Properties and Therapeutic Application of Bromelain: A Review
Bromelain belongs to a group of protein digesting enzymes obtained commercially from the fruit or stem of pineapple. Fruit bromelain and stem bromelainare prepared differently and they contain different enzymatic composition. “Bromelain” refers usually to the “stem bromelain.” Bromelain is a mixture of different thiol endopeptidases and other components like phosphatase, glucosidase, peroxidase, cellulase, escharase, and several protease inhibitors. In vitro and in vivo studies demonstrate that bromelain exhibits various fibrinolytic, antiedematous, antithrombotic, and anti-inflammatory activities. Bromelain is considerably absorbable in the body without losing its proteolytic activity and without producing any major side effects. Bromelain accounts for many therapeutic benefits like the treatment of angina pectoris, bronchitis, sinusitis, surgical trauma, and thrombophlebitis, debridement of wounds, and enhanced absorption of drugs, particularly antibiotics. It also relieves osteoarthritis, diarrhea, and various cardiovascular disorders. Bromelain also possesses some anticancerous activities and promotes apoptotic cell death. This paper reviews the important properties and therapeutic applications of bromelain, along with the possible mode of action.
Pineapple is the common name of Ananas comosus (syns. A. sativus, Ananassa sativa, Bromelia ananas, B. comosa). Pineapple is the leading edible member of the family Bromeliaceae, grown in several tropical and subtropical countries including Philippines, Thailand, Indonesia, Malaysia, Kenya, India, and China. It has been used as a medicinal plant in several native cultures  and these medicinal qualities of pineapple are attributed to bromelain (EC 184.108.40.206), which is a crude extract from pineapple that contains, among other compounds, various closely related proteinases, exhibiting various fibrinolytic, antiedematous, antithrombotic, and anti-inflammatory activities in vitro and in vivo. Bromelain has been chemically known since 1875 and is used as a phytomedical compound . Bromelain concentration is high in pineapple stem, thus necessitating its extraction because, unlike the pineapple fruit which is normally used as food, the stem is a waste byproduct and thus inexpensive . A wide range of therapeutic benefits have been claimed for bromelain, such as reversible inhibition of platelet aggregation, sinusitis, surgical traumas , thrombophlebitis, pyelonephriti angina pectoris, bronchitis , and enhanced absorption of drugs, particularly of antibiotics [6, 7]. Several studies have been carried out indicating that bromelain has useful phytomedical application. However, these results are yet to be amalgamated and critically compared so as to make out whether bromelain will gain wide acceptance as a phytomedical supplement . Bromelain acts on fibrinogen giving products that are similar, at least in effect, to those formed by plasmin . Experiment in mice showed that antacids such as sodium bicarbonate preserve the proteolytic activity of bromelain in the gastrointestinal tract . Bromelain is considered as a food supplement and is freely available to the general public in health food stores and pharmacies in the USA and Europe . Existing evidence indicates that bromelain can be a promising candidate for the development of future oral enzyme therapies for oncology patients . Bromelain can be absorbed in human intestines without degradation and without losing its biological activity [12, 13].
2. Biochemical Properties
The crude aqueous extract from stem and fruit of pineapple is known as bromelain. It is a mixture of different thiol endopeptidases and other components like phosphatases, glucosidase, peroxidases, cellulases, glycoproteins, carbohydrates, and several protease inhibitors . Stem bromelain (EC.220.127.116.11) is different from fruit bromelain (EC.18.104.22.168) . The enzymatic activities of bromelain comprise a wide spectrum with pH range of 5.5 to 8.0 . Different protein fractions were obtained by mean of various “biochemical techniques as sodium dodecyl sulphate polyacrylamide gel electrophoresis” (SDS-PAGE), isoelectric focusing (IEF), and multicathodal-PAGE [17, 18]. Nowadays, bromelain is prepared from cooled pineapple juice by centrifugation, ultrafiltration, and lyophilization. The process yields a yellowish powder, the enzyme activity of which is determined with different substrates such as casein (FIP unit), gelatin (gelatin digestion units), or chromogenic tripeptides [7, 17, 19, 20].
