Herbal Drug Interaction Chart - Hamilton Family Health Team

HERBAL Drug Interaction Chart 1,2,3,4,8,10,11,12 B. Jensen BSP © ww.RxFiles.ca Sep 2011 0
Herb
(botanical name)
Agrimony
Alfalfa # po
(Medicago sativa)
Interaction/Side effects (SE)
warfarin ! INR " herb may be a coagulant SE: photo dermatitis
cholesterol meds" herb may further ! lipids
cyclosporin/steroids" ? herb immuno-stimulating
hypoglycemic meds"herb may cause further hypoglycemia
warfarin $! INR " herb may contain warfarin constituents
or ! effect because of Vit K content in herb. Rare: salmonella
SE: May $K + , rare pancytopenia & worsening of lupus CI: Lupus
digoxin & thiazide$cardiac SE" b/c electrolyte imbalance ; thyroid dysfunction
Not if breastfeeding. SE: contact dermatitis, !K + esp with insulin !
Echinacea # po !
Purple coneflower
E. purpurea, pallida
& angustifolia North America
No ! in infection:
kids -Taylor JAMA 2003 ; or
-Turrner NEJM 05
adult colds
-Barrett AnnIntMed 10
Elecampane
amiodarone, anabolic steroids, ketoconazole, methotrexate" herb may
have additive hepatotoxicity if used for > 8 weeks
corticosteroids/cyclosporin" avoid combination
glycemic control " herb may cause hypo/hyperglycemia
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
Aloe (Aloe vera) # top
# po (non-latex)
Angelica # po,top Anise #
warfarin $ INR " herb may contain warfarin constituents
Not recommended with breastfeeding. SE: photo dermatitis
po
(Aniseed)
Aristolochia
(found in Xie Gan Wan)
MAOI's" herb may $ risk of hypertensive crisis
warfarin $ INR " herb may contain warfarin constituents
amiodarone, anabolic steroids, ketoconazole, methotrexate" additive
hepatotoxicity effect SE: nephrotoxic, cancer (Canada warning Mar'05 Arnica(Wolf bane)
)
warfarin $ INR " herb may contain warfarin constituents
Asafoetida # po Ayurvedic syrup
Betel nut
(Areca catechu)
Black cohosh #
warfarin $ INR " herb may contain warfarin constituents- in vivo
phenytoin"herb may ! phenytoin levels as well as ! efficacy
SE: heavy metal poisoning. 20% of products have lead/mercury/arsenic Saper04 & 08
antipsychotics"herb may $ extrapyramidal SE (strong cholinergic
effects); asthmatics" inadequate control of asthma
po
(Cimicifuga racemosa)
Not effective Newton’06,Geller’09
Remifemin 20mg bid
Bladderwrack
hormones" herb may have estrogen-like effect.Dose: 40-80mg/day.
iron" herb has tannic acids which may ! iron absorption; cisplatin?
warfarin $INR"herb may contain salicylates. Rare $LFTHealth CND05
SE:For menopausal symptoms" may cause mild GI effects & ! BP
warfarin $ INR " herb may have anticoagulant action
(Fucus,Kelp)
Bogbean
Borage
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
Broom
Calamus
Capsicum #
Antihypertensive meds" herb may $ BP by itself
Sedatives" herb may potentiate sedation. Generally unsafe
po,top
(Chili peppers)
MAOI's" herb $ risk of hypertensive crisis SE:dermatitis,GI upset.
ACE inhibitor" may $ cough; theophylline" may $ absorption
Cascara # po
(Rhamnus purshiana)
Cassia #
Various meds" ! absorption since going quicker via GI system
Digoxin/thiazides/steroids" herb may potentiate hypokalemia
po Celery #
warfarin $ INR " herb may inhibit platelet aggregation
po
(seed/extract)
Cereus
warfarin $ INR " herb may contain warfarin constituents
sedatives" herb may potentiate sedation. Herb" ? diuretic action.
MAOI’s/SSRI's/TCA's"herb may $ risk of serotonin syndrome
Chamomile # po,top warfarin $INR "herb may contain warfarin constituents,$bleed
(Matricaria recutita)
(German/Roman)
Segal’06
iron" has tannic acids which may !iron absorption ; may help anxiety Amsterdam’09
Chaparral
(Larrea tridentata)
Chinese herb mixture
Chondroitin #
1200mg/day
Reichenbach
sedatives" herb may $ sedation; allergic reactions, conjunctivitis
amiodarone, anabolic steroids, ketoconazole, methotrexate" herb may
have additive hepatotoxicity effect. Generally unsafe Health CND’05
Jakkula 04
Rare: heavy metal contamination. Not help Hepatits C ’07-?no benefit;?Kahan
warfarin $INR" herb may $bleeds & chondroitin sulfate is part of the
antithrombotic-danaparoid. ?bovine cartilage & ?Prostate cancer concern.
