A Tool for Rapid Identification of Potential Herbal Medicine—Drug Interactions

Public knowledge, attitudes, and practices towards herbal medicines; a cross-sectional study in Western Saudi Arabia

BACKGROUND

Herbal medicines, derived from medicinal plants, are among the most popular alternative remedies around the globe. In Saudi Arabia, herbal medicines are extensively used by public as part of the culture as well as religious norms. Therefore, this study aimed to evaluate knowledge, attitudes, and practices regarding herbal medicines among the general population in Saudi Arabia.

METHODS

A descriptive cross-sectional survey study was conducted on the general population of Jeddah city with the help of a validated and self-administered questionnaire. Sample size was calculated to be 450 with subjects between 20 and 60 years of either gender. Descriptive and inferential statistical analysis was performed using SPSS.

RESULTS

Results of our data showed that 173 (42.2%) of the total participants used herbal medicines, however, significant association was found between female gender and the usage of herbal medicines (p < 0.001). Approximately, more than half (56.0%) of the respondents agreed that herbal medicines could be used to promote health and treat illnesses, and 45% respondents agreed that herbal medicines are safe. 153 (37.4%) of the participants opined that herbal medicines could be taken with conventional or allopathic medicine. The data also showed a significant (p < 0.05) association between knowledge about the source of herbal medicine and gender where females were found to have more knowledge compared to males. Moreover, a significantly higher number of chronic disease patients were using herbal medicines compared to individuals with no medical problems (p < 0.001). Strikingly, majority (n = 204; 49.9%) of the respondents used herbal medicines as a first choice when sick, while a good number (n = 172; 42.1%) of respondents did not consult doctors before taking herbal medicines.

CONCLUSION

The use of herbal medicines is common among the general population of Jeddah. Although most of the participants believed that the herbal medicines are safe and do not require consultation, there is a dire need to increase awareness as well as to establish effective strategies to evaluate the safety, efficacy and quality of the herbal medicines for propitious consequences of this commonly used entity in the local society.

Herb-drug interactions: a novel algorithm-assisted information system for pharmacokinetic drug interactions with herbal supplements in cancer treatment

PURPOSE

To develop a system to estimate the risk of herb-drug interactions that includes the available evidence from clinical and laboratory studies, transparently delineates the algorithm for the risk estimation, could be used in practice settings and allows for adaptation and update.

METHODS

We systematically searched Drugbank, Transformer, Drug Information Handbook, European and German Pharmacopoeia and MEDLINE for studies on herb-drug interactions of five common medicinal plants (coneflower, ginseng, milk thistle, mistletoe and St. John's wort). A diverse set of data were independently extracted by two researchers and subsequently analysed by a newly developed algorithm. Results are displayed in the form of interaction risk categories. The development of the algorithm was guided by an expert panel consensus process.

RESULTS

From 882 publications retrieved by the search, 154 studies were eligible and provided 529 data sets on herbal interactions. The developed algorithm prioritises results from clinical trials over case reports over in vitro investigations and considers type of study, consistency of study results and study outcome for clinical trials as well as identification, permeability, bioavailability, and interaction potency of an identified herbal perpetrator for in vitro investigations. Risk categories were assigned to and dynamically visualised in a colour-coded matrix format.

CONCLUSIONS

The novel algorithm allows to transparently generate and dynamically display herb-drug interaction risks based on the available evidence from clinical and laboratory pharmacologic studies. It provides health professionals with readily available and easy updatable information about the risk of pharmacokinetic interactions between herbs and oncologic drugs.

Management of natural health products in pediatrics: a provider-focused quality improvement project

INTRODUCTION

The use of natural health products by pediatric patients is common, yet health care providers often do not provide management guidance. The purpose of this project was to improve management of natural health products by pediatric nurse practitioners.

METHOD

Pediatric nurse practitioners from large metropolitan city were recruited (n = 32). A paired pretest-posttest design was used. Study participants were engaged to improve knowledge of natural health products, and a management toolkit was created and tested.

RESULTS

Mean knowledge scores increased from 59.19 to 76.3 (p < .01). Management practices improved with regard to patient guidance (p < .01) and resource utilization (p < .01). Assessments of product use (p = .51) and drug/herb interactions (p = .35) were not significant.

DISCUSSION

This investigation is the first known study to improve knowledge and management of natural health products in pediatric clinical practice.

CAM use in pediatric neurology: an exploration of concurrent use with conventional medicine

BACKGROUND

Previous studies have found that up to 60% of children with neurologic conditions have tried complementary and alternative medicine (CAM).

OBJECTIVE

To assess the use of CAM among patients presenting to neurology clinics at two academic centers in Canada.

METHODS

A survey instrument was developed to inquire about use of CAM products and therapies, including reasons for use, perceived helpfulness, and concurrent use with conventional medicine, and administered to patients or their parents/guardians at the Stollery Children's Hospital in Edmonton and the Children's Hospital of Eastern Ontario (CHEO) in Ottawa.

