Interactions Between Herbal Medicines and Prescribed Drugs

Herbal Supplements: Can They Cause Hypomania?

Herbal medication use is prevalent and increasing in the general population. A comprehensive review of complementary and alternative medicine use including herbal medications and supplements is often overlooked by physicians. Patients generally believe that all herbal products are safe without any side-effects. Herbal medications may have complex pharmacodynamics and can be associated with various psychiatric symptoms. The general population, as well as physicians, may be unaware of the risks and side-effects associated with herbal supplement use and further research may be needed. The objective is to describe a case report of acute onset of symptoms of hypomania associated with the increasing use of herbal supplements. A 49-year-old man developed symptoms of hypomania after a two-month history of daily use of a combination of more than 25 herbal supplements and daily cannabis use. Hypomania symptoms were temporally associated with the use of multiple herbal supplements that included ginseng. We recommend that a thorough history of medication use including herbal supplements and other alternative medications and a collateral report from family members and other providers including herbalists be obtained on all patients presenting with psychiatric symptoms. Further research is needed to identify the pharmacodynamics, risks, and adverse effects, and drug and food interactions of each herb.

Improving pharmacy practice in relation to complementary medicines: a qualitative study evaluating the acceptability and feasibility of a new ethical framework in Australia

BACKGROUND

There is a need for clearer guidance for pharmacists regarding their responsibilities when selling complementary medicines. A recently published ethical framework provides guidance regarding the specific responsibilities that pharmacists need to meet in order to fulfil their professional obligations and make a positive contribution to health outcomes when selling complementary medicines.

OBJECTIVE

Evaluate the acceptability and feasibility of a new ethical framework for the sale of complementary medicines in community pharmacy.

METHODS

Australian community pharmacists were invited to participate in online focus groups and interviews. Participants were recruited via multiple methods, including social media and the professional networks of pharmacy groups. Participants were provided the ethical framework prior to the discussion. Discussions were transcribed verbatim and analysed using thematic analysis.

RESULTS

Seventeen community pharmacists participated in the study (11 in 4 focus groups and 6 in individual interviews). There was good representation among participants in terms of gender, years of practice, pharmacy location and script volume. Participants differed in how proactive they were in relation to selling and providing advice on complementary medicines, how they interpreted evidence in relation to complementary medicines, and how they navigated their practice within the retail environment of community pharmacy. The majority of participants found the framework was acceptable for practice and was feasible for implementation with targeted support. Participants identified two important areas for targeted support in implementing the framework: improved access to evidence-based information resources on complementary medicines and independent evidence-based education and training on complementary medicine for pharmacists and pharmacy support staff.

CONCLUSION

The ethical framework addresses an important gap in providing specific professional guidance to pharmacists when selling complementary medicines. The results of the study suggest that the framework may be acceptable to community pharmacists and be feasible to implement with targeted support.

Indian Medicinal Herbs and Formulations for Alzheimer's Disease, from Traditional Knowledge to Scientific Assessment

Cognitive impairment, associated with ageing, stress, hypertension and various neurodegenerative disorders including Parkinson's disease and epilepsy, is a major health issue. The present review focuses on Alzheimer's disease (AD), since it is the most important cause of cognitive impairment. It is characterized by progressive memory loss, language deficits, depression, agitation, mood disturbances and psychosis. Although the hallmarks of AD are cholinergic dysfunction, β-amyloid plaques and neurofibrillary tangle formation, it is also associated with derangement of other neurotransmitters, elevated levels of advanced glycation end products, oxidative damage, neuroinflammation, genetic and environmental factors. On one hand, this complex etiopathology makes a response to commonly used drugs such as donepezil, rivastigmine, galantamine and memantine less predictable and often unsatisfactory. On the other hand, it supports the use of herbal medicines due to their nonspecific antioxidant and anti-inflammatory activity and specific cholinesterase inhibitory activity. The popularity of herbal medicines is also increasing due to their perceived effectiveness, safety and affordability. In the present article, the experimental and clinical evidence have been reviewed for various Indian herbal medicines such as Centella asiatica, Bacopa monnieri, Curcuma longa, Clitoria ternatea, Withania somnifera, Celastrus paniculatus, Evolvulus alsinoides, Desmodium gangeticum, Eclipta alba, Moringa oleifera and Convolvulus pluricaulis, which have shown potential in cognitive impairment. Some commonly available herbal formulations for memory impairment in India have also been reviewed.

Herbal Medicine for Slowing Aging and Aging-associated Conditions: Efficacy, Mechanisms and Safety

Aging and aging-associated diseases are issues with unsatisfactory answers in the medical field. Aging causes important physical changes which, even in the absence of the usual risk factors, render the cardiovascular system prone to some diseases. Although aging cannot be prevented, slowing down the rate of aging is entirely possible to achieve. In some traditional medicine, medicinal herbs such as Ginseng, Radix Astragali, Ganoderma lucidum, Ginkgo biloba, and Gynostemma pentaphyllum are recognized by the "nourishing of life" and their role as anti-aging phytotherapeutics is increasingly gaining attention. By mainly employing PubMed here we identify and critically analysed 30 years of published studies focusing on the above herbs' active components against aging and aging-associated conditions. Although many plant-based compounds appear to exert an anti-aging effect, the most effective resulted in being flavonoids, terpenoids, saponins, and polysaccharides, which include astragaloside, ginkgolide, ginsenoside, and gypenoside specifically covered in this review. Their effects as antiaging factors, improvers of cognitive impairments, and reducers of cardiovascular risks are described, as well as the molecular mechanisms underlying the above-mentioned effects along with their potential safety. Telomere and telomerase, PPAR-α, GLUTs, FOXO1, caspase-3, bcl-2, along with SIRT1/AMPK, PI3K/Akt, NF-κB, and insulin/insulin-like growth factor-1 pathways appear to be their preferential targets. Moreover, their ability to work as antioxidants and to improve the resistance to DNA damage is also discussed. Although our literature review indicates that these traditional herbal medicines are safe, tolerable, and free of toxic effects, additional well-designed, large-scale randomized control trials need to be performed to evaluate short- and long-term effects and efficacy of these medicinal herbs.

An investigation of the information provided to the parents of young people with mental health needs on an internet forum

BACKGROUND

Access to Children and Adolescent Mental Health Services (CAMHS) can be difficult, with lengthy wait times. Many of the young people and their parents are not signposted to any form of support during their wait for initial assessment or treatment and people are increasingly turning towards web-based resources for help and advice. However, there are some concerns about the quality of the information shared online. Research on the use and quality of information shared on online platforms for mental health inquiries is limited.

AIMS

We aimed to investigate the content and quality of the responses shared by forum users on an online forum for parents of young people with mental health needs (Mumsnet 'Talk'). Forum users were primarily parents, but 8 posts were written by posters identifying as a healthcare worker, teacher, or autism spectrum specialist.

METHODS

Qualitative methodology was adopted for this study. Forum content from Mumsnet was extracted in an anonymised form and thematic analysis was conducted to explore the content. Information shared in the online forum was assessed for quality by comparing the responses with clinical guidelines.

RESULTS

Thread topics related to 16 mental health problems. "Autistic Traits/Autism Spectrum Disorder", "Obsessions and Intrusive Thoughts/ Obsessive Compulsive Disorder" and "Comorbid Anxiety and Depression" were the most prevalent thread topics, consisting 38.3% of the extracted content. The investigation focused on "Information Offered" as the general dimension. Based on the thematic analysis, there were four second-order themes regarding the information offered by forum users; referral, advice, anecdotal information and opinion on case. The quantitative assessment of responses found that 58.3% of the knowledge exchange on Mumsnet was congruent with evidence-based clinical guidelines.

CONCLUSIONS

Themes indicate that parents of children and young people with mental health needs seem to use online fora for informational support. It is promising that a significant proportion of the information shared within the extracted forum content is congruent with evidence-based knowledge. However, further investigation is needed to generate better understanding of the overall quality of mental health information available on online platforms.