SE:GI.!oral absorption ~10% ,IM form in other countries,
Chromium picolinate#
?minimal effectMichel'05,Wildi’11 .
po
May !insulin resistance FDA
nephrotoxic drugs"herb may $renal failure & rhabdomyolysis,not !A1C Kleefstra 06
hypoglycemic"may cause !glucose Nahas’09;not help impaired glucose tol. Gunton'05
Clove # top Coltsfoot
(Tussilago farfar)
Comfrey
(Symphytum species)
Co-enzyme Q10 (Ubiquinone) #
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).
po
-Bonakdar'05 ,Pharm Let ’10
Young’07 & Med Let Feb06,
betablockers,phenothiazines,TCA's,doxorubicin" herb may !cardiac
SE from these meds. {60-200mg daily}
Wyman’10
limited studies in heart failure. SE:GI, rash.
cardiac & antihypertensives " may improve effect of cardiac meds
HMG-Co A & hypoglycemics" may ! natural levels of Q10 in body
Couchgrass
Dandelion #
warfarin !INR " herb may !effect of warfarin. Antiplatelet. Watch LFTs.
diuretics"herb may $ potassium loss; lithium"herb may alter level.
sedatives" herb may potentiate sedation
po diuretics & lithium"herb may $ diuretic effect & $ lithium toxicity
warfarin ! INR" ! effect due to Vitamin K content in the herb; $K +
Danshen
DHEA Dehydroepiandrosterone
#
warfarin $ INR " clinical bleed due to ? acetylsalvianolic acid
po
Devil's Claw #
warfarin $ INR " herb may have fibrinolytic potential. Watch LFTs.
triazolam $level due to DHEA. Banned by the NFL/Olympics. Med Let05
po
(Harpagophytum
procumbens)
heart & BP meds" herb may interfere ($! ) with BP
hypoglycemics " herb may $!glucose. ??help low back pain Gagnier 07
warfarin"?purpura SE:headache, ringing ears,!appetite,!taste, GI
Dong Quai # po,top
Ephedra !
(Ma huang)
Herbal Ecstasy
Ephedrine/
Pseudoephedrine
(Ban in olympics)
?~1% ephedrine.
Tea~15-30mg
ephedrine/cup.
anticonvulsants"$ seizure; urine"may false positive with amphetamine;
caffeine,decongestants,stimulants"herb may $nervousness, $BP & 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, MI & death esp. with caffeine. FDA ban Apr/04.
FDA max: 8mg/dose & 24mg/day for !1week. May !dexamethasone
(Angelica sinensis)
heart meds" herb has quinidine like activity
warfarin $ INR "herb ?contain warfarin constituent-Case reports
Not recommended with breastfeeding. SE: photosensitive
level
Not if breastfeeding. NOT considered SAFE. May $thyroid hormones
Evening Primrose
oil # po (Oenothera biennis )
Fenugreek
anaesthetics/antipsychotics/anticonvulsants"herb may $seizures
antiplatelet/warfarin"herb contains GLA may $bleeding
? For menopause/itch, EFA omega-6 source SE: nausea, headache, !BP & soft stool
warfarin $INR "herb may contain warfarin constituents; may!glucose Nahas’09
Feverfew # po
Tanacet 125mg od
(Tanacetum
parthenium)
-only 6 of 30 lots had
labeled content
CPJ Draves 2003/2004
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

Goldenseal
(Hydrastis
canadensis)
Gotu kola
Green tea # po,top
?!hypertension
?$LFT’sBonkovsky 06
Guar gum # po
(Cyamopsis
tetragonolobus)
Yang 04
Hawthorn Dahmer AFP’10
(Crataegus monogyna)
Hops
Horse chestnut
?!venous insufficiency Pittler06
heart & antihypertensives"herb can alter heart & blood pressure
heparin " herb can oppose the action of heparin
sedatives" herb may $ sedation. Expensive & often adulterated.
sedatives" herb may $ sedation statins " herb may $ lipids
iron"herb has tannic acids which may !iron absorption; ? !glucose Nahas’09
warfarin !INR " herb may contain $vit K (in vitro). ? TTP Liatsos’10
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. Fiber.
digoxin &!BP meds" herb may interfere. Pittler’08 but SPICE negative trial for HF
MAOI's: may contain tyramine " $ risk of hypertensive crisis. $K +
sedatives" herbs may $ sedation; herb has estrogen like chemicals
aspirin & warfarin $ INR " herb may contain warfarin constituents
SE: irritant to stomach & hypoglycemia (Aesculus hippocastanum)
Saiboku-to
Asian herb mixture
Sassafras
Sauropus
androgynus
Saw palmetto # po
(Serenoa repens)
Sabal fruit
May cause false –‘ve PSA
test & ?make normal
prostate cells more
sensitive to radiation
Scullcap
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/contraceptive/hormone" herb may have anti-androgen
& estrogenic activity. {160mg bid} (? cause of floppy iris Syndrome)
iron"herb has tannic acids"may !iron absorption ; may $bleeding ASA, warfarin
SE: Used for benign prostatic hyperplasia but causes headache, GI
(nausea, abd pain, constipation & diarrhea), may $BP ; & rare hormonal
actions (breast tenderness, loss of libido & venous thrombosis) & pancreatitis.
