Appendix 1 QUICK GUIDE TO HERB-DRUG INTERACTIONS

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1 Appendix 1 QUICK GUIDE TO HERB-DRUG INTERACTIONS The rapid increase in the use of herbal medicines has created a rapidly growing database of known herb-drug interactions, many of which are presented in the table below. Keep in mind, however, that our knowledge of the interactions among prescription medicines, over-the-counter medicines, and herbal medicines continues to change constantly. To help detect possible herb-drug interactions, encourage patients to be open about all medicines they may be taking, whether prescription, over the counter, or herbal. Ask them to bring all of their medications with them to their next appointment. Caution patients not to take herbal medicines in higher doses or more often than recommended. Also, caution them not to experiment with herbal medicines. Urge them to tell all of their health-care practitioners about all of the medicines they take. If patients are known to have adverse drug reactions, such as allergies, chronic skin rashes, or pre-existing liver disease related to prescription medicines, warn them that they have a higher risk of side effects from herbs as well. Reinforce the importance of reporting any side effects of prescription, over-the-counter, and herbal medicines to a health-care practitioner. Elderly patients, pregnant women, and children have an increased risk of interactions and side effects from herbal medicines and should be referred to a practitioner with specialized training in the field of herbal medicine.also, make a point of telling pregnant women that some herbs are unsafe to take during pregnancy and breast-feeding. 298

2 ALOE GEL/JUICE Glyburide Increased hypo- Yongchaiyudha glycemic effect et al., 1996 ALOE LATEX Antiarrhythmics May potentiate the Blumenthal et al., Cardiac glycosides action of 1998 Corticosteroids cardiac glyco- Licorice root sides and anti- Thiazide diuretics arrhythmic agents (as do the other drugs listed) ASTRAGALUS Acyclovir Increases effects DeSmet & ROOT Interleukin-2 D Arcy, 1996 Azathioprine Cyclosporine Methotrexate Caution use BITTER MELON Chlorpropamide Increases hypo- Aslam & glycemic effect Stockley, 1979 BORAGE Anticonvulsants May lower seizure Miller, 1998 threshold BROMELAIN Anticoagulants Increases Blumenthal et al., bleeding 1998 Tetracycline Increases plasma Neurauer, 1961 and urine drug levels Chloramphenicol Enhances drug Neurauer, 1961 Erythromycin levels Novobiocin Penicillin 5-fluorouracil Can improve Taussig & Batkin, Vincristine efficacy 1998 BREWER S YEAST MAO inhibitors Increased blood Blumenthal et al., pressure 1998 BUCKTHORN Cardiac glyco- May potentiate Blumenthal et al., BARK, BERRY sides toxicity with 2000 Quinidine long-term use BUGLEWEED Thyroid Contraindicated Blumenthal et al., preparations 1998 Thyroid McGuffin et al., treatments

3 BUPLEURUM Alcohol May increase WHO, 1999 CNS depressants sedation Sedatives CASCARA Cardiac glyco- May potentiate Blumenthal et al., SAGRADA BARK sides toxicity with 2000 Quinidine long-term use CHASTE TREE Dopamine- May weaken Blumenthal et al., BERRY receptor antag- effect (animal 1998 onists (such as studies) haloperidol) Metoclopramide Possible inter- Blumenthal et al., actions 2000 Hormone therapy Contraindicated Blumenthal et al., Oral contracep tives CAYENNE PEPPER Aspirin Reduced mucosal Yeoh et al., 1995 damage if cayenne taken 30 minutes before aspirin CINCHONA BARK Anticoagulants Increases effects Blumenthal et al., 1998 COLA NUT Caffeine Contraindicated Blumenthal et al., Psychoanaleptic 1998 drugs DEVIL S CLAW Antiarrhythmics Contraindicated ESCOP, 1999 ROOT DONG QUAI Coumadin May increase Heck et al., 2000 effects of medication ECHINACEA Amiodarone If 8 weeks, Miller, 1998 Anabolic steroids potential for Ketoconazole hepatotoxicity Methotrexate Corticosteroids Cyclosporin Antagonistic effects EPHEDRA Cardiac glyco- Cardiac arrhyth- Blumenthal et al., (MA HUANG) sides mias 1998 Halothane Guanethidine Enhances sympa- Blumenthal et al., thomimetic effect

