Holistic vets recommend elderberry
Holistic vets recommend elderberry

By Jon Stack, DVM

Methods: I performed a literature review between July 12 and August 14, 2018. Databases accessed include PubMed, Google Scholar, and Web of Science. Literature from 1970 to present was reviewed.

Elderberries have been used for millennia in traditional medicinal practices of Native American, Mediterranean, and European cultures. Elderberries are still one of the most widely used natural remedies in the world, and there is growing scientific evidence supporting some of the claimed health benefits. As an increasing number of people find potential benefit in elderberries, they may also wonder about the potential benefits for their pets. This article aims to review the scientific evidence for the health benefits of elderberries and evaluate the potential benefits and risks to animals more specifically.  Below please find a summary table that lists animal studies that have used products containing elderberries.

There are a number of claimed health benefits of elderberry plants, including anti-inflammatory, diuretic, expectorant, and pain-relieving effects.1Porter, R. S. & Bode, R. F. A Review of the Antiviral Properties of Black Elder (Sambucus nigra L.) Products. Phyther. Res. 31, 533–554 (2017). The medical use with the most scientific support is for viral respiratory infections. Multiple studies have shown natural compounds in elderberry extracts interfere with viral infections. These compounds (flavonoids, lectins, and pectins) work in multiple ways. The  flavonoids (pigmented molecules which give elderberries their color) bind to influenza virus and prevent entry into cells.2Roschek, B., Fink, R. C., McMichael, M. D., Li, D. & Alberte, R. S. Elderberry flavonoids bind to and prevent H1N1 infection in vitro. Phytochemistry 70, 1255–61 (2009). Some proteins, called lectins, block the virus’ ability to bind to the cells by binding to sugar molecules on the surface of cells3Rogers, G. N. et al. Single amino acid substitutions in influenza haemagglutinin change receptor binding specificity. Nature 304, 76–8 4Rogers, G. N. & Paulson, J. C. Receptor determinants of human and animal influenza virus isolates: differences in receptor specificity of the H3 hemagglutinin based on species of origin. Virology 5Gamblin, S. J. & Skehel, J. J. Influenza Hemagglutinin and Neuraminidase Membrane Glycoproteins. J. Biol. Chem. 285, 28403–28409 (2010). 6Connor, R. J., Kawaoka, Y., Webster, R. G. & Paulson, J. C. Receptor specificity in human, avian, and equine H2 and H3 influenza virus isolates. Virology 205, 17–23 (1994). . When this happens, the virus can no longer use these same sugar molecules to bind to cells and then gain entry. Still another class of compounds called pectins seem to stimulate the immune response, which may help speed recovery once infection sets in.7Kinoshita, E., Hayashi, K., Katayama, H., Hayashi, T. & Obata, A. Anti-influenza virus effects of elderberry juice and its fractions. Biosci. Biotechnol. Biochem. 76, 1633–8 (2012). 8Ho, G. T. T. et al. Structure-activity relationship of immunomodulating pectins from elderberries. Carbohydr. Polym. 125, 314–22 (2015). 9Ho, G. T. T., Zou, Y.-F., Aslaksen, T. H., Wangensteen, H. & Barsett, H. Structural characterization of bioactive pectic polysaccharides from elderflowers (Sambuci flos). Carbohydr. Polym. 135, 128–37 (2016). Several small studies using elderberry extract in humans also show faster recovery after influenza infection occurs.10Zakay-Rones, Z. 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 11Zakay-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. 12Kong, F.-K. Pilot Clinical Study on a Proprietary Elderberry Extract: Efficacy in Addressing Influenza Symptoms. Online J. Pharmacol. Pharmacokinet. 5, 32–43 (2009). These studies are small and are not as powerful as a large clinical trial, but they do provide additional evidence that elderberry extract might be helpful in fighting the flu. Elderberry also seems to have effects against other viruses, including human immunodeficiency virus (HIV) and certain strains of herpes virus.13Mahmood, N. et al. Inhibition of HIV infection by flavanoids. Antiviral Res. 22, 189–199 (1993). 14Amoros, M., Simõs, C. M. O., Girre, L., Sauvager, F. & Cormier, M. Synergistic Effect of Flavones and Flavonols Against Herpes Simplex Virus Type 1 in Cell Culture. Comparison with

