Occurrence of neurotoxic 4'-O-methylpyridoxine in Ginkgo biloba leaves, Ginkgo medications and Japanese Ginkgo food

Ultrasound-assisted fermentation of ginkgo kernel juice by Lactiplantibacillus plantarum: Microbial response and juice composition development

This study is aimed to explore the feasibility of ultrasound on enhancing the fermentation properties of ginkgo kernel juice by Lactiplantibacillus plantarum Y2. Specifically, ultrasound at 20 kHz and different intensities (mild ultrasound intensity-84.42 W/L, moderate ultrasound intensity-115.50 W/L, high ultrasound intensity-173.88 W/L) with a pulse mode were applied to facilitate the fermentation process. The number of viable cells of Lactiplantibacillus plantarum Y2 increased by 5.06, 5.05 and 2.19% in the sonicated groups at 173.88, 115.50 and 84.42 W/L, compared with the non-sonicated juice after 24-h fermentation. Furthermore, mild intensity ultrasonication improved the permeability of the cell membrane, which is beneficial for the metabolism of phenolics, amino acids and organic acids. Ultrasonication increased in-vitro antioxidant activity of fermented ginkgo kernel juice by promoting the metabolism of phenolic acids, such as ferulic acid, chlorogenic and caffeic acids. At the end of fermentation, the sonicated group at 84.42 W/L has the maximum consumptions of total sugars and proteins (increased by 12.52 and 18.73%). Moreover, the reduction rate of the poison material 4'-O-methylpyridoxine (MPN) in ginkgo kernel juice increased by more than 16.40% with ultrasound treatment at 173.88 W/L after the fermentation for 48 h. Overall, ultrasound can improve the metabolizations of Lactobacillus plantarum and reduce the toxic substances, which promoted the nutritional value and flavors of ginkgo kernel juice.

Fermentation of ginkgo biloba kernel juice using Lactobacillus plantarum Y2 from the ginkgo peel: Fermentation characteristics and evolution of phenolic profiles, antioxidant activities in vitro, and volatile flavor compounds

In this study, a strain of Lactobacillus plantarum Y2 was isolated from the ginkgo peel, and showed adequate adaptation to the ginkgo biloba kernel juice. After 48 h of fermentation, the number of viable cells in the stable growth phase was remained at 10.0 Log CFU/mL, while the content of total organic acid increased by 5.86%. Phenolic substances were significantly enriched, and the content of total phenolic substances increased by 9.72%, and the content of total flavonoids after fermentation exceeded 55.33 mg/L, which was 3.6 times that of the unfermented ginkgo juice. The total relative content of volatile flavor compounds increased by 125.48%, and 24 new volatile flavor substances were produced. The content of total sugar, total protein, and total free amino acid decreased to 44.85, 67.51, and 6.88%, respectively. Meanwhile, more than 82.25% of 4'-O-methylpyridoxine was degraded by lactic acid fermentation, and the final concentration in ginkgo biloba kernel juice was lower than 41.53 mg/L. In addition, the antioxidant and antibacterial activities of fermented ginkgo biloba kernel juice were significantly enhanced. These results showed that LAB fermentation could effectively improve the nutritional value and safety of ginkgo biloba kernel juice.

Ginkgo biloba: A Treasure of Functional Phytochemicals with Multimedicinal Applications

Ginkgo biloba is an ancient plant species that is thought to provide a variety of health benefits to living organisms and contains plenty of bioactive components, making it a chemically diversified plant. G. biloba has been shown to have a variety of medicinal and pharmacological properties, including anticancer, antidementia, antidiabetic, antiobesity, antilipidemic, antimicrobial, antioxidant, antilipid peroxidation, antiplatelet, anti-inflammatory, hepatoprotective, antidepressant, antiaging, immunomodulatory, antihypertensive, and neuroprotective effects and is frequently used to treat neurological, cardiovascular, and respiratory diseases, such as tardive dyskinesia. Therefore, this review described the therapeutic applications of G. biloba. In addition to describing the therapeutic potential, this review also evaluates the chemical constituents, toxicity, adverse effect, synergistic effect, and the clinical studies of this plant which have been utilized for therapeutic benefits but have demonstrated other consequences. The capacity of G. biloba components to act as free radical scavengers is critical, and combining its extract with other plant extracts has been shown to synergistically boost antioxidant properties. G. biloba used long-term or at high doses that resulted in some adverse effects. Severe drug interactions have also been reported in both animals and humans when combined with other medications. The available data established from both preclinical and clinical studies confirm the potential of G. biloba plant extract in various diseases. Besides, the safety and efficacy of G. biloba continue to require verification through additional experimentation to guide medicinal use.

