HERB-DRUG INTERACTIONS

S.RUPESH KUMAR

T.SRI KRISHNA*

PRESENTED BY

4th YEAR B.PHARM

Under the guidance of

HERB-DRUG INTERACTIONS

INTRODUCTION When Herbal Medicinal Products and Western drugs

administered together may interact each other in body leading to kinetic and dynamic alterations

Herbs are often administered in combination with therapeutic drugs, raising the potential of herb-drug interactions.

An estimated 5-20% of general people consume herbal medicines because

1. Naturally available2. Consideration of safe to use3. Ready available

Adverse Events and Drug-Interaction Caused by Herbal or Traditional Medicines by the study of

– ANIMAL STUDY

– CONTROLLED TRIAL

– SINGLE CASE REPORT

– MULTIPLE CASE REPORTS

EVIDENCE

Facts about drug interactions/herbal medicine/

herb-drug interactions Drug interactions - 4th – 6th Cause of

death At least 100 preoperative fatalities

due to herb -drug/surgery interactions

>70 – 80 Herbs - Increase risk of bleeding

>30 – 40 Herbs possibility of causing hepatic failure

Ephedra – 54 deaths , 1600 Adverse events

Aloe vera injection – 4 Deaths Pennyroyal tea – 2 infants

Multiorgan Dysfunction Aristolochic Acid – Death of 100

Belgian Women

HERB-DRUG INTERACTIONS

PHARMACOKINETIC PHARMACODYNAMIC

Related to action of herb and drug

Interactions can be predicted

Antagonism or Synergism

Modify metabolic pathways in body

Mainly occur in

GIT

Kidney

Liver

EFFECT OF HERBS ON PHARMACOKINETICS

INCREASED DECREASED

ABSORPTION GingerGreen Tea

Black Pepper

FibresMucilage

herbs

METABOLISM

Guggul Grape fruit

ELIMINATION

LaxativeDiuretic

herbs

Liquorice

REASONS FOR HERB-DRUG INTERACTION

oClinicians lack of adequate knowledge of combinations

oNo quality assurance for purity and potency

oNo advancement in research

– May ↑ bleeding times with anticoagulants– ↓ blood levels and toxicity of protease inhibitors like ritonavir, indinavir….etc

May ↑ bleeding with anticoagulants↓ effect of antacids

Ginger might decrease blood sugar

High blood pressure (Calcium channel blockers) interacts with GINGER

Insulin, Chlorpropamide , Glipizide, Tolbutamide

verapamil , felodipine , amlodipin

GINGER:

GARLIC:

BLACKPEPPERBlack and white pepper might decrease how quickly the liver breaks down some medications

lovastatin (Mevacor) ketoconazole (Nizoral) Itraconazole (Sporanox), …etc.

It will decrease the action of antacidsThe black pepper majorly shows interaction and increase the AUC of The drugs are:

Phenytoin (Dilantin)Carbamazepine (Tegretol) tranquilizers

Propranolol (Inderal)

RifampinTheophylline

in healthy volunteers

in patients with pulmonary tuberculosis.

CINNAMON

Taking cinnamon bark along with diabetes medications might cause your blood sugar to go too low.

Some medications used for diabetes include glimepiride (Amaryl), glyburide (DiaBeta, Glynase PresTab, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), and others.

Decreased effectiveness of Fluoroquinolones, Increased risk of photo toxicity with tetracycline's

It increase the AUC of anti hypertensive's.

Medications that can harm the liver (Hepatotoxic drugs) interacts with CASSIA CINNAMON these are miodarone, carbamazepine (Tegretol), isoniazid (INH), methotrexate (Rheumatrex), methyldopa ,and others.

CLOVE BUDS

Clove contains eugenol. Eugenol is the part of clove that might slow blood clotting.

It may increase the bleeding with drugs such as anticoagulants (heparin, warfarin ), and NSAIDS like aspirin, diclofenac, ibuprofen, naprox, and others.

In children decrease the effect of anti-epileptic drugs as phenytoin by damaging the liver.

GREEN TEA

High in tannin, do not take with codeine

Large amounts may↑ effects and side effects of theophylline

May ↓ effect of coronary vasodilator drugs

May ↓ effects of warfarin Green tea and aspirin should not be

mixed because they both prevent platelets from clotting

– May ↑ bleeding with anticoagulants– May ↑ effects of antibiotics– ↑ efficacy of 5-fluorouracil and vincristine

May bleeding with anticoagulants (Anticoagulant / Anti platelet drugs) interacts with CAPSICUM

Medications for high blood pressure (ACE inhibitors) interacts with CAPSICUM might increase the side effects of cocaine including heart attack and death.

Cayenne:

Bromelain:

Capsicum increase the theophylline absorption of the body & also increases the side effects of theophylline

PEPPERMINT

The peppermint will decrease the metabolism of cyclosporin (Neoral, Sandimmune)

Some medications that are changed by the liver include amitriptyline (Elavil), haloperidol (Haldol), ondansetron (Zofran), propranolol (Inderal),theophylline verapamil (Calan, Isoptin, others), and others.Medications changed by the liver (Cytochrome P450 2C19 (CYP2C)

TAMARIND:

Tamarind (Tamarindus indica) Aspirin Increased bioavailability of aspirin52

TURMERIC:

Increase the blood-thinning effect with drug like warfarin, aspirin(NSAIDs).

cs the activity of antacids (Lansoprazole …etc).

Actively participate in the ce the blood glucose level, when taken with anti diabetic drugs that cause risk of lower blood sugar (hypoglycaemia).

GRAPE JUICE:

Increase the oral bioavailability (human).

Gastrointestinal absorption and bioavailability of statins like levostatin

Dicreases the total body metabolic rate.

May ↑ bleeding with anticoagulants May ↑ activity and side effects of MAO inhibitors Increases blood pressure when combined with a thiazide diuretic and even caused coma Increases the digoxin plasma levels

GINSENG(PANAX GINSENG):

Increases the AUC of digoxin

Decreased activity of opioids – clear mechanism is unknown

Increased CNS side effects due to additive effect of

MAO inhibitors

Phenelzine

Ginkgo:

Valerian induces the sleep with anti-seizure medications like barbiturates.Ex. phenobarbitone, pentobarbitoneProlongation of aesthesia with anaesthetics

Produce sadation with barbiturates &benzodiazepines– Contraindicated with hepatotoxic drugs and alcohol– ↓ efficacy of Parkinson drugs (L-Dopa)

VALERIAN:

KAVA:

AUC Corticosteroids like prednisalone , methylprednisalone

↓ efficacy, ↑ toxicity of diuretics ↓ efficacy, side effects of digoxin

↓ hepatotoxicity of drugs (haloperidol, phenytoin)

↓ kidney toxicity of anesthetics

Milk Thistle:

Liquorice:

PHARMACIST’S ROLE

Advising

Monitoring

Reporting

Health care professionals and pharmacists have to play an important role in giving advisory knowledge on monitoring concurrent use of herbal and conventional medicines and to collect data for suspected herb-drug interactions.

We need to bring into lime light about the herb – drug interactions

CONCLUSION

Baravkar A A, Sawant S D- “Herb-Drug-Interactions”Wheaton A G, Blanck H M- “Medicinal herb use in population

based survey”Arthur M. Presser- “Herb-Drug Interactions”Dorothea Dayley- “Drug-Herb-Nutrient Interactions”Schuyler W.Lininger- “Drug-Herb-Vitamin InteractionsNatural medicines - Comprehensive database by

editors of Pharmacist’s letter and Prescriber’s letter

REFERENCES

Thank you