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Home , Anidulafungin, Voriconazole

Herbal interactions for clinicians

Antifungal Herbal interaction - As Aloe Moderate, use carefully. Aloe latex can possibly reduce absorption of some drugs due to delayed GI transit time.1 Moderate possible, use carefully. Aloe latex can possibly reduce absorption of some drugs due to delayed GI transit time.1 Unknown (no interaction found). isavuconazole Unknown (no interaction found). Moderate possible, use carefully. Aloe latex can possibly reduce absorption of some drugs due to delayed GI transit time.1 Unknown. Unknown. Unknown. Moderate possible, use carefully. Aloe latex can possibly reduce absorption of some drugs due to delayed GI transit time.1 Unknown.

Antifungal Herbal interaction - Cs Cannabidiol (CBD) itraconazole Moderate, use carefully. CBD possibly increases itraconazole levels and side effects.2 Itraconazole possibly increases CBD levels and side effects. Consider reducing CBD dose.4 voriconazole Severe – do not take CBD as it can increase voriconazole levels and side effects.3 posaconazole Moderate, use carefully. Posaconazole possibly increases CBD levels and side effects. Consider reducing CBD dose.4 isavuconazole Moderate, use carefully. CBD possibly increases isavuconazole levels and side effects.2 Isavuconazole possibly increases CBD levels and side effects. Consider reducing CBD dose.4 fluconazole Moderate, use carefully. Fluconazole possibly increases CBD levels and side effects. Consider reducing CBD dose.4 anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

Antifungal Herbal interaction - Cs Chaparral itraconazole Theoretical interaction – potential additive effects on the when used with hepatotoxic drugs, as it is a hepatotoxin itself.5 voriconazole Theoretical interaction – potential additive effects on the liver when used with hepatotoxic drugs, as it is a hepatotoxin itself.5 posaconazole Theoretical interaction – potential additive effects on the liver when used with hepatotoxic drugs, as it is a hepatotoxin itself.5 isavuconazole Theoretical interaction – potential additive effects on the liver when used with hepatotoxic drugs, as it is a hepatotoxin itself.5 fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Theoretical interaction – potential additive effects on the liver when used with hepatotoxic drugs, as it is a hepatotoxin itself.5 Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Cs Chlorella itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Cs Coltsfoot itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

Antifungal Herbal interaction - Cs Cumin itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Es Elecampne itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Es Eucalyptus itraconazole Moderate – use cautiously or avoid. Eucalyptus oil might inhibit CYP3A4, so may increase levels of itraconazole – monitor.6 voriconazole Moderate – use cautiously or avoid. Eucalyptus oil might inhibit CYP3A4, so may increase levels of itraconazole – monitor.6 posaconazole Unknown – no interactions found. isavuconazole Moderate – use cautiously or avoid. Eucalyptus oil might inhibit CYP3A4, so may increase levels of itraconazole – monitor.6 fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

Antifungal Herbal interaction - Gs Garlic itraconazole Mild - products with no significant allicin content such as garlic oil and extracts containing allicin and allinase, don’t seem to affect CYP3A4. Until more is known about a potential interaction though, use cautiously.7 voriconazole Mild - products with no significant allicin content such as garlic oil and extracts containing allicin and allinase, don’t seem to affect CYP3A4. Until more is known about a potential interaction though, use cautiously.7 posaconazole Unknown – no interactions found. isavuconazole Mild - products with no significant allicin content such as garlic oil and extracts containing allicin and allinase, don’t seem to affect CYP3A4. Until more is known about a potential interaction though, use cautiously.7 fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Gs Ginger (tea) itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ks Knotweed itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found. Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