A Facile Method to Determine the Native Contents of 4'-O-Methylpyridoxine and 4'-O-Methylpyridoxine-5'-glucoside in Ginkgo biloba Seeds

4'-O-Methylpyridoxine (MPN) and MPN-5'-glucoside (MPNG) are collectively known as ginkgotoxin, which are the main toxic ingredients of excessive consumption of Ginkgo biloba seeds. Water extraction is the generally adopted sample preparation method for high-performance liquid chromatography determination of ginkgotoxin. However, endogenous enzymes such as glycosidases in Ginkgo biloba seeds can hydrolyze MPNG to MPN in the process of water extraction, which will result in the measured contents of MPN and MPNG but not their natural contents in Ginkgo biloba seeds. In this work, inhibitors for the endogenous enzymes were first screened, and it was found that silver fluoride could effectively inhibit endogenous enzymes such as glucosidase and phosphatase. The optimized concentration of silver fluoride was 25 mmol/L, which could effectively inhibit the endogenous enzymes for more than 60 h. A new sample preparation method based on water extraction with 25 mmol/L silver fluoride addition was thus developed. This method was employed to determine the native contents of MPN and MPNG in the exotesta and kernel of five Ginkgo biloba seed cultivars. The result showed that the contents of MPNG in the exotesta and kernel of five cultivars were significantly higher than those of MPN. MPNG was present at high content in raw seeds, which was the main form of ginkgotoxin in seeds. The method established in this work is simple and effective and can be used to accurately quantify the native contents of MPN and MPNG.

In vivo toxicity assessment of 4'-O-methylpyridoxine from Ginkgo biloba seeds: Growth, hematology, metabolism, and oxidative parameters

4'-O-methylpyridoxine (MPN), a recognized antivitamin B₆ compound, is a potentially poisonous substance found in Ginkgo biloba seeds and leaves. In this work, the body weights, histopathological changes, plasma vitamin B₆ (VB₆), biochemical parameters, oxidative stress responses, and amino acids of rats were investigated after intragastric administration of MPN for 15 days. Results showed that intragastric administration of 50 mg/kg BW MPN caused pathological changes in the brain and heart tissues of rats. Administration of 10 mg/kg and 30 mg/kg BW MPN can significantly increase VB₆ analogs in the plasma of rats, such as pyridoxal-5'-phosphate, pyridoxal. Results of biochemical parameters indicated that MPN can damage brains and hearts by changing the enzyme activity of these organs. These results suggest that consumption of Ginkgo biloba seeds for the long term, even in a small quantity, may lead to poisoning.

Electroencephalographic investigation of the effects of Ginkgo biloba on spike-wave discharges in rats with genetic absence epilepsy

OBJECTIVE

EGb 761, a plant extract obtained from the leaves of the Ginkgo biloba tree, is widely used in modern medicine and traditional medicine applications in the treatment of many diseases. However, in some clinical case reports, it has been suggested that G. biloba causes epileptic seizures. A limited number of experimental animal studies related to the effects of G. biloba on epileptic seizures do not provide sufficient information on the solution of a serious clinical problem with contrasting findings. We aimed to investigate the effects of EGb 761 administered in different doses to adult male Wistar Albino Glaxo/Rijswijk (WAG/Rij) rats which is the genetic animal model of absence epilepsy, on absence seizures using in vivo electrophysiological method. In addition, the effects of EGb 761 doses on locomotor behavior of WAG/Rij rats were evaluated with open-field and rotarod behavioral tests.

METHODS

50, 100, 200, and 400 mg/kg doses of EGb 761 were administered to male WAG/Rij rats with implanted EEG electrodes by oral gavage for 28 days. Evaluation of absence seizures was performed on spike-wave discharges (SWDs) in EEG recorded for 4 h each week. The number of SWDs, the total duration of SWDs, and the mean duration of SWD were determined for the analysis.

RESULTS

In the group treated with 400 mg/kg EGb 761, the number of SWDs and the mean duration of SWD at the 1st and 7th doses and the total duration of SWDs at the 1st, 7th and 14th doses were significantly increased (p < 0.05). In all experimental groups treated with EGb 761 doses, there was no significant change in locomotor activity in the open-field and the rotarod tests.

CONCLUSION

Ginkgo biloba extract EGb 761 increased the epileptic SWD parameters of WAG/Rij rats at high doses (400 mg/kg), causing a pro-epileptic effect on absence seizures. It should be noted that in patients with epilepsy and in high-dose applications, G. biloba extract EGb 761 may lead to an increase in neuronal excitability.