If elderberry extracts are safe in humans, and potentially carry these anti-viral benefits, could it be used for pets and domestic animals as well? Just like in humans, there is some evidence from studies on animals that elderberry is also helpful against the flu. Table 1 provides a summary of the studies which have been performed on animals using elderberry products. Nearly half of the studies evaluated the efficacy against influenza infections.  Elderberries or products containing elderberries seem to be protective or reduce the duration of disease in chimpanzees, mice, and chickens infected with influenza.7Kinoshita, E., Hayashi, K., Katayama, H., Hayashi, T. & Obata, A. Anti-influenza virus effects of elderberry juice and its fractions. Biosci. Biotechnol. Biochem. 76, 1633–8 (2012). 15Karimi, S., Dadras, H. & Mohammadi, A. The effect of the extracts of Echinacea purpurea and Sambucus nigra (black elderberry) on virus shedding in H9N2 avian influenza infected chickens. Iran. 16Burge, B., Mumcuoglu, M. & Simmon, T. The effect of Sambucol on flu-like symptoms in chimpanzees: prophylactic and symptom-dependent treatment. Int. Zoo News 46, 16–19 (1999). 17Smee, D. F., Hurst, B. L. & Wong, M. H. Effects of TheraMax on influenza virus infections in cell culture and in Mice. Antivir. Chem. Chemother. 21, 231–237 (2011).  As mentioned before, one of the ways that elderberries seem to be protective against the flu is by binding to sugar molecules on the surface of cells in the human body and thereby blocking the entry of the virus. And similarly, dogs, pigs, horses, sheep, guinea pigs, and ducks6Connor, R. J., Kawaoka, Y., Webster, R. G. & Paulson, J. C. Receptor specificity in human, avian, and equine H2 and H3 influenza virus isolates. Virology 205, 17–23 (1994). 18Nelli, R. K. et al. Comparative distribution of human and avian type sialic acid influenza receptors in the pig. BMC Vet. Res. 6, 4 (2010). 19Suzuki, Y. et al. Sialic acid species as a determinant of the host range of influenza A viruses. J. Virol. 74, 11825–31 (2000). 20Ito, T. et al. Receptor Specificity of Influenza A Viruses Correlates with the Agglutination of Erythrocytes from Different Animal Species. Virology 227, 493–499 (1997).  have been shown to have sugars which bind to both influenza and the natural compounds in elderberries. Even though we do not have studies for each of these species, it is tempting to speculate that elderberries may be protective in a broad range of species.

