Suppliers of Benzo-Pyrones for the Treatment of Lymphoedema (and other High-Protein Oedemas)

Judith R. Casley-Smith

This document was last amended on December 2004.

The actions of the benzo-pyrone drugs in lymphoedema and other high-protein oedemas are covered in a separate Section. They are so useful, and so many patients have difficulty in obtaining them, that it seemed necessary to set out their availabilities in some detail.

Coumarin (5,6 benzo-alpha-pyrone, 56BaP,
1,2 benzopyrone)

This is the simplest and the lowest dose available of the benzo-pyrones because it is a small molecule. The minimum effective dose of the oral form is 400 mg/day, but some patients achieve better results with 800 mg.

Adverse Reactions

An elevation of liver enzymes occur in some patients. The present best estimates are that 3 patients per 1,000 are likely to have a form of hepatitis caused by the drug (but only between 3 and 9 months after starting it - not after this). Most will recover completely, but 3 per 10,000 may die. (This is not certain since the two deaths in Australia had other factors and both deaths were only 'possibly' caused by coumarin, however we feel we should present the worst picture.)

We emphasis that these liver problems do not occur with the powder or ointment or any other benzo-pyrones. These may be substituted for the tablets if one uses 5 ml per day of the ointment or 10 ml per day of the powder. (These should be measured in a spoon available from pharmacists.) Since these amounts are rather large, we suggest applying half of them twice a day. Topical preparations are at the present time only available from compounding pharmacists in the U.S.A. and Italy

Benzo-Pyrone Suppliers

INDIA: "Lympedim®'' (Coumarin) 200 mg. tablets. Pharm Products, Private Ltd., "Vijai", Medical College Rd, Thanjavur 613007, Tamil Nadu, INDIA; fax: 91+ (4362) 231650; tel: 91+ (4362) 239176, e-mail; pppl@eth.net Chennai office: Fax 91+(44) 26222415; Tel: 91+(44) 26213496; email: ppplm@vsnl.com. website: www.pharmproducts.com. Many countries permit the importation of drugs for personal use.

The Indian tablets can also be obtained from: Onerahi Pharmacy, Onerahi Shopping Centre, 116 Onerahi Rd., Whangarei, New Zealand; tel & fax 64 9 4360567. They supply on a fax (which must include a Dr's prescription) and can handle most credit cards.

U.S.A. & CANADA

Until recently this drug was not available in the U.S.A. & Canada and supplies had to be imported from countries where it is available. The F.D.A. has now authorised it for clinical trial use. It is also now available (upon prescription only) from compounding pharmacists:

Barry Smith, Medical-Dental Pharmacy, 689 E. Nees, Fresno, California 93720, ph (559)439-1190, (800)794-2832, fax (559)439-1655, e-mail mdpii@aol.com

Oral (200 or 400 mg delayed-release capsules), 10% ointment and 10% powder are all available from the above.

AUSTRALIA
Lympaction® Poppy Lane Skin Care and Lymphoedema Clinic, 139 Hollywood Drive Lansvale NSW 2166 Australia. Phone (02) 9723 5402 Fax: (02) 9726 3322, email juliegeorge@lymph.com.au  Website: www.lymph.com.au. Lympaction® is an oral mixture of benzo-pyrones (rutin and bioflavonoid) taken as 1½ tsps/day in a glass of water. The flavour is pleasant; this is much less expensive than many other listed products. This does not need a doctor’s prescription.
The web purchase site for the oral preparation is www.lymph.com.au. Lympaction™ is an oral mixture of benzo-pyrones (rutin and bioflavonoid) taken as 1½ tsps/day in a glass of water. This is much less expensive than many other listed products. Lympaction does not require a prescription.
Also available is the book written by Juliet George titled 'Diet for lymphoedema'. The foreword is written by Dr. Judith Casley-smith. The website for this book is www.lymph.com.au

Venalot

'Venalot'® (Schaper & Brümmer, Postfach 61 11 60, D-3324 Salzgitter 61, Germany), comes in a number of forms. Capsules contain Melilotus extract, standardized to 5 mg of coumarin, with 25 mg of rutin. Ampoules contain 5 mg coumarin and 25 mg Sodium rutin sulphate per ml. 'Venalot Depot'®, an injectable form contains 15 mg coumarin and 90 mg of troxerutin, in a slow-release form.

