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Boswellia serrata

Boswellia serrata is a branching tree and member of the Boswellia genus native to India, Northern Africa, and the Middle East. (43) Its active ingredient, known as boswellic acid (BA), is derived from the gum resin of Boswellia plants and has been traditionally used in Ayurvedic and Unani medicines. BA targets multiple physiological signal transduction cascades providing anti-inflammatory, expectorant, anti-septic, anxiolytic, anti-neurotic, analgesic, tranquilizing, and anti-bacterial properties. (37)

Six major α and β-boswellic acids have been identified, including:

3-acetyl-11-keto-β-boswellic acid (AKBA)
11-keto-β-boswellic acid (KBA)
α-boswellic acid (αBA)
β-boswellic acid (βBA)
3-acetyl-α-boswellic acid (AαBA)
3-acetyl-β-boswellic acid (AβBA) (15)

Of these BAs, AKBA and KBA possess the most powerful inhibitory effects on pro-inflammatory enzymes and on the production of inflammatory cytokines, which has led to their widespread therapeutic application in chronic inflammatory conditions. (24)(37)(43)

Not be confused with:

Frankincense (olibanum resin/oil produced by Boswellia trees including Boswellia serrata, Boswellia carteri, Boswellia frereana, and Boswellia sacra) (14)
Guggul (resin from Commiphora wightii, Commiphora mukul, Commiphora gileadensis, Boswellia serrata, Boswellia carterii, Boswellia sacra, Boswellia ovalifoliolata, Boswellia dalzielii, Boswellia frereana, and Boswellia thurifera) (28)

Main uses

Inflammatory disorders, including: musculoskeletal, gastrointestinal, respiratory, and dermal

Formulations

Form	Standardization
Non-formulated Boswellia serrata extracts	Non-formulated extracts used in research have ranged in total BAs >35-80% (29)(36) Contains AKBA: 3.3-4.4%, KBA: 0.45-0.58%, αBA: 0.87-1.6%, βBA: 5.4-25%, AαBA: 3.8-19.3%, and AβBA: 3.8-19.3% (16)(49) Note that extracts may fall outside of this range, and can vary with respect to the proportion of individual BAs
5-Loxin®, BE-30	Standardized to AKBA: >30% (38)(40)
ApresFLEX®, Aflapin®	Standardized to AKBA: >20% in a non-volatile oil formulation (40)(48) Bioavailability: ~52% more bioavailable than 5-Loxin® in rats (39)
Boswellin®	Standardized to total BAs of >50% – AKBA: 30%, KBA: 1.5%, AβBA: 3.5%, and βBA: 7.5% (30)
BSE-18	Standardized to total BAs of >55% – AKBA: 3.7%, KBA: 6.1%, αBA: 13.2%, βBA: 18.2%, AαBA: 3.3%, and AβBA: 10.5% (1)(46)
Cap Wokvel™	Standardized to total BAs of >40% – AKBA: 2%, KBA: 6.44%, αBA: 6.93%, βBA: 18.51%, AαBA 1.853%, and AβBA: 8.58% (25)(45)
H15 Gufic™, Sallaki™	Standardized to total BAs of >30% – AKBA: 1.9-2.8%, KBA: 2.6-3.5%, and AβBA: 8% (1)(21)(26)
Phytosome®	Standardized to total BAs of >33% in a 1:1 ratio of soy lecithin formulation (Casperome™) to Boswellia serrata extract (22)(36) Bioavailability: ↑ absorption speed by 1.5-2 hours for all BAs; ↑ plasma Cmax AKBA (4-fold), AβBA, βBA, αBA, and AαBA (2-fold) (36)
S. Compound™	Standardized to contain AKBA: 0.7%, KBA: 0.63%, and 1.5% AβBA/βBA (1)
Zinc carnosine	Contains 23% elemental zinc Also known as Polaprezinc
Zinc aspartate	Contains 20% elemental zinc

