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As described in a previous article (The interactions of herbs and drugs, 2000 START Manuscripts), the nature of herb-drug interactions is not a chemical interaction between a drug and an herb component to produce something toxic. Such responses can occur with drug-drug interactions and with food-drug interactions, so the finding of some instances of herb-drug interaction would not be surprising. The Chinese culture is one in which herbs were a dominant medical therapy during the 20th Century, and drugs were a relatively recent addition to the medical field. Today, doctors and pharmacists are provided courses and educational materials outlining potential problems with herbs that their patients may be using. This chart first divides interaction concerns into broad subgroups, the main ones being related to pharmacodynamic interactions (mostly involved with herbs and drugs yielding similar effects or counteracting one another) and pharmacokinetics (such as changing the rate of absorption or elimination of a drug).
Due to the paucity of actual reports of herb-drug interactions, lists of herb-drug interactions are usually padded with other information, such as reports of simple adverse reactions (not involving interactions).
When published reports alluding to adverse herb reactions (but not interactions) and to pharmacology studies only are eliminated, one is left with few instances of reported herb-drug interactions.
Drug-herb interaction among commonly used conventional medicines: a compendium for health care professionals.
Put simply, there were very few well-supported interactions detected: namely 22 that involved more than an individual report, or a simple pharmacology study, or a mere suggestion of potential interaction.
If a patient merely asks you to assure that the herbs you prescribe will not interact or be a problem with a drug regimen being used at the same time, it is not possible to give such assurances. All major medical journals, and many minor medical journals, have their articles listed-and often abstracted-in a huge database maintained by the National Center for Biotechnology Information (NCBI) of the National Library of Medicine (NLM), a division of the National Institutes of Health (NIH). This site (which can also be accessed through any search engine by typing in Entrez-PubMed and then following the first link) will provide a space into which the user may type the search terms, to yield a series of abstract titles, with access to abstracts (or fuller reference information when abstracts are not available).
Upon hitting the return button of the keyboard or clicking on the "go" icon on the screen, the search is rapidly completed.
Hazardous pharmacokinetic interaction of Saint John's wort (Hypericum perforatum) with the immunosuppressant cyclosporin. Institute of Clinical Pharmacology, Charite University Medical Center, Humboldt University of Berlin, Germany.
Contrary to common belief, over-the-counter herbal remedies may cause clinically relevant drug interactions.
The small number of reports of specific herb-drug interactions is the reason for getting this as a typical result.
If a report of interaction appears, it is important to check the abstract (when provided) for details to confirm that there is an actual report of herb-drug interaction (as with the St. There are more sophisticated searches that can be performed by listing more key words to try and capture more references on the first search. Absence of a report in the literature doesn't guarantee that there is no possibility of an herb-drug interaction. It is not advisable to give firm assurances that there can be no problem, but it is also not advisable to overstate the concerns. The herbs mentioned in this abstract are those suspected of interacting with Warfarin, a drug with a narrow therapeutic window often used by sensitive patient populations. As noted above, the drug with greatest concern for interactions is Warfarin, but there is also a concern for interaction with any blood-thinning drug. Potential interactions between herbal medicines and conventional drug therapies used by older adults attending a memory clinic. OBJECTIVE: Herbal medicines and conventional drug therapies are often taken in combination.
This report would seem to give a shocking result: that nearly one-third of herb users (at least, among this elderly population) were at risk for herb-drug interactions. Non-steroidal anti-inflammatory drugs (NSAIDs), particularly aspirin, have the potential to interact with herbal supplements that are known to possess antiplatelet activity (ginkgo, garlic, ginger, bilberry, dong quai, feverfew, ginseng, turmeric, meadowsweet and willow), with those containing coumarin (chamomile, motherwort, horse chestnut, fenugreek and red clover) and with tamarind, enhancing the risk of bleeding. A mild antiplatelet activity for ginkgo has been proposed as one of its mechanisms for aiding circulation to the brain and, thereby, enhancing memory. Since elderly patients are more susceptible to spontaneous bleeds due to weakness of capillaries as well as having a prolonged healing time for response to incidents, this caution would seem reasonable.
