Natural = Safe

OTC Supplements: Impact on Periodontics
Karen A. Baker, M.S., R.Ph.
Associate Professor
Dept. Oral Pathology, Radiology and Medicine - U of Iowa College of Dentistry
Dept. Clinical and Administrative Pharmacy - U of Iowa College of Pharmacy
I. DEFINITIONS & PATIENT UTILIZATION
Alternative Medicine (as defined by the Office of Alternative Medicine (NIH))


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Those treatments & health care practices not taught widely in medical schools
Not generally used in hospitals
Not usually reimbursed by medical insurance companies
Definitions of popular alternative therapies

Holistic medicine: As the term implies, deals with a being as a "whole" and integrated system rather
than individual parts and advocates the synergistic use of herbs to heal the being. Also referred to as
alternative or complementary medicine, it is composed of a series of disciplines including chiropractics,
naturopathy, reflexology, acupuncture, massage, and the following.

Homeopathy: Based on the principle of "like cures like”--very small doses of naturally derived botanical,
mineral, or animal compounds are diluted to treat a condition. The same substance in larger doses in a
healthy subject would cause symptoms similar to those of the disease being treated.
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Herbal medicine: Rests on the usage of preparations and medications derived from botanical
components such as roots, leaves, and flowers to promote healing.

Naturopathy: Adopts a non-invasive approach emphasizing natural remedies, a healthy diet, and
exercise to heal rather than surgery or synthetic drugs. N.D. is “Doctor of Naturopathy”
Common Viewpoint Among Traditional Healthcare Providers: “Either Worthless or Dangerous!!”

Until the 1940s much of the U.S. Pharmacopoeia was composed of drugs of herbal origin

25% of common Rx drugs contain at least one active ingredient derived from plants
aspirin, atropine, belladonna, capsaicin, cocaine, colchicine, digoxin, ephedrine, ergotamine, opium,
physostigmine, pilocarpine, quinidine, scopolamine, taxol, vincristine, vinblastine

80% of the world’s population (7 billion people) use herbal medicine for some aspect of primary health
care according to the W orld Health Organization…. W hat are the reasons???
1) Patient dissatisfaction with conventional treatments because of lack of effect, adverse effects, or
perceptions that treatments are too impersonal, highly technical, or costly;
2) The need for personal control is met because patient becomes a “co-therapist”;
3) Alternative therapies are more attractive because patients view them as more compatible with their
value s ystems.

70% of patients will not tell health care providers they are taking herbal products

U.S. Market for dietary supplements was almost 26 billion in 2009

Top 10 herbal products account for 60% of the total herbal medicine market
HERBAL SUPPLEMENT SALES DATA FROM HERBALGRAM. 2011; 90:64-67.
II.
Effectiveness of The Most Popular Vitamins and Herbal Medicines
1. Effect of Vitamin and Mineral Supplementation on Chronic Diseases
a. B vitamins and Heart Disease-Folic Acid (B-9), B-6, B-12
b. Retinoids (Vitamin A) – little evidence for prevention of cancers
c. Vitamin D – 800-1200IU daily not to exceed 2000IU daily
d. Antioxidants (lycopene, lutein, zeaxanthine)
Lutein – proven to help prevent macular degeneration
Lycopene – may reduce risk of prostate cancer
e. Vitamin C (ascorbic acid) – can’t prevent the common cold
f. Calcium Supplements – 1000-1500mg/day but no more than 600mg at one time due
to absorption limitations. Need stomach acid to absorb calcium and citrate is best for this
3
2. Glucosamine Sulfate +/- Chondroitin
-glucosamine sulfate 1500-2000mg/day but may raise glucose in diabetics
-chondroitin 200-400mg 2-3x/day and takes up to 4 months to show effectiveness
3. SamE
Likely effective: depression at 1600mg/day
Likely effective: osteoarthritis at 200mg tid
Mechanism: increases dopamine and NE in CNS
Also has anti-inflammatory and analgesic properties
4. Coenzyme Q10
Used For: CHF, angina, periodontal disease, Parkinsons’ Disease
Effectiveness: may enhance the therapeutic effect of other heart failure drugs but doesn’t improve CHF itself
Neither topical nor systemic CoQ-10 has been shown to improve or prevent periodontal disease.
Dosage: 300mg-2400mg/day
5. Fish Oils (Omega-3 Fatty Acids EPA and DHA, NOT ALA)
Used for: hyperlipidemia, CHD, hypertension
Effectiveness: fish oil supplements reduce triglycerides by 20-50%. BCPs may interfere with this effect.
Dosage: 1-4 grams of fish oil/day, 2.7 ounces of fish contains 3.65g omega 3 fatty acids
Tuna, mackerel, wild salmon are best but mercury content is of great concern with daily consumption!
At least 1000mg of total EPA/DHA is needed for therapeutic effects
6. Melatonin (Pineal Gland Hormone)
Used for: jet lag, insomnia, shift-work disorder
Likely effective: modestly improves jet lag
Dosage: For jet lag take 2-5mg at bedtime of local time and for 2-5 nights afterward.
Likely effective: sleep latency (improved on average by 12 minutes)
Sleep/wake cycle disturbances-MR, autism
7. Probiotics (Culturelle, Activia Yogurt, etc.)
Bifidobacteria or Lactobacillus GG are NOT destroyed by stomach acid
Yogurt with active cultures is variably effective due to destruction of bacteria in stomach acid
Lactobacillus likely effective for: Rotaviral diarrhea – need 10 billion CFU/48 hour
Antibiotic-associated diarrhea – reduces risk by 69% but not in hospitalized patients
Yogurt consumption may reduce vaginal candidosis but lactobacillus orally does not
8. Bee Products (Royal Jelly) – expensive way to ingest B vitamins
9. 5-HTP (5-Hydroxytryptophan) – EMS caused deaths in 1989
10. Gelatin – not effective for osteoarthritis
11. Digestive Enzymes (Pancreatin, etc.) – not effective if no deficiency
12. Ginkgo Biloba
Used for: dementia, memory loss, difficulty with concentration, mental acuity
Modestly effective for dementia (delays progression by six months)
NOT effective for improving memory in the elderly
Dosage: 120-240mg ginkgo leaf extract daily
13. Garlic
Used For: hypertension, hyperlipidemia, preventing CHD and atherosclerosis
Effectiveness: lowers total cholesterol 4-12%, lowers blood pressure 2-7%
Dosage: Odorless garlic contains 3% of active ingredient found in fresh garlic. Garlic extract 600-1200mg/d
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14. Echinacea – doesn’t prevent the common cold and is in the ragweed family
15. Ginseng
Used for: stress resistance, preventing the effects of aging
Effectiveness: Type 2 diabetics who take up to 3 grams of American Ginseng 2 hours prior to meals have
Reduced postprandial blood glucose. Dosage: 250-500mg bid
16. Saw Palmetto
Used for: reducing symptoms of BPH
Effectiveness: Improves BPH symptoms same as Proscar. No additional benefit when added to Rx therapy
Dosage: 1-2 grams of whole berries/day or 320mg/day of lipophilic extract
17. St. John’s Wort (Goat Weed)
Used for: depression, anxiety
Effectiveness: Works as well as tricyclic antidepressants for mild to moderate depression.