4'-O-methylpyridoxine: Preparation from Ginkgo biloba Seeds and Cytotoxicity in GES-1 Cells

Ginkgo biloba seeds are wildly used in the food and medicine industry. It has been found that 4′-O-methylpyridoxine (MPN) is responsible for the poisoning caused by G. biloba seeds. The objective of this study was to explore and optimize the extraction method of MPN from G. biloba seeds, and investigate its toxic effect on human gastric epithelial cells (GES-1) and the potential related mechanisms. The results showed that the extraction amount of MPN was 1.933 μg/mg, when extracted at 40 °C for 100 min, with the solid–liquid ratio at 1:10. MPN inhibited the proliferation of GES-1 cells, for which the inhibition rate was 38.27% when the concentration of MPN was 100 μM, and the IC₅₀ value was 127.80 μM; meanwhile, the cell cycle was arrested in G2 phase. High concentration of MPN (100 μM) had significant effects on the nucleus of GES-1 cells, and the proportion of apoptotic cells reached 43.80%. Furthermore, the Western blotting analysis showed that MPN could reduce mitochondrial membrane potential by increasing the expression levels of apoptotic proteins Caspase 8 and Bax in GES-1 cells. In conclusion, MPN may induce apoptosis in GES-1 cells, which leads to toxicity in the human body.

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

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

Advances in the chemical constituents and chemical analysis of Ginkgo biloba leaf, extract, and phytopharmaceuticals

Ginkgo biloba leaf (GBL) is an important botanical drug that can be used for treating many diseases. This review summarizes the reported chemical constituents from GBL or Ginkgo biloba extract (GBE) to date, as well as the recent advances in the extraction, purification, qualitative and quantitative analysis methods (from 2015 to 2020). To date, about 110 flavonoids have been reported to have unambiguous structures, including flavonol and its glycosides, flavone and its glycosides, flavanone and its glycosides, isoflavone and its glycosides, flavan-3-ols, bioflavonoids, and biginkgosides. In recent years, in addition to new flavonoids, new terpenoids and lignan have been also isolated from GBL. Further, several extraction and purification methods have been described and compared. Quantitative analysis of the constituents have been mainly carried out by high-performance liquid chromatography with different detector methods. Many studies have focused on variations of compounds contents in GBL from different regions, tree ages, or collection times, which provide references for the selection of GBL. Liquid chromatography-mass spectrometry coupled with activity assay methods were used to on-line screen the bioactive compounds from GBL or its phytopharmaceuticals. The application of other analytical technologies such as MS imaging, supercritical fluid chromatography, capillary electrophoresis, quantitative nuclear magnetic resonance, and spectroscopy, has also been discussed. This review of the chemical constituents and analytical methods of Ginkgo will provide a reference for the research on the quality control and discovery of effective constituents for GBL and its related phytopharmaceuticals.

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

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

[Food Poisoning by Ginkgo Seeds through Vitamin B6 Depletion]

Overconsumption of Ginkgo biloba seeds induces food poisoning characterized by tonic-clonic convulsions and vomiting. The primary toxic component, 4'-O-methylpyridoxine (MPN), was purified from the seeds in 1985. This review includes the following aspects of ginkgo seed poisoning: 1) toxicity related to the content of MPN and MPN glucoside in G. biloba seeds; 2) the effect of MPN on vitamin B₆ analogs, including an increase in pyridoxal and pyridoxic acid and decrease in pyridoxal-5'-phosphate plasma concentrations; 3) case reports of ginkgo seed poisoning in Asia, North America, and Europe, and their effective treatment via vitamin B₆ administration. Considering the increase in the use of G. biloba seeds, it is essential to raise global awareness of their potential toxicity.

Effect of heat treatment on 4'-O-methylpyridoxine (MPN) content in Ginkgo biloba seed extract solution

BACKGROUND

A vitamin B₆ derivative, 4'-O-methylpyridoxine (MPN), is responsible for food poisoning by Ginkgo biloba seeds. In this study, we investigate the content of pyridoxine and MPN in MPN standard solution and G. biloba seed extract solution upon heat treatment in order to evaluate the reduction of toxic components in G. biloba seed by such treatment.

RESULTS

Heat treatment was conducted at 90-150 °C for 0-60 min, and all samples were adjusted to the same concentration of 1 g L^-1 . The MPN content decreased to 994.92-563.69 mg kg^-1 for MPN standard solution and to 371.56-76.84 mg kg^-1 for G. biloba seed extract solution, and in both cases decreased even further with increasing heat treatment time. However, in all samples, except for the 90 °C heat treatment group, the pyridoxine content in MPN standard solution increased with increasing heat temperature and time; in addition, the extract solution showed a similar tendency. This may be the result of thermal degradation of MPN into pyridoxine.

CONCLUSION

We can expect to improve the utilization of functional food materials by applying suitable heat treatment conditions and decreasing the MPN content of the G. biloba seed. © 2018 Society of Chemical Industry.

