Deadly Mix: Herbs, Supplements, and Drug Interactions

Deadly Mix: Herbs, Supplements, and Drug Interactions

اسلاید 1: www.tabaye.ir

اسلاید 2: Deadly Mix: Herbs, Supplements, and Drug InteractionsGeneva Briggs, Pharm.D., BCPSMedOutcomes, Inc.

اسلاید 3: ObjectivesDiscuss 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. 1

اسلاید 4: “Poisons and medicines are oftentimes the same substances given with different intents”Peter Mere Latham (1789-1875)2

اسلاید 5: Complementary and Alternative Medicine Practices ~40% of the US population uses dietary supplements often~ 50% of people have used herbals~ 4% rely exclusively on alternativesIn Germany over 700 herbs are available and prescribed by 70% of physiciansNEJM 1993;328:246-52.JAMA 1998;279:1548-53.3

اسلاید 6: Complementary and Alternative Medicine Practices<40% of patients inform someone they are taking alternative medicationsMost 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 affluentJ Am Diet Assoc 2003;103:1500-5JAMA 1998;280:1569-75Pharmacotherapy 2000;20:877-914

اسلاید 7: Pharmaceuticals vs PhytomedicinesMust prove efficacy and safetyMandatory ADE monitoringProduct formulation standardsConsensus for useMarketing more restrictedSafety & efficacy data may be lackingADE monitoring not mandatoryNo product standards mandatedDosing uncertainNo treatment or cure claims on label5

اسلاید 8: Concerns with PhytomedicineVariability of active constituentsMisidentification of the plantSelection of the wrong part of the plantInadequate storageContaminationAdulterationMislabeling of the final product6

اسلاید 9: Asian or Chinese patent medicinesOf 251 purchased in CA , 24 contained lead, 36 arsenic, 35 mercury24% of 2,609 samples of Chinese patent medicines contained pharmaceutical adulterantsJ Clin Pharmacol 1997; 37: 344­50.  BMJ 1994; 308: 1162. N Engl J Med 1998; 339: 8477

اسلاید 10: Which herbals are most likely to cause significant adverse effects?8

اسلاید 11: Top 10 OffendersKava [Piper methysticum] ComfreyChaparral [Larrea tridentata] Germander [Teucrium genus]Aristolochic acid Germanium dioxide or lactate citrate Lobelia [Indian tobacco]Stephania L-tryptophan Ephedra (ma-huang)9

اسلاید 12: Beyond the Top 10Pennyroyal oilSassafrasBorageCalamusColtsfootLife root10

اسلاید 13: Significant Interactions with Alternative Supplements11

اسلاید 14: St John’s Wort [Hypericum perforatum]DigoxinWarfarinTheophyllineNefazodoneOral contraceptivesAntiretroviralsCyclosporineImatinib (Gleevec)Irinotecan [Camptosar]SimvastatinAmitriptylineSSRI (fluoxetine, sertraline, etc.)Lancet 2000;355:1343-8Pharmacotherapy 2004;24:1508-1412

اسلاید 15: Herbal and Supplement Products That Interact with Warfarin Increased INRGinkgo BilobaDong Quai (Angelica sinesis)Danshen (Salvia miltiorrhiza)Vitamin EDecreased INRSt. John’s WortCoenzyme Q10American ginsengAltered PlateletsGarlic [Allium sativum]FeverfewGinsengTurmericMeadowsweetWillow barkContain Coumarins*Horse chestnutRed cloverLancet 2000;355:13438J Clin Pharm Ther 2002;27:391-40113

اسلاید 16: Significant Interactions with Alternative Meds and SupplementsSiberian Ginseng (Eleutherococcus senticocous) - DigoxinValerian [Valeriana officinalis] – alcohol, benzodiazepines, anticonvulsants, TCALicorice - ACE-I, ARB, diuretics, digoxinLancet 2000;355:1343814

اسلاید 17: Significant Interactions with Alternative Meds and SupplementsKava and valerian– alcohol, barbiturates, antispychotic drugs, sedatives, benzodiazepines, Garlic – saquinavirRed rice yeast [Chinese red rice]- statins, gemfibrozil, fenofibrate15

اسلاید 18: Patient Groups Most Likely to have ProblemsMultiple medicationsHIV/AIDSCancerTransplantTreated with warfarin, digoxin, or other agents prone to drug interactionsUndergoing surgeryAm J Health-Syst Pharm 2004;61:1707-1116

اسلاید 19: Avoid Recommending HerbalsPregnant and lactating womenChildren17

اسلاید 20: Problem Products in SurgeryGinkgo biloba Saw PalmettoAmerican Ginseng [Panex quinquefolias]KavaSt John’s wortFeverfew18

اسلاید 21: Problem Products in Cancer TreatmentGarlicGinkgoEchinaceaPanax ginsengSt John’s wortKavaJ Clin Oncol 2004;22:2489-50319

اسلاید 22: Reasonably Effective HerbalsAloe Vera (topical)Arnica (topical)Black CohoshChamomile teaEchinaceaEvening primrose oilFeverfew GarlicGingerGinkgo BilobaHawthornPeppermint teaSaw PalmettoSiberian GinsengSt John’s wortValerian20

اسلاید 23: Reliable Printed ResourcesHerbal medicine: Expanded Commission E monographsReview of Natural ProductsTyler’s Herbs of Choice. The Therapeutic Use of PhytomedicinalsTyler’s Honest Herbal: A Sensible Guide to the Use of Herbs and Related Products.Facts and Comparisons: The Review of Natural Products21

اسلاید 24: Reliable Online Resources consumerlab.comherbalgram.com American Botanical Councilnccam.nih.gov NIH’s National Center for Complementary and Alternative Medicinevm.cfsan.fda.govCenter for Food Safety and Applied Nutrition22

اسلاید 25: Reliable Online Resourceswww.uic.edu/pharmacy/research/diet/content/scont_about_evaluations.htmUniversity of Illinoiswww.pharmacist.com/pdf/dietary_supplements.pdfHealthcare Professional’s Guide to Evaluating Dietary Supplementswww.herbalwatch.com23

اسلاید 26: To Buy Anything and Everything www.herbalremedies.comBlood CirculatorMade 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.24

اسلاید 27: Patient CounselingEncourage disclosure of ALL medicinal substancesDiscuss available information about alternative medicinesDiscuss health risk and self-monitoringSet objective goals to follow progressSteer patients seeking to self-treat serious disorders such as depression to a physician25

اسلاید 28: How to Report an Adverse EffectComplete the Medwatch form online www.fda.gov/medwatch/report/hcp.htmReport 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

اسلاید 29: Evaluating Products for QualityLook for USP standardizationfeverfew, ginger, chamomile, cranberry, ginkgo biloba, St John’s wort, saw palmetto, milk thistle, valerian, siberian ginseng, and echinaceaReputable manufacturerConsumerlab.com evaluations27

اسلاید 30: ConclusionCurrent regulation of dietary supplements fails to address substantial risk to public healthEducate patients to give “Full Disclosure”Know the problem herbs and most common interacting herbsReport adverse events28