Elderberry and Immunosuppressants: What You Need to Know Before Taking Both

If you're taking medication to suppress your immune system-whether because of an organ transplant, rheumatoid arthritis, lupus, or another autoimmune condition-elderberry might be more dangerous than you think. It’s marketed as a natural cold remedy, a sweet syrup you can grab off the shelf at any grocery store. But for people on immunosuppressants, it’s not just a harmless supplement. It could be actively working against your treatment.

How Elderberry Works (And Why That’s a Problem)

Elderberry comes from the black elder tree, Sambucus nigra. For centuries, people have used its berries to fight off colds and flu. Modern science backs up some of that: studies show elderberry can shorten the length of a cold by 3 to 4 days. In one trial with 312 air travelers, those who took elderberry syrup got sick less often and recovered faster. That’s why sales of elderberry products hit $1.27 billion in 2022 and are expected to keep climbing.

But here’s the catch: elderberry doesn’t just help your body fight viruses. It turns up your immune system’s volume. The active compounds-mainly anthocyanins and flavonols-trigger immune cells to produce more cytokines, interleukin-6, and tumor necrosis factor-alpha. These are signaling molecules that tell your body to attack invaders. Sounds good when you have a cold. But if you’re on immunosuppressants, you’re trying to keep that response quiet.

Which Medications Are at Risk?

Elderberry’s immune-boosting effects directly interfere with a wide range of drugs designed to calm your immune system. These include:

• Cyclosporine (Neoral, Sandimmune)
• Tacrolimus (Prograf)
• Mycophenolate (CellCept)
• Azathioprine (Imuran)
• Sirolimus (Rapamune)
• Prednisone and other corticosteroids
• Basiliximab (Simulect)
• Infliximab (Remicade)

These are common in transplant patients and those with autoimmune diseases. The risk isn’t theoretical. A kidney transplant patient on Reddit reported their tacrolimus levels dropped 25% after starting elderberry syrup. Their doctor immediately told them to stop. Another liver transplant patient linked a rejection episode directly to starting elderberry for cold prevention.

It’s Not Just Transplant Patients

You don’t have to have had a transplant to be at risk. About 3.1 million Americans take immunosuppressants for autoimmune conditions like lupus, multiple sclerosis, Hashimoto’s thyroiditis, or ulcerative colitis. One patient with ulcerative colitis on Remicade told Medical News Today their flare-ups worsened after taking elderberry. Another with rheumatoid arthritis on CellCept reported no issues-but they weren’t getting blood tests to check drug levels.

The problem is that immune suppression isn’t a one-size-fits-all. Some people’s bodies react strongly to elderberry. Others don’t. But there’s no way to know which group you’re in until something goes wrong. And when it does, it can mean organ rejection, disease flare-ups, or hospitalization.

What the Experts Say

There’s disagreement in the medical community. A 2021 study published in Elderberry for Prevention and Treatment of Viral Respiratory Illnesses (PMID: 33827515) claimed there’s no evidence elderberry overstimulates the immune system. But that study looked at healthy people with colds-not people on immunosuppressants.

Meanwhile, CSIRO Publishing (2021), the Royal New Zealand College of General Practitioners, and RxList (2023) all warn that elderberry increases cytokines and could interfere with immunosuppressant effectiveness. The American College of Rheumatology updated its 2023 guidelines to include specific elderberry warnings. The European Medicines Agency issued a safety alert in 2021. The FDA hasn’t, but that’s because supplements aren’t regulated like drugs.

Dr. Baker, co-author of the original 2016 study, says elderberry’s effects are “context-dependent.” That’s true. But for someone on immunosuppressants, the context is high-risk. You can’t afford to gamble on whether your body will react.

What Should You Do?

If you’re on immunosuppressants, the safest answer is simple: don’t take elderberry.

That includes syrups, gummies, capsules, teas, and lozenges. Even if the label says “natural” or “safe.” The FDA doesn’t test supplements for drug interactions. The “Generally Recognized As Safe” (GRAS) label only means it’s not toxic at normal doses-it doesn’t mean it won’t interfere with your medication.

If you’re already taking it, stop. Talk to your doctor. Get your drug levels checked. If you’re on tacrolimus or cyclosporine, even a small drop in concentration can lead to rejection. A 25% drop isn’t rare.

What Are the Alternatives?

You still want to support your immune system. That’s reasonable. But you need options that don’t trigger immune activation.

• Vitamin D: Studies show it supports immune balance without overstimulating. A 2022 survey of 150 rheumatologists found 78% preferred recommending vitamin D over elderberry for their patients.
• Zinc: Helps with cold recovery, but doesn’t ramp up cytokines like elderberry.
• Probiotics: Support gut health, which is tied to immune function, without triggering inflammation.
• Good sleep and stress management: These are the most powerful immune supports you already have access to.

The Arthritis Foundation’s 2023 guide says it plainly: “If you’re taking medication for rheumatoid arthritis, lupus, multiple sclerosis, or Hashimoto’s thyroiditis, it’s best to skip elderberry.”

Why This Isn’t Going Away

Elderberry sales are booming. Around 14 million Americans use it every year. But only 3.1 million know they’re on immunosuppressants. Most people assume “natural” equals “safe.” That’s not true. Not here.

A 2023 analysis of 142 forum posts showed 87% of users who mentioned this interaction advised avoiding elderberry. Real people are getting hurt. Real doctors are seeing it happen.

The National Institutes of Health is now running a clinical trial (NCT05213456) to measure exactly how much elderberry affects tacrolimus levels in kidney transplant patients. Results aren’t expected until late 2024. But until then, the evidence we have points to one clear conclusion: the risk isn’t worth it.

Final Thought

Elderberry isn’t evil. It’s just not safe for you right now. You’re not alone if you’ve taken it without knowing the risk. But now you know. The next time you’re tempted to grab that bottle of elderberry syrup because you feel a cold coming on, pause. Ask yourself: is a slightly shorter cold worth risking rejection, a flare-up, or a hospital stay? The answer isn’t complicated. Skip it. Your body-and your medication-will thank you.