Drug and Nutraceutical Interplay Maureen Jennings, DPM, MS Masters in Doctor of Podiatric LECTURE OUTLINE

• REVIEW TODAY’S POPULAR NUTRACEUTICALS • REVIEW -DRUG INTERACTIONS • REVIEW DRUG-NUTRACEUTICAL INTERACTIONS • REVIEW POSSIBLE ADVERSE EFFECTS OF NUTRACEUTICAL/- DRUG INTERPLAY

Geriatric Popular Nutraceuticals

• - • GREEN TEA CHONDROITIN • THISTLE • ECHINACEA • SAINT JOHN’S WORT • GARLIC • SAW PALMETTO • GINKGO BIBOLA • TUMERIC • NUTRACEUTICALS AND THEIR POSSIBLE BENEFITS • GLUCOSAMINE-CONDROITIN: STRUCTURAL ELEMENTS OF CARTILAGE. EXPERTS DISAGREE ON HELP FOR OA. • ECHINACEA: TREATMENT FOR COMMON COLD, BRONCHITIS. CERTAIN PREPARATIONS SHOW SOME BENEFITS. • GARLIC: IMPROVE BLOOD PRESSURE , CHOLESTEROL LEVEL,BOOSTS THE IMMUNE SYSTEM. CONTAINS K+, CA++, B6,C AND FIBER • GINKGO BIBOLA: ANTIOXIDANT,FIGHTS INFLAMMATION, INCREASES BLOOD FLOW, DECREASE SYMPTOMS OF DEMENTIA,REDUCE ANXIETY. • GINSENG: BETTER MEMORY, INCREASE ENERGY,STIMULATES INSULIN PRODUCTION, HEADACHE RELIEF, REDUCE STRESS. NUTRACEUTICAL BENEFITS CONT’D

GREEN TEA: POWERFUL ANTIOXIDANT, IMPROVES BRAIN FUNCTION, REDUCE BLOOD SUGAR, STABALIZE CHOLESTEROL LEVELSREDUCES BODY WEIGHT. MILK THISTLE: BOOST THE HEALTH OF THE LIVER AND FILTER HARMFUL TOXINS. ST JOHN’S WORT: DEPRESSION-INCREASES SEROTONIN. SAW PALMETTO: ENLARGED PROSTRATE, HAIR LOSS,LOW SPERM COUNT TUMERIC:CONTAINS CURCUMIN-POWERFUL ANTI-INFLAMMATORY, INCREASES ANTI-OXIDANT CAPACITY OF THE BODY, DEPRESSION

REVIEW OF DRUG-DRUG INTERACTIONS

• DRUG INTERACTION IS DEFINED AS ONE DRUG ALTERING THE INTENSITY OF THE PHARMACOLOGICAL EFFECT OF ANOTHER DRUG • THE ALTERATION CAN HAPPEN DURING DRUG ABSORPTION, METABOLISM OR EXCRETION PHARMACOKINETICS • ABSORPTION: ALTERATIONS IN GASTRIC pH , EMPTYING TIME • DISTRIBUTION: AFFECT THE DEVELOPMENT OF DRUG- PROTEIN COMPLEXES WHICH CAN INCREASE OR DECREASE FREE DRUG • METABOLISM: RESULT IN EITHER MORE OR LESS AVAILABLE DRUG DEPENDING ON WHICH METABOLIC PATHWAY IS TAKEN • ELIMINTION: ALTER THE GFR, TUBULAR SECRETION OR TUBULAR REABSORPTION

