Transcript Deadly Mix: Supplements and Drug Interactions

Deadly Mix: Herbs, Supplements,
and Drug Interactions
Geneva Briggs, Pharm.D., BCPS
MedOutcomes, Inc.
Objectives
 Discuss the alternative medications that
are most dangerous.
 Identify the most common drug
interactions with alternative medications.
 List five sources for unbiased information
on alternative medications and
supplements.
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“Poisons and medicines are
oftentimes the same
substances given with different
intents”
Peter Mere Latham
(1789-1875)
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Complementary and Alternative
Medicine Practices
 ~40% of the US population uses dietary
supplements often
 ~ 50% of people have used herbals
 ~ 4% rely exclusively on alternatives
 In Germany over 700 herbs are available
and prescribed by 70% of physicians
NEJM 1993;328:246-52.
JAMA 1998;279:1548-53.
3
Complementary and Alternative
Medicine Practices
 <40% of patients inform someone they are
taking alternative medications
 Most commonly purchased – echinacea,
feverfew, garlic, ginseng, ginkgo,
goldenseal, kava, St. John’s wort, saw
palmetto, and valerian
 “Typical” user – female, 35-64, white,
college graduate, relatively affluent
J Am Diet Assoc 2003;103:1500-5
JAMA 1998;280:1569-75
Pharmacotherapy 2000;20:877-91
4
Pharmaceuticals vs
Phytomedicines
Must prove efficacy
and safety
 Mandatory ADE
monitoring
 Product formulation
standards
 Consensus for use
 Marketing more
restricted

Safety & efficacy data
may be lacking
 ADE monitoring not
mandatory
 No product standards
mandated
 Dosing uncertain
 No treatment or cure
claims on label

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Concerns with Phytomedicine
 Variability of active constituents
 Misidentification of the plant
 Selection of the wrong part of the plant
 Inadequate storage
 Contamination
 Adulteration
 Mislabeling of the final product
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Asian or Chinese patent
medicines
 Of 251 purchased in CA , 24 contained lead,
36 arsenic, 35 mercury
 24% of 2,609 samples of Chinese patent
medicines contained pharmaceutical
adulterants
J Clin Pharmacol 1997; 37: 34450.
BMJ 1994; 308: 1162.
N Engl J Med 1998; 339: 847
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Which herbals are most likely to
cause significant adverse
effects?
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Top 10 Offenders






Kava [Piper methysticum]
Comfrey
Chaparral [Larrea
tridentata]
Germander [Teucrium
genus]
Aristolochic acid
Germanium dioxide or
lactate citrate
Lobelia [Indian
tobacco]
 Stephania
 L-tryptophan
 Ephedra (ma-huang)

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Beyond the Top 10
 Pennyroyal oil
 Sassafras
 Borage
 Calamus
 Coltsfoot
 Life root
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Significant Interactions with
Alternative Supplements
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St John’s Wort [Hypericum
perforatum]
•
•
•
•
•
•
•
•
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Digoxin
Warfarin
Theophylline
Nefazodone
Oral contraceptives
Antiretrovirals
Cyclosporine
Imatinib (Gleevec)
Irinotecan
[Camptosar]
 Simvastatin
 Amitriptyline
 SSRI (fluoxetine,
sertraline, etc.)

Lancet 2000;355:1343-8
Pharmacotherapy 2004;24:1508-14
Herbal and Supplement Products
That Interact with Warfarin

Increased INR

• Ginkgo Biloba
• Dong Quai (Angelica
sinesis)
• Danshen (Salvia
miltiorrhiza)
• Vitamin E

Decreased INR
• St. John’s Wort
• Coenzyme Q10
• American ginseng
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Altered Platelets
•
•
•
•
•
•

