Medical professional with capsules elderberry interactions and precautions
Medical professional with capsules elderberry interactions and precautions

By Nnenna Udensi, MD

For centuries, traditional medicine in a myriad cultures has used both wild and cultivated elderberry to treat and prevent ailments.  Given its numerous uses over such a long period of time, it’s no wonder that the value of elderberry is still recognized generations later and now increasingly within the medical community. Medicinal applications aside, elderberry is often consumed simply in its capacity as fruit and in meal preparations derived from fruit such as desert and juices. That said, as with many other plant-derived foods in our diet, there is always the possibility of unwanted reactions or interactions.  This report provides an overview of potential undesired interactions from consuming elderberry. The majority of the data for elderberry concerning precautions, adverse events, and contraindication revolves around the toxicity of raw berries, bark and other parts of the plant; the resulting gastric distress, and use in pregnant or lactating women.  Potential medication and allergic interactions are also described. Otherwise, I did not find any specific contraindications to elderberry use described in the literature.  To prepare this report I reviewed scientific articles relating to this subject from Google Scholar and Pub Med covering the time period 1982 to 2018.

Potential for Interactions and Side Effects – Hydrogen Cyanide (HCN)

One particularly harmful aspect is that consuming raw elderberries is toxic.1Battelli MG, Citores L, Buonamici L, et al. Toxicity and cytotoxicity of nigrin b, a two-chain ribosome-inactivating protein from Sambucus nigra  : comparison with ricin. Archives of Toxicology. 1997;71(6):360-364. doi:10.1007/s002040050399 The ripe fruit with its high sugar content can also produce hydrogen cyanide while undergoing fermentation. It seems that as the fruit progresses through ripening, fermentation, and decay, the concentration of hydrogen cyanide and its substrates increase.13Pogorzelski E. Formation of cyanide as a product of decomposition of cyanogenic glucosides in the treatment of elderberry fruit (Sambucus nigra). Journal of the Science of Food and Agriculture. 1982;33(5):496-498. doi:10.1002/jsfa.2740330516 Hydrogen cyanide11National Research Council (US) Subcommittee on Acute Exposure Guideline Levels. Hydrogen Cyanide: Acute Exposure Guideline Levels. Acute Exposure Guideline Levels for Selected Airborne Chemicals: Volume 2. https://www.ncbi.nlm.nih.gov/books/NBK207601/. Published January 1, 13Pogorzelski E. Formation of cyanide as a product of decomposition of cyanogenic glucosides in the treatment of elderberry fruit (Sambucus nigra). Journal of the Science of Food and Agriculture. 1982;33(5):496-498. doi:10.1002/jsfa.2740330516  is a poison that affects cell biology by preventing the cell from utilizing oxygen. It causes headaches, fast heart rate, vomiting, and diarrhea initially; and prolonged or substantial exposure can cause seizures and low blood pressure.8Leads from the MMWR. Poisoning from elderberry juice. JAMA: The Journal of the American Medical Association. 1984;251(16):2075-2075. doi:10.1001/jama.251.16.2075 17Sidor A, Gramza-Michałowska A. Advanced research on the antioxidant and health benefit of elderberry (Sambucus nigra) in food – a review. Journal of Functional Foods. 2015;18:941-958. doi:10.1016/j.jff.2014.07.012

