Botanical Botanical Contraindications and Contraindications and

Drug InteractionsDrug Interactions  

Dr.Talal Aburjai Dr.Talal Aburjai Faculty ofFaculty of PharmacyPharmacy University ofUniversity of JordanJordan

STATEMENT OF OBJECTIVESSTATEMENT OF OBJECTIVES   Upon completion of this lesson you Upon completion of this lesson you

should:should:    1. Recognize possible drug interactions 1. Recognize possible drug interactions

and contraindications of the most popular and contraindications of the most popular botanical products. botanical products. 

2. Learn where to seek more information 2. Learn where to seek more information

regarding herb-drug interactions and/or regarding herb-drug interactions and/or contraindications.  contraindications. 

3. Understand the importance of the 3. Understand the importance of the pharmacist's role in recognizing herb-pharmacist's role in recognizing herb-drug interactions and/or drug interactions and/or contraindications.contraindications.

    4. Explain the appropriate patient 4. Explain the appropriate patient

counseling considerations associated counseling considerations associated with herb-drug interactions and/or with herb-drug interactions and/or contraindications. contraindications. 

INTRODUCTIONINTRODUCTION

There is little doubt that the use of herbal There is little doubt that the use of herbal medicines is growing. It is estimated that medicines is growing. It is estimated that 42.1% of patients use complementary 42.1% of patients use complementary therapies and 18.4% of all prescription therapies and 18.4% of all prescription users concurrently take herbal medicines users concurrently take herbal medicines or high-dose vitamins. or high-dose vitamins.

Science has taught us repeatedly that all Science has taught us repeatedly that all things recycle and we are now in another things recycle and we are now in another era of resurgent interest in plants as era of resurgent interest in plants as medicine. medicine.

Ethnobotany, rain forest depletion, limits Ethnobotany, rain forest depletion, limits in advancement using synthetic drugs in advancement using synthetic drugs have all taught us that nature has always have all taught us that nature has always provided us with clues on how to develop provided us with clues on how to develop new medicines. This will never cease. new medicines. This will never cease.

We have learned over and again the need to We have learned over and again the need to properly identify plants as to correct genus, properly identify plants as to correct genus, species, variety and even chemovars. species, variety and even chemovars.

Computers have been brought into play to help Computers have been brought into play to help us identify and categorize plants using us identify and categorize plants using classical morphology and chemotaxonomy. classical morphology and chemotaxonomy.

Lessons from the complex phytochemistry of Lessons from the complex phytochemistry of biologically active constituents have taught us biologically active constituents have taught us that each plant is a veritable chemical factory.that each plant is a veritable chemical factory.

Often in pharmacognostical research, Often in pharmacognostical research, new physiological and pharmacological new physiological and pharmacological concepts were developed once it was concepts were developed once it was recognized that a new chemical structure recognized that a new chemical structure had a specific property. had a specific property.

These were designated "molecular keys" These were designated "molecular keys" and include such classic examples : and include such classic examples :

morphine (the chemical basis for morphine (the chemical basis for synthetic opioids), synthetic opioids),

cocaine (the chemical basis for cocaine (the chemical basis for synthetic local analgesics), synthetic local analgesics),

and ephedra (the chemical basis for and ephedra (the chemical basis for CNS stimulants like the CNS stimulants like the amphetamines and decongestants amphetamines and decongestants such as pseudoephedrine).such as pseudoephedrine).

A more recent example is capsaicin A more recent example is capsaicin from hot peppers, previously used from hot peppers, previously used as a "counter irritant" and now as a "counter irritant" and now reintroduced as an analgesic, reintroduced as an analgesic, because in low doses it is known to because in low doses it is known to deplete newly discovered deplete newly discovered "substance P," which is involved in "substance P," which is involved in pain transmission.pain transmission.