There are also a handful of rodent studies which show that the benefits of elderberry extract may extend beyond its antiviral properties. Diabetic rats fed elderberry extracts showed stabilization of blood sugar levels, reduced insulin secretion, increased activity of anti-oxidant systems, and reduced formation of compounds which contribute to atherosclerosis (the cause of heart attacks in humans).21Salvador, Â. C. et al. Effect of Elderberry (Sambucus nigra L.) Extract Supplementation in STZ-Induced Diabetic Rats Fed with a High-Fat Diet. Int. J. Mol. Sci. 18, 13 (2016). 23Opris, R. et al. The effect of Sambucus nigra L. extract and photosynthesized gold nanoparticles on diabetic rats. Colloids Surfaces B Biointerfaces 150, 192–200 (2017). Elderberry extract also improved function of HDL cholesterol (the “good” cholesterol), lowered markers of inflammation, and reduced atherosclerosis in a strain of mice which had excessive lipids (fats) in the blood.24Farrell, N., Norris, G., Lee, S. G., Chun, O. K. & Blesso, C. N. Anthocyanin-rich black elderberry extract improves markers of HDL function and reduces aortic cholesterol in hyperlipidemic mice. Obese mice seem to benefit from elderberry extract as well, with reduced markers of inflammation in the blood and improved sensitivity to insulin.25Farrell, N. J. et al. Black elderberry extract attenuates inflammation and metabolic dysfunction in diet-induced obese mice. Br. J. Nutr. 114, 1123–31 (2015). In hamsters, elderberry extract protected against excessive lipids in the blood of hamsters fed large amounts of fish oil.26Dubey, P., Jayasooriya, A. P. & Cheema, S. K. Fish oil induced hyperlipidemia and oxidative stress in BioF1B hamsters is attenuated by elderberry extract. Appl. Physiol. Nutr. Metab. 37, 472–9   Beyond metabolic and cardiovascular benefits, elderberries may also be protective against heavy metal toxicities. Freeze-dried elderberry fruit reduced accumulation of cadmium in the livers of rats while protecting kidney function (although cadmium continued to accumulate in bones and kidneys). The protective effect on the kidneys may be related to its diuretic effect.27Beaux, D., Fleurentin, J. & Mortier, F. Effect of extracts ofOrthosiphon stamineus benth, Hieracium pilosella L.,Sambucus nigra L. andArctostaphylos uva-ursi (L.) spreng. in rats. Phyther. Res. 13, 222–225 (1999). All of these studies add weight to the body of evidence supporting the potential health benefits of elderberries beyond the well-established anti-oxidant and anti-inflammatory effects.22Ciocoiu, M. et al. The effects ofSambucus nigra polyphenols on oxidative stress and metabolic disorders in experimental diabetes mellitus. J.Physiol Biochem. 65, 297–304 (2009). 28Lazzé, M. C. et al. Anthocyanins protect against DNA damage induced by tert-butyl-hydroperoxide in rat smooth muscle and hepatoma cells. Mutat. Res. Toxicol. Environ. Mutagen. 535, 103–115 (2003). 29Youdim, K. A., Martin, A. & Joseph, J. A. Incorporation of the elderberry anthocyanins by endothelial cells increases protection against oxidative stress. Free Radic. Biol. Med. 29, 51–60 (2000). 30Duymuş, H. G., Göger, F. & Başer, K. H. C. In vitro antioxidant properties and anthocyanin compositions of elderberry extracts. Food Chem. 155, 112–119 (2014). 31Ho, G., Wangensteen, H. & Barsett, H. Elderberry and Elderflower Extracts, Phenolic Compounds, and Metabolites and Their Effect on Complement, RAW 264.7 Macrophages and Dendritic Cells. Int. J. Mol. Sci. 32Viapiana, A. & Wesolowski, M. The Phenolic Contents and Antioxidant Activities of Infusions of Sambucus nigra L. Plant Foods Hum. Nutr. 72, 82–87 (2017). 33Nowak, D., Gośliński, M. & Szwengiel, A. Multidimensional comparative analysis of phenolic compounds in organic juices with high antioxidant capacity. J. Sci. Food Agric. 97, 2657–2663 (2017).    

From my point of view (that of a DVM), the results of these studies make elderberry products intriguing. Diabetes, obesity, and infectious diseases are all major problems for companion animals like dogs and cats, as well as production animals (“livestock”). Influenza is a major disease of horses34Landolt, G. A. Equine Influenza Virus. Vet. Clin. North Am. Equine Pract. 30, 507–522 (2014). , while in recent years, canine influenza has become a significant disease, causing large outbreaks in cities across the United States.35Voorhees, I. E. H. et al. Multiple Incursions and Recurrent Epidemic Fade-Out of H3N2 Canine Influenza A Virus in the United States. J. Virol. 92, (2018). Cats are quite susceptible to upper respiratory infections caused by herpes, which in some cats can become chronic and difficult to manage.36Thiry, E. et al. Feline Herpesvirus Infection: ABCD Guidelines on Prevention and Management. J. Feline Med. Surg. 11, 547–555 (2009). Diabetes is a major concern in both dogs and cats.37Niaz, K. et al. Comparative occurrence of diabetes in canine, feline, and few wild animals and their association with pancreatic diseases and ketoacidosis with therapeutic approach. Vet. World 11, 410–422 Respiratory infections are a huge problem in production animal settings as well, leading to reduced weight gain, abortions, and increased production costs.38Cusack, P. M. V., McMeniman, N. & Lean, I. J. The medicine and epidemiology of bovine respiratory disease in feedlots. Australian Veterinary Journal 81, 480–487 (2003). If the early results in laboratory settings can translate to other species, it certainly seems there could be a place for elderberry in managing the health of pets and farm animal alike. At the very least elderberry warrants further research. 

