Authors' objectives: BACKGROUND The herbal drug preparation ginkgo biloba is thought to reduce inflammation and improve cerebral blood flow; it is also thought to have antioxidant and neuroprotective effects. In Switzerland, ginkgo-based medicinal products (doses 120 mg to 240 mg) have been approved and are reimbursed for adults with mental performance deficits (MPD), peripheral arterial occlusive disease (PAOD), vertigo, and tinnitus. However, some studies have reported conflicting results regarding the effectiveness of this therapy. Within the context of the Federal Office of Public Health (FOPH) Health Technology Assessment (HTA) Program, the evidence for these coverage decisions is to be re-evaluated. OBJECTIVE This HTA report assesses the efficacy, safety, cost-effectiveness, and budget impact, as well as ethical, legal, social, and organisational (ELSO) benefits and harms of ginkgo biloba for the indications as described above in Switzerland.

Authors' results and conclusions: A total of 42 RCTs were included in the clinical SLR on the efficacy and safety of ginkgo biloba in MPD (k=28), PAOD (k=8), vertigo (k=2), and tinnitus (k=4). All results are reported as mean difference (MD) or relative risk (RR) with 95% confidence intervals (CIs). Efficacy and safety Mental performance deficits In patients with MPD, there was a statistically significant and clinically meaningful difference between 24 weeks of treatment with either 240 mg ginkgo biloba or placebo in cognitive function assessed with Syndrom-Kurz-Test (SKT) scores (MD -2.32 [95% CI -3.82 to -0.83]; 4 RCTs; 1’406 patients; moderate certainty evidence; MCID 2 points). After 24 weeks of treatment with 240 mg ginkgo biloba or placebo, there was a statistically significant and clinically meaningful difference in favour of ginkgo biloba in the Neuropsychiatric Inventory (NPI) Composite Total Score (MD -4.03 [95% CI -7.32 to -0.74]; 4 RCTs; 1’360 patients; moderate certainty evidence; MCID 4 points). In addition, 24 weeks of treatment with 240 mg ginkgo biloba was statistically significantly better than placebo in functioning assessed using the Alzheimer’s Disease Activities of Daily Living International Scale (ADL-IS) score (MD -0.17 [95% CI -0.22 to -0.12]; 2 RCTs; 806 patients; high certainty evidence; MCID not identified; SMD -0.50 [95% CI -0.64 to -0.36]); and health-related quality of life (HRQoL) on the Dementia-Related Quality of Life (DEMQOL)proxy (MD 2.00 [95% CI 0.85 to 3.15]; 2 RCTs; 806 patients; moderate certainty evidence; MCID not identified; SMD 0.24 [95% CI 0.10 to 0.38]). Comparing 240 mg ginkgo biloba and placebo for 24 weeks, there was no statistically significant difference in the risk of experiencing either any adverse event (AE) (RR 0.97 [95% CI 0.90 to 1.05]; 5 RCTs; 1’716 patients; moderate certainty evidence) or any serious adverse event (SAEs) (RR 0.98 [95% CI 0.53 to 1.83]; 3 RCTs; 1’143 patients; moderate certainty evidence). Peripheral arterial occlusive disease In patients with PAOD, 24 weeks of treatment with 160 mg ginkgo biloba was associated with statistically significantly better pain-free walking distance (PFWD) than placebo (MD 36.0 m [95% CI 15.4 to 56.6]; 2 RCTs; 73 patients; very low certainty evidence; MCID 20 m). Similarly, 120 mg ginkgo biloba was associated with statistically significantly better PFWD than placebo after 24 weeks (MD 24.4 m [95% CI 4.9 to 43.9]; 3 RCTs; 225 patients; low certainty evidence; MCID 20 m). A daily dose of 120 mg ginkgo biloba for 24 weeks is associated with a statistically significant improvement in pain measured on a visual analogue scale (VAS; range 0 to 100 mm) compared with placebo, but it is unclear whether the difference is clinically meaningful due to substantial variability in the MCID reported in the literature (MD -13.4 mm [95% CI -19.7 to -7.1]; 2 RCTs; 116 patients; low certainty evidence; MCID median 23 mm [interquartile range 12 to 39]). The available findings do not support any conclusions regarding other measures of mobility, peripheral blood circulation, or safety (all very low certainty evidence). No studies were identified that reported HRQoL in patients with PAOD. Vertigo Based on 2 RCTs in patients with vertigo, there were no statistically significant differences in vestibular symptoms after 12 weeks comparing either 240 mg ginkgo biloba (multiple outcome measures; 1 RCT; 160 patients; low certainty evidence) or 160 mg ginkgo biloba (multiple outcome measures; 1 RCT; 31 patients; very low certainty evidence) with 32 mg betahistine. However, patients treated with 240 mg ginkgo biloba for 12 weeks were statistically significantly less likely to experience any AEs, compared to 32 mg betahistine (RR 0.61 [95% CI 0.38 to 0.99]; 1 RCT; 160 patients; moderate certainty evidence). No studies were identified that reported HRQoL in patients with vertigo. Tinnitus Evidence regarding the use of ginkgo biloba in tinnitus was heterogeneous in terms of both dosage of ginkgo biloba and comparator treatment, resulting in no possible meta-analyses and low or very low certainty regarding the treatment effect in all efficacy and safety outcomes. No statistically significant differences