3. Absorption and Bioavailability
The body can absorb significant amount of bromelain; about 12 gm/day of bromelain can be consumed without any major side effects . Bromelain is absorbed from the gastrointestinal tract in a functionally intact form; approximately of labeled bromelain is absorbed from intestine in high molecular form . In a study carried out by Castell et al.  bromelain was detected to retain its proteolytic activity in plasma and was also found linked with alpha 2-macroglobulin and alpha1-antichymotrypsin, the two antiproteinases of blood. In a recent study, it was demonstrated that 3.66 mg/mL of bromelain was stable in artificial stomach juice after 4 hrs of reaction and also 2.44 mg/mL of bromelain remained in artificial blood after 4 hrs of reaction .
4. Medicinal Uses
Clinical studies have shown that bromelain may help in the treatment of several disorders.
4.1. Effects of Bromelain on Cardiovascular and Circulation
Bromelain prevents or minimizes the severity of angina pectoris and transient ischemic attack (TIA). It is useful in the prevention and treatment of thrombophlebitis. It may also break down cholesterol plaques and exerts a potent fibrinolytic activity. A combination of bromelain and other nutrients protect against ischemia/reperfusion injury in skeletal muscle . Cardiovascular diseases (CVDs) include disorders of the blood vessels and heart, coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, heart failure, and congenital heart disease . Stroke and heart disease are the main cause of death, about of people with diabetes die from stroke or heart disease. Bromelain has been effective in the treatment of CVDs as it is an inhibitor of blood platelet aggregation, thus minimizing the risk of arterial thrombosis and embolism . King et al.  reported that administration of medication use to control the symptoms of diabetes, hypertension, and hypercholesteromia increased by from 1988–1994 to 2001–2006 () and was greater for patients with fewer healthy lifestyle habits. Bromelain supplement could reduce any of risk factors that contribute to the development of cardiovascular disease. In a recent research, Bromelain was found to attenuate development of allergic airway disease (AAD), while altering CD4+ to CD8+ T lymphocyte populations. From this reduction in AAD outcomes it was suggested that bromelain may have similar effects in the treatment of human asthma and hypersensitivity disorders . In another study, carried out by Juhasz et al., Bromelain was proved to exhibit the ability of inducing cardioprotection against ischemia-reperfusion injury through Akt/Foxo pathway in rat myocardium .
4.2. Bromelain Relieves Osteoarthritis
Osteoarthritis is the most common form of arthritis in Western countries; in USA prevalence of osteoarthritis ranges from 3.2 to dependent on the joint . A combination of bromelain, trypsin, and rutin was compared to diclofenac in 103 patients with osteoarthritis of the knee. After six weeks, both treatments resulted in significant and similar reduction in the pain and inflammation . Bromelain is a food supplement that may provide an alternative treatment to nonsteroidal anti-inflammatory drug (NSAIDs) . It plays an important role in the pathogenesis of arthritis . Bromelain has analgesic properties which are thought to be the result of its direct influence on pain mediators such as bradykinin [33, 34]. The earliest reported studies investigating bromelain were a series of case reports on 28 patients, with moderate or severe rheumatoid or osteoarthritis .
4.3. Effect of Bromelain on Immunogenicity
Bromelain has been recommended as an adjuvant therapeutic approach in the treatment of chronic inflammatory, malignant, and autoimmune diseases . In vitro experiments have shown that Bromelain has the ability to modulate surface adhesion molecules on T cells, macrophages, and natural killer cells and also induce the secretion of IL-1β, IL-6, and tumour necrosis factor α (TNFα) by peripheral blood mononuclear cells (PBMCs) [37–43]. Bromelain can block the Raf-1/extracellular-regulated-kinase- (ERK-) 2 pathways by inhibiting the T cell signal transduction . Treatment of cells with bromelain decreases the activation of CD4 (+) T cells and reduce the expression of CD25 . Moreover, there is evidence that oral therapy with bromelain produces certain analgesic and anti-inflammatory effects in patients with rheumatoid arthritis, which is one of the most common autoimmune diseases .
4.4. Effect of Bromelain on Blood Coagulation and Fibrinolysis
Bromelain influences blood coagulation by increasing the serum fibrinolytic ability and by inhibiting the synthesis of fibrin, a protein involved in blood clotting . In rats, the reduction of serum fibrinogen level by bromelain is dose dependent. At a higher concentration of bromelain, both prothrombin time (PT) and activated partial thromboplastin time (APTT) are markedly prolonged . In vitro and in vivo studies have suggested that bromelain is an effective fibrinolytic agent as it stimulates the conversion of plasminogen to plasmin, resulting in increased fibrinolysis by degrading fibrin [49, 50].