Inhibition and induction of CYP enzymes in humans: an update

The cytochrome P450 (CYP) enzyme family is the most important enzyme system catalyzing the phase 1 metabolism of pharmaceuticals and other xenobiotics such as herbal remedies and toxic compounds in the environment. The inhibition and induction of CYPs are major mechanisms causing pharmacokinetic drug–drug interactions. This review presents a comprehensive update on the inhibitors and inducers of the specific CYP enzymes in humans. The focus is on the more recent human in vitro and in vivo findings since the publication of our previous review on this topic in 2008. In addition to the general presentation of inhibitory drugs and inducers of human CYP enzymes by drugs, herbal remedies, and toxic compounds, an in-depth view on tyrosine-kinase inhibitors and antiretroviral HIV medications as victims and perpetrators of drug–drug interactions is provided as examples of the current trends in the field. Also, a concise overview of the mechanisms of CYP induction is presented to aid the understanding of the induction phenomena.

Prevalence, expenditures, and associated factors of purchasing non-prescribed Chinese herbal medicine in Taiwan

BACKGROUND AND AIMS

Purchasing Chinese herbal medicine (CHM) without a physician's prescription may have adverse effects on health. However, the recent status of purchasing non-prescribed CHM and the associated factors are not completely understood. We aimed to report the prevalence of purchasing CHM and associated factors.

METHODS

Using data from the 2017 Taiwan Survey of Family Income and Expenditure, we identified 16,528 individuals (householders) aged 18 years and older. Sociodemographic factors, expenditures on medical services and health behaviours were compared between people with and without a history of purchasing non-prescribed CHM by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in a multiple logistic regression analysis.

RESULTS

The one-year prevalence of purchasing non-prescribed CHM was 74.8% in Taiwan. In addition to sociodemographics, marital status (OR 2.14, 95% CI 1.88-2.44), the use of traditional Chinese medicine (OR 3.62, 95% CI 3.30-3.97), the purchasing of non-prescribed biochemical medications (OR 3.09, 95% CI 2.75-3.48), the purchasing of health foods (OR 2.59, 95% CI 2.33-2.86), the use of folk therapy (OR 2.27, 95% CI 1.95-2.64), and a high level of expenditure on alcohol (OR 3.79, 95% CI 3.29-4.36) were strongly correlated with purchasing non-prescribed CHM.

CONCLUSION

The one-year prevalence of purchasing non-prescribed CHM is very high in Taiwan and is correlated with sociodemographics, health behaviours, and the utilization of medical care. The interaction of non-prescribed CHM with physician-prescribed herbal medicine and biomedical medications requires more attention.

Opportunities and challenges in managing antibiotic resistance in bacteria using plant secondary metabolites

Development of antibiotic resistance (ABR) in bacteria and its multidimensional spread is an emerging global threat that needs immediate attention. Extensive antibiotics (AB) usage results in development of ABR in bacteria by target modification, production of AB degrading enzymes, porin modifications, efflux pumps overexpression, etc. To counter this, apart from strict regulation of AB use and behavioural changes, research and development (R&D) of newer antimicrobials are in place. One such emerging approach to combat ABR is the use of structurally and functionally diverse plant secondary metabolites (PSMs) in combination with the conventional AB. Either the PSMs are themselves antimicrobial or they potentiate the activity of the AB through a range of mechanisms. However, their use is lagging due to poor knowledge of mode of action, structure-activity relationships, pharmacokinetics, etc. This review paper discussed the opportunities and challenges in managing ABR using PSMs. Mechanisms of ABR development in bacteria and current strategies to counter them were studied and the areas where PSMs can play an important role were highlighted. The use of PSMs, both as an anti-resistance and anti-virulence agent in combination therapy to counter multi-drug resistance along with their mechanisms of action, has been discussed in detail. The difficulties in the commercialisation of PSMs and strategies to overcome them along with future priority areas of research have also been given. Following the given R&D path will definitely help in better understanding and utilising the full potential of PSMs in solving the problem of antimicrobial resistance (AMR).

Herb-drug interaction between Styrax and warfarin: Molecular basis and mechanism

BACKGROUND

Styrax, one of the most famous folk medicines, has been frequently used for the treatment of cardiovascular diseases and skin problems in Asia and Africa. It is unclear whether Styrax or Styrax-related herbal medicines may trigger clinically relevant herb-drug interactions.

PURPOSE

This study was carried out to investigate the inhibitory effects of Styrax on human cytochrome P450 enzymes (CYPs) and to clarify whether this herb may modulate the pharmacokinetic behavior of the CYP-substrate drug warfarin when co-administered.

STUDY DESIGN

The inhibitory effects of Styrax on CYPs were assayed in human liver microsomes (HLM), while the pharmacokinetic interactions between Styrax and warfarin were investigated in rats. The bioactive constituents in Styrax with strong CYP3A inhibitory activity were identified and their inhibitory mechanisms were carefully investigated.

METHODS

The inhibitory effects of Styrax on human CYPs were assayed in vitro, while the pharmacokinetic interactions between Styrax and warfarin were studied in rats. Fingerprinting analysis of Styrax coupled with LC-TOF-MS/MS profiling and CYP inhibition assays were used to identify the constituents with strong CYP3A inhibitory activity. The inhibitory mechanism of oleanonic acid (the most potent CYP3A inhibitor occurring in Styrax) against CYP3A4 was investigated by a panel of inhibition kinetics analyses and in silico analysis.

RESULTS

In vitro assays demonstrated that Styrax extract strongly inhibited human CYP3A and moderately inhibited six other tested human CYPs, as well as potently inhibited warfarin 10-hydroxylation in liver microsomes from both humans and rats. In vivo assays demonstrated that compared with warfarin given individually in rats, Styrax (100 mg/kg) significantly prolonged the plasma half-life of warfarin by 2.3-fold and increased the AUC_(0-inf) of warfarin by 2.7-fold when this herb was co-administrated with warfarin (2 mg/kg) in rats. Two LC fractions were found with strong CYP3A inhibitory activity and the major constituents in these fractions were characterized by LC-TOF-MS/MS. Five pentacyclic triterpenoid acids (including epibetulinic acid, betulinic acid, betulonic acid, oleanonic acid and maslinic acid) present in Styrax were potent CYP3A inhibitors, and oleanonic acid was a competitive inhibitor against CYP3A-mediated testosterone 6β-hydroxylation.

CONCLUSION

Styrax and the pentacyclic triterpenoid acids occurring in this herb strongly modulate the pharmacokinetic behavior of warfarin via inhibition of CYP3A.

Chemical modification of ovatodiolide revealed a promising amino-prodrug with improved pharmacokinetic profile

Stepwise modification of ovatodiolide revealed a prodrug, NMP-diepoxyovatodiolide, which can provide sustained release of an active compound, substantial metabolic stability and a unique accumulation profile in the liver. Besides, NMP-diepoxyovatodiolide demonstrated therapeutic benefits in an acute autoimmune hepatitis mouse model and a broad safety window. Therefore, NMP-diepoxyovatodiolide is a very promising candidate for further development of liver-related drugs.

Emerging Complementary and Integrative Therapies for Geriatric Mental Health

PURPOSE

The use of complementary and integrative medicine (CIM) is on the rise among diverse populations of older adults in the USA. CIM is commonly perceived as safer, less expensive, and more culturally acceptable. There is a growing body of evidence to support the use of CIM, especially mind-body therapies, diet and nutritional supplements used for mental disorders of aging.

RECENT FINDINGS

We summarize the results of the recent clinical trials and meta-analyses that provide the evidence for the role of CIM in treating older adults with mood or cognitive disorders that includes the use of diet and supplements, and mind-body therapies.

SUMMARY

Dietary and mind-body therapies have become increasingly popular and show the strongest evidence of efficacy for mood and cognitive disorders. Although the use of vitamins and supplements is the most popular CIM practice, only mixed evidence supports their use with additional concerns for herb (supplement)-drug interactions. Despite increasing use of CIM by the general population, information to guide clinicians providing care for older adults remains limited with variable scientific rigor of the available RCTs for a large number of commonly used CIM interventions for the mental health of older adults.

