Use of herbal remedies and potential drug interactions in rheumatology outpatients

Evidence of the interactions between immunosuppressive drugs used in autoimmune rheumatic diseases and Chinese herbal medicine: A scoping review

OBJECTIVES

Chinese herbal medicine (CHM) has been shown to be effective in autoimmune rheumatic diseases, but harmful herb-drug interactions might be inherent. We aim to review the evidence regarding herb-drug interactions between immunosuppressive drugs used in autoimmune rheumatic diseases and CHM.

METHODS

We searched PubMed, EMBASE and CINAHL from inception till 30 April 2023 using keywords that encompassed 'herb-drug interactions', 'herbs' and 'immunosuppressants'. Articles were included if they contained reports about interactions between immunosuppressive drugs used in the treatment of rheumatic diseases with CHM. Level of evidence for each pair of interaction was graded using the algorithm developed by Colalto.

RESULTS

A total of 65 articles and 44 unique pairs of interactions were identified. HDIs were reported for cyclophosphamide, cyclosporine, tacrolimus, methotrexate, mycophenolic acid, glucocorticoids, sulfasalazine, tofacitinib and biologic disease-modifying antirheumatic drugs. Among these, cyclosporine (n = 27, 41.5%) and tacrolimus (n = 19, 29.2%) had the highest number of documented interactions. Hypericum perforatum had the highest level of evidence of interaction with cyclosporine and tacrolimus. Consumption reduced the bioavailability and therapeutic effects of the drugs. Schisandra sphenanthera had the highest level of evidence of interaction with tacrolimus and increased the bioavailability of the drug. Majority of the articles were animal studies.

CONCLUSION

Overall level of evidence for the included studies were low, though interactions between cyclosporine, tacrolimus, Hypericum perforatum and Schisandra sphenanthera were the most and well-documented. Healthcare professionals should actively enquire about the concurrent use of CHM in patients, especially when drugs with a narrow therapeutic index are consumed.

Signal Detection and Assessment of Herb-Drug Interactions: Saudi Food and Drug Authority Experience

INTRODUCTION

Numerous investigations on herbal medicine that have been undertaken in the past several years demonstrate the general acceptance of its safety. The Saudi Food and Drug Authority (SFDA) established the Herb-Drug Interaction (HDI) project to detect and assess potential HDIs to ensure safety. The aim is to detect safety signals and assess them based on available evidence.

METHODS

First, SFDA-registered herbal products (n = 30) were selected and prioritized based on commonly used herbs. Second, reported potential HDIs were retrieved from the World Health Organization global database of individual case safety reports (VigiBase), AdisInsight®, and the Natural Medicines database. We excluded drugs non-registered by SFDA and labeled interactions in the product information of SFDA, the US Food and Drug Administration (FDA), and the European Medicines Agency (EMA). Finally, a comprehensive evaluation of potential HDIs was carried out using several evidence sources: literature, global cases, local cases, and other relevant documents. The Drug Interaction Probability Scale (DIPS) scale was used to assess the probability of a causal relationship between the interacting herb and drug and the event.

RESULTS

The search yielded 566 potential signals, and 41 had published evidence and were referred for assessment. The assessment results using DIPS were: 22 possible (53.6 %), 7 probable (17%), and 12 doubtful (29.2%) interactions. The recommendation was to include probable HDIs in the product information, including turmeric-tacrolimus, etoposide-Echinacea, Ginkgo biloba-ibuprofen, green tea-warfarin, and licorice-thiazides interactions.

CONCLUSION

The HDI project assessed the screening and identification of potential HDIs. The action plan of this project can be used in post-marketing activities to identify potential drug interactions.

Bombax Costatum extract abrogates piroxicam-mediated hepatic and gastric toxicities in rats

OBJECTIVE

Concurrent administration of orthodox drugs and herbs is common in tropical Africa. This study investigates the effect of co-administration of piroxicam and Bombax costatum on hepatic and gastric toxicities and levels of oxidative stress markers.