were found between treatment with ginkgo biloba (120 mg or 150 mg) and placebo in patients’ subjective assessment of tinnitus severity over 12 weeks, measured with a variety of categorical and continuous scales (2 RCTs; 815 patients; low certainty evidence). In the trial investigating 150 mg ginkgo biloba vs. placebo for the condition of tinnitus, there was no statistically significant difference in the number of people with ≥1 AE during 12 weeks of treatment (RR 1.06 [95% CI 0.74 to 1.52]; 1 RCT; 978 patients; low certainty evidence). No studies were identified that reported HRQoL in patients with tinnitus. Safety across indications To supplement the findings regarding the safety of ginkgo biloba in each indication, meta-analyses were conducted to assess the number of patients experiencing ≥1 AE when treated with ginkgo biloba compared with placebo across indications (i.e. MPD, PAOD, vertigo, and tinnitus studies were analysed together). Among patients treated with either 120 mg ginkgo biloba or placebo for 24 weeks, there was no statistically significant difference in the occurrence of AEs across indications (RR 0.91 [95% CI 0.70 to 1.18]; 7 RCTs; 1133 patients). Similarly, there was no statistically significant difference in the proportion of patients experiencing ≥1 AE comparing 24 weeks of treatment with any dose of ginkgo biloba (120 mg, 150 mg, 160 mg, or 240 mg) vs. placebo (RR 0.96 [95% CI 0.89 to 1.04]; 12 RCTs; 2728 patients). Note that 2 additional trials (total of 14 RCTs and 2’801 patients) did not contribute to the meta-analysis because they reported zero AEs in both treatment groups. Costs, cost-effectiveness, and budget impact The economic SLR identified a total of 3 eligible studies. All 3 were cost-comparison economic analyses that used data collected from RCTs to model the direct costs of ginkgo biloba, from a public payer perspective, in patients with Alzheimer’s disease (AD) or dementia. Two studies conducted in Austria included the costs of ginkgo biloba, as well as estimated costs of patient care (i.e. physician visits, nursing care) modelled using efficacy data from an RCT comparing ginkgo biloba to placebo. Both analyses found that ginkgo biloba was cost-saving compared to placebo due to estimated delays in symptom progression when patients received ginkgo biloba. The third study, conducted in Germany, included the drug costs of ginkgo biloba and galantamine; they also used data from 6 RCTs comparing galantamine to placebo and 1 RCT comparing ginkgo biloba to placebo to estimate costs of patient care (i.e. physician visits, long-term care insurance, and caregiver time). In this study, ginkgo biloba was found to be more costly than galantamine for mild-to-moderate AD from the payer perspective. The most recent study was published in 2015, so these findings may not be representative of current clinical practice or current costs. Results from the present Swiss customized budget impact analysis show that the reimbursement of ginkgo biloba resulted in a 5-year total spending of CHF 167’154’958. Indication-specific costs were CHF 56’912’066 (MPD), CHF 29’956’227 (PAOD), CHF 20’325’738 (vertigo), and CHF 59’960’927 (tinnitus). Scenario analysis showed that when patients with dementia switched from ginkgo biloba to an alternative treatment, the total budget impact was higher, resulting in excess costs regardless of the treatment: rivastigmine (CHF 12’180’648), donepezil (CHF 23’302’095), galantamine (CHF 9’514’923), memantine (CHF 21’713’115), and a weighted average of these treatments (CHF 16’757’340). Ethical, legal, social, and organisational issues A total of 23 studies on ELSO domains were included; identified study designs were systematic and narrative reviews (k=12), governmental guidance documents (k=2), pharmacovigilance studies (k=2), pharmacologic studies (k=2), expert interviews (k=2), discrete choice experiment (k=1), retrospective analysis of RCT data (k=1), and clinical guidelines (k=1). Study quality was not assessed. This review did not identify any serious ethical or social issues specific to ginkgo biloba. The identified ELSO issues were generally related to effective communication of benefits and risks in vulnerable populations and equitable access to care, which are broadly applicable to the patients in these populations. CONCLUSIONS The present HTA identified 42 RCTs evaluating the efficacy of ginkgo biloba. Based on these studies, 240 mg ginkgo biloba showed benefits in patients with MPD after 24 weeks of treatment, specifically in cognitive functioning, neuropsychiatric symptoms, functional status, and HRQoL. For PAOD, vertigo, and tinnitus, the available findings do not support any conclusions of benefit compared with placebo for most outcomes. The findings do not indicate increased risks of AEs or SAEs associated with ginkgo biloba. The BIM provides information on the estimated costs (i.e. reimbursement costs) of ginkgo biloba over 5 years, as well as scenario analyses that assess the economic impact of treatment switching. However, the scenario analyses are based in part on expert opinion due to gaps in the scientific literature and should be interpreted with caution.