Researchers who are working to demonstrate the potential health value of herbs may be drawn to demonstrating the anti-coagulation potential for herbs during laboratory animal studies.


To be safe, a practitioner would either not prescribe ginkgo to a regular user of NSAIDS, especially aspirin and particularly for the elderly patient.
Millions of people regularly take blood-thinning drugs such Warfarin, and even more take aspirin and similar medications to prevent heart attacks and strokes. Herbs may interact with the blood thinning drugs in different ways, some of them beneficial, some of them potentially harmful. Meanwhile, physicians are starting to realize that many herbs possess potent pharmacological activity.
Vitamin K is found in high concentrations in many foods, including dark green leafy vegetables (especially turnip greens), alfalfa sprouts, broccoli, asparagus, egg yolks and dairy products. Another aspect of blood clotting involves the clumping together of platelets: the combination of platelets clumps and the fibrin clot is what causes blood to thicken into full clots. If using anticoagulants has impaired a person's normal clotting mechanism, good platelet function is obviously an important backup system. If your doctor starts you on anticoagulant medication and your diet already includes vegetables rich in vitamin K.
While you're taking anticoagulants, avoid regular use of concentrated, standardized extracts of herbs that are known to have antiplatelet activity, such as ginkgo, which is commonly sold as 50:1 concentrate.
If you are generally healthy and taking an antiplatelet drug such as aspirin for preventive purposes, you may want to try switching to ginkgo, which has many benefits.
Given the increasingly large number of people taking complex mixtures of herbs, vitamins and drugs, it's probable that we will see more reports of side effects and negative interactions. Cupp MJ, Herbal remedies: adverse effects and drug interactions, American Family Physician 1999. Chang HM and But PPH (editors), Pharmacology and Applications of Chinese Materia Medica, (2 vols.), 1986 World Scientific, Singapore.
This is likely due to the low dose of any individual herb component usually consumed and the simple absence of significant interaction at any reasonable dose. A variety of electronic databases and hand-searched references were used to identify documentation of interactions between herbal products and drugs from the most commonly used therapeutic classes.
With the enclosed report we would like to alert other physicians that herbal extracts of Saint John's Wort (Hypericum perforatum) may cause a sudden remarkable decrease of cyclosporin trough concentrations.
These herbs are often provided in single-herb products where they are at a relatively large dosage. The objective of our study was to identify the range of natural health products and conventional drug therapies used by older adults (aged 65 years and over) attending a memory clinic, and to specifically evaluate the frequency of potential interactions between herbal medicines and conventional drug therapies.
Preferably avoid use in patients on antiplatelet (aspirin, dipyridamole, ticlopidine) or anticoagulant (Warfarin) therapy. At the same time, with the use of herbal medicines more popular now than ever, surveys show that most people don't tell their physicians about their use of herbs or vitamin supplements.
Concerns have been raised in prominent medical journals that this activity could have detrimental effects, especially for patients taking certain types of medications.
Doctors typically give anticoagulant to people with high risk of blood clotting, such as those who have artificial heart valves, deep vein thrombosis (a large blood clot) in the legs, or arterial fibrillation (a chronic irregularity in heart rhythm). Well, there are several options, depending on the degree of effort one is willing to put out. While a daily cup of ginkgo tea or dropperful of tincture is unlikely to cause problems, the extract is much more potent. MEDLINE, Allied and Complementary Medicine Database, CINHAL, HealthSTAR, and EMBASE were searched from 1966 to the present. John's Wort the most common herb (54 cases) involved." Thus, 14 cases were well-documented in this report published about 2 years earlier than the new report which found 22 reasonably supported cases. A kidney transplantation patient treated with 75 mg bid doses of cyclosporin for many years experienced a sudden drop in her cyclosporin trough concentrations. DESIGN: We interviewed consecutive patients attending the Memory Disorders Clinic at the Baycrest Centre for Geriatric Care, a University of Toronto teaching hospital, between 4 July and 15 August 2000. Cautious physicians have chosen the route of absolute avoidance rather than risk an adverse reaction, they recommend that patients stop taking herbs altogether.
