Herb-Drug Interactions in Mental Health Care. Acupuncture Today December 1, 2016 Benjamin Zappin, L.Ac.,RH(AHG) Five Flavors Herbs, Inc.

Transcription

1 Herb-Drug Interactions in Mental Health Care Acupuncture Today December 1, 2016 Benjamin Zappin, L.Ac.,RH(AHG) Five Flavors Herbs, Inc.

2 Learning Objectives To review existing literature on herbdrug interactions in order to identify potential risks and to optimize therapeutic outcomes specific to mental health concerns. To raise questions about some less reported medicinals in the herb drug literature.

3 Considerations in providing mental health care Increased incidence of PTSD/Abuse hx Increased incidence of substance abuse/drug-seeking behavior Unstable living situations Less access to mental health care service and consistent follow ups with psychiatrist Nutritional deficiencies Decreased advocacy

4 Potential risks and barriers to inclusion of herbs in treatment of individuals with mental illness Cost Inconsistency in treatment Lack of access to skilled practitioners Self medication with substances with potential interactions May use as an alternative rather than an adjunct to pharmacological treatment

5 Common categories of psychiatric medications Antipsychotics (1st and 2nd generation) Benzodiazepines and other anxiolytics SSRIs and other antidepressants Lithium and other mood-stabilizers Anti-convulsants and TCAs Opiates and opioid derivatives

6 Pharmacodynamics: the study of the biochemical and physiological effects of drugs and the mechanisms of their actions, including the correlation of their actions and effects with their chemical structure. Pharmacokinetics: the action of drugs in the body over a period of time, including the processes of absorption, distribution, localization in tissues, biotransformation, and excretion.

7 Herb-Drug Interaction Nexus Herb-drug Herb-nutrient Herb-herb Herb-multiple drugs Herbal formula - drug Herb-drug transition Herbalist-doctor Herbalist-patient Herbalist-family Herbalist-pharmacist Herbalist-herbalist

8 General principles Transitions in protocols hold the greatest potential for interactions that may affect intended therapeutic outcomes Individuals vary greatly in response to both drugs and herbs due to biochemical variability as well as health status and condition Professional management implies supervision by collaborating health care professionals with appropriate training in botanical therapeutics within an integrative framework

9 Classes of Safety & Interactions Safety Classes Class 1. Safe when used appropriately Class 2. Some restrictions apply 2a: External use only 2b: Not in pregnancy 2c: Not in nursing Class 3. Should be used under clinical supervision Interaction Classes Class A. No clinically relevant interactions Class B. Interactions are biologically plausible Class C. Interactions are known to occur

10 Types of interactions and significance Potentially or theoretically adverse interaction of uncertain severity Minimal to mild adverse interaction; vigilance necessary Potentially harmful or serious adverse interaction; avoid

11 Probability guide for interactions 1.Certain: Occurrence is definite 2.Probable: A relatively high probability of this interaction occurring 3.Possible: Variable probability of this interaction occurring depending on circumstance 4.Plausible: Inadequate evidence to support conclusive judgement but likelihood exists 5.Improbable: Unlikely to occur in most individuals 6. Unknown

12 Qualities of interaction Impaired drug absorption and bioavailability of varying severity Adverse drug effect on herbal therapeutics Beneficial or supportive action Prevention of drug adverse effect Drug-induced nutrient depletion

13 Source material evaluation Consensus Emerging Preliminary Mixed Inadequate Speculative

14 Western herbal actions used to treat the mind, mood, & emotion Hypnotics/Sedatives Valerian (Valeriana officinalis) Nervines o Tonics Oats (Avena sativa) o Relaxants Lemon Balm (Melissa officinalis), Skullcap (Scutellaria lateriflora) Stimulants Tea (Camellia sinensis) Adaptogens Ashwagandha (Withania somnifera)