Determination and Comparison of 4'- O-Methylpyridoxine Analogues in Ginkgo biloba Seeds at Different Growth Stages

The antivitamin B₆, 4'- O-methylpyridoxine (MPN); its glucoside, 4'- O-methylpyridoxine-5'-glucoside (MPNG); and vitamin B₆ compounds, including pyridoxal (PL), pyridoxamine, pyridoxine, pyridoxal-5'-phosphate (PLP), and pyridoxamine-5'-phosphate, exist in Ginkgo biloba seeds, which are widely used as food and medicine. This work aimed to determine the MPN analogues in G. biloba seeds at different growth stages in terms of cultivars and ages of trees. The highest total MPN contents of 249.30, 295.62, and 267.85 μg/g were obtained in the mature stages of three selected G. biloba samples. The total contents of vitamin B₆ compounds decreased significantly in the entire growth period of the three samples. Principal-component analysis revealed that MPN and MPNG were important contributors in the MPN-analogue metabolism of G. biloba seeds. The influence of the cultivar on the content and composition of MPN analogues was greater than that of the age of the G. biloba tree.

Review of Ginkgo biloba-induced toxicity, from experimental studies to human case reports

Ginkgo biloba seeds and leaves have been used as a traditional herbal remedy for thousands of years, and its leaf extract has been consumed as a botanical dietary supplement for decades. Ginkgo biloba extract is a complex mixture with numerous components, including flavonol glycosides and terpene lactones, and is one of the most widely sold botanical dietary supplements worldwide. Concerns about potential health risks for the general population have been raised because of the widespread human exposure to Ginkgo biloba and its potential toxic and carcinogenic activities in rodents. The National Toxicology Program conducted 2-year gavage studies on one Ginkgo biloba leaf extract and concluded that there was clear evidence of carcinogenic activity of this extract in mice based on an increased incidence of hepatocellular carcinoma and hepatoblastoma. Recently, Ginkgo biloba leaf extract has been classified as a possible human carcinogen (Group 2B) by the International Agency for Research on Cancer. This review presents updated information on the toxicological effects from experimental studies both in vitro and in vivo to human case reports (caused by ginkgo seeds or leaves), and also summarizes the negative results from relatively large clinical trials.

Review of the use of botanicals for epilepsy in complementary medical systems--Traditional Chinese Medicine

In traditional Chinese medicine, botanical remedies have been used for centuries to treat seizures. This review aimed to summarize the botanicals that have been used in traditional Chinese medicine to treat epilepsy. We searched Chinese online databases to determine the botanicals used for epilepsy in traditional Chinese medicine and identified articles using a preset search syntax and inclusion criteria of each botanical in the PubMed database to explore their potential mechanisms. Twenty-three botanicals were identified to treat epilepsy in traditional Chinese medicine. The pharmacological mechanisms of each botanical related to antiepileptic activity, which were mainly examined in animal models, were reviewed. We discuss the use and current trends of botanical treatments in China and highlight the limitations of botanical epilepsy treatments. A substantial number of these types of botanicals would be good candidates for the development of novel AEDs. More rigorous clinical trials of botanicals in traditional Chinese medicine for epilepsy treatment are encouraged in the future. This article is part of a Special Issue entitled "Botanicals for Epilepsy".

Identification and quantification of biomarkers to confirm the poisoning by Ginkgo biloba seeds in a 2-year-old boy

Ginkgo seed poisoning was confirmed by measuring 4′-O-methyl pyridoxine (MPN) as a serum biomarkers. Picture shows the kinetic of MPN at 14 (B) and 20 (C) hours from intake.

Quantification of a botanical negative marker without an identical standard: ginkgotoxin in Ginkgo biloba

A new strategy for the analysis of natural products uses a combination of quantitative (1)H NMR (qHNMR) and adsorbent-free countercurrent separation (CS) methodology to establish a quantification method for ginkgotoxin (4'-O-methylpyridoxine) in Ginkgo biloba preparations. The target analyte was concentrated in a one-step CS process using the ChMWat +2 solvent system (CHCl3-MeOH-H2O, 10:5:5) and subsequently assayed by qHNMR. While commercial G. biloba seeds contained 59 μg of ginkgotoxin per seed, the compound was below the limit of detection (9 ppm) in a typical leaf extract. Due to the enrichment potential and loss-free operation of CS, the combination of CS and qHNMR is a generally suitable approach for threshold assays aimed at quantifying target compounds such as botanical negative markers at the low ppm level. As the proof of principle is demonstrated for relatively small CS capacities (20 mL, 1:40 loading) and modest NMR sensitivity (n = 16, 400 MHz, 5 mm RT probe), the approach can be adapted to quantification at the ppb level. The procedure enables the quantification of a botanical negative marker in the absence of identical reference material, which otherwise is a prerequisite for LC-based assays.

Herbal remedies, mood, and cognition

Herbal medicines were the "sole" source of medicine for thousands of years, in every culture since the advent of human civilization. Today, patients are increasing the use of these botanicals for numerous conditions, such as mood and cognition. This article will explore commonly used herbal remedies for mood and cognition functioning. It is imperative that nurses and nurse practitioners obtain expertise with these botanicals with regard to efficacy, adverse effects and contraindications, possible drug interactions, and safety considerations.