Drug Interactions: Avoid serotonergic drugs like meperidine, pentazocine, or tramadol.
Dosage: standardized 0.3% hypericin extract 300mg tid.NOT FOR SEVERE DEPRESSION
18. Topical Zinc for the Common Cold
ZICAM (1% zinc gluconate nasal gel) – use every 2 hours at first symptom of a cold
Reduces duration of cold from 7 days for placebo gel to 1.5 days with active product
Zinc prevents the rhinoviruses from binding to mucous membranes
Safe for children 2 years and older
III. REGULATORY ISSUES & SAFETY
A. Federal Trade Commission (FTC) is in charge of over-the-counter advertising
 Currently herbal medicines can only be marketed in the U.S. as dietary supplements
 Manufacturers/distributors cannot make specific health claims without FDA approval
B. Legislation
 Dietary Supplements Health & Education Act (DSHEA) 1994
 Congress “freed” the population to pursue self-medication with herbal and alternative products
vitamins, minerals, essential fatty acids, enzymes, coenzymes, plant derived (herbs), animal-derived
(glucosamine), bacteria, glandular products (adrenal extracts), hormonal (melatonin)
 Act limits FDA’s regulation of “dietary supplements” to superficial labeling features because the act was not
fully funded. New legislative initiatives may change this very soon.
C. Problems with DSHEA
 Products are not required to:
Gain prior marketing approval by the FDA
Be Monitored for identity or potency of chemicals in the supplement
Be backed by company data supporting safety or efficacy
 Natural = Safe ???
Paradox – public is more afraid of tested drugs than of untested dietary supplements
15-20% of adults in US have used herbals within the past year according to USDHHS
D. Problems with Herbals
 Intentional fraudulent adulteration with another active drug
 Accidental substitution of a more toxic species for the intended plant material
 Contaminants – chemicals, toxins, biologic pathogens
 Inappropriate amounts of chemical  or 
 Adverse herb-drug or herb-disease interactions
 Intrinsic toxicity, low margin of safety
E. Testing for Active Ingredient and Labeling –Consumer Lab gives a CL approved seal
-USP dietary supplement verified seal
-NSF International certifies products
-GMP Seal Required as of June 2010
F. Examples of Reliable Herb Companies – Phytopharmica, Nature’s Way, Puritan’s Pride,
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G. Patient History: Screening Questions on Dental Health Questionnaire
 Do you regularly take dietary supplements or herbal medicines?
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If YES, do you regularly take any of the following:

Diet or Energy supplements
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Kava
St. John’s W ort
Echinacea
Garlic
Ginger Ginkgo
Ginseng
Valerian
Vitamin E >400I.U. Fish Oil >3 grams/day
Do you regularly use natural or herbal oral health products?
 Have you recently substituted herbs for prescription or over-the-counter drugs?
H. Drug Interactions with Herbal Products: [www.rxfiles.ca/acrobat/cht-herbal-di.pdf]
 W hy are herb-drug interactions difficult to assess?
o Actual doses may differ from label and herbals may contain adulterants
o Potency varies by crop year
o Collection, storage and marketing methods promote contamination
IV. Dental Impact of Herbal Supplements
What are we worried about in clinical dental practice??
 Increased bleeding or effects on hemostasis
 Delayed wound healing
 Effects on the immune system
 Sedation and other CNS effects
 Interactions with dental medications
A. Surgical Considerations for Patients Taking Selected Herbal Supplements_____
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Adapted from: Ang Lee, MK and Moss J. Herbal medicines and perioperative care. JAMA 286(2):208-216, 20
C.
DIETARY SUPPLEMENTS WITH ANTI- OR PRO-COAGULANT ACTIVITY
Irreversible platelet effects: Feverfew, garlic, panax ginseng. D/C 7-10 days prior to surgery.
Reversible platelet effects: Ginkgo, Vitamin E. D/C 3 days prior to surgery.
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V. TWELVE DIETARY SUPPLEMENTS NO ONE SHOULD TAKE!!!
Name
Dangers
(Also known as)
DEFINITELY HAZARDOUS
Documented organ failure and known carcinogenic properties
Aristolochic acid (Aristolochia, birthwort, snakeroot,
Potent human carcinogen;
snakeweed, sangree root, sangrel, serpentary, serpentaria; kidney failure, sometimes
asarum canadense, wild ginger). Can be an ingredient in requiring transplant; deaths
Chinese herbal products labeled fang ji, mu tong, ma dou reported.
ling, and mu xiang. Can be an unlabeled substitute for
other herbs, including akebia, asarum, clematis, cocculus,
stephania, and vladimiria species.
Regulatory actions
FDA warning to consumers and industry
and import alert, in April 2001. Banned in
7 European countries and Egypt, Japan,
and Venezuela.
VERY LIKELY HAZARDOUS
Banned in other countries, FDA warning, or adverse effects in studies
Comfrey (Symphytum officinale, ass ear, black root,
Abnormal liver function or FDA advised industry to remove from
blackwort, bruisewort, consolidae radix, consound, gum damage, often irreversible; market in July 2001.
plant, healing herb, knitback, knitbone, salsify, slippery deaths reported.
root, symphytum radix, wallwort)
Androstenedione
(4-androstene-3, 17-dione, andro, androstene)
Increased cancer risk,
decrease in HDL
cholesterol.
FDA warned 23 companies to stop
manufacturing, marketing, and
distributing in March 2004. Banned by
athletic associations.
Chaparral (Larrea divaricata, creosote bush, greasewood, Abnormal liver function or FDA warning to consumers in December
hediondilla, jarilla, larreastat)
damage, often irreversible; 1992.
deaths reported.
Germander (Teucrium chamaedrys, wall germander, wild Abnormal liver function or Banned in France and Germany.
germander)
damage, often irreversible;
deaths reported.
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Kava (Piper methysticum, ava, awa, gea, gi, intoxicating Abnormal liver function or FDA warning to consumers in March
pepper, kao, kavain, kawa-pfeffer, kew, long pepper,
damage, occasionally
2002. Banned in Canada, Germany,
malohu, maluk, meruk, milik, rauschpfeffer, sakau, tonga, irreversible; deaths reported. Singapore, South Africa, and Switzerland.
wurzelstock, yagona, yangona)
LIKELY HAZARDOUS Adverse-event reports or theoretical risks
Bitter orange (Citrus aurantium, green orange, kijitsu,
High blood pressure;
neroli oil, Seville orange, shangzhou zhiqiao, sour orange, increased risk of heart
zhi oiao, zhi xhi)
arrythmias, heart attack,
stroke.
None
Organ/glandular extracts(brain/adrenal/pituitary/
placenta/other gland “substance” or “concentrate”)
FDA banned high-risk bovine materials
from older cows in foods and
supplements in January 2004. (High-risk
parts from cows under 30 months still
permitted.) Banned in France and
Switzerland.
Theoretical risk of mad
cow disease, particularly
from brain extracts.