15 Ashwagandha (Withania somnifera) Safety Class: 2b (avoid in pregnancy) Interaction Class: A Actions/Uses Used to support the immune system, reduce anxiety/depression, improve mental clarity, enhance sexual function Drug Interactions Speculative: may potentiate effects of barbiturates due to sedative properties (based on rodent studies in 1960s-1970s) Complementary Adjuncts Simultaneous use of imipramine and ashwagandha showed improved antidepressant effect in rat study Maity et al. As study on evaluation of antidepressant effect of imiprimine adjuct with ashwagandha and bramhi. Nepal Medical College Journal, 2011 Dec; 13(4):250-3

16 Asian Ginseng (Panax ginseng) Safety Class: 1 Interaction Class: A Actions/Uses Qi tonic, calms the spirit in TCM; adaptogenic, immunosupportive, enhances sexual function and benefits the cardiovascular system. Caution Overstimulation can occur, so it should not be used when there is anxiety, nervousness, or emotional imbalance. Especially of concern in individuals with hx of Bipolar disorder and/or mania. (Case reports of ginseng-induced mania) Drug Interactions (hypothetical) May potentiate stimulant effects of ADHD medications/other stimulants May interfere with the efficacy of antipsychotics (e.g., haloperidol) May increase risk of bleeding when combined with SSRIs or warfarin due to antiplatelet effects Complementary Adjuncts?

17 California Poppy (Eschscholzia californica) Safety Class: 2b (avoid in pregnancy) Interaction Class: A Actions/Uses Promotes sleep, alleviates pain & anxiety Drug Interactions May increase sedative effects of antipsychotics, anxiolytics and opioids due to inhibition of catecholamine degradation and synthesis Complementary Adjuncts Useful as an adjunct to anxiolytics, antipsychotics, and opioids for the treatment of anxiety, pain, and psychosis Use for the treatment of drug withdrawal Kleber et al. Modulation of key reactions of the catecholamine metabolism by extracts of Eschscholzia californica and

18 Cannabis sativa & indica Safety Class: No rating Interaction Class: No rating Actions/Uses Besides recreational use, now widely used for pain, appetite stimulation, glaucoma, and other chronic conditions. Contraindications Do not use in personal or family history of schizophrenia, since psychotic symptoms may be induced even with moderate consumption. Drug Interactions May have additive effects in conjunction with opiates, alcohol, benzodiazepines/barbiturates. Complimentary Adjuncts Has been used to ease withdrawal from alcohol and opiates

19 Chamomile (Matricaria recuitita) Safety Class: 1 Interaction Class: A Actions/Uses Relaxing nervine, digestive bitter Drug Interactions Hypothetical risk of increased sedation when combined with other sedatives May increase risk of bleeding when combined with SSRIs (hypothetical due to coumarin content) May provide antidepressant benefits as well as anxiolytic Complementary Adjuncts May reduce opiate dependence and withdrawal Amsterdam JD, Chamomile (Matricaria recutita) may provide antidepressant activity in anxious, depressed humans: an exploratory study. Altern Ther Health Med Sep-Oct;18(5):44-9.

20 Chaste Tree (Vitex agnus-castus) Safety Class: 1 Interaction Class: A Actions/Uses Hormonal regulator used in the treatment of PMS & irregular menses Drug Interactions May potentiate dopaminergic effects when combined with other dopamine agonists (bromocriptine, carbidopa/levodopa) May weaken the effect of dopamine antagonists (most antipsychotics) due to dopaminergic effects Complementary Adjuncts Possibly useful as an adjunct to various medications in the mania, depression, or psychosis

21 Coffee (Caffea arabica) Safety Class: No review Interaction Class: No review Actions/Uses Common stimulant, laxative Cautions Prolonged/excessive use may cause adverse reactions such as insomnia, restlessness, anxiety, irritability, and digestive upset Drug Interactions Increases clozapine levels and increases risk of toxicity due to inhibition of liver metabolism Antagonizes the effects of barbiturates and benzodiazepines Complementary adjuncts

22 Gingko biloba Safety Class: 1 Interaction Class: 2 Actions/Uses Used for cognitive enhancement Drug Interactions Case reports of abnormal bleeding and a breakthrough seizure An average dose of 209 mg/day ginkgo leaf extract in 33 women and 30 men offset sexual dysfunction following antidepressant use consisting of selective reuptake inhibitors (SSRIs including fluoxetine, sertraline and paroxetine), as well as sexual dysfunction from the MAOI phenelzine, the tricyclic antidepressant vivactil [protriptyline], and sexual dysfunction from the serotonin and norepinephrine reuptake inhibitors (SNRIs) venlafaxine, nefazodone and bupropion (human clinical study).

