Herb-Drug Interaction, Herbs, Counseling, Herbal Preparation INTRODUCTION Matter, Etc
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International Journal of Pharmacy and Pharmaceutical Sciences, Vol. 1, Supply 1, Nov.-Dec. 2009 Review Article HERB-DRUG INTERACTIONS AND PATIENT COUNSELING MOHAMMAD YAHEYA MOHAMMAD ISMAIL* Dept. of Pharmacy, Higher College of Technology, P.O.Box 74 PC 133, Sultanate of Oman E mail: [email protected] (*Corresponding author) ABSTRACT Millions of people today use herbal therapies along with prescription and non prescription medications. Although considered natural, many of these herbal therapies can interact with other medications, causing either potentially dangerous side effects and / or reduced benefits from the medication. Currently, there is very little information published on herb-drug interactions whilst the use of herbs is progressively growing across the world. As there is large belief that herbal medicines are safe to use, it needs to be understood that depending on the amount and potency of the pharmacologic principles contained in the herbal preparation, potential exists for herb-drug interaction to occur when the herbal product is consumed with the modern day medicine. It should be understood that herbal preparations contain active phytochemicals in varying proportions which have a tendency like any other active pharmacological substance to alter the enzymatic systems, transporters and / or the physiologic process. The intent of this review is to update on some imminent issues that may arise if the modern medicine is mixed with a suspecting herbal preparation. These situations may arise in our daily lives due to the lack of strict adherence to regular drug prescription practices, unabated use of over the counter drug products and / or self prescription practices. Health-care practitioners should caution patients against mixing herbs and pharmaceutical drugs. Keywords: Herb-Drug Interaction, Herbs, Counseling, Herbal Preparation INTRODUCTION matter, etc. Herbal drugs constitute only those Herbs have been used for medicinal purposes traditional medicines, which primarily use since the beginning of recorded time. medicinal plant preparation for therapy. Although most people believe that herbs are WHO estimates that about three quarters of harmless plants, about one third of our drugs world population currently use herbs and (including digitalis, morphine, atropine and other forms of traditional medicines to treat several chemotherapeutic agents) were developed their disease. Even as we entered into the new from plants. So, indeed, herbs can be potent century with its exciting prospect of gene products. Herbs can affect body functions; therapy, herbal medicines remain one of the therefore, when herbs are taken concurrently common forms of therapy available to the with drugs, interactions are possible. world population. The increasing awareness of herbal medicines Botanical medications have increased in is acknowledged by World Health popularity. In the United States, botanical Organization (WHO). WHO has recently products are now a $1.5 billion per year defined traditional medicine (including herbal industry. It is estimated that 60% to 70% of drugs) as comprising therapeutic practices the American population is taking botanical that have been in existence, almost for several products, but less than one third of these hundreds of years, before the development persons inform their medical practitioners of and spread of modern medicine and still in such use1. use today. The traditional preparations Today, our understanding of the interactions comprise medicinal plants, minerals, organic between drugs and herbs and between drugs 151 and food is still in its infancy. Much research increases with the number of products is still required in herbal therapy to examine consumed e.g., for 2 products, the risk is 6%; individual plant constituents and to determine for 5 products, 50%; and for 8 or more how plants interact with drugs and food. products, 100%4. The mechanisms for drug Some researchers suggest that herb-drug interaction can be divided into two general interactions occur less often than predicted. If categories i.e. pharmacokinetics (absorption, an interaction between an herb and a drug distribution, metabolism, and excretion of a does occur, conventional drugs are usually drug) and pharmacodynamic interactions (the the culprits because they are more combined pharmacological effects of a drug). pharmacologically active2, 3. Pharmacokinetic interactions In this review an attempt has been made to Absorption update the most commonly occurring herb- Herbs that have hydrocolloidal carbohydrate drug interactions. components such as gums and mucilage are HERB-DRUG INTERACTIONS soluble in water but poorly absorbable; Many medicinal herbs