4.5. Effects of Bromelain on Diarrhea
Evidence has suggested that bromelain counteracts some of the effects of certain intestinal pathogens like Vibrio cholera and Escherichia coli, whose enterotoxin causes diarrhoea in animals. Bromelain appears to exhibit this effect by interacting with intestinal secretory signaling pathways, including adenosine 3′ : 5′-cyclic monophosphatase, guanosine 3′ : 5′-cyclic monophosphatase, and calcium-dependent signaling cascades . Other studies suggest a different mechanism of action. In E. coli infection, an active supplementation with bromelain leads to some antiadhesion effects which prevent the bacteria from attaching to specific glycoprotein receptors located on the intestinal mucosa by proteolytically modifying the receptor attachment sites [52, 53].
4.6. Effect of Bromelain on Cancer Cells
Recent studies have shown that bromelain has the capacity to modify key pathways that support malignancy. Presumably, the anticancerous activity of bromelain is due to its direct impact on cancer cells and their microenvironment, as well as on the modulation of immune, inflammatory, and haemostatic systems . Most of the in vitro and in vivo studies on anticancer activity of bromelain are concentrated on mouse and human cells, both cancerous and normal, treated with bromelain preparations. In an experiment conducted by Beez et al chemically induced mouse skin papillomas were treated with bromelain and they observed that it reduced tumor formation, tumor volume and caused apoptotic cell death . In one study related to bromelain treatment of gastric carcinoma Kato III cell lines, significant reduction of cell growth was observed  while in another study bromelain reduced the invasive capacity of glioblastoma cells and reduced de novo protein synthesis . Bromelain is found to increase the expression of p53 and Bax in mouse skin, the well-known activators of apoptosis . Bromelain also decreases the activity of cell survival regulators such as Akt and Erk, thus promoting apoptotic cell death in tumours. Different studies have demonstrated the role of NF-κB, Cox-2, and PGE2 as promoters of cancer progression. Evidence shows that the signaling and overexpression of NF-κB plays an important part in many types of cancers [57, 58]. Cox-2, a multiple target gene of NF-κB, facilitates the conversion of arachidonic acid into PGE2 and thus promotes tumour angiogenesis and progression [59, 60]. It is considered that inhibiting NF-κB, Cox-2, and PGE2 activity has potential as a treatment of cancer. Bromelain was found to downregulate NF-κB and Cox-2 expression in mouse papillomas  and in models of skin tumourigenesis . Bromelain was also shown to inhibit bacterial endotoxin (LPS)-induced NF-κB activity as well as the expression of PGE2 and Cox-2 in human monocytic leukemia and murine microglial cell lines [62, 63]. Bromelain markedly has in vivo antitumoural activity for the following cell lines: P-388 leukemia, sarcoma (S-37), Ehrlich ascetic tumour, Lewis lung carcinoma, and ADC-755 mammary adenocarcinoma. In these studies, intraperitoneal administration of bromelain after 24 hours of tumour cell inoculation resulted in tumour regression .
4.7. Role of Bromelain in Surgery
Administration of bromelain before a surgery can reduce the average number of days for complete disappearance of pain and postsurgery inflammation [64, 65]. Trials indicate that bromelain might be effective in reducing swelling, bruising, and pain in women having episiotomy . Nowadays, bromelain is used for treating acute inflammation and sports injuries .
4.8. Role of Bromelain in Debridement Burns
The removal of damaged tissue from wounds or second/third degree burns is termed as debridement. Bromelain applied as a cream ( bromelain in a lipid base) can be beneficial for debridement of necrotic tissue and acceleration of healing. Bromelain contains escharase which is responsible for this effect. Escharase is nonproteolytic and has no hydrolytic enzyme activity against normal protein substrate or various glycosaminoglycan substrates. Its activity varies greatly with different preparations . In two different enzymatic debridement studies carried out in porcine model, using different bromelain-based agents, namely, Debriding Gel Dressing (DGD) and Debrase Gel Dressing showed rapid removal of the necrotic layer of the dermis with preservation of the unburned tissues [68, 69]. In another study on Chinese landrace pigs, enzymatic debridement using topical bromelain in incised wound tracks accelerated the recovery of blood perfusion, pO2 in wound tissue, controlled the expression of TNF-α, and raised the expression of TGT-β . Enzymatic debridement using bromelain is better than surgical debridement as surgical incision is painful, nonselective and exposes the patients to the risk of repeated anaesthesia and significant bleeding [71–74].
