Elder (Sambucus nigra L.): A Comprehensive Reference
1. Identity and Botanical Classification
The genus Sambucus L. (elderberry) belongs to the Adoxaceae family, which consists of 7 different genera that have berry fruit. The most commonly occurring species is Sambucus nigra L. Its common names include elder, elderberry, black elder, European elder, European elderberry, and European black elderberry. Sambucus L. consists of 5–30 species and 6–11 subspecies, depending on the taxonomy system.
Sambucus nigra L. has three subspecies: S. nigra L. ssp. nigra, S. nigra L. ssp. canadensis, and S. nigra L. ssp. cerulea — the two latter ones, which were in the past considered separate species, are native to North America. European black elderberry naturally occurs in most of Europe (except for certain parts of Scandinavia and Russia) and in North Africa (the Atlas Mountains of Algeria, Morocco, and Tunisia).
Sambucus nigra is a small tree or shrub, 1–8 m tall with a strong odor. The bark is brownish, with longitudinal fractures and deep grooves. The leaves are opposite, imparipinnate, with 5–7 elliptic-lanceolate, dentate leaflets. The inflorescence is an umbel with many milky-white flowers. The fruit is a shiny black-purple color, with a subspherical drupe. The plant is found in woods, clearings, and hedges from sea level to mountainous elevations.
The name Sambucus is a generic Greek name that comes from an ancient musical instrument built with the wood of this tree. In traditional medicine, all parts of the tree have long been used; various factors, including cultivar, location, ripening stage, and environmental circumstances, influence the chemical content of S. nigra.
Common Forms and Preparations
Both the fruit (berry) and the flower are employed medicinally and as food, typically in processed forms. Elder flower (the common name for the flowers of the plant Sambucus nigra L.) is processed either by drying and comminuting the flowers, or by placing the plant material in a solvent such as ethanol to dissolve compounds and form a liquid extract. Herbal medicines containing these preparations are usually available as herbal tea to be drunk and in liquid forms to be taken by mouth.
For the berries, commercially available preparations include syrups, liquid extracts, capsules, gummies, lozenges, and juices. The berries can be cooked and used to make juice, jams, chutneys, pies, and elderberry wine. The flowers are often boiled with sugar to make a sweet syrup or infused into tea.
The EMA community herbal monograph for elder flower specifies: dried flower (herbal substance), liquid extract (DER 1:1, extraction solvent: 25% v/v ethanol), and tincture (DER 1:5, extraction solvent: 25% v/v ethanol).
2. Traditional and Historical Use
Ancient and Classical Antiquity
The history of elderberry in medicine dates back as far as 400 BC, and Hippocrates, the "Father of Medicine," called the elder tree his "medicine chest." In Europe and parts of Asia, elderberry has been used for thousands of years in folk medicine to prevent ailments such as colds and arthritis and to relieve pain and fever.
European Folk Medicine
Black elder has been used for centuries in Europe, northern Africa, and some parts of Asia for such purposes as to keep evil spirits away, to prevent or cure numerous ailments and health problems. Traditional medicinal use of elder flower connected to the relief of the symptoms of the early phase of the common cold has been documented in handbooks such as Madaus (1938), Hagers Handbuch (Hänsel et al., 1994), Bisset and Wichtl (2001), and the British Herbal Compendium (Bradley, 1992).
Historically, the flowers and leaves have been used for pain relief, swelling, inflammation, stimulating the production of urine, and inducing sweating. The bark was used as a diuretic, a laxative, and to induce vomiting. In folk medicine, the dried berries or juice are used to treat influenza, infections, sciatica, headaches, dental pain, heart pain, and nerve pain, as well as as a laxative and diuretic.
In folk medicine, elder berries have been used for their diaphoretic, laxative, and diuretic properties, and to treat various illnesses such as stomach ache, sinus congestion, constipation, diarrhea, sore throat, common cold, and rheumatism.
