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POSSIBLY EFFECTIVE

• Bowel preparation. Some research suggests that oral castor oil is effective for bowel preparation; however, it is unclear if it is as effective as other products used for this purpose. Clinical practice guidelines do not recommend castor oil for bowel preparation. Details: Clinical research shows that taking a single dose of castor oil 30-60 mL orally is effective for bowel preparation prior to barium and gallium-67 imaging studies when compared with no bowel preparation (40090,40166). However, research evaluating castor oil in comparison to other bowel preparations is limited by complex regimens and high dropout rates. Some clinical research shows that oral castor oil, alone or in combination with a cleansing enema, has similar efficacy for bowel preparation as bisacodyl or bisacodyl plus magnesium citrate (40166,40173,40185). However, other research shows that bisacodyl plus magnesium citrate is superior to castor oil or castor oil plus calcium bisdioctyl sulfosuccinate (40163,40187). Also, solutions of oral sodium phosphate seem to be more effective for bowel preparation prior to a colonoscopy compared to castor oil (40192). According to the American Society for Gastrointestinal Endoscopy (ASGE), castor oil is not a recommended agent for bowel preparation prior to colonoscopy (101419).
• Constipation. Oral castor oil seems to improve symptoms of constipation. Details: Taking castor oil orally is effective as a stimulant laxative for reducing constipation (272). A single 15 mL dose is commonly used (15).
• Dry eye. Some clinical research suggests that castor oil eye drops can improve symptoms of dry eye in adults. Castor oil eye drops appear to reduce tear evaporation but do not increase tear production. Details: One clinical study in patients with mild to moderate dry eye shows that using castor oil 1.25% emulsion eye drops three times daily for 30 days decreases tear evaporation rate when compared with a hypromellose ophthalmic lubricant (40178). Another clinical study in patients with dry eye secondary to obstructive meibomian gland dysfunction shows that using castor oil 2% lubricating eye drops six times daily for 2 weeks improves gland obstruction assessments and dry eye symptom scores and decreases tear evaporation when compared with saline eye drops (40169).
• Parturition. Oral castor oil seems to stimulate labor in pregnant patients who are at term or post-term. Details: Clinical research in pregnant patients who are at term or post-term with no prior signs of labor shows that taking a single 60 mL dose of castor oil stimulates labor within 24 hours in 52-58% of patients compared with about 4% of patients receiving no treatment (7191,40177). There is also some evidence that patients at term pregnancy with premature membrane rupture who take a single dose of 5-120 mL of castor oil have a higher incidence of labor onset and a lower incidence of cesarean section when compared with patients who take no medication (1122).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Abortion. Although there has been interest in using intravaginal castor oil for abortion, there is insufficient reliable information about the clinical effects of castor oil for this purpose.
• Contraception. It is unclear if oral hulled castor seeds are effective for contraception. Details: Small clinical studies in healthy females show that taking a single dose of castor seeds with the outer coat removed can protect against pregnancy for up to 8-12 months (7127,7128). The validity of this finding is limited by the lack of a comparator group.
• Denture stomatitis. It is unclear if topical castor oil is beneficial in patients with denture stomatitis. Details: A small clinical study in institutionalized elderly patients shows that using a specific castor oil polymer mouthwash (Perioquil, Poliquil Araraquara Polimeros Quimicos Ltd) four times daily for 30 days can improve the severity of denture stomatitis when compared to baseline, but does not reduce Candida albicans counts when compared to treatment with miconazole oral gel or nystatin (93503).
• Furuncles (boils). Although there has been interest in using topical castor oil for boils, there is insufficient reliable information about the clinical effects of castor oil for this purpose.
• Osteoarthritis. Although there has been interest in using oral and topical castor oil for osteoarthritis, there is insufficient reliable information about the clinical effects of castor oil for this purpose.
• Rheumatoid arthritis (RA). Although there has been interest in using oral castor oil for RA, there is insufficient reliable information about the clinical effects of castor oil for this purpose. More evidence is needed to rate castor bean for these uses.

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LIKELY EFFECTIVE

• Constipation. Rectal glycerol is beneficial in children and adults with constipation. Details: Glycerol rectal suppositories and enemas are approved by the US Food and Drug Administration (FDA) for over-the-counter use to treat occasional constipation in adults and children at least 2 years of age (15).

