Gotu Kola for Venous Insufficiency and Circulation

Heavy, aching legs that swell by evening. Ankles that leave a sock mark. A dull throb after a day standing at work, relieved by putting your feet up. That cluster is chronic venous insufficiency, and it is the second of gotu kola’s two evidence-backed uses — the one where the standardised extract was studied hardest, by a small number of European research groups, mostly between 1987 and 2001.

That date range is the whole story of this article. The evidence is real, it is measured with objective instruments rather than opinion, and it is old, small, concentrated in a handful of laboratories, and published substantially in a single sponsored journal supplement. All of that is knowable from the papers themselves, and all of it is left out of supplement copy. Here it is in full.

What Chronic Venous Insufficiency Actually Is
Why a Connective-Tissue Herb Was Tried Here
TTFCA and the Doses Actually Studied
The 1987 Multicentre Trial
The Italian Microcirculation Programme
What the 2013 Systematic Review Concluded
Flight Oedema and Diabetic Microangiopathy
The Honest Limitations
Where It Fits Beside Compression
Practical Use
Cautions and Red Flags
Key Research Papers
Connections

What Chronic Venous Insufficiency Actually Is

Leg veins have to move blood uphill. They manage it because the calf muscles squeeze them with every step and one-way valves stop the blood falling back between squeezes. When those valves leak — from age, pregnancy, genetics, prolonged standing, obesity or a previous clot — blood pools in the lower leg and the pressure inside the veins stays high even when you are walking. That sustained pressure is called venous hypertension, and it is what does the damage.

High pressure pushes fluid out of the capillaries into the tissue faster than the lymphatics can clear it. That is the swelling. Over years the leaked fluid carries proteins and red cells with it, and the skin around the ankle becomes discoloured, thickened and fragile — and eventually, in some people, ulcerates.

The clinical stages run roughly: telangiectasia and spider veins, then varicose veins, then oedema, then skin changes (pigmentation, eczema, lipodermatosclerosis), then healed ulcer, then active ulcer. Gotu kola has been studied at the early and middle end of that ladder — symptoms, oedema and capillary leak. It has not been shown to heal ulcers or to prevent progression to them.

Why a Connective-Tissue Herb Was Tried Here

The rationale is the same chemistry that underlies the wound-healing use, pointed at a different tissue. A vein wall is largely connective tissue — collagen, elastin and the cells that maintain them. A capillary wall is a single layer of endothelium sitting on a basement membrane. If a compound modulates fibroblast behaviour, collagen synthesis and endothelial integrity, then a leaky, distensible, chronically stretched vein is a reasonable place to test it.

The specific claims made for the triterpenic fraction in this setting are that it improves the tone and reduces the distensibility of the vein wall, and that it reduces the abnormal permeability of the capillaries in the affected skin. Both were tested with instruments rather than questionnaires, which is the strongest single feature of this literature.

TTFCA and the Doses Actually Studied

The venous trials used the standardised fraction, referred to as TTFCA (total triterpenic fraction of Centella asiatica) or TECA (titrated extract). It is not dried leaf and not a tea.

Study	Regimen	Daily total	Duration
Pointel 1987	Two arms versus placebo	60 mg and 120 mg	2 months
Belcaro 1990	60 mg three times daily	180 mg	2 weeks
De Sanctis 2001	30 mg or 60 mg three times daily	90 mg and 180 mg	4 weeks
Incandela 2001 (venous)	Two dose levels versus placebo	60 mg and 120 mg	Short term
Cesarone 2001 (flights)	60 mg three times daily	180 mg	2 days before, day of, 1 day after flight
Incandela 2001 (diabetic)	60 mg twice daily	120 mg	12 months

So the studied range is roughly 60 to 180 mg of the triterpenic fraction per day, in two or three divided doses, for periods from a few days to a year. Where dose-ranging was done, higher doses generally did more: De Sanctis and colleagues concluded that 180 mg/day beat 90 mg/day, and Incandela and colleagues distinguished 120 mg/day from 60 mg/day on objective measures.

The 1987 Multicentre Trial

The most conventionally designed study in the set is also the oldest. Pointel and colleagues, publishing in Angiology in 1987, enrolled 94 patients with venous insufficiency of the lower limbs into a multicentre, double-blind, placebo-controlled trial. After randomisation they received TECA 120 mg/day, TECA 60 mg/day, or placebo for two months.

Findings:

Significant benefit (p < 0.05) for TECA over placebo on heaviness in the legs and oedema, and on the patient’s own overall assessment.
Venous distensibility, measured with a mercury strain-gauge plethysmograph at three occlusion pressures, improved in both TECA groups — and worsened in the placebo group over the same two months.

