Interactions Between Herbal Medicines and Prescribed Drugs

Phenolic Compounds and Its Bioavailability: In Vitro Bioactive Compounds or Health Promoters?

Botanical preparations present a widespread and secular history of use. In fact, natural matrices possess a rich pool of phytochemicals, with promising biological effects. Among them, phenolic compounds have revealed to confer very important attributes to improve the well-being and longevity of worldwide population. Numerous in vitro studies have been carried out evaluating the wide spectrum of bioactivities of phenolic compounds, including its health effects, but through in vivo experiments some of these previous results cannot be properly confirmed, and considerable variations are observed. Pharmacokinetic parameters, including the assessment of bioavailability and bioefficacy of phenolic compounds, still continue to be largely investigated and considered a great hot topic among the food science and technology researchers. Thus, based on these crucial aspects, this chapter aims to provide an extensive approach about the question of the bioavailability of phenolic compounds, describing its biosynthetic routes and related mechanisms of action; to focus on the current facts and existing controversies, highlighting the importance of in vivo studies and the impact of phenolic compounds on the quality of life and longevity.

Unproven Therapies for Diabetes and Their Implications

Diabetes is a chronic disease and is one of the leading causes of morbidity and mortality worldwide. Being an ancient disease, many individuals follow complementary and alternative medicinal (CAM) therapies for either the cure or prevention of the disease. The popularity of these practices among the general public is in no way a testimony to their safety and efficacy. Due to the possibility of undesirable interactions with conventional medicines, it is imperative that patients are asked about CAM use during patient assessment. Patient- and physician-targeted awareness programs on various aspects of CAM use must be initiated to create a better understanding of evidence-based use of these practices. In addition, there should be guidelines in place based on clinical trial outcomes, and stricter regulations need to be enforced on CAM practices to ensure their safety and effectiveness.

Deleterious effects of reactive metabolites

A number of drugs have been withdrawn from the market or severely restricted in their use because of unexpected toxicities that become apparent only after the launch of new drug entities. Circumstantial evidence suggests that, in most cases, reactive metabolites are responsible for these unexpected toxicities. In this review, a general overview of the types of reactive metabolites and the consequences of their formation are presented. The current approaches to evaluate bioactivation potential of new compounds with particular emphasis on the advantages and limitation of these procedures will be discussed. Reasonable reasons for the excellent safety record of certain drugs susceptible to bioactivation will also be explored and should provide valuable guidance in the use of reactive-metabolite assessments when nominating drug candidates for development. This will, in turn, help us to design and bring safer drugs to the market.

Co-administration of St. John's wort and hormonal contraceptives: a systematic review

OBJECTIVES

St. John's wort (SJW) is a known strong inducer of the cytochrome P450 (CYP) 3 A4 enzyme, and both the ethinyl estradiol and progestin components of hormonal contraceptives are substrates of CYP3A4. This systematic review examined whether the co-administration of SJW and hormonal contraceptives leads to significant safety or efficacy concerns.

STUDY DESIGN

Systematic review.

METHODS

PubMed and Cochrane Library databases were searched for articles of any comparative study design (clinical or pharmacokinetic) that examined potential interactions between SJW and hormonal contraceptives in women of reproductive age.

RESULTS

Of the 48 identified articles, four studies met inclusion criteria and compared use of combined oral contraceptives (COCs) alone to the use of COCs co-administered with SJW. Two studies demonstrated no change in markers of ovulation, but one study demonstrated increased follicular growth and probable ovulation when COCs were co-administered with SJW. Three studies demonstrated an increased risk of breakthrough bleeding with COCs and SJW. Three studies showed changes in at least one pharmacokinetic parameter that suggested a significantly decreased exposure to hormone concentrations when COCs were co-administered with SJW. The only study that did not demonstrate any significant pharmacokinetic differences examined a SJW product containing a low amount of hypericin.

CONCLUSION

Limited evidence showing increased risk of ovulation and breakthrough bleeding raises concern for decreased contraceptive efficacy when COCs are co-administered with SJW. The pharmacokinetic evidence is mixed but suggests that SJW administration may be associated with weak to moderate induction of the metabolism of COCs.

Evaluation of the impact of 16-dehydropregnenolone on the activity and expression of rat hepatic cytochrome P450 enzymes

16-dehydropregnenolone (DHP) is a promising novel antihyperlipidemic agent developed and patented by Central Drug Research Institute (CDRI), India. The purpose of the present study was to investigate whether DHP influences the activities and mRNA expression of hepatic drug-metabolizing cytochrome P450 (CYP) enzymes (CYP1A2, CYP2C11, CYP2D2, CYP2E1 and CYP3A1) in Sprague-Dawley (SD) rats. A cocktail suspension of CYP probe substrates which contained caffeine (CYP1A2), tolbutamide (CYP2C11), dextromethorphan (CYP2D2), chlorzoxazone (CYP2E1) and dapsone (CYP3A1) was administered orally on eighth- or fifteenth-day to rats pre-treated with DHP intragastrically at a dose of 36 and 72mg/kg for one week and two weeks. The concentrations of probe drugs in plasma were estimated by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Alongside, the effect of DHP on CYPs activity and mRNA expression levels were assayed in isolated rat liver microsomes and by real-time reverse transcription-polymerase chain reaction (RT-PCR), respectively. DHP had significant inducing effects on CYP1A2, 2C11, 2D2 and 2E1 with no effect on CYP3A1 in dose- and time-dependent manner, as revealed from the pharmacokinetic profiles of the probe drugs in rats. In-vitro microsomal activities and mRNA expression results were in good agreement with the in-vivo pharmacokinetic results. Collectively, the results unveiled that DHP is an inducer of rat hepatic CYP enzymes. Hence, intense attention should be paid when DHP is co-administered with drugs metabolized by CYP1A2, 2C11, 2D2 and 2E1, which might result in drug-drug interactions and therapeutic failure.

Trends in the use of oral contraceptives among adolescents and young women in Spain

Background

We aimed to determine the prevalence of consumption of oral contraceptives (OCs) among adolescents and young women living in Spain and to identify the factors associated with this consumption.

Methods

We performed a cross-sectional study on the consumption of OCs by women aged 15–30 years residing in Spain. We used secondary individualized data from the 2006 (n = 2513) and 2012 (n = 1530) Spanish National Health Surveys. The dependent variable was the use of OCs in the previous 2 weeks. Independent variables included sociodemographic characteristics, comorbidity, lifestyle, and healthcare resource utilization.

The prevalence of OC consumption was analysed by investigating the changes observed between 2006 and 2012. We used multivariate logistic regression to identify the independent factors associated with OC use in each year.

Results

In 2006, 14.42 % of women reported using OCs; this percentage dropped to 10.21 % in 2012 (p < 0.05). Multivariate analysis revealed an association between OC use and visits to the gynaecologist (AOR, 5.60 [95 % CI, 2.93–10.73] in 2006; and AOR, 3.55 [95 % CI, 1.30–9.73] in 2012), Pap smear tests (AOR, 1.8 [95 % CI, 1.23–2.87] in 2006; and AOR, 2.42 [95 % CI, 1.30–4.51] in 2012), and smoking in 2006 (AOR, 1.42 [95 % CI, 1.04–1.93]).

Conclusions

There was a significant decrease in OC use from 2006 to 2012 among adolescents and young women living in Spain. In the present study, consumers of OCs were women who visited a gynaecologist more often and complied more with preventive measures such as Pap smear testing. Also, women who reported having used OCs were more likely to smoke than the rest of the study population, although the smoking habit is a risk factor for thrombotic events in women who take OCs.

Efficacy of Hypericum extract WS(®) 5570 compared with paroxetine in patients with a moderate major depressive episode - a subgroup analysis

OBJECTIVES

efficacy and tolerability of WS(®) 5570 for the treatment of acute mild-to-moderate depression, has been demonstrated in various studies. Here, we present a subgroup analysis of a double blind, randomised trial to compare the therapeutic efficacy of WS(®) 5570 with paroxetine in patients suffering from a major depressive episode with moderate symptom intensity.