POSSIBLY EFFECTIVE

• Athletic performance. Oral glycerol may improve hydration during exercise, but clinical studies evaluating glycerol for improving measures of athletic performance are limited and conflicting. Details: Several clinical studies show that glycerol increases serum osmolality and improves hydration status during exercise (2475,2476,93757,93760,93761,93765). One meta-analysis, including 14 studies and 99 patients, shows that glycerol-induced hyperhydration increases body water by approximately 2.5-fold when compared with water-induced hyperhydration (93757). Also, taking glycerol along with table salt 7.5 grams per liter fluid seems to improve hydration status when compared withg glycerol alone (99162). Research regarding the effects of glycerol on thirst, comfort, temperature regulation, sweating, and heart rate is conflicting (2475,2476,93760,99162). While glycerol may improve hydration status during exercise, it is unclear whether it can improve measures of athletic performance. An early meta-analysis including a total of 36 athletes shows that taking glycerol increases endurance performance by 2.6%. Although this is a small difference, it might be considered meaningful to athletes (93757). Some small clinical studies in athletes suggest that glycerol increases endurance and time to exhaustion, with no effect on heat regulation (2475,2479,93764). However, other small studies suggest that glycerol does not reduce perceived exhaustion or improve exercise performance (2476,93760). Also, glycerol has not been shown to increase time to exhaustion in triathletes (2492). When used to improve athletic performance, glycerol is most often taken at doses of 1-1.5 gram/kg in conjunction with approximately 1.5 L of fluid, 60-120 minutes before competition, and in some cases continued during the competition (2475,93757,93760,93764).
• Ichthyosis. Topical application of a specific product containing glycerol and paraffin may improve symptoms of ichthyosis in children. The benefits of topical glycerol alone in these patients is unknown. Details: A large clinical trial in children aged 1 month to 18 years shows that applying a specific product (Dexeryl, Pierre Fabre Laboratoires) containing glycerol 15% and paraffin 10% for 4 weeks reduces symptoms of non-bullous ichthyosis by at least 50% in an additional 17% of children when compared with a placebo cream. Applying this specific product also improves pruritus by an additional 45% when compared with placebo (93756). It is unclear if these findings are due to glycerol, paraffin, or the combination.

POSSIBLY INEFFECTIVE

• Meningitis. Some clinical research suggests that oral glycerol does not reduce the risk of mortality or seizures in adults and children with bacterial meningitis, although it may reduce certain sequelae. Details: A meta-analysis of five low-quality clinical trials including 1,270 patients shows that adjunctive treatment with glycerol as an oral osmotic agent does not reduce the risk of mortality, seizures, or gastrointestinal symptoms in adults and children with acute bacterial meningitis, although it may modestly reduce the risk of deafness and residual neurological deficit in surviving children (99160). Clinical research included in the meta-analysis has used glycerol 1.5 grams/kg every 6 hours in children aged 2 months to 16 years (93762,93763).
• Prematurity. Rectal glycerol does not appear to reduce the time to enteral feeding in premature infants. Details: Glycerol is used as an enema or given by suppository to facilitate the evacuation of meconium in premature infants in order to reduce the time to enteral feeding. However, two meta-analyses of small studies in preterm infants, that include some of the same studies, show that administering glycerol suppositories does not reduce the number of days to full enteral feeds when compared with placebo or no treatment (99166,112003). However, the interpretation of these findings is limited by the heterogeneity of dosages used in the included studies.

