Star Fruit

Generic name: Averrhoa Carambola L.
Brand names: Belimbing, Blimbing, Carambolo, Chinese Gooseberry, Kamaranga, Kamrakh, Kamranga, Star Fruit, Starfruit, Tamarindo, Thambaratham

Usage of Star Fruit

Analgesic effects

Animal data

In a mouse pain model, intraperitoneally administered star fruit extract inhibited both neurogenic pain and inflammatory responses. Antinociceptive effects appeared to be secondary to anti-inflammatory effects; reductions in paw edema observed with polysaccharides extracted from star fruit were similar to those with the positive controls meloxicam and indomethacin.(Leivas 2016)

Anti-inflammatory effects

Clinical data

In 29 healthy subjects (mean age, 72.4 years; range, 54 to 87 years) who consumed fresh star fruit juice 100 g twice daily for 4 weeks, significant reductions in some proinflammatory cytokines (ie, tumor necrosis factor alpha [TNF-alpha], interleukin 23) and nitric oxide (NO) were observed (P<0.001 for each vs weeks 0 and 2 of the control period).(Leelarungrayub 2016a)

Antioxidant effects

Clinical data

A preliminary study conducted in 27 Thai subjects (mean age, 69.5 years; range, 56 to 85 years) receiving fresh star fruit juice 100 g twice daily for 4 weeks demonstrated significant improvements in 3 of 4 oxidative stress parameters (ie, total antioxidant capacity, malondialdehyde, protein hydroperoxide; P<0.05 for each). Additionally, star fruit juice consumption led to significant increases in serum levels of vitamins C and A, but not E (P<0.05 each).(Leelarungrayube 2016b)

Exercise capacity

Clinical data

In 29 healthy subjects (mean age, 72.4 years; range, 54 to 87 years) consuming fresh star fruit juice 100 g twice daily for 4 weeks, a significant increase in exercise capacity (6-minute walking distance) was observed at week 6 (P<0.0001 vs weeks 0 and 2). Levels of TNF-alpha were negatively correlated to exercise capacity, while a positive correlation was seen with NO levels (P=0.027 and P=0.004, respectively).(Leelarungrayub 2016a)

Fluoride toxicity

Animal data

Fluoride-induced carbohydrate, hepatic, lipid, and antioxidant alterations in rats were improved or ameliorated in a dose-dependent manner with oral administration of star fruit powder.(Vasant 2014)

Lipid effects

Clinical data

In 27 Thai subjects (mean age, 69.5 years; range, 56 to 85 years) who consumed fresh star fruit juice 100 g twice daily for 4 weeks, significant improvements in high-density lipoprotein and low-density lipoprotein cholesterol were observed (P=0.03 and P=0.02, respectively, vs weeks 0 and 2). Changes in triglycerides and total cholesterol were not significant.(Leelarungrayube 2016b)

Star Fruit side effects

A case of oral allergy syndrome (itching/burning sensation in lips, mouth, and ear canal) was reported in a Japanese female pastry chef within 15 minutes of consuming star fruit. Her medical history was positive for severe atopic dermatitis, pollinosis to cedar and cypress, and mild asthma. She had previously demonstrated a similar reaction after eating kiwi and papaya. Skin sensitization to star fruit via atopic skin was suspected. Immunoblotting testing revealed no cross-reactivity of star fruit to cedar, cypress, kiwi, or papaya.(Numata 2015)

A case of anaphylactic shock to star fruit was reported in a 58-year-old male within minutes of eating 4 pieces of star fruit for the first time. His medical history was negative for other food reactions and anaphylaxis. The subject cared for racing pigeons as a hobby; immunoblot assays revealed cross-reactivity of star fruit proteins to seed proteins in pigeon feed. Sensitization to star fruit via routine handling of birdseed was suspected.(Vazquez-Revuelta 2021)

A case series included adults with and without comorbidities who presented to the hospital with acute renal injury after consuming 3 to 6 starfruits. Symptoms most commonly reported following acute star fruit intoxication were nausea, vomiting, and abdominal/back pain, with a subsequent reduction in urine output and increased serum creatinine levels over hours to days. Nephrotoxicity was determined to be due to tubular obstruction by calcium oxalate crystals. Urinalysis for all 4 patients demonstrated oxalate crystals. Compared to "sweet" starfruit, the "sour" starfruit is known to contain more oxalate. All patients recovered within 1 month of discharge.(Herath 2021)

Before taking Star Fruit

Avoid use. Information regarding safety and efficacy in pregnancy and lactation is lacking.

How to use Star Fruit

200 g/day of fresh star fruit juice (in 2 divided doses) for 4 weeks has been used in clinical trials.(Leelarungrayub 2016a, Leelarungrayub 2016b)

Warnings

Symptoms of star fruit poisoning are thought to be a result of excessive stimulation of the GABAergic system and include hiccups, altered consciousness, confusion, incoherent speech, vomiting, psychomotor agitation, insomnia, paresthesias, muscle weakness, epileptic seizures, hypotension, shock, coma, and death.(Aranguren 2017) Neurological presentation may mimic, and be misinterpreted as, a stroke.(Alessio-Alves 2012)

Nephrotoxicity and neurotoxicity have been described in several studies and have been attributed mostly to the star fruit components caramboxin and oxalic acid. Caramboxin is a renally excreted neurotoxin that crosses the blood-brain barrier, whereas oxalate causes direct corrosive injury to the GI tract and subsequently obstructs renal tubules via formation of oxalate crystals.(Aranguren 2017, Stumpf 2020) A systematic review analyzed 123 cases of nephrotoxicity related to star fruit intoxication; 80% occurred in patients with CKD, of whom 27 died. In the remaining 20% of patients with previously normal renal function, consumption was associated with acute nephropathy; 1 patient died, 3 developed CKD, and 2 became dialysis dependent. Neurological symptoms were reported to be more severe in patients with preexisting CKD.(Aranguren 2017)

Treatment depends on clinical presentation, with hemodialysis the most reasonable approach, particularly when neurological symptoms are present. Little evidence supports the use of more conservative treatments (ie, prednisolone, urinary alkalization, diuretic therapy), and peritoneal dialysis does not appear to be effective in more severe intoxications.(Stumpf 2020) Animal studies suggest that administration of N-acetyl cysteine can attenuate star fruit–induced renal dysfunction, possibly via reduction of oxidative stress and normalization of redox status.(Shimizu 2017)

What other drugs will affect Star Fruit

Inhibition of CYP3A enzymes has been demonstrated in in vitro and in vivo studies.(Vasant 2014)

Bosutinib: Star fruit may increase the serum concentration of bosutinib. Avoid combination.(Bosulif November 2014, Bosulif July 2015, Hidaka 2004, Hidaka 2006, Zhang 2007)

Panobinostat: Star fruit may increase the serum concentration of panobinostat. Avoid combination.(Farydak February 2015, Hidaka 2004, Hidaka 2006, Zhang 2007)

Venetoclax: Star fruit may increase the serum concentration of venetoclax. Avoid combination.(Venclexta April 2016)

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