4 MAO inhibitors May cause fatal Blumenthal et al., hypertension 1998 Ergotamine Hypertension WHO, 1999 Oxytocin EUCALYPTUS OIL Drugs weakened Affects liver Blumenthal et al., (EXTERNAL OR or shortened detoxification 2000 INHALED) EVENING Anticonvulsants May lower seizure Miller, 1998 PRIMROSE OIL threshold FENNEL Ciprofloxacin Affects absorption, Zhu et al., 1999 distribution, elimination FENUGREEK Hypoglycemic May exaggerate Natural Mediagents effects cines, 2000 Sulfonylureas FEVERFEW Aspirin May increase Herbst, 1999 Coumadin bleeding time Miller, 1998 Nonsteroidal anti- Inhibits effects of Miller, 1998 inflammatory herb drugs FLAXSEED Conventional May delay Blumenthal et al., medicines absorption 1998 Antidiabetic May slow glucose Blumenthal, medications absorption 2000 GARLIC Coumadin May increase Sunter, 1991 bleeding time Herbst, 1999 Miller, 1998 Ottariano, 1999 GINGER Anticoagulants May increase Lumb, 1994 bleeding time Herbst, 1999 Miller, 1998 GINKGO BILOBA Aspirin May increase Rosenblatt, 1997 Coumadin bleeding time Herbst, 1999 Miller, 1998 Papaverine May potentiate Sikora et al., effects of drug 1989 Trazodone May cause severe Prescriber s Let- CNS depression ter, September

5 GREEN TEA Coumadin May increase Heck et al., 2000 effects GURMAR LEAVES Glyburide May have additive Baskaran et al., Tolbutamide effects 1990 Insulin May reduce insu- Shanmugasunlin requirements daram et al., 1990 HAWTHORN LEAF Cardiac glyco- May enhance Blumenthal, WITH FLOWER sides effects of drug 2000 Adenosine May increase Blumenthal, Caffeine coronary artery 2000 Epinephrine dilatation Papaverine (controversial) Sodium nitrate Theophylline Digoxin May affect drug Miller, 1998 level monitoring KARELA Biguanides May cause Miller, 1998 Insulin interactions Sulphonylureas KAVA KAVA Alcohol May potentiate Herbst, 1999 Barbiturates effects Benzodiazepines Levodopa May reduce effects Schelosky et al., 1995 LICORICE ROOT Spironolactone May increase loss WHO, 1999 of potassium Miller, 1998 Amiloride May increase loss WHO, 1999 Cardiac glyco- of potassium sides Thiazide diuretics Digoxin May create prob- Miller, 1998 lems with drug monitoring MARSHMALLOW All May decrease Blumenthal et al., LEAF AND ROOT absorption of 1998 medications OAK BARK All May decrease Blumenthal et al., absorption of 1998 medications 302

6 PAPAYA Coumadin Increases effect of Shulman, 1997 medication PANAX GINSENG MAO inhibitors May interact Blumenthal et al., Phenelzine 1998 Miller, 1998 Coumadin May alter bleeding Miller, 1998 times Corticosteroids May have additive Miller, 1998 Estrogens effects Digoxin May affect drug Miller, 1998 levels Biguanides Should not admin- Miller, 1998 Insulin ister together Sulfonylureas PSYLLIUM Conventional May delay Blumenthal et al., medicines absorption 1998 Antidiabetic May slow glucose Blumenthal et al., drugs absorption 1998 RHUBARB ROOT Antiarrhythmics Increases toxic WHO, 1999 Cardiac glyco- effects sides Corticoadrenal steroids Thiazide diuretics SARSAPARILLA Bismuth Increases Blumenthal et al., ROOT Digitalis glyco- absorption 1998 sides Hypnotics Accelerates Blumenthal et al., elimination 1998 SAW PALMETTO Iron May limit Miller, 1998 absorption SCOTCH BROOM MAO inhibitors May cause hyper- Blumenthal, tensive crisis 2000 SENNA Cardiac glyco- Long-term use can Blumenthal, sides increase loss of 2000 Quinidine serum potassium SIBERIAN Kanamycin May enhance Vereshchagin et GINSENG Monomycin effects of drugs al., 1998 STINGING Diclofenac Increased anti- Chrubasik et al., NETTLES inflammatory 1997 effects 303