MATERIALS AND METHODS

Twenty male wistar rats were grouped into four. Rats in group one were administered 1mL/kg distilled water as normal control; group two were treated with 400mg/kg of extract; group three were treated with 20mg/kg of piroxicam; while those in group four were treated with both extract and piroxicam at 400mg/kg and 20mg/kg, respectively. All treatments were given orally for 14 days. At the end of the treatment period, the rats were euthanised; blood samples and stomach were collected for determination of hepatic and gastro-toxicity alongside with oxidative stress markers.

RESULTS

Treatment with piroxicam alone shows the presence of oxidative stress with marked hepatic and gastric toxicities. Oxidative stress markers, hepatic and gastric toxicity indices after treatment with extract alone and in combination with piroxicam appear like that of the control group.

CONCLUSION

Concurrent administration of piroxicam and Bombax costatum prevents piroxicam-induced hepatic and gastric toxicities with a positive effect on antioxidant levels. This may indicate important health benefits of this drug-herb combination.

Complementary medicine use in rheumatology: A review

Complementary and alternative medicine (CAM) use is increasing worldwide; specifically it appears that these treatment modalities are popular among rheumatology patients. The most commonly reported CAM therapies are herbal medicines, homeopathy, chiropractic, acupuncture and reflexology. Despite high reported rates of CAM use, the number of patients disclosing use to their rheumatologists remains low. This review highlights rates of current CAM use in rheumatology in studies performed worldwide, and discusses potential reasons for nondisclosure of CAM use to clinicians.

Khaya senegalensis inhibits piroxicam mediated gastro-toxicity in wistar rats

OBJECTIVE

The purpose of this study was to investigate the effects of piroxicam co-administration with ethanolic stem-bark extract of Khaya senegalensis on biomarkers of oxidative stress and gastro-toxicity in Wistar rats.

MATERIALS AND METHODS

Thirty healthy male and female Albino Wistar rats (190-220 g) were grouped into six (n = 5) with designated treatments including: Normal saline, piroxicam (20 mg/kg), extract (200 and 400 mg/kg) alone and both doses of the extract co-administered with piroxicam. The drugs were administered orally to all the rats for fourteen consecutive days and on the fifteenth day, they were euthanized with chloroform inhalation. Blood samples and the stomachs were isolated for evaluation of the oxidative stress biomarkers and gastro integrity, respectively.

RESULTS

The results of the study revealed that the levels of oxidative stress markers didn't differ significantly between the groups receiving the extract alone, the extract in combination or piroxicam alone. Gross and histological observations of the stomach showed gastric mucosal changes and mild atrophic lesions in the piroxicam group only.

CONCLUSION

This study illustrates the interaction of Khaya senegalensis and piroxicam results in the gastro-protective beneficial effects. The extract's outcome on various prostaglandin levels and synthesis is being considered towards possible elucidation regarding the exact mechanism of cytoprotection.

Safety and efficacy of herbal remedies in obstetrics-review and clinical implications

OBJECTIVE

to review the literature on safety and efficacy of the most commonly used herbs to enable midwives to give evidence-based information to pregnant women.

DESIGN

survey and review of the scientific literature.

SETTING

the survey was performed at the antenatal clinic at Norfolk and Norwich University Hospital between 26 November 2007 and 15 February 2008.

PARTICIPANTS

a total of 578 expectant mothers at least 20-weeks pregnant.

MEASUREMENTS AND FINDINGS

57.8% of the participants used one or more herbal remedies. The most commonly used herbal preparations during pregnancy were ginger, cranberry, raspberry leaf, chamomile, peppermint and echinacea. Altogether, 14 studies focusing on the safety and/or efficacy of these herbals in human pregnancy were identified. Ten studies of ginger, one of cranberry, two of raspberry leaf and one of echinacea were located.

KEY CONCLUSIONS

there is limited documentation on the safety and efficacy of many herbs commonly used during pregnancy.

IMPLICATIONS FOR PRACTICE

midwives are important caregivers for pregnant women and should strive to give evidence-based advice on herbal use in pregnancy. If 'traditional use' is the only available information, the pregnant woman should be made aware of this to enable her to make an informed decision about the eventual use.

Raspberry leaf--should it be recommended to pregnant women?