To briefly cite a few examples of natural To briefly cite a few examples of natural products which led to the understanding of products which led to the understanding of several major areas in physiology and several major areas in physiology and pharmacology:pharmacology:

1. The effects of reserpine, ephedrine, and the 1. The effects of reserpine, ephedrine, and the ergot alkaloids led to the elucidation of the ergot alkaloids led to the elucidation of the adrenergic system;adrenergic system;

2. The effects of physostigmine, muscarine, and 2. The effects of physostigmine, muscarine, and atropine disclosed the complexities of the atropine disclosed the complexities of the cholinergic system; cholinergic system;

3. The properties of tubocurarine led to an 3. The properties of tubocurarine led to an understanding of the neuromuscular junction;understanding of the neuromuscular junction;

4. The unique effects of nicotine explained the 4. The unique effects of nicotine explained the properties of the ganglion junction;properties of the ganglion junction;

5.5. The unparalleled qualities of the digitalis The unparalleled qualities of the digitalis glycosides which to this day sustain the glycosides which to this day sustain the cardiovascular system, andcardiovascular system, and

6. The action of papaverine and the xanthine 6. The action of papaverine and the xanthine derivatives on smooth muscle.derivatives on smooth muscle.

Again, these phytomedicines have long Again, these phytomedicines have long served as "molecular keys" and models for the served as "molecular keys" and models for the synthesis of numerous, useful pharmaceutical synthesis of numerous, useful pharmaceutical derivatives.derivatives.

In some cases, herbs can interact with In some cases, herbs can interact with prescription medicines or their use may be prescription medicines or their use may be contraindicated with certain disease states. contraindicated with certain disease states.

In many cases the doctor may not be aware In many cases the doctor may not be aware the patient is using some form of the patient is using some form of complementary therapy. complementary therapy.

In one survey, only 38.5% of patients told their In one survey, only 38.5% of patients told their physicians that they were using physicians that they were using complementary therapies. complementary therapies.

The majority of herbal products are The majority of herbal products are purchased in a drugstore. purchased in a drugstore.

This places pharmacists in an ideal This places pharmacists in an ideal position to warn patients about the position to warn patients about the possible risks of combining herbal possible risks of combining herbal products with prescription medicines.  products with prescription medicines. 

Generally there are three types of Generally there are three types of information sources which document information sources which document botanical/ drug botanical/ drug interactions/contraindications; interactions/contraindications;

1.1. theoretical or empirical, theoretical or empirical, 2.2. case reports, case reports, 3.3. and those seen in clinical trials.and those seen in clinical trials.

The theoretical or empirical occurrences The theoretical or empirical occurrences derive their evidence from in-vitro derive their evidence from in-vitro laboratory action, animal studies or laboratory action, animal studies or historical usage. historical usage.

In many cases theoretical evidence is In many cases theoretical evidence is suggestive and provides evidence to suggestive and provides evidence to advise caution. advise caution.

Case reports use data collected from Case reports use data collected from individual patients with their reactions to individual patients with their reactions to individual botanical products. individual botanical products.

It is beneficial if these reports provide It is beneficial if these reports provide specific details dose taken and duration, specific details dose taken and duration, specific botanical product with Latin specific botanical product with Latin name, was the product analyzed for name, was the product analyzed for contamination, etc. Ideally case reports contamination, etc. Ideally case reports should provide support for theoretical should provide support for theoretical warnings. warnings.

Clinical trial results provide the best Clinical trial results provide the best evidence to support botanical warnings. evidence to support botanical warnings.

Regrettably, at this time there is little data Regrettably, at this time there is little data on botanical contraindications or on botanical contraindications or interactions derived from clinical trials. interactions derived from clinical trials. 

BLACK COHOSHBLACK COHOSHالبق البق قاتل قاتل

Possibly the most commonly recommended Possibly the most commonly recommended botanical preparation used to help with botanical preparation used to help with menopause is black cohosh (Cimicifuga menopause is black cohosh (Cimicifuga racemosa). racemosa).

Most of the clinical studies have used a Most of the clinical studies have used a product standardized to 1 mg of 27-product standardized to 1 mg of 27-deoxyacetein per dose or tablet. There has deoxyacetein per dose or tablet. There has been some debate as to how this botanical been some debate as to how this botanical helps with the symptoms associated with helps with the symptoms associated with menopause. menopause.

It is believed that black cohosh inhibits It is believed that black cohosh inhibits the secretion of luteinizing hormone the secretion of luteinizing hormone (LH),5,35 even though some studies (LH),5,35 even though some studies have observed no changes in LH levels.have observed no changes in LH levels.

