Elderberry

What Is Elderberry?

Elder is a fast-growing shrub or small tree whose creamy flower heads and near-black berries are two of Europe’s oldest cold and flu remedies. The flowers are made into tea, and the cooked berries into syrups, cordials, jams and wine.

Sambucus nigra is native to Europe, western Asia and the Caucasus, and has been carried to North Africa, the Americas, Australia and New Zealand ^{31Reference 31GBIF Secretariat (accessed 2026) · 2026Sambucus nigra LView study →}.

The berries are deeply coloured by anthocyanins, and a standardised berry extract has been tested in several small trials for influenza and colds. The results have been mixed ^{1,2,3,4,5,6Reference 1Zakay-Rones et al. · 2004RCTRandomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections — randomized controlled trialView study →Reference 2Zakay-Rones et al. · 1995RCTInhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract during an outbreak of influenza B Panama — placebo-controlled, in vitroView study →Reference 3Tiralongo et al. · 2016RCTElderberry supplementation reduces cold duration and symptoms in air-travellers: a randomised, double-blind placebo-controlled clinical trial — RCTView study →Reference 4Hawkins et al. · 2019Meta-analysisBlack elderberry (Sambucus nigra) supplementation effectively treats upper respiratory symptoms: a meta-analysis of randomized, controlled clinical trials — meta-analysisView study →Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →Reference 6Wieland et al. · 2021Systematic reviewElderberry for prevention and treatment of viral respiratory illnesses: a systematic reviewView study →}.

The raw plant is a different matter from the cooked berry. Raw berries, leaves, bark and roots cause nausea and vomiting, and only the flowers and properly heated ripe berries are used.

How Is Elderberry Used?

• Flowers — dried and taken as a hot tea at the first signs of a cold. In the European Union, elder flower is registered as a traditional herbal medicine for the early symptoms of the common cold ^{30Reference 30Committee on Herbal Medicinal Products ( · 2018ReviewEuropean Union herbal monograph on Sambucus nigra L., flos (EMA/HMPC/611512/2016) — regulatory monographView study →}.
• Berries — always cooked. Made into syrups, cordials and jams, and into the standardised berry extracts (Sambucol, Rubini and similar) used in the clinical trials.
• Leaves — applied externally in folk practice, for wounds.
• Bark — an old purgative, now rarely used.

Traditional Uses

Elder seeds, pollen and dried fruit have been found at a Bronze Age site in Tuscany ^{28Reference 28Mariotti-Lippi et al. · 2010Palaeovegetational reconstruction based on pollen and seeds/fruits from a Bronze Age archaeological site in Tuscany (Italy)}, a Neolithic site in the French Alps ^{29Reference 29Martin et al. · 2008Plant economy during the Neolithic in a mountain context: the case of “Le Chenet des Pierres” in the French Alps (Bozel-Savoie, France)}, and the Durankulak site on the Black Sea coast of north-eastern Bulgaria.

Western Herbal Medicine

Elder flower is taken as a hot tea for colds and sore throats, and it was commonly combined with yarrow or boneset for colds and influenza.

The berries and bark were used as a purgative and, in larger amounts, as an emetic. The leaves were applied to wounds, and the whole plant was used as a diuretic.

Ayurvedic Medicine

The berries are listed as a diuretic and aperient (a mild laxative), and the bark as a hydragogue, cathartic and anti-epileptic.

Traditional Chinese Medicine: Chinese Elder (Sambucus chinensis)

Chinese medicine uses related elders, Sambucus formosana and S. chinensis, rather than S. nigra. They are used occasionally for liver disease, and are classed as warm and bitter, for dispelling blood stasis.

Indonesian Folk Medicine: Sambucus javanica

In Indonesia the related Sambucus javanica is used for pain relief, beriberi and jaundice.

Indications

• Influenza and colds, taken at the first symptoms [standardised berry extract] ⚠Caution: Small early trials found faster recovery, but the largest and best-controlled influenza trial found no benefit, and a 2021 systematic review rated the evidence as uncertain ^1,2,3,4,5,6.
• Early symptoms of the common cold [flower tea; European traditional use]
• Sore throat [flower; Western herbal use]
• Constipation [berries, bark; Western folk use]
• Fluid retention [whole plant; Western folk use]
• Wounds [leaves, topical; Western folk use]

Botany

Elder is a large, multi-stemmed deciduous shrub or small tree. It usually grows 3–6 m tall and can reach 10 m, and it spreads quickly by suckering from the roots ^{33,34Reference 33NasirSambucaceae: Sambucus nigra — flora treatmentView study →Reference 34NC State Extension (accessed 2026) · 2026Sambucus nigra (black elder) — plant profileView study →}. The stems are marked with raised pores (lenticels) ^{33Reference 33NasirSambucaceae: Sambucus nigra — flora treatmentView study →}.