Elderberry has for a long time been used in folk medicine as a diaphoretic, antipyretic, and diuretic agent.
Indigenous North American Use
Indigenous people traditionally used elder to treat fever and rheumatism, while the ancient Egyptians used it to improve their complexions and heal burns. When settlers journeyed to the New World, they brought the elderberry tradition with them — only to find that Native American tribes were already using local species of elder for similar purposes.
Regulatory Recognition of Traditional Use
The European Medicines Agency (EMA) Committee on Herbal Medicinal Products (HMPC) concluded that, on the basis of their long-standing use, elder flower preparations can be used for the relief of early symptoms of the common cold. Elder flower medicines should only be used in adults and adolescents over the age of 12 years. The HMPC conclusions on the use of these elder flower medicines are based on "traditional use," meaning that although there is insufficient evidence from clinical trials, decades of documented traditional practice underpin the classification.
In 2008, the EMA issued the Community herbal monograph on Sambucus nigra flos with the following approval: "Herbal medicinal product traditionally used for the relief of early symptoms of common cold. The product is a traditional herbal medicinal product for use in specified indications exclusively based upon long-standing use."
3. Key Constituents and Active Compounds
Anthocyanins
The major constituents of elderberry fruit extract are the polyphenols, anthocyanins, representing approximately 80%. Large amounts of anthocyanins are present in fresh fruits; the main constituents have been identified as cyanidin-3-glucoside (65.7% of total anthocyanins) and cyanidin-3-sambubioside (32.4% of total anthocyanins), in addition to small amounts of others.
Anthocyanins, which are the major fraction of the constituents of the European elderberry (S. nigra) and the American elderberry (S. canadensis), are polyphenolic compounds — a subclass of flavonoids and the most commonly occurring flavonoids in food. Anthocyanins are water-soluble glycosides; chemically, they are derivatives of the 2-phenylbenzopyrylium or flavylium salts.
Flavonols and Other Polyphenols
The biochemical and pharmacological actions of elderberry extracts are correlated with their phenolic composition, mainly characterized by a high content of anthocyanins (e.g., cyanidin-3-O-glucoside and cyanidin-3-O-sambubioside) and significant amounts of flavonoids (e.g., quercetin-3-O-rutinoside) and hydroxycinnamic acids such as 5-O-caffeoylquinic acid. Several studies have highlighted the predominant presence of flavonoids, particularly rutin, in elderberry fruits, underscoring their role in the plant's antioxidant activity.
Elderflower-Specific Constituents
Key constituents found in elderflower (Sambucus nigra) include flavonoids (isoquercertin, hyperoside, rutin), phenolic acids (chlorogenic acid), triterpenes (ursolic and oleanolic acids), and a small quantity of essential oil. Elder flower (Sambuci flos) consists of the dried flowers of Sambucus nigra L. and contains not less than 0.80 per cent of flavonoids, calculated as isoquercitrin. The British Pharmacopoeia (BP) also requires not less than 0.8% flavonoids expressed as isoquercitroside.
Nutritional Constituents
Elderberry is rich in nutrients, such as carbohydrates, proteins, fats, fatty acids, organic acids, minerals, vitamins, and essential oils. The main sugars identified were glucose (33.33–50.23 g/kg fresh weight) and fructose (33.99–52.25 g/kg fresh weight), whereas only small amounts of sucrose were present. Carbohydrates in Sambucus nigra fruit also include dietary fiber, in particular pectin, pectic acid, protopectin, Ca-pectate, and cellulose. Elderberry is a source of whole protein — its content is 2.7–2.9% in berries, 2.5% in flowers, and 3.3% in leaves. This protein includes sixteen amino acids, nine of which are essential; the total content of essential amino acids is approximately 9% in flowers and 11.5% in leaves. Glutamic acid, aspartic acid, and alanine are the dominant amino acids.
