INTERAKSI

OBAT -
HERBAL
 OBAT HERBAL

 Menurut Badan Pengawas Obat dan Makanan (BPOM), definisi obat tradisional (OT) adalah bahan atau
ramuan berupa tumbuhan, bagian hewan, mineral, atau campuran dari bahan-bahan tersebut yang
digunakan secara turun-temurun untuk pengobatan.
 Obat tradisional juga sering disebut Obat Bahan Alam (OBA) atau obat herbal.
 Obat tradisional di Indonesia secara umum terbagi tiga yaitu, jamu, obat herbal terstandar (OHT), dan
fitofarmaka.
 Semakin populer dengan semangat back to nature.
 Dianggap aman tanpa efek samping.

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 INDONESIA

Traditional Medicine

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 KANDUNGAN OBAT HERBAL

 Obat herbal biasanya mengandung banyak senyawa yang aktif secara farmakologi, sehingga dalam
beberapa kasus tidak diketahui konstituen mana yang memberi efek terapi.
 Satu pendekatan yang dilakukan adalah meninjau atau menguji keseluruhan ekstrak herbalnya sebagai
komponen aktif → untuk uji efikasinya sangat kompleks ketimbang senyawa (obat) sintetik.
 Efek terapi banyak.
 Sering ditemukan pasien menggunakan obat bersama herbal → interaksi yang membahayakan, karena
informasi yang berkembang semua herbal aman dikonsumsi bersama obat.

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PERMASALAHAN PENGGUNAAN OBAT HERBAL
 Aman dan alami, tetapi
 Kurangnya standardisasi penggunaan obat
herbal terutama terkait dosis
 Kandungan fitokimia obat herbal yang
kompleks yang belum sepenuhnya
teridentifikasi
MEMUNGKINKAN TERJADINYA
 Ramuan obat herbal dengan banyak komposisi INTERAKSI OBAT - HERBAL
 Penggunaan bagian tumbuhan yang beragam
 Kondisi tempat tumbuh dan iklim yang
beragam
 Proses produksi yang belum semua terstandar
 Toksisitas dan adverse effects dari obat herbal Noonanaand Noonan, 2006, Toxicology 221: 4-8.
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  Ginkgo Evaluation of Memory (GEM) Study cohort
 82.5% used at least 1 dietary supplement, with 54.5% using 3+.
 The overall mean number of prescription drugs was 3.5 ± 2.7 and dietary supplements were and 3.4 ± 3.0
 83% of prescription drug users also used dietary supplements, and 90% of supplement users also used
prescription drugs

JAGS 57:1197–1205, 2009

UC IRVINE - REYNOLDS GRANT 8

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 A HERB-DRUG INTERACTION

 Any pharmacological modification caused by a herbal substance(s) to another prescription medication

(diagnostic, therapeutic or other action of a drug) in or on the body
 A herb might mimic, ↓ or ↑ the effects of co-administered drugs
 Consequences can be beneficial, undesirable or harmful effects

Brazier and Levine, 2003.Am J Ther10: 163-169

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EVIDENCE FOR HERB-DRUG INTERACTIONS
 Case reports
 Underreported? 70% “don’t ask-don’t tell”
 Lab studies
 Define mechanisms
 Recent interest in CYP450 induction
 Not necessarily borne out in trials
 Human studies – interpret with caution
 Trials using probe drugs
 May be too short or expensive
 May be done on healthy population (not always)
 Genetic polymorphisms
 Multiple drug/herb users, elderly patients De Smet, Br J Clin Pharm 2006; 63:258-67
DRUG INTERACTION RESOLUTION

 Require dosage adjustments

 Temporary or complete elimination of one or the other agent to avoid serious consequences
 Close monitoring of the subject
 Total change of drug therapy
PREVALENCE: CANADIAN SENIORS

 Canadian seniors with osteoarthritis

 Survey, n = 191. Average 2.8 prescriptions, 1.9 self-care products
 Potential interactions detected using standard databases
 214 instances, 14% possible clinical significance
 7 herbs/supplements, associated with 5 clinically insignificant interactions
 1 recommendation to stop medications (diltiazem + atorvastatin -> statin side effects intensified)
 Clinically significant interactions may be rare – but thus easier to forget about and harder to
monitor!