4.9. Toxicity of Bromelain
According to Taussig et al.  bromelain has very low toxicity with an LD50 (lethal doses) greater than 10 g/kg in mice, rates, and rabbits. Toxicity tests on dogs, with increasing level of bromelain up to 750 mg/kg administered daily, showed no toxic effects after six months. Dosages of 1500 mg/kg per day when administered to rats showed no carcinogenic or teratogenic effects and did not provoke any alteration in food intake, histology of heart, growth, spleen, kidney, or hematological parameters . Eckert et al.  after giving bromelain (3000 FIP unit/day) to human over a period of ten days found no significant changes in blood coagulation parameters.
Bromelain has a wide range of therapeutic benefits, but the mode of its action is not properly understood. It is proved that bromelain is well absorbed in body after oral administration and it has no major side effects, even after prolonged use. All the evidences reviewed in this paper suggest that bromelain can be used as an effective health supplement to prevent cancer, diabetes, and various cardiovascular diseases in the long run.
6. Future Trends and Perspectives
Bromelain can be a promising candidate for the development of oral enzyme therapies for oncology patients. It is clear from this paper that bromelain is a multiaction enzyme; however, more research is required to understand the proper mechanism of action of bromelain so that the multiaction activities of bromelain can be harnessed efficiently.
The authors are grateful to DEAN, Department of Biotechnology, IBMER, Mangalayatan University, Aligarh, India, for providing necessary facilities and encouragement. They are also thankful to all faculty members of the Institute of Biomedical Education and Research, Mangalayatan University, Aligarh, India, for their generous help and suggestions during the paper preparation.
S. Mondal, S. Bhattacharya, J. N. Pandey, and M. Biswas, “Evaluation of acute anti-inflametry effect of Ananas Comosus leaf extract in Rats,” Pharmocologyonline, vol. 3, pp. 1312–1315, 2011.View at: Google Scholar
S. J. Taussig and S. Batkin, “Bromelain, the enzyme complex of pineapple (Ananas comosus) and its clinical application: an update,” Journal of Ethnopharmacology, vol. 22, no. 2, pp. 191–203, 1988.View at: Google Scholar
R. M. Heinicke and W. A. Gortner, “Stem bromelain: a new protease preparation from pineapple plants,” Economic Botany, vol. 11, no. 3, pp. 225–234, 1957.View at: Publisher Site | Google Scholar
M. Livio, G. De. Gaetano, and M. B. Donati, “Effect of bromelain of fibrinogen level, protrombin complex and platelet aggregation in the rat-a preliminary report,” Drugs under Experimental and Clinical Research, vol. 1, pp. 49–53, 1978.View at: Google Scholar
R. A. Neubauer, “A plant protease for potentiation of and possible replacement of antibiotics,” Experimental Medicine and Surgery, vol. 19, pp. 143–160, 1961.View at: Google Scholar
G. Renzini and M. Varego, “Die resorsption von tetrazyklin ingenenwart von Bromelain bei oraler application,” Arzneimittel-Forschung Drug Research, vol. 2, pp. 410–412, 1972.View at: Google Scholar
H. R. Maurer, “Bromelain: biochemistry, pharmacology and medical use,” Cellular and Molecular Life Sciences, vol. 58, no. 9, pp. 1234–1245, 2001.View at: Google Scholar
B. N. Tochi, Z. Wang, S. Y. Xu, and W. Zhang, “Therapeutic application of pineapple protease (Bromelain): a review,” Pakistan Journal of Nutrition, vol. 7, no. 4, pp. 513–520, 2008.View at: Publisher Site | Google Scholar
S. J. Taussig, “The mechanism of the physiological action of bromelain,” Medical Hypotheses, vol. 6, no. 1, pp. 99–104, 1980.View at: Google Scholar