23 Gotu Kola Centella asiatica Safety Class: 1 Interaction Class: A Actions/Uses Supports cognitive function, anxiolytic, neuroprotective, vulnerary for wound healing topically. Drug Interactions None known Complementary Adjuncts Some preliminary research has demonstrated ulceroprotective effects as an adjunct to aspirin and NSAIDS Sairam K Effect of Centella asiatica Linn on physical and chemical factors induced gastric ulceration and secretion in rats. Indian J Exp Biol Feb;39(2):

24 Lavender (Lavandula spp.) Safety Class: 1 Interaction Class: A Actions/Uses Relaxing nervine, anxiolytic Growing evidence base for standardized dose of essential oil (Silexan) for treatment of anxiety disorders Drug Interactions None known; no evidence of inhibitory or enhancing effects on CYP450 pathways Complementary Adjuncts Doroshyenko et al. Drug cocktail interaction study on the effect of orally administered lavender oil preparation Silexan. Drug Metabolism & Disposition, 2013, vol. 41 no. 5, Kasper, S. An orally administered lavandula oil preparation (Silexan) for anxiety disorder and related conditions. International journal of psychiatry and clinical practice, August 2013 [Epub ahead of print]

25 Milk Thistle Silybum marianum Safety Class: 1 Interaction Class: A Actions/Uses Hepatoprotective, antioxidant; used in tx of cirrhosis, hepatitis, acute poisoning Drug Interactions Despite actions on the liver, Milk Thistle has not been shown to have significant in vivo effects on most drugs utilizing CYP450 pathways, except for possibly reducing availability of metronidazole (Flagyl) Complementary Adjuncts Prevention of hepatotoxicity when co-administered with certain psychiatric drugs (antipsychotics, TCAs), anticonvulsants, halogenated anesthetics, ethanol, aspirin and acetaminophen, or after discontinuing such medications.

26 St. John s Wort Hypericum perforatum Safety Class: 2d Interaction Class: C Actions/Uses Relaxing & tonic nervine, anti-viral, anti-inflammatory; used for depression, nervousness, nerve pain, wound healing, herpes simplex & zoster Commonly taken as standardized extract 0.3% hypericin, 2.0% to 4.5% hyperforin. Extracts available without standardization thought to be safer for coadministration Madabushi et al. Hyperforin in St. Johns wort drug interactions. Eur. J. Clinical pharmacology Cautions/Contraindications Avoid excessive exposure to sunlight and in use with laser or ultraviolet therapy

27 Antidepressant Amitriptyline and other tricyclics. Drug is a 3A4.p glycoprotein cosubstrate. Herb lowers bioavailability. Interaction proven experimentally, no case reports Johne et al, Decreased plasma levels of amitriptyline and its metabolites on comedication with St. John's wort. J. Clinical psychopharmacology SSRIs May lead to pharmacokinetic and pharmacodynamic interactions. Mild symptoms of serotonergic excess possible. Reports of varying reliability exist but significance is not established. Stargrove et al 2008 Anxiolytics Alprazolam and other benzodiazepines SJW lessens bioavailability by inducing 3A4 enzyme production. Interaction proven experimentally, no case reports. Stargrove et al 2008

28 Other drug herb interactions to consider seriously w/ Hypericum Immunosuppressants Anticoagulants Antiarrhythmics Calcium channel blockers Hormonal contraceptives Antivirals Statins Anticancer drugs Beta adrenergic blockers Hypoglycemics Antifungals Anticonvulsants

