Herb and Nutrient-Drug Interaction Table This table provides an overview of the drugs that have been found to interact with the herbal and nutritional medicines discussed in this book. The table is intended to be used as a quick reference guide only and is not exhaustive. As always, due dili- gence is required on a case-by-case basis when making clinical judgements. If a class of drug is not listed here, there was no known interaction found during litera- ture search at the time of publication. However, for many of the herbal extracts listed in the table, further research is required in order to properly establish (or rule out) evidence for herb-drug interactions. The table is organised by drug class. The level of interaction is indicated using the following key: • SI = Serious interaction • UC = Use caution • OB = Clinical observation needed • BI = Potential benefi cial interaction • CYP = Cytochrome P450 © Springer International Publishing Switzerland 2017 185 D. Camfi eld et al. (eds.), Evidence-Based Herbal and Nutritional Treatments for Anxiety in Psychiatric Disorders, DOI 10.1007/978-3-319-42307-4 186 Herb and Nutrient-Drug Interaction Table cial interaction cial cial interaction cial cial interaction cial ] 8 cial interaction cial ]. Observe in patients who ]. Observe 1 Possible benefi Benefi Possible benefi Discontinue 2–3 weeks prior to [ surgery Avoid combining with alcohol Avoid [ consume moderate to high amounts of alcohol Medical supervision and monitoring of patient advised Medical supervision and monitoring of patient advised Possible benefi Recommendations ] Avoid concurrent use. 7 ]. 9 ] 6 , 5 ] 4 , 3 ] ] ] 1 1 1 ] 2 not yet demonstrated in clinical trials cacy Known interaction with CYP enzymes [ Known Theoretically based on pharmacological study demonstrated action. In vivo in induced liver effects hepatoprotective damage [ Kava has a synergic effect with CNS effect has a synergic Kava depressants [ Evidence to suggest that NAC promotes the Evidence to suggest that NAC metabolism of alcohol and decreases and heart [ damage to the liver Kava has a synergic effect with CNS effect has a synergic Kava depressants [ Kava has a synergic effect with CNS effect has a synergic Kava depressants [ In vivo studies demonstrated inhibited In vivo morphine tolerance and dependence [ Effi Several studies demonstrating studies demonstrating Several thistle of St Mary’s effect hepatoprotective indicate this herb may reduce hepatic tissue damage related to alcohol consumption [ = additive = additive effect = additive = additive effect = decreased side = decreased side = decreased drug = decreased side = reduced drug = additive = additive effect SI effectiveness BI effects UC BI effects SI UC BI tolerance and dependence BI effects (St. Hypericum perforatum wort) John’s Schisandra chinensis Schisandra somnifera Withania Piper methysticum N-Acetylcysteine N-Acetylcysteine Piper methysticum Herb Potential interaction Evidence Silybum marianum Silybum Piper methysticum Anaesthetics (general) Analgesics Codeine Drug class Morphine Alcohol Herb and Nutrient-Drug Interaction Table 187 ] cance cance (continued) 11 cial interaction cial interaction cial ] ] 8 8 cial interaction as well Possible benefi Possible benefi Observe patient with concurrent Observe interaction is use; however, [ unlikely Observe patient with concurrent Observe for use. Interaction risk is low at doses of standardized extracts [ 240 mg/day or lower Observe patient with concurrent Observe interaction is use; however, [ unlikely Unknown clinical signifi Unknown Benefi being a treatment for paracetamol (typically administered overdose in a hospital setting intravenously in the case of overdose) Avoid concurrent use Avoid ] ] Unknown clinical signifi 8 13 ] 7 ] ] 4 7 , ] 3 3 ] ] ] 12 13 10 Based on pharmacological action, may have Based on pharmacological action, may have against liver effect a hepatoprotective damage from paracetamol [ NAC is a proven antidote for is a proven NAC in a as reviewed acetaminophen overdose, 2540 patients. Most protective study of over within 8 h of is taken when NAC paracetamol ingestion [ In vitro seizure models demonstrated [ activity anticonvulsant Demonstrated anticonvulsant activity [ activity Demonstrated anticonvulsant Known interaction with CYP enzymes Known drug metabolism. May cause effecting [ decreased drug effectiveness Based on pharmacological action, may have Based on pharmacological action, may have against liver effect a hepatoprotective damage from paracetamol [ Induction of CYP enzymes, with potentially it has increased drug metabolism; however, not been reported in clinical studies [ One case report of fatal seizure. Possible One case report of fatal acid and interaction with valproic [ reducing drug effectiveness