That last detail is worth pausing on. The instrument result was not merely “treated group better” but “treated group improved while untreated group deteriorated”, over a period long enough for natural progression to show. It is the single most persuasive piece of data in the gotu kola venous literature. It is also thirty-nine years old, with roughly thirty patients per arm, reported in an abstract that does not describe the randomisation or blinding procedure in any detail.

The Italian Microcirculation Programme

Nearly everything else comes from one interconnected research effort centred on Gianni Belcaro, Maria Rosaria Cesarone, Maria Teresa De Sanctis and Luciano Incandela, working between the G. D’Annunzio University in Chieti, Italy and the Irvine Vascular Laboratory at St Mary’s Hospital, London. Their contribution was methodological: instead of asking patients whether their legs felt better, they built a battery of microcirculatory measurements.

The instruments, in plain terms

Capillary filtration rate (CFR) — how fast fluid leaks out of the capillaries into the tissue, measured by venous occlusion plethysmography. Higher means leakier.
Rate of ankle swelling (RAS) — how quickly the ankle enlarges over a standardised period. A direct proxy for oedema formation.
Laser Doppler flowmetry — skin blood flux at rest, plus the venoarteriolar response, a reflex that should shut down skin flow when you stand. In venous disease that reflex is blunted.
Transcutaneous PO₂ and PCO₂ — oxygen and carbon dioxide measured through the skin. Poor microcirculation shows as falling oxygen and rising carbon dioxide.
Vacuum suction chamber (VSC) — raises a small wheal on the skin near the ankle and times how long it takes to disappear. Longer means more capillary leak.

What they reported

Belcaro 1990 used the VSC device with laser Doppler in 10 normal subjects, 22 patients with moderate superficial venous hypertension and 12 with post-phlebitic limbs and severe venous hypertension. Each was observed for two weeks untreated, then treated for two weeks with TTFCA 60 mg three times daily. Wheal disappearance time was longer in the patients than the controls at baseline, unchanged over the untreated fortnight, and significantly shorter after treatment — alongside improvement in microcirculatory measures and symptoms. The untreated run-in period is a genuine strength: it shows the change tracked the drug rather than the passage of time.

De Sanctis 2001 was a dose-ranging, placebo-controlled study: 20 patients on 180 mg/day, 20 on 90 mg/day, 12 on placebo, and 10 healthy subjects also given 180 mg/day as a reference. After four weeks, capillary filtration rate, ankle circumference and ankle-swelling time all fell significantly in the treated patients, more so at the higher dose. Nothing changed on placebo — and, notably, nothing changed in the healthy subjects taking the drug, which is what you would expect if the effect depends on abnormal capillary leak being present in the first place.

Incandela 2001 combined laser Doppler with transcutaneous gas measurements in patients with venous hypertensive microangiopathy, and found that the whole battery separated 120 mg/day from 60 mg/day from placebo, with symptom scores moving in parallel with the instrument readings.

Cesarone 1994, published in Italian in Minerva Cardioangiologica, was an earlier double-blind study of microcirculatory activity in venous insufficiency from the same group.

What the 2013 Systematic Review Concluded

Chong and Aziz at the University of Malaya searched thirteen electronic databases including the Cochrane Central Register for randomised trials of Centella asiatica in chronic venous insufficiency. Eight studies met inclusion criteria, and two authors independently extracted data.

Their findings:

Pooling comparable studies showed significant improvement in microcirculatory parameters — transcutaneous PCO₂ and PO₂, rate of ankle swelling, and venoarteriolar response.
Three of the eight studies reported no quantitative data at all, describing improvement in leg heaviness, pain and oedema without numbers to pool.
Their stated conclusion: Centella asiatica may be beneficial for signs and symptoms of chronic venous insufficiency, but this “needs to be interpreted with caution as most of the studies were characterised by inadequate reporting and thus had unclear risks of bias, which may threaten the validity of the conclusions”.

That is a fair verdict and worth reading twice. The direction of effect is consistent. The quality of the underlying reports is not good enough to be confident about the size of it.

Flight Oedema and Diabetic Microangiopathy

The same group extended TTFCA into two adjacent problems.

Flight-related leg swelling. Cesarone and colleagues studied passengers aged 30–50 with mild-to-moderate superficial venous disease and varicose veins, travelling in economy class on flights longer than three hours. The treated group took TTFCA 60 mg three times daily for two days before the flight, on the day itself, and for one day after. In untreated controls, carbon dioxide, rate of ankle swelling and oedema score rose progressively with flight time while skin flux and the venoarteriolar response fell. In the TTFCA group the changes were milder, and ankle swelling and oedema were significantly lower (p < 0.025). Note that the control group received no treatment at all — there was no placebo, so expectation effects are uncontrolled.