The leaves are pinnately compound, up to about 25 cm long, with 3 to 9 toothed, oval leaflets. They give off an unpleasant smell when crushed ^{33,34Reference 33NasirSambucaceae: Sambucus nigra — flora treatmentView study →Reference 34NC State Extension (accessed 2026) · 2026Sambucus nigra (black elder) — plant profileView study →}.

In early summer elder bears tiny creamy-white, musky-scented flowers in broad, flat-topped clusters 12–20 cm across ^{33,34Reference 33NasirSambucaceae: Sambucus nigra — flora treatmentView study →Reference 34NC State Extension (accessed 2026) · 2026Sambucus nigra (black elder) — plant profileView study →}. These ripen into glossy black to blue-black berries about 5–10 mm across, each holding a few small, wrinkled stones ^{33,34Reference 33NasirSambucaceae: Sambucus nigra — flora treatmentView study →Reference 34NC State Extension (accessed 2026) · 2026Sambucus nigra (black elder) — plant profileView study →}.

Floras differ on its family. It is placed in the moschatel family (Adoxaceae), in Viburnaceae, or in a family of its own, Sambucaceae, and older works file it under the honeysuckles ^{33,34Reference 33NasirSambucaceae: Sambucus nigra — flora treatmentView study →Reference 34NC State Extension (accessed 2026) · 2026Sambucus nigra (black elder) — plant profileView study →}.

Red elder (Sambucus racemosa) is a different species. It bears red berries in a large, branched cluster rather than elder’s flat-topped heads. Its foliage can hold toxic levels of cyanide, and other parts of the plant may be poisonous to people ^{32Reference 32Fryer · 2008ReviewSambucus racemosa — species reviewView study →}.

Dwarf elder (Sambucus ebulus) is a separate species that grows wild across many temperate areas. Much of the elder toxicology literature was done on it rather than on black elder ^{26Reference 26Jiménez et al. · 2015ReviewEbulin from dwarf elder (Sambucus ebulus L.): a mini-reviewView study →}.

Distribution

Elder grows wild across most of Europe, from Ireland and Portugal east to European Russia, and through the Caucasus, Turkey and western Iran to the eastern Mediterranean ^{31Reference 31GBIF Secretariat (accessed 2026) · 2026Sambucus nigra LView study →}. In Norway, Sweden, Finland and North Africa it is recorded as introduced ^{31Reference 31GBIF Secretariat (accessed 2026) · 2026Sambucus nigra LView study →}.

It has been planted and has naturalised far beyond that range, including in China, Pakistan, Canada, the United States, South America, Australia and New Zealand ^{31,33Reference 31GBIF Secretariat (accessed 2026) · 2026Sambucus nigra LView study →Reference 33NasirSambucaceae: Sambucus nigra — flora treatmentView study →}. In gardens it can become weedy, because it suckers and self-seeds readily ^{34Reference 34NC State Extension (accessed 2026) · 2026Sambucus nigra (black elder) — plant profileView study →}.

Growing Conditions

Cultivation snapshot for Elderberry

LifeperennialZoneUSDA 5–8

• Thrives in full sun to partial shade, flowering and fruiting most heavily in full sun.
• Prefers moist to wet, humus-rich, well-drained soil but tolerates a wide range of ground.
• Cold-hardy through roughly USDA zones 5–8; a vigorous grower that can sucker and spread.
• Matures into a large multi-stemmed shrub (8–20 ft), so give it room or cut it back hard.

