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2017 HCHB_digital

Herbal Supplements:

Herbal Supplements: Interactions Herbal Supplements – Interactions Herb/herb group Possible interacting drugs Possible interaction(s) References Pomegranate (Punica granatum) Pomelo juice (Citrus maxima) Psyllium seed Metformin Reduced metformin Tmax reported in rats 264 Cyclosporin Increased bioavailability reported in healthy volunteers 135 Tacrolimus Case report of increased plasma levels 136 Digoxin, warfarin, lithium, carbamazepine and possibly other drugs Decreased absorption from GIT possible, with simultaneously administered drugs, though controversial Quercetin Irinotecan Enhanced drug bioavailability suggested by studies on rats 139 Reishi mushroom Benzodiazepines and other sedatives Potentiated hypnotic effects shown in rats 140 (Ganoderma lucidum) Resveratrol Diclofenac Increased diclofenac bioavailability 266 Rhodiola rosea Losartan Increased oral drug bioavailability reported in rabbits 231 Rhubarb (Rheum palmatum) (Rheum officinale) Cyclosporin Reduced cyclosporin bioavailability reported in rats 265 Digoxin and other cardiac glycosides Potassium loss and thus increased risk of cardiovascular toxicity, with 3, 4 prolonged use or abuse Methotrexate Increased drug plasma levels reported in rats 239 Rosemary Azathioprine Protection against azathioprine-induced liver toxicity 141 Safflower flowers (Carthamus tinctorius) Chemotherapy drugs Metoprolol Enhanced intracellular accumulation of doxorubicin and vinblastine reported in vitro Reduced metabolism and possible enhanced bioavailability reported in rodent studies Sage Azathioprine Protection against azathioprine-induced liver toxicity 141 Salboku-to (Asian herbal mixture; contains same herbs as Shosaiko-to, plus xiao chai hu tang, poria cocos, Magnolia officinalis, Perillae frutescens) Schisandra (Schisandra chinensis and S. sphenanthera) Sedatives (eg, valerian, hops, kava, passionflower) Senna (Cassia spp) Senega (Polygala senega) Shankhapushpi (Ayurvedic preparation) Sho-saiko-to (Minor bupleurum) Siberian ginseng (Eleutherococcus senticosus) Prednisolone or prednisone Increased steroidal effects possible 143 Ciclosporin A Enhanced oral drug bioavailability at low but not high drug dosages in rats 232 137, 138 Cytotoxics Possible enhanced cytotoxic effects by large doses due to reversal of multi-drug 144, 145, 146 resistance by gomisin A and schisandrol A Paclitaxel Enhanced oral drug bioavailability in rats 221 Rapamycin Enhanced oral drug bioavailability in healthy volunteers 233 Tacrolimus Sedative drugs (eg, benzodiazepines, clonidine, opioid analgesics, phenobarbitone) Cardiac glycosides and antiarrhythmics (eg, quinidine) Enhanced oral bioavailability in healthy volunteers. Reduced schisandra lignin 147, 240 plasma levels in rats Potentiation of sedative effects 6, 117 Hypokalaemia leading to increased risk of cardiac toxicity 3, 4 Hypoglycaemic drugs Possible enhancement of hypoglycaemic effects 148 Phenytoin Decreased phenytoin concentrations, loss of seizure control 149 Carbamazepine Reduced plasma levels measured in rats after large doses 150 Digoxin Interference with certain laboratory serum digoxin measurements reported 151 Slippery elm Various drugs Theoretical reduction in absorption and thus clinical effects Sophora flavescens Various drugs Theoretical enhancement of effects through inhibition of CYP450 3A4 152 (Kushen) St John’s wort Amitriptyline and nortriptyline Possible reduction in plasma levels and antidepressant effects 153 Atorvastatin Reduced hypocholesterolaemic effects possible 154 Carbamazepine Theoretical reduction in plasma levels although no effects reported clinically 155 Cisplatin Possible protection against cisplatin nephrotoxicity by pre-treatment with large doses 142 212 156 Page 202 HEALTHCARE HANDBOOK 2017-2018 References Charts

Herbal Supplements – Interactions Herb/herb group Possible interacting drugs Possible interaction(s) References St John’s wort cont. Clopidogrel Enhanced antiplatelet effects reported in hyporesponders 247 Clozapine Case report of reduced plasma drug levels and clinical deterioration 220 Cyclosporin, tacrolimus and other immunosuppressants Possible reduction in plasma immunosuppressant levels and thus compromised treatment/ transplant rejection Daunorubicin Possible reduction in plasma levels and thus failure of cytotoxic effect 158 Digoxin Possible reduction in plasma digoxin levels, and thus therapeutic failure 159 Docetaxel Possible reduced plasma levels and thus failure of cytotoxic effect 153 Fexofenadine Reduction of plasma levels and thus antihistaminic effects 160 Gliclazide Reduced plasma levels possible 161 Imatinib mesylate Possible reduced plasma levels and thus failure of cytotoxic effects 162 Indinavir, saquinavir, ritonavir and other Possible reduction in plasma levels, and thus failure of antiviral effect 135 protease inhibitor antivirals Irinotecan Reduced plasma levels of active metabolite SN-38 in cancer patients reported 164, 165 Ivabradine Reduced plasma levels possible 166 MAOIs Theoretical possibility of serious serotonin syndrome, though no cases reported Methadone Case reports of reduced plasma levels in two methadone patients 167 Midazolam Reduced plasma levels in volunteer study 168 Morphine Potentiated antinociceptive effects reported in mice 169 Nevirapine Reduced plasma levels reported 170 Nifedipine Reduced plasma levels possible 171 Omeprazole Reduced plasma levels reported 172 Oral contraceptives Increased breakthrough bleeding possible; case reports of unwanted 173, 174, 175 pregnancies though no evidence of reduced efficacy from 3 controlled studies Oxycodone Possible reduction in plasma levels and thus analgesic effect 211 Phenprocoumon Reduced plasma levels and thus anticoagulant effects 176 Phenytoin Theoretical reduction in plasma levels 177 Phenobarbitone Theoretical reduction in plasma levels 177 Procainamide Single dose of SJW increases procainamide plasma levels in mice 178 Quazepam Reduced plasma levels possible 179 Simvastatin Reduced plasma concentrations and thus hypocholesterolaemic effects 180 SSRI antidepressants (eg, fluoxetine, sertraline, paroxetine) Theoretical possibility of serious serotonin syndrome, though few case reports to date Talinolol Reduced plasma levels possible 181 Tacrolimus Reduced plasma levels reported in renal transplant patients 182, 183 Tolbutamide Increased incidence of hypoglycaemia 176 Triptans (sumatriptan, naratriptan, Theoretical possibility of serotonin syndrome, though no case reports to date rizatriptan, zolmitriptan) Verapamil Reduced bioavailability reported in healthy volunteers 184 Warfarin Possible reduction in anticoagulant effect 185, 186 Zolpidem Reduced plasma drug levels reported 210 St Mary’s thistle – see milk thistle Sutherlandia frutescens Nevirapine Reduced drug bioavailability in rats 222 Sympathomimetics ACE inhibitors Severe hypertension 187 (eg, ephedrine and pseudoephedrine from Anaesthetics Arrhythmia 188 Ephedra spp.) Antidepressants Hypertensive crises with MAOIs; hypertension, arrhythmias with tricyclics 189, 190 Antihypertensives, antipsychotics, betablockers Antagonism, hypertension (possibly severe) 191, 187 157 Page 203

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