METHODS

moderate depression was defined by a baseline Hamilton Depression Rating Scale (HAM-D) total score between 22 and 25. Patients received, after a single blind placebo run-in phase of 3-7 d, either 3 × 300 mg/d WS(®) 5570 or 20 mg/d paroxetine for six weeks. The change of the HAM-D total score was used to describe the efficacy of WS(®) 5570 compared with paroxetine in the subgroup of patients with moderate depression.

RESULTS

the reductions of the HAM-D total score were significantly more pronounced in patients treated with 3 × 300 mg/d WS(®) 5570 compared to 20 mg/d paroxetine.

CONCLUSIONS

patients treated with WS(®) 5570 not only showed a reduction in depression severity score but also yielded greater response and remission rates compared with patients treated with paroxetine. Keypoints Various studies showed the efficacy and tolerability of WS(®) 5570 for the treatment of acute mild-to-moderate depression. Beneficial effects of WS(®) 5570 have been also shown in patients with moderate-to-severe depression. In this study reductions of the HAM-D total score were significantly more pronounced in patients with moderate depression treated with WS(®) 5570 compared with paroxetine. Patients treated with WS(®) 5570 not only showed a reduction in depression severity score but also yielded greater response and remission rates compared with patients treated with paroxetine.

Menstrual Management for Adolescents With Disabilities

The onset of menses for adolescents with physical or intellectual disabilities can affect their independence and add additional concerns for families at home, in schools, and in other settings. The pediatrician is the primary health care provider to explore and assist with the pubertal transition and menstrual management. Menstrual management of both normal and abnormal cycles may be requested to minimize hygiene issues, premenstrual symptoms, dysmenorrhea, heavy or irregular bleeding, contraception, and conditions exacerbated by the menstrual cycle. Several options are available for menstrual management, depending on the outcome that is desired, ranging from cycle regulation to complete amenorrhea. The use of medications or the request for surgeries to help with the menstrual cycles in teenagers with disabilities has medical, social, legal, and ethical implications. This clinical report is designed to help guide pediatricians in assisting adolescent females with intellectual and/or physical disabilities and their families in making decisions related to successfully navigating menarche and subsequent menstrual cycles.

Complementary and alternative medicine use among cancer patients in Palestine with special reference to safety-related concerns

ETHNOPHARMACOLOGICAL RELEVANCE

The use of CAM including herbal medicine as the most preferred CAM modality, among cancer patients who are taking prescription medications has shown to be highly prevalent worldwide as well as in several Middle Eastern countries, with a high percentage of the patients do not disclose their CAM use to treating physician.

AIM OF THE STUDY

The current study aimed to evaluate the patterns of CAM use among two cohorts of cancer patients in Palestine over a three-year period, and to identify socio-demographic factors that are associated with CAM use.

MATERIALS AND METHODS

Across-sectional survey of patients attending outpatient cancer clinics. The method was based on a semi-structured questionnaire. In order to identify safety-related concerns associated with the products listed, a literature search was conducted using different databases (PubMed, Micromedex, AltMedDex, and the Natural Medicine Comprehensive Database).

RESULTS

In 472 cancer patients including 372 of the 2011 cohort; and 100 of the 2014 cohort, the overall prevalence of CAM use was 69.5%. CAM users were more likely to be ≤65 years old, village resident, being in the midst of chemotherapy, to have high interest spiritual quest, and to have no other chronic diseases. A significant number of CAM users reported using herbal preparations (98.3%, and 89.6% in the two study cohorts, respectively). In the current study, a total of 40 plant taxa belonging to 23 botanical families were reported by ≥3 cancer patients in the two cohort groups. The top most commonly used plant in the 2011 cohort group was Arum palaestinum (43.5%), while Ephedra foeminea emerged as the top most commonly utilized plant (from 0.0% in 2011 to 55.2% in the 2014 cohort), mainly due to a recent publicizing and portraying of the plant in the local media as an effective cancer herbal remedy. Safety-related concerns were associated with 33 (82.5%) herbs, including herb-drug interactions with altered pharmacokinetics (8, 20% herbs), direct toxic effects (16, 40% herbs), and increased in vitro response of cancer cells to chemotherapy (30, 75% herbs).

CONCLUSIONS

CAM use, especially herbal medicine in cancer is highly prevalent in Palestine. This study has demonstrated the role of the media on the emergence of new CAM herbal therapies among cancer patients in Palestine, and discussed its potential implications on patients and for oncologists who are treating them. Some of the most widely used herbal medicines by cancer patients in the present work are known to interact with conventional anticancer drugs. Hence, the disclosure of the use of herbal remedies by patients to health professionals with sufficient training in CAM use is important for the later in order to assess whether there are any possible herbal drug interactions and/or harmful drug reactions.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

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 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.

Travel to High Altitude Following Solid Organ Transplantation

Luks, Andrew M. Clinician's corner: travel to high altitude following solid organ transplantation. High Alt Med Biol. 17:147-156, 2016.-As they regain active lifestyles following successful organ transplantation, transplant recipients may travel to high altitude for a variety of activities, including skiing, climbing, and trekking. This review is intended to provide information for medical providers who may encounter transplant patients seeking advice before planned high altitude travel or care for medical issues that develop during the actual sojourn. There is currently limited information in the literature about outcomes during high-altitude travel following solid organ transplantation, but the available evidence suggests that the physiologic responses to hypobaric hypoxia are comparable to those seen in nontransplanted individuals and well-selected transplant recipients with no evidence of organ rejection can tolerate ascents as high as 6200 m. All transplant recipients planning high-altitude travel should undergo pretravel assessment and counseling with an emphasis on the recognition, prevention, and treatment of altitude illness, as well as the importance of preventing infection and limiting sun exposure. Transplant recipients can use the standard medications for altitude illness prophylaxis and treatment, but the choice and dose of medication should take into account the patient's preexisting medication regimen and current renal function. With careful attention to these and other details, the healthy transplant recipient can safely experience the rewards of traveling in the mountains.

Top 10 Things Primary Care Physicians Should Know About Maintenance Immunosuppression for Transplant Recipients

The success of organ transplantation allows many transplant recipients to return to life similar to nontransplant patients. Their need for regular health care, including preventive medicine, has switched the majority of responsibilities for their health care from transplant specialists to primary care physicians. To take care of transplant recipients, it is critical for primary care physicians to be familiar with immunosuppressive medications, their side effects, and common complications in transplant recipients. Ten subjects are reviewed here in order to assist primary care physicians in providing optimal care for transplant recipients.

Inhibitory action of Epilobium hirsutum extract and its constituent ellagic acid on drug-metabolizing enzymes

Epilobium hirsutum (EH) is a medicinal plant for treating various diseases. Despite its wide usage, there is no available information about its potential influences on drug metabolism. The present study was undertaken to determine the in vivo effects of EH on hepatic CYP2B, CYP2C, CYP2D, and CYP3A enzymes that are primarily involved in drug metabolism. Male Wistar rats were injected intraperitoneally with EH water extract (EHWE) and ellagic acid (EA) at a daily dose of 37.5 and 20 mg/kg, respectively, for 9 days and hepatic drug-metabolizing enzymes were assessed at activity, protein and mRNA levels. Erythromycin N-demethylase activity was inhibited by 53 and 21 % in EHWE- and EA-treated rats, respectively. Benzphetamine N-demethylase and 7-benzyloxyresorufin-O-debenzylase activities were decreased by 53 and 43 %, and 57 and 57 % in EHWE-and EA-treated rats, respectively. Moreover, protein levels of CYP2B1, CYP2C6, CYP2D2, and CYP3A1 also decreased by 55, 15, 33, and 82 % as a result of EHWE treatment of rats, respectively. Similarly, CYP2B1, CYP2C6, CYP2D2, and CYP3A1 protein levels decreased by 62, 63, 49, and 37 % with EA treatment, respectively. qRT-PCR analyses also showed that mRNA levels of these enzymes were significantly inhibited with bothEHWE and EA treatments. In conclusion, inhibition of drug clearances leading to drug toxicity because of the lowered activity and expression of drug-metabolizing enzymes might be observed in the people who used EH as complementary herbal remedy that might be contributed by its EA content.