Garlic [Allium sativum]
Feverfew
Ginseng
Turmeric
Meadowsweet
Willow bark
Contain Coumarins*
• Horse chestnut
• Red clover
Lancet 2000;355:13438
J Clin Pharm Ther 2002;27:391-401
Significant Interactions with
Alternative Meds and Supplements
 Siberian Ginseng (Eleutherococcus
senticocous) - Digoxin
 Valerian [Valeriana officinalis] – alcohol,
benzodiazepines, anticonvulsants, TCA
 Licorice - ACE-I, ARB, diuretics, digoxin
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Lancet 2000;355:13438
Significant Interactions with
Alternative Meds and Supplements
 Kava
and valerian– alcohol, barbiturates,
antispychotic drugs, sedatives,
benzodiazepines,
 Garlic – saquinavir
 Red rice yeast [Chinese red rice]- statins,
gemfibrozil, fenofibrate
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Patient Groups Most Likely to
have Problems
 Multiple medications
 HIV/AIDS
 Cancer
 Transplant
 Treated with warfarin, digoxin, or other
agents prone to drug interactions
 Undergoing surgery
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Am J Health-Syst Pharm 2004;61:1707-11
Avoid Recommending Herbals
 Pregnant and lactating women
 Children
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Problem Products in Surgery
 Ginkgo biloba
 Saw Palmetto
 American Ginseng [Panex quinquefolias]
 Kava
 St John’s wort
 Feverfew
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Problem Products in Cancer
Treatment
 Garlic
 Ginkgo
 Echinacea
 Panax ginseng
 St John’s wort
 Kava
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J Clin Oncol 2004;22:2489-503
Reasonably Effective Herbals
Aloe Vera (topical)
 Arnica (topical)
 Black Cohosh
 Chamomile tea
 Echinacea
 Evening primrose oil
 Feverfew
 Garlic

Ginger
 Ginkgo Biloba
 Hawthorn
 Peppermint tea
 Saw Palmetto
 Siberian Ginseng
 St John’s wort
 Valerian

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Reliable Printed Resources
Herbal medicine: Expanded Commission E
monographs
 Review of Natural Products
 Tyler’s Herbs of Choice. The Therapeutic Use of
Phytomedicinals
 Tyler’s Honest Herbal: A Sensible Guide to the Use
of Herbs and Related Products.
 Facts and Comparisons: The Review of Natural
Products

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Reliable Online Resources
 consumerlab.com
 herbalgram.com
• American Botanical Council
 nccam.nih.gov
• NIH’s National Center for Complementary and
Alternative Medicine
 vm.cfsan.fda.gov
• Center for Food Safety and Applied Nutrition
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Reliable Online Resources
 www.uic.edu/pharmacy/research/diet/con
tent/scont_about_evaluations.htm
• University of Illinois
 www.pharmacist.com/pdf/dietary_supple
ments.pdf
• Healthcare Professional’s Guide to Evaluating
Dietary Supplements
 www.herbalwatch.com
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To Buy Anything and Everything
 www.herbalremedies.com
Blood Circulator
Made of medicinal rhubarb,
prepared rehmannia root, common
peony root, peach seed, bitter
apricot seed, licorice root, scute,
dun fly, gadfly, leech, June beetle
grub, dried lacquer and ground
beetle.
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Patient Counseling
Encourage disclosure of ALL medicinal
substances
 Discuss available information about alternative
medicines
 Discuss health risk and self-monitoring
 Set objective goals to follow progress
 Steer patients seeking to self-treat serious
disorders such as depression to a physician

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How to Report an Adverse Effect
 Complete the Medwatch form online
• www.fda.gov/medwatch/report/hcp.htm
 Report by telephone (1-800-FDA-1088)
 Download a copy of the form and either fax
it to 1-800-FDA-0178 or mail it back using
the postage-paid addressed form.
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Evaluating Products for Quality
 Look for
• USP standardization
– feverfew, ginger, chamomile, cranberry, ginkgo
biloba, St John’s wort, saw palmetto, milk thistle,
valerian, siberian ginseng, and echinacea
• Reputable manufacturer
• Consumerlab.com evaluations
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Conclusion
 Current regulation of dietary supplements
fails to address substantial risk to public
health
 Educate patients to give “Full Disclosure”
 Know the problem herbs and most common
interacting herbs
 Report adverse events
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