BLACK COHOSHBLACK COHOSH It had been proposed that this decrease in LH It had been proposed that this decrease in LH

was due to an estrogen-like effect. was due to an estrogen-like effect.

Further studies have failed to find an Further studies have failed to find an estrogenic effect, and decreases in LH are now estrogenic effect, and decreases in LH are now believed to be due to its interference with believed to be due to its interference with neurotransmitters. neurotransmitters.

There is still much work to be done to There is still much work to be done to determine a definite mechanism of action.  determine a definite mechanism of action. 

Drug interactionDrug interaction

There are no known drug interactions noted There are no known drug interactions noted with black cohosh. with black cohosh.

It is considered to be contraindicated during It is considered to be contraindicated during pregnancy and lactation. This is due to pregnancy and lactation. This is due to empirical evidence of its emmenagogue (an empirical evidence of its emmenagogue (an agent that stimulates menstrual flow) effect and agent that stimulates menstrual flow) effect and possible toxicity when taken in high doses.possible toxicity when taken in high doses.

In in vitro animal studies, extracts of In in vitro animal studies, extracts of black cohosh have demonstrated affinity black cohosh have demonstrated affinity for estrogen receptors.for estrogen receptors.

The human significance of this finding is The human significance of this finding is not known.  not known. 

There has been some concern over the use of There has been some concern over the use of black cohosh and the possible risk of black cohosh and the possible risk of proliferation of estrogen-receptor-positive proliferation of estrogen-receptor-positive cancerous cells. cancerous cells.

However, black cohosh has been shown to However, black cohosh has been shown to inhibit the growth of breast carcinoma cells.inhibit the growth of breast carcinoma cells.

Black cohosh was also found to antagonize the Black cohosh was also found to antagonize the effects of estradiol on DNA synthesis. effects of estradiol on DNA synthesis.

There have even been study results that There have even been study results that showed black cohosh augmented the showed black cohosh augmented the anti-proliferative effects of Tamoxifen. anti-proliferative effects of Tamoxifen.

Due to the above findings, the use of Due to the above findings, the use of black cohosh is not contraindicated in black cohosh is not contraindicated in patients with a history of breast cancer.patients with a history of breast cancer.

ECHINACEAECHINACEAالقنفذ القنفذ حشيشة حشيشة

There are three species of echinacea (E. There are three species of echinacea (E. angustifolia, E. purpurea, and E. pallida) that angustifolia, E. purpurea, and E. pallida) that are used medicinally. are used medicinally.

Extracts of echinacea exert several actions on Extracts of echinacea exert several actions on the body's immune system: the body's immune system:

increasing phagocytosis, increasing phagocytosis, increasing production of interferon and increasing production of interferon and

interleukins, interleukins, increased production of white blood cells and increased production of white blood cells and

other non-specific immunostimulatory actions.other non-specific immunostimulatory actions.

There have been no documented cases There have been no documented cases of drug interactions with echinacea of drug interactions with echinacea products.products.

Due to its stimulation of the immune Due to its stimulation of the immune system, this botanical directly opposes system, this botanical directly opposes the effects of immunosuppressants.the effects of immunosuppressants.

It is generally considered to be contraindicated It is generally considered to be contraindicated in systemic and autoimmune diseases, such as in systemic and autoimmune diseases, such as rheumatoid arthritis, tuberculosis, and multiple rheumatoid arthritis, tuberculosis, and multiple sclerosis although, there is no clinical evidence sclerosis although, there is no clinical evidence or case reports to support this.or case reports to support this.

It is considered to be contraindicated for AIDS It is considered to be contraindicated for AIDS and HIV patients because it can enhance and HIV patients because it can enhance secretion of tumor necrosis factor and alpha-secretion of tumor necrosis factor and alpha-interferon. interferon.

Echinacea products are thought to be Echinacea products are thought to be contraindicated in tuberculosis because they contraindicated in tuberculosis because they contain arabinagalactan constituents that may contain arabinagalactan constituents that may be similar to arabinagalactans found in be similar to arabinagalactans found in Mycobacteria cell walls.Mycobacteria cell walls.