Antifungal Herbal interaction - Ls Licorice itraconazole Mild - Licorice extract from G.glabra species contains the constituent glabridin, which is a moderate CYPA4 inhibitor in vitro, so might increase itraconazole levels. It’s not present in other licorice species. Use cautiously with CYP3A4 substrates until more is known about interactions.8 voriconazole Mild - Licorice extract from G.glabra species contains the constituent glabridin, which is a moderate CYPA4 inhibitor in vitro, so might increase voriconazole levels. It’s not present in other licorice species. Use cautiously with CYP3A4 substrates until more is known about interactions.8 posaconazole Unknown – no interactions found. isavuconazole Mild - Licorice extract from G.glabra species contains the constituent glabridin, which is a moderate CYPA4 inhibitor in vitro, so might increase isavuconazole levels. It’s not present in other licorice species. Use cautiously with CYP3A4 substrates until more is known about interactions.8 fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ls Lobelia itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ls Lungwort itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ms Marshmallow leaf tea itraconazole Moderate – use with caution. Possible interaction – mucilage in marshmallow may impair absorption of oral drugs.1 voriconazole Moderate – use with caution. Possible interaction – mucilage in marshmallow may impair absorption of oral drugs.1 posaconazole Moderate – use with caution. Possible interaction – mucilage in marshmallow may impair absorption of oral drugs.1 isavuconazole Moderate – use with caution. Possible interaction – mucilage in marshmallow may impair absorption of oral drugs.1 fluconazole Moderate – use with caution. Possible interaction – mucilage in marshmallow may impair absorption of oral drugs.1 anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Moderate – use with caution. Possible interaction – mucilage in marshmallow may impair absorption of oral drugs.1 Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ms Mullein itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Os Oregano itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Os Osha root itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ps Pelargonium root itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ps Peppermint oil itraconazole Moderate - possible interaction, use cautiously. Peppermint oil may inhibit CYP3A4 particularly at high concentrations. So it may increase levels of drugs metabolised by CYP3A4, such as itraconazole.6 voriconazole Moderate – possible interaction, use cautiously. Peppermint oil may inhibit CYP3A4 particularly at high concentrations. So it may increase levels of drugs metabolised by CYP3A4, such as voriconazole. 6 posaconazole Moderate – possible interaction, use cautiously. Peppermint oil may inhibit CYP3A4 particularly at high concentrations. So it may increase levels of drugs metabolised by CYP3A4.6

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

isavuconazole Moderate – possible interaction, use cautiously. Peppermint oil may inhibit CYP3A4 particularly at high concentrations. So it may increase levels of drugs metabolised by CYP3A4. 6 fluconazole Moderate – possible interaction, use cautiously. Peppermint oil may inhibit CYP3A4 particularly at high concentrations. So it may increase levels of drugs metabolised by CYP3A4.6 anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ps Plantain Leaf itraconazole Moderate – probable interaction. Black psyllium (plantain leaf 1:1 extract) theoretically might slow or reduce absorption of some oral drugs. Take black psyllium 30-60 minutes after oral medication.9 voriconazole Moderate – probable interaction. Black psyllium (plantain leaf 1:1 extract) theoretically might slow or reduce absorption of some oral drugs. Take black psyllium 30-60 minutes after oral medication.9 posaconazole Moderate – probable interaction. Black psyllium (plantain leaf 1:1 extract) theoretically might slow or reduce absorption of some oral drugs. Take black psyllium 30-60 minutes after oral medication.9 isavuconazole Moderate – probable interaction. Black psyllium (plantain leaf 1:1 extract) theoretically might slow or reduce absorption of some oral drugs. Take black psyllium 30-60 minutes after oral medication.9 fluconazole Moderate – probable interaction. Black psyllium (plantain leaf 1:1 extract) theoretically might slow or reduce absorption of some oral drugs. Take black psyllium 30-60 minutes after oral medication.9 anidulafungin Unknown – no interaction found. caspofungin Unknown – no interaction found. micafungin Unknown – no interaction found. terbinafine Moderate – probable interaction. Black psyllium (plantain leaf 1:1 extract) theoretically might slow or reduce absorption of some oral drugs. Take black psyllium 30-60 minutes after oral medication.9 Amphotericin B Unknown – no interaction found.