LIKELY INEFFECTIVE

• Stroke. Intravenous glycerol may not improve mortality or symptoms in patients with acute ischemic stroke. Details: Several clinical studies show that intravenous administration of glycerol does not improve symptoms of acute stroke (2480,2481,2482,2484,2486). Additionally, one clinical study in elderly patients with acute ischemic stroke shows that while glycerol can improve initial survival, it does not reduce the risk of overall mortality when compared with placebo (2483).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Dandruff. Topical glycerol has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: One clinical trial in adults with dandruff shows that applying a leave-in hair lotion containing glycerol 10%, stearic acid 2.5%, and sunflower seed oil 0.6%, 3 times weekly for 8 weeks, modestly reduces dandruff severity throughout use and for up to one week after the last application when compared with a placebo lotion. The glycerol lotion also reduced total water loss from the scalp by 8% and increased moisturization by 23% (93758). It is unclear if these findings are due to glycerol, other ingredients, or the combination.
• Dry skin. Topical glycerol has only been evaluated in combination with other ingredients for the management of dry skin associated with kidney failure; its effect when used alone is unclear. Details: One small, open-label clinical study in adults with kidney failure and moderate to severe uremic xerosis shows that applying an emulsion containing glycerol 15% and paraffin 10% twice daily for 7 days reduces the severity of xerosis when compared with a placebo emulsion. The glycerol-containing emulsion produces a treatment response in an additional 29% of patients, improves quality of life, and reduces scale density and thickness when compared with placebo (93754). It is unclear if these findings are due to glycerol, paraffin, or the combination.
• Glaucoma. Although there has been interest in using oral glycerol for glaucoma, there is insufficient reliable information about the clinical effects of glycerol for this purpose.
• Intracranial hypertension. Although there has been interest in using intravenous glycerol to reduce intracranial pressure in patients with brain tumors, central nervous system (CNS) trauma, encephalitis, idiopathic intracranial hypertension, meningitis, and Reye syndrome, there is insufficient reliable information about the clinical effects of glycerol for this purpose.
• Meniere disease. It is unclear if intravenous glycerol is beneficial in patients with Meniere disease. Details: A small, uncontrolled clinical study in adults with unilateral, intractable Meniere disease shows that intravenous administration of glycerol 10% at a dose of 0.5 grams/kg once daily for 2 consecutive days, twice monthly for 6 months, reduces the frequency of vertigo attacks and improves quality of life when compared to baseline. Patients reported an average of 3.2 vertigo attacks per month at baseline and 1.2 vertigo attacks per month after 6 months of treatment (106649). The lack of a control group limits the validity of these findings.
• Neonatal jaundice. It is unclear if rectal glycerol improves jaundice-related outcomes in premature infants. Details: A small clinical study in neonates receiving phototherapy for jaundice shows that administering glycerol suppositories has no effect on the duration of phototherapy needed for jaundice treatment, or on bilirubin levels or the rate of bilirubin decline when compared with no glycerol suppositories (99165).
• Obesity. It is unclear if oral glycerol is beneficial in patients who are overweight or obese. Details: One small clinical study in adults on a low-calorie diet shows that taking glycerol 7.5 grams before meals for 6 weeks does not increase weight loss when compared with placebo (2485).
• Otitis externa. Topical glycerol has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: One small clinical study in adults with otitis externa shows that inserting ribbon gauze soaked in glycerol and ichthammol into the ear canal reduces pain and swelling as effectively as the application of antibiotic and steroid drops three times daily (93759). It is unclear if these findings are due to glycerol, ichthammol, or the combination. More evidence is needed to rate glycerol for these uses.

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LIKELY SAFE ...when castor oil is used orally and appropriately, short-term (16). In clinical research, a single oral dose of up to 60 mL of castor oil has been used prior to imaging procedures of the colon (40090,40163,40166,40185,40187,40188,40192).

POSSIBLY SAFE ...when the hulled castor seed is used orally and appropriately, short-term. There is some evidence that a single dose of castor seed with the outer coat removed (hulled) can be used safely (7127,7128). ...when castor oil is used topically and appropriately. Castor oil eye drops appear to be safe when used for up to 30 days (40169,40178).

POSSIBLY UNSAFE ...when castor oil is used orally in high doses or for extended periods. Taking castor oil for greater than one week or exceeding the typical dose of 15-60 mL per day can increase the risk of fluid and electrolyte disturbances (272).

UNSAFE ...when the whole seed is used orally. Safety depends on whether or not the seed is chewed or if the outer coat is ruptured. Chewing as few as 1-6 whole seeds can be lethal in an adult. If the seed is swallowed intact, poisoning is less likely; however, prompt medical attention should be sought after ingestion of any whole castor seed (5611).

CHILDREN: POSSIBLY SAFE
when castor oil is used orally and appropriately, short-term (16).

CHILDREN: POSSIBLY UNSAFE
when castor oil is used orally in high doses or for extended periods. Taking castor oil for greater than one week or exceeding the typical children's dose of 1-15 mL per day, depending on age, can increase the risk of fluid and electrolyte disturbances (272).

CHILDREN: UNSAFE
when the whole seed is used orally. The chewed or uncoated seeds can cause severe toxic effects (5611,5612) and death (5611). There is insufficient reliable information available about the safety of the hulled seed or topical use of castor in children.