These arabinagalactans are associated with These arabinagalactans are associated with the suppression of the lymphocyte response the suppression of the lymphocyte response observed in tuberculosis.11 Again this observed in tuberculosis.11 Again this evidence is considered empirical.evidence is considered empirical.

EVENING PRIMROSEEVENING PRIMROSEاالخدريةاالخدرية

This is the fifth most-popular herb in world This is the fifth most-popular herb in world pharmacies. The seeds of evening primrose pharmacies. The seeds of evening primrose (Oenothera biennis), are one of the richest (Oenothera biennis), are one of the richest sources of gamma-linolenic acid(GLA).sources of gamma-linolenic acid(GLA).

This essential fatty acid is used to help treat This essential fatty acid is used to help treat atopic eczema,diabetic neuropathy, and atopic eczema,diabetic neuropathy, and premenstrual syndrome.premenstrual syndrome.

Evening primrose oil appears to be safe Evening primrose oil appears to be safe for most people.for most people.

There is the possibility of an increased There is the possibility of an increased risk of epileptic episodes for risk of epileptic episodes for schizophrenics taking phenothiazines.28 schizophrenics taking phenothiazines.28

However some authors question this However some authors question this possibility. possibility.

Evening primrose oil can increase Evening primrose oil can increase production of prostaglandin E1 (PGE1) production of prostaglandin E1 (PGE1) and may act synergistically with NSAIDs.and may act synergistically with NSAIDs.

Evening primrose oil should be used Evening primrose oil should be used with caution in patients concurrently with caution in patients concurrently taking anticoagulants.taking anticoagulants.

FEVERFEWFEVERFEWمريم مريم شجرة   شجرة

This product is known mainly for its ability, This product is known mainly for its ability,

when taken regularly, to help reduce the when taken regularly, to help reduce the frequency and severity of migraine headaches. frequency and severity of migraine headaches. The mechanism of action is not fully The mechanism of action is not fully understood, but it may involve the inhibition of understood, but it may involve the inhibition of prostaglandin synthesis.prostaglandin synthesis.

There have been no reported drug interactions There have been no reported drug interactions with feverfew (Tanacetum parthenium). with feverfew (Tanacetum parthenium).

It has been suggested that nonsteroidal It has been suggested that nonsteroidal antiinflammatory drugs (NSAIDs) or antiinflammatory drugs (NSAIDs) or corticosteroids may reduce the efficacy of corticosteroids may reduce the efficacy of feverfew.feverfew.

It is considered to be contraindicated in It is considered to be contraindicated in pregnancy due to empirical evidence of its pregnancy due to empirical evidence of its emmenagogue effect.emmenagogue effect.

Individuals with a hypersensitivity to other Individuals with a hypersensitivity to other members of the daisy family should not use members of the daisy family should not use feverfew. feverfew.

Patients taking anticoagulants should be Patients taking anticoagulants should be cautioned and monitored for bleeding. cautioned and monitored for bleeding.

There is theoretical evidence that There is theoretical evidence that feverfew may decrease platelet feverfew may decrease platelet aggregation and interact with aggregation and interact with anticoagulant therapy. anticoagulant therapy.

Feverfew is contraindicated in nursing Feverfew is contraindicated in nursing mothers and in infants under two years of mothers and in infants under two years of age. age.

GARLICGARLICالثومالثوم

This product is the second best-selling product This product is the second best-selling product in World pharmacies, to a total of $10.1 million in World pharmacies, to a total of $10.1 million dollars in 1998. dollars in 1998.

The most prominent indication for garlic The most prominent indication for garlic preparations is to help treat hyperlipidemia and preparations is to help treat hyperlipidemia and hypercholesterolemia. It is also used to a hypercholesterolemia. It is also used to a lesser extent to treat hypertension and as an lesser extent to treat hypertension and as an antimicrobial.antimicrobial.

This botanical is generally considered This botanical is generally considered safe when used for dietary purposes,safe when used for dietary purposes,

but when taken in higher doses the but when taken in higher doses the potential for adverse effects becomes potential for adverse effects becomes possible. possible.

Garlic (Allium sativum) is considered to Garlic (Allium sativum) is considered to be contraindicated during pregnancy and be contraindicated during pregnancy and lactation.lactation.