Antifungal Herbal interaction - Ss Sage itraconazole Moderate – possible interaction, use with caution. Aqueous extracts of sage may inhibit CYP3A4 in vitro, but this has not been reported in humans as yet. Until more is known use cautiously when taking drugs metabolised by CYP3A4. 10 Common sage (salvia officinalis) may also inhibit P-glycoprotein in vitro. So theoretically sage may increase levels of drugs affected by P- glycoprotein, such as itraconazole, but clinical relevance is unclear.11

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

voriconazole Moderate – possible interaction, use with caution. Aqueous extracts of sage may inhibit CYP3A4, CYP2C19 and CYP2C9 in vitro, but this has not been reported in humans as yet. Until more is known use carefully when taking drugs metabolised by CYP3A4 and CYP2C9 such as voriconazole. 10 Common sage (salvia officinalis) may also inhibit P-glycoprotein efflux transport in vitro. So theoretically sage may increase levels of drugs affected by P-glycoprotein, but clinical relevance is unclear. 11 posaconazole Moderate – possible interaction, use with caution. Common sage (salvia officinalis) may inhibit P-glycoprotein in vitro. So theoretically sage may increase levels of drugs affected by P-glycoprotein, such as posaconazole, but clinical relevance is unclear.11 isavuconazole Moderate – possible interaction, use with caution. Aqueous extracts of sage may inhibit CYP3A4 in vitro, but this has not been reported in humans as yet. Until more is known use carefully with drugs metabolised by CYP3A4. 10 fluconazole Unknown - no interactions found. anidulafungin Unknown - no interactions found. caspofungin Unknown - no interactions found. micafungin Unknown - no interactions found. terbinafine Unknown - no interactions found. Amphotericin B Unknown - no interactions found.

Antifungal Herbal interaction - Ss St. John’s Wort (SJW) itraconazole Severe interaction – do not take this combination. Clinically significant interactions reported with SJW containing 1mg hyperforin or more. SJW induces CYP3A4, so can reduce levels of drugs metabolised by CYP3A4, such as itraconazole. 12 SJW induces P-glycoprotein, so this can prevent absorption of some medications such as itraconazole. 13 voriconazole Severe interaction – do not take this combination. SJW induces CYP2C19, CYP3A4 and CYP2C9. SJW increases voriconazole metabolism by approximately 107%, primarily by CYP2C19, with CYP2C9 and CYP3A4 also involved. SJW reduces exposure to voriconazole and increases its elimination, so it may reduce its antifungal effect.14 posaconazole Unknown – no interactions found. isavuconazole Severe interaction – do not take this combination. Clinically significant interactions reported with SJW containing 1mg hyperforin or more. SJW induces CYP3A4, so can reduce levels of drugs metabolised by CYP3A4, such as itraconazole. 12 SJW induces P-glycoprotein, so this can prevent absorption of some medications such as itraconazole. 13 fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

Antifungal Herbal interaction - Ts (in diffuser) itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ts Thyme itraconazole Unknown – no interactions found. voriconazole Unknown – no interactions found. posaconazole Unknown – no interactions found. isavuconazole Unknown – no interactions found. fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found. Amphotericin B Unknown – no interactions found.

Antifungal Herbal interaction - Ts Turmeric (curcumin) itraconazole Moderate – theoretical interaction. Turmeric and its constituent curcumin inhibit CYP3A4 in vitro, so might increase levels of metabolised by CYP3A4 in clinical practice, monitor.15 Curcuminoids and other constituents in turmeric can increase P-glycoprotein activity, so may increase absorption of P- glycoprotein substrates.16 voriconazole Moderate – theoretical interaction. Turmeric and its constituent curcumin inhibit CYP3A4 in vitro, so might increase levels of antifungals metabolised by CYP3A4 in clinical practice, monitor.15 posaconazole Unknown – no interactions found. isavuconazole Moderate – theoretical interaction. Turmeric and its constituent curcumin inhibit CYP3A4 in vitro, so might increase levels of antifungals metabolised by CYP3A4 in clinical practice, monitor.15 fluconazole Unknown – no interactions found. anidulafungin Unknown – no interactions found. caspofungin Unknown – no interactions found. micafungin Unknown – no interactions found. terbinafine Unknown – no interactions found.