Lobelia (Lobelia inflata, asthma weed, bladderpod,
Breathing difficulty, rapid Banned in Bangladesh and Italy.
emetic herb, gagroot, lobelie, indian tobacco, pukeweed, heartbeat, low blood
vomit wort, wild tobacco)
pressure, diarrhea, dizziness,
tremors; possible deaths
reported.
Pennyroyal oil(Hedeoma pulegioides, lurk-in-the-ditch,
mosquito plant, piliolerial, pudding grass, pulegium, runby-the-ground, squaw balm, squawmint, stinking balm,
tickweed)
Liver and kidney failure,
None
nerve damage, convulsions,
abdominal tenderness,
burning of the throat; deaths
reported.
Scullcap (Scutellaria lateriflora, blue pimpernel, helmet
flower, hoodwort, mad weed, mad-dog herb, mad-dog
weed, quaker bonnet, scutelluria, skullcap)
Abnormal liver function or None
damage.
Yohimbe (Pausinystalia yohimbe, johimbi, yohimbehe,
yohimbine)
Change in blood pressure, None
heart arrythmias, respiratory
depression, heart attack;
deaths reported.
According to product labels.
Sources: Natural Medicines Comprehensive Database 2007 and
Consumers Union's medical and research consultants.
VI. Advice For the Patient

If it seems too good to be true it probably is!
“Scientific Breakthrough”
“Miraculous Cure”
“Exclusive Product”
“Secret Ingredient”
“Ancient Remedy”
How to Spot False Claims
Medical Conspiracy to Suppress Product
Case Histories Claiming Amazing Results
Product Has Limited Availability
Money-Back Guarantee
Weight Loss is Easy and Fast
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Key Issues For Consumers
“Natural” is not synonymous with “Safe”
Lack of standardization may result in great variation among products
Never use in pregnant women, the elderly, or in young children
Consumers must protect themselves in the current regulatory environment
VII. “Natural” Oral Health Products: Help or Hype?
A. What “Natural” Oral Health Products DON’T Contain
-Alcohol
-Artificial colors or artificial sweeteners like saccharine
-Harsh chemical preservatives or dyes
-Sodium Lauryl Sulfate
-Triclosan or chlorhexidine
B. What “Natural” Oral Health Products DO Contain
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Aloe vera has a soothing and anti-inflammatory effect.
Calendula (Calendula officinalis) has soothing, anti-inflammatory properties that help heal irritated, tender gums. It also has a mild
antiseptic action. It is in the ragweed family and can cause allergic reactions in those allergic to ragweed.
Echinacea (Echinacea spp.), an immune-stimulating herb, helps combat infection; it is anti-inflammatory and antiviral.
Essential Oils, such as anise, cinnamon,clove, eucalyptus, fennel, lavender, peppermint, rosemary, spearmint, and thymol kill bacteria
Goldenseal (Hydrastis canadensis) has anti-inflammatory, antiviral and antibiotic properties; it's good for healing and preventing gum
problems.
Grapefruit seed extract, made from the seeds and pulp of grapefruit, has antiseptic and antibacterial properties to fight infection.
Horsetail is rich in silica, vitamin E, selenium and other minerals. When used as a mouth rinse, it can help in coagulation, decrease
bleeding and heal oral infections.
Myrrh (Commiphora molmol) has antimicrobial and astringent properties that help to tighten the gums. It is considered one of the best
herbs for healing bleeding gums and mouth ulcers, and helps fight the bacteria that cause tooth decay and gum disease.
Neem (Azadirachta indica), long considered a top antibacterial herb in Ayurvedic healing, helps prevent plaque. Ayurveda, a form of
traditional medicine originating in India, is practiced in the western world, including the United States, as a form of alternative or
complementary medicine.
Oregon grape root (Mahonia spp.), possessing a high concentration of antimicrobial compounds and astringent properties, is excellent
for helping to prevent and heal gum problems.
Ozone or olive oil with ozone, for caries and bacteria reduction. Primarily used in Europe but growing in the U.S.
Peppermint (Mentha piperita) provides a pleasant, freshening flavor and sensation.
Sage (Salvia officinalis) has strong astringent properties, making it a favorite herb for tightening the gums and soothing a sore mouth.
Tea tree (Melaleuca alternifolia), a potent antimicrobial essential oil, fights the bacteria that cause tooth decay and gum disease. It is
often used in combination with other natural herbs, such as rosemary, chamomile, echinacea, aloe and fresh mint.
Vitamin K strengthens teeth.
White oak bark (Quercus alba), a strong astringent, is helpful for healing swollen, tender and bleeding gums and mucous membranes,
and has a clotting and antiseptic effect.
Xylitol, a natural non-cariogenic sweetner made from birch trees has been clinically shown to prevent tooth decay
C. Common “Alternative” Ingredients and Clinical Evidence?
-Loturbark, Neem, Tulsi, Myrrh
.
.
* Pai MR, Acharya LD, Udupa N. Evaluation of antiplaque activity of Azadirachta indica leaf extract gel--a 6-.
week clinical study. J Ethnopharmacol 2004;90:99-103
.* Antinociceptive action of Ocimum sanctum (Tulsi) in mice: possible mechanisms involved. J Ethnopharmacol 2003;88:293-6
* Myrrh is the oleo-gum resin exuded from fissures or cuts in the bark of Commiphora species trees.
-Peelu (Miswak Chewing Stick)
*Use of miswak versus toothbrushes: oral health beliefs and behaviours among a sample of
Jordanian adults. RS Tubaishat, ML Darby, DB Bauman and CE Box pages 126–136
*Namibian Chewing Stick, Diospyros lycioides, Contains Antibacterial Compounds against
Oral Pathogens
Cai, L.; Wei, G.-X.; van der Bijl, P.; Wu, C. D. J. Agric. Food Chem.; (Article); 2000; 48(3); 909-914.
10
-Melaleuca (Australian Tea Tree Oil)
Gingivitis Helped, But Not Plaque: In a DB PC study of 49
adults with severe chronic gingivitis given either TTO-gel (2.5%), chlorhexidine (CHX) gel (0.2%), or a placebo gel to apply
with a toothbrush twice daily, no adverse reactions to any of the gels were reported. The TTO group had significant reduction in bleeding
and gingivitis. However,TTO did not reduce plaque scores, which tended to increase over the latter weeks of the study period. The effects
of a tea tree oil-containing gel on plaque and chronic gingivitis. Soukoulis S, Hirsch R. University of Adelaide, South Australia. Aust Dent
J. 2004 Jun;49(2):78-83.
-Propolis (Bee Product)
* Santos FA, Bastos EM, Uzeda M, et al. Antibacterial activity of Brazilian propolis and fractions against oral anaerobic
Bacteria. J Ethnopharmacol 2002;80:1-7.
* Park YK, et al. Antimicrobial activity of propolis on oral microorganisms. Curr Microbiol 1998;36:24-8.
-Essential Oils (eucalyptus, rosemary, thyme(thymol 30-70%))
*Silva J, Abebe W, Sousa SM, et al. Analgesic and anti-inflammatory effects of essential oils of Eucalyptus.