L. P. Hale, “Proteolytic activity and immunogenicity of oral bromelain within the gastrointestinal tract of mice,” International Immunopharmacology, vol. 4, no. 2, pp. 255–264, 2004.View at: Publisher Site | Google Scholar
C. M. Ley, A. Tsiami, Q. Ni, and N. Robinson, “A review of the use of bromelain in cardiovascular diseases,” Journal of Chinese Integrative Medicine, vol. 9, no. 7, pp. 702–710, 2011.View at: Publisher Site | Google Scholar
K. Chobotova, A. B. Vernallis, and F. A. A. Majid, “Bromelain's activity and potential as an anti-cancer agent: current evidence and perspectives,” Cancer Letters, vol. 290, no. 2, pp. 148–156, 2010.View at: Publisher Site | Google Scholar
J. V. Castell, G. Friedrich, C. S. Kuhn, and G. E. Poppe, “Intestinal absorption of undegraded proteins in men: presence of bromelain in plasma after oral intake,” American Journal of Physiology, vol. 273, no. 1, pp. G139–G146, 1997.View at: Google Scholar
B. K. Bhattacharyya, “Bromelain: an overview,” Natural Product Radiance, vol. 7, no. 4, pp. 359–363, 2008.View at: Google Scholar
A. D. Rowan and D. J. Buttle, “Pineapple cysteine endopeptidases,” Methods in Enzymology, vol. 244, pp. 555–568, 1994.View at: Publisher Site | Google Scholar
S. Yoshioka K Izutsa, Y. Asa, and Y. Takeda, “Inactivation kineticsof enzyme pharmaceuticals in aqueous solutions,” Pharmaceutical Research, vol. 4, pp. 480–485, 1991.View at: Google Scholar
T. Harrach, K. Eckert, K. Schulze-Forster, R. Nuck, D. Grunow, and H. R. Maurer, “Isolation and partial characterization of basic proteinases from stem bromelain,” Journal of Protein Chemistry, vol. 14, no. 1, pp. 41–52, 1995.View at: Publisher Site | Google Scholar
A. D. Napper, S. P. Bennet, M. Borowski et al., “Purification and characterization of multiple forms of the pineapple-stem-derived cysteine proteinases ananain and comosain,” Biochemical Journal, vol. 301, no. 3, pp. 727–735, 1994.View at: Google Scholar
W. Cooreman, “Bromelain,” in Pharmaceutical Enzymes- Properties and Assay Methods, R. Ruyssen and A. Lauwers, Eds., pp. 107–121, E. Story-Scientia Scientific Publishing Co., Gent, Belgium, 1978.View at: Google Scholar
I. Y. Filippova, E. N. Lysogorskaya, E. S. Oksenoit, G. N. Rudenskaya, and V. M. Stepanov, “L-Pyroglutamyl-L-phenylalanyl-L-leucine-p-nitroanilide: a chromogenic substrate for thiol proteinase assay,” Analytical Biochemistry, vol. 143, no. 2, pp. 293–297, 1984.View at: Google Scholar
J. Seifert, R. Ganser, and W. Brendel, “Absorption of a proteolytic enzyme originating from plants out of the gastro-intestinal tract into blood and lymph of rats,” Zeitschrift fur Gastroenterologie, vol. 17, no. 1, pp. 1–8, 1979.View at: Google Scholar
P. S. Shiew, Y. L. Fang, and F. A. A. Majid, “In vitro study ofbromelain activity inartificial stomach juiceand blood,” in Proceedings of the 3rd International Conference on Biotechnology for the Wellness Industry, PWTC, 2010.View at: Google Scholar
C. Neumayer, A. Fügl, J. Nanobashvili et al., “Combined enzymatic and antioxidative treatment reduces ischemia-reperfusion injury in rabbit skeletal muscle,” Journal of Surgical Research, vol. 133, no. 2, pp. 150–158, 2006.View at: Publisher Site | Google Scholar
World Health Organization, “Cardiovascular diseases,” 2011, http://www.who.int/cardiovascular diseases/en/.View at: Google Scholar
R. M. Heinicke, L. van der Wal, and M. Yokoyama, “Effect of bromelain (Ananase) on human platelet aggregation,” Experientia, vol. 28, no. 10, pp. 844–845, 1972.View at: Publisher Site | Google Scholar
D. E. King, T. M. Ellis, C. J. Everett, and A. G. Mainous, “Medication use for diabetes, hypertension, and hypercholesterolemia from1988–1994 to 2001–2006,” Southern Medical Journal, vol. 102, no. 11, pp. 1127–1132, 2009.View at: Publisher Site | Google Scholar