Ginkgo biloba and ginkgotoxin

Products prepared from Ginkgo biloba are top-selling phytopharmaceuticals especially in Europe and major botanical dietary supplements in the United States. In European medicine, G. biloba medications are used to improve memory, to treat neuronal disorders such as tinnitus or intermittent claudication, and to improve brain metabolism and peripheral blood flow. The whole array of indications is reflected by a number of defined natural product constituents in G. biloba. The most well-known ones are flavonoids and terpene lactones, but they also include allergenic and toxic compounds such as ginkgotoxin (1). Consequently, there are reports attributing beneficial as well as adverse effects to G. biloba products. The present paper summarizes recent experiences with G. biloba and its derived products and explains why their restricted use is recommended.

Vitamin B6: a long known compound of surprising complexity

In recent years vitamin B6 has become a focus of research describing the compound’s critical function in cellular metabolism and stress response. For many years the sole function of vitamin B6 was considered to be that of an enzymatic cofactor. However, recently it became clear that it is also a potent antioxidant that effectively quenches reactive oxygen species and is thus of high importance for cellular well-being. In view of the recent findings, the current review takes a look back and summarizes the discovery of vitamin B6 and the elucidation of its structure and biosynthetic pathways. It provides a detailed overview on vitamin B6 both as a cofactor and a protective compound. Besides these general characteristics of the vitamin, the review also outlines the current literature on vitamin B6 derivatives and elaborates on recent findings that provide new insights into transport and catabolism of the compound and on its impact on human health.

The Pdx1 family is structurally and functionally conserved between Arabidopsis thaliana and Ginkgo biloba

Vitamin B6 is one of the most important compounds in living organisms, and its biosynthesis has only recently been understood. Because it is required for more than 100 biochemical reactions, lack of the vitamin is fatal. This is of special importance to mammals and humans, which cannot biosynthesize the vitamin and thus depend on its external uptake. Here we describe the cloning of a vitamin B6 biosynthetic gene GbPDX1 from Ginkgo biloba. The gene is expressed in seeds, leaf and trunk tissue. Using yeast 2-hybrid and pull-down assays, we show that the protein can interact with itself and with members of Arabidopsis thaliana AtPDX1 and AtPDX2 families. Furthermore, we prove the function of GbPDX1 in vitamin B6 biosynthesis by complementation of an Arabidopsis AtPDX1.3 mutant rsr4-1, at the phenotypical level and increasing vitamin B6 levels caused by ectopic GbPDX1 expression in the mutant background. Overall, this study provides a first description of Ginkgo vitamin B6 metabolism, and demonstrates a high degree of conservation between Ginkgo and Arabidopsis.

Herbal medicine and epilepsy: proconvulsive effects and interactions with antiepileptic drugs

The use of complementary and alternative medicine is on the rise, including among patients with epilepsy. Herbal medicine, one of the most popular forms of CAM, is considered to be both safe and effective by most consumers. Yet many herbs may increase the risk for seizures, through intrinsic proconvulsant properties or contamination by heavy metals, as well as via effects on the cytochrome P450 enzymes and P-glycoproteins, altering antiepileptic drug (AED) disposition. Herb-drug interactions may be difficult to predict, especially since the quality and quantity of active ingredients are often unknown. Since most patients do not inform their physicians that they are taking herbal medicines, health care professionals must initiate a dialogue in order to prevent complications with the combined regimen. At the same time, further research is required regarding the effect of herbs on seizure activity and interactions with AED treatment.

Ginkgo biloba leave extract: biological, medicinal, and toxicological effects

Ginkgo biloba leave extract is among the most widely sold herbal dietary supplements in the United States. Its purported biological effects include: scavenging free radical; lowering oxidative stress; reducing neural damages, reducing platelets aggregation; anti-inflammation; anti-tumor activities; and anti-aging. Clinically, it has been prescribed to treat CNS disorders such as Alzheimer's disease and cognitive deficits. It exerts allergy and changes in bleeding time. While its mutagenicity or carcinogenic activity has not been reported, its components, quercetin, kaempferol and rutin have been shown to be genotoxic. There are no standards or guidelines regulating the constituent components of Ginkgo biloba leave extract nor are exposure limits imposed. Safety evaluation of Ginkgo biloba leave extract is being conducted by the U.S. National Toxicology Program.

The human pyridoxal kinase, a plausible target for ginkgotoxin fromGinkgo biloba

Ginkgotoxin (4'-O-methylpyridoxine) occurring in the seeds and leaves of Ginkgo biloba, is an antivitamin structurally related to vitamin B(6). Ingestion of ginkgotoxin triggers epileptic convulsions and other neuronal symptoms. Here we report on studies on the impact of B(6) antivitamins including ginkgotoxin on recombinant homogeneous human pyridoxal kinase (EC 2.7.1.35). It is shown that ginkgotoxin serves as an alternate substrate for this enzyme with a lower K(m) value than pyridoxal, pyridoxamine or pyridoxine. Thus, the presence of ginkgotoxin leads to temporarily reduced pyridoxal phosphate formation in vitro and possibly also in vivo. Our observations are discussed in light of Ginkgo medications used as nootropics.

