Is Elderberry Dangerous? The True Risks and Benefits of a Popular Herbal Medicine

Even though cold and flu season is currently on the decline here in the northern hemisphere, I'd like to address some fears surrounding the elder plant (Sambucus ssp.), a popular herbal remedy more widely known as elderberry. I have been using my own homemade elderberry tincture daily since the start of the SARS-CoV-2 pandemic and as a daily tonic every fall and winter for years prior. I make two quarts of tincture annually to always have on hand. I'll tell you how easily you can, too, at the end of this article. In fact, getting a head start on making elderberry tincture now is a good idea, so you'll be fully stocked for next fall and winter! And of course, if elder grows near you, you can also harvest and tincture it in the summer months.

Elderberry is definitely in the top tier of my favorite herbal remedies, not merely because of the sweet and pleasant taste of both the berries and flowers but also due to its effectiveness in relieving cold and flu symptoms and shortening their duration (or potentially even preventing them). Ever since using elderberry as a daily tonic during respiratory virus season for the past 8 years, I have yet to get sick with a flu-like illness. However, I have had several common colds and three rounds with the infamous SARS-CoV-2. Such is life.

Elderberry may be more specific to inhibiting influenza viruses than others, though it does have a decent anti-viral range. The fruit juice of Sambucus nigra was found to inhibit Human Influenza A (H1N1) infection through a variety of modes, specifically due to an antioxidant compound within the fruit known as anthocyanin 3-glucoside.[1] Anthocyanins give various species of elderberry their purple, blue, and sometimes red colors, and they have a range of other health benefits, including improving cardiovascular health. While elderberry's anti-viral properties may be more limited than other more broadly anti-viral herbs (shout-out to Chinese Skullcap!), it is an overall useful herb for many viral infections not only due to its anti-viral actions but also its immune-modulating and anti-inflammatory properties, which I will return to shortly.

Firstly, however, I'd like to address two main sources of fear surrounding the plant. The first derives from the fact that certain parts of the plant, such as the stem, leaves , and (somewhat) berries, contain compounds that can cause nausea and vomiting in particularly sensitive individuals. This is almost entirely a risk if those parts are consumed raw (such as eating raw berries or fresh juice from the leaves or stems). There have been no reported deaths from these compounds nor any serious long-term effects. In fact, of the roughly two percent of poison control calls made each year in relation to plants, few if any involve Elder.[2]

However, to avoid this issue, simply use dried berries before making preparations and ideally before even tincturing them (some people can experience mild side effects from raw berry tincture). You can also cook fresh and dried berries, which are essential for making jam and syrup (also excellent and tasty ways to incorporate elderberry). Herbalist Stephen Harrod Buhner suggested boiling all desired parts for 30 minutes, starting with cold water and increasing the heat. [3] The specific compounds, hydrocyanic acid, also known as cyanide, are only poisonous if consumed in an isolated form (but not from whole plant preparations of elder). According to Buhnner, the elder plant produces the compounds in just the right amount to deter certain herbivores from over-consuming parts of the plant, but otherwise, such effects are harmless. [4] A recent analysis published in 2021 found that the concentrations of cyanogenic glycocides in elder were so low they were not a risk to consumers of elderberry products within the American market.[5] In over a decade of using elderberry consistently, neither I nor anyone I've known has ever had any problems associated with elder.

The second source of fear surrounding elderberry, and my primary issue here, derives from fears about its potential to cause a "cytokine storm," a dysregulated immune response known more technically in the biomedical community as macrophage activation syndrome (MAS). The fear is that during an active influenza infection, elderberry's immune-stimulating properties will over-stimulate the immune system, leading to a dangerous or even deadly situation. In the context of influenza or other flu-like viruses, MAS results mainly from an immune system not functioning correctly due to some underlying disease (such as rheumatic diseases). In the case of a novel viral infection, MAS occurs when the immune system is unable to effectively neutralize the pathogen. It is basically a last-ditch effort of the immune system to fight off a highly aggressive infection. The body seriously ramps up the immune response, resulting in a very high fever and, in dangerous situations, internal bleeding or sepsis-like conditions.

However, there are times when MAS occurs and spontaneously subsides, and the individual recovers. Yet, MAS can be turn deadly in some situations. In hospital settings, MAS can be diagnosed quickly through noting elevated levels of certain proteins in the blood, and drugs can be administered in an attempt shut down the process if the situation is suspected of being dangerous. However, physicians may wait for some time before administering drugs to see if the MAS will resolve on its own. This is important to understand, because MAS can be a natural and effective expression of the immune response, but it does pose dangers, in that it can lead to damage of vital organs even if it turns out to be non-lethal.

As is relevant for my discussion here, is the question of whether or not elderberry can cause MAS to occur. The short answer is....no. There is no scientific evidence that elderberry has ever resulted in MAS. Yet, this belief persists due to entirely hypothetical reasoning. I am aware of some herbalists who claim this is a danger with elderberry, yet as far as I am aware, none have provided evidence. I do not entirely blame herbalists for this fear; they are responding to the cultural phytohysteria within the biomedical community and rationally utilizing the precautionary principle. I once believed this to be a risk myself. All humans, no matter who (and no matter how educated and qualified), are susceptible to believing untrue things. For herbalists who have become social media influencers or notable public figures, it is also understandable to be overly cautious if such a thing were remotely possible since, being influencers, they influence a lot of people. And herbalists being typically kind-hearted folk, would rather first do no harm.