Fortunately, heat treatment7Jiménez P, Cabrero P, Cordoba-Diaz D, Cordoba-Diaz M, Garrosa M, Girbés T. Lectin Digestibility and Stability of Elderberry Antioxidants to Heat Treatment In Vitro. Molecules. 2017;22(1):95. doi:10.3390/molecules22010095 of the of ripe, raw fruit at 150 degrees for about 30 minutes reduces the hydrogen cyanide without destroying the compounds responsible for the potential health benefits in both ripe and fermented berries.13Pogorzelski E. Formation of cyanide as a product of decomposition of cyanogenic glucosides in the treatment of elderberry fruit (Sambucus nigra). Journal of the Science of Food and Agriculture. 1982;33(5):496-498. doi:10.1002/jsfa.2740330516 So it is recommended that elderberry fruit is “cooked” before consumption. It is important to note that this process stops well short of boiling, which would render the beneficial properties of elderberry ineffective.7Jiménez P, Cabrero P, Cordoba-Diaz D, Cordoba-Diaz M, Garrosa M, Girbés T. Lectin Digestibility and Stability of Elderberry Antioxidants to Heat Treatment In Vitro. Molecules. 2017;22(1):95. doi:10.3390/molecules22010095 There are also reports21Golej J, Boigner H, Burda G, Hermon M, Trittenwein G. Severe respiratory failure following charcoal application in a toddler. Resuscitation. 2001;49(3):315-318. doi:10.1016/s0300-9572(00)00362-2  of unripe elderberries causing gastric distress in young children, however the vast majority of the literature is devoted to the effects of ripe fruit. Elderberry is not unique when it comes to this food toxicity. Raw bitter almonds are notorious for producing the same toxin and are largely banned in the US. Toxicity levels also depend on the species of elderberry, some being far more toxic than others.

Potential for Interactions and Side Effects – Ribosome Inactivating Proteins (RIP)

The seeds, leaves, stem, bark, roots  of the Elder plant are potentially harmful as well, especially if infused and consumed as an herbal tea.1Battelli MG, Citores L, Buonamici L, et al. Toxicity and cytotoxicity of nigrin b, a two-chain ribosome-inactivating protein from Sambucus nigra  : comparison with ricin. Archives of Toxicology. 1997;71(6):360-364. doi:10.1007/s002040050399 In addition to hydrogen cyanide, these parts contain chemical substances, called ribosome inactivating proteins (RIP), that affect cell biology by inactivating the structures in animal cells that create proteins.1Battelli MG, Citores L, Buonamici L, et al. Toxicity and cytotoxicity of nigrin b, a two-chain ribosome-inactivating protein from Sambucus nigra  : comparison with ricin. Archives of Toxicology. 1997;71(6):360-364. doi:10.1007/s002040050399 2Bratu MM, Doroftei E, Negreanu-Pirjol T, Hostina C, Porta S. Determination of Antioxidant Activity and Toxicity of Sambucus nigra Fruit Extract Using Alternative Methods. April 2012:1-6. Not all RIPs are toxic to humans when consumed. They exist in plants and bacteria as a form of protection.15Shahidi-Noghabi S, Damme EJMV, Smagghe G. Expression of Sambucus nigra agglutinin (SNA-I′) from elderberry bark in transgenic tobacco plants results in enhanced resistance to different insect species. Transgenic Research. 2008;18(2):249-259. doi:10.1007/s11248-008-9215-2 Elderberry’s RIPs are toxic to insects prompting research into its potential use as an insecticide. However, despite the clear demonstration of toxicity to human cells,16Shang C, Chen Q, Dell A, Haslam SM, Vos WHD, Damme EJMV. The Cytotoxicity of Elderberry Ribosome-Inactivating Proteins Is Not Solely Determined by Their Protein Translation Inhibition Activity. Plos One. 2015;10(7). the effects studied so far are limited mostly to laboratory experiments. Gastrointestinal and neurological effects from elderberry toxicity are attributed to the effects of hydrogen cyanide (HCN).11National Research Council (US) Subcommittee on Acute Exposure Guideline Levels. Hydrogen Cyanide: Acute Exposure Guideline Levels. Acute Exposure Guideline Levels for Selected Airborne Chemicals: Volume 2. https://www.ncbi.nlm.nih.gov/books/NBK207601/. Published January 1, 13Pogorzelski E. Formation of cyanide as a product of decomposition of cyanogenic glucosides in the treatment of elderberry fruit (Sambucus nigra). Journal of the Science of Food and Agriculture. 1982;33(5):496-498. doi:10.1002/jsfa.2740330516