In vitro and animal studies, it has shown In vitro and animal studies, it has shown uterine-stimulating effects.uterine-stimulating effects.

The odour of garlic has been noticed in the The odour of garlic has been noticed in the milk of lactating mothers and has been milk of lactating mothers and has been associated with colic in their children.associated with colic in their children.

One paper also suggests that this botanical be One paper also suggests that this botanical be avoided after tissue transplants, due to its avoided after tissue transplants, due to its reported ability to enhance natural killer cell reported ability to enhance natural killer cell function, a major mechanism responsible for function, a major mechanism responsible for tissue rejection.tissue rejection.

There have been reports of allergic There have been reports of allergic reactions to garlic preparations. reactions to garlic preparations.

Since garlic contains active thiol groups, Since garlic contains active thiol groups, it should be avoided by individuals who it should be avoided by individuals who suffer from attacks of pemphigus, a rare suffer from attacks of pemphigus, a rare auto-immune disease.auto-immune disease.

The most noted drug interaction with The most noted drug interaction with garlic involves its ability to enhance the garlic involves its ability to enhance the effectiveness of anticoagulants. effectiveness of anticoagulants.

There are case reports detailing There are case reports detailing excessive post-operative bleeding in excessive post-operative bleeding in patients who revealed a large, chronic patients who revealed a large, chronic garlic intake.garlic intake.

It is also possible that garlic may It is also possible that garlic may potentiate the anticoagulant effects of potentiate the anticoagulant effects of warfarin and ASA. warfarin and ASA.

One reference believes that garlic may One reference believes that garlic may interfere with existing diabetic interfere with existing diabetic management. This may be due to its management. This may be due to its hypoglycemic effect, which has been hypoglycemic effect, which has been documented in animal studies.documented in animal studies.

Regular dietary consumption of garlic Regular dietary consumption of garlic appears to be relatively safe.appears to be relatively safe.

Those patients currently taking Those patients currently taking anticoagulant medicines should be anticoagulant medicines should be cautioned about taking larger amounts of cautioned about taking larger amounts of garlic preparations.  garlic preparations. 

GINGERGINGERالزنجبيلالزنجبيل

Ginger is a soothing remedy for the Ginger is a soothing remedy for the stomach and an aid for indigestion. stomach and an aid for indigestion.

Larger doses have considerable Larger doses have considerable therapeutic effects. Larger than dietary therapeutic effects. Larger than dietary doses of ginger root (Zingiber officinale) doses of ginger root (Zingiber officinale) are used to help fight nausea, are used to help fight nausea, inflammation and indigestion.inflammation and indigestion.

The exact mechanism of action of ginger The exact mechanism of action of ginger is not known. Chemical constituents of is not known. Chemical constituents of ginger have demonstrated the ability to ginger have demonstrated the ability to inhibit platelet aggregation, inhibit inhibit platelet aggregation, inhibit prostaglandin synthesis, and antagonize prostaglandin synthesis, and antagonize 5-HT3 receptors. 5-HT3 receptors.

There have been no specific drug There have been no specific drug interactions noted with ginger. interactions noted with ginger.

Empirical evidence suggests that it Empirical evidence suggests that it should be used with caution when should be used with caution when patients are currently on anticoagulant patients are currently on anticoagulant therapy. therapy.

Yet, no case reports of bleeding Yet, no case reports of bleeding complications could be found. complications could be found.

Ginger is also considered to be Ginger is also considered to be contraindicated for patients with contraindicated for patients with gallstones. gallstones.

This is due to empirical and animal This is due to empirical and animal evidence suggesting that ginger is a evidence suggesting that ginger is a cholagogue, or a stimulator of bile flow.cholagogue, or a stimulator of bile flow.

Paradoxically, this botanical has an Paradoxically, this botanical has an argument for contraindication11 and argument for contraindication11 and efficacy when used in pregnancy.29 efficacy when used in pregnancy.29 Empirical evidence has stated that Empirical evidence has stated that ginger, when taken in larger amounts, ginger, when taken in larger amounts, can have emmenogogue and can have emmenogogue and abortifacient effects. abortifacient effects.