UGT concentrations in human rectal tissue after multidose, oral curcumin

In vitro studies have demonstrated that curcumin is a substrate for uridine diphosphate glucuronosyltransferase (UGTs), with a putative ability to both induce expression and inhibit function, highlighting the potential for interaction with some drugs. Therefore, we sought to evaluate the effect of oral curcumin on intestinal UGT expression. Healthy volunteers, ages 40-80 years, who had received recent screening colonoscopy were recruited. Participants did not have any gastrointestinal or bleeding disorders, lab abnormalities, or recent antibiotic use. All participants received daily curcuminoid extract, 4 g, for 30 days. Untreated, rectal mucosal pinch biopsies were obtained at baseline and at 30 days. Microsomes were prepared from biopsy samples, using sequential centrifugation. Quantification of 14 UGT 2As and 2Bs was performed by LC-MS/MS(MS, mass spectrometry), using quantitative- targeted absolute proteomics. Lowest LODs were ~0.1 pmol/mg protein. Comparisons were performed using Wilcoxon signed-rank test. Paired baseline and 30 days biopsy samples were available for 38 participants. UGTs 1A10 and 2B17 were detected in 35 and 33 paired samples, respectively, while all other UGTs were below the limit of quantification (BLOQ). Median baseline UGT1A10 concentration was 0.60 pmol/mg (95% CI:0.32-0.92), and 0.60 pmol/mg (95% CI:0.43-1.00) after 30 days (P = 0.23). For UGT2B17, median baseline concentration was 0.83 pmol/mg (95% CI:0.32-1.62), and 1.18 pmol/mg (95% CI:0.39-1.77) after 30 days (P = 0.24). We found no differences in rectal mucosal UGT concentrations before and after 30 days of oral curcumin administration, indicating that daily curcumin use is unlikely to alter colonic UGT expression. Distal gut biopsies may not accurately reflect the proximal gut environment where UGT expression and curcumin concentrations may be higher.

Trans-Resveratrol Enhances the Anticoagulant Activity of Warfarin in a Mouse Model

Aim: Resveratrol is a popular ingredient in dietary supplements. Some patients concomitantly use dietary supplements and medicines in Japan. In the present study, we determined whether trans-resveratrol and melinjo (Gnetum gnemon L.) seed extract (MSE), which contains resveratrol dimers, interacted with drugs using a mouse model.

Methods: Male C57BL/6J mice were fed experimental diets containing 0.005%, 0.05%, or 0.5% (w/w) trans-resveratrol or MSE for 1 or 12 weeks. The expression of liver cytochrome P-450 (CYP) mRNA and activity of liver microsomal CYP were measured. To determine the influence of resveratrol or MSE on drug efficacy, the anticoagulant activity of warfarin was examined in mice that were fed diets containing trans-resveratrol or MSE for 12 weeks.

Results: When the mice were fed experimental diets for 1 week, none of the doses of trans-resveratrol and MSE affected body weight, liver weight, or plasma AST and ALT levels. Trans-resveratrol also did not affect CYP1A1, CYP1A2, CYP2C, or CYP3A activities. In contrast, 0.5% MSE slightly increased CYP1A1 activity. When the mice were fed experimental diets for 12 weeks, 0.05% trans-resveratrol increased CYP1A1, CYP2C, and CYP3A activities, whereas 0.5% MSE suppressed CYP3A activity. Under these conditions, 0.5% trans-resveratrol enhanced the anticoagulant activity of warfarin, although CYP2C activity increased. However, MSE did not affect the anticoagulant activity of warfarin.

Conclusion: The 0.05% trans-resveratrol did not interact with warfarin in a mouse model, whereas 0.5% trans-resveratrol may have enhanced the anticoagulant activity of warfarin.

Prediction of sensitivity to warfarin based on VKORC1 and CYP2C9 polymorphisms in patients from different places in Colombia

INTRODUCTION

In the search to prevent hemorrhages associated with anticoagulant therapy, a major goal is to validate predictors of sensitivity to warfarin. However, previous studies in Colombia that included polymorphisms in the VKORC1 and CYP2C9 genes as predictors reported different algorithm performances to explain dose variations, and did not evaluate the prediction of sensitivity to warfarin. 

OBJECTIVE

To determine the accuracy of the pharmacogenetic analysis, which includes the CYP2C9 *2 and *3 and VKORC1 1639G>A polymorphisms in predicting patients' sensitivity to warfarin at the Hospital Militar Central, a reference center for patients born in different parts of Colombia. 

MATERIALS AND METHODS

Demographic and clinical data were obtained from 130 patients with stable doses of warfarin for more than two months. Next, their genotypes were obtained through a melting curve analysis. After verifying the Hardy-Weinberg equilibrium of the genotypes from the polymorphisms, a statistical analysis was done, which included multivariate and predictive approaches. 

RESULTS

A pharmacogenetic model that explained 52.8% of dose variation (p<0.001) was built, which was only 4% above the performance resulting from the same data using the International Warfarin Pharmacogenetics Consortium algorithm. The model predicting the sensitivity achieved an accuracy of 77.8% and included age (p=0.003), polymorphisms *2 and *3 (p=0.002) and polymorphism 1639G>A (p<0.001) as predictors. 

CONCLUSIONS

These results in a mixed population support the prediction of sensitivity to warfarin based on polymorphisms in VKORC1 and CYP2C9 as a valid approach in Colombian patients.

Garlic Lowers Blood Pressure in Hypertensive Individuals, Regulates Serum Cholesterol, and Stimulates Immunity: An Updated Meta-analysis and Review

BACKGROUND

Garlic has been shown to have cardiovascular protective and immunomodulatory properties.

OBJECTIVES

We updated a previous meta-analysis on the effect of garlic on blood pressure and reviewed the effect of garlic on cholesterol and immunity.

METHODS

We searched the Medline database for randomized controlled trials (RCTs) published between 1955 and December 2013 on the effect of garlic preparations on blood pressure. In addition, we reviewed the effect of garlic on cholesterol and immunity.

RESULTS

Our updated meta-analysis on the effect of garlic on blood pressure, which included 20 trials with 970 participants, showed a mean ± SE decrease in systolic blood pressure (SBP) of 5.1 ± 2.2 mm Hg (P < 0.001) and a mean ± SE decrease in diastolic blood pressure (DBP) of 2.5 ± 1.6 mm Hg (P < 0.002) compared with placebo. Subgroup analysis of trials in hypertensive subjects (SBP/DBP ≥140/90 mm Hg) at baseline revealed a larger significant reduction in SBP of 8.7 ± 2.2 mm Hg (P < 0.001; n = 10) and in DBP of 6.1 ± 1.3 mm Hg (P < 0.001; n = 6). A previously published meta-analysis on the effect of garlic on blood lipids, which included 39 primary RCTs and 2300 adults treated for a minimum of 2 wk, suggested garlic to be effective in reducing total and LDL cholesterol by 10% if taken for >2 mo by individuals with slightly elevated concentrations [e.g., total cholesterol >200 mg/dL (>5.5 mmol/L)]. Garlic has immunomodulating effects by increasing macrophage activity, natural killer cells, and the production of T and B cells. Clinical trials have shown garlic to significantly reduce the number, duration, and severity of upper respiratory infections.

CONCLUSIONS

Our review suggests that garlic supplements have the potential to lower blood pressure in hypertensive individuals, to regulate slightly elevated cholesterol concentrations, and to stimulate the immune system. Garlic supplements are highly tolerated and may be considered as a complementary treatment option for hypertension, slightly elevated cholesterol, and stimulation of immunity. Future long-term trials are needed to elucidate the effect of garlic on cardiovascular morbidity and mortality.

Phytopharmacologic preparations as predictors of plant bioactivity: A particular approach to Echinacea purpurea (L.) Moench antioxidant properties

OBJECTIVE

A large body of evidence has confirmed a multitude of health benefits of plant products and their derived formulations. Echinacea purpurea (L.) Moench is a good example, widely used due to its therapeutic properties. In the present study, the chemical composition of the different samples and antioxidant properties of E. purpurea hydroethanolic and aqueous extracts obtained from dry or fresh raw material were evaluated and compared with dietary supplements based on the same plant (tablets and syrup), to determine the most active phytopharmacologic preparation or formulation.