29 Valerian Valeriana officianalis Safety Class: 1 Interaction Class: B Actions/Uses Anxiolytic and sleep aid Drug Interactions Caution advised during the use of benzodiazepines and other sedative drugs as it may potentiate the effects of some sedatives Complementary Adjuncts May be useful in reducing the side effects of benzodiazepine withdrawal

30 Some other favorite medicinal plants for mental health Rhodiola rosea Ocimum sanctum Verbena officinalis piper methysticum Nepeta cataria Scutellaria lateriflora Albizia julibrissin Anemone occidentalis Ganoderma lucidum

31 Anticonvulsants may increase drug metabolism Phenytoin or Dilantin Carbamazepine or Tegretol Phenobarbital All may increase drug metabolism and thus increase the dose of herbs if necessary

32 Antipsychotics may interfere with drug absorption Haldol Risperdal May interfere with drug absorption thus decrease or increase dose of herbs if necessary. Also consider dosing herbs 2 hours away from medications

33 Risperidone Brand name: Risperdal uses and side effects Uses: Risperdal is used to treat schizophrenia Bipolar disorder Used with autistic children to treat symptoms of irritability Common SE: headache; dizziness, drowsiness, tired feeling; tremors, twitching or uncontrollable muscle movements; agitation, anxiety, restless feeling; depressed mood; dry mouth, upset stomach, constipation; weight gain; or pain in your arms or legs.

34 More serious or urgent SE uncontrolled muscle movements in your face (chewing, lip smacking, frowning, tongue movement, blinking or eye movement); breast swelling or tenderness (in men or women), nipple discharge, impotence, lack of interest in sex, missed menstrual periods; severe nervous system reaction--very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors, feeling like you might pass out; low white blood cells--sudden weakness or ill feeling, fever, chills, sore throat, mouth sores, red or swollen gums, trouble swallowing, skin sores, cold or flu symptoms, cough, trouble breathing; low levels of platelets in your blood--easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin; high blood sugar--increased thirst, increased urination, hunger, dry mouth, fruity breath odor, drowsiness, dry skin, blurred vision, weight loss; or penis erection that is painful or lasts 4 hours or longer.

35 Fluoxetine/Olanzapine (SSRIs) Prozac & Zyprexa -used alone and separately Uses: Depression Acute depressive episodes in combination Bloating or swelling of the face, arms, hands, lower legs, or feet body aches or pain confusion congestion cough delusions dementia dryness or soreness of the throat fever hoarseness rapid weight gain runny nose shakiness in the legs, arms, hands, or feet tender, swollen glands in the neck

36 Venlafaxine or Effexor SSNRI or Selective Serotonin and Norepinephrine Reuptake Inhibitor Uses: For major depressive disorder Anxiety Panic attacks Side Effects: High blood pressure Lack or loss of strength Severe headache Sweating Chest pain Mood swings Tachycardia Suicidal thoughts

37 Lithium carbonate Use: Manic episodes associated with bipolar disorder Side effects: Confusion Fainting Frequent urination Increased thirst Breathing trouble Stiff arms and legs Weight gain Tiredness Irregular heartbeat

38 Common medication withdrawal experiences *Antidepressants and Neuroleptics flu-like syndrome with headache, muscle aches, chills, nausea, vomiting, diarrhea, and loss of appetite Lithium less side effects generally than other classes insomnia, anxiety, irritability. Minor Tranquilizers, Sedatives sudden withdrawal can result in life-threatening seizures; withdrawal must be very gradual seizures common in early stages of withdrawal muscular reactions such as uncontrollable rhythmic movements and tremors (these are more severe with neuroleptics) insomnia, emotional distress, feeling like one is going crazy other reactions can include flu-like syndrome (see above), muscle tics, restlessness, and anxiety withdrawal symptoms usually take a few days to develop, but can occur immediately and get worse during the first week.