PREGNANCY: POSSIBLY SAFE
when castor oil is used orally in pregnant women at term. Although there have been reports of fetal meconium passage being more common with castor oil use in pregnant women (40184), clinical research shows that the incidence of fetal meconium passage does not significantly differ from no castor oil use (7191,40177). Midwives routinely use castor oil for labor induction in pregnant women at term. This practice does not appear to adversely affect the mother or fetus (1122,7191,40177). However, castor oil should not be used without the supervision of a clinician.

PREGNANCY: LIKELY UNSAFE
when castor oil is used orally in pregnant women who are not at term. Castor oil might induce premature labor and induce miscarriage (12); avoid using.

PREGNANCY: UNSAFE
when the whole seed is used orally. The chewed or uncoated seeds can cause severe toxic effects, including death (5611); avoid using. There is insufficient reliable information available about the safety of using the hulled seed or topical use of castor during pregnancy.

LACTATION:
Insufficient reliable information available; avoid using.

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LIKELY SAFE ...when used rectally and appropriately. Glycerol rectal suppositories and enemas are approved by the US Food and Drug Administration (FDA) for over-the-counter use to treat occasional constipation (15,272). ...when used topically and appropriately as a lotion, emulsion, or humectant (15,272,93754,93758,93759,99164).

POSSIBLY SAFE ...when used orally, short-term. Glycerol has been used with apparent safety in clinical trials at doses of up to 1.5 grams/kg (2474,2475,99162).

POSSIBLY UNSAFE ...when used intravenously. While some research suggests that intravenous glycerol can be safely administered for two consecutive days twice monthly for up to 6 months (106649), in another study, hemolysis was reported in 98% of patients treated with intravenous glycerol for acute ischemic stroke (2482).

CHILDREN: LIKELY SAFE
when used rectally and appropriately. Glycerol rectal suppositories and enemas are approved by the US FDA for over-the-counter use to treat occasional constipation in children 2 years of age and older (15,272). ...when used topically and appropriately as an emulsion or humectant in children 1 month of age and older (15,272,93756).

CHILDREN: POSSIBLY SAFE
when used orally, short-term. Glycerol has been used with apparent safety in clinical trials in children 2 months to 16 years of age at doses of 1.5 gram/kg, up to a maximum dose of 25 grams, taken every 6 hours (93762,93763).

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using.

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DIURETIC DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, castor oil might increase the risk of hypokalemia when taken with diuretic drugs.  Details There is some concern that overuse of castor oil might compound diuretic-induced potassium loss (15).

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General ...Orally and topically, castor oil is generally well tolerated. Hulled castor seeds with the outer coat removed also seem to be well tolerated when used orally. High doses or long-term use of castor oil may be unsafe, and whole castor seeds are generally regarded as unsafe in any amount.
Most Common Adverse Effects:
Orally: Abdominal discomfort, cramping, dizziness, and nausea (castor oil).
Serious Adverse Effects (Rare):
Orally: Severe abdominal pain, diarrhea, fluid and electrolyte disturbances, gastrointestinal bleeding, hemolysis, nausea, vomiting, and death (whole castor bean seeds).

Cardiovascular ...Orally, hulled castor seeds can result in elevated blood pressure (7128). In one case report, a woman at full-term pregnancy experienced amniotic fluid embolism and cardiopulmonary arrest within one hour of ingestion of 30 mL of castor oil (1219).
Orally, chewing whole castor bean seeds can cause peripheral vascular collapse (5611,5612,92998,93000,93505,93507).

Dermatologic ...Topically, the castor plant, crushed castor seeds, or castor seed dust can cause dermatitis in some patients (5611). Castor oil does not appear to cause these effects. In one case report, a child developed cheilitis over the course of 3 weeks, which was determined to be an allergic reaction to castor oil contained in lip balm (103864).

Gastrointestinal ...Orally, castor oil, like all stimulant laxatives, can cause abdominal discomfort, cramping, nausea, and faintness (15,272,40183,40186,40187,40192,40177,40185,40188,40163). Nausea can also occur because of the unpleasant taste of castor oil (7191). Using flavored products might reduce this effect. Castor oil can also cause fluid and electrolyte loss, particularly potassium, which can result in hypokalemia. It can also cause malabsorption from intestinal hypermotility (15,272). Chronic ingestion over long periods of time can lead to cathartic colon (15).
Chewing whole castor bean seeds causes severe toxicity. Gastrointestinal symptoms of castor seed toxicity typically occur with 4-6 hours of ingestion and include nausea, vomiting, diarrhea, and abdominal pain which usually resolves after supportive care (7128,13715,92998,93000,93505).