J Ethnopharmacol 2003;89:277-83.
-Coenzyme Q10 (Ubiquinone)
.
*Hanioka T, Tanaka M, Ojima M, et al. Effect of topical application of coenzyme Q10 on adult periodontitis.
Molec Aspects Med 1994;15:S241-8.
*Turunen M, Olsson J, Dallner G. Metabolism and function of coenzyme Q.
Biochim Biophys Acta 2004;1660:171-99
-Green Tea Extract
* Wu CD and Wei GX. Tea as a functional food for oral health. Nutrition 2002; 18 (5). 443-444.
*Krahwinkel T, Willershausen B. The effect of sugar-free green tea chew candies on the degree of
inflammation of the gingiva. Eur J Med Res 2000;5:463-7
.
-Antioxidants (pycnogenol, Vitamin E)
*Garewal HS, Katz RV, Meyskens F, et al. Beta-carotene produces sustained remissions in patients with oral
.
Leukoplakia: results of a multicenter prospective trial. Arch Otolaryngol Head Neck Surg 1999;125:1305-10
*Liede K, Hietanen J, Saxen L, et al. Long-term supplementation with alpha-tocopherol and beta-carotene and prevalence of
oral mucosal lesions in smokers. Oral Dis 1998;4:78-83
*Benner SE, Winn RJ, Lippman SM, et al. Regression of oral leukoplakia with alpha-tocopherol: a community clinical oncology
.
program chemoprevention study. J Natl Cancer Inst 1993;85:44-7
-Vitamin C (Ascorbic Acid)
*Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Dietary Vitamin C and the risk for
periodontal disease. J Periodontol 2000: 71: 1215– 1223
- Aloe Vera
* Wynn, R. Aloe Vera in Dentistry. AGD Journal Jan-Feb, 2005.
B. Common Alternative Dental Products
Product/Manufacturer
“Active Ingredients”
Claims
Auromere (www.auromere.com)
Invigorates/purifies
Neem, Peelu, 24 herbal extracts
Dabur (www.dabur.com)
Astringent/cleaning
Tulsi, Loturbark, essential oils
DentiCare Tooth Polish (Melaleuca, Inc.)
Benefits bleeding gums
Melaleuca, propolis, myrrh
Dentaforce (www.BioforceUSA)
Astringent/stimulant
Echinacea, rosemary, essential oils
Eco-Dent (Eco-Dent 888.Eco.Dent)
Hardens enamel w/o F
-
BS, tartaric acid, CaCo3, myrrh
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Product/Manufacturer
“Active Ingredients”
Claims
Cool Mint (www.nature’s-gate.com)
Antiseptic/ free calcium
Sage, VitaminC, Ca Glycerophosphate
Healthy Gums Toothpaste and Oral Rinse
www.naturaldentist.com, Medford, MA
Prevent cavities/fight gingivitis,
protects and soothes gums/mouth
MFP, aloe vera, bee propolis, echinacea,
goldenseal,calendula, grapefruit seed ex.
Homeodent (Boiron-Borneman)
No-mint,no effect on homeopathy
Calendula, plantain, witch hazel
Jason Toothpaste (www.jasonnatural.com)
Best Tasting Natural Toothpaste!
CoQ10, Aloe Vera, Sea Salt, Melaleuca,
Gum support/perio protection
Perilla Seed Extract
Kiss My Face (www.kissmyfacewebstore)
Wildly effective,fairly priced
Aloe,xylitol,CoQ10,some with Fluoride
MouthFx (www.mouthrx.com)
97% effective in 41 countries
100% natural essential oils
Nutribiotic Dental Gel
(www.nutribiotic.com/dentalgel)
Supports teeth and gums
Grapefruit Seed Extract, Zinc citrate,
sanguinaria, aloe vera, stevia
Peelu (www.peelu.com)
Miswak/Siwak chewing stick
Peelu fiber, natural sweetners
Propolis TP (Beehive Botanicals)
Protects hive, benefits mankind
Propolis, xylitol, flavoring oils
Spry (www.sprydental.com)
Dental Defense System
Xylitol, aloe, NaF, Calcium salts
Tea Tree Oil TP (Desert Essence)
Especially good for gingivitis/perio
Melaleuca, propolis, ginger
Tea Tree TP (Thursday Plantation)
Healthy gums, decrease tartar
0.4% melaleuca, chlorophyllin-copper
Tom’s of Maine (Tom’s of Maine)
No dyes, preservatives,
MFP, CaCo3, silica, zinc for TC
Tooth and Gum Paste (Dental Herb
Company 800.747.4372)
Substantive, no SLS, “natural
fluoride source” from tea
Echinacea, green tea, essential oils
No Fluoride which is toxic
Best with Fluoride: Healthy Gums, Jason Sea Fresh & Healthy Mouth CoQ10, Kiss My Face Anticavity, Spry
with Fl-,Tom’s of Maine Whole Care, Anti-cavity for Kids, Cavity Protection,Wicked Fresh Natural Fluoride
VIII. Herbal and Nutritional Drug Product References
Natural Medicines Comprehensive Database
-“Gold Standard” for objectivity and comprehensive information
-patient handout option very useful and database can be searched by disease state
-updated daily and fully referenced with abstracts available for review
-priced at $75/year at www.naturaldatabase.com
Nutrition Action Health Letter
-10 issues per year. Subscribe at www.cspinet.org for US or CA versions
- -nonprofit “food police” address dietary supplement controversies
-price $24/year or $42/24 months, to order fax 202.265.4954.
Other Useful Websites
-www.consumerlab.com -analytical reports on specific products
-www.americanbotanicalsociety.com or www.herbalgram.org (Mark Blumenthal)
-www.nccam.nih.gov/health/ or www.occam.nih.gov/health/
-www.ific.org/publications/other/driupdateom.cfm.
-www.mskcc.org/mskcc/html/11570.cfm.