Potential for Interactions and Side Effects – Allergies

As with any food, allergies should be considered when consuming it for the first time. That includes elderberry, where the risk of allergy is likely to be higher in people who are also allergic to honeysuckle as the plants are closely related. It seems the RIPs present in elderberry have allergenic potential that can be reduced to some degree with heat treatment.7Jiménez P, Cabrero P, Cordoba-Diaz D, Cordoba-Diaz M, Garrosa M, Girbés T. Lectin Digestibility and Stability of Elderberry Antioxidants to Heat Treatment In Vitro. Molecules. 2017;22(1):95. doi:10.3390/molecules22010095

Potential for Interactions and Side Effects – when taken with other medicine

Thus far I have reviewed the potential risks from consuming elderberry as food or drink. Taken medicinally, however, the potential side effects and interactions of elderberry are less clear.

While there are no confirmed drug interactions with elderberry, there is a slew of theoretical and laboratory identified interactions. The distinction between theory and actual lab results is important because although the theories have not been empirically tested, the information can still be considered when doing risk assessments for a particular disease or therapy. For instance, given the reports of elderberry’s laxative and diuretic effects,17Sidor A, Gramza-Michałowska A. Advanced research on the antioxidant and health benefit of elderberry (Sambucus nigra) in food – a review. Journal of Functional Foods. 2015;18:941-958. doi:10.1016/j.jff.2014.07.012 22Picon PD, Picon RV, Costa AF, et al. Randomized clinical trial of a phytotherapic compound containing Pimpinella anisum, Foeniculum vulgare, Sambucus nigra, and Cassia augustifolia for chronic constipation.  BMC Complementary someone already taking medications for constipation or diuresis may want to avoid the addition of elderberry to their regimen as excessive diarrhea and diuresis can lead to electrolyte imbalances and other undesired effects. There are other potential effects as well.

Currently research suggests caution should be exercised when consuming  an elderberry supplement together with:

  • Antidiabetic drugs4Ciocoiu M, Mirón A, Mares L, et al. The effects of Sambucus nigra polyphenols on oxidative stress and metabolic disorders in experimental diabetes mellitus. Journal of Physiology and Biochemistry. 2009;65(3):297-304. doi:10.1007/bf03180582
    • Active ingredients in elderberry have documented effects on binding of sugar in the blood. Potential for hypoglycemia if combined with drugs with similar effects.
  • Morphine6Jakovljevi V, Popovic M, Mimica-Dukic N, Sabo J. Interaction of Sambucus nigra Flower and Berry Decoctions with the Actions of Centrally Acting Drugs in Rats. Pharmaceutical Biology. 2001;39(2):142-145. doi:10.1076/phbi.39.2.142.6260
    • An animal study showed decreased analgesic action after the subject also consumed elderberry. Potential for reducing the effectiveness of pain medications
  • Phenobarbital6Jakovljevi V, Popovic M, Mimica-Dukic N, Sabo J. Interaction of Sambucus nigra Flower and Berry Decoctions with the Actions of Centrally Acting Drugs in Rats. Pharmaceutical Biology. 2001;39(2):142-145. doi:10.1076/phbi.39.2.142.6260
    • An animal study showed a decrease in induction time or the time it takes to have its effect, an increase in sleep time. This potential effect may be acceptable if the person taking the medications has trouble falling and staying asleep. However, it may be undesired in a person undergoing anesthesia.
  • Immuno-active drugs5Citores L, Iglesias R, Muñoz R, Ferreras J, Jimenez P, Girbes T. Elderberry (Sambucus nigraL.) seed proteins inhibit protein synthesis and display strong immunoreactivity with rabbit polyclonal antibodies raised against 10Millar CL, Norris GH, Jiang C, et al. Long-Term Supplementation of Black Elderberry Promotes Hyperlipidemia, but Reduces Liver Inflammation and Improves HDL Function and Atherosclerotic Plaque Stability in Apolipoprotein E-Knockout 12Newkirk MM, Fournier M-JE, Shiroky J. Rheumatoid factor avidity in patients with rheumatoid arthritis: Identification of pathogenic RFs which correlate with disease parameters and with the gal(O) glycoform of IgG. Journal
    • Several laboratory and animal studies have shown that chemicals present in elderberry interact with the immune system in various ways. So there is an argument to be made that other medications designed to interact with the immune system may also interact with elderberry.