Putnam, Can Fam Physician 2006; 52:340-45

PREVALENCE: MAYO CLINIC

 6 specialty areas
 Survey of 1795 patients; 39.6% used supplements
 Potential interactions detected using Lexi-Interact (available on PDA)
 107 interactions with potential clinical significance
 Garlic, valerian, kava, ginkgo and St. John’s wort accounted for most potential interactions – 68%
 Antithrombotics, sedatives, antidepressants, and antidiabetics most involved in interactions – 94%
 No patient was seriously harmed by herb-drug interaction

Sood et al. 2008; 121(3):207-11

DRUG-HERB INTERACTION MECHANISM

Chavez et al, 2006, Life science 78: 2146-2157

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INTERAKSI OBAT – HERBAL
(FASE ABSORBSI)

Contoh : Tetrasiklin, mineral, vitamin vs Tanin, pektin, resin, serat

Tanin, pektin, resin dan serat yang terkandung pada

herbal dapat mengikat (membentuk kompleks)
tetrasiklin, mineral, vitamin

Ukuran molekul tetrasiklin, mineral, vitamin bertambah

Absorbsi tetrasiklin, mineral dan vitamin menurun →

efek menurun

Pengatasan: Pemberian diselang minimal 2 jam

 HERBAL LAXATIVES

 Decrease blood levels of drugs by shortening gastrointestinal transit time

 Increase potassium loss
 Common herbal laxatives : Aloe, cascara, rhubarb, senna

AbebeW, 2003., J Dental Hygiene 77:37-46

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INTERAKSI OBAT – HERBAL
(FASE ABSORBSI)
Contoh : Simetidin vs Antrakinon

Antrakinon yang terkandung pada daun

senna, dan lidah buaya bersifat laksativ

Mengurangi waktu transit simetidin dalam

usus

Absorbsi simetidin berkurang → efek

simetidin berkurang
 Kaminskyand Zhang, 1997, PharmacolTher73: 67-74

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 HERBS AND CYP450 SYSTEM

 A herb can be an inducer of a CYP isoform

 St. John's Wort, tea, cruciferous vegetables, common valerian, ginkgo
 A herb can be an inhibitor of a CYP isoform
 Horse chestnut, kava-kava root, echinacea purpurea, feverfew herb, common sage, devil's claw root,
grapefruit juice, peppermint oil, red clover blossom, milk thistle (silymarin)
 Results: Increase / Decrease in the rate of metabolism of enzyme substrates

Block and Gyllenhaal, 2002, Integrative Cancer Therapies 1: 83-89

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 HERBS, DRUG AND CYP450 SYSTEM

 These drugs are substrates for CYPs

enzymes and their therapeutic
concentrations can be affected by
concomitant use of previously mentioned
herbs

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HERBS AND P-GLYCOPROTEINS

P-glycoproteins
 Act as pump to remove drugs from cells against a steep concentration gradient.
 P-GP plays important roles in the absorption, distribution or elimination of drugs from various tissues
 Curcumin
 Ginsenosides
 Piperine
 Sylimarin
 Catechins & flavonoids(quercetin)
 29% of the drugs that interact with herbs are substrates for P-glycoprotein (P-gp)

Pizzagalliet al, 2001, Gastroenterology 120: 525-533

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HERBS AND P-GLYCOPROTEINS

 Digoxin
 Warfarin/Phenprocoumon
 Cyclosporine
 Fexofenadine
 Indinavir
 Simvastatin
 Irinitecan

Faber et al, 2003, Advanced Drug Delivery Reviews 55: 107-124

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 POPULAR HERBAL PRODUCTS AND THEIR
INTERACTIONS WITH THERAPEUTIC DRUGS

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ST JOHN’S WORT (Hypericum perforatum L.)