Cyanogenic Glycosides and Lectins
Elderberry also contains cyanogenic glycosides, which are potentially toxic. Black elder contains substantial amounts of a cyanogenic glycoside, sambunigrin, which is considered highly toxic due to its decomposition to chemically reactive hydrogen cyanide. The highest amounts of sambunigrin are present in elder leaves (27.68–209.61 µg/g fresh weight), lower amounts were found in flowers (1.23–18.88 µg/g), whereas berries contain the lowest amounts of this compound (0.08–0.77 µg/g).
4. Mechanisms of Action
Antioxidant Activity
Polyphenols, known for their free-radical scavenging (antioxidant) activity, are the most important group of bioactive compounds present in elderberry in relatively high concentration. The high antioxidant activity of elderberry fruit and flowers is associated with their therapeutic properties. In agreement with its high phenolic content, the antioxidant capacity of elderberry is among the strongest measured in fresh fruits.
Elderberry fruit extract has reportedly inhibited oxidative stress in a dose-dependent manner, with 1.0 mg/mL of colon-digested elderberry fruit extract exerting an antioxidant activity able to protect colon cells against the harmful effects of oxidative stress. This effect was achieved by decreasing the production of excessive intracellular reactive oxygen species (ROS) and preventing the oxidative damage of DNA in human mucosal cells of the colon.
Anti-Inflammatory Pathways
In addition to the free-radical scavenging pathway, other mechanisms and pathways are implicated in the pharmacological effects of anthocyanins, including the cyclooxygenase pathway, the mitogen-activated protein kinase pathway, and inflammatory cytokine signaling.
Elderberry extracts have been shown to inhibit nitric oxide (NO) release from lipopolysaccharide (LPS)-activated RAW 264.7 macrophage cells. An anti-inflammatory effect of in vitro-digested elderberry products was also demonstrated by reducing interleukin-6 (IL-6), TNF-α, and PGE2 release from LPS-stimulated RAW 264.7 cells.
Elderberry anthocyanins specifically have been shown to protect against oxidative stress in bovine aorta and porcine coronary artery endothelial cells. In concert with other elderberry polyphenolic compounds, they promote quinone reductase (a protective enzyme) and inhibit cyclooxygenase-2 (COX-2) and ornithine decarboxylase associated with the initiation and promotion phases of carcinogenesis.
Antiviral and Immunomodulatory Mechanisms
The protective effect of elderberry flavonoids and pectins against the influenza virus is probably mediated by stimulating the immune system of the host through enhancing the production of inflammatory cytokines such as interleukins IL-6, IL-8, and tumor necrosis factor (TNF), and the subsequent stimulation of macrophages.
Elderberries contain many active chemicals, including anthocyanins (primarily cyanidin 3-glucoside and cyanidin 3-sambubioside), which have been shown to boost immune function and exhibit anti-viral effects. Oral ingestion of elderberry results in detectable levels of these anthocyanins in blood plasma.
Cardiovascular Mechanisms
Black elderberry anthocyanins can improve vascular health by promoting the production of nitric oxide, which in turn promotes vascular permeability and vasodilation and reduces blood pressure. In a functional model of the initial stages of atherosclerosis, elderberry prevents the adhesion of monocytes to endothelial cells by suppressing VCAM-1 expression and the reduction of pro-inflammatory cytokines.
Antidiabetic Mechanisms
Research results highlight the promising antidiabetic potential of elderberry extracts, specifically targeting their ability to inhibit enzymes involved in carbohydrate digestion, such as α-glucosidase and α-amylase. Elderberry extracts also modulated the levels of inflammatory cytokines in diabetic rats.
5. Scientific Evidence by Area of Use
5.1 Influenza and Upper Respiratory Tract Infections
This is the most-studied area for elderberry preparations, and it is where the strongest — though still limited — human clinical evidence exists.