Caution is also advised in certain groups due to higher vulnerability, and lack of explicit safety data in these groups. The medical field generally avoids taking unnecessary risks in pregnant and lactating women, young children, and people with compromised immune systems.

Potential for Interactions and Side Effects – for immunocompromised individuals

The literature on side effects in this patient population is a bit more nuanced. The potential for small beneficial outcomes, often involving symptom relief, is described in the literature.12Newkirk MM, Fournier M-JE, Shiroky J. Rheumatoid factor avidity in patients with rheumatoid arthritis: Identification of pathogenic RFs which correlate with disease parameters and with the gal(O) glycoform of IgG. Journal  However, focusing on short-term gains in this way is short sighted. Particularly when one takes into account elderberry’s ability to alter normal functioning of the immune system in ways yet unclear to us.12Newkirk MM, Fournier M-JE, Shiroky J. Rheumatoid factor avidity in patients with rheumatoid arthritis: Identification of pathogenic RFs which correlate with disease parameters and with the gal(O) glycoform of IgG. Journal

In theory, elderberry could affect autoimmune disease precipitated inflammation, thus calming symptoms and potentially benefiting immune conditions such as arthritis, diabetes, or inflammatory bowel disease. Several studies10Millar CL, Norris GH, Jiang C, et al. Long-Term Supplementation of Black Elderberry Promotes Hyperlipidemia, but Reduces Liver Inflammation and Improves HDL Function and Atherosclerotic Plaque Stability in Apolipoprotein E-Knockout  show elderberry to reduce inflammation in laboratory and animal studies. But this effect has not yet been studied as extensively in autoimmune disease or clinical trials. Conversely, given studies describing immune modulating effects,5Citores L, Iglesias R, Muñoz R, Ferreras J, Jimenez P, Girbes T. Elderberry (Sambucus nigraL.) seed proteins inhibit protein synthesis and display strong immunoreactivity with rabbit polyclonal antibodies raised against 12Newkirk MM, Fournier M-JE, Shiroky J. Rheumatoid factor avidity in patients with rheumatoid arthritis: Identification of pathogenic RFs which correlate with disease parameters and with the gal(O) glycoform of IgG. Journal treatment could also further modify an already malfunctioning immune system in ways we don’t yet understand. In the absence of conclusive evidence reporting the benefits of elderberry treatment in these diseases, it is difficult to justify exposing affected patient populations to the potential risks. Especially when proven and cost-effective therapies are available.

The appeal is understandable though. Immunocompromised disease states are especially pertinent because they often involve lifelong treatment with potent, and potentially expensive drugs. These drugs can be difficult to take or cause side effects of their own, sending patients looking for answers and relief wherever they can find it. This makes the lure of alternative therapies strong for some looking for natural ways to treat lifelong illnesses. And for some immune diseases, the data in support of elderberry having benefits for these illnesses shows potential.5Citores L, Iglesias R, Muñoz R, Ferreras J, Jimenez P, Girbes T. Elderberry (Sambucus nigraL.) seed proteins inhibit protein synthesis and display strong immunoreactivity with rabbit polyclonal antibodies raised against 12Newkirk MM, Fournier M-JE, Shiroky J. Rheumatoid factor avidity in patients with rheumatoid arthritis: Identification of pathogenic RFs which correlate with disease parameters and with the gal(O) glycoform of IgG. Journal  Even still, this population of patients should exercise caution. Effects tolerated by people with healthy immune systems may vary in people with immune disorders. The only thing current research in this area tells us conclusively is that we do not know.