Nutraceuticals: potential roles and potential risks for pain management

Over the past 2 decades, the world health market has been flooded with over the counter herbal products, also known as nutraceuticals. Although many of these products are neither recommended nor prescribed by conventional medical practitioners, an increasing number of people are taking these products on a daily basis. A recent survey at Texas Tech University School of Medicine in Lubbock, Texas concluded that 32% of patients scheduled for elective surgery or pain procedures were taking one or more herbal supplements; however, 70% did not disclose these during a routine anesthetic assessment.(1) Pain physicians are also increasingly needed in the care of these patients. As many of these agents carry a potential to cause bleeding problems, we have reviewed here briefly, the basic mechanisms of coagulation and correlated the role of commonly used herbs known to possess side effects, which can cause excessive bleeding. In addition, we have reviewed a number of potential useful herbal derived agents for pain management.

Analysis of the Arabidopsis rsr4-1/pdx1-3 mutant reveals the critical function of the PDX1 protein family in metabolism, development, and vitamin B6 biosynthesis

Vitamin B6 represents a highly important group of compounds ubiquitous in all living organisms. It has been demonstrated to alleviate oxidative stress and in its phosphorylated form participates as a cofactor in >100 biochemical reactions. By means of a genetic approach, we have identified a novel mutant, rsr4-1 (for reduced sugar response), with aberrant root and leaf growth that requires supplementation of vitamin B6 for normal development. Cloning of the mutated gene revealed that rsr4-1 carries a point mutation in a member of the PDX1/SOR1/SNZ (for Pyridoxine biosynthesis protein 1/Singlet oxygen resistant 1/Snooze) family that leads to reduced vitamin B6 content. Consequently, metabolism is broadly altered, mainly affecting amino acid, raffinose, and shikimate contents and trichloroacetic acid cycle constituents. Yeast two-hybrid and pull-down analyses showed that Arabidopsis thaliana PDX1 proteins can form oligomers. Interestingly, the mutant form of PDX1 has severely reduced capability to oligomerize, potentially suggesting that oligomerization is important for function. In summary, our results demonstrate the critical function of the PDX1 protein family for metabolism, whole-plant development, and vitamin B6 biosynthesis in higher plants.

Ginkgo biloba Use in Nursing Home Elderly with Epilepsy or Seizure Disorder

PURPOSE

Ginkgo biloba, among the most widely used herbs, possesses the capacity both to induce and to inhibit seizures. The purpose of this study was to describe the prevalence of ginkgo and other common herb prescribing in a sample of nursing home (NH) elderly diagnosed with epilepsy/seizure (Epi/Sz) disorder and to determine demographic, clinical, and functional factors associated with ginkgo use.

METHODS

This was a 1-year prevalence study of 68,403 NH residents living in 557 nursing facilities throughout the United States.

RESULTS

Overall, herb use in the NHs was very low (0.41%). Ginkgo was prescribed 162 times, more than any other herb. St. John's wort was prescribed 40 times; garlic, 29 times; and all others, <20 times, for a total of 307 herb orders. Among all residents with an herb order, ginkgo was prescribed for 61.9% of residents with an Epi/Sz diagnosis and 58.0% (p = 0.820) of residents without an Epi/Sz diagnosis. Dementia, educational level, and the interaction of age group with cognitive impairment were all significantly associated with herb use among Epi/Sz residents. Cognitive impairment and the interaction of Epi/Sz disorder with dementia were associated specifically with ginkgo use.

CONCLUSIONS

Ginkgo is the most frequently prescribed herb in this population in which >50% of all herb orders were written for ginkgo. The concern with ginkgo use among elderly with Epi/Sz is the lack of standardization that characterizes ginkgo products. In the absence of standardization, the likelihood is increased that ginkgo products may be adulterated with the Ginkgo biloba plant parts most commonly associated with seizure provocation.

Possible contraindications and adverse reactions associated with the use of ocular nutritional supplements

The role of oxidation in the development of age-related eye disease has prompted interest in the use of nutritional supplementation for prevention of onset and progression. Our aim is to highlight possible contraindications and adverse reactions of isolated or high dose ocular nutritional supplements. Web of Science and PubMed database searches were carried out, followed by a manual search of the bibliographies of retrieved articles. Vitamin A should be avoided in women who may become pregnant, in those with liver disease, and in people who drink heavily. Relationships have been found between vitamin A and reduced bone mineral density, and beta-carotene and increased risk of lung cancer in smoking males. Vitamin E and Ginkgo biloba have anticoagulant and anti-platelet effects respectively, and high doses are contraindicated in those being treated for vascular disorders. Those patients with contraindications or who are considered at risk of adverse reactions should be advised to seek specialist dietary advice via their medical practitioner.