RESULTS

Overall CAM use at the Stollery was 78%, compared to 48% at CHEO. The most common CAM products used were multi-vitamins (84%), vitamin C (37%), homeopathic remedies (24%), and fish oil/omega 3 s (22%). The most common CAM practices used were massage (47%), chiropractic (37%), faith healing (18%), aromatherapy (16%), homeopathy (16%), and relaxation (16%). Many patients used CAM products at the same time as conventional medicine but just over half (57%) discussed this concurrent use with their physician.

CONCLUSION

CAM use is common in pediatric neurology patients and most respondents felt that it was helpful, with few or no harms associated. However, this use is often undisclosed, increasing possibility of interactions with conventional drugs. We urge clinicians to inquire about CAM use during routine history taking at every patient visit. Parents would clearly like more information about CAM from their specialty clinics; such information would be easier to share if more primary data were available about the safety and effectiveness of commonly used therapies.

Public awareness, patterns of use and attitudes toward natural health products in Kuwait: a cross-sectional survey

BACKGROUND

There has been a global rise in the use of natural health products (NHPs). Proper regulation of NHPs is pivotal to ensure good quality control standards, enhance consumers' safety and facilitate their integration into modern healthcare systems. There is scarcity of published data on the prevalence of NHPs usage among the general Kuwaiti population. Hence, this study was designed to determine awareness, patterns of use, general attitude and information requirements about NHPs among the public in Kuwait.

METHODS

A descriptive cross-sectional survey was performed using a pretested self-administered questionnaire on a sample of 1300 Kuwaiti individuals, selected from six governorates in Kuwait using a multistage stratified clustered sampling. Descriptive and multivariate logistic regression analysis were used in data analysis.

RESULTS

The response rate was 90.2%. NHPs were thought to be herbal remedies by most of participants (63.5%), followed by vitamins/minerals (40.5%), traditional medicines (21.1%), probiotics (14.9%), amino acids and essential fatty acids (7.2%), and homeopathic medicines (5.6%). NHPs usage was reported by 71.4% (95% CI: 68.8-74.0%) of respondents, and mostly associated with females (OR: 1.90; 95% CI: 1.44-2.51). Herbal remedies were the most commonly used (41.3%; 95% CI: 38.5-44.2%). The most common reasons for using NHPs were to promote and maintain health and to prevent illness and build immune system. Family members and/or friends and mass media were the main sources for providing information about NHPs. About 18% of consumers have experienced a side effect due to using a NHP. Attitudes toward NHPs were generally positive; with more than 75% of participants believing that the Ministry of Health in Kuwait should regulate the claims made by the manufacturers of NHPs and it is important to talk to a medical doctor or a pharmacist prior to using NHPs. Most of the respondents showed increased interest to acquire knowledge about different types of information related to NHPs.

CONCLUSIONS

The prevalence of use of NHPs among Kuwaiti population is high. The present findings have major public health policy implications for Kuwait. Therefore, there is an apparent need to establish effective health education programs and implement better and more regulated NHPs use policies in Kuwait.

The co-use of conventional drugs and herbs among patients in Norwegian general practice: a cross-sectional study

BACKGROUND

Different patient groups are known to use herbal remedies and conventional drugs concomitantly (co-use). This poses a potential risk of herb-drug interaction through altering the drug's pharmacokinetics or pharmacodynamics. Little is known about co-use among patients in general practice. The primary aim of this study was to compare patients in general practice that co-use herbal remedies and conventional drugs with those who do not. The secondary aim was to register the herb-drug combinations with potential clinical relevant interactions among the co-users.

METHOD

A questionnaire based cross-sectional study conducted in the autumn 2011 in a general practice office with four general practitioners (GPs) and one intern in Western Norway. Adults >18 years who came for an office visit were invited. The questionnaire asked about demographics, herbal use, conventional drug use and communication about herbal use. Multivariable logistic regression was used to compare co-users to the other patients.

RESULTS

Of the 381 patients who completed the questionnaire, the prevalence of herbal use was 44%, with bilberry (41%), green tea (31%), garlic (27%), Aloe vera (26%) and echinacea (18%) as the most frequently used. Among those using conventional drugs regularly, 108 (45%) co-used herbs. Close to 40% of patients on anticoagulants co-used herbs, with garlic and bilberry as the most frequent herbs. Compared to all other patients, co-users had significantly (p < 0.05) increased odds to be female (adjOR 2.0), age above 70 years (adjOR 3.3), use herbs to treat an illness (adjOR 4.2), use two or more herbs (polyherbacy, adjOR 12.1) and having experienced adverse effects of herbal use (adjOR 37.5). Co-use was also associated with use of analgesics or dermatological drugs (adjOR 5.1 and 7.9 respectively). Three out of four patients did not discuss herbal use with any health care professional.

CONCLUSION

A sizable proportion of the GP patients co-used herbs with conventional drugs, also combinations with reported interaction potential or additive effects like anticoagulants and garlic. The low disclosure of herbal use to their GP, polyherbacy and the risk of interactions in vulnerable groups like elderly and chronically ill patients, warrant increased awareness among GPs.

