Notoginseng

In Traditional Chinese Medicine, notoginseng (san qi) is considered sweet, slightly bitter and warm.

It is used to stop bleeding while dispersing blood stasis, and to reduce swelling and relieve pain.

Its traditional indications include injuries, bruising, chest pain, coughing or vomiting blood, blood in the urine, abnormal uterine bleeding and blood stasis. It is used especially for bleeding that comes with stagnation, swelling or pain.

Western herbalists use notoginseng mainly as a circulatory and cardiovascular herb, in formulas for the circulation, bruising and recovery from injury.

A 2023 double-blind, placebo-controlled trial at 67 centres in China randomised 3,072 people within 14 days of an ischemic stroke to the Xuesaitong soft capsule, 120 mg twice daily, or placebo for 3 months ^{1Reference 1Wu et al. · 2023RCTEfficacy and Safety of Panax notoginseng Saponins in the Treatment of Adults With Ischemic Stroke in China — a multicentre, double-blind, placebo-controlled randomised clinical trialView study →}.

Of the 2,966 analysed, 89.3% on the capsule reached functional independence (a modified Rankin Scale score of 0–2) at 3 months, against 82.4% on placebo (odds ratio 1.95, 95% CI 1.56–2.44). Serious adverse events occurred in 1.0% and 1.1% ^{1Reference 1Wu et al. · 2023RCTEfficacy and Safety of Panax notoginseng Saponins in the Treatment of Adults With Ischemic Stroke in China — a multicentre, double-blind, placebo-controlled randomised clinical trialView study →}.

A 2021 meta-analysis of 43 trials (4,170 patients) found PNS added to conventional treatment improved functional independence at 90 days, neurological deficit scores and activities of daily living ^{3Reference 3Wang et al. · 2021Meta-analysisSystematic Review and Meta-Analysis of Randomized Controlled Trials on Efficacy and Safety of Panax notoginseng Saponins in Acute Ischemic StrokeView study →}.

In a 2011 double-blind trial of 140 patients, the sanchitongshu capsule (200 mg three times daily) plus low-dose aspirin improved neurological deficit and daily-living scores more than aspirin alone ^{5Reference 5He et al. · 2011RCTRadix/rhizoma notoginseng extract (sanchitongtshu) for ischemic stroke — a randomised controlled studyView study →}.

The 2008 Cochrane review of 8 trials (660 participants) judged sanchi beneficial and safe for acute ischemic stroke, but rated seven of the eight trials as poor quality ^{2Reference 2Chen et al. · 2008Systematic reviewSanchi for acute ischaemic stroke — Cochrane systematic reviewView study →}.

A 2026 network meta-analysis of 50 trials found PNS plus aspirin improved functional outcome more than aspirin alone ^{4Reference 4Zhang et al. · 2026Meta-analysisComparative effectiveness of Panax notoginseng saponins-related agents and antiplatelet agents in ischemic stroke — a systematic review and network meta-analysisView study →}. A 2026 review reached a similar conclusion and noted the lack of high-quality trials ^{6Reference 6Zeng et al. · 2026Systematic reviewPanax notoginseng saponins against ischemic stroke: from molecule to clinic — a systematic reviewView study →}.

Gap: the signal belongs to standardised PNS (soft capsule and injection) and does not automatically extend to the powdered root. Apart from the 2023 trial, the trials are small and at meaningful risk of bias.

A meta-analysis of 36 trials found PNS preparations lowered the maximum platelet-aggregation rate compared with placebo and with non-antiplatelet agents, and added to the effect of antiplatelet drugs. Bleeding events did not increase. The authors rated the evidence weak because of heterogeneity and poor methodological quality ^{12Reference 12Li et al. · 2017Meta-analysisEffect of Panax notoginseng preparations on platelet function — a meta-analysis of 36 randomised controlled trialsView study →}.