E. R. Secor Jr., F. C. William, M. C. Michelle et al., “Bromelain exerts anti-inflammatory effects in an ovalbumin-induced murin model of allergic disease,” in Cellular Immunology, vol. 237, pp. 68–75, 2005.View at: Google Scholar
B. Juhasz, M. Thirunavukkarasu, R. Pant et al., “Bromelain induces cardioprotection against ischemia-reperfusion injury through Akt/FOXO pathway in rat myocardium,” American Journal of Physiology, vol. 294, no. 3, pp. H1365–H1370, 2008.View at: Publisher Site | Google Scholar
R. C. Lawrence, C. G. Helmich, F. Arnett et al., “Estimates of prevalence of arthritis and selected musculoskeletal disorders in the United States,” Arthritis & Rheumatism, vol. 41, pp. 778–799, 1998.View at: Google Scholar
N. M. Akhtar, R. Naseer, A. Z. Farooqi, W. Aziz, and M. Nazir, “Oral enzyme combination versus diclofenac in the treatment of osteoarthritis of the knee—a double-blind prospective randomized study,” Clinical Rheumatology, vol. 23, no. 5, pp. 410–415, 2004.View at: Publisher Site | Google Scholar
S. Brien, G. Lewith, A. Walker, S. M. Hicks, and D. Middleton, “Bromelain as a treatment for osteoarthritis: a review of clinical studies,” Evidence-Based Complementary and Alternative Medicine, vol. 1, no. 3, pp. 251–257, 2004.View at: Google Scholar
C. F. Mojcik and E. M. Shevach, “Adhesion molecules: a rheumatologic perspective,” Arthritis and Rheumatism, vol. 40, no. 6, pp. 991–1004, 1997.View at: Publisher Site | Google Scholar
T. Bodi, “The effects of oral bromelains on tissue permeability to antibiotics and pain responseto bradykinin: double blind studies on human subjects,” Clinical Medicine, vol. 73, pp. 61–65, 1966.View at: Google Scholar
S. Kumakura, M. Yamashita, and S. Tsurufuji, “Effect of bromelain on kaolin-induced inflammation in rats,” European Journal of Pharmacology, vol. 150, no. 3, pp. 295–301, 1988.View at: Google Scholar
A. Cohen and J. Goldman, “Bromelain therapy in rheumatoid arthritis,” Pennsylvania Medical Journal, vol. 67, pp. 27–30, 1964.View at: Google Scholar
H. Barth, A. Guseo, and R. Klein, “In vitro study on the immunological effect of bromelain and trypsin on mononuclear cells from humans,” European Journal of Medical Research, vol. 10, no. 8, pp. 325–331, 2005.View at: Google Scholar
L. P. Hale and B. F. Haynes, “Bromelain treatment of human T cells removes CD44, CD45RA, E2/MIC2, CD6, CD7, CD8, and Leu 8/LAM1 surface molecules and markedly enhances CD2-mediated T cell activation,” Journal of Immunology, vol. 149, no. 12, pp. 3809–3816, 1992.View at: Google Scholar
P. V. Lehmann, “Immunomodulation by proteolytic enzymes,” Nephrology Dialysis Transplantation, vol. 11, no. 6, pp. 953–955, 1996.View at: Google Scholar
L. Desser, A. Rehberger, E. Kokron, and W. Paukovits, “Cytokine synthesis in human peripheral blood mononuclear cells after oral administration of polyenzyme preparations,” Oncology, vol. 50, no. 6, pp. 403–407, 1993.View at: Google Scholar
L. Desser, A. Rehberger, and W. Paukovits, “Proteolytic enzymes and amylase induce cytokine production in human peripheral blood mononuclear cells in vitro,” Cancer Biotherapy, vol. 9, no. 3, pp. 253–263, 1994.View at: Google Scholar
K. Eckert, E. Grabowska, R. Stange, U. Schneider, K. Eschmann, and H. R. Maurer, “Effects of oral bromelain administration on the impaired immunocytotoxicity of mononuclear cells from mammary tumor patients,” Oncology Reports, vol. 6, no. 6, pp. 1191–1199, 1999.View at: Google Scholar
C. R. Engwerda, D. Andrew, M. Murphy, and T. L. Mynott, “Bromelain activates murine macrophages and natural killer cells in vitro,” Cellular Immunology, vol. 210, no. 1, pp. 5–10, 2001.View at: Publisher Site | Google Scholar