A Review of Medicinal Plants in Cardiovascular Disorders: Benefits and Risks

Many cultivated and wild plants are used for the management of various diseases, specifically renal and hepatic diseases and those of the immune and cardiovascular systems. In China, medicinal plants from ancient to modern history have been used in patients with angina pectoris, congestive heart failure (CHF), systolic hypertension, arrhythmia, and venous insufficiency for centuries. The latest increase in the fame of natural products and alternative medicine has revived interest in conventional remedies that have been consumed in the management of CVD. The cardio-protective properties of the various herbs are possibly due to their anti-oxidative, antihypercholesterolemic, anti-ischemic activities, and inhibition of platelet aggregation that reduce the risk of CVD. Ethno-pharmacological and biological properties of these plants are explored, based upon published scientific literature. Although a majority of medicinal plants having a biological mechanism that linked with CVD management, to date, published literature pertaining to their promising scientific properties are still poorly understood. Compared with synthetic medicines, alternative medicines do not need scientific studies before their formal approval from the government sector and due to this purpose; their safety, as well as efficacy, still remain elusive. Taken together, we addressed all accessible evidence on alternative medicines commonly consumed in CVD management. Our comprehensive analysis of the scientific literature indicated that many TCMs are available and valuable herbal medication would be the best alternative for the management of CVD as a complementary therapy. Furthermore, practitioners should always discuss possible benefits-risks of alternative medicines with patients so that they are aware of the consumption of alternative medications.

The Utilization of Complementary and Alternative Medicine among Saudi Older Adults: A Population-Based Study

BACKGROUND

Complementary and alternative medicine (CAM) is an integral part of patients' therapeutic experience worldwide. Among Saudi older adults, less is known about CAM utilization.

OBJECTIVES

To determine the prevalence, patterns, and factors associated with CAM utilization among SOA.

METHODS

In the Saudi National Survey for Elderly Health (SNSEH), subjects were asked about CAM use during the last twelve months before the interview. CAM use was defined as any use of herbal products, acupuncture, bloodletting, cauterization, medical massage, bones manual manipulation, honey, or religious rituals. Demographic characteristics included gender, age, marital status, region, educational level, and residence area. In addition, multiple comorbidities were included as possible factors that may be associated with CAM use. Multivariable logistic regression was used to explore factors associated with CAM utilization. All statistical analyses were done using STATA v.14.

RESULTS

Out of 2946 respondents, 50.4% were males, the mean age was 70.3 ± 8.3 years, and 70% were illiterate. CAM use was prevalent (62.5%). The most common CAM types were herbal products (25.4%), acupuncture (21.2%), bloodletting (12%), honey (9.5%), cauterization (7.4%), medical massage and bones manual manipulation (4%), and traditional bone setting (2.1%). In the multivariable regression, age, gender, and marital status did not have an impact on the odds of using CAM. Subjects from rural areas were 2.92 times more likely to use CAM compared with subjects in urban areas (OR = 2.92; 95%CI: 2.28-3.75). Subjects with metabolic disorders (OR = 0.50; 95% CI: 0.42-0.60) or kidney disease were less likely to use CAM (OR = 0.30; 95%CI: 0.14-0.64). About pain, CAM is used more in neck pain (OR = 1.69; 95%CI: 1.30-2.21) and also used in back pain (OR =  1.22; 95%CI: 1.03-1.46).

CONCLUSIONS

CAM use was very prevalent among SOA. Clinicians and pharmacists must ask about CAM use among older adults as many of CAM may interact with patients medications.

Nonvitamin, Nonmineral Dietary Supplement Use in Individuals with Rheumatoid Arthritis

BACKGROUND

Over-the-counter, natural product-based (nonvitamin, nonmineral) dietary supplement (NVNM DS) use is common in adults with rheumatoid arthritis (RA), a group at risk for drug-DS interactions, due to polypharmacy, but this use is underreported to health care providers. Recent dramatic changes in US sales of specific NVNM DS suggest that the prevalence and types of NVNM DS used in RA populations may also have shifted.

OBJECTIVES

A study was undertaken to identify current and past use of specific NVNM DS for RA disease treatment and to examine associations between use of NVNM DS, RA pharmaceuticals, and/or vitamin or mineral (VM) DS.

METHODS

We developed a survey instrument to capture current and ever use of specific NVNM DS, VM DS, and RA pharmaceuticals, with 696 subjects self-reporting an RA diagnosis recruited online or in clinic for survey participation. Analyses were limited to 611 subjects reporting RA diagnosis after age 18 y and treatment with specific RA pharmaceuticals.

RESULTS

Most participants reported DS use, with current usage prevalence 49.6% (n = 303), 83.5% (n = 510), or 87.6% (n = 535) for NVNM, VM, or any DS, respectively. While not having appeared in previous RA surveys, turmeric and ginger were among the top 3 NVNM DS in current use, along with fish oil/ω-3 (n-3) PUFA. Concurrent NVNM DS use was reported by 48.2% (n = 243) of participants currently using RA pharmaceuticals (n = 504) and was more common in those using disease-modifying antirheumatic drugs only (no biologics). Most methotrexate users (83%) reported concurrent folate supplementation, with one-third also using turmeric, which is notable because methotrexate and turmeric have been associated with hepatotoxicity.

CONCLUSION

Individuals with RA commonly use NVNM DS in combination with RA pharmaceuticals, including a previously undocumented but popular use of turmeric or ginger supplements with an unclear risk/benefit ratio.

Challenges and Opportunities for Clinical Pharmacogenetic Research Studies in Resource-limited Settings: Conclusions From the Council for International Organizations of Medical Sciences-Ibero-American Network of Pharmacogenetics and Pharmacogenomics Meeting

PURPOSE

The symposium Health and Medicines in Indigenous Populations of America was organized by the Council for International Organizations of Medical Sciences (CIOMS) Working Group on Clinical Research in Resource-Limited Settings (RLSs) and the Ibero-American Network of Pharmacogenetics and Pharmacogenomics (RIBEF). It was aimed to share and evaluate investigators' experiences on challenges and opportunities on clinical research and pharmacogenetics.

METHODS

A total of 33 members from 22 countries participated in 2 sessions: RIBEF studies on population pharmacogenetics about the relationship between ancestry with relevant drug-related genetic polymorphisms and the relationship between genotype and phenotype in Native Americans (session 1) and case examples of clinical studies in RLSs from Asia (cancer), America (diabetes and women health), and Africa (malaria) in which the participants were asked to answer in free text their experiences on challenges and opportunities to solve the problems (session 2). Later, a discourse analysis grouping common themes by affinity was conducted.

FINDINGS

The main result of session 1 was that the pharmacogenetics-related ancestry of the population should be considered when designing clinical studies in RLSs. In session 2, 21 challenges and 20 opportunities were identified. The social aspects represent the largest proportion of the challenges (43%) and opportunities (55%), and some of them seem to be common.

IMPLICATIONS

The main discussion points were gathered in the Declaration of Mérida/T'Hó and announced on the Parliament of Extremadura during the CIOMS-RIBEF meeting in 4 of the major Latin American autochthonous languages (Náhualth, Mayan, Miskito, and Kichwa). The declaration highlighted the following: (1) the relevance of population pharmacogenetics, (2) the sociocultural contexts (interaction with traditional medicine), and (3) the education needs of research teams for clinical research in vulnerable and autochthonous populations.

Complementary and alternative medicine use in coronary heart disease patients: a cross-sectional study from Palestine

BACKGROUND

There is a lack of data on the use of complementary and alternative medicine (CAM) in patients with coronary heart disease (CHD). This study examined the use of CAM among patients with CHD, the reasons and factors influencing their use, the types of CAM used, and the relationship between patient's demographics and the use of CAM.

METHODS

In order to determine the prevalence and usage of CAM among Palestinian patients with CHD, a cross-sectional descriptive study was performed from three different hospitals. Using a convenient sampling method, a questionnaire was completed in a face-to-face interview with the patients. Descriptive statistics were used for socio-demographic, and clinical variables. Siahpush scale was used to examine the attitude of CHD patients toward CAM use.

RESULTS

Of the 150 patients that were interviewed, 128 (85.3%) of the patients completed the questionnaire. The majority of CAM users reported CAM use for health problems other than CHD, while a total of 59 (45.9%) patients have used CAM for their heart problems. On the other hand, it was found that the place of residency and pattern of CHD were significantly associated with CAM use (p = 0.039 and 0.044, respectively). In addition, religious practices were found to be the most common form of CAM used by patients, while body and traditional alternative methods were the least being used. A significant association between the attitudes of patients with CHD and their use of CAM was found (patients' attitudes towards alternative medicine and natural remedies were p = 0.011 and 0.044, respectively).