-www.asahq.org-“Herbals and Anesthesia” brochure for sale
-www.quackwatch.org – nonprofit corp battles healthcare quackery
(botanical name)
Agrimony
Alfalfa
(Medicago sativa)
Aloe (Aloe vera)
Angelica
Anise
(Aniseed)
Aristolochia
Arnica (Wolf bane)
Asafoetida
Ayurvedic syrup
Betel nut
(Areca catechu)
Black cohosh
(Cimicifuga
racemosa)
Remifemin 20mg bid
Bladderwrack
(Fucus,Kelp)
Bogbean
Borage
Broom
Calamus
Capsicum
(Chili peppers)
Cascara
(Rhamnus purshiana)
Cassia
Celery
(seed/extract)
Cereus
Chamomile
(Matricaria reutita)
(German/Roman)
Chaparral
(Larrea tridentata)
Chinese herb mixture
Chondroitin
1200mg/day
Chromium
picolinate
Clove
Coltsfoot
(Tussilago farfar)
Comfrey
(Symphytum species)
Co-enzyme Q10
(Ubiquinone)
Couchgrass
Dandelion
Danshen
Dehydroepiandrosterone-DHEA
Devil's Claw
(Harpagophytum
procumbens)
Dong Quai
(Angelica sinensis)
warfarin ↓ INR → herb may be a coagulant
SE: photo dermatitis
cholesterol meds→ herb may further ↓ lipid levels
cyclosporin/steroids→ ? herb immuno-stimulating
hypoglycemic meds→herb may cause further hypoglycemia
warfarin ↑↓ INR → herb may contain warfarin constituents
or ↓ effect because of Vitamin K content in herb
SE: May ↑K+, rare pancytopenia & worsening of lupus CI: Lupus
digoxin & thiazide↑ cardiac toxicity→ due to electrolyte imbalance
Not recommended with breastfeeding. SE: contact dermatitis, ↓K+
warfarin ↑ INR → herb may contain warfarin constituents
Not recommended with breastfeeding. SE: photo dermatitis
MAOI's→ herb may ↑ risk of hypertensive crisis
warfarin ↑ INR → herb may contain warfarin constituents
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect SE: nephrotoxic
warfarin ↑ INR → herb may contain warfarin constituents
warfarin ↑ INR → herb may contain warfarin constituents- in vivo
phenytoin→herb may ↓ phenytoin levels as well as ↓ efficacy
SE: heavy metal poisoning from contamination
antipsychotics→herb may ↑ extrapyramidal SE (strong
cholinergic effects); asthmatics→ inadequate control of asthma
hormones→ herb may have estrogen-like effect.Dose: 40-80mg/day.
iron→ herb contains tannic acids which may ↓ iron absorption
warfarin ↑ INR → herb may contain salicylates
SE:For menopausal symptoms→ may cause mild GI effects & ↓ BP
warfarin ↑ INR → herb may have anticoagulant action
levothyroxine→herb is a source of iodine→caused hyperthyroidism
warfarin ↑ INR → herb may have hemolytic activity
antipsychotics/anticonvulsants/TCA's→herb may ↑ seizures
amiodarone, steroids anabolic, ketoconazole, methotrexate→ herb may ↑
hepatotoxicity effect. Generally unsafe. Not help atopic dermatitis Takwale 2003
Antihypertensive meds→ herb may ↑ BP by itself
Sedatives→ herb may potentiate sedation. Generally unsafe
by Brent Jensen Sept 2004
www.RxFiles.ca
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
Echinacea è
may have additive hepatotoxicity if used for > 8 weeks
Purple
corticosteroids/cyclosporin→ avoid combination
coneflower
glycemic control → herb may cause hypo/hyperglycemia
E. purpurea, pallida
& angustifolia
Not ↓ kids resp.
infection -Taylor JAMA 2003
Elecampane
Ephedra è
(Ma huang)
Herbal Ecstasy
Ephedrine/
Pseudoephedrine
(Ban in olympics)
?~1% ephedrine.
Tea~15-30mg
ephedrine/cup.
Evening
Primrose oil
warfarin ↑ INR → herb may contain warfarin constituents
Fenugreek
Feverfew
Tanacet 125mg od
(Tanacetum
parthenium)
-only 6 of 30 lots had
labeled content
CPJ Draves 2003/2004
Flaxseed
Garlic
è
(Allium sativum)
Active agents:
allicin & ajoene
Need high doses to
work. Only short 3hr
half life & acid labile
→ enteric coated better
Various meds→ ↓ absorption since going quicker via GI system
Digoxin/thiazides/steroids→ herb may potentiate hypokalemia
warfarin ↑ INR → herb may inhibit platelet aggregation
(Teucrium
chamaedrys)
MAOI’s/SSRI's/TCA's→herb may ↑ risk of serotonin syndrome
warfarin ↑ INR → herb may contain warfarin constituents
iron→ herb contains tannic acids which may ↓ iron absorption
sedatives→ herb may potentiate sedation; allergic reactions
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect. Generally unsafe
Rare: heavy metal contamination. Not help Hepatits C Jakkula 04
warfarin ↑ INR → herb may increase bleeding & chondroitin sulfate
is a component of the antithrombotic danaparoid
SE: GI. Poor oral absorption ~<10%, IM form in other countries.
nephrotoxic drugs→herb may ↑ renal failure & rhabdomyolysis
hypoglycemics → herb may cause hypoglycemia
warfarin ↑ INR → herb contains eugenol –a platelet inhibitor
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect. Not rec. with breastfeeding
herb may have additive or as monotherapy a hepatotoxic effect
(Health Canada warning Dec 2003). Generally unsafe (FDA 2001).
betablockers,phenothiazines,TCA's,doxorubicin→ herb may ↓
cardiac side effects from these medications
cardiac & antihypertensives → may improve effect of cardiac meds
HMG-Co A & hypoglycemics→ may ↓ natural levels of Q10 in body
warfarin ↓ INR → herb may decrease effect of warfarin
diuretics→herb may ↑ potassium loss; lithium→herb may alter level.
sedatives→ herb may potentiate sedation
diuretics & lithium→herb may ↑ diuretic effect & ↑ lithium toxicity
warfarin ↓ INR→ ↓ effect due to Vitamin K content in the herb;↑K+
warfarin ↑ INR → clinical bleed due to ? acetylsalvianolic acid
warfarin ↑ INR → herb may have fibrinolytic potential.
triazolam level can ↑ due to DHEA. Banned by the NBA.
heart & blood pressure meds→ herb may interfere (↑↓ ) with BP
hypoglycemics → herb may cause hypo/hyperglycemia
warfarin→?purpura SE:headache, ringing ears,↓ appetite,↓ taste
heart meds→ herb has quinidine like activity
warfarin ↑ INR →herb ?contain warfarin constituent-Case reports
Not recommended with breastfeeding. SE: photosensitive
anticonvulsants→herb may cause seizures
caffeine,decongestants,stimulants→herb may ↑nervousness & tremor
heart & blood pressure meds→ herb may ↑ heart rate & BP
hypoglycemics → herb may cause hypo/hyperglycemia
SE: Used in many weight loss or energy products but over 800
reports of nervousness, insomnia, irritability, psychosis, headache,
dizziness, seizures, stroke, premature ventricular contraction,
hypertension, myocardial infarction & death. FDA ban Apr/04.
FDA maximum: 8mg/dose & 24mg/day for no more than a week.
Not recommended with breastfeeding. NOT considered SAFE
anaesthetics/antipsychotics/anticonvulsants→herb ↑ seizures
SE: For menopause but can cause nausea, headache & soft stools
(Oenothera biennis)
MAOI's→ herb ↑ risk of hypertensive crisis SE:dermatitis,GI upset.
ACE inhibitor→ may ↑ cough; theophylline→ may ↑ absorption
warfarin ↑ INR → herb may contain warfarin constituents
sedatives→ herb may potentiate sedation. Herb→ ? diuretic action.
warfarin ↑ INR→ herb in vitro ?↑ INR →by ↓ warfarin metabolism
SE: Often used for 2 weeks for an acute infection but can cause rash,
allergic reaction,tiredness,somnolence,dizziness,headache&GI upset.