C. R. Engwerda, D. Andrew, A. Ladhams, and T. L. Mynott, “Bromelain modulates T cell and B cell immune responses in vitro and in vivo,” Cellular Immunology, vol. 210, no. 1, pp. 66–75, 2001.View at: Publisher Site | Google Scholar
T. L. Mynott, A. Ladhams, P. Scarmato, and C. R. Engwerda, “Bromelain, from pineapple stems, proteolytically blocks activation of extracellular regulated kinase-2 in T cells,” Journal of Immunology, vol. 163, no. 5, pp. 2568–2575, 1999.View at: Google Scholar
E. R. Secor Jr., A. Singh, L. A. Guernsey et al., “Bromelain treatment reduces CD25 expression on activated CD4+ T cells in vitro,” International Immunopharmacology, vol. 9, no. 3, pp. 340–346, 2009.View at: Publisher Site | Google Scholar
J. Leipner, F. Iten, and R. Saller, “Therapy with proteolytic enzymes in rheumatic disorders,” BioDrugs, vol. 15, no. 12, pp. 779–789, 2002.View at: Google Scholar
H. Lotz-Winter, “On the pharmacology of bromelain: an update with special regard to animal studies on dose-dependent effects,” Planta Medica, vol. 56, no. 3, pp. 249–253, 1990.View at: Publisher Site | Google Scholar
M. Livio, G. De Gaetano, and M. B. Donati, “Effect of bromelain on fibrinogen level, prothrombin complex factors and platelet aggregation in rat: a preliminary report,” Drugs under Experimental and Clinical Research, vol. 4, pp. 21–23, 1978.View at: Google Scholar
M. De-Guili and F. Pirotta, “Bromelain: interaction with some protease inhibitors and rabbit specific antiserum,” Drugs under Experimental and Clinical Research, vol. 4, pp. 21–23, 1978.View at: Google Scholar
S. J. Taussig and S. Batkin, “Bromelain, the enzyme complex of pineapple (Ananas comosus) and its clinical application: an update,” Journal of Ethnopharmacology, vol. 22, no. 2, pp. 191–203, 1988.View at: Google Scholar
T. L. Mynott, S. Guandalini, F. Raimondi, and A. Fasano, “Bromelain prevents secretion caused by Vibrio cholerae and Escherichia coli enterotoxins in rabbit ileum in vitro,” Gastroenterology, vol. 113, no. 1, pp. 175–184, 1997.View at: Publisher Site | Google Scholar
D. S. Chandler and T. L. Mynott, “Bromelain protects piglets from diarrhoea caused by oral challenge with K88 positive enterotoxigenic Escherichia coli,” Gut, vol. 43, no. 2, pp. 196–202, 1998.View at: Google Scholar
T. L. Mynott, R. K. J. Luke, and D. S. Chandler, “Oral administration of pro tease inhibits enterotoxigenic Escherichia coli receptor activity in piglet small intestine,” Gut, vol. 38, no. 1, pp. 28–32, 1996.View at: Google Scholar
R. Béez, M. T. P. Lopes, C. E. Salas, and M. Hernández, “In vivo antitumoral activity of stem pineapple (Ananas comosus) bromelain,” Planta Medica, vol. 73, no. 13, pp. 1377–1383, 2007.View at: Publisher Site | Google Scholar
S. J. Taussig, J. Szekerczes, and S. Batkin, “Inhibition of tumour growth in vitro by bromelain, an extract of the pineapple plant (Ananas comosus),” Planta Medica, vol. 6, pp. 538–539, 1985.View at: Google Scholar
B. B. Tysnes, H. R. Maurer, T. Porwol, B. Probst, R. Bjerkvig, and F. Hoover, “Bromelain reversibly inhibits invasive properties of glioma cells,” Neoplasia, vol. 3, no. 6, pp. 469–479, 2001.View at: Publisher Site | Google Scholar
A. Mantovani, P. Allavena, A. Sica, and F. Balkwill, “Cancer-related inflammation,” Nature, vol. 454, no. 7203, pp. 436–444, 2008.View at: Publisher Site | Google Scholar
R. L. Ferris and J. R. Grandis, “NF-κB gene signatures and p53 mutations in head and neck squamous cell carcinoma,” Clinical Cancer Research, vol. 13, no. 19, pp. 5663–5664, 2007.View at: Publisher Site | Google Scholar
S. P. Hussain and C. C. Harris, “Inflammation and cancer: an ancient link with novel potentials,” International Journal of Cancer, vol. 121, no. 11, pp. 2373–2380, 2007.View at: Publisher Site | Google Scholar
