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An Updated Review on the Psychoactive, Toxic and Anticancer Properties of Kava. J Clin Med 2022; 11:jcm11144039. [PMID: 35887801 PMCID: PMC9315573 DOI: 10.3390/jcm11144039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 01/27/2023] Open
Abstract
Kava (Piper methysticum) has been widely consumed for many years in the South Pacific Islands and displays psychoactive properties, especially soothing and calming effects. This plant has been used in Western countries as a natural anxiolytic in recent decades. Kava has also been used to treat symptoms associated with depression, menopause, insomnia, and convulsions, among others. Along with its putative beneficial health effects, kava has been associated with liver injury and other toxic effects, including skin toxicity in heavy consumers, possibly related to its metabolic profile or interference in the metabolism of other xenobiotics. Kava extracts and kavalactones generally displayed negative results in genetic toxicology assays although there is sufficient evidence for carcinogenicity in experimental animals, most likely through a non-genotoxic mode of action. Nevertheless, the chemotherapeutic/chemopreventive potential of kava against cancer has also been suggested. Both in vitro and in vivo studies have evaluated the effects of flavokavains, kavalactones and/or kava extracts in different cancer models, showing the induction of apoptosis, cell cycle arrest and other antiproliferative effects in several types of cancer, including breast, prostate, bladder, and lung. Overall, in this scoping review, several aspects of kava efficacy and safety are discussed and some pertinent issues related to kava consumption are identified.
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Krum BN, de Freitas CM, Busanello A, Schaffer LF, Fachinetto R. Ex vivo and in vitro inhibitory potential of Kava extract on monoamine oxidase B activity in mice. J Tradit Complement Med 2021; 12:115-122. [PMID: 35528470 PMCID: PMC9072822 DOI: 10.1016/j.jtcme.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 01/13/2023] Open
Abstract
Background and aim Experimental procedure Results Conclusion Kava extract confirmed anxiolytic-like effect in mice. Kava extract reduced MAO-B activity in cortex and in the region containing substantia nigra in mice. Kava extract inhibited reversibly the MAO-B activity in vitro.
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3
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Zhao X, Su C, Ren R, Zhang B, Wang Y, Su X, Lu F, Zong R, Yang L, Zhang W, Ma X. Simultaneous determination of both kavalactone and flavokawain constituents by different single-marker methods in kava. J Sep Sci 2021; 44:2705-2716. [PMID: 33951745 DOI: 10.1002/jssc.202100198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/01/2021] [Accepted: 05/02/2021] [Indexed: 12/27/2022]
Abstract
Kava, the rhizomes and roots of Piper methysticum Forst, is a popular edible medicinal herb traditionally used to prepare beverages for anxiety reduction. Since the German kava ban has been lifted by the court, the quality evaluation is particularly important for its application, especially the flavokawains which were believed to be responsible for hepatotoxicity. Now, by employing two different standard references and four different methods to calculate the relative correction factors, eight different quantitative analyses of multicomponents by single-marker methods have been developed for the simultaneous determination of eight major kavalactones and flavokawains in kava. The low standard method difference on quantitative measurement of the compounds among the external standard method and ours confirmed the reliability of the mentioned methods. A radar plot clearly illustrated that the contents of dihydrokavain and kavain were higher, whereas flavokawains A and B were lower in different kava samples. Only one of eight samples did not detect flavokawains that may be related to hepatotoxicity. In summary, by using different agents as an internal standard reference, the developed methods were believed as a powerful analytical tool not only for the qualitative and quantitative of kava constituents but also for the other multicomponents when authentic standard substances were unavailable.
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Affiliation(s)
- Xiaojun Zhao
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Chao Su
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Ruru Ren
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Bo Zhang
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Yingli Wang
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Xiaojuan Su
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Fangfang Lu
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Rong Zong
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Lingling Yang
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Wannian Zhang
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
| | - Xueqin Ma
- Department of Pharmaceutical Analysis, School of Pharmacy, Key Laboratory of Hui Ethnic Medicine Modernization, Ministry of Education, Ningxia Medical University, Yinchuan, P. R. China
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Krum BN, Molz de Freitas C, Chiapinotto Ceretta AP, Barbosa CP, de Moraes Reis E, Scussel R, da Silva Córneo E, Machado-de-Ávila RA, Boligon AA, Fachinetto R. Kava decreases the stereotyped behavior induced by amphetamine in mice. JOURNAL OF ETHNOPHARMACOLOGY 2021; 265:113293. [PMID: 32841698 DOI: 10.1016/j.jep.2020.113293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/31/2020] [Accepted: 08/13/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Kava extract (Piper methysticum) is a phytotherapic mainly used for the treatment of anxiety. Although the reported effects of Kava drinking improving psychotic symptoms of patients when it was introduced to relieve anxiety in aboriginal communities, its effects on models of psychosis-like symptoms are not investigated. AIM OF THE STUDY To investigate the effects of Kava extract on behavioral changes induced by amphetamine (AMPH) and its possible relation with alterations in monoamine oxidase (MAO) activity. MATERIALS AND METHODS Mice received vehicle or Kava extract by gavage and, 2 h after vehicle or AMPH intraperitoneally. Twenty-five minutes after AMPH administration, behavioral (elevated plus maze, open field, stereotyped behavior, social interaction and Y maze) and biochemical tests (MAO-A and MAO-B activity in cortex, hippocampus and striatum) were sequentially evaluated. RESULTS Kava extract exhibited anxiolytic effects in plus maze test, increased the locomotor activity of mice in open field test and decreased MAO-A (in cortex) and MAO-B (in hippocampus) activity of mice. Kava extract prevented the effects of AMPH on stereotyped behavior and, the association between Kava/AMPH increased the number of entries into arms in Y maze test as well as MAO-B activity in striatum. However, Kava extract did not prevent hyperlocomotion induced by AMPH in open field test. The social interaction was not modified by Kava extract and/or AMPH. CONCLUSION The results showed that Kava extract decreased the stereotyped behavior induced by AMPH at the same dose that promotes anxiolytic effects, which could be useful to minimize the psychotic symptoms in patients.