In contrast, there have been clinical trials In contrast, there have been clinical trials showing safety and efficacy in nausea showing safety and efficacy in nausea associated with pregnancy. The dose associated with pregnancy. The dose used was 250 mg powdered ginger, four used was 250 mg powdered ginger, four times a day. This appears to be the times a day. This appears to be the maximum dose to ensure safety in maximum dose to ensure safety in pregnancy. Many authors feel that ginger pregnancy. Many authors feel that ginger can be another treatment option for can be another treatment option for nausea during pregnancy.nausea during pregnancy.

GINKGOGINKGOالجنكوالجنكو

The fourth most popular botanical The fourth most popular botanical product in Canadian pharmacies product in Canadian pharmacies happens to be one of the oldest plant happens to be one of the oldest plant species known to man. Today it is used species known to man. Today it is used to help improve memory, intermittent to help improve memory, intermittent claudication, Alzheimer's and dementia. claudication, Alzheimer's and dementia.

The exact mechanism of action is not The exact mechanism of action is not known but it appears extracts of Ginkgo known but it appears extracts of Ginkgo biloba can inhibit platelet activating factor biloba can inhibit platelet activating factor (PAF). (PAF).

It is this inhibition of PAF that is It is this inhibition of PAF that is responsible for most of this herb's responsible for most of this herb's contraindications. contraindications.

The only absolute contraindication is The only absolute contraindication is hypersensitivity to Ginkgo biloba hypersensitivity to Ginkgo biloba preparations.preparations.

This may be due to the presence of This may be due to the presence of ginkgolic acids, which are similar ginkgolic acids, which are similar compounds to the allergens found in compounds to the allergens found in poison ivy. Its safety in pregnancy and poison ivy. Its safety in pregnancy and lactation has not been established. lactation has not been established.

Many authors caution that extracts of Many authors caution that extracts of Ginkgo biloba may potentiate the effects Ginkgo biloba may potentiate the effects of anticoagulants.of anticoagulants.

There have been case reports of ginkgo There have been case reports of ginkgo products causing bleeding complications products causing bleeding complications when taken alone,25 and when taken when taken alone,25 and when taken with ASA.with ASA.

One animal study investigated the One animal study investigated the effects on platelet aggregation with the effects on platelet aggregation with the combination of ginkgo and ticlopidine. combination of ginkgo and ticlopidine.

The results showed that there was The results showed that there was decreased platelet aggregation seen decreased platelet aggregation seen compared to ticlopidine alone. compared to ticlopidine alone.

For this reason, patients should be For this reason, patients should be warned about the possible impact that warned about the possible impact that extracts of Ginkgo biloba may have on extracts of Ginkgo biloba may have on their anticoagulant therapy. their anticoagulant therapy. 

GINSENGGINSENGالجنسغالجنسغ

Ginseng is the third most popular herbal Ginseng is the third most popular herbal product in Canadian pharmacies, with sales of product in Canadian pharmacies, with sales of $7.1 million in 1998.$7.1 million in 1998.

There are three types of ginseng commonly There are three types of ginseng commonly seen in pharmacies: Asian ginseng (Panax seen in pharmacies: Asian ginseng (Panax ginseng), Canadian or American ginseng ginseng), Canadian or American ginseng (Panax quinquefolium), and Siberian ginseng (Panax quinquefolium), and Siberian ginseng (Eleutherococcus senticosus). Siberian (Eleutherococcus senticosus). Siberian ginseng is not in the same genus as the Panax ginseng is not in the same genus as the Panax ginseng but it has a similar action on the body.ginseng but it has a similar action on the body.

Ginseng is used to help combat stress Ginseng is used to help combat stress and fatigue, and increase athletic and fatigue, and increase athletic performance.performance.

Many argue that there are few human Many argue that there are few human clinical studies to support ginseng use, clinical studies to support ginseng use, but its historical use in Asia should not be but its historical use in Asia should not be overlooked.overlooked.

It is believed that ginseng's ability to It is believed that ginseng's ability to alleviate fatigue involves the modulation alleviate fatigue involves the modulation of the hypothalamic-pituitary-adrenal axis of the hypothalamic-pituitary-adrenal axis (HPA). (HPA).