M. T. Wang, K. V. Honn, and D. Nie, “Cyclooxygenases, prostanoids, and tumor progression,” Cancer and Metastasis Reviews, vol. 26, no. 3-4, pp. 525–534, 2007.View at: Publisher Site | Google Scholar
K. Bhui, S. Prasad, J. George, and Y. Shukla, “Bromelain inhibits COX-2 expression by blocking the activation of MAPK regulated NF-kappa B against skin tumor-initiation triggering mitochondrial death pathway,” Cancer Letters, vol. 282, no. 2, pp. 167–176, 2009.View at: Publisher Site | Google Scholar
J. R. Huang, C. C. Wu, R. C. W. Hou, and K. C. Jeng, “Bromelain inhibits lipopolysaccharide-induced cytokine production in human THP-1 monocytes via the removal of CD14,” Immunological Investigations, vol. 37, no. 4, pp. 263–277, 2008.View at: Publisher Site | Google Scholar
R. C. W. Hou, Y. S. Chen, J. R. Huang, and K. C. G. Jeng, “Cross-linked bromelain inhibits lipopolysaccharide-induced cytokine production involving cellular signaling suppression in rats,” Journal of Agricultural and Food Chemistry, vol. 54, no. 6, pp. 2193–2198, 2006.View at: Publisher Site | Google Scholar
G. C. Tassman, J. N. Zafran, and G. M. Zayon, “Evaluation of a plate proteolytic enzyme for the control of inflammation and pain,” Journal of Dental Medicine, vol. 19, pp. 73–77, 1964.View at: Google Scholar
G. C. Tassman, J. N. Zafran, and G. M. Zayon, “A double-blind crossover study of a plant proteolytic enzyme in oral surgery,” The Journal of Dental Medicine, vol. 20, pp. 51–54, 1965.View at: Google Scholar
R. C. L. Howat and G. D. Lewis, “The effect of bromelain therapy on episiotomy wounds—a double blind controlled clinical trial,” Journal of Obstetrics and Gynaecology of the British Commonwealth, vol. 79, no. 10, pp. 951–953, 1972.View at: Google Scholar
J. C. Houck, C. M. Chang, and G. Klein, “Isolation of an effective debriding agent from the stems of pineapple plants,” International Journal of Tissue Reactions, vol. 5, no. 2, pp. 125–134, 1983.View at: Google Scholar
L. Rosenberg, Y. Krieher, E. Silverstain et al., Selectivity of a Bromelain Based Enzymatic Debridement Agent: A Porcine Study, Elsevier, 2012.
A. J. Singer, S. A. McClain, B. R. Taira, J. Rooney, N. Steinhauff, and L. Rosenberg, “Rapid and selective enzymatic debridement of porcine comb burns with bromelain-derived Debrase: acute-phase preservation of noninjured tissue and zone of stasis,” Journal of Burn Care and Research, vol. 31, no. 2, pp. 304–309, 2010.View at: Publisher Site | Google Scholar
S. Y. Wu, W. Hu, B. Zhang, S. Liu, J. M. Wang, and A. M. Wang, “Bromelain ameliorates the wound microenvironment and improves the healing of firearm wounds,” Journal of Surgical Research, vol. 176, pp. 503–509, 2012.View at: Google Scholar
W. Hu, A. M. Wang, S. Y. Wu et al., “Debriding effect of bromelain on firearm wounds in pigs,” The Journal of Trauma, vol. 71, no. 4, pp. 966–972, 2011.View at: Publisher Site | Google Scholar
J. G. Miller, H. R. Carruthers, and D. A. R. Burd, “An algorithmic approach to the management of cutaneous burns,” Burns, vol. 18, no. 3, pp. 200–211, 1992.View at: Publisher Site | Google Scholar
R. L. Sheridan, R. G. Tompkins, and J. F. Burke, “Management of burn wounds with prompt excision and immediate closure,” Journal of Intensive Care Medicine, vol. 237, pp. 68–75, 1994.View at: Google Scholar
R. E. Salisbury, “In-thermal burns,” in Plastic Surgery, J. C. McCarthy, Ed., vol. 1, pp. 787–830, 1990.View at: Google Scholar
S. J. Taussig, M. M. Yokoyama, and A. Chinen, “Bromelain: a proteolytic enzyme and its clinical application: a review,” Hiroshima Journal of Medical Sciences, vol. 24, no. 2-3, pp. 185–193, 1975.View at: Google Scholar
I. N. Moss, C. V. Frazier, and G. J. Martin, “Bromelain -the pharmacology of the enzyme,” Archives of International Pharmacody, vol. 145, pp. 166–189, 1963.View at: Google Scholar