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Affiliation(s)
- Bárbara Nunes Krum
- Programa de Pós-Graduação Em Farmacologia, Universidade Federal de Santa Maria, RS, Brazil.
| | - Catiuscia Molz de Freitas
- Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica Toxicológica, Universidade Federal de Santa Maria, RS, Brazil.
| | | | - Caroline Pilecco Barbosa
- Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica Toxicológica, Universidade Federal de Santa Maria, RS, Brazil.
| | - Elizete de Moraes Reis
- Programa de Pós-Graduação Em Farmacologia, Universidade Federal de Santa Maria, RS, Brazil.
| | - Rahisa Scussel
- Programa de Pós-Graduação Em Ciências da Saúde, Universidade Do Extremo Sul Catarinense, Criciúma, SC, Brazil.
| | - Emily da Silva Córneo
- Curso de Biomedicina, Universidade Do Extremo Sul Catarinense, Criciúma, SC, Brazil.
| | | | - Aline Augusti Boligon
- Programa de Pós-Graduação Em Ciências Farmacêuticas, Universidade Federal de Santa Maria, RS, Brazil.
| | - Roselei Fachinetto
- Programa de Pós-Graduação Em Farmacologia, Universidade Federal de Santa Maria, RS, Brazil; Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica Toxicológica, Universidade Federal de Santa Maria, RS, Brazil.
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Bian T, Corral P, Wang Y, Botello J, Kingston R, Daniels T, Salloum RG, Johnston E, Huo Z, Lu J, Liu AC, Xing C. Kava as a Clinical Nutrient: Promises and Challenges. Nutrients 2020; 12:E3044. [PMID: 33027883 PMCID: PMC7600512 DOI: 10.3390/nu12103044] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 12/20/2022] Open
Abstract
Kava beverages are typically prepared from the root of Piper methysticum. They have been consumed among Pacific Islanders for centuries. Kava extract preparations were once used as herbal drugs to treat anxiety in Europe. Kava is also marketed as a dietary supplement in the U.S. and is gaining popularity as a recreational drink in Western countries. Recent studies suggest that kava and its key phytochemicals have anti-inflammatory and anticancer effects, in addition to the well-documented neurological benefits. While its beneficial effects are widely recognized, rare hepatotoxicity had been associated with use of certain kava preparations, but there are no validations nor consistent mechanisms. Major challenges lie in the diversity of kava products and the lack of standardization, which has produced an unmet need for quality initiatives. This review aims to provide the scientific community and consumers, as well as regulatory agencies, with a broad overview on kava use and its related research. We first provide a historical background for its different uses and then discuss the current state of the research, including its chemical composition, possible mechanisms of action, and its therapeutic potential in treating inflammatory and neurological conditions, as well as cancer. We then discuss the challenges associated with kava use and research, focusing on the need for the detailed characterization of kava components and associated risks such as its reported hepatotoxicity. Lastly, given its growing popularity in clinical and recreational use, we emphasize the urgent need for quality control and quality assurance of kava products, pharmacokinetics, absorption, distribution, metabolism, excretion, and foundational pharmacology. These are essential in order to inform research into the molecular targets, cellular mechanisms, and creative use of early stage human clinical trials for designer kava modalities to inform and guide the design and execution of future randomized placebo controlled trials to maximize kava's clinical efficacy and to minimize its risks.
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Affiliation(s)
- Tengfei Bian
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (T.B.); (P.C.); (Y.W.); (J.B.)
| | - Pedro Corral
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (T.B.); (P.C.); (Y.W.); (J.B.)
| | - Yuzhi Wang
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (T.B.); (P.C.); (Y.W.); (J.B.)
| | - Jordy Botello
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (T.B.); (P.C.); (Y.W.); (J.B.)
| | - Rick Kingston
- College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Tyler Daniels
- Thorne Research Inc., Industrial Road, 620 Omni Dr, Summerville, SC 29483, USA;
| | - Ramzi G. Salloum
- Department of Health Outcome & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Edward Johnston
- The Association for Hawaiian Awa (kava), Pepe’ekeo, HI 96783, USA;
| | - Zhiguang Huo
- Department of Biostatistics, College of Public Health & Health Professions, College of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Junxuan Lu
- Department of Pharmacology, Penn State University College of Medicine, Hershey, PA 17033, USA;
| | - Andrew C. Liu
- Department of Physiology and Functional Genomics, College of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Chengguo Xing
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (T.B.); (P.C.); (Y.W.); (J.B.)