METHODS

Chemical composition of the different samples was assessed through the determination of free sugars, organic acids and tocopherols. The in vitro antioxidant properties were determined using four assays: 2,2-Diphenyl-1-picrylhydrazyl (DPPH) radicals scavenging activity, reducing power, inhibition of b-carotene bleaching and inhibition of lipid peroxidation by thiobarbituric acid reactive substances (TBARS) assay. Total phenolics and flavonoids were also determined.

RESULTS

Overall, the hydroethanolic extract of fresh plant revealed the highest activity, directly related with its higher contents in phenolic (229.22 ± 4.38 mg gallic acid equivalent [GAE]/mL), flavonoids (124.83 ± 7.47 mg GAE/mL), organic acids (8.89 ± 0.10 g/100 g), and tocopherols (4.55 ± 0.02 mg/100 g). Tablets followed by syrup revealed the worst effect, positively correlated with the lowest abundance in bioactive molecules. The weak in vitro antioxidant potential of commercial phytopharmacologic formulations could be related to their chemical composition, including the addition of excipients.

CONCLUSION

Further studies are necessary to deepen knowledge on this area, namely focusing on in vivo experiments, to establish upcoming guidelines to improve the quality and bioavailability of phytopharmacologic formulations.

Effect of Red Ginseng on cytochrome P450 and P-glycoprotein activities in healthy volunteers

Background

We evaluated the drug interaction profile of Red Ginseng (RG) with respect to the activities of major cytochrome P450 (CYP) enzymes and the drug transporter P-glycoprotein (P-gp) in healthy Korean volunteers.

Methods

This article describes an open-label, crossover study. CYP probe cocktail drugs, caffeine, losartan, dextromethorphan, omeprazole, midazolam, and fexofenadine were administered before and after RG supplementation for 2 wk. Plasma samples were collected, and tolerability was assessed. Pharmacokinetic parameters were calculated, and 90% confidence intervals (CIs) of the geometric mean ratios of the parameters were determined from logarithmically transformed data using analysis of variance after RG administration versus before RG administration.

Results

Fourteen healthy male participants were evaluated, none of whom were genetically defined as poor CYP2C9, 2C19, and CYP2D6 metabolizers based on genotyping. Before and after RG administration, the geometric least-square mean metabolic ratio (90% CI) was 0.870 (0.805–0.940) for caffeine to paraxanthine (CYP1A2), 0.871 (0.800–0.947) for losartan (CYP2C9) to EXP3174, 1.027 (0.938–1.123) for omeprazole (CYP2C19) to 5-hydroxyomeprazole, 1.373 (0.864–2.180) for dextromethorphan to dextrorphan (CYP2D6), and 0.824 (0.658–1.032) for midazolam (CYP3A4) to 1-hydroxymidazolam. The geometric mean ratio of the area under the curve of the last sampling time (AUC_last) for fexofenadine (P-gp) was 0.963 (0.845–1.098). Administration of concentrated RG for 2 wk weakly inhibited CYP2C9 and CYP3A4 and weakly induced CYP2D6. However, no clinically significant drug interactions were observed between RG and CYP and P-gp probe substrates.

Conclusion

RG has no relevant potential to cause CYP enzyme- or P-gp-related interactions.

Clinical trial registration number (ClinicalTrials.gov): NCT02056743.

Interactions between traditional Chinese medicine and western drugs in Taiwan: A population-based study

BACKGROUND

Drug-drug interactions have long been an active research area in clinical medicine. In Taiwan, however, the widespread use of traditional Chinese medicines (TCM) presents additional complexity to the topic. Therefore, it is important to see the interaction between traditional Chinese and western medicine.

OBJECTIVE

(1) To create a comprehensive database of multi-herb/western drug interactions indexed according to the ways in which physicians actually practice and (2) to measure this database's impact on the detection of adverse effects between traditional Chinese medicine compounds and western medicines.

METHODS

First, a multi-herb/western medicine drug interactions database was created by separating each TCM compound into its constituent herbs. Each individual herb was then checked against an existing single-herb/western drug interactions database. The data source comes from the National Health Insurance research database, which spans the years 1998-2011. This study estimated the interaction prevalence rate and further separated the rates according to patient characteristics, distribution by county, and hospital accreditation levels. Finally, this new database was integrated into a computer order entry module of the electronic medical records system of a regional teaching hospital. The effects it had were measured for two months.

RESULTS

The most commonly interacting Chinese herbs were Ephedrae Herba and Angelicae Sinensis Radix/Angelicae Dahuricae Radix. Ephedrae Herba contains active ingredients similar to in ephedrine. 15 kinds of traditional Chinese medicine compounds contain Ephedrae Herba. Angelicae Sinensis Radix and Angelicae Dahuricae Radix contain ingredients similar to coumarin, a blood thinner. 9 kinds of traditional Chinese medicine compounds contained Angelicae Sinensis Radix/Angelicae Dahuricae Radix. In the period from 1998 to 2011, the prevalence of herb-drug interactions related to Ephedrae Herba was 0.18%. The most commonly prescribed traditional Chinese compounds were MA SHING GAN SHYR TANG (23.1%), followed by SHEAU CHING LONG TANG (15.5%) and DINQ CHUAN TANG (13.2%). The prevalence of herb-drug interactions related to Angelicae Sinensis Radix, Angelicae Dahuricae Radix was 4.59%. The most common traditional Chinese compound formula were TSANG EEL SAAN (32%), followed by HUOH SHIANG JENQ CHIH SAAN (31.4%) and SHY WUH TANG (10.7%). Once the multi-herb drug interaction database was deployed in a hospital system, there were 480 prescriptions that indicated a TCM-western drug interaction. Physicians were alerted 24 times during two months. These alerts resulted in a prescription change four times (16.7%).

CONCLUSION

Due to the unique cultural factors that have resulted in widespread acceptance of both western and traditional Chinese medicine, Taiwan stands well positioned to report on the prevalence of interactions between western drugs and traditional Chinese medicine and devise ways to reduce their incidence. This study built a multi-herb/western drug interactions database, embedded inside a hospital clinical information system, and then examined the effects that drug interaction alerts had on clinician prescribing behaviour. The results demonstrated that western drug/traditional Chinese medicine interactions are prevalent and that western-trained physicians tend to change their prescribing behaviour more than traditional Chinese medicine physicians in their response to medication interaction alerts.

Time-Dependent Inhibition of CYP2C19 by Isoquinoline Alkaloids: In Vitro and In Silico Analysis

The cytochrome P450 2C19 (CYP2C19) enzyme plays an important role in the metabolism of many commonly used drugs. Relatively little is known about CYP2C19 inhibitors, including compounds of natural origin, which could inhibit CYP2C19, potentially causing clinically relevant metabolism-based drug interactions. We evaluated a series (N = 49) of structurally related plant isoquinoline alkaloids for their abilities to interact with CYP2C19 enzyme using in vitro and in silico methods. We examined several common active alkaloids found in herbal products such as apomorphine, berberine, noscapine, and papaverine, as well as the previously identified mechanism-based inactivators bulbocapnine, canadine, and protopine. The IC50 values of the alkaloids ranged from 0.11 to 210 µM, and 42 of the alkaloids were confirmed to be time-dependent inhibitors of CYP2C19. Molecular docking and three-dimensional quantitative structure-activity relationship analysis revealed key interactions of the potent inhibitors with the enzyme active site. We constructed a comparative molecular field analysis model that was able to predict the inhibitory potency of a series of independent test molecules. This study revealed that many of these isoquinoline alkaloids do have the potential to cause clinically relevant drug interactions. These results highlight the need for studying more profoundly the potential interactions between drugs and herbal products. When further refined, in silico methods can be useful in the high-throughput prediction of P450 inhibitory potential of pharmaceutical compounds.