 Extract of the dried flowering portion

 Used commonly alone or in combination with other
supplements.
 Indications: Depression; anxiety; stress; insomnia
 Efficacy: good scientific evidence for mild to moderate
depression.
 Standardized ingredient: Hyperforin; Hypericin
 Other phytochemicals are present

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ST JOHN’S WORT (Hypericum perforatum L.)

 Hyperforin is believed to be the major constituent responsible for its antidepressant activity, as it
inhibits the reuptake of neurotransmitters in synapses
 Proposed action: inhibits 5-HT, NE, DA uptake; GABA receptor ligand;
 Case reports suggesting PK interactions (most important of SWJ interactions)
 Lab and clinical studies indicate PK interactions:
 CYP450 3A4 mechanism
 short-term inhibition
 Long-term induction; of most importance clinically
 Reduces various drugs to subtherapeutic levels
 Hyperforin, an active constituent, is a ligand for the xenobiotic pregnane X receptor -> CYP450
3A4
ST JOHN’S WORT (Hypericum perforatum L.)

 Other PK interactions
 P-glycoprotein (PgP): involved in multidrug resistance, acts as a pump to remove drugs from cells
 SJW induces; thus removes drugs from cells
 Also regulates MDR-1 (multidrug resistance gene) and other drug transporters

Chavez, Life Sci 2006; 78:2146-57

ST. JOHN’S WORT: PK INTERACTIONS
 Human trial with irinotecan (cancer)
 Blood levels of active metabolite were reduced
 Other drugs affected
 Cyclosporin, tacrolimus, indinavir, nevirapine, imatinib, alprazolam, midazolam, amitriptyline, digoxin,
fexofenadine, methadone, omeprazole, theophylline, verapamil, etoposide.
 Human study with oral contraceptives indicating reduced OC exposure and breakthrough bleeding
(pregnancies resulted).
 Case of delayed emergence from general anesthesia observed.
 Multiple potential interactions with oncology drugs (but rare use by oncology patients?).
 Other CYP450s
 May inhibit CYP1A2, does not inhibit CYP2D6, hyperforin inhibits CYP2C9

Murphy Contraception 2005; 71:402-8

ST. JOHN’S WORT
 PD interactions
 With other antidepressants
 Serotonin syndrome
 SJW has both SSRI and MAO inhibitor activity
 Restlessness, nausea, vomiting, tachycardia, hallucinations etc.
 Case reports with buspirone, loperamil, nefazodone, paroxetine, sertraline, venlafaxine
 Possible adrenergic crisis
 MAO inhibitor activity (not major activity)
 Photosensitivity
 Active constituent hypericin is photosensitizing but generally not a problem with healthy persons.
Potential interaction with other photosensitizing drugs?
CLINICAL STRATEGY

 Avoid use with other medications unless checked out in an interaction database. Will have similar
interaction profile to other CYP450 3A4 inducers.
 Major drug-drug interaction pathway
 ECHINACEA

 Alcoholic extract of the root of E. angustifolia

 The juice from the fresh aerial parts of E. purpurea
 Immunostimulant
 The German Commission E monograph approved the oral use of E.
purpurea herb for treatment of colds, RTI, and UTI
 Topically : poorly healing wounds
 Constituents
 Alkamides(phagocytosis stimulatory effect), vol. Oils, pyrrolizidene
alkaloids, ferulicacid derivatives and complex polysaccharides

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 ECHINACEA& INTERACTIONS

 The German Commission Emonograph, recommends that Echinacea not be taken by patients receiving
 Immunosuppressive medications
 Autoimmune conditions
 HIV infection
 > 8 weeks?
 Hepatotoxic drugs (Methotrexate, anabolic steroids)

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 ECHINACEA& INTERACTIONS

 PK : (In vitro studies) in 8 days

 Inhibits 1A2
 May inhibit intestinal 3A4 but induce hepatic
 Clinical significance unclear

Gorskiet al, 2004, Clinical Pharm. Therap. 75: 89-100

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 GINKGO BILOBA L.