Authors' methods: Two systematic literature reviews (SLRs) were conducted to identify the clinical and economic evidence on formulations of ginkgo biloba approved and reimbursed in Switzerland for use in adults with MPD, PAOD, vertigo, and tinnitus. A single, combined search strategy for each database (MEDLINE, Embase, EconLit, CENTRAL, Cochrane Database of Systematic Reviews [CDSR], National Health Service [NHS] Economic Evaluation Database [EED]) was utilised for both SLRs. Screening of the literature was performed by 2 independent reviewers. Data were extracted by one reviewer with full data validation by a second reviewer. For the clinical SLR, eligible studies were randomised controlled trials (RCTs) comparing ginkgo biloba with placebo or active comparators. Where possible, studies were pooled and summary effect estimates calculated by meta-analyses. To assess whether differences were clinically meaningful, minimum clinically important differences (MCIDs) were identified; where MCIDs were unavailable, standardised mean differences (SMDs) were used to categorize effect sizes as trivial/no effect, small, moderate, or large. When pooling results was not possible, results for individual studies are reported. The overall quality of evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For the economic SLR, eligible studies were cost analyses or any type of economic evaluation of ginkgo biloba. Evidence from available health economic evaluations was synthesised narratively and presented as tabular summaries. To assess the total costs and budget impact of ginkgo biloba, a budget impact model (BIM) was developed in accordance with appropriate guidelines. For the evaluation of ELSO domains, the publications included in the SLR were reviewed and were supplemented by targeted literature searches in MEDLINE, Embase, and the grey literature.

Project Status: Completed

URL for project: https://www.bag.admin.ch/en/ginkgo-biloba-in-patients-with-decreasing-mental-performance-peripheral-arterial-occlusive-disease-vertigo-or-tinnitus

URL for protocol: https://www.bag.admin.ch/dam/en/sd-web/tcTK7CpjIMUd/h0086gbdt-hta-protocol.pdf

Year Published: 2026

URL for published report: https://www.bag.admin.ch/dam/en/sd-web/YJVQXIwAz50S/HTA%20Report.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Switzerland

Organisation Name: Swiss Federal Office of Public Health (FOPH)

Contact Address: Federal Office of Public Health, Schwarzenburgstrasse 157, CH-3003 Berne, Switzerland

Contact Name: Stephanie Vollenweider

Contact Email: hta@bag.admin.ch

Copyright: Swiss Federal Office of Public Health