This can induce the secretion of This can induce the secretion of adrenocorticotropic hormone (ACTH), adrenocorticotropic hormone (ACTH), which assists in the production and which assists in the production and secretion of certain adrenal hormones. secretion of certain adrenal hormones. Ginseng also has the ability to stimulate Ginseng also has the ability to stimulate the CNS.the CNS.

There have been a few case reports of There have been a few case reports of drug interactions with Panax ginseng and drug interactions with Panax ginseng and Siberian ginseng. Siberian ginseng.

One case report revealed that taking One case report revealed that taking Panax ginseng with the monoamine Panax ginseng with the monoamine oxidase (MAO) inhibitor phenelzine led to oxidase (MAO) inhibitor phenelzine led to manic-like symptoms.manic-like symptoms.

In one clinical study, Panax ginseng had In one clinical study, Panax ginseng had a hypoglycemic effect in diabetic a hypoglycemic effect in diabetic patients.patients.

There is one case report of unexplained There is one case report of unexplained elevated digoxin levels while a patient elevated digoxin levels while a patient was taking Siberian ginseng. It is was taking Siberian ginseng. It is believed that this was due to believed that this was due to contamination of the Siberian ginseng contamination of the Siberian ginseng product.product.

Animal studies have shown both an Animal studies have shown both an increase and decrease in the increase and decrease in the effectiveness of barbiturate-induced effectiveness of barbiturate-induced sleeping time. sleeping time.

In one clinical study, Siberian ginseng In one clinical study, Siberian ginseng enhanced the efficacy of monomycin and enhanced the efficacy of monomycin and kanamycin in children under treatment for kanamycin in children under treatment for Shigella dysentery.Shigella dysentery.

It is recommended that all ginseng be It is recommended that all ginseng be used with caution in hypertension, used with caution in hypertension, premenopausal women with unstable premenopausal women with unstable hormonal cycles, concomitant use of hormonal cycles, concomitant use of stimulants and all people with diabetes.stimulants and all people with diabetes.

Its safety in pregnancy, lactation and Its safety in pregnancy, lactation and children has not been established. children has not been established.

There have been case reports There have been case reports concerning neonatal/ maternal concerning neonatal/ maternal androgenization with Panax ginseng use.androgenization with Panax ginseng use.

This effect was believed to be due to This effect was believed to be due to contamination.contamination.

Extract of ginseng has been shown to Extract of ginseng has been shown to inhibit the aggregation of human platelets inhibit the aggregation of human platelets and should be used with caution in and should be used with caution in people using anticoagulants. people using anticoagulants.

ST. JOHN'S WORTST. JOHN'S WORTالقلب حشيشة القلب الهيوفارقيون، حشيشة الهيوفارقيون،

Popular media has made this one of the Popular media has made this one of the more asked-about botanical products. more asked-about botanical products. Extracts of St. John's wort (Hypericum Extracts of St. John's wort (Hypericum perforatum) are used primarily to treat perforatum) are used primarily to treat mild to moderate depression.32mild to moderate depression.32

The mechanism of action is not quite The mechanism of action is not quite clear. However, studies have suggested clear. However, studies have suggested that this botanical may inhibit reuptake of that this botanical may inhibit reuptake of neurotransmitters (serotonin and neurotransmitters (serotonin and norepinephrine), inhibit monoamine norepinephrine), inhibit monoamine oxidase and catechol-O-oxidase and catechol-O-methyltransferase.methyltransferase.

Excessive exposure to UV-light is considered Excessive exposure to UV-light is considered to be contraindicated while taking St. John's to be contraindicated while taking St. John's wort. A constituent of St. John's wort, hypericin, wort. A constituent of St. John's wort, hypericin, can cause a photosensitization reaction in fair-can cause a photosensitization reaction in fair-skinned people. skinned people.

St. John's wort is considered contraindicated St. John's wort is considered contraindicated during pregnancy due to empirical evidence during pregnancy due to empirical evidence that it can act as an emmenogogue and that it can act as an emmenogogue and abortifacient. abortifacient.

In vitro and animal studies have demonstrated In vitro and animal studies have demonstrated uterine stimulatory action. uterine stimulatory action.

There is little published literature about human There is little published literature about human exposure to St. John's wort during pregnancy exposure to St. John's wort during pregnancy or lactation. or lactation.