Dosing & administration

Asthma
General outcomes from A-level evidence	No data currently available.
Dosing & administration	300 mg (S. Compound™) three times per day to adults for 6 weeks
Outcomes	↓ dyspnea, rhonchi, number of attacks, erythrocyte sedimentation rate, and eosinophils ↑ FEV1, FVC, and PEFR (18)
Class of evidence	C
Dosing & administration	500 mg (Casperome®) per day to adults for 4 weeks with ICS and LABAs
Outcomes	↓ the number of concomitant inhalations required per day within 1 week of administration Effects continue to reduce the frequency of needed concomitant therapy with each week (12)
Class of evidence	C

Chronic colitis
General outcomes from A-level evidence	No data currently available.
Dosing & administration	350 mg three times per day to adults for 6 weeks
Outcomes	Improved one or more parameters for stool properties, histopathology and scan microscopy, or blood parameters for Hb, Fe, Ca, P, proteins, total leukocytes and eosinophils to a similar extent to sulfasalazine therapy (19)
Class of evidence	C

Collagenous colitis (microscopic colitis)
General outcomes from A-level evidence	No data currently available.
Dosing & administration	400 mg (80% boswellic acid) three times per day to adults for 6 weeks
Outcomes	↑ chance of clinical remission (29)
Class of evidence	C

Crohn’s disease
General outcomes from A-level evidence	No data currently available.
Dosing & administration	1200 mg (H15 Gufic™) three times per day for 8 weeks
Outcomes	↓ Crohn Disease Activity Index to the same extent as mesalazine (17)
Class of evidence	C

Diffuse axonal injury
General outcomes from A-level evidence	No data currently available.
Dosing & administration	360 mg (60% Boswellia serrata gum resin) three times per day to adolescents or adults for 6 weeks
Outcomes	↑ cognitive ability for self-care score No effect disability rating scale overall (32)
Class of evidence	C

Irritable bowel syndrome
General outcomes from A-level evidence	No data currently available.
Dosing & administration	250 mg (Casperome®) per day to adults for 1-6 months
Outcomes	↓ GI pain, cramps, gas, bowel movements, and need for rescue medications or additional medical care to a similar extent to standard therapy within 1 month, but more effectively within 3 months ↓ oxidative stress by 6 months (8)(35)
Class of evidence	C

Joint pain
General outcomes from A-level evidence	No data currently available.
Dosing & administration	500 mg (Casperome®) per day for 5 days to athletes with knee pain, then 250 mg per day for 23 days adjunct with acetaminophen or NSAIDs
Outcomes	Compared with standard therapy alone: ↓ VAS-pain score, number of px with pain on effort, joint effusion, structural damage, intramuscular hematomas, biomarkers of cartilage damage and inflammation (COMP and CRP, respectively), and hyperthermic area ↑ pain-free walking distance (13)
Class of evidence	C
Dosing & administration	150 mg (FlexiQule®) three times per day to adults with joint pain in the hand for 2 weeks during a standard rehabilitation plan
Outcomes	↓ pain, hyperthermic areas, erythrocyte sedimentation rate and need for NSAIDs or corticosteroids to control pain ↑ hand function more quickly and effectively than standard rehabilitation alone (7)
Class of evidence	C

Knee osteoarthritis (OA)
General outcomes from A-level evidence	No data currently available.
Dosing & administration	50-125 mg (5-Loxin®) twice per day for 3 months to adults with knee OA
Outcomes	↓ pain & stiffness scores, and MMP-3 secretion and TNFα-induced ICAM-1 secretion ↑ physical function scores (38)(40)
Class of evidence	B
Dosing & administration	50 mg (Aflapin®) twice per day for 1-3 months to adults with knee OA
Outcomes	↓ pain and stiffness scores ↑ physical function scores (40)(48)
Class of evidence	B
Dosing & administration	333 mg (Cap Wokvel™) three times per day for 2-6 months to adults with knee OA
Outcomes	↓ pain, swelling, and loss of movement scores ↑ physical function scores (25)(45)
Class of evidence	B
Dosing & administration	170 mg (Boswellin®) twice per day for 4 months to adults with knee OA
Outcomes	↓ pain & stiffness scores, serum hs-CRP, osteophytes (spur), and reductions in joint space from loss of articular cartilage ↑ physical function and QoL scores (30)
Class of evidence	C