phenytoin, Induction of CYP enzymes, with potential it has increased drug metabolism; however, on an effect been reported not to have carbamazepine kinetics [ = additive = additive sedative = additive = additive sedative = reduced drug = reduced drug = possible reduced = decreased side = decreased side = decreased side = reduced drug BI effects BI effects UC effects UC effects SI effectiveness BI effects UC effectiveness UC effectiveness OB drug effectiveness Schisandra chinensis Schisandra Hypericum perforatum Silybum marianum Silybum N-Acetylcysteine Piper methysticum Hypericum perforatum Piper methysticum Hypericum perforatum Ginkgo biloba Paracetamol Paracetamol Phenobarbitone and phenytoin Phenobarbitone Anticonvulsants Carbamazepine Anticonvulsants Anticonvulsants (general) 188 Herb and Nutrient-Drug Interaction Table ] 11 ] 12 ] 12 Recommendations Avoid concurrent use, unless Avoid under medical supervision. Potential for serotonin syndrome with concurrent use. Use such as extracts low-hyperforin Ze117 [ patient with concurrent Observe for use. Interaction risk is low at doses of standardized extracts [ 240 mg/day or lower Observe patient due to possible Observe state effects/hypomanic additive Avoid concurrent use, unless Avoid under medical supervision. Potential for serotonergic syndrome with concurrent use. such extract Use low-hyperforin as Ze117 [ Mechanism of interaction patient with Observe unknown. concurrent use ] 15 cant ] 8 ] 7 ] 11 ] 14 , ]. However, clinically signifi ]. However, 8 , 32 7 Case study (combination valerian and kava and kava Case study (combination valerian when preparation) increased lethargy [ combined with paroxetine A case report in a patient with Alzheimer’s A case report in a patient with Alzheimer’s disease suggested a possible increase in the receptors leading to function of GABA sedation with concurrent use of trazodone [ Due to the theories of serotonergic Due to the theories of serotonergic mechanism of action MI, caution should when using in conjunction be exercised wort. with antidepressants or St. John’s no reported cases of serotonin However, syndrome associated with MI to date [ interactions appear to be dose dependent [ Concurrent use may increase serotonin inhibition [ reuptake Induces CYP enzymes and P-glycoprotein. Pharmacokinetic trials and case studies reporting symptoms of serotonin syndrome [ rmed) = additive = additive effect = potential additive = potential additive = additive = additive effect = additive = additive effect UC BO effects OB (although effects unconfi SI SI inositol - Herb Potential interaction Evidence Piper methysticum Ginkgo biloba Myo Hypericum perforatum Hypericum perforatum Selective Selective serotonin inhibitors reuptake and serotonin norepinephrine inhibitors reuptake Drug class Antidepressants Atypical (bupropion) (continued) Herb and Nutrient-Drug Interaction Table 189 ] ] (continued) 11 11 cial interaction cial ] 12 patient and rmed. Observe patient and rmed. Observe Avoid concurrent use, unless Avoid under medical supervision. Potential for serotonergic syndrome with concurrent use. such extracts Use low-hyperforin as Ze117 [ Mechanism of interaction unconfi caution with concurrent exercise for use. Interaction risk is low at doses of standardized extracts [ 240 mg/day or lower Mechanism of interaction unconfi use caution with concurrent use. for Interaction risk is low at doses of standardized extracts [ 240 mg/day or lower Avoid concurrent use to ensure Avoid treatment effectiveness Possible benefi ] 8 ] extract) has extract) 16 ] ]. EGb 761 ]. One clinical trial ] 12 6 3 11 with cant side effects ] 6 Ginkgo biloba Case study reporting priapism, possibly due [ effects to vasodilation Clinical trial demonstrating increased with concurrent use and decreased effects [ side effects extrapyramidal reported no signifi concurrent treatment [ Based on pharmacological action, may have Based on pharmacological action, may have against drug- effect a hepatoprotective damage [ induced liver (standardized in not demonstrated interaction effects clinical trials [ May decrease plasma levels of tricyclics of tricyclics May decrease plasma levels and increase serotonin [ Pharmacokinetic trials demonstrating decreased blood concentration of with concurrent use [ fexofenadine = reduced drug = additive = additive effect = additive = additive effect and = reduced drug side = reduced drug OB OB reduced side effects BI effects SI effectiveness UC effectiveness Silybum marianum Silybum Hypericum perforatum Ginkgo biloba Ginkgo biloba Hypericum perforatum Ginkgo biloba Tricyclics Tricyclics Risperidone Antipsychotics Haloperidol Antihistamines Fexofenadine 190 Herb and Nutrient-Drug Interaction Table ] ] ] ] ] 7 7 7 7 11 ] 11 , 8 ] 11 , 8 Recommendations