7 ST. JOHN S WORT Selective serotonin Nausea, headache, Lantz et al., 1999 reuptake inhibitors tremors Roundtree, 2001 Anticonvulsants Contraindicated Roby et al., 2000 Antifungals because of Piscitelli et al., Antiretrovirals possible break Calcium channel through bleeding, blockers lowered blood Chemotherapeutics levels, de- Cyclosporine creased drug Macrolide anti- effectiveness biotics Nonsedating antihistamines Oral contraceptives Warfarin Tetracycline Increased risk of Herbst, 1999 blood clots Iron May limit Miller, 1998 absorption VALERIAN Alcohol May potentiate Upton, 1999 Barbiturates effects Herbst, 1999 McCaleb et al., 2000 *The Food and Drug Administration has a list of unsafe herbs. The Internet address is: 304

8 Appendix 2 HERBS THAT MAY INCREASE CLOTTING TIMES OR INTERACT WITH ANTICOAGULANTS Astragalus Bilberry Bromelain Capsaicin Dong quai Evening primrose oil Feverfew Garlic Ginger Sources: Heck et al., 2000 and Ottariano, Ginkgo biloba Ginseng Green tea Horse chestnut Red clover Skullcap Sheep sorrel Willow bark Appendix 3 HERBS THAT MAY HAVE A LAXATIVE EFFECT Aloe latex Boneset Buckthorn Cascara sagrada Dandelion root and leaf Sources: Ottariano, 1999 and McGuffin, Elder Fennel Milk thistle Psyllium Senna 305

9 Appendix 4 HERBS THAT SHOULD NOT BE TAKEN INTERNALLY LIVER TOXICITY: Comfrey Germander Chaparral Life root CANCER-CAUSING EFFECTS: Sassafras LIFE-THREATENING TOXICITY IN ANIMALS: Pennyroyal oil (has killed some animals after use as a flea repellent.) Warning: Many plants are toxic and should never be used internally; consult a book on poisonous plants. Appendix 5 HERBS THAT SHOULD NOT BE TAKEN DURING PREGNANCY Agave Alder Aloe (oral use) Angelica Buckthorn Barberry Basil Bilberry leaves Birthroot Blue cohosh root Black cohosh Black walnut Buchu Cascara Castor oil Chaste tree berry Coltsfoot Comfrey 306

10 Appendices Cotton root bark Damiana Devil s claw root Dong quai Ephedra Ergot False unicorn Feverfew Ginger Ginkgo biloba (Egb) Ginseng Goldenseal Gotu kola Green tea (caffeine content) Hawthorn Hops Horehound Horse chestnut Horseradish Horsetail Hyssop Juniper berries Kava kava Licorice Lobelia Milk thistle Mistletoe Mugwort Myrrh Oregon grape Osha Pennyroyal leaf, flower, and oil Pleurisy root Red clover Rue leaf Rhubarb Sarsaparilla Scotch broom Senna Shepherd s purse Southernwood St. John s wort Tansy leaf Uva ursi Wormwood Yarrow Yellow dock Warning: Urge patients to use all herbs cautiously during pregnancy. Some herbs in the list above may induce abortion or stimulate the uterus to contract. Other herbs may have a laxative effect. Advise patients against exceeding recommended dosages, and tell patients to consult with their health-care practitioners about the length of time to take any herbal medicine. For more information on herbs that may or may not be used safely in pregnancy, consult the Botanical Safety Handbook. 307

11 Appendix 6 HERBS THAT SHOULD NOT BE TAKEN WHILE BREAST-FEEDING Aloe (oral use) Barberry Bilberry leaves Black cohosh Bladderwrack Borage Buckthorn Bugleweed Cascara sagrada Chaste tree berry Coltsfoot Comfrey Elecampane Ephedra Feverfew Garlic Ginseng Goldenseal Green tea (caffeine content) Hawthorn Horse chestnut Horseradish Hyssop Kava kava Licorice root Psyllium Senna Stillingia Wormwood Yellow dock Warning: Other herbs may be unsafe also. Tell patients to consult a health-care practitioner before taking any herb while breast-feeding. 308

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