Radiotherapy-induced dermatitis
General outcomes from A-level evidence	No data currently available.
Dosing & administration	2% Boswellia topical cream in Phytosome® (Bosexil®) applied to skin twice per day immediately after radiation therapy and before bed to adults with breast cancer
Outcomes	↓ erythema intensity grade and the proportion of patients using topical hydrocortisone therapy (47)
Class of evidence	C

Radiotherapy-related edema
General outcomes from A-level evidence	No data currently available.
Dosing & administration	1200-1400 mg (H15) three times per day to adults with cerebral tumors during radiotherapy
Outcomes	↓ cerebral edema and may reduce need for steroids during brain irradiation (26)
Class of evidence	C
Dosing & administration	4500 mg (Monoselect AKBA™) per day to adults with Glioblastoma multiforme during radiochemotherapy with temozolomide for a max of 34 weeks
Outcomes	↑ proportion of reduced or stabilized edema ↓ use of steroids to treat cerebral edema (10)
Class of evidence	C

Rheumatoid arthritis (RA)
General outcomes from A-level evidence	No data currently available.
Dosing & administration	400-1200 mg (H15®) two or three times per day to adults for 1-6 months
Outcomes	↓ pain and swelling, erythrocyte sedimentation rate, morning stiffness, and need for NSAIDs ↑ general health and well-being scores (11)
Class of evidence	B

Skin aging
General outcomes from A-level evidence	No data currently available.
Dosing & administration	0.5% Boswellia topical cream applied to the face once per day for 30 days
Outcomes	↓ photoaging score, skin roughness, fine lines, sebum excretion ↑ skin elasticity, thickness, and deposition of collagenous and elastic fibers (9)(33)
Class of evidence	C

Type II diabetes
General outcomes from A-level evidence	No data currently available.
Dosing & administration	250-400 mg (olibanum gum resin from Boswellia serrata) twice per day to adults on metformin for 8-12 weeks
Outcomes	↓ FBG, HBA1C, insulin, total cholesterol, LDL, and TGs (3)(31)
Class of evidence	B
Dosing & administration	300 mg (gum resin from Boswellia serrata) three times per day to adults on oral hypoglycemic therapy for 6 weeks
Outcomes	↓ total cholesterol, LDL-C fructosamine, SGPT and SGOT ↑ HDL-C (2)
Class of evidence	C

Ulcerative colitis
General outcomes from A-level evidence	No data currently available.
Dosing & administration	250 mg (Casperome®) per day to adults for 4 weeks
Outcomes	↓ GI pain & cramp intensity and frequency, frequency of diarrhea, feces with blood or mucus, bowel movements, need for medication, and medical attention (34)
Class of evidence	C
Dosing & administration	300 mg three times per day to adults for 6 weeks
Outcomes	Improves stool properties, histopathology and scan microscopy, and blood parameters for Hb, Fe, Ca, P, proteins, total leukocytes and eosinophils to a similar extent to sulfasalazine therapy (20)
Class of evidence	C

Adverse effects

Generally considered to be safe. The most commonly reported side effects include gastrointestinal reflux, pain, and/or nausea. (5)(6)

Pharmacokinetics

Absorption

Stable plasma levels are achieved after 30 hours. (42)
All six major BAs may be found in the plasma, however the principle acid, AKBA, is not always detectable. All of the acids show high variability. (16)
BAs have low intestinal absorption due to BAs lipophilic properties. (41) AKBA, AαBA, and AβBA have particularly low absorption as shown in rats. (1)(4)(15)(27)
Bioavailability can be increased when consumed with fatty food (44)(46) or in soy lecithin formulations. (22)(36) Phosphatidylcholine or phospholipid formulations may also increase bioavailability as shown in rats. (23)(41)

Distribution

BAs are distributed to the brain, eyes, liver, kidney, and skeletal muscle as shown in rats. (15)(22)

Metabolism

Phase 1: KBA, αBA, and βBA are metabolised via intestinal and hepatic CYP3A4 mediated oxidation to form hydroxylated metabolites. AKBA, AαBA, and AβBA are not extensively metabolized. (1)(4)(15)(27)
Phase 2: No major role identified (15)

Excretion

BAs have a half-life of approximately six hours. (42)