and pharmaceutical examples include psyllium, rhubarb, flax- drugs are therapeutic at one dose and toxic at seed, marshmallow and aloe. These another. Interactions between herbs and drugs compounds bind to other drugs, particularly may increase or decrease the pharmacological when consumed in their whole or powdered or toxicological effects of either component. forms. For example, psyllium (an herb high in Synergistic therapeutic effects may mucilage) inhibits the absorption of lithium. complicate the dosing of long-term Rhubarb and aloe can cause diarrhea, which medications e.g., herbs traditionally used to reduces the action of drugs that have a narrow decrease glucose concentrations in diabetes therapeutic index (eg, digoxin, warfarin). In could theoretically precipitate hypoglycaemia order to prevent an herb from binding with if taken in combination with conventional drugs, the drug should be taken 1 hour before drugs. Because of the possible herb–drug or 2 hours after these herbal products. interactions, health care providers need to be Distribution aware of herb and supplement use by their Herbs such as meadowsweet and black patients 1. willow, which contain pain-reducing A drug interaction is defined as any salicylates, may displace highly protein- modification caused by another exogenous bound drugs such as warfarin and chemical (drug, herb or food) in the carbamazepine thus increasing the adverse diagnostic, therapeutic or other action of a effects of these drugs. These products should drug in or on the body. The possibilities of not be taken concurrently 2, 3. drug interaction are endless, because more Metabolism than 30000 over-the-counter products; more Liquorice (as an herb, not a sweetener) than 1000 unique chemical substances from decreases the metabolism of corticosteroids, which prescription drugs are produced; and leading to adverse and toxic effects from the hundreds of herbs, vitamins and minerals are buildup of corticosteroids. Recently, available. The risk for drug interactions researchers discovered that St. John’s wort 152 can induce hepatic microsomal enzymes in Many medicinal herbs contain anticoagulant the cytochrome P-450 system; thus, it coumarins (not all coumarins are increases the metabolism of drugs anticoagulant), which can also have additive metabolized in this system, such as digoxin effects when combined with pharmaceutical and theophylline, protease inhibitors and anticoagulants7. A Chinese herb, danshen cyclosporine. The drugs are thus rendered less (Salvia miltiorrhiza) has been associated with effective, so concurrent use of liquorice with three cases of profound anticoagulation in these drugs is not recommended 2, 3. patients on warfarin. Dong quai or danggui Pharmacodynamic interactions (Angelica sinensis, syn A. polymorpha), An example of a pharmacodynamic another Chinese herb, doubled prothrombin interaction is additive activity. For example, time (PT) and International Normalized Ratio the hypnotic activity of benzodiazepines is (INR) in a 46-year-old African-American increased by valerian and the anticoagulant woman, previously stabilized on warfarin, action of warfarin is enhanced by ginkgo and who had ingested dong quai for four weeks. possibly by many other herbs. It is best not to Laboratory values normalized within one take these products concurrently 3. month of discontinuing the herb8. In rabbits, INTERACTION RISKS IN SPECIFIC dong quai extract affected neither baseline PT PATIENT POPULATIONS nor warfarin pharmacokinetics9. Given the The following section reviews potential case reports, however, caution would dictate effects of dietary supplements in patients that patients avoid combining dong quai with taking anticoagulants, cardiovascular warfarin. medications, psychiatric medications, laxatives, In one poorly documented case report, the diabetic medications or medications for anticoagulant effect of warfarin was human immunodeficiency virus (HIV) potentiated by consuming an extract of the infection. green fruit of papaya (Carica papaya) 10. Patients receiving anticoagulants Green papayas, high in papain are commonly Warfarin and other coumarin anticoagulants consumed in Southeast Asia. Although interact with many drugs, foods and feverfew (Tanacetum parthenium) and ginger medicinal herbs. Both garlic (Allium sativum) (Zingiber officinale) often are invoked as and ginkgo (Ginkgo biloba) interfere with anticoagulant herbs in the literature, no cases platelet function in vitro and may increase the of bleeding problems have been linked to risk of bleeding when combined with these herbs. Although feverfew extracts and warfarin. Garlic inhibits platelet aggregation its sesquiterpene lactone constituents, notably and fibrinolytic activity in both patients with parthenolide, inhibit platelet aggregation by coronary artery disease