In Summary

After reviewing available scientific research on elderberry, I would describe it as a useful supplement that has an array of potentially beneficial effects. The better documented and studied benefits primarily involve the antiviral/microbial, antioxidant, and anti-inflammatory effects of elderberry. With these effects as mechanisms of action, elderberry seems to potentially affect a wide range of conditions including influenza,27Zakay-Rones Z, Thom E, Wollan T, Wadstein J. Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment of Influenza A and B Virus Infections.  Journal 28Zakay-Rones Z, Varsano N, Zlotnik M, et al. Inhibition of Several Strains of Influenza Virus in Vitro and Reduction of Symptoms by an Elderberry Extract (Sambucus nigra L.) during an hyperlipidemia23Dubey P, Jayasooriya AP, Cheema SK. Fish oil induced hyperlipidemia and oxidative stress in BioF1B hamsters is attenuated by elderberry extract.  Applied Physiology, Nutrition, and Metabolism. 2012;37(3):472-479. doi:10.1139/h2012-030. 24Vauzour D, Tejera N, Oneill C, et al. Anthocyanins do not influence long-chain n-3 fatty acid status: studies in cells, rodents and humans.  The Journal of Nutritional Biochemistry. 2015;26(3):211-218. doi:10.1016/j.jnutbio.2014.09.005.  obesity,29Chrubasik C, Maier T, Dawid C, et al. An observational study and quantification of the actives in a supplement withSambucus nigraandAsparagus officinalisused for weight reduction.  Phytotherapy Research. 2008;22(7):913-918. doi:10.1002/ptr.2415. gingivitis,25Levine WZ, Samuels N, Sheshet MEB, Grbic JT. A Novel Treatment of Gingival Recession using a Botanical Topical Gingival Patch and Mouthrinse.  The Journal of Contemporary Dental Practice. 2013;14:948-953. doi:10.5005/jp-journals-10024-1431. 26Harokopakis E, Albzreh MH, Haase EM, Scannapieco FA, Hajishengallis G. Inhibition of Proinflammatory Activities of Major Periodontal Pathogens by Aqueous Extracts From Elder Flower (Sambucus nigra).  Journal of Periodontology. 2006;77(2):271-279. stress,23Dubey P, Jayasooriya AP, Cheema SK. Fish oil induced hyperlipidemia and oxidative stress in BioF1B hamsters is attenuated by elderberry extract.  Applied Physiology, Nutrition, and Metabolism. 2012;37(3):472-479. doi:10.1139/h2012-030. diabetes,4Ciocoiu M, Mirón A, Mares L, et al. The effects of Sambucus nigra polyphenols on oxidative stress and metabolic disorders in experimental diabetes mellitus. Journal of Physiology and Biochemistry. 2009;65(3):297-304. doi:10.1007/bf03180582 inflammatory diseases23Dubey P, Jayasooriya AP, Cheema SK. Fish oil induced hyperlipidemia and oxidative stress in BioF1B hamsters is attenuated by elderberry extract.  Applied Physiology, Nutrition, and Metabolism. 2012;37(3):472-479. doi:10.1139/h2012-030. 30Lee Y-M, Yoon Y, Yoon H, Park H-M, Song S, Yeum K-J. Dietary Anthocyanins against Obesity and Inflammation.  Nutrients. 2017;9(10):1089. doi:10.3390/nu9101089.  and more.  When prepared correctly,  research shows that consumption of elderberry is safe in several different forms and doses, over various periods of time.

As a clinician, I would advise people considering medicinal elderberry use to ensure it is prepared correctly or otherwise stick to supplement preparations. There are several different preparations to choose from, but extracts have more robust data. Start with a small dose to test for allergic reactions and stay within the manufacturers’ recommended dosage for the product. Nevertheless, given the wide range of dosages indicated by supplement manufacturers, it’s unclear how they are establishing their recommendations.

I would suggest limiting use of elderberry supplements to the duration of the symptoms for colds and upper-respiratory infections and discourage use for chronic conditions where proven medications are readily available. For supplemental use it is safe, and perhaps a good idea in adults whose diet is lacking similar berries and fruits. There is little data on long-term use, but likely safe in moderation over extended periods of time. I would caution against pregnant/nursing women, small children, and immunocompromised people using this supplementation since safety studies have not be done in these groups, and the benefits may not outweigh the potential risks. A diet higher in dark berries and other similar fruits would provide a comparable level of nutrition and benefit in these groups and should be pursued first.