 It is among the most sold medicinal plants in the world (sales >
1 billion dollars)
 Special standardized extracts from the leaves
 EGb761® is registered in Germany and other countries for the
treatment of dementia disorders& cerebral circulatory
disturbances
 Standardized leaves constituents
 Terpenetrilactones(ginkgolides& bilobalides)
 Flavonolglycosides
 Biflavonesand proanthocyanidins

Kanowskiet al, 1996, Pharmacopsychiatry 29: 47-56

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GINKGO INTERACTION

Cases/trials on interactions:
 Aspirin – hyphema
 Acetaminophen - bilateral subdural hematomas
 Warfarin - intracerebral hemorrhage but no effect in 2 clinical trials
 Ibuprofen -- cerebral hemorrhage
 Rofecoxib – bleeding, case report
 Valproate: 2 cases of seizures
 Risperidone – priapism; vasodilating effect of both substances?
 Induction of CYP2C19 – clinical trial, case report.
 Possible/weak effects on CYPs 3A4 and 2C9
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 GINKGO AND PSYCHOTROPICS

 Female with Alzheimer disease was switched from bromazepam and vitamin E to trazodone and
ginkgo lapsed into a coma (later reversed).
 Antioxidant effect may result in enhanced activity of haloperidol (antipsychotic).
 Ginkgo – 2 case reports of interaction with phenelzine (MAO inhibitor); insomnia, headache, irritability

Galluzzi, J Neurol Neurosurg Psych 68:679-80

Zhang, J Clin Psychopharm 21:85-88
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GINSENG

 Panax ginseng C.A, P. quinquefolium L., P. Japonicus M.(Araliaceae)

 Long-term traditional use for over 2000 yrs
 Approved by Commission E in 1981 as a tonic to counteract
weakness and fatigue, a restorative for declining stamina and
impaired concentration
 Some evidences for applications in geriatric patients (improved
“quality of life”) and in diabetes Roots constituents
 Steroidal saponins > 30 ginsenosides, varying conc

Lieberman, 2001, ClinInvest 102: 1016-1023

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 CASE REPORT AND INTERACTIONS (PD)

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 International Normalized Ratio (INR) and Stroke

Warfarin (Coumadin) given as long-term therapy after stroke; dose is adjusted by periodic monitoring of INR
WARFARIN-HERB INTERACTIONS

 Numerous drug-drug interactions: macrolides, NSAIDs, COX2s, SSRIs, omeprazole, 5FU etc (variable
quality of evidence).
 Possible pathways:Vitamin K activity lowers INR
 Foods: leafy greens (healthy diet)
 “Green drinks” – clinical interactions with oncology patients. Case reports with cranberry juice
also.
 Multivitamins (low vitamin K dose)
 CoQ10: similar structure to vitamin K, but RCT found no effect on INR. Case reports suggest
monitoring.

Rhode, Curr Opin Clin Nutr Metab 2007; 10:1-5

Engelsen, Throm Hemost 2002; 87:1075-6
WARFARIN-HERB INTERACTIONS

 PK
 decreased absorption from GI tract due to mucilage (comfrey, Iceland moss) or laxative herbs
(senna, rhubarb etc)
 CYP450 2C9 inhibition/induction, which metabolizes the active S-enantiomer of warfarin (saw
palmetto, kava, bromelain possible but only lab data)
 PD
 Herbs that decrease platelet aggregation
 Decreased thromboxane synthesis
 Herbs with coumarin content (though coumarin is a relatively weak anticoagulant)
WARFARIN AND CHINESE HERBS

 Asian ginseng (Panax ginseng) – ginsenosides may inhibit platelet aggregation (anticoagulant). 2 case
reports of lowered or unsteady INR (procoagulant)
 RCT in healthy volunteers showed no effect of Asian ginseng on INR, platelet aggregation.Vitamin K
in extracts? Monitor closely.
 American ginseng (Panax quinquefolius) – RCT in healthy volunteers indicated moderately reduced
INR, warfarin levels, AUC.