Diabetic microangiopathy. Incandela and colleagues ran a twelve-month placebo-controlled study of TTFCA 60 mg twice daily in patients with diabetic microangiopathy, with and without neuropathy, alongside healthy controls. Resting flux and rate of ankle swelling fell in the treated groups, with a corresponding decrease in oedema; untreated patients deteriorated progressively over the year while healthy subjects did not change. A companion paper from the same programme evaluated the same question with the microcirculatory model. Twelve months is a long study for a botanical, and progressive deterioration in the placebo arm is a meaningful comparator.

The same laboratory also published a study on the echogenicity of carotid plaques after TTFCA in the same 2001 supplement, which gives a sense of how broadly the group was testing this single compound.

The Honest Limitations

Five, in order of importance.

One research programme dominates the evidence. A large share of the trials share overlapping authors, a shared laboratory, and shared methods. Independent replication by unconnected groups is what converts a promising finding into an established one, and it has largely not happened here.
Much of it appeared in a single journal supplement. Angiology volume 52, supplement 2, October 2001, carries a run of TTFCA papers back to back. Supplement issues are frequently sponsored and are not always subject to the same peer review as the parent journal. This does not make the data false. It does mean they should carry less weight than the same results in a regular issue.
The endpoints are mostly surrogates. Capillary filtration rate and transcutaneous gas tensions are legitimate physiological measures, and better than a satisfaction score — but no trial shows that treating them with gotu kola prevents a venous ulcer, prevents progression, or reduces the need for a procedure. Those are the outcomes patients actually care about.
The studies are small and short. Arms of 12 to 30 patients. Durations of two to eight weeks, with one twelve-month exception. Nothing here is a modern multicentre trial.
Reporting quality is poor by current standards. The systematic reviewers said so directly, and three of eight trials could not even be pooled for want of numbers.

Where It Fits Beside Compression

Compression is the foundation of venous care, and nothing displaces it. Graduated compression stockings work by external mechanics: they oppose the pressure driving fluid out of the capillaries. Calf-muscle activity, leg elevation, and weight management do the same job from other directions. For varicose veins with symptoms, endovenous ablation and related procedures treat the underlying reflux.

Venoactive drugs — the class gotu kola belongs to — are adjuncts to that, not substitutes. The class also includes micronised purified flavonoid fraction (diosmin and hesperidin), horse chestnut seed extract, ruscus preparations and hydroxyethylrutosides. Some of those have a larger trial base than gotu kola does.

Measure	Realistic expectation from TTFCA
Leg heaviness and aching	Modest improvement, seen in trials
Ankle and leg swelling	Measurable reduction at 90–180 mg/day
Capillary leak measures	Consistently improved in instrumented studies
Visible varicose veins	No evidence of change
Preventing ulcers or progression	Not demonstrated
Replacing compression	No — nothing supports this

Practical Use

Get the right product. Look for a stated triterpene standardisation or the words “titrated extract”. Unstandardised dried-leaf capsules were not what any of these trials used, and their triterpene content is unknown.
Dose in the studied range. 60–180 mg/day of the triterpenic fraction, split into two or three doses with food. Most trials sat at 120–180 mg/day.
Give it four to eight weeks. The instrumented changes appeared over two to four weeks; symptom change generally lags.
Do not run it indefinitely. The liver case reports involved 20–60 days of continuous oral use. Time-limited courses with breaks are the sensible pattern, and are also how it has traditionally been taken.
Keep doing the things that actually work. Stockings, walking, elevating the legs above heart level for periods each day, and weight management outperform any capsule.
For long flights, the studied regimen started two days before travel. Hydration, an aisle seat, calf exercises and compression socks have better support.

Cautions and Red Flags

See a doctor urgently for one-sided leg swelling, especially with calf pain, warmth or redness, or with breathlessness or chest pain. That is a possible deep vein thrombosis or pulmonary embolism and it is a medical emergency, not a herb problem.
A leg ulcer needs proper wound care and vascular assessment. No botanical substitutes for compression bandaging and an ankle-brachial pressure index.
New or rapidly worsening swelling in both legs can reflect heart, kidney or liver disease, or a drug side effect (calcium channel blockers are a common culprit). That deserves a diagnosis before a supplement.
Liver. Rare hepatotoxicity has been reported with oral Centella asiatica — see the forms and safety article. Avoid if you have liver disease; stop for unexplained fatigue, nausea, dark urine or jaundice.
Pregnancy and breastfeeding. Avoid oral use. Pregnancy-related leg swelling is common and should be assessed by your maternity team, not self-treated.
Sedation and surgery. Possible additive effect with alcohol, sedatives and anaesthesia; stop about two weeks before planned surgery.
Diabetes medication. If you use gotu kola for diabetic microangiopathy, keep monitoring glucose and tell your prescriber. It is an add-on to diabetes care, never a replacement.