Most recently, a systematic review published in 2021 concluded that there is no evidence to support the claim that elderberry causes MAS. After reviewing 1187 records, which included 5 randomized clinical trials, the authors concluded that "we have not identified any cause for concern about the overstimulation of the immune system during elderberry supplementation." [6] Of course, as with all scientific papers, the authors stress that more research is needed for more confidence. However, to date, this is the most robust evidence we have to argue against the claims of elderberry's MAS inducing potential. Studies often show that elderberry can both increase and decrease cytokine production, leaving researchers hesitant to draw firm conclusions. However, these mixed results derive from the fact that elderberry, like the vast majority of herbs when used as whole plant preparations, have modulating effects on various bodily systems rather than direct and specific effects like pharmaceutical drugs. This means that, in the case of elderberry and its impact on immunity, if cytokine production is too low, it helps to increase it, but if it's too high, it helps to reduce it. Herbs are not drugs.

A very recent study published in May 2023, conducted on 53 healthy human subjects, revealed this exact effect over a four-week period of Sambucus ebulus tea consumption. [7] There were significant reductions in pro-inflammatory proteins (including cytokines) and a general reduction in inflammation within the subjects overall by the end of the study. These results suggest that elderberry may not only be useful as a general immune system modulator but also for reducing systemic inflammation, a likely result of many of the anti-inflammatory antioxidants the berries contain. Elderberry's abundance of anythocyanins have immune modulating properties and also have benefits in countering cardiovascular disease and other disease processes related to high levels of inflammation. More reasons to add this very common berry to your herb cabinet and diet, and it's why I've been more recently utilizing this wonderful plant on a near daily basis.

So, there you have it. Elderberry is a safe cold and flu season remedy, something you can continue to enjoy even when you're actively sick with the flu, common cold, or that recent and unfortunate addition to respiratory viral circulation, SARS-CoV-2. While we do not have robust scientific evidence that elderberry can prevent or stop MAS from occurring in an individual susceptible to it, it does have proven immune-modulating effects, and, therefore, if anything, it would be helpful in dampening down the situation. Of course, personally, if I were such a highly susceptible person, I wouldn't rely on elderberry tincture or syrup alone in combatting such a situation. Still, at least it will not make a bad situation worse, so let's stop fearing elderberry, an extraordinary and abundant plant that offers numerous health benefits. Lastly, as I have hinted to above, I use elderberry more as a preventative rather than a primary treatment, but I will continue to use it, in higher amounts actually, when actively sick but also alongside many other herbs. Something to keep in mind.

How to Make Elderberry Tincture

All the supplies you need to make your own quart of elderberry tincture: A quart mason jar and lid, kitchen scale, 100 proof vodka, and 4 ounces of dried elderberries.

Tinctures are fantastic because they have an indefinite shelf life and can be easily taken wherever you go. Drop a bottle of elderberry into your backpack, purse, or luggage, and you have a simple, safe, and effective cold and flu remedy whenever you need it. As I mentioned at the start of this article, I make a few quarts a year for myself and my partner, and in case anyone I know might need some. You can also make elderberry syrup, which kids often love (due to the high sugar content). Personally, I find the syrup a bit more time-intensive, and with its shorter shelf life and slight messiness, I tend to prefer the tincture since it's so much easier to deal with. But if you love DIY kitchen projects, then by all means, go for the syrup option.

I typically purchase dried elderberries from Mountain Rose Herbs or Frontier by the pound (I also make a delicious elderberry/hibiscus infusion in the summer months, which is an antioxidant-filled delight, so I always have plenty of dried elderberries around). I'd suggest buying at least a pound since you're likely to make more than one quart of tincture or batch of syrup. Just make sure to keep your berries away from sunlight and stored in a dark place for future use. Simply place 4oz of dried berries into a glass, quart mason jar (wide mouth is ideal so you can more easily strain it when it’s done), and then fill it close to the top with 100 proof vodka. Put the lid on, put a label on it, and the date, and that's it!

Four dried ounces of elderberries ready to put in a quart mason jar.

Four ounces of dried elderberries ready for a quart of vodka filled nearly to the top.

Now, with dried berries, I like to let my tinctures sit for at least 6 months, but I often won't use it for about a year. With dried plant tinctures especially, it can take a bit longer for all of the desired constituents to get released into the alcohol. However, you will have a usable tincture at minimum of six weeks. Also feel free to shake it up daily or whenever you remember to. I usually shake my tinctures daily for the first few weeks.

While tincture making is literally that simple, if you'd like to learn more about the rationale behind it as well as the ins and outs of teas and infusions and some historical, cultural, and anthropological context of modern, Western herbalism, be sure to check out my upcoming online course, Lifestyle Herbalism. It's a great foundational course for learning so many things that literally took me over a decade to figure out. Also, so much of the content is applicable not just to herbal medicine making, but to overall improving your diet. After digesting the course, you'll be well on your way to building an apothecary or even heading toward a potential career as an herbalist yourself. Herbal medicine is for the people, and it's something we can all easily learn about and do! Subscribe to my free newsletter and you’ll receive a discount code and update when it’s released.

References

[1] Torabian, G., Valtchev P., Adil Q., Dehghani F. “Anti-influenza activity of elderberry (Sambucus nigra).” Journal of Functional Foods, 54 (2019) 353-360. https://doi.org/10.1016/j.jff.2019.01.031

Debunking Elderberry Fears: Toxicity and Cytokine Storm

Chad Woodward, CMT