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Kashyap K, Kakkar R. Pharmacophore-enabled virtual screening, molecular docking and molecular dynamics studies for identification of potent and selective histone deacetylase 8 inhibitors. Comput Biol Med 2020; 123:103850. [PMID: 32658783 DOI: 10.1016/j.compbiomed.2020.103850] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/15/2022]
Abstract
Histone deacetylases (HDACs) play important roles in various biological processes, but are also notorious for their over-expression in numerous cancers and neurological disorders. Therefore, the development of isoform selective HDAC inhibitors is crucial in order to prevent any side effects of pan inhibition. This work focuses on identifying novel inhibitors for the selective inhibition of HDAC8, an isoform implicated in fatal diseases like T-cell lymphoma, colon cancer and childhood neuroblastoma. Virtual screening of the 'In-trials' subset of ZINC database has been carried out with the help of two pharmacophore models signifying potent and selective HDAC8 inhibition. A detailed molecular docking strategy, followed by molecular dynamics simulations and post-scoring with MM-GBSA calculations, has led to the identification of six promising molecules that have excellent binding with the HDAC8 active site. In order to establish the selectivity profile of these molecules, their binding to off-target HDAC isoforms has also been evaluated. Substitution analyses of the proposed inhibitors suggest that aromatic substituents that access the adjacent hydrophobic pocket of the HDAC8 active site have the potential to further enhance the HDAC8 selectivity.
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Affiliation(s)
- Kriti Kashyap
- Computational Chemistry Laboratory, Department of Chemistry, University of Delhi, Delhi, 110007, India
| | - Rita Kakkar
- Computational Chemistry Laboratory, Department of Chemistry, University of Delhi, Delhi, 110007, India.
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Nami M, Mehrabi S, Kamali AM, Kazemiha M, Carvalho J, Derman S, Lakey-Betia J, Vasquez V, Kosagisharaf R. A New Hypothesis on Anxiety, Sleep Insufficiency, and Viral Infections; Reciprocal Links to Consider in Today's "World vs. COVID-19" Endeavors. Front Psychiatry 2020; 11:585893. [PMID: 33250794 PMCID: PMC7674554 DOI: 10.3389/fpsyt.2020.585893] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/24/2020] [Indexed: 12/19/2022] Open
Abstract
In today's ever-growing concerns about the coronavirus disease (COVID-19) pandemic, many experience sleep insufficiencies, such as difficulty falling or staying asleep, sleep-related behavioral symptoms, and out-of-phase circadian rhythmicity despite the lack of history of earlier such symptoms. Meanwhile, the disruption in sleep bioparameters is experienced more in people with a history of sleep disorders. The behavioral sleep disorders in the current situations are prevalent given the today's amount of anxiety everyone is feeling about COVID-19. On the other hand, evidences indicated that the cross-link between impaired sleep efficiency and disrupted innate immunity makes people susceptible to viral infections. The present brief review highlights the links between psychosocial stress, sleep insufficiency, and susceptibility to viral infections in relevance to COVID-19 situation. The stress management measures, including addressing sleep-related disorders and sleep hygiene, will have a notable impact by harnessing immune response and thus reducing the susceptibility to viral infections.