Venalot is also available in a number of countries: Brazil, The Argentine. These forms, but named Esberiven, are available from Funai (40 Tsuriganecho 2-chome, Higashi-ku, Osaka, JAPAN) and from Iquinosa (Alpedrete 24, 28045 - Madrid, SPAIN; fax: 34+1-468-59-34), and probably in some other countries.

However it is VITAL to realise that rutin are large molecules, only a small part of which is the true benzo-pyrone portion i.e. the double benzene ring. Hence one must take 16 tablets of Venalot a day to equal 400 mg (2 tablets) of coumarin; to equal 800 mg one must take 32 tablets!

Flavonoids (Bioflavonoids)

Flavonoids (also known as bioflavonoids) are much bigger molecules than coumarin so one must take 3,000 mg per day to equal 400 mg of coumarin, or 6,000 mg to equal 800 mg of coumarin.
Even worse, bioflavonoids are usually only available as 'bioflavonoid complex' which contains only 50% bioflavonoids. One must take 6,000 mg per day of this to equal 400 mg of coumarin, 12,000 mg per day to equal 800 mg. The first of these doses is the minimum to have any useful effect; double this is often much more effective.

Some find the bioflavonoids upset their stomachs, so we advise patients to start with smaller doses and work up. We also advise them to split the dose up into halves.

Rutin is available in health food shops in many countries, as are bioflavonoids (but be careful about whether the amounts are quoted as 'bioflavonoids' or 'bioflavonoid complex' (see above). Powdered rutin tastes rather like cardboard - but at least it is cheap!

'Daflon 500'® (Servier,6 Place des Pléiades, 92415 Courbevoie Cedex, France) is available in most countries (not Australia or the USA). It comes as 500 mg coated capsules, containing 90% diosmin and 10% hesperidin. The recommended dose (1,000 mg/day) is for veins. Reports suggest that 2,000 or, better, 4,000 mg/day are needed for lymphoedema.

'Paroven'® ('Venoruton'®, 'Relvène'® - Zyma, CH-1260, Nyon, Switzerland) is available in most countries of the World (not the USA). It comes as capsules of 100, 250, or (in some countries) 500 or 1,000 mg. The minimum effective dose for lymphoedema is 3,000 mg/day (6,000 is often better). Often no prescription is necessary.

'Pure Citrus Bio-flavonoids with Rose Hips'® (Nature's Answer, Bio-Botanica, 75 Commerce Drive, Hauppauge, NY 11788, U.S.A.) is a liquid, and is said to be a 63 % solution of actual flavonoids (equivalent to 125% solution of the complex) in water (with 12-14% ethanol). (However we have heard reports that the concentration is not as given above; but this company refuses to answer a number of letters and faxes from Australia - so we cannot confirm this important detail!) If each ml did contain 630 mg of flavonoids (i.e. 1,250 mg of complex), the minimum effective dose would be 5 ml (i.e. one teaspoon) per day. Double this may work better.
This can be used topically on the skin - e.g. on painful or inflamed regions, ulcers, etc - much like coumarin ointment or powder, or it can be used orally.

Topical Benzo-Pyrones

Italy

"Linfovenodren" (Coumarin) 50gr powder SMA s.a., Via Tre Settembre, 11-Dogana (Rep. San Marino); tel: 00378-909532; fax 00378-909547 (prescription necessary), who are also now supplying an oral mixture of benzo-pyrones.

Other Drugs which work like Benzo-Pyrones

Calcium dobesilate is not a benzo-pyrone, but it has many similar actions (including on the macrophages and the lymphatics). It is marketed as 'Doxium'® by Laboratoires OM (C.P. 84, CH-1217 Meyrin 2, Geneva, Switzerland) in 500mg capsules; use 3,000 mg/day.

Unguentum lymphaticum® This herbal cream is available in Germany (Pharmazeutische Gesellschaft MBH & Co., Fürstenstrasse 6, D-8000 München 2, Germany). It also works on the macrophages and the lymphatics, like the topical benzo-pyrones. In fact it does not contain them but similar molecules with similar actions (e.g. topically on lymphoedema).