Perioperative anesthesia clinical considerations of alternative medicines

The presence of nutraceutical agents in the United States health care system dictates the need for a general understanding of these agents by all physicians and health care providers. Increasing trend toward reimbursement of herbal medicines by the insurance companies and managed care organizations have further encouraged their use. Because herbs are listed under the "supplement" category by the Food and Drug Administration, the Dietary Supplement and Health Education Act establishes no protocol for standardization of the products labeled as "supplements" thereby increasing the risk for adverse effects associated with the use of these products. Moreover, there is little motivation for the manufacturers to conduct randomized, placebo-controlled, double-blinded safety and efficacy trials on these drugs. Reports indicate that within the last 2 decades,more than 100 herbogenic deaths have occurred [100]. Many serious complications have been reported, including renal failure and need for renal or hepatic transplantation after taking nutraceuticals [101-107]. The anesthesiologists should have a detailed knowledge and understanding of the potential risks and purported benefits of herbal medicines and should thoroughly inquire about patient's use of herbal products [108- 11 ]. In addition,the education of each patient regarding the serious, potential drug-herb inter-actions should be a routine component of preoperative assessment. The American Society of Anesthesiologists (ASA), suggests that all herbal medications should be discontinued 2 to 3 weeks before an elective surgical procedure. If the patient is not sure of the contents of the herbal medicine, he or she should be urged to bring the container so that the anesthesiologist can review the contents of the herb or preparation. Although this idea holds some promise in the elective-care settings, anesthetic care in emergency settings should be based on a thorough drug-intake history from the patient or a relative, if possible.Unfortunately, the anesthesia literature has not addressed this new group of health supplements, despite many of these drugs having the potential to cause serious health problems and drug-herb interactions. There is a need to conduct additional scientific clinical trials to study the anesthetic responses to commonly used nutraceutical agents.

A surgeon’s guide to herbal supplements

The use of herbal supplements has steadily increased in the United States over the last decade. Despite the increased awareness of alternative therapies by the government and lay public, many physicians do not ask their patients about their use of these alternative medications. In addition, many physicians are unaware of the possible side effects that may occur when a patient consumes these substances. Considering a number of these supplements have been associated with adverse reactions in the perioperative period, it is important for a surgeon to understand all of the herbs a patient may be taking. The purpose of this article is to discuss the growing trend of herbal use among surgical patients and give the reader some background on the most commonly used herbs.

Herbs commonly used by women: an evidence-based review

OBJECTIVE

To review the evidence of herbs commonly used by women.

DATA SOURCES

Articles were located by searching Medline, Cochrane Database of Systemic Reviews, and the Combined Health Information Database and by hand searching the reference lists of recent systematic reviews. The databases were searched in January 2000 and October 2000 by using the Latin and common name of each herb.

METHODS OF STUDY SELECTION

Preference was given to randomized, placebo-controlled trials. When available, English language studies were reviewed. If not, data are presented from review articles that summarize the foreign study.

RESULTS

Many women use herbal therapies. In the United States, herbs are considered dietary supplements. The Food and Drug Administration (FDA) cannot remove them from the market unless they are proven unsafe. The herb industry plans to improve monitoring. Many prospective randomized controlled trials are being funded. Gingko biloba seems to slow the progression of dementia but increases the risk of bleeding. St John's Wort is efficacious for treating mild to moderate depression but has many drug interactions. Ginseng seems to improve well being in perimenopausal women, but it is often impure and has side effects and drug interactions. Garlic slightly lowers blood pressure and lipids. Echinacea slightly decreases the duration of colds but does not prevent them. Valerian is beneficial for insomnia, but there is no long-term safety data. Black cohosh may help the symptoms of perimenopause, and chasteberry may improve premenstrual syndrome. More study is needed on both herbs.

CONCLUSION

Some herbs are medically useful, but the American public would benefit from increased regulation. Manufacturers should be able to ensure that herbs contain pure ingredients. Side effects and drug interactions should be listed. Well-designed studies are being conducted. The results will be helpful to physicians and patients when the clinical evidence becomes available.