CI: HIV,TB,transplant pts, RA,MS,lupus →herb immunostimulant
sedatives→ herb may potentiate sedation
Germander
Ginger
(Zingiber officinale)
Ginkgo biloba
è
(Maidenhair Tree)
~40mg po tid ac
iron→ herb contains tannic acids which may ↓ iron absorption
NSAIDS/STEROIDS→ may ↓ the therapeutic effect of feverfew
warfarin ↑ INR → herb in vitro ? inhibit binding of platelets
Recommend 0.2% but most products contain <0.1% parthenolide
SE: Often used for migraine headaches but can cause gastric
discomfort, oral ulcers, lip & tongue swelling & rebound headache
when herb stopped. Not recommended with breastfeeding.
warfarin ↑ INR →herb may ↑ bleeding time (Linum usitatissimum)
antihypertensive meds→ this herb may ↓ BP thus caution advised
aspirin/warfarin ↑ INR → ajoene, a product of allicin breakdown is
believed to be responsible for reversible inhibition of platelet
aggregation- clinical bleeding has occurred (Case reports)
hypoglycemics→herb may cause hypoglycemia;saquinavir→↓ level
SE: Often used for hypertension & high cholesterol but can cause
burning sensation, nausea, heartburn, menorrhagia, diaphoresis,
lightheadedness, odoriferous skin & breath & contact dermatitis.
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect
Generally considered unsafe- 30 cases of acute liver failure.
heart & antihypertensives→ herb may ↑ or ↓ effect with these meds
hypoglycemics → herb may cause hypoglycemia
warfarin ↑ INR → herb may inhibit platelet aggregation (in vitro)
SE: An antiemetic Portnoi 2003 but cause heart burn & allergic reactions.
acetaminophen & ergotamine/caffeine→ subarachnoid
hemorrhage & subdural hematoma
anticonvulsant/TCA/trazodone→may ↓seizure threshold→↑ seizures
aspirin/clopidogrel/dipyridamole/ticlopidine/warfarin ↑ INR →
ginkolide B may inhibit platelet activating factor by displacement
from its receptor binding sites (Case reports)
thiazides → with herb may lead to hypertension (1 case)
SE: Often used to help circulation & cognition but may cause headache,
dizziness, restlessness, nausea, vomiting, diarrhea & dermal sensitivity.
Ginseng,
Eleuthero or
Siberian
(Eleutherococcus
senticosus)
Ginseng,
è
American
(Panax
quinquefolius)
Korean/Asian
(Panax
ginseng)
Only 25% of
ginseng products
actually contained
ginseng in a recent
study, plus
85% did not
contain
ginseng in a
1990 survey.
Glucosamine
~500mg po tid
digoxin→ herb may ↑ digoxin serum level (? Maybe assay
interference with level or from contaminated P. sepium)
heart & blood pressure meds→ herb may change BP/↑ heart rate
warfarin ↑INR →herb ? ↓ platelet aggregation & contain coumarin
Not recommended with breastfeeding. May ↑K+
alcohol→ may ↑ alcohol clearance from the body
corticosteroids → herb may affect steroid concentrations
heart & blood pressure meds→ herb has negative chronotropic &
inotropic activity, as well as possible ↓ blood pressure
estrogens/corticosteroids→ herb may have possible additive effects
(reported mastalgia & postmenopausal bleeding)
furosemide→ case report of diminishing furosemide effect
hypoglycemics → herb may have additive hypoglycemic effect
MAOI's→ may inhibit reuptake of various neurotransmitters &
↑ tremor/mania thus contraindicated
mood stabilizers→herb may induce mania
oral contraceptives→ herb may interfere in effectiveness of sex
hormone treatment
sedatives→ herb may potentiate/antagonize sedative side effects
warfarin ↑ ↓ INR → herb may cause ↑ bleeding by itself
or ↓ INR (Case reports,Yuan 2004)
SE: in general for ALL species: nervousness, excitation,
diarrhea, insomnia, inability to concentrate, headache,
hypertension, epistaxis, allergies & skin eruptions.
Not recommended with breastfeeding
Hypoglycemics/insulin→does not ↑HgA1C Scroggie 2003, may cause
insulin resistance & ? ↑ resistance to doxorubicin & etoposide.
Well absorbed ~90%, IV elsewhere. Some efficacy Richy 2003. Shellfish allergy.
SE: For osteoarthritis but may cause GI side effects such as diarrhea.
56
HERBAL DRUG INTERACTION CHART 1,2,3,4,8,10,11,12
Herb
Interaction/Side effects (SE)
(Hydrastis
canadensis)
sedatives→ herb may ↑ sedation
Gotu kola
Green tea
?↓hypertension Yang 04
Guar gum
(Cyamopsis
tetragonolobus)
Hawthorn
(Crataegus monogyna)
Hops
Horse chestnut
snakeroot
Jamaican Dogwood
Karela
Kava kava
iron→ herb contains tannic acids which may ↓ iron absorption
warfarin ↓ INR → herb may contain ↑ vitamin K content (in vitro).
Contains 10-80mg caffeine/cup. Lithium level ↑ if stop caffeine.
digoxin & penicillin V→slows absorption in the stomach
glyburide,iron & metformin→ ↓ absorption with some formulations
SE: rare gastric obstruction. May ↓ cholesterol levels.
è
(Piper methysticum)
Stop-sale order in
Canada after Aug/02
-a social drink in
South Pacific
Kelp
Kombucha
Kyushin
Life root
(Senecio aureus)
Licorice
(Glcyrrhiza glabra)
High dose is
>50 grams/day
Most licorice in the
USA contains
anise oil rather
than licorice.
Meadowsweet
Melilot (Sweet clover)
Milk thistle
(Silybum
marianum)
Mistletow
Nettle
Papain/Papaya
Parsley
Passionflower
Pennyroyal
(Mentha puleguim)
Plantain
(Black psyllium)
Pleurisy root
Poplar
Prickly Ash
Psyllium(P.ovata)
Quassia
Red Clover
Asian herb mixture
Sassafras
Sauropus
androgynus
Saw palmetto
(Serenoa repens)
Sabal fruit
digoxin & antihypertensives→ herb may interfere with these meds
MAOI's: may contain tyramine → ↑ risk of hypertensive crisis. ↑K+
sedatives→ herbs may ↑ sedation; herb has estrogen like chemicals
May cause false
negative PSA test
aspirin & warfarin ↑ INR → herb may contain warfarin constituents
SE: irritant to stomach & hypoglycemia (Aesculus hippocastanum)
Scullcap
warfarin ↑ INR →peroxidase stimulates arachidonic acid metabolites
Horseradish
Indian
(Bitter melon)
statins → herb may ↑ lipids
Sage
Saiboku-to
antihypertensives & digoxin→ herb can ↑ effect
antidepressants→ herb can ↓ effect (reserpine found in herb)
sedatives→ herb may potentiate sedative SE
hypoglycemics → herb may affect blood glucose levels
alcohol/antipsychotics/sedatives→ herb may ↑ sedation
alprazolam /benzodiazepines→ has led to additive depression
(Case report of ↑lethargy/?coma with alprazolam)
antiparkinsonian meds→herb may exacerbate Parkinson's–case report
SE: Often used for anxiolytic but causes headache,dizziness,GI
discomfort & local numbess after oral ingestion; dry scaly skin &
discoloration (yellow), leukopenia, thrombocytopenia,
photosensitivity & eye redness with long term use or high dosages.