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe

Amphotericin B Unknown – no interactions found.

References

1. Brinker F. Herb contraindications and drug interactions 2nd ed. Sandy OR. Eclectic Medical Publications. 1998. 2. Yamaori S, Ebisawa J, Okushima Y et al. Potent inhibition of human 3A isoforms by cannabidiol: role of phenolic hydroxyl groups in the resourcinol moiety Life Sci 2011; 88(15-16): 730-6. 3. Harvey DJ. Absorption, distribution and biotransformation of the cannabinoids. Marijuana and medicine. 1999; 91-103. 4. Epidiolex (cannabidiol) prescribing information. Greenwich Biosciences, Inc., Carlsbad, CA, 2019. Available at: www.epidiolex.com/sites/default/files/EPIDIOLEX_Full_Prescribing_Information.pdf (accessed 5/9/2019) 5. Estes JD, Stolpman D, Olyaei A, et al. High prevalence of potentially hepatotoxic herbal supplement use in patients with fulminant hepatic failure. Arch Surg 2003;138:852-8.. View abstract. 6. Unger M, Frank A. Simultaneous determination of the inhibitory potency of herbal extracts on the ativity of six major cytochrome P450 enzymes using liquid chromatography/mass spectrometry and automated online extraction. Rapid Commun Mass Spectrom 2004:18:2273-81. 7. Gallicano K, Foster B, Choudhri S. Effect of short-term administration of garlic supplements on single- dose in healthy volunteers. Br J Clin Phamacol 2003;55(2):199-202. 8. Kent UM, Aviram M, Rosebblat M. Hollenberg PF. The licorice root derived isoflavan glabridin inhibits the activities of human cytochrome P4502 3A4, 2B6 and 2C9. Drug Metab. Dispos 2002;30:709-15. 9. Semen plantaginis in: WHO Monographs on selected medicines plants, volume 1. World Health Organization, Geneva, 1999. Available at https://apps.who.int/medicinedocs/en/d/Js2200e/22.html Accessed 11 March 2020. 10. Foster BC, Vandenhoek S, Hana J et al. In vitro inhibition of human cytochrome P450-mediated metabolism of marker substrates by natural products. Phytomedicine 2003;10:334-42. 11. Hellum BH and Nilsen OG. In vitro inhibition of CYP3A4 metabolism and P-glycoprotein-mediated transport by trade herbal products. Basic Clin Pharmacol Toxicol. 2008;102(5):466-475. 12. Roby CA, Anderson GD, Kantor E et al. St. John Wort’s: Effect on CYP3A4 activity. Clin Pharmacol Ther 2000;67:451-7. 13. Hennessy M, Kelleher D, Spiers JP et al. St John’s Wort increases expression of P-glycoprotein: implications for drug interactions. Br J Clin Pharmacol 2002:53:75-82. 14. Dolton MJ, Mikus G, Weiss J et al. Understanding variability with voriconazole using a population pharmacokinetic approach: implications for optimal dosing. J Antimicrob Chemother 2014;69(6):1633-41. 15. Appiah-Opong R, Commandeur JN, Vugt-Lussenburg B and Vermeulen NP. Inhibition of human recombinant cytochrome P450s by curcumin and curcumin decomposition products. Toxicology 6-3- 2007;235(1-2):83-91. 16. Junyaprasert VB, Soonthorncharennon N, Thongpraditchote S, Murakami T and Takano M. Inhibitory effect of Thai plant extract on P-glycoprotein mediated efflux. Phytother. Res. 2006;20(1);79-81.

Some of these references cited in the Natural Medicines Database are very old, but from searching PubMed, I was unable to find more recent citations.

Interactions searched via: https://naturalmedicines.therapeuticresearch.com/tools/interaction- checker.aspx#P

Interactions key: Mild Moderate Severe