While elderberry’s efficacy continues to be studied and debated in academia, the increasing number of studies seeking to answer questions regarding its additional medical potential, are one of the highest forms of validation the medical field can offer. It suggests that governments, scientists, academics, doctors, and pharmaceutical companies all recognize the medical potential of elderberry and think it a worthwhile pursuit. The scientific community is gradually coming to accept some of the beliefs and anecdotes about the benefits of elderberry held by  many civilizations that predate ours.

1 Battelli MG, Citores L, Buonamici L, et al. Toxicity and cytotoxicity of nigrin b, a two-chain ribosome-inactivating protein from Sambucus nigra  : comparison with ricin. Archives of Toxicology. 1997;71(6):360-364. doi:10.1007/s002040050399
13 Pogorzelski E. Formation of cyanide as a product of decomposition of cyanogenic glucosides in the treatment of elderberry fruit (Sambucus nigra). Journal of the Science of Food and Agriculture. 1982;33(5):496-498. doi:10.1002/jsfa.2740330516
11 National Research Council (US) Subcommittee on Acute Exposure Guideline Levels. Hydrogen Cyanide: Acute Exposure Guideline Levels. Acute Exposure Guideline Levels for Selected Airborne Chemicals: Volume 2. https://www.ncbi.nlm.nih.gov/books/NBK207601/. Published January 1, 1970. Accessed October 14, 2018.
8 Leads from the MMWR. Poisoning from elderberry juice. JAMA: The Journal of the American Medical Association. 1984;251(16):2075-2075. doi:10.1001/jama.251.16.2075
17 Sidor A, Gramza-Michałowska A. Advanced research on the antioxidant and health benefit of elderberry (Sambucus nigra) in food – a review. Journal of Functional Foods. 2015;18:941-958. doi:10.1016/j.jff.2014.07.012
7 Jiménez P, Cabrero P, Cordoba-Diaz D, Cordoba-Diaz M, Garrosa M, Girbés T. Lectin Digestibility and Stability of Elderberry Antioxidants to Heat Treatment In Vitro. Molecules. 2017;22(1):95. doi:10.3390/molecules22010095
21 Golej J, Boigner H, Burda G, Hermon M, Trittenwein G. Severe respiratory failure following charcoal application in a toddler. Resuscitation. 2001;49(3):315-318. doi:10.1016/s0300-9572(00)00362-2
2 Bratu MM, Doroftei E, Negreanu-Pirjol T, Hostina C, Porta S. Determination of Antioxidant Activity and Toxicity of Sambucus nigra Fruit Extract Using Alternative Methods. April 2012:1-6.
15 Shahidi-Noghabi S, Damme EJMV, Smagghe G. Expression of Sambucus nigra agglutinin (SNA-I′) from elderberry bark in transgenic tobacco plants results in enhanced resistance to different insect species. Transgenic Research. 2008;18(2):249-259. doi:10.1007/s11248-008-9215-2
16 Shang C, Chen Q, Dell A, Haslam SM, Vos WHD, Damme EJMV. The Cytotoxicity of Elderberry Ribosome-Inactivating Proteins Is Not Solely Determined by Their Protein Translation Inhibition Activity. Plos One. 2015;10(7). doi:10.1371/journal.pone.0132389
22 Picon PD, Picon RV, Costa AF, et al. Randomized clinical trial of a phytotherapic compound containing Pimpinella anisum, Foeniculum vulgare, Sambucus nigra, and Cassia augustifolia for chronic constipation.  BMC Complementary and Alternative Medicine. 2010;10(1). doi:10.1186/1472-6882-10-17.
