صفحه 1:
۱ 0
eo
صفحه 2:
Deadly Mix: Herbs,
Supplements, and Drug
Interactions
Geneva Briggs, Pharm.D.,
BCPS
MedOutcomes, Inc.
صفحه 3:
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.
و .و و«
صفحه 4:
“Poisons and medicines
are oftentimes the same
۱ revs ل
different intents”
Peter Mere Latham
(1789-1875)
صفحه 5:
Smee iy Roe ane Ley eee ga rare Bs Mc dee eee
Alternative Medicine
Practices
® ~40% of the US population uses
dietary supplements often
| ~ 50% of people have used herbals
0 ~ 4% rely exclusively on alternatives
' In Germany over 700 herbs are
available and prescribed by 70% of
physicians
صفحه 6:
ee ا دص( Sh ree ae”
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
NON oe hehe cleat)
0م 07:62 : 000:00 © روصم امسوم 4
نیا
صفحه 7:
Pharmaceuticals vs
Phytomedicines
® Must prove efficacy ® Safety & efficacy
and safety data may be lacking
Mandatory ADE ! ADE monitoring not
monitoring mandatory
1 Product formulation ° No product
standards standards
5 mandated
لظ
Consensus for use ‘i feet 5
Marketing more 1 تلكا ۳۱۵
restricted No treatment or
cure claims on label
صفحه 8:
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
صفحه 9:
Asian or Chinese patent
medicines
© Of 251 purchased in CA , 24
contained lead, 36 arsenic, 35
۱۱۸۱27
' 24% of 2,609 samples of Chinese
patent medicines contained
pharmaceutical] adulterants noo,
.©0065 :006 :0560 ل 00م
ره 0
صفحه 10:
Which herbals are most
likely to Cause significant
adverse effects?
صفحه 11:
Top 10 Offenders
® Kava [Piper ® Lobelia [Indian
methysticum] tobacco]
| Conley ۲ 1
۱ i ۳
tridentata] L-tryptophan
° Germander ° Ephedra (ma-
[Teucrium genus] 3
Aristolochic acid 2
Germanium dioxide
or lactate citrate
صفحه 12:
Beyond the Top 10
Pennyroyal oil
Sassafras
Borage
Calamus
Coltsfoot
Life root
ا د ا
10
صفحه 13:
Significant Interactions with
Altermmative Supplements
صفحه 14:
۱ < ۱0۱۱۲۱ ا9
922/92
* Digoxin © |rinotecan
3 [Camptosar]
* Theophylline 0 Simvastatin
ae ١
ge} 5
1100110 0 SSRI (fluoxetine,
Antiretrovirals sertraline, etc.)
Cyclosporine
Imatinib (Gleevec)
Lancet 2000;355:1343-8
2 2 0
04
صفحه 15:
و Fig he و ول د
Products That 9۵۲۵
with Warfarin
® Increased INR 0 Altered Platelets
Ginkgo Biloba Garlic [A/lium sativum]
Dong Quai (Angelica الع ]رع رامع
sinesis) Ginseng
Danshen (Salvia Turmeric
miltiorrhiza) ۱ footie
Ml Teas ta
7 06۲6۵560 [7 0 1 0 را
56. )زوللا 5" ماه[ Horse chestnut
Coenzyme Q10 انا
American ginseng
Lancet 2000;355:13438
108} J Clin Pharm Ther 200 391-01
صفحه 16:
Sisjititioeiiin SO ات ee ee
Alternative Meds and
Supplements
Siberian Ginseng (E/eutherococcus
senticocous) - Digoxin
Valerian [ Va/eriana officinalis] -
alcohol, benzodiazepines,
anticonvulsants, TCA
Licorice - ACE-I, ARB, diuretics,
digoxin
Lancet 2000;355:13438
14
صفحه 17:
Sisjititioeiiin SO ات ee ee
Alternative Meds and
Supplements
! Kava and valerian- alcohol,
barbiturates, antispychotic drugs,
sedatives, benzodiazepines,
! Garlic - saquinavir
" Red rice yeast [Chinese red rice]-
statins, gemfibrozil, fenofibrate
15
صفحه 18:
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
Am J Health-Syst Pharm
16 2004:61:1707-1
صفحه 19:
۸۱۷۵۱ Recommending
Herbals
' Pregnant and lactating women
© Children
17
صفحه 20:
Problem) Products in
SUFGeny.
Ginkgo biloba
Saw Palmetto
American Ginseng [Panex
quinquefolias]
Kava
St John’s wort
NAIA KSA]
18
i
i
0
0
1
صفحه 21:
Problem) Products in
Cancer Ireatment
Garlic
Ginkgo
Echinacea
Panax ginseng
St John’s wort
Kava
ا د ا
J Clin Oncol 2004;22:2489-
19 503
صفحه 22:
Reasonably Effective
Herbals
® Ginger
Ginkgo Biloba
Hawthorn
Peppermint tea
Saw Palmetto
Siberian Ginseng
St John’s wort
Valerian
20
0
Aloe Vera (topical)
Arnica (topical)
Black Cohosh
Chamomile tea
Echinacea
Evening primrose oil
الاع ]اع باعع]
Garlic
صفحه 23:
Reliable ۳۲۲۱۱۱۲۵۵ ۵
® 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
CCE EE Ek
2M
صفحه 24:
Reliable Online Resources
® consumerlab.com
' herbalgram.com
» American Botanical Council
' nccam.nih.gov
» NIH’s National Center for Complementary
and Alternative Medicine
! ym.cfsan.fda.gov
» Center for Food Safety and Applied
Nutrition
22
صفحه 25:
Reliable Online Resources
® www.uic.edu/pharmacy/research/
diet/content/
scont_about_evaluations.htm
» University of Illinois
' www.pharmacist.com/pdf/
dietary_supplements.pdf
» Healthcare Professional's Guide to
Evaluating Dietary Supplements
1 www.herbalwatch.com ۳
و .و و و«
صفحه 26:
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
ات(
24
صفحه 27:
Patient Counseling
و .و«
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 toa
hysician
a 25)
صفحه 28:
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.
26
صفحه 29:
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
27
صفحه 30:
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 se
و .و و و«