The process by which blood thickens into a clot involves a chain reaction: various proteins interact to produce thrombin, which then produces fibrin, the protein material that forms the clot's core.


Or, if you are taking antiplatelet drugs everyday, the addition of ginkgo or one of the herbs listed in the first two sections of the chart above could lead to uncontrolled bleeding. This same rationale applies to concentrated forms of any of the antiplatelet herbs, although it's probably safe to eat fresh ginger or garlic in food or to have a cup or two of green tea every day.
But rather than turning back the clock on herbal medicine, I propose learning from these examples and upgrading our database of medical information. This change was in temporal relationship to hypericum extract co-medication, and a re-challenge gave similar results….The potential clinical consequence of this pharmacokinetic herb-drug interaction is apparent, since low cyclosporin levels are associated with an increased risk of rejection after organ transplantation and are usually not suspected upon intake of plant products….
Several of these interacting proteins are made in the liver, where vitamin K is essential for their production. In this situation, it's more important that if your diet changes, you inform your doctor so that the PT can be checked again. If you feel that it's essential to your health to continue taking any of the anticoagulant or antiplatelet herbs listed in the chart along with prescription, there's another option. We collected information on current and previously-used natural health products and current conventional drug therapies. Aspirin is the most common antiplatelet agent; others include dipyridamole (Persantine), sulfinpyrazone (Anturane), clopidogrel (Plavix), and ticlodipine (Ticlid).
Ask your doctor if he or she would be willing to monitor your bleeding time along with the PT.
Using a matrix of 165 possible drug-herb interaction pairs (15 therapeutic drug classes by 11 herbal products), we identified 51 (31%) interactions discussed in the literature. John's Wort declined dramatically after revelations that it could cause herb-drug interactions along with reports questioning its effectiveness.
Patients were classified as having the potential for an interaction if they were using a current herbal medicine in combination with a conventional drug therapy and the interaction had been reported previously in the medical literature. If your bleeding time stays on normal range, you're less likely to have an unexpected hemhorrage.
Twenty-two of these 51 drug-herb pairs (43%) were supported by randomized clinical trials, case-control studies, cohort studies, case series, or case studies. PARTICIPANTS: We interviewed 195 consecutive patients attending the Memory Disorders Clinic at the Baycrest Centre for Geriatric Care, Toronto, Ontario, Canada. The remaining interaction pairs reflected theoretic reasoning in the absence of clinical data. RESULTS: Of the 195 patients in our sample, 33 (17%) were 'current users', 19 (10%) were "past users," and 143 (73%) were "never users" of herbal medicines. Most interactions were pharmacokinetic, with most actually or theoretically affecting the metabolism of the affected product by way of the cytochrome P450 enzymes.
Among the 52 patients who were "current or past users," the most frequently used herbal medicines were ginkgo (Ginkgo biloba) [39 users], garlic (n = 10), glucosamine sulphate (n = 9), and echinacea (n = 8). Among the 33 patients who were current users, the most commonly-used herbal medicines were ginkgo (n = 22), glucosamine sulphate (n = 8) and garlic (n = 6). Among the 33 current users, we identified 11 potential herb-drug interactions in nine patients. To create a comprehensive and valid list of herb-drug interactions would require a substantial increase in research activities in this area. The 11 herb-drug interactions we identified were between ginkgo and aspirin [n = 8], ginkgo and trazodone (n = 1), ginseng and amlodipine (n = 1), and valerian and lorazepam (n = 1). Almost one-third of current users of herbal medicines were at risk of a herb-drug interaction. John's Wort has been blamed for several instances of transplant rejection due to its lowering of cyclosporin concentrations. This finding has important potential implications because both of these products are regularly used by older people.



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