39 My favorite CM formulas Bupleurum w/ oyster shell and dragon bone -Chai hu jia long gu mu li tang Bupleurum and cinnamon - Chai hu gui zhi tang Bupleurum, cinnamon, and ginger -Chai hu gui zhi gan jiang Rambling powder with added flavorsjia wei xiao yao san Cinnamon twig w/ oyster shell and dragon bone -gui zhi jia long gu mu li Zizyphus combination- suan zao ren tang

40 Ginseng and Longan combination- Gui Pi Tang Warm the Menses Decoction- Wen Jing Tang Rectify Center Pill - Li Zhong Wan Licorice, Wheat, and Jujube -Gan Mai Da Zao Tang Coptis and donkey hide gelatin decoction- Huang Lian E Jiao Tang

41 Cinnamon Twig, Oyster Shell and Dragon Bone Palpitations Anxiety Insomnia Dream disturbed sleep Nightmares Hair loss Spontaneous perspiration Amnesia Infantile night crying Dreams of sexual intercourse in women A cold sensation on the tip of the penis Loss of appetite Dizziness Depression Lack of motivation Night sweats Spermatorrhea Nocturnal emissions Lower abdominal contraction and pain Occasional watery diarrhea T: Slightly pale P: Hollow and slow or Hollow and slightly tight

42 Bupleurum w/ Oyster Shell and Dragon Bone Formula Category Calm the Spirit Sedate and Calm the Spirit Clinical Usage and Indications Used for heat that is lodged in the chest affecting all yang stages, also for phlegm in the liver/gall bladder. Generally used for a range of psychological conditions, aiding with drug withdrawal and related issues. Symptoms include chest oppression, anxiety, irritability, palpitations, excessive/delirious speech, heavy sensation of body, constipation, urinary issues. The Pulse will be wiry and rapid and the Tongue will be red with a slippery tongue coating.

43 Licorice, Wheat, and Jujube Nourishes the Heart and calms the Spirit Harmonizes the Middle Jiao. Indications Depression, moodiness, frequent melancholy and crying, sadness, frequent yawning, restless sleep with possible sweating, in severe cases there can be abnormal speech and behavior

44 17 y.o. female Severe autism, developmental delay beginning at age 3, severe o.c.d., explosive episodes Medications Risperidal Fluoxitine Herbal treatment- Skullcap Scutellaria lateriflora Vervain Verbena officianalis Xiao Yao San Free and Easy Wanderer Chaste Tree Berry Vitex agnus castus

45 60 y.o. female Hx. of dissociative disorder severe add.adhd ptsd reports fatigue loose stools difficulty focusing anxiety Therapies include: Adderal Meditation Licorice Glycyrrhiza sp. Ginger Zingiber officianalis Ginseng panax ginseng Skullcap Scutellaria lateriflora California poppy Eschschozia californica

46 39 y.o. female Hx of mania and depression, refuses medication in favor of attempted course of herbs and acupuncture at onset of manic episode. Following subsequent hospitalization, patient takes Lithium, Effexor, and Wellbutrin. To treat SE of fatigue, low libido, and diminished affect uses Maca Lepidium sp. Yin Yang Huo Epimedium sp. Damiana Turnera sp.

47 30 y.o. Male complains of fatigue, anxiety, palpitations, depression, and continuous ha s following accidental electrocution and subsequent episode of ventricular tachycardia. cardiac ablation surgery Zoloft Hawthorne berry Crataegus oxycantha Ginseng panax ginseng schizandra berries Schizandra chinensis Ginseng and Longan gui pi tang

48 33 y.o. male prescribed Zoloft following a dramatic life episode and reported that the agitation from the drug was more severe than prior to starting it. presenting sx include frequent crying, yawning, and restlessness. Herbal rx. Licorice Glycyrrhiza glabra Jujube dates Zizyphus jujube Wild oats Avena fatua Tincture 120 drops Q.I.D. patient reported immediate relief of agitation and shortly thereafter discontinued drug while continuing herbs.