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Affiliation(s)
- Mohammad Nami
- Department of Neuroscience, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran.,Dana Brain Health Institute, Iranian Neuroscience Society-Fars Chapter, Shiraz, Iran.,Academy of Health, Senses Cultural Foundation, Sacramento, CA, United States.,Neuroscience Center, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panama City, Panama.,Sleep Disorders Laboratory, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Samrad Mehrabi
- Sleep Disorders Laboratory, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.,Division of Pulmonology, Department of Internal Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali-Mohammad Kamali
- Department of Neuroscience, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran.,Dana Brain Health Institute, Iranian Neuroscience Society-Fars Chapter, Shiraz, Iran
| | - Milad Kazemiha
- Department of Neuroscience, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran.,Dana Brain Health Institute, Iranian Neuroscience Society-Fars Chapter, Shiraz, Iran
| | | | - Sabri Derman
- Sleep Disorders Unit, American Hospital, Koc Foundation, Istanbul, Turkey
| | - Johant Lakey-Betia
- Centre for Biodiversity and Drug Discovery, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panama City, Panama
| | - Velmarini Vasquez
- Neuroscience Center, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panama City, Panama
| | - Rao Kosagisharaf
- Neuroscience Center, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Panama City, Panama
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8
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Petersen GE, Tang Y, Fields C. Chemical and in vitro toxicity analysis of a supercritical fluid extract of Kava kava (Piper methysticum). JOURNAL OF ETHNOPHARMACOLOGY 2019; 235:301-308. [PMID: 30710733 DOI: 10.1016/j.jep.2019.01.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/21/2018] [Accepted: 01/27/2019] [Indexed: 06/09/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Kava and kava extracts have shown great potential as a way to minimize anxiety-associated symptoms and to help alleviate pain. Hepatoxicity has been associated with the consumption of kava products. The chemical compounds, kavalactones (KL) and flavokavains (FK) have been implicated in kava's psychotropic and possible hepatotoxic properties. AIM OF THE STUDY To investigate the kavalactone and flavokavain content and in vitro toxicity of KAVOA™, a supercritical carbon dioxide extraction (SFE) of kava. MATERIALS AND METHODS Kavalactone and flavokavain content of SFE kava and noble kava root were determined following extraction in acetone, cell culture media, and water using ultra high-performance liquid chromatography (UHPLC). Using water extractions of the kava products, the cell viability and toxicity on the human hepatocellular carcinoma cell line (HepG2) were determined using luminescent and fluorescent assays, respectively. The half maximal inhibitory concentration (IC50) of the SFE kava and noble kava root, extracted in cell culture media, were determined utilizing a luminescent cell viability assay. RESULTS Quantification of the KAVOA™, a SFE extract of kava and kava root showed similar profiles of kavalactone and flavokavain content. Water extracted SFE and root kava did not show a negative impact on cell viability and toxicity when compared to the vehicle control treated cells. IC50 values were determined for the SFE kava and kava root extracted in cell culture media in respect to cell viability, 78.63 and 47.65 µg/mL, respectively. CONCLUSIONS KAVOA™, a supercritical carbon dioxide extract of kava displays a similar kavalactone profile to a noble variety of kava. In relation to total kavalactone content, KAVOA™ also has a lower content of the cytotoxic compound FKB. Aqueous extractions of KAVOA™ and noble kava root had no significant negative impact on cell viability and toxicity on HepG2 cells when compared to vehicle controlled treated cells. Results indicate KAVOA™ demonstrates a similar in vitro safety profile to that of noble kava root when experiments are normalized to kavalactone content.
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Affiliation(s)
- Greg E Petersen
- Applied Food Sciences, Inc., 2500 Crosspark Road, Coralville, IA 52241, USA.
| | - Yijin Tang
- Applied Food Sciences, Inc., 2500 Crosspark Road, Coralville, IA 52241, USA.
| | - Christine Fields
- Applied Food Sciences, Inc., 2500 Crosspark Road, Coralville, IA 52241, USA.
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The effectiveness and safety of Kava Kava for treating anxiety symptoms: A systematic review and analysis of randomized clinical trials. Complement Ther Clin Pract 2018; 33:107-117. [PMID: 30396607 DOI: 10.1016/j.ctcp.2018.09.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/23/2018] [Accepted: 09/12/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND To determine if Kava Kava is an effective treatment for combating symptoms of anxiety despite warnings of hepatotoxicity from the Centers for Disease Control and Prevention (CDC). METHODS Databases PubMed, CINAHL, and PsycINFO were utilized to obtain clinical trials on Kava Kava and its effects on anxiety. A total of 11 articles met inclusion/exclusion criteria: 2 for Kava Kava vs. another anti-anxiety medication, 2 detailing additional adverse events, and 7 for Kava Kava vs. placebo. Mantel-Haenszel fixed-effects model was used to analyze the data, with responder rates being pooled to compute weighted risk ratios. RESULTS Kava Kava was shown to be more effective than placebo in 3 of the 7 trials. A final risk ratio of 1.50 (95% CI: 1.12, 2.01) from responder rates was calculated in favor of the intervention from 5 clinical trials (n = 330). Adverse events were shown to be the same as placebo (P = 0.574), and laboratory values analyzing hepatotoxicity were no different when compared to baseline except in two studies. CONCLUSIONS Kava Kava appears to be a short-term treatment for anxiety, but not a replacement for prolonged anti-anxiety use. Although not witnessed in this review, liver toxicity is especially possible if taken longer than 8 weeks.
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Khoshroo A, Hosseinzadeh L, Sobhani-Nasab A, Rahimi-Nasrabadi M, Ehrlich H. Development of electrochemical sensor for sensitive determination of oxazepam based on silver-platinum core–shell nanoparticles supported on graphene. J Electroanal Chem (Lausanne) 2018. [DOI: 10.1016/j.jelechem.2018.05.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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11
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White CM. The Pharmacology, Pharmacokinetics, Efficacy, and Adverse Events Associated With Kava. J Clin Pharmacol 2018; 58:1396-1405. [PMID: 29791008 DOI: 10.1002/jcph.1263] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/26/2018] [Indexed: 12/12/2022]
Abstract
Kava is a plant with numerous kavapyrones that can induce pharmacologic effects and drug interactions through the cytochrome P450 and P-glycoprotein systems. Kava is used recreationally and for the treatment of anxiety. Clinical trials verify anxiolytic effects in excess of placebo, but the effects are not seen immediately and the optimal dose and dosing schedule needs to be determined. Clinical trials usually lasting for 4 weeks found generally good tolerability and safety; however, dermatologic, hepatologic, and cognitive adverse effects may occur. Some of these adverse effects are known to occur from the kavapyrones themselves, while others can be caused or exacerbated by use of substandard kava products. There is tremendous variability in the constitution of a kava product based on the parts of the plant that are being extracted and the extraction method. The most commonly studied extract for the treatment of anxiety is the acetone extract.