Genitourinary ...Orally, hulled castor seeds have been associated with cases of dysmenorrhea (7128). Although there have been reports of fetal meconium passage being more common with castor oil use in pregnant women (40184), clinical research shows that the incidence of fetal meconium passage does not significantly differ from no castor oil use (7191,40177). In one case report, a woman at full-term pregnancy experienced amniotic fluid embolism and cardiopulmonary arrest within one hour of ingestion of 30 mL of castor oil (1219). However, midwives routinely use castor oil for labor induction in pregnant women at term. This practice does not appear to adversely affect the mother or fetus (1122,7191,40177).

Hematologic ...Orally, chewing whole castor bean seeds can cause dehydration, hemolysis, and severe fluid and electrolyte disturbances (5611,5612,92998,93000,93505,93507).

Hepatic ...Orally, chewing whole castor bean seeds can cause damage to liver 2-5 days after ingestion (5611,5612,92998,93000,93505,93507).

Immunologic ...Exposure to castor beans, plants, or seed dust can cause contact dermatitis and anaphylaxis in sensitive individuals (5611). Castor oil does not appear to cause these effects. In one case report, a child developed cheilitis over the course of 3 weeks, which was determined to be an allergic reaction to castor oil contained in lip balm (103864). Orally, castor oil did not cause rash in clinical research (40185).

Musculoskeletal ...After inhalation, ricin, the toxic constituent of the castor seed hull, typically causes severe illness within 8 hours, but symptoms may be delayed. Symptoms include arthralgias and fever (13715).

Neurologic/CNS ...Orally, castor oil has been associated with syncope or dizziness in 2-20% of patients in clinical research (40188,40163,40187,40192). In a study of women taking castor seeds as a contraceptive, there were some reports of headache (7128).

Ocular/Otic ...Ophthalmically, castor oil emulsion eye drops resulted in blurred vision in 2 of 27 patients in one study (40178). In another study 2% castor oil eye drops caused slight eye irritation after storage at 60°C for four weeks, and no irritation when stored at 4°C (40169).

Psychiatric ...Taken orally for bowel cleansing, castor oil has been associated with insomnia (40185).

Pulmonary/Respiratory ...After inhalation, ricin, the toxic constituent of the castor seed hull, typically causes respiratory illness within 8 hours, but symptoms may be delayed. Symptoms include cough, dyspnea, and fever. Progression to respiratory distress and death can occur (13715).

Renal ...Orally, chewing whole castor bean seeds can cause renal failure secondary to hypovolemia. Cellular damage to kidneys typically occurs 2-5 days after ingestion (5611,5612,92998,93000,93505,93507).

Other ...Intravenously, castor bean extract can cause multi-organ failure and death. In one case report, a 26-year-old male presented to the emergency room with severe abdominal cramps, nausea, and headache after intravenously injecting castor bean extract as a suicide attempt. The patient rapidly deteriorated and died from multi-organ failure 10 hours after injection despite supportive care (100835).
Orally, chewing whole castor bean seeds can cause significant toxicity and death (5611,5612,92998,93000,93505,93507).

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General ...Orally, rectally, and topically, glycerol seems to be well tolerated. Intravenously, glycerol may be unsafe.
Most Common Adverse Effects:
Orally: Bloating, diarrhea, nausea, vomiting, dizziness, and headache.
Topically: Burning, irritation, and pruritus.
Intravenously: Hemolysis in patients with acute ischemic stroke.

Dermatologic ...Topically, glycerol has been reported to cause burning, irritation, and pruritus (93754,93756). Rectally, the regular administration of glycerol 50% enemas has been reported to cause generalized urticaria in at least two patients; in both patients, symptoms resolved after discontinuation (110019,110025).

Gastrointestinal ...Orally, glycerol can cause bloating, nausea, vomiting, thirst, and diarrhea (15,2475).

Hematologic ...Intravenously, glycerol has been reported to caused hemolysis in people treated for acute ischemic stroke (2480,2482).

Neurologic/CNS ...Orally, glycerol can cause mild headache and dizziness (15,2475).

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