Chavez, Life Sci 2006; 78:2146-57

Jiang, Br J Clin Pharm 2004; 57:592-9
Yuan, Ann Intern Med 2004; 141:23-7
WARFARIN AND “G” HERBS

 Garlic (Allium sativum) – 2 case reports. Continuing ingestion of high levels of garlic or garlic oil can
decrease platelet aggregation
 Ginger (Zingiber officinalis) – Inconclusive results in studies in healthy volunteers but case reports
exist.
 Ginkgo (Ginkgo biloba) –Preliminary human study indicates no effect on INR, but case reports suggest
interaction
 Green tea (Camellia sinensis) – Inhibits platelet synthesis of thromboxane (lab). Case report of
decreased INR in patient drinking 1 gal/day green tea – vitamin K.

Chavez, Life Sci 2006; 78:2146-57

WARFARIN AND LIPID-BASED AGENTS

 Omega-3 fatty acids (fish oil, algal formulas) – case report of increased INR with fish oil in a stabilized
warfarin patient, 67-y/o female.
 Strong antiinflammatory effects, but did not affect INR in an RCT.
 Saw palmetto – lipid extract. Case report of intraoperative hemorrhage (w/o warfarin) and increased
INR in 2 warfarin patients.

Chavez, Life Sci 2006; 78:2146-57

CASE REPORT

 Female, age 76, hx of hypertension, osteoarthritis, gastropathy due to NSAIDs, atrial fibrillation, stroke:
presents at ER with hematuria and bleeding gums.
 Meds: hydrochlorothiazide, warfarin, acetaminophen. No recent illnesses, antibiotics, diet change
reported.
 CBC normal, previous INR was 2.1 but now 7.0
 Appropriate INR for stroke patients is 2.0-3.0.
 Elderly are at risk for bleeding d/t lower body weight, low vitamin K intake, drug interactions.
 Drug interactions include acetaminophen (not widely recognized): metabolized by 2C9, as is warfarin.
 Patient recently increased acetaminophen intake d/t osteoarthritis flare; cautioned to reduce dose, use
daily (not intermittently) and monitor INR more frequently.
CASE REPORT
 INR at a therapeutic level for 6 m.
 Patient then returned with nosebleed and INR of 10.
 Acetaminophen, aspirin, warfarin doses had remained the same, no illnesses.
 Closer questioning revealed use of ginger for upset stomach – ginger tea and ginger root.
 Patient advised to stop ginger consumption & monitor INR more frequently; excessive anticoagulation
stopped with iv vitamin K.
 Problem: ginger did not cause CYP450 interaction in pharmacodynamic/pharmacokinetic study and
trials in healthy patients indicated only questionable clinical effect on coagulation
 Combined effect of ginger anticoagulant effect and acetaminophen 2C9 effect? Patient age?
 Very similar story for chamomile (very weak antiinflammatory effects).
Lesho EP et al. Cleve Clinic J Med 2004; 71:651-655
Segal R et al CMAJ 2006; 174:1281-2
HERBS AND STATINS

 Pharmacodynamic interactions: the “herbal statins” (frequently in cholesterol-lowering supplements).