CONCLUSIONS

CAM use among our respondents is common. Despite a lack of evidence-based research supporting its potential benefits and side effects. Understanding the factors that affect CAM use by CHD patients offers healthcare workers and policymakers an opportunity to better understand CAM use and ultimately improve patient-physician interactions.

The Perceived Credibility of Complementary and Alternative Medicine: A Survey of Undergraduate and Graduate Students

The popularity of complementary and alternative medicine (CAM) appears to be increasing, especially among college students. We surveyed 146 undergraduate and graduate students with the CAM Health Belief Questionnaire and obtained credibility and frequency ratings for a select group of CAM therapies: yoga, meditation, massage, chiropractic medicine, biofeedback, hypnosis, acupuncture, spirituality/religion, therapeutic touch, the use of herbs/vitamins, and aromatherapy/essential oils. Graduate students held more favorable views about integrating CAM into conventional medical practice. Female students reported using a wider variety of therapies than male students. Spirituality/religion and herbs/vitamins were the most popular CAM approaches. Students rated yoga, meditation, and massage as being highly credible practices. They rated hypnosis and therapeutic touch low in credibility. We discuss hypnosis as an example of a therapy that suffers from poor public perception despite having a relatively strong evidentiary base.

Use of natural medicine and dietary supplements concomitant with conventional medicine among people with Multiple Sclerosis

BACKGROUND

The use of complementary and alternative medicine (CAM) are widespread among people with Multiple Sclerosis (PwMS) and are often used concomitant with conventional treatment. Natural medicine and dietary supplements (NADS) are the most frequently used CAM modality and among other patient groups use of NADS concomitant with conventional medicine has been reported as a potential risk to patients' safety due to risk of drug interactions. The use of NADS concomitant with conventional medicine has, however, not been investigated among PwMS. This study's aim was to investigate the prevalence of NADS and conventional MS-related medicine use among PwMS, specific types of NADS and conventional MS-related medicine used, the prevalence of NADS used concomitant with conventional MS-related medicine, and to characterize PwMS who use NADS and PwMS who use NADS concomitant with conventional MS-related medicine in a Danish context.

METHODS

The study was a cross-sectional study conducted as an interviewer-administered survey via phone in April 2019. The questionnaire includes questions about the use of NADS and conventional MS medicine as well as sociodemographic and health-related factors. In total 384 PwMS answered the questionnaire. Both descriptive and logistic analyses were used to analyze the data.

RESULTS

The results show that the majority of PwMS use conventional MS-related medicine. In total, 85 % (n=322) had used at least one NADS within the last 12 months including vitamin D. When excluding vitamin D, the use of NADS within the last 12 months was 78.4% (n=298). Beside vitamin D the most reported types of NADS used were fatty acids (37%), Multivitamins (37%), and Calcium (35%). A total of 75.8% (n=288) reported using NADS concomitant with conventional MS medicine, and the products most often combined with conventional MS medicine were Vitamin D, Multivitamin, Calcium, Magnesium, and fatty acids. The results suggest that PwMS using NADS concomitant with conventional MS-related medicine are characterized by a high prevalence of young and newly diagnosed patients with a high education level.

CONCLUSION

The study contributes to a better understanding of NADS used among PwMS. The study shows that the majority of PwMS use NADS and that they use it concomitant with conventional MS-medicine. Furthermore, the detailed mapping of the specific types of NADS used gives a nuanced insight into the specific products of NADS used among PwMS, including different kinds of vitamins, minerals, and herbal remedies.

Inhibitory Effect of Lygodium Root on the Cytochrome P450 3A Enzyme in vitro and in vivo

Purpose

The aim of the present study was to investigate the interactions of the main components of Lygodium root (ie, p-coumaric acid, acacetin, apigenin, buddleoside and Diosmetin-7-O-β-D-glucopyranoside) with cytochrome P450 3A enzyme activity both in vitro and in vivo.

Methods

In vitro inhibition of drugs was assessed by incubating rat liver microsomes (RLMs) with a typical P450 3A enzyme substrate, midazolam, to determine their 50% inhibitory concentration (IC50) values. For the in vivo study, healthy male Sprague Dawley rats were consecutively administered acacetin or apigenin for 7 days at the dosage of 5 mg/kg after being randomly divided into 3 groups: Group A (control group), Group B (acacetin group) and Group C (apigenin group).

Results

Among the five main components of Lygodium root, only acacetin and apigenin showed inhibitory effects on the cytochrome P450 3A enzyme in vitro. The IC50 values of acacetin and apigenin were 58.46 μM and 8.20 μM, respectively. Additionally, the in vivo analysis results revealed that acacetin and apigenin could systemically inhibit midazolam metabolism in rats. The T_max, AUC_(0-t) and C_max of midazolam in group B and group C were significantly increased (P<0.05), accompanied by a significant decrease in V_z/F and CL_z/F (P<0.05).

Conclusion

Acacetin and apigenin could inhibit the activity of the cytochrome P450 3A enzyme in vitro and in vivo, indicating that herbal drug interactions might occur when taking Lygodium root and midazolam synchronously.

Do the Natural Chemical Compounds Interact with the Same Targets of Current Pharmacotherapy for Weight Management?-A Review

BACKGROUND

Obesity has become a worldwide health concern. Pharmacotherapies are now being introduced because lifestyle modifications alone are insufficient for weight management. The treatment outcomes of current approved anti-obesity agents are not satisfying due to drug-related intolerances. And so natural therapies including herbal medicines are popular alternatives for weight reduction; however, there are limited studies about their mechanism of actions.

METHODS

Five databases (PubMed, Scopus, Google Scholar, Science Direct, Proquest) were searched to investigate the targets and safety profiles of the current and past anti-obesity drugs that have been approved by the Food and Drug Administration (FDA) or the European Medicines Agency (EMA) as well as the commonly used off-label agents. The targets for weight-loss natural products and their principle bioactive components have also been searched. Only articles in English were included.

RESULTS

The targets for current anti-obesity single agents include pancreatic lipase, Glucagon Like Peptide-1(GLP-1) receptor, and serotonin 2C (5-HT2C) receptor. Potential targets such as amylin, pancreatic alpha amylase, leptin receptor, melanocortin receptor 4 receptor (MC4R), Peroxisome Proliferator- Activated Receptors gamma (PPAR γ), endocannabinoid 1 (CB1) receptor and Adenosine Monophosphate (AMP)-Activated Protein Kinase (AMPK) were discussed in various studies. Natural compounds have been found to interact with targets like pancreatic lipase, pancreatic alpha amylase, AMPK and PPAR γ to achieve weight reduction.

CONCLUSION

Current pharmacotherapies and natural chemical compounds do act on same targets. Further investigations on the interactions between herbal compounds and the above targets are essential for the development of novel weight-loss therapies.

Herbal Medicine for Cardiovascular Diseases: Efficacy, Mechanisms, and Safety

Cardiovascular diseases (CVDs) are a significant health burden with an ever-increasing prevalence. They remain the leading causes of morbidity and mortality worldwide. The use of medicinal herbs continues to be an alternative treatment approach for several diseases including CVDs. Currently, there is an unprecedented drive for the use of herbal preparations in modern medicinal systems. This drive is powered by several aspects, prime among which are their cost-effective therapeutic promise compared to standard modern therapies and the general belief that they are safe. Nonetheless, the claimed safety of herbal preparations yet remains to be properly tested. Consequently, public awareness should be raised regarding medicinal herbs safety, toxicity, potentially life-threatening adverse effects, and possible herb–drug interactions. Over the years, laboratory data have shown that medicinal herbs may have therapeutic value in CVDs as they can interfere with several CVD risk factors. Accordingly, there have been many attempts to move studies on medicinal herbs from the bench to the bedside, in order to effectively employ herbs in CVD treatments. In this review, we introduce CVDs and their risk factors. Then we overview the use of herbs for disease treatment in general and CVDs in particular. Further, data on the ethnopharmacological therapeutic potentials and medicinal properties against CVDs of four widely used plants, namely Ginseng, Ginkgo biloba, Ganoderma lucidum, and Gynostemma pentaphyllum, are gathered and reviewed. In particular, the employment of these four plants in the context of CVDs, such as myocardial infarction, hypertension, peripheral vascular diseases, coronary heart disease, cardiomyopathies, and dyslipidemias has been reviewed, analyzed, and critically discussed. We also endeavor to document the recent studies aimed to dissect the cellular and molecular cardio-protective mechanisms of the four plants, using recently reported in vitro and in vivo studies. Finally, we reviewed and reported the results of the recent clinical trials that have been conducted using these four medicinal herbs with special emphasis on their efficacy, safety, and toxicity.