Elderberries seem to have a lot of promising qualities, but are they safe? Properly prepared, elderberry products such as food, wine, and extracts are absolutely safe for most humans when consumed in appropriate amounts or as part of a well-balanced diet.39Vlachojannis, J. E., Cameron, M. & Chrubasik, S. A systematic review on the sambuci fructus effect and efficacy profiles. Phyther. Res. 24, 1–8 (2010). Raw parts of the elderberry plant (unripe berries, leaves, stems, roots, and seeds), however, contain two known toxins: a cyanogenic glycoside (cyanide bound to a sugar molecule) and an alkaloid. These toxins can cause diarrhea, nausea, vomiting, and neurologic symptoms. Although cases are rare, humans who drank raw, improperly prepared elderberry juice have become poisoned and required hospitalization. It is important to note that the group prepared the juice using other parts of the plant, including the stems.40Poisoning from Elderberry Juice. CDC Website Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00000311.htm. (Accessed: 14th August 2018) Livestock such as sheep, pigs, and cattle can die after ingesting the raw plant due to the presence of compounds which can be converted into cyanide once in the body. In general, ruminants such as cattle and sheep are extremely sensitive to this poisoning due to fermentation of sugars which contain cyanide molecules. It is also toxic to horses and pigs, however, they are less sensitive compared to cattle. Toxicity can occur within minutes, and affected animals may drool, stagger, or have difficulty breathing. In severe cases, death can occur within 30-45 minutes of ingestion. Younger plants tend to contain higher amounts of cyanide, and risk of toxicity is greater after frosts and droughts, which cause plants to accumulate more cyanide.41Llewellyn, D. A. & Norberg, S. Prussic acid poisoning in livestock. (2014). 42Arnold, M., Gaskill, C., Smith, S. & Lacefield, G. Cyanide Poisoning in Ruminants. Agric. Nat. Resour. Publ. (2014). The flowers and ripened berries are safe to eat, and cooking will degrade the toxins found in the other parts of the plant, rendering them safe for humans.39Vlachojannis, J. E., Cameron, M. & Chrubasik, S. A systematic review on the sambuci fructus effect and efficacy profiles. Phyther. Res. 24, 1–8 (2010). 43Senica, M., Stampar, F., Veberic, R. & Mikulic-Petkovsek, M. Processed elderberry (Sambucus nigra L.) products: A beneficial or harmful food alternative? LWT - Food Sci. Technol. 72, 182–188 (2016). The flowers of the plant (but not the berries) are on the US Food and Drug Administration (FDA) Generally Recognized as Safe product list (GRAS) when used as a food ingredient or additive.1Porter, R. S. & Bode, R. F. A Review of the Antiviral Properties of Black Elder (Sambucus nigra L.) Products. Phyther. Res. 31, 533–554 (2017).

  There are no controlled studies specifically evaluating elderberry safety in domestic animals, although it seems to be well-tolerated in laboratory animals. Despite its apparent safety, there should always be caution when supplementing new compounds to domestic animals. Toxicity can be surprising and unpredictable. Chocolate, garlic, onions, grapes, and avocados are all examples of foods that, while safe in humans, can be toxic to pets. Many of the medications used in humans which are relatively safe are also dangerous to our pets due to the differences in our abilities to metabolize and eliminate certain compounds. That said, commercial elderberry extracts appear to be currently used by some veterinarians who practice holistic and alternative medicine. On the Veterinary Information Network, a resource for veterinarians, one veterinary toxicologist has commented that, to his knowledge, commercial extracts are safe.44VIN Boards - Black elderberry safety? (sambucus nigra). (2008). Available at: https://www.vin.com/Members/Boards/DiscussionViewer.aspx?documentid=3874252&ViewFirst=1&FindSince=26280000. (Accessed: 1st August 2018) Although scientifically rigorous studies in domestic animals are lacking, it would appear there is abundant anecdotal evidence of its safety.