This review evaluates the safety and efficacy of raspberry leaf (Rubus idaeus) in pregnancy. The electronic databases PubMed, ISI Web of Science, AMED, EMBASE, Natural Medicines Comprehensive Database and Cochrane Library were searched. Altogether 12 original publications with focus on safety or efficacy during pregnancy, pharmacology and in vitro tests explaining mode of action or constituents in Rubus idaeus were reviewed. Limited documentation exists and part of it is 50 years old or older. Only the latest animal study indicates an increased risk for the unborn child; however, all the studies are small and cannot rule out negative effects on pregnancy outcome. The efficacy of raspberry leaf is not convincingly documented. The use of raspberry leaf in pregnancy is a traditional herbal therapy and is recommended by some midwives. Due to the lack of evidence for safety and efficacy such recommendations are questionable. Suggestions for future work are given.

DNA based customized nutraceutical "gene therapy" utilizing a genoscore: a hypothesized paradigm shift of a novel approach to the diagnosis, stratification, prognosis and treatment of inflammatory processes in the human

We hypothesize that using a multi-variant nutrigenomic index for the purposes of customizing or adjusting the formulation of nutritional supplements will result in an improved and novel approach to the diagnosis, stratification, prognosis, and treatment of inflammatory processes in the human. This multi-variant genetic index, or Genoscore, is derived by analyzing genotype and/or phenotype through measuring multiple genetic mutations of single nucleotide polymorphisms, gene expression, or other forms of genetic and phenotypic measurements. We also propose that manipulation of neurochemical reward circuitry in the mesolimbic brain region providing dopamine release at the nucleus accumbens (NAc), will have both pain and stress relief benefists, which are a cornerstone to the human inflammatory process. This hypothesis, applies to all genes currently discovered or which will be discovered and any nutritional or dietary supplement ingredient currently available or which will become available. For example, if a DNA test was measuring two genes through single nucleotide polymorphisms (Gene A and Gene B), the index scores (Genoscore) that would be reported to the clinician and patient would be based upon the number of mutations. An index score of 0 would mean no mutation. An index score of 1 may mean a mutation in Gene A. An Index Score of 2 may mean a mutation in Gene B. An Index Score of 3 may mean a mutation in Gene A and Gene B, resulting in a simple report, easily understandable to both the clinician and patient that provides insights into disease diagnosis, stratification, prognosis, as well as the metabolism, efficacy and/or toxicity associated with specific vitamins, minerals, herbal supplements, homeopathic ingredients and other ingredients in the nutritional and/or dietary supplement regimen. Furthermore, we have provided support that evidence shows the importance of the dopaminergic connection as an anti-pain and anti-stress molecule, working at the mesocorticolimbic region of the brain, specifically at the NAc. Additionally, we have provided support that clinical evidence demonstrates the effectiveness and safety of natural substances for joint health, such as glucosamine sulfate , chondroitin sulfate, and Ganoderma lucidum.

Interactions between herbal remedies and antirheumatic drugs

Many patients with rheumatological conditions use herbal remedies as an adjunct to their conventional antirheumatic medication, often without seeking advice. Herbal remedies are exempt from the usual drug safety requirements and may be a cause of both adverse effects and drug interactions. Data on interactions between herbal remedies and conventional antirheumatic medication is scarce. Reasons include a perception that herbal remedies are safe, a lack of reporting by patients and healthcare professionals and a lack of knowledge about the pharmacology and composition of herbal remedies, as well as adulteration. Interactions are likely between herbal remedies with antiplatelet or nephrotoxic effects and NSAIDs, hepatotoxic herbal remedies and disease-modifying antirheumatic medication, and between St. John's Wort and cyclosporin.

Treatment options for patients with osteoarthritis of the knee

Knee osteoarthritis (OA) affects many older people and may result in pain and loss of function in the knee. The article explores the wide spectrum of treatments available, including education, exercise, pharmacological agents and surgery. The evidence for these treatments is examined so that nurses have a knowledge base on which to build their practice. The importance of individual patient characteristics and available resources when deciding on treatment options is emphasized. The article is intended to be of use for both acute and primary care nurses who care for patients with knee OA.