Key Clinical Trials
Zakay-Rones et al. (2004): Investigators investigated the efficacy and safety of oral elderberry syrup for treating influenza A and B infections. Sixty patients (aged 18–54 years) suffering from influenza-like symptoms for 48 hours or less were enrolled in this randomized, double-blind, placebo-controlled study during the influenza season of 1999–2000 in Norway. Patients received 15 ml of elderberry or placebo syrup four times a day for 5 days and recorded their symptoms using a visual analogue scale. Symptoms were relieved on average 4 days earlier, and use of rescue medication was significantly less in those receiving elderberry extract compared with placebo. These findings were noted to need confirmation in a larger study.
Tiralongo et al. (2016): Tiralongo, Wee, and Lea conducted a randomized, double-blind, placebo-controlled clinical trial on elderberry supplementation in air-travellers, published in Nutrients, 8(4): 182. The study involved 312 economy class passengers traveling from Australia to an overseas destination. Data suggest that for a participant suffering from a cold episode, supplementation with elderberry is associated with about a 2-day reduction in cold duration and significantly lower overall symptom severity.
Systematic Reviews and Meta-Analyses
Hawkins et al. (2019) meta-analysis (PubMed PMID: 30670267): Black elderberry (Sambucus nigra) has been used to treat cold and flu symptoms; this meta-analysis quantifies the effects of elderberry supplementation and evaluates moderators including vaccination status and the underlying pathology. The analysis included a total of 180 participants. Supplementation with elderberry was found to substantially reduce upper respiratory symptoms. The quantitative synthesis of the effects yielded a large mean effect size.
Wieland et al. (2021) systematic review (BMC Complement Med Ther): This systematic review searched six databases, four research registers, and two preprint sites for studies. Two reviewers independently assessed studies for inclusion, extracted data, assessed risk of bias using Cochrane tools, and evaluated certainty of estimates using GRADE. Outcomes included new illnesses and the severity and duration of illness. The review screened 1,187 records and included five randomized trials on elderberry for the treatment or prevention of viral respiratory illness. The authors concluded: Elderberry may not reduce the risk of developing the common cold; it may reduce the duration and severity of colds, but the evidence is uncertain. Elderberry may reduce the duration of influenza, but the evidence is uncertain. Compared to oseltamivir, an elderberry-containing product may be associated with a lower risk of influenza complications and adverse events.
For the objective of assessing the effects of elderberry in the treatment of viral respiratory illness, the review found three RCTs with 151 participants evaluating elderberry compared to placebo for the treatment of influenza and one RCT with 473 participants evaluating a product containing echinacea and elderberry (Echinaforce® Hotdrink) compared to oseltamivir for the treatment of influenza.
Overall Strength of Evidence — Respiratory Infections
The overall body of clinical evidence for elderberry in upper respiratory illness is preliminary to moderate. Individual RCTs show promising signals for reduced illness duration and symptom severity, but trials are generally small, use varied elderberry preparations and doses, and the 2021 Cochrane-methodology systematic review rates the overall certainty of evidence as uncertain. Larger, rigorously designed trials are needed before definitive conclusions can be drawn.
5.2 Cardiovascular and Lipid Effects
Evidence here is primarily preclinical (in vitro and animal studies). In vivo studies demonstrate improved atherosclerotic plaque stability and high-density lipoprotein (HDL) function in apoE−/− mice, as well as lowering of insulin resistance in type 2 diabetic models. Elderberry has displayed protective effects against oxidative stressors in endothelial cells and the ability to modulate inflammation activity in macrophages and dendritic cells.
Health effects of elderberry's polyphenols include attenuation of cardiovascular, neurodegenerative, and inflammatory disorders, as well as anti-diabetic, anticancer, antiviral, and immuno-stimulatory effects. A large body of literature pertaining to in vitro, in vivo, and human trials has demonstrated the health functions of elderberry based on the attenuation of oxidative stress via its antioxidative effect and its anti-inflammatory, anti-diabetic, cardiovascular-protective, and neuroprotective activities. However, the weight of this evidence remains in the preclinical domain; robust clinical trials specifically targeting cardiovascular endpoints are limited.