Integrative oncology: an overview

Integrative oncology, the diagnosis-specific field of integrative medicine, addresses symptom control with nonpharmacologic therapies. Known commonly as "complementary therapies" these are evidence-based adjuncts to mainstream care that effectively control physical and emotional symptoms, enhance physical and emotional strength, and provide patients with skills enabling them to help themselves throughout and following mainstream cancer treatment. Integrative or complementary therapies are rational and noninvasive. They have been subjected to study to determine their value, to document the problems they ameliorate, and to define the circumstances under which such therapies are beneficial. Conversely, "alternative" therapies typically are promoted literally as such; as actual antitumor treatments. They lack biologic plausibility and scientific evidence of safety and efficacy. Many are outright fraudulent. Conflating these two very different categories by use of the convenient acronym "CAM," for "complementary and alternative therapies," confuses the issue and does a substantial disservice to patients and medical professionals. Complementary and integrative modalities have demonstrated safety value and benefits. If the same were true for "alternatives," they would not be "alternatives." Rather, they would become part of mainstream cancer care. This manuscript explores the medical and sociocultural context of interest in integrative oncology as well as in "alternative" therapies, reviews commonly-asked patient questions, summarizes research results in both categories, and offers recommendations to help guide patients and family members through what is often a difficult maze. Combining complementary therapies with mainstream oncology care to address patients' physical, psychologic and spiritual needs constitutes the practice of integrative oncology. By recommending nonpharmacologic modalities that reduce symptom burden and improve quality of life, physicians also enable patients to play a role in their care. Critical for most patients, this also improves the physician-patient relationship, the quality of cancer care, and the well-being of patients and their families.

Issues and promise in clinical studies of botanicals with anticonvulsant potential

Botanicals are increasingly used by people with epilepsy worldwide. However, despite abundant preclinical data on the anticonvulsant properties of many herbal remedies, there are very few human studies assessing safety and efficacy of these products in epilepsy. Additionally, the methodology of most of these studies only marginally meets the requirements of evidence-based medicine. Although the currently available evidence for the use of cannabinoids in epilepsy is similarly lacking, several carefully designed and well controlled industry-sponsored clinical trials of cannabis derivatives are planned to be completed in the next couple of years, providing the needed reliable data for the use of these products. The choice of the best botanical candidates with anticonvulsant properties and their assessment in well-designed clinical trials may significantly improve our ability to effectively and safely treat patients with epilepsy. This article is part of a Special Issue entitled "Botanicals for Epilepsy".

Modelling of compound combination effects and applications to efficacy and toxicity: state-of-the-art, challenges and perspectives

The development of treatments involving combinations of drugs is a promising approach towards combating complex or multifactorial disorders. However, the large number of compound combinations that can be generated, even from small compound collections, means that exhaustive experimental testing is infeasible. The ability to predict the behaviour of compound combinations in biological systems, whittling down the number of combinations to be tested, is therefore crucial. Here, we review the current state-of-the-art in the field of compound combination modelling, with the aim to support the development of approaches that, as we hope, will finally lead to an integration of chemical with systems-level biological information for predicting the effect of chemical mixtures.

Use of over-the-counter (OTC) drugs and perceptions of OTC drug safety among German adults

PURPOSE

In Europe, little empirical evidence is available about over-the-counter (OTC) drug consumption and risk perceptions. The objective of this study was to describe consumers' OTC drug use and perceptions of OTC drug safety in Germany.

METHODS

An online survey based on a quota sample with combined strata for age, gender, and education of 300 adult German participants was conducted in June and July 2013. The survey questionnaire covered the participants' OTC and prescription drug use, risk perceptions of OTC and prescription drugs, package leaflet reading habits, and OTC drug off-label use.

RESULTS

Seven day prevalences of OTC drug use were higher in women (52.0%) than in men (40.8%). The risk perception of specific OTC drugs was impacted by the route of administration, the indication, and the drugs' ingredients. Products for dermal application or plant-based products were considered 'rather not risky' by 82.7-96.6 of the participants, depending on the product. Products for oral use or chemically synthesized substances were considered less safe. While 48.0% of consumers reported always reading the package leaflet of OTC drugs, 44.5% reported not reading it if they knew the drug or believed the drug was very safe. People, 60 years and older, reported significantly lower levels of OTC drug off-label use (9.3%) than younger people (22.0%).

CONCLUSIONS

The 7-day prevalence of OTC drug use in Germany is high, especially among women. Consumers generally have balanced perceptions regarding OTC drug safety. Behaviours and knowledge related to OTC drug use should be considered by health care providers and regulators.

Adverse drug reactions and drug-drug interactions with over-the-counter NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen have a long history of safe and effective use as both prescription and over-the-counter (OTC) analgesics/antipyretics. The mechanism of action of all NSAIDs is through reversible inhibition of cyclooxygenase enzymes. Adverse drug reactions (ADRs) including gastrointestinal bleeding as well as cardiovascular and renal effects have been reported with NSAID use. In many cases, ADRs may occur because of drug-drug interactions (DDIs) between the NSAID and a concomitant medication. For example, DDIs have been reported when NSAIDs are coadministered with aspirin, alcohol, some antihypertensives, antidepressants, and other commonly used medications. Because of the pharmacologic nature of these interactions, there is a continuum of risk in that the potential for an ADR is dependent on total drug exposure. Therefore, consideration of dose and duration of NSAID use, as well as the type or class of comedication administered, is important when assessing potential risk for ADRs. Safety findings from clinical studies evaluating prescription-strength NSAIDs may not be directly applicable to OTC dosing. Health care providers can be instrumental in educating patients that using OTC NSAIDs at the lowest effective dose for the shortest required duration is vital to balancing efficacy and safety. This review discusses some of the most clinically relevant DDIs reported with NSAIDs based on major sites of ADRs and classes of medication, with a focus on OTC ibuprofen, for which the most data are available.

Characterization of Changes in Global Genes Expression in the Distal Colon of Loperamide-Induced Constipation SD Rats in Response to the Laxative Effects of Liriope platyphylla

To characterize the changes in global gene expression in the distal colon of constipated SD rats in response to the laxative effects of aqueous extracts of Liriope platyphylla (AEtLP), including isoflavone, saponin, oligosaccharide, succinic acid and hydroxyproline, the total RNA extracted from the distal colon of AEtLP-treated constipation rats was hybridized to oligonucleotide microarrays. The AEtLP treated rats showed an increase in the number of stools, mucosa thickness, flat luminal surface thickness, mucin secretion, and crypt number. Overall, compared to the controls, 581 genes were up-regulated and 216 genes were down-regulated by the constipation induced by loperamide in the constipated rats. After the AEtLP treatment, 67 genes were up-regulated and 421 genes were down-regulated. Among the transcripts up-regulated by constipation, 89 were significantly down-regulated and 22 were recovered to the normal levels by the AEtLP treatment. The major genes in the down-regulated categories included Slc9a5, klk10, Fgf15, and Alpi, whereas the major genes in the recovered categories were Cyp2b2, Ace, G6pc, and Setbp1. On the other hand, after the AEtLP treatment, ten of these genes down-regulated by constipation were up-regulated significantly and five were recovered to the normal levels. The major genes in the up-regulated categories included Serpina3n, Lcn2 and Slc5a8, whereas the major genes in the recovered categories were Tmem45a, Rerg and Rgc32. These results indicate that several gene functional groups and individual genes as constipation biomarkers respond to an AEtLP treatment in constipated model rats.

The roles of carboxylesterase and CYP isozymes on the in vitro metabolism of T-2 toxin

BACKGROUND

T-2 toxin poses a great threat to human health because it has the highest toxicity of the currently known trichothecene mycotoxins. To understand the in vivo toxicity and transformation mechanism of T-2 toxin, we investigated the role of one kind of principal phase I drug-metabolizing enzymes (cytochrome P450 [CYP450] enzymes) on the metabolism of T-2 toxin, which are crucial to the metabolism of endogenous substances and xenobiotics. We also investigated carboxylesterase, which also plays an important role in the metabolism of toxic substances.

METHODS

A chemical inhibition method and a recombinant method were employed to investigate the metabolism of the T-2 toxin by the CYP450 enzymes, and a chemical inhibition method was used to study carboxylesterase metabolism. Samples incubated with human liver microsomes were analyzed by high performance liquid chromatography-triple quadrupole mass spectrometry (HPLC- QqQ MS) after a simple pretreatment.

RESULTS

In the presence of a carboxylesterase inhibitor, only 20 % T-2 toxin was metabolized. When CYP enzyme inhibitors and a carboxylesterase inhibitor were both present, only 3 % of the T-2 toxin was metabolized. The contributions of the CYP450 enzyme family to T-2 toxin metabolism followed the descending order CYP3A4, CYP2E1, CYP1A2, CYP2B6 or CYP2D6 or CYP2C19.