Grow it yourself

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Pharmacology & Research

Elder has one of the larger clinical literatures among Western herbs used for respiratory infection. Four placebo-controlled trials, a meta-analysis and a systematic review address influenza and the common cold ^{1,2,3,4,5,6Reference 1Zakay-Rones et al. · 2004RCTRandomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections — randomized controlled trialView study →Reference 2Zakay-Rones et al. · 1995RCTInhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract during an outbreak of influenza B Panama — placebo-controlled, in vitroView study →Reference 3Tiralongo et al. · 2016RCTElderberry supplementation reduces cold duration and symptoms in air-travellers: a randomised, double-blind placebo-controlled clinical trial — RCTView study →Reference 4Hawkins et al. · 2019Meta-analysisBlack elderberry (Sambucus nigra) supplementation effectively treats upper respiratory symptoms: a meta-analysis of randomized, controlled clinical trials — meta-analysisView study →Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →Reference 6Wieland et al. · 2021Systematic reviewElderberry for prevention and treatment of viral respiratory illnesses: a systematic reviewView study →}. Three early trials reported faster recovery; a 2020 emergency-room trial found no benefit ^{5Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →}.

The rest of the evidence is preclinical: antioxidant, anti-inflammatory, metabolic and antibacterial work, mostly in cells, on the berry’s anthocyanins and flavonoids ^{7,8,9,10,15,16,17,20Reference 7Roschek et al. · 2009In vitroElderberry flavonoids bind to and prevent H1N1 infection in vitroView study →Reference 8Krawitz et al. · 2011In vitroInhibitory activity of a standardized elderberry liquid extract against clinically-relevant human respiratory bacterial pathogens and influenza A and B viruses — in vitroView study →Reference 9Barak et al. · 2001In vitroThe effect of Sambucol, a black elderberry-based natural product, on the production of human cytokines: IView study →Reference 10Abuja et al. · 1998In vitroAntioxidant and prooxidant activities of elderberry (Sambucus nigra) extract in low-density lipoprotein oxidation — in vitroView study →Reference 15Mascolo et al. · 1987In vitroBiological screening of Italian medicinal plants for anti-inflammatory activity — in vitroView study →Reference 16Yeşilada et al. · 1997In vitroInhibitory effects of Turkish folk remedies on inflammatory cytokines: interleukin-1α, interleukin-1β and tumor necrosis factor α — in vitroView study →Reference 17Harokopakis et al. · 2006In vitroInhibition of proinflammatory activities of major periodontal pathogens by aqueous extracts from elder flower (Sambucus nigra) — in vitroView study →Reference 20Zielińska-Wasielica et al. · 2019In vitroElderberry (Sambucus nigra L.) fruit extract alleviates oxidative stress, insulin resistance, and inflammation in hypertrophied 3T3-L1 adipocytes and activated RAW 264.7 macrophages — in vitroView study →}. A few small human studies have looked at blood lipids and blood sugar ^{11,13,14Reference 11Murkovic et al. · 2004RCTEffects of elderberry juice on fasting and postprandial serum lipids and low-density lipoprotein oxidation in healthy volunteers: a randomised, double-blind, placebo-controlled study — RCTView study →Reference 13Rust et al. · 2023RCTOne-week elderberry juice treatment increases carbohydrate oxidation after a meal tolerance test and is well tolerated in adults: a randomized controlled pilot study — RCTView study →Reference 14Teets et al. · 2024RCTA one-week elderberry juice intervention augments the fecal microbiota and suggests improvement in glucose tolerance and fat oxidation in a randomized controlled trial — RCTView study →}.

The berries were not given a German Commission E monograph, because the research available at the time was judged insufficient ^{18Reference 18Vlachojannis et al. · 2010Systematic reviewA systematic review on the sambuci fructus effect and efficacy profiles — systematic reviewView study →}.

1. Antiviral (Influenza / Cold)

A 1995 placebo-controlled study during an influenza B outbreak on a kibbutz found that nearly 90% of the extract group were fully recovered within 2–3 days, against at least 6 days in the placebo group. The same extract (Sambucol) inhibited several influenza A and B strains in cell culture ^{2Reference 2Zakay-Rones et al. · 1995RCTInhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract during an outbreak of influenza B Panama — placebo-controlled, in vitroView study →}.

A 2004 double-blind RCT in Norway (n=60) gave 15 mL of berry syrup four times daily for 5 days. Symptoms were relieved on average four days earlier than with placebo, and less rescue medication was used ^{1Reference 1Zakay-Rones et al. · 2004RCTRandomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections — randomized controlled trialView study →}.

A 2016 trial in 312 air travellers, using a standardised membrane-filtered berry extract, found significantly shorter and milder colds. The reduction in the number of colds (12 against 17) was not significant ^{3Reference 3Tiralongo et al. · 2016RCTElderberry supplementation reduces cold duration and symptoms in air-travellers: a randomised, double-blind placebo-controlled clinical trial — RCTView study →}.