5.3 Antidiabetic Effects
Preclinical data show that elderberry flower and fruit extracts can inhibit the enzymes α-glucosidase and α-amylase in vitro, which are enzymes involved in carbohydrate digestion. Research highlights the promising antidiabetic potential of examined extracts, specifically targeting their ability to inhibit enzymes involved in carbohydrate digestion such as α-glucosidase and α-amylase; optimized extraction conditions maximized the yields of bioactive compounds, particularly polyphenols like chlorogenic acid and rutin. These findings are currently limited to in vitro and animal models; no high-quality clinical trials in humans specifically examining glycemic control as a primary endpoint have been identified in the peer-reviewed literature.
5.4 Antioxidant and Anti-Inflammatory Activity
Elderberries have a high content of polyphenols — including phenolic acids, flavonols, proanthocyanidins, and anthocyanins — that are associated with a beneficial antioxidant effect, although most of this knowledge comes from results obtained by conventional colorimetric quantitative methods such as the scavenging of ABTS radical or other radicals. Human clinical evidence for these effects as standalone therapeutic outcomes is limited; most data derive from in vitro and ex vivo models.
5.5 Anti-Inflammatory and Antinociceptive Activity (Preclinical)
The primary polyphenol constituents in the flower extract were flavonoids and phenolic acids, while anthocyanins were the main components in the fruit extract. Elderberry fruit extract revealed pronounced and dose-dependent in vivo anti-inflammatory activity assessed by the cotton pellet-induced granuloma test. Doses of 10, 20, and 50 mg/kg body weight of the fruit extract reduced the weight of induced granuloma in rats by 20.3%, 20.5%, and 28.4%, respectively. At the highest dose (50 mg/kg), the extract had significant anti-inflammatory activity comparable to that of diclofenac. These findings are in animal models and cannot be directly extrapolated to human clinical use.
5.6 Skin and Photoprotection
Research on botanical medicine with potential antioxidant and anti-inflammatory properties is popular in the search for a means of preventing and treating UV-mediated dermatological diseases. Elderberry is a common supplement in a variety of processed foods and beverages. In Europe and parts of Asia, elderberry has been used for thousands of years in folk medicine to prevent ailments such as colds and arthritis and to relieve pain and fever. While in vitro keratinocyte research has explored elderberry's role in UVB-induced photoaging, clinical evidence in humans for skin applications remains very limited.
5.7 Neuroprotection
Research has shown the effectiveness of extracts from S. nigra, particularly from its flowers, in neuroprotection and the modulation of oxidative stress in SH-SY5Y cells. This finding is limited to cell-line research and has not yet been replicated in human clinical studies.
6. Body Systems and Health Areas
- Immune system: The best-supported area of use. Elderberry (S. nigra) has traditionally been prescribed to prevent or treat respiratory disorders, including the common cold, influenza, and infections due to novel coronaviruses.
- Respiratory system: Traditional and emerging clinical evidence for upper respiratory tract infection symptom relief.
- Cardiovascular system: Preclinical evidence for endothelial protection, vascular function, and HDL support via anthocyanin-driven nitric oxide pathways.
- Metabolic/Endocrine: Preclinical evidence for antidiabetic enzyme inhibition and modulation of insulin resistance.
- Gastrointestinal: Traditional diuretic and laxative use; protection of colon cells from oxidative damage demonstrated in vitro.
- Integumentary (Skin): Historical use for burns, complexion, and wound healing; emerging in vitro evidence for photoprotection.
- Nervous system: Preliminary cell-line evidence for neuroprotection; no clinical human trials identified.