4 Ciocoiu M, Mirón A, Mares L, et al. The effects of Sambucus nigra polyphenols on oxidative stress and metabolic disorders in experimental diabetes mellitus. Journal of Physiology and Biochemistry. 2009;65(3):297-304. doi:10.1007/bf03180582
6 Jakovljevi V, Popovic M, Mimica-Dukic N, Sabo J. Interaction of Sambucus nigra Flower and Berry Decoctions with the Actions of Centrally Acting Drugs in Rats. Pharmaceutical Biology. 2001;39(2):142-145. doi:10.1076/phbi.39.2.142.6260
5 Citores L, Iglesias R, Muñoz R, Ferreras J, Jimenez P, Girbes T. Elderberry (Sambucus nigraL.) seed proteins inhibit protein synthesis and display strong immunoreactivity with rabbit polyclonal antibodies raised against the type 2 ribosome-inactivating protein nigrin b. Journal of Experimental Botany. 1994;45(4):513-516. doi:10.1093/jxb/45.4.513
10 Millar CL, Norris GH, Jiang C, et al. Long-Term Supplementation of Black Elderberry Promotes Hyperlipidemia, but Reduces Liver Inflammation and Improves HDL Function and Atherosclerotic Plaque Stability in Apolipoprotein E-Knockout Mice. Molecular Nutrition & Food Research. 2018:1800404. doi:10.1002/mnfr.201800404
12 Newkirk MM, Fournier M-JE, Shiroky J. Rheumatoid factor avidity in patients with rheumatoid arthritis: Identification of pathogenic RFs which correlate with disease parameters and with the gal(O) glycoform of IgG. Journal of Clinical Immunology. 1995;15(5):250-257. doi:10.1007/bf01540882
27 Zakay-Rones Z, Thom E, Wollan T, Wadstein J. Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment of Influenza A and B Virus Infections.  Journal of International Medical Research. 2004;32(2):132-140. doi:10.1177/147323000403200205.
28 Zakay-Rones Z, Varsano N, Zlotnik M, et al. Inhibition of Several Strains of Influenza Virus in Vitro and Reduction of Symptoms by an Elderberry Extract (Sambucus nigra L.) during an Outbreak of Influenza B Panama.  The Journal of Alternative and Complementary Medicine. 1995;1(4):361-369. doi:10.1089/acm.1995.1.361.
23 Dubey P, Jayasooriya AP, Cheema SK. Fish oil induced hyperlipidemia and oxidative stress in BioF1B hamsters is attenuated by elderberry extract.  Applied Physiology, Nutrition, and Metabolism. 2012;37(3):472-479. doi:10.1139/h2012-030.
24 Vauzour D, Tejera N, Oneill C, et al. Anthocyanins do not influence long-chain n-3 fatty acid status: studies in cells, rodents and humans.  The Journal of Nutritional Biochemistry. 2015;26(3):211-218. doi:10.1016/j.jnutbio.2014.09.005.
29 Chrubasik C, Maier T, Dawid C, et al. An observational study and quantification of the actives in a supplement withSambucus nigraandAsparagus officinalisused for weight reduction.  Phytotherapy Research. 2008;22(7):913-918. doi:10.1002/ptr.2415.
25 Levine WZ, Samuels N, Sheshet MEB, Grbic JT. A Novel Treatment of Gingival Recession using a Botanical Topical Gingival Patch and Mouthrinse.  The Journal of Contemporary Dental Practice. 2013;14:948-953. doi:10.5005/jp-journals-10024-1431.
26 Harokopakis E, Albzreh MH, Haase EM, Scannapieco FA, Hajishengallis G. Inhibition of Proinflammatory Activities of Major Periodontal Pathogens by Aqueous Extracts From Elder Flower (Sambucus nigra).  Journal of Periodontology. 2006;77(2):271-279. doi:10.1902/jop.2006.050232.
30 Lee Y-M, Yoon Y, Yoon H, Park H-M, Song S, Yeum K-J. Dietary Anthocyanins against Obesity and Inflammation.  Nutrients. 2017;9(10):1089. doi:10.3390/nu9101089.