Deadly Mix: Herbs, Supplements, and Drug Interactions

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Deadly Mix Herbs, Supplements, and Drug
Interactions

• Geneva Briggs, Pharm.D., BCPS
• MedOutcomes, Inc.

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Objectives

• Discuss the alternative medications that are most
  dangerous.
• Identify the most common drug interactions with
  alternative medications.
• List five sources for unbiased information on
  alternative medications and supplements.

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Poisons and medicines are oftentimes the same
substances given with different intents Peter
Mere Latham (1789-1875)
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Complementary and Alternative Medicine Practices

• 40 of the US population uses dietary
  supplements often
• 50 of people have used herbals
• 4 rely exclusively on alternatives
• In Germany over 700 herbs are available and
  prescribed by 70 of physicians

NEJM 1993328246-52. JAMA 19982791548-53.
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Complementary and Alternative Medicine Practices

• lt40 of patients inform someone they are taking
  alternative medications
• Most commonly purchased echinacea, feverfew,
  garlic, ginseng, ginkgo, goldenseal, kava, St.
  Johns wort, saw palmetto, and valerian
• Typical user female, 35-64, white, college
  graduate, relatively affluent

J Am Diet Assoc 20031031500-5 JAMA
19982801569-75 Pharmacotherapy 200020877-91
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Pharmaceuticals vs Phytomedicines

• Must prove efficacy and safety
• Mandatory ADE monitoring
• Product formulation standards
• Consensus for use
• Marketing more restricted

• Safety efficacy data may be lacking
• ADE monitoring not mandatory
• No product standards mandated
• Dosing uncertain
• No treatment or cure claims on label

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Concerns with Phytomedicine

• Variability of active constituents
• Misidentification of the plant
• Selection of the wrong part of the plant
• Inadequate storage
• Contamination
• Adulteration
• Mislabeling of the final product

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Asian or Chinese patent medicines

• Of 251 purchased in CA , 24 contained lead, 36
  arsenic, 35 mercury
• 24 of 2,609 samples of Chinese patent medicines
  contained pharmaceutical adulterants

J Clin Pharmacol 1997 37 34450.  BMJ 1994
308 1162. N Engl J Med 1998 339 847
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Which herbals are most likely to cause
significant adverse effects?
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Top 10 Offenders

• Kava Piper methysticum
• Comfrey
• Chaparral Larrea tridentata
• Germander Teucrium genus
• Aristolochic acid
• Germanium dioxide or lactate citrate

• Lobelia Indian tobacco
• Stephania
• L-tryptophan
• Ephedra (ma-huang)

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Beyond the Top 10

• Pennyroyal oil
• Sassafras
• Borage
• Calamus
• Coltsfoot
• Life root

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Significant Interactions with Alternative
Supplements
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St Johns Wort Hypericum perforatum

• Digoxin
• Warfarin
• Theophylline
• Nefazodone
• Oral contraceptives
• Antiretrovirals
• Cyclosporine
• Imatinib (Gleevec)

• Irinotecan Camptosar
• Simvastatin
• Amitriptyline
• SSRI (fluoxetine, sertraline, etc.)

Lancet 20003551343-8 Pharmacotherapy
2004241508-14
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Herbal and Supplement Products That Interact with
Warfarin

• Increased INR
• Ginkgo Biloba
• Dong Quai (Angelica sinesis)
• Danshen (Salvia miltiorrhiza)
• Vitamin E
• Decreased INR
• St. Johns Wort
• Coenzyme Q10
• American ginseng

• Altered Platelets
• Garlic Allium sativum
• Feverfew
• Ginseng
• Turmeric
• Meadowsweet
• Willow bark
• Contain Coumarins
• Horse chestnut
• Red clover

Lancet 200035513438 J Clin Pharm Ther
200227391-401
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Significant Interactions with Alternative Meds
and Supplements

