Herb-drug interactions

doi:10.1016/S0140-6736(99)06457-0

The Lancet

Volume 355, Issue 9198, 8 January 2000, Pages 134-138

https://doi.org/10.1016/S0140-6736(99)06457-0 Get rights and content

Summary

Concurrent use of herbs may mimic, magnify, or oppose the effect of drugs. Plausible cases of herb-drug interactions include: bleeding when warfarin is combined with ginkgo (Ginkgo biloba), garlic (Allium sativum), dong qual (Angelica sinensis), or danshen (Salvia miltiorrhiza); mild serotonin syndrome in patients who mix St John's wort (Hypericum perforatum) with serotonin-reuptake inhibitors; decreased bioavailability of digoxin, theophylline, cyclosporin, and phenprocoumon when these drugs are combined with St John's wort; induction of mania in depressed patients who mix antidepressants and Panax ginseng; exacerbation of extrapyramidal effects with neuroleptic drugs and betel nut (Areca catechu); increased risk of hypertension when tricyclic antidepressants are combined with yohimbine (Pausinystalla yohimbe); potentiation of oral and topical corticosteroids by liquorice (Glycyrrhiza glabra); decreased blood concentrations of prednisolone when taken with the Chinese herbal product xaio chai hu tang (sho-saiko-to); and decreased concentrations of phenytoin when combined with the Ayurvedic syrup shankhapushpi. Anthranoid-containing plants (including senna [Cassia senna] and cascara [Rhamnus purshiana]) and soluble fibres (including guar gum and psyllium) can decrease the absorption of drugs. Many reports of herb-drug interactions are sketchy and lack laboratory analysis of suspect preparations. Health-care practitioners should caution patients against mixing herbs and pharmaceutical drugs.

Section snippets

Source and extent of review

Sources for this review include MEDLINE 1966–98 (searched under MeSH terms “drug interactions” combined with “herbal medicine”, “traditional medicine”, “Chinese traditional medicine”, “African traditional medicine”, “Ayurvedic medicine”, “Oriental traditional medicine”, “Unani medicine”, and “Arabic medicine”); EMBASE 1994–99 (searched under the same terms); reference dredging; and my own files on the subject.

Many reports of herb-induced interactions lack crucial documentation on temporal

Misidentification, adulteration, and contamination

Labelling of herbal products may not accurately reflect their contents, and adverse events or interactions attributed to specific herbs may actually be due to misidentified plants, pharmaceutical drugs, or heavy metals.⁵⁶ For example, a “Siberian ginseng” (Eleutherococcus senticosus product implicated in a case of neonatal androgenisation⁵⁷ was found on analysis to be an unrelated species, Chinese silk vine (Periploca sepium).⁵⁸ In Hong Kong, encephalopathy and neuropathy associated with a

Counselling of patients about herb-drug interactions

Use of herbal and dietary supplements is extremely common: in one US survey of adults who regularly take prescription medication, 18·4% reported the concurrent use of at least one herbal product or high-dose vitamin (and 61·5% of those who used unconventional therapies did not disclose such use to their physicians).⁶³ A survey of 515 users of herbal remedies in the UK found that 26% would consult their general practitioner for a serious adverse drug reaction associated with a conventional