Proper dosing of elderberry extracts is unclear despite its current, occasional use by some veterinarians. Because there are no pharmacologic studies in dogs, cats, or other domestic species, it is hard to know what the proper amount of extract one species should receive versus another. The influenza study performed on chickens administered 0.4 mL of Sambucol per kilogram of body weight daily, while the chimpanzee study administered 10 mL of Sambucol (the labeled dose for humans) per animal daily. For an average human weighing 62 Kg (137 lbs.), that amounts to 0.16 mL/kg of product daily, less than half of what was administered to the chickens when corrected for bodyweight. Generally, the dosage recommendations by veterinarians using these products that have been developed for humans is to reduce the dose proportionally to the size of the animal. However, absorption and efficacy will vary widely across species. What is appropriate and optimal for each species is unknown, and this seems to be the case in humans as well.39Vlachojannis, J. E., Cameron, M. & Chrubasik, S. A systematic review on the sambuci fructus effect and efficacy profiles. Phyther. Res. 24, 1–8 (2010). Moreover, the percentage of active elderberry ingredient in each product is likely to vary too and can complicate dosage recommendations.

Elderberry extract certainly seems to have great potential as an alternative therapy among non-humans and warrants further research and consideration, especially in the management of influenza and other viral infections. It seems unlikely to cause harm as long as it is appropriately prepared, however, until proper safety information is available, I always recommend consulting with a veterinarian prior to beginning any supplements or medications, as unexpected things can occur. Discuss specific extract formulations with your veterinarian, and make sure they do not contain any known toxic compounds which can often find their way into supplements and have your veterinarian determine a dose based on each specific product. Hopefully, future scientific research into elderberries’ health effects will give us further insight into how they can be used to further animal health.

Table 1: Summary of animal studies using elderberry extracts or products.

Application

Species

Type of Product

Result

Study

Influenza

Chimpanzees

Sambucol (elderberry-containing product)

Reduced, frequency, severity and duration of illness

Burge et al. 1999

Influenza

Chickens

Sambucol (elderberry-containing product)

Reduced viral shedding in airway and fecal secretions

Karimi et al. 2014

Influenza

Mice

Theramax (elderberry-containing product)

Reduced lung hemorrhages, slowed time to death (mortality remained high)

Smee et al. 2011

Influenza

Mice

Concentrated elderberry juice

Suppression of viral replication, increased circulating antibodies

Kinoshita et al. 2012

Diabetes

Rats

Elderberry extract

Improvement of blood sugar levels, reduced insulin secretion

Salvador et al. 2016

Diabetes

Rats

Elderberry extract

Improvement in blood sugar parameters, reduced LDL cholesterol oxidation

Ciocoiu et al. 2009

Diabetes

Rats

Gold nanoparticle-conjugated elderberry extract

Increased anti-oxidant activity, decreased inflammation in liver

Opris et al. 2017

Atherosclerosis and

HDL Cholesterol

Mice

Elderberry extract

Reduced atherosclerosis, improved HDL cholesterol function

Farrell et al. 2015

Obesity

Mice

Elderberry extract

Decreased inflammatory markers, decreased insulin resistance,

Farrell et al. 2015

Hyperlipidemia

Hamsters

Elderberry extract

Reversed lipid accumulation in the blood

Dubey et al. 2012

Cadmium and Lead

Toxicity

Mice

Freeze-dried elderberry fruit

Reduced cadmium accumulation in the liver, protected kidney function

Kopeć et al. 2016

Diuresis

Rats

Elderberry extract

Diuretic effect, increased sodium and potassium loss in urine

Beaux et al. 1999

Related article: IS ELDELBERRY GOOD FOR PETS?