 Effect on statin side effects (liver, myalgia, rhabomyolysis)?
 Usually due to polypharmacy.
 Red yeast rice (monacolin = lovastatin); case report of rhabdomyolysis with lovastatin and cyclosporine
after initiating red yeast rice
 pantethine (a stabilized form of vit B5 included in some cholesterol lowering supplements), artichoke,
reishi mushroom, tocotrienols, policosanol, guggul, garlic, possibly goldenseal, fish oil (also raises LDL
cholesterol), resveratrol, plant stanols, chlorogenic acid (coffee, though not absorbed easily), luteolin
(parsley, peppers), luteolin 7-0-glucoside (dandelion flower)

Armitage 2007; Lancet 370; 1781-90; NAPRALERT; naturalstandard.org

HERBS AND STATINS
 Pharmacokinetic interactions:
 CYP450 3A4: lovatstatin, simvastatin, atrorvastatin.
 CYP 2C9: fluvastatin, rouvastatin, pitavastatin
 Herb/supplement 3A4 and 2C9 inhibitors/inducers:
 berberine Oregon grape (contains berberine)
 bromelain resveratrol
 cranberry St. John’s wort
 DHEA schizandra
 uncaria
 feverfew
 Also grapefruit juice
 PHYTOESTROGENS CONTAINING HERBS

 Secondary plant metabolites with estrogenic properties found in Plants, fruits, vegetales & foodstuffs
(e.g., cereal grains, soy milk)
 Classes
 Isoflavonesin legumes(genistein and daidzein)
 Lignans in cereal brans, flax seeds(enterodiol and enterolactone)
 Coumestans in bean sprouts(coumestrol)

Savaet al, 1998, Proc Soc Exp Biol217: 369-378

TEACH A COURSE 49
 PHYTOESTROGENS CONTAINING HERBS

 Asian cultures: Long consumption of soy associated with lower rates of breast, endometrial and
prostate cancers
 Animal studies: Soy and some soy isoflavones decrease prostate cancer and breast cancer growth
 Increased phytoestrogen ingestion may decrease hot flashes, osteoporosis and other postmenopausal
symptoms
 Soy-Cardiovascular Benefits
Favorable effects on cholesterol balance; “heart healthy”

TEACH A COURSE 50
 INTERACTIONS

 In vitro and animal studies: estrogen agonist effects of isoflavones might increase the growth of breast
cancer cells
 Genistein enhances effect of Adriamycinon breast cancer cells but blocks inhibitory effect of Tamoxifen
 In vitro studies: CYP3A4 activation by soy extracts (no clinical support)
 ↓ Abs. of levothyroxine

Messina, 2006, J PeriAnesthesia Nursing 21: 268-278

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 GARLIC (ALLIUM SATIVUM L.)

 The herb of the year (2004) by the Herb Society

of America
 Medicinal purposes
 Composed of dried garlic powder standardized
for allicin content
 Used as: Antiplatelet, Antioxidant, Fibrinolytic
effects, Anti hypercholesterolemic, Treatment of
common cold, Reduced Cancer risk

Valliand Giardina, 2002, J.Am. College of Cardiology 39: 1083-1095.

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GARLIC (ALLIUM SATIVUM)

 Garlic & CYPs/P-gp

 Studies suggest that garlic can act as an enzyme inhibitor during acute dosing and an enzyme inducer
during chronic dosing
 Garlic & phase II enzymes
 Hepatic phase II enzymes GST and QR; were induced strongly by the trisulfide(dose:10 μmol/kg) and
weakly by the disulfide, but not by diallyl sulfide
CASE REPORT
KAVA (PIPER METHYSTICUM)

 One case report of coma induced by a combination of kava and alprazolam-a benzodiazepine
 Extrapyramidal side effects-4 cases of dopamine antagonism-oral, lingual and trunk dyskinesia
(spasmodic movements)
 Inhibition of CYP2E1 – clinical trial
 Do not combine with alcohol, sedatives, tranquilizers or CYP2E1 substrates
LICORICE (GLYCYRRHIZA GLABRA)
 Sore throat, dyspepsia, peptic ulcer disease
 Triterpene saponins-glycyrrhizin
 Prolonged use > 6weeks of >50 g/day-
pseudaldosteronism
 Potassium depletion, sodium retention, edema,
hypertension and weight gain
 Drug Interactions
 Thiazide and loop diuretics, cardiac glycosides
 Antihypertensives
 Spironolactone or amiloride
 Only clinically significant in cases of excessive
use, however… appears with excessive
licorice candy
 Possible with multiple use of herbal formulas
containing licorice (ie in Chinese formulas)
LICORICE: POSITIVE INTERACTION