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Affiliation(s)
- C Michael White
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Director, Health Outcomes, Policy, and Evidence Synthesis (HOPES) Research Group, UConn and Hartford Hospital, Hartford, CT, USA
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12
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Ooi SL, Henderson P, Pak SC. Kava for Generalized Anxiety Disorder: A Review of Current Evidence. J Altern Complement Med 2018; 24:770-780. [PMID: 29641222 DOI: 10.1089/acm.2018.0001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Generalized anxiety disorder (GAD) is a chronic and debilitating condition characterized by persistent and overpowering anxiety. Treatment of GAD with antidepressants and benzodiazepines is only moderately effective and not free from side effects. Kava (Piper methysticum) has been explored as a potential phytotherapeutic option for GAD. OBJECTIVES To perform a systematic review and meta-analysis of the available evidence on Kava as a treatment for GAD. METHODS Systematic search of English-language publications from major databases for clinical trials reporting the effects of Kava for the treatment of GAD. RESULTS Twelve articles were included in this review. Evidence supporting Kava as an effective treatment for GAD was found in two placebo-controlled trials and a reference-controlled trial. One negative trial demonstrated that Kava was not more effective than placebo. Meta-analyses of the results of three placebo-controlled trials (n = 130) favored Kava for GAD treatment with effect sizes between 0.59 and 0.99 (standard mean difference) without reaching statistical significance. Kava is an appealing treatment option to GAD patients who are more attune to natural remedies or lifestyle approaches to reduce stress. Positive patient experiences and improvement of vagal cardiac control due to Kava treatment were also reported in the literature. Kava is safe and well tolerated for short-term (4-8 weeks) therapeutic use at a dosage of 120-280 mg per day of Kavalactones, regardless of dosage schedule. CONCLUSIONS Current evidence, although promising, is insufficient to confirm the effect of Kava for GAD treatment beyond placebo. New evidence is expected from a large, multisite ongoing trial.
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Affiliation(s)
- Soo Liang Ooi
- 1 Centre for Complementary and Alternative Medicine , Singapore, Singapore
| | - Penny Henderson
- 2 School of Biomedical Sciences, Charles Sturt University , Bathurst, Australia
| | - Sok Cheon Pak
- 2 School of Biomedical Sciences, Charles Sturt University , Bathurst, Australia
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13
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Yeung KS, Hernandez M, Mao JJ, Haviland I, Gubili J. Herbal medicine for depression and anxiety: A systematic review with assessment of potential psycho-oncologic relevance. Phytother Res 2018; 32:865-891. [PMID: 29464801 DOI: 10.1002/ptr.6033] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/08/2017] [Accepted: 12/21/2017] [Indexed: 12/14/2022]
Abstract
Anxiety and depression are prevalent among cancer patients, with significant negative impact. Many patients prefer herbs for symptom relief to conventional medications which have limited efficacy/side effects. We identified single-herb medicines that may warrant further study in cancer patients. Our search included PubMed, Allied and Complementary Medicine, Embase, and Cochrane databases, selecting only single-herb randomized controlled trials between 1996 and 2016 in any population for data extraction, excluding herbs with known potential for interactions with cancer treatments. One hundred articles involving 38 botanicals met our criteria. Among herbs most studied (≥6 randomized controlled trials each), lavender, passionflower, and saffron produced benefits comparable to standard anxiolytics and antidepressants. Black cohosh, chamomile, and chasteberry are also promising. Anxiety or depressive symptoms were measured in all studies, but not always as primary endpoints. Overall, 45% of studies reported positive findings with fewer adverse effects compared with conventional medications. Based on available data, black cohosh, chamomile, chasteberry, lavender, passionflower, and saffron appear useful in mitigating anxiety or depression with favorable risk-benefit profiles compared to standard treatments. These may benefit cancer patients by minimizing medication load and accompanying side effects. However, well-designed larger clinical trials are needed before these herbs can be recommended and to further assess their psycho-oncologic relevance.