NUTRACEUTICAL DRUG INTERACTIONS

• ECHINACEA: MAY AFFECT CYP1A2 & CYP3A4 WHICH CAN AFFECT SOME ANTIPYSCHOTICS AND ANTI-DEPRESSANTS • GARLIC: WILL DECREASE THE CONCENTRATION OF THAT USE THE P-GLYCOPROTEIN TRANSPORTER SYSTEM (COLCHICINE,CRESTOR) • GINKGO: INHIBITS PLATELET AGGREGATION- INCREASE BLEEDING • GINSENG:INDUCES CYP3A4-DECREASE CHANNEL BLOCKERS,STATINS NUTRACEUTICAL-DRUG INTERACTION CONT’D • GREEN TEA: INCREASE ZOCOR DUE TO p-GLYCOPROTEIN INHIBITION. ALSO QUINOLONE AND SOME BETA BLOCKERS • MILK THISTLE: POTENTIAL TO DECREASE WARFARIN, PHENYTOIN AND DIAZEPAM – THEY ARE METABOLIZED BY CYP2C9 • ST JOHN’S WORT: INDUCES CYP3A4 AND P-GLYCOPROTEIN THEREFORE DECREASE THE EFFECTIVENESS OF WARFARIN, DIGOXIN, THEOPHYLLINE P-GLYCOPROTEIN NUTRACEUTICAL OVERDOSES POISON CONTROL 8OO- 222-1222

• GLUCOSAMINE-CHONDROITIN= NAUSEA, HEARTBURN, DIARRHEA, CONSTIPATION. USE AS DIRECTED-1,500MG • ECHINACEA=AVOID CAFFEINE- CAN LEAD TO HEADACHES, PALPATATIONS, JITTERINESS. USE AS DIRECTED. • GARLIC= ODOR, SKIN IRRITATION,HEADACHE, VMITING AND HEARTBURN. 300-1,500 MG AS TOLERATED. NUTRACEUTICAL OVERDOSE

• GINKGO BIBOLA=DIARRHEA, N & V, LACK OF MUSCLE TONE, EASY BLEEDING. 80-480 MG/DAY • GINSENG= TACHYCARDIA, PALPITATIONS, HYPOGLYCEMIA. 1-2 GRAMS DAILY • GREEN TEA= CAFFEINE INTOLERANCE, DEPLETION OF MINERALS(FE), DEHYDRATION, ACID REFLUX. NO MORE THAN 3 CUPS PER DAY. • MILK THISTLE=ABDOMINAL BLOATING, DIARRHEA, GAS, LOSS OF APPETITE. LIVER: 160-800MG DAILY. DIABETES:200-230MG/D NUTRACEUTICAL OVERDOSE

ST JOHN’S WORT= FEVER, HALLUCINATIONS, DIFFICULTY WALKING, RAPID HEART BEAT. 300 MG TID WITH MEALS SAW PALMETTO= INCREASED BLEEDING, DIARHEA, HEADACHE, FATIQUE. PROLONGED USE=LOWER LIBIDO. 160-320 MG DAILY. TUMERIC= ABDOMINAL PAINS, PROLONGED USE= STOMACH ULCERS. 500-2000 MG/DAY. Drug- Food Interaction

• Can delay, decrease or enhance absorption of a drug • Food can prevent medicine from working the way it should • Food can cause side effects to become worse or better and/or cause new side effects • Drugs can also change the way the body uses food EXAMPLES OF DRUG-FOOD INTERACTIONS • GREEN VEGETABLES, BANANAS = THEIR K ANATAGONIZES WARFARIN, ACE INHIBITORS (LISINOPRIL) • GRAPEFRUIT JUICE= CAN INCREASE THE POTENCY OF STATINS • COKE= CAN INCREASE THE PLASMA CONCENTRATION OF IBUPROFEN • LICORICE =CAUSES A DECREASE IN K+ AND NA RETENTION- NOT WITH ANTI-HYPERTENSIVES • CHEESE= CAN INTERACT WITH MONOAMINE OXIDASE INHIBITORS (FOR PARKINSON’S) AND INCREASE SIDE EFECTS OF HEADACHES AND PALPITATIONS. Herbal Supplements that Thin the Blood

• Fish/ Turmeric • Garlic Caps Primrose Oil • Ginger Vitamin E • Ginkgo Biloba Red Rice Yeast • Glucosamine-chondroitin Magnesium • St John’s Wort Milk Thistle RELIABLE SOURCES

• PUBMED • NIH’S OFFICE OF DIETARY SUPPLEMENTS • HTTPS://ODS.OD.NIH.GOV