A 2019 meta-analysis pooling 180 participants reported a large reduction in upper-respiratory symptoms ^{4Reference 4Hawkins et al. · 2019Meta-analysisBlack elderberry (Sambucus nigra) supplementation effectively treats upper respiratory symptoms: a meta-analysis of randomized, controlled clinical trials — meta-analysisView study →}.

In the laboratory, elderberry flavonoids bind directly to H1N1 virions and block them from entering cells. The whole extract had an IC50 of about 252 µg/mL; a methylated quercetin and dihydromyricetin were among the active compounds ^{7Reference 7Roschek et al. · 2009In vitroElderberry flavonoids bind to and prevent H1N1 infection in vitroView study →}. A standardised extract also inhibited influenza A (H5N1) and B viruses and several respiratory bacteria ^{8Reference 8Krawitz et al. · 2011In vitroInhibitory activity of a standardized elderberry liquid extract against clinically-relevant human respiratory bacterial pathogens and influenza A and B viruses — in vitroView study →}.

A 2020 double-blind RCT (n=87) in influenza-positive emergency-room patients found no reduction in the duration or severity of symptoms. A post-hoc analysis suggested that elderberry taken without oseltamivir did about 2 days worse than placebo taken alone ^{5Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →}.

A 2021 systematic review of five randomised trials concluded that elderberry may shorten colds and influenza, but that the evidence is uncertain ^{6Reference 6Wieland et al. · 2021Systematic reviewElderberry for prevention and treatment of viral respiratory illnesses: a systematic reviewView study →}.

Gap: the positive trials are small, several share authors or products, and the largest influenza RCT was negative. No large independent confirmatory trial exists.

2. Antioxidant

The berry’s anthocyanins, chiefly cyanidin-3-glucoside and cyanidin-3-sambubioside, account for most of its antioxidant activity. In vitro, an elderberry extract incorporated into low-density lipoprotein made the LDL more resistant to oxidation, though the same study noted prooxidant behaviour under some conditions ^{10Reference 10Abuja et al. · 1998In vitroAntioxidant and prooxidant activities of elderberry (Sambucus nigra) extract in low-density lipoprotein oxidation — in vitroView study →}.

In a human trial, 2 weeks of a spray-dried anthocyanin extract had only a minor effect on serum antioxidant capacity, and the LDL’s resistance to oxidation did not change over 3 weeks ^{11Reference 11Murkovic et al. · 2004RCTEffects of elderberry juice on fasting and postprandial serum lipids and low-density lipoprotein oxidation in healthy volunteers: a randomised, double-blind, placebo-controlled study — RCTView study →}.

A separate 30-day study in 21 volunteers reported improved serum antioxidant capacity and thiol levels, but it used an infusion of Sambucus ebulus (dwarf elder), a related but distinct species ^{12Reference 12Ivanova et al. · 2014Improved lipid profile and increased serum antioxidant capacity in healthy volunteers after Sambucus ebulus L. fruit infusion consumption — human intervention study (different species: dwarf elder)View study →}.

Gap: robust in vitro activity, but the human antioxidant signal is small, short-term, and partly derived from a different Sambucus species.

3. Anti-Inflammatory

Elder flower and berry preparations modulate inflammatory signalling in vitro and ex vivo. Early screening of Italian medicinal plants found anti-inflammatory activity in Sambucus nigra extracts ^{15Reference 15Mascolo et al. · 1987In vitroBiological screening of Italian medicinal plants for anti-inflammatory activity — in vitroView study →}.

In a study of Turkish folk remedies, elder flower and leaf extracts inhibited at least one of the inflammatory cytokines IL-1α, IL-1β and TNF-α ^{16Reference 16Yeşilada et al. · 1997In vitroInhibitory effects of Turkish folk remedies on inflammatory cytokines: interleukin-1α, interleukin-1β and tumor necrosis factor α — in vitroView study →}.

An aqueous elder flower extract suppressed the proinflammatory activity of two periodontal pathogens, through inhibition of NF-κB and PI3-kinase ^{17Reference 17Harokopakis et al. · 2006In vitroInhibition of proinflammatory activities of major periodontal pathogens by aqueous extracts from elder flower (Sambucus nigra) — in vitroView study →}.