• Siberian Ginseng (Eleutherococcus senticocous) -
  Digoxin
• Valerian Valeriana officinalis alcohol,
  benzodiazepines, anticonvulsants, TCA
• Licorice - ACE-I, ARB, diuretics, digoxin

Lancet 200035513438
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Significant Interactions with Alternative Meds
and Supplements

• Kava and valerian alcohol, barbiturates,
  antispychotic drugs, sedatives, benzodiazepines,
  
• Garlic saquinavir
• Red rice yeast Chinese red rice- statins,
  gemfibrozil, fenofibrate

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Patient Groups Most Likely to have Problems

• Multiple medications
• HIV/AIDS
• Cancer
• Transplant
• Treated with warfarin, digoxin, or other agents
  prone to drug interactions
• Undergoing surgery

Am J Health-Syst Pharm 2004611707-11
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Avoid Recommending Herbals

• Pregnant and lactating women
• Children

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Problem Products in Surgery

• Ginkgo biloba
• Saw Palmetto
• American Ginseng Panex quinquefolias
• Kava
• St Johns wort
• Feverfew

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Problem Products in Cancer Treatment

• Garlic
• Ginkgo
• Echinacea
• Panax ginseng
• St Johns wort
• Kava

J Clin Oncol 2004222489-503
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Reasonably Effective Herbals

• Aloe Vera (topical)
• Arnica (topical)
• Black Cohosh
• Chamomile tea
• Echinacea
• Evening primrose oil
• Feverfew
• Garlic

• Ginger
• Ginkgo Biloba
• Hawthorn
• Peppermint tea
• Saw Palmetto
• Siberian Ginseng
• St Johns wort
• Valerian

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Reliable Printed Resources

• Herbal medicine Expanded Commission E monographs
• Review of Natural Products
• Tylers Herbs of Choice. The Therapeutic Use of
  Phytomedicinals
• Tylers Honest Herbal A Sensible Guide to the
  Use of Herbs and Related Products.
• Facts and Comparisons The Review of Natural
  Products

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Reliable Online Resources

• consumerlab.com
• herbalgram.com
• American Botanical Council
• nccam.nih.gov
• NIHs National Center for Complementary and
  Alternative Medicine
• vm.cfsan.fda.gov
• Center for Food Safety and Applied Nutrition

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Reliable Online Resources

• www.uic.edu/pharmacy/research/diet/content/scont_a
  bout_evaluations.htm
• University of Illinois
• www.pharmacist.com/pdf/dietary_supplements.pdf
• Healthcare Professionals Guide to Evaluating
  Dietary Supplements
• www.herbalwatch.com

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To Buy Anything and Everything

• www.herbalremedies.com

Blood Circulator Made of medicinal rhubarb,
prepared rehmannia root, common peony root, peach
seed, bitter apricot seed, licorice root, scute,
dun fly, gadfly, leech, June beetle grub, dried
lacquer and ground beetle.
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Patient Counseling

• Encourage disclosure of ALL medicinal substances
• Discuss available information about alternative
  medicines
• Discuss health risk and self-monitoring
• Set objective goals to follow progress
• Steer patients seeking to self-treat serious
  disorders such as depression to a physician

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How to Report an Adverse Effect

• Complete the Medwatch form online
• www.fda.gov/medwatch/report/hcp.htm
• Report by telephone (1-800-FDA-1088)
• Download a copy of the form and either fax it to
  1-800-FDA-0178 or mail it back using the
  postage-paid addressed form.

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Evaluating Products for Quality

• Look for
• USP standardization
• feverfew, ginger, chamomile, cranberry, ginkgo
  biloba, St Johns wort, saw palmetto, milk
  thistle, valerian, siberian ginseng, and
  echinacea
• Reputable manufacturer
• Consumerlab.com evaluations

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Conclusion

• Current regulation of dietary supplements fails
  to address substantial risk to public health
• Educate patients to give Full Disclosure
• Know the problem herbs and most common
  interacting herbs
• Report adverse events

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