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Affiliation(s)
- K Simon Yeung
- Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Marisol Hernandez
- Information Systems/Medical Library, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Jun J Mao
- Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Ingrid Haviland
- Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Jyothirmai Gubili
- Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
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Niu L, Ding L, Lu C, Zuo F, Yao K, Xu S, Li W, Yang D, Xu X. Flavokawain A inhibits Cytochrome P450 in in vitro metabolic and inhibitory investigations. JOURNAL OF ETHNOPHARMACOLOGY 2016; 191:350-359. [PMID: 27318274 DOI: 10.1016/j.jep.2016.06.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 05/18/2016] [Accepted: 06/13/2016] [Indexed: 06/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Flavokawain A, the major chalcone in kava extracts, was served as beverages for informal social occasions and traditional ceremonials in most South Pacific islands. It exhibited strong antiproliferative and apoptotic effects against human prostate and urinary bladder cancer cells. AIM OF THE STUDY The current study was purposed to investigate the interaction between Flavokawain A and Cytochrome P450, including the inhibitory effects of Flavokawain A on predominant CYP450 isotypes and further clarified the inhibitory mechanism of FKA on CYP450 enzymes. Besides, study about identifying the key CYP450 isotypes responsible for the metabolism of FKA was also performed. MATERIALS AND METHODS In this study, probe-based assays with rat liver microsome system were used to characterize the inhibitory effects of FKA. Molecular docking study was performed to further explore the binding site of FKA on CYP450 isoforms. In addition, chemical inhibition experiments using specific inhibitors (a-naphthoflavone, quinidine, sulfamethoxazde, ketoconazole, omeprazole) were performed to clarify the individual CYP450 isoform that are responsible for the metabolism of FKA. RESULTS FKA showed significant inhibition on CYP1A2, CYP2D1, CYP2C6 and CYP3A2 activities with IC50 values of 102.23, 20.39, 69.95, 60.22μmol/L, respectively. The inhibition model was competitive, mixed-inhibition, uncompetitive, and noncompetitive for CYP1A2, CYP2D1, CYP2C6 and CYP3A2 enzymes. Molecular docking study indicated the ligand-binding conformation of FKA in the active site of CYP450 isoforms. The chemical inhibition experiments showed that the metabolic clearance rate of Flavokawain A decreased to 19.84%, 50.38%, and 67.02% of the control in the presence of ketoconazole, sulfamethoxazde and a-naphthoflavone. CONCLUSION The study showed that Flavokawain A has varying inhibitory effect on CYP450 enzymes and CYP3A2 was the principal CYP isoform contributing to the metabolism of Flavokawain A. Besides, CYP2C6 and CYP1A2 isoforms also play important roles in the metabolism of FKA. Our results provided a basis for better understanding the biotransformation of FKA and prediction of drug-drug interaction of FKA.
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Affiliation(s)
- Lifeng Niu
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China
| | - Lina Ding
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China
| | - Chunyun Lu
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China
| | - Feifei Zuo
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China
| | - Ke Yao
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China
| | - Shaobo Xu
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China
| | - Wen Li
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China
| | - Donghua Yang
- Department of Pharmaceutical Sciences,College of Pharmacy and Health Sciences, St. John's University, 8000 Utopia Parkway, Queens, New York, NY 11439, USA
| | - Xia Xu
- College of Pharmacy, Zhengzhou University, Ke Xue Road, Zhengzhou, China.
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15
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Howland RH. Oxazepam for the Treatment of Substance Abuse and Depression: Is it Appropriate? J Psychosoc Nurs Ment Health Serv 2016; 54:21-4. [DOI: 10.3928/02793695-20160420-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Savage KM, Stough CK, Byrne GJ, Scholey A, Bousman C, Murphy J, Macdonald P, Suo C, Hughes M, Thomas S, Teschke R, Xing C, Sarris J. Kava for the treatment of generalised anxiety disorder (K-GAD): study protocol for a randomised controlled trial. Trials 2015; 16:493. [PMID: 26527536 PMCID: PMC4630875 DOI: 10.1186/s13063-015-0986-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Generalised anxiety disorder (GAD) is a chronic and pervasive condition that generates high levels of psychological stress, and it is difficult to treat in the long term. Current pharmacotherapeutic options for GAD are in some cases only modestly effective, and may elicit undesirable side effects. Through targeted actions on the gamma-aminobutyric acid (GABA) pathway, the South Pacific medicinal plant kava (Piper methysticum) is a non-addictive, non-hypnotic anxiolytic with the potential to treat GAD. The evidence for the efficacy of kava for treating anxiety has been affirmed through clinical trials and meta-analyses. Recent research has also served to lessen safety concerns regarding the use of kava due to hepatotoxic risk, which is reflected in a recent German court overturning the previous kava ban in that country (which may in turn influence a reinstatement by the European Union). The aim of current research is to assess the efficacy of an 'aqueous noble cultivar rootstock extract' of kava in GAD in a larger longer term study. In addition, we plan to investigate the pharmacogenomic influence of GABA transporters on response, effects of kava on gene expression, and for the first time, the neurobiological correlates of treatment response via functional and metabolic imaging. METHODS/DESIGN This clinical trial is funded by the Australian National Health and Medical Research Council (APP1063383) and co-funded by MediHerb (Integria Healthcare (Australia) Pty. Ltd). The study is a phase III, multi-site, two-arm, 18-week, randomised, double-blind, placebo-controlled study using an aqueous extract of noble kava cultivar (standardised to 240 mg of kavalactones per day) versus matching placebo in 210 currently anxious participants with diagnosed GAD who are non-medicated. The study takes place at two sites: the Centre for Human Psychopharmacology (Swinburne University of Technology), Hawthorn, Melbourne, Australia; and the Academic Discipline of Psychiatry (The University of Queensland) based at the Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia. Written informed consent will be obtained from each participant prior to commencement in the study. The primary outcome is the Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A). The secondary outcomes involve a range of scales that assess affective disorder symptoms and quality of life outcomes, in addition to the study of mediating biomarkers of response (assessed via genomics and neuroimaging). DISCUSSION If this study demonstrates positive findings in support of the superiority of kava over placebo in the treatment of GAD, and also is shown to be safe, then this plant-medicine can be considered a 'first-line' therapy for GAD. Genomic and neuroimaging data may reveal clinical response patterns and provide more evidence of the neurobiological activity of the plant extract. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov: NCT02219880 Date: 13 August 2014:.