CONCLUSION

Carboxylesterase and CYP450 enzymes are of great importance in T-2 toxin metabolism, in which carboxylesterase is predominant and CYP450 has a subordinate role. CYP3A4 is the principal member of the CYP450 enzyme family responsible for T-2 toxin metabolism. The primary metabolite produced by carboxylesterase is HT-2, and the main metabolite produced by CYP 3A4 is 3'-OH T-2. The different metabolites show different toxicities. Our results will provide useful data concerning the toxic mechanism, the safety evaluation, and the health risk assessment of T-2 toxin.

Effect of kanglaite on rat cytochrome P450

CONTEXT

Kanglaite (KLT) is an oily substance extracted from Coix lacryma-jobi Linn. (Cramineae) and has been proved to significantly improve the life span and quality of life of patients, when combined with chemotherapy, radiotherapy, or surgery.

OBJECTIVE

The purpose of this study was to find out whether KLT influences the effect on rat cytochrome P450 (CYP) enzymes (CYP1A2, CYP2B6, CYP2C9, CYP2C19, and CYP3A4) by using cocktail probe drugs in vivo.

MATERIALS AND METHODS

A cocktail solution at a dose of 5 mL/kg, which contained phenacetin (20 mg/kg), bupropion (20 mg/kg), tolbutamide (5 mg/kg), omeprazole (20 mg/kg), and midazolam (10 mg/kg), was given as oral administration to rats treated with 7 d intraperitoneal injection of KLT. Blood samples were collected at a series of time-points and the concentrations of probe drugs in plasma were determined by HPLC-MS/MS. The corresponding pharmacokinetic parameters were calculated by the software of DAS 2.0 (SPPS Inc., Chicago, IL).

RESULTS

In the experiment, there was a statistically significant difference in the t1/2, Cmax, AUC(0-∞), and CL for phenacetin, bupropion, tolbutamide, omeprazole, and midazolam. Our study showed that treatment with multiple doses of KLT had induction effect on rat CYP1A2, while CYP2B6, CYP2C9, CYP2C19, and CYP3A4 enzyme activities had been inhibited after multiple doses of KLT treatment.

CONCLUSIONS

KLT can either induce or inhibit activities of CYP. Therefore, caution is needed when KLT is co-administration with some CYP substrates in clinic, which may result in herb-drug interactions.

Safety Analysis of Panax Ginseng in Randomized Clinical Trials: A Systematic Review

Background:Panax ginseng C.A. Meyer is one of the most frequently used herbs in the world. The roots of Panax ginseng have been used as a traditional tonic and medicine for thousands of years in Korea and China. Today, ginseng root is used as a dietary supplement and complementary medicine and for adjuvant therapeutics worldwide. The efficacy of ginseng has been studied in a wide range of basic research and clinical studies. However, it has been reported that the results from clinical studies are conflicting, and they depend on the parameters of the protocol design including the conditions of the participants and the types of ginseng used such as red ginseng, white ginseng, fermented ginseng and cultured ginseng. Meanwhile, in addition to clinical efficacy, the safety of ginseng is a highly important matter for customers. With globally increasing demand for Panax ginseng as a dietary supplement or complementary medicine, it is necessary to provide information on its safe use to customers to improve their health conditions. Although the safety of Panax ginseng in pre-clinical studies is well known, the evaluation of safety in clinical studies has so far been insufficient. This systematic review was conducted to assess the safety of ginseng in randomized controlled clinical trials (RCT) over the last 10 years. We chose the last 10 years because many clinical trials have been conducted in the past 10 years, and it will help to understand the recent trends in RCTs of ginseng.

Methods: Articles on ginseng studies were searched with keywords in MEDLINE and four other Korean online database sites. Studies with ginseng as a monopreparation were selected while studies with single administration, preparations combined with other herbs or drug combinations were excluded from the selected studies. Data from the selected studies meeting the criteria were extracted and reviewed in terms of study design, condition and number of participants, type of ginseng, dosage, duration, main results, adverse events and adverse reactions.

Results: Forty-four studies met the selection criteria. These studies covered the efficacy of ginseng in areas such as cardiovascular function, glucose metabolism, sexual function, anti-oxidation, anti-fatigue and psychomotor function. Twenty-nine studies showed positive results while fifteen studies showed no effect. Sixteen studies reported adverse events while five studies had no adverse events. Twenty-three studies did not mention any adverse events. The main adverse events of ginseng reported were general symptoms such as hot flushes, insomnia and dyspepsia with no significant difference in frequency and symptoms between the ginseng and placebo groups. The symptoms were mild and temporary with no serious or severe adverse events.

Conclusion:Panax ginseng showed a very safe profile in a limited number of RCTs with a small number of participants with various conditions ranging from healthy participants to patients with symptoms. However, to increase the usefulness and lower the health risk of Panax ginseng to customers, clinical trials on a larger scale and with a higher standard are necessary to define its efficacy and safety as a dietary supplement or complementary medicine.

Common use of dietary supplements for bipolar disorder: a naturalistic, self-reported study

Background

Dietary supplements are taken by about half of Americans. Knowledge of dietary supplement use is important because they may interact with prescription drugs or other supplements, cause adverse reactions including psychiatric symptoms, or contain inherently toxic ingredients or contaminants. This study explores the use of dietary supplements by patients with bipolar disorder in the US.

Methods

Data were obtained from an ongoing, naturalistic study of patients with bipolar disorder who received pharmacological treatment as usual. The patients self-reported their daily mood, sleep, and medications taken, including all drugs prescribed for bipolar disorder or that the patient felt impacted their mood. These included other prescribed drugs, over-the-counter drugs and dietary supplements. Drugs that received premarketing approval from the FDA were not included as dietary supplements. Patient demographics and daily medication use were characterized.

Results

Data were available from 348 patients in the US who returned a mean 249.5 days of data. In addition to prescribed psychiatric drugs, 101 of the 348 patients (29 %) used a dietary supplement for at least 7 days and 69 (20 %) used a supplement long term (for at least 50 % of days). Of the 101 supplement users, 72 (71.3 %) took one supplement daily. The 101 patients tried over 40 different supplements, and the long-term users took 19 different supplements. The most commonly taken supplements for both groups were fish oil, B vitamins, melatonin, and multivitamins. Patients using supplements were more likely to be white (p < 0.001), older (p = 0.009), and ill for more years (p = 0.025).

Conclusions

Many patients with bipolar disorder use dietary supplements in addition to prescribed drugs. Physicians should obtain detailed information about all dietary supplements taken by patients with bipolar disorder.

Inhibitory effects of cytochrome P450 enzymes CYP1A2, CYP2A6, CYP2E1 and CYP3A4 by extracts and alkaloids of Gelsemium elegans roots

ETHNOPHARMACOLOGICAL RELEVANCE

Gelsemium elegans (GE), widely distributed in East Asia, South East Asia and Northern America, is a kind of well-known toxic plant throughout the world. Yet it has been used as a Chinese folk medicine for treatment of malignant tumors, pain, rheumatic arthritis, psoriasis and immune function.

AIM OF THE STUDY

The present study was to investigate the potential inhibitory effects of G. elegans (GE) roots on four major cytochrome P450 (CYP450) isoforms (CYP1A2, CYP2A6, CYP2E1 and CYP3A4) in vitro.

MATERIALS AND METHODS

Four extracts (petroleum ether, dichloromethane, EtOAc and aqueous) of GE and two commercially available alkaloids (koumine and humantenmine) were screened for their CYP isoforms inhibitory activity. Four enzyme inhibition assays were examined according to the method of the literature. Phenacetin, coumarin, chlorzoxazone and testosterone were used as probe substrates in order to determine CYP1A2, CYP2A6, CYP2E1 and CYP3A4 catalytic activity, respectively. Each probe substrate was incubated with or without each extract and active constituent for corresponding isoform, followed by determination of the kinetics parameters, IC50 and Ki, to characterize inhibitory effects.