A Systematic Review of the Effect of Dietary Supplements on Cognitive Performance in Healthy Young Adults and Military Personnel

Intake of dietary supplements has increased, despite evidence that some of these have adverse side effects and uncertainty about their effectiveness. This systematic review examined the evidence for the cognitive benefits of a wide range of dietary supplements in healthy young adult samples; the aim was to identify if any might be useful for optimising cognitive performance during deployment in military personnel. Searches were conducted in 9 databases and 13 grey literature repositories for relevant studies published between January 2000 and June 2017. Eligible studies recruited healthy young adults (18-35 years), administered a legal dietary supplement, included a comparison control group, and assessed cognitive outcome(s). Thirty-seven of 394 identified studies met inclusion criteria and were included for synthesis. Most research was deemed of low quality (72.97%; SIGN50 guidelines), highlighting the need for sound empirical research in this area. Nonetheless, we suggest that tyrosine or caffeine could be used in healthy young adults in a military context to enhance cognitive performance when personnel are sleep-deprived. Caffeine also has the potential benefit of improving vigilance and attention during sustained operations offering little opportunity for sleep. Inconsistent findings and methodological limitations preclude firm recommendations about the use of other specific dietary supplements.

Herbal Medicinal Product Use During Pregnancy and the Postnatal Period: A Systematic Review

Synthesis of pooled data on herbal medicinal products used during and after pregnancy highlights the need for robust safety studies.

OBJECTIVE:

To report the incidence and nature of herbal medicinal products' adverse events and herb–drug interactions used by some pregnant and postnatal women.

DATA SOURCES:

The Allied and Complementary Medicine Database, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, the Cochrane Library, MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov were searched from inception until August 2018.

METHODS OF STUDY SELECTION:

Any studies reporting adverse events, herb–drug interactions or absence thereof associated with herbal medicinal products used during pregnancy or the postnatal period were included. Conference abstracts, pilot studies, and nonhuman studies were excluded. All included studies were critically appraised by two independent reviewers.

TABULATION, INTEGRATION AND RESULTS:

Database searches retrieved 3,487 citations. After duplicate removal and review of titles, abstracts, and full-text, 115 articles were critically appraised. After excluding irrelevant and low-quality articles, 74 articles were included for data extraction and synthesis. Adverse drug reactions, congenital malformations, fetal growth retardation or herb–drug interactions were the primary study objective reported by 19 of the 74 included studies, 16 cohort studies, one cross-sectional survey, and two randomized controlled trials. A total of 47 herbal medicinal products and 1,067,071 women were included in this review. Use of almond oil was associated with preterm birth (odds ratio 2.09, 95% CI 1.07–4.08), oral raspberry leaf was associated with cesarean delivery (adjusted odds ratio [AOR] 3.47, 95% CI 1.45–8.28); heavy licorice use was associated with early preterm birth by 3.07-fold (95% CI 1.17–8.05). African herbal medicine mwanaphepo was associated with maternal morbidity (AOR 1.28; 95% CI 1.09–1.50), and neonatal death or morbidity. Fourteen studies reported absence of adverse events. Four studies reported herb–drug interactions, but none studied adverse events arising from them.

CONCLUSION:

The use of herbal medicinal products during pregnancy and the postnatal period should be discouraged until robust evidence of safety is available.

SYSTEMATIC REVIEW REGISTRATION:

PROSPERO, CRD42017081058.

Evaluation of potential herbal-drug interactions of a standardized propolis extract (EPP-AF®) using an in vivo cocktail approach

ETHNOPHARMACOLOGICAL RELEVANCE

Propolis has been employed extensively in many cultures since ancient times as antiseptic, wound healing, anti-pyretic and others due to its biological and pharmacological properties, such as immunomodulatory, antitumor, anti-inflammatory, antioxidant, antibacterial, antiviral, antifungal, antiparasite activities. But despite its broad and traditional use, there is little knowledge about its potential interaction with prescription drugs.

AIM OF THE STUDY

The main objective of this work was to study the potential herbal-drug interactions (HDIs) of EPP-AF® using an in vivo assay with a cocktail approach.

MATERIALS AND METHODS

Subtherapeutic doses of caffeine, losartan, omeprazole, metoprolol, midazolam and fexofenadine were used. Sixteen healthy adult volunteers were investigated before and after exposure to orally administered 125 mg/8 h (375 mg/day) EPP-AF® for 15 days. Pharmacokinetic parameters were calculated based on plasma concentration versus time (AUC) curves.

RESULTS

After exposure to EPP-AF®, it was observed decrease in the AUC^0-∞ of fexofenadine, caffeine and losartan of approximately 18% (62.20 × 51.00 h.ng/mL), 8% (1085 × 999 h.ng/mL) and 13% (9.01 × 7.86 h.ng/mL), respectively, with all 90% CIs within the equivalence range of 0.80-1.25. On the other hand, omeprazole and midazolam exhibited an increase in AUC^0-∞ of, respectively, approximately 18% (18.90 × 22.30 h.ng/mL) and 14% (1.25 × 1.43 h.ng/mL), with the upper bounds of 90% CIs slightly above 1.25. Changes in pharmacokinetics of metoprolol or its metabolite α-hydroxymetoprolol were not statistically significant and their 90% CIs were within the equivalence range of 0.80-1.25.

CONCLUSIONS

In conclusion, our study shows that EPP-AF® does not clinically change CYP1A2, CYP2C9, CYP2C19, CYP2D6 and CYP3A activities, once, despite statistical significant, the magnitude of the changes in AUC values after EPP-AF® were all below 20% and therefore may be considered safe regarding potential interactions involving these enzymes. Besides, to the best of our knowledge this is the first study to assess potential HDIs with propolis.

Regulation of P-glycoprotein by Bajijiasu in vitro and in vivo by activating the Nrf2-mediated signalling pathway

CONTEXT

Bajijiasu (BJJS), a main bioactive compound from Morinda officinalis F.C. How. (Rubiaceae), is widely administered concomitantly with other drugs for treating male impotence, female infertility, fatigue, chronic rheumatism, depression, etc. Objective: This study investigates the regulation of P-glycoprotein (P-gp) by BJJS in vitro and in vivo.

MATERIAL AND METHODS

HepG2 cells were incubated with BJJS (10, 20 or 40 μM) for 48 h. C57 mice were orally treated with BJJS (25, 50 or 100 mg/kg) for 2 weeks. The protein and mRNA levels of P-gp were measured by using Western blot and real-time PCR, respectively. siNrf2 RNA was used to explore the mediation effects of Nrf2 on the P-gp expression. The efflux activity of P-gp was tested via a flow cytometry.

RESULTS

Incubation of HepG2 cells with BJJS at 10, 20, and 40 μM up-regulated the P-gp protein expression by 12.3%, 82.9%, and 134.3%, respectively. Treatment of C57 mice with BJJS at 25, 50 and 100 mg/kg increased the P-gp protein expression by 49.3%, 75.8% and 106.0%, respectively. Incubation of the cells with BJJS at 10, 20 and 40 μM up-regulated the total Nrf2 protein levels by 34.3%, 93.1% and 118.6%, respectively, and also increased the nuclear Nrf2 protein levels by 14.8%, 44.4% and 59.25%, respectively. The total Nrf2 protein levels were increased by 46.3%, 66.5%, and 87.4%, respectively, in the mice exposed to BJJS at 25, 50, and 100 mg/kg. Inhibition of Nrf2 by siRNA diminished the P-gp induction by 25.0%, 33.4%, and 38.7%, respectively, in the cells. In addition, BJJS enhanced the efflux activity of P-gp by 9.6%, 37.1%, and 48.1%, respectively, in the cells.