1 Porter, R. S. & Bode, R. F. A Review of the Antiviral Properties of Black Elder (Sambucus nigra L.) Products. Phyther. Res. 31, 533–554 (2017).
2 Roschek, B., Fink, R. C., McMichael, M. D., Li, D. & Alberte, R. S. Elderberry flavonoids bind to and prevent H1N1 infection in vitro. Phytochemistry 70, 1255–61 (2009).
3 Rogers, G. N. et al. Single amino acid substitutions in influenza haemagglutinin change receptor binding specificity. Nature 304, 76–8
4 Rogers, G. N. & Paulson, J. C. Receptor determinants of human and animal influenza virus isolates: differences in receptor specificity of the H3 hemagglutinin based on species of origin. Virology 127, 361–73 (1983).
5 Gamblin, S. J. & Skehel, J. J. Influenza Hemagglutinin and Neuraminidase Membrane Glycoproteins. J. Biol. Chem. 285, 28403–28409 (2010).
6 Connor, R. J., Kawaoka, Y., Webster, R. G. & Paulson, J. C. Receptor specificity in human, avian, and equine H2 and H3 influenza virus isolates. Virology 205, 17–23 (1994).
7 Kinoshita, E., Hayashi, K., Katayama, H., Hayashi, T. & Obata, A. Anti-influenza virus effects of elderberry juice and its fractions. Biosci. Biotechnol. Biochem. 76, 1633–8 (2012).
8 Ho, G. T. T. et al. Structure-activity relationship of immunomodulating pectins from elderberries. Carbohydr. Polym. 125, 314–22 (2015).
9 Ho, G. T. T., Zou, Y.-F., Aslaksen, T. H., Wangensteen, H. & Barsett, H. Structural characterization of bioactive pectic polysaccharides from elderflowers (Sambuci flos). Carbohydr. Polym. 135, 128–37 (2016).
10 Zakay-Rones, Z. 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. J. Altern. Complement. Med. 1, 361–369 (1995).
11 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. J. Int. Med. Res. 32, 132–40 (2004).
12 Kong, F.-K. Pilot Clinical Study on a Proprietary Elderberry Extract: Efficacy in Addressing Influenza Symptoms. Online J. Pharmacol. Pharmacokinet. 5, 32–43 (2009).
13 Mahmood, N. et al. Inhibition of HIV infection by flavanoids. Antiviral Res. 22, 189–199 (1993).
14 Amoros, M., Simõs, C. M. O., Girre, L., Sauvager, F. & Cormier, M. Synergistic Effect of Flavones and Flavonols Against Herpes Simplex Virus Type 1 in Cell Culture. Comparison with the Antiviral Activity of Propolis. J. Nat. Prod. 55, 1732–1740 (1992).
15 Karimi, S., Dadras, H. & Mohammadi, A. The effect of the extracts of Echinacea purpurea and Sambucus nigra (black elderberry) on virus shedding in H9N2 avian influenza infected chickens. Iran. J. Vet. Res. 15, 256–261 (2014).
16 Burge, B., Mumcuoglu, M. & Simmon, T. The effect of Sambucol on flu-like symptoms in chimpanzees: prophylactic and symptom-dependent treatment. Int. Zoo News 46, 16–19 (1999).
17 Smee, D. F., Hurst, B. L. & Wong, M. H. Effects of TheraMax on influenza virus infections in cell culture and in Mice. Antivir. Chem. Chemother. 21, 231–237 (2011).
18 Nelli, R. K. et al. Comparative distribution of human and avian type sialic acid influenza receptors in the pig. BMC Vet. Res. 6, 4 (2010).
19 Suzuki, Y. et al. Sialic acid species as a determinant of the host range of influenza A viruses. J. Virol. 74, 11825–31 (2000).
20 Ito, T. et al. Receptor Specificity of Influenza A Viruses Correlates with the Agglutination of Erythrocytes from Different Animal Species. Virology 227, 493–499 (1997).
21 Salvador, Â. C. et al. Effect of Elderberry (Sambucus nigra L.) Extract Supplementation in STZ-Induced Diabetic Rats Fed with a High-Fat Diet. Int. J. Mol. Sci. 18, 13 (2016).
23 Opris, R. et al. The effect of Sambucus nigra L. extract and photosynthesized gold nanoparticles on diabetic rats. Colloids Surfaces B Biointerfaces 150, 192–200 (2017).