Standardised Sambucol preparations had the opposite effect on healthy human monocytes. They increased production of inflammatory cytokines, TNF-α most of all (about 45-fold), which the authors described as immune activation ^{9Reference 9Barak et al. · 2001In vitroThe effect of Sambucol, a black elderberry-based natural product, on the production of human cytokines: IView study →}.

A 2021 systematic review looked for evidence that elderberry might provoke a harmful “cytokine storm” and found none ^{6Reference 6Wieland et al. · 2021Systematic reviewElderberry for prevention and treatment of viral respiratory illnesses: a systematic reviewView study →}.

All of this is in vitro or ex vivo, the findings point in both directions, and no clinical inflammatory endpoint has been measured.

4. Cardiometabolic (Lipids & Glucose)

In a randomised placebo-controlled trial in 34 volunteers, a spray-dried elderberry extract had only a small, non-significant effect on cholesterol at the dose tested. The authors suggested that higher, still food-level doses might be needed ^{11Reference 11Murkovic et al. · 2004RCTEffects of elderberry juice on fasting and postprandial serum lipids and low-density lipoprotein oxidation in healthy volunteers: a randomised, double-blind, placebo-controlled study — RCTView study →}.

A 30-day study of dwarf elder (S. ebulus) fruit infusion in 21 volunteers reported falls of about 15% in triglycerides and total cholesterol, but in a different species ^{12Reference 12Ivanova et al. · 2014Improved lipid profile and increased serum antioxidant capacity in healthy volunteers after Sambucus ebulus L. fruit infusion consumption — human intervention study (different species: dwarf elder)View study →}.

Two small crossover pilots gave overweight adults 100% elderberry juice twice daily for a week. In the first, carbohydrate oxidation rose after a test meal, but blood glucose and insulin did not change ^{13Reference 13Rust et al. · 2023RCTOne-week elderberry juice treatment increases carbohydrate oxidation after a meal tolerance test and is well tolerated in adults: a randomized controlled pilot study — RCTView study →}. In the second, blood glucose after the meal fell, fat oxidation rose, and the gut bacteria shifted ^{14Reference 14Teets et al. · 2024RCTA one-week elderberry juice intervention augments the fecal microbiota and suggests improvement in glucose tolerance and fat oxidation in a randomized controlled trial — RCTView study →}.

In vitro, elderberry extract reduced reactive oxygen species and improved glucose uptake in enlarged fat cells ^{20Reference 20Zielińska-Wasielica et al. · 2019In vitroElderberry (Sambucus nigra L.) fruit extract alleviates oxidative stress, insulin resistance, and inflammation in hypertrophied 3T3-L1 adipocytes and activated RAW 264.7 macrophages — in vitroView study →}.

Gap: the human data are small pilots with mixed, dose-dependent results, and the clearest lipid effect comes from a different species (S. ebulus).

5. Antibacterial

A standardised elderberry liquid extract (Rubini) inhibited three Gram-positive respiratory bacteria (Streptococcus pyogenes and group C and G streptococci) and one Gram-negative one (Branhamella catarrhalis), alongside influenza A and B, in broth-dilution and cell-culture assays ^{8Reference 8Krawitz et al. · 2011In vitroInhibitory activity of a standardized elderberry liquid extract against clinically-relevant human respiratory bacterial pathogens and influenza A and B viruses — in vitroView study →}.

This rests on a single in vitro study of one commercial preparation, with no animal or human confirmation.

Mechanisms

Elderberry flavonoids bind to influenza virions and block them from entering cells in vitro. The berry’s anthocyanins carry the antioxidant and metabolic findings, and the flower and berry extracts have been studied for their effects on inflammatory cytokines.

The raw plant also carries ribosome-inactivating proteins, which account for its toxicity when eaten uncooked. Every row below is an in vitro or ex vivo finding.

Clinical Trials

Registered human trials include completed influenza efficacy trials (NCT03410862, NCT00375115), a completed metabolic study (NCT05723497), an immune-support study of unknown status (NCT05435144), and several functional-food trials not yet recruiting. No large confirmatory antiviral trial has yet been run.

Last checked: July 2026.

Phytochemistry

Elderberries are deeply coloured by anthocyanins, chiefly cyanidin-3-sambubioside and cyanidin-3-glucoside, together with their 5-glucosides ^{19Reference 19Mikulic-Petkovsek et al. · 2014Investigation of anthocyanin profile of four elderberry species and interspecific hybridsView study →}. The dominant flavonol is rutin (quercetin-3-O-rutinoside).