RESULTS

GE dichloromethane extract selectively inhibited activities of CYP2E1 (IC50=29.04µg/ml) and CYP2A6 (IC50=46.84µg/ml), with Ki of 10.16 and 19.33µg/ml, respectively. In the case of alkaloids, koumine exhibited significant inhibitory effects on CYP2E1 while humantenmine showed more potent inhibition on CYP2E1 and CYP2A6 (IC50 of 47.44, 18.34 and 45.87µg/ml, Ki of 31.20, 35.06 and 52.06µg/ml, respectively). Because of their relatively high Ki values, the active constituents in GE dichloromethane extract were analyzed. The UPLC-DAD-ESI-MS/MS data showed that GE dichloromethane extract contains 6 kinds of indole alkaloids (koumine, humantenmine, humantenine, humantenirine, N-methoxytaberpsychine, and sempervirine). As for CYP1A2 and CYP3A4, the negligible inhibitions were observed.

CONCLUSION

G. elegans extracts inhibited several CYP450 enzyme activities with varying potency. Strong inhibition was observed in CYP2E1 and CYP2A6 isoforms by GE dichloromethane extract, koumine and humantenmine, inferring the involvement of alkaloids chemical constituents from GE dichloromethane extract in the effect.

Concomitant use of dietary supplements and medicines in patients due to miscommunication with physicians in Japan

We previously reported that some patients used dietary supplements with their medication without consulting with physicians. Dietary supplements and medicines may interact with each other when used concomitantly, resulting in health problems. An Internet survey was conducted on 2109 people who concomitantly took dietary supplements and medicines in order to address dietary supplement usage in people who regularly take medicines in Japan. A total of 1508 patients (two admitted patients and 1506 ambulatory patients) and 601 non-patients, who were not consulting with physicians, participated in this study. Purpose for dietary supplement use was different among ages. Dietary supplements were used to treat diseases in 4.0% of non-patients and 11.9% of patients, while 10.8% of patients used dietary supplements to treat the same diseases as their medication. However, 70.3% of patients did not declare dietary supplement use to their physicians or pharmacists because they considered the concomitant use of dietary supplements and medicines to be safe. A total of 8.4% of all subjects realized the potential for adverse effects associated with dietary supplements. The incidence of adverse events was higher in patients who used dietary supplements to treat their disease. Communication between patients and physicians is important for avoiding the adverse effects associated with the concomitant use of dietary supplements and medicines.

Schisandrin B inhibits cell growth and induces cellular apoptosis and autophagy in mouse hepatocytes and macrophages: implications for its hepatotoxicity

A number of drugs and herbal compounds have been documented to cause hepatoxicity. Schisandrin B (Sch B) is an active dibenzocyclooctadiene isolated from Schisandrae fructus, with a wide array of pharmacological activities. However, the potential hepatotoxicity of Sch B is a major safety concern, and the underlying mechanism for Sch B-induced liver toxic effects is not fully elucidated. In the present study, we aimed to investigate the liver toxic effects and the molecular mechanisms of Sch B in mouse liver and macrophage cells. The results have shown that Sch B exhibits potent grow inhibitory, proapoptotic, and proautophagic effects in AML-12 and RAW 264.7 cells. Sch B markedly arrested cells in G₁ phase in both cell lines, accompanied by the down-regulation of cyclin dependent kinase 2 (CDK2) and cyclin D1 and up-regulation of p27 Kip1 and checkpoint kinase 1. Furthermore, Sch B markedly increased the apoptosis of AML-12 and RAW 264.7 cells with a decrease in the expression of B-cell lymphoma-extra-large and (Bcl-xl) B-cell lymphoma 2 (Bcl-2), but an increase in the expression of B-cell lymphoma 2-associated X protein (Bax). Sch B promoted the cleavage of caspase 3 and poly-adenosine diphosphate-ribose polymerase (PARP) in both cell lines. Additionally, Sch B significantly induced autophagy of AML-12 and RAW 264.7 cells. Sch B inhibited the activation of phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt)/mammalian target of rapamycin (mTOR) signaling pathway, as indicated by their altered phosphorylation, contributing to the proautophagic effect of Sch B. Taken together, our findings show that the inducing effects of Sch B on cell cycle arrest, apoptosis, and autophagy may contribute to its liver toxic effects, which might provide a clue for the investigation of the molecular toxic targets and underlying mechanisms for Sch B-induced hepatotoxicity in herbal consumers. More studies are warranted to fully delineate the underlying mechanisms, efficacy, and safety of Sch B for clinical use.

A review of nurses' knowledge, attitudes, and ability to communicate the risks and benefits of complementary and alternative medicine

AIMS AND OBJECTIVES

This study reviewed existing literature to investigate how frequently nurses include complementary and alternative forms of medicine in their clinical practice. In so doing, we investigated nurses' knowledge of and attitudes towards complementary and alternative medicine as well as their ability to communicate the risks and benefits of these therapies with patients.

BACKGROUND

Little information is available concerning nurses' knowledge and attitudes towards complementary and alternative medicine or how they incorporate these therapies into their practice. In addition, little is known about the ability of nurses to communicate the risks and benefits of complementary and alternative medicine to their patients.

STUDY DESIGN

This study used a scoping review method to map and synthesise existing literature.

DATA SOURCES

Both electronic and manual searches were used to identify relevant studies published between January 2007 and January 2014.

REVIEW METHODS

The review was conducted in five stages: (1) identification of research question(s), (2) locate studies, (3) selection of studies, (4) charting of data, and (5) collating, summarising, and reporting of results.

RESULTS

Fifteen papers met the inclusion criteria for this review, among which 53·7% referenced how frequently nurses include complementary and alternative medicine in their practice. We found that 66·4% of nurses had positive attitudes towards complementary and alternative medicine; however, 77·4% did not possess a comprehensive understanding of the associated risks and benefits. In addition, nearly half of the respondents (47·3-67·7%) reported feeling uncomfortable discussing complementary and alternative medicine therapies with their patients.

CONCLUSION

The lack of knowledge about complementary and alternative medicine among nurses is a cause for concern, particularly in light of its widespread application.

RELEVANCE TO CLINICAL PRACTICE

Findings from this study suggest that health care professionals need to promote evidence informed decision-making in complementary and alternative medicine practice and be knowledgeable enough to discuss complementary and alternative medicine therapies. Without involvement of complementary and alternative medicine communication on the part of our profession, we may put our patients at risk of uninformed and without medical guidance.

Estimation of the binding modes with important human cytochrome P450 enzymes, drug interaction potential, pharmacokinetics, and hepatotoxicity of ginger components using molecular docking, computational, and pharmacokinetic modeling studies

Ginger is one of the most commonly used herbal medicines for the treatment of numerous ailments and improvement of body functions. It may be used in combination with prescribed drugs. The coadministration of ginger with therapeutic drugs raises a concern of potential deleterious drug interactions via the modulation of the expression and/or activity of drug-metabolizing enzymes and drug transporters, resulting in unfavorable therapeutic outcomes. This study aimed to determine the molecular interactions between 12 main active ginger components (6-gingerol, 8-gingerol, 10-gingerol, 6-shogaol, 8-shogaol, 10-shogaol, ar-curcumene, β-bisabolene, β-sesquiphelandrene, 6-gingerdione, (-)-zingiberene, and methyl-6-isogingerol) and human cytochrome P450 (CYP) 1A2, 2C9, 2C19, 2D6, and 3A4 and to predict the absorption, distribution, metabolism, excretion, and toxicity (ADMET) of the 12 ginger components using computational approaches and comprehensive literature search. Docking studies showed that ginger components interacted with a panel of amino acids in the active sites of CYP1A2, 2C9, 2C19, 2D6, and 3A4 mainly through hydrogen bond formation, to a lesser extent, via π-π stacking. The pharmacokinetic simulation studies showed that the [I]/[Ki ] value for CYP2C9, 2C19, and 3A4 ranged from 0.0002 to 19.6 and the R value ranged from 1.0002 to 20.6 and that ginger might exhibit a high risk of drug interaction via inhibition of the activity of human CYP2C9 and CYP3A4, but a low risk of drug interaction toward CYP2C19-mediated drug metabolism. Furthermore, it has been evaluated that the 12 ginger components possessed a favorable ADMET profiles with regard to the solubility, absorption, permeability across the blood-brain barrier, interactions with CYP2D6, hepatotoxicity, and plasma protein binding. The validation results showed that there was no remarkable effect of ginger on the metabolism of warfarin in humans, whereas concurrent use of ginger and nifedipine exhibited a synergistic effect on platelet aggregation in humans. Moreover, ginger components showed a rapid half-life and no to low toxicity in humans. Taken together, this study shows that ginger components may regulate the activity and expression of various human CYPs, probably resulting in alterations in drug clearance and response. More studies are warranted to identify and confirm potential ginger-drug interactions and explore possible interactions of ginger with human CYPs and other functionally important proteins, to reduce and avoid side effects induced by unfavorable ginger-drug interactions.