There have been two case studies reported. In There have been two case studies reported. In one of the cases, there was late onset one of the cases, there was late onset thrombocytopenia and jaundice in the infant at thrombocytopenia and jaundice in the infant at the fifth day, but little information was provided the fifth day, but little information was provided about the second case. about the second case.

Until more is known, it would be advisable to Until more is known, it would be advisable to avoid the use of this product during avoid the use of this product during pregnancy.  pregnancy. 

VALERIANVALERIAN

الناردينالناردين

This herbal is best known for its ability to help This herbal is best known for its ability to help with sleeping difficulties. There is a small with sleeping difficulties. There is a small amount of clinical data regarding its efficacy, amount of clinical data regarding its efficacy, drug interactions and contraindications. It is drug interactions and contraindications. It is thought that valerian (Valeriana officinalis) thought that valerian (Valeriana officinalis) promotes sleep and relaxation via increased promotes sleep and relaxation via increased GABA secretion and inhibition of its reuptake.5 GABA secretion and inhibition of its reuptake.5 Most of the information on its safety is Most of the information on its safety is extrapolated from in vitro and animal findings.  extrapolated from in vitro and animal findings. 

Animal studies have shown increased sleeping Animal studies have shown increased sleeping times when valerian was given with times when valerian was given with pentobarbital and thipoental.pentobarbital and thipoental.

It is also believed that this botanical may It is also believed that this botanical may enhance the effects of other CNS depressants enhance the effects of other CNS depressants and alcohol. Due to possible teratogenic and alcohol. Due to possible teratogenic effects, seen in animal studies, it is considered effects, seen in animal studies, it is considered to be contraindicated in pregnancy until more is to be contraindicated in pregnancy until more is known. known.

The German Commission E monograph for The German Commission E monograph for valerian lists no contraindication or drug valerian lists no contraindication or drug interactions.interactions.

CONCLUSIONCONCLUSION

Pharmacists are considered to be reliable Pharmacists are considered to be reliable sources of information about self-sources of information about self-medication and over-the-counter (OTC) medication and over-the-counter (OTC) medications. One could argue that medications. One could argue that botanicals, vitamins and supplements botanicals, vitamins and supplements should be considered OTC medications. should be considered OTC medications.

As the most accessible and trusted As the most accessible and trusted healthcare professional, pharmacists are healthcare professional, pharmacists are in the unique position of being able to in the unique position of being able to extend the current definition of extend the current definition of pharmaceutical care to include the pharmaceutical care to include the appropriate and safe use of botanicals appropriate and safe use of botanicals and other supplements. and other supplements. 

As research has shown, many patients As research has shown, many patients do not tell their physicians about their do not tell their physicians about their supplement use.1 It is important that supplement use.1 It is important that pharmacists relay appropriate information pharmacists relay appropriate information about botanical safety. By utilizing the about botanical safety. By utilizing the information from this course and the information from this course and the other references listed, pharmacists other references listed, pharmacists should be able to answer most questions should be able to answer most questions related to the safe use of botanicals.  related to the safe use of botanicals. 

Dr. V.E. Tyler argues that true herbal Dr. V.E. Tyler argues that true herbal medicines have a greater safety profile medicines have a greater safety profile than allopathic drugs.36 In many cases than allopathic drugs.36 In many cases this is true, but in cases where botanicals this is true, but in cases where botanicals are used with prescription drugs it may are used with prescription drugs it may not hold true. One could argue that there not hold true. One could argue that there is little clinical evidence documenting is little clinical evidence documenting contraindications or drug interactions with contraindications or drug interactions with botanicals. botanicals.

It would be prudent to err on the side of It would be prudent to err on the side of caution based on the evidence available. caution based on the evidence available. As with pharmaceuticals, post-marketing As with pharmaceuticals, post-marketing adverse reaction reporting provides adverse reaction reporting provides valuable safety information. As a valuable safety information. As a profession, pharmacists should display profession, pharmacists should display pharmaco-vigilance by warning patients pharmaco-vigilance by warning patients about possible risks and documenting about possible risks and documenting adverse reactions to botanical products.adverse reactions to botanical products.