Clinicians Should Discuss Herbal Supplements with Their Patients

Complementary and alternative medicine (CAM) approaches have become popular options for disease state management and prevention by patients.  Some of the most common CAM options utilized in outpatient settings are nonvitamin, nonmineral dietary supplements (NNDS) which include herbal medicines.  It has been estimated that approximately 18% of adults 18 years of age and older use NNDS.^1,2  Utilization of CAM by adults also impacts children.  It has been shown that children of parents who partake in CAM activities have a two-fold higher incidence of NNDS use compared to other children.  Overall, approximately 4% of children and adolescents (2.9 million Americans) take herbs and/or dietary supplements.⁴  

People often seek herbals to maintain health and prevent or treat illness.^4,5  These products which are easily accessible in retail settings (e.g. pharmacies, grocery and nutritional supplement stores)  and online, may be viewed by patients as safe, natural, over-the-counter (OTC) alternatives or additions to conventional therapy but this may not necessarily be the case.  Use of herbals with conventional treatment can independently affect disease state management and lead to drug-herb interactions which can result in undesired side effects, toxicities and poorer outcomes. It is important to ask patients about their use of herbals so a discussion about the risks and benefits can occur.  Evidence suggests that >50% of elderly patients⁶ and 67% of adults⁷ do not report the use of herbal products to their healthcare provider.⁶  Taking the time to speak with patients can help reduce and potentially avoid drug-herb interactions and negative consequences associated with them. 

The following are some common herbal medications (echinacea, garlic, goldenseal, kava kava, and St. John’s Wort) with popular uses, potential risks and important counseling points for your patients.

Echinacea

Why is it popular?

Echinacea is often viewed by patients as an immune system booster so it may be used to treat and/or prevent colds.^8-10   

Why is it problematic?

Since echinacea is purported to exert its effects by enhancing the immune response, its safety concerns are associated more with exacerbating immune system related conditions (e.g. rheumatoid arthritis, systemic lupus erythematosus, and multiple sclerosis) rather than drug-herb interactions.¹¹

Patient Counseling

Speak with a health care professional if you are considering the use of echinacea for a respiratory sickness such as a cold. Since your condition is related to your immune system being overstimulated, echinacea can make it worse or counteract the effects of the medications used to treat it.

Garlic

Why is it popular?

Garlic is used by some for its anti-tumor and anti-microbial properties and to reduce the risk of cardiovascular disease and blood glucose levels.¹² 

Why is it problematic?

Although garlic is fairly safe, it may potentiate the anticoagulant effects of warfarin¹³ and reduce concentrations of saquinavir and ritonavir.⁹

Patient Counseling

Some people turn to garlic supplementation when managing some of their conditions. (For warfarin): Unfortunately, with your medication garlic may add to its effects and increase your risk of bleeding. You may notice that you bruise easier, have a little pink on your toothbrush when brushing your teeth or it may take more time to stop bleeding. If this becomes severe, you notice blood in your urine or stool or you start to have unusual bleeding such as nose bleeds call me or seek medical attention immediately. (For saquinavir/ritonavir): Unfortunately, garlic may reduce the levels and effects of your medication(s). Since it is extremely important to keep your medication levels consistent and your counts low, using garlic supplements could be harmful.