7. Dosage Forms and Dosages Reported in Studies
The following dosages are reported directly from published clinical sources and regulatory monographs and should not be interpreted as prescriptive recommendations:
- Elderberry syrup (berry extract) — Influenza treatment: Patients received 15 ml of elderberry or placebo syrup four times a day for 5 days in the Zakay-Rones 2004 RCT. Each 15-ml dose of the oral liquid contained the fruit juice equivalent to 5.7 g of Sambucus nigra (black elderberry).
- Elderberry syrup — Emergency room study (ages 5 and above): Participants aged ≥ 13 years were instructed to orally ingest 15 ml of the study medication 4 times a day for 5 days, and those 5–12 years old were prescribed 15 ml [at a lower frequency per the study protocol].
- Elderflower infusion (EMA-referenced doses): Preparations described include an infusion prepared of 3–4 g (1–1½ spoons) of flowers in 200 ml boiling water, or infusion prepared of two 1.5 g sachets in 200 ml boiling water, or infusion of two 2 g sachets or 3–4 g of flowers in 200 ml boiling water.
- Elderflower tincture (reported herbal practice): Flower tincture (1:5 | 40% ethanol): 6–12 ml daily; infusion/decoction: one tablespoon of dried elderflowers per cup.
According to the European Medicines Agency (EMA), for elderberry preparations, complete information on their traditional use based on a specified posology is missing, as well as the necessary information on their specified strength.
8. Safety Considerations and Interactions
Cyanogenic Glycosides: Toxicity of Raw and Unripe Plant Parts
Unripe or uncooked parts of the elder tree (including leaves, stems, and berries) can be dangerous if ingested, as they contain toxins such as sambunigrin, a cyanogenic glycoside. The toxins can lead to nausea, vomiting, diarrhea, and more serious consequences if ingested in large quantities.
Elderberry contains m-hydroxy-substituted glycosides such as zierin and holocalin. These compounds are potentially toxic and life-threatening because they can be hydrolysed, resulting in the release of cyanide. However, they occur primarily in unripe berries and are degraded during heat treatment.
Higher temperatures not only reduced the content of beneficial compounds but also decreased the levels of harmful cyanogenic glycosides by 44% in elderberry juice, by 80% in tea, and by as much as 96% in elderberry liqueur and spread.
One study found no quantifiable trace of cyanogenic glycosides in commercial American elderberry juice. Levels of cyanogenic glycosides found in various fruit tissues of American elderberry cultivars ranged from 0.12 to 6.38 µg/g. In pressed juice samples, the concentration range measured was 0.29–2.36 µg/mL. TCP (total cyanogenic potential) was highest in the stems and green berries. Concentration levels in all tissues were generally low and at a level that poses no threat to consumers of fresh and processed products.
Immunostimulatory Effects and Autoimmune Disease
Elderberry should not be used in patients with autoimmune diseases and/or taking immunosuppressant medications. This consideration arises from elderberry's demonstrated cytokine-stimulating effects; in individuals with already-overactive immune responses, this activity could theoretically be counterproductive.
Potential Drug Interactions
Many commercial elderberry products contain additional ingredients such as echinacea. Echinacea may impact the metabolism of cytochrome P-450 enzymes, including CYP3A4 and CYP1A2, leading to potential drug interactions. This concern pertains to combination products rather than elderberry alone.
EMA Regulatory Position on Elderberry Fruit
The EMA assessment report concluded that there is not enough evidence to suggest an immune-modulatory effect of elderberry extract. No studies are available that can support the laxative effect of elderberry. The EMA assessment for elderberry fruit (Sambuci fructus) found insufficient clinical data to grant a traditional use designation equivalent to that given to elderflower.
Variability in Commercial Products
The phytochemical constituents in elderflower and elderberry preparations will vary depending on a range of factors that include geographical origin, genetics, environmental conditions, and harvesting season. The use of health products containing European elder fruits is not fully supported by experimental or clinical data. Product quality, standardization of anthocyanin content, and processing methods vary widely across commercial preparations.