Reports of hepatotoxicity FDA Mar/02.Not recomm. with breastfeeding
levothyroxine→herb source of iodine→caused hyperthyroidism
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect.Source of anthrax outbreak.
digoxin→herb may interfere with dynamics/monitoring
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect. Generally unsafe
antihypertensives/digoxin/loop diuretics/spironolactone/thiazides →
herb may cause hypokalemia, plus sodium & fluid retention which
can ↑ blood pressure (ie. Pseudoaldosteronism)
corticosteroids→herb may ↑ oral & topical steroid effects
digoxin→herb may interfere with pharmacodynamically/monitoring
hypoglycemics → herb may cause ↓ glucose tolerance thus caution
oral contraceptive→ may lead to hypertension,edema & ↓ potassium
warfarin ↑ INR → herb may inhibit platelet activity
SE: lethargy, headache & electrolyte imbalances.
Not recommended with breastfeeding. Generally unsafe
warfarin ↑ INR → herb may contain salicylate constituents
Senna
(Cassia senna)
Shankapulshpi
Shepherds Purse
Sho-saiko-to
St. John's è
Wort (Hypericum
perforatum)
~300mg po tid
-not for major
depressionJAMA APR 01 & 02
Active agents:
0.3% hypericin
& hyperforin
(Used commonly
–esp. in Germany)
Only 2/54 products
contained within
10% of the labeled
amount. CJC Pharmacol 2003
Tamarind
Tonka Bean
Umbelliferae
Uzara root
Valerian
è
(Valeriana
officinalis)
warfarin ↑ INR → herb may contain warfarin constituents
hypoglycemics → herb may have additive hypoglycemic effect
SE: Gastric pain, diarrhea, vomiting & allergic reactions.
In Europe available IV to "detoxify the liver".Oral ~25% absorbed.
warfarin ↓ INR → herb may contain lectins → ↓ agglutination
iron→ herb contains tannic acids which may ↓ iron absorption
sedatives→ herb may potentiate sedation
warfarin ↓ INR → herb may contain Vitamin K; May ↑K+
warfarin ↑ INR → may ↑ INR (Carica papaya)
SE: gastritis
antihypertensives→ herb has sympathomimetics→watch for ↑ BP
MAOI's→ herb ↑ risk of hypertensive crisis.Herb may contain Vit K
MAOI’s/SSRI's/TCA's→herb may ↑ risk of serotonin syndrome
sedative→ herb↑ sedation;warfarin ↑ INR→may contain coumarins
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect (? Treat → acetylcysteine)
carbamazepine/digoxin/iron/lithium/warfarin→ ↓ absorption by herb
digoxin→herb may interfere with absorption/dynamics/monitoring
MAOI's→ herb ↑ risk of hypertensive crisis
warfarin ↑ INR → herb may contain salicylate constituents
warfarin ↑ INR → herb may contain warfarin constituents
carbamazepine/digoxin/iron/lithium/warfarin→ herb ↓ absorption
warfarin ↑ INR → herb may contain warfarin constituents
Verbena(Vervain)
Vitamin E
Wild Carrot
Wild Lettuce
Willow/Wintergreen
Woodruff
Yarrow
Yohimbe
(Pausinystalia
yohimbe)
Xaio chai hu tang
sedatives→ herb may potentiate sedation
corticosteroids→herb may ↑ prednisolone levels
Same herbs→sho-saiko-to,Poria cocos,Mangolia officinalis&Perillae frutescens
SE: sedation. Generally considered unsafe (S. albidum)
amiodarone, anabolic steroids, ketoconazole &
methotrexate→ herb may potentiate hepatotoxicity
estrogen/contraceptives/hormones→ herb may have antiandrogen & estrogenic activty
iron→ herb contains tannic acids which can ↓ iron absorption
SE: Often used for benign prostatic hyperplasia but causes
headache, GI discomfort(nausea, abd pain, constipation & diarrhea)
& rare hormonal actions (breast tenderness, loss of libido & venous
thrombosis). Efficacy: ¼ Proscar but likely < than ∝1 blockers
amiodarone, anabolic steroids, ketoconazole, methotrexate→ herb
may have additive hepatotoxicity effect (? due to adulterants)
sedatives→ herb may potentiate sedation
digoxin/thiazides/steroids→ herb may potentiate hypokalemia
various meds→ ↓ absorption→going quicker via GI system
phenytoin→herb may ↓ phenytoin levels as well as ↓ efficacy
(Ayurvedic mixed herb syrup)
MAOI's→ may contain tyramine thus ↑ risk of hypertensive crisis
sedatives→ herb may potentiate sedation
prednisolone→↓ levels for prednisolone (Asian herb mixture)
antihypertensive meds→ this herb may ↑ BP thus caution advised
barbiturates→ herb may ↓ barbiturate induced sleeping time
cyclosporin/digoxin/fexofenadine/imatinib/indinavir/
irinotecan/midazolam/ nevirapine/omeprazole/oral
contraceptives/ sumatriptan/theophylline/warfarin→herb
may ↓ levels of these drugs via ↑ metabolism (P450 3A4 inducer)
iron→ herb contains tannic acids which can ↓ iron absorption
MAOI's/SSRI's/TCA's→herb may ↑ risk of serotonin syndrome
(6 case reports-tremor, delirium…) by ↑ serotonin levels plus
since MAOI action → restriction tyramine food is wise.
narcotics→ may prolong narcotic induced sleeping time
piroxicam/tetracyclines→ can ↑ photosensitize reaction
sedatives→ herb may potentiate sedation
SE: Often for mild to moderate depression but may cause allergic
reactions, headache, dizziness, restless, fatigue, dry mouth, mania,
nausea, vomiting, constipation,dreams, hair loss & photosensitivity
& possible uterotonic activity. Possible cataract link thus rec to
wear wrap around sunglasses. Hold for 2 weeks before any surgery.
aspirin→ ↑ bioavailability of aspirin (Tamarindus indica)
warfarin ↑ INR → herb may contain warfarin constituents
warfarin ↑ INR → herb may contain dicumoral constituents
digoxin→herb may have additive effects or interfere with monitoring
sedatives→ herb may potentiate sedation
Possible acute hepatitis reported (? Due to adulterants).
