulant—it could be harmful.
Certain autoimmune diseases have real (non-hypothetical) risks of cytokine storms.
Diseases such as lupus and Still's disease already have a tendency to have cytokine dysregulation, in which there are times of overactive immune signaling that leads to severe organ injury. This is not an overly theoretical risk because Astragalus (up as a consequence of its immune stimulating action) enhances the production of cytokines. It is a true clinical issue – it isn't just something that can simply be written on a supplement label.
Healthy people's safety data does not necessarily apply to people with auto immune disorders who use the herb.
A large part of the studies to investigate Astragalus's immunostimulatory properties are done in people with compromised immune systems, such as cancer patients, elderly people with weak immune systems or healthy volunteers. This kind of extrapolation without any adjustments to the findings is a frequent category error found in wellness literature and involves autoimmune patients.
It is the clinical problem that is the one of unpredictability.
In cases where Astragalus doesn't seem to have caused an immediate adverse reaction this does not necessarily mean that the herb did not affect underlying immune activity. Because autoimmune flares can occur days to weeks after triggering events, it is hard to determine cause and effect, unless done on a systematic basis.
Importance of clinical supervision/lab work
One of the common misconceptions in the supplement industry is that if it's natural, it's safe to use as a self-prescribed supplement. This merging can be detrimental and in no area is this more apparent than with autoimmune treatments. In this context, astragalus is not a harmless tonic, it's an immune-active botanical and immune-active means that it has the ability to impact immune activity in a measurable way. Taking it on your own is a way of playing Russian roulette with your immune system, with no base line, no safety net.
A trained integrative physician, licensed Naturopathic Doctor or trained clinical herbalist with knowledge of herb-drug interactions will first assess the patient's immune terrain. Usually this will include an analysis of any relevant lab markers such as ANA titers, anti-dsDNA antibodies (in the case of lupus), anti-TPO and anti-TG antibodies (in thyroid autoimmunity), complement levels and inflammatory markers such as high-sensitivity CRP and ESR, and, if applicable, T-cell subset panels. These numbers convey a message that symptoms do not. It's possible for a person to feel just fine, yet rise in inflammatory markers are slowly, silently ticking up — and this upward movement is exactly what a practitioner should see before making the decision to consider any immune-active intervention.
This discussion should also include a discussion on all current medications. When evaluating herb-drug interactions in patients with autoimmune disorders, it is not something that one can do simply as a check box exercise. It involves knowledge of the pharmacodynamics of the immunosuppressants in question, the proposed mechanisms by which the herb in question works and any common pathways. Without someone with both of these pieces of knowledge in mind at the time of assessment, and without the inclination to say "not right now," or "not for this patient," based on the evidence, this level of assessment simply can't happen. With integrative care, it's not about using as many tools as possible. Use of the correct tools, for the correct person and with the proper monitoring.
Moving towards individual safety dialogs
Astragalus truly packs a punch therapeutically, if used appropriately in clinical situations. For many, that isn't an Autoimmune diagnosis at all. If you're asked a question regarding this herb in clinical practice, the most important first step is not reading the instructions on the supplement bottle, but carefully and honestly evaluating the individual's immune biology, his/her medications, disease activity and overall health trajectory. When it comes to safety in autoimmunity, it is never a "one size fits all," or a "one-size-fits-all" protocol with a set timing. It's always a snapshot of the unique topography within one person at one time, which is read accurately by someone with the clinical depth to read it. If you're taking care of an auto-immune issue and have questions about Astragalus, or any botanical that might be immune active, you can be your own best friend and consult a qualified practitioner and not a search engine.
The issue isn't whether or not to take it. The issue is: do you want to (or does your clinician say you should) — and there is no time limit on that.