Use in Special Populations
Elder flower medicines should only be used in adults and adolescents over the age of 12 years, per the EMA HMPC conclusion. Safety data in pregnancy, lactation, and young children are insufficient for definitive conclusions, and the EMA elderberry fruit assessment notes: no reproductive and developmental toxicity studies have been found.
Adverse Reactions
Ingestion of elderberry plant parts in larger doses may cause gastrointestinal disorders such as nausea, vomiting, weakness, and dizziness. The EMA has noted no adverse reactions associated with Sambucus nigra flower preparations, either alone or in combination, on record in their surveillance database. This reflects the generally favorable tolerability profile of properly processed elder preparations, distinct from the toxicity risk of raw or improperly prepared material.
References
- Sidor A, Gramza-Michałowska A. Bioactive properties of Sambucus nigra L. as a functional ingredient — PMC/NIH
- Trandafir I et al. Bioactive Potential of Elderberry (Sambucus nigra L.): Antioxidant, Antimicrobial Activity, Bioaccessibility and Prebiotic Potential — PMC
- Torabian G et al. The Pros and Cons of Using Elderberry (Sambucus nigra) for Prevention and Treatment of COVID-19 — PMC
- Stróżyk A et al. Black Elder and Its Constituents: Molecular Mechanisms of Action Associated with Female Reproduction — PMC
- Osman AG et al. Elderberry Extracts: Characterization of the Polyphenolic Chemical Composition, Quality Consistency, Safety, Adulteration — PMC
- Strugała P et al. A Comprehensive Study on the Biological Activity of Elderberry Extract and Cyanidin 3-O-Glucoside — PMC
- Wieland LS et al. Elderberry for prevention and treatment of viral respiratory illnesses: a systematic review — PMC/BMC Complementary Medicine and Therapies (2021)
- Hawkins J et al. Black elderberry (Sambucus nigra) supplementation effectively treats upper respiratory symptoms: A meta-analysis of randomized, controlled clinical trials — Complement Ther Med 2019
- Zakay-Rones Z et al. Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment of Influenza A and B Virus Infections — J Int Med Res 2004
- Tiralongo E, Wee SS, Lea RA. Elderberry Supplementation Reduces Cold Duration and Symptoms in Air-Travellers: A Randomized, Double-Blind Placebo-Controlled Clinical Trial — Nutrients 2016
- Elder Elderberry Extract Outpatient Influenza Treatment for Emergency Room Patients Ages 5 and Above: a Randomized, Double-Blind, Placebo-Controlled Trial — J Gen Intern Med 2021
- Festa M et al. Elderberry extract improves molecular markers of endothelial dysfunction linked to atherosclerosis — PMC
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- Antidiabetic Potential of Black Elderberry Cultivars Flower Extracts: Phytochemical Profile and Enzyme Inhibition — PMC 2024
- Montoya CA et al. Cyanogenic Glycoside Analysis in American Elderberry — PMC
- In Vivo Anti-Inflammatory and Antinociceptive Activities of Black Elder (Sambucus nigra L.) Fruit and Flower Extracts — PMC 2024
- Ozgen M et al. Total phenolic, anthocyanin contents and antioxidant capacity of selected elderberry (Sambucus canadensis L.) accessions — PMC
- European Medicines Agency (EMA). Sambuci flos — Herbal medicinal product overview
- EMA HMPC. Assessment Report on Sambucus nigra L., flos — European Medicines Agency
- EMA HMPC. Assessment Report on Sambucus nigra L., fructus — European Medicines Agency
- Children's Mercy Hospital. State-of-the-Art Pediatrics: Elderberry — Clinical Safety Overview 2021
- Charlebois D. Elderberry as a Medicinal Plant — Purdue University New Crops Symposium 2007
- Herbal Reality. Elderflower (Sambucus nigra): Benefits, Safety, Uses — Monograph
- Młynarczyk K et al. Processed elderberry (Sambucus nigra L.) products: A beneficial or harmful food alternative? — Journal of Functional Foods 2016
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