Effects of capsicine on rat cytochrome P450 isoforms CYP1A2, CYP2C19, and CYP3A4

Due to the frequent consumption of capsaicin (CAP) and its current therapeutic application, the correct assessment of this compound is important from a public health standpoint. The purpose of this study was to find out whether CAP affects rat cytochrome P450 (CYP) enzymes (CYP1A2, CYP2C19, and CYP3A4) by using cocktail probe drugs in vivo. A cocktail solution at a dose of 5 mL/kg, which contained phenacetin (15 mg/kg), omeprazole (15 mg/kg), and midazolam (10 mg/kg), was given orally to rats treated for 7 d with oral administration of CAP. Blood samples were collected at a series of time-points and the concentrations of probe drugs in plasma were determined by HPLC-MS. The results showed that treatment with multiple doses of CAP had no significant effect on rat CYP1A2. However, CAP had a significant inhibitory effect on CYP2C19 and an inductive effect on CYP3A4. Therefore, caution is needed when CAP is co-administered with some CYP substrates clinically because of potential drug-CAP interactions.

Microbiological profiling and the demonstration of in vitro anti-bacterial traits of the major oral herbal medicines used in Dhaka Metropolis

Present study attempted to assess the level of microbiological contamination in oral herbal medicines, frequently used for medications, through conventional cultural and biochemical tests along with the antibiogram of the isolates. Moreover, the anti-bacterial potential of the herbal medicines was also aimed to be checked by the agar well diffusion method and minimum inhibitory concentration (MIC) assay. Out of 10 categories of liquid oral herbal medicine samples (n = 50) studied, all were found to be contaminated with bacteria (10(3)-10(5) cfu/mL), specifically with Staphylococcus spp. in 8 samples; while 2 samples harbored Klebsiella spp. Fungal presence was observed only in one sample. Study of antibiogram revealed Klebsiella spp. to be strongly resistant against penicillin G and erythromycin, whereas S. aureus possessed 80% sensitivity. The in vitro anti-bacterial activity was observed in 7 samples. Of them, one sample was found to exhibit the activity against almost all the test bacteria and another was found effective against 5 out of 8 test bacteria. Five samples showed the activity within a minor range while 3 samples were devoid of such trait. Samples 2 and 4 were found to stall the bacterial growth below 10 mg/mL of concentration in MIC test. Overall, the prevalence of specific pathogens was not so significant in the samples studied as well as only one drug-resistant isolate was identified. Besides, the anti-bacterial trait of 5 samples indicated that most of herbal medicines might be considered effective for medication.

Concurrent use of drugs and supplements in a community-dwelling population aged 50 years or more: potential benefits and risks

BACKGROUND

The use of vitamin and mineral (VMs) and non-vitamin/non-mineral supplements (non-VMs) in the general population and the older population in developed countries has increased. When combined with drugs, their use can be associated with benefit and potential risks.

OBJECTIVE

The aims of this study were to determine the extent and associated factors of the combined use of drugs and VM/non-VM supplements, and to examine the potential major drug-supplement interactions

METHODS

Cross-sectional analysis of first-wave data of TILDA, The Irish Longitudinal Study on Ageing, nationally representative a cohort including 8,081 community-dwelling persons aged ≥50 years. Prevalences including 95 % confidence intervals (CI) were weighted to the population. Group differences in drug and supplement use were assessed using Pearson's Chi-square test, and associations between concurrent drug-supplement use and covariates were assessed using logistic regression. Potential interactions between drugs and supplements were assessed using relevant sources.

RESULTS

Every seventh respondent (14.0 %; 95 % CI 13.1-15.0) reported regular concurrent use of drugs and supplements; 7.9 % (95 % CI 7.3-8.6) took only VMs, 3.9 % (95 % CI 3.4-4.4) took only non-VMs, and 2.2 % (95 % CI 1.8-2.6) took at least one of each concurrently with drugs. Concurrent use was more prevalent in women and in the oldest (≥75 years) group. Chronic disease, female sex, third-level education and private medical insurance were associated with an increased likelihood of use of both supplement types, whereas those classed as employed were much less likely to use any supplements. Supplements were combined with drugs in all of the commonly prescribed therapeutic groups, ranging from just under 60 % with drugs for bone diseases to 15.7 % with drugs for diabetes. Potential major drug-supplement interactions were detected in 4.5 % (95 % CI 3.4-5.8) of concurrent drug-supplement users, and were more prevalent in older respondents.

CONCLUSIONS

Concurrent use of drugs and supplements among those aged over 50 years in the Irish population is substantial and increases with age. There is considerable variation in usage, and the outcome of this approach is evidence of unmet need and therefore unrealised benefits among some subgroups, and of exposure to avoidable and potential serious drug interactions among others.

Systematic review of the incidence of herbal drug-induced liver injury in Korea

ETHNOPHARMACOLOGICAL RELEVANCE

Herbal drugs have been generally believed to be safe, based on the natural sources and long clinical experience. With the increasing use of herbal medicine worldwide, the potential toxicity of herbal drugs, especially drug-induced liver injury (DILI), frequently becomes a medical issue. This study was aimed to estimate the incidence of DILI following herbal drug consumption in Korea

METHODS AND MATERIALS

A literature search for herbal DILI in eight databases, including PubMed, Medline, the Cochrane Library, EMBASE, and four Korean electronic databases.

RESULTS

Six studies (three prospective and three retrospective) met the necessary criteria for assessment of the risk of DILI following herbal medicine exposure. The total number of participants in the six studies was 1699 (756 males and 943 females), and the incidence of herbal DILI varied from 0 to 1.92 among them. Total incidence of herbal DILI was 0.71% (12 patients with herbal DILI), and it was significantly higher in male (1.32%) than female (0.21%) respectively (p<0.01). All of the patients that experienced DILI concomitantly ingested herbal medicine and conventional drugs.

CONCLUSIONS

This result showed the comprehensive data indicating the incident risk of hepatotoxicity in patients using herbal drugs in Korea, and presented the possibility of increased risk for the DILI by concurrent administration of herbal and conventional medicines.

Pinelliae rhizoma, a toxic chinese herb, can significantly inhibit CYP3A activity in rats

Raw Pinelliae Rhizoma (RPR) is a representative toxic herb that is widely used for eliminating phlegm or treating cough and vomiting. Given its irritant toxicity, its processed products, including Pinelliae Rhizoma Praeparatum (PRP) and Pinelliae Rhizoma Praeparatum cum Zingibere et Alumine (PRPZA), are more commonly applied and administered concomitantly with other chemical drugs, such as cough medications. This study aimed to investigate the effects of RPR, PRP, and PRPZA on CYP3A activity. Testosterone (Tes) and buspirone (BP) were used as specific probe substrates ex vivo and in vivo, respectively. CYP3A activity was determined by the metabolite formation ratios from the substrates. Ex vivo results show that the metabolite formation ratios from Tes significantly decreased, indicating that RPR, PRP, and PRPZA could inhibit CYP3A activity in rats. CYP3A protein and mRNA levels were determined to explore the underlying mechanism. These levels showed marked and consistent down-regulation with CYP3A activity. A significant decrease in metabolite formation ratios from BP was also found in PRPZA group in vivo, implying that PRPZA could inhibit CYP3A activity. Conclusively, co-administration of PR with other CYP3A-metabolizing drugs may cause drug–drug interactions. Clinical use of PR-related formulae should be monitored carefully to avoid adverse interactions.