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Affiliation(s)
- Karen M Savage
- The University of Melbourne, Department of Psychiatry, The Melbourne Clinic, Melbourne, Australia.
- Swinburne University of Technology, Centre for Human Psychopharmacology, Swinburne, Australia.
| | - Con K Stough
- Swinburne University of Technology, Centre for Human Psychopharmacology, Swinburne, Australia.
| | - Gerard J Byrne
- Department of Psychiatry, The University of Queensland, Melbourne, Australia.
| | - Andrew Scholey
- Swinburne University of Technology, Centre for Human Psychopharmacology, Swinburne, Australia.
| | - Chad Bousman
- Swinburne University of Technology, Centre for Human Psychopharmacology, Swinburne, Australia.
- Department of Psychiatry, The University of Melbourne, Parkville, Australia.
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia.
- Department of General Practice, The University of Melbourne, Parkville, Australia.
| | - Jenifer Murphy
- The University of Melbourne, Department of Psychiatry, The Melbourne Clinic, Melbourne, Australia.
| | - Patricia Macdonald
- Department of Psychiatry, The University of Queensland, Melbourne, Australia.
| | - Chao Suo
- Brain and Mental Health Laboratory, School of Psychological Science, Monash University, Monash, Australia.
| | - Matthew Hughes
- Swinburne University of Technology, Brain and Psychological Sciences Centre, Swinburne, Australia.
| | - Stuart Thomas
- School of Psychological Science, Monash University, Monash, Australia.
| | - Rolf Teschke
- Department of Internal Medicine II, Section of Gastroenterology and Hepatology, Klinikum Hanau, Teaching Hospital of the Johann Wolfgang Goethe University of Frankfurt/Main, Frankfurt, Germany.
| | - Chengguo Xing
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Duluth, USA.
| | - Jerome Sarris
- The University of Melbourne, Department of Psychiatry, The Melbourne Clinic, Melbourne, Australia.
- Swinburne University of Technology, Centre for Human Psychopharmacology, Swinburne, Australia.
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Kava in the treatment of generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychopharmacol 2013; 33:643-8. [PMID: 23635869 DOI: 10.1097/jcp.0b013e318291be67] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Kava (Piper methysticum) is a plant-based medicine, which has been previously shown to reduce anxiety. To date, however, no placebo-controlled trial assessing kava in the treatment of generalized anxiety disorder (GAD) has been completed. A total of 75 participants with GAD and no comorbid mood disorder were enrolled in a 6-week double-blind trial of an aqueous extract of kava (120/240 mg of kavalactones per day depending on response) versus placebo. γ-Aminobutyric acid (GABA) and noradrenaline transporter polymorphisms were also analyzed as potential pharmacogenetic markers of response. Reduction in anxiety was measured using the Hamilton Anxiety Rating Scale (HAMA) as the primary outcome. Intention-to-treat analysis was performed on 58 participants who met inclusion criteria after an initial 1 week placebo run-in phase. Results revealed a significant reduction in anxiety for the kava group compared with the placebo group with a moderate effect size (P = 0.046, Cohen d = 0.62). Among participants with moderate to severe Diagnostic and Statistical Manual of Mental Disorders-diagnosed GAD, this effect was larger (P = 0.02; d = 0.82). At conclusion of the controlled phase, 26% of the kava group were classified as remitted (HAMA ≤ 7) compared with 6% of the placebo group (P = 0.04). Within the kava group, GABA transporter polymorphisms rs2601126 (P = 0.021) and rs2697153 (P = 0.046) were associated with HAMA reduction. Kava was well tolerated, and aside from more headaches reported in the kava group (P = 0.05), no other significant differences between groups occurred for any other adverse effects, nor for liver function tests. Standardized kava may be a moderately effective short-term option for the treatment of GAD. Furthermore, specific GABA transporter polymorphisms appear to potentially modify anxiolytic response to kava.