Key Research Papers

Chong NJ, Aziz Z. A systematic review of the efficacy of Centella asiatica for improvement of the signs and symptoms of chronic venous insufficiency. Evidence-Based Complementary and Alternative Medicine. 2013;2013:627182. Eight trials; benefit on microcirculatory parameters; unclear risk of bias throughout.
Pointel JP, Boccalon H, Cloarec M, Ledevehat C, Joubert M. Titrated extract of Centella asiatica (TECA) in the treatment of venous insufficiency of the lower limbs. Angiology. 1987;38(1 Pt 1):46–50. 94 patients, multicentre, double-blind, 60 and 120 mg/day versus placebo.
Belcaro GV, Grimaldi R, Guidi G. Improvement of capillary permeability in patients with venous hypertension after treatment with TTFCA. Angiology. 1990;41(7):533–540. Vacuum suction chamber study with a two-week untreated run-in.
De Sanctis MT, Belcaro G, Incandela L, Cesarone MR, Griffin M, Ippolito E, et al. Treatment of edema and increased capillary filtration in venous hypertension with total triterpenic fraction of Centella asiatica: a clinical, prospective, placebo-controlled, randomized, dose-ranging trial. Angiology. 2001;52(Suppl 2):S55–S59. 180 mg/day outperformed 90 mg/day.
Incandela L, Belcaro G, De Sanctis MT, Cesarone MR, Griffin M, Ippolito E, et al. Total triterpenic fraction of Centella asiatica in the treatment of venous hypertension: a clinical, prospective, randomized trial using a combined microcirculatory model. Angiology. 2001;52(Suppl 2):S61–S67.
Cesarone MR, Laurora G, De Sanctis MT, Incandela L, Grimaldi R, Marelli C, et al. [The microcirculatory activity of Centella asiatica in venous insufficiency. A double-blind study.] Minerva Cardioangiologica. 1994;42(6):299–304. In Italian.
Cesarone MR, Incandela L, De Sanctis MT, Belcaro G, Geroulakos G, Griffin M, et al. Flight microangiopathy in medium- to long-distance flights: prevention of edema and microcirculation alterations with total triterpenic fraction of Centella asiatica. Angiology. 2001;52(Suppl 2):S33–S37. No placebo arm — controls were untreated.
Incandela L, Belcaro G, Cesarone MR, De Sanctis MT, Nargi E, Patricelli P, et al. Treatment of diabetic microangiopathy and edema with total triterpenic fraction of Centella asiatica: a prospective, placebo-controlled randomized study. Angiology. 2001;52(Suppl 2):S27–S31. Twelve months, 120 mg/day.
Cesarone MR, Incandela L, De Sanctis MT, Belcaro G, Bavera P, Bucci M, et al. Evaluation of treatment of diabetic microangiopathy with total triterpenic fraction of Centella asiatica: a clinical prospective randomized trial with a microcirculatory model. Angiology. 2001;52(Suppl 2):S49–S54.
Cesarone MR, Belcaro G, Nicolaides AN, Geroulakos G, Bucci M, Dugall M, et al. Increase in echogenicity of echolucent carotid plaques after treatment with total triterpenic fraction of Centella asiatica: a prospective, placebo-controlled, randomized trial. Angiology. 2001;52(Suppl 2):S19–S25. Included to show the breadth of the same programme, not as evidence of cardiovascular benefit.
Grimaldi R, De Ponti F, D’Angelo L, Caravaggi M, Guidi G, Lecchini S, et al. Pharmacokinetics of the total triterpenic fraction of Centella asiatica after single and multiple administrations to healthy volunteers. A new assay for asiatic acid. Journal of Ethnopharmacology. 1990;28(2):235–241. Confirms oral absorption.
Brinkhaus B, Lindner M, Schuppan D, Hahn EG. Chemical, pharmacological and clinical profile of the East Asian medical plant Centella asiatica. Phytomedicine. 2000;7(5):427–448. Reviews the venous literature as it stood in 2000.

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