No efficacy Barry’11 ; Maybe?: ! Proscar but likely < than %1 blockers.
amiodarone, anabolic steroids, ketoconazole, methotrexate" herb may have
additive hepatotoxicity effect (? due to adulterants); sedatives" may $sedation
Horseradish # po Indian
snakeroot
Jamaican Dogwood
warfarin $ INR "peroxidase stimulates arachidonic acid metabolites
antihypertensives & digoxin" herb can $ effect
antidepressants" herb can ! effect (reserpine found in herb)
sedatives" herb may potentiate sedative SE
Karela
(Bitter melon)
hypoglycemics " herb may affect blood glucose levels Nahas’09
Kava kava !
(Piper methysticum)
Stop-sale order in
Canada Aug/02,
but still avail. Mills 03
-a social drink in
South Pacific
alcohol/antipsychotics/sedatives" herb may $ sedation
alprazolam /benzo’s" led to additive depression. (Case report of
$lethargy/?coma with alprazolam). May inhibit some P450 enzymes.
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 2002,Tesche’10 Kelp
Kombucha
Kyushin
.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
Life root
(Senecio aureus)
Licorice #
amiodarone, anabolic steroids, ketoconazole, methotrexate" herb may
have additive hepatotoxicity effect. Generally unsafe
po (50 grams/day
antihypertensives/digoxin/loop diuretics/spironolactone/thiazides "
herb may cause hypokalemia, plus sodium & fluid retention which
can $ blood pressure (ie. Pseudoaldosteronism), encephalopathy,
corticosteroids"herb may $ oral & topical steroid effects
digoxin"herb may interfere with pharmacodynamically/monitoring
hypoglycemics " herb may cause ! glucose tolerance thus caution
Most licorice in the
oral contraceptive" may lead to hypertension,edema & ! potassium
USA contains
warfarin $ INR " herb may inhibit platelet activity
anise oil rather
SE: lethargy, headache & electrolyte imbalances. ??help liver
than licorice.
Dhiman’05
Not recommended with breastfeeding. Generally unsafe
Meadowsweet warfarin $ INR " herb may contain salicylate constituents
Melilot (Sweet clover)# po warfarin $ INR " herb may contain warfarin constituents
Milk thistle # po hypoglycemics " herb may have additive hypoglycemic effect
(Silybum
marianum)
SE: Gastric pain, diarrhea, vomiting & allergic rx. May !indinavir.
In Europe avail. IV to "detoxify the liver?? Rambaldi'05 ".Oral ~25% absorbed Mistletow
Nettle
.
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 + . SE: GI, rash
Papain/Papaya # po warfarin may $INR;(Carica papaya) Allergy: Digibind SE: gastritis
Parsley # po antihypertensives" herb has sympathomimetics"watch for $ BP
MAOI's" herb $ risk of hypertensive crisis.Herb may contain Vit K
Passionflower # po MAOI’s/SSRI's/TCA's"herb may $ risk of serotonin syndrome
sedative" herb$ sedation;warfarin $ INR"may contain coumarins
Pennyroyal amiodarone, anabolic steroids, ketoconazole, methotrexate" herb may
(Mentha puleguim)
Plantain #
have additive hepatotoxicity effect (? Treat " acetylcysteine)
po (with $ fluid) carbamazepine/digoxin/iron/lithium/warfarin" ! absorption by herb
(Black psyllium) fibre digoxin"herb may interfere with absorption/dynamics/monitoring
Pleurisy root MAOI's" herb $ risk of hypertensive crisis
Poplar # top Prickly Ash
warfarin $ INR " herb may contain salicylate constituents
warfarin $ INR " herb may contain warfarin constituents
Psyllium(P.ovata) carbamazepine/digoxin/iron/lithium/warfarin" herb ! absorption; fiber.
Quassia
Red Clover #
warfarin $ INR " herb may contain warfarin constituents
po
(Promensil)
oral contraceptive/tamoxifen/letrozole" may !effect/interfere.
warfarin $INR"may contain warfarin . SE:rash. Made cheetah's sterile.
Royal jelly asthma meds" may cause bronchospasm. Expensive source
of “B” vitamins. Severe allergies reported with bee products.
