Appendix

Tab. A1: Abnormal clinical laboratory test results due to use of herbal supplements

Herbal supplement Abnormal test result Comments

Abnormal liver function tests

Kava Highly elevated liver enzymes

Kavalactones cause liver damage

Death attributed to kava toxicity

Chaparral, comfrey Signifi cantly elevated liver enzymes

Liver toxicity is a major concern

Germander Signifi cantly elevated liver enzymes

Teucrin A is a liver toxin

LipoKinetix May elevate liver enzymes

Sodium usniate causes liver damage

Pennyroyal May elevate liver enzymes

Pulegone is a liver toxin

Mistletoe May elevate liver enzymes

Viscotoxins and lectins are liver toxins

Abnormal kidney function tests

Chinese weight loss products Elevated creatinine and urea

Certain Chinese weight loss products containing aristolochic acid

Calamus, sassafras, wormwood Elevated creatinine These herbs may damage kidney

Abnormal thyroid profi le

Kelp Abnormal TSH, T3 and T4

Kelp contains high amounts of iodine and interferes with thyroid function

Unexpected hypoglycemia

Ginseng, fenugreek Lower glucose level May lower glucose but not suitable for treating diabetes

Chromium Lower glucose level Chromium can sensitize insulin, causing hypoglycemia

Milk thistle May lower glucose

Unexpectedly elevated digoxin

Oleander, Chan Su, Lu-Shen-Wan

Signifi cantly elevated digoxin

Supplements interfere with digoxin immunoassays

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Tab. A2: Clinically signifi cant drug-herb interactions

Herbal supplement Interacting drug Comments

Boldo Warfarin Risk of bleeding

Borage Warfarin Risk of bleeding

Bromelain Naproxen Increased bleeding

Coenzyme Q10 HydrochlorothiazideMetformin, GlipizideWarfarin

HypotensionHypoglycemiaRisk of bleeding

Devil’s claw Warfarin Risk of bleeding

Echinacea Ketoconazole, methotrexateSimvastatin, lansoprazole

Liver toxicityIncreased effect

Evening primrose oil Warfarin Risk of bleeding

Fenugreek Warfarin Risk of bleeding

Feverfew IronCyclosporine, azathioprineTacrolimusWarfarin

Reduced absorptionReduced effectReduced effectRisk of bleeding

Fish oil MetoprololWarfarin

HypotensionRisk of bleeding

Flaxseed oil Aspirin Increased bleeding

Garlic SaquinavirIbuprofenChlorpropamideWarfarin

Reduced effectBleedingHypoglycemiaRisk of bleeding

Ginkgo biloba Aspirin, clopidogrelDipyridamole, ticlopidineTrazodonePhenytoin, valproic acidWarfarin

BleedingBleedingComaReduced effectsRisk of bleeding

Ginger Warfarin Risk of bleeding

Glucosamine AcetaminophenGlyburide

Reduced effectHyperglycemia

Golden seal Warfarin Reduced effi cacy

Green tea Warfarin Reduced effi cacy

Horse chestnut Warfarin Risk of bleeding

Kava Alprazolam, benzodiazepines Coma

Licorice Atenolol Hypotension

Milk thistle Warfarin Reduced effi cacy

Saw palmetto AspirinWarfarin

BleedingRisk of bleeding

(Continued )

116 Appendix

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Herbal supplement Interacting drug Comments

St. John’s wort Cyclosporine, tacrolimusWarfarinIndinavir, saquinavir, atazanavirLamivudine, nevirapineImatinib, irinotecanDigoxin, verapamil, nifedipineAlprazolam, midazolam, quazepamMephenytoin, phenobarbitalGliclazideErythromycin, voriconazoleTheophyllineOmeprazoleSimvastatin, atorvastatinEthinylestradiol and related compoundsAmitriptyline, methadone, oxycodone

Reduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacyReduced effi cacy

Valerian Midazolam, barbiturates Increased sedation

Tab. A3: Important fruit juice-drug interactions

Fruit juice Interacting drug Comments

Grapefruit FelodipineNitrendipinePranidipineNimodipineAmiodaroneSimvastatinAtorvastatinPitavastatin, lovastatinDiazepam, triazolam, midazolamCarbamazepineCyclosporine, tacrolimusSaquinavirItraconazoleColchicineFexofenadineDigoxinPhenytoin

Several fold increase in blood levelIncreased bioavailability by 100%73% increase in bioavailabilityModest increase in bioavailabilitySignifi cantly increased AUCAUC may be increased 3.6 foldAUC increased by 83%Modest increase in AUCSignifi cantly increased blood level

Increased blood levelModest to signifi cant increase in blood levelsSignifi cant increase in blood levelModest increase in blood levelIncreased toxicityReduction in blood levelNo interactionNo interaction

Orange PravastatinCeliprolol

Signifi cant increase in AUCAUC reduced by 83%

Seville orange Felodipine AUC increased by 76%

Pomelo Cyclosporine, tacrolimusSildenafi l

Increased blood levelReduced blood level

Pomegranate CarbamazepineWarfarin

Increased AUC by 1.5 foldIncreased effectiveness

Cranberry Warfarin INR >50 in a patient causing death

(Continued )

Appendix 117

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Brought to you by | National Chung Hsing UniversityAuthenticated | 140.120.135.222Download Date | 3/29/14 3:03 PM