Complementary and alternative medicine in child and adolescent psychiatry: legal considerations

The rising popularity of complementary and alternative medicine (CAM) in child and adolescent psychiatry raises unique ethical and legal concerns for psychiatrists and other conventional health care providers. This article explores these concerns and provides clinical advice for promoting patient health and safety while minimizing the psychiatrist's risk. Although any departure from the conventional standard of care is a potential risk, the risk of malpractice liability for practicing integrative medicine in child and adolescent psychiatry is low. CAM is most safely recommended from a legal standpoint when there is some published evidence of safety and efficacy.

Use of Natural Health Products

Introduction. Little is currently known about how and why consumers choose to use natural health products (NHPs), such as herbs and vitamins. Objective. The objective of this study was to explore how the product attributes of NHPs and conventional pharmaceutical sleep aids are linked to consequences and values in consumers’ decision making. Methods. During the spring and summer of 2007, 60- to 90-minute semistructured, laddering interviews based on the means-ends chain approach were conducted with 25 participants experiencing sleep problems in Toronto, Canada, who were selected to have a range of demographic characteristics. Results. Participants varied considerably in the complexity of their decision processes, as between 3 and 14 attribute-consequence-value associations were elicited per interview. The factors found to be most important in determining the type of sleep aid chosen by consumers were whether the product was natural or chemical, whether it was perceived to work or have side effects, and participants’ perceptions of the impact of product use on their relationships and, subsequently, on their quality of life. Participants described making different tradeoffs between product attributes (e.g., naturalness) and perceived consequences (e.g., efficacy and side effects) depending on the situational context and indicated that these tradeoffs were done in an effort to maximize values such as overall quality of life. Conclusions. The naturalness and associated perceived lack of side effects of a product were more important than perceived efficacy for consumers selecting sleep aids for regular use. Only in special cases where efficacy was deemed essential (e.g., prior to important life or work events) did efficacy become a more important factor in the decision-making process.

Natural health product-drug interactions: evolving responsibilities to take complementary and alternative medicine into account

Natural health products (NHPs) (known as dietary supplements in the United States) are a popular form of self-care, yet many patients do not disclose their use to clinicians. NHP-drug interactions are known to occur and can harm patients and affect the efficacy of conventional treatment. Using the example of an HIV-positive adolescent who had been responding well to antiretroviral therapy but then experienced a sudden unexplained deterioration in her condition, we review (1) clinicians' obligation to inquire about complementary and alternative medicine (CAM) use when assessing, treating, and monitoring patients, (2) how clinicians' duty to warn about risks associated with treatment has evolved and expanded, and (3) patients' and parents' responsibility to disclose CAM use. It also addresses the responsibility of hospitals and health facilities to ensure that the reality of widespread CAM/NHP use is taken into account in patient care to effectively protect patients from harm.

Pharmacists' participation in research: a case of trying to find the time

Objective

The objective of this case study was to explore how pharmacists involved in the Pharmacy Study Of Natural Health Product Adverse Reactions (SONAR) project perceived the barriers and facilitators to participating in clinical research.

Methods

A total of 19 semi-structured interviews were completed with pharmacy staff members who had recently completed data collection in the SONAR study which involved asking patients if they had experienced any unwanted effects while taking natural products. Other data sources included detailed field notes and interviews with SONAR researchers. Basic content analysis with multiple coders was used to analyse the data and triangulation was used to highlight areas of consistency and contrasting view points across the data types.

Key findings

None of the participating pharmacies was able to collect as much data as expected by the SONAR team. Lack of time was stated as the main reason why pharmacy staff had trouble with the data collection. However, observational data and detailed probing in interviews confirmed that data collection itself took very little time (seconds per patient). Lack of time was provided as a socially acceptable excuse that masked deeper issues related to fears associated with challenges modifying established work routines and perceived lack of value associated with research participation.

Conclusion

To successfully engage pharmacists in practice-based natural health product research it is necessary to establish the direct and indirect benefits of participation because those that believe in the value of the research will make the time for participation.

Assessment of herbal medicinal products: challenges, and opportunities to increase the knowledge base for safety assessment

Although herbal medicinal products (HMP) have been perceived by the public as relatively low risk, there has been more recognition of the potential risks associated with this type of product as the use of HMPs increases. Potential harm can occur via inherent toxicity of herbs, as well as from contamination, adulteration, plant misidentification, and interactions with other herbal products or pharmaceutical drugs. Regulatory safety assessment for HMPs relies on both the assessment of cases of adverse reactions and the review of published toxicity information. However, the conduct of such an integrated investigation has many challenges in terms of the quantity and quality of information. Adverse reactions are under-reported, product quality may be less than ideal, herbs have a complex composition and there is lack of information on the toxicity of medicinal herbs or their constituents. Nevertheless, opportunities exist to capitalise on newer information to increase the current body of scientific evidence. Novel sources of information are reviewed, such as the use of poison control data to augment adverse reaction information from national pharmacovigilance databases, and the use of more recent toxicological assessment techniques such as predictive toxicology and omics. The integration of all available information can reduce the uncertainty in decision making with respect to herbal medicinal products. The example of Aristolochia and aristolochic acids is used to highlight the challenges related to safety assessment, and the opportunities that exist to more accurately elucidate the toxicity of herbal medicines.