In the flowers, flavonol glycosides (rutin and the kaempferol and isorhamnetin rutinosides) make up about 90% of the flavonoids. Two caffeoylquinic acids, 5-O-caffeoylquinic acid (chlorogenic acid) and 1,5-di-O-caffeoylquinic acid, make up about 70% of the phenolic acids ^{21Reference 21Christensen et al. · 2008Selection of elderberry (Sambucus nigra L.) genotypes best suited for the preparation of elderflower extracts rich in flavonoids and phenolic acids — chemical profilingView study →}. The acylated kaempferol glycoside tiliroside and isorhamnetin also occur.

The fruit also supplies about 1% triterpenoids, notably ursolic acid, along with vitamins A, B6 and C ^{18,21Reference 18Vlachojannis et al. · 2010Systematic reviewA systematic review on the sambuci fructus effect and efficacy profiles — systematic reviewView study →Reference 21Christensen et al. · 2008Selection of elderberry (Sambucus nigra L.) genotypes best suited for the preparation of elderflower extracts rich in flavonoids and phenolic acids — chemical profilingView study →}.

The bark, leaves and unripe fruit carry ribosome-inactivating proteins such as nigrin b, first isolated from black elder bark. The related ebulin proteins come from dwarf elder ^{22,26Reference 22Girbés et al. · 2004ReviewDescription, distribution, activity and phylogenetic relationship of ribosome-inactivating proteins in plants, fungi and bacteria — reviewReference 26Jiménez et al. · 2015ReviewEbulin from dwarf elder (Sambucus ebulus L.): a mini-reviewView study →}.

Anthocyanin content varies considerably between elder species and hybrids ^{19Reference 19Mikulic-Petkovsek et al. · 2014Investigation of anthocyanin profile of four elderberry species and interspecific hybridsView study →}.

Constituent Summary

Anthocyanins and flavonols are given as mg per 100 g fresh fruit (cyanidin-3-glucoside equivalents). Figures vary with genotype, ripeness and drying.

Dosage

The trials almost always used a standardised, heat-processed berry extract or syrup rather than raw fruit, and no marker dose is shared across products ^{1,3,5Reference 1Zakay-Rones et al. · 2004RCTRandomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections — randomized controlled trialView study →Reference 3Tiralongo et al. · 2016RCTElderberry supplementation reduces cold duration and symptoms in air-travellers: a randomised, double-blind placebo-controlled clinical trial — RCTView study →Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →}. Antiviral dosing was short: begun at the first sign of illness and continued for about five days ^{1,5Reference 1Zakay-Rones et al. · 2004RCTRandomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections — randomized controlled trialView study →Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →}.

Traditional Dosage

These are the flower doses in the EU herbal monograph for traditional use, for adults and adolescents. They are not the berry-extract trial doses above ^{30Reference 30Committee on Herbal Medicinal Products ( · 2018ReviewEuropean Union herbal monograph on Sambucus nigra L., flos (EMA/HMPC/611512/2016) — regulatory monographView study →}.

The EU monograph does not recommend elder flower medicines for children under 12, for lack of data ^{30Reference 30Committee on Herbal Medicinal Products ( · 2018ReviewEuropean Union herbal monograph on Sambucus nigra L., flos (EMA/HMPC/611512/2016) — regulatory monographView study →}.

Safety & Pregnancy

Cooked berries, the flowers and the standardised extracts are well tolerated. The raw plant is not: its berries, leaves, bark, roots and unripe fruit cause nausea and vomiting unless heated.

Full Safety & Interactions Detail

Prepared extracts. Standardised, heat-processed elderberry extracts were well tolerated across the clinical trials, with no serious adverse events and a safety profile similar to placebo ^{1,3,5Reference 1Zakay-Rones et al. · 2004RCTRandomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections — randomized controlled trialView study →Reference 3Tiralongo et al. · 2016RCTElderberry supplementation reduces cold duration and symptoms in air-travellers: a randomised, double-blind placebo-controlled clinical trial — RCTView study →Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →}. The EU monograph lists no known side effects for elder flower ^{30Reference 30Committee on Herbal Medicinal Products ( · 2018ReviewEuropean Union herbal monograph on Sambucus nigra L., flos (EMA/HMPC/611512/2016) — regulatory monographView study →}.