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Citation Excerpt :
Therefore, what is most found in the literature about herb-warfarin interactions are in vitro studies and case studies. Both have limitations, but they can be excellent for directing scientific research efforts (Brantley et al., 2014; Fasinu et al., 2012; Fugh-Berman, 2000; Ge et al., 2014; Leite et al., 2021a, 2021b; Yeung et al., 2018). In this sense, there are studies indicating that some compounds present in the genus Lippia have anticoagulant and high platelet activities (Oliveira et al., 2014), being a potential source of interaction with anticoagulants such as warfarin.
Lippia alba (Mill.) N.E.Br. ex Britton & P. Wilson is traditionally used in Brazil as an adjunct in the relief of mild anxiety, as an antispasmodic, and as an antidyspeptic. This medicinal species was included in the Phytotherapeutic Form of the Brazilian Pharmacopeia 2nd edition (2021) and has already been described as the most used medicinal plant in a study with patients from an Anticoagulation Clinic in Brazil. Meanwhile, no studies were found that support the safety of the use of L. alba in patients using anticoagulants, a drug with several safety limitations.
Provide scientific evidence to ensure the safety of the concomitant use of L. alba and warfarin and support the management of these patients by evaluating its in vitro anticoagulant effect and chemical composition. And, as a timely complementation, evaluate the potential of this medicinal species in the development of new antithrombotics.
The chemical profile of L. alba derivatives was analyzed by chromatographic methods such as Ultra-Performance Liquid Chromatography (UPLC) coupled with electrospray ionization mass spectrometry (ESI-MS), qualitative UPLC using Diode-Array Detection, and Thin Layer Chromatography. The anticoagulant activity was evaluated by the innovative Thrombin Generation Assay by Calibrated Automated Thrombogram method and using traditional coagulometric tests: prothrombin time, activated partial thromboplastin time, and plasma fibrinogen measurement.
Extracts and fractions prolonged the coagulation time in all the tests and reduced thrombin formation in thrombin generation assay. Coagulation times with the addition of ethanloic extract (2.26 mg/mL) was 17.78s, 46.43s and 14.25s respectively in prothrombin time, activated partial thromboplastin time and fibrinogren plasma measurement. In thrombin generation test, this same extract showed ETP as 323 nM/min compared to control (815 nM/min) with high tissue factor and 582 nM/min compared to control (1147 nM/min) using low tissue factor. Presence of flavonoids, phenylpropanoids, and triterpenes were confirmed by chromatographic methods and 13 compounds were identified by UPLC-ESI-MS. Based on these results and on the scientific literature, it is possible to propose that phenylpropanoids and flavonoids are related to the anticoagulant activity observed.
The results demonstrate the in vitro anticoagulant activity of L. alba, probably due to the activation of intrinsic and extrinsic pathways. It is concluded, then, that there is a potential for interaction, which needs to be further studied, between L. alba and warfarin. Also, this medicinal species shows a great potential for use in the development of new antithrombotics.
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Dietary supplements comprise a diverse array of products that include vitamins, botanicals, amino acids, and probiotics. The origins of dietary supplements are disparate and draw from both food and medicinal use of ingredients. Currently, dietary supplements are defined in the United States as products intended to supplement the diet taken orally and available in many forms (e.g., pills, capsules, tinctures). Public health concerns about the toxicity of dietary supplements stem from their widespread use at relatively high dose levels. Multiple historical factors contribute to the current safety landscape for dietary supplements, including their use pattern and guiding regulatory structure. This chapter addresses the various historical events and decisions that have led to the current toxicity concerns surrounding dietary supplements. First, the origins of prominent groups within the dietary supplement umbrella (i.e., vitamins, botanicals, and probiotics) are presented. Next, the regulatory landscape is illustrated by describing the legislative progression impacting dietary supplements from the Pure Food and Drug Act of 1906 to the 1994 Dietary Supplement Health and Education Act and beyond. Finally, historically important examples of dietary supplement toxicity are presented to highlight the various categories of concerns including ingredient toxicity, adulteration, contamination, and drug-supplement interactions.
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View full text

ReviewHerb-drug interactions

Summary

Section snippets

Source and extent of review

Misidentification, adulteration, and contamination

Counselling of patients about herb-drug interactions

Lancet

Ann Thorac Surg

Biochem Pharmacol

Lancet

Lancet

Lancet

Life Sci

Lancet

J Ethnopharm

Traditional plant medicines as treatments for diabetes

Diabetes Care

Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients

J Am Geriatr Soc

Dietary supplements and natural products as psychotherapeutic agents

Psychosom Med

Is St John's Wort (Hypericum perforatum) an effective antidepressant?

J Nerv Ment Dis

Betel nut-induced extrapyramidal syndrome: an unusual drug interaction

Mov Disord

Topical capsaicin induces cough in patient receiving ACE inhibitor

Ann Allergy

Influence de l'alimentation épicéé et piquante sur l'absorption de la théophylline

Thérapie

Warfarin interactions with Chinese traditional medicines; danshen and methyl salicylate medicated oil

Aust NZ J Med

Chinese herbs and warfarin potentiation by ‚danshen’

J Intern Med

The effects of danshen (Salvia miltiorrhiza) on warfarin pharmacodynamics and pharmacokinetics of warfarin enantiomers in rats

J Pharm Pharmacol

Warfarin danshen interaction

Ann Thorac Surg

Traditional remedies and food supplements: a five year toxicological study (1991–1995)

Drug Saf

Potentiation of warfarin by dong quai

Pharmacotherapy

Untitled (photograph and brief case report)

BMJ

Elevated serum digoxin levels in a patient taking digoxin and Siberian ginseng

Can Med Assoc J

Drug interactions with herbal and other non-toxic remedies

Garlic as a possible risk for postoperative bleeding

Plast Reconstruc Surg

Garlic and the risk of TURP bleeding

Br J Urol

Spontaneous spinal epidural hematoma with associated platelet dysfunction from excessive garlic consumption: a case report

Neurosurgery

Spontaneous hyphema associated with ingestion of ginkgo biloba extract

N Engl J Med

Effect of a ginkgolide mixture (BN 52063) in antagonizing skin and platelet responses to platelet activating factor in man

Lancet

Spontaneous bilateral subdural hematomas associated with chronic Ginkgo biloba ingestion

Neurology

Ginkgo biloba

Neurology

Review
Herb-drug interactions