CONCLUSIONS

BJJS activates Nrf2 to induce P-gp expression, and enhanced the efflux activity of P-gp. The possibility of potential herb-drug interactions when BJJS is co-administered with other P-gp substrate drugs should be carefully monitored.

Modulation of hepatic ABC transporters by Eruca vesicaria intake: Potential diet-drug interactions

The aim of this work was to evaluate whether oral administration of Eruca vesicaria, a species of rocket cultivated in Argentina, could modify cyclophosphamide (CP)-induced genotoxicity through modulation of hepatic ABC transporters. Daily oral administration of E. vesicaria fresh leaves juice (1.0, 1.4 and 2.0  g/kg) for 14 days did not alter genotoxicity biomarkers -alkaline comet assay and micronucleus test -in neither male nor female mice. Instead, repeated intake of this cruciferous decreased CP-induced DNA damage dose-dependently and it caused hepatic overexpression of P-glycoprotein (P-gp; 1.4 and 2.0  g/kg) and multidrug resistance protein 2 (MRP2; 2.0  g/kg), but not breast cancer resistance protein (Bcrp). The antigenotoxic effect of E. vesicaria was prevented by 50 mg/kg verapamil (P-gp inhibitor) or 10 mg/kg indomethacin (MRP2 inhibitor). In turn, CP-induced cytotoxicity (10 mM, 24 h) on human hepatoma cells (HepG2/C3A) was significantly reduced by preincubation with E. vesicaria (1.4 mg/ml; 48 h); this effect was absent when CP was coincubated with 35 μM verapamil, 80 μM indomethacin or 10 μM KO-143 (BCRP inhibitor). Altogether, these results allow us to demonstrate that repeated intake of E. vesicaria exhibited antigenotoxicity, at least in part, by induction of hepatic ABC transporters in vivo in mice as well as in vitro in human liver cells. This could account for other diet-drug interactions.

Dietary and Supplement-Based Complementary and Alternative Medicine Use in Pediatric Autism Spectrum Disorder

Previous literature has shown that complementary and alternative medicine (CAM) is steadily increasing in autism spectrum disorder (ASD). However, little data is currently available regarding its use, safety, and efficacy in children with ASD. Thus, the purpose of this study is to describe the use of supplement-based CAM therapies in children between the ages of 4 to 17 years with ASD. This population-based, cross-sectional study evaluated children with ASD regarding supplement use. A total of 210 participants were recruited from a variety of sources including educational and physical activity programs, and social media to complete a questionnaire. Primary caregivers provided information on current supplement based CAM use. Data evaluated the proportion of children that used supplement therapies, the types of supplements used, reasons for use, perceived safety, and demographic factors associated with use (e.g., income, parental education, severity of disorder). Seventy-five percent of children with ASD consumed supplements with multivitamins (77.8%), vitamin D (44.9%), omega 3 (42.5%), probiotics (36.5%), and magnesium (28.1%) as the most prevalent. Several supplements, such as adrenal cortex extract, where product safety has not yet been demonstrated, were also reported. A gluten free diet was the most common specialty diet followed amongst those with restrictions (14.8%). Health care professionals were the most frequent information source regarding supplements; however, 33% of parents reported not disclosing all their child’s supplements to their physician. In conclusion, the use of supplement therapies in children with ASD is endemic and highlights the need for further research concerning public health education surrounding safety and efficacy.

Traditional Medicine and Its Role in the Management of Diabetes Mellitus: "Patients' and Herbalists' Perspectives"

BACKGROUND

Diabetes mellitus is a complicated health condition with multiple causes and many treatment options. Various myths may influence diabetics' health-seeking behavior, and they may use traditional medicines, which include normal foods and herbs, for primary health care. The aim of this study was to determine patients' and herbalists' practices and perspectives regarding the use of traditional medicines and the role of traditional medicines in the management of diabetes.

METHODS AND FINDINGS

We conducted a cross-sectional study with a mixed-methods design. We interviewed 140 patients attending diabetic clinics using a structured questionnaire, conducted focus group discussions with an additional 20 diabetic patients, and conducted in-depth interviews with 8 local herbalists. The majority of the diabetic participants believed that diabetes is caused by a high-carbohydrate diet. Of the 140 participants who answered the questionnaire, 67.2% reported using traditional medicines to manage their diabetes, including 58.6% who reported using both conventional medicines and traditional medicines. Some participants believed that combining conventional and traditional medicines improved the effectiveness of treatment. Reasons given for using traditional medicines included the high cost of conventional treatment and the availability and accessibility of the traditional medicines. The most commonly used traditional medicines were indigenous vegetables and medicinal plant products including amalanth leaves, hare lettuce leaves, nightshade leaves, spider plant leaves, okra pods, moringa leaves and seeds, soursop leaves, black plum back, avocado seed, and lemongrass.

CONCLUSION

Patients and herbalists provided a range of perspectives regarding the use of traditional medicines to treat diabetes. Further research is needed to identify bioactive compounds present in commonly used traditional medicines and their efficacy.

Association between complementary and alternative medicine use and prolonged time to conventional treatment among Thai cancer patients in a tertiary-care hospital

Objectives

The purpose of this study is to investigate the patterns of complementary and alternative medicine use and its association with time to conventional treatment.

Design

A cross-sectional study design was designed.

Setting and participants

The study was performed at the Chonburi Cancer Hospital, with chart reviews and interviews performed for 426 patients with various cancers between May and December 2018.

Results

The results indicated that 192 of the 426 patients (45.1%) reported using complementary and alternative medicines; herbal products were the most common type. Approximately 34.3% of these medicines involved unlabeled herbal products with unidentifiable components. The rates of complementary and alternative medicine use were significantly elevated for men and patients with stage IV cancer. The multivariable linear regression analysis of the relationship between factors and the time until conventional treatment was received revealed that the regression coefficient of the use of complementary and alternative medicine was 56.3 (95% confidence interval [27.9-84.6]). This coefficient reflected an additional 56.3 days of time until conventional treatment, relative to patients who did not use complementary and alternative medicine.

Conclusions

The present study revealed that complementary and alternative medicine use was fairly common among Thai patients with cancer and was associated with a prolonged time to receiving conventional treatment.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Drug-drug interactions and clinical considerations with co-administration of antiretrovirals and psychotropic drugs

Psychotropic medications are frequently co-prescribed with antiretroviral therapy (ART), owing to a high prevalence of psychiatric illness within the population living with HIV, as well as a 7-fold increased risk of HIV infection among patients with psychiatric illness. While ART has been notoriously associated with a multitude of pharmacokinetic drug interactions involving the cytochrome P450 enzyme system, the magnitude and clinical impact of these interactions with psychotropics may range from negligible effects on plasma concentrations to life-threatening torsades de pointes or respiratory depression. This comprehensive review summarizes the currently available information regarding drug-drug interactions between antiretrovirals and pharmacologic agents utilized in the treatment of psychiatric disorders-antidepressants, stimulants, antipsychotics, anxiolytics, mood stabilizers, and treatments for opioid use disorder and alcohol use disorder-and provides recommendations for their management. Additionally, overlapping toxicities between antiretrovirals and the psychotropic classes are highlighted. Knowledge of the interaction and adverse effect potential of specific antiretrovirals and psychotropics will allow clinicians to make informed prescribing decisions to better promote the health and wellness of this high-risk population.

Interaction between phytotherapy and oral anticancer agents: prospective study and literature review

Cancer is becoming more prevalent in elderly patient. Due to polypharmacy, older adults with cancer are predisposed to drug-drug interactions. There is also an increasing interest in the use of complementary and alternative medicine (CAM). Thirty to seventy percent of patients with cancer have used CAM. Through pharmaceutical counseling sessions, we can provide advices on herb-drug interactions (HDI). All the patients seen in pharmaceutical counseling sessions were prospectively included. Information was collected during these sessions: prescribed medication (oral anticancer agents (OAA) and other drugs), CAM (phytotherapy especially), and use of over-the-counter (OTC) drugs. If pharmacist considered an interaction or an intervention clinically relevant, the oncologist was notified. Then, a literature review was realized to identify the potential HDI (no interactions, precautions for use, contraindication). Among 201 pharmacist counseling sessions, it resulted in 104 interventions related to 46 HDI, 28 drug-drug interactions and 30 others (wrong dosage, omission…). To determine HDI, we review 73 medicinal plants which are used by our patients with cancer and 31 OAA. A total of 1829 recommendations were formulated about 59 (75%) medical plants and their interaction with an OAA. Herb-drug interactions should not be ignored by healthcare providers in their management of cancer patients in daily practice.

