Clinicians Should Discuss Herbal Supplements with Their Patients

Clinicians Should Discuss Herbal Supplements with Their Patients
Clinicians Should Discuss Herbal Supplements with Their Patients

Goldenseal

Why is it popular?

Often formulated with echinacea, goldenseal is commonly used for upper respiratory tract and cold prevention.9  Others turn to goldenseal for gastrointestinal relief or as a topical antimicrobial.14  

Why is it problematic?

Goldenseal is associated with CYP2D6 and CYP3A4/5 enzyme inhibition leading to significant drug interactions.9,14,15  This can lead to increased concentrations of medications such as cyclosporine and midazolam.9

Patient Counseling

Some people use herbal medications such as goldenseal to prevent or treat colds or respiratory infections. Although you may think herbals are safe, many of them interact with numerous medications. This is the case for goldenseal. It may prevent the breakdown of many medications which ultimately increases their levels in your blood.Check with me if you are considering an herbal medication.


Kava Kava

Why is it popular?

Kava kava has been used as a sedative to help with anxiety.9,16,17

Why is it problematic?

Kava kava may inhibit cytochrome P450 enzymes (CYP450) and reduce the efficacy of levodopa.18  It is also associated with an increased risk of hepatotoxicity.17,19

Patient Counseling

Many people consider herbal medications to help with their anxiety.  Unfortunately, some of them like kava kava can interact with the breakdown of medications and cause liver damage. Always check with me if you are considering an herbal medication so we can discuss the potential benefits and risks.


St. John's Wort

Why is it popular?

St. John's Wort is one of the most commonly used herbal medicines.  It is often taken to manage depression and a variety of other mood disorders (e.g. generalized anxiety, obsessive compulsive, and seasonal affective disorders).  Some people also consume it for antimicrobial effects.20  

Why is it problematic?

St. John's Wort has been shown to significantly interact and inhibit the effects of numerous medications, predominantly through CYP450 (2C9, 2C19, 2D2 and 3A4) and/or P-glycoprotein induction.9,18,20  This can affect a variety of medications used to treat and/or manage cardiovascular disease (digoxin, warfarin, nifedipine, verapamil), hypercholesterolemia (simvastatin, atorvastatin), anxiety (amitriptyline, alprazolam, midazolam), infections (indinavir, nevirapine, erythromycin), gastrointestinal disorders (omeprazole), organ transplant (cyclosporine, tacrolimus), birth control (ethinyl estradiol, norethindrone), pain (methadone, oxycodone, ibuprofen), and cancer (irinotecan, imatinib).9,20

Patient Counseling

St John's Wort is a popular herbal medication that people think is safe but actually blocks the effects of many different types of common medications. If your medication is not working well enough or you are looking for something to help with your mood, please let me know. We have many options to choose from that have shown to work with minimal interactions to your other medications.


References

  1. Peregoy JA, Clarke TC, Jones LI, Stussman BJ, Nahin RL. Regional variation in use of complementary health approaches by U.S. adults. NCHS Data Brief. 2014;(146):1-8.
  2. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008;(12):1-23
  3. Wu CH, Wang CC, Kennedy J. The prevalence of herb and dietary supplement use among children and adolescents in the United States: Results from the 2007 National Health Interview Survey. Complement Ther Med. 2013;21(4):358-63.
  4. Cheung CK, Wyman JF, Halcon LL. Use of complementary and alternative therapies in community-dwelling older adults. J Altern Complement Med. 2007;13(9):997-1006.
  5. Wheaton AG, Blanck HM, Gizlice Z, Reyes M. Medicinal herb use in a population-based survey of adults: prevalence and frequency of use, reasons for use, and use among their children. Ann Epidemiol. 2005;15(9):678-85.
  6. Bruno JJ, Ellis JJ. Herbal use among US elderly: 2002 National Health Interview Survey. Ann Pharmacother. 2005;39(4):643-8.
  7. Kennedy J. Herb and supplement use in the US adult population. Clin Ther. 2005;27(11):1847-58.
  8. Caruso TJ, Gwaltney JM Jr. Treatment of the common cold with echinacea: a structured review. Clin Infect Dis. 2005;40(6):807-10.
  9. Gurley BJ, Fifer EK, Gardner Z. Pharmacokinetic herb-drug interactions (part 2): drug interactions involving popular botanical dietary supplements and their clinical relevance. Planta Med. 2012;78(13):1490-514.
  10. Schoop R, Klein P, Suter A, Johnston SL. Echinacea in the prevention of induced rhinovirus colds: a meta-analysis. Clin Ther. 2006;28(2):174-83.
  11. Tsai HH, Lin HW, Simon Pickard A, Tsai HY, Mahady GB. Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: a systematic literature review. Int J Clin Pract. 2012;66(11):1056-78.
  12. Bayan L, Koulivand PH, Gorji A. Garlic: a review of potential therapeutic effects. Avicenna J Phytomed. 2014;4(1):1-14.
  13. Ge B, Zhang Z, Zuo Z. Updates on the clinical evidenced herb-warfarin interactions. Evid Based Complement Alternat Med. 2014;2014:957362.
  14. Shi S, Klotz U. Drug interactions with herbal medicines. Clin Pharmacokinet. 2012;51(2):77-104.
  15. Gurley BJ, Swain A, Hubbard MA, et al. Clinical assessment of CYP2D6-mediated herb-drug interactions in humans: effects of milk thistle, black cohosh, goldenseal, kava kava, St. John's wort, and Echinacea. Mol Nutr Food Res. 2008;52(7):755-63.
  16. Ernst E. Herbal remedies for anxiety - a systematic review of controlled clinical trials. Phytomedicine. 2006;13(3):205-8.
  17. Sarris J, LaPorte E, Schweitzer I. Kava: a comprehensive review of efficacy, safety, and psychopharmacology. Aust N Z J Psychiatry. 2011;45(1):27-35.
  18. Izzo AA, Ernst E. Interactions between herbal medicines and prescribed drugs: an updated systematic review. Drugs. 2009;69(13):1777-98.
  19. Bunchorntavakul C, Reddy KR. Review article: herbal and dietary supplement hepatotoxicity. Aliment Pharmacol Ther. 2013;37(1):3-17.
  20. Russo E, Scicchitano F, Whalley BJ, et al. Hypericum perforatum: pharmacokinetic, mechanism of action, tolerability, and clinical drug-drug interactions. Phytother Res. 2014;28(5):643-55.