 Small trial of women being treated for polycystic ovary syndrome with spironolactone (antiandrogen
and diuretic – PCOS due to high androgen levels), which has side effects of diuresis, low blood
pressure, volume depletion. 20% of drug-alone, none of drug + licorice had symptoms, also
metrorrhagia due to spironolactone improved. Also useful due to estrogenic effect of licorice.

Armanini Eur J Obst Gynecol Reprod Biol. 2007; 131:61-7

HERBAL LAXATIVES

 Decrease blood levels of drugs by shortening gastrointestinal transit time

 Increase potassium loss
 Common herbal laxatives: aloe, cascara sagrada, rhubarb, senna

Abebe W, 2003. J Dental Hygiene 77(1):37-46

OTHER POTENTIAL INTERACTIONS

 Ephedra (diet pills) – illegal in US but possibly obtained internationally/Internet. Increase in blood
pressure, thus contraindicated with antihypertensives and stimulants (e.g. caffeine).
 Black Cohosh (menopausal symptoms) – although debated, some expert analyses suggest rare
hepatoxicity, thus should not be used with hepatoxic drugs.
OTHER POSSIBLE INTERACTIONS

 Tamoxifen – inhibitors of CYP2D6 should not be taken because of metabolism of prodrug to its active
form. Genetic polymorphism in population. Several antidepressants are strong inhibitors but SJW is
weak if at all.Valerian in vitro activity. Goldenseal – strong inhibition in clinical trial.
 Chinese herbs – Scutellaria species – induction of CYP2E1, 2C9. Angelica dahurica – inhibited
CYP1A2 (but no effect of Angelica tenuissima). Hundreds of other Asian herbs with no info.
SURGERY AND DENTAL PROCEDURES

 Drug interactions and physiological reactions:

 CNS herbs: potential PD interactions with anesthesia:
 Valerian, kava, St. John’s wort (PK interaction also), lavender, passionflower, lemon balm, ashwaganda,
ginseng, ephedra). Midazolam – SJW, goldenseal and possibly ginkgo PK effects but ginkgo studies are
contradictory
 Blood sugar – ginseng, bitter melon, chromium, fenugreek, cinnamon

Ang-Lee, JAMA 2001; 286:208-16

SURGERY AND DENTAL PROCEDURES

 Anticoagulant herbs: post-op bleeding and interaction with aspirin or other NSAIDs that may cause
bleeding.
 Garlic, ginger, ginkgo, ginseng, feverfew.
 Angelica, asafoetida, anise, astragalus, arnica, bogbean, bromelain, borage seed, capsicum, clove,
curcumin, dong quai, fenugreek, fish oil, green tea, horsechestnut, juniper, licorice, meadowsweet, onion,
pau d’arco, parsley, passionflower, quassia, red clover, reishi, salvia, turmeric, willow.
SURGERY AND DENTAL PROCEDURES

 Stop herb and supplement use 7-14 days prior to surgery.

 All pre-surgical patients should be questioned about herb/supplement use to determine recent
consumption of anticoagulant or drug-interacting herbs.
CLINICAL COPING

 Counteract “don’t ask-don’t tell”

 Open and nonjudgmental discussion
 Follow up herb use found in case histories
 Explain importance of potential interactions
 Avoid SJW and warfarin interactions
 Patients on complicated medical regimens should avoid herbs and supplements unless carefully
screened/supervised
THANK YOU!