SE: Often used for sedative & anxiolytic action but may cause
headache, excitability, ataxia & gastric complaints. (Case report of
withdrawal syndrome involving cardiac abnormalities & delirium)
MAOI's→ herb ↑ risk of hypertensive crisis
warfarin ↑ INR → herb may ↓ platelet aggregation.In sunflower seeds.
sedatives→ herb may potentiate sedation
sedatives→ herb may potentiate sedation
warfarin ↑ INR → herb may contain salicylate constituents
warfarin ↑ INR → herb may contain warfarin constituents
warfarin ↓ INR → herb may be a coagulant in vivo
clonidine & antihypertensives→herb may ↑ BP since is Á 2 blocker
TCA antidepressants→herb may ↑ risk of hypertension
SE: nervousness, tremor, headache, dizzy, flushing & nausea
corticosteroids→herb may ↓ blood level of prednisolone
Unsafe Herb list: (American Journal Health System Pharmacy, Jan 15/1999) borage, calamus,
chaparral, coltsfoot, comfrey, ephedra, germander, licorice, life root, sassafras, star anise
Potentially safe herb but still interactions: (American Journal Health System Pharmacy, Jan 15/1999)
feverfew, garlic, ginkgo, ginseng-Asian, saw palmetto, St. John's wort, valerian
Frequently Allergic reactions with: (American Journal of Medicine, Feb 1998)
Agnus Castus,Angelica,Aniseed,Apricot,Arnica,Artichoke,Asafoetida,Boneset,Cassia,Celery,
Cinnamon,Cowslip,Dandelion,Elecampane,Euphobia,Feverfew,Fucus,Gravel Root,Gauicum,
Holy Thistle,Hops, Hydrangea,Juniper,Lady's Slipper,Meadowsweet,Motherwort,Parsley,
Pilewort,Plantain,Pulsatilla,Rosemary,Royal Jelly,Tansy,Wild Carrot,Yarrow
Natural medicine does NOT guarantee SAFETY. 1/4 of all modern drugs have a natural/botanical origin.
oral contraceptive→ herb may ↓ effect. Made cheetah's sterile. Medicinal herbs are drugs with potential harm & benefit! Concerns regarding purity, potency & quality are
especially important in the herbal industry. A sample of 2609 sample of traditional Chinese medicines collected
warfarin ↑ INR → herb may contain warfarin. SE: rash
(Promensil)
from 8 hospitals in Taiwan, 23.7% contained pharmaceutical adulterants, most commonly acetaminophen,
asthma medications→ herb may cause bronchospasm
Royal jelly
caffeine, hydrochlorothiazide, indomethacin & prednisolone.5,7 Other NSAIDS & benzodiazepines found in
Expensive source of “B” vitamins. Food for queen bee.
Chinese patent medicines sold outside Asia6. In 24 of 251 Asian patent medicines there was lead; 36 arsenic &
Web links: //vm.cfsan.fda.gov/~dms/supplmnt.html
//nccam.nih.gov
35 contained mercury.9 Like all drugs there are some serious side effects & interactions that occur.
www.ars-grin.gov/duke
www.quackwatch.com
www.ncahf.org
References: 1. Hansten and Horn's Drug Interactions Analysis and Management 2003. 2. AHFS Drug Information 2003.
www.herbmed.org
www.consumerlab.com
www.drugfacts.com
3. American Family Physcian Mar 1/1999. 4. CPS - Product Monographs, 2003. 5. J Clin Pharmacol 1997;37:344-350.
6.Arthritis Rheum 1995;38:614-617. 7. BMJ 1994;308:1162. 8. The Lancet 2000;355:134-138. 9. NEJM 1998 339:847.
www.naturaldatabase.com www.mskcc.org/aboutherbs
10. Pharmacy Practice June 1999 & June 2000 11. Natural Medicines Comprehensive Database 2003. 12. Review of Natural Products 2003.
www.hc-sc.gc.ca/hpfb-dgpsa/nhpd-dpsn/index_e.html
www.herbs.org
BP-Blood pressure CI-Contraindication GI-Gastrointestinal K=potassium INR-international normalization ratio (ie. bleeding risk)
http://www.cfsan.fda.gov/~dms/supplmnt.html
è-a concern if given pre-op (JAMA July 11/2001) SE-side effect
57
heart & antihypertensives→herb can alter heart & blood pressure
heparin → herb can oppose the action of heparin
sedatives→ herb may ↑ sedation. Expensive & often adulterated.
Goldenseal
Additonal references:
De Smet PA. Herbal remedies. N Engl J Med. 2002 Dec 19;347(25):2046-56.
Draves AH, Walker SE. Analysis of the hypericin and pseudohypericin content of commercially available St John's Wort preparations. Can J Clin Pharmacol. 2003 Fall;10(3):114-8.
Draves AH, Walker SE. Parthenolide content of Canadian commercial feverfew preparations (Label claims are misleading in most cases). CPJ Dec 2003/Jan 2004, Vol. 136, No. 10, p23-30.
Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St John's wort) in major depressive disorder: a randomized controlled trial. JAMA. 2002 Apr 10;287(14):1807-14.
Jakkula M, Boucher TA, Beyendorff U, et al. A randomized trial of Chinese herbal medicines for the treatment of symptomatic hepatitis C. Arch Intern Med. 2004 Jun 28;164(12):1341-6.
Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled trials. Ann Intern Med. 2002 Nov 19;137(10):805-13.
Mills E, Singh R, Ross C, Ernst E, Ray JG. Sale of kava extract in some health food stores. CMAJ. 2003 Nov 25;169(11):1158-9.
Portnoi G, Chng LA, et al. Prospective comparative study of the safety and effectiveness of ginger for the treatment of nausea and vomiting in pregnancy. Am J Obstet Gynecol. 2003 Nov;189(5):1374-7.
Richy F, et al. Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis. Arch Intern Med. 2003 Jul 14;163(13):1514-22.
Scroggie DA, Albright A, Harris MD. The effect of glucosamine-chondroitin supplementation on glycosylated hemoglobin levels in patients with type 2 diabetes mellitus: a placebo-controlled, doubleblinded, randomized clinical trial. Arch Intern Med. 2003 Jul 14;163(13):1587-90.
Shelton RC, Keller MB, et al. Effectiveness of St John's wort in major depression: a randomized controlled trial. JAMA. 2001 Apr 18;285(15):1978-86.
Takwale A, Tan E, Agarwal S, et al. Efficacy and tolerability of borage oil in adults and children with atopic eczema: randomised, double blind, placebo controlled, parallel group trial
BMJ 2003;327:1385, doi:10.1136/bmj.327.7428.1385
Taylor James A.,et al. Efficacy and Safety of Echinacea in Treating Upper Respiratory Tract Infections in Children. A Randomized Controlled Trial. JAMA. 2003;290:2824-2830.
van Gurp G, Meterissian GB, Haiek LN, McCusker J, Bellavance F. St John's wort or sertraline? Randomized controlled trial in primary care. Can Fam Physician. 2002 May;48:905-12.
Wooltorton E. Herbal kava: reports of liver toxicity. CMAJ. 2002 Mar 19;166(6):777.
Yale SH., Liu K., Echinacea purpurea therapy for the treatment of the common cold. Arch Intern Med. 2004;164:1237-41.
Yang YC, Lu FH, Wu JS, Wu CH, Chang CJ. The protective effect of habitual tea consumption on hypertension. Arch Intern Med. 2004 Jul 26;164(14):1534-40.
Yuan CS, Wei G, Dey L, et al. Brief communication: American ginseng reduces warfarin's effect in healthy patients: a randomized, controlled Trial. Ann Intern Med. 2004 Jul 6;141(1):23-7.