Sage # po,top Senna #
sedatives" herb may potentiate sedation
po
digoxin/thiazides/steroids" herb may potentiate hypokalemia various
(Cassia senna)
Shankapulshpi
Shepherds Purse
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
Sho-saiko-to
St. John's #
prednisolone"! levels for prednisolone (Asian herb mixture)
po !
Wort (Hypericum
perforatum)
~300mg po tid
-not for major
Depression JAMA 01/& 02
but ?positive"Szegedi05, Linde08
& Gastpar06 for Mild-Moderate
depression.
Active agents:
0.3% hypericin
& hyperforin
(Used commonly
–esp. in Germany)
Antihypertensive meds" this herb may $ BP thus caution advised
barbiturates" herb may ! barbiturate induced sleeping time
alprazolam/ amio-,drone-darone / cyclosporin / dabigatran / dasa,
erlo, gefi, ima, lapa, nilo & suni-tinib / dig /exemestane / fexofenadine /
indinavir / irinotecan/ maraviroc /midazolam /nevirapine/omeprazole
/oral contraceptive/oxycodone/rilpivirine/rivaroxaban/sirolimus/sorafenib
/statin/sumatriptan/ theophylline / verapamil / voriconazole /
warfarin"herb !levels of these meds via $P450 3A4 metabolism
Only 2/54 products
contained within
10% of the labeled
amount. CJC Pharmacol 2003
inducer.
Clopidogrel "may $ bleeding since more active metabolite formed
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 $sleeping time; loperamide: delirium & agitation report
piroxicam/tetracyclines" can $ photosensitize reaction
sedatives" herb may potentiate sedation; Thyroid meds: may$ TSH
Tamarind
Tonka Bean
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/!sperm. 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
Umbelliferae
Uzara root
Valerian #
warfarin $ INR " herb may contain dicumoral constituents
digoxin"herb may have additive effects or interfere with monitoring
po !
(Valeriana officinalis)
-see Hadley'05 article
eg. Nytol Natural Source
Sedatives, alprazolam" 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)
Verbena (Vervain) # po MAOI's" herb $ risk of hypertensive crisis
Vitamin E # po,top Wild Carrot #
warfarin $ INR "herb may ! platelet aggregation. In sunflower seeds.
po Wild Lettuce #
sedatives" herb may potentiate sedation
po Willow/Wintergreen
sedatives" herb may potentiate sedation
warfarin $INR" herb may contain salicylate constituent Woodruff
; may affect BP
warfarin $ INR " herb may contain warfarin constituents
Yarrow
warfarin ! INR " herb may be a coagulant in vivo!
Yohimbe
clonidine & antihypertensives"herb may $ BP since is " 2 blocker
(Pausinystalia
yohimbe)
Xaio chai hu tang
TCA antidepressants"herb may $ risk of hypertension
SE:nervousness, tremor, headache,dizzy,flushing,$urinary frequency & nausea
corticosteroids"herb may ! blood level of prednisolone
Xuezhikang “Red Yeast” caution with other hepatotoxic or antihyperlipidemic drugs
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 1999)
feverfew, garlic, ginkgo, ginseng-Asian, saw palmetto, St. John's wort but DI’s important , 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.
Medicinal herbs are drugs with potential harm & benefit! (Eg. Red yeast may contain lovastatin). Concerns
regarding purity, potency & quality are especially important in the herbal industry. A sample of 2609
sample of traditional Chinese medicines collected from 8 hospitals in Taiwan, 23.7% contained
pharmaceutical adulterants, most commonly acetaminophen, caffeine, hydrochlorothiazide,
indomethacin & prednisolone. 5,7 Other NSAIDS & benzodiazepines found in Chinese patent medicines
sold outside Asia 6 . In 24 of 251 Asian patent medicines there was lead; 36 arsenic & 35 contained mercury. 9
Web links: http://www.fda.gov/food/dietarysupplements/default.htm
http://nccam.nih.gov/ www.ars-grin.gov/duke www.quackwatch.com
www.ncahf.org www.herbmed.org www.consumerlab.com
www.camline.ca www.naturaldatabase.com www.mskcc.org/aboutherbs
http://www.hc-sc.gc.ca/dhp-mps/prodnatur/index-eng.php www.herbs.org
Like all drugs there are some serious side effects & interactions that occur.
References: 1. Hansten and Horn's Drug Interactions Analysis and Management 2009. 2. AHFS Drug Information 2009.
3. American Family Physcian Mar 1/1999. 4. CPS - Product Monographs, 2009. 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.
10. Pharmacy Practice June 1999 & June 2000 11. Natural Medicines Comprehensive Database 2010. 12. Review of Natural Products 2005.
BP-Blood pressure CI-Contraindication GI-Gastrointestinal K=potassium INR-international normalization ratio (ie. bleeding risk)
LFT=liver function tests !-a concern if given pre-op (JAMA 2001) SE-side effect # Possibly safe but DI & SE.
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