Chemical analysis of Ginkgo biloba leaves and extracts

The chemical analysis and quality control of Ginkgo leaves and extracts is reviewed. Important constituents present in the medicinally used leaves are the terpene trilactones, i.e., ginkgolides A, B, C, J and bilobalide, many flavonol glycosides, biflavones, proanthocyanidins, alkylphenols, simple phenolic acids, 6-hydroxykynurenic acid, 4-O-methylpyridoxine and polyprenols. In the commercially important Ginkgo extracts some of these compound classes are no longer present. Many publications deal with the analysis of the unique terpene trilactones. They can be extracted with aqueous acetone or aqueous methanol but also supercritical fluid extraction is possible. Still somewhat problematic is their sample clean-up. Various procedures, not all of them validated, employing partitioning or SPE have been proposed. Some further development in this area can be foreseen. Separation and detection can be routinely carried out by HPLC with RI, ELSD or MS, or with GC-FID after silylation. TLC is another possibility. No quantitative procedure for flavonol glycosides has been published so far due their difficult separation and commercial unavailability. Fingerprint analysis by gradient RP-HPLC is possible. After acidic hydrolysis to the aglycones quercetin, kaempferol and isorhamnetin and separation by HPLC, quantitation is straightforward and yields by recalculation an estimation of the original total flavonol glycoside content. For biflavones, simple phenols, 6-hydroxykynurenic acid, 4-O-methylpyridoxine and polyprenols analytical procedures have been published but not all assays are yet ideal. Lately a there is a lot of interest in the analysis of the undesired alkylphenols and a few validated procedures have been published. The analysis of Ginkgo proanthocyanidins is still in its infancy and no reliable assays exist.

Ginkgo seed poisoning

A 2-year-old girl presented with vomiting and diarrhea 7 hours after eating a large quantity of ginkgo seeds. She exhibited an afebrile convulsion 9 hours after ingestion. The serum concentration of 4-metoxypyridoxine was as high as 360 ng/mL. Although reported cases of ginkgo seed poisoning usually involve children who exhibit repetitive seizures that can be fatal, prompt administration of pyridoxal phosphate (2 mg/kg) may have prevented additional seizures. This is the first English-language case report measuring 4-metoxypyridoxine concentration during ginkgo seed poisoning. Awareness of the potential danger of overconsumption of this traditional food and its prompt treatment with pyridoxal phosphate may hasten recovery.

Properties and interaction of heterologously expressed glutamate decarboxylase isoenzymes GAD(65kDa) and GAD(67kDa) from human brain with ginkgotoxin and its 5'-phosphate

Two isoforms of glutamate decarboxylase (GAD(65kDa) and GAD(67kDa)) from human brain, which had previously been overexpressed in Escherichia coli as fusion proteins containing a glutathione-S-transferase domain, were purified by affinity chromatography on glutathione Sepharose 4B. Both isoforms were also expressed in Saccharomyces cerevisiae. After modification of a HPLC based assay, the enzymes were characterized with respect to their biochemical properties. Comparison of kinetic data, pH, and temperature optima as well as of the mode of interaction with pyridoxal phosphate as a cofactor revealed several significant differences between the two isoenzymes reflecting their somewhat different physiological and molecular features. Investigation of the influence of 4'-O-methylpyridoxine (ginkgotoxin) (1), a neurotoxin occurring in Ginkgo biloba L., on the different isoenzymes, indicates that the phosphorylated form of the toxin, 4'-O-methylpyridoxine-5'-phosphate (2), decreases GAD(65kDa) activity, although in unphysiologically high concentrations, whereas GAD(67kDa) activity seems to be hardly affected.

Perioperative considerations for the patient taking herbal medicines

There has been a significant increase in the proliferation and use of dietary supplements known as neutraceuticals. Since 1994, herbal products have been regulated by the Dietary Supplement Health and Education Act (DSHEA), which does not require burden of proof to demonstrate premarketing safety and efficacy studies. Scientific literature and government policies have not adequately addressed this fast-emerging group of more than 20,000 health supplements. Lack of purity and standardization of these agents, combined with minimal education in traditional homeopathic medical education, has led to serious health-related problems including arrhythmias, cardiovascular compromise, strokes, and deaths. Even though 30% of our traditional medicines are derived from botanicals, most physicians are either unfamiliar or unwilling to develop any level of expertise with neutraceuticals. A review emphasizing perioperative considerations is provided of the history of herbal medicines, governmental policies, and specific herbal agent-drug interactions.

Biosynthesis of 4'-O-methylpyridoxine (Ginkgotoxin) from primary precursors

Cell suspension cultures of Ginkgo biloba and Albizia tanganyicensis were investigated for the presence of 4'-O-methylpyridoxine (ginkgotoxin, 2), the 4'-O-methyl derivative of vitamin B(6) (pyridoxine, 1). The cultures produced the toxin even in the absence of vitamin B(6) (a common additive to plant cell culture media). This indicates that the pyridoxine ring system of ginkgotoxin is synthesized de novo by the cultured cells. A feeding experiment with D-[U-(13)C(6)]glucose revealed that the mode of incorporation of label into the pyridoxine moiety of 2 matched that observed for 1 in Escherichia coli. Thus, the data obtained in this investigation provide independent proof supporting the current hypothesis on vitamin B(6) biosynthesis. The 4'-O-methyl group of ginkgotoxin (2) was labeled from L-[methyl-(13)C(1)]methionine. This indicates that ginkgotoxin is likely to be derived by 4'-O-methylation of pyridoxine (1). The G. biloba cell suspension culture may be a suitable system to get further insight into vitamin B(6) and/or ginkgotoxin biosynthesis.