What has been the impact of the Traditional Herbal Registration (THR) scheme in the UK on information provided with herbal products bought over the counter?

BACKGROUND

In 2011 there was a strengthening of European Union (EU) legislation on the licencing of herbal products which, in the UK, resulted in the introduction of the Traditional Herbal Registration (THR) scheme. This scheme sets out standards for the safety and quality of herbal medicines and includes the provision of information to the customer on the safe use of the product. The aim of this study is to replicate a survey undertaken in 2011, prior to the implementation of the THR scheme, and evaluate the impact of this scheme on the information provided with herbal products bought over-the-counter.

METHODS

We undertook a survey on 5 herbal products commonly available over-the-counter (St John's wort, echinacea, Ginkgo biloba, Asian ginseng, garlic). The information was searched for key safety messages identified by the National Center for Complementary and Integrative Health (NCCIH). We also explored the presence of risk of harm information.

RESULTS

We recorded a rise in the number of products registered with the THR scheme (37% in 2016 compared to 7% in 2011). We also identified a reduction in the number of products that did not contain key safety information (75% in 2011 compared to 20% of products obtained in 2016). Risk of harm information was only communicated in products containing a PIL. We identified more products containing frequency of risk of harm information but this was not statistically significant.

CONCLUSION

The introduction of the THR scheme appears to be associated with an increase in the provision of information about key safety messages on the safe use of herbal products. However, it is important to note that at least half of the products on the market that are not included in the THR scheme do not contain any information about their safe use; this includes information about precautions, interactions and side effects. The use of NCCIH herbal monographs replicated the methods used in the previous study; we recognise that the use of a different resource might effect the appraisal of the information provided. We also acknowledge that surveying presence of information does not assure that the latter is effectively communicated to patients, for which a close textual analysis would be required. While it is promising that more information is available after the introduction of the THR scheme, the public needs to be informed about ways to optimise safe use of all herbal products.

Systematic review of published data on herb induced liver injury

ETHNOPHARMACOLOGICAL RELEVANCE

Herbal products have been widely used as a means of ethnomedicine worldwide. Recently, the potential hepatotoxicity of herbs has become a medical issue but comprehensive studies are limited.

AIM OF THE STUDY

This study aims to determine the clinical features of herb induced liver injury (HILI) including its constituent ratio among liver injury case cohorts that included both HILI and drug induced liver injury (DILI).

MATERIALS AND METHODS

A systematic review was conducted using a literature search for DILI/HILI in seven electric databases including PubMed, Cochrane and Embase. We analyzed the DILI/HILI cases and clinical characteristics in terms of herbs, conventional drugs, concomitant, or others.

RESULTS

Thirty-one studies met the necessary criteria and included 9 prospective and 22 retrospective studies. Among total number of overall DILI/HILI cases (7511, male 2819, female 3669 and unknown 1023), 25.0% (1874 cases) were implicated in herbs. HILI was relatively higher in females (69.8% vs. 30.2% male), compared to conventional drugs (57.3% female vs. 42.7% male, p < 0.01), while it was prone to induce hepatocellular injury (hepatocellular 78.8%, cholestatic 8.9%, mixed type 12.3%), contrary to conventional drugs (hepatocellular 56.7% vs. cholestatic 22.1% vs. mixed 21.2%), respectively (p < 0.01). The main herbs causing HILI included Polygonum multiflorum, Psoralea corylifolia, Corydalis yanhusuo, and Rheum officinale.

CONCLUSIONS

This review created the comparative and comprehensive feature of hepatotoxicity by herbal products, which provides reference data for the clinical applications and establishing pharmacovigilance system of herbs.

Potential Influence of Centrally Acting Herbal Drugs on Transporters at the Blood-Cerebrospinal Fluid Barrier and Blood-Brain Barrier

Complementary and alternative medications (CAM) with known or suspected pharmacologic activity in the central nervous system (CNS) are common. These herbal preparations may cause clinically significant drug-drug interactions (DDIs) when coadministered with medications that act in the CNS. This can result in negative outcomes such as toxicity or loss of efficacy. Most drug interaction reports with CAM focus on cytochrome P450 (CYP) modulation. However, drug interactions between CAM and conventional medications may occur via mechanisms other than CYP inhibition or induction; in particular, modulation of drug transport proteins represents an important mechanism by which such interactions may occur. This article provides an updated review of transporter-mediated mechanisms by which herbal products may theoretically interact with centrally acting medications at the blood-brain barrier and blood-cerebrospinal fluid (CSF) barrier. Further research is required before the true clinical impact of interactions involving modulation of centrally located membrane transporters can be fully understood.

Understanding the relevance of herb-drug interaction studies with special focus on interplays: a prerequisite for integrative medicine

Integrative medicine refers to the blending of conventional and evidence-based complementary medicines and therapies with the aim of using the most appropriate of either or both modalities for ultimate patient benefits. One of the major hurdles for the same is the chances of potential herb–drug interactions (HDIs). These HDIs could be beneficial or harmful, or even fatal; therefore, a thorough understanding of the eventualities of HDIs is essential so that a successful integration of the modern and complementary alternative systems of medicine could be achieved. Here, we summarize all the important points related to HDIs, including types, tools/methods for study, and prediction of the HDIs, along with a special focus on interplays between drug metabolizing enzymes and transporters. In addition, this article covers future perspective, with a focus on background endogenous players of interplays and approaches to predict the drug–disease–herb interactions so as to fetch the desired effects of these interactions.

Influences of Corydalis decumbens on the Activities of CYP450 Enzymes in Rats with a Cocktail Approach

Corydalis decumbens, a Traditional Chinese Medicine, has been widely used for the alternative and/or complementary therapy of hypertension, arrhythmias rheumatoid arthritis, sciatica, stroke, hemiplegia, paraplegia, and vascular embolism. The aim of this study was to determinate the potential effects of Corydalis decumbens on the five cytochrome P450 (CYP) enzyme activities (CYP1A2, CYP3A4, CYP2C9, CYP2C19, and CYP2D6) by cocktail approach. To evaluate whether concurrent use of Corydalis decumbens interferes with the effect of several prescription drugs, saline (control group) or Corydalis decumbens (XTW group) were administrated via gavage for 7 successive days. A probe cocktail solution (phenacetin, omeprazole, metoprolol, tolbutamide, and midazolam) was given 24 h after the last dose of saline or Corydalis decumbens. A specific and sensitive UHPLC–MS/MS method was validated for the determination of five substrates and their metabolites in control group and XTW group. Our results indicated that Corydalis decumbens could have inductive effects of CYP2C19 and inhibit the activities of CYP1A2 and CYP3A4. However, Corydalis decumbens had no significant influence on CYP2C9 and CYP2D6. The herb-drug interaction should require more attention by careful monitoring and appropriate drug dosing adjustments to the concurrent use of western medications which were metabolized by CYP1A2, CYP2C19, and CYP3A4 in human—Corydalis decumbens, Cytochrome P450, Cocktail, Pharmacokinetics, herb–drug interactions.

Pregnant women's use and attitude toward herbal, vitamin, and mineral supplements in an academic tertiary care center, Riyadh, Saudi Arabia

BACKGROUND

Herbal medicine has been widely utilized by pregnant women despite the limited available evidence regarding the safety and efficacy of that practice. The current available studies, from different countries, estimated that the use of herbal medicine during pregnancy range from 7% up to 96%. The aim of this study is to determine the prevalence, attitude, source of information, and reasoning behind the use of herbal medicine among pregnant women in Saudia Arabia.

METHODS

A cross-sectional study conducted using a convenience sample including pregnant women who visited the obstetric clinics at King Abdulaziz Medical City in Riyadh, Saudi Arabia. A survey was administered in order to evaluate the prevalence and perception toward herbal medicine use among pregnant women in Saudi Arabia.