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Plant-based medicines for anxiety disorders, part 2: a review of clinical studies with supporting preclinical evidence. CNS Drugs 2013; 27:301-19. [PMID: 23653088 DOI: 10.1007/s40263-013-0059-9] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Research in the area of herbal psychopharmacology has revealed a variety of promising medicines that may provide benefit in the treatment of general anxiety and specific anxiety disorders. However, a comprehensive review of plant-based anxiolytics has been absent to date. Thus, our aim was to provide a comprehensive narrative review of plant-based medicines that have clinical and/or preclinical evidence of anxiolytic activity. We present the article in two parts. In part one, we reviewed herbal medicines for which only preclinical investigations for anxiolytic activity have been performed. In this current article (part two), we review herbal medicines for which there have been both preclinical and clinical investigations of anxiolytic activity. A search of MEDLINE (PubMed), CINAHL, Scopus and the Cochrane Library databases was conducted (up to 28 October 2012) for English language papers using the search terms 'anxiety' OR 'anxiety disorder' OR 'generalized anxiety disorder' OR 'social phobia' OR 'post-traumatic stress disorder' OR 'panic disorder' OR 'agoraphobia' OR 'obsessive compulsive disorder' in combination with the search terms 'Herb*' OR 'Medicinal Plants' OR 'Botanical Medicine' OR 'Chinese herb*', in addition to individual herbal medicines. This search of the literature revealed 1,525 papers, of which 53 plants were included in the review (having at least one study using the whole plant extract). Of these plants, 21 had human clinical trial evidence (reviewed here in part two), with the other 32 having solely preclinical evidence (reviewed in part one). Support for efficacy was found for chronic use (i.e. greater than one day) of the following herbs in treating a range of anxiety disorders in human clinical trials: Piper methysticum, Matricaria recutita, Ginkgo biloba, Scutellaria lateriflora, Silybum marianum, Passiflora incarnata, Withania somniferum, Galphimia glauca, Centella asiatica, Rhodiola rosea, Echinacea spp., Melissa officinalis and Echium amoenum. For several of the plants studied, conclusions need to be tempered due to methodological issues such as small sample sizes, brief intervention durations and non-replication. Current evidence does not support Hypericum perforatum or Valeriana spp. for any anxiety disorder. Acute anxiolytic activity was found for Centella asiatica, Salvia spp., Melissa officinalis, Passiflora incarnata and Citrus aurantium. Bacopa monnieri has shown anxiolytic effects in people with cognitive decline. The therapeutic application of psychotropic plant-based treatments for anxiety disorders is also discussed, specifically Psychotria viridis and Banisteriopsis caarti (ayahuasca), Psilocybe spp. and cannabidiol-enriched (low tetrahydrocannabinol (Δ(9)-THC)) Cannabis spp.
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Sarris J, Laporte E, Scholey A, King R, Pipingas A, Schweitzer I, Stough C. Does a medicinal dose of kava impair driving? A randomized, placebo-controlled, double-blind study. TRAFFIC INJURY PREVENTION 2013; 14:13-17. [PMID: 23259514 DOI: 10.1080/15389588.2012.682233] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OVERVIEW Increasing concerns over the potentially impairing effects of prescriptive sedative drugs such as benzodiazepines on driving have been raised. However, other alternatives such as natural medicines may also carry similar risks with respect to driving safety. Kava (Piper methysticum) is a psychotropic plant commonly used both recreationally and medicinally in the United States, Australia, and the South Pacific to elicit a physically tranquilizing effect. To date no controlled study has tested a medicinal dose of kava versus placebo and a standard sedative drug on driving ability and driving safety. OBJECTIVE Due to the need to establish the safety of kava in operating a motor vehicle, we compared the acute effects of the plant extract versus the benzodiazepine oxazepam and placebo using a driving simulator. METHODS A driving simulator (AusEd) was used by 22 adults aged between 18 and 65 years after being randomly administered an acute medicinal dose of kava (180 mg of kavalactones), oxazepam (30 mg), or placebo one week apart in a crossover design trial. RESULTS No impairing effects on driving outcomes were found after kava administration compared to placebo. Results on specific driving outcome domains revealed that the oxazepam condition had significantly slower braking reaction time compared to the placebo condition (p =.002) and the kava condition (p =.003). The kava condition had significantly fewer lapses of concentration compared to the oxazepam condition (p =.033). No significant differences were found between conditions for steering deviation, speed deviation, and number of crashes. Results were not modified by driving experience. On the Bond-Lader visual analogue sub-scale of alertness, a significant Treatment × Time interaction (p =.032) was found, with a significant reduction over time for oxazepam decreasing alertness (p <.001), whereas no significant reduction was found in the kava or placebo conditions. CONCLUSION The results indicate that a medicinal dose of kava containing 180 mg of kavalactones does not impair driving ability, whereas 30 mg of oxazepam shows some impairment. Research assessing larger recreational doses of kava on driving ability should now be conducted.
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Affiliation(s)
- J Sarris
- The University of Melbourne, Department of Psychiatry, Richmond, Melbourne, Victoria, Australia.
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