24 Farrell, N., Norris, G., Lee, S. G., Chun, O. K. & Blesso, C. N. Anthocyanin-rich black elderberry extract improves markers of HDL function and reduces aortic cholesterol in hyperlipidemic mice. Food Funct. 6, 1278–1287 (2015).
25 Farrell, N. J. et al. Black elderberry extract attenuates inflammation and metabolic dysfunction in diet-induced obese mice. Br. J. Nutr. 114, 1123–31 (2015).
26 Dubey, P., Jayasooriya, A. P. & Cheema, S. K. Fish oil induced hyperlipidemia and oxidative stress in BioF1B hamsters is attenuated by elderberry extract. Appl. Physiol. Nutr. Metab. 37, 472–9 (2012).
27 Beaux, D., Fleurentin, J. & Mortier, F. Effect of extracts ofOrthosiphon stamineus benth, Hieracium pilosella L.,Sambucus nigra L. andArctostaphylos uva-ursi (L.) spreng. in rats. Phyther. Res. 13, 222–225 (1999).
22 Ciocoiu, M. et al. The effects ofSambucus nigra polyphenols on oxidative stress and metabolic disorders in experimental diabetes mellitus. J.Physiol Biochem. 65, 297–304 (2009).
28 Lazzé, M. C. et al. Anthocyanins protect against DNA damage induced by tert-butyl-hydroperoxide in rat smooth muscle and hepatoma cells. Mutat. Res. Toxicol. Environ. Mutagen. 535, 103–115 (2003).
29 Youdim, K. A., Martin, A. & Joseph, J. A. Incorporation of the elderberry anthocyanins by endothelial cells increases protection against oxidative stress. Free Radic. Biol. Med. 29, 51–60 (2000).
30 Duymuş, H. G., Göger, F. & Başer, K. H. C. In vitro antioxidant properties and anthocyanin compositions of elderberry extracts. Food Chem. 155, 112–119 (2014).
31 Ho, G., Wangensteen, H. & Barsett, H. Elderberry and Elderflower Extracts, Phenolic Compounds, and Metabolites and Their Effect on Complement, RAW 264.7 Macrophages and Dendritic Cells. Int. J. Mol. Sci. 18, 584 (2017).
32 Viapiana, A. & Wesolowski, M. The Phenolic Contents and Antioxidant Activities of Infusions of Sambucus nigra L. Plant Foods Hum. Nutr. 72, 82–87 (2017).
33 Nowak, D., Gośliński, M. & Szwengiel, A. Multidimensional comparative analysis of phenolic compounds in organic juices with high antioxidant capacity. J. Sci. Food Agric. 97, 2657–2663 (2017).
34 Landolt, G. A. Equine Influenza Virus. Vet. Clin. North Am. Equine Pract. 30, 507–522 (2014).
35 Voorhees, I. E. H. et al. Multiple Incursions and Recurrent Epidemic Fade-Out of H3N2 Canine Influenza A Virus in the United States. J. Virol. 92, (2018).
36 Thiry, E. et al. Feline Herpesvirus Infection: ABCD Guidelines on Prevention and Management. J. Feline Med. Surg. 11, 547–555 (2009).
37 Niaz, K. et al. Comparative occurrence of diabetes in canine, feline, and few wild animals and their association with pancreatic diseases and ketoacidosis with therapeutic approach. Vet. World 11, 410–422 (2018).
38 Cusack, P. M. V., McMeniman, N. & Lean, I. J. The medicine and epidemiology of bovine respiratory disease in feedlots. Australian Veterinary Journal 81, 480–487 (2003).
39 Vlachojannis, J. E., Cameron, M. & Chrubasik, S. A systematic review on the sambuci fructus effect and efficacy profiles. Phyther. Res. 24, 1–8 (2010).
40 Poisoning from Elderberry Juice. CDC Website Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00000311.htm. (Accessed: 14th August 2018)
41 Llewellyn, D. A. & Norberg, S. Prussic acid poisoning in livestock. (2014).
42 Arnold, M., Gaskill, C., Smith, S. & Lacefield, G. Cyanide Poisoning in Ruminants. Agric. Nat. Resour. Publ. (2014).
43 Senica, M., Stampar, F., Veberic, R. & Mikulic-Petkovsek, M. Processed elderberry (Sambucus nigra L.) products: A beneficial or harmful food alternative? LWT - Food Sci. Technol. 72, 182–188 (2016).
44 VIN Boards - Black elderberry safety? (sambucus nigra). (2008). Available at: https://www.vin.com/Members/Boards/DiscussionViewer.aspx?documentid=3874252&ViewFirst=1&FindSince=26280000. (Accessed: 1st August 2018)