RESULTS

A total of 297 pregnant women completed the survey. The results showed that 56% of the respondents have used some type of herbal medicine during their pregnancy. Olive oil was utilized in 26% of the respondents followed by cumin 20% and garlic 15%. In addition, 37% of the respondents used herbal medicine by their own initiative, while 33% and 12% used herbal medicine based on recommendations from their families and friends, respectively. Furthermore, 19% of the respondents reported a positive attitude toward herbal medicine use during pregnancy. In addition, the percentage of women with positive attitude was marginally higher among respondents with lower educational level.

CONCLUSION

The prevalence of using herbal medicine is considerably high among pregnant women in Saudi Arabia. Unfortunately, the majority of the users relied on informal sources to use herbal medicine during pregnancy.

Clinical Use of Digitalis: A State of the Art Review

The history of digitalis is rich and interesting, with the first use usually attributed to William Withering and his study on the foxglove published in 1785. However, some knowledge of plants with digitalis-like effects used for congestive heart failure (CHF) was in evidence as early as Roman times. The active components of the foxglove (Digitalis purpurea and Digitalis lanata) are classified as cardiac glycosides or cardiotonic steroids and include the well-known digitalis leaf, digitoxin, and digoxin; ouabain is a rapid-acting glycoside usually obtained from Strophanthus gratus. These drugs are potent inhibitors of cellular membrane sodium-potassium adenosine triphosphatase (Na⁺/K⁺-ATPase). For most of the twentieth century, digitalis and its derivatives, especially digoxin, were the available standard of care for CHF. However, as the century closed, many doubts, especially regarding safety, were raised about their use as other treatments for CHF, such as decreasing the preload of the left ventricle, were developed. Careful attention is needed to maintain the serum digoxin level at ≤ 1.0 ng/ml because of the very narrow therapeutic window of the medication. Evidence for benefit exists for CHF with reduced ejection fraction (EF), also referred to as heart failure with reduced EF (HFrEF), especially when considering the combination of mortality, morbidity, and decreased hospitalizations. However, the major support for using digoxin is in atrial fibrillation (AF) with a rapid ventricular response when a rate control approach is planned. The strongest support of all for digoxin is for its use in rate control in AF in the presence of a marginal blood pressure, since all other rate control medications contribute to additional hypotension. In summary, these days, digoxin appears to be of most use in HFrEF and in AF with rapid ventricular response for rate control, especially when associated with hypotension. The valuable history of the foxglove continues; it has been modified but not relegated to the garden or the medical history book, as some would advocate.

Effects of Common CYP1A2 Genotypes and Other Key Factors on Intraindividual Variation in the Caffeine Metabolic Ratio: An Exploratory Analysis

The caffeine metabolic ratio is an established marker for cytochrome P450 (CYP) 1A2 activity. Optimal sample size calculation for clinical pharmacokinetic xenobiotic–caffeine interaction studies requires robust estimates of interindividual and intraindividual variation in this ratio. Compared with interindividual variation, factors contributing to intraindividual variation are less defined. An exploratory analysis involving healthy nonsmoking non‐naïve caffeine drinkers (1–3 cups/day; 12 men, 12 women) administered caffeine (160 mg) on five occasions evaluated the effects of CYP1A2 induction status (based on genotype) and other factors on intraindividual variation in CYP1A2 activity. Results were compared with those from previous studies. Regardless of whether a hyperinducer (CYP1A2*1A/*1F or CYP1A2*1F/*1F) or normal metabolizer (CYP1A2*1A/*1A,CYP1A2*1C/*1F, or CYP1A2*1C*1F/*1C*1F), sex, age, oral contraceptive use by women, and smoking status, intraindividual variation was ≤30%. A value of 30% is proposed for optimal design of pharmacokinetic xenobiotic–caffeine interaction studies. Prospective studies are needed for confirmation.

Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review

Background

The WHO estimates that a considerable number of people in Sub-Saharan Africa (SSA) rely on traditional, complementary and alternative medicine (TCAM) to meet their primary healthcare needs, yet there remains a dearth of research evidence on the overall picture of TCAM utilisation in the region.

Methods

We conducted a literature search of original articles examining TCAM use in SSA between 1 January 2006 and 28 February 2017, employing Medline, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Scopus, ProQuest, PubMed, Embase and African Journals Online databases. A critical appraisal of relevant articles reporting a quantitative or mixed-method design was undertaken.

Results

Despite the heterogeneity and general low quality of the identified literature, the review highlights a relatively high use of TCAM alone or in combination with orthodox medicine, in both general population and in specific health conditions in SSA. TCAM users compared with non-TCAM users are more likely to be of low socioeconomic and educational status, while there were inconsistencies in age, sex, spatial location and religious affiliation between TCAM users and non-TCAM users. Most TCAM users (55.8%–100%) in SSA fail to disclose TCAM use to their healthcare providers, with the main reasons for non-disclosure being fear of receiving improper care, healthcare providers’ negative attitude and a lack of enquiry about TCAM use from healthcare providers.

Conclusion

TCAM use in SSA is significant, although most studies emerge from a few countries. Factors associated with TCAM use in SSA are similar to those observed in other regions, but further research may be required to further elucidate challenges and opportunities related to TCAM use specific to SSA.

Traditional medicines and alternative practice in the management of prostate diseases in southern Ghana

Objective

This study was aimed at identifying Ghanaian traditional medicines used for the management of prostate diseases and their constituents. Reviews of studies conducted on them are also presented.

Methodology

This was a prospective study. Traditional Medicine samples from consecutive patients with either lower urinary symptoms (LUTS) presenting at the Urology Unit of the Korle Bu Teaching Hospital (KBTH) in Accra from January 2015 to June 2016 and had a prior treatment with traditional medicines, had the samples retrieved. Additionally, all the 58 licensed pharmaceutical shops in Okaishie, a whole sale and retail depot for medicines in the main business district of Accra, were visited and traditional medicines for the management of prostate diseases acquired. The products constituent as labeled were documented and entered once on a proforma. This study was part of a study on the management of benign prostate hyperplasia at the KBTH approved by the Medical Directorate.The findings were analyzed and presented using descriptive statistics and presented as a table.

Results

Eleven products were identified with the main indigenous medicinal plant identified being the root extract of Croton membranaceus. This was the constituent in four products (Uro 500^®, UR-Quick mixture^®, Prostacure® and prostat®60). Although studies on the basic pharmacology and animal studies have confirmed its effect on the prostate, only one clinical study was identified.

Conclusion

Croton membranaceus was the indigenous traditional medicine identified for relieving LUTS due to prostate disease. There is the need for empirical evidence on its efficacy in treating Prostate cancer.

Funding

Not declared.

Complementary Medicine Use, Symptom Burden and Non-Adherence in Kidney Transplant Recipients

BACKGROUND

Complementary Medicine (CAM) is often used by patients with chronic illness and may not be disclosed to health care providers without prompting. In other populations, patients who use CAM were more likely to alter medications without discussing it with their provider. This study examined the relationship between self-reported use of CAM, attitudes toward care, and adherence to medical therapy in a population of inner-City kidney transplant recipients.

METHODS

Cross-sectional observational analysis in a random convenience sample from the outpatient transplant clinic. Data were obtained via face-to-face structured closed-ended interview using validated survey instruments.

RESULTS

45% of patients reported using CAM. Of the study participants who used CAM, 39.1% reported non-adherence to immunosuppressant medications within the past three months, while among the non-CAM users, 17.9% reported non-adherence (p value=0.084). Adherence to hypoglycemic medication was significantly lower CAM users,(p=0.029). Patients who reported having somatic symptoms were more likely to use CAM. Symptom sum was significantly associated with CAM use, p=0.030, with 47.8% CAM users reporting skin problems vs. 10.7% non-CAM users,p=0.003 and 17.4% CAM users noting loss of appetite, compared to 3.5% of non-CAM users,p=0.002 In a random subgroup of 26 patients, 15% who did not use CAM reported medication side effects, while 53% of CAM users reported them, p =0.039.

CONCLUSIONS

Use of CAM was common in our kidney transplant population. Patients who use CAM reported more somatic symptoms, more medication side effects and were more likely to be non-adherent to non-immunosuppressant medications. Positive response to questions about CAM use may be a surrogate marker for high symptom burden and risk of non-adherence to non-immunosuppresion medications in kidney transplant recipients.