The raw plant. Unheated berries, and especially the leaves, bark, roots, unripe fruit and seeds, contain cyanogenic glycosides and ribosome-inactivating proteins that cause nausea, vomiting and diarrhoea ^{34Reference 34NC State Extension (accessed 2026) · 2026Sambucus nigra (black elder) — plant profileView study →}. In dwarf elder, briefly heating ripe-fruit extracts made the protein ebulin f digestible by stomach pepsin, which is the basis for cooking the berries ^{26Reference 26Jiménez et al. · 2015ReviewEbulin from dwarf elder (Sambucus ebulus L.): a mini-reviewView study →}. Nausea means the dose is too high or the material was not heated enough.

Ribosome-inactivating proteins. These are sugar-binding proteins that stop ribosomes from making proteins. Ricin, the toxin from castor beans, is the best-known example. Several have been isolated from black elder, including nigrin b from the bark, and the related ebulin proteins from dwarf elder ^{22,23,24,26Reference 22Girbés et al. · 2004ReviewDescription, distribution, activity and phylogenetic relationship of ribosome-inactivating proteins in plants, fungi and bacteria — reviewReference 23Stirpe · 2004ReviewRibosome-inactivating proteins — reviewReference 24Lapadula et al. · 2013Revising the taxonomic distribution, origin and evolution of ribosome inactivating protein genesView study →Reference 26Jiménez et al. · 2015ReviewEbulin from dwarf elder (Sambucus ebulus L.): a mini-reviewView study →}.

How they compare with ricin. At the ribosome, the elder proteins act as strongly as ricin, but they are far less toxic to cells and animals ^{26Reference 26Jiménez et al. · 2015ReviewEbulin from dwarf elder (Sambucus ebulus L.): a mini-reviewView study →}. Ebulin l is about 10,000 times less toxic than ricin to cultured mammalian cells, and its lethal dose in mice when injected into the abdomen is about 2.5 mg/kg ^{26Reference 26Jiménez et al. · 2015ReviewEbulin from dwarf elder (Sambucus ebulus L.): a mini-reviewView study →}. Ricin’s lethal dose by the same route is 0.023 mg/kg ^{25Reference 25He et al. · 2010AnimalRicin toxicokinetics and its sensitive detection in mouse sera or feces using immuno-PCR — animal studyView study →}.

Much of this toxicology comes from dwarf elder (Sambucus ebulus), not black elder. Nigrin b from black elder is grouped with ebulin l as one of the non-toxic members of this class ^{26Reference 26Jiménez et al. · 2015ReviewEbulin from dwarf elder (Sambucus ebulus L.): a mini-reviewView study →}.

Immune effects. A 2021 systematic review found no evidence that elderberry overstimulates the immune system or provokes a harmful “cytokine storm” ^{6Reference 6Wieland et al. · 2021Systematic reviewElderberry for prevention and treatment of viral respiratory illnesses: a systematic reviewView study →}.

Interactions. No dedicated drug-interaction study has been done, and the EU monograph reports none ^{30Reference 30Committee on Herbal Medicinal Products ( · 2018ReviewEuropean Union herbal monograph on Sambucus nigra L., flos (EMA/HMPC/611512/2016) — regulatory monographView study →}. In the 2020 emergency-room trial, a post-hoc analysis suggested that elderberry taken without oseltamivir did about two days worse than placebo; this was an unplanned analysis and has not been tested directly ^{5Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →}.

Children. In the 2020 influenza trial, children aged 5–12 took half the adult dosing frequency ^{5Reference 5Macknin et al. · 2020RCTElderberry extract outpatient influenza treatment for emergency room patients ages 5 and above: a randomized, double-blind, placebo-controlled trial — RCTView study →}. Use only heated ripe-berry or flower preparations, and dose conservatively.

References

1. Zakay-Rones, Z., Thom, E., Wollan, T., & Wadstein, J. (2004). Randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza A and B virus infections — randomized controlled trial. Journal of International Medical Research, 32(2), 132-140. https://pubmed.ncbi.nlm.nih.gov/15080016/
2. Zakay-Rones, Z., Varsano, N., Zlotnik, M., et al. (1995). Inhibition of several strains of influenza virus in vitro and reduction of symptoms by an elderberry extract during an outbreak of influenza B Panama — placebo-controlled, in vitro. Journal of Alternative and Complementary Medicine, 1(4), 361-369. https://pubmed.ncbi.nlm.nih.gov/9395631/
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