A 2022 meta-analysis of 20 trials (2,216 patients) with coronary heart disease or ischemic stroke found PNS preparations plus aspirin lowered platelet aggregation, fibrinogen and D-dimer more than aspirin alone, again without more bleeding events ^{13Reference 13Dai et al. · 2022Meta-analysisPanax notoginseng preparation plus aspirin versus aspirin alone on platelet aggregation and coagulation in coronary heart disease or ischemic stroke — a meta-analysisView study →}.

In an assessor-blinded trial of 42 people with stable coronary heart disease and chronic gastritis, two months of PNS plus aspirin inhibited platelets more than aspirin alone and eased dyspeptic symptoms. In rats, PNS reduced aspirin-induced gastric injury ^{14Reference 14Wang et al. · 2021RCTCombination of Panax notoginseng saponins and aspirin potentiates platelet inhibition with alleviated gastric injury — a randomised, assessor-blinded trialView study →}.

The endpoint in these trials is platelet aggregation, a surrogate rather than a clinical outcome. The same action is the basis of the bleeding caution with blood-thinning drugs.

An 18-trial meta-analysis (1,828 patients, 16 of the trials using injections) found notoginseng preparations improved angina symptoms and ECG readings and reduced cardiovascular events. Cardiac mortality did not differ, and reporting quality was generally poor ^{7Reference 7Song et al. · 2017Meta-analysisPanax notoginseng Preparations for Unstable Angina Pectoris — a systematic review and meta-analysisView study →}.

A 17-trial review of oral PNS in unstable angina reported improvements in the primary endpoint, ECG readings, the frequency and duration of angina attacks, nitroglycerin use and blood lipids ^{8Reference 8Duan et al. · 2018Meta-analysisEfficacy and safety of oral Panax notoginseng saponins for unstable angina patients — a meta-analysis and systematic reviewView study →}.

A 17-trial review of oral notoginseng preparations for coronary heart disease (1,747 participants) found symptom and ECG improvement but no significant reduction in cardiovascular events ^{9Reference 9Shang et al. · 2013Systematic reviewOral Panax notoginseng Preparation for Coronary Heart Disease — a systematic review of randomised controlled trialsView study →}.

In acute myocardial infarction, a meta-analysis of 20 trials (1,881 patients) found PNS injection added to standard care lowered major adverse cardiac events ^{10Reference 10Chen et al. · 2024Meta-analysisEfficacy and safety of Panax notoginseng saponin injection in acute myocardial infarction — a systematic review and meta-analysis of randomised trialsView study →}.

A 1,200-patient double-blind trial of high-dose Xueshuantong injection in unstable angina, designed around major adverse cardiovascular events, published its protocol in 2020 ^{11Reference 11Long et al. · 2020RCTEfficacy and safety of high-dose Xueshuantong injection (lyophilised) in reducing major adverse cardiovascular events — a randomised controlled trial protocolView study →}.

Gap: most trials used injections rather than the oral root, reporting quality is poor, and the reviews disagree on cardiovascular events.

Dencichine (β-N-oxalyl-L-α,β-diaminopropionic acid) is a non-protein amino acid in the root, separate from the saponins. Given orally to rats, it shortened bleeding time. In platelets it raised calcium and thromboxane release, an effect blocked at AMPA-type glutamate receptors ^{15Reference 15Huang et al. · 2014In vitroDencichine enhances hemostasis of activated platelets via AMPA receptors — in vitroView study →}.

A synthetic form, D-dencichine, raised platelet counts in mice with chemotherapy-induced thrombocytopenia and stimulated megakaryocyte adhesion, migration and proplatelet formation in vitro ^{16Reference 16Ding et al. · 2018AnimalD-dencichine regulates thrombopoiesis by promoting megakaryocyte adhesion, migration and proplatelet formation — animal model in vivoView study →}.

In people, a meta-analysis of 20 trials (1,891 patients) found PNS injection improved outcomes in acute intracerebral hemorrhage ^{17Reference 17Xu et al. · 2014Meta-analysisEfficacy and Safety of Panax notoginseng Saponin Therapy for Acute Intracerebral Hemorrhage — a meta-analysisView study →}. A meta-analysis of 20 trials (1,831 patients) found PNS preparations improved blood hypercoagulability in chronic obstructive pulmonary disease without raising bleeding risk ^{18Reference 18Zhou et al. · 2024Meta-analysisClinical efficacy and safety of Panax notoginseng saponins in chronic obstructive pulmonary disease with blood hypercoagulability — a meta-analysisView study →}.

Gap: no human trial has tested the crude root for bleeding. The saponins inhibit platelets while dencichine promotes clotting, and the net effect of a whole-root preparation has not been measured.

In apolipoprotein-E-deficient mice, PNS inhibited RAGE/MAPK signalling (JNK, p38, ERK1/2) and NF-κB activation, lowering adhesion molecules and chemokines in atherosclerotic lesions ^{19Reference 19Dou et al. · 2012AnimalPanax notoginseng saponins suppress RAGE/MAPK signalling and NF-κB activation in apolipoprotein-E-deficient atherosclerosis-prone mice — in vivoView study →}.

In rats after myocardial infarction, PNS at 40 mg/kg daily lowered C-reactive protein and TNF-α and reduced cardiac fibrosis through the ATF3/MAP2K3/p38 MAPK and NF-κB pathways ^{21Reference 21Ma et al. · 2020AnimalPanax notoginseng saponins inhibits ventricular remodelling after myocardial infarction in rats through ATF3/MAP2K3/p38 MAPK and NF-κB pathways — in vivoView study →}.

Notoginsenoside R1 shows anti-inflammatory activity across animal models of ischemia-reperfusion injury ^{25Reference 25Tong et al. · 2019Systematic reviewNotoginsenoside R1 for organ ischemia/reperfusion injury — a preclinical systematic reviewView study →}.

No human trial has used inflammation as its main endpoint.

In rats on a high-fat diet with zymosan-induced inflammation, PNS at 100 mg/kg by injection lowered total cholesterol, triglycerides and blood viscosity, and eased the changes of atherosclerosis in the aorta ^{20Reference 20Zhang et al. · 2008AnimalPanax notoginseng saponins attenuate atherosclerosis in rats by regulating the blood-lipid profile and an anti-inflammatory action — in vivoView study →}.

In apolipoprotein-E-deficient mice, four weeks of PNS reduced lesion size and macrophage numbers in the brachiocephalic artery and reactive-oxygen-species production in the aortic root ^{19Reference 19Dou et al. · 2012AnimalPanax notoginseng saponins suppress RAGE/MAPK signalling and NF-κB activation in apolipoprotein-E-deficient atherosclerosis-prone mice — in vivoView study →}.

In people, a meta-analysis of oral PNS in unstable angina reported improved blood lipids as a secondary outcome ^{8Reference 8Duan et al. · 2018Meta-analysisEfficacy and safety of oral Panax notoginseng saponins for unstable angina patients — a meta-analysis and systematic reviewView study →}. No trial has measured atherosclerosis itself.

In rats given carbon tetrachloride and in cultured hepatic stellate cells, PNS lowered ALT and AST, reduced fibrous septa and hydroxyproline, and suppressed TGF-β1, α-SMA and collagen I through the Jak2/Stat3 pathway ^{22Reference 22Hui et al. · 2016In vitroInhibitory effect of Panax notoginseng saponins on liver fibrosis — carbon-tetrachloride rat model and hepatic stellate cells, in vivo/in vitroView study →}.

In obese mice with non-alcoholic fatty liver disease, PNS reduced liver fat and fibrosis by acting on the gut–liver axis ^{23Reference 23Xu et al. · 2021AnimalGut–liver axis modulation of Panax notoginseng saponins in non-alcoholic fatty liver disease — mouse model in vivoView study →}.

There is no human liver-disease trial.

Antioxidant effects are usually reported as a secondary readout. PNS raised superoxide dismutase and glutathione and lowered malondialdehyde in apolipoprotein-E-deficient mice ^{19Reference 19Dou et al. · 2012AnimalPanax notoginseng saponins suppress RAGE/MAPK signalling and NF-κB activation in apolipoprotein-E-deficient atherosclerosis-prone mice — in vivoView study →}.

In senescence-accelerated (SAMP8) mice, eight weeks of PNS improved memory, raised glutathione and lowered malondialdehyde in the brain, and enhanced mitophagy ^{24Reference 24Yang et al. · 2024AnimalPanax notoginseng saponins prevent dementia and oxidative stress in brains of SAMP8 mice by enhancing mitophagy — in vivoView study →}.

The organ-protective effects of notoginsenoside R1 are partly antioxidant ^{25Reference 25Tong et al. · 2019Systematic reviewNotoginsenoside R1 for organ ischemia/reperfusion injury — a preclinical systematic reviewView study →}.

These are measurements in animal tissue, not clinical outcomes.

Blood-thinning drugs. Standardised saponin preparations lower platelet aggregation on their own and add to the effect of aspirin and other antiplatelet drugs ^{12,13Reference 12Li et al. · 2017Meta-analysisEffect of Panax notoginseng preparations on platelet function — a meta-analysis of 36 randomised controlled trialsView study →Reference 13Dai et al. · 2022Meta-analysisPanax notoginseng preparation plus aspirin versus aspirin alone on platelet aggregation and coagulation in coronary heart disease or ischemic stroke — a meta-analysisView study →}. The meta-analyses found no increase in bleeding events when PNS was added to aspirin ^{12,13Reference 12Li et al. · 2017Meta-analysisEffect of Panax notoginseng preparations on platelet function — a meta-analysis of 36 randomised controlled trialsView study →Reference 13Dai et al. · 2022Meta-analysisPanax notoginseng preparation plus aspirin versus aspirin alone on platelet aggregation and coagulation in coronary heart disease or ischemic stroke — a meta-analysisView study →}. The additive effect is still a reason for care with anticoagulant and antiplatelet drugs (warfarin, aspirin, clopidogrel, DOACs), and for stopping concentrated extracts one to two weeks before surgery or dental procedures.

Dencichine. The root also contains dencichine, which promotes platelet activation and clotting ^{15,16Reference 15Huang et al. · 2014In vitroDencichine enhances hemostasis of activated platelets via AMPA receptors — in vitroView study →Reference 16Ding et al. · 2018AnimalD-dencichine regulates thrombopoiesis by promoting megakaryocyte adhesion, migration and proplatelet formation — animal model in vivoView study →}. Chemically it is β-N-oxalyl-L-α,β-diaminopropionic acid (β-ODAP), the neurotoxic amino acid behind lathyrism from grass pea (Lathyrus sativus). Its neurotoxicity is why researchers synthesised a separate form, D-dencichine, for testing ^{16Reference 16Ding et al. · 2018AnimalD-dencichine regulates thrombopoiesis by promoting megakaryocyte adhesion, migration and proplatelet formation — animal model in vivoView study →}. No harm from it has been reported at notoginseng doses.

Side effects. Adverse reactions in the trials were mild ^{3Reference 3Wang et al. · 2021Meta-analysisSystematic Review and Meta-Analysis of Randomized Controlled Trials on Efficacy and Safety of Panax notoginseng Saponins in Acute Ischemic StrokeView study →}. In the largest trial, serious adverse events occurred in 1.0% on the capsule and 1.1% on placebo ^{1Reference 1Wu et al. · 2023RCTEfficacy and Safety of Panax notoginseng Saponins in the Treatment of Adults With Ischemic Stroke in China — a multicentre, double-blind, placebo-controlled randomised clinical trialView study →}.

Drug metabolism. Human